Role of Multidetector CT

(MDCT)
Dr. Peter Johnson
Consultant Radiologist
University Hospital of the
West Indies
• What does MDCT mean ?
CT-Principle
 Advantages of MDCT over
SDCT
• Improved spatial resolution
• Improved temporal resolution
 MDCT & Spatial Resolution
• 16 Slice scanners : Isotrophic
• No appreciable improvement in
quality (spatial resolution) with > 16
detectors
Multiplanar Reconstructions
(MPR)
Multiplanar Reconstructions
(MPR)
Multiplanar Reconstructions
(MPR)
Multiplanar Reconstructions
(MPR)
Volume Rendering
Surface Rendering
 MDCT & Temporal
Resolution
• > number of detectors, greater
volume covered per unit time
• > number of detectors, faster
scanning
• Better for CTA and Cardiac (esp)
• Advantage of 64 slice over 16 slice
etc.
 Temporal Resolution
• Useful for:
– Vascular work eg. CTA, CTV
– Phased scanning eg. Liver, Kidneys
– Functional work eg. CT Perfusion,
Cardiac CT
• Reduces scan time hence great for:
– Uncooperative patients
• SOB
• Confused (eg. Head injury etc)
• Paediatric
Reduced Frequency of Sedation of
Young
Children with Multisection Helical
CT
Pappas John N., Donnelly Lane F., Frush Donald P.

CONCLUSION: The rate of sedation was

reduced threefold with multisection helical
CT compared with standard helical CT, and
the need for sedation was eliminated in
some age groups.
Temporal Resolution
 Clinical Applications
• General body imaging (Chest, Abdomen &
Pelvis)
• Trauma
• CT Angiography (CTA)
• Cardiac CT
• Virtual Colonoscopy (and other virtual
endoscopy)
• CT perfusion
• Other
 Clinical Applications
• Cardiac….driving force in MDCT
– CT Coronary Angiography
– 4D Cardiac CT…..ventricular function
etc.
– Cardiac calcium scoring
 Coronary CTA
Interpreting the evidence: How accurate is
coronary computed
tomography angiography?

Abstract: Coronary CT angiography (CTA) has evolved rapidly into a

powerful diagnostic tool. More than 30 accuracy studies have reported
accuracy results in >2000 patients. A meta-analysis of 29 studies found
per-patient accuracy of 96% sensitivity, 74% specificity, 83% positive
predictive value, and 94% negative predictive value. Several clinical studies
support the safety and accuracy of coronary CTA for acute chest pain, after
inconclusive stress testing, and in preoperative evaluation of patients
before cardiac valve surgery. Accuracy studies suffer from selection bias
because of the inclusion only of patients previously selected to undergo
invasive angiography. This increases the incidence of true disease, raising
apparent sensitivity and lowering negative predictive value, although the
latter remains high at 94%. CTA has relatively low accuracy for the
quantitative assessment of stenosis severity. CTA accuracy studies show
high figures for sensitivity and negative predictive value in detection of
coronary lesions. CTA less accurately shows lesion severity, and
intermediate-grade lesions require physiologic evaluation. Clinical studies
 Coronary CTA
• High sensitivity and negative
predictive value
• Good selection tool for excluding
patients who are not candidates for
invasive cardiac catheterization
• Good screening tool
• Less acurate at demonstrating lesion
severity
– These patients need intervention
anyways !
 Coronary CTA
• The greater the detectors….better
temporal resolution
• MDCT scanners with greater detector
numbers perform better than lower
numbers

Coronary Arteries: Diagnostic Performance of 16-versus 64-

Section Spiral CT
Compared with Invasive Coronary Angiography-Meta-Analysis

Conclusion: Sixty-four-section spiral CT has significantly higher

specificity and PPV on
a per-patient basis compared with 16-section CT for the detection
 Pulmunary Thrombo-
embolism
– CT Pulmunary Angiography (CTPA) +/-
CT venography
– Recommended by PIOPED II
 CTPA
Suspected Acute Pulmonary Embolism: Evaluation with Multi-
Detector Row
CT versus Digital Subtraction Pulmonary Arteriography

PURPOSE: To determine diagnostic accuracy of four-channel

multi-detector row
computed tomography (CT) in emergency room and inpatient
populations suspected
of having acute pulmonary embolism (PE) who prospectively
underwent both CT and
pulmonary arteriography (PA).

CONCLUSION: Multi-detector row CT has an accuracy of 91% in the

depiction of
 Virtual Colonoscopy
• Utilizes endo-luminal rendering
• Similar bowel prep as optical
colonoscopy
• No need for sedation
• Several studies demonstrate Virtual Colonoscopy
performance on par with optical colonoscopy. Some
indicate superior performance

Johnson CD, Dachman AH. CT colonography: the next colon screening examination. Radiology
2000;216:331–341

Macari M, Bini EJ, Milano A, et al. Clinical significance of missed polyps at CT colonography. AJR
Am J Roentgenol
2004;183:127–134.

Pickhardt PJ, Choi JR, Hwang I, et al. Computed tomographic virtual colonoscopy to screen for
colorectal neoplasia in
asymptomatic adults. N Engl J Med 2003;349:2191–2200
 Virtual Colonoscopy:
Patient Tolerance
“Patients undergoing colorectal cancer screening prefer CT colonography to both
colonoscopy and DCBE. The
majority of patients experience discomfort and inconvenience with cathartic bowel
preparation.”

Thomas M. Gluecker, MD, C. Daniel Johnson, MD, William S. Harmsen, MS, Kenneth P. Offord, MS, Ann M.
Harris, BA, Lynn A.
Wilson, RN and David A. Ahlquist, MD
Radiology 2003;227:378-384

“CT colonography was considered less painful and less difficult overall than
colonoscopy and was the
preferred examination”
Maria H. Svensson, MD, Elisabeth Svensson, PhD, Anders Lasson, MD and Mikael Hellström, MD, PhD
Radiology 2002;222:337-345

“Patients preferred CT colonography to colonoscopy; however, this preference

decreased in time, while
outcome considerations gradually replaced temporary experiences of
inconvenience”
Virtual Colonoscopy
Virtual Colonoscopy
 Virtual Colonoscopy
• No established international or even
national protocol for:
– Performing study
– Evaluating and reporting studies
• Some differences in performance of
VC software by manufacturer
 Virtual Colonoscopy
• Problems:
– Poor detection rate for “flat” lesions
– Artefacts
– No consensus in performance and
reporting of studies
– No tissue sampling
– Patient compliance
– Cost
 Virtual Colonoscopy
• Current Established Indications:
– Failed Optical Colonoscopy (OTC)
– Evaluation of colon proximal to an
obstructing lesion
– Patients with contraindications to OTC
• Future:
– Screening….pending outcomes of Trials
 Brain Imaging
• MDCT rarely adds to routine brain
imaging
• Useful for:
– CTA (SAH)
– CT perfusion (Stroke)
– ENT imaging
 Cerebral CTA
• Has replaced catheter angiography
as the initial evaluation of the cause
of acute subarachnoid haemorrhage
in many centres
 Cerebral CTA
MDCT Angiography for Detection and Quantification of
Small Intracranial
Arteries: Comparison with Conventional Catheter
Angiography

CONCLUSION: Except for the recurrent artery of

Heubner and the anterior
choroidal artery, MDCT angiography depicted 90% or
more of all examined
small intracranial arteries detected with digital
subtraction angiography. The
mean sensitivity was 0.91, and the mean specificity
was 0.7.

Villablanca JP, Rodriguez FJ, Stockman T, Dahliwal S, Omura M, Hazany S, Sayre J.

AJR 2007; 188:593-602
 Cerebral CTA
Intracranial Aneurysms: Role of Multidetector
CT Angiography
in Diagnosis and Endovascular Therapy
Planning

Conclusion: Multidetector CT angiography offers high

diagnostic accuracy-
equivalent to that of DSA-in the detection of
intracranial aneurysms. Also,
the possibility of coil embolization can be reliably
determined with
multidetector CT angiography.

Karsten Papke, MD Christian K. Kuhl, MD Martin Fruth, MD Cornel Haupt, MD Martin

 Peripheral CTA
• Good non-invasive tool for evaluating
peripheral arterial disease.
 Peripheral CTA
Aortoiliac and Lower Extremity Arteries Assessed with 16–
Detector Row CT
Angiography: Prospective Comparison with Digital
Subtraction Angiography

“In this study, the improved spatial resolution obtained with a 16–
detector row CT
scanner is reflected in the total sensitivity and specificity (96% and
97%, respectively,
for both readers) in the detection of hemodynamically significant
arterial stenosis of
aortoiliac and lower extremity arteries. In particular, excellent
sensitivities (ie, 96% and
97% for readers 1 and 2, respectively) and specificities (ie, 95% and
96% for readers 1
and 2, respectively) for grading small popliteocrural arteries were
obtained in this
Peripheral CTA
 Whole Body CT
Cost-effectiveness of Whole-Body CT
Screening

“Compared with routine care, whole-body

CT
screening provided minimal gains in life
expectancy
(0.016 6 years or 6 days) at an average
additional cost
of $2513 per patient, or an incremental
cost
 However….
• MDCT is not indicated for
everything !
• It isn’t indicated at all in certain
cicumstances
• Not the study of choice in many
circumstances
• Should be used with caution in some
circumstances
e.g.
 Not the study of Choice:
• MRI:
– Intra and extra-axial intracranial
tumours
– Congenital brain anomalies
– Myelopathy & Radiculopathy (Traumatic
& Non-traumatic)
 Not the study of Choice:
• Ultrasound:
– Initial evaluation of neonatal intracranial
events e.g. Germinal Matrix
Haemorrhage (CT not indicated for this
pathology), ? Hydrocephalus.
– Acute gynecologic events e.g. ? Ectopic,
ruptured ovarian cysts, ovarian torsion
 Use with caution……
• Pregnant patients (especially 1st
trimester)
• Paediatric patients

Radiation Effects
 Radiation Dose
“On the basis of such risk estimates and data on CT use from
1991 through
1996, it has been estimated that about 0.4% of all cancers in
the United States
may be attributable to the radiation from CT studies. By
adjusting this
estimate for current CT use, this estimate might now be in the
range of 1.5 to
2.0%”

David J. Brenner, Ph.D., D.Sc., and Eric J. Hall, D.Phil., D.Sc.

NEJM 2007; 357:2277-2284
Radiation Risks
 Radiation Dose
“Relative to CT scanners from the
early 1990s,
present-day MDCT scanners result in
doses that
are ~1.5 and -1.7 higher per unit mAs
in head
and body phantoms, respectively.”

Huda W, Vance A
AJR 2007; 188:540-546
 However……..
• To date, no example of cancer
definitely attributable to exposure to
diagnostic x-ray doses has been
reported.
• Data represent extrapolated risk
estimates related to known cancer
incidences from exposure at
Hiroshima and “therapeutic Xray
treatments” in the early 20th century.
 Radiation
• Care and good judgement should be
excersised….esp. paediatric
population.
• Risk/Benefit
• Indications
• Contraindications (including no
indication !)
 And so…….
• MDCT has revolutionized diagnostic
imaging
• Tremendous potential
• High radiation dose
• Not indicated for everything !
• Not a replacement for other
modalities
Thank you