Computed Tomography (CT)

Computed tomography (CT) is one of the most commonly used imaging methods because it is
widely available, fast, and reliable. CT scans deploy X-rays to obtain cross-sectional images of
the body. A CT scanner consists of a tube that rotates around the patient and emits an X-ray
beam and a detector that uses specialized software to receive and convert the beam to an
image. The ability to create multiple views (axial, sagittal, coronal) and use contrast
(intravenous, oral, rectal) allows for enhanced diagnostic yield. Patients are exposed to
radiation, and special consideration should be given to patients with a history of iodine allergy,
renal disease, or thyroid disease or patients who are pregnant.

Last updated: February 14, 2023

CONTENTS

Terminology and Technology

Contrast Enhancement
Interpretation
Indications
Special Considerations and Contraindications
Other Imaging Methods
References

Terminology and Technology

General components
 Rotating X-ray tube:
Spins around the patient
High-energy electrodes in the tube emit radiation beams.
Radiation passes through the patient’s body.
Radiation detectors:
On the opposite side of the patient’s body from the X-ray tube
Absorbs and measures the remaining radiation (in the form of varying density) after it
has passed through tissues
Computer software detects the tomography generated by the detector and
reconstructs an image.
Motorized table: advances the patient through the scanner

CT scan components:
Arrangement of the X-ray tube and detectors in the CT scanner
Image by Lecturio.
Types of CT scanners
Helical (“spiral”):
Most common due to its speed
As the patient is moved through the CT, the rotating beam and X-ray detector spin. This
creates a helical path.
Results in a 3-dimensional data set
Minimizes errors due to patient movement or breathing
Sequential (step-and-shoot):
Was the conventional method before helical CT
The patient is moved through the CT with short pauses to capture images at each
position.
Results in an ↑ radiation dose
Used for high-resolution scanning of the lungs and coronary arteries and for coronary CT
angiography
 Differences between sequential and helical CT scanners:
Sequential CT takes discrete imaging slices as the patient moves through the scanner, whereas the
continuous movement of the helical CT results in a spiral path.
Image by Lecturio.

Image processing
Digital images are created with a matrix of voxels (3-dimensional pixels), which are
measured in Hounsfield units (HU).
An index used to universally quantify the radiodensity of imaged findings on CT
Based on the amount of radiation that a material absorbs:
Dense material will appear bright.
Less dense material will appear dark.
The index is constructed on assigned values to water (0 HU) and air (–1000 HU).
Postprocessing can be used to accentuate tissues of different densities.
Lung window
Bone window
Soft tissue window
Images can also be produced in different viewing planes.
Axial (looking from the feet up to the head)
Sagittal (looking from the side)
Coronal (looking from the front)
Table: Density of different material images on CT

Substance Hounsfield units (HU)

Air –1000 The darkest (most hypodense)

Fat –100 to –50

Water 0

Soft tissue 20–300

Bone 250‒700
The brightest (most hyperdense)

This table shows the density of different materials that would be imaged on CT. As you can see,
materials with a higher density than water will have a positive value (and are brighter), while
negative values are assigned to those with lower densities (and are darker).
CT image viewing planes:
The slices through this model demonstrate how axial, coronal, and sagittal images correlate with the
patient’s anatomy.
Image by Lecturio.
Contrast Enhancement
Contrast
Contrast agents may be used to enhance visualization of targeted tissues.
Oral:
Used for defining the bowel on abdominal and pelvic CT scans
Agents:
Barium sulfate (most common)
Isovue (an iodine-based solution)
Gastrografin (water-soluble, used to evaluate for bowel perforation)
Does not affect the kidneys
IV:
Used for enhancement and differentiation of vascular structures and solid organs
Agent: iodinated, low ionic, low osmolar solution
X-rays are absorbed by the contrast → ↑ attenuation
Contrast becomes more dilute as it moves from the arteries → tissues → veins
Image appearance changes over time.
Enhancement is based on:
The amount of blood flow
Timing of the image after contrast administration
Excreted by kidneys (should be used judiciously in acute or chronic renal failure)
Rectal:
Used for suspected penetrating colonic injury
Agents:
Isovue
Gastrografin
Given as an enema
Phases
Multiphase CT can identify structures at various intervals after IV contrast administration.
 Noncontrast phase: prior to contrast injection
Vascular (arterial) or bolus phase:
15–20 seconds after injection
Contrast diffuses into the vasculature.
Opacifies the aorta and its branches
Allows differentiation of renal cortex and medulla
Redistribution (venous) phase:
1–3 minutes after injection
Contrast diffuses from intravascular to extravascular compartment.
Opacifies the inferior vena cava, large veins, and solid organ parenchyma
Equilibrium (delayed) phase:
6–10 minutes after injection
Contrast reaches dynamic equilibrium in the intravascular and extravascular
compartments.
Opacifies the renal collecting system, ureters, and urinary bladder

Axial multiphase CT images of the abdomen:

a: Unenhanced image shows an infiltrative tumor-like hepatic mass.
b: Postcontrast arterial phase shows a nonenhancing, hypoattenuating lesion.
c: Postcontrast portal-venous phase shows a faint enhancement of fibroinflammatory components
surrounding the parasitic pseudocyst.
Image (https://commons.wikimedia.org/wiki/File:Parasite140075-fig2_Hepatic_alveolar_echinococcosis_imaging.png):
„Parasite140075-fig2 Hepatic alveolar echinococcosis imaging“ by Wenya Liu. Licence: CC BY 4.0
(https://creativecommons.org/licenses/by/4.0/)

Interpretation
The best approach is a systematic approach.
Check the patient’s demographics and name and the date.
Note the reason for the study.
Determine the part of the body that was imaged.
Look for prior imaging to allow for comparison.
Determine the image viewing plane and orientation.
Use multiple window levels and scroll through multiple times to ensure that all sections
are covered.
Viewing windows can be changed to optimize imaging of the desired organ system.
Evaluate one organ at a time.
Indications
Head CT
Noncontrast:
Severe head trauma
Stroke
Intracranial bleeding (appears hyperdense when acute)
Contrast:
Enhances neoplasms and infections
The angiographic phase is used to look for:
Large-vessel occlusion
Arteriovenous malformation
Aneurysm
Chest CT
Lung parenchymal diseases:
Interstitial lung disease
Pneumonia
Lung cavitations
Abscess
Lung cancer
Chest trauma:
Rib fractures
Pulmonary contusion
Diaphragmatic rupture
Laceration of the aorta or great vessels
Pleural disease:
Loculated effusions
Empyema
Hemothorax
Mediastinal pathology:
Cardiac tumors
Pericardial effusion
Pneumomediastinum
Vascular disease:
Pulmonary embolism
Aortic aneurysm or dissection
Abdominal and pelvic CT
Evaluation for abdominal and pelvic pathology:
 Blunt or penetrating abdominal injury
Appendicitis
Diverticulitis
Pancreatitis
Intra-abdominal infections
Renal, ureteral, and bladder calculi
Pneumoperitoneum
Bowel obstruction
Aortic aneurysm and dissection
Retroperitoneal hemorrhage
Evaluation of visceral malignancies:
Characterization of abdominal and pelvic masses
Staging evaluation of known malignancy
Monitoring with treatment

CT scan of the middle abdomen showing a subcapsular hepatic hematoma on the surface of the right lobe
of the liver (hypodense area indicated by the arrows) with a source of active bleeding (circle)
Image (https://openi.nlm.nih.gov/detailedresult?img=PMC4504646_medi-94-e1041-
g002&query=intra%20abdominal%20hematoma%20CT&it=xg&lic=by&req=4&npos=35): “CT scan of middle abdomen
showing a subcapsular hepatic hematoma” by From the Department of General Surgery, C.S. General and Emergency
Surgery, Azienda Ospedaliera - IRCCS Arcispedale Santa Maria Nuova, Reggio Emilia, Italy. License: CC BY 4.0
(http://creativecommons.org/licenses/by/4.0)
Special Considerations and Contraindications
Radiation exposure
Like other imaging methods, CT scans expose patients to radiation.
Ionizing radiation is additive.
Number of scans should be limited whenever possible.
Radiation dose:
Chest and abdominal CT: 10 mSv
Pelvic CT: 7 mSv
Head CT: 2 mSv
In context:
Chest X-ray: 0.013 mSv
Low risk of fetal malformation: < 50 mSv
Substantial fetal damage: > 500 mSv
Effects of radiation:
Molecular damage
Free radical formation
Disruption of cellular metabolic function
Cell death after a certain threshold
Carcinogenic risk increases with exposure.

Contraindications
Allergic reactions to contrast agents:
May manifest as hives or anaphylaxis
Patients can be premedicated with steroids and antihistamines if a contrast CT is
necessary.
Pregnancy: Iodinated contrast can cross the placenta.
Thyroid disease:
Iodinated contrast will reduce uptake of radioactive iodine → treatment is less
effective
Hyperthyroidism patients may develop thyroid storm from contrast.
Chronic or acutely worsening renal disease: Iodinated contrast can cause acute tubular
necrosis.

Other Imaging Methods

Comparison of imaging methods
Table: Comparison of imaging methods

Radiography CT Ultrasound MRI

Mechanism of Ionizing Ionizing Acoustic Ferromagnetic

acquisition radiation radiation energy pulses

Relative cost Inexpensive Expensive Inexpensive Very expensive

Portable Yes No Yes No

Length of exam Seconds < 1 minute Seconds Approximately 1

hour

Contrast No May be May be May be needed

needed needed

Imaging method options by system

 Imaging of the CNS (brain, spinal cord, and vertebral column):
Radiography is often used to evaluate for fractures of the vertebral column.
CT is a good choice for head trauma and to exclude intracranial hemorrhage.
MRI provides more detailed images of the brain and spinal cord, allowing
identification of infarction, tumors, disc herniation, and demyelinating disease.
Pulmonary radiology and imaging of the mediastinum:
Radiography is the preferred initial imaging study for viewing lung pathology.
CT scan provides more detailed views of the lung parenchyma, mediastinal
structures, and vasculature.
MRI is not often used, but may be employed for evaluating malignancies and cardiac
disease.
Ultrasonography can be used for a rapid bedside trauma assessment and for
guiding procedures (thoracentesis).
Breast imaging:
Mammography is often the initial choice for breast cancer screening.
MRI may be used to further evaluate and stage breast cancer.
Ultrasonography is helpful for evaluating lymph nodes and to guide biopsy.
Imaging of the abdomen and renal imaging:
Radiography is often used to evaluate for kidney stones, bowel obstruction, and
pneumoperitoneum. In addition, barium may be used to assess swallowing and
bowel function.
CT and MRI provide more detailed assessments of the abdominal viscera and
vasculature.
Nuclear medicine can be used to assess gallbladder function and gastric emptying
and for GI bleeding.
Imaging of the uterus and ovaries:
Ultrasonography is the most commonly used method to evaluate the ovaries and
uterus, including assessing pregnancies and the causes of
abnormal uterine bleeding.
CT and MRI provide more detailed views and are often useful in assessing cysts,
malignancies, and benign masses.
Imaging of the musculoskeletal system:
Radiography is often used to exclude fractures.
CT is more sensitive to bone pathology, including osteomyelitis.
MRI is preferred for a soft tissue evaluation, such as assessing for malignancy and
myositis.
Bone scanning can be useful in finding occult fractures, osteomyelitis, and metabolic
bone disease.

References
1. Kocak, M. (2019). Computed tomography. MSD Manual Professional Version. Retrieved December 2, 2020,
from https://www.msdmanuals.com/professional/special-subjects/principles-of-radiologic-imaging/computed-
tomography (https://www.msdmanuals.com/professional/special-subjects/principles-of-radiologic-
imaging/computed-tomography)
2. Stark, P. (2020). Principles of computed tomography of the chest. In Finlay, G. (Ed.), UpToDate. Retrieved
December 2, 2020, from https://www.uptodate.com/contents/principles-of-computed-tomography-of-the-
chest (https://www.uptodate.com/contents/principles-of-computed-tomography-of-the-chest)
3. Rawson, J. V., Pelletier, A. L. (2013). When to order a contrast-enhanced CT. American Family Physician
88(5):312–316.
4. Knipe, H., and Nadrljanksi, M.M. (2019). Computed tomography. Radiopedia. Retrieved December 2, 2020,
from https://radiopaedia.org/articles/computed-tomography (https://radiopaedia.org/articles/computed-
tomography)
5. Fertikh, D. (2015). Head computed tomography scanning. In Taylor, C.R. (Ed.), Medscape. Retrieved
December 2, 2020, from https://emedicine.medscape.com/article/2110836-overview
(https://emedicine.medscape.com/article/2110836-overview)
6. Taylor, C. R., Abramovici, G. (2017). Abdominal computed tomography scanning. In Mathur, M. (Ed.),
Medscape. Retrieved December 2, 2020, from https://emedicine.medscape.com/article/2114236-overview
(https://emedicine.medscape.com/article/2114236-overview)
7. Rogers, D. C., and Tadi, P. (2020). Intravenous contrast. StatPearls. Retrieved January 19, 2021, from
https://www.ncbi.nlm.nih.gov/books/NBK557794/ (https://www.ncbi.nlm.nih.gov/books/NBK557794/)