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Robust CT Protocols

for Pediatric Cardiovascular Examinations

Chiappino, D.1
ediatric cardiovascular disorarticle are non-gated Helical scans
Amoretti, F.1
ders are extremely complex in
performed at a high pitch. Not gating
Verlooij, C.2
nature and present with a widethese studies immediately reduces
ly variable array of abnormal
dose to approximately one quarter of
anatomy. Imaging these disora gated scan. The use of a high pitch
ders presents a unique set of
scanning keeps the average thoracic
challenges for the cardiovascular
examination time down to just a few
team. Complex anatomical variseconds and few patients scanned at
ations require detailed volumetric image interMassa require sedation. An additional benefit of
pretation with high spatial and temporal resoluhigh-pitch scanning is the ability to reduce temtion. In addition, the patients are invariably
poral resolution to about 200 ms for a half scan
young. They may not co-operate with a lengthy
reconstruction.
scan procedure and sedation must be considThe overall image quality and temporal reered. Radiation dose must be of primary consolution of the studies presented in this article is
cern, as these patients will usually require perisuperb for assessing cardiovascular anatomy and
odic follow-up x-ray examination procedures.
disease in pediatric patients. Many thanks to the
The team at the radiology department of
hard working staff at Massa, Dr Dante Chiappino
l'Ospedale G. Pasquinucci in Massa (Italy) develand Dr Francesca Amoretti, for taking the time
oped a robust CT protocol using the Aquilion 16
to collate these excellent, complex and interestMSCT scanner that addresses both examination
ing case studies. Furthermore, I hope that the
time and radiation dose providing detailed volprotocols described in this article will be of use
umetric interpretation. The scan protocols in this
to other Aquilion users.

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Case 1

Interrupted Aortic Arch

This volume-rendered image


demonstrates the excellent
vascular detail provided
by this 4-second scan.

History: A 12-day old male neonate was transferred to our department with a presumptive diagnosis of interrupted aortic arch. His general
condition was poor and he needed mechanical
ventilation and massive inotropic support.
Echocardiography demonstrated a large VSD, a
hypoplastic aorta (4.5 mm) and a large ductus
arteriosus. The aortic arch was not well visualised. A CT examination was then performed.

Computed Tomography

Protocol description

Scan information
Scanner
Scan region
Scan length
Scan direction
High Voltage
Tube current
Rotation time
Slice collimation
CT pitch factor (Helical pitch)
Total scan time
Scan field
Number of series

Aquilion 16
Body
166 mm
Cranio-caudal
120 kV
60 mA
0.5 sec
16 x 1 mm
1.4375:1 (23:16)
4 sec
240 mm
1

Reconstruction information
Reconstruction algorithm
Reconstruction filter
Image width
Reconstruction interval
Total number of images

TCOT
FC 1
1 mm
0.5 mm
333

Contrast information
Contrast
Concentration
Volume
Flow rate
Scan start method

Ultravist 370
370 mgI/l
20 ml
1.5 ml/s
Manual at 7 s.

Post-processing information

Diagnosis was performed based on 1 mm axial


slices in combination with MPR images and 3D
images generated from 1 mm-thin slices with
0.5 mm reconstruction interval.

This coronal MinIP projection


demonstrates poor pneumatisation
of the lungs bilaterally.

11

Case 1

The hypoplastic ascending


aorta is clearly defined on
this 3D image. This abnormal vessel supplies the
innominate and left
carotid arteries.
The hypoplastic ascending
aorta and large pulmonary
trunk are demonstrated on
this axial MIP image.

An oblique 3D view
demonstrates a large,
patent ductus arteriosus
giving rise to the
left subclavian artery.

Conclusion

A diagnosis of type B interrupted aortic arch


was made. The ascending aorta giving rise to the
innominate and left carotid artery, the pulmonary artery and the ductus arteriosus giving
rise to the left subclavian artery and continuing
in the descending aorta were clearly visualised.
Interactive rotation of the 3D volume was employed by the cardiac surgeons to evaluate the
relationships and the distances between these
abnormal vascular structures and for planning
the optimal surgical strategy. The patient underwent a palliative banding of the pulmonary
artery branches leading to a dramatic improvement of the haemodynamics and subsequent
biventricular repair.

12

Case 2

MAPCAs
History: A 9-year old girl with pulmonary atresia
and ventricular septal defect underwent cardiac
catheterisation that showed the presence of major aortopulmonary collateral arteries (MAPCAs).
The cardiologist requested a CT examination in
order to detect any collateral vessels not seen
during the catheter study before proceeding to
coil embolization.

The ventricular septal defect


is demonstrated on this oblique
slab MIP image.

Computed Tomography

Protocol description

Scan information
Scanner
Aquilion 16
Scan region
Thorax
Scan length
210 mm
Scan direction
Cranio-caudal
High Voltage
120 kV
Tube current
150 mA
Rotation time
0.5 sec
Slice collimation
16 x 1 mm
CT pitch factor (Helical pitch) 1.4375:1 (23:16)
Total scan time
4.6 sec
Scan field
400 mm
Number of series
1
Reconstruction information
Reconstruction algorithm
Reconstruction filter
Image width
Reconstruction interval
Total number of images

TCOT
FC 1
1 mm
0.5 mm
420

Contrast information
Contrast
Concentration
Volume
Flow rate
Scan start method

Ultravist 370
370 mgI/l
50 ml
2 ml/s
Manual at 15 s.

The complex mediastinal anatomy


is well demonstrated in this image.

Post-processing information

All collateral vessels were seen on MIP and 3D


images, generated from 1 mm-thin slices, with
0.5 mm reconstruction interval.

Conclusion
Pulmonary atresia with ventricular septal defect
and MAPCAs is a complex congenital heart disease. There is considerable variability in the
anatomy, morphology and geometry of the
native pulmonary arteries and of the collateral

13

Case 2

A large MAPCA is
demonstrated on the
coronal MIP image.

Two additional MCPAs


are identified on this 3D volume
rendered image.

vessels. Detailed imaging


of the anatomy is crucial
for the planning of the surgical or interventional
therapy: MSCT with 3D
reconstructions is a reliable, non-invasive imaging modality useful in the
preoperative assessment
of the pulmonary artery
and MAPCAs site and size.

14

The origin of this MAPCA


is seen arising from the
descending thoracic aorta.

Case 3

Aortic Coarctation
History: A 3-month old infant was referred to
our Cardiology Department with suspected
coarctation of the aorta. The clinical examination
revealed weak femoral pulses and echocardiography showed the presence of flow acceleration
across an aortic narrowing. However, the
acoustic window was not optimal and a complete morpho-functional assessment of the lesion was not feasible. Consequentially, the child
underwent a CT exam to determine the severity
of the stenosis and to plan the surgical correction.

The aortic coarctation is


easily identified on the
3D volume rendered image.

Computed Tomography

Protocol description

Scan information
Scanner
Aquilion 16
Scan region
Thorax
Scan length
124 mm
Scan direction
Cranio-caudal
High Voltage
120 kV
Tube current
80 mA
Rotation time
0.5 sec
Slice collimation
16 x 1 mm
CT pitch factor (Helical pitch) 1.4375:1 (23:16)
Total scan time
3.8 sec
Scan field
240 mm
Number of series
1
Reconstruction information
Reconstruction algorithm
Reconstruction filter
Image width
Reconstruction interval
Total number of images

TCOT
FC 1
1 mm
0.5 mm
248

Contrast information
Contrast
Concentration
Volume
Flow rate
Scan start method

Ultravist 370
370 mgI/l
30 ml
2 ml/s
Manual at 8 s.

Post-processing information

Diagnosis was performed on the basis of 1 mm


axial images combined with MPR and 3D images
generated from 1 mm-thin slices with 0.5 mm
reconstruction interval.

15

Case 3

A curved planar reconstruction from the aortic


valve to the abdominal
aorta provides excellent
evaluation of the vessel
lumen. The aortic coarctation is severe with stenosis
of approximately 75%.

Conclusion

Dr. D. Chiappino,
1
Dr. F. Amoretti
(Hospital G.
Pasquinucci,
Massa, Italy)
2
C. Verlooij
(Clinical Application
Specialist TMSE)
1

16

The exam showed the


presence of a serious
coarctation of proximal
thoracic aorta and patency of the ductus arteriosus.
Treatment planning was
performed on the basis of
the CT study alone. The
patient underwent surgical correction with an
extended
end-to-end
anastomosis of the aorta
and ligation of the ductus
arteriosus. The patient was
discharged from the hospital nine days after
surgery.

On this sagittal MPR image a patent ductus


arteriosus is shown feeding into the aorta.

The origin of the ductus arteriosus


from the pulmonary trunk is demonstrated
on the axial oblique MIP image.