2018

PRIMO B. MONTANA, RXT, RRT, RSO, M.A.Ed.

 Head, B.S. Radiologic Technology Program
Holy Infant College

FUNDAMENTAL
PRINCIPLES OF COMPUTED
TOMOGRAPHY (CT)
for B.S. Radiologic Technology
 All x-ray imaging is based on the absorption of x-rays as they
pass through the different parts of a patient’s body.

Depending on the amount absorbed in a particular tissue such

as muscle or lung, a different amount of x-ray will pass through and exit the
body. The amount of x-rays absorbed contributes to the radiation dose to the
patient.
During conventional x-ray imaging, the exiting x-rays interact
with a detection device (x-ray film or other image receptor) and provide a
2D projection image of the tissue within the patient’s body– an x-ray
produced “photograph” called “radiograph”.

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Although also based on the variable absorption of x-rays by different
tissues, COMPUTED TOMOGRAPHY Imaging provides a different form of
imaging known as “cross-sectional imaging”.

The origin of the word “Tomography” is from the Greek word

”Tomos” meaning “slice” or “section” and “Graphe” meaning “drawing”.
A CT imaging system produces cross-sectional images or
“slices” of anatomy, like the slices in a loaf of bread.

The cross-sectional images produced are used for a variety of diagnostic and
therapeutic purposes.

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 COMPUTED TOMOGRAPHY
Is the process of creating a cross-sectional tomographic plane (slice)
of any part of the body which is then reconstructed by a computer using x-
ray absorption measurements collected at multiple points about the
periphery (external surface) of the part being scanned.

It is an imaging method in which a

cross-sectional (slice) image of the
structures in a body plane is reconstructed
by a computer program from the x-ray
absorption of x-ray beams projected
through the body in the image plane.

BENEFITS OF CT SCANNER

1. The capability to present a cross-sectional (slice) image in any part of the

body.

2. The ability to distinguish more minute differences among various tissues.

3. CT images can be altered at the viewing console to optimize the

presentation of the diagnostic information.

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 COMPUTED TOMOGRAPHY SCANNING HAS BEEN VARIOUSLY IDENTIFIED
AS:

• Computerized Axial Tomography

• Computerized Transaxial Tomography

• Computerized Reconstruction Tomography

• Digital Axial Tomography

COMPUTED TOMOGRAPHY (CT) – is the nomenclature that has been

substantially accepted to identify this diagnostic tool.

HISTORICAL PERSPECTIVE

The invention of CT is considered to be the greatest

innovations in the field of radiology since the discovery of x-rays on Nov. 8,
1895 by Wilhelm C. Roentgen.
The cross-sectional imaging technique provided Diagnostic
Radiology with better insights into the pathogenesis of the body thereby
increasing the chances of recovery
The successfully clinical demonstration of CT was conducted
in 1970 by Engr. Godfrey Hounsfield from the Central Research Laboratory
of EMI Limited in England. In 1979, Godfrey N. Hounsfield and Allan M.
Cormack was awarded the Nobel Prize in medicine and physics for the
invention of Computed Tomography.
Allan M. Cormack developed the mathematics used to
reconstruct CT image.
The first CT scanner
developed by Hounsfield in his
laboratory at EMI took several hours
to acquire the raw data for a single
scan or “slice” and took days to
reconstruct a single image from this
raw data.

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 The original Axial CT image in 1975 that
shows a coarse 128 x 128 matrix were
physicians fascinated by the ability to see
the soft tissue structures of the brain
including the black ventricles.

In 1971, the first full scale CT unit used to examine the skull and diseases of
the brain called the Head Scanning was installed at Atkinson Morley’s
Hospital, England.

Figure 1. Whole body scanner with larger patient

openings became available in 1976 and CT
became widely available by about 1980.

The first CT unit in the U.S. was installed in 1973 at the Mayo Clinic and
Massachusetts General Hospital.

In 1974, Dr. Robert Ledley at Georgetown University Medical Center

developed the first scanner capable of visualizing any section of the body.

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PRINCIPLES OF OPERATION

The precise methodology (set of methods) by which a CT

scanner produces a cross-sectional image is extremely complicated and
requires a good knowledge of physics, engineering and computer science.

Hounsfield imagined the subject to be

scanned as being divided into axial slices.
The x-ray beam to be used was collimated
down to a narrow (pencil-width) beam of x-
rays. The size of the beam was 3 mm within
the plane of the slice and 13 mm wide
perpendicular to the slice (along the axis of
the subject).

In fact, it is this beam width that typically specifies the slice thickness to be
imaged. The x-ray tube is rigidly linked to an x-ray detector located on the
other side of the subject so that they moved synchronously.

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Together, the tube and the detector scan across the subject, sweeping the
narrow x-ray beam through the slice

This linear transverse scanning motion of the tube and the detector across
the subject is referred to as a translation. The arrangement is diagramed in
Figure 2.

CT arrangement. Axial slice FIGURE 2. through

patient is swept out by narrow (pencil-width) x-ray
beam as linked x-ray tube–detector apparatus scans
across patient in linear translation. Translations are
repeated at many angles. Thickness of narrow beam is
equivalent to slice thickness.
During translation motion, measurements of x-ray transmission
through the subject are made by the detector at many locations (Fig. 3). The
x-ray beam path through the subject corresponding to each measurement is
called a “ray”.

FIGURE 3. X-ray transmission

measurements. Measurements are obtained
at many points during translation motion of
tube and detector. X-ray path corresponding
to each measurement is designated a ray, and
set of rays measured during translation is
designated a view. Views are collected at many angles (in 1° increments in
this example) to acquire sufficient data for image reconstruction.

The set of measurements made during the translation and

their associated rays is a “view”. Hounsfield's Mark I scanner measured
the transmission of 160 rays per view. The corresponding number of
measurements for today's scanners is typically over 750.

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When the “Source-Detector” assembly makes one sweep/translation across
the patient’s body, the internal structures of the body “attenuate” the x-ray
beam according to their density and effective atomic numbers.

After completion of the translation, the tube–

detector assembly is rotated around the subject by
1°, and the translation is repeated to collect a
second view.

The intensity of radiation detected

varies according to this attenuation
pattern and forms a “projection” or
“intensity profile”.

At the end of this “translation or sweep” the “source-

detector” assembly will return to its starting position and the entire
assembly will rotate and begin a second sweep. During the second
translation/sweep, the detector signal will again be proportional to the
beam attenuation of anatomic structure and a second detector intensity
pattern will be describe or displayed.
If this process is repeated several times, a large number of
“intensity profiles” or “projections” will be generated. These intensity
profiles are not displayed visually on the CRT, but are stored in numeric or
digital form in the computer.

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 The computer processing of this data involves the effective
superimposition of each intensity
profile to reconstruct the anatomic
structures. And through the use of
simultaneous equations, a matrix of
values is obtained that represent the
“cross-sectional anatomy”.

SUMMARY OF THE PRINCIPLES OF CT SCAN

A collimated x-ray beam is directed on the patient and the

attenuated (reduced) remnant radiation is measured by a detector whose
response is transmitted to a computer. The computer then considers the
location of the patient and the spatial relationship of the x-ray beam to the
“region of interest” (ROI) and analyzes the signal from the detector so that a
visual image can be reconstructed and displayed on the cathode ray tube
(CRT). Once the image is already on the CRT, it can be photographed for
later evaluation and file.
The computer reconstruction of the cross-sectional anatomy
is accomplished with mathematic equations adapted for computer
processing called the “algorithm”.

CT SCANNER DESIGNS and OPERATIONAL MODES:

1. FIRST GENERATION CT SCANNER

The first generation CT scanner has the characteristic of

having a finely collimated x-ray beam-single detector assembly translating
across the patient’s body and rotating between successive translations.

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 It uses a single detector element to
capture a beam of x-rays and was designed
to scan the head only.
The original EMI scanner
required 180 translations, and each is
separated by a one degree rotation. These
systems incorporate two detectors and
split the finely collimated x-ray beam so that
two slices could be imaged during each scan.
The scan time for first generation scanners was almost five (5)
minutes to complete one scan and it requires a water-filled bag for patient
positioning and detector normalization during scanning and to eliminate air
interfaces.
The water is
necessary also to moderate
the abrupt change in x-ray
attenuation that would
occur between air and skull
bone.

The early generations of

scanners were designed so that the x-ray tube and detector/s were required
to go through a complex series of motions to collect the absorption data for
reconstructing an image.

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 It requires 15 seconds to 5 minutes to gather sufficient data
before it can reconstruct an image. And because of this inherently slow
scanning speed as well as other limitations, these systems were used
exclusively for “Neurologic” work”. The detectors used in the early scanners
were Sodium Iodide Scintillation crystals with photomultiplier tubes.

In the First Generation scanner, a pencil

thin slit field, 3mm x 26mm, scanned a 180 degrees
arc around the patient’s head.
First generation units used a rotating scan
and index system that scanned the head linearly
(from one side to the other). The x-ray tube was on
during scanning and off during indexing (rotating).
The scan time of the early systems was too long which causes
natural motions such as patient breathing and intestinal peristalsis blurred
the images. That is why these scanners were often referred to as “Head
Scanners”.
The majority of scanners being produced today employ a
“Fan-Beam” of radiation that rotate in a continuous 360 degrees motion
around the patient. With these scanners being produced today, the time
for collecting the required data to reconstruct an image typically ranges
from 1-10 seconds depending on the particular system being used and the
examination being conducted.

This fast scan times have

greatly reduced or eliminated artifacts
that were caused by peristalsis, vascular
pulsation or respiratory artifacts
produced by the slower scanners. These
systems have many applications for
scanning any portion of the anatomy and often referred to as “Whole Body
Scanners”.
The CT scanner is a revolutionary where there is no image
receptor such as film or an image intensifier and it does not record an image
in a conventional way like radiography.

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Major Characteristics of the First Generation CT Units:

• Used for Head only

• Linear scan and rotate (180 scans, at 1 degree rotation.
• 4.5 – 5 minutes scan time
• Uses a single ray pencil beam.
• Uses a single detector.

2. SECOND GENERATION CT SCANNER

The Second generation CT scanner was introduced in 1975.

These systems also known as “hybrid” machines used five to thirty
detectors intercepting a fan-shaped x-ray beam as opposed to pencil beam.

Like the First generation, these

scanners also used a “translate-rotate” design
and were for the most part head only scanner.

The disadvantage of the Second generation

scanners is that having a fan-shaped x-ray
beam instead of a pencil beam, it increases
scatter radiation which affect the image just like a conventional
radiography.
A lead mask was added to the detectors to assist in reducing
the scatter reaching the detectors.

The principal advantage of the Second generation CT scanner

is the “speed”. These scanners have five to thirty detectors in the
detector assembly and therefore, shorter scan times as possible. The scan
time was reduced to between 10 and 90 seconds, a reasonable respiratory
suspension time, thus permitting examination of the whole body.

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Because of multiple detector array, a single translation results in the same
number of data points as several translations with a first generation CT
scanner.
The Second
generation CT scanner is equipped with a
Linear Detector Array.

The simultaneous detection of multiple detector channels also

enhances image quality.
The cost of the Second generation CT scanner is considerably
more than the first generation because of the additional electronics and
computer capacity required to accommodate multiple simultaneous
information channels.

MAJOR CHARACTERISTICS OF THE SECOND CT

UNIT GENERATION

• Single projection fan-shaped beam

(permitting whole body scanning).

• Up to 30 detectors.

• 10-90 seconds scan time

• Linear scan and rotate

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 3. THIRD GENERATION SCANNER

Third Generation scanner used a wider fan-shaped beam and

a curved array of 250-750 detectors to achieve a single projection. The fan-
shaped beam was wide enough to include the entire body in a single
exposure and rotated 360 degrees within the gantry, thus eliminating the
linear scan and rotate system.
As “rotate” only scan, third
generation scanner accommodate scan
time between 1 and 12 seconds, permitting
sequential images to crudely approximate
dynamic functions.
Third generation units
featured dynamic scanning usually
performed at about four scans per minute which equals the routine
scanning time of a fourth generation unit.
The third generation scanners employ a curvilinear detector array
containing at least thirty (30) elements and a fan-shaped beam.

In third generation scanners, the fan-

beam and detector array view the entire
patient at all times. The curvilinear detector
array results in a constant source-to-detector
path length, which is an advantage for good
image reconstruction.

One of the principal disadvantages of Third generation CT scanner is the

occasional appearance of “ring” or “circular” artifact. This ring or circular
artifacts occur when a single detector or detectors malfunction.

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 The malfunctioning of the detector or detectors results in the
absence of signal thereby having these artifacts on the reconstructed image.
However, a properly formulated “image reconstruction algorithm” or
“software corrected image reconstruction algorithm” minimizes such
artifacts.

MAJOR CHARACTERISTICS OF THE THIRD GENERATION CT SCANNER

4. FOURTH GENERATION CT SCANNER

The Fourth generation CT units were developed as a result of

competitive contract awarded to the American Science and Engineering
Company (AS & E) by the United States National Institutes of Health.
They use a single-projection fan-shaped beam with 600-2,000
stationary detectors arrayed in a 360 degrees
ring.
This ring of detectors eliminates
movement of the detectors, thereby decreasing
the calibration requirements. As many as
1,200,000 measurements may be processed per
section.
A wider range of scan arcs, including arcs over 360 degrees
are usually possible with scan times ranging from 0.5 to 10 seconds. Some
fourth-generation scanners are capable of dynamic scanning rates in the
range of 15 scans per minute. The limiting factor is the interscan time and
the computer processing time, not the actual scanning time. Dynamic
scanning is usually achieved by reducing the interscan time to 1-2 seconds
and not indexing the gantry.

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 Another technique, called the “overscan” may also be
available in this unit. Overscanning uses a scan of more than 360 degrees.
This overscan may be displayed as segmented data from 2, 3 or 4 scans as a
single image. These fourth-generation scanners are designed as for the third
generation in which it has a rotate motion only.
With the fourth-generation scanners, the x-ray source rotates,
but the detector assembly does not. Radiation detection is accomplished
through a fixed circular array of detectors which contains as many as 1,000
individual elements.
These units are capable of
one-second scanning time and can
accommodate variable slice thickness
through automatic pre-patient collimation
and can provide the image manipulation
capabilities of earlier scanners. The
fixed circular array of detectors in fourth-
generation CT scanners does not result in a constant beam-path from the
source to all detectors, but it does allow each detector to be calibrated and
its signal normalized during each scan.

The principal disadvantage of

fourth-generation machines appears to
be “patient dose” which is somewhat
higher than that with other types of
machines.
Likewise the cost of these
machines maybe somewhat higher
because of the large number of
detectors and their associated electronics.

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5. FIFTH-GENERATION SCANNERS
The Fifth generation of scanners is represented by the
technology utilized in a dedicated cardiac unit designed around a rotating
electron beam. This is sometimes referred to as “Electron Beam
Tomography” (EBT) or “Cardiac Cine CT.

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 The x-ray tube is replaced with a huge electron gun that uses
a deflection coil to direct a 30 degrees beam of electrons in a 210 degrees
arc around a 360 degrees anode ring. The fan-beam that is produced is
intercepted by a 360 degrees detector array. Because the electron beam
rotates around the anode ring, there is no moving gantry in this design.

The patient is placed within the anode ring. This unit is a

dynamic scanner because it can produce four sections simultaneously within
50msec. It is also capable of multisection sequencing of injected contrast
media triggered by the patient’s ECG.
This is fast enough to provide real-time dynamic sectional
images of the beating heart. Because these images are essentially
anatomical movies (or cine) the examination is sometimes referred to as
“Cine CT”.

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6. SIXTH GENERATION (HELICAL/SPIRAL COMPUTED
TOMOGRAPHY)
Helical (Spiral) scanners were made possible by advances in
slip ring connection technology. Slip rings consist of brushes that fit
into grooves to permit the current and voltage to the x-ray tube to be
supplied while the tube is in continuous rotation around the gantry.
This permits scanning of the entire
body in a helical pattern without
stopping the tube.
When the patient
table (couch) is moved slowly during
the x-ray exposure while the tube is
in continuous rotation, data
comprising a continuous helical scan
of the patient is acquired.

The term “spiral” is a misnomer. A

spiral is a circular motion with a decreasing
or increasing diameter.
The actual scanning motion has a
set circular diameter, which is a helix
(spiral in form). The data is acquired
in a helical, not spiral motion.

The primary advantage of the Helical scanning is a much shorter total scan
time (30-40 sec. for the entire abdomen). This in turn permits the use of
less contrast media.
Another advantage is that for many patients the entire
examination can be completed in one-breath hold, eliminating overlaps and
missed areas due to variations in the amount of air in the lungs between
scan sections. This also reduces the possibility of motion artifacts.

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7. SEVENTH GENERATION (MULTISECTION or MULTISLICE
COMPUTED TOMOGRAPHY)
Computed Tomography units with multiple detectors are
known by several terms.

“Multisection or Multislice Computed Tomography” (MSCT)

“Multidetector Computed Tomography” (MDCT),

“Multiple Detector Array Scanner” (MDA)

The most appropriate term

to use is “Multisection Computed
Tomography” (MSCT) because the
term “slice” is professional slang
and just because a scanner has
multiple detectors does not
necessarily indicate that multiple
sections of data are being
collected simultaneously.
Multisection CT units represent a
major change in CT technology in that
multiple detectors are exposed
simultaneously.
At the turn of the century there
were major advancements in detector
technology that permitted an array of
thousands of parallel bands of detectors to
operate simultaneously instead of a single
band of detectors.
This advancement permitted a single beam exposure to produce multiple
sets of image receptor data.
When this technology is combined with the helical scanning,
total examination time is reduced dramatically, with the entire chest or
abdomen procedure completed in 15-20 seconds. Because section thickness
can be reduced with MSCT, resolution can be increased remarkably.

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 Section thickness with
single section CT scanners is
determined by the collimator
size, not the width of the
detector.
Because MSCT scanners are
exposing multiple detectors
simultaneously, section thickness
is determined by the width of the
detector, even though the collimation of the beam is wide enough to
expose several other bands of the detectors.

For this reason, resolution in MSCT

scanners is determined by the width of the detector, not the width of the
collimator.
The MSCT design is more efficient, reduces patient exposure,
increases image resolution and allows post-acquisition reconstruction at
new levels. Some MSCT scanners allows users to set the pitch <1 in order to
increase the mAs/section available. This increases the quantity of data to
each detector without overloading the x-ray tube.

All MSCT units use a helical

scan system that produces extremely
rapid scanning time while maintaining
the advantages of higher resolution and
reconstruction flexibility.

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 RELEVANT NOMENCLATURES
• Algorithm – is a procedure for solving a certain type of mathematical
problem. It is a step by step method of getting a diagnosis.

• Artifact – area of information on

reconstructed image that does not exist
in reality which may be caused by the
operator motion, patient motion or
equipment peculiarities.

• Attenuation – process of energy absorption described by percent of

radiation absorbed while x-ray pass through objects. It is the reduction in
intensity of the beam as it passes through an
object.

• Aperture – opening of the gantry through which

patient passes during scan.

• Cathode Ray Tube (CRT) – is a television screen

used to display CT image and to communicate
with the computer.

• Computed Tomography (CT) – a process resulting in visualization of cross-

sectional image of the body part. In CT, image is created by computer
using multiple x-ray attenuation readings taken around the periphery of
objects.

• Computerized Axial Tomography (CAT) – early term used to describe CT

scanning. And since images produced are taken at various angles, “Axial”
has been deleted.

• CT Dose Index – is a radiation dose descriptor calculated with normalized

beam width for 14 contiguous sections or slices.

• CT Numbers – are numbers used to define relative absorption coefficient for

each pixel of tissue in image as compared with absorption coefficient of
water.

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 • Data Acquisition System (DAS) –
radiation detection system that measures
amount of radiation passing through
patient.
It refers to a method by which
the patient is systematically scanned by
the x-ray tube and detectors to collect
enough information/data for image
reconstruction

• Gantry – is the framework that holds the x-ray tube

and radiation detector system. This is referred to
as “doughnut” of the patient.

• Localizer Image - image used to localize specific body part.

• Matrix – a two dimensional array of numbers

used to describe number of pixels in CT image on the
CRT. Is the number of pixels that are used to display
the image on the Cathode Ray tube.

• Pixel (Picture Element).

CT image displayed on the CRT is composed of many
small squares (pixels), each of which represents
specific volume of the body. Each pixel is assigned CT
number for image display purposes.

• Protocol – is the instruction for CT examination specifying the slice thickness,

table increment, contrast administration, scan diameter and any other
requirements specified by the radiologist.

• Field of View (FOV) – is the area of anatomy displayed by the CRT; this can be
adjusted to include entire body section of a specific part of the patient
anatomy being scanned.

• Scan – is the motion of an x-ray tube and radiation detector system required
to collect data for reconstructing CT image.

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 • Scan Diameter – referred to as the zoom or focal plane of a CT scan.

• Scan Field – circular field of measurement covered by the x-ray tube and
detector array.

• Slice – a cross-sectional of the body

part that is scanned for generating CT
image. It is the actual rotation of the
x-ray tube about the patient and it is
used as a generic reference to one
slice of an entire examination.

• Voxel (Volume Element) – is the basic element

that defines volume of tissue that each pixel
represents in a reconstructed image.
- It is a 3D volumetric portion of
an image where viewing face is the pixel and
whose depth is the third dimension.

* Hounsfield Unit (HU) – is the numeric information contained in each pixel.

COMPARISON CT WITH CONVENTIONAL RADIOGRAPHY.

Reviewing conventional radiography helps

explain the uniqueness of CT diagnostic
information. When a conventional x-ray
exposure is made, the trans-mitted radiation
passes through the patient and is detected by
x-ray film. And for each exposure to radiation,
diagnostic image with a fixed density and
contrast is produced and with a 3D body
structures superimposed.

The highlighting of certain anatomy requires exact positioning of the patient

and often with the use of contrast media and frequently more than one
exposure.

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 Whereas, in a typical CT study, from 10-20 or more individual
slices are required for a single CT examination. Low tissue density that
would normally be obscured by higher density anatomy on a conventional
radiograph can be clearly visualized in CT.
For this reason, CT is valuable in neurologic work in which
brain is surrounded by the skull. Likewise, in many body examinations, low
tissue density that would be hidden or blend with surrounding anatomy can
be clearly visualized in CT.
It should also be noted that the CT image displays the entire
cross-section of the slice of anatomy that was scanned. Thus, the size and
location of any pathologic condition can be determined with extreme
accuracy within a given CT slice.

Now, with conventional radiography,

multiple exposures and contrast media
are often required to estimate the size
and location of the diseased area.
Furthermore, a series of
CT scans identifies the location of the
pathologic findings in 3 dimensions when each slice is analyzed.

SPIRAL COMPUTED TOMOGRAPHY

Spiral – is a winding or coiling around a
center or axis, usually getting closer or
farther away from it.

In 1989, “Spiral Computed Tomography”

was introduced with great promise for
advancement in the modality.

The term “Spiral” or “Helical”

was coined/created because it is
the apparent motion of the x-
ray tube during scan.

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 Spiral CT has emerged as a new and improved diagnostic tool.
It provides improved imaging of anatomy compromised by respiratory
motion.
Spiral CT is particularly good for the chest, abdomen and pelvis. It has also
the ability to perform conventional transverse imaging for regions of the
body where motion is not a problem such as the head, spine and
extremities.

SPIRAL CT SCAN PRINCIPLES

When the examination begins, the x-ray tube is rotating

continuously without reversing. While the x-ray tube is rotating, the couch
moves the patient through the plane of the rotating x-ray beam.
With all Spiral CT Scans, data is
collected continuously which
can be reconstructed at any
desired Z-axis position along the
patient.

INTERPOLATION ALGORITHM
The ability to reconstruct an image at
any Z-axis position is due to “Interpolation”.

If one wishes to estimate a value

between two known values that is
“interpolation”.
Estimating a value beyond the range of
known value is “extrapolation”.

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 During Spiral CT, image data is received continuously. When
an image is reconstructed, the plane of the image does not contain
enough data for reconstruction. Data must be estimated by
“interpolation”.
Data interpolation is performed by a special computer called
“interpolation algorithm”. The first interpolation algorithms used a
360 degree “linear interpolation”.

This figure illustrates a side

view of a helical scan and parameters
used in the 360 degree linear
interpolation algorithm (360LI), where
Zref indicates the position of the axial
slice to be interpolated.

360 degrees was used because the estimated image plane

information was interpolated from data 360 degrees apart in rotation.
Linear was used because the algorithm assumed a straight-line
relationship between two known data points. The result is a
transverse image nearly identical with that of a conventional CT.
When these images will be formatted into “sagittal” and
“coronal” views, prominent blurring would be obvious compared with
conventional CT reformatted views. The solution to this problem is
interpolation of values separated by 180 degrees. This results in
improved Z-axis resolution and greatly improved reformatted sagittal
and coronal views.

TWO TYPES OF 180 DEGREE ALGORITHMS

1. Simple Linear Interpolation

2. Cubic-Spline Interpolation

Simple Linear Interpolation is a method of curve fitting using linear

polynomials. It calculates the unknown rates as if it lies on a
straight line between the two rates, and is the simplest way to
calculate the unknown rate.

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 Given the two
red points, the blue line is the
linear interpolation between
the points

Linear Interpolation and its calculations deeply employed in

mathematics particularly numerical analysis and numerous applications
including graphics.

Linear Interpolation on a data set (red points)

consists of pieces of linear interpolation (blue
lines).

• Cubic-Spline Interpolation is often referred to as “polynomial

interpolation” because it yields similar results even when using low-
degree splines.

• In computer graphics, splines are

popular curves because of the
simplicity of their construction, their
ease and accuracy of evaluation and
their capacity to approximate complex
shapes through curve fitting and interactive curve design.

Interpolation with cubic-spline

between 8 points.
Hand drawn technical
drawings were made for
shipbuilding using flexible rulers
that were bent to follow pre-
defined points.

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 The disadvantage of the 180 degree interpolation algorithm is
the increased image noise (reduced visibility of low contrast objects)
compared with 360 degree interpolation algorithm.
However the use of a cubic-spline interpolation algorithm can
produce that is called a “breakup” artifact at high contrast interfaces
such as bone-tissue.
In addition, to improve Sagittal and Coronal reformatted
views, 180 degree interpolation algorithm allows imaging as a “Pitch”
greater than 1.

SPIRAL SCAN PITCH RATIO

Because the patient table moves during the exposure, a
method to measure and reproduce this motion must be established.
PITCH is the term that is used to define this extension or contraction of the
helix. It is simply the ratio of the distance the table moves (feed) during one
360 degree tube rotation to the total beam collimation.
Among the different manufacturers, there are various
definitions of “Pitch” depending on whether a “single-detector” (single slice)
or “multi-detector” (multi-slice) CT scanner is used.

• For a Single-Slice Helical Scanner the Pitch is:

PITCH = Table movement per rotation/Slice Collimation

Or it is the relationship between the patient couch movement

and the x-ray beam collimation or slice thickness.

Pitch is also defined as the ratio of the table speed per rotation and the total
collimation (slice thickness).

Couch movement (mm/sec) per 360 degrees rotation

PITCH = --------------------------------------------------------------------------------
Collimation

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Pitch is expressed as a ratio; 1:1, 1:5 or 2:1 and a Pitch Ratio of 1:1 will
result in the best image quality.

I Where P = Pitch
P = ------ I = Table increment per 360 degrees
B B = Beam width in millimeter

Pitch in CT is the ratio of the patient table increment to the

total nominal beam width for a CT scan. The choice of “Pitch Factor” which
relates to the volume coverage speed to the thinnest sections that can be
reconstructed is determined on practical considerations and on the
availability of the Computed Tomography Algorithms and parameters for
image reconstruction.

Another definition of Pitch for International Standard is:

PITCH=TF (Table feed in mm per 360 degree rotation/(N [number of

detector rows] x SC (slice collimation in mm).

Sample Questions in computing the Pitch Ratio of a Scanner:

During a 360-degree x-ray tube rotation, the patient couch

moves 8 millimeters. Section collimation is 5mm. What is the Pitch?

Couch movement per 360 degree rotation

PITCH = ----------------------------------------------------------------------
Collimation

8mm
= ----------------
5mm

= 1.6mm

PR ≈ 1.6:1

30
 Increasing Pitch above 1:1 increases the volume of tissue that
can be imaged in a given time. The ability to image a large volume of tissue
in a single breath-hold is the principal advantage to Spiral Computed
Tomography. This is particularly helpful in CT Angiography, Radiation
Therapy treatment planning and imaging uncooperative patients.

The relationship between the volume of “Tissue Imaged” and

“Pitch” is given as follows:

Tissue Imaged = Collimation x Pitch x Scan Time

QUESTION:
How much tissue will be imaged if collimation is set to 8mm,
with a scan time of 25 seconds, and a pitch of 1.5:1?

Tissue Imaged = 8mm x 25 x 1.5

= 300mm ≈ 30 centimeters

NOTE: 10 millimeters = 1 centimeter

What if the gantry rotation time is not 360 degrees in one second?
If the tube heat capacity is limited, slower rotation may be necessary. In
such a situation, the equation would become:

Collimation x Pitch x Scan Time

Tissue Imaged = ------------------------------------------
Gantry Rotation Time

This equation will allow the CT Technologist to compute the volume of

tissue to be imaged before beginning the examination.

QUESTION:

How much tissue will be imaged with 5mm collimator, a pitch

of 1.6:1, and a 20 second scan time at a gantry rotation time of 2 seconds?

31
 Collimation x Pitch x Scan Time
Tissue Imaged = --------------------------------------------------------
Gantry Rotation

5mm x 1.6 x 20 second

= ----------------------------------------
2 second

= 80 millimeters

≈ 8 centimeters

SCANNER DESIGN

Spiral CT was made possible by “Slip-Ring Technology”. The

results of shorter scan times and more tissue volume imaged without loss of
image quality was also due to improvements in the x-ray tube, high voltage
generator and detector array.

SLIP RING TECHNOLOGY

Slip rings are electromagnetic

devices that conduct electricity and electrical
signals through rings and brushes across a
rotating surface into a fixed surface.
One surface will be a smooth ring
and the other, a ring with brushes that sweep
the smooth ring.

Spiral CT is made possible by the use of slip ring, which allows the gantry to
rotate continuously without interruption.

32
 Take note that conventional CT scanning is performed with a
pause between each gantry rotation. During the pause, the patient couch is
moved and the gantry may be rewound to a starting position.
In Slip Ring gantry system, power and electric signals are
transmitted through a stationary rings within the gantry that make
continuous rotation possible and eliminating the need for electrical cables.

SPIRAL CT SCANNERS HAVE TWO DESIGNS OF SLIP RING

1. DISK Design incorporates concentric conductive rings in the plane of

rotation.

2. CYLINDER Design has the

conductive rings lying parallel to the
axis of rotation forming a cylinder.

X-RAY TUBE
In conventional CT, the x-ray tube is energized for one
rotation, usually 1 second and every 6-10 seconds that allows the tube to
cool between scans.
Spiral CT places a considerable thermal demand on the x-ray
tube. Because of the continuous rotation and energization of the x-ray tube
for longer times, higher power levels must be sustained.
“High heat capacity” and “High Cooling Rates” are trademarks of x-ray tubes
designed for Spiral CT. Spiral CT x-ray tubes have anode heat storage
capacity of 5 Million Heat Units (HU) or more. Less than 3 million HU is
unacceptable. It has also an anode cooling rate of 1 MHU per
minute.

33
RADIATION DETECTORS

The efficiency of the x-ray detector array reduces patient

dose, it allows faster scan times and it improves image quality by increasing
signal-to-noise ratio.
Consequently, “Solid State” is the preferred detector array
which has an over-all efficiency of approximately 80% compared to gas-
filled detectors which have an approximate efficiency of 60% only.
Solid State detectors combine a calcium tungstate, yttrium or
gadolinium ceramic scintillator with a photo detector. The scintillator is
bonded to the top of the photodiode to assure accurate pickup of the
emitted photons.
When the in-coming x-ray beam photon activates the
scintillator, light photons are emitted isotropically in proportion to the
intensity of the in-coming light.
A major advantage of the scintillator is that, it has a large
acceptance angle for incoming x-ray photons. This greatly increases the
sensitivity of the detector by allowing the x-ray beam to be in diverging fan-
shape. In other words, the detector does not have to be positioned directly
under the perpendicular central ray (CR) of the x-ray beam. This allows the
entire array of bands of detectors to operate simultaneously. The
photodiode detects the light photons emitted by the scintillator and
converts them into an electrical signal.
However, they require a small gap between adjacent
detectors to avoid “crosstalk” between one another. This limits how close
together the detectors can be placed and this impacts the resolution of the
scanner.
CT Solid-State detectors used in MSCT (Multislice CT) scanner
are typically 1.0mm x 1.5-15mm.
Digital radiography systems use detectors that are much
smaller (typically 0.1-0.2mm on each side).
One reason CT detectors are so much larger is because the CT
signal must be very low noise in order to achieve the 20-bit gray scale depth
necessary for effective diagnosis.

34
 Because the crosstalk between adjacent detectors is related
to the angle of the incoming x-ray beam, some scanners are designed with
more narrow detectors at the isocenter of the x-ray beam where the
incoming x-ray photon arrive at near 90 degrees angles.
Additional techniques for decreasing detector crosstalk
include both pre- and post-patient collimation. The post-patient collimator
is a set of lead shields immediately in front of the detectors.
There are also innovative post-acquisition algorithms that
show promise of additional increases in resolution by correlating
information from overlapping sets of binned detectors.

HIGH VOLTAGE GENERATOR

The design constraints placed on the High voltage generator

are the same as those for x-ray tube. Approximately 50kW power is
necessary.

35
 CT SYSTEM COMPONENTS
Components of a Conventional x-ray unit are the following:

1. Operating Console/Control
Console

2. High Voltage Generator

3. X-ray Tube

While a CT Scanner has also Three (3) Major System Components:

1. GANTRY 2. COMPUTER SYSTEM 3. CONTROL CONSOLE

To complete this CT scanner, each of these Major components has several

Subsystems which are involved in their operation.

36
A. GANTRY

Is the framework that holds the x-ray tube

and radiation detection system. It is a
mechanism upon which both the x-ray
source and the detector/s are mounted.
The Source and Detector array are
mounted on opposite sides of the gantry
and maintain a fixed positional relationship so that they move
synchronously.

The center around which the gantry rotates is called the “axis
of rotation”. The gantry includes a 50-85cm (20”-34”) aperture for the
patient.
Obese patients who exceed the tabletop weight limits must
never be forced into the aperture. Most gantries can be angled up to 30
degrees to permit positioning for partial coronal images. This is especially
desirable in obtaining transverse scans perpendicular to the vertebral
column.
Positioning lights are usually mounted on the gantry as well.
Intense halogen lights and low-power red laser lights are used for
positioning. The body part of interest must be properly centered to the
aperture because the extreme edge of the scanning field produces a
severely degraded image.
There are often three positioning lights for accurate sagittal,
coronal and transverse centering.

37
The Subsystems of the Gantry includes:

A. X-ray Tube
B. Radiation Detector Array
C. High Voltage Generator
D. Patient Support Couch/Patient Couch
E. Mechanical Support

X-RAY TUBE
Unlike the x-ray tubes used for
taking intra-oral radiography, the CT x-ray
source (x-ray tube) must put out a
continuous stream of X-rays of a simple
pulse.

X-ray tube employed in CT systems

must also produce a thin, divergent,
fan-shaped x-ray beam and must have
the following special requirements:

1. The Anode Heating Capacity must

be at least 500,000 HU. Although some tubes designed specifically for
CT have 1.5 MHU capacities.
2. Some x-ray tubes operate at relatively low tube current (less than
100mA).
3. High speed rotors are employed in most, for best heat dissipation.

Just like any diagnostic x-ray,

x-ray tube must have the smallest possible
focal spot in order to avoid the penumbra
effect (the shadow behind an object lit by
an area light source). Focal spot size is also important in most designs even
though the scanner is not based in principle of direct geometric imaging.
CT scanners designed for high spatial resolution imaging incorporate x-ray
tubes with a small focal spot.

38
 Finally, the energy spectrum of the x-ray beam defines how
well the x-rays can penetrate the body, as well as their expected relative
attenuation as they pass through materials of different density.
Higher energy x-rays penetrate more effectively than lower-
energy ones, but are less sensitive to changes in material density and
composition. Lower energy x-rays are more prone to attenuation by soft
tissue, and since soft tissue is often the specific target of the CT scan, the
beam constraints a lot of low frequency x-ray photons.
On the other hand, Large Focal spot is used for high technique
studies of large anatomy.

X-ray tubes are energized (rouse into activity) differently

depending on the CT scanner design.

Example:

For Translate-Rotate units, the x-ray beam is “on” only during

the translate portion, and in this mode, tube currents up to 50mA are
employed.
While the Rotate-only scanners operate with either a
“continuous” or a “pulsed” x-ray beam.
The rapid exposures required to produce CT images produce
massive amounts of heat in the x-ray tube. Most CT X-ray tube difficulties
have revolved around attempts to solve this problem. The early scanners
used a stationary anode with a 2mm x 16mm focal spot operating at 120
kVp and 30mA which reduces image resolution significantly. However,
since the first generation images were usually displayed on an 80 x 80
matrix, the x-ray tube was not a problem in this system.
As the matrix size increased to 512 x 512, rotating anode
tubes with focal spot as small as 0.6mm x 1.2mm came into use. Small focal
spot scanners used a pulsed beam to reduce the heat load.
Modern pulsed scanner tubes operate at 120kVp, 1-5msec
pulses, and up to 140kVp to be selected, sometimes in alternate pulses, for
dual-energy scanning in which comparisons can be made between images at
different kVp values.

39
 In addition, 0.5 – 5.0 million heat units’ anodes of layered
alloys, cylindrical anodes and liquid-cooled and air-cooled tube housing
designs have been developed. A CT tube may produce 30 exposures per
examination. Because most CT units are scheduled for 10-20 examinations
per day, a tube may accumulate 10,000 exposures in a single month. It is
not unusual for a CT tube to fail after several months. Only a few last a full
year.
The radiation beam is double collimated; One at the tube exit
and again at the detector entrance. This collimator assists in eliminating
scatter information. Collimation is variable from 1mm to 13mm and is
usually controlled by the
software program. The
dimension of the collimation
width determines the voxel
length or section thicknesses.

DETECTOR ASSEMBLY
An electronic component of CT scanner that measures
remnant radiation exiting the patient and converting the radiation to an
analog signal proportionate to the radiation intensity measured.

Detector assembly is a
sensor that measures the
extent to which the x-ray
signal has been attenuated
by the object.
The individual detectors are arranged in a one-dimensional
line or arc instead of in a 2D array. The detector must be capable of
responding with extreme speed to a signal without lag, must quickly discard
the signal and prepare for the next.
They must also respond consistently and be small in size.
They are usually placed with a source-to-image receptor distance of 44
inches (110cm).

40
 CT Detectors should have high capture efficiency, high
absorption efficiency and high conversion efficiency. These three
parameters are called the “Detector Dose Efficiency”.

Capture Efficiency

+Absorption Efficiency

+Conversion Efficiency
DOSE EFFICIENCY

The Capture Efficiency is how well the detectors receive

photons from the patient and is controlled primarily by detector size and
the distance between detectors.
Absorption Efficiency is how well the detectors convert
incoming x-ray photons and is determined primarily by the materials used
(for example, the scintillation crystals or the gas) as well as the size and
thickness of the detector.
Conversion Efficiency is determined by how well the detector
converts the absorbed photon information to a digital signal for the
computer.

CT detectors should also have high stability, fast response time and wide
dynamic range.
Stability is controlled by how often the detectors must be
recalibrated to meet quality control standards.
Response Time is the speed with which the detector can react
to recognize an incoming photon and recover for the next input.
The Dynamic range is the ratio of the largest signal that can
be measured to the smallest.
Typical modern scanners are capable of dynamic ranges of
1,000,000 to 1.
The early CT scanners employ one detector, but modern CT
scanners uses multiple detectors in an array numbering up to 2,400, and has
Two General Classifications:
1. Scintillation Detector
2. Gas Detector

41
SCINTILLATION DETECTOR

Early Scintillation Detector arrays contained “Crystal

Photomultiplier Tube
Assembly”. These
detectors could not be
packed tightly together
since they require a
power supply for each
photomultiplier tube.
This system was used in Nuclear Medicine for many years
prior to the advent of CT. A
Sodium Iodide (NaI) crystal
absorbs an x-ray photon and
produces light flashes
(scintillations) in proportion to the
energy of the photon and at the
exact location where the photon struck within the crystal. The light is then
amplified (multiplied) by the Photomultiplier (PM) tube. The light photon
strikes the cathode of the PM tube where it is converted into electrons. The
electrons are then amplified by a series of dynodes as they move through
the tube. Each dynode has a higher voltage, thereby increasing the number
and voltage of the electrons as they move toward the anode. Upon striking
the anode, the electrons are converted into a digital signal which can be
processed by the computer. Although Sodium Iodide scintillation crystals
are nearly 100% efficient within the diagnostic x-ray range, they exhibit
phosphorescence afterglow or lag. This makes them useless with the rapid
sequential exposures in the later generation scanners.
Some units were produced using Calcium Fluoride (CaF2),
Bismuth Germanate (Bi4,Ge,O12), Cesium Iodide (CsI), Gadolinium
Ceramics, and Cadmium Tungstate (CdWO4) scintillation crystals, which,
although less efficient (90%) have minimal afterglow. These materials are
often bonded directly to the Photocathode.
A major disadvantage of Scintillation-PM detectors was their
size and interspace material, which prohibited packing them closer in the
detector array which reduces their total detection efficiency to less than
50%.

42
The earliest scanners used a “Sodium
Iodide Crystal” which was quickly replaced
by “Bismuth Germanate”. And the current
crystals of choice being used today are the
“Cesium Iodide and Cadmium Tungstate”.

The spacing of these

detectors varies from one design to another, but generally, one to four
detectors, or one to three detectors per degree are available.
The concentration of
scintillation detectors is an
important characteristic of a CT
scanner because it affects the
Spatial Resolution of the system.
The Scintillation Detector has
relatively high in “intrinsic detection efficiency”, and approximately 90% of
the x-ray incident on the detector will be absorbed and contribute to the
output signal.
This detector is not possible to pack just to have the space
between them become small; instead, the detector interspace may occupy
50% of the total area intercepting the x-ray beam.

GAS DETECTOR
Gas-filled detectors are also used in CT scanners. They are
constructed of a large metallic chamber
with baffles spaced only at approximately 1
to 1.5 millimeter intervals/apart. The
spacing determines the maximum detector
(and therefore display pixel size)
resolution.

These baffles are like grid strips which

divide the large chamber into many small
chambers, and each small chamber function as a separate radiation
detector.

43
 In Gas Detector, the entire detector array is hermitically (air-
tight) sealed and filled under pressure with a high atomic number inert gas
such as “Xenon” or Xenon-Krypton” mixture. Gas-filled detectors are less
efficient than Solid-State detectors. The problem can be partially overcome
by the following three ways:

• BY using xenon, the heaviest of the inert gas.

• BY compressing the xenon 20-30 atmospheres to increase its density.
• By using a long ion chamber to increase the number of atoms along the
path of the beam.

Disadvantage of Xenon Gas Detector

1. Low density of the absorbing material.

2. Absorption of x-rays by the front window which is needed to contain
the high pressure of gas.

If the Scintillation detector has high “intrinsic detection

efficiency”, the Gas detector has only about 45% intrinsic detection
efficiency.
Ionization of the gas in
each chamber is proportional to the
radiation incident on the chamber and is
detected in much same way as the ideal
gas-filled detector. However, the over-
all total detection efficiency is
approximately 45%.
Xenon Ionization Chamber operates on the same principle as
an ionization chamber. Essentially, they measure ionization in air by
attracting to an electrode the ions created by x-ray photons in the air.
The electrodes are alternately charged with positive and
negative voltages. The quantity of ionic charge at the electrode is
proportional to the energy of the photons detected between the electrodes.

44
 The detected energy
comprises a digital
signal that is sent to
the computer.
Although ion gas
detector efficiency
may be only 45%,
these detectors can
be packed extremely close in the detector array, permitting detection
efficiency of slightly less than 50% which is similar to that of Scintillation-PM
detectors.
Xenon detectors are highly
directional, in other words, they must be
set in a fixed position oriented to the x-
ray source. This is why Helical scanners
do not use xenon detectors.

45
TWO BASIC DESIGNS OF RADIATION DETECTORS USED IN TODAY’S
CT SCANNERS

1. Detectors rotate in conjunction

with the x-ray tube (x-ray source)

2. The tube (x-ray source) rotates within a

stationary array of detectors.

46
COLLIMATION

Collimation is also required during CT scanning for precisely

the same reason that is required in conventional radiography.

PURPOSE OF COLLIMATION IN CT SCANNERS:

1. Reduce patient dose by restricting the volume of tissue irradiated.
2. It enhances image quality by
limiting the volume of tissue
available to generate scatter
radiation.

In Conventional radiography, there is only one collimator in

which it is mounted on the tube housing, while in CT Scanning, there are
TWO collimators.

1. PRE-PATIENT COLLIMATOR
Is mounted on the tube
housing or adjacent to it. It has a contoured
aperture for emitting a generally rectangular
shaped x-ray fan-beam. It limits the area of
the patient that intercepts the useful beam
and thereby determines the slice thickness
and patient dose.
As its name implies, the Pre-
patient collimator is positioned between the
x-ray source and the patient.
Since x-ray photons emitted from the x-ray
tube comes a very wide range, the pre-
patient collimator restricts the x-ray flux (flow) applied to a narrow region as
it is applied to the patient.
For a Single slice CT, it is not only reduces dose to the patient,
it also defines the slice thickness of the imaging plane. For the Multislice
CT, the slice thickness is defined by the detector aperture instead of the
collimator. Because 99% of the x-ray photons emitted from the x-ray tube
are blocked by the pre-patient collimator, x-ray tube efficiency for CT is
poor.

47
 Because of geometric
limitations, the x-ray beam, after passing
through the pre-patient collimator, has
two regions:

1. Umbra
2. Penumbra

UMBRA – a dark area especially the blackest part of a shadow from

which all light is cut-off.

PENUMBRA – the partial or

imperfect shadow outside the
complete shadow of an opaque
body.

The x-ray flux is homogenous in the “umbra” region. The x-

ray source is not blocked by the collimator at any point inside this region;
the entire x-ray focal spot can be seen at any point inside the region.
The “Penumbra” is a non-homogenous region. The x-ray focal
spot is always partially blocked by the pre-patient collimator. Special
attention must be given to the design of the pre-patient collimator to
ensure a satisfactory slice sensitivity profile.

48
2. POST-PATIENT COLLIMATOR or PRE-DETECTOR COLLIMATOR

Typically two kinds of collimators are used; 1. In-plane and 2. cross-

plane.
The In-plane collimation (grid) is used by Third generation CT
scanners to reject scattered x-ray photons. This type of collimator is made
of many thin and highly attenuating plates. These plates are placed in front
of the detector, focusing on the x-ray source.
Since the path of the scattered
radiation generally deviates from the original
x-ray photon (primary photon) path, the plates
block the photons from entering the detector.
Cross-plane collimation is
employed by both third and fourth generation
scanners. For the Third generation scanner, it serves mainly as an additional
collimator to improve the slice sensitivity profile of the scanner. Because
of the geometric limitations, it is often difficult to design a pre-patient
collimator that provides very thin slice profile for the scanner.
To achieve this objective, additional collimation is employed
near the surface of the detector to further restrict the x-ray beam to a
narrow slice thickness. The disadvantage to this approach is the penalty to
the dose efficiency of the scanner because a portion of the x-ray photons
that pass through the patient is not used.
A post-patient cross-plane grid is sometimes used by the
fourth scanners to reject scatter radiation in a manner similar to the in-
plane collimation (grid) for the third generation scanner. Although the role
of fourth generation scanners is fading, the use of the grid is likely to be
employed by the third generation scanners.
As the volume coverage of the detector increases, the scatter-
to-primary ratio (the amount of scatter radiation compared to the primary
radiation) will increase.
Post-patient or Pre-detector collimator restricts the x-ray field
viewed by the detector array. It reduces the scatter radiation incident on
the detector, and when properly coupled with the pre-patient collimator, it
helps define the slice thickness but it do not influence patient dose.

49
FILTERS
The x-ray photons emitted
from the x-ray tube exhibit a wide
spectrum; many soft (low energy) x-
rays are present.

The low energy x-rays are most

absorbed by the patient and
contributes little to the detected signal.
Therefore it is necessary to remove these soft x-rays to reduce the dose to
the patient.
To achieve this objective, most CT manufacturers employ
additional x-ray filtration to improve the quality of the beam. The most
commonly used filters are the flat filter and bowtie filter.
The flat filter is typically made of copper or aluminum and is
placed between the x-ray source and the patient. This modifies the x-ray
spectrum uniformly across the entire field of view.
Observing the fact that a
cross-section of a patient is mostly oval-
shaped, some manufacturers employ a
bowtie filter to modify the intensity of the
x-ray beam inside the field of view to
further reduce dose to the patient.

HIGH VOLTAGE GENERATOR

All CT scanners operate on 3-phase
power generator in order to accommodate the
higher x-ray tube rotor speeds, and the
instantaneous power characteristics of pulsed
system.
Some manufacturers conserve space
by building the generator into the gantry or by
mounting it on the rotating wheel of the gantry so
that winding and unwinding a power cable is unnecessary.

50
PATIENT SUPPORT COUCH
The patient
couch is one of the more
important components of
the CT scanner. It supports
the patient comfortably,
and must be constructed of
a low atomic number (Z)
material so that it does not
interfere with x-ray beam
transmission and patient
imaging and to reduce attenuation of the x-ray beam.
The CT table may be
either flat or curved. It is usually
made of carbon graphite fiber to
decrease beam attenuation.
Because the top must
extend beyond the table to move
the patient into the gantry aperture,
it must be capable of supporting the
entire weight of the patient without sagging when fully extended.
Tabletops are rated for maximum weight and it is critical that
the radiographer must make sure that this weight is not exceeded.
Extensive damage to the table may results when attempts are
made to examine very large patients who exceed the tabletop weight limit.
The top is motor-driven to permit the patient to be moved the
exact desired distance between sections. Section intervals may be
controlled automatically by a program initiated at the control console.
The table must also be capable of vertical movement, both for
positioning within the aperture and for ease of patient transfer. Likewise the
patient couch should be capable of automatic indexing so that the operator
does not have to enter the examination room between each scan.

51
COMPUTER
The computer is a unique
subsystem of the CT scanner. It would
not be possible were it not for the ultra-
high speed digital computer. Large
capacity computer is required in order
that depending on image format; as
many as 30,000 equations must be solved simultaneously.

Most computers require a

special and controlled environment.
Consequently, many CT scan facilities
must have an adjacent room
dedicated to the computer.
So, most computers are
installed in a room separated from
other functions. The reason for this
separation is that, air conditioning
and power requirements for a computer are critical and must be optimized.
In a computer room, humidity must be maintained at less
than 30% relative and temperatures must be maintained below 20 degrees
Celsius. Higher temperature and humidity can contribute to computer
failure.
The computer performs a great number of complex
calculations to reconstruct the cross-sectional image of the object, and, as
the scan is produced, the Data Acquisition System (DAS), converts x-ray
attenuation measurements into digital signals that are sent to the
computer.
At the heart of the computer used in CT are the
“Microprocessor” and “Primary Memory”. These two determine the time
between the end of the scan and the appearance of an image, which is
called the “Reconstruction Time”. The efficiency of an examination is
greatly influenced by the reconstruction time, especially when a large
number of a slice are involved.

52
 Many CT scanners use an “Array Processor” instead of
microprocessor for image reconstruction. This array processor does many
calculations simultaneously. It is significantly faster than the
microprocessor, wherein an image is reconstructed in less than one second.
The CT computer is designed to control data acquisition,
processing, display and storage.
The CT console provides the radiographer with access to the
software program that controls data acquisition, processing and display.
Remote controls may also be linked to the system to permit display and
storage functions.
Control of data storage may be available at the control
console, remote workstations or at the storage units themselves.
A system program is used to start up the CT unit. This
program turns on and performs quality assurance checks on numerous
components in the x-ray equipment and computer hardware systems,
warms up the x-ray tube, etc. It also permits the radiographer to record
various problems that need the attention of the service engineer.
One of its main functions is to perform calibration checks on
the detectors, although this may be an ongoing process during scanning.
A diagnostic program with specific quality assurance tests is
used by service engineers to troubleshoot the system.
The CT console operates from a menu or index directory of operations. The
radiographer simply uses a keyboard, mouse trackball, or other input device
to indicate the desired operation.
At the beginning of each examination, patient information,
such as identification, history and the like is entered or input via a radiology
or hospital data system. This information permits retrieval of the images at
a later date and will also be displayed adjacent to each image.
The data acquisition program controls a variety of operations,
including tube and detector collimation (pixel size), matrix size, gantry
angle, tabletop entrance into the gantry aperture, section increment
movements of the tabletop, x-ray tube voltage and amperage, scan speed,
pitch, detector/resolution, and the direction of detector signals to the
digital image processing section of the computer.

53
EQUIPMENTS & METHODOLOGY
Major areas and equipments required for generating a CT
scan includes:

1. Examination Area
2. Operators Console
3. Computer Room
4. Diagnostic Viewing Console

EXAMINATION ROOM
The major components in the patient area are the patient
couch and gantry. The table and gantry should be positioned so that
the operator can see into the gantry to observe the patient when the
technologist is seated at the operator’s console.
It is often advisable to add mirrors or a TV system to help
observed the patient who is on far side of the gantry from the
operator’s console.
The gantry houses the x-
ray tube and detector system. And
the entire motion of the detector
and the x-ray tube occurs within the
housing of the gantry.
To obtain other than
perpendicular, cross-sectional
projections with respect to the
patient’s table, it is possible to tilt
most gantries before acquiring the data.

54
OPERATOR’S CONSOLE/CONTROL CONSOLE
Operator’s
console is a special area that
contains meters and controls
for selecting radiographic
technique factors and for
proper mechanical movement
of the gantry.
Many CT
scanners are equipped with two
consoles; one for CT radiographer to operate the unit and one for the
radiologist to view the image and manipulate its contrast, size and general
visual appearance.
The operator’s console contains many meters and controls for
selecting proper radiographic technique factors, for the gantry and patient
couch, and for computer commands that allow image reconstruction and
transfer.
The physician’s viewing console accepts the reconstructed
image from the operator’s console and displays for viewing and diagnosis.
A typical operator’s console contains controls and monitors
for the various technique factors. Operation is generally is excess of
100kVp. The usual mA station will be 100mA if the x-ray beam is continuous
and several hundreds mA if it is a pulsed beam. The scan time is often
selectable and varies from 1-5 seconds.
The thickness of the tissue slice to be imaged can also be
adjusted. Nominal thicknesses are 1-10 millimeters, but some units provide
slice thickness as small as 0.5mm for high resolution scanning. Slice
thickness is selected from the console by automatic collimator adjustment.
Controls are also provided for automatic movement and
indexing of the patient couch. This allows the operator to program for
contiguous slices, for intermittent slices or spiral scanning.
The operating console usually has two television monitors.
One is used by the operator to indicate patient data on the scan (hosp. i.d.,
name, patient number, age and gender), and to provide identification for
each scan (scan number, techniques and couch position).

55
 The second monitor is used by the operator to view the
resulting image before transferring it to either hard copy or to the
physician’s viewing console.
Once the patient has been positioned on the table and moved
into the gantry, the technologist controls the CT system from the operator’s
console.
Nowadays, many improvements of the operator’s console had
been made to simplify the commands for the technologist so that
understanding and complex computer terminology is minimized. This
simplification allows the technologist to focus most attention on the patient
and the diagnostic results.
Before the technologist can begin to scan, patient data must
be entered into the computer, the proper radiographic parameters must be
selected and the x-ray tube rotor must be initiated.
After the exposure for an individual slice has been completed,
the table is automatically indexed (moved) to the position for the next slice.
Today, most CT systems include the
capability that enables the technologist to
generate a “localizer image” of the patient
that is viewed at the operator’s viewing
console.

Through this localizer image, the technologist knows the

specific area being scanned because the system described exactly the
position of the table and the gantry. This image localizer is useful during
examination such as the spinal column.

56
IMAGE CHARACTERISTICS
To the human observer, the internal structures and functions
of the human body are not generally visible. However, by various
technologies, images can be created through which the medical professional
can look into the body to diagnose abnormal conditions and guide
therapeutic procedures. The medical image is a window to the body. No
image window reveals everything. Different medical imaging methods
reveal different characteristics of the human body.
With each method, the range of image quality and structure
visibility can be considerable, depending on characteristics of the imaging
equipment, skill of the operator, and compromises with factors such as
patient radiation exposure and imaging time.
The figure below is an overview of the medical imaging
process. The five major components are the patient, the imaging system,
the system operator, the image itself, and the observer, the objective is to
make an object or condition within the patient's body visible to the
observer.

The visibility of specific anatomical features depends on the

characteristics of the imaging system and the manner in which it is
operated. Most medical imaging systems have a considerable number of
variables that must be selected by the operator.

57
 They can be changeable system components, such as
intensifying screens in radiography, transducers in sonography, or coils in
magnetic resonance imaging (MRI). However, most variables are adjustable
physical quantities associated with the imaging process, such as kilovoltage
in Radiography, gain in Sonography, and echo time (TE) in MRI. The values
selected will determine the quality of the image and the visibility of specific
body features.
The image contained in CT scanning is
unlike that obtained in
conventional
radiography wherein
image is formed directly
on the radiation detector
such as films. With CT
scanners, the x-rays form a stored electronic image that is displayed as a
matrix of intensities.

IMAGE MATRIX
Matrix – is the number of pixels that are
used to display the image on the CRT. The
CT image that is viewed on the CRT is
actually made up of thousands of small
pixels (picture elements), or it is composed
of “matrix of pixels” where each pixel
represent a volume of tissue (voxel).

Image Matrix simply refers to a layout

of rows and columns usually of numbers, in
boxes or cells which is determined by the
characteristics of the imaging equipment
and by the capacity of the computer.

58
 The CT scan format
consists of many cells each assigned
a number and displayed as a density
or brightness level on the video
monitor.
The original image format
consists of an 80 x 80 matrix for a
total of 6,400 individual cells of information.
Each cell of information is “pixel” (picture element), and the
numeric information contained in each pixel is a “CT Number” or
“Hounsfield Unit” for image display purposes.
The “Pixel” is a two-dimensional representation of a corresponding tissue
volume, while the tissue volume is known as a “Voxel” (volume element).
The voxel is determined by multiplying the pixel size by the
thickness of the CT scan slice, or it is an individual pixel with the associated
volume of tissue based on slice thickness.
The diameter of the constructed image is
called the “Field of View”. When
the FOV is increased for a fixed matrix
size; for example a 512x512 matrix, the
size of each pixel is increased
proportionately.
When the matrix size is increased, for example from 512 x 512
to 1024 x 1024, pixel size is smaller.
“CT Pixel Size” is determined by dividing the FOV by the
Matrix size.

Example:
Compute the Pixel size for the following characteristics of a CT
scanner used for CT Brain.

A. Field of View of 20cm, 120 x 120 Matrix.

Note: 1 centimeter = 10 millimeters
200mm
=------------------------
120 Pixels
= 1.7mm/Pixel

59
B. Field of view of 20cm, 512x512 Matrix.

200mm
= --------------- = 0.4mm/pixel
512 pixels

C. Field of view is 36cm, 512x512 Matrix

360mm
= -------------- = 0.7mm/Pixel
512 Pixels

The VOXEL (volume element) is the basic element that defines

volume of tissue that each pixel represents in a reconstructed image. It is
the area of the pixel multiplied by the thickness of the slice.
The thickness of the slice is generally determined by the
examination being performed and may range from 1.0mm to 10mm in
thickness.
Although thinner slices generally provide better resolution, a
greater number of slices are required to examine a given area and the
radiation dose to the patient generally increases.
AGAIN, each imaginary cell of information is a “pixel”, and the
numeric information contained in each pixel is a “CT Number” or
“Hounsfield Unit” which is a measure of a structure density.

CT NUMBER
Is defined as a relative comparison of the x-ray attenuation of
each voxel of tissue with an equal volume of water.
It is an arbitrary number assigned by computer to indicate
relative density of a given tissue which is expressed in “Hounsfield Unit”
(HU) where the units range from -1000 to +1000 for each pixel.
CT number value is calculated from the attenuation coefficient value for
each voxel and becomes the value for the corresponding pixel in the digital
image.
Water (H2O) is used as the reference and calibration material
for CT numbers. Water has the assigned CT number value of zero. Tissues
or other substances that are more dense than water will have positive (+)
values and those that are less dense will have negative (-) values.

60
A CT Number of -1000 corresponds to air
CT Number of +1000 to a dense
bone
CT Number of “0” indicates water
Muscle is 50 HU
White Matter is 45 HU
Gray Matter is 40 HU
Blood is 20 HU
CSF is 15 HU
Fat is -100
Lung is -200

61
 CT image quality characteristic is visibility. That is the visibility
of anatomical structures, various tissues, and signs of pathology. However,
visibility depends on a somewhat complex combination of the five (5) more
specific image characteristics:

1. Contrast Sensitivity
2. Visibility of Detail (as affected by blurring) sometimes called “spatial
resolution”.
3. Visual (Image) Noise
4. Artifacts
5. Spatial or Geometric characteristic of image

All of the image characteristics are important and have a

potential effect on visibility but the characteristic, contrast sensitivity, is
especially significant in CT because it is what makes it a superior imaging
modality for many clinical procedures. The concept of contrast
sensitivity is illustrated here. Contrast sensitivity is a characteristic of
the imaging process. That is the capabilities of the imaging equipment
(CT scanner) and how it is adjusted. Contrast sensitivity controls the
conversion of the physical contrast within the body to the visible
contrast in an image.

62
CONTRAST SENSITIVITY

With CT imaging
the principle source of physical
contrast within a body are the
differences in physical density
among the tissues. An
exception is when an iodine-
based contrast medium is used where it becomes more of an atomic
number (Z) effect.
Compared to other x-ray imaging modalities CT has a very
high contrast sensitivity for "seeing" the soft tissues and differences among
the tissues in the body. Within a
body there will be tissues and
objects with a range of densities
and physical contrast. As
illustrated here things like bones,
bullets, and barium have a very
high physical contrast relative to
the soft tissues. Imaging them is
not a problem. The real challenge is imaging the very low density
differences between and among the soft tissues. That is where CT excels!
Contrast sensitivity determines the range of visibility with respect to
physical contrast. If a procedure has low contrast sensitivity then only
objects with high physical contrast will be visible.
When a procedure, such as CT, has high contrast sensitivity
then tissues with small differences in density will be visualized. If the
contrast sensitivity is low, either because of limitations of the specific
imaging modality or the adjustments of the imaging protocol factors then
tissues that have small differences in density (physical contrast) will not be
visible.

63
 Contrast is the degree of difference between two substances
in some parameters that depend on the technique used. The ability to
distinguish material of one composition from another without regard for
size or shape is called “Contrast Resolution”.
In CT scanning, the amount of radiation penetrating the
patient is determined also by the “mass density” of the body part.
Consider the situation of “Fat-Muscle-Bone” structure. In this three
structures, not only are the atomic numbers are different, but the mass
densities also are different. Although these differences are measurable,
they are not imaged well in conventional radiography.
The CT image is able to amplify these differences between the
atomic numbers of the structure and the mass density. The amplified
differences in subject contrast results in a “High-Contrast Resolution”. The
contrast resolution provided by CT scanners is considerably better than that
available in conventional radiography principally because of the scatter
radiation rejection of the fan-beam collimator.
The ability to image low-contrast objects with a CT scanner is
limited by the size and uniformity of the object and by the Noise of the CT
system. While the ability of the CT scanner to demonstrate different tissue
density is “Contrast Resolution”.

VISIBILITY OF DETAIL
A characteristic of all imaging methods, including human
vision, is that there is some blurring that occurs within the process. The
effect of this blurring is that it reduces visibility of detail (small objects and
features). When we have blurred vision we can't read the fine print. Each
medical imaging method has inherent sources of blurring that limits visibility
of detail and determines the types of diagnostic procedures it can be used
for. For example, radiography which has relatively low blur and provides
high visibility of detail is used for visualizing small bone fractures.

64
 The general relationship
of detail to the blurring
within the imaging
process is illustrated
here. As the blurring
increases more and
more of the small
objects become
invisible.
In the CT imaging
process there are several sources of blurring that collectively limit visibility
of detail.
There are adjustable protocol factors associated with each of
these sources of blur as we will soon see. Now that brings up and
interesting question, If we can adjust the blurring why not set it to a low
value and get very high visibility of detail? The problem is when we reduce
the blurring it increases another undesirable image characteristic, visual
noise, and can also lead to increased radiation dose to the patient. That is
why we must have optimized imaging protocols that take all of these factors
into account and provide a proper balance.
SPATIAL RESOLUTION is the ability of CT scanner to
demonstrate small objects within the body plane being scanned. In Spatial
resolution, the larger the pixel size and the lower the subject contrast, the
poorer will be the spatial resolution.
The design of the Pre-patient and Pre-detector collimation
will affect also the level of scatter radiation and influencing spatial
resolution by affecting the contrast of the system.
The ability of the CT scanner to reproduce with accuracy a
high-contrast edge is expressed mathematically as the “Edge Response
Function” (ERF). The measured edge response function can be transformed
into another mathematical expression called the “Modulation Transfer
Function” (MTF). The MTF and its graphic representation are most cited to
express the Spatial Resolution of a CT scanner.

65
VISUAL or IMAGE NOISE
All
medical imaging
methods produce
images with some
visual noise. This is
generally an
undesirable
characteristic that
reduces visibility of
certain types of objects and structures as illustrated here.
Specifically, noise reduces the visibility of low-contrast
objects. This is especially significant in CT which is often used to image low-
contrast differences among tissues. Let's take a moment to distinguish
between noise and blurring. Both are characteristics that reduce visibility,
but of different types of objects. Noise reduces visibility of low-contrast
objects, blurring reduces visibility of small objects or detail.
The noise in a CT image can be adjusted with a combination of
protocol factors. So, why don't we adjust it to a low value and have great
visibility? The challenge is that the factors that can be used to adjust and
reduce noise also have an effect on either image detail (blurring) or
radiation dose to the patient. That is why we must have optimized imaging
protocols that take all of these factors into account and provide a proper
balance.

SPATIAL & GEOMETRIC CHARACTERISTICS

The spatial and geometric
characteristics of a CT
image play a major role in
optimizing the imaging
protocols. That is because
the CT image is made up of
many small elements or
Voxels as illustrated here.

66
 The typical CT image is of a slice through the body. During the
image reconstruction phase the slice is divided into a matrix of Voxels. It is
the size of the Voxels that has a major impact on image blurring, noise, and
on radiation dose to the patient.

SYSTEM NOISE
Unlike screen-film radiographs, images acquired with
computed tomography (CT) never look overexposed in the sense of being
too dark or too light. The normalization of CT data to represent a fixed
amount of attenuation relative to that of water ensures that the image
always appears properly exposed. Thus, CT users have not been compelled
to decrease the tube current–time product or the peak kilovoltage for
scanning in small patients, and, as a result, such patients often were
exposed to an excessive radiation dose.
In addition, image quality changes noticeably (specifically, with
regard to the amount of noise or graininess) according to the patient’s body
habitus. For scanning in large patients, the dose must be increased to obtain
diagnostic-quality images. Thus, there has been a tendency to increase the
tube current–time product (patient dose) to avoid excessive noise on
images, particularly for large patients and at thin-section CT, which is more
readily available with the newer generations of scanners.
As the growth in CT utilization increased, particularly in
pediatric patients, and as concern about the population dose from CT began
to be expressed in the scientific literature and lay press, it became clear that
the responsible use of CT required an adjustment of technique factors on
the basis of patient size (attenuation characteristics).
In response to these concerns, the radiology community
(radiologists, medical physicists, and manufacturers) implemented CT dose
management procedures that correspond to the principle of ALARA (as low
as reasonably achievable). The guiding principle in selecting the right dose
for a CT examination is that the specific patient attenuation and the specific
diagnostic task must be taken into account. For large patients, a dose that
is higher than that for small patients is consistent with the ALARA principle.

67
 In a CT scanner, if one images a uniform material (e.g., a
water bath) and looks at the CT-numbers for a localized region, one would
find that the CT-numbers are not all the same, but that they vary around
some average or mean value. This variation is called the noise of the system.
Noise is a very important measure of CT scanner performance since the
naturally occurring difference in attenuation coefficient between normal
and pathological tissues is small. CT numbers above or below the average
value is the Noise of the system. Noise of a CT scanner can be measured by
scanning a uniform water phantom.
This should be done for all potential modes (subject size, kVp,
and scan diameters/pixel widths) of clinical use. The noise should be
indicated by the standard deviation (computed from for a sufficient number
of pixels (e.g. 25 or more). Noise should be examined for both central and
peripheral regions of a scan.
System Noise should be evaluated daily by scanning a 20cm diameter water
bath. All scanners have the ability to identify a region of interest (ROI) and
compute the mean and standard deviation of CT Numbers in that ROI.
When the CT radiographer measures Noise, the ROI must
encompass at least 100 pixels. Such noise measurements should include
five determinations --- four on the periphery and one in the center to
monitor the spatial uniformity.

SYSTEM NOISE DEPENDS ON MANY FACTORS OF OPERATIONS:

1. kVp and Filtration

2. Pixel Size
3. Slice Thickness
4. Detector Efficiency
5. Patient Dose – which is the number of x-rays used by the detector to
produce the image that controls noise.
Noise is manifested on the final image by apparent graininess,
where low noise systems appear spotty or blotchy.

68
 Even though the most common display of the results of a CT
scan is a gray level picture which is interpreted for clinical results end
photographed for storage, the fundamental measurement of CT-scanners is
narrow beam transmission resulting in a cross sectional reconstruction of
numbers presumably related to the x-ray linear attenuation coefficient, μ.
The linear attenuation coefficient depends upon (1) physical density
(grams/cm3), (2) atomic composition, and (3) photon energy.
Most CT scanners utilize a polychromatic x-ray source and
provide numbers related to an x-ray linear attenuation coefficient which has
been averaged over the various energies in the photon spectrum being
detected. Because of this, CT numbers relative to water may depend on
the size of the object being scanned and other physical properties of the
object.
Since the number scale in any given CT scanner is arbitrary,
one must determine the contrast scale (that is, the change in linear
attenuation coefficient per CT-number) in order to reduce the CT-number
standard deviation to a machine independent basis.

Linearity
It is also of interest to establish whether CT-numbers vary in a
linear fashion with the linear attenuation coefficients of the material
studied. The verification of linearity is of interest because it establishes the
constancy of contrast scale over the range of CT-numbers of clinical interest.
Obviously, one must have the means of varying the linear x-
ray attenuation by amounts adequate to give a reasonable difference in CT-
numbers. Linearity is the consistent representation of CT Numbers.

Example: Water must be zero and other tissues by their

appropriate CT values.
To check the Linearity, CT Number must be frequently
calibrated. A check calibration that can be made daily requires scanning
material of known CT Numbers. Any deviation from “Linearity” is an
indication of misalignment of malfunction of the scanner. A minor deviation
would result in inaccurate CT number generation, but would probably not
significantly affect the visual/image noise. Such a minor deviation could
affect quantitative CT analysis of tissue.

69
70
71
ARTIFACTS
An artifact is
generally something that
appears in an image that is not
a direct visualization of an
object or structure in the
body. There are quite a few
possible artifacts coming from
a variety of conditions that
can occur during an imaging
procedure. Some are very
obvious such as streaks and "ghosts" while others are less visible but more
in the form of changes in how certain areas or objects are displayed.
With the advances in CT technology many artifacts are less
common. The most effective approach to learning CT artifacts is through
their observation and analysis while viewing clinical images.

SOURCES OF ARTIFACTS

Artifact – is everything that does not conform to the idealized image. It is a

distortion or error in image that is unrelated to the subject being studied.

1. Patient

* moving
* breathing
* metals
* concentrated Gastrografin (contrast media)
* presence of barium sulfate
* orthopedic plates & screws

2. Machine

* ring artifacts

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74
75
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79
QUALITY ASSURANCE IN CT SYSTEM
History of CT and Evolution of Spiral Scanners

The term tomography stems from the Greek word "tomos"

meaning "section“. Scientists and mathematicians have described, "body
section radiography" in many different ways since the 1920's. It wasn't until
the 1960's after much research, that the world's first CT scanner emerged.
The inventor was Godfrey Newbold Hounsfield, born in England 1919. He
and Alan Cormack, a medical physicist, together developed and placed the
first brain scanner into operation in 1971 for a company called EMI Ltd. In
1979, they were awarded the Nobel Prize in medicine and physiology.
Initially data acquisition in CT scanning was very slow. The
first experimental brain scan in 1967 took 9 days. By 1971 they had reduced
the scan time to 20 minutes. In 1989, the helical (spiral) concept was
considered one of the most significant developments in CT. This
development meant continuous rotation of the x-ray tube without reversal
between images. The new continuous motion was given the name "slip-
ring" technology, and it reduced brain scan times to as low as 0.8 seconds.
As technology continues to develop with multi-slice systems, times are
getting even shorter (0.4 sec.).
Data from spiral or helical scanners is often referred to as
"volumes" of tissue rather than individual cross-sectional slices. These
images are "overlapped" and do not have a gap in between them. This
allows complete coverage with no "missed" areas of tissue. This modern
equipment has allowed more rapid image production for trauma and
pediatric patients; however, they can sometimes deliver a higher dose of
ionizing radiation.
Since Hounsfield's first operational scanner in 1971 to today's
modern "multi-slice" spiral scanning devices, a lot of progress has been
made to improve image quality and most importantly, to decrease patient
ionizing radiation dosage. With this evolution of technology has come the
need for more comprehensive quality assurance programs, new phantoms
specific to spiral CT, and higher standard safety guidelines. Not only are
specific tests conducted to maintain equipment operation at an acceptable
level, but these programs are also designed to recognize and create a
corrective action for quality assurance issues.

80
 The development of faster scan times has also created some
drawbacks such as: the need for x-ray tubes with higher heat ratings; more
powerful generators to sustain added heat volumes; and, increased image
noise consistent with the rapid reconstruction of images. This "image noise"
can cause an artifact known as the venetian blind artifact. This occurs with
multi-slice scanners and appears as bright and dark bands superimposed on
three dimensional images.
Another drawback from helical scanners is the notable
difference in low contrast resolution. This problem has created the need for
additional test tools and more suitable phantoms for spiral and multi-slice
scanners. Even after a close review; the benefits of spiral scanners definitely
still outweigh the drawbacks.
Although Preventive Maintenance is generally performed by
the vendor, the technologist should be routinely involved in scanning
phantoms and performing other tests to ensure that the scanner is
operating properly. Quality Assurance on CT scanners is subject to all the
misalignment, miscalibration and malfunctioning difficulties.
CT scanners have the additional complexities of multi-
motional gantry, the interactive console and the associated computer. Each
of these subsystems allows more possibilities for drift and instability,
resulting in degradation of image quality. For this reason, a Quality
Assurance Program is essential for each scanner. Such programs include
daily, weekly, monthly and annual measurement and observations in
addition to the on-going preventive maintenance.

Phantoms and Required Test Tools for Spiral CT Scanners

The International Commission on Radiation Units &
Measurements (ICRU) defines tissue substitutes and phantoms as the
following: tissue substitute - any material that simulates body tissue
interaction with ionizing radiation; and, phantom - any structure that
contains tissue substitutes, at least one, which can simulate radiation
interactions in the human body.
There are two categories of phantoms:
calibration phantoms and imaging phantoms.
Calibration phantoms are for testing detectors and
correcting quantitative information obtained from
digital images. Imaging phantoms assess image quality and are usually further
classified as head, body, standard, or reference phantoms.

81
 This photograph of a CT
phantom used to perform
quality assurance testing.
Phantoms are made of Plexiglas,
which has a density of 120
Hounsfield units. The black
holder is also used to perform
fine alignments of the phantom
in the gantry and to the
localizing laser lights. There are several types of phantoms, for example, one
type may be used for head dose calculations, and another for body dose
calculations. Different manufacturers will recommend testing their
equipment with specific phantoms. All phantoms must meet performance
standards set by the Food and Drug Administration (FDA).

Quality assurance for the spiral CT scanner consists of these

basic required elements of testing: contrast scale and mean (standard
deviation), CT number for water, high-contrast resolution, low contrast
resolution, laser light alignment and accuracy, image noise, uniformity and
artifacts; slice thickness and localization, and patient dose. There is a wide
array of tests that may be performed as well as test tools that can be used.
The facility's quality assurance manager or medical physicist generally
decides this. The selection of these tests should be based upon the type of
equipment and the frequency in which the equipment is to be utilized. This
will usually limit some of the more complex tests to an annual survey.
A good QA program will provide regular testing, prompt
interpretation of test data, and faithful record keeping. A current logbook
or computer file should be readily available for viewing by any regulatory
agency in the event of an unscheduled inspection. In addition to the
following tests, daily visual checks should be done on table/gantry
movement, cables, cords, operating console, controls, and print system if
installed. These visual tests should be documented as well, for future
comparison.

82
Acceptance testing includes the following baseline type tests:

*Light alignment
*Slice thickness
*Noise
*Contrast resolution
*Heat Unit linearity
*Uniformity
*Spatial resolution
*Patient dose

Basic Quality Assurance Tests

Test 1 - CT number for water (average & standard deviation)

Computed tomography involves complex processing of digital

data using mathematical principles called reconstruction algorithms. Scan
data is based on penetration and attenuation measurements of photons as
they traverse matter. This raw data must then be converted to digital data
and displayed as a CT image. Each pixel in the image is assigned a number
collectively referred to as a CT number. CT numbers are referred to as
Hounsfield Unit (HU) named after the inventor of computed tomography.
The Hounsfield scale (H scale) is a calculation from the linear
attenuation coefficients of tissues that make up an image slice. CT numbers
are relative to the attenuation of water, which is assigned a value of 0 HU.
Using water as the reference the maximum brightness of a pixel is -1000 HU
and will appear white on the CT image. The opposite end of the H scale is
maximum darkness, which is +1000 HU and the image will be black.
Between these extremes are various shades of gray that make a diagnostic
CT image. Therefore, when we check the CT number for water we are
effectively checking the reconstruction algorithm that computes CT
numbers across the image.

83
 This chart shows the
various CT numbers
(Hounsfield units)
calculated for various
tissues and substances
based on the density of
water. Notice that at the
extremes is bone (+1000
HU) and air (-1000 HU).
Water has a CT number
of zero, which is used to
test for the function of
the algorithm that
calculates CT numbers.

To perform the CT number test a water phantom test tool is

used. The phantom is a water-filled cylinder with a 20cm diameter for head
technique calibration, or 32 cm diameter for body simulated calibration.
Scan with usual technique for the body part represented by the phantom
type. A 20 cm diameter phantom and head technique is most frequently
used. Select a ROI (region of interest) of about 2-3 cm or containing about
200-300 pixels and measure the average CT number. Air measures -1000
HU; water should be close to 0 (zero). Water should not exceed +/-3 HU at
the center of the image, and no more than +/- 5 HU from center to
periphery. If the CT number in the center of the image is not within 3 HU the
scanner fails this test.
Recalibrate and retest if not within limits. Keep in mind that
although the CT number for water is measured daily there are two media
used in calibration, these are water and air. At least once a month a ROI
outside the phantom image in a region representing air is taken. This
reading should measure -1000 HU, +/- 5 HU.
This reading is to check contrast since water is zero and air
measures –1000 HU. When the algorithm that calculates CT numbers is
accurate, water is within +/- 3 HU of zero, and air is within +/- 5 HU of –1000
HU.

84
 The CT number for water- (average & standard deviation) test
is done to ensure equipment manufacturer specifications for CT number,
field uniformity, and noise. The test for CT number of water is done daily.
Possible causes for the CT number of water to be out of range is
miscalibration of the algorithm generating CT numbers.
This is a type of problem that needs immediate attention of
the biomedical engineer or radiation safety officer. When the CT number for
water and air fail the recommended range it must be immediately corrected
to insure accuracy of the displayed CT image. If the CT number fluxuates
significantly, but remains within the acceptable range, this too should be
brought to the attention of the radiation safety officer.

CT Number for Water

• Water filled plastic cylinder (20 cm diameter)

• Take scan, reconstruct image, place ROI 200-300 pixels in center of field
and take measurement.
* Expected results: CT number of water equal to zero, but range of +/- 3 at
center of image is acceptable, and +/- 5 HU at peripheral locations.
* Cause of failure is usually miscalibration of the algorithm that generates
CT numbers.
• CT number test is Performed Daily.
• Test an area outside the image representing air for CT number of air,
monthly. The acceptable range is -1000 HU, +/-5 HU.
The water phantom test images shown here demonstrate a
clear uniform field free of artifacts. The image on the right shows a ROI
placed in the center
of the image to
measure the CT
number for water.
In this example the
ROI measured 0.07
HU with a standard
deviation of 3.33 HU. This measurement is within acceptable
performance guidelines of the manufacturer. This is a simple test that
confirms the proper functioning of algorithms that calculate CT numbers
and provides a quick check of the field for artifacts.

85
Test 2 - Noise and Field Uniformity

When we think of image noise in traditional radiographic

imaging using screen-film imaging we are referring to the overall graininess
of the image. CT is a type of digital imaging processing in which image noise
can be caused by a variety of factors. Noise in CT is mainly related to the
following: (1) number of detected photons; (2) matrix size (pixel size); (3)
slice thickness; (4) algorithm; (5) electronic noise (detector electronics); (6)
scattered radiation; and (7) object size.
Noise limits low contrast resolution and may hide anatomy
similar to surrounding tissue. Most pathology imaged in CT is seen in soft
tissues such as the lungs, kidney, liver, and brain. To test for image noise a
simple cylinder or container of about 20 cm. in diameter is used. The
phantom used to calculate the CT number for water and air is used for the
noise uniformity test.
The phantom is scanned at different slice thicknesses, and
gradual increases in mAs. Measure an ROI of about 200-300 pixels and find
the standard deviation of the CT number at the center of each image. The
image field is sampled along the periphery as well as in the center of the
image. There should be uniformity in the CT numbers throughout the image.
The noise level can be stated as a percentage of image contrast in CT
numbers. The stand deviation for noise should be +/- 3. Since CT numbers
range from +/-1000 HU, noise is less than 0.3%. The maximum standard
deviation between the center ROI and any peripheral ROI is less than +/- 5
HU.
The result should show the noise in the image being directly
proportional to the standard deviation of the CT number of water. The
number should decrease as the slice width and mAs are increased.
Increased noise can be a result of poor beam/detector alignment, reduced
detector sensitivity, or reduced output from the tube.1, 2 be sure that the
noise levels produced by the equipment do not increase with age.
A higher noise level will result in a lower dose to the patient
and lower noise level results in a higher dose. There must be a balance
between the two to maintain quality images and low doses. Out of range CT
numbers for standard deviation could be caused by decreased dose or
increased electronic noise.

86
 Standard deviation describes the difference between the
lowest ROI value and the maximum ROI value. Testing is performed daily
with the CT number for water and also upon acceptance of new equipment.

These two CT images taken of a water phantom show an ROI

in the center and periphery of the field to measure field uniformity. The
same locations for measuring should be used each day. The image on the
right shows a grid that has been inserted on the image to help with
consistent daily placement of the ROI's. The image on the left shows the
ROI's without the grid. The center ROI measured 0.25 HU and the four ROI's
in the periphery measured within the acceptable < +/- 5 HU of center
measurement. Comparing peripheral field HU's is necessary since
attenuation of x-rays by different body tissues when displayed in different
parts of the image field must be accurate.
Region of interest selected from the scanners monitor is also
capable of measuring the standard deviation within the ROI. Keep in mind
that the standard deviation is dependent on several factors including kVp,
mA, scan time, slice thickness, phantom size, and ROI position. This is why
the technical factors used to measure HU for phantom tests must be
standardized so that they are constant each day.
Likewise, when measuring field uniformity it is important not
to place peripheral ROI's too close to the edges of the image since at this
location standard deviation is lower than towards the center. Ideally, the
standard deviation should be small; however, more importantly it should be
compared to the latest service record standard. It should not vary by much
from day to day and an increasing pattern should be brought to the
attention of the service department.

87
 An increase in the standard deviation indicates the image is
becoming "noisier." Possible causes include decrease in tube output,
increased detector, amplifier(s), analog-to-digital converter, or other issues.

Test 3 - High-Contrast (Spatial) Resolution

Spatial resolution is important in detecting the edges of

structures, margins of tumors, small foreign bodies, and small bony
structures. This test measures spatial resolution by measuring the high-
resolution pattern in a phantom image. This test measures how the scanner
distinguishes between two high contrast objects placed close together, and
how small an object that can be visualized.
Resolution phantoms come in a variety of test patterns.
Generally, the test tool will have a bar pattern or series of holes cut in the
Plexiglas within the phantom. Generally, each bar patter contains a set of 5
holes or bars and spaces of constant equal dimension. Each block decreases
in size from one pattern to another. Measurements are taken of the depths
of different drilled holes usually into an acrylic or hard resin-like substance.
The holes may be filled with air giving 100% contrast or water giving 12 to
20% contrast.
All holes or bars should be seen on the scan image; however,
we are only interested in the smallest row in which all five bars and spaces
can be clearly seen. The resolution block contains the following bar sizes
1.6mm, 1.3mm, 1.0mm, 0.6mm, and 0.5mm. The smallest the row clearly
seen indicates better performance of the scanner and image quality.
Expected result is that complete set of bars or holes and accompanying
spaces will be in the range of 0.75 to 1.0 mm. All modern scanners should
have a resolution of 0.5% contrast for 5mm. The minimum size of the holes
visualized should not increase over the life of the equipment.
High-contrast resolution tests should be performed upon
acceptance of equipment and monthly. Baseline is established at
acceptance or referenced to manufacturer's specifications. Test failure is
related to an enlarging x-ray tube focal spot, poor registration, detector
failures, mechanical misalignments, mechanical wear and so forth. In any
case the biomedical engineer should be notified if resolution degrades from
baseline measurement.

88
 The
photograph
on the left
is of a
phantom
designed
for multiple
QA testing.
The yellow
arrow
points to the bar pattern in the phantom that is used to measure scanner
high-resolution. The resulting image is seen on the right. Notice the bar
pattern is filled with air giving 100% contrast. The smallest row of bars is
recorded and compared to baseline value in this test. Expected result is that
a complete set of bars or holes in some rows in the range of 0.75 to 1.0 mm
or 0.5% contrast for 5 mm for modern CT scanners.
As we have discussed, spatial resolution is a measure of detail
resolution. Sometimes it is practical to evaluate the spread of information
within the CT system. To do this we look at what is known as the
modulation transfer function (MTF). The MTF is the most common method
of describing spatial resolution in CT, digital radiography, and film-screen
radiography systems. The MTF analysis allows us to compare system
performance on a day-to-day basis, or to compare a system's performance
against another CT system.
Modulation transfer function is expressed in line pairs per
centimeter (lp/cm). When counting a line pair, one line and its adjacent
space are called a line pair. To measure MTF directly a line pair phantom is
imaged and the number of line pairs is counted. If 5 line pairs are counted,
the spatial resolution is reported as 5 lp/cm. If 10, 15, or 20 line pairs are
seen, the spatial resolution is reported as 10 lp/cm, 15 lp/cm or 20 lp/cm
respectively. The number of line pairs seen in a given length is known as the
spatial frequency.
Because CT scanners are not created equally, how well a given
scanner displays an object is also a function of the size of that object and
the spatial resolution of the scanner. An object's size in a given length is also
known as its' spatial frequency.

89
 What this means is that how frequently an object fits into a
given space is it spatial frequency. Generally speaking, the smaller an object
is the higher spatial frequency and the more difficult it is to be displayed
accurately.
Likewise, a large object will have low spatial frequency and
will be more accurately displayed. If an object is displayed accurately as it is,
then the MFT is given a value of 1.0. The modulation transfer function scale
is from zero to 1. A MTF value of 0 would mean the image is blank and
contains no information about the object scanned. Scanned objects will
have values between 0 and 1; however, the closer to 1 an object is the
better the MTF of the scanner.

This picture
demonstrates
how object
size is related
to their
spatial
frequency.
Small objects
have low
spatial frequency since more of them fit into a prescribed length. Large
objects have high spatial frequency since they fit fewer times into a given
length.
In practical terms, the information needed during quality
assurance testing or when comparing CT scanners for purchase appear in
graph form called MTF graphs. Modular transfer function is plotted along
the y-axis and object spatial frequency along the x-axis. When comparing
the function of a scanner over time, or when comparing the performance of
different scanners, we look at what is called limiting resolution. Limiting
resolution is the spatial frequency at MTF of 0.1 for any scanner. MTF of 0.1
is referenced because it is the lowest MTF that will result in a visible CT
image. A scanner with a higher spatial frequency will be able to image small
objects.

90
 This graph of MTF and
spatial frequency for
three scanners is
shown. At limiting
resolution (0.1 MTF)
scanner "A" have a
spatial frequency of
11.5 lp/cm. Scanner
"B" at a MTF of 0.1
gives a spatial frequency of 17.0, and scanner "C" the spatial frequency is
20.0. Interpretation of the graph implies that scanner "C" is better able to
display small objects than scanners "B or C".

Test 4 - Low Contrast Resolution/Detectability

Purpose of this test is to determine the ability of the scanner

to discriminate low contrast objects. Keep in mind that most relevant detail
in the human body is made of soft tissue, and is low contrast. Arguably, this
is perhaps the most important quality control performance test. This test
measures the scanners ability to detect objects that vary only slightly from
its background. This is especially important when trying to detect low-
density tumors that lie in soft tissues.
The most common areas where this is important are the
brain, kidney, and liver. Often intravenous or oral contrast media is used to
increase density difference that can be detected by x-ray. In other words,
contrast agents increase the sensitivity of low contrast resolution. The
visibility of low contrast objects is constrained mainly by amplitude and
frequency characteristics of the image noise.
Subject contrast is a product of both high and low contrast
within and surrounding a structure. Subject contrast in a CT image is in
simple terms the difference in average CT numbers between two adjacent
regions of the image. So we must be assured that low-contrast resolution is
accurate and there is accuracy in the display of high-contrast image
resolution. Low contrast sensitivity is where CT excels over conventional
radiography.

91
 CT can resolve small differences in tissue densities because
there must be at least a 10% density difference to be detected with
conventional x-ray imaging. This is why we use a 15% increase or decrease
in the kVp to change the scale of contrast in conventional radiography. CT
on the other hand is able to resolve density differences as little as 0.1%.
Notwithstanding, the size of a low contrast object, its inherent density
(calcium vs. fat), image noise, and viewing window setting will in part
determine its detectability.
To perform this test various types of low-contrast inserts are
available for the CT phantom: therefore, scanning for this test is
manufacturer specific. Our low contrast detectability test phantom image is
defined by the smallest hole size visible for a given contrast level and dose.
The phantom contains a doped polystyrene membrane suspended in water.
The membrane is pierced with holes ranging from 10.0mm, 7.5mm, 5.0mm,
3.0mm and 1.0mm.
The basic of this test is that the number of object visualized
on the phantom image is determined, and the mean value of each visualized
hole and surrounding material is recorded. The smallest holes that should
be visualized is 5 mm in diameter or smaller for 5% contrast objects.

This low
contrast
detectability
phantom
image
displays
various sized
holes used to
determine
low contrast (left). The various sizes are labeled on the right image;
however, it is difficult to see the smallest holes. This test measures the
scanners ability to detect an objects density when it is close to background
density.

92
 Low-resolution contrast is determined as the difference in HU
of objects and background. High noise in the image will cause a decrease in
low-contrast resolution. To get an accurate measure of low contrast we
need to know the CT number for the polystyrene membrane. This is
accomplished by taking the CT number for water over an area that does not
include the membrane. A second measurement is taken over an area that
includes the membrane superimposed on water (called water plus the
membrane). The CT number taken for water is subtracted from the water
plus membrane to get the CT number for the membrane.
To perform this test, measure using a box ROI above and
below the membrane in the water section (labeled A and B in the phantom
image below). Take a box ROI in the polystyrene membrane above the holes
(labeled B) and below the holes (labeled C). Subtract "A" from "B" and
subtract "D" from "C". When the measurements are completed and
recorded adjust the Window Width to 20 and the Window Level to the CT
number recorded for water. This will allow for an accurate reading of the
number of holes visible.

This CT phantom image shows

boxed ROI's placed over the
polystyrene membrane and over
water when calculating low contrast
detectability. The membrane shown
by yellow arrow contains spaced
holes of different densities. There
are various types of low contrast
testing phantom inserts that are
equipment specific. This on is used
for the GE Lightspeed scanners.

Low contrast test tools are still being perfected as there

remain questions as to the most optimal means of testing. The low contrast
sensitivity test shows ideal results with the new polyurethane resin material
phantoms. The low-contrast sensitivity in the image plane was easily
measured with no dependence on temperature or beam quality. Additional
phantoms are also available for testing low resolution in three dimensions.
Contrast measurements should be within equipment manufacturer
specifications. Tests for contrast are done monthly and upon acceptance.

93
Test 5 - Slice thickness (sensitivity profile)

The purpose for the slice thickness test is to determine if

collimators, which shape the x-ray beam, correctly open to the appropriate
size set at the console. Traditionally, 45 degree tilted ramps (aluminum or
plastic), a spiral, or step wedge are used. There is a hole drilled in them that
allows the beam to pass through it projecting an image of the width and
length of the hole needed to match the width of the x-ray beam exactly.
For example: slice widths of 7mm or greater should match
nominal slice width within 2mm or less. But for narrower slice widths, there
is a larger margin for error, possibly even doubled. This is generally just a
matter of adjusting the calibration. This traditional test was once fairly time-
consuming however; today's spiral and multi-slice scanners, new phantoms
have been developed that can be used as an insert with a CT performance
phantom. It has virtually no set-up time and is much more accurate. The
new phantoms also reduce partial volume averaging and do not
compromise z-axis (patient coverage). They can even perform accurately
when not parallel to the imaging plane.
After the phantom and test tool have been imaged, the
stainless steel bearings within the phantom create graphs on the test
monitor providing information as to whether or not the equipment is within
limits. The pixel values obtained from each image are plotted and the data
processed and normalized. This test is done to determine if the beam is
actually creating an exact match with the specified slice programmed. So let
us look at how this test is performed on the GE Lightspeed scanner.
For this test the phantom insert contains a block pattern of air
filled holes designed to demonstrate slice thickness. Each visible hole or line
in the phantom is at 1mm thickness that is aligned perpendicular to the scan
plane. It is important when determining slice thickness that the display
image is viewed at the recommended window level and width for counting
visible lines. The width is always set at 250 HU, and for a slice thickness of
10mm the level is set at 10 HU. For 5.0mm slice thickness viewing is at
250/0 HU; 3.0mm slice thickness viewing is at 250/-50 HU; 1.5mm slice
thickness is viewed at 250/-100 HU. Standard limits are +/- 1mm. This test is
done semi-annually and upon acceptance.

94
 The quality assurance phantom on the right is used to
perform several tests including the slice thickness test. On the left is the
resulting image used to determine slice thickness. The block pattern
showing line thickness appears along the edges (yellow oval) of the pattern.

Because
several factors affect
viewing of the line
pairs for width
sensitivity profile, it
is recommended on
some scanners that
the window/level
setting be
standardized. This
chart shows the
standard viewing
windows for the GE
Lightspeed scanners for each slice thickness being tested for. A slice
thickness of 10mm is viewed at W/L 250/50, whereas for 3mm the
recommended viewing is 250/-50 W/L. When this test is properly performed
and the collimators working correctly, the number of visible lines should
equal the chosen slice thickness.

95
This image
taken on the
CT phantom
shows 10 one-
millimeter lines
on the corners
of the image.
The slice
thickness is
10mm
according to this image, which is what was set at the console for the slice
thickness test. The window and level setting for this image was set at
250/50 according to the manufacturer�s recommendation. The results of
this test confirm that the collimators that shape the x-ray beam are open to
the appropriate size. One can also vary the slice thickness to test for
linearity of the system. Collimators that shape slice thickness should be
accurate to +/- 1mm of the setting at 10mm.

Test 7 - Table/bed indexing accuracy

This test is done to ensure the distance the bed is

moving between scans is accurate to what the equipment reads. This test is
performed at same time as localization test. One way to do the test is with a
piece of x-ray film taped to the table. The piece of film is generally covered
or in a holder to prevent exposure. A series of 10 to 12 scans are done
10mm apart.
A scan can be done at any thickness to check indexing. Using a
ruler or tape measure, determine the distance between bands. The
distances should be equal between selected increments. If there is more
than a +/-2 mm. difference between any slice, equipment needs to be
serviced. This test is done monthly and upon acceptance.

96
PATIENT PREPARATION and USE OF CONTRAST AGENTS
The patient preparation for most CT examinations is minimal.
In certain cases, a contrast medium is used to enhance designated areas and
to better differentiate disease processes. Although the specified
preparation varies according to the hospital and physician, the following
preparations are frequently used.

BRAIN SCANS (CT BRAIN)

In preparation for a CT scan, patients are often asked to avoid

food, especially when contrast material is to be used. If the procedure is
just CT of brain without contrast, there is no preparation for the patient.
Contrast material may be injected intravenously, or
administered by mouth or by an enema in order to increase the distinction
between various organs or areas of the body. Therefore, fluids and food
may be restricted for 4 hours prior to the examination.
If the patient has a history of allergy to contrast material (such
as iodine), the requesting physician and radiology staff should be notified.
All metallic materials and certain clothing around the body are
removed because they can interfere with the clarity of the images.
If you are pregnant or suspect that you may be pregnant, you
should notify your doctor. Radiation exposure during pregnancy may lead
to birth defects. If it is necessary for you to have a CT of the brain, special
precautions will be made to minimize the radiation exposure to the fetus.
Nursing mothers should wait 24 hours after contrast material
is injected before resuming breastfeeding.

BODY SCANS (CT OF ABDOMEN & PELVIS)

 Clear fluids only – 8 hrs prior to exam (patient can void)

• Nothing to eat or drink 2 hrs prior to exam

• Patient is to arrive 1 ½ hrs prior to exam time, so we can give the oral
preparation in the department

97
 The night before the exam before going to bed, all patients should
have 10 mls of Gastrografin mixed in 450 mls (16 ozs.) of clear fluid
(including water).

 Repeat this procedure with the remaining 10 mls of Gastrografin 1

hour prior to the scan.

 Patients should have nothing to eat, drink or smoke for two (2) hours
prior to the test, other than the Gastrografin preparation.

 Patient is to arrive at the Diagnostic Imaging department 1 hour prior

to your appointment because the C.T. Technologist will give you an
additional dose of Gastrografin preparation prior to the examination.

CHEST CT PREPARATION:

• Continue to take your routine medications.

• Take nothing by mouth 3 hours prior to your exam.

• Please notify the technologist if you have had a barium study within
the last 3 days.

• Please notify the technologist if you are pregnant or could be

pregnant.

• Allow 15-30 minutes for the exam.

PREPARATION FOR CT OF EXTREMITIES

• If IV iodinated contrast is needed and you have an allergy to the

iodinated contrast media, you will need to be pre-medicated.
• Contrast agents may be administered intra-venously or orally.
• Patients may be asked to dress into an exam gown.
• There is no restriction on your water intake.

98
 I.V. contrast medium is occasionally needed to enhance the
contrast in CT scans of the brain, body organs and extremities. The contrast
medium used is the same as that employed for Excretory Urography. Oral
Contrast agents (Barium or an Iodinated contrast agents for GI work) are
used for enhancement in certain body examinations.

PATIENT POSITIONING:
Patient Positioning is determined by;

1. The desired plane of anatomy that is to be imaged.

2. The ability of the patient to cooperate.
3. The limitation of the gantry angulation.
4. The diameter of the opening for the patient into the gantry.

Positioning of the Patient Involves Two Major Concerns:

1. The accuracy with which the patient can be positioned (generally, a

specific position optimizes the diagnostic information.
2. The patient comfort.

Most Brain scans are taken with

the gantry placed at a caudal angle of
approximately 15-20 degrees to the
patient’s orbito-meatal line (OML).

Most Body scans are typically taken

perpendicular to the patient’s table.

99
 One exception is the CT
examination of the spine for
which slices through the disk
space are obtained at various
required angles. Up to 25
degrees of angulation maybe
required for imaging of the L5-
S1 intervertebral spaces.

Any movement during examination is undesirable and can lead to a loss of

diagnostic information. Therefore, cushioning the head and placing pillows
under the knees are recommended. Restraining straps should be used
whenever possible to help immobilize the patient while not causing undue
discomfort.

SLICE THICKNESS and LOCATIONS:

* The actual thickness of the tomographic slice is controlled by the “Source
Collimator”.
* Generally, thin slices (from 1.0 to 5mm) are used for fine detail on
examinations such as visualization of the Optic nerve, Pituitary gland and
Posterior fossa of the brain.

* Another application requiring thin slices is the production of “sagittal” and

“coronal” reformatted images from the cross-sectional scans.

• For routine Brain scans and most body scans, a one (1) centimeter slice
thickness is generally acceptable.

• A common exception is scanning the adrenal

gland for which thinner slices are typically
taken.

100
• In some studies such as generalized survey for Lymphoma or metastasis,
one (1) centimeter slices are generally taken every other centimeter.

• The total number of slice depends on the size of the anatomic area to
be scanned.

And as a general guideline:

# Most Brain scans taken between 9-11 slices.

# Pancreas typically consists of 11 slices.

# The liver & spleen range from 11-14 slices.

# Kidney takes 14-16 slices.

## If unenhanced (without contrast) and contrast enhanced images are

desired, the number of slices taken becomes double.

BASIC PATIENT POSITIONING & TECHNIQUES

The brain, being a three-dimensional object, can be cut into three different
planes of orientation. They are:

• Coronal

• Sagittal

• Horizontal

• Coronal: Sections looking head-on toward an upright subject directly

facing you

• Sagittal: Sections looking head-on toward an upright subject facing

sideways

• Horizontal: Also known as “transverse” or “axial” sections are parallel

to the floor when the subject is standing upright. These views are very
common with imaging techniques such as CT or MRI .

101
TWO KINDS OF BODY POSITIONING EMPLOYED IN CT SCANNING

1. Supine position – 80% of examinations are taken in this position.

2. Prone position – 20% of examinations employs this position including

coronal images.

GANTRY ANGULATION

1. “0” Angle

2. “+” Angle

3. “-” Angle

102
 CT SCANNING PROCEDURES
CRANIAL CT
A. STANDARD CT BRAIN (With or Without Contrast)

Computed Tomography (CT or CAT scan) is a noninvasive

diagnostic imaging procedure that uses a combination of X-rays and
computer technology to produce horizontal, or axial, images (often called
slices) of the body. A CT scan shows detailed images of any part of the body,
including the bones, muscles, fat, and organs. CT scans are more detailed
than standard X-rays.
CT scans of the brain can provide more detailed information
about brain tissue and brain structures than standard X-rays of the head,
thus providing more information related to injuries and/or diseases of the
brain.

Indications:

A CT scan of the brain may be performed to assess the brain for tumors and
other lesions, injuries, intracranial bleeding, structural anomalies such as
hydrocephalus, infections, brain function or other conditions, particularly
when another type of examination such as X-rays or physical examination
are not conclusive.

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.
 Determine whether inflammation or other changes are present in
the paranasal sinuses.
 Plan radiation therapy for cancer of the brain or other tissues.

103
 Guide the passage of a needle used to obtain a tissue sample
(biopsy) from the brain.
 Assess aneurysms or arteriovenous malformations through a
technique called CT angiography.

CT scans may be performed on an outpatient basis or as part

of your stay in a hospital. Procedures may vary depending on your
condition and your physician's practices.
Generally, a CT scan of brain follows this process:
You will be asked to remove any clothing, jewelry, or other
objects that may interfere with the procedure, such as eyeglasses,
hairpins, dentures, and possibly hearing aids. If you are asked to
remove clothing, you will be given a gown to wear.
If you are to have a procedure done with contrast, an
intravenous (IV) line will be started in the hand or arm for injection of the
contrast dye. For oral contrast, you will be given medication to swallow.
You will lie on a scan table that slides into a large, circular
opening of the scanning machine. Your head may be immobilized to
prevent movement during the procedure.
The technologist will be in another room where the scanner
controls are located. However, you will be in constant sight of the
technologist through a window. Speakers inside the scanner will enable
the technologist to communicate with and hear you. You will have a call
button so that you can let the technologist know if you have any
problems during the procedure. The technologist will be watching you
at all times and will be in constant communication.
As the scanner begins to rotate around you, X-rays
will pass through the body for short amounts of time. You will hear
clicking sounds, which are normal.
The X-rays absorbed by the body's tissues will be
detected by the scanner and transmitted to the computer. The
computer will transform the information into an image to be
interpreted by the radiologist.
It will be very important for you to remain very still during the
procedure. You may be asked to hold your breath at various times
during the procedure.

104
 PROCEDURES:

• Head is positioned in
normal AP of the skull.
• One centimeter slice
thickness is generally
employed.
• The first slice/line starts
from the OML to the

vertex.

• Gantry angulation is from

15-20 degrees caudal to the
patient’s OML.
• Filming program is one film
without contrast and one
film for with contrast.

SPECIAL TECHNIQUES OF THE SKULL

1. POSTERIOR FOSSA

ANATOMY OF THE POSTERIOR FOSSA:

The posterior fossa is the deepest

and most capacious of the three cranial
fossae. It houses the brainstem and
cerebellum. The brainstem contains all
the cranial nerve nuclei and many
efferent and afferent fiber tracts that
connect the brain with the rest of the
body. The cerebellum is the major organ
of coordination for all motor functions, as
well as mental activities of the brain.

105
 Located centrally in the posterior
fossa is the foramen magnum. The
posterior fossa is surrounded by deep
grooves containing the transverse sinuses
and sigmoid sinuses. This location within
the head requires a special use of scan
parameters to observe and categorized
pathologies.
Additionally, special care and
attention has to be taken to artifacts caused mainly by beam
hardening.

• Patient is usually placed in supine position

with a zero degree gantry angulation.
• This reduces artifacts from dental implants
and spares the lenses as far as possible.
 Slice planning is parallel to the base of the
skull.

106
 AXIAL CUTS

PETROUS BONE/PETROUS PYRAMID & INTERNAL AUDITORY

MEATUS:

The petrous apex lies at the

anterior superior portion of the temporal
bone. Access to this region is difficult and
often requires special surgical skills. The
region is associated with severe life-
threatening complications of otitis media.
Neoplastic and inflammatory
lesions are the most common pathologic
processes in the petrous apex. Imaging
studies have greatly increased the ability to
diagnose these lesions, especially in view of
the often-vague symptomatology associated
with these lesions. A number of the
processes are diagnosed as incidental
findings, and consultation is sought to
determine the appropriate diagnosis and therapeutic plan.

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 Patient is in supine position in normal head positioning.
 1-2 millimeters slice thickness/increment is employed
 Axial scanning along the OML.
 Filming program is one film for Bone window and one film for soft
window.

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 PETROUS PYRAMID & INTERNAL
AUDITORY MEATUS

• Patient in supine with the neck hyperextended so that the OML is

parallel with the table.
• 1-2 millimeters slice thickness.
• Filming program is Soft & Bone
windows.

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CT OF ORBITS
• Normal head positioning
• 2 millimeters slice thickness
• Scanning Technique: Axial/Transverse & Coronal Cuts
• Filming program is Soft & Bone windows
• Inject 80ml of contrast medium.

CT SELLA TURCICA
The
Pituitary gland
is the master
gland of the
body because
it controls
most of the body’s endocrine functions by
means of the hypothalamic-pituitary axis. The Sella Turcica is a depression
hollowed out on the upper surface of the body of the Sphenoid bone
wherein the pituitary gland lies within it.

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 The sellar and parasellar region is an anatomically complex
area where a number of neoplastic, infectious, inflammatory,
developmental and vascular pathologies can occur. Differentiation among
various etiologies may not always be easy, since many of these lesions may
mimic the clinical, endocrinologic and radiologic presentations of pituitary
adenomas. The diagnosis of sellar lesions involves a multidisciplinary effort,
and detailed endocrinologic, ophthamologic and neurologic testing are
essential. CT and, mainly, MRI are the imaging modalities to study and
characterize normal anatomy and the majority of pathologic processes in
this region.

Technique:

In the ideal situation, CT of the pituitary gland is performed

with multidetector-row CT. Volumetric (64-section) CT scanners produce
coronal reformations with a resolution near that of direct coronal
acquisitions. Single-channel axial and helical CT of the pituitary gland is
best performed in the direct coronal plane by maximally extending the
patient's neck while the patient is either supine or prone. This method
allows for the demonstration of pituitary abnormalities with radiation dose
to the lens that is lower than that possible with axial imaging.
As an alternative, pituitary CT can be performed in the axial
plane with thin (1-mm) contiguous sections after the intravenous
administration of 100 mL of contrast medium. Exposure parameters are
approximately 120 kV, 200 mA, 2-second scanning time, and a soft tissue
algorithm. Images are reformatted in the coronal and sagittal planes.

Normal Pituitary Fossa taken in Coronal and Sagittal

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 Computed tomography (CT) was
the first imaging modality to directly
visualize the pituitary gland, hypothalamus,
and optic chiasm. The bony structures in
this region can be well evaluated with CT.
It is more sensitive than either
plain radiographs or magnetic resonance
imaging (MRI) in the detection of
calcifications within soft tissues. However,
intravenous contrast agents frequently are
necessary to improve the image contrast and
to enhance the vasculature, and CT involves
radiation exposure.

A major disadvantage of CT is that

soft-tissue characterization is less than ideal.
Artifacts from beam hardening, related to the
dense bone in the skull base, obscure soft-tissue
detail. Additionally, on direct coronal imaging,
there often are artifacts that are due to metallic
dental fillings. Intravenous contrast is used to
improve soft-tissue contrast and highlight the
vasculature, but the contrast agent may cause
life-threatening reactions.

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 Computed Tomography
Scan of the Spine
Examinations of the spinal
column with both, Magnetic Resonance
(MR) imaging and Computed Tomography
(CT), often require a precise three-
dimensional positioning, angulation and
labeling of the spinal disks and the
vertebrae. A fully automatic and robust
approach is a prerequisite for an automated
scan alignment as well as for the
segmentation and analysis of spinal disks
and vertebral bodies in Computer Aided
Diagnosis (CAD) applications.
CT scans of the spine can
provide more detailed information about
the vertebrae (bones of the spine) and other
spinal structures and tissues than standard
X-rays of the spine, thus providing more
information related to injuries and/or diseases of the spine.

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Anatomy of the Spine
The spinal column is made up of 33 vertebrae that are
separated by spongy disks and classified into distinct areas.

• The cervical area consists of seven vertebrae in

the neck.
• The thoracic area consists of 12 vertebrae in the
chest area.
• The lumbar area consists of five vertebrae in the
lower back area.
• The sacrum has five, small fused vertebrae.
• The four coccygeal vertebrae fuse to form one
bone, called the coccyx or tailbone.

The spinal cord, a major part of the central

nervous system, is located in the vertebral canal and
reaches from the base of the skull to the upper part of the
lower back. The spinal cord is surrounded by the bones of
the spine and a sac containing cerebrospinal fluid. The
spinal cord carries sense and movement signals to and
from the brain and controls many reflexes.

Indications for the procedure:

A CT scan of the spine may be performed to assess the spine

for a herniated disk, tumors and other lesions, the extent of injuries,
structural anomalies such as spina bifida (a type of congenital defect of the
spine), blood vessel malformations, or other conditions, particularly when
another type of examination, such as X-rays or physical examination, is not
conclusive. CT of the spine may also be used to evaluate the effects of
treatment of the spine, such as surgery or other therapy. There may be
other reasons for your physician to recommend a CT scan of the spine.

114
 If you are pregnant or suspect that you may be pregnant, you
should notify your physician. Radiation exposure during pregnancy may lead
to birth defects. If it is necessary for you to have a CT of the spine, special
precautions will be made to minimize the radiation exposure to the fetus.
Nursing mothers should wait 24 hours after contrast material is injected
before resuming breastfeeding.
If contrast dye is used, there is a risk for allergic reaction to
the dye. Patients who are allergic to or sensitive to medications should
notify their physician. Studies show that 85 percent of the population will
not experience an adverse reaction from iodinated contrast; however, you
will need to let your physician know if you have ever had a reaction to any
contrast dye, and/or any kidney problems. A reported seafood allergy is not
considered to be a contraindication for iodinated contrast.
Patients with kidney failure or other kidney problems should
notify their physician. In some cases, the contrast dye can cause kidney
failure. The effects of kidney disease and contrast agents have attracted
increased attention over the last decade, as patients with kidney disease are
more prone to kidney damage after contrast exposure.
Also, patients taking the diabetes medication (Glucophage)
should alert their doctor before having IV contrast, as it may cause a rare
condition called metabolic acidosis. If you take metformin, you will be asked
to stop taking it 24 hours before and for 48 hours after your injection. A
blood test may be required before you can start taking metformin again.

PROCEDURES OF CT LUMBAR SPINE

CT scans can be performed on an outpatient basis or as part of your hospital

stay. Procedures may vary depending on your condition and your physician's
practices.

Generally, a CT scan of the bones, joints, and soft tissue follows this process:

• You will be asked to remove any clothing, jewelry, or other objects that
may interfere with the procedure, such as eyeglasses, hairpins,
dentures, and possibly hearing aids.
• If you are to have a procedure done with contrast, an intravenous (IV)
line will be started in the hand or arm for injection of the contrast dye.
For oral contrast, you will be given medication to swallow.

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 You will lie on a scan table that slides into a large, circular opening of
the scanning machine.
 Pillows and straps may be used to prevent movement during the
procedure.
 The technologist will be in another room where the scanner controls
are located. However, you will be in constant sight of the
technologist through a window.
 Speakers inside the scanner will enable the technologist to
communicate with and hear you.
 You will have a call button so that you can let the technologist know
if you have any problems during the procedure.
 The technologist will be watching you at all times and will be in
constant communication.
• The scanner will begin to rotate around you and X-rays will pass
through the body for short amounts of time. You will hear clicking
sounds, which are normal.
• The X-rays absorbed by the body's tissues will be detected by the
scanner and transmitted to the computer. The computer will
transform the information into an image to be interpreted by the
radiologist.
 It will be important for you to remain very still during the procedure.
You may be asked to hold your breath at various times during the
procedure.
 If contrast dye is used for your procedure, you will be removed from
the scanner after the first set of scans has been completed. A second
set of scans will be taken after the contrast dye has been
administered.
 If contrast dye is used for your procedure, you may feel some effects
when the dye is injected into the IV line. These effects include a
flushing sensation, a salty or metallic taste in the mouth, a brief
headache, or nausea and/or vomiting. These effects usually last for a
few moments.
 When the procedure has been completed, you will be removed from
the scanner.

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  If an IV line was inserted for contrast administration, the line will be
removed.
 You may be asked to wait for a short period of time while the
radiologist examines the scans to make sure they are clear.

CT of the lumbar is
always in supine
position with the
Scanogram taken in
Lateral view. The
slice thickness is from
2-3mm.
Slices are taken from
the intervertebral spaces perpendicular from the superior end plate of
the body to the inferior end plate from L1 to S1.
Printed in Soft & Bone window.

CT Myelogram
CT scanning involving the
diagnostic tool of Myelography is used to
evaluate both the bony structure of the spine as
well as the nerve structures. In preparation for
this procedure the patient may be asked to
remove any metal, hearing aids, and/or
removable dental work. This procedure requires
the patient to follow a few preps that will be
provided by your ordering physician.
This procedure requires two
parts. During the first portion of this procedure
the patient will have Contrast dye injected into
his or her cerebral spinal fluid which coats the
spinal canal.

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 The contrast dye will coat the
spinal canal, the spinal cord, and the
nerve roots, which will illuminate any
malformations in the spine during the
scan. The patient will then be
transferred to the CT table where they
will be asked to lie on his or her back for
the second portion of this procedure.

Positioning sponges and Velcro may be used to reduce motion and aligning
the spine for the scan.
The technologist will center the area being scanned using the
laser lights on the scanner. Shortly after the technologist leaves the room
the table will then move through the scanner producing a “scout”
image. There will be a slight pause while the technologist uses the scout
image to set up the exam.
The table will then move through the scanner at least one
more time for the examination. Patients are not permitted to drive
immediately following this procedure and will need to make arrangements
for transportation home.

CT Cervical Spine
CT scanning of
the Cervical Spine is
typically used to evaluate
the spine before and after
surgery, detect various
types of tumors, diseases,
fractures, spinal stenosis,
disc herniations, and or
any malformations. In
preparation for this procedure the patient may be asked to remove any
metal, hearing aids, and/or removable dental work. If the procedure is an
Enhanced Study it calls for contrast media to be used and further
preparations may be needed.

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 The patient typically lies on his or her back and their head is
placed into a cradle. Small positioning sponges or Velcro straps may be
used to reduce motion and keep the head and neck aligned properly for the
scan.

The technologist will center the area being scanned using the
laser lights on the scanner. Shortly after the technologist leaves the room
the table will then move through the scanner producing a “scout”
image. There will be a slight pause while the technologist uses the scout
image to set up the exam. The table will then move through the scanner at
least one more time for the examination depending on whether or not
contrast media is needed.

Indications for Having a Cervical Spine CT Scan

The most common reason for a spinal CT scan is to check for

injuries after an accident. However, the test may also order to investigate:

 Herniated discs (the most common cause of back pain)

 Birth defects of the cervical spine in children.
 Tumors that may have originated in the spine or elsewhere in the
body.
 Broken bones.
 It can also provide important information if you have certain bone
diseases, such as arthritis or osteoporosis, by measuring your bone
density.

This can help your doctor determine the severity of your

condition and identify any weakened areas that should be protected from
fractures. This will also aid your doctor when doing biopsy (tissue removal)
or removing fluid from an infected area in your cervical spine. The doctor
may use a CT scan of your neck as a guide during the procedure.
A CT scan of the neck may be done along with other tests, such as MRI scans
or X-rays.

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Note: CT Cervical is excellent in demonstrating the complete bony ring of
C1.

• Scanogram is taken in Lateral.

• Employing a 2 millimeters slice

thickness.

• Printed in Soft & Bone window

CT Thoracic Spine
CT scanning of the Thoracic or
Dorsal Spine is typically used to evaluate
the spine before and after surgery,
detect various types of tumors, diseases,
fractures, spinal stenosis, disc
herniations, and or any
malformations. In preparation for this
procedure the patient may be asked to
remove any metal, hearing aids, and/or
removable dental work. If the
procedure is an Enhanced Study it calls
for contrast media to be used and further preparations may be needed.

120
 The patient typically lies on his or her back with their feet
facing the scanner. Positioning sponges may be placed under the knees for
comfort and to assist in aligning the spine for the scan. If possible the
patient will be asked to raise their arms above their head. The technologist
will center the area being scanned using the laser lights on the scanner.
Shortly after the technologist leaves the room the table will
then move through the scanner producing a “scout” image. There will be a
slight pause while the technologist uses the scout image to set up the
exam. The table will then move through the scanner at least one more time
for the examination depending on whether or not contrast media is
needed. You must inform the technologist, radiology nurse and/or
physician of any allergies you may have before your exam.
While positioning you on the exam table, the technologist will
explain your procedure. If contrast dye is being used, it will be injected
through your IV. During the injection you may experience a warm sensation
all over your body and a metal taste in your mouth. This is normal.
If you experience any itching, sneezing, nasal congestion, scratchy throat or
swelling of your face you should notify the technologist immediately.
Most often, you will be asked to lie flat on your back with your arms
positioned above your head.
The table you are on will slide into the scanner. A portion of
the body is covered by the scanner, and the scanner is open at the back and
the front, allowing the patient to see out.
The technologist will always be able to see and hear you during your exam.
You will be asked to hold very still and at times to hold your breath.
This procedure usually takes approximately 30 minutes.

Indications of the Procedure:

Fractures of the thoracic spine can occur whenever the spinal

column is subjected to forces that exceed its strength and stability. Common
causes of thoracic spinal fractures include falling from a height, motor
vehicle accidents, violent weather, military and civilian blast injury, and
penetrating trauma. Less common injury patterns may be related to athletic
accidents. After traumatic aortic rupture, spinal cord injuries represent the
most serious long-term morbidities resulting from thoracic trauma.

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 The goal of diagnostic imaging in patients who have sustained
thoracic spinal trauma is to correctly identify spinal fractures, to identify
injuries to the spinal cord and nerve roots, to aid in surgical planning, and to
judge the stability of postoperative fixation. This article highlights the typical
patterns of injury within a classification based on the mechanism of injury
while focusing on the imaging methods that are most useful in clinical
practice.

• Scanogram taken in AP view

• Slice thickness is 2 millimeters slice

thickness.

• Printed in Soft & Bone window.

CT Paranasal Sinuses
CT scanning of the Sinuses is typically used to evaluate the
sinus cavities for fluid, thickened sinus membranes, planning for surgery,
tumors, and to detect any inflammation. In preparation for this procedure
the patient may be asked to remove any metal, hearing aids, and/or
removable dental work. If the procedure is an Enhanced Study it calls for
contrast media to be used and further preps may be needed.

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 The patient typically lies on his or her back and their head is
placed into a cradle. Depending on what is being evaluated during the
procedure the patient may be asked to lie on his or stomach and place their
chin on a positioning device. Small positioning sponges or Velcro straps may
be used to reduce motion and keep the head aligned properly for the scan.
The technologist will center the area being scanned using the
laser lights on the scanner. Shortly after the technologist leaves the room
the table will then move through the scanner producing a “scout”
image. There will be a slight pause while the technologist uses the scout
image to set up the exam. The table will then move through the scanner at
least one more time for the examination depending on whether or not
contrast media is needed.

PARANASAL SINUSES (AXIAL CUTS)

- 5 millimeters slice thickness

- Reference point is parallel from the floor of the maxillary
sinuses.
- Slice planning starts from the mid part of the upper teeth up to the end
portion of the frontal sinuses.

CORONAL CUTS:
- 5 millimeters slice thickness
- Reference point is from the back of the sphenoid sinuses up to the
frontal sinuses.

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CT OF NECK REGION
CT of neck for soft tissue evaluation generally includes
imaging of the following anatomic structures:
Pharynx, Thyroid Glands, Nasopharynx, Parotid glands & Submandibular
glands.

CT is generally the modality of choice for the following indications:

• Detection of Sialolithiasis (salivary gland calculi)

• Following trauma to the soft tissue of the neck.
• During foreign body evaluation
• After initial radiographic assessment for a radiopaque foreign body.

A. CT THYROID GLANDS
A CT Soft Tissue Neck is
typically ordered to evaluate the soft
tissues and organs of the
neck. Capturing images of all anatomy
including the tonsils, adenoids, airways,
thyroid, glands, and the blood vessels:
evaluating for tumors, masses, and or
swelling. In preparation for this
procedure the patient may be asked to
remove any metal, hearing aids, and/or removable dental work.

124
 If the procedure is an
Enhanced Study it calls for contrast media to
be used and further preps may be needed.
The patient typically lies on his
or her back and their head is placed into a
cradle. Small positioning sponges or Velcro
straps may be used to reduce motion and
keep the head aligned properly for the
scan. The technologist will center the area being scanned using the laser
lights on the scanner.
Shortly after the technologist leaves the room the table will
then move through the scanner producing a “scout” image. There will be a
slight pause while the technologist uses the scout image to set up the
exam.
The table will then move through the scanner at least one
more time for the examination depending on whether or not contrast
media is needed. The technologist may ask you to withhold from
swallowing during the scan to reduce motion and will inform you when it is
ready to resume normal swallowing activities.

CT Upper Extremity
A CT scan of the Upper Extremities is typically used to
evaluate abnormalities found within the soft tissue and bony anatomy of
that extremity. CT scans of
this nature assess the
muscles, bones, joints, and
soft tissues for arthritis,
fractures, tumors,
bleeding, and
inflammation.
In preparation for this procedure the
patient may be asked to remove any metal and change into a gown. If the
procedure is an Enhanced Study it calls for contrast media to be used and
further preparations may be needed.

125
 The patient
typically lies on his or her
back. Small positioning
sponges or Velcro straps
may be used to reduce
motion and keep the
Extremity being imaged
aligned properly for the
scan. The technologist
will center the area being scanned using the laser lights on the
scanner. Shortly after the technologist leaves the room, the table will move
through the scanner producing a “scout” image. There will be a slight pause
while the technologist uses the scout image to set up the exam. The table
will then move through the scanner at least once more depending on
whether or not contrast dye is being used.

CT Lower Extremity
A CT scan of the Lower
Extremities is typically used to evaluate
abnormalities found within the soft tissue and
bony anatomy of that extremity. CT scans of
this nature assess
the muscles,
bones, joints, and
soft tissues for
arthritis,
fractures, tumors, bleeding, and inflammation.
In preparation for this procedure the
patient may be asked to remove any metal and
change into a gown. If the procedure is an
Enhanced Study it calls for contrast media to
be used and further preparations may be needed.

126
 The patient typically lies on his
or her back. Small positioning sponges or
Velcro straps may be used to reduce
motion and keep the Extremity being
imaged
aligned
properly for
the scan. The
technologist
will center the area being scanned using the
laser lights on the scanner. Shortly after the
technologist leaves the room, the table will
move through the scanner producing a “scout”
image. There will be a slight pause while the
technologist uses the scout image to set up the exam. The table will then
move through the scanner at least once more depending on whether or not
contrast dye is being used.

CT CHEST
CT scanning of the Chest is typically used to evaluate
abnormalities found on conventional chest X-rays or in diagnosing clinical
symptoms of coughing, chest pain, fever, or trauma. CT scans of the chest
may also evaluate for Pulmonary Embolisms (Blood Clots), tumors, and lung
nodules. In preparation for this procedure the patient may be asked to
remove any metal and change into a gown.

127
 The patient typically lies on his or her back with their feet
facing the scanner. Positioning sponges may be placed under the knees for
comfort and to assist in aligning the body for the scan. If possible the
patient will be asked to raise their arms above their head. The technologist
will center the area being scanned using the laser lights on the scanner.
Shortly after the technologist leaves the room, a recorded
voice will request the patient to hold their breath. At this point the table
will then move through the scanner producing a “scout” image, and the
patient will be instructed to breathe normally. There will be a slight pause
while the technologist uses the scout image to set up the exam. The table
will then move through the scanner at least one more time for the
examination depending on whether or not contrast media is needed.

Procedure:

# Patient in supine position with

hands raised to avoid
superimposition with the
chest area.
# Scanogram is taken in AP
position.
# Reference line is from C7 down
below the diaphragm.
# Axial cuts only with a 10mm
slice thickness.
# “0” gantry angulation.
# Contrast medium is injected before scanning.
# “Breath hold” technique.

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CT Abdomen and Pelvis
CT scans of the Abdomen, Pelvis, or
a combination of the two are typically used to
evaluate abnormalities found within the organs of
the abdominopelvic cavity. CT scans of this nature
assess the liver, urinary tract, spleen, intestines,
and vasculature for multiple diseases and or
infections. In preparation for this procedure the
patient may be asked to
remove any metal and
change into a gown.
The patient typically lies on his or her back
with their feet facing the scanner. Positioning
sponges may be placed under the knees for comfort
and to assist in aligning the body for the scan. If
possible the patient will be asked to raise their arms
above their head. The technologist will center the
area being scanned using the laser lights on the
scanner. Shortly after the technologist leaves the room, a recorded voice
will request the patient to hold their breath.
At this point the table will then move through the scanner
producing a “scout” image, and the patient will be instructed to breathe
normally. There will be a slight pause while the technologist uses the scout
image to set up the exam. The table will then move through the scanner at
least one more time for the examination depending on whether or not
contrast media is needed.

CT of the Abdomen includes imaging of the following anatomical

structures:
1. Liver, Biliary tract including gall bladder.
2. Pancreas
3. Gastrointestinal tract
4. Spleen
5. Kidneys
6. Adrenal glands

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7. Abdominal aorta
8. Inferior Vena Cava
9. Abdominal lymph nodes
10. Other retroperitoneal structures.

General Abdominal CT Indications:

 Abdominal pain
 Lymph Adenopathy
 Palpable abdominal mass
 Post-operative evaluation for complications
 Trauma
 Tumor evaluation
 Hematuria
 Renal lesions

Procedure:
• Scanogram is taken in AP.
• Contrast medium is a must before the
procedure.
• Axial cuts only with 10mm slice
thickness.
• “0” gantry angulation.
• Reference line starting above the
diaphragm dome to the symphysis
pubis.

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CT Liver
The CT scan of the Abdomen using a Liver Protocol is typically
used to evaluate abnormalities found within the Liver and Hepatic
System. CT scans of this nature assess for liver tumors, bleeding, jaundice,
and liver diseases. In preparation for this procedure the patient may be
asked to remove any metal and change into a gown. This procedure is an
Enhanced Study meaning it calls for contrast media to be used. Further
preps may be needed and should be provided by the ordering physician. If
you are allergic to IV contrast, diabetic, or experiencing lower kidney
functions inform the ordering physician and the technologist.

The patient may be asked to drink an oral form of the IV

Contrast prior to the scan in order to fill the stomach and small
intestines. During the scan the patient typically lies on his or her back with
their feet facing the scanner. Positioning sponges may be placed under the
knees for comfort and to assist in aligning the body for the scan. The
technologist will place an Intravenous (IV) Catheter in the patient’s
arm. Note: this procedure is an Enhanced Study and calls for IV contrast to
be used. If possible the patient will be asked to raise their arms above their
head.
The technologist will center the area being scanned using the
laser lights on the scanner. Shortly after the technologist leaves the room, a
recorded voice will request the patient to hold their Breath.
At this point the table will then move through the scanner
producing a “scout” image, and the patient will be instructed to breathe
normally. There will be a slight pause while the technologist uses the scout
image to set up the exam. The table will then move through the scanner
several times as the IV Contrast is injected. This catches the liver in multiple
stages of enhancement which aids with the diagnosis.

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Procedure:

• Axial cuts only.

• Without contrast

• 10mm slice thickness.

• “0” gantry angulation.

CT Pancreas
The CT Scan of the Abdomen
using a Pancreatic Protocol is typically used to
evaluate abnormalities found within the
Pancreas. CT scans of this nature assess for
tumors and Pancreatitis, or inflammation of
the pancreas. In preparation for this procedure
the patient may be asked to remove any metal
and change into a gown. This procedure is an
Enhanced Study meaning it calls for contrast
media to be used. Further preparations may be needed and should be
provided by the ordering physician.
If you have allergic to I.V. contrast, diabetic or experiencing lower kidney
functions, inform the physician and the technologist.
The patient may be asked to drink an oral contrast prior to the
scan in order to fill the stomach and small intestines. During the scan the
patient typically lies on his or her back with their feet facing the
canner. Positioning sponges may be placed under the knees for comfort
and to assist in aligning the body for the scan. The technologist will place an
Intravenous (IV) Catheter in the patient’s arm. Note: this procedure is an
Enhanced Study and calls for IV contrast to be used. If possible the patient
will be asked to raise their arms above their head.

132
 The technologist will center the area being scanned using the
laser lights on the scanner. Shortly after the technologist leaves the room, a
recorded voice will request the patient to hold their breath. At this point
the table will then move through the scanner producing a “scout” image,
and the patient will be instructed to breathe normally. There will be a slight
pause while the technologist uses the scout image to set up the exam. The
table will then move through the scanner several times as the IV Contrast is
injected. This catches the pancreas in multiple stages of enhancement
which aids with the diagnosis.

Procedure:

• Patient is given contrast medium the night before the procedure.

• Patient is again required to drink another contrast medium in the
department.
• 5mm slice thickness.

CT Cardiac Score
Cardiac Scoring in CT is used to
evaluate for a condition called Coronary
Artery Disease. Major risk factors for
Coronary Artery Disease include but are not
limited to diabetes, smoking, high blood
pressure, high blood cholesterol, and
obesity.

133
 In preparation for this procedure the patient may be asked to
remove any metal and change into a gown. If you are a smoker or drink
large amounts of caffeine you may be asked to withhold from doing so a
few hours prior to your exam. A complete prep will be provided by your
ordering physician.
The patient typically lies on his or her back with their feet
facing the scanner. Positioning sponges may be placed under the knees for
comfort and to assist in aligning the body for the
scan. If possible the patient will be asked to
raise their arms above their head. A set of
electrodes will be placed on the patient’s chest
connecting them to an ECG (electrocardiograph)
machine which records the electrical activity of
the heart. The technologist will center the area
being scanned using the laser lights on the scanner.
Shortly after the technologist leaves the room, a recorded
voice will request the patient to take a shallow breath in and hold it. At this
point the table will then move through the scanner producing a “scout”
image, and the patient will be instructed to breathe normally. There will be
a slight pause while the technologist uses the scout image to set up the
exam. The table will then move through the scanner at least one more time
for the examination and the request to suspend breathing will be
announced again.

CT Urogram
A CT Urogram is typically used to evaluate abnormalities
found within the Urinary System. CT scans of this nature assess the kidneys,
ureters, and bladder for
blockages, kidney stones,
infections, growths, and other
diseases. In preparation for this
procedure the patient may be
asked to remove any metal and
change into a gown.

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 This procedure is an Enhanced Study meaning it calls for
contrast media to be used. Further preps may be needed and should be
provided by the ordering physician. If you are allergic to IV contrast,
diabetic, or experiencing lower kidney functions inform the ordering
physician and the technologist.
The patient typically lies on his or her back with their feet
facing the scanner. Positioning sponges may be placed under the knees for
comfort and to assist in aligning the body for the scan. The technologist will
place an Intravenous (IV) Catheter in the patient’s arm. Note: this
procedure is an Enhanced Study and calls for IV contrast to be used.
If possible the patient will be asked to raise their arms above
their head. The technologist will center the area being scanned using the
laser lights on the scanner. Shortly after the technologist leaves the room, a
recorded voice will request the patient to hold their breath. At this point
the table will then move through the scanner producing a “scout” image,
and the patient will be instructed to breathe normally.
There will be a slight pause while the technologist uses the
scout image to set up the exam. The table will then move through the
scanner as the IV Contrast is being injected. Once that portion of the scan in
completed the technologist will assist the patient in relaxing his or her arms
at their side. The patient will have to wait a total of ten minutes at this
point in order to allow the IV Contrast to fill the Urinary Tract.
After the ten minute mark, the patient will be asked to raise
their arms for another scan. If the urinary tract is filled with contrast the
scan is complete, if not, the patient will be asked to lay prone (on their
abdomen) for another scan to evaluate the Urinary System.

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CT Angiography Head / Circle of Willis
CT Angiography of the head is
typically used to evaluate abnormalities
found within the blood vessels that run
through the
brain. CT
scans of this
nature assess
the arteries
and veins for
plaque, atherosclerosis, dissections, and
aneurysms. In preparation for this procedure
the patient may be asked to remove any
metal and change into a gown.
This procedure is an Enhanced Study meaning it calls for
contrast media to be used. Further preps may be needed and should be
provided by the ordering physician. If you are allergic to IV contrast,
diabetic, or experiencing lower kidney functions inform the ordering
physician and the technologist.
The patient typically lies on his or her back and their head is
placed into a cradle. Small positioning sponges or Velcro straps may be
used to reduce motion and keep the head and neck aligned properly for the
scan. The technologist will place an Intravenous (IV) Catheter in the
patient’s arm. Note: this procedure is an Enhanced Study and calls for IV
contrast to be used.
The technologist will center the area being scanned using the
laser lights on the scanner. Shortly after the technologist leaves the room,
the table will move through the scanner producing a “scout” image.
There will be a slight pause while the technologist uses the scout image to
set up the exam. The table will then move through the scanner at least two
additional times.

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CT Angiography Neck (Carotids)

CT Angiography of the Neck is typically used to evaluate

abnormalities found within the blood vessels that run through that portion
of the body. CT scans of this nature assess the arteries and veins for plaque,
atherosclerosis, dissections, and aneurysms. In preparation for this
procedure the patient may be asked to remove any metal and change into a
gown.
This procedure is an Enhanced Study meaning it calls for
contrast media to be used. Further preps may be needed and should be
provided by the ordering physician. If you are allergic to IV contrast,
diabetic, or experiencing lower kidney functions inform the ordering
physician and the technologist.
The patient typically lies on his
or her back and their head is placed into a
cradle. Small positioning sponges or Velcro
straps may be used to reduce motion and
keep the head and neck aligned properly for
the scan. The technologist will place an
Intravenous (IV) Catheter in the patient’s
arm. Note: this procedure is and Enhanced
Study and calls for IV contrast to be used. The technologist will center the
area being scanned using the laser lights on the scanner. Shortly after the
technologist leaves the room, the table will move through the scanner
producing a “scout” image. There will be a slight pause while the
technologist uses the scout image to set up the exam. The table will then
move through the scanner at least two additional times.

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CT Angiography Chest
CT Angiography of the
chest is typically used to evaluate
abnormalities found within the blood
vessels that run through that portion of
the body. CT scans of this nature assess
the arteries and veins for plaque,
atherosclerosis, dissections, and
aneurysms. In preparation for this
procedure the patient may be asked to
remove any metal and change into a
gown. This procedure is an Enhanced
Study meaning it calls for contrast media to be used. Further preps may be
needed and should be provided by the ordering physician. If you are allergic
to IV contrast, diabetic, or experiencing lower kidney functions inform the
ordering physician and the technologist.
The patient typically lies on his or
her back with their feet facing the
scanner. Positioning sponges may be placed
under the knees for comfort and to assist in
aligning the body for the scan. The
technologist will place an Intravenous (IV)
Catheter in the patient’s arm. Note: this
procedure is an Enhanced Study and calls for
IV contrast to be used. If possible the patient
will be asked to raise their arms above their head.
The technologist will center the area being scanned using the
laser lights on the scanner. Shortly after the technologist leaves the room, a
recorded voice will request the patient to hold their breath. At this point
the table will then move through the scanner producing a “scout” image,
and the patient will be instructed to breathe normally. There will be a slight
pause while the technologist uses the scout image to set up the exam. The
table will then move through the scanner at least two additional times.

138
CT Angiography Abdomen/Pelvis
CT Angiography of the Abdomen, Pelvis,
or a combination of the two is typically used to
evaluate abnormalities found within the blood
vessels that run through that portion of the
body. CT scans of this nature assess the arteries
and veins for plaque, atherosclerosis, dissections,
and aneurysms. In preparation for this procedure
the patient may be
asked to remove
any metal and change into a gown.
This procedure is an Enhanced
Study meaning it calls for contrast media to
be used. Further preps may be needed and
should be provided by the ordering
physician. If you are allergic to IV contrast,
diabetic, or experiencing lower kidney
functions inform the ordering physician and
the technologist.
The patient typically lies on his or her back with their feet
facing the scanner. Positioning sponges may be placed under the knees for
comfort and to assist in aligning the body for the scan. The technologist will
place an Intravenous (IV) Catheter in the patient’s arm. Note: this
procedure is an Enhanced Study and calls for IV contrast to be used. If
possible the patient will be asked to raise their arms above their head.
The technologist will center the area being scanned using the
laser lights on the scanner. Shortly after the technologist leaves the room, a
recorded voice will request the patient to hold their breath. At this point
the table will then move through the scanner producing a “scout” image,
and the patient will be instructed to breathe normally. There will be a slight
pause while the technologist uses the scout image to set up the exam. The
table will then move through the scanner at least two additional times.

139
CT Angiography Extremities
CT Angiography of the Extremities is
typically used to evaluate abnormalities found within
the blood vessels that run through that portion of the
body.
CT scans of this nature assess the arteries
and veins for plaque, atherosclerosis, dissections, and
aneurysms. In preparation for this procedure the
patient may be asked to remove any metal and change
into a gown.
This procedure is an Enhanced Study
meaning it calls for contrast media to be used. Further
preps may be needed and should be provided by the
ordering physician. If you are allergic to IV contrast, diabetic, or
experiencing lower kidney functions inform the ordering physician and the
technologist.
The patient typically lies on his or her back. Small positioning
sponges or Velcro straps may be used to reduce motion and keep the
Extremity being imaged aligned properly for the scan. The technologist will
place an Intravenous (IV) Catheter in the patient’s arm. Note: this
procedure is an Enhanced Study and calls for IV contrast to be used. The
technologist will center the area being scanned using the laser lights on the
scanner. Shortly after the technologist leaves the room, the table will move
through the scanner producing a “scout” image. There will be a slight pause
while the technologist uses the scout image to set up the exam. The table
will then move through the scanner at least two additional times.

140
CT Heart Angiography
CT Heart Angiography is commonly used to evaluate for a
condition called Coronary Artery Disease. Major risk factors for Coronary
Artery Disease include but are not limited to diabetes, smoking, high blood
pressure, high blood cholesterol, and obesity.
During this procedure the Heart,
Cardiac blood vessels and circulation, and
great vessels are imaged in both high
resolution and 3-Dimensionally as the heart
beats.
In preparation for this procedure
the patient may be asked to remove any
metal and change into a gown. If you are a
smoker or drink large amounts of caffeine you may be asked to withhold
from doing so a few hours prior to your exam. A complete prep will be
provided by your ordering physician.
The patient typically lies on his
or her back with their feet facing the
scanner. Positioning sponges may be placed
under the knees for comfort and to assist in
aligning the body for the scan. The
technologist will place an Intravenous (IV)
Catheter in the patient’s arm. Note: this
procedure is an Enhanced Study and calls for
IV contrast to be used. If you are allergic,
diabetic, or experiencing lower kidney functions inform the ordering
physician and the technologist.
After the IV access is established, a set of electrodes will be
placed on the patient’s chest connecting them to an ECG
(electrocardiograph) machine which records the electrical activity of the
heart. If possible the patient will be asked to raise their arms above their
head. The technologist will center the area being scanned using the laser
lights on the scanner. Shortly after the technologist leaves the room, a
recorded voice will request the patient to take a shallow breath in and hold
it.

141
 At this point the table will then move through the scanner
producing a “scout” image, and the patient will be instructed to breathe
normally. There will be a slight pause while the technologist uses the scout
image to set up the exam. A medication that slows or stabilizes the
patient’s heart may be used to increase the diagnostic value of the
images. The table will then move through the scanner at least one more
time for the examination and the request to suspend breathing will be
announced again.

142