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CT IMAGING
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CT IMAGING
PRACTICAL PHYSICS,
ARTIFACTS, AND PITFALLS
Editor:
Alexander C. Mamourian MD
Professor of Radiology
Division of Neuroradiology
Department of Radiology
Perelman School of Medicine of the
University of Pennsylvania
Philadelphia, Pennsylvania
Contributors:
Harold Litt MD, PhD Nicholas Papanicolaou MD, FACR
Assoc. Professor of Radiology and Medicine Co-Chief, Body CT Section
Chief, Cardiovascular Imaging Professor of Radiology
Department of Radiology Department of Radiology
Perelman School of Medicine of the Perelman School of Medicine of the
University of Pennsylvania University of Pennsylvania
Philadelphia, Pennsylvania Philadelphia, Pennsylvania
Supratik Moulik MD Josef P. Debbins PhD, PE, DABMP

Fellow, Cardiovascular Imaging Staff Scientist
Department of Radiology Keller Center for Imaging Innovation
Perelman School of Medicine of the Department of Radiology
University of Pennsylvania St. Joseph’s Hospital and Medical Center
Philadelphia, Pennsylvania Phoenix, Arizona
1 2013
1
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Library of Congress Cataloging-in-Publication Data

CT imaging : practical physics, artifacts, and pitfalls / editor,
Alexander C. Mamourian; contributors, Harold Litt ... [et al.].
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-19-978260-4(pbk. : alk. paper)
I. Mamourian, Alexander C. II. Litt, Harold I.
[DNLM: 1. Tomography, X-Ray Computed. 2. Cardiac Imaging Techniques.
3. Nervous System—radiography. 4. Radiation Dosage. 5. Radiation Protection.
6. Whole Body Imaging. WN 206]
LC Classification not assigned
616.07'5722—dc23
2012038160
1 3 5 7 9 8 6 4 2
Printed in the United States of America
on acid-free paper
CONTENTS
Introduction vii
Acknowledgements ix
Dedication xi
1 HISTORY AND PHYSICS OF CT IMAGING 1

Alexander C. Mamourian
2 RADIATION SAFETY AND RISKS 35

Alexander C. Mamourian and Josef P. Debbins
3 CARDIAC CT IMAGING TECHNIQUES 55

Supratik Moulik and Harold Litt
4 CARDIAC CT ARTIFACTS AND PITFALLS 71

5 NEURO CT ARTIFACTS 113

6 NEURO CT PITFALLS 147

7 BODY CT ARTIFACTS 197

Nicholas Papanicolaou
8 BODY CT PITFALLS 215

9 TEST QUESTIONS 225

Index 233
INTRODUCTION
I could say that computed tomography (CT) and my career started together, since the first units arrived
in most hospitals the same year that I entered my radiology residency. But while I knew the physics of
CT well at that time, over the next 30 years CT became increasingly complicated in a quiet sort of way.
While MR stole the spotlight during much of that time, studies that were formerly unthinkable, like CT
imaging the heart and cerebral vasculature, have become routine in clinical practice. But these expand-
ing capabilities of CT have been made possible by increasingly sophisticated hardware and software.
And while most manufacturers provide a clever interface for their CT units that may lull some into
thinking that things are under control, the user must understand both the general principles of CT as
well as the specific capabilities of their machine because of the potential to harm patients with X-rays.
For example, it was reported not long ago that hundreds of patients received an excessive X-ray dose
during their CT brain perfusion exams. Although that was troubling enough, the unusually high dose
was eventually attributed in some share to the well-meaning but improper use of software commonly
used to reduce patient X-ray dose but only for specific applications that do not include perfusion.
This book was never intended to be the defi nitive text on the history, physics, and techniques of CT
scanning. Our goal was to offer a collection of useful advice taken from our experience about modern
CT imaging for an audience of radiology residents, fellows, and technologists. It was an honor and a
pleasure to work with my co-authors, an all-star cast of experts in this field, and it is our collective
hope you will fi nd this book helpful in the same way that the owner’s manual that comes with a new
car is helpful; not enough information to rebuild the engine, but what you need to reset the clock when
daylight saving rolls around or change the oil. Many experienced CT users will very likely fi nd some
things useful here as well.
The review of CT hardware in Chapter 1 should get you off to a good start since the early scanners
were just simpler and for that reason easier to understand. The following chapters build on that foun-
dation. Chapter 2 provides a review of the language of X-ray dose and dose reduction, followed by a
comprehensive description of the advanced techniques used for cardiac CT in Chapter 3. Feel free at
any time to explore the cases in Chapters 4 through 8. Most of these include discussions of practical
physics appropriate to that particular artifact or pitfall. In the fi nal chapter, you will fi nd 10 questions
that will test your understanding of CT principles. Take it at the start or at the end to see how you
stand on this topic. While there is a rationale to the arrangement of the book you may want to keep
it nearby and go to appropriate chapters for those questions that may arise about CT dose, protocols,
and artifacts in your daily practice.
If you get nothing else from reading this book, you should be sure to learn the language of CT dose
explained in Chapter 2. Understanding radiation dose specific to CT has become more important
than ever in this time of increasing patient awareness, CT utilization, and availability of new software
tools for dose reduction. We hope that this book will help you to create the best possible CT images,
at the lowest possible dose, for your patients.
ACKNOWLEDGMENTS
I want to thank Cheryl Boghosian and Neil Roth in New Hampshire, for their wonderful hospitality,
generous spirit, and faithful friendship over many years, and most recently for giving me the time and
space to fi nish this book. My sincere thanks also go to Andrea Seils at Oxford Press. Every writer
should be blessed with an editor of her caliber. I will be forever grateful to Dr. Robert Spetzler and
all the staff at the Barrow Neurological Institute for giving me the inspiration and the opportunity to
write at all.
DEDICATION
I dedicate this book to my parents, Marcus and Maritza, who have given unselfi shly of themselves to
so many.
To Pamela, Ani, Molly, Elizabeth, and Marcus, I can fi nd no words that can express my endless
affection and gratitude.
1 HISTORY AND PHYSICS OF
CT IMAGING
2 CT IMAGING
The discovery of X-rays over 100 years ago by Wilhelm Roentgen marks the stunning beginning of
the entire field of diagnostic medical imaging. While the impact of his discovery on the fields of phys-
ics and chemistry followed, the potential for medical uses of X-rays was so apparent from the start
that, within months of his fi rst report, the fi rst clinical image was taken an ocean away in Hanover,
New Hampshire. A photograph of that particular event serves as a reminder of how naïve early users
of X-ray were with regard to adverse effects of radiation (Figure 1.1). We can only hope that our
grandchildren will not look back at our utilization of CT in quite the same way.
Although plain X-ray images remain the standard for long bone fractures and preliminary chest
examinations, they proved to be of little value for the diagnosis of diseases involving the brain, pel-
vis, or abdomen. This is because conventional X-ray images represent the net attenuation of all the
tissue between the X-ray source and the fi lm (Figures 1.2–1.4).
This inability to differentiate tissues of similar density on X-ray is due in part to the requirement for
the X-ray beam to be broad enough to cover all the anatomy at once. As a result of this large beam,
many of the X-rays that are captured on film have been diverted from their original path into other
directions, and these scattered X-rays limit the contrast between similar tissues. This problem was well
known to early imagers, and, prior to the invention of computed tomography (CT), a number of solu-
tions were proposed to accentuate tissue contrast on X-ray images. The most effective of these was a
device that linked the X-ray tube and film holder together, so that they would swing back and forth in
reciprocal directions on either side of patient, around a single pivot point. This was effective to some
Figure 1.1 This photograph captures the spirit of early X-ray exams. Note the pocket watch used to time the exposure (left ) and the
absence of any type of radiation protection for the patient or observers. The glowing cathode ray tube (positioned over the arm of
the patient, who is sitting with his back to the photographer) was borrowed from the department of physics at Dartmouth College. As
rudimentary as this apparatus might appear, it was effective in demonstrating the patient’s wrist fracture. Image provided courtesy of
Dr. Peter Spiegel, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
History and Physics of CT Imaging 3
(A) (B)
Film
Net attenuation
X-ray
1 1 20 1 1 24
beam
X-ray
5 4 5 5 5 24
beam
Figure 1.2 While X-ray images (A) are useful for demonstrating contrast between bone, soft tissue, and air, they are not effective at
showing contrast between tissues of similar attenuation. In this image, the pancreas, liver, and kidneys cannot be identified separately
because they all blend with nearby tissues of similar density. That is in part because the flat X-ray image can only show the net attenu-
ation of all the tissues between the X-ray source and the film or detector. This is illustrated mathematically in B, where these two rows
of blocks of varying attenuation would nevertheless have the same net attenuation on a conventional X-ray image.
degree because it created blurring of the tissues above and below the pivot plane (Figure 1.5), and this
technique became know as simply tomography. When I was a resident, we used several variations of
this technique for imaging of the kidneys and temporal bones to good effect since the tissues in the
plane of the pivot point were in relatively sharp focus, at least sharper than conventional X-rays.
Computed tomography proved to be much more than an incremental advance over simple X-ray
tomography, however. That is because it both improved tissue contrast and, for the fi rst time, allowed
imagers to see the patient in cross-section. The remarkable sensitivity to tissue contrast offered by
CT was in some sense serendipitous since it was the byproduct of the use a very narrow X-ray beam
for data collection (Figure 1.6). This narrow beam, unlike the wide X-ray beam used for plain fi lms,
significantly reduces scatter radiation. For physicians familiar with conventional X-ray images, those
early CT images were really just as remarkable as Roentgen’s original X-ray images.
The benefits offered by CT imaging to health care was formally acknowledged with the 1979
Nobel Prize for medicine going to Godfrey Hounsfield, just 6 years after his fi rst report of it. The
prize was shared with Allan Cormack, in recognition of his contributions to the process of CT image
reconstruction. But this prestigious award was not necessary to bring public attention to this new
imaging device. At the time the Nobel was awarded, there were already over 1,000 CT units operat-
ing or on order worldwide.
At the time of his discovery, Godfrey Hounsfield was employed by a British fi rm called EMI
(Electrical and Musical Industries) that had interests in both music and musical hardware. While
EMI is better known now for its association with both Elvis Presley and the Beatles, it was much
more than a small recording company with some good fortune in signing future stars. EMI manu-
factured a broad range of electrical hardware, from record players to giant radio transmitters, and
4 CT IMAGING
Figure 1.3 and 1.4 Another significant limitation of plain film is that there is no indication of depth even when sufficient image
contrast is present. For example, on this single plain film of the skull it appears at first glance that this patient’s head is full of metal
pins (1.3). This is because an X-ray image is just a two-dimensional representation of a three-dimensional object, and each point on
the image reflects the sum attenuation of everything that lies between the X-ray source and that point on the film. While you can easily
see that there are a large number of metal pins superimposed on the skull in this example, you cannot tell whether they are on top of
the skull, behind the skull, or inside the skull (perhaps from some terrible industrial accident). The computed tomography (CT) image
of this patient shows that they are, fortunately, hairpins that are outside the skull (Figure 1.4; arrows).
a fortuitous and unusual combination of broad interests in electronics with substantial financial
support offered by its music contracts apparently gave Hounsfield the latitude necessary for his
distinctly unmusical research into CT imaging. In his lab, he built a device intended to measure the
variations in attenuation across a phantom using a single gamma ray source and single detector.
Gamma rays are, of course, naturally occurring radiation, and so the fi rst device he built did not use
an X-ray tube at all but a constrained radioactive element.
By measuring precisely how much the phantom attenuated the gamma rays in discrete steps from
side to side, and then repeating those measurements in small degrees of rotation around the object,
Hounsfield showed that it was possible to recreate the internal composition of a solid phantom
using exclusively external measurements. While CT is commonplace now, at the start this capabil-
ity to see inside opaque objects must have seemed analogous to Superman’s power to see through
solid walls. That large dataset collected by Hounsfield’s device was then converted into an image
using known mathematical calculations (Figures 1.7, 1.8) with the aid of a computer of that era.
Computed tomography was initially considered to be a variation of existing tomography, so it was called
“computed” tomography, or more accurately computed axial tomography aka CAT scanning. This acro-
nym was commonly a source of humor when confused with the pet (no pun intended), and eventually it
was shortened to just “CT.” Hounsfield was honored for the creation of this remarkable imaging tool by
having the standard unit of CT attenuation named a “Hounsfield unit,” which is abbreviated HU.
Figure 1.5 This drawing from a patent illustration shows the complex mechanics of a tomography device. In this design, the X-ray
tube is under the patient table and the film above. The belt at the bottom drives the to-and-fro movement of the entire apparatus. From
AG Filler. The history, development and impact of computed imaging in neurological diagnosis and neurosurgery: CT, MRI, and DTI.
Doi:10.103/npre.2009.3267.5
The medical implications of his device were quite evident to Hounsfield from his earliest experi-
ments, and EMI was supportive of his research in this direction. As the invention moved into a
clinical imaging tool, the mathematical reconstruction used for initial experiments proved to be too
time-consuming using the computers available at that time. Faster reconstruction was essential for
clinical use and, in recognition of his research that contributed to the faster reconstruction speeds
for CT, Allan Cormack was also recognized with a share of the 1979 Nobel Prize.
In common with many scientific advances, Cormack’s investigations preceded the invention of CT
imaging by many years. It was twenty years prior to Hounsfield’s work, after the resignation of
the only other nuclear physicist in Capetown, South Africa, that Cormack became responsible for
the supervision of the radiation therapy program at a nearby hospital. Without a dedicated medical
background, he brought a fresh perspective on his new responsibilities and was puzzled at the usual
therapy planning process used at that time. It presumed that the human body was homogeneous as far
as X-rays are concerned, when it clearly was not. He thought that if the tissue-specific X-ray attenua-
tion values for different tissues were known, it would eventually be of benefit not only for therapy but
also for diagnosis. He eventually published his work on this subject in 1963, nearly a decade prior to
Hounsfield’s first report of his CT device. In his Nobel acceptance lecture, Cormack reflected that,
immediately after the publication of his work, it received little attention except from a Swiss center for
avalanche prediction that hoped it would prove to be of value for their purposes. It did not.
6 CT IMAGING
Figure 1.6 This early CT of the brain allowed the imager to see the low attenuation CSF within the ventricles as well as the high
attenuation calcifications in the ventricular wall in this patient with tuberous sclerosis.
Axial Versus Helical Imaging
While early CT scanners were quite remarkable in their time, they were really quite slow as they went
about their businesslike “translate-rotate” method of data collection. For example, it took about
5 minutes to accumulate the data for two thick (>10mm) slices of the brain at an 80 ×80 matrix.
While still remarkable at that time, these scanners were deemed inadequate for much else apart from
brain imaging.
Even with their limitations, early EMI CT scanners were very expensive, costing about $300,000
dollars even in 1978, and that got the attention of many other manufacturers around the world. It
became a race among them to establish a foothold in this lucrative new market. As a result of this
concerted effort, CT scan times dropped rapidly as manufacturers offered faster and better units; as
a result, it was not long before EMI was left behind.
Those fi rst-generation scanners were made obsolete by faster “second-generation” units that used
multiple X-ray sources and detectors. Not long afterward, these second-generation scanners were
surpassed by scanners using what we call “third-generation” design, which eliminated the “trans-
late” movement. Now the X-ray fan beam, along with its curved detector row (Figure 1.9), could
spin around the patient without stopping. That design still remains the preferred arrangement on
current scanners since it readily accommodates large X-ray tubes, both axial and helical imaging,
and wide detector arrays. Since they spin together, the large detector arrays nicely balance the large
X-ray tubes.
Figure 1.7 Hounsfield’s patent on CT included an illustration (upper left drawing labeled A) of the lines of data that were collected
in a translate-rotate pattern, shown here for only three different angles. From AG Filler. The history, development and impact of com-
puted imaging in neurological diagnosis and neurosurgery: CT, MRI, and DTI. Doi:10.103/npre.2009.3267.5
On the early CT units, the only technique of imaging available was what we now call axial mode
or step-and-shoot. The later term better captures the rhythm of axial mode imaging since all the
data necessary for a single slice is collected (shoot) in a spin before the patient is moved (step) to the
next slice position. While axial mode has advantages in some circumstances and is still available
on scanners, it takes more time than helical scanning since the stepwise movement of the patient is
time-consuming relative to the time spent actually scanning.
On early scanners with only a single detector row, the act of decreasing slice thickness by half
would result in doubling the scan time. That is because scanning the same anatomy but with thinner
sections was just like walking but taking smaller steps. The process of acquiring single axial scans
had other limitations and many were due the relatively long scan time. For example, if there were
any patient motion during acquisition of those single scans, misregistration or steps would appear
between slices on reconstruction (Figure 1.10).
This aversion to patient motion during axial CT scanning, imprinted on imagers for over a decade,
made the spiral CT technique all the more remarkable when it was introduced in 1990. Now, patient
8 CT IMAGING
Xray source
Phantom
Detector
Mathematical
0 0 0 0 0 0 0 01 3 7 3 3 3 0 0 0 0 0 0 0 0 attenuation
Projection
Figure 1.8 This illustrates just one pass of the collector and gamma ray source across a phantom containing water surrounding a
aluminum rod. In CT language, this simple motion was called “translate.” After each pass across the object, the entire assembly would
rotate 1 degree and collect another projection; so, this motion of first-generation CT scanners was called “translate-rotate.”
The line below marked “mathematical” shows a numeric representation of the attenuation measurements collected by the detectors
that could be used for image reconstruction. This information can also be represented graphically, as seen in the line “projection.”
The first CT images were made using an algebraic reconstruction, but later all CT scanners used the projections in a reconstruction
technique called back-projection, or more specifically filtered back-projection, because it proved to be faster than the purely algebraic
reconstruction using computers of that era.
motion became a requirement for CT scanning. This innovative approach to CT imaging is credited
to Willi Kalender, and the terms “spiral” and later “helical” were used to describe the path now
traced by the rotating X-ray beam onto the moving patient (Figure 1.11).
Helical imaging at fi rst was limited by scanner hardware, and only a short section of anatomy at
a time could be covered in a scan because the wires that attached the X-ray tube to the gantry had
to be unwound. Eventually, CT hardware was improved to maximize the benefits of helical scan-
ning, and once continuous gantry rotation became possible, CT scan times dropped precipitously.
Continuous gantry spin was made possible by the use of a slip-ring attachment between the tube and
detectors to conduct power and data, respectively. But this was not a uniquely CT invention as slip
rings were already commonplace on tank turrets and home TV antennas (Figures 1.12, 1.13).
When we perform CT in the axial mode, the data for one slice goes on to image reconstruction as
a discrete packet of information. In helical mode, since the X-ray beam actually sweeps obliquely to
the moving patient, each of the axial slices must be created using data collected from more than one
of those rotations. The attenuation values for the direct axial slice, or from any other plane for that
X-ray tube
Detectors
Figure 1.9 The arrangement of tube and detectors in a third-generation CT scanner. Unlike the “translate-rotate” approach, in this
design, the tube and detectors move in a circle around the patient. While early versions of this design used a single row, current CT
scanners use the same design but incorporate multiple detectors rows each with hundreds of individual detectors.
Figure 1.10 The irregular contour of this skull (arrows) is due to patient motion during the acquisition of the axial scans used for the
reconstruction.
matter, are estimated from the known data points that were measured during the helical scan. This
process of estimating the attenuation values in nearby tissue using the known, but only nearby, data,
is called interpolation. It is really very much like the method used to estimate the value of a house
before it is placed on the market. To provide a reliable estimate of a sale price, the appraiser does
not actually add up the value of the many components of a house to determine its market value. The
10 CT IMAGING
(A)
(B)
Figure 1.11 In axial mode (A), the CT scanner gantry spins around just once and in the plane perpendicular to the patient. In helical
mode (B), the gantry spins in the same but continuously while the patient table moves through the its center. The combination of these
simultaneous motions (i.e., continuous rotation of the tube and the advancement of the patient), results in an oblique path of the X-ray
beam across the patient. This X-ray beam trajectory can be described as “helical,” and this term is preferred instead of “spiral” since
that term implies a continuously changing diameter as well.
projected selling price is based almost entirely on the recent sale prices of comparable houses nearby.
For example, if there had been completed sales during the past year of the houses on either side of
your house, the estimated value of your house would be much more reliable than if you were sell-
ing a custom built ten room mansion is upper Maine and the closest reference houses were in towns
many miles away. The same principle holds true for helical imaging. The closer the helical wraps are
together, the more accurate those estimated or interpolated attenuation values will be in tissues not
directly in the scan trajectory. This explains why the use of a low pitch, that allows interpolation
over a shorter distances, provides better resolution. In cases where a pitch value less than one is used,
the overlapping of the helical sweeps allows the scanner to measure attenuation of some of the tissues
more than once and that also decreases noise but at the expense of time and patient dose.
Multidetector CT: Beam Collimation Versus Detector

Collimation
The fi nal advance that will bring us up to date with modern CT scanners was the addition of multiple
detector rows to the helical scanner. It is worth acknowledging that the very first EMI scanners also
acquired more than one slice at a time, so the notion is not entirely new to CT, although the ratio-
nale for it changed with the different generations of scanners. On those very early translate-rotate
scanners, a single rotation around the patient might take 5 minutes, so the use of a pair of detectors
could significantly reduce total scan time. With the arrival of second and third generation designs,
however, the second detector row was dropped presumably to save cost and reduce the complexity
of reconstruction.
Figure 1.12 Hard for many to believe now, but there was a time when the TV signal was collected free using a fixed antenna attached
to the roof of a house. The quality of the TV image was of course related to the strength of the signal received and that meant, for many
rural households far from the transmitters, that decent TV signal reception required sensitive antennas. The best of these could be rotated
remotely from the living room while standing near the TV set in order to optimize the direction of the antenna and viewing the image as the
antenna was rotated. By using slip ring contacts on the shaft of the antenna (arrows), the antenna could be rotated in either direction without
worrying about later having to climb on the roof to unwrap the antenna wires. This was no small comfort on a cold Vermont winter night.
Twenty years after the EMI scanner, Elscint reintroduced the use of multiple detector row CT, but
the rationale at that time was to limit tube heating during helical scanning. After the arrival of slip ring
scanners, many sites were experiencing unwanted scanner shutdowns when performing wide coverage,
helical imaging and that was because continuous scanning would make the X-ray tubes of that time over-
heat. Once that occurred, it required a forced break from imaging to provide time for the X-ray tube to
cool off. This often occurred in inopportune moments, for example while imaging a patient after major
trauma, and there were few precedents since it had been only rarely encountered previously when using
CT scanners in the axial mode. This was because the time spent moving the patient between each rota-
tion of the gantry, albeit short, provided enough time for the X-ray tube to cool off. Elscint’s design was
intended to limit tube heating by decreasing the duration of the “tube on” time for the helical scans.
Manufacturers quickly found there were other significant benefits of multidetector scanning, even
after the tube heating problems were minimized by the introduction of X-rays tubes with substan-
tially more heat capacity. While early multidetector scanners could provide either faster scan times or
thinner slices, as the number of detector rows increased it became possible to provide both. Over the
course of the next decade, scanners would appear with 4, 8, 16, 64, 128, and most recently 320 rows
(Figure 1.14). Keep in mind that multidector arrays come at a cost since each detector row still contains
nearly a thousand individual detector elements, and the use of metal dividers between rows to limit
scatter meant that these multi-detector arrays are heavy, difficult to build, and expensive.
12 CT IMAGING
Figure 1.13 A slip ring on a CT scanner (arrows). The contacts fixed on the large plate on the left ride on the circular conductive
metal rails provide power and convey data while the entire gantry freely rotates.
Users need to be aware of exactly how the detector rows are arranged on their scanners since that
can vary among the different manufacturers, and there is almost no way to know their arrangement
intuitively. It is also important to recognize that some scanners provide fewer data channels than the
number of available detector rows. So, a manufacturer may offer a scanner called the “Framostat
40” with only 20 data channels. In that case, you will fi nd that the scans can take longer than
expected when using the thinnest detector collimation because only half of the total detector rows
are active at the smallest detector collimation (Figure 1.15).
The advantage of offering choices for the activation of detector rows is that it gives the user the
options of using either the narrow center detector rows to provide the best detail or using all the
rows for rapid coverage of large anatomic regions. So, keep in mind that your choice of “detector
collimation” is not trivial since it determines not only the scan resolution but also the total number
of detector rows activated, and that has a significant effect on scan time.
CT Image Contrast
At the risk of stating the obvious, the shades of gray on a CT image are based on a linear scale of
attenuation values. Wherever the X-rays are significantly absorbed or deflected, i.e. attenuated, by
the tissues, very few X-rays will arrive at the detectors and those corresponding tissues will appear
white on the image. Wherever there is little or no attenuation of the X-ray beam, more X-rays will
arrive at the detectors and those tissues will be represented as black on the CT image. That is why air
Figure 1.14 This fountain pen was placed on the plastic shield in this 320-detector row scanner to provide some perspective to its
width. Using this scanner, the detector array is sufficiently wide to cover the entire head in a single rotation of the gantry.
appears black, bone appears white, and fat and brain are represented as shades of gray in between
(Figure 1.16). This direct correlation of just the single value of X-ray attenuation with gray scale
display differs substantially from magnetic resonance (MR) images, where there are multiple sources
of information displayed on image, and so a dark area on the image might be attributed to signal
loss from flow, low proton density, or even magnetic susceptibility effects depending on the scan
technique and the anatomic location.
Although CT imaging seems simpler than MR in principle, a number of factors confound our
ability to assign the correct attenuation values to the imaged tissue and there are many illustra-
tions of this problem included in the case fi les. For example, a renal cyst may appear to have higher
attenuation on CT due to pseudo-enhancement (Chapter 8, pitfall 1), or CSF in the sella may be
mistakenly assigned the same attenuation value as fat due to beam hardening (Chapter 5, artifact
6). So, while CT image display seems to be more straightforward than MR imaging, you must fully
understand the many factors that can confound the accuracy of attenuation values displayed on a
CT scan.
Slice Thickness
While early scanners produced images with choppy images with visibly large pixels, since they used
a matrix of 80 ×80, the in-plane resolution of CT images improved quickly. With each new genera-
tion of CT scanner, pixel size decreased fairly quickly to the current submillimeter standard size.
But CT image resolution is determined by voxel size and that is determined by both the pixel size
and the slice thickness.
14 CT IMAGING
64 - 0.625 mm detector rows

total widh = 4.0 cm
16 - 1.5 mm 32 - 0.625 mm 16 - 1.5 mm

detectors detectors detectors
Total width = 7cm
Figure 1.15 These two different scanners both have 64 detector rows on their detector arrays but provide different usable scan
widths depending on how they are activated. In the top example, the 64 detector rows are each 0.625mm wide, evenly spaced, and
there is a data channel for each row. This arrangement could offer -.625mm detector collimation with a total usable scan width of 4cm.
In the lower example, there are also 64 rows but only the center 32 rows are 0.625mm wide. The remaining 32 rows are all 1.5mm
wide and arranged as a pair of 16 detector rows on the outside of the array. A scanner with this arrangement would offer only 2cm of
coverage when using 0.625mm detector collimation, and that is half of that of the upper arrangement.
However, using the center rows in pairs, they would function like an additional 16 1.5mm rows, and using that arrangement the total
usable array width becomes 48–1.5mm detector rows. This would provide 7cm of coverage with each rotation, and that is nearly twice
that of the upper array. So one manufacturer might offer their scanner with the lower arrangement to provide a wider array width for
rapid body or lung imaging with the option to do finer imaging, like brain CT angiography. However, a CTA using a detector collimation
of 0.625mm with the lower array would take twice as long as the same scan using the upper array. You need to know how the detector
elements are arranged to correctly design scan protocols on your scanner for different imaging requirements.
Whenever images are created using thick slices, small structures may be obscured because each
voxel is represented by a single attenuation value, and that is determined by the average attenuation
of all the contents. This resembles the presidential primary process for states like Florida. There,
all the delegates are awarded to the overall winner, unlike in New Hampshire, where they are frac-
tionally awarded based on the candidate’s portion of the total vote. For example, if a single voxel
contains both fat (low attenuation) and calcification (high attenuation), the mean attenuation of that
voxel could be exactly the same as normal brain, making both the fat and calcification inapparent
on a CT scan. It is more common to fi nd that a very small, dense calcification that occupies only a
fraction of a voxel will cause the entire voxel to have the attenuation of calcium and that will result
in an exaggeration of actual size of the calcification on a CT scan.
On early single-slice CT scanners it was undesirable to decrease slice thickness for most imaging
tasks because that significantly increased the time required to compete the scan. However, when
Figure 1.16 This patient was lying on an ice bag during the CT exam performed for neck pain. Notice that the ice blocks (arrow ) are
darker than the surrounding water. By CT convention, this means that the ice attenuates the X-ray beam less than liquid water. Since
both the liquid water and solid ice have exactly the same molecular composition, this difference in attenuation must be the result of
the slight separation of water molecules as water changes state to crystalline ice. In addition to this high sensitivity of CT imaging to
differences in attenuation, it also provides sufficiently high resolution to show the air, note the dark spots, frozen within the ice.
using CT scanners with multiple detector rows, scan time is for all practical purposes independent
of slice thickness. For example, a scanner with 64 channels using sub millimeter slice thickness can
provide faster scans over comparable anatomy than can a four-slice scanner using 5mm slice thick-
ness. This capability of multidetector scanners to provide very thin slice thickness without adding to
scan time has made high quality multiplanar reconstructions commonplace.
Isotropic Voxels and Reconstructions
The ability to scan with very thin sections has proved to be among the most significant advances of
modern CT imaging. While early CT scanners were capable of providing good quality axial images
when viewed slice by slice, whenever they were reconstructed into another plane of display the qual-
ity of these reconstructions was surprisingly poor due to thick slice thickness. For example, using
a slice thickness of 1cm meant that the depth of each voxel was more than 10 times larger than the
pixel size. These asymmetric voxels resulted in reconstructions with a striking “stair-step” appear-
ance that were of little diagnostic value apart from gross alignment. However, the ability to scan
using cubic or isotropic voxels in which the slice thickness is the same as the pixel size provides
reconstructions in any plane that are equivalent in quality to the images in the acquisition plane
(Figures 1.17, 1.18).
16 CT IMAGING
(A) (B)
Figure 1.17 These drawing show the difference between (A) voxels created using thick CT detector collimation, called anisotropic,
compared with (B) those using very thin detector collimation, called isotropic voxels. Isotropic, or cubic voxels, are created when the slice
data is nearly the same dimension as the length of one side of a pixel. For example, when using a 512 × 512 matrix for scan reconstruction,
the detector collimation needs to be less than 1 mm in order to provide cubic voxels. The advantage of creating isotropic voxels is that the
scan reconstructions in any plane (e.g., sagittal, coronal, or oblique) will be nearly equivalent in quality to images in the plane of acquisition.
Illustrations provided by Dr. Rihan Khan, University of Arizona, Department of Radiology.
(A) (B)
Figure 1.18 Sagittal view made from standard 5mm reconstructions (A) and the 0.7mm original scan data (B).
While high-quality reconstructions are routine now for body and neuroimaging, it is important to
consider that when using the thinnest available detector collimation, the signal-to-noise ratio (SNR)
on each slice will be less than that available with the use of either wide detector collimation or slice
reconstruction thickness when using narrow detector collimation (Figure 1.19).
If the thin sections are to have the same SNR as thicker sections, the radiation dose for the scan
must be increased. In practice, however, this problem is mitigated because the thin sections are
rarely viewed primarily. By reconstructing the submillimeter data images in the desired plane of
section at 3–5 mm slice thickness, the overall SNR is significantly better the thin source images.
The principle of “scan thin, view thick” is the basis of most brain imaging because detector
(A) (B)
Figure 1.19 Notice that the noise visible in the 0.625mm section (A) becomes less apparent after merging data from multiple detec-
tors together into a thicker slice, here as a 4.5 mm slice (B).
B
A
Figure 1.20 Helical imaging requires collecting data from either 180 or 360 degrees of tube rotation so that corresponding views
are available of any structure (note black structure A). However, off-center structures (note black structure B) may only be imaged
once because of the divergence of the X-ray beam necessary for CT scanners with wide detector arrays. This undersampling artifact is
called “partial volume” and it can results in blurring of the margins of that structure. This artifact should not be confused with volume
averaging the (see Chapter 7).
collimation also minimizes beam hardening artifacts in posterior fossa and, for helical imaging,
cone beam and partial volume artifacts ( Figure 1.20). But, when considering X-ray dose in this
context, keep in mind that a small increase in dose can provide sufficient image quality for high
quality reconstructions and that will ultimately save patient dose if it eliminates the need for a
second scan. For example, by reconstructing axial CT data of the paranasal sinuses into the coro-
nal plane, it eliminates the need for direct coronal scanning and thus reduces the total patient
dose for the scan by nearly 50%.
18 CT IMAGING
Image Reconstruction and Detector Arrays
Hounsfield’s fi rst CT experiments used a pure algebraic reconstruction (Figure 1.21) to create images.
In fact, it would appear that his first device was basically designed to collect the numbers in a man-
ner best suited to solve the reconstruction formula.
Although effective, algebraic reconstruction proved impractical for two reasons. First, it is very
computationally demanding, and, second, it is impossible to use straight calculations to solve for the
unknowns in an equation when the known values are not quite correct. That is the case with CT
mathematical reconstructions since CT measurements include noise and a whole variety of artifacts.
While there has been renewed interest in pure algebraic reconstruction techniques now that comput-
ers are fast enough to make it feasible, most CT scanners still use a less demanding approach called
back-projection or more accurately filtered back-projection. The scan information can be thought
of as a series of projections rather than a set of numbers (as shown previously in Figure 1.8). This
technique, patented by Gabriel Frank in 1940, was originally proposed as an optical back-projection
technique 30 years before the discovery of CT (Figure 1.22).
To correct for the edge artifacts that are inherent with back-projection, an additional step is added
to improve the quality of the fi nal CT images. This step is called filtering, although that term should
not be confused with the physical act of fi ltering of the X-ray beam use to eliminate the low-energy
X-rays. There are many filters, also called “kernels” which eliminates the confusion with metal
X-ray filters, that the user can choose for reconstructing CT images. These range from “soft” fi lters
that reduce noise at the expense of some image blurring to “sharp” fi lters used to display bone but
increase apparent noise. The process of fi ltering occurs after data acquisition but prior to image
display and can not be modified by the viewer afterwards. This of course differs from the setting of
window and level used to view the reconstructed images (Figure 1.23).
Upon the introduction of helical scanning, a new method for CT reconstruction was necessary
to allow reconstruction of date acquired in a continuous fashion as the patient moved past the
2 3 4 9
1 5 9
7 2 1 10
10 8 10 6
Figure 1.21 This 3 × 3 matrix demonstrates simply how one can use the sum of all the rows, columns, and diagonals outside the
matrix to predict the value of the central, unknown, cell. In this simple example, the value of the blank cell in the center is of course
3. Early scanners used an 80 ×80 matrix that required hours of calculations using this algebraic approach. That approach was soon
replaced with back-projection reconstruction techniques largely because they are faster.
Figure 1.22 In this drawing from Gabriel Frank’s patent on back-projection, you can see that it was initially intended it to be a visual
projection technique. Image B shows the light inside a cylinder that has collected the projections of the revolving object, line by line,
in A. CT now uses a mathematical, not optical, application of this concept for reconstruction. From AG Filler. The history, development
and impact of computed imaging in neurological diagnosis and neurosurgery: CT, MRI, and DTI. Doi:10.103/npre.2009.3267.5
detectors. This style of reconstruction incorporates the notion of estimation or interpolation of

attenuation values for those tissues that fall between those actually measured during the X-ray beam
sweep over the body (Figures 1.24, 1.25).
Other challenges had to be addressed with each advance in CT technology complexity. For exam-
ple, techniques needed to be developed for reconstruction of data collected simultaneously from
each channel of a large multidetector array in helical mode. This was not simply an issue of handling
larger datasets. As the number of detector rows increased, the X-ray beam increased in width in the
craniocaudal direction to cover the array. That is why the thick fan beam of CT is sometimes called
a “cone beam.” Since the beam arises from a small focal spot on the anode, the X-rays striking the
outer detector rows arrive at a much steeper angle compared with those in the center rows. As a
result, even for a uniform phantom, the X-rays arriving at the outer rows will have a longer path
than those in the center. The already complex reconstruction algorithms now had to accommodate
the differences in X-rays path lengths. As one might expect, these new methods for reconstruction
also introduced some new and unfamiliar artifacts.
The computational requirements for image reconstruction increased as the total number of detectors
used for data acquisition exploded. Considering that since most scanners now have 700–1,000 sepa-
rate detectors in each detector row, one rotation of the gantry provides a stunning amount of data to
process. For example, one commercial dual-source scanner has over 77,000 separate detector elements
in its two arrays that are intended to continuously collect data during each subsecond rotation of the
gantry.
20 CT IMAGING
(A) (B)
(C) (D)
Figure 1.23 These four images illustrate the difference between image filtering and windowing. The image in A is processed with a
soft tissue filter and is displayed at a soft tissue window. The image in B shows the same dataset but now processed with a bone filter
but displayed with the same soft tissue window and level as in Figure A. Notice how much more noise is apparent as result of this
change in filter.
The image in C was also processed using a bone filter but it is displayed with a bone window and level. Notice how much detail is now
evident in the skull bones. The image in D shows the scan data displayed with the same bone window and level, but reconstructed
using a soft tissue filter. Notice on this image how the bone edges appear much less sharp than image C.
These paired images illustrate the balance between edge enhancement and noise that is determined by your choice of filter. Your
choice of filter, also called kernel, will indirectly influence the dose necessary to scan the patient since it is an important factor in your
perception of noise on the images.
Cone Beam Imaging
A logical next step in the evolution of cross-sectional imaging would replace the complex multidetector
array with a single flat detector similar to the ones that have replaced image intensifiers used for con-
ventional angiography (Figure 1.26). While there are some similarities in configuration between a wide
multidetector array and a flat-panel detector, there are also some significant differences to consider.
9 9 7 8 8 8 7 6 5 4 4 4 3
Figure 1.24 When using helical mode for scanning, the X-ray beam trajectory is angled to the long axis of the patient, and this angle
increases as pitch increases. In order to assign attenuation values to the voxels that lie in between the actual beam path, the attenuation
values need to be estimated or “interpolated” from known data points. And, the further away those directly measured points reside, the
greater the degree of estimation. In this drawing the numbers that are not circled must be estimated based on known values determined
from the directly measured points that lie on the oblique lines (solid lines).
9 8 7 7.5 8 7 6 5.5 5 2.5 0 1.5 3
Figure 1.25 In this drawing there are more known values (circled) so there is less estimation of the values between the oblique lines
necessary. Note the the values in between the solid circles are different from those in Figure 1.24. This illustrates why high pitch heli-
cal imaging, since the scan lines are farther apart, will have lower resolution.
Unlike conventional X-ray images, in which both direct and scattered X-rays contribute to the image,
early CT scanners used a relatively narrow- ray beam that limited the contribution of scattered X-rays
to the final image. As the number of detector rows in modern CT scanner’s detector array increased the
beam became wide in two directions, its shape now resembled a cone rather than a fan (Figures 1.27,
1.28) since it must diverge from the anode in two directions, i.e., side-to-side and top-to-bottom.
To minimize scattered X-rays from striking the detectors when using the wide fan beam in a usual
multidetector scanner, the detector arrays incorporate thin metal plates, called septa, between each
detector row. These septa absorb most of the scattered X-rays and are designed to allow only those
X-rays oriented perpendicular to the detector to contribute to the image. While the use of septa
improves image quality, they add weight and complexity to the array and also add to patient dose.
A CT scanner using a flat-plate detector must also have a wide beam in two dimensions to provide
even coverage of the flat panel. The terminology gets somewhat confusing, since the beam shaped
used on a multidetector scanner can also be described as a cone beam, but many authors call any CT
device using a flat-panel detector instead of multiple row detectors a “cone beam scanner.” But, these
flat panel scanners, since the panel does not lend itself well to the use of septa common to multide-
tector scanners, must offer other methods to minimize the deleterious effect of scattered X-rays on
image contrast. The use of a grid, not unlike those used with conventional X-ray films, can improve
image quality but their use again requires an increase in patient dose. For example, as much as 20%
of the total patient dose may be lost in the septa of a multidetector scanner and it is anticipated that
this percentage could be more when using a grid on a flat panel or cone beam scanner.
22 CT IMAGING
Figure 1.26 This image of an angiography unit during assembly demonstrates the flat-panel detector (arrows) at the top of the C arm
with its X-ray tube at the bottom.
Figure 1.27 Multidetector scanners use an X-ray beam pattern that resembles the blades of this kitchen tool, used to cut butter into
flour, since it also diverges in two directions.
X-ray source
Patient
Detector
Figure 1.28 The usual third-generation CT scanner design has the X-ray tube (top, left image) move around the patient accompanied
by the detectors (bottom, left image) that are rigidly attached opposite the tube on the gantry. Viewed from the side, the X-ray beam
on a single-detector scanner is very narrow from head to foot and like a paper fan (middle drawing ). However, to accommodate the
multiple detector arrays on modern scanners, the X-ray beam must be wide from head to foot as well as from side to side (far right
drawing ).This figure provided by Josef Debbins PhD, Barrow Neurological Institute, Phoenix, Arizona
These factors are considered in the term dose efficiency, and this measurement is the composite
of both the absorption efficiency and geometric efficiency of the scanner hardware. For example,
the early single-slice scanners had a very high geometric efficiency since almost all the X-rays in the
beam were collected by the single detector row. However, those early scanners had relatively low
absorption efficiency because of the materials then available for the detectors. This has improved so
that modern CT scanners offer a very high absorption efficiency, >90%, but a lower geometric effi-
ciency compared with single-slice scanners. This give and take explains the surprising fact that the
patient dose using a single-slice scanner in axial mode may be lower than the dose for an equivalent
CT scan using modern multidetector scanner in helical mode.
So, if dose increases and contrast decreases using a flat panel for CT, why bother? One reason is
that flat panel scanners offer the potential for improved resolution compared with multidetector CT.
Another is that a flat panel detector weighs considerably less than a large detector array and that
offers the possibility of faster rotation times. But there is another limiting factor to rotation time
that is rarely considered these days called recovery time. The limit to gantry rotation speed is usually
considered to be the physical limits of spinning a very heavy object at high speeds. But another limit-
ing factor is the time necessary for the detectors to reset after each exposure to the X-ray beam. For
example, there would be no point in spinning the gantry at four rotations a second if it required a
full second for the detectors to return to their baseline state after each exposure. This time necessary
for the detectors to reset, also called afterglow, was a problem with older detector design but is neg-
ligible on modern multidetector scanners. However, flat-panel scanners will require more time for
recovery so even though the gantry can physically spin faster, it won’t matter unless faster recovery
time for the detector panel become possible.
Dose constraints and potentially lower contrast, along with complex reconstruction algorithms
have proved to be obstacles to the commercial development of cone beam CT for the time being. But
this design does offer some advantages, and it deserves our continued attention since it is likely that
24 CT IMAGING
many of these problems can be addressed with ongoing development of this technique. Cone beam
CT is currently offered as an option on some angiography units and has proved to be useful in that
setting for problem solving during complex interventions and the management of emergencies dur-
ing interventional procedures.
Iterative Reconstruction
All current CT scanners use variations of back-projection for image reconstruction. Recently, many
scanner manufacturers began offering variations of mathematical or algebraic reconstruction, usu-
ally called iterative reconstruction (IR), for their scanners. There are two good reasons why. First,
because of the increased utilization of CT, there has been an appropriate emphasis placed on reduc-
ing CT dose. Second, as a result of the relatively low price of supercomputer capabilities, it is now
feasible to perform algebraic reconstructions at acceptable speeds and cost. Early indications suggest
that dose reductions on the order of 50–75% are feasible for body imaging using IR without signifi-
cant compromise in image quality using these mathematical reconstruction techniques.
Many variations on this theme are now provided by vendors of CT equipment. Some versions even
limit noise by accounting for the specific errors in the imaging chain, also called optics. Others,
rather than use a pure mathematical reconstruction, use hybrid techniques that start with the tradi-
tional fi ltered back-projection but then use a mathematical technique to reduce noise by comparing
that reconstruction to the raw data in an iterative process.
The term “iterative reconstruction” describes a process of revising the image data in order to provide a
“best fit” with the actual scan data. This is done in a continually updating, or iterative, process. I think
of this much like the way one fills in a crossword puzzle (Figure 1.29). The reason most of us use a pencil
to fill out these puzzles is because we may find opportunities to reconsider our response to an “across”
clue once we figure out the “down” clue in that same location. I think of the iterative reconstruction
process in this simple way; the software takes it best shot at creating the image, then goes back to the
raw data to see how well it did, adjusts a few things, and checks again to see if that fits any better.
One reason why this cannot be easily accomplished in a single, powerful calculation is that the raw
data itself contains errors and noise. As a result, there is no single solution for the calculations, and so
the most that can be hoped for is the creation of a “best fit” for that dataset. Think of it like a crossword
puzzle but, in several spots on the grid, there is no word can satisfy both the “across” and “down” clues.
While IR can be used to reduce dose or improve image quality at the same dose, it does require special
software and computer hardware and currently it adds time for processing. Nevertheless, because it
holds considerable promise for significant dose reduction and will be widely adopted in some fashion.
This approach also offers new tools for minimizing streaks that arise from implanted metal.
While some other and less expensive postprocessing options are available that do not refer back to
the raw data in the same way, these should be considered carefully since they present the risk of cre-
ating “pretty” images at the expense of smoothing over clinically important contrast. For example,
a postprocessing algorithm that eliminates noise in homogeneous areas of anatomy could potentially
obscure true but subtle differences in attenuation. But iterative reconstruction combined with large
decreases in dose will without doubt have its own limitations, and it will take some time to validate
all these new techniques in the clinical arena before they can be used with complete confidence.
(A) 5 2 1
H B
A O
2
N
G R E T A
K
A
3 4
S O P H I A R
N T
(B) 5 2 1
T H E K I N G A N D I
A N
2
N
G R E T A
K
R
3 4
S O P H I A I
N D
Figure 1.29 In A, you could choose “Bogart” for #1 down: a six-letter word for a leading actor in the movie Casablanca , but you
would have to revise it when you find that the first letter of the word must be “I” after you fill in #5 across: title of a film nominated for
nine academy awards starring Yul Brynner and Deborah Kerr (B).
Gantry Angulation and Image Display
Most single-slice CT scanners included a mechanism to tilt the scanner gantry relative to the patient
table. This was used on a regular basis to optimize the plane of imaging for axial brain scanning or,
when combined with head tilt, to provide direct coronal images of the brain or sinuses. One substan-
tial benefit to angulation on early scanners was that, by using tilt, one could minimize the number of
26 CT IMAGING
slices necessary to cover the brain. And when imaging with CT was considered in terms of “minutes
per slice,” eliminating one slice was not trivial. As scanner speed improved, the primary function for
angulation in brain imaging was dose reduction to the eyes, and it was generally recommended to
exclude them from the scan since they are susceptible to radiation injury.
Now, however, on most scanners in helical mode and those units with large multidetector arrays
or two sources, gantry tilt is not available for brain imaging. In spite of this change in hardware,
it is commonplace to continue to present head CT scans with the traditional angulation since it is
familiar to imagers and it makes comparison with prior CT scans easier.
While gantry tilt had been used with patient positioning to provide direct coronal imaging for
temporal bone and paranasal sinus imaging, since most modern scanners offer near isotropic voxel
images, direct coronal imaging is really no longer necessary. Now, even reconstructions in sagittal
views that were formerly unthinkable are routine. In fact, isotropic voxel imaging has created an
imaging environment that resembles MR since even oblique reconstructions of diagnostic quality are
now available on multidetector scanners in both axial and helical modes (Figure 1.30A and B).
The loss of gantry angulation has created two new problems, however. The radiation dose to the
eye is lowest on those scanners that offer gantry angulation if the user prescribes the scan angle and
range to exclude the orbits. However, on scanners that do not allow gantry angulation, the eyes are
always included in the scan but the imager may not be as aware that the eyes were included if the
data is reconstructed into the traditional display angle.
So, while the lens is always included on head scans performed on new scanners without gantry
angulation, the measured dose to the eye during direct helical imaging with a modern multislice
scanner is still quite low. This represents another one of the compromises of CT imaging. As scan-
ners enlarged to incorporate multiple detector rows, the tilt option was lost but the potential for
increased dose was offset by more sophisticated automatic exposure control, beam filtering, and
diminished dose from overbeaming with more detector rows (see Chapter 2, Overbeaming). While
the use of automatic exposure control for brain imaging may not make sense otherwise for a roughly
(A) (B)
Figure 1.30 A, B This high quality coronal CT image (A) was reconstructed from the thin section axial imaging data. Note the small defect
in the bone of the sphenoid sinus (arrow) that corresponds to the site of a CSF leak noted on the coronal MR T2 weighted scan (B, arrow).
spherical object, it can be worthwhile by providing greater dose reduction to the lens. Another
option to reduce lens dose is to use bismuth X-ray attenuating eyecups, but this adds cost and time
(see Chapter 2, Shielding).
The second problem encountered with brain scans performed without gantry tilt is that the user
needs to be attentive to artifacts from hardware in the mouth, such as amalgam, crowns, and
implanted posts. While these were almost never an issue when gantry tilt was used, the metal arti-
facts arising from X-ray shadowing behind these very dense materials frequently projects directly
over the posterior fossa and, in some cases, significantly degrades the diagnostic value of the CT scan
(Figure 1.31). One option to minimize this artifact is to instruct cooperative patients to tuck their
chins during the scan. This recreates the traditional imaging angle without requiring gantry angula-
tion and should be helpful in limiting the metal artifacts from teeth and, if carefully done, it offers
the potential for reducing eye dose as well.
Medical practice is at times an odd mix of eager acceptance of new technology and rigid resis-
tance to change in almost every other way. With the arrival of scanners without the capability of
gantry angle, the only real benefit now to viewing CT brain scans in the old fashion is that the
orientation is familiar to imagers. Straight imaging in many respects would make it easier to com-
pare CT scans with MR scans, since the later are routinely displayed without angle (Chapter 5,
Artifact 9). But it seems likely that, as more centers move to isotropic imaging of the brain, head
scans will eventually be presented in two or three orthogonal planes for review similar to the way
most body CT images are displayed now.
(A) (B)
Figure 1.31 The axial CT scan (A) shows considerable artifact overlying the cranio-cervical junction without a clear source. The
coronal reconstruction (B) shows that the streaks are arising from dental amalgam and projects over the skull base in this case
because no gantry tilt was available on this scanner.
28 CT IMAGING
Scan Acquisition Speed
One of my friends with a very large front lawn once told me that he bought a new mower about
every 10 years, and every new mower had a wider blade than the last. He figured that by the time he
retired, he would be able to mow his whole lawn in one trip down and back. That is essentially how
CT detector arrays have changed over time. While the earliest scanners had one or two detectors and
took up to half an hour to scan the brain, there are now scanners with 320 detector rows that can
cover the entire brain in a single, subsecond rotation.
The three factors that determine scan speed using helical technique are beam collimation,
table speed, and tube rotation time. The term “pitch” is a useful concept that incorporates all
three factors into one term. Pitch may be defi ned in several ways, but we will use it specifi cally
to mean:
Table Movement in cm During Each Tube Rotation ÷ Beam Collimation in cm (2).
For example, if the beam collimation is 4cm, the table moves 4cm per second, and tube rotation
time is 1 second, then the pitch for that scan would be equal to 1. At an intuitive level, a pitch of
1 can be visualized as though the X-ray beam paints a continuous helical stripe around the patient,
with no gaps and no overlap. Now, if we just decrease the rotation time to 0.5 seconds but keep the
beam collimation and table movement the same, the pitch is now equal to 2. With that pitch, there
will be wide gaps between the stripes covered by the X-ray beam, and that will decrease resolution
and increase minimum slice thickness. To its credit, however, higher pitch values can be used to
decrease radiation dose and overall scan time (Figure 1.32).
(A)
(B)
Figure 1.32 This illustration shows how the use of a high pitch value (A) leaves wide gaps in the beam trajectory compared with a
scan using a lower pitch (B). The advantage of using higher pitch values is that it offers faster scan times and potentially at a lower
dose at the expense of resolution and minimum slice thickness.
Rotation Time
When scanning in helical mode, decreasing rotation time will have a significant impact on total scan
time. Decreasing rotation time by half effectively cuts scan time in half and this is important for imaging
moving tissues like the heart (see Chapter 3). When using step-and-shoot, however, the time spent actu-
ally scanning is just a fraction of the total scan time since that is disproportionately composed of moving
the patient from slice to slice. Decreasing rotation time usually reduces overall image quality because
fewer projections are obtained, but most new scanners routinely use rotation times of 0.5 seconds for CT
angiography (CTA) since is the benefits of fast scanning outweigh the incremental image degradation.
Dual-Energy, Dual-Source CT Scanning
Computed tomography scan times are remarkably short now, with a brain scan requiring less than
10 seconds. That can be compared with the 5 minutes per slice that was routine at the start of my
radiology career. By my calculations, that means that a brain CT scan is about 250 times faster now
compared with the same scan 30 years ago. I have wondered why the charge for CT has not gone
down, too, but that is another matter entirely.
One would have thought that CT scanners are now fast enough for any diagnostic problem, but
faster scanning has created many new opportunities for CT imaging but a few problems, too. For
example, when imaging the brain and neck, it has become necessary to build in a time delay after
giving contrast because otherwise the scan will be over before sufficient contrast can accumulate in
abnormal tissue (see Pitfall 8, Chapter 6), and CTA is now so fast that incomplete fi lling of the carot-
ids can create an artifact easily mistaken for dissection. But these limitations should be recognized
and adjustments made. Overall, faster imaging has created entirely new applications, and it seems
that CT can never be fast enough for some purposes.
One current approach to further decreasing scan time is to build scanners with two tubes and two
detector arrays set 90 degrees apart (Figure 1.33). Because the attenuation value of an X-ray passing
through the body should be about the same from left to right as right to left, only 180 degrees of
imaging, or one-half of a rotation, is really necessary. Therefore, by using two tubes and detectors
simultaneously, only a 90-degree gantry rotation is really necessary to acquire the necessary data for
image reconstruction.
Another advantage of using two completely separate and independent tube–detector sets on the
gantry is that they can be set up differently. For example, if one tube operates at a low kV and the
other at high kV, the same slice can be reconstructed from a pair of images with different image
contrast characteristics. The difference in the way the tissues attenuate the X-rays at the two energies
can then be used to better characterize the tissues. This technique, called dual-energy CT scanning,
is particularly helpful for differentiating bone from contrast since they can have the same attenu-
ation value when imaged using a single kV. That is because iodine selectively absorbs low-energy
X-rays, called the photoelectric effect, while bone largely scatters X-rays at both energies. Since
iodine will appear to have a much higher attenuation value when imaged using a low kV, these two,
30 CT IMAGING
X-ray tube 1
Detector X-ray
array 2 tube 2
Detector array 1
Figure 1.33 The arrangement of X-ray tubes and detectors in a dual-source CT scanner. While it still uses standard third-generation
geometry, it requires only a 90-degree rotation to collect the equivalent of 180 degrees of rotation on a single-source scanner.
otherwise indistinguishable, tissues can be separated on the basis of their behavior at two different
kV values. This has been shown helpful for many things, including differentiating a hemorrhagic
renal cyst from an enhancing tumor, blood from contrast in the brain, and for creating CTA and CT
venography (CTV) images with the bone removed (Figure 1.34).
Dual-energy scanning is not just limited to scanners with two tube–detector sets. It can also be
performed on some scanners that have a specially designed, but single, X-ray source that can rapidly
switch between two different tube voltages during the scan.
Because of the rapid image acquisition available on current CT scanners, several new imaging
techniques have become routine, such as cardiac imaging and whole-brain perfusion, and there is
some hope for time-resolved CTA in the near future. That would be of value in some cases because
it is commonplace to see both veins and arteries on normal CTA. As a result, they cannot be used
for the diagnosis or follow-up of small arteriovenous malformations of the brain or spine in most
cases. If CTA scans can be acquired in distinct vascular phases (i.e., arterial, capillary, and venous),
that information may be sufficient to fi nd areas of arteriovenous shunting noninvasively. The cur-
rent limitations include insufficient temporal resolution on most scanners and the expected radiation
dose incurred by repeated scanning over time, but these may be addressed in the near future.
CT Imaging Techniques
As you can appreciate from this review, the hardware and software used for CT imaging are com-
plex, both separately and in their integration. Variations in scanner design among different manu-
facturers make it very difficult to export techniques used on one scanner to another. For example, if
the detector array on one scanner is farther away from the tube than another, it may require more
(A) (B)
(C)
(D) (E)
Figures 1.34 A–E These axial images (A and B) were obtained simultaneously on a dual-source, dual-energy CT scanner immedi-
ately after intra-arterial thrombolysis of a middle cerebral artery occlusion. The kV 80 image (A) shows high attenuation material in the
right basal ganglia and its measurement within a cursor shows an attenuation value of 349 HU. The corresponding image using a kV
140 (B),at the same location, shows an attenuation value of only 189 HU. The doubling of attenuation value between a low kV and high
kV image is due to photoelectric effect and is characteristic of iodine. CT follow-up confirmed that the high attenuation in this patient
was due to contrast staining.
This carotid surface reconstruction seen in C illustrates one benefit of bone removal CTA when imaging at the skull base. By removing
the bone surrounding the internal carotid artery, using its imaging characteristics at the two energies, this carotid stenosis is quite
evident. It might easily be overlooked on conventional CTA since the surrounding bone obscures it on both the source image at that
level (D, arrow ) and axial maximum intensity projection (MIP) (E) reconstruction.
tube current to provide equivalent images. That is, of course, unless it has more efficient detectors
or thinner septa in the detector array. And we still haven’t accounted for the filtration devices used
to modify the X-ray beam, and these can differ in both materials and shape. In fact, each manufac-
turer makes choices for the detector array, software, X-ray tube, and the like that, in sum, define
32 CT IMAGING
the performance characteristics of their unit. So don’t be frustrated when the technique that always
works on your GE scanner will not provide comparable images or dose on your Siemens unit. That
is also why specific techniques will not be recommended in this book.
What makes it even more complex these days to design CT protocols is that the manufacturers
often build into their scanners automatic adjustments that may unobtrusively offset changes made
by the user. The manufacturers have taken some control of the unit away from the user with the
intent of ensuring good quality-images and patient safety. For example, you may fi nd that when you
increase pitch to lower the patient dose the scanner has automatically increased the mA to offset the
increased image noise expected from using the higher pitch value.
This is most important to keep in mind when using automatic exposure control or AEC. In that
mode, the scanner will adjust the dose to meet preset values of image “noise index” or “reference
mA” equivalent. If this is the case, you will fi nd that “automatic” does not necessarily mean “lower.”
Patient dose can reach surprisingly high values in large patients or when AEC is used inappropriately
(e.g., for brain perfusion). And keep in mind that the reference values for AEC that are preset by
the manufacturer may be ideal for image quality, but completely acceptable imaging can usually be
achieved by lowering those reference values and thereby limit dose for your patients. You must be
aware of how your scanner will respond to changes in technique and patient size if you are to truly
manage X-ray dose.
The antilock brakes or dynamic steering controls available on most new cars are intended to keep
you out of trouble in challenging driving situations. But, by interpreting your steering and braking
input, they separate you from direct control of the vehicle. On Ferraris (or so I am told), a switch on
the steering wheel allows the driver to completely turn off these driving aids in order to deliver com-
plete control of the car to the hopefully skilled driver, thus allowing them to explore the unfettered
performance limits of the vehicle. Most CT scanners have no such switch, so the user will need to
be aware that the software installed by the manufacturer may modify user input. Make it a habit to
check that the scanner has not offset some change that you made in the protocol with an adjustment
somewhere else. And that brings us to Chapter 2, on CT dose and dose reduction techniques.
SUGGESTED READING
Kalendar WA, Wolfgang S, Klotz E, Vock P. Spiral volumetric CT with single-breath-hold technique, continu-
ous transport, and continuous scanner rotation. Radiology. 1990;176(1):181–183.
Gupta R, Cheung AC, Bartling SH, Lisauskas J, Grasruck M, et al. Flat-panel volume CT: Fundamental prin-
ciples, technology, and applications. Radiographics. 2008;28:2009–2022.
Tan JSP, Tan KL, Lee JCL, Wan CM, Leong JL, Chan LL. Comparison of eye lens dose on neuroimag-
ing protocols between 16- and 64-section multidetector CT: Achieving the lowest possible dose.
AJNR.2009;30:373–377.
Mahesh M. The AAPM/RSNA physics tutorial for residents. Search for isotropic resolution in CT from con-
ventional through multiple-row detector. RadioGraphics. 2002;22:949–962.
Karcaaltincaba M, Aktas A. Dual-energy CT revisited with multidetector CT: Review of principles and clinical
applications. Diagn Interv Radiol. 2011;17:181–194.
Goldman LW. Principles of CT: Radiation dose and image quality. J Nucl Med Tech. 2007;35:4:213–225.
Bauhs JA, Vrieze TF, Primak AN, Bruesewitz MR, McCollough CH. CT dosimetry: Comparison of measure-
ment techniques and devices. RadioGraphics. 2008;28:245–253.
Parry RA, Glaze SA, Archer BR. The AAPM/RSNA physics tutorial for residents. RadioGraphics.
1999;19:1289–1302.
Barrett JF, Keat N. Artifacts in CT: Recognition and avoidance. RadioGraphics. 2004;24:1679–1691.
Kilic K, Erbas G, Guryildirim M, Arac M, Llgit E, Coskun B. Lowering the dose in head CT using adaptive
statistical iterative reconstruction. AJNR. 2011:32:1578–1582.
2 RADIATION SAFETY AND RISKS
Alexander C. Mamourian and Josef P. Debbins

36 CT IMAGING
Patient Dose and Dose Reduction Techniques
For anyone involved with medical imaging, it is essential to be on familiar terms with radiation ter-
minology. Those who are not will fi nd themselves on unsteady ground either when reading the litera-
ture or discussing the particulars of a computed tomography (CT) scan with patients. The numerous
terms used to describe radiation dose contribute substantially to the confusion, and I believe the fi rst
step to a solid understanding is to use only two or three terms for dose measurement. Otherwise,
you will eventually get lost by using the full range of units e.g. Roentgen, rad, rem, Gray, Sievert, and
their respective conversion factors. In this book, the terminology of radiation dose will be limited to
the most commonly used measurements.
You will also fi nd it helpful to keep a few hard numbers in mind, such as background radiation
effective dose (3mSv) and the American College of Radiology (ACR) limits in units of CT dose index
volume (CTDIvol) for an abdominal CT scan (25mGy) and head CT scan (75mGy). These can pro-
vide reference points as you consider variations of technique. You can then build on that foundation
over time as new techniques for dose reduction are introduced and your depth of understanding
increases.
Commonly Used Measures of CT Dose
CTDI VOL
A number of CT dose measurements have been used over time, and these are variations of a term
called CT dose index or CTDI. Some that are no longer in common use are CTDI FDA, CTDI100,
and CTDIw. Fortunately, there is only one you should be familiar with now, the measurement
CTDIvolume (CTDIvol)since it is calculated on most commercial CT scanners and is widely used in
the literature.
The meaning of CTDI has changed over time in response to advances in CT technology. The mea-
surement of CTDIvol is performed in a phantom and incorporates some weighting of the peripheral
dose compared with the lower central dose, as well as the pitch used for helical scanning. Keep in
mind, however, that CTDIvol for a CT scan is just a calculated value based on X ray tube settings.
Although it does account for the specific features of the scanner, such as beam filtration, when
reported by the scanner at the end of a scan, it is not at all a direct measurement of the dose delivered
to a particular patient. It is in truth a measurement of the X-ray tube output and is based on specific
scan parameters, including mA, kV, and pitch, as well as dose modulation. It can be quite helpful as
long as one recognizes that in some situations it may not accurately reflect the actual patient dose,
and CT brain perfusion has been cited as one example.
Although CTDIvol is by no means a perfect measure of dose it is useful in day-to-day CT opera-
tions. Many fi nd it helpful whenever they want to see how the modification of one scan parameter
will influence patient dose because that change will be reflected in the CTDIvol. This number also
allows comparison of the dose of the same scan performed on different machines even when they
are from different manufacturers. And, by just glancing at the dose report, now available for each
Radiation Safety and Risks 37
patient exam, one can determine whether a specific exam falls within both the ACR’s and your own
institutional guidelines. For example, if the dose page from a head CT scan shows a CTDIvol of
90mGy, it should serve as a warning that there is a problem with the scan protocol that should be
addressed immediately.
Absorbed Dose
The absorbed dose is the measure of ionizing radiation deposited into a specific volume of tissue.
Although absorbed dose does not take into account the behavior of that tissue or provide an estimate
of the risk of radiation, it does correlate well with the immediate or deterministic effect s of radia-
tion. The units of absorbed dose in common use are the Gray (Gy) and milli-Gray (mGy) named
for the physicist Louis Harold Gray. The actual absorbed dose can be quite difficult to determine
since it depends on the energy of the X-rays, their total number, and the nature and depth of tissues
involved. Although it is easiest to measure dose at the skin surface, it is the total absorbed dose that
is of interest, and so this number for CT is always an estimate.
The absorbed dose can be used to predict whether the radiation was likely to be the cause of red-
dening of the skin or even hair loss in a particular patient. Just so you have some benchmark values,
keep in mind that the absorbed dose of a head CT is about 50mGy and temporary hair loss occurs
at a dose of 3Gy at the skin. Thus, it would take over 50 diagnostic head CT scans to cause tempo-
rary hair loss, assuming there is a cumulative effect. There are reports of hair loss after a single CT
brain perfusion scan in patients who also had more than one cerebral angiogram, thus supporting
the concept of cumulative effect of diagnostic radiation.
Deterministic Effects
Radiation sickness leading to death is the most severe of the immediate or deterministic effects of
radiation and is usually associated with nuclear warfare or reactor accidents. There are rare excep-
tions, however. For example, about 5 years ago, Alexander Litvinenko, a former officer in the KGB,
died from radiation sickness after being intentionally poisoned with polonium 210. His cause of
death was initially overlooked since polonium kills with alpha particles, not gamma rays, making it
very difficult to detect if this poison is not suspected.
In clinical practice, deterministic effects are only rarely encountered because the absorbed dose of
a diagnostic scan is so far below the threshold for effects. However, it is not uncommon to see skin
and hair changes from radiation after prolonged interventional procedures or in patients who have
multiple high-dose imaging procedures during a single hospitalization (Figure 2.1). In addition, it
is very important for anyone involved with CT imaging to be aware of the possibility of determin-
istic effects and know what they look like. For example, it was reported that some patients who
experienced hair loss after improperly administered CT scans were initially sent to dermatologists
because the connection between the recent CT scan and their symptom of hair loss was not initially
recognized.
38 CT IMAGING
Figure 2.1 Photograph of the typical band-like hair loss

from brain CT perfusion. In this case, it was temporary and
secondary to the cumulative dose from multiple high-dose
imaging procedures and not from the radiation dose incurred
during a single perfusion scan.
Effective Dose
The effective dose is measured in units of Sieverts or milli-Sieverts (mSv), named for physicist Rolf
Sievert. It is a measurement of dose that, unlike absorbed dose, takes into account the sensitivity of
the tissues that receive the radiation. For example, while CT imaging of the head requires a relatively
large radiation dose, its effective dose is only 2mSv. That is less that the average individual’s effective
dose from background radiation in the United States (3mSv). The reason the effective dose of a head
CT is so low is that the brain is relatively insensitive to radiation. Compare that with a chest CT that
has a much lower absorbed dose but an effective dose that is three to five times more than a head CT.
That is because the organs included in the chest CT, such as breast and esophagus, are much more
sensitive to radiation, and this is reflected its high effective dose.
Stochastic Effects
The effective dose is use to predict the late or stochastic effects of radiation. The word “stochastic”
is not commonly used in medicine apart from this circumstance. Its meaning in this situation is usu-
ally taken to be “randomly determined” but its derivation is attributed to the Greek word skokhos,
“to aim,” although some would say more aptly from the word stokhazesthai, “to guess.” The mag-
nitude of the stochastic effect for diagnostic radiation remains unclear, but it is generally accepted
that the late adverse effects of diagnostic radiation may appear years after radiation exposure. What
remains uncertain to this day is the precise level of radiation exposure necessary to even entertain
the possibility of these late effects. The authors of an article on virtual colonoscopy using CT wrote,
“ An estimated 70 million CT scans are performed in the U.S. every year, up from three million in
early 1980s, and as many as 14,000 people may die every year of radiation induced cancers as a
result.” A more recent paper in the Lancet suggested that just three CT scans of the head incurred
prior to age 15 will increase the risk of brain cancer in that patient by several fold. These are just
estimates and difficult to confi rm since it is almost impossible to determine which cancers are related
to radiation, among the many that occur every year.
There is little doubt, however, that late effects can occur from a long exposure to high doses of
radiation. It is worthwhile for anyone involved in medical imaging to read about those who died from
radiation as a result of early medical or scientific investigations. Perhaps the most famous example
is Marie Curie. She is credited in some share with introducing the term “radioactivity” and with the
discovery of polonium (named after her homeland Poland) and, later, radium. Her tireless work to
isolate the element radium required long exposures to pitchblende, a radioactive ore. She died in 1934
from aplastic anemia that seems undoubtedly the result of her prolonged exposure to radiation.
The American Association of Physicists in Medicine (AAPM) in December 2011 took the position
that, for diagnostic tests with an effective dose of 50mSv or less, when incurred in a single exposure,
or 100mSv in multiple exams over a short time, the late effects may be “nonexistent” (their word). It
is also important to keep in mind that medical radiation has a purpose, and the expectation is that
the risk should be offset by the benefits of the exam for the patient. Since the actual risk of low-dose
radiation is unknown, and a small risk is reasonable for a large gain, it is very difficult to know how
much concern should be attached to a single CT exam. However, common sense would indicate that
less radiation is better, and many patients are having multiple CT scans. These are the best reasons
why medical imagers must be attentive to using the smallest amount of radiation necessary to make
the diagnosis using CT or any other X-ray device.
This idea is captured in the term ALARA (As Low As Reasonably Achievable) and should be our
goal whenever considering the necessary dose for medical imaging.
Dose Length Product Conversion to Effective Dose
Dose length product (DLP) is expressed in the units of mGy-cm. Its determination is really quite
uncomplicated; it is simply the calculated CTDIvol multiplied by the length of the scan, from head
to foot, in centimeters. But this simple calculation has been demonstrated to provide a remarkably
accurate measure of effective dose when compared with the much more sophisticated Monte Carlo
simulation. Although sounding very James Bond-ish, this method uses a mathematical representa-
tion of the body with approximate shapes of organs and their estimated radiation sensitivity to pre-
dict the effects of radiation. It has been demonstrated that multiplying the DLP by a predetermined
constant for a specific body part will provide a value for effective dose in mSv that is a surprisingly
close to the calculated effective dose using the Monte Carlo simulation.
For brain imaging, that constant is .002 mSv/mGy-cm. Since the average head CT has a CTDIvol of
under 70mGy and a DLP of about 1,000 mGy-cm, the calculated effective dose of a head CT is 2mSv
(.002mSv/mGy-cm × 1,000mGy-cm). Now, if we were to use the exact same imaging parameters for
40 CT IMAGING
a CT scan of the neck and assume it has the same DLP of 1,000 mGy-cm, we would then use a larger
constant (.005 mSv/mGy-cm) to predict effective dose because of the increased sensitivity to radia-
tion of the tissues in the neck. The conversion factor for chest CT is even higher, .018 mSv/mGy-cm,
because the tissues there are even more sensitive to the effects of radiation.
Techniques for Dose Reduction
ESTIMATING OPTIMAL DOSE

One of the most difficult challenges for the diagnostic imager is to determine the “optimal dose” for
CT imaging. This is in part due to the very subjective nature of this assessment, which can vary widely
among individuals based on their experience and expertise. It is important to keep in mind at all times
that the goal is not just to produce exquisite CT images. It should be to use just enough radiation to
provide images as good as they need to be in order to establish the diagnosis. And, keep in mind that
when we talk about “radiation cost,” it is the patient paying the price. That is why the CT user needs
to find a reasonable compromise between patient dose and image quality. Although it is tempting to
create images of extraordinary quality—and even if you find them easier to interpret—if this requires
a higher dose, it must be justified by the clinical question.
Another problem to consider when determining optimal dose for CT is our inability to per-
ceive when a CT was performed using too much dose. Early X-ray images were no different
from photographs taken with a fi lm camera. Those early fi lm negatives accurately refl ected the
relationship between the available light, the sensitivity of the fi lm, and the camera settings. For
example, if the aperture was set too wide on a sunny day, the picture would appear dark from
overexposure. There was a time when making a high-quality X-ray image, in much the same
way, required a good deal of judgment so that the proper settings of kV, mA, and exposure time
were combined to give the correct exposure of the radiographic fi lm. I still remember my dis-
comfort when looking at the nearly black X-ray image that was taken of one of my children by
a student radiographer many years ago. Both of us clearly recognized that too much radiation
was used.
As many newly unemployed newspaper photographers well know, photography using digital cam-
eras is much more forgiving because only a loose relationship remains between the exposure settings
and the fi nal image. That is due largely to the use of electronic detectors instead of fi lm in modern
cameras. These can provide acceptable images under a wide range of lighting situations just by
modifying the sensitivity of the sensor. Within reasonable limits of X-ray dose, modern CT scanners
function the same way as digital cameras since they also provide acceptable images within a wide
range of exposures.
In fact, when CT scans are performed with too much radiation there will be few complaints from
imagers because the CT images actually look better—the higher the dose, the better the images.
Modern CT scanners therefore require that the user have a good understanding of the dose reports
since image assessment alone can be misleading. Even when CT images are made with too little dose
they might pass for a time as adequate if their poor quality is attributed to other confounding factors
like motion (Figures 2.2, 2.3).
Figures 2.2 This scan was mistakenly performed using a Figure 2.3 Scan performed with usual CTDIvol of 60 mGy.
CTDIvol of only 19mGy, a value that is one-third of the usual
dose used on this scanner. Although there is some degra-
dation in image quality, it may be difficult to appreciate until
you compare it with a scan of a different patient performed
with the usual dose at CTDIvol of 60mGy (see Figure 2.3).
CT Dose Reduction: Indications
Years ago, a writer reflected that the most effective way to minimize travel time was to just stay
home. In the same way, the simplest and most powerful way to minimize patient radiation dose is
to not perform a CT scan at all. You must consider whether the patient will benefit from imaging
and, if so, if CT is ideal for the diagnosis (since there are now many other options for imaging, such
as magnetic resonance [MR] and ultrasound). Another strategy that immediately reduces dose, and
one you may have more control over, is to severely restrict your use of high dose techniques such as
multiphase CT. In most circumstances, there is no need for both pre- and postcontrast imaging of
the brain or chest, for example. For sites that have access to a dual-source, dual energy CT scanner
a technique called “virtual non-contrast” may be an option for dose reduction. For example, when
obtaining a contrast enhanced brain CTA there can be substantial dose reduction for the patient by
not performing a non-contrast head scan prior to the CTA. For example, with conventional CTA is
difficult to determine whether there exists subarachnoid hemorrhage without a non-contrast exam.
But, by using the imaging characteristics of iodine and blood at the different energies it becomes pos-
sible to provide a “virtual” non-contrast scan from the CTA data by removing the contrast enhanc-
ing structures (see Chapter 6, pitfall 5).
42 CT IMAGING
Critical evaluation of the need for CT scanning does not require canceling all exams, just a
thoughtful approach and some humility when considering whether our patient’s health has improved
in proportion to the increased use of CT over the past 15 years.
Axial Versus Helical Scans
An important starting point when designing a scan protocol is the decision of whether to use axial or
helical mode imaging. In general, axial imaging will prove to be slower and have inferior reconstruc-
tions compared with helical mode, but, at the same time, it offers better control of the dose distribu-
tion and, in many cases, produces fewer artifacts. Other factors may not be immediately apparent as
you consider these two options for brain imaging. For example, the use of helical mode means that
the gantry cannot be tilted on some scanners.
But for those CT scans that must be fast, such as chest imaging and CT angiography (CTA), helical
mode is the better choice. With regard to dose distribution, there are two terms you need to under-
stand when considering the choice between axial and helical: overbeaming and overranging.
Overbeaming and Overranging
On all CT scanners, the shape of the X-ray beam that emerges from the tube is modified using metal
plates called collimators. On the old single-slice CT scanners, the fan beam width was the same or
less than the width of the detector row (Figure 2.4) and so the entire X-ray dose was utilized in some
fashion to create the image. If we choose to discount differences in detector sensitivity, this arrange-
ment provided a very high “dose efficiency.”
This is not the case in multidetector scanners, where the beam width must always be wider than
the detectors. That is because the X-ray beam must cover all the active detector rows evenly. Since
the X-ray beam diverges from a point on the anode, a portion of the X-ray beam must always fall
outside the end detectors in the array, and this dose is effectively wasted since it does not contribute
to the image. The portion of the beam that extends beyond the detectors is called the penumbra, and
this effect is called overbeaming. It is important to recognize that this extra dose occurs over the
entire length of the detector array (Figure 2.5) and, on average, this adds about 1.5mm of extra tis-
sue radiation on either side of the array. While seemingly small, this extra radiation adds up quickly
when using a scanner with a narrow detector array since it will require many rotations to cover the
chest and abdomen, for example. However, overbeaming can be discounted for scanners using 32
rows or more since they require so many fewer rotations to cover the same anatomy.
As the number of detector rows increased, however, another source of added dose became more
significant called overranging (Figure 2.6). Because of the very nature of helical image reconstruc-
tion, the X-ray beam must begin and end its path outside the region of interest. This bit of extra
scanning is necessary to provide the data points needed for interpolation on the end slices. This
added dose, unlike overbeaming, is not really wasted since it is necessary for reconstruction, but it is
easy to overlook when considering patient dose. The magnitude of this added dose from overranging
increases with beam collimation, number of detector rows, and the pitch value.
X ray tube
Single detector row
Figure 2.4 On a single-slice scanner, the beam collimation is always the same as or less than the width of the detector row. Since all
the X-rays are directed at detector elements, this arrangement is described as having high dose efficiency.
X ray tube
Figure 2.5 This illustration shows the added dose that falls on either side of the array. It is not feasible to constrain the beam to only
cover the detectors, as seen in Figure 2.4, since that would mean the outer rows receive less of the dose than their neighboring rows,
and this will degrade the quality of reconstructions. That portion of the beam that falls beyond the detectors is called overbeaming.
In practice, the proportion of the total dose from overranging diminishes as the scan length
gets longer since overranging at the ends is the same whether the scan length is short or long. This
means that overranging can add significantly to total dose on focused exams like temporal bone
scans, but its contribution is considered insignificant on studies that cover a lot of anatomy, such as
chest-abdomen-pelvis scans.
In cases where the dose contribution from overranging is considered substantial, you should con-
sider using axial mode imaging to better constrain the dose. It may be hard to really gauge the impact
of overranging, however, since some of the current generation of large-array scanners can limit the
added dose from overranging through sophisticated collimation at both ends of the scan range. And,
44 CT IMAGING
(A)
region of interest
(B)
axial mode
(C)
helical mode
Figure 2.6 When covering a short segment of anatomy (A) using axial mode imaging, the scan (B) essentially begins and ends at
the top and bottom of the region of interest. When you choose helical mode, where image reconstruction depends on estimation of
attenuation between two known points, the scan must begin above the region of interest and end below (C). When using wide arrays
and high pitch values, overranging can add substantially to the total dose.
for some scanners with very wide detector arrays, helical imaging is not even necessary for head scans
since they can be performed with a single axial rotation that eliminates overranging altogether.
Pitch
The choice of pitch is always a compromise among scan speed, patient dose, and image resolution.
It is useful to consider using a pitch of 1 as a starting point (Figure 2.7). Pitch 1 means that there are
no gaps in the path covered by the X-ray beam, and no tissue is exposed more than once. Increasing
the pitch above 1 means that gaps will appear in coverage by the X-ray beam so that some tissue
receives much less radiation. Although this would result in complete gaps in imaging when using
axial mode scanning, because of the interpolation of data these gaps in the helical scan simply
mean that the estimations are less accurate. In principle, this can be used to reduce dose as long as
adequate image quality is preserved, and increasing pitch allows faster coverage of the anatomy. For
example, this is a good option to consider for CTA of the chest, where resolution demands are less
than for brain CTA but rapid coverage of a large section of anatomy is necessary.
With the exception of cardiac imaging, it is uncommon to use a pitch of less than 1, but it may be
helpful for high-detail exams such as temporal bone scans. With low pitch, there is actually overlap
of the X-ray path over the body. This results in increased dose in those areas, but, this oversampling
allows a more accurate measurement of attenuation values and lower noise. Low pitch also requires
more time to cover the same anatomy.
Tube Rotation Time
Rotation time and mA are interdependent and are sometimes combined in the term milliampere
seconds (mAs). That is because the number of X-rays produced is a function of the magnitude of the
tube current and the amount of time the tube is turned on. Since the tube is generally on the entire
time it is moving, the mAs can be decreased both by using a lower tube current or by spinning the
gantry faster so that the rotation is completed faster.
On some scanners, however, decreasing the tube rotation time will cause the scanner to automati-
cally increase the tube current to offset the shorter time the tube is on. This results in no net change
in mAs and, as a result, there is no dose reduction and little impact on image quality. But the faster
rotation speed may prove to be an advantage since, for CTA, it can increase the chances of imag-
ing the contrast during the arterial phase in the brain. But for detailed imaging, like temporal bone
exams or routine brain imaging, where there is usually no advantage to decreasing the total scan
time from 10 seconds to 5 seconds, it is usually better to use a longer rotation time since it provides
better a signal-to-noise ratio (SNR) at equivalent dose.
mA and kV
There are many factors that you can alter to lower dose. These include X-ray tube kV and mA,
tube rotation time, detector collimation, tube collimation, pitch, reconstructed slice thickness,
Figure 2.7 This illustration shows the wide gaps between the X-ray beam wraps when using a high pitch (upper image) com-
pared with a low pitch (below ). It also shows why so much more anatomic coverage is possible in the same time using the larger pitch.
46 CT IMAGING
reconstruction kernel, and more. The two that are usually considered the most important contribu-
tors to total patient dose are the X-ray tube electrical current (mA) and the potential (kV).
Voltage and amperage are standard measurements of electrical current that acknowledge the con-
tributions of Andre-Marie Ampere and Alessandro Volta to our understanding of electricity. If you
have trouble understanding what these measures of electrical energy mean—and many do—you may
fi nd it is easier to picture water instead of electrical current. For example, you can consider that volt-
age is equivalent to the water pressure at the end of a hose, whereas amperage indicates the actual
volume of water flowing from the hose.
My grandfather explained this to me when I was child (which I suppose says a lot about my
grandfather and my childhood) by using two streams of water emerging from holes in a large water
tank. A large hole just below the top of the tank would allow a lot of water to escape but at very low
pressure. This is comparable to the low voltage but high amperage current provided by a car bat-
tery. Now visualize a very small hole near the bottom of the tank. That hole would allow a small,
low-volume stream to shoot out of the tank but under tremendous pressure. In electrical terms, that
stream would be equivalent to the high voltage and low amperage current typically used to drive the
flash in your camera or phone. Static electricity, which we consider harmless, is measured in thou-
sands of volts but with very low amperage.
When considering an X-ray tube, increasing the tube current (referred to in milliamperes or mA)
will result in more X-rays created at the anode, but the energy of those X-rays is determined by the
electrical potential across the tube, which is measured in kilovolts (kV). A higher kV means a greater
electrical potential across the tube, and that leads to higher mean energy X-rays emerging from
the anode, with greater potential for tissue penetration. A change in kVp, however, alters both the
energy of the X-rays emerging from the tube and their number.
Although we frequently talk about CT scans in terms of a single kV value (i.e., kV 120), you should
keep in mind that this number represents the peak voltage across the X-ray tube and not the average
energy of the X-rays. Although kV reflects the energy range of the X-rays, the beam is composed of
X-rays at multiple energies—it is polychromatic. The actual energy of the X-rays in the beam can be
described in terms of thousand-electron volts or keV. At a kVp of 80, the lowest X-ray energies in the
beam could be as low as 20keV, but no X-rays will be higher than 80keV. The mean energy within this
polychromatic X-ray beam is about one-third to one-half of the peak energy predicted by the kVp.
The use of specially shaped metal filters between the X-ray source and the patient can substantially
alter the energy range of the beam. It is commonplace to use a filter that strips out the very lowest energy
X-rays since these contribute to dose without contributing to the image. Another benefit to using a filter
is that by narrowing the range of X-ray energies in the beam, it reduces the beam hardening that occurs
within the patient. The filter is also shaped to better suit the shape of the patient, to reduce the number
of X-rays at the edges where there is usually less tissue to penetrate than at the center.
The magnitude of the tube current corresponds roughly to the number of X-rays emerging from
the X-ray tube, and the imager should use no more and no less necessary for diagnosis. The dose
relationship to mA is linear—lower the mA by half, and you cut the dose by half. But whenever you
decrease mA by half, you need to remember that noise increases by about 40%. It is also important
to recognize that tube current (mA) may be expressed in several different ways that can lead to some
confusion when you are changing scan parameters. Tube current can be expressed as mA, mAs, or
effective mAs. That last term incorporates the rotation time and tube current, as well as the scan
pitch. Effective mAs (mAseff) is simply the mAs divided by the pitch. For example, if the pitch is
decreased from 1 to 0.5, the mAseff doubles.
Why do you need to know this? So that you are not surprised to find that your scanner automati-
cally decreased the tube current when you selected a pitch below l to improve the quality of your
temporal bone exams. The scanner software may be set up to keep effective mAs constant, and you
will fi nd that the CTDIvol measure of the scan did not change with the alteration of pitch, nor do
your scans look better. That is why you need to check the values of mAs and dose for the resulting
scans whenever you alter scan parameters.
The tube potential or kVp determines both the energy of the X-rays and also the number created at
the anode of the X-ray tube. For many users, a kVp of 120 is adequate for nearly all scans, but this “one-
size-fits all” approach is quite different from conventional X-ray imaging, in which the kV is frequently
adjusted to suit the imaging task. Many believe that CT imaging should take more advantage of this
approach since the ideal kV value should be based on the size of the patient, imaging goals, and whether
CT contrast is administered, since contrast has a powerful effect on radiation dose to the patient.
When to Increase kV
The choice of kV has a much larger impact on patient dose than does the choice of mA. That is because
patient radiation dose increases proportionately to mA but increases approximately by the square of kV.
For example, an increase of kV from just 120 to 140 results in a 30% increase in patient dose. Although
using low kV for CT is desirable when possible, since low-energy X-rays are attenuated more easily, it
may be necessary in some circumstances to actually increase kV above 120 (Figures 2.8, 2.9). This is usu-
ally the case in large patients or in patients with implanted metal. Although it is reasonable to consider
increasing mA first to accommodate requirements when imaging large patients, in some cases the tube
limits may be exceeded by the requirements. And it does not seem reasonable to use more low-energy
X-rays when what is really required are higher energy X-rays that have better penetration. That is cer-
tainly the case when imaging patients with titanium aneurysm clips. Adding more low-energy X-rays in
that situation makes little difference toward minimizing artifacts since they are related to photon starva-
tion, and this is best addressed by using X-rays with better penetration. And keep in mind that using a
lower kV does not mean there will be a decrease in X-ray dose in all cases. Because noise increases as kV
decreases, it is possible that the additional X-rays needed to offset the increased noise may result in a net
increase in patient dose. This is more likely to occur in large patients and with non-contrast CT scans.
New scanner software that incorporates both kV, mA adjustments based on the scout view, and not just
tube current as nearly all AEC does now, should help the user optimization these two factors.
When to Decrease kV
Adequate low-kV CT imaging is frequently possible when performing body imaging in children and
thin adults. This is because the quality of penetration of high-kV X-rays may not be necessary for
that patient population. Although decreasing kV is accompanied by an increase in image noise and
48 CT IMAGING
Figure 2.8–2.9 On these sagittal reconstructions from a neck CT demonstrate image quality is worse in the lower cervical-upper
thoracic segments. This is because insufficient X-rays were arriving at the detectors at those levels because of the patient’s large
shoulders. Although increased mA is a consideration, in such cases, increasing kV may be necessary to provide adequate imaging
and there is an upper limit to tube mA.
beam hardening artifacts, the improvement in contrast conspicuity whenever using iodinated con-
trast in most circumstances offsets these disadvantages. You should recall that iodine is more evident
on low-kV CT scans because of the photoelectric interaction of low-energy X-rays with iodine. Since
X-ray beams are polychromatic, the X-ray beam generated using kV 80 will contain many X-rays
close to the k-edge of iodine, around 30keV. The increased noise at low kV can be made less evident
with an increase in mA while still providing a lower total dose. Although brain imaging is nearly
always performed with kV 120, for high-dose exams like brain perfusion, this property of iodine
allows adequate imaging using kV 80 (Figures 2.10, 2.11). Although not commonly considered in
practice, the increased conspicuity of iodine should also allow the use of less contrast for some appli-
cations. This could prove to be an advantage for patients with marginal renal function.
Detector Collimation and Slice Reconstruction
It is preferable to use narrow detector collimation to improve resolution and decrease artifacts,
as long as sufficient dose is utilized. Since there are fewer photons collected per detector when
using detector collimation of less than 1mm compared with say 2mm detector collimation the SNR
reflected on images will be lower. Noise can be estimated as 1/[square root of slice thickness]. This
means that a 10mm slice has three times less noise than a 1mm slice.
Figures 2.10–2.11 These images of the same level in the brain were created simultaneously on a dual-energy scanner. You will
notice that, in Figure 2.10 (left), the lower kV image, the contrast staining in the patient’s left hemisphere is much more apparent
compared with Figure 2.11 (right), the kV140 image. This improvement in contrast conspicuity explains why low kV CT imaging
should be considered for abdominal and pelvic scans since the decrease in signal-to-noise ratio may be offset by the improvement in
contrast and it substantially reduces patient dose.
In practice, the primary use of thin detector collimation proves to be less of a problem than one
might expect. That is because the data from each thin detector can be combined with three or more
neighbors to provide image reconstructions at 5mm, with considerably more SNR than if images
were reconstructed at a displayed slice width of 0.625mm. However, whenever the very thin sec-
tions are used primarily for diagnosis, the mAs will need to be increased as detector collimation
decreases to preserve image quality.
A variation of using thin detectors and thick reconstructions that preserves SNR and some of
the benefits of viewing the thin sections directly is to reconstruct relatively thick images but at a
smaller increment than the displayed slice thickness. For example, you have the option of generating
2mm reconstructions but at 0.5 mm intervals. The only real disadvantage of this approach is that it
increases the total number of slices necessary for storage and review.
You might wonder: “If I am going to combine data from detector rows, and SNR is better with
thicker detector collimation, why use thin detector collimation at all?” First, keep in mind that if
you perform the scan using thick detector collimation you cannot later go back later and reconstruct
thinner sections. There are other benefits of thin detector collimation, however. It decreases the
artifacts from partial volume that may appear as indistinct edges of structures on helical reconstruc-
tions and volume averaging. It also reduces the beam hardening artifacts that degrade posterior fossa
imaging on brain CT.
50 CT IMAGING
Filter or Kernel
The terms filter and kernel are used interchangeably and refer to the method of raw data reconstruc-
tion after the scan is acquired. There is potentially less confusion if you use the word “fi lter” to refer
to the metal plate that is designed to optimize the X-ray beam and use “kernel” to refer to your
choice of image reconstruction algorithm.
The choice of kernel proves to be significant in any dose reduction project since apparent image
noise will influence decisions regarding the dose necessary for adequate scanning. So, although the
reconstruction technique is not commonly considered a dose reduction tool, you should at least be
aware of how this parameter may influence your perception of image quality.
Automatic Exposure Control
It is one thing to select ideal scan parameters when examining a small part of the anatomy, such
as the temporal bones, but quite another when performing a scan that includes several body parts
of very different thickness, shape, and composition, such as chest and abdomen. The problem with
these parts of the anatomy that have wide variations in shape and thickness is that the ideal choice
of kV and mA for one portion of the exam will prove to be either too much or too little for another
portion covered during the same scan. For example, the appropriate choice for tube current in the
chest will be insufficient for imaging the abdomen. Even within a single slice through the chest, what
may be an appropriate dose in the anterior to posterior (AP) direction may prove to be insufficient
to penetrate side to side across both shoulders. This has become a more commonplace problem as
helical imaging has allowed coverage of long sections of the body in a single scan.
To better allow the scanner to match the tube current to the requirements of varying anatomy, most man-
ufacturers offer some variation of automatic exposure control (AEC) on their scanners. This dose reduc-
tion tool is based on one or two scanograms that are created at the start of the exam (Figure 2.12).
Automatic exposure control usually modifies only the tube current (i.e., mA) during the scan, not
the kV. That is why it is sometimes called tube current modulation. By modifying the dose during the
scan to match the attenuation of that part of the body, both from slice to slice and within the same
slice, significant dose reduction is possible without image degradation. Automatic exposure control
should be considered for CT imaging whenever the scan covers a portion of the body where there
are significant variations in thickness or attenuation. On some scanners continuous adjustments are
made even during a single rotation. This technique is called angular adjustment and it provides more
X-rays during the part of the rotation from side to side through the shoulders than when imaging
from front to back. The use of that software tool can provide a lower overall dose with better qual-
ity, assuming the reference values are correctly set.
There are four important things you need to understand about AEC to use it properly. First, as
suggested by the word “automatic,” the user needs to recognize that they have given up a small
degree of control over the scan parameters and therefore the fi nal patient dose.
Second, you need to understand that AEC does not “automatically” lower dose. All it does is
match tube current to the anatomy based on some target value, such as noise level or mAs equivalent.
Tube current Radiation Safety and Risks 51
Z-axis position
Figure 2.12 This illustration shows how the scanner uses the scanogram obtained at the start of the exam to calculate a dose profile
for the patient. This profile is then used to automatically make adjustments to the tube current (mA) during the scan acquisition. These
adjustments are also based on some predetermined imaging benchmark of quality e.g. image noise or a preselected mA equivalent.
Even though intended as a dose reduction tool, if the desired benchmark is set high, the scanner may use a dose that is higher than
you might have selected without AEC.
It is up to the user to pick an appropriate mA or noise value in order to provide acceptable images
but at the lowest possible dose. Third, when imaging thin patients and children, is very important
to decide on the appropriate tube voltage fi rst. Automatic exposure control on nearly all scanners
will only modify tube current. For thin patients and children, fi rst consider decreasing kV for body
imaging since that has a more substantial impact on dose than does AEC. When modifying kV, keep
in mind that AEC quality settings are commonly relevant for only one kV selection. For example, if
you choose to decrease tube voltage and also activate AEC, the increase in noise at the lower kV may
lead to the AEC to apply a much higher mA value than necessary. Fourth, keep in mind that AEC
is intended to accommodate changing anatomy. One instance where AEC may result in excessive
patient dose is when it is used during continuous imaging such as CT brain perfusion. In one hospi-
tal, it was reported that 200 patients received unusually high doses of radiation during CT perfusion
exams in part because AEC was turned on for the brain perfusion studies. This was selected with the
intent to reduce dose, but the software “automatically” provided a very high dose. The images were
very likely of excellent quality, which may explain why this problem went undetected for so long.
Shielding
Since X-ray dose at diagnostic energies is much higher in superficial tissues, there has been some
interest in using radiation shields over particularly sensitive tissues like breast, thyroid, and eyes.
These shields are usually made of bismuth, which has desirable attenuation characteristics compared
with lead, for example (i.e., X-ray attenuation without significant metal artifact). These shields are
not in widespread use in part because they add cost when used for eyes (eye shields are one-time use),
and they add to exam time elsewhere in the body since they need to be applied after the scanogram
but before the scan. This is important to keep in mind whenever AEC is used with shields since
it is the scanogram that is used to select the tube current on most scanners. If the shield is put in
52 CT IMAGING
place prior to the scanogram, say at the beginning of the scan, the software would direct the AEC
to increase tube current at the level of the shield and that would effectively offset any benefit to
shielding. In spite of these current limitations, shielding should at least be considered as part of any
comprehensive dose reduction program.
Iterative Reconstruction
The first CT scans used a purely mathematical reconstruction of the collected data to create images.
That was found to be too slow for clinical imaging and all current scanners routinely use some variety
of back-projection. With increasing concern about patient dose from CT and the decreasing cost of
computer hardware, it has become commonplace for vendors to offer some variety of mathematical
reconstruction called iterative reconstruction. By referring back to the source data, and in some ver-
sions accounting for the fixed noise in the system, iterative reconstruction can improve the imaging
SNR and that can be used for better images at the same dose or equivalent imaging at a lower dose.
Although there is no question it can help with dose reduction, its impact on diagnosis is still uncer-
tain. With any new reconstruction tool, it would be expected that new artifacts may appear, and
altered image contrast may alter sensitivity. Early reports, however, indicate that dose reductions of
at least 50% for body CT imaging and 10–20% for brain imaging are to be expected once iterative
reconstruction is fully integrated into clinical scanners. It seems highly likely that some version of
pure mathematical reconstruction or a blend of back-projection and iterative reconstruction will
become routine for CT reconstructions.
Pediatric CT Imaging
Children are considered most vulnerable to the stochastic effects of radiation because any DNA dam-
age that occurs is amplified by both the number of years of life and by the fact that it occurs before
the reproductive years. That is why the effective dose for a head scan in a child is higher than for a
head scan with the same DLP in an adult. Another factor to consider is that CT is being used more
frequently to diagnosis nonmalignant diseases, such as appendicitis in young patients, and in nearly
all cases of head trauma. In fact, the likelihood of getting some sort of CT imaging after any sort of
trauma is quite high at many U.S. hospitals since clinical signs may be misleading. This broadening
of indications for CT and its widespread availability have led to an explosion of utilization in spite of
increased access to MR during the same time period. So, although it is important to minimize X-ray
dose for all CT patients, the benefit of reducing dose is even larger for children.
In response to this concern, considerable attention to dose reduction has already occurred at most
pediatric centers. One common method to reduce patient dose in children is to decrease the kV of the
exam since there may be no need for the same X-ray penetration in children as in adults. For body
imaging with contrast agents there can be substantial benefits to imaging with a lower kV. Because
dose increases as the square of kV, decreasing kVp from 120 to 80kVp results in a 65% decrease in
dose at the same mA. Although noise increases, the improved image contrast because of the pho-
toelectric interaction of low-energy X-rays with iodine provides acceptable image quality after an
adjustment of mA.
Some useful CT scan protocol recommendations can be found on the web by searching for the
term “Image Gently.” Although you may hope to fi nd a set of protocols based on age and size,
remember that because of the very complex interplay between X-ray tubes, fi lters, detectors, and
scanner dimensions, it is unlikely that what is optimal for one site will be optimal for another. In an
attempt to accommodate these differences in scanners, the recommendations you will fi nd on that
website are expressed in terms of percent change from adult technique instead of absolute values.
Iterative image reconstruction will very likely offer opportunities to substantially reduce dose for
both body and head CT imaging in children, and so you should be aware of this option and consider
using it once it becomes available on your scanner.
SUGGESTED READINGS
Nievelstein RAJ, van Dam IM, van der Molen AJ. Multidetector CT in children: Current concepts and dose
reduction strategies. Pediatr Radiol. 2010;40:1324–1344.
Lee CH, Goo JM, Lee HF, Joon S, Park CM, Chun EF, Im JG. Radiation dose modulation techniques in the
multidetector CT era: From basics to practice. Radiographics. 2008;28:1451–1459.
Golding SJ. Radiation exposure in CT: What is the professionally responsible approach? Radiology.
2010;255:683–686.
Kalra MK, Maher MM, Toth TL, Hambert LM, Blake MA, Shepard J, Saini S. Strategies of CT radiation dose
optimization. Radiology. 2004;230:619–628.
Verdun FR, Bochud F, Gudinchet F, Aroua A, Schynder P, Meuli R. Radiation risk: What you should know to
tell your patient. RadioGraphics. 2008;28:1807–1816.
Schilham A, Molen A, Prokop M, Jong HW. Overranging at multisection CT: An underestimated source of
excess radiation exposure. RadioGraphics. 2010;30:1057–1067.
Tamm EP, Rong JX, Cody DD, Ernst RD, Fitzgerald NE, Kundra V. Quality initiatives. CT radiation
dose reduction: How to implement change without sacrificing diagnostic quality. RadioGraphics.
2011;31:1823–1832.
Huda W, Ogden KM, Khorasani MR. Converting dose-length product to effective dose at CT. Radiology.
2008;248:3.
3 CARDIAC CT IMAGING TECHNIQUES

56 CT IMAGING
Temporal Resolution: The Key to Cardiac Imaging
The basic principle of cardiac imaging is to acquire the scan data during a motion-free portion of the
cardiac cycle (Figure 3.1). This is no small thing because of the continuous, rhythmic motion of the heart.
The solution is to identify a relatively motion-free part of the cardiac cycle (i.e., end diastole) and acquire
images during that short window in time of approximately 120–170 msec. It is also possible, with retro-
spective gating, to dissect from a helical computed tomography (CT) scan images of the heart at multiple
time points in the cardiac cycle, but this partitioning of data is limited by the temporal resolution.
Temporal resolution is an important concept toward your understanding of motion-free imaging of
the heart. In the language of cardiac CT, temporal resolution is the shortest time necessary to acquire a
detector array’s worth of information sufficient to reconstruct images (Figure 3.2). This time varies with
the design and capabilities of the scanner, of course, but gantry rotation time is the most important factor
to consider. If we are to provide the best temporal resolution, gantry rotation time needs to be as short as
possible. But there are physical limitations on how fast the gantry can rotate since tremendous centrifugal
forces are generated at high rotation speeds because of the combined weight of the X-ray tube, filters, col-
limators, and detector apparatus, which includes the septa and the detectors themselves (Figure 3.3).
The magnitude of these forces can be calculated using the angular velocity (ω) of the gantry, the
radius of the gantry track, and the total mass of the spinning hardware. If you have ever had an unbal-
anced washing machine stop during a spin cycle when you wash a heavy blanket, you know intuitively
that the heavier the spinning object and the faster the spin, the greater the force. Since multidetector
scanners require heavy X-ray tubes to allow continuous imaging, and the scanner diameter needs to
be large enough to fit patients, there is a limit to gantry rotation time since the forces increase as the
Figure 3.1. Normal cardiac cycle.
5 segment 10 segment 20 segment
171 msec 86 msec* 43 msec
Figure 3.2 The temporal resolution determines how finely the information can be divided within a given cardiac cycle. For example,
when there is high temporal resolution, 20 segments can be created compared with only 5 at lower temporal resolution.
Cardiac CT Imaging Techniques 57
Figure 3.3 Single-source CT scanner with third generation

geometry.
Table 3.1 Gantry rotation speed for various generations of CT scanners
Gantry rotation time

First generation 5 min
Second and third generation (narrow and wide fan beam) 2 sec
Electron beam 100 msec
Fan beam MDCT 0.3–1 second MDCT
Cone beam MDCT 270–500 msec
Dual-source 285–332 msec
square of angular velocity. Although flat-panel detectors have been developed that are significantly
lighter than current multidetector arrays, the need to balance the weight of the X-ray tube largely
negates any potential weight benefit of flat-panel detectors (remember the washing machine). The rota-
tion speed and temporal resolution of the various generation scanners are provided in Table 3.1.
How Temporal Resolution Can Be Shorter than Gantry

Rotation Time
Given the physical limitations on gantry rotation speed, further improvement in temporal resolu-
tion can also be achieved with advanced reconstruction methods. The two most widely utilized
methods are partial scan acquisition and segmented reconstruction. Each of these techniques has its
58 CT IMAGING
Figure 3.4 This illustration shows how the complete 360-degree dataset for CT reconstruction can be obtained in thirds over three
consecutive cardiac cycles.
advantages and disadvantages, although both provide significant improvements in temporal resolu-
tion (Figure 3.4).
SEGMENTED ACQUISITION
Segmented acquisition means that the data necessary to reconstruct an image are acquired in pieces
during multiple cardiac cycles. For nearly all multidetector scanners, it requires a half a second or
more for one complete gantry rotation. But because the optimal window for motion-free cardiac
imaging—end diastolic imaging—is only about 150 msec long, this means that, during that single
gantry rotation, the heart would be viewed in multiple phases of the cardiac cycle. By using data from
just one-third of the full rotation, however, and collecting the rest of the necessary data over the fol-
lowing two cardiac cycles, temporal resolution can be shorter than the gantry rotation time, but only
if the gantry rotation is decoupled (phase offset) from the heart rate. For example, if the gantry speed
is one rotation per second and the heart rate is 60 beats per minute (bpm), then each gantry rotation
would result in an identical dataset that will be insufficient for reconstruction. That occurs, of course,
because a full rotation is necessary for reconstruction, and, although that can be pieced together from
multiple rotations, each fraction of the 360-degree rotation must occur in the correct temporal win-
dow with respect to the cardiac cycle. You can think of it in this way: if you want to see all the people
on a merry-go-round that completes one rotation every minute, and you are only allowed to look at it
for intervals of 10 seconds, then you must vary the intervals of your observations. If you were to look
up every minute on the minute, you would see the same people each time.
This issue is most commonly resolved by allowing the scanner to perform variable pitch scanning,
such that the pitch is continuously modulated based on the heart rate. This entire process of spread-
ing the acquisition of image data over multiple cardiac cycles is known as segmented acquisition.
In the ideal case, when the gantry rotation and heart rate are completely decoupled and there is
no overlap in projection data, the improvement in temporal resolution can be expressed as gantry
rotation time divided by the number cycles used for acquisition. For example, if you were to use four
rotations for data acquisition, and gantry rotation time was 1 second, then the temporal resolution
will be only 125 msec. Imperfect decoupling and other practical factors tend to degrade the actual
improvement in temporal resolution, however. The radiation dose to the patient is also higher with
this method. Ideally, when using segmented acquisition, there should be identical motion and posi-
tion of the heart from one cardiac cycle to the next. This would imply a consistent breath-hold, with
no significant variability in the heart rate or cardiac contractility. In practice, since most patients
have some degree of beat-to-beat variability in heart rate, as well as imperfect breath-holding, seg-
mented acquisition may have limited utility compared to other techniques.
PARTIAL SCAN
When considering the projection data acquired from a scanner with narrow beam geometry
(Figure 3.5), it would seem that the data acquired from the horizontal tube position should be
identical to the data acquired when the source and detector are reversed, if we discount the differ-
ences due to the diverging beam. This observation can be exploited to decrease scan acquisition
time by performing the image reconstruction from only 180 degrees of data compared with the
usual 360-degree dataset. Using this approach, the CT scan temporal resolution can be improved by
roughly a factor of 2 without changing the gantry rotation speed at all.
DUAL-SOURCE CT
Further improvement in scanner temporal resolution for cardiac CT has been made possible through the
introduction of multisource scanners. The most widely used variation for cardiac CT scanning positions
the two source-detector pairs at approximately 90 degrees with respect to each other (Figure 3.6). The
Figure 3.5 Justification for half-scan technique. The measured projections should be identical with beam at zero and 180 degrees.
60 CT IMAGING
Figure 3.6 This view down the bore of dual-source CT scanner shows the two tubes at 90 degrees in the gantry, here shown at the
top and right side of the bore. Their corresponding detectors are evident opposite each tube.
actual gantry rotation speed for one commercially available unit is approximately one-third of a second,
which is remarkable considering the mass of the spinning hardware in such a design. If the scan data from
the two tube-detector pairs is combined to create a single image, then the gantry needs only to rotate 90
degrees in order to obtain sufficient data to reconstruct a respectable image. When utilizing such a scan-
ner using partial scan technique, only one-quarter of a gantry rotation in necessary with a dual-source
scanner. Using this combination of acquisition technique and scanner hardware, the temporal resolution
is 83 msec. And, when using both segmented acquisition and the partial scan technique with a dual-
source scanner, one can expect temporal resolution that is actually superior to electron beam CT while
still providing motion-free imaging within the range of normal heart rates (60–100 bpm).
Electrocardiogram Synchronization
Motion-free CT cardiac imaging is necessary so that the CT scan data acquisition can be synchro-
nized to the patient’s electrocardiogram (ECG). Two widely implemented techniques for linking
these two data streams are called prospective triggering and retrospective gating.
It is important to consider when to acquire the images during the cardiac cycle since an increase in
heart rate disproportionally shortens the diastolic fi lling period, while the systolic phase will remain
relatively constant over the common range of heart rates. For low heart rates (<60), the end diastolic
phase represents the longest part of the cardiac cycle that is relatively motion free. As the heart rate
increases to 80 and above, however, the diastolic phase shortens enough so that imaging is roughly
equivalent to when the scan is acquired at end systole or end diastole.
Prospective triggering is a sequential axial acquisition (step-and-shoot) method synchronized to

the patient’s ECG. In this technique, the image acquisition is triggered by the ECG, so that it occurs
at a specific time in the cardiac cycle. Since end diastole is the longest motion-free portion of the
cardiac cycle, triggered studies are timed to take place during that window. To allow prediction of
this timing in subsequent cardiac cycles, the scanner software monitors the patient’s heart rate over
the preceding 3–7 cardiac cycles in order to determine the patient’s average rate and variability. Once
the image acquisition has begun, the scanner performs one gantry rotation, and the image projec-
tion data are collected over slightly greater than half of the rotation. In a single gantry rotation, the
scanner is able to simultaneously collect projection data sufficient to reconstruct multiple axial slices
that are proportional to the width of the detector and number of detector rows. Once that acquisi-
tion is complete, the patient table is moved by one detector array width (2.8 to 4.0 cm, depending on
detector array size and detector arrangement), which typically takes the duration of the next cardiac
cycle (approximately 1 sec) to complete. Scan acquisition proceeds in this manner until the heart is
covered, which only requires 4–5 steps on most modern 64-slice scanners.
Retrospective gating, conversely, is a helical scan technique. In this approach, partially overlapped
low-pitch scans are acquired over the scan range while simultaneously recording the patient’s ECG.
The resulting dataset includes the imaging data for each section of the heart in multiple phases of
the cardiac cycle. During reconstruction, partitioning of the data can correct for errors in phase
selection and can produce a multiphase (4D) dataset for a functional cardiac evaluation. When com-
pared to prospective triggering, retrospective gating is more tolerant of variations in the heart rate
and errors in ECG synchronization, but this large dataset comes with a price of significantly higher
patient radiation dose (approximately four times without tube current modulation).
Methods of CT Dose Optimization
The CT scan signal-to-noise ratio (SNR) is a complex function of the CT scanner, the acquisition,
patient size and consistency, and image reconstruction-related factors. Several important imaging
parameters can be adjusted at the time of the procedure to provide adequate image quality balanced
with acceptable radiation dose. The two most important factors for CT imaging are kV (tube volt-
age) and mA (tube current). The tube voltage determines the spectral distribution of the incident
radiation beam (quality), whereas the tube current determines the number of photons that are actu-
ally generated (quantity) (Figure 3.7).
The quality, or spectral distribution, of the incident photon beam is controlled at the scanner by
adjusting the tube voltage (kV). Although the spectrum and peak energy of the X-rays are determined
primarily by the tube voltage, there are additional peaks within the X-ray spectrum related to the tar-
get material (typically tungsten or molybdenum). These portions of the energy spectrum represent the
transition between various outer and inner electron shells and are related to electron ejection from the
inner shell by a high-energy incident electron. Increasing the energy of the incident electron beam, as
controlled by increasing the kV, causes a shift in the spectral profile toward higher energies, resulting in
increased beam penetrating power. Increasing the tube current (mA) increases the intensity of the resul-
tant X-ray beam, but maintains the spectral distribution determined by the kV and target material.
62 CT IMAGING
Retrospective Coronary CTA Prospective Coronary CTA

20 10
15
Estimated Dose (mSv)
Estimated Dose (mSv)

80 retro 80 retro
100 retro 100 retro
10 120 retro 5 120 retro
Linear (80 retro) Linear (80 retro)
0 0
22 32 42 52 22 32
Figure 3.7 These two graphs indicate the radiation dose for prospectively triggered and retrospectively gated cardiac CT at various
kV settings, using automatic exposure control for the retrospective studies. The horizontal axis of the plots is the Etopo, which is a
measure of patient size and density extracted from the topogram image and the vertical axis is dose in mSv. Note the higher doses
when using retrospective gating. Tube voltage is a parameter that should be carefully considered when performing any CT scan, but
particularly in cardiac scans, since it can significantly impact both the diagnostic quality of the scan as well as the overall radiation
dose.
It is important to consider the relative effects of changing tube current and voltage on radiation
dose. The radiation dose changes linearly with the tube current since it alters the quantity of photons
without much effect on the energy spectrum. The radiation dose changes as the square of the tube
voltage (kV); therefore, even small variations in the tube voltage can results in significant changes in
the radiation dose. Experimentally, taking into account fi ltering and other technical factors, chang-
ing the tube voltage from 120 to 100 kV results in an approximately 50% reduction in radiation
dose, whereas changing from 140 to 80 kV results in a 78% reduction. The normal range of operat-
ing voltages for CT scanners is 80–140 kV, with the upper portion of that range reserved for imaging
large patients and the lower portion having utility for dose reduction in thin patients. The kV for a
cardiac CT is typically set at 120 kV by default, a level that usually produces high image quality in
patients weighing up to 100 kg; however, it is often possible to decrease the kV to 100 or 80 while
maintaining diagnostic image quality.
To adjust the kV appropriately, one needs to consider the density profile of the region to be scanned. If
the patient is large, with abundant subcutaneous tissue, or if there is significant muscular hypertrophy,
increasing either the quantity (mA) or quality (kV) of the X-ray beam may be necessary (Figure 3.8).
When imaging large patients, the X-ray tube output for each of the individual heads of a dual-source
scanner may be insufficient to produce the desired SNR. In that case, the two scanner heads can be
used together to boost the effective output of the scanner; this allows a dual-source scanner to behave
like a single-source scanner with a higher X-ray tube output. As a result of using the tubes together,
however, the temporal resolution of the scanner becomes closer to that of a single source scanner.
Automatic tube current modulation—also known as automatic exposure control (AEC)—is a tech-
nique that has become available on many CT scanners in the past decade, to help address issues
of radiation dose and nonuniform density distribution within the scan field. The need for tube cur-
rent modulation in noncardiac CT is best understood by considering a chest CT performed with the
patient’s arms down at his sides (Figure 3.9). When positioned in the AP direction, the X-ray beam is
(A) (B)
(C)
Figure 3.8 A: This volume-rendered image (A) from a CT scan of the chest shows the patient’s right arm positioned against the body,
which increases the apparent thickness of the patient in the coronal plane. Reconstructed coronal (B) and sagittal (C) images from this
scan illustrate the difference in apparent chest thickness.
attenuated by only a small amount of chest wall soft tissue and the intrathoracic structures. Conversely,
when oriented to the patient’s side, the beam encounters significantly more soft tissue, as well as bone
and intrathoracic structures. Without AEC, a CT scan of tissues that vary in thickness and attenuation
along the craniocaudal direction will either require more X-ray dose than necessary or have portions
of the scan that are of poor image quality because of insufficient dose. Since the tube current increases
or decreases to match tissue attenuation, the dose can be optimized for the imaging problem.
To address this problem of variations in patient tissue thickness and attenuation, the tube current
can be adjusted on the fly. One approach involves measuring the attenuation of a constant beam energy
64 CT IMAGING
(A) (B)
Figure 3.9 Axial images from a chest CT performed for trauma with the patient’s arms at his sides. The image on the left (A) illustrates
the path of a cone beam in the AP direction. The image on the right (B) illustrates how the apparent chest wall thickness is increased by
the patient’s arms despite the fact that the actual variations in chest wall thickness are minimal.
for the patient over a full or half rotation and then utilizing that information to prospectively modu-
late the tube current over the next gantry rotation. This is the approach used in Siemens CareDose.
Alternatively, the patient’s attenuation profile can be predicted using both the frontal and lateral topo-
gram, and that is used to determine the required tube current modulation at the start of the scan. This
approach is used in the GE SmartScan and Auto mA. In all variations of AEC, the operator needs to set
some reference value for image quality, so that the software can provide the necessary tube current. This
can be expressed either as a specific average noise level or as a reference mA, which represents the image
quality expected if a scan was performed at that reference current but in an average size patient.
Tube current modulation in the craniocaudal and, in some versions, front-to-side directions is suf-
ficient for noncardiac studies performed at a pitch close to 1. Cardiac studies, however, are typically
performed at a very low pitch (~0.3), so there is the added requirement of temporal tube current
modulation based on the ECG, in addition to modulation in the spatial directions (Figure 3.10).
For optimal dose reduction, it is important to recognize that although multiphase imaging data is
useful for functional evaluations, high SNR is not necessary throughout the entire cardiac cycle.
Electrocardiogram-based tube current modulation directs the scanner to adjust the quantity of the
radiation beam based on the phase of the cardiac cycle. This provides some of the benefits of prospec-
tive triggering to be realized in retrospectively gated studies by decreasing tube current to 4–20% of
the expected value during phases of the cardiac cycle outside the window of motion-free imaging. The
imaging data from the low tube current portions of the cardiac cycle are then used primarily to assess
cardiac function. To offset the low SNR of these tube current modulated images, it is beneficial to
reconstruct images using a matrix size of 256 × 256 rather than the full 512 × 512 and increase slice
thickness to 1.5 mm instead of the usual 0.6 mm. These changes will decrease the in-plane resolution
of the image but increase the SNR, thereby providing images of sufficient quality for functional and
some structural evaluation. For example, the proximal coronary arteries typically measure between
2 and 4 mm in diameter, whereas the distal coronary arteries and first-order branches are typically
(A)
(B)
Figure 3.10 Electrocardiogram tracings from two patients undergoing retrospectively gated coronary CTA for evaluation of chest
pain. The first patient (A) had a slow, regular rate that allowed the scanner to apply brief periods of full tube current while decreasing
the current during the remainder of the cardiac cycle. This results in narrow temporal bands of full tube current, seen on the tracing
with lower values during the off peak phases. The second patient (B) was in atrial fibrillation and had a premature ventricular beat,
which required full radiation dose throughout the entire scan since the irregular rate makes it impossible for the scanner software to
predict the cardiac cycle reliably.
less than 1–2 mm. With an appropriately selected end diastolic phase and properly selected reference
mA, but without AEC, the image quality is typically sufficient to evaluate vessels of less than 1 mm in
diameter. When using AEC, since it decreases tube current, the images are usually sufficient to evalu-
ate vessels down to 2 mm, but the submillimeter branches may not be well imaged.
The degree to which tube current modulation can be matched to the cardiac cycle depends on the
consistency and speed of the heartbeat. Similar to the method of triggered prospective acquisition,
the scanner software monitors the ECG to determine average heart rate and variability, in order to
anticipate the timing of the next end diastolic phase. This allows using the full tube current only
during the end diastolic phase. For patients with a low and regular heart rate, the end diastolic win-
dow is relatively easy for the scanner to predict reliably. For low heart rates, the end diastolic widow
for image acquisition is relatively short compared to the length of the overall cardiac cycle (e.g.,
150 msec for a 1,000 msec cycle at 60 bpm or 15%). At faster heart rates, even though the actual
time window is smaller, the percentage of the cardiac cycle will increase (e.g., 125 msec for 600 msec
cycle or 21%). Therefore, the dose reduction afforded by tube current modulation is dependent upon
both the absolute heart rate and its variability.
In patients with a normal sinus rhythm and low beat-to-beat variability, the tube current modula-
tion software can accurately predict the next cardiac cycle in order to apply the tube current appro-
priately. When the heart rate varies, the window during which the scanner must apply the full tube
current in order to ensure inclusion of the end diastolic phase is increased in proportion to the degree
of variability. At the extreme, in a patient with atrial fibrillation, the full tube current must be almost
continuously applied, thus negating any dose reduction with tube modulation.
To date, filtered back-projection (FBP) algorithms have been used for CT image reconstruction.
Purely mathematical calculation was used for reconstruction in the earliest CT systems, but this method
was soon supplanted by FBP because it is significantly less computationally intensive. The advances
in computational hardware and decreasing costs of late have made it possible to use a mathematical
66 CT IMAGING
reconstruction commonly called iterative reconstruction (IR) without significantly decreasing work-
flow. Iterative reconstruction, as the name implies, is a recursive algorithm that starts with a rough
image and then refines projections of that image. These computed projections are then compared with
the actual scan data and modified according to prespecified rules. This process can be repeated until
the error (difference between calculated projections and measured projections) is less than some prede-
termined level or some time limit elapses. When comparing the image quality of FBP to IR reconstruc-
tions, comparable image quality can be achieved using a lower dose with IR (Figure 3.11).
A technique called prospectively triggered high-pitch helical acquisition is a new method that is
now commercially available on some dual-source scanners. Using a single-source scanner, the highest
pitch that can be used without large gaps in the projection data is about 1.5. One of the interesting
features of dual-source scanning is that the helical path traced out by the X-ray beams can be adjusted
by altering the pitch, so that gaps in the data from one source-detector pair are fi lled in with data
from the other pair. Using this technique, a pitch of approximately 3.4 is possible, and that is 10–15
times higher than that used for typical retrospectively gated cardiac CT (Figure 3.12). By performing
such rapid acquisitions, the entire heart can be imaged in a single cardiac cycle, although there will
be a 300 ms phase difference between the beginning and end of the scan. With this technique and
a dual-source scanner, it is possible to achieve a temporal resolution of approximately 75 msec at a
very low radiation dose since dose is inversely proportional to the pitch of a helical scan.
Nonsynchronization Issues in Cardiac Imaging
The coronary vessels typically measure between 2 and 4 mm proximally and less than 1 mm dis-
tally. Imaging these small vessels may be limited by artifacts from high-density structures in and
around the vessel. Vascular calcification and coronary artery stents are the most common cause of
(A) (B)
Figure 3.11 Coronary CT images reconstructed from the same acquisition using filtered back-projection (A) and iterative reconstruc-
tion (B) demonstrate decreased noise in the IR images.
Figure 3.12 Dual-source CT scanner with the pitch set greater than 1, such that neither source-detector pair alone is able to provide
gap free projection data. The pitch is selected (3.4) such that there is a phase offset between the two helical tracings of projection
data; when combined in the appropriate manner, gap-free projection data results (far right).
(C)
(B)
(A)
Figure 3.13 Multiple images from a coronary CT angiography (CTA) including volume rendered (A) and multiplanar reformatted
images parallel (B) and perpendicular (C) to a stent within the proximal circumflex coronary artery. The patency of the stent is difficult
to determine based on these images.
these artifacts on cardiac CT angiography (CTA) studies (Figure 3.13). Quantification of coronary
artery calcium (i.e., calcium scoring) is an established method of risk stratification for patients with
coronary artery disease. However, the presence of these coronary artery calcifications will degrade
the quality of coronary CTA and image quality due to beam hardening and blooming artifacts.
Blooming artifact in CT scans makes small, dense objects appear larger than their actual size. On coro-
nary CTA studies, this can result in an overestimation of stenosis near a small calcified coronary artery
plaque. The factors that contribute to the appearance of blooming artifact include finite scanner resolu-
tion, partial volume effects, motion artifact, and some degree of beam hardening. Given the resolution
of modern CT scanners, which is 0.5–0.625 mm in the z-axis with in-plane resolution of 0.3 mm, if a
68 CT IMAGING
sufficiently small calcified plaque is centered within a voxel, the plaque will appear to fill the entire voxel
but with a lower density value. If this calcified plaque is included in two adjacent voxels and is sufficiently
dense, it will increase the attenuation value of both voxels above the threshold for calcium, making it
now appear to be two voxels in size. The factors to consider are the density of the plaque and its actual
size relative to the resolution or voxel size used for the scan. Since partial volume effects occur only at the
edges of a plaque, this blooming effect will be negligible for a dense, relatively large object.
For any coronary vessel evaluation, the scan data used to reconstruct the image must be acquired
from a narrow time window in the cardiac cycle. If the right coronary artery was imaged at 75%
of the R-R interval, except during one cycle that was imaged at 55%, the reconstructed images will
be degraded by this anatomic misalignment. When this misalignment occurs in a calcified segment
of coronary artery, the calcium becomes blurred and therefore will appear larger. The relative con-
tribution of calcium motion, making it appear larger or bloom, depends on the uniformity of the
cardiac cycle. As discussed above, the optimal phase for motion-free cardiac imaging shifts from
end diastole to end systole as the heart rate increases over the physiologic range. The corollary to
that statement is that the likelihood of artifact related to incorrect phase selection increases with the
heart rate. Another factor that influences the magnitude of blooming artifacts from cardiac motion
is the scanner detector. The smaller the detector collimation, the larger the effect of motion on the
apparent area of the calcified plaque.
Blooming artifacts can be minimized by ensuring a low and regular heart rate. This can be done
by administering beta-blockers prior to scanning and is one of the most important steps for optimiz-
ing overall scan quality. Utilizing the smallest available focal spot size also helps to minimize the
blooming from partial volume effects. In the postprocessing phase, the use of sharp reconstruction
kernels can also help minimize blooming artifacts by providing images with higher spatial resolu-
tion, but at the expense of increased image noise (Figure 3.14).
Metal in coronary artery stents is another source of high-density artifact in cardiac CTA stud-
ies that may compromise the diagnostic quality of a scan. Although stent patency is an important
factor to consider on a coronary CTA, the stent metal will attenuate the incident X-ray beam, but
(A) (B)
Figure 3.14 Multiplanar image (A) using a standard reconstruction kernel demonstrates marked blooming artifact that largely
obscures the stent lumen. B: Use of a sharper kernel reduces the blooming artifacts.
to varying degrees, and this can result in gaps in the projection data, a phenomenon called photon
starvation. These gaps in the projection data can mimic plaque when reconstructed with standard
filtered back-projection algorithms. The degree of artifactual stent narrowing from metal artifact
depends primarily on the material used within the stent and ranges from complete obscuration of the
lumen (Wiktor and Wallstent) to only partial. In general, stents made of tantalum create the most
artifacts, whereas nitinol and titanium stents produce the least artifact, and stainless steel stents fall
between those two extremes.
RECOMMENDED READING
Achenbach S, Giesler T, Ropers D, et al. Detection of coronary artery stenoses by contrast-enhanced, ret-
rospectively electrocardiographically-gated, multislice spiral computed tomography. Circulation
2001;103:2535–2538.
Desjardins, B et al. ECG-Gated Cardiac CT. American Journal of Radiology 2004;182:993–1010.
Cody D. Technologic advances in multidetector CT with a focus on cardiac imaging. RadioGraphics
2007:1829–1837.
Flohr, T G. Multi-detector row ct systems and image-reconstruction techniques. Radiology 2005;
235:756–773.
Jakobs TF, Becker CR, Ohnesorge B, et al. Multi-slice helical CT of the heart with retrospective ECG gat-
ing: reduction of radiation exposure by ECG-controlled tube current modulation. European Radiology.
2002;12:1081–1086.
Kroft, L et al. Artifacts in ECG-synchronized MDCT coronary angiography. American Journal of Radiology
2007;189:581–591.
Schoepf, UJ, et al. CT of coronary artery disease. Radiology. 2004; 232:18–37.
Shuman W, et al. Prospective versus retrospective ECG gating for 64-detector CT of the coronary arteries:
comparison of image quality and patient radiation dose. Radiology 2008;248:431–437.
4 CARDIAC CT ARTIFACTS AND
PITFALLS
72 CT IMAGING
Artifact 1
This 58-year-old female with long history of morbid obesity and oxygen-dependent lung disease pre-
sented to her pulmonologist complaining of chest pain and shortness of breath. Based on her history
and risk factors, a coronary computed tomography angiogram (CTA) was ordered. The scanogram
image (Figure 4A.1.1) indicates why the coronary CTA was performed using a large-patient protocol
on a dual-source scanner (Figure 4A.1.2 A,B).
When performing CTA in large patients, the temporal resolution using a dual-source scanner is:
(1) unchanged (83 msec).
(2) twice as long (165 msec).
(3) even longer (332 msec).
(4) ranges between 83 and 165 msec.
Figure 4A.1.1 This scanogram image was obtained prior to a cardiac CT angiogram (CTA). It demonstrates a large body habitus and
tracheostomy tube.
Cardiac CT Artifacts and Pitfalls 73
(A)
(B)
Figure 4A.1.2 Axial (A) and sagittal (B) images at the level of the mid heart from her CTA shows grainy images with low signal-
to-noise ratio (SNR) despite a maximal radiation dose and 120 mL of intravenous contrast. Note that the elevation of the right
hemi-diaphragm places the liver immediately adjacent to the heart. This increases the X-ray beam attenuation that is already
compromised by the subcutaneous fat.
The temporal resolution of a dual-source scanner using two independently acquired datasets is approx-
imately 83 msec. Because of the increased tube output requirements when imaging large patients, it may
be necessary to combine the data from both source-detector pairs in order to provide adequate image
quality. The degree of blending of the projection data from the two detectors can be adjusted during
postprocessing. As a result, the actual temporal resolution of a given reconstructed sequence may vary
between 83 msec (total separation of data) and 165 ms (total merging of datasets).
The image mottle that indicates the signal-to-noise ratio (SNR) on a CT scan is determined by
several factors that directly or indirectly influence the number of photons that reach the detectors.
74 CT IMAGING
If, for the time being, we ignore the effect of automatic exposure control (AEC), the most common
manually modified parameters that influence the number of X-rays falling upon the detector are kV
(tube voltage) and mA (tube current).
The quality of the X-ray beam is modified by adjusting the tube kV. As kV increases, the energy
spectrum of the beam shifts toward a higher average energy level, which is manifested as increased
penetrating power and improved SNR. There is an upper and lower limit to the range of usable kV for
imaging since, at a very high kV value, the beam would pass through the patient largely unaffected
and therefore provide no real attenuation information about the intervening tissues. Conversely, at a
sufficiently low value of kV, the X-ray beam would be completely absorbed within the soft tissues of
the body, also giving us no useful information.
The electrical potential across the tube or voltage reflects the energy with which the electrons
impact the tube anode, and that determines the energy distribution of the resultant X-rays. The
tube current largely determines how many electrons strike the anode; thus, an increased current
will result in more X-rays emerging, but at the same energy if kV is unchanged (Figure 4A.1.3). You
should recognize that this is an oversimplification since increasing kV also increases the number of
X-rays emerging from the tube.
For the patient in this case, the scan was performed at 140 kV using AEC with a reference mAs of
approximately 350. The limitations of the tube output were addressed by combining the scan data
from both source-detector pairs and therefore sacrificing temporal resolution. Unfortunately, even
using the maximal kV and mA current available for this scanner, the attenuation of the beam within
the chest wall soft tissues resulted in overall poor image quality. Although in this particular patient the
attenuation of the X-ray beam occurred in the chest wall, a similar problem can occur in patients with
large, dense breasts or thick chest wall musculature. In fact, as can be inferred from its CT density val-
ues, muscle is much denser than fat, and this means that many healthy young men with even moderate
chest wall musculature will require an adjustment in tube current to maintain image quality.
Figure 4A.1.3 Diagrammatic representation of X-ray beam attenuation. Based on the density profile of the patient’s soft tissues
traversed, the X-ray beam intensity that exits the patient’s body will always be some fraction of the incident beam. The lower the beam
energy or kV, the smaller the fraction.
Correct answer: 4
Artifact 2
This 24-year-old male was brought to the emergency room after being found unconscious with abra-
sions over his chest and face. He became combative and was noncompliant with instructions during
transport to the CT scanner. Although he calmed down once on the CT scanner table, he again
became agitated during the scan (Figures 4.A2.1, 4.A2.2).
Rank the degree of difficulty (highest to lowest) of compensating for each type of patient motion
that may be encountered during a cardiac CT scan:
(1) cardiac motion in a patient with normal sinus rhythm.
(2) cardiac motion in a patient with atrial fibrillation.
(3) random patient motion.
(4) respiratory motion.
Figure 4A.2.1 This axial image at the level of the thoracic inlet demonstrates blurring due to motion, rendering that portion of the
scan insufficient for diagnosis.
76 CT IMAGING
When motion occurs in a cyclic manner, such as cardiac motion, or can be monitored externally,
such as respiratory motion, strategies can be used to correct for the motion. In terms of respiratory
motion artifact, several acquisition techniques are available, ranging from caudal-cranial scanning
to respiratory motion gating with markers placed on the upper abdomen. CT scans can also be syn-
chronized to the patient’s electrocardiogram (ECG) in order to suppress cardiac motion (as discussed
in Chapter 3), and there are techniques to deal with a regular rhythm, as well as with irregular
rhythms, when using ECG editing techniques.
Random patient motion, since it is difficult or impossible to predict, is therefore the most difficult
motion to compensate for in either the acquisition or postprocessing phases. When imaging the
uncooperative patient, it beneficial to use shorter scan times using high-pitch scanning techniques to
narrow the window necessary for cooperation as well as to reduce the errors introduced by motion
during the scan acquisition.
The effect of patient motion is easiest to understand when considering axial imaging, in which the
image data for an entire section of the scan are acquired over the course of a single gantry rotation.
When there is gross patient motion, the relative positioning of the stack is disturbed, as detailed in
Figure 4A.2.3.
When considering helical acquisitions with a pitch of less than 1, instead of axial scanning, how-
ever, the image reconstruction process is much more complicated, with information from multiple
gantry rotations interpolated in order to produce the image. Since there is continuous data acquisi-
tion, the motion artifact will be complicated instead of a simple shift of a slice from the neutral scan
position.
Prevention is the most effective method for dealing with patient motion. Careful patient instruc-
tion is an important part of alleviating the anxiety related to the scanning process, as well as in
preparing the patient for new experiences, such as contrast injection. It is also important to tailor the
scan to the clinical question and shorten acquisition scan time whenever possible. Tight longitudinal
collimation not only results in decreased radiation dose, but also shortens the length of the scan,
which minimizes the potential for patient motion. High pitch (e.g., >3) scanning is a useful method
for dealing with patient motion since it allows performance of an entire chest or abdominal CT in
less than 3 seconds. Compared to a retrospectively gated CTA acquired at a pitch of 0.3, these high-
pitch techniques can achieve relatively motion-free scanning in one-tenth the time. Finally, posi-
tioning aids such as wedges and pillows, which allow the patient to rest comfortably in the desired
position, may be of value.
Figure 4A.2.4 illustrates how patient motion can be tracked via markers. The image (A) represents
the patient in a neutral position. The marker, which is positioned above the patient, is at the neutral
position as well. The second image (B) represents patient motion in the y-direction, which is indi-
cated by a shift in the marker position. The fi nal image (C) is a return to the neutral position.
Modern CT scanners offer some other techniques to compensate for motion artifact; these include
overscanning and software correction algorithms during reconstruction. Overscanning means that
more than a 360-degree gantry rotation is used and the data from those additional degrees of cover-
age are then averaged with the initial portions of the scan to minimize the motion artifacts during any
given slice. Other motion compensation methods have been proposed that combine multipoint, skin
marker motion tracking in a manner similar to that used by the movie and video game industries.
Figure 4A.2.2 This sagittal reconstruction from the scan seen in Figure 4A.2.1 demonstrates a stair-step artifact due to patient
motion during the cervico-thoracic portion of the scan acquisition. Nevertheless, the lower part of the study was still of diagnostic
quality.
The underlying premise is to treat the body as a rigid structure and to track its motion in three
dimensions. This motion data can be then be added to the projection data at corresponding time
points. The limitation of this technique is that the human body is not rigid, and patients do not move
stiffly on the CT table. Although it seems likely that further developments in optical motion capture
techniques will translate into improved motion suppression, no such systems are currently in use.
78 CT IMAGING
Figure 4A.2.3 In this graphical representation of motion artifact during an axial acquisition, the top image shows the expected
relationships without motion, whereas the bottom image shows how one slice appears offset relative to its neighbor due to motion.
Figure 4A.2.4 These images illustrate how patient motion can be tracked via markers. The left image represents the patient in a
neutral position. The marker, which is positioned above the patient, is at the neutral position as well. The second image (middle)
represents patient motion in the y-direction, which is indicated by a shift in the marker position. The final image (right) is a return to
the neutral position.
Correct answer: 3, 2, 4, 1
Artifact 3
This patient is a 60-year-old female who presented to the emergency room complaining of acute
onset of shortness of breath 3 hours previously (Figure 4A.3.1). She recently returned from vacation-
ing in Europe and also complains of left leg pain and swelling. The patient is alert and oriented ×4,
although she remains hypoxic (90% oxygen saturation) and short of breath on 2 L oxygen via nasal
cannula. She was unable to maintain the breath-hold during CT pulmonary angiogram performed
on a dual-source CT scanner.
What is the most reliable way to differentiate respiratory motion from cardiac motion on a chest
CT?
(1) Look for blurring of cardiac contours on axial images.
(2) Look for blurring of pulmonary vascularity on axial images.
(3) Look for stepwise artifact in the sternum on sagittal images.
(4) Compare pre- and postcontrast images.
Figure 4A.3.1 This axial image from a CT pulmonary angiogram demonstrates respiratory motion artifact that limits the visualiza-
tion of many pulmonary artery branches.
80 CT IMAGING
(A)
(B)
Figure 4A.3.2 Sagittal image (B) in a different patient demonstrates the typical irregularity of the sternum seen with respiratory
motion. Lateral scanogram image from the same scan (A) demonstrates a normal sternum in that area. The respiratory motion artifact
is seen on an axial image from that level (C).
On cardiac gated studies, differentiating cardiac from respiratory motion helps to separate those
cases with cardiac motion that will benefit from postprocessing techniques from those with respira-
tory motion in which postprocessing will prove to be of limited utility. Blurring of the cardiac con-
tours and pulmonary vascularity on axial images may be evident as a result of both respiratory and
cardiac motion (Figure 4A.3.2 A–C). The key to differentiating the two is the presence or absence of
chest wall motion artifact, and that will be most evident on the sagittal image of the sternum.
(C)
Figure 4A.3.2 (Continued)
In general, respiratory motion artifact is deleterious on only a limited portion of a scan, leaving the
other parts of the scan unaffected. Similar to gross patient motion discussed previously (Artifact 2),
prevention is the most reliable method for dealing with this particular artifact. In the case of respi-
ratory motion artifact, the most important factor to consider is the patient’s respiratory status and
factors such as severe chronic obstructive pulmonary disease (COPD) or fibrotic lung disease that
limits his or her ability to perform a 10–20 second breath-hold.
The most commonly used methods for prevention of respiratory motion artifact include longitudi-
nal axis collimation (i.e., minimizing the volume scanned), caudal-cranial scanning, and high-pitch
scanning. Minimizing scan length decreases the time required for image acquisition and breath-hold,
as well as minimizing the radiation dose, which is directly proportional to the coverage area. Worse
yet, as the breath-hold gets longer, there will be some degree of reflex tachycardia, which exacerbates
the motion artifact.
For severely hypoxic patients, shortening the scan to allow coverage of the region of interest in a
single breath-hold may help to obtain a diagnostic scan that might otherwise be impossible. Caudal-
cranial scanning can be beneficial in patients being scanned for evaluation of pulmonary embolism
since most pulmonary emboli occur in the lower and middle lobe branches; so, by scanning this
area fi rst, image quality improves in the region of greatest interest. High-pitch (3.4) scanning is a
new method available on some scanners that allows for triggered, full-volume coverage with non-
overlapping helical acquisition that utilizes two X-ray sources, as well as specialized reconstruction
algorithms.
82 CT IMAGING
Figure 4A.3.3 Axial image through lung bases.
Figure 4A.3.4 Four-dimensional CT. Images from a 4D CT were obtained for radiation therapy planning in a patient with right lower
lobe lung cancer. The CT acquisition was performed continuously throughout the respiratory cycle at a low pitch to allow reconstruc-
tion of image sets at eight different phases throughout the respiratory cycle. Each image shown is a two-dimensional (2D) projection
created from the retrospective phase dataset (12% on the left). The arrows mark the position of the right sixth and eighth ribs; the
position of the right lower lobe mass varies throughout the respiratory cycle relative to these ribs.
This axial image through the lung bases (Figure 4A.3.3) from a different patient illustrates the
difficulty in evaluating adequate images when the question is pulmonary embolism, as respiratory
motion mimics vascular fi lling defects.
Other more complicated and uncommonly used methods for respiratory motion compensation
exist and provide varying degrees of utility. In the setting of radiotherapy/proton beam therapy for
treatment of lung tumors, four-dimensional (4D) CT scanning is being investigated for potential
clinical applications (Figure 4A.3.4).
Correct answer: 3
Artifact 4
This patient is a 55-year-old female with a history of intermittent chest pain who presented to the emer-
gency room with worsening shortness of breath (Figure 4A.4.1 A,B). The patient had negative cardiac
enzymes, and a retrospectively gated cardiac CTA was performed. During the image acquisition, the
patient experienced reflex tachycardia up to 80 beats per minute (bpm) from a baseline rate of 60 bpm.
Which of the following is correct regarding tube current modulation during cardiac CTA:
(1) Irregular heart rates allow using a lower radiation dose.
(2) The method used for predicting the appropriate dose modulation is similar to that used in
prospectively triggered acquisitions.
(3) Increased heart rates facilitate dose reduction.
(4) Image quality will be the same in all phases of the cardiac cycle.
(A)
(B)
Figure 4A.4.1 Volume-rendered (A) and oblique coronal (B) images from a retrospectively gated coronary CT angiogram (CTA)
demonstrate bands of high image noise artifact resulting from improper tube current modulation.
84 CT IMAGING
Figure 4A.4.2 Electrocardiogram tracing from a retrospectively gated cardiac CT. The dark bars represent the 75% phase set as end
diastole. The shaded areas throughout the rest of the cardiac cycle represent the lower tube current portions of the acquisition.
With tube current modulation, the scanner tries to predict the timing of the selected end diastolic
phase based on the previous 3–5 cardiac cycles, a method very similar to prospectively triggered
cardiac CT studies. Irregular heart rates make it difficult or impossible to predict the appropriate
timing of the next cardiac cycle reliably, which increases the portion of the cardiac cycle requiring
the full tube current. Thus, answer 1 is incorrect. Increased heart rate decreases the effectiveness of
tube current modulation because the overall cardiac cycle is shorter, which decreases the time win-
dow when current can be lowered. Thus, answer 3 is incorrect. The image quality for any given slice
depends largely on the quantity of the X-rays that contribute to the image, and that is determined by
the tube current. During the phases of the cardiac cycle when the tube current is decreased for dose
reduction, there will be more noise compared with the phases when the full tube current is used.
Thus, answer 4 is incorrect.
Tube current modulation is a widely used dose reduction technique on modern CT scanners. The
radiation dose is then optimized based on the specific patient’s density profi le and cardiac phase
without significant image quality penalty. In cardiac CT acquisition, tube current modulation pro-
vides the benefits of prospective triggering to be partially realized in retrospectively gated studies.
The basic principle is that the relatively motion-free parts of the cardiac cycle are end systole (usu-
ally occurring at 35% of the R-R interval) and end diastole (at 75%). The projection data for the
remainder of the cardiac cycle are used primarily for functional analysis since that does not require
the same image quality or spatial resolution as a coronary artery evaluation. Similar to the tech-
niques utilized for prospective triggering, the tube current can be decreased to a fraction (4–20%) of
the full dose during phases of the cardiac cycle that are unlikely to provide motion-free imaging of
the coronary arteries. The fraction of the cardiac cycle that receives the reduced dose is dependent
primarily on the rate and regularity of the heartbeat. For low heart rates, the end diastolic window
for image acquisition is relatively short compared to the length of the overall cardiac cycle (e.g.,
150 msec of a 1,000 msec cycle is 15%), whereas rapid rates mean an increase in this percentage
(e.g., 125 msec of a 600 msec cycle is 21%). Therefore, the dose reduction afforded by tube current
modulation is dependent not only on the variability of the heart rate, but also on the heart rate itself
(Figure 4A.4.2).
(A)
(B)
Figure 4A.4.3 Short axis images from a retrospectively gated coronary CT angiogram (CTA) reconstructed at 75% (A) and 95% (B)
of the R-R interval with tube current modulation active.
In the setting of normal sinus rhythm with a low variability from beat to beat, tube current
modulation can accurately predict subsequent cycles and adjust the tube current appropriately
(Figure 4A.4.3 A,B). With a variable heart rate, however, it is more difficult to predict the timing
of the next cardiac cycle, so the scanner must widen the window of full tube current to ensure that
the true end diastolic phase is covered. As a result, in patients with a high degree of heart rate vari-
ability or atrial fibrillation, tube current modulation will provide very little dose reduction. Since
projection data are acquired continuously throughout the cardiac cycle, it is possible to recon-
struct images during any cardiac phase. As demonstrated in this case, when tube current modula-
tion is active, the image noise increases in the dose modulated portions of the scan, which results
in a grainy appearance (Figure 4A.4.4). However, those images are still sufficient for functional
86 CT IMAGING
evaluation, although their poorer SNR may make them inadequate for evaluation of the smaller
(<2 mm) coronary vessels.
The bandlike high image noise artifact apparent in Figure 4A.4.5 is typical of tube current modu-
lation errors. If the rate varies significantly from one beat to the next, the end diastolic phase may
incorrectly receive the decreased tube current. When that happens, there will be a lower SNR in the
projection data during the end diastolic phase but only in those sections of the scan captured when
there was a variable heart rate. This artifact is easy to identify on sagittal or coronal images because
there will be a bandlike zone of high noise corresponding to the timing of improper tube current
modulation. Other arrhythmias can also account for these artifacts, both from direct effects on the
cardiac cycle length as well as from the ECG editing required to compensate for ectopic beats and
irregular rhythms.
Figure 4A.4.4 Electrocardiogram tracing from a patient with an erratic baseline that leads to an inappropriately detected R wave.
Variability in heart rate forces the scanner to limit tube current modulation until a regular and predictable rate is established and
maintained for several beats.
Figure 4A.4.5 Sagittal (A) and axial images (B, C) from a retrospectively gated CT angiogram (CTA) that demonstrate an area of
typical tube current modulation artifact. The corresponding axial images at (C) and above (B) the area of artifact highlights the marked
difference in signal-to-noise ratio between the areas of tube current modulation and the full current image.
Correct answer: 2
Artifact 5
This patient is a 54-year-old female (Figure 4A.5.1) who presented to the emergency department
complaining of atypical chest pain and palpitations. Her initial workup was negative, and a coro-
nary CTA was ordered for further evaluation. While scanning through the level of the aortic root,
the patient had a premature ventricular contraction (PVC) that resulted in the artifact depicted.
If a patient exhibits frequent PVCs during prescan monitoring, what is the appropriate next step
in management?
(1) Send the patient back to the emergency department and tell the referring physician that the
scan cannot be performed.
(2) Perform an ungated study since ECG synchronization is useless in these patients.
(3) Analyze the regularity of the rhythm and frequency of PVCs and determine what scan, if any,
can be performed to answer the clinical question of concern.
(4) Keep administering beta-blockers until the PVCs stop.
Figure 4A.5.1 Multiphase images reconstructed at 10% intervals throughout the cardiac cycle from a patient who had a premature
ventricular contraction (PVC) during image acquisition. The electrocardiogram tracing shows an irregularly irregular heart beat,
resulting in variable overlap between the 10 cardiac phases in each beat (distinct vertical bars between each QRS complex). The data
between the PVC and the subsequent QRS has been excluded from the image reconstruction (oblique bars).
88 CT IMAGING
It may be the case that the clinical question cannot be answered, but that cannot be determined
until the ECG is analyzed and alternative acquisition protocols considered. Gating is not necessar-
ily useless, but rather the studies generally require some degree of postprocessing to minimize the
impact of PVCs and ensure that each coronary segment is evaluated. It is, in general, very difficult to
prevent ectopy with beta-blockade, and it would be dangerous to attempt to do so for a CT.
In general, it is useful to think of premature contractions as either regular, such as in bigeminy,
or erratic, because they are treated differently. When dealing with erratic PVCs, the number of such
events during image acquisition determines the degree of ECG editing necessary to extract diagnostic
information from the scan. It is also important to consider whether the scan was acquired prospec-
tively or retrospectively since more postprocessing options are available for retrospective studies.
When using prospective triggering, the most common problem that arises from PVCs is that the
cardiac phase predicted by the scanner may not correspond with the end diastolic phase. Thus,
the sections of the scan corresponding to the PVC are reconstructed using projection data from a
portion of the cardiac cycle prone to motion-related blurring. Some newer scanners have enhanced
arrhythmia detection algorithms that direct the scanner to reacquire data for those portions of the
cardiac volume affected when a PVC has occurred. If the scan is completed with suboptimal cardiac
phase data, the entire scan may need to be repeated if image quality is insufficient to answer the
clinical question.
For retrospectively gated studies, ECG editing tools are available in the postprocessing stage
(Figure 4A.5.2 A,B). The three tools routinely utilized include multiphase reconstruction, deletion of
(A) (B)
Figure 4A.5.2 Retrospectively gated cardiac CT angiogram (CTA) with multiple premature ventricular contractions (PVCs). The first
image (A) demonstrates multiple band artifacts. With beat 5 disabled (B), there is insufficient data to reconstruct the image, and blur-
ring occurs from interpolation of the data from adjacent portions of the scan.
unwanted synchronizations, and disabling of unwanted synchronizations. The importance of multi-

phase reconstructions is that the relative motion of the coronary arteries is most commonly minimal
at end diastole/end systole, although the exact timing of those phases may not occur precisely at
75% and 35% of the R-R interval. Creating multiphase reconstructions allows evaluation of each
coronary segment throughout the cardiac cycle since it is only necessary for a given coronary artery
segment to appear normal in one phase for it be considered normal.
If a gating artifact from a PVC limits the evaluation of a coronary segment, the ECG can be edited
manually to adjust for phase errors prior to image reconstruction. Disabling an ECG-synchronization
means that specific beat will be ignored during image reconstruction, and the missing image data
can be filled from adjacent cardiac cycles, This approach is useful in the setting of a single PVC or
even with regular PVCs, such as in bigeminy. Deleting a beat removes that portion of the scan data
from the reconstruction and can be effective if there is sufficiently redundant data to allow image
reconstruction without those projections. If the compensatory pause that occurs after a PVC is suf-
ficiently short, it may be possible that there is still sufficient data to reconstruct the image even with
a disabled or deleted beat.
Correct answer: 3
90 CT IMAGING
Artifact 6
This patient is a 73-year-old male with a long history of hypertension and diabetes. He presented
for a preoperative evaluation prior to his elective laparoscopic cholecystectomy (Figure 4A.6.1 A–C).
A coronary CTA was obtained for risk assessment since the patient was unable to tolerate exercise
stress testing and refused invasive catheterization.
Which of the following is true when imaging densely calcified coronary vessels?
(1) Calcium causes underestimation of the degree of stenosis.
(2) Coronary calcifications are a contraindication to coronary CTA.
(3) Calcium, unlike metal, does not cause beam hardening or streak artifacts.
(4) Calcium outside of the coronary arteries can still adversely impact the diagnostic evaluation.
(A) (B)
(C)
Figure 4A.6.1 Volume-rendered image (A) from a CT coronary angiogram, as well as magnified images of the left anterior descend-
ing (LAD) (B) and circumflex (C) coronary arteries demonstrating calcified plaque.
Figure 4A.6.2 Dense mitral annular calcifications result in artifactual low attenuation in the immediately surrounding tissues.
Dense calcifications near the coronary arteries can impact evaluation. Good examples of this are
cases in which dense mitral annular calcifications can limit the CT evaluation of the circumflex
artery (Figure 4A.6.2).
Dense calcifications in the setting of coronary artery disease can cause artifacts similar to metal
or other dense objects in the field, including blooming and beam hardening.
In the setting of calcified vessels, beam hardening results in artifactual low attenuation within
the vessel lumen. If there are large focal or dense circumferential calcified plaques, the lumen can
appear significantly lower in density than expected, which can then mimic occlusion/thrombosis
(Figure 4A.6.3).
Even with these limitations, diagnostic evaluation of the coronary arteries is still possible in the
presence of moderate coronary artery calcifications.
92 CT IMAGING
Figure 4A.6.3 Dense circumferential coronary artery calcifications resulting in artifactual central low density.
Correct answer: 4
Artifact 7
This 40-year-old female presented to the emergency department complaining of chest pain and
shortness of breath, and a coronary CTA was ordered to evaluate for coronary artery disease
(Figure 4A.7.1). Based on the patient’s age and heart rate (50–60 bpm), the decision was made to per-
form the study using prospective triggering. The patient was instructed to take a normal breath and
hold it to minimize variations in heart rate. The calcium scoring portion of the exam was uneventful,
although at the start of the contrast injection, the patient’s heart rate increased to 80 then decreased
to 50 bpm during the 8 second scan.
Which of the following statements is true regarding prospectively triggered studies?
(1) End systole is the optimal time to image, and occurs at approximately 50% of the R-R
interval.
(2) End diastole is the optimal time to image, and occurs at approximately 75% of the R-R
interval.
(3) Tube current modulation is an important factor in minimizing radiation dose on prospectively
triggered cardiac scans.
(4) Triggered studies are more tolerant of variations in heart rate than are gated studies.
Figure 4A.7.1 Sagittal image from a coronary CT angiogram (CTA) demonstrating blurring artifact (arrow ) that is the result of an
erroneous prediction of end diastole. The reconstruction of that data will show the heart in the wrong phase of the cardiac cycle
94 CT IMAGING
End systole (at 35% of the R-R interval) and end diastole (~75%) are the two phases in the cardiac cycle
with the least motion, and it is for this reason that they are considered to be the optimal time to image.
The end diastolic phase is slightly longer than end systole and more reliably motion free; thus, it is the
most often used phase for triggered studies. Tube current modulation is used only in retrospectively gated
studies to mimic the dose reduction achieved with triggered studies by decreasing the tube current during
portions of the cardiac cycle. Triggered studies are less tolerant of heart rate variations because changes
will result in incorrect estimation of the end diastolic phase, leading to slab and motion artifacts.
In the setting of a PVC or premature atrial contraction (PAC), the R peak is detected early, and
this typically inhibits the scanner. At this point, the table translation is also paused until the resump-
tion of a normal cardiac cycle. This can be the return to the initial heart rate or a new, different,
but stable rate. In any event, the image acquisition is paused until the cardiac phase can be reliably
anticipated by the scanner software.
When the patient exhibits a gradually increasing or decreasing heart rate, problems may arise
because the scanner typically adjusts the prospective triggering based on the previous cardiac cycles.
If the degree of variability is sufficient, it will result in imaging different phases of the cardiac cycle
for different portions of the heart. When this occurs, portions of the acquisition will occur during
high-motion portions of the cardiac cycle (e.g., during systolic contraction), and the resultant images
will be degraded by the typical motion artifacts shown in previous cases. One major drawback to
using triggered acquisition in patients with variable heart rate is the inability to reassign cardiac
phases during postprocessing (Figure 4A.7.2 A,B).
(A) (B)
Figure 4A.7.2 Axial images reconstructed at the same location demonstrate a limited ability to adjust the reconstruction phase
on a triggered study (e.g., 73%) (A) and 70% (B). The motion artifact apparent at this level is not alleviated by the slight phase shift
afforded by the triggered acquisition.
Correct answer: 2
Artifact 8
This 70-year-old female with an implanted defibrillator, placed 10 years prior, presented to the
emergency room complaining of headaches, fatigue, and atypical chest pain (Figure 4A.8.1 A,B).
Although there was a low suspicion for obstructive coronary artery disease and negative cardiac
enzymes, a coronary CTA was performed.
The low attenuation near the metal hardware in this case can be attributed to:
(1) fatty deposits near the implants.
(2) incomplete projection data related to photon attenuation.
(3) increase in tube current driven by the AEC.
(4) cardiac motion.
(A)
(B)
Figure 4A.8.1 Axial CT image (A) through the level of the aortic root demonstrates metallic artifact from metal leads in the right
atrium, left ventricle, and superior vena cava. Another image (B) at the level of the aortic arch demonstrates the metallic artifact around
the generator in the left chest wall.
96 CT IMAGING
CT scan images are reconstructed from the data collected by the detectors using a technique called
filtered back-projection (FBP). Objects that have sufficient density to fall outside the 12-bit range
covered by standard scan data produce gaps in the projection data analogous to a shadow. The
image reconstruction using incomplete projection data produces these metal artifacts, which are
commonly seen with orthopedic hardware as well.
Metallic artifacts on CT are really the manifestation of several key effects. Beam hardening occurs
when the X-ray beam encounters a dense object that attenuates or disperses a significant portion of
the low-energy X-rays (Figure 4A.8.2). Metallic artifacts represent the extreme of this phenomenon
since the complete attenuation of the beam results in gaps in the data from these shadows in the
projection data. When using a FBP method, these gaps in the projection data produce dark bands
on the images around the metallic object. Blooming artifact (see Chapter 3) results from small high-
density structures, such as metal and calcium, making them appear larger than their actual size
(Figure 4A.8.3). The actual density of metallic objects is another factor to consider since metals like
titanium cause much less artifact than the platinum used to mark the ends of stents so that they are
visible on fluoroscopy. Finally, motion at the interface between metal and surrounding tissue can
cause an accentuation artifact. One example of this can be seen with pacemaker leads within the
cardiac chambers.
Metallic densities in any part of the body produce similar artifacts, although there are some spe-
cial considerations in cardiac imaging related to stents, coronary artery bypass graft (CABG) clips,
and pacemaker leads, all of which occur in regions where the patency of small vessels is of primary
concern. With sufficiently small vessels or dense stent materials, the beam hardening effect and gaps
in the projection data can produce an artifactually low density of the voxels within the stent lumen
that can be misinterpreted as in-stent stenosis. The degree to which the lumen is obscured relates
primarily to the type of stent.
Some reconstruction methods have been described for metal artifact reduction (MAR), but most
involve mathematical manipulation of the projection data to compensate for the gaps in data pro-
duced by the metal “shadowing.” When using FBP, linear or bilinear interpolation is typically used
to fill in the missing projection data. These methods have been used clinically, although they produce
a separate set of artifacts that limits their utility. Utilizing a sharp reconstruction kernel, as shown in
Figure 4A.8.2 Spectral graph of the relative distribution of photon energies in an unfiltered (left ) and filtered (right ) X-ray beam.
The addition of filtering preferentially removes the lower energy photons and increases the mean energy of the beam.
Figure 4A.8.3 Metallic artifact from a bullet, with low density areas surrounding the metal from gaps in the projection data from
X-ray beam attenuation by the lead bullet.
Figure 4A.8.4, minimizes the blooming artifact related to metallic artifact and increases the visibil-
ity of voxels that would otherwise be obscured by the beam hardening artifact. The major drawback
to the use of sharp reconstruction kernels is the increase in noise and poor soft-tissue contrast.
The standard range of CT values utilized for image reconstruction is 12-bit unsigned integers,
which can represent 0–4,096 possible values. It is important to note that the range is arbitrary and
meant to include the values commonly encountered in the human body, but densities of metals often
extend outside that range. One MAR technique available commercially uses an extended CT range
(either with 16-, 32-, or 64-bit integers) in the reconstruction process. This allows for the actual
densities of the metals to be represented so that there are no black voxels in those areas that exceed
the CT range. In practice, however, this is not usually helpful in cardiac imaging since the metallic
structures encountered are small and the regions of interest are adjacent to the metal, rather than
the metal object itself. Iterative reconstruction, an alternative and more computationally intensive
reconstruction method, provides another means of minimizing metallic artifact since it is less sensi-
tive to gaps in the projection data. When dealing with metallic foreign bodies, it is advisable to avoid
low-kV scanning since this would be expected to worsen the artifact. When performing retrospec-
tive gating in patients with pacemakers, it is important to look at all of the cardiac phases since the
relative position of pacemaker leads with respect to the arteries changes throughout the cardiac
cycle. Disabling tube current modulation may also improve image quality throughout noncritical
portions of the cardiac cycle but at the expense of increased radiation dose.
98 CT IMAGING
(A) (B)
Figure 4A.8.4 Two multiplanar reformatted images through the left anterior descending (LAD) coronary artery. The image on the
left (A) is reconstructed utilizing a standard soft-tissue kernel, and the image on the right (B) utilizes a sharper kernel. The blooming
artifact within the LAD is decreased, with the sharper kernel making it easier to see that the vessel is patent. However, the increased
image noise as a result of the sharper kernel image is also apparent on these images.
Correct answer: 2
Artifact 9
This patient is a 48-year-old female with a history of stab wounds to the chest 20 years ago
(Figure 4A.9.1 A,B). She now presents with intermittent atypical chest pain. A coronary CTA was
ordered to evaluate for coronary artery disease. During inspiration just prior to the scan, one of the
ECG leads loosened, and synchronization was lost for a portion of the acquisition. Near the end of
the scan, however, the synchronization was regained. A sagittal reformatted image shows numerous
areas of band artifact related to improper synchronization and data gaps in the reconstruction. Upon
inspection of the ECG, it was determined that the patient was most likely in normal sinus rhythm
throughout the study, with a rate of 58–62 bpm. The ECG was adjusted manually, utilizing those
portions of the rhythm at the beginning and end of the scan as a reference (Figure 4A.9.2 A,B).
Electrocardiogram editing (i.e., adding or disabling synchronizations) is least helpful in which of
the following situations?
(1) Arrhythmias such as atrial fibrillation.
(2) Ventricular tachycardia.
(3) Uninterpretable tracing but with presumed underlying sinus rhythm.
(4) Solitary premature ventricular contraction.
(A)
(B)
Figure 4A.9.1 Coronal image (A) from a coronary CT angiogram (CTA) demonstrates multiple incorrect phase selection artifacts as
well as cardiac motion artifact. The corresponding electrocardiogram recording (B) demonstrates irregular baseline activity without
discernible QRS complexes or appropriate synchronization.
100 CT IMAGING
(A) (B)
Figure 4A.9.2 Oblique coronal images (A and B) reconstructed from the same scan data as Figure 4A.9.1 but with manual
placement of the electrocardiogram synchronizations. The blurring artifacts in the images now appear in different places due to the
variations in the cardiac phase used for image reconstruction.
Atrial fibrillation is a challenging problem for ECG synchronization due to its inherent irregular-
ity. As discussed in Artifact 4, it is usually possible to obtain diagnostic information by using ECG
editing and multiple reconstructions in order to evaluate each coronary segment separately. Solitary
PVCs are also fairly straightforward to handle with synchronization disabling (see Artifact 5). In
cases with a normal sinus rhythm but incorrect ECG recording, typically, sufficient projection data
are available to allow appropriate image reconstruction if the synchronizations can be reconstructed.
Ventricular tachycardia poses several significant problems for ECG synchronization, but the most
important is that the rate typically exceeds 120 bpm. This is outside the temporal resolution of even
dual-source scanners and, for that reason, should not be attempted.
It is not uncommon for baseline tremor or poor ECG lead contact to interfere with ECG record-
ing. As with many of the artifacts discussed in this chapter, prevention is the best way to avoid this
artifact. It is important to include questions about lotion use on the prescan survey, as well as to use
a visual and tactile inspection of the patient’s skin surface since it may be necessary to shave excess
hair or use alcohol wipes to clear a portion of skin for optimal application of the ECG leads. Deep
inspiration can also result in loss of ECG lead skin contact. Thus, monitoring the ECG while hav-
ing the patient practice respiration is important both to evaluate for heart rate changes as well as to
verify proper lead electrical contact throughout scan acquisition.
If the preventive measures fail and the scan is performed with an uninterpretable ECG, the next
step is to inspect the ECG and determine if there is an underlying regular rhythm. If the patient is
believed to have a regular underlying rhythm, it is reasonable to insert synchronizations throughout
the ECG at regular intervals. This will be aided by using any existing R waves and knowledge of the
patient’s rate in a trial-and-error method. If the underlying rhythm is indeterminate or believed to be
irregular, the problem of scan salvage becomes more difficult, although a trial-and-error approach
remains the best option apart from repeating the scan. Other more advanced techniques (outside
the scope of this text) exist for extracting the phases of the cardiac cycle from the projection data
through kymogram detection and kymogram-correlated image reconstruction. These methods sort
the projection data into the appropriate phases of the cardiac cycle by analyzing temporal and spatial
variations of the projection data itself.
Retrospectively gated coronary CTA is done using a low pitch (approximately 0.3), which results
in considerable redundancy within the collected image data. A reasonable approximation of the opti-
mal pitch can be determined using the product of the gantry rotation time (in seconds) and the heart
rate in beats per second. For example, using a standard rotation speed (0.33 second) for a cardiac CT
of a patient with heart rate of 60 bpm, which is 1 beat per second, the optimal pitch is 0.3. It should
be apparent, then, that the pitch should be adjusted for patients with heart rates below 50 or above
75 bpm. With some scanners, it is possible to adjust the pitch continuously based on the patient’s
heart rate in order to maintain an optimal pitch despite variations in heart rate.
During helical acquisition, each cardiac segment is imaged throughout the cardiac cycle at a sam-
pling rate determined by the temporal resolution of the scanner. In ECG gated studies, helical data
acquisition occurs independently of the ECG tracing (ignoring tube current modulation). For this
reason, in the setting of technical failure of ECG recording, multiphase scan data with regular spac-
ing are still available and can be used for reconstruction of images if an appropriate estimation of
the cardiac cycle can be made.
Correct answer: 2
102 CT IMAGING
Artifact 10
This 45-year-old female with history of cocaine abuse presented to the ER with a 3-day history of
chest pain (Figure 4A.10.1). Her laboratory testing was positive for cocaine and methamphetamine.
Despite judicious and cautious use of beta-blockers, the patient’s heart rate remained in the high 80s
to low 90s. Clinical suspicion for coronary artery disease was sufficient that the decision was made
to proceed with coronary CTA (Figure 4A.10.2 A,B).
As heart rate increases, what portion of the cardiac cycle is most profoundly impacted, and what
effect does this have on the ability to perform motion-free imaging?
(1) QRS complex; ECG synchronization is limited by the abnormal QRS duration.
(2) Ventricular systole; no impact.
(3) Ventricular diastole; as rate increases, it requires better temporal resolution by the scanner.
(4) Atrial contraction; image quality is inversely related to the duration of atrial contraction.
Figure 4A.10.1 Electrocardiogram tracing from a retrospectively gated cardiac CT angiogram (CTA) demonstrates elevated and
moderately variable heart rate.
(A) (B)
Figure 4A.10.2 Axial image (A) at the level of the mid heart demonstrates blurring of the mid right coronary artery (RCA) due to
image reconstruction using the incorrect cardiac phase. A magnified, curved, planar reformatted image (B) shows the z-axis extent of
the blurring along the length of the RCA.
As heart rate increases, the diastolic phase is disproportionately shortened, such that motion-free
imaging of the end diastolic phase becomes correspondingly more difficult. At a rate of 60 bpm, the
optimal phase for motion-free imaging is end diastole. For heart rates closer to 70 or 80 bpm, the
end systolic phase may provide better CT evaluation, but that depends upon the temporal resolution
of the scanner. The QRS complex is an electrical phenomenon that remains relatively stable in dura-
tion (80–100 msec) regardless of heart rate. The duration of ventricular and atrial systole are both
relatively stable with increases of heart rate within the range typically utilized for cardiac imaging.
For retrospective cardiac CT studies, the typical pitch is approximately 0.3 since this provides
sufficiently redundant coverage throughout the cardiac cycle to allow for multiphase reconstruction
of the heart. As the rate increases, there is a gradual shift of the optimal time for imaging from end
diastole in patients with rates of less than 60 bpm to end systole for those patients with rates greater
than 80.
The cardiac cycle is composed of several distinct phases, each of which corresponds to distinct
electrical activity recorded on the ECG. At a heart rate of 75 bpm, the entire cardiac cycle encom-
passes only 800 msec, which can be divided into 300 msec for systole and 500 msec for diastole.
However, at a rate of 200 bpm, the cardiac cycle is only 300 msec long and can be divided into
160 msec for systole and 140 msec for diastole. As you can see, there is a disproportionate short-
ening of the diastolic phase relative to systole at higher rates, which results in shorter motion-free
periods for image acquisition ( Figure 4A.10.3 A,B). It is for this reason that end systole may pro-
vide more optimal motion-free evaluation of the coronary arteries for patients with rates above
70 bpm.
(A) (B)
Figure 4A.10.3 Volume-rendered (A) and axial cross-sectional images (B) from a CT coronary angiogram performed on a patient
with tachycardic reflex and heart rate variability during the acquisition. The volume-rendered image demonstrates multiple bandlike
areas of contour irregularity, similar to gross motion artifact although limited to the heart.
104 CT IMAGING
The best temporal resolution of most dual-source scanners is approximately 83 msec, compared
with 165 msec for a single-source scanner. Temporal resolution is important to consider with pro-
spective ECG triggering. One potential method to deal with elevated heart rates is to use segmented
acquisition, in which information for a given section of the heart is acquired over several heartbeats
(Figure 4A.10.4). The benefit of this method is an improved temporal resolution, but at the expense
of higher radiation dose because of the need for data redundancy, since each cardiac segment is
imaged throughout several cardiac cycles. The other limitation of segmented acquisition methods is
the motion artifact caused by beat-to-beat variability of the heart.
Figure 4A.10.4 In segmented acquisition, only a portion of the data for a given section of the scan is acquired during one cardiac
cycle. By spreading the acquisition over several cardiac cycles, the effective temporal resolution is improved by a factor correspond-
ing to the number of cardiac cycles over which the acquisition is distributed.
Correct answer: 3
Artifact 11
This 35-year-old female with a history of persistent chest pain and shortness of breath following a
upper respiratory infection presented to her primary care physician for follow-up evaluation after
completing a course of antibiotics (Figure 4A.11.1). The physician was concerned for pulmonary
embolism and ordered a CT pulmonary angiogram, given her persistent symptoms. At the time of
the exam, the patient was anxious but otherwise cooperative with commands and was able to com-
plete the exam without any issues. It was noted by the technologist that the patient was very eager
to perform the best breath-hold possible and actually performed a Valsalva maneuver in order to
maximize the duration of her inspiratory effort (Figure 4A.11.2).
You can minimize the risk of suboptimal contrast enhancement using all of these methods, with
the exception of:
(1) Instruct the patient not to Valsalva during breath-hold procedure.
(2) Perform pressure testing of IV access prior to contrast administration.
(3) Increasing kV from 100 to 120.
(4) Increase volume of administered contrast for large patients.
Figure 4A.11.1 Axial postcontrast image from a CT pulmonary angiogram demonstrates very little contrast in the systemic and
pulmonary arterial systems. The patient also has thick chest wall soft tissues, another limitation to optimal scanning.
106 CT IMAGING
Figure 4A.11.2 Coronal maximum intensity projection image from the same patient demonstrates a dense column of contrast within
the left brachiocephalic and subclavian veins, as well as in the proximal superior vena cava.
As noted above, Valsalva during contrast administration produces a physiologic washout of con-
trast from the pulmonary circulation and cessation of contrast flow to the heart. One of the most
common causes of insufficient or absent contrast in an otherwise healthy patient is failure of the
injection mechanism or tubing. Larger patients may require an increased volume of contrast because
of their increased intravascular volume, as well as the increased X-ray attenuation within their soft
tissues.
Increasing the kV from 100 to 120 kV actually lowers the conspicuity of contrast on CT images.
That is why low-kV imaging, although increasing image noise, is so effective for contrast-enhanced
scans in thin patients. Contrast resolution indicates the smallest low-contrast object visible relative
to background noise. The measurement is typically presented as X mm at Y%, such as 2 mm at 5%.
This means a 2 mm object is discernible at 5% of the background density. In the range of commonly
used tube voltages of 80–140kV, contrast visibility increases with decreasing kV. Intravenous con-
trast administration is essential for imaging of small vascular structures such as coronary arteries.
With suboptimal contrast administration, larger vascular structures, such as main coronary arteries,
may still be visible, but their segmental branches will usually not be adequately seen because of poor
contrast resolution.
Contrast opacification is dependent on numerous factors, including selection of proper dose; iodine
concentration in the contrast agent; proper functioning of injector, tubing, and intravenous access;
and normal patient physiology. Changes in any of these factors can result in suboptimal contrast
enhancement. Meticulous attention to each part of the scan technique should be incorporated into
the prescan preparation to ensure uniform and optimal scan quality.
The proper dose of contrast for a study depends on the body part being imaged, as well as on
patient factors such as body habitus. As discussed in Artifact 1, the contrast dose should be adjusted
along with the kV and tube current to achieve optimal image contrast at the lowest radiation and
contrast dose. In general, it is desirable to increase the contrast dose when scanning larger patients
to account for beam attenuation.
The ideal mechanism for administering contrast uses a power injector with triggering either
through bolus tracking or a timing bolus. It is important to perform a pressure test of the line,
especially with injection rates at 3 mL/sec or above, to ensure proper connections and minimize
the risk of venous rupture and contrast extravasation. When using bolus tracking, it is important
to have proper placement of the bolus tracking region of interest in the vessel of interest. For most
systemic arterial studies, triggering should be performed using the descending thoracic or upper
abdominal aorta. However, some circumstances require special consideration. For example, in the
setting of severely depressed cardiac function, it may be necessary to trigger the acquisition manually
to account for slowed transit of contrast throughout the systemic arterial tree. Alternatively, a test
bolus may be performed in these patients to select the appropriate trigger delay based on the patient’s
physiology. If the patient has a known dissection, or there is high clinical concern for dissection, the
technologist or radiologist should be prepared to trigger the scan manually in case the ROI is inad-
vertently placed in the false lumen.
During CT scans that require scan acquisition and breath-holding early in the process of contrast
administration (i.e., right heart or pulmonary artery imaging), there are special considerations for
patient instruction and scanning. When a patient performs the Valsalva maneuver, several physi-
ologic changes occur that should be considered in the contrast injection process. During the initial
inspiratory portion of a Valsalva maneuver, the negative intrathoracic pressure increases venous
return to the right heart from both the superior vena cava (SVC) as well as from the inferior vena
cava (IVC). This response fills the pulmonary arterial tree with dilute contrast and forces the con-
trast that was initially in the pulmonary circulation into the left-sided heart chambers and systemic
circulation. After the inspiratory phase of a Valsalva, the patient bears down. This then increases
intrathoracic pressure and limits blood flow from the axillary and subclavian veins to the SVC. This
combination of physiologic changes results in a characteristic appearance on pulmonary angiograms,
showing modest systemic arterial contrast, limited pulmonary arterial contrast, and a static column
of contrast in the extrathoracic portions of the venous system (Figure 4A.11.3 A,B). It is often useful
to observe at least one practice inspiratory cycle prior to contrast injection to determine if the patient
needs any further instruction. It may be sufficient to instruct the patient to simply suspend respira-
tion or take a small breath rather than the deep breath that may result in the Valsalva effect.
108 CT IMAGING
(A)
(B)
Figure 4A.11.3 Coronal (A) and axial (B) CT images from a different patient demonstrating dense contrast within the superior vena
cava and subclavian vein with suboptimal pulmonary arterial contrast and moderate systemic arterial contrast. This pattern is typical
of Valsalva type inspiratory effort.
Correct answer: 3
Artifact 12
This 64-year-old male with a history of refractory atrial fibrillation presents for pre-pulmonary vein
ablation mapping with CT (Figure 4A.12.1 A,B). At the time of the exam, the patient was in atrial
fibrillation with a rate ranging between 50 and 110 bpm. The images demonstrate the characteris-
tic blurring artifact that can be evident in the setting of PVCs due to the use of data from different
phases of the cardiac cycle for image reconstruction (Figure 4A.12.2).
When considering cardiac CT for patients with irregular heart rates:
(1) it is not possible to perform a diagnostic exam.
(2) artifacts can be shifted to different parts of the scan but are difficult to eliminate entirely.
(3) prospective triggering eliminates any artifacts.
(4) increasing the pitch of a retrospectively gated acquisition will help minimize artifacts.
(A) (B)
Figure 4A.12.1 Axial images at the level of the right (A) and left ventricular (B) outflow tracts from a coronary CT angiogram (CTA)
demonstrate cardiac motion artifact at multiple levels. Motion artifact is notably absent along the posterior wall of the left atrium,
which is a relatively stationary portion of the heart.
110 CT IMAGING
Figure 4A.12.2 Electrocardiogram from the study demonstrating irregularly irregular rhythm as well as two premature ventricular
contractions (PVCs) during the course of the acquisition.
By carefully adjusting the cardiac synchronization throughout reconstruction using phase adjust-
ment and other ECG editing techniques, it is usually possible to obtain diagnostic information from
a gated cardiac exam performed on a patient with an irregular heart rate. Prospective studies suffer
from the same problem of variable cardiac cycle length, although the lack of data overlap limits post-
processing options. Although the heart rate of patients with irregular rhythms can intermittently
increase to over 100 bpm, it is generally not advisable to increase the pitch of the acquisition because
redundant data will prove to be very helpful during postprocessing.
The typical blurring artifacts associated with rapid and irregular heart rates are caused by motions
of cardiac structures that exceed the temporal resolution of the scanner. An example of this is blur-
ring of the right coronary artery (RCA) when imaged during systolic contraction. Stair-step artifacts
generally arise from either motion (see Artifact 2) or utilization of data from the incorrect cardiac
phase for image reconstruction. The latter is generally a result of heart rate variability since it pro-
duces an incorrect assignment of end diastolic and systolic phases.
Heart rate variability also adversely affects dose reduction techniques and compromises image
quality. In general, CT imaging of patients with rapid arrhythmias, regardless of their site of ori-
gin (e.g., atrial flutter, atrial fibrillation with rapid ventricular response, and ventricular fibrilla-
tion/tachycardia), should be avoided since the risk of generating a nondiagnostic study increases
with increasing cardiac irregularity and rate. Slow atrial fibrillation, wandering pacemaker, and
rate-controlled junctional rhythms may be imaged to answer specific clinical questions, such as pul-
monary venous anatomy or overall cardiac function. Performing diagnostic coronary angiography
is more challenging, and retrospective gating is essential to provide multiphase reconstruction and
evaluation, although nondiagnostic imaging of some coronary artery segments is typical.
Even with appropriate application of ECG editing techniques, blurring and stair-step artifacts are
typically just shifted from one part of the scan to another rather than eliminated. In the ideal case,
these artifacts can be shifted to areas outside the region of interest of the scan and still provide a
diagnostic evaluation. In addition to incorrect phase assignments, another problem that arises when
editing the ECG synchronization for irregular rhythms is the production of data gaps. These may
render the corresponding scan segments nondiagnostic. Figure 4A.12.3 demonstrates an attempt to
disable the synchronization associated with a PVC in this patient with underlying rate-controlled
atrial fibrillation. This technique can potentially result in a large data gap that the reconstruction
algorithm attempts to compensate for by averaging data from above and below the data gap. This
can result in nondiagnostic segments in the scan. See also Figure 4A.12.4.
(A)
(B)
(C)
Figure 4A.12.3 The electrocardiogram tracing from a cardiac CT angiogram (CTA) (A) demonstrates two premature ventricular
contractions (PVCs), the first prior to image acquisition and the second in the middle of acquisition. Modification of the synchroniza-
tions (B) by disabling the synchronization related to the PVC leaves too large a data gap. The resultant image (C) is the product of
interpolation of data from the sections of the scan above and below the data gap.
112 CT IMAGING
Figure 4A.12.4 Coronal images (left) from a different patient demonstrate artifacts related to the patient’s arrhythmia at multiple
levels throughout the scan. Coronal images (right) post electrocardiogram editing show how the artifacts can be shifted to a different
portion of the scan. In most cases, however, they cannot be completely eliminated.
Correct answer: 2
5 NEURO CT ARTIFACTS
114 CT IMAGING
Artifact 1
This 25-year-old helmetless bicycle rider crashed after colliding with an opening car door. A 5mm
section from his axial computed tomography (CT) scan (Figure 5A.1.1) and the lateral scanogram
(Figure 5A.1.2) are provided here. Why do you think that it is so hard to see the fracture on the CT
slice since it is so well seen on the scanogram (arrows)?
Figure 5A.1.2 Lateral scanogram.
Figure 5A.1.1 Axial CT, 5 mm section.
(1) There is no fracture; that dark line represents a fold in the head-holder foam.
(2) Volume averaging artifact obscures it on the CT scan.
(3) The fracture is in the same plane as this axial scan.
Neuro CT Artifacts 115
On cross-sectional CT scans, the attenuation of tissues is reflected by assigning a shade of gray

to each of the picture elements, called pixels. These are the smallest building blocks of the image, a
quantum of imaging if you like. The pixel size has an inverse relationship with the matrix size: the
larger the matrix, the smaller the pixels assuming the same field of view.
On early scanners, a matrix of 80 × 80 was used to limit the demands of image processing, but
modern scanners use a matrix of 512 ×512. At that matrix, and with the usual field of view, the pixel
dimension on most brain scans is about half a millimeter on each side.
The attenuation value assigned to each pixel represents the average attenuation of all the tissues
within the three-dimensional element called a voxel. You can think of an image like shoeboxes
stacked against a wall, with the information about what lies inside each box stamped on its end fac-
ing the center of the room. In the case of shoes, that information might be size and style, but for CT
scans it is the net attenuation of the tissues inside the box. While the pixel size reflects the dimen-
sions of the end of the box, the depth of the box and the size of the voxel is determined by the slice
thickness.
Considering the small pixel size used to form the image, it is natural to think that the tissues
within the corresponding voxel must all be about the same. But remember that the pixel represents
only the end of the box and, depending on the depth of the voxel, it may contain a mix of things that
are not at all homogeneous.
Because each voxel can only be assigned a single shade of gray (the average attenuation of every-
thing within its corresponding voxel), the low attenuation of this linear fracture was obscured once
its low attenuation was averaged with the higher attenuation of the adjacent cortical bone. This
effect of volume averaging of voxels on imaging can be thought of like the effect of dilution in liq-
uids. One drop of food coloring becomes invisible when added into a swimming pool but would be
easily seen in a shot-glass of water. In this same way, fi ne structures disappear in large voxels because
their attenuation is averaged with the surrounding tissue. When we reconstruct the data using very
thin slices, however, fi ner details can be uncovered and it is for this reason that this linear fracture
is more apparent on the 1.25 mm slice (Figure 5A.1.3) than the 5 mm slice (Figure 5A.1.1). That is
because the fracture now occupies a larger percentage of the voxel and as a result there is less “dilu-
tion” of the low-attenuation fracture.
This effect of volume averaging is also evident in these two other patients, one with a nondisplaced
fracture (Figure 5A.1.4 A,B) and the other with a displaced fracture (Figure 5A.1.5, A,B). But the
benefit of thin sections is not limited to the imaging of fractures. Thin sections can be helpful when-
ever we want to optimize imaging of small structures that might otherwise be obscured by volume
averaging. But keep in mind that thin sections may have worse SNR and that can obscure detail
unless sufficient dose is used to maintain image quality.
Although these three cases are all examples of false negatives due to volume averaging, it is not at
all uncommon for a normal scan to be interpreted as abnormal because of volume averaging. This
usually occurs as the result of averaging of normal brain with nearby bone at the skull base. Look for
this near the orbital roof and petrous bone, and be careful not to confuse this artifact with hemor-
rhage (Figure 5A.1.6 A–C).
116 CT IMAGING
Figure 5A.1.3 The fracture line (arrow ) is much more evident on this 1.25 mm slice created from the same dataset as the 5 mm sec-
tion seen in Figure 5A.1.1.
(A) (B)
Figure 5A.1.4 This linear skull base fracture (arrows) is much more evident on the 1.25 mm thick reconstructions (A) compared
with the 4.5 mm reconstructions (B).
(A) (B)
Figure 5A.1.5 Not only is it much easier to identify this depressed skull fracture (arrow ) on the 1.25 mm sections (A) compared
with the 5 mm sections (B), but the associated pneumocephalus is also more evident. That is because the low attenuation of the small
bubbles of air becomes more evident once they occupy a larger proportion of a smaller voxel and are no longer volume averaged with
the high attenuation of adjacent bone on the 5 mm reconstruction.
118 CT IMAGING
(A) (B)
(C)
Figure 5A.1.6 This axial 4.5 mm image (A) shows intermediate attenuation along the inferior right temporal lobe (arrow ) suggest-
ing hemorrhage. The appearance of the slice below, however, should suggest to the imager that this could be an artifact from volume
averaging of the low attenuation brain with the high attenuation of the bone of the petrous ridge (B). This can be confirmed by creating
a coronal reconstruction which shows no evidence of a parenchymal or extra-axial hemorrhage in the corresponding region of the
brain (C).
Correct answer: 2
Artifact 2
The high attenuation (arrow) in Figure 5A.2.1 represents a subarachnoid, not parenchymal,
hemorrhage.
(1) True
(2) False
(3) Not sure
Figure 5A.2.1 This helical mode brain CT was performed with pitch
1 and detector collimation 0.625. On this 5 mm reconstruction there is
asymmetric high attenuation in the right cerebellum (arrow ).
If your answer is 3, what would you do to clarify this finding?

120 CT IMAGING
Figure 5A.2.2 This coronal reconstruction shows a linear

configuration of the hemorrhage indicating that it is within the
subarachnoid space.
This high attenuation is due to subarachnoid hemorrhage in the horizontal fissure that has been
volume averaged with adjacent brain. If you have any uncertainty about the anatomic space of
blood, coronal reconstructions are of considerable value. You are frequently better off simply look-
ing at the coronal reconstruction in cases of trauma (Figure 5A.2.2) since detection of hemorrhage
can be a difficult in some cases on axial imaging. In this case its linear configuration closely matches
the shape of the wide horizontal fissure on the other side, and that offers convincing evidence that
the blood is outside the brain i.e. not parenchymal.
If the CT scan is performed using narrow detector collimation, the dataset can be used to create
high-quality reconstructions in other planes. The misidentification of the anatomic space of hem-
orrhage is actually quite common and seems to occur more often in the posterior fossa. In a second
case, shown in Figure 5A.2.3, the symmetry of the blood may lead you to again place it in the suba-
rachnoid space, but it is in fact within the parenchyma of the cerebellum (Figure 5A.2.4). If you look
at the image thoughtfully, the correct location is suggested by the adjacent, low-attenuation edema
on the patient’s left.
Figure 5A.2.3 The blood in cases of remote cerebellar hemorrhage after brain surgery is frequently mistaken for subarachnoid
hemorrhage. The parenchymal location of the hemorrhage is confirmed by its appearance on the coronal reconstruction (see Figure
5A.2.4). Note the low attenuation of the cerebellum lateral to the blood on the patient’s left.
Figure 5A.2.4 Coronal reconstruction of Figure 5A.2.3.
Correct answer: 3
122 CT IMAGING
Artifact 3
This scout view suggests a skull fracture (Figure 5A.3.1, arrows), but you are having trouble fi nding
it on the thin bone images from this axial CT scan, acquired in helical mode, that cover the fracture
from its upper to lower extent (Figure 5.3.2).
You conclude this is due to:
(1) blurring from motion.
(2) volume averaging.
(3) in-plane location of the fracture.
(4) a vascular groove.
Figure 5A.3.1 Scout view of head trauma case.

(A) (B)
(C) (D)
(E)
Figure 5A.3.2 A–E: Axial CT, in helical mode, covering skull fracture from top to bottom in the same order as the their assigned
letters.
124 CT IMAGING
On just one slice, and almost impossible to recognize in axial section, the attenuation of the skull
on the patient’s right is lower than on the slices above and below (Figure 5A.3.3, arrows). The low
attenuation, of course, represents the fracture itself, but since the fracture is in the same plane as the
plane of section, it is almost entirely contained in one slice. The sagittal reconstruction of the same
data (Figure 5A.3.4) better demonstrates the fracture since its low attenuation is now more evident
in contrast to the normal high-attenuation cortical bone on either side.
Figure 5A.3.3 This is image C from Figure 5A.3.2. Note the nearly imperceptible change in skull attenuation due to the fracture in
the plane of the image (arrows).
Figure 5A.3.4 Sagittal reconstruction of axial slices seen in Figure 5A.3.2 well demonstrates the dark fracture line in contrast to
the adjacent cortical bone.
Correct answer: 3
126 CT IMAGING
Artifact 4
This 29-year-old male presented to the emergency room with blurry vision and severe headaches 48
hours after he was assaulted. The images in Figures 5A.4.1 and 5A.4.2 demonstrate:
(1) patient motion.
(2) a fracture of the zygomatic arch.
(3) a fracture and patient motion.
Figure 5A.4.1 CT scan of patient after head trauma during assault.
Figure 5A.4.2 Adjacent section to 5A.4.1.

These images show how patient movement during the acquisition of a CT scan can easily be mis-
taken for a fracture. In this case, the motion created an apparent discontinuity of the right zygomatic
arch. It is important to keep in mind when you are looking at CT scans that the scans are collected
over a span of time, albeit short, and they are not snapshots, like conventional X-rays. Even though
scan times have decreased substantially in the past decades, CT images will always have a temporal
component that must be considered.
The scanogram taken prior to the CT scan is particularly deceptive in this respect because it
resembles a conventional X-ray, but it requires 4–6 seconds to create, unlike a conventional X-ray
that is acquired in a fraction of a second. The scanogram is generated by parking the gantry and
using the narrow X-ray beam to build the image line by line as the patient is moved across the detec-
tor with the motorized tabletop. Because the top and bottom of the scanogram are therefore collected
at slightly different times, any patient motion occurring during the time of collection will influence
how the lines of data are displayed. Patient motion during the scanogram can, in some cases, lead to
a distortion that reminds me of looking into those curved mirrors that I fi rst saw at the Fun House
on the boardwalk in Asbury Park, New Jersey. As strange as some scanograms may look, if you just
keep in mind how the scanogram is created and you will not be misled (Figures 5A.4.3, 5A.4.4).
The effect of motion on CT images may be evident on axial images, but when those images are
viewed in another plane and appear to show malalignment on the reconstruction, it becomes more
troublesome. Careful inspection will usually show some evidence of motion on the source images,
however, and, for that reason, reconstructions should always be correlated with the axial exam
whenever you see abnormal alignment (Figure 5A.4.5 A–D).
128 CT IMAGING
Figure 5A.4.3 Scanogram motion artifact.
Figure 5A.4.4 Scanogram of the same patient in Figure 5A.4.3 made just minutes later. Motion can readily distort the spatial
relationships on a scanogram image since it is collected line by line by moving the patient on the motorized table across the parked
gantry with the X-ray tube turned on and not as a single subsecond exposure like a conventional X-ray.
(A) (B)
(C) (D)
Figure 5A.4.5 These sagittal reconstructions (A, B) show malalignment of the spine that could be mistaken for traumatic injuries.
Review of the axial images, however, will be helpful in such cases by showing the motion effects that may be obscured on the recon-
structions. For example, while the coronal reconstruction appears to show a mandible fracture (C, arrow ), a corresponding axial scan
clearly shows the effects of motion (D).
Correct answer: 1
130 CT IMAGING
Artifact 5
This patient had a craniectomy with removal of much of the right skull to prevent brain herniation
after significant head trauma. On a CT scan, you notice a nearly perfectly round structure at the
top of the skull (Figure 5A.5.1) and wonder if the surgeons left something behind. You also wonder
if this could be:
(1) a cone beam artifact.
(2) partial volume artifact.
(3) a detector calibration error.
(4) a motion artifact.
Figure 5A.5.1 Axial CT of patient with craniectomy.

This commonplace CT ring artifact can be mistaken for disease when it appears as only a slight
increase or decrease in attenuation within a normal structure on the scan. An artifact of this sort
was found in one retrospective study to have caused several patients to go on to have magnetic reso-
nance (MR) imaging, and one patient to have continued treatment for suspected tuberculosis. This
artifact is the result of a failing or, more likely, an out-of-calibration detector. This can be distin-
guished from the artifact caused by helical reconstruction, which may be evident on curved surfaces,
such as the skull vertex (Figure 5A.5.2). This artifact has a characteristic “windmill” or “whirling”
appearance, unlike the complete ring seen in Figure 5A.5.1.
This windmill artifact can be minimized by decreasing detector collimation, beam collimation,
and pitch but, of course, can be eliminated altogether by choosing to image in the axial instead of
helical mode (Figure 5A.5.3). In fact, this was the rationale for many imaging groups to use axial
mode for brain imaging long after body imagers had switched to helical scanning. Most sites have
now switched to helical for all imaging because of the high quality of those reconstructions, and,
with narrow detector collimation scanning, this artifact has become much less evident.
This ring artifact may seem pretty straightforward on axial scans, but, like motion artifacts, it will
be more challenging to recognize when it appears on reconstructions (Figure 5A.5.4 A, B).
Figure 5A.5.2 On this image from a helical brain scan, notice the radiating lines of white and black at the top of the skull. This is an
artifact of reconstruction of data acquired in helical mode.
132 CT IMAGING
Figure 5A.5.3 This dry skull was imaged with both axial (left ) and helical technique (right ) using a 64-bit detector scanner, thin
detector collimation, and low pitch. There is really no difference in these two images, and so one would expect in practice that there
would be no visible degradation of head scanning when choosing to use and thin detector collimation instead of axial.
Image provided by Rihan Khan, Department of Radiology, University of Arizona, Tucson, Arizona.
(A) (B)
Figure 5.5.4 There is little difficulty recognizing this ring artifact on the axial thoracic spine exam (A). On reconstruction of those
slices into the coronal plane, however, it has a much less familiar “corduroy” or “zipper” appearance because the artifact visible on
multiple axial images is now stacked (B).
Correct answer: 3
Artifact 6
This 50-year-old patient on Coumadin presented with persistent headaches for 3 weeks after being
struck in the head with a baseball while watching his son play. You see something on the patient’s
CT scan (Figures 5A.6.1–6.2 arrows) and wonder if this represents:
(1) a chronic subdural hemorrhage.
(2) a beam hardening artifact.
(3) an empyema in the subdural space.
(4) an old infarct.
Figure 5A.6.1 Coumadin-treated patient after minor head trauma.
Figure 5A.6.2 Same patient as in Figure 5A.6.1.

134 CT IMAGING
The low-attenuation zone along the skull in this case is an artifact due to beam hardening. That
term, mistakenly used by some to explain almost every streak or artifact on a CT scan, should
be reserved for artifactual low attenuation that is the result of the disproportionate loss of the
low-energy X-rays as the beam traverses the body. In that same vein, you should drop from your list
of CT terminology the expression “streak artifact” since that indicates nothing about the cause of
the artifact and is merely a description of its appearance on the images. This would be akin to calling
the signal loss caused by blood on gradient echo MR images a “dark artifact” instead of a “suscepti-
bility artifact,” or high signal in the vessels from an entry slice effect on MR a “bright artifact.”
To understand the concept of beam hardening on CT you will need to recognize at the start that
the X-ray beam is composed of a spectrum of energies and does not contain X-rays of a single energy
level. While one might say that a particular CT scan was made using an X-ray beam of kV 120, but
this value only indicates the peak voltage applied to the tube (and, therefore, peak X-ray energy). The
average energy among the many individual X-rays contained within the X-ray beam created using
that electrical voltage will be approximately 50 keV (thousand electron volts) and that is less than
half of the energy of the highest energy X-rays in the beam (120 keV).
The number of X-rays that make it to the detectors should directly reflect the attenuation of the
intervening tissues between them and the X-ray source; but this would only be true if the X-ray beam
were composed of photons at a single energy level. Since the beam is composed of a range of energies,
and the lowest energy X-rays are easily lost due to scatter and absorption, the average energy of the
beam in fact increases as it traverses tissues. The high energy X-rays will disproportionately make it
to the detectors, but the detectors do not discriminate their energy, only their numbers. Since there
are more X-rays arriving than there really should be based on the thickness of tissues traversed, how-
ever, the image reconstruction algorithm must assign a lower attenuation to the intervening tissues
to account for all these unexpected X-rays. For example, in depressions along the skull where most if
not all the low-energy X-rays are lost in the cortical bone the reconstruction assigns very low atten-
uation values to the other tissues along that path to account for the fact that so many X-rays (albeit
the high-energy ones) made it to the detectors.
The effects of beam hardening may be more subtle and thereby more problematic in some other
circumstances. For example, if you measure the attenuation of the cerebrospinal fluid (CSF) in an
empty sella, you may fi nd that it has an unanticipatedly low attenuation—less than water. It can even
have a calculated attenuation that is very similar to fat, i.e. in the range of -70 HU. That is because
the surrounding bone around the sella causes significant beam hardening, which leads the scan
reconstruction to calculate an artifactually low attenuation value for the CSF there since so many
high energy X-rays still make it through to the detectors.
This effect does not require bone for beam hardening and can be evident even in broad expanses
of homogeneous tissues, like the liver, or within any fluid collection. That is why this is also called
a “cupping” artifact because the center portion of the homogenous fluid will appear to have lower
attenuation than its periphery. This effect can be corrected to some degree on CT scanners using
correction factors in the reconstruction software, but it is still commonplace on head scans in the
pons (Figure 5A.6.3) and occipital lobes (Figure 5A.6.4).
Figure 5A.6.3 On this image, note the band of low attenuation that extends across the pons at the level of the petrous bones. This
represents another manifestation of beam hardening, here due to the dense petrous bones.
136 CT IMAGING
Figure 5A.6.4 This image through the occipital lobes demonstrates artifactual low attenuation (arrows) in the cortex of those
lobes, resembling infarcts. In this case, the beam hardening artifact is due to the thicker bone evident in the posterior skull.
Correct answer: 2
Artifact 7
This 18-year-old was shot in the head 10 days ago. Surrounding the bullet are several areas of very
low attenuation that measure -700 HU in calculated attenuation. These dark areas represent:
(1) pneumocephalus from the penetrating injury.
(2) beam hardening.
(3) photon starvation.
(4) helical reconstruction artifacts.
Figure 5A.7.1 Gunshot injury to brain.

138 CT IMAGING
(A) (B)
Figure 5A.7.2 This pair of images comes from a dual-energy, dual-source CT angiogram (CTA) of the brain of a patient who had
previously had an aneurysm treated surgically with a cobalt alloy clip. The image reconstructed from the kV 80 tube detectors (A) has
a larger artifact arising from the clip than does the corresponding image from the kV 140 tube (B). This is because the lower mean
energy X-rays from the tube set to 80 kVp are more easily attenuated by the metal in the clip than are the X-rays arising from the tube
set to 140 kVp. As a result, less information is available for reconstruction at the lower tube energy and therefore larger artifacts are
generated on the images. This explains why 140 kVp is preferred for imaging when metals that are lower than lead in the periodic
table, like titanium, are present.
Figure 5A.6.1 is an illustration of the artifactual low attenuation on CT scans that occurs due to
beam hardening. In Figure 5A.7.1, however, the lead in this bullet does not simply alter the composition
of X-ray beam energy—it blocks nearly all of the X-rays from making it through to the detectors. This
property of lead is, of course, why it is used to shield rooms from emerging X-rays within the radiology
department. Since there is insufficient data for the reconstruction algorithm to provide accurate values
near the bullet, these white and black lines appear as the result of faulty data. This artifact can also
be called metal artifact, but “photon starvation” or shadowing better captures the basis of the artifact
(Figure 5A.7.2A,B). Photon starvation is the reason why CTA cannot be used to follow patients with
coiled aneurysms. Since the platinum used in all these coils has an atomic number similar to lead, it cre-
ates X-ray shadowing that is difficult to correct with hardware or software solutions.
This problem can be mitigated with both scanner technique adjustments as well as reconstruction
software solutions. Higher energy X-rays are more likely to traverse those metals with relatively low
atomic numbers, such as aluminum and titanium. For example, by using kVp 140 instead of 120,
you should fi nd that CT angiography (CTA) will provide adequate imaging of the cerebral vascula-
ture in the region of titanium aneurysm clips (Figure 5A.7.3 A–C).
Most manufacturers offer reconstruction techniques that can reduce metal artifacts, and iterative
reconstruction offers some promise for metal artifact suppression as well. Preliminary results also
suggest that by using a dual-energy scanner and special software, a virtual-high-energy X-ray image
can be created that in early testing shows a substantial reduction in metal artifact.
(A) (C)
(B)
Figure 5A.7.3 Notice how the photon starvation artifacts become increasingly apparent on CT scans in these three patients with a
titanium clip (A), a cobalt alloy clip (B), and platinum coils in an aneurysm (C).
Correct answer: 3
140 CT IMAGING
Artifact 8
Vertical dark stripes are evident that are overlying the cerebellum in this patient (Figure 5A.8.1).
These are due to:
(1) motion in the phase encoding direction.
(2) dental amalgam.
(3) beam hardening artifact.
Figure 5A.8.1 Posterior fossa artifact.

(A) (B)
Figure 5A.8.2 In this nonangled axial scan (A) of a patient who has a bullet in the brain, it is simple to recognize the very prominent
artifact arising from X-ray shadowing from the lead bullet. When the scan data is then reconstructed and displayed at the traditional
CT angle (B), however, the artifacts now project onto a different slice where its origin is not evident.
Tilting the gantry of the CT scanner relative to the patient, a routine practice at one time, is not
allowed on many multidetector scanners when operating in helical mode, all wide array multidetec-
tor scanners, and most dual-source scanners. But CT images of the brain have traditionally been
both collected and then displayed at an angle relative to the patient table (see Artifact 9 that fol-
lows). In order to present the images in a familiar way, the non-angled data are reconstructed at the
traditional angle. There is some logic to this since most imagers expect to see the anatomy that way,
and it facilitates comparison with other CT scans. But this post-processing angulation can create
new problems because the plane of reconstruction is now disassociated from the image acquisition
plane. In addition, considerable metal artifacts now can be seen routinely overly the cerebellum in
patients with dental hardware that would otherwise be excluded from the scan if it were generated
at the usual angulation.
Using this approach, it is routine to see CT image with artifacts that appear distant from their
source and, if the source images are not offered as well, it may be hard to recognize the artifacts as
such (Figure 5A.8.2 A,B, Figure 5A.8.3 A,B).
Other commonplace artifacts, such as the beam hardening that occurs between the petrous bones
that ordinarily would be recognized as such, can take on an ominous appearance on reconstructions
(Figure 5A.8.4 A,B).
So, although reconstructions are essential to the proper interpretation of CT scans, be sure to
review any abnormalities in the plane of acquisition (Figure 5A.8.5 A,B).
142 CT IMAGING
(A)
(B)
Figure 5A.8.3 These axial scans (A) were reconstructed at the traditional CT angle (arrows, B), but the scan was performed without
any angle as indicated by the four lines at the bottom of image (B).
(A)
(B)
Figure 5A.8.4 This axial CT demonstrates the low beam hardening attenuation between the temporal bones (A, arrows) sometimes
called the “Hounsfield artifact,” although it is really not his fault. When those axial images are then reconstructed into the sagittal
plane (B, arrow ) the same artifact now resembles an area of encephalomalacia in the pons.
144 CT IMAGING
(A)
(B)
Figure 5A.8.5 This patient was scanned with no angle (A) and there is a very prominent metal artifact, this time from a coil mass in
a basilar tip aneurysm. But the photon starvation artifacts due to the platinum in the coils can appear in an unexpected location when
the scan is reconstructed into the traditional angle of display (B).
Correct answer: 2
Artifact 9
This 81-year-old male presents with the history “rule out infarct,” and you see abnormal low attenu-
ation in the right frontal lobe white matter (Figure 5A.9.1). You are uncertain whether this indicates
a new infarct or an old one since there is no apparent mass effect. You see that he has an MRI from
1 year ago, and, on review of those images, fi nd a similar lesion but in what appears to be a more
posterior location (Figure 5A.9.2).
You decide that:
(1) they are different lesions, and he has a new infarct.
(2) you are not sure and recommend an MRI with diffusion.
(3) you are quite sure they are the same lesion.
Figure 5A.9.1 CT with right frontal abnormality.
Figure 5A.9.2 Magnetic resonance image of the same patient in Figure 5A.9.1.
146 CT IMAGING
From the very beginning, axial MR images of the brain were acquired perpendicular to the long
axis of the table, whereas CT images were angled along the line from the lateral canthus of the eye
to the external auditory canal. These conventions in fact reflect the respective limitations of early
hardware. Even though MR images can now be acquired at any angle by manipulating the gradients,
on early scanners only direct axial scans were available. Computed tomography predates MRI, and
those early brain scans were always angled to the table to reduce the number of slices needed to cover
the brain. You can appreciate that this was an important consideration when each slice took 5 min-
utes to acquire. As scanners got faster, the practice of angulation was continued since there is also a
substantial reduction of lens dose whenever the eyes can be excluded from the scan.
This difference in the angle of the slices relative to the brain between CT and MRI of the brain
often resulted in a visual mismatch when comparing the two. Although this makes little difference
when viewing central structures like the pineal or third ventricle, it can make a substantial difference
when peripheral brain structures like the central sulcus. For example, it is very common to encounter
reports in which one reader describes the location of a lesion on MRI as being in the parietal lobe
while another reader describes the very same lesion as being in the frontal lobe on a CT scan due to
differences in the angulation of the scans. Some authors have suggested changing the angle of MR
scans to match CT, but the question has come full circle as large-detector CT scanners can no longer
provide any angle during scan acquisition.
Correct answer: 3
6 NEURO CT PITFALLS
Defi nition: Pitfall, a unsuspected difficulty or a covered pit in the ground used as a trap.
148 CT IMAGING
Pitfall 1
This 44-year-old male, who was hospitalized for extensive head trauma, had this scan on arrival
to the ER after transfer from an outside hospital. You think the abnormal low attenuation on these
images (Figures 6P.1.1 and 6P.1.2) reflects:
(1) air in the subarachnoid space that usually indicates a fracture through one of the paranasal
sinuses or mastoid air cells.
(2) venous air that refluxed from an IV line.
(3) fat emboli from a long-bone fracture.
(4) air in the arteries overlying the brain.
Figure 6P.1.1 CT of a patient with extensive head trauma. Figure 6P.1.2 Same patient as in Figure 6P.1.1.
Neuro CT Pitfalls 149
This is a relatively common scenario when reading trauma computed tomography (CT) images,
and a thoughtful approach will allow you to make the correct choice between these possibilities.
First, establish that it is indeed air. You should be able to confirm that by looking at it on the bone
window image. If it is air, it will stay black at all window and level settings. In any event, the low-
attenuation fi ndings in this case are too large to represent fat emboli. The fat in that disease is very
difficult to visualize on CT and, in most cases, the diagnosis is established by the finding of multiple
infarcts of the same age in a patient with a bone fracture (Figure 6P.1.3).
Air in the arterial system (Figure 6P.1.4) is very rare and is nearly always seen in patients with a
misplaced central line or, even rarer, an esophageal-atrial fistula in the heart. In Figure 6P.1.4, you
can see how the contours and size of the air collections in that disorder differ from that of air in the
subarachnoid space (Figures 6P.1.1 and 6P.1.5). Since the air is intravascular, it is constrained into
curvilinear shapes within the arteries, compared with air in the subarachnoid space that forms large,
rounded bubbles.
Although air in the intracranial arteries is a medical emergency, air in the veins is routinely seen
on CT and especially so in the setting of trauma. It is nearly always the result of reflux of air that
was unintentionally injected along with the IV fluid at the start of an infusion (Figures 6P.1.6 A,B).
Injection of venous air is commonplace, clears quickly, and will cause no symptoms in small vol-
umes. This fi nding is particularly common in patients who require resuscitation since the volume
of IV fluid and the urgency of their delivery increases the likelihood of the inadvertent injection of
venous air.
150 CT IMAGING
Figure 6P.1.3 This magnetic resonance (MR) scan demonstrates

innumerable infarcts in both hemispheres as a result of fat emboli to
the brain.
Figure 6P.1.4 This axial CT scan shows intra-arterial air from a

mis-placed central line. Note that the air contour is linear, not round
bubbles, even though it appears at first glance to lie within the suba-
rachnoid space (arrow ).
(A) (B)
Figure 6P.1.5 This young athlete was struck in the right eye with a javelin while marking the other athlete’s throws at a track meet. He
retained full vision but complained of severe headaches. His CT scan demonstrated extensive pneumocephalus (A, arrows). Bone win-
dows show fractures along the trajectory of the javelin (B, long arrow ). The pneumocephalus in this case is due to the fracture in the
back wall of the sphenoid sinus, allowing air from the sinus to enter the subarachnoid space through a tear in the dura (B, short arrow ).
(A) (B)
Figure 6P.1.6 This axial CT (A, arrows) shows air in the epidural veins along the anterior spinal canal, as well as in multiple veins in
the neck, that was injected at the time of IV placement. This axial CT scan (B, arrow ) shows a small amount of intracranial air within
the straight sinus for the same reason. Do not mistake this iatrogenic air for pneumocephalus that accompanies a fracture of the skull
base or penetrating injury in the setting of trauma.
Correct answer: 1
152 CT IMAGING
Pitfall 2
This 80-year-old female presented to the emergency room with transient left arm and leg weakness.
A CT scan of the head was obtained to determine whether this was the result of an infarct or hemor-
rhage (Figure 6P.2.1). You see an area of low attenuation that does not resemble cerebrospinal fluid
(CSF, arrow) and decide this is most likely:
(1) an artifact of volume averaging.
(2) an acute infarct.
(3) an old infarct.
(4) a brain tumor because the cortex is normal.
Figure 6P.2.1 Head CT, rule out infarct.

Volume averaging (see Artifact 1) is commonplace on CT scans because the attenuation of an

entire voxel must be represented by a single value of the corresponding pixel. In this patient, who
has wide CSF spaces due to age-related brain atrophy, the low attenuation of CSF in a sulcus is
blended with the higher attenuation of brain giving a number of voxels an attenuation that is half-
way between both.
This common pitfall can usually be discounted with greater confidence by looking carefully at
reconstructions made from thin-section data or simply reviewing those thin sections since the smaller
voxel size on thin slices offers much less volume averaging (Figure 6P.2.2).
Figure 6P.2.2 This coronal image was reconstructed from the thin
data used to create the CT scan seen in Figure 6P.2.1. It shows
a wide sulcus on the patient’s right that corresponds to the low
attenuation evident on the axial view. In this patient there was no
infarct, only volume averaging of normal brain with the low attenua-
tion CSF in a wide sulcus.
Correct answer: 1
154 CT IMAGING
Pitfall 3
This 25-year-old female presented with the complaint of new headaches and vision change. Do you
see an abnormality on these images from her CT scan (Figure 6P3.1 A–C)?
(1) Yes, they show a small subdural hematoma.
(2) No, they are normal.
(3) Yes, the patient has a sellar mass.
(A) (B) (C)
Figure 6P.3.1 A–C: CT scan of 25-year-old female patient.

If you made the diagnosis, did you see it the fi rst time through the images? Correctly identifying
sellar or skull base masses on CT can be quite difficult because the anatomy is presented in the plane
of the skull base, and abnormalities are, in almost all cases, easier to recognize in the planes perpen-
dicular i.e. coronal or sagittal planes (Figure 6P.3.2 A,B).
Another common problem encountered with axial imaging is illustrated in this case of a Chiari
I malformation (Figure 6P.3.3 A,B). The sagittal reconstructions are usually necessary to establish
that diagnosis from CT since the appearance of the cerebellar tonsils, with respect to the fora-
men magnum, is strongly influenced by the angle of scan acquisition. Figure 6P.3.4 A,B illustrates
another skull base abnormality that can be easily overlooked.
(A) (B)
Figures 6P.3.2 The coronal view (A) was generated from the same data as the axials in Figure 6P.3.1. It shows a sellar mass
impinging on the optic chiasm that was better demonstrated on her coronal MR scan with contrast (B). The findings are consistent
with a pituitary macroadenoma.
156 CT IMAGING
(A) (B)
Figures 6P.3.3 This axial scan (A) shows effacement of the cerebrospinal fluid (CSF) at the level of the foramen magnum. This find-
ing, however, is not sufficient to make the diagnosis of either a Chiari I malformation or intracranial hypotension because this finding
can also be evident in normal patients whenever the images are generated at a steep angle. The sagittal midline reconstruction (B) of
the thin section data, however, shows the cerebellar tonsils extending well below the foramen magnum.
(A) (B)
Figure 6P.3.4 This axial scan (A) of a patient with a history of nasal mass shows abnormal remodeling of bone in the region of the
ethmoid sinus and superior nasal cavity. On the coronal MR scan (B) the inferior frontal lobes of the brain are visible below the skull
base; this appearance is most consistent with a fronto-ethmoidal encephalocele.
Correct answer: 3
Pitfall 4
This 25-year-old presented to the emergency room after falling off his bike. He had no loss of con-
sciousness, no visible soft-tissue abnormality, and he was neurologically normal. His head CT scan,
however, was abnormal (Figure 6P.4.1). The high-attenuation abnormality in his right posterior
temporal lobe most likely represents:
(1) a shear hemorrhage.
(2) a cavernoma.
(3) volume averaging with the temporal bone.
Figure 6P.4.1 Axial CT section with right posterior temporal lobe

abnormality.
158 CT IMAGING
Since CT images are simply the representation of X-ray attenuation, there is frequently some ambigu-
ity about the nature of lesions since their appearance is rarely characteristic. In many circumstances, like
this one, it can be quite difficult to distinguish hemorrhage from calcification, for example.
In the setting of trauma, there it is hard to resist calling all lesions that have high attenuation on
CT hemorrhage. In this case, however, the benign history suggested that this fi nding may not be
acute hemorrhage at all. A magnetic resonance imaging (MR) scan was ordered for that reason, and
it demonstrated the typical imaging fi ndings of a cavernoma (Figure 6P.4.2 A,B).
Although multiple cavernomas are certainly not uncommon, it is unusual to fi nd a single shear
hemorrhage in MRI after trauma (Figure 6P.4.3 A,B). See also Figure 6P.4.4 A–D.
(A) (B)
Figures 6P.4.2 A, B The MR 15 degree flip angle gradient echo image (A) at the same level as Figure 6P.4.1 demonstrates the
same lesion now with “blooming” that can be seen with both acute and chronic hemorrhages. The MR T2 weighted image (B), how-
ever, shows a complete low-signal ring that is characteristic of a cavernoma.
(A) (B)
Figure 6P.4.3 A,B This axial CT (A) of a patient after significant head trauma shows multiple hemorrhages at the gray–white inter-
face, in addition to a subarachnoid hemorrhage in the sylvian fissure (arrow ) and intraventricular hemorrhage. Note how there more
hemorrhages are evident on the shallow flip angle gradient echo MR scan (B), such as one in the left midbrain (arrow ), that was not as
apparent on the CT.
160 CT IMAGING
(A) (B)
(C) (D)
Figures 6P.4.4 In this case of trauma, the high-attenuation lesion on the patient’s left (A, arrow ) resembles subarachnoid hemor-
rhage in the sylvian fissure. Reconstructions of the axial thin section data indicate that it is in fact parenchymal (B, arrow ). MR scan
was also obtained in this case and was very helpful for establishing the diagnosis of a brain cavernoma (C, short arrows) masquerad-
ing as a traumatic hemorrhage. The MR also demonstrates an enhancing vessel nearby that is most consistent with a developmental
venous anomaly (C, arrowhead and D, arrowheads ). These commonly accompany cavernomas.
Correct answer: 2, but 1 is a reasonable choice with the available imaging.

Pitfall 5
One day after her lumbar myelogram this 50-year-old woman presented to the emergency room with
the worst headache of her life. On the basis of her symptoms, a CT scan of the brain was obtained.
Based on these images (Figures 6P.5.1, 6P.5.2), you think her CT scan:
(1) is normal.
(2) is diffusely abnormal and shows subarachnoid hemorrhage.
(3) is abnormal, but you wonder if this might reflect contrast from her myelogram.
Figures 6P.5.1 CT of a fifty-year-old woman complaining Figure 6P.5.2 Same patient as in Figure 6P.5.1.
of severe headache after a recent lumbar myelogram.
162 CT IMAGING
Figure 6P.5.3 This axial CT scan at the level of the third ventricle
in a different patient shows high attenuation material within the third
ventricle (arrow ) consistent with intraventricular hemorrhage.
This is an easy pitfall to drop into. Based on the history, you should be looking for subarachnoid
hemorrhage, so when her CT shows high attenuation in the subarachnoid space, you should be
thinking of a ruptured aneurysm. However, severe headaches are not at all uncommon after any
myelogram, and it is expected that the intrathecal contrast from the myelogram will move to the
subarachnoid space over the hemispheres since that is the normal flow pattern of CSF. The only thing
unexpected about this case is that she was imaged at all. Chances are that if you scanned everyone
after myelograms, most would look just like this patient.
So, how can one be sure that this is not blood or contrast and blood mixed? One important fi nding
to look for is hydrocephalus. Very often, after subarachnoid hemorrhage, the ventricles will enlarge
as a result of impaired transport of CSF across the arachnoid granulations, resulting in a communi-
cating hydrocephalus. It is also helpful to look into the ventricles (Figure 6P.5.3) for blood since it is
very unlikely that myelographic contrast would reflux back into the ventricles.
What may prove to be the most powerful way to distinguish contrast from hemorrhage in the
brain the use of dual-energy scanning and virtual noncontrast image processing. This technique
provides an image that effectively removes the high attenuation iodine, based on its respective
attenuation values at the two energies, from the image. If the subarachnoid space still appears
dense on a virtual non-contrast scan, it means that the high attenuation is due to hemorrhage
(Figure 6P.5.4 A–C). In another case, with high attenuation of the brain parenchyma as well as
subarachnoid space, the virtual noncontrast image demonstrated that it was all contrast staining
(Figure 6P.5.5 A–C).
(Case 6P.5 was provided by Bryan Pukenas MD, Department of Radiology, Division of
Neuroradiology, Hospital of the University of Pennsylvania, Philadelphia.)
(A) (B)
(C)
Figures 6P.5.4 In this patient with a diffuse subarachnoid hemorrhage, note the dilated temporal horns of the ventricles (A) due to
an acute communicating hydrocephalus. The patient had a CT angiogram (CTA) (B) on a dual-energy scanner and, on this bone-
removed image, the vessels appear of high attenuation since they are filled with contrast. Ordinarily, it is impossible to be confident
about whether there is also a small amount of underlying subarachnoid blood on CTA images. But on a “virtual noncontrast” image
that can be generated from the same dual-energy data used for the CTA (C), once the contrast-filled vessels have been removed, the
remaining high attenuation in the cisterns from blood becomes evident.
164 CT IMAGING
(A) (B)
(C)
Figures 6P.5.5 This image from a cerebral angiogram shows a distal internal carotid artery and proximal left middle cerebral artery
near occlusion (A, arrow ). Intra-arterial thrombolysis was performed, and the post-procedure CT demonstrated extensive high atten-
uation in the cortex of the brain, as well as in the subarachnoid space around the midbrain (B, arrows). At this point, there would be
some uncertainty whether the high attenuation on this CT all represents contrast from the procedure or if there is also hemorrhage in
the subarachnoid space. Since the scan was performed on a dual-energy scanner, in anticipation of this common dilemma, a virtual
noncontrast image (C) was created. Since the software “removes” those voxels that behave like iodine and the cisterns appear normal,
one can conclude from this image that the high attenuation visible on the postprocedure image (B) was due to contrast staining the
cortex and then weeping into the subarachnoid space.
Correct answer: 3
Pitfall 6
On the night of the homecoming football game, this 17-year-old player from the visiting team was
brought to the emergency room after he lost consciousness after a hard tackle during the game. By
the time he arrived in the emergency room, he had some short-term memory difficulties and head-
ache but was otherwise recovered and wanted to go back home with his team.
The scan was quickly reviewed in a brain and bone window setting and called normal (Figure 6P.6.1).
He was discharged into the care of his parents, who by then had arrived at the emergency room. On
the way home, however, he felt ill and his parents took him to another emergency room, where they
found a subdural hemorrhage on CT.
The subdural:
(1) very likely was there but missed on the fi rst CT scan.
(2) must have appeared after he left your emergency room.
Figure 6P.6.1 CT scan of patient following a head injury.

166 CT IMAGING
It is essential to review all trauma scans in at least three windows if you want to avoid being
involved in cases like this one. Small subdural hemorrhages tucked along the inner table of the skull
may be inapparent the reader if they are using just two window settings. That is because subdurals
match the contour of the inner table of the skull and, since they are of high attenuation, can merge
visually with the skull when the viewing settings are set to optimize either brain or bone. If your
usual window setting for the brain is about 100—and it is for most readers—you should double that
when you look for blood in the extra-axial space.
Window and level settings may have a powerful impact on our perception of contrast when view-
ing CT scans. The reconstructed images ideally should be normalized so that water has an attenua-
tion of 0 HU, air -1,000, and bone about +1,000. To accurately display all those attenuation values
on a single image, however, would require 2,000 shades of gray. Even if one could build a monitor
that could display that range, the human eye can only perceive about 20 shades of gray. As a result,
the imager must choose to display only a portion of all the possible range of values, and the way that
is done will always represents a compromise between showing a wide range of approximate attenu-
ation values or displaying a narrow part of the total range but with higher sensitivity. Effective use
of the latter approach has risks, however, since all attenuation values above or below that range will
appear completely white or black, respectively.
In this particular case, the first image, Figure 6P.6.1, was reconstructed with a soft kernel to pro-
vide low apparent noise in the brain. That reconstruction was presented with typical brain settings,
specifically a window of 80 HU and a level of 35 HU. Those values mean that the center value was
about the attenuation of brain, 35 HU, and only those attenuation values in a narrow range of 40
HU above and 40 HU below the center level of 35HU (-5HU to 75HU) would be assigned a shade
of gray other than plain white or black.
Fresh hemorrhage should be expected to have an attenuation of about 75–85 HU. Since every-
thing with attenuation of 75 HU and higher will be displayed as just white on the image, a subdural
hemorrhage and the skull (500 HU or greater) can appear exactly the same; white. But when that
same image is viewed using a wider window of 200 HU instead of 80 HU, an acute hemorrhage can
now be seen because the blood has been assigned a different value for gray than the adjacent skull
(Figure 6P.6.2, 6P.6.3).
Your choice of window and level for viewing any CT scan are always a compromise. For example,
if you are looking for an early infarct in the brain, it is best to choose a very narrow window, about
40 HU, and a level of about 40 HU. The use of those values will allow imaging of only those tissues
with a range of attenuation values of 20–60 HU (Figure 6P.6.4). Although this is considered the best
way to exaggerate image contrast in the brain to see early infarcts, all attenuation values above and
below are either black or white. This means that skull lesions will be obscured and, as in the previous
case, hemorrhage near bone will be unapparent.
Beyond detection, very useful information can often be uncovered simply by taking some time to
use multiple windows and levels to view CT images (Figures 6P.6.5 A,B and 6P.6.6).
So, viewing the brain CT scan at multiple window and level settings is helpful for both detection
and characterization of abnormalities. It is also helpful to use coronal reconstructions viewed with
several window and level settings to fi nd small subdurals (Figure 6P.6.7 A,B), particularly along the
tentorium.
Figure 6P.6.2 This is the same image as 6P.6.1, only now

displayed with a wider window and higher level. Now the blood
(arrows) in the subdural space is visible in contrast to the higher
attenuation bone of the skull.
(a)
−1000 0 40 80 1000
Black Window 80 White

Level 40
(b)
−1000 0 20 40 60 80 1000
Black Window 40 White

Level 40
Figure 6P.6.3 This illustration shows graphically how the range of CT attenuation values is assigned, marking the center value on
the scale 0, as the attenuation of water. Since the viewer cannot perceive, and monitors cannot display, 2,000 shades of gray a deci-
sion must be made about how to display of the information. The upper scale (A) indicates one typical brain view setting of level 40 HU
with a window of 80 HU. But, if the same image is displayed as shown in the lower scale (B) using a narrower window setting of only
40 instead of 80, it will have the same number of shades of gray but they will now distributed over a much smaller range of attenua-
tion values. This would be ideal for demonstrating subtle difference is attenuation of the brain and is preferred for detection of early
infarcts.
168 CT IMAGING
Figure 6P.6.4 This patient has a right hemispheric infarct with swelling.
This image was made using a narrow window and a level of 34 HU in order to
maximize image contrast within the brain tissue. Note that the skull appears
featureless, and the fat (-70 HU), cerebrospinal fluid (0 HU), and air (-1,000
HU) all look exactly the same (i.e., black) because those values all fall outside
of the display window using a level of 34HU.
(A) (B)
Figure 6P.6.5 On this pair of images through the same level of the brain it appears that there is bone covering the right brain
(A, arrows), but when the same image is viewed using a much wider window (B), it appears that the right side of the skull consists
of something other than bone. This patient had a prior craniectomy that was closed with an acrylic flap instead of the patient’s native
skull. In some cases, air may be trapped within the cranioplasty flap when polymethylmethacrylate is used in this circumstance.
That air will remain locked in the flap indefinitely and can be mistaken by the unaware for osteomyelitis with a gas-forming organism
(see Figure 6P.6.6, arrows).
Figure 6P.6.6 This coronal reconstruction shows that the

right- sided cranioplasty is filled with small bubbles of air. These
were trapped in the polymethylmethacrylate cranioplasty during its
formation.
(A) (B)
Figure 6P.6.7 The axial CT scan (A) shows mild asymmetry of the tentorium that could be overlooked. But, on the coronal scan
(B), there is clearly a band of high attenuation along the right tentorium (arrow ), consistent with a small subdural hemorrhage in this
trauma patient.
Correct answer: 1
170 CT IMAGING
Pitfall 7
This 39-year-old male presented with facial swelling in the left cheek 10 days after his girlfriend
struck him in the face with a comb. His CT scan (Figures 6P.7.1–6P.7.2) demonstrates:
(1) air in the soft tissues (arrow, 6P.7.2) from the prior penetrating injury.
(2) air in soft tissues from active infection with a gas-forming organism.
(3) the comb fragment.
Figure 6P.7.1 History of facial swelling after trauma.
Figure 6P.7.2 On this slice adjacent to Figure 6P.7.1

note the sharply marginated very low attenuation structure
(arrow). It resembles air on this window and level.
This case is a reminder that you should not assume that all things that appear black on CT are
air. The sharply defi ned margins in of the air-like density in this case suggests that it represents
something structural of low attenuation such as plastic or wood. It is easy to check the bone win-
dow in that location since air should remain black and featureless at all window and level settings
(Figure 6P.7.3).
The lesion in this case proved to be a fragment of plastic comb that broke off in the patient’s cheek.
This is a common problem on imaging and viewing images at multiple windows will help you to
avoid calling everything that appears dark air (Figure 6P.7.4 A,B).
The distinction between fat and air proves to be a commonplace question in the cavernous sinus
since both can appear there (Figure 6P.7.5 A,B).
Although plastics will usually have an attenuation intermediate between air and brain, wood may
not. This is particularly troublesome in the setting of penetrating injury (Figure 6P.7.6 A,B). In such
cases, the diagnosis of retained wood can be established by its configuration (e.g., sharp corners, and
visualization internal structure on careful windowing e.g. growth rings or grain, but this requires a
reasonable degree of suspicion.
Like Gelfoam, the appearance of wood varies depending on its hydration. For example, the dry
wood used for lumber or fi rewood will have a much lower attenuation, closer to that of air, than
freshly cut wood or a twig broken from a live tree.
Figure 6P.7.3 On the bone window image, however,

the structure has intermediate signal.
172 CT IMAGING
(A) (B)
Figures 6P.7.4 The axial soft-tissue window image (A) shows a rounded area of low attenuation deep to a craniotomy. This same
region on bone window (B) reveals that this area has internal structure and intermediate attenuation (i.e., it does not remain black).
This is the typical appearance of Gelfoam, and its attenuation represents a mix of its components of fluid (0 HU), blood (80 HU), and
trapped air (-1,000 HU). For this reason, the appearance of Gelfoam can be variable and change over time as fluid replaces the small
pockets of retained air. On some occasions, Gelfoam can even be mistaken for fat if the three components combine to have a net
attenuation in the range of fat (i.e., -75 HU).
(A) (B)
Figures 6P.7.5 On this axial CT scan slice at the level of the cavernous sinus (A), the low attenuation (arrow ) could reflect either air
or fat since both can be found there. This can be resolved simply by looking at the image in a bone window setting. The bone window
in this case (B) shows that the low attenuation in the cavernous sinus follows the appearance of air also seen in the mastoid air cells
and frontal sinuses, not the subcutaneous fat.
(A) (B)
Figures 6P.7.6 This wood fragment became a lethal projectile during a wood splitting session after penetrating this patient’s brain.
Note how the wood fragment, still in place during this scan, has a rectangular shape (A) that correspond to the appearance of the frag-
ment ex-vivo (B) that would not be expected with retained air.
Correct answer: 3
174 CT IMAGING
Pitfall 8
This 57-year-old presented to the emergency room with new seizures. Her head CT scan appeared
asymmetric (Figure 6P.8.1), and you wonder if this is due to a right-sided extra-axial mass, isodense
subdural, or atrophy on the left. She has a cochlear implant however, so MRI is not an really an
option. You order a contrast-enhanced scan, but the technologist points out that the patient had
a CT angiogram (CTA) just a week ago (Figure 6P.8.2), and she wonders about the need for an
enhanced scan now. You decide to:
(1) proceed with the contrast CT scan because CTA is not equivalent.
(2) cancel it because the patient received intravenous contrast for her CTA and, if there were a
tumor, it should have been evident.
Figure 6P.8.1 CT scan of patient with new seizures. Figure 6P.8.2 CT angiogram (CTA) of same patient at the
same level as Figure 6P.8.1.
Imaging of the brain parenchyma is not equivalent on CTA and a contrast enhanced brain CT
scan. From the time when the contrast injection begins until the end of a CTA scan, hardly a minute
has elapsed. That is insufficient time for contrast to accumulate within a tumor or in the wall of an
abscess. In fact, it is ideal to wait 5–15 minutes after the intravenous injection of contrast fi nishes to
allow time for the contrast to circulate before imaging. Increasing both the dose of contrast and the
time delay accentuates the conspicuity of enhancing abnormalities on both MR and CT exams of the
brain. This is because the normal brain does not enhance, because of the blood–brain barrier and
for that reason the dynamics of contrast enhancement differ in the brain from body imaging. For
example, delayed imaging of the liver may in many cases obscure the abnormality because the both
the lesion and surrounding normal liver will enhance to the point that they have the same attenua-
tion. On the other hand, with brain imaging lesions that slowly accumulate contrast become more
conspicuous after a short wait or with higher contrast conentration because the blood-brain barrier
limits the effect of contrast on the surrounding normal brain. In this case the short time from injec-
tion to imaging on the CTA did not allow enough time for this strongly enhancing meningioma to
become apparent on CT (Figures 6P.8.3 A,B).
Don’t rely on CTA alone to determine enhancement qualities of a tumor and, whenever possible,
use a time delay to your and the patient’s advantage when performing enhanced CT scans of the
brain (Figure 6P.8.4 A,B and Figure 6P.8.5).
This problem of insufficient time for enhancement can be encountered with routine soft-tissue
neck imaging as well, and particularly so whenever using multidetector scanners. Since the entire
neck can be examined in less than 15 seconds, if the scan begins immediately after the contrast
injection is started, there will usually be insufficient time for the contrast to accumulate in abnormal
tissues. Pathology, such as a malignant lymph node or an abscess wall, will become more apparent
if a delay is built into routine neck CT scans. Otherwise, the time from the start of contrast infusion
to scan completion would be about the same as a CTA (Figure 6P.8.6).
(A) (B)
Figures 6P.8.3 This axial postcontrast image (A) is at the same level as Figure 6P.8.1 and demonstrates homogeneous enhance-
ment of this meningioma (arrows) that was can be seen to faintly enhance in retrospect on the CT angiogram (CTA) (Figure 6P.8.2).
Coronal reconstruction (B) of the postcontrast scan confirms this tumor’s extra-axial location typical for meningiomas.
176 CT IMAGING
(A) (B)
Figures 6P.8.4 This image from a noncontrast head CT (A) shows a low-attenuation mass in the posterior fossa that was noted
on an MRI from an outside hospital. A CT angiogram (CTA) was obtained to determine its relationship to the vertebral artery; on this
exam, the mass appears to enhance minimally (B, arrows). While the location is appropriate, this enhancement pattern is not at all
typical for a nerve sheath tumor or meningioma.
Figure 6P.8.5 On this enhanced axial T1 weighted image from the outside MR
exam, however, the mass shows strong enhancement and the diagnosis of a
nerve sheath tumor was confirmed at surgery.
So, after all the expense and research to create increasingly faster CT scanners, we have come to
the point at which scan times are at times too fast for human physiology. There are some analogies to
this situation with digital camera technology. For years, photographers paid dearly for cameras and
lenses that would allow photography in low light conditions without the need for a flash; but now,
some camera sensors are so fast that a dark fi lter is necessary over the lens to block out some light
to provide longer shutter times. In some circumstances the blurring that occurs is desirable to show
the effect of motion. In that same way, optimal CT imaging may in some situations require slowing
things down now that scanner times have become so fast.
(A) (B)
(C)
Figure 6P.8.6 A,B, C This axial image from an enhanced neck exam was (A) was obtained immediately after the start of the contrast
injection. Note that the arteries are enhanced but the soft tissues of the neck all have approximately the same attenuation. On this
second image at the same level (B) but from a scan performed immediately after the first you can see contrast enhancement of the
submandibular glands and lymph nodes. One approach to allow time for contrast enhancement of soft tissues is to use a two-phase
injection. For this scan of a different patient (C) half of the contrast was given in an initial injection, followed by a delay, and then a
slow infusion of the reminder of the contrast at only 1–2 mL/sec. This technique provided enough time for this abscess wall, that
might otherwise be difficult to distinguish from the abscess contents, to be quite evident due to enhancement (arrows)
Correct answer: 1
178 CT IMAGING
Pitfall 9
This 25-year-old male presented with headache and dizziness.

You think the low attenuation lesion on the patient’s right side of the brain (arrow) is most likely:
(1) a cerebellar infarct.
(2) an occipital lobe infarct.
(3) an arachnoid granulation.
Figure 6P.9.1 Cerebellar low attenuation finding on CT. Figure 6P.9.2 Coronal reconstruction from same patient seen in
Figure 6P.9.1.
This case illustrates both how difficult it can be to defi ne anatomy along the tentorium on axial CT
imaging alone and that giant Pacchionian granulations can provide a source of confusion on CT as
well as MR imaging. On the axial images (Figure 6P.9.1), it is not at all clear where the low attention
resides in the brain, relative to the tentorium. The coronal reconstruction (Figure 6P.9.2), along with
the axial exam, shows that it in fact lies within the transverse sinus.
The very low attenuation of the lesion is entirely consistent with a giant arachnoid granulation,
since these lesions may resemble CSF on CT and MRI. A review of the patient’s enhanced MRI
confi rms the diagnosis of giant arachnoid granulation and also shows that there is more than one
(Figure 6P.9.3, arrows).
Another common pitfall in this anatomic region is mistaking the high attenuation of the transverse
sinus for a tentorial subdural hemorrhage. In patients with a blood hematocrit level at the upper lim-
its of normal, the intravascular blood can be quite conspicuous, with attenuation values that may be
nearly twice those of normal brain. Adding to the difficulty of making the correct diagnosis, the left
and right transverse sinuses are often quite asymmetric (Figures 6P.9.4 and 6P.9.5). Coronal imaging
can be very helpful in these cases.
How can one tell be sure when the high attenuation within a dural sinus is due to normal fl owing
blood and not thrombus? This can be a difficult question to answer in pregnant women and ath-
letes, who may have a high hematocrit, and even more so in patients with polycythemia. But, when
a thrombus forms, its attenuation is expected to go up. This is the cause of the hyperdense middle
cerebral artery sign in cases of acute stroke. The same logic applies to thrombus within the veins, but
with venous occlusion asymmetric density is not helpful since both sides can be abnormal. In cases
where venous thrombosis is a consideration, it can be useful to actually measure the attenuation of
the venous structures since the upper limit in normal patients is about 70HU. If there is any question,
and symptoms are appropriate, it would be prudent to go directly to either an MR venogram (MRV)
or a CT venogram (CTV) depending on the circumstances.
Figure 6P.9.3 This axial postcontrast T1 weighted MR image

demonstrates multiple defects within the enhancing right trans-
verse sinus due to giant arachnoid granulations (arrows).
180 CT IMAGING
Figure 6P.9.4 This image could be Figure 6P.9.5 The coronal reconstruction well dem-
misinterpreted as showing a right sided subdural onstrates that high attenuation on the right conforms to
hematoma. the expected shape of the transverse sinus and that the
patient has a left-sided hypoplastic transverse sinus.
Correct answer: 1
Pitfall 10
These three axial images (Figures 6P.10.1–6P.10.3) are from three different patients, all with recent
onset of ataxia.
On the basis of their imaging you think that:
(1) all three had cerebellar infarcts.
(2) none of them had a cerebellar infarct.
(3) only the patient shown in 6P.10.1 had a cerebellar infarct.
(4) only the patient shown in 6P.10.3 had a cerebellar infarct.
Figure 6P.10.1 CT of patient presenting Figure 6P.10.2 A second patient with Figure 6P.10.3 A third patient with focal
with ataxia. focal low attenuation in the cerebellum. low attenuation in the cerebellum.
182 CT IMAGING
Distinguishing an infarct from a wide sulcus in the brain is a common problem on CT imaging, and
your best chance of getting it right is to first recognize the limits of axial imaging. Older patients who are
at risk for brain infarcts frequently have some degree of brain atrophy. If a CT slice happens to include a
wide sulcus, its low attenuation once volume averaged with nearby brain can resemble an infarct.
This is a particularly common problem when imaging the posterior fossa because of the contour of
the horizontal fissure, effects of head tilt, and limited imaging at times due to bone artifacts. If you
scan with sufficiently thin detector collimation, using either helical or axial technique, the multipla-
nar reconstructions will allow you to feel more confident about abnormal posterior fossa fi ndings in
many cases by simply correcting for head tilt. In each of these three cases, the coronal reconstruc-
tions were very helpful (Figure 6P.10.4 A–C).
(A) (B)
(C)
Figures 6P.10.4 These three images are displayed in matching order to the axial images above (Figures 6P.10.1–6P.10.3).
Figure A confirms that the cerebellar lesion evident in Figure 6P.10.1 is an infarct, not a sulcus, seen here coronal plane. The low
attenuation in the right cerebellum in Figure 6P.10.2, however, was due to volume averaging of brain with the prominent sulci and
no abnormality was evident on the coronal reconstruction (B). The low attenuation in the left cerebellum in Figure 6P.10.3 is due to
an asymmetrically wide horizontal fissure better seen on the coronal reconstruction (C).
Early infarcts in the cerebellum are frequently obscured by beam hardening artifacts, but, at
the same time, these same artifacts can look remarkably like an infarct in normal patients (Figure
6P.10.5 A,B). With good scan technique and diligent review of multiplanar imaging, however, your
diagnostic accuracy in the posterior fossa will increase substantially.
(A) (B)
Figures 6P.10.5 The low attenuation in the right cerebellum visible on this axial image at the skull base (A) suggests that the patient
has a cerebellar infarct. However, the coronal reconstruction of the scan data (B) shows that the low-attenuation zone has a nonana-
tomic, linear configuration (arrows) typical for a beam hardening artifact.
Correct answer: 3
184 CT IMAGING
Pitfall 11
This patient presented with left-sided weakness (Figure 6P.11.1). You think the patient has:
(1) a right-sided subdural hemorrhage.
(2) a right-sided brain tumor.
(3) a old left hemispheric infarct.
Figure 6P.11.1 CT scan of a patient with left-sided weakness.

This case illustrates a common problem that may be encountered with unexpected subacute hem-
orrhage in the subdural space. Although acute subdural blood has high attenuation compared with
brain, and chronic subdural blood has lower attenuation than brain (Figure 6P.11.2 A,B), there is an
intermediate phase of blood in which it may have the exact same attenuation as brain. It is easier to
recognize if you have seen it before, and it is helpful to make it a habit of fi nding the cortical ribbon
on every head CT (Figure 6P.11.3).
Another common pitfall encountered in the extra-axial space is mistaking a wide subarachnoid
space for a chronic subdural, or the reverse. Although they can look remarkably similar, careful scru-
tiny of the small cortical veins can be very helpful in distinguishing the two (Figure 6P.11.4 A–D).
This distinction may prove very significant when imaging young children who have mild head
enlargement. It is relatively common to see benign enlargement of the subarachnoid spaces in
this patient group, but this condition must be distinguished from chronic subdural hemorrhages
since the latter suggests the possibility of child abuse if there is no other apparent explanation
(Figure 6P.11.5 A,B). The limitation of CT in this circumstance is that subdural hygromas, chronic
subdurals, and wide subarachnoid spaces can have similar attenuation on CT, unlike on MR FLAIR
imaging where hygromas and wide subarachnoid spaces always suppress with the normal CSF, and
so it is essential to use the cortical veins to identify patients with fi ndings suspicious for subdural
collections and go on to MR whenever further evaluation is necessary.
(A) (B)
Figures 6P.11.2 This pair of images demonstrates the evolution of a subdural hemorrhage from high attenuation (A, arrows) in the
acute phase to low attenuation in the chronic phase 3 weeks later (B, arrows).
186 CT IMAGING
Figure 6P.11.3 This axial CT scan of the same patient seen in

Figure 6P.11.1 shows the wavy cortical ribbon (arrows) that is dis-
placed away from the inner table of the skull by this isodense subdural.
(A) (B)
(C) (D)
Figures 6P.11.4 A,B,C,D All four of these patients have prominent fluid spaces around the frontal lobes of the brain. Look carefully
at A and B, and you will see that the cortical veins course through the fluid space (arrows). This appearance is typical whenever a
patient has wide subarachnoid spaces. Now look at C, and note that the cortical veins are lined up in a row and displaced away from
the inner table. This is even more apparent in D, where the veins are pressed against the brain and into the cortical sulci (arrows).
These latter two patients have traumatic subdural hygromas. These are low attenuation since they are composed of cerebrospinal fluid
(CSF), and are usually due to traumatic tears of the arachnoid allowing CSF to enter the subdural space.
188 CT IMAGING
(A) (B)
Figures 6P.11.5 This axial CT image (A) demonstrates wide, low-attenuation fluid spaces around the brain. While this might
suggest wide subarachnoid spaces at first glance, note the displaced cortical vein adjacent to the brain. This appearance suggests
a chronic subdural collection, not a wide subarachnoid space, and prompted this MR scan (B) that confirmed that the patient had bilat-
eral subdural hygromas. You can more easily see the abnormal position of the cortical veins on this T2 weighted MR scan (arrows).
Correct answer: 1
Pitfall 12
This 40-year-old man presented to the emergency room with aphasia. The request for his scan read
“rule out stroke.”
You think the left-sided fi nding (arrow) represents:
(1) a volume averaging artifact from CSF in a wide left sylvian fissure.
(2) an underlying brain tumor.
(3) an early sign of a left middle cerebral artery (MCA) territory infarct.
Figure 6P.12.1 History: rule out stroke in a patient with aphasia.

190 CT IMAGING
This is a true pitfall at two levels. First, this history frequently sets up the imager for a fall since it
suggests that the diagnosis is evident clinically. Tumors and infarcts may not be distinguished clini-
cally based on a three-word history. And second, there is a lesion that corresponds roughly to the
side of the symptoms and sort of looks like an infarct.
You should consider the possibility of volume averaging with the sylvian fissure (see Pitfall
10), but the subarachnoid spaces are so small elsewhere that it seems unlikely to fully explain
this fi nding. The imaging provided is not at all typical for an infarct because the gray matter is
normal. One would expect that an infarct would preferentially involve the gray matter since it is
metabolically more active that the white matter. This image of another patient with a typical infarct
(Figure 6P.12.2) is provided to illustrate this point.
The fi rst patient (Figure 6P.12.1) went on to have an MR scan the day following the CT. That
exam (Figure 6P.12.3) demonstrated an enhancing lesion corresponding to the white matter location
on CT, which proved to be a primary brain tumor at surgery.
Figure 6P.12.4 was from the CT of another case in which the initial reading of the CT scan
was infarct, but which later proved to represent a metastatic brain tumor (Figure 6P.12.5). Be
attentive to the details of CT imaging, and do not allow an incomplete history to contribute
to misdiagnosing a tumor as an infarct. If you have any doubt, by all means, suggest MR or
enhanced CT.
Figure 6P.12.2 This axial CT scan shows a typical Figure 6P.12.3 This axial postcontrast T1 weighted
wedge-shaped infarct (arrows) with more gray matter MR image of the patient seen in Figure 6P.12.1 shows
than white matter involvement. a left-sided ring-enhancing scan typical for a tumor.
This proved to be an anaplastic glioma.
Figure 6P.12.4 Low attenuation right frontal lobe lesion Figure 6P.12.5 The patient later had an MR scan that dem-
(arrow) in patient with new seizures. Note the sparing onstrated focal enhancement from a metastatic brain tumor.
of the cortex. That is not expected with infarcts, see
Figure 6P.12.2.
Correct answer: 2
192 CT IMAGING
Pitfall 13
This 49-year-old male presented after a fi rst-time prolonged seizure. These CT images were obtained
upon his arrival in the emergency room. The patient had received medication for his seizures in the
ambulance, and he was uncooperative for the CT scan. As a result, motion is evident on his scans.
The patient has:
(1) herpes encephalitis.
(2) mesial temporal sclerosis.
(3) a normal brain.
(4) a malignant glioma.
(5) an infarct.
Figure 6P.13.1 Patient presenting after prolonged, Figure 6P.13.2 Another CT section of patient seen in
first-time seizure. Figure 6P.13.1. Note the motion artifacts.
This case illustrates—or doesn’t, depending on how literal you are—the most glaring pitfall of CT.
In many cases, you just cannot make the diagnosis from the CT scan alone. As we have seen with
many of the previous cases, CT is a powerful diagnostic tool, but it is still less sensitive than MRI to
small differences in brain soft-tissue composition. In fact, in almost all cases of nontraumatic central
nervous system (CNS) disease, MRI will make the abnormalities more conspicuous than will CT
(Figures 6P.13.3 A,B, 6P.13.4 A,B, and 6P.13.5 A,B).
Even experienced imagers fi nd CT imaging challenging because the abnormalities are frequently
visible, but only in retrospect (Figures 6P.13.6 and 6P.13.7 A,B). Both the referring physician and
imagers should be aware of the limitations of CT for CNS disease and use it only when indicated.
Beware of obtaining CT when MRI is undoubtedly better just because it was easier to fit the patient
into the CT schedule. We used to call this phenomenon “looking in the wrong place because the
light is better.”
(A) (B)
Figures 6P.13.3 The axial MR FLAIR image (A) and postcontrast T1 weighted image (B) of the patient seen in Figure 6P.13.1
demonstrate abnormal signal in the left temporal lobe lateral to the temporal horn (arrow ). This proved to be a primary brain tumor,
specifically glioblastoma, at surgery.
194 CT IMAGING
(A) (B)
Figures 6P.13.4 This patient had an enhancing metastatic lesion in the brain that is at best faintly visible on CT (A, arrow ) but much
more apparent on this postcontrast T1 weighted MR scan (B, arrow ).
(A) (B)
Figures 6P.13.5 The CT scan (A) of this 50-year-old with vertigo does reveal an abnormality, but only if you know where to look
(arrow ). The postcontrast T1 weighted MR scan (B) much more clearly demonstrates this right-sided vestibular schwannoma that
extends into the cerebello-pontine angle cistern. It is the cystic portion of the tumor that is just visible on the CT (A).
Figure 6P.13.6 Although this axial CT scan shows low attenuation

in the left frontal lobe, it is difficult to determine whether it is the
result of a prior infarct, demyelination, or tumor.
(A) (B)
Figures 6P.13.7 The noncontrast T2 weighted MR scan of the same patient (A) demonstrates a mass in the extra-axial space overly-
ing the left frontal lobe. That can be established because there is a cerebrospinal fluid (CSF) cleft between the tumor and the surface
of the brain (arrowheads ). The postcontrast T1 weighted MR image (B) shows an enhancing extra-axial meningioma that can be faintly
seen but only in retrospect on the CT exam (Figure 6P.13.6).
Correct answer: 4
7
BODY CT ARTIFACTS
198 CT Imaging
Artifact 1
This 32-year-old woman with right lower quadrant pain had a computed tomography (CT) scan to
answer the clinical question of whether she had appendicitis (Figure 7A.1.1).
The scanogram (Figure 7A.1.1) reveals a metallic object in or on the patient’s lower abdominal region.
The presence of metallic objects in or on a patient should be a red flag for the CT technologist since all
patients should be questioned whether they have any metallic or electronic devices in or on them. It is
not unusual for patients, who may be distracted or forgetful, to respond “no” when that is not the case.
It is advisable to ask “Do you have any implanted metal?” rather than “You don’t have any implanted
metal, do you”? The latter seems to beg for a negative response. Unlike in magnetic resonance imaging
(MRI), where some implanted metals may put the patient at considerable risk, in CT, metal artifacts
may obscure the region of interest. Whenever possible, metal should be removed from the patient.
The visualized object in this case is a:
(1) cell phone.
(2) umbilical ring and chain.
(3) ingested foreign body.
(4) surgical clip.
Figure 7A.1.1 Scanogram showing metallic object.

Body CT Artifacts 199
This and other similar metallic objects are certainly capable of generating significant artifacts. The
composition of the metal and the kV of the scan influence the magnitude of the artifact. High atomic
number metals, such as gold, will create larger artifacts than will titanium, and the artifact will be
more evident on low kV imaging.
Correct answer: 2
200 CT Imaging
Artifact 2
This CT image of the abdomen (Figure 7A.2.1) shows retained barium in the right side of the colon
from the patient’s upper GI exam 3 days prior. This CT scan was ordered for evaluation of the
patient’s left flank pain. Which of the following responses is correct?
(1) Reschedule the examination and recommend the use of a mild laxative.
(2) Proceed with the examination after consideration of the anticipated artifacts.
(3) Image using another technique.
(4) Cancel the examination.
Figure 7A.2.1 Axial CT section showing the high

attenuation retained barium.
You have several options to manage this commonplace clinical problem. You may recommend
proceeding with the CT exam if the area of clinical interest, in this case the left side, is unlikely to be
obscured by the artifact from the barium. Since optimal image quality throughout the entire field of
view is ideal, rescheduling an examination is a reasonable option if the delay will not put the patient
at risk or prove to be a hardship. Consideration should be given to alternative imaging modalities,
such as ultrasound or MR, if they can provide the equivalent information. Cancelation of a justified
diagnostic study without presenting an alternative plan is irresponsible.
Correct answers: 1, 2, 3
202 CT Imaging
Artifact 3
This 38-year-old man fell off a ladder onto his head and upper torso. This CT of the abdomen with
IV contrast, shown here with the scanogram (Figures 7A.3.1 and 7.A.3.2), is suboptimal due to arti-
facts across the dorsal aspect of the upper abdomen.
The cause for this artifact is:
(1) patient motion.
(2) metallic object overlying the body of the patient.
(3) photon starvation.
(4) partial volume.
Figure 7A.3.1 Multiple streaks are evident on this

image through the posterior liver, spleen, and kidneys.
The patient’s arms, when placed down by his sides, may result in photon starvation depending on
the selected dose for CT and the capabilities of the tube current modulation. This can occur as a
result of scanning through other high-attenuation anatomy, such as the shoulders and hips. Since the
horizontally directed beam is attenuated most, insufficient X-rays reach the detectors in that direc-
tion, and this results in limited information for reconstruction from those projections. Most multide-
tector CT scanners are equipped with automatic exposure control (AEC) software that modifies the
tube current to accommodate differences in attenuation. Some new scanners can modify the current
not only from scan to scan in the craniocaudal direction but also during a single rotation. This pro-
vides more current when imaging across the shoulders compared with the front-to-back direction,
where there is less tissue to traverse.
However, the best and easiest way to avoid this artifact is to scan with the arms raised whenever pos-
sible (Figures 7A.3.3 and 7A.3.4 A,B). This will result in better quality images at a lower radiation dose.
Figure 7A.3.2 Scanogram obtained at the start of the scan.

204 CT Imaging
Figures 7A.3.3 Compare the image quality of this

scan that is of roughly the same anatomic area as
Figure 7A.3.1, but this one was obtained with the
arms raised.
(A) (B)
Figures 7A.3.4 This companion case shows how the spleen was obscured by photon starvation artifact because the patient was
initially imaged with her arms down (Figure 7A.3.4A). This CT exam was followed by a repeat scan 3 days later that was performed
with the arms up (Figure 7A.3.4B) that more clearly demonstrates her splenic infarct (arrow ).
Correct answer: 3
Artifact 4
This 76-year-old patient with carcinoma of the prostate treated with radical prostatectomy under-
went abdominal and pelvic CT with IV contrast enhancement for his rising prostate-specific antigen
(PSA) level. CT imaging of his abdomen was sub-optimal (Figure 7A.4.1 A,B).
These artifacts are caused by:
(1) incomplete (out of field) projection artifact.
(2) patient motion.
(4) detectors out of calibration.
(A) (B)
Figure 7A.4.1 CT coronal reconstruction (A) and axial scan through the upper pelvis (B) demonstrate artifacts along the patient’s
left lateral abdominal wall.
206 CT Imaging
The parts of the body lying outside the scan field of view will still attenuate the X-ray beam, but
the incomplete set of projections arising from the excluded body part results in severe streaking
and shading of the image. The likelihood of encountering this artifact is diminished on large-bore
scanners, and these have become commonplace over the last several years.
Positioning of the patient in such a way that all the body lies within the scan field of view is of
paramount importance (Figures 7A.4.2, 7A.4.3 A,B).
Figure 7A.4.2 On follow-up scanning, the

patient was repositioned so that no body part
was outside the scan field, which resulted in
significant artifact reduction and improved
image quality.
(A) (B)
Figure 7A.4.3 In this companion case, the scanogram shows soft tissues extending across the scanner table (A). This suboptimal
patient positioning resulted in an artifactual band of high attenuation in the subcutaneous fat (B, arrow ).
Correct answer: 1
Artifact 5
A nonenhanced CT of the pelvis was obtained in a 34-year-old male with lower abdominal pain. It
shows normal anatomy, but there is a centrally located, sharply defi ned ring on successive images
(Figures 7A.5.1, 7A.5.2). The cause for this circular artifact is:
(1) an unevenly calibrated or malfunctioning detector in the array.
(2) beam hardening from the bony pelvis.
(3) inapparent surgical clips from a prior operation.
(4) photon starvation from the high attenuation soft tissues of the pelvis.
Figure 7A.5.1 Nonenhanced CT of the pelvis.
Ring artifacts occur frequently with third-generation CT scanners. They appear as full or par-
tial circles and are formed by an erroneous detector reading at each part of the gantry rotation
(Figure 7A.5.3 A,B). This explains why they are always centered on the gantry rotational axis. Keep
in mind this may not necessarily correspond to the center of the patient since the patient may be
positioned off midline. Scanners with solid-state detectors, in which each detector is a separate unit,
are more prone to ring artifacts compared to older scanners that used xenon gas detectors, but these
solid-state detectors have a much higher sensitivity to X-rays and less afterglow, thus allowing faster
tube rotation times and potentially lower dose.
208 CT Imaging
Many factors can alter detector calibration including changes in temperature. Careful monitoring
of the scanning conditions, as well as frequent recalibration can minimize the occurrence of this
artifact. A more difficult-to-manage source of detector divergence is the differential sensitivity of the
detectors to variations in beam energy or hardness.
Because they are associated with beam hardening, ring artifacts can be reduced by using a filtered
X-ray beam. Ring artifacts are more amenable to software remedies than beam hardening.
Figure 7A.5.2 Nonenhanced CT showing ring artifact.
(A) (B)
Figures 7A.5.3 A,B Companion case showing more evident ring artifacts (A, B)
Correct answer: 1
Artifact 6
This patient with fever, leukocytosis, and hypotension had a CT scan to identify a source of sepsis
(Figures 7A.6.1, 7A.6.2). The CT images were suboptimal, due to faint halos evident around solid
organs, and the ribs appear duplicated. These artifacts can be minimized by:
(1) using a higher pitch.
(2) breath-holding during scanning.
(3) ensuring that the patient is comfortable.
(4) using the overscan mode.
(5) all of the above.
Figure 7A.6.1 Chest CT.
Figure 7A.6.2 Same patient.

210 CT Imaging
Patient-related motion artifacts can be eliminated or at least minimized by securing the patient’s
cooperation and by taking advantage of the contributions of available scanner software. Furthermore,
additional respiratory or cardiac gating should be added whenever indicated. The scan user should
make the patient aware of what to expect, and do what is necessary to make the patient comfortable
for the duration of the study. Today’s fast scans can cover the chest, abdomen, and pelvis in 20–25
seconds, making it easier for patients to control their voluntary movements and suspend respiration.
Since the largest discrepancies in detector readings occur toward the beginning and end of each 360-
degree scan, manufacturers often use an overscan mode for axial body imaging in which an extra
10–15% degrees of rotation are added to the 360-degree rotation. You can think of it as one full
rotation and then some. These oversampled projections are then averaged, leading to image smooth-
ing and a reduction of motion artifacts but at the cost of a slightly higher radiation dose. Some other
examples are provided in Figures 7A.6.3 A,B and 7A.6.4 A,B.
(A)
(B)
Figures 7A.6.3 Another case showing motion

blurring particularly evident around the right hip joint
(A, B). Note how the muscles and bone are poorly
delineated there compared to the left groin and hip.
(A)
(B)
Figures 7A.6.4 These images from a different case

demonstrates both motion and ring artifacts (A, B).
Correct answer: 5
212 CT Imaging
Artifact 7
This patient underwent CT imaging with IV and oral contrast material, for staging of testicular
malignancy. Curvilinear gas-filled structures (Figure 7A.7.1, arrow) are noted within the gastric
lumen. This finding is caused by:
(1) a coiled nasogastric tube.
(2) gas bubble motion artifact.
(3) patient motion artifact.
(4) a large spaghetti meal prior to scanning.
Figure 7A.7.1 Pelvic CT with IV and oral con-

trast, note low attenuation in the stomach (arrows).
This is another example of motion on CT, but this time of only gas moving within the stomach.
Curvilinear or semicircular tubular motion artifacts may be evident whenever imaging a hollow
structure that contain gas bubbles floating on top of fluid. Air motion can be commonly seen in seg-
ments of small bowel due to their normal smooth muscle activity, called peristalsis.
The imaging parameters that influence the appearance of this artifact are the size of the gas bub-
ble, the speed and magnitude of its movement, the scanner rotation speed, and the relative position
of the X-ray tube. The bubble speed has been estimated at about 15–35 mm/s; therefore, shortening
rotation time should decrease or eliminate the artifact. With longer rotation times, and if gas bubble
motion artifacts are anticipated to be problematic, the administration of glucagon can help by reduc-
ing peristalsis.
Figure 7A.7.2 The effect of moving air due to

peristalsis is evident throughout the abdomen in
this companion case.
Correct answer: 2
8 BODY CT PITFALLS
216 CT IMAGING
Pitfall 1
This 45-year-old woman underwent computed tomography (CT) of the abdomen with IV con-
trast enhancement for her persistent left lower quadrant pain. A 12 × 9 mm low-attenuation,
well-marginated, homogeneous lesion with an imperceptible wall was evident in the right kidney
(arrow, Figure P8.1.1). It measured 40 HU in attenuation (Figure 8P.1.2). The lesion had all the mor-
phologic features of a simple cyst except for its relatively high attenuation value.
You think this represents:
(1) a renal cancer.
(2) a hemorrhagic cyst.
(3) an angiomyolipoma.
(4) pseudo-enhancement of a benign renal cyst.
Figure P8.1.1 Abdominal CT with IV contrast enhancement.
Figure P8.1.2 The same image with measurement of attenuation in the cyst.
Body CT Pitfalls 217
On further imaging with sonography, this proved to be a simple cyst. It has been documented
in the literature that the attenuation measurements of small, cystic renal lesions after IV contrast
administration may be unreliable. This is typically seen with small renal cysts that are entirely intra-
renal in location and the phenomenon is known as renal cyst pseudo-enhancement.
Benign renal cysts may be denser than expected (i.e., >10 HU) due to partial volume averaging
or whenever the cyst is fi lled with bloody or proteinaceous fluid (called a complicated cyst). Partial
volume averaging artifact can be eliminated as a cause by viewing thin slice reconstructions. The
diagnosis of a complicated cyst can be established whenever an otherwise benign-appearing cyst
has high attenuation on a noncontrast scan and there is no change in the fluid attenuation after IV
administration of contrast material.
Imaging research using phantoms has shown that renal cyst pseudo-enhancement is independent
of partial volume averaging and that the cyst attenuation increases with more detector rows and the
use of a higher tube potential (e.g., the use of 140 KVp compared to 90 KVp). Other independent
factors predisposing to renal cyst pseudo-enhancement include intrarenal location, small size of the
lesion, and imaging during peak renal parenchymal enhancement.
The best theory to date for the cause of pseudo-enhancement is that it is the result of the combina-
tion of a beam hardening correction and the helical image reconstruction algorithm used by many
manufacturers. Remember that beam hardening does not require bone or other high-attenuation tis-
sues to occur. CT imaging of a uniform fluid phantom will appear to have a central low-attenuation
zone to the miscalculation of the true attenuation in the middle due to beam hardening. This arti-
fact, at least in a uniform phantom, can be corrected by using a correction factor during the recon-
struction to arbitrarily increase attenuation values in the center but this correction has the potential
to create artifacts elsewhere.
Correct answer: 4
218 CT IMAGING
Pitfall 2
There is a round area of low attenuation in the medial aspect of the pancreatic head (Figure P8.2.1,
arrow) in this patient who was being staged for renal cell carcinoma of the left kidney. This is:
(1) an enlarged peripancreatic lymph node.
(2) a solid neoplasm in the pancreatic head.
(3) a cystic lesion in the pancreatic head.
(4) normal low attenuation of the nonenhanced superior mesenteric vein (SMV).
Figure P8.2.1 Arterial phase abdominal CT.

This is a commonplace fi nding on multiphase imaging of the upper abdomen that is most often
performed to improve visualization of the liver or pancreas. This normal structure becomes more
conspicuous against the surrounding pancreatic parenchyma when imaging occurs during the arte-
rial phase of enhancement. When imaged later, during the portal venous phase of enhancement
(Figure P8.2.2), it is more easily recognized as the SMV. Contrast is exaggerated again since the
pancreatic parenchymal enhancement is past peak.
Radiologists have long been aware that certain vascular lesions in the liver or pancreas, such as
hepatocellular carcinoma, may only be seen during arterial phase CT scans. Multiphase imaging is
also used commonly for the evaluation of the kidneys, where a delayed, excretory phase is necessary
for opacification of the pyelocalyceal systems and ureters (Figures P8.2.3 A,B and P8.2.4).
Figure P8.2.2 Portal venous phase image, same slice as Figure P8.2.1.
220 CT IMAGING
(A) (B)
Figure P8.2.3 This patient had a triple-phase CT to characterize a hepatic lesion and on this image again note the low attenua-
tion of the superior mesenteric vein (SMV) on arterial phase imaging (A, arrow ) that later enhances during the portal venous phase
(B, arrow ).
Figure P8.2.4 It is important to direct attention to all phases of the imaging. In this patient with cirrhosis and portal hypertension,
the low attenuation in the region of the superior mesenteric vein (SMV) is due to nonocclusive thrombus in the SMV (arrow ).
Correct answer: 4
Pitfall 3
There appears to be a central low-attenuation fi lling within the deep venous structures extending
from the groin to the mid inferior vena cava in this patient with ulcerative colitis (Figures P8.3.1,
P8.3.2). The CT scan was performed following IV injection of 100 mL contrast material at a rate
of 2 cc/sec, with a scan delay time of 75 seconds after the initiation of the contrast injection. This
fi nding indicates:
(1) a potentially life-threatening venous thrombosis; further investigation and treatment is
warranted.
(2) a flow artifact due to insufficient volume of contrast or early scanning after start of injection.
(3) the usual appearance of veins.
(4) contrast mixing with unopacified venous blood.
Figure P8.3.1 Abdominal CT in a patient with ulcerative colitis.
Figure P8.3.2 Pelvic CT image from same patient seen in Figure P8.3.1.
222 CT IMAGING
This fi nding is most consistent with extensive, nonocclusive venous thrombus, and that puts the
patient at risk for a pulmonary embolism. Distinguishing flow artifacts within the veins from non-
occlusive thrombus is very important and can be challenging in practice. The venous luminal fill-
ing defects in this case are well defi ned and, on axial images, appear as round or polygonal filling
defects. In addition, the right external iliac vein is expanded (Figure P8.3.2, arrow), a fi nding that
can be seen with acute thrombosis but not with a flow artifact.
The goal for imagers is to avoid false-positive diagnoses of venous thrombosis. The best technique
for making this distinction between venous thrombus and flow artifact is a delayed post contrast image
rather than giving a larger amount of contrast material. In some cases, a venous ultrasound study will
be necessary for the timely confirmation or exclusion of deep venous thrombosis (Figure P8.3.3 A,B).
(A)
(B)
Figure P8.3.3 These companion cases demonstrate venous flow artifact. This axial CT shows faint low attenuation within the lumen
of both common femoral veins (A, arrows) due to incomplete mixing of blood and contrast material. A CT section from another patient
who was evaluated for a ventral hernia with CT shows a faint, linear filling defect in the lumen of the left external iliac vein (B, arrow )
typical of a flow artifact.
Correct answer: 1
Pitfall 4
On this patient’s abdominal CT with IV contrast enhancement, a small, low-attenuation lesion is

evident in the left lower kidney. On 5 mm axial imaging, it has an attenuation value of 42 HU, but
of only 14 HU on 2 mm coronal imaging. The difference in apparent attenuation of the cyst contents
is due to:
(1) beam hardening.
(2) pseudo-enhancement.
(3) volume averaging.
(4) motion.
Figure P8.4.1 Axial CT section with IV contrast enhancement with cyst contents measurement 42HU.
224 CT IMAGING
Figure P8.4.2 Coronal reconstruction, CT of same patient as in Figure P8.4.1. On this view the cyst attenuation measures 14HU.
Volume averaging on CT occurs because the appearance of a voxel represents the average attenu-
ation value of all the different tissues within the voxels (i.e., gas, fluid, fat, bone, etc.). The larger
the voxel, the more tissues within, and that may lead to inconsistencies or frank errors in CT rep-
resentation of attenuation values. The reason the cyst has a higher attenuation value on the axial
view is that the slice is thicker and that means the voxel is larger. Since the cyst is in fact very low
attenuation—in fact, close to 0 HU, since the voxels that show it include both cyst fluid and the
nearby higher-attenuation enhanced kidney—it is displayed with a higher than expected attenua-
tion value. Thin-slice acquisition and reconstruction may provide a more accurate attenuation mea-
surement, as long as the dose is sufficient for an adequate signal-to-noise ratio on these thinner
sections.
Correct answer: 3
9 TEST QUESTIONS
226 CT IMAGING
Question 1
The CT measure of how much of the total radiation dose contributes to the images is called dose
efficiency. It incorporates both the scanner detector and geometric efficiency. Assuming the detector
efficiency is the same for all, place these different abdominal imaging techniques in order of dose
efficiency from highest to lowest.
(1) Axial mode using a 16-row detector array
(2) Axial mode using a single-slice scanner
(3) Helical mode using a four-row detector array
Question 2
Which of these scan techniques would deliver a lower patient dose for an abdominal CT scan,
assuming identical coverage, pitch, and tube rotation time?
(1) Low kV-High mA (i.e., 80 kV, mAs 400)
(2) High kV-Low mA (i.e., 140 kV, mAs 200)
Question 3
Match the answers with the questions. (There are more answers than questions.)
(1) The effective dose of a routine head CT scan is .
(2) The background radiation exposure of a North American adult is .
(3) The American College of Radiology (ACR) recommends using a CT dose index volume
(CTDIvol) of < for head imaging.
(4) The ACR recommends using a CTDIvol of < for abdominal imaging.
Answers:
(A) 25 mGy
(B) 2 mSv
(C) 5 mSv
(D) 3 mSv
(E) 75 mGy
(F) 100 mGy
Test Questions 227
Question 4
This 18-year-old female presents with headaches. Four images are included from her head CT
(Figures 9.1.1–9.1.4), along with a sagittal reconstruction (Figure 9.1.4). You suspect the appearance
of the pituitary is due to:
(1) a Rathke cyst.
(2) a microadenoma.
(3) a beam hardening artifact.
Figure 9.1.1 Figure 9.1.2

228 CT IMAGING
Figure 9.1.3 Figure 9.1.4
Question 5
If you were to count them, there are over individual detectors in a single row on a multidetector
array.
(1) >10
(2) >50
(3) >500
(4) >1,000
Question 6
A chest CT has an effective dose that is times more than a PA and lateral chest X-ray.
(1) >10
(2) >20
(3) >50
(4) >100
Test Questions 229
Question 7
A routine head CT scan is performed with a CTDIvol ten times higher than a chest CT. As a result,
the effective dose of a head CT is also much higher than that of a chest CT.
True or False?
Question 8
The widespread use of modern multidetector scanners has substantially reduced patient dose from a
single CT scan compared with that from single slice CT scanners.
True or False?
Question 9
The mean energy, in keV, of the X-rays arising from an X-ray tube is:
(1) the same value as peak kV (kVp).
(2) 90% of the kvP.
(3) 75% of the kVp.
(4) 40% of the kVp.
(5) 25% of the kVp.
Question 10
Automatic exposure control varies both the kV and mA of the X-ray tube to accommodate differ-
ences in thickness and attenuation of the body tissues.
True or False?
230 CT IMAGING
Answers
1. Correct answer: 2, 1, 3
Many will fi nd this surprising since we have been conditioned to believe that new means better in
every way. When we consider CT critically, however, that is not necessarily true. Single-slice scan-
ners have the highest geometric dose efficiency because the width of the X-ray beam is never wider
than the detector. As a result, nearly all the X-rays that traverse the patient contribute to the image.
Unlike single-slice CT scanning, however, the use of a multidetector array requires that the X-ray
beam extend beyond the end detector rows so that every row sees the same number of X-rays as its
neighbors. In order for the X-ray beam to cover all rows evenly, a portion of the beam must therefore
extend beyond the detectors. This additional, and in one sense wasted, dose is described by over-
beaming (see Chapter 2). The 16-slice scanner will be more dose efficient than a four-slice scanner,
not because it has less overbeaming, but simply because requires fewer rotations to cover the same
anatomy. By using helical technique with the 4 slice scanner there is not only the added dose from
overbeaming but also the extra dose from “over-ranging”. In practice, the impact of overbeaming is
considered insignificant on any CT scanners with more than 32 detector rows.
2. Correct answer: 1
The impact of a small increase or decrease of the kV used on the patient dose is much greater
than a comparable change in mA. That is because the total dose increases as the square of kV but
proportionally to mA. Whenever you choose to use a lower kV, as a result of the greater proportion
of low-energy X-rays lost in peripheral tissue, an increase in mA will be necessary to provide com-
parable image quality. Even with that adjustment, however, the increase in dose from increasing the
mA in thin patients and children will usually not be sufficient to offset the more substantial dose
reduction from decreasing kV.
If low-kV imaging is beneficial, you may be wondering why most sites use a kV of 120 instead of
80, 90, or even 100 kV for most head CT imaging. The choice of kV depends on the size and com-
position of the patient and tissues imaged. Even though it is preferred to use as low a kV as possible,
it is still necessary to get enough X-rays to the detectors for adequate images. In fact, for very large
patients and those with implanted metal, it may necessary to even increase the usual kV from 120
to 140 to provide adequate imaging. Low-dose but non-diagnostic imaging reminds me of a saying
(if I may paraphrase a quote from Thomas Jefferson): The item you purchase on sale but don’t really
want will prove to be the most expensive after all. Your goal should be to provide adequate imaging
at the lowest possible dose but no one benefits from low-dose, non-diagnostic images.
3. Correct answers: 1-B, 2-D, 3-E, 4-A
The sagittal reconstruction (Figure 9.1.4) shows a low-attenuation area within the pituitary that
corresponds to the low attenuation evident on the axial image within the sella (Figure 9.1.3). This
is due entirely to beam hardening caused by the bony margins of the sella. In this case, the pituitary
was imaged in the direct coronal view, and that image shows a prominent but normal pituitary gland
for a woman of her age.
Test Questions 231
In a single row, there are usually 700–1,000 individual detectors. Multiply that by the 128 detec-
tor rows or more that are routine on many new CT scanners, and you not only have a lot of detectors
but also a stunning amount of data streaming to the computer on each and every rotation.
A chest X-ray has an effective dose of 0.1 mSv, whereas a chest CT has an effective dose of 7–10
mSv.
7. Correct answer: False

Since the effective dose reflects both the magnitude of the absorbed dose as well as the sensitivity
of the involved tissues to radiation, the chest CT has a 3–5 times higher effective dose than does a
head CT. That is because the stochastic risks of radiation to the brain are considered to be much
lower than the same or even less dose applied to breast tissue and esophagus.

It is somewhat counterintuitive, but the late-generation single-slice axial scanners were quite effi-
cient in their use of radiation. Wider detector arrays with helical imaging and narrow detector col-
limation have improved imaging speed and make many new exams possible but do not necessarily
reduce dose for comparable scans. The use of automatic exposure control (AEC) in many cases,
along with careful attention to the scan technique, will significantly mitigate any of the dose inef-
ficiencies inherent with multidetector CT imaging. There is great hope for newer reconstruction
techniques to bring patient dose down even lower.
The energy of the X-rays emitted by the anode is expressed in keV, thousand electron Volts, not as
kVp. Yet the two values are linked. These X-rays have a range of values. Although none of these will
have a higher energy than that predicted by the kVp, depending on filtration the mean of the all the
X-ray energies will be about 30–50% of that of the highest.

Automatic exposure control on most scanners modulates only the mA. Although kV undoubtedly
has a significant impact on dose, the scanner software will not vary it in response to the tissues
examined. For those of you familiar with camera operation, think of AEC like the automatic aper-
ture mode on a camera. Although both shutter speed and aperture can be used together and inde-
pendently to influence the exposure of a photograph, in aperture mode only the size of the aperture
varies and shutter speed always stays the same. Some modern CT scanners offer a method to alter
both kV and mA but that requires the use of a ‘‘contrast index’’ since noise index or equivalent mA
reference values will need to be altered as kV changes.
THE END
INDEX
Index entries followed by t indicate a table; by f indicate a figure.
absorbed dose, 37 streak, 134

absorption efficiency, 23 susceptibility, 134
accentuation artifact, 96 volume averaging, 114–18, 114f–118f, 152–53, 152f–153f,
acute stroke, 179 223–24, 223f–224f
acute subdural hemorrhage, 185, 185f windmill, 130–31, 130f–132f
AEC. See automatic exposure control artifacts, body CT
afterglow, 23 barium, 200, 200f
air detector array, 207–8, 207f–208f
in arterial system, 149, 150f gas bubble motion artifact, 212–13, 212f–213f
cranioplasty fl ap, trapping, 168f–169f incomplete projection, 205–6, 205f–206f
fat compared to, 171, 172f metallic artifacts, 198–99, 198f
peristalsis and, 213, 213f photon starvation, 202–3, 202f–204f
in subarachnoid space, 148–51, 148f–151f random patient motion, 209–10, 209f–211f
in veins, 149, 151f volume averaging artifacts, 223–24, 223f–224f
ALARA. See As Low As Reasonably Achievable artifacts, cardiac imaging
algebraic reconstructions, 18, 18f densely calcified coronary vessels, 90–92, 90f–92f
amperage principles, 46. See also milli-ampere ECG editing, 99–101, 99f–100f
angiography unit fl at plate detector, 22f heart rate increases, 102–4, 102f–104f
angular adjustment, 50 irregular heart rates, 109–11, 109f–111f
anisotropic voxels, 16f metal hardware, 95–98, 95f–98f
arachnoid granulation, 178–80, 178f–180f prospective triggering, 93–94, 93f, 94f
arms raised, photon starvation avoided with, 203, 204f PVCs, 87–89, 87f, 88f
artifacts random patient motion, 75–78, 75f–78f
accentuation, 96 respiratory motion differentiated from cardiac motion,
beam hardening, 133–35, 133f, 135f–136f, 141, 143f 79–82, 79f–82f
blooming, 67–68, 68f, 97, 98f suboptimal image contrast, 105–8, 105f–106f, 108f
blurring, 109–11, 177 temporal resolution, 72–74, 72f–73f
chest wall motion artifact, 80–81 tube current modulation and cardiac CTA, 83–86, 83f–86f
craniectomy, 130–31, 130f–132f artifacts, neuro CT
CTA, 67–68, 68f beam hardening, 133–35, 133f, 135f–136f, 141, 143f
cupping, 135 dental amalgam, 140–41, 140f–144f
from densely calcified coronary vessels, 90–92, 90f–92f detector calibration error, 130–31, 130f–132f
dental amalgam, 140–41, 140f–144f from gantry angulation, 141
gas bubble motion, 212–13, 212f–213f in-plane skull fractures, 122, 122f–125f
Hounsfield, 143f from MRI location compared to CT, 145–46, 145f
incomplete projection, 205–6, 205f–206f photon starvation, 137–39, 137f–139f
metallic, 68–69, 95–98, 95f–98f, 198–99, 198f random patient motion causing, 126–27, 126f–129f
posterior fossa, 140, 140f subarachnoid hemorrhage attenuation values, 119–21,
from prospective triggering, 93–94, 93f, 94f 119f–121f
from random patient motion, 75–78, 75f–78f, 126–27, volume averaging, 114–18, 114f–118f, 152–53, 152f–153f
126f–129f As Low As Reasonably Achievable (ALARA), 39
respiratory motion differentiated from cardiac motion, atrial fibrillation, 100, 109
79–82, 79f–82f attenuation values, 12–13, 15f
in scanograms, 126–27, 126f–129f arachnoid granulation, 178–80, 178f–180f
stair-step, 109–11 CSF in empty sella, 134
234 INDEX
attenuation values (Cont.) body CT pitfalls

metallic artifacts and, 95–98, 95f–98f false-positive venous thrombosis diagnosis, 222, 221f–222f
pixel size, 115 renal cyst pseudo-enhancement, 216–17, 216f–217f
SMV, 218–19, 218f–220f SMV normal low attenuation values, 218–19, 218f–220f
subarachnoid hemorrhage and, 119–21, 119f–121f volume averaging artifacts, 223–24, 223f–224f
of subdural hemorrhage, 165–66 bolus tracking, 107
voxel, 115 brain atrophy, 182
automatic exposure control (AEC), 32, 203, 231 brain scans, gantry angulation issues with, 26, 27f
for chest CT, 62–63, 64f brain tumor, 189–90, 189f–191f
important reminders for, 50–51 infarct misdiagnosis of, 189–90, 189f–191f
mA modulation with, 229, 231 metastatic, 190, 191f
radiation dose reduction and, 50, 52 breath-holding procedure, 59, 81–82, 107, 209
shields and, 51–52 bullets and metal artifact, 97f
tube current modulation adjustments for radiation dose,
61–62 calcifications. See densely calcified coronary vessels
axial imaging, 26f cancellation of diagnostic study, 220
Chiari I malformation problems, 155, 156f cardiac cycle phases, 103–4
detector calibration error artifacts, 131, 132f cardiac imaging
helical imaging compared to, 6–10, 42 of coronary vessels, 66–67, 67f
limits of, 182 CTA studies with, 67–68, 67f
misregistration in, 7, 9f densely calcified coronary vessel artifacts in, 90–92,
motion effects on, 127, 129f 90f–92f
for MRI, 145 dual-source CT scanning improvements for, 59–60, 60f
prospective triggering and, 60–61 ECG editing artifacts in, 99–101, 99f–100f
random patient motion and, 76–77, 77f ECG synchronization for, 60–61
rotation time in, 29 heart rate increases artifacts in, 102–4, 102f–104f
scan time for, 7 irregular heart rate artifacts in, 109–11, 109f–111f
metal hardware artifacts in, 95–98, 95f–98f
back-projection, 8f, 52. See also fi ltered back-projection nonsynchronization issues in, 66–69
fi lters for, 18 normal rhythm in, 56f
history of, 18, 18f, 19f partial scan for, 59, 59f
barium artifacts, 200, 200f photon starvation in, 69
beam collimation, 10–12, 28 prospective triggering artifacts in, 93–94, 93f, 94f
efficiency of, 42, 43f PVC artifacts in, 87–89, 87f, 88f
beam hardening, 46 radiation dose optimization for, 61–66, 62f
artifacts, 133–35, 133f, 135f–136f, 141, 143f random patient motion artifacts in, 75–78, 75f–78f
detector array sensitivity to, 208 respiratory motion differentiated from cardiac motion
infarct obscured by, 183, 183f artifacts in, 79–82, 79f–82f
photo starvation compared to, 138 segmented acquisition for, 58–59
principles of, 133–34 SNR needs in, 62
pseudo-enhancement from, 217 suboptimal image contrast artifacts in, 105–8, 105f–106f,
beta-blockers, 68 108f
bismuth, 51 temporal resolution and, 56–57, 56f
blood, in extra-axial space, 166 temporal resolution artifacts in, 72–74, 72f–73f
blood hematocrit levels, 179 tube current modulation and cardiac CTA artifacts in,
blooming artifact 83–86, 83f–86f
in CTA, 67–68, 68f tube current modulation matched to cycle of, 64
high-density structures and, 96, 96f cardiac motion
blurring artifacts, 109–11, 177 ECG suppressing, 76
body CT artifacts respiratory motion, 79–82, 79f–82f
barium, 200, 200f cavernoma, 157–58, 157f–160f
detector arrays unevenly calibrated or malfunctioning cavernous sinus, 172f
causing, 207–8, 207f–208f central nervous system disease, MRI over CT for, 193,
gas bubble motion artifact, 212–13, 212f–213f 193f–194f
incomplete projection, 205–6, 205f–206f cerebellar infarct, 181–83, 181f–183f
metallic artifacts, 198–99, 198f cerebellopontine angle cistern, 194f
photon starvation, 202–3, 202f–204f cerebellum, 120
random patient motion, 209–10, 209f–211f hemorrhage of, 121f
Index 235
cerebrospinal fluid (CSF) contrast index, 231

attenuation values in empty sella of, 134 contrast opacification, 106
in subdural space, 185, 187f contrast staining, 162, 164f
chest CT Cormack, Allan, 3, 5
AEC for, 62–63, 64f coronal reconstruction
chest X-ray effective dose compared to, 228, 231 for arachnoid granulation, 178f, 179
effective dose in head CT compared to, 228, 231 for posterior fossa, 182, 182f
respiratory motion differentiated from cardiac motion in, for transverse sinus asymmetry, 179, 180f
79–82, 79f–82f window and level settings for, 166, 170f
chest wall motion artifact, 81 coronary artery bypass graft (CABG), 96
Chiari I malformation, 155, 156f coronary vessels, 66–67, 67f
children. See pediatric CT imaging densely calcified, 90–92, 90f–92f
chronic subdural hemorrhage, 185, 185f cortical ribbon, 185, 186f
chronic subdural, wide subarachnoid space mistaken for, craniectomy, 130–31, 130f–132f
185, 187f cranioplasty, air trapped in, 168f–169f
cobalt alloy clip, 139f CT. See computed tomography
coiled aneurysms, photon starvation and, 138–39, 144f CTA. See computed tomography angiography
collimators, 42 CTDI. See computed tomography dose index
comb (plastic) fragments, 170–71, 170f–173f CTDIvol. See computed tomography dose index volume
complicated cyst, 216 CTV. See computed tomography venogram
computed axial tomography (CAT and CT scanning), 4 cupping artifact, 135
computed tomography (CT), 2. See also dual-energy CT Curie, Marie, 39
scanning; dual-source CT scanning; multidetector CT Cyst and CT
algebraic reconstructions for, 18, 18f complicated, 216
cone beam imaging, 20–24, 22f pseudo enhancement of renal, 216–17, 216f–217f
contrast-enhanced, 174–77, 174f–177f
dose measures for, 36–37 data gaps, 110–11, 111f
EMI development of, 4–5 densely calcified coronary vessels, 90–92, 90f–92f
Hounsfield’s advances with, 4–5, 7f dental amalgam artifacts, 140–41, 140f–144f
indications for, 41–42 detector arrays
MRI compared to, 192, 193, 194f, 195f beam hardening, 208
MRI for central nervous system disease over, 192, 193f–194f in multidetector CT, 228, 231
neuro CT artifacts comparing MRI to, 145–46, 145f reconstructions and, 15–17, 18–20
pediatric, 52–53 septa in, 21
resolution and voxel size in, 13 solid-state, 207
speed, 177 unevenly calibrated or malfunctioning, 207–8, 207f–208f
spiral, 7–8 xenon gas, 207
third-generation units, 9f, 23f detector calibration error artifacts, 130–31, 130f–132f
time delay, 29 detector collimation, 16
computed tomography angiography (CTA), 29 narrow, 131
blooming artifact in, 67–68, 68f slice thickness and, 49
cardiac imaging studies with, 67–68, 68f thin, 49
densely calcified coronary vessels and, 90–92, 90f–92f deterministic effects, of radiation dose, 37, 38f
future of, 30 developmental venous anomaly, 160f
retrospective gating and, 101 diastolic phase
SNR modification in, 73–74 end, 93–94
speed of, 29–30 heart rate increases shortening, 103
temporal resolution with dual-source CT scan for large DLP. See dose length product
patients in, 72, 73 dose. See radiation dose
tube current modulation and cardiac, 83–86, 83f–86f dose efficiency, 23
computed tomography dose index (CTDI), 36–37, 226 of various scanners, 226, 230
computed tomography dose index volume (CTDIvol), 36 dose length product (DLP), 39–40
computed tomography venogram (CTV), 179 dual-energy CT scanning, 49f
cone beam, 19 benefits of, 29, 31f
cone beam imaging, 20–24, 22f future of, 30
contrast. See image contrast virtual noncontrast image processing and, 162, 163f
contrast-enhanced CT scan, CTA compared to, 174–77, dual-source CT scanning
174f–177 gantry rotation time for, 60
236 INDEX
dual-source CT scanning (Cont.) isotropic voxels and, 26, 26f

prospectively triggered high-pitch helical acquisition for, neuro CT artifacts from, 140
66, 67f radiation dose to eye in, 26–28
scan acquisition speed in, 29, 30f gantry rotation time
temporal resolution for cardiac imaging improvements with, for dual-source CT scanning, 59–60
59–60, 60f limitations to, 56, 57f
temporal resolution for CTA in large patients with, 72–75, partial scan and, 59, 59f
72f–73f segmented acquisition and, 58–59
temporal resolution and, 56–57, 57t
ECG. See electrocardiogram temporal resolution improvements for, 57–60, 58f
ectopic beats, 86 gas bubble motion artifact, 212–13, 212f–213f
effective dose, 226 gastric lumen, 212, 212f
in chest CT compared to head CT, 228, 231 Gelfoam, 171, 172f
of chest CT to chest X-rays, 228, 231 geometric efficiency, 23
DLP conversion to, 39–40 glucagon, 213
measuring, 38 gold, 199
Monte Carlo simulation and, 39 Gray (Gy), 37
effective mAs (mAseff), 46–47 Gray, Louis Harold, 37
Electrical and Musical Industries (EMI), 4–5, 6, 10 gunshot injury to brain, 138–39, 138f–139f, 141f
electrocardiogram (ECG) Gy. See Gray
artifacts problems with editing of, 99–101, 99f–100f
cardiac motion suppressed with, 76 hair loss, 37, 38f
data gaps from PVC editing disruption in, 110–11, 111f head CT scan, 36
lead contact and, 100–101 effective dose in chest CT compared to, 2289, 231
PVC editing in, 87–89, 87f, 88f heart rates
retrospective gating and editing of, 88, 88f, 101 cardiac imaging artifacts with irregular, 109–11, 109f–111f
synchronization, 60–61, 99–101, 99f–100f diastolic phase shortening by increase in, 103
tube current modulation and, 62–93, 64f motion-free imaging and artifact issues with increases in,
Elscint, 11 102–4, 102f–104f
EMI. See Electrical and Musical Industries prospective triggering and variation of, 94, 94f
end diastolic imaging, 58 radiation dose reduction and variability of, 110
end diastolic phase, 93–94 segmented acquisition and temporal resolution for elevated,
end systole phase, 93–94 104, 104f
extra-axial space tube current modulation and irregular, 84
blood in, 166 helical imaging
wide subarachnoid space mistaken for chronic subdural axial imaging compared to, 6–10, 42
space in, 185, 187f for detector calibration error artifacts, 130–31, 130f–132f
eye and dose, gantry angulation, 26–27 interpolation and, 10
interpolation for reconstruction in, 20, 21f
fat, air compared to, 171, 172f prospectively triggered high-pitch helical acquisition for,
fat emboli, 148–49, 148f 66, 67f
FBP. See fi ltered back-projection retrospective gating and, 60–61
fi ltered back-projection (FBP), 8f rotation time in, 29
iterative reconstruction, compared to, 66, 66f slip rings for, 8, 11f
metallic artifacts and, 96, 97f X-ray beam trajectory in, 21f
for reconstruction, 65–66 hematocrit levels, blood, 179
fi lters hemorrhage, 115, 118f
for back-projection, 18 attenuation values and subarachnoid, 119–21, 119f–121f
dark, 177 cerebellar, 121f
types of, 18 missed subdural, 165–66, 165f–169f, 184–85, 184f–188f
windowing compared to, 17f high-pitch scanning, 76, 81
fl at-panel detector, 20, 23. See also cone beam imaging Hounsfield, Godfrey, 3–4
flow artifacts, venous thrombosis compared to, 222, 222f CT advances of, 4–5, 7f
four-dimensional CT scanning, for respiratory motion, 82, 82f Hounsfield artifact, 143f
Frank, Gabriel, 18, 19f Hounsfield unit (HU), 4
gamma rays, 4 image contrast

gantry angulation basis of, 12–13
image display and, 25–27 kV increases and, 106
Index 237
minimizing suboptimal, 105–7, 105f–106f, 108f meningioma, 177, 175f

time delay and CT, 175, 175f metallic artifact reduction (MAR), 96–97
window and level settings for, 166, 167f–169f metallic artifacts, 68–69. See also photon starvation
image display, gantry angulation and, 25–27 attenuation values and, 95–98, 95f–98f
“Image Gently,” 53 bullets, 97f, 137–39, 137f–139f, 141f
implanted metal, 198 dental amalgam artifacts and, 140–41, 140f–144f
incomplete projection artifact, 205–6, 205f–206f FBP and, 96, 97f
infarct IR for, 97
beam hardening obscuring, 183, 183f mGy. See milli-Gray
brain tumor misdiagnosed as, 189–90, 189f–191f middle cerebral artery (MCA), 189
cerebellar, 181–83, 181f–183f milli-ampere (mA)
wide sulcus distinguished from, 181–83, 181f–183f AEC modulating, 229, 231
inferior vena cava (IVC), 107, 108f kV changes compared to, 226, 230
in-plane location of skull fractures, 122, 122f–125f, 124 principles of, 45–46
interpolation, 9 radiation dose linear relationship to, 46
helical imaging and, 10 rotation time and, 45
for helical imaging reconstruction, 19, 21f SNR with modification of, 73–74
iodine, photoelectric effect with, 29, 31f milli-ampere seconds (mAs), 45
IR. See iterative reconstruction milli-Gray (mGy), 37
irregular heart rates. See heart rates milli-Sieverts (mSv), 38
isotropic voxels misregistration, in axial imaging, 7–8, 9f
gantry angulation and, 26, 26f Monte Carlo simulation, 39
reconstructions with, 15–17, 16f motion. See also random patient motion
iterative reconstruction (IR), 24, 25f axial imaging and, 127, 128f
FBP compared to, 66, 66f cardiac, 76, 79–82, 79f–82f
for metallic artifacts, 97 gas bubble motion artifact, 212–13, 212f–213f
radiation dose reduction and, 52 overscanning for, 76
random patient, 75–78, 75f–78f, 126–27, 126f–129f,
Kalender, Willi, 8 192–93, 192f–195f
kernels, 18. See also fi lters respiratory, 79–82, 79f–82f
fi lter terminology choice compared, 50 mSv. See milli-Sieverts
kilovolt (kV) multidetector CT
choosing strength of, 226, 230 detector arrays in, 228, 231
decreasing, 47–48, 49f fl at-panel detector compared to, 21, 23
image contrast increasing, 106 history and advancements with, 10–11
increasing, 47, 48f overbeaming in, 42, 43f
principles of, 45–46 slice thickness of, 15
radiation dose relationship to, 47 320-row, 11, 13f
SNR with modification of, 73–74 widespread use of, 229, 231
myelographic contrast, 162, 162f
lens dose, 146
level settings, image contrast and, 166, 167f–169f neck imaging, time delay for soft-tissue, 175, 177f
Litvinenko, Alexander, 37 neuro CT artifacts
longitudinal axis collimation, 81 beam hardening, 133–35, 133f–136f, 141, 143f
lumbar myelogram, 161–64, 161f–164f dental amalgam, 140–41, 140f–144f
detector calibration error, 130–31, 130f–132f
mA. See milli-ampere from gantry angulation, 141
magnetic resonance imaging (MRI), 13, 41 in-plane location of skull fractures in, 122,
axial imaging for, 145 122f–125f, 124
of cavernoma, 158, 158f–160f from MRI compared to CT, 145–46, 145f
for central nervous system disease over CT, 192–93, photon starvation, 137–39, 137f–139f
192f–195f random patient motion causing, 126–27, 126f–129f
CT compared to, 192–93, 194f, 195f subarachnoid hemorrhage attenuation value, 119–20,
metallic artifact risks for, 198 119f–121f
neuro CT artifacts comparing CT to, 145–46, 145f volume averaging, 114–15, 114f, 116–18f, 152–53,
magnetic resonance venogram (MRV), 179 152f–153f
mAs. See milli-ampere seconds neuro CT pitfalls
mAseff. See effective mAs air in subarachnoid space, 148–49, 148f–151f
matrix size, pixel size relationship with, 115 air misconceptions, 170–72, 170f–173f
238 INDEX
neuro CT pitfalls (Cont.) air in subarachnoid space, 148–49, 148f–151f

arachnoid granulation, 178–79, 178f–180f air misconceptions, 170–72, 170f–173f
brain tumor misdiagnosed as infarct, 189–90, 189f–191f arachnoid granulation, 178–79, 178f–180f
cavernoma, 157–58, 157f–160f brain tumor misdiagnosed as infarct, 189–90, 189f–191f
CTA disadvantages compared to contrast enhanced CT cavernoma, 157–58, 157f–160f
scan, 174–75, 174f–177f, 177 CTA disadvantages compared to contrast enhanced CT
infarct distinguished from wide sulcus, 181–83, 181f–183f scan, 174–75, 174f–177f, 177
lumbar myelogram, 161–64, 161f–164f infarct distinguished from wide sulcus, 181–83, 181f–183f
missed subdural hemorrhage, 165–66, 165f, 167f–169f lumbar myelogram, 161–64, 161f–164f
random patient motion, 192–93, 192f–195f missed subdural hemorrhage, 165–66, 165f, 167f–169f,
”rule out stroke,” 189–90, 189f–191f 184–85, 184f–188f
sellar masses, 154–55, 154f–156f random patient motion, 192–93, 192f–195f
volume averaging artifact, 152–53, 152f–153f ”rule out stroke,” 189–90, 189f–191f
“noise index,” 32 sellar masses, 154–55, 154f–156f
volume averaging artifact, 152–53, 152f–153f
occipital lobes, 135, 136f pituitary gland, beam hardening and, 227, 227f–228f, 230
optics, 26 pituitary macroadenoma, 155f
optimal dose, 40, 41f pixel size, 13
orbital roof, 115 attenuation values assigned to, 115
osteomyelitis, 168f matrix size relationship with, 115
overbeaming, 26 plastic, 171, 171f
in multidetector CT, 42, 43f pneumocephalus, 151f
overranging, 42–44, 44f pons, 135, 135f
overscanning, 76, 210 encephalomalacia in, 143f
posterior fossa, 120
PAC. See premature atrial contraction artifacts, 140, 140f
Pacchionian granulations, 179 coronal reconstruction helpful for imaging, 182, 182f
partial scan, 59, 59f CT problems imaging, 182
patient comfort, 210 premature atrial contraction (PAC), 94
patient motion. See random patient motion premature ventricular contraction (PVC)
pediatric CT imaging data gaps in disabled ECG synchronization from, 109–10,
radiation dose and, 52–53 111f
subarachnoid space enlargement in, 185, 188f ECG editing for, 87–89, 87f, 88f
penetrating injury, wood and, 171, 173f prospectively triggered high-pitch helical acquisition,
penumbra, 42 66, 67f
peristalsis, 213, 213f prospective triggering
petrous bone, 115 artifacts from, 93–94, 93f, 94f
photoelectric effect, 29, 31f axial imaging and, 60–61
photon starvation heart rate variation and, 94, 94f
arms raised for avoiding, 202–3, 202f–204f radiation dose reduction with tube current modulation and,
beam hardening compared to, 138 84–86, 84f
body CT artifacts with, 202–3, 202f–204f proximal left middle cerebral artery, 164f
in cardiac imaging, 68–69 pseudo-enhancement, renal cyst, 216–17, 216f
coiled aneurysms and, 138, 144f PVC. See premature ventricular contraction
neuro CT artifacts from, 137–39, 137f–139f
titanium aneurysm clips and, 138, 139f QRS complex, 103
pitch
choosing, 44, 45f, 45f radiation cost, 40
high-pitch scanning, 76, 81 radiation dose
prospectively triggered high-pitch helical acquisition and, AEC and reduction of, 50–51
66, 67f cardiac imaging optimizing, 61–66, 62f
scan acquisition speed and, 28, 28f deterministic effects of, 37, 38f
pitfalls, body CT to eye in gantry angulation, 26–27
false-positive venous thrombosis diagnosis, 221–22, heart rate variability and reduction of, 110
221f–222f IR and reduction of, 52
renal cyst pseudo-enhancement, 216–17, 216f kV relationship to, 47
SMV normal low attenuation values, 218–19, 218f–220f mA linear relationship to, 46
pitfalls, neuro CT measures for, 36–37
Index 239
optimal, 40, 41f scan acquisition speed

overranging and, 42–44, 45f in dual-source CT scanning, 29, 30f
pediatric CT imaging and, 52–53 factors determining, 28
reduction techniques for, 40–41 pitch and, 28–29, 28f
stochastic effects of, 38–39 scanograms, 50, 51f
terminology for, 36 artifacts in, 126–27, 126f–129f
tube current modulation adjustments without AEC for, “scan thin, view thick” principle, 16
63–64 segmented acquisition, temporal resolution and, 58–59,
tube current modulation and prospective triggering 104, 104f
reducing, 84–86, 84f septa, 21
tube current modulation linear changes with, 62 shields, 51–52
tube voltage square changes with, 62 Sievert, Rolf, 38
radiation sickness, 37 Sieverts, 38
radioactivity, 39 signal-to-noise ratio (SNR), 16, 48–49
random patient motion cardiac imaging needs with, 66
artifacts from, 75–78, 75f–78f, 126–27, 126f–129f CTA modification of, 73–74
axial imaging and, 76, 78f kV and mA modification for, 74
body CT artifacts from, 209–10, 209f–211f optimizing, 61–66
neuro CT artifacts from, 126–27, 126f–129f tube current modulation increasing, 85–86, 86f
overscanning for, 76 skull base masses, 154–55, 154f–156f
preventing, 76, 78f skull fractures
skull fractures mistaken for, 126–27, 126f–129f in-plane location of, 122, 122f–125f
tracking, 76–77, 78f random patient motion mistaken for, 126–27, 126f–129f
reconstruction. See also coronal reconstruction sagittal reconstruction of, 124, 125f
algebraic, 18, 18f slice thickness and, 116f–118f
beam hardening artifacts appearance in, 141, 143f slice thickness
detector arrays and, 18–19 detector collimation and, 48–49
FBP for, 65–66 historical improvements in, 13–15
interpolation for helical imaging, 19, 21f of multidetector CT, 15
isotropic voxels for, 15–17, 16f skull fractures and, 116f–118f
iterative, 24, 25f SNR and, 16
kymogram-correlated, 100 voxel clarity and, 115, 116f
multiphase, 88–89 slip rings
skull fractures and sagittal, 124, 124f–125f artifacts from, 130–31, 130f–132f, 207–8, 208f
windowing for, 17f, 18 for helical imaging, 8, 12f
recovery time, 23 for television antennas, 11f
“reference mA,” 32 SMV. See superior mesenteric vein
renal cyst pseudo-enhancement, 216–17, 216f SNR. See signal-to-noise ratio
rescheduling examination, 200–201 soft-tissue neck imaging, time delay for, 175, 177f
resolution, 13 solid-state detectors, 207
respiratory motion spectral distribution, 61
cardiac motion differentiated from, 79–82, 79f–82f speed problems, for CT, 177
four-dimensional CT scanning for, 82, 82f spiral CT, 7–8. See also helical imaging
retrospective gating, 60–61 splenic infarct, 204f
CTA and, 101 stair-step artifacts, 110
ECG editing in, 88–89, 88f, 101 step-and-shoot. See axial imaging
right coronary artery (RCA), 110 stochastic effects, of radiation, 38–39
right-sided subdural hemorrhage, 183 streak artifact, 134
rings. See slip rings stroke, rule out, 189–90, 189f–191f
Roentgen, Wilhelm, 2 subarachnoid hemorrhage
rotation time, 23, 28. See also gantry rotation time attenuation values representing, 119–20, 119f–121f
in axial imaging, 29 cerebellar hemorrhage mistaken for, 121f
in helical imaging, 29 hydrocephalus and, 162, 162f–163f
mA and, 45 tentorial, 179, 180f
“rule out infarct,” 145 subarachnoid space
“rule out stroke,” 189–90, 189f–191f air in, 148–49, 148f–151f
pediatric CT imaging showing enlargement of, 185, 188f
sagittal reconstruction, of skull fractures, 124, 125f virtual noncontrast image processing for, 162, 163f–164f
240 INDEX
subcutaneous fat, 171, 172f umbilical ring and chain, 198–99, 198f
subdural hemorrhage
acute, 185, 185f venous air, 149, 151f
attenuation values of, 166 venous thrombosis, 179
chronic, 185, 185f body CT pitfalls of false-positive diagnosis of, 221–22,
cortical ribbon in, 185, 186f 221f–222f
missed, 165–66, 165f, 167f–169f, 184–85, 184f–188f flow artifacts compared to, 222, 222f
right-sided, 183 ventricular diastole, 102–4
superior mesenteric vein (SMV), 218–19, 218f–220f ventricular tachycardia, 100
super vena cava (SVC), 107, 108f virtual noncontrast image processing, 162, 163f–164f
SVC. See super vena cava Volta, Alessandro, 46
sylvian fi ssure, 160f, 190 voltage. See also kilovolt
systole phase, end, 94 measuring, 46
principles of, 45–46
table speed, 28 X-ray beam energy and, 74
television antennas, 11f volume averaging artifacts
temporal resolution body CT pitfalls with, 223–24, 223f–224f
cardiac imaging and, 56–57, 56f neuro CT pitfalls with, 114–15, 114f, 116–18f, 152–53,
for CTA in large patients with dual-source CT scan, 72–74, 152f–153f
72f–74f voxels, 115
dual-source CT scanning improvements for, 59–60, 60f anisotropic, 16f
gantry rotation time and, 56–57, 57t attenuation values, 115
gantry rotation time improvements for, 57–60, 58f isotropic, 15–17, 16f, 26, 26f
partial scan and, 59, 59f resolution and size of, 13
segmented acquisition and, 58–59, 104, 104f slice thickness and clarity of, 115, 116f
test answers, 230–31
test questions, 225–29 wide subarachnoid space, chronic subdural space mistaken for,
thrombus, 179 185, 187f
time delay, 29 wide sulcus, infarct distinguished from, 181–83,
with contrast-enhanced CT scans, 175, 176f 181f–183f
image contrast increasing, 177, 175f windmill artifact, 130–31, 130f–132f
for soft-tissue neck imaging, 175, 177f windowing
titanium, 199 fi lters compared to, 17f
titanium aneurysm clips, 138, 139f reconstruction using, 17f, 18
tomography. See also computed tomography for wood in penetrating injury, 171, 173f
mechanics of, 5f window settings, image contrast and, 166, 167f–169f
X-ray, 3 wood
“translate” movement, 7, 8f appearance variations of, 171
transverse sinus, 179, 179f windowing for penetrating injury with, 171, 173f
asymmetry, 179, 180f
tube current modulation, 50. See also automatic exposure xenon gas detectors, 207
control X-rays. See also beam hardening
cardiac CTA and, 83–86, 83f–86f chest CT effective dose compared to chest,
cardiac imaging cycle matched to, 65 229, 231
ECG and, 64–65, 65f depth limitations of, 4f
irregular heart rates and, 84 discovery and early use of, 2, 2f
photon generation quantity determined by, 61–62, 62f energy composition of, 134
radiation dose linear changes with, 62 helical, 10f
radiation dose reduction with prospective triggering and, helical imaging trajectory of, 21f
84–86, 84f mean energy from anode of, 229, 231
radiation dose without AEC adjusting, 63–64 photoelectric effect with iodine and, 29, 31f
SNR increases with, 85–86, 86f scattering problem of, 2–3, 21
tube voltage tissue contrast limitations of, 2, 3f
radiation dose changes with square of, 62 tomography, 3
spectral distribution quality determined by, 61, 62f voltage and beam energy of, 74

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CT IMAGING

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Supratik Moulik MD Josef P. Debbins PhD, PE, DABMP

Oxford New York

© Oxford University Press 2013

Published in the United States of America by Oxford University Press

All rights reserved. No part of this publication may be reproduced,

Library of Congress Cataloging-in-Publication Data

1 HISTORY AND PHYSICS OF CT IMAGING 1

2 RADIATION SAFETY AND RISKS 35

3 CARDIAC CT IMAGING TECHNIQUES 55

4 CARDIAC CT ARTIFACTS AND PITFALLS 71

5 NEURO CT ARTIFACTS 113

6 NEURO CT PITFALLS 147

7 BODY CT ARTIFACTS 197

8 BODY CT PITFALLS 215

9 TEST QUESTIONS 225

Axial Versus Helical Imaging

Multidetector CT: Beam Collimation Versus Detector

64 - 0.625 mm detector rows

16 - 1.5 mm 32 - 0.625 mm 16 - 1.5 mm

Total width = 7cm

Isotropic Voxels and Reconstructions

Image Reconstruction and Detector Arrays

detectors. This style of reconstruction incorporates the notion of estimation or interpolation of

Cone Beam Imaging

9 8 7 7.5 8 7 6 5.5 5 2.5 0 1.5 3

Gantry Angulation and Image Display

Scan Acquisition Speed

Table Movement in cm During Each Tube Rotation ÷ Beam Collimation in cm (2).

Dual-Energy, Dual-Source CT Scanning

Alexander C. Mamourian and Josef P. Debbins

Patient Dose and Dose Reduction Techniques

Commonly Used Measures of CT Dose

Figure 2.1 Photograph of the typical band-like hair loss

Dose Length Product Conversion to Effective Dose

Techniques for Dose Reduction

ESTIMATING OPTIMAL DOSE

CT Dose Reduction: Indications

Axial Versus Helical Scans

Overbeaming and Overranging

Single detector row

Tube Rotation Time

Detector Collimation and Slice Reconstruction

Automatic Exposure Control

Supratik Moulik and Harold Litt

Temporal Resolution: The Key to Cardiac Imaging

Figure 3.1. Normal cardiac cycle.

5 segment 10 segment 20 segment

171 msec 86 msec* 43 msec

Figure 3.3 Single-source CT scanner with third generation

Table 3.1 Gantry rotation speed for various generations of CT scanners

Gantry rotation time

How Temporal Resolution Can Be Shorter than Gantry

Prospective triggering is a sequential axial acquisition (step-and-shoot) method synchronized to

Methods of CT Dose Optimization

Retrospective Coronary CTA Prospective Coronary CTA

Estimated Dose (mSv)

Nonsynchronization Issues in Cardiac Imaging

Figure 4A.3.2 (Continued)

Figure 4A.3.3 Axial image through lung bases.

unwanted synchronizations, and disabling of unwanted synchronizations. The importance of multi-

Figure 5A.1.2 Lateral scanogram.