CT Protocols
SOFT TISSUE
NECK
HRCT
CT Neck
& Chest with
Chest Contrast
CT SOFT TISSUE NECK
Scan range: Mastoids to SC- Joints.
Post contrast scan should be
sufficient. Delay time 80s.
100ml of contrast, 30ml Saline
@1.5ml/s.
One sequence.
CT Soft
Tissue Neck
CT CHEST
High Resolution chest could be done as a
pre contrast scan.
For post contrast scans a HiRes protocol should
not be used. The recons are on Bone and Lung –
not sufficient to look at mediastinum.
HRCT CHEST
If there are ground-glass opacities in
the lungs, also perform an expiratory
phase HRCT chest (ask radiologist if not
sure of the ground-glass pattern).
If there are basal dependent opacities
(at the bottom of the lungs, and
posteriorly), ask the radiologist if a
PRONE HRCT chest must also be done.
Ground Glass Opacities
is a descriptive term referring to
an area of increased attenuation marked gravity-dependent
in the lung on computed gradient with increased
tomography (CT) with preserved opacification
bronchial and vascular markings.
Case courtesy of Dr Mohammad [Link]
Taghi Niknejad, [Link], rID: .1148/radiol.10092307
21062
Bone algorithm Soft algorithm
Soft algorithm
• Post contrast CT Chest investigations.
• Routine pre-contrast, arterial and venous.
• If contrast injection and scan technique
planned
carefully – arterial phase can be omitted.
DISCUSSION:
• Biphasic contrast injection followed by
single post contrast scan 60s after beginning
of injection.
CT CHEST ARTERIAL
•
PHASE
Contrast enhancement of:
▪ pulmonary arteries and veins,
▪ cardiac chambers,
▪ the aorta and its branches.
• Differentiate between central arterial
and
venous structures.
CT CHEST ARTERIAL PHASE
• BUT no enhancement of:
– returning systemic veins contralateral to
side injected from head and neck,
– infradiaphragmatic veins (especially azygos
vein),
– any mediastinal and hilar masses,
– lymph nodes,
– lung pathology.
• Difficulty differentiating unenhanced venous
structures
Arterial
Phase
NORMAL 60S POST DELAY SCAN
Contrast enhancement:
• Vascular structures, mass lesions, lymph nodes within
chest adequate.
• But differentiation between central arterial & venous structures &
returning systemic venous structures relies on anatomical
identification, as contrast density of these structures is usually
very similar.
• Pulmonary arteries and branches often insufficient to
demonstrate incidental pulmonary arterial emboli.
CONTRAST
INJECTION
Contrast used for routine chest CT 100 – 120ml. (Weight
based??)
‘Rule of thumb’: from the time of the contrast injection
into
antecubital vein it takes:
• 9s to reach heart,
• 12s through lungs back to heart,
• 15s to reach descending thoracic aorta.
9s + + 15s = 36s
CONTRAST INJECTION RATES
• 2 – 5ml/s, sequence dependent.
• Contrast injection 100ml @ 4ml/s = 25s bolus of contrast.
• Multislice scanners scan whole thorax 10 - 16s with 1-2mm
throughout.
• If timing perfect in every patient, one can theoretically perform
good arterial phase diagnostic scans of the chest with only 16s
x 2.5ml/s = 40ml of contrast.
VENOUS OPACIFICATION
Initial 80ml starting 60s before scan allows
adequate contrast filling of returning systemic
veins (particularly brachiocephalic & azygos
veins).
Injection rate kept similar to that of ‘traditional’
chest CT scan.
Contrast is ‘pushed’ by saline chaser injection at
same rate, followed by a calculated delay.
ARTERIAL OPACIFICATION
Second contrast injection begins 15s before CT scan starts.
Will enhance pulmonary arteries and veins, aorta in the chest.
Timing allows end of second phase bolus of contrast to
densely enhance central vessels (pulmonary arteries and
veins).
Lead portion of this second bolus will have reached
descending aorta in almost all patients.
TIMING
• Fit patients - timing invariably adequate.
Patients with poor cardiac function:
• Blood flow is slower. Start the scan a little later – possibly 65s.
• Usually adequate as the contrast bolus tends to dissipate over 20s.
• The 60s initiation of the scan after beginning of contrast injection,
means scan effectively starts 64s. Built-in delay for scan to initiate is ±3s
after completion of the contrast injection in arm.
• Timing should be adequate for dense arterial phase.
• A final saline chaser injection pushes the contrast towards the chest.
ADRENALS
Pancreas
CT
Tri-phase
Abdomen
Liver
IVP
Staging
CT
Adrenals
CT ADRENALS
• Done to characterize a lesion.
• Pre Contrast:
used to calculate wash out.
• Venous:
Full abdomen (Diaphragm to symph). To get an overview of
the abdomen. 60s delay.
• 15 min Delay:
Region of interest. (This is only required if there is an
adrenal
mass)
USE THE DIFFERENT PHASES TO
CALCULATE THE WASHOUT OF THE
ADRENAL MASS. THE PERCENTAGE OF
WASHOUT WILL DETERMINE IF IT IS A
BENIGN OR MALIGNANT LESION.
CT ADRENALS
Pre contrast:
•Full abdomen
(Diaphragm to
symph).
•To get an
overview of the
abdomen. HU
CT ADRENALS
60s delay:
•Full abdomen
(Diaphragm to
symph).
•To get an
overview of the
abdomen.
CT
Adrenals
15 minute delay:
•Over region of interest (ask
the radiologist – does he
want a full abdo or just the
liver)
•To get an overview of
the abdomen.
•Should you do this if
there is
CT ADRENALS
CT Pancreas
Protocol
• Give the patient 2 glasses of water before the scan,
to distend the duodenum and visualize it better.
• Pre contrast scan: To localize the pancreas (no need
to scan from carina
to crest)
• Arterial phase (x2): 20s delay, with general contrast
protocol. Repeat group once. To see the enhancement of
the pancreas. Help to differentiate between anatomy and
pathology. OR use bolus tracking and do one phase.
• Venous phase: Full abdomen (Diaphragm to symph). To get
CT PANCREAS
PROTOCOL
Pre contrast scan:
•To localize the pancreas
(no need to scan from
carina to crest)
CT Pancreas
protocol Arterial phase (x2):
• 20s delay, with general
contrast protocol.
• Repeat group once. (To get 2
groups)
• To see the enhancement of the
pancreas.
• Help to differentiate between
anatomy and pathology.
OR
CT Pancreas
protocol
Venous phase:
• Full abdomen
• (Diaphragm to symph).
• To get an overview of
the
abdomen.
CT Pancreas
protocol
Unenhanced Early
Arterial
Late Venou
arterial s
CT TRI-PHASE LIVER
• Arterial: Upper abdomen to include the liver.
Looking at the arterial flow through the liver
• Venous: Full abdomen (Diaphragm to symph).
To
get an overview of the abdomen.
• 5 min Delay: Too look if any lesion fill up
with contrast or stay hypo dense.
CT Tri-Phase
Liver
Arterial:
•Upper abdomen to include
the liver.
•Looking at the arterial flow
through the liver
CT Tri-Phase
Liver
Venous:
•Full abdomen (Diaphragm
to symph).
•To get an overview of the
abdomen.
CT TRI-PHASE LIVER
5 min Delay:
•Too look if any lesion
fill
up or stay hypo dense.
Early Late Arterial / Porto
Arterial venous
Venou Delayed
s
ARTERIAL AND VENOUS
LIVER
Arterial
VENOUS
5 min
delay
CT venous Abdomen
only
Venous:
• Use 70s delay with
flow rate 2ml/s
CT venous Abdomen
only
CT TRI-PHASE IVP
TRIPLE BOLUS
MULTIDETECTOR CT
UROGRAPHY
Visualize Renal parenchymal, excretory
and vascular contrast enhance phases.
Reduce number of unnecessary scans
to asses urinary tract.
Not used for dedicated renal artery
scan
and uncontrasted scans for renal colic.
OLD SCHOOL CT IVP
Unenhanced – renal stones
Arterial phase – renal arteries and
parenchyma
Venous phase – renal veins and
venous structures
Delayed phase – excretion of kidneys
CT TRI-PHASE IVP
• Position patient on table (center on Xiphi-sternum).
• Do pre contrast scan (diaphram to symph).
• Insert IV cannula / flush existing drip.
• Hand inject 30ml ICM 300/350 (check time as the next scan is 10
mins
from now).
• Draw up 120ml ICM 300/350 and 60ml Saline in double syringes.
• After 10 mins inject contrast using CT IVP protocol with 90s delay.
ICM = iodinated contrast media
CT TRI-PHASE IVP
• Position patient on table (center on Xiphi-sternum).
• Do pre contrast scan (diaphram to symph).
• Insert IV cannula / flush existing drip.
• Hand inject 30ml Jopamiron 300 (check time as the next scan is 10 mins from
now).
• Draw up 120ml Jopamiron 300 and 60ml Saline in double syringes.
• Patient are rolled once or twice
• Repeat scout / topogram
• After 10 mins inject contrast using CT IVP protocol with 90s delay.
ADVANTAGES
• Less images to go through (radiologist
and
referring doctor).
• Dose reduction (half the dose).
• Reduce wear and tear.
• Less images to print / archive.
What happens during CTtheTRI-PHASE
delay? IVP
1. 30ml contrast hand injected, wait 10 min
(excretory
phase)
Injector:
2. 60ml contrast @ 1.5ml/sec followed by
3. 20ml saline @ 1.5ml/sec followed by
3. a 17s delay
4. 60ml contrast @3ml/sec injected follow by
5. 30 ml saline @3ml/sec
CT TRI-PHASE IVP IN
SUMMARY
• Excretory phase – about 10 min after the first
30 ml injection.
• Nephrographic phase – 90 sec after start of
the second injection.
• Corticomedullary/arterial phase – 20 sec
after start of third injection.
CT IVP
Pre Contrast = Renal Tract:
• To see if there is any
renal stones
• Start from the diaphragm
to symph
CT IVP
Tri-phase:
• Renal arteries
• To get an overview of the
abdomen.
• To look at the kidneys
excreting, the ureters and
the bladder.
CT CAP FOR STAGING
• Same injection technique.
• Extend scan range to symphysis
pubis..
CAP = Chest, Abdomen &
Pelvis
CT CAP for
Staging
CT CAP for
Staging
READ THE REFERRAL
LETTER TO ENSURE
YOU SELECT THE
CORRECT PROTOCOL!
Thank you!
