CT low-dose – indicatii si

tehnici

DR. RADU DUMITRU

DR. SORINA POPESCU
 CT low-dose – etaj toracic

- screening pentru cancerul pulmonar (detectia nodulilor pulmonari);

- cuatificarea densitometriei pulmonare si detectia emfizemului
pulmonar;
- fibroza chistica in segmentul pediatric (Thin-Section low-dose CT);
- calcificari pe arterele coronare – valoare predictiva pentru bolile
cardio-vasculare;
• - low-dose CT : 2.1 ± 0.5 mSv
• - ultralow-dose CT : 0.13 ± 0.04 mSv
• filtered back projection (FBP) pentru low-dose CT
• iterative reconstruction (IR) pentru ultralow-dose CT
 CT low-dose – etaj toracic

- la pacientii normoponderali se poate efectua

CT sincronizat EKG (gating EKG) – rezultate foarte
bune in detectia stenozelor arterelor coronare.
- Sensibiliatate : 100%
- Specificitate : 82%
 TABLE 1: Quantitative Assessment of Emphysema and Image Noise in
Low-Dose and Ultralow-Dose CT
Value Low-Dose CT Ultralow-Dose Ultralow-Dose p
With Filtered CT CT
Back Projection Filtered Back Iterative
Projection Reconstruction

Total lung 5180 ± 1161 5183 ± 1173 5192 ± 1171 0.942

volume (mL)
Mean lung −825 ± 32 −818 ± 32 −820 ± 32 < 0.001
attenuation
(HU)
Emphysema 1.3 ± 1.7 8.4 ± 4.1 3.5 ± 2.5 < 0.001
index (%)
15th Percentile −902 ± 23 −923 ± 23 −907 ± 23 < 0.001
of lung
attenuation
(HU)

Image noise 14 ± 3 44 ± 10 26 ± 5 < 0.001

(HU)
 CT low-dose – etaj abdomino-pelvin
• Apendicita acuta
• Litiaza reno-vezicala
• Colecistita acuta
• Diverticulita
• Enterografia in boala Crohn (ileala)
• Polipoza colo-rectala
• Biopsii/drenaje
• Screening al continuturilor ilegale intracorporeale
(“Body Packing”)
 APENDICITA ACUTA
• 500 mL contrast oral cu cel putin 1 ora inainte de
examinare, pentru opacifiere cecala optimala

• LDCT: colimare 5mm, pitch 1,25; 120 kv si 30 mAs, cu

CTDIvol= 2,1 mGy
• Standard CT: 120 ml contrast iv, achizitie la 60’’ de la
injectare; colimare 5mm, pitch 1.0; 120 kv 180 mAs cu
CTDIvol= 12,6 mGy

• DLP: LDCT= 1,2 ± 0,2 mSv vs Standard CT= 7.2±0.6 mSv

 Protocol de examinare
• Studiu ecografic initial, ce triaza pacientii in functie
de rezultat (pozitiv pentru apendicita, indeterminat
sau pozitiv pentru o patologie alternativa)

• LDCT cu contrast oral

• CT standard cu injectare iv la pacientii la care LDCT

este neconcludent sau la care se obiectiveaza o
patologie alternativa
 Criterii CT low-dose de diagnostic
• Prezenta apendicolitului

• Diametrul > 6mm

• Prezenta/ absenta gazului intralumenal apendicular

• Ingrosare parietala cecala la nivelul bazei apendiculare

• Infiltrarea grasimii periapendiculare

• Abces pericecal

• Arrowhead sign

• Lipsa opacifierii intralumenale apendiculare

• Lichid liber in gutiera paracolica dreapta sau fundul de sac Douglas

LDCT. Apendicita perforata
a,b – low-dose CT; c,d – standard CT
a - arrowhead sign and caecal wall thickening (arrow). B Enlargement of the appendix
a b

c d
a,b – low-dose CT; c,d – standard CT
 LITIAZA RENO-VEZICALA
• CT KUB este gold standard pentru litiaza reno-vezicala;

• marea majoritate a calculilor sunt radiodensi (99%); calculi > 1 mm sunt vizualizati CT
- sensibilitate 85.7% ; specificitatea CT fiind de 100% .

• CT KUB poate de asemenea detecta semne secundare obstructiei urinare:

- ureterohidronefroza si edem perirenal.

• Datorita paucitatii tesutului adipos la pacientii subponderali, pot aparea dificultati in

diferentierea flebolitilor de calculi;

• 2 semne ne pot ajuta:

• comet-tail sign: flebolit
• soft-tissue rim sign: calcul
• PENTRU TRIEREA PACIENTILOR SE PRACTICA US!!!!!
 LITIAZA RENO-VEZICALA
DOZA de iradiere :
• Standard CT: 857 mGy ∙ cm +/- 395
• Low dose-CT: 101 mGy ∙ cm +/- 39
• 2.5mm; 0.5 s; pitch 1.375; 50–100 mA; 80 kV
(rinichi-creasta iliaca)/100 kV (creasta iliaca-
pelvis);
• Standard-dose CT: 21.7 mGy
• Reduced/low-dose CT: 3.4 mGy
LITIAZA RENO-VEZICALA
STD CT Reduced/Low-dose CT
LITIAZA RENO-VEZICALA
 COLECISTITA ACUTA
Colecistita acuta presupune o inflamatie acuta a colecistului, apare ca urmare a litiazei, in cele
mai multe din cazuri .
Clinic:
- durere in hipocondrul drept cu iradiere in umarul drept;
- durerea persista mai mult de 6 h, comparativ cu durerea intermitenta din colica biliara;
- se poate asocia cu greata, febra, varsaturi;
Patologie:
- aproximativ 90-95% din cazuri se datoreaza calculilor;
- obstructie de cauza litiazica a infundibulului sau cisticului;
- inflamatie a mucoasei datorita sarurilor biliare cu cresterea presiunii intralumenale, distensie
importanta intralumenala cu restrictia fluxului sangvin (hidrops vezicular);
- ingrosarea peretelui (edem si modificari inflamatorii);
- secundara infectiilor bacteriene la cca. 66% din pacienti;
Ecografia:
- prezenta calcului si semn Murphy pozitiv ecografic !!!
- ingrosarea peretelui (>4 mm) si lichid pericolecistic;
- distensia colecistului si sludge;
 COLECISTITA ACUTA
CT:
Litiaza (doar daca sunt calculi cu continut crescut de saruri de Ca)
- distensia colecistului;
- ingrosarea peretelui colecistului;
- fluid pericolecistic si densificarea grasimii din adiacenta;
- ~75% sensibilitate si ~95% specificitate .
CRITERII CT:
MAJORE:
– Prezenta calculilor;
– Ingrosarea peretelui;
– Fluid pericolecistic;
– Edem
MINORE:
– Distensia colecistului;
– Sludge;
Diagnosticul de colecistita acuta se pune daca sunt prezente: 1 criteriu major
si 2 minore !
 COLECISTITA ACUTA
• Protocol CT:
- 500 mL contrast oral negativ cu cel putin 30 min
inainte de examinare, pentru distensia cadrului
duodenal;

LDCT: colimare 5mm, pitch 1,25; 120 kv si 30 mAs, cu

CTDIvol= 2,1 mGy

DLP: LDCT= 1,2 ± 0,2 mSv vs Standard CT= 7.2±0.6 mSv

COLECISTITA ACUTA
COLECISTITA ACUTA
 DIVERTICULITA

Diverticuloza este de obicei asimptomatica,

pacientii acuzand dureri abdominale sau
tulburari de tranzit asemanatoare celor din
sindromul de colon iritabil. La 10-25% din
pacientii cu diverticuloza pot aparea
complicatii.
 DIVERTICULITA

Clinic:
- durere continua in FIS cu aparare musculara;
- in cazul unui flegmon constituit se poate uneori palpa;

Diverticulita reprezinta rezultatul unei obstructii a capului diverticulului, cu inflamatie secundara –

perforatie – infectie. Initial inflamatia si infectia sunt localizate (cloazonate) – ulterior se pot abceda –
peritonita generalizata.

CT:
- densificarea grasimii pericolice;
- ingrosare segmentara a peretelui intestinal;
- iodofilie a peretelui colonic;
- perforatie diverticulara;  
- extravazare de aer si fluid in pelvis si cavitatea peritoneala;
- formarea unui abces (in cca. 30% cazuri), poate contine bule de gaz, fluid sau mixt;
- formare de fistule (vizualizare de aer in vezica urinara sau directa vizualizare a unui traiect fistulos)
 DIVERTICULITA
Complicatii:

1. Abces;
2. Fistula:
- colo-vezicala;
- colo-vaginala;
- colo-enterica;
- colo-colica;
- colo-cutanata;
3. Obstructii de intestin subtire datorate aderentelor;
4. Perforatia – pneumoperioneu;

Tratamentul depinde de comorbiditatile pacientului si stadiu.

Stadiu I,II – tratament conservator cu antibiotice.
Abces mare – drenaj!
 DIVERTICULITA

• Low-dose CT nativ are performante similare cu cel al Standard CT cu

contrast!

• 1500 ml contrast oral negativ cu cca. 1h 30’-2 h inainte de examinare in

cazul diverticulitei necomplicate;

• 1500 ml contrat oral pozitiv cu cca. 1h 30’-2 h inainte de examinare in

cazul diverticulitei complicate;

• 120 kVp, 35mA, colimare 2.5mm, contrast i.v. 2ml/s la 70s

 DIVERTICULITA
Reduced/Low-dose CT STD CT
 ENTEROGRAFIA IN BOALA CROHN (ILEALA)

• Half-dose CT: reconstructii cu filtered back

projection (FBP) si sinogram-affirmed iterative
reconstruction (SAFIRE)
• Full-dose CT
 ENTEROGRAFIA IN BOALA CROHN (ILEALA)

- 1500 ml contrast oral negativ (apa simpla sau apa cu Manitol

1000 ml apa cu 500 ml Manitol)

The volume CT dose index (CTDIvol):

- de la 3.62 -44.5 mGy (mean, 13.1 mGy;median, 7.36 mGy)

pentru full-dose scans;
- de la 1.81-22.25 mGy (mean, 6.5 mGy; median, 3.68 mGy)
pentru halfdose scans.

- 0.5s, 6mm pitch, 3mm (thick reconstructed sections)

Boala CROHN – boala inflamatorie intestinala ce poate afecta intregul tract digestiv cu leziuni
“pe sarite”.

Clinic:
- diaree cronica;
- dureri abdominale;
- manifestari extraintestinale:
Intestin subtire :70-80% 
Intestin subtire si gros: 50%
Intestin gros: 15-20%

CT
• fat halo sign;
• comb sign;
• Iodofilia peretelui afectat;
• Ingrosarea peretelui (1-2 cm) mai frecvent la nivelul ileonului terminal (83% ); 
• Stricturi sau fistule;
• abcese intraabdominale (15-20% din cazuri) sau formare de flegmon;

CT poate da informatii si despre:

- boala perianala;
- boala hepatobiliara.
(a), half-dose FBP (b), half-dose SAFIRE 3 (c) half-dose SAFIRE 4 (d) with a confidence score of
“probably” or “definitely” Crohn disease
(a), half-dose FBP (b), half-dose SAFIRE 3 (c), and half-dose SAFIRE 4 (d) show
hyperenhancement and marked wall thickening in terminal ileum (arrows). All readers
accurately diagnosed active disease with a confidence score of “probably” or “definitely”
Crohn disease.
 Polipoza colo-rectala

• Colimare 4 x2.5-mm; 3 mm grosime; 1.0-mm

reconstruction interval, 17.5 mm/sec table speed;
gantry rotation time of 0.5 seconds, 140 kV, 10 mAs.
• 2.74 mGy.
• Timp de achizitie 14-20 s.
• Low-dose CT colonography are rezultate comparabile
cu cele ale colonoscopiei pentru detectia polipilor
colo-rectali de 6 mm sau > 6 mm diametru
(performante scazute pentru detectia polipilor < 5
mm).
Polip de 7 mm (a) Transverse CT colonographic image shows the polyp with round borders in the sigmoid colon. (b)
Coronal CT colonographic image clearly shows the polyp. (c) Three-dimensional volume-rendered endoluminal CT image
clearly demonstrates the polyp’s sessile structure. (d) Initial conventional colonoscopic image shows the polyp, which
was removed at second colonoscopy and found to be a tubular adenoma at histologic analysis.
Polip de 14 mm (a) Transverse CT colonographic image shows the polyp with round borders in the transverse colon. (b)
Coronal CT colonographic image findings confirm the presence of the polyp. (c) Three-dimensional volumerendered
endoluminal CT image clearly demonstrates that the polyp is located behind a colonic fold (arrowheads). (d) Second
conventional colonoscopic image shows the polyp. Despite its relatively large size, this polyp was missed at initial
colonoscopy and difficult to detect even at second colonoscopy owing to its location behind the colonic fold. Histologic
evaluation revealed this polyp to be a tubulovillous adenoma.
2 polipi de 4 si 8 mm (a) Initial conventional colonoscopic image shows the 8-mm polyp (white arrow) within the cecum.
The 4-mm polyp (black arrow) can also be seen. These polyps were not detected at CT colonography by the three
observers, and both were confirmed and removed at second colonoscopy. At histologic analysis, these lesions were
shown to be hyperplastic polyps. (b) Coronal CT colonographic image obtained at retrospective analysis shows no
abnormality in the well-distended cecum (C). (c) Three-dimensional volumerendered endoluminal CT image obtained at
retrospective analysis clearly shows the anatomy of the cecum, but no polyp is depicted. (d) Another three-dimensional
volume-rendered endoluminal CT image obtained at retrospective analysis reveals no abnormality of the cecal mucosa.
Leziune fals-pozitiva de 4 mm (a) Transverse CT colonographic image shows the lesion in the sigmoid colon. (b) Sagittal CT
colonographic image findings confirm the presence of the lesion. (c) Three-dimensional volume-rendered endoluminal CT
image clearly shows the lesion. Although all three observers reported this lesion to be a polyp, it was not seen at first or
second colonoscopy. This lesion is believed to represent fecal residue.
 Drenaje/biopsii
• (a) scaderea planului de scanare cranio-
caudal;
• (b) scaderea (kVp),
• (c) scaderea (mA),
• (d) cresterea pitch.
Illegal Intracorporeal Containers
(“Body Packing”)
VA MULTUMESC PENTRU ATENTIE!