CT Agiography

CTA

Leena Ketonen, MD, Ph.D.

Neuroradiology

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 •! The Fun and Easy Way
to use CTA and CTP
•! Your First Aid Kit for
Reconstructions on
Workstation
•! Creating Your First
Shaded Surface
Rendered Image in
Plain English
•! How to get
reimbursement
•! How to finance 16
slice CT scanners
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 •!

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 Clinical Use of CTA & CTP

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 CT & CTA
•! CT: Most accessible neurological imaging
modality

•! Fast, efficient and minimally invasive way

to look at brain and neck vessels

•! Suitable for high volume institutions

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 CT Angiography
1.! Fast, thin section volumetric spiral CT
examination

2.! Performed with a time-optimized bolus of

contrast

3.! Reformatting of cross sectional images

(raw data !source images)

4.! Postprocessing and 3D imaging

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 CTA
•! Can be performed in minutes

•! Downside: uses radiation and intravenous

contrast

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 NEW CT TECHNOLOGY
Light Speed Light Speed
–! 16 slice / multislice –! 4 slice / multislice
–! 4,000 programmable protocols –! 4,000 programmable protocols
–! 3D image processing and display –! 3D Image processing and display
–! Perfusion, advanced vessel anal. –! Perfusion, advanced vessel anal.
–! Dynamic scan: 960 scans/minute –! Dynamic scan 240 scans/minute
–! Image reconstruction time: 6 fps –! Image reconstruction time; 6 fps

•! Year product introduced: 2002 •! Available since 1998

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 CT Study for Stroke
16 slice scanner can do it all
•! NCCT
•! CT PERFUSION
•! CT ANGIOGRAPHY

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 Clinical Aspects
CTA - MRA
CTA MRA
•! Fast, needs less sedation •! No radiation
•! Less invasive than DSA •! Information regarding flow
•! All ERs have CT direction
•! Life support etc •! (DWI)
•! Less expensive than MRA

Downsides:
Downsides:
•! Difficult if monitors or life support,
•! Radiation
•! Sedation
•! Uses contrast
•! Long examination time
•! No flow directions
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 CTA study

•! The value of CTA and MRA depends

significantly on secondary
reconstruction possibilities

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 CTA Postprocessing
•! Image reformatting, performed by techs at the
scanner console is the recomputation of raw CTA
image data into source images with varying slice
thickness, interslice spacing and display FOV

•! Reconstructions refers to the creation of 2D and 3D

models from CTA data sets for purposes of diagnosis
and communication to referring clinicians

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 CTA Postprocessing
2D 3D
•! MIP: maximum intensity •! SSD: Shaded surface
projection display

•! Curved reformat
•! VR: Volume rendering
•! MPR: Multiplanar
reformats

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 CTA Postprocessing
MIP (maximum intensity projection) VR (volume rend.) - the best
•! Most commonly used •! Groups of voxels within defined
attenuation thresholds selected
•! Useful for rapid detection of
vascular discontinuities •! Transparent images; opacity
assigned
•! Part of standard software
SSD (shaded surface display)
•! Loss of information; only
•! First layer of voxels within a
single layer of the brightest defined thresholds used for
voxels are displayed display

•! depth
 information is lost •! depth
 information preserved
but attenuation information
lost
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 Advantage of Multisection CT
for vascular imaging of stroke patient

Less than 20 seconds Perfusion CT

•! Intracranial vessels •! 4 detectors: 2cm
slab
•! Carotid bifurcations
•! 16 detectors: 3 cm
•! Origins from aortic slab
arch
–! Whole brain CTP is
not yet possible
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 Imaging Protocol
for Lightspeed multislice scanner

•! 1st group:C-1/2 to vertex

•! 2nd group:Arch to C-1/2
•! Contrast: IV: 120 cc nonionic contrast, 3 cc/sec,
25 sec delay
•! Computer merges both groups
•! MIP reformatted images constructed within
minutes
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 CTA -- MRA
MRA CTA
–! Flow direction –! Shows collateral flow
–! Does not visualize –! Does not show flow
collateral flow direction

CTA and MRA are

complementary tests

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 Neck Vessels
MRA vs CTA
•! PC (2D/3D)
–! Velocity dependent. Needs specification for
VENC (arterial vs venous flow) and flow
direction (left-to-right, right-to-left, s/i, a/p)
•! 2D TOF
–! Antegrade flow. Saturation pulse to minimize
the retrograde flow (including jugular vein)
•! CE MRA
–! T1 WI, does not take in account the flow
direction or velocity. Uses rapid bolus of Gd
–!3D TOF
-for circle of Willis
•! CTA-one technique
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 New need: 3D Lab Service
•! Since late 1990s
•! MGH (June 2003)
–! Processed 67 exams/day
•! 47 were neuro CTA/MRA studies and
20 nonvascular 3D CT and MRI exams

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 3D post-processing
by experiences tech

•! It takes 45-60 minutes for head/neck CTA

post-processing (source images and MIPs are
available immediately)

•! Full training of a tech took two months

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 Normal Anatomy

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 Various ways to look at the
Anatomy in CTA
•! 2D •! 3D

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 Normal Anatomy

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 IC-EC Graft, curved reformatted
image

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 Curved reformatted image

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 Curvature Reformatted Image
Tracing The Vessel

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 Vertebrobasilar Analysis

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 Analysis of Carotid bifurcation

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 34 year old with headaches

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 Venous angioma

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 Saphenous IC-EC Graft

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 Clinical Use of CTA & CTP

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 CT Perfusion
CTP
•! IV bolus of contrast

•! Changes of brain tissue attenuation

monitored during the 5 second
transit time with high-temporal
resolution dynamic CT

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 CT Perfusion
•! 40 cc bolus of contrast
IV
•! Semiautomated
postprocessing
•! TTP, CBF, CBV in less
than a minute

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 TIA vs Stroke
•! NC CT •! CTA with contrast:
Perfusion window
(CBV)

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 TIA vs Stroke
•! DWI •! Perfusion MRP: MTT

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 CTA
•! MIP
•! Source image

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 CTA
MIP vs 3D

•! MIP – Ca++ marked with •! 3D VR -demonstrates Ca

arrows. Residual lumen not ++ and lumen
visualized.

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 91 y/o with stroke
•! Perfusion window
(poor man

s perfusion study,
CBV)

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 CTA, MIP

•! Patient underwent
IA thrombolysis with
good initial result

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 Acute Stroke
•! NCCT •! MIP

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 CTA, Stroke
1 year follow-up
•! Initial CTA •! Recanalized vessel

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 Acute Stroke
•! CECT •! Source image

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 CTA
Curved reformat images

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 Acute Stroke

•! Basilar artery

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 CTA
75 y/o with stroke

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 Acute stroke
•! NCCT •! CT perfusion window

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 Acute stroke
•! 3/3/03 NCCT •! 3/2/03 perfusion window
•! Follow-up •! Initial CTA

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 CTA Embolus
MIP

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 CTA
Stroke; 77 y/o Female
•! Source •! MIP

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 Acute Stroke
•! DWI •! ADC

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 Acute Stroke

•! MTT
•! MIP

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 Clinical Use of CTA & CTP

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 Orbital Trauma a Week Ago
Proptosis
•! CECT

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 CTA
R/O AV fistula
Source image

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 CTA
video reversal

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 ICH

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 CTA
Aneurysm
•! Noncontrast CT •! Source image

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 CTA
Aneurysm

•! Coronal MIP •! MIP; magnified

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 CTA
Surface Rendered Image
3D Image

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 SAH

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 CTA
ruptured aneurysm
•! Surface rendered •! MIP

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 CTA
basilar tip aneurysm

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 CTA
?Aneurysm
•! 3D SSD

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 CTA
Aneurysm

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 CTA
Aneurysm
•! MIP, mag

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 CTA
Aneurysm

•! Source image •! MIP

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 CTA
Postprocessed images
•! Curved reformat •! Surface rendered

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 CTA
72 y/o with TIA vs stroke

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 Clinical Use of CTA & CTP

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 Neck Vessel CTA
•! Arch

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 CTA
78 y/o with dizziness and abnormal US

•! R/O glomus jugulare tumor.

Abnormal US •! MIP

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 Carotid Dissection
Curved reformatted image
•! Source image

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 CTV
•! Contrast enhanced CT •! CTV

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 CTV

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 The End
Thank You

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