Computed tomography

 Computed tomography (CT), was originally known as "EMI scan" as it was developed at a research branch of EMI, a company best known today for its music and recording business. It was later known as computed axial tomography (CAT or CT scan) and body section roentgenography. It is a medical imaging method employing tomography where digital geometry processing is used to generate a three-dimensional image of the internals of an object from a large series of two-dimensional X-ray images taken around a single axis of rotation. The word "tomography" is derived from the Greek tomos (slice) and graphein (to write). CT produces a volume of data which can be manipulated, through a process known as windowing, in order to demonstrate various structures based on their ability to block the X-ray beam. Although historically (see below) the images generated were in the axial or transverse plane (orthogonal to the long axis of the body), modern scanners allow this volume of data to be reformatted in various planes or even as volumetric (3D) representations of structures.

Although most common in healthcare, CT is also used in other fields, for example nondestructive materials testing. Another example is the DigiMorph project at the University of Texas at Austin which uses a CT scanner to study biological and paleontological specimens.

Additional recommended knowledge Weighing the right way Correct Test Weight Handling Guide: 12 Practical Tips Essential Laboratory Skills Guide Contents 1 History 2 Previous studies 2.1 Tomography 2.2 Tomosynthesis 3 Types of Modern CT acquisition 3.1 Scout/Pilot/Topogram 3.2 Axial 3.3 Cine 3.4 Helical/Spiral 3.5 DRR 4 Generations 4.1 Electron Beam CT 4.2 Helical or Spiral CT 4.3 Multislice CT 4.4 Dual Source CT 4.5 256+ Slice CT 4.6 Inverse geometry CT 5 Diagnostic use 5.1 Cranial 5.2 Chest 5.3 Pulmonary Angiogram 5.3.1 Diagnostic use 5.3.2 Acquisition 5.3.3 Interpretation 5.4 Cardiac 5.5 Abdominal and pelvic 5.6 Extremities 6 Advantages and hazards 6.1 Advantages over projection radiography 6.2 Radiation exposure 6.2.1 Typical scan doses 6.3 Adverse reactions to contrast agents 7 Process 7.1 Windowing 8 Artifacts 9 Three dimensional (3D) Image Reconstruction 9.1 The principle 9.2 Multiplanar reconstruction 9.3 3D rendering techniques 9.4 3D rendering software 9.5 Image segmentation 9.6 Example 10 References

History

In the 1930s the Italian radiologist Alessandro Vallebona proposed a method to represent a single slice of the body on the radiographic film. This exam was known as tomography. The idea is based on simple principles of projective geometry: moving synchronously and in opposite directions the radiogen tube and the film, the image created by the points on the focal plane appears sharper, while the images of the other points annihilate as noise.

Tomography has been one of the pillars of radiologic diagnostics until the early 80's, when the advent of computer and of the circular methodic, this last due to Godfrey Newbold Hounsfield and Allan McLeod Cormack, gradually supplanted it in favour of CT.

The first commercially viable CT scanner was invented by Sir Godfrey Newbold Hounsfield in Hayes, United Kingdom at EMI Central Research Laboratories using X-rays. Hounsfield conceived his idea in 1967, and it was publicly announced in 1972. Allan McLeod Cormack of Tufts University, Massachusetts, USA independently invented a similar process, and both Hounsfield and Cormack shared the 1979 Nobel Prize in Medicine.

The original 1971 prototype took 160 parallel readings through 180 angles, each 1° apart, with each scan taking a little over five minutes. The images from these scans took 2.5 hours to be processed by algebraic reconstruction techniques on a large computer.

The CT scanner was "the greatest legacy" of the Beatles, with the massive profits resulting from their record sales enabling EMI to fund scientific research^[1], including into computerised tomography. The first production X-ray CT machine (in fact called the "EMI-Scanner") was limited to making tomographic sections of the brain, but acquired the image data in about 4 minutes (scanning two adjacent slices) and the computation time (using a Data General Nova minicomputer) was about 7 minutes per picture. This scanner required the use of a water-filled Perspex tank with a pre-shaped rubber "head-cap" at the front, which enclosed the patient's head. The water-tank was used to reduce the dynamic range of the radiation reaching the detectors (between scanning outside the head compared with scanning through the bone of the skull). The images were relatively low resolution, being composed of a matrix of only 80 x 80 pixels. The first EMI-Scanner was installed in Atkinson Morley's Hospital in Wimbledon, England, and the first patient brain-scan was made with it in 1972.   In the U.S., the first installation was at the Mayo Clinic. As a tribute to the impact of this system on medical imaging the Mayo Clinic has an EMI scanner on display in the Radiology Department.

The first CT system that could make images of any part of the body, and did not require the "water tank" was the ACTA scanner designed by Robert S. Ledley, DDS at Georgetown University.

Previous studies

Tomography

CT's primary benefit is the ability to separate anatomical structures at different depths within the body. A form of tomography can be performed by moving the X-ray source and detector during an exposure. Anatomy at the target level remains sharp, while structures at different levels are blurred. By varying the extent and path of motion, a variety of effects can be obtained, with variable depth of field and different degrees of blurring of 'out of plane' structures.

Although largely obsolete, conventional tomography is still used in specific situations such as dental imaging (orthopantomography) or in intravenous urography.

Tomosynthesis

Digital tomosynthesis combines digital image capture and processing with simple tube/detector motion as used in conventional radiographic tomography - although there are some similarities to CT, it is a separate technique. In CT, the source/detector makes a complete 360 degree rotation about the subject obtaining a complete set of data from which images may be reconstructed. In digital tomosynthesis, only a small rotation angle (e.g. 40 degrees) with a small number of discrete exposures (e.g. 10) are used. This incomplete set of data can be digitally processed to yield images similar to conventional tomography with a limited depth of field. However, because the image processing is digital, a series of slices at different depths and with different thicknesses can be reconstructed from the same acquisition, saving both time and radiation exposure.

Because the data acquired is incomplete, tomosynthesis is unable to offer the extremely narrow slice widths that CT offers. However, higher resolution detectors can be used, allowing very-high in-plane resolution, even if the Z-axis resolution is poor. The primary interest in tomosynthesis is in breast imaging, as an extension to mammography, where it may offer better detection rates, with little extra increase in radiation exposure.

Reconstruction algorithms for tomosynthesis are significantly different from conventional CT, as the conventional filtered back projection algorithm requires a complete set of data. Iterative algorithms based upon expectation maximization are most commonly used, but are extremely computationally intensive. Some manufacturers have produced practical systems using commercial GPUs to perform the reconstruction.

Types of Modern CT acquisition

Scout/Pilot/Topogram

A Scout image is used in planning the exam and to establish where the target organs are located. The beginning and end of the scan are set by the target region and the location of the patient on the table. Once the Scout image is created it is used to determine the extent of the desired Axial/Helical scan. During the Scout scan the gantry is rotated to a fixed position and the table is translated as x-ray is delivered. The image appears similar to a radiograph.

Axial

In axial "step and shoot" acquisitions each slice/volume is taken and then the table is incremented to the next location. In multislice scanners each location is multiple slices and represents a volume of the patient anatomy. Tomographic reconstruction is used to generate Axial images.

Cine

A cine acquisition is used when the temporal nature is important. This is used in Perfusion applications to evaluate blood flow, blood volume and mean transit time. Cine is a time sequence of axial images. In a Cine acquisition the cradle is stationary and the gantry rotates continuously. Xray is delivered at a specified interval and duration.

Helical/Spiral

Helical is a very fast way to examine the target anatomy. The volume is scanned very quickly because the table is in constant motion as the gantry rotates continuously. There is no interscan delay between slices as in a Axial acquisition.

DRR

A Digitally Reconstructed Radiograph (DRR) is used to help plan the treatment. The DRR is corrected for the fan beam effect. This is the prime difference from the Scout/Pilot image.

Generations

Since the introduction of the first clinical system by Hounsfield, several generations of scanners have been produced, with distinguishing tube-detector configuration and scanning motion (Canadian Association of Medical Radiation Technologists CT Imaging 1-Theory textbook).

Although numbered sequentially, the 3rd and 4th generation designs developed at approximately the same time. The concept of electron beam CT, which some authors have called 5th generation, followed later. Some authors have described up to 7 generations of CT design. However, it is only generations one to four that are widely, and consistently, recognised.

In the first and second generation designs, the X-ray beam was not wide enough to cover the entire width of the 'slice' of interest. A mechanical arrangement was required to move the X-ray source and detector horizontally across the field of view. After a sweep, the source/detector assembly would be rotated a few degrees, and another sweep performed. This process would be repeated until 360 degrees (or 180 degrees) had been covered. The complex motion placed a limit on the minimum scan time at approximately 20 seconds per image.

In the 3rd and 4th generation designs, the X-ray beam is able to cover the entire field of view of the scanner. This avoids the need for any horizontal motion; an entire 'line' can be captured in an instant. This allowed simplification of the motion to rotation of the X-ray source. Third and fourth generation designs differ in the arrangement of the detectors. In 3rd generation, the detector array is as wide as the beam, and must therefore rotate as the source rotates. In 4th generation, an entire ring of stationary detectors are used.

The third generation design suffers because it is highly sensitive to detector performance. Because of the fixed relationship of a detector to a specific part of the beam, any miscalibration or malfunction of an individual detector will appear as a ring in the final reconstructed image. As the detectors moved and were exposed to physical stress, loss of calibration and subsequent 'ring artifacts' were commonplace. The fourth generation, with its fixed detectors benefited not just from improved reliability of the detectors, but because the detectors could be automatically calibrated as the X-ray beam approached, and because the different reconstruction geometry meant that a malfunction would lead only to subtle loss of image contrast (fogging) rather than a visible ring.

Solving the issue of detector stability has led 3rd generation designs to the dominant position in contemporary designs. 4th generation designs suffered very high cost (due to the large number of detectors) and had very high susceptibility to 'streak artifacts' (due to compton scattering). All current CT scanners are of the 3rd generation design.

Electron Beam CT

Electron beam tomography (EBCT) was introduced in the early 1980s, by medical physicist Andrew Castagnini, as a method of improving the temporal resolution of CT scanners. Because the X-ray source has to rotate by over 180 degrees in order to capture an image the technique is inherently unable to capture dynamic events or movements that are quicker than the rotation time.

Instead of rotating a conventional X-ray tube around the patient, the EBCT machine houses a huge vacuum tube in which an electron beam is electro-magnetically steered towards an array of tungsten X-ray anodes arranged circularly around the patient. Each anode is hit in turn by the electron beam and emits X-rays that are collimated and detected as in conventional CT. The lack of moving parts allows very quick scanning, with single slice acquisition in 50-100 ms, making the technique ideal for capturing images of the heart. EBCT has found particular use for assessment of coronary artery calcium, a means of predicting risk of coronary artery disease.

The very high cost of EBCT equipment, and its poor flexibility (EBCT scanners are essentially single-purpose cardiac scanners), has led to poor uptake; fewer than 150 of these scanners have been installed worldwide. EBCT's role in cardiac imaging is rapidly being supplanted by high-speed multi-detector CT, which can achieve near-equivalent temporal resolution with much faster z-axis coverage.

Helical or Spiral CT

See main article Helical cone beam computed tomography

Helical, also called spiral, CT was introduced in the early 1990s, with much of the development led by Willi Kalender and Kazuhiro Katada. In older CT scanners, the X-ray source would move in a circular fashion to acquire a single 'slice', once the slice had been completed, the scanner table would move to position the patient for the next slice; meanwhile the X-ray source/detectors would reverse direction to avoid tangling their cables.

In helical CT the X-ray source (and detectors in 3rd generation designs) are attached to a freely rotating gantry. During a scan, the table moves the patient smoothly through the scanner; the name derives from the helical path traced out by the X-ray beam. It was the development of two technologies that made helical CT practical: slip rings to transfer power and data on and off the rotating gantry, and the switched mode power supply powerful enough to supply the X-ray tube, but small enough to be installed on the gantry.

The major advantage of helical scanning compared to the traditional shoot-and-step approach, is speed; a large volume can be covered in 20-60 seconds. This is advantageous for a number or reasons: 1) often the patient can hold their breath for the entire study, reducing motion artifacts, 2) it allows for more optimal use of intravenous contrast enhancement, and 3) the study is quicker than the equivalent conventional CT permitting the use of higher resolution acquisitions in the same study time. The data obtained from spiral CT is often well-suited for 3D imaging because of the lack of motion mis-registration and the increased out of plane resolution. These major advantages led to the rapid rise of helical CT as the most popular type of CT technology.

Despite the advantages of helical scanning, there are a few circumstances where it may not be desirable - there is, of course, no difficulty in configuring a helical capable scanner for scanning in shoot-and-step mode. All other factors being equal, helical CT has slightly lower z-axis resolution than step-and-shoot (due to the continual movement of the patient). Where z-resolution is critical but where it is undesirable to scan at a higher resolution setting (due to the higher radiation exposure required) e.g. brain imaging, step-and-shoot may still be the preferred method.

Multislice CT

Multislice CT scanners are similar in concept to the helical or spiral CT but there are more than one detector ring. It began with two rings in mid nineties, with a 2 solid state ring model designed and built by Elscint (Haifa) called CT TWIN, with one second rotation (1993): It was followed by other manufacturers. Later, it was presented 4, 8, 16, 32, 40 and 64 detector rings, with increasing rotation speeds. Current models (2007) have up to 3 rotations per second, and isotropic resolution of 0.35mm voxels with z-axis scan speed of up to 18 cm/s.^[2]. This resolution exceeds that of High Resolution CT techniques with single-slice scanners, yet it is practical to scan adjacent, or overlapping, slices - however, image noise and radiation exposure significantly limit the use of such resolutions.

The major benefit of multi-slice CT is the increased speed of volume coverage. This allows large volumes to be scanned at the optimal time following intravenous contrast administration; this has particularly benefitted CT angiography techniques - which rely heavily on precise timing to ensure good demonstration of arteries.

Computer power permits increasing the postprocessing capabilities on workstations. Bone suppression, volume rendering in real time, with a natural visualization of internal organs and structures, and automated volume reconstruction really change the way diagnostic is performed on CT studies and this models become true volumetric scanners. The ability of multi-slice scanners to achieve isotropic resolution even on routine studies means that maximum image quality is not restricted to images in the axial plane - and studies can be freely viewed in any desired plane.

Dual Source CT

Siemens introduced a CT model with dual X-ray tube and dual array of 64 slice detectors, at the 2005 Radiological Society of North America (RSNA) medical meeting. Dual sources increase the temporal resolution by reducing the rotation angle required to acquire a complete image, thus permitting cardiac studies without the use of heart rate lowering medication, as well as permitting imaging of the heart in systole. The use of two x-ray units makes possible the use of dual energy imaging, which allows an estimate of the average atomic number in a voxel, as well as the total attenutaion. This permits automatic differentiation of calcium (e.g. in bone, or diseased arteries) from iodine (in contrast medium) or titanium (in stents) - which might otherwise be impossible to differentiate. It may also improve the characterization of tissues allowing better tumor differentiation.

256+ Slice CT

At RSNA 2007, Philips announced a 256 slice scanner, while Toshiba announced a "dynamic volume" scanner based on 320 slices. The majority of published data with regard to both technical and clinical aspects of the systems have been related to the prototype unit made by Toshiba Medical Systems. The recent 3 month Beta installation at Johns Hopkins Press Release using a Toshiba system tested the clinical capabilities of this technology JHU Gazette. The technology currently remains in a development phase but has demonstrated the potential to significantly reduce radiation exposure by eliminating the requirement for a helical examination in both cardiac CT angiography and whole brain perfusion studies for the evaluation of stroke.

Inverse geometry CT

Inverse geometry CT (IGCT) is a novel concept which is being investigated as refinement of the classic third generation CT design. Although the technique has been demonstrated on a laboratory proof-of-concept device, it remains to be seen whether IGCT is feasible for a practical scanner. IGCT reverses the shapes of the detector and X-ray sources. The conventional third-generation CT geometry uses a point source of X-rays, which diverge in a fan beam to act on a linear array of detectors. In multidetector computed tomography (MDCT), this is extended in 3 dimensions to a conical beam acting on a 2D array of detectors. The IGCT concept, conversely, uses an array of highly collimated X-ray sources which act on a point detector. By using a principle similar to electron beam tomography (EBCT), the individual sources can be activated in turn by steering an electron beam onto each source target.

The rationale behind IGCT is that it avoids the disadvantages of the cone-beam geometry of third generation MDCT. As the z-axis width of the cone beam increases, the quantity of scattered radiation reaching the detector also increases, and the z-axis resolution is thereby degraded - because of the increasing z-axis distance that each ray must traverse. This reversal of roles has extremely high intrinsic resistance to scatter; and, by reducing the number of detectors required per slice, it makes the use of better performing detectors (e.g. ultra-fast photon counting detectors) more practical. Because a separate detector can be used for each 'slice' of sources, the conical geometry can be replaced with an array of fans, permitting z-axis resolution to be preserved.

Diagnostic use

Since its introduction in the 1970s, CT has become an important tool in medical imaging to supplement X-rays and medical ultrasonography. Although it is still quite expensive, it is the gold standard in the diagnosis of a large number of different disease entities. It has more recently begun to also be used for preventive medicine or screening for disease, for example CT colonography for patients with a high risk of colon cancer. Although a number of institutions offer full-body scans for the general population, this practice remains controversial due to its lack of proven benefit, cost, radiation exposure, and the risk of finding 'incidental' abnormalities that may trigger additional investigations.

Cranial

  Diagnosis of cerebrovascular accidents and intracranial hemorrhage is the most frequent reason for a "head CT" or "CT brain". Scanning is done with or without intravenous contrast agents. CT generally does not exclude infarct in the acute stage of a stroke. However, CT is useful to exclude an intra-cranial hemorrhage as a cause, or complication of the stroke. For the detection of acute hemorrhage, especially subarachnoid hemorrhage, CT is the test of choice as it is more sensitive than MRI.

For detection of tumors, CT scanning with IV contrast is occasionally used but is less sensitive than magnetic resonance imaging (MRI).

CT has an important role in evaluation of the functioning of a ventriculoperitoneal shunt by demonstrating the volume of the ventricular system. Although CT cannot assess intracranial pressure, it can demonstrate several important causes of raised intracranial pressure. Despite the limitation that CT may not detect raised intracranial pressure, it may help in the clinical decision to perform lumbar puncture and is often performed in this context.

CT is also useful in the setting of trauma for evaluating facial and skull fractures.

In the head/neck/mouth area, CT scanning is used for surgical planning for craniofacial and dentofacial deformities, evaluation of cysts and some tumors of the jaws/paranasal sinuses/nasal cavity/orbits, diagnosis of the causes of chronic sinusitis, and for planning of dental implant reconstruction.

Chest

  CT is excellent for detecting both acute and chronic changes in the lung parenchyma. A variety of different techniques are used depending on the suspected abnormality. For evaluation of chronic interstitial processes (emphysema, fibrosis, and so forth), thin sections with high spatial frequency reconstructions are used - often scans are performed both in inspiration and expiration. This special technique is called High resolution CT (HRCT)....... Note: HRCT is normally done with thin section with skipped areas between the thin sections. Therefore it produces a sampling of the lung and not continuous images. Continuous images are provided in a standard CT of the chest.

For detection of airspace disease (such as pneumonia) or cancer, relatively thick sections and general purpose image reconstruction techniques may be adequate. IV contrast may also be used as it clarifies the anatomy and boundaries of the great vessels and improves assessment of the mediastinum and hilar regions for lymphadenopathy; this is particularly important for accurate assessment of cancer.

CT angiography of the chest is also becoming the primary method for detecting pulmonary embolism (PE) and aortic dissection, and requires accurately timed rapid injections of contrast (Bolus Tracking) and high-speed helical scanners. CT is the standard method of evaluating abnormalities seen on chest X-ray and of following findings of uncertain acute significance.

Pulmonary Angiogram

CT pulmonary angiogram (CTPA) is a medical diagnostic test used to diagnose pulmonary embolism (PE). It employs computed tomography to obtain an image of the pulmonary arteries.

Diagnostic use

It is a preferred choice of imaging in the diagnosis of PE due to its minimally invasive nature for the patient, whose only requirement for the scan is a cannula (usually a 20G). Before this test is requested, it is usual for the referring clinician to have carried out a D-dimer blood test and requested a chest X-Ray to rule out any other possible differential diagnosis.

Acquisition

• MDCT (multi detector CT) scanners give the optimum resolution and image quality for this test
• Images are usually taken on a 0.625mm slice thickness, although 2mm is sufficient.
• 50 - 100 mls of contrast is given to the patient at a rate of 4 ml/s.
• The tracker/locator is placed at the level of the Pulmonary Arteries, which sit roughly at the level of the carina.
• Images are acquired with the maximum intensity of radio-opaque contrast in the Pulmonary Arteries. This is done using bolus tracking.

CT machines are now so sophisticated that the test can be done with a patient visit of 5 minutes with an approximate scan time of only 5 seconds or less.

Interpretation

  A normal CTPA scan will show the contrast filling the pulmonary vessels, looking bright white. Ideally the aorta should be empty of contrast, to reduce any partial volume artefact which may result in a false positive. Any mass filling defects, such as an embolus, will appear dark in place of the contrast, filling / blocking the space where blood should be flowing into the lungs.

Cardiac

With the advent of subsecond rotation combined with multi-slice CT (up to 64-slice), high resolution and high speed can be obtained at the same time, allowing excellent imaging of the coronary arteries (cardiac CT angiography). Images with an even higher temporal resolution can be formed using retrospective ECG gating. In this technique, each portion of the heart is imaged more than once while an ECG trace is recorded. The ECG is then used to correlate the CT data with their corresponding phases of cardiac contraction. Once this correlation is complete, all data that were recorded while the heart was in motion (systole) can be ignored and images can be made from the remaining data that happened to be acquired while the heart was at rest (diastole). In this way, individual frames in a cardiac CT investigation have a better temporal resolution than the shortest tube rotation time.

Because the heart is effectively imaged more than once (as described above), cardiac CT angiography results in a relatively high radiation exposure around 12 mSv. For the sake of comparison, a chest X-ray carries a dose of approximately 0.02^[3] to 0.2 mSv and natural background radiation exposure is around 0.01 mSv/day. Thus, cardiac CTA is equivalent to approximately 100-600 chest X-rays or over 3 years worth of natural background radiation. Methods are available to decrease this exposure, however, such as prospectively decreasing radiation output based on the concurrently acquired ECG (aka tube current modulation.) This can result in a significant decrease in radiation exposure, at the risk of compromising image quality if there is any arrhythmia during the acquisition. The significance of radiation doses in the diagnostic imaging range has not been proven, although the possibility of inducing an increased cancer risk across a population is a source of significant concern. This potential risk must be weighed against the competing risk of not performing a test and potentially not diagnosing a significant health problem such as coronary artery disease.

It is uncertain whether this modality will replace invasive coronary catheterization. Currently, it appears that the greatest utility of cardiac CT lies in ruling out coronary artery disease rather than ruling it in. This is because the test has a high sensitivity (greater than 90%) and thus a negative test result means that a patient is very unlikely to have coronary artery disease and can be worked up for other causes of their chest symptoms. This is termed a high negative predictive value. A positive result is less conclusive and often will be confirmed (and possibly treated) with subsequent invasive angiography. For the record, the positive predictive value of cardiac CTA is estimated at approximately 82% and the negative predictive value is around 93%.

Dual Source CT scanners, introduced in 2005, allow higher temporal resolution by acquiring a full CT slice in only half a rotation, thus reducing motion blurring at high heart rates and potentially allowing for shorter breath-hold time. This is particularly useful for ill patients who have difficulty holding their breath or who are unable to take heart-rate lowering medication.

The speed advantages of 64-slice MSCT have rapidly established it as the minimum standard for newly installed CT scanners intended for cardiac scanning. Manufacturers are now actively developing 256-slice and true 'volumetric' scanners, primarily for their improved cardiac scanning performance.

The latest MSCT scanners acquire images only at 70-80% of the R-R interval (late diastole). This prospective gating can reduce effective dose from 10-15mSv to as little as 1.2mSv in follow-up patients acquiring at 75% of the R-R interval. Effective doses at a centre with well trained staff doing coronary imaging can average less than the doses for conventional coronary angiography.

Abdominal and pelvic

CT is a sensitive method for diagnosis of abdominal diseases. It is used frequently to determine stage of cancer and to follow progress. It is also a useful test to investigate acute abdominal pain. Renal/urinary stones, appendicitis, pancreatitis, diverticulitis, abdominal aortic aneurysm, and bowel obstruction are conditions that are readily diagnosed and assessed with CT. CT is also the first line for detecting solid organ injury after trauma.

Oral and/or rectal contrast may be used depending on the indications for the scan. A dilute (2% w/v) suspension of barium sulfate is most commonly used. The concentrated barium sulfate preparations used for fluoroscopy e.g. barium enema are too dense and cause severe artifacts on CT. Iodinated contrast agents may be used if barium is contraindicated (e.g. suspicion of bowel injury). Other agents may be required to optimize the imaging of specific organs: e.g. rectally administered gas (air or carbon dioxide) for a colon study, or oral water for a stomach study.

CT has limited application in the evaluation of the pelvis. For the female pelvis in particular, ultrasound and MRI are the imaging modalities of choice. Nevertheless, it may be part of abdominal scanning (e.g. for tumors), and has uses in assessing fractures.

CT is also used in osteoporosis studies and research along side DXA scanning. Both CT and DXA can be used to assess bone mineral density (BMD) which is used to indicate bone strength, however CT results do not correlate exactly with DXA (the gold standard of BMD measurement). CT is far more expensive, and subjects patients to much higher levels of ionizing radiation, so it is used infrequently.

Extremities

CT is often used to image complex fractures, especially ones around joints, because of its ability to reconstruct the area of interest in multiple planes. Fractures, ligamentous injuries and dislocations can easily be recognised with a 0.2 mm resolution.^{[citation needed]}

Advantages and hazards

Advantages over projection radiography

First, CT completely eliminates the superimposition of images of structures outside the area of interest. Second, because of the inherent high-contrast resolution of CT, differences between tissues that differ in physical density by less than 1% can be distinguished. Third, data from a single CT imaging procedure consisting of either multiple contiguous or one helical scan can be viewed as images in the axial, coronal, or sagittal planes, depending on the diagnostic task. This is referred to as multiplanar reformatted imaging.

Radiation exposure

CT is regarded as a moderate to high radiation diagnostic technique. While technical advances have improved radiation efficiency, there has been simultaneous pressure to obtain higher-resolution imaging and use more complex scan techniques, both of which require higher doses of radiation. The improved resolution of CT has permitted the development of new investigations, which may have advantages; e.g. Compared to conventional angiography, CT angiography avoids the invasive insertion of an arterial catheter and guidewire; CT colonography may be as useful as a barium enema for detection of tumors, but may use a lower radiation dose.

The greatly increased availability of CT, together with its value for an increasing number of conditions, has been responsible for a large rise in popularity. So large has been this rise that, in the most recent comprehensive survey in the UK, CT scans constituted 7% of all radiologic examinations, but contributed 47% of the total collective dose from medical X-ray examinations in 2000/2001.^[4] Increased CT usage has led to an overall rise in the total amount of medical radiation used, despite reductions in other areas.

The radiation dose for a particular study depends on multiple factors: volume scanned, patient build, number and type of scan sequences, and desired resolution and image quality. Additionally, two helical CT scanning parameters that can be adjusted easily and that have a profound effect on radiation dose are tube current and pitch.^[5] CT scans of children have been estimated to produce non-negligible increases in the probability of lifetime cancer mortality leading to calls for the use of reduced current settings for CT scans of children.^[6] A 2007 report in the New England Journal of Medicine suggested that the radiation from current CT-scan use may cause as many as 1 in 50 future cases of cancer.^[7]

According to the USAToday, and members of the American Heart Association, an average CT scan can expose a patient to between 1,000 to 10,000 millirems of radiation, depending on the exact machine and the examination being performed. However, Japanese people who were 1 mile from ground zero received only 3,ooo millirems of radiation, on average. ^[8]

Typical scan doses

Adverse reactions to contrast agents

Because CT scans rely on intravenously administered contrast agents in order to provide superior image quality, there is a low but non-negligible level of risk associated with the contrast agents themselves. Certain patients may experience severe and potentially life-threatening allergic reactions to the contrast dye.

The contrast agent may also induce kidney damage. The risk of this is increased with patients who have preexisting renal insufficiency, preexisting diabetes, or reduced intravascular volume. In general, if a patient has normal kidney function, then the risks of contrast nephropathy are negligible. Patients with mild kidney impairment are usually advised to ensure full hydration for several hours before and after the injection. For moderate kidney failure, the use of iodinated contrast should be avoided; this may mean using an alternative technique instead of CT e.g. MRI. Perhaps paradoxically, patients with severe renal failure requiring dialysis do not require special precautions, as their kidneys have so little function remaining that any further damage would not be noticeable and the dialysis will remove the contrast agent.

Process

  X-ray slice data is generated using an X-ray source that rotates around the object; X-ray sensors are positioned on the opposite side of the circle from the X-ray source. Many data scans are progressively taken as the object is gradually passed through the gantry. They are combined together by the mathematical procedure known as tomographic reconstruction.

Newer machines with faster computer systems and newer software strategies can process not only individual cross sections but continuously changing cross sections as the gantry, with the object to be imaged, is slowly and smoothly slid through the X-ray circle. These are called helical or spiral CT machines. Their computer systems integrate the data of the moving individual slices to generate three dimensional volumetric information (3D-CT scan), in turn viewable from multiple different perspectives on attached CT workstation monitors.

In conventional CT machines, an X-ray tube and detector are physically rotated behind a circular shroud (see the image above right); in the electron beam tomography (EBT) the tube is far larger and higher power to support the high temporal resolution. The electron beam is deflected in a hollow funnel shaped vacuum chamber. X-rays are generated when the beam hits the stationary target. The detector is also stationary.

The data stream representing the varying radiographic intensity sensed reaching the detectors on the opposite side of the circle during each sweep is then computer processed to calculate cross-sectional estimations of the radiographic density, expressed in Hounsfield units. Sweeps cover 360 or just over 180 degrees in conventional machines, 220 degrees in EBT.   CT is used in medicine as a diagnostic tool and as a guide for interventional procedures. Sometimes contrast materials such as intravenous iodinated contrast are used. This is useful to highlight structures such as blood vessels that otherwise would be difficult to delineate from their surroundings. Using contrast material can also help to obtain functional information about tissues.

Pixels in an image obtained by CT scanning are displayed in terms of relative radiodensity. The pixel itself is displayed according to the mean attenuation of the tissue(s) that it corresponds to on a scale from -1024 to +3071 on the Hounsfield scale. Pixel is a two dimensional unit based on the matrix size and the field of view. When the CT slice thickness is also factored in, the unit is known as a Voxel, which is a three dimensional unit. The phenomenon that one part of the detector cannot differ between different tissues is called the "Partial Volume Effect". That means that a big amount of cartilage and a thin layer of compact bone can cause the same attenuation in a voxel as hyperdense cartilage alone. Water has an attenuation of 0 Hounsfield units (HU) while air is -1000 HU, cancellous bone is typically +400 HU, cranial bone can reach 2000 HU or more (os temporale) and can cause artifacts. The attenuation of metallic implants depends on atomic number of the element used: Titanium usually has an amount of +1000 HU, iron steel can completely extinguish the X-ray and is therefore responsible for well-known line-artifacts in computed tomograms.

Windowing

Windowing is the process of using the calculated Hounsfield units to make an image. The various radiodensity amplitudes are mapped to 256 shades of gray. These shades of gray can be distributed over a wide range of HU values to get an overview of structures that attenuate the beam to widely varying degrees. Alternatively, these shades of gray can be distributed over a narrow range of HU values (called a "narrow window") centered over the average HU value of a particular structure to be evaluated. In this way, subtle variations in the internal makeup of the structure can be discerned. This is a commonly used image processing technique known as contrast compression. For example, to evaluate the abdomen in order to find subtle masses in the liver, one might use liver windows. Choosing 70 HU as an average HU value for liver, the shades of gray can be distributed over a narrow window or range. One could use 170 HU as the narrow window, with 85 HU above the 70 HU average value; 85 HU below it. Therefore the liver window would extend from -15 HU to +155 HU. All the shades of gray for the image would be distributed in this range of Hounsfield values. Any HU value below -15 would be pure black, and any HU value above 155 HU would be pure white in this example. Using this same logic, bone windows would use a "wide window" (to evaluate everything from fat-containing medullary bone that contains the marrow, to the dense cortical bone), and the center or level would be a value in the hundreds of Hounsfield units. Processing will most likely take between five minutes and one hour.

Artifacts

Although CT is a relatively accurate test, it is liable to produce artifacts, such as the following.

• Aliasing Artifact or Streaks

These appear as dark lines which radiate away from sharp corners. It occurs because it is impossible for the scanner to 'sample' or take enough projections of the object, which is usually metallic. It can also occur when an insufficient mA is selected, and insufficient penetration of the x-ray occurs. These artifacts are also closely tied to motion during a scan.

• Partial Volume Effect

This appears as 'blurring' over sharp edges. It is due to the scanner being unable to differentiate between overlying structures and respective HU's. The processor tries to average out the two densities or structures. This can be partially overcome by scanning using thinner slices.

• Ring Artifact

Probably the most common mechanical artifact, the image of one or many 'rings' appears within an image. This is due to a detector fault.

• Noise Artifact

This appears as gaining on the image and is caused by a low signal to noise ratio. This occurs more commonly when a thin slice thickness is used. It can also occur when the kV or mA is too low.

• Motion Artifact

This is seen as blurring which is caused by movement of the object being imaged.

• Windmill

Streaking appearances can occur when the detectors intersect the reconstruction plane. This can be reduced with filters or a reduction in pitch.

• Beam Hardening

This can give a 'cupped appearance'. It occurs when there is more attenuation in the center of the object than around the edge. This is easily corrected by filtration and software.

Three dimensional (3D) Image Reconstruction

The principle

Because contemporary CT scanners offer isotropic, or near isotropic, resolution, display of images does not need to be restricted to the conventional axial images. Instead, it is possible for a software program to build a volume by 'stacking' the individual slices one on top of the other. The program may then display the volume in an alternative manner.

Multiplanar reconstruction

  Multiplanar reconstruction (MPR) is the simplest method of reconstruction. A volume is built by stacking the axial slices. The software then cuts slices through the volume in a different plane (usually orthogonal). Optionally, a special projection method, such as maximum-intensity projection (MIP) or minimum-intensity projection (mIP), can be used to build the reconstructed slices.

MPR is frequently used for examining the spine. Axial images through the spine will only show one vertebral body at a time and cannot reliably show the intervertebral discs. By reformatting the volume, it becomes much easier to visualise the position of one vertebral body in relation to the others.

Modern software allows reconstruction in non-orthogonal (oblique) planes so that the optimal plane can be chosen to display an anatomical structure. This may be particularly useful for visualising the structure of the bronchi as these do not lie orthogonal to the direction of the scan.

For vascular imaging, curved-plane reconstruction can be performed. This allows bends in a vessel to be 'straightened' so that the entire length can be visualised on one image, or a short series of images. Once a vessel has been 'straightened' in this way, quantitative measurements of length and cross sectional area can be made, so that surgery or interventional treatment can be planned.

MIP reconstructions enhance areas of high radiodensity, and so are useful for angiographic studies. mIP reconstructions tend to enhance air spaces so are useful for assessing lung structure.

3D rendering techniques

Surface rendering

A threshold value of radiodensity is chosen by the operator (e.g. a level that corresponds to bone). A threshold level is set, using edge detection image processing algorithms. From this, a 3-dimensional model can be constructed and displayed on screen. Multiple models can be constructed from various different thresholds, allowing different colors to represent each anatomical component such as bone, muscle, and cartilage. However, the interior structure of each element is not visible in this mode of operation.

Volume rendering

Surface rendering is limited in that it will only display surfaces which meet a threshold density, and will only display the surface that is closest to the imaginary viewer. In volume rendering, transparency and colors are used to allow a better representation of the volume to be shown in a single image - e.g. the bones of the pelvis could be displayed as semi-transparent, so that even at an oblique angle, one part of the image does not conceal another.

3D rendering software

Some examples of CT 3D surface rendering software include

VGStudio, Mimics, 3D doctor, Amira....etc

Image segmentation

Main article: Segmentation (image processing)

Where different structures have similar radiodensity, it can become impossible to separate them simply by adjusting volume rendering parameters. The solution is called segmentation, a manual or automatic procedure that can remove the unwanted structures from the image.

Example

Some slices of a cranial CT scan are shown below. The bones are whiter than the surrounding area. (Whiter means higher radiodensity.) Note the blood vessels (arrowed) showing brightly due to the injection of an iodine-based contrast agent.

A volume rendering of this volume clearly shows the high density bones.

After using a segmentation tool to remove the bone, the previously concealed vessels can now be demonstrated.

References