I.2. Contrast Medium Administration and Scan Timing for MDCT. Scan Timing. Introduction. Jay P. Heiken and Kyongtae T. Bae.

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1 I.2 Contrst Medium Administrtion nd Scn Timing for MDCT Jy P. Heiken nd Kyongte T. Be Introduction As computed tomogrphy (CT) technology hs evolved from single-slice imging to 4- nd 16-slice scnners, the speed t which the ptient is pssed through the gntry hs incresed up to eight-fold, depending on the technique used (Tle 1). Therefore, the time to scn ody prt or the entire ody hs een reduced sustntilly. For exmple, chest scn tht used to require 36 s on singleslice scnner with 3-mm collimtion now tkes 5 10 s on 16-slice scnner with mm detector collimtion; chest domen pelvis exmintion, which ws not relly fesile with singleslice scnners (requiring 80 s), is now possile in s. The mrkedly reduced scn durtions for multidetector row CT (MDCT) exmintions hve mde scn timing more criticl thn for single-detector CT. At the sme time, these short scn times hve provided rdiologists with n opportunity to improve contrst enhncement with MDCT. It is therefore importnt for rdiologists nd technologists to: (1) understnd the fctors tht determine oth the timing nd mgnitude of rteril nd heptic prenchyml contrst enhncement for CT, nd (2) identify the modifictions needed to optimize contrst enhncement for 4-, 8-, 16-, nd the new 64-row MDCT scnners. Tle 1. Chnges in tle feed with evolution in CT technology Detector configurtion Tle feed, mm/s Single row (3-5 mm detector collimtion) 8 4 detector rows (1-mm detector collimtion) 10 4 detector rows (2.5-mm detector collimtion) detector rows (0.75-mm detector collimtion) detector rows (1.5-mm detector collimtion) 60 Scn Timing Technicl Fctors The most importnt technicl fctor tht ffects scn timing is the durtion of contrst medium injection [1-3], which is determined y the volume of contrst medium nd the rte t which it is dministered. In ptients with norml crdic output, pek rteril contrst enhncement is chieved shortly fter the termintion of injection of contrst medium [4]. As the contrst medium volume increses, the time it tkes to rech the peks of rteril nd heptic prenchyml contrst enhncement lso increses (Fig. 1) [5]. Conversely, n increse in injection rte results in shorter time to pek enhncement (Fig. 2) [5]. Therefore, short injection durtion (i.e., smll volume or high injection rte) results in erlier pek rteril nd heptic prenchyml enhncement, which requires short scn dely. A long injection durtion (i.e., lrge volume or low injection rte) results in lter pek enhncement, requiring long scn dely. Ptient-Relted Fctors The most importnt ptient-relted fctor tht ffects scn timing is crdic output [6]. Decresed crdic output (i.e., incresed crdiovsculr trnsit time) results in delyed rrivl of the contrst olus in the ort, which leds to delyed rteril nd heptic prenchyml enhncement (Fig. 3). Becuse of sustntil vrition in crdic output mong ptients, it is importnt to individulize the scn dely for imging studies in which scn timing is criticl, e.g., CT ngiogrphy (CTA). Scn dely cn e individulized y using test olus [7, 8] or olus-trcking softwre progrm [9]. The test olus method (Fig. 4) is the more commonly used technique, ut it must e dpted for use with the fster scnners. Typiclly, we give

2 14 MDCT: Scnning nd Contrst Protocols Contrst Enhncement (HU) Fig. 1,. Simulted contrst enhncement curves with three different contrst medium volumes. Simulted enhncement curves of the ort nd the liver sed on hypotheticl dult mle with fixed height (5 8 or 173 cm) nd ody weight (150 l or 68 kg), suject to injection of 75, 125, nd 175 ml of 320 mg I/ml contrst medium t 2 ml/s. The time to pek enhncement nd the mgnitude of pek enhncement increse with incresed contrst medium volume. (Reprinted from [28]) Contrst Enhncement (HU) Contrst Enhncement (HU) Contrst Enhncement (HU) Fig. 2,. Simulted contrst enhncement curves with three different contrst medium injection rtes. Simulted enhncement curves of the ort nd the liver sed on hypotheticl dult mle with fixed height (5'8 or 173 cm) nd ody weight (150 l or 68 kg), suject to 150 ml of 320 mg I/ml contrst medium injected t 1, 3, nd 5 ml/s. The curves show tht for constnt volume of contrst medium, s the rte of injection increses, the time it tkes to rech the pek of enhncement decreses nd the mgnitude of pek enhncement increses. (Reprinted from [29]) Aortic Enhncement (HU) Fig. 3. Simulted contrst enhncement curves t seline nd reduced crdic outputs. Simulted enhncement curves of the ort sed on hypotheticl dult mle with fixed height (5'8 or 173 cm) nd ody weight (150 l or 68 kg), suject to injection of 120 ml of 320 mg I/ml contrst medium t 4 ml/s. A set of ortic nd heptic contrst enhncement curves were generted from the model y reducing the seline crdic output, i.e ml/min, y 20%, 40%, nd 60%. (Reprinted from [29])

3 I.2 Contrst Medium Administrtion nd Scn Timing for MDCT Fig. 4. Test olus method for individulizing the scn dely. On single- or 4-detector-row scnners, the scn dely (the time etween the strt of contrst medium dministrtion nd tht of scnning) is determined s the time necessry for ortic enhncement to pek fter smll olus injection of contrst medium. With fster scnners, scnning must e delyed further (α) if imging is to e performed during the pek enhncement of the ort. Horizontl lines, scnning period for 1- or 4detector-row scnners (red) nd for 16-detector-row scnners (lue) TDELAY = TTEST +α; Time to pek CE test olus: TTEST slice CT α 16 1,4 TDELAY = TTEST ; 1-, 4-slice CT pek of ortic enhncement. This is done y dding n dditionl dely (α) to tht clculted on the sis of the test olus. The test olus method is effective for determining the scn dely for single ptient, ut it is not n efficient method ecuse it requires n dditionl volume of contrst medium nd is time-consuming. A more efficient nd elegnt method to determine the correct timing of scnning fter contrst medium dministrtion involves the use of olustrcking softwre with region of interest (ROI) plced over the ort (Fig. 5). A regulr olus of smll olus (15 20 ml) of contrst medium t the rte to e used for the dignostic exmintion, nd we determine when ortic enhncement peks. For single- nd 4-detector-row scnners, the time of pek ortic enhncement fter smll olus is used s the scn dely for the dignostic exmintion; this ssures tht dignostic scnning is performed during the pek of ortic enhncement fter dministrtion of full olus of contrst medium. However, with fster scnners nd thus shorter scn durtions, scnning must e delyed even further if imging is to e performed during the Fig. 5,. Determintion of scn dely using olus-trcking softwre. Ptient with norml crdic output: the 100 HU threshold is reched t out 25 s. Ptient with poor crdic output: the 100 HU threshold is not reched until 50 s fter olus injection. Hd this exmintion een strted t 25 s (the scn dely typiclly used for ptients with norml crdic output), the olus would hve een missed nd imging would hve een performed too erly

4 16 MDCT: Scnning nd Contrst Protocols contrst medium is dministered nd, pproximtely 10 s fter the olus injection is egun, low-dose monitoring scns re mde to trck enhncement in the ort.when predetermined threshold (e.g. 100 HU) is reched, regulr scnning is triggered. This method mkes it possile to ppropritely determine the scn dely for individul ptients with only single injection of contrst medium. Incresing the scn dely is one pproch to optimizing scn timing when working with fster CT scnners. Alterntively, with 8- nd 16-row MDCT, one cn tke dvntge of the very short scn durtions y reducing the volume of contrst medium dministered; for exmple, using 16-detectorrow scnner, excellent imges cn e otined using only 75 ml of iodinted contrst medium c Fig. 6. Endoluminl stent grft repir of n dominl ortic neurysm. CTA performed on 16-row multidetector CT scnner using only 75 ml of contrst medium. Trnsxil imge. Volume-rendered imge. c Mximum intensity projection imge (Fig. 6). The new 64-row scnner my llow further reduction in the volume of contrst medium. Nonetheless, the use of smller volumes of contrst medium my require tht the scnning protocol e optimized to overcome the possiility of reduced enhncement. Contrst Enhncement Mgnitude Technicl Fctors Arteril Enhncement. The mgnitude of rteril enhncement is determined y the rte of iodine delivery into the vsculr system. The rte of iodine delivery depends upon three fctors: (1) the

5 I.2 Contrst Medium Administrtion nd Scn Timing for MDCT 17 Contrst Enhncement (HU) Aort Liver Injection Rte (ml/sec) Fig. 7. Effect of contrst medium injection rte on the mgnitude of pek contrst enhncement (from simulted contrst enhncement curves). Pek ortic nd heptic contrst enhncements t different injection rtes re simulted sed on hypotheticl dult mle with fixed height (5'8 or 173 cm) nd ody weight (150 l or 68 kg), suject to injection of 120 ml of 320 mgi/ml contrst medium. (Reprinted from [1]) Aortic CE (HU) Heptic CE (HU) 5 Fig. 8,. Simulted contrst enhncement curves with fixed mount of iodine mss ut three different contrst medium concentrtions injected t constnt rte. Simulted enhncement curves of the ort nd liver sed on hypotheticl dult mle with fixed height (5 8 or 173 cm) nd ody weight (150 l or 68 kg), suject to 5 ml/s injection of the sme mount of iodine mss ut t three different concentrtions nd volumes: 300 mg I/ml, 140 ml; 350 mg I/ml, 120 ml; nd 400 mg I/ml, 105 ml. The ortic nd heptic time-enhncement curves demonstrte tht the use of high-concentrtion contrst mteril is ssocited with erlier nd greter pek ortic enhncement. The effect on heptic prenchyml enhncement is miniml. (Reprinted from [29]) concentrtion of iodine in the contrst medium, (2) the injection rte (Fig. 7), nd (3) the injection volume (primrily through recircultion of contrst medium lredy in the vsculr system). Increses in iodine concentrtion [10], injection rte [1, 11], nd volume [10] ll result in incresed rteril enhncement. Use of contrst mteril with higher iodine concentrtion produces more ortic contrst enhncement, even if the totl iodine dose nd injection rte re unchnged, y virtue of incresing the rte of iodine delivery to the vsculr system (Fig. 8). When the contrst medium volume is reduced for CTA with 8- nd 16-row (nd in future 64-row) MDCT, n incresed injection rte nd high iodine concentrtion cn compenste for the somewht decresed mgnitude of ortic enhncement chieved with the smller contrst medium volume. Heptic Prenchyml Enhncement. Heptic prenchyml enhncement is determined y the totl iodine dose dministered [3, 12 18], which in turn is determined y the contrst medium volume nd iodine concentrtion. Use of contrst mteril with higher iodine concentrtion improves heptic prenchyml enhncement to the extent tht it increses overll iodine dose [19]. The injection rte plys more limited role in heptic prenchyml contrst enhncement (Fig. 7); the concentrtion of iodine in the contrst medium hs little effect on heptic prenchyml enhncement if the totl dose is constnt (Fig. 8).

6 18 MDCT: Scnning nd Contrst Protocols kg kg kg kg kg kg kg kg Fig. 9,. Simulted contrst enhncement curves with four different ody weights. Simulted enhncement curves of the ort nd liver sed on hypotheticl dult mle with fixed height (5'8 or 173 cm) nd vrying ody weight (110, 160, 200, nd 260 l), suject to injection of 125 ml of 320 mg I/ml contrst medium t 5 ml/s. The mgnitude of contrst enhncement is inversely proportionl to the ody weight. (Reprinted from [28]) Although rpid injection rte (e.g. 5 ml/s) does not increse the mgnitude of heptic prenchyml enhncement compred with n intermedite injection rte (e.g. 2 3 ml/s), it does increse the mgnitude of heptic rteril enhncement nd it seprtes the peks of heptic rteril nd heptic prenchyml enhncement [1], thus improving detection of hypervsculr liver msses [20]. Similrly, rpid injection rte increses pncretic prenchyml enhncement [21, 22]. Therefore rpid injection rte is useful for dedicted heptic nd pncretic imging protocols. Use of higher-concentrtion contrst mteril increses tumor-to-liver contrst of heptocellulr crcinom during the rteril phse of enhncement, nd therefore is lso useful for detecting hypervsculr liver msses [23]. Ptient-Relted Fctors The most importnt ptient-relted fctor tht ffects the mgnitude of oth rteril nd heptic prenchyml contrst enhncement is ody weight [14, 24], which is inversely relted to the mgnitude of enhncement. In lrger, hevier ptients, less contrst enhncement is chieved for given iodine dose compred with smller ptients (Fig. 9). Therefore, when imging hevy ptients, one should consider modifying the contrst dministrtion protocol y incresing the contrst medium concentrtion, volume, or injection rte. Scnning Protocol Modifictions for MDCT As stted previously, with MDCT, the shorter scn durtion requires longer scn dely to imge during the pek prenchyml enhncement (Fig. 10). For CT ngiogrphy preferle lterntive to delyed imging with the stndrd injection protocol is to reduce the volume of contrst medium. With smller volume, we cn imge during the pek of Enhncement (H.U.) Time 10 sec 20 sec 30 ssec Fig. 10. Timing of heptic CT scnning s function of prenchyml enhncement kinetics nd speed of the CT scnner. With fster scnners, scnning is strted lter fter the dministrtion of contrst medium nd is performed for shorter period

7 I.2 Contrst Medium Administrtion nd Scn Timing for MDCT 19 ortic enhncement using scn dely similr to tht of the trditionl injection protocol. While reduced volume of contrst medium is dvntgeous for mny resons, the mgnitude of pek contrst enhncement is reduced. This disdvntge my e compensted for y injecting t fster rte or y using contrst medium with n incresed iodine concentrtion. Sline Flush Use of sline flush immeditely fter contrst medium injection hs severl dvntges. It increses pek ortic enhncement y: (1) pushing into the crdiovsculr system contrst mteril tht otherwise would e left in the injection tuing, nd (2) improving olus geometry y limiting contrst medium dispersion. Thus, when sline flush is employed, one cn chieve n equivlent mgnitude of contrst enhncement with smller contrst medium volume [25-27]. An dditionl dvntge of sline flush is tht it minimizes strek rtifct from dense contrst mteril in the rchiocephlic vein nd superior ven cv on thorcic CT exmintions [25, 26]. Conclusions With MDCT, scn timing is even more criticl thn with single-detector CT, nd will continue to e so s the numer of detector rows increses to 32 nd 64. For CTA, in which scn timing is prticulrly criticl, the scn dely cn e ccurtely determined y use of test olus or olus-trcking softwre. The mgnitude of rteril enhncement is determined primrily y iodine flux (g/s) nd therefore is strongly nd directly correlted with injection rte nd contrst medium concentrtion. With fst scnners (e.g., 8 nd 16 detector rows), the short scn durtion requires longer scn dely for CTA nd heptic prenchyml imging. Alterntively, we cn modify the injection protocol, tking into considertion the type of imging to e performed. For rteril imging, it is possile to decrese the volume of contrst medium when using rpid injection rtes nd high contrst medium concentrtions. However, for heptic prenchyml imging, the mgnitude of enhncement is minly determined y the totl iodine dose, nd injection rte mkes only limited contriution. Therefore, when performing heptic imging with fst CT scnners, only limited reduction of iodine dose is fesile. Contrst volume cn e reduced to greter extent if higher concentrtion contrst medium is used. References 1. Be KT, Heiken JP, Brink JA (1998) Aortic nd heptic pek enhncement t CT: effect of contrst medium injection rte, phrmcokinetic nlysis nd experimentl porcine model. Rdiology 206: Heiken JP, Brink JA, McClennn BL et l (1993) Dynmic contrst-enhnced CT of the liver: comprison of contrst medium injection rtes nd uniphsic nd iphsic injection protocols. Rdiology 187: Chmers TP, Bron RL, Lush RM (1994) Heptic CT enhncement. Prt I. Altertions in the volume of contrst mteril within the sme ptients. Rdiology 193: Be KT (2003) Pek contrst enhncement in CT nd MR ngiogrphy: when does it occur nd why? Phrmcokinetic study in porcine model. Rdiology 227: Hn JK, Kim AY, Lee KY et l (2000) Fctors influencing vsculr nd heptic enhncement t CT: experimentl study on injection protocol using cnine model. J Comput Assist Tomogr 24: Be KT, Heiken JP, Brink JA (1998) Aortic nd heptic contrst medium enhncement t CT. II. Effect of reduced crdic output in porcine model. Rdiology 207: Vn Hoe L, Mrchl G, Bert AL et l (1995) Determintion of scn dely-time in spirl CT-ngiogrphy: utility of test olus injection. J Comput Assist Tomogr 19: Hittmir K, Fleischmnn D (2001) Accurcy of predicting nd controlling time-dependent ortic enhncement from test olus injection. J Comput Assist Tomogr 25: Silvermn PM, Roerts, S, Tefft MC et l (1995) Helicl CT of the liver: clinicl ppliction of n utomted computer technique, SmrtPrep, for otining imges with optiml contrst enhncement. AJR Am J Roentgenol 165: Fleischmnn D (2002) Present nd future trends in multiple detector-row CT pplictions: CT ngiogrphy. Eur Rdiol 12[Suppl 2]:S Fleischmnn D (2003) Use of high-concentrtion contrst medi in multi-detector row CT: principles nd rtionle. Eur Rdiol 13[Suppl 5]:M14-M Berlnd LL, Lee JY (1988) Comprison of contrst medi injection rtes nd volumes for heptic dynmic incremented computed tomogrphy. Invest Rdiol 23: Den PB, Violnte MR, Mhoney JA (1980) Heptic CT contrst enhncement: effect of dose, durtion of infusion nd time elpsed following infusion. Invest Rdiol 15: Heiken JP, Brink JA, McClennn BL et l (1995) Dynmic incrementl CT: effect of volume nd concentrtion of contrst mteril nd ptient weight on heptic enhncement. Rdiology 195: Clussen CD, Bnzer D, Pfretzschner C et l (1984) Bolus geometry nd dynmics fter intrvenous contrst medium injection. Rdiology 153: Chmers TP, Bron RL, Lush RM (1994) Heptic CT enhncement. II. Altertions in contrst mteril volume nd rte of injection within the sme ptients. Rdiology 193:

8 20 MDCT: Scnning nd Contrst Protocols 17. Hrmon BH, Berlnd LL, Lee JY (1992) Effect of vrying rtes of low-osmolrity contrst medi injection for heptic CT: correltion with indocynine green trnsit time. Rdiology 184: Grci P, Genin G, Bret PM et l (1999) Heptic CT enhncement: effects of the rte nd volume of contrst medium injection in n niml model. Adom Imging 24: Furut A, Ito K, Fujit T et l (2004) Heptic enhncement in multiphsic contrst-enhnced MD- CT: comprison of high- nd low-iodine-concentrtion contrst medium in sme ptients with chronic liver disese. AJR Am J Roentgenol 183: Kim T, Murkmi T, Tkhshi S et l (1998) Effect of injection rtes of contrst mteril on rteril phse heptic CT. AJR Am J Roentgenol 171: Tulin ME, Tessler FN, Cheng SL et l (1999) Effect of injection rte of contrst medium on pncretic nd heptic helicl CT. Rdiology 210: Kim T, Murkmi T, Tkhshi S et l (1999) Pncretic CT imging: effects of different injection rtes nd doses of contrst mteril. Rdiology 212: Awi K, Tkd K, Onishi H (2002) Aortic nd heptic enhncement nd tumor-to-liver contrst: nlysis of the effect of different concentrtions of contrst mteril t multidetector-row helicl CT. Rdiology 224: Kormno M, Prtnen K, Soimkllio S (1983) Dynmic contrst enhncement of the upper domen: effect of contrst medium nd ody weight. Invest Rdiol 18: Hopper KD, Mosher TJ, Ksles CJ et l (1997) Thorcic spirl CT: delivery of contrst mteril pushed with injectle sline solution in power injector. Rdiology 205: Hge P, Schmitz-Rode T, Hüner D et l (2000) Reduction of contrst mteril dose nd rtifcts y sline flush using doule power injector in helicl CT of the thorx. AJR Am J Roentgenol 174: Dorio PJ, Lee FT, Henseler KP et l (2003) Using sline chser to decrese contrst medi in dominl CT. AJR Am J Roentgenol 180: Be KT, Heiken JP (2000) Computer modeling pproch to contrst medium dministrtion nd scn timing for multislice CT. In: Mrincek B, Ros PR, Reiser M, Bker ME (eds) Multislice CT: prcticl guide. Springer pp Be KT (2003) Technicl spects of contrst delivery in dvnced CT. Appl Rdiol 32[Suppl]:12-19

9 SECTION II Adominl Imging

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