CE Article #2

Computed Tomography:
Principles and Applications
Charlotte Whatmough, BVetMed
Christopher R. Lamb, MA, VetMB, DACVR, DECVDI
The Royal Veterinary College
University of London

ABSTRACT: Computed tomography (CT) is gradually becoming more widely available in

veterinary referral practices and has advantages for the investigation of patients with a variety of
lesions affecting most parts of the body.The cross-sectional depiction of anatomy in CT images
eliminates the problem of superimposition of body parts, which significantly limits conventional
radiography.Therefore, CT has a higher sensitivity for detecting disease and enables more accurate
assessment of the extent of lesions, which is important in surgical planning.

C
omputed tomography (CT) has been in from the detectors are then passed to a computer,
clinical use in humans since 1973. 1 which reconstructs the data into a two-dimen-
Although CT was originally developed sional image representing a cross-section of the
for imaging the brain, CT scanners are used patient2 (Figure 1). A CT scanner represents a
today for a wide range of examinations of most high-quality piece of engineering that includes a
parts of the body, particularly the head, thorax, high-output x-ray tube, a gantry that supports
and abdomen. CT is gradually becoming more the x-ray tube, detector array, and a patient bed.
widely available in veterinary referral practices; Operation of the scanner is controlled by com-
therefore, it is important that practitioners be puter. CT images are viewed as they are acquired
aware of this imaging modality. on a monitor. Other scans can be viewed or
manipulated on a remote workstation without
PRINCIPLES interfering with the scan in progress. CT images
Image Formation may be printed onto film so that they may be
In conventional radiography, a broad x-ray viewed on a light box.
beam is emitted from a stationary tube and passes During a scan, the x-ray tube normally revolves
through the patient, casting a shadow on a flat continuously through 360˚ around the patient
screen that absorbs the x-rays and then re-emits as the patient is moved through the aperture of
their energy as light, which affects photographic the scanner; the patient is moved either in a
film. In CT, a narrow, fan- series of small increments (axial scan mode) or
Send comments/questions via email to shaped x-ray beam is emitted continuously (helical scan mode; Figure 2). The
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Visit CompendiumVet.com for pass through the patient are precisely selected by the radiographer. Images
full-text articles, CE testing, and CE counted by a series of small representing thin slices (i.e., 1 to 2 mm) of the
test answers. electronic detectors; signals patient may be acquired when maximal resolu-

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790 CE Computed Tomography: Principles and Applications

Figure 1. A CT system. achieved by using thicker slices with a correspond-

ingly higher radiation dose.2
CT scans have properties similar to those of con-
ventional radiographs because both are produced via
the absorption of x-rays by tissues of different density;
thus low-density tissues (e.g., lungs) appear black or
dark gray, and high-density tissues (e.g., bone) appear
light gray or white. The major differences between
conventional radiographs and CT images are:

• Each CT image represents a thin section of the

patient; thus multiple images are required to
cover a particular anatomic structure or body
cavity (Figure 3).

The components of a typical CT system. In addition, images may be sent

• CT images are digital and composed of many pix-
els, each with a number that describes the attenu-
to a printer or archived via a radiology information system to an image
server (not shown). ation of the tissue within that pixel (Figure 4).
• Because CT images display the attenuation
directly assigned to each pixel, whereas conven-
tional radiographs present the sum of attenua-
tions within all superimposed structures within
the thickness of the patient, CT can detect dif-
ferences in tissue density that are too small to be
visible on conventional radiographs.2

Image Interpretation
Each pixel in a CT image is assigned a number
that describes the amount of attenuation of the x-
ray beam by that part of the patient. These numeric
values, known as CT numbers or Hounsfield units
(HU), encompass a wide range (e.g., –1,000 HU for
air, 0 HU for water, 3,000 HU for compact cortical
bone; Figure 5). The CT image observed on the
computer monitor may be adjusted so that the
potentially wide range of attenuation values in the
tissues being examined (known as the window) can
A CT scanner with the front cover removed during installation.The be displayed using the relatively few gray levels that
arrows in the aperture indicate the direction of the x-ray beam. the monitor produces. A wide window is used to
display a wide range of attenuation in air- or bone-
containing structures (e.g., in the head or thorax),
tion of small, high-contrast structures is required (e.g., whereas a narrow window must be used to display the
when examining the bones of the middle and inner ear). more limited range of attenuation associated with soft
As an alternative, thicker slices (i.e., 5 to 8 mm) can be tissues (e.g., in the brain or abdomen; Figure 6). It is
used when it is important to distinguish between tissues normal practice to view images using multiple windows
of similar attenuation (e.g., parts of the brain, abdomi- to thoroughly examine different tissue types. CT can
nal organs). Thicker slices are necessary because recog- distinguish different soft tissue and fluid types (e.g.,
nition of small differences in attenuation (i.e., low- blood may be distinguished from transudate based on
contrast resolution) depends mainly on minimizing sta- their CT numbers) as well as differentiate between soft
tistical variations (i.e., “noise”) in the images; this is tissues and some fluids.2

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 Computed Tomography: Principles and Applications CE 791

Figure 2. Illustration of a CT scan in progress.The patient can be moved through the aperture in a series of small increments (i.e.,
axial scan mode) or continuously (i.e., helical scan mode).

The principles of interpreting CT images are the

same as those for interpreting conventional radio-
graphs. For example, the same radiographic signs
(i.e., number, position, size, shape, margination,
opacity) are used, with tissue density replacing
opacity. The terms hyperdense, isodense, and hypo-
dense are used to describe the relative attenuation of
structures in CT images, although tissue density
may also be described precisely according to its CT
number.
CT images are often easier to interpret than con-
ventional radiographs because the cross-sectional
depiction of anatomy eliminates the problem of
superimposition of body parts; however, to recog-
nize and describe structures correctly, it is necessary
to learn cross-sectional anatomy in detail.3–6 CT
images are usually acquired in the transverse plane,
although it is possible to reprocess the data after
acquisition to produce sagittal, dorsal, or oblique Figure 3. Multiple CT images are required to cover a body
images and three-dimensional reconstructions (Fig- part. In this instance, a pilot (i.e., scout) image of the head (top;
ure 7). Depending on the slice thickness used to resembling a lateral radiograph) has been used to plan the position of
acquire the original data, reconstructions can have a transverse images.The number of images required to cover a particular
coarse appearance and, although they may some- body part depends on their thickness and spacing.
times look impressive, do not add any information
to the original format.
the scan, and sometimes a repeat scan after intravenous
Practicalities injection of contrast medium. Therefore, CT scans usu-
Just as with conventional radiography, accurate patient ally take several minutes and patients are usually sedated
positioning is important in obtaining optimal CT or anesthetized. For most scans, we prefer to position pa-
images. For example, oblique positioning can complicate tients in sternal recumbency.
the interpretation of CT images just as it does in radiog- Anesthetized animals are usually monitored from
raphy. Although the exposure time for a CT scan of a outside the room while CT is conducted. Animals are
body region such as the thorax may be as little as 30 sec- not manually restrained for CT scans; however, for crit-
onds, the patient must remain perfectly still for an initial ically ill patients requiring constant monitoring, it may
“pilot” image (used to select the position of CT images), be necessary for a person (wearing a lead apron and

November 2006 COMPENDIUM

792 CE Computed Tomography: Principles and Applications

period of hyperventilation of anesthetized animals

can induce apnea for up to 1 minute, which is
enough time to complete the scan while personnel
are out of the room.
Contrast studies such as intravenous urography7
(Figure 8), myelography,8 and portography9 can be
combined with CT. Intravenous contrast medium
tends to accumulate in vascular, hemorrhagic, or
edematous lesions, which aids in their identifica-
tion. Contrast medium accumulation may also
enable lesion margins to be defined more precisely
(this is discussed later).
Figure 4. CT scans are digital images composed of many pixels
(i.e., picture elements).A close-up (on left) of part of a thoracic CT scan of CT scans can be affected by various artifacts that
a dog shows the pixels, although they are not readily apparent when the degrade image quality and make interpretation more
image is at normal size.The typical matrix size of a CT image is 512 × 512 difficult.10 Movement of the patient during the scan
pixels. causes blurring (Figure 9). Highly attenuating struc-
tures such as metallic implants or positioning sand-
bags can cause streak artifacts (Figure 10).

APPLICATIONS
CT enables more detailed examination of a wider
range of structures than does conventional radiogra-
phy or ultrasonography. Thus CT may be used:

• As an alternative to a multiple-view radiographic

study
• Following normal results of radiography or ultra-
sonography
• To gain more information about a suspected
abnormality observed via radiography or ultra-
sonography
Figure 5. Each pixel in a CT image is assigned a number
(i.e., Hounsfield unit [HU]) representing the attenuation of • To guide biopsy of a known lesion
tissue at that location. HU is a unitless number representing the
degree of x-ray attenuation in tissue (µtissue) relative to water (µwater).The • To determine the extent of a lesion before sur-
scale of HU ranges includes –1,000 HU for air (lower end) to +3,000 gery or radiation therapy
HU for compact cortical bone (upper end).Water has a value of 0 HU.
Unlike conventional radiography, CT can distinguish between various In practice, the selection of cases for CT depends
soft tissues. partly on an assessment of the individual patient’s
needs and partly on various local factors, including
the cost, convenience, and availability of other
thyroid shield) to remain in the room during the scan. imaging facilities. CT is generally more expensive than
The radiation dose to the patient is considerably higher ultrasonography and less expensive than magnetic reso-
with CT than with conventional radiography; however, nance imaging (MRI).
the amount of scatter is relatively low because the pri-
mary x-ray beam is a highly collimated, narrow fan Head
beam and is contained within the gantry.2 CT scans of CT is particularly well suited to examinations of the
the thorax requiring some manipulation of breathing head because of the high contrast provided by bone and
(e.g., maximal lung inflation) may require that the air-containing structures and because cross-sectional
anesthetist be in the room. As an alternative, a short images eliminate problems associated with superimposi-

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 Computed Tomography: Principles and Applications CE 793

tion that affect radiography of the head. Figure 6. Once a CT scan has been acquired, the range of HU
Therefore, CT is useful in assessing animals displayed may be adjusted according to the tissue of interest. These
two CT images of the same part of the head of a dog can be compared.
with head trauma (Figure 11). Although MRI
is generally considered the optimal modality
for imaging the brain, CT can be a useful
alternative when there is limited access to
MRI or costs must be minimized. CT scans of
the brain have less anatomic detail than MRI
scans but may nevertheless enable detection of
intracranial hemorrhage11 (Figure 11), hydro-
cephalus, and intracranial masses12–14 (Figure
12). When the brain is examined, CT scans
are typically obtained before and after adminis-
tration of intravenous contrast medium. The Selecting a narrow window shows A wide window is better suited to
differences within organs with a tissues with a wide range of HU (e.g.,
blood–brain barrier normally prevents contrast
narrow range of HU (e.g., the brain). bone).
medium from reaching the neural tissues; how-
ever, many inflammatory or neoplastic lesions
damage the blood–brain barrier, thereby allow- Figure 7. Although CT images are usually acquired in the transverse
ing accumulation of contrast medium and facil- plane, the data can be reprocessed after acquisition to produce sagittal,
itating detection of lesions affecting the brain. dorsal, or oblique images and three-dimensional reconstructions.
Other indications for CT of the head in
small animals include exophthalmos15 (Figure
13), suspected otitis media,16 and chronic nasal
discharge. CT scans clearly show the fine
detail of the turbinates and nasal conchae;
thus small intranasal lesions or sites of bone
invasion by nasal neoplasms that could be
missed on conventional radiographs are seen
on CT scans.17,18 Accurate assessment of the
extent of a nasal lesion aids in determining the
prognosis and treatment options. Rhinitis and
nasal neoplasia may be reliably distinguished
using CT19 (Figure 14). The frontal sinuses Transverse plane in a normal dog. Dorsal image of a normal dog.
are normally included in a nasal CT study
because fluid accumulation, mucosal thicken-
ing, and bone lesions often occur secondary to
nasal disease. Postcontrast CT scans can be
used if invasion of the brain is suspected. The
retropharyngeal lymph nodes can be included
in the study to look for signs of local spread of
disease.

Thorax
For the thorax, a helical CT scan technique is
preferred to minimize scan time, which reduces
the likelihood of movement artifacts resulting
from patient breathing. CT is used for imaging
Three-dimensional reconstruction of Three-dimensional reconstruction of a
all thoracic structures except the heart, which a normal dog. dog with a highly invasive nasal
appears blurred. CT images of the lungs are neoplasm that has destroyed large
parts of the maxillae, nasal and frontal
bones, and right zygomatic arch.
November 2006 COMPENDIUM
794 CE Computed Tomography: Principles and Applications

particularly useful, often re-

vealing lesions (e.g., metas-
tases) that are not visible on
survey radiographs or enabling
detailed assessment of the
extent of a lesion, which aids
in surgical planning. Sus-
pected pulmonary metastasis20
(Figure 15), thoracic mass21,22
(Figure 16), and nontraumatic
(“spontaneous”) pneumo-
thorax23 are frequent indica-
tions for thoracic CT.
Figure 8. Contrast CT may be used to more clearly identify structures or lesions.
Intravenous contrast medium excreted by the kidneys has opacified the ureters (arrows), making it
easier to identify them adjacent to the colon (left) and their sites of termination in the bladder Abdomen
(center and right).This type of CT scan has been used to examine dogs with suspected ectopic At most institutions, ab-
ureters. dominal CT studies are rela-
tively infrequent compared
with abdominal ultrasonog-
Figure 9. Motion blur artifact. raphy because of the conven-
ience and lower cost of the latter; however,
CT is useful for the examination of abdominal
structures that are difficult to examine via
ultrasonography, such as the pancreas, 24,25
mesentery, and pelvic canal. There is evidence
that CT is a more accurate method of deter-
mining the extent of abdominal lesions, which
may be important when resection is planned
(Figure 17). Reports have described the use of
CT for investigation of portosystemic shunt-
ing,9 adrenal gland disease26 (Figure 18), and
Patient movement during a CT scan The same scan while the cat was still
produces a streaky appearance. (after an additional dose of sedative). ectopic ureters.27
(text continues on p. 798)

Figure 11. CT scan of a dog hit by a car.

Figure 10. Beam-hardening artifact.

Attenuation of the x-ray beam by metal causes
streaking, as in this CT image of an air-gun pellet Multiple depressed fractures affecting A focal hyperdense lesion (*) affecting
lodged in a cat’s right tympanic bulla.To avoid this the right frontal bone (arrow) are the right frontal lobe of the brain is
problem, metal objects (e.g., electrocardiogram displayed by using a wide window. visible by using a narrow window.This
leads) should be kept out of the aperture. lesion represents a hematoma.
Figure 12. CT scans of a dog with an intracranial mass resulting from granulomatous meningoencephalitis. Although the
initial CT scan (left) appears normal, a repeat scan (center) after administration of intravenous contrast medium shows focal accumulation in
the left lobe of the cerebellum (arrow).A postgadolinium T1-weighted MRI (right) of the same dog more clearly shows the anatomy of this
region and the mass lesion (arrow). MRI is preferred in imaging the brains of dogs and cats; although CT produces lower-quality images, it does
have other advantages, including lower cost and shorter scan time, which may enable scanning without anesthesia in critically ill patients.

Initial CT scan. Postcontrast CT scan. Postgadolinium T1-weighted MRI.

Figure 13. The use of CT to investigate exophthalmos. Pre- and

postcontrast CT images of the head of a dog with left exophthalmos and signs of
pain when opening the mouth. In the precontrast scan, there is swelling of the left
masticatory muscles (note the convex dorsal contour [arrow on left]). Contrast
accumulation in the left temporal muscle (* on right) supports a diagnosis of myositis.

Precontrast CT image. Postcontrast CT image.

Figure 14. CT is particularly well suited to nasal cavity examinations because of the high contrast provided by bone and
air-containing structures.

A CT scan of a normal nasal cavity. In dogs with destructive rhinitis (e.g., Replacement of turbinates by a soft tissue
aspergillosis), destruction of the nasal mass with destruction of the surrounding
turbinates is readily observed. bone is typical of a nasal tumor.
 Figure 16. Sequential CT images of a dog with a pulmonary carcinoma affecting
the left caudal lobe.

Figure 15. CT scan of an obese A pulmonary nodule (arrow) Impingement on the esophagus Lack of lesions affecting the
dog with fibrosarcoma between the raises the possibility that the (*) suggests possible invasion, ribs and the presence of
scapulae. A small nodule in the dorsal mass has metastasized. which would complicate bronchus within the mass
left caudal lobe (arrow) is compatible resection of the mass. (arrow) support a diagnosis of
with pulmonary metastasis. pulmonary mass.

Figure 17. Postcontrast CT images of the abdomen of a dog with pheochromocytoma affecting the right adrenal gland.

The tumor (*) is clearly visible between the The margins of the mass are ill-defined, with The left ureter is encased by the tumor
aorta and caudal vena cava. evidence of retroperitoneal infiltration by (arrow). Resection of this lesion would require
the tumor (arrow). a left nephrectomy.

Figure 18. Postcontrast CT images of the abdomen of a dog with adenocarcinoma affecting the right adrenal gland.
These images indicate invasion of the tumor into the caudal vena cava, resulting in a blood clot or tumor thrombus.

The tumor (*) is visible between the right In an image just cranial to the one on the The intrahepatic part of the caudal vena cava is
kidney and the caudal vena cava. left, the tumor merges with the caudal vena filled with a thrombus, leaving only a thin rim of
cava (arrow). contrast medium in the surrounding lumen
(arrow).
 Figure 20. Spectrum of CT findings in dogs with incomplete
ossification of the humeral condyle.

In a normal dog, there is a relatively An incomplete sagittal fissure with

uniform trabecular pattern within the surrounding sclerosis.
Figure 19. CT scan of the elbow of a dog with
humeral condyle.
arthritis secondary to fragmented medial
coronoid process (arrow). (R = radius; U = ulna)

Figure 21. Images of a dog with a tumor

destroying the fifth thoracic vertebra (T5).

A complete but nondisplaced fissure. Pathologic fracture through the middle

of the humeral condyle.The dog had a
Robert Jones bandage and plastic gutter
Lateral radiograph showing a subtle lucency affecting splint applied to support the injured limb.
the base of the dorsal spine (arrow). This support was left in place for the CT
scan because it does not adversely affect
the images.

Figure 22. CT-guided biopsy of a vertebral neoplasm.

CT image more clearly showing the extent of the

lesion, which has destroyed the base of the dorsal Poorly marginated foci of bone Repeat scan showing a hypodermic
spine (*), dorsal lamina, and left pedicle (arrowhead). destruction affecting the body of the needle placed as a guide for the biopsy
A pathologic fracture (arrow) is also visible. In this first lumbar vertebra, floor of the needle, which was subsequently
instance, the CT scan enables more confident vertebral canal, right pedicle, and base inserted alongside.The streak artifact
diagnosis of a vertebral lesion and more detailed of the transverse process. from the tip of the needle indicates a
depiction of the extent of the lesion.This information safe path to the lesion.The histologic
was used to guide biopsy. diagnosis was plasmacytoma.
798 CE Computed Tomography: Principles and Applications

Musculoskeletal Structures using helical computed tomographic excretory urography in healthy dogs. Vet
Radiol Ultrasound 44(2):155–164, 2003.
The detection of minimally displaced or incomplete 8. Jones JC, Inzana KD, Rossmeisl JH, et al: CT myelography of the thoraco-
fractures using conventional radiography can depend on lumbar spine in 8 dogs with degenerative myelopathy. J Vet Sci 6(4):341–348,
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position may be a matter of luck, and it is possible to 10. Barrett JF, Keat N: Artifacts in CT: Recognition and avoidance. Radiograph-
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800 CE Computed Tomography: Principles and Applications

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ARTICLE #2 CE TEST
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1. Which is a major advantage of CT compared 6. Which statement regarding the use of CT for
with conventional radiography? investigation of nasal disease is incorrect?
a. CT is much quicker to perform than radiography. a. Sites of bone invasion by nasal neoplasms may be
b. CT results in a much lower radiation dose to patients missed with conventional radiography but are usually
than does conventional radiography. visible with CT.
c. Anesthesia or sedation is rarely required in CT. b. Rhinitis and nasal neoplasia may be reliably distin-
d. The cross-sectional depiction of anatomy in CT images guished by CT.
eliminates the problem of superimposition of body c. CT can be used to detect signs of brain invasion by a
parts. nasal neoplasm.
d. The retropharyngeal lymph nodes are too small to
2. CT scanners produce an x-ray beam in the shape be examined by CT.
of a
a. cone. c. fan. 7. CT is more sensitive in detecting pulmonary me-
b. pencil beam. d. rectangle. tastasis than is conventional radiography because
a. motion blur is not a problem in CT.
3. Each pixel in a CT image is assigned a number b. the patient’s radiation dose is much higher in CT.
that describes c. CT eliminates the problem of superimposition by
a. its width and thickness. ribs and other structures that could obscure pul-
b. its position relative to the center of the x-ray beam. monary lesions.
c. the attenuation of tissues in that pixel. d. CT uses a much lower kilovolt peak than does con-
d. the radiation dose to the patient. ventional thoracic radiography, making nodules more
visible.
4. When CT is used to scan the brain of a dog with
a suspected intracranial mass, which protocol 8. The CT number (HU) represents the amount of
should be used? x-ray attenuation of a tissue relative to
a. thick slices; narrow window a. air. c. blood.
b. thick slices; wide window b. water. d. bone.
c. thin slices; narrow window
d. thin slices; wide window 9. Which is the most appropriate window width in
examining a sclerotic lesion affecting a vertebra?
5. Which statement regarding the use of contrast a. 3,000 HU
medium in CT is correct? b. 1,000 HU
a. Intravenous contrast medium normally penetrates c. 500 HU
the blood–brain barrier. d. –1,000 HU
b. Intravenous contrast medium tends to accumulate in
hemorrhagic or edematous lesions. 10. Which organ is the least well depicted by CT?
c. Larger doses of intravenous contrast medium are a. the brain
necessary for CT than for conventional radiography. b. the liver
d. Intrathecal administration of contrast medium is not c. the heart
necessary in CT myelography. d. the lungs

COMPENDIUM November 2006