CT Basics, CT contrast

protocol and CT adverse

reaction

Moderator Dr. Hardik Veerwal

Dr. Manishi L Narayan Junior Resident
Professor and Head
Dept. of Nuclear Medicine
Dept. of Nuclear Medicine
 C.T. scan (Computed tomography scan)

• Computed tomography (CT) scan machines uses X-rays

• CT combines X ray radiation and radiation detectors coupled with a computer

to create cross sectional image of any part of the body.
CT image represents a cross section of the imaged subject rather than the x-
ray shadow of the anatomy, as in a conventional radiograph
• With a conventional radiograph, information with respect to the
dimension parallel to the x-ray beam is lost

• Limitation can be overcome, to some degree, by acquiring two images

at an angle of 90 degrees to one another
• The CT image is produced by the process of reconstruction

• Digitally combining information from x-ray projections through the

patient from many different angles to produce the cross-sectional
image.
A simple CT scan produces a one-dimensional strip radiograph for each
projection through the patient
 In a CT of a single section of tissue using a single detector
The x-ray beam is collimated to the desired image thickness

The detector array record the intensity of the beam passing through
the tissue along the path from the x-ray tube to the element.

System captures a simple projection x-ray through the patient as a 1

dimensional radiograph

The scanner then rotates the source and detector - capture additional
1D “strip x-rays”

stored in the computer memory for later reconstruction

• In multislice CT this operation is performed simultaneously for many
arrays of detectors stacked side by side along the z-axis (long axis) of
the patient
• Each row of detectors can measure a separate transmission signal for
the tissue section that lies between the detector row and the tube

• The width of tissue that is sampled by each detector row is

determined by the physical width of the detector elements along the
z-axis

• “16-slice” CT scanner- 16–detector row CT scanner

means that the scanner can acquire up to 16 individual detector data

sets at one time.
• The individual data elements acquired - acquired images or acquired
projection data.

• Multidetector-row scanner –

The data are often acquired in thicknesses of 0.5 to 0.7 mm and

reconstructed in image thicknesses of 3 to 5 mm.
CT Reconstruction
• Collection of 1d projection radiographs

• Methods for reconstruction - filtered backprojection (FBP) and

iterative reconstruction (IR)

use computerized combine the 1D 2D maps of the

mathematical projection attenuation of the
operations attenuation scanned subject
information
• The image is 2D

• But it represents a 3D volume of tissue with a finite thickness (usually

a very small thickness compared to the field-of-view (FOV) size [≈2-5
mm])
Linear Attenuation
source of ionizing radiation is transmitted through
an object to recreate an image of the object
based on its x-ray absorption

The intensity of the transmitted radiation beam is

given by the equation

I = I0 e−µ x
I0 is the incident intensity of x-ray
I is the transmitted intensity
e is Euler’s constant
µ - the linear attenuation coefficient
• Attenuation of an x-ray beam by attenuating material depends on

The atomic number

Density

• When collecting one projection, it is not possible to determine what

combination of atomic number and density resulted in the measured
attenuation.

very dense materials (bone)

Produce strong attenuation
Materials with a high atomic number
(iodine contrast media)
CT NUMBER SCALE
• The reconstructed CT image is a map of tissue attenuation

• Maps are quantitative owing to the use of a scale called the

Hounsfield unit (HU) scale.

• A relative scale for linear attenuation of the tissues.

• A CT numbering system that relates a CT number to the linear
attenuation coefficients of x-rays in different absorbers compared to
water is given by
• When K = 1000 the CT number scale is the HU scale.

• air - −1000 HU
• water - 0 HU
• dense bone - +1000 HU

• Advantage - density differences of 1 part in 1000 (0.1%) can be

represented by distinct values
• CT scanners can easily demonstrate differences < 1%.

• the human eye cannot appreciate contrast differences < 10%

• User can select a small range of gray levels from the entire CT
number scale

• By presetting an appropriate “window/level” setting

 GENERATION OF A CT IMAGE
• The scanning process begins with data
acquisition.

Data Acquisition refers to a method by which the

patient is systematically scanned by the X ray
tube and detectors to collect enough
information for image reconstruction.

• A basic data acquisition scheme consists of

• X ray tube
• Filters
• Collimators
• Detectors
 CT gantry internal components
1.X-ray tube & collimator

2.Detector assembly

3.Tube controller

4.High freq. generator

5.Onboard computer

6.Stationary computer
 X-RAY TUBE
• Rotating anode type

• More heat loading and heat

dissipation capabilities

• Small focal spot size (0.6mm) to

improve spatial resolution
 FILTERS
Compensation filter is being used

• To absorb low energy x rays

• To reduce patient dose

• To provide a more uniform beam

• The compensating filters called bowtie filters- because of their shape.

• The filter is thinnest at the central ray of the beam

• thicker toward the azimuthal edges of the fan beam

• Thinnest part of the filter is in line with the thickest path length
through the patient’s body as the gantry rotates, and the thicker part
of the filter is in line with the thinner peripheral anatomy
COLLIMATORS
To decrease scatter radiation
• To reduce patient dose
• To improve image quality
• Collimator width determines
the slice thickness
 DETECTORS
• The detectors gather information by measuring the xray transmission
through the patient.

• Scintillation crystal detector

cadmium telluride and gadolinium oxysulfide

The crystals convert x-rays to light pulses whose intensity is proportional to

the total energy of photons striking the crystal

The light is converted to current and hence a voltage across a resistance-

detected as digital data for use by the reconstruction system
GENERATIONS
• Scan time reduction is the predominant reason for introducing new
configurations
 FIRST GENERATION
• Narrow pencil beam
• Single detector per slice
• Translate –Rotate movements
of Tube- detector combination
• duration of scan – 25 -30 min
• Designed only for evaluation
of brain
• Head kept enclosed in a
water bath
• Two side-by-side detectors
• A reference detector
 SECOND GENERATION
• Linear detector array(30)
• Translate-Rotate movements of
Tube-Detector combination
• Fewer linear movements are
needed as there are more detectors
to gather the data.
• Between linear movements, the
gantry rotated 30o

• Scan time <90secs

 THIRD GENERATION
• Rotate(tube)-Rotate(detectors)
Translatory motion is completely eliminated
• Pulsed wide fan beam(500-550)
• Arc of detectors(600-900)
• Detectors are perfectly aligned
with the X-Ray tube

Scan time< 5secs

 FOURTH GENERATION
• Continuous wide fan beam(500-550)
• Ring of detectors(> 2000)
• Rotate(tube)-Fixed(detector)
• X-ray tube rotates in a circle inside the
detector ring
• When the tube is at predescribed
angles, the exposed detectors are read.
• Scan time< 2 secs
Spiral (Helical) Scanning
• The patient is moved through a rotating x-ray beam and detector set
• From the perspective of the patient, the x-ray beam from the CT
traces a helical path - results in a three-dimensional data set

• Helical CT allows a scan to be performed in a single breath-hold

• Motion artifacts are minimized in spiral CT

key terms associated with helical scanning

• Acquisition is the entire volume of data collected during a continuous

spiral scan.

• Revolutions refer to the number of 360-degree rotations of the x-ray

tube during a single acquisition.

• Pitch is the distance the couch travels during one 360-degree revolution
of the x-ray tube divided by a length associated with the x-ray beam and/or
data acquisition
Interpolation is a reconstruction method (most accurately described

as “deconvolution”) that permits the realignment of spiral/helical scan data for

reconstruction of an axial (cross-sectional)slice
Advantages over conventional CT
• Motion artifacts are minimized – faster
scan times associated with the examination
(versus step-and-shoot axial scanning)

• reduced patient dose by extending the

pitch factor for a given study

• Decreased incidence of misregistration

between consecutive
axial slices
 DUAL SOURCE

• Dual source scanner employs two

complete imaging assemblies

• Each consisting of an x-ray tube and

detector array mounted at right
angles to one another and aligned
to scan the same plane
simultaneously
• 360-degree sampling can be achieved with a partial revolution of the
scanning frame

• increases scanning speed

Ct contrast protocols
 Purpose
• The purpose of contrast-enhanced CT (CECT) is to find pathology by
enhancing the contrast between a lesion and the normal surrounding
structures
• Hypovascular
• Hypervascular
 Methods
• Bolus Tracking
• Timing
 Amount of Contrast

• Standard dose is given related to the weight of the patient:

• Weight < 75kg : 100cc
• Weight 75-90kg: 120cc
• Weight > 90kg : 150cc
 Injection rate
5cc/sec through a 18 gauge i.v. catheter
• For all indications
• Especially for GI-bleeding, liver tumor characterisation, pancreatic
carcinoma, pulmonary emboli.
3-4cc/sec through a 20 gauge pink venflon
• If 5cc/sec is not possible or not needed
• If only interested in the late portal phase.
 Oral contrast
Positive oral contrast to mark the bowel has certain disadvantages:
• -Usually only a portion of the bowel is filled with contrast.
• -More radiation is needed in areas of positive contrast to get the same quality of
images.
• -Enhancement of the bowel wall is obscured.

Indications Of Positive Oral Contrast:

• Site of Perforation
• Site of Anastomosis Leak
 Oral contrast

Neutral oral contrast to mark the bowel (Small Bowel) :

• Fat containing milk as negative oral contrast
• If the patient doesn't drink milk we simply use water: Neutral Contrast

• Mannitol: Neutral Contrast

• When looking for Large Bowel Pathology
• Tuberculosis
• Inflammatory Bowel Disease
 Rectal Contrast
• Positive contrast: 750 cc water with 50 cc non-ionic water soluble
contrast
• Given in cases of:
• Suspected bowel perforation
• Anastomosis leakage
• Rectal/ Colon Malignancy
Liver: Triple Phase
Pancreatic Protocol
 Adrenal Protocol
• Non enhanced CT
• Enhanced Phase: 65-70 seconds ( 1 minute)
• Delayed Phase: 15 minutes
CT Urography
Nonenhanced Precontrast Lung bases to Calculi, hemorrhage/hemorrhagic cysts
pubic
symphysis

Corticomedullary 25 and 70 sec Cortical nephrogram

• Renal vasculature, Possibility that a
detected renal mass may represent an
aneurysm or arteriovenous
malformation or a fistula, Maximal
opacification of the renal vein and
arteries occurs during this phase,
allowing confident diagnosis of tumor
extension to the vein.
Nephrogram 100 sec (80-180 sec) Lung bases to Homogeneous or tubular nephrogram
pubic results in which corticomedullary
symphysis differentiation is lost
• Renal tumors
Excretory 5-8 min (after 180 seconds) Lung bases to Better delineate the relationship of a
base of centrally located mass with the collecting
bladder system
• Papillary necrosis, urothelial
carcinoma
A, The corticomedullary phase demonstrates dense enhancing cortex with minimal
enhancement of the renal medulla.
B, After a brief delay the parenchymal enhancement becomes uniform, resulting in the
nephrographic phase; in the late nephrographic phase, calyces may be opacified.
Small Bowel Pathology
• Oral Neutral contrast agent: 1.5 to 2 hours

Large Bowel Pathology

• Oral Mannitol: 1.5 to 2 hours
CT Enterography
• Neutral oral contrast that produces attenuation similar to the
attenuation of water is the choice in most examinations.
Adverse reaction following contrast
administration
Adverse reaction following contrast
administration
• Mild: nausea, vomiting, cough, sneezing, warmth, headache, dizziness,
shaking, altered taste, itching, pallor, flushing, chills, sweats, rash, hives,
nasal stuffiness, anxiety, sneezing, swelling – eyes, face.

• Moderate: tachycardia / bradycardia, hypertension / hypotension,

pronounced cutaneous reaction, dyspnea, bronchospasm / wheezing.

• Severe: laryngeal edema, convulsions, profound hypotension, clinically

manifest arrhythmias, unresponsiveness, cardiopulmonary arrest.
Types of reactions:
• Anaphylactoid

• Non-anaphylactoid

1. chemotoxic
2. vasovagal
3. idiopathic

• Combined (1 and 2)
Anaphylactoid reactions
• Anaphylactoid reactions occur unexpectedly and the specific cause is
uncertain. Therefore, anaphylactoid reactions are often referred to as
“idiosyncratic”.
Chemotoxic Reactions :
• Chemotoxic side effects include neurotoxicity, cardiac depression,
arrhythmia, electrocardiogram changes, and renal tubular or vascular
injury.

• Some chemotoxic side effects appear to relate to the ionic nature

and content of contrast media that dissolved in solution.

• Nonionic contrast media are associated with fewer chemotoxic side

effects.
Vasovagal Reactions :
• Vagal reactions occur as a result of increased vagal tone on the heart
and blood vessels. The result is bradycardia and decreased blood
pressure and may be accompanied by apprehension, confusion,
sweating, unresponsiveness, and loss of bowel or bladder control
signals.

• Some vagal reactions may not be caused by the contrast media but
instead may be the result of coincident events related to the
examination (e.g., needle puncture, or abdominal compression).
Combined Reactions:
• Anaphylactoid reactions and nonanaphylactoid reactions can occur or
appear to occur simultaneously. The end result may be a complex,
life-threatening situation with a patient in shock.

• Careful attention to the specific signs and symptoms of a reaction

should help in identifying the exact causes of the reaction.

• A careful history of any medications ingested prior to the exam can

aid in identifying possible contributory effects of the medications.
Patient Selection & Preparation Strategies
• The approach to patients has two general aims:
1. to prevent a reaction from occurring and
2. to be fully prepared to treat a reaction should one occur.

• History should focus on the factors that may indicate either a

contraindication to contrast media use or an increased likelihood of a
reaction.

• Hemodynamic, neurologic, and general nutritional status should be

assessed. In regard to specific risk factors.
• True concern should be focused on patients with significant allergies,
such as prior anaphylactic response to one or more allergens.

• A history of asthma indicates an increased likelihood of a contrast

reaction.

• Patients with any know allergies have a four fold chance of a reaction
to contrast media.
Treatment
Premedication strategies
• It is most important to target premedication to those who, in the past, have had
moderately severe or severe reactions requiring treatment.

• Two frequently used regimens are:

1. Prednisone – 50 mg by mouth at 13 hours, 7 hours, and 1 hour before contrast

media injection, plus Diphenhydramine – 50 mg intravenously, intramuscularly, or
by mouth 1 hour before contrast medium.

2. Methylprednisolone (Medrol®) – 32 mg by mouth 12 hours and 2 hours before

contrast media injection. An anti-histamine (as in option 1) can also be added to
this regimen injection.
• If the patient is unable to take oral medication, 200 mg of
hydrocortisone intravenously may be substituted for oral prednisone.
(Greenberger protocol)
Management of Acute reaction
Urticaria
• Discontinue injection if not completed

• No treatment needed in most cases

• Give H1-receptor blocker: diphenhydramine PO/IM/IV 25–50 mg.

• If severe or widely disseminated: give alpha-agonist (arteriolar and

venous constriction): epinephrine SC (1:1,000) 0.1–0.3 ml (= 0.1–0.3
mg) [if no cardiac contraindications].
Facial or Laryngeal Edema

• Give O2 6–10 liters/min (via mask).

• Give alpha agonist (arteriolar and venous constriction): epinephrine SC or IM

(1:1,000) 0.1–0.3 ml (= 0.1–0.3 mg) or, especially if hypotension evident, epinephrine
(1:10,000) slowly IV –3 ml (= 0.1–0.3 mg).

• Repeat as needed up to a maximum of 1 mg.

• If not responsive to therapy or if there is obvious acute laryngeal edema,

seek appropriate assistance (e.g., cardiopulmonary arrest response team).
Hypotension with Tachycardia
• Legs elevated 60 degree or more (preferred).
• Monitor: electrocardiogram, pulse oximeter, blood pressure.
• Give O2 6–10 liters/min (via mask).
• Rapid intravenous administration of large volumes of Ringer’s lactate
or normal saline.
• If poorly responsive: epinephrine (1:10,000) slowly IV 1 ml (= 0.1 mg)
Repeat as needed up to a maximum of 1 mg.
• If still poorly responsive seek appropriate assistance (e.g.,
cardiopulmonary arrest response team)
Hypotension with Bradycardia (Vagal
Reaction)
• Secure airway: give O2 6–10 liters/min (via mask)
• Monitor vital signs.
• Elevate legs.
• Secure IV access: rapid administration of Ringer’s lactate or normal
saline.
• Give atropine 0.6–1 mg IV slowly if patient does not respond quickly to
steps 2–4.
• Repeat atropine up to a total dose of 0.04 mg/kg (2–3 mg) in adult.
• Ensure complete resolution of hypotension and bradycardia prior to
discharge.
Hypertension, Severe
• Give O2 6–10 liters/min (via mask).

• Monitor electrocardiogram, pulse oximeter, blood pressure.

• Give nitroglycerine 0.4-mg tablet, sublingual (may repeat × 3); or, topical
2% ointment, apply 1-inch strip.

• If no response, consider labetalol 20 mg IV, then 20 to 80 mg IV every 10

minutes up to 300 mg.

• Transfer to intensive care unit or emergency department.

Seizures or Convulsions
• Give O2 6–10 liters/min (via mask).

• Consider diazepam (Valium®) 5 mg IV (or more, as appropriate) or

midazolam (Versed®) 0.5 to 1 mg IV.

• If longer effect needed, obtain consultation; consider phenytoin

(Dilantin®) infusion — 15–18 mg/kg at 50 mg/min.

• Careful monitoring of vital signs required, particularly of pO2because of

risk to respiratory depression with benzodiazepine administration.
First-line emergency drugs and instruments that should
be in the room where contrast medium is injected

• Oxygen
• Adrenaline 1:1000
• Antihistamine H1 – suitable for injection
• Atropine
• B2 agonist metered dose inhaler
• Intravenous fluids-normal saline or ringer’s solution
• Anti convulsive drugs (diazepam)
• Sphygmomanometer
• One-way mouth “breathing” apparatus
References
• CT and MRI of the Whole Body: John R. Haaga

• ACR Manual on Contrast Media - 2021

Thank You