Jay P.

Heiken, MD James
#{149} A. Brink, MD Michael
#{149} W. Vannier, MD

Spiral (Helical) CT’

Spiral
phy (CT)
(helical) computed
involves continuous
tomogra-
patient
S PIRAL computed tomography (CT) tween
turers
scans. Recently,
have incorporated
most manufac-
slip-ring
(also referred to as helical or vol-
translation during x-ray source rota- ume-acquisition CT), in which x-ray technology2 into their gantry assem-
tion and data acquisition As a result, source rotation and patient transla- bly to allow continuous rotation of
a volume data set is obtained in a tion occur simultaneously during data the x-ray source and detectors. The
relatively short period of time. For acquisition, represents the latest tech- introduction of a slip-ring gantry sys-
chest or abdominal scanning, an en- nologic advance in CT imaging. Intro- tern has not only decreased interscan
tire examination can be completed in duced into clinical practice in 1989, delays to less than 5 seconds, but has
a single breath hold of the patient or spiral CT has gained widespread ac- made volume-acquisition CT scan-
in several successive short breath ceptance and has been applied suc- ning possible.
holds. The data volume may be cessfully to all areas of the body. By Volume-acquisition CT involves
viewed as conventional transaxial overcoming some of the fundamental simultaneous translation of the pa-
images or with multiplanar and constraints of standard CT, spiral tient at a constant rate through the
three-dimensional methods. The au- scanning has advanced established gantry during continuous rotation of
thors review the technologic aspects CT applications, including multipla- the source-detector assembly (1). As a
of spiral CT, as well as its advan- nar reformations and dynamic con- result, a spiral or helical projection
tages, limitations, and current clinical trast material enhancement, and has data set is obtained, often within a
applications. enabled new applications such as CT single breath hold of the patient. Scan
angiography. These advances, how- times range from less than 10 seconds
Index terms: Abdomen, CT, 70.12115 Blood
#{149}
ever, are not without some minor to as long as 50 seconds. The terms
vessels, CT, 90.12915 Bones,
#{149} CT, 40.12115 drawbacks such as increased noise “spiral” and “helical” CT are derived
Computed tomography (CT), helical Head,
#{149} and slight longitudinal blurring. We from the fact that during the scanning
CT, 10.12115 #{149}Muscles, 40.12115 State-of-art
#{149} review the technologic aspects of spi- process, the x-ray focus describes a
reviews Thorax, 60.12115
#{149}
ral CT, as well as its advantages, limi- spiral or helical path around the pa-
tations, and current clinical applica- tient. After acquisition of the raw pro-
Radiology 1993; 189:647-656
tions. jection data set, transaxial planar im-
ages are generated by means of
conventional filtered backprojection
BACKGROUND
methods after interpolation of projec-
Conventional chest or abdominal tion data between adjacent turns of
CT scanning (incremental scanning) is the spiral path. The reconstruction of
performed by obtaining a series of a sequence of transaxial sections from
individual scans during suspended a spiral/helical raw projection data set
respiration. Between scans, the pa- results in a data volume that may be
tient is allowed to breathe while the viewed as conventional transaxial pla-
table is moved to the next scanning nar images or with multiplanar and
position. Before the introduction of three-dimensional methods.
slip-ring interfaces in gantry construc-
tion, CT scanners incorporated electri-
TECHNOLOGIC
cal cabling to couple the x-ray tube
CONSIDERATIONS
and detector assembly to the recon-
I From the Matlinckrodt Institute of Radiol- struction processor and high-voltage Interpolation Algorithms
ogy, Washington University School of Medicine, power supply external to the gantry.
5i0 S Kingshighway Blvd. St Louis, MO 63110. This necessitated oscillatory motion of
Interpolation is required to synthe-
Received May 26, 1993; accepted and revision the source-detector assembly within size transaxial images from the vol-
requested June 18; revision received July 12. Ad-
the gantry to allow for cable length ume data set because direct recon-
dress reprint requests to J.P.H. struction of images from data
2 In a slip-ring gantry system, power is trans- limitations and tethering. Because of
mitted through stationary rings within the gan- the requirement for repeated stop-
try, eliminating electrical cables that would ping, changing the direction of mo-
hinder continuous rotation. This advance was
tion, and restarting the x-ray tube and Abbreviations: FWHM = full width at half
permitted by improvement in generator size
and efficiency. detector assembly within the gantry, a maximum, MIP = maximum intensity projec-
e RSNA, 1993 delay of 5-10 seconds resulted be- tion, SSP = section-sensitivity profile.

647
 200
obtained over any 360#{176} segment of a the reduced spatial resolution in the
spiral scan would result in nonuni- longitudinal plane with 360#{176}
interpo-
1150 ... FWHM..Dynamicl0..9.Omm
form section thickness and orienta- lation. Current spiral CT scanners -.. Sp.ral.8mm FWHM..Spiral8 11.1mm
lails broadened by 3.2mm
tion due to patient transport (2). The (most of which use 180#{176}
interpolation
z
I 1100
simplest approach is linear interpola- algorithms) allow scanning with table
t
tion between spiral projection data speeds greater than the collimation 1050

sets from adjacent turns (ie, 360#{176} (pitch > 1) without substantial pen-
apart) (3-5). However, 360#{176}
linear in- alty in longitudinal resolution, per- -20 -10 0 0 20

terpolation (also called full-scan with mitting coverage of relatively large

interpolation) diminishes the longitu- volumes. Figure 1. SSPs for conventional (dynamic)
dinal resolution, which can produce and spiral CT. Average SSPs for 10-mm colli-
mated conventional and 8-mm collimated
volume-averaging artifacts due to spiral scans show similar effective section
broadening of the section-sensitivity Radiation Dose thickness (full width at half maximum
profile (SSP) (3,6). Consequently, most [FWHM]) but broadening of the spiral “tails”
Because spiral CT employs continu-
current spiral CT scanners reorder the relative to the conventional scan. The “tails”
ous scanning, the x-ray-tube power refer to the peripheral portions of the profile,
projection data and perform interpo-
(ie, the highest permissible milliam- which describe the section sharpness in the
lation from views separated by 180#{176}
pere-second setting) is currently lim- longitudinal direction. (Reprinted from refer-
(180#{176}
linear interpolation or half-scan
ited to less than that used for stan- ence 6.)
with interpolation) (3-5). In this way
dard CT scanning. This power
the spiral scan range used for recon-
limitation is greatest for long scans
struction of each image is reduced,
(eg, 24 seconds or longer) and results
thereby diminishing the problem of introduction of new x-ray tubes with
in increased quantum noise. Given
volume-averaging artifacts. higher heat capacity.
the same x-ray-tube power, the radia-
tion dose to the patient for a spiral CT
SSP scan is equal to that for standard con- Operator-controlled Parameters
tiguous-section CT, if a pitch of 1 is
The SSP defines the voxel dimen- For each spiral CT scan, the radiolo-
used (ie, if the table speed is matched
sion and characteristics along the z gist must specify several scanning and
to the collimation). Radiation dose for
axis, the direction of table motion. reconstruction parameters including
spiral CT is decreased when the pitch
The ideal SSP at CT has a rectangular collimation, table speed, total scan
is greater than 1, compared with stan-
shape with a width equal to that of time, and image reconstruction inter-
dard contiguous-section CT. Since the
the section collimation. In practice, vals. As with standard CT, the choice
highest permissible milliampere-sec-
however, this ideal SSP is not achieved, of collimation depends on the par-
ond setting for long-duration spiral
even for standard CT scanning, be- ticular imaging task. For example, a
scans is currently less than that used
cause it is limited by geometric un- high-resolution examination of a lung
for standard CT, the radiation dose to
sharpness and scatter. With spiral nodule or the renal arteries may re-
the patient is currently less for long-
(helical) CT, the SSP is broadened to quire 2-3-mm collimation, whereas an
duration spiral CT.
varying degrees as a function of table examination of the neck, kidney, or
speed (3) (Fig 1). Simulated data show pancreas may require 5-mm collima-
that for a table speed equal to the nomi- tion and a routine examination of the
Noise
nal section thickness (pitch = i), the chest or liver may require 8-mm colli-
FWHM of the SSP is increased by ap- Image noise is measured as the mation. Total scan time is dependent
proximately 30% if 360#{176} linear inter- standard deviation of pixel values in a primarily on the patient’s ability to
polation is used, but it is not increased homogeneous region of interest. With hold his or her breath, but it is also
if 180#{176}interpolation is used (3). For a 360#{176}linear interpolation processing, influenced by scanner capabilities. For
table speed equal to twice the nomi- noise has been shown experimentally example, the scanners of some manu-
nal section thickness (pitch = 2), to be reduced by i7%-18% compared facturers are capable of programming
simulations show that the FWHM of with the noise in a standard single- only one spiral scan at a time, after
the 5SF is more than doubled with section CT study with the same nomi- which the scanner must be repro-
360#{176}
interpolation but increased only nal section thickness and radiation grammed. The delay between sepa-
30% with 180#{176}
interpolation (3). How- dose (3,5,6). The decrease in noise re- rately programmed spiral scans is sev-
ever, a phantom study has demon- sults from the relative increase in eral minutes. By contrast, other CT
strated no broadening of the SSP photon statistics with 360#{176} interpola- scanners are capable of preprogram-
when 180#{176}
linear interpolation is used tion compared with conventional CT. ming multiple spiral scan sequences.
at pitches up to 2 (7). It is clear that As noted earlier, however, use of 360#{176} The spiral scanning strategy used will
scanning with a pitch greater than 1 linear interpolation results in some depend on both the imaging task and
requires a 180#{176} data processing algo- partial volume-averaging effects. With the scanning capabilities available.
rithm. The difference between 360#{176} 180#{176}linear interpolation, noise has The strategy that is generally most
and 180#{176} interpolation is particularly been found experimentally to be in- useful for scanners allowing only one
apparent when one is performing creased by i2%-13% due to the rela- preprogrammed spiral sequence is to
multiplanar reconstructions, due to tive decrease in photon statistics corn- image the largest possible volume
pared with conventional CT (3,6). within the constraints of the particu-
Although such a small increase in lar imaging task. Such a scan requires
3 Pitch is defined as the table feed distance per noise is not readily apparent visually, a relatively long breath hold on the
360’ rotation divided by the section collimation. the combined effect of 180#{176} interpola- part of the patient (ie, 24-50 seconds).
Since spiral scanning is generally performed at
tion and limited x-ray-tube power can In contrast, scanners capable of pre-
one 360#{176}rotation per second, this definition can
be simplified to the table speed divided by the result in slightly noisier images. This programming multiple spiral se-
section collimation. problem is being overcome with the quences allow the flexibility of per-

648 Radiology
#{149} December 1993
a. b.

C. d.
Figure 2. Postoperative bronchial stricture. (a) Transaxiat and (b) off-coronal oblique spiral CT images show focal narrowing involving the
distal left mainstem, left upper lobe, and superior segmental bronchi (arrowheads, a) 4 months after resection of an endobronchial carcinoma.
Minimum intensity projection images (c, d) demonstrate the abnormality in different obtiquities about the longitudinal (c) and transverse
(d) axes. In c, note increased attenuation in collapsed left lower lobe (arrows). Scans were obtained by using 2-mm collimation, 4 mm/sec table
speed, and 1-mm reconstruction intervals.

forming multiple shorter spiral scans structed image is determined pri- Advantages
(eg, 10-20 seconds) in fairly rapid suc- manly on the basis of the collimation
cession, connected by short (eg, 7-10- used to acquire the data and is in- The potential for improved lesion
second) breathing periods. Such a dependent of the reconstruction detection with spiral CT is related to
technique allows large volume cover- interval. two main factors: the elimination of
age without requiring the patient to respiratory misregistration and the
hold his or her breath for an excessive ADVANTAGES AND ability to reconstruct overlapping im-
period. In addition, shorter spiral scans ages at arbitrary intervals. Since the
LIMITATIONS OF SPIRAL CT
allow the use of higher milliampere introduction of whole-body CT, radi-
setting, thus avoiding the problem of Spiral CT scanning has a number of ologists have appreciated the fact that
increased image noise associated with important potential advantages com- small lesions can be missed if the
longer spiral scan sequences. pared with standard incremental CT patient’s degree of inspiration or expi-
After the acquisition of a spiral vol- including improved lesion detection, ration varies from scan to scan. Be-
ume data set, the images can be re- improved lesion densitometry, opti- cause the volume data set of spiral CT
constructed at arbitrarily determined mization of enhancement with intra- is acquired during a single breath
positions and intervals along the z venous contrast material, reduction of hold, such respiratory misregistration
axis. The spiral technique allows re- total contrast material volume, and is eliminated, thus minimizing the
construction of overlapping images improved multiplanar and three-di- possibility of missing small lesions.
spaced at intervals as small as 1 mm mensional reconstructions. Current Using spiral CT and conventional CT
or less, although the use of such limitations of the spiral technique in- in a group of 39 patients suspected of
tightly overlapping images is usually dude increased image noise, de- having pulmonary nodules, Remy-
not necessary. The choice of recon- creased longitudinal resolution, in- Jardin and colleagues were able to
struction intervals is based on practi- creased time for image processing, identify a statistically significantly
cal considerations of the particular and increased requirements for data greater number of nodules with spiral
clinical problem being addressed. storage. Each of these advantages and CT (8). In a group of 20 patients, Cos-
It should be noted, however, that disadvantages is discussed in further tello and colleagues detected with
the section thickness of each recon- detail below. spiral CT four additional nodules not

Volume 189 Number

#{149} 3 Radiology 649
#{149}
Figure 3. Type A aortic dissection. The inti- a. C.
mat flap in the ascending aorta is demon-
Figure 4. Peridiaphragmatic mass evaluated with spiral CT. (a) Transaxiat image shows a
strated on spiral CT scan after administration
tobutated soft-tissue mass adjacent to the right hemidiaphragm (2-mm collimation, 2 mm/sec
of 75 mL of intravenous contrast material table speed, 1-mm reconstruction intervals). (b) Coronal and (c) sagittat reconstructions dem-
(8-mm collimation, 8 mm/sec table speed).
onstrate the abnormality to be an eventration of the diaphragm with liver protruding beyond
the expected diaphragmatic contour.

detected with standard incremental

CT (9). The ability to reconstruct im-
ages at intervals smaller than the scan can be obtained during the peak of
collimation reduces the possibility contrast enhancement. For liver scan-
that a small lesion will be missed be- ning, spiral CT has important implica-
cause of partial volume averaging. tions. One is that the liver can be
Urban et al have shown that by view- imaged completely during the non-
ing images of the liver reconstructed equilibrium phase, thus avoiding im-
at 4-mm intervals, 7% more lesions aging during the equilibrium phase
could be detected in a group of pa- when lesions can be obscured due to
tients with liver metastases, compared interstitial enhancement (1 1). Addi-
with viewing images of the same pa- tionally, spiral CT is capable of imag-
tients reconstructed at 8-mm intervals ing the liver during both the arterial
(10). The benefit of using overlapping and portal venous phases of hepatic
image reconstruction was found to be enhancement, allowing for optimal
most significant for small lesions. Be- visualization of both vascular and
Figure 5. Spiral CT arterial portogram
cause spiral CT reconstructions are nonvascular lesions.
shows multiple hepatic metastases. The ex-
performed retrospectively, overlap- For many types of CT examina- amination required only 60 mL of intrave-
ping images are obtained without ad- tions, the total volume of contrast ma- nous contrast material (8-mm collimation, 8
ditional radiation exposure to the pa- terial used for spiral scanning can be mm/sec table speed, 4-mm reconstruction
tient. An additional factor affecting reduced compared with that needed intervals).
the potential for improved lesion de- for standard CT because of the very
tection is the capability of optimizing short scanning times. A spiral CT ex-
enhancement with intravenous con- amination of the neck or chest re- high-quality reformatted images of
trast material (discussed below). quires only 60-80 mL of contrast me- vascular structures or of thoracic and
Improved lesion densitometry is dium, approximately half the volume abdominal organs can be produced
made possible with spiral CT by vir- generally used for standard CT ex- from the volume data sets because
tue of the ability to reconstruct images aminations of these areas (12,13). Re- spiral CT allows the acquisition of
at arbitrarily chosen positions along duction of contrast material volume continuous data, free from respiratory
the z axis. This capability ensures that for spiral CT examinations of the ab- misregistration. One drawback of us-
an image can be reconstructed domen, if feasible, will probably be ing multiple short breath holds, rather
through the center of any lesion, more modest. than a single breath hold, to complete
minimizing the effect of partial vol- High-quality multiplanar and a spiral CT study is loss of the data
ume averaging, which is often a prob- three-dimensional reformatted im- continuity and perfect registration
lern with standard single-section-ac- ages of the skull, bony pelvis, and ex- between adjacent spiral segments.
quisition CT. tremities can be produced by using An additional potential advantage
Because the spiral volume data set standard CT because of the lack of of spiral CT is improved patient
is acquired during a relatively short motion of these body parts during throughput, made possible by the re-
period of time (eg, 24-50 seconds) scanning (14,15). By contrast, multi- duced scanning time. Although this
compared with the time required for planar and three-dimensional recon- factor is expected to be of some im-
standard CT (generally 2 minutes or structions of intrathoracic and intra- portance in improving the efficiency
more), the enhancement effect of in- abdominal structures based on of scanning critically injured patients,
travenously administered contrast standard incremental CT scans are it will probably have limited impact
material can be optimized. By timing degraded by motion-induced misreg- on the overall throughput of routine
the spiral scan appropriately, the data istration artifacts. With spiral CT, patients. Moreover, the current soft-

650 Radiology
#{149} December 1993
a. b. C.

d. e.
Figure 6. Pancreatic adenocarcinoma. (a, b) Transaxiat images demonstrate a large mass in the tail of the pancreas encasing the left renal vein

-
(large arrow, b) and the splenic (arrowhead, a) and left renal (small arrow, b) arteries (5-mm collimation, 7 mm/sec table speed, i-mm recon-
struction intervals). (c) Left-sided sagittat reconstruction shows spread of tumor along the transverse mesocoton (black arrowheads) to the gas-
trocolic ligament (white arrowheads). The renal artery (small arrow) and ovarian vein (large arrow) are encased by tumor. M = pancreatic
mass, P = normal pancreas, S = stomach, C = transverse colon. (d) Oblique off-coronal reconstruction shows tumor encasing the superior mes-
enteric vein (arrow). (e) Coronal reconstruction shows extensive tumor involvement of the gastrocotic tigament (T). S = stomah, C trans-
verse colon.

ware of some manufacturers does not Spiral CT requires additional time quently tailored to the clinical prob-
allow realization of this potential say- for image processing compared with lem.
ings of time. standard CT. The increased time re-
quirement stems partly from the need
for data interpolation before planar CLINICAL APPLICATIONS
Limitations
images can be reconstructed. In addi-
Head and Neck
The increased image noise with spi- tion, the larger amount of image data
ral CT is related to both the interpola- generated by spiral CT requires more Spiral CT allows rapid acquisition
tion process and the limitation in x- frequent archiving, which tempo- of high-quality CT scans of the head
ray-tube power necessitated by rarily interrupts patient scanning. The and neck during one or two breath
continuous scanning (3,6). As noted need for larger-capacity archival de- holds, thus minimizing artifacts due
earlier, the introduction of higher vices is currently another minor to swallowing and respiratory mo-
heat capacity x-ray tubes will elimi- drawback. However, the use of more tion. In a study of 21 patients with
nate the latter problem. Reduction in efficient storage devices, such as digi- suspected or diagnosed upper aerodi-
longitudinal resolution with spiral CT tal audiotapes, may decrease the im- gestive tract abnormalities, Suojanen
is due to broadening of the SSP, which pact of this inconvenience. The most et al (13) obtained excellent vascular
results in varying degrees of volume- potentially time-consuming aspect of opacification and lesion enhancement
averaging artifacts (3,6). The partial vol- spiral CT is the postprocessing time by using less than 25 g of iodine per
ume-averaging effect is negligible when required for the radiologist or tech- examination. The technique also per-
table speed is matched to collimation, nologist to review the data and gener- mitted high-resolution three-dimen-
but it increases as pitch is increased ate multiplanar or three-dimensional sional and multiplanar reconstruc-
above 1 (3-7,16). However, this effect images, if they are required. Physician tions without additional scanning.
is minimized with use of 180#{176} interpo- input is often required to perform Spiral CT has been shown to be
lation algorithms (3,7). such reconstructions, as they are fre- comparable to ultrasounci and mag-

Volume 189 Number

#{149} 3 Radiology 651
#{149}
a. b. C.

Figure 7. Insutinoma. (a) Transaxial spiral CT image demonstrates a centrally calcified mass in the tail of the pancreas and a calcified tumor-
containing lymph node anterior to the pancreas (arrowhead) (5-mm collimation, 5 mm/sec table speed, i-mm reconstruction intervals). (b) A
more cephatic section shows an additional enhancing tumor-containing lymph node (arrow). (c) An oblique off-coronal reconstruction demon-
strates the relationship of the tumor (T) to the splenic vein (arrowheads). The lymph node metastasis in b is identified (arrow) cephalic to the
splenic artery.

netic resonance angiography in

evaluating the degree of internal ca-
rotid artery stenosis at the carotid ar-
tery bifurcation (17). A potential ad-
vantage of spiral CT compared with
the other two techniques is the ability
to demonstrate calcium in plaques
without distortion of surrounding
structures. Further work is needed to
determine the usefulness of spiral CT
as a screening technique for the Figure 8. Biliary ductal dilatation. Angled
coronal reconstruction displays the entire
evaluation of carotid artery disease.
length of the dilated common bite duct (ar-
Thus far, high-quality spiral CT im-
rowheads). No mass or stone is identified.
ages of the brain have been produced Image from endoscopic retrograde cholan- a.
in infants and young children but not giopancreatography confirmed the ductal
in older children, owing to the pre- dilatation without obstructing mass or stone.
sent limitation in x-ray-tube current Arrow points to dilated pancreatic duct
(18). In a study of 50 spiral CT exami- (5-mm collimation, 5 mm/sec table speed,
1-mm reconstruction intervals).
nations of the head, images of the
brain in adolescents and older chil-
dren were diagnostic but grainy due
to the larger head size and thicker ter of a small nodule. This advantage
calvarium in children older than 2 can be negated, however, if the sec-
years (18). The amount of contrast tion thickness is greater than the di- b.
material used for each spiral examina- ameter of the nodule or if the pitch is Figure 9. Renal cell carcinoma. (a) Trans-
axial spiral CT image shows a 1.5-cm mass
tion was one-sixth to one-quarter the greater than 1 (20). For most accurate
(arrow) in the lower pole of the left kidney.
amount routinely injected for conven- densitometry the section thickness
With conventional scanning, such a mass
tional CT. should be one-half the diameter of could be missed due to respiratory misregis-
the nodule. Volume-acquisition CT tration (2-mm collimation, 2 mm/sec table
also provides exquisite delineation of speed, i-mm reconstruction intervals).
Thorax (b) Coronal reconstruction clearly delineates
the tracheobronchial tree, allowing
the mass.
With spiral CT, the entire thorax or detailed multiplanar and three-di-
a selected region can be examined mensional image reconstructions, free
during a single breath hold. The re- from respiratory misregistration (21-
sulting images are comparable to 23) (Fig 2). We have found spiral CT material-enhanced spiral CT of the
those obtained with standard single- of the bronchi to be particularly help- chest is the noninvasive diagnosis of
section CT (9,19). Because of the con- ful in evaluating lung transplant re- central pulmonary thromboembolism.
tinuous data collection and the elimi- cipients and patients with endobron- A study of 41 patients has shown that
nation of respiratory misregistration, chial lesions. spiral CT is capable of demonstrating
spiral CT is capable of demonstrating As a consequence of the short scan- thromboemboli in second- to fourth-
additional small pulmonary nodules ning time, the volume of contrast ma- order pulmonary arteries (25). Three-
not shown by standard CT (8,9). In terial used to enhance the thoracic dimensional images of the pulmonary
addition, thin-section spiral CT pro- vascular structures can be reduced to vasculature can be produced with
vides excellent lesion densitometry approximately one-half that used for resolution of peripheral vessels
due to the ability to reconstruct retro- dynamic incremental CT (11,24) (Fig smaller than 2 mm in diameter
spectively an image through the cen- 3). A potential application of contrast (21,22,25).

652 Radiology
#{149} December 1993
 ever, dynamic incremental scanning
takes too long to image the liver dur-
ing both the arterial and portal ye-
nous enhancement phases. In con-
trast, spiral CT provides the potential
to image the entire liver twice, once
during arterial and once during portal
venous enhancement, although this
capability has not yet been demon-
strated clinically (28,29). We anticipate
that such dual hepatic imaging will
not become a routine application of
spiral CT but will be used in selected
patients. An important consideration
is that imaging the liver twice doubles
the radiation dose when a pitch of 1 is
a. b. used. Total radiation dose can be lim-
Figure 10. Leiomyosarcoma of the inferior vena cava. (a) Coronal reformatted image from ited by using a pitch greater than 1.
dynamic contrast-enhanced conventional CT examination (5-mm collimation, 8-mm intervals) The continuous data acquisition
shows a heterogeneously enhancing mass (M) arising from the inferior vena cava (arrows). with spiral CT makes possible two
(b) Coronal reconstruction from spiral CT examination (5-mm collimation, 7 mm/sec table additional hepatic imaging advan-
speed, 1-mm reconstruction intervals) demonstrates the same findings, free of respiratory mis-
tages compared with standard incre-
registration artifacts. Arrows delineate inferior vena cava, M = mass.
mental CT: (a) the potential for im-
proved lesion detection due to both
elimination of respiratory misregistra-
A further application of spiral CT is 50-60 seconds after the end of the tion and retrospective image recon-
the evaluation of peridiaphragmatic bolus administration (ii). Since cur- struction at arbitrary positions along
abnormalities. Multiplanar recon- rent state-of-the-art incremental CT the z axis and (b) production of high-
structions are helpful in localizing a scanners require 1.5-2.5 minutes to quality multiplanar images. Spiral CT
peridiaphragmatic mass to the abdo- scan the entire liver, standard incre- with smaller interscan spacing (eg, 4
men, diaphragm, pleura, or lung pa- mental CT is generally not capable of mm instead of 8 mm) increases confi-
renchyma (Fig 4). scanning the entire liver during the dence in detection and overall detec-
optimum liver scanning interval. Spi- tion rate of focal liver lesions (10).
ral CT overcomes this problem be- Multiplanar and three-dimensional
Abdomen
cause of its relatively short scanning reconstructions of the volume-ac-
Administration of intravenous con- time. With spiral CT, the entire liver quired data are useful in precisely
trast material during CT of the liver can be imaged during the peak of he- localizing and defining the extent of
improves the detection and character- patic enhancement without scanning hepatic tumors prior to resection.
ization of hepatic lesions. The pre- during the equilibrium phase. These advantages make spiral CT an
ferred contrast-enhanced scanning An equally important potential ad- excellent way to perform CT arterial
technique for routine liver screening vantage of spiral CT is the ability to portography (30,31) (Fig 5).
with conventional CT is dynamic in- scan the liver during both the hepatic Spiral CT also has been successfully
cremental scanning (ii). With this arterial and portal venous phases of applied to imaging the pancreas (32-
technique, a bolus of approximately enhancement. Hepatic arterial en- 34) (Figs 6, 7). The high contrast levels
150 mL of contrast material is admin- hancement begins approximately 20 achieved with spiral CT accentuate
istered as either a uniphasic (eg, 2-3 seconds after bolus initiation, with the difference between normal pan-
mL/sec) or biphasic (eg, 3-5 mL/sec portal venous enhancement peaking creas and tumor and allow exquisite
for the initial 50 mL, followed by 1 at 70-120 seconds. Three-quarters of evaluation of arterial and venous in-
mL/sec for the remainder) intrave- hepatic parenchymal blood supply is volvement by pancreatic disease.
nous injection. After a delay of ap- contributed by the portal vein, Studies have shown equivalent or
proximately 45 seconds from the start whereas tumors derive their blood superior peripancreatic vascular
of delivery of the contrast agent bo- supply entirely from hepatic artery opacification by using smaller
lus, images through the entire liver branches. Dynamic incremental he- amounts of contrast material corn-
are obtained as rapidly as possible. patic CT scanning protocols are de- pared with standard CT (32,33). The
The decision to begin scanning 45 sec- signed to optimize imaging during ability to scan the entire pancreas
onds after the start of the bolus ad- the portal venous predominant phase during arterial enhancement and to
ministration is a compromise, as peak of enhancement because most metas- reconstruct images at overlapping
hepatic enhancement does not occur tases are hypovascular compared intervals may improve the ability of
until 70-120 seconds after the start of with normal hepatic parenchyma CT to demonstrate small pancreatic
the injection, depending on the when imaged during this phase. islet cell tumors.
method of administration (26). This However, many primary hepatic neo- The porta hepatis, because of its
compromise is accepted, however, plasms and some metastases are iso- complicated anatomy and oblique
because a delay in scanning of longer or hypervascular and can become iso- orientation, is a difficult area to evalu-
than 45 seconds would result in imag- attenuating during the portal venous ate with standard CT. Volume-acqui-
ing a portion of the liver during the predominant phase. Because of their sition CT allows the radiologist to re-
equilibrium phase, when focal hepatic vascularity, such neoplasms are better format images of the porta hepatis in
lesions can be obscured. The equilib- imaged during the arterial phase of any plane to depict optimally the im-
rium phase begins approximately hepatic enhancement (27,28). How- portant vascular and biliary struc-

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#{149} 3 Radiology 653
#{149}
a. b.
Figure 11. Abdominal aortic aneurysm. (a) MI? and (b) shaded surface display renderings show a fusiform infrarenat aortic aneurysm. Scans
were obtained with 3-mm collimation, 5 mm/sec table speed, and 2-mm reconstruction intervals. The MIP image (a) demonstrates mural calcifi-
cation and thrombus (arrowheads). On the shaded surface display image (b), the mural thrombus is not displayed and the mural calcifications
(arrows) appear to be “floating” anterior and lateral to the aneurysm lumen. The renal arteries are clearly delineated. (Images courtesy of Ceof-
frey D. Rubin, MD, Stanford University School of Medicine, Palo Alto, Calif.)

tures. Detection of common bile duct lect data with continuous anatomic
stones and strictures can be improved information, spiral CT is capable of
with contrast-enhanced spiral CT, producing detailed three-dimensional
particularly when an interactive cine displays of blood vessels in any part
display console is used to determine of the body. Because thoracic and ab-
the most beneficial planes for display- dominal scans can be obtained in a
ing the biliary tree (35) (Fig 8). Al- single breath hold, the resulting
though intravenous cholangiographic three-dimensional image reforma-
contrast agents have been used in tions in these areas are not degraded
conjunction with spiral CT to produce by the respiratory misregistration that
positive three-dimensional images of limits such images derived from stan-
the bile ducts (36), oral agents-which dard CT scans. In addition, the short Figure 12. Portogram derived from CT arte-
are safer and less concentrated-may imaging time of spiral CT allows uni- rial portography study of the liver (8-mm
be more appropriate for use with spi- form vascular enhancement during collimation, 8 mm/sec table speed, 4-mm re-
construction intervals). An x-axis (transaxial)
ral CT. the entire scan. Bolus timing and vol-
MIP rendering demonstrates third-order
Spiral CT also has shown promise ume and rate of contrast medium de- branches of the portal venous system.
for improving the imaging evaluation livered are critical for optimal results.
of the kidneys (Fig 9). It has been For imaging the abdominal vascula-
found to be useful for studying small ture, flow rates of 4-5 mL/sec are gen-
renal masses that are indeterminate erally required to achieve adequate duction in collimation may severely
with other imaging techniques (37). intravascular concentrations of con- limit this option in the abdomen with
As in the lung, liver, and pancreas, trast material (39). However, in addi- present limitations in tube current.
the lack of registration artifacts and tion to adequate concentration of in- Two general methods of three-di-
the ability to reconstruct images at travascular contrast material, vascular mensional data display have been
overlapping intervals make it less resolution with CT angiography is found useful for CT angiography:
likely that a small mass will be missed. dependent on voxel size. Vascular maximum intensity projection (MIP)
In addition, three-dimensional recon- resolution is limited by partial volume (40-42) and shaded surface display
structions may provide useful infor- effect if the section thickness is larger (43,44) (Fig ii). MIP is a volume-ren-
mation in the staging of renal cell than the luminal diameter of the yes- dering technique widely used for MR
carcinoma and in the planning of con- sels being imaged. Under such cir- angiography displays (40,41). With
servation renal surgery in selected cumstances the severity of stenoses in this technique, a two-dimensional
patients (38). Spiral CT with multipla- transversely oriented vessels may be image is created by projecting math-
nar reconstructions may be useful in underestimated. Options to overcome ematical rays through a volume of
any situation in which anatomic rela- this limitation are the use of thinner reconstructed sections. The intensity
tionships are complex (Fig 10). collimation with matched table speed, of each pixel is the maximum inten-
resulting in coverage of a smaller vol- sity (in Hounsfield units) encountered
ume, or the use of thinner collimation along the ray as it traverses the vol-
Vasculature
coupled with increased table speed ume. In a similar way, minimum in-
One of the most exciting aspects of (ie, pitch > 1) to maintain a larger tensity projections can be constructed
spiral CT is its application to vascular volume of coverage. Regardless, the to display structures of very low pixel
imaging. By virtue of its ability to col- increase in noise associated with re- intensity such as the tracheobronchial

654 Radiology
#{149} December 1993
tree (Fig 2c, 2d). MIPs are generally small fracture displacements. Per- 12. Costello P, Dupuy DE, Ecker CP, Tetlo R.
Spiral CT of the thorax with reduced vot-
computed for multiple viewing angles forming the examination in less than
ume of contrast material: a comparative
and can be displayed on a cine loop to 1 minute minimizes the potential for study. Radiology 1992; 183:663-666.
convey three-dimensional structure patient motion, preserving anatomic 13. Suojanen JN, Mukherji 5K, Dupuy DE, Ta-
(42). Shaded surface displays are gen- relationships for multiplanar and kahashi JH, Costello P. Spiral CT in
evaluation of head and neck lesions: work-
erated by computing a mathematical three-dimensional displays.
in-progress. Radiology 1992; 183:281-283.
model of a surface that connects all 14. Vannier MW, Marsh JL, Warren JO.
pixels with Hounsfield units greater Three-dimensional CT reconstruction im-
than a user-defined threshold (42). A CONCLUSION ages for craniofaciat surgical planning and
evaluation. Radiology 1984; 150:179-184.
limitation of the shaded surface dis- By overcoming some of the con-
15. Scott WWJr, Fishman EK, Magid D. Ac-
play technique is its dependence on a straints of conventional CT, spiral CT etabular fractures: optimal imaging. Radi-
single threshold. Voxels with attenua- has advanced established CT applica- ology 1987; 165:537-539.
tion values above the chosen thresh- tions, including multiplanar recon- 16. Rigauts H, Marchat C, Baert AC, Hupke R.
old are considered to be of equal den- Initial experience with volume CT scan-
struction and dynamic contrast en-
ning. J Comput Assist Tomogr 1990; 14:
sity and those below the threshold are hancement, and has enabled new 675-682.
eliminated. Lowering the threshold applications such as CT angiography. 17. Schwartz RB,Jones KM, Chernoff DM, et
level results in a greater number of Experience with spiral CT is still lim- al. Common carotid artery bifurcation:
smaller blood vessels being visualized evaluation with spiral CT. Radiology 1992;
ited, and its clinical applications are
185:513-519.
but may also cause greater blood yes- currently evolving. Although addi- 18. Zimmerman RA, Cusnard DA, Bitaniuk LT.
sel obscuration due to visualization of tional experience will be required to Pediatric craniocervicat spiral CT. Neurora-
the surrounding enhanced paren- judge its full impact on clinical radiol- diology 1992; 34:112-116.
chyma (39). An additional limitation 19. Vock P, Soucek M, Daepp M, Katender
ogy, it is clear that spiral techniques
WA. Lung: spiral volumetric CT with
of shaded surface display is that calci- will play an increasingly important single-breath-hold technique. Radiology
fications cannot be distinguished from role in CT imaging in the coming 1990; 176:864-867.
intraluminal contrast material. Thus, a years. #{149} 20. Cann CE. Quantitative accuracy of spiral
calcified atheromatous plaque causing versus discrete volume CT scanning (abstr).
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