Contrast Medium Administration and Scan Timing for MDCT Jay P.Heiken and Kyongtae T. Bae Introduction computed tomography ( has evolved from single-slice imaging to 4- and 16-slice scanners, the speed at which the patient is passed ination, which was not really feasible with si fierce ae 10-205, The m: reduced scan durations for mul= tidetector-row CT (MDCT) examinations have made scan timing more critical than for single-de- tector CT. At the same time, these short scan times have provided radiologists with an opportunity to therefore important for radiologists and technolo- gists to: (1) understand the factors that determine both the timing and magnitude of arterial and he- patic parenchymal contrast enhancement for CT, and (2) identify the modifications needed to opti- mize contrast enhancement for 4, 8-, 16-, and the new 64-r0w MDCT scanners. ‘Table 1. Changes in table feed with evolution in T technology ‘Detector configuration ‘Table feed, mms ‘Single row (3-5 mm detector collimation) 4 detector rows (1-mm detector collimation) 4 detector rows (2.5-mm detector collimation) 8 10 “ 16detector rows (0:75-mm detector collimation) 30 16detector rows (1.5-mm detector collimation) 60 Scan Timing Technical Factors jection [1-3], which is determined by the volume of medium and the rate at whichitis admin- trast medium [4]. As the contrast medium volume increases, the time it takes to reach the peaks of ar- terial and hepatic contrast enhance- ment alo increases (Fg. 1) [5]. Conversely, ania in injection rate results in a shorter time to peak enhancement (Fig 2) [5]. There, a short injection daration (i, small volume or high in- jection rate) resultsin earlier peak arterial and he- pati parenchymalenhancement i aa en ope ie) oatta lacy peak enhancement, requiring a long scan delay. Patient-Related Factors ‘The most important -related factor that af- focts scan timing is cardiac output [6]. Decreased ‘cardiac output (ie.,increased cardiovascular tran- sit time) results in delayed arrival of the contrast ‘bolus in the aorta, which leads to delayed arterial and hepatic parenchymal enhancement (Fig 2) Because of substantial variation in cardiac output ing iscritical, eg.,CT angiography (CTA). Scan de- lay can be individualized by using a test bolus [7, 8] or a bolus-tracking software program [9]. ‘The test bolus method (Fig. 4) is the more com- monly used technique, but it must be adapted for use with the faster scanners. Typically, we give ag| Cea Fa aeeeaET TIT setae >» 5 mom om mam Tine cy a Fig, 1a, b. Simulated contrast enhancement curves with tre different contrast medium volumes. Simulated enhancernent curves fa adult rae with afeed eng Vl contact medium at 2 enhancement increas with increased contrast medium value. Reprinted fom [8]} ‘the gota and bthe liver based ona “to ijecion oF 75,125, and 17S i ren pk nnn nde mag pt Cora Fanaa TOT] Tine ase) a That Panamera HO) ofa the aorta ard be ve based ona ment increases. Reprinted fom [5]) Fig 2a, b. Simulated contrast enhancement curves with three ferent contrast medium injection rates Simulated enhancement curves adut male wih. Fd eight (So 173 cm and body weight (150 or 68g), sub- [bet 150m of 320 gin contrast main injected a1, 3 and § m/s. The curves show that for constant wolume of contrast med tunyasthe rat finjecton increases, the ime it takes to reach the peak af enhancement decreases andthe magnitude of peak enhance- Simulated contrast enhancement caves at baseline and cardiac outs. Semulated enhancement curves ofthe {20rd ona hypetheical du male witha fed hgh SB" Flames Uncontmasum sls Aeta sree and enhancement cues were from ‘Be mel iy edecny the bce cdc opt Le 6500 iin, by 20, 40%, and 60% Reprinted om 25)Tees Velie CT peak CF tent bolas: Tra . Test bolus meth fo ncvdualzing the scan delay. On single or -cetecocrow scanner, the scan delay the time between the start of contrast medium Tame pe} nai baie / \ administration and that of scanning) is determined 25 the time necessary for catc enhancement ta peakafes 2 nal bolus injection of contrast medium. With faster scanners, scan must be delayed further cx imag- ing tobe performed during the peak enhancement of the aorta, Memzonta fines, canning period fr I-or 4+ detector-ow scanners (re) and for 16-datectarsaw scanners fue) small bolus (15-20 ml) of contrast medium at the rate to be used for the diagnostic examination, and. we determine when aortic enhancement peaks. For single- and 4-detector-row scanners, the time of peak aortic enhancement after a small bolus is used as the scan delay for the diagnostic examina- tion; this assures that diagnostic scanning is per- formed during the peakof aortic enhancement af- teradmini stration of full bolusof contrast medi= um. However, with faster scanners and thus short- er scan durations, scanning must be delayed even further if imaging is to be performed during the peak of aortic enhancement. This is done by adding an additional delay (2) to that calculated on the basis of the test bolus. The test bolus method is effective for determining the scan delay for asingle patient, but itis not an efficient method because it requires an additional volume of con- trast medium and is time-consuming. [A more efficient and elegant method to deter- mine the correct timing of scanning after contrast medium administration involves the use of bolus- tracking software with a region of interest (ROI) placed over the aorta (Fig. 5). A regular bolus of Fig. Sa, b. Determination of scan delay using bolus-rackng software. a Patient with normal cardiac output the 100 HU threshold is reached 2¢ about 25 sb atient with poor cardiac output: the IO0HU theshold is nat reached url SDs after bolus amination been started 2t 25 (the scan delay typicaly used for patents with normal and imagjing would Pave been perforata exty econ Had hse, réfac output the bolus would have Deen missedcontrast medium is administered and, approximate ly 10 s after the bolus injection is begun, low-dose monitoring scans are made to track enhancement in. the aorta. When a predetermined threshold (e.g. 100 HU) is reached, regular scanning is triggered. This method makes it possible to appropriately deter- mine the scan delay for individual patients withon- ly a single injection of contrast medium. Increasing the scan delayis one approach to op- timizing scan timing when working with faster CT. scanners. Alternatively, with 8- and 16-row MDCT, one can take advantage of the very short scan du- rations by reducing the volume of contrast medi- um administered; for example,using a 16-detector- row scanner, excellent images can be obtained us- ing only 75 ml of iodinated contrast medium Fig. 6. Endoluminal stent graft repair of an abdominal aortic aneurysm. CTA performed on a 16-row mulide- tector (scanner using only Sen of contrast mecsum. a Transaxial image. b Valume-tendered image. ¢ Max ‘mum intensity projection image (Fig. 6), The new 64-row scanner may allow a fur- ther reduction in the volume of contrast medium. Nonetheless, the use of smaller volumes of contrast medium may require that the scanning protocol be optimized to overcome the possibility of reduced enhancement. Contrast Enhancement Magnitude Technical Factors Arterial Enhancement. The magnitude of arterial enhancement is determined by the rate of iodine delivery into the vascular system. The rate of io- dine delivery depends upon three factors: (1) theAer Canrant Pakancon ent) Fig. 7. Efecto contrast medium injection rte o the magnitude ‘of peak contrast enhancement (fom simulated contrast enhance ‘meni curves). Peak aortic and hepatic contrast enhancements at ‘ifferen injection rater are smulated based on a hypothetical ‘adult male with 2 fixed eight (5" or 173 cr) and (150 Ib or 68g) subject to tajecton of 120 ml af 320 ‘trast medium. (epeinted fom [1) icon * . ‘Time (20) ony Tepe CE TIO Fig. 8a, b. Semulsted contrast enhancement cuneswith afired amount ofiadine mass but thee cifferent contrast mecium concentra ‘on injected at constant rate. Semulated enhancement curves of athe oct and liver based on ahypotheticaladultmalewith afixed beg or 13 onlancbdy wage SD Bg ig uber BU mg of the same amount of iodine mass butatthree dit ‘and 200 mgr, 105 rl The aortic and hepatic teen [ance aves comnts ha ew oighoncnree cote atrial wih ealtand une pak nee hancement. The effect on hepatic parenchymal enkancement is minimal (leprnted from [29]) concentration of iodine in the contrast medium, €2) he injection ate (Fig 7). and (3) he nection ‘volume (primarily through recirculation of trast medium already in the vascular system). In creases iniodine concentration [10], injection rate 1,11], and volume [10] all result in increased arte- rial enhancement. Use of contrast material with a higher iodine concentration ‘more aortic contrast enhancement,e venif the total iodine dose and injection rate are unchanged, by virtue of in- creasing the rate of iodine delivery to the vascular system (Fig. 8). When the contrast medium volume is reduced for CTA with 8-and 16-row (andin fu- ture 64-row) MDCT, an increased injection rate and highiodine concentration can compensate for the somewhat decreased magnitude of aortic en- hancement achieved with the smaller contrast medium volume, Hepatic Parenchymal Enhancement. Hepatic cen ‘enhancement is determined by the totaliodine dose administered [3, 12-18], whichin improve ‘hepatic parenchymal enhancement to the extent thatit increases overall iodine dose [19]. The injec- tion rate plays a more limited role in hepatic parenchymal contrast enhancement (Fig. 7); the concentration of iodine in the contrast medium hhas little effect on cenhance- ment if the total dose is constant (Fig. 8).Tene (wind 4 SE or ihre yogi eee 18 we SEL oe inversely proportanal leona Somo/s0 nga nears he nape ‘the bac weight. Reprinted frm 2 rapid in 5 mls) does not increase hepatic parenchymal e cabancemeatchrpard with sein. termediate injection rate (e g.2-3ml/s),it doesin- crease the magnitude of hepatic arterial enhance- ment and it separates the peaks of hepatic arterial and parenchymal enhancement [1], thus improving dhectonthypervesruar iver oases [20]. Similarly, a rapid injection rate increases pan- ereatic parnchymalenhancement 21,22) There. nection rats mma during the arterial phase of enhancement, and thereforeis also useful for detecting, liver masses [23]. Patient-Related Factors ‘The most -related factor that af- iets te maple of both arterial and hepatic parenchymal contrast enhancement is body ‘weight [14,24], which is imersey related to the ‘magnitude of enhancement. In larger, heavier pa- tients, less contrast enhancements achieved far a iodine dose compared with smaller patients eo 8). Therefore, when imaging beary paints one should consider modifying the contrast stnistaion protocol by inctesing the contrast ‘medium concentration, volume, or injection rate. Scanning Protocol Modifications for MDCT As stated previously, with MDCT, the shorter scan duration requires a longer scan delay to image dur- ‘the peak enhancement (Fig. 10). je the Peak Parcachymal {28.10 layed imaging with the standard injection protocol isto reduce the volume of contrast medium. With a smaller volume, we can image during the peak of ge = Ws Zz. = t. — Ws 5 a. 2. 5 3 tae, | ee tate stena, Fig. 10. Timing of pbc scanning asa function of parenciy- salentancenert ttstmeium ands permed fora sores pendaortic enhancement using a scan delay similar to that of the traditional injection protocol. While a reduced volume of contrast medium is advanta- geous for many reasons, the magnitude of peak contrast enhancement is reduced. This disadvan- tage may be compensated for by injecting at a faster rate or by using a contrast medium with an increased iodine concentration. Saline Flush Use of a saline flush immediately after contrast medium injection has several Itin- ‘creases peak aortic enhancement by: (1) pushing into the cardiovascular system contrast material that otherwise would be left in the i tub- Jngpand (2) improving boas geometry contrast medium dispersion. Thus, when a saline magnitude: er contrast medium volume [25-27]. An additional of a saline flush is that it minimizes Conclusions With MDCT, scan timings even more critical than ‘with single-detector CT, and will continue to be so as the number of detector rows increases to 32 and ‘64, For CTA, in which scan timing is critical, the scan delay can be accurately deter mined by use ofa test bolus or bolus-tracking soft- ‘ware. ‘The magnitude of arterial enhancement is de- termined primarily by iodine flux (g/s) and there- fore is strongly and directly correlated with injec- tion rate and contrast medium concentration. With fast scanners (eg., 8 and 16 detector rows), she hon sam duration segues a ager sand lay for CTA and hepatic taking Ine tonalderadon te pe of aging 16 ‘be performed. For arterial imaging, itis possible to decrease the volume of contrast medium when us- ing rapid injection rates and high contrast medi- um concentrations. However, for hepatic imaging, the magnitude ofenhance- ment is mainly determined by the total iodine dose, and injection rate makes only a limited con- tribution. Therefore, when performing hepatic im- aging with fast CT scanners, only limited reduc- tion of iodine dose is feasible. Contrast volume can ‘be reduced to a greater extent if a higher concen- tration contrast medium is used. References 1, Boe KT, Helken JP, Brink JA (1998) Aortic and he- patie peak enhancement at CT: effect of contrast medium injection rate, pharmacokinetic analysis and experimental porcine model. Radiology 20645546 +2 Heiken JP, Brink JA, McClennan BL et al (1903)Dy- namic contrastenhanced CT of the liver: compari- sonofcontrast medium injection rates and unipha- sic and biphasic injection protocols. Radiology 187327-331 3. Chambers TP, Baron RL, Lush RM (1994) Hepatic CT enhancement, Part . Alterations in the volume ‘of contrast material within the same patients. 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