CT was developed in 1972-1974 by Sir Geoffrey Hounsfield and his colleagues in England.
Strengths of CT Fast - typical high-quality brain CT requires 10-20 seconds (it takes far more time to position patient in machine than it does to do scan) – easy to use for follow up of critically ill patients.
Easy to monitor patients (vs. MRI incompatibility with ferromagnetic materials)
Simplicity of interpretation - all contrast on CT images is due to differences in electron density (appearance is determined by single parameter - images are relatively easy to interpret).
If disease of interest does not change electron density, it will be invisible on CT!
Can easily detect acute hemorrhage and calcification
Excellent for studying bones
Weaknesses of CT Less sensitive to parenchymal lesions (than MRI) - normal intracranial structures have narrow range of electron density.
**in any case of suspected acute hemorrhage, contrast medium should not be administered (similar attenuation characteristics to acute extravascular blood)
N.B. acute hematoma has high attenuation owing to clot retraction with separation of high-density erythrocytes from lower density plasma;
N.B. unclotted blood (coagulopathy or hyperacute active bleeding) is seen as relative lucency!
brain windows (60-80 HU) accentuate minor difference in Hounsfield units between white and gray matter.
bone windows (2000-4000 HU): brain is not seen!
bone evaluation (in trauma, bone infection, bone neoplasm)
detection of intracranial air (can separate air and fat density).
subduralwindows (150-200 HU) - to identify acute subdural hematomas (would blend with calvarium on routine brain images).
Intravenous contrast enhancement
Basics, Indications → see p. D45 >>
Pregnancy concerns – see below >>
In general, it is preferable to perform MRI than to perform CT with contrast enhancement
CT without contrast enhancement is of little value in diagnosis of brain tumors or other mass lesions!
although hemorrhage, calcifications, hydrocephalus, shifts can be well seen on non-contrast CT, underlying causative structural abnormality can be missed.
routine use of nonenhancedCT scan before enhanced scan is of limited usefulness (recommended only for lesions with hemorrhagic / calcified components).
- water-soluble iodinated:
non-ionic (more expensive but safer! - low-osmolality - extremely low incidence of side effects)
Specific indications for nonionic contrast agents: previous adverse reaction to ionic agent, asthma, multiple allergies, cardiac problems (incl. CHF, pulmonary hypertension), severe general debilitation.
Maximum dose with normal renal function – 86-90 gm of iodine in 24 hour period.
given as intravenous drip or as IV bolus.
CTA uses ≈ 21 gm of iodine – GFR has to be > 45 (vs. > 30 for gadolinium)
Side effects - iodinated contrast agents are physiologically inert except for:
In general, both high- and low-osmolar contrast agents are extremely safe!
Allergy (rare*, readily manageable); prophylaxis (e.g. in patients with allergic histories – best use MRI instead):
prednisone 50 mg orally (13, 7, and 1 hour before contrast injection).
diphenhydramine 50 mg orally (1 hour before contrast injection).
history of laryngospasm / hypotension with previous use of contrast → anesthesiologist should be present during contrast administration.
*severe allergic reactions - 0.04% patients receiving nonionic media
sensation of heat, pain, nausea, vomiting (well-known side effect of ionic contrast media).
potential nephrotoxicity (contrast nephropathy);
risk is very little in normally hydrated patients who do not have kidney disease.
states that predispose to kidney injury: advanced age, multiple myeloma, severe diabetes, dehydration, recent aminoglycoside exposure, preexisting chronic renal dysfunction (anuria, hepatorenal syndrome, serum creatinine > 3 mg/dL).
definition of contrast nephropathy: rise in serum [creatinine] of at least 1 mg/dL within 48 h of contrast administration.
prognosis is usually favorable.
prophylaxis – good hydration (± bicarbonates, acetylcysteine) prior IV contrast administration.
Guidelines for use of IV contrast in impaired renal function:
Serum Creatinine, μmol/L (mg/dL)
< 133 (< 1.5)
Use contrast at 2 mL/kg (max. 150 mL total)
Use nonionic contrast; hydrate diabetics
> 177 (> 2.0)
Consider noncontrast CT or MRI
Nonionic contrast contraindicated in diabetics
> 265 (> 3.0)
Nonionic contrast given only to patients undergoing dialysis within 24 h
Iodinated contrast (IV or intra-arterial) may delay excretion of metformin;
manufacturer recommends withholding metformin 48 hrs prior to and following contrast administration (or longer if there is evidence of declining renal function following use of contrast).
N.B. avoid of iodine contrast in diabetics who are getting oral antidiabetic agents like metformin - risk of lactic acidosis!!!