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Roland Bruening Thomas Flohr
Neuroradiology Siemens Medical Solutions
Department of Clinical Radiology CT Division
University of Munich – Grosshadern Siemensstr. 1
Marchioninistr. 15 91301 Forchheim
81377 Munich Germany
Germany

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DOI 10.1007/978-3-662-05142-9

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 Preface

The radiology community has seen a substantial technical innovation with the development
of multislice computed tomography (CT). The introduction of multiple parallel detectors is
undoubtedly one of the most important technical improvements in the field of CT. More-
over, the new advantages of CT may also have an impact on the general use of CT and mag-
netic resonance imaging (MRI).
Multislice CT is becoming increasingly available in industrialized countries. Conse-
quently, interest in practical aspects of the method is also growing. Common questions in-
clude when and how to use the systems. While the initial scanners were equipped with two
or four detector rows, current advances have led to scanners with up to 16 rows becoming
available for clinical use. And there is still more to come.
As these multislice CT systems maintain the general advantages of CT, i.e. reliability and
short examination times, their ability to investigate large areas of the body in a very short
time with improved transverse resolution has broadened the potential medical applications
of CT. Thus, new medical indications for CT, such as cardiac CT, have emerged. Some ques-
tions in diagnostic imaging, e.g. a non-invasive neck study for suspected carotid stenosis,
may in future be solved more frequently with multislice CT than with MRI. Other indica-
tions such as the staging of rectal or laryngeal cancer may see a higher sensitivity and spe-
cificity with multislice CT than with single-slice systems.
There is also a substantial change in the way the examination is planned and carried out.
Instead of individual axial slices, there is a thin-collimation acquisition of a volume. Subse-
quent reconstructions are becoming more and more important. In some protocols, such as
the cranial sinuses, only the coronal reconstructions are read at our institution, while the
axial data are not used. Thin-collimation acquisition is also useful for minimizing artefacts.
It is here that reconstructions are made in thicker slices to minimize image noise.
Care must be taken so as not to increase the patient radiation dose unnecessarily. There-
fore, whenever possible, the mAs must be adapted and reduced, the scanned volume must
be restricted and last but not least the indication for the examination must be established.
The increased speed of multislice CT suggests a change in the use of intravenous contrast
agents. While the different injection doses, velocities and concentrations are currently
under investigation, the protocols in this book include a subjective recommendation for
use.
This book includes a personal selection of protocols for application with four-row or
16-row scanners. These protocols have been optimized for Siemens scanners; however, the
protocol layout and the data presented can also be employed with different bands. While we
made substantial effort to adjust the protocols to the current knowledge, preferences on the
use of protocols change quickly and also vary from site to site. Therefore, if the reader has
any comments or suggestions for variations of these protocols, they should not hesitate to
contact us. Please note that despite careful proofreading, there can be no liability on the part
of the authors for the use of any of the protocols.
VI Preface

We would like to express our sincere thanks to all the contributors and to the local CT tech-
nicians. We gratefully acknowledge Prof. Maximilian Reiser, who enabled and encouraged
this early clinical experience with multislice CT in Großhadern by his personal patronage
and vision. Springer kindly supported the idea of publishing this volume and provided us
with invaluable assistance. We hope that everyone interested in the technique of multislice
CT finds this book useful.

R. Bruening Munich
T. Flohr Forchheim
 Contributors

Becker, C Flohr, T.
Department of Clinical Radiology Siemens Medical Solutions
University of Munich – Grosshadern CT Division
Marchioninistr. 15 Siemensstr. 1
81377 Munich 91301 Forchheim
Germany Germany

Bruening, R. Glaser, C.
Department of Clinical Radiology Department of Clinical Radiology
University of Munich – Grosshadern University of Munich – Grosshadern
Marchioninistr. 15 Marchioninistr. 15
81377 Munich 81377 Munich
Germany Germany

Eibel, R. Haw, Loke Gie

Department of Clinical Radiology Siemens Medical Solutions
University of Munich – Grosshadern CT Division
Marchioninistr. 15 Siemensstr. 1
81377 Munich 91301 Forchheim
Germany Germany

Ertl-Wagner, B. Hofmann, R.
Department of Clinical Radiology Department of Clinical Radiology
University of Munich – Grosshadern University of Munich – Grosshadern
Marchioninistr. 15 Marchioninistr. 15
81377 Munich 81377 Munich
Germany Germany

Flatz, W. Hong, C.
Department of Clinical Radiology Department of Clinical Radiology
University of Munich – Grosshadern University of Munich – Grosshadern
Marchioninistr. 15 Marchioninistr. 15
81377 Munich 81377 Munich
Germany Germany
VIII Contributors

Jaeger, L. Rust, G.F.

Department of Clinical Radiology Department of Clinical Radiology
University of Munich – Grosshadern University of Munich – Grosshadern
Marchioninistr. 15 Marchioninistr. 15
81377 Munich 81377 Munich
Germany Germany

Kohl, G. Schaller, S.
Siemens Medical Solutions Siemens Medical Solutions
CT Division CT Division
Siemensstr. 1 Siemensstr. 1
91301 Forchheim 91301 Forchheim
Germany Germany

Kulinna, C. Schoepf, U.J.

Abteilung für Radiologie Dept. of Radiology
AKH Wien Brighams Woman Hospital
Universität Wien Boston, MA 02115
Währinger Gürtel 18–20 USA
1090 Wien
Austria Wieser, A.
Department of Clinical Radiology
Mueller-Lisse, U. University of Munich – Grosshadern
Department of Clinical Radiology Marchioninistr. 15
University of Munich – Grosshadern 81377 Munich
Marchioninistr. 15 Germany
81377 Munich
Germany Wintersperger, B
Department of Clinical Radiology
Ohnesorge, B. University of Munich – Grosshadern
Siemens Medical Solutions Marchioninistr. 15
CT Division 81377 Munich
Siemensstr. 1 Germany
91301 Forchheim
Germany
 Contents

Technical Principles and Applications of Multislice Spiral CT . . . . . . . . . . . . . . . 1

4-row Scanning

Head

Routine CCT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Contrast-Enhanced CCT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Temporal Bone and Inner Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
CTA Intracranial Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Venous Sinus CTA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Cerebral Perfusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Neck

Routine Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Routine Sinuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Sinus Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Nasopharynx and Oropharynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Larynx and Hypopharynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
CTA Carotids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Chest

Routine Chest and HR-Chest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Pulmonary Embolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Combi Thorax. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
CTA Aortic Arch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
X Contents

Heart

Coronary Artery Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

CTA Bypasses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
CTA Coronary Arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Abdomen

Routine Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Venous Upper Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Biphasic Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Biphasic Liver (Including CTAP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
CT Enteroclysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Biphasic Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Routine Kidney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Renal Differential Diagnosis and Tumors. . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Rectal Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
CTA Abdomen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Spine

Cervical Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Thoracic Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Lumbar Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Peripherals

Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Ankle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Peripheral CTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
 Contents XI

Interventions

Drainages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Biopsies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Sympaticolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

16-row Scanning

Head

Routine CCT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

Temporal Bone and Inner Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
CTA Intracranial Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

Neck

Routine Neck. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

Larynx and Hypopharynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
CTA Carotids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

Chest

Routine Chest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

Pulmonary Embolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
CTA Aortic Arch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

Heart

Coronary Artery Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

CTA Coronary Arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

Abdomen

Routine Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

CTA Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
XII Contents

Spine

Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126

Peripherals

Peripheral CTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
 Abbreviations

CCT cranial CT
CT computed tomography
CTA CT angiography
FOV field of view
HR high resolution
MDCT multidetector CT
MIP maximum intensity projections
MPR multiplanar reformats
MRI magnetic resonance imaging
MSCT multislice CT
SSD shaded surface display
STS sliding thin slices
US ultrasound
VRT volume rendering techniques
 1

Technical Principles and Applications

of Multislice Spiral CT

T. Flohr · B. Ohnesorge · G. Kohl · S. Schaller

Introduction slice width on a 4-slice CT system, obtaining

high-quality image data for volumetric visu-
With the introduction of multislice comput- alization, evaluation, and quantification. As
ed tomography (CT) into clinical practice a a consequence, volumetric viewing and di-
new era began, leading to the possibility of agnosis in a volumetric mode have become
nearly isotropic voxel imaging and high- integrated elements of the routine workflow.
quality reconstructions. The main draw- Still, true isotropic resolution cannot be
backs of single-slice spiral CT are insuffi- reached with 4-slice CT systems. In a typical
cient volume coverage of the patient within abdomen examination the in-plane resolu-
the time of one breathhold and missing spa- tion is about 0.5 mm using a standard body
tial resolution in the z-axis due to wide col- kernel. This is not fully matched by the axial
limation. Larger volume coverage and im- resolution of about 1 mm. For long-range
proved axial resolution may be achieved by studies, such as peripheral CTAs, even thick-
simultaneous acquisition of more than one er slices (2.5 mm collimated slice width)
slice and by a shorter rotation time. In 1998, have to be chosen for acceptable scan times.
all major CT manufacturers introduced mul- Consequently, an increased number of si-
tislice CT systems offering increased scan multaneously acquired slices and sub-milli-
speed, improved axial resolution, and better meter collimation for routine clinical appli-
utilization of the tube output. These new de- cations were seen to be the next steps on the
vices typically offer simultaneous acquisi- way towards true isotropic scanning with
tion of four slices at 0.5 s rotation time, thus multislice CT, and 16-slice CT systems were
increasing the performance of a single-slice introduced in 2001.
CT scanner at 1 s rotation time by a factor of This technical introduction concentrates
8. This increased performance allows for the on the principles of multislice scanning with
optimization of different clinical parame- established 4-slice CT systems and ends
ters: for example, the examination time for a with an outlook to state-of-the-art 16-slice
standard protocol may be reduced by a fac- technology.
tor of 8, which is clinically important in a va-
riety of instances, such as in dealing with
trauma or uncooperative patients. Alterna- Technical Principles
tively, the scan range may be extended cor- of 4-Slice Scanning
respondingly, as for oncological screening
or for CT angiographies (CTAs) of the ex- In the following subsections we will discuss
tremities. Most important, however, is the the relevant design features for volumetric
capacity to scan a given volume in a given scanning with established 4-slice CT sys-
time with considerably smaller slice width, tems.
thus to approach the ideal of isotropic reso-
lution. Chest and abdomen examinations
may be routinely performed with 1.25-mm
2 Technical Principles and Applications of Multislice Spiral CT

Detector Design

The simplest model of a 4-slice CT detector

consists of four detector rows: with this,
however, only one fixed-beam collimation
may be realized. For clinical purposes a va-
riety of different beam collimations is abso-
lutely necessary.A useful 4-slice detector has
to have more than four detector rows, which
are combined differently according to the
selected beam collimation. The adaptive ar-
ray detector (Schaller 2000; Ohnesorge
2000a) consists of eight detector rows with
different widths and allows for the following
beam collimations: 2×0.5 mm, 4×1 mm, 4×
2.5 mm, 4 ×5 mm, 2× 8 mm, and 2 × 10 mm
(see Fig. 1). The selection determines the in-
trinsic axial resolution of a scan; for a spiral
mode, the slice width can be adjusted inde-
pendently (see “Multislice Spiral Concept”).
The adaptive array detector is designed for
optimum dose efficiency, as the width of the
detector rows is tailored to the available
beam collimations and unnecessary cuts
and dead zones are avoided.
Fig. 1. Adaptive array detector for a 4-slice CT-
system.The detector consists of eight rows of dif-
ferent size, which define slices between 1 mm
Multislice Spiral Concept and 5 mm in the center of rotation. Due to geo-
metrical magnification, the detector itself is
Basic Parameters: about 40 mm wide
Definition of Pitch and Dose

A very important parameter to characterize cording to the needs of the clinical examina-
a spiral scan is the pitch. A historical, now tion.
obsolete definition for a multislice spiral For a better comparison with single-slice
scanner is the volume pitch (Pvol). CT systems, an alternative definition, the
For a multislice spiral CT scanner, we de- normalized pitch factor P, also called nor-
fine the volume pitch Pvol: malized pitch, must be used. According to
IEC this is the official definition of the pitch.
Pvol =tablefeed per rotation/ (1) This definition uses the total width of the X-
width of one subbeam ray beam in the denominator, giving:

For a beam collimation of 4 ×1 mm, the P=tablefeed per rotation/ (2)

beam consists of four subbeams, each 1 mm total width of X-ray beam
wide at the center of rotation. With 7 mm
table feed per rotation, the volume pitch is In the above example, P=7/4. The usable
Pvol =7. The usable pitch range of a 4-slice pitch range of a 4-slice scanner then is 0.25
scanner is between 1 and 8. Within this to 2. In this volume, the normalized pitch
range, the pitch can be freely selected, ac- factor is used throughout.
 Technical Principles and Applications of Multislice Spiral CT 3

Fig. 2. Full width at half maximum (FWHM) of the slice sensitivity profile as a function of the pitch for
the two most commonly used single-slice spiral interpolation approaches, 180LI and 360LI. For both,
the slice significantly broadens with increasing pitch.As a consequence,multiplanar reformats (MPRs)
of a spiral z-resolution phantom scanned with 2-mm collimation (180LI) show increased blurring of
the 1.5-mm and 2-mm cylinders with increasing pitch

Clinically appropriate measures for dose Short Review of Single-Slice Spiral CT

are the local dose as given by the weighted
computerized tomographic dose index The most commonly used single-slice spiral
(CTDI) or, more appropriate to volume interpolation schemes are the 360° and 180°
scanning, the dose-length product (McCol- linear interpolations (360LI and 180LI):
lough 2000).With the above definition of the
pitch factor P (see Eq. 2), the dose of a spiral ∑ The slice width [i.e., the full width at half
scanner with rotation time trot is given by: maximum (FWHM) of the slice sensitiv-
ity profile (SSP)] significantly increases
Dose=mA¥trot ¥1/P¥CDTI, (3) with increasing pitch (see Fig. 2). This is a
consequence of the increasing axial dis-
with CTDI in mGy/mAs. This fundamental tance of the projections used for spiral
equation is valid both for single-slice and interpolation.
for multislice CT. ∑ The image noise is independent of the
pitch, if the tube current (mA) is left un-
changed.