229
Techniques and Protocols for Acquisition and Display of Contrast-Enhanced CT Angiography
CHRISTOPH R. BECKER, MD
the human heart may change rapidly, in particular under special conditions such as breath-holding and Valsalva maneuver.
When multisector reconstruction is performed, the temporal resolution then depends on the actual heart rate and may vary during the acquisition. For this reason, this technique is of lim- ited practical use under clinical conditions.
In general the redundant radiation exposure in the systole can substantially be reduced by a technique called prospective ECG tube current modulation. On the basis of the ECG signal, the X-ray tube current is switched to its nominal value during the diastole phase and is reduced significantly during the sys- tole phase of the heart, respectively. This technique is most effective in patients with low heart rates. If the heart rate is lower that 60 beats per minute (bpm), the radiation exposure will be reduced by approx 50% (3).
In addition, retrospective ECG gating allows for reconstruc- tion of images at any time within the cardiac cycle. However, with the currently available temporal resolution in MDCT, the image quality is poor only if the images are reconstructed in any other than the mid-diastolic phase. The accuracy of the func- tional assessment by MDCT may be influenced if motion arti- facts are present or if a β-blocker have been administered.
PATIENT PREPARATION
For a 16-row-detector CT scanner with 420 ms gantry rotation, an optimized partial scan view lasts about 200 ms.
Reasonably good image quality with this temporal resolution can be achieved only in patients with low heart rates—e.g., <70 bpm (4). Therefore, caffeine or any drug like atropine or nitroglycerin that increases the heart rate should be avoided prior to a cardiac CTA investigation. Instead the use of a β-blocker may become necessary for patient preparation aim- ing at a heart rate of 60 bpm or even less.
To consider β-blocker for patient preparation, contraindica- tions (bronchial asthma, AV block, severe congestive heart failure, aortic stenosis, and so on [5]) have to be ruled out and informed consent must be obtained from the patient. In case the heart rate of a patient is significantly above 60 bpm, 50 to 200 mg of Metoprololtartrat can be administered orally 30–90 min prior to the investigation. Alternatively, 5–20 mg of Metopro- loltartrat divided into 4 doses can be administered intravenously (5) immediately prior to scanning. Monitoring of vital func- tions (heart rate and blood pressure) is essential during this INTRODUCTION
Contrast-enhanced computed tomography (CT) studies of the coronary arteries were performed first to visualize the ves- sel lumen and to achieve an angiographic-like presentation of the coronary arteries in combination with 3D postprocessing methods (1). Because short exposure times are essential for coronary CT angiography (CTA), investigations initially were performed with electron beam CT (EBCT) scanners. These dedicated cardiac CT scanners were originally designed to measure myocardial perfusion (2). For morphological assess- ment of cardiac structures, a restrictive scan protocol with EBCT allows for 100-ms exposure time, 3-mm slice thickness, and 130-kVp, 630-mA electron-gun power. The acquisition of every single slice is triggered prospectively by the electrocar- diogram (ECG) signal at the end systolic phase of the cardiac cycle.
Multidetector-row CT (MDCT) scanners operate with a dif- ferent acquisition mode called retrospective ECG gating. The combination of fast gantry rotation, slow table movement, and multislice helical acquisition allows for acquisition of a high number of X-ray projection data. The ECG trace is recorded simultaneously during the helical scan acquisition. The X-ray projections of the mid-diastolic phase are selected to recon- struct images from the slow-motion diastole phase of the heart.
In MDCT the temporal resolution (approx 200 ms) is longer and the radiation exposure (approx 10 mSv) is higher than in EBCT. On the other hand, image quality is superior in MDCT compared to EBCT because of higher spatial resolution, lower image noise, and continuous volume acquisition.
In MDCT an attempt has been made to improve temporal resolution by multisector reconstruction. For this technique, X-ray projections of more than one heartbeat are used to recon- struct an image. This technique requires absolute consistent data from at least two consecutive heartbeats for successful image reconstruction. For multisector reconstruction, the table feed needs to be reduced to collect enough projections. This leads to longer scan times and higher radiation exposure com- pared to a partial scan reconstruction. However, the rhythm of
22
From: Contemporary Cardiology: CT of the Heart:
Principles and Applications
Edited by: U. Joseph Schoepf © Humana Press, Inc., Totowa, NJ
230 BECKER
approach. There are four positive effects of β-blocker on MDCT scanning: better patient compliance, less radiation exposure and cardiac motion artifacts, and higher vascular enhancement.
MDCT SCANNING
For retrospective ECG gating with MDCT, the pitch factor (detector collimation divided by table feed per gantry rotation) must not exceed 0.3 to allow for scanning the heart at any heart rate higher than 40 beats per minute. In a 4-detector-row CT with 1-mm slices and 500-ms gantry rotation, a typical scan range of 12 cm lasts approx 40 s. In a 16-detector-row CT with 0.75-mm slices and a gantry rotation time of 420 ms, the entire scan lasts about 20 s.
In 4- and 16-detector-row CT, tube current is set to 400 and 500 effective mAs, respectively. The higher tube current is needed to compensate for higher image noise caused by both thinner slices and the higher temporal resolution used with a 16- compared to 4-detector-row CT scanner. Higher temporal resolution equates to shorter exposure times and therefore does not necessarily translate into higher radiation exposure. The patient may either be exposed for a longer time with a lower tube current or for a shorter exposure time with higher tube current; however, the final amount of radiation for the same image noise remains the same.
The patients should be instructed not to press when taking a deep breath in, to avoid the Valsalva maneuver. During the Valsalva maneuver, the intraabdominal pressure increases with blood from the inferior vena cava entering the right atrium.
With an increased pressure in the right atrium, blood mixed with contrast medium from the superior vena cava is prevented from entering the right atrium. Furthermore, as a reflex the increased blood volume in the right atrium leads to a decrease in heart rate.
The Valsalva maneuver may last several seconds under breath-hold conditions. After it releases, high-density contrast medium may enter the right atrium and the heart rate recovers to its original or even slightly higher frequency (6). As a result, the CT may not be homogeneously enhanced and image quality may suffer from rapid changes of the heart rate.
After scan acquisition has been completed, reconstruction of the axial slices always begins with a careful analysis of the ECG trace recorded with the helical scan. The image recon- struction interval is best been placed in between the T and the P wave of the ECG, corresponding to the mid-diastole interval.
Table 1
Scan Parameters for 4- and 16-Detector-Row CT
4-Detector CT 16-Detector CT
Slice thickness 1 mm 0.75
Tube current 400 mAs 500 mAs
Tube voltage 120 kVp 120 kVp
Gantry rotation 500 ms 420 ms
Table feed 3 mm/s 6 mm/s
Breath hold 40 s 20 s
Spatial resolution 8 linepairs (lp)/cm 8 lp/cm
Temporal resolution 250 ms 200 ms
Number of slices 200 240
The point of time for the least coronary motion may be different for every coronary artery. Minimal motion artifacts may result for reconstructing the right coronary artery (RCA), left anterior descending (LAD) artery, and left circumflex (LCx) artery at 50%, 55%, and 60% of the RR interval, respectively. Indi- vidual adaptation of the point of time for reconstruction seems to further improve image quality (4). However, the lower the heart rate, the easier it is to find the best interval for all three major branches of the coronary artery tree. Images are recon- structed with spatial in-plane resolution of 8 linepairs (lp)/cm (0.6 mm). The slice thickness and reconstruction increment is 1.3 with 0.7 mm and 1 with 0.5 mm in 4- and 16-detector-row CT, respectively. Therefore, near-isotropic spatial resolution may be achieved only with the 16-detector-row CT.
Depending on the preparation, patient investigation time may last approx 10–15 min. Image reconstruction and post processing can be performed within approx 10 min. Because coronary CTA is performed with thin slices and low image noise, the radiation dose with tube current modulation is sig- nificantly higher (approx 5 mSv) that for coronary calcium screening (approx 1 mSv). However, the radiation of a CTA investigation is comparable to what is applied during a diag- nostic coronary catheter procedure. Scan parameters are sum- marized in Table 1.
IMAGE POSTPROCESSING
The detection of coronary artery pathology in axial CT images is difficult since every slice displays only a small frag- ment of the entire coronary artery. Two- or three-dimensional postprocessing display such as multiplanar reformations and maximum intensity projections (MIP) or shaded surface dis- play, virtual coronary endoscopy, and volume-rendering tech- nique (VRT), respectively, may be helpful for a first glance at the course of the coronary arteries or for angiographic-like projections. It should be considered that any 2D or 3D recon- structions may come along with a loss of spatial resolution.
Smaller side branches, for instance, which are visible in the axial source, may not be seen in volume-rendered images, and the presence of coronary artery stenosis may be overestimated.
In particular, motion and ECG trigger artifacts in 2D and 3D images may appear as pathologies or even stenoses that do not exist. In addition, the primary axial slices are superior to any postprocessing method to rule out coronary artery disease (CAD) and atherosclerosis. Therefore, none of the available
This projection plane spreads the branches of the LAD and is therefore called the “spider view.” The spider view is well suited to demonstrate the proximal part of all three major coronary arteries (Fig. 4).
ANALYSIS OF AXIAL CT IMAGES
All findings from postprocessed images have to be con- firmed in the original axial CT slices. The primary axial slices are superior to any postprocessing method to rule out CAD.
Image analysis begins with identification of the coronary artery segments in the axial CT slices. Coronary segments can be numbered (Fig. 5) according to the model suggested by the American Heart Association (9).
In patients with acute or chronic myocardial infarctions, a lack of contrast uptake in the myocardium or thinning of the myocardial wall may be detected only in the axial slices (10).
Depending on the coronary vessel affected, different anatomic regions may be involved (Fig. 6). In case of an involvement of postprocessing tools is better than the axial slices to detect
coronary artery stenosis (7).
VRT requires the segmentation of the sternum, the rips, and the vertebral column. The auricle of the left atrium may also be segmented to gain access to the left main coronary artery. Stan- dardized projection views around the long axis of the heart allow for display of the superficial course of all three major coronary arteries (Fig. 1).
Standardized thin (3 mm) MIP slices with 1.5-mm incre- ment between the slices may be reconstructed in three different planes, similar to standard cardiac catheter projections (8). MIP along the interventricular groove creates images in the right anterior oblique plane that best displays the course of the LAD (Fig. 2). MIP along the atrioventricular groove in the left ante- rior oblique plane displays best the course of the right and circumflex coronary artery (Fig. 3). In addition, a left anterior oblique projection can be reconstructed following the course of the left anterior descending coronary artery in the lateral view.
Fig. 1. Volume-rendering technique after segmentation of the bones and auricle performed along the long axis of the heart (A). Selective images display the course of the left anterior descending and circumflex coronary artery (B) as well as the proximal and middle right coronary artery (C). At the base of the heart, the distal right and posterior descending coronary artery can be seen (D).
232 BECKER
Fig. 2. The right anterior oblique (RAO) view reconstructed along the septum (A) is designed to display the course of the left anterior descending coronary artery (B).
Fig. 3. (right) The left anterior oblique (LAO) view (A) reconstructed along the atrio-venticular groove is best suited to display the right (B) and circumflex coronary artery (C).
the left anterior descending, a myocardial infarction may be identified in the anterior left-ventricular wall, the roof of the left ventricle, the apex, the superior part of the septum, or in the anterior papillary muscle. The posterior left-ventricular wall and the posterior papillary muscle are supplied by the circum- flex coronary artery. The inferior left-ventricular wall and the inferior part of the septum finally are supplied by the right coronary artery.
With later development, a subendocardial or transmural myocardial infarction may result in an aneurysm. As a result of hypokinesia in the aneurysm, thrombus formation is likely to develop in the cardiac chamber and can be detected by CTA even better than by transthoracic ultrasound (11).
Fig. 4. Left anterior oblique (Spider) views are reconstructed along the plane of the left anterior descending coronary artery (A) for dis- playing this vessel and its major diagonal branches (B).
Fig. 5A–G. (right and page 224) In the axial slices, the coronary artery segments are identified and numbered according the American Heart Association model.
A late uptake of contrast media after first pass in the myo- cardium of patients after infarction was observed in CT about 17 yr ago (11). It is rather likely that this kind of myocardial enhancement may correspond to nonviable myocardium due to interstitial uptake of contrast media within necrotic myocytes, 6 wk to 3 mo after onset. To allow for superior detection of the late myocardial enhancement with the new generation MDCT scanners, images should be acquired with thick slices, high signal-to-noise ratio, and reconstructed with a very soft tissue kernel. The optimal point of time for scanning may be between 10 and 40 min after first pass (12).
with a larger field of view, or a more dedicated (CT) inves- tigation should then be recommended.
234 BECKER
Fig. 5A–G. (continued from page 223)
Fig. 6. The myocardium can be divided into three different territories:
the anterior, inferior, and posterior wall, supplied by the left anterior, right, and circumflex coronary artery. In this particular image, an infarction scan can be seen in the posterior wall.
CONCLUSION
With 16-detector-row scanners, investigation of the coro- nary arteries and the myocardium becomes a feasible and prac- tical CT application. Patient preparation and instruction is mandatory to acquire diagnostic image quality for the coronary arteries. Under these conditions, postprocessing in a standard- ized fashion may help to identify the pathology. However, any finding needs to be confirmed by the source images to identify artifacts that may arise from motion. Pathologies arising from the peri- and myocardium may be assessable only in the axial slices.
REFERENCES
1. Moshage WE, Achenbach S, Seese B, Bachmann K, Kirchgeorg M.
Coronary artery stenoses: three-dimensional imaging with electro- cardiographically triggered, contrast agent-enhanced, electron-beam CT. Radiology 1995;196(3):707–714.
2. Boyd D. Computerized transmission tomography of the heart using scanning electron beams. In: Higgins C (ed), CT of the Heart and the Great Vessels: Experimental Evaluation and Clinical Application.
Futura, Mount Kisco, New York: 1983.
3. Jakobs TF, Becker CR, Ohnesorge B, et al. Multislice helical CT of the heart with retrospective ECG gating: reduction of radiation exposure by ECG-controlled tube current modulation. Eur Radiol 2002;12(5):1081–1086.
4. Hong C, Becker CR, Huber A, et al. ECG-gated reconstructed multi- detector row CT coronary angiography: effect of varying trigger delay on image quality. Radiology 2001;220(3):712–717.
5. Ryan T, Anderson J, Antman E, et al. ACC/AHA guidelines for the management of patients with acute myocardial infarction. A report of the American College of Cardiology/American Heart Associa- tion Task Force on Practice Guidelines (Committee on Manage- ment of Acute Myocardial Infarction). J Am Coll Cardiol 1996;28:
1328–1428.
6. Mao SS, Oudiz RJ, Bakhsheshi H, Wang SJ, Brundage BH. Varia- tion of heart rate and electrocardiograph trigger interval during ultrafast computed tomography. Am J Card Imaging 1996;10:239–243.
7. Vogl TJ, Abolmaali ND, Diebold T, et al. Techniques for the detec- tion of coronary atherosclerosis: multi-detector row CT coronary angiography. Radiology 2002;223(1):212–220.
8. Johnson M. Principles and practice of coronary angiography. In:
Skorton D, Schelbert H, Wolf G, Brundage B (eds), Marcus Cardiac Imaging: A Companion to Braunwald’s Heart Disease. 2nd ed. WB Sanders Company, Philadelphia: 1996;220–250.
9. Austen WG, Edwards JE, Frye RL, et al. A reporting system on patients evaluated for coronary artery disease. Report of the Ad Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery, American Heart Association. Circulation 1975;51(4 Suppl):5–40.
10. Paul JF, Dambrin G, Caussin C, Lancelin B, Angel C. Sixteen-slice computed tomography after acute myocardial infarction: from perfusion defect to the culprit lesion. Circulation 2003;108(3):
373–374.
11. Masuda Y, Yoshida H, Morooka N, Watanabe S, Inagaki Y. The usefulness of x-ray computed tomography for the diagnosis of myo- cardial infarction. Circulation 1984;70:217–225.
12. Huber D, Lapray J, Hessel S. In vivo evaluation of experimental myocardial infarcts by ungated computed tomography. AJR 1981;
136:469–473.
13. Horton KM, Post WS, Blumenthal RS, Fishman EK. Prevalence of significant noncardiac findings on electron-beam computed tomog- raphy coronary artery calcium screening examinations. Circulation 2002;106(5):532–534.
