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COMPUTED TOMOGRAPHY PRESENTED BY DR.ANUNAIR Tomography derieved from greek word tomos-slice,graphia means picture.

. Computed tomography (CT) scanning, also called computerized axial tomography (CAT) scanning, is a medical imaging procedure that uses x-rays to show cross-sectional images of the body. HISTORY: Johann Radon showed in 1917 that 2-D section images could be reformulated using mathematical transformation of projection data Sir Godfrey Hounsefield Allen Macleod Cormack 1970 are pioneers of computed tomography and received Nobel prize for medicine. With radioactive americium source,he collected data in steps of 1 degree through 180 degree,1st reconstruction took 9 days,2nd images obtained did not originate from averaging or blurring information. The first CT scanner ElectricMusic Industries limited Mark 1, produced images with 8080 pixel resolution.

INDICATIONS: Investigations of intracranial diseases-tumors,hemorrhage and infarcts. Investigations of suspected intracranial and spinal cord damage following trauma to head and neck. Assessment of fracture involving orbit,nasoethmoidal complex,cranial base,odontoid peg and cervical spine. Tumor staging assessment of size,site and extend of benign and malignant tumor affecting maxillary antra,base of skull,pterygoid region,pharynx,larynx Investigation of tumors and tumor like discrete swellings intrinsic and extrinsic to salivary glands. Investigation of the tmj. Preoperative assessment of maxillary alveolar bone height and thickness before inserting implants.

BASIC PRINCIPLE OF CT: Ct scanners use xrays to produce sectional images. Patients body interposed between xray source and detectors and series of exposure made over an arc of 180 to 360 degrees with xray beam collimated to determine the thickness of slice. Detectors measure intensity of xray beam emerging from patient and converts to digital data stored and manipulated by computer. Numerical information is converted to gray scale representing different tissue densities allowing visual image to be generated. Image can be reformatted into tomographic sections of body ,adjusted for optimal viewing to detect minute differences in tissue alteration. Image stored on magnetic tape or optical discs. EQUIPMENT: THE XRAY GANTRY: XRAY TUBE -stationary anode energized continuously. -rotating anode operated in impulse mode. RADIATION DETECTORS: Scintillation detectors Gas counters. ANCILLARY COMPONENTS: THE COMPUTER SYSTEM GANTRY: Consist of xray unit-transmitter,

data acquisition unit - functions as receiver.

2 components housed in ring shaped unit called gantry. Its movable frame of system having xray tube,detectors and associated electronics. Dimensions are: Height:2-2.5m Width:2-3m Depth:0.5-1m Weight:2000kg Ability of gantry to angle plus or minus 30 Degree in case of coronal imaging. APERTURE: Patient has to lie in this system whilst being scanned. It is 70cm in diameter.if larger apertures,xray source and detector are farther apart,xray tube must have higher output to ensure that there is a high enough xray photon flux at detectors. TABLE: Motorized table and movements are smooth so that patient can be accurately positioned to exact anatomical position. PATIENT ALIGNMENT LIGHTS: High intensity halogen bulbs focussed as white light are used for alignment of patient in correct anatomical position in centre of the table. SHIELDING: CT scanner equipped with grids,collimators and filters to provide sheilding against scattered radiation to define scan slice and provide shielding against scattered radiation. X RAY PRODUCTION: Tubes used in modern CT scanners have a power rating of 20-60kw at voltages of 80-140kv. Tube alignment:

Misalignment causes severe degradation in the form of concentric rings and linear streaks. DETECTORS: Situated opposite the xray tube.Converts incident xrays of varying intensity to electric signals.Collects data transmitted from patient,transfer to computer.Data from the patient is in form of attenuated beam and is weak and changed to signal.its equivalent to xray cassette and films in conventional radiography.Distance between xray source and detectors is 110cm.detectors have high efficiency to minimize patient radiation dose.3 types-geometric efficiency-area of detectors sensitive to radiation as fraction of total exposed area.quantum efficiency-fraction of incident ray on detector that are absorbed and contribute to measured signal.conversion efficiency-ability to accurately convert the absorbed xray signal to electric signal. Types of detectors: Sodium iodide Calcium fluoride Bismuth germinate Classified to: Scintillation detectors: array of scintillating crystal and photodiodes. It has a high quantum and conversion efficient efficiency. Gas ionization:array of detectors containing compressed gas,high voltage applied to tungsten septa between chambers to collect ions produced by radiation.it has excellent stability,large dynamic range,lower quantum efficiency. MULTI-ROW DETECTOR: Simultaneous scanning several slices,scan time can be reduced significantly or smallest details can be scanned.

In adaptive array detectors,rows inside detectors very narrow,becomes wider as it moves towards its outer edges in z direction combination of collimation and electronic interconnection provides considerable flexibility in the selection of slice thicknesses

same time the space required by the detector septa,and therefore the unused space, is minimized.

SCANNER PARAMETER THAT DETERMINE IMAGE QUALITY : COLLIMATION: Radiation beam emitted by xray tube is shaped using special diaphragmscollimators. 2types-source collimator,detector collimator. Source collimator: Located in front of the radiation source,reduces radiation beam to form maximum required fan beam. Detector collimator: Detector collimator positioned directly in front of the detector source,sheilds scattered radiation. INCREMENT:

Determines distance between images reconstructed from a data volume.If appropriate increment used,overlapping images can be reconstructed.Sequential ct,overlapping images obtained if table feed between sequence is smaller than collimated slice thickness.increases patient dose. Spiral ct,increment is freely selectable as reconstruction parameter.degree of overlap determined without increasing the dose.

PITCH: Pitch=table feed per rotation/collimation.Larger table feed,faster body region can be scanned.If table feed too large,image quality will be impaired.Good image quality-pitch between 1 and 2.Dose reduced if pitch >1 is applied in single row system.Multirow system pitch cannot be defined clearly.

ROTATION TIME: Time interval needed for a complete 360 degree rotation of tube detector system around patient.Ultra modern ct system requires only 0.4sec for one rotation. Advantages of short rotation time includes: Long spiral scan acquired in same scan time. Same volume and same slice thickness scanned in less time. Motion artifacts are eliminated. Savings on contrast media through shorter examination time Reduced patient discomfort since less contrast medium is required. For shorter examination time or fast acquisition a subsecond rotation time is required. MAs: mA value is the product of tube current and rotation time.Multi-row CT,its effective mAs-product of tube current and exposure time for one slice.Selected depending on type of examination.Higher mAs reduce image noise,improving the detectabiity of lower contrast. Visualization of soft tissue,-regions of low contrast,high dose and larger slice thickness are required.

GENERATIONS: FIRST GENERATION SYSTEM: Based on parallel beam geometry with a rotate translate principle of the tube detector principle. Xray beam collimated to dimensions of roughly 2*13mm.detectors-12,pencil thin detectors used. Small detectors monitored the intensity of beam before entering body to yield the value of incident intensity.Beam detected by scintillation crystal . Disadvantages: Long scanning time. Image quality suffered due to patient motion. Limited use to body parts such as head which can be immobile.

SECOND GENERATION SYSTEM Based on rotate translate principle Included fan beam reconstruction with linear detector array.Beam converted to fan shape with diverging angle between 3-10 degrees.scan time is 10sec,detectors 3-52.narrow fan beam used.More xray detectors used,reducing number of angular rotation and increasing number of views. 1st and 2nd generation xray beam was not wide enough to cover entire width of slice of interest.Mechanical arrangement was required to move xray source and detector horizontally across the field of view.Source/detector assembly rotated by 1 degree,another sweep performed.process repeated until 180 translation.180 measurements made for one complete translation are profile or view. THIRD GENERATION SYSTEM: Based on rotate-rotate principle.Use wide angle fan beam geometry,arc of detectors and xray tube rotate continuously around patient for 360 degree.Detectors fixed radially and do not view the scan area uniformly.centre detectors in array see pixels at centre of field of view.Fixed relation allows detectors to be highly collimated,reduces scatter radiation and decrease image noise.third generation was highly sensitive to detector performance.Miscalibration or malfunction of individual detector appear as ring in final reconstructed image. Disadvantages: Limited spatial resolution. FOURTH GENERATION SYSTEM Use wide angle fan beam geometry(50-55 degrees)tube rotates within 360 degree arc of stationary detectors.Sample obtained over width of fan angle and several data samples acquired per detectors.This geometry permits very high spatial resolution ,but forces a wider collimation of detector,in turn cause an increase in detection of scattered rays.detectors are automatically calibrated as xray beam approached.malfunction loss of image contrast rather than its use.600-4800 dectors,exposure of 1sec wide fan shape used. Disadvantages: Produces increased scatter.

High cost and high susceptibility to streak artifacts FIFTH GENERATION SYSTEM Developed by Dr.E.Woods of Mayoclinic.Consists of multiplex rays tubes and detectors. Electron beam CT: Introduced by Andrew Castagnini as a method of improving the temporal resolution of CT scanners.EBCT machine houses a huge vacuum tube in which an electron beam is electromagnetically steered towards an array of tungsten Xray anodes arranged circularly around the patient.Each anode hit in turn by the electron beam and emits xrays that are collimated and detected as in conventional CT.The lack of moving parts allows very quick scanning with single slice acquisition in 50-100 ms. EBCT has found particular used for assessment of coronary artery disease. High cost of EBCT equipment,and its poor flexibility led to poor uptake. HELICAL OR SPIRAL CT-SIXTH GENERATION: Introduced in 1990 by Willi Kalender and Kazuhiro Katada.Xray source attached to freely rotating gantry.During scan table moves the patient smoothly through the scanner,the name derives from helicalpath traced by xray beam. The xray beam travels through the helical path.2technologies made it practical.Slip rings and swithched mode power supply. Slip rings to transfer power and data on and off rotating gantry and switched mode power supply powerful enough to be installed on gantry. Advantages: Speed Patient can hold their breath for the entire study. Allows optimal use of intravenous contrast enhancement. Use high resolution acquisitions in z axis. Decrease incidence of misregistration between consecutive axial slices. Enhanced multiplanar or three dimensional renderings.

PREPARATION OF PATIENT FOR CT OF HEAD AND NECK

Removal of outdoor coats and cardigans done in gantry along with false teeth,wigs,earings,hairpins and hearing aids. Fasting before 4hrs prior to scan to reduce vomiting. Positioning: Posterior fossa Pituitary fossa/orbits/internal auditory meatus Routine head studies-axial Routine head studies-coronal Two reference lines: Radiographic base line-a line drawn from the outer canthus of eye to the midpoint of external auditory meatus. Reids base line-a line drawn from the lower border of the orbits to the superior border of external auditory meatus. Positioning for routine head studies axial: 10 degree to scan plane. Scanning is commenced after forming a scout view of area under investigation. Scanning started 1cm below the base of the skull through the vertex with 10mm slice thickness and 10mm slice increments. Positioning for coronal scan: Patient laid down prone or supine with head flexed or extended in such a way that beam falls perpendicular to the orbitomeatal line. Stabilization achieved by coronal head support or existing table or shoulder support. Reformatted axials or gantry angulation can be used to achieve coronal scans if correct base line not obtained due to neck stiffness,trauma,degeneration of cervical spine. RADIATION DOSE Effective dose 2-4msv for head scan and 5-15msv for body scan. 2 major factors-

Inherent design features:this depends on Type of xry tube-with stationary xray tube there is a higher radiation dose to the patient. Collimation:it will reduce radiation dose and also the reduction in penumbra effect of the beam will reduce the overlap of radiation dose. Beam splitting device-reduces radiation dose. Tube patient detector distance-shorter the distance,higher the radiation dose. It also depends on the efficiency of detectors. Radiographic technique: High kvp-increases the radiation dose. Patient positioning-position within scan field results in increased radiation dose. Slice thickness-to obtain images of high spatial resolution thin slice techniques may be used. Slice spacing-increasing gap between slices reduces radiation dose to the patient. Specialized examination-may increase the overall radiation dose to the patient. CARE dose technical measure package: (Combined application to reduce exposure) Shorter examination times,lowest possible exposure to radiation and imaged of excellent quality. In ultra modern computer ,each rotation,the radiation is continuously measured and modulated according to current attenuation level. Depending on patient anatomy it reduces as much as 56%. IMAGE DISPLAY Console operates entire system is a free standing unit which houses keyboard,through operator directs the scanning sequences and viewing of images. Operating console-it is from here that the operator controls the overall system.

Reporting console-this displays the image for radiologists or physicians to follow. Independent console-it has its own central processing unit and disc drive where operating and reporting consoles are usually linked to main systems central processing unit and disc drive. Three main function buttons: Scan Display Manage SCAN: Patients identification Patients name Name of person who referred the patient Radiologists name

Radiographers name Area under investigation Radiographic technique factors: Kvp Ma Scan speed Slice thickness Pixel and matrix size Partial volume effect Scan field size Algorithm used. DISPLAY

Allows operator to use the console not only for scanning but for viewing images.the other diagnostic facilities available include: Grid application-helpful in centering patient exactly in the scan field. Region of interest-allows operator to quantify ct over specific area. Image flip-clear indication of left and right side of body can be viewed clearly. Magnification-allows area under suspicion to be closely viewed. Multiple image-allows multiple images to be viewed at the same time Annonated display-allows images to have a text written over them for teaching purpose Measure-allows organs or pathology within an organ to be measured accurately. Dual window level-allows viewing of tissues with different density on same image. Image location-scout view may be marked by slice or series of slice to demonstrate areas scanned. Histogram-used to check patency of blood flow through organ or for checking patency of an artery. IMAGE ACQUISITION: Xray beam attenuation data collected in grid pattern called a matrix.Each square in a matrix is made of pixel which represents the absorption characteristics or linear attenuation coefficient of particular volume of tissue(voxel).Ct image recorded and displayed as matrix of individual blocks called voxels. Matrix sizes include-256*256 or 512*512 pixels.Ct image made of slices-represents anatomy of a layer of tissue. Ct scans of head imaging require 3mm slices. Size of pixel determined by: Geometry of the scan Frequency and spacing of measurements Number of penetration profile The size of xray source and detector.

CT NUMBERS OR HOUNSFIELD UNITS: Numeric data in each pixel are called CT number or Hounsfield unit. They correspond to linear attenuation coefficient of particular tissue at designed kilovoltage. CT numbers(hounsfield unit) may range from -1000 to +1000 constituting different levels of optical density. Relative densities is based on air(-1000),water(0) and dense bone(+1000) H=1000 m-water/water m and water are linear attenuation coefficient for tissue material and water respectively. TISSUE AIR WATER BONE MUSCLE HOUNSFIELD UNITS -1000 0 1000 35-70 -300 1600-2400 2500-3000 -60 - -100 40-80

LUNG DENTINE ENAMEL FAT SOFTTISUE

IMAGE RECONSTRUCTION: Algorithm can be also used.its a mathematical formula used to process the scan data into the final image. Back projection,iterative reconstruction,analytic reconstruction. Iteration method:

Series of successive approximations made.Final answer is close approximation of the attenuation of each voxel in tissue. Back projection method: Each pixel in resultant image is proportional to sum of xrays projected through its corresponding voxel.The attenuation measurement apportioned equally among all voxels in path of xray beam. Starburst pattern artifacts are produced. Analytic method: Use complex mathematical equation to address minute variation in tissue density when data are missing.More accurate image,time intensive.Most commonly used methods-two dimensional fourier analysis,filtered back projection method. Filtered back projection allows short computation with relatively accurate solution.Allows processing of each ray sum immediately after its obtained while data acquisition continues for other ray sum Partial volume effect: Tissue is scanned two different densities may occur in one single slice,the average of two densities represented on displayed image.the voxel in this case is average of two densities termed as partial volume effect.Most CT scanners offer a choice of filters selected by operator to enhance either soft tissue feature or bone detail in images. Common filters used include ramp filter,Ram Lak filter.Kernel is also used. IMAGE CHARACTERISTICS: RESOLUTION: Spatial and contrast resolution are used. Spatial resolution measure ability of system it is to differentiate two objects that are closer together.in ct its 15lp/cm. spatial resolution limited by size of focal spot,spacing of array and magnification factor.Can be calculated when number of detectors known.Two detectors to capture line pair. Contrast resolution is the ability of imaging system to differentiate between structures only with minimal density difference.This allows CT to examine soft tissues. Low contrast produced with CT limited by noise,or stastical fluctuation in transmitted radiograph photons in imaging system.Modern scanners detect density difference of less than 0.5%.

IMAGE ENHANCEMENT Windowing is the term used for the method of varying the density and contrast.Window width is the range of CT numbers selected for display,window level is the central CT number about which the window is chosen. Highest number-white,lowest number-black. Air will be displayed as black and cortical bone appears relatively bright.When window is at low reading,there is a high contrast image with predominance of black and white areas with very little grey scale. Image with narrower window appears noiser MANAGE: Control day to day running of the house keeping routine of the system. Image storage and recording: Computers system disc may store in excess of 1000 images. When disc is full they must be either discarded or stored on magnetic tape,floppy disk or hard copy film. ARTIFACTS IN COMPUTED TOMOGRAPHY: CT artifacts can be defined as image degradation due to either physical,mechanical or computer malfunction or to physical state or condition of the patient. System related artifact: Xray tube-quality and quantity of photons emerging from the tube.the quality will vary and major cause of such a change is ageing of tube.in addition,physical damage to rotar bearings,glass insert,anode surface or filament will result in image degradation. Detectors-artifacts occur if system of detectors has not been calibrated or if there is a malfunction of circuit. Operators fault-artifacts can be caused due to incorrect technique. Patient related artifacts:artifacts related to patient include Patient motion: Patient movement Cardiac motion

Peristalisis Breathing/swallowing High density artifacts: Fillings in the teeth Surgical flaps Surgical shunts Hair pins/hair grips Hearing aids Poor patient positioning CONTRAST AGENTS: Improves visualization of sructures.Uses iodine administered intravenously to enhance soft tissue and vascular image in detail. Improves visualization of sructures.Iodine has large atomic number and absorbs xrays.Iodine perfusing tissues increase radiographic density and makes margin detectable.Also helps to visualise enlarged lymph nodes containing metastaic carcinoma NEWER ADVANCES: MULTISLICE SPIRAL CT More than one detector ring. Built by Elscint called CT TWIN with one second rotation.Current models have upto 3 rotations per second and isotropic resolution of 0.35mm voxels with z axis scan speed up to 18cm/s.Major benefit of multislice CT is increased speed of volume coverage.allows large volume to be scanned at optimal time following intravenous contrast administration. DUAL SOURCE CT: Dual xray tube and dual array of 64 slice detectors. Increase temporal resolution by reducing rotation angle required to acquire complete image.Makes possible use of dual energy imaging which allows an estimate of average atomic number in voxel as well as total attenuation. Improves characterization of tissues allowing better tumor differentiation INVERSE GEOMETRY CT:

Inverses geometry ct is a novel concept which is being investigated as refinement of classic third generation ct design. Reverses the shapes of the detector and Xray sources.in mdct,this is extended in 3 dimensions to conical beam act on linear array of detector. Uses an array of highly collimated Xray source which act on point detector. By using principle of EBCT,individual source activated by steering an electron beam onto each source target. As Z axis width of cone beam increases the quantity of scattered radiation reaching the detector increases and zaxis resolution is degraded because of increasing z axis distance that each ray must traverse. THREE DIMENSIONAL CT: Multiplanar reformatting and dental MPR. 2types available: Those that run on scanners online computer or second operators console. Those designed to run on free standing independent computer workstation. Shaded surface display Volume rendering Maximum intensity projection Each rectangle parallel piped or rectangular solid may be dimensionally altered into multiple cuboidal voxels.this process is called interpolation.3DCT image may be further manipulated by rotation about any axis to display structured images from many angles.its been used both for treatment of congenital and acquired deformities and for evaluation of intracranial tumors,benign and malignant lesions of maxillofacial complex. SHADED SURFACE DISPLAY: 150 HU is predefined as threshold.all pixels,voxels which exceeds this threshold value contribute to result image.Surface is then reconstructed from totality of pixel and elluminated by artificial light source to create shading effect. Gray scale values are no longer related to orginal density of structure.SSD displays depend on threshold value selected.Used to document results for 3D displays MAXIMUM INTENSITY PROJECTION: Based on voxels with highest density(CT number).voxels with highest density value is displayed in resulting image.Its a 2D projection image. Minimum of

density information is retained.Projection is always a combination of those voxels from entire volume and have highest density irrespective of wether they are located front or back of image.Its possible to display pixels with lowest intensity in projection image called MinIP images. VOLUME RENDERING TECHNIQUE: Process of reconstructing a 3D model from a 2D image stack.All density values along a virtual beam which have suitable weighting can contribute to result image. Entire hounsfield scale can be included in VRT.Possible to simultaneously display extremely wide variety of tissue structures of various density or HU value in single volume data set. VIRTUAL ENDOSCOPY: Used to obtain a perspective view of display region.Used for anatomical cavities including large vessels,colon and paranasal sinuses. Endoscope inserted in a cavity displayed with perspective rendering technique,gives impression of flying through displayed region. Advantages of 3D displays: Realistic display of volumes Presentation of entire volume in single image Improved recognition of diagnostically relevant details Helpful for precise surgical planning. CT image data as a basis for three dimensional models. Possible free rotation of 3D objects. DENTA SCAN IMAGING: Invented by Schwarz -1987.Reformats axial CT images of jaw into panoromic and paraxial images and provides programmed reformation,organisation and display of imaging study.Similar to CT procedure,proper patient positioning with scan plane parallel to mandible and maxilla. Scan parameters used are:contiguous axial 1mm slices with bone algorithm,,15cm field of view,512*512 matrix,140kv and 70 mA.Computer is programmed to generate referenced cross sectional and tangential/panoromic images along with three dimensional images of arch. INDICATIONS:

Preoperative evaluation for implants. Post implantation complications like encroachment of canal.maxillary sinus,nasal cavity,and periimplantitis. Assess inflammatory diseases-apical periodontitis,sclerosing osteitis. Tumors and cyst Oro-antral fistulas-exact size an location of the fistulas. Root fractures assessed. Plan surgical procedure like sinus-lift procedure. Locate foreign bodies in jaw in causo cranial as well as buccolingual direction. ADVANTAGES: Minimum additional cost Low radiation dosage Mutiplanar reformation Eliminates streak artifacts Exact information about alveolar bone dimensions Location of mandibular canal,maxillary sinus. Images in 1:1 ratio. In implant imaging height and buccolingual dimension of ridge at implant site,extent of bone resorption,amount of bone at the implant site Location of vital structure Limitation: Image may not be of true size and may require compensation for magnification. Limited range of diagnostic gray scale. Determination of bone quality require other aids. ADVANTAGES OF CT: Relationships of hard and soft tissue can be observed directly.

Ability to rotate images and to add or subtract structural components. Contiguous structures can be seperated,normal hidden surface examined in detail Accurate linear and volumetric measurements can be made. And their changes determined by sequential scan. Eliminates superimposition of images of structures outside area of interest. Single CT imaging procedure consisting of either multiple contiguous or one helical scan can be viewd as images in axial,coronal or sagittal planes. LIMITATIONS OF CT: Image represent discrete subdivision of space,effect of blurring is greater than conventional radiographs. Resolution of image limited by size represented by pixel which is greater than size of silver specks. Detail of computed tomographic image is not as fine as that obtainable on other radiograph. Application in longitudinal monitoring of implant prosthesis is limited and contraindicated because of image artifacts created by metals Metallic objects such as fillings produce streak artifacts across CT image. Equipment is very expensive. REFERENCE: TEXT BOOK OF ORAL AND MAXILLOFACIAL RADIOLOGY-FRENY KARJODKAR ORAL RADIOLOGY-WHITE AND PHAROAH-6TH EDITION. COMPUTED TOMOGRAPHY-THORTSEN.M.BUZUG DIAGNOSTIC IMAGING OF THE HEAD AND NECK-ROBERT W. DALLEY, WILLIAM D. ROBERTSON COMPUTED TOMOGRAPHY-CUNNINGHAM. COMPUTED TOMOGRAPHY OF BRAIN,HEAD AND NECK-JOHN .R.HAAGA,RALPH J.ALFIDI.

ADVANCES IN DENTAL IMAGING-DCNA,VOL 37,NUMBER4,OCT 93. APPLICATIONS OF DIGITAL IMAGING MODALITIES FOR DENTISTRY-DCNA,VOL44,NUMBER2,APRIL-2000

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