BASIC -CT-SCAN -MODULE

Module Code: RAD 3101

Credit Hours: 6 Cr Hr

Prepared by: Melkamu W.(Senior MRT(Msc))

Duties and responsibilities of students

• Punctuality
• Active class room participation
• Submitting duties on the due time.
 Course outline
section I. Physics and Instrumentation
- Basic principles of CT
-Methods of data acquisition
- Post processing
 Section II. Patient care
- Patient communication and care
- Contrast agent and imaging technique
- Radiation Dosimetry in CT

Section III. Crossectional Anatomy

- Neuro-anatomy
-Thoracic anatomy
-Abd/Pelvic and MSK
Section IV.Imaging procedures and protocols
-Neurologic/Thoracic/Abd-pelvic and MsK Imaging
Assessment method
• Daily quiz and reading
assignment.(15%)
• Class room presentation,
discussion and clinical
seminar(15%).
• Practical assessment of KAS
20%
• Final exam 50 %
Learning objective

At the end of Section I session students will able to

• Explain Basic principles of CT
• List and explain different Ct-generation.
• Explain Methods of data acquisition
• Identify Post processing Mechanisms.
Starting point

History/Hx
28-year-old male, sustained facial trauma during a motor vehicle accident
R/o Facial bone fracture ?
Section I. Physics and Instrumentation


Basic principles of CT
Methods of data acquisition
Post processing
 X-ray Production
• There are two types of X-ray generated: characteristic radiation and
bremsstrahlung radiation.

1. Bremsstrahlung Radiation “Breaking Radiation”

2. Characteristic x-ray
Quiz 1
1. Explain the two types of X-ray?
2. List Facial bones?
3. List Sinus of the skull and facial bone?
4. Summerize the concept of x-ray production?
“The cornerstone of a technologist’s
responsibility is to produce consistently
high-quality examinations while
ensuring the safety and well-being of
patients.”
Conventional radiographs depict a three-dimensional
object as a two-dimensional image. This results in superimposed on the image, a major limitation of conventional radiography.

 The word tomography has as its Greek root “tomos”, meaning to cut,
section, (a cutting). In the case of CT, a sophisticated computerized
method is used to obtain data and transform them into “cuts,” or cross-
sectional slices of the human body.

 The first scanners were limited in the ways in which these cuts could
be performed. All early scanners produced axial cuts; that is, slices
looked like the rings of a tree visualized in the cut edge of a log.
Therefore, it was common to refer to older scanning systems as
computerized axial tomography, hence the common acronym, CAT
scan
 Newer model scanners offer options in more than just the
transverse plane. Therefore, the word “axial” has been dropped
from the name of current CT systems. If the old acronym CAT is
used, it now represents the phrase computer-assisted tomography.

 The preliminary image each scanner produces may be referred to

as a “topogram” (Siemens), “scout” (GE Healthcare), or
“scanogram” (Toshiba). Another wellknown example is a method
of scanning that, generically, is referred to as continuous
acquisition scanning; this method can also be called “spiral”
(Siemens), “helical” (GE Healthcare), or “isotropic” (Toshiba)
scaining.
 Each CT slice represents a specific plane in the patient’s body. The thickness of the
plane is referred to as the Z axis. The Z axis determines the thickness of the slices.

• An object that has the ability to absorb much of the x-ray beam is often referred to as
having high attenuation. Areas of intermediate attenuations are represented by various
shades of gray.

• The number of the photons that interact depends on the thickness, density, and atomic
number of the object.
BEAM ATTENUATION
The degree to which an x-ray beam is reduced by an object is referred to as
attenuation.

 In CT, the x-ray beam passes through the patient’s body and is recorded by the
detectors. The computer then processes this information to create the CT image. In
both cases, the quantities of x-ray photons that pass through the body determine
the shades of gray on the image. In both cases, the quantities of x-ray photons that
pass through the body determine the shades of gray on the image.
shades of gray on the image.
 Generation CT

1. 1st generation CT
X-ray tube and single detector are connected and move together by
translation and then rotation (Translate-Rotate ).
X-ray beam has linear (pencil-like) shape.
This method took 5 minutes per slice to scan.
 Generation CT cont.
2. 2nd generation CT
Same type of movement (Translate-Rotate ).
Fan shaped x-ray beam instead of linear shaped.
The x-ray beam is picked-up by a row of up to 30 detectors.
This method took 5-90 seconds per slice.
 Generation CT cont.
3. 3rd generation CT
The x-ray beam hits a row of detectors wide enough to image the
whole slice
The two then rotate together to image a different angle ( Rotate-
Rotate )
This is repeated until a single slice is scanned then the array is moved
to a different slice (axial scanning). Alternatively, the detector array is
continually moved down the patient as it rotates (spiral scanning).
This is the most commonly used method today and takes about 0.3
seconds to image a single slice
3rd generation of CT machine 4th generation of CT machine
 Generation CT cont.
4. 4th generation CT
There is a fixed complete ring of detectors.
The x-ray source rotates around to capture a slice (Rotate-fixed ).
Both then move down the patient to begin imaging a different slice.
This is not commonly used today.
5. Electron Beam Scanner (Sometimes described as 5th generation CT).
Fast scanning of 50-250 milliseconds.
Mainly used for certain cardiac imaging.
 Parts of CT scan and their function

Components

X-ray tube
High Voltage ( HV ) tank
Collimator
Filter
Detector
Detector electronics (DAS)
 X-ray tube
High heat capacity

Modern tubes very large & heavy

External cooling (oil heat exchanger)

High speed rotation of the anode

Heat units: heat capacity of 3.5 to 5 million heat units (MHU)

Focal spot size of an x-ray tube is determined by the size of the

filament and cathode which is determined by the manufacturer
 High Voltage ( HV ) tank

Supplies power to x-ray tube

- Filament and high voltage
Different power 30-60Kilowatts
Allowing range of exposure techniques: 80,100,120,130,and 140kV
and 30,50,65,100,125,150,175, and 200,mA
 Collimators
Tube/Source collimators: restricts beam to slice of interest
Pre-patient collimators: maintain the width of the beam as it travels
toward the patient
Post-patient/Pre-detector collimators: below patient and above
detector proper beam width at detector and reduce no. of scattered
photons at detector
 Filter

protects patient from low-energy photons

provides a beam closer to mono-energetic
provides a more uniform beam (hardening)
There are two types of filtration
1.Inherent filtration from components in the x-ray tube, i.e.
window, housing, cooling oil, anode target itself (equivalent to 0.5-1.0
mm Al)
2.Added filtration from interchangeable metal sheets (Al, Cu, etc.)
Mathematical filtration: bone/tissue algorithms (recons. Process)
 Detector ( Image Receptor )

Collect attenuated photon energy and convert it to electrical signal,

which will then be converted to a digital signal for computer
reconstruction.
Two types : scintillation or solid state and Ionization chamber
detector (xenon gas detectors)
 Scintillation detectors- uses a crystal that fluoresces when struck by
x-ray photon which produces light energy
– A photodiode, attached to scintillation portion, transforms light
energy into electrical or analog energy
– Strength of the detector signal is proportional to number of
attenuated photons that are successfully converted to light energy and
then to an electrical signal
 Detector electronics (DAS)

Data Acquisition System (DAS)

– Receives weak signal form detector
– includes A-D converter
– Amplification :- provides digital information to reconstruction
compute

DAS Control Board

 Slip-ring

The slip ring technology is a device that allows for the transmission of
electrical power and signals through rotating shafts.
Specific functions of slip rings include:
-Transferring high voltage to power the rotating device
-Transferring information to the rotating device (for example
from a CT control room to the CT scanner)
-Transferring information from the rotating device (for example
from a CT detector array)
How does a CT image form
 Image Reconstruction Algorithm

Algorithm :-
- Defined as "set of rules or directions for getting a specific
output from specific input".
CT reconstruction algorithms converts each attenuation coefficient
values Obtained splits it into intensity and location at Object, Forming
an image with specific grayscale.
TYPES OF IMAGE RECONSTRUCTION
1. Back-projection
2. Analytical Methods: Fourier analysis and filtered back projection
3. Iterative Methods: Simultaneous Reconstruction, Ray by Ray
Correction, point by point correction. Algebraic reconstruction
technique
 Filtered back projection
Filtered back projection is an analytic reconstruction algorithm
designed to overcome the limitations of conventional back projection;
it applies a convolution filter to remove blurring. It was, up until
recently the primary method in cross-sectional imaging
reconstruction.
It utilizes simultaneous equations of ray sums taken at differing angles
of a sine wave to compute the values of attenuation coefficients
within a cross section.
 Iterative Reconstruction

This is generally a more time-consuming method but is proving useful

for low dose CT studies.
It involves several steps:
1. Filtered back projection is initially performed to assign a number
value to all pixels in the matrix.
2. The computer then calculates what it expected the detectors to have
received based on the image generated THEN works out the difference
between the actual detector measurements and the calculated
measurements. It then uses this information to generate an updated
image.
3. This continues through multiple iterations, each time bringing the
calculated values closer and closer to the true values.
 Types of scan

1. Axial
2. Helical
3. Cine
4. Cardiac
Axial Scanning
• “Step and shoot”
• Gantry stops and rotates to acquire data from single slice
• X-rays switched off
• Patient moves to next slice
• Rotates to acquire data from next slice
Axial scanning
 Helical (Spiral ) Scanning
• Gantry keeps rotating continuously releasing x-ray beams.
• The couch simultaneously moves.
• This results in a continuous spiral scanning pattern.

Spiral scanning
 CT parameters
1. Detector Coverage
2. Pitch
3. Speed/rotation
4. Rotation time
5. Kvp
6. mAs
 Detector Coverage

 It is the width of detector along z-axis.

 It is determine the anatomical coverage.
 The wider the detector the better temporal resolution.
 Pitch

The pitch is the measure of overlap during scanning.

Pitch = distance couch travels / width of slice

Pitch = 20/10 = 2
 Pitch = 5/10 = 0.5

Pitch = 10/10 = 1
 Speed/rotation

 It is a parameter for table movement per gantry rotation.

Rotation Time

 It is the time taken for complete/full gantry rotation.

 Image quality

 Image quality is the visibility of diagnostically important structure in

the CT/MRI image and other radiology imaging procedures.
Image quality in CT scan depends up on the following factors
1. Spatial Resolution
2. Contrast Resolution
3. Temporal Resolution
4. Noise
5. Artifact
 Spatial Resolution

Spatial resolution in CT is the ability to distinguish between object or

structures that differ in density.
 Factors affecting CT spatial resolution
• Field of view
• as the FOV increases so do the pixel size; resulting in a decrease
• Pixel size
• the smaller the pixel size the higher the spatial resolution
• Focal spot size
• a larger focal spot will decrease the resolution
• Magnification
• increasing will decrease the resolution
• Motion of the patient
• Pitch
• is inversely related to the resolution, the higher the pitch the less the
resolution
• Kernel
• edge enhancement kernels will have a higher resolution than soft tissue
kernels
• Slice thickness
• the larger the slice thickness the lower the resolution
• Detector size
• increase in detector size decreases resolution
 Contrast Resolution

 It is refers to the ability of the system to differentiate on the image, objects with
similar densities.

 Factors affecting contrast resolution:-

• mAs ……………….. Direct relationship

• Pixel size …………….. Direct relationship
• Slice thickness ……. Direct relationship
• Patient size …………. Inversely relationship
• Gantry rotation speed ……. Inversely relationship
 Temporal Resolution

Is the ability to captured fast moving objects in the displayed CT

image.
 A good temporal resolution in CT is realized by fast data acquisition
( fast rotation of the x-ray tube ).
 Noise
 Noise in CT is measured via the signal to noise ratio (SNR); comparing
the level of desired signal (photons) to the level of background noise
(pixels deviating from normal).
The higher the ratio, the less noise is present in the image.
 Factors affecting noise:-
• mAs
• Slice thickness
• Patient size
• Noise Metrix
 CT Artifacts

Causes of image artefacts can be grouped into a few categories:

• Physics based
• Patient properties
• Scanner based
• Helical and multislice artefacts
 Physics based

1. Beam hardening

• As the beam passes through a dense area the lower energy photons are more
likely to be absorbed and the higher energy photons are more likely to
remain.

• This focally increased mean beam energy is interpreted as being due to it

passing through a less attenuating material relative to the surroundings and so
a lower Hounsfield unit is assigned and the image will be represented as more
black.

• This is particularly common in the posterior fossa on a CT head scan due to

the dense petrous bones.
Solutions to beam hardening
• Pre-patient filter: This absorbs the soft x-rays and minimizes the
beam hardening artefact
• Bow-tie filter: Pre-harden the x-ray beam
2.Partial volume artefact

• If a dense object only partially protrudes into a detector stream the

attenuation is averaged with its surroundings and it will be assigned a
lower Hounsfield unit.

• In the image below, the dense circle lies on a less dense background.

• These streak artefacts can be caused, for example, when a patient’s arms
are by their side and are imaged in some projections but not others.

Solution
• Smaller slice thickness Partial volume artefact
3.Photon starvation

• This is another cause of streak artefacts.

• In projections that have to travel through more material, e.g. across

the shoulders, as the x-ray beam travels through more x-ray photons
are absorbed and removed from the beam.

• This results in a smaller proportion of signal reaching the detector

and, therefore, a larger proportion of noise.

• The streaks are due to the increased noise which is why they occur in
the direction of the widest part of the object being scanned.
Solutions

• Adaptive filtering: the regions in which the attenuation exceeds a

specified level are smoothed before undergoing backprojection.
• mA modulation: the tube current (mA) can be varied with the gantry
rotation.
- Higher mA’s (greater signal) are used for the more attenuating
projections to reduce the effect of photon starvation.
- The mA required can either be calculated in advance from the scout
view or during the scan from the feedback system of the detector.
 Patient properties

1. Metallic artefacts
• The metal produces a beam-hardening and photon starvation
artefact.
• This can also happen with other high attenuation materials such as IV
contrast.
2.Patient motion

• Motion artefact can be caused by:-

- Patient swallowing
- Breathing
- Pulsatility of heart and vessels
- Patient moving
Solutions
• Scan parameters
• Shorten scan time
• Spiral scanning
• ECG gating: this can be used prospectively to trigger image
acquisition during a specific point on the ECG when heart motion is
lowest, or retrospectively by reconstructing acquired data from
specific ECG phases

• Patient parameters
• Breath hold
• Ensure comfortable patient position
• Tell patient to stay still and give clear instructions
 Scanner based

Ring artefact
• If there is a faulty detector and the detectors do not have the same gain
relative to each other (they are operating at different baselines) then as
the gantry rotates around the patient this detector will outline a circle.
• On back-projection this will cause a ring artefact.
 Spiral and multislice based

Helical artefacts:
• As gantry rotates it is moving in the z-axis. Any object that changes in
position or size along the z-axis may be distorted as they will be in
different positions for different projections
Cone beam artefact:
• Due to wider collimation, the beam has a volume and becomes cone-
shaped. A similar artefact to partial voluming occurs for off-centre
objects in the detector field. The artefact is worse for objects at the
edges of the beam.
Solution
• Reconstruction algorithm minimises cone beam artefacts
 CT dose

1. CT Dose Index (CTDI)

• Dose to the phantom from single gantry rotation
• Units = mGy
• Affected by = Collimator Focus-isocentre distance
2. Weighted CTDI (CTDIw)

• The dose is not equal across the scan plane. It is higher in the periphery
than in the center.

• We need to adjust for this by making the average periphery dose make
up 2/3 of the dose to give us the weighted CTDI.

• There are separate calculations for imaging the head, body and
paediatric patients.

• In adults we use a head phantom (16 cm) and a body phantom (32 cm)
with dosimeters placed at the periphery and center in order to calculate
the weighted average of doses.
CTDIw = 1/3 CTDIcentre + 2/3
CTDIperiphery
3. Volume CTDI (CTDIvol)

• We don’t scan single slices. The concentration of the dose along a

patient is determined by the pitch.

• The higher the pitch, the larger the gaps between slices and the lower
the dose. Taking into account the pitch gives us the volume CTDI.

• However, many manufacturers auto compensate for changes in pitch by

adjusting mA to keep the noise and dose constant..

CTDIvol = CTDIw / pitch

4. Dose length product (DLP)

• We know the CTDlvol, we multiply this by the distance along the

patient we have scanned to give us the dose length product.

• It is proportional to the radiation risk to the patient.

• Units = mGy*cm

DLP = CTDIvol x distance scanned

5. Effective dose (E)

• Physical effect of total dose on patient determined by the sensitivity of

imaged area to radiation.

• Each organ has a sensitivity to radiation that needs to be taken into

account.

E = ΣT (WT) x ΣR (WRDT,R) or
E = Σ WTHT
Key:
HT or WTDT,R is the equivalent dose in a tissue or organ (T)
WT is the tissue weighting factor
 Factors affecting dose

• Tube current
• Doubling mA = doubling of CTDI, DLP and E
• Rotation time
• Doubling rotation time = doubling of CTDI, DLP and E
• Pitch
• Doubling pitch = halving of CTDI, DLP and E
• kVp
• Dose is approximately ∝ kVp2 i.e. doubling the kVp will increase
the dose by a factor of 4 (approximately).
Radiation Safety/Quality Assurance Program
• Quality assurance is a program used by management to maintain
optimal diagnostic image quality with minimum hazard and distress to
patients.

• The programmers includes:-

- Periodic quality control test
- Administrative procedures
- Corrective action
- Training
 Periodic quality control test

 Daily test
- Equipment warm-up test
- CT number for water
- Field uniformity test
 Monthly test
- CT light alignment test
- CT number accuracy
- Slice Positioning Accuracy
- Image Noise, Uniformity and Image artifact
Annual test
- Visual inspection and programme review
- X-ray generator
- Radiation dose
- X-ray beam width
- Special resolution
Contrast media used in CT scan
 Iodinated contrast media

• Iodinated contrast media are contrast agents that contain iodine atoms used
for x-ray-based imaging modalities such as computed tomography (CT).

• Although the intravenous route of administration is most common, they are

also administered by many other routes, including gastrointestinal (oral,
rectal), cystourethral, vaginal, intraosseous, etc.
 Specific agents

Water-soluble
• Water-soluble iodinated contrast media is usefully classified by osmolality:

1.High osmolality contrast media

• High osmolality contrast media (HOCM) are approximately five to eight
times the osmolality of serum.

• As the first generation of iodinated contrast agents, HOCM were associated

with high rates of adverse events and fell out of favor in the 1990s for
intravascular and intrathecal purposes.
e.g. Gastrografin, MD-Gastroview, Cystografin
2.Low osmolality contrast media

• Low osmolality contrast media (LOCM) are less than three times the
osmolality of human serum and preferred for intravascular and intrathecal
administration.
• LOCM in current use include the following:
- iopamidol (Isovue)
- iohexol (Omnipaque)
- iopromide (Ultravist)
- ioversol (Optiray)
- ioxilan (Oxilan)
• The LOCM category also includes iso-osmolality contrast media (IOCM),
which are approximately the same osmolality as serum.

• The only IOCM in current use is a non-ionic dimer, which is composed of two
covalently bound tri-iodinated benzene rings:
e.g. iodixanol (Visipaque)

• Non-ionic LOCM are available in varying concentrations ranging from 240 to

400 mg iodine/mL.

• Higher concentration formulations produce a greater peak of enhancement

(measured in Hounsfield units ) but are also more viscous.
 Contraindications

documented previous severe reaction to iodinated contrast media,

including anaphylaxis, angioedema and bronchospasm

milder previous reactions to iodinated contrast media/excipients

renal impairment/failure

risk factors for adverse reactions to iodinated contrast media

myasthenia gravis: caution is advised, as reports suggest a clear risk of

exacerbation of respiratory symptoms
Section III. Crossectional Anatomy

Neuro-anatomy
The Skull
The word skeleton comes from a Greek word meaning “dried-up body” or
“mummy,
the 206 named bones of the human skeleton are grouped into the axial and
appendicular skeletons
The axial skeleton, which forms the long axis of the body, has 80 named bones
arranged into three major regions: the skull, vertebral column, and thoracic cage
Serve as a protective tool for the brain, spinal cord, and the organs in the thorax.

With the lower jaw removed, the skull resembles a lopsided, hollow, bony sphere.
The facial bones form its anterior aspect, and the cranium forms the rest.

Cranium can be divided into a vault and a base. The cranial vault, also called the
calvaria(kal-va re-ah; “bald part of skull”) or skullcap, forms the superior, lateral,
and posterior aspects of the skull, as well as the forehead region.
The Cranial bone
• The eight large bones of the cranium are the paired parietal and temporal bones
and the unpaired frontal, occipital, sphenoid,and ethmoid bones. Together these
bones form the brain’s protective “shell.” Because its superior aspect is curved,
the cranium is self-bracing. This allows the bones to be thin, and, like an eggshell,
the cranium is remarkably strong for its weight.
• The two large parietal bones, shaped like curved rectangles, make up the bulk of
the cranial vault; that is, they form most of the superior part of the skull, as well as
its lateral walls( parietal wall).
• The frontal bone forms the forehead and the roofs of the orbits,
BRAIN
CT
MRI
CT Vs MRI
How do you get more surface areas in a
limited space?
SAGITAL VIEW OF SULCUS AND
GYRUS
• https://youtu.be/7IZ30V75a34
“Hope for the best Prepare for the
Worst”
Quiz 3
1. List seven cranial nerves?
2. List and Explain parts of Cerebral cortex and cerbellum?
3. Explain blood supply of the brain starting from SVC and IVC?
4. Compare the advantage and disadvantage of Chest CT vs Chest X-
ray?
5. List functions of the limbic system?
6. List components of ventricular system?