CT

Indian Institute of Technology, Kharagpur
Computerized Tomography Basic Principles

Dr. Bhaskar Azad
School of Medical Science and Technology Indian Institute of Technology
Kharagpur, West Bengal
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Dr Bhaskar Azad
Diagnostic Radiology
A CT Scan Records (on a film) or displays (on a monitor) a pattern of densities (on a film) or illumination levels (on a monitor) corresponding to the organs of the subject through which beam of X-Rays have been passed.
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What exactly is an IMAGE?
It is a representation or map of the spatial distribution of some selected tissue or anatomical site.
Pixel or Picture Element represents not only a value of a physical property but also the spatial relationship of location of that value with respect to other measured values. A pixel localizes the measured value.
A pixel is generally used to described 2D images. To get a description of spatial extent we use the term voxel or volume element in 3D.
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The size of this spatial extent reflects the spatial resolution of the measurement. Spatial resolution in CT is in the order of 0.25 mm.
Image contrast is dependent on the differences in pixel values between one location & its surroundings.
To visualize internal organs in a non invasive manner, we require some form of energy which is capable of penetrating into the human body. E/m waves of visible wave length have very low energy & penetrance - a lighted bulb when placed against your hand can illuminate through the soft tissue but will not be able to penetrate deeper or give any information capable of forming a diagnostic image. Contd..
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When Wilhelm Conrad Roentgen on November 8th, 1895 held his hand in the path of an electro-magnetic wave of lower wavelength and higher penetrance, he was able to see the outline of his skeleton & thus he discovered X-Rays. He was awarded the first Nobel Prize for Physics in 1901. Electro-magnetic radiation is the transport of energy through space as a combination of electric and magnetic fields. Electro-magnetic radiation is produced by a charge being accelerated. All types of electro-magnetic radiations in vacuum have the same velocity i..e., 3 x 108 meters / sec. This is usually referred to as velocity of light & given the symbol c Contd..
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Relation of electro-magnetic radiations are expressed in velocity, wave length & frequency i.e.
C When, C V
= = = =
v velocity of light (m/sec), wavelength (in meters), frequency (per sec.).
Since C remains constant, frequency & wavelength are inversely proportional. Wavelength of an X-Ray used for diagnostic purposes is very short & expressed in Angstrom units () and 1 is equal to 10-10 meters. Contd..
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E/m radiation Radio, TV, Radar Infrared Radiation Visible light Ultraviolet Radiation Diagnostic X-Rays -
Wavelength 3 x 105 to 1 cm. 0.01 to 0.00008 cm.(8000 ) 7500 (0.000075 cm.) to 3900 3900 to 20 1 to 0.1 0.1 to 10- 4
Therapeutic X-Rays & Gamma-Rays

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It was in April 1972 at the Annual Conference of Radiology that G.N. Hounsfield, a senior research scientist at E M I limited in Middlesex, England, announced a new invention called computerized axial transverse scanning which is today more familiar to us as Computerized Tomography or C T Scan. In this method Hounsfield demonstrated that a C T system could use XRays with thinly collimated beams to take the images of a cross section of the head from multiple angles. The transmitted radiation was then counted by a scintillation detector, fed into a computer for analysis by a mathematical algorithm & reconstructed as a tomographic image. This method was able to show density difference between soft tissue, gray matter, white matter, blood clot, oedema, fat & of course skull bones.
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CT, X-Ray and Tomography

To understand the value of CT in medical imaging, it helps to understand and appreciate the basic differences between conventional radiography, conventional tomography, and CT. Ordinary plain x-ray films are superimposition shadowgrams which means that the images of all superimposed structures appear on the film. The PA film of the upper bony thorax, for example, contains superimposed images of the aortic arch, trachea, and vertebral bodies.
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Conventional Tomography
Conventional tomography studies effectively slice the living patient so that you can study the shadows cast by certain structures free of superimposed shadows. For example, the coronal tomogram in the next slide shows the anterior part of the bony thorax where the clavicles meet the manubrium. Note that only this plane of the body is visible clearly and the rest of the bones are out of focus. Compare this image with the x-ray shown above where all the structures in various planes are sharply defined.
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CT-Scan
Unlike conventional tomography, computed tomography (CT) gives focused radiographic information about one cross-sectional slice of the patient only, without any confusing superimposed images. Within a slice the scan provides a range of density values for the various anatomic structures, and the spatial relationship between these structures in the body is seen much more accurately in this imaging modality. In the next slide is a CT scan of the thorax of a frozen cadaver.
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A CT image is a display of the anatomy of a thin slice of the body developed from multiple X-Ray absorption measurements made around the bodys periphery. Basic components of a CT scanner :-
1. 2. 3. 4.
An X-Ray source, Detectors, Associated electronics, A table or cradle which has forward ,backward, upward & downward movements on which the patient lies.
All these are mounted on a frame termed as a gantry which moves to produce the scan
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First Generation Scanners (now obsolete) :Scanners in which X-Ray tube & detectors move in rotatetranslate fashion. The translation motion is time consuming and so there may be mismatch between patient position & pixel position giving streak artifacts.
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Second Generation Scanners:Scanners in which X-Ray tube & detectors move in rotate rotate fashion, i.e., they rotate around the object but here to reduce time multiple detectors are used to collect data from multiple pencil beams.
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Third Generation Scanners :Rotate only systems where X-Ray source rotates & detectors are stationary.
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Fourth Generation Scanners :Though the 3rd generation scanners are faster than 1st / 2nd generation scanners, they have the problem of detector calibration as the detectors are stationary and behind the patient all the time & cannot be calibrated between individual scans. This leads to formation of ring artifacts as each detector needs to be calibrated to assume constancy & uniformity of response as compared to adjacent detectors to give artifact - free images.
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Fifth Generation Scanners :-
In this there is a stationary gantry detector system with an electron beam sweeping across an extended anode target arranged semi-circularly around the patient. This causes formation of multiple fan beams of X-Ray with which multiple images can be acquired very fast (about 50 cm sections / image). By this, cine type scanning & flow studies and cardiac imaging can be done.
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HOW A CT SCAN IS PERFORMED
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A typical CT scanner is shown in the previous slide. When a CT scan is performed, the patient is lying on the table as it moves through the center of the doughnut-shaped structure called the gantry. As shown in the next slide, the gantry houses the x-ray tube and special electronic detectors which make CT scanning possible.
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In the first generation scanners, a single scan took as long as 5 6 minutes and today we can do subsecond scanning and with the help of spiral CT & multi slice CT can scan the entire abdomen in as little time as a single breath-hold.
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Methodology
Once a scan begins, a pencil-thin collimated beam of x-rays passes through the body in the axial plane chosen for study as the x-ray tube moves in a continuous arc around the patient. Carefully aligned and placed directly opposite the xray tube are the detectors which convert the exiting beam on the other edge of the body slice into electronic signals, the intensity of which depends upon the amount of the remaining beam of x-rays that has not been absorbed by the intervening tissues.
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Methodology
Thus if the beam has passed mainly through dense areas of the body such as bone, fewer xrays will emerge than when the beam traverses mainly low-density tissue such as lung. As fast as data is received by the detectors, it is conveyed to a computer which then calculates the x-ray absorption for each voxel, or pixel, of a cross-sectional slice.
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Methodology
The pictorial arrangement of x-ray absorption values makes up the final CT image. Denser tissues such as bone appear white, while less dense tissues such as air appears black.
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DETECTORS
1. Scintillation Detectors plus Photomultiplier Sodium Iodide, Calcium fl Bismuth germanate
2. Scintillation crystals plus photo-diode
Cadmium tungstate Cesium Iodide (Solid State detectors).
3. Ionization Chamber
Xenon (under pressure).
(Gaseous detectors).
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A detector should have the following criteria :1. High absorption efficiency, i.e., it should be able to make maximum utilization of the photons incident on its surface. 2. High conversion efficiency:- The detector should convert the absorbed X-Ray energy to enable electronic signal. 3. High capture efficiency :- The detectors should be placed & aligned in such a way that maximum no. of incident photons are captured by it. The above 3 criteria together form the dose efficiency of a detector.
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A detector should have the following criteria :-(Contd.)

4. High temporal response :- The detector has a very short time in which it receives, detects & processes the incident photon to an electronic signal & then gets ready to face the next barrage of photons. This is in milliseconds. Some detectors may take longer time for this & have a delayed response which is called after glow or phosphorescence. A detector with high temporal response will have little after glow. 5. Wide dynamic range :- Detectors should be able to analyse efficiently & respond linearly to a wide range of X-Ray intensities. 6. Finally, detectors should have high reproducibility & stability to avoid detector fluctuation or noise.
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Scintillation detectors + photodiodes - solid state detectors Ca tungstate Cesium Iodide. More than 95% dose efficiency. Xenon Gas detector 50% - 70% dose efficiency. Advantages of Xenon Gas detector :1. Can be small & configured close to one another to have better capture efficiency 2. Xenon being a gas perfuses evenly throughout the ionization chamber so as to get more uniform response.
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Disadvantages :-
1. Xenon being a gas has less absorption efficiency as compared to solid state detectors. High pressure ionization chambers are used to increase density of Xenon to increase absorption efficiency.
2. Some attenuation loss occurs within the thick face plate of the pressurized Xenon gas chamber.
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What is attenuation?
Attenuation is simply defined as the removal of X-Ray photons
from the beam. This removal can be accomplished either by

absorption (energy deposited at or near the site of photon interaction) or scatter (energy removed from site of photon
interaction). Tissues have different attenuation characteristics

which depend on their atomic number & physical density and on the incident photon energy. The attenuation of a material can be described as attenuation co-efficient (u) in cm.-1.
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An arbitrary scale of attenuation co-efficient specifies air as 1000, water as 0 & bone as +1000 and is called a Hounsfield scale. The numbers are called CT number of Hounsfield number.
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The model or calculation scheme used for reconstruction of images is called an algorithm. The most popular algorithm for clinically used commercial scanners is the back projection algorithm. In this algorithm the ray sum scan for each row of pixels for a first approximation is assigned to each pixel in the row (back projection). As each data set corresponding to a new angle of scan is determined, it is also back projected & averaged into each pixel. The image for a number of different angles and the sum or superimposition of all the views represents a reconstruction of the original image.
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CALCULATION OF ATTENUATION COEFFICIENT OF INDIVIDUAL PIXELS FROM VARIOUS RAYSUMS
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Before each back projection, the intensity profile is modified or filtered to minimize artifacts.
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To form an image from the ray sums we need to have some means of collecting the X-Ray transmission data. All CT scanners are hence fitted with a radiation detector. The signal from the radiation detector is digitized with the help of Analog to digital converter and thereafter fed to a computer for processing. The computer performs the complex mathematical processes to reconstruct the images. These images are then displayed on a video monitor. The images are stored in a hard disk till one needs them. For archiving one can use hard copy or films or one can store them on an MOD, floppy, CD etc.
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C T image display :-
1. Video monitor gray scale, i.e., brightness & contrast from darkest to brighter illumination in graded steps or continuous illumination. 2. Window settings.
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Window & Levels

Because we cannot see the difference between 2000 different shades of grey it would be pointless to produce an image which covered the whole range of Hounsfield numbers. In order to produce a useful image of the area of interest a system of windowing and levels is used.
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WINDOWING
The available grey scale is spread over the chosen range of Hounsfield numbers. The window defines the upper and lower limits of this range. To produce an image which shows up most major structures a large window is used. For more detailed information about tissues with very similar density a small window is used. The smaller the window the more detailed the image but the range of tissue density that is seen is reduced
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LEVELS
The level is the Hounsfield number at the centre of the window. This is chosen so that the window covers the type of tissue you are interested in. To image dense tissues a high level is used and to image low density tissues a low level is used.
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Lung window
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This image was produced with a window of 1000 HU at level 700HU.
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Mediastinal window
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This image was produced with a window of 500HU at level +50HU.
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SMOOTH
SHARP
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Hounsfield (CT) Number

The Hounsfield number of a tissue varies according to the density of the tissue with more dense tissues having higher numbers. Hounsfield numbers range between +1000 HU and 1000 HU for bone and air respectively (although the scale has been recently been extended to +4000 for bone imaging). By convention, probably to maintain consistency with the shades produced in a radiograph, high numbers are shown as white and low numbers as black.
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A representation of Hounsfield's scale. The bottom scale shows the grey scale in a scan at level 0, window 200.
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C T number = K up -uw uw K = magnifying constant, Up = linear attenuation coefficient of pixel Uw = linear attenuation coefficient of water Processing algorithm may introduce artifacts not present in the original data. Factors affecting CT Number Accuracy :1. 2. 3. 4. 5. 6.
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X-Ray beam Kv & filtration. Patient thickness & shape. Tissue type & location. Partial volume effect. Algorithm & calibration shifts. Field calibration Accuracy.
Dr Bhaskar Azad
CT number accuracy is important in getting correct representation of tissues. It is also used to calculate, bone mineral density, calcium scoring in coronary artery disease & identification of calcified vs. non-calcified lung nodules.
CT number can vary between one CT scan unit & another, even same type of units.
Calibration of CT units regularly by service engineers required to get best efficiency.
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Recap .
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ARTIFACTS 1. Artifacts can be demonstrated either visibly in the image, e.g., streaks, rings. 2. Quantitative demonstration of artifacts in inaccurate CT numbers.
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Motion Artifacts :1. Streak artifacts 2. Poor spatial resolution loss of fine detail. 3. Poor tissue resolution loss of ability to visualize small differences in tissue densities. Corrected by :1. Immobilization of patient / sedation of patient. 2. Time exposures during the period when patient is not moving. 3. Over scanning scan beyond normal range of 180 to 360 & get more views. Then average out the difference increased scan time.
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MOTION ARTIFACTS
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Polychromatic artifacts
Photons in X-Ray beam are polychromatic & so have wide distribution of energy. While traversing the patient, the lower energy photons are absorbed preferentially so the beam becomes harder. Different degrees of beam hardening occur along the different paths and those crossing high density structures like bones, e.g., petrous bones, skull vault, etc. will cause a general decrease in CT numbers causing dark streaks. Several correction methods are used to overcome these artifacts.
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Polychromatic artifact
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Equipment Misalignment :-
Improper alignment of the X-Ray source & detectors can cause streak artifacts.
Faulty X-Ray source :- If the X-Ray beam itself is faulty & has altered radiation level, the detectors will not be able to distinguish between the actual attenuation due to tissues vs. that due to faulty X-Ray beam energy. This may occur due to error in speed of anode rotation or high voltage fluctuation and arcing leading to criss cross streak artifacts. Reference detectors are placed to detect these changes.
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Artifacts due to data acquisition :-
Partial volume effect A voxel of tissue has within it contents of varying CT numbers, there is linear averaging of these CT numbers giving that voxel a CT number which is not actually contained in that voxel. These are more prominent & cause artifacts when tissue of highly different CT numbers are present within a voxel, e.g., liquid & air, metallic objects, dense bone.
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Metallic Artifacts
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Artifacts due to data measurement :1. Detector faults or poor efficiency in collection & transformation of photon intensities.
2. Scatter collimation :- Scatter radiation from the incident beam can pollute the final intensity of photons passing through an object, particularly a dense object.
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Artifacts due to data processing :Source & detector collimation :-
Like any X-Ray device with finite size focal spot, CT is also subject to effects of penumbra. To reduce dose to the patient, collimation of the source & detector can be done. Third generation CT scanners can easily incorporate collimators but fourth generation scanners cannot as each detector has to detect X-Rays energy from different angles.
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BREAK
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Practical applications of CT
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Normal brain
Contusion haemorrhage
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Contrast enhanced CT
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Oral Contrast The gastrointestinal tract lumen can be opacified by the administration of oral contrast material, which the patient drinks one to two hours before the CT exam. Oral contrast materials can opacify the stomach, duodenum, small bowel, and colon. The colon may also be directly opacified by the rectal administration of colon contrast materials. Bowel contrast is useful in that it provides information about the thickness and character of the bowel and can be used to differentiate fluid-filled loops of bowel from other abdominal abnormalities.
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Contrast
Intravenous Contrast Intravenous administration of contrast material during CT scanning produces a temporary increase in the density of the arteries, the capillary-perfused parenchyma, and, finally, of peripheral veins. This is called contrast enhancement and is extremely useful for identifying abdominal pathology. The intravenous contrast material is excreted renally, and therefore the renal collecting systems and ureters will be shown to be opacified on delayed CT scans.
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Image Contrast
It is the final displayed density difference on an image in the film or display monitor. To separate different body organs & vascular structures we need to increase these density differences. This is helped by giving oral iodinated contrast (to separate bowel loops) & I.V. iodinated contrast to see blood vessels and organ / lesion vascularity by extra-vascular & intra-vascular contrast enhancement.
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SUBJECT CONTRAST
DENSITY DIFFERENCE : One of the most important factors in causing subject contrast. Density : - Mass per unit volume. Greater density greater X-Ray attenuation.
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SUBJECT CONTRAST
ATOMIC NUMBER DIFFERENCE
Attenuation of X-Ray beam in diagnostic radiology is based mostly on photoelectric effect.
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Effective Atomic Numbers

Bone 13.8
Muscle
Fat
7.4
5.9
Contrast-media
Iodine 53
Barium
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Contrast Agents Used
Ionic iodinated contrast. Non-ionic iodinated contrast. Iodine concentration is usually 300 370 mg. / ml. Volume and Rate of I.V. injection vary according to region of interest & disease process. All are Benzene ring derivatives with three atoms of iodine and six atoms of carbon per molecule of ring anion
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Iodinated Contrast Agents

1. Hyperosmolar ionic contrast agent.
2. Hyperosmolar non-ionic contrast agent. 3. Low osmolar non-ionic contrast agent.
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Side Effects
1) Hypersensitivity reactions like urticaria, pruritus & angiooedema, other minor complaints like nausea, vomiting, heat sensation, abdominal discomfort usually transient. 2) Contrast agents are associated with some nephrotoxicity. S. Creatine may show faint minor increase. In diabetic patients or those with renal failure, low osmolar contrast agents should be used.
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Side effects
Contd.
3) Serious reactions Rarely occur like laryngeal oedema, dyspnoea, bronchospasm, pulmonary oedema, anaphylactic shock. Anaphylactoid reactions can occur irrespective of the dose & mode of administration. 4) Cardiac Symptoms arrhythmias or signs of ischaemia, vagal reactions with hypotension & bradycardia.
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Side effects
5)
Contd.
Rare condition of iodide mumps swelling & tenderness of salivary glands for upto approximately 10 days after I.V. contrast injection. Intra-arterial injection may cause vasospasm with consequent symptoms. Thrombophlebitis may occur after I.V. injection. Intra-thecal injection : - Similar to L.P. headache, nausea, vomiting, dizziness. May present hours or days after procedure. Fatality rate very very rare.
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6)
7)
8)
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Contra indications of I.V. Contrast

1. Known hypersensitivity to iodine. 2. Renal failure with very high serum creatinine levels. 3. Better avoided in pregnancy & lactation evaluate risk vs. benefit. 4. Special precautions in diabetes, myeloma & other para-proteinemias.
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Helical CT
Sixth Generation CT Volume Imaging Slip Ring Technology
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SLIP RING TECHONOLOGY

It allows for continuous one-way rotation of the XRay Tube & detector assembly without the need for rewinding the X-Ray tube & its cables. Simultaneous movement of the patient through the gantry allows acquiring data over large volumes of the body in a single breathhold. This is the basis of SPIRAL OR HELICAL SCANS.
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In slip ring technology, cables & connections are not fixed to the XRay tube, but connections are made via rings rotating with the tube but sliding in contact with rings supplying the electrical energy.
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Advantages of slip ring technology

-Faster scanning -volumetric scanning -cine studies -CT fluroscopy
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Ct helical 1 to 7
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PITCH (Table movement/slice thickness) COVERAGE (Pitch x Helical scan time x slice thickness)/3600 R
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Advantages of Volumetric Data Acquisition 1 Enables us to create axial images in a desired slice thickness and inter slice gap. 2 Multiplanar and curved reconstructions. 3 3D, SSD and Volume rendering 4 Excellent angiographic demonstration 5 Virtual reconstructions
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RADIATION DOSE IN SPIRAL CT
1. Tube mA current are lower for spiral scans than conventional scan because in spiral scans tube heating is more & so tube mA loading is a limiting factor. 2. Overlapping slices are not necessary. 3. Repeat scans are less & patients motion is less. 4. Large volume of patient covered in less time.
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Reformatted Images
Reformatted CT images The CT scanner computer itself, or a separate computer workstation, can stack a series of axial CT slices on top of one another so that the stack can be sliced in other planes such as coronal or sagittal. The resulting images are called reformations, and they can be very helpful in viewing an abnormality that extends vertically through several axial slices.
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Axial image of Knee
Coronal reformat
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Axial image
Volume Rendering
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3D CT
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Carcinoma caecum
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Virtual colonoscopy
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CT
ANGIO
GRAPHY
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Artifacts in Helical CT
Because the patient moves continuously through the Gantry for a 360-degree rotation, the reconstructed image will be blurred with only the same filtered back-projection algorithm as conventional CT. Thats why we should interpolate our image data before the filtered back-projection is used. This process leads to a higher noise level and artifacts such as stair-step artifact.
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Artifacts
Although the inconsistency of data arises from the acquisition can be reduced by interpolation, some inconsistency will remain exist because the cross section of an object in the scan plan may change in the longitudinal direction. It will cause some image artifacts like the changes of diameter of skull.
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Motion Artifacts
The most efficient way to reduce motion artifacts is to reduce our scanning time Although it has been achieved by helical CT, the effort of reducing patient motion artifacts is still in the making. Methods to reduce patient motion artifacts include patient immobilization, ECG gated CT, and some correction algorithms.
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Metal Artifacts
Metallic materials such as prosthetic devices, dental fillings, surgical clips, and electrodes produce streak artifacts on the image Several methods have been provided to remove the artifacts come from metal. One of them is metal artifact reduction (MAR) by using threshold values to define metal images and interpolate missing images to reconstruct a new image data. This method of threshold technique can also be used in reducing artifacts result from arterial wall calcification
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Artifacts
Beam Hardening Artifacts Partial Volume Artifacts Stair-step Artifacts The particular geometry of helical CT causes complex periodic asymmetries and inconsistencies in the volumetric data sets that give rise to less-recognized effects such as variable noise distribution and section thickness across the transverse plane and longitudinal aliasing.
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These phenomena appear as artifacts on transverse images and as stair-steps, or strips (zebra artifact) on multiplanar reformation or 3-D rendered images
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MULTISLICE COMPUTERISED TOMOGRAPHY Seventh Generation CT

Conventional Spiral CT Single-slice acquired per rotation using single row of detector elements. MSCT Multiple slices acquired per rotation using multiple rows of detectors.
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MSCT Requires
1. 2. 3. 4. Faster gantry rotation. Multiple detector array. Multiple data acquisition system. High-speed image reconstruction system. 5. Multi-slice reconstruction technique.
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8 AND 16 SLICE DETECTORS
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Uses of MSCT
1. Cardiac Imaging, Coronary Artery Imaging, CACS. 2. Brain perfusion CT to assess ischaemia. 3. Body perfusion CT e.g. liver, musculoskeletal 4. Imaging of obese patients. 5. Thin section scanning, Virtual endoscopy, 3D CT & CT Angiography are better in MSCT.
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Benefits of MSCT
1. Faster, hence reduced motion artifacts and improved temporal resolution. 2. Larger volumes scanned in equal or less time. 3. Improved spatial resolution. 4. Cardiac CT possible. 5. Improved demonstration of intra-vascular contrast. 6. Decreased radiation exposure.
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MSCT ANGIOGRAPHY
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CT ARTERIOGRAPHY
CT PORTOGRAPHY
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RENAL ANGIO
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CT UROGRAPHY
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CAROTID ARTERY ANGIO
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VIRTUAL COLONSCOPY
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Coronary Artery Imaging
1. High speed of multi-slice CT data acquisition enables CECT demonstrate coronary arteries in a moving organ like heart. 2. Imaging done with prospective or retrospective ECG gating. 3. Prospective gating imaging only during diastole less radiation dose. 4. Retrospective gating imaging through out cardiac cycle more data available.
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Temporal Resolution (TR)
What is Temporal Resolution?

A measure of the length of time within an image
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CORONARY ARTERY IMAGING
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NORMAL CORONARY ARTERIES
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Coronary Calcium Scoring
1. Coronary artery calcium indicator of CAD. 2. Two methods presently used i) EBCT. ii) MSCT.
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ELECTRON BEAM C T
A beam of electrons is used to hit a stationary circular anode. The electrons can be directed very quickly along the circumference of the anode, hence exposure is very fast enabling fast data acquisition and sequential/dynamic studies.
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Dr Bhaskar Azad
Advantages of EBCT in CACS
1. Faster than single slice spiral CT & MSCT. 2. Earlier detection & more precise assessment.
Disadvantages of EBCT in CACS

1. Limited availability & high cost of equipment. 2. Signal to noise ratio lower than MSCT with more partial volume averaging.
Omkar
Dr Bhaskar Azad
Omkar
Dr Bhaskar Azad
Omkar
Dr Bhaskar Azad
Omkar
Dr Bhaskar Azad
CAC Scoring Process

INTERPRET
Customer Must Interpret the Results

Based on review of over 10 years of published results using EBCT Must factor in other risk factors such as age, cholesterol, tobacco use, etc..
Omkar
User is Solely Responsible for Interpreting the Results Dr Bhaskar Azad
NEW
Patient Report
Patient Report
Customizable Patient demographics Cardiac History Physicians message about the exam Percentile ranking Editable calcium score category table Heart Diagram Printed images demonstrating calcium Ability to customize the report information: Diagnosis Clinical Interpretation Gender and Age Issues Recommend Clinical Action
Patient report images are selectable
Omkar
Dr Bhaskar Azad
PLAQUES KEY MAKE UP CHOLESTEROL ESTERS
SOFT PLAQUE Fatty Plaque < 50 HU Fibrotic Plaque 50 130 HU
HARD PLAQUE Calcific Plaque > 130 HU
Omkar
Dr Bhaskar Azad
Soft Plaque
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Dr Bhaskar Azad
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Dr Bhaskar Azad
LCX stent
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Dr Bhaskar Azad
Advancement
PET /Gamma Camera Gamma Camera + CT
Omkar
Dr Bhaskar Azad
HawkEye
Omkar
Dr Bhaskar Azad
Omkar
Dr Bhaskar Azad
Perfusion CT
CBF
CBV
MTT
Patient < 4 hours post-stroke CBF and MTT shows right side abnormality tissue at risk Non-contrast CT and CBV show little abnormality tissue likely can be saved
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Courtesy of Royal North Shore Hospital, Sydney Dr Bhaskar Azad
CT PERFUSION
Body Imaging
Omkar
Dr Bhaskar Azad
Case 1 - MD Anderson - Houston TX
TBF*
TBV*
MTT
Patient with metastatic renal cell carcinoma to the rib and thigh undergoing antiangiogenic therapy with Endostatin Tumor perfusion CT was performed to quantify the blood flow, blood volume, and mean transit time as a baseline before treatment. These parameters will be used for monitoring the treatment response for antiangiogenic therapy. This information is not available on routine IV contrast enhanced CT.
*) TBF & TBV: Tumor Blodd Flow & Tumor Blood Volume
Omkar
Dr Bhaskar Azad
Case 2 - MD Anderson - Houston TX
TBF
TBV
MTT
Patient with metastatis from renal cancer
Omkar
Dr Bhaskar Azad
What are we after in tumor perfusion imaging?

Determine permeability decrease due to antiangiogenesis drugs
Follow treatment of thermal and radio-therapeutic treatment Measure the vascular density of the tumor to
predict the activity of the tumor and decrease thereof

Omkar
Dr Bhaskar Azad
Interpretation of a Scan
It is conventional to view the axial CT scan as though you were looking up at it from the patients feet. Since patients are typically laying supine during the scan, it is therefore important to remember that structures seen on your right are those on the left side of the patients body, just as they are when you view an ordinary chest film.
Omkar
Dr Bhaskar Azad
Omkar
Dr Bhaskar Azad
CT Brain
Omkar
Dr Bhaskar Azad
Case 1
A 35 y/o woman with headache and soft tissue swelling on the back of her head, no h/o trauma
Omkar
Dr Bhaskar Azad
Diagnosis: Epidural abscess with extension through calvarium resulting in a subperiosteal abscess
Omkar
Dr Bhaskar Azad
Case 2
A young male with h/o RTA
Frontal contusion with subarachnoid hemorrhage.
Omkar
Dr Bhaskar Azad
The axial CT scan shows the presence of bilateral frontal bone fractures (arrow heads) as well as subcutaneous air. There is some degree of depression of the left frontal bone fracture.
Omkar
Dr Bhaskar Azad
CT Chest Anatomy
Omkar
Dr Bhaskar Azad
Suspected Bronchogenic Cancer
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Dr Bhaskar Azad
Abdominal CT Scan Anatomy
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Dr Bhaskar Azad
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Dr Bhaskar Azad
Further Down
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Dr Bhaskar Azad
Case 3
Omkar
Dr Bhaskar Azad
The patient has an unruptured abdominal aortic aneurysm. An aneurysm is defined as an irreversible dilatation of an artery to at least 1.5 X its normal caliber.
Omkar
Dr Bhaskar Azad
3D Recon
Omkar
Dr Bhaskar Azad
Omkar
Dr Bhaskar Azad
Dx: Acute Pancreatitis
Omkar
Dr Bhaskar Azad
Chronic Pancreatitis
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Dr Bhaskar Azad
Omkar
Dr Bhaskar Azad
Cholecystitis Inflamed Gall Bladder (MCC Gallstones)
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Dr Bhaskar Azad
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Dr Bhaskar Azad
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Dr Bhaskar Azad
Omkar
Dr Bhaskar Azad
IVP of another patient with renal stones
Omkar
Dr Bhaskar Azad
Omkar
Dr Bhaskar Azad
The liver on this patients scan contains multiple hypovascular masses consistent with metastatic disease. Metastases may be hypo- or hyper-vascular and therefore a CT scan for suspected metastatic disease should include scans taken at various time intervals, or phases, after the administration of IV contrast. A scan done during the early arterial phase will best show hypervascular masses, while a scan taken during a later parenchymal phase best shows hypovascular masses
Omkar
Dr Bhaskar Azad
Metastatic Liver Disease
Omkar
Dr Bhaskar Azad
THANK YOU
Omkar
Dr Bhaskar Azad

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Indian Institute of Technology, Kharagpur

Computerized Tomography Basic Principles

Indian Institute of Technology, Kharagpur

What exactly is an IMAGE?

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

v velocity of light (m/sec), wavelength (in meters), frequency (per sec.).

Indian Institute of Technology, Kharagpur

Therapeutic X-Rays & Gamma-Rays

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

CT, X-Ray and Tomography

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Fifth Generation Scanners :-

Indian Institute of Technology, Kharagpur

HOW A CT SCAN IS PERFORMED

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

2. Scintillation crystals plus photo-diode

Cadmium tungstate Cesium Iodide (Solid State detectors).

Xenon (under pressure).

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

A detector should have the following criteria :-(Contd.)

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

from the beam. This removal can be accomplished either by

interaction). Tissues have different attenuation characteristics

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

CALCULATION OF ATTENUATION COEFFICIENT OF INDIVIDUAL PIXELS FROM VARIOUS RAYSUMS

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Window & Levels

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur

Indian Institute of Technology, Kharagpur