CT Teaching Manual A Systematic Approach To CT Reading, 2nd Edition

Matthias Hofer
Second edition
I Keyto AnatomicStructures Front CoverFlap Normal AnatomyofthePetrousBone (Coronal
andAxial) 46
on pages 26-73, 152/153 (head / neck) Normal Variants of the Cranium 50

TypicalPartial VolumePhenomenaof theCranium 52
NotesfortheUser,"Whatyoushouldknow" Front Cover Flap
Cerebral CT,PathologicFindings
Notesforthe User,ListoftheCTdiagrams IntracranialBleeds 54

Cerebral Infarcts 58
ForewordandListof Abbreviations 3 Cerebral Tumorsand Metastases 59
Inflammatory Processes 60
Physical and Technical Fundamentals Orbital Changes 61

GeneralPrinciplesofCT 6 ChangesoftheFacialBonesandParanasal Sinuses 62
Comparisonof ConventionalCTwithSpiralCT 7
Spatial Resolution, Pitch 8 NeckCT
Section Collimation:ResolutionalongtheZ-axis 9 Selectionof theImagePlane 64
AdaptiveDetector Design 10 Checkiist fora SystemicApproach 64
ReconstructionAlgorithms 11 Normal Anatomyofthe Neck 65
EffectsofkV,mAs andScanTime 12
Three-dimensional Reconstruction Methods: 13 Neck CT, Pathologic Changes
Maximum Intensity Projection(MIP) InflammatoryProcessesandTumors 70

Multiplanar Reconstruction(MPR) Thyroid Gland 71
Surface Rendering Test yourselfl 72
Basic Rules for Reading CT Examinations Key to Anatomic Structures Back Cover Flap
Anatomic Dri entation 14 on pages 71, 74-1 49 (thorax / abdomen)
Partial Volume Effects
Distinguishing Nodular from Tubular Structures 15 Chest CT
Densitometry Sel ection of the Image Plane 74
Density Levels of DifferentTIssues 16 Systemic Sequential Approach to
Interpretation
Documentation Using Different Window Settings 17 Checklist for Interpreting Chest
CT 74
Norm al Anatomy of the Chest 75
Preparing the Patient Test yourself! 82
Medical History 18
Renal Function Chest CT, Pathologic Changes
Hyperthyroidism Anatom y of the Pulmonary Segments 84
Adverse Reaction to Contrast Agents HRCT of the Lungs:Technique, Effects,
Indications 86
Premedication Anatomic Variants of the Chest 88
Oral Administration of Contrast Agents 19 Chest Wall
Informing the Patient Abnormal Lymph Nodes 89
Rem oval of Foreign Objects Breast, Bony Thorax 90
Controlling Respiration Mediastinum
Tumor Masses 91
Administration of Contrast Agents Enlarged Lymph Nod es 92
OralAdm inistration of Contrast Agents 20 Vascular Pathology 93
Selection oftheAppropriate Contrast Agents Heart 94
Duration and Dose Lun g
In avenous Injection of Contrast Agents Intrap ulmonary Nodules 95
In avenous Access 21 Bronchial Carcinom a, Malignant Lym phangiomatosis 96
:l1ilo'o Effect of Contrast Agents Sarcoidosis,Tuberculosis,Aspergillosis 97
~""re
. 8 Reaction to Contrast Agents andTh eir Therapy 24 Pleural Changes,Asbestosis 98
-ayro;o � Crisis and its Therapy 25 Silicosis, Pu lmonary Emphysema 99
......,,,,,,,1 CT
Interstitial Pu lmonary Fibrosis
Test yourselfl
100
100
s.= ec OJ ' ImagePlane 26
'3 _-=-~:'O
02 to Interpretation Abdomen CT
Cranial CT 26 Selection of the Image Plane 102
Systemic Sequential Approach to Interpretation
Checklist for Interpreting Abdom en CT 10,
27 NormalAnatomy of theAbdomen 104
32 Normal Anatomy of the Pelvis (Male) 11,
it (Axial) 33 Normal Anatomy of the Pelvis (Female) 114
-Bones (Coronal) 41
45
Table of Contents
Abdomen CT, Pathologic Changes Spine

AnatomicVariants oftheAbdomen 116 Cervical Spine (C-spine) 152
Typical Partial Volume Phenomena C-Spine, DiskProlapse and Fractures 153
Abdominal Wall Thoracic Spine (T-spine): 15t
Enlarged LymphNodes,Abscesses 117 Normal Findingsand Fracture
Subcutaneous HeparinInjections 118 Lumbar Spine (L-spine): 155
AbdominalWallMetastases Normal Findingsand Lumbar DiskProlapse
Inguinal Hernias L-spine,Fractures 156
liver L-spine,Tumors/ Metastases 157
AnatomyoftheHepaticSegments 119 L-spine,Inflammations/Internal Fixation 158
Examination Protocols 120
SelectionofWindow Display LowerExtremity
Bolus Passageof ContrastAgents NormalAnatomyoftheThigh 159
CTPortography NormalAnatomyofthe Knee 160
Hepatic Cysts 121 NormalAnatomyoftheCalf 161
Hepatic Metastases 122 NormalAnatomyoftheFoot 162
SolidHepaticLesions: 123 Fractures ofthe Foot 163
Hemangioma PelvisandThigh:InflammatoryProcesses 166
Adenoma Knee,Fractures,ChecklistFracture Diagnosis 167
Focal NodularHyperplasia
DiffuseHepatic Changes: 124 CT-guidedInterventions 168
Fatty Liver
Hemochromatosis Examination Protocols for Spinal CT 169
Cirrhosis
Biliary System Radiation Protection
Pneumobilia 124 Radiation Dose / Cancer Risk 174
Cholestasis AutomatedBolusTracking (BT) 176
Gallbladder TubeCurrent Modulation 177
Cholecystolithiasis 124
ChronicInflammatoryProcesses 125 CT-Angiography
Spleen Intracranial Arteries 178
Enhancement, Splenomegaly 126 Cranial Dural VenousSinus 179
Focal SplenicChanges 127 CarotidArteries 180
Pancreas Aorta 182
Acute and ChronicPancreatitis 128 Heart: CoronaryArteries, 184
Pancreas Neoplasms Screening for Coronary
Adrenal Glands Artery Calcifications
Hyperplasia,Adenomas, Metastases,Neoplasm 130 Pulmonary Vasculature (Pulmonary
Emboli) 186
Kidneys Abdom inal Vasculature 187
Congenital Variants 132 Iliofemoral Vasculature 188
Cysts,Hydronephrosis 133 VascularProtheses,Outlook 189
SolidTumors 134 Test Yourself! 190
VascularRenal Changes 135
Urinary Bladder The Fundamentals of Interpreting CT 192
Indwelling Catheter, Diverticula, SolidLesions 136
Genital Organs Answers to Test Yourself 196
Uterus 137
Ovaries, Prostate Gland,Vas Deferens 138 Index 203
Gastrointestinal Tract
Stom ach 139 References Back Cover Flap
Inflammatory Bowel Diseases 139
Colon 140 Keyto AnatomicStructures BackCoverFlap
Ileus 141 on pages 152-167 (spine / leg)
Test Yourself! 141
Retroperitoneum Keyto AnatomicStructures Back CoverFlap
Aneurysms 142 onpages71,74-149 (thorax/abdomen)
VenousThromboses 143
Enlarged LymphNodes 144
Skeletal Changes
Bony Pelvis: Normal Findings, Metastases 145
Fractures 147
Hip Dysplasia,NecrosisoftheFemoralHead 148
Test Yourself! 149
Table
moveme nt
Table
moveme nt
Physical and Technical Fundamentals
Fig. 6.1
General Principles of CT
Computed tomography is a special type of x-ray procedure that
involvestheindirectmeasurementof the weakening,or attenuation,
ofx-raysatnumerouspositionslocated around the patient
being investigated.Basicallyspeaking,allweknowis
� whatleavesthex-ray tube,
� what arrives at the detectorand
� thepositionofthe x-raytubeanddetectorfor eachposition.
Simplystated, everything else isdeducedfrom thisinformation.
Most CTslices areoriented verticaltothebody'saxis. Theyare
usually called axial or transverse sections. For each section the
x-ray tube rotates around the patient to obtain a preselected
section thickness (Fig. 6.1). Most CT systems employ the
continuous rotation and fan beam design: with this design, the
x-ray tube anddetector are rigidlycoupled and rotate continuously
around the scan field while x-rays are emitted and detected.
Thus,thex-rays, whichhavepassed through thepatient, reach the
detectorsonthe oppositeside ofthetube. Thefan beam opening
ranges from 40� to 60�, depending on the particular system
Fig.6.2
I "
design,and isdefined bythe angle originating atthe focusofthe

x-raytube andextendingtothe outerlimitsofthedetectorarray.
Typically, images are produced for each360�rotation,permitting
ahigh numberofmeasurementdata tobeacquired andsufficient
dosetobe applied.Whilethe scanis being performed, attenuation
profiles,also referred to as samplesor projections,are obtained.
Attenuation profilesarereallynothing otherthan acollectionofthe
signalsobtainedfromallthedetector channelsatagiven angular
positionofthetube-detectorunit. Modern CTsystems(Fig.6.4)
acquire approximately1400 projectionsover 360�,oraboutfour
projections per degree. Each attenuation profile comprises the
data obtained from about 1500 detector channels, about 30
channelsperdegreeincaseofa50�fan beam.Whilethe patient
table is moving continuously through the gantry, a digital radiograph
("scanogramm" or "localizer", Fig. 6.2) is produced on
which the desiredsections canbe planned. For aCT examination
of the spine or the head, the gantry is angled to the optimal
orientation (Fig.6.3).
Angulnlion
Gantry
�o .. �
~.
~
Fig. 6.3
Multiple-Row Detector Spiral CT

Multiple-row detector CT (MOCn is the latest scanner development.
Rather than one detector row, multiple detector rows are
placed oppositethe x-ray tube.Thisshortens theexamination time
and improvesthetemporalresolution,allowing,for instance,the
determinationoftherateofvascular enhancement.
Thedetectorrowsalong thez-axisoppositethe x-raytubeare

unequal inwidth,withtheouterrowswiderthantheinnerrowsto
provide better conditions for image reconstruction affer data
acquisition (see pages 9-11).
Fig. 6.4
Comparison ofConventionalCT with Spiral CT

In conventional CT,a seriesofequallyspacedimagesisacquired
sequentially through a specific region, e.g. the abdomen or the
head (Fig.7.1).Thereisashort pauseaftereachsectioninorder
toadvance the patient table tothe nextpreset position.Thesection
thickness and overlap/intersection gap areselectedatIhe outset.
Theraw dataforeach imagelevelisstored separately.The short
pause between sections allows the conscious patient to breathe
without causing major respiratory artifacts.
However,theexaminationmaytakeseveralminutes,depending on
the bodyregion and the size ofthe patient.Propertimingofimage
acquisition after Lv. contrast media is particularly important for
assessing perfusion effects. CT is the technique of choice for
acquiring complete 20 axial images of the body without the
disadvantages of superimposed bone and / or air as seen in
conventional x-ray images.
Imaging
v o lume "\
--.~,,-
Continuous
tab le
movem ent
/.
X -ray lube
~
Rotat ion
Fig. 7.2
One of the advantages of the helical technique is that lesions

smallerthantheconventionalthicknessofaslice canbedetected.
Smallliver metastases (7)willbemissedifinconsistent depthof
Fig.7.3a Conventional CT
Ste p-w ise

table
movement
Gantry
x-ray tube
Fig. 7.1
Both single-row detectorCT (SOCT)and multiple-rowdetector CT

(MOCl) continuously acquire data of the patient while the
examination table moves through the gantry. The x-ray tube
describes an apparent helical path around the patient (Fig. 7.2). If
tableadvance iscoordinatedwiththetimerequired fora360'
rotation (pitch factor), data acquisition is complete and uninterrupted.
Thismoderntechnique hasgreatlyimprovedCTbecause
respiratoryartifactsandinconsistenciesdonot affectthe single
dataset asmarkedlyasin conventionalCT. Thesingledataset can
be usedtoreconstructslicesofdiffering thicknessorat differing
intervals.Evenoverlapping slicescan be reconstructed.
Data acquisition forthe abdomen takes only 1-2 minutes: two or

three helices,eachabout10to20seconds,areobtained.Thetime
limit is determined by the duration a patient can hold his breath
andthenecessarycoolingofthex-raytubes. Image reconstruction
takes longer. An assessment of renal function following CM will
requirea shortbreaktoallowfor CM excretiontooccur.
respiration resultsinthem notbeing includedinthe section(Fig.

7.3a). The metastases would appear in overlapping reconstructionsfromthe
datasetof the helicaltechnique(Fig.7.3b).
------------------
5
Fig.7.3b Spiral CT
Spatial Resolution
Thereconstructedimages shouldhaveahightemporalresolution
to separate even smallstructuresfrom eachother.This generally
createsno problem along thex-or y-axis oftheimagesince the
selected field of view (FOV) typically encompasses 512 x 512 or
morepicture elements(pixel).These pixels appear on the monitor
Fig. 8.1a
The imagequalityshouldimprovewith smallervoxels, butthisonly

applies tothespatial resolution since athinnersection lowersthe
signal-to-noise ratio.Anotherdisadvantageofthinnersectionsis
the inevitable increase in the radiation dose to the patient (see
page 175). Nonetheless, smaller voxels with identical measurements
in all three dimensions (isotropic voxels) offer a crucial
Fig.8.2MPRfrom isotropicvoxels
Pitch
Bynow, severaldefinitionsexistfor the pitch,which describesthe
rate of table increment per rotation in millimeter and section
thickness. A slowly moving table per rotation generates a tight
acquisition spiral (Fig.8.4a).Increasingthetable incrementper
rotation without changing section thickness or rotation speed
creates interscan spaces oftheacquisition spiral (Fig.8.4b).
Themostlyuseddefinition ofthe pitch describesthetable travel

(feed) per gantry rotation, expressed in millimeters, and selected
collimation,alsoexpressed inmillimeters.
as grey values proportionate to their attenuation (Fig. 8.1b). In

reality,however,they are not squares butcubes (voxel = volume
element) with their length along the body axis defined by the
section thickness (Fig. 8.1 a).
~"
'/
.:
/
I
i
122J..
\ 50 l-11<,
r-, \1
'I '
\\
129'"
7
,3~
7';;::V
v:r.:::v
Fig.8.1b
advantage: The multiplanar reconstruction (MPR) in coronal,

sagittalor otherplanesdisplaysthe reconstructedimages freeof
any step-likecontour (Fig. 8.2).Using voxelsofunequaldimension
(anisotropic voxels) for MPR is burdened by a serrated
appearance of the reconstructed images (Fig. 8.3), which, for
instance,can makeitdifficultto excludeafracture(Fig. 148.5b).
Fig. 8.3 MPR from anisotropic voxels
Pitch = 1 Pitch = 2
mn ~
Fig. 8.4 a b
Tabletravel /rotation
Pitch =
Co llimation
Feed! rotation 24mm ! rotation 24mm

Pitch = e.g.: = -=
1
Collimation 16x 1.5 mm 24mm
Sincetheunits(mm) inthe numeratoranddenominatorcancelout,

the pitch is a dimensionless number. For a while, a so-called
volumepitch wasstatedfor multiple-rowdetectorCTscanners,
which relatesthetable feedtoasingle sectionratherthan tothe
entirearrayof sectionsalongthez-axis.Forthe examplegiven
above, this means a volume pitch of 24 mm ! 1.5 mm = 16.
However, there seems to be a trend to returning to the original
definition ofthepitch.
Section Collimation: Resolution Along the Z-Axis

Theresolution (alongthe body axisorz-axis)oftheimages can
alsobe adapted tothe particularclinicalquestion bythechoiceof
thecollimation. Sections between 5and
8mmgenerallyaretotallyadequateforstandardexaminationsoftheabdomen.
However,
the exactlocalizationofsmallfracturefragmentsortheevaluation
ofsubtle pulmonarychangesrequirethinslices between 0.5 and
2mm. What determines thesection thickness?
The term collimation describes how thin or thick the acquired
slices can bepreselected along thelongitudinalaxisofthepatient
_ x-ray tube
Collimator
Q"
1, 1\\
"[ >-I' ll " I I
II I\\
II I\\
/I I\\
IJ I\\
I ,I\\
II I\\
I II\\
,JI I\'
II I\ \
/ : : : \~
, ::t:tl:L'\
,,,
I Collimator I, I \1 I
,!!
I
II 1
z-axis
Fig,9.1 Wide sectioncollimation
Depending onthewidthofcollimator'saperture,theunitswithonly
onedetectorrow behindthepatient(singlesection) cangenerate
sectionswithawidthof10mm,8 mm, 5mm oreven1mm.ACT
examinationobtainedwithverythinsectionsisalsocalled ahigh
resolution CT(HRCT)and,ifthesectionsareatthesub-millimeter
level,ultrahighresolutionCT(UHRCn. The UHRCTisusedforthe
The new scanners give the examiner the option to select e

craniocaudalextension(z-axis)of theregiontobeexaminedon e
topogramaswell as the rotationtime, sectioncollimation(thinor
thick sections?)and examinationtime (breath-holdingintervals?).
The software, e.g., "SureView�," calculates the suitable pitch,
usually providing values between 0.5 and 2.0.
(= z-axis),Theexaminercanlimitthefan-likex-raybeam emitted
from the x-ray tube by a collimator, whereby the collimator's
aperture determineswhetherthefanpassingthroughthecollimatorandcollectedby
the detector units behindthepatientis either
wide(Fig.9.1)or narrow(Fig.9.2),withthenarrowbeam allowing
a better spatial resolution along the z-axis of the patient. The
collimator cannotonly beplaced nexttothex-raytube,butalsoin
front of the detectors,i.e.,"behind"thepatient as seenfromthe
x-ray source.
_ x-raytube
Collimator
J,t,\
--..1, ,1,\1...
"("".I
" 1'\
" .\
I:I ~
,
I .I 1\
,:I: \
I I I�\
I :I ~
,
': I ,I
, , ,: \
I,
I , \
I,
I \
, ,:, ';;
::=::t11~
~
, ...
! -....1: ! ,1.....--
Ir c' ,. . ,ijB
z-axrs
Fig.9.2Narrow section collimation
petrous bone with about 0.5 mm sections to detect delicate

fracturelinesthrough the cranial baseor auditory ossiclesinthe
tympaniccavity(see pages46 -49). Fortheliver,however,the
examination is dominated by the contrast resolution since the
question here is the detectability of hepatic metastases (here
somewhat thicker sections).
Variable section thickness

++++
~~
17mwl I !4 x5.0 mm
4 x 2.5 mm
4x 1.0 mm
2 x 8.0 mm
2 x 0.5 mm
Fig. 10.1 Detector designof a4-row unit, as foundintheSiemensSensation4
Adaptive Array Design

Afurther developmentofthe single-slicespiral technologyis the
introduction of the multislice technique, which has not one
detectorrows but severaldetector rows stacked perpendicularto
the z-axis opposite the x-ray source. This enables the simultaneousacquisition
ofseveralsections.
Adaptive detector design 4-row unit
/ ,,, I ,
I I,
/,
,III I,
:> / ,,,,II I ,,
II
,/ , I ,,I,
I ,
U,
es
u / '2 5 i j;j ;" I"25\ , z-axis
co / 5
, I , I-"" I'\ ' \ 5 ,
,
/ , IIII',,
/ II I,
,"
/ II I I,
Detectors I I II,
I I II,
Resolutionalong the z-axis

adaptable toclinical Question
The detectorrows are not inevitably equal inwidth.The adaptive

array design consists of detectors that increase in width from the
centertotheedgeofthedetector ring andconsequentlyallows
various combinations of thickness and numbers of acquired
sections.
Adaptive detector design 6-row unit
Collimator
/ " " I /l1I1l\1I \\ \ -,
.. II ,,11111\1\ \ \ '\e; / I II 11/11111\ \ \ \ "
U, L ---:;~!:;:~::!
~
~~,
.':~:;::::JI.
/.~'/'!:~
''''
__---__:_.
il ' . .~
\
.~
/3'2,ill 1\1\2\ 3 \ z-ans
....~
/ JJ I""",'I \ \ \ ...
/ "/I 1/1 JI1' 1\ \ \ \ "
.. 11 11 11 111 11\\\ \
I,
/ II 1/ J IIII\I \ \Detectors I "11'1111 \ \ \

I,,,
II '"IIIII\ \ \ , ,
Resolutionalong thez-axls
adaptabletoclinical Question
6 x 0.5 mm
6 x 1.0 mm
6 x 2.0 mm
6 x 3.0 mm
Fig. 10.2Detector designofa6-rowunit,asfoundinthe SiemensEmotion6

Forinstance,a16-slice examinationcan be performedwith16thin

sectionsofahigherresolution (fortheSiemensSensation16,this
means16x0.75 mm)orwith16 sectionsoftwicethethickness.Foraniliofemoral CTA(see page
188),itis preferableto acquireaiong
volumealongthez-axisinasinglerun,ofcoursewitha selectedwide collimationof16x1.5mm.
Adaptive detector design16-rowunit
x-ray tube
Collimator
_____ /11 I '

\~
_
~II.
,,,
,f:/, \\~~~"
III/ I \\\ \\,\
~-----A(-If;i
~A----/~
II
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r
lll'\\
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\\ \~\
II ' ,'",1/1111 11\\ \ \' \\ \\
> 1111111
1
11l
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o 1 1/"/,""1
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f-------,1I'��' ."" "," �.��:.' f:----...
(1;\ /, I I �'.' �" \\''\\
H. I / 15 II fII I I Q75\\\\\\ 15 \ \ z-axis

V~
// .' I I II III ' \\, \\\ '\ \\
/11/ 1II IIIJIIII\\\ \\\ \ \\\
I II 1 /1 111,'1111\ \\\\\ \ \ \ \
I I.' / // /II I I Jl l 1 \\\\\\ \\\ \

Detectors ' 111 1111111 '\\\\\\ \\" \.
I ( 11/ 1 1111 11 11\\\\\ \ \ \ \
Resolution along the z-axis

adaptable toclinical question
16x 1.5 mm
Fig.l1.1 Detector designofa16-rowunit, as foundinthe Siemens Sensation 16
Thedevelopmentofthe CThardwaredidnotend with16slicesandfasterdata

acquisitioncanalready beachievedwith32-and64-row
scanners.Thetrend to thinnerslicesisassociatedwith higher patient
exposuretoradiation,requiring additional andalreadyintroduced
measuresforexposure reduction(see pages 174-177).
When both liver and pancreas are included, many users prefer a
reducedslicethickness from10mmto3 mm toimprove image
sharpness. This increases, however, the noise level by approximateiy
80%.Thereforeit wouldbenecessaryto employ80%more
rnAorto lengthen the scantime(this increasesthe mAs product)
to maintain image quality.
Reconstruction Algorithm
Spiral users have an additional advantage: In the spiral image
reconstructionprocess,mostofthe datapointswere notactually
measured in the particular slice being reconstructed (Fig. 11.2).
Instead,dataare acquiredoutside thisslice (e) andinterpolated
with moreimportance,or "contibutinn",beingattached tothedata
located closest to the slice (X). In other words: The data point
closesttotheslice receives more weight,orcounts more,inthe
reconstructionofanimage atthedesired table position.
This results in an interesting phenomenon. The patient dose

(actually given in mGy) is determined by the mAs per rotation
dividedbythepitch,andtheimage doseisequaltothe mAs per
rotationwithoutconsideringthepitch.Ifforinstance150mAs per
rotationwithapitchof 1.5areemployed,the patient dose inmGy
islinearrelated to100mAs,andtheimagedoseis related to150
mAs. Therefore spiral users can improve contrast detectability by
measured
data
table positio n
slice
Fig.11.2 Wide (360�) spiral reconstructionalgorithm
selecting high rnA values, increase the spatial resolution (image

sharpness)byreducingslice thickness, and employ pitch toadjust
the lengthofthespiral range as desired,allwhile reducingthe
patient's dose! Moreslices can be acquiredwithout increasingthe
dose orstressing the x-raytube.
Thistechnique is especially helpful whendataare reformattedto
create other 2D views, like sagittal, oblique, coronal, or 3D views
(MIP, surface shaded imaging, see pp.8and 13).
Thedataobtainedatthedetectorchannelare passedon,profilefor
profile,tothedetectorelectronics aselectricsignalscorresponding
totheactualx-ray attenuation.These electricsignals are digitized
and then transmitted to the image processor. At this stage, the
imagesare reconstructedbymeansofthe"pipelineprinciple",
consisting of preprocessing, convolution, and back projection
(Fig.12.1).
Preprocessing includes all the corrections taken to prepare the

measured scan data for reconstruction, e.q., correction for dark
current, dose output, calibration, channel correction, beam
hardening,and spacing errors.Thesecorrections are pertormed to
furtherminimize theslightvariationsinherentlyfoundinthetube
anddetectorcomponentsof theimagingchain.
Convolutionisbasicallytheuseofnegative values tocorrect for

smearing inherent to simple back projecfion. II, for instance, a
cylindric water phantom is scanned and reconstructed without
convolution, the edges of this phantom will be extremely blurry
(Fig. 12.2a): Whathappens whenjusteight attenuation profiles of
asmall,highlyabsorbentcylindricalobjectare superimposed to
createanimage?Sincethe samepartofthe cylinderismeasured
bytwo overlapping projections,a star-shaped imageis produced
instead of what is in reality a cylinder. By introducing negative
valuesjustbeyondthe positive portionofthe attenuationprofiles,
the edges ofthis cylindercan be sharplydepicted (Fig,12.2b).
Back projection involves the reassigningof the convolved scan

datatoa20image matrixrepresentingthe section ofthe patient
thatis scanned. Thisis pertormed profilefor profilefor theentire
image reconstruction process.The imagematrix can bethoughtof
asanalogoustoachessboard,consisting oftypically512x 512 or
1024 x 1024 picture elements, usually called "pixels". Back
projectionresuitsinanexact densitybeing assigned toeach of
these pixels,which are then displayed asalighteror darker shade
ofgrayThe lighterthe shadeofgray,thehigherthe densityofthe
tissue withinthepixel(e.g., bone).
~
---------------------------,
-+, 0 -0 -0+
,
0
,,
Dataacquisitionsystem Preprocessing Convolution Backprojection : Imagedisplay
TheInfluenceof kV
When examininganatomicregions withhigherabsorption (e.g.,CT
ofthehead,shoulders,thoracicorlumbar spine,pelvis,and larger
patients),itisoftenadvisabletousehigher kVlevelsin additionto,
or instead of, higher mA values: when you choose higher kV, you
are hardeningthex-ray beam.Thusx-rayscanpenetrate anatomic
regions with higher absorption more easily. As a positive side
effect,thelower energycomponentsofthe radiationare reduced,
whiCh is desirable since low energy x-rays are absorbed by the
patient anddonot contribute tothe image.Forimagingofinfants
orbolustracking,it maybeadvisabletoutilize kVlowerthanthe
standard setting.
Tube Current[mAs]
Thetube current,stated inmilliampere-seconds [mAs],also hasa
significanteffectonthe radiation dose deliveredtothepatient.A
patient with more body Width requires an increase in the tube
currentto achieve an adequate image quality. Thus, morecorpulent
patients receive alargerradiation dose than,forinstance,chiidren
witha markedly smaller body width.
Body regionswith skeletalstructuresthatabsorbor scatterradiation,
such as shoulder and pelvts, require a higher tube current
than,forinstance,theneck,aslenderabdominal torsoorthelegs.
Thisrelationship has beenactivelyappliedtoradiation protection
for some time now (compare with page 177)..
Scan Time
It is advantageous to select a scan time as short as possible,
particularlyin abdominalorcheststudies where heart movement
andperistalsis may degradeimagequality.OtherCTinvestigations
can also benefit fromlastscan times due to decreased probability
of involuntary patientmotion.Onthe otherhand,it maybe necessarytoselectalonger
scan timetoprovidesufficientdoseorto
enablemoresamplesformaximal spatialresolution. Some users
may also consciously choose longer scan times to lower the mA
settingand thusincrease the likelihood oflongerx-raytube life.
Simple Back Projection vs. Convolution
Fig.12,1 Thepipelineprincipleof imagereconstruction Fig.12.2a Backprojection

Fig.12.2bBack projection
without convolution with convolution
3D Reconstructions
3ecause the helical or spiral technique acquires a continuous,
sirlgle volume dataset for an entire body region, imaging of
, actures and blood vessels has Improved markedly, Several
c' erentmethodsof3Dreconstructionhavebecomeestablished:
aximal lntensily Projection
IPisamathematical method that extracts hyperintense voxels

, am 20 or 3D datasets [6, 7], These voxels are selected from
severaldifferent angiesthrough the datasetandthen projectedas
a20image(Fig, 13.1),A3D impressionisacquiredbyalteringthe
projection anglein small steps and then viewing the reconstructed
imagesin quicksuccession(I.e" incine mode). Thisprocedure is
also usedfor examiningcontrast-enhancedblood vessels.
Multiplanar Reconstruction
Fig. 13.1
\4
\4
O rigina l
dataset of
axial sections
I
II Lateral
r:
r:
projection
Frontal
project ion
This techniquemakesitpossibietoreconstruct coronaland sagittalaswellasoblique
planes,MPRhasbecomeavaluabletoolinthediagnosisoffractures and otherortho
pedic indications, For example, conventional axial sections do not always provide
enoughinformation aboutfractures,A goodexampleis the undispiacedhairline frac
ture(*)without corticaldiscontinuitythatcan be moreeffectivelydemonstrated byMPR
{Fig, 13.2a),
Fig.13,2a
3D Surface Shaded Display
Thismethodshowsthesurfaceofan organora bonethathas been definedinHouns~
eld
units aboveaparticular threshold value,Theangleofview,aswell asthe location
a a hypothetical source of light (from which the computer calculates shadowing) are
crucialforobtainingoptimalreconstructions.Thefractureof the distalradiusshownin
eMPRin Figure13.2aisseenclearlyinthe bonesurfacein Figure13.2b.
Figs. 13,2aand13.2bsuppliedwiththekind permission

ofJ, Brackins Romero,M,0" Recklinghausen,Germany) Fig.13.2b
3D surfaceshadeddisplaysarealso valuableinplanning surgeryas inthe case

ofthetraumaticinjurytothe spinalcolumnseenin
Figures13.3a,b, andc. Since theangleof viewcan be freelydetermined,thethoracic
compressionfracture ( *) and the state of the
intervertebralforamina can beexaminedfrom several
differentangles(anteriorinFig.13.3aandlateralinFig.13.3b),Thesagittal MPR
in Figure 13.3c determines whetheranybonefragmentshave
becomedislocatedintothespinal canal (compare withmyelography CT
on page 147).
Fig. 13.3a Fig.13,3b
*
Fig. 13.3c
,
Basic Rules of Reading CT Examinations
14 I
Anatomic Orientation
Animage on thedisplayisnot onlya20
representation of anatomy, it contains
information about the mean attenuation
of tissue in a matrix consisting of about
512x 512elements(pixels).Asection
(Fig.14.1)hasadefined thickness(dS)
andiscomposed ofa matrixofcubicor
cuboid units (voxels) of identical size.
Thistechnicalaspectisthe reasonforthe
partial volumeeffectsexplainedbelow.An
imageis usually displayed asif the body
were viewed from caudal. Thus the right
side ofthepatientis on theleftsideof the
image and vice versa (Fig. 14.1). For
example, the liver (122) is located in the
right half of the body, but appears in the
left half of the image. Organs of the left
side such as the stomach (129) and the
Rotation
x-ray tu be
II
50
Image level
122
Detecto r
Fig. 14.1
spleen(133) appearontherighthalfofanimage. Anterioraspectsofthebody,for examplethe

abdominal wall,are representedinthe
upper partsofanimage, posterioraspectssuchasthe spine(50)are
lower.WiththissystemCTimagesaremore easily comparedwith
conventional x-ray-images.
Partial Volume Effects

The radiologist determines the thickness of the image (dS)'
8-10 mm is usually chosen for thoracic or abdominal examinations,
and2-5mm fortheskull,spine, orbits,orpetrosalbones.A
structure may therefore be included in the entire thickness of a
slice(Fig.14.2a)orin onlyapartofit(Fig.14.3a).Thegray scale
value ofa voxel dependson the mean attenuation of all structures
withinit. Ifastructurehasaregularshapewithin asection,itwill
appearwelldefined.Thisis the casefortheabdominal aorta (89)
andtheinferiorvenacava (80)showninFigures14.2a,b.
Partial volumeeffectsoccurwhenstructuresdonot occupythe

entirethicknessof aslice,for examplewhena section includes
partofavertebralbody(50) and partofadisk(50e)theanatomy
willbepoorlydefined (Figs.14.3a,b).Thisis also trueifan organ
taperswithinasectionas seenin Figures 14.4a, b.Thisis the
reasonfor thepoordefinitionof the renalpolesor thebordersof
the gallbladder (1 26)or urinary bladder.
Artifacts caused by breathing during image acquisition are discussed
onpage 19.
80
anatomic
level
Fig. 14.2a
/'
89
50
-------
--------
--------
-
---------s::-?9-~--:J---------
50 '\
'-..../
Fig. 14.4a
Fig. 14.3a
CT image
00
Fig. 14,2b
Fig. 14.4b
Fig.14.3b
Distinguishing Between Nodularand TubularStructures
is essential to differentiate between possibly

enlarqedor affected LNsandvesselsor muscles
which have been cut in transverse section. This
may be extremely difficult in a single image
oecause these structures have similar density
aiues(graytones). One shouldtherefore always

analyze adjacent cranial and caudal images and
comparethestructures inquestiontodetermine
wnetnertheyarenodularswellings orcontinueas
more or less tubular structures (Fig. 15.1): A
lymph node (6) will appear in only one or two
shoes and cannot be traced in adjacent images
compare Figs. 15.1 a, b,and c).The aorta(89)or

:ne inferiorcava(80),ora muscle,forexample the
Iiopsoas (31), can be traced through a cranio:
audalseriesof images.
" ere is a suspicious nodular swelling in one
Cilage. it should become an automatic reaction to

7.mpare adjacent levels to clarify whether it is
:;-"
-;nplya vesselor muscleincross-section. This
xoceoure willalso enablequickidentificationof
partial volume effects described on the pre-

JUs page.
80
135
b :: -:_ :::::::::::
Fig. 15.1
89
tt-
---b
-----_Q_
c:or106
@@
50
31 31
a
6 --0
~�
50
31 31
~@
50
31 31
c
ensitometry (Measurement of Density)

" �isuncertain,forexample,whetherfluidfound inthe pleural
~
isapleural effusionorahemothorax.ameasurementof the
:;(lid's density will clarify the differential diagnosis. The same

~:
Dlie
s
tofocallesionsinthe parenchymaoftheliverorthekidney.
-: 'lever. itisnotadvisabletocarry out measurementsofsingle
cxels(= volumeelement, seeFig,14.1)sincesuch dataareliable
;,: statistical fluctuations which can make the attenuation un
�
o~b
le
.
Itismoreaccuratetoposition alarger'regionofinterest"
0)/) consistingofseveral voxelsinafocal lesion,asnucture, oran

,,';)QUntoffluid.The computercalculatesthe mean densitylevels
:' allvoxelsandalso providesthe standard deviation (SO).
:-e must beparticularlycarefulnotto overlookbeam-hardening
'utacts (Fig.19.2)orpartialvolumeeffects.Ifamass does not
e>:endthroughtheentirethicknessof aslice,measurementsof
:~
ns
ity
willinclude thetissuenexttoit (Figs. 121.2 and133.1
33.3).The densityofa masswillbemeasured correctlyonlyifit

: stheentirethicknessoftheslice(dS)(Fig.15.2).Itisthen more
." Iy that measurements will include only the mass (hatched
areain Fig.15.2a).IfdSisgreaterthan themass's diameter,for

exampleasmalllesion inanunfavorableposition.it can onlyappear
in partial volumeatanyscanlevel (Fig.15.2b).
~~r
-IE)'
__ __ __ ~~1--.... ..........__.__...
Fig. 15.2 a b
16
Density Levels of Different Types of Tissues

Modern equipment has a capacity of 4096 gray tones, which
represent differentdensitylevelsin HUs.Thedensityof water was
arbitrarily setat0 HUandthatofairat-1000 HU (Table16.1a).
The monitor can display a maximum of 256 gray tones. However,
the human eye isable todiscriminate oniy approximately 20.Since
thedensitiesof humantissues extendoverafairlynarrow range (a
window) ofthetotal spectrum(Table16.1b),itis possibletoselect
awindow setting torepresentthedensityofthe tissueofinterest.
The mean density levelofthewindow shouldbesetascloseas

possibletothe densitylevelofthetissueto be examined.Thelung.
withitshighair content,isbest examinedatalow HU window setting
(Fig.17.1c),whereasbonesrequire an adjustmenttohigh
levels (Fig. 17.2c). The width of the window influences the
contrastoftheimages: the narrowerthewindow,the greaterthe
contrastsincethe20graytones coveronlyasmallscaleof densities.
1000
700
500
300
100
-100
-300
-500
-700
-1 00
Table16.1a Densityofalltissues Table16.1b Densityof parenchymalorgansandfluids
FaV
connective
tissue
Fat
-90 ~
10
Air
-1000
Clotted blood
90HU
Thyroid gland
Compact
80HU
bone
70 HU
Liver
Spongy bone
230HU Parll'nChymal
> 250
orgars
30HU
90HU 10Hul
50� 40
Lung
500 HU
Water
80 � 10 70HU
60HU Blood 60HU
70 ", 10 60HU 65 � 5
Spleen/muscle!
Pa ncreas lymphoma 50HU
50HU 50HU 55 � 5
4D HU Kidney
45 ", 5 40HU
30HU ExsudaleJeffusiOll
40 � 10 30HU Suprarenal gland
Transudate 20 HU 20 HU 25HU
I 25 � 5 30 � 10
18 ~2
10 HU
17 � 7
-900 HU
~
-700 ~
200
O�5
It is noteworthy that the density levels of almost all soft-tissue

organs lie within a narrow range between 10 and 90 HUs (Table
16.1b).Theonly exceptionisthe lung and,as mentioned above,
this requires a special window setting (Figs. 17.1 a-c). With
respect tohemorrhages,it shouldbetakeninto accountthat the
densitylevelof recentlycoagulated bloodliesabout30HUabove
thatof freshblood.Thisdensity drops againinolder hemorrhages
orliquefiedthromboses. An exudatewithaproteincontentabove
30gilcannotbe readilydistinguishedfrom atransudate(protein
content below 30gIl) atconventional windowsettings.Inaddition,
the high degree ofoverlap between the densities of,forexample,
lymphomas,spleen,muscles,and pancreasmakes it clearthatitis

notpossibleto deduce, fromdensitylevelsalone,whatsubstance
or tissue is present.
Finally,standarddensity values alsofluctuate betweenindividuals,

dependingaswell ontheamountofCMinthecirculating blood and
intheorgans. Thelatteraspect isofparticularimportancefor the
examination of the urogenital system, since Lv. CM is rapidly
excreted by the kidney, resulting in rising density levels in the
parenchymaduring the scanning procedure.This effect can beput
touse whenjudging kidney function (see Fig. 135.1).
Documentation ot Oiflerent Windows
en the images have beenacquired,a hard copy isprintedfor

cocumentanon. Forexample:inordertoexaminethe mediastinum
ancthesofttissuesofthe thoracicwall,thewindow is set such
;natmuscles (13,14,20-26), vessels(89,90,92...), and fatare
:learty represented in shades of gray. The soft-tissue window
Fig.17.1a)iscentered at50HU withawidth ofabout350HU.The

'"suit is a representation of density values from -125HU (50350/
2)upto+225HU(50+350/2).All tissueswitha density lower
than-125HU, suchasthe lung,are represented inblack.Those

with density levels above +225 appear white and their internal
structuralfeatures cannotbedifferentiated.
Iflungparenchymaisto be examined,for examplewhen scanning
fornodules,thewindowcenterwill be lowerat about-200HU.
and the windowwider(2000 HU). Low-densitypulmonarystructures
(96) can be much more clearly differentiated in this socalled
lung window(Fig.17.1c).
� Grayscale
Hounsfield units (H U)
�
-g.17.1a: Softtissuewindow
Fig. 17.1b Fig. 17.1c: Lung window
-order to achieve maximal contrast between gray and white

-~tte
r
inthe brain.itis necessarytoselectaspecial brainwindow
:-=cause the density values of gray and white matter differ only
: : tly.The brainwindow must be verynarrow(80to100HU=>
-:11 contrast)andthe center mustlieclosetothe mean densityof
:"rebral tissue (35HU) to demonstrate these slight differences
i'ig.17.2a).Atthissettingitisofcourse impossibletoexaminethe
;-ull since all structures hyperdense to 75-85 HU appear
.e.Thebone windowshould therefore haveamuchhigherceni,"'
at about+300HU,andasufficientwidthofabout1500HU.The
metastases (7)inthe occipital bone (55d)would onlybe visible in

the appropriate bone window (Fig. 17.2c). but not in the brain
window (Fi9. 17.2a). On the other hand. the brain is practically
invisibleinthe bonewindow;smallcerebral metastases wouldnot
be detected. One must always be aware of these technical
aspects. especially since hard copies are not usually printed at
each windowsetting.The examinershould reviewthoroughlythe
images on the screen in additional windows to avoid missing
important pathologic features. Examination of the liver poses
specialproblems and is dealtwithseparatelyonpage120.
-.17.2a: Brain window Fi9�17.2b Fig.17.2c: Bonewindow

Preparing the Patient
Medical History
Priorto any CTexamination,athoroughmedicalhistoryneedsto
beobtained whichfocusesonfactorsthatmayrepresentacontraindication
tocontrast media use orindicateanincreased likelihood
ofa reaction. Inpatientswithsuspectedrenaldysfunction baselineblood
urea nitrogen andcreatinine levelsshouldbe obtained
(see below). It is important to note whether prior CT images are
available for comparison. Information about prior surgery and
radiation therapyin the anatomic region tobeexaminedbyCTis
also important. Careful consideration of the pertinent radiologic
findingsonthecurrentstudy in contextwithpriorresultsand the
patientsclinicalhistory allow the radiologisttorender
ameaningfuldifferentialdiagnosis.
Renal Function
With the exception of few (such as stone protocol, fracture
assessment) most CT exams require the Lv. administration of
iodinated contrastagentsfor adequateassessmentof theclinical

question at hand. Since contrast agents are excreted by the
kidneys and may cause changes in renal hemodynamics and
tubular toxicity [8], the physician should evaluate the patient's
renalfunction by measuringthe plasma creatininepriortoCT. If
resultssuggest renaldysfunction, contrast agentsshouldonly be
givenina verynarrow rangeofindications[9, 10].Furthermore,
the useoflowosmolalityiodinatedcontrastis associatedwitha
lower risk of renal toxicity and should be considered under this
circumstance. Adequate patient hydration is also an important
adjunct measure.Lastly,administrationof acetylcysteine informof
tablets (Mucomyst �) hasshowna renoprotectiveeffectin some
studies. Diabetic patients on metformin therapy, an oral
antihyperglycemicmedication,
must be givenspecial attention[8,9J.
In these patients, contrast agents may cause lactic acidosis
especiallywhen thereiscoexistingrenaldysfunction.Thereforeit
is recommendedtowithholdmetforminonthedayofthe examand
the following48hoursandtoreinstate therapyafter repeatserum
creatininemeasurementhas confirmedstable renalfunction.Until
recently,incases wherecontrastagentswasabsolutely necessary
for a dialysis patient, the CT examination wasscheduled so that
dialysisfollowed immediately. Recentreports, however, show that
there is no need for urgent dialysis [11]. However, residual renal
function inadialysispatient cansuffer from circulating contrast.
Otherwisethereseemtobe noothercomplications ifthe contrast
agent circulates fora day ortwountil the next dialysis.
Creatinine levels can be checked quickly and are inexpensive;
Inorderto save time you may wanttohavetheresultavailable on
the requisitionfortheexamfor immediate review bythe radiologist
when prescribing the examprotocol.
Hyperthyroidism
Examining for hyperthyroidism is costly and time-consuming.
Nevertheless, the referring physician must exclude hyperthyroidism
if thereissuch aclinical suspicion beforeaCTexarnl
nation involving CONTRAST AGENTS is carried out. Laboratory

parameters and possibly scintigraphy may be necessary. Inother
cases,theinformation "noclinical evidence of hyperthyroidism"or
evenbetter, the documentation ofthyroidfunctiononthe requisition
is helpful. Thus, the radiologist can be sure that testing has
been done.Notethatreferencevalues (Table18.1)mayvaryfrom
one laboratory to another. Check with your laboratory about
commonly usedunits andnormal rangesifthese are notincluded
on thereport.Theriskof thyrotoxicosiscausedbythe iodinated
contrast agents can thus be avoided. If radioiodine therapy for
hyperthyroidism orthyroid cancerisplanned,theLv.application of
contrast agents could lead to a saturation of the iodine uptake
systeminthethyroidgland forseveral weeks.Radioiodinetherapy
may have tobe delayed for sometimeasaresult.
Table18.1 Normalthyroidhormonelevels
TSH: 0.23 -4.0 pg I ml
TT3: 0.8-1.8 ng/ ml TT4: 45-115ng /ml
FT3: 3.5 -6.0 pg I ml FT4: 8.0 -20.0 pg I ml
Adverse Reactions to Contrast Media

Ever sincenonionic contrastagentswereintroduced attheendof
the 1970s, adverse reactions have only rarely been encountered
[12-14]. Nevertheless, previous reactions are a pointer to an
increased riskand should be elicited bytaking acareful medical
history.Theseverityofany reactionto contrastagents inthe past
is of great importance. If the patients give a history of itching or
hives following prior contrast administration, premedication is
advisable. With a history of hypotension or cardiovascular
collapse,contrastagentsshouldnot be givenatallor only after
thorough assessment of the clinical indication and appropriate
premedication.Asa general rule,patientswhorequirepremedication
because of a previous reaction should be kept NPO 6 hours
prior to the examination. This reduces risk at aspiration in case of
severe anaphylactic reaction requiring intubation and ventilation
(fordetailed information seepp.24-25).
Premedication (history of previous adverse reactions to

contrast agents) In cases of mild adverse reactions,
premedicationisaccomplishedwiththree
oraldosesofPrednisone, 50mg
each,taken13,8 and1hourbeforethe examination.Inaddition,
50mgofintramuscularantihistamine drug (e.g. Benadryl)isgiven
1 hour before the exam. Side effects such as raised intraocular
pressure or urinary retention may occur. In addition, drowsiness
may occur for about 8 hours following administration of these
drugssodriving mustbeavoidedforthis period.Ifan outpatientCT
examination is scheduled, the patient must be informed about
potential drowsiness and the possibility of temporarily impaired
vision;heorsheshould beaccompaniedon the way home.
You will find checklists of all key words concerning medical
historiesandsuggestions forpremedication on apracticalcardin
the rearfoldout.
' ,':2.
.~~:
: : -
~-:,:xa' ,':2.
.~~:
: : -
~-:,:xa
Preparing the Patient
Administration of Contrast Agents

--" cperiodoffasting,liquid contrast agentsshouldbedrunkin isanysuspicionof
perforationorfistula(see also p. 20). In such
-, ingthe Patient Manypatientsare relievedto knowthatthey can communicate

.r :~'s;andab
ly,
patientshave doubtsabout the harmful er ects of
withtheradiographersinthecontrolroomviaanintercom andthat
-0 ,-rayburden involvedinCT.Worriescanusually bereducedif theexaminationcan
beinterruptedorterminatedatanytimeif
�� , ate diagnostic x-ray exposure fa natural background thereare unexpected

problems.Patientswith claustrophobia may
-=: ~
;joo.
Naturally,thepatientmusthavethefeelingthatheorshe feel
morecomfortableiftheyclosetheireyesduringtheexaminas
:,,~
taken seriously andhisor herworriesareunderstood, tion;thecloseproximityof
thegantryisthenlessofa problem.In
-~'
ise confidence andtrustintheradiologistarethreatened. veryrare cases,amild
sedativemaybehelpful.
:. iration
:c': , starting the examination, the patient should be told of the need for
controlled
: ' 2.--ling. For conventional CT, the patient is instructed to breathe before each
new image
�-::; .,'on andthentoholdhisorherbreathforafewseconds.Inthehelicaltechniqueitis
.
~:
-ssarv to stop breathing for about 20-30 seconds. If the patient cannot comply,
�,--'cgmatic movement will lead to image blurwith a marked deterioration in image

:0
iy (Fig.19.2).Inthecaseofneckexaminations,swallowing influencesthequalityofthe
-,,;,$morethan breath ing.
Fig. 19.2
val of all Metallic Objects
~:_
ally, jewelry of any kind and removable
prostheses must be removed before the
or neck are examined in order to avoid
�
' acts. In Figures 19.3a and b, the effects of
artifacts (3) are obvious. Only the cervical
l
body (50) and the adjacent vessels (86)
� = defined; the other structures are unre:-:;
'�zable. Forthesame reasonallclothingwith
-,,:2. ic hooks, buttons, or zippers should be
~-_ ed before thoracic or abdominal CTs are
:"
~
0l'm
ed.
=-=. oortions over a period of 30-60 minutes before the CT

~-canon startssothatthe entireGITis completely opacified.
-'" cauentshould thereforearriveatleast 1hourbeforean abo
::--2. CT examination.Inordertofacilitatethecorrectchoiceof
:.. cast agent,theradiologist mustbeinformedonthe request
~:
ethersurgeryis planned shortlyafterCTor whether there
9.1 aFig. 19.1b

cases water-soluble gastrografin would be used instead of a contrast
agentcontaining bariumsulfate.Andfinally, where possible,
CTof theabdomen should bedelayedfor 3 days afteraconventional
barium examination has been carried out (for example:barium
swallow, barium meal, smallbowlenema,bariumenema).Usually,
thedigital projection radiograph(scanogram Fig.19.1a, scouf .
view) would showfhatresidual

barium inthe GITwould result in
major artifacts (Fig. 19.1 b),
rendering CT valueless. The
sequence of diagnostic procedures
for patients with abdominaldiseasesshouldthereforebe
carefullyplanned.
Fig.19.3a
Fig.19.3b
Oral Administrationof Contrast Agents

For CT examination of the abdomen and pelvis, it is of major
advantageto be abletoreadilydifferentiatethe GITfromadjacent
musclesorotherorgans.Thiscan beaccomplishedbyopacifying
the intestinal lumen with an orally administered contrast agent.
For example, withoutof contrastagent itisdifficulttodistinguish
betweenthe duodenum(130) andtheheadof the pancreas(131
inFig. 20.1).
Equally,otherpartsoftheintestinal tract (140)wouldalsobevery
similar to neighboring structures. After an oral contrast agent,
both the duodenum and the pancreas can be well delineated
(Fig. 20.2a,b).Inordertoacquireimagesofoptimalquality,the
patientshouldfast(be NBM)beforedrinkingcontrast agents.
Fig.20.2a
Choice ofthe Appropriale Contrast Agents

The best coating of the mucous membranes is achieved with
bariumsulfate;however,thisisnotwater soluble.Thisoral contrast
agent should therefore not be used if abdominal surgery
involvingopeningofthe bowel lumenisscheduled,suchasinpartial
resections or anastomotic sutures, or if there is any risk of
injurytothe bowel.Neithershould bariumsulfatebe usedincases
ofa suspectedfistulaora GITperforation.Awatersolublecontrast
agent,suchasgastrografin,isthen employed; it canberesorbed
bythe bodyafterit spreadsintotheabdominal cavity.
Foran optimalassessmentofthestomach walls,plain wateris
increasinglyusedasahypodensecontrast agentin combination
withintravenous buscopan,whichrelaxesthe muscularis[15, 16].
If the urinary bladder has been removed and an i1ial conduit
constructed, the abdomen is examined first with an intravenous
contrast agentwhichisexcreted intotheurineintheconduitbut
notwithin thenativeintestines. If necessary, theintestines can be
examinedina second scanafteroralcontrastagents.
Fig. 20.1
Fig.20.2b
The TimeFactor
To opacify the proximal parts of the GIT, a period of about
20-30minissufficient;the patient swallows thecontrast agent
in severalsmall portions.However,iftheentire colon andespeciallytherectum
need tobe opacified with barium sulfate,a periodof
at least 45-60 min is necessary in a fasting patient. The
watersolublecontrastagentgastrografinspreadssomewhat
morerapidly.
Forthe peivicorgans (bladder, cervix, or ovary), 100-200 ml of
contrast agent may be given rectally to insure that tumors are
clearly differentiated from the lower intestinal tract.
Dosage
To achieve completeopacificationofthe entireGIT, 250-300mlof
abarium sulfate suspensionaredissolvedandthoroughlymixed
with water (1000 ml). For adequate contrast of the entire GIT,
10-20mlof water-solublegastrografin(in1000mlof water)are
enough.
If onlytheupperpartoftheGITneedsto beopacified,500mlof
eithermedium are sufficient.
enous Contrast Agents
--ease in the density of blood vessels not only demarcates

--r oener from muscles and organs butalso provides informathe
rate of blood perfusion (contrast agent uptake) in
:".-ically altered tissues: disturbances of the blood-brain
ebordersofabscesses,ortheinhomogeneousuptake of
,
-
_trast agentsintumorlike lesionsareonlyafew examples.This
:-:-oo11enoniscalledcontrast enhancement,l.e,thedensityis
:-e2sed bythecontrastagentandthus thesignalintensified.

:~J.'
nd
ing
uponthequestion being asked,anunenhanced(plain)
-shouldbeobtainedbeforeinjectingthe contrast agentsintra
_ -!y. Vascular grafts, inflammatory processes in bone, as well

;;; acscesswalls are moreeasilydiagnosed if unennanced images
~-:~
comparedwith contrast-enhanced images.Thesame holds
-_~
'or ocalliver lesionsexaminedusingconventionalCTtech-:_
~.
I
helicalCTisavailable,aseriesofliverimagesinthe early
:--eofarterial contrast agentperfusionfollowedbyaseriesin
-~
: aseofvenousdrainage [17]wouldbeobtainedinsteadof
_eo-anced images.Thisprocedure makes it possibletodetect
eo =~
small focal lesions (see p, 120).
-reparing the i.v.Line

--: contrastagents areinjectedintravenously,andthebolusbe:.:
-~
longer and diluted as it passes through the pulmonary
--::_anon.Theinjection should thereforeideallyhavearapidflow
~'c
of 2-6 0111 1secforachieving sufficientdensityenhancement
:' --evessels[18].A Venflon canulawitha diameterofat least
� : 011011 (20G), or preferably 1.2-1.4 011011 (18G-17G), is used.

Checking thatthe canulais correctlysitedinthevesselis very
important.Atrial injectionofsterilesalineata high flow rateinto
theveinshould becarriedoutbefore injecting contrastagents.The
absenceofsubcutaneousswellingconfirms properpositioning;the
fact thatthe vein can accommodate theintendedflow canalso be
confirmed.
Dosage
Dosage is calculated on the basis of b.w. and according to the
diagnostic question athand:examinationsoftheneckorofan
aorticaneurysm(for example in ordertoexcludethepresenceofa
dissection flap), require higher concentrations than cranial CTs.
Whentolerancetocontrast agentsandoptimal vesselcontrast are

balanced,adosageof,forexample, 1.2mllkg
b.w.ataconcentrationof0.623glopromidlmlingeneralprovides
good results.
Inflow Phenomena
Thestreaming artifact of enhanced andunenhanced blood results
fromashortinterval between the startofinjectionandtheonset of
data acqulsltlon. Since inflowisusuallyfrom oneside viatheaxillary,
subclavian,andbrachiocephalic veins (91) intothesuperior
venacava (92),thereis an apparentfillingdefectwithinthe vena
cava(Figs. 21.1a-21.3b).Knowingaboutsuchinflowphenomena
avoidsafalsepositive diagnosisof venousthrombosis.Using too
high concentrationsof contrast agentsinthisarea couldresultin
disturbing artifacts, especially with the helical technique (Fig.
23.3a). More inflow phenomena will be described on the next
pages.
22
Application of Contrast Agents

Flowphenomena canalsobe seen inthe inferior venacava (80) atthe levelofthe renal
veins(111).Theseveins maycontainbloodwhich
hasafairlyhighconcentrationof contrastagentsandthisblood
mixeswithunenhancedbloodreturning fromthelowerextremitiesand
pelvicorgans.Inthe earlypost-contrastphase the venacava (80)
caudaltotheleveloftherenalveinsishypodenserelativetothe
adjacentaorta(89) asin Figures 22.1a,b.
Fig.22.1a Fig.22.1b
Immediatelyabove therenal veins, thecontentsoftheinferiorvenacava may appear
bilaterallyenhancedby the blood fromthe kidneys
whereasthe centralpartisstill unenhanced
(Fig.22.2a,b).Iftherenalveinsdonotemptyintothe cavaat thesamelevelorifa kidney
has beenremoved,aunilateralenhancementmayoccur (Fig.22.3a,b).
Suchdifferencesindensityshouldnot bemistaken forthrombosisoftheinferiorcava(
ct. Figs.23.1 and144.1).
Fig. 22.2a Fig.22.2b
Fig. 22.3a Fig. 22.3b

Flow Phenomena
Ifwetracetheinferior vena cavacraniallytowardtherightatrium,
additionalflow phenomena become apparentasmoreveins empty
into it. The cava has spiraling eddies of inhomogeneous density
(+ in Fig. 23.1)causedbymixing ofthe blood asdescribed on
the previous page. Moments later such inhomogeneities are no
longerevidentinthe lumen (80)anddensityleveis are identicaito
thoseinthe aorta (89) (Fig,23.2a,b).
8ytheway, didyounoticethe artheroscleroticplaqueinthedorsal

walloftheaorta (174in89inFig. 22.3a)?Thisplaqueappearsalso
in Figure 23.2a.Thepatienthad well-developedosteophytes (64)
on thevertebral bodies (50).
Fig.23.1
Fig. 23.2a
Fig. 23.2b
Details Specific for Spiral GT

If data acquisition begins immediately after contrast agents have
beenadministered,theconcentrationofcontrast agentsinthe axillary,
subclavian, and brachiocephalic (91) veins might be high
enoughtocausemajorartifacts(3)inthethoracicinlet. Inimages
such as in Figure 23.3, it is not possible to assess the lung or
neighboringaxillary tissues.An SCTof thethoraxshouldtherefore

beobtainedfrom caudaltocranial.Inthatway structuresnearthe
diaphragm are imaged first, and when cranial parts are scanned
the contrast agentswillhave been spreadafterhavingpassedthe
pulmonary circulation. This trick helps avoid the artifacts (3)
shown in Figure 23.3.
Fig. 23.3a
Fig. 23.3b
24
I
I
Adverse Reactions to Contrast Agents
Adversereactions arerare;most appearduringthefirst30 immediately.
Rememberthati.v.injectionofHl-andH2-receptor
minutes,70%of casesoccurwithinthefirst5 minutesafter
antagonistsdoesnotalleviatesymptoms immediately. Thereisa
contrast injection[13].Onlyhigh-riskpatientsneedtobesuperperiodoflatency,
and these antagonistsarethereforeprimarily
visedfor morethan30minutes.Sincesuchpatientscanusuallybe eftectivein
preventingthesymptomsfromworsening. Serious
recognized by taking a thorough medical history, they can be incidents
(pulmonaryedema,circulatoryshock, convulsions)occur
premedicatedaccordingiy(seep.14). veryrarelywiththe newcontrast
media;theyrequireimmediate
If, despiteprecautions, erythema developsafteranl.v,injectionof intensive care.
contrast agents,perhapsalsohives,itching,nausea orvomiting,or Be sure to document
any incident in your report. Radiologists
inextreme casesevenhypotensionorcirculatoryshockorshortpertorming
futureexaminationswillbeforewarnedabout the
nessofbreath,thecountermeasuresiisted belowmustbeinitiated
patient'ssensitivitytocontrast agents.
Management of Acute Reactions in Adults
Urticaria
Bronchospasm
1 Discontinueinjectionifnotcompleted 1 GiveO26-10liters/min(via mask)

2 No treatment needed in mostcases Monitor;electrocardiogram,O2saturation(pulse
oximeter),
3 GiveH,-receptorblocker; Diphenhydramine(Benadryl�) andbloodpressure.
PO/ 1M/ IV 25-50mg 2 Givebeta-agonistinhalers:bronchiolardilators,suchas

ifsevereorwidelydisseminated; metaproterenol(Alupent�j,terbutaline(Brethaire�),or
Alphaagonist (arteriolarandvenousconstriction) albuterol(proventil�,Ventolin�j2-
3pufts;repeatprn.
EpinephrineSC(1;1,000)0.1-0.3ml =0.1-0.3 mg Ifunresponsivetoinhalers,us
SC,1MorIVepinephrine
(ifnocardiaccontraindications) 3 GiveepinephrineSCor1M(1:1,000)0.1-0.3ml
(= 0.1-0.3mg)or,if hypotension evident,

Epinephrine(1:10,000)slowlyIV1ml(= 0.1 mg)
Facial or Laryngeal Edema
Repeatasneeded uptoamaximum of1mg
Alternatively:
1
Givealphaagonist(arteriolarand venousconstriction);
Give aminophylline:6 mg I kgIV inD5Wover
Ephinephrine SCor 1M (1;1,000)0.1-0.3ml(= 0.1-0.3 mg)
10-20minutes(loading dose),then0.4-1mg I kg I hr,
or, if hypotension evident,
as needed (caution: hypotension)
Epinephrine (1;10,000)slowlyIV1ml (= 0.1 mg)
Callfor assistance (e.q., cardiopulmonary arrest responseteam)
Repeatasneededuptoa maximum of1mg
forsevere bronchospasm orifO2saturation <88%persists.
2
Give O26-10iiters/ min(via mask)
Ifnotresponsivetotherapyorif thereis obvious
acute laryngeal edema,seekappropriateassistance Hypotension with Tachycardia
(e.q., cardiopulmonaryarrest response team)

1
Legs elevated60�or more(preferred)
orTrendelenburg position
2 Monitor:electrocardiogram, pulse oximeter, blood pressure
3 Give O26-10liters I min (via mask)
4 Rapidintravenousadministrationoflargevolumesof
isotonicRinger's lactateor normalsaline.
Ifpoorly responsive:
Epinephrine(1:10,000)slowlyIV1ml (=0.1 mg)

(if nocardiac contraindications)
Repeat as needed up to a maximum of 1 mg
ifstillpoorlyresponsive seekappropriateassistance
(e.q.,cardiopulmonaryarrest response team)
Management of Acute Reactions in Adults
Hypotension with Bradycardia
(Vagal Reaction)
1 Monitor vital signs

2 Legselevated60' ormore(preferred)
or Trendelenburg position
3 Secureairway:giveO26-10liters/ min (viamask)
4 SecureIV access:rapidfluidreplacementwith
Ringer's lactate ornormalsaline

5 Give atropine 0.6 mg IVslowly if patient does
not respond quickly to steps 2-4
6 Repeatatropine uptoatotaldoseof0.04 mg/kg(2-3 mg)
inadult
7 Ensurecomplete resolution of hypotension
andbradycardia priorto ctschanqe
Hypertension, Severe
1 Give O26-10 liters/ min (viamask)

2 Monitorelectrocardiogram, pulseoximeter,blood pressure
3 Give nitroglycerine0.4-mg tablet,sublingual
(may repeat x3) ortopical 2% ointment, apply 1 in. strip

4 Transfertointensive care unitoremergencydepartment
5 For pheochromocytoma-phentolamine5mgIV
Iodine-provoked Hyperthyroidism
Fortunately, thiscomplicationis very rare with modernnon-ionic
iodinated contrast agents.Inpatientswithamedical historyof
yperthyroidism consider blocking the thyroid gland before l.v

applicationofcontrast agentsby administering athyrostaticdrug
such as sodium perchlorate. Alternatively, carbimazole can be
edtoblockhormone synthesis. Bothtreatments take approxiately1weektobecomefully

effective. Effectivenessmustbe
:isterminedbyrepeating the thyroid function tests.
Seizures orConvulsions
1 GiveO26-10liters/min (viamask)
2 Consider diazepam (ValiUm�)5mg (or more, as appropriate)
ormidazolam (Versed�)0.5-1mgIV
3
If longer effect needed, obtain consultation;
considerphenytoin(Dilantin�)infusion -15-18mg/ kg
at50mg/ min
4
Careful monitoringofvitalsignsrequired,particularlyof p02
because ofrisktorespiratorydepressionwith
benzodiazepine administration
5 Consider using cardiopulmonary arrest responseteam
for intubation if needed
Pulmonary Edema
1 Elevate torso;rotating tourniquets(venous compression)

2 Give O26-10liters/ min (viamask)
3 Givediuretics-furosemide(LaSix�)20-40 mg IV,slowpush
4 Consider giving morphine(1 -3mgIV)
5 Transferto intensivecare unitoremergencydepartment
6 Corticosteroids optional
In patientswith unrecognizedsubclinicalhyperthyroidism,theuse
ofiodine containingcontrast agents canunmaskthediseaseor
even induce thyrotoxicosis. The symptoms may includediarrhea,
muscle weakness as wellasfever, sweating,dehydration,anxiety
andrestlessness,or eventachyarrhythmia. Themainproblem is
the long periodof latencybeforethethyrotoxicosiscrisisbecomes
manifest.
�Some patientswithhyperthyroidism orotherthyroid disease(especially thosewho

liveiniodine-deficient areas)maydevelop iodine
orovoked delayed hyperthyroidism.This effect mayappear4to6weeks after

theintravascularcontrastadministrationin some ofthese
catients.It canoccur afterthe administrationofeither ionic,high-osmolalityor

nonionic,low-osmolality contrast.Itisusuallysett-limt
:sd.
"atientswith carcinomaofthe thyroid deservespecialconsiderationbefore

theintravascularor oraladministrationofiodinatedcontrast
,edia(ionicor nonionic). Uptakeof1-131in thethyroidbecomes moderatelydecreasedto

about50%atone weekafteriodinated
-
-trastinjection butseemstobecomenormalwithinafewweeks.Therefore,ifsystemic
radioactiveiodinetherapyispartofplanned
-satmen\, a pretherapy diagnostic study of the patient using iodinated radiographic

contrast medium (intravascular or oral) may be
traindicated;
consultationwiththeorderingclinicianpriortocontrastadministrationinthesepatientsisr
ecommended."
Cranial CT .
ManycranialCT(CCT) examinationscanbeperformedwithoutinjectionof contrastmedium:

Forinstance,thedifferentialdiagnosis(DO)
ofcerebralbleeding versusinfarctionin patientwithsuddenonsetof neurologicdeficits
does notrequirethe administrationofcontrast
medium. However,intravenousinjectionofcontrastmedium is necessarytodetect an
impaired blood-brainbarrier(BBB) asfoundin
tumors, metastases or inflammations.
I
I
Selection of the ImagePlane
The desired image planes parallel to the orbitomeatal line are selected on the
sagittal
localizer image(topogram)(Fig.26.1).Thisisa readily reproducible line drawnfromthe
supraorbital ridge to the external auditory meatus, allowing reliable comparison
with
follow-upCT examinations.The posteriorfossaisscannedinthinsections(2-3 mm)to
minimize beam hardening artifacts, and the supratentorial brain above the pyramids
in
thickersections (5 mm).
The images are displayed as seen from below (caudal view) and consequently are
laterallyreversed,i.e., the leftlateral ventricleis on therightandvice
versa.OnlyCTs
obtainedforneurosurgicalplanningareoftendisplayedas seen from above(right = right)
sincethiscranialviewcorrespondstothe neurosurgicalapproach forcranialtrepanation.
Fig. 26.1
Systematic Interpretation
Each examinerisfreetofindapreferredsequencefor reviewing becauseof age-
relatedwideningoftheCSFspaces.Anyblurring
theimages.Thismeansthatthe examinercanchoosebetween ofthegrey-whitematterjunction
asmanifestationofcerebral
several acceptableapproachesandisnot restrictedtoa "oneand edemashouldbelookedfor
(seebelow).Ifapathologicchangeis
only"strategy.However,stayingwitha consistentarrangementof
suspected,theadjacentsectionsshouldbeinspectedtoavoid any
theimagestobeinterpretedhastheadvantagethatfewerfindings misinterpretationduetoa
partial volume effect(see Fig.29.1and
areoverlooked, especiallybythenovice. Thechecklist belowjust Fig.52.2).
containsrecommendationsthat canserveasgood guidelinefor Alwaysusethelegends
onthefrontcoverflapforthischapter.The
thenovice. listednumbers applytoall headandneckimages.Thesubsequent
First,thesizeoftheventriclesand extracerebral CSFspaceshasto
pagesprovideyouwithasurveyofthenormalanatomy,followed
be evaluated to exclude a life threatening space-occupying bynormalvariants
andthemostfrequentpathologicfindings.
processrightaway.Hereby,the patient'sagehasto be considered
Checklist for Reading Cranial CT
Age?(becauseofthe age-related widthofthe CSFspaces I cerebral atrophy; see page 50)
Medical Historv: � Risk factors? (Trauma -+ Chance of intracranial bleeding)

(Hyperte nsion, diabetes, nicotine -+ Vascular stenoses, infarcts)
Signs ofspace-occupying lesion:
� Normalconfigurationofthe-tth ventricle?(posteriortothepons,see pages28/29)

� Normalconfigurationofthe3rdventricle?(interthalamic,narrow/slit-like,seepage 30)
� Normal symmetryofthelateralventricles?(concavelateralborderoftheanteriorhornand
centralventricularregion?)
� Midlineshift?(signof largespace-occupying process)
� Preservedbasalcistern?(e.g.,quadrigeminalcistern:smiliefaceI bat manfigure, see
Fig.30.1)
� Cortex +-~
whitematterdemarcation OK?(blurredinterface =signof edema)
� Widthofthe extracerebral CSFOKfor patient'sage? (Sylvianfissure,referto p.50)
Focallesions: �Unenhanced:DOphysiologiccalcification(choroidplexus,pinealgland/
partialvolume; refertoFigures 29.3and30.2)
versusgenuinehyperdensebleeding (DOtypes ofbleeding,seepages54-57)
� Contrastenhanced:Signof impairedBBB?(causedbytumors,metastases,inflammations,...)
Osseouslesions: � Checkcranialvault and baseinbonewindowforosteolyticlesionsI

osseousinfiltration
�Intraumapatient:Ruleoutfractures (especiallycranialbase,midfacialbones-DOsutures)
Cranial CT Normal Anatomy
The scan usually begins at

the base of the skull and
continues upward. Sincethe
hardcopies are orientedsuch
that thesectionsareviewed
from caudal, all structures
appear as if they were
lelUrightreversed(see p.t4).
The small topogram shows
you the corresponding position
of each image.
-Fig. 27.1b
You shouldfirstcheckforany
swellings in the soft tissues
whichmayindicatetrauma to
the head. Always examine
the condition of the basilar
artery (90) in scans close to
the baseoftheskullandthe
brainstem (107). The viewis
often limited by streaks of
artifacts (3) radiating from
thetemporal bones (55b).
When examining trauma
Fig. 27.2b
patients. remember to use
the bone window to inspect
the sphenoid bone (60). the
zygomaticbone(56),and the
calvaria (55) for fractures. In
the caudal slices you can
recognize basai parts of the
temporal lobe (110) and the
cerebellum (104).
Orbitalstructuresare usually
viewed in another scanning
plane (see pp. 33�40). In
Figure27.1-3 we seeonlya
partialslice ofthe upper parts
of theglobe (150),the extra
ocular muscles (47),andthe
oifactory bulb (142).
, 27.1a
-, . 27.2a
-e-27.3a Fig. 27.3b

Cranial CT . Normal Anatomy
As the series of slices continuesdorsally.

thecristagalli
(1 62) and the basal parts of

thefrontallobe (111) appear.
The pons/medulla (107) are
often obscured by artifacts
(3). The pituitary gland (146)
and stalk (147) are seen
between the upper border of
the sphenoid sinus (73) and
the clinoid process (163). Of
the dural sinuses, the sigmoid
sinus (103) can be
readily identified. The basilar
artery (90) and the superior
cerebellar arlery (95a) lie
anterior to the pons (107).
The cerebellar tentorium
(131).which liesdorsal tothe
middlecerebralartery (91b),
shouldn't bemistakenforthe
posterior cerebral artery
(91c)attheleveldepicted in
Figure 29.1 a on the next
page. The inferior (temporal)
hornsofthelateral ventricles
(133) as well as the 4th
ventricle (135)can be identified
in Figure 28.3. Fluid
occurring in the normally
air-filled mastoid cells (62) or
in the frontal sinus (76) may
indicate a fracture (blood) or
an infection(effusion).
A small portion of the roof of
the orbit (*) can still be seen
in Figure28.3.
Fig.28.1a Fig.28.1b
Fig. 28.3a Fig. 28.3b

In Figures 28.3a and 29.1 a

partial volume effects of the
orbit (*) or the petrosal bone
I(* *) might also be misinterpreted

as fresh hemorrhages
in the frontal (111) or the
temporallobe (110).
The cortex next to the frontal

bone (55a) often appears
hyperdense compared to
adjacent brain parenchyma,
but this is an artifact due to
beam-hardening effects of
bone. Note that the choroid
plexus (123) in the lateral
ventricle (133) is enhanced
after Lv. infusion of eM. Even
in plain scans it may appear
hyperdense becauseofcalcifications.
You will soon have recognizedthat

theeeTimageson
thesepages weretaken after
l.v. administration of eM: the

vessels of the circle of Willis
are markedly enhanced. The
branches (94)of themiddle
cerebral artery (91 b) are
visible in the Sylvian fissure
(127). Even the pericallosal
artery (93).a continuation of
the anterior cerebral artery
(91a), can be clearly identified.
Nevertheless, it is often
difficult to distinguish betweenthe
opticchiasm(145)
and the pituitary stalk (147)
because these structures
havesimilar densities.
In addition to the abovementioned

cerebral arteries
(93, 94), the falx cerebri
(130) is a hyperdense structure.

In Figure 30.2a you can
see the extension of the
hyperdense choroid plexus
(123) through the foramen of
Monro, which connects the
lateral ventricles (133) with
the 3rdventricle (134).Check
whether the contours of the
lateral ventricles are symmetric.
A midline shift could be an
indirect sign of edema.
Calcifications in the pineal
(148) gland and the choroid

plexus (123) are a common
finding in adults, and are
generallywithout anypathologic
significance. Due to
partial volume effects, the
upper parts of the tentorium
(131) often appear without
clear margins so that it becomes
difficult to demarcate
the cerebellar vermis (105)
and hemispheres (104) from
the occipital lobe (112).
It is particularly important to
carefully inspect the internal
capsule (1 21) and the basal
ganglia: caudate nucleus
(117), putamen (118), and
globuspallidus (119) aswell
as the thalamus (120).
Consultthenumber codes in
the front foldout for the other
structures not specifically
mentioned onthesepages.
Fig.30.1a Fig. 30.1 b
Fig.30.2a Fig.30.2b
Fig.30.3a Fig.30.3b
The position of the patient's

headis notalways asstraight
asinourexample.Even small
inclinations may lead to
remarkably asymmetric
pictures of the ventricular
system, though inrealityitis
perfectly normal. You may
see onlyapartialsliceofthe
convex contoursofthelateral
ventricles (133). This could
give you the impression that
they are not well defined
(Fig. 31.1a).
The phenomenon must not
be confused with brain
edema: as long as the sulci
(external SAS) are not
effaced, but configured
regularly, the presence of
edema israther improbable.
For evaluating the width of

the SAS, the patient's age is
animportant factor. Compare
the images on pages 50 and
52 in this context. The para-
ventricular and supra-
ventricular white matter
(143) must be checked for

poorly circumscribed hypodense
regions of edema due
to cerebral infarction.
As residues of older infarctions,
cystic lesions may
develop. In late stages they
are well defined and show
the same density as CSF
(see p. 58).
I
Inthe uppersections(Figs.32.1-32.3) calcificationsinthecerebralfalx (130)

oftenappear.Youshould
differentiatethiskind oflesion,whichhasnoclinicalsignificance,from calcified
meningioma.Thepresenceof
CSF-filled sulci(132)inadultsisanimportant findingwithwhichtoexclude
brainedema.After
athoroughevaluationofthecerebral soft-tissue window,acarefulinspection
ofthebonewindowshould
follow.Continue tocheckforbonemetastasesor fracturelines.
Onlynowisyourevaluationofacranial
CT really complete.
Test yourself! Exercise 1:
Notefrom memoryasystematicorderfortheevaluationofcranialCTs.Ifyou
havedifficulties,returnto
thechecklist onpage 26.
Note:
I�
�
�
�
�
�
�
�
Fig, 32.1a Fig. 32.2a Fig. 32.3a
Fig, 32.1 b Fig, 32,2b Fig. 32.3b
Onthe following pagestheatlasof normalanatomycontinueswith scansofthe

orbits(axial),theface(coronal),andthe petrosalbones
(axialandcoronal).Afterthese youwill
findthemostcommonanatomicvariations,typicalphenomenacausedbypartial volumeeffects
andthe mostimportantintracranialpathologicchanges onpages50to60.
Cranial CT
"ig. 33.1a
=-. 33.1b
Normal Anatomy of the Orbit (Axial)
The face andtheorbitsare usuallystudiedinthinslices(2 mm)

using 2-mm collimation steps. The orientation of the scanning
plane is comparable to that for CCTs (see p. 26). In the sagittal
topogramthelineof referenceliesparalleltotheflooroftheorbit
atanangle of about 15� tohorizontal (Fig. 33.2).
The printouts are
usually presented in
theview from caudal:
all structures on the
right side ofthe body
appear on theleft.and
vice versa.
Fig. 33.2
Alterationsinthesoftstructures oftheorbits and the paranasal

sinuses can be readily evaluated inthesoft-tissuewindow(Fig.
33.1b).Forthedetectionofatumor-related arrosionofbone ora
fracture.the bone windowshouldalsobechecked(Fig.33.1a).
The following pages therefore present each scan level in both
windows.The accompanying drawing (Fig.33.1c)referstoboth.
The numbercodesforalldrawings arefound inthe legendinthe
front foldout.
Onthelowerslicesofthe orbits you will seepartsofthemaxillary

sinus (75).the nasal cavity(77) withtheconchae (166).the
sphenoid sinus (73). and the mastoid cells (62) as air-filled
spaces. Ifthereisfluidorasoft-tissue mass.thismay indicatea
fracture, an infection. or a tumor of the paranasal sinuses. For
examples ofsuchdiseases.see pages 58to 61.
Two parts of the mandible appearontheleftside:inadditionto
thecoronoidprocess (58).thetemporomandibularjoint withthe
head ofthe mandible(58a) isseenonthe left.The carotidartery.
however,isoftendifficultto discerninthe carotidcanal(64),
whetherinthesoft-tissue orbone window.
In the petrous part of the temporal bone (55b), the tympanic

cavity (66) and the vestibular system are visible. For a more
detailed evaluationofthe semicircular canalsandthe cochlea.
images obtained with the petrous bone technique are more
appropriate (pp. 44-47). CM was infused intrave nously before
theexamination ofthe orbits.Thebranches ofboth thefacial
and angular vessels(89)as wellasthebasilarartery (90)therefore
appear markedly hyperdense in the soft-tissue window
(Fig. 33.1b).
-e-33.1c
Cranial CT Normal Anatomy of the Orbit (Axial)
Itisnotalways possibleto achieve aprecise sagittal position ofthe head.

Evenaslighttilt (Fig. 34.1) will makethetemporal lobe (110)
appearonone side. whereas onthe other side themastoidcells (62) can beseen.
Fig. 34.1a
Fig. 34.2a
Fig. 34.1b
Fig. 34.2b
Fig. 34.1c
Fig. 34.2c
-~
, perienceshows,itis difficulttodeterminethe courseoftheinternal carotidartery
(85a) through the base of the skull and to
:e-:;rcate the pterygopalatine fossa (79), through which,amongother structures,
thegreater palatinenerve and thenasal branchesof
-~
::erygopalatine ganglion (fromCNVand CNVII) pass.
Fig. 35.2a
I g. 35.1a
Fig. 35.2b
Fig. 35.1b
Fig. 35.2c
Ontheflooroftheorbit,theshortinferior obliquemuscle(47f)oftenseems
poorlydelineatedfrom thelowerlid.Thisisduetothesimilar
densitiesofthesestructures.Directlyinfrontoftheclinoid process/dorsum sellae (163)
liesthepituitarygland (146) initsfossa,which
islaterallybordered bythecarotidsiphon (85a).
Fig. 36.1a
Fig, 36.2a
Fig. 36,lb
Fig, 36,2b
Fig. 36.1c
~
1o-_~_"lM1I
.s
Fig, 36.2c
allinclinationsofthehead causeslightly asymmetricviewsoftheglobe(150)andthe

extraocularmuscles(47).Themedialwallof
enasolacrimalduct (152)isoften sothinthatit cannot bedifferentiated.Atfirst
sightthe appearanceoftheclinoid process (163),
etweenthe pituitarystalk(147)andthe carotid siphon(85a) on the left side only, may
be confusingin Figure 37.2b.
Fig.37.2a
19.37.1a
Fig. 37.1b
Fig. 37.1c
AfterintravenousinjectionofeM,the
branchesofthemiddlecerebralartery(91b)originatingfromtheinternalcarotidartery(85a)a
re readily
disijnguished.Thegray shadeoftheopticnerves (78) as they pass through the chiasm
(145) tothe optic tracts(144), however,is verysimilarto
that ofthesurrounding CSF(132).Youshouldalways check onthesymmetry
oftheextraocularmuscles(47) intheretrobulbarfattytissue(2).
Fig. 38.2a
Fig. 38.1 a
Fig. 38.1b
Fig. 38.2b
Fig. 38.2c
Fig. 38.1c
-~
; obe(150)youcan
nowseethehyperdenselens(150a).Noticetheobliquecourseoftheophthalmicartery(* )
crossing theoptic
-, 8)inthe retrobulbarfattytissue(2).
Figure39.2bshowsaslightswelling(7)oftherightlacrimalgland (151) compared to the
-" seeFig. 40.1b).
Fig. 39.2a
Fig. 39.2b
Fig. 39.2c
Figure40.1bclarifiesthatinthis casethereisindeedaninflammationortumor-
likethickening (7)intherightlacrimalgland (1 51).The
superior rectus muscle (47a) appears at the roof of the orbit and immediately
nexttoitliesthelevator palpebrae muscle (46).Dueto
similardensities,these musclesarenot easilydifferentiated.
Fig.40.2a
Fig.40.1a
Fig.40.1b
Fig.40.1c Fig.40.2c
Theaxialviews oftheorbitsandthefaceendherewiththeappearance ofthefrontal

sinus(76).Examplesofpathologic changes ofthe
orbitsorfracturesoffacial bonesarefound onpages61to 63.
Cranial CT Normal Anatomy of the Facial Skeleton (Coronal)
---oossfbilitiesofanglingtheCf gantryarelimited.Inordertoacquirescansinthe coronal

-..epatient must thereforebepositionedasshownintheplanning topogramtothe
; -(Fig. 41.1). The patient should be in a prone position, with the head completely
.--cell.Whenexaminingtraumapatients,anylesionsof thebonesor ligamentsofthe
-caspinemust alwaysbeexcludedbyconventionalradiographypriorto eeT.

~-;~
viewedfromanterior:theanatomicstructures on thepatient'srightsideappearon
: -=~
intheimagesandconversely,asif the examinerwerefacingthepatient.
00-100 ingfor fractures,imagesare usuallyacquiredinthe thin-slicemode(slice and

-~won
,
each2mm) andviewed onbonewindows.Evenfinefracturelinescanthenbe
_~
.
Asuspectedfracture ofthe zygomaticarch mayrequireadditionalscansinthe
-: ane(seep.34).In Figure 41.2atheinferioralveolarcanal (*l in the mandible (58)
: --~
foramen rotundum (**l inthesphenoidbone(60) areclearlyvisible.Asfor the Abb.41.1
schapter,thecode numbersforthe drawingsare explained inthe legend inthefront
-t
Fig. 41.2b
Fig. 41.3b
Fig. 42.1a Fig. 42.1b
Fig. 42.2a Fig. 42.2b
Fig. 42.3a Fig. 42.3b

Fig. 43.1b Fig. 43.1b
-!3.2a Fig.43.2b
Fig. 43.3b
44 ,
Fig.44.1b Fig.44.2b Fig.44.3b
The insertions of the extraocular muscles on the globe (150) can

also be clearly identified (47 a-I) in the anterior slices.The short
inferioroblique muscle(471),however,isollen seen only incoronal
scanning planes,becauseit doesnotpass withthe othersmuscles
throughthe retrobulbarfattyconnectivetissue.Thesameproblem
occurs in axial scans of the face (compare with Fig. 36.2b and
Fig. 36.2c).
Ifacaseofchronicsinusitisissuspected,itis very importantto

check whetherthesemilunarhiatus isopen.Itrepresentsthemain
channel for discharging secretions of the paranasal sinuses. In
Figure 60.3youwillfind examplesofanatomic variationswhich
narrowthischannel andmay promote chronicsinusitis.
Sometimes one discoversa congenitally reduced pneumatization

of a frontal sinus (76) or an asymmetric arrangement of other
paranasal sinuses without any pathologic consequences. You
should always make sure that all paranasal sinuses are filled
exclusively withair.thatthey are well defined and present no airfluid
levels.Hemorrhageintothe paranasalsinusesorthe detection
ofintracranialbubblesofairmustbeinterpretedas anindirect
signofafracture -youwillfindexamplesofsuchfractureson
page63.
_,, : -9.) _,, : -9.)
Test Yourself!
:~
-epreviouspagesyouhavelearnedaboutthenormalanatomy
Withoutdoubt,youwillimproveyourunderstandingofthesubject
:-' =-;; brain,theorbits,andtheface.It maybe sometime agothat ifyoutacklethegapsin
yourknowledgeinsteadofskipping
__ 5, diedthetechnical basicsofCTandabout
adequatepreproblemsorlookingattheanswersattheendof
thebook.Reterto
:-anon of the patient. Before going on with the anatomyof the the relevant pages
only if you getstuck.
:.=-J()(al bone, it would be good to check on and refresh your
: edge of the last chapters. All exercises are numbered

:
:-.;.~utive
ly,
beginning with the firstone on page 32.
~
Writedown frommemorythe typicalwindow parametersforimagesofthelungs,bones,
andsofttissues. Noteprecisely
-;;width andcenterofeachwindowinHUand give reasonsfor
thedifferences.Ifyouhavedifficultiesansweringthisquestion,go back
-:.:;es16/17torefreshyourmemory.
_; I pleurawindow: Center Width Gray scalerange
HUto HU
: : -;;window:
HU to HU
: :-:<ssue window:
HU to HU
-�," Whichtwotypesoforal CMdoyouknow?Whatspecificaspectsmustyou

considerwhenadministeringthiskindofCM
.;;-:�ngontheclinical problem?Arethereanyconsequencesforyourlist?
:'" _, (name) Indication Special schedule
= -"";.ed out with gadolinium as the CM. (The
c)
=: ;0 questions3and4canbefound on pp.
Howwouldyoudifferentiate betweenlongstructures such asvessels,nerves,orcertain

musclesandnodularstructures
�ph nodesortumors? (You willfindthe answeronp.15.)

Inwhichvessels mightyoufindturbulencephenomena,causedbythe CMinjection,that mustnot
bemistakenfora
~..i
i Iiyou don'tremember,checkbacktopp.21-23.)
oe are
-,a . n
What aspects should you always a)
referring your patients to a CT
which probably requires the l.v,
-.s:' ofCM?The same applies if you consider
b)
=c~
;
someonetoa venogram/angiogram oran
_ ::-procedures are carried outwith nonionic
::--oiningiodine). MRI examinations, however,
Cranial CT Normal Anatomy of the Temporal Bone (Coronal)
In order to evaluate the organ of hearing and balance, the petrosal bone is
usually examinedinthinsliceswithout overlap (2/2).Toensure optimalresolution,
thewholeskull isnotimaged,justtherequiredpartofthepetrosalbone.The
two petrosal bones (55b) are therefore enlarged and imaged separately. Only
then is it possible to differentiate small structures like the ossicles (61a-i:),
cochlea (68),andthesemicircularcanals(70a-i:).
The topogram (Fig.46.1) indicates the coronal imaging plane.The patient must �
be placed ina prone positionwithhisor her head hyperextended.Notethe
pneumatization of themastoidcells (62) andtheusuallythinwallsofthe outer
auditory canal (63b).Inflammationoftheseair-filledsinusesleadsto characte
risticeffusionandswellingofthe mucousmembranes (seeFig.60.2a).
Fig. 46.1
Fig. 46.2a Fig. 46.2b
55b
~5.0a......
Fig. 46.3a Fig. 46.3b
Cranial CT Normal Anatomy of the Temporal Bone (Coronal)
Fig. 47.1b
-:. ~7
.2a
Fig. 47.2b
-_
.
~7.3a
Fig. 47.3b
Cranial CT Normal Anatomy of the Temporal Bone (Axial)
Analogoustocoronalimages, axial images are obtained withthinslices without

overlap, i.e.,2mmthicknessand 2mm increment and viewed on bone windows.
Thecerebellar hemispheres (104),thetemporallobe (110),andthesofttissues
of thegaleaare therefore barely identifiable.Apart from the ossicles (61 a--i:) and
the semicircularcanals(70a-c),the internal carotid artery (64),thecochlea

(68),andtheinternal(63a)and externalauditorycanals(63b)arevisualized.The
funnel-shaped depressionin the posterior rim ofthe petrosal bone (Fig,48,2a)
represents the opening of the perilymphatic duct (** = aqueduct of the,
cochlea) intothesubarachnoidspace. InFigure49.1anotethelocalizationofthe
geniculate ganglionofthe facial nerve (*) ventral to the facial canal. The topogram
(Fig.48.1)showsan axial planeofsection, obtainedwiththepatientlying

supine.
Test Yourself! Exercise NO.7: Think aboutdifferential diagnoses involving
effusioninthemiddle ear (66),theouterauditorycanal,orthe mastoidcells(62)
and compare your resultswiththe cases shownon pages 60and 62to63.
Fig. 48.1
Fig. 48.2a
Fig. 48.3a
~~
Fig. 48.2b
146 00
Fig. 48.3b
Fig. 49.1b
146
~
163
Fig. 49.2b
163
~
Fig. 49.3b
Fig. 49.1b
146
~
163
Fig. 49.2b
163
~
Fig. 49.3b
Cranial CT Normal Variants
Doyou rememberthesystematicsequenceforevaluatingeeTscans?If
not,pleasegobacktothechecklist onpage26orto yourown
notes on page 32.
AfterevaluatingthesofttissuesitisessentialtoexaminetheinnerandoutereSFspaces.Thewid
thofthe ventriclesandthesurface SAS
increasescontinuously with age.
Fig.50.1a Fig.50.1b
Since thebrainofa child (Fig.50.1a) fills the cranium(55),theoutersubarachnoidspace

isscarcelyvisible,butwithincreasing age the
sulcienlarge(Fig.50.2a)andeSF (132) becomesvisible betweencortexandcalvaria.In
somepatientsthisphysiologicdecreasein
cortex volumeisespecially obviousinthefrontal lobe(111).Thespace
betweenitandthefrontal bone(55a)becomesquite large.This
so-calledfrontally emphasized braininvoiution should notbemistakenfor pathologiC
atrophyofthebrainor congenitaimicrocephalus.
IftheeTscanin Figure50.1ahad
beentakenofaneiderlypatient,onewouldhavetoconsiderdiffuse cerebraledemawith
pathologicallyeffaced
gyri.Beforemakingadiagnosisof cerebraledemaor
brainatrophyyoushouldthereforealwayscheckonthe ageofthe
patient.

Figure50.2ashowsanadditionalvariation from thenorm.Especiallyinmiddle-
agedfemalepatientsyouwill sometimesfindhyperostosis
of the frontal bone (55a) (Steward-Morel-Syndrome) without any pathologic
significance. The frontal bone (55a) Is internally
thickenedonbothsides, sometimesWith anundulatinq contour.
Incasesofdoubt.thebonewindowcanhelptodifferentiate between
normal spongiosa and malignant infiltration.
Cranial CT Normal Variants
An incomplete fusion of the

septum pellucidum (133a)
can, as another variation,
lead to the development of a
so-called cavum of the
septum pellucidum. Please
review the normal scans in
Figures 30.2a, 30.3a, and
31.1a for comparison.
Usually only the part of the
septum located between the
two anterior horns of the
lateral ventricles (Fig. 51 .1 a)
is involved, less frequently
the cavum extends all the
way to the posterior horns
(Fig.51.2a).
In the plane of Figure 51.1 ,

justmedial ofthehead ofthe
caudate nucleus (117), you
can evaluate both foramina
of Monro (141) which function
as arouteforthechoroid
plexus (123) and the CSF
from the lateral ventricles
(1 33) to the 3rd ventricle

(134).
Refresh your anatomic skills
by naming all other structures
in Figure 51 .1 and
checking your results in the
legend.
The radiologist will rarely be
confro nted with an eye prosthesis
( *) after enucleation
of a globe (150). In patients
with a history of orbital
tumor, a local relapse, t.e, in
the retrobulbar space (2) has
to be ruled out in check-up
CT scans.
The CT scan of the orbit in
Figure 51.3a showed minor
postoperative change withoutanyevidence
of recurrent
tumor.
Fig. 51.3b
Cranial CT Partial Volume Effects
Oneofthe mostimportant rulesofCT scan interpretationisto always compare

severaladjacent planes(see pp. 14-15). Ifthe headistilted evenslightlyduring
the scan procedure, one lateral ventricle (133) for example, can appear in the
image plane (dS)' whereas the contralateral ventricle is still outside the plane
(Fig. 52.1). Oniy its roofwill appear.
The computertherefore calculates ablurred,hypodense area which couldbe

mistaken fora cerebral infarction (Fig. 52.2a).By comparingthisplanewiththe
adjacent one below it (Fig. 52.3a), the situation becomes clear, since the
asymmetriccontoursofthe imaged ventricles arenow obvious.
Fig. 52.1
Fig. 52.3a
Fig. 52.2b
Fig. 52.3b
Thisexampleillustratesthe importanceofthe correctplacementofthepatient'shead.The

exact positionofthenoseinan a.p,projectionisobtainedbyusingthe
gantry positioninglights.Involuntary movementsofthe
headcanbekeptataminimumbysoftpadding.In
ventilatedorunconsciouspatients an additionalimmobilization ofthehead with
suitablebandingsmaybe necessary.
Cranial CT Partial Volume Effects
:c, "Ithefirststepsininterpreting CCTsis theinspectionofthe

---: tssues, Contusions with subcutaneous hematomas (8) may
-: cateskulltrauma(Fig.53.1a)andcallfora carefulsearchfor
-"rracranialhematoma. Manyinjuredpatientscannotbeexpec?:
:0 have theirheadsfixedforthe durationoftheCT scan,and
--, Questionofwhetheritisjust anasymmetricprojectionof the

"_ base or a real hematoma can be answered by comparing
OL,ccent sections (Fig.53.2a).Inthis example the bones ofthe
:-C111 base caused the hyperdense partial volume effect. Despite
-~
obvious right frontal extracranial contusion, intracranial
this leadstoconsiderable rotation.Asymmetriccontours (* in Fig.
53.1a)of the roofoftheorbit(55a), thesphenoid bone(60),orthe

petrosal bone (not asymmetric in the illustrated examplesI) are
thereforefrequentoccurrencesand mayleadtomisinterpretations
ofthehyperdense bone asafresh intracranialhematoma.
Fig. 53.1 b
bleeding could not be confirmed. Please note the considerable

beam hardening (bone) artifacts (3) overlapping the brain stem
(107). Such artifacts would not appear in MR images of these
levels.
Fig. 53.2b
Cranial Pathology Intracranial Hemorrhage
After havingdiscussed thatpartialvolume effectsdueto asymmetricprojections

(i.e.,55binFig.54.2b) maybemisinterpreted as acute
hematomas,thischapterwill
pointoutthecharacteristicsofthedifferenttypesofintracranial hemorrhage.
Fig. 54.1a
Fig. 54.2a Fig. 54.2b
Contusion frequentlyleadstoan epidural.subdural,orsubarach
Type of bleeding
noid hemorrhage and may leak into the ventricles (Fig. 55.1 a).
Possible complications of such leakage or of a subarachnoid
Subarachnoid
hemorrhagearedisturbed eSFcirculationcausedbyobstruction of
bleeding
thepacchioniangranulations,theforamenof Monro,orofthe 4th

ventricle. An hydrocephalus with increased intracranial pressure
Subdural bleeding
andtranstentorial herniationofthe brainmayresult.
Epidural and subdural hematomas can also lead to major displacement

of brain tissue and to midline shifts. Quite frequently
this in turn causes obstruction of the contralateral foramen of
Monro resulting in unilateral dilation of the lateral ventricle on the
Epidural bleeding
side oppositethebleeding(Fig.56.3).Thecharacteristicsusefulin
differentialdiagnosisofthe varioustypes ofintracranial bleeding
are listed in Table 54.1 .
Table 54.1
Bleeding Caused by a Contusion

As a direct consequence of skull
trauma,cerebral contusion bleeding
may occur (Fig. 54.1a). An acute
hemorrhage (8) appears as a
hyperdense mass which may be
accompanied by surrounding
edema (180) and displacement of
adjacent brain tissue. In anemic
patients the hematoma is less
dense and may therefore appear
isodenseto normal brain.
~
the vascular wailisdamaged only
secondarily by hypoperfusion mediated
byedema,hemorrhagemay
notoccuruntil hoursor. more rarely,
days after skull trauma. A eeT
obtained immediately after skull
trauma which does not show any
pathologic changes is therefore not
a good predictor since deiayed
cerebral bleeding cannot be ruled
out. A foilow-up scan should be
obtained if the patient's condition
deteriorates.After completeresorptionofahematoma
(Fig.54.2a),a
well-defined defect isodense with
eSFremains (132).
Characteristics
Hyperdenseblood inthe subarachnoid

spaceorthebasalcisterna instead
ofhypodense eSF
Fresh hematoma:crescent-shaped,
hyperdense bleeding closeto the
calvariawithipsilateral edema;
hematoma isconcave toward
hemisphere; may extend beyond
cranial sutures
Biconvex,smooth ellipsoidal in shape;
close tocalvaria; doesnot exceed
cranialsutures; usuailyhyperdense,
rarelysedimented
Cranial Pathology
-00'= is intraventricular extension of intracranial hemorrhage

-55.1a),physiologiccalcificationofthechoroidplexus(123),
" lateral(133)and3rdventricles(134),aswellasthoseofthe
-='" aeandthe pineal(148), must be distinguished fromfresh,
:�'Censebloodclots (8). Pleasenotethe edema(180)surroun,

-.e hemorrhage (Fig.55.1a).
-= canent has been lying supine, a horizontal fluid-fluid level
ec Jy blood sedimentingintheposteriorhorns of thelateral
Intracranial Hemorrhage
ventricles may be seen (Fig. 55.2a). The patient is in danger of

transtentorial herniation if the ambient cistern is effaced (Fig.
55.2b). In this case the 3rd ventricle is completely filled with
clotted blood(..inFig.55.2a,b),and both lateral ventricles are
markedly dilated. CSF has leaked into the paraventricular white
mater (�). In addition, a lower section of this patient shows
subarachnoidhemorrhageintotheSAS ( inFig.55.2b).
=, 55.1b Fig. 55.2b Fig.55.3b
id::aro!oC.
hnoid Hemorrhage
-_"ecnve hydrocephalus,ascausedbysubarachnoid hemorrhage(8inFig.55.3a, b), may

easilybeidentifiedbecause thetemporal
_ 33)ofthelateralventriclesappeardistended.
InsuchcasesitisimportanttohaveacloserlookatthewidthoftheSASoverthe
-=-"-suriace:bluntedcerebralgyriusuallyindicateadiffusecerebral edema.Inthepresent
casethough,thewidthofthe Sylvian
=(127)andthesurfaceSAS arenormal.Acuteedemaisthereforenotpresenl(yet).
Cranial Pathology Intracranial Hemorrhage
Sincethesurface SASs arevery narrowin youngerpatients,itis

possible tomissasubarachnoidhemorrhageinchildren.Theonly
identifiablesignmaybeasmallhyperdense area adjacenttothe
falx (130).Inadultsa small subarachnoidhemorrhage alsocauses
only a minor, circumscribed area of hyperdensity (8 in Fig. 56.1 a).
At thetimeofthisCTscanthebleedingwassoslightthatithad not
yetcaused anydisplacementofbraintissue.
Subdural Hematoma
Bleeding intothesubduralspace resultsfrom cerebralcontusions,
damaged vessels inthepiamater, orfromtorn emissary veins.The
hematomainitiallyappearsasa long,hyperdensemargincloseto
theskull(8in Fig.56.2a). In contrasttoanepiduralhematoma,it
isusuallysomewhatirregularinshape and slightlyconcavetoward

the adjacenthemisphere.Thiskindofbleedingisnotconfinedby
cranialsutures and mayspreadalongtheentire convexityof the
hemisphere.
Subdural hematomas can also cause marked displacement of

braintissue(Fig. 56.3a) and leadtodisturbancesin CSFcirculation
andtoincarceranonofthe brainsteminthetentorial notch.It
isthereforenot as important,fortreatment purposes,todistinguish
between a subhematoma or an epidural hematoma as it is to
ascertaintheextentofthe hemorrhage.Hematomaswiththepropensityto
expand,especiallyif edemaisathreat,shouldtherefore
be drained or treated surgically.
Fig.56.1b Fig.56.2b Fig.56.3b
Chronicsubdural hematomas(8in Fig.

56.3a)mayappearhomogeneouslyhypodenseorshowinhomogeneousdensitywithsedimentation
ofblood.Thedangerinvolvedinasmall, venous bleedisthesymptom-free
intervalandtheslowonsetofsomnolence uptothe
developmentofacoma.Therefore,a
patientwithsuspectedbleedingaftercranialtraumashouldalways be kept
underobservationin
order todetect anyclinical deterioration.
Fig. 57.2b
Cranial Pathology
Extradural Hematomas
Bleedings intothe extraduralspaces are usuallycaused bydamageto
the middle meningealartery,andrarely byvenousbleeding
romthesinusesorthe pacchionianbodies.Predisposed areasare

temporoparietal regionsorsometimesthe posteriorcranialfossa,
inwhichcasethereisseveredanger of tonsillar
herniation.Arterialhemorrhageliftsthedurafrom
the innersurfaceofthe cranium
(55) and then appears as a biconvex, hyperdense area with a

smoothbordertothe adjacent hemisphere. Thehematoma does
not extendbeyond the suturesbetweenthe frontal(55a),temporal
(55b), parietal (55c), or occipital (55d) bones. In small extradural
hematomas (8)thebiconvexshapeisnotdistinct (Fig,57,1a),
makingitdifficulttodifferentiatethefindingfromasubdural
hematoma.
Intracranial Hemorrhage
Itisimportantto distinguishbetween aclosedskull fracturewith

anintact dura,and acompound skull fracturewiththe dangerof
secondary infection. An unequivocal sign of a compound skull
fracture(Fig.57.2a) istheevidence ofintracranialairbubbles(4),
whichprovethat thereisaconnection betweenintracranial spaces
andthe paranasalsinuses ortheoutside.Itisdifficulttodetermine
whether the bilateral, hyperdense hematomas (8) in Figure 57.2
are extraduralorsubdural. Inthis casethedistortionofthemidline
was caused by the right-sided, perilesional edema (left side of
Fig. 57.2a) since it was shifted toward the left (the side of the
hematoma).
Test Yourself! Exercise 8:
Spaceforyour suggestedanswer:
Fig, sr.ie
.vhenlookingattheimageofanotherpatient (Fig.57.3),youwill note

severalpathoiogicchanges.Usethefreespacebelowthepicture
: notehow manydifferenttypesof bleeding(if
any)youcandistinguishandwhatotherpathology/complicationsyoususpect.Youwili
< dtheanswersatfheendofthe book,butremember:bea good sport and don't
cheat,thinkfirst!
Cranial Pathology Stroke
Apart from cardiovascular and malignant diseases, cerebral

infarctionsareamong the most frequent causes
ofdeath.Athrombusoccludesacerebralartery,
whichleadsto irreversiblenecrosis
in the area of blood supply. Vascular occlusion develops in
association with atherosclerotic changes of cerebral arteries or,
lessfrequently.asaresultofarteritis.Afurther cause areblood
clots from the left heart or thrombotic plaques from the carotid
bifurcationwhichembolize intoacerebralvessel.
Incaseof embolization,diffuselysituated,small,hypodensezones
of infarctionin both basalgangliaand hemispheresaretypical. Old
emboliresultinsmall,well-definedareas(180)which eventually
appearisodensetotheCSF (132).Suchareas are calledlacunal
infarcts(Fig.58.1a).Adiffuse pattern ofdefectscalls forcolorflow
Dopplerimagingorcarotidangiographyand an ecnocaroiocramto
exclude atrial thrombus.
Fig.58.1a
Fig. 58.2a
Fig. 58.2b
Please remember that in a suspected stroke it might take up te

30 hours to distinguish clearly the accompanying edema as "
hypodense lesion from unaffectedbrain tissue.A CT scanshoulc
be repeatediftheinitial scandoes not showany pathologicchanges
even though the patient is symptomatic and if symptoms de
notresolve (resolutionofsymptoms pointstoatransient ischemic
attack,TIA).Incase ofaTIA: no abnormalitiesarevisibleintheCT
scan.
IncontrasttotheTIA,the prolongedreversibleischemicneurologic
deficit (PRIND) is often associated with hypodense zones of
edema in the CTscan.
If the area of infarction corresponds

to the distribution of a
cerebral artery, one should consider
an occlusion of the correspondingblood
vessel.Inclassical
infarctions of branches of the
middle cerebral artery, ischemia
will cause a hypodense area a
edema ( inFig. 58.2a).
Depending onthe size,the infarction

may have severe mass effect
and cause midline shift. Smaller
areas of infarction do not usually
show any significant midline
shift. If the arterial walls are
Fig. 58.1b
damaged, bleeding may occur
and appearashyperdenseareas
coating the neighboring gyri.
The unenhanced follow-up CT

scan in Figure 58.2b shows an
additional bleed into the head of
the right caudate nucleus ( )
and right putamen ( ). Inthis
casethe infarctionIs 2 weeks old
and necrotic tissue has been
mostly resorbed and replaced by
CSF.
Whereas differential diagnosis (DD)
of intracranial hemorrhage and
infarction may be obtained without
the use of CM, detection of cranial
metastases (7) is definitely improved
by the administration of i.v
CM. Even small areas in which the
blood-brain barrier is disturbed
become visible (Fig. 59.1a). Large
metastases sometimes cause surrounding
edema (180) which could
be misinterpretedasinfarct-related
edemaon unenhanced imagesifthe
metastasis appears isodensetothe
adjacent tissue. After l.v. CM the
lesion intheleft hemisphere (7)is
clearly demarcated(Fig. 5g.2a).Did
you also spot the second, smaller
metastasis within the right frontal
lobe, which also shows some
surrounding edema (180)?
The differential diagnosis of brain

tumors ismade much easier bythe
injection of i.v. CM. In the unenhanced
image (Fig. 59.3a), the
temporoparietalglioblastoma onthe
left (7)whichhasacentral necrosis
(181) could have been mistaken for

cerebral infarction. The post-CM
image,however, revealsthe typical
appearance of a glioblastoma with
an irregularrimenhancementofits
margin (Fig. 59.3c).
-= 59.3a Fig. 59.3b Abb.59.3c
Cranial Pathology Inflammatory Processes
Another exampleofthe advantages
of i.v. CM is the demonstration of
inflammatory processes, since the
accompanying defect in the blood
brain barrier will not show on an
unenhanced image. Figure 60.1a
shows hypodense edema (" ) in
an unenhancedsectionofa patient
suffering from aorticvalve endocard
itis. Contrast medium (Fig. 60.1b)
confirmed the finding by enhancing
the inflammatory process (+).
Bacteria from the aortic valve
caused this septic embolism in the
leff occipital lobe.
Inflammation of the paranasal
sinuses and of the middle ear can
already be diagnosed in native
images aseffusions (8),for example
in the normally air-filled mastoid
cells (62). Swelling of the mucous
membranesofthe external auditory
canal (63b) is visible without the
need for CM. Figure 60.2a shows
bilateral otitis externa and media,
which is more severe on the right
side where it involves the antrum

and the mastoidcells.Withprogress
ingabscess formation,animage on
bone windows shouldbe obtained in
ordertodetectpossible bone erosion.
Fig.60.2a Fig.60.2b
Aretention cyst,which oftenappearsinoneoftheparanasalsinuses,shouldbe

considered in the differential diagnosis of advanced inflammations. They
typically have a broad base on the wall of a paranasal sinus, extend into its
lumen,and havearoundish convex shape ( 1\ " in Fig. 60.3).
Such cystsareonlyof significanceifthey obstructtheinfundibulum (0)ofthe

maxillary sinus or the semilunar canal (@), causing an accumulation of
secretions.In patientswith chronic sinusitis,itisthereforeimportantto check
for an unobstructed lumen of the semi lunar canal (@) or for variations which
may restrict mucociliarytransport of secretoryproducts.
Haller's cells ("), a pneumatized middle concha (166), and a pneumatized

uncinate process (@}) are among the most frequent variations. All of these
variations can obstruct the semilunar canal and cause chronic, relapsing
sinusitis.
Fig. 60.3 \
@
Fig. 61.1b
You have already seen pathologic

changes in the lacrimal gland (pp.
39/40) and the CT morphology of an
eye prosthesis (p.51). Every mass
within the orbitshould,ofcourse,be
diagnosed early and treated effectively
because ofthepossibly severe
consequencesto vision.Inorder not
to miss tumor invasion into the walls
of the orbit, bone windows should
also be obtained. In Figure 61 .1 a
thereisa hemangioma (7) withinthe
retrobulbar fat (2), which is not necessarily
an indication for operation
because of its benign character. In
thiscaseit causesaminorproptosis.
Endocrine Ophthalmopathy
Minimal discrete changes can be
missedduringthereportingof aCT
scan: endocrine ophthalmopathy
often appears as part of Graves'
disease and can, in its early stage,
only be diagnosed on the basis of a
thickening of the external ocular
muscles, e.g. the inferior rectus
muscle(47b in Figs.61.za, 61.3a).
Myositisshould be consideredinthe
differential diagnosis. " this early
signisnotdetected,the diseaseof
the orbital tissue, which is most
probably an autoimmune disease,
may progress in the absence of
therapeutic intervention. Therefore,
you should always examine the
symmetry of the external ocular
muscles (47) when looking at an
orbital CTscan.
Therewilletten be atypicaltempo
ral patternofinvolvement. Thefirst

findingisan increaseinthe volume
oftheinferior rectus muscle (47b).
Thedisease willcontinue and affect
themedial rectus muscie(47cl,the
superior rectus muscle (47a), and
finally all the other external ocular
muscles.
Cranial Pathology Facial Skeleton and Sinuses
Incontrastto benign retention cysts(p.60), malignanttumorsofthe paranasalsinuses

oftenleadtodestructionofthe facialbonesand
mayinvadetheorbit,the nasalcavity(77),oreventhe cranialfossa.Itis thereforeusefulto
examineboththesofttissueandbone
windows.Forplanningaresection,differentCT
planesmightbenecessary.Thefollowingexampleshowsatumorofthe paranasalsinuses
(7)inanaxial(Fig. 62.1a)and acoronal view(Fig.62.2a). Originatingfromthemucous

membranesofthe rightmaxillarysinus (75),the
tumorhasinfiltratedthenasal cavity (77) and theethmoidcells.
Fig. 62.1 a
Fig. 62.1b
Fig. 62.2b
Fig. 63.1b
Fig. 63.2b
Fig. 63.3b
The most common reason for

doing acoronal CT scanis,apart
from determining the extent of
chronic sinusitis, thediagnosis of
fractures: in fractures of the
orbital floor (Figs. 63.1 a, 63.2a)
any accompanying herniation of
retrobulbar fat (2) or the inferior
rectus muscle (47b) into the
fracture site (* ) oreven intothe
subjacent maxillary sinus (75)
should be determined preoperatively.
Diagnosis of the fracturein
Figure 63.2a is easier because
there are dislocated bone fragments.
In addition. it is important
to detect indirect signs of fracture.
suchas very fine,step-like
contours of the bones and
secondary bleeding (8) into the
nasal cavity (77) or the frontal
(76) and maxillary sinuses (75).
Another important question is
whether or not the head of the
mandible (58a in Fig. 63.3a) is
fractured or the maxillary bone
(57) has been fractured and

displaced (*) from the sphenoid
(50) bone (Fig. 63.4a). In this
case, severe bleeding (8) required
intubation (182) and a
nasogastrictube (182).
Fractures of the facial skull
(Le Fort[33])
IYill Straight across the
maxiliary bones and the maxil
lary sinuses(Guerin'sfracture)
IYP~
Across the zygomatic
process of the maxilla, into the
orbit, and through the frontal
process of the maxilla to the

contralateral side; maxillary
sinus not involved
IYI!.U!! Involving the lateral
wall of the orbit and the frontal
process of the maxilla to the
contralateralside;ethmoid cells
and zygomatic arch usually
involved, sometimes also
affectingthe baseofthe skull.
-g. 63.4a Fig. 63.4b

Cervical CT
Whenever there is no contraindication, CT examinations of the
neckarecarried outafteri.v. administrationofCM.Malignantand
inflammatory processescanbedepicted more accuratelywiththe
aid of CM. Adequate enhancement of cervical vessels requires
higherdosesofCMthan,forexample, inCTs ofthe head.Inspiral
CT, theinjectionofCM mustbepreciselytimed tothe acquisition
of data. There are specific recommendations and suggested
schemesforCM injectionatthe end ofthemanual.
Selection of the Image Plane

Inananalogousmannertohead CT,asagittal planning topogram
(scanogram) at lower resolution is obtained first. The transverse
(axial) levelsandgantryangulationaredeterminedfrom thistopogram

(Fig,64.1).Usually sections of the neck are obtained usinga
4-5 mm thickness.The axialimagesare obtained and printed as
viewedfrom caudally so theright lobeofthe thyroidisimagedto
the left of the trachea, the left lobe to the right.
Images should be obtained with a small-scan field-of-view to

optimize detailinsmallerstructures intheneck.Asthethoracic
inletisapproached duringthescanning,thescanfield-of-view is
increased toinclude possibleabnormalities intheclavicularfossa
and the axilla.
Artifacts caused by dental prostheses (3)

usuallyobscure surrounding structures (*)
in only one or two levels (Fig. 64.2a). It
may be necessary to carry out a second
acquisitionatanotherangle (Fig. 64.2b) to
reveal areas hidden by artifact (* ).
Fig. 64.1 Fig.64.2a Fig.64.2b
Systematic Sequence for Readings

We have already recommended a systematic
approachwithwhichtoreadCTscans ofthehead
(see p. 26). For cervical CTs there is also no 'one
and only' approach. The checklist presented here
was deveioped throu gh experience and is just one
ofmany optionsforthe beginner.Each examineris
free tosetup hisorher own checklist and strategy.
Duringneckimaging, separatehard copies at bone

windows are rarely printed owing to cost. The
radiologist must remember to check images at
bonewindowsonthe screenforfracturesor lytic
lesions.
Checklist for Reading Cervical CT Images
-+ Symmetry of neck musculature?

-+ Condition and clarityof fat?
-+ Normal perfusion of vessels?
-+ Thromboses or atherosclerotic stenoses?
-+ Symmetryanddefinitionof salivary glands?
-+ Thyroid parenchymahomogeneousandwithout
nodules?
-+ Any focalpathologic enhancementwithCM?
-+ Narrowing ofthe tracheallumen?
-+ Assessmentoflymphnodes? Numberandsize?
-+ Cervical vertebraeexamined inbone window?
-+ Vertebral canalpatentor narrowed?
Cervical CT
--eradiologist quicklyreachesthelimitsofCTresolution (perhaps

;..so of his/her anatomic knowledge)whentryingtoidentifyallof
-9 differentneckmuscles.We havethereforereducedthe amount
:' detailintheaccompanying drawingssothatsmaller muscles
;;8 grouped. Single muscles have little clinical relevance and thus
-elegendstothese imagesrefertocombinedmusclegroups,e.g.
:;-e scalene muscles, the erector spinae muscles. Readers who
ant moreanatomicdetail shouldconsult therelevantliterature
:5,31]
:ervical imagesusuallybeginatthebaseoftheskullandcontinue
:audallytothethoracicinlet. Thecranialsections (Figs.65.1-65.3)
neretoreincludethemaxillarysinus (75).thenasal cavity (77),
Normal Anatomy
and thepharynx(176).Dorsaltothepharynxliethelonguscapitis
and longuscervicismuscles(26),whichextendcaudally.Lateralto
the mandible (58). beginning in Figure 65.2a. the parotid gland
(153)issituatednexttothelarge cervical vesselsandvagusnerve

(also p. 64). In front of the pons/medulla oblongata (107), the
vertebral arteries (88) join to form the basilar artery (90).
Thespreadofinflammatoryprocesses withinthecervicalconnectivetissuespacesis
restricted withincompartmentsdefined bythe
cervicalfascia[30].The differentlayersof the cervicalfascia are
explained onthe following page (Fig. 66.4).
-. 65.1b Fig. 65.2b Fig. 65.3b

Cervical CT Normal Anatomy
Further caudally the following cervical

muscles become visible beneath the trapezius
muscle(23):medial liethe semispinalis
capitis(28) andlongissimuscapitismuscles
(27),andmore laterallythe splenius capitis

muscle (25). The parotid gland (153) is
situated cranial and posterior to the submandibulargland
(154) nexttothemandible
(58). The pharynx (176) is surrounded by
Waldeyer'sringoftonsillartissue (157,156).
Note that the carotid bulb is situated between
Figures 67.4a and 68.2a; it is the
point at which the common carotid artery
(85)bifurcatesintointernal (85a) andexternal(
85b)carotidbranches. Underthetongue
(155)thefloorofthe mouthisorganized in
layers. From cranial to caudal are: the
genioglossus muscle (33), further laterally
the geniohyoid muscle (34),andthe anterior
belly of the digastric muscle (31) . The thin
superficialmuscleistheplatysma (48).
Compartments of the Neck
If infections or inflammatory processes originate in the suprasternal (0) or
pretracheal
spaces between the superficial fascia (* ) and the dorsal layer of the
pretrach eal fascia (**), they cannot spread into the mediastinum because both
fascias insertintothe sternum(56inFig. 66.4).Attheleveloftheparotidgland there
isasimilar barrierconsistingofthe sagittal septumwhichsplitsaretropharyngeal
froma parapharyngealspace.Inflammationsoriginating furtherdorsal,betweenthe
pretracheal (* * ) and the prevertebral (*** ) fascias,canspread caudallyintothe
mediastinum. .
Fig. 66.1b Fig. 66.2b Fig. 66.3b

Fig.67.4b
t==t�=-::;'J=fL-Fig. 66.1
-r---71+ -+t-Fig. 66.2
7"--7"-CH--I+Fig.
66.3
H--H-"~'--"::'_....".+-++-H-f ig. 67.1 "-I+--H-++-Hg. 67.2 -t+++-++-Fig. 67.3
-';H-,Lf---++-Fig. 67.4
8
Fig. 67.5
Fig.67.4b
t==t�=-::;'J=fL-Fig. 66.1
-r---71+ -+t-Fig. 66.2
7"--7"-CH--I+Fig.
66.3
H--H-"~'--"::'_....".+-++-H-f ig. 67.1 "-I+--H-++-Hg. 67.2 -t+++-++-Fig. 67.3
-';H-,Lf---++-Fig. 67.4
8
Fig. 67.5
Cervical CT
The bifurcation of the common carotid artery (85) is an area of

predilection for atherosclerotic plaques (Fig. 68.1 a) which may be
complicated bythrombusdeposition (* ). Notethe positionsofthe
cricoid (167) and arytenoidcartilages (168) atthe rimaglottidis
(178).Inthese normal individuals, eMenhancesthedensitynot
only of the internal (86a), the external (86b), and the anterior
jugular veins (86c), but also of the vertebral artery (88) in the
Normal Anatomy
transverse foramina of the cervical vertebrae. Always check for

degenerative changes at the margins of the bodies of cervical
vertebrae(50)orforherniated discswhichmightnarrow thespinal
canal containing the cervical cord (54). On either side of the
trachea (81) lie the two lobes of the thyroid gland (83), which
shouldhaveasmoothoutlineand havehomogeneousparenchyma
(Fig. 68.3a).
Fig. 68.1a
Fig. 68.3a Fig. 68.3b
Fig. 68.2a
Cervical CT Normal Anatomy
seofitsiodinecontent,thethyroid gland (83)appears hyperdense compared

-surroundingmusclesbothbeforeand,evenmoreso,aftertheadministrationof eM
"'";5.69.1-69.3).Beginnersoccasionallymistake the esophagus (82),dorsal to the

'-ea(81),for swollenlymphnodesora tumor. Incaseofdoubt, comparisonwith
srsectionsishelpful:usuallyasmall,hypodense areaindicatesairin the lumen of
Fig.68.1 -t+--+''+.....
_. esophaqus in an adjacent section. As a rule, the cervicothoracic junction is

Fig.68.2 -++---++ ----,
II
7 ~
-n
e
d
withthearms elevatedtominimize artifactsduetobones.Themusclesofthe
Fi 68.3 -+t==+=h~~'~~=t=~
Fig
gg.
.. 69.1
I girdleas well as the shoulder joints thereforeappear in unfamiliar positions.

Fig. 69.2 -++----+---+I---'----+--.....,;---+--H
II
-'c 'allowingchapterdealswithneckpathologyand includesashort"Test Yourself"; Fig.

69.3 -++------+---fl,,.--'----:------fl---+--H
-d;esanddrawingsof normalanatomy extendingfurthercaudallyare continuedon
-:~
74.
Fig. 69,lb
Fig.69.2b
-. 69.3a
Cervical Pathology Inflammatory Processes and Tumors
Enlargedcervical LNs(Fig.70.1a)appearconspicuouslyasisolated
nodular masses (6) thatcannot befollowed into adjacent levels
(seep.15). Large lymphomas (7) orconglomerate LN masses(Fig.
70.1a) oftendevelop central necrosis(181).Itis sometimesdifficult
to distinguish them from abscesses with central necrosis
(181) asshown,for example,inFigure70.2a.Abscesses typically

infiltratethe surroundingadiposetissue withastreaky pattern of
edema (180) sothatstructures suchasarteries,veins,ornerves
(on the leftsideoftheneckin Fig.70.2a) becomedifficultto identify.
In immune-suppressed patients. abscesses can become
remarkably large. Compare the scans in Figures 70.3a (unenhanced)
and70.3b(enhanced):afterinjectionofCM,the outerwall
of the abscess (*) as well as the central septa have become
enhanced.Theseappearancesaresosimilarto large hematomas
or necrotic tumors that a differential diagnosis may be difficult
without a detailed clinical history.
Notealsothe atheroscleroticplaquesorthrombosesin the lumen

ofthecarotidartery (85) asinFigure 70.1a.
Fig.70.1b Fig.70.2b Fig. 70.3b (enhanced)

Fig.71.1b
t. 1.2b Fig. 71.3b

Cervical Pathology
--carenchvrnaofthe thyroidgland (83)shouldappear sharply

srcated and have an homogeneous pattern in CT scans. The
=;etransverse diameterofeachlobe is1-3 em,1-2 em
_-,Iyand 4-7 em incraniocaudal direction.Thetotalvolume
-~
yroid gland varies between 20and 25ml.Ifthethyroidis
Thyroid Gland
enlarged, checkfortrachealcompressionorstenosis (81)andthe

caudal borderofthe goitershouldbe determined.
A benign struma (83) may extend into retrosternal regions and

laterally displace supra-aortic vessels(85,87,88) (Fig. 71 .2).
--E oarenchyrnal structure of a thyroid carcinoma (7) appears

-: "ilOgeneous, and the contours are not easily distinguish ed
tr: eremaining normaiparenchyma (83) (Fig 71.1a).
sc ancedstagesof carcinoma (Fig. 71.3),cervicalvesselsand

--esarecompletelysurroundedbytumor,and areasofnecrosis
(181) appear.Thetrachealwalls (81)are compressed andmay

becomeinfiltrated.After partial resection of astruma(Fig. 71.4),
somethyroidtissue (83) maystillbeseenclosetothetrachea.In
thiscase theleftinternal jugularvein was also removed andthe
lumenofthe rightone(86a)is therefore largerthan normal.
Fig. 71.4b
Test Yourself!
Before continuing tothe next chapters, these exercises give youan

opportunity to check your knowledge. The questions become
increasinglydifficultas yougoalong: thefirstquestionshould pose
no problems, whereas the last onesof each chapterwillbea real
challenge. Make the most of this opportunity for self-assessment
andtakeitin goodgraceifyoufind youmissedsomething.Inour
experiencethese littletestswill helpyouto rememberbetterwhat
you have learned.
Itis muchmoreeffectivetolook upeach gapinyourknowledge as

itoccursthantoskipa problem andturn directlytotheanswer.You
should thereforeonlyturntotheanswersatthe backofthe book
when you havesolved eachproblembyyourself.Thatway you will
notsee answerstoquestions you haven'ttackled yet. Itwill keep
you in suspense!
....Whichwindowsetting(windowcenterandwindowwidthinHU)would youselectforan
optimalbrainCT?Why?Before
beginningthe examination, whatgantryangledoyouchooseforyourslicesinthe
planningtopogramandwhat sectionthicknessand
sectionincrements doyouuse?Whydid youchoosethese settings?
tBDIiI Whatdoyou
rememberaboutthecriteriawithwhichtodistinguishthefourtypesofintracranialhemorrhage?
Withwhich
kindsofhemorrhageareyou familiar? Howcan youdifferentiate betweenthemin CT
morphology?Whatcomplicationsorconsequences
mustyou particularly watchoutfor (consultpp. 54-57 for help)?
Type ofhemorrhage: Characteristics:
�
�
IDIilIiI How can you recog nize a subarachnoid hemorrhage in childre n?
~Imaginetheanatomyofthe cerebral basal

gangliaandthendrawatransversesectionattheleveloftheinternalcapsule.
Compare yoursketchwith Figures30,2aand30,2b.Repeatthis
exerciseoccasionallyuntilyoucandoitwith ease.
tDDD Examine Figure 72,1 carefully. The patient was ~Figure 72,2 containsan
unusualvariation;can you
involved in a car accident. Do not settle for the most obvious
findit?Afterhavinqnotedit,lookagainto see whether you have

feature; look for other variations or abnormalities. What do you
reallydiscovered all pathologicfeatures.

suspect?
Test Yourself!
0DlIliI
The eeT in Figure
73.1 is of a 43-yearold
patient. Make a
note of your tentative
diagnosis and
how youwould proceed
.
Glili!I!Ii2t
Is there any feature

in this orbital scan
(Fig. 73.3) that
would not be considered
a normal
finding? Note your
observations below.
Don't give up too
quickly!
Fig. 73.1
Fig. 73.3
tm:mmI
Do you recognize
anything unusual in
Figure73.2?Isthere
a pathologic abnormality?
Or isit simply
an artifact or even
a normal finding?
GDEI
A confused patient,
from a home for the
elderly, with sus
pected intracranial
bleeding is brought
in for a eeT. How
many fresh hemor

rhages (Fig. 73.4)
doyou see? What is
your differential dia
gnosis? Which of
them is the most
probable diagnosis?
Which additional
information could
alsobe helpful?
Fig. 73.2
Fig. 73.4
Thoracic CT
After havingdiscussed normalanatomyofcaudalcervicalsections
(p.67), normal thoracic anatomyispresented.Fromthis page on,

youwillfindthenumbercodes forthe drawings intherearfoldout.
Selection of Image Plane
Asarule,thesectionsofthe thoraxarechosen inthetransverse or
axial plane at thicknesses and steps of 8 to 10 mm. Sections
10mmthickwilloverlap by 1mm,for example, whenthe patient
table is advanced in 8-mm steps. A small topogram (Fig. 75.1)
accompanying eachsheetofimagesshowsthepositionofthesections
relative to the major anatomic structures of the region. In
order nottomissanypathologicchangeswithinthe lung (review
p.13),ithasbecomeaccepted practiceto makeahard copyof

both soft-tissue and lung windows or to provide a CD with the
image data.Each image can thereforebeviewed attwodifferent
window settings.Againthe largenumberofimagesnecessitatesa
systematictechniqueforevaluationsoasnot towastetimelooking
randomly backandforth betweenthem.
Systematic Sequencefor Readings
The beginneroften forgetstocheckthesoftlissuesofthethoracic
wallbecause the examinationofthemediastinumand the lungsis
Sincethepleuralwindowis very wide,themarrowof

thespinalcoiumnaswellastheparenchymaof the ,
lung can be examined. It is therefore possible to
evaluatebonestructure inadditiontothe pulmonary
vasculature. When examining the lung vessels, look
for a gradual reduction in their diameter as you
proceed from the hilum to the periphery. Pulmonary
oligemiaisnormal onlyalongthe margins ofthelobes
and inthe periphery.
Itis essentialtodifferentiatebetween cross-sectioned
vessels and solid masses by comparing adjacent
levels (ct.p.15). Moreorlesssphericalsolidmasses
may indicateintrapulmonarymetastases.Thecheck
list will help you read thoracic CTs systematically.
The simultaneous presentation of two window settings

inonehard copy (boththe lung andthesoft-tissue
window)hasnotprovedpractical becausepathologic
abnormalitieswhichhave densitylevels between the
twowouldbeoverlooked. Consultthelung chapteron
pages84ff.for scansinthelung window.
automatically considered more important. These tissues should

therefore be evaluated first. Common sitesof abnormality are the
breasts and fat in the axilla (2). After this-also using soft-tissue
windows-the mediastinum ischeckedforpathologicmasses.The
easiest approach is to orient yourself relative to the arch of the
aorta (89b), which can be recognized even by the inexperienced
(Fig,77.3).Fromthispointcranially, themajorbranchesareidentified
toexclude pathologicmasses inthe upper mediastinumnext
tothe brachiocephalictrunk (88),the leftcommoncarotidartery
(85), the subclavian artery (87), as well as the brachiocephalic
veins(91),superiorvenacava(92),trachea (81),ormoredorsally,
theesophagus(82).Caudally,themost common sites for enlarged
LNsare:at the aortopulmonarywindow,directly belowthe bifurcationofthetrachea(
81a),in the perihilartissue,posteriortothe
cruraofthe diaphragm(=retrocrural) nexttothedescendingaorta
(89c).ThepresenceofafewLNs smallerthan1.5 cmindiameter
intheaortopulmonarywindowmaybeconsidered normal[19,41].
Anteriortotheaorticarch(89b) LNsofnormalsize arerarelyseen
in the CT. The evaluation of the soft-tissue window is complete
whenthe heart(anycoronarysclerosis,dilations?) andthe lung
hila(vesselswell defined andnotlobulatedorenlarged)have been
checked.Onlynowshouldthe radiologistturn tothelungorpleural
window.
Checklist for Thorax Readings
1, On the soft-tissue window:
� soft tissues, especially:

-axillary LNs
-breast (malignant lesions?)
� mediastinum infour regions:
-from the aorticarch cranially (LNs?,thymoma I struma?)
-hilar region (configuration andsize ofvessels, lobulatedand
enlarged?)
-heartandcoronary arteries(scterosisj)
-fourtypical sites of predilection for LNs:
�anteriortoaorticarch (normal:almostnoneor <6mm)

� intheaortopulmonarywindow (normal: < 4LNs < 15 mm)
� subcarinal(normal: < 10mm;DO: esophagus)
� nexttodescendingaorta (normal: < 10mm; DO:azygos)
2, On the lung window:
� Parenchymaofthelung:
-normal branching pattern and caliber ofvessels?
-vascular oligemiaonlyat interlobarfissures?bullae?
-any suspicious iung foci?inflammatoryinfiltrates?
� Pleura:
-plaques, calcification,pleuralfluid, pneumothorax?
� Bones (vertebrae, scapula, ribs):

-normal structureof marrow?
-degenerative osteophytes?
-focallytic or scleroticprocesses?
-stenosesofthespinai canal?
Artifacts (3)willbeobservedatthelevelofthethoracicinletif eM
ispresentinthesubclavian
vein(87)atthetimeofdata acquisition (cf. Fig.23.3).The parenchymaofthethyroidgland
(83) should appear homogeneous and clearly defined from the surrounding fat (2).
Asymmetryinthe diameterofthejuguiarvein (86) isseen quiteoften and hasnopathoiogic
significance. Orthogonallysectioned branchesofthe axillary(93)andiateralthoracic
(95)
vessels must be distinguishedfrom axillary LNs.Ifthearms
areelevated.thesupraspinatus
muscle(19)liesmedialtothespineof the scapula(53b)andtheinfraspinatusmuscie (20).
Usuallythepectoralismajor(26a)andminor (26b)muscles are separated
byathinlayeroffat.
Fig. 75.2 ;:jJ;j:~~t3~~I=I=~~3:lj
Fig. 75.3 --:
Fig. 75.4
74
Fig. 75.1
Fig. 75.2a Fig. 75.2b
Fig . 75.3b
Fig. 75.4b
Thoracic GT Normal Anatomy
ThoracicCTsarealsoviewedfrom caudally. Theleftlung(84) appears ontheright sideof

theimageandviceversa.Beginningat the
aorticarch (B9bin Fig.77.2),the layout ofthe aortic arch vesselsshould be
thoroughlyfamiliartoyou.Atthe sectionin Figure 76.1,the
left subclavianartery (87)isseen mostposteriorlyandcan befollowedincranial
direction intheimagesonpage75.In frontofthesubclavian
arterylietheleftcommon carotid artery (85) and the
brachiocephalictrunk(88).Moretotherightandanteriorlyare thebracniocephalic
veins(91),whichformthesuperior venacava (92)atthe levelsof Figures76.3to
77.1.Inthefatofthe axilla(2),normal LNs
(6)areoftenrecognizableby theirtypicalindentedshape:thehilum
containsfat.Atadifferent angle,the hypodensehilumwillappearin
the center of an oval. Healthy LNs are well defined and should not exceed 1 em in
diameter in this location (Figs. 76.1 and 76.3).
Fig. 76.1a
Fig. 76.2a Fig. 76.2b
Fig. 76.3a Fig. 76.3b

Theazygos vein (104) liesdorsaltothetrachea (81) nexttothe esophagus (82).
Directlyabove theright main bronchus, itarchesanteriorlyintothe superior vena
cava(92in Fig.77.2).Besurenottoconfuse the paravertebral azygosvein(104),
the hemiazygos vein (105) or accessory hemiazygos (105a) with paraaortic LNs
(Figs. 77.3 and 76.3).
Fig. 77.la
Fig. 77.2a Fig. 77.2b
Fig. 77.3a Fig. 77.3b

Thoracic GT Normal Anatomy
78 I
Immediately caudal tothearchof the aorta (89b) issituated the pulmonarytrunk(90),

which divides intotheright(90a)and left (90b)
pulmonary arteries(Fig.78.2).AtthelevelofFigures 78.1 and78.2, thereisthe
aortopulmonarywindow,asiteof predilectionfor
mediastinalLNs(6).Also checkforenlargedLNsor malignantmassesinthesubcarinalposition
betweenthetwomainbronchi (81b)
closetothe pulmonaryvessels(96) (Fig.78.3). Neartheinternalthoracic (mammary)
vessels(94) liestheregionallymphaticdrainage
ofthemedial parts ofthe breasts,whereas thelymphatic drainage ofthe lateral

portions ofthe breasts isprimarilytotheaxillary nodes.
Fig. 78.1a
Fig. 78.2a
Fig. 78.3a Fig. 78.3b

Iheglandulartissue (73)inthefatofthe breasts oftheanteriorthoracicwalliseasily
oifferentiated from skintumorsbecauseofthe symmetry(Figs.79.1 and79.2).The
main coronaryarteries (77) arealso distinguishable inthe epicardialfat(2)(Fig.
79.3).Developa clearmentalpictureofthepositionsoftheazygosvein (104) and
;;Ie esophagus(82)nexttothe descending aorta(89c) sothatyouwilllater beable
;0 recognize any pathologicLNs close tothese structures.
Fig. 79.1b
Fig. 79.2b
Fig. 78.2
Fig. 78.1 ~~~~i~~~~~~~
Fig. 78.3
Fig. 79.1
Fig. 79.2
Fig. 79.3
Fig. 79.3a Fig. 79.3b

Thoracic CT Normal Anatomy
The leftatrium (74c)isthe mostposterior chamberoftheheart,whereastheoutletoftheleft

ventricle(74d) and the ascending aorta
(89a)lieinthe centerofthe heart.Therightatrium(74a)lies ontherightlateral
sideandtherightventricle(74b)anteriorly behindthe
sternum(56). Onlythelarger central branchesofthe pulmonary vessels(96) can
beseenonthesoft-tissuewindow.Thesmaller,more
peripheral lung vessels are better judged on the lung window (notshown here).
Notethejunctionbetweenthehemiazygosvein(105)andtheazygos vein (104),whichmustnotbe
confusedwithaparavertebral
lymphoma (Fig. 80.2).
Fig. 80.1 a
Fig. 80.2a Fig. 80.2b
Fig. 80.3a Fig. 80.3b

Fig. B1.3b Fig. B1.3b
Thoracic CT Normal Anatomy
Theinferior venacava(80)isseenmorecaudally(Figs. 82.1

and82.2),andfinallythediaphragm (30)appearstogetherwiththeupper
partsofthe liver(122).Manyradiologistswhosuspect the presenceofa
bronchialcarcinoma(BG)obtainimagestothecaudaledgea
theliver(seep.83) becauseaBCoften metastasizesto the liverand theadrenal
giands.Thecaliberoflungvessels nearthe periphery
ofthediaphragmissosmallthattheyare notvisibleon thesoft-tissuewindow,
asinthepresentimages.Thepatternofthepulmonary
vasculatureshouldthereforebeexamined onthelungwindows,whichincludethe
negativedensity valuesoftheHounsfield scale. Only
afterthisstep hasbeencarriedout istheevaluationofachestCTcomplete.
Fig. B2.1a
Fig. 82.2a Fig. 82.2b
Test Yourself! Exercise 1g:

Writedowna concise
butcompletesequenceofallcriteriaforinterpretingathoracicCT.Thencompareyournoteswith
thecheckliston
page74and repeatthis exercisefromtimetotimeuntil youremembereverycriterion.
1) Soft-tissue window:
soft-tissues, especially:
Thoracic CT High-Resolution CT -Normal Anatomy
Segments ofthe Lung

It isespeciallyimportantto be abletoidentifythe segmentsofthelungsinCTimages
ifbronchioscopyisplanned forbiopsyorto remove
aforeign body.Therightlunghas10 segments.Intheleftlung,theapicalandposterior
upperlobe segmentshaveacommon bronchus
andthere is no 7th segment (paracardiac [medialbasal]segmentof the lowerlobe).
1/2
3
4
Fig.84.1 Bronchialtree,view from anterior
"I \:'--_-
(?0,'I=:'---5
1
2
3 --1AI
6
4
1 apical
Upper lobe 2 posterior
3 anterior
Middle lobe
4 lateral (superiorlingula)
5 medial (Inferior lingula)
Lower lobe
6 superior/apical
7 paracardiac/med ial basal
8 anterior basal
9 lateral basal
10 posterior basal
The parenchyma next to the

interlobular tissures (--)
appears avascular.
The borders ofthe segments
(.��.) are usually not

visible in sections of normal
thickness and can only be
identified by the branches of
the pulmonary veins (96)
which pass along these borders.
Fig.84.2a
Fig. 84.4a 1.... _
-�.85.3a
Thoracic GT High-Resolution GT -Pathology
High-Resolution Technique
HRCTstandsforhigh-resolutioncomputedtomography usingthin
HRCTisthereforenotthemethodof choiceforroutinechest
sections and a high spatial resolution reconstruction algorithm. examination
because radiation dosage is much higher if more
Even conventional CT scanners can acquire images of narrower
slicethicknessthan the standard 5-8 mm.The image acquisition

parameters can be adjusted on the console to a thickness of
1-2 mm if necessary.
Inthe SCTtechnique,thinner sections can also be computedata

pitchfactorof1:1afteracquisition(see alsop.169).However,itis
notusuallyworthreconstructingslicesof lessthan 1mmthickness
becausethe lowsignal-to-noise ratio reduces image quality.
High-Resolution Effects on
Image Quality
Figure86.1 showsaconventional
scan of a pulmonary lesion (7)
surroundedbya zone ofedema or
an infiltrate (185).Ata dS setting
of10 mm thiszonecloseiyresem
bles the poorly ventilated area at
the back of the posterior lobe
(178)
HRCT distinguishesthese areas of
increased density more clearly
(Fig. 86.2) because voxel
averaging does not have any
appreciable effect (see also p. 14).
The DD includes bronchial carci
sections are acquired.Longer examinationtimes andhigherhardcopy

filmcost ("slice pollution")arealsoarguments againstusing
HRCT.Onlystructures withnaturallyhighlevelsof contrast suchas
areas surrounding bonewill be well demonstrated.
Fig. 86.1a
noma,metastasisofbreast cancer
resulting in lymphangitis caretnomatosa,
and atypical pneumonia.
These imagesshowararecomplication
after catheterization of the
right heart.The catheter was positioned
too peripherally and caused
hemorrhage (173) into adjacent
parts of the lung. Follow-up3weeks
latershowed completerecovery.
Fig. 86.2a Fig. 86.2b

Fig. 87.3b
~-------....,
=.
87.1a
=.
87.1b Fig. 87.3b
~-------....,
=.
87.1a
=.
87.1b
Thoracic CT High-Resolution CT -Pathology
~tissue can-
: "ofthe manyadvantagesoftheHRCTtechniqueisthat older
be distinguished from acute inflammation, for
pie in immune-suppressed patients or bone marrow reel:
o-ts.Older scartissue(186)isalways welldefined(Fig.87.1),
ereas fresh infiltratesare surrounded bya zone of edematous
ue(185)asinFigure 87.2.HRCT isoften theonly methodwith
-htodeterminewhether chemotherapyshould becontinuedin
: fmphoma patient who is in the aplastic phase on therapy or
whether chemotherapy must be discontinued because of fungal

pneumonia.Fresh infiltrates(178) can sometimesbe seen nextto
older scar tissue (186) (Fig. 87.3).
Because theslicesare extremely thin,thehorizontalinterlobular

fissure (*) may appear as a bizarre ring or crescentic (Figs. 87.1
and 87.2).
',/lorareasof collapse,whichareusuallyfoundclose tothe pleuraposteriorlyinthe lung,

mustbe differentiatedfromflat sections
:'fissures(178inFig.87.1).Indoubtfulcases,itmay be helpfultorepeatascaninthe prone
position.Areasofcollapse and poor
ontilation maythen disappearorbeseenanteriorly.
Pulmonaryabnormalitiesduetoaninfiltrateortoa pneumoconiosiswouldbe
hanged.
Thoracic CT Anatomic Variants
Amongthemanyanatomicvariationsofthethorax,an atypicaicourseoftheazygosvein (140)

isrelativelycommon.It canpassfrom theposteriormediastinumthroughtherightapical lobe
tothesuperior venacava(92).Itis locatedwithinafoldofthe pleuraandthereforeseparates
theazygoslobefromtheremainderoftheright upperlobe.This variation is

usuallydiscovered
incidentallyonaconventional chest X-ray (~
inFig.88.1)and hasnoclinicalsignificance.
Figures 88.2 to 88.4 show the anomalous path of the vessel as it appears in CT
images.
Atypicalpositionsorbranchingoftheaorticarch(89) vesselsare
rarer.Anexampleistheright
subclavianartery,known asthe"Arterialusoria,"which can resemblealesion intheupper
mediastinum.
Notethatnormal breasttissue,surroundedbyfat (2),mayhaveveryirregularcontours(72in
Fig.88.4). Whenusinglungwindows, youshouldnotonlylookforsolidroundlesionsand
inflammatoryinfiltrates,butalsorecognize anythinning or evenabsence of lungvessels.
However, attenuationof vesselsisnotalwaysa signofemphysema.

Asymmetry in the broncnovascular pattern develops after a
part of the lung has been resected. In the patient imaged in Figure88.5,
theleft upperlobehad beenremoved and the remaining
lungtissue hascompensatedandfilledtheentireleftthoracic cavity(
righthalfoftheimage).Therearefewerlung vessels perunit
volume andanipsilateralshiftofthemediastinum.Thesechanges
are accompaniedbyaslight elevationofthediaphragm.Atthe
timeofthisfollow-upCT,the patientwas healthyandhad neither
emphysema nor recurrent tumor.
Fig. 88.1
Fig. 88,5
Thoracic Pathology
ordingtothe sequence inthe checklistonpage74,one should

turn to soft-tissue windows in order to examine the soft
esof the chestwall. Mostabnormalitieswill belocated inthe
aeandinthe femalebreast.
-aerations in Lymph Nodes
al axillary LNs (6) are usually oval and less than 1 em in
--" sion.They often have ahypodense centerorarehorseshoe
--;er metastaticLNs(7)areusually poorlydefinedanddifficultto

� erentiate from surrounding fat (2). They often have central
-easof necrosis (181),sothatthedifferentialdiagnosisofanabs.
;SS with central liquefaction must be considered (Fig. 89.3). If
larylymph node metastaseshave been treated operativelyor

" radiotherapy,thedate andtreatmentshouldbenotedonthe
Thorax Wall
shapedasin Figure 89.1,afeatureknown asthe "hilumfatsign."

The architecture of a normal LN is characterized by vessels
enteringthehilum,which containshypodense fat. Many abnormal
LNshavelosttheirnormalcontoursand are rounderorirregular.
SuchLNsall appearsolidand lackthe hilumfatsign, asseenin
those in the left axilla in Figure 89.2. For direct comparison, two
lymph nodesontheotherside inthe same image are normal.
referral sheet for follow-up CT. Postoperative healing processes

andscarring (186)changethe morphologyofLNs(Fig. 89.4),so
theyresembleabnormal nodes(see above).Againthe lack of clinical
information makes diagnosis unnecessarily difficult for the
radiologist.
Thoracic Pathology Thorax Wall
Breast
The normal parenchyma (72) of the female breast has very
irregularcontours and slender, finger-like extensions into the surroundingfat
(2) (cf. Fig.88.4).Bizarreshapes can often be seen
(Fig.90.1).Advanced stagesofbreastcancer (7) haveasolid.irregular
appearance (Fig. 90.1). The malignant tissue crosses the
fascial planes or infiltrates the thoracic wall, depending on size.
BaselineCTaftermastectomy (Fig.90.2) shouldhelpin the early
Thoracic Skeleton
Osteolysis within the thoracic skeleton is not uncommon and is
usuallydueto eithermetastasesoraplasmacell tumor. In Figure
90.3,ametastasis (7) fromathyroid carcinomahasdestroyedpart
ofthe leftclavicle (52).Osteolysiscan,however,also becausedby
an enchondroma or an eosinophilic granuloma, for example of a
rib. In addition todestructiveprocesses (cf. Fig. 22.3),degenerative
processes involving sclerosis and osteophyte formation of
bone mustbedifferentiatedfrom osteoscleroticmetastases,which
aretypicalof,for example,prostatecarcinoma (cf.p.145).
identificationofrecurrent tumor.Thediagnosisof recurrent tumor

ismade more difficult byfibrosisafter radiation,postoperative scar
tissue,andtheabsenceof surroundingfat.Specialattention must
therefore be paidtotheregional LNs (ct.pp.74, 89) and the bones.
so that metastases (7) in the vertebrae (50) (Fig. 90.2) are not
overlooked.Thebonewindow mustbeexamined insuchcases.
Fig.90.3b Fig.90.3c
Thoracic Pathology
-~
e being able to detect lesions and lymphadenopathy, you
~...s
'
knowthenormalanatomy.If youareapreclinicalstudenf,
shouldfirstlystudynormalsectionalanatomy. Itisinyour own
eststo workthroughthefollowing pagesonlywhenyou are
~cien
t
ly
familiar with the previouschapters.
rs
, :.= ign increaseinfat(2) duetocortisone therapyis occasion
observedinthe anteriormediastinum (Fig.91.1).In doubtful

-.ses. densitometryis helpfulinthe DO(cf.p.15).Inthis example,
-; average density within the region of interest (RDI), which is
-uoned in possible fatty tissue, is -89.3HU with a standard
Mediastinum
deviation ofabout20HU(ct. Table 16.1).As arule.thesize 01 an

ROIinem'(AR)is alsoprovided (Fig.91.1).The DOofsuchamass
wouldincluderetrostemal goiterand thymoma.
Inchildrenandyoung adults,thedensityofthe thymusis about

+45HU.Asaresultof involution,the densityof the organdecreases
withagefromthethird decade onward untilit has droppedtothe
densitytypical 01fat(-90 HU).Theleftlobeofthethymusis often
largerthan the rightand canreachthe aortopulmonary window.A
lobe shouldnotbethickerthan1.3 em inadults;uptothe ageof
20,1.8 em is considerednormal.
-,,91,l a Fig. 91 .1b

-;. 91.2a
, gnant thickening of the walls of the esophagus must be

~~[ent
iated
fromgastric conduitsfollowing esophagealsurgery
-g. 91.2).Possible enlargementofLNs(6)nexttothestomach
-29) must be excluded by follow-up CTs. Occasionally posteranve
metal clips cause artifacts (*), which make assessment
-.a mediastinummoredifficult. Following esophagealresection,
.s 01the colon (..)maybecome drawnupinto the anterior
-".: astinum (Fig. 91.3). Comparison with adjacent sections

c yshowsthatthisstructureisnotan emphysematousbulla,
_' S atubular organ containinga lumen.
Fig.91 .2b
Fig. 91 .3
Thoracic Pathology Mediastinum
Enlarged Lymph Nodes

NormalLNsare oftenfoundatthe leveloftheaortopulmonarywindow.Theyaremainly
ovalorirregular,less than10 mmacross [19],
and sharply delineatedfrom mediastinalfat
(2).LNs(6)inthisareaarenotusuallyconsidered suspiciousuntiltheyexceed1.5cmin
diameter.Thedemonstrationofa"hilumfatsign"(ct. p. 89)isnotObligatory,but
doessuggestabenign nature(Fig.92.1).
Fig. 92.1a Fig. 92.1b
Ifmorethanthree LNsareseenintheaortopulmonarywindowor
ifasingle LNis abnormally enlarged,the DD includes not onlya
Normal size (diameter)ofthoracic lNs [19,41]:
metastasis from a bronchial carcinoma, but also a lymphoma

(Fig.92.2).
� anterior mediastinum < 6 mm

Enlarged mediastinal, and especiallyhilar, LNs are also characte�
aortopulmonarywindow < 15 mm
ristic of sarcoidosis (Boeck's disease) (6 in Fig. 92.3). In Figure
� hilar < 10 mm
92.2, there are intrapulmonary metastases (7) aswell. Did you
� subcarinal < 10 mm
notice them? Other sites of predilection for abnormal LNs are
anteriorto the aorticarch,beneath the bifurcation ofthe trachea � para-aortic < 7mm
(subcarinal), and the para-aortic and retrocrural regions.

lar Pathologies
phenomenaofCMinjectedthrough an arm vein(ct. p. 21)and anomalous

vessels(cf.p.88)inthe mediastinumhavealreadybeen
.ssed. IncompletelymixedCMmustbedistinguishedfroma
possiblethrombus(173)inthelumenofthebrachiocephalicvein (91).
-athrombus canadheretoacentralvenous catheter(182inFig.93.1).
" , 93.1a
--osclerotic plaques (174) intheaorta (89) are oftenaccompa-.;-:

by thromboticdeposits(173in Fig.93.3).They promoteaortic
,; -gationanddilation and canultimatelyleadto an aneurysm
-,1). Dilation of the thoracic aorta is considered to be an
,; rysmifthelumeniswiderthan 4em.Recordingthe measure-,;-;

s of distances and sizes (Fig. 93.2) makes it easier to assess
!r progressivedilationinfollow-upCTs.Itisimportantto check
a yinvolvementofthebranchesof the greatvesselsorforthe
issecting Aneurysms of the Aorta

accordingtodeBakey [20])
Type r (approx.50%)
Ascending aorta; may extendto
abdominal bifurcation
Type II (approx. 15%)

Only ascending aorta, extendingto
brachiocephalic trunk
Iype III (approx. 25%)

Tornintimadistal toleftsubclavian
artery
Fig. 93.1b
presence of a dissection flap (172 in Fig. 93.4). Three types of

dissection can be diagnosed according to the extent of the
dissection flap(see de Bakey [20]).
Atrue aneurysmwithadiameterof morethan 6em.withamore

saccular than fusiform shape or with an eccentric lumen. has a
higherincidenceof rupture.Theconsequencesof ruptureinclude
amediastinal hematoma,a hemothorax,orpericardialtamponade.
Pulmonary Embolism
Ifalarge embolus has detached from athrombusinadeep vein of
theleg,itwillbe visibleasahypodensearea(" )withintheinvolved
pulmonary artery oncontrast-enhanced images (Fig.94.1).
Afterlargepulmonary emboli,the affected segmentsorlobes('\)
usually become poorly ventilatedandatelectasis occurs. Thepumonaryvessels
become attenuated,whichcanbedemonstrated in
conventionalx-rays.TheCT-angiographicdetection of pulmonary
emboli is described on page 186 in moredetail.
Heart
Youhavealreadyfamiliarizedyourselfwiththe normalanatomyof
the heart on pages 79 to 81. Dilation resulting from valvularincompetence
or from cardiomyopathies, as well as intracardiac
filling defects can be recognized in CT images. If CM has been
injected,itis possible todetectatrial thrombusora thrombosed
ventricularaneurysm.Theimagein Figure94.2 illustrates acase
of global cardiac failure with markedly dilated atria (* *) and
incidentalthoracic vertebral degenerative osteophytes(" ).
Pericardialeffusionsmay occurwithviralinfections,uremia,the collagen

vasculardiseases,a heartattack,ortuberculosis,among other
causes.Apericardialeffusion (8)appearsasa broad rimoflow-densityfluid (between 10
and 40 HU)surroundingthe heart (Fig. 94.3).
Onlyfreshblood wouldhaveahigherlevelofdensity.Massive effusionsas seenin
Figure94.3notonly compresstheadjacentlungs
(178),but alsocompromise heartfunction.
Fig.94.3a
Effusionsmayleadtopericardialfibrosisor calcification(" " ),

whichinturn causes constrictive pericarditis(Fig.94.4).Notethat
insuchcases the vena cava,the azygos vein.oreven the atriamay
be markedlydilated as asign ofcardiacinsufficiency.
Atherosclerosisofthecoronaryarteries causescalcificationthatis
well demonstrated by thin,hyperdenselinesintheepicardialfat.
At present, however, a complete assessment of the degree of
stenosis requires angiography.
Thoracic Pathology
'"xal lntrapulmonary lesions

-~n
multiplelungmetastases are faradvanced,thelesionscan
"'" be recognized inthe topogram (Fig. 95.1 a). Depending upon

-age and vascularization of the metastases, they appear as
c=rical nodules of varying sizes (Fig. 95.1 b).The more irregular
" contoursofthe lesions (for exampl e,stellateor spiculated),the
-;.95.1a
: -onarymetastases arenotvisibleinconventionalx-raysunless
-e arelargerthan5or6mmindiameter.InCTimages,however,
-: can be detected at 1 to 2 mm in diameter. If metastases are
Lung
morelikelythey aretobe malignant.If, however,theyare solitary

and have central calcification(likea popcorn),or peripheral calcification,
thelesions are most likelytobeabenign hamartomaor
granuloma.
Fig. 95.1b
vesselscutincross-section.Small metastases locatedclosetothe

hilum are muchmoredifficulttodistinguishfromvessels.Insuch
cases,thedetailedanalysisofhigh-resolutionscans(HRCn may
bethe best method. :u:ed in the periphery, it is easy to differentiate them from
blood
-~.
95.2a Fig.95.2b
--" correct choice ofimagedisplay(window)is essential:Small

:u lesions (7) of the lung (84) do not appear on soft-tissue
-'ows(Fig.95.2a)ormay be mistakenfornormalvessels(96).
_-gwindows (Fig. 95.2c)shouldalwaysbeusedfor examining
-; parenchyma. In the case below (Fig. 95.3a), the multiple
Fig. 95.2c
small metastases (7) close to the pleura would have been overlooked
if lung windows had not been used (Fig. 95.3c). These
examples demonstratethe importanceofviewing eachimage on
long andsntt-tissue windows.
=e-95.3a Fig. 95.3b Fig. 95.3c

Thoracic Pathology Lung
Asaresultotchangesinthebehaviorofsmokers,theincidence of
bronchial carcinomas (BC), especially among women and young
people,hasincreased.In addition tothehistologicdiagnosisand
grading ofcarcinoma,thelocationofthe lesionis an important
prognostic factor:a BGofconsiderable size(7) intheperipheryof
the lung (Fig. 96.1) will almost certainly be visible on a con-
Fig. 96.1 a
ventional chest x-ray. More advanced BGs located centrally are

usuallynotoperableand may obstruct thebronchiallumen, resultingindistalcollapse
(178).Figure96.2illustratesanadvanced
case in which the tumor has areas of central necrosis (181) ana
thelung issurroundedbya pleural effusion(8).
Fig.96.2a Fig.96.2b
Lymphangitiscarcinomatosa(7in Fig.96.3)spreads from

thehilumorthevisceralpleuraintothe interstitialtissueofthelungbywayof
thelymphatic vessels.Obstructionofthese vessels bycancer cells leadsto
lymphaticcongestion(185).Atfirst,theupperlobes remain
clear.butasthediseaseprogresses these
alsobecomeinfiltrated.ThelargerlymphaticsandLNsgraduallybecomeinfiltratedby
metastatic disease.
Fig.96.3a Fig.96.3b
idosis
'" changes of sarcoidosis

-':k's disease) must be
-,-gntiated from multiple
---;ases inthelung: epithe;

ranulomas usually infil
~
the hilar lymph nodes (6)
"orally (Fig,97.1)and then
,3d within the perivascular
e and along the Iympha
o the periphery of the

ultiple small pulmonary
:-esand various degreesof
-'3 itial fibrosis may be
ssent, Largegranulomas (7),
seen in Figure 97,2, may

:11ble intrapulmonary me
ases.
... Fig. 97.1a ,, ------------Fig.

97.2a Fig. 97.2b
-. erculosis
, arqer mass cavitates(181),the DDwillinclude,for example,a
bronchialcarcinomawithcentralnecrosisorcavitary tuberculosis,
-, re97.3illustratesthelatterinan atypicallocationinan HIV+, immune-
compromisedpatient.Notealsotheemphysematous
-'-gesinthetissueattheperipheryofthelesion (176).
rgillus
-_~finfec
t
ion
with Aspergillus may occur within a pre-existing
7f in immune-compromised patients. The spores of A. fumi5are
commoninplant materialandsoil. Oftenthecavityisnot
Jletely filled withthe aspergillusball so that a small crescent
,-can berecognized( " inFig. 97.4).Aspergillosismay also
--to allergic bronchial asthma or provoke exogenous allergic
~D1
itis
.
Fig. 97.4
Pleura
Massive pleural effusions(8),asseen
in the case illustrated in Figure 98.1 ,
compress thelung(84)and may cause
largeareas ofatelectasis (178) affecting
individual segments or even an
entirelobe.Effusions appear ascollections
of homogeneous fluid of nearwater
densitywithin the pleural spaces.
Effusions usually accompany infections,
lung congestion due to right
heartfai lure, as well as venous conges-Fig. 98.1a
tion due to mesothelioma and peripheral
bronchial carcinoma.
Pleural drainage by the insertion of a

catheter (182) is indicated if atelectasis
(178) affects large portions ofthe
lung (Fig. 98.2). In the case shown in
Figure 98.2, the drainage tube was
blocked by fibrin-rich fluid. The lung
canonly be re-inflatedifthefibrinclot
is cieared or the catheter is replaced.
Fig. 98.2
Foreignbodiesare rarelyfoundinthe pleural spaces(166in

Fig.98.3),butmustbeconsideredafterthoracotomy(chestsurgery).Images
on lungwindows (Fig. 98.3c) clearly show the inflammationand collapse
(178)surrounding alost swab.
Asbestos-Related Lung Disease

Asbestos-related lung diseasehas afine reticulonodularpatternof
increased densities scattered throughoutthe lung tissue, especially
at interlobularsepta (t and ' in Fig.98.4).Typical pathologicfeatures
in the pleura are thickening and plaques (186 in Fig.
98.4). Fibrosis and scar emphysema appear in later stages of the
disease.Th e spindle-shaped or moretriangularareas of increased
attenuation are often difticult to distingu ish from those characteristic
of bronchialcarcinomas.
Fig. 98.3a Fig. 98.3b Fig. 98.3c
Thoracic Pathology
costs
-ole, well-definednodulesappearinfhe interstitial connective

=inresponsetophagocytosed particles ofsilica. Theupper
lOS of the lung are most commonly affected. Signs of fibrosis,
-: may progresstoa honeycomb pattern,canbest-and at
,( stages -be detected with HRCT (using 2-mm rather than
-om slice thickness; Fig.99.1). Thefiner,smallernodules can
= 99.1 Fig. 99.2
Fig.99.3
Lung
be found scattered throughout the lung; larger opacities, which

may cavitate,arelocatedwithinareasofdenserfibrosis(, in
Fig. 99.2). Enlarged mediastinal or hilar lymph nodes (Fig. 99.3)
often develop aneggshellpattern ofcalcification.Asthe disease
progresses, fibrosis and scar emphysema increase (.. in Fig.
99.1 ).
--ysema
"":<;'essive emphysema with accompanying bullae (176 in imagesinthe early stages.
Theseinfiltratesaremore easily seen
=J 99.4b)orbronchiectasiswith associatedinflammatorylnfllanddetected
sooneronthin sectionimagesusinglungwindows
'"::...0$ (178 in Fig. 99.5) are not visible on soft-tissue window [25-27].
Fig. 99.4b
--99.5a Fig. 99.5b Fig. 99.5c
The pathogenesisof interstitialfibrosisofthelung (Fig.100.1)cannotalwaysbe

establishedandis referredtoasidiopathicpulmonary
fibrosis. Thisis particularlytruewhenit affectsmiddle-agedwomen.
Thepatternoffibrosisresemblesthatillustrated ontheprevious
pageswith theexceptionthat emphysematouschangestypicallybegininsuopleural
regions.Rbrosisof the lungcanaccompanyanyof
thecollagenvasculardiseasesinthe advanced stages andlead
tosimilarmorphologicchanges.forexampleinscleroderma (Fig.100.2)
or polyarteritis nodosa (Fig. 100.3).
Fig. 100.1 Fig.100.2 Fig. 100.3
Test Yourself!
Youshouldtrytoanswerallthequestionsonthisandthefollowingpagebeforeturningtothe
backofthebookfortheanswersso as not
tospoilthefun oftackling eachone.
GD1IIa
Do you recognize any
How would you interpret

abnormalities in Figure
the dense area in the left
100.4 or is it a scan of
lungin Figure1oo.5? Disnormal
anatomy?Discuss
cuss your DD and make a

your DD.
list of additional information

that you need and the
steps necessary in order
to be certain about the
--_.
lesion.
~
Describe
~
in detail the pathologic
changes visible in Figure
A62-year-oldpatient pre
sented with intenseback
100.7 and the steps in

pain and was examined
your DD.
by CT. What is your diagnosis

of the changes
seen in Figure 100.6?
Can you classily the type
ofchange andthedegree
ofseverity?
......
Fig. 100.5
Test Yourself!
0Dl'iEt
GDmI
Detecting even minute

xocedures would you
at further diagnostic
changes may be decisive

'ocommend for the case
in order to arrive at the

~trate
d
inFigure101.l?
correct diagnosis.What do
Nhat do you suspect the
you see in Figure 101.2?

':sion to be? What other
:tJangesdoyourecognize?
Fig. 101 .1
....
CIDtID
, patient in her
A56-year-oldwoman with
2'6
~
week of
a history of smoking pre
xepnancv corn
sented with unintended
Jlained of snort
weight loss and severe
'=S 5 of breath.
attacks ofcoughingwhich
~a
r
physician ini
had already lasted for 3
Jally thought it
months. She had no pre
Nas because of a
igh diaphragm.
Two weeks later
shewas examined
Jy CT. Make careful
note of all abnormal
changes
you see in Figure
101.3 and the

stepsin yourDO.
vious illnesses. Does Figure101.4
illustratenormal
anatomy, a normal variant.
or anabnormality?
~
Do Figures 101.5a and101.5billustrate normal anatomy,ananomaly,oralymphoma? Discuss
your opinion.
Abdominal CT
ill general, all soft-tissue organs should appear uniform and be

Nelldefined, exceptwhen partial volume effectsoccur(cf.p.14)or
JUringtheearlyarterialphaseof CM enhancementinahelicalscan
cf.pp.120and126).Structuressuchasblood vesselsandbowel
oops should be clearly defined in intra-abdominal fat. The same
appliestothefat in muscles.
"oorly definedconnective-tissue spacesmayindicateedemaor an

nflammatory or malignant infiltrafion. If the anatomy cannot be
:learlyresolved, additionalinformationcanbegained
bymeasuingthedensityofspecificareas
orbycomparingunenhancedwith
:M-enhancedscans(cf.pp. 15and 121 ).
!,gain,the proposed checklistisnotintendedtobe"prescriptive",

xn to givean useful toolfor the novice inorderto reducethenum
:er of missedpathologicai findings.
Systematic Sequence for Readings

;nalogoustointerpreting chest CTs,wesuggestyou
:egin with the tissues of the abdominal wall. Consicerabletimeissaved
ifyouconsistentlylookatthem
'romcranial to caudal. Forbeginners a systematicinspectionof
eachorgan orsystemfromcranialtocau
jal is recommended, so that you do not need to

.oncentrate on toomanystructures atonce.Theprooosec
procedureencompasses twoorthree passages
mrouqntheimages. As youbecomeexperienced, you
may wish to devise your own method. Experienced
-eaoers are more easily able to detect all pathologic
: angesinonepassagefrom cranialtocaudal.
: issensibleto evaluateinternai organsthat lieinthe

same transverse plane. The uniformity of the paren:
nyma,thesize and thesmoothsurfaceofliver and
sateenshouldbecheckedtogether.The same istrue
'orthe assessment ofthe pancreasandthe adrenal
; ands: they also lie at the same level (cl. pp.
.05/106). If the entire urinary system is to be exami-
ed,it savestimetoinspectthereproductiveorgans
'"d bladder inthelesserpelvisbefore lookingatthe
:ranial parts of the GIT, or the regional lymph nodes
'00 the retroperitoneal vessels (see checklist on the

-ght).
=lIlally, thepresenceofscleroticandlyticbonelesions
'1dthestateofthespinal canalshould bechecked
c'. p.155).
Selection of Image Plane
The sections of the abdomen are also acquired transversally
(= axially).lfthetableadvance issetat8mmwithaslicethickness
of10 mm,therewillbe an overlapof1mmon eachsideofthe
section. In recent years, there is a trend towards thinner slices
with aslicethickness between 5 and 8 mm.
The small topograms on
thefollowing pages (based
on Fig. 103.1) clearly show
theslice positionsas relatedtotheanatomyof
major
structures for each series
of images.
Fig.103.1
Checklist for Abdominal Readings
Abdominal wall:
liver and spleen:
Gallbladder:
Pancreas, adrenals:
Kidneys, ureter,
and bladder
Reproductiveorgans:
GIT:
Retroperitoneum:
Bone window:
(especially periumbilical and inguinal regions)

hernias, enlarged lymph nodes?
homogeneous parenchyma without focal lesions?

well-defined surfaces?
well-defined,thin wall?calculi?
well-defined,size normal?
symmetric excretion ofeM?

obstruction,atrophy,bladder wall smooth
and thin?
uniform prostateof normal size?

spermatic cord, uterus, and ovaries?
well defined?normalthicknessofwalls?
stenoses or dilations?
vessels: aneurysms?
thromboses?
enlarged lymphnodes?
mesenteric (normally <10mm)
retrocrural (normally< 7mm)
para-aortic (normally < 7 mm)
parailiacal (normally< 12mm)
parainguinal (normally<18mm)
lumbarspine and pelvis:
degenerative lesions? fractures?
focal scleroticorlyticlesions?
spinal stenoses?
Abdominal CT Normal Anatomy
Theimagesofthe abdominalorgans includethe costodiaphragmaticrecessesofthe lungs

(84),whichextend quitefarcaudally,laterally,
and dorsally.Liver(122)and spleen (133)parenchymausuallyappearhomogeneouswithout
focallesionsinthevenousphaseofCM
enhancement:branchesoftheportal vein (102) andthefalciformligament (124)can
bedistinguished.Inorderto assessthegastricwall
(129a),thestomach(129) can befilled withwater,which acts asalow-density
CM,afteranLv.injectionofBuscopan.Thediaphragm
(30)betweenthethoracicand abdominal cavitieshas

anattenuationsimilartotheparenchymaoftheliverandspleenandcantherefore
notbedifferentiatedfrom theseorgansifitsthindomeis sectionedobliquely.
Fig.l04.1a
Fig.l04.2a
Fig. l04.3a Fig.l04.3b

Th eright adrenal gland usually lies cranialtothe upper pole ollhe kid ney (135),
whereas
the left adrenal gland lies ventral to the upper poleof the kid ney. Consequentiy,
thetwoadre nal glands(134) are seen on the same sections. Note the position ofthe
Jiaphragm (30) betweenthelung (84) and the inferiorvena cava (80). Th evesselson
e lesser curvature of the stomach (109) and the gastric walls (1 29a) are usually
flell defined and clearlydemarcated inthesurrounding fatand connective tissue (2).
Th eright adrenal gland usually lies cranialtothe upper pole ollhe kid ney (135),
whereas
the left adrenal gland lies ventral to the upper poleof the kid ney. Consequentiy,
thetwoadre nal glands(134) are seen on the same sections. Note the position ofthe
Jiaphragm (30) betweenthelung (84) and the inferiorvena cava (80). Th evesselson
e lesser curvature of the stomach (109) and the gastric walls (1 29a) are usually
flell defined and clearlydemarcated inthesurrounding fatand connective tissue (2).
Fig. l 05.2b
Typicallythe pancreas(131) haswell-

definedparenchymawithanirregularoutline.Theheadanduncinate processofthepancreas
extendquitefarcaudally (downto Fig.107.2).Theleft adrenal gland (134)is often v-
snaoed,whereas therightadrenal gland maylook
likeanarroworacomma.Notetheoriginoftheceliactrunk (97) andtheSMA
(106)fromtheabdominalaorta(89).Enlargedlymphnodes
mayfrequentlybefound inthis vicinity.InFigure106.3,thecontrast-enhancing
effectofanarterialbolusof CM becomesevident.Atthis
point, theSMA(106)hasenhancedmore thantheaccompanyingvein(107), which does
notcontainanyCMyet. Withinmoments(Fig.
107.1),the bolus ofCMhas also opacified thesuperior mesenteric vein (107).
Fig.l06.1 a Fig. l 06.1b
Fig. l06.2a
Fig.l 06.3a Fig.l06.3b

-ookforarterialcalcifications intheoriginsoftherenalarteries (110) atthelevelof the
~na
l
veins(111).Theleftrenalveindoesnotalwayspass betweentheaorta(89) and
-9 SMA(106)totheinferiorvenacava (80),asitdoesinFigure107,1.Anatomic variaznsare
not unusual(ct.p.116). Benigncysts(169)frequently occurintherenalpelvis
136) nexttothe ureter(137)orintherenalparenchyma(135)(Figs,107.2and107.3).

3uchcystsdonotenhance aftereMinjection (cl.p.133).
Fig. 107.1b
Fig.107.2b -. , 107.2a
Fig. 107.3b
Closetothegallbladder(126),you cansometimesseepartialvolumeeffects (Fig.108.1)of

the adjacentcolon(143/144),thewallsof
which (152)should normallybethinandwelldefined incontrasttothe
rootofthesmallbowelmesentery (asinFig. 108.3).Theduodenum
(130)can onlybedistinguishedfrom theotherintestinalloops(140)onthe basisofits
position.Atthislevel,youshouldalsocheck
the kidneys (135)forsmoothmarginsand possibleparenchymalscarring.The
presenceoffatmakesit easiertoidentifythe rectus
abdominis muscle(29)aswellas theobliquemusclesoftheabdominalwall(28a-c).
Fig,108,lb
Fig.l08.2a Fig.l08.2b
Fig.l08.3a Fig.l08.3b
tethetypicalpositionofthe proximalpartsoftheureters (137),medialtotheinferior

:desofthekidneys (135)and anteriortothepsoasmuscle(31a). In Figures109.2
-id109.3,theluminaofbothuretersappearhyperdensebecauseeMisbeing excretec in the
urine.Partsof the renalfascia (5)canbe identifiedin Figures109.2and
109.3.Haustrations caused bythe semilunarfolds(haustral folds) (149) aretypical

-,me colon(142-144inthefigures below).
Fig. 109.1b
Fig.
109.2b
-. 109.3a Fig. 109.3b

InFigure110.1.thebranching patternofthe
superiormesentericvessels(108)whichsupplythesmall bowel (140)canbeseen.Atthe
bifurcation ofthe aorta (89) (usuallyat L4 vertebral body, Fig. 110.2), thecommon
iliacarteries (113) are anteriortothecorresponding
veins(116).Thetwo ureters(137)are locatedmorelaterallyin frontofthe psoas muscles
(31a).Alongwiththe iliacbones(58)the
gluteusmediusmuscles (35a)appearand sometimes
containcalcifiedintramuscularinjectionssites(cf. Fig.117.3).
Fig. 110.2a Fig. 110.2b
Fig. 110.3a Fig. 110.3b

Fig. 111.2b
Fi g. 111.1b
-order to exclude the presence of an abdominal hernia you should check for a
-Jrmal width of the linea alba (47) between the rectus abdominis muscles (29).
~recaudally(Fig. 111 .3)there is a site of predilectionfor en larged LNs atthedivi:
on of the iliac vessels into external artery/vei n (11 5/118). which pass
anteriorly,
;old intern al arteryivein (114/117), which are located more posteriorl y. The
transi;;
00 from thelum bar spine (50) tothe sacru m (62) lies atthis level.
Fig. 111.2b
Fi g. 111.1b
-order to exclude the presence of an abdominal hernia you should check for a
-Jrmal width of the linea alba (47) between the rectus abdominis muscles (29).
~recaudally(Fig. 111 .3)there is a site of predilectionfor en larged LNs atthedivi:
on of the iliac vessels into external artery/vei n (11 5/118). which pass
anteriorly,
;old intern al arteryivein (114/117), which are located more posteriorl y. The
transi;;
00 from thelum bar spine (50) tothe sacru m (62) lies atthis level.
-_. 111.3a Fig.111.3b
112
In the following images, the ureters (137) pass posteriorly to approach the lateral
aspects of the base of the bladder (138). Withi n the bladder, differences in the
con centration
of excreted eM in the urine can be recogni zed asfluid-flui d levels of different
densities (Figs. 112.3 and 113.1). On the next page, a male pelvis is shown,
demonstrating the prostate (153), seminal vesicle (1 54), spermati c cord (1 55),
and
root of pen is (156). Note in particular the internal obturator muscles (41a) and
the
levator an i muscles (42) lateral to the anal canal (146a); images of the female
pelvis
on pages 114 / 115 were not obtained as far caudall y asin themale.
Fig. 112.1
Fig. 112.2
Fi9'112'3~~~~~~~~~~~~Fig.113.1
Fig. 113.2
Fig. 113.3
Fig. 112.1a
Fig. 112.3a
112
In the following images, the ureters (137) pass posteriorly to approach the lateral
aspects of the base of the bladder (138). Withi n the bladder, differences in the
con centration
of excreted eM in the urine can be recogni zed asfluid-flui d levels of different
densities (Figs. 112.3 and 113.1). On the next page, a male pelvis is shown,
demonstrating the prostate (153), seminal vesicle (1 54), spermati c cord (1 55),
and
root of pen is (156). Note in particular the internal obturator muscles (41a) and
the
levator an i muscles (42) lateral to the anal canal (146a); images of the female
pelvis
on pages 114 / 115 were not obtained as far caudall y asin themale.
Fig. 112.1
Fig. 112.2
Fi9'112'3~~~~~~~~~~~~Fig.113.1
Fig. 113.2
Fig. 113.3
Fig. 112.1a
Fig. 112.3a
Fig. 112.3b
Abdominal CT Pelvic Anatomy (Male)
q g. 113.4a Fig. 113.4b

114
Inthefemale pelvis,thesizeandpositionofthe uterus (158) relativetotheurinary

bladdercan varyconsiderablyfrom patienttopatient.Theuterusmayliecranialor
lateraltothe bladder(Figs. 114.1-115.1).Thecervixandthe vagina aresituated
betweenthebladder (138)andtherectum (146),whereastheovaries(159) lie more
laterally. Depending onageand the phaseofthemenstrualcycle,ovarianfollicles
might be misinterpreted as cystic lesions (cl. o. 133).
Fig. 114.1a
Fig. 114.2a
Fig. 114.3a
� Abdominal CT Pelvic Anatomy (Female)
:' eeintra-abdominaltluid(ascitesorhemorrhage)may occurintherectouterine pouch

betweenrectumanduterus,as wellasinthe
esicouterinespace.Intheinguinalregion,lymph nodes(6)can beupto2 cmindiameterand
benormal(Figs.115.2and115.3).The
sue ofnormal abdominallymphnodes does notusually exceed 1cm.Itis not possibleto
examinethehipjoints onsoft-tissuewindows
Fig. 115.3);the headsofthefemurs(66a)intheacetabularfossae(59/61)can bestbe
analyzed onbonewindows(notshown here).
'oJ assessmentof bone windowscompletesthe examinationoftheabdominalandpelvicimages.
Fig. 115.1b
Fig. 115.2b
Fig.115.3a Fig.115.3b
Abdominal Pathology Variants
Anatomic Variations
For thebeginner,it isimportant to be familiar
with the most common anatomic variations
which may lead to misinterpretations of CT
images.Insome patients,the contoursofthe
rightlobeoftheliver (122) mayappearscallopedby
impressionsofthe diaphragm(30)
which could be mistaken for liver lesions
(Fig. 116.1). The walls of an empty stomach
(129) arethickandmay suggest amalignant

lesion (129a).
Fig. 116.1a Fig. 116.1b
Ultrasound may mistake

an anomalous left renal
vein (111) for a retroaortic
LN. Usuallytheleft
renal vein passes between
the SMA (106)
and the aorta (89).
However, the vein may
be retroaortic and pass
between the aorta and
the spinal column (50)
to the inferiorvena cava
(80) (Figs. 116.2 116.4).

Duplication of
the left renal vein with
preaortic and retroaortic
components can also
occur.
Characteristic Partial Volume Effects
Ifthewallofone organindents thatofanother, cross-sectional
imageswill make itlookasifone organwerewithinthe other.
For example,the sigmoidcolon (145)mayappear"within" the
urinary bladder (138) (Fig. 116.5a). By comparing adjacent
sections (Figs.116.5aand c),itiseasytorecognizethat only
partsofboth organshave beenimaged.Ina similarmanner,
the right colic flexure (142) may appear to be "within" the
gallbladder (126) (Fig.116.6).
Fig. 116.6a Fig. 116.6b

Abdominal Pathology Abdominal Wall
lymph Node Hyperplasia

?athologic lesionsoftheabdominal wall occurmostfrequentlyin
theinguinalregion.l ymph nodehyperplasiawithnodesupto2em
dimension should notbeconsidered abnormal.l arge conglomerate

masses of lNs (+) arefoundin non-Hodgkin's lymphoma
(Fig. 117.1)and less frequently in Hodgkin's disease.
An inguinalhematoma (173) caused byhemorrhagefromafemoralartery
puncturesiteaftercoronaryangiography shouldbeconsidered
(Fig, 117,2) inthe DO.
Abscesses
Intramuscularinjectionsitesinthe glutealregionresulting insubcutaneous
fat (2) necrosis or postinflammatory residue (..)
typically are well-defined, hyperdense, partially calcified lesions
(Fig. 117,3).
An abscess may spread from the gluteal muscles to the pelvis
throughthe ischiorectalfossa.Afterdiffuse infiltration (178)of the
glutealmuscles(35)withsurrounding edema(185inFig.117.4),
quefaction (181) may occur and. depending on the localization

andsize,theabscesscan involvethesciatic nerve(Fig. 117.5).
Abdominal Pathology Abdominal Wall
The CT in Figure 118.1 shows subcutaneous lesions, resulting from heparin

injections (173) or small hematomas that may mimic
cutaneous metastases(7)or malignantmelanomas(Fig.118.2). Larger metastasestend
toinvadethemusclesofthe abdominal wall
(29)andoftenhave hypodense,central necrosis(181).

EnhancementafterintravenousCMmayalsopointto malignancyoraflorid
inflammatoryprocess.IfthedegreeofCM enhancementis
uncertain,aregionofinterestfordensitometricanalysisis placedinthelesion
ona pre-CMand compared witha post-CM (Fi9.118.2).
Metastasesinthe abdominalwallmaynot
beevidentuntiltheybecomeinfectedanddevelopintoanabscess (181),which
wascatheterizedanddrainedinthe
caseillustrated (182inFig.118.3).Thesecondmetastasis(7),justbeneaththeright
abdominalwall (28),was
notrecognizedatfirstbecausethe patient's symptoms were attributed tothe adjacent
abscess.
Abdominal Pathology Liver
Segmentsof theliver
taliverbiopsyorradiotherapyisplanned,itishelpfultoknowinwhichsegmentafocal lesion
issituated. Theliverishorizontally
subdivided(bluelinein Fig.119.1)bythe main branchesoftheportal vein
(102) into a cranial and caudal part. The main hepatic veins (103) mark the
oordersofthesegmentsin thecranialpart(Fig.119.2).The border between
eleft and right lobesis notmarked bythefalciform ligament(124),butby
eplanebetweenthemiddle hepaticvein and gallbladder(126) fossa.
III
I caudate lobe
II lateral segment, cranial part
Left lobe
III lateral segment, caudalpart

IV quadrate lobe(a: cranial,b:caudal)
V anterior segment. caudal part

VI posteriorsegment,caudal part
Right lobe
VII posterior segment, cranial part

VIII anterior segment,cranial part
Fig. 119.1
II
=-g.119.4 Fig. 119.5
Abdominal Pathology
Choice of Window
In conventional (nonhelical) CT, the unenhanced liver (122) is
imagedonaspecial liverwindowwidth(Fig.120.1a)setbetween
120 and 140 HU. Normal liver parenchyma can be more clearly
distinguished from lesions on narrow-window-width images
because they provide high image contrast. If there is no fatty
infiltration of the liver (which would reduce attenuation), intra-
Liver
hepatic vessels(103) appear as hypodense structures.In casesof

fattyinfiltration,theveinsmay appearisodenseoreven hyperdense
on unenhanced images. The post-contrast agents CT
images areviewedusingawindowwidthofapproximately350 HU;
this smootnes the gray scale contrast (Fig. 120.1c).
Fig. 120.1a Fig.120.1b
Passage of a Bolus of Contrast Agents

Inathree-phasehelicalacquisition ofearly arterial,portalvenous,
andlatevenousphasesofcontrastagents enhancement, an unenhanced
study is not necessary [17, 18]. Hypervascular lesions
become much moreclearlydefinedintheearlyarterial phase(Fig.
CT Portography
Thechancesofdemonstratingthetrueextentof liverlesions(e.g.
metastases) are greatly improved if contrast agents are injected
directly into the SMA or the splenic artery and images are then
acquired intheportal venousphase[17,21). Sincetheprincipal
blood supplyformost metastasesandtumorscomesfrom thehe-
Fig. 120.1c
120.2a)thaninthelate venous phase.Inthelatevenous(equilibrium)

phase (Fig.120.2b),thedensitylevelsofthe arterial, portal
venous,andvenous systemsarepractically identical.
paticartery,these lesionswillappearhypodensewithinthehyperdensenormal
parenchyma thathasenhancedwithcontrastagents
(Fig. 120.3a).Inthe samepatient,the earlyarterialphase image
(Fig.120.3b) showsthat withoutcontrast agentsportography,the
extentofthemetastaseswould have beengreatlyunderestimated.
� Abdominal Pathology Liver
Hepatic Cysts
Hepatic cysts(169)containing serousfluidare sharply defined,thin-
walled,homogeneouslesionswithdensityvaluesclosetothoseof
later (Fig.121.1). Partialvolume effectsmaycause poordelineationfromadjacenthepatic

parenchyma(122)ifthecystsaresmall.If
indoubt,a ROI shouldbe positionedwithinthe cystfordensity measurement
(Fig,121.2a).ItisimportanttoensuretheROI is correctly
placedinthecenterofthecyst,wellawayfromthecystwalls(cf.pp.15 and 133).In
smallcysts,forexamplethe poorlydefined lesion
in Figure121.2b,theaverage densitymeasurementwastoohigh, because adjacent
liverparenchyma was included inthecalculation.
atethatbenigncysts donotshowanysignificantenhancementafteri.v CM.
-iydatid (Echinococcus granulosus) cystshavea very characteristicmultiloculated

appearance,oftenwithradially arranged septations
oetweendifferentcysts(169in Fig.121.3).It mayprovedifficulttodifferentiate
betweencollapsed, deadcysts andotherintrahepatic
esions.Therightlobeoftheliveris mostfrequently
affected,sometimestheleftlobeorthespleen (133)becomeinvolved,asshownin
Figure 121.3. The density of the cyst

'Iuid is usually between 10 and 40 HU
JI1 an unenhanced image. Partial or
completewall calcificationisfrequent
anc the outer membrane may enhance
Hith CM. The DD includes infections
Hith E. alveolaris (not shown) and
occaslonally hepatocellular carcinoma
at is poorly defined with irregular

satellitelesions.
LiverMetastases
Multiplefocal lesionswithintheliver suggest metastases.Common
sites oforiginare thecolon, stomach, lung,breast,kidneys,and
uterus.The morphologyandvascularitydiffer betweenthetypesof
livermetastases.An enhanced helical scanisthereforeobtained in
Fig. 122.1a
Hypo-andhypervascularmetastases share
the hypodense (dark) appearance in the
venous phase becauseofrapidwash-outof
contrast material. If spiral CT is not available,
it is helpful to compare unenhanced
images (Fig. 122.2) withenhancedimages
(Fig. 122.3). In the example on the right,
number and size of the hepatic lesions (7)
would have been underestimated on the
enhanced images. It is easily comprehensible
that individual small metastases can
escapedetection ifunenhancedimages are
passed over. To increase the contrast in the
hepatic parenchyma (122), a narrow window
setting should always be used wh en
viewing these unenhanced images (see
page117). Thismight evenbringoutsmall
metastases (7) (Fig. 122.2). These small
livermetastases(7) differfromsmallcysts
by exhibitinq an indistinct margin and a
higherdensity after intravenousinjectionof
contrast medium (Fig. 122.4) indicative of
enhancement.The average densityvalues
were55and 71HU,respectively(Fig. 122.4).
Incase ofdiagnosticdoubtandfor referenceat follow-upduring

therapy, it is useful to compare the CT images with ultrasound
findings.Apartfrom thetypicalhypoechoichalo,metastaseshave
varied ultrasound appearances, just as in CT images [23]. The
ultrasound diagnosis may be difficult, especially when calcificationin
metastases leadstoacousticshadowing.Even thoughthey
are quite rare, slowly enlarging mucinous metastases (i.e. those
from coloncarcinomas) maybecome verycalcified (" inFig.
122.5).
boththevenousphase(Fig.118.1a)andtheearlyarterial phase
(Fig.118.1c).Inthismanner,smallerlesions(7) become welldefinedandhepaticveins(
103) willnotbe mistakenfor metastases.
Abdominal Pathology
Solid Hepatic Lesions

A hemangioma is the most common benign hepatic lesion. In
unenhanced images small hemangioma are well-delined homogeneous
areas 01 decreased attenuation. After injection of CM,
enhancement typically begins in the periphery and progresses
towardthe centerofthe hemangioma(Fig.123.1a),reminiscentof
theclosing ofan optic diaphragm.In dynamic bolus-enhanced CT
sequences, enhancement progresses centripetally. Following
Fig. 123.1a
Liver
administration of a CM bolus, a series of CT images is acquired

every few seconds at the same location. Accumulation of CM
within the cavities of the hemangioma (,, ) leads to homogeneous
enhancement inthelatevenousphase (Fig.123.1b).In
large hemangiomas, this might take several minutes or be inhomogeneous.
Fig. 123.1b
Hepaticadenoma(" )occursmostfrequentlyinwomen between

theagesof20and60years who havea longhistoryoftakingoral
contraceptives.An adenoma originatesinhepatocytesandmaybe
solitaryor multiple.Theadenoma isusuallyisodense,sometimes
ypervascular (Fig. 123.2), and may be accompanied by hypodenseinfarction,
central necrosis. and/or spontaneoushyperdense
emorrhage. Surgical excision is recommended due to the
oossibilityof acute hemorrhageand malignant degeneration.By
contrast, focalnodularhyperplasia(FNH) doesnotshowany tendencyof

malignantdegeneration,andlesionsofthiskind contain
biliaryducts. On unenhancedimages, FNHappearsashypodense,
sometimes isodense, but well-defined lesions. After Lv. CM, FNH
oftendemonstratesanirregulariyshaped,hypodense central area
(*) representing itscentralbloodsupply;howeverthis featureis
seeninonly 50%ofallFNH(Fig.123.3).
Fi g.123.2 Fig. 123.3 Fig. 123.4

-iepatocellularcarcinoma(HCC) often occursinpatientswhohave
a long history of hepatic cirrhosis and is seen most often in men
overthe ageof40 years.In one-thirdof allcases,HCCissolitary
although multifocallesionsare notrare. Thrombosesinthebrancnesofthe
portalvein causedby tumorinvasionintothe lumenof
tne vesselmaybeseeninone-thirdof cases.The CTappearance
HCC (Fig.123.4)is extremelyvariable.On unenhancedimages,

.,CC usually appears hypodense or isodense; CM may show
diffuseorrimenhancementand centralnecrosis. Whenthereis

alsocirrhosis,itmay be difficultto definetheborderof an HCC.
Secondarylymphomashouldbeconsideredinthe DO becauseit
may infiltrate the liverparenchymaandmay be thecauseofdiffusehepatomegaly.
Ofcourse,thisdoes not mean that everycase
ofhepatomegalyisdue toalymphoma.Non-Hodgkin'slymphomas
resembleHCCbecause oftheirsimilaritiesinvascularityandnodulargrowth.
Diffuse Hepatic lesions
Infattychangesoftheliver,thedensityofthe unenhancedparen
chyma, which is normally about 65 HU, may reduce so that it is
eitherisodenseoreven hypodensewithregardtotheblood vessels
(Fig. 124.1; cf. also p. 120). In hemochromatosis (Fig. 124.2), the
accumulation of iron leads to increased attenuation above 90 HU
and mayreach asmuchas140 HU.lnthese cases, the naturalcontrastbetween

parenchyma and vessels iseven greater.Cirrhosis
(Fig. 124.3), resulting from chronic liver damage, has a diffuse
nodularappearance andusuallygivestheorgan an irregular,lumpy
contou r.
Fig. 124.1 Fig. 124.2 Fig. 124.3
Abdominal Pathology Gallbladder
Biliary Tract
After surgical choledochoenteric anastomosis, sphincterotomy, or
endoscopic retrograde cholangiopancreatography (ERCP), hypodense
gas (+) is usually present within the intrahepatic bile
ducts (Fig. 124.4). These causes of biliary gas must be differen tiatedfrom
gas-forming anaerobic bacteria within an abscess.
Dilatation of the intrahepatic biliary tract (128) is called cholestasis
(Fig.124.5). It mayresultfrom gallstones,amalignantobstruc-
If it is not possible to treat the

cause of cholestasis surgically,
inserting a stent (182 in Fig.
124.6) may decompress an
obstructed biliaryduct(1 28).
Abdominal Pathology Gallbladder
"hesizeandshapeofthegallbladdervary depending onwhenthe patientlast atefood.A

hydropsofthegallbladdershouldonlybe
:iagnosedifthere isvery markeddilatation,thatisifthediameter exceeds5cm in
severaltransverseplanes.Theattenuationofbileis
usuallyjust greaterthanthatof water(0HU)butmayincreasetoupto25
HUifthebileishighlyconcentrated [4].
Cholecystolithiasis
tones (167)withinthegallbladder(126) mayshowdifferent

patternsofcaicification(Fig.125.1). Cup-shaped and ring-likecalcifications
canbe seen instonescontaining cholesteroland bilirubin (Fig.125.2).If stones
obstructgallbladderdrainage orinflammationhascaused
stenosis, sludge may form resulting in increased attenuation and sedimentation of
bile (Fig. 125.3). Common duct stones should be
diagnosedusingthin-section CTbecause smallerstonesmight bemissedin
standardthickness sections.
Fig. 125.2b Fig. 125.3b

Chronic Inflammatory l esions
Cholecystolithiasiscanlead tochronicinflammation, resulting inastone-
filled,shrunken gallbladder, acute cholecystitis,oranempyema
ofthegallbladder(recognized byanirregularlythickened wall)( '\,
inFig.125.4).Thereisanincreased riskotmalignantchange
withchronicinflammatory processes[24].Thedevelopmentofa
porcelaingallbladder(Fig.125.5) with an egg-shell-likepatternofcal
cification (174) may be a premalignant lesion.
Fig. 125.4 Fig. 125.5a Fig. 125.5b

Abdominal Pathology Spleen
Contrast Enhancement
Before readingfurther,tryto
defineacharacteristicfeatureofthespleenbylookingatFigure126.1a.Thenormalsplenicpare
nchyma
(133) has an attenuation ofapproximately45HUon unenhanced images.The attenuation

ofthe spleen willonly appear homogeneous in
an unenhancedimageorinthelate venousphaseofan enhancedstudy(Fig.126.1c).In the
earlyarterialphase (Fig. 126.1a),itwill
enhanceheterogeneouslyand appearpatchyormarbled,apatternrepresentingits
trabeculararchitecture.This patternshouldnot be
misinterpretedasanabnormality.NotealsotheunevendistributionofeMwithintheinferiorven
acava(80) andthetwo(!)hepatic
metastases(7)in thesameimage(Fig.126.1a). Didyouspottheareasofnear-water
attenuationrepresenting perisplenic/perihepatic
ascites(8)?
J, 122 J' /
.�.. ~~
./
~l~
Rg.1m1a Rg.1m1b Rg.1m1c
Thesplenicartery(99)istypicallyelongated andtortuoussothatit may beimagedin

severalconsecutiveslices.Inelderly patients,itis
commonto seeatherosclerotic plaques (174inFig.126.2).
Occasionally,ahomogeneoussplenunculus[accessoryspleen'],well
demonstrated inthe surrounding fat,may be seen atthehiiumortheinferior poleofthe
spleen (Fig.126.3). Differentiating betweena
splenunculusandan abnormallyenlargedLNmay bedifficult.
Fig. 126.2a
Splenomegaly
Diffuse enlargementofthespleen(Fig.127.1)may becaused by severalconditions: portal
hypertension, leukemia/lymphoma, myelofibrosis and hemolytic anemia, or by various
storage diseases.Assessmentofsplenic sizeismadedifficult by individual variationsin
shape.Marked splenomegalyis easiiyrecognized,butinborderlinecases of splenomegaly

andforfollow-up one should knowthenormairangeofsplenicsize.Inthetransverse
plane,thelengthofthe spleen(I)shouldmeasureno morethan10 cm (dottedline)and
itswidth (d, atright angletothe dotted line)shouldnotexceed5cm (Fig. 126.4).
In ultrasound, the spleen is not measured in a transverse plane but in an ob
liq
u~
plane
paralleltothe intercostal space.Inthis plane,theupperlimitofnormalis11cmforthe long
axis [28].
The craniocaudal dimension of the spleen should not exceed 15 cm, so that at a
slice
thickness of 1 cm it should not be visible on more than 15 sections. Splenomegaly
is
diagnosedifatleasttwoof thesethreeparametersareexceeded. Fig.126.4
� Abdominal Pathology Spleen
!.s splenomegaly develops, the typical normal

:rescentic shape is lost (Fig. 127.1 ). Gross
splenorneqaly. which may be caused by chronic
mphocytic leukemia, acts as a space-occupying

nass and displaces adjacent organs. In Figure
127.1,theleft kidneyis compressed( "').If the
:loodsupplycannot keeppacewithsplenicgrowth,
ntarctions( ,,)mayresult. Theseappearashypocense
areas that do not enhance with CM (Fig.
127.2).
-ocal Splenic lesions

Spleniccystssharethe
samecharacteristicsofhepaticcysts(cf.p.121).Metastasesinthespleen(7)arerare and
difficultto distinguish
~om
cysts.Inthe caseillustrated inFigure127.3,thediagnosisofsplenicmetastases was
relativelyeasybecausetherewere hepatic
-slons andmalignantascites(8).IftherearemultifocallesionswithinhomogeneousCM
enhancement,adiagnosisoffocalsplenic
mphomaor spleniccandidiasisshouldbe considered.Ascites (8)mayaccompanycandidiasis,
asshownin Figure 127.4.Splenic
mphomais usuallycharacterizedby diffuseinfiltration andthespleenmayappear normal.
Ine examinationof the spleen (133) afterabluntthoracicorabdominal trauma mustbe

meticulous.Lacerationsofthe parenchyma(181)
;;Jayleadto hematomas(8) beneaththe capsule, and delayed ruptureof the capsue may
cause massive hemorrhage into the abdomiClal
cavity (Fig. 127.5).
=ig. 127.3b
-�e remnants of smaller hematomas may

xesent as subcapsular (~
) or parenchy-
al( t )calcifications (Fig.127.6).
seotanens within splenic cystic lesions
'1g. 127.7) are strongly suggestive of

,:ninococcosis,and appearquitesimilarto
-e in the liver. In most cases the liver is
'so affected (cf. p121 ).
Abdominal Pathology Pancreas
Acute andChronic Pancreatitis

Acutepancreatitis maypresent as edematousinterstitialpancreatitis (Fig.
128.1).Hypodensepenpancreaticfluid (exudate) (8)and
edemaofthe connectivetissue
(185)arefrequentfindings.CTshowsblurringofthepancreaticcontours;thenormallylobularp
atternof
the pancreasiseffaced(Figs.128.1 and128.2).Inhemorrhagicnecrotizingpancreatitis
(Fig.128.2),theextentof necrosisisaprognostic
feature.
Chronic pancreatitis progresses

either slowly and progressively or
inrecurrentepisodes.The twomost
common causes of chronic pan
creatitis are alcohol abuse and

cholelithiasis
Typicalfindingsinchronic pancreatitisare
fibrosis and multifocalcalcifications
(174), irregular dilatation
of the pancreatic duct (132),
and sometimes the formation of
pseudocysts (169) within, or next
to,the pancreas (131) (Figs. 128.3
and128.4).Thedisease mayleadto
pancreaticatrophyas alatefeature.
Thepossibilitythat pancreaticcarcinoma
develops in association
with chroniccalcific pancreatitis is
presently being discussed.
Pancreatic Neoplasms
Mostpancreaticcarcinomas(7)arelocatedwithinthe headofthepancreas (131).Asaresult,
evensmalltumorsmaycausecholestasis
by obstructing thecommonbileduct(127)(Fig. 128.5).Pancreaticcarcinomastend to
metastasizeveryearlytotheliver and theregionalLNs.
Incaseofdoubt, ERCPshouldbecarriedouttoimagethe pancreatic
andcommonbileducts.Isletcell tumors,75%ofwhich
arefunctional,arelocatedwithinthe bodyofthepancreas.The Zollinger-Ellison syndrome
(Fig. 128.6) iscaused byagastrin-secreting
tumor ("). Otherneoplasmsassociatedwiththepancreasareinsulinomas, glucagonomas, and
serotonin-producing masses.
'4iIIIIIItr;"'"~.rl Jr. . ......

Abdominal Pathology
The normal position and shape of the adrenal glands has been
describedonpages 105to106.The maximumlengths ofthe adrenalglands
rangebetween2.1 and2.7em,therightadrenaloften
being somewhat longer than the left. The thickness of the limbs
should notexceed 5to8mminthe transverse plane.Afusiformor
Adrenal Glands
nodularthickening (7)islikelyto beabnormalinCT, andisusually

indicativeofhyperplasiaoranadenomaof the adrenalgland(134
in Fig.130.1). Typically,the adrenals canbeclearlydifferentiated
fromadjacenttat,thediaphragm(30),thekidney (135),theliver
(122), andtheinferiorvenacava (80).
Fig. 130.1b
Thefollowingconditionsmay be dignosed according tothe specific

hormonal excess: congenital adrenal cortical hyperplasia
(androgens), Conn's syndrome (aldosterone), and Cushing's
syndrome (cortisone). An upper pole renal cyst (Fig. 130.2) or a
renalangiomyolipoma (cl.Fig,134.4) mustbeincludedinthe DO.
Attenuation values forbenigncysts (169) shouldlieclose tothose
forwater (=-1 HUinthepresentcase)(Fig.130.2).(Compare
with cysts on p. 133.)
Fig. 130.2b
In cases of heterogeneous enlargement of the adrenal gland or

infiltration of adjacent organs, a metastasis or a carcinoma
(Fig. 130.3) must be suspected. Since bronchogenic carcinomas
often metastasizetothe liverandthe acrenals, staging chest CT
studiesforlung cancershouldbe extendedtoincludethecaudal
marginoftheliver and theadrenals. Tumorsofthe paravertebral
sympathetictrunks, which are located close tothe adrenal glands,
may also be detected, but they are rare. The MRI images in
Figures 130.4a and 130.4b show a neuroblastoma ("j in the
sagittal(a)and coronal (b)planes.
Fig.130.3 Fig. 130.4a Fig.130.4b

,
,
Abdominal Pathology Adrenal Glands
.vhenever doubtexistswhetheranenlargedadrenalglandrepreconsiderablymorerapidwash-
outofthe contrastenhancement
sents a benign process, densitometry (see pages 121 and 131) than malignant
lesions, such as metastases and adrenal gland
withdeterminationofthe enhancement patternshouldbeconsidcarcinomas(
Fig. 131.1).This methodrequiresanadditionalscan
ered:benignadenomasoftheadrenalglandshowatendencyofa at thelevelofthe
adrenalglandsafter3,10,or30minutes.
Dens ity
86�14
(HU) 79�1 8
1 100
67�20 64�22
80
60
40
20
66�13
59�1 2
32�17
Time
Unenhanced 30 sec. 60 sec. 90 sec. 3 min . 10 min. 30 min.
I g.131.1Rapidwash-outof contrast medium inbenign adrenal glandsadenomas(blue)

in comparison with non-adenomas (gray)
Jalignant tumorsof the adrenal glandtendtohaveaprolonged

contrast enhancement. This difference can be applied to the
differential diagnosis. The dynamic enhancement pattern in the
adrenal glands has been extensively investigated in numerous
studies,which revealed furtherdifferences inabsoluteand rela
tive wash-outofthepeak contrast enhancement. This wash-out

pattern, however, shows a certain overlap between the tumor
types,andthereforetheassessment hasbeen proven usefulonly
whenapplying thefollowingparameters [42]:
Densitometry inthe DDofspace-occupying lesionsofthe adrenal glands
Unenhanced:
10min.after injectionof contrast medium:
30min.afterinjection of contrast medium:
=Orthesethree values,therangeofthehistogramsor so-called

oox-whiskerplotsof Fig. 131.1doesnotoverlapforbothtumor
'ipes, and a benign tumor of the adrenal glands can be safely
assumedifthe measured density valuesfallbelowthese values.
< 11 HU =>
< 45 HU =>
< 35 HU =>
Adenoma
Adenoma
Adenoma
In all other cases, a benign adenoma cannot be assumed with

acceptabledegree ofsensitivityand specificityand furtherevaluation
is recommended.
Abdominal Pathology Kidney
/'
Congenital Variations
The attenuation of the renal parenchyma (135) on unenhanced A kidney may have an
atypical orientation as in Figure 132.2.
imagesisapproximately30HU.Thekidneysoccasionallydevelop
However,ifakidneyliesintheiliacfossa(Fig.132.3).thisdoesnot
todifferentsizes.If the outlinesare smooth andthe parenchymal

indicateanectopiclocation,butarenaltransplant(135).Theorgan
thicknessisnot irregular,itis likelyto representunilateralrenal

isconnectedtotheiliacvessels(113/116)andtheurinarybladder
hypoplasia(Fig.132.1).The smallerkidney neednotbe abnormal. (138).
Fig. 132.2b
Markeddifferencesin size,asinFigure132.2,may indicate partialor complete
renal duplicationononeside.Thepositionsand numberofrenal arteriesmayvary
considerably(110inFig.132.1b).Therenalarteries must be examinedcarefully
forevidenceofstenosis asacauseof renalhypertension.The ureter(137..)can
bepresentasapartial orcomplete duplexureter(Fig.132.4).In complete renal
duplication, therenal pelvis isalso duplicated.
Occasionally, the low-density fat in the hilum (* in Fig. 132.5b) is only poorly
demarcatedfrom the renalparenchyma (135) owing toa beam-hardening artifact
orpartial volume averaging (Fig.132.5a).Thisgivestheincorrectimpressionofa

renaltumor. Comparisonwith animmediately adjacentsection
(Fig.132.5c)demonstratesthatonlyhilarfat was present.The actual
tumorinthis particular example(7)issituated atthe
posteriormarginoftherightlobeoftheliver (122).
Fig. 132.5a Fig. 132.5c

Fig.133.1 Fig.133.2 Fig. 133.3
iIlcreaseddensityorcalcificationsina massmay indicate pastrenaltuberculosis,current

Echinococcusinfestation(hydatiddisease),or
acysticrenal cellcarcinoma.Thedifferencebetweenpre-andpost-
contrastimagesalsoprovidesinformation on renalfunction:after
approximately30secondsthewell-perfusedrenalcortexis thefirstpartofthekidneyto
accumulatethe CM(cf. Figs.133.2and133.3).
Afteranother30to60secondsthe
CMisexcretedintothemoredistaltubulesleadingtoenhancementofthemedulla.Theresultis
homogeneousenhancementofthe
renalparenchyma(cf. Fig.133.1).
The appearances of multiple renal cysts in children with congenital autosomal

recessive polycystic kidney disease are dramatically
different fromthoseoftheoccasional
cystsfoundinadults,whicharegenerallyincidentalfindings.Polycystic
kidneydiseaseintheadult
\169inFig.133.4)isautosomal dominant and associated withmultiple cystsofthe
liver,the bileductsand, morerarely,with cystsinthe
pancreasorwithabdominal orcerebral aneurysms.
Fig. 133.4a Fig. 133.5
Hydronephrosis
"arapelvic cysts maybeconfusedwithgrade1hydronephrosis(Fig.
133.5),whichischaracterizedintheunenhancedimagebyadilated
renal pelvisand ureter.Ingrade 2hydronephrosis,the renalcalyces become
poorlydefined.When parenchymalatrophyensues,the
ydronephrosisiscategorized asgrade3 (seep.134).Sinceno CMhad

beengiventothepatientin Figure133.5,thehyperdense lest)
f\ (If )intherightkidney mustbe arenalcalculus.
-orthediagnosisof nephrolithiasisalone,CTshouldbeavoidedbecauseofundue radiation
exposure(ref.p.174ff.).Sonographyis the
ethodofchoice fornephrolithiasis as wellashydronephrosis.
Abdominal Pathology
Cysts
"enal cysts are frequentincidentalfindingsinadultsand maybe
located anywhereinthe parenchyma.Theymay be exophyticor
parapelvic, in which case they can resemble a hydronephrosis.
3enigncystscontainaserous,usuallyclear liquidwithanattenuaeonof
between -5and+15HU. Theydonotenhancewith CM
becausethey areavascular.Theattenuation measurementmay be
inaccurateifthereare partial volumeaveraging artifactsdueto
Kidney
slice thickness (Fig.133.1:-25HU)ortoeccentricpositioning of

theROI(Fig. 133.2:-22HU)(cf. pp.15 and 121). Onlythecorrect
positioningofthe ROIinthecenterofthecyst(0 inFig.133.3)will
provideanaccurate average of10 HU.Inrarecases,hemorrhage
into benign cystswillresultinhyperdense values on unenhanced
images. Theattenuationvalues willnotchange on post-contrast
images.
Hydronephrosis, which causes

dilatation of the ureter (137)
and the renal pelvis (136),
impairs renal function (Fig.
134.1). In this image, the left
renal parenchyma (135) shows
delayed and reduced CM
enhancement as compared
withthe normal rightkidney.
Chronic grade 3hydronephrosis
reduces the parenchyma to a
narrow rim of tissue (Fig.
134.2), resulting finally in
atrophy and a non-functioning
kidney. In cases of doubt, iden
tifying the dilated ureter( " in
Fig.134.2b)canresolve theDD
between a parapelvic cyst and
hydronephrosis. CM accumula
tes in a dilated renal pelvis, but
not in a cyst.
Fig. 134.2a Fig. 134.2b
Solid Tumors
EnhancementwithCMoften helpstodistinguish between partial volume averaging ofbenign
renalcystsand hypodense renal tumors,
since CT morphologyalonedoesnotprovidesufficientinformation about the
etiologyofalesion.Thisis especiallysowhena mass(* )
is poorly definedwithinthe parenchyma
(Fig.134.3).Inhomogeneousenhancement,infiltrationof adjacentstructures,and
invasionof
the pelvisorthe renal vein arecriteriaofmalignancy.
Fig. 134.3 Fig. 134.4 Fig. 134.5

However,whenamassconsists not onlyof solid,inhomogeneousareas,
butalsocontainsfat,anangiomyolipoma(7)must be considered
(Figs. 134.4and 134.5).These benignhamartomas containfat,atypicalmusclefibers,and
blood vessels.Thevesselwalls are abnormal,
andthe complicationofintratumoralorretroperitoneal hemorrhage
mayoccur(notdepictedhere).
,
contoursat thekidney (135) appearblurred,anddepending on the

extent of hemorrhage, hyperdense fresh hematoma (8) can be
detected in the retroperitoneal spaces. in this case, enhanced
images (Figs. 135.1cand135.1b)showthatthe renalparenchy
Fig.135.1a Fig.135.1c
~fterextracorporeal shock-wave lithotripsy (ESWl), renal injuriesmay

rarelyoccurthatleadtosmall hematomasorextravasation ofurine
"am the ureter. If there is hematuria or persisting pain after ESWl , it is
essential to obtain delayed images. Urine leaking into the
'; troperitoneal spaces (+ inFigs.135.2a through 135.2c) wouldnot beopacified in
images obtai nedbeforethe kidneyhasexcreted CM.
4g. 135.2a Fig. 135.2b Fig. 135.2c
=""nalinfarctions (180)usuallyhaveatrian"
arshape on CT images corresponding to
-, vascular architecture at the kidney
I g.135.3).The broad base abutsthecap,
e and the triangle gradually tapers
. 'lardthepelvis (136).Atypicalfeatureis
-e lackof enhancementafteri.v.CMinthe
;'
~y
perfusion phaseand in the late excre
phase. Embolisms usually originate in

-e left heart, or in the aorta in cases of
=-erosclerosis (174 in Fig. 135.3) or
'-.eurysms (ct. p. 142).
, mere is a low attenuation filling defect
73) in the lumen of the renal vein (111)

rt sr aCM injection,the presenceofbland
r-ombus (Fig. 135.4) or tumor thrombus
-JITl a renal carcinoma extending into
-~
inferior vena cava (80) must be conscered.
Abdominal Pathology Urinary Bladder
Catheters
Thewallsoftheurinarybladderare bestexamined ifthebladderis
distended.Ifaurinarycatheter(182)isinplaceatthetimeofCT
(Fig. 136.1),sterilewatercan be instilled as alow-density CM.Focal ordiffuse
wallthickeningofatrabeculatedbladder, associatedwith
prostatichyperplasia,will be demonstrated clearly.Ifa ureter(137) has been
stented(182)forstricturesor retroperitonealtumors.the
distal end of the JJ stent may bevisibleinthebladderlumen(138)(bilateral JJ stents
in Fig. 136.2).
Diverticula
Diverticulasituated attheperipheryofthebladder
caneasily
be distinguished from ovarian
cystsbyusing CM (Fig.136.3).
The"jet phenomenon"is often
seen in the posterior basal
recess of the bladder and is
caused by peristalsis in the
ureters. They inject spurts of
CM-opacified urine into the
bladder, which is filled with
hypodenseurine (Fig. 136.4).
Fig. 136.3 Fig. 136.4
Solid Tumors
Bladderwalltumors(7),which become visible afterintravenous orintravesical CM, have
characteristic,irregularmarginsthat do not
enhancewith CM (Fig.136.5).Tumors
mustnotbeconfusedwithintravesicularbloodclotsthatmay occurfollowingtransurethral
resection oftheprostate.Itisimportantto determine the precise size atthetumor and
towhat extent adjacentorgans(e.g.,cervix, uterus,
or rectum)havebeeninfiltrated (.. inFig.136.6).
Fig. 136.5a Fig. 136.5b Fig. 136.6

Abdominal Pathology Urinary Bladder
, the bladder has been resected because of carcinoma, a urinary reservoir (* ) can
be constructed using a loop of small bowel
eumconduit)whichhasbeenisolatedfromtheGil Urineis excretedfrom
thereservoirintoaurostomy bag(..inFig.137.1b).
J Figure 137.2acolostomy( )isalsoseen(ct.p.140).
=nreignbodiesintheuterinecavity(158),e.g.anintrauterine oftheuterus(7in
Fig.137.4).Iftheadjacentwallsofthebladder
:ootraceptivedevice (166),arenotalwaysasclearlyvisibleina
(138)ortherectum(146)areinfiltrated,thetumorismostlikelyto
transverse image as in Figure 137.3. Calcifications (174) are a be malignant (Fig.
137.5). Central necrosis (181) occurs in both
:naracteristicfeatureof benignuterinemyomas. Neverthelessit kindsof
tumorsandisusuallyindicativeofa rapidly growing,
canbedifficulttodistinguishmultiplemyomasfromacarcinoma malignanttumor(Fig.137.4).
:;g.137.1a Fig. 137.1b Fig.137.2
Abdominal Pathology Reproductive Organs
erus
-. 137.3b Fig. 137.5b

Abdominal Pathology Reproductive Organs
Ovaries
The mostcommonovarian lesionsare thin-walled follicularcysts (169)thatcontainaclear
fluidwithadensityequivalenttothatofwater,
which is below 15HU(Fig.138.1). Densitymeasurements, however,are unreliablein small
cysts(cf.p.133).Thesecannot beclearly
differentiatedfrom
mucinouscystsorhemorrhagiccysts.Thislattertypeofcystmaybecausedbyendometriosis.Some
timescystsreach
considerablesizes (Fig.138.2)with consequentmasseffect.
The malignant nature of solid ovarian tu
morscanbe suspected ifthere are thefol
lowinggeneralcriteriaused forothertumors:
1) ill-defined margins;
2) infiltrationof adjacent structures;
3) enlargedregionalLNs;and
4) inhomogeneous enhancementwith CM.
Peritoneal carcinomatosis (Fig. 138.3)
frequently occurs in advanced ovarian
carcinoma, and is characterized by the
appearance of multiple fine nodules and
edema (185)in thegreater omentum,the
root of the mesenteric, and the abdominal
wall,and byascites(8). Fig.138.3a Fig.138.3b
Prostate, Vas Deferens

High-densitycalcification representingpostinflammatory
residueisoftenencounteredfollowingprostatitis(Fig. 138.4).Calcificationsare
also occasionallyseeninthe
vasdeferens(Fig.138.5).Carcinomaoftheprostateisonlydetectableinadvancedstages
(Fig.138.6)when
the bladderwallorthe adjacentischiorectalfossafatisinfiltrated.Ifaprostate
carcinomaissuspected,allimages shouldbe carefully
viewed on bonewindowsforsclerotic metastases (seep.145).
Fig, 138.4 Fig. 138.5 Fig. 138.6

Abdominal Pathology
Stomach
espite the advantages of using water as a hypodense CM for

:nagingthestomachafter intravenous Buscopan [15,16],small
unors may escapedetectionduring conventionalCTs.Endoscopy
-dendosonographyshouldbeemployedtocomplementCT.
arked focal wall thickening, which occurs in carcinoma of the
iornacn,isusuallyeasilyrecognized(.. in Fig.139.1).Incases
flammation of the Intestines

",e entire small and large bowel must be examined for wall
" . keningorinfiltrationofthesurroundingfatas perthecheckiist
_ page81.Bothulcerativecolitis (Fig.139.4)andCrohn'sdisease
I g. 139.5)are characterized bythickeningoftheaffectedbowel

call(t )sothatseveral layersofthewallmay becomevisible.
=ssernlnatedintravascularcoagulopathy (DIC) orover-anticoagula
nwith warfarinmay causediffuse hemorrhage(8) in the bowel
ofdiffusewallthickening(Fig.134.2),theDDshouldalso include
lymphoma, leiomyoma, orleiomyosarkoma ofthestomach.It is
vitaltolookfor bubblesofintraperitoneal gas(" inFig. 139.3),
which is evidence of a small perforation possibly occuring with
ulcersoradvanced ulcerating carcinomas.
wall(140) andalsoleadtomuralthickening (Fig.139.6).TheDD

shouldinciude ischemia if the abnormality islimitedto segments
intheterritoryof the mesentericvessels,e.g.,in thewallsofthe
colon (152), as a result of advanced atheroscierosis (174), or an
embolus (Fig.139.7).Youshouldthereforecheckthatthemesenteric
vessels (108) andthewallsoftheintestineenhancehomogeneouslyafterl.
v. CM.
=9,139.5 Fig. 139.6b

Abdominal Pathology Gastrointestinal Tract
Colon
Elderly patients frequently have diverticular disease (168) of the descending colon
(144) and sigmoid colon (145 in Fig. 140.1). The
condition is more significant if acute diverticulitis has developed (Fig. 140.2),
whichischaracterizedbyill-defined colonicwallsand
edematous infiltration of the surrounding mesenteric fat ( in Fig. 140.2).
Fig. 140.1a Fig. 140.1b Fig. 140.2
Malignant thickeningofthecolonicwall (152 in Fig. 140.3) isnot

lefthemicolectomyorsigmoidcolectomywaspertormedbecause
alwayseasilydistinguishedfromthatfoundin colitis(cf.p.139):in
ofpertorateddiverticulitisorcarcinoma.Thecolostomyis permaboth
conditions there is stranding of the pericolic fat. The liver nent if the rectum
was excised. A potential complication of a
shouldalways be checked formetastasesifthecause ofthecolocolostomy
can be seen inFigure 140.5:there is an abscessinthe
nicabnormalityis uncertain. abdominalwall (181).Acarcinoidlesionofthesmall
bowel( in
A temporary colostomy(170 in Fig. 140.4) may be necessary if a Fig. 140.6)
maysimulateacarcinomaofthe colon.
Fig. 140.4b Fig. 140.6

Abdominal Pathology
eus
-odzontalair-fluidlevels(....)and atonic,dilated bowel loops

140) are typical features of ileus. If dilatation is recognized in the
:opogram (Fig. 141 .1), orinanoverviewoftheabdomen,an ileus
-ust be suspected. If only the small intestine (Fig. 141.2) is
valved,themostlikely causeisa mechanicalobstruction dueto
adhesions.A gallstone may causeobstruction ofthe small bowel

(gallstone ileus).Thisfollowscholecystitiswiththe formation ofa
cholecystoenteral fistula and the passage ofagallstone into the
bowel. The gallstone may obstruct the narrower caliber of the
distalileum(167in Fig. 141.3).
'echanical obstruction of the colon leads to similar air-fluid levels

, d dilatation ( .... in Fig. 141.4).When lookingfor thecause ofan
Fig. 141.3
Fig. 141 .2
eus,the enfirecolon mustbe examinedfor obstructingorconstrict'

gtumorsorfocal inflammation.

-rethereanysuspicious findings other than thecolicileusin Figure
�~1.
4?
Doestheimage remindyouof othersinthemanual?Makethe
sf of the figures by returning to previous chapters, coveringthe
""xl, and identifyingasmanystructuresaspossible. Youwillimprove
our learning efficiency by revi ewing the images and diagrams and
..sing the legends to make sure you gotit right.
Space for notes andcompletingthe exercise:

Fig. 142,3a
Fig. 142.3b
Fig. 142.2a
Fig. 142.2b
Fig. 142.1a
Retroperitoneal Pathology
Aneurysms
Ectasiaoraneurysmsof the abdominal aorta (89) areusuallythe
resultofatheroscleroticdisease(174) whichleadsto muralthrombosis(
173 in Fig.142.1).Ananeurysmofthe abdominalaortais
presentifthe diameterofthepatentlumenhasreached3cmor
the outer diameter of the vessel measures more than 4 cm
(Fig. 142.2). Surgical intervention in asymptomatic patients is
usuallyconsideredwhenthedilatation has reachedadiameterof

5cm. The generalconditionof the patientandtherateatwhich
dilatation is progressing must be considered.Ifthe patent lumenis
centralandissurrounded by muralthrombosis(173inFig.142.2),
theriskofrupture andconsequenthemorrhageis reduced.
The risk of rupture is greater if the patent lumen is eccentric (

inFig.142.4)orif the cross-sectional shapeofthevessel isvery
irregular.Dilatationinexcessof6cmdiameteralso hasahighrisk
of rupture. Surgical pianning requires the determination of
whether,andtowhatdegree, the renai,mesenteric(97),andiliac
(113) arteriesareinvolvedbythe aneurysm(Fig. 142.3). Sudden

pain mayaccompanyruptureordissection,which can extendfrom
the thoracic to the abdominal aorta (cf. p. 93). Dynamic
CMenhancedCTwillshowthedissection
flap (172in Fig. 142.5).
Fig. 142.4 Fig. 142.5a
lenous Thromboses
011 casesofthrombosisinaveinofthelower extremity(
� esnotalwaysclearlyshowwhetherornotthethrombusextendsinto
=elvic veins(Figs.143.1a and143.1b).The CM.whichisinjectedintoa
superficial veinof thefoot.isoftendilutedtosuch adegreethatitbecomes
; iculttoassessthe lumenof thefemoral/iliacveins( "
-suchcases.itisnecessaryto performaCTwithl.v. CM.
), ve nograp hy
in Fig.143.1 c).
Thelumen of a vein containing a
"'eshthrombus(,,) is general.
atleasttwice aslargeasnor""
al (Fig. 143.2a). The segment
:ootaining the thrombusiseither
,;]iformly hypodense compared
Mlhthe accompanying artery, or
: shows a hypodense filling
:efect. representing the throm:
us itself. In the case illustrated Fig. 143.2a Fig. 143.2b
:n theright,thethrombus exten:
ed through the left common
;;ac vein (, ) to the caudal
seqrnentoftheinferior venacava
Fig. 143.2b), where it can be

",enasahypodensearea (t )
serrounded by contrast-enhanced,
"0I'ling blood (Fig. 143.2c). CT
;icesmust be continued cranialJ
until the inferior vena cava no
;/lgershows anysignsofthrom-Fig.143.2c
.us ( in Fig. 143.2d).
--e injection of CM into a superficial foot vein opacifies satis(

Figs. 143.3a and 143.3b). Such collaterals are known as a
";torilyonly theipsilateral leg,soitmaybeadvisabletoinjectCM
"Palmashunt",andthesecanalso besurgicallycreatedifathrom,
stemicallythroughanarmveininorderto examine bothsidesof businadeepervein resists
dissolution.Youshouldbecarefulnot
-e pelvic venous system. If one side has become occluded,
tomistakeaninguinalLNwithphysiologicallyhypodense hilarfat
~
aterals maydevelop( )viatheprepubic networkof veins ("hilarfatsign""
inFig.143.3c)fora partiallythrombosedvein.
Fig. 143.2d
In order to avoid pulmonary embolism
in cases of thrombosis (173) of the
inferiorvenacava (80inFig. 144.2),the
patient must be immobilized until the
thrombus has either become endo
thelialized or has responded totherapy
and dissolved. Occasionally, marked
collateral circulation develops via the
lumbarveins (121).
Depending upon the individual patient

andthesizeofthe thrombus,the vessel
may be surgically explored and thrombectomyperformed.
If thromboses are
recurrent,anarterio-venous shunt may
beindicatedinorder toavoidrelapse.
Thesuccess ofaparticulartherapymay
also be checked with venography or
color-Doppler ultrasound.
Fig, 144.1 b
EnlargedLymph Nodes
ThedensityofLNsisapproximately50HU,whichcorrespondstothat of
muscle.LNswithdiametersbelow1cmaregenerally considered
normal. Sizes between 1.0 and 1.5 cm are considered borderline, and those that
exceed 1.5 cm are abnormally enlarged. Sites of
predilectionfor enlargedLNsaretheretrocrural,mesenteric( ),interaortico-
caval( ,\),andpara-aorticspaces(cf.p. 103).
Figure144.3illustrates thecase of
a patient with chronic lymphatic
leukemia.
Itisessential tobefamiliarwiththe
major pathsoflymphaticdrainage.
The drainage of the gonads, for
example, is directly to LNs at renal
hilar level. LN metastases ( " in
Fig. 144,4)from atesticulartumor
will be found in para-aortic nodes
Fig.144.3
aroundtherenal vesselsbutnotin
the iliac nodes, as would be expected
with primary carcinomas of
the urinary bladder, uterus, or
prostate.
Conglomerate LN masses (6/7)

surrounding the aorta (89) and its
majorbranchessuch as the celiac
trunk (97) are a typical finding in
cases of non-Hodgkin lymphoma
(Fig. 144,5).
Fig. 144.5a
Fig. 144.4
Fig.144.5b
Skeletal Pathology Pelvic Bones
.ormal Anatomy
--eimportanceofexaminingbonewindowsduring abdominal CTshasalreadybeen stressedon
page103.Themarrowspaceoftheiliac
-es(58)and thesacrum(62)is normallyhomogeneous.and thesurfacesofthe
sacroiliacjointsshould besmoothandregular
I g. 145.1).
tastases
:-erotic bone metastases (7), for example from a carcinoma of (Fig. 145.3a) only
after they have reached considerable size.
-e prostate, arenot always as evidentasinFigure 145.2a and can be much more
accurately detected on bone windows
-.ayvaryinsizeand degreeofcalcification.Evensmalland poorly (Fig.145.3c).
Thiscaseshowsametastatic diseaseofthe right
:~'in
ed
metastasesshouldnot beoverlooked( inFig.145.2b).
ilium(58)thathasdestroyedthetrabeculaeandmuchofthe cor-'
eycannotroutinely berecognized onsoft-tissuewindows. tex.The
erosionextendstothesacroiliacjoint. Seethefollowing
_-cmetastases(7), whichcanbeseen onsoft-tissuewindows pagesfor
furtherimagesofthispatient.
a
28
35b
��
62
=:. 145.3a Fig. 145.3b Fig. 145.30
The mechanical integrity of a bone is suspect if any process

involves its structure. Adjacent joint involvement must also be
determined.MPRs(seep.13)at various angles,forexamplesagittal
or coronal, provide additional information. If necessary, 3D
reconstructions can alsobe performed.
In the case shown on the previous page (see Fig. 145.3), the
.--
question of stability is easily answered: the coronal MPR

(Fig.146.1a)showsthatthetrabeculae oftherightiliac bone have
Fig. 146.1a
The3Dreconstructionofthis pelvis(Fig.146.2) does notadd any

more information,because itshowsonlythe corticaldisruption
(" )asseenfrom thelateral perspective.
The degree to which the trabeculae and marrow have been

destroyed cannot be seen in this reconstruction because the
attenuation level was set to detect the cortical bone, and the
deeper trabeculae aretherefore covered.
Fig. 146.2
been completely destroyed for approximately 10 cm ( ). The

lesionextendsfrom the acetabulumto themid-pointofthe sacroiliacjoint
and hasalsodestroyedmuchofthecortex.In several
areas, the cortex is disrupted (+ ). If you compare the bilateral
sagittal reconstructions(Figs. 146.1band1c),itis easytoseethat
there is acute risk of fracture.
Fig. 146.1b
'tJ'
�
Skeletal Anatomy Pelvic Bones
f ractures
30newindowsshouldof course
ce used for the detection of
. actures: hairline fractures and
minimal dislocations cannot
usually be recognized on softtissue
windows.
; is also essential to give infornanon
on the precise fractu re
s' e and position of possible
Fig. 147.1a Fig. 147.1b
.agmentsforpreoperative plan~
ing
.
ln
thecase ontheright,the
zacture (187) of the femoral
-ead (66a) is seen both in the
axial plane (Fig. 147.1) and in
me sagittal reconstruction
(Fig. 147.2) (ct. p. 13),
.Il Fig.147.3a.Becareful nottomistakethe acetabularsuture( ,,)withthe realischial

fracture (')1
-orjointssuch asthe hip joint, it may be helpful to makean MPR inthe obliqu e plane
(Figs.147.3).The angle of reconstruction is shown
35b
Fig. 147.2a
Fig. 147.3a
Fig, 147.3b
58
66
~---~
Fig. 147.3c
-notner exampleofafracturethatmay bemistakenforasutureis

lustratedin Figure147.4.Thesutures (,,) are bilaterallysymmetric,
the fractures arenot.
nthis case, several fragmentsofbone (.. ..) are seen at the

rightiliopubicjunction,buttheright acetabulum isintact. Notealso
me asymmetry in the Imagewhichiscaused bydifferences inthe
evels of the femoral heads. The patient had left acetabular
:ysplasia (cf. figures on p 148).
Fig. 147.4
Fragmentsarenotalwaysasobviouslydisplacednoristhefracturegap( )aswide
asinthecaseillustratedinFigure148.1.
Lookforfinebreaks( )anddiscreteirregularities(..)inthecorticaloutlinein
ordernottomissa fractureorasmallfragment
(Fig. 148.2).
Fig. 148.1
Femoral Head Necrosis and Dysplasia of the HipJoint
A fracture through the femoral head or even direct trauma to the
hip joint may interrupt the blood supply to the head via the
acetabular artery (see alsoFigures 147.1 and 147.2). Necrosis of
the head makes it appear poorly defined ( ) as seen in Figure
148.3a and causes shortening of the leg.An image obtained 2cm
Fig. 148.2
more craniallyshows thatapseudoarthosishas developed inassociation

with the right acetabular dysplasia (Fig. 148.3b). A
3Dreconstruction givesanoverview,butdoesnotprovideasmuch
detail as a series of coro nal MPRs (Fig. 148.5b with orientation in
Fig. 148.5a).
Fig. 148.3a
Fig. 148.3b
MPRs are often used for diagnostic purposes and in planning

surgeryofcomplexfractures. They contribute valuableadditional
informationtothe conventional axialimages.SCTproduces particularlyaccurate
MPRimagesbecausedisruptivestepartitactscan
be avoided ifthepatientis abletocooperate byholdinghisorher
breath.
3D reconstructions. such as the one in Figure 142.4, yield

impressiveimages, butarehelpfulonlyforspecificproblemssuch
as plastic surgery. The amount of
time and costnecessarytoacquire

and reconstruct 3Dimagesarein
most cases also veryhigh.
Test Yourself!
"neimagesand questionsonthispagewill againhelp youtocheckon

howmuchyouhaveunderstood;the questionsbecomecontinuallymoredifficulttoanswer.
Ityoualwaysrememberthe basicrulesof CT reading, youwill avoidjumpingtothewrong
conclusions.
J<Jn'tlook uptheanswers too soonI
Ihat abnormalitycanyou
Identify as many organs

dentify in Figure 149.1?
andblood vessels asposameasmanybloodves
sible in Figure 149.2.

sels as you can!
Look for any abnormalities.
What anatomic variation
"Doyousmoke?"What
or abnormality do you
abnormalities did you

recognizeinFigure 149.3?
find inFigure149.4?
Be sureyouhaven't missed
anything.
emmID
mrmma
Often abnormalities are

hepatic lesion in Figure
is easy to recognize the
not limited to one organ.
What do yourrecognize in
Figure 149.6?
149.5.Whatisyour DO?
Test Yourself!
Thefollowing questionsmay seemtricky,but you should

beabletoanswermostofthemifyougobythe"rulesofthebook."
Describe the hepatic lesion

in Figure 150.1.
What steps did you take
to arrive at your differentialdiagnosis?
Howwould
youproceed toverifyit?
omf:!lEI
Whichofthe twoimagelevelsontheright wouldyou

select for performing densitometric measurements
of thekidney lesion? Why?
A patient is admitted for

staging of a malignant
melanoma(Figure 150.4).
How far advanced is the
lesion? What else would
you do to obtain more
information?
Are the changes

in Figure 150.2
"normal," or do
yoususpect that
they are pathologic
findings?
Atraumapatient could not

be scanned in the prone
position.What doyoususpect
in Figure 150.5, and
what wouldyoudoto obtain
moreinformation?
Test Yourself!
! problem for those
oho alreadyhavesome
ine (Figure 151.1).
"'()Wlongdidittakeyou R
find two pathologic
-terat ons and diag
-use themaccurately?
!, least three differential
: agnoses shouldbecon
-dered for Figure 151.3.
Which one is the most
�ely?
at doyou suscect
isthe casein
I gure 151.5?
Hhat additional
. formation do
u need?
151
Do you see anything
abnormal in Figure
151.2? If so, what

would you call it (the
small figure indicates
a structure filled with
liquid)?
In Figure 151.4, there are

also several possibilities to
explain the obvious alteration.
Areyou abletofind
all possible lesions in an
image of this kind?
This image (Figure

151 .6) may contain
several puzzles. Again,
list the most likely
diagnosesand thenask
yourself what further
information you need.
Skeletal Pathology
Theoccipital condyles atthe base oftheskull articulate with thefirst

vertebra,theatlas
(50a),whichisthe onlyvertebrato lackabody. Thedens(50b)ofthe axisprotrudes
upward intotheatlasand isheldinplacebythetransverse iigament (*) (Figs. 152.1 and
152.2). Thisiigamentmay betornbyawhiplashinjuryduringroad tra~accidents.
The width of the space (

~)
between the anterior arch of the atlas (* * in Figs. 152,1
and152.2)and thedens isalso measured, asinconventional x-ray images (Fig. 152.3).
Inadultsit shouldnot exceed 2mm;in children, 4mm.Thevertebral artery passesthrough
thetransverse foramen (88).
Fig. 152.1 Fig. 152.2
Cervical Spine
(4 :< 2mm
Fig. 152.3
The images below show normal anatomyat the level of the atlas(Fig. 152.4) and the
body of the axis (Fig. 152.5). The cartilageof an
intervertebral disc (50e in Fig. 152.6) will appear more homogen eous and hypoden
sethan the typical pattern of trabeculae.
Fig. 152.6b Fig. 152.5b Fig. 152.4b
Skeletal Pathology
Cervical Disc Protrusion

Adisc protrusion (prolapsofthe
nucleuspulposus)isdemonstratedoptimallyinCTsectionsafter
myelography(CM intheSAS). The
spinal cord is virtually isodense to CSF in unenhanced images,
making it difficult to define thecontoursof thecord . After a myelogram,
the CSF(132)willappearhyperdensetothecord (54) as
well as to a disc.
Cervical Spine
Normally, the CSF uniformly surrounds the cervical cord

(Fig.153.1).Adiscprolapse (7). protruding intotheCSFspacecan
be seen because it is hypodense to the opacified CSF. The gap
betweenthe cord (54)andvertebralbody(50)isfilledin.Didyou
recognize the pyriform fossa (172), the hyoid bone (159), the
thyroid cartilage (169), and the cricoidcartilage (167)7
-disc prol apse will beseen even more clearl y inanMR image. The intense CSF space
(..) infro nt ofthecord .The axial T, -weighted
32gittalT,-weighted imagein Figure153.3ashowstheextentof image
(Fig.153.3b)showsthatthe prolapse extendstotheleft
:otrusionsattwodiskspaces.Thedisk protrudesintothehyper-
andhascausedstenosisoftheintervertebralforamen( ).
ica
l
Spine Fractures~rv-'sespeciallyimportanttolookforfracturesofthecervical spine
ed.Figures 153.4athroughcshowacoronal MPRinwhichthe
_or tornligaments aftertrauma(ref.p.152) sothat damageto rightoccipitalcondyle
(160)isfractured(188)butthedens(50b)
-e cordis avoidedifthe patient needstobemovedor transport-isstillin normal
position.
Fig. 153.4b Fig. 153.4c

Skeletal Pathology Thoracic Spine
Thethoracic vertebraearticulatewitheachotherattheirsuperior and

inferiorarticularfacets(SOd) andwiththe ribs(51)at theinferior
andsuperior costal facetsandthe transverseprocesses (SOl).
Figure154.1showsanormalthoracicimage:thecontoursofthecortical
boneare smooth andthetrabeculaehavea homogeneous pattern.
Fig. 154.1a
Fig. 154.2a
Fig. 154.3a
Fig. 154.1b
Fig. 154.2b
Fig. 154.3b
Fractures of the Thoracic Spine

Displaced fragments are identified by virtue of the fracture lines
(187) and are best seen on bone windows. In Figure 154.2,

boththe transverse process (SOl) andthecorrespondingrib (51)
are fractured. In complex fracture dislocations (Figs. 154.3),
torsion orshearing may causecompression orcomplete dislocation
of the spine as a whole (Figs. 154.3a, e). The axial image in
Figure154.3ashowstwovertebrae(,,)atonelevel; the topogram
in154.3bindicatesthe position ofthesagittalMPRshownin
Figure154.3e. The MPRgives amoreprecise pictureofthefracture
and the fragments than the oblique anterior and oblique
posterior3Dviews inFigures154.3cand d.
Skeletal Pathology
-�e transverse processes (50!) of the lumbar vertebrae are

xcastonany called costal processes.Lumbarvertebrae havemuch
-gerbodies(50)than thoracic vertebrae,andtheangleoftheir
ctervertebraljoints(50d)issmaller.Lumbarspinous processesdo
-0 extend as far caudally as the thoracic ones. Images of the
-oonallumbar spine usuallyshow well-definedcorticalboneand
50
31
22
9g,155.1b Fig. 155.2b

)egenerativechangeofthe vertebraecan be seeninthefacetjoints(50d)(Fig.
155.3).Thereisincreasedsubchondralsclerosis
50e
Lumbar Spine
homogeneoustrabeculae.Atthelevelofa disk (Fig.155.2),the

hypodense cartilage (50e) may seem irregularly surrounded by
bone:thisisanoblique partialvolumeeffectinwhichpartsofan
adjacentbody(50)are included withthe disk.TheligamentaIlava
(*) extend from one lamina to the next and can sometimes be
seen behindthe cord(Fig. 155.1a).
~_22Fig. 155.3b
..,,,)indicativeofarthrosis ofthe joint.
.urnbar Disk Prolapse

-s with cervical disk protrusions (see p. 153), it is important to
: tabllshwhetherthenucleuspulposushas protrudedthroughthe
rosterior longitudinal ligament. This ligament is applied to the
: teriorbordersof thevertebral bodiesanddisks.Disk material
win-dows (Fig.155.4a) because of their high density, but are dearty

seen on bone windows (Fig. 155.4b). A T2-weighted MR image
(Fig.155.5)showstheextentofthe prolapse:the abnormaldisk
(+) isthinner,isdesiccated (shows alowersignallevel[darker]),
-t has penetrated the posterior longitudinal ligam ent and

.ecome detach ed from the disk is referred to as a sequestration
**). This can narrow the spinal canal or a lateral recess (Fig.
�55.4). Thesestructures arenot well demonstrated on soft-tissue
and the extruded
material ( ,,) impinges
onthetheca.
Skeletal Pathology Lumbar Spine
Fractures
In conventionalx-ravs, itis oftendifficultto seethefractureofalumbartransverse
process (501) ifthe fragmentisnotoronly minimallydislocated
(187).InCTsections, however,afracture can be clearly demonstrated (Fig. 156.1).
Figure 156.2 illustratesa case in which
the spinous process (50c) wasfractured.An arthrosis may developifa
fracturehasinvolvedajoint (Fig . 156.3).There are fractu res of
boththesuperior and the inferior articularprocesses (50d). <,
~~50C/ V~187-187
, ,""~~'t)~22
6 22
b .Fig.
156.1b Fig. 156.2b Fig . 156.3b
Older fractures donot show awel l-defined fracture line (1 87). Increased sclerosis
and new bone often efface thefracture lineora pseudarthrosis
may develop. Inthe case shown in Figure 156.4, the fractured pedicle has developed
a pseudarthosis. In conventional x-rays,
increased sclerosis following a fracture is often difficultto differentiate from
that resulting fro m degenerative disease.
I
Fig.156.4a Fig. 156.4b

-umors and Metastases

at all bone lesions originate within the bone. Malignant tumors of paravertebral
tissues can also
'Vadethe bones.
=igure 157.1 shows an osteolytic lesion (,, ) in the body of a lumbar vertebra in a
patient with
:arcinoma of the cervix. On soft-tissue windows (Fig. 157.2), there is a
paravertebral metastasis (7)
A't1ichhassurroundedthebifurcationofthecommoniliac artery(114/5)and
hasinfiltratedtheright
anterolateral aspect of the vertebral bod y.
DRsinthecoronai(Figs.157.3aandb) andsagittal(Figs.157.4aandb)planesshowthe
extenttowhichthebonehas been eroded
"nd that there is risk of fracture.As inFigure146.2.the3Dreconstructions (Figs.
157.5aand b) clearlyshow thelesionfromanterior
'-dlateral perspectives,butnotthedegreetowhichtheinteriortrabeculaehavebeen
destroyed.
I
158
Infection
Abscessesinthe paravertebralsofttissuesorinfectiveorinflammatoryarthritides
(181)inthe smalljoints ofthe spine may leadto
diskitis which ultimately destroys the intervertebral disk (Fig.
158.1). An advanced abscess can be detected on soft-tissue windows
(Fig.158.1a)asan areaofheterogeneousdensitysurroun-
Fig. 158.1a
I
I
Methodsof Stabilization
If therapeutic measures such as chemotherapy,
antibiotics, and/or surgery have
been effective in the treatment of a metastasis
orinfection,itis possible tostabilizethe
spine by inserting bone prosthetic
material(Fig. 158.2a, b).
The choice of material depends upon the
size ofthe defect and upon otherindividual
factors. In follow-up examinations, these

materials may cause considerable image
artifacts because of their high relative
density.
Fig. 158.2a
Space foradditional notes:
ded bya hyperdense enhancing rimrepresenting reactive hyperperfusion.

On bonewindows(Fig.158.1c),onlysmall remnantsof
bonebelongingtothevertebralbodyare present andsomeare displaced.
Fig. 158.2b
Lower Extremity
iheanteriormusclesofthethigh includethe sartoriusmuscle(38),

andthe four componentsofthe quadriceps muscle (39).Themost
anterioristherectusfemoris (39a), and lateraltothisisthevastus
.ateralis (39b).The vastusintermedius (39c) andvastusmedialis
(39d) form the anterolateral borders of the adductor canal. This
contains the superficial femoral artery and vein (119/120). The
adductor muscles comprise the superficially located gracilis
muscle (38a) and the adductor longus (44a), brevis (44b), and
magnus(44c)muscles.Thepectineusmuscle(37)isonly seen in
memostcaudal images ofthe pelvis.
Normal Anatomy of the Thigh
The posteriormusclesofthethigh extendthehipjointandflexthe

knee joint.The groupconsistsofthelong andshortheadsofthe
biceps femoris muscle (188) and the semitendinosus (38b) and
semimembranosus muscles (38c). In the proximal third of the
thigh (Fig.159.1),the hypointense tendon ofthe biceps muscleis
adjacenttothe sciaticnerve (162).Inthe distalthirdof thethigh
(Fig.159,3),the medialpopliteal nerve (162a),whichsuppliesthe
dorsal muscles,can be seenseparatefromthelateral popliteal
nerve (162b). Note the close relationship ofthe profundafemoris
arteryand vein(119a/120a)tothefemur(66)andthesuperficial
posi-tion ofthe longsaphenous vein (211a).
Fig. 159,lb
Fig.159.2b
Fig.159.3b
=jg. 159.3a
Lower Extremity
The popliteal artery (209) and vein (21 0), formed cranial to the
jointline,aredemonstrated atthelevelofthe patella (191) Inthe
fossabetweenthe femoral condyles (66d)(Fig.160.1).Thetibial
nerve (162a) liesdirectly posteriortothe vein,whereasthefibular
(peroneal)nerve (162b) lies more laterally.Themedial(202a)and
lateral (202b)headsofthegastrocnemiusmuscle and the plantaris
muscle (203a) can be seen posterior to the femoral condyles.
Thelongsaphenousvein(211a) lies mediallyinthesubcutaneous
Normal Anatomy of the Knee
fat covering the sartorius muscle (38), and the biceps femoris
muscle (188) lies laterally.
Onthesectionjust caudaltothepatella(Fig.160.2),thepatellar
tendon (191c)canbeidentified,posteriortowhichistheinfrapatellar
fat pad (2). Between the femoral condyles lie the cruciate
ligaments(191b).Transversesections such asthesearefrequently
combined with coronal and sagittal MPRs (see also the images
ofa fractureon p. 167).
Fig. 160.1c Fig. 160.2c

Lower Extremity
Themusclesofthelowerlegare separated intofour compartments

uythe interosseusmembrane betweenthetibia (189)andthefibula
(190) and by the lateral and posterior intermuscular septa

Figs. 161.1 to161.3).Theanterior compartment containsthetibiatis
anterior muscle (199), the extensor hallucis longus muscle
(200a)andthedigitorumlongusmuscle(200b)nexttothe anteriortibial
vessels(212).
Thelateral compartment containsthe peroneuslongus(201 a)and
orevls (201b)musclesnexttotheperoneal vessels (214).In slencerindividualswhohave
nofatbetween the muscles,these ves-
Normal Anatomy of the Lower Leg
sels andthe peroneal nerveareonly poorly defined(Fig.161.2).

Theflexormusclescan beseparatedintoasuperficial andadeep
group. The superficial group encompasses the gastrocnemius
muscle with medial (202a) and lateral (202b) heads, the soleus
muscle (203), andtheplantaris muscle(203a). Thedeepgroup
includes the tibialis posterior (205), the flexor natlucis longus
(206a), and the flexor digitorum longus muscles (206b). These
musclesareparticularlywelldefined inthe distalthirdofthe lower
leg (Fig.161.3).Thetibilalisposteriorvessels (213)andthetibial
nerve (162a)pass betweenthetwoflexor groups.
Fig. 161.1b
Fig. 161 .2b
Fig. 161.3b
,
Lower Extremity
The following three pages

show the normal anatomy of
thefootonthe bonewindow.
You will find the numbers to
the legendsinthe backfoldout.
The imageseries beginsina

plane throughthetalus (192)
just distal to the talocrural
joint. Figure 162.1 shows the
distal end of the fibula or
lateral malleolus (190a) as
well as the upper part of the
calcaneous (193). In Figure
162.2, the sustentaculumtali
(193a) of the caicaneous is
Normal Anatomy of the Foot

Fig. 162.1bFig. 162.1 a
Fig.162.3a Fig. 162.3b
seen.
More distally,additional metatarsal

bones are seen: the
navicular bone (194) has
begun to appear in Figure
162.2. but its joint with the

talus is better assessed in
Figure 162.3. The articular
surfaces are normallysmooth
and the synovial space betweenthe
bones isofuniform
I width.
Compare these images of a

normal foot with the images
of fractures on pages 164
and 165.
The Achilles tendon (215),

which arises from both the
soleus (203) and the gastrocnemius
(202) muscles, is
seen posteriorly on these
images.
Lower Extremity Normal Anatomy of the Foot
The cuboid bone (195) is

seenonthelateral marginof
the foot, between the
calcaneus (193) and the
navicular (194). The lateral
(196c). intermediate (196b),
andmedial (196a) cuneiform
bones lie anterior to the
navicular (Fig. 163.1).
The transition to the metatarsal

bones (197) is not
always well defined, because
the plane of the tarsometatarsal
joints is at an oblique
angle to the sections (partial
volume effects (Fig. 163.2).
Thejoints can bemore clearly
assessed in mulliplanar
reconstructions that take
this obliquity into account
(cf. Fig, 164.1).
The lumbrical and quadratus

plantae muscles and the
short flexor muscles of the
foot (208) are seen just
below the arch of the meta
tarsal bones. These muscles
Iare onlypoorly definedinCT

images (Fig. 163.3).
-.163.3a Fig. 163.3b

Lower Extremity Normal Anatomy of the Foot
Multiplanar reconstructions
are very valuable for visualizing
fractures of the foot.
Thelateral digital radiograph
in Figure 164.1a Indicates
theangleof theimage plane,
paralleltothelong axisof the
foot,seen inFigure164.1b.This reconstructedimage
extends from the lateral (190a) and medial (189a)
malleoli (atthelower edgeof the image) throughthe
talus (192) and the navicular (1 94) to the three
cuneiform bones (196a-c). Two of the metatarsal
bones (197)are includedin the section. Notethatthe
surfaces of the jointsare smooth andevenly spaced.
Thesagittalimagein Figure164.2b wasreconstructed
slightlymore laterally(see position in164.2a)so
that the cuboid bone (1 95) is included. The short
flexor muscles (208) and the plantar ligaments are
seenbelowthearchof thefoot. TheAchillestendon Fig.164.1b Fig.164.1c
(21 5) isseen posteriorly.

I Fig.164.2a Fig.164.2b Fig.164.2c
Diagnosis of Fractures
Typicalsignsofafracturecan beseenintheoriginalaxialplane(Fig. 164.3a):
irregularitiesinthecortical outline( ), displacedfragments(
)andafractureline( )in thecalcaneous.The MPRinthecoronal plane(indicatedin
Fig.164.3b)showsthatnot onlyis
the calcaneous( l\)fractured,butthereisa hairline fractureof the
talus(..)involvingtheanklejoint(Fig.164.3c).
Lower Extremity Pathology
Fracturesof the footmayinitially escapedetectioninconventional

x-raysifthereisnomajordisplacementof bonefragments. Ifthe
foot remains painful, a follow-up x-ray may show the fracture
because fine hairline fractures can be seen when filled with
hemorrhage. As an alternative, CT would show discrete fracture
lines (187),asforexample ofthe talus(192) inFigure165.1.
In chronic fractures, the displaced fragment (*) has usually become

rounded off(Fig.165.2).Inthisexample.itis obviousthat
Fractures of the Foot
there were actually twofragments because a second fracture line

('" )is seennexttothemain one (187).
It isoftendifficulttotreatcomminutedfracturesofthecalcaneus
(193), incurred for example during a fall (Fig. 165.3), because
therearemanysmalldisplaced fragments.Astabilereconstruction
of the arch of the foot may not be possible, resulting in a long
periodof sick leave.
-.165.1b Fig.165.2b Fig.165.3b

Lower Extremity Pathology Pelvis and Upper Leg
Infections
Theassessmentoffracturesoflongbones is generallythedomain
of conventional radiology. But CT examinations are helpful for
locating displaced fragments and in the preoperative planning of
comminuted fractures. Infections, however, are more accurately
imaged by CT than by conventional radiographs because bone
destruction ismore readilyseen on bone windows (Fig.166.1c)
and soft-tissue involvement (178) is documented on soft-tissue
windows (Fig. 166.1a).This patient had septic arthritisofthe left
hipjointwithinvolvementofthe acetabulum(60)andfemoralhead
(66a). I
The abscess appears more clearly after contrast enhancement
(cf.Figs.166.2aand 166.2c).Theincreased vascularityofthewall
and the fluid within the abscess (181) are well demarcated from
surrounding fat(2). Adjacent muscles (38, 39,44)arenolonger
individually definedbecause ofedema (compare with the rightleg).
Gas (4) has been produced and is loculated in the adjacent tissues.
Fig. 166.1c Fig. 166.2c

Lower Extremity Pathology Knee Joint
Fractures
.afracture involvesthe kneejoint,itisparticularlyimportanttoreducethe

fragmentsaccuratelyto avoidjointsurfaceincongruitiesthat
mightlead toarthosis.Inthecasebelow,axial
sectionsclearlyshowthelateraldisplacementofalarge fragment(,,)ofthetibia
Figs.167.1aand167.1b).ThecoronalMPR(Fig.167.2b.withlevelshownin167.2a)illustratesho
w muchofthetibial plateauis affected.
Fig. 167.1b Fig. 167.2b Fig. 167.3b
"he3Dreconstructionseenfroma posterolateral projection

(Fig.167.3a)isnotveryhelpful,buttheview fromcranial(Fig.167.3b)gives
;goodimpressionofthetibialplateau andfractureline becausethefemoralcondyleshavebeen
excluded.
Checklist Skeletal System: Fracture Diagnosis
..... Step-offordiscontinuityof thecortex(evidenceoffracture)?

..... Articularinvolvementofafracture(riskofsecondarydegenerative changes)?
..... Stability on weight-bearing?
Spine:e.g.�3-columnmodel accordingtoDenis(C-spine);A-B-Cclassificationaccordingto
Magerl (T-spine)
..... Simplefractureorcomminutedfracture,
extentofdisplacementofthefracturefragments(surgicalplanning)?
..... Age of thefracture?
� Acute => \ ragg ed and sharply demarcated fracture clefts

� Old => sclerotic rim, callus formation
Riskof pseudoarthrosiswith persistent fracturecleft?
..... Traumaticorpathologicfracture(underlyingbonetumor)?
Interventional CT
Itis notalwayspossibletodeterminethe natureofalesionfrom

CTappearanceanddensitometryalone. Inthesecases,needle biopsies
may becarried outunderultrasoundorCTguidance.The

patient'splateletcountandcoagulation st~
'
us
mustbe checked andInformed
consent obtained.
InFigure 161.1,amassinthe caudate

lobe (*) of the liver (122) is being
biopsied. The close proximity of the
hepaticarteryand portalvein(98/102)
andinferiorvena cava (80) leaveonlya
narrow path fortheneedletoapproach
from the rightside(Fig.168.1a).Firstly
the section on which the lesion
appears largest is determined. The
skin is cleaned and anesthetized with
local anaestheic.
The needleisthen insertedthroughthe

liver parenchyma toward the lesion.
Slight changes inanglemay be necessary
(Figs. 168.1b,168.1c,and168.1d).
Distances can also be calculated
duringtheprocedure,as seenin Figure
168.1b. After biopsy has been completed,
an Image is acquired to detect
any hemorrhage. If a pneumothorax
occurred followinglungbiopsy, expiratoryimagesofthethoraxare
acquired
tocheckforatension pneumothorax.
Fig. 168.1a Fig. 168.1b
Fig. 168.1c Fig. 168.1d
Ifthere isa retroperitoneallesion close

tothe spinalcolumn,abiopsymaybe
carried out In the prone position. The
orientation inFigure168.2 istherefore
unusualand one must be carefulnotto
confuse left with right, but the procedure
isidentical.
After selectionoftheoptimallevel(lar
Fig. 168.2a Fig.168.2b
gest diameter of the lesion),andafter

skincleaning andlocalanesthesia,the
needle is inserted (Fig. 168.2b) and

the biopsy taken. The material should
be promptly prepared forcytology and
histology.
Thesizeand extentofacutaneousfistulacanoften
be more clearly assessedIf
CM isinstilledthroughatube(Fig.
168.3). In this example, the hip had
becomeinfected andan abscessfilled
thejoint after prostheticsurgery.
Fig. 168.3a
Fig. 168.3b
Skull:
Bleeding ?
Metastases?
Fracture ?
Infratentorial:
3 / 3 / Supratentorial:
8/ 8/ -
1,5
1,5
130
130
130
260
260
260
H 30
H 30
H 30
caudocranial
ca udoc ranial
250 / 40
90 / 35
1500 / 450
60 / 1,5 60
Mid-facial bones:
Coronal, fracture ?
Axial
Axial to coronal reconstruction
2/3 / 1
2 / 3 /2
2 / 3 /1
1,5
1,5
1,5
130
130
130
80
80
80
H 70
H 70
cra niocaudal
craniocaudal
1500 /450
1500 /450
and 350 140
Petmus bone: 1 / 1,5/ 0,5 1,5 1,5 130 135 H 80 craniocaudal 1500 /450
C1 and C2 multiple trauma: 2 / 2/2 130 170 8 50 craniocaudal 350 / 40
1500 /450
Extremities (fracture?): 2/2/ 1,5 130 70 B 80 craniocaudal 350 /450
1500 / 450
Neck:
Thyroid carcinoma ?
Staqing of the pulmonary apex
Thorax!abdomen: Staging ?
Liver arterial + thorax
Liver portovenous + pelvis
Gynecologic + other tumors of
the lesser pelvis
5 /5 /5
517,5 / 4
8 / 12 / 8
5/8/5
1,5
1,5
1,6
0,8
0,8
0,8
0,8
130
130
110
130
100
140
140
140
B 50
B40
B 40
B40
cra niocaudal
craniocaudal
cran iocaudal
cra nic caudal
350 /40
2000 / � 300
350 / 40
350 / 40
350 /40
70/2,0
120 / 3,0 -5,0
100 / 2,5
25 -40
8T
post 90
60
Vena cava: Thrombosi s 8 / 12/8 1,5 0,8 130 140 B40 craniocaudal 350/40 120 / 2,5
2x 50ml bipedal
90 -100
Pulmonary embolism: 2 / 4 /2 2 0,8 130 100 B 40 craniocaudal 350/ 40
2000 /�300
120 / 3,0 -4,0 8T
A.asc.
Lung: Soft tissue window
Pulmonary window
5 / 8/5 1,5 0,8 130 110 B40 caudocranial 350 /40
2000 / -300
100 / 2,0 BT
Liver series: hemangioma ?
(dynamic at the same level)
8/ 0/ -1,0 130 140 B 40 craniocaudal 350 /40 130 /2,0
Adrenal glands:
Unenhanced
Arterial
Portovenous
Late venous
Tumor ?
5
/~
5
/4
5
/
~5
/4
5
/
~
5/
4
5/~
5/
4
1,5
1,5
1,5
1,5
0,8
0,8
0,8
0,8
130
130
130
130
120
140
140
140
840
840
B 40
B40
caudocranial 350 /40 80�100 /2 ,0 arterial:
BT
Venous:
about 90
Perfusion: He ad� unenhanced Basis 3 / 3 /Neurocran.
8 /8 / 1,5
130
11 0
260
106
H 30
H 30
caudocranial 250 / 40 +
90 /3 5
IV eM-conce ntration 300 �370 10/0 / 350/
40 40 /8
Bone: Densitc metrv t-solne 10 / 0 / 80
81 S 80 craniocaudal 350/ 40
Dental: 1 / 1,5 /0 ,5 1,5 0,8 130 90 H 70 cramocaudal 1500 / 450
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Examination Protocols for 4-slice Spiral CT
Thesearethe examination protocolsfora 4-slicespiralCT,

established fortheSiemensSensation 4.For
clinical questions not suitableforspiral techniquein
our experience, the expression "seq." is listed
instead of the table feed per rotation ("feed/rot.").
The collimation ("coiL") must be selected by the
examinerinadvance,whileinmultislice scannersthe
reconstructedeffective sectionthickness("ST")can
be selected later. The reconstruction interval ("RI")
statesthe distance between thesectionsforthe subsequent
reconstruction from the three-dimensional
data set. The term kernel refers to the edge algorithmofthemanufacturer:
H = Head,U= Uitrahigh,
B= body.
For the application of the contrast medium ("GM"),

the amount in ml of a concentration of 300-350 g
iodine/ml andtheflowrateofthe injector("flow")in
ml/second isstated.In addition,theterm "delay"
states in seconds when the gantry begins its data
acquisitionafterthebeginning oftheinjectionofcontrast
medium.Theterm "BT"referstobolustracking,
anautomated software program.Forinstance,an ROI
is placed over the descending aorta, and when the
intravascular density exceeds a preselected level
(e.q., the bolusof contrast medium isarriving),data
acquisition beginsautomatically(seepage 176). In
modernunits,the examinerselectsthecraniocaudal
spanofthe bodyregionto beexamined,the desired
examinationtime,the rotationspeed, and thesection
collimation. The scanner then optimizes table feed
and pitch on its own.
Seq. = Sequential data acquisition

Feed/rot. =Tablefeedper rotation
Coli. = Section collimation
ST = Section thickness
RI =Reconstruction interval
CM =Contrast medium
Flow =CM volume/ time
Delay =Delay after the beginning of the
CM injection
BT =Automatic bolustracking
Pitch = Pitch
kV =Tube voltage
mAs = Tube current
Kern = Kernel, edgealgorithm
ST = Sinusthrombosis
MPR = Multiplanarreconstruction
MIP = Maximum intensityprojection
RTP = Renaltransplant
HCC = Hepatocellular carcinoma
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00 0 0 0
C\l(\jC\lC\J (\J.... .,......
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x x x x x
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t-t-
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0000
ci 0 cl
Th e pitchwas caiculated according to theformula:
Feed / rotation
Pitch =
Collimation ( e.g. 4 x 2,5 =10)

Chest -
Bronchialcarcinoma Arterial 4x5
Liver BCI
Abdomen NPL, lymphoma Arterial 4 x 2,5

Venous 4 x 2,5
Stomach: Hydro CT Arterial 4 x 2,5
I(stomach filled with H?O Venous 4x25
Pancreas/k idn eys 1NPL Unenhanced 4x5

Arterial 4 x 1
Venous 4x25
Adrenal glands 1Adenoma Unenhanced 4 x 2,5

Arterial 4 x l
After 3 min 4 x 2,5
Optional After 10 min 4x25
3-phase liver 1Hemangioma, HCC Unenhanced 4 x 2,5

Arterial 4 xl
Venous + 4 x 2,5
ocnonat oetvis
Chest-abdomen INPL, lymphoma Arterial 4x5

Venous 4x 5
Lunq
Pelvis IVascular state (RTP) Unenhanced 4 x 2,5
DVT Venous 4 x 2,5
Heart
Triaaer 4 x 1
CTAngio
Cranial vessels Arterial 4x1
Cervical vessels Arterial 4 x 1
Abdominal. vessels Arterial 4 x 1
Iliofemoral vessels Arterial 4 x 2,5
C spine Fracture Unenhanced 4xl

L spine Fracture Unenhanced 4 xl
Myelo-CT Unenhanced 4xl
Only for MPR

Aorta IDissection Arterial 4 x 2,5
Aneurysm
7
7
5
5
5
5
7
3
5
5
3
5
5
5
3
5
7
7
7
5
5
1 25
1,25
1,5
1,25
3
2
2
2
1,25
3
30
12,5
12,5
12,5
12 5
25
4
12,5
12,5
4
12,5
12 5
12,5
4
12,5
25
25
12,5
12,5
15
5
5,5
6
15
5,5
2,5
2,5
15
1,5
1,25
1,25
1,25
1 25
1,25
1
1 25
1,25
1
1,25
1 25
1,25
1
1,25
1,25
1,25
1,25
1,25
038
1,25
1,38
1,5
1,5
1,38
0,6
0,6
1,5
7
7
5
5
5
5
7
3
5
5
3
5
5
5
3
5
7
7
7
5
5
08
1
1
1
1,5
2
2
2
1
1,5
0,5
0,5
0,5
0,5
05
0,5
0,5
05
0,5
0,5
0,5
05
0,5
0,5
0,5
0,5
0,5
0,5
0,5
05
0,5
0,5
0,5
0,5
0,75
0,75
0,75
0,5
120
120
120
120
120
120
120
120
120
120
120
120
120
120
120
120
120
120
120
120
140
120
120
120
120
120
120
120
90
155
155
155
155
155
165
155
155
165
155
155
155
165
155
155
155
155
155
400
90
100
130
130
150
330
330
130
B 30
B 60
B 30
B 30
B 30
B 30
B30
B 30
B 30
B 30
B 30
B 30
B 30
B 30
B 30
B 30
B 30
B 30
B 70
B 30
B30
B 30
H 10
B 20
B 20
B 20
B 70
B 20
B 20
B 20
B30
350/ 50
2000/ -300
200 /40
350 / 50
350 / 50
350/ 50
350/50
350/ 50
350 /50 I
350 /50
350/50
350/ 50 I
350/ 50
350/ 50
250 / 40
350/ 50
350/ 50
350 /50
2000/ -500
350 /50
110 /35
350/ 50
350 / 50
350 / 50
3000 / 600
3000/ 600
3000 /600
3000/ 600 1
350/ 50 I
I Coronal/
MPR/MIP
MIPNRT
MIPNRT
MIPNRT
MIPN RT
MPR
MPR
Saaittal
Coronal
80-100 / 3,0
100-120 / 3,0
50-75
25-30 1100-120 / 3,0
50-75
25-30
I 30-40 1100-120 / 3,0

IBT
I 30-40 1100-120/ 3,0

(BT)
25-30 1100-120 / 3,0

(BT)
25-30 I 120 / 3,0

(BT)
100 (BT
140 / 3,0
120 / 30
18 (BT)
75 /3,0
15 (BT)
110 / 3,5
20-25
100-120/ 3,0
25-30
150 / 2,5-3,0
120 (BT) 1120 -140 / 3,0
Han d/Feet IFracture Detail

diagnosis
Knee IBone
Soh tissues
Dental Before implantation
Unenhanced
Unenhanced
Unenhanced
2 x 0,5
4 x l
4 x 1
0,5
1,25
5
1
1
4
2,7
1
1
0,68
0,3
1
5
0,8
0,75
0,75
0,75
120
120
120
100
90
70
U 90
B 60
B 30
H 60
3000/ 600
sagittal
3000/ 600
350 / 50
3000 I 600 I Dertal evaluation
Bone 4 x 2,5 10 Sea. 0,5 80 125 S 80 1800 I 500 .L Bone oensn
110 / 35 Perfusion Bleeding lnfratentortal 4 x 1 4 Seq. 4 0,75 120 300 H 40
Supratentorial 2x8 8 Seq. 8 0,75 120 260 H 40 80/ 35
Stroke Arterial 2x5 10 Multiscan 10 1 80 250 H 30 120 / 35 I Perfusion stare I
4 I 80 / 5,0
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'" '"
Infralentorial 16xO,75
Supratentorial 16x 1,5
lnfratentorial 16 x O,751 4 1 5 1 0,42 1 4 I 0,75 1 120 1 260 1 H 40 1 110 / 35 1 1
60 1 50 /2,0
IVenous vesse ls (SVT)
Supratentorial 16 x 1,5
Skull: ST I I 35
Orbita [Tumor 16 x O,751 4 5 0,42 4 0,75 120 100 H 30 250 /50 1 45 1 75 /2,0
1 0,7 H 30 250 /50 Coronal
Fracture I 116 x o,75 2 5 0,42 2 0,75 120 100 H 60 3000 / 600
1 07 H 60 3000 / 600 ICoronal
Paranasal Sinusitis, nasal pOIY PoSiSl 116 XO,75 4 5 0,42 4 0,75 120 80 H 40 1500 /
50
sinuses
Onlv for coronal MPR 1 07 H 60 1500 /50 Coronal
Facial bones Tumor 16 x O,75 3 5 0,42 3 0,75 120 100 H 30 350 /50 ,I 45 I 75 /2,0
Fracture 1 07 H 60 3000 /600 Coronal
Petrous bone IFracture 16 x O,75 0,75 5 0,42 0,5 1 120 120 U 90 3000 /600 Coronal
OnIv for film documentation 1 1 U 90 3000 /600
Neck Lymphoma, tumor 16 x 1,5 5 24 1 5 0,75 120 150 B 30 250 /50 1 1 45 1 100 / 3,0
Chest Fibrosis, fungi IUnenhanCedl 16 X1,5 5 30 1,25 5 0,5 120 100 B 40 350 /50
HR 16 xO,75 1 13,5 1,1 3 0,7 0,75 120 90 B 80 2000 / -soolcoronai
5 5 B 30 350 / 50
NPL, lymphoma I Arterial 116x 1,5 6 30 1,25 6 0,5 120 100 B 40 350 /50 1 125-301 80
/2,0
(BT)
Pulmonary emboli 1 Arterial 116 xO,751 5 15
1
1
,25 I 0~7I 0,5
I
120
I
100 IB 30 I 350 / 50 Ic oronall 20-25 I100-120 /
1 Sagittal (BT) 3,5
Organ Indications Coli ST Feed I Pitch RI Sec I Voltage Current Kern Window
ReconDelay
CM I flow
[mm] [mm] rotation [mm) rotation (kV) (mAs) with CM struct. [sec) [ml/ml/sec]
Bronchial carcinoma Arterial 16x 1,5 6 30 1,25 6 0,5 120 100 840
350 /50 80
8C):Lunawindow 6 6 870
2000 /-500
Arterial 16 x O,7, 5 12 1 5 120 140 830
20-25
NPL, lymphoma 0,5 200/40 1 100-120 / 3,5

Venous 16 x l ,S 5 24 1 5 0,5 120 120 830 350 /50 Coronal 50-75
Stomach : Hydra CT Arterial 16 x 0,7 5 12 1 3 0,5 120 140 830 350150 25-30 1 100-
120 /3,5
I(stomach filledwith H 01 Venous 16 x O7 3 12 1 3 05 120 140 830 350 /50 50-75
Pancreas! INPL Un enhanced 16 x 1,5 5 24 1 5 0,5 120 120 8 30 350 /50
kidneys Arterial 16xO ,75 5 12 1 5 0,5 120 140 830 350 / 50 1 Coronal 1 20-25 1
100-120 /3,5
I ~Venous 16 x 1 5 5 24 1 5 05 120 120 8 30 350 / 50 50-75
Adrena/ glands 1Adenoma Uncnhanced 16 x 1,5 5 24 1 5 0,5 120 120 8 30 350 / 50
Arterial 16xO,75 1 12 1 0,7 0,5 120 140 8 30 350 /50 1 Corona l 1 30-40 I 100-120 /
3,0
After 3 min 16 x 1,5 3 24 1 3 0,5 120 120 8 30 350 /50 (BT)
Optional After 10 min 16 x 1 5 5 24 1 5 05 120 120 B 30 350 / 50
3 �phase liver IHemangioma, HCC Unenhanced 16 x l ,S 5 24 1 5 0,5 120 120 B 30
350 / 50
Arterial 16 x O,75 5 12 1 5 0,5 120 140 B 30 250 / 40 1 Caranal 120+25 I 100-120
13,5
Venous + 16 x l ,S 5 24 1 5 0,5 120 120 8 30 350 /50 50-75
ootional oelvis
Chest-AbdomenINPL, lymphoma Arterial 16 xl ,S 5 24 1 5 0,5 120 140 B30 350 /50 25
30 120 / 3,0 1 1 -1Venous 16 x 1,5 5 24 1 5 0,5 120 140 B30 350 /50 (BT)
Luna 7 7 8 70 2000 / -500
Pelvis 1Vascular state (RT P) Unenhanced 16 x O,75 5 24 1 5 0,5 120 140 B30 350 /
50
DVT Venous 16 xl ,S 3 12 1 3 0,5 120 140 B 30 350 /50 10018T' 120 13,0
IHeart Triaaer 16xO,75 1 34 029 0 7 042 120 550 8 30 350 /50 MPRIMIP 100 130
ICT Angio Cranial vessels Arterial 16 x O,75 1 15 1,25 0,7 0,5 140 100 H 2O 110 /
35 MIPNRT 18 (BTl 75 /3,5
Cervical vessels Arterial 16 x O, 75 1 12 1 0,7 0,5 120 120 830 350 150 MIPIVRT 15
(8T) 1001 4,0
Abdominal vessels Arterial 16 x O,75 1 15 1,25 0,7 0,5 120 130 830 350 /50 MIPIVRT
20-25 1DO-l20I3,Ch3,5
Pelvic-leg vessels Arterial 16 x l ,S 2 24 1 1,5 0,5 120 130 830 350 /50 MIPIVRT
25-30 150 / 3,0-3,5 IC spine 1 Fracture Arterial 16xO ,75 1 12 1 0,7 075 120 150
870 3000 /600 MPR ILspine IFracture Un enhanced 16 x O,75 1 6 0,5 0,7 0,75 120 330
860 3000 /600 MPR
Myela-CT Unenhanced 16 x O,75 3 6 0,5 3 0,75 120 330 860 3000 1600
Only far MPR Unenhanced 1 0,7 8 60 3000 /600 MPR
IAorta 1Dissection 16 x 1,5 2 21 0,88 1 0,5 120 130 830 350/50 MPRIMIP 120 (BT) I
120 / 3,0
Aneurysm Arterial VRT
Hand!Feet I Fracture -1Unenhanced 116 xo,75/0,75 I 6,8 10,57 1 0,5 I 0,75 I 120 1
120 I U 90 13000/ 6001 MPRIDetail diagnosis
IKnee IBone Unenhanced 16~-1--13~5--f~f3-OY-O,75120 120 B 60 3000T 600 1 MPR
Soft tissues 5 5 8 30 350 /50
Dental Before implantation Unenhanced 16 x 0,7E 0,75 6 0,5 0,5 0,75 120 80 H 60
3000 / 600 108nl1l1ovalualiJI1
Bone 2 x 5,0 10 Sea. 0,5 80 125 S80 1800 / 500180nedens!!)
Perfu sion 81eeding Infratentorial 16 x 0,7E 4 5,1 0,43 4 1 120 260 H 40 11 0 / 35
Supratentorial 16 X 1,5 8 10,2 0,42 8 1 120 260 H 40 80 /35
Strake I Arterial 16 x i.s 12 Multiscan 1 1 80 209 H 30 120 I 35 IPertusion state I
4 I 40 /8,0
~
......
-...J
W
Radiation Dose/Cancer Risk
Thephysicalradiationdose0(energyabsorbedperunit mass)is An
evenbettercomparisonofthe biologiceffectcan beachieved
expressedinGray(Gy),usedforanytypeofradiation andalsoin withtheeffectivedoseE,
whichisthesumofthedosesdetheradiationtherapyof
malignanttumors.Ithasto be distinliveredtotheindividualorgan.
Thiseffectivedose,which weighs
guishedfromthe equivalencedose Hexpressedin Sievert(Sv), therelativeinherent
sensitivities,is alsoexpressedin Sievert(Sv)
whichrepresentsthephysicalradiationdosemultipliedbyaproorMillisievert(
mSv).
portionalityfactorthatconsiderstheuniqueradiationsensitivityof
Furthermore,thepatient'sageatthe timeofradiationexposure
a particular tissue: Epithelium, mucosa of the respiratory and must be included in
a rational assessment of the radiation risk
gastrointestinaltractandothertissueswithahighrateofcell
sincethelatencyperiodofaradiation-induced tumorcan beratdivision
(e.g., blood forming cells of the bone marrow) are more her long (decades).Table
174,1 liststherisk
coefficientsofdiffesensitivetoionizingradiationthantissuewithdormantcelldivision.
rentorgansfollowingalow-dose exposuretotheentire body.
, Tab. 174.1 Age-dependency ofcancermortality caused byionizingradiation

Estimated risk factors in (% / Sv) for men/ women (italics)
Age at exposure Total Leukemia Lung/Respiratory MDT Chest Others
5 years 12,8/ 15,3 1,1 /0,8 0.2 / 0,5 3,6/ 6,6 1,3 7,8 / 6,3
15 years 11 ,4/ /5,7 1,1 /0,7 0,5 / 0,7 3,7 / 6,5 3,0 6,1 / 4,8
25 years 9,2 /11,8 0,4 / 0,3 1,2/ 1,3 3,9/ 6,8 0,5 3,7/ 2,9
45 years 6,0 / 5,4 1,1 / 0,7 3,5 / 2,8 0,2/ 0,7 0,2 1,2/ 1,0
65 years 4,8/ 3,9 1,9/ 1,5 2,7/ 1,7 0,1/ 0,5 0,1/ 0,2
85 years 1,1 /0,9 1,0/0,7 0,2 / 0,1 -/ 0, 04 -/
Mean 7,7 / 8,1 1,1 / 0,8 1,9/ 1,5 1,7 /2,9 0,7 3,0 / 2,2
This implies that the risk of radiation-induced malignancies exists that protective
effects predominateinthe low-dose range
markedly decreaseswithincreasingageatthetimeof exposure. throughactivationof
protectivecellfactors(DNAreparaseand
But notonlythepatient'sage,butalsotheamountofthe individuothers).
Fora betterassessmentoftherisk associatedwith the
al doseandthelengthofthetimeintervalsplayadecisive role.As medicalapplicationof
ionizingradiation,itis revealingtoconsider
aruleofthumb,thelowertheindividual doseandthelongerthe the dailyexposurefromnatural
backgroundradiation:Themajor
intervalsbetweenseveral radiationexposures,thelowertheriskof
componentofthenaturalradiationexposurecomesfromradon,a
asubsequentlyinduced neoplasm. Amongotherfactors,this noblegas,which
getsintotheairthroughthe building materialsof
dependsonthe capabilityofthecellular nucleito repairDNA
housesandapartments.Usingastrictlytheoreticalcalculation,
breakswiththe helpofrepairenzymesaslongasthereparative radonandits decayproducts
mayinduce5 to 10% ofallbronchial
capacityisnotexceededbyhighindividualdoses.Evidenceeven
carcinomas.Incontrast,medicalapplicationofionizingradiation
"only" induces less than
Radiation Source effektive %of 1.5%of all malignancies.

annual dose annual exposure
The average annual radia
Inhalation ofradoninapartments -1,4 33,3 %
tion exposure of about
Terrestric radiation -0,4 9,5 %
2.4 mSv has to be put in

Cosmic radiation -0,3 7,1 %
perspective with the man
Incorporation of radioactive isotopes -0,3 7,1 %
made radiation exposure of
Subtotal of natural radiation exposure -2,4 mSv 57,0%
1.8 mSv (Table 174.2).

Applicationofionizing radiationinmedicine -1,5 35,7%
AccidentoftheChernobyl nuclear reactor (Europe) -0,02 0,5 %
Fall-outfrom nuclear weapon tests -0,01 0,2%
Operation ofnuclearreactors -0,01 0,2 %
Occupational radiation exposure -0,01 0,2%
Subtotal of man-made radiation exposure -1,8 mSv 43,0%
Total annual radiation exposure in the

Federal Republic of Germany -4,2 mSv 100,0%
Tab.174.2 Relativecontributionof severalradiationsourcestothetotalannual

exposure(Europe).
Radiation Dose/Dose Reduction
In general, "hard"x-raysusedforconvenfionalradiographyofthe witha particular

examination.Becauseof thetissue-dependent
chestarescatteredandabsorbedlessin humantissuethan"soft" variabilityofthe
riskfactorsandthedifferentcharacteristicsofthe
x-raysusedfor mammography.Thescatterradiationalsoconvariousmodalities
usedindiagnosticradiology,theorgandoses
tributes totheabsorption and consequentlyto the riskassociated arequitediverse
(Table 175.1).
Examination Organ / tissue Organ dose Effective dose E

Conventionalradiology,chest Lung, breast 0,3 mSv 0,2mSv
Conventional radiology,skull Red bonemarrow 4,0mSv 0,2 mSv
Radiology,C-spine Thyroid gland 4,5mSv 2,0 mSv
Radiology,T-spine Breast, lung 14,0 mSv 5,0 mSv
Radiology,L-spine Redbonemarrow 1,0 mSv 0,4 mSv
DSAofthe heart Lung 20,0mSv 10,0 mSv
DSAofthekidneys Red bonemarrow 30,0mSv 10,0 mSv
Fluoroscopy,UGI series Red bonemarrow 17,0 mSv 6,0 mSv
Fluoroscopy, BE Red bone marrow 3,0 mSv 3,0 mSv
Cranial CT Red bone marrow 5,0mSv 2,0 mSv
Chest CT Lung,chest 20,0 mSv 10,0 mSv
Abdomen CT Red bone marrow 10,0 mSv 7,0 mSv
Tab.175.1 Radiationdoseofdifferentradiographicexaminations.
Togetherwitharteriographyandfluoroscopy. CTisresponsiblefor
tionsperformedannuallyrevealsthatCTis responsibleforabout
arather highradiationexposurein diagnosticradiology.Multiplyathirdofthe
collectivetotal dose.ThedifferentCTexaminations
ingtheindividualvalueswiththenumberofthedifferent examina-deliverthefollowing
averageradiationdoses (Table175.2).
Typeofspiral CT Emotion1row Emotion2rows Emotion6rows Sensation10rows

Sensation16rows
Head 4,2/ 4,5 mSv 4,2/ 4,5 mSv 4,4/ 4,7 mSv 4,6/ 4,8 mSv 4,5/4,8 mSv
Chest 3,9/ 5.0 mSv 2,6/ 3,3 mSv 3,2/ 4,1 mSv 3,0/ 3,8 mSv 2,8/3,6 mSv
Abdomen/ 3,7/ 8,8 mSv 3,7/ 5,6 mSv 6,3/ 9,6 mSv 6,0/ 9,0 mSv 6,5/ 10,0 mSv
pelvis
Tab.175.2Comparisonof dosesinmillisievert(mSv)fordifferentCT unitsofSiemensMedical

Systems.Valuesformen/ women (italics).
Thisdoesnot considertheeffectsofthesectionthickness(see Theradiation

exposureisslightlyhigherin unitswithcompact
page 9-11): Asa ruleofthumb,the thinnerthesectionthickness geometryandshorterfocus
distance(Emotion 6).
the higherthe radiation dose (Table175.3).
Preselected
collimation
Somatomplus 4
\1 row
Somatom Volume Zoom
4 row
Emotion
6 row
Sensation
16 row
4 x 5,0 mm
4 x 2,5mm
4 x 1,0mm
4,5
4,3(3mm)
4,9
4,6
5,1
6,1
6,8
7,2
8,4
4,2 (1,5 mm)
4,7 (0,75 mm)
Tab, 175,3 Dosis increase per 100 mAs forthin section collimation.
Radiation Dose/Dose Reduction in CT
Comparison with air traveling is often used in public health

discussions: On a long, high altitude transatlantic flight, cosmic
rays cause a not irrelevant additional exposure. On a flight from
Europetothe West Coast ofthe U.S.A.,this can easily beinthe
rangeofcertain CTexaminations. Othercalculationsofthe cancer
risk compare conventional chest radiography with cigarette
smoking:Asingle chest radiographis believed to have the same
cancerrisk assmoking sevencigarettes.Itshouldbe keptinmind,
however,that all mathematicallymodelsinclude several aspects
andcofactorsthat are elusive toexact statistically calculations.
While these comparisons put into perspective an excessive
concernofthe potentialriskofmedicalradiographicexaminations,
Automatic Bolus Tracking (BT)

For CT,severaltechniquesare availableforreducingthe radiation
dose to the patient. Especially CT requiring optimal contrast
enhancementinthe vessels,e.g.,aboveallCTangiography,should
be performed with automatic bolus tracking toavoidunnecessary
duplications because of inadequate intravascular contrast enhancement.
This softwaresolution offersthe examinerthe possibilitytoplacea
regionofinterest (ROI)( t:2 )just before oratthe
beginningofthetarget region,e.g.,the lumenofthe descending
aorta(Fig. 176.1a).After selecting acertain thresholdvalue forthe
Fig. 176.1aPositionof ROI,e.g.,

overthedescending aorta.
In addition, theamountofcontrast medium neededtoachievethe

same contrast enhancement can be reduced: sterile physiologic
NaCI solution is injected from a second syringe of the injection
pump (see front cover flap) at the same flow rate immediately
following the injection of contrast medium in order to push the
contrastmedium fasterandatahigherconcentrationthroughthe
brachial veinstowardtheheartandthroughthe pulmonarycirculation.
theyshouldnot bemisusedtobelittletheradiationrisk.Toavoid
unnecessary risks to the general population, it has become
established policytoavoiddispensable radiation exposurein conventionalradiology
and CT,andto take advantageofanypossible
reduction ofradiation exposure topatients.
It is for the same reason that pulsed fluoroscopy has replaced

continuous fluoroscopy for upper GI series, enteroclysis and
barium enema: The examiner selects between several pulse
sequences with 1, 2, 4, and 8 images per second. The resultant
dose reductionisconsiderable.Thenext pages describe solutions
suitablefordosereductionthat are especially applicableforCT.
density of the aorta, e.g., 100 HU, the unit measures the density
automaticallyat the preselected site everysecond afterthe beginning
oftheintravenous injectionofcontrastmedium,usually
throughthe cubital vein.
Data acquisition (the actualscanning process)beginsas soonas
thedensityin the aortic lumenexceeds the thresholdvalue,i.e.,
exactlywhen the bolus ofthe contrast mediumhasreached the
selected target region after passage through the pulmonary
circulation (Fig. 176.1 b).
Density
[HU]
100 ---------------
-
80
60
50
40
20
o
Start t [sec]
Fig.176,1bAutomaticdelayofdataacquisition untilarrival
oftheCMbolusatthetarget region.
Taking Advantageof thePitch

By usingafastertable feed toincreasethepitch,afewsingle-slice
CT units can reduce the effective patient dose by spreading the
spiralofdataacquisition (seeFig.8.4).
The softwareof the multislicetechnologyusesacompensatory
mechanism thatautomaticallyincreasesthetube
currentwhenevertheexaminerincreasesthepitch
-effectivelydelivering the
sametotaldoseforthe examination.Fora16-sliceCT,the examinercanselectthe
craniocaudalspanof the z-axis, thecollimation
and scantime for the desired volume -and thesoftware determines
the optimaltablefeedor, respectively,pitch,andthetube
current.
Dose Reduction
ReducedTube CurrentforThin PatientsandChildren

Asa ruleofthumb,thenoisedoublesforeachS-cmincreaseinthe
markedlylowerradiationdoseis adequate.In olderunitslacking
patient's diameter. Dose and noise are exponentially related: instant
radiationmeasurementsat the levelof the detectorsand
Doublingthedosereducesthenoise onlybyafactorof1.4. To modulation ofthe tubecurrent
(seebelow),thedose canberepenetrate
thin patientsandchildrenforasatisfactoryimage,a ducedbyloweringthe
preselectedtubecurrent(mAs).
Automatic Tube Current Modulation
The idea underlying this feature of the combined applications to

reduceexposure(CARE)isassimpleasitiseffective:itisbased on
the assumptionthatthe cross-sectionsofmost bodyregionsare
oval ratherthan circular.With the patientsupine, theAP diameter
(t ) ofthe chest,abdomen,and pelvisis definitelyshorterthan the

transverse diameter ( -). Consequently, the tube current is
higherinlateral angulationthan inanterioror posterior angulation
(Fig.177.1).After each semi-circulation,e.g., everylS0 degrees,
the same dosis is needed since the additive attenuation of the
x-ravsis directionallyneutral (Fig.177.2).Itis theessenceofthe
automatedmodulation thatthe tubecurrent measurestheattenuation
profileforeachtube angulation and calculatesthe corresponding
minimaldosestilladequatetoachieveanoptimalimageafter FIg. 1771
'
.
anadditional l SD-degree angulation.As aresult,the tube current
ismodulatedwithal SD-degree delay. Plotting thetubecurrent
alongthetimeaxisdisplaysacurve reminiscentofasinus curvewith
the amplitudestendingtodecreasefrom theshouldertothe legs(Fig.
177.3)andwithmaximaat thelevelofthe shoulderandpelvis.
Tube current f\
[mAs]
v
Scan direction
Fig. 177.2 -, Fig. 177.3
Compared with units delivering the same image quality without
Effects ofautomatictubecurrent modulation
tube current modulation, the dose-reducing potential ot this

techniqueisimpressive,withthehighestreductioncoincidingwith Bodyregion
Dosereduction
Skull 14-26 %
areas of considerable radiation absorption, e.g., at the shoulder

andpelvis(Table177.1). Shoulderregion 22-56 %
Chest 19-27 %
Inaddition,thelifeexpectancyofthex-raytubeisextended and Abdomen 11-24 %

image artifacts induced by the arms placed along the patient's Pelvis 21-30 %
body,asfrequentlyfoundintraumaand ICUpatients,are reduced. Extremities 33-41 %
Tab.177.1
f\ f\
r-. r-; i-Gv r-. c?,~r'CJ
v v
v
V V
CT Angiography
Bringing out the information contained in images of CT anqioIntracranialArteries

graphy requires a review using different perspectives (MIP = The individual axial
sections are usually supplemented with
maximumintensity projection),differentreconstructionplanes displaysusing
MIPand,e.g.,sagittalMPRaswellasVRT (see
(MPR = multiplanar reconstruction) or a tbree-dirnensional
above).Agooddiagnosticevaluationofthecerebralarteriescanbe
visualization (VRT = volume rendering technique). All these reo achieved with thin
overlapping section reconstructions using a
construction imagesusedtobe degraded bythe resolutionof0.5
sectionthicknessof1.0to1.25mmandareconstructioninterval
mmperpixellengthinthetransverseplane(xy-plane)anda (RI)of0.6to0.8 mm.
markedlyhigherresolution alongthe bodyaxis(z-axls), resulting
Toachieveahighvascularcontrast,thedataacquisition hasto be
inan anisotropicvoxel(see page8)with differentlengths.The exactlytimedto
encompassthefirstpassageofcontrastmedium
advancesofthemultidetectorCT (MOCT)withtheintroductionof
throughthecircleofWilliswithastart-delayof20 seconds,if
thets-sucetechnologyintheyear2001permittheinclusionof an possiblebefore
contrastmediumhasreachedthe venoussinus.If
adequatelylarge bodyvolumewithalmostisotropicvoxelsin the
bolustracking(BT)isnotavailable,atestbolusshouldbeinjected
sub-millimeterrangewithjustifiable scantimes.Thefollowing todeterminethe
individualcirculationtime. Thefollowing examipagespresentrecommended
examinationprotocolsfor different
nationprotocolscanserveasguidesforthevisualizationofthe
vascularregionsincludingseveral representative images. circle ofWillis:
CT system Call. ST Feed Pitch RI Sec.! Volt. Current Kernel Window Delay CM
[mm] [mm] I Rot. [mm] Rot. [KV] [mAs] [W/C] [sec] [ml/ ml/sec)
1 row 1 1,0 2 2,0 0,5 0,8 110 120 H30 250/40 18-22 120/3,0
4rows 4xl 1,25 5 1,25 1,0 0,5 120 90 H10 110/35 18 /BT 75/3,0
16rows 16xO,75 1,0 15 1,25 0,7 0,5 120 100 H20 110/35 18/BT 75/3,5
Thesubsequently reconstructedindividualsectionscandisplay the vessels asseenfrom

belowwithtransverse MIP(Fig,178.1b),fromthefrontwithcoronal MIP(Fig,178.1c)or
from thesidewithsagittalMIP(Fig.179.1a).Thefirsttwoplanesclearlyshowthemajor
branchesoftheanterior (91a)and middle (91b)cerebral arteries.
Figure 178.1dshowsa 3D VRTof anotherpatientwithan aneurysm( ")arisingfrom

the anterior communicating artery.Thejunctionofbothvertebral arteries(88)toformthe
basal artery (90) and posterior cerebral arteries (91c) is clearly identified.
Furthermore,
thebranchesoftheanteriorcirculation are identifiable:branches ofthe medialcerebral
artery(91b)andthepericallosalarteries (93).
Fig. 178.1 a
Fig.178.1b Fig. 178.1c Fig. 178.1d

CT Angiography
Venous Sinus
Tovisualizethevenouschannels,the FOVhastobeextendedto thesagittal cranialvault(Fig.
179.1a)andthestartdelayincreasedto
about100 seconds. Craniocaudalsectionsare recommendedfor both typesofCTA(arterial
andvenous cerebralvessels).Thesagittal
plane (Fig.179.1b)preferablyshowscontrastinthe veinofGalen (100)and venouschannels
(101a. 102a).
C1 system Call. 51 Feed Pitch RI Sec.! Vall Current Kernel Window Delay CM
[mm] [mm] I Rot. [mm] Rot. [KV] [mAs] [W/C] [sec] [mil mllsec]
4 rows 4 x1 1,25 5 1,0 -1,5 0,8 0,5 120 90 soft 110/35 100 120 /3 ,0
Fig. 179.1a Fig.179.1b

CT Angiography
Carotid Arteries
Importantcriteriaforstenoticprocessesofthecarotid arteries are
the exactdetermination oftheseverityof the stenosis.Itisforthis
reasonthattheexamination iscarried outwith thinsections,for
instance,4x1mmor16x0.75 mm,allowing directplanimetric
quantificationof the stenosiswith adequate accuracy on individu
alaxialsections.Furthermore,thesagittal andcoronal MIP(0.7
1.0mm RI with50%sectional overlapping)shows nomajorstep

deformity(see page8).
Thebestreconstruction with maximalcontrastofthecarotidartery
isachievedwith minimalcontrast inthejugularvein.Therefore,
theuseofa bolustracking program isstronglyadvised.Ifapreceding
Dopplerexamination suggestsavascularprocess atthebifurcation,
transverse images in caudocranial direction are recommended.
For processes near the cranial base, a craniocaudal
direction can be superior.VRToften proveshelpfultogetoriented
(Figs. 180.1 d, e). I
CT system
Coli. 5T Feed Piteh RI sec.! VotL Current Kernel W/ C Delay CM
[mm] [mm] / Rot. [mm] Rot. [KV] [mAs] [HU] [sec] [ml/ mJlsee]
1row 2,0 4,0 2 1,0 0,8 110 120 B30 350/50 12-15 100/3,0
4 rows 4 xll,5 5,5 1,38 1,0 0,5 120 100 B20 350/ 50 15 /BT 110 / 3,5
16rows 16xO,75 1,0 12,0 1 0,7 0,5 120 120 B30 350I 50 15 I BT 100 I 4,0
Fig. 180,la
Fig. 180.1 b Fig. 180.1e
Figure180.1 showsthelateraltopogram (a)forpositioning ofthe

FOVaswellaslateral(b)andanterior(c)imagesofanMIPandan
imageinVRT(d),showingnormalfindings.Incontrast,Figure180.2shows
imagesofsagittalMIPandVTRthatreveal twoindentations
ofthevascularcontrastcolumn atthetypicalsiteforacarotidstenosis:TheleftACI (85a)
showsashortsegmentofasevereluminalnarrowingjustdistaltothebifurcation("
)afteraprecedingbulbarstenosis( ~
)oftheACC(85) attheoriginoftheACE(85b).
Fig. 180.1d
Fig.180.2a Fig.180.2b
CT Angiography
182
Aorta
The CT angiography of the aorta must above all exclude the respiration-induced
motion artifacts that primarily affect the
aneurysms, isthmus stenoses and possible dissection, and if regions close to the
diaphragm since involuntary respiratory
present,visualize their extent. Automatic bolus tracking (BT: ROI excursionsare
morelikelyattheendofthe examination.Furtherplaced
over the aorta) is advisable, especially in patients with more, caudocranial
imaging avoids the initial venous inflow of
cardiacdiseaseswhohavevariable pulmonarycirculationtimesof contrast medium through
the subclavian and brachiocephalic
contrastmedium.Imagingincaudocranialdirectioncanminimize
veinsandanysuperimpositiononthesupra-aorticarteries.
CT system Call. ST Feed Pitch RI SecJ Volt. Current Kernel WI C Delay CM
[mm] [mm] I Rot. [mm] Rot. [KV] [mAs] [HU] [sec.] [mIl ml/sec]
1row unenhanced 8,0 12,0 1,5 8,0 0,8 110 80 B30 350/ 40
1 row CM 3,0 6,0 2,0 I ,D 0,8 110 100 B30 350/50 BT 120 /3 ,0
4rows 4x2,5 3,0 15,5 1,5 1,5 0,5 120 130 B20 350 /50 BT 130/3 ,0
16rows 16xl,5 2,0 21,0 0,9 1,0 0,5 120 130 B30 350/50 201BT 120 /3,0
As reconstructionimages,MIPandMPR(Figs.182.2,182.3)often
allowan exactquantification ofthevascularpathology as survey
imagesinVRT (Fig 182.4).asseenhereasan exampleofaninfrarenalaneurysmoftheabdominal
aorta:The aneurysmaldilatation
(171) begins immediately distal to the renal arteries (110) and

sparesboththe superiormesentericartery (106) andiliac arteries
(113).
For planning any vascular surgery, it is crucial to know any
involvementof visceralandperipheralarteriesand anypossible
associateddissection.Furthermore.thelevelofthe aorticoriginof
the artery of Adamkiewicz, which supplies the thoracospinal
transition ofthespinal cord, mustbeconsideredforaneurysmsof
the descendingthoracic aorta.
Fig. 182.1 a b
Fig. 182.2 Fig. 182.3 Fig. 182.4

CT Angiography
Frequently,acinemode reviewofthecoronalorsagittal MPRimageson

asecond monitorcanbe helpfulforaquickand convincing
determinationofthe extentofa pathologicfinding,asshown here
ina caseofthrombosis within an abdominalaorticaneurysm.The
cinemodeof thecoronal MPR imagesrevealsnot onlyaninfrarenalthrombus(
173) along theleftlateral wall(Fig.183.1)but
alsoasecondthrombusfurther cranial alongtheright lateral wall

attheleveloftheoriginoftherightrenalartery (110) (Fig.
183.1). which is still pertused (Fig. 183.3). The individual axial
sections (Figs.183.4,5) allow aplanimetricquantificationofthe
stenosis,andthesagittal MPR(Fig. 183.6)aclear separation from
the originoftheanterior mesentericartery (106).
Fig. 183.1 Fig.183.2 Fig. 183.3
Fig.183.4 Fig. 183.5
Of course, the benefit of the three-dimensional visualization by

meansofVRT also dependsontheviewingangle.While viewing
from an angle (Fig 183.7) can underestimate the extent of the
thrombus and easily mistake it for a soft plaque, the extent is
much better appreciated if seen from different viewing angles
Fig. 183.6
(Figs. 183.8and183.9).Thefinalimages illustrate theeffectofa

careful elimination of interfering superimposed osseous structures.
Becauseof itshighdensity,thelumbarspinedominates the
initialimage (Fig.183.8).andthevascular findingsareonly fully
appreciated aftersubtractionofthe lumbarspine (Fig. 183.9).
Fig. 183.7 Fig.183.8 Fig. 183.9

CT Angiography (Heart)
Coronary Arteries
Visualizingthe coronaryarteriesrepresentsa special challenge should

beginjustabovethetrachealbifurcationandextentto the
sincethecardiaccontractionsrequireshortscantimesandexact diaphragm(Fig.184.1).
ObliqueMIPsparalleltothemainbranch
timing. Foracardiacrateexceeding70 beatsperminute,apreoftheleft

coronaryarteryas wellasspecialprojectionsof theRIVA
medicationwithabeta blockershouldbe consideredunlessconandRCA(

right coronaryartery)and3Dviews areobtained.The
traindicatedin viewof otherclinicalfindings.Eventheshortest applicationofcontrast

mediumshouldbebiphasicwithaninitial
rotationtimesavailable(0.42secondsfora16-sliceCTatthetime bolusof40mlataflowrateof4
mils and, after a pause of 10
of thepublicationofthisbook)requireadditionalEKGtriggering.To
seconds,asecondbolusof80mlata flowrateof2 mils. Bolus
achieveadiagnosticimagequality,thewidthoftheFOVshouldbe trackingshouldbeusedwith
theROIovertheascendingaorta.
reduced to the cardiac size and the craniocaudal acquisition
CT system Coli. ST Feed Pitch RI Sec.! Volt. Current Kernel WI C Delay CM

[mm] [mm] I Rot. [mm] Rot. [KV] [mAs] [HU] [sec.] [ml I rnl/sec]
4 rows 4 x1,0 1,5 0,37 0,5 0,5 120 250 -400 B20 500 I 80 BT 120 I 2-4
16rows 16xO,75 3,6 0,3 0,5 0,42 120 400 heart 450 I 60 BT 120/2-4
ThefollowingimagescompareaCT(Fig.184.2a)oftheleftcoro(
Fig. 184.2b).Figures184.3aand 184.3bshowthesamecomnaryartery
(77a),including circumflexbranch(77C) and RIVA parisonfortherightcoronaryartery
(77d).
(77b), with coronary angiography taken as gold standard
89a
77a/
Fig. 184.1
Fig.184.2a Fig.184.2b
Fig.184.4 Fig.184.3a Fig.184.3b

CT Angiography (Heart)
Screeningfor CoronaryArteryCalcifications
Compared with angiographic imaging of the coronary arteries illustrated on the
preceding pages, a slightly thicker section can be
selectedwhenscreening thecoronaryarteriesfor
calcifications.Administrationofcontrastmediumisnot necessary,andthe unenhanced
imagesareobtainedincraniocaudaldirection.
CT system Coli. ST Feed Pitch RI SecJ Volt. Current Kernel WI C

[mm) [mm) I Rot. [mm) Rot. [KY] [mAs) [HUj
4 rows 4 x 2,5 3 1,5 0,37 0,5 0,5 120 133 heartmedium 370 /50
16 rows 16 xl ,S 3 3,6 0,3 0,5 0,42 120 130 heart 450/ 60
89a
90
,0
Fig.185.1
Fig. 185.2 Fig. 185.3
Quantificationof coronarycalcifications(174)isbestcarriedout onadedicated

separateworkstation butcanalsobedoneona normal
work station after postprocessing (Fig. 185.1-3). In thiscase. however,the
unenhanced imagesare usedtoobtain,forinstance,the
Agatston score [43, 44),which correlateswiththeriskof coronaryartery disease.
Agatston Score
Clinical Relevance Recommended Therapy
o
(negative,noidentifiablecalcific Negativepredictive valuefor coronary None
plaques) artery disease 90-95%
1-10 (minimal identifiable calcific Stenosis unlikely General guidelines
forprevention
plaque burden)
11 -100 (definite.at leastmild calcific Coronaryarterydiseasepossible
Furtherevaluationindicated
plaque burden)
101 -400 (definite,atleastmoderate Coronaryarterydiseasewithstenosis
Instituterisktactor moditicationand
calcificplaque burden) possible specific cardiac therapy
> 400 (extensive calcificplaque Highprobabilityforcoronaryarterydisease Stress EKG
isindicated-depending on
burden) withstenosis possible outcomefollowedbycoronaryangiogram
Usefulsuggestionsandrecommendationstorconducnnoscreeningforcoronaryarterycalcificat
ionscanbefound inthefollowingoriginal
articles:
[43]
Kopp AF,OhnesorgeB, Becker Cetal:Reproducibilityand accuracyof
coronarycalciummeasurementswith multi-detectorrow
versuselectron-beam-CT. Radiology (2002) 225: 113-119
[44]
RumbererJA,BrundageBH,RaderDJetal:Electron beam CTcoronarycalcium scanning. Review
andguidelinesforusein
asymptomatic persons. Mayo Clin Proceed (1999)74: 243-252
[45]
JanowitzWR,Agatston AS,ViamonteM: Comparison ofserial quantitative
evaluationofcalcified coronaryartery plaqueby ultrafast
computedtomographyinpersonswithandwithoutobstructive coronaryarterydisease.AmJ
Cardiol (1991 ) 68: 1-6
[46J HaberlR,BeckerA,LeberAetal:Correlationofcoronary calcificationand
angiographicallydocumentedstenosesinpatientswith
suspected CAD: results of 1764patients. JAm Coli Cardiol (2001)37: 451 -457
CT Angiography
Pulmonary Vasculature (Pulmonary Emboli)

FOV and volume to be scanned are marked on the topogram
(Fig. 186.1), beginning from just above the aortic arch. to visualizeprimarilythe
central hilar vesselsandtheheartwiththeright
atrium (apossiblesourceof emboli). Lateral and apical regionsof
the lung are dispensable. The total acquisition time should not
exceed 15secondsin ordertocompletetheexamination duringa
single breathholdwithoutartifacts.The imagesarebestobtained
CT system Coli. ST Feed Pitch RI

[mm] [mm] I Rol [mrn]
4rows 4xl,0 1-3 6,0 1,5 0,5
16rows 16xO,75 1-3 15,0 1,25 0,5
Thevascularlumina contrast wellwiththe
pulmonary tissue (Figs. 186.2 -186.5) and
extend all the way to the periphery. Acute
pulmonaryemboli(Figs. 186.6and 186.7)
cause intravascular defects representing
thrombi (173), located in this case in the
rightpulmonary artery(90a).
Fig. 186.1 Fig. 186.2
from caudalto cranial,tohavethemotion-sensitive areasclose to

the diaphragm alreadycompleted duringtheendphaseandtominimizetheartifactscaused
bythevenousinflowofcontrastmedium
through brachiocephalic veins and superior vena cava. Exact
timingwith bolustracking (8T, ROI over the pulmonary outflow
tract)isstronglyadvised.Thereconstructedsections shouldnotbe
lessthan 3mm inwidth.Thesectionsfor the MIP shouldbe close
to1.0mm toavoid overlooking smallsubtlepulmonary emboli.
Sec.! Voll Current Kernel WI C Delay CM
Rol [KV] [mAs] [HU] [sec.] [mil ml/sec]
0,5 120 140 8 20 420/60 16/8T 120/4,0
0,5 120 130 8 30 450 /60 16/8T 120/4,0
Fig.186.3
Fig. 186.4
Fig.186.5 Fig. 186.6 Fig.186.7

CT Angiography
Abdominal Vessels
Most pathologic vascularprocessesarelocated
closetothecenterattheoriginofmajorvascular
branches,allowing the FOV to be
confined tothecentraltwothirds ofthe abdominal space onthe
topogram (Fig.187.1).Theorigins ofthe vessels arising fromthe
abdominal aortaare visualizedon axial sections and on MIPand
MPR images.Ifalargervolumeneedstobe acquired onthez-axis,
afour-sliceCT needsacollimationof4x2.5 mmtoachieve an
acceptableacquisitiontime during onebreath hold.Incontrast,a
suspected renalartery stenosisrequiresareduction oftheacqui-
CT system Coli. ST Feed Pitch RI

[mm) [mm) I Rol. [mm)
1 row 3,0 6,0 2,0 1,5
4 rows 4x l ,0 1,25 6,0 1,5 1,0
16rows 16 xO,751 ,0 15,0 1,25 0,7
sitionvolumetothe renal region. To achieve an adequatevisualization

ofpossiblestenosesinthinrenalarteries,the examination
shouldbe performedwiththin sections of,forinstance,4x1 mm
andwith an RIofonly0.5 mm.
Since the individualcirculationtimes oftenvary,afixed delayofthe
injection ofcontrastmediumisnotrecommended,andtheuseof
a test bolus or bolus tracking is suggested instead. The ROI to
registertheincreaseindensity(arrivalofthecontrast medium =
commencement of the measurement) is best placed over the
lumenofthe descendingaorta(see page176).
Sec.! Voli. Current Kernel WI C Delay CM
Rol. [KV] [mAs) [HU) [sec.) [mil ml/sec)

0,8 110 100 B30 350/ 50 20/ BT 120/ 3,0
0,5 120 130 B20 350/ 50 20/ BT 110/ 3,0
0,5 120 130 B30 350 / 50 20/ BT 110/ 3,5
Fig.187.1 Fig.187.2 Fig.187.3
The FOV isplaced overthecentralabdominalspace(Fig.187.1).Normally,thevisceral

branchesof theabdominalaortashowagood
luminalcontrastwithoutfillingdefects.includingthe branchesofthemesenterial
vesselsasshowninFigures187.2and187.3.In case
ofan occlusionofthe superiormesentericartery (106).theinterrupted vascular
lumen(..)andthe collateral vessels( ~)
are
easily recognized onVRT and MIPimages (Figs. 187.4-6).
Fig. 187.4 Fig. 187.5 Fig.187.6

CT Angiography
Iliofemoral Vessels
ForCTangiographyoftheiliofemoralvessels,thepatientisplaced
Problemscanarisewiththetimingof theinjectionofcontrast
feetfirston thetable.Thelengthofthe relevantbody regionalong medium,especiallywith

unilateralhigh-degreestenosesbecause
thez-axisiscritical(Fig.188.2), andthereforeitisgenerallypreofthe
slowflow(see below)intheperipheral vessels 01 the
ferred to use a wide collimation of 4 x2.5 mm or16x1.5 mm

affectedside.Ifbolustracking(B1)is used,theROIisplacedover
(insteadof4 x 1 mmor16x0.75mm),whichallowsafaster table thedescendingthoracic

aortaorabdominalaortatoregister the
feed. Narrow overlapping reconstructions should guarantee the increaseinthecontrast

medium-induced density(seepage176).
qualityofthe final images. Already VRT images allow a good overview from the aortic
bifurcationtotheanklein mostcases (Fig.188.1).
CT system Call. ST Feed Pitch RI Sec.! Volt Current Kernel WIC Delay CM
[mm) [mm) I Rot [mm) Rot. [KV) [mAs) [HU) [sec.) [mil mllsec)
4 rows 4x2,5 3,0 15,0 1,5 1,5 0,5 120 130 B20 350 I 50 251BT 150 I 3,0
16 rows 16x1,5 2,0 24,0 1,0 1,5 0,5 120 130 B30 350 I 50 251BT 150 I 3,5
Fig, 188.1
Fig. 188.3
Fig. 188.4 a 4b
Fig. 188.2
Incasesofperipheralarterialocclusivedisease,botharterioscleroticplaques (174)and
luminalnarrowingwithimpairedflowdistally
(Fig. 188.4a) are clearlyrecognizedin comparison withanormalpost-stenoticflowinthe
tibioperoneal vessels (Fig.188.4b). Inhighdegreeperipheralarterialocclusivedisease
examined withatablefeedof >3ern/sec, theflow can besomuchdelayed that the
craniocaudal acquisitionleavesthebolusbehind.
CT Angiography
Vascular Prothesis
CTangiographyisalsosuitabletofollowimplantedstentsor muralcalcifications
becauseofacousticshadowing(Fig.189.1'3)
vascular prostheses(182)thatinterferewiththeassessmentof in
colorduplexsonographyimages.
;1"
'89
97
98
1.//
~
99
~~
.\-:-., /
)L'"'l.
L -..... t
,.
..,...,~~
, A;110~
135 . 1061 :f\ . '. 135

,,,, \ '
1\
Fig. 189.1 Fig. 189.2 Fig. 189.3
Outlook
CT angiography undergoes rapid technical changes and its advancement
can beexpected toescalate duetomorechip capacity
and increasing computer power. It is foreseeable that separate
work station with user-friendly software and partially automated
programs willshorten reconstructionsusing VRTfurther. Genera
tingimages ofthedescendingaorta (Fig.189.4)ormajorthoracic

vessels(Fig.189.5)withVRTand MIPasillustrated herewillbecomeevermore
effortless.Thisrepresentsachallengefortheuser
to stay abreast with the technical developmentsand to keep the
departmentalprotocolsof the variousCTA applicationsuptodate.
Fig. 189.4
Fig. 189.5a
Fig. 189.5b
Test Youself !
Tests 47to49:
Thefollowingthreeimages containseveralpathologic findings,someobvious
andothersrathersubtle.Goodluckwhentacklingthetests!
Theanswerscan befoundon page202 below.
Fig. 190.1 Fig. 190.3

Fig. 190.2
A Primer of CT Evaluation
Occasionally,thebeginnerfacesthe questiontodecidewhethera sectionscan often

behelpful.Furthermore, uncertaintyarises
findingrepresentsa truelesionorjustanartifact.Acontralateral when

describingalesionwithout familiaritywith theappropriate
comparison or a comparison with adjacent cranial or caudal vocabulary.This primer

aims to remedy these problems.
A GeneralApproach toan Abnormalityofthe CTMorphology:

Where? Location,lateralization,relativeposition tootherorgans/vessels
Size? Size(diameterin[mm,em]; important,e.g., monitoringoftherapy)
Density?
Relativetoitssurrounding:isodense(equaldensity);hyperdense(denser);orhypodense(less
dense)
Structure? Homogenous(e.g., fluids)orheterogenous/ septate/ geographic
Shape? Tubular(vessels,muscles,...jornodular(tumor,lymph nodes)?

Reticular(resemblinganet), striate ofdiffuse?
Demarcation?
Sharply marginated(morelikely benign)or
indistinctly marginated (infiltrationinto the
surrounding,e.g.,inflammation,malignancy)
Caution: Partial volume effect can mimic an indistinct margin!
Perfusion? No, peripheral,homogenousorheterogenouscontrast enhancement
Expansion? Space-occupyingeffectnotinvariablytobe equalledwithmalignancy:

e.g.,largebenign cystscandisplace adjacentvessels
B
Useful Terms, in Alphabetic Order
Airinclusions � Infectionwithgas-forming bacteria

� compound fracture
Ampullary Dilatation ofthe renal pelvis
(� physiologicvariantor obstructive uropathy)
Articularinvolvement Evaluation offractures
[ec-riskOf degenerativeosteoarmntis)
Bolus CT
Dynamicexamination, often withouttable
movement to assess the contrast enhancement
pattern
Bullae Lung [ee-pulmonary emphysema)

Capping Periventricular abnormalityin thewhite matter
[eo transependymaldiffusionofCNS;sign of SAE)
Cavity Intrapulmonaryhollowspace (� tuberculosis)
Central Inthecenterofalesionorcloseto
thehilumof parenchymafous organs

Clubbing e.g.,ofalimboftheadrenal gland
(� adenoma,metastases)
CM Contrast medium,
given orally,rectallyorintravenously
Concentric Location ofintravascularthrombi
(eo acrnc aneurysm)
Courseof fracture JinesEvaluationwith additionalMPH
[ee-surgical planning)
Crescentic Typicalconfiguration,e.g.,subdural hematoma or

perihepatic effusion I ascites
Defect Pathologic phenomenon inopacified vessels /
urinary collecting system

Defect In opacified vessels[eo thrombus),
in urinary bladder (� tumor, bloodclot)
Demarcation Depending on the vascularization, lesions become
visible onlyafter administration ofcontrast medium
Dense band
Densitometry
Diffuse
Dumbbell-like
Eggshell-shaped
Enhancement
Enhancement pattern
Excentric
Fluid Levels
Fractures
Ground glass density
Halo
Hemorrhagic
Hilarfat
Honeycombing
HRCT
Hyperdense
[eo Application, Possible Significance)
Band-like density [�> lung, connectivetissue:
post-inflammatory, scar)
Measuringofdensity(� differentialdiagnosis)
Uniform,neitherfocal nornodular;e.g.,liver:
hypodense � hepatic steatosis (fatty liver)
hyperdense � hemochromatosis
Typicalcalcification pattern ofbenign hamartomas
[e> lung)
Calcification pattern of perihilar lymph nodes
( lung � silicosis; porcelain gallbiadder)
Increased densitydue to
accumulation ofcontrast medium
Pertusion pattern (homogenous, timely or delayed)

Intravascular locationofthrombi {eo aortic aneurysm)
Phenomenon (� sedimentedhematoma)orair-fluid
levels [eo paralytic iieusor intestinal obstruction)

Corticalstepdeformity,displacement,number of
fragments, stabi lity, articularsurface?

Diffuse, slightincreasedensity
seeninperifocaledema[eo fat,lung)
Confinedperifocaledema (� aroundinflammatory
toci and metastases)
Blood -containing[eo large infarcts, e.g.,cerebral)
Benigncriterionfor lymph nodes (� nodalindex)
Typicalfor vascular rarefaction inthe lung
[eo emphysema)
High resolution computed tomography (thin sections)
[eo lung;also for MPRand3D)
Denser thanthesurroundingtissue
(bright -e-fresncerebralbleedingorcalcification)
Hyperperfusion Enhancement Perifocal Circulararoundalesion (edematousl one)

(e::> inflammation,hypervasculartumor) Perihilar
Topographicdescriptionofanintrapulmonarylesion
Hypodense Less densethanthe surrounding Peripheral
Alongtheperiphery,incontrasttocentral
(dark � fluid,fat,air) Pitch Ratioof tablefeedperrotationandsection
Imbibition Striatetodiffuse enhancement thickness [ee-spiraltechnique, see p.8 /9)
(� fattyfissue:scar,inflammation) Pixel Pictureelement(imageformation,seep.14)
Indentation Blunt convex bUlging I displacementofadjacent Ptaque Intravascular[eo
arteriosclerosis),
structures (� tumors) pleura-based [ee-asbestosis)

Indistinct Outline of a lesion (see marginal indistinctness) Polycyclic ~
scalloped, cauliflower-like (� hilar lymph nodes
Indistinctmargin Causedbyinflammatoryandtumorousinfiltration ofthelung,
e.g.,Boeck'sdisease)
ofthesurroundingtissue(caution:DOpartial Popcorn Typical pattern

ofbenigncalcifications [ee-lung)
volumeeffect) Process Favoredtermfor"1don'tknowwhatismeans"

Induration Thickenedfibroustissue(e-scar,pulmonaryfibrosis) Pseudocysts c::>
chronic pancreatitis
Infiltration Perifocal extension of an inflammatory or Pulsation Can induce
artifacts along vessels
malignantprocess (� aorticaneurysm)
Infloweffect Incompletemixingofcontrastmedium, Rarefaction Less
vesselsperpulmonaryvolume
canmimic intravascular thrombi (� emphysema, SIP lobectomy)
Intramural Locatedinthewallofahollowviscus Respectingsoft-tissue
Lackinginmalignanttumorsor advanced
planes
(� gas,tumor) inflammations(nolongerrespectingnatural
Iriseffect Centripetalenhancement borders => infiltration)
[ee-hepatichemangiomas) Retentioncyst Convex projectionintotheparanasalsinus,

Isodense As denseas ... (= isointense) homogenous
Jet effect Inflow of opacified urine Reticular Net-like pattern
fromtheureterintotheurinarybladder (�fibrosisofthepulmonaryinterstitium)
lacuna Lacunar defect[eolatestageaftercerebralinfarct, Retrocrural
Preferredposterior paravertebrallymphnode
isointense with CSF) station

LN Lymphnode(tor size seechecklists, � hilarfat) Riskofherniation
Internalherniationofbrain stemduetoincreased
lymphangiomatosis Groundglass-density intracranial pressure
(� pulmonary parenchyma,breast carcinoma)

[ec-quadrigeminal andambient cisterns)
MPR
Multiplanarreconstructionof variousimageplanes ROI Regionofinterest (�
densitometry)
(sagittal, coronal � diagnostic evaluationofe.g. Roundlesion Focalspace-
occupyinglesion(onlyintrapulmonic)
fractures) Scalloped Peripheral contrastenhancement [ec-glioblastoma)
enhancement
Multiphasetechnique
Dataacquisitionduringearlyarterial,portovenous
orlatevenouspassageofthecontrastmedium Siteofpredilection
Preferredsiteforcertainchanges
bolus(� spiralCToftheliver) [�> lymphnodes, metastases)

Multislice Newmultislicetechniqueconsistingof Sludge Thickenedbile[eo
cholestasls,cholecystitis)
simultaneousacquisitionsofseveralsectionsin Space-occupying
Tumorofunknownnature(ubiqurtouslyapplicable)
process
spiral mode
Muralthickness Singleor multiplelayers(wallofa hollowviscus: Spindle-shaped
Biconvexconfiguration
� ischemia, inflammation) (� aortic aneurysm; epidural hematoma)
Narrowed parenchymal � Renalatrophy(degenerative,hydronephrosis) SpiralCT

Acquisitionofa3Ddatasetwithcontinuoustable
rim feedandany sectionreconstruction, seep.7
Necrosis Central,hypodenseorhomogenousliquefaction Stellar Hypodensestar-
likefigure[ec-fNH ot the liver)
Nodalindex
Longitudinal-transversediameterratio Stellate Septation[eoechinacaccalcyst)
(characterizationoflymphnodes) Stent Shorttubeofvariousmaterialstostentvessels,
Nodular
Nodularconfiguration (� lymphnodes,tumors, ureterorcommonbileduct
adenomas), miliary < granular < fine-nodular Stepdeformity bonyCortex(eo
fracturediagnosis)
< large-nodular <confluent Structure Non-descriptivetermofalesion.
(� pulmonaryinterstitium) try touse more precise term
Obliterated
Surfaceofcerebralgyri[eocerebraledema,DO: Subcarinal Preferred lymphnodestation
child)orpancreasoutline(� acute pancreatitis) TImely
Symmetricandtimelyrenalenhancementand
Osteolytic Destructionofbonymatrix excretionofcontrast medium =normal

[eo metastases,multiplemyeloma) Triangular Wedge-shaped
Osteoproliferative Osseousapposition (<> degenerative),
[eotypicalinfarctpattern,scarresidue)
lessfrequentduetoscleroticmetastases Tumorextension
Renalveinorvenacava[eorenaltumor)
Partialvolumeeffect Effectofpartialvolume Vascularconfiguration
Normalconfigurationofthepulmonaryhila
(causesapparentindistinctness) Voxel Volumeelement(imageformation,seepagelA)
Patchy Parenchymal per1usion pattern in the spleen Wedge-shaped Triangular
configuration
during the ea~y
arterial phase [ec-typical infarct pattern,scarresidue)
B Practical Terms, Organ-related
The following list contains helpful terms, which
are used for interpreting CT examinations of a
particular organ. Terms locating the findings are
followedbyterms describingtypicalmorphologic
changes, which are incorporated with possible
conclusions and subseouent organ-related pecu
liarities.
Thelistdoesnotclaimtobecomplete (thiswould
makeit far too convoluted), but should helpthe
reader to look up some of the most frequent
organ-related termsquickly.
Skull, intracranial
Locational descriptions
� Supra� ! infratentorial
� Frontal I temporal I parietal I occipital
� SingularI multiple
� WhitematterI cortical
Typical morphology � possible diagnoses
� Midlinedisplacement,obliterated cisterns,
effaced sulci, narrow subarachnoidspaceor
small ventricles;
Obliterated whitematter I cortex intertace
eo:> increased intracranial pressure; possible
herniation
� Capping
� Transependymal diffusion ofadvanced
increased ventricular CSFpressure
� Intracranial air inclusions
� Compoundfractureofthecranial vaultor
cranial base
� Cystic homogeneous hypodense
� Hygroma/ arachnoidal cyst
� Hyperdense, biconvex / crescentic spaceoccupying
process along the internal table
ofcranial vault
� epidural I subdural hematoma
� Hyperdenseextracerebral CSFspace
� Subarachnoidal hemorrhage
� Hypodensewhitematterlesions
� Infarcts, embolic residues
� CSHsodense lacunar defect
� Infarct residue
� Peripheral scalloped enhancement
� Typical tor glioblastoma
� Subtleroundingofthetemporalhom
Earlyincrease inCSFpressure
� Ventricular enlargement
� Internal hydrocephalus
� increased CSF pressure !
Notable lindings
� Immediatetherapeuticinterventionwith
pendingherniation !
Paranasal sinuses
� Frontalsinus,ethmoidsinus, sphenoid sinus,

maxillary sinus
� Semilunarcanal(important drainageduct)
Typical morphology � possiblediagnoses
� Round, broad-based, convex homogeneous

space-occupying lesion � retention cyst
Notable findings
� Normal variants: Haller's cells, pneumatic nasal

conchae oruncinateprocess
� Riskofvisuallosswithorbitalfracture
� Fractureclassificationoffacialbonesaccording
to Le Fort (see page 63)
Orbit
� Orbital floor,orbitalroof,medialandlateral
orbital wall, retrobulbar
� Thickened extraocular muscles

� Endocrineophthalmopathy, Myositis
Nofable findings
� Riskofvisionlosswithfractures oftheorbital
floorsolely throughcicatricial pull on theorbital
fattytissue
Neck
� Nuchal, submandibular, prevertebral,paratracneal,

parapharyngeal,epiglottic, subglottic,
neurovascularbundle,intra-/ suprahyoidal
Typicalmorphology � possible diagnoses
� Heterogenousinternalstructure,possiblywith
intrathyroidal calcifications � nodular struma
� Multiple ovoidlesionsalongtheneurovascular
bundle � lymph nodes
Chest
� Peripheral = subpleuralI central = perinilar:

� Basal/apical,segmental/ lobular;
Name segment!
� Polycyclic bulky hila

� Boeck's disease; hilar nodal metastases
� Multiple, only indistinctlyoutlined nodules
� pulmonarymetastases / granulomas
� Sharplyoutlined,striatedensity Without
perifocal edema� fibrotic edema
� Perifocal ground glass-like density in HRCT
� Acute inflammatoryprocess
� Irregular nodularthickened interlobar septae
withfine-reticular thickening
<> l ymphangiomatosis
� Bullaewithvascularrarefaction,honeycombing
� emphysema
� CaVitywithlayeredgroundglassdensity below
air pocket � aspergilloma
� Fusiformthickeningalong interlobarspace
-e-encapsulateo pleural effusion
� Apicalpleural thickening,cavities,hilar lymph
nodes � tuberculosis
� Popcorn-likeorclub-likecalcifications
� benign hamartomas, post-inflammatory
residues
Notabte findings
� Normal variant oftheazygous lobe

� HRCTwiththinnersections(doyouremember
fherational? Refertop.86-87)
� Don'tforgetthepulmonarywindow
Liver
LocationaJ descriplions
� Subdiaphragmatic,subcapsular,perihilar, name
thesegment (not onlythelobe),periportal,
diNuseI focalI multifocal, parahepatic
Typicalmorphology � possible diagnoses
� Diffuse hypodensity with resultant hyperdense

vessels (unenhanced)
� fattyliver (hepatic steatosis)
� Diffusehyperintensity � hemochromatosis
� Homogeneous-hypodense, round sharply
marginatedroundlesion withoutenhancement
� benign cysts
� Focalroundlesionwithenhancement
� metastases; abscess
� Roundlesionwithcentralhypodensestellar
figure � FNH
� Cameralcystswithstellateseptations
� echinococcus(splenic involvement?)
� Hypodense cannulated, but irregularly
branching � cholestasis
� "intraparenchymal" hypodenseair pockets
� pneumobilia; SIP biliointestinal anastomosis
Notabte findings
� Multiphase spiral CT: early arterial, portal and

latevenousforimproved detectionoffocal
lesions
� Dynamic bolusCT Without table feed
� iriseffect inhemangiomas
� PortographyCTafterprecedingcatheterplacementintosplenicormesenteric
artery
Gallbladder
Typical morphology ", possible diagnoses
� Multi-layered edematous wall thickening with

perifocal "ascites" � acute cholecystitis
� Intraluminal wall-basedthickeningwith
calcification � polyp
� Intraluminal sedimentation phenomenon
� sludge
� Eg
gshe
l
l
~l
ike
peripheral calcification
� Porcelain gallbladder, precancerosis
Spleen
iocstionst descriptions
� SUbdiaphragmatic, subcapsular,perihilar,
perisplenic
Typical morphology '" possible diagnoses
� Leopard-likemarble patternduringtheearly
arterial phase of enhancement � physiologic
� Wedge -shaped perfusion defect � infarct
� Perisplenic roundlesion,isodensewithsplenic
parenchyma � accessory spleen; LN
Pancreas
Loeat/analdescriptions
� Head,body,tail,peripancreaticfatty tissue,
uncinate process
Typical morphology '" possibie diagnoses
� Diffuseenlargementwith obliteratedoutlineand
exudate pathways � acute pancreatitis
� Atrophic organ,dilated ducts,calcificationsand
pseudocysts � chronic pancreatitis
Kidneys
� Parapelvic, medullary, parenchymal, cortical,

subcapsular,arising, polar, perirenal, uni-/
bilateral, lateralization
Typical morphology", possible diagnoses
� Homogenous-hypodense,round, sharply
demarcatedspace-occupying lesion without
contrastenhancement � benigncyst
� Hypodense clubbing of thecollecting system
� obstruction; ampullaryrenalpelvis,
parapelvic cyst
� Irregularwallthickeningot thecystwifh
contrast enhancement
� suspiciousfor malignancy
� Thinning oftheparenchymal rim, generalized
decrease in size � renal atrophy
� Heterogenous space-occupyinglesion
extendingbeyondtheorgan outline
� renal cellcarcinoma
� Hypodensewedge-shaped periusiondefect
-e-renal infarct
Notable lindings
� Densitometryofcysticchangesforcomparison
with unenhancedsections
� Evaluationof excretion: symmetric,timely?
Dilated ureteral lumen?
Urinary Bladder
Locaffonal descripuons
� lntra-, extra-,paravesical,bladderfloor,
bladder roof,trigonum
Typical morphology", possibie diagnoses
� Diffusewallthickening � cystitis,trabeculated
bladder; edemafollowing radiation
� Focalwallthickening,polypoidprojecting into
the lumen � suspiciousfor malignancy
Nolable Ilndings
� Jeteffect,diverticulum,catheterballoon;
indwelling catheter fa be clamped betore
examination!
Genital Organs
Locaffonal ttescriptions
� Parametrial,intramural,submucosal,
endometrial,ischial fossa,pelvicwall,
periprostatic
Typicalmorphology � possiblediagnoses
� Hypodense,water-isodense space-occupying
lesion inthescrotum � hydrocele, varicocele
� Nodularthickeningofthe myometrium<>
benign myomas, but also small uterine cancers
� Growth beyond organ outline,infiltrationof
rectal and bladder wall � suspicious for
malignancy
Nolabie findings
� Thin sectionsthroughthelesser pelvis,rectal

administration of contrastmedium
Typicalmorphology'" possiblediagnoses
� Generalizeddiffusewallthickening
� lymphoma; ischemia; ulcerative colitis
� Segmental wallthickening � Crohn's disease
� Air-fluid levelswithinlumen and dilatation �
intestinal atonyto ileus
� Free airintheabdomen � perforation
� Intramuralair � suspiciousfor necrotic
intestinal wall(ischemic or inflammatory);
caution: DO diverticulum!
Nolable findings
� Selectionofsuitable oral contrast medium

(refer to p. 19)
Vessels I retroperitoneum
Locationa/ descriptions
� Para-aortal, paracaval, interaortocaval,

prevertebral, retrocrural, mesenteric, para-iliac,
inguinal, cervical
Typical morphology '" possible diagnoses
� Dilatedaorticlumenwithdifferenttimesof
opacification and detection of a septum
� dissected aneurysm
� Beticulnnodular thickeningof theperitoneum
with nodular projections and ascites
� peritoneal carcinomatosis
� Endoluminal hypodense defects � thrombi;
caution: DOinflow effect
(refer to pp.21 -23,73)
Bone I Skeleton
� Cortical,subchondral, juxta-articular,
metaphyseal, diaphyseal, epiphyseal,
intra-and extraspinal
� Step-deformityofthecortex,corticalbreak,
fractureline � fracture
� Articular involvement � risk of secondary
degenerativeosteoarthritis
� Focal hypodensity of the spongiosa with absent
trabeculae � pathologic bonemarrow
infiltration
Nolable findings
� Evaluationofstability, MPR,3Dreconstruction,
myelo-CT ofthespine
c Checklists
The checklists represent the third part of this

primer. They are not repeated here. They can be
foundasinserts oron thefollowing pages:
Region Page
Skull 26
Neck 64
Chest 74
Abdomen 103
Skeleton 167
Solutions to Test Yourself!
Theexercisesand solutionshave beennumberedconsecutively. After

youhavecompletedtheexercises,compareyour scoreand
Someof theexerciseshaveseveraldifferentcorrectsolutions.If resultswith
thoseofyourcolleagues.Thescore ontherightgives
theexercisescanbesolvedsimplybyreferringto thechaptersin youanimpressionof
thedegreeofdifficulty.Enjoy thechallenge!
the book, I have indicated where you will find the necessary
information.
Solutiontoexercise1(p.32): 9Points
Youwillfindthe sequenceforinterpreting CCTs onpage26.Eachstepgivesyou
'12pointwith3extrapointsfor thecorrectsequence,
which addsupto9.
Solution to exercise 2 (p. 45): 9 Points

Levei Width Gray scale
Lung/pleuralwindow -200HU 2000HU -1200to+ 800 HU 3
Bone window +300 HU 1500 HU -450 to +1050 HU 3
Soft-tissue window + 50HU 350 HU -125to+ 225 HU 3
Solutionto exercise3(p. 45): 10Points
a) Barium sulfate Routine forabdominal/pelvic CT 30minbeforeCT of upper abdomen 4

if thereare no contraindications 60 minbefore fullabdominal CT
b) Gastrografin Watersoluble, but expensive; 20min beforeCT ofupp erabdomen 4
if perforation ileus orfistulas 45 min before full abdominal CT
aresuspected; prior to surgery
Nooral CM shortly after surgery foran ileal con duit!
Solution to exercise4 (p. 45): 6 Points
a) Renal failure (creatinine, possibly creatinine clearance, function following

kidney transplant or nephrectomy) 2
b) Hyperthyroidism(clinical signs? if yes,hormone status, possibly thyroid
ultrasound and scintigraphy) 2
c) Allergy to CM (has CM-containing iodine already been injected? Are there
anyknown previous allergic reactions?) 2

Tubular an d nodular structures can be differentiated bycomparing a series of
images.
Vesselsinwhich beam-hardeningartifactsoccurbecauseofCMinfloware the

superiorvenacava, infertorvenacava,and the subclavian vein.
Solutionto exercise7 (p.48): 3Points

Fractures,inflammatoryprocesses, andtumorsormetastasescan cause
swellingofmucousmembranes andretentionoffluidsinthe
mastoidsinusesandmiddleear;theseare normallyfilledwithair.
This imagerequirescarefulstudy.Youwilldiscoverseveraltypes
ofintracranialhemorrhageandthecomplicationsresulting from them.
�Bruisingoftheleft frontoparietal softtissues
(extracranial,indicativeoftraumatothehead) 1
� Subdural hematoma over the right hemisphere extending tooccipital
levels(hyperdense) 2
�Edemaintherightfrontopartetalareas,possiblyaccompaniedby anepiduralhematoma 2
�Signsof subarachnoidbleedinginseveral
sulciinparietalareasontheright,adjacenttothefalx 2
�Thehematoma haspenetratedinto therightlateralventricle,whichis practically
obliterated 4
�Choroid plexusintheleftlateral ventricleappearsnormal 1
�Thereisa midlineshift towardtheleft, andedemasurroundstheperiventricularwhite
matteronthe right 2
�Raisedintracranialpressure(obstructedventricle)and herniationofthebrain
(edema)canbeexpected 4
Solution toexercise 9 (p. 72): 9 Points

Grayand whitematterappearwelldefined on narrowbrainwindows.
Level Width Gray scale
+ 35HU 80HU -5 HUto+75HU

3
CCTsectionsare normally oriented parallel totheorbitomeatalline,
so thatInitialandfollow-upstudiescan bepreciselycompared. 2
2-mm sectionsat 4-mmincrements are acquiredthroughthe petrosal bone, 2
then thickness and tablemovementare setat8 mm. 2
Solution toexercise 10(p. 72): 16Points
Intracerebral hemorrhage inearly phases hyperdense,often with 2
hypodense peripheral edema
Subarachnoidhemorrhage hyperdense bloodinsteadof hypodense CSFinthesulciand

cisterns 2
Subduralhemorrhage hyperdensecrescenticareaclosetothe calvaria, 4
concavetowardthecortex, notlimitedbycranialsutures
Epidural hemorrhage hyperdense,biconvexareaclose tothe calvaria, 4
smoothtowardthecortex, always limitedby cranial sutures
Complications hemorrhage intoaventricle, CSFflow is obstructed,edema,danger

ofherniation 4

Subarachnoid hemorrhagein childrenmaybe visibleonly nextto
thefalxorinthelateral(Sylvian) fissure.
Solution toexercise 12(p. 72): 10Points

Practicemakes perfect!

Fractureoftherightfrontalboneandabsentrightfrontalsinus(thelatterisa congenital
variation,notahemorrhage, as indicatedbythe
osseoustrabecuiae)
Solution toexercise 14(p. 72): 8 Points

Thiswasadifficultquestion.Intheleft
internaljugularveinthereisunusualsedimentationofthe
CMduetoslowbloodflow.Theasymmetryofthejugularveinsis
notasignof thrombosis.Aleft cervicalabscessmakesthe neckmusclesappearpoorly
defined.

In thispatientthe surface subarachnoid spaces are clearlytoo narrowand the
ventricles distended.These signsindicatethat CSFdrainageisreducedor
blockedandthereisimminent dangerofbrainherniation. Thereis generalizedbrain edema.A
neurosurgeonshould
be consultedaboutinserting an intraventricularshunt.

Itispossibletomistakethesubarachnoidhemorrhagearoundthe leftfrontallobe as an
artifact.Theleft frontalcortex isoutlined byblood.
Ifyoudidnotsee anyabnormality, returntothe chapteraboutthe head.
Solution toexercise 17(p. 73):

You haveofcoursetakenthe hintaboutnotgiving
up too soon; the right medial rectus muscle (47c)
isthickened.Itisthe second muscleto become

involved in endocrine ophthalmopathy.
Ifyoucannot rememberwhichmuscleisaffected
first, return to page 61 .

Part of the question was misleading. but

thiswas intentional, and Ihopeyoutakeit
in the right spirit. No fresh intracranial
bleeding can be seen in this image
(Fig.73.4isthe same asFig.198.1). The
abnormalityinthelettfrontal lobe isan
area ofreducedattenuation representing
an earlier hemorrhage (180) which has
now reached the resorption phase
(4 points). Theextracranial swelling and
bruising in the lett frontoparietal area
(1 point) is also 2 weeks old. In order to
determine the natureof the hyperdense
foci, particularly on the right side, you
should of course ask to see adjacent
images (4 points).
The next caudal section (Fig. 198.2)

shows that these foci are formed by the
orbital roofs (*), the sphenoidbone(60),
and the petrosal bone (** ) (1 point for
each). These partial volume effects were
discussed on page 53. If you misinterpretedtheminthe
question,takeitasawarningand
youwillbeless likelytomake this
mistake again.
CompareyourchecklistforCCTwiththeone onpage74.
As inexercise 1,eachitemis worth 'J, point andthecorrectsequence isworth 3points.
II
4 Points
Thereisanareaoflowattenuation duetoincomplete CMfillinginthe azygos vein,
rnostlikelybecauseofathrombosis(2 points).The
esophagus isnotwell defined. There arehypodenselines crossing thepulmonarytrunk and

rightpulmonaryarterywhich are artifacts
because theyextend beyondthelumen ofthe vessels(2 points).
Fig. 198.2a Fig. 198.2b

Solution to exercise 21 (p. 100):
Did yousuggestdoingbronchioscopyorbiopsy inordertoknowmoreaboutthe
"Iesion"?Then you mustrevisitthebasic rulesofCTinterpretation. Butif you
rememberedtolookfirstofallattheotherimagesinthe series, asforexampletheone
ontheright,youwill have seenthatthe "Iesion" belongstothesternoclavicularjoint(
'" ).
This is another example of a partial volume effect. There is degenerative
changeinthisjoint,butnopulmonary lesionor inflammation.
Abb.198.3
Solutiontoexercise 22(p.100):
The cause of sudden back pain in this
patient was the dissection (172) of the
aortic aneurysm (1 point). At this level,
both the ascending (89a) and the
descending (89c) aorta (1 point each)
show a dissection flap. It is a de Bakey
typeI dissection (1 point).
Solution toexercise 25(p.101):

Thesmallmetalclip(183) isa
hint that the stomach has
been surgically transposed
into the mediastinum. The
thick-walled structure with
the irregular lumen isapartof
the stomach (129), not an
esophageal tumor. At the
moment of data acquisition
thestomach was contracting
and is thereforenotas easily
identifiedasinFi9ure 91.2.
Solution to exercise27(p. 101):

Perhaps the first thing you
noticed was the irregular
contour of the diaphragm
(30) (1 point), but this is a

normal finding. The patient
was a smoker and had
complained of weight loss.
You should first ask for lung
windows inordertocheckfor
metastases (7) or primary
bronchial carcinoma (5
points). When a chest is
examined, it should become
your standard procedure to
use both soft-tissue and lung
Solution toexercise23(p.100):
Thisisacaseof bronchial carcinoma (the
bronchial obstruction is not seen at this
level).There isatelectasisoftheentireleft
lung (84) (2 points) and an effusion (8)
fillsthepleuralspaces (2points).Did you
detect the metastatic mediastinal LN(6)?
(2 points)
Solutiontoexercise 24(p.101):
The most obvious abnormality is the
bronchial carcinoma (7) in the left lung.
The right lung shows emphysematous
bullae (176). CT-guided biopsy of the
tumor shouldbepossiblewithout causing
a pneumothorax because it has a broad
pleural base (2 points).
Youarealreadyfamiliar withthis tragiccase of

bronchial carcinomaina young pregnantwoman
(thus no CM enhancement, see Fig. 98.2). The
anteriorlocuteofthemalignant effusion(3points)
had caused the right lung to collapse (2 points)
and was theretore drained. After the tibrin clot
had been removed from the catheter the lung
was reinflated and the mother's life was prolongeduntil
thebirthofherhealthy child.Didyou
noticethe metastatic LNinthe right axilla?
(1 point)
windows (Fig. 199.5a).
Solution to exercise 28 (p. 101 ):

These two images show an aberrant branch of the aortic arch: The subclavian artery
passes
II
posteriortothetrachea andtheesophagustowardtherightsideofthebody.Youmayrememberthat
this anatomic variationwasmentioned,but notshown,on page120.
4 Points
I
Solution to exercise 29(p. 141):
In additiontotheair-fluid levelsinthedilatedbowel(2 points) associatedwithan ileus,

youshould haveseenthedilatedright ureter
anteriortothe psoasmuscle(2
points).Thecorrectdiagnosisisthereforeileusandhydronephrosis.Youmayrecognizethispar
ticularcase
as the sameoneshownin Figure 134.2a,ataslightlymore cranial level.
Solutiontoexercise30(p.149):
Solutiontoexercise31 (p.149): 7Points
You shouldhave seenthe adenoma(134) inthe rightadrenalgland
(2 points).For'j, point each youshould be abletonametenother
organs.Consultthe numberlegendsif youare uncertain.

Thisisindeed acase ofsitusinversus(2 points).Youwillalsohave
noticedthattheattenuation oftheliver (122) isabnormallylow:
fatty liver(2points).
Hopefully you saw the fairly large, irregular metastasis (7) in the
posteriorsegmentoftheliver(122)(1 point). Didyoualsoseethe
smaller,moreanteriormetastasis?(3 points).TheDDmayhave included
anatypicalhepaticcyst(1 point)or,for the anteriorlesion, partial
volumeaveraging ofthe falciform ligament (1 point).
29
The question itself will have drawn your attention to the atheroscleroticplaques
(174) inthecommon iliac arteries (113) (1 point).
Theleft one ispartofan aorticaneurysm (2points).
Solutiontoexercise35(p. 149): 5Points

Thetwocysts (169)intherightkidney (135)areimpossibleto
miss (1point).Buttherearealso multiple,hypodenselesionsinthe
spleen(133),duetosplenic candidiasis (3 points).You mayalso
have consideredararecaseof nodularlymphomaor melanoma
metastases inthe spleen ('j, point each).

Figure201.1isthe section nexttotheonein Figure150.1and
showsthatthehypodensearea intheliveristhe gallbladder.If you
suggested doing anything else, for example aspiration or biopsy,
beforeseeing adjacent sections,take 3points away.
Solution to exercise 37 . 150 :

You may havethoughtthatthehyperdense focinextto therectum
(146) representcalcified LN(6) (1 point). However,the lymphatics

are so well demarcated because they are still opacified after
lymphography (3 points). Did you also notice the atherosclerotic
plaques (174)inthefemoralarteries (119)(1 point)?
You willachieve the most accuratedensitometryofa cystif youselectasectionwithout
any partial volume effectsfromrenalparenchyma
asin Figure150.3b(1point).Resultsofmeasurementsin
Figure150.3awouldbetoohigh(2points).Sincethisverycasewas
discussedon page133,take away2 pointsforthe incorrectanswer.

The illustrationshowed onlyone metastasisinthe right lobeofthe
liver (1 point) in a case of hepatomegaly (1 point). By using triphasic
SCT, additionalmetastasesbecomevisible(2 points).CT
arterial portography
(3 points) is
moreinvasivethan
SCT alone, but it
dem onstrated that
the spleen also

has metastases.
Fig. 201.3 """"::;....~

_
Solution toexercise 41 (p.151): 10Points

Ifyoudetected thefresh thrombosis (173)intherightfemoralvein
(118), youget3 points.Did youalsoseethesynovialcyst(175)on
the left (3 points)? Your DD may have included a lymphoma, a
femoraloringuinal hernia,orametastasis(1 pointeach). Ifyou
mistook the cystforthrombosisoftheleftfemoralveinas well,
take away 3points! Thevein(118)lies nexttothe cyst.
Solution to exercise 40 . 150 : 6 Points
Forfurtherdocumentation youshould asktoseebonewindows
(2points)andof coursetheadjacentsections(2 points)inorderto

assess the pelvic fracture. It is also important to determine
whether the acetabular fossa was involved (2 points). The

fractures of the
pubic bones were
already visible on
soft-tissue windows
(Fig. 150.5)
because the
fragments were
slightly displaced.
Solutiontoexercise42(p. 151): 7Points

Another exampleofa partialvolume effect:thesigmoidcolon was
only apparently "within" the urinary bladder (4 points). The first
thing you should have asked to see was adjacent sections
You may remember

that this case
wasdiscussed on
page11 6 (seeFig.
116.5a). There's
also pararectal
ascites (1 point).
Solutiontoexercise43(p.151): Solution to exercise 44(p.151):
The beam-hardening artifacts (3) due to drainage tubes (182) You may have thought
that Figure 151.4 shows a gastric
were a hint that this image was taken shortly after surgery pullthrough for
esophageal carcinoma (1 point) or that the
(2 points). The abnormal structures containing gases (4) are esophageal walls are
thickened due to metastases (2 points).
surgical packs(5points)placedtocontrol bleeding after multiple However, this was a
case of a paraesophageal sliding hiatus
trauma.Whenthepatient'sconditionhadstabilizedtheywould be hernia(3points).If
youforgottoaskforlungwindows,youwillnot
removedina secondoperation.Your DOmayhaveincludedfecal have seenthe
largerightparamediastinalemphysematousbulla
impactionin Chilaiditi's syndrome(2 points)or anabscesswith (..)(2 points).
gas-forming bacteria (2points).

Solution to exercise 45(p. 151): 11 Points
In Figure151.5apoorlydefinedtangential sectionofadiverticulumoftheurinarybladdercan
be seennexttotherectum ontheright
side (*) (5points).Your DOmay haveincludeda pararectalLN(2
points).Theirregularitiesintheattenuationvaluesoftheurinearedue
to eMandthe'jetphenomenon' (2points each). Figures202.3and 202.4areadjacentto
Figure151.5.
"
Solution toexercise 46(p.151):
The sameoldproblem!Thehyperdense
(enhanced) C-shaped structure in the
pancreas (131) in Figures 151.6 or
202.5isa loopofthe splenicartery(99)
(4 points). The adjacent sections (c. d,
and e) show that the splenic artery can
bevery tortuous.
4 Points
Fig.202.5d
� Solutiontoexercise47-49(p.190): 6Points
Astenosisofthethoracic aortaisclearlyidentified (Fig.190.1),aswell as
athrombusintherightpulmonaryvessels(Fig.190.2)andan
inflow effectof contrastmediminto thesuperior venacavaasdifferentialdiagnosisofa
genuine cavathrombosis(Fig.190.3).
il,ilThieme
Excerpt from:
Hofer, Matthias
CT Teaching Manual
"
ISBN 3�13-124352-X
ISBN 1-58890-277-3
Checklist forAbdominal Readings
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Abdominal wall: (especially periumbilical and inguinal regions)
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hernias, enlarged lymph nodes?
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liverand spleen: homogeneousparenchymawithout focal lesions?
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well-defined outline?
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Gallbladder: well-defined,thin wall? calculi?
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Pancreas, adrenals: well-defined, size normal?
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Kidneys, ureter symmetric excretion of eM?
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andbladder: obstruction, atrophy, bladderwall smooth
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and thin?
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Reproductiveorgans: homogeneousprostate ofnormal size?
c
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spermatic cord, uterus, andovaries?
E ,;".~
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Gil: well defined? normal thickness of walls?
0 ~
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stenoses or dilations?
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Retroperitoneum: vessels: aneurysms?
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thromboses?
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enlarged lymph nodes?
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mesenteric (norma! < 10 mm)
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retrocrural (normal < 7 mm)
g .e
para-aortic (normal < 7 mm)
S '" ~
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parailiacal (normal < 12 mm)
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parainquinal (normal < 18 mm)
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Bone window: lumbar spine and pelvis:

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degenerative lesions? fractures?
j; &iI
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focal scleroticorlytic lesions?
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spinalstenoses?
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Excerptfrom:
Hofer, Matthias
CT TeachingManual
ISBN 3-13-124352-X
ISBN 1-58890-277-3
Checklist forThorax Readings
1. On the soft-tissue window:

� softtissues, especially:
-axillary LNs
-breast (malignant lesions?)
� mediastinum infourregions:
-from theaorticarchcranially (LNs?, thymoma/goiter?)
-hilarregion (configuration andsizeof vessels,lobulatedand
enlarged?
-heart and coronary arteries (sclerosis?)
� fourtypicalsitesofpredilectionforLNs:
� anterior to aortic arch (normal: almost noneor < 6 mm)
� intheaortopulmonarywindow(normal: <4LNs<15mm)
� subcarmal (normal: < 10 mm; DO: esophagus)
� nextto descendingaorta(normal: <10mm; DD:azygos)
2. On thelungwindow:
� Parenchymaof thelung:
-normalbranchingpatternandcaliberof vessels?
-vascular oligemia only at interlobar fissures? bullae?
� anysuspicious lung foci?inflammatory infiltrates?
� Pleura
-plaques,calcification, pleural fluid, pneumothorax?
� Bones(vertebrae, scapula, ribs):
-normal structure of marrow?
-degenerative ostenphytes?
-focal lytic or sclerotic processes?
-stenosesofthe spinal canal?
Checklist for Reading Cervical CT Images
� Symmetryofneckmusculature?
� Fat planes preserved and sharplydemarcated?
� Normal perfusion ofvessels?
� Thromboses or atherosclerotic stenoses?
� Symmetry and definition ofsalivaryglands?
� Thyroid parenchyma homogeneouswithout nodules?
� Any focal pathologic enhancement with eM?
� Narrowingofthetracheal lumen?
� Assessmentoflymph nodes? Numberand size?
� Cervicalvertebrae examined inbone window?
� Vertebral canalpatentor narrowed?
Lymph Nodes Normal Diameters
Anterior mediastinum < 6 mm (DO: thymus!)

Aortopulmonary window < 15 mm (normalfewerfhan 4 nodes)
Perihilar < 10 mm
Subcarinal <10mm(DO:esophagus')
Paraaortic < 7 mm (DO: azygos vein')
Mesenteric <10mm
Parailiac < 12 mm (DO: ovaries!)
Parainguinal < 18 mm
Thesevalues areinfendedasguidelines, largerlymphnodes

are not necessarily pathological.
Excerpt from:
Hofer, Matthias
l!l Thieme CTTeaching Manual

ISBN3-13-124352-X
ISBN1� 58890�277�3
IlJ
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Checklist: Preparing the Patient
Four aspects should be considered :
Renal function? (elimination of eM)
� Creatinine: normal0.7 -1.3 mg/dl == 60-130 urnol/l

� Creatinineclearance:normal100-160m!/min, ifthereiscreatinine
retention, 2litersofliquidorallyafteri.v.eMwillincreasediuresis
(special monitoringifcardiacfailure)
Idiosyncraticreactionto eM?(premedicationnecessary, beinformed about
glaucoma,prostate hypertrophy)
� Patientshould receive premedication andeM onan empty stomach

(reduces thechancesof aspirationinsevereincidentswithlossof
consciousness)
� IfpremedicationisnecessarybefororaleM,thepatientmustbeatthe
unit at least one hour before CT begins
Abdominal orpelvicCT? SchedulingOK?
�Toapplyoral CMpatientmustbeatunit30 minutespriorto CT

�
previousGITimaging procedureswithoralCM?(thismaycause artifacts
upto3dayslaterduetoresidual CM)
Hyperthyroidism?Ifproblemswith iodine-containingCM are suspected,fT3,
fT4andTSHshould bedetermined; possiblyalsoultrasound orscintigraphy
Checklist for Referral Sheet
Necessary information:
� Whatregionorregionsofthe bodywillbescanned?
� What disease? since when?
� Clinicalobservations
� Previousoperationsorradiotherapy?When?
� PreviousCT?Includeprintoutsif possible.
� Renalparameters:atleastcurrentcreatininelevels
� Thyroidparametersorstatement thathyperthyroidismisnotsuspected
� Anyknownincidentofhypersensitivityto CM?
Forabdominal andpelvic CTs: (because eM is administered orally)
� Isabdominal surgery planned? (water-soluble CM)

� Isthereanilealconduitorurostomybag?(inition scan unenhanced,then
enhanced scan)
� Isalesion suspectedinthe lesser pelvis?(rectalCM)
Checklist for Reading Cranial CTs
� Age of thepatient?Medical history?

� Posttraumatic changes in the soft-tissue structures: bruises I tumors?
�Normalcontoursof Quadrigeminal andbasalcisterns? (Riskofbrainstemherniation)
� Sizeandcontoursof ventricles and CSF spaces appropriateto patient's age?
� Anyblockagetoflowof CSF(obstructivehydrocephalus)
orsignsof brain edema(=effacedsulci)?
� Asymmetries:duetoheadpositionortrue asymmetry?
� Plainor contrast-enhanced CT: cerebral arteries regular?
(Especiallyafterinjectionof CM)
�
Calcificationsinthechoroidplexus andpinealbodyonly?(Commonfindings)
Anyadditional hyperdense foci?
�
Paraventricularwhitematterandcortex inconspicuousandwelldefined?
Any focal lesions or local edema?
�
Basal gangliaandinternal capsule intact?
(Most common locationsof cerebralinfarctions)
� Bramstern, pons and cerebellumnormal?
� Skullcheckedforfracturesandmetastasesinthebonewindow?
Type of bleeding
Characteristics
Subarachnoid Hyperdense blood in the subarachnoid space

bleeding orthe basalcisternainsteadofhypodens CSF
Subdural bleeding
Fresh hematoma:crescent,hypertense bleeding
close to the calvaria with ipsilateral edema;
hematomais concave toward hemisphere;
mayextend beyond cranial sutures
Epidural bleeding
Biconvex, smooth eltipsoidalln shape; close to
calvaria; does not exceed cranial sutures; usually
hyperdense, rarely sedimented

CT Teaching Manual A Systematic Approach To CT Reading, 2nd Edition

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Matthias Hofer

on pages 26-73, 152/153 (head / neck) Normal Variants of the Cranium 50

Notesforthe User,ListoftheCTdiagrams IntracranialBleeds 54

Physical and Technical Fundamentals Orbital Changes 61

Maximum Intensity Projection(MIP) InflammatoryProcessesandTumors 70

Abdomen CT, Pathologic Changes Spine

design,and isdefined bythe angle originating atthe focusofthe

Multiple-Row Detector Spiral CT

Thedetectorrowsalong thez-axisoppositethe x-raytubeare

Comparison ofConventionalCT with Spiral CT

One of the advantages of the helical technique is that lesions

Ste p-w ise

Both single-row detectorCT (SOCT)and multiple-rowdetector CT

Data acquisition forthe abdomen takes only 1-2 minutes: two or

respiration resultsinthem notbeing includedinthe section(Fig.

The imagequalityshouldimprovewith smallervoxels, butthisonly

Themostlyuseddefinition ofthe pitch describesthetable travel

as grey values proportionate to their attenuation (Fig. 8.1b). In

advantage: The multiplanar reconstruction (MPR) in coronal,

Fig. 8.3 MPR from anisotropic voxels

Feed! rotation 24mm ! rotation 24mm

Sincetheunits(mm) inthe numeratoranddenominatorcancelout,

Section Collimation: Resolution Along the Z-Axis

"[ >-I' ll " I I

Fig,9.1 Wide sectioncollimation

The new scanners give the examiner the option to select e

Fig.9.2Narrow section collimation

petrous bone with about 0.5 mm sections to detect delicate

Variable section thickness

Adaptive Array Design

Adaptive detector design 4-row unit

u / '2 5 i j;j ;" I"25\ , z-axis

Resolutionalong the z-axis

The detectorrows are not inevitably equal inwidth.The adaptive

Adaptive detector design 6-row unit

/ " " I /l1I1l\1I \\ \ -,

.. II ,,11111\1\ \ \ '\e; / I II 11/11111\ \ \ \ "

/ "/I 1/1 JI1' 1\ \ \ \ "

/ II 1/ J IIII\I \ \Detectors I "11'1111 \ \ \

Variable section thickness

Fig. 10.2Detector designofa6-rowunit,asfoundinthe SiemensEmotion6

Forinstance,a16-slice examinationcan be performedwith16thin

Adaptive detector design16-rowunit

_____ /11 I '

III/ I \\\ \\,\

(1;\ /, I I �'.' �" \\''\\

H. I / 15 II fII I I Q75\\\\\\ 15 \ \ z-axis

I I.' / // /II I I Jl l 1 \\\\\\ \\\ \

Resolution along the z-axis

Variable section thickness

Fig.l1.1 Detector designofa16-rowunit, as foundinthe Siemens Sensation 16

Thedevelopmentofthe CThardwaredidnotend with16slicesandfasterdata

measuresforexposure reduction(see pages 174-177).

This results in an interesting phenomenon. The patient dose

Fig.11.2 Wide (360�) spiral reconstructionalgorithm

selecting high rnA values, increase the spatial resolution (image

Preprocessing includes all the corrections taken to prepare the

Convolutionisbasicallytheuseofnegative values tocorrect for

Back projection involves the reassigningof the convolved scan

Dataacquisitionsystem Preprocessing Convolution Backprojection : Imagedisplay

Simple Back Projection vs. Convolution

Fig.12,1 Thepipelineprincipleof imagereconstruction Fig.12.2a Backprojection

aximal lntensily Projection

�� , ate diagnostic x-ray exposure fa natural background thereare unexpected