Cardiac CT

Basic Principles
David M. Whitaker, MD
 Outline
Steps to get a CT
Types of CT Acquisition
Brief history of multislice CTs
ECG Gated Reconstruction
ECG Synchronization
Patients with fast heart rates
Radiation Exposure & ECG modulation
 CT Basics
Steps involved
Data acquisition
Image reconstruction
Post-processing
Evaluation
Reporting & Communication
 CT Basics
Data Acquisition
X-ray source produces a collimated
beam in the shape of a fan
As it passes through object – photons
are either absorbed or scattered
Attenuation = reduction in X-ray
transmission
Depends on anatomic composition & density
of tissue & energy of the photons
After passing through patient – X-rays
collected by detectors – converted to
electrical/digital signals
Since the tube and detectors rotate
CT Basics
 CT Basics
Image Reconstruction
Must be pre-processed to correct for
beam hardening and scattered radiation
Raw data then filtered by convolution
kernels
Because the pt moves through gantry
during scan, X-ray measurements
acquired at different longitudinal
positions
To reconstruct a slice at a particular
position, attenuation measurements from
> 180o of the X-ray tube rotation are
required
A back-projection technique then used to
calculate density values within the plane
 CT Basics
Image Processing
Digital axial source images can be
converted to electrical signals and shown
in gray-scale on a screen
For CCT however, usually requires some
post-processing prior to evaluation.
 CT Basics
Data Storage
A single CT slice is approximately 500kB
A complete cardiac study (containing
more than 200 slices) will require at least
500MB
 CT Basics
Image Display
CT density values are expressed as
Houndsfield Units (HU)
Range from –1024 to +3071 HU
Theoretically the entire range could be
displayed in a sliding scale from black to
white but human eye cannot distinguish
such fine detail in the middle of the
range
Therefore the images must be displayed
with settings that provide optimal
contrast between structures
CT Basics
 Types of CT
Acquisition
Cardiac Sequential CT
Can do ECG-triggered acquisition
After an R wave the acquisition is
initiated and performed during the
predicted diastolic phase based on
the R-R interval of the previous
cycles. Table then moves and waits
for next R wave
Image quality of triggered multi-slice
CT regarded inferior compared to
spiral, but the radiation is used more
efficiently and thus often used for
calcium scoring in the preventative
setting
 Types of CT
Acquisition
Electron Beam CT (EBCT)
A non-mechanical sequential CT scanner
No mechanically rotating parts
Temporal resolution is 100ms
Acquisition time is about 50ms
Can be triggered by ECG
Can get a single or up to 3 acquisitions of
a single slice – thus can chose the best
data set
 Types of CT
Acquisition
Spiral CT
Table moves at a constant speed while
the detectors continuously acquire data
Larger sections can thus be scanned in
same amount of time
Slip ring technology made this possible
as cord wrap around is not an issue
Types of CT
Acquisition
 Types of CT
Acquisition
Sequential CT
Shoot and move
Time inefficient & only limited coverage
can be achieved in the same amount of
time
 Types of CT
Acquisition
Multislice CT
Instead of a single detector row, have
several parallel detector rows
Allows simultaneous acquisition of
several slices
Again, larger sections scanned in shorter
time
 Evolution of
Multislice CT
1998 – Four-slice scanners
Rotation time of 500ms
Slice thickness varying from 0.5 to
1.25mm
Using partial scan algorithms the
reconstruction time reduced to about 250
ms
This time proved sufficient to visualize
coronary arteries without motion artifact
during diastole
 Evolution of
Multislice CT
2002 – 16-slice scanners

Rotation time of newer scanners was

reduced below 400 ms

Slice thickness between 0.5 and

0.75mm

A complete scan could be completed in

less than 20 seconds
 ECG Gated
Reconstruction
Imaging the heart requires acquisition
that is synchronized to the motion of
the heart
Sequential scanners acquire slices
prospectively triggered by the pt ECG
Spirals acquire continuous, overlapping
data throughout the cardiac cycle
The recorded ECG is used afterwards to
select spiral data acquired during the
same cardiac phase to reconstruct
slices
Reconstruction of any cardiac phase can
be performed
Patients with Fast
Heart Rates
Qualitative assessment of lumenal
narrowing is most accurate when HR is
less than 60-65 bpm

Temporal resolution is limited, thus

much effort put into developing
technology with faster rotation speeds

Also referred to as “pitch”

Patients with Fast
Heart Rates
Patients with Fast
Heart Rates
Use oral or IV beta blockers to achieve
slower HR unless contraindicated

If unable to use BB
Alternative scanning & reconstruction
methods are available
The effectiveness of these alternative
algorithms varies with the actual HR in
relation to the rotation time of the
scanner
Patients with Fast
Heart Rates
 ECG
Synchronization
Cardiac phase with minimal coronary
displacement is mid- to end- diastole
Reconstructions can be performed at
time positions relative to the previous
or upcoming R-wave
Or a position as a percentage of the R-R
cycle can be selected
 ECG
Synchronization
 ECG
Synchronization
Pitfalls
Requires a good ECG signal
Avoid electrical interference from
underlying musculature etc…
Software detects the up-slope or R
wave and call this T=0 – Leads I and II
usually the most useful
If abnormal rhythm or unusual ECG
pattern, other leads should be used
 Radiation
Exposure
Determinants of total exposure
Scanner Parameters
Scanner Type
X-ray output (kV and mA)
Pitch
Collimation: slice number and width
Scan Range
ECG triggered X-ray tube modulation
Patient Gender, Size, Heart Rate
 ECG Gated
Reconstruction
Radiation exposure can be reduced by
modulating the X-ray tube prospectively
Guided by the ECG, output is decreased
during the systolic phase while full
output occurs during an interval within
the diastolic phase
Total radiation exposure can be reduced
by 30-40% depending on the heart rate
 ECG Gated
Reconstruction