Computerized Tomography (CT) Scan in India : What You Should Know?

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Computerized Tomography (CT) Scan

Computed Tomography

A Multislice CT Scanner: Philips ‘Brilliance’ 64-channel thin-slice

Computed tomography (CT) is a medical imaging method employing tomography. Digital geometry processing is used to generate a three-dimensional image of the inside of an object from a large series of two-dimensional X-ray images taken around a single axis of rotation. The word “tomography” is derived from the Greek tomos (slice) and graphein (to write).

Computed tomography was originally known as the “EMI scan” as it was developed at a research branch of EMI, a company best known today for its music and recording business. It was later known as computed axial tomography (CAT or CT scan) and body section röntgenography.

CT produces a volume of data which can be manipulated, through a process known as windowing, in order to demonstrate various structures based on their ability to block the X-ray/Röntgen beam. Although historically (see below) the images generated were in the axial or transverse plane (orthogonal to the long axis of the body), modern scanners allow this volume of data to be reformatted in various planes or even as volumetric (3D) representations of structures.

Although most common in medicine, CT is also used in other fields, such as nondestructive materials testing. Another example is the DigiMorph project at the University of Texas at Austin which uses a CT scanner to study biological and paleontological specimens.

History

In the early 1930s, the Italian radiologist Alessandro Vallebona proposed a method to represent a single slice of the body on the radiographic film. This method was known as tomography. The idea is based on simple principles of projective geometry: moving synchronously and in opposite directions the X-ray tube and the film, which are connected together by a rod whose pivot point is the focus; the image created by the points on the focal plane appears sharper, while the images of the other points annihilate as noise. This is only marginally effective, as blurring occurs only in the “x” plane. There are also more complex devices which can move in more than one plane and perform more effective blurring.

Tomography had been one of the pillars of radiologic diagnostics until the late 1970s, when the availability of minicomputers and of the transverse axial scanning method, this last due to the work of Godfrey Hounsfield and Allan McLeod Cormack, gradually supplanted it as the modality of CT.

The first commercially viable CT scanner was invented by Sir Godfrey Hounsfield in Hayes, United Kingdom at EMI Central Research Laboratories using X-rays. Hounsfield conceived his idea in 1967, and it was publicly announced in 1972. Allan McLeod Cormack of Tufts University in Massachusetts independently invented a similar process, and both Hounsfield and Cormack shared the 1979 Nobel Prize in Medicine.

The prototype CT scanner

The original 1971 prototype took 160 parallel readings through 180 angles, each 1° apart, with each scan taking a little over five minutes. The images from these scans took 2.5 hours to be processed by algebraic reconstruction techniques on a large computer. The scanner had a single photomultiplier detector, and operated on the Translate/Rotate principle.

It has been claimed that thanks to the success of The Beatles, EMI could fund research and build early models for medical use. The first production X-ray CT machine (in fact called the “EMI-Scanner”) was limited to making tomographic sections of the brain, but acquired the image data in about 4 minutes (scanning two adjacent slices), and the computation time (using a Data General Nova minicomputer) was about 7 minutes per picture. This scanner required the use of a water-filled Perspex tank with a pre-shaped rubber “head-cap” at the front, which enclosed the patient’s head. The water-tank was used to reduce the dynamic range of the radiation reaching the detectors (between scanning outside the head compared with scanning through the bone of the skull). The images were relatively low resolution, being composed of a matrix of only 80 x 80 pixels. The first EMI-Scanner was installed in Atkinson Morley Hospital in Wimbledon, England, and the first patient brain-scan was made with it in 1972.

A historic EMI-Scanner

In the U.S., the first installation was at the Mayo Clinic. As a tribute to the impact of this system on medical imaging the Mayo Clinic has an EMI scanner on display in the Radiology Department.

The first CT system that could make images of any part of the body and did not require the “water tank” was the ACTA (Automatic Computerized Transverse Axial) scanner designed by Robert S. Ledley, DDS at Georgetown University. This machine had 30 photomultiplier tubes as detectors and completed a scan in only 9 translate/rotate cycles, much faster than the EMI-scanner. It used a DEC PDP11/34 minicomputer both to operate the servo-mechanisms and to acquire and process the images. The Pfizer drug company acquired the prototype from the university, along with rights to manufacture it. Pfizer then began making copies of the prototype, calling it the “200FS” (FS meaning Fast Scan), which were selling as fast as they could make them. This unit produced images in a 256×256 matrix, with much better definition than the EMI-Scanner’s 80×80.

Previous Studies

Tomography

A form of tomography can be performed by moving the X-ray source and detector during an exposure. Anatomy at the target level remains sharp, while structures at different levels are blurred. By varying the extent and path of motion, a variety of effects can be obtained, with variable depth of field and different degrees of blurring of ‘out of plane’ structures.

Although largely obsolete, conventional tomography is still used in specific situations such as dental imaging (orthopantomography) or in intravenous urography.

Tomosynthesis

Digital tomosynthesis combines digital image capture and processing with simple tube/detector motion as used in conventional radiographic tomography – although there are some similarities to CT, it is a separate technique. In CT, the source/detector makes a complete 360 degree rotation about the subject obtaining a complete set of data from which images may be reconstructed. In digital tomosynthesis, only a small rotation angle (e.g. 40 degrees) with a small number of discrete exposures (e.g. 10) are used. This incomplete set of data can be digitally processed to yield images similar to conventional tomography with a limited depth of field. However, because the image processing is digital, a series of slices at different depths and with different thicknesses can be reconstructed from the same acquisition, saving both time and radiation exposure.

Because the data acquired is incomplete, tomosynthesis is unable to offer the extremely narrow slice widths that CT offers. However, higher resolution detectors can be used, allowing very-high in-plane resolution, even if the Z-axis resolution is poor. The primary interest in tomosynthesis is in breast imaging, as an extension to mammography, where it may offer better detection rates, with little extra increase in radiation exposure.

Reconstruction algorithms for tomosynthesis are significantly different from conventional CT, as the conventional filtered back projection algorithm requires a complete set of data. Iterative algorithms based upon expectation maximization are most commonly used, but are extremely computationally intensive. Some manufacturers have produced practical systems using commercial GPUs to perform the reconstruction.

Types of modern CT acquisition

1. Dynamic volume CT
   During the Radiological Society of North America (RSNA) in 2007, Toshiba Medical Systems introduced the world’s first dynamic volume CT system, Aquilion ONE. This 320-slice CT scanner, with its 16 cm anatomical coverage, can scan entire organs such as heart and brain, in just one single rotation, thereby also enabling dynamic processes such as blood flow and function to be observed.
   Whereas patients exhibiting symptoms of a heart attack or stroke have until now normally had to submit to a variety of examinations preparatory to a precise diagnosis, all of which together took up a considerable amount of time, with dynamic volume CT this can be decreased to a matter of minutes and one single examination. Functional imaging can thus be performed rapidly, with the least possible radiation and contrast dose combined with very high precision.
2. Scout/pilot/tomogram
   A Scout image is used in planning the exam and to establish where the target organs are located. The beginning and end of the scan are set by the target region and the location of the patient on the table. Once the Scout image is created it is used to determine the extent of the desired Axial/Helical scan. During the Scout scan the gantry is rotated to a fixed position and the table is translated as x-ray is delivered. The image appears similar to a radiograph.
3. Axial
   In axial “step and shoot” acquisitions each slice/volume is taken and then the table is incremented to the next location. In multislice scanners each location is multiple slices and represents a volume of the patient anatomy. Tomographic reconstruction is used to generate Axial images.
4. Cine
   A cine acquisition is used when the temporal nature is important. This is used in Perfusion applications to evaluate blood flow, blood volume and mean transit time. Cine is a time sequence of axial images. In a Cine acquisition the cradle is stationary and the gantry rotates continuously. Xray is delivered at a specified interval and duration.
5. Helical/spiral
   A helical scan is a very fast way to examine the target anatomy. Here a gantry holding the source and detector array rotates as the patient is translated along the axis of rotation. The volume is scanned very quickly because the table is in constant motion as the gantry rotates continuously. There is no interscan delay between slices as in an Axial acquisition.
6. DRR
   A Digitally Reconstructed Radiograph is a simulation of a conventional 2D x-ray image, created from computed tomography (CT) data. A radiograph, or conventional x-ray image, is a single 2D view of total x-ray absorption through the body along a given axis. Two objects (say, bones) in front of one another will overlap in the image. By contrast, a 3D CT image gives a volumetric representation. (Earlier CT data sets were better thought of as a set of 2D cross sectional images.) Sometimes one must compare CT data to a classical radiograph, and this can be done by comparing a DRR based on the CT data. An early example of their use is the beam’s eye view (BEV) as used in radiotherapy planning. In this application, a BEV is created for a specific patient and is used to help plan the treatment.
   DRRs are created by summing CT intensities along a ray from each pixel to the simulated x-ray source.
   Since 1993, the Visible Human Project (VHP) has made full body CT data available to researchers. This has allowed several universities and commercial companies to try and create DRR’s. These have been suggested as useful for training simulations in Radiology and Diagnostic Radiography. It takes a significant number of calculations to create a summative 3D image from a large amount of 2D data. This is an area of medical science and education that has benefited from the advancing of graphics card technology, driven by the computer games industry.
   Another novel use of DRR’s is in identification of the dead from old radiographic records, by comparing them to DRR’s created from CT data.
7. Electron beam CT
   Electron beam tomography (EBCT) was introduced in the early 1980s, by medical physicist Andrew Castagnini, as a method of improving the temporal resolution of CT scanners. Because the X-ray source has to rotate by over 180 degrees in order to capture an image the technique is inherently unable to capture dynamic events or movements that are quicker than the rotation time.
   Instead of rotating a conventional X-ray tube around the patient, the EBCT machine houses a huge vacuum tube in which an electron beam is electro-magnetically steered towards an array of tungsten X-ray anodes arranged circularly around the patient. Each anode is hit in turn by the electron beam and emits X-rays that are collimated and detected as in conventional CT. The lack of moving parts allows very quick scanning, with the single slice acquisition in 50-100 ms, making the technique ideal for capturing images of the heart. EBCT has found particular use for assessment of coronary artery calcium, a means of predicting risk of coronary artery disease.
   The very high cost of EBCT equipment, and its poor flexibility (EBCT scanners are essentially single-purpose cardiac scanners), has led to poor uptake; fewer than 150 of these scanners have been installed worldwide. EBCT’s role in cardiac imaging is rapidly being supplanted by high-speed multi-detector CT, which can achieve near-equivalent temporal resolution with much faster z-axis coverage.
8. Helical or spiral CT
   Helical, also called spiral, CT was first introduced by Slavin PE in March, 1969 (US Patent 3432657,”X-RAY HELICAL SCANNING MEANS FOR DISPLAYING AN IMAGE OF AN OBJECT WITHIN THE BODY BEING SCANNED”). In older CT scanners, the X-ray source would move in a circular fashion to acquire a single ‘slice’, once the slice had been completed, the scanner table would move to position the patient for the next slice; meanwhile the X-ray source/detectors would reverse direction to avoid tangling their cables.
   In helical CT the X-ray source (and detectors in 3rd generation designs) are attached to a freely rotating gantry. During a scan, the table moves the patient smoothly through the scanner; the name derives from the helical path traced out by the X-ray beam. It was the development of two technologies that made helical CT practical: slip rings to transfer power and data on and off the rotating gantry, and the switched mode power supply powerful enough to supply the X-ray tube, but small enough to be installed on the gantry.
   The major advantage of helical scanning compared to the traditional shoot-and-step approach, is speed; a large volume can be covered in 20-60 seconds. This is advantageous for a number or reasons:
   • often the patient can hold their breath for the entire study, reducing motion artifacts,
   • it allows for more optimal use of intravenous contrast enhancement, and
   • the study is quicker than the equivalent conventional CT permitting the use of higher resolution acquisitions in the same study time.

   The data obtained from spiral CT is often well-suited for 3D imaging because of the lack of motion mis-registration and the increased out of plane resolution. These major advantages led to the rapid rise of helical CT as the most popular type of CT technology.
   Despite the advantages of helical scanning, there are a few circumstances where it may not be desirable – there is, of course, no difficulty in configuring a helical capable scanner for scanning in shoot-and-step mode. All other factors being equal, helical CT has slightly lower z-axis resolution than step-and-shoot (due to the continual movement of the patient). Where z-resolution is critical but where it is undesirable to scan at a higher resolution setting (due to the higher radiation exposure required) e.g. brain imaging, step-and-shoot may still be the preferred method.

9. Multislice CT
   Multislice CT scanners are similar in concept to the helical or spiral CT but there are more than one detector ring. It began with two rings in mid nineties, with a 2 solid state ring model designed and built by Elscint (Haifa) called CT TWIN, with one second rotation (1993): It was followed by other manufacturers. Later, it was presented 4, 8, 16, 32, 40 and 64 detector rings, with increasing rotation speeds. Current models (2007) have up to 3 rotations per second, and isotropic resolution of 0.35 mm voxels with z-axis scan speed of up to 18 cm/s.. This resolution exceeds that of High Resolution CT techniques with single-slice scanners, yet it is practical to scan adjacent, or overlapping, slices – however, image noise and radiation exposure significantly limit the use of such resolutions.
   The major benefit of multi-slice CT is the increased speed of volume coverage. This allows large volumes to be scanned at the optimal time following intravenous contrast administration; this has particularly benefitted CT angiography techniques – which rely heavily on precise timing to ensure good demonstration of arteries.
   Computer power permits increasing the postprocessing capabilities on workstations. Bone suppression, volume rendering in real time, with a natural visualization of internal organs and structures, and automated volume reconstruction really change the way diagnostic is performed on CT studies and this models become true volumetric scanners. The ability of multi-slice scanners to achieve isotropic resolution even on routine studies means that maximum image quality is not restricted to images in the axial plane – and studies can be freely viewed in any desired plane.
10. Dual-source CT
    Siemens introduced a CT model with dual X-ray tube and dual array of 64 slice detectors, at the 2005 Radiological Society of North America (RSNA) medical meeting. Dual sources increase the temporal resolution by reducing the rotation angle required to acquire a complete image, thus permitting cardiac studies without the use of heart rate lowering medication, as well as permitting imaging of the heart in systole. The use of two x-ray units makes possible the use of dual energy imaging, which allows an estimate of the average atomic number in a voxel, as well as the total attenuation. This permits automatic differentiation of calcium (e.g. in bone, or diseased arteries) from iodine (in contrast medium) or titanium (in stents) – which might otherwise be impossible to differentiate. It may also improve the characterization of tissues allowing better tumor differentiation.
11. 256+ slice CT
    At RSNA 2007, Philips announced a 256-slice scanner, while Toshiba announced a “dynamic volume” scanner based on 320 slices. The majority of published data with regard to both technical and clinical aspects of the systems has been related to the prototype unit made by Toshiba Medical Systems. The recent 3 month Beta installation at Johns Hopkins Press Release using a Toshiba system tested the clinical capabilities of this technology JHU Gazette. The technology currently remains in a development phase, but has demonstrated the potential to significantly reduce radiation exposure by eliminating the requirement for a helical examination in both cardiac CT angiography and whole brain perfusion studies for the evaluation of stroke.
12. Inverse geometry CT
    Inverse geometry CT (IGCT) is a novel concept which is being investigated as refinement of the classic third generation CT design. Although the technique has been demonstrated on a laboratory proof-of-concept device, it remains to be seen whether IGCT is feasible for a practical scanner. IGCT reverses the shapes of the detector and X-ray sources. The conventional third-generation CT geometry uses a point source of X-rays, which diverge in a fan beam to act on a linear array of detectors. In multidetector computed tomography (MDCT), this is extended in 3 dimensions to a conical beam acting on a 2D array of detectors. The IGCT concept, conversely, uses an array of highly collimated X-ray sources which act on a point detector. By using a principle similar to electron beam tomography (EBCT), the individual sources can be activated in turn by steering an electron beam onto each source target.
    The rationale behind IGCT is that it avoids the disadvantages of the cone-beam geometry of third generation MDCT. As the z-axis width of the cone beam increases, the quantity of scattered radiation reaching the detector also increases, and the z-axis resolution is thereby degraded – because of the increasing z-axis distance that each ray must traverse. This reversal of roles has extremely high intrinsic resistance to scatter; and, by reducing the number of detectors required per slice, it makes the use of better performing detectors (e.g. ultra-fast photon counting detectors) more practical. Because a separate detector can be used for each ‘slice’ of sources, the conical geometry can be replaced with an array of fans, permitting z-axis resolution to be preserved.
13. Peripheral Quantitative Computed Tomography (pQCT)pQCT or QCT devices are optimized for high precision measurements of physical properties of bone such as bone density and bone geometry. In comparison to the commonly used DXA system which measures bone mass only (BMD), QCT systems can determine bone strength as a mechanical property and the resulting fracture risk. Hence one outcome parameter is the Stress-Strain Index (SSI) comparing bone strength to results of three point bending tests commonly used for mechanical material tests.
    Typical application is Osteoporosis diagnostics where single slices at the Tibia or the Radius are measured resulting in a very low local Radiation dose of 1-2 μSv.

    Typical application is Osteoporosis diagnostics where single slices at the Tibia or the Radius are measured resulting in a very low local Radiation dose of 1-2 μSv.

14. Synchrotron X-ray tomographic microscopy
    Synchrotron X-ray tomographic microscopy is a 3-D scanning technique that allows non-invasive high definition scans of objects with details as fine as 1,000th of a millimetre, meaning it has two to three thousand times the resolution of a traditional medical CT scan.
    Synchrotron X-ray tomographic microscopy has been applied in the field of palaeontology to perform non-destructive internal examination of fossils, including fossil embryos to be made. Scientists feel this technology has the potential to revolutionize the field of paleontology. The first team to use the technique have published their findings in Nature, which they believe “could roll back the evolutionary history of arthropods like insects and spiders.”
    Archaeologists are increasingly turning to Synchrotron X-ray tomographic microscopy as a non-destructive means to examine ancient specimens.
15. X-ray tomography
    X-ray Tomography is a branch of X-ray microscopy. A series of projection images are used to calculate a three dimensional reconstruction of an object. The technique has found many applications in materials science and later in biology and biomedical research. In terms of the latter, the National Center for X-ray Tomography (NCXT) is one of the principal developers of this technology, in particular for imaging whole, hydrated cells.