PATIENT PREPARATION

AND POSITIONING INCT

CT PROCEDURE OF
THORAX
 INTRODUCTION
> CT chest is used primarily to evaluate and further define
disease identified by routine chest radiograph
> Although many lung disorders can be diagnosed from
the plain chest radiograph but it’s limitation in providing a
definite diagnosis are widely known
> Imaging of lung has changed completely during the past
decade with the improvement of CT imaging techniques,
shorter examination time, thinner sections and higher
resolution are now possible without loosing image quality
ANATOMY :THORACIC CAGE
Region of the body between neck and abdomen
Roof:- suprapleural membrane Floor:-
diaphragm Walls:-
1. muscles:- intercostal muscle,
pectoral muscle, serratus ant.,tere;

major and minor, sub-scapularis, erector spinae,

trapezius
2. skeleton:- 12 thoracic vertebra , 12 pairs of ribs and
sternum
 DIAPHRAGM
Forms floor of the thoracic cage
Arises from vertebral , costal and
sternal origins and forms the
central tendon
1. vertebral part:
Arises from the crura and arcuate
ligament
The right crus is attached to the
bodies and disc of L1 and L3
vertebra
Lumbar
portion
✓ The smaller left crus arises from the vertebral
body and disc of L1 and L2 vertebra

> Costal part:

✓ Arises in slips from the lower six costal
cartilage

> Sternal part:

✓ Arises in two small slips of muscle from the
post. Surface of the xiphisternum
 THE PLEURA
✓ Is a serous membrane
✓ Visceral pleura:- covers
the lungs
✓ Parietal pleura lines the
thoracic cavity and
mediastinum
 THE TRACHEA AND BRONCHI
Trachea and Major Bronchi
0 A. TRACHEA .Anterior View

> Begins at the lower

border of the cricoid
cartilage at the level of
C6 vertebra
> It extend to the carina at
the level of sternal angle
> 15 cm long and 2 cm in
diameter
0 B. MAIN BRONCHI
> CARINA:- carina
✓ Anteroposterior ridge at the
junction of the main bronchus
✓ It lies at the level of T5
vertebra and sternal angle
✓ It measures approximately 65
deg. That is 25 deg. to the right of
the midline and 40 deg. to the left
 THE LUNGS
Described as having costal,
mediastinal, apical and
diaphragmatic surfaces
\
The right lung has three and left
has two lobes Lm*'

One terminal bronchiole with

lung tissue forms an acinus
which, together with vessels,
lymphatics and nerves, forms the
primary lobule.Three to five
primary lobules form a
secondary lobules
B INTERLOBAR FISSURE
» THE OBLIQUE (MAJOR FISSURE)
✓ Similar in both right and left lungs
✓ Extends from T4/T5 post, to the diaphragm ant.
✓ Left major fissure is more vertically than
right » THE TRANSVERSE (MINOR FISSURE)
/ Separates the upper and middle lobe of rt lung
^ Runs horizontally from the hilum to the ant.
and lateral surface of the right lung at the
level of the ant costal cartilage
 CROSS SECTION ANATOMY
1. THORACIC INLET LEVEL
JPEG 6 40:1 Q=90 (lossy)

Left common
artery

Left
Subclavian
2. LEFT BRACHIOCEPHALIC VEIN LEVEL
4. AZYGUS ARCH-AORTOPULMONARY WINDOW
s 5. PULMONARY ARTERY LEVEL

Main 4
Pjjlmonary
Artery

Lt.
Pulmonaryi
artery
Rt Pulmonary
artery Lt main
stem
Rt mairf bronchus
stem
bronchus
0 6. LEFT ATRIAL LEVEL
JPEG 6 40:1 Q=90 (lossy)

Right
ventricl
e
Right
atriu
m
•mm*--

Rt Pulmonary
vein
Left
atriu
a 7. FOUR CHAMBER LEVEL
JPEG 6 25:1 Q=90 (lossy)

Inter ventricular
/ septum

Inter
atnal
septunv
Left
ventncular
wall

ronchi
Pulmonary
Artery
branches
8. Ventricle level
Righ^/eMWcle

.erventricular Septum
Liver

Left Nitride

m/
Right Dome of - Esophagus
Diaphragm
Descending
/ Ao
Inferior^ena C^vca*

I Body
/W ,,
/# Latissimus
Dorsi Muscle
 GUIDELINES FOR CT CHEST
✓ Generally with contrast in case of
PE , Pulmonary Nodular Amyloidosis, TUMOR,
TRAUMA
✓ COPD without
✓ Pulmonary nodules (follow up):- without
✓ ILD without
✓ Bronchiectasis without
 CT CHEST
s INTRODUCTION
✓ The most sensitive and advanced way of
evaluating the chest and lungs
✓ Images are far more detailed than a
conventional chest radiograph
✓ Thorax contains tissue with CT no. ranging
from -1000 for air through lung parenchyma, fat
and soft tissue to cortical bone with CT no of
over +1500
 INDICATIONS

✓ Intra-thoracic assessment of the tumor/lesion

✓ Metastatic evaluation/follow up
✓ Diaphragmatic abnormalities
✓ Pulmonary disease
✓ Cardiovascular abnormality
✓ To plan radiation therapy and assess the
response of treatment
✓ Post operative assessment
✓ In case of trauma/emergency
✓ Baseline study
✓ CT guided FNAC
 RELATIVE
/

CONTRAINDICATIONS

✓ Hypersensitivity to iodinated
CM
✓ Pregnancy (? Risks vs benifits)
✓ DM
✓ Renal dysfunction
✓ MM
✓ Thyroid disorder
✓ Cardiac disorder
✓ Acute sickle cell crisis
 PATIENT PREPARATION

CECT:- 6 hrs fasting before examination

except drinking of clear liquids
✓ Blood urea and serum creatinine report
(done within a month) is required within
normal limit
✓ Take history of any medication
or disease, if yes, consult the
doctor/radiologist
✓ Rule out pregnancy
 CONTD ■■■

✓ Take well informed written

consent
✓ Remove all metallic or artifact
causing objects from the region of
✓ interest
Better to avoid breast feeding for
24-48 hours after CECT examination
✓ Manage life saving drugs and life
support facilities
 CECT CHEST

✓ Establish IV access 18-20 g cannula on the

opposite side of the region of interest to avoid
streak artifacts due to concentrated contrast in
the venous system
✓ Non ionic water soluble, iodinated,300-370
mg l/ml 300-600 mgl/kg body wt , 60-100 ml
✓ Injection rate of 2.5-3.5 ml/sec
✓ Rate of injection and the scan delay time vary
depending on the study (35-45s)
 CONTD ...
✓ Preferred bolus tracking for timing the
scan delays
✓ Scanning begin when the vessels of interest
is opacified (eg. For PE, the PA needs to be
opacified 10-30 sec delay and for aortic
abnormalities 20-30 sec)
✓ Preferred mechanical injection of the
CM, ensuring no extravasation
✓ Manual injection in case if IV access is of small
guage or in the superficial vein or CM being
injected through CVP line
 CONTD ...

✓ IV access is preserved for at least 1/2 an hour

after the examination and observed any sign of
hypersensitivity reaction
GENERAL CONSIDERATION
✓ Justification of clinical history and examination
✓ Review of records and reports of the previous
treatment/investigation
✓ Sedation of irritable and uncooperative
patients to avoid involuntary movements
✓ Proper monitoring of the vital signs
Protocol
✓ depends on type of scanner,
manufacturers
scanner and the aim for study. However,
several general principles apply to all chest CT
scan
✓ Pt positioning- head first/ supine with arms
elevated above the level of the head
✓ Mode of sacn- helical with single breath hold
✓ Topogram/landmark - AP/one inch below the
level of chin to umbilicus to include diaphragm
and upper abdomen
✓ Scan orientation- caudocranial with start
point-imaginary line joining the two cp angles
and end point-1 cm above the apex of the
lungs
 CONTD ...
✓ Contrast administration- iv, oral air/positive contrast
esophageal evaluation
✓ Slice thickness in recon- 3-5 mm
✓ Slice intervel-1.5-2.5 mm
✓ Recon algorithm/ kernel- medium smooth, sharp for
pulmonary parenchyma and bone
✓ 3D- recon: MPR, MIP, VRT if needed
Comments-
o when scanning chest and abd in a single examination,
abd protocol should be followed
o Scanned volume should be extentded to the level of
Adrenals in suspected bronchogenic ca and to the level of
coeliac axis in ca esophagus
o Additional prone & decubitus scans should be taken
through the region of interest in cases of cavitary lesions
to demonstrate mobility of its contents
 CONTD ...
PATIENT POSITIONING
✓ Supine on scanner table, head first, arms
raised and pulled behind the head out of the
scan plane.
✓ Scan plane perpendicular to the long axis
of the body
✓ Positioning is added by trans axial, coronal
and sagittal alignment of laser light
✓ MSP should be perpendicular and
coronal plane parallel to the scanner table
top
 CONTD ...

✓ Table height is adjusted to ensure that the

coronal plane alignment light is at the level of
the mid axillary line
✓ The patient is now moved into the scanner
until the scan reference point is at 2 inch above
the level of the sternal notch
 [T CHEST: Air way evaluatio

INDICATIONS
✓ Screening
✓ Congenital airway anomalies
✓ Tracheobronchial fistula/stenosis
✓ Tracheobronchial injury, wall thickening
PROTOCOL
s Scanogram AP, 2” above the apex level to
umblicus
 *p sI

Hi
CONTD ... B

✓ Mode of scan helical with single breath hold

✓ Field of view medial 2/3rd of the lung field on
either side
✓ Scan orientation craniocaudal starting from
glottis to 2 cm below the carina for upper
airway/from C6 to dome of diaphragm for lower
airway
✓ Contrast media nil
✓ Slice thickness 1-3 mm/interval 0.5 to 1.5
mm
 CONTD ■■■

Reconstruction algorithm/kernelsharp
3D recon MPR, MIP, Min IP, VRT if needed,
virtual bronchoscopy

COMMENTS
✓ Low dose scanning to reduce radiation dose
because of inherent contrast between air and
soft tissue
✓ Tumor: follow routine chest protocol with
thinner slices of 1-2 mm at the level of tumor
 CONTD ...

✓ Tracheo-bronchmalacia : additional scan in

the expiratory phases with 5 mm slices

✓ Suspected foreign body : scanning should

begin from the level of C6 vertebra and
additional expiratory scan in the region of
interest are taken to rule out air trapping
 HRCT CHEST
a INTRODUCTION
✓ HRCT is now regarded as an indispersable tool
for the investigation of patients with suspected or
known parenchymal disease
✓ The cross sectional perspective and high
resolution make HRCT superior to other imaging
modality
✓ HRCT relies on the use of thin collimation and
image reconstruction with a high spaital
frequency algorithm
 CONTD ...
✓ Offer a high spatial resolution in the z-axis and
yields sharper images. Thin collimation decreases
partial volume averaging and improves the ability
of the CT to demonstrate smaller pulmonary
lesions
✓ Intravenous contrast agents are not used for
HRCT as the lung has inherently very high
contrast (soft tissue against air) and the technique
itself is unsuitable for assessment of the soft
tissue and blood vessels, which are the major
targets of the contrast agent
 INDICATIONS

✓ Diffused interstitial lung disease

✓ Emphysema
✓ Chronic obstructive airway
disease
✓ Bronchiectasis
 CONTD ...
HRCTCHEST PROTOCOL
✓ PATIENT POSITIONING:- Head first,
supine with arms elevated at the level of
head
✓ TOPOGRAM:- AP, from one cm above the
apex of the lungs upto the imaginary line
joining the CP angles
✓ Gantry tilt - nil
✓ FOV- just fitting to the lung fields
✓ Slice thickness/interval-1 mm/10 mm
✓ Algorithm/kernel- sharp
same Reconstruction in High resolution algorithm

same scan data

 RCT CHEST PROTOCOL

kV 140 120 1
p mm 6.0
m
Slice mm 0.75 s
As
thickness Very sharp
Pitch
Rotation 1600W -
time 600C
Kernal
Reconstruction tasks 1 mm width +50% (0.5 mm) overlap!
Window

British Journal of Radiology (2003) 76, 536-540

The British institute of Radiology
doi: 10.1259/bjr/21813112
 DIFFERENCE BETWEEN
ROUTINE CHEST CT HRCT CHEST

v'As small as 1 -2 mm
^Helpful in detecting ^High resolution images
more than 5mm sized ^Slice thickness < 2mm
lesion ^High radiation dose to
^Low resolution images improve SNR ^Without
^Slice thickness 5-10 mm contrast media ^FOV
'''Low radiation dose reduced to cover the lung
^Scan length usually parenchyma only
from 1” inch above the
apices to the levels of
CTPA(CT PULMONARY ANGI
> CTPA was introduced in the 1990 as an
alternative to ventilation/perfusion
scanning ,which relies on radionuclide imaging
of the blood vessels of the lungs.
^ It is regarded as a highly sensitive and specific
test for pulmonary embolism
 INDICATION
Pulmonary embolism
Aortic dissection
Aortic overloading
Left ventricular stress
Teratology of fallot
AVM of the lungs
Congenital narrowing of the
pulmonary vessels
Pulmonary artery aneurysms
Pulmonary hypertension
Pulmonary tumors and masses
Pulmonary sequestration
 CONTRAINDICATION

✓ Renal insufficiency/failure
✓ Severe allergy to iodinated CM
✓ Severe diabetes
✓ Pregnant patient
 PATIENT PREPERATION
✓ Enquire about pregnancy from
females
✓ Renal parameter are to be checked
✓ Well informed
Nil oral consent
for 4-6 hrs is to be got from pt.
All metal objects are to be removed from
the region of interest
Pt is asked to wear hospital’s cotton gow,
Enquire about h/o allergy, medication an
other diseases

(•h
□ Pt positioning- head first, supine with arms elevated
above the level of the head
□ Topogram position/ landmark-AP/ one inch below the
level of the chin to umbilicus
□ Mode of scan- helical with single breath hold
□ Scan orientation- caudocranial
# start location- dome of diaphragm
# end location -2 cm above the aortic arch
□ Gantry tilt- nil
□ FOV- medial two thirds of the lungs
 CONTRAST MEDIA

✓ 1.2 ml/kg of non iodinated

contrast medium is injected l/V
into the patient using pressure
injector (100-150 ml)
✓ Rate of injection:- 3-5
ml/sec
✓ Scan delay-15-20 sec (bolus
tracking method is used)
E Slice thickness in recon- thinnest available in the
scanner(0.5-1 mm)
E Slice interval- 0.25-0.5mm

E Recon algorithm/ kernel- medium smooth, sharp

E 3D recon- MPR, MIP, VRT, virtual angioscopy if
needed
✓ High level of arterial opacification greater than
200 HU in central pulmonary artery with well
opacified main lobar and segmental arteries of
all lobes is recommended for good image
 PROTOCOL FOR CTPA
Protocol for 16-Section CT of I'ulmonarv Embolism

Parameter Normal-sized Patients Large Patients (>250 lb)

Detector width (mm) 1.25 2.5
Reconstruction interval (mm) 0.625 1.25
Table movement (mm per rotation) 13.75 6.88
Pitch 1.375:1 0.562:1
Peak voltage (kVp) 120 140
Tube current (mAs) Maximum Maximum
Rotation time (sec) 0.5 0.5
Contrast material injection
Volume (ml.) 135 135
Rate (mL'sec) 4 4
Scanning delay* Variable Variable
‘Scanning delay is determined by dividing the acquisition time for lung imaging by 2 and subtracting the
result
from the total injection time (34 seconds). Thus, for example, with an acquisition time of 10 seconds, the
scan¬
ning delay will be 34 seconds - 5 seconds, or 29 seconds. No timing bolus is necessary' unless the patient
has a
Source:- radiographics
| known history' RG vol.24 no.5
of heart disease. Conrad Wittrant, MB, ChB • MichaelM. Maher, MD • Albert
-1
J. Yoo, ML Mannudeep K. Kalra, MD •Jo-Antic 0. Shepard,
MD Theresa C. McLoud, MD
 BOLUS TRACKING (CTPA)

The radiograph on the left is a scout taken to localize the pulmonary trunk, which
is just at or below the level of the bifurcation of the trachea (white lines). The
resulting axial CT localization image is shown on the right. An elliptical ROI is
placed in the right pulmonary artery to measure the time for contrast to reach this
area from the injection site. The pulmonary artery will become bright as radio
contrast infuses the artery. The time it takes to reach 100% saturation will be
calculated and displayed in a graph.
 ADVANTAGES
✓ Less time consuming
✓ Non invasive nature of
test
✓ Less complication than convention
pulmonary angio
✓ Simple post procedure care
✓ Can be done in out patient basis
 RADIATION SAFETY
✓ CT chest deliver an average dose of 8-10
mSv (plain CXR 0.02 mSv) and dose to the breast
tissue during a chest CT might be over 30 mSv
HOW TO REDUCE DOSE ?
✓ Proper pt positioning higher noise image can
occur when patients are not well centered in the
scan FOV. By positioning the body at isocentre,
the need to increase mA to
compensate for the noise is eliminated
Limiting the scan length more accurately selecting
the coverage area, limits the start and end
location and therefore reduce the dose
Dose modulation before the scan, the technologist
selects the desired noise/image quality, the
scanner then automatically tailors the exposure
based on the scout and body habitus of the
patient
Utilization of BMI chartdose can be reduce without
image degradation by observing the patient’s
weight and size
Reducing mA and KvPif mA is reduced by half, the
corresponding dose is reduced by half. If kvp is
reduced the relationship is non linear for
example if we reduce kvp from 120 kvp to 100
kvp the result in a dose reduction of almost 40%
 NCCTOR CECT HEAD
> Introduction
> Indication
> Contraindication
> Contrast media
> Equipment
> Patient
Preparation
> Technique
> Aftercare
INTRODUCTION

>A Computed Tomography of the head is the most common and non-
invasive diagnostic imaging procedure.

>CT scan provide more details information of head injuries , stroke brain
tumors and other brain disease.
>It has wide ability to answer complex clinical condition.

>Because it is quick and relatively available.

INDICATIONS

>Trauma

> Tumors.

> Congenital abnormalties.

> Intra cranial Infections.

> Headache of unknown cause.

> stroke( damage of brain from stop of blood

>Mass
supply)
Cont
• Seizures (strong attack of an illness)
• Apnea (breathing stop)
• Syncope (loss of consciousness)
• Ataxia (lack of body balance)
• Encephalitis (inflammation in brain)

> Hydrocephalus

> Suspected acute intracranial hemorrhage.

> Mental status change.

> Neurologic deficits

• (balloon like structure of artery)
CONTRAINDICATIONS

> Pregnancy

> Kidney failure

> Reaction to contrast

> Patient decline consent
media
CONTRAST MEDIA

Contrast media: nonionic, iodinated contrast media used.

> Volume: 40-60ml.

> Rate: lml to 3ml/sec.

>Contrast media administration:IV
PATIENT PREPARATION
>Fasting 4-6 hours.
>Identify the patient and explain the procedure to the patient.

>An IV line is secured.

> Remove metal or radio-opaque object such as ear rings, metallic headbands etc.

>Patient should change into clean hospital gown.

>unstable patient may be sedated prior to examination.

>Take consent sign .

POSITION

> Patient lies supine, head first into the gantry the head placed in the head holder
with arm bilaterally downwards
>Table height is raised until the (EAM) is at the Centre of gantry.fexternal auditory
meatus).
> Three alignment lights are used for positioning the patients (axial, sagittal,
coronal).
>After the position finish the laser light should be off.

>POSITION LANDMARK-2-3 cm above the vertex

 patient positioning

POSITION
J Patient Position: Spine / Position/Landmark:
with head first arms
2-3cm (20-30mm)
bilaterally downwards, with
the head in the head holder. above the vertex.
Center the table height v' Start Location:
such that external auditory Skull base.
meatus (EAM) is at center
of the gantry. To decrease / End Location: Skull
the ocular lens exposure, vertex.
the scan angle should be
/ Gantry Tilt: 15 to 20
parallel to a line created by
the supraorbital ridge and degrees angulation
the inner table of the of the gantry to the
posterior margin of the canthomeatal line or
foramen magnum. tilting the patient’s
J Topogram Direction: chin toward the
Craniocaudal J Scan chest (“tucked”
PROTOCOL
>Scanogram (scout) /topogram: Scano from the base of

the skull to vertex. > The slice thickness is 2 mm in

adults and 5mm or less in Children. s Contrast: Nil s Slice

Thickness: 2-5 mm s ^Rotation Time (s): 1
Algorithm: standard, bone s
^Pitch: 10.65 mm
Respiratory Phase: None
^Tube Voltage (Kv): 120 sContrast: Nil ^Image
s Tube Current (mAs): 300-
450 Format: DICOM
PROTOCOL

> Scan extent: from the vertex to the base of skull.

> Scan direction : cranio-caudal(head to feet)

>Scan type :Axial

> Pre contrast series: Axial images are acquired covering from the vertex to the
base.
^contrast series: Axial images are acquired covering from the vertex to the
base.
Topogram of head with scan Axial NCCT head showing EDH
lines showing the plane and
scan range Intracerebral hemorrhage axial C
 CONTRAST ENHANCED CT HEAD PROTOCOL

s Patient Position: Spine with head

Indications: first arms bilaterally downwards, with
the head in the head holder. Center the
S Suspicion of mass table height such that external auditory
meatus (EAM) is at center of the gantry.
Known primary
s To decrease the ocular lens exposure,
the scan angle should be parallel to a
tumour line created by the supraorbital ridge
and the inner table of the posterior
^Metastases margin of the foramen magnum
s Topogram Direction: Craniocaudal
sAneurysm
sAbscesses
^Meningitis
 CONTINUE
s Scan Type: Helical
S Contrast: Nonionic
S Position/Landmark: 2-3 cm (20-30
mm) above the vertex.
low osmolar lodinated
v' Start Location: 1 cm inferior to Skull Contrast media
base.
s Contrast
v' End Location: 1 cm superior to Skull
vertex. Administration:
J Gantry Tilt: 15 to 20 degrees
angulation of the gantry to IV
the canthomeatal line or ^Volume: 60-100 ml
tilting the patient's chin
toward the chest (“tucked” s Rate of Injection: 2-3
position).
✓ DFOV: 25cm ml
/s
S Slice Thickness: 2-5
mm
 CONTINUE
S Scan Delay: 30-50sec ^Tube Voltage (Kv):
s Algorithm: Standard, 135-240
Soft tissue ^Tube Current (mAs):
S Recons and 150-220
Reformations: MPR, ^Rotation Time (s): 0.5-
MIP 0.7
^Respiratory Phase: ^Image Format: DICOM
Any
A L * ^ .<
Topogram of head with scan
lines showing the plane and
scan range
CECT axial image showing
normal brain

♦mi
 CT TEMPORAL BONES PROTOCOL

Indications:
> Inflammatory middle ear diseases
> Cholesteatoma > Mastoiditis

> Hearing Loss > Neoplastic lesions

>Trauma >Congenital anomalies

 AXIAL PROJECTION

^Patient Position: Spine with head first, head in head

rest.
^Topogram Direction: Craniocaudal in axial plane or in
spine position.
s Scan type: Helical
^Position /landmark: Midforehead in axial plane. sStart
Location: Skull base
S End Location: Superior margin of petrous temporal
bone .d
s Gantry Tilt: No tilt in
axial plane.

✓ DFOV: 20 cm s Scan
field of view: 25 cm v
Contrast
Administration: IV S
Volume: 80-100 ml s
Rate of Injection: 2-3
ml /s s Scan Delay: 30-
v Algorithm: Bone

Slice Thickness: 1-

2mm Tube Voltage

(Kv): 140 Tube

Current (mAs): 350

Rotation Time (s):

0.5 Image Format:

 CORONAL PROJECTION

> Patient Position: Prone with s Start Location: Anterior margin of

head first, with extended neck petrous temporal bone
and chin on chin rest. s End Location: Posterior margin of
> Topogram Direction: Posterior petrous temporal bone
to anterior in coronal plane or in S Gantry Tilt: 17-23 degrees to
prone position make the scanning plane
> Scan Type: Helical perpendicular to bony palate in
coronal plane.
> Position/Landmark: 2-3 cm
(20-30 mm) anterior to the ✓ DFOV: 18 cm
forehead in coronal plane. s Scan field of view: 25 cm
Contrast: Nonionic low
osmolar lodinated Contrast
media
S Contrast
Administration: IV s
Volume: 80-100 ml s
Rate of Injection: 2-3
ml Is s Algorithm:
Standard, Bone
s Recons and
Reformations:
MPR, MIP
s Scan Delay: 30-40 sec
S Slice Thickness: 1-3mm
^ Tube Voltage (Kv): 140
s Tube Current (mAs): 150-
350
s Rotation Time (s): 0.5 s
Image Format: DICOM
Topogram of temporal bone skewing scan range
Coronal section oftemporal bone
AFTER CARE

> Patient is brought out of the gantry

> Bring the patient down from the scanner table.
> Ask the patient to dress up.
> patient should be observed for possible CM reaction post procedure.
>If non is observed , IV cannula should be removed from the patient’s hand gently.
> Ensure that the patient is stable before leaving the department.
>Inform patient time and where to collect the result.
CT procedure of neck
 Indications

• Inflammatory, nodal and tumoral diseases including

lymphoma and metastases.
• Thyroid diseases
• Pharyngeal lesions
• Salivary glands pathologies
• Detection /confirmation of
lesions
• Follow-ups
• Trauma
 Contra-indications

• Hypersensitivity to iodinated contrast

media
• Pregnancy(relative)
• Renal diseases
 Patient Preparation

• Clear history should be taken along with reports of

previous investigations.
• Pregnancy needs to be ruled out.
• Radiopaque materials should be removed from
FOV.
• Proper information and instruction
about the procedure.
• NPO for 4-5 hours prior to procedure
for CECT
 Patient Preparation

• Blood Creatinine levels should be in its normal

limit (M=o.6 to I.5,F=O.5-I.2 mg/dl) and Blood
urea level should range between 9 to 42 mg/dl
• Signed informed consent from patient or
his/her close relatives.
• Irritable/uncooperative and Pediatric
patients should be sedated.
• Neck should be in neutral position.
• The patient should be instructed to
avoid swallowing movements.
 Routine Neck protocol

> Patient positioning

Head first, supine with arms by the sides of the trunk
with hands tucked under the hips.
Head rest/support can be applied to restrict the neck
movement.
> Topogram position/Landmark
lateral; level of forehead
> Mode of scanning
Helical with single breath-hold technique
> Scan orientation
> Cranio-caudal
Starting location -
Base of the skull End
location
Arch of the aorta
Cranio-caudal
orientation reduces
artifacts at the level
of the thoracic inlet
caused by the beam-
hardening effects of
the contrast agent.
> FOV
 Routine Neck protocol

> Gantry tilt

To make the plane of the scanning parallel to the hard palate
or perpendicular to the plane of larynx.
> Contrast
administration
Intravenous and monophasic
> Volume of contrast
- 80-100 ml
> Rate of injection of
contrast
- 2-3 ml/sec
> Scan delay
30-40 sec
 Routine Neck protocol

> Slice thickness in

reconstruction
>- 3-5Slice
mm interval in reconstruction

> 1.5-2.5 mm

> Reconstruction algorithm/kernel

Medium smooth for soft tissue.
Sharp for cartilage, bone and lung parenchyma in the scan
range.

> 3D-Reconstructions
>
MPR ,
MIP
 Comments

• Unless contraindicated , IV contrast media is

used when scanning the neck.
• The goals in CT scanning of the neck are to
allow sufficient time after contrast
administration for mucosa , lymph nodes , and
pathology tissue to enhance , yet acquire images
while the vasculature remains opacified.
• Scanning too early after the contrast media
injection could result in certain types of
neoclassic and inflammatory processes going
undetected .
 Cont...

• However, by delaying scan acquisition , the injected

contrast agent will no longer opacity the
vasculature .
• One strategy for addressing these
contradictory goals is a split bolus .
• The total contrast dose is split, often in half.
• The first dose is given and a delay of about 2
minutes is observed.
• This allows time for structures that are slower
to enhance to be opacified.
 Cont...

• This allows time for structures that are

slower to enhance to be opacified.
• The delay is followed by a second bolus
containing the remainder of the contrast;
scanning is initiated soon after the second
injection to more fully opacify the vessels.
• The split bolus injection technique is also
frequently used for maxillofacial studies in
which contrast media is indicated.
CT ABDOMEN PROTOCOLS
■ Routine
abdomen
■ Liver scan
■ Renal scan
■ Adrenal scan
■ Pancreatic scan
PROTOCOL: ABDOMEN (ROUTINESCAN)

■ INDICATIONS:
■ Abdominal pain (acute or chronic pain),
■ History of malignancy (lymphoma, cancer of the colon, breast
etc.),
■ Abdominal or pelvic mass,
■ Suspected abscess,
■ Infection, weight loss and bowel obstruction,
■ Follow up Ca screening.
PROTOCOL: ABDOMEN (ROUTINE SCAN)

■ CONTRAINDICATIONS:
■ As per IV contrast such as:
• Sensitivity to contrast media,
■ Pregnancy,
■ Radioactive iodine treatment for thyroid
disease,
■ Metformin use,
■ Chronic or acutely worsening renal disease.
PROTOCOL: ABDOMEN (ROUTINE SCAN)
■ PATIENT PREPARATION:
■ Procedure is explained to the patient.
■ 4-6 hour fast,
■ Oral contrast for 1 to 2 hours prior to scan.
■ Iodine-based solutions such as Gastrografin, and Barium
sulphate based solutions.
■ Non-ionic Intravenous contrast solution;
* Clothing around the area of interest is removed.
■ Patient changed into a clean hospital gown.
PROTOCOL: ABDOMEN (ROUTINE SCAN)

■ SERIES: TWO SERIES (PRE AND POST-

CONTRAST)
■ PATIENT POSITIONING:
■ Patient lies supine with the feet first into the gantry.
■ Arms are raised and placed under the head.
■ Landmark:
■ Sagittal light should coincide with the mid-sagittal plane.
■ Axial light is centred at the Xiphoid sternum.
■ Coronal light should coincide with the mid-axillary line.
PROTOCOL : ABDOMEN (ROUTINE SCAN)
■ SCANNING TECHNIQUE:
■ PRE CONTRAST SERIES
■ Scout: Anteroposterior and lateral
■ Scan type: Helical
■ Coverage: superiorly from the dome of the
diaphragm to the symphysis pubis.
■ Instruction: Images acquired during
suspended inspiration.
■ For oesophageal or stomach mass, an
additional glass of contrast is to be ingested
via drinking straw while the patient is on the
table.
PROTOCOL: ABDOMEN (ROUTINE SCAN)
■ I.V CONTRAST SERIES
■ Protocol same as the pre-contrast.
■ CONTRAST MEDIA:
■ Volume: 60-80mls
■ Injection rate: 2-3mls/second
■ Injection type: Injection pump
■ Tracking tool: Fixed delay
■ Scan delay: 60-75
■ Comments:
■ Rectal contrast may be required for rectal carcinoma or perforated
bowel.
■ Vaginal contrast tampons may be required for female patients having
pelvic scans.
PROTOCOL: ABDOMEN (ROUTINE SCAN)
• IMAGE RECONSTRUCTION:
■ 1st reconstruction
■ 5mm / 5mm (soft tissue/mediastinal)
■ 2nd reconstruction
■ l-3mm / l-3mm (MPRs)
■ FILMING
■ Format: 20 format
■ Window width / window level 350ww / 40wl (soft tissue) (also
called standard)
■ Comment
■ Include lung bases with lung setting at the end of the study.
PROTOCOL: ABDOMEN (LIVER SCAN)

■
INDICATION:
■ Haemangioma,
■ Metastases,
■ Tumours,
■ Abscesses,
■ Cysts of the
liver.
PROTOCOL: ABDOMEN (LIVER
SCAN)
■ CONTRAINDICATION:
■ The same as for the routine abdomen.
PROTOCOL : ABDOMEN (LIVER SCAN)
■ PRE (NON) CONTRAST
■ TRIPHASIC SCAN:
■ Arterial phase (18-21 post trigger)
■ Portal venous phase (70-80 sec delay)
■ Delayed Phase (3-5 min delay)
■ Normal liver parenchyma receives about 70 of its blood from the portal vein and
30 from the hepatic artery.
■ Most primary and metastatic liver tumours, however, receive their blood from the
hepatic artery.
■ Arterial phase of the liver improves the detection of some small, malignant hepatic
neoplasms when performed in addition to portal venous scanning. The value is
greatest in those patients who have hypervascular neoplasms.
PROTOCOL: ABDOMEN (LIVER SCAN)

• CONRAST INJECTION PROTOCOL (Bolus tracking):

■ Monitoring slice (region of interest): abdominal aorta at
the level of L2.
■ Threshold for contrast agent enhancement: 100-150 HU
■ Volume: 80-100 ml of non-ionic contrast with a 100 ml
saline chaser at 4.5/5 ml/s.
■ Respiration phase: Deep arrested inspiration.
PROTOCOL: ABDOMEN (LIVER SCAN)
PROTOCOL : ABDOMEN (RENAL SCAN)

■ INDICATIONS:
■ Acute flank pain, hematuria, suspected renal colic
■ Renal mass
■ Hematuria
■ Prior renal cell carcinoma (post partial nephrectomy or at high risk for
bilateral tumours)
■ History of bladder cancer, abnormal IVU suggesting upper tract disease
■ Pyelonephritis unresponsive to antibiotics (pre contrast shows stones,
enhanced and delayed views evaluate for pyelonephritis, abscess,
obstruction.
■ Perinephric haemorrhage, evaluate for renal tumour or other cause.
■ Renal donor.
PROTOCOL: ABDOMEN (RENAL SCAN)
■ CONTRAINDICATIONS:
■ The same as for the routine
abdomen.
PROTOCOL: ABDOMEN (RENAL SCAN)

■ PATIENT PREPARATION:
■ Patient should not eat solid food 4-6 hours before exams but should be
encouraged to take a lot of water.
■ Clothing around the area of interest is removed.
• Artifacts are also removed,
• Patient changed into a clean hospital gown.
PROTOCOL: ABDOMEN (RENAL SCAN)

■ PATIENT POSITIOINiNG:
■ The same as for the routine abdomen.
PROTOCOL : ABDOMEN (RENAL SCAN)

■ SCANNING TECHNIQUE:
■ Scout: Anteroposterior and lateral
■ Scan type: Helical

■ Coverage: Include Xiphisternum to the symphysis

pubis. However, this can be modified based on the local
protocol.
PROTOCOL: ABDOMEN (RENAL SCAN)
■ Comment:
■ For renal stone:
■ Number of series: 3
■ Pre-contrast series
■ Nephrographic phase
■ Delay (secretory phase).
■ Images acquired during suspended inspiration.
■ Renal mass:
■ Number of series 4
■ Pre-contrast series,
■ Arterial phase (corticomedullary phase),
■ Portal venous phase,
■ Delay (secretory phase).
PROTOCOL: ABDOMEN (RENAL SCAN)
■ RENAL ARTERY STENOSIS:
■ Number of series: 4
■ Pre-contrast series,
■ Arterial phase (corticomedullary phase),
■ Nephrographic phase,
■ Delay (secretory phase).
■ CONTRAST INJECTION TECHNIQUE:
■ Volume: 60-80mls
■ Injection rate: 2-3mls/second, however, for renal angiography, it should be 4-
5ml/sec
■ Mode of injection: Bolus tracking using an automatic injector.
PROTOCOL: ABDOMEN (ADRENAL SCAN)

■ INDICATIONS:
■ Metastases,
■ Lipoma,
■ Adrenal cortical adenoma,
■ Evaluation of mass,
PROTOCOL : ABDOMEN (ADRENAL SCAN)

CONTRAINDICATIONS:
■ The same as for the routine abdomen.
PROTOCOL: ABDOMEN (ADRENAL SCAN)

■ PATIENT PREPATION AND POSITIONING:

■ The same for the routine abdomen.
PROTOCOL : ABDOMEN (ADRENAL SCAN)

■ SCANNING TECHNIQUE:
■ The same for the triphasic liver scan.
PROTOCOL: ABDOMEN (PANCREATIC SCAN)

■ INDICATIONS:
■ Acute pancreatitis (assess severity, presence of haemorrhage or necrosis if
extensive disease, usually add pelvis to look for complications there).
■ Painless jaundice and weight loss.
■ Suspect pancreatic cancer Islet cell tumour.
■ Chronic pancreatitis: Characterize lesion
seen on prior imaging (ultrasound, ERCP).
■ Pancreatic mass.
PROTOCOL: ABDOMEN (PANCREATIC SCAN)

■ CONTRAINDICATIONS:
■ The same as for the routine abdomen.
PROTOCOL: ABDOMEN (PANCREATIC SCAN)

■ CONTRAINDICATIONS:
■ The same as for the routine abdomen.
PROTOCOL: ABDOMEN (PANCREATIC SCAN)

■ PATIENT PREPARTION:
■ The same as for the routine abdomen.
PROTOCOL : ABDOMEN (PANCREATIC SCAN)

■ SCANNING TECHNIQUE AND CONTRAST MEDIA

INJECTION:
■ The same as for the triphasic liver scan.
TABLE 13-2 Contrast Arrival Times After Injection Into the Right
Cubital Vein
Right atrium 6-12S
Main pulmonary artery 9-15 s
Left atrium 13-20 s
Aorta 15-22 s
Carotids 16-24 s
Renal arteries 18-27 s
Femoral arteries 22-33s
Jugular vein 22-30s
Renal veins 22-30s
Suprarenal IVC 24-32s
Infrarenal IVC 120-250s
Splenic vein 30-45 S
Mesenteric veins 35-50s
Liver veins 50-80s
Femoral veins 120-250S
From Prokop* wrth
permission. IVC * inferior
vena cava.
TABLE 13-1 Terms Used to Describe Contrast Phases and
Approximate Times*
Early arterial phase 15-25S
Late arterial phase 35-45s
Hepatic arterial phase 17-25S
Late hepatic arterial phase 40-55s
Portal venous phase 65-80S
Hepatic venous phase 75-85S
Early delayed hepatic phase (i.e.,
vascular
equilibrium) 3-5 min
Late delayed hepatic phase (i.e.,
parenchy-
mal equilibrium) 10-15 min
Parenchymal pancreatic phase 40-60s
Enteric phase 40-50s
Corticomedullary phase 30-70s
Nephrographic phase 80-130s
Excretory phase 3-15 min
Systemic venous phase (inferior 3 min
vena cava)
•Frequently the various terms are used inconsistently; there is no
consensus regarding the exact times after a bolus contrast injec-
tion these phases are reached. In addition, both injection para me*
ters and patient factors will have a significant impact on when each of the phases
occur.
THANK YOU
FOR
LISTENING