SPECIAL SERIES

RADIOLOGIC IMAGES IN DERMATOLOGY

The basic principles of computed tomography

and magnetic resonance imaging
Karen S. Caldemeyer, MD,a and Kenneth A. Buckwalter, MDb Indianapolis, Indiana

C omputed tomography (CT) and magnetic

resonance imaging (MRI) are the most wide-
ly used cross-sectional imaging methods
used in medicine. CT was a revolutionary develop-
ment of the 1970s. The term computed tomography
derives from computed (with computer), tomo (to
cut), and graph(y) (pictures). CT uses ionizing radi-
ation, or x-rays, coupled with an electronic detector
array to record a pattern of densities and create an
image of a “slice” or “cut” of tissue. The x-ray beam
rotates around the object within the scanner such
that multiple x-ray projections pass through the
object (Fig 1). The internal structure of the object
Fig 1. Diagram of CT scanner. X-ray beam rotates around
can then be reconstructed from the multiple projec-
patient lying in the center of the scanner. X-rays pass
tions of that object.1 through the patient from multiple projections and are
As x-rays pass through the patient, they are atten- detected by an electronic detector array that records pat-
uated. The amount of attenuation depends on the tern of densities. Through complex reconstruction meth-
type of tissue through which the x-ray beam passes. ods, an image is generated that records internal structure
X-ray imaging contrast is generated as a conse- of object.
quence of differences in attenuation between adja-
cent tissues. The higher the attenuation of the x-ray
beam, the brighter the tissue on CT images, and the
lower the attenuation, the darker the tissue on CT
images. Therefore bone and calcification that signif-
icantly attenuate the x-ray beam are white. Fat,
being rich in carbon, is more transparent than water
containing oxygen, which attenuates x-rays to a
greater degree.1 Therefore fat is blacker than water
on CT. Air causes little attenuation of x-rays and is
very black (Figs 2 and 3). Regional or focal devia-
tions from the normal CT appearance will be Fig 2. Relative CT density of structures is shown.

From the Department of Radiology, Division of Neuroradiology,a

and Division of Musculoskeletal Imaging,b Indiana University
School of Medicine.
Reprint requests: Karen S. Caldemeyer, MD, Indiana University
School of Medicine, University Hospital, Room 0279, 550 N
University Blvd, Indianapolis, IN 46202-5253.
J Am Acad Dermatol 1999;41:768-71.
Copyright © 1999 by the American Academy of Dermatology, Inc.
0190-9622/99/$8.00 + 0 16/1/98499
described as either increased (whiter) or decreased
(blacker) attenuation or density.
CT is excellent for detection of calcification and
evaluation of bone structures. Iodinated contrast
media can be used to increase the contrast between
normal structures and pathologic tissues and to
“opacify” the vascular structures (Fig 4). Iodine caus-

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VOLUME 41, NUMBER 5, PART 1

A B
Fig 3. Axial CT scans of brain without contrast (A is inferior to B) show the relative density of
fat (1), air (2), brain (3), bone (4), cerebrospinal fluid (5), and calcification (6). Anatomic struc-
tures labeled include frontal sinus (2), sphenoid sinus (s), temporal lobe (t), cerebellum (cb),
cortex (c), white matter (w), falx cerebri (f), lateral ventricle (open white arrow), and calcifi-
cation on choroid plexus (6).

A B
Fig 4. A, Axial CT scan without contrast shows no definite abnormality. B, Axial CT scan with
intravenous contrast shows two enhancing lesions (solid arrows), which were toxoplasmosis
in this patient with AIDS. Blood vessels are opacified with contrast and appear white (open
arrows).
770 Caldemeyer and Buckwalter J AM ACAD DERMATOL
NOVEMBER 1999

B C
Fig 5. A, T1-weighted axial MR image shows relative signal of cerebrospinal fluid (1) that is
darkest, followed by gray matter (cortex, 2; basal ganglia, 3), and white matter (4). B, On T2-
weighted axial MR image, cerebrospinal fluid (CSF) (1) is brightest, followed by gray matter (2,
3), then white matter (4). C, FLAIR axial MR image is a T2-like contrast image, but CSF (1) is
very dark. This increases the conspicuity of lesions, particularly diseased lesions adjacent to the
lateral ventricles, which might otherwise be obscured by bright CSF on T2-weighted images.

es significant x-ray beam attenuation and therefore ferent from CT. MRI does not rely on “transmission”
appears white on CT scans. of x-ray photons like CT but on the absorption and
MRI, unlike CT, uses no ionizing radiation. The emission of radiowaves from tissue protons exposed
physical principles underlying MRI are markedly dif- to a strong magnetic field. Smaller superimposed
J AM ACAD DERMATOL Caldemeyer and Buckwalter 771
VOLUME 41, NUMBER 5, PART 1

A B
Fig 6. A, T1-weighted axial image shows large frontal meningioma (arrows). B, On T1-weight-
ed axial image with intravenous contrast, the mass is much more obvious (straight arrows).
Note posterior displacement of the lateral ventricles (curved arrow). (Compare with normal
appearance in Fig 5.)

magnetic fields are employed to encode spatial local-
ization. Tissue contrast is the relative MR signal inten-
sity difference between adjacent anatomic
structures.2,3 The creation of MR images is complex
and beyond the scope of this article. However, in clin-
ical practice, two different image types are commonly
generated: T1-weighted images, and T2-weighted
images. These images look markedly different. On T1-
weighted images, cerebrospinal fluid is darkest, fol-
lowed by gray, then white matter (Fig 5, A). On T2-
weighted images, cerebrospinal fluid is brightest, fol-
lowed by gray, then white matter (Fig 5, B).
Fluid-attenuated inversion recovery images (FLAIR)
produce T2-like images, but suppress the signal of
fluid that appears dark (Fig 5, C). Changes from the
normal appearance on MRI are described as increased
signal (whiter) or decreased signal (darker).
Air, cortical bone, and rapidly flowing blood will
appear black on standard T1- and T2-weighted
images. Relative tissue contrast is generally much
greater on MR images than CT images, particularly
with respect to soft tissue structures. Unlike CT, MRI
is insensitive for detection of calcification and fine
bone detail. Like CT, intravenous MRI contrast media
may be used to enhance the contrast difference
between normal and pathologic tissue (Fig 6). This
“enhancement” is best seen on T1-weighted images
and the enhancing tissues will appear bright.
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2. Wehrli FW, McGowan JC. The basis of MR contrast. In: Atlas SW,
editor. Magnetic resonance imaging of the brain and spine. 2nd
ed. Philadelphia: Lippincott-Raven; 1996. p. 29-48.
3. Joseph PM. Principles of image formation. In: Atlas SW, editor.
Magnetic resonance imaging of the brain and spine. 2nd ed.
Philadelphia: Lippincott-Raven; 1996. p. 49-63.