CT Scan

Computed tomography (CT) scanning is an extremely common imaging

modality in modern medicine. With advancements in technology, it is
rapidly replacing many diagnostic radiographic procedures.

In this article, we will outline the basic science behind CT scans,

describe the principles of interpretation, and highlight their advantages
and drawbacks compared to other imaging techniques.

Basic Principles

CT scans are created using a series of x-rays, which are a form of

radiation on the electromagnetic spectrum. The scanner emits x-rays
towards the patient from a variety of angles – and the detectors in the
scanner measure the difference between the x-rays that are absorbed
by the body, and x-rays that are transmitted through the body. This is
called attenuation.

The amount of attenuation is determined by the density of the imaged

tissue, and they are individually assigned a Hounsfield Unit or CT
Number.

High density tissue (such as bone) absorbs the radiation to a greater

degree, and a reduced amount is detected by the scanner on the
opposite side of the body
Low density tissue (such as the lungs), absorbs the radiation to a lesser
degree, and there is a greater signal detected by the scanner.

Conventional x-rays provide the radiographer with a two-dimensional

image, and require the patient to be moved manually to image the
same region from a different angle. In contrast, because of the
advanced mathematical algorithms involved with CT, the three-
dimensional planes of the human body can be imaged and displayed on
a monitor as stacked images, detailing the entirety of the field of
interest.

This is accomplished by acquiring projections from different angles and

through a process known as reconstruction, the three-dimensional data
is viewable on a two-dimensional monitor. The data collected can
theoretically never be a perfect replica of what is being scanned, but is
a close enough representation to be used for medical diagnostic
purposes.

By Timeholder (Own work) [CC BY 3.0], via Wikimedia Commons

Fig 1 – In CT scanning, three-dimensional planes of the human body can

be imaged and displayed on a monitor as stacked images, detailing the
entirety of the field of interest.

Contrast Imaging
Depending on the structure being imaged, CT scans can be used with
and/or without contrast. The introduction of an intravenous
radiofluorescent contrast into the bloodstream can be used for a
variety of diagnostic purposes, for example:

Used to visualise the cardiovascular system (e.g. investigating for

suspected aneurysms, dissections, or atherosclerotic diseases).

Used to identify whether a tumour is malignant.

After approximately 7 minutes after an intravenous injection with

iodinated CT contrast, the contrast begins to expel from the body via
the urinary system. The contrast can be seen in the ureters going into
the bladder creating a CT Urogram; a procedure that is commonly
replacing the traditional intravenous pyelogram seen in radiography.

Oral contrast can also be administered if investigation is required of the

digestive system. (Crohn’s disease, bowel obstruction, diverticulitis,
appendicits).

By James Heilman, MD (Own work) [CC BY-SA 3.0], via Wikimedia

Commons

Figure 2 – Contrast enhanced CT scan, demonstrating an abdominal

aortic aneurysm
Interpreting a CT scan

Orientation

When interpreting at CT scan, it is important to determine the

orientation. Images are most commonly presented in the transverse
plane, and are orientated so that we are looking up the body from the
patient’s toes.

A helpful way to get your bearings is the acronym RALP. Starting at the
9 o’clock position and moving clockwise in 90 degree intervals, we are
looking at the Right, Anterior, Left and Posterior aspects of the patient.

Radiologists will often use images reconstructed in the coronal and

sagittal plane to help supplement their diagnosis.

The Image

The density of the body tissue determines the degree to which the x-
rays are attenuated. In turn, this affects the brightness and contrast of
the imaged tissues.

Those tissues with high attenuation coefficients (strong absorption)

show up white, and those which absorb with low attenuation
coefficients (weak absorption) show up black. This is quantified by the
Hounsfield Scale of radiodensity. Tissues with a high Hounsfield score
have a high attenuation coefficient, and so appear white:
Substance Hounsfield Value

Air -1000

Fat -70

Water 0

Blood 70

Bone 1000

Clinical Relevance: Intracranial bleeds

Intracranial bleeds are potentially life-threatening conditions, and occur

most commonly as an acute or delayed response to trauma. They can
occur spontaneously from the rupture of cerebral aneurysms, but this is
less common.

CT scanning has evolved to become to mainstay of investigation of

patients with a suspected intracranial bleed. There are four broad types
of intracranial bleed:

By TeachMeSeries Ltd (2019)

Fig 1.1 – CT scan of a massive extradural haematoma

Extradural: A bleed outside the dura mater, which creates a lentiform

(lemon shaped) bleed on CT. These are arterial, and frequently related
to blunt trauma. There may be a midline shift.

Subdural: A bleed between the dura and arachnoid layers, most

commonly due to a tearing of the bridging veins in the elderly. These
can become symptomatic up to a month after the initial insult. These
create crescenteric lesions on head CT, with a possible midline shift.

Subarachnoid: A ruptured aneurysm in the subarachnoid space leads to

a subarachnoid haemorrhage, although they can be a consequence of
trauma. Their radiographic features can be subtle; the CSF becomes
paler as it becomes tinted with blood, and the normally dark
subarachnoid cisterns turn white.

Intracerebral haemorrhage: Causes include hypertension, diabetes, and

trauma. They present on CT angiography as localised lesions, with
surrounding oedema due to inflammation.

Comparison to Other Imaging Techniques

CT scanning is the ideal imaging modality in emergency cases. It is often

the choice of examination for trauma patients in the emergency room
(due to its quick scan times). It is more efficient when an immediate
diagnosis is required such as intracranial bleeds, dissection of a blood
vessel, or renal stones.
The biggest drawback of CT is that it utilises radiation that can
potentially be harmful, especially with younger patients and children.
However, the benefits often outweigh the risk, and there has been an
upward trend in the use of CT in diagnostic imaging.

Technological advancements in CT have paved the way for more

advanced applications – such as virtual colonoscopy – which is quickly
replacing traditional barium enema studies. Cardiac gating on CT
scanners have allowed institutions to perform studies dedicated to the
cardiac arteries and to perform measurements of ejection fraction.
Specialised software has advanced 3D applications in CT, allowing for
better visualisation of certain pathologies.

Below is a summary table of the common imaging modalities.

Depending on the tissue being imaged, the urgency of the investigation
and the level of detail required, any of these techniques may be
preferred.

Factor CT (CT abdo used as example) MRI X-ray (CXR used as

example) Ultrasound

Duration 3-7 minutes 30-45 min 2-3 min 5-10 minutes

Cost Cheaper Expensive Cheap Cheap

Dimensions 3 3 2 2
Soft tissue Poor detail Excellent detail Poor detail Poor detail

Bone Excellent detail Poor detail Excellent detail Poor detail

Radiation 10mSv None 0.15mSv None