Protocols for Multislice CT

4- and 16-row Applications

Roland Bruening
Thomas Flohr
R. Bruening · T. Flohr

Protocols for Multislice CT

4- and 16-row Applications
Springer-Verlag Berlin Heidelberg GmbH
R. Bruening · T. Flohr

Protocols
for Multislice CT
4- and 16-row Applications

With 195 Figures

123
Roland Bruening Thomas Flohr
Neuroradiology Siemens Medical Solutions
Department of Clinical Radiology CT Division
University of Munich – Grosshadern Siemensstr. 1
Marchioninistr. 15 91301 Forchheim
81377 Munich Germany
Germany

ISBN 978-3-540-40584-9 ISBN 978-3-662-05142-9 (eBook)

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

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 Preface

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

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

R. Bruening Munich
T. Flohr Forchheim
 Contributors

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

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

Eibel, R. Haw, Loke Gie

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

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

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

Jaeger, L. Rust, G.F.

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

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

Kulinna, C. Schoepf, U.J.

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

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

4-row Scanning

Head

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

Neck

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

Chest

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

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

Heart

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

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

Abdomen

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

Spine

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

Peripherals

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

Interventions

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

16-row Scanning

Head

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

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

Neck

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

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

Chest

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

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

Heart

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

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

Abdomen

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

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

Spine

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

Peripherals

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

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

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

Technical Principles and Applications

of Multislice Spiral CT

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

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

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

Detector Design

The simplest model of a 4-slice CT detector

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

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

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

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

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

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

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

Fig. 3. Adaptive axial interpolation for a 4-slice CT-system: slice sensitivity profile (SSP) of the 2-mm
slice (for 4×1-mm collimation) for selected pitch values.The functional form of the SSP, and hence the
slice width, is independent of the pitch. Consequently, MPRs of a spiral z-resolution phantom scanned
with 2-mm slice width show clear separation of the 1.5-mm and 2-mm cylinders for all pitch values

∑ The patient dose decreases with increas- Four-Slice Spiral CT: 180° and 360°
ing pitch, according to Eq. 3. Multislice Linear Interpolation
∑ Spiral artifacts gradually increase with Versus Adaptive Axial Interpolation
increasing pitch.
If 180° or 360° linear interpolation tech-
Due to its narrower SSP, the 180° linear in- niques are simply extended to multislice spi-
terpolation is almost exclusively used for ral scanning (180MLI or 360MLI), a compli-
single-slice CT scanning, despite its in- cated dependence of both slice width and
creased susceptibility to artifacts and its in- image noise on the pitch results. As a conse-
creased image noise: for the same mAs, quence, multislice CT scanners relying on
noise is about 15% higher than in sequential 180MLI or 360MLI techniques offer only few
mode. discrete pitch values to the user, such as 3/4
and 6/4. To maintain a free selection of the
pitch according to the clinical needs of an
examination, a generalized nonlinear spiral
weighting approach, the adaptive axial in-
terpolation is recommended (as shown in
the work of Schaller et al. 2000). That paper
introduces a new concept in multislice spiral
 Technical Principles and Applications of Multislice Spiral CT 5

Fig. 4. Axial sampling scheme with four slices. Although the sampling pattern and the sampling den-
sity vary with pitch, the sampling distance in the center of rotation is never larger than the subbeam
collimation for any pitch factor up to 2 (volume pitch up to 8)

scanning: the functional form of the SSP

and consequently the slice width, is com-
pletely independent of the pitch. As an ex-
ample, Fig. 3 shows the SSP of the 2-mm slice
(for 4 ×1-mm collimation) for selected pitch
values.A major reason why a pitch-indepen-
dent SSP can be realized is the axial sam-
pling scheme with multiple slices (see
Fig. 4). Although the sampling pattern and
the sampling density vary with the pitch, the
sampling distance in the center of rotation is
never larger than the subbeam collimation
for any volume pitch up to 8 (corresponding
to pitch factor P≤ 2). For Pvol >4 (P>1), the
complementary rays have to be taken into
account. To achieve a constant SSP, appro-
priate spiral weighting functions are used,
whose functional forms are automatically Fig. 5. With the 4-slice CT scanner evaluated, the
adapted to the pitch and the desired slice tube current is automatically adapted to the
width. pitch to compensate for the increasing axial
sampling density with decreasing pitch. As a
consequence, both image noise and patient
dose are independent of the pitch
Image Noise and Patient Dose

With the adaptive axial interpolation, the current (mA) is adapted to the pitch of the
image noise would decrease with decreasing spiral scan as an automatic procedure (Oh-
pitch if the tube current mA was left un- nesorge 1999). The user selects a certain im-
changed, due to the increasing axial sam- age noise level and hence a certain image
pling density (overlapping spiral sampling). quality by choosing an effective mAs value.
To maintain constant image noise, the tube The tube current is then automatically ad-
6 Technical Principles and Applications of Multislice Spiral CT

a b

Fig. 6. a SSPs for slice widths of 1 mm, 1.25 mm, 1.5 mm, 2 mm, 3 mm, 4 mm, and 5 mm, which are avail-
able for 4 × 1-mm collimation (not shown are the SSPs for slice widths of 6 mm, 7 mm, 8 mm, and
10 mm). b SSPs of the 3-mm slice for 4 × 1-mm and 4 ×2.5-mm collimation. The slice width (FWHM) is
equal, but the profile is more rectangular for the narrow collimation (4 × 1 mm)

justed to the pitch and the rotation time ac- Adaptive Axial Interpolation:
cording to the following (and see also Eq. 3): Key Properties

mA=eff. mAs × 1/trot × P (4) In summary, multislice spiral scanning with

adaptive axial interpolation has the follow-
This relation is graphically sketched in ing properties: freely selectable pitch, slice
Fig. 5. As a consequence, in a deviation from width independent of pitch, image noise in-
single-slice spiral scanning, not only the im- dependent of pitch, and lastly patient dose
age noise but also the patient dose is inde- independent of pitch and simply given by
pendent of the pitch. Introducing Eq. 4 into Dose=eff. mAs × CTDI. Spiral artifacts grad-
Eq. 3 simply yields: ually increase with increasing pitch. (See
“Short Review of Single-Slice Spiral CT” for
Dose=eff. mAs × CTDI (5) a comparison with single-slice spiral CT.)
Using this adaptive axial interpolation,
The spiral dose is therefore constant and slice width and collimation are no longer di-
equal to the dose of a sequential scan with rectly related as with single-slice spiral CT
the same mAs. (Schaller et al. 2000). Instead, for each colli-
mation a variety of different slice widths are
available. For instance, from the data taken
at 4 × 1-mm collimation, any slice width be-
tween 1.0 mm and 10.0 mm may be recon-
structed (as an example, the SSPs up to
5 mm are shown in Fig. 6a). Hence, from the
same data set both narrow slices for high-
contrast details (or as an input for 3D post-
processing) and wide slices for low-contrast
 Technical Principles and Applications of Multislice Spiral CT 7

information (and/or overview and filming) examination technique reconstructing dif-

may be derived. On the other hand, for each ferent slice widths from the same CT raw da-
slice width (e.g., 3 mm) at least two different ta). In combination with the improved rota-
collimation settings are available: a narrow tion speed of 0.5 s, a scan range of 30 cm can
collimation to acquire the data set with be covered in 21 s. Figure 7 shows an exam-
highest axial resolution, i.e., closest to iso- ple of thorax images obtained with this pro-
tropic resolution, and a wider collimation tocol. Please note that the close-to-isotropic
for short examination times (in this exam- resolution enables three-dimensional (3D)
ple, 4×1 mm and 4×2.5 mm).With regard to renderings of diagnostic quality and that
image quality, narrow collimation is prefer- multiplanar reformats (MPRs) and oblique
able to wide collimation, due to better sup- maximum intensity projections (MIPs) are
pression of partial volume artifacts and a of a resolution similar to the original axial
more rectangular slice sensitivity profile images.
(see Fig. 6b), even if the pitch has to be in- We expect that the availability of multi-
creased for equivalent volume coverage. slice CT technology will change the way
Similar to single-slice spiral CT, narrow col- radiologists think about CT imaging. In CT,
limation scanning is the key to the reduction one traditionally distinguishes between
of artifacts and improved image quality. axial and in-plane resolution. It must be
appreciated that this distinction is made
mainly for historical reasons. Before the in-
Applications troduction of spiral CT, axial resolution was
determined by slice collimation only, while
Standard Applications in-plane resolution was determined by the
convolution kernel. With spiral CT, collima-
As mentioned in the introduction, clinical tion is no longer the only factor determining
applications benefit from multislice tech- axial resolution, but the spiral interpolation
nology in several ways: function also has to be considered. This has
been a first step towards decoupling the slice
∑ Shorter scan time (important for exam- width of the images from the beam width
ple in cardiac imaging, CTA) determined by the collimation. Multislice
∑ Extended scan range (important for CTA, CT represents a further step to be taken:
chest-abdomen scans) adaptive axial interpolation allows for re-
∑ Improved axial resolution (beneficial for construction of arbitrary slice widths from a
all reconstructions). given collimation (as long as the desired
slice width is not smaller than the collima-
Some protocols even benefit from a combi- tion). In many applications, narrow collima-
nation of all of these advantages. Consider a tion data are recommended independently
thorax exam with a scan range of 30 cm. In of the slice width desired for primary view-
order to cover that range in a reasonable ing. In practice, two different slice widths
time of around 25 s with a single-slice CT are commonly reconstructed by default:
scanner using 1 s rotation time, a collima- thick slices for filming and thin slices for 3D
tion of 7 mm can be used at a pitch of 2. The postprocessing and evaluation (please refer
breakthrough that multislice technology has to the individual protocols).
brought is not the fact that this exam can Alternatively, one can reconstruct close-
now be performed in a much shorter time to-isotropic high-resolution volumes and
(6 s), but that it can deliver close to isotropic still limit the image noise by making use of
resolution (with 1-mm reconstructions) in thick MPRs. Hence, images with the desired
this time. Thus, a typical thorax protocol us- slice width can be obtained in arbitrary di-
es a collimation of 4× 1 mm at a volume rections. In this approach, the axis of rota-
pitch of 6–7 (e.g., Combi Thorax, a thorax tion and the corresponding axial plane of
8 Technical Principles and Applications of Multislice Spiral CT

Fig. 7. Case study using a fast high-resolution thorax protocol. Collimation 4 ×1 mm, pitch factor 2,
reconstructed slice-width 1.25 mm. Left: axial images show the central thrombosis of the right sub-
clavian vein. Right: maximum intensity projection (MIP) images show different views of the filiform
stenosis of the right brachiocephalic vein proximal to the confluence of the superior vena cava.
(Images courtesy of Dr. Lell, University of Erlangen, Germany)
 Technical Principles and Applications of Multislice Spiral CT 9

reconstruction is no longer a limit for CT

imaging. The transition from CT as a cross-
sectional slice modality to a volume imaging
modality has finally been made. Figure 8
shows an example of an abdominal case
study that has been diagnosed interactively
on a 3D workstation (Virtuoso; Siemens
Medical Solutions, Germany) using a vol-
ume-rendering technique (VRT) by pushing
a clip plane through the volume.

Special Applications

Cardiac CT

One of the most exciting new applications of

multislice CT is the ability to image the
heart. Increased rotation speed combined
with dedicated ECG-synchronized recon-
struction algorithms effectively allow one to
freeze the heart motion (Ohnesorge et al.
2000a,b; Becker et al. 2000). The details of
this new technique have been discussed in
several recent publications, therefore we re-
strict this chapter to a brief overview. One
important application of cardiac CT is the
quantitative evaluation of coronary calcifi-
cation as a risk indicator in asymptomatic
patients, which previously was a domain of
electron beam CT technology (EBT). Stud-
Fig. 8. VRT images rendered on a 3D workstation. ies have shown that ECG-gated spiral imag-
The 3D volume can be explored by interactively ing with reconstruction of overlapping im-
navigating clip planes and manipulating the VRT ages can significantly reduce interscan vari-
settings. The images demonstrate a renal donor ability (Ohnesorge and Flohr 2002). Good
study. The dual-phase CT angiogram provides
repeatability of quantitative measurements
definition of both the potential donor’s renal ar-
tery(s) (top) as well as the venous anatomy (bot- is prerequisite for longitudinal studies, such
tom). This study is used as the guide for laparo- as controlling the same individual for effec-
scopic nephrectomy. Note the two left renal tiveness of medication. Newly developed
arteries. (Images courtesy of Dr. Fishman, Balti- software for quantitative evaluation of coro-
more, USA) nary calcium allows efficient calculation of
the established Agatston score (as well as
other score system values, such as lesion vol-
ume scores and others).
Due to the improved signal-to-noise ra-
tio when compared with EBT and the high-
er axial resolution that can be achieved with
1-mm collimation, it has been shown that al-
so noncalcified (soft) plaques can be visual-
ized with high accuracy when using CTA
10 Technical Principles and Applications of Multislice Spiral CT

Fig. 9. CT angiography of the coronary vessels. Left: normal anato-

my in VRT renderings from standard viewing directions labeled
according to American Heart Association conventions. (Images
courtesy of Dr. Becker, Grosshadern, Munich, Germany). Right:
noncalcified, soft plaques. (Images courtesy of Dr. Schröder, Uni-
versitätsklinikum Tübingen, Germany)
 Technical Principles and Applications of Multislice Spiral CT 11

(Becker et al. 2000). This might turn out to Recent Developments:

be a promising tool for assessing risk for 16-Slice Scanning
myocardial infarction. Figure 9 shows an ex-
ample of coronary CTAs without pathology
(left column) as well as several soft plaques Since their introduction in 1998, 4-slice CT
(right column). systems have been accepted as a clinical
standard. The main advantage of the new
technology can be summarized as rapid
Lung Cancer Screening close-to-isotropic imaging with the ability
to freeze cardiac motion for low to moderate
Another possible future application within heart rates using ECG synchronization. To
the arena of preventive care is the early de- further increase acquisition speed and to al-
tection of lung cancer (Henschke 1999). Ba- low for true isotropic resolution in routine
sic requirements here are the ability to cov- clinical examinations, the tendency toward
er the entire lung in a single breathhold at even narrower collimation and higher num-
sufficient resolution to detect small, suspi- ber of slices continues. Improved temporal
cious nodules while keeping the dose to an resolution for a better clinical stability of
acceptable level. In principle this is also pos- ECG-gated multislice CT examinations of
sible using single-slice CT, but substantial the heart and the coronary arteries, and for
workflow improvements can be achieved us- examination of patients with higher heart
ing multislice CT. In the early lung cancer rates, requires even shorter gantry rotation
action project (ELCAP) study (Henschke et times. In 2001, the first 16-slice CT scanners
al. 1999), suspicious nodules were found in were introduced, representing the next gen-
around 25% of the screened population eration of multislice CT. Similar to estab-
(and these patients accordingly received fur- lished 4-slice systems, these scanners use a
ther work-up). Generally accepted schemes detector with, for example, 24 detector rows
for work-up of small nodules is to follow offering simultaneous acquisition of 16 slic-
and monitor their growth, or to surgically es with 0.75-mm or 1.5-mm beam collima-
remove them, depending on various factors. tion. Figure 10 shows a schematic drawing
However, accurate volume assessment of of the detector (Siemens) and a picture of a
small nodules requires high-resolution data detector module. The key difficulty for im-
sets and could not be based on the ELCAP age reconstruction with 16-slice CT systems
initial screening study. Therefore, the perti- is the fact that, in contrast to single-slice CT,
nent patients had to be rescheduled. With the acquired rays are no longer perpendicu-
multislice CT, the screening scan can be lar to the axis of rotation, but are tilted by
done at high resolution, obviating the need the cone angle.While neglect of this effect in
for rescheduling. We propose a protocol us- all currently available 4-slice CT systems is
ing a 4× 1-mm collimation at 0.5-s rotation justified in theory, it is mandatory to ac-
and volume pitch 7 (pitch factor 1.75), cov- count for the cone angle in systems with 16
ering a 30-cm range in 21 s.With 120 kV and slices.
20 eff. mAs, the effective patient dose is be- A newly developed image reconstruction
low 1 mSv, which is less than the natural technique adaptive multiple plane recon-
background radiation exposure of half a struction (AMPR) (Schaller 2001; Flohr et al.
year. 2002) delivers high-quality images at opti-
mum dose usage over a wide range of pitch
values. As an intermediate step, employing
the AMPR approach, a variety of partial im-
ages on double oblique image planes are cal-
culated, which are individually adapted to
the spiral path and to the multislice detector
12 Technical Principles and Applications of Multislice Spiral CT

Fig. 10. Adaptive array detector of a recently introduced 16-slice CT system. Left: schematic drawing.
By proper combination of the signals of the 24 detector rows, the basic collimations of 16 ×0.75 mm
and 16 ×1.5 mm can be realized. Right: picture of a detector module, which consists of 16 ×24 detec-
tor elements

Fig. 11. Schematic of the adaptive multiple plane reconstruction, AMPR. Left: depending on the spiral
pitch, the multislice raw data are divided into overlapping segments. As an intermediate step, a vari-
ety of partial images on double oblique image planes are calculated, which are individually adapted
to the spiral path and to the multislice detector geometry and fan out like the pages of a book. Right:
the final images are obtained by an axial interpolation between the tilted partial image planes, simi-
lar to an MPR

geometry, and these fan out like the pages of due to an automatic adjustment of the tube
a book (see Fig. 11a). The final images with current according to Eq. 4. For the CT scan-
full dose utilization are obtained by an ap- ner evaluated, the pitch factor ranges be-
propriate axial interpolation between the tween 0.5 and 1.5. Figure 12 shows images of
tilted partial image planes, similar to an a pelvis phantom scanned with 16× 1.5-mm
MPR (Fig. 11b). The shape and the width of collimation, 0.5-s gantry rotation time, pitch
the interpolation function are freely select- factor P=1, corresponding to a table feed of
able; different slice sensitivity profiles (SSP) 48 mm/s, on the left side for a reconstruc-
and hence different slice widths can there- tion neglecting the cone angle of the mea-
fore easily be adjusted in this z-reformation surement rays, on the right side for AMPR.
step. Furthermore, the spiral concept intro- The conventional approach without consid-
duced with adaptive axial interpolation can eration of the cone-beam geometry leads to
be maintained with AMPR: the spiral pitch severe artifacts and geometrical distortions
is freely selectable, the slice width is inde- of high-contrast objects (Fig. 12, left). Cone
pendent of the pitch. Both patient dose and artifacts are considerably reduced with the
image noise are independent of the pitch, AMPR algorithm, and the spatial integrity of
 Technical Principles and Applications of Multislice Spiral CT 13

Fig. 12. Axial slice (top) and MPR (bottom) of a pelvis phantom scanned with a recently introduced 16-
slice CT system, 16× 1.5-mm collimation, 2-mm reconstructed slice width, 0.5-s rotation time, pitch
factor 1.0, i.e., table feed 48 mm/s. Left: conventional multislice spiral reconstruction neglecting the
cone angle of the measurement rays. Cone-beam artifacts are indicated by arrows. Right: AMPR. Cone-
beam artifacts are effectively suppressed

the objects is restored (Fig. 12, right). Using axial resolution of 0.6 mm, the ideal of true
16 × 0.75-mm collimation and overlapping isotropic resolution for routine applications
image reconstruction, it is possible to main- has finally been reached with state-of-the-
tain an axial resolution of about 0.6 mm in- art 16-slice CT-systems. For ECG-gated
dependent of the pitch. This is demonstrat- scanning, the CT scanner evaluated offers a
ed by Fig. 13, which shows MPRs of a minimum gantry rotation time of 0.42 s to
z-resolution phantom scanned at pitch fac- provide a temporal resolution of up to
tors P=0.75, 1.0, 1.25, and 1.5. Overlapping 105 ms for clinically robust cardiac imaging
images with 0.75-mm slice width and 0.4- even at higher heart rates.
mm increment were reconstructed, and Improved axial resolution goes hand in
MPRs in the axial direction were generated. hand with considerably reduced scan times,
Independent of the pitch, all cylinders down facilitating the examination of uncoopera-
to 0.6-mm diameter can be clearly resolved tive patients and reducing the amount of
and the MPRs are free of geometric distor- contrast agent needed – but also requiring
tions. With an in-plane resolution of about optimized contrast agent protocols. Fur-
0.5 mm using a standard body kernel and an thermore, new clinical applications will
14 Technical Principles and Applications of Multislice Spiral CT

manage the huge amounts of data generated

and not cause a bottleneck in the flow of
clinical diagnosis and treatment.

References
Becker C, Knez A, Ohnesorge B, Schöpf UJ, Reiser
MF (2000) Imaging of non-calcified coronary
plaques using helical CT with retrospective
gating. AJR:175
Flohr T, Stierstorfer K, Bruder H, Simon J, Schal-
ler S (2002) New technical developments in
multislice CT. Part 1: approaching isotropic
resolution with sub-millimeter 16-slice scan-
ning. RöFo 174:839–845
Henschke CI, McCauley DI, Yankelevitz DF, Nai-
dich DP, McGuinness G, Miettinnen OS, Libby
DM, Pasmantier MW, Koizumi J, Altorki AK,
Smith JP (1999) Early lung cancer action proj-
ect, overall design and findings from baseline
screening. Lancet 354:99–105
Ohnesorge B, Flohr T, Schaller S, Klingenbeck-
Regn K, Becker C, Schöpf UJ, Brüning R, Rei-
ser MF (1999) Technische Grundlagen und
Fig. 13. MPRs of a z-resolution phantom scanned Anwendungen der Mehrschicht-CT. Radiolo-
with 16× 0.75-mm collimation at pitch factors P = ge 39:923–931
0.75, 1.0, 1.25, and 1.5, reconstruction slice width Ohnesorge B, Flohr T, Becker CR, Kopp AF, Knez
of 0.75 mm. Independent of the pitch, all cylin- A, Baum U, Klingenbeck-Regn K, Reiser MF
ders down to a 0.6-mm diameter can be clearly (2000a) Cardiac imaging by means of electro-
resolved and the MPRs are free of geometric dis- cardiographically gated multisection spiral
tortions, thus proving the spatial integrity of the CT – initial experience. Radiology 217:564–
3D image 571
Ohnesorge B, Flohr T, Becker C, Knez A, Kopp A,
Fukuda K, Reiser M (2000b) Herzbildgebung
evolve as a result of the tremendously in- mit schneller, retrospektiv EKG-synchroni-
sierter Mehrschichtspiral CT. Radiologe 40:
creased volume scan speed. CTA examina-
111–117
tions in the pure arterial phase will become Ohnesorge B, Flohr T, Fischbach R, Kopp AF, Knez
feasible. A CTA of the circle of Willis with A, Schröder S, Schöpf UJ, Crispin A, Klotz E,
0.75-mm collimation, 0.5-s rotation time, Reiser MF, Becker CR (2002) Reproducibility
and pitch factor 1.5 requires only 3.5 s for a of coronary calcium quantification in repeat
scan range of 100 mm (table feed 36 mm/s). examinations with retrospectively ECG-gated
Examining the entire thorax (350 mm) with multisection spiral CT. Eur Radiol 12:1532–
0.75-mm collimation, 0.5-s rotation time, 1540
and pitch factor 1.375 (table feed 33 mm/s) Schaller S, Flohr T, Klingenbeck K, Krause J, Fuchs
T, Kalender WA (2000) Spiral interpolation al-
can be done in 11 s.
gorithm for multi-slice spiral CT. Part I: Theo-
In conclusion, 16-slice technology will al- ry. IEEE Trans Med Imag 19:822–834
low for isotropic imaging in virtually any Schaller S, Stierstorfer K, Bruder H, Kachelriess
application. Consequently, the number of M, Flohr T (2001) Novel approximate ap-
slices reconstructed will increase even fur- proach for high-quality image reconstruction
ther, and those involved with network and in helical cone beam CT at arbitrary pitch.
workstation performance can be expected Proc SPIE Int Symp Med Imag 2001
to experience great pressure to properly
4-row Scanning
16 4-row Scanning Head

Routine CCT

Indications. Differential diagnosis cerebral infarct, intracranial bleeding, traumata (includ-

ing skull fractures, see “Comments”), unconsciousness, atrophy, central neural disturbances
of unclear origin, hydrocephalus.

Patient Positioning. Supine, arms bilaterally downward, use of headrest recommended.

Topogram 3D Reconstructions
MIP No
MPR No
VRT No
Other No

Criteria of Good Image Quality

1. Symmetric positioning of the patient’s
head.
2. Absence of motion artifacts.

Fig. 1. Region: from skull base upward

(use gantry tilt if necessary)
Caveat
1. If the patient tends to move, positioning
devices should be used in addition to the
headrest.
Example of Axial Scan

Fig. 2 a, b
 Routine CCT 17

Scan Parameters
Parameter Mode
Spiral 1 (skull base) Spiral 2 (cerebrum)
Collimation 4 ¥ 1 mm 4 ¥ 2.5 mm
Pitch factor 0.65–0.75 0.65–0.75
Reconstruction 4 mm 5–8 mm
Rotation time 0.75 s 0.75 s
Scan orientation Caudo-cranial Caudo-cranial
Scanner settings 120 kV, 300 eff. mAsa 120 kV, 300 eff. mAsa
Kernel (algorithm) Soft (brain) Soft (brain)
Window 120/45 80/35
(width/center)
Contrast medium No
Administration
Volume
Flow rate
Scan delay
a
All mAs values in the scan protocols are effective mAs values; please refer to the technical
overview chapter for definition.

Comments
The decision whether spiral or sequential data acquisition will be utilized in the future will
be the subject of further debate.
For the detection or exclusion of skull fractures, a subsequent (second) reconstruction of
the raw data with a high-resolution bone kernel is recommended. Even though this second
reconstruction is usually sufficient for an overview, for suspected temporal bone fractures
the protocol “Temporal Bone and Inner Ear,” and for maxillofacial fractures the protocol
“Routine Sinuses” (under “Neck”) must be added.
In the example given in Fig. 2a, an ischemia with secondary bleeding on the left in a
young adult is shown. In Fig. 2b, early signs are visible of a partial infarction of the left MCA
territory.
18 4-row Scanning Head

Contrast-Enhanced CCT

Indications. Exclusion or detection of brain tumor, cerebral metastasis, or intracranial

abscess.

Patient Positioning. Supine, arms bilaterally downward, use of headrest recommended.

Topogram 3D Reconstructions
MIP In selected cases
MPR In selected cases
VRT No
Other In selected casesa
a
MIP or SSD

Criteria of Good Image Quality

1. Low noise.
2. Enhanced density from contrast material
in the sagittal sinus.
3. Symmetric positioning.
Fig. 1. Region: from skull base upward
(use gantry tilt if necessary)
Caveats
1. If the patient tends to move, positioning
Example of Axial Scan devices should be used.
2. Identical slice positions should be en-
sured for contrast-enhanced CCT and
unenhanced CCT.

Fig. 2a–c.
 Contrast-Enhanced CCT 19

Scan Parameters
Parameter Mode
Spiral 1 (skull base) Spiral 2 (cerebrum)
Collimation 4 ¥ 1 mm 4 ¥ 2.5 mm
Pitch factor 0.65–0.75 0.65–0.75
Reconstruction 4 mm 5–8 mm
Rotation time 0.75 s 0.75 s
Scan orientation Caudo-cranial Caudo-cranial
Scanner settings 120 kV, 300 eff. mAs 120 kV, 300 eff. mAs
Kernel (algorithm) Soft (brain) Soft (brain)
Window 120/45 80/35
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 100 ml
Flow rate 3 ml/s
Scan delay 40 s Start second spiral immediately

Comments
The decision whether spiral or sequential data acquisition will be utilized in the future, will
be the subject of further debate.
One of the advantages of spiral (helical) thin-collimation scanning is shown in Figs. 1
and 2. In Fig. 2a, there is a left frontal hyperdense spot. The thin-collimation spiral data
allowed further reconstruction of MIPs (Fig. 2b) and SSD (Fig. 2c) from the same data set,
without exposing the patient to a second scan. The diagnosis was developmental venous
abnormality (DVA).
20 4-row Scanning Head

Temporal Bone and Inner Ear

Indications. Posttraumatic fracture of the temporal bone, cholesteatoma and chronic otitis
media as preoperative work-up, otosclerosis, tumors of the cerebellopontine angle (if MRI
is not possible), postsurgical complications.

Patient Positioning. Supine, arms bilaterally downward, use headrest.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
Oblique coronal and oblique sagittal (along
and perpendicular to temporal bone axis; see
“Comments”).

Criteria of Good Image Quality

1. Sufficient delineation of ossicles, tym-
panic cavity, and mastoid cells.
2. MPR reconstruction devoid of stepping
artifacts.
Fig. 1. Region: upper mastoid cells to lower end
of mastoid (avoid lenses)
Caveats
Example of Axial Scan 1. Patient positioning and gantry tilt must
avoid direct exposure of the lenses.
2. The temporal bone needs a separate MPR
with an FOV (<9 cm) for each side.

Fig. 2a, b.
 Temporal Bone and Inner Ear 21

Scan Parameters
Parameter Mode
Spiral
Collimation 2 ¥ 0.5 mm
Pitch factor 1.0
Reconstruction Slice 0.5 mm, increment 0.2 mm for MPR, 0.5/1 mm filming
Rotation time 0.75–1.0 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 120 eff. mAs
Kernel (algorithm) Ultra sharp
Window 2,000/300
(width/center)
Contrast medium No
Administration
Volume
Flow rate
Scan delay

Comments
In our setting, the axial image data acquisition and the subsequent coronal (and sagittal)
MPRs are replacing the image acquisition in both planes. However, there can also be a direct
coronal acquisition performed in either supine or prone position. In the protocol suggested,
however, the quality of the coronal MPRs are sufficient to replace the primary coronal image
acquisition.
Figure 2a shows the detail possible with a 0.5-mm data acquisition and a reconstruction
using the high-resolution kernel on a patient with a transverse fracture of the temporal
bone.
Figure 2b shows an MPR of the same patient; a double-angulated reconstruction plane
allows visualization of the extent of the fracture.
A marked reduction of dose can be considered e.g., for children, then 120 kV, 80–100 mAs
should be sufficient.
22 4-row Scanning Head

CTA Intracranial Aneurysm

Indications. Suspected inzidental intracranial aneurysm, detection of intracranial an-

eurysm after subarachnoid hemorrhage, suspected arterial occlusion (see “Comments”),
noninvasive diagnosis of suspected occlusion, AV malformations.

Patient Positioning. Supine, arms downward, use of headrest recommended.

Topogram 3D Reconstructions
MIP Yesa
MPR Yes
VRT Yes
Other No
a
STS MIPs or thin MPRs give the best in-
formation (e.g., 3-mm thickness, 1.5-mm
increment).

Criteria of Good Image Quality

1. High contrast of the arterial vessels.
2. No or little contrast media in the veins.
3. Thin overlapping reconstructions for
Fig. 1. Region: the scan range should be adapted good reconstruction quality.
to the suspected area (sample for circle of Willis)
Caveats
1. Timing of the contrast injection is critical
(a test bolus injection or bolus tuning is
recommended).
2. A routine (unenhanced) CCT should pre-
Example of Axial Scan cede this protocol.

Fig 2 a–d
 CTA Intracranial Aneurysm 23

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mm
Pitch factor 1.0–1.5
Reconstruction Slice 1.25 mm, increment 0.8 mm
Rotation time 0.5 s
Scan orientation Caudo-cranial
Scanner settings 120 kV, 90–180 eff. mAs
Kernel (algorithm) Soft
Window 400/100
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 120 ml
Flow rate 3 ml/s
Scan delay 20 s (test bolus or bolus tuning recommended)

Comments
Depending on the individual need, various postprocessing procedures can be used. Initially,
axial slices can be reconstructed (Fig. 2a). For an overview,VRT can be seen in Fig. 2b, where
the aneurysm at the carotid bifurcation is visualized. However, a close-up reconstruction
using VRT (Fig. 2c) can show the exact relationship of the aneurysmal sac, the aneurysmal
neck, and the neighboring vessels. Also, a sagittal MPR may be of help (Fig. 2d).
When MPRs or other reconstructions are planned, the reconstruction increment should
be reduced to 0.6 mm with 50% overlap.
The tube voltage recommended for cerebral CTA is currently under discussion and may
be reduced even below 100 kV; the mAs should be varied depending on the scan range and
the noise reduction necessary.
24 4-row Scanning Head

Venous Sinus CTA

Indications. Suspected thrombosis of the cerebral sinuses or thrombosis of the large cere-
bral veins.

Patient Positioning. Supine, arms downward.

Topogram 3D Reconstructions
MIP Yesa
MPR No
VRT Yesa
Other No
a
Either postprocessing procedure recommend-
ed.

Criteria of Good Image Quality

1. Sufficient contrast enhancement of all
sinuses/veins.
2. Thin overlapping axial reconstructions
for high-quality MIP.
Fig. 1. Region: coverage of the entire brain is nec-
essary Caveats
1. Venous filling takes time.
2. Axial slices and MIPs both have to be
read in order to reach a diagnosis.
3. A routine head protocol (CCT) should
Example of Axial Scan precede this protocol.

Fig. 2 a–c. (Case courtesy of Dr. B. Ertl-Wagner)

 Venous Sinus CTA 25

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mm
Pitch factor 1.0–1.5
Reconstruction Slice 1.25 mm, increment 1 mm
Rotation time 0.5 s
Scan orientation Caudo-cranial
Scanner settings 120 kV, 90–180 eff. mAs
Kernel (algorithm) Soft
Window 120/45
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 120 ml
Flow rate 3 ml/s
Scan delay 100 s

Comments
This protocol can be used to detect or exclude a thrombosis of the superior sagittal sinus,
the sigmoid sinus, or the large cephalic veins. CTA is not capable of detecting or excluding
a cavernous sinus thrombosis or of the cephalic veins.
Figure 2a shows an example of an axial cut in a female patient with bleeding and an
extensive sinus vein thrombosis, Fig. 2b is a coronal MIP reconstruction, and Fig. 2c is a MIP
reconstruction showing the full extent of the thrombosis in the superior sagittal sinus.
26 4-row Scanning Head

Cerebral Perfusion

Indications. Suspected early stage of cerebral infarction, cerebral ischemia pretherapy.

Patient Positioning. Supine, arms downward, use of headrest recommended.

Topogram 3D Reconstructions
MIP No
MPR No
VRT No
Other Yesa
a
Special postprocessing is necessary to derive
blood flow, blood volume, and other hemo-
dynamic parameters (see “Comments”).

Criteria of Good Image Quality

1. No head movement during the repeated
scans.
Fig. 1. Region: two parallel slices in the region of 2. Measurable arterial input function as
the basal ganglia (avoid lenses) vascular reference.
3. Injection of compact bolus.

Caveats
1. No movement must occur during the
scan; sometimes restraints have to be
Example of Axial Scan used.
2. Large-caliber venous access is necessary.
3. An unenhanced CCT should precede this
protocol.

Fig.2 a–c. Right MCA occluded by embolic throm-

bus
 Cerebral Perfusion 27

Scan Parameters
Parameter Mode
Sequential multiscan
Collimation 4 ¥ 5 mm
Pitch factor 0, no table feed
Reconstruction 2 ¥ 10 mm
Rotation time 1.0 s
Scan orientation Caudo-cranial
Scanner settings 120 kV, > 110 mAs
Kernel (algorithm) Soft
Window 120/45
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 40–50ml
Flow rate 8 ml/s (5–10 ml/s)
Scan delay 0 s, repeat scanning

Comments
Perfusion CT is a modern imaging procedure for visualizing local cerebral perfusion. The
findings on the perfusion maps are positive much earlier than on a normal CCT scan. Thus,
perfusion CT is used for early detection of ischemia. Various parameters can be calculated
from this dynamic examination:
1. Relative cerebral blood flow (CBF) can be calculated as CBF=CBV/MTT or as max. gra-
dient of curve/max. peak enhancement. CBF is reduced in the patient with embolic MCA
occlusion shown in Fig. 2a.
2. Relative cerebral blood volume (CBV) represents the intravascular volume within a given
cerebral structure (Fig. 2b).
3. Other parameters such as “time to peak” (TTP; Fig. 2c), which detects a delayed arrival
of the contrast bolus.
In suspected acute cerebral ischemia, in order to
save time the perfusion scan should immediately
follow the routine CCT. In most centers, prerequi-
sites for a therapeutic lysis are a normal CCT, posi-
tive clinical signs, and a vascular study (perfusion
CT and angiography or ultrasound) indicative of
vascular occlusion. The findings on the rCBF/rCBV
maps are positive much earlier than a normal CCT
scan. Thus, it can be used for early detection of
ischemia.
The lenses should not be in the scan planes.
28 4-row Scanning Neck

Routine Neck

Indications. Suspected cervical lymph nodes, lymphoma, abscesses, phlegmonous inflam-

mation, staging and restaging thyroid goiter (hyperthyroidism).

Patient Positioning. Supine, arms downward, remove dental prostheses, necklaces, etc.

Topogram 3D Reconstructions
If many dental fillings are present, two dif- Image reconstruction in the axial plane is
ferent spiral acquisitions with angulation recommended.
are used. The shoulder should be lowered as
much as possible. MIP No
MPR No
VRT No
Other No

Criteria of Good Image Quality

1. Contrast opacification of arteries and
veins more than 120 HU.
2. No swallowing artefacts.
3. Gantry parallel to C4–C5 intervertebral
space.

Fig. 1. Region: hard palate to upper mediastinum

(parallel to hard palate or dental fillings)
Caveats
1. Motion artifacts should be minimized.
Example of Axial Scan 2. Dental artifacts may obscure enlarged
retropharyngeal nodes (artifacts are
minimized with 1-mm collimation).

Fig. 2.
 Routine Neck 29

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 2.5
Pitch factor 1.375–1.5
Reconstruction 5 mm
Rotation time 0.75 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 150 eff. mAs
Kernel (algorithm) Soft
Window 380/50
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 80–110 ml
Flow rate 3 ml/s
Scan delay 45 s

Comments
The short investigation time with the breathhold technique decreases the likelihood of
movement artifacts.
A flexible FOV should be used to enlarge areas of interest (anterior portion of the neck).
Thin-collimation imaging decreases dental artifacts. If severe artifacts are present, angu-
lation of the gantry may be necessary.An example of the routine neck technique in a patient
with hypopharyngeal and supraglottic infiltration is shown in an axial slice in Fig. 2.
30 4-row Scanning Neck

Routine Sinuses

Indications. Trauma to facial skeleton (including LeFort fractures), inflammatory disease

(benign sinusitis), septum deviation and exclusion of cysts or polyps for preoperative work-
up, polyposis, preoperative work-up for corrective surgery.

Patient Positioning. Supine, all scans are performed in the axial plane, arms downward, use
headrest.

Topogram 3D Reconstructions
See “Comments”. Alternatively, also direct MIP No
coronal image acquisition in either supine MPR Yesa
or prone position as possible. VRT No
Other No
a
For sinusitis and polyposis, image reconstruc-
tion in the coronal plane is recommended
and may alone be sufficient for image read-
ing. For trauma and fractures, image recon-
struction in at least the axial and the coronal
plane is recommended.

Criteria of Good Image Quality

1. Artifact-free reconstructions of all sinu-
ses and of the entire facial skeleton.
2. Absence of motion artifacts.
Fig. 1. Region: including frontal sinus to alveolar
ridge (dental roots; axial scan)
Caveat
Example of Reconstruction 1. Dental artifacts should not alter the scan
Quality quality or obscure the sinuses.

Fig. 2a, b.
 Routine Sinuses 31

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mm
Pitch factor 0.875–1.25
Reconstruction 2 mm
Rotation time 0.75 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 70–100 eff. mAs
Kernel (algorithm) Bone
Window 2,000/300
(width/center)
Contrast medium No
Administration
Volume
Flow rate
Scan delay

Comments
Since the lenses are within the scanned region, a reduction of the tube current is strongly
suggested.
Due to the high percentage of artifacts caused by dental fillings, we suggest the general
use of this protocol with axial scanning and the reading of coronal MPRs alone for the work-
up of benign sinus disease. Alternatively, coronal acquisition can be performed and recon-
structed.
Due to the high contrast of tissue versus air, tube current can be reduced to about 70 mAs.
This helps reduce the dose. However, a clear indication for the CT is warranted. Use this pro-
tocol for benign sinusitis (Fig. 2) or fractures only. For the staging and differentiation of
tumor or mucoceles, the “Sinus Tumors” protocol is recommended. For the appropriate
appreciation of fractures, the reading of the MPRs in axial and
coronal planes are recommended. The data acquired can also be
used for virtual endoscopy (Fig. 3). While this technique is still
under investigation, benefits may include safer endonasal sur-
gery, especially of the ethmoids.

Fig. 3.
32 4-row Scanning Neck

Sinus Tumors

Indications. Fungal disease of the sinuses, granulomatosis, mucocele, papilloma, carcinoma

of the sinuses, other sinonasal tumors and tumor-like conditions.

Patient Positioning. Supine, arms downward, use headrest.

Topogram 3D Reconstructions
MIP No
MPR Yes
VRT No
Other No

Image reconstructions in axial and coronal

planes in both soft tissue and bone kernel
are recommended. MPR reconstructions in
the soft-tissue kernel should be made with
3–4-mm reconstruction thickness for opti-
mal quality.

Fig. 1. Region: including frontal sinus to alveolar

ridge (dental roots)
Criteria of Good Image Quality
1. Artifact-free reconstructions of the
entire facial skeleton including infratem-
Example of Axial Scan poral space.

Caveat
1. For lymph node staging, an additional
investigation is necessary (see “Routine
Neck”).

Fig. 2. (Case courtesy of Dr. L. Jaeger)

 Sinus Tumors 33

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mm
Pitch factor 0.875
Reconstruction 2 mm
Rotation time 0.75 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 140 eff. mAs
Kernel (algorithm) Soft tissue and bone
Window 450/60 + 2,000/300
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 100 ml
Flow rate 3 ml/sec
Scan delay 40 s

Comments
A higher dose compared to the “Routine Sinuses” protocol is necessary in order to visualize
the soft tissue. For the detection or exclusion of bone erosion, the bone kernel is necessary.
If lymph node extension is not known, add the protocol “Routine Neck.” Alternatively, a
direct coronal image acquisition in either the supine or prone position is possible. If a tumor
with intracranial infiltration is suspected, coronar reconstructing (MPR) and a contrast
enhanced MRI should be performed.
Figure 2 shows an example of aspergillosis of the right maxillary sinus.
34 4-row Scanning Neck

Nasopharynx and Oropharynx

Indications. Complications of inflammation such as abscesses, tumors in the naso- or

oropharynx of either benign or malignant origin, masses of the salivary glands, suspected
arrosion of skull base.

Patient Positioning. Supine, arms (and shoulders) downward, remove dental prostheses
and necklaces, etc.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
Image reconstructions in coronal planes in
soft tissue are recommended in all cases of
suspected skull base infiltration, in extensive
tumor extension, and in postsurgical cases
where anatomy is obscured.

Criteria of Good Image Quality

Fig. 1. Region: frontal sinus to upper mediasti-
num 1. High-quality axial scans.
2. Sufficient opacification of the vessels.

Caveat
Example of Axial Scan
1. For lymph node staging, an additional
spiral is necessary (see “Routine Neck”).

Fig. 2 a–c. (Case courtesy of Dr. L. Jaeger)

 Nasopharynx and Oropharynx 35

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mm
Pitch factor 1.375–1.5
Reconstruction 2–3 mm
Rotation time 0.75 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 140–150 eff. mAs
Kernel (algorithm) Soft and bonea
Window 450/60 + 2,000/300
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 100 ml
Flow rate 3 ml/s
Scan delay 40 s
a
Coronal MPR reconstructions in bone kernel could be made to exclude skull base infiltration; oth-
erwise the skull base should be evaluated by bone kernel and/or direct coronal cuts, as necessary.

Comments
In order to visualize the mass and to define its maximum extent and the differential diag-
nosis, both CT and MRI may be necessary. For the detection or exclusion of bone erosion,
bone kernel or coronal MPRs are necessary. If lymph node extension is not known, add the
“Routine Neck” protocol.
Figure 2 shows a tumor of the left nasopharynx invading the skull base (Fig. 2a), the
osseous part of the middle cranial fossa (Fig. 2b). While the osseous destructions is best
observed in the coronal MPRs of the CT, the
MRI has superior sensitivity to detect intracra-
nial infiltrations (Fig. 2c).
36 4-row Scanning Neck

Larynx and Hypopharynx

Indications. Laryngeal fractures, laryngeal inflammation of unknown origin, benign and

malignant laryngeal tumors, laryngoceles, tumors of the hypopharynx.

Patient Positioning. Supine, arms downward, remove dental prostheses, necklaces, etc.

Topogram 3D Reconstructions
See “Comments.” With regard to both “e” – MIP No
phonation and breathhold, attempt should MPR Yes
be made to avoid artifacts from lots of den- VRT No
tal fillings. The shoulder(s) should be low- Other No
ered as much as possible.

Image reconstructions in the coronal and

sagittal planes with soft-tissue kernels are
recommended (for fractures, bone kernel).

Criteria of Good Image Quality

1. High-quality coronal reconstructions.
2. Breathhold imaging of both spirals.

Caveats
1. The scan level to scan the larynx varies
Fig. 1. Region: from the mandible to the subglot- with each patient; check should be made
tic region; two spirals, breathhold and “e” phona- that the entire larynx is on the scan.
tion 2. The patient should be properly instruct-
ed before the examination.
Example of Axial Scan
 Larynx and Hypopharynx 37

Scan Parameters
Parameter Mode
Spiral 1 (breathhold) Spiral 2 (phonation)
Collimation 4 ¥ 1 mm 4 ¥ 1 mm
Pitch factor 1.375–1.5 1.375–1.5
Reconstruction Slice 1 mm, Slice 1 mm,
increment 0.5 mm increment 0.5 mm
Rotation time 0.75 s 0.75 s
Scan orientation Cranio-caudal Cranio-caudal
Scanner settings 120 kV, 180 eff. mAs 120 kV, 180 eff. mAs
Kernel (algorithm) Softa Softa
Window 450/60 450/60
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 100 ml
Flow rate 3 ml/s
Scan delay 40 s Start second spiral immediately
a
For fractures, alter the suggested protocol with bone kernel reconstruction in breathhold, if possi-
ble.

Comments
Breathhold imaging is a general requirement. For the differentiation of T2 and T3 laryngeal
carcinoma, the movement of the vocal cord is crucial. Repeat scanning of the larynx with “e”
phonation; quiet breathing and the Valsalva maneuver then become necessary. Vocal cord
paralysis is readily possible to document.
Every third image is filmed.
While the axial image is important and gives very high spatial resolution (Fig. 2a), coro-
nal (Fig. 2b) and sagittal (Fig. 2c) MPR reconstructions significantly contribute to the
understanding of the infiltration pattern. They are recommended especially for preopera-
tive staging.
For nodal staging, add a spiral examination of the neck (“Routine Neck” protocol).

Fig. 2 a–c.
38 4-row Scanning Neck

CTA Carotids

Indications. Suspected stenosis, occlusion or dissection of the common or internal carotid

artery or parts thereof.

Patient Positioning. Supine, arms downward, remove dental prostheses, necklaces, etc.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT Yes
Other No
a
STS-MPR can be used for reconstructions;
however, segmentation will be necessary in
the skull base.

Criteria of Good Image Quality

1. High opacification of the carotid artery.
2. Little contrast in the jugular vein.

Fig. 1. Region: from 3–4 cm above the sella tur-

cica to the collarbone Caveats
1. Scan and contrast timing is critical.
2. A test bolus injection is recommended.
Example of Axial Scan

Fig. 2 a–c. (Case courtesy of Dr. B. Wintersperger, Munich)

 CTA Carotids 39

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mm
Pitch factor 1.375–2.0
Reconstruction Slice 1.5 mm, increment 0.8 mm
Rotation time 0.5 s
Scan orientation Caudo-cranial
Scanner settings 120 kV, 100–150 eff. mAs
Kernel (algorithm) Soft
Window 380/50
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 100 ml
Flow rate 3–5 ml/s
Scan delay 12 sa
a
A test bolus or bolus triggering is recommended for the exact timing of the injection. The best
reconstruction quality will be achieved when the artery has the maximum contrast opacification,
and the jugular vein the minimum.

Comments
As the scan of the entire carotid will take about 20 s (at 1 mm the current maximum table
speed is 16 mm/s), the caudo-cranial direction is recommended for bifurcation stenosis. If
the suspected disease is in the more cranial part (e.g., dissection of the ICA), cranio-caudal
scanning may be better.
For a quick overview,VRT reconstructions seem to be very efficient. However, maximum
reproducibility is achieved by axial scans in
area measurements.
If no MPR reconstruction is planned, the
reconstruction increment can be as large as
5 mm. When MPRs are planned, the recon-
struction increment should be reduced to
0.8 mm with 50% overlap.
Figure 2 shows a CTA of the carotids in a
young male patient with an ICA occlusion
(dissection) on the left side. Coronal and
sagittal MPR reconstructions of the left ICA
in this patient are seen in Fig. 2a,b. An
example of a VRT reconstruction (same
patient) can be seen in Fig. 2c.
40 4-row Scanning Chest

Routine Chest and HR-Chest

Indications. Mediastinal and axillary lymph nodes; tumors of the anterior, medial, and pos-
terior mediastinum; posterior mediastinum, including thyroid goiter; staging; thoracic
abnormalities (e.g., situs inversus viscerum); abscesses.

Patient Positioning. Supine position, arm(s) elevated over the head (in asbestosis prone
position also, see “Comments”).

Topogram 3D Reconstructions
MIP No
MPR No
VRT No
Other No

The chest routine program is not optimized

for the secondary reconstructions of either
lung or mediastinum. For these options,
please refer to treatments in this book on
combithorax, chest aortic arch, or chest
CTA.
Fig. 1. Region: from lung apices, to under the
diaphragm (including the adrenals in bronchial
carcinomas) Criteria of Good Image Quality
1. Caudo-cranial acquisition.
2. Breathhold acquisition.
3. Sufficient contrast in arteries and veins.
Example of Axial Scan
Caveat
1. For screening of lung nodules or inflam-
matory changes only, the low-dose proto-
col should be used (see “Comments”).

Fig. 2 a, b. (Case courtesy of Dr. U. J. Schoepf,

Boston, US)
 Routine Chest and HR-Chest 41

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 2.5 mma
Pitch factor 1.5
Reconstruction 6 mm lung and 6 mm soft tissue
Rotation time 0.5 s
Scan orientation Caudo-cranialb
Scanner settings 120 kV, 90–120 eff. mAs
Kernel (algorithm) Soft tissue, lung
Window 420/50, 1,500/–600
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 80 ml
Flow rate 3.0 ml/s
Scan delay 35 s
a
Scan time is usually below 15 s, which in breathhold is well tolerated by most patients.
b
Since the sensitive lower parts are scanned first, caudo-cranial scan orientation helps to minimize
artifacts from breathing.Artifacts from venous inflow are also reduced.The reconstructions should
be cranio-caudal.

Comments
This protocol is designed to serve as a routine protocol (soft and lung window; see Fig. 2a,b).
Demarcation of the esophagus is optimized when giving a swallow of barium suspension
shortly before initiation of the scan.
For screening, detection, or exclusion of pulmonary nodes or infiltrates only, a low-dose
high resolution HR lung protocol as follows is recommended:
– Collimation: 4¥2.5 mm
– Pitch factor 1.5
– Reconstruction: 3 mm
– Scanner setting: 120 kV, 10–20 mAs (!)
– Rotation time: 0.5–0.75 s
– Kernel (algorithm): lung
– Window: lung window 1,500/–600
Administration of contrast material is not necessary. This protocol drastically reduces the
dose of the CT scan at the expense of more noise.
To detect or exclude asbestosis or orthostatic changes, an additional scan of this proto-
col in the prone position is recommended.
ECG triggering may be used in selected cases to minimize motion artifacts (soft and lung
window: Fig. 2) (Schoepf et al. 1999).
42 4-row Scanning Chest

Pulmonary Embolism

Indications. Detection or exclusion of suspected pulmonary embolism, evaluation of atyp-

ical chest pain.

Patient Positioning. Supine, arms elevated above the head.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
MIP reconstructions can be used to detect
embolism in rather subtle cases (see Fig. 2 b).

Criteria of Good Image Quality

1. Sufficient contrast in pulmonary arteries.
2. Absence of motion artifacts.

Caveat
Fig. 1. Region: concentrated on central hilar por-
tion, from above the aortic arch
1. The high flow of contrast material in-
jected may cause artifacts from the supe-
Example of Axial Scan rior vena cava.

Fig. 2 a, b. (Case courtesy of Dr. U.J. Schoepf )

 Pulmonary Embolism 43

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mm
Pitch factor 1.5–1.75
Reconstruction 3 mm, for MPR reconstructing 1 mm with 0.5 mm increment
Rotation time 0.5 s
Scan orientation Caudo-cranialb
Scanner settings 120 kV, 140 eff. mAs
Kernel (algorithm) Soft/mid
Window 420/60 and 1,500/–600
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 120 ml
Flow rate 4.0 ml/s
Scan delay 16 sc
a
Scan time is usually below 15 s, which is well tolerated in breathhold by most patients.
b
Since the sensitive lower parts are scanned first, the caudo-cranial scan orientation helps to mini-
mize artifacts from breathing. Also, artifacts from venous inflow are reduced. The reconstructions
should be cranio-caudal.
c
This interval should be determined by a test bolus injection or a bolus tracking.

Comments
The protocol can be used to exclude or to detect pulmonary embolism (Fig. 2a). The MPR
can help to view the full extent of the thrombotic material (Fig. 2b). Using MSCT, the source
of embolization, as for example the right heart, can also be visualized.
Demarcation of the esophagus is optimized when giving a barium suspension shortly
before beginning the scan.
44 4-row Scanning Chest

Combi Thorax

Indications. Evaluation of the lung tissue in conjunction with detailed analysis of the medi-
astinal structures, e.g., in sarcoidosis; alternatively, to evaluate bronchogenic carcinoma or
other chest disease.

Patient Positioning. Supine, arms elevated above the head.

Topogram 3D Reconstructions
MIP Yes
MPR Yes
VRT No
Other No

MIP reconstructions of the Combi Thorax

in the coronal and sagittal planes are supe-
rior for visualization of the pulmonary
arteries, while MPR reconstructions have
been found to be superior for central and
peripheral bronchi and lung parenchymal
changes (Eibel et al 1999).
Fig. 1. Region: including from below the dia-
phragm to the lung apices
Criteria of Good Image Quality
Example of Axial Scan 1. Absence of motion artifacts.
2. Low noise.
3. Sufficient contrast in vessels.

Caveat
1. This Combi Thorax protocol should be
used for the combined evaluation of HR
lung and soft-tissue mediastinum.

Fig. 2a–c. (Case courtesy of Dr. U.J. Schoepf )

 Combi Thorax 45

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mma
Pitch factor 1.5–1.75
Reconstruction Soft: 8 mm; lung: 1 mm
Rotation time 0.5 s
Scan orientation Caudo-cranialb
Scanner settings 120 kV, 90–140 eff. mAs
Kernel (algorithm) Soft, hard
Window 420/60, 1,500/–600
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 80 ml
Flow rate 2.5 ml/s
Scan delay 35 s
a
Scan time is usually below 25 s, which in breathhold is well tolerated by most patients.
b
Since the sensitive lower parts are scanned first, the caudo-cranial scan orientation helps to mini-
mize artifacts from breathing. Artifacts from the venous inflow are also reduced. The reconstruc-
tions should be cranio-caudal.

Comments
The Combi Thorax protocol is ideal for the work-up of cases in which the combined inves-
tigation of lung parenchyma and mediastinal and hilar soft tissue is necessary. A case with
sarcoidosis (Fig. 2) shows both the lung tissue in 1-mm reconstruction thickness with the
high-resolution kernel (Fig. 2a,b) and the soft tissue with the soft-tissue kernel (Fig. 2c), as
generated for one spiral data set.
Demarcation of the esophagus can be optimized by giving a barium suspension shortly
before starting the scan.
46 4-row Scanning Chest

CTA Aortic Arch

Indications. Detection or exclusion of aortic aneurysms, bleeding, dissection, or thrombo-

sis of the ascending aorta, arch, and descending aorta.

Patient Positioning. Supine, arm elevated over the head.

Topogram 3D Reconstructions
MIP Yes
MPR Yesa
VRT No
Other No
a
MPR helps to visualize the cranio-caudal
extent of the disease (see Fig. 2).

Criteria of Good Image Quality

1. High contrast of the arterial vessels.
2. Little or no contrast media in the veins.
3. High quality of secondary reconstruc-
tions.

Fig. 1. Region: including lung apices to below the

diaphragm, or to the distal end of any aneurysm
Caveat
(must include supra-aortic arches)
1. The timing of the contrast injection is
critical and should be determined by a
Example of Axial Scan test bolus or bolus tracking.

Fig. 2 a, b. (Cases courtesy of Dr. B. Ohnesorge)

 CTA Aortic Arch 47

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mma
Pitch factor 1.5–2.0
Reconstruction Slice 1.25–2 mm, 1 mm increment
Rotation time 0.5 s
Scan orientation Caudo-cranialb
Scanner settings 120 kV, 110–150 eff. mAs
Kernel (algorithm) Soft
Window 420/50
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 120 ml
Flow rate 3.0 ml/s
Scan delay 15 s
a
Scan time is usually low and breathhold is well tolerated by most patients.
b
The caudo-cranial scan orientation helps to minimize artifacts from breathing since the sensitive
lower parts are scanned first. Artifacts from venous inflow are also reduced. The reconstructions
should be cranio-caudal.

Comments
In patients with possible alteration of the circulation time, a bolus timing technique or use
of a test bolus is recommended for optimal contrast in the spiral acquisition.
The protocol can be adapted to extend coverage to the chest and abdomen (using
4¥2.5 mm).
Triggering improves the image quality, especially in the ascending portion of the aorta
(see Fig. 2a). MPR can improve the visualization of, for instance, dissections, as shown in
Fig. 2b.
48 4-row Scanning Heart

Coronary Artery Screening

Indications. Suspected coronary artery disease; symptomatic patients, atypical chest pain;
asymptomatic patients, risk stratification.

Patient Positioning. Supine, arms elevated, ECG trigger on.

Topogram 3D Reconstructions
MIP No
MPR No
VRT No
a
Other
a
Calcifications are postprocessed to deter-
mine the Agatston score, a volume or mass
score. Postprocessing can take place at the
scanner's console or at a separate worksta-
Fig. 1. Region: scan from above the tracheal bi- tion. Elevated values of these scores are
furcation to the diaphragm known to correlate with an increased risk of
coronary artery disease (CAD) (see the sec-
ond table).

Example of Axial Scan Criteria of Good Image Quality

1. Motion-free visualization of the coronar-
ies and the coronary calcifications.
2. Focused FOV.
3. Heart rates of less than 70 beats per
minute are optimal.

Caveats
1. Variation of the trigger delay may be nec-
essary.
2. Automated programs for deriving scores
need supervision.
3. The lung window also needs to be read!
4. ECG gating and the coverage of the entire
heart (Fig. 1) is necessary for sufficient
Fig. 2.
image quality (see Fig. 2) and score re-
producibility. Set the trigger to 40–70%
of the ECG R interval.
 Coronary Artery Screening 49

Scan Parameters
Parameter Mode
Sequential
Collimation 4 ¥ 2.5 mm
Pitch factor 0.375
Reconstruction 3 mm
Rotation time 0.5 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 133 eff. mAs
Kernel (algorithm) Heart view medium
Window 370/50
(width/center)
Contrast medium No
Administration
Volume
Flow rate
Scan delay

Comments
For direct visualization of the lumen of the coronary arteries, please add the protocol “CTA
Coronary Arteries.”
Clinical interpretation of the calcium score should be made according to suggestions
based on the articles of Haberl et al. 2001 and of Janowitz et al. 1991, among others (see “Ref-
erences”).

Agatston scorea Interpretation Clinical implication Possible therapeutic

implications
0 Negative score Negative predictive None
value for CAD
90 %–95 %
1–10 Minimal calcium Stenosis unlikely General preventive
deposits treatment
11–100 Small calcium CAD possible Another evaluation
deposit(s) required
101–400 Severe calcium Stenosing CAD Treatments of risk
deposits possible factors and dedicated
cardiological therapy
> 400 Excessive calcium High probability Indication for stress
deposits for stenosing CAD ECG, catheterization as
indicated
a
The table is modified from Rumberger et al. 1999.The applicability of the MSCT data to the Agats-
ton score is dealt with in the work by Knez et al. 2002 and Kopp et al. 2002 (see “References”).
50 4-row Scanning Heart

CTA Bypasses

Indications. Follow-up after coronary bypass surgery.

Patient Positioning. Supine.

Topogram 3D Reconstructions
MIP Yesa
MPR Yesa
VRT Yes
Other No
a
STS MPRs or STS MIPs are recommended.

Criteria of Good Image Quality

1. High contrast in the coronary arteries
Fig. 1. Region: from the aortic arch to below the
heart
and in the bypass.
2. Adapted FOV.

Example of Axial Scan Caveats

1. A test bolus is recommended for good
timing of the contrast injection.
2. FOV must cover the entire heart plus aor-
tic root.

Fig. 2. (Case courtesy of Dr. C. Becker)

 CTA Bypasses 51

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mm
Pitch factor 0.375
Reconstruction 1.25 mm
Rotation time 0.5 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 260–400 eff. mAs
Kernel (algorithm) Soft/mid
Window 500/80
(width/center)
Contrast medium Yes
Administration Biphasica
Volume 40 ml 80 ml
Flow rate 4 ml/s 2 ml/s
b
Scan delay 10 s later
a
Adapted from C. Becker (unpublished data).
b
Determined by test bolus or bolus tracking.

Comments
Retrospective ECG gating and the coverage of the entire heart and proximal aorta is neces-
sary for optimal image quality. Using this protocol, a heart rate of less than 70 is optimal. If
necessary, premedication (beta-blocker) can be considered. Alternatively, a prospectively
ECG-triggered sequential scan may also be used (4 ¥2.5 mm collimation, 0.5 s, 120 mAs at
120 kV).
Figure 2 shows a patent sequential bypass at the level of the aortic insertion (the frontal
bypass graft was revised with a stent).
52 4-row Scanning Heart

CTA Coronary Arteries

Indications. Suspected coronary artery disease.

Patient Positioning. Supine, arms elevated, ECG trigger on.

Topogram 3D Reconstructions
MIP Yesa
MPR No
VRT Yes
Other No
a
Oblique (45° parallel to main stem) STS MIPs
are recommended (3 mm slice thickness, 1.5
mm increment) for the visualization of the
main stem, LAD and RCA.

Fig. 1. Region: from above the tracheal bifurca-

tion to the diaphragm
Criteria of Good Image Quality
1. Absence of motion artifacts.
2. High contrast in coronary arteries.
3. Heart rates of less than 70 beats per
minute are optimal.
Example of Axial Scan
Caveats
1. A test bolus should always be used.
2. Offline postprocessing is required.
3. All of the coronary system must be opaci-
fied (proximal, mid, and distal).

Fig. 2. (Case courtesy of Dr. C. Becker)

 CTA Coronary Arteries 53

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mm
Pitch factor 0.375
Reconstruction Slice 1.25 mm, increment 0.8 mm
Rotation time 0.5 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 400 eff. mAs
Kernel (algorithm) Soft
Window 420/60
(width/center)
Contrast medium Yes
Administration Biphasica
Volume 40 ml 80 ml
Flow rate 4 ml/s 2 ml/s
b
Scan delay 10 s later
a
Adapted from C. Becker (unpublished data).
b
To be determined by test bolus or bolus tracking.

Comments
ECG gating and the coverage of the entire heart is necessary to derive sufficient image qual-
ity and score reproducibility. If the heart rate exceeds 70 beats/min, oral premedication
(beta-blockers) can be considered.
An illustration of high-contrast opacification is given in Fig. 2, which is an example of
partially calcified and partially soft plaques.
54 4-row Scanning Abdomen

Routine Abdomen

Indications. Screening, detection, or exclusion of abscesses; control scans; follow-ups.

Patient Positioning. Supine, arms elevated above the head.

Topogram 3D Reconstructions
MIP No
MPR No
VRT No
Other No

Criteria of Good Image Quality

1. Absence of gross motion artifacts.
2. Good contrast opacification of arteries,
veins, and the portal system.

Caveat
Fig. 1. Region: from above the diaphragm to the
symphysis pubis
1. For the detection or exclusion of venous
thrombosis, vary the injection time.

Example of Axial Scan

Fig. 2 a, b. (Case courtesy of Dr. C. Hong)

 Routine Abdomen 55

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 2.5 mm
Pitch factor 1.0–1.5
Reconstruction 5–8 mm
Rotation time 0.5 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 165–200 eff. mAs
Kernel (algorithm) Soft
Window 420/60
(width/center)
Contrast medium i. v. + oral + rectala
Administration i. v., monophasic
Volume 120 ml
Flow rate 3 ml/s
Scan delay 65 s
a
Oral contrast media for the optimal distention of the stomach should be administered immedi-
ately before scanning, and for the bowel up to 2 h (with 900 ml) before scanning.The rectal admin-
istration of water or methylcellulose should be immediately before scanning.

Comments
To further reduce radiation, especially in young patients, the tube currents should be
adapted to the habitus and can be reduced to 120 mAs.
The patient should do deep breathing before the beginning of the spiral scan.
A normal abdominal slice with a patent vena cava is shown in Figure 2a. To exclude
venous thrombosis of the pelvis or the inferior vena cava (Fig. 2b), the scan delay should
exceed 65 s. The injection rate of the contrast material may also be varied.
56 4-row Scanning Abdomen

Venous Upper Abdomen

Indications. Detection or exclusion of liver abscesses, follow-up of liver metastasis, sus-

pected portal thrombosis, portal obstruction.

Patient Positioning. Supine, arms elevated.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
For planned reconstructions, a 1.5-mm recon-
struction interval is recommended (and the
reconstruction thickness can be 3 mm).

Criteria of Good Image Quality

1. Absence of breathing artifacts.
2. A venous phase providing positive con-
trast in the portal veins and inferior vena
cava.
Fig. 1. Region: from the diaphragm to the iliac
crest

Caveat
Example of Axial Scan
1. The scan delay can be as long as 80 s to
safely exclude a portal venous thrombus.

Fig. 2.
 Venous Upper Abdomen 57

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 2.5 mm
Pitch factor 1.0–1.5
Reconstruction Slice 5–8 mm
Rotation time 0.5 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 165–200 eff. mAs
Kernel (algorithm) Soft
Window 420/60
(width/center)
Contrast medium Yes
Administration Monophasica
Volume 120 ml
Flow rate 3 ml/s
Scan delay 65 s
a
Administration of the oral contrast media for optimal distention of the stomach should take place
immediately before scanning, and for the bowel up to 2 h (with 900 ml) before scanning.

Comments
To reduce radiation, especially in young patients, the tube currents should be adapted to the
habitus and can be reduced to 120 mAs.
Patients should be instructed to breathe deeply before scanning. Water should be given
before scanning for better filling of the stomach.
The MDCT data can be used to reconstruct coronal and sagittal planes (in a 4¥2.5-mm
spiral, a reconstruction thickness of 3 mm and a reconstruction increment of 1.5 mm are
recommended). These additional reconstructions may help to localize metastases in the
individual liver segments. Figure 2 shows a case with multiple metastases to segments 2, 4a,
7, and 8.
58 4-row Scanning Abdomen

Biphasic Abdomen

Indications. Known liver metastasis; hepatocellular carcinoma; restaging, including lymph

node staging.

Patient Positioning. Supine, arm elevated to the head.

Topogram 3D Reconstructions
MIP No
MPR Optionala
VRT No
Other No
a
For planned segmental resection of the liver,
the MPR reconstructions are especially help-
ful when the tumor is near large vascular
structures (such as the hepatic veins) or the
central portal structures. In these cases, sagit-
tal and coronal reconstructions are strongly
recommended.

Criteria of Good Image Quality

1. Good arterial and venous contrast opaci-
Fig. 1. Region: entire liver biphasic – (1) spiral
acquisition, dotted lines; and (2) venous ab-
fication of the liver parenchyma.
domen acquisition, solid lines 2. No breathing artifacts (especially critical
in the MPRs).

Example of Axial Scan Caveat

1. For the imaging in breathhold and cor-
rect contrast injection, timing is essential
for optimal contrast.

Fig. 2 a, b. (Cases courtesy of Dr. C. Hong)

 Biphasic Abdomen 59

Scan Parameters
Parameter Mode
Spiral 1 (dotted line) Spiral 2 (solid line)
Collimation 4 ¥ 2.5 mm 4 ¥ 2.5 mm
Pitch factor 1.0–1.5 1.25–1.5
Reconstruction 5–8 mm, for MPR 3 mm 5–8 mm, for MPR 3 mm
Rotation time 0.5 s 0.5 s
a
Scan orientation Cranio-caudal Caudo-cranial
Scanner settings 120 kV, 165–220 eff. mAs 120 kV, 165–220 eff. mAs
Kernel (algorithm) Soft Soft
Window 420/60 420/60
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 120 ml
Flow rate 3 ml/s
Scan delay 35 s 65 s
a
This orientation is advantageous for better contrast of liver veins in a second spiral acquisition.

Comments
The diagnostic quality of the MPR reconstructions can be appreciated in Fig. 2, showing two
patients with hepatocellular carcinoma. One patient (Fig. 2a) displays a huge lesion but no
thrombosis, and the other patient (Fig. 2b) has a central thrombosis of the portal venous
system.
Patient should do deep breathing before the beginning of the spiral.
To exclude a secondary venous thrombosis of the vena cava, the scan delay of spiral 2 may
exceed 80 s.
60 4-row Scanning Abdomen

Biphasic Liver (Including CTAP)

Indications. Hepatocellular carcinoma, differentiation of hepatic lesions, small bowel

metastasis, cholangiocellular carcinoma, etc.

Patient Positioning. Supine, arms elevated.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
1-mm axial reformatting is recommended if
MPR reconstructions are desired.

Criteria of Good Image Quality

1. Contrast enhancement, arterial: initial
parenchymal contrast and high-contrast
vessels.
2. No breathing artifacts.

Fig. 1. Region: from above the diaphragm to the

upper iliac crest
Caveats
1. In the two spiral acquisitions, the delay
(35 s, 55 s) is critical.
Example of Axial Scan 2. No oral contrast medium is required.

Fig. 2 a, b. (Case courtesy of Dr. C. Hong)

 Biphasic Liver (Including CTAP) 61

Scan Parameters
Parameter Mode
Spiral 1 Spiral 1 + 2
Collimation 4 ¥ 2.5 mm 4 ¥ 2.5 mm
Pitch factor 1.0–1.5 1.0–1.5
Reconstruction Slice 5 mm, increment 5 mm Slice 5 mm, increment 5 mm
Rotation time 0.5 s 0.5 s
Scan orientation Cranio-caudal Caudo-cranial
Scanner settings 120 kV, 155–220 eff. mAs 120 kV, 155--220 eff. mAs
Kernel (algorithm) Soft Soft
Window 420/60 420/60
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 120 ml
Flow rate 3 ml/s
Scan delay 20 s 55 s

Comments
If an endocrine-active tumor is suspected, the arterial phase is important (especially in gas-
trinomas and Zollinger-Ellison syndrome). The arterial phase gives high contrast in highly
vascularized metastases of renal cell or breast carcinomas.
For the differential diagnosis of liver lesions, it may be necessary to perform a dynamic
scan (5–10 mm slice thickness, table feed 0, start delay about 15 s, approximately 1 image/s).
The patient must hold their breath for the entire length of scanning (approximately 40 s).
This dynamic series can be evaluated using ROI time/density curves (differentiation of
focal nodular hyperplasia, adenoma, and hemangioma).
This protocol can also be used to perform a CT arterial portography (CTAP). Here, an
intra-arterial catheter must be placed with the tip in the superior mesenteric artery or the
splenic artery, with the injection of 60 cc contrast diluted 1:1 with saline, and a scan delay
of 15 s.
Arterial plus venous scanning has been employed in Fig. 2. Figure 2a shows a liver metas-
tasis with marked hyperdensity in the arterial phase. Using thin overlapping slices (recon-
struction increment 1.5 mm), MPRs of the same patient can be created, as seen in Fig. 2b.
In case of a suspected gallbladder or cholangio-cellular carcinoma, an increased scan
delay is recommended, as these tumors tend to have a prolonged contrast uptake. Metas-
tases are usually supplied by the hepatic artery and thus enhance less than the liver
parenchyma.
The patient should do deep breathing before the start of the spiral scan.
To reduce radiation, especially in young patients, the tube currents should be adapted to
the habitus and can be reduced to 120 mAs.
62 4-row Scanning Abdomen

CT Enteroclysis

Indications. Evaluation of the small bowel, inflammatory processes such as Crohn's disease
and their complications, wall thickness, and metastasis to the small bowel.

Patient Positioning. Supine, arms elevated.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
It is strongly recommended that MPRs be
done in the coronal and sagittal planes.

Criteria of Good Image Quality

1. Distention of the small bowel.
2. Clear bowels.
3. Use of paraffin methylcellulose (PMC)
solution to induce hypodensity of lumen.

Fig. 1. Region: from above the diaphragm to

below the symphysis pubis
Caveat
1. The methylcellulose solution must be
given via a nasogastric tube; oral intro-
duction is not recommended.
Example of Axial Scan

Fig. 2a–c. (Cases courtesy of Dr. G.F. Rust)

 CT Enteroclysis 63

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mm
Pitch factor 1.0–1.5
Reconstruction Slice 1.25 mm, increment 0.6 mm
Rotation time 0.5 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 165 eff. mAs
Kernel (algorithm) Soft
Window 420/60
(width/center)
Contrast medium i. v., Enteral
Administration i. v., Monophasic
Volume 120 ml
Flow rate 3 ml/s
Scan delay 35 s

Comments
All of the named indications are currently under investigation (work in progress). CT ente-
roclysis offers distinct advantages over MR enteroclysis, such as high spatial resolution in
very short acquisition times. In contrast, MR enteroclysis has superior soft-tissue contrast
and does not use ionizing radiation.
Patient preparation: Approximately 18 h before the examination, internal cleaning needs
to be initiated. In addition to fluid load, the patients are given antigas medication (e.g.,
Lefax®, Asche, Germany). A nasoduodenal tube (e.g. 8 Fr, 150 cm, Guerbet, Germany) is in-
serted in all of our patients. This tube must be placed beyond the duodenal-jejunal junction.
The enteral contrast material (paraffin solution) should be given via the nasogastric tube
only, and after reflux has been ruled out. Two ampoules
of, for instance, Buscopan® should be given i.v. shortly
before the CT examination.
PMC solution is recommended as a negative contrast
material. A low pump rate of between 30 and 70 ml per
minute (the mean value for the patients we examined
was 40 ml/min) is suggested. A normal case is shown in
Fig. 2 (Fig. 2a being axial, Fig. 2b sagittal, and Fig. 2c
coronal MPR reconstructions).
64 4-row Scanning Abdomen

Biphasic Pancreas

Indications. Suspected tumors of the pancreas, differential diagnosis of pancreatic lesions.

Patient Positioning. Supine, arms elevated.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
In selected cases, MPR reconstructions can
help to determine the cranio-caudal infiltra-
tion pattern.

Criteria of Good Image Quality

1. High contrast and clear visualization of
vessel structures surrounding the pan-
creas.
2. Duodenal “C” properly distended.
Fig. 1. Region: focused on the pancreas and sur-
roundings
Caveats
1. Oral contrast material (water) is re-
quired.
Example of Axial Scan 2. The patient should be instructed to
breathe deeply before scanning.
3. The FOV should be adapted to the pan-
creas.

Fig. 2 a–c.
 Biphasic Pancreas 65

Scan Parameters
Parameter Mode
Spiral 1 Spiral 2
Collimation 4 ¥ 1 mm 4 ¥ 1 mm
Pitch factor 0.75–1.5 0.75–1.5
Reconstruction Slice 2 mm, increment 1 mm; Slice 2 mm, increment 1 mm;
for MPRs slice 1.25 mm, for MPRs slice 1.25 mm,
increment 0.5 mm increment 0.5 mm
Rotation time 0.5 s 0.5 s
Scan orientation Cranio-caudal Caudo-cranial
Scanner settings 120 kV, 165–250 eff. mAs 120 kV, 165–250 eff. mAs
Kernel (algorithm) Soft Soft
Window 420/60 420/60
(width/center)
Contrast medium Yesa
Administration Monophasic
Volume 120 ml
Flow rate 3 ml/s
Scan delay 35 s 70 s
a
For the optimal distention of the stomach, oral contrast media should be administered immedi-
ately before scanning, and for the bowel up to 2 h (with 900 ml) before scanning.

Comments
This is a dedicated examination for suspected pancreatic disease (other than pancreatitis)
and local metastasis only.
For the diagnosis of pancreatitis, a different protocol is recommended (e.g., “Routine
Abdomen CT”).
Distention of the duodenum with water (for negative contrast) is recommended. The
duodenal wall then shows a positive contrast. Some authors recommend giving water in a
right-sided position and scanning in supine position; others recommend use of an agent
such as Buscopan.
Patients should do deep breathing before
the start of the spiral scan.
Using this protocol, an optimal image
quality can be achieved in the axial, coronal,
and sagittal planes (Fig. 2a–c).
66 4-row Scanning Abdomen

Routine Kidney

Indications. Follow-up of renal tumors, inflammations, infarcts of the kidneys.

Patient Positioning. Supine, arms elevated.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
Optional, either of the two spirals can be
reconstructed using MPR: the first without
contrast enhancement (unenhanced) and the
second with a delayed contrast enhancement
(parenchymal; excretory phase)

Criteria of Good Image Quality

1. Absence of breathing artifacts.
Fig. 1. Region: from mid-liver to mid-pelvis 2. Timing of the second spiral to obtain pa-
renchymal contrast.

Caveat
1. This protocol is intended for the follow-
up of known lesions. For the differentia-
tion of renal tumors, the protocol “Renal
Differential Diagnosis and Tumors”
Example of Axial Scan should be used.

Fig. 2 a, b. (Case courtesy of Dr. U. Mueller-Lisse)

 Routine Kidney 67

Scan Parameters
Parameter Mode
Spiral 1 Spiral 2
Collimation 4 ¥ 2.5 mm 4 ¥ 2.5 mm
Pitch factor 1.0–1.5 1.0–1.5
Reconstruction 5 mm 5 mm
Rotation time 0.5 s 0.5 s
Scan orientation Cranio-caudal Cranio-caudal
Scanner settings 120 kV, 165–200 eff. mAs 120 kV, 165–200 eff. mAs
Kernel (algorithm) Soft Soft
Window 420/60 420/60
(width/center)
Contrast medium Unenhanceda Yes
Administration Monophasic
Volume 80 ml
Flow rate 3 ml/s
Scan delay 40 s
a
To contrast the renal pelvis, a dose of 20 ml can be injected 5 min before each spiral.

Comments
MDCT images are recommended of the kidney in the precontrast phase, the nephrographic
phase, and the excretory phase (Mueller-Lisse and Oberneder (2001). Since the natural CT
contrast between the renal cortex and the lesions is often small, contrast enhancement with
iodinated contrast medium is frequently required to allow diagnosis.
To exclude renal vein and vena cava thrombosis, the second (contrast enhanced) spiral
can be extended to the right atrium.
If a renal artery stenosis is suspected, no oral contrast material should be given and a
protocol with 4¥1-mm collimation and a reconstruction increment of 0.5 mm should be
used (see the protocol “CTA Abdomen”). The contrast injection should be at least 100 ml at
a rate of 3 ml/s and the delay should be 25 s.
Figure 2 shows an example of a renal cyst in the unenhanced spiral (Fig. 2a) and in the
excretory (Fig. 2b) phase.
68 4-row Scanning Abdomen

Renal Differential Diagnosis and Tumors

Indications. Differential diagnosis of renal masses.

Patient Positioning. Supine, arms elevated.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
Coronal MPRs are optimal (in 3-mm recon-
struction thickness and < 2-mm increment).

Criteria of Good Image Quality

1. Absence of breathing artifacts (especially
on MPR).
2. Timing of the spirals to obtain optimal
nephrographic and excretory phase con-
Fig.1. Region:from mid-liver to mid-pelvic region
trast.

Example of Axial Scan Caveats

1. This protocol is designed for the differ-
entiation of renal lesions.
2. Due to the triple spiral, the radiation ex-
posure is relatively high, mandating care-
ful selection of appropriate patients.
3. This protocol is recommended for tumors.

Fig. 2 a, b. (Case courtesy of Dr. U. Mueller-Lisse)

 Renal Differential Diagnosis and Tumors 69

Scan Parameters
Parameter Mode
Spiral 1 Spiral 2 Spiral 3
Collimation 4 ¥ 1 mm 4 ¥ 1 mm 4 ¥ 2.5 mm
Pitch factor 1.0–1.5 1.0–1.5 1.0–1.5
Reconstruction 1.25 mm 1.25 mm 5 mm
Rotation time 0.5 s 0.5 s 0.5 s
Scan orientation Cranio-caudal Caudo-cranial Cranio-caudal
Scanner settings 120 kV, 120 kV, 120 kV,
155–200 eff. mAs 155–200 eff. mAs 155–200 eff. mAs
Kernel (algorithm) Soft Soft Soft
Window 420/60 420/60 420/60
(width/center)
Contrast medium Unenhanced after Yes Yes
preinjectiona
Administration Multiphasic Multiphasic
Volume 20 mla 100 ml
Flow rate 3 ml/s 3 ml/s
Scan delay 40 s 70 s 100 s
a
Preinjection of 20 ml for the positive contrast of the renal pelvis.

Comments
MDCT images of the kidneys are possible in the precontrast phase, nephrographic phase,
and excretory phase. Because the natural CT contrast between the renal cortex and the
lesions is often small, contrast enhancement with iodinated contrast medium is frequently
required so as to allow diagnosis. Significantly more renal lesions are detected during the
nephrographic phase (equal contrast in renal cortex and medulla) than during the corti-
comedullary phase with its strong renal cortical enhancement and less enhancement of the
renal medulla. [See Fig. 2 (renal cell carcinoma) and the reference in “Routine Kidney” pro-
tocol.]
Peak renal enhancement occurs 35–45 s after injection. This can be evaluated by a test
bolus imaging series that covers the renal parenchyma.
To exclude renal vein and inferior vena cava thrombosis, the second spiral can be
extended to the right atrium.
In suspected masses of the renal pelvis, a late spiral (>100 s) may be considered (spiral 3).
The second “standard” plane of view in MDCT of the kidney should be coronal.
To reduce radiation, especially in young patients, the tube currents should be adapted to
the habitus and can be reduced to 120 mAs.
70 4-row Scanning Abdomen

Rectal Tumors

Indications. Staging of tumors of the rectum, preoperative work-up.

Patient Positioning. Supine, arms above the head.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
For the second spiral acquisition in the pelvic
region, the MPR reconstructions are helpful in
delineating infiltrations in the rectum or blad-
der.

Criteria of Good Image Quality

1. Sufficient distention of rectum.
2. Timing of the venous injection.

Caveat
Fig. 1. Region: (1) from diaphragm to the upper
iliac crest; (2) from the upper iliac crest to below
the symphysis pubis (spiral 1, dotted lines; spiral 1. Stool retention will reduce image quality;
2, solid lines) therefore, a careful preparation of the
patient is of paramount importance.
Example of Axial Scan

Fig. 2 a, b. (From Kulinna et al. 2001)

 Rectal Tumors 71

Scan Parameters
Parameter Mode
Spiral 1 (upper abdomen) Spiral 2 (pelvis)
Collimation 4 ¥ 2.5 mm 4 ¥ 1 mm
Pitch factor 1.25–1.5 1.0–1.5
Reconstruction 8 mm 1.25 mm
Rotation time 0.5 s 0.5 s
Scan orientation Cranio-caudal Cranio-caudal
Scanner settings 120 kV, 165–200 eff. mAs 120 kV, 165–200 eff. mAs
Kernel (algorithm) Soft Soft
Window 420/60 420/60
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 120 ml
Flow rate 3 ml/s
Scan delay 65 s To start after first spiral

Comments
The well-known beam-hardening artifacts are markedly reduced with this protocol.
Especially in young patients, a dose reduction should be considered (scanner settings
<200 mAs).
Water or methylcellulose (solution) should be administered rectally immediately before
scanning. Alternatively, water or gel (e.g., ultrasound gel) can be given; however, for the dis-
tention of the entire rectum, methylcellulose is seen as optimal.
Two spirals are recommended, (1) to cover the upper abdomen and (2) as a thin collima-
tion spiral to provide raw data for the MPR reconstructions of the pelvis (dotted lines in
Fig. 1). It is also possible to cover the entire abdomen with a thin collimation spiral, but the
amount of data is markedly increased. For the second spiral, breathhold is not necessary.
In Fig. 2, the optimal distention of the rectum with methylcellulose suspension is shown:
a rectal carcinoma is seen in axial (Fig. 2a) and sagittal MPR reconstructions (Fig. 2b).
72 4-row Scanning Abdomen

CTA Abdomen

Indications. To quantify or to exclude aneurysms of the abdominal aorta, to measure the

diseased portions of the abdominal aorta before minimally invasive or open intervention,
to detect or exclude aortic rupture or retroperitoneal bleeding.

Patient Positioning. Supine, arm elevated over the head.

Topogram 3D Reconstructions
MIP Yesa
MPR Yesa
VRT No
Other No
a
MIPs or MPRs help to visualize the cranio-cau-
dal extent of the aneurysms (see Fig 2).

Criteria of Good Image Quality

1. High contrast in the abdominal aorta
throughout the scan.
2. Little contrast in the parenchymal organs
and negative contrast in the bowel.

Fig. 1. Region: from above the diaphragm to

below symphysis pubis
Caveat
1. Axial images and reconstructions must
visualize aortic branches such as renal
Example of Axial Scan arteries, superior mesenteric artery, etc.

Fig. 2 a–c. (Case courtesy of Dr. B. Wintersperger)

 CTA Abdomen 73

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mm (4 ¥ 2.5 mm)a
Pitch factor 1.0–2.0
Reconstruction Slice 2 mm, increment 1 mm
Rotation time 0.5 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 130–180 eff. mAs
Kernel (algorithm) Soft
Window 420/50
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 120 ml
Flow rate 3.0 ml/s
Scan delay 18 sb
a
4 ¥ 2.5 mm can be used, e.g., for reevaluation if details such as the renal arteries are of less impor-
tance and a higher volume coverage is important.
b
In patients with possible alteration of the circulation time, a test bolus application or bolus track-
ing is recommended to achieve optimal contrast in the spiral acquisition.

Comments
If a renal artery stenosis is suspected, no oral contrast material should be given and a pro-
tocol should be instituted with 4¥1-mm collimation and a reconstruction increment of 0.5
mm. The contrast injection should be at least 100 ml at a rate of 3 ml/s with a delay of 25 s.
Figure 2 shows a patient with an intrarenal aortic aneurysm. While the renal arteries are
appreciated on the axial images (e.g., Fig. 2a), the full extent of the lesion can be visualized
on either MIP (Fig. 2b) or MPR (Fig. 2c)
reconstructions.
74 4-row Scanning Spine

Cervical Spine

Indications. Disk protrusion, disk herniation, suspected fractures, spondylolisthesis,

unclear MR findings when performed as post-myelographic CT, MR contraindications.

Patient Positioning. Supine, arms parallel to the body, shoulders down, remove dental pros-
theses, necklaces, etc.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
We recommend using MPRs in an angulated
fashion regularly in the way shown in Fig 1b.
Using the thin 1-mm raw data, the angulated
slice thus obtained reduces noise and
achieves superior detail.

Criteria of Good Image Quality

1. Zoomed images (FOV smaller than 90 mm).
2. Angulation of the reconstructions paral-
lel to the disks.

Caveat
1. The axial acquisition must cover the
entire scanned volume, while the recon-
structions must be angulated to the indi-
vidual disk level.

Example of Axial Scan

Fig. 1. a For the scanning protocol, region to be

adapted to the region of interest, as seen. b For
the reconstructions, angulate reconstructions as
shown perpendicular to cervical canal

Fig. 2 a, b.
 Cervical Spine 75

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mm
Pitch factor 0.625–1.0
Reconstruction Angulated axial and sagittal slices: slice 2–3 mm, increment 1.5 mm
Rotation time 0.75 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 200 eff. mAs
Kernel (algorithm) Soft; if fracture, bone kernel
Window 420/60, 2000/300 or adapteda
(width/center)
Contrast medium No
Administration
Volume
Flow rate
Scan delay
a
After the myelographic intralumbar injection of contrast material in CT, a window of 1,200/400 is
recommended.

Comments
The combination of angulated axial and sagittal reconstructions is most advantageous.
Figure 2a shows the sagittal MPR reconstruction of a male patient with an anterior lis-
thesis after a motor vehicle accident. Figure 2b shows an example of a postmyelographic
examination in a female patient with persistent pain after ventral osteosynthesis. The my-
elographic contrast helps to delineate nawaring of the spinal cord and the CSF.
76 4-row Scanning Spine

Thoracic Spine

Indications. Disk protrusion, disk herniation, suspected fractures, spondylolisthesis, post-

myelographic CT, MR contraindications.

Patient Positioning. Supine, arms elevated.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT Optional (see “Comments”)
Other No
a
MPRs in sagittal and axial orientation are rec-
ommended. The axial MPRs must be angu-
lated to the individual disk level.

Criteria of Good Image Quality

1. Focused images
(FOV smaller than 90 mm).

Caveat
Fig. 1. Region: to be adapted to the region of
interest
1. The axial reconstructions must cover the
entire volume of interest.
Example of Axial Scan

Fig. 2 a–c. (c: Case courtesy of Dr. U.J. Schoepf )

 Thoracic Spine 77

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mm
Pitch factor 0.625–1.0
Reconstruction Angulated axial and sagittal slices: slice 2–3 mm, increment 1.5 mm
Rotation time 0.75 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 250 eff. mAs
Kernel (algorithm) Soft; if fracture, bone kernel
Window 420/60, 2000/300 or adapteda
(width/center)
Contrast medium No
Administration
Volume
Flow rate
Scan delay
a
After the myelographic intralumbar injection of contrast material in CT, a window of 1,200/400 is
recommended.

Comments
The combination of angulated axial and sagittal MPR reconstructions is most advanta-
geous.
For the detection of fractures, even in patients with severe osteoporosis, sagittal MPRs
(Fig. 2a) can show type and extent of fracture. Alternatively, VRTs can be used for a three-
dimensional data visualization (Fig. 2b).
A combination of CT and myelography is recommended for increased contrast if an
intraspinal process is suspected (Fig. 2c) (disk protrusion).
78 4-row Scanning Spine

Lumbar Spine

Indications. Disk protrusion, disk herniation, suspected fractures, spondylolisthesis,

unclear myelographic finding (as post-myelographic CT), MR contraindications.

Patient Positioning. Supine, arms elevated, legs elevated for comfort.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
We recommend using MPRs in an angulated
fashion regularly in the way shown in Fig. 1b.
Using the thin 1-mm raw data, the angulated
slices obtained in this manner yield low noise
and superior detail.

Criteria of Good Image Quality

1. Zoomed images (FOV about 90 mm).
2. Angulation parallel to the disks.

Caveat
1. The axial scan must cover the entire vol-
ume while the reconstructions are angu-
lated to the individual disk level.

Fig. 1. a For the scanning protocol, region to be

adapted to that of interest in lumbar spine, as
seen. b For the reconstructions, slices as seen
 Lumbar Spine 79

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mm
Pitch factor 0.625–1.0
Reconstruction Angulated axial and sagittal slices: slice 2–3 mm, increment 1.5 mm
Rotation time 0.75–1.0 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 300 eff. mAs
Kernel (algorithm) Soft; if fracture, bone kernel
Window 420/60, 2000/300 or adapteda
(width/center)
Contrast medium No
Administration
Volume
Flow rate
Scan delay
a
After the myelographic intralumbar injection of contrast material in CT, a window of 1,200/400 is
recommended.

Comments
The combination of angulated axial and sagittal MPRs is most advantageous. The recon-
structions are based on one unangulated spiral, as shown in Fig. 1a. The positions of the
angulated MPRs are shown in Fig. 1b.An example of the image quality is given in Fig. 2a and
of the sagittal reconstruction in Fig. 2b (patient with L5/S1 disk herniation). A combination
of CT and myelography is recommended for increased contrast if an intraspinal or
intradural process is suspected.

Example of Axial Scan

Fig. 2 a, b.
80 4-row Scanning Peripherals

Wrist

Indications. Complicated wrist trauma, atypical distal radial fracture, scaphoid fracture or
other carpal fracture unclear on conventional X-ray.

Patient Positioning. Prone, arm elevated over the head.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
MPRs are obligatory in coronal, optional in
sagittal plane.

Criteria of Good Image Quality

1. High resolution kernel.
2. Absence of motion artifacts through sta-
ble positioning.

Fig. 1. Region: from metacarpals to distal radius

shaft
Caveat
1. If the hand cannot be positioned above
the head, please refer to “Comments”.
Example of Axial Scan

Fig. 2 a, b.
 Wrist 81

Scan Parameters
Parameter Mode
Spiral
Collimation 2 ¥ 0.5 mm
Pitch factor 1.0
Reconstruction Slice 0.5 mm, increment 0.25 mm
Rotation time 0.75–1.0 s
Scan orientation Distal to proximal
Scanner settings 120 kV, 100–150 eff. mAs
Kernel (algorithm) Bone (high resolution)
Window 2,000/300
(width/center)
Contrast medium No
Administration
Volume
Flow rate
Scan delay

Comments
High-resolution imaging of the wrist should always include MPR reconstructions.
Stable positioning is the key to getting good image quality.
An example of an occult scaphoid is shown in Fig. 2a (coronal) and Fig. 2b (sagittal
view).
If the hand cannot be positioned over the head, position it in supine position on the belly.
Tube current must then be increased to more than 300 mAs to get sufficient noise suppres-
sion.
82 4-row Scanning Peripherals

Shoulder

Indications. Suspected occult or complicated fractures, preoperative evaluation, post-

arthrographic evaluation e.g. of the anterior labrum.

Patient Positioning. Supine, examined arm downward, contralateral side up (see Fig. 1).

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
Coronal and sagittal MPRs are recommended,
angulated parallel and perpendicular to the
axis of the scapula.

Criteria of Good Image Quality

Fig. 1. Region: including clavicle, acromion, and
the proximal humerus (the contralateral arm
should be elevated) 1. Low noise.
2. Absence of motion artifacts.
3. In arthrographic evaluation, sufficient
filling.

Caveat
1. High tube current is usually necessary.
Example of Axial Scan

Fig. 2 a, b. (Case courtesy of Dr. C. Glaser)

 Shoulder 83

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mm
Pitch factor 1.0
Reconstruction Slice 1 mm, increment 0.5 mm
Rotation time 1.0–1.5 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 200–250 eff. mAs
Kernel (algorithm) Bone
Window 2,000/300
(width/center)
Contrast medium None or arthrographic
Administration
Volume
Flow rate
Scan delay

Comments
The elevation of the contralateral arm is aimed to reduce the X-ray beam absorption as
much as possible.
Figure 2 shows a 13-year-old boy with a suspected fracture. While slight incongruence in
the articular portion is visible in the axial image (Fig. 2a), the coronal reconstruction
(Fig. 2b) shows that no fracture is present.
84 4-row Scanning Peripherals

Ankle

Indications. Complicated fracture of the distal tibia, talus, or calcaneus, especially when a
surgical intervention is planned.

Patient Positioning. Supine, foot rest adapted, knee bend elevated and made comfortable
with cushions.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
MPRs are obligatory in the coronal and sagit-
tal planes.

Criteria of Good Image Quality

1. Absence of patient motion or metal arti-
facts.
Fig. 1. Region: from distal calf including calca-
neus (use foot rest!)
Caveat
1. Reconstructions for MPRs should in-
clude one side only.
2. The use of positioning devices is espe-
cially important for a comfortable and
stable position.
Example of Axial Scan

Fig. 2 a, b.
 Ankle 85

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mm
Pitch factor 0.5–0.75
Reconstruction Slice 1 mm, increment 0.5 mm
Rotation time 0.75–1.0 s
Scan orientation Proximal-distal
Scanner settings 120 kV, 100–200 eff. mAs
Kernel (algorithm) Bone
Window 2,000/300
(width/center)
Contrast medium No
Administration
Volume
Flow rate
Scan delay

Comments
High-resolution imaging of the ankle should always include sagittal MPR reconstructions.
While a lot of details such as intra-articular fragments and destructions in this male
patient with postraumatic arthrosis are visible in axial images (Fig. 2a), reconstructions in
the coronal plane give the best overview (Fig. 2b).
86 4-row Scanning Peripherals

Knee

Indications. Suspected trauma on conventional x-rays, occult suspected depression of the

articular surface, presurgical evaluation.

Patient Positioning. Supine.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
MPR reconstructions are obligatory in the
sagittal and coronal planes.

Criteria of Good Image Quality

Fig. 1. Region: from the distal femur to beyond 1. Absence of motion artifacts.
the tibial plateau

Caveats
1. To detect or exclude injury of the menisci
or the cruciform ligaments, MRI is rec-
ommended.
2. Reconstructions should focus on one
side only.
Example of Axial Scan

Fig. 2 a, b.
 Knee 87

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 1 mm
Pitch factor 0.5–0.75
Reconstruction Slice 1 mm, increment 0.5 mm
Rotation time 0.75–1.0 s
Scan orientation Proximal-distal
Scanner settings 120 kV, 200 eff. mAs
Kernel (algorithm) Bone
Window 2,000/300
(width/center)
Contrast medium No
Administration
Volume
Flow rate
Scan delay

Comments
To take full advantage of MSCT, reconstructions of lateral and medial injuries from the axial
data (Fig. 2a) as applied to the coronal plane are recommended (see Fig. 2b). Sagittal recon-
structions are optimal for anterior and posterior processes.
88 4-row Scanning Peripherals

Trauma

Indications. Quick evaluation of patients with major trauma and suspected injuries of the
spine, chest and abdomen.

Patient Positioning. Supine.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
Imaging of trauma patients should include
sagittal MPR reconstructions of the spine (see
“Comments”).

Criteria of Good Image Quality

1. Good contrast opacification of both ves-
sels and parenchymal organs.
2. For MPRs of the spine, low noise at the
cervicothoracic junction.
Fig. 1. Region: from collar bones to symphysis
pubis
Caveat
Example of Axial Scan 1. Reconstructions of the spinal canal
necessitate thin overlapping reconstruc-
tions in addition to the soft-tissue
images.

Fig. 2.
 Trauma 89

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 2.5 mm
Pitch factor 1.25–2.0
a
Reconstruction
Rotation time 0.5 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 120–150 eff. mAs
Kernel (algorithm) (1) Soft; (2) bonea
Window (1) 420/60; (2) 2,000/300
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 150 ml
Flow rate 3 ml/s
Scan delay 45 s
a
The reconstructions for parenchymal organ injury in 6-mm-thick slices should be (1) followed by
a thin reconstruction of the spinal canal, (2) made with an adapted FOV and at least sagittal recon-
structions,and (3) a possible third reconstruction in a lung window for lung parenchymal changes.

Comments
Figure 2 shows a case of splenic rupture.
For the different reconstruction protocols see protocols “Routine Chest”, Routine
Abdomen” and Spine (e.g.“Thoracic Spine”).
Depending on the medical situation, this protcol can be completed by a CT study of the
head, the temporal bone, HR thorax, peripherals or a CTA study of the region of interest.
90 4-row Scanning Peripherals

Peripheral CTA

Indications. Peripheral stenotic or occluding artery disease.

Patient Positioning. Supine, arms elevated.

Topogram 3D Reconstructions
MIP Yesa
MPR Yesa
VRT Yesa
Other No
a
All reconstruction methods can be used (see
Fig. 2).

Criteria of Good Image Quality

1. High contrast opacification of the arte-
rial run-off vessels.

Caveats
Fig.1. Region:from the renal arteries down to the
ankles
1. A stenotic process on only one side may
pose a problem in the contrast material
timing.
Example of Axial Scan 2. Spatial resolution has to be sufficient.

Fig. 2 a, b.
 Peripheral CTA 91

Scan Parameters
Parameter Mode
Spiral
Collimation 4 ¥ 2.5 mm
Pitch factor 1.5–2.0
Reconstruction Slice 3 mm, increment 1.5 mm
Rotation time 0.5 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 110–160 eff. mAs
Kernel (algorithm) Soft
Window 420/60
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 150 ml
Flow rate 3 ml/s
Scan delay 25–30 sa
a
A test bolus injection or bolus tracking is recommended.

Comments
The collimation of 4¥2.5 mm is preferred because it offers higher table feed than the
4¥1-mm collimation. Thin overlapping reconstructions maintain the quality of the recon-
struction.
A MIP reconstruction (Fig. 2a) and a VRT reconstruction (Fig. 2b) are shown in a patient
with severe arteriosklerotic stenosis of the crossover bypass graft. The peripheral run-off is
documented on both sides.
92 4-row Scanning Interventions

Drainages

Indications. Local fluid collection with suspected inflammation, abscesses, cysts, pericar-
dial effusion not drainable by US-guided approach.

Patient Positioning. Supine; may be varied to prone if the safest (and shortest) path to
reach the area of interest is ventral, or to sagittal for similar considerations.

Topogram 3D Reconstructions
MIP No
MPR No
VRT No
Other Fluoroscopya
a
Fluoroscopy is recommended, especially
when the patient is unable to cooperate well
and when the area of interest is within the
basal parts of the lung, the heart, or the upper
abdomen.

Criteria of Good Image Quality

Fig. 1. Region: Patient positioning in the CT scan-
ner
1. Documentation of the drainage when the
needle is in position before and after
aspiration.

Example of Axial Scan Caveat

1. A follow-up spiral must be done after
drainage is in place.

Comments
Patient must be informed and must have
signed an informed consent form prior to
the investigation. Further patient prepara-
tion includes a venous drip, premedication,
if necessary, and local anesthesia. Data on
Fig. 2. (From Bruening et al. 2002)
blood coagulation and patient file must be
available.
Sterile table preparation:
– Syringe of 10–50 ml; needle for local
anesthesia; scalpel; sterile clothing and
gloves; Seldinger needle (18 G); guide
wire (0.035 F, 75 cm)
 Drainages 93

Scan Parameters
Parameter Mode
Sequential
Collimation 5 mm
Table feed 0
Reconstruction 5 mm
Rotation time 0.5 s
Scan orientation No table movement
Scanner settings 120 kV, 70–150 mAs
Kernel (algorithm) Soft
Window 420/60
(width/center)
Contrast medium No
Administration
Volume
Flow rate
Scan delay

Unsterile table preparation:

– Spray; sterile drainage sets (8–20 F); suture set
Procedure:
1. Perform and review spiral data (in expiration) and move the table to an optimal posi-
tion.
2. Mark the optimal entry point with either pen or barium paste (e.g., Mikrotrast).
3. Give local anesthesia.
4. Use a scalpel for incision.
5. Use a Seldinger puncture needle for entry into the chest or abdomen.
6. Proceed under fluoroscopic or single-shot CT control.
7. Verify the needle tip as within the fluid collection.
8. Insert the guide wire, extract the needle.
9. Use dilators to prepare for entry of the drain (or drains).
10. Introduce drain(s).
11. Aspirate as much as possible with the syringe; send the specimen to microbiology labo-
ratory.
12. Link the drain(s) to an external reservoir.
13. Fix drain(s) with a suture.
14. Perform control scans.
15. Keep the patient in bed for at least 6 hours.
Figure 2 shows the placement of a pigtail catheter in a pericardial effusion, using a lateral
approach.
94 4-row Scanning Interventions

Biopsies

Indications. Histology specimen needed from structures deep to the surface, e.g., lung, pan-
creas, liver, retroperitoneal lymph nodes.

Patient Positioning. Supine; may be varied to prone if the safest (and shortest) path to
reach the area of interest is ventral, or to sagittal for similar considerations.

Topogram 3D Reconstructions
MIP No
MPR No
VRT No
Other Fluoroscopya
a
Fluoroscopy is recommended, especially
when the patient is unable to cooperate well
and the area of interest is within the basal
parts of the lung or the upper abdomen.

Criteria of Good Image Quality

Fig. 1. Biopsy device
1. The needle in position before and after
the biopsy to document the exact posi-
tion.

Example of Axial Scan Caveat

1. One or more follow-up scans after the
conclusion of the procedure are strongly
recommended in order to exclude com-
plications (e.g., subclinical bleeding or
pneumothorax).

Comments
Before the procedure is initiated, the patient
must be informed and have signed an
informed consent form 24 h prior to the
investigation. Further patient preparation
includes a venous drip, premedication as
necessary, and local anesthesia. Data on
blood coagulation and the patient file must
Fig. 2. Example of a lung nodule biopsy in the be available.
prone position. (From Muehlstaedt et al. 2002) Before performing the biopsy, it is
strongly recommended to scan the region of
interest in the planned position of the
patient, usually with contrast, to include the
neighboring tissues.
 Biopsies 95

Scan Parameters
Parameter Mode
Sequential/fluoroscopy
Collimation 5 mm
Table feed 0
Reconstruction 5 mm
Rotation time 0.5 s
Scan orientation No table movement
Scanner settings 120 kV, 70–150 mAs
Kernel (algorithm) Soft
Window 420/60
(width/center)
Contrast medium Optional
Administration
Volume
Flow rate
Scan delay

Sterile table preparation:

– Syringe (10 cc); needle for local anesthesia; scalpel; sterile clothing; biopsy needle [16, 18,
or 20 G; length 10–16 cm (see Fig. 1)]
Unsterile table preparation:
– Sterile gloves (packed); spray; biopsy device; cases for the specimen to be sent to micro-
biology, pathology, and/or cytology (no formalin for microbiology specimen)
Procedure:
1. Review the spiral data and move the table to the optimal position.
2. Mark the optimal entry point with either a pen or barium paste.
3. Give local anesthesia.
4. Make the incision.
5. Introduce the needle into the chest or abdomen.
6. Carry out further procedures under fluoroscopic or single-shot CT control.
7. Verify the needle is in the correct position and that there is enough room for the needle
tip to be advanced (up to 25 mm!; see Fig. 2)
8. Adjust the biopsy device.
9. Perform the biopsy.
10. Before removing the needle, perform a control scan to document the exact position of
the needle tip within the lesion! This is important, if the biopsy is negative
11. Perform the control scan.
Figure 2 shows a patient with a single pulmonary nodule, biopsied in the prone position
using this protocol.
96 4-row Scanning Interventions

Sympaticolysis

Indications. Advanced peripheral arteriosclerotic disease otherwise untreatable.

Patient Positioning. Prone.

Topogram 3D Reconstructions
MIP No
MPR No
VRT No
Other Fluoroscopya
a
Fluoroscopy can be used, especially when the
patient is unable to cooperate well.

Criteria of Good Image Quality

1. Clear visualization of the lumbar spine
and the great abdominal vessels at the L3
level.

Fig. 1. Region: the region of interest in the prone

position
Caveat
1. Documentation of an exact positioning
Example of Axial Scan with a test injection with contrast me-
dium is necessary before the injection of
concentrated alcohol.

Fig. 2. The injected mixture of alcohol, contrast

material and local anesthesia in a patient with
chronic symptomatic arteriosclerosis of the
pelvis and legs
 Sympaticolysis 97

Scan Parameters
Parameter Mode
Sequential/fluoroscopy
Collimation 5 mm
Table feed 0
Reconstruction 5 mm
Rotation time 0.5 s
Scan orientation No table movement
Scanner settings 120 kV, 70–150 mAs
Kernel (algorithm) Soft
Window 420/60
(width/center)
Contrast medium No
Administration
Volume
Flow rate
Scan delay

Comments
Patient must be informed and must have signed an informed consent form prior to the
investigation. Further patient preparation includes a venous drip, premedication as neces-
sary, and local anesthesia. Data on blood coagulation and the patient file must be available.
Sterile table preparation:
– Syringe (ml); needle for local anesthesia; sterile clothing and gloves, Fransen needle (18
or 20 G)
Unsterile table preparation:
– Spray; alcohol (96%); contrast material (1 ml); local anesthesia
Procedure:
1. Perform and review the CT data (in prone position) and move the table to the optimal
position at the level of lumbar vertebra 4.
2. Mark the optimal entry point; the optimal point of injection is ventral to the lumbar ver-
tebra. Therefor, a lateral entry may be necessary.
3. Give local anesthesia.
4. Proceed under fluoroscopic or single-shot CT control.
5. Verify the needle position with the tip in front of the lumbar vertebra and clear of the
great vessels.
6. Carry out a test injection (1 ml contrast + 1 ml local anesthesia).
7. Perform control scans.
8. Inject the therapeutic agent (8 ml 96% alcohol + 1 ml contrast + 1 ml local anesthesia)
until pain occurs.
9. Perform control scans.
10. Retract the needle.
11. Keep the patient in bed for at least 4 h.
16-row Scanning
100 16-row Scanning Head

Routine CCT

Indications. Suspected infarct, bleeding, trauma (including fractures, see “Comments”),

unconsciousness of unclear origin, atrophy, central neural disturbances of unclear origin,
hydrocephalus.

Patient Positioning. Supine, arms bilaterally downward, use of headrest recommended.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
Coronal or sagittal MPRs may assist in
selected cases.

Criteria of Good Image Quality

1. Symmetric positioning of the patient’s
head.
2. Absence of motion artifacts.
Fig. 1. Region: from the base of the skull upward
(exposure of lenses should be avoided by patient
positioning) Caveat
1. If patient tends to move, positioning
devices should be used in addition to the
Example of Axial Scan headrest.

Fig. 2 a, b. (Case courtesy of Dr. B. Ertl-Wagner)

 Routine CCT 101

Scan Parameters
Parameter Mode
Spiral 1 (infratentorial) Spiral 2 (supratentorial)
Collimation 0.75 mm 1.5 mm
Pitch factor 0.57 0.57
Reconstruction 4 mm 8 mm
Rotation time 0.75 s 0.75 s
Scan orientation Caudo-cranial Caudo-cranial
Scanner settings 120 kV, 260–350 eff. mAs 120 kV, 260–400 eff. mAs
Kernel (algorithm) Soft (brain) Soft (brain)
Window 100/45 80/35
(width/center)
Contrast medium No No
Administration
Volume
Flow rate
Scan delay

Comments
Especially when using the 16-row scanner, helical data acquisition is very tempting and pre-
liminary testing at our institution gave comparable results to sequential scanning quality. It
remains controversial, however, whether the established sequential scans can be substituted
by helical multislice CT; confirmation by controlled studies is needed. Alternatively to the
above protocols with two separate spirals, one single spiral with 0.75-mm collimation can
be considered.
For the detection or exclusion of skull fractures, a subsequent (second) reconstruction of
the raw data (especially of spiral 1) with a high-resolution bone kernel is recommended.
To avoid artifacts at the skull base, the use of algorithms designed for their reduction is
recommended.
Figure 2 shows an investigation of a calcifying breast cancer metastasis to the brain.
Indications for contrast material administration as in the 4 row protocols
102 16-row Scanning Head

Temporal Bone and Inner Ear

Indications. Posttraumatic fracture of the temporal bone, cholesteatoma and chronic otitis
media, otosclerosis.

Patient Positioning. Supine, arms bilaterally downward, use headrest.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
Axial acquisition and MPRs in oblique coronal
and oblique sagittal (along and perpendicu-
lar to the temporal bone) are recommended.

Criteria of Good Image Quality

1. Sufficient delineation of ossicles, tym-
Fig. 1. Region: from upper mastoid cells to lower panic cavity, and mastoid cells.
end of mastoid (avoid direct exposure of lenses) 2. MPR reconstruction without stepping ar-
tifacts.

Caveats
Example of Axial Scan
1. Patient positioning without gantry tilt
must avoid direct exposure of the lenses.
2. The temporal bone needs a separate MPR
with a FOV (<9 cm) for each side.

Fig. 2 a, b. (Case courtesy of Dr. B. Ertl-Wagner)

 Temporal Bone and Inner Ear 103

Scan Parameters
Parameter Mode
Spiral
Collimation 0.75 mm
Pitch factor 1.0
Reconstruction 0.75 mm
Rotation time 1.0 s
Scan orientation Caudo-cranial
Scanner settings 120 kV, 120 eff. mAsa
Kernel (algorithm) Ultra-hard (inner ear)
Window 2,000/30
(width/center)
Contrast medium No
Administration
Volume
Flow rate
Scan delay
a
A further reduction of dose can be considered for children (120 kV, 70–100 mAs).

Comments
In our setting, the axial image data acquisition and the subsequent coronal (and sagittal)
MPRs as described are replacing the image acquisition in both planes.
Figure 2a (axial MPR) and 2b (coronal MPR) show reconstructions of a normal inner
ear, incus-malleus articulation, and mastoid.
104 16-row Scanning Head

CTA Intracranial Aneurysm

Indications. Suspected intracranial aneurysm; thrombosis of basilar or other intracranial

artery (if no angiographic correlation can be achieved); suspected occlusions; malforma-
tions; variants.

Patient Positioning. Supine, arms downward, use of headrest recommended.

Topogram 3D Reconstructions
MIP Yesa
MPR Yesa
VRT Yesa
Other No
a
Both MIP and MPR as well as VRTs can be ben-
eficial for the detection or exclusion of an
aneurysm and should be routinely used as an
adjunct to the axial scans.

Fig. 1. Region: adapted to the suspected area Criteria of Good Image Quality
1. High contrast of the arterial vessels.
2. No or little contrast media in the veins.

Caveats
1. Timing of the contrast injection is critical
(a test bolus injection is recommended).
2. This protocol should follow a routine
Example of Axial Scan (unenhanced) CCT.

Fig. 2 a, b. (Case courtesy of Dr. R. Hofmann)

 CTA Intracranial Aneurysm 105

Scan Parameters
Parameter Mode
Spiral
Collimation 0.75 mm
Pitch factor 0.57–1.25
Reconstruction 0.5–1.0 mm
Rotation time 0.5 s
Scan orientation Caudo-cranial
Scanner settings 120 kVa, 100–200 eff. mAs
Kernel (algorithm) Soft
Window 450/60
(width/center)
Contrast medium
Administration
Volume 100–120 ml
Flow rate 3–4 ml/s
Scan delay 35 sb
a
The tube voltage recommended for cerebral CTA is currently under discussion and may be
reduced to even below 100 kV.
b
For the optimal timing of the contrast injection, a test bolus tracking technique is recommended.
The timing should also take into consideration the desired scan length. With the protocol sug-
gested here, table feed is 24–30 mm/s.

Comments
This protocol should follow a routine CCT protocol.
Figure 2 reveals a small fusiform aneurysm in a female with complex developmental ab-
normalities of the cerebral vessels of the right posterior artery.
106 16-row Scanning Neck

Routine Neck

Indications. Cervical lymph nodes, lymphoma, abscesses, staging and restaging, thyroid
goiter (hyperthyroidism).

Patient Positioning. Supine, arms downward, remove dental prostheses, necklaces, etc.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
For staging and restaging, coronal and sagit-
tal MPR may be helpful. Image reconstruction
in the axial plane is recommended.

Criteria of Good Image Quality

1. Good contrast opacification.
Fig. 1. Region: from the hard palate to the upper
mediastinum (parallel to hard palate),or adapted
2. Absence of swallowing or gross motion
to the area of interest artifacts.

Example of Axial Scan Caveat

1. Dental artifacts may obscure enlarged re-
tropharyngeal nodes.

Fig. 2 a, b. (Case courtesy of Dr. W. Flatz)

 Routine Neck 107

Scan Parameters
Parameter Mode
Spiral
Collimation 1.5 mm
Pitch factor 1.33
Reconstruction 5 mm
Rotation time 0.75 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 150 eff. mAs
Kernel (algorithm) Soft
Window 450/60
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 80–120 ml
Flow rate 3 ml/s
Scan delay 45 s

Comments
The even shorter investigation time of 16-row scanners in conjunction with the breathhold
technique decreases the likelihood of movement artifacts.
A flexible FOV should enlarge areas of interest (anterior portion of the neck).
Thin collimation imaging decreases dental artifacts and may be necessary if the region
of interest is at the same level.
A carcinoma of the left hypopharynx with contact to the left supraglottic larynx is shown
in Fig. 2a (axial) and 2b (coronal MPR).
108 16-row Scanning Neck

Larynx and Hypopharynx

Indications. Laryngeal fractures, laryngeal inflammation of unknown origin, benign and

malignant tumors, laryngoceles.

Patient Positioning. Supine, arms downward, remove dental prostheses, necklaces, etc.

Topogram 3D Reconstructions
MIP No
MPR Yes (obligatory)
VRT No
Other No

MPR reconstructions in the coronal and

sagittal planes using soft tissue kernels are
strongly recommended (for fractures, bone
kernel).

Fig. 1. Region: from the tip of epiglottis to the

subglottic region in two spirals: breathhold and
Criteria of Good Image Quality
“e” phonation. The shoulders should be lowered
as much as possible 1. High quality coronal reconstructions.
2. Breathhold imaging of both spirals.

Caveats
Example of Axial Scan 1. The level for scanning the larynx varies
with each patient; the entire larynx must
be on the scan.
2. The patient must be properly instructed
before the examination.

Fig. 2 a, b. (Case courtesy of Dr. W. Flatz)

 Larynx and Hypopharynx 109

Scan Parameters
Parameter Mode
Spiral 1 (breathhold) Spiral 2 (“e” phonation)
Collimation 0.75 mm 0.75 mm
Pitch factor 1.0–1.33 1.0–1.33
Reconstruction 1 mm for MPR, 3 mm 1 mm for MPR, 3 mm
Rotation time 0.5 s 0.5 s
Scan orientation Cranio-caudal Cranio-caudal
Scanner settings 120 kV, 150–200 eff. mAs 120 kV, 150–200 eff. mAs
Kernel (algorithm) Soft Soft
Window 450/60 450/60
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 100 ml
Flow rate 3 ml/s
Scan delay 40 s Start second spiral immediately

Comments
Breathhold scanning is a requirement for good imaging of laryngeal carcinoma. The com-
bination of the two spirals in breathhold and “e” phonation becomes important when infil-
tration of the vocal cord is suspected.
For routine scanning to rule out carcinoma, breathhold maybe sufficient.
MPR reconstructions are very important for understanding the anatomy (Fig. 2a,b).
They are recommended in every investigation in coronal orientation.
For nodal staging, add the “Routine Neck” protocol.
110 16-row Scanning Neck

CTA Carotids

Indications. Suspected stenosis, occlusion or dissection of the common or internal carotid

artery or parts thereof.

Patient Positioning. Supine, arms downward, remove dental prostheses, necklaces, etc.

Topogram 3D Reconstructions
MIP Yesa
MPR Yesa
VRT Yesa
Other No
a
Various forms of postprocessing exist. STS/
MPR are recommended, but MIP or VRT can
also be used. Segmentation may be neces-
sary in the skull base.

Criteria of Good Image Quality

1. High opacification of the carotid artery,
Fig. 1. Region: from 3–4 cm above the sella tur- but little contrast in the jugular vein.
cica to the sternal notch

Caveats
1. Scan and contrast timing is critical; a test
Example of Axial Scan bolus injection is recommended.
2. Huge scan ranges increase the radiation
dosage.

Fig. 2 a, b.
 CTA Carotids 111

Scan Parameters
Parameter Mode
Spiral
Collimation 0.75 mm
Pitch factor 1.0
Reconstruction 3 mm; 1 mm for 3D reconstructions
Rotation time 0.5 s
Scan orientation Caudo-cranial
Scanner settings 120 kV, 120–200 eff. mAs
Kernel (algorithm) Soft
Window 450/60
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 100–120 ml
Flow rate 3 ml/s
Scan delay 12–15 sa
a
A test bolus of the aortic arch is recommended for the exact timing of the injection (+ 3 s).The best
reconstruction quality will be attained when the artery has a maximum contrast opacification,and
the jugular vein the minimum.

Comments
For a quick overview, VRT reconstructions seem to be very efficient.
If no MPR reconstruction is planned, the reconstruction increment can be as high as 5
mm.
When MPRs are planned, the reconstruction slice width should be reduced to 1 mm,
increment 0.5 mm.
Figure 2a shows an MPR and a VRT reconstruction in a young female to rule out carotid
occlusion after a chiropractic maneuver.
112 16-row Scanning Chest

Routine Chest

Indications. Mediastinal and axillary lymph nodes; tumors of the anterior, medial, and pos-
terior mediastinum; staging.

Patient Positioning. Supine position, arm(s) elevated over the head.

Topogram 3D Reconstructions
MIP No
MPR Yes
VRT No
Other No

The chest routine program is not optimized

for the secondary reconstructions of either
lung or mediastinum. However, if MPR re-
constructions are desired, a thin reconstruc-
tion increment is important.

Fig. 1. Region: from the lung apices to below the

diaphragm (in bronchial carcinoma including Criteria of Good Image Quality
the adrenals)
1. Breathhold acquisition.

Caveat
1. For screening of lung nodules or inflam-
matory changes only, the low-dose proto-
col should be used (see “Comments”).
Example of Axial Scan

Fig. 2 a, b. (Case courtesy of Dr. R. Eibel)

 Routine Chest 113

Scan Parameters
Parameter Mode
Spiral
Collimation 1.5 mm
Pitch factor 1.25–1.5
Reconstruction 6 mm
Rotation time 0.5 s
Scan orientation Caudo-cranial
Scanner settings 120 kV, 100–150 eff. mAs
Kernel (algorithm) Soft
Window 450/60 and 1,500/600
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 80 ml
Flow rate 3 ml/s
Scan delay 30 s

Comments
This is meant to serve as a routine protocol. The reconstructions should be cranio-caudal.
Detection of an intrapulmonary scar in ruling out primary bronchogenic carcinoma in
the right upper lobe is the subject of Fig. 2.
114 16-row Scanning Chest

Pulmonary Embolism

Indications. Detection or exclusion of suspected pulmonary embolism, evaluation of atyp-

ical chest pain.

Patient Positioning. Supine, arms elevated above the head.

Topogram 3D Reconstructions
MIP Yesa
MPR Yesa
VRT No
Other No
a
Coronal and axial MIP or MPR reconstructions
are used to detect embolism in subtle cases.

Criteria of Good Image Quality

1. Sufficient contrast in the pulmonary
Fig. 1. Region: from above the aortic arch with
concentration on the central hilar portion
arteries.
2. Absence of motion artifacts.

Caveat
1. The high flow of contrast material
injected may cause artifacts from the
superior vena cava.
Example of Axial Scan

Fig. 2 a, b. (Cases courtesy of Dr. R. Eibel)

 Pulmonary Embolism 115

Scan Parameters
Parameter Mode
Spiral
Collimation 0.75 mm
Pitch factor 1.25–1.5
Reconstruction 5 mm; 1 mm for 3D reconstructions
Rotation time 0.5 s
Scan orientation Caudo-cranial
Scanner settings 120 kV, 100–150 eff. mAs
Kernel (algorithm) Soft
Window 450/60
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 120ml
Flow rate 4 ml/s
Scan delay 16 sa
a
The delay should be determined by a test bolus injection or bolus tracking (pulmonary artery).

Comments
The protocol can be used to exclude or to detect pulmonary embolism. The MPR can help
in viewing the full extent of the thrombotic material. Using MSCT, the source of emboliza-
tion (as for example in the right heart) can also be visualized.
Figure 2a reveals a small embolus in the paracardial segment of the right lung; Fig. 2b
shows a normal MPR.
116 16-row Scanning Chest

CTA Aortic Arch

Indications. Detection or exclusion of aortic aneurysms, bleeding, dissection, or thrombo-

sis of the ascending aorta, arch, and descending aorta.

Patient Positioning. Supine, arms elevated over the head, ECG gating on.

Topogram 3D Reconstructions
MIP Yesa
MPR Yesa
VRT Yesa
Other No
a
Reconstructions using either technique helps
in viewing the vessel lumen itself and the
relationship to neighboring structures.

Criteria of Good Image Quality

1. High contrast of the arterial vessels.
Fig. 1. Region: from above the lung apices to
below the diaphragm (or lower tip of aneurysm).
2. Little or no contrast media in the veins.
Put ECG pads on! 3. Good quality secondary reconstructions.

Caveat
1. Timing of the contrast injection is critical
and should be determined by bolus
Example of Axial Scan tracking or a test bolus.

Fig. 2 a, b. (Case reconstructions by Dr. Loke Gie Haw)

 CTA Aortic Arch 117

Scan Parameters
Parameter Mode
Spiral
Collimation 1.5 mm
Pitch factor 0.28–0.32 (ECG-gating)
Reconstruction 3–6 mm; 2 mm for 3D reconstructions
Rotation time 0.42–0.5 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 200–250 eff. mAs
Kernel (algorithm) Soft
Window 450/60
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 120 ml
Flow rate 3–5 ml/s
Scan delay 15 sa
a
If an alteration of the circulation time is suspected, the use of a bolus tracking technique or a test
bolus (+ 5 s) is recommended.

Comments
ECG gating is recommended to reduce pulsation artifacts.
A detail of the region of the origin of the vertebral arteries is given in Fig. 2a (hypoplas-
tic, but not stenotic vertebral artery on the right). Figure 2b demonstrates the possibility of
reconstructing details such as the brachial artery.
118 16-row Scanning Heart

Coronary Artery Screening

Indications. Suspected coronary artery disease. Symptomatic patients, atypical chest pain;
asymptomatic patients, risk stratification.

Patient Positioning. Supine, arms elevated, ECG gating on.

Topogram 3D Reconstructions
MIP No
MPR No
VRT No
a
Other
a
Calcifications are postprocessed to deter-
mine the Agatston score, or a volume or mass
score. Elevated values of these scores are
known to correlate with an increased risk of
Fig. 1. Region: from above the tracheal bifurca- coronary artery disease.
tion to the diaphragm

Criteria of Good Image Quality

Example of Axial Scan 1. Motion-free visualization of the coronar-
ies and the coronary calcifications.
2. Focused FOV.

Caveats
1. Variation of the trigger delay may be nec-
essary.
2. Automated programs for deriving scores
need supervision.
3. The lung window should also be read.
4. Heart rates less than 70 beats per minute
are optimal (see comments).

Fig. 2. (Case courtesy of Dr. C. Becker)

 Coronary Artery Screening 119

Scan Parameters
Parameter Mode
Spiral
Collimation 1.5 mm
Pitch factor 0.28–0.32
Reconstruction 3 mm
Rotation time 0.42 sa
Scan orientation Cranio-caudal
Scanner settings 120 kV, 133 eff. mAs
Kernel (algorithm) Cardiac
Window 450/60
(width/center)
Contrast medium No
Administration
Volume
Flow rate
Scan delay
a
This is to be ECG-gated.

Comments
ECG gating and coverage of the entire heart is necessary in order to derive sufficient image
quality and score reproducibility. Set the trigger to 40–70% (default 60%) of the ECG R
duration.
Instead of spiral acquisition, sequential scanning is also possible (120 kV, 30 mAs, rota-
tion time 0.42 s, 1.5 mm per slice).
If the heart beat exceeds 70 beats/min, oral premedication using a beta blocker may be
considered.
For direct visualization of the lumen of the coronary arteries, please add the “Coronary
Artery Screening” protocol.

For the interpretation of the coronary artery scores, please refer to the third table in the
“Coronary Artery Screening” protocol (page 49) as well as to the literature cited therein.

An example of subtle calcifications in the LAD is given in Fig. 2.

120 16-row Scanning Heart

CTA Coronary Arteries

Indications. Suspected coronary artery disease.

Patient Positioning. Supine, arms elevated, ECG gating on.

Topogram 3D Reconstructions
MIP Yesa
MPR No
VRT No
Other Yesa
a
Oblique (45°, parallel to main stem) STS MIPs
are recommended (3 mm slice thickness, 1.5
mm increment) for the visualization of the
main stem, as well as LAD and RCA projec-
tions.
Fig. 1. Region: from above the tracheal bifurca-
tion to the diaphragm
Criteria of Good Image Quality
1. Absence of motion artifacts.
2. High contrast in coronary arteries.

Example of Axial Scan Caveats

1. A test bolus should be used.
2. All parts of the arteries must be opacified
(proximal, mid, and distal).

Fig. 2 a, b. (Case courtesy of Dr. C. Becker)

 CTA Coronary Arteries 121

Scan Parameters
Parameter Mode
Spiral
Collimation 0.75 mm
Pitch factor 0.28–0.32
Reconstruction 1 mmd
Rotation time 0.42 sa
Scan orientation Cranio-caudal
Scanner settings 120 kV, >400 eff. mAs
Kernel (algorithm) Cardiac
Window 450/60
(width/center)
Contrast medium Yes
Administration Biphasicb
Volume 40 ml 80 ml
Flow rate 4 ml/s 2 ml/s
c
Scan delay 10 s later
a
ECG gated.
b
Adapted from C. Becker (unpublished data).
c
To be determined by test bolus or bolus tracking.
d
Reconstruction slice width 0.75 mm should be restricted to detail diagnosis of stents or severely
calcified coronary arteries.

Comments
ECG gating and coverage of the entire heart is necessary for sufficient image quality.
Set the trigger to 60% of ECG R duration. Individual patient optimization may be
required, which is best achieved by a series of test images with different phase settings at the
level of mid-RCA. The LAD and RCA may require separate optimizations of the reconstruc-
tion phase.
Using this protocol, heart rates of less than 70 beats per minute are optimal. If the rate
exceeds 70 beats/min, oral premedication using beta blockers should be considered.
The quality that may be achieved with this technique is illustrated in Fig. 2a, where high-
contrast opacification and motion-free visualization of the LAD is shown. The quality of
STS MIPs may be appreciated in Fig. 2b.
122 16-row Scanning Abdomen

Routine Abdomen

Indications. Screening, detection or exclusion of abscesses, control scans, follow-ups.

Patient Positioning. Supine, arms elevated above the head.

Topogram 3D Reconstructions
MIP Yes
MPR Yes
VRT No
Other No

Criteria of Good Image Quality

1. Absence of gross motion artifacts.
2. Good contrast opacification of arteries
and veins. including the portal system.

Caveat
Fig. 1. Region: from above the diaphragm to the
symphysis pubis 1. For the detection or exclusion of venous
thrombosis, vary the injection time.

Example of Axial Scan

Fig. 2 a, b. (Case courtesy of Dr. A. Wieser)

 Routine Abdomen 123

Scan Parameters
Parameter Mode
Spiral
Collimation 1.5 mm
Pitch factor 1.0–1.5
Reconstruction 5–6 mm
Rotation time 0.5 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 140–165 eff. mAs
Kernel (algorithm) Soft
Window 450/60
(width/center)
Contrast medium i. v. + oral + rectala
Administration i.v., monophasic
Volume 120 ml
Flow rate 3 ml/s
Scan delay 25–80 sb
a
Oral contrast for the optimal distention of the stomach should be given immediately before, and
for the bowel up to 2 h (with 900 ml) before scanning.Water or methylcellulose should be rectally
administered immediately before scanning.
b
Depending on the desired contrast, the scan delay may be varied from 25 s for portal venous con-
trast to over 80 s for systemic venous contrast.

Comments
To reduce radiation, especially in young patients, the tube currents should be adapted to the
habitus and can be reduced to 120 mAs.
The patient should do deep breathing before beginning the spiral.
Liver metastases the left liver segments are shown in Fig. 2a; at the same time Fig. 2b,
using appropriate sagittal reconstructions, reveals sclerotic plaques of the abdominal aorta.
124 16-row Scanning Abdomen

CTA Abdomen

Indications. To quantify or to exclude aneurysms of the aorta, to measure the diseased por-
tions of the abdominal aorta before minimally invasive or open intervention, to detect or
exclude aortic rupture or retroperitoneal bleeding.

Patient Positioning. Supine, arm elevated over the head.

Topogram 3D Reconstructions
MIP Yesa
MPR Yesa
VRT Yesa
Other No
a
All of the reconstructions help to visualize the
three-dimensional extent and should be used
in addition to the axial data.

Criteria of Good Image Quality

1. High contrast in the abdominal aorta
throughout the scan.
2. Little contrast in the parenchymal organs
and no or negative contrast in the bowel.
Fig. 1. Region: adapted to the area of interest
Caveat
1. Axial images and reconstructions must
visualize aortic branches such as the
renal arteries and superior mesenteric
Example of Axial Scan artery.

Fig. 2 a, b.
 CTA Abdomen 125

Scan Parameters
Parameter Mode
Spiral
Collimation 0.75 mm
Pitch factor 1.00–1.25
Reconstruction 5 mm; for 3D reconstructions 0.75–1.0 mm
Rotation time 0.5 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 130–200 eff. mAs
Kernel (algorithm) Soft
Window 450/60
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 120 ml
Flow rate 3 ml/s
Scan delay 18 sa
a
In patients with possible alteration of the circulation time, a bolus tracking technique or a test
bolus application (+ 8 s) is recommended so as to achieve optimal contrast in the spiral acquisi-
tion.

Comments
This protocol can be adapted to an extended coverage to include neck, chest, and abdomen
(using a collimation of 1.5 mm with a pitch factor of >1).
Figure 2 shows an infrarenal aortic aneurysm (reconstruction of the aneurysm in VRT
by Dr. Loke Gie Haw).
126 16-row Scanning Spine

Spine

Indications. Suspected disk protrusion or herniation; suspected fractures, spondylolisthe-

sis; unclear findings such as from a post-myelogram CT; MRI contraindications.

Patient Positioning. Supine, arms downward for cervical spine, arms elevated for thoracic
and lumbar spine.

Topogram 3D Reconstructions
MIP No
MPR Yesa
VRT No
Other No
a
We recommend using MPRs in an angulated
fashion regularly in the manner of Fig. 1.
Using the thin axial raw data, the slices angu-
lated in this way yield low noise and superior
detail.

Criteria of Good Image Quality

1. Zoomed images (FOV about 90 mm).
2. Angulation parallel to the disks.

Caveat
1. The axial scan must cover the entire vol-
ume while the reconstructions are angu-
lated to the individual disk level.

Fig. 1 a, b. Region: adapted to the area of interest.

Depending on the region, Fig. 1a for scanning
protocol, Fig. 1b for reconstructions
 Spine 127

Scan Parameters
Parameter Mode
Spiral
Collimation 0.75 mm
Pitch factor 0.50–0.75
Reconstruction Angulated axial and sagittal slices 3 mm thick, 1.5 mm increment
Rotation time 0.75 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 330 eff. mAs
Kernel (algorithm) Soft; if fracture, bone kernel
Window 450/60; 2,000/300 or adapteda
(width/center)
Contrast medium No
Administration
Volume
Flow rate
Scan delay
a
After a myelographic intralumbar injection of contrast material a window of 1200/400 is recom-
mended.

Comments
The combination of angulated axial and sagittal MPR reconstructions is most advanta-
geous. This way an angulation of the gantry is not necessary for any spinal investigation. The
MPR reconstructions can be routinely used and viewed instead of the axial cuts.
Figure 2 shows findings in a young man with anterior listhesis on L4–L5 and consecutive
disk protrusion in the lumbar spine at the level L4–L5.

Example of Axial Scan

Fig. 2 a, b. (Case by Dr. A. Wieser)

128 16-row Scanning Peripherals

Peripheral CTA

Indications. Peripheral stenotic or occluding artery disease.

Patient Positioning. Supine, arms downward.

Topogram 3D Reconstructions
MIP Yesa
MPR Yesa
VRT Yesa
Other No
a
All reconstruction methods can be used (VRT
is shown in Fig. 2 b).

Criteria of Good Image Quality

1. High contrast opacification of the arte-
rial run-off vessels throughout the scan
range.

Caveat
1. A stenotic process on only one side may
be a problem in the contrast material
timing.
2. Spatial resolution has to be sufficient.

Fig. 1. Region: from the renal arteries or pelvis

down to the ankle

Example of Axial Scan

Fig. 2 a, b.
 Peripheral CTA 129

Scan Parameters
Parameter Mode
Spiral
Collimation 1.5 mm
Pitch factor 1.25–1.50
Reconstruction 6.0 mm; 2 mm for 3D reconstruction
Rotation time 0.5 s
Scan orientation Cranio-caudal
Scanner settings 120 kV, 130–150 eff. mAs
Kernel (algorithm) Soft
Window 450/60
(width/center)
Contrast medium Yes
Administration Monophasic
Volume 150 ml
Flow rate 3 ml/s
Scan delay 25–30 sa
a
A bolus tracking technique or test bolus injection (+ 16 s) is recommended.

Comments
Depending on the scan range, the collimation can be varied; the collimation in conjunction
with the pitch factor offers increased table feed. Thin overlapping reconstructions maintain
the quality of the 3D reconstructions.
An arteriosclerotic portion of the abdominal aorta and pelvic arteries are shown in
Fig. 2a. Please note that the calcified plaques can also be viewed on the VRTs (as in Fig. 2b).
 131

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