Eur Radiol Suppl (2005) 15 [Suppl 5]: E60-E65

DOI 10.1007/s10406-005-0166-x

MDCT imaging: new challenges for scan and contrast optimization

Springer-Verlag 2005

Dominik Fleischmann

D. Flesichmann (
)
Department of Radiology
Stanford University Medical Center
300 Pasteur Drive, 5-072
Stanford, CA 94305-5105
United States
E-mail: d.fleischmann@stanford.edu
Tel.: 650-7237647
Fax: 650-7257296

How to design injection protocols

for multiple detector-row
CT angiography (MDCTA)

Abstract The basis of the development of optimal injection protocols

for multiple detector-row CT-angiography is knowledge of the physiological and pharmacokinetic principles of arterial enhancement.
This article reviews the key rules of
early arterial contrast medium dynamics: (1) Arterial enhancement
is directly proportional to the iodine
administration rate (iodine flux),
and can be controlled by the injection flow rate and the iodine concentration of the contrast medium;
(2) Arterial enhancement continuously increases over time with
longer injection durations, due to
the cumulative effects of bolus
broadening and recirculation; (3)
The strength of an individuals enhancement response to intravenously administered CM depends primarily on the patients cardiac output and correlates inversely with
body weight.

Multiple detector-row CT (MDCT) technology continues to rapidly evolve and, from generation to generation, spatial resolution has gradually improved. With
state of the art 16-channel MDCT systems, routine submillimetre resolution data acquisition has become possible, allowing CT angiography to replace diagnostic conventional angiography for many clinical applications. At
the same time, CT acquisition speed has dramatically increased. For example the scan times of an abdominal
CT angiography (CTA) have decreased from 20 s to less
than 5 s when comparing 4-, 8-, 16- and now 64-channel

In CTA, any of the following strategies can be employed alone, or in

combination, to achieve adequate
arterial enhancement in spite of
short acquisition times: Increasing
the injection rate, using higher concentration CM or increasing the injection duration (and scanning delay) relative to the scan time. Both
injection volumes and flow rates
should be adjusted to body weight,
at least for patients 60 kg and
90kg BW.
Rationally designed injection protocols based on physiological concepts
allow optimal CM utilisation and
take full advantage of the technical
capabilities offered by modern MDCT scanners.

Keywords Computed tomography

(CT), angiography contrast
medium, intravenous contrast
medium, pharmacokinetics

systems. While fast acquisitions at unprecedented spatial resolution offer new opportunities in CTA, contrast
material (CM) delivery becomes more difficult and less
forgiving at the same time. When one is fortunate
enough to be faced with the problem of designing new
injection protocols for CTA with a newly installed fast
CT scanner, it is necessary to integrate the scanner capabilities with the fundamentals of arterial enhancement, which are not entirely intuitive.
Several traditional concepts of CM injection for
CTA which were conceived empirically for single-de-

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tector row CT, are not valid for faster scan times. The
most common misconception regarding arterial enhancement is the assumption that a constant-rate intravenous injection of CM leads to an enhancement
plateau. In addition, the ball-park rule of choosing an
injection duration equal to the scanning time works
well for long scan times (20 s or so), but obviously cannot be used for a 4 s or shorter acquisition time. Finally,
the appealing idea that faster scans will naturally result
in better arterial enhancement is not necessarily true either, the opposite is actually the case; faster scanners
tend to result in lower arterial opacification if one applies traditional injection concepts.
So how can one design CTA injection protocols for a
fast scanner; that is, how can one make sure that adequate arterial opacification is achieved within a much
shorter time window of CT angiographic acquisition?
The key is knowledge of the physiological and pharmacokinetic principles of arterial enhancement, knowledge
of the effects of user-adjustable injection parameters
and the iodine concentration of the contrast medium.

The prerequisites
Early arterial contrast medium dynamics
There are essentially two controllable parameters
which, for a given individual, determine the time-course
of arterial enhancement [1]: these are the iodine administration rate (iodine flux), and the injection duration
(Fig. 1). The iodine administration rate is directly proportional to arterial enhancement and can be controlled
by the injection flow rate and the iodine concentration
of the CM. Thus, an increase in the injection rate and a
higher iodine concentration of the contrast medium directly translate into increased vascular enhancement.
Secondly, arterial enhancement continuously increases
over time with longer injection durations. This relationship is less intuitive but can be illustrated graphically
when considering a long injection (e.g 32 s) as the sum
of 8 smaller injections of 4 s duration (Fig. 1). Note that
the overall enhancement effect can be drawn as the integral (time-sum) of eight separate smaller enhancement curves, which overlap in time. It is obvious from

Fig. 1 Relationship between contrast medium injection and arterial enhancement. The simple
additive model illustrates the effects of the injection flow rate (iodine flux) and injection duration on arterial enhancement. (A) Intravenous
contrast medium injection causes (B) an arterial
enhancement response, which consists of an early
first pass peak and a lower recirculation effect. (C) Doubling the injection flow rate (doubling the iodine administration rate) results in
(D) approximately twice the arterial enhancement. (E) The effect of the injection duration can
be regarded as (F) the sum (time integral) of several enhancement responses. Note that due to the
asymmetric shape of the test enhancement curve
and to recirculation effects, arterial enhancement
following an injection of 128 ml (the time integral of eight consecutive injections of 16 ml) increases continuously over time

E62

this plot that shorter injection durations lead to lower

arterial enhancement.
There is substantial variability in the strength of arterial enhancement between individuals receiving the
same injection [2, 3]. The most important physiological
parameter determining arterial enhancement for a given
individual, is cardiac output [4, 5]. Increased cardiac output results in decreased arterial opacification. Low cardiac output results in stronger arterial enhancement because the iodine molecules administered per unit of time
are diluted in a smaller volume per unit of time, thus increasing the iodine concentration within the blood. Cardiac output is usually unknown in a given individual, but
correlates fairly well with body weight.
The basic rules of early arterial contrast medium dynamics can be summarised as follows:
1. Arterial enhancement is directly proportional to the
iodine administration rate (iodine flux, grams of Iodine per second), and can be controlled by the injection flow rate (mL/s) and the iodine concentration of
the contrast medium (mg I/mL).
2. Arterial enhancement continuously increases over
time with longer injection durations due to the cumulative effects of bolus broadening and recirculation.
Thus, increasing the injection duration also improves
vascular opacification.
3. The strength of an individuals enhancement response to intravenously administrated CM is controlled by cardiac output and central blood volume
and correlates with body weight.
Contrast Medium Transit Time (tCMT) and Individual
Scan Timing
The time interval for an intravenously injected bolus of
CM to appear in the arterial territory of interest is generally referred to as the contrast medium transit time
(tCMT). In patients with cardiocirculatory disease, the
scanning delay needs to be individualised relative to the
patients tCMT. The tCMT can be determined either by using a test bolus injection or by using automated bolus
triggering techniques [6, 7].
Traditionally, the scanning delay in CTA studies has
been chosen to equal a patients tCMT. However, with
faster scan times and shorter injection durations, this is
not necessarily the best strategy. Instead, a patients tCMT
may be used as an individual landmark, with an additional time delay (diagnostic delay) before initiation of
CT data acquisition. For example, a scanning delay of
tCMT+8 s means that scanning begins 8 s after arrival of
the CM bolus in a patients aorta.
Automated bolus triggering
Automated bolus triggering has the advantage that it
does not require a separate test-bolus injection for indi-

vidualising the scanning delay. However it is important

to be aware of the fact that the use of automated bolus
triggering inherently increases the scanning delay relative to the tCMT obtained with the test-bolus technique.
This is due to technical factors, such as the sampling interval for the monitoring slices, image reconstruction
time and a minimal delay required for changing the collimation and table repositioning after reaching the predefined threshold of opacification within the target vessel. Furthermore, when a prerecorded breath-hold command is used in conjunction with bolus triggering, this
may further delay the initiation of CT data acquisition.
While an increase of the scanning delay of a few seconds improves rather than deteriorates arterial enhancement, the main problem with bolus triggering is
that its inherent delay is not necessarily obvious to the
user and that it may differ substantially between scanner
models and manufacturers. The obvious solution is to
identify the inherent delay associated with bolus triggering for a given scanner model and to factor this slight delay into the injection duration. So, for example, if bolus
triggering results in an
8 s increase in the scanning delay relative to the true
tCMT, the injection duration needs to be 8 s longer than
the scan time.
Double-barrel power injectors and saline-flushing
The latest models of power injectors are equipped with
two syringes, which can be filled with CM and normal
saline, respectively. Routine flushing of the arm veins
after CM injection improves CM utilization and slightly
prolongs and increases arterial enhancement. Furthermore, saline-flushing may reduce perivenous streak artifacts in cardio-thoracic CT. Saline flushing is relatively
more important when using small amounts of contrast
agent and if high-concentration agents are being used.
Iodine concentration of contrast medium
The absorption of X-ray photons by intravenous contrast agents is exclusively determined by their iodine
content. The effect of the iodine concentration of a contrast agent on arterial enhancement is therefore
straightforward: enhancement is directly proportional to
the iodine concentration. Higher concentration agents
allow proportionally greater Iodine administration rates
for a given injection flow rate.
Injection strategies for CT angiography
Before considering specific injection strategies for CTA
it is helpful to think about CTA injection protocols. Injection protocols (and of course the subsequent arterial
enhancement) have a time-dimension and should be understood as Injection rate and Injection duration and

E63

not as Injection volume and injection rate. The injection volume is not an important parameter in the setting
of CTA, in contrast to parenchymal imaging, which has
fundamentally different kinetics.
The initial and most important step in the design of
injection protocols for CTA is then to consider the anticipated scan-time.
Injection strategies for slow acquisitions
Slow acquisitions refer to scanning durations in the range
of 20 s or longer. Such scan times are common with 4channel MDCT, notably with large volume coverage
(chest abdomen pelvis CTA), and even with 16 channel MDCT when EKG-gating is used. For slow acquisitions, traditional protocols yield reliable arterial enhancement. For example, one can use a standardized injection (e.g. 1.2-1.5 g of Iodine/s for an average individual
with approximately 75 kg of BW) for the duration of the
scan time. For example, for a 25 s scan, one might inject
at a flow rate of 4 mL/s for 25 s (i.e., a total volume of 100
mL). The scanning delay is set to the patients tCMT, as established by a test-bolus injection or by automated bolus
triggering. Higher (5-6 ml/s) or lower (3 mL/s) flow rates
should be used in larger (>90 kg) and smaller (<60 kg)
patients, respectively. With long scan times, biphasic or

multiphasic injections lead to more uniform arterial enhancement over time [8-10].
Injection Strategies for fast acquisitions
For fast acquisitions, the injection parameters and the
choice of the scanning delay need to be adapted in order to achieve adequate arterial enhancement. Based
on the first two rules (1 and 2) of early contrast medium
dynamics, one can apply two strategies to increase arterial enhancement for fast acquisitions. Alone or in combination, as illustrated in Figure 2: one can (1) increase
the iodine flux (grams of Iodine injected per unit of
time), which will translate into a proportionally stronger
enhancement. The iodine flux can be increased by the
selection of a higher iodine concentration of the contrast medium and/or by increasing the injection flow
rate (Fig. 1). In addition (2) one can increase the scanning delay relative to a patients tCMT. This will also increase arterial enhancement because of the continuing
rise of opacification with longer injection duration
(Fig. 1). It is crucial, however, to also increase the injection duration in this case, otherwise the arterial enhancement would not be maintained long enough. Both
strategies, increased injection rate and increased injection duration with increased scanning delay, are used to

Fig. 2 Strategies to improve arterial enhancement for fast MDCTA. Two strategies to increase arterial enhancement when compared
to a baseline 16 s injection at 4 mL/s (upper
left panel) can be employed; either alone or in
combination. Increasing the injection rate
from 4 to 5 mL/s increases the enhancement
approximately 20% (lower left panel). Increasing the iodine concentration from 300 to
400 mg/mL would achieve an even greater enhancement increase without the need to increase the injection rate. Alternatively, one
can also increase the injection duration and
the scanning delay taking advantage of the
fact that enhancement increases with longer
injection durations (right upper panel). Maximum enhancement can be achieved when
both the injection rate (and or the iodine concentration) and the injection duration are increased (right lower panel) simultaneously

E64

Fig. 3 Abdominal CT angiogram of a 43 year old woman with

Lupus vasculitis. Volume rendered image of a 16-channel MDCT, 16 x 1.25 mm dataset. Note the multiple strictures and
aneurysms leading to a beaded appearance of the short gastric,
gastroduedenal and gastroepiploic branches of the mesenteric
vasculature. Visualisation of such small detail requires strong arterial opacification. For this 12-second CT acquisition, a 20 s injection duration was used (scan-time + 8 s). The flow rate was 5
mL/s, resulting in a total volume of 100 mL. The scanning delay
was tCMT+8s; CT acquisition was initiated 8 s after CM arrival in
the abdominal aorta

opacify very small vessels in the clinical example shown

in Figure 3.
Injection Strategies for 64-Channel MDCT acquisitions
If one extends the above strategy for fast acquisition to
even faster scans, for example with a scan-time of only 4
s, which is easily possible with 64-channel MDCT, what
should be injected? Obviously one cannot inject 4 mL/s
for only 4 s, as the effect would be equal to that obtained
from injecting a test-bolus and certainly not enough to
study small arterial branches at high resolution. The solution would again be to increase the iodine flux (this
time to 2 g/s) and to increase both the scanning delay and
the injection duration by for example 8 s. Specifically,
this would translate into using a flow rate of 5mL/s of
400mg/mL CM, injected for 12 s (5+8), with a scanning
delay of tCMT +8s. The total volume would only be 60 mL.
With 64-channel MDCT, however, one can follow another strategy. Instead of attempting to tailor the injection to the very fast scan times, one can deliberately reduce the acquisition speed of the scanner in order to
adapt it to a robust injection protocol that results in

Fig. 4 Abdominal CT angiogram in a 75 year old woman with an

infrarenal abdominal aortic aneurysm. Study was obtained using
a 64-channel MDCT scanner with a scan time of only 5 s and
with the scan initiated immediately after contrast medium arrival
in the aorta (using bolus tracking software). Note that there is
not enough time for the contrast medium to fill the entire
aneurysm and only poorly opacified blood fills the aorta and iliac vessels distal to the aneurysm. This could have been avoided
by using a longer scanning delay and by reducing the acquisition
speed of the scanner

Table 1 64-Channel CTA acquisition and injection protocol for

abdominal CTA
Acquisition
Pitch
Scan time
Injection duration
Scanning delay
Body weight
<55 kg
56-65 kg
66-85 kg
86-95 kg
>95 kg

64 x 0.6 mm (channel x channel width)

variable (depends on volume coverage)
FIXED to 10 s
FIXED to 18 s
tCMT+8s (scan starts 8 s after
contrast arrives in the aorta)
CM Flow rate CM Volume
4.0 mL/s
72 mL
4.5 mL/s
81 mL
5.0 mL/s
90 mL
5.5 mL/s
99 mL
6.0 mL/s
108 mL

maximum vessel opacification. It is not necessary to operate such powerful scanners at maximum acquisition
speed. There is no advantage to using a 4 s versus a 10 s
acquisition for CT angiographic applications. Maximum
speed may even be detrimental because a very fast acquisition may not allow complete and sufficient opacification of a diseased arterial tree. This has been observed
in mesenteric CTA, in peripheral (lower extremity)
CTA [11], and even in abdominal CTA. Figure 4 shows
the case of a patient with an infrarenal abdominal aortic
aneurysm. Since no diagnostic delay was used, and because the scanner was operated with fast gantry rotation

E65

and pitch settings, the acquisition outraced the bolus in

the aorta, leading to poor opacification of the distal
aneurysm and the iliac arteries. So the final strategy, to
optimize injections for 64-channel MDCT, is to slow
down the acquisition of the scan and to use the same
scan-time for each patient (the pitch thus varies between
patients). This is the strategy we are currently adopting.

When scan times are constant, one can also use constant
injection durations for all patients. Flow rates can then
easily be individualised for patient weight (Table 1).
When automated tube current modulation is used, this
strategy results in very simple, robust CTA protocols,
which result in good arterial enhancement and similar
image noise across a wider range of patient physiques.

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and rationale. Eur Radiol 13 [Suppl
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2. Hittmair K, Fleischmann D (2001)
Accuracy of predicting and controlling
time-dependent aortic enhancement
from a test bolus injection. J Comput
Assist Tomogr 25(2):287-294
3. Sheiman RG, Raptopoulos V, Caruso
P et al (1996) Comparison of tailored
and empiric scan delays for CT
angiography of the abdomen. AJR
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9. Fleischmann D, Rubin GD, Bankier

AA, Hittmair K (2000) Improved
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Copyright of European Radiology is the property of Springer Science & Business Media B.V. and its content
may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express
written permission. However, users may print, download, or email articles for individual use.