Small Animal/Exotics

Compendium June 2000

EMERGING TECHNOLOGY

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Three-Dimensional Computed Tomography: User-Friendly Images
Jeryl C. Jones, DVM, PhD Diplomate, ACVR Department of Small Animal Clinical Sciences Virginia-Maryland Regional College of Veterinary Medicine Blacksburg, Virginia tient. The x-ray energy is converted to an electric signal and sent to the CT computer for processing. The CT computer translates the electric signal to numeric (digital) information, which in turn is used to display images on a computer monitor. To perform 3-D CT reformatting, the computer first combines all digital information from a set of transverse CT images.3–6 The outside picture elements (pixels) of each transverse slice are selected to create a surface display of the volume image. Although the images are actually shown in two dimensions, depth is perceived through the use of surface shading. The volume image appears to be illuminated by a single source of light, with objects closest to the observer displayed in white and those farthest away in black. The operator can select which tissue densities are to be shown and which viewing angle is to be used. By selecting sequential 3D viewing angles, a videotape animation in which the image appears to be rotating in space can be created. The operator can also remove unwanted overlying structures from the image, select only certain structures to be displayed, assign colors to selected structures, and measure the volume of a specific region. One limitation of 3-D CT is the appearance of reconstruction artifacts.2,7–10 Artificial bone defects (pseudoforamina) may occur in areas with low tissue density. Reconstruction artifacts can be minimized by reducing the threshold for the range of displayed bone densities. Comparisons with the opposite side may help differentiate pseudoforamina from true lytic lesions. Another limitation is the “stair-step” pattern (raster effect) that can occur on the surface of 3-D images. This problem is primarily caused by inaccurate computer interpolation at the junctions between adjacent transverse slices. This effect can be minimized by using thinner slices, increasing slice overlapping, or using oblique slice planes.

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omputed tomography (CT) is an imaging technique that uses x-ray energy and computer processing to create cross-sectional (transverse) slices of internal structures (e.g., within the head, torso).1,2 One of the main advantages of CT over conventional radiography is the ability to eliminate superimposition; CT images are not only clearer but can isolate a specific internal region. A disadvantage of CT is that transverse sectional anatomy is often unfamiliar and, therefore, difficult to interpret. New computer processing (reformatting) techniques are now available that can create three-dimensional (3-D) CT images. Because the images that are created more closely resemble the way anatomic structures look during physical examination or surgery, the information gleaned from 3-D CT images is often easier to interpret than that from transverse CT images.

Background Each CT slice is formed from multiple x-ray exposures captured as the scan completes a 360˚ rotation. Transmitted x-ray energy is recorded by detectors positioned opposite the pa-

Uses The most common uses for 3-D CT are clarifying spatial relationships for surgical planning, determining volume and extent of involvement for tumor staging, and facilitating client communication.11–14 Some of the more advanced 3-D CT computer programs also perform virtual endoscopy,12,15–17 surgical simulations,18–23 and radiation therapy planning.12,24–26 Virtual endoscopy is a noninvasive method for evaluating the interior of hollow organs. A movie that sequentially displays color 3-D CT images allows viewers to “fly through” such structures as the trachea, bronchi, stomach, and bowel. Surgical simulation is a technique in which color 3-D CT images are used to “rehearse” operations. The surgeon can compare different approaches by rotating the computer-generated images and using electronic cursors to selectively remove or replace tissue. Some promising new applications for 3-D CT in veterinary medicine include evaluation of the abdomen (Figure 1), spine, thorax, pelvis (Figure 2), skull, and brain (Figure 3; Table I).27–31

Compendium June 2000

Small Animal/Exotics

Figure 1B Figure 1A Figure 1—(A) Transverse, postcontrast CT image of a dog with a left adrenal mass (M). Surgical landmarks are the right kidney (RK), left kidney (LK), aorta (A), caudal vena cava (C), and portal vein (P). (B) Three-dimensional CT image of the same dog demonstrates the adrenal mass and landmarks in color, without superimposed structures. The kidneys and ureters are in yellow, adrenal glands in dark pink, and blood vessels in blue.

Figure 2A

Figure 2B

Figure 2—(A) Color 3-D CT image of a dog with a right gluteal sarcoma. Overlying soft tissue structures have been removed to permit visualization of the mass (blue) relative to the pelvis. The mass and pelvis appear to have multiple “stair steps” because of a reconstruction artifact caused by computer misinterpretation of the margins between two adjacent slices. (B) The pelvis has been removed to permit 3-D volume measurement for tumor staging. The calculated volume of the mass is displayed at the top of the image in green text (82.97 ml).

Access and Cost Considerations In practices anticipating client demand for fewer than 10 scans per week, access to 3-D CT may best be achieved by using tertiary veterinary referral centers or local medical imag-

ing facilities. Costs per scan may range from $200 to $1200, depending on geographic location and individual imaging center policies. In practices anticipating client demand for 10 or more scans per week, pur-

chasing the equipment may be a viable option (Table II). Many manufacturers provide installment plans. Yearly maintenance contracts are highly recommended and may be obtained at a cost of approximately

Small Animal/Exotics

Compendium June 2000

Figure 3—Color CT images of a dog with a rostral cerebral meningioma. On the right are transverse, sagittal, and dorsal planar views of the brain mass (purple). On the left is a 3-D view of the head, with a cube-shaped tissue section removed to permit visualization of the mass relative to such surgical landmarks as the eye (E), cribriform plate (C), and frontal sinus (F).

10% of the equipment purchase price. Most of the newer CT scanners can produce basic 3-D images.

Single-slice (third- or fourth-generation) CT scanners acquire one transverse slice at a time. The costs range

from $200,000 to $400,000. Multislice (spiral) scanners acquire data from the entire volume of tissue at one time and then retrospectively create the transverse slices. This capability permits rapid examinations, often in less than 1 minute.6 The cost of multislice scanners ranges from $500,000 to $1,200,000. Advanced 3-D image manipulation (e.g., color enhancement, virtual endoscopy) requires a reformatting computer workstation that performs more complex image manipulations (interactive creation and viewing of images). 27,29,31,32 Workstations can also be used to convert CT images into formats that can be transferred over the Internet and viewed at any personal computer. Reformatting workstations may be added to a conventional or spiral CT scanner system for $80,000 to $120,000. Obtaining a workstation made by the same company as the CT scanner minimizes the risk of software incompatibilities and associated downtime. Most manufacturers include the cost of applications training for

TABLE I Some Disease Indications for Three-Dimensional Computed Tomography
Disease Adrenal masses Lateral disk herniation Vertebral osteomyelitis Vertebral trauma Rib masses Mediastinal masses Pelvic masses Craniofacial masses Craniofacial trauma Nasal masses Brain masses Uses Determine relationship of mass to adjacent blood vessels for treatment planning and prognosis Plan approach for removal of disk fragment Determine extent of involvement for treatment planning and prognosis Determine locations and origins of fracture fragments and demonstrate subluxation/luxations Determine extent of involvement and margins for surgical excision Determine relationship of mass to adjacent vital structures for surgical planning and prognosis Determine extent of involvement and margins for surgical excision Determine extent of involvement and margins for surgical excision Determine extent of involvement for treatment planning and prognosis Determine tumor volume and extent of involvement for staging and radiation therapy planning Determine tumor volume and extent of involvement for staging and radiation therapy planning; plan surgical approach for removing mass

Compendium June 2000

Small Animal/Exotics

TABLE II Estimated Costs
Equipment Single-slice CT scanner Multislice CT scanner Single-slice CT scanner and workstation Multislice CT scanner and workstation
a

Purchase Price $200,000–$400,000 $400,000–$1,000,000 $280,000–$520,000

Yearly Maintenance Contract $20,000–$40,000 $40,000–$100,000 $28,000–$52,000

Cost per Scan (10 scans/week)a $308–$616 $616–$1538 $431–$800

Cost per Scan (20 scans/week)a $154–$308 $308–$770 $216–$400

$580,000–$1,320,000

$58,000–$132, 000

$892–$2031

$446–$1015

Assumes 10 years of use and 300% markup to cover employee time, utilities, site preparation, film, camera costs, and software upgrades. CT = computed tomography.

up to two staff members with the purchase of a new scanner and workstation system. Applications training may be completed at an off-site center and often involves 2 to 3 days of intensive workshops. An alternative is to schedule three to four on-site visits. Veterinarians or radiologic technologists would be the most suitable candidates for 3-D CT training.

References
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