CT Protocols
CT Protocols
MDCT Protocols
Whole Body and Emergencies
Capitolo III
Andrea Laghi
Editor
MDCT Protocols
Whole Body and Emergencies
Co-authors
ALESSANDRO BOZZAO RICCARDO FERRARI
Neuroradiology, Department of Radiology
NESMOS Department San Giovanni Addolorata Hospital
Faculty of Medicine and Psychology Rome, Italy
Sapienza University of Rome
MARCO RENGO
Rome, Italy
Department of Radiological Sciences
F. FRAIOLI Oncology and Pathology
Chest Imaging Team Sapienza University of Rome
Department of Radiological Sciences Polo Pontino, Latina, Italy
Oncology and Pathology
LUIGIA ROMANO
Sapienza University of Rome
Department of Diagnostic Imaging
Rome, Italy
A. Cardarelli Hospital, Naples, Italy
Technical Basis
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2 The Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.1 Scanner Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.2 Systems for Reducing Dose Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.3 Multi-Energy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
3 Contrast-Medium Administration . . . . . . . . . . . . . . . . . . . . . . . 11
3.1 Arterial Enhancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.2 Parenchymal Enhancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.3 Timing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.4 Saline Flush . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4 Special Examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4.1 Thorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4.2 Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
4.3 Urinary System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.4 Small Bowel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.5 Colon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
4.6 Perfusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
5 Essential References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Clinical Cases
Neuro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Aneurysm with Subarachnoid Hemorrhage . . . . . . . . . . . . . . . . . . . . . 40
Arteriovenous Malformation in a Patient with Acute
Cerebellar Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
VIII Contents
Thorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Air Trapping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Mosaic Oligoemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Pulmonary Embolism, Standard Protocol . . . . . . . . . . . . . . . . . . . . . . . . 78
Pulmonary Embolism, CT Perfusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Pulmonary Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Arteriovenous Pulmonary Malformation . . . . . . . . . . . . . . . . . . . . . . . . 84
Pulmonary Nodules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Computer-assisted Detection (CAD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Lung Cancer, CT Perfusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Whole-Thorax Perfusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
COPD, Dual Energy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Liver. Hemangioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Liver. Adenoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Liver. Focal Nodular Hyperplasia (FNH) . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Liver. Hepatocellular Carcinoma (HCC) . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Liver. HCC, Perfusion Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Liver. Peripheral Cholangiocarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Liver. Hypovascular Metastases from Lung Cancer . . . . . . . . . . . . . . . 108
Liver. Hypervascular Metastases from Renal Cell Carcinoma . . . . . . 110
Contents IX
Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Dilated Cardiomyopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Hypertrophic Cardiomyopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Non-compaction Cardiomyopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Atrial Myxoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Transplant (Postoperative Study) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Transposition of the Great Vessels (Postoperative Study of the
Great Vessels) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Bicuspid Aortic Valve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Iatrogenic Coronary Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Coronary Artery Anomaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Three-Vessel Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Chronic Total Occlusion of the Left Anterior Descending Artery
with Associated Apical Infarction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Plaque with Positive Remodeling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Stenosis of the Left Anterior Descending Artery . . . . . . . . . . . . . . . . . 180
X Contents
Vascular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Whole-Body Angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Carotid Arteries-Carotid Stenosis with Ulcerated Plaque . . . . . . . . . 192
Evaluation of Carotid Stent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Lusory Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Post-traumatic Thoracic Aorta Aneurysm (with Cardiac Gating) . . . 198
Perforating Ulcer of the Thoracic Aorta (without Cardiac Gating) . 200
Aortic Dissection Type A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Aortic Dissection Type B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Mesenteric Vessels Anomalies and Pathologic Presentations . . . . . 206
Aneurysm of the Subrenal Abdominal Aorta . . . . . . . . . . . . . . . . . . . . 208
Aortic Endoprosthesis with Type I Endoleak . . . . . . . . . . . . . . . . . . . . . 210
Aortic Endoprosthesis with Type II Endoleak . . . . . . . . . . . . . . . . . . . . 212
Aortic Endoprosthesis with Peri-prosthetic Inflammation . . . . . . . . 214
Celiac Trunk Stent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
Aorto-Bifemoral Bypass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Bifurcation Endoprosthesis and Patent Femoro-femoral Bypass . . 220
Lower Limbs-Peripheral Arterial Disease . . . . . . . . . . . . . . . . . . . . . . . . 222
Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Post-traumatic Arterio-porto-biliary Fistula of the Liver . . . . . . . . . . 224
Obstructive Jaundice by Cystic Lymphangioma of the Anterior
Para-renal Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Bleeding Colonic Diverticulum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Hemopneumoperitoneum Due to a Weapon-related Injury
of the Pericardium and Diaphragm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
Volvulus in a Left Paraduodenal Hernia . . . . . . . . . . . . . . . . . . . . . . . . . 232
Fistula Between a Right Iliac Arterial Aneurysm in a Loop of Small
Intestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Mechanical Obstruction of the Small Intestine by Gallstone Ileus . 236
Bleeding Jejunal Gastrointestinal Stromal Tumor . . . . . . . . . . . . . . . . 238
Phytobezoar-induced Mechanical Intestinal Obstruction . . . . . . . . . 240
Iatrogenic Injury of the Right Diaphragmatic Artery
by Thermo-ablation of a Liver Nodule . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
Traumatic Injury to the Right Hemi-diaphragm . . . . . . . . . . . . . . . . . . 244
Contents XI
GIOVANNA RUSSO
Department of Diagnostic Imaging
A. Cardarelli Hospital
Naples, Italy
Capitolo 1
Technical Basis
1 Introduction 3
2 The Technology 5
3 Contrast-Medium Administration 11
4 Special Examinations 19
5 Essential References 33
Capitolo 3
1 Introduction
2 The Technology
plus the fan angle. The rapid evolution of multidetector technology has im-
proved gantry rotation speeds, reducing temporal resolution. When the MD-
CT standard reached 64 slices per gantry rotation, the gantry rotation time
was 360 ms but it is now as low as 270 ms.
Temporal resolution also can be improved by the introduction of a
second X-ray MDCT source with an independent detector system. Dual-
source MDCT features two X-ray MDCT sources and detector systems
separated from one another by 90. Consequently, when both MDCT
tubes are used, the temporal resolution is halved, from 165 ms to 83 ms,
because only a quarter gantry rotation is needed for reconstruction. This
implies, for example, the possibility to perform cardiac studies in pa-
tients with a rapid heart rate, without the need to administer beta-block-
ers but still obtaining high-quality images.
Adjustment of the tube current and/or the voltage applied to the X-ray
tube reduces the number and/or average energy of the photons gener-
ated, respectively. Furthermore, both directly affect image SNR. The
radiation dose is approximately proportional to the number of mAs and
is adjustable, thereby allowing amperage values to be customized ac-
cording to body mass. Failure to adjust this parameter downwards for
thin patients will result in unnecessary radiation. It is important to re-
duce mAs as much as possible while ensuring a high enough SNR to
obtain diagnostic-quality images.
Another approach to reduce the dose delivered to the patient is to
reduce the tube voltage. Tube kVp affects both peak photon energy
8 MDCT Protocols
and image contrast. Tube voltage has a more dramatic effect on ra-
diation dose, which is exponentially proportional to kVp. However,
the use of photons with a lower average energy leads to an increase
in the attenuation values of elements of higher atomic number and
greater absorption coefficients because of the increased interaction re-
sulting from the photoelectric effect; the greater disadvantage of this
approach is a reduction in diagnostic accuracy caused by increased
beam-hardening artifacts in the calcified plaque as well as a reduc-
tion of the SNR, even if the latter is compensated by a slight incre-
ment in tube current.
2.3 Multi-Energy
3 Contrast-Medium Administration
3.1.2 CT Angiography
3.3 Timing
reported, along with a significant increase in the aortic peak but no ev-
idence of improved hepatic enhancement. However, a saline flush does
not improve the magnitude of liver parenchyma enhancement in clini-
cal imaging, whereas in time-density analyses it significantly improves
the time to peak of liver, portal vein, and aortic enhancement. Further-
more, the CM left in the dead space contributes to vascular enhance-
ment by a slow and late flowing. The clearing of this CM volume is re-
flected in a more rapid decline of intravascular attenuation after the peak
such that scanning during this period may result in insufficient contrast
enhancement.
Capitolo 19
4 Special Examinations
4.1 Thorax
Multiplanar Reconstruction
With MPR algorithms, images can be easily obtained and oriented in
all planes of vision while modified by the operator in real time. The raw
data are used for the reconstruction such that there is no loss of image
quality. The MPR technique can be applied to increase the diagnostic
sensitivity in the evaluation of diffuse lung diseases, allowing improved
determination of their location and extent. The radiologist profits from
the ability to select the orientation plane that best reveals a key aspect
of the disease, thus raising the diagnostic power of the method.
Computer-aided Detection
Computer-aided image analysis methods can aid the radiologist in de-
tecting lung nodules. These computer algorithms have been enabled by
4.2 Heart
In order to obtain good image quality, the patients heart rate (HR) should
be < 65 bpm. This can be achieved by the use of chronotropic agents,
such as beta-blockers. These drugs are administered according to their
pharmacodynamics, either orally (e.g., metoprolol tartrate 50200 mg
4560 min prior to the examination) or intravenously (metoprolol tar-
trate in bolus 5 mg at 1 mg/min, 15 mg maximum, or esmololol 0.5 mg/kg
in 1 min, followed by continuous infusion at 0.05 mg/kg/min). The use
of these agents is limited by the following contraindications: congested
heart failure and cardiogenic shock, grade II and grade III sinoatrial and
atrioventricular block diseases, COPD, marked hypotension (systolic
blood pressure < 100 mmHg), and bradycardia (HR < 50 bpm).
If the examination is performed to evaluate the myocardium, the peri-
cardium, the anatomy of the large vessels, or myocardial function, patients
22 MDCT Protocols
with higher HRs or atrial fibrillation (with low ventricular response) can
be pre-treated with chronotropic agents and then more accurately stud-
ied.
The administration of nitroglycerin derivatives (e.g., isosorbide dini-
trate, 5 mg sublingually) immediately prior to the examination produces
a vasodilatation of the coronary arteries and improves the evaluation
of stenoses, particularly in small-diameter segments. The administra-
tion of these agents is contraindicated in patients with severe aortic
stenosis, severe hypotension, and those taking sildenafil citrate.
When the ideal HR has been reached, the patient can be positioned
on the examination bed and the ECG electrodes connected. To obtain a
correct ECG trace, three electrodes should be placed on the patients
chest: at the right shoulder, the left shoulder, and the left hypochondri-
um. To avoid irregularities in the ECG trace, direct contact of the elec-
trodes with the deltoid, pectoral, and intercostal muscles should be avoid-
ed. At this stage, the regularity of the ECG trace needs to be checked
and a test breath-hold performed, since the latter can markedly reduce
the HR or cause the appearance of premature beats.
In MDCT studies of the urinary tract, there is no need for special pa-
tient preparation other than oral hydration, which is aimed at increas-
ing diuresis. This can be achieved by the intravenous administration of
about 500 mL of saline solution or by the intravenous injection of a di-
uretic (low-dose furosemide: 0.1 mg/kg up to a maximum of 10 mg).
Different types of enteral contrast agents are used to obtain proper disten-
sion of the small-bowel loops. They are classified according to their den-
sity as positive, or high density, and neutral, or low density, contrast agents.
Neutral contrast agents, with X-ray attenuations similar to that of water,
are preferred for most clinical indications. In particular, the association
with intravenous iodinate contrast results in a better depiction of wall
enhancement due to the higher attenuation difference with the hypoden-
sity of the lumen. This is particularly important for the evaluation of in-
flammatory bowel disease (IBD) and neoplastic diseases or when an-
giography-like 3D reconstructions are required. Although water is the safest
and cheapest agent, it suffers the limitation of intestinal absorption, which
compromises an adequate distension of the distal ileum in a large num-
ber of patients. To minimize absorption, water is usually mixed with high
molecular weight compounds that do not alter water density and taste. Thus,
neutral contrast agents are mainly water-based solutions of osmotic com-
pounds such as polyethylene glycol (PEG), mannitol, sugar alcohols, or
sorbitol. Recently, a neutral oral contrast agent, a low concentration bar-
ium sulfate (0.1% ) containing sorbitol, was expressly developed for CT
enteral studies.
Positive contrast agents, which have high X-ray attenuation, are usu-
ally a mixture of barium sulfate (12% ) or iodinate contrast agents
(23% ). These enteral agents are preferred for all situations in which
a high intraluminal density is recommended, such as the evaluation of
perforations or fistulas, complications of Crohns disease, and for the
evaluation of intraluminal masses, such as polyps or tumors. Because
the high intraluminal density reduces contrast resolution with enhanc-
ing structures, positive contrast agents are contraindicated when the eval-
uation of wall enhancement patterns is required, as in IBD. On the oth-
er hand, positive CM can be used when intravenous contrast agents do
not influence the conspicuity of the pathology or in the setting of diffi-
cult intravenous access or renal failure.
4 Special Examinations 27
4.4.2 Enterography
4.4.3 Enteroclysis
MDCT enteroclysis was developed in the early 1990s and involves the
infusion, by hand or by a peristaltic pump through a naso-jejunal tube,
of variable amounts of low-density (methylcellulose or water) or high-
density (45% sodium diatrizoate, 1% barium sulfate) CM prior to the
CT scan. Manual infusion is limiting whereas better distension is achieved
using the peristaltic pump, even if this does not always allow optimal
distension of the entire bowel loops.
The naso-jejunal tube is placed under fluoroscopic guidance in order
to avoid a time-consuming procedure inside the CT scanner. It is also
advisable to use a tube with an anti-reflux balloon, which will prevent
duodeno-gastric reflux.
Volume and infusion rate are crucial for the success of the examina-
tion, as in conventional enteroclysis. Volume varies among individuals,
ranging between 1500 and 3000 mL, while the infusion rate varies in
the range of 80150 mL/min. The use of spasmolytics to reduce ab-
28 MDCT Protocols
4.5 Colon
4.6 Perfusion
5 Essential References
Neuro
Thorax
Abdomen
Heart
Vascular
Emergency
NEURO Aneurysm with Subarachnoid Hemorrhage
1 2
3 4
1 Aneurysm of the bifurcation of the internal carotid artery in a patient with in-
traparenchymal and subarachnoid hemorrhage (arrows). 2 Aneurysmatic di-
latation of the internal carotid artery bifurcation (arrows) is seen in this volume
rendering (VR) reconstruction overview. 3 The relationships and dimensions
are better identified in the maximum-intensity projection (MIP) reconstruction.
4 Digital angiography confirms the finding (arrows)
NEURO Aneurysm with Subarachnoid Hemorrhage 41
Study Protocol
References
Agid R, Willinsky RA, Farb RI, Terbrugge KG (2008) Life at the end of the tunnel:
why emergent CT angiography should be done for patients with acute sub-
arachnoid hemorrhage. AJNR Am J Neuroradiol 29:e45
Chen W, Wang J, Xing W et al (2009) Accuracy of 16-row multislice computerized
tomography angiography for assessment of intracranial aneurysms. Surg Neuro
l71:32-42
Fox AJ, Symons SP, Aviv RI (2008) CT angiography is state-of-the-art first vascu-
lar imaging for subarachnoid hemorrhage. AJNR Am J Neuroradiol 29:e41-42
Lubicz B, Levivier M, Franois O et al (2007) Sixty-four-row multisection CT angio-
graphy for detection and evaluation of ruptured intracranial aneurysms: inter-
observer and intertechnique reproducibility. AJNR Am J Neuroradiol 28:1949-
1955
Tomandl BF, Kstner NC, Schempershofe M et al (2004) CT angiography of in-
tracranial aneurysms: a focus on postprocessing. RadioGraphics 24:637-655
NEURO Arteriovenous Malformation in a Patient
with Acute Cerebellar Hemorrhage
1 2
3 4
Study Protocol
References
Gupta V, Chugh M, Walia BS et al (2008) Use of CT angiography for anatomic lo-
calization of arteriovenous malformation Nidal components. AJNR Am J Neuro-
radiol 29:1837-1840
Leclerc X, Gauvrit JY, Trystram D et al (2004) Cerebral arteriovenous malforma-
tions: value of the non invasive vascular imaging techniques. J Neuroradiol 31:349-
358
Matsumoto M, Kodama N, Sakuma J et al (2005) 3D-CT arteriography and 3D-CT
venography: the separate demonstration of arterial-phase and venous-phase on
3D-CT angiography in a single procedure. AJNR Am J Neuroradiol 26:635-641
NEURO Acute Pre-occlusive Stenosis of the Right
Middle Cerebral Artery
1 2
3 4
Study Protocol
References
Camargo EC, Furie KL, Singhal AB et al (2007) Acute brain infarct: detection and
delineation with CT angiographic source images versus nonenhanced CT scans.
Radiology 244:541-548
Nguyen-Huynh MN, Wintermark M, English J et al (2008) How accurate is CT an-
giography in evaluating intracranial atherosclerotic disease? Stroke 39:1184-1188
Schaefer PW, Yoo AJ, Bell D et al (2008) CT angiography-source image hypo-
attenuation predicts clinical outcome in posterior circulation strokes treated with
intra-arterial therapy. Stroke 39:3107-3109
Sylaja PN, Puetz V, Dzialowski I et al (2008) Prognostic value of CT angiography
in patients with suspected vertebrobasilar ischemia. J Neuroimaging 18:46-49
NEURO Acute Thrombosis of the Left Transverse
Sinus
1 2
3 4
Study Protocol
References
Gaikwad AB, Mudalgi BA, Patankar KB et al (2008) Diagnostic role of 64-slice
multidetector row CT scan and CT venogram in cases of cerebral venous throm-
bosis. Emerg Radiol 15:325-333
Linn J, Ertl-Wagner B, Seelos KC et al (2007) Diagnostic value of multidetector-
row CT angiography in the evaluation of thrombosis of the cerebral venous si-
nuses. AJNR Am J Neuroradiol 28:946-952
Wasay M, Azeemuddin M (2005) Neuroimaging of cerebral venous thrombosis.
J Neuroimaging 15:118-128
NEURO Acute Thrombosis of the Right Rolandic Vein
1 2
3 4
Study Protocol
References
Gaikwad AB, Mudalgi BA, Patankar KB et al (2008) Diagnostic role of 64-slice
multidetector row CT scan and CT venogram in cases of cerebral venous throm-
bosis. Emerg Radiol 15:325-333
Linn J, Ertl-Wagner B, Seelos KC et al (2007) Diagnostic value of multidetector-
row CT angiography in the evaluation of thrombosis of the cerebral venous si-
nuses. AJNR Am J Neuroradiol 28:946-952
Wasay M, Azeemuddin M (2005) Neuroimaging of cerebral venous thrombosis.
J Neuroimaging 15:118-128
NEURO Posterior Communicating Artery
Occasional Aneurysm
1 2
3 4
1 Basal CT scan documents the presence of a mildly hyperdense lesion in the left
para-chiasmatic area. Angio-CT study, with partition images (2) and 3D overall
(3) and detailed (4) reconstructions, respectively, clearly identifies the aneurys-
mal dilatation, where it is possible to define the size of the sac and the neck and
the relationship with the artery of origin. This information may be sufficient for
subsequent therapeutic deductions and, as needed, for eventual follow-up
NEURO Posterior Communicating Artery Occasional Aneurysm 51
Study Protocol
References
Agid R, Willinsky RA, Farb RI, Terbrugge KG (2008) Life at the end of the tunnel:
why emergent CT angiography should be done for patients with acute sub-
arachnoid hemorrhage. AJNR Am J Neuroradiol 29:e45
Chen W, Wang J, Xing W et al (2009) Accuracy of 16-row multislice computerized
tomography angiography for assessment of intracranial aneurysms. Surg Neuro
l71:32-42
Fox AJ, Symons SP, Aviv RI (2008) CT angiography is state-of-the-art first vascu-
lar imaging for subarachnoid hemorrhage. AJNR Am J Neuroradiol 29:e41-42
Lubicz B, Levivier M, Franois O et al (2007) Sixty-four-row multisection CT angio-
graphy for detection and evaluation of ruptured intracranial aneurysms: interob-
server and intertechnique reproducibility. AJNR Am J Neuroradiol 28:1949-1955
Tomandl BF, Kstner NC, Schempershofe M et al (2004) CT angiography of in-
tracranial aneurysms: a focus on postprocessing. RadioGraphics 24:637-655
NEURO Occasional Aneurysm
1 2
3 4
Study Protocol
References
Agid R, Willinsky RA, Farb RI, Terbrugge KG (2008) Life at the end of the tunnel:
why emergent CT angiography should be done for patients with acute sub-
arachnoid hemorrhage. AJNR Am J Neuroradiol 29:e45
Chen W, Wang J, Xing W et al (2009) Accuracy of 16-row multislice computerized
tomography angiography for assessment of intracranial aneurysms. Surg Neuro
l71:32-42
Fox AJ, Symons SP, Aviv RI (2008) CT angiography is state-of-the-art first vascu-
lar imaging for subarachnoid hemorrhage. AJNR Am J Neuroradiol 29:e41-42
Lubicz B, Levivier M, Franois O et al (2007) Sixty-four-row multisection CT angio-
graphy for detection and evaluation of ruptured intracranial aneurysms: interob-
server and intertechnique reproducibility. AJNR Am J Neuroradiol 28:1949-1955
Tomandl BF, Kstner NC, Schempershofe M et al (2004) CT angiography of in-
tracranial aneurysms: a focus on postprocessing. RadioGraphics 24:637-655
NEURO Acute Occlusion of the Middle Cerebral
Artery Frontal Branches
1 2
3 4
Study Protocol
References
Camargo EC, Furie KL, Singhal AB et al (2007) Acute brain infarct: detection and
delineation with CT angiographic source images versus nonenhanced CT scans.
Radiology 244:541-548
Nguyen-Huynh MN, Wintermark M, English J et al (2008) How accurate is CT angio-
graphy in evaluating intracranial atherosclerotic disease? Stroke 39:1184-1188
Schaefer PW, Yoo AJ, Bell D et al (2008) CT angiography-source image hypo-
attenuation predicts clinical outcome in posterior circulation strokes treated with
intra-arterial therapy. Stroke 39:3107-3109
Sylaja PN, Puetz V, Dzialowski I et al (2008) Prognostic value of CT angiography
in patients with suspected vertebrobasilar ischemia. J Neuroimaging 18:46-49
NEURO Acute Occlusion of the Middle Cerebral Artery
1 2
3 4
5 6
1 Basal CT scan, performed in a hyper-acute situation 4 h after the onset of left hemi-
paresis, documents a hyperdensity at the right middle cerebral artery (arrows).
2 CT perfusion study generates a map of cerebral blood volume (CBV). 3 The
identified hypoperfused area appears even larger in the MTT (mean transit time) map.
4 Microcatheters of the occluded artery with intra-arterial fibrinolysis. 5 Arter-
ial patency as seen on angio-MRI performed 20 h later. 6 The size of the lesion
in the MRI diffusion-weighted images is similar to that documented in the CBV maps
NEURO Acute Occlusion of the Middle Cerebral Artery 57
Study Protocol
References
de Lucas EM, Snchez E, Gutirrez A et al (2008) CT protocol for acute stroke: tips
and tricks for general radiologists. RadioGraphics 28:1673-1687
Schaefer PW, Barak ER, Kamalian S et al (2008) Quantitative assessment of
core/penumbra mismatch in acute stroke: CT and MR perfusion imaging are
strongly correlated when sufficient brain volume is imaged. Stroke 39:2986-2992
Wintermark M (2005) Brain perfusion-CT in acute stroke patients. Eur Radiol 15
(Suppl 4): D28-D31
NEURO Arteriovenous Malformation (AVM)
1 2
3 4
Study Protocol
References
Gupta V, Chugh M, Walia BS et al (2008) Use of CT angiography for anatomic lo-
calization of arteriovenous malformation Nidal components. AJNR Am J Neuro-
radiol 29:1837-1840
Leclerc X, Gauvrit JY, Trystram D et al (2004) Cerebral arteriovenous malforma-
tions: value of the non invasive vascular imaging techniques. J Neuroradiol 31:349-
358
Matsumoto M, Kodama N, Sakuma J et al (2005) 3D-CT arteriography and 3D-CT
venography: the separate demonstration of arterial-phase and venous-phase on
3D-CT angiography in a single procedure. AJNR Am J Neuroradiol 26:635-641
NEURO Moya-Moya Disease
1 2
3 4
5
1 MRI diffusion-weighted images
document an acute ischemic area in
the right frontal region. 2 On MRI
TOF angiography there is a lack of vi-
sualization of the homolateral middle
cerebral artery. 3 Angio-CT docu-
ments the effective arterial occlusion
(arrows), but there are rich cortical
anastomotic circles. 4 Digital an-
giography shows the arterial occlusion
(arrowhead). 5 Compensation cir-
cles are visualized by the injection of
the posterior circle (arrows) with the
typical appearance of the disease
(cloud of smoke, arrows in 4)
NEURO Moya-Moya Disease 61
Study Protocol
References
Gazzola S, Aviv RI, Gladstone DJ et al (2008) Vascular and nonvascular mimics
of the CT angiography spot sign in patients with secondary intracerebral
hemorrhage. Stroke 39:1177-1183
NEURO Multiple Aneurysms in Subarachnoid
Hemorrhage
1 2
3 4
Study Protocol
References
Agid R, Willinsky RA, Farb RI, Terbrugge KG (2008) Life at the end of the tunnel:
why emergent CT angiography should be done for patients with acute sub-
arachnoid hemorrhage. AJNR Am J Neuroradiol 29:e45
Chen W, Wang J, Xing W et al (2009) Accuracy of 16-row multislice computerized
tomography angiography for assessment of intracranial aneurysms. Surg Neuro
l71:32-42
Fox AJ, Symons SP, Aviv RI (2008) CT angiography is state-of-the-art first vascu-
lar imaging for subarachnoid hemorrhage. AJNR Am J Neuroradiol 29:e41-42
Lubicz B, Levivier M, Franois O et al (2007) Sixty-four-row multisection CT an-
giography for detection and evaluation of ruptured intracranial aneurysms: in-
terobserver and intertechnique reproducibility. AJNR Am J Neuroradiol 28:1949-
1955
Tomandl BF, Kstner NC, Schempershofe M et al (2004) CT angiography of in-
tracranial aneurysms: a focus on postprocessing. RadioGraphics 24:637-655
NEURO Dural Arteriovenous Fistula
1 2
3 4
5
Patient with acute cerebral hemorrhage.
1 Basal CT study documents the pres-
ence of left frontal subcortical cerebral
hemorrhage. 2 Angio-CT study per-
formed in the same session reveals a
complex vascular malformation likely
attributable to an arteriovenous fistula
(arrows). 3, 4 The point of the fis-
tula is best documented in the MIP im-
ages, which show its localization at the
level of the base of the frontal skull,
originating from the ophthalmic artery
branches (arrows). 5 Digital angio-
graphy confirms the malformation and
the point of the fistula (arrows)
NEURO Dural Arteriovenous Fistula 65
Study Protocol
References
Gupta V, Chugh M, Walia BS et al (2008) Use of CT angiography for anatomic lo-
calization of arteriovenous malformation Nidal components. AJNR Am J Neuro-
radiol 29:1837-1840
Leclerc X, Gauvrit JY, Trystram D et al (2004) Cerebral arteriovenous malforma-
tions: value of the non invasive vascular imaging techniques. J Neuroradiol 31:349-
358
Matsumoto M, Kodama N, Sakuma J et al (2005) 3D-CT arteriography and 3D-CT
venography: the separate demonstration of arterial-phase and venous-phase on
3D-CT angiography in a single procedure. AJNR Am J Neuroradiol 26:635-641
NEURO Pre-occlusive Stenosis of the Basilar Artery
1 2
3 4
5 6
Study Protocol
References
Bash S, Villablanca JP, Jahan R et al (2005) Intracranial vascular stenosis and occlusive
disease: evaluation with CT angiography, MR angiography, and digital subtrac-
tion angiography. AJNR Am J Neuroradiol 26:1012-1021
Hirai T, Korogi Y, Ono K et al (2002) Prospective evaluation of suspected stenooc-
clusive disease of the intracranial artery: combined MR angiography and CT angio-
graphy compared with digital subtraction angiography. AJNR Am J Neuroradiol
23:93-101
Nguyen-Huynh MN, Wintermark M, English J et al (2008) How accurate is CT angio-
graphy in evaluating intracranial atherosclerotic disease? Stroke 39:1184-1188
NEURO Pre-occlusive Stenosis of the Vertebral
Arteries
1 2
3 4
Patient with small lacunar ischemic stroke in the right thalamus. 1, 2 The
stenosis is visualized on volumetric and in MIP reconstructions, respectively, and
confirmed (3) by angio-MRI. 4 The lacunar stroke is evident in the contrast-
enhanced CT scan
NEURO Pre-occlusive Stenosis of the Vertebral Arteries 69
Study Protocol
References
Bash S, Villablanca JP, Jahan R et al (2005) Intracranial vascular stenosis and oc-
clusive disease: evaluation with CT angiography, MR angiography, and digital
subtraction angiography. AJNR Am J Neuroradiol 26:1012-1021
Hirai T, Korogi Y, Ono K et al (2002) Prospective evaluation of suspected stenooc-
clusive disease of the intracranial artery: combined MR angiography and CT angio-
graphy compared with digital subtraction angiography. AJNR Am J Neuroradiol
23:93-101
Nguyen-Huynh MN, Wintermark M, English J et al (2008) How accurate is CT angio-
graphy in evaluating intracranial atherosclerotic disease? Stroke 39:1184-1188
NEURO Acute Thrombosis of the Superior Sagittal
Sinus
1 2
3 4
Study Protocol
References
Gaikwad AB, Mudalgi BA, Patankar KB et al (2008) Diagnostic role of 64-slice
multidetector row CT scan and CT venogram in cases of cerebral venous throm-
bosis. Emerg Radiol 15:325-333
Linn J, Ertl-Wagner B, Seelos KC et al (2007) Diagnostic value of multidetector-
row CT angiography in the evaluation of thrombosis of the cerebral venous
sinuses. AJNR Am J Neuroradiol 28:946-952
Wasay M, Azeemuddin M (2005) Neuroimaging of cerebral venous thrombosis.
J Neuroimaging 15:118-128
NEURO Arteriovenous Malformation (AVM)
in a Patient with Acute Intraventricular
Hemorrhage
1 2
3 4
Study Protocol
References
Gupta V, Chugh M, Walia BS et al (2008) Use of CT angiography for anatomic lo-
calization of arteriovenous malformation Nidal components. AJNR Am J Neuro-
radiol 29:1837-1840
Leclerc X, Gauvrit JY, Trystram D et al (2004) Cerebral arteriovenous malforma-
tions: value of the non invasive vascular imaging techniques. J Neuroradiol 31:349-
358
Matsumoto M, Kodama N, Sakuma J et al (2005) 3D-CT arteriography and 3D-CT
venography: the separate demonstration of arterial-phase and venous-phase on
3D-CT angiography in a single procedure. AJNR Am J Neuroradiol 26:635-641
THORAX Air Trapping
1 2
3 4
1, 2 Comparison between inspiratory and expiratory scans: the trachea in the ex-
piratory scan is collapsed (arrow) and the density decreased. Comparison be-
tween inspiratory (3) and expiratory (4) CT scans shows multiple areas with a
less than normal increase in attenuation (arrowheads). These areas correspond
to secondary lobules
THORAX Air Trapping 75
Study Protocol
Patient preparation: It is important to ensure that the patient can maintain a breath-
hold long enough to allow the images to be obtained. The patient must be able to
stop breathing and hold his or her breath at full inspiration and full expiration when
instructed to do so. Expiratory scans should be obtained with a medium breath, fol-
lowed by complete exhalation and a breath-hold at full expiration. The patient should
be instructed to take 2 normal breaths, followed by a medium breath, then exhale
completely, with a breath-hold at full expiration.
Pre-contrast scan: This can be the only phase acquired; a comparison between in-
spiratory and expiratory CT scans is helpful when air trapping is subtle or diffuse.
Inspiratory scan: Helical mode, 0.5-s gantry rotation time, pitch 1.4, 120 kVp, 64
0.6-mm (Sensation 64) or 16 0.75-mm (Sensation 16) detector configuration CARE-
Dose on*.
Expiratory scan: Non-contiguous axial (non-helical) mode, 0.5-s gantry rotation time,
120 kVp, 2 1-mm detector configuration with a 20-mm slice interval, CAREDose on*.
Post-contrast scan: Usually not necessary.
Comments: Air trapping is the retention of air in the lung at a site distal to an ob-
struction (usually partial). It is seen on end-expiration CT scans as parenchymal ar-
eas with a less than normal increase in attenuation and a lack of volume reduction.
Differentiation from areas of decreased attenuation resulting from hypoperfusion as
a consequence of an occlusive vascular disorder (e.g., chronic thromboembolism) may
be problematic on the inspiratory scan; however in hypoperfusion, the vascular net-
work is often decreased in inspiratory as well as in expiratory phase.
References
Teel GS, Engeler CE, Tashijian J H, duCret RP (1996) Imaging of small airways
disease. Radiographics 16(1):1627-1641
Bankier AA, Mehrain S, Kienzl D et al (2008) Regional heterogeneity of air trap-
ping at expiratory thin-section CT of patients with bronchiolitis: potential im-
plications for dose reduction and CT protocol planning. Radiology 247(3):862-
870
Bankier AA, Schaefer-Prokop C, De Maertelaer V et al (2007) Air trapping: com-
parison of standard-dose and simulated low-dose thin-section CT techniques.
Radiology 242(3):898-906
Mller NL, Thurlbeck WM (1996) Thin-section CT, emphysema, air trapping, and
airway obstruction. Radiology 199(3):621-622
THORAX Mosaic Oligoemia
1 2
Study Protocol
Patient preparation: It is important to be sure that the patient can maintain a breath-
hold long enough to allow the images to be obtained. The patient must be able to
stop breathing and hold his or her breath at full inspiration and full expiration when
instructed to do so. Expiratory scans should be obtained with a medium breath, fol-
lowed by complete exhalation and a breath-hold at full expiration. The patient should
be instructed to take 2 normal breaths, followed by a medium breath, then to exhale
completely, with a breath-hold at full expiration.
Pre-contrast scan: This can be the only phase acquired; a comparison between in-
spiratory and expiratory CT scans can be helpful when air trapping is subtle or dif-
fuse.
Inspiratory scan: Helical mode, 0.5-s gantry rotation time, pitch 1.4, 120 kVp, 64
0.6-mm (Sensation 64) or 16 0.75-mm (Sensation 16) detector configuration CARE-
Dose on*.
Expiratory scan: Non-contiguous axial (non-helical) mode, 0.5-s gantry rotation time,
120 kVp, 2 1-mm detector configuration with a 20-mm slice interval, CAREDose on*.
Post-contrast scan: Usually not necessary.
Comments: Differentiation from air trapping is achieved by comparing inspiratory
and expiratory scans. In oligoemia, multiple patchy areas of hypolucency are seen in
both phases, whereas in air trapping a loss in density is seen only during expiration.
Moreover, the density loss in oligoemia can easily be seen as mainly due to a decrease
of vessel density.
Different disorders, such as primitive pulmonary hypertension, left to right cardiac
shunt, thrombo-embolic disease, peripheral vascular malformation (AVM, anomalous
pulmonary venous return, Botallos duct) may be responsible for the mosaic pattern.
However, other causes mimicking the disease include: patchy interstitial disease and
obliterative small-airways disease. An accurate evaluation of inspiratory and expira-
tory phases as well as vascular and bronchial density within the patchy areas may
be helpful in the final diagnosis.
References
Hansell DM, Bankier AA, MacMahon H et al (2008) Fleischner Society glossary of
terms for thoracic imaging. Radiology 246(3):697-722. Epub 2008 Jan 14
Stern EJ, Mller NL, Swensen SJ, Hartman TE (1995) CT mosaic pattern of lung
attenuation: etiologies and terminology. J Thorac Imaging 10(4):294-297
Martin KW, Sagel SS, Siegel BA (1986) Mosaic oligemia simulating pulmonary in-
filtrates on CT. AJR Am J Roentgenol 147(4):670-673
Eber CD, Stark P, Bertozzi P (1993) Bronchiolitis obliterans on high-resolution CT:
a pattern of mosaic oligemia. J Comput Assist Tomogr 17(6):853-856
THORAX Pulmonary Embolism, Standard Protocol
1 2
3 4
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G cannula placed on the
right side.
CM volume: According to scan time.
Patient weight (kg) < 60 < 80 > 80
CM concentration (mgl/mL)
300 100 130 150
320 95 125 140
350 85 115 130
370 80 110 120
400 75 100 110
CM injection flow rate (mL/s) 1.6 gI/s 1.8 gI/s 2.0 gI/s
CM concentration (mgI/mL)
300 5.3 6.0 6.7
320 5.0 5.6 6.2
350 4.6 5.1 5.7
370 4.3 4.8 5.4
400 4.0 4.5 5.0
Pre-contrast scan: Not indispensable.
Post-contrast scan:
Arterial phase: 7 s (4-s scan + 3-s delay).
Bolus-tracking technique: 3 s after the threshold of 100 HU is reached, with the ROI
in the lumen of the pulmonary artery.
Venous phase: 180 s from the start of CM injection to evaluate deep-vein thrombosis.
Scan delay:
The bolus-tracking monitoring technique is used.
Arterial phase: 3 s after the threshold of 100 HU is reached.
Venous phase:180 s from the start of CM injection.
References
Pruszczyk P, Torbicki A, Pacho R et al (1997) Noninvasive diagnosis of suspected
severe pulmonary embolism: transesophageal echocardiography vs spiral CT.
Chest 112:722-728
Remy-Jardin M, Remy J, Deschildre F (1996) Diagnosis of pulmonary embolism
with spiral CT: comparison with pulmonary angiography and scintigraphy. Radiol-
ogy 200:699-706
Winer-Muram HT, Rydberg J, Johnson MS (2004) Suspected acute pulmonary em-
bolism: evaluation with multi-detector row CT versus digital subtraction pul-
monary arteriography. Radiology 233:806-815
THORAX Pulmonary Embolism, CT Perfusion
1 2
3 4
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G cannula placed on the
right side.
CM volume: Adapted to the patients body weight, at 1.35 mL/kg.
Patient weight (kg) < 60 < 80 > 80
CM concentration (mgl/mL)
300 100 130 150
320 95 125 140
350 85 115 130
370 80 110 120
400 75 100 110
CM injection flow rate (mL/s) 1.6 gI/s 1.8 gI/s 2.0 gI/s
CM concentration (mgI/mL)
300 5.3 6.0 6.7
320 5.0 5.7 6.2
350 4.6 5.0 5.7
370 4.3 4.8 5.4
400 4.0 4.5 5.0
Pre-contrast scan: Images are acquired in a single breath-hold in the caudo-cranial
direction from the costophrenic angle to the lung apex. This may be important to re-
duce diaphragmatic movement at the end of the scan (uncooperative patients) and
to reduce cone-beam artifacts within the superior vena cava.
Post-contrast scan: Two simultaneous helical scans are acquired with two tube volt-
ages, 140 and 80 kV.
Scan delay:
The delay is usually longer than in the standard pulmonary embolism protocol in or-
der to reduce possible artifacts from the flowing of CM. High IDR is recommended,
as well as saline bolus chaser. A bolus tracking technique should be used starting the
acquisition 11 seconds after the threshold of 100 HU in the main pulmonary artery.
References
Nazarolu H, Ozmen CA, Akay HO et al (2009) 64-MDCT Pulmonary angiogra-
phy and CT venography in the diagnosis of thromboembolic disease. AJR Am
J Roentgenol 192(3):654-661
Stein PD, Yaekoub AY, Matta F et al (2010) Resolution of pulmonary embolism on
CT pulmonary angiography. AJR Am J Roentgenol 194(5):1263-1268
Wildberger JE, Schoepf UJ, Mahnken AH et al (2005) Approaches to CT perfusion
imaging in pulmonary embolism. Semin Roentgenol 40(1):64-73
Herzog P, Wildberger JE, Niethammer M et al (2003) CT perfusion imaging of the
lung in pulmonary embolism. Acad Radiol 10(10):1132-1146
THORAX Pulmonary Hypertension
1 2
3 4
5 6
Study Protocol
References
Adelman M, Haponik EF, Bleecker ER et al (1985) Cryptogenetic hemoptysis: clin-
ical features, bronchoscopic findings and natural history in 67 patients. Ann Int
Med 102:829-834
Khail A, Fartoukh M, Tassart M et al (2007) Role of MDCT in identification of
the bleeding site and the vessels causing hemoptysis. AJR Am J Roentgenol
188:117-125
Peacock AJ (1999) Primary pulmonary hypertension. Thorax 54:1107-1118
THORAX Arteriovenous
Air Trapping Pulmonary Malformation
1 2
3 4
Study Protocol
References
Bruzzi JF, Martine RJ, Delhaye D et al (2006) Multi-detector row CT of hemopty-
sis. RadioGraphics 26:3-22
Coulier B (2003) Detection of pulmonary arteriovenous malformations by multislice
spiral CT angiography. JBR-BTR 86:28
Nawaz A, Litt HI, Stavropoulos SW et al (2008) Digital subtraction pulmonary
arteriography versus multidetector CT in the detection of pulmonary arterio-
venous malformations. J Vasc Interv Radiol 19:S1582-S1588
THORAX Pulmonary Nodules
1a 1b 1c
2a 2b
2c
References
MacMahon H, Austin JH, Gamsu G et al (2005) Guidelines for management of small
pulmonary nodules detected on CT scans: a statement from the Fleischner Society.
Radiology 237(2):395-400
Brandman S, Ko J (2011) Pulmonary nodule detection, characterization, and man-
agement with multidetector computed tomography. J Thorac Imaging 26(2):90-
105
Truong MT, Sabloff BS, Ko JP (2010) Multidetector CT of solitary pulmonary nod-
ules. Radiol Clin North Am 48(1):141-155
Wormanns D, Diederich S (2004) Characterization of small pulmonary nodules by
CT. Eur Radiol 14(8):1380-1391
THORAX Computer-assisted Detection (CAD)
1, 2 Although very similar in source images and despite the difficulty in deter-
mining and comparing their axial maximum diameters, these two lesions are eas-
ily identified using computer-aided detection (CAD). In fact, with computerized
schemes the dimensions, volumes, and modifications between baseline and fol-
low-up studies can be better evaluated
THORAX Computer-assisted Detection (CAD) 89
Study Protocol
General information: The lung CAD CT device is a CAD tool designed to assist ra-
diologists in the detection of solid pulmonary nodules. Early detection of lung nod-
ules is extremely important for the diagnosis and clinical management of lung can-
cer. CAD CT allows the computer-guided localization of lesions, close-up inspection
of suspected lesions by applying MPR, automatic segmentation and volumetric mea-
surements of lung lesions, visualization of the segmented lesions with perspective
volume-rendering (VR) displays or MPR techniques, and the dedicated and flexible
reporting of all findings.
References
Hansell DM, Bankier AA, MacMahon H et al (2008) Fleischner Society: glossary
of terms for thoracic imaging. Radiology 246(3):697-722. Epub 2008 Jan 14
Laurent F (2010) Role of CAD for the detection of lung nodules on CT. J Radiol
91(3 Pt 1):259-260
Fraioli F, Serra G, Passariello R (2010) CAD (computed-aided detection) and CADx
(computer aided diagnosis) systems in identifying and characterising lung nod-
ules on chest CT: overview of research, developments and new prospects. Radiol
Med 115(3):385-402
Sahiner B, Chan HP, Hadjiiski LM et al (2009) Effect of CAD on radiologists de-
tection of lung nodules on thoracic CT scans: analysis of an observer perfor-
mance study by nodule size. Acad Radiol 16(12):1518-1530
THORAX Lung Cancer, CT Perfusion
1 2
3 4
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G cannula on the right side.
CM volume: 500600 mgI (iodine dose) per kg body weight.
Patient weight (kg) < 60 < 80 > 80
CM concentration (mgl/mL)
300 100 130 150
320 95 125 140
350 85 115 130
370 80 110 120
400 75 100 110
CM injection flow rate (mL/s) 1.6 gI/s 1.8 gI/s 2.0 gI/s
CM concentration (mgI/mL)
300 5.3 6.0 6.7
320 5.0 5.6 6.2
350 4.6 5.1 5.7
370 4.3 4.8 5.4
400 4.0 4.5 5.0
Pre-contrast scan: Images are acquired in a single breath-hold in the caudo-cranial
direction from the costophrenic angles to the lung apex. This is important to reduce
both diaphragmatic movement at the end of the scan (uncooperative patients) and
cone-beam artifacts within the superior vena cava.
Post-contrast scan: Two simultaneous helical scans are acquired with two tube volt-
ages, 140 and 80 kV.
Scan delay: The scan is initiated with a bolus-tracking technique, in which the arrival
of the contrast bolus in the pulmonary trunk is detected at a threshold of 100 HU. Based
on common experience, with dual-energy iodine maps, a 7-s scan delay after the thresh-
old should be used.
Comments: Lung dual-energy may be useful in the pre-operative evaluation of lung
cancer patients. Indeed, perfusional scintigraphy is often necessary before lung surgery
to evaluate the outcome of residual status in patients who have undergone pneu-
monectomy or enlarged lobectomy. Dual-energy CT may be able to obtain similar
information, correlating with the results of NMR.
References
Nazarolu H, Ozmen CA, Akay HO et al (2009) 64-MDCT Pulmonary angiogra-
phy and CT venography in the diagnosis of thromboembolic disease. AJR Am
J Roentgenol 192(3):654-661
Stein PD, Yaekoub AY, Matta F et al (2010) Resolution of pulmonary embolism on
CT pulmonary angiography. AJR Am J Roentgenol 194(5):1263-1268
Xiong Z, Liu JK, Hu CP et al (2010) Role of immature microvessels in assessing
the relationship between CT perfusion characteristics and differentiation grade
in lung cancer. Arch Med Res 41(8):611-617
THORAX Whole-Thorax Perfusion
1 2
3 4
5 6
7 8
Study Protocol
References
Fraioli F, Anzidei M, Zaccagna F et al (2011) Whole-tumor perfusion CT in patients
with advanced lung adenocarcinoma treated with conventional and antiangio-
genetic chemotherapy: initial experience. Radiology 259(2):574-582. Epub 2011
Feb 25
Li Y, Yang ZG, Chen TW et al (2008) Whole tumour perfusion of peripheral lung
carcinoma: evaluation with first-pass CT perfusion imaging at 64-detector row
CT. Clin Radiol 63(6):629-635
THORAX COPD, Dual-Energy
1 2
3 4
1 Analysis of air volume and emphysema using dual-source CT. The morpho-
logical image in B60 is compared with the results obtained from the automatic
assessment of air volumes and emphysematous areas within the lungs on the
same axial projection (3) and in volume-rendering (4). 2 Perfusional analy-
sis of the same case
THORAX COPD, Dual-Energy 95
Study Protocol
Patient preparation: The patient must be able to maintain a breath-hold long enough
for the images to be obtained. The patient must be able to stop breathing and to
perform a breath-hold at full inspiration and full expiration when instructed to do
so. Expiratory scans should be obtained with a medium breath, followed by complete
exhalation and a breath-hold at full expiration. The patient should be instructed to
take 2 normal breaths, followed by a medium breath, then to exhale completely with
a breath-hold at full expiration.
CM volume: 500-600 mgI (iodine dose) per kg body weight.
Patient weight (kg) < 60 < 80 > 80
CM concentration (mgl/mL)
300 100 130 150
320 95 125 140
350 85 115 130
370 80 110 120
400 75 100 110
CM injection flow rate (mL/s) 1.6 gI/s 1.8 gI/s 2.0 gI/s
CM concentration (mgI/mL)
300 5.3 6.0 6.7
320 5.0 5.6 6.2
350 4.6 5.1 5.7
370 4.3 4.8 5.4
400 4.0 4.5 5.0
Pre-contrast scan: This can be the only phase acquired. Comparisons between inspi-
ratory and expiratory CT scans can be helpful when air trapping is subtle or diffuse.
Inspiratory scan: Helical mode, 0.5-s gantry rotation time, pitch 1.4, 120 kVp, 64 0.6-mm
(Sensation 64) or 16 0.75-mm (Sensation 16) detector configuration CAREDose on*.
Expiratory scan: Non-contiguous axial (non-helical) mode, 0.5-s gantry rotation time,
120 kVp, 2 1-mm detector configuration with a 20-mm slice interval, CAREDose on*.
Post-contrast scan: When lung perfusion is required.
Scan delay: Double quantification (pulmonary destruction and CT-p quantification
of COPD have been improved over the years, yielding a good method of quantifica-
tion and allowing appropriate follow-up. Densitometry has been recognized as the
most important scheme to quantify pulmonary emphysema.
Recently, different commercial software packages have been used in the determination
of lung emphysematous areas, allowing the preoperative evaluation of candidates
for lung surgery aimed at volume reduction, or simply for a more accurate follow-up
to evaluate the response to bronchodilator therapy.
References
Hansell DM, Bankier AA, MacMahon H et al (2008) Fleischner Society: glossary
of terms for thoracic imaging. Radiology 246(3):697-722. Epub 2008 Jan 14
Bafadhel M, Umar I, Gupta S et al (2011) The Role of CT scanning in multidi-
mensional phenotyping of COPD. Chest 140(3):634-642
Dirksen A (2008) Is CT a new research tool for COPD? Clin Respir J 2(Suppl 1):76-83
ABDOMEN Liver. Hemangioma
1 2
3 4
Study Protocol
References
Kebapci M, Kaya T, Gurbuz E et al (2003) Differentiation of adrenal adenomas (lipid
rich and lipid poor) from nonadenomas by use of washout characteristics on de-
layed enhanced CT. Abdom Imaging 28:709-715
Mayo-Smith WW, Boland GW, Noto RB et al (2001) Sate of the art of adrenal imag-
ing. RadioloGraphics 4:995-1012
Park BK, Kim B, Ko K et al (2006) Adrenal masses falsely diagnosed as adenomas
on unenhanced and delayedcontrast-enhanced computed tomography: patholog-
ical correlation. Eur Radiol 16:642-647
ABDOMEN Liver. Adenoma
1 2
3 4
1 Hepatic arterial phase shows a large, solid, focal hepatic lesion containing a hy-
pervascular component with marked inhomogeneity due to the presence of inter-
nal necrotic areas. 2 Portal phase: solid enhancing components (arrowhead) can
be better differentiated from the hypodense necrotic areas (asterisk). 3 Late
phase: evident wash-out of the contrast medium. 4 Coronal reformation better
demonstrates the size of the lesion and the partly exophytic growth pattern (arrow).
The remaining liver parenchyma shows no sign of chronic liver disease
ABDOMEN Liver. Adenoma 99
Study Protocol
References
Brancatelli G, Federle MP, Vullierme MP et al (2006) CT and MR imaging evalua-
tion of hepatic adenoma. J Comput Assist Tomogr 30(5):745-750
Lim AK, Patel N, Gedroyc WM et al (2002) Hepatocellular adenoma: diagnostic dif-
ficulties and novel imaging techniques. Br J Radiol 75(896):695-699
Ichikawa T, Federle MP, Grazioli L, Nalesnik M (2000) Hepatocellular adenoma:
multiphasic CT and histopathologic findings in 25 patients. Radiology 214(3):861-
868
ABDOMEN Liver. Focal Nodular Hyperplasia (FNH)
1 2
3 4
Study Protocol
References
Brancatelli G, Federle MP, Katyal S, Kapoor V (2002) Hemodynamic characteriza-
tion of focal nodular hyperplasia using three-dimensional volume-rendered multi-
detector CT angiography. AJR Am J Roentgenol 179:81-85
Lin MC, Tsay PK, Ko SF et al (2008) Triphasic dynamic CT findings of 63 hepatic
focal nodular hyperplasia in 46 patients: correlation with size and pathological
findings. Abdom Imaging 33:301-307
Xu AM, Cheng HY, Chen D et al (2002) Plane and weighted tri-phase helical CT
findings in the diagnosis of liver focal nodular hyperplasia. Hepatobiliary Pan-
creat Dis Int 1:219-223
ABDOMEN Liver. Hepatocellular Carcinoma (HCC)
1 2
3 4
5 6
Study Protocol
References
Iannaccone R, Laghi A, Catalano C et al (2005) Hepatocellular carcinoma: role of
unenhanced and delayed phase multi-detector row helical CT in patients with
cirrhosis. Radiology 234:460-467
Laghi A, Iannaccone R, Rossi P et al (2003) Hepatocellular carcinoma: detection with
triple-phase multi-detector row helical CT in patients with chronic hepatitis.
Radiology 226:543-549
Mori K, Yoshioka H, Takahashi N et al (2005) Triple arterial phase dynamic MRI
with sensitivity encoding for hypervascular hepatocellular carcinoma: compari-
son of the diagnostic accuracy among the early, middle, late, and whole triple
arterial phase imaging. AJR Am J Roentgenol 184:63-69
ABDOMEN Liver. HCC, Perfusion Study
1 2
3 4
Study Protocol
CT scan parameters:
kV: 80
mAs: 145
Thickness: 4 mm
Acquisition length: 28 cm
Patient preparation: A 6-h fast prior to the examination.
Before scanning: 20 mg butyl scopolamine (Buscopan, Boehringer, Ingelheim, Ger-
many) is injected to suppress peristalsis.
CM volume: 60-80 mL of CM according to patient weight.
CM injection flow rate (mL/s) 1.6 gI/s 1.8 gI/s 2.0 gI/s
CM concentration (mgI/mL)
300 5.3 6.0 6.7
320 5.0 5.6 6.2
350 4.6 5.1 5.7
370 4.3 4.8 5.4
400 4.0 4.5 5.0
Pre-contrast scan: Baseline CT images without CM and with a thickness of 2.55.0 mm
are acquired to locate liver lesion and to select the volume for the perfusion scans.
Post-contrast scan: 40 contiguous sections with 5-s delay are obtained at 2.2 s dur-
ing the first 30 s and at 5 s during the last 30 s (80 kV, 145 mAs, 4-cm scanning field
of view, 512 512 mm matrix).
References
Petralia G, Fazio N, Bonello L et al (2011) Perfusion computed tomography in pa-
tients with hepatocellular carcinoma treated with thalidomide: initial experience.
J Comput Assist Tomogr 35(2):195-201. PubMed PMID: 21412089
Ng CS, Chandler AG, Wei W et al (2011) Reproducibility of CT Perfusion para-
meters in liver tumors and normal liver. Radiology Jul 25. [Epub ahead of print]
PubMed PMID: 21788525
Spira D, Schulze M, Sauter A et al (2011) Volume perfusion-CT of the liver: In-
sights and applications. Eur J Radiol May 2. [Epub ahead of print] PubMed PMID:
21543180
ABDOMEN Liver. Peripheral Cholangiocarcinoma
1 2
3 4
Study Protocol
References
Choi YH, Lee JM, Lee JY et al (2008) Biliary malignancy: value of arterial, pan-
creatic, and hepatic phase imaging with multidetector-row computed tomogra-
phy. J Comput Assist Tomogr 32(3):362-368
Kim NR, Lee JM, Kim SH et al (2008) Enhancement characteristics of cholangio-
carcinomas on mutiphasic helical CT: emphasis on morphologic subtypes. Clin
Imaging 32(2):114-120
Uchida M, Ishibashi M, Tomita N et al (2005) Hilar and suprapancreatic cholan-
giocarcinoma: value of 3D angiography and multiphase fusion images using
MDCT. AJR Am J Roentgenol 184(5):1572-1577
ABDOMEN Liver. Hypovascular Metastases from
Lung Cancer
1 2
3 4
Study Protocol
References
Dawson P, Blomley M (2002) The value of mathematical modelling in understand-
ing contrast enhancement in CT with particular reference to the detection of hy-
povascular liver metastases. Eur J Radiol 41:222-236
Silverman PM (2006) Liver metastases: imaging considerations for protocol devel-
opment with multislice CT (MSCT). Cancer Imaging 6:175-181
Soyer P, Poccard M, Boudiaf M et al (2004) Detection of hypovascular hepatic metas-
tases at triple-phase helical CT: sensitivity of phases and comparison with sur-
gical and histopathologic findings. Radiology 231:413-420
ABDOMEN Liver. Hypervascular Metastases from
Renal Cell Carcinoma
1 2
3 4
1 In the baseline study: the lesion is not evident due to the absence of contrast
with the surrounding hepatic parenchyma. 2 Late arterial phase shows marked
enhancement of the metastatic lesion (arrow) located in segment VI, now clearly
differentiated from the surrounding parenchyma. 3 Partial wash-out of the cen-
tral portion of the lesion (asterisk), indicative of malignancy. 4 In the equi-
librium phase, a complete wash-out of the lesion, of which the peripheral por-
tion is still moderately hypodense compared to the surrounding hepatic
parenchyma, can be appreciated
ABDOMEN Liver. Hypervascular Metastases from Renal Cell Carcinoma 111
Study Protocol
References
Ascenti G, Visalli C, Genitori A et al (2004) Multiple hypervascular pancreatic metas-
tases from renal cell carcinoma: dynamic MR and spiral CT in three cases. Clin
Imaging 28:349-352
Meyer BC, Frericks BB, Voges M et al (2008) Visualization of hypervascular liver
lesions during TACE: comparison of angiographic C-arm CT and MDCT. AJR
Am J Roentgenol 190:W263-269
Namasivayam S, Salman K, Mittal PK et al (2007) Hypervascular hepatic focal le-
sions: spectrum of imaging features. Curr Probl Diagn Radiol 36:107-123
ABDOMEN Biliary Tree. Intraductal Papillary
Carcinoma of the Common Bile Duct
1 2
3 4
1 Non-enhanced axial scan at the level of the hepatic hilum highlights a dilata-
tion of the main bile duct (arrowhead) and the first intrahepatic branches (arrow).
Distal to the dilatation of the main bile duct, a rounded mass with well-defined
margins and soft-tissue density can be appreciated (asterisk). 2 Late arterial
phase shows enhancement of the solid tissue (arrow) located within the lumen
of the main bile duct, consistent with intraductal carcinoma. 3 Portal phase
shows persistent enhancement of the intraductal lesion (arrow); this scan demon-
strates intraluminal growth without infiltration of the surrounding adipose tissue.
4 The coronal MPR in the portal phase shows the longitudinal extension of the
intraductal lesion and proximal dilatation of the biliary tract
ABDOMEN Biliary Tree. Intraductal Papillary Carcinoma 113
Study Protocol
References
Itatsu K, Fujii T, Sasaki M et al (2007) Intraductal papillary cholangiocarcinoma and
atypical biliary epithelial lesions confused with intrabiliary extension of metasta-
tic colorectal carcinoma. Hepatogastroenterology 54:677-680
Ji Y, Fan J, Zhou J et al (2008) Intraductal papillary neoplasms of bile duct. A dis-
tinct entity like its counterpart in pancreas. Histol Histopathol 23:41-50
Kim NR, Lee JM, Kim SH et al (2008) Enhancement characteristics of cholangio-
carcinomas on mutiphasic helical CT: emphasis on morphologic subtypes. Clin
Imaging 32:114-120
ABDOMEN Pancreas. Ductal Adenocarcinoma
1 2
3 4
1 Pre-contrast axial scan shows a solid lesion with irregular margins (arrow-
heads) in the body of the pancreas. While alteration of the anterior peri-pancre-
atic adipose tissue can be appreciated, posteriorly it is impossible to define the re-
lationship with the vascular structure. 2 Post-contrast axial image in the
pancreatic phase evidences a voluminous, newly formed, solid tissue (asterisk)
moderately hypovascular compared to the surrounding pancreatic parenchyma,
at the level of the pancreas body-head. Signs of infiltration of the peri-pancreatic
adipose tissue anteriorly and of the anterior pararenal fascia posteriorly can be
seen; there is also encasement of the celiac tripod and of the origin of the splenic
artery (arrow). 3 Axial MIP reconstruction in the pancreatic phase shows in-
filtration of the celiac tripod and the splenic artery, with a reduced diameter of the
pancreas and diffuse parietal irregularity (arrow). In this phase, there is already
complete occlusion of the splenic vein (arrowhead), with evidence of collateral
circulation. 4 Post-contrast axial scan in the portal phase confirms a mass in
the body of the pancreas, with infiltration of the peri-pancreatic adipose tissue an-
teriorly and of the anterior pararenal fascia posteriorly; para-aortic lym-
phadenopathies are also evident (arrowhead)
ABDOMEN Pancreas. Ductal Adenocarcinoma 115
Study Protocol
References
Brennan DD, Zamboni GA, Raptopoulos VD, Kruskal JB (2007) Comprehensive
preoperative assessment of pancreatic adenocarcinoma with 64-section volumetric
CT. RadioGraphics 27:1653-1666
Chaudhari VV, Raman SS, Vuong NL et al (2007) Pancreatic cystic lesions: dis-
crimination accuracy based on clinical data and high resolution CT features.
J Comput Assist Tomogr 31:860-867
Gomez D, Rahman SH, Won LF et al (2006) Characterization of malignant pancre-
atic cystic lesions in the background of chronic pancreatitis. JOP 7:465-472
ABDOMEN Pancreas. Serous Cystic Neoplasm
1 2
3 4
Study Protocol
References
Edirimanne S, Connor SJ (2008) Incidental pancreatic cystic lesions. World J Surg
32(9):2028-2037
Garcea G, Ong SL, Rajesh A et al (2008) Cystic lesions of the pancreas. A diag-
nostic and management dilemma. Pancreatology 8(3):236-251
Sahani D, Prasad S, Saini S et al (2002) Cystic pancreatic neoplasms evaluation by
CT and magnetic resonance cholangiopancreatography. Gastrointest Endosc Clin
N Am 12(4):657-672
ABDOMEN Pancreas. Intraductal Papillary
Mucinous Neoplasm (IPMN)
1 2
3 4
1 Pre-contrast axial scan shows a swelling of the uncinate process (arrow), which
appears mildly hypodense to the surrounding pancreatic parenchyma. 2 Post-
contrast axial scan in the pancreatic phase: evident enhancement of the normal
pancreatic parenchyma is sharply contrasted with the hypodensity of the region
of the uncinate process, which has a cystic-like appearance (arrow). 3 Post-
contrast axial scan in the portal phase: the cystic-like ectasia (arrowhead) of a sec-
ondary ventral duct (arrow) draining the region of the uncinate process is com-
patible with a diagnosis of intraductal mucinous tumor. 4 Coronal reformation
in the portal phase: the entire course of the secondary dilated ventral duct and the
cystic-like appearance of the distal tract are shown
ABDOMEN Pancreas. Intraductal Papillary Mucinous Neoplasm (IPMN) 119
Study Protocol
References
Kawamoto S, Lawler LP, Horton KM et al (2006) MDCT of intraductal papillary
mucinous neoplasm of the pancreas: evaluation of features predictive of inva-
sive carcinoma. AJR Am J Roentgenol 186(3):687-695
Takada A, Itoh S, Suzuki K et al (2005) Branch duct-type intraductal papillary mu-
cinous tumor: diagnostic value of multiplanar reformatted images in multislice
CT. Eur Radiol 15(9):1888-1897
Takeshita K, Kutomi K, Takada K et al (2008) Differential diagnosis of benign or
malignant intraductal papillary mucinous neoplasm of the pancreas by multide-
tector row helical computed tomography: evaluation of predictive factors by lo-
gistic regression analysis. J Comput Assist Tomogr 32(2):191-197
ABDOMEN Spleen. Post-traumatic Arteriovenous
Intrasplenic Fistulas
1 2
3 4
Study Protocol
References
Anderson SW (2006) Sixty-four multi-detector row computed tomography in mul-
titrauma patient imaging: early experience. Curr Probl Diagn Radiol 35:188-198
Anderson SW, Varghese JC, Lucey BC et al (2007) Blunt splenic trauma: delayed-
phase CT for differentiation of active hemorrhage from contained vascular in-
jury in patients. Radiology 243:88-95
Shanmuganathan K, Mirvis SE, Boyd-Kranis R et al (2000) Nonsurgical manage-
ment of blunt splenic injury: use of CT criteria to select patients for splenic ar-
teriography and potential endovascular therapy. Radiology 217:75-82
ABDOMEN Stomach. Adenocarcinoma
1 2
3 4
Study Protocol
References
Chen CY, Hsu JS, Wu DC et al (2007) Gastric cancer: preoperative local staging
with 3D multi-detector row CT-correlation with surgical and histopathologic
results. Radiology 242(2):472-482
Kim AY, Kim HJ, Ha HK (2005) Gastric cancer by multidetector row CT: preoper-
ative staging. Abdom Imaging 30(4):465-472
Lee SM, Kim SH, Lee JM et al (2008) Usefulness of CT volumetry for primary gas-
tric lesions in predicting pathologic response to neoadjuvant chemotherapy in
advanced gastric cancer. Abdom Imaging PMID: 18546037
ABDOMEN Small Bowel. Crohns Disease of the
Terminal Ileum
1 2
3 4
Study Protocol
References
Hara AK, Alam S, Heigh RI et al (2008) Using CT enterography to monitor Crohns
disease activity: a preliminary study. AJR Am J Roentgenol 190:1512-1516
Hara AK, Leighton JA, Heigh RI et al (2006) Crohn disease of the small bowel: pre-
liminary comparison among CT enterography, capsule endoscopy, small-bowel
follow-through, and ileoscopy. Radiology 238:128-134
Bodily KD, Fletcher JG, Solem CA et al (2006) Crohn disease: mural attenuation
and thickness at contrast-enhanced CT enterography-correlation with endoscopic
and histologic findings of inflammation. Radiology 238:505-516
ABDOMEN Small Bowel. Gastrointestinal Stromal
Tumor (GIST)
1 2
3 4
Study Protocol
References
Da Ronch T, Modesto A, Bazzocchi M et al (2006) Gastrointestinal stromal tumour:
spiral computed tomography features and pathologic correlation. Radiol Med
111:661-673
De Leo C, Memeo M, Spinelli F, Angeletti G (2006) Gastrointestinal stromal tumours:
experience with multislice CT. Radiol Med 111:1103-1114
Rimondini A, Belgrano M, Favretto G et al (2007) Contribution of CT to treatment
planning in patients with GIST. Radiol Med 112:691-702
ABDOMEN Colon. Diverticulosis
1 2
3 4
1 Focal wall thickening in the sigmoid colon (arrow) and diverticula (arrow-
heads) as seen on axial two-dimensional CT colonography: pre-contrast scan with
the patient in the prone position. 2 Post-contrast scan, coronally reformatted,
shows a thickened segment of sigmoid colon without surrounding inflammatory
changes in the peri-colonic fat; there are no signs of diverticulitis or perforation.
3 Three-dimensional intraluminal VR reconstruction shows two diverticula of
the sigmoid colon (arrows). 4 Tissue transition projection reconstruction sim-
ulates a double-contrast enema and is extremely useful in demonstrating the
location of narrowing. In this case, a reduction of the colonic lumen from the rec-
tum to the ascending colon (arrows) and a diverticulum of the cecum (arrow-
head) are seen
ABDOMEN Colon. Diverticulosis 129
Study Protocol
Patient preparation: Patients have to be adequately prepared: liquid diet the evening
before the exam, fasting the day of exam, cathartic preparation, PEG (70 mg in 4 l of
water the day before the exam).
Alternatively, either of two different fecal tagging techniques, with less cathartic effect
and better patient compliance, can be used: (a) 200 ml of amidotrizoate meglumine
the day before the exam, 100 ml in the morning and 100 in the afternoon; (b) same-
day preparation: two bags of macrogol solution (20 mg), before meals, 2 days before
the exam. Administration of 100 ml of a solution containing meglumine 3 h before
the exam.
Pre-contrast scan: Acquired in prone and supine position, with low mAs.
Post-contrast scan: Not necessary.
References
Halligan S, Saunders B (2002) Imaging diverticular disease. Best Practice Res Clin-
ical Gastroenterol 16(4):595-610
Lawrimore T, Rhea JT (2004) Computed tomography evaluation of diverticulitis.
J Intensive Care Med 19(4):194-204
ABDOMEN Colon. Adenocarcinoma of the Sigmoid
Colon
1 2
3 4
1 Pre-contrast scan with the patient in the prone position shows a stenosing le-
sion within the lumen (arrow) of the sigmoid colon. 2 Post-contrast scan in
the supine position: the lesion is easily identifiable (arrow) and displays contrast
enhancement. 3 Post-contrast coronal reformatted image with patient in the
supine position shows the stenosing appearance of the mass (arrow). 4 Tis-
sue transition projection reconstruction, which simulates a double-contrast en-
ema and is extremely useful in demonstrating the location of the lesion. The ap-
ple-core sign, typical of malignancies of the colon, can be appreciated (arrow).
5 Three-dimensional intraluminal VR reconstruction shows marked distortion
of the normal morphology of the haustra coli
ABDOMEN Colon. Adenocarcinoma of the Sigmoid Colon 131
Study Protocol
Patient preparation: Patients have to be prepared adequately: liquid diet the evening
before the exam, fasting the day of exam, cathartic preparation, PEG (70 mg in 4 l of
water the day before the exam).
Alternatively, two different fecal tagging techniques, with less cathartic effect and bet-
ter patient compliance can be used: (a) 200 ml of amidotrizoate meglumine the day
before the exam, 100 ml in the morning and 100 in the afternoon; (b) same-day prepa-
ration: two bags of macrogol solution (20 mg) before meals in 2 days before the exam.
Administration of 100 ml of a solution containing meglumine 3 h before the exam.
CM volume: 500600 mgI (iodine dose) per kg body weight.
Patient weight (kg) < 60 < 80 > 80
CM concentration (mgl/mL)
300 100 130 150
320 95 125 140
350 85 115 130
370 80 110 120
400 75 100 110
Pre-contrast scan: Patient in prone position, low mAs.
Post-contrast scan: Patient in supine position, single portal phase.
Scan delay: Portal phase: 60-70 s from the start of the CM injection.
References
Kim DH, Pickhardt PJ, Hoff G, Kay CL (2007) Computed tomographic colonogra-
phy for colorectal screening. Endoscopy 39:545-549
Mang T, Graser A, Schima W, Maier A (2007) CT colonography: techniques, indi-
cations, findings. Eur J Radiol 61:388-399
Taylor SA, Laghi A, Lefere P et al (2007) European Society of Gastrointestinal and
Abdominal Radiology (ESGAR): consensus statement on CT colonography. Eur
Radiol 17:575-579
ABDOMEN Colon. Pedunculated Polyp of the
Ascending Colon
1 2
1 Scan with patient in the prone position shows the presence of a pedunculated
polyp in the ascending colon (arrow), covered by luminal fluid opacified by the
oral iodinated contrast medium. 2 Scan with patient in the supine position: the
large pedunculated polyp (arrow) is still completely covered by the luminal fluid
and is visible due to the opacification effect of the fluid (oral contrast medium).
3 Coronal MPR image obtained after electronic cleansing: electronic removal
of the opacified fluid, which enables virtual cleansing of the colon by electron-
ically subtracting the opacified fluid, shows the polypoid lesion with the pe-
duncle. 4 Intraluminal VR reconstruction after electronic cleansing: the poly-
poid lesions is well visualized within the lumen of the colon
ABDOMEN Colon. Pedunculated Polyp of the Ascending Colon 133
Study Protocol
Patient preparation: Patients have to be prepared adequately: liquid diet the evening
before the exam, fasting the day of exam, cathartic preparation, PEG (70 mg in 4 l of
water the day before the exam).
Alternatively, two different fecal tagging techniques, with less cathartic effect and bet-
ter patient compliance, can be used: (a) 200 ml of amidotrizoate meglumine the day be-
fore the exam, 100 ml in the morning and 100 in the afternoon; (b) same-day prepara-
tion: two bags of macrogol solution (20 mg), before the meals, in 3 days before the ex-
am. Administration of 100 ml of a solution containing meglumine 3 h before the exam.
CM volume: 500600 mgI (iodine dose) per kg body weight is suggested only for
staging of an accidental cancer.
Patient weight (kg) < 60 < 80 > 80
CM concentration (mgl/mL)
300 100 130 150
320 95 125 140
350 85 115 130
370 80 110 120
400 75 100 110
Pre-contrast scan: Patient in prone and supine position, with 100 mAs if injection is
not required.
Post-contrast scan: Patient in supine position, 200 mAs.
References
Kim DH, Pickhardt PJ, Hoff G, Kay CL (2007) Computed tomographic colonogra-
phy for colorectal screening. Endoscopy 39:545-549
Mang T, Graser A, Schima W, Maier A (2007) CT colonography: techniques, indi-
cations, findings. Eur J Radiol 61:388-399
Taylor SA, Laghi A, Lefere P et al (2007) European Society of Gastrointestinal and
Abdominal Radiology (ESGAR): consensus statement on CT colonography. Eur
Radiol 17:575-579
ABDOMEN Colon. Angiodysplasia of the Sigmoid
Colon
1 2
1 Axial image in portal phase: foci of vascular hyperdensity in the wall of the
sigmoid colon (arrows). 2 Coronal MIP image in portal phase: a vascular tan-
gle of sigmoid wall (arrow). 3 Axial image shows hyperdense sigmoid-wall
thickening caused by multiple vascular ectasias (red and white arrows); the
bowel lumen is distended by hypodense corpuscular fluid. 4 Sagittal MIP re-
construction in venous phase: angiodysplasia of the sigmoid wall (arrow)
ABDOMEN Colon. Angiodysplasia of the Sigmoid Colon 135
Study Protocol
References
Hammerstingl RM, Vogl TJ (2005) Abdominal MDCT: protocols and contrast con-
siderations. Eur Radiol (15 Suppl) 5:E78-E90
Jaeckle T, Stuber G, Hoffmann MH et al (2008) Detection and localization of acute
upper and lower gastrointestinal (GI) bleeding with arterial phase multi-detec-
tor row helical CT. Eur Radiol 18:1406-1413
Yoon W, Jeong YY, Kim JK (2006) Acute gastrointestinal bleeding: contrast-enhanced
MDCT. Abdom Imaging 31:1-8
ABDOMEN Rectum. Carcinoma
1 2
3 4
Study Protocol
Patient preparation: A 6-h fast prior to the examination; a cleaning enema of the
rectum the morning of the exam is useful. Some centers prefer to perform rectal dis-
tension with air or water; excessive distension is not recommended..
CM volume: 500600 mgI (iodine dose) per kg body weight.
Patient weight (kg) < 60 < 80 > 80
CM concentration (mgl/mL)
300 100 130 150
320 95 125 140
350 85 115 130
370 80 110 120
400 75 100 110
CM injection flow rate (mL/s) 1.6 gI/s 1.8 gI/s 2.0 gI/s
CM concentration (mgI/mL)
300 5.3 6.0 6.7
320 5.0 5.6 6.2
350 4.6 5.1 5.7
370 4.3 4.8 5.4
400 4.0 4.5 5.0
Pre-contrast scan: Useful.
Post-contrast scan: 2 phases (late arterial and portal).
Scan delay: The bolus-tracking monitoring technique is used.
Late arterial phase: 18-23 s after a treshold of 100 HU is reached.
Portal phase: 60-70 s from the start of the CM injection.
References
Kanamoto T, Matsuki M, Okuda J et al (2007) Preoperative evaluation of local in-
vasion and metastatic lymph nodes of colorectal cancer and mesenteric vascu-
lar variations using multidetector-row computed tomography before laparoscopic
surgery. J Comput Assist Tomogr 31:831-839
Sinha R, Verma R, Rajesh A, Richards CJ (2006) Diagnostic value of multidetector
row CT in rectal cancer staging: comparison of multiplanar and axial images with
histopathology. Clin Radiol 61:924-931
Vliegen R, Dresen R, Beets G et al (2008) The accuracy of multi-detector row CT
for the assessment of tumor invasion of the mesorectal fascia in primary rectal
cancer. Abdom Imaging 33(5):604-610
ABDOMEN Rectum. CT Perfusion
1 2
3 4
5 6
1 Pre-contrast sagittal MPR image. Note the marked thickening of the rectal wall
(arrow), due to the presence of a large neoplastic parietal lesion. Sagittal scan
shows the exact longitudinal extension of the tumor, which is necessary for vol-
ume placement in the perfusion study. 2 Post-contrast axial scan in the venous
phase: enhancement of the lesion involving the circumference of the rectum (ar-
rowheads), with sparing only of the right posterolateral wall. Note the neoplastic
infiltration of the mesorectum (arrow). 3 Post-contrast coronal MPR image in
the venous phase: the tumor is shown in its entire longitudinal extension as are the
bands of tumor infiltration in the mesorectum (arrowhead). Locoregional lym-
phadenopathies can also be appreciated (arrow). Perfusion analysis carried out with
dedicated software shows: 4 (color map: blood flow) an increase in flow (red ar-
eas) as expected in a neoplastic lesion; 5 (color map: blood volume) an increase
ABDOMEN Rectum. CT Perfusion 139
Study Protocol
References
Bellomi M, Petralia G, Sonzogni A et al (2007) CT perfusion for the monitoring of
neoadjuvant chemotherapy and radiation therapy in rectal carcinoma: initial ex-
perience. Radiology 244:486-493
Goh V, Padhani AR, Rasheed S (2007) Functional imaging of colorectal cancer an-
giogenesis. Lancet Oncol 8:245-255
Sahani DV, Kalva SP, Hamberg LM et al (2005) Assessing tumor perfusion and treat-
ment response in rectal cancer with multisection CT: initial observations. Radi-
ology 234:785-792
in blood volume (orange areas) in the tumor with respect to the adjacent tissue;
6 (color map: mean transit time) a reduction in the values in the tumor (red ar-
eas). The latter finding reflects the presence of multiple arteriovenous shunts in the
pathologic tissue with respect to normal tissue
ABDOMEN Peritoneum. Carcinomatosis
from Malignant Ovarian Cancer
1 2
3 4
5 6
Study Protocol
References
Pannu HK, Bristow RE, Montz FJ et al (2003) Multidetector CT of peritoneal car-
cinomatosis from ovarian cancer. Radiographics 23(3):687-701
ABDOMEN Adrenal Glands. Adenoma
1 2
3 4
5
1 Pre-contrast study highlights a small
solid nodule of the left adrenal gland,
hypodense, with regular margins and
clear cut edges (arrow). 2 The mor-
phologic appearance of the lesion needs
to be integrated with quantitative data,
such as measurement of the lesions
density through the placement of a ROI.
The finding of an adipose density (neg-
ative HU values) allows the lesion to be
characterized as an adrenal adenoma.
The behavior of adrenal lesions after
the intravenous administration of contrast medium, evaluated qualitatively, is not
pathognomonic, either (3) in the arterial phase (arrow) or (4) in the portal
phase (arrow). 5 In the late phase at 10 min, benign adrenal lesions tend to dis-
play a marked wash-out compared to earlier phases. Late wash-out should also be
evaluated quantitatively by measuring the density in the portal phase and in the late
phase using the formula: (1 HU late phase/HU portal phase) 100. A late wash-
out > 50% is suggestive of a benign adrenal lesion, as are absolute values < 30 HU
in the late phase
ABDOMEN Adrenal Glands. Adenoma 143
Study Protocol
References
Bae KT, Fuangtharnthip P, Prasad SR et al (2003) Adrenal masses: CT characteri-
zation with histogram analysis method. Radiology 228:735-742
Korobkin M, Brodeur FJ, Yutzy GG et al (1996) Differentiation of adrenal adeno-
mas from nonadenomas using CT attenuation values. AJR Am J Roentgenol
166:531-536
Yamada T, Ishibashi T, Saito H et al (2003) Adrenal adenomas: relationship between
histologic lipid-rich cells and CT attenuation number. Eur J Radiol 48:198-202
ABDOMEN Adrenal Glands. Metastases from Lung
Cancer
1 2
3 4
1 Pre-contrast study shows an increase in the size of the left adrenal gland with
pseudonodular morphology (arrow). Numerous large hepatic lesions can also be
appreciated. The pre-contrast phase is crucial for the characterization of adrenal
lesions. The imaging characteristics are based not only on morphological and size
criteria (lesions > 4 cm are more probably malignant) but also on quantitative cri-
teria. The density of the adrenal lesion needs to be measured with the placement
of a ROI. Benign lesions (adrenal adenomas) are characterized by the presence of
intracellular adipose tissue that produces low-density characteristics (negative HU
values). Adrenal lesions with density > 10 HU cannot be interpreted as benign and
are at risk of being metastatic. The qualitative evaluation of the behavior of
adrenal lesions after the intravenous administration of contrast medium is not
pathognomonic, as shown in 2 the arterial phase and 3 the portal phase. 4 In
the late phase at 10 min, malignant adrenal lesions tend to display poor wash-out
with respect to the earlier phases. Late wash-out should also be quantitatively eval-
uated by measuring the density in the portal and late phases using the formula:
(1 HU late phase/HU portal phase) 100. A late wash-out < 50% is suggestive
of a malignant adrenal lesion, as are absolute values > 30 HU in the late phase
ABDOMEN Adrenal Glands. Metastases from Lung Cancer 145
Study Protocol
References
Kebapci M, Kaya T, Gurbuz E et al (2003) Differentiation of adrenal adenomas (lipid
rich and lipid poor) from nonadenomas by use of washout characteristics on de-
layed enhanced CT. Abdom Imaging 28:709-715
Mayo-Smith WW, Boland GW, Noto RB et al (2001) Sate of the art of adrenal imag-
ing. RadioloGraphics 4:995-1012
Park BK, Kim B, Ko K et al (2006) Adrenal masses falsely diagnosed as adenomas
on unenhanced and delayedcontrast-enhanced computed tomography: patholog-
ical correlation. Eur Radiol 16:642-647
ABDOMEN Kidney. Carcinoma and Angiomyolipoma
1 2
3 4
Study Protocol
References
Sheir KZ, El-Azab M, Mosbah A et al (2005) Differentiation of renal cell carcino-
ma subtypes by multislice computerized tomography. J Urol 174:451-455; dis-
cussion 455
Zhang J, Lefkowitz RA, Ishill NM et al (2007) Solid renal cortical tumors: differ-
entiation with CT. Radiology 244:494-504
Zhang J, Lefkowitz RA, Wang L et al (2007) Significance of peritumoral vascularity
on CT in evaluation of renal cortical. tumor. J Comput Assist Tomogr 31:717-723
ABDOMEN Urinary Tract. CT Urography
1 2
3 4
1 Pre-contrast axial scan, coronal MPR image. A large calcific structure can be
seen at the level of the renal pelvis (arrow); above it a tubular structure with par-
tially calcified walls is visible (arrowhead). 2 Post-contrast axial scan in the
arterial phase shows enhancement of the tubular structure referable to the left
common iliac artery (arrowhead). 3 Post-contrast axial scan in the uro-
graphic phase: the calcified structure (arrow) is located within the left upper uri-
nary tract, with proximal dilatation of the ureter. 4 Post-contrast scan: the
three-dimensional VR image shows the ureter in its proximal course, with steno-
sis caused by the calcified stone (arrow)
ABDOMEN Urinary Tract. CT Urography 149
Study Protocol
Patient preparation: A 6-h fast prior to the examination; fluid administration (oral
or i.v.) to stimulate diuresis.
CM volume: 500-600 mgI (iodine dose) per kg body weight.
Patient weight (kg) < 60 < 80 > 80
CM concentration (mgl/mL)
300 100 130 150
320 95 125 140
350 85 115 130
370 80 110 120
400 75 100 110
CM injection flow rate (mL/s) 1.6 gI/s 1.8 gI/s 2.0 gI/s
CM concentration (mgI/mL)
300 5.3 6.0 6.7
320 5.0 5.6 6.2
350 4.6 5.1 5.7
370 4.3 4.8 5.4
400 4.0 4.5 5.0
Pre-contrast scan: Indispensable for the detection of radio-opaque structures.
Post-contrast scan: 3 phases (arterial, portal, excretory).
Scan delay: The bolus-tracking monitoring technique is used.
Arterial phase: 10 s after a threshold of 100 HU is reached.
Portal phase: 60-70 s from the start of the CM injection.
Excretory phase: 7 min from the start of the CM injection.
References
Memarsadeghi M, Schaefer-Prokop C, Prokop M et al (2007) Unenhanced MDCT
in patients with suspected urinary stone disease: do coronal reformations improve
diagnostic performance? AJR Am J Roentgenol 189:W60-W64
Paulson EK, Weaver C, Ho LM et al (2008) Conventional and reduced radiation dose
of 16-MDCT for detection of nephrolithiasis and ureterolithiasis. AJR Am J
Roentgenol 190:151-157
Poletti PA, Platon A, Rutschmann OT et al (2007) Low-dose versus standard-dose
CT protocol in patients with clinically suspected renal colic. AJR Am J Roentgenol
188:927-933
ABDOMEN Urinary Tract. Low-dose CT for Urolithiasis
1 2
3 4
Study Protocol
References
Kalra MK, Maher MM, D'Souza RV et al (2005) Detection of urinary tract stones
at low-radiation-dose CT with z-axis automatic tube current modulation: phan-
tom and clinical studies. Radiology 235:523-529. Epub 2005 Mar 15
Kim BS, Hwang IK, Choi YW et al (2005) Low-dose and standard-dose unenhanced
helical computed tomography for the assessment of acute renal colic: prospec-
tive comparative study. Acta Radiol 46:756-763
Poletti PA, Platon A, Rutschmann OT et al (2007) Low-dose versus standard-dose
CT protocol in patients with clinically suspected renal colic. AJR Am J Roentgenol
188:927-933
ABDOMEN Bladder. Carcinoma
1 2
3 4
5 6
1 Non-enhanced CT image shows neoplastic tissue bulging from the right lat-
eral wall of the bladder (arrow). 2 In arterial phase, bladder carcinoma is clearly
visible (arrow). 3 Portal phase shows mild enhancement of the neoplastic
mass (arrow). 4 Excretory phase with the patient in supine decubitus does not
clearly depict neoplastic margins due to high-density iodinated urine shading the
bladder wall. 5 Excretory phase, acquired with the patient in prone decubitus
(optional phase for selected patients), shows clearly neoplastic margins (arrow).
Note blood clots as hypodense inclusions in the bladder lumen (arrowhead).
6 In arterial phase, a metastatic lymph node, enlarged, round, with homogeneous
enhancement, is evident near the anterior wall of the bladder
ABDOMEN Bladder. Carcinoma 153
Study Protocol
Patient preparation: A 6-h fast prior to the examination; fluid administration (oral
or i.v.) to stimulate diuresis.
CM volume: 500600 mgI (iodine dose) per kg body weight.
Patient weight (kg) < 60 < 80 > 80
CM concentration (mgl/mL)
300 100 130 150
320 95 125 140
350 85 115 130
370 80 110 120
400 75 100 110
CM injection flow rate (mL/s) 1.6 gI/s 1.8 gI/s 2.0 gI/s
CM concentration (mgI/mL)
300 5.3 6.0 6.7
320 5.0 5.6 6.2
350 4.6 5.1 5.7
370 4.3 4.8 5.4
400 4.0 4.5 5.0
Pre-contrast scan: Indispensable for the detection of radio-opaque structures.
Post-contrast scan: 3 phases (arterial, portal, excretory).
Scan delay: The bolus-tracking monitoring technique is used.
Arterial phase: 10 s after a threshold of 100 HU is reached.
Portal phase: 60-70 s from the start of the CM injection.
Excretory phase supine: 7 min from the start of the CM injection.
Excretory phase prone (optional): 7 min from the start of the CM injection.
References
Memarsadeghi M, Schaefer-Prokop C, Prokop M et al (2007) Unenhanced MDCT
in patients with suspected urinary stone disease: do coronal reformations improve
diagnostic performance? AJR Am J Roentgenol 189:W60-W64
Paulson EK, Weaver C, Ho LM et al (2008) Conventional and reduced radiation dose
of 16- MDCT for detection of nephrolithiasis and ureterolithiasis. AJR Am J
Roentgenol 190:151-157
Poletti PA, Platon A, Rutschmann OT et al (2007) Low-dose versus standard-dose
CT protocol in patients with clinically suspected renal colic. AJR Am J Roentgenol
188:927-933
ABDOMEN Prostate. CT Perfusion
1 2
3 4
1 Perfusion analysis (color map: blood flow), axial (upper image) and coronal
(lower image) planes. The map, obtained with a dedicated software application,
shows an increase in flow (arrow) as expected in a neoplastic lesion. In this map,
a focal hotspot was absent but a diffuse increase in flow values may be see also
in the contralateral region (asterisk). 2 Perfusion analysis (color map: blood
volume), axial (upper image) and coronal (lower image) planes. The map
shows an increase in blood volume (red areas, arrow) in the tumor with respect
to the adjacent tissue. 3 Perfusion analysis (color map: mean transit time),
axial (upper image) and coronal (lower image) planes. The map shows a
reduction in the values in the tumor (blue area); this finding reflects the pres-
ence of multiple arteriovenous shunts in the pathologic tissue with respect to nor-
mal tissue. 4 Perfusion analysis (color map: permeability surface area prod-
uct), axial (upper image) and coronal (lower image) planes. The map shows an
increase in permeability (red areas, arrow) in the peripheral tumor area, as ex-
pected with inflammation tissues (angiogenesis behavior). The tumors center
shows lower permeability values, as expected for well-shaped vessels (asterisk)
ABDOMEN Prostate. CT Perfusion 155
Study Protocol
References
Bellomi M, Viotti S, Preda L et al (2010) Perfusion CT in solid body-tumours part
II. Clinical applications and future development. Radiol Med 115:858-874
Petralia G, Preda L, DAndreas G et al (2010) In: Bellomi M (ed) La Radiologia
Medica. CT perfusion in solid-body tumours. Part I: technical issues. Radiol Med,
pp 843-857
Sahani DV, Kalva SP, Hamberg LM et al (2005) Assessing tumor perfusion and treat-
ment response in rectal cancer with multisection CT: initial observations. Radi-
ology 234:785-792
HEART Dilated Cardiomyopathy
1 2
3 4 5
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in the right antecubital vein. Contraindications to the administration of negative
chronotropic drugs and nitrates should be carefully investigated. The administra-
tion of negative chronotropic drugs, such as beta blockers and calcium antagonists,
is mandatory to reduce and to stabilize heart rate (HR). Control of HR should be
decided according to the technology used. For a 64-slice CT scanner, the HR should
be < 65 bpm. The administration of nitrates is recommended to dilate the coro-
nary arteries.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline or 10 ml of CM + 40 ml of saline at the same flow rate.
Pre-contrast scan (calcium score): Useful for the quantification of coronary calcium.
Post-contrast scan:
CM injection protocol with injection time = scan time + 7-s trigger delay.
Trigger delay: 7 s after the threshold of 100 HU is reached in the ascending aorta
using a bolus-tracking technique.
Gating: Retrospective or prospective (according to patients HR and the technology
available).
Scan region: From the ascending aorta to the heart apex.
References
Andreini D, Pontone G, Pepi M et al (2007) Diagnostic accuracy of multidetector
computed tomography coronary angiography in patients with dilated cardiomy-
opathy. J Am Coll Cardiol 49:2044-2050
Butler J (2007) The emerging role of multi-detector computed tomography in heart
failure. J Card Fail 13:215-226
Williams TJ, Manghat NE, McKay-Ferguson A et al (2008) Cardiomyopathy: ap-
pearances on ECG-gated 64-detector row computed tomography. Clin Radiol
63:464-474
HEART Hypertrophic Cardiomyopathy
1 2
3 4
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in the right antecubital vein. Contraindications to the administration of negative
chronotropic drugs and nitrates should be carefully investigated. The administra-
tion of negative chronotropic drugs, such as beta blockers and calcium antagonists,
is mandatory to reduce and to stabilize heart rate (HR). Control of HR should be
decided according to the technology used. For a 64-slice CT scanner, the HR should
be < 65 bpm. The administration of nitrates is recommended to dilate the coro-
nary arteries.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline or 10 ml of CM + 40 ml of saline at the same flow rate.
Pre-contrast scan (calcium score): Useful for the quantification of coronary calcium.
Post-contrast scan:
CM injection protocol with the injection time = scan time + 7-s trigger delay.
Trigger delay: 7 s after the threshold of 100 HU is reached in the ascending aorta
using a bolus-tracking technique.
Gating: Retrospective or prospective (according to patient HR and technology avail-
able).
Scan region: From the ascending aorta to the heart apex.
References
Ghersin E, Lessick J, Litmanovich D et al (2006) Comprehensive multidetector CT
assessment of apical hypertrophic cardiomyopathy. Br J Radiol 79:e200-204
Mitsutake R, Miura S, Sako H et al (2008) Usefulness of multi-detector row com-
puted tomography for the management of percutaneous transluminal septal my-
ocardial ablation in patient with hypertrophic obstructive cardiomyopathy. Int J
Cardiol 129:e61-63
Sparrow P, Merchant N, Provost Y et al (2009) Cardiac MRI and CT features of in-
heritable and congenital conditions associated with sudden cardiac death. Eur
Radiol 19:259-270. PMID: 18795295
HEART Non-compaction Cardiomyopathy
1 2
3 4
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G catheter in the right
antecubital vein. Contraindications to the administration of negative chronotrop-
ic drugs and nitrates should be carefully investigated. The administration of nega-
tive chronotropic drugs, such as beta blockers and calcium antagonists, is manda-
tory to reduce and to stabilize heart rate (HR). The control of HR should be decid-
ed according to the technology used. For a 64-slice CT scanner, the patients HR
should be < 65 bpm. The administration of nitrates is recommended to dilate the
coronary arteries.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline or 10 ml of CM + 40 ml of saline at the same flow rate.
Pre-contrast scan (calcium score): Useful for the quantification of coronary calcium.
Post-contrast scan:
CM injection protocol with injection time = scan time + 7-s trigger delay.
Trigger delay: 7 s after the threshold of 100 HU is reached in the ascending aorta
using a bolus-tracking technique.
Gating: Retrospective or prospective (according to patient HR and technology avail-
able).
Scan region: From the ascending aorta to the heart apex.
References
Eilen D, Peterson N, Karkut C et al (2008) Isolated noncompaction of the left
ventricular myocardium: a case report and literature review. Echocardiography
25:755-761
Jacquier A, Revel D, Saeed M (2008) MDCT of the myocardium: a new contribu-
tion to ischemic heart disease. Acad Radiol 15:477-487
Orakzai SH, Orakzai RH, Nasir K et al (2006) Assessment of cardiac function using
multidetector row computed tomography. J Comput Assist Tomogr 30:555-563
HEART Atrial Myxoma
a b
2
a b
3
a b
4
A 77-year-old patient with dyspnea, palpitations, and chest pain but with no ECG
or enzymatic changes underwent echocardiography, which revealed the presence
of a mobile mass within the atrium. As the relationship of the mass with the heart
chamber could not be correctly visualized, an MDCT examination was requested.
1, 2 Three- and four-chamber MPR images of the heart during systole (a) and
HEART Atrial Myxoma 163
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in the right antecubital vein. Contraindications to the administration of negative
chronotropic drugs and nitrates should be carefully investigated. The administra-
tion of negative chronotropic drugs, such as beta blockers and calcium antagonists,
is mandatory to reduce and to stabilize heart rate (HR). The control of HR should
be decided according to the technology used. For a 64-slice CT scanner, the HR
should be < 65 bpm. The administration of nitrates is recommended to dilate the
coronary arteries.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline or 10 ml of CM + 40 ml of saline at the same flow rate.
Pre-contrast scan (calcium score): Useful for the quantification of coronary calcium.
Post-contrast scan:
CM injection protocol is calculated with injection time = scan time + 7-s trigger delay.
Trigger delay: 7 s after the threshold of 100 HU is reached in the ascending aorta
using a bolus-tracking technique.
Gating: Retrospective or prospective (according to patient HR and technology avail-
able).
Scan region: From the ascending aorta to the heart apex.
References
Grebenc ML, Rosado-de-Christenson ML, Green CE et al (2002) Cardiac myxoma:
imaging features in 83 patients. RadioGraphics 22:673-689
Neragi-Miandoab S, Kim J, Vlahakes GJ (2007) Malignant tumours of the heart: a
review of tumour type, diagnosis and therapy. Clin Oncol (R Coll Radiol) 19:748-
756
Yuan SM, Shinfeld A, Lavee J et al (2009) Imaging morphology of cardiac tumours.
Cardiol J 16:26-35
diastole (b). Note the presence of a mass (asterisk) within the left atrium (LA)
that during diastole (b) migrates within the left ventricle (LV). 3 Short-axis
MPR image of the heart. The reconstruction shows the relations between the mass
(asterisk) and the mitral valve (arrow). 4 Axial MPR image shows the inser-
tion (arrow) of the atrial mass (asterisk) at the level of the interatrial septum
HEART Transplant (Postoperative Study)
1 2
3 4
5 6
Study Protocol
Patient preparation: A 6-h fast prior to the examination. 18G intravenous catheter
in the right antecubital vein. The administration of negative chronotropic drugs is
useless because of the denervation of the transplanted heart.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline or 10 ml of CM + 40 ml of saline at the same flow rate.
Pre-contrast scan (calcium score): Unnecessary.
Post-contrast scan:
CM injection protocol with injection time = scan time + 7-s trigger delay.
Trigger delay: 7s after the threshold of 100 HU is reached in the ascending aorta us-
ing a bolus-tracking technique.
Gating: Retrospective or prospective (according to patient HR and technology avail-
able).
Scan region: From the ascending aorta to the heart apex.
References
Ferencik M, Gregory SA, Butler J et al (2007) Analysis of cardiac dimensions, mass
and function in heart transplant recipients using 64-slice multi-detector computed
tomography. J Heart Lung Transplant 26:478-484
Gregory SA, Ferencik M, Achenbach S et al (2006) Comparison of sixty-four-slice
multidetector computed tomographic coronary angiography to coronary an-
giography with intravascular ultrasound for the detection of transplant vascu-
lopathy. Am J Cardiol 98:877-884
Iyengar S, Feldman DS, Cooke GE et al (2006) Detection of coronary artery dis-
ease in orthotopic heart transplant recipients with 64-detector row computed to-
mography angiography. J Heart Lung Transplant 25:1363-1366
of the heart: massive left atrial dilatation, characteristic of the transplant particu-
larly when done with biatrial technique. Note the site of the anastomosis (arrow).
5 Short-axis MPR image of the heart identifies concentric ventricular hypertro-
phy; this finding is common in transplant patients and results from the immuno-
suppressive treatment and systemic hypertension. 6 Axial MPR image shows
anastomosis of the pulmonary artery (arrow). (Reproduced with the kind per-
mission of Dr. Gorka Bastarrika, University Clinic of Navarra, Pamplona, Spain)
HEART Transposition of the Great Vessels
(Postoperative Study of the Great Vessels)
1 2
3 4
Evaluation of a left pulmonary artery stent due to frequent stenosis after the pro-
cedure. Following the Jatene procedure, the coronary arteries were excised from
the aorta, which was sectioned and then inverted together with the pulmonary
artery. Before the vessels are anastomosed, the pulmonary artery is positioned in
front of the aorta. This maximizes the length of the neo-aorta and minimizes the
risk of kinking or compression of the coronary arteries. The coronary arteries are
then re-implanted on the neo-aorta. In patients undergoing the arterial switch pro-
cedure, there is a substantial risk of early or late coronary stenosis or occlusion.
1 VR reconstruction shows the pulmonary artery (arrow) running in front of the
aorta (asterisk). 2 Short-axis MPR image of the heart highlights concentric hy-
pertrophy of the right ventricle with thinning of the interventricular septum (ar-
row). 3 Axial MIP reconstruction shows the left pulmonary stent with initial
intimal hyperplasia (arrowhead). Note the pulmonary artery running in front of
the aorta (arrow) and the anomalous position of the ascending aorta (a) with re-
spect to the descending aorta (b). 4 On oblique MPR image, the left pulmonary
stent with initial intimal hyperplasia (arrow) is seen. Note the compression of the
HEART Transposition of the Great Vessels 167
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in the right antecubital vein. Contraindications to the administration of negative
chronotropic drugs and nitrates should be carefully investigated. The administration
of negative chronotropic drugs, such as beta blockers and calcium antagonists,is manda-
tory to reduce and to stabilize heart rate (HR). The control of HR should be decided ac-
cording to the technology used. For a 64-slice CT scanner, the HR should be < 65 bpm.
The administration of nitrates is recommended to dilate the coronary arteries.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline or 10 ml of CM + 40 ml of saline at the same flow rate.
Pre-contrast scan (calcium score): Unnecessary.
Post-contrast scan:
CM injection protocol with injection time = scan time + 7-s trigger delay.
Trigger delay: 7s after the threshold of 100 HU is reached in the ascending aorta
using a bolus-tracking technique.
Gating: Retrospective or prospective (according to patient HR and technology avail-
able.
Scan region: from the ascending aorta to the heart apex.
References
Eichhorn JG, Long FR, Hill SL et al (2006) Assessment of in-stent stenosis in small
children with congenital heart disease using multi-detector computed tomogra-
phy: a validation study. Catheter Cardiovasc Interv 68:11-20
Lee T, Tsai IC, Fu YC et al (2006) Using multidetector-row CT in neonates with
complex congenital heart disease to replace diagnostic cardiac catheterization
for anatomical investigation: initial experiences in technical and clinical feasi-
bility. Pediatr Radiol 36:1273-1282
Leschka S, Oechslin E, Husmann L et al (2007) Pre- and postoperative evaluation
of congenital heart disease in children and adults with 64-section CT. Radio-
Graphics 27:829-846
pulmonary artery on the ascending aorta, which predisposes the pulmonary ar-
teries to stenosis. (Reproduced with the kind permission of Dr. Gorka Bastarrika,
University Clinic of Navarra, Pamplona, Spain)
HEART Bicuspid Aortic Valve
1 2
3 4
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in the right antecubital vein. The administration of negative chronotropic drugs,
such as beta blockers and calcium antagonists, is mandatory to reduce and to sta-
bilize heart rate (HR). The administration of nitrates is recommended to dilate the
coronary arteries.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline or 10 ml of CM + 40 ml of saline at the same flow rate.
Pre-contrast scan (calcium score): Useful for the quantification of coronary calcium.
Post-contrast scan:
CM injection protocol with injection time= scan time + 7-s trigger delay.
Trigger delay: 7 s after the threshold of 100 HU is reached in the ascending aorta
using a bolus-tracking technique.
Scan protocol:
Gating: Retrospective or prospective (according to patient HR and technology avail-
able).
Scan region: From the ascending aorta to the heart apex.
References
Gilkeson RC, Markowitz AH, Balgude A et al (2006) MDCT evaluation of aortic
valvular disease. AJR Am J Roentgenol 186:350-360
Ryan R, Abbara S, Colen RR et al (2008) Cardiac valve disease: spectrum of find-
ings on cardiac 64-MDCT. AJR Am J Roentgenol 190:W294-303
HEART Iatrogenic Coronary Dissection
1 2
3 4
5 6
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in the right antecubital vein. The administration of negative chronotropic drugs, such
as beta blockers and calcium antagonists, is mandatory to reduce and to stabilize
HR. The administration of nitrates is recommended to dilate the coronary arteries.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline or 10 ml of CM + 40 ml of saline at the same flow rate.
Pre-contrast scan (calcium score): Unnecessary.
Post-contrast scan:
CM injection protocol with injection time = scan time + 7-s trigger delay.
Trigger delay: 7 s after the threshold of 100 HU is reached in the ascending aorta
using a bolus-tracking technique.
Scan protocol:
Gating: Retrospective or prospective (according to patient HR and technology avail-
able).
Scan region: From the ascending aorta to the heart apex.
References
Cheng CC, Tsao TP, Tzeng BH et al (2008) Stenting for coronary intervention-re-
lated dissection of the left main coronary artery with extension to the aortic root:
a case report. South Med J 101:1165-1167
Kantarci M, Ceviz N, Sevimli S et al (2007) Diagnostic performance of multide-
tector computed tomography for detecting aorto-ostial lesions compared with
catheter coronary angiography: multidetector computed tomography coronary an-
giography is superior to catheter angiography in detection of aorto-ostial lesions.
J Comput Assist Tomogr 31:595-599
Yoshikai M, Ikeda K, Itoh M et al (2008) Detection of coronary artery disease in
acute aortic dissection: the efficacy of 64-row multidetector computed tomography.
J Card Surg 23:277-279
HEART Coronary Artery Anomaly
1 2
3 4
5 6
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G catheter in the right
antecubital vein. The administration of negative chronotropic drugs, such as beta
blockers and calcium antagonists, is mandatory to reduce and to stabilize HR. The
administration of nitrates is recommended to dilate the coronary arteries.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline or 10 ml of CM + 40 ml of saline at the same flow rate.
Pre-contrast scan (calcium score): Useful for the evaluation of the coronary anato-
my in case of anomalous origin.
Post-contrast scan:
CM injection protocol with injection time = scan time + 7-s trigger delay.
Trigger delay: 7 s after the threshold of 100 HU is reached in the ascending aorta
using a bolus-tracking technique.
Scan protocol:
Gating: Retrospective or prospective (according to patient HR and technology available).
Scan region: From the ascending aorta to the heart apex.
References
Cademartiri F, Runza G, Luccichenti G et al (2006) Coronary artery anomalies: in-
cidence, pathophysiology, clinical relevance and role of diagnostic imaging. Ra-
diol Med 111:376-391
Dodd JD, Ferencik M, Liberthson RR et al (2007) Congenital anomalies of coro-
nary artery origin in adults: 64-MDCT appearance. AJR Am J Roentgenol
188:W138-146
Kacmaz F, Ozbulbul NI, Alyan O et al (2008) Imaging of coronary artery anomalies:
the role of multidetector computed tomography. Coron Artery Dis 19:203-209
A 63-year-old patient with no family history or risk factors for coronary artery
disease reported an episode of angina; ECG signs of myocardial ischemia were
absent. VR reconstruction and curved MPR image show: 1 a fibrocalcific plaque
at the level of the proximal segment of the right coronary artery (arrow); 2 a
large fibrocalcific plaque extending for the entire length of the proximal tract of
the left anterior descending coronary artery (arrow); 3 an extensive fibrocalcific
plaque at the level of the circumflex artery (arrow) and corresponding with the
first marginal branch
HEART Three-Vessel Disease 175
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in the right antecubital vein. The administration of negative chronotropic drugs,
such as beta blockers and calcium antagonists, is mandatory to reduce and to sta-
bilize heart rate (HR). The administration of nitrates is recommended to dilate the
coronary arteries.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline or 10 ml of CM + 40 ml of saline at the same flow rate.
Pre-contrast scan (calcium score): Useful for the quantification of coronary calcium.
Post-contrast scan:
CM injection protocol: Injection time = scan time + 7-s trigger delay.
Trigger delay: 7s after the threshold of 100 HU is reached in the ascending aorta
using a bolus-tracking technique.
Scan protocol:
Gating: Retrospective or prospective (according to patient HR and technology avail-
able).
Scan region: From the ascending aorta to the heart apex.
References
Cademartiri F, Romano M, Seitun S et al (2008) Prevalence and characteristics of
coronary artery disease in a population with suspected ischemic heart disease
using CT coronary angiography: correlations with cardiovascular risk factors and
clinical presentation. Radiol Med 113:363-372
Meijboom WB, van Mieghem CA, Mollet NR et al (2007) 64-slice computed to-
mography coronary angiography in patients with high, intermediate, or low pretest
probability of significant coronary artery disease. J Am Coll Cardiol 50:1469-1475
Meijboom WB, van Mieghem CA, van Pelt N et al (2008) Comprehensive assess-
ment of coronary artery stenoses: computed tomography coronary angiography
versus conventional coronary angiography and correlation with fractional flow
reserve in patients with stable angina. J Am Coll Cardiol 52:636-643
HEART Chronic Total Occlusion of the Left Anterior
Descending Artery with Associated Apical
Infarction
1 2
5 6
A 73-year-old patient with a prior episode of chest pain (3 years earlier) was
treated pharmacologically but undergoes CT coronary angiography at the return
of symptoms. 1 Axial MPR image shows the occluded left anterior descend-
ing artery (arrow) distal to the origin of the first diagonal branch. 2 Vertical
long-axis MPR image of the heart shows the extension of the occlusion (arrow),
which involves the entire vessel. 3 MPR image in a plane orthogonal to the
HEART Chronic Total Occlusion of the Left Anterior Descending Artery 177
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G catheter in the right
antecubital vein. The administration of negative chronotropic drugs, such as beta
blockers and calcium antagonists, is mandatory to reduce and to stabilize HR. The
administration of nitrates is recommended to dilate the coronary arteries.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline or 10 ml of CM + 40 ml of saline at the same flow rate.
Pre-contrast scan (calcium score): Useful for the quantification of coronary calcium.
Post-contrast scan:
CM injection protocol: Injection time= scan time + 7-strigger delay.
Trigger delay: 7s after the threshold of 100 HU is reached in the ascending aorta
using a bolus-tracking technique.
Scan protocol:
Gating: Retrospective or prospective (according to patient HR and technology available).
Scan region: From the ascending aorta to the heart apex.
References
Hecht HS (2008) Applications of multislice coronary computed tomographic an-
giography to percutaneous coronary intervention: how did we ever do without
it? Catheter Cardiovasc Interv 71:490-503
Otsuka M, Sugahara S, Umeda K et al (2008) Utility of multislice computed to-
mography as a strategic tool for complex percutaneous coronary intervention.
Int J Cardiovasc Imaging 24:201-210
Yokoyama N, Yamamoto Y, Suzuki S et al (2006) Impact of 16-slice computed tomo-
graphy in percutaneous coronary intervention of chronic total occlusions. Catheter
Cardiovasc Interv 68:1-7
longitudinal axis of the vessel. Note the complete absence of contrast material
within the vessel (arrow). 4 VR reconstruction demonstrates complete occlu-
sion of the vessel (arrow). 5, 6 Three-chamber short-axis MPR images show
diffuse hypoattenuation indicating the ischemic area, which resulted from the oc-
clusion of the left anterior descending artery. (Reproduced with the kind per-
mission of Dr. Nico R. Mollet, Erasmus Medical Center, Rotterdam, Netherlands)
HEART Plaque with Positive Remodeling
1 2
RCA
RCA
3 4
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G catheter in the right
antecubital vein. The administration of negative chronotropic drugs, such as beta
blockers and calcium antagonists, is mandatory to reduce and to stabilize HR. The
administration of nitrates is recommended to dilate the coronary arteries.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline or 10 ml of CM + 40 ml of saline at the same flow rate.
Pre-contrast scan (calcium score): Useful for the quantification of coronary calcium.
Post-contrast scan:
CM injection protocol: Injection time = scan time + 7-s trigger delay.
Trigger delay: 7s after the threshold of 100 HU is reached in the ascending aorta
using a bolus-tracking technique.
Scan protocol:
Gating: Retrospective or prospective (according to patient HR and technology avail-
able).
Scan region: From the ascending aorta to the heart apex.
References
Mowatt G, Cummins E, Waugh N et al (2008) Systematic review of the clinical ef-
fectiveness and cost-effectiveness of 64-slice or higher computed tomography
angiography as an alternative to invasive coronary angiography in the investi-
gation of coronary artery disease. Health Technol Assess 12(17):iii-iv, ix-143
Narula J, Garg P, Achenbach S et al (2008) Arithmetic of vulnerable plaques for non-
invasive imaging. Nat Clin Pract Cardiovasc Med (5 Suppl) 2:S2-10
Schmid M, Pflederer T, Jang IK et al (2008) Relationship between degree of remod-
eling and CT attenuation of plaque incoronary atherosclerotic lesions: an in-vi-
vo analysis by multi-detector computed tomography. Atherosclerosis 197:457-464
HEART Stenosis of the Left Anterior Descending
Artery
1 2
3 4
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in the right antecubital vein. The administration of negative chronotropic drugs, such
as beta blockers and calcium antagonists, is mandatory to reduce and to stabilize
HR. The administration of nitrates is recommended to dilate the coronary arteries.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline or 10 ml of CM + 40 ml of saline at the same flow rate.
Pre-contrast scan (calcium score): Useful for the quantification of coronary calcium.
Post-contrast scan:
CM injection protocol: Injection time = scan time + 7-s trigger delay.
Trigger delay: 7s after the threshold of 100 HU is reached in the ascending aorta
using a bolus-tracking technique.
Scan protocol:
Gating: Retrospective or prospective (according to patient HR and technology avail-
able).
Scan region: From the ascending aorta to the heart apex.
References
Foster G, Shah H, Sarraf G et al (2009) Detection of noncalcified and mixed plaque by
multirow detector computed tomography. Expert Rev Cardiovasc Ther 7:57-64
Schmid M, Achenbach S, Ropers D et al (2008) Assessment of changes in non-cal-
cified atherosclerotic plaque volume in the left main and left anterior descend-
ing coronary arteries over time by 64-slice computed tomography. Am J Cardi-
ol 101:579-584
Schuijf JD, Jukema JW, van der Wall EE et al (2007) Multi-slice computed tomo-
graphy in the evaluation of patients with acute chest pain. Acute Card Care 9:214-
221
HEART Right Coronary Artery Stent
1 2
3 4
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in the right antecubital vein. The administration of negative chronotropic drugs, such
as beta blockers and calcium antagonists, is mandatory to reduce and to stabilize
HR. The administration of nitrates is recommended to dilate the coronary arteries.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline or 10 ml of CM + 40 ml of saline at the same flow rate.
Pre-contrast scan (calcium score): Useful for the quantification of coronary calcium.
Post-contrast scan:
CM injection protocol: Injection time = scan time + 7-s trigger delay.
Trigger delay: 7s after the threshold of 100 HU is reached in the ascending aorta
using a bolus-tracking technique.
Scan protocol:
Gating: Retrospective or prospective (according to patient HR and technology avail-
able).
Scan region: From the ascending aorta to the heart apex.
References
Maintz D, Seifarth H, Raupach R et al (2006) 64-slice multidetector coronary CT
angiography: in vitro evaluation of 68 different stents. Eur Radiol 16:818-826
Mitsutake R, Miura S, Nishikawa H et al (2008) Usefulness of the evaluation of stent
fracture by 64-multi-detector row computed tomography. J Cardiol 51:135-138
Pugliese F, Cademartiri F, van Mieghem C et al (2006) Multidetector CT for visu-
alization of coronary stents. Radiographics 26:887-904
HEART Aneurysm of an Aorto-coronary Venous Graft
1 2
3 4
Study Protocol
References
Abbasi M, Soltani G, Somali A, Javan H (2009) A large saphenous vein graft
aneurysm one year after coronary artery bypass graft surgery presenting as a left
lung mass. Interact CardioVasc Thorac Surg 8:691-693
Trop I, Samson L, Cordeau MP (1999) Anterior mediastinal mass in a patient with
prior saphenous vein coronary artery bypass grafting. Chest 115:572576
Williams ML, Rampresaud E, Wolfe WG (2004) A man with saphenous vein graft
aneu- rysm after bypass surgery. Ann Thorac Surg 77:1815-1817
HEART Double Bypass
1 2
3 4
5 6
Study Protocol
References
Jones CM, Chin KY, Yang GZ et al (2008) Coronary artery bypass graft imaging
with 64-slice multislice computed tomography: literature review. Semin Ultra-
sound CT MR 29:204-213
Marano R, Liguori C, Rinaldi P et al (2007) Coronary artery bypass grafts and MD-
CT imaging: what to know and what to look for. Eur Radiol 17:3166-3178
Nabuchi A, Kurata A, Okuyama H et al (2008) Three-dimensional images of extra-
routine grafts in CABG by multi detector computed tomography. Ann Thorac
Cardiovasc Surg 14:333-335
1 2 3
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in the right antecubital vein. The administration of negative chronotropic drugs, such
as beta blockers and calcium antagonists, is mandatory to reduce and to stabilize HR.
The administration of nitrates is recommended to dilate the coronary arteries.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline or 10 ml of CM + 40 ml of saline at the same flow rate.
Pre-contrast scan (calcium score): Useful for the quantification of coronary calcium.
Post-contrast scan:
CM injection protocol: Injection time = scan time + 7-s trigger delay.
Trigger delay: 7s after the threshold of 100 HU is reached in the ascending aorta
using a bolus-tracking technique.
Scan protocol:
Gating: Retrospective or prospective (according to patient HR and technology avail-
able).
Scan region: From the lungs apex to the heart apex.
References
Crusco F, Antoniella A, Papa V et al (2007) Evidence based medicine: role of mul-
tidetector CT in the follow-up of patients receiving coronary artery bypass graft.
Radiol Med 112:509-525
Jabara R, Chronos N, Klein L et al (2007) Comparison of multidetector 64-slice com-
puted tomographic angiography to coronary angiography to assess the patency
of coronary artery bypass grafts. Am J Cardiol 99:1529-1534
Mueller J, Jeudy J, Poston R et al (2007) Cardiac CT angiography after coronary by-
pass surgery: prevalence of incidental findings. AJR Am J Roentgenol 189:414-419
VASCULAR Whole-Body Angiography
1 2
3 4
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in the right antecubital vein and 1.2 gl/s.
Iodine flow rate: 2.0 gI/s and 1.2 gl/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7/40.
320 6.2/3.7
350 5.7/3.4
370 5.4/3.2
400 5.0/30.
Pre-contrast scan: Unnecessary.
Post-contrast scan:
CM injection protocol:
Fixed injection time: 35 s (for patients between 60 and 90 kg).
Biphasic protocol: 1/3 of CM at 2 gl/s followed by 2/3 of CM at 1.2 gl/s every s after
the threshold of 100 HU is reached in the ascending aorta using a bolus-tracking
technique.
Saline flush: 50 ml of saline at the same flow rate.
Scan protocol: An arterial phase is mandatory. The diagnostic protocol provides low-
er kV values (80100 kV) with fixed mA (200 mA); alternatively, automated techniques
to reduce mA can be used.
Scan region: From the aortic arch to the foot.
References
Jackowski C, Persson A, Thali MJ et al (2008) Whole body postmortem angiography
with a high viscosity contrast agent solution using poly ethylene glycol as con-
trast agent dissolver. J Forensic Sci 53:465-468
Napoli A, Anzidei M, Francone M et al (2008) 64-MDCT imaging of the coronary
arteries and systemic arterial vascular tree in a single examination: optimisation
of the scan protocol and contrast-agent administration. Radiol Med 113:799-816
Ross S, Spendlove D, Bolliger S et al (2008) Postmortem whole-body CT angiography:
evaluation of two contrast media solutions. AJR Am J Roentgenol 190:1380-1389
VASCULAR Carotid Arteries-Carotid Stenosis with
Ulcerated Plaque
1 2
3 4
Study Protocol
Patient preparation: A 6-h fast pior to the examination; 18G intravenous catheter
in the right antecubital vein.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline at the same flow rate.
Pre-contrast scan: Unnecessary.
Post-contrast scan:
CM injection protocol: Injection time = scan time + 3-s delay.
Diagnostic delay: 3 s after the value of 100 HU is reached, with the ROI in the
ascending thoracic aorta.
Scan protocol: Spiral, caudate-cranial with maximum values of pitch and thin colli-
mation.
Scan region: From the aortic arch to the skull base.
References
Forsting M (2005) CTA of the ICA bifurcation and intracranial vessels. Eur Radiol
15 Suppl 4:D25-D27
Koelemay MJ, Nederkoorn PJ, Reitsma JB et al (2004) Systematic review of com-
puted tomographic angiography for assessment of carotid artery disease. Stroke
35:2306-2312
Saba L, Sanfilippo R, Pirisi R et al (2007) Multidetector-row CT angiography in the
study of atherosclerotic carotid arteries. Neuroradiology 49:623-637
VASCULAR Evaluation of Carotid Stent
1 2
3 4 7
5 6
1 The stent is evident in volumetric images (arrow), which do not provide in-
formation about its patency. 2 Data obtained through the analysis of longitu-
dinal axial-oblique reconstructions of the stent axis. 3-6 The condition of the
stent is seen on the anterior-posterior scanogram. 7 No information was
obtained from the angio-MRI study with gadolinium
VASCULAR Evaluation of Carotid Stent 195
Study Protocol
Patient preparation: A 6-h fast pior to the examination; 18G intravenous catheter
in the right antecubital vein.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline at the same flow rate.
Pre-contrast scan: Unnecessary.
Post-contrast scan:
CM injection protocol: Injection time = scan time + 3-s delay.
Diagnostic delay: 3 s after the value of 100 HU is reached, with the ROI in the
ascending thoracic aorta.
Scan protocol: Spiral, caudate-cranial with maximum values of pitch and thin colli-
mation.
Scan region: From the aortic arch to the skull base.
References
Kwon BJ, Jung C, Sheen SH et al (2007) CT angiography of stented carotid arter-
ies: comparison with Doppler ultrasonography. J Endovasc Ther 14:489-497
Orbach DB, Pramanik BK, Lee J et al (2006) Carotid artery stent implantation: eval-
uation with multi-detector row CT angiography and virtual angioscopy-initial
experience. Radiology 238:309-320
VASCULAR Lusory Artery
1 2
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in the right antecubital vein.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline at the same flow rate.
Pre-contrast scan: Unnecessary.
Post-contrast scan:
CM injection protocol: Injection time = scan time + 7-s trigger delay.
Trigger delay: 7s after the threshold of 100 HU is reached in the ascending aorta
using a bolus-tracking technique.
Scan protocol:
Scan region: From the aortic arch to the heart apex.
Spiral with maximum values of pitch and thin collimation.
References
Dursun M, Yilmaz S, Sayin OA et al (2007) Combination of unicuspid aortic valve,
aortic coarctation, and aberrant right subclavian artery in a child: MR imaging
and CTA findings. Cardiovasc Intervent Radiol 30:547-549
VASCULAR Post-traumatic Thoracic Aorta Aneurysm
(with Cardiac Gating)
1 2
3 4
Post-traumatic pseudoaneurysm at the level of the isthmus, the area of the aorta
most frequently involved by traumatic lesions. In this study of the thoracic aorta
with cardiac gating, note the presence of artifacts produced by ectopic heart beats.
1 Sagittal MIP reconstruction. 2 The 2D axial image shows a detail of the neck
of the pseudoaneurysm. Note the close relation with the esophageal wall, a risk
factor for possible fistula formation. 3 VR reconstruction identifies the pseudoa-
neurysm, highlighting its atypical morphology, which is quite different from the
saccular or spindle-like morphology of true aneurysms. 4 VR reconstruction
shows the aneurysm and its anatomical relations
VASCULAR Post-traumatic Thoracic Aorta Aneurysm (with Cardiac Gating) 199
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in the right antecubital vein.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline at the same flow rate.
Pre-contrast scan: Unnecessary.
Post-contrast scan:
CM injection protocol: Injection time = scan time + 7-s trigger delay.
Trigger delay: 7 s after the threshold of 100 HU is reached in the ascending aorta
using a bolus-tracking technique.
Scan protocol:
Gating: Retrospective or prospective (according to patient HR and technology avail-
able).
Scan region: From the aortic arch to the heart apex.
References
Ledbetter S, Stuk JL, Kaufman JA et al (1999) Helical (spiral) CT in the evaluation
of emergent thoracic aortic syndromes. Traumatic aortic rupture, aortic aneurysm,
aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer.
Radiol Clin North Am 37:575-589
Manghat NE, Morgan-Hughes GJ, Roobottom CA et al (2005) Multi-detector row com-
puted tomography: imaging in acute aortic syndrome. Clin Radiol 60:1256-1267
Salvolini L, Renda P, Fiore D et al (2008) Acute aortic syndromes: role of multi-
detector row CT. Eur J Radiol 65:350-358
VASCULAR Perforating Ulcer of the Thoracic Aorta
(without Cardiac Gating)
1 2
3 4
Study of the thoracic aorta without cardiac gating. 1 Sagittal MPR image
shows a large perforating ulcer of the posterior wall of the thoracic aorta (arrow)
and a small ulcer of the inferior wall of the aortic arch (arrowhead). 2 The 2D
axial image shows a detail of the perforating ulcer of the thoracic aorta. Note the
thrombotic apposition within the ulcer itself. 3 VR reconstruction demon-
strates the spindle-shaped aneurysm of the ascending aorta and the two plus im-
ages (arrows) corresponding to the two parietal ulcers. 4 Oblique MIP recon-
struction shows the perforating ulcer of the thoracic aorta, highlighting its marked
retro-aortic extension
VASCULAR Perforating Ulcer of the Thoracic Aorta (without Cardiac Gating) 201
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in the right antecubital vein.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline at the same flow rate.
Pre-contrast scan: Unnecessary.
Post-contrast scan:
CM injection protocol: Injection time = scan time + 7-s trigger delay.
Trigger delay: 7s after the threshold of 100 HU is reached in the ascending aorta
using a bolus-tracking technique.
Scan protocol:
Scan region: From the aortic arch to the heart apex.
Spiral with maximum values of pitch and thin collimation.
References
Hayashi H, Matsuoka Y, Sakamoto I et al (2000) Penetrating atherosclerotic ulcer
of the aorta: imaging features and disease concept. RadioGraphics 20:995-1005
Johnson TR, Nikolaou K, Wintersperger BJ et al (2007) Optimization of contrast
material administration for electrocardiogram-gated computed tomographic angio-
graphy of the chest. J Comput Assist Tomogr 31:265-271
Takahashi K, Stanford W (2005) Multidetector CT of the thoracic aorta. Int J Cardio-
vasc Imaging 21:141-153
VASCULAR Aortic Dissection Type A
1 2
3 4
1 Two-dimensional axial image shows the dissection arising at the level of the
ascending aorta and the double lumen at the level of the descending thoracic
aorta, with less enhancement of the false lumen. 2 On oblique MPR image,
the dissection can be seen extending along the thoraco-abdominal aorta up to the
iliac arteries. 3 Detail of the entry site at the level of the origin of the right re-
nal artery, which arises from the true lumen. 4 The dissection involves both
common iliac arteries
VASCULAR Aortic Dissection Type A 203
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in the right antecubital vein.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline at the same flow rate.
Pre-contrast scan: Unnecessary.
Post-contrast scan:
CM injection protocol: Injection time = scan time + 7-s trigger delay.
Trigger delay: 7 s after the threshold of 100 HU is reached in the ascending aorta
using a bolus-tracking technique.
Scan protocol:
Gating: Retrospective or prospective (according to patient HR and technology avail-
able) to best evaluate the aortic arch.
Scan region: From the aortic arch to the pelvis.
Spiral with maximum values of pitch and thin collimation.
References
Chirillo F, Salvador L, Bacchion F et al (2007) Clinical and anatomical character-
istics of subtle-discrete dissection of the ascending aorta. Am J Cardiol 15:1314-
1319
Heye T, Karck M, Richter G et al (2007) Visualization of entry and re-entry tears
in a complex type A aortic dissection by 64-slice dual-source computer tomog-
raphy. Eur J Cardiothorac Surg 32:935
Theisen D, von Tengg-Kobligk H, Michaely H et al (2007) CT angiography of the
aorta. Radiologe 47:982-992
VASCULAR Aortic Dissection Type B
1 2
Spindle-shaped aneurysmal dilatation of the thoracic aorta after the origin of the
left subclavian artery. Note the lamellar thrombotic apposition of the posterior
wall and the point of entry of the intimal dissection. 1 Two-dimensional axial
image. 2 VR reconstruction shows the extension of the dissection above the
common iliac bifurcation. 3 On oblique MIP reconstruction, the dissection can
be seen extending along the thoraco-abdominal aorta. The left renal artery arises
from the false lumen (arrow). 4 VR reconstruction shows the origin of the left
main artery from the false lumen
VASCULAR Aortic Dissection Type B 205
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in the right antecubital vein.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline at the same flow rate.
Pre-contrast scan: Unnecessary.
Post-contrast scan:
CM injection protocol: Injection time = scan time + 7-s trigger delay.
Trigger delay: 7s after the threshold of 100 HU is reached in the ascending aorta us-
ing a bolus-tracking technique.
Scan protocol:
Scan region: From the aortic arch to the pelvis.
Spiral with maximum values of pitch and thin collimation.
References
Mosquera VX, Marini M, Rodrguez F et al (2007) Complicated acute type B aor-
tic dissection with involvement of an aberrant right subclavian artery and rup-
ture of a thoracoabdominal aortic aneurysm, Crawford type I: successful emer-
gency endovascular treatment. J Thorac Cardiovasc Surg 134:1055-1057
Romano L, Pinto A, Gagliardi N et al (2007) Multidetector-row CT evaluation of
nontraumatic acute thoracic aortic syndromes. Radiol Med 112:1-20
Salvolini L, Renda P, Fiore D et al (2007) Acute aortic syndromes: role of multi-
detector row CT. Eur J Radiol 65:350-358
VASCULAR Mesenteric Vessels Anomalies and
Pathologic Presentations
1 2
3 4
These VR reconstructions show: 1 the celiac trunk, with the common origin of the
splenic artery, common hepatic artery and the superior mesenteric artery; 2 Crohns
disease, with hypertrophy of the vasa recta of the last ileal loop affected by the dis-
ease (arrow); 3 an aneurysm of the inferior pancreaticoduodenal artery (arrow);
4 the right hepatic artery arising from the superior mesenteric artery (arrow)
VASCULAR Mesenteric Vessels Anomalies and Pathologic Presentations 207
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in an antecubital vein.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline at the same flow rate.
Pre-contrast scan: Unnecessary.
Post-contrast scan:
CM injection protocol: Injection time= scan time + 8-s trigger delay.
Trigger delay: 8 s after the value of 100 HU is reached, with the ROI in the abdomi-
nal aorta, using a bolus-tracking technique.
Scan protocol:
Arterial phase is mandatory. The diagnostic protocol provides lower kV values
(80100 kV) with fixed mA (200 mA); alternatively automated techniques to reduce
mA can be used.
Spiral with maximum values of pitch and thin collimation.
Scan region: From the diaphragmatic dome to the pelvis.
References
Capuay C, Carrascosa P, Martn Lpez E et al (2009) Multidetector CT angiogra-
phy and virtual angioscopy of the abdomen. Abdom Imaging 34:81-93. PMID:
18709405
Ofer A, Abadi S, Nitecki S et al (2009) Multidetector CT angiography in the evalua-
tion of acute mesenteric ischemia. Eur Radiol 19:24-30. PMID:18690454
Saba L, Mallarini G (2008) Multidetector row CT angiography in the evaluation of
the hepatic artery and its anatomical variants. Clin Radiol 63:312-321
VASCULAR Aneurysm of the Subrenal Abdominal
Aorta
1 3
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in an antecubital vein.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline at the same flow rate.
Pre-contrast scan: Unnecessary.
Post-contrast scan:
CM injection protocol: Injection time = scan time + 8-s trigger delay.
Trigger delay: 8 s from reaching the value of 100 HU with ROI in abdominal aorta
using a bolus tracking technique.
Scan protocol:
Arterial phase. The diagnostic protocol provides lower kV values (80100 kV) with
fixed mA (200 mA); alternatively, automated techniques to reduce mA can be used.
Spiral with maximum values of pitch and thin collimation.
Scan region: From the diaphragmatic dome to the pelvis.
References
Albrecht T, Meyer BC (2007) MDCT angiography of peripheral arteries: technical con-
siderations and impact on patient management. Eur Radiol 17 Suppl 6:F5-F15
Heijenbrok-Kal MH, Kock MC, Hunink MG (2007) Lower extremity arterial dis-
ease: multidetector CT angiography meta-analysis. Radiology 245:433-439
Kock MC, Dijkshoorn ML, Pattynama PM et al (2007) Multi-detector row computed
tomography angiography of peripheral arterial disease. Eur Radiol 17:3208-3222
VASCULAR Aortic Endoprosthesis with Type I
Endoleak
1 2
3 4
1 This 2D axial image in the arterial phase shows the bifurcated endoprosthe-
sis with type I endoleak (asterisk) arising from the distal end of the left iliac arm.
2 Oblique MIP reconstruction shows the origin of the endoleak (arrow) at the
distal end of the left iliac arm due to an ineffective seal at the end of the graft.
3 Sagittal MIP reconstruction shows the type I endoleak. Note the beam-hard-
ening artifacts due to the metallic stent. 4 On VR reconstruction, the calcified
wall of the aneurysmal sac with the presence of the endoleak can be seen
VASCULAR Aortic Endoprosthesis with Type I Endoleak 211
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in an antecubital vein.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline at the same flow rate.
Pre-contrast scan: Necessary to evaluate hyperdense components of the stent.
Post-contrast scan:
CM injection protocol: Injection time = scan time + 8-s trigger delay.
Trigger delay: 8 s after the value of 100 HU is reached, with the ROI in the abdomi-
nal aorta, using a bolus-tracking technique.
Scan protocol:
Arterial phase and a late phase with a 180-s delay to assess the late endoleak are
mandatory. The diagnostic protocol provides lower kV values (80 100 kV) with fixed
mA (200 mA); alternatively, automated techniques to reduce mA can be used.
Spiral with maximum values of pitch and thin collimation.
Scan region: From the diaphragmatic dome to the pelvis.
References
Barbiero G, Baratto A, Ferro F et al (2008) Strategies of endoleak management follow-
ing endoluminal treatment of abdominal aortic aneurysms in 95 patients: how,
when and why. Radiol Med 113:1029-1042
Iezzi R, Cotroneo AR, Filippone A et al (2008) Multidetector-row computed tomo-
graphy angiography in abdominal aortic aneurysm treated with endovascular re-
pair: evaluation of optimal timing of delayed phase imaging for the detection of
low-flow endoleaks. J Comput Assist Tomogr 32:609-615
Rydberg J, Lalka S, Johnson M et al (2004) Characterization of endoleaks by dy-
namic computed tomographic angiography. Am J Surg 188:538-543
VASCULAR Aortic Endoprosthesis with Type II
Endoleak
1 2
3 4
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in an antecubital vein.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline at the same flow rate.
Pre-contrast scan: Necessary to evaluate hyperdense components of the stent.
Post-contrast scan:
CM injection protocol: Injection time = scan time + 8-s trigger delay.
Trigger delay: 8 s after the value of 100 HU is reached, with the ROI in the abdomi-
nal aorta, using a bolus- tracking technique.
Scan protocol:
Arterial phase and a late phase with a 180-s delay to assess the late endoleak are
mandatory. The diagnostic protocol provides lower kV values (80 100 kV) with fixed
mA (200 mA); alternatively, automated techniques to reduce mA can be used.
Spiral with maximum values of pitch and thin collimation.
Scan region: From the diaphragmatic dome to the pelvis.
References
Chernyak V, Rozenblit AM, Patlas M et al (2006) Type II endoleak after endoaortic
graft implantation: diagnosis with helical CT arteriography. Radiology 240:885-693
Saba L, Pascalis L, Montisci R et al (2008) Diagnostic sensitivity of multidetector-
row spiral computed tomography angiography in the evaluation of type-II en-
doleaks and their source: comparison between axial scans and reformatting tech-
niques. Acta Radiol 49:630-637
Tolia AJ, Landis R, Lamparello P, Rosen R, Macari M (2005) Type II endoleaks af-
ter endovascular repair of abdominal aortic aneurysms: natural history. Radiol-
ogy 235:683-686
VASCULAR Aortic Endoprosthesis with
Peri-prosthetic Inflammation
1 2
3 4
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in an antecubital vein.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline at the same flow rate.
Pre-contrast scan: Necessary to evaluate hyperdense components of the stent.
Post-contrast scan:
CM injection protocol: Injection time = scan time + 8-s trigger delay.
Trigger delay: 8 s after the value of 100 HU is reached, with the ROI in the abdomi-
nal aorta, using a bolus-tracking technique.
Arterial phase and a late phase with a 180-s delay to assess the late endoleak are
mandatory. The diagnostic protocol provides lower kV values (80100 kV) with fixed
mA (200 mA); alternatively, automated techniques to reduce mA can be used.
Scan protocol:
Spiral with maximum values of pitch and thin collimation.
Scan region: From the diaphragmatic dome to the pelvis.
References
Chernyak V, Rozenblit AM, Patlas M et al (2006) Type II endoleak after endoaortic
graft implantation: diagnosis with helical CT arteriography. Radiology 240:885-693
Saba L, Pascalis L, Montisci R et al (2008) Diagnostic sensitivity of multidetector-
row spiral computed tomography angiography in the evaluation of type-II en-
doleaks and their source: comparison between axial scans and reformatting tech-
niques. Acta Radiol 49:630-637
Tolia AJ, Landis R, Lamparello P, Rosen R, Macari M (2005) Type II endoleaks af-
ter endovascular repair of abdominal aortic aneurysms: natural history. Radiol-
ogy 235:683-686
VASCULAR Celiac Trunk Stent
1 2
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in an antecubital vein.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline at the same flow rate.
Pre-contrast scan: Necessary to evaluate hyperdense components of the stent.
Post-contrast scan:
CM injection protocol: Injection time = scan time + 8-s trigger delay.
Trigger delay: 8 s after the value of 100 HU is reached, with the ROI in the abdomi-
nal aorta, using a bolus-tracking technique.
Scan protocol:
Arterial phase and a late phase with a 180-s delay to assess the late endoleak are
mandatory. The diagnostic protocol provides lower kV values (80100 kV) with fixed
mA (200 mA); alternatively, automated techniques to reduce mA can be used.
Spiral with maximum values of pitch and thin collimation.
Scan region: From the diaphragmatic dome to the pelvis.
References
Ferrari R, De Cecco CN, Iafrate F et al (2007) Anatomical variations of the coeliac
trunk and the mesenteric arteries evaluated with 64-row CT angiography. Radiol
Med 112:988-998
Grierson C, Uthappa MC, Uberoi R et al (2007) Multidetector CT appearances of
splanchnic arterial pathology. Clin Radiol 62:717-723
Smith CL, Horton KM, Fishman EK (2006) Mesenteric CT angiography: a discus-
sion of techniques and selected applications. Tech Vasc Interv Radiol 9:150-155
VASCULAR Aorto-Bifemoral Bypass
1 2
3 4
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in an antecubital vein.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline at the same flow rate.
Pre-contrast scan: Unnecessary.
Post-contrast scan:
CM injection protocol: Injection time = scan time + 8-s trigger delay.
Trigger delay: 8 s after the value of 100 HU is reached, with the ROI in the abdomi-
nal aorta, using a bolus-tracking technique.
Scan protocol:
Arterial phase is mandatory. The diagnostic protocol provides lower kV values
(80100 kV) with fixed mA (200 mA); alternatively, automated techniques to reduce
mA can be used.
Spiral with maximum values of pitch and thin collimation.
Scan region: From the diaphragmatic dome to the knee.
References
Fleischmann D, Hallett RL et al (2006) CT angiography of peripheral arterial disease.
J Vasc Interv Radiol 17:3-26
Lopera JE, Trimmer CK, Josephs SG (2008) Multidetector CT angiography of infra-
inguinal arterial bypass. RadioGraphics 28:529-548
Willmann JK, Baumert B, Schertler T et al (2005) Aortoiliac and lower extremity
arteries assessed with 16-detector row CT angiography: prospective comparison
with digital subtraction angiography. Radiology 236:1083-1093
VASCULAR Bifurcation Endoprosthesis and Patent
Femoro-femoral Bypass
1 4
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in an antecubital vein.
Iodine flow rate: 2.0 gI/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7
320 6.2
350 5.7
370 5.4
400 5.0
CM volume: (Scan time + trigger delay)*flow rate.
Saline flush: 50 ml of saline at the same flow rate.
Pre-contrast scan: Necessary to evaluate hyperdense components of the stent.
Post-contrast scan:
CM injection protocol: Injection time= scan time + 8-s trigger delay.
Trigger delay: 8 s after the value of 100 HU is reached, with the ROI in the abdomi-
nal aorta, using a bolus-tracking technique.
Scan protocol:
Arterial phase and a late phase with a 180-s delay to assess the late endoleak are
mandatory. The diagnostic protocol provides lower kV values (80100 kV) with fixed
mA (200 mA); alternatively, automated techniques to reduce mA can be used.
Spiral with maximum values of pitch and thin collimation.
Scan region: From the diaphragmatic dome to the knee.
References
Chernyak V, Rozenblit AM, Patlas M et al (2006) Type II endoleak after endoaortic
graft implantation: diagnosis with helical CT arteriography. Radiology 240:885-693
Saba L, Pascalis L, Montisci R et al (2008) Diagnostic sensitivity of multidetector-
row spiral computed tomography angiography in the evaluation of type-II en-
doleaks and their source: comparison between axial scans and reformatting tech-
niques. Acta Radiol 49:630-637
Tolia AJ, Landis R, Lamparello P, Rosen R, Macari M (2005) Type II endoleaks af-
ter endovascular repair of abdominal aortic aneurysms: natural history. Radiol-
ogy 235:683-686
VASCULAR Lower Limbs-Peripheral Arterial Disease
1 2
The study provides a perfect representation of the arteries of the lower limb down
to the dorsalis pedis arteries. 1 Panoramic VR reconstruction with transparency
of the skeletal structures. 2 Axial image at the level of the iliac bifurcation. Note
the stenosis of the left common iliac artery with a not hemodynamically signifi-
cant reduction in the lumen (arrow). 3 Axial image at the level of the arterial
vessels of the lower limbs. Note the perfect representation of the interosseous (a)
and posterior tibial (b) arteries, with bilateral stenosis of the anterior tibial arteries
(black circles). 4 VR reconstruction of the vessels of the lower limbs
VASCULAR Lower Limbs-Peripheral Arterial Disease 223
Study Protocol
Patient preparation: A 6-h fast prior to the examination; 18G intravenous catheter
in an antecubital vein.
Iodine flow rate: 2.0 gI/s and 1.2 gl/s.
CM concentration (mgl/mL) Flow rate (mL/s)
300 6.7/40.
320 6.2/3.7
350 5.7/3.4
370 5.4/3.2
400 5.0/30.
Pre-contrast scan: Unnecessary.
Post-contrast scan:
CM injection protocol:
Fixed injection time: 35 s (for patients between 60 and 90 kg).
Biphasic protocol: 1/3 of CM at 2 gl/s followed by 2/3 of CM at 1.2 gl/s every s after
the threshold of 100 HU is reached in the ascending aorta using a bolus-tracking
technique.
Saline flush: 50 ml of saline at the same flow rate.
Scan protocol: An arterial phase is mandatory. The diagnostic protocol provides low-
er kV values (80100 kV) with fixed mA (200 mA); alternatively, automated techniques
to reduce mA can be used.
Scan region: From the diaphragmatic dome to the foot.
References
Fleischmann D, Hallett RL et al (2006) CT angiography of peripheral arterial disease.
J Vasc Interv Radiol 17:3-26
Lopera JE, Trimmer CK, Josephs SG (2008) Multidetector CT angiography of in-
frainguinal arterial bypass. Radiographics 28:529-548
Willmann JK, Baumert B, Schertler T et al (2005) Aortoiliac and lower extremity
arteries assessed with 16-detector row CT angiography: prospective comparison
with digital subtraction angiography. Radiology 236:1083-1093
EMERGENCY Post-traumatic Arterio-porto-biliary
Fistula of the Liver
1 2
3 4
1 Small lesion with pseudoaneurysmal aspect in segment VIII of the liver (black
arrow), adjacent to intraparenchymal dilated biliary branches containing hyper-
dense blood clots (black arrowhead). In the portal phase, there are no hepatic
parenchymal lacerations and only a minimal layer of hemoperitoneum (white ar-
rows). Aerobilia in the intraparenchymal left branches (white arrowhead) is ev-
ident. 2 Axial MIP reconstruction obtained in the arterial phase identifies a si-
multaneous opacification of a segmental arterial branch (black arrow) and an
intrahepatic segmental portal branch (white arrow). 3 Coronal MIP recon-
struction in the arterial phase documents a mild post-traumatic fistula between the
arterial branch of segment VIII and its corresponding portal branch (arrow).
4 Axial scan performed in equilibrium phase shows blood clots in the lumen of
the common biliary duct (black arrow). There is a small abscess in the subhepatic
space (white arrow) and a hematoma of the abdominal wall (arrowhead)
EMERGENCY Post-traumatic Arterio-porto-biliary Fistula of the Liver 225
Study Protocol
References
Becker H, MarKus PM (1994) Bile ducts lesions in liver trauma. Chirurg 65:766-774
Fragulidis G, Marinis A, Polidorou A et al (2008) Managing injuries of hepatic duct
confluente variants after major hepatobiliary surgery: an algorithmic approach.
World J Gastroenterol 14:3049-3053
Samek P, Bober J, Vrzgula A et al (2001) Traumatic hemobilia caused by false aneurysm
of replaced right hepatic artery: case report and review. J Trauma 51:153-158
EMERGENCY Obstructive Jaundice by Cystic Lymph-
angioma of the Anterior Para-renal Space
1 2
3 4
5 6
1 In this adolescent patient, the axial scan in the portal phase shows a neoformation
occupying the cephalo-pancreatic region (white arrow). The mass is encapsulated,
with a micro-and macrocytic appearance; it adheres to the head of the pancreas, which
is compressed and deflected toward the midline (arrowhead). The superior mesen-
teric vein is medialized (red arrow). 2 An axial scan also acquired in the portal
phase shows the distended common bile duct (red arrow) and gallbladder lumen
(arrowheads). The body and tail of the pancreas are normal (white arrow).
3 Wirsung dilation (arrowhead) is observed. 4 MIP reconstruction, in the axial
plane and arterial phase, shows the pancreatic-duodenal artery shifted forwards and
to the left from the midline (arrowhead). 5 Sagittal MIP reconstruction in the
arterial phase confirms displacement of the pancreatic-duodenal artery forwards
(arrow). The artery has thin walls and is of normal caliber; thin arterial branches from
EMERGENCY Obstructive Jaundice by Cystic Lymphangioma 227
Study Protocol
Patient preparation: The examination is performed in emergency. No preparation
is possible.
CM volume: 500600 mgI (iodine dose) per kg body weight.
Patient weight (kg) < 60 < 80 > 80
CM concentration (mgl/mL)
300 100 130 150
320 95 125 140
350 85 115 130
370 80 110 120
400 75 100 110
CM injection flow rate (mL/s) 1.6 gI/s 1.8 gI/s 2.0 gI/s
CM concentration (mgI/mL)
300 5.3 6.0 6.7
320 5.0 5.6 6.2
350 4.6 5.1 5.7
370 4.3 4.8 5.4
400 4.0 4.5 5.0
Pre-contrast scan: Low dose, useful to detect dystrophic calcification and intralesional
hemorrhage.
Post-contrast scan: The bolus-tracking monitoring technique is used.
Late arterial phase: 18-23 s after threshold of 100 H. ROI placed at the level of the di-
aphragmatic dome, to evaluate the arterial vasculature and to identify vascular ab-
normalities (arteriovenous fistula).
Portal phase: 60-70 s from the start of CM injection, to evaluate the portal tree and
to identify parenchymal lesions.
Comments: The localization of a multiloculated expansive cystic mass in the anteri-
or para-renal space, contiguous with the pancreatic head and compressing the ex-
trahepatic bile duct, results in a difficult differential diagnosis that includes cystic pan-
creatic neoplasms. In the case above, i.e., obstructive jaundice in a pediatric patient,
the arterial phase was instrumental to assess the anatomical relationships with the
pancreatic-duodenal artery, allowing diagnosis of a retroperitoneal tumor with com-
pression of the pancreatic head. After surgery, histological examination showed a lym-
phangiomatosis, and the pancreas was not resected.
References
Candanedo-Gonzales F, Luna-Prez P (2000) Cystic lynphangioma of the mesentery.
Clinical, radiological, and morphological analysis. Rev Gastroenterol Mex 65:6-10
Colovic RB, Grubor NM, Micey MT et al (2008) Cystic lynphangioma of the pancreas.
World J Gastroenterol 14:6873-6875
Ravasse P, Le Treust M, Levesque C et al (1995) Cystic retroperitoneal lynphangioma:
a tumor of polymorphic clinical manifestations. A propos of three cases. Arch
Pediatr 2:232-236
the superior mesenteric artery and supplying the mass (arrowhead) are visible.
6 Oblique coronal reconstruction obtained in the portal phase confirms distention
of the common bile duct at the middle third (dotted arrow), compression and de-
viation of the ducts retro-pancreatic aspect, and a neoformation (arrowhead), lo-
cated below the head of pancreas, which is, consequently, markedly compressed
EMERGENCY Bleeding Colonic Diverticulum
1 2
3 4
1 Axial scan obtained in the arterial phase shows active bleeding in a divertic-
ular formation (arrow) of the ascending colon. Contrast medium is seen in the
inferior vena cava due to the use of the right common femoral vein as the venous
access site. 2 Peripheral concentric distribution of the extravasated contrast
medium in the colonic lumen (arrowheads) during venous phase. 3 MPR
coronal reconstruction highlights the profile of the diverticulum in the medial as-
cending colon (arrow). 4 MPR sagittal reconstruction shows contrast medium
in the colonic lumen (arrows)
EMERGENCY Bleeding Colonic Diverticulum 229
Study Protocol
References
Kazuoki H, Nobutoshi M, Takayuki M et al (2009) Colonic diverticular bleeding: pre-
cise localization and successful management by a combination of CT angiogra-
phy and interventional radiology. Abdoml Imaging (published on line Oct 24)
Kinouchi M, Kuroda F, Doi T et al (2005) A case of bleeding from ascending colon
diverticula diagnosed by abdominal enhanced CT. Journal of Abdominal Emer-
gency Medicine 25:929-932
Kuhle WG, Sheiman RG, Sheiman E (2003) Detection of active colonic hemorrhage
with use of helical CT: findings in a swine model. Radiology 228:743-752
EMERGENCY Hemopneumoperitoneum Due
to a Weapon-related Injury of the
Pericardium and Diaphragm
1 2
3 4
1 Axial scan of the chest through the ventricular chambers documents a pneu-
mopericardial flap (arrow). The break point of the pericardium, where the weapon
penetrated (arrowhead), is clearly visible. 2 Sagittal reconstruction of the chest
confirms the presence of pneumopericardium (arrow) as well as air bubbles fil-
tering up through the cervical region (arrowhead). 3 Sagittal reconstruction of
the thoraco-abdominal region shows a pneumopericardial flap (arrow) and pneu-
momediastinal air bubbles that involve the cervical region (red arrowhead). In the
antero-upper abdomen, a layer of free air (pneumoperitoneum) surrounds the gas-
tric fundus (white arrowhead). 4 Axial scan of the abdomen confirms pneu-
moperitoneum (arrowhead) and documents the presence of a hemopneumoperi-
toneal flap in the perihepatic and perisplenic regions (arrow). 5 Axial scan
passing through the base of the neck confirms the presence of pneumomediasti-
nal air bubbles filtering up through the cervical region (arrow)
EMERGENCY Hemopneumoperitoneum 231
Study Protocol
References
Carrick MM, Pham HQ, Scott BG et al (2007) Traumatic rupture of the pericardi-
um. Ann Thorac Surg 83:1554
Lee SY, Lee SJ, Jeon CW (2008) Pneumopericardium occurring after stab wound
to the chest. Am J Surg 196:e10-e11
Romano L, Giovine S, Rossi G et al (1999) Rupture of the pericardium with luxa-
tion of the heart after blunt trauma. Emerg Radiol 6:252-254
EMERGENCY Volvulus in a Left Paraduodenal Hernia
1 2
3 4
1, 2 Axial scans performed, respectively, in the arterial and the portal phase
show dilation and tortuosity of the mesenteric vessels, both arterial and venous
(whirlpool sign), indicative of an intestinal volvulus (white arrows). How-
ever, the intestinal loops involved retain normal wall thickness and homoge-
neously enhance. 3, 4 Axial scans, performed in portal phase, show the
peritoneal gap in the left paraduodenal region, in which the bowel loops are also
herniated (white arrows). Aero-hydrodistension of the loop located immediately
over of the herniated jejunal loops (red arrow) is also clearly demonstrated. The
typical vortex appearance of the involved mesenteric vessels is extremely im-
portant for the diagnosis of volvulus
EMERGENCY Volvulus in a Left Paraduodenal Hernia 233
Study Protocol
References
Blachar A, Federle MP, Dodson SF (2001) Internal hernia: clinical and imaging find-
ings in 17 patients with emphasis on CT criteria. Radiology 218:68-74
Iannucci JD, Grand D, Murphy BL (2009) Sensitivity and specificity of eight CT signs
in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y
gastric bypass surgery. Clin Radiol 64:373-380. Epub 2008 Dec 16
EMERGENCY Fistula Between a Right Iliac Arterial
Aneurysm in a Loop of Small Intestine
1 4
1 Pre-contrast axial scan shows an aneurysm of the right common iliac artery.
Note the calcified walls with interruption of the anterior margin (arrow). 2 Ar-
terial phase shows parietal fissuring with passage of contrast medium (arrow-
head); an ileal loop adherent to the vascular wall (arrow) is visible. 3 Late
phase clearly illustrates rupture of the aneurysm (red arrow) and its irregular wall
(white arrow). 4 Coronal MIP reconstruction shows the right common iliac
artery aneurysm and its fissuring. 5 VR reconstruction shows the three-
dimensional aspect of the aneurysmal sac (arrow)
EMERGENCY Fistula Between a Right Iliac Arterial Aneurysm 235
Study Protocol
References
Hayashi H, Kumazaki T (2005) Multidetector-row CT. Evaluation of aortic disease.
Radiat Med 23:1-9
Lawlor DK, De Rose G, Harris KA et al (2004) Primary aorto-iliac enteric fistula:
report 6 new cases. Vasc Endovascular Surg 38:281-286
Milona S, Ntai S, Pomoni M et al (2007) Aorto-enteric fistula: CT findings. Abdom
Imaging 32:393-397
EMERGENCY Mechanical Obstruction of the Small
Intestine by Gallstone Ileus
1 2
3 4
1, 2 Axial and coronal scans in the portal phase show the ileal-jejunal loops with
regular perfusion of the wall and lumen distended by fluid-filled, hypertonic
folds. The gallbladder-duodenal fistula (arrows) is clearly visible. 3, 4 Coro-
nal and sagittal reconstructions show jejunoileal overdistension extending to the
pelvic cavity, where a transition zone is visible. Upstream of this zone, the di-
lated ileal loop has a rounded hyperdense formation in the lumen (arrowheads).
The downstream loops are collapsed (arrows)
EMERGENCY Mechanical Obstruction of the Small Intestine by Gallstone Ileus 237
Study Protocol
References
Farooq A, Memon B, Memon MA (2007) Resolution of gallstone ileus with spon-
taneous evacuation of gallstone. Emerg Radiol 14:421-423
Lassandro F, Gagliardi N, Scuderi M et al (2004) Gallstone ileus analysis of radio-
logical findings in 27 patients. Eur J Radiol 50:23-29
Leen GLS, Finlay M (1990) CT diagnosis of gallstone ileus. Acta Radiol 31:497-498
Ripolles T, Miguel-Dasit A, Errando J et al (2001) Gallstone ileus: increased diagnos-
tic sensitivity by combining plain film and ultrasound. Abdom Imaging 26:401-405
EMERGENCY Bleeding Jejunal Gastrointestinal
Stromal Tumor
1 2
3 4
5 6
1 Axial scan in arterial phase shows an expansive mass occupying one of the first
jejunal loops (arrow). The lesion is characterized by an intense peripheral vas-
cular enhancement with a central hemorrhagic area. 2 Axial scan in arterial
phase: a mesenteric arterious vessels supplies the lesion (arrow). 3 Axial scan
in portal phase: an expansive mass in the first jejunal loops within the hemorrhagic
area inside (arrow); an endovisceral hyperdensity referable to active bleeding is
not visible. 4 VR reconstruction angiography: a mesenteric arterial branch
(arrow), originating from the superior mesenteric artery, supplies the lesion.
5 Sagittal MPR reconstruction in arterial phase: a hyperdense endovisceral
EMERGENCY Bleeding Jejunal Gastrointestinal Stromal Tumor 239
Study Protocol
References
Bartolotta TV, Taibbi A, Galia M et al (2006) Gastrointestinal stromal tumour: 40-
row multislice computed tomography findings. Radiol Med 111:651-660
Chi-Ming Lee, Hsin-Chi Chen, Ting-Kai Leung et al (2004) Gastrointestinal stromal
tumor: computed tomographic features. World J Gastroenterol 5; 10:2417-2418
Kim JY, Lee JM, Kim KW, Park HS et al (2009) Ectopic pancreas: CT findings with
emphasis on differentiation from small gastrointestinal stromal tumor and leiomy-
oma. Radiology 252:92-100
lesion; the adjacent jejunal loops have a spastic reflex (asterisks). 6 Coronal
MPR reconstruction in arterial phase: an expansive formation occupies one of the
first jejunal loops, about 30 cm from the ligament of Treitz (arrow)
EMERGENCY Phytobezoar-induced Mechanical
Intestinal Obstruction
1 2
3 4
1 Proximal and middle Ileal and jejunal loops are dilated by liquid content. Prior
to the administration of contrast medium, a foreign body within the lumen (ar-
row) is clearly visible. 2 The wall of the involved loop shows physiological
enhancement (arrow). 3 Coronal MPR reconstruction shows the homogeneous
enhancement of the ileal loop walls. The mesentery seems normal but the down-
stream loops are collapsed (arrow). 4 Sagittal MPR reconstruction clearly
shows a foreign body (arrow) suggestive of hypodense material surrounding cen-
tral hyperdense nuclei. The phytobezoar resulted in mechanical obstruction of
the small intestine
EMERGENCY Phytobezoar-induced Mechanical Intestinal Obstruction 241
Study Protocol
References
Andrus Ch, Ponsky JL (1988) Bezoars: classification, pathophysiology and treatment.
Am J Gastroenterol 83:476-478
Di Mizio R, Scaglione M (eds) (2007) Ileo meccanico dellintestino tenue. Aspetti
TC e correlazioni eco-radiografiche. Springer-Verlag Italia, Milano
Zissin R, Osadchy A, Gutman V et al (2004) CT findings in patients with small bow-
el obstruction due to phytobezoar. Emerg Radiol 10:197-200
EMERGENCY Iatrogenic Injury of the Right
Diaphragmatic Artery by
Thermo-ablation of a Liver Nodule
1 4
1 The pre-contrast scan clearly shows a large right pleural effusion with a hy-
perdense formation indicative of a blood clot (arrow). 2 In arterial phase, there
is a small site of active bleeding inside the clot (arrow). 3 Venous phase, there
is an increase in the active bleeding (arrow). 4 Sagittal reconstruction shows
a hypodense region of the liver (arrow), the outcome of thermo-ablation, and a
hyperdensity of the surrounding diaphragm caused by active bleeding (white
arrow). 5 Coronal MIP image, in venous phase, shows an interruption of the
diaphragm profile above the thermo-ablation treatment site (arrow), where
signs of active bleeding (arrowhead) can be appreciated
EMERGENCY Iatrogenic Injury of the Right Diaphragmatic Artery 243
Study Protocol
References
Keckler S, Welch M, Danks RR (2006) Blunt injury to the right inferior phrenic artery
without associate hepatic injury. Injury Extra 37:218-219
Mizobata Y, Yokota J, Yaijma Y et al (2000) Two cases of blunt hepatic injury with
active bleeding from the right inferior phrenic artery. J Trauma 48:1153-1155
Sung Wook Shin, Young Soo Do, Sung Wook Choo et al (2006) Diaphragmatic weak-
ness after trascatheter arterial chemoembolization of inferior phrenic artery for
treatment of hepatocellular carcinoma. Radiology 241:581-588
EMERGENCY Traumatic Injury to the Right
Hemi-diaphragm
1 2
3 4
1 Axial scan of the liver dome shows a large parenchymal contusion of segment
VII (arrows). 2 Wide notch of segment VI between the thoracic and abdom-
inal cavities, corresponding to the collar sign (arrows). 3 Coronal MPR re-
construction shows intrathoracic displacement of most of the liver and corre-
sponding vascular structures. An area of atelectasia of the lung parenchyma
(arrows) can also be seen. 4 Sagittal MPR reconstruction with evidence of
parenchymal contusion and laceration of segment VII (red arrow) and corre-
sponding atelectasia of the lung (white arrow)
EMERGENCY Traumatic Injury to the Right Hemi-diaphragm 245
Study Protocol
References
Larici AR (2002) Helical CT with sagittal and coronal reconstructions: accuracy for
detection of diaphragmatic injury. AJR Am J Roentgenol 179:451-457
Rees O, Mirvis SE, Shanmuganathan K (2005) Multidetector-row CT of right hemidi-
aphragmatic rupture caused by blunt trauma: a review of 12 cases. Clin Radiol
60:1280-1289
EMERGENCY Abdominal Aortic Aneurysm with
Aorto-caval Fistula
1 2
3 4
1 Pre-contrast axial scan shows an aneurysm of the abdominal aorta with pari-
etal thrombotic apposition, calcification, and peripheral hyperdensity of the lu-
men (arrow). 2 The arterial phase shows a simultaneous enhancement of the
inferior vena cava (white arrow) and aorta (arrowhead); also clearly visible is
the link between the aortic lumen and the caval lumen (red arrow). 3 Coro-
nal MIP reconstruction in arterial phase shows hyperflow in the caval lumen and
fistula between the aorta and inferior vena cava (arrow). 4 VR reconstruction
allows an accurate evaluation of the two vessels involved (arrow)
EMERGENCY Abdominal Aortic Aneurysm with Aorto-caval Fistula 247
Study Protocol
References
Coulier B, Tilquin O, Etienne PY (2004) Multidetector row CT diagnosis of aortocav-
al fistula complicating aortic aneurysm: a case report. Emerg Radiol 11:100-103
Rubin G (2003) MDCT imaging of the aorta and peripheral vessels. Eur J Radiol
45:S42-49
Schwartz SA, Talijanovic AM, Smyth S et al (2007) CT findings of rupture, impeding
rupture, and contained rupture of abdominal aortic aneurysms. AJR Am J Roent-
genol 188:W58-W62
EMERGENCY Ileal Volvulus Complicated by
Intestinal Ischemia
1 2
3 4
Study Protocol
References
Yikilmaz A, Karahan OI, Senol S et al (2011) Value of multislice computed tomog-
raphy in the diagnosis of acute mesenteric ischemia. Eur J Radiol 80:297-302.
PubMed PMID: 20719444
Menke J (2010) Diagnostic accuracy of multidetector CT in acute mesenteric ischemia:
systematic review and meta-analysis. Radiology 256(1):93-101. Review. PubMed
PMID: 20574087
Furukawa A, Kanasaki S, Kono N et al (2009) CT diagnosis of acute mesenteric is-
chemia from various causes. AJR Am J Roentgenol 192(2):408-416. Review.
PubMed PMID: 19155403
EMERGENCY Perforated Peptic Ulcer
1 2
3 4
Study Protocol
References
Grassi R, Romano S, Pinto A et al (2004) Gastro-duodenal perforations: conventional
plain film, US and CT findings in 166 consecutive patients. Eur J Radiol 50:30-36
Pinto A, Scaglione M, Giovine S et al (2004) Quaranta pazienti con perforazione gas-
tro-intestinale: confronto tra la sede dei reperti TC spirale multidetettore di per-
forazione e la sede di perforazione riscontrata allintervento chirurgico. Radiol
Med 108:208-217
Pinto A, Scaglione M, Pinto F et al (2000) Helical computed tomography diagno-
sis of gastrointestinal perforation in the elderly patient. Emerg Radiol 7:259-262
EMERGENCY Active Bleeding in a Hematoma
of the Back
1 2
3 4
1 Pre contrast axial CT scan shows an extensive hematoma of the right gluteus
muscle (arrow). 2, 3, 4 Arterial, portal, and delayed acquisition phases show
a rounded lesion of about 3 cm (arrowheads) with distinct margins, within the
hematoma in the right gluteus muscle, with similar enhancement and wash-out
of arteries, suggesting gluteal artery pseudoaneurysm. Note that the shape of le-
sion does not change in the three post-contrast acquisition phases
EMERGENCY Active Bleeding in a Hematoma of the Back 253
Study Protocol
References
Anderson SW, Soto JA, Lucey BC et al (2008) Blunt trauma: feasibility and clinical
utility of pelvic CT angiography performed with 64-detector row CT. Radiology
246:410-519
Ptak T, Rhea JT, Novelline RA (2001) Experience with a continuous, single-pass
whole-body multidetector CT protocol for trauma: the three minute multiple trau-
ma CT scan. Emerg Radiol 8:250-256