BRINK CCTA Protocols Contrast Media Optimization · Contrast Media Optimization James A. Brink,...
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Coronary CT Angiography: Protocols Contrast Media Optimization
James A. Brink, M.D.
Yale University
School of Medicine
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Cardiac CT Angiography
• Intravenous Contrast Material• Flow Rate• Concentration• Type• Duration (Volume)• Scan Delay
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Iodine Concentration in Blood/Tissue
Concentration (I mg/cc)
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120 Kvp
137 Kvp
Tissue Concentration (I mg/ml)
25 HU per mg I / ml
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Peak Enhancement vs. Flow Rate
ComputerSimulation
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0 5 10 15 20 25 30 35
Time after the start of injection (sec)
Recirculation
Increase in bloodflow caused bythe injection
Courtesy of Ty Bae
InjectionDuration
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Injection Duration
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Aor
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HU
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Time after the start of injection (sec)
Porcine Model
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Time after the start of injection (sec)
30-sec injection20-sec injection12-sec injection8-sec injection5-sec injection3-sec injection1-sec injection
Computer Simulation
Bae KT. Radiology 2003;227:809-816
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Duration(Volume)Duration(Volume)
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IV Contrast for CTA
Injection Duration = Scan Duration
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0 5 10 15 20 25 30 35 40
Time after the start of injection (sec)
30-sec20-sec12-sec8-sec5-sec3-sec1-sec
30 sec4DCT
8 sec16DCT
InjectionDuration
30 sec4DCT8 sec
16DCT
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Time after the start of injection (sec)
30-sec20-sec12-sec8-sec5-sec3-sec1-sec
8 sec16DCT
8 sec16DCT
InjectionDuration
8 sec16DCT
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IV Contrast for CTA
Injection Duration = Scan DurationSDCT and 4DCT:
Injection Duration = Scan Duration + 1016DCT and 64DCT:
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Saline Flush
• Facilitated with double-barrel injector
• Eliminates messy loading of saline on top of contrast in single-barrel systems
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Saline Flush
• Eliminates excess contrast in tubing
• Flushes contrast from peripheral veins into central veins
• Permits reduction in contrast volume by about 20 to 40%
• Reduces beam hardening artifact in RCA
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64DCT – Uni Flow• 2 Injection Phases:
• Contrast
• Saline
• Less contrast material, but no visualization of right heart w/ dilute contrast
• Better definition / segmentation of left heart and coronary arteries
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64DCT – Uni Flow
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64DCT – Uni Flow (Yale)
• 2 Injection Phases: (Iodixanol 320, 5ml/s)
• Contrast 70 ml (14s)
• Saline 30 ml (6s)
• Scan duration = 3-5 sec • Injection duration = 14 sec • Injection duration = Scan duration + 10 sec
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Time after the start of injection (sec)
30-sec20-sec12-sec8-sec5-sec3-sec1-sec
InjectionDuration
14-sec
3-5 sec64DCT
3-5 sec64DCT
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64DCT -- Dual Flow
• 3 Injection Phases:
• Contrast
• Contrast + Saline
• Saline
• Permits visualization of right heart and interventricular septum w/ dilute contrast
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64DCTDual Flow
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64DCT -- Dual Flow
RCA LAD LCX
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64DCT -- Dual Flow (Yale)
• 3 Injection Phases: (Iodixanol 320, 5ml/s)
• Contrast 60 ml (12s)
• Contrast(60%) + Saline(40%) 50 ml (10s)
• Saline 40 ml (8s)
• Scan duration = 3-5 sec • ‘Effective’ Injection duration = 18-22 sec
‘Effective’ ID = SD + 15 sec
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Time after the start of injection (sec)
30-sec20-sec12-sec8-sec5-sec3-sec1-sec
‘Effective’InjectionDuration
3-5 sec64DCT
3-5 sec64DCT
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64DCT – Dual Flow
• Right heart visualization
• Right heart mass
• Valve disease
• Prolonged injection duration:• Triple Rule-Out• Complete thorax (CABG)
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64DCT – Dual Flow – Triple R/O
Prospective Gating
(100 kV; 5-7 mSv)
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Scan DelayScan Delay
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Scan Delay for Cardiac CTA
• Scan Delay
• May be fixed for patients presumed to have normal cardiac output - risky
• Pitfall
• Abnormal cardiac output --> marked delay in vascular enhancement
• test bolus or bolus tracking
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Cardiac Output --> Aortic Enhancement
Time (min)
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c.o. = 25%
c.o. = 50%
c.o. = 100%
c.o. = 200%
Computer Simulation, 5ml/sec. Bae, Heiken, Brink. Radiology Radiology 1998; 207:657-662
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Test Bolus
• Measure circulation time• 20 ml @ 5 ml/sec (4 sec inj.)• Scan at carina (Asc. Aorta & PAs):
• 10 - 30 sec q 1-2 sec
• Plot enhancement curve and find peak• If no peak, change arm position, repeat
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Test Bolus
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Time (sec)
4 sec
4DCT 64DCT
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30-sec20-sec12-sec8-sec5-sec3-sec1-sec
‘Effective’InjectionDuration
3-5 sec64DCT
3-5 sec64DCT
Peak + 4-8 sec
Timing for Dual Flow 64DCT CCTA
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Bolus Tracking
• ROI in aorta (usually descending aorta)
• Low-dose monitoring scans q 1-2 sec
• Trigger when enhancement > 100 HU• Absolute value of 150 HU
• Add delay to initiate scanner, breath-hold patient, and allow adequate enhancement
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‘Effective’InjectionDuration
3-5 sec64DCT
3-5 sec64DCT
ContrastArrival
‘Eff’ Inj Duration+ -Scan
Duration
3-5 sec64DCT
Timing for Dual Flow 64DCT CCTA
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Triple Rule-Out: Test Bolus
Scan delay is mid-point between time to peak in PA and Aorta
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10 sec64DCT
10 sec64DCT16 36
Pulmonary Artery
25 45
Aorta
Triple Rule-Out: Dual Flow 64DCT ‘Effective’InjectionDuration: 20 sec
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Cardiac CTA: Protocol Development
• Technique
• Flow Rate
• Concentration
• Volume
• Scan Delay
• 64DCT Uni Flow
• 5 ml/sec
• 320-370 mgI/ml
• 70(100%), 30(NS)
• Test Bolus + 4-8 sec*
• 64DCT Uni Flow
• 5 ml/sec
• 320-370 mgI/ml
• 70(100%), 30(NS)
• Test Bolus + 4-8 sec*
* Bolus Tracking: Contrast Arrival + Injection Duration - Scan Duration
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Cardiac CTA: Protocol Development
• Technique
• Flow Rate
• Concentration
• Volume
• Scan Delay
• 64DCT Dual Flow
• 5 ml/sec
• 320-370 mgI/ml
• 60(100), 50(60/40), 40(NS)
• Test Bolus + 4-8 sec*
• 64DCT Dual Flow
• 5 ml/sec
• 320-370 mgI/ml
• 60(100), 50(60/40), 40(NS)
• Test Bolus + 4-8 sec*
* Bolus Tracking: Contrast Arrival + Injection Duration - Scan Duration