Computed Tomography: Advanced Clinical Applications Shayne Chau Christopher Hayre

Computed
Tomography
Advanced Clinical Applications
Shayne Chau
Christopher Hayre
Editors
123
Computed Tomography
Shayne Chau • Christopher Hayre
Editors
Computed Tomography
Advanced Clinical Applications
Editors
Shayne Chau Christopher Hayre
Discipline of Medical Radiation Science College of Health and Medicine
University of Canberra University of Exeter
Australian Capital Territory Exeter, UK
ACT, Australia
ISBN 978-981-19-9345-9 ISBN 978-981-19-9346-6 (eBook)

https://doi.org/10.1007/978-981-19-9346-6
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Singapore Pte Ltd. 2023
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
whether the whole or part of the material is concerned, specifically the rights of translation,
reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any
other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd.
The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore
189721, Singapore
Dr. Hayre would like to dedicate this book to his wife, Charlotte
and daughters, Ayva, Evelynn and Ellena. Love to all.
Shayne Chau would like to dedicate this book to his parents
and brother. To my wife, Jo, I can find no words that can
express my endless affection and gratitude.
Foreword
Computed Tomography is a dynamic technology and as such it keeps evolv-

ing at a rapid pace, producing technical innovations that play a significant
role in the medical care and management of the patient. These recent devel-
opments have also facilitated more advanced clinical applications, which is
the subject matter of this book; Computed Tomography: Advanced Clinical
Applications, edited by Shayne Chau and Dr. Christopher M. Hayre. Chris is
the Editor in Chief for the Journal of Social Sciences and Allied Health
Professions, and Social Media Editor for the reputable journal, Disability and
Rehabilitation. In addition, both Shayne and Chris have years of experience
in teaching in medical imaging at both undergraduate and graduate degree
programmes, and as such they have gained worldwide respect as medical
imaging educators.
This text provides a useful insight into understanding advanced clinical
applications described in four sections of this text, namely: Radiobiology and
Patient Care; CT in an Emergency Setting; CT-Guided Interventions; CT
Forensic Imaging; and CT in Education. There are 11 chapters authored by
well-respected authors in the field of CT. In this regard, they have now pre-
sented yet another textbook which will be a worthwhile in addition to the CT
literature. Both radiologists and radiographers will appreciate the vast amount
of current information on the topics covered in this text, and this book offers
the opportunity for them to enhance their clinical practice skills and ulti-
mately improve the care of the patient undergoing CT examinations.
Chris is a Senior Lecturer at the University of Exeter and holds a Senior
Fellowship with the University of Suffolk. He also serves as a Research
Associate for the University of Johannesburg. Shayne is currently a Senior
Lecturer in Medical Imaging at the University of Canberra, Australia.
Furthermore, Chris is a prolific editor for Medical Imaging textbooks, and he
has championed a new book series called Medical Imaging in Practice
intended to provide “a sound understanding of key and emerging topics relat-
ing to general imaging, computed tomography, magnetic resonance imaging,
nuclear medicine, mammography, ultrasonography, patient care and image
interpretation”. Several notable examples in the series includes General
Radiography: Principles and Practice; Research Methods for Student
Radiographers: A Survival Guide; and Computed Tomography: A Primer for
Student Radiographers. This series is published by CRC Press (Taylor and
Francis Group).
vii
viii Foreword
It is my sincere prediction that this book Computed Tomography: Advanced

Clinical Applications will become one of the most important tools, not only
for students studying CT, but also for those working in clinical practice.
Additionally, colleges and universities delivering medical imaging education
should have copies in their libraries.
Shayne and Chris have done an excellent job in covering these advanced
clinical applications in Computed Tomography.
Euclid Seeram
Monash University, Clayton, VIC, Australia
Charles Sturt University, Bathurst, NSW, Australia
University of Canberra, Canberra, Australia
VCA Education Solutions for Health Professionals, Toronto, ON, Canada
Acknowledgements
The editors would like to thank all contributors for their dedication towards
this advanced text. This book invited contributions from advanced practitio-
ners in the computed tomography. This has resulted in high-quality chapters
providing insight into contemporary practices. It has been a pleasure to work
with peers worldwide, emphasizing an international appeal to radiographers.
Finally, the editors agree that this has been an exciting and prosperous proj-
ect, which we hope readers utilize in both clinical and academic spaces.
ix
Contents
Part I Radiobiology and Patient Care

Radiobiology and Radiation Protection�� 3
Abel Zhou

Patient Care and Self-Care in CT�� 19
Tristan Charles
Part II CT in an Emergency Setting
in an Emergency Setting �� 39

CT
Lindiwe Gumede and Nicole Badriparsad

Trauma Imaging Protocols and Image Evaluations �� 61
Karen Dobeli
Stroke Imaging Protocols�� 79
Karen Dobeli

Responses to Trauma and Stroke �� 91
Karen Dobeli
Whole-Body CT�� 99
Elio Arruzza and Shayne Chau
Part III CT Guided Interventions
Indications, Technique and Pitfalls�� 111

Edel Doyle and Prasanna J. Ratnakanthan

Tips, Tricks, Radiation Dose and Protection �� 127
Part IV CT Forensic Imaging
CT Forensic Imaging �� 137

Edel Doyle and Anthony J. Buxton
xi
xii Contents
Part V CT Education
Education in CT �� 159

Andrew Kilgour
Part I
Radiobiology and Patient Care
Radiobiology and Radiation
Protection
Abel Zhou
Abstract 1 Radiobiology and Radiation

Protection
This section provides an overview of ionizing
radiation exposure and radiation protection Ionizing radiation interacts with the tissues of the
using computed tomography (CT). Patients human body and can lead to cell damages, such
undergoing CT examinations as part of their as cell death or changes in cell function.
diagnosis or treatment are exposed to ionizing Radiobiology is the study of the effects of ioniz-
radiation. A net benefit is justified for patients ing radiation on living organisms. Ionizing radia-
against potential risks induced by exposure to tion is named because of its capability to eject an
ionizing radiation. This section contains two orbiting electron from its atom. Medical X-ray
main subsections: (1) radiobiology and radia- imaging uses high-energy photons to produce
tion protection and (2) radiation dose in CT diagnostic or guidance information for the man-
examinations. The first subsection reviews the agement of diseases. The use of X-ray imaging is
interactions between ionizing radiation and regulated owing to its potential health risks,
matter, biological effects of ionizing radiation, which are minimized by radiation professionals
causative relationship between radiation expo- while maximizing the benefit of undergoing an
sures and their effects, and radiation protection X-ray imaging examination.
methods. The second subsection systemati-
cally reviews radiation measurements with a
special focus on CT dose metrics and discusses 1.1 Interactions Between Photons
their applications and limitations. and Matter
Keywords Radiation, an energy packet traveling in space at

the speed of light, is an electromagnetic wave
Deterministic effect · Stochastic effect · Linear possessing an electric field and a magnetic field.
no-threshold (LNT) · Radiation protection · Radiation is commonly known as photons and is
CT dose index (CTDI) · CTDIFDA · CTDI100 · measured in electron volts (eV), kiloelectron
CTDIW · CTDIvol · Dose-length product (DLP) volts (keV), or megaelectron volts (MeV). The
terms radiation, X-rays, and photons are used
A. Zhou (*) interchangeably in X-ray imaging. Photons may
Department of Medical Radiation Science, Faculty of also be measured in terms of the wavelength by
Health, University of Canberra, Canberra, Australia the relationship λ = h × c ÷ Eph. Here, λ is the
e-mail: [email protected]
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 3
S. Chau, C. Hayre (eds.), Computed Tomography, https://doi.org/10.1007/978-981-19-9346-6_1
4 A. Zhou
wavelength, h is the Planck constant Beer (1852) exponential attenuation law

(6.62607004 × 10−34 m2kg/s or J/s), c is the speed expressed in Eq. (1), for a homogenous medium
of light in vacuum (2.99792458 × 108 m/s), and and monoenergetic X-ray beams.
Eph is the energy in J. For example, the wave-  µ 
 − ×l 
length of a 124-eV photon is approximately Il = I0 × e  ρ 
(1)
10 nm. Wavelength measurements of photons are
uncommon in X-ray imaging. where Il is the number of photons traversing a dis-
Photons with energies above the binding energy tance l in the homogeneous medium without inter-
of an orbiting electron can eject an electron from its actions, I0 is the number of monoenergetic photons
atom. In X-ray imaging, the X-ray beam consists of entering the medium, μ and ρ are the linear attenu-
many polychromatic photons whose energy ranges ation coefficient and density, respectively, of the
from approximately 10–150 keV. The minimum medium, and e is the Euler’s number, an irrational
and maximum energies depend on the total filtra- number approximately equal to 2.71828.
tion and tube voltage, respectively. Photons of
these energies can interact with tissues through 1.1.1 Rayleigh Scattering
three interaction models: Rayleigh scattering, Rayleigh scattering or coherent scattering occurs
Compton scattering, and photoelectric absorption. when an incident photon is deflected by the elec-
The interactions between photons and matter are tromagnetic field inside an atom. The photon
also known as attenuation. The probability of each changes its trajectory, and its energy is preserved.
interaction has a coefficient that is available from The incident photon interacts with the atom and
the NIST (2004). Interaction probabilities depend its orbiting electrons as a whole, leading to a
on several factors: photon energy, tissue composi- change in its direction (Fig. 2). No electrons are
tion, density, and thickness. The total mass attenu- ejected, and the atoms are not ionized. Rayleigh
ation coefficients of soft tissue, bone cortical, and scattering dominates in low-energy X-ray pho-
brain are illustrated in Fig. 1 for photon energies tons, such as those used in mammography. When
from 10 to 150 keV. traversing through a 10-cm soft tissue, an X-ray
An X-ray beam traversing through tissues beam of radiation quality RQT 8 (IEC 60627:
reduces the total number of primary photons 2005)–100 kilovoltage peak (kVp), 0.2 mm Cu
along the path. The reduction of primary photons added filtration, and 6.9 mm Al first half-value
follows the Bouguer (1729)–Lambert (1760)– layer, will have approximately 10% of photons
Fig. 1 Total mass

Mass attenuation coefficient, µ/ρ (cm2/g)
attenuation coefficients Soft tissue

(μ/ρ) of soft tissue, bone
cortical, and brain for Bone cortical
photon energies from 10 10
to 150 keV. μ and ρ are Brain
the linear attenuation
coefficient and density,
respectively
0
0 30 60 90 120 150
Photon energy (keV)
Radiobiology and Radiation Protection 5
Fig. 2 Rayleigh scattering—the orbiting electrons and

the atom interact as a whole with an incident photon and
changes its direction without causing energy loss
Fig. 3 Illustration of Compton scattering. An incident
photon interacts with an orbiting electron. The photon
undergoing Rayleigh scattering, more than 50% loses some energy and is deflected away from the incident
direction. The electron is ejected with a certain kinetic
undergoing Compton scattering, while approxi- energy
mately 20% undergo photoelectric absorption.
1.1.2 Compton Scattering

Compton scattering, also known as inelastic scat-
tering, was discovered by Arthur Holly Compton.
In Compton scattering, an incident photon inter-
acts with an orbiting electron, loses energy, and
changes its direction (Fig. 3). A part of the energy
of the photon is transferred to the electron, which
gains kinetic energy and escapes from the atom.
The sum of the kinetic energy and the binding
energy of this electron equals the energy lost by
the photon. The direction of the electron is con-
fined to an angle that is not more than π/2 rad
with respect to the original direction of the pho- Fig. 4 Illustration of photoelectric absorption. An inci-
dent photon is absorbed by an orbiting electron. The elec-
ton. During Compton scattering, photons are tron is ejected with a kinetic energy equal to the difference
more likely to interact with loosely bound or of the energy of the incident photon energy and the bind-
outer-shell electrons. Compton scattering results ing energy of the electron
in scattered radiation and ionization.
whose binding energies are the closest to, but less
1.1.3 Photoelectric Absorption than its energy. Photons with energies exceeding
Photoelectric absorption or the photoelectric the K-shell binding energy are most likely to
effect is the process that an orbiting electron interact with the K-shell electrons through photo-
absorbs a photon and escapes from the atom. The electric absorption. After a K-shell electron is
electron absorbs all the energy of the photon and ejected, the atom is ionized with a K-shell elec-
escapes from the atom with a kinetic energy equal tron vacancy. This vacancy can be filled by an
to the difference between the energy of the photon electron from a nearby shell with a lower binding
and the binding energy of the electron (Fig. 4). energy (in this example, the L-shell). The electron
Photoelectric absorption occurs only if the photon filling this vacancy, however, can be from any
energy exceeds the electron binding energy. A outer shell, for example, the M shell or N shell. As
photon is most likely to interact with the electrons the electron escapes from its orbit, it creates
6 A. Zhou
another vacancy, which is then filled with an elec- the atomic level, these interactions can break
tron from an even lower binding energy shell. chemical bonds, relocate atoms within cell mol-
Thus, an electron cascade from the outer shells to ecules, and lead to change or loss in the function
the inner shells occurs. In an electron cascade, the of the molecule and damage cells. Damaged cells
difference in binding energy is released as pho- may repair themselves correctly and survive.
tons, which are known as characteristic X-rays. A They may incorrectly repair themselves and die.
bound electron, possibly from the same shell of If they survive, they can progress to abnormality
the cascading electron, can absorb a characteristic or they may not manifest any abnormalities dur-
X-ray emitted by the cascading electron. After ing the lifetime of the person. The effects of ion-
absorbing the X-ray, this bound electron escapes izing radiation on humans can be deterministic or
from the shell and is known as an Auger electron stochastic.
(first discovered by Meitner (1922)). The emis-
sion of Auger electrons and characteristic X-rays 1.2.1 Deterministic Effects
are competing processes. The probability of the Deterministic effects include acute damages to the
emission of characteristic X-ray decreases as the organs and tissues. Damages often occur in the
atomic number of the material decreases. Soft tis- form of the loss of tissue or organ functions, such
sues are mostly composed of materials with low as cell death and, in extreme cases, death of the
atomic number. Characteristic X-ray emission irradiated individual. Deterministic effects have
does not frequently occur in soft tissues, but threshold doses and occur when the dose exceeds
Auger electron emission predominates. the threshold dose. Some threshold doses are listed
in Table 1. Threshold doses depend on the type of
1.1.4 Pair Productions irradiated organ/tissue and type of clinical effects
Photons with energy of at least 1.022 MeV may on the organ/tissue exposed. If the radiation dose
undergo pair productions with a strong electric received by an individual exceeds the threshold
field from the nucleus. In a pair production inter- dose, the severity of the deterministic effect
action, the photon energy is completely absorbed increases as the dose increases. The threshold
by the nucleus, resulting in the production of an doses may be revised with an increasing number
electron and a positron. The electron and positron of observations for deterministic effects. There is
have the same energy and are separated by 180° much evidence to show that radiation-induced eye
or move in opposite directions. cataracts and circulatory diseases occur at lower
radiation doses than previous estimations.
1.2 Effects of Ionizing Radiation 1.2.2 Stochastic Effects

Stochastic effects include cancerous and non-
Interactions between photons and matter result in cancerous risks for irradiated individuals and herita-
energy deposition in tissues and damage cells. At ble risks passed on to their offspring. Following
Table 1 Threshold doses for the incidence of morbidity in tissues and organs in adults exposed to acute or chronic
irradiation
Organ/ Time to develop Acute exposure Annual (chronic) dose rate for many
Effect tissue effect (Gy) years (Gy/year)
Temporary sterility Testes 3–9 weeks ~0.1 0.4
Permanent sterility Testes 3 weeks ~6 2.0
Permanent sterility Ovaries <1 week ~3 >0.2
Depression of Bone 3–7 days ~0.5 >0.4
hematopoiesis marrow
Cataract (visual Eye >20 years ~0.5 ~0.5 divided by years duration
impairment)
radiation exposures, stochastic effects occur by The stochastic effects of radiation exposure
probabilities, and there is no guarantee that an irradi- have been observed in a wide range of investiga-
ated individual will develop any signs or symptoms tions, such as the increased incidence of cancers
of diseases. There is a latent period before any signs in the offspring of Japanese atomic bomb survi-
or symptoms manifest. Cancerous risks result from vors (Little et al. 2009b), development of cancers
damages to genes by direct or indirect energy depo- in experimental animals, and the significantly
sitions in deoxyribonucleic acids (DNAs). Cells high rates of cancers among irradiated popula-
have several repair mechanisms that correct them- tions. Significantly higher rates of breast cancers
selves during cell division cycles. Unrepaired or were reported among female patients with tuber-
wrongly repaired DNA damages may cause cancers culosis who underwent extensive diagnostic fluo-
in irradiated individuals. These are known as somatic roscopy and the incidence was found to be
effects. If the damages result in a disease in the off- approximately 10–15 years after the initial exami-
spring of the irradiated individual, it is known as a nations. Among the patients who received a low
heritable effect. Heritable risks of radiation expo- dose between 10 and 90 mGy, a significantly
sures are observed among the offspring of Japanese higher risk remained (Doody et al. 2000). Higher
atomic bomb survivors. Non-cancerous risks include risks of breast cancers were also reported in
cataracts, atherosclerotic diseases, inflammatory patients who underwent radiation therapy for a
responses, and myocardial infarction (Little et al. mean dose of 290 mGy to the breast (Eidemüller
2008b; Baker et al. 2011; Picano et al. 2012). et al. 2009, 2011). Similar results were observed
Stochastic effects are proportionally related to in women who were treated for postpartum masti-
the cumulative radiation dose of an individual. tis with doses typically ranging from 1 to 6 Gy
The severity of the stochastic effects is not related (Hall and Giaccia 2019). An increase in lung can-
to the dose. A cancer induced by 2 Gy is not cers has also been reported in patients treated with
worse than that induced by 0.1 Gy. Stochastic radiation doses of 5 Gy or more (Travis et al.
effects have no threshold doses. A single instance 2002; Dores et al. 2002). Leukemia is one of the
of an unrepaired DNA damage can cause cancers malignant cancers that are most likely linked to
or hereditary defects, though with a very low radiation exposures. Leukemia is commonly diag-
probability (Mossman 2006). The best practice in nosed in X-ray workers, physicists, and engineers
X-ray imaging involves keeping radiation expo- working near accelerators and other sources of
sures as low as reasonably achievable (ALARA) ionizing radiation (Little et al. 2009a). The latest
to minimize stochastic effects. evidence of stochastic effects comes from a study
of about 950,000 children and young adults
1.2.3 Evidence of Ionizing Radiation (before age 22 years) of nine European countries.
Effects The study shows a significantly linear dose-
On July 31, 2010, the New York Times reported response relationship for brain cancers after CT
Walt Bogdanich’s findings about adverse clinical brain examinations (Hauptmann et al. 2023).
symptoms including hair loss, headaches, mem-
ory loss, and confusion in patients who under-
went CT brain perfusion scans because of the 1.3 Linear No-Threshold Model
intentional use of high levels of radiation to
obtain high-quality images. CT brain perfusion The risks of cancers owing to exposure to ioniz-
scans are performed to evaluate cerebral blood ing radiation have been widely observed and are
flow, such as in the diagnosis of stroke. More unavoidable. A causative relationship between
than 400 patients at eight U.S. hospitals might radiation doses and cancer risks is described by a
have been affected by brain perfusion scans. linear no-threshold (LNT) model that is modeled
These symptoms were due to large acute radia- on epidemiological and animal data (Little et al.
tion exposures and are typical examples of deter- 2008a). The LNT theory predicts that stochastic
ministic effects. effects are proportional to cumulative radiation
8 A. Zhou
doses. The LNT model is established for high radiation professionals to apply relevant methods
radiation doses with dose-specific estimates of consistently to ensure that the amount of radia-
risks determined from people exposed to acute tion is kept at the minimum while producing
doses of 200 mSv or greater. images with optimal quality. A practical chal-
In medical imaging, radiation exposure or frac- lenge with the ALARA principle lies in produc-
tionated exposures with acute fractions are less ing acceptable image quality with the lowest
than a few mSv. It is difficult to detect cancer risks possible radiation doses. Dose limits are set for
resulting from low radiation doses in epidemio- regulatory guidance on radiation protection for
logical studies. ICRP (2007) it is generally radiation professionals. It states that the radiation
accepted that the risks from LNT should be divided dose a professional receives annually and accu-
by the dose and dose-rate effectiveness factor mulates over the professional practical period
(DDREF) to model the risks at low radiation should not exceed the recommended dose limits.
doses. DDREF values for doses at or below 2 Gy These limits are intended to prevent deterministic
have a value of 2. In comparison, the Biological effects and reduce the stochastic effects of radia-
Effects of Ionization Radiation (BEIR) Committee tion exposure on radiation professionals.
recommends DDREF values in the range of 1.1– The exposure time, distance from a radiation
2.3, based on the Bayesian statistics of the combi- source, and shielding are essential factors for radia-
nation of the life span studies of atomic-bomb tion protection. The total radiation exposure
survivors and selected animal studies. received by an individual is proportional to the
exposure time and inverse square of the distance
from the radiation source. Minimizing the time of
1.4 Radiation Protection exposure to ionizing radiation is an essential
method for reducing the total radiation dose
The stochastic effects of radiation exposure are received by the individual. Healthcare profession-
modeled by the LNT theory. The best X-ray als should minimize the time during which they
imaging practice is to keep radiation exposure have to be in areas where the generation of X-rays
ALARA, while producing optimal quality is active, for example, during CT fluoroscopy
images. The primary goal of radiation protection examinations. Increasing the distance from the
is to prevent the occurrence of deterministic radiation source is another important approach for
effects and minimize stochastic effects. In medi- reducing radiation exposure. During X-ray imag-
cal X-ray imaging, the principles of justification, ing, the radiation from the source is divergent and
optimization, and dose limits are recommended travels in all directions. The amount of radiation
for radiation protection. reaching a given area depends on its distance from
The principle of justification refers to the the source and is proportional to the inverse square
fact that every radiation exposure received by of the distance. Thus, the further the source, the less
patients must be associated with a positive net radiation the received. When a patient undergoes a
benefit. The justification principle is intended for CT examination, the body becomes a source of
healthcare professionals who can prescribe X-ray scattered radiation, which moves in all directions.
imaging examinations. It is an effort to reduce During CT fluoroscopy examinations, healthcare
radiation exposure to patients by avoiding unnec- personnel should stand at a reasonable distance
essary X-ray imaging examinations. from the scatter source. The use of shielding is
The principle of optimization is based on the another effective radiation protection method.
ALARA principle. This means that all radiation Shielding is designed to reduce radiation exposure
exposures must be kept as low as reasonably to personnel. Shielding devices are made of high
achievable without compromising the image atomic number materials, such as lead plastics, to
diagnostic quality, with economic and social fac- absorb radiation. Personal shielding devices com-
tors taken into consideration. The practical monly include lead aprons, gloves, goggles, and
implementation of the ALARA principle requires thyroid shielding. Transparent plate-glass shielding
can be used to protect personnel from scattered cation of tube current modulation and AEC is a
radiation without limiting vision. The CT room common radiation dose reduction method found
walls are shielded to protect persons from exposure in modern CT scanners.
to scattered radiation. Shielding may not be Patient centering in CT scans, which affects
intended for patients; it could not protect the patient the radiation dose to the patient, is controlled by
from exposure to scattered radiation arising from radiation professionals. Inaccurate centering
herself/himself. For the patient, shielding is only mostly occurs in the vertical direction (y-axis)
useful if it is used to stop the primary beam. If the owing to too low or high patient table positions
primary beam must be stopped, beam collimation and is less frequent for patients lying to the side
should first be used to exclude regions where the of the table (x-axis). Occasionally, patients may
shielding would have been applied. be off-centered in both directions. Ideal centering
requires the patient to be centered on the gantry’s
iso-center for data acquisition and accurate imag-
1.5 Image Quality Optimization ing. Off-centering can lead to partial scan cover-
and Dose Reduction age (Fig. 5), increase patient radiation doses, and
degrade image quality. With a CT body phantom,
Several techniques are used to reduce radiation a 3-cm off-centering and a 6-cm off-centering
exposures to patients and improve image quality. resulted in an increase in the patient dose by 18%
These include beam filtration, collimation, cur- and 41%, respectively (Li et al. 2007; Toth et al.
rent modulation, automatic exposure control, 2007; Kataria et al. 2016). Off-centering can
patient centering, and noise reduction recon-
struction algorithms. X-ray beam filtration
reduces the number of low-energy photons, lead-
ing to an increase in the average beam energy.
Filtration devices can be applied to deliver radia-
tion in the most appropriate distribution over
Over table beam
gantry angles with regard to the regions and
shapes of the irradiated anatomy. Beam filtration
devices are applied between the X-ray tube and
the patient. Some manufacturers have also used
filters specific to patient size and/or cardiac CT
examinations. Beam collimation is applied to Partial scan
volume coverage
limit the beam to the minimal dimensions
required. Beam collimation occurs along the
z-axis to define the body length to be scanned
and across the patient table to define a scan field
of view (SFOV).
Tube current modulation and automatic
exposure control (ACE) are used to adjust the
radiation exposure in response to variations in Under table beam
imaging object sizes and shapes in real time dur-
ing data acquisition. Some manufacturers adjust
the current based on attenuation changes along
the z-axis while others control the current by
attenuation changes with respect to the gantry
Fig. 5 Illustration of off-centering in the vertical direc-
rotation (in the x–y plane). Others combine both tion. Off-centering can cause partial scan volume cover-
approaches to achieve a predetermined image age, resulting in increased noise and reduced image
noise level by controlling the current. The appli- quality
10 A. Zhou
affect the CT numbers or Hounsfield numbers the real sinogram data, and their differences are
(HU). CT numbers are converted from linear used to update the image data. This iteration con-
attenuation coefficients, which are calculated tinues until a predefined condition is reached. A
from the sinogram data acquired during the scan. convolutional neural network (CNN) algorithm
CT numbers are whole numbers truncated from has shown great success in reducing image noises
the results calculated using Eq. (2). CT numbers and the effect of scatter radiation (Zhou et al.
are relative to the linear attenuation coefficient of 2020). The fundamental advantage of AI is
water. The CT number of water is always zero. machine learning, in which the algorithm can pro-
Changes of more than 20 HUs were found in a duce a mapping from raw inputs to specific out-
10-cm off-centering from the iso-center. The puts. CNN algorithms trained with low-dose CT
majority of off-centering in clinical CT examina- image data have been tested using routine-dose
tions was less than 2 cm and less than 2% of CT images (Wolterink et al. 2017; Chen et al.
examinations exhibited an off-centering exceed- 2017a,b). AI is expected to play a major role in
ing 4-cm (Szczykutowicz et al. 2017). the reconstruction of CT images. IR algorithms
have been proven to be a great technique available
µ tissue − µ water
HU = 1000 × (2) in clinical practice for noise reduction.
µ water

where HU is the Hounsfield number, and μtissue 2 Radiation Dose in CT

and μwater are the linear attenuation coefficients of Examinations
the tissue and water, respectively.
Noise reduction reconstruction algorithms The LNT model quantitatively predicts the caus-
use iterative procedures to reduce image noises. ative relationship between cancer risk and radiation
The traditional filtered back projection (FBP) exposure. The measurements of radiation delivered
reconstruction method produces high-quality to patients are useful for risk assessment in X-ray
images from data acquired with optimal radiation imaging. The effects of ionizing radiation on tissues
exposure. For low radiation exposures, the FBPs depend on several factors, including the amount of
of most manufacturers fail to reduce image noises energy deposited in the tissue, the type of radiations,
and result in poor image quality. Iterative recon- and the type of tissues. For the same radiation dose,
struction (IR) algorithms are generally more use- different types of radiations can have different
ful for image reconstruction at low or ultra-low degrees of effects on tissues. A radiation weighting
radiation exposures (Willemink and Noël 2019; factor (Table 2) is used to account for the relative
Willemink et al. 2014). Many CT manufacturers biological effectiveness (RBE) of different types of
offer IR algorithms along with their new CT scan- radiations. A tissue weighting factor (Table 3) is
ners. During the last decade, artificial intelligence used for the radiosensitivity of tissues. Radiation
(AI) algorithms with the potential for high image measurements also consider other factors that affect
quality at ultra-low radiation exposures have the biological effects. Several radiation measure-
emerged for CT image reconstruction. Most IR ments are used in X-ray imaging, and some of them
algorithms fall into two major categories: hybrid are dedicated to CT examinations.
and model-based. Hybrid IR algorithms first itera-
tively filter the sinogram data to achieve noise Table 2 Radiation weighting factors
reduction and then perform back projection. After
Radiation weighting
back projection, the image data are iteratively fil- Radiation type factor, WR#
tered to reduce image noises. Model-based IR Photons, electrons 1
algorithms first perform backward projections to Protons 2
obtain the image data and then perform forward Alpha particles 20
projections to produce artificial sinogram data. Neutrons (a function of the 5–20
The artificial sinogram data are then compared to energy)
Table 3 Tissue weighting factors

Tissue WT, individual ∑WT#
Bone red marrow, colon, lung, stomach, breast, 0.12 0.72
remainder tissuesa
Gonads 0.08 0.08
Bladder, esophagus, liver, thyroid 0.04 0.16
Bone surface, brain, salivary glands, skin 0.01 0.04
Total 1.00
a
Remaining tissues: adrenals, extrathoracic region, gall bladder, heart, kidneys, lymphatic nodes, muscle, oral mucosa,
pancreas, prostate (M), small intestine, spleen, thymus, uterus/cervix (F)
2.1 Absorbed Dose nor for the detailed specific retrospective investi-
gations of individual exposures and risks.
The amount of energy deposited per unit mass is The application of an effective dose in medi-
known as the absorbed dose (Eq. 3), and its SI cal X-ray imaging has limitations. The effective
unit is Gray (Gy) or J/kg. The absorbed dose is dose facilitates the comparison of biological
one of the most frequently used radiation mea- effects between different types of diagnostic
surements in X-ray imaging and can be measured examinations. The effective dose may be used to
with a dosimeter, such as an ionization chamber. communicate with patients concerned about the
potential harm of their X-ray imaging examina-
ε
D= (3) tions. The effective dose has an advantage and
m can be compared to the annual effective dose
where D is the absorbed dose in Gy (or J/kg), and from naturally occurring background radiation. It
ε is the energy deposited in a mass of m kg. varies from region to region and is approximately
3.0 millisievert (mSv) in the United States or
1.5 mSv in Australia.
2.2 Effective Dose Controversies over effective dose values may
arise because of the calculation methodology and
The effective dose accounts for the biological data sources. The effective dose is a measure of
effects owing to energy deposition, radiation the relative “whole-body” uniform radiation
type, and tissue type. To calculate the effective exposure, which differs from the exposure to a
dose, the absorbed dose is ideally measured with divergent X-ray beam generated in X-ray imag-
a uniform radiation beam exposing the whole ing. In addition, X-ray imaging examinations
body. The effective dose (E) is calculated using often include only a part of the body, variations in
Eq. (4), which is the product of the absorbed dose the calculation of effective doses for X-ray imag-
(D), radiation weighting factor (WR), and tissue ing examinations occur.
weighting factor (WT).
E = WR × WT × D (4)
2.3 Organ Dose
The effective dose is intended for radiation Organ dose is useful when radiation protection of
protection, such as radiation dose assessments for individual organs is considered. The organ dose
occupationally exposed personnel and planning is the total energy deposited in an organ divided
and optimization in radiological protection. It is a by its mass. The unit for organ dose is Gy. The
statutory quantity for demonstrating compliance direct measurement of organ doses is impractical.
with dose limits and cannot be used to assess They can be appropriately determined using
individual risks. The effective dose is recom- Monte Carlo simulations or experimental setups
mended neither for epidemiological evaluations with phantoms.
12 A. Zhou
2.4 Exposure phragms, and geometry of the focal spot. The dis-
tributions of radiation doses in the SFOV for small
Radiation exposure is a measure of the number of and large imaging objects are illustrated in Figs. 6
electrical charges of a single sign that is produced and 7, respectively. The radiation doses were higher
by ionizing radiation per unit mass of gas, for in the peripheral regions and lower toward the cen-
example, air. Exposure is based on the fact that tral regions for both the 16-cm diameter head phan-
for each gas, the average energy needed to ionize tom and the 32-cm diameter torso phantom. The
one pair of ions is constant. For example, the distributions also depend on the tube kVp; gener-
average energy needed to create one pair of ions ally, the lower the kVp, the greater is the difference
in air is approximately 34 eV. between the peripheral region doses and the central
Radiation exposure can be directly measured region doses (Imhof et al. 2003; Geleijns et al.
with air-filled radiation detectors for biological 2009) owing to the greater radiation attenuation of
purposes because the effective atomic number of lower energy photons.
the air is close to that of soft tissues. Radiation
exposure is nearly proportional to the absorbed
dose in soft tissues over the range of photon ener- 2.6 Dose Distribution Along Scan
gies used in medical X-ray imaging. The unit of Length
radiation exposure may be expressed as Roentgen
(R) or coulomb per kilogram (C/kg). Exposure The radiation reaching a location in the SFOV
can be converted to the absorbed dose. One R is depends on the scattered radiation from the
approximately 8.73 mGy. planned scan volume and the geometries of the
X-ray focal spot and collimation diaphragms.
The radiation dose can be modeled from the radi-
2.5 Dose Distribution in SFOV ation distribution of a single-slice scan. In a
single-slice scan, an ideal distribution of radia-
Contiguous irradiation during gantry rotations con- tion along the scan length (z-axis) through any
tributes to the radiation dose at a location in the point in the SFOV is a square-wave (Fig. 8b)
SFOV because of scatter radiation, collimation dia- because of the perfect point source (an infinitely
a Relative dose b Relative dose

100 kVp 1.00 140 kVp 1.00
0.95 0.95
0.90 0.90
0.85 0.85
0.80 0.80
0.75 0.75
0.70 0.70
0.65 0.65
Fig. 6 Radiation dose distributions in a 16-cm diameter about 1.5 times the doses in the central areas for both the
head phantom. The doses decrease from the peripheral to 100-kVp (a) and 140-kVp (b). The radiation dose infor-
the central regions. The doses in the peripheral regions are mation is from Imhof et al. (2003)
a Relative dose b Relative dose

100 kVp 1.00 140 kVp 1.0
0.90
0.9
0.80
0.8
0.70
0.7
0.60
0.50 0.6
0.45
0.5
Fig. 7 Radiation dose distribution in a body phantom of doses in the central regions. (b): For 140-kVp the periph-
32 cm in diameter with higher doses at the peripheral eral doses are about twice the doses in the central regions.
regions and lower doses at the central region. (a): For 100- The radiation dose information is from Imhof et al. (2003)
kVp, the peripheral area doses are about 2.4 times the
a small focal spot) and lack of scattered radiation.

Collimated
x-ray beam
The actual radiation distribution is nearly bell-
shaped, forming a narrow bell along the scan
length through a point in peripheral regions of the
SFOV, and a broad bell along the scan length
Detector
through a point in the central regions of the SFOV
(Fig. 8c) (Geleijns et al. 2009).
CT radiation dose assessments are performed
b D under standardized conditions that provide clini-
cal geometries. A small phantom with a diameter
Ideal dose of 16 cm and a large phantom with a diameter of
distribution
32 cm were used to simulate a patient’s head and
Z a torso/body, respectively (Fig. 9). Both phan-
toms, made from solid acrylic, were drilled with
D holes at specific locations for placing the pencil
c dosimeters. When radiation detectors are not
Actual dose placed in the holes, they are plugged using acrylic
distribution plugs.
Z
Fig. 8 Distribution of radiation along the scan length

(z-axis) from a single-slice scan. (a) represents the detec-
2.7 CT Dose Index
tor with the collimated x-ray beam source. At any point in
the SFOV (the x–y plane), an ideal distribution along the The CT dose index (CTDI) measures the absorbed
z-axis is a square-wave (b). An actual dose distribution dose in CT examinations. The CTDI is intended
closely resembles a narrow bell shape along the z-axis
to account for the radiation from a series of adja-
through a point in peripheral regions of the SFOV and
broad bell shape along the z-axis through a point in central cent scans by measuring the radiation dose distri-
regions of the SFOV (c) bution from a single gantry rotation scan. The
14 A. Zhou
D(z)
a
-z z
CTDI
b
Fig. 9 CT cylindrical acrylic phantom for head and torso

radiation dose measurements. The phantom comprised of
three cylindrical parts and 13 acrylic plugs which are
assembled with an outer diameter of 32 cm for torso dose
measurements. The two inner cylinders are assembled
with an outer diameter of 16 cm for head dose measure-
ments. The cylinders are 15 cm high with 13 holes drilled
through: four holes on the periphery of each cylinder and
a central hole on the smallest one
Z
-nT/2 nT/2
CTDI model is given in Eq. (5). The CTDI is
measured in Gy (or J/kg).
Fig. 10 Illustration of the equivalent area under the
z
1 curve. (a) demonstrates the distribution of the radiation
D ( z ) dz
nT −∫z
CTDI = (5) dose along the z-axis resulting from a single-slice scan;
(b) shows a square-wave CTDI distribution over the X-ray
beam width of a single-slice scan. The areas under the
curves in (a) and (b) are equal. (b) demonstrates that the
where n is the number of slices acquired in a sin-
CTDI is equivalent to the absorbed dose measured from
gle gantry revolution (for single-slice scanners, n the radiation that would have only exposed regions given
= 1; for multiple-slice scanners, n depends on the by (−nT/2, nT/2) but have exposed regions across loca-
activated data channels used for data acquisition tions in (−z, z)
with n = no. of active channels, and one channel
is for one image slice). T is the width of a single The physical meaning of this area is the product
slice along the z-axis. In single-slice scanners, T of dose and length. When the area is divided by
is the slice thickness. In multiple-slice scanners, the X-ray beam width (nT), it results in an aver-
where several detector elements may be grouped age dose of radiation that would have exposed
together to form one data channel, T is the width only regions located in (−nT/2, nT/2) but had
of one data channel, and nT is the effective beam actually exposed regions in (−z, z). The average
width. z is the location along the direction of radiation dose within the X-ray beam width (nT)
movement of the patient table. It has a range of is illustrated in Fig. 10b, in which the area under
values to cover a longer length than the single- the CTDI curve equals the area under the dose
slice scan length to measure the radiation dose curve in Fig. 10a. The average radiation dose was
due to the scan of the multiple slices. D(z) is the calculated using the CTDI. Indeed, the CTDI
dose at location z.The integration in Eq. (5) cal- represents the radiation dose that would have
culates the area under the dose curve (Fig. 10a). been measured when a series of contiguous irra-
Fig. 11 Illustration of

CT radiation dose profile
of several contiguous
scan slices. Each
individual slice has a X-ray beam
bell-shaped dose
distribution (middle)
along the z-axis. The
resultant dose
distribution along the
z-axis over the range of
the scanned slices is
shown at the bottom
Dose distribution of
individual slices
z
Average
Resultant dose distribution
diations along the z-axis had been performed 14-nominal-slice width to determine the radia-
from −z to z, as illustrated in Fig. 11. tion dose, which was then denoted as CTDIFDA.
To determine the CTDI, the radiation was mea- CTDIFDA is calculated using Eq. 6 and its unit is
sured with a pencil dosimeter from one revolution Gy. For the determination of CTDIFDA, the stan-
of the gantry. As the active detection length of the dard scattering media for the head and torso
dosimeter is longer than the collimated X-ray phantoms are polymethylmethacrylate (PMMA)
beam width (slice thickness), the radiation reach- cylinders with a length of 14-cm cm and diame-
ing the adjacent regions is also measured. The ters of 16 and 32 cm for head and body examina-
result of the measurement using a pencil dosime- tions, respectively.
ter is a dose distribution over the z-direction of the 7T
1
scan, or dose versus length along the movement CTDI FDA =
nT ∫ D ( z ) dz, (6)
direction of the patient table. The dose distribu- −7T
tion is integrated, and the result is then divided by
the X-ray beam width (or slice thickness) to where n is the number of slices acquired in a single
obtain an average absorbed dose, the CTDI. The gantry revolution (for single-slice scanners, n = 1;
CTDI is determined in the axial scan mode for a for multiple-slice scanners, n depends on the acti-
single gantry revolution to assess the radiation vated data channels used in the data acquisition
dose that would have resulted from a series of with n equal to no. of active channels). In a single-
contiguous irradiations along the z-axis. slice scanner, T is the slice thickness, whereas in
multiple-slice scanners, several detector elements
may be grouped together to form one data channel
2.8 CTDIFDA and T is the width of one data channel.
CTDI does not standardize the width for the inte-

gration to include the radiation profile tails, 2.9 CTDI100
which are illustrated in Figs. 8 and 11. For stan-
dardized dose measurements, Food and Drug CTDIFDA also depends on the nominal slice
Administration (FDA) of USA introduced a width and tail of the radiation profiles. Potential
16 A. Zhou
variations in dose measurements owing to the 2.11 CTDIvol

scan-
slice width are avoided using CTDI100,
which represents the average radiation dose at The determinations of CTDI, CTDIFDA, CTDI100,
the central region of a 100-mm scan. The deter- and CTDIw are performed with a single gantry
mination of CTDI100 requires that the radiation revolution. Clinical CT scan protocols often
dose measurements extend 50 mm to each side cover a range of anatomy and require multiple
of the scan location (Eq. 7). The data for deter- contiguous gantry rotations to complete data
mining CTDI100 was acquired using a 100-mm acquisition. The patient table moves a distance
long, 3-cc active volume CT pencil ionization equal to, less than, or greater than the collimated
chamber and standard CTDI acrylic phantoms. X-ray beam width between the gantry rotations.
The measurements were performed with a sta- A factor, known as the pitch, is used to describe
tionary couch. the ratio of the table movement distance to the
50 beam width. To account for the effect of pitch on
1
CTDI100 =
nT ∫ D ( z ) dz (7) the radiation dose, CTDIvol, which is calculated
−50 using Eq. (9), was used.
1
where n is the number of slices acquired in a sin- CTDI vol = × CTDI w (9)
gle gantry revolution (for single-slice scanners, n Pitch
= 1; for multiple-slice scanners, n depends on the where the pitch equals the distance moved by the
activated data channels used in the data acquisi- table in a gantry rotation divided by the beam
tion with n = no. of active channels). T is mea- width. A pitch equal to 1 indicates the absence of
sured in mm. In single-slice scanners, T is the a gap between adjacent slices while a pitch less
slice thickness, whereas in multiple-slice scan- than 1 means an overlap between adjacent slices,
ners, T is the width of one data channel formed and therefore, more radiation exposure to the
by detector elements grouped together. patient during the scan. A pitch greater than 1
indicates a gap between adjacent slices and
hence, less radiation exposure to the patient but
2.10 CTDIW compromised image quality.
CTDIvol depends on both the peripheral and
CTDI, CTDIFDA, and CTDI100 represent the central CTDI100, which neglects the scatter tails
absorbed dose that would have been measured if beyond 50 mm on each side of the scan slice.
contiguous scan slices along the z-axis were per- Consequently, this underestimates the equilib-
formed. They vary across the SFOV from the rium dose for body scan lengths of 250 mm or
peripheral regions to central areas. To account for more by a factor of 0.6, on the central axis, by
radiation dose variations in the SFOV, an average about 0.8, on the periphery, and by a factor of 0.7,
of CTDI100 is proposed estimating the absorbed for the dose-length product for all scan lengths
dose across the SFOV. This quantity, denoted by (Boone 2007; Mori et al. 2005).
CTDIw, is calculated by Eq. (8). The values 1/3 CTDIvol is a single CT dose parameter that can
and 2/3 approximate the relative areas represented be measured directly and easily, and represents
by the center and peripheral regions, respectively. the average absorbed dose within the scan vol-
ume for a standardized phantom. CTDIvol repre-
1 2
CTDI w = × CTDI100, center + × CTDI100, edge sents the average absorbed dose over the x, y, and
3 3
(8) z directions for an imaging object whose attenua-
tion is similar to that of the CTDI phantom.
where CTDI100,center and CTDI100,edge are the CTDIvol neither represents the average absorbed
CTDI100 at the central and peripheral areas of the dose for objects of substantially different sizes,
SFOV, respectively. shapes, and attenuation, nor measures the total
energy deposited in the scan volume as the scan References

length is not accounted for by the CTDIvol.
Baker JE, Moulder JE, Hopewell JW. Radiation as a risk
factor for cardiovascular disease. Antioxid Redox
Signal. 2011;15:1945–56.
2.12 Dose-Length Product Boone JM. The trouble with CTDI 100. Med Phys.
2007;34:1364–71.
The overall energy deposition in the scan volume Chen H, Zhang Y, Kalra MK. Low-dose CT with a resid-
ual encoder-decoder convolutional neural network.
given by individual scan protocols can be IEEE Trans Med Imaging. 2017a;36:2524–35.
accounted for by a multiplication factor, known Chen H, Zhang Y, Zhang W. Low-dose CT via con-
as the scan length. The product of the scan length volutional neural network. Biomed Opt Express.
and CTDIvol is a better approximation to the total 2017b;8:679–94.
Doody MM, Lonstein JE, Stovall M, Hacker DG,
energy deposition in the scan volume and is Luckyanov N, Land CE. Breast cancer mortality after
known as the dose-length product (DLP) (Eq. 10), diagnostic radiography: findings from the US scoliosis
which has a unit Gy·cm. cohort study. Spine. 2000;25:2052–63.
Dores GM, Metayer C, Curtis RE, Lynch CF, Clarke EA,
DLP = CTDI vol × scan _ length (10) Glimelius B, STORM H, Pukkala E, van Leeuwen FE,
Holowaty EJ, Andersson M, Wiklund T, Joensuu T,
Van’t Veer MB, Stovall M, Gospodarowicz M, Travis
DLP indicates the total energy deposited in LB. Second malignant neoplasms among long-term sur-
the scan volume and thus represents the poten- vivors of Hodgkin’s disease: a population-based evalu-
ation over 25 years. J Clin Oncol. 2002;20:3484–94.
tial biological effect of the examination. This is
Eidemüller M, Holmberg E, Jacob P, Lundell M,
particularly useful; for example, an abdomen- Karlsson P. Breast cancer risk among Swedish hem-
only CT scan may have a CTDIvol equal to the angioma patients and possible consequences of
CTDIvol of an abdomen and pelvis CT examina- radiation-induced genomic instability. Mutat Res.
2009;669:48–55.
tion; the former would have a short scan length
Eidemüller M, Holmberg E, Jacob P, Lundell M, Karlsson
and hence a smaller DLP. The difference in P. Breast cancer risk after radiation treatment at infancy:
these CT examinations shows that DLP is a bet- potential consequences of radiation-induced genomic
ter approximation of the potential biological instability. Radiat Prot Dosim. 2011;143:375–9.
Geleijns J, Salvadó Artells M, de Bruin PW, Matter R,
effects than CTDIvol.
Muramatsu Y, McNitt-Gray MF. Computed tomogra-
Many contemporary CT scanners take advan- phy dose assessment for a 160 mm wide, 320 detec-
tage of helical scans, which require data inter- tor row, cone beam CT scanner. Phys Med Biol.
polation between two points for all projection 2009;54:3141–59.
Hall EJ, Giaccia AJ. Radiobiology for the radiologist.
angles. Thus, the images at the beginning and
Netherlands: Wolters Kluwer; 2019.
end of the helical scan require data acquired Imhof H, Schibany N, Ba-Ssalamah A, Czerny C, Hojreh
beyond the planned scan locations, that is, the A, Kainberger F, Krestan C, Kudler H, Nöbauer I,
beginning and end of the anatomical range that Nowotny R. Spiral CT and radiation dose. Eur J
Radiol. 2003;47:29–37.
are desired for the scan. This increases the
International Electrotechnical Commission. Medical
actual scan length at the beginning and end of diagnostic x-ray equipment-radiation conditions
the helical scan. The increase in DLP owing to for use in the determination of characteristics.
the necessary additional scan regions for data Geneva, Switzerland: International Electrotechnical
Commission; 2005.
interpolation is known as “overranging.” In
Kataria B, Sandborg M, Althén JN. Implications of patient
multiple-detector-row CT (MDCT) scanners, centering on organ dose in computed tomography.
the additional scan length strongly depends on Radiat Prot Dosim. 2016;169:130–5.
the pitch. A typical increase in the scan length is Li J, Toth UK, Seamans TL, Al JE. Automatic patient
centering for MDCT: effect on radiation dose. Am J
1.5 times the width of the individual beam. The
Roentgenol. 2007;188:547–52.
effect of overranging also depends on the length Little MP, Hoel DG, Molitor J, Boice JD, Wakeford
of the anatomical coverage; the shorter the cov- R, Muirhead CR. New models for evaluation of
erage, the greater the effect. radiation-induced lifetime cancer risk and its uncer-
18 A. Zhou
tainty employed in the UNSCEAR 2006 report. Radiat chronic low-dose ionizing radiation exposure. BMC
Res. 2008a;169:660–76. Cancer. 2012;12:157.
Little MP, Tawn EJ, Tzoulaki I, Wakeford R, Hildebrandt Szczykutowicz TP, Duplissis A, Pickhardt PJ. Variation
G, Paris F, Tapio S, Elliott P. A systematic review of in CT number and image noise uniformity according
epidemiological associations between low and moder- to patient positioning in MDCT. Am J Roentgenol.
ate doses of ionizing radiation and late cardiovascular 2017;208:1064–72.
effects, and their possible mechanisms. Radiat Res. The international Commission on Radiological Protection
2008b;169:99–109. (ICRP) publication 103. Ann ICRP. 2007;37(2.4):2.
Little MP, Wakeford R, Kendall GM. Updated estimates Toth T, Ge Z, Daly MP. The influence of patient cen-
of the proportion of childhood leukaemia incidence tering on CT dose and image noise. Med Phys.
in Great Britain that may be caused by natural back- 2007;34:3093–101.
ground ionising radiation. J Radiol Prot. 2009a;29:467. Travis LB, Gospodarowicz M, Curtis RE, Clarke EA,
Little MP, Wakeford R, Tawn EJ, Bouffler SD, de Andersson M, Glimelius B, Joensuu T, Lynch CF, van
Gonzalez AB. Risks associated with low doses and Leeuwen FE, Holowaty E. Lung cancer following che-
low dose rates of ionizing radiation: why linear- motherapy and radiotherapy for Hodgkin's disease. J
ity may be (almost) the best we can do. Radiology. Natl Cancer Inst. 2002;94:182–92.
2009b;251:6–12. Willemink MJ, Noël PB. The evolution of image recon-
Meitner L. Über die Entstehung der β-Strahl-Spektren struction for CT—from filtered back projection to arti-
radioaktiver Substanzen. Z Phys. 1922;9:131–44. ficial intelligence. Eur Radiol. 2019;29:2185–95.
Mori S, Endo M, Nishizawa K, Tsunoo T, Aoyama T, Willemink MJ, Takx RA, de Jong PA. Computed tomog-
Fujiwara H, Murase K. Enlarged longitudinal dose raphy radiation dose reduction: effect of different
profiles in cone-beam CT and the need for modified iterative reconstruction algorithms on image quality.
dosimetry. Med Phys. 2005;32:1061–9. Comput Assist Tomogr. 2014;38:815–23.
Mossman KL. Radiation risks in perspective. CRC Press; Wolterink JM, Leiner T, Viergever MA, Isgum
2006. I. Generative adversarial networks for noise reduc-
NIST. 2004. XCOM: Photon Cross Sections Database tion in low-dose CT. IEEE Trans Med Imaging.
[Online]. Available: https://www.nist.gov/pml/xcom- 2017;36:2536–45.
photoncross-sections-database [Accessed 16 Jan Zhou, A., Tan, Q. & Davidson, R. Image enhancement
2021]. using convolutional neural network. Third International
Picano E, Vano E, Domenici L, Bottai M, Thierry-Chef Conference on Image, Video Processing and Artificial
I. Cancer and non-cancer brain and eye effects of Intelligence, 2020 Shanghai, China: SPIE.
Patient Care and Self-Care in CT
Tristan Charles
Abstract on common scenarios seen in a CT depart-

ment, such as trauma, oncology staging and
When exploring how we can best look after anxious patients. Lastly, we explore areas of
our patient’s needs, we often neglect to look self-care for healthcare professionals and
at the other side of the coin; our own needs as techniques to manage and improve outcomes
healthcare professionals. If someone is oper- on an individual and institutional basis.
ating from a place of dissociation, anxiety,
stress or burnout, they are not aptly equipped Keywords
to meet the wide variety of needs of their
patients. It is therefore necessary to explore Patient care · Self-care · Health and well-
both of these areas in parallel, as one comple- being · Radiographers · CT scanning
ments the other. In this chapter, we explore
the multifaceted layers of patient care, and
what this looks like in a CT department. We 1 Introduction
discuss how to effectively inform a patient of
the details involving their scan, and how to When it comes to caring for patients and staff in
legally, ethically and efficiently obtain con- a CT department, there unfortunately is no “one
sent around radiation exposure and IV con- size fits all” approach; each individual has their
trast. It is also important to understand that own specific needs and values. It is therefore nec-
each individual patient has unique needs in a essary to find a balanced approach which opti-
physical, mental and emotional sense. mises outcomes for both the patient and the
Learning how to meet the patient at their healthcare workers on a case-by-case basis, as
unique place, whilst at the same time effi- well as ensure the entire department operates in a
ciently managing the workflow of your CT safe and efficient manner.
department is an important balancing tool to This chapter explores the areas of patient care
have as a radiographer. We specifically touch and self-care where this balance needs to be found.
T. Charles (*)
RadTrain, Ulladulla, NSW, Australia
20 T. Charles
2 Clinical Considerations the yearly background radiation received is

for Patients Undergoing a CT 1.5 mSv (ANSTO 2021). So if the dose from a
Examination diagnostic CT was estimated at 1.5 mSv, this
would equate to 1 year BERT. This does not nec-
2.1 Obtaining Informed Consent essarily explain any possible risks associated
with these doses, but it can help put the levels
Informed consent in clinical practice can be used into context for the patient to make a more
for two main purposes: first, as a legal covenant informed decision.
to protect the healthcare provider from reprisal in Due to the relatively low levels of radiation
the chance of an adverse incident, and second to received in diagnostic CT, the ambiguous data
educate the patient around risks vs benefits of a and risk models, as well as the difficulty in simply
medical procedure in order to improve autonomy explaining risk associated with radiation levels,
in decision-making. formal written consent specific to ionising radia-
Obtaining consent from patients prior to a CT tion is not necessarily required from patients prior
scan has extra complexity around adequately to having a CT scan (Brink and Goske 2012). The
informing patients about the risks and benefits, reason behind this is that the majority of patients
because there is a large discrepancy between the cannot give proper informed consent because they
available statistics and the actual risks. Ionising cannot be accurately informed of the relevant
radiation, iodinated contrast media administration risks of radiation exposure from diagnostic imag-
and interventional procedures all carry risk, how- ing exams. The exemption to this may be for preg-
ever it is often difficult to present these risks to the nant women receiving a CT scan, where the
patient in an unambiguous and accurate manner. perceived risks to the foetus can be much higher.
In this section, we will explore all three of
these areas and discuss if informed consent is 2.1.2 Iodinated Contrast Media
practical, and if so, what this would look like. Explaining the risks vs benefits of performing a
CT scan with intravenous (IV) iodinated contrast
2.1.1 Ionising Radiation media is an important part of obtaining informed
Stochastic risk models from ionising radiation consent from patients. IV administration of con-
are still being debated amongst the international trast is considered an invasive procedure and car-
community. Although the linear no-threshold ries extra risk in regard to potential allergic
model has largely been implemented for the past reactions and contrast-induced nephropathy.
few decades in a variety of contexts, there is no Since the advancement of non-ionic low-
definitive evidence that doses less than 100 mSv osmolarity contrast media, there has been a 5–10-
are linked to increased cancer incidence or mor- fold reduction in mild to moderate reactions,
tality (Cardarelli and Ulsh 2018, pp. 11). Also, compared to ionic high-osmolarity contrast
stochastic risk is related to age and, to a lesser (Royal Australian and New Zealand College of
extent, gender, so it is not accurate to have a one- Radiologists (RANZCR) 2018). This statistically
size-fits-all approach when discussing radiation changes the risk vs benefits debate, however
risk with patients. there is still a need to inform the patient of the
Informing patients of what is known and what chances of an adverse reaction.
is not known about radiation risk in an easy-to- Other factors to take into consideration when
understand way is important in improving patient discussing risk vs benefits are the patient’s age,
autonomy (Brink and Goske 2012). Background renal function, medical history, and the requested
Equivalent Radiation Time (BERT) is a useful scan and clinical query. Certain CT scans require
tool to help patients understand radiation levels IV contrast in order to answer the clinical query
in diagnostic imaging compared to natural back- (for example, a CTPA to rule out pulmonary
ground radiation levels. On average in Australia, emboli), so the risk of not obtaining an accurate
Patient Care and Self-Care in CT 21
diagnosis may outweigh the risks associated with small they may be) can have serious conse-
contrast media for these scenarios. quences, so this needs to be clearly conveyed to
Ultimately, the patient has the right to refuse the patient.
iodinated contrast media. If this is the case, the Presenting the patient with a written informa-
options presented to the patient would either be a tion sheet, paired with a relevant medical history
non-contrast CT scan (if clinically valid), or questionnaire and a space for the patient to pro-
alternative diagnostic tests. The accuracy of these vide their written consent is advisable prior to
alternative tests should be clearly discussed with CT-guided interventional procedures.
the patient so that they can make an informed
decision.
Presenting the patient with a written infor- 2.2 Preparation and Safety for CT
mation sheet, paired with a relevant medical Scans Requiring IV Contrast
history questionnaire and a space for the
patient to provide their written consent is 2.2.1 Dietary Restriction
advisable prior to administering iodinated con- It is common practice to ensure a patient has
trast media. nothing to eat prior to receiving IV contrast for
their CT scan. The primary reason behind this is
2.1.3 CT-Guided Interventional to minimise the risk and severity of the patient
Procedures aspirating if they experience vomiting as a side-
Therapeutic and diagnostic interventional proce- effect on the contrast injection. It also reduces the
dures carried out under CT-guidance carry their volume of bodily fluids expelled if a vomiting
own unique risks. episode occurs, making cleaning and infection
Radiation levels are generally low enough for control measures easier for the staff. A secondary
routine procedures to not warrant too much con- reason for food restriction is the improved visu-
cern, however CTDIvol can escalate to danger- alisation of the stomach and small intestine
ous levels for complicated procedures. lumen on the CT images, however this matter can
Other risks include allergic reactions to medi- be subjective depending on the reporting
cation, infection, infarction and physical injury radiologist.
such as nerve or joint damage. There is evidence that suggests dietary restric-
Collating consistent, accurate statistics of tion offers no significant difference in adverse
these risks can be challenging for a number of symptoms from IV contrast administration
reasons: (namely nausea and vomiting) in patients com-
pared to no dietary restriction (Barbosa et al.
1. Some adverse events are very rare, so the 2018). Consideration needs to be weighed for
numbers are considered to be statistically assuring safe, effective practice, and simplification
inaccurate and comfort for the patient. This may very well be
2. Individual experience and technique of the patient-specific. For example, dietary restriction in
interventional radiologist play a big role in diabetics poses extra risk compared to the rest of
risk and outcomes the population, so implementing conditional pro-
3. Many adverse statistics are obtained from tocols for certain circumstances can result in
interventional procedures carried out under reduced risk and improved outcomes.
other image-guidance procedures, such as The duration for dietary restriction can be
fluoroscopy, which carry a greater risk com- variable between organisations, generally rang-
pared to CT-guided procedures ing from 2–6 h. Again, a balance needs to be
achieved between image quality, workflow, and
That being said, the risks associated with patient safety and comfort when deciding on the
interventional procedures under CT (however duration.
22 T. Charles
When explaining dietary restriction prepara- lines are recommended by the Royal Australian
tion to a patient, it is important to refrain from and New Zealand College of Radiologists
using the word “fast” or “fasting”, as this implies (RANZCR):
the restriction of fluid intake as well. Having a
patient that is well hydrated is important prior to 1. eGFR > 45 ml/min: risk of CIN is non-
and after IV contrast administration because: existent. No special precautions pre- or post-
administration is needed.
1. It improves the success rate of cannulation. 2. eGFR 30–45 ml/min: risk of CIN is very
2. It can reduce the risk of contrast-induced low to non-existent. Consider reduced con-
nephropathy, especially in moderate-to-high- trast volume if possible. Oral hydration
risk patients (Cheungpasitporn et al. 2014). pre- and post-administration may be of
benefit.
2.2.2 Contrast-Induced Nephropathy 3. eGFR < 30 ml/min (or actively deteriorat-
(CIN) ing renal function): increased risk of
Also called “Contrast-Induced Acute Kidney CIN. Careful weighing of risks vs benefits of
Injury”, CIN is defined as a significant worsening contrast administration should be undertaken,
of renal function as measured by an increase in and alternative diagnostic tests considered.
serum creatinine levels of ≥25% following the Periprocedural hydration and reduced con-
administration of iodinated contrast media trast volume are recommended.
(Bartosz 2016).
It is recommended that all patients should be 2.2.3 Hypersensitivity to IV Contrast
screened prior to contrast administration, and the Allergic reaction to iodinated contrast media
following patients should be flagged as high-risk administered intravenously is classified as per
and a recent eGFR should be obtained (RANZCR Table 1 below (RANZCR 2018):
2018):
Some Key Points About Allergic Reactions
1. Known kidney disease (including transplant). (Cardarelli and Ulsh 2018)
2. Diabetics. • About 97% of reactions occur within 30 min of
3. Patients over 65 years old. injection, with only about 3% of reactions hav-
ing a delayed onset between 1 hour and 1 week.
In regard to safe eGFR ranges for the use of • Delayed reactions are typically mild (rash)
iodinated contrast media, the following guide- and not typically associated with broncho-
Table 1 Classification of allergic reactions to IV contrast media

Classification Likelihood Symptoms Treatment
Mild 1–3% Nausea, vomiting, pruritus (itching), • Stop administration of contrast
urticaria (hives) • Closely monitor patient
• Non-sedating oral antihistamines
Moderate 0.04% Marked urticaria, bronchospasm, • Stop administration of contrast
laryngeal oedema, vasovagal attacks • Call for help/ambulance
• O2 via mask ± Ventolin
• IM adrenaline (0.5 ml adults)
• Lay flat and monitor vitals
Severe 0.001– Shock, respiratory/cardiac arrest, As per above, plus:
(anaphylactic) 0.04%a convulsions • Commence CPR if required
• IV saline for hypotension
• Airways management if required
Risk of death from anaphylaxis is 0.001% or 1 in 100,000
a
spasm or laryngeal oedema. These are not with IV contrast outweigh the risk for a patient,
necessarily medically urgent; however, then it is recommended to follow the premedica-
patients should be advised to seek medical tion regimen below:
attention as a precaution.
• Non-ionic, low osmolar contrast is 5–10 times 1. 50 mg prednisone orally 13 hour prior to con-
safer than ionic, high osmolar contrast. If a trast administration
patient has had an allergic reaction to ionic 2. 50 mg prednisone orally 7 hour prior to con-
contrast, then it is worthwhile weighing the trast administration (optional)
risks vs. benefits of this patient receiving non- 3. 50 mg prednisone orally 1 hour prior to con-
ionic contrast, since there is a possibility that a trast administration +/− 50 mg diphenhydr-
patient will not experience any adverse events. amine orally.
• The likelihood of a reaction is 10 times higher
in patients who have experienced previous 2.2.4 Extravasation of Contrast
hypersensitivity, however this depends on Media
whether or not the contrast was ionic or Extravasation occurs when contrast media is
non-ionic. not delivered correctly into the intended vessel
• Patients with asthma are 6 times more likely to and instead leaks into the surrounding soft
experience hypersensitivity to contrast. The tissue.
risk is related to the degree of control of their Rates of extravasation are largely dependent
asthma symptoms. on the skill and experience of the person inserting
• Patients with other allergies requiring medical the cannula, as well as the due-diligence of the
treatment are 3–5 times more likely to experi- CT technician prior to injecting the contrast.
ence mild contrast reactions. Below are some tips to reduce the chance and/
• Shellfish allergy is not associated with or severity of contrast extravasation:
increased risk of contrast media hypersensitiv-
ity (apart from the 3–5 times risk associated • Remain in close proximity to the patient and
with other food allergies) (Bottinor et al. injector for at least the first 5–10 seconds dur-
2013). ing contrast administration in order to monitor
• Topical iodine allergy is not associated with the injection site for signs of extravasation. If
increased risk of contrast media this is not possible due to protocol time restric-
hypersensitivity. tions, consider using a timing bolus method
with 10–15 ml contrast to “test” the efficacy
Premedication for Patients with Previous of the cannula.
Allergic Reactions to Contrast • Warm contrast to 38°C prior to
Premedication with corticosteroids ± H1 antihis- administration.
tamines (e.g. diphenhydramine) has been shown • Use a slower flow rate if the efficacy of the
to decrease reaction rate in patients with previous cannula is suspected to be compromised, or if
history of hypersensitivity to iodinated contrast a narrow-gauged cannula is used.
media to 0.5%, compared to 9.1% in patients • Ensure the cannula is not kinked in-situ during
who do not receive premedication (Greenberger contrast administration. If the cannula is
and Patterson 1991). placed in the patient’s cubital fossa, then
For patients with a history of hypersensitivity, ensure their elbow remains straightened
the best option is to consider alternative diagnos- throughout administration of contrast.
tic tests, such as ultrasound, MRI, or CT without • Always flush the cannula before connecting to
IV contrast. If it is decided that the benefits of CT the contrast injector.
24 T. Charles
If contrast extravasation occurs, the following Breastfeeding

management protocols should be followed: Studies have shown that the amount of iodine
excreted in breastmilk over a 24-hour period
1. Stop contrast injection as soon as possible, post-iodinated contrast administration is 0.5% of
and make note of approximate volume extrav- the original maternal dose. Less than 1% of the
asated into tissue. iodine excreted in breastmilk will be absorbed by
2. Remove cannula. the infant if ingested (Nielsen et al. 1987). That
3. Conservative management for patient com- is, if 100 ml of contrast has been administered to
fort, such as limb elevation, and alternating a breastfeeding patient, less than 0.005 ml of this
hot/cold compression, until pain and swelling may be absorbed by the infant. This can be con-
subsides. sidered negligible.
4. Inform the patient about signs and risks of Therefore breastfeeding mothers should be
compartment syndrome, and the need to seek told that cessation of breastfeeding or discarding
urgent medical attention if it occurs. This of breastmilk is not necessary after receiving
includes: iodinated contrast, and the benefits to the child
(a) Increasing pain. and mother of continuation of breastfeeding far
(b) Tingling or burning sensation. outweigh any risks associated with contrast
(c) Loss of sensation, especially distally to excretion.
extravasation site.
2.2.5 Pregnancy and Breastfeeding 3 Patient Interaction

in Relation to Iodine Contrast and Communication
Pregnancy 3.1 Values & Biases in Patient

There are no studies to date that have linked Interaction
iodinated contrast administration during preg-
nancy to foetal injury, malformations or Cambridge Dictionary defines bias as: “the action
adverse events. There has been concern about of supporting or opposing a particular person or
the uptake of iodine in the foetus’ thyroid, as thing in an unfair way, because of allowing per-
free iodine in the contrast solution is easily sonal opinions to influence your judgment”.
permeable through the placenta. However, of Evidence shows that bias behaviour is often car-
the limited retrospective studies there have ried out on a subconscious level, meaning the
been no links to contrast and abnormal thyroid individual may not even realise they are behaving
function in the infant at birth (Tremblay et al. in a biased way (Byrne and Tanesini 2015).
2012).
Due to the limited data available, as a precau- 3.1.1 Values & Biases
tion, it is recommended that pregnant patients of the Healthcare Professional
only receive iodinated contrast if It is a healthcare professionals’ duty to provide
equal and unbiased care to their patients, regard-
1. There are no other alternative diagnostic tests less of race, gender, age, social status or any other
(radiation exposure also needs be taken into area that potentially creates division.
consideration). When an individual is presented with a situa-
2. The information obtained from the scan is of tion which clashes with their own personal values
benefit to both mother and child. and opinions, they are more likely to act in a
3. The scan cannot be delayed until biased manner. Therefore, understanding personal
postpartum. values and opinions is key to avoiding biased
4. The infant obtains a thyroid function test at behaviour. These usually are expressed in the
1 week postpartum. form of the statement: “X is always Y”, where
“X” is a certain demographic and “Y” is a particu- factors that are largely out of their control (e.g.
lar action or trait. The key problem with this state- race, gender, religion, socioeconomic status),
ment is the word “always”. Very few things can then they will more likely behave in a manner
be said to always occur, so bringing awareness to that can appear as rude, uncooperative or even
statements like this is the first step to understand- aggressive toward other healthcare professionals.
ing when an individual may be acting out of bias. In the limited time a patient spends in the CT
Here is an example: department, it is not possible to truly empathise
“ALL patients who live in the far end of town (X) with a patient in order to understand their past
are ALWAYS rude and violent (Y)”. experiences and resulting biases; however, the
CT technologist has a choice in how they respond
While there may be a statistical increase in to certain behaviours:
this behaviour amongst this demographic, it is
biased to say that ALL patients in this demo- 1. They can let their own biases confirm their
graphic will ALWAYS act in this way. This type of opinion about a particular demographic that a
statement can also result in confirmation bias, patient represents, and respond with a similar
where an individual subconsciously only remem- mannerism;
bers events where this statement was proven to be 2. They can play the victim (e.g. this patient
true, but fails to remember other events where does not like ME), and respond defensively or
people from this demographic were not rude and even aggressively; or
violent. 3. They can apply a level of empathy and try to
Believing such statements can result in a understand the patient’s perspective, and
change in behaviour and attitude of the health- respond in a balanced way that meets the
care professional toward individual patients, patient at their unique position, whilst main-
which can have an impact on the level of care the taining integrity and respect for their own
patient receives, and their outcomes (FitzGerald wellbeing and safety.
and Hurst 2017). It is therefore important to
ensure that each individual patient is treated on The third option is not always the easiest to
“face value”. That is, the level of care should be achieve, as it requires the technologist to put their
adapted to each individual patient’s needs and own ego aside for the greater good of the patient’s
situation, regardless of their demographics and outcomes. However if the situation is handled
background. It also means that if a patient is with respect and care, it can be a transformative
acting in a certain way (regardless if it confirms a experience for all parties involved, and may even
biased opinion or not), then the level of care resolve a level of bias for each individual going
should be adapted to respond to this behaviour, forward.
whilst ensuring safety and respect for everyone
involved.
3.2 Language and
3.1.2 Values & Biases of the Patient Communication
Similarly to how personal values and biases can
influence the behaviour of a healthcare profes- Taking a patient-centred approach with
sional, each patient will present with their own technologist-
patient communication leads to
values and biases which will influence their improved patient outcomes and satisfaction (Itri
behaviour. These values and biases are often 2015). Itri proposes an acronym-based commu-
formed from a patient’s past experience in a nication model that can assist technologists,
healthcare system, either directly or witnessed, AIDET.
and can be a mix of positive and negative.
If a patient has received or witnessed bias care • Acknowledge—when greeting the patient,
from healthcare professionals in the past due to acknowledge any unique or specific circum-
26 T. Charles
stances regarding their visit (e.g. apologise if and effective way to ensure the majority of
running late, address any concerns or ques- patients are informed and safe.
tions they might have, identify any areas of Most CT scanners will have multiple languages
special needs that may require extra or differ- available for patient instructions in the scanning
ent care). protocols. If the required language is not available,
• Introduce—state your name and role. most scanners also have the capability to record
• Duration—provide a timeframe for the verbal instructions. It can be useful to hire a profes-
examination. sional medical interpreter to record a range of
• Explanation—explain what will happen dur- patient instructions on the scanner for later use.
ing the examination, what the patient may
experience, relevant risks and benefits (indica-
tions) of the examination, and provide the 3.3 Patient Greeting
opportunity for any questions.
• Thank you—thank the patient for their Use the initial interaction with a patient to address
cooperation. the following:
The above model can be used as a framework 1. Introduce yourself and your role
when communicating to a patient, however it is 2. Patient identity check—name, date of birth
important to be flexible with the flow of an inter- and address
action with a patient. The most important factors 3. Paperwork check—referral, medical history
from a patient-experience perspective include and consent forms, previous reports, pathol-
acknowledgement of a patient’s concerns, being ogy, etc.
treated with respect, and being treated like a per- 4. Check for any special needs or requirements
son (Steele et al. 2015). If a patient perceives that that the patient may have—this initial stage of
their technologist is simply ticking off a list of the patient’s visit can dictate the quality and
things to address in order to meet their minimum outcomes for all subsequent stages, so it is
due-diligence, then all three of the above factors important to remain extra vigilant for any spe-
will be impeded. Rather, an open dialogue cific needs of the patient, and to address any
between technologist and patient is required for questions or concerns with respect and care
both patient safety and satisfaction.
3.2.1 Language Barriers 3.4 Patients with Specific Needs

If the technologist and the patient do not speak the
same language, it is necessary to ensure an inter- 3.4.1 Anxiety
preter is available to translate any necessary Anxiety can have a variety of causes and mani-
instructions, preparation and medical questions fest in a variety of ways for each patient:
before undergoing their scan (except in the event of
an emergency). It is ideal to enlist the service of Causes
either a professional medical interpreter or a mem- • Claustrophobia
ber of staff who speaks the language, however this • Needle-phobia
is not always available. A patient’s family member, • “Scanxiety”—anxious about the results of the
friends or a member of the public are all options for scan
interpretation, however these come with added • Previous trauma or sexual assault
medico-legal risk. Each organisation will have their
own policy on this which needs to be followed. Signs & Symptoms
Providing translated information and consent • Stiff and rigid body language
forms has become an accreditation requirement • Short, abrupt communication (this may seem
in some regions and is a relatively inexpensive like the patient is being rude or aggressive)
• Introspective and quiet 2. Ensure brakes are applied to the patient trans-
• Shallow, rapid breathing port device before moving the patient
• Sweating 3. Avoid twisting motion when supporting the
patient’s weight
The most important thing a technologist can 4. Ensure adequate number of staff to minimise
do when caring for patients with anxiety is to strain
make them feel safe and in control of the situa- 5. Use transfer equipment when available/
tion. Try to actively listen to what the patient has needed
to say, even if it may seem irrational. The patient
needs to know that the people caring for them are Sometimes it is necessary to adjust the CT
“on their side”. Simply telling a patient “don’t scanning protocol or method to accommodate a
worry” or “you’ll be fine” when they are anxious patient’s ability. This can include:
about their scan will not be effective, and may
even elevate their anxiety levels even further, as • Placing the patient in a different position,
they may feel as though they are not being lis- including position of their arms—if arms are
tened to. placed in the region being scanned, ensure the
Giving the patient options, rather than telling exposure factors are adjusted accordingly
them they must do something, can also give • Reducing the duration of respiratory instruc-
them a level of control of the situation. This can tions—by increasing tube rotation speed,
even be around having the scan itself; except for pitch and/or beam collimation
extreme circumstances, a patient cannot be • Remove or displace any externally attached
forced to have a CT scan against their will, so medical equipment from the region of scan
reiterating this to the patient can help to relieve
anxiety. Interventions such as IV contrast should 3.4.3 Children
also be presented to the patient as an option that The interaction and management of children in
they can refuse, however the risks vs benefits of CT are quite similar to that of patients with high
their choice need to be clearly articulated to the levels of anxiety, as outlined previously. Some
patient. key points to improving the success rate of CT
Finally, it is the healthcare professional’s scans on children include:
responsibility to not pass judgement onto
patients. It is impossible to truly empathise with • Keep formal instructions to a minimum—do
a patient in regard to what is causing their anxiety not overwhelm the patient with unnecessary
and how they are feeling, therefore it is not a information or instructions. Any medico-legal
place to judge. How the technologist chooses to discussions should be directed to the child’s
interact with the patient has a significant influ- carer, ideally away from the patient.
ence on either lowering or elevating their anxiety • Maintain a light, colloquial mannerism.
levels, and this can change the outcomes of their • Find a balance between letting the patient
examination and treatment. direct the pace and progression of the exami-
nation, while not allowing for too many
3.4.2 Physical Limitations/Disabilities delays. The less time the patient is on the
When caring for patients with physical limita- table, the less likely they will experience stress
tions or disabilities, ensure the physical safety of and anxiety, however rushing through the
both the staff and the patient. Practicing safe exam may also elevate stress and anxiety.
manual handling techniques when transferring • Allow the child’s parents or carers to stay in
patients on and off the CT table can include: the CT room with the child for as long as pos-
sible. Avoid having any unnecessary people in
1. Establish a safe CT table height—this is gen- the room during radiation exposure. If this is
erally hip height of the average staff member unavoidable, ensure these people wear the
28 T. Charles
appropriate radiation protection equipment Depending on the requested exam and clinical
and stand as far away from the gantry opening history, there may be a need to obtain a more
as possible. thorough medical history. This can be used to
obtain a more accurate diagnosis, as well as
3.4.4 Aggressive & Intoxicated improve patient safety.
Patients
Ensuring the physical, psychological and emo- 3.5.1 Common Medical Questions
tional well-being of the CT department staff is for IV Contrast Administration
the number one priority when dealing with Include
aggressive or intoxicated patients. Below are • Previous exposure to iodinated contrast
some methods to help achieve this: media.
• History of allergies.
• Do not allow a staff member to be alone with • Other medical conditions—asthma, diabetes,
high-risk patients. thyroid dysfunction, renal impairment, preg-
• Maintain physical distance where possible. nancy, breastfeeding.
• Do not engage in the patient’s rhetoric—argu-
ing, disagreeing with or judging the patient 3.5.2 Common Medical Questions
can exacerbate the situation. for Interventional Procedures
• Apply a reasonable level of empathy towards • Current medications, including
the patient’s situation—understanding that anticoagulants.
aggressive behaviour can be an effect of • History of allergies.
numerous causes, sometimes out of the • Patient transport arrangements (required for
patient’s own control or awareness, can allow nerve blocks and epidural injections).
the staff member to empathise with the
patient.
4 Navigating the CT
Department
3.5 Medical History & Referral as a Technologist
Review
4.1 Alignment of Values between
When reviewing a patient’s CT referral, there is the Healthcare Professional
some key information that must be checked prior and the Healthcare Institution
to performing the examination:
Earlier in the chapter we discussed how values
1. Patient’s details—name, date of birth, address, and biases can impact on the level of patient care
etc. provided. Similarly, a mismatch of values
2. Type of scan—ensure it does in fact state between the individual worker and an organisa-
“CT”, and if there are any specific requests tion/department can lead to conflict, lack of pro-
such as “angiogram”, “multiphase”, “non ductivity and a reduction in overall patient care
contrast”, etc. and safety.
3. Region of scan—chest, abdomen, brain, etc. Understanding one’s own values is the first
4. Clinical history and indication—ensure the step in determining if there will be an alignment
requested scan is the most suitable for demon- or conflict in the values of the organisation or
strating the clinical question. department that they work in. Values can be
5. Referrer’s details and signature—a signature divided into two categories:
is a medico-legal requirement in most regions.
6. Date of referral—ensure the referral has not 1. Negotiable values—these are the values that
expired, subject to regional requirements. are important to an individual or organisation,
but can be compromised in certain scenarios, • Provide unbiased, compassionate care to all
depending on the context and outcomes. patients.
2. Non-negotiable (core) values—these values • Refine and improve CT protocols to optimise
are absolute for an individual or organisation, image quality and radiation dose.
and generally cannot be compromised. • Provide extra support to patients with special
needs.
When there appears to be a conflict in values
in a workplace, identifying if these values are These examples can also be closely tied with
negotiable or non-negotiable is the first step personal and professional goals. Setting goals
towards any sort of resolution. It is possible to can be a beneficial practice for improving job sat-
have a happy and productive work environment, isfaction, productivity and motivation, as well as
even when there is a conflict of negotiable values. limiting burnout and other job-related ailments
Exploring if there is some level of compromise (Locke and Latham 1991). Goals provide a
between the individual and/or organisation may framework for how to act and where to focus
be enough to satisfy both parties. However, if energy and attention. Achieving goals provides a
there is a conflict of non-negotiable values in a sense of achievement and value, that often cannot
workplace, a resolution may not be possible, and be obtained with the traditional remuneration
may result in adverse outcomes for the individ- frameworks in a workplace.
ual, the organisation and their patients if the cur-
rent trajectory is allowed to continue.
4.3 Balancing Workflow in a CT
Department
4.2 Roles, Responsibilities & Goals
for CT Technologists 4.3.1 Trilemma of CT Workflow
Working in a busy CT department requires a tight
Every workplace should have an explicit list of balancing act, but ultimately there will always be
the roles and responsibilities for CT technolo- certain areas that need to be “sacrificed” in favour
gists. These can include, but not limited to: of others. When looking at CT department work-
flow, there are three main factors that need to be
• Responsible for the safety and well-being of balanced, with time being the overarching
patients from the start of preparation, scan- constant:
ning and afterwards (until the time of any pos-
sible delayed adverse events has passed). 1. Quality—producing high quality images with
• Obtain diagnostic images that answer the clin- minimal mistakes.
ical question, at the highest possible image 2. Quantity—completing a high number of
quality and the lowest possible radiation dose. examinations.
• Flag potential “red flag” or urgent pathologies 3. Patient care—ensuring patient’s needs are met
with the radiologist. so they are comfortable and safe.
• Ensure all medications, consumables and
accessories are stocked and within their use- In a set time frame, without an increase in
by date in the department. resources, it is impossible to favour all three of
• Maintain relevant training and ongoing these factors. This can sometimes be referred to
education. as a trilemma (triangle dilemma) (Fig. 1).
Individual radiographers may choose to list 1. If the focus was shifted towards patient care/
their own roles and responsibilities that do not comfort/safety and quality, then the potential
necessarily fall within the industry or organisa- number of examinations performed would
tional policies. Some examples can include: decrease.
30 T. Charles
Trilemma of CT Workflow thetic. However this statement alone can lead to

confusion regarding how to act and feel in a clini-
cal setting, especially since there is a common
interchangeable misuse of these words (Jeffrey
QUALITY 2016).
Empathy is the ability to understand or
imagine another person’s experience, feelings
or psychological state (Neukrug 2017).
Empathy does not necessarily involve any
actions to intervene or relieve the other per-
PATIENT CARE QUANTITY son’s suffering, but may involve the observer
communicating their understanding of the situ-
ation to the individual.
Sympathy is closely linked to compassion,
Fig. 1 Trilemma of CT workflow and is when the observer experiences concern for
another person’s experience, feelings or psycho-
logical state. Sympathy is often attached to the
2. If the focus was shifted towards quality and observer’s own emotions and reactions, and the
quantity, then there would be less time and desire to relieve someone else’s suffering may
resources to focus on patient care. arise from egoistic motivation to relieve one’s
3. Finally, if the focus was shifted towards own distress (Jeffrey 2016).
patient care and quantity, then the quality of It is therefore important for the healthcare pro-
work may suffer. fessional to understand their own experience,
feelings or psychological state in the context of
Unfortunately there is no percentage or num- patient care, in order to determine the most
ber that dictates what an appropriate balance appropriate way to act in a situation. This under-
would be. The CT department workflow needs to standing provides a framework for the individu-
respond and adapt to the resources and require- al’s emotional and professional availability to
ments in each moment, for each patient. The provide care. This also needs to be factored in
work needs to flow between all three factors to with their ability (both personally and profes-
reach the most practical and desirable outcome sionally) to provide relevant care, as well as the
for everyone—the patient, staff and department. resources and protocols within the institution
they are working in to accommodate for such
• For a full patient list that is running behind, care. This relationship is displayed in Fig. 2
quantity may need to be favoured more-so in below:
order to minimise waiting times and delays in For optimum workflow in the CT Department,
results. a balance needs to be found between the above
• If there are patients with special needs or factors. Regardless of how much ability and
requirements, then it may be acceptable to availability an individual healthcare professional
reduce the number of scans being performed has for providing patient care, the optimal level
and run behind on the worklist. will not be reached if the institution does not pro-
• If the experience and skill level of the staff are vide sufficient resources or relevant protocols to
low, then focussing on quality may be neces- allow for this care to be provided, and vice versa.
sary in order to minimise errors.
4.3.3 Patient-Centred Care
4.3.2 Empathy vs Sympathy The concept behind patient-centred care states
Healthcare professionals are often taught to be that each individual patient has their own unique
empathetic towards their patients, not sympa- needs and values, and that decisions regarding
HEALTHCARE
HEALTHCARE INSTITUTION’S
PROFESSIONAL’S
INSTITUTION’S PROFESSIONAL’S PROTOCOLS &
ABILITY &
PROTOCOLS & ABILITY &
RESOURCES
AVAILABILITY
RESOURCES AVAILABILITY
PATIENT-CENTERED
INDIVIDUAL CARE
PATIENT NEEDS &
VALUES
PATIENT CARE
Fig. 2 Patient care—each individual healthcare profes-

sional’s ability and availability to provide care to patients
Fig. 3 Patient-centred care
is unique. The amount of care a patient receives is also
dependent on the resources and protocols of the institution
that the healthcare professional works within
5.1 Healthy Lifestyle and Work
Habits
their health need to be a collaborative discussion
between the patient and their healthcare provider A healthy lifestyle can be difficult to establish,
(Delaney 2017). but it is easier to maintain once it becomes part of
Including individual patient needs and values a routine/habit. Working in a busy CT department
into the above model of patient care adds an extra can take its toll on the staff’s physical, mental
layer of complexity and a smaller “target” to and emotional health, but there are practices that
achieve optimum balance in CT department each individual can put into place to minimise the
workflow (see Fig. 3 below); however, outcomes health impacts of their work environment.
for both patient and institution will improve as a
result (Itri 2015). 5.1.1 Scheduled Breaks
Effective communication, patient education, Every organisation and industry will have laws
physical and emotional support, and respect of and policies around maximum working hours
the patient’s autonomy, values and preferences and minimum break times for its workers. While
are all key factors in ensuring patient-centred the duration of a break can influence the sustain-
care in a CT Department (Itri 2015). ability of a workplace, the quality of an individu-
al’s break can have a far more meaningful impact.
Below are some tips for utilising work breaks for
5 Self-Care as a CT maximum benefit:
Radiographer
1. Spend time outside—many CT workspaces
When exploring how to best look after a patient’s have little-to-no natural light, so ensuring at
needs, the needs of the healthcare professional least some part of the day is spent outside can
are often overlooked. If an individual is operating help boost vitamin D and mood.
from a place of dissociation, anxiety, stress or 2. Minimise screen time—working in CT results
burnout, they are less likely to meet the wide in high amounts of screen time, which has
variety of needs of their patients. Therefore, it is been linked to reduced quality of sleep and
essential to address sustainable and healthy work other health impacts (Feng et al.). Use the
and lifestyle practices for CT technicians in order scheduled breaks to have a rest from screens
to achieve a high standard of care for their and readjust the eyes.
patients. 3. Eat healthy, nutritious food and drink water.
32 T. Charles
5.1.2 Breath and Body Awareness The key to mindfulness is to find what works
Becoming aware of breathing patterns, muscle for each individual—different tools and sched-
tension and overall body posture throughout the ules may work better or worse for different indi-
day are useful habits that can immediately viduals, depending on their unique circumstances,
improve physical and mental states, as well as personality, attitude and motivation. There are a
reduce chronic health conditions. variety of tools that can be used to achieve a
During times of high stress or pressure, there mindful state, such as journaling, creative work,
is a tendency to inhale shallowly and/or through physical exercise, meditation and breathwork,
the mouth, which has been linked to numerous but ultimately these practices need to be per-
physical and mental health conditions (Nestor formed with appropriate intention and awareness
2020). Forming a habit of becoming aware of in order to achieve the best outcomes.
breath patterns throughout the day can interrupt
the cycle of incorrect or poor breathing Journaling
techniques. Writing in a journal can result in a variety of ben-
Similarly, becoming aware of poor posture efits, such as identifying, expressing and regulat-
and repetitive or sustained areas of tension of the ing feelings and emotions more effectively,
body, especially during times of stress, can help improving cognitive function and decision-
prevent repetitive strain injuries and muscle making ability, and improved self-awareness,
soreness. reflection and insights. It has been proven to
Creating a workspace that promotes good pos- increase compassion satisfaction, and reduce
ture can help prevent repetitive strain injuries. compassion fatigue and burnout in healthcare
Setting the bench at a height so that the CT moni- professionals (Dimitroff et al. 2016).
tors are at eye level whilst standing will prevent
slouching and also reduce the amount of seden- Physical Exercise
tary time, which has been linked to deleterious Certain roles within a CT department can be
health outcomes (Biswas et al. 2015). favourable for preventing sedentary behaviour
amongst staff (due to activities such as patient
5.1.3 Mindfulness and Other Self- transport and escorting, walking in and out of the
Care Tools scanning room); however, other roles such as
When an individual is mindful, they are aware of scanning and post processing can increase seden-
their thoughts in the present moment (i.e. their tary behaviour. This, coupled with high screen
thoughts are not taking them back to the past or time, can be attributed to a decrease in physical
projecting them into the future). This present and mental well-being in CT staff (Feng et al.
moment awareness provides a foundation for cre- 2014).
ating more positive and efficient thoughts and Maintaining a regular physical activity sched-
actions going forward. It can help prevent some- ule both inside and outside of work can lead to a
one from unconsciously falling into a mental or wide range of physical and mental health
habitual routine that can often be self-destructive improvements. Activities outside of work are the
and have a negative impact on others. Mindfulness responsibility of the individual, and dependent on
has been shown to reduce anxiety, depression and their unique circumstances, however steps can be
stress (Khoury et al. 2013), as well as improve taken to improve physical activity inside the
the overall well-being of seemingly “healthy” workplace:
individuals.
There is no tangible goal with being mindful; 1. Establish a standing workspace at the CT
it is a conscious mindset that requires continuous scanner and/or post-processing area.
awareness and adjustment. However like most 2. Promote role-rotation amongst staff to encour-
things, it improves with practice. age a wider range of physical movements.
3. Encourage staff to take a walk during their level—something healthcare professionals

scheduled breaks. are exposed to on a regular basis.
4. Organise a social sport team amongst work 3. Box Breathing: Breathing through the nose,
colleagues. inhale for 5 s, hold for 5 s, exhale for 5 s, hold
for 5 s. Repeat this cycle for as long as
Meditation and Breathwork required or comfortable. The duration of each
Meditation and breathwork are closely linked phase can be increased or decreased as pre-
practices that help improve mindfulness and ferred (e.g. 4, 4, 4, 4 s; or 6, 6, 6, 6 s; etc.).
awareness of the subconscious cycles that often This can be applied almost anywhere in your
influence an individual’s thoughts and actions in day-to-day settings, and can be used to calm
day-to-day life. They can also be used to regain the nervous system, focus on a task and
composure throughout the day, release built-up achieve increased sustained performance dur-
stress, tension and emotions, process past trau- ing physical exertion.
mas, and ultimately realise one’s own potential,
purpose and place in life. 5.1.4 Managing Stressful or
There is no specific training or pre-requisite to Traumatic Situations in a CT
be able to practice and benefit from meditation Department
and breathwork, and they can be practiced any- CT department staff are prone to being exposed
time and in a variety of settings. Below are some to stressful or traumatic events, regardless of
practical techniques that can be used during and whether they work in a public hospital or private
outside of work for CT technicians: practice. This can include:
1. Breath Awareness: Become aware of your • Scanning patients who have experienced
breath during times of stress and pressure, for severe physical trauma/injury.
example when caring for a trauma patient. If • Patients passing away on the CT table.
you notice your breath has become shallow, • Patients experiencing an allergic reaction to
through the mouth or if you are holding your IV contrast.
breath; consciously take a deep, active inhale • Detecting a serious disease on a patient’s scan.
through the nose and then gradually let the • Witnessing the deterioration of a patient’s
exhale out as a “shhhh” sound through the health on subsequent follow-up scans.
mouth (the sound is optional). Repeat as many
times as necessary. Minimising exposure to such events is not
2. Conscious Connected Breath: Find a quiet always practical, so learning how to manage and
space to sit or lay comfortably with your eyes process these events when they do occur is a
closed. Start taking active continuous, con- more realistic approach to self-care for CT
nected breaths through an open mouth, so that technicians.
there is no pause between the inhale and When witnessing a stressful or traumatic
exhale, or the exhale and inhale. Continue this event, the individual can respond on a variety of
breathing pattern for 5, 10 or 15 min (or lon- levels:
ger), staying aware of whatever sensations or
experiences arise without trying to control the • Mental—cognitive understanding that the
process—just keep breathing. This technique event was distressing. The individual may try
is valuable as a daily practice to reduce stress, to create a mental narrative around the event,
regulate emotions and become more grounded such as a step-by-step rundown of the differ-
and present. It can be especially useful to pro- ent individual components or aspects to the
cess and integrate traumatic experiences event. Cognitive dissonance can be a delayed
(either direct or witnessed) on a subconscious response, where the individual has a frag-
34 T. Charles
mented memory of the events and often dis- References

misses the event as insignificant.
• Physical—experiencing a visceral reaction, ANSTO. (2021). What is Radiation? ANSTO. https://
www.ansto.gov.au/education/nuclear-facts/what-is-
such as nausea, trembling, hot/cold sensa- radiation#:~:text=Average%20exposures%20to%20
tions, increased respiratory and heart rate, etc. background%20radiation,background%20level%20
These are often linked with an activated sym- is%20not%20harmful.
pathetic nervous system (fight, flight or Barbosa, P., Bitencourt, A., Tyng, C., Cunha,
R. Preparative fasting for contrast-enhanced CT in
freeze). a cancer centre: a new approach. Am J Roentgenol.
• Emotional—for example, sadness, fear, grief, 2018;210(5):941–7. AJR online. https://www.ajron-
anger, etc. line.org/doi/full/10.2214/AJR.17.19061.
Bartosz, M. Renal safety of iodinated contrast media
depending on their osmolarity – current outlooks.
The first step to processing a traumatic event Polish J. Radiol. 2016;81(1):157–65. NCBI. https://
is for the individual to acknowledge how it made www.ncbi.nlm.nih.gov/pmc/articles/PMC4830331/
them feel. By “pretending” the event did not have Biswas A, Oh P, Faulkner G, Bajaj R, Silver M, Mitchell
an impact on their mental, physical or emotional M, Alter D. Sedentary time and its association with
risk for disease incidence, mortality, and hospitaliza-
state, the individual is likely to remain in an acti- tion in adults: a systematic review and meta-analysis.
vated sympathetic nervous system state, poten- Ann Intern Med. 2015;162(2):123–32. PubMed.
tially resulting in a cascade of short- and Bottinor, W., Polkampally, P., Jovin, I.. Adverse reac-
long-term implications. If the individual is tions to iodinated contrast media. Int J Angiol.
2013;22(3):149154. NCBI. https://www.ncbi.nlm.nih.
exposed to any subsequent traumatic events with- gov/pmc/articles/PMC3770975/#JR130018-25
out adequately processing previous events, then Brink, J. A., Goske, M.. Informed decision making trumps
the likelihood of cognitive dissonance increases informed consent for medical imaging with ionizing
and the post-traumatic symptoms may solidify or radiation. Radiology. 2012;262(1): 11–4. RSNA.
Byrne, A., Tanesini, A. Instilling new habits: addressing
worsen (Levine and Frederick 1997). implicit bias in healthcare professionals. Adv Health
The next step is prioritising the time and Sci Educ. 2015;20(1):1255–62. Springer Link.
resources for CT technicians to debrief and pro- Cardarelli, J., Ulsh, B.. It is time to move beyond the lin-
cess their witnessed traumatic events. There are a ear no-threshold theory for low-dose radiation protec-
tion. Dose-Res Int J. 2018;16(3):1–24. Sage.
variety of tools and resources available to CT Cheungpasitporn, W., Thongprayoon, C., Brabec, B.,
technicians, including (but not limited to): Edmonds, P., O'Corragain, O., Erickson, S.. Oral hydra-
tion for prevention of contrast-induced acute kidney
1. Counselling or talk therapy. injury in elective radiological procedures: a systematic
review and meta-analysis of randomized controlled tri-
2. Debriefing with colleagues. als. N Am J Med Sci. 2014;6(12):618–24. NCBI. https://
3. Taking a 5 min break after an event to recom- www.ncbi.nlm.nih.gov/pmc/articles/PMC4290050/.
pose and decompress. Delaney, L. J.. Patient-centred care as an approach
4. Self-care practices such as journaling, physi- to improving health care in Australia. Collegian.
2017;25(1):119–23. Science Direct. https://
cal exercise, meditation and breathwork, etc. www.sciencedirect.com/science/article/abs/pii/
(as discussed previously). S1322769617300422.
Dimitroff LJ, Sliwoski L, O’Brien S, Nichols LW. Change
It is worth noting that successful processing of your life through journaling–the benefits of jour-
naling for registered nurses. J Nurs Educ Pract.
traumatic events is often carried out on a subcon- 2016;7(2):90–8.
scious level, which helps to regulate the auto- Feng, Q., Zhang, Q., Du, Y., Ye, Y., & He, Q. Associations
nomic nervous system and complete any of physical activity, screen time with depression,
emotional response that may have been inter- anxiety and sleep quality among Chinese college

freshmen. PLoS One. 2014;9(6):e100914.
rupted. That is, an individual cannot always think FitzGerald C, Hurst S. Implicit bias in healthcare pro-
or talk themselves out of a trauma response, but fessionals: a systematic review. BMC Med Ethics.
rather they must feel and experience their way 2017;18(1):19.
through it (Levine and Frederick 1997). Greenberger, P. A., Patterson, R. The prevention of
immediate generalized reactions to radiocontrast
media in high-risk patients. J Allergy Clin Immunol. Neukrug, E. Creative and novel approaches to empa-
1991;87(4): 867–72. PubMed. https://pubmed.ncbi. thy. Counseling Today; 2017. https://ct.counseling.
nlm.nih.gov/2013681/. o r g / 2 0 1 7 / 0 2 / c r e a t i v e -n o v e l -a p p r o a c h e s -
Itri, J. N.. Patient-centered radiology. RadioGraphics. empathy/#:~:text=In%20fact%2C%20his%20
2015;35(6): 1835–48. RSNA. https://pubs.rsna.org/ actual%20definition,the%20%E2%80%9Cas%20
doi/full/10.1148/rg.2015150110. if%E2%80%9D%20sense.
Jeffrey, D.. Empathy, sympathy and compas- Nielsen ST, Matheson I, Rasmussen JN, Skinnemoen
sion in healthcare: is there a problem? Is there K, Andrew E, Hafsahl G. Excretion of iohexol
a difference? Does it matter? J R Soc Med. and metrizoate in human breast milk. Acta Radiol.
2016;109(12):446–52. https://journals.sagepub.com/ 1987;28(5):523–6. PubMed.
doi/full/10.1177/0141076816680120. Royal Australian and New Zealand College of
Khoury, B., Lecomte, T., Fortin, G., Masse, M., Therien, Radiologists. RANZCR iodinated contrast guide-
P. Mindfulness-based therapy: a comprehensive lines. RANZCR; 2018. ranzcr.com/college/
meta-analysis. Clin Psychol Rev. 2013;33(6):763–71. document-library/ranzcr-iodinated-contrast-guidelines.
Science Direct. Steele, J., Jones, A., Clarke, R., Shoemaker, S. Health
Levine P, Frederick A. Waking the Tiger: healing trauma. care delivery meets hospitality: a pilot study in radiol-
Berkeley, CA: North Atlantic Books; 1997. ogy. J Am Coll Radiol. 2015;12(6):587–93. Elsevier.
Locke, E. A., Latham, G. P.. A theory of goal set- https://www.sciencedirect.com/science/article/abs/pii/
ting & task performance. Acad Manag Rev. S1546144014006395.
1991;16(2):480–3. https://www.researchgate.net/ Tremblay, E., Thérasse, E., Thomassin-Naggara, I.,
publication/232501090_A_Theory_of_Goal_Setting_ Trop, I. Quality initiatives: guidelines for use of
Task_Performance. medical imaging during pregnancy and lactation.
Nestor, J.. Breath: the new science of a lost art. Penguin RadioGraphics. 2012;32(3):897–911. RSNA. https://
Life; 2020. pubs.rsna.org/doi/full/10.1148/rg.323115120.
Part II
CT in an Emergency Setting
CT in an Emergency Setting
Lindiwe Gumede and Nicole Badriparsad
Abstract ples of a few of many variations in current

practice and to recommend what could be
Computed tomography (CT) has become a adopted to be standard protocols.
central component in the imaging of both
traumatic brain injury (TBI) and non-trau- Keywords
matic brain injury (nTBI) patients as it pro-
vides a key role in patient triage and Traumatic brain injury · Computed tomogra-
management. Radiographers play a crucial phy · Emergency · Protocols
role during imaging and must maintain an
ongoing responsibility to ensure radiation
safety during all CT procedures. However, 1 Introduction
CT imaging protocols used in TBI and nTBI
patients remain unstandardized and may vary CT is used worldwide to diagnose neurologic
from department to department. Consequently, emergencies, such as acute TBI, nTBI (stroke),
imaging techniques play an integral role in and aneurysmal hemorrhage (Kuo et al. 2019).
the diagnosis and management of patients For this chapter, a CT emergency is regarded as
presenting with TBI and nTBI and may influ- the setting in the radiology department that must
ence life or death decisions. This chapter aim to reduce the mortality rate in patients pre-
presents CT imaging techniques which senting with traumatic brain injury (TBI) and
include imaging algorithms and indications, non-traumatic brain injury (nTBI). It is important
CT protocols, and management of radiation to note that most TBIs are the result of road traf-
dosages in the imaging of TBI and nTBI fic accidents, assault, falls, penetrating injuries,
patients. This chapter aims to present exam- and others (Gitto et al. 2015). Depending on the
specific history and the clinical presentation of
the TBI and nTBI, most of these patients are
L. Gumede (*) referred for CT trauma brain (Ringl et al. 2010).
Faculty of Health Science, Medical Imaging and
Radiation Sciences, University of Johannesburg, This is since CT is usually the modality of choice
Johannesburg, South Africa for TBI and nTBI as it is fast and cost-effective.
e-mail: [email protected] In support Lolli et al. (2016), Koegel et al. (2018)
N. Badriparsad state that CT is the most frequently used as an
Faculty of Health Sciences, Medical Imaging and initial examination for imaging of TBI and
Radiation Sciences, University of Johannesburg, nTBI. CT is also considered the “gold standard”
Johannesburg, South Africa
40 L. Gumede and N. Badriparsad
for detection of acute hemorrhages (Hemphill medical departments (Nayebaghayee and

et al. 2015; Morgenstern et al. 2010; Vilela and Afsharian 2020). Additionally that patients
Wiesmann 2020). with TBI have noteworthy CT findings requir-
TBI is a vital condition that has a noteworthy ing neurological intervention (Singata and
global impact (Charry et al. 2017). For this chap- Candy 2018).
ter, trauma will be defined as either deliberate or Regarding neurological intervention, the
non-deliberate, while extensive trauma will be Glasgow Coma Scale (GCS) is considered as the
defined as an injury that needs further intensive scoring system used to score the acuteness of the
attention and occasionally surgery (Hardcastle TBI and can offer a broad framework for clinical
et al. 2016). Despite being common knowledge, grading by assessment of verbal, visual, and
radiographers are not responsible for reporting motor components ranging from 3 to 15 (Whitnall
CT images; however, it is important to acknowl- et al. 2006; Jalali and Rezaei 2014). Therefore,
edge pattern changes to alert the radiologists classifying TBIs considers the lowest GCS in the
soonest (Etheredge 2011; Hlongwane and first 48 hours and therefore serves as a useful tri-
Pitcher 2013). This may facilitate a quicker age tool to ascertain the need for CT (Haaga and
awareness on the radiologists’ side especially in Boll 2017: p.430). However, in practice even
cases of outpatients presenting with nTBI. It is when the GCS score is normal, the CT results
rather important to note that the diagnoses of may be positive. TBI imaging in the emergency
intracranial hemorrhage, contusion, and trau- setting is done to avoid possible secondary neu-
matic infarction represent the most important rologic damage from developing from the pri-
clinical questions that CT imaging can assist mary brain injury (Besenski 2002). NCCT is
with solving and that the correct diagnosis of important for triage in imaging of TBIs and fol-
fractures is next in importance (Ringl et al. low-up of patients with primary TBI symptoms
2010). Protocols vary from one department to because it is quick to diagnose TBI and is avail-
another and therefore below are illustrations of able in most hospitals (Schweitzer et al. 2019;
common protocol considerations which are usu- Figueira Rodrigues Vieira and Guedes Correa
ally changed according to the radiologist’s pref- 2020).
erence or patient condition in a specific Indications for imaging can be divided into
department. However, for most protocols con- considerable risk, moderate risk, and minimal
cerning structural imaging of the brain and skull risk groups (Besenski 2002) as seen below in
base, a non-contrast CT (NCCT) is usually ade- Table 1:
quate (Romans 2011).
Table 1 Risk classification for TBI (indications)

2 Traumatic brain injury Considerable risk Moderate risk Minimal risk
Severely Minor Mild or
TBI is the most common cause of death after impaired disturbances of moderate
trauma. The primary cause of TBI varies consciousness consciousness posttraumatic
worsening headaches
according to the patient’s age (Kim and Gean
without
2011). In general, pediatric patients and geriat- improvement
ric patients are prone to accidental falls, while Focal Progressive No loss of
young adults and adults are more prone to vehi- neurological headaches consciousness
cle accidents and assaults (Gerritsen et al. signs accompanied by
vomiting
2018). Therefore, medical practitioners carry
Penetrating head Fracture of the
the responsibility to differentiate between injury skull base
minor and serious TBI (Gerritsen et al. 2018). It Patients with
is deemed common that TBI is regarded as the multiple
highest contributor to workloads in emergency injuries
CT in an Emergency Setting 41
2.1 TBI imaging Protocols Routinely a general NCCT covers the base to
the vertex of the skull in 5–8 mm (Lampignano
There is still no standardization for TBI CT pro- and Kendrick 2020). Whereas Schweitzer et al.
tocols across institutions, different protocols can (2019: 240) recommend specific algorithms that
be found in the available literature, which varies can be used to make a 3D reconstruction. In con-
in timing acquisition and the number of phases trast, Kumamaru et al. (2016) suggest that 3D
(Lacobellis et al. 2020). However, NCCT trauma reconstruction protocol should only apply to dif-
remains the modality of choice as it quickly and ficult or restless patients.
accurately provides diagnoses in any emergency There might be a few challenges with imag-
setting (Kim and Gean 2011). The NCCT trauma ing the posterior fossa in CT. This is due to the
brain protocol will produce bony algorithms and significant varying beam attenuation ability
soft tissue algorithms in one scan (Lampignano between the opaque bone of the skull and the
and Kendrick 2020). Below is an explanation much less opaque parenchyma thus causing
stipulating general protocol procedure for NCCT. streak artifacts. The radiographer can avoid
this intrinsic limitation by reducing the slice
2.1.1 General Protocol for NCCT thickness CT of the posterior fossa and
Patient positioning starts with the patients’ head increasing the kVp settings (Schweitzer et al.
in the bore of the machine while the radiographer 2019).
ensures that the patient is comfortable. Usually,
the fundamentals of general radiography skull
positioning apply to CT, depending on depart- 3 Stroke (nTBI)
mental protocols and the radiologist’s request
(Lampignano and Kendrick 2020). According to Stroke is characterized by sudden onset of symp-
Schweitzer et al. (2019), the radiographer should toms, depending on the area of the brain affected,
immobilize the patient using sponges on either and the most common clinical signs are sudden
side of the patient’s head and secure with Velcro onset of facial weakness, unilateral hemiplegia,
straps. This will alleviate any possible rotation and abnormal speech (Thurnher 2012). Stroke is
(Lampignano and Kendrick 2020). This proce- subject but not limited to various risk classifica-
dure usually requires no breathing technique. On tions which can be separated into modifiable and
the Multi-Slice CT (MSCT), the radiographer non-modifiable risk classifications (Zafar et al.
needs to center on supra orbito-meatal line to 2016) as listed below:
ensure radiation reduction to the patient’s eyes Modifiable risk characteristics:
(Schweitzer et al. 2019). Furthermore, if a rou-
tine brain is requested, the radiographer must use • Age
the axial technique; however, to supply more • Gender
information, coronal views may be requested. • Ethnicity
Schweitzer et al. (2019) suggest that coronal • Genetics
view positioning can be achieved through two • and Race
methods, with the patient either supine or prone.
In the prone position, the patient must extend the Non-modifiable risk characteristics:
chin and in the supine position, the patient must
drop the head back as far as possible and be • Hypertension
positioned in a special holder. The gantry may be • Diabetes mellitus
angled to obtain a more coronal plane should • Hypercholesterolemia
there be challenges with positioning. Irrespective • Atrial fibrillation
the final images should be the same in either • Smoking
position (Schweitzer et al. 2019). • Alcoholism
As a result, stroke is regarded as one of the effective treatment of ischemic cerebrovascular

leading causes of death and the leading cause of (CVA) events (Jenson et al. 2019). Therefore, this
long-term disability worldwide (Myint et al. protocol aims to rapidly diagnose and quantify
2017) and its effect is well known worldwide and strokes to enable proper urgent management.
in South Africa (Daffue et al. 2016). The term NCCT can show the early signs of a stroke, but
stroke is usually used vaguely when referring to most importantly will exclude intracerebral hem-
neurological symptoms that may represent cere- orrhage (ICH) and lesions that might mimic acute
bral infarction and cerebral hemorrhage. ischemic stroke (Birenbaum et al. 2011; Lee
Furthermore, stroke is defined as a focal neuro- 2017). NCCT is also used in the evaluation of
logical deficit that persists for more than 24 h acute ICH as it produces good contrast between
owing to the interruption of the blood supply to the high attenuating (“bright”) clot and the low
the brain, this definition shows a contrast between attenuating (“dark”) cerebrospinal fluid (CSF)
stroke and transient ischemic attack (TIA), which (Birenbaum et al. 2011). In addition to the clear
does not persist beyond 24 h but can be otherwise distinction by NCCT, the protocol also provides
clinically identical (Mair and Wardlaw 2014). some information on the presence of arterial
Three main stages are used to describe the CT thrombus usually seen as the hyperdense artery
manifestations of stroke: acute (less than 24 h), sign and on the extent of ischemia seen as a loss
sub-acute (24 h to 5 days), and chronic (weeks) of gray-white matter differentiation, hypoattenu-
(Igbaseimokumo 2009). So, protocols for stroke ation of brain tissue, and evidence of swelling
must be set to give an immediate diagnosis to (Mair and Wardlaw 2014). The images in Fig. 1a
allow the necessary management soonest thus show ischemic stroke which appears darker on
rapidly acquiring and interpreting NCCT images the right and Fig. 1b shows a brighter hemor-
of a patient suspected of having an acute stroke is rhagic stroke on the left.
critical (Potter et al. 2019). Therefore, non- NCCT also provides information regarding
invasive cross-sectional imaging plays a crucial the volume of blood, an extension to the cerebral
role in the assessment, planning, and follow-up parenchyma, the presence of hydrocephalus, and
of vascular disease (Murphy et al. 2019). the potential location of the aneurysm (Caceres
and Goldstein 2012). However, on occasion
NCCT can result in incorrect diagnosis or delay
3.1 Stroke (nTBI) imaging Protocols in diagnosis of brain pathology (Minné et al.
2014). Figure 2 shows the middle cerebral artery
The aim of brain imaging in stroke patients is the (MCA) on the left MCA territory. This sign is
detection of the relevant ischemic tissue pathol- usually identified as attenuation at the center of
ogy (Forster et al. 2012). The choice of protocols the main stem (M1) portion of the MCA (Chieng
is determined by the indications the patient preset al. 2020). While skull base streak artifact can
ents with. Stroke imaging usually includes mimic the hyper-attenuating MCA sign due to
NCCT, CT perfusion, and CT angiography (aor- the beam hardening from the bones (Chieng et al.
tic arch to the vertex of the skull) (Macellari et al. 2020), coronal and sagittal reformations can
2014). improve visualization and help one distinguish
artifact infarct and hemorrhage (Potter et al.
3.1.1 Non-contrast CT (NCCT) 2019). NCCT is considered to have a low sensi-
for Stroke tivity for the depiction of hyper-acute and early
NCCT is usually listed as a primary imaging acute hypo-attenuating ischemic changes hence
modality for acute stroke for several reasons such an acute territorial infarct is mostly visible once it
as availability, quick examination, therefore, is greater than one-third of the MCA territory
allowing easier management of unstable patients (Potter et al. 2019). Contrast media may be
(Mair and Wardlaw 2014). Reducing delays in administered when further information is
diagnosis and treatment remains paramount to necessary.
a b
Fig. 1 Ischemic (a) and hemorrhagic stroke (b) (Milpark Radiology 2020)
function history due to the acute presentation in

the emergency setting (Khosravani et al. 2013).
Hence, the value of CT has seen an increasing
appreciation with regard to hematoma growth
and CM enhancement of the spot sign (Aguilar
and Brott 2011). Almost all CT procedures of the
brain require CM injection which may be intro-
duced either through low-pressure hand injection
or via a high-pressure injector (Lampignano and
Kendrick 2020).
Brain tissue has a natural selective diffusion
barrier that allows only certain substances
through and is termed the blood–brain barrier
(Abbott et al. 2010). In cases of intra-parenchymal
and subarachnoid hemorrhage, the blood–brain
barrier will show CM outside of normal vascula-
ture (Lampignano and Kendrick 2020). Tube
voltage X-ray energy is an important factor
affecting CM enhancement because vascular
opacification is directly proportional to iodine
Fig. 2 MCA sign (Milpark radiology 2020) delivery to the region of interest (ROI) (Saade
et al. 2016). This proportionality increases with
decreasing CT tube voltage, leading to increased
3.1.2 Contrast Media (CM) vascular opacification, as X-ray photon energy
Considerations gets closer to the K-edge of iodine at lower volt-
Guidelines published in the past decade recom- ages (Saade et al. 2016). Therefore, it may be
mend that patients should be screened for possi- concluded that low voltage not only improves
ble renal failure before CM administration vascular opacification, but it also reduces the vol-
intravenously however in cases of CTA for stroke ume and concentration of CM needed and the
(nTBI) and TBI protocols are initiated without radiation dose administered to the body (Cho
information regarding CM allergy and renal et al. 2012).
The injection rate is also another factor that formed by sequentially imaging a defined section
will help determine the opacification necessary of tissue after a single high-flow bolus of CM is
for a specific study. With regard to MSCT, an administered (Potter et al. 2019). CTP is there-
injection rate of 4–5 ml/s is usually sufficient in fore used to produce useful perfusion maps while
providing excellent arterial opacification for most adhering to ALARA, radiologists need to under-
vascular studies; venous imaging does not require stand patterns and issues with interpretation, as
as high injection rates (Murphy et al. 2019). the role of CTP grows in the diagnosis and treat-
Usually, long scan durations necessitate long ment of acute stroke (Lui et al. 2010). The pivotal
injection times and short scan durations can be factor to CTP is the interpretation of several per-
performed with short injection times (Saade et al. fusion parameters, among which cerebral blood
2016). Altering how CM is distributed to show flow post a single bolus of CM injected during
the vascular tree completely is important when the use of MSCT scanner (Munich et al. 2016).
using helical scanners as they cover a larger scan Through CTP the following variables can be
range quicker (Saade et al. 2016). Thus, the short- estimated: cerebral blood flow (CBF) (Fig. 3a),
est possible scan duration is an important vari- cerebral blood volume (CBV) (Fig. 3b), time to
able that needs to be considered when designing peak (TTP) (Fig. 3c), and mean transit time
protocols related to CTA (Cho et al. 2012). (MTT) (Fig. 3d) (Munich et al. 2016; Lin et al.
2013). These variables may be used to estimate
3.1.3 CT Perfusion (CTP) areas of irreversible brain damage and potential
CTP is commonly used in acute stroke (nTBI) salvageable areas of hypoperfusion (Borst et al.
patients but can be used in TBI patients where 2015). Munich et al. (2016) state that CBF is
CM can be administered using different variables measured in mL of blood per 100 g of paren-
to ascertain cerebral perfusion (Lui et al. 2010). It chyma per minute (normal: 50 ml/100 g/min),
may be imperative to note that adding CTP will while CBV is measured in mL of blood per 100 g
add approximately 10–15 min to the scanning of parenchyma (normal: 5 ml/100 g); MTT is a
time, which includes processing (Lui et al. 2010). measurement of the meantime for blood to travel
CTP is mostly useful for differentiating the core through a given volume of the brain, to show the
of the infarct from the penumbra (Lukies and duration of the CM bolus to travel from the arte-
Gaillard 2020). Therefore a higher index indi- rial to the venous circulation (Konstas et al.
cates a greater relative size of penumbra and 2009). TTP is therefore considered the delay
therefore better prognosis as seen in Fig. 3 where between the first entry of CM intracranially and
the penumbra and infarct size seen on MCA ter- the period taken by the CM to reach its maximum
ritory indicate a potential recuperation ratio concentration within the area of interest in the
(PRR) of 75.38%. This procedure is usually per- parenchyma (Lin et al. 2013). In most tertiary
a b c d
Fig. 3 CBF (a), CBV (b), TTP (c) and MTT (d) (Milpark Radiology 2020)
a b
Fig. 4 CTA axial image (a) (Milpark Radiology 2020) and CTA of the COW showing spot sign (b) (Mashao and
Dzichauya 2020)
stroke centers, CTP with cerebral blood flow, bolus into the central blood volume because the
cerebral blood volume, and mean transit time is bolus tail would remain unused in the peripheral
usually done concurrently with CTA to help dif- veins if saline is not administered (Murphy et al.
ferentiate between hemorrhagic infarct and intra- 2019).
cranial hemorrhage (Choi et al. 2012). CM leaking from the hematoma may help
identify the “spot sign” (Fig. 4b) which can save
3.1.4 CT Angiography (CTA) those patients that are at risk of poor neurological
The CTA protocol is fundamental to advanced outcomes due to the hematoma expanding in case
treatment choice in acute ischemic stroke as a of an ischemic stroke (Mirza and Gokhale 2017;
screening tool to exclude the possibility of hem- Macellari et al. 2014; Vilela and Wiesmann 2020;
orrhage and occlusion of vessels (Choi et al. Al-Mufti et al. 2018). The spot sign is recognized
2012; Hemphill et al. 2015). Although only an as a factor that helps with identifying the hemor-
NCCT is necessary to rule out hemorrhage to rhagic areas in the brain during CTA (Zhang et al.
administer CM to eligible patients, many stroke 2018). It is important to note that CTA is not per-
centers have long used CTA (Fig. 4a) to detect formed routinely in the acute phase in most clini-
carotid stenosis, intracranial atherosclerosis, and cal settings due to the cost and time to execute as
large vessel occlusions at the time of presentation compared to NCCT (Zhang et al. 2018).
(Douglas et al. 2015). CTA is non-invasive; avail-
able worldwide (Douglas et al. 2015), preferred
as it provides high spatial resolution and saves 4 General Considerations
time compared to the conventional method in of Findings on CT Scan TBI
assessing TBIs (Romans 2011; Lolli et al. 2016). and nTBI
Usually, the procedure requires the use of a high-
pressure injector to allow uniform high injection Currently, there are numerous studies about nTBI
rate CM bolus delivery, and use of a saline flush evaluation and acquiring outcome information
should be routine to help push the tail of the CM concerning the seriousness of the TBI (Mutch
et al.2016). According to Igbaseimokumo (2009), hemorrhages that may show isodense to the sur-
the basics of CT brain scans include consider- rounding brain tissue (Mutch et al. 2016). The
ation of three basic densities. The author states TBI hematoma is usually the result of ruptured
that the density of TBI lesions seen on CT can be vessels within the brain and the leaking blood
hyperdense (white), hypodense (darker tone), then causes a circumscribed area of edema which
and isodense (the combination of hyper and hypo later determines patient prognosis as they both
densities). In particular, the most common hyper- expand following the first insult (Al-Mufti et al.
dense irregularity in brain CT scan is the blood 2018: 119). Figure 5 demonstrates a case of
which changes over time. The pineal gland and worsening cerebral edema concerning the left-
coracoid processes are the only exceptions to sided infarct with mass effect and midline shift.
“everything white is blood” (Igbaseimokumo The evolution of hematoma on TBI and nTBI
2009). CT images is therefore dependent on the location
The appearance of an ICH on CT changes as of hemorrhage and usually clears faster on CSF
time progresses (Romans 2011). During the first spaces (Vilela and Wiesmann 2020). Within the
imaging evaluation in a patient with a stroke, it is immediate first hours of the TBI, the hemorrhage
paramount to establish if there is an ICH or a will have similar attenuation as that of the cortex
large, well-established, hypo-attenuating territo- and is hard to differentiate (Mirza and Gokhale
rial infarct (Potter et al. 2019). This is due to the 2017; Vilela and Wiesmann 2020), notably
red blood cells within the hemorrhage which known as the hyper-acute phase (Mirza and
deteriorate within several hours after leaving the Gokhale 2017). Therefore, the TBI hemorrhage
vasculature (Romans 2011). These changes are both hyperdensity (blood) and hypodensity
complex and depend on many factors, such as (edema) components of hemorrhage change sig-
whether the patient is anemic and to what degree nificantly within the first 24 h (Wilkes et al. 2018)
the blood has mixed with CSF (Macellari et al. being brightest the first day of the injury and
2014). Initial rapid NCCT evaluation within 4.5 h slowly fading with time. For about 3 days, the
from the onset in patients without other contrain-
dications should focus on identification of a large
territorial infarct and exclusion of ICH (Potter
et al. 2019).
CT imaging can assist with approximating the
age of hematomas, by assessing the density of the
lesions measured in Hounsfield units (HU) which
are related to the estimate of X-ray attenuation
corrected for the coefficient of water (Macellari
et al. 2014). According to Baldon et al. (2020),
biological processes of the hematoma on acute
TBI are similar to that of primary nTBI (Stroke)
since the development of the hematoma results in
secondary injury to the surrounding brain paren-
chyma, thus promoting mass effect which
increases intracranial pressure with further brain
injury. The density of the hematoma on CT in the
case of TBI may be associated with the age of the
hematoma over time and the number of foci of
the hemorrhage as well as to hematocrit (Barras
et al. 2009). The density of the hematoma gener-
ally reduces with time which may sometimes
pose issues for detection of sub-acute and chronic Fig. 5 Cerebral edema (Mashao and Dzichauya 2020)
hematoma is hyperdense to normal brain tissue, and a higher blood volume. Usually, the density
after which it will gradually decrease in density of tissue on CT is estimated by HUs whereby
(Wilkes et al. 2018). Igbaseimokumo (2009) lower density tissue will show lower HU and the
agrees by stating that the hematoma appears other way around (Kim et al. 2019). The HU for
brightest on thin tissue for 3 days, after which it water is equal to 0, blood is between 30 and 45,
will gradually decrease in density. The edges the gray substance is between 37 and 45, the
around the hematoma may appear hypodense white substance is between 20 and 30, while the
within the first and progress for up to 2 weeks bone is between 700 and 3000 (Macellari et al.
post the TBI hemorrhage onset (Majidi et al. 2014; Bhargava 2019). Note that HU scale zero
2016). Within the 2 weeks, a hyperdense center refers to pure water; the value of cerebrospinal
surrounded by concentric areas of hyperdense fluid (CSF) is slightly above that of water
and hypodense tissue can be seen on CT (Mirza (Romans 2011). Variability in HU values is dis-
and Gokhale 2017). About one and a half weeks tinguished by the protocol parameters for a par-
(10–14 days), the hematoma density drops and is ticular examination (Kim et al. 2019).
likely to show an isodense center surrounded by Most primary findings emanate from TBI and
areas of hypodense tissue (Rao et al. 2016). By include scalp injuries, skull fractures, extra-axial,
6 months, the ICH will be hypodense to the brain. and intra-axial hemorrhages, whereas secondary
The skull is not always symmetric owing to findings stem from complications of primary
factors during CT positioning therefore radiolo- findings which are inclusive of ischemic and
gists measure the midline shift by drawing the damage due to lack of oxygen, cerebral edema,
Ideal Midline (IML) joining the most anterior and brain herniation (Lolli et al. 2016). So, to
and posterior visible points on the fall and then allow proper planning for management on either
measuring the farthest point on the septum pel- finding a trauma assessment system will provide
lucidum as perpendicular from the IML (Brant information on the seriousness of the TBI
and Helms 2012). Therefore, when considering (Mahadewa et al. 2018). In rare cases, neurologi-
brain CT findings, any shift of the midline struc- cal examinations may be unreliable following
ture is regarded as a lesion on the side from which sedation in patients with severe TBI, therefore
the midline is displaced (Liao et al. 2018). CT prediction outcomes for TBI which allows
Additionally, the scan is considered abnormal if classification according to the damage demon-
the two sides of the brain show asymmetry, if the strated on neuroimaging is an important primary
image is uniform on each slice, then the scan may role in the early management of TBI and in pre-
be considered normal (Igbaseimokumo 2009). dicting secondary effects thereof (Lolli et al.
Igbaseimokumo (2009) considers CSF as the 2016). Below is a brief description of common
compass of the brain, stating that it is important classification systems used in CT TBI cases:
to be able to find the normal flow of CSF in the
brain. Leakage of CSF is found in 2% of all TBI • The Marshall classification system of trau-
patients and 12–30% of cases of basilar skull matic brain injury (MCTC) score was pub-
fractures (Parizel and Philips 2020). Typically, lished in 1992 which shares correspondence
brain swelling is when the gyri appear larger and between TBI on CT and intracranial pressure.
the sulci smaller (Igbaseimokumo 2009). This is a CT-scan derived metric using only a
During CT TBI and nTBI consideration of few features and has been shown to predict
findings, narrow window widths are used to show outcomes in patients with TBI (Mahadewa
the brain, due to the slight variation in attenuation et al. 2018).
between the gray matter and the white matter • The Rotterdam score system (RSS) is a more
(Romans 2011). It is further explained that the recent tool that is useful in prognosis of mor-
slightly higher attenuation of the gray matter of tality of patients with severe TBI by ensuring
the brain compared with the white matter may be prediction of outcome based on abnormalities
a result of both lower gray matter water content detected, for example, basal cisterns’ condi-
tion, midline shift, traumatic subarachnoid or it can be identified in the periphery as a lens-
intraventricular hemorrhage, and epidural shaped (biconvex), high-density lesion (Khairat
hematoma (Charry et al. 2017). and Waseem 2020).
• Helsinki CT score tool is another classifica-
tion system, which considers bleeding type
and size, intraventricular hemorrhage, and 5.2 Subdural Hematoma
suprasellar cisterns (Lolli et al. 2016). The
Helsinki CT score provides an accurate prog- A subdural hematoma is a venous hemorrhage
nosis in patients with mildly complicated, between dura mater and arachnoid mater, result-
moderate, or severe TBI due to its ability to ing from rupture of veins in the dura meninges
predict long-term outcomes (Yao et al. 2017). (Heit et al. 2017). Symptoms develop over a
course of time. The hematoma is usually found
adjacent to the inner table of the skull as a
5 Common Primary Findings crescent-shaped high density (Heit et al. 2017).
for TBI and nTBI Explained The density decreases overtime on CT. Figure 7
illustrates a traumatic acute right-sided subdural
NCCT shows extra-axial hemorrhage, intra-
axial hemorrhage, and skull fractures (Haaga
and Boll 2017; Kim and Gean 2011). See
Table 2 below:
With regard to hemorrhage, the type of hem-
orrhage depends on location and whether it is an
arterial hemorrhage or venous hemorrhage. The
benefits of CT for TBI assessments are the
responsiveness to acute extra-axial and intra-
axial hemorrhages, mass effect, ventricular size,
and skull fractures (Lolli et al. 2016). Epidural
and subdural hematomas are generally associated
with TBI however they may also be the result of
nTBI (Vilela and Wiesmann 2020).
5.1 Epidural Hematoma
Epidural hematoma (Fig. 6) is an acute arterial

bleed, between the skull and dura mater.
Laceration of the medial meningeal artery results
in this complication (Parizel and Philips 2020).
Epidural hematoma is usually associated with
significant mass effect midline shift and acute
Fig. 6 Epidural hematoma (Mashao and Dzichauya
neurological symptoms (Heit et al. 2017). On CT, 2020)
Table 2 Common Findings in CT scan for TBI and nTBI

Extra-axial hemorrhage Intra-axial hemorrhage Skull fractures
Epidural Cortical contusion Linear fractures
Subdural Intra-parenchymal hematoma Depressed fractures
Subarachnoid/intraventricular Shear injury Basilar fractures
hematoma with associated midline shift and sub- 5.3 Subarachnoid/Intraventricular

glacial hematoma. hematoma
According to Parizel and Philips (2020), injury

to surface veins, cerebral parenchyma, or corti-
cal arteries may result in a subarachnoid/intra-
ventricular hematoma. Additional to that the
bleeding is produced into the ventricular system
sometimes resulting in hydrocephalus and it can
be identified on CT as a hyperdensity in the sub-
arachnoid space. Figure 8b demonstrates a find-
ing of blood in the area of the circle of Willis
consistent with acute subarachnoid hemorrhage
with no evidence of hydrocephalus (Fig. 8a).
5.4 Intra-Axial Hemorrhage
According to Ullah et al. (2015), “Intra-axial

hemorrhage is bleeding within the brain itself.”
This category includes intraparenchymal hemor-
rhage, or bleeding within the brain tissue, and
intraventricular hemorrhage, bleeding within the
Fig. 7 Subdural Hematoma (Mashao and Dzichauya brain’s ventricles.
2020)
a b
Fig. 8 Subarachnoid/intraventricular (a & b) (Milpark Radiology 2020)

5.5 Intraparenchymal Hematoma • A is the largest hemorrhage diameter on the

(IPH) selected slice in centimeters (cm) by CT
(Fig. 10a).
Intraparenchymal hematoma (IPH) refers to • B is the largest diameter perpendicular (90°)
hemorrhaging in the brain parenchyma (Mirza to A on the same slice (Fig. 10a).
and Gokhale 2017). Figure 9 shows NCCT of the • C is the approximate number of CT slices in
brain showing right frontal lobe IPH surrounded which the hemorrhage is seen multiplied by
by edema. Stroke (nTBI) IPH in older patients is the slice thicknesses often 0.5 cm slices,
the result of hypertensive individuals, with cere- Fig. 9b shows 2.82 cm (Fig. 10b).
bral amyloid angiopathy also noteworthy in nor-
motensive individuals (Cox et al. 2017). Rapid A, B, and C are then multiplied, and the prod-
brain imaging is recommended to differentiate uct is divided by 2 (Kothari et al. 1996).
ischemic stroke and IPH, whereas CTA may be
undertaken to identify those patients that are at
risk of hematoma expansion (Morgenstern et al. 5.6 Cortical Contusions
2010; Khosravani et al. 2013). Acute IPH is usu-
ally detected by NCCT an intra-axial hyperdense Cortical contusions are bruises of the brain paren-
region of hemorrhage that is classically centered chyma due to impact at the coup and contra coup
within the basal ganglia, cerebellum, or occipital sites, most commonly in the inferior frontal lobes
lobes (Vilela and Wiesmann 2020; Patel et al. and anterior-inferior temporal lobes (Schweitzer
2019). et al. 2019). These TBIs are characterized by
IPH volume can be calculated by using the hyperdense lesions within the brain parenchyma
ABC/2 method (Huttner et al. 2006). According itself, and they are caused by a micro-vascular
to these authors, the ABC/2 method adheres to arterial or venous injury. A follow-up CT is nec-
the steps depicted below: essary to monitor any growth of the hematoma,
thus the radiographers and radiologists need to be
aware of this to avoid premature discharging of
patients due to inadequate monitoring (Heit et al.
2017). The CT presentation of cortical contu-
sions is heterogeneous, hyperdense cortical
lesions surrounded by an irregular margins
hypodense (edematous) component (Parizel and
Philips 2020). Figure 11 demonstrates cortical
contusion on the left inferior frontal lobe.
5.7 Skull Fractures
Skull fractures are caused by high energy impact

exceeding the mechanical integrity of the calvar-
ium and are usually associated with severe TBIs
(Gitto et al. 2015: 44). Skull fractures may be
missed on initial CT scan as thicker slices are set
for the routine NCCT; however, follow-up CT
could detect the fractures as thinner slices are
used and reconstructed sagittal CT will assist in
Fig. 9 Intraparenchymal hematoma (IPH) (Milpark radi- demonstrating the fracture effectively (Hosaka
ology 2020) et al. 2015: 3).
a b
Fig. 10 (a and b): ABC/2 method (Milpark Radiology 2020)
recommended if there is a high suspicion for

basilar skull fractures (Haaga and Boll 2017).
On the other hand, the smaller vasculature pre-
sented on MDCT may be incorrectly consid-
ered as fractures (Simon and Newton 2020) and
linear fractures that come in the plane of a CT
slice may not be shown unless they are
depressed or separated (Chawla et al. 2015).
CTA is usually recommended to confirm vascu-
lar injury in such critical settings (Simon and
Newton 2020).
Basilar fractures have various presentations
depending on the severity of the head injury
(Mokolane et al. 2019). A basilar fracture is
defined as any fracture involving the floor of the
anterior, middle, or posterior cranial fossa that
results from substantial blunt force trauma
(Simon and Newton 2020). The presence of clini-
cal signs such as raccoon eye, rhinorrhea, rhinor-
rhagia, anosmia, visual impairment, otorrhea,
Fig. 11 Cortical contusion (Milpark Radiology 2020) otorrhagia, hearing loss, neurovascular injuries,
battle sign, phonation problems, vocal cord
There are three main types of skull fractures, paralysis, and/or aspiration are regarded as sig-
namely linear fractures, depressed fractures, nificant predictors of basilar fractures (Mokolane
and basilar fractures (Haaga and Boll 2017). et al. 2019). TBIs with basilar skull fractures may
The NCCT results may not demonstrate frac- advance to have vascular air embolism if the air
tures that are linear and non-displaced, there- was not identified on initial examination (Kai
fore MDCT with thinner slices may be et al. 2020).
a b c
Fig. 12 Soft tissue window (a), bone window (b), and 3D reconstruction of depressed skull fractures (c) (Milpark
Radiology 2020)
Depressed skull fracture arises when pieces of of all strokes (Macellari et al. 2014). ICH is
the fractured skull press inward causing trauma described as spontaneous extravasation of blood
to the brain (Gitto et al. 2015). The most common into the brain parenchyma associated with high
dural sinus injury usually results from depressed mortality and disability (Senn et al. 2014). The
skull fracture over superior sagittal sinus with location of the ICH can be classified as deep, lobar,
notable fatalities (Ahmad et al. 2018). Figure 12a and infra-tentoria. Moreover, Domingues et al.
shows a depressed skull fracture viewed in a soft (2015) indicate that the anatomical location aid in
tissue window algorithm. NCCT with 3D recon- identifying the underlying cause of bleeding.
structions (Fig. 12b) and bone window algo- According to Macellari et al. (2014: 903), the
rithms (Fig. 12b) can help to establish a clear TBI NCCT brain is commonly used for diagnosis in
diagnosis in case of suspected depressed fracture case of acute stroke because of its convenience
(Ibrahimaa and Motah 2015). and its high sensitivity for detecting ICH, which
is a contraindication to thrombolytic therapy.
Moreover, NCCT allows quantifying hematoma
6 Common Secondary volume and monitoring of hemorrhage evolution
Findings in CT TBI and nTBI in ICH accurately (Macellari et al. 2014: 903).
Domingues et al. (2015) state that NCCT also per-
Secondary findings are usually the result of com- mits the identification of the anatomic distribution of
plications; hence they are more critical than pri- the hematoma, extension to the ventricular system,
mary effects (Bae et al. 2014). These may include and estimation of hematoma volume. Furthermore,
the development of new hemorrhage, worsening ICH appears as a hyperdense lesion within minutes
vasogenic edema, or cytotoxic edema, which all after the onset of symptoms, however NCCT has
promote the increase of the intracranial pressure decreased sensitivity 1 week after ICH onset because
that will subsequently introduce herniation, isch- the lesion becomes isodense concerning the brain
emia, and infarction (Haaga and Boll 2017). parenchyma (Domingues et al. 2015).
6.1 Hemorrhagic Stroke 6.2 Transient Ischemic Attack

(TIA)
There are two main types of hemorrhagic strokes,
namely ICH (Fig. 1b) and subarachnoid hemor- Transient ischemic attack (TIA) and minor isch-
rhage (SH) (Fig. 8) which accounts for about 5% emic stroke are associated with brain dysfunction
in a circumscribed area caused by a regional sels, nerves, and the ventricular system (Gilardi
reduction in blood flow resulting in either tran- et al. 2019). Kim and Gean (2011: 47–48) have
sient or minor observable clinical symptoms identified several variations when brain herniation
(Coutts 2017). TIA is a medical emergency and is considered, these variants are described briefly:
forewarns of an imminent stroke (Siket and
Edlow 2013). A TIA is a clinical syndrome char- • Subfalcine herniation is commonly referred to
acterized by the sudden onset of a focal neuro- as midline shift and occurs when the cingulate
logic deficit presumed to be on a vascular basis gyrus herniates under the falx cerebri.
(Simmons et al. 2012). The ABCD2 (age, blood • “Uncal herniation results when the medial
pressure, clinical presentation, diabetes mellitus, temporal lobe herniates through the tentorial
duration of symptoms) score estimates the risk of incisura and compresses the ipsilateral supra-
stroke following a suspected TIA (Salunke et al. sellar cistern” (Kim and Gean 2011: 47)
2020). The ABCD2 method should be determined • Descending transtentorial herniation occurs
during the initial evaluation and risk assessment with downward herniation of both temporal
of repeat ischemia and stroke, i.e., the higher the lobes through the tentorial incisura, compress-
score the greater the probable severity of the ing the basilar cisterns.
stroke (Simmons et al. 2012). Therefore, imaging • Upward transtentorial herniation occurs in the
can support the diagnosis, but TIA is primarily a opposite direction, with the cerebellum
clinical diagnosis. Three challenges identified in extending through the tentorial incisura and
the management of patients with TIA include (Yu effacing the quadrigeminal cistern.
and Coutts 2018): • Tonsillar herniation results when the cerebel-
lar tonsils herniate into the foramen magnum.
• Rapid accurate diagnosis.
• Establishing mechanism of stroke and the risk CT characteristics of brain herniation usually
of early reoccurrence. include widening and displacement of structures
• Precipitate investigations and treatments. in the brain depending on the variant manifesting
with the given case. Probst et al. (2009) state that
Therefore, the use of neuroimaging in TIA is brain herniation on CT findings can be classified
crucial for both diagnosis and accurate risk- under three categories, namely the frank
stratification (Sorensen and Ay 2011). Patients herniation; significant shift, without frank hernia-
with minor ischemic stroke and TIA who are at tion; or minimal or no shift. Refer to Fig. 13 to
the highest risk of recurrent events and disability appreciate the manifestation of a significant mid-
can be identified using non-invasive CTA (Coutts line shift to the left with compression of lateral
2017). Interestingly several studies (Forster et al. ventricles.
2012; Yu and Coutts 2018; Moreau et al. 2013)
suggest that CT imaging is unable to positively
detect suspected ischemic lesions due to its low 6.4 Ischemic Stroke
sensitivity in detecting very small cortical and
subcortical infarctions (Forster et al. 2012). Rapid neuroimaging to differentiate an ischemic
Infarcts discovered in TIA are very small, lack stroke from ICH (Fig. 1a, b) is vital to patient
edema and mass effect and show no or very subtle management (Osborn et al. 2018). According to
contrast enhancement (Sorensen and Ay 2011). the American Heart Association/ American
Stroke Association (AHA/ASA) guidelines for
evaluation, screening and initial treatment to
6.3 Traumatic Brain Herniation determine ischemic stroke should be performed
expeditiously (Jauch et al. 2013). Focal sulcal
Brain herniation requires immediate diagnosis as effacement is an important early secondary sign
it is potentially life-threatening and may result in of acute ischemia and can help identify subtle
various issues secondary to compression of ves- acute infarcts (Potter et al. 2019).
Fig. 13 Brain herniation (Milpark radiology 2020)

Fig. 14 Infarct on left MCA territory (Milpark Radiology
2020)
6.5 Infarction
et al. 2013). Secondly, MSCT is helpful as it
The sensitivity and specificity for acute infarction reduces the number of deaths in emergency room
(Fig. 14) on NCCT likely depend on the duration, patients while increasing the hospital’s revenue
infarct size, and degree of ischemia (Potter et al. (Imai et al. 2018). Thirdly, the use of MSCT has
2019). The imaging findings of acute infarct can allowed the acquisition of thinner slices in a brief
be difficult to notice in the following locations: time due to the multi-row detector fitted within
the extreme vertex owing to volume averaging; the unit. (Imai et al. 2018). Lastly, MSCT allows
the inferior temporal lobes, where the gray-white studies of the head to be routinely acquired with
matter junction is oriented axially; the occipital thinner slices than in the past with −1.25 mm
lobes owing to frequent artifact caused by the thickness being typical. This is recommended for
irregular contours of the skull; and the deep gray parenchymal assessment to ensure accuracy of
matter, particularly the caudate heads. The insula, slice thickness ranging from 0.5 to 3 mm and
caudate heads, and basal ganglia show early find- preferably with an arrangement of 0.5–1.5 mm
ings of proximal middle cerebral artery (MCA) (Lacobellis et al. 2020).
thrombosis at NCCT and should be carefully Romans (2011) supports the concept of thin-
evaluated (Potter et al. 2019). ner slices and states that thin slices help to reduce
beam-hardening artifacts since they can be
merged into thicker slices for viewing. To mini-
7 Emerging Protocols: (MSCT) mize motion artifacts, helical CT is often used for
3D reformations. In general, routine head studies
In principle, MSCT use has seen a legitimate rise are done using an axial mode, and CTA studies of
in recent years due to its fast acquisition, wide the head and neck are done using a helical mode
availability, cost-effectiveness, and reliability in (Romans 2011). Cross-sectional slices of the
the detection of acute hemorrhage (Rosa-Junior brain are viewed in multiple window settings.
Windowing algorithms are important because protocols may require careful thought (Mair and
some findings are not obvious (Koegel et al. Wardlaw 2014).
2018). For instance, other unique processing Kumamaru et al. (2016) state that it is impor-
algorithms can demonstrate specific anatomy tant to develop protocols that can be followed by
(Lampignano and Kendrick 2020) such as a mag- any radiographer regardless of their skill level
nified version of a small bony structure. because radiographers are expected to carry out
CT remains the primary imaging modality for these protocols precisely while taking care of the
emergent indications such as trauma and acute patient (Trattner et al. 2014). Therefore, when
changes in neurologic status. Patient characteris- new protocols are implemented, they must sup-
tics, contrast parameters, and CT scanning ply a reduced radiation dose to the patient
parameters are considered to affect image qual- (Kumamaru et al. 2016). This can be achieved by
ity. Wherein, CT-related factors include scan deliberating on the CT dose index (CTDIvol),
duration, direction, contrast bolus arrival time, dose length product (DLP), and the diagnostic
scan delay concerning contrast injection, and CT reference level (DRL). According to Smith-
tube voltage (Saade et al. 2016). Therefore, in Bindman et al. (2019) CTDvol index considers
cases of fracture detection, using highly special- the average dose value of the slice thickness,
ized 3D reconstruction algorithms which are while the DLP supplies the measure of CT tube
designed especially for fracture detection will radiation to the patient. Further to this, earlier
help remove misleading structures, such as vas- research shows that dose reference levels vary
cular channels that could be mistaken for frac- according to patients, institutions, and countries.
tures (Ringl et al. 2010) and will allow for However, it was recently suggested that CT pro-
high-quality 3D reconstructions (Le and Gean tocols and radiation doses have diverse represen-
2006). tations worldwide depending on the technical
parameters (Smith-Bindman et al. 2019; Vano
et al. 2017: 72).
8 Standardizing CT Protocols
Despite the lack of standardized protocols, the 9 Responses to Trauma,

aim of neuroimaging in the case of TBI and nTBI Stroke, and/or Intensive Care
is always to supply information quickly to ensure Patients
quick decision-making without delay, thus avoid-
ing secondary complications (Lin and Liebeskind Care of the TBI patient does not end in the oper-
2016). Therefore, having standard protocols will ating room or resuscitation bay. Admittedly much
ensure that all TBI and nTBI patients take prior- focus has been placed on the initial management
ity over all other booked requests. In both cases of the trauma patient; consequently, the ICU has
of TBI and nTBI, it is imperative to adhere to received less attention (Shere-Wolfe et al. 2012).
standardized protocols, for instance, within some TBI requires treatment in an intensive care unit
institution’s patients presenting with acute isch- (ICU) in close collaboration with a multidisci-
emic stroke are considered candidates of both plinary team consisting of various medical spe-
CPT and CTA (Munich et al. 201). Furthermore, cialists (Stroker 2019). Mortality is lower in
Mair and Wardlaw (2014) postulate that to per- ICU-treated neurological patients (Aguilar and
ceive the full prospects of CPT; a standardized Brott 2011).
CTP must be worked out. Consequently, without Clinical examination remains a fundamental
the CTP standardization, there are no set value monitoring procedure to identify neurological
estimates whereby poses a challenge in detecting deterioration and potential indications for surgical
penumbra and the infarct core. Similarly, this can interventions (Stocchetti et al. 2017).
be correlated in CT protocols for TBI and nTBI Conventionally, evaluation of the non-contrast CT
in general, that any attempt to standardize CT images of a possible stroke patient occurs at the
scanner console at the time of the acquisition, and extravasation of contrast as a predictor of cerebral
hemorrhagic contusion expansion, poor neurological
findings are directly communicated to the refer- outcome and mortality after traumatic brain injury:
ring physician (Potter et al. 2019). While the initial a systematic review and meta-analysis. Pub Lib Sci
TBI classification remains typically based on clin- (PLOS). 2020;15(9):1–12. https://doi.org/10.1371/
ical severity, using the GCS coupled with investi- journal.Pone.0235561.
Barras CD, Tress BM, Christensen S, MacGregor L,
gation of pupil diameter and reactivity to light. Collins M, Desmond PM, Skolnick BE, Mayer SA,
Time is very critical when caring for these Broderick JP, Diringer, Steiner T, Davis MS. Density
patients because these lesions progress in more and shape as CT predictors of intracerebral hemor-
than 50% during the first several hours after rhage growth. Stroke. 2009;40:1325–31. https://doi.
org/10.1161/STROKEAHA.108.536888.
impact contusion/intracerebral hematoma, either Besenski N. Traumatic injuries: imaging of head injuries.
expanding or developing new, non-contiguous Eur Radiol. 2002;12:1237–52. https://doi.org/10.1007/
hemorrhagic lesions (Stroker 2019). Considering s00330-002-1355-.
this it is therefore just as critical to note that TBI Bhargava R. CT imaging in neurocritical care. Ind J Crit
Care Med. 2019;23(Suppl 2):S98–S103. https://doi.
with associated neural injuries poses an even org/10.5005/jp-journals-10071-23185.
greater challenge since even mild TBI can blos- Birenbaum D, Bancroft LW, Felsberg GJ. Imaging in acute
som into a life-threatening condition when com- stroke. West J Emerg Med. 2011;12(1):67–76. https://
pounded by hypoxia and hypotension. Hence, www.ncbi.nlm.nih.gov/pmc/articles/PMC3088377/
pdf/wjem12_1p0067.pdf
prevention of secondary injury should be among Borst J, Marquering HA, Beenen LFM, Berkhemer OA,
the highest priories in any patient with evidence Dankbaar JW, Riordan AJ, Majoie CBLM. Effect of
or suspicion of CNS injury (Shere-Wolfe et al. extended CT perfusion acquisition time on ischemic
2012). Furthermore, the main determinant of out- Core and penumbra volume estimation in patients
with acute ischemic stroke due to a large vessel occlu-
come from TBI is the severity of the primary sion. PLoS One. 2015;10(3):e0119409. https://doi.
injury, which is irreversible. Thus, it can be con- org/10.1371/journal.pone.0119409.
cluded that much emphasis should be placed on Brant WE, Helms CA. Fundamentals of diagnostic radiol-
the type and mechanism of the injury which has ogy. 4th ed. Philadelphia: Wolters Kluwer/Lippincott
Williams & Wilkins Health; 2012.
an important bearing on the likely course after Caceres J, Goldstein JN. Intracranial hemorrhage. Emerg
TBI (Helmy et al. 2007). Med Clin N Am. 2012;30(3):771–94. https://doi.
org/10.1016/j.emc.2012.06.003.
Charry JD, Falla JD, Ochoa JD, Pinzón MA, Tejada JH,
Henriquez MJ, Solano JP, Calvache C. External vali-
References dation of the Rotterdam computed tomography score
in the prediction of mortality in severe traumatic brain
Abbott JN, Patabendige AAK, Dolman DEM, Yusof SR, injury. J Neurosci Rural Pract. 2017;8(Suppl 1):S23–
Begley DJ. Structure and function of the blood–brain 6. https://doi.org/10.4103/jnrp.jnrp_434_16.
barrier. Neurobiol Dis. 2010;37(1):13–25 . ISSN 0969- Chawla H, Yadav RK, Griwan MS, Malhotra R, Paliwal
9961. https://doi.org/10.1016/j.nbd.2009.07.030. PK. Sensitivity and specificity of CT scan in reveal-
Aguilar MI, Brott TG. Update in intracerebral hemor- ing skull fracture in medico-legal head injury vic-
rhage. Neurohospitalist. 2011;1(3):48–159. https:// tims. Austr Med J. 2015;8(7):235–8. https://doi.
doi.org/10.1177/1941875211409050. org/10.4066/AMJ.2015.2418.
Ahmad S, Afzal A, Rehman L, Javed F. Impact of Chieng JSL, Singh DR, Chawla A, Peh WCG. The hyper-
depressed skull fracture surgery on outcome of head dense vessel sign in cerebral computed tomography:
injury patients. Pak J Med Sci. 2018;34(1):130–4. pearls and pitfalls. Singap Med J. 2020;61(5):230–7.
https://doi.org/10.12669/pjms.341.13184. Cho ES, Yu JS, Ahn JH, Kim JH, Chung JJ, Lee HK,
Al-Mufti F, Thabet AM, Singh T, El-Ghanem M, Amuluru Lee KH. CT angiography of the renal arteries: com-
K, Gandhi CD. Clinical and radiographic predictors of parison of lower-tube-voltage CTA with moderate-
intracerebral hemorrhage outcome. Intervent Neurol. concentration iodinated contrast material and
2018;7:118–36. https://doi.org/10.1159/000484571. conventional CTA. Am J Roentgenol. 2012;199(1):96–
Bae DH, Choi KS, Yi HJ, Chun HJ, Ko Y, Bak KH. Cerebral 102. https://doi.org/10.2214/AJR.11.7450.
infarction after traumatic brain injury: incidence and Choi PMC, Ly JV, Srikanth V, Ma H, Chong W, Holt
risk factors. Kor J Neurotr. 2014;10(2):35–40. https:// M, Phan TG. Differentiating between hemorrhagic
doi.org/10.13004/kjnt.2014.10.2.35. infarct and parenchymal intracerebral hemorrhage.
Baldon IV, Amorim AS, Santana LM, SollaI DJ, Kolias Radiol Res Pract. 2012;2012:475497. https://doi.
A, Hutchinson P, Paiva WS, Rosa Junior M. The org/10.1155/2012/475497.
Coutts SB. Diagnosis and management of transient www.hst.org.za/publications/South%20African%20

ischemic attack. Continuum (Minneap Minn). Health%20Reviews/15%20Trauma%20a%20pre-
2017;23(1):82–92. https://doi.org/10.1212/ ventable%20burden%20of%20disease%20in%20
CON.0000000000000424. South%20Africa%20Review%20of%20the%20evi-
Cox M, Bisangwa S, Herpich F, Crudele A, Pineda dence%20with%20a%20focus%20on%20KZN.pdf
C. Fluid levels in the bleeding brain: a marker for Heit JJ, Iv M, Wintermark M. Imaging of intracranial
coagulopathy and hematoma expansion. Inter Emerg hemorrhage. 2017;J Stroke, 19(11):11–27. https://doi.
Med. 2017;12:1071–3. https://doi.org/10.1007/ org/10.5853/jos.2016.00563.
s11739-017-1604-1. Helmy A, Vizcaychipi M, Gupta AK. Traumatic brain
Daffue K, Joubert G, Otto S. Computed tomography stroke injury: intensive care management. Br J Anaesth.
findings and population demographics at Pelonomi 2007;99(1):32–42. https://doi.org/10.1093/bja/
hospital, Bloemfontein. S Afr J Radiol. 2016;20, 6(1) aem139.
https://doi.org/10.4102/sajr.v20i1.993 Hemphill J, Greenberg SM, Anderson CS, Becker K,
Domingues R, Rossi C, Cordonnier C. Diagnostic Bendok BR, Cushman M, Fung GL, Goldstein JN,
evaluation for nontraumatic intracerebral hemor- MacDonald RL, Mitchell PH, Scott PA, Selim MH,
rhage. Neurol Clin. 2015;33(2):315–28. https://doi. Woo D. American Heart Association Stroke Council;
org/10.1016/j.ncl.2014.12.001. Council on Cardiovascular and Stroke Nursing;
Douglas V, Shamy M, Bhattacharya P. Should CT angi- Council on Clinical Cardiology. Guidelines for the
ography be a routine component of acute stroke imag- management of spontaneous intracerebral hemor-
ing? Neurohospitalist. 2015;5(3):97–100. https://doi. rhage: a guideline for healthcare professionals from
org/10.1177/1941874415588393. the American Heart Association/American Stroke
Etheredge HR. An opinion on radiography, ethics and the Association. Stroke. 2015;46(7):2032–60. https://doi.
law in South Africa: peer-reviewed opinion article. S org/10.1161/STR.0000000000000069.
Afr Radiogr. 2011;49(1):9–12. Hlongwane ST, Pitcher RD. Accuracy of after-hour
Figueira Rodrigues Vieira G, Guedes Correa JF. Early dot’ trauma radiograph triage by radiographers
computed tomography for acute post-traumatic diffuse in a south African regional hospital. S Afr Med J.
axonal injury: a systematic review. Neuroradiology. 2013;103(9):638–40.
2020;62:653–60. https://doi.org/10.1007/ Hosaka A, Yamaguchi T, Yamamoto F, Shibagaki
s00234-020-02383-2. Y. Cerebral venous air embolism due to a hidden skull
Forster A, Gass A, Kern R, Ay H, Chatzikonstantinou A, fracture secondary to head trauma. Hindawi Pub Corp
Hennerici MG, Szabo K. Brain imaging in patients Case Rep Neurol Med. 2015;2015:1–3. https://doi.
with the transient ischemic attack: a comparison of org/10.1155/2015/730808.
computed tomography and magnetic resonance imag- Huttner HB, Steiner T, Hartmann M, Köhrmann M,
ing. Eur Neurol. 2012;67(3):136–41. https://doi. Juettler E, Mueller S, Wikner J, Meyding-Lamade U,
org/10.1159/000333286. Schramm P, Schwab S, Schellinger PD. Comparison
Mutch, C.A, Talbott, J.F and Gean, A. (2016). Imaging of ABC/2 estimation technique to computer-
evaluation of acute traumatic brain injury. Neurosurg assisted planimetric analysis in warfarin-related
Clin N Am, 27(4):409–439. https://doi.org/10.1016/j. intracerebral parenchymal hemorrhage. Stroke.
nec.2016.05.011. 2006;37(6):404–8. https://doi.org/10.1161/01.
Gerritsen H, Samim M, Peters H, Schers H, van der STR.0000221786.81354.d6.
Laar F. Incidence, course and risk factors of head Ibrahimaa F, Motah M. Depressed skull fracture by a mass
injury: a retrospective cohort study. Br Med J of 3 kg in short putt an adolescent of 13 years. A rare
Open. 2018;8:e020364. https://doi.org/10.1136/ sports injury A rare fracture of the skull-deflection
BMJopen-2017-020364. shot putt. Int J Surg Case Rep. 2015;6:203–5. https://
Gilardi B, López JIM, Villegas ACH, Mora JAG, doi.org/10.1016/j.ijscr.2014.10.024.
Rodríguez OCR, Appendini RC, Malváez MD, Calleja Igbaseimokumo U. Brain CT scans in clinical practice.
JAH. Types of cerebral herniation and their imaging New York: Springer; 2009.
features. Radiographics. 2019;39:1598–610. https:// Imai S, Akahane M, Konishi Y, Imamura T. Benefits
doi.org/10.1148/rg.2019190018. of computed tomography in reducing mortal-
Gitto L, Arunkumar P, Maiese A, Bolino G. A sim- ity in emergency medicine. Open Access De
ple depressed skull fracture in an old man with Gruyter. 2018;13:394–401. https://doi.org/10.1515/
Paget disease: forensic implications in a rare med-2018-0058.
case. Med Sci Law. 2015;55(1):44–9. https://doi. Jalali R, Rezaei M. A comparison of the Glasgow
org/10.1177/0025802414524384. coma scale score with full outline of unrespon-
Haaga JR, Boll DT. CT and MRI of the whole body, vol. siveness scale to predict patients’ traumatic brain
1. 6th ed. Philadelphia: Elsevier; 2017. injury outcomes in intensive care units. Crit
Hardcastle TC, Oosthuizen G, Clark D, Lugte E. Trauma, Care Res Pract. 2014;2014:289803. https://doi.
a preventable burden of disease in South Africa: a org/10.1155/2014/289803.
review of the evidence, with a focus on KwaZulu- Jauch E.C, Saver J.L, Adams H.P Jr, Bruno A, Connors
Natal. S Afr Health Rev. 2016;2016(1):179–89. https:// J.J, Demaerschalk B.M, Khatri P, McMullan P. W Jr,
Qureshi A.I, Rosenfield K, Scott P.A, Summers D.R, Kuo W, Hane C, Murkherjee P, Malik J, Yuh EL. Expert-
Wang D. Z, Wintermark M. and Yonas H.; on behalf level detection of acute intracranial hemorrhage on
of the American Heart Association Stroke Council, head computed tomography using deep learning. Proc
Council on Cardiovascular Nursing, Council on Natl Acad Sci USA. 2019;116(45):22737–45. https://
Peripheral Vascular Disease, and Council on Clinical www.pnas.org/content/pnas/116/45/22737.full.pdf
Cardiology (2013). Guidelines for early manage- Lacobellis F, Romano L, Rengo A, Danzi R, Scuderi MG,
ment of patients with acute ischemic stroke: a guide- Brillantino A, Scaglione M. CT protocol optimiza-
line for healthcare professionals from the American tion in trauma imaging: a review of current evidence.
Heart Association/American Stroke Association. Curr Radiol Rep. 2020;8(8). https://doi.org/10.1007/
Stroke. 44(3): 870-947. https://doi.org/10.1161/ s40134-020-00351-5.
STR.0b013e318284056a. Lampignano JP, Kendrick LE. Textbook of radiographic
Jenson M, Libby J, Soule E, Sandhu SJ, Fiester PJ, Rao positioning and related anatomy. 10th ed. St Louis:
D. CT perfusion protocol for acute stroke expedites Mosby; 2020.
mechanical thrombectomy. Cureus. 2019;11(4):e4546. Le TH, Gean AD. Imaging of head trauma. Semi
https://doi.org/10.7759/cureus.4546. Roentgenol. 2006;41(3):177–89. https://doi.
Kai H, Hirose T, Nishiura T, Noma T, Ogawa Y, Yamada org/10.1053/j.ro.2006.04.003.
T, Nakae H, Mizushima Y. Air in the right ventricle Lee SH. Stroke revisited diagnosis and treatment of isch-
and vein after basilar skull fracture: a case report. emic stroke. Berlin: Springer; 2017.
Int J Emerg Med. 2020;13(59):1–3. https://doi. Liao C, Chen Y, Xiao F. Brain midline shift measure-
org/10.1186/s12245-020-00326-5. ment and its automation: A review of techniques and
Khairat A, Waseem M. Epidural hematoma. Treasure algorithms. Int J Biomed Imaging. 2018;2018:1–13.
Island (FL): StatPearl Publishing; 2020. https://doi.org/10.1155/2018/4303161.
Khosravani H, Mayer SA, Demchuk A, Jahromi BS, Lin MP, Liebeskind DS. Imaging of ischemic stroke.
Gladstone DJ, Flaherty M, Broderick J, Aviv Continuum (Minneap Minn). 2016;22(5):1399–423.
RI. Emergency noninvasive angiography for acute https://doi.org/10.1212/CON.0000000000000376.
intracerebral hemorrhage. Am J Neuroradiol. Lin L, Birvard A, Parsons MW. Perfusion patterns of
2013;34(8):1481–7. https://doi.org/10.3174/ajnr. ischemic stroke on computed tomography perfusion.
A3296. J Stroke. 2013;15(3):164172. https://www.ncbi.nlm.
Kim JJ, Gean AD. Imaging for the diagnosis and man- nih.gov/pmc/articles/PMC3859000/
agement of traumatic brain injury. Neurotherapeutics. Lolli V, Pezullo M, Delpierre I, Sadeghi N. Emergency
2011;8(1):39–53. https://doi.org/10.1007/ radiology special feature: review article MDCT imag-
s13311-010-0003-3. ing of traumatic brain injury. Br J Radiol. 2016;89:1–
Kim K, Kim Y, Song E, Yoon BC, Choi YH, Kim K, Kim 14. https://doi.org/10.1259/bjr.20150849.
D. Changes in the gray and white matter of patients Lui YW, Tang ER, Allmandingen AM, Spektor
with ischemic-edematous insults after traumatic brain V. Evaluation of CT perfusion in the setting of cere-
injury. J Neurosurg. 2019;131:1243–53. https://doi. bral ischemia: patterns and pitfalls. Am J Neuro
org/10.3171/2018.5.JNS172711. Radiol. 2010;31(9):1552–63. https://doi.org/10.3174/
Koegel C, McCallum R, Greenhill M, García DL, Kohli ajnr.A2026.
A, Mallon M, Koenigsberg R, Kazmi KS. Imaging of Lukies, M., Gaillard, F.. CT perfusion in ischaemic
traumatic intracranial hemorrhage. J Am Osteop Coll stroke; 2020. https://radiopaedia.org/articles/
Radiol. 2018;8(3):13–20. https://cdn.agilitycms.com/ ct-perfusion-in-ischaemic-stroke.
jaocr/PDFs/Issues/Vol8Iss3_RA2_Koegel.pdf Macellari F, Paciaroni M, Agnelli G, Caso
Konstas AA, Goldmakher GV, Lee TY, Lev MH. Theoretic V. Neuroimaging in intracerebral hemorrhage.
basis and technical implementations of CT perfu- Stroke. 2014;35(3):903–8. https://doi.org/10.1161/
sion in acute ischemic stroke, part 1: theoretic basis. STROKEAHA.113.003701.
Am J Neuroradiol. 2009;30(4):662–8. https://doi. Mahadewa TGB, Golden N, Saputra N, Ryalino
org/10.3174/ajnr.A1487. C. Modified revised trauma–Marshall score as a pro-
Kothari RU, Brott T, Broderick JP, Barsan WG, Sauerbeck posed tool in predicting the outcome of moderate and
LR, Zuccarello M, Khoury J. The ABCs of measur- severe traumatic brain injury. Open Access Emerg
ing intracerebral hemorrhage volumes. Stroke. Med. 2018;10:135–9.
1996;27(8):1304–5. https://doi.org/10.1161/01. Mair G, Wardlaw JM. Imaging of acute stroke prior
STR.27.8.1304. to treatment: current practice and evolving tech-
Kumamaru K, Kogure Y, Suzuki M, Hori M, Nakanishi niques. Br J Radiol. 2014;87(1040):1–14. https://doi.
A, Kamagata K, Hagiwara A, Andica C, Ri K, org/10.1259/bjr.20140216.
Houshido N, Aoki S. A strategy to perfect radia- Majidi S, Rahim B, Gilani SI, Gilani WI, Adil MM,
tion exposure for non-contrast head CT: comparison Qureshi AI. CT evolution of hematoma and surround-
with the Japanese diagnostic reference levels. Jpn ing hypodensity in a cadaveric model of intracerebral
J Radiol. 2016;34:451–7. https://doi.org/10.1007/ hemorrhage. J Neuroimaging. 2016;26(3):346–50.
s11604-016-0545-3. https://doi.org/10.1111/jon.12306.
Mashao, D, and Dzichauya. Incorporated: specialist radi- matic brain injury - an introduction. J. Hodler et al.
ologists. Practice Images. 2020. (eds.), Diseases of the brain, head and neck, spine
Milpark Radiology. Incorporated: diagnostic radiologists. 2020–2023, Springer Series; 2020. https://doi.
Pract Images. 2020. org/10.1007/978-3-030-38490-6_7.
Minné C, Kisansa M, Ebrahim N, Suleman F, Makhanya Patel A, Schreuder FHBM, Klijn CJM, Prokop M, van
N. The prevalence of undiagnosed abnormalities on Ginneken B, Roos YBWEM, Irem Baharoglu M, Meijer
non-contrast-enhanced computed tomography com- FJA, Manniesing R. Intracerebral hemorrhage seg-
pared to contrast-enhanced computed tomography of mentation in non-contrast CT. Sci Rep. 2019;9:17858.
the brain. S Afr J Radiol. 2014;18(1):1–7. https://doi. https://doi.org/10.1038/s41598-019-54491-6.
org/10.4102/sajr.v18i1.598. Potter CA, Vagal AS, Goyal M, Nunez DB, Leslie-Mazwi
Mirza S, Gokhale S. Neuroimaging in intra- TB, Lev MH. CT treatment selection in acute isch-
cerebral hemorrhage, hemorrhagic stroke - emic stroke: a code stroke primer. Radiographics.
an update. IntechOpen. 2017; https://doi. 2019;39(6):1717–38. https://doi.org/10.1148/
org/10.5772/67303. https://www.intechopen. rg.2019190142.
c o m / b o o k s / h e m o r r h a g i c -s t r o k e -a n -u p d a t e / Probst MA, Baraff LJ, Hoffman JR, Wolfson AB, Ourian
neuroimaging-in-intracerebral-hemorrhage AJ, Mower WR. Can patients with brain herniation on
Mokolane N, Minne C, Dehnavi A. Prevalence and pat- cranial computed tomography have a Normal neuro-
tern of basal skull fracture in head injury patients in logic Exam? Acad Emerg Med. 2009;16(2):145–50.
an academic hospital. S Afr J Radiol. 2019;23(1):1–7. Rao MG, Singh D, Khandelwal N, Sharma
https://doi.org/10.4102/sajr.v23i1.1677. SK. Dating of early subdural hematoma: A cor-
Moreau F, Asdaghi N, Modi J, Goyal M, Coutts relative clinico-radiological study. J Clin Diagn
SB. Magnetic resonance imaging versus com- Res. 2016;10(4):HC01–5. https://doi.org/10.7860/
puted tomography in transient ischemic attack JCDR/2016/17207.7644.
and minor stroke: the more you see the more you Ringl H, Schernthaner RE, Schueller G, Balassy C, Kienzl
know. Cerebrovasc Dis. 2013;3:130–6. https://doi. D, Botosaneanu A, Weber M, Czerny C, Hajdu S, Mang
org/10.1159/000355024. T, Herold CJ, Schima W. The skull unfolded: a cranial
Morgenstern LB, Hemphill JC 3rd, Anderson C, Becker CT visualization algorithm for fast and easy detection
K, Broderick JP, Connolly ES Jr, Greenberg SM, of skull fractures. Radiology. 2010;255(2):553–62.
Huang JN, MacDonald RL, Messé SR, Mitchell PH, https://doi.org/10.1148/radiol.100910968.
Selim M, Tamargo RJ, American Heart Association Romans LE. Computed tomography for technologists.
Stroke Council and Council on Cardiovascular Maryland: Lippincott. Williams & Williams; 2011.
Nursing. Guidelines for the management of spon- Rosa-Junior M, da Rocha AJ, Saade N, Maia-Junior ACM,
taneous intracerebral hemorrhage: a guideline for Gagliardi JR. Active extravasation of contrast within
healthcare professionals from the American Heart the hemorrhage (spot sign): a multidetector computed
Association/American Stroke Association. Stroke. tomography finding that predicts growth and a worse
2010;41(9):2108–29. https://doi.org/10.1161/ prognosis in non-traumatic intracerebral hemorrhage.
STR.0b013e3181ec611b. Arq Neuropsiquiatr. 2013;71(10):791–7. https://doi.
Munich SA, Shakir HJ, Snyder KV. Role of CT perfusion in org/10.1590/0004-282X20130124.
acute stroke management. Elsevier. 2016;58(2):e215– Saade C, Deeb IA, Mohamad M, Al-Mohiy H, El-Merhi
24. https://doi.org/10.1016/j.crvasa.2016.01.008. F. Contrast medium administration and image acqui-
Murphy DJ, Aghayev A, Steigner ML. Vascular CT and sition parameters in renal CT angiography: what
MRI: a practical guide to imaging protocols. Insights radiologists need to know. Diagn Interv Radiol.
Imaging. 2019;9:215–36. https://doi.org/10.1007/ 2016;22(2):116–24. https://doi.org/10.5152/
s13244-018-0597-2. dir.2015.15219.
Myint PK, Bachmann M, Loke YK, Musgrave SD, Salunke AA, Warikoo V, Pathak SK, Nandy K, Mujawar
Price GM, Hale R, Metcalf AK, Turner DA, Day DJ, J, Mendhe H, Shah A, Kottakota V, Menon V, Pandya
Warburton EA, Potter JF. Important factors in predict- S. A proposed ABCD scoring system for better tri-
ing mortality outcome from stroke: findings from the age of patients with COVID-19: use of clinical fea-
Anglia stroke clinical network evaluation study. Age tures and radiopathological findings. Diabetes Metab
Ageing. 2017;46(1):83–90. https://doi.org/10.1093/ Syndr Clin Res Rev. 2020;14(6):1637–40. https://doi.
ageing/afw175. org/10.1016/j.dsx.2020.08.019.
Nayebaghayee H, Afsharian T. Correlation between Schweitzer AD, Niogi SN, Whitlow CT, Tsiouris
Glasgow coma scale and brain computed tomogra- J. Traumatic brain injury: imaging patterns and com-
phy scan findings in head trauma patients. Asian J plications. Radiographics. 2019;39(6):1571–95.
Neurosurg. 2020;11(1):46–9. http://www.asianjns.org https://doi.org/10.1148/rg.2019190076.
Osborn AG, Hedlund G, Salzman KL. Osborn’s brain: Senn R, Elkind MSV, Montaner J, Christ-Crain M, Katan
imaging, pathology, and anatomy. 2nd ed. Amsterdam: M. Potential role of blood biomarkers in the man-
Elsevier; 2018. agement of nontraumatic intracerebral hemorrhage.
Parizel, P.M. and Philips, C.D. Traumatic Cerebrovasc Dis. 2014;38(6):395–409. https://doi.
Neuroemergency: imaging patients with trau- org/10.1159/000366470.
Shere-Wolfe RF, Galvango SM, Grissom TE. Critical care J Am Coll Radiol. 2014;11(3):271–8. https://doi.
considerations in the management of trauma patient org/10.1016/j.jacr.2013.10.016.
following initial resuscitation. Scandinavian J Trauma Ullah W, Ali M, Mehmood K. Spectrum of surgi-
Resuscit Emerg Med. 2012;20(68):1–15. http://www. cally treated closed head injury in Department of
sjtrem.com/content/20/1/68 Neurosurgery Lady Reading Hospital Peshawar. Pak
Siket MS, Edlow J. Transient ischemic attack: an evidence- J Neurol Surg. 2015;19(2):106–9.
based update. Emerg Med Pract. 2013;15(1):1– Vano E, Miller DL, Martin CJ, Rehani MM, Kang K,
28. https://www.ebmedicine.net/media_library/ Rosenstein M, Ortiz P, Mattsson S, Padovani R,
files/0113%20TIA.pdf Rogers A. International Commission of Radiological
Simmons BB, Cirignano B, Gadegbeku AB. Transient Protection (ICRP) Publication No.135: diagnostic ref-
ischemic attack: part 1. Diagnosis and evaluation. Am erence levels in medical imaging. ICRP. 2017;46(1)
Fam Phys J. 2012;86(6):521–6. https://www.aafp.org/ https://doi.org/10.1177/0146645317717209.
afp/2012/0915/p521.html. Vilela, P and Wiesmann, M. (2020) Nontraumatic intra-
Simon LV, Newton EJ. Basilar skull fractures. Treasure cranial hemorrhage. In: Hodler J., Kubik-Huch R., von
Island: StatPearls Publishing; 2020. https://www.ncbi. Schulthess G. (eds) Diseases of the brain, head and
nlm.nih.gov/books/NBK470175/. neck, spine 2020–2023. Springer, Champions https://
Singata C, Candy S. Is computed tomography of the head doi.org/10.1007/978-3-030-38490-6_5.
justified in patients with minor head trauma present- Whitnall L, McMillan TM , Murray GD, Teasdale GM.
ing with Glasgow coma scale 15/15? S Afr J Radiol. Disability in young people and adults after head injury:
2018;22(1):a1329. https://doi.org/10.4102/sajr. 5-7 year follow up of a prospective cohort study.
v22i1.1329. Journal of Neurology, Neurosurgery and Psychiatry,
Smith-Bindman R, Wang Y, Chu P, Chang R, Einstein AJ, 2006;77, pp. 640–45. https://doi.org/10.1136/
Balcombe J, Cocker M, Das M, Delman BN, Flynn jnnp.2005.078246.
M, Gould R, Lee RK, Yellen-Nelson T, Schindera S, Wilkes S, McCormack E, Kenney K, Stephens B, Passo
Seibert A, Starkey J, Suntharalingam S, Wetter A, R, Harburg L, Silverman E, Moore C, Bogoslovsky
Wildberger JE, Migliorett DL. International varia- T, Pham D, Diaz-Arrastia R. Evolution of traumatic
tion in radiation dose for computed tomography parenchymal intracranial hematomas (ICHs): com-
examinations: prospective cohort study. Br Med J. parison of hematoma and edema components. Front
2019;364:k4931. https://doi.org/10.1136/BMJ.k4931. Neurol. 2018;9(527):1–7. https://doi.org/10.3389/
Sorensen AG, Ay H. Transient ischemic attack definition, fneur.2018.00527.
diagnosis, and risk stratification. Neuroimaging Clin Yao S, Song J, Li S, Cao C, Fang L, Wang C, Xu
N Am. 2011;12(2):303–13. https://doi.org/10.1016/j. G. Helsinki computed tomography scoring system can
nic.2011.01.013. independently predict long-term outcome in traumatic
Stocchetti N, Carbonara M, Citerio G, Ercole A, Skrifvars brain injury. World Neurosurg. 2017;101:528–33.
MB, Smielewski P, Zoerle T, Menon DK. Severe trau- https://doi.org/10.1016/j.wneu.2017.02.072.
matic brain injury: targeted management in the inten- Yu AYX, Coutts SB. Role of brain and vessel imaging for
sive care unit. Lancet Neurol. 2017;16(6):452–64. the evaluation of transient ischemic attack and minor
https://doi.org/10.1016/S1474-4422(17)30118-7. stroke. Am Heart Assoc J. 2018;49(7):1791–5. https://
Stroker RA. Intensive care in traumatic brain injury doi.org/10.1161/STROKEAHA.118.016618.
including multi-modal monitoring and neuroprotec- Zafar A, Al-Khamis FA, Al-Bakr A, Alsulaiman AA,
tion. Multidisc Dig Pub Inst. 2019;7(37) https://doi. Msmar AH. Risk factors and subtypes of acute isch-
org/10.3390/medsci7030037. emic stroke. Neurosci J. 2016;21(3):246–51. https://
Thurnher M. Brain imaging with MRI and CT: an image doi.org/10.17712/nsj.2016.3.20150731.
pattern approach. New York: Cambridge University Zhang D, Chen J, Xue Q, Du B, Li Y, Chen T, Jiang Y, Hou
Press; 2012. L, Dong Y, Wang J. Heterogeneity signs on noncon-
Trattner S, Pearson GDN, Chin C, Cody DD, Gupta R, trast computed tomography predict hematoma expan-
Hess CP, Kalra MK, Kofler JMJNR, Krishnam MS, sion after intracerebral hemorrhage: a meta-analysis.
Einstein AJ. Standardization and optimization of Hindawi BioMed Res Int. 2018;2018:1–9. https://doi.
computed tomography protocols to achieve low-dose. org/10.1155/2018/6038193.
Trauma Imaging Protocols
and Image Evaluations
Karen Dobeli
Abstract Keywords
CT is a key imaging modality in the diagnosis Trauma imaging · Brain perfusion ·

of traumatic injuries and stroke. Patients pre- Intracranial haemorrhage · Solid organ
senting to CT for these clinical indications laceration · Bladder rupture · CT cystogram ·
may pose numerous challenges for the radiog- Cerebral ischemia · Intraosseous injection
rapher including the need for rapid imaging
and results; a patient’s inability to follow com-
mands or be positioned in the standard man- 1 Introduction
ner; disease- or treatment-induced alterations
in the patient’s haemodynamics; non-standard Trauma can be roughly divided into two catego-
venous access and the potential for a multi- ries: polytrauma and isolated trauma. Polytrauma
tude of injuries or diagnoses in a single patient. describes an event that results in injury to multi-
This chapter explores CT imaging proto- ple body regions while an isolated trauma injury
cols and procedures for trauma and stroke. is confined to one particular part of the body. The
Considerations for technique modification in nature of the force applied to the body (whether
response to the patient’s condition and venous blunt or penetrating, weak or strong, low or high
access and imaging evaluation for common speed) as well as the direction of the force, the
critical findings in the emergency setting, body impact site and personal characteristics of
including solid organ laceration, bladder rup- the victim (e.g. age, weight, health status) will
ture, and acute brain haemorrhage and infarc- influence the type of injuries the patient may sus-
tion, are also discussed. tain (Eid and Abu-Aidan 2007).
With a thorough understanding of the prin- Younger patients who suffer polytrauma are
ciples presented in this chapter, a radiographer more likely to have been involved in high-energy
may provide crucial support for the timely and traumas such as a major motor vehicle accident
accurate assessment of critically ill patients. (MVA) or a fall from a considerable height
(Leichtle et al. 2019). Older patients may sustain
multiple, serious injuries from relatively minor
incidents such as a fall from standing or low
K. Dobeli (*) speed motor vehicle or bicycle accident (de Vries
Royal Brisbane and Women’s Hospital, et al. 2018).
Herston, Australia
62 K. Dobeli
Risks for multiple and/or serious injury responses (Teasdale and Jennett 1974) and is
include (de Vries et al. 2018; Hildreth et al. 2012; usually described clinically as the patient’s
Leichtle et al. 2019): Glasgow Coma Scale, or GCS (Institute of
Neurological Sciences, n.d.). The Glasgow
• High-speed motor vehicle accident. Coma Scale grades a patient’s responsiveness
• Other markers of serious motorised vehicle based on their eye opening, verbal and motor
accident, such as death of another passenger responses (Table 1).
within the same compartment, rollover, full or CT of the head may be indicated if the patient
partial ejection from the vehicle, and has any risk factors for, or signs of TBI. Intoxicated
intrusion. patients with lowered GCS but no signs of head
• Pedestrian/cyclist collision with a vehicle with injury may not have an immediate CT; instead
the pedestrian/cyclist being thrown or run they may be held in the emergency department
over. for observation until they become clinically
• Motorcycle crash at 30 km/h or more. sober. The need for CT may then be reassessed
• Fall from greater than 2 stories or 6 m. before discharging the patient (Trauma Victoria
• Haemodynamic instability on arrival to the 2021).
trauma centre. Traumatic spine injuries include fracture,
facet joint dislocation, intervertebral disc rupture,
ligament tear and sprain, cord oedema and cord
2 Head and Spine Injuries transection. Motor vehicle accidents are the most
common events that lead to spinal injury; falls,
Head and spine injuries are common outcomes of assaults and sporting mishaps are also notable
polytrauma. Focal head injuries usually result contributors (Singh et al. 2014; Young et al.
from the head striking a solid object such as the 2019). Spinal injuries are more prevalent in ado-
ground or the steering wheel/windscreen of a lescents and young adults, who tend to engage in
vehicle (Fadl and Sandstrom 2019) and include higher risk activities, and also in the elderly, who
skull fracture, intracranial haemorrhage and dif- are more susceptible to fractures in general due to
fuse axonal injury (Figs. 1, 2, 3, and 4). osteoporosis/osteopenia and have a higher inci-
Older patients are more likely to suffer from a dence of falls and motor vehicle accidents
traumatic brain injury (TBI) from polytrauma (Blackmore et al. 1999a; Jabbour et al. 2008;
compared to a younger person (Trauma Victoria Lomoschitz et al. 2002).
2021); a possible reason for this is that the brain Patients who have undergone blunt trauma are
shrinks with age (Fig. 5), and the increased sub- assumed to have a spinal injury until proven oth-
dural space is vulnerable to haemorrhage (de erwise (Stein et al. 2015). Over half of all spinal
Vries 2018). Potential signs of TBI include sei- injuries occur at the cervical level (Young et al.
zure post injury, significant (>30 min) loss of 2019), and neck pain after experiencing even
memory of events leading up to the head injury, minor trauma is common (Matthews and
loss of consciousness and/or several episodes of Arguelles 2015). Rapid assessment of the cervi-
vomiting post the event, blackened eyes, cerebro- cal spine to exclude injury is important because
spinal fluid or blood leak from the ears, or spine immobilisation and/or hard collars can
reduced level of consciousness (National Institute interfere with the management of a patient’s air-
for Health and Care Excellence 2019). way and can increase intracranial pressure (Como
The severity of a TBI can be indicated by a et al. 2009). Consequently, early removal of
patient’s eye opening, verbal and motor immobilisation/hard collar in patients without
Trauma Imaging Protocols and Image Evaluations 63
a b
c d
Arachnoid Arachnoid
mater mater
Subdural
haematoma
Extra dural
haematoma
Pia Pia
Cerebrum mater Cerebrum mater
Skull Skull
Dura Dura
mater mater
Fig. 1 Traumatic intracranial bleeds: extradural haema- the dural sinuses. The haematoma is not confined as with
toma (EDH) and subdural haematoma (SDH). EDH an EDH and therefore it is free to spread widely over the
(a—black arrow heads) is commonly associated with a hemisphere, which gives it a wavy concave outline (d).
skull fracture (b—black arrow head). In the normal state, SDH is often associated with underlying deep brain tissue
the extradural space is only a potential space because the damage, which produces oedema. The oedema increases
dura mater is attached to the inner table of the skull. the mass effect of the injury. With SDH, the amount of
However, a fracture can cause a tear of the meningeal oedema usually has the most significance for the patient’s
arteries, and the force of the arterial flow can be great prognosis. SDH can be seen in all age groups; however,
enough to strip the dura away from the bone. An EDH the usual mechanism of injury is different: in babies and
appears as a smooth biconvex haematoma (c). Any associ- infants, the main cause is non-accidental injury; in young
ated midline shift is usually proportional to the size of the adults, it is motor vehicle and motor cycle accidents,
bleed. Because the dura invaginates into the sutures join- while in the elderly they are typically caused by falls. CT
ing the plates of the skull, a SDH will not usually cross a may have limitations in showing thin subdural collections
suture line. A SDH (a—white arrow heads) is formed against the inner table of the skull; the use of a wider win-
from tearing of vessels that bridge the cerebral cortex and dow width can improve their detection
64 K. Dobeli
a b
Arachnoid
mater
Subarachnoid
haemorrhage
Pia
Cerebrum mater
Skull
Dura
mater
c d
Arachnoid
mater
Intracranial
haemorrhage
Pia
Cerebrum mater
Skull
Dura
mater
Fig. 2 Traumatic intracranial bleeds: subarachnoid contusion. An ICH is located within the brain tissue and is
haemorrhage (SAH) and intracerebral haemorrhage due to bruising or contusion of the tissue. In trauma they
(ICH). SAHs are due to injury to the surface veins and are often accompanied by other cerebral pathology. (c)
arteries on the pia or arachnoid meninges, therefore blood shows the location of an intracranial haemorrhage. (d)
is found within the subarachnoid spaces (a) e.g. around shows both ICH (black arrow head) and SAH (white
the sulci and within the ventricular system (b—white arrow heads) in a 48-year-old female who fell down the
arrow heads). Their significance in trauma is usually over- stairs
shadowed by other findings such as EDH, SDH and/or
other, and there is no consensus on which rule

optimises the use of imaging, a dangerous mech-
anism of injury or the presence of focal neuro-
logical deficit requires imaging according to
most rules. On the other hand, an alert patient
without neck pain, focal neurological symptoms
or distracting injury, and with a functional range
of neck motion can be cleared after a clinical
exam only (Stein et al. 2015).
Prior to the widespread availability of wide-
coverage multi-slice CT, plain radiographs were
routinely performed as the first-line imaging
modality for clearing the cervical spine, with CT
reserved for when the plain X-ray views were
inconclusive or unable to be obtained. However,
more recent studies have shown CT to be more
sensitive (Mathen et al. 2007), time-efficient
(Daffner 2001) and cost effective (Blackmore
Fig. 3 Traumatic intracranial bleeds: diffuse axonal
injury (DAI). DAI is caused by severe trauma and rota- et al. 1999b) than plain films, particularly consid-
tional forces, which results in damage to the white matter ering most trauma patients at high risk for cervi-
axons, especially in the midline. They are most commonly cal spine fracture already require CT imaging for
seen in high-speed motor vehicle accidents. It is a very
other potential injuries. Furthermore, advances in
serious injury, often with a poor prognosis, yet the CT
appearance may be unremarkable. CT signs include dif- CT radiation dose reduction enable current CT
fuse cerebral swelling, loss of grey-white matter differen- systems to provide radiation doses more compa-
tiation, small foci of haemorrhage and, occasionally, rable to those for 3-view X-ray imaging of the
subarachnoid blood (Mesfin et al. 2020)
cervical spine (Mulkens et al. 2007). Plain X-rays
are therefore now generally reserved for the
cervical spine injury is desirable. Imaging all screening of patients at low risk of cervical spine
patients who require clearance of the cervical injury (Stein et al. 2015).
spine would lead to excessive radiation dose and CT of the cervical spine is also indicated if an
demand on imaging services, so clinical decision intracranial bleed is demonstrated in a patient
rules, for example the NEXUS criteria (Hoffman who was referred for CT head only after blunt
et al. 1998) and the Canadian C-spine rules (Stiell trauma, even if the patient did not meet criteria
et al. 2001), are widely used to determine which for cervical spine imaging, due to an increased
patients should undergo imaging. Although these risk of associated C-spine injury (Thesleff et al.
clinical decision rules differ slightly from each 2017).
66 K. Dobeli
a b
Fig. 4 CT density changes in an evolving intracranial likely represent active bleed as non-clotted blood has
bleed. Bilateral acute subdural haematomas (white arrow similar density to brain. 1 week later (b), the CT density
heads) in a 70-year-old woman appear mostly hyperdense has reduced; some areas of the haemorrhage now appear
on first presentation (a). There are some low-density com- isodense compared to the brain, while others are
ponents on the right side (black arrow heads), which most hypodense. Some hyperdense areas remain
a b
Fig. 5 Age-related changes of the subdural space. Images nence in the older woman (white arrow head), reflecting
from the CT head exam of a 15-year-old female (a) and a brain volume loss
96-year-old female (b). Note the global CSF space promi-
Table 1 Glasgow Coma Scale 3 Thorax, Abdomen & Pelvis

Eye opening Verbal
Score response response Motor response Blunt trauma to the torso is most commonly the
1 No response No response No response result of a motor vehicle accident or fall from a
2 Opens eyes to Producing Elbow
height (Avey et al. 2006; Mayberry 2000). Severe
pressure (e.g. sounds only straightens in
pressure to the response to chest injuries are associated with compression
supraorbital pain and/or sudden deceleration of the thorax and
notch or (abnormal include pulmonary laceration and contusion,
trapezius response to
pneumothorax, haemothorax, diaphragmatic rup-
squeeze) pain)
3 Opens eyes to Produces Elbow bends ture and aortic or oesophageal tear (Raptis 2019).
sound occasional, (normal Injuries caused by direct force that does not result
unconnected response) & in deceleration or thoracic compression are gen-
words wrist bends erally limited to the soft tissues and minor frac-
(abnormal
response) to tures (Geyer and Linsenmaier 2016).
pain Chest radiography is the primary imaging tool
4 Opens eyes Confused Elbow bends for minor chest trauma and is routinely performed
spontaneously in response to in major trauma after the secondary assessment
pain (normal
of the patient to detect critical injuries such as
response to
pain) flail chest, tension pneumothorax and aortic rup-
5 Orientated Only moves ture, and to confirm the position of lines and
with full limbs in an tubes (Geyer and Linsenmaier 2016). MDCT is
clear attempt to indicated for polytrauma and significant chest
sentences remove a
painful trauma, and in minor trauma if the chest X-ray is
stimulus (e.g. abnormal.
pressure to The liver and spleen are the most frequently
the injured abdominal organs (Coleman 2015) and
supraorbital
notch or are often associated with lower rib fractures
trapezius (Raptis 2019). Pelvic or abdominal X-ray may be
squeeze) performed initially to identify markers for severe
6 Can control trauma such as pelvic and chance fractures
limbs on
(Fig. 6). A FAST examination of the abdomen is
command
indicated if the clinical examination of the patient
The patient's score for each of the three response criteria
are added. A fully alert patient with no brain injury will is compromised by the patient’s level of con-
have a GCS of 15. The lowest GCS possible is 3. A GCS sciousness or distracting bony injuries of the
equal to or greater than 13 is classified as minor TBI, chest or abdomen (Coleman 2015). The primary
while a GCS between 9 and 12 indicates moderate brain purpose of the FAST scan of the abdomen is to
injury. Severe TBI is classified as GCS less than, or equal
to 8. Only the upper limbs are assessed for motor response detect intraperitoneal free fluid, which, in the
as lower limb response is an unreliable indicator of brain context of trauma, would be highly suggestive of
injury (Adam et al. 2017). GCS may not be a reliable indi- intra-abdominal haemorrhage (Bloom and
cator of severity of TBI if the patient is under the influence Gibbons 2020). CT is warranted if the FAST
of drugs or alcohol (Trauma Victoria 2021)
68 K. Dobeli
a b c
Fig. 6 Chance fracture of the first lumbar vertebra in a involve all three spinal columns, and they are associated
31-year-old male who struck a barricade while riding a with an increased risk of bowel injury (Grossbach et al.
motorcycle and was thrown 10 m. (a) is a radiograph of 2013, Hayes et al. 1991). The fracture is visible as a loss
this patient, highlighting the location of the fractures of vertebral height (arrows) on the screening pelvic X-ray
(black arrows). (b) is an axial lumbar spine CT at L1 ver- that was performed soon after the patient’s arrival in the
tebra. (c) is a sagittal plane of the lumbar spine CT. Chance emergency department. The subsequent trauma CT scan
fractures are caused by a flexion-distraction mechanism, shows a comminuted fracture through the body, pedicles
most commonly at thoracolumbar junction, for example and laminae of the L1 vertebrae (a, b) with retropulsion
flexion over a lap seat belt with a front impact motor vehi- into the spinal canal (c). The patient also has fractures of
cle collision. They are an unstable fracture because they the L2 and L5 vertebra (c)
exam is positive and the patient is haemodynami- more frequently result in pelvic bleeding only,
cally stable, or if the FAST scan is negative but while pelvic fractures sustained from a poly-
there are clinical signs of intra-abdominal injury, trauma event are often associated with additional
such as abdominal distension or seatbelt sign blood loss from other injuries (Montmany et al.
(Coleman 2015). 2015).
Diagnosis of pelvic fractures from polytrauma Bladder rupture is an uncommon but signifi-
is critical as pelvic fracture has high risk of mor- cant injury associated with pelvic fracture (Hertz
bidity and mortality from blood loss. A pelvic et al. 2020). Clinical predictors of bladder rup-
fracture itself can be responsible for considerable ture include wide (>1 cm) diastasis of the pubic
blood loss, but pelvic fractures are also frequently symphysis or sacroiliac joints, or fracture of the
associated with blood loss from other serious or pelvic ring with associated displacement >1 cm,
life-threatening injury, including head injury, in combination with high red blood cell count on
solid organ laceration and aortic tear (Demetriades urinalysis or gross haematuria (Avey et al. 2006)
et al. 2002). Pelvic fractures as a result of a fall (Fig. 7).
a b
Fig. 7 Axial (a, b) and coronal (c) images of bladder rup- vic fractures (white arrow heads) and extravasation of
ture in a 22-year-old male involved in a motor vehicle col- contrast from the bladder (black arrow heads), indicating
lision with a tree. The patient had been transferred from a rupture. The patient also has a fractured right femur (b, c
regional hospital due to the severity of his injuries. The white arrows)
CT performed at the tertiary hospital shows multiple pel-
4 Penetrating and Vascular trauma can also result in damage to arteries and/or

Injuries veins. In the neck, dissection of the carotid artery,
although rare, is the most frequent outcome, and
Penetrating trauma is most commonly associated high-speed MVA the main cause of blunt vascular
with stabbings, shootings, explosive devices and injury (Fusco and Harrigan 2011). Neck hyperex-
the use of cutting or piercing tools in the work- tension and rotation appear to be a major mecha-
place or home (e.g. nail gun). The strength of the nism of blunt injury to the neck vessels (Fadl and
force by which the penetrating object enters the Sandstrom 2019). The vertebral arteries are less
body influences the type and location of inju- prone to injury overall as they are protected from
ries sustained. Low-velocity penetrating trauma direct impact by the cervical vertebrae (Wahlberg
results in damage to the organs along the trajec- and Goldstone 2017a); however, they are more
tory only, whereas pressure waves triggered by vulnerable than the carotid arteries in the setting
high-velocity projectiles can cause blunt injuries of subluxation and/or fractures of the upper cervi-
further afield (Chand 2019). High-velocity pene- cal spine (Fassett et al. 2008).
trating trauma invariably causes both vascular and In the chest and abdomen, blunt traumatic vas-
organ injury (Wahlberg and Goldstone 2017a). cular injuries can result from direct compression,
Penetrating trauma is the most common mech- for example compression of the aorta against the
anism for vascular injury (Lateef Wani et al. 2012; spine by the sternum or steering wheel during a
Wahlberg and Goldstone 2017b); however, blunt motor vehicle accident or by rapid deceleration
70 K. Dobeli
a b
Fig. 8 Axial (a) and oblique sagittal (b) maximum inten- blood vessel (the intima and tunica media) rupture. The
sity projection (MIP) images of a traumatic aortic pseu- blood is contained with the outpouching (white arrow
doaneurysm due to intimal tear in a 39-year-old male heads) (Eisenberg 2019). This patient had multiple other
involved in a motorcycle accident. A pseudoaneurysm is injuries, including left diaphragmatic rupture, high-grade
an abnormal dilatation of the outer wall (tunica adventitia) contusion of the caecum and ascending colon, liver lacer-
of a blood vessel that occurs when the inner layers of the ation and pseudoaneurysm of the left vertebral artery
(Fadl and Sandstrom 2019; Geyer and Linsenmaier 6 CT Imaging of Trauma
2016). Compression forces tend to cause intimal
tears and intramural haematoma, while decelera- A full body polytrauma scan on a 64-slice or
tion can cause stretching and twisting of vessels atgreater MDCT typically covers from the vertex to
points of attachment (Wahlberg and Goldstone below the symphysis pubis (Dreizin and Munera
2017b). Major vascular injuries are usually found 2012). Depending on the volume coverage of the
in conjunction with damage to multiple organs, CT and institution preference, the scan may be
such as the liver, pancreas and bowel (Fig. 8). Pre-acquired as separate exposures of the head, neck,
hospital mortality is high with blunt aortic trauma.chest and abdomen, or as a reduced number of
Patients who do reach care in time are often in combined scans. The individual components of a
shock and highly unstable (Neschis et al. 2008); polytrauma protocol are explained below:
consequently, they are frequently taken straight to Head: A non-contrast scan of the head is manda-
the operating theatre without CT imaging. tory to assess for intracranial haemorrhage because
the presence of intravenous contrast can mask
bleeds, which, when new, appear hyperdense
5 Extremities (Fig. 4). Bone reconstructions of the skull are stan-
dard. To avoid unnecessary movement of the neck,
Injuries to the extremities may not be assessed polytrauma patients are usually not positioned with
during an initial polytrauma CT examination to their head in the head rest. Additional exposure may
expediate diagnosis and treatment of life- therefore be required to penetrate the thicker table
threatening head, neck and torso injuries. top and maintain image quality. With the patient in
However, in some instances an injury to an this position, the face will usually be included
extremity may require immediate intervention, so within the scan range for the head (Fig. 9). Dedicated
an urgent CT may be requested to evaluate the multiplanar +/− 3D reformats of the face can thus
extent of injury and/or to plan surgical treatment, be reconstructed if the patient has signs of facial
for example fracture/dislocation with compro- trauma, or if a facial fracture or significant soft tis-
mised blood flow or traumatic amputation. sue injury is identified on the head images.
feature is available, a single acquisition of the

head and cervical spine may be preferred as it
would avoid scan overlap at the base of skull/
upper cervical spine. Soft tissue reconstructions
of the cervical spine using a large enough field of
view to extend to the pharynx anteriorly and the
skin margin posteriorly should be included
because swelling of the soft tissues may be the
only CT indicator of a fracture or unstable liga-
mentous injury (Friesen and Brownlee 2014).
CT angiogram: CT angiography of the chest
and abdomen is indicated for high-risk mecha-
nisms of injury (Dreizin and Munera 2012).
Minimum coverage is from the lower neck (to
demonstrate the origins of the major neck and
Fig. 9 Typical head position for a multitrauma patient. upper limb vessels) to below the solid abdominal
The patient will often be scanned with their head on the organs, e.g. liver, kidneys, spleen (as these are
tabletop. In this position, the scan range for the head scan prone to laceration and haemorrhage). The supe-
will usually include most of the face rior scan limit may be extended to the Circle of
Willis if the mechanism of injury puts the patient
Cervical spine: The cervical spine may be at risk of carotid or vertebral injury. A separate
acquired by various means; as a separate non- CTA of the neck is not required with 64-slice or
contrast scan; as a continuation of the head scan; greater MDCT as sensitivity of an extended body
or reconstructed from a CT angiogram of the CTA is equivalent to that of dedicated CTA neck
neck. CTA protocols often use higher pitch than for trauma (Sliker et al. 2008). If a pelvic fracture
that for a dedicated cervical spine scan; thus, the is demonstrated on the screening pelvis X-ray or
bony reconstructions from the angiography data on the CT scanogram (Fig. 10), the CTA can be
may have insufficient spatial resolution to detect extended to the symphysis pubis to allow for
subtle fractures. However, this is less of a p roblem assessment of active bleeding in the pelvis.
with current wide-coverage MDCT and this Portal venous abdomen ± pelvis: Lacerations
method reduces radiation dose by eliminating the of solid organs such as the liver, kidneys and
dedicated cervical spine scan. In combined non- spleen are best demonstrated on portal venous
contrast head and cervical spine acquisitions, phase imaging. This phase also helps to distin-
care is required to ensure adequate exposure for guish between pseudoaneurysm and active bleed-
the brain while avoiding overexposure of the ing and provides some clues to the rate of
spine. Dose modulation, a standard feature on bleeding, which can be estimated by the volume
most MDCT systems, is very effective for adjust- of extravasated contrast (Dreizin and Munera
ing dose relative to patient density where con- 2012) (Figs. 11 and 12). If the CT angiogram
stant noise levels are required. However, brain included the pelvis, the portal venous phase may
CT requires lower image noise compared to spine extend from the diaphragm to just below the solid
CT; thus, if the acquisition is set to achieve the organs, although a full portal venous scan from
lower noise level for the head, standard dose the diaphragms to symphysis pubis is commonly
modulation would result in excess radiation to performed. Oral contrast is not required (Skinner
the neck. If, on the other hand, the noise level for and Driscoll 2013).
dose modulation is set to that for the spine, the Delayed phase: Delayed phase imaging,
brain would be underexposed. Some MDCT acquired 3–5 min after the arterial phase scan is
scanners allow the setting of different image indicated for significant renal trauma to assess
quality levels across a single acquisition; if this for disruptions to the ureters and renal collecting
72 K. Dobeli
system and to distinguish between urinoma and

haematoma (Iacobellis et al. 2020) (Fig. 13).
CT cystogram: Indications for CT cystogra-
phy include gross haematuria, free intraperito-
neal or peri-vesical fluid or a pelvic ring injury
(Fadl and Sandstrom 2019). The preferred CT
cystography technique involves retrograde filling
of the bladder with 250–350 ml of 3–5% iodin-
ated solution via gravity-drip infusion (Joshi
et al. 2018). A delayed CT of the bladder per-
formed after a contrast-enhanced scan is not rec-
ommended unless there is suspected urethral
injury contraindicating the insertion of a Foley
catheter because this method does not produce
very high bladder pressure, and injuries may be
missed if the bladder is not sufficiently distended
(Urry et al. 2016; Wirth et al. 2010).
Thoracic and lumbar spine reconstructions:
Dedicated thoracic and lumbar spine CT is not
necessary as reconstructed views from the CT
angiogram and/or portal venous abdomen scan
using targeted field of view and bone algorithm
have high sensitivity and specificity for the diag-
nosis of spine fracture (Shah and Ross 2016).
Reconstructions of the whole spine are particu-
larly important when a vertebral fracture is iden-
Fig. 10 Pelvic fractures visible on the anteroposterior
tified at any stage of the trauma CT examination
(AP) scanogram for a trauma CT (arrow heads). In this
patient, the CT angiogram was extended to the symphysis as approximately 10% of patients have concomi-
pubis to assess for pelvic bleeding tant spinal fractures in another spinal column
a b
Fig. 11 Traumatic arteriovenous fistula and pseudoaneu- There is no change to the distribution of the contrast
rysm of the left external iliac artery and left external iliac between the arterial (a) and portal venous (b) phases, indi-
vein in a 37-year-old male who was shot in the thigh. cating the blood is contained
a b
Fig. 12 Active bleeding with pseudoaneurysm formation accident. The portal venous phase (b) shows an increase
within the posterior right hepatic lobe in a 43-year-old in accumulated contrast (arrow heads) compared to the
male who was involved in a high-speed motor vehicle arterial phase (a), indicating active bleed
a b c
Fig. 13 Renal laceration with extension into the renal scan (c) demonstrates extravasation of contrast into the
hilum in a 47-year-old patient involved in a motor vehicle retroperitoneal space (arrow heads), indicating rupture of
accident. The arterial (a) and portal venous phases (b) did the collecting system
not demonstrate active bleeding. Five-minute delayed
(Wang et al. 2015; Hanson et al. 2000; Young and retropulsion of bone fragments into the spi-
et al. 2019) (Fig. 14). Sagittal and coronal multi- nal canal (Dreizin and Munera 2012).
planar reconstructions improve the detection of Volume-rendered reconstructions: Three-
axially orientated fractures and better demon- dimensional rendering of the CTA chest data to
strate transverse and spinous process fractures show the rib cage with the shoulder girdles and
74 K. Dobeli
high-density foreign objects such as tubes and spine for significant fractures can provide impor-
lines electronically removed provides important tant spatial information to assist surgical plan-
information about rib fractures for not only clini- ning (Dreizin and Munera 2012) (Fig. 16).
cal management, but also for legal and forensic The principles outlined above for CT imaging
reasons (Geyer and Linsenmaier 2016) (Fig. 15). of polytrauma can also be applied to specific ana-
Volume-rendered reconstruction of the pelvis or tomical regions affected by isolated trauma.
a b c
Fig. 14 Trauma scan on a 19-year-old male involved in a patient also had compression fractures of C7, T3 and T4 (c
high-speed motor vehicle accident demonstrates an unsta- white arrows)
ble burst fracture of C5 (a & b white arrow heads). The
a b
Fig. 15 Volume-rendered (a) and maximum intensity segments move paradoxically with the chest during respi-
projection (MIP) (b) reconstructions of the ribs in a ration, i.e. when the patient breathes in, the rib cage
43-year-old female post fall. Ribs 5–10 had obvious frac- expands but the flail segment moves inwards, and when
tures (arrow heads), and there were possible fractures in the patient breathes out, the rib cage deflates but the flail
ribs 2–4. Some of the lower ribs were broken in two segment moves outwards (Kaewlai et al. 2008). Flail chest
places, indicating a radiological flail segment. The term indicates significant trauma. This patient had multiple
flail chest is used when 3 or more contiguous ribs have other injuries, including haemothorax, and liver and
been fractured in two or more places. The fractured rib splenic lacerations
a b
Fig. 16 Volume-rendered reconstruction of the pelvis viewed anteriorly (a) and posteriorly (b) in a 40-year-old male
who had fallen from 5 m. The patient underwent surgical reconstruction of his right acetabulum
JA, Shapiro MB, Winston ES. Practice management

References guidelines for identification of cervical spine injuries
following trauma: update from the eastern Association
Adam S, Osboorne W, Welch J. Neurological problems. for the Surgery of trauma practice management guide-
In: Adam S, Osborne W, Welch J, editors. Critical care lines committee. J Trauma. 2009;67(3):651–9. https://
nursing: science and practice. 3rd ed. Oxford: Oxford doi.org/10.1097/TA.0b013e3181ae583b.
University Press; 2017. Daffner RH. Helical CT of the cervical spine for
Avey G, Blackmore CC, Wessells H, Wright JL, Talner trauma patients: a time study. Am J Roentgenol.
LB. Radiographic and clinical predictors of bladder 2001;177(3):677–9. https://doi.org/10.2214/
rupture in blunt trauma patients with pelvic frac- ajr.177.3.1770677.
ture. Acad Radiol. 2006;13(5):573–9. https://doi. Demetriades D, Karaiskakis M, Toutouzas K, Alo K,
org/10.1016/j.acra.2005.10.012. Velmahos G, Chan L. Pelvic fractures: epidemiology
Blackmore CC, Emerson SS, Mann FA, Koepsell and predictors of associated abdominal injuries and
TD. Cervical spine imaging in patients with outcomes. J Am Coll Surg. 2002;195(1):1–10. https://
trauma: determination of fracture risk to optimize doi.org/10.1016/S1072-7515(02)01197-3.
use. Radiology. 1999a;211(3):759–65. https://doi. de Vries R, Reininga IHF, Pieske O, Lefering R, El
org/10.1148/radiology.211.3.r99jn22759. Moumni M, Wendt K. Injury mechanisms, pat-
Blackmore CC, Ramsey SD, Mann FA, Deyo terns and outcomes of older polytrauma patients: an
RA. Cervical spine screening with CT in trauma analysis of the Dutch trauma registry. PLoS One.
patients : a cost-effectiveness analysis. Radiology. 2018;13(1):e0190587. https://doi.org/10.1371/jour-
1999b;212(1):117–25. https://doi.org/10.1148/radiolo nal.pone.0190587.
gy.212.1.r99jl08117. Dreizin D, Munera F. Blunt polytrauma: evalua-
Bloom, BA, Gibbons RC, Focused assessment with tion with 64-section whole-body CT angiography.
sonography for trauma. In: StatPearls [internet]. Radiographics. 2012;32(3):609–31. https://doi.
Treasure Island (FL): StatPearls Publishing. 2020. org/10.1148/rg.323115099.
https://www.ncbi.nlm.nih.gov/books/NBK470479/. Eid HO, Abu-Aidan FM. Biomechanics of road traffic
Accessed: 07 February 2021. collision injuries: a clinician’s perspective. Singapore
Chand R. Chest trauma. In: Eltorai AEM, Hyman CH, J Med. 2007;48(7):693–700.
Healey TT, editors. Essential radiology review a Eisenberg RL. Aorta. In: Eisenberg RL, editor. What radi-
question and answer guide. 1st ed. Champions: ology residents need to know: chest radiology. Cham:
Springer International Publishing; 2019. https://doi. Springer International Publishing; 2019. p. 247–55.
org/10.1007/978-3-030-26044-6. https://doi.org/10.1007/978-3-030-16826-1_18.
Coleman JJ. Blunt abdominal trauma. In: Saclarides TJ, Fadl SA, Sandstrom CK. Pattern recognition: a mechanism-
Myers JA, Millikan KW, editors. Common surgical based approach to injury detection after motor vehicle
diseases: an algorithmic approach to problem solving. collisions. Radiographics. 2019;39(3):857–76. https://
New York, NY: Springer New York; 2015. doi.org/10.1148/rg.2019180063.
Como JJ, Diaz JJ, Dunham CM, Chiu WC, Duane TM, Fassett DR, Dailey AT, Vaccaro AR. Vertebral artery inju-
Capella JM, Holevar MR, Khwaja KA, Mayglothling ries associated with cervical spine injuries: a review of
76 K. Dobeli
the literature. J Spinal Disord Tech. 2008;21(4):252–8. diagnosis: RadioGraphics fundamentals | online pre-
https://doi.org/10.1097/BSD.0b013e3180cab162. sentation. Radiographics. 2018;38(1):92–3. https://
Friesen B, Brownlee R. The role of CT and MRI in doi.org/10.1148/rg.2018170125.
suspected acute cervical spine trauma. Hong Kong Kaewlai R, Avery LL, Asrani AV, Novelline
J Emerg Med. 2014;21(6):368–72. https://doi. RA. Multidetector CT of blunt thoracic trauma.
org/10.1177/102490791402100605. Radiographics. 2008;28(6):1555–70. https://doi.
Fusco MR, Harrigan MR. Cerebrovascular dissec- org/10.1148/rg.286085510.
tions: a review. Part II: blunt cerebrovascular injury. Lateef Wani M, Gani Ahangar A, Ahmad Ganie F, Nabi
Neurosurgery. 2011;68(2):517–30. https://doi. Wani S, Wani N. Vascular injuries: trends in manage-
org/10.1227/NEU.0b013e3181fe2fda. ment. Trauma Mon. 2012;17(2):266–9. https://doi.
Geyer, LL & Linsenmaier, U, 2016, MDCT of chest org/10.5812/traumamon.6238.
trauma. In Multidetector-row CT of the thorax. Leichtle SW, Poulos NG, Whelan J, Aboutanos M. Field
Springer International Publishing, Cham, pp. 525– triage of motor vehicle crashes: which factors predict
544. http://10.1007/978-3-319-30355-0_25. high injury severity? Am Surg. 2019;85(7):764–7.
Grossbach AJ, Dahdaleh NS, Abel TJ, Woods GD, https://doi.org/10.1177/000313481908500740.
Dlouhy BJ, Hitchon PW. Flexion-distraction injuries Lomoschitz FM, Blackmore CC, Mirza SK, Mann
of the thoracolumbar spine: open fusion versus per- FA. Cervical spine injuries in patients 65 years old and
cutaneous pedicle screw fixation. Neurosurg Focus. older: epidemiologic analysis regarding the effects of
2013;35(2):E2. https://doi.org/10.3171/2013.6.FO age and injury mechanism on distribution, type, and sta-
CUS13176. bility of injuries. Am J Roentgenol. 2002;178(3):573–
Hayes CW, Conway WF, Walsh JW, Coppage L, Gervin 7. https://doi.org/10.2214/ajr.178.3.1780573.
AS. Seat belt injuries: radiologic findings and clinical Mathen R, Inaba K, Munera F, Teixeira PGR, Rivas L,
correlation. Radiographics. 1991;11(1):23–36. https:// McKenney M, Lopez P, Ledezma CJ. Prospective
doi.org/10.1148/radiographics.11.1.1996397. evaluation of multislice computed tomography versus
Hanson JA, Blackmore CC, Mann FA, Wilson plain radiographic cervical spine clearance in trauma
AJ. Cervical spine injury: a clinical decision rule to patients. J Trauma. 2007;62(6):1427–31. https://doi.
identify high-risk patients for helical CT screening. org/10.1097/01.ta.0000239813.78603.15.
Am J Roentgenol. 2000;174(3):713–7. https://doi. Mathews WA, Arguelles CS. The cervical spine. In:
org/10.2214/ajr.174.3.1740713. Daniels JM, editor. Common musculoskeletal prob-
Hertz AM, Hertz NM, Johnsen NV. Identifying bladder lems : a handbook. 2nd ed. Cham: Springer; 2015.
rupture following traumatic pelvic fracture: a machine Mayberry JC. Imaging in thoracic trauma: the
learning approach. Injury. 2020;51(2):334–9. https:// trauma Surgeon’s perspective. J Thorac
doi.org/10.1016/j.injury.2019.12.009. Imaging. 2000;15(2):76–86. https://doi.
Hildreth AM, Martin RS, Meredith JW. Introduction to org/10.1097/00005382-200004000-00002.
trauma care. In: Peitzman AB, Schwab CW, Yealy Mesfin, FB, Gupta, N, Hays Shapshak, A, Tayor, R,
DM, editors. The trauma manual: trauma and acute 2020, Diffuse axonal injury. In StatPearls [inter-
care surgery. 4th ed. Philadelphia: Wolters Kluwer net], StatPearls Publishing, Treasure Island, Florida.
Health; 2012. p. 1–9. https://www.ncbi.nlm.nih.gov/books/NBK448102/.
Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective Accessed 29 Aug 2020.
cervical spine radiography in blunt trauma: meth- Montmany S, Rebasa P, Luna A, Hidalgo JM, Cánovas G,
odology of the National Emergency X-radiography Navarro S. Source of bleeding in trauma patients with
utilization study (NEXUS). Ann Emerg Med. pelvic fracture and Haemodynamic instability. Cirugia
1998;32(4):461–9. https://doi.org/10.1016/ Española (English Ed). 2015;93(7):450–4. https://doi.
S0196-0644(98)70176-3. org/10.1016/j.cireng.2015.01.005.
Iacobellis F, Romano L, Rengo A, Danzi R, Scuderi MG, Mulkens T, Marchal P, Daineffe S, Salgado R, Bellinck
Brillantino A, Scaglione M. CT protocol optimization P, te Rijdt B, Kegelaers B, Termote J-L. Comparison
in trauma imaging: a review of current evidence. Curr of low-dose with standard-dose multidetector
Radiol Rep (Philadelphia, PA ). 2020;8(6) https://doi. CT in cervical spine trauma. Am J Neuroradiol.
org/10.1007/s40134-020-00351-5. 2007;28(8):1444–50. https://doi.org/10.3174/ajnr.
Institute of Neurological Sciences, Glasgow. The Glasgow A0608.
structured approach to assessment of the Glasgow National Institute for Health and Care Excellence. Clinical
Coma Scale. n.d.. https://www.glasgowcomascale. Guideline [CG176] head injury: assessment and early
org/what-is-gcs/. Accessed 7 Nov 2020. management. 2019. https://www.nice.org.uk/guidance/
Jabbour P, Fehlings M, Vaccaro AR, Harrop JS. Traumatic cg176/chapter/1-Recommendations#assessment-in-
spine injuries in the geriatric population. Neurosurg the-emergency-department-2. Accessed 2 Jan 2021.
Focus. 2008;25(5):E16. https://doi.org/10.3171/ Neschis DG, Scalea TM, Flinn WR, Griffith BP. Blunt
FOC.2008.25.11.E16. aortic injury. N Engl J Med. 2008;359(16):1708–16.
Joshi G, Kim EY, Hanna TN, Siegel CL, Menias CO. CT https://doi.org/10.1056/NEJMra0706159.
cystography for suspicion of traumatic urinary bladder Raptis C. Chest trauma: nonvascular injuries. In: Rosado
injury: indications, technique, findings, and pitfalls in de Christenson ML, Bhalla S, Abbott GF, Martinez-
Jimenez S, editors. Chest imaging. New York: Oxford Thesleff T, Kataja A, Öhman J, Luoto TM. Head injuries
University Press; 2019. and the risk of concurrent cervical spine fractures.
Shah LM, Ross JS. Imaging of spine trauma. Acta Neurochir. 2017;159(5):907–14. https://doi.
Neurosurgery. 2016;79(5):626–42. https://doi. org/10.1007/s00701-017-3133-0.
org/10.1227/NEU.0000000000001336. Trauma Victoria. Major trauma guidelines & education.
Singh A, Tetreault L, Kalsi-Ryan S, Nouri A, Fehlings 2021. www.trauma.reach.vic.gov.au. Accessed 2 Jan
MG. Global prevalence and incidence of traumatic 2021.
spinal cord injury. Clin Epidemiol. 2014;6:309–31. Urry R, Clarke D, Bruce J, Laing G. The incidence, spec-
https://doi.org/10.2147/CLEP.S68889. trum and outcomes of traumatic bladder injuries within
Skinner DV, Driscoll PA. ABC of major trauma. 4th ed. the Pietermaritzburg metropolitan trauma service.
London: Wiley; 2013. Injury. 2016;47(5):1057–63. https://doi.org/10.1016/j.
Sliker CW, Shanmuganathan K, Mirvis SE. Diagnosis injury.2016.01.020.
of blunt cerebrovascular injuries with 16-MDCT: Wahlberg, E, Goldstone, J, 2017a, Vascular injuries to the
accuracy of whole-body MDCT compared with neck. In Wahlberg E, Goldstone J, editors. Emergency
neck MDCT angiography’. Am J Roentgenol vascular surgery: a practical guide, Springer, Berlin,
(1976). 2008;190(3):790–9. https://doi.org/10.2214/ Heidelberg.
AJR.07.2378. Wahlberg, E, Goldstone, J, 2017b, Abdominal vas-
Stiell IG, Wells GA, Vandemheen KL, Clement CM, cular injuries. In Wahlberg, E, Goldstone, J, edi-
Lesiuk H, De Maio VJ, Laupacis A, Schull M, tors. Emergency vascular surgery: a practical guide,
McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Springer, Berlin, Heidelberg.
Eisenhauer MA, Greenberg GH, MacPhail I, Morrison Wang H, Zhou Y, Ou L, Li C, Liu J, Xiang L. Traumatic
L, Reardon M, Worthington J. The Canadian C-spine vertebral fractures and concomitant fractures of the rib
rule for radiography in alert and stable trauma patients. in Southwest China, 2001 to 2010: an observational
J Am Med Assoc. 2001;286(15):1841–8. https://doi. study. Medicine (Baltimore). 2015;94(44):–e1985.
org/10.1001/jama.286.15.1841. https://doi.org/10.1097/MD.0000000000001985.
Stein DM, Pineda JA, Roddy V, Knight WA IV. Emergency Wirth GJ, Peter R, Poletti P, Iselin CE. Advances in the
neurological life support: traumatic spine injury. management of blunt traumatic bladder rupture: expe-
Neurocrit Care. 2015;23(S2):155–64. https://doi. rience with 36 cases. BJU Int. 2010;106(9):1344–9.
org/10.1007/s12028-015-0169-y. https://doi.org/10.1111/j.1464-410X.2010.09377.x.
Teasdale G, Jennett B. Assessment of coma and Young CC, Chiarelli PA, Hofstetter CP. In: Ellenbogen
impaired consciousness: a practical scale. Lancet RG, Sekhar LN, Kitchen ND, editors. Principles
(British Edition). 1974;304(7872):81–4. https://doi. of neurological surgery. 4th ed. Philadelphia, PA:
org/10.1016/S0140-6736(74)91639-0. Elsevier; 2019. p. 475–92.
Stroke Imaging Protocols
Karen Dobeli
Abstract Keywords
A stroke occurs when blood flow to a portion Stroke · Intra-arterial thrombectomy ·

of the brain is suddenly interrupted. Strokes Decompressive hemicraniectomy · CT
can arise when a cerebral artery is blocked by perfusion · Consultant radiographer
a blood clot (ischemic stroke) or when there is
spontaneous rupture of a blood vessel within
or on the surface of the brain (haemorrhagic 1 Introduction
stroke). When the blood supply to part of the
brain is cut off during a stroke, the brain tissue There are various treatments for stroke, depend-
normally supplied by the affected artery can ing on the type, size, location and cause of the
survive for some time because it can receive stroke as well as the time elapsed between the
blood from collateral blood vessels. The rate event and the patient presenting to the emergency
of death of brain cells is determined by the department. Immediate treatment for ischemic
volume and speed of delivery of blood sup- stroke includes:
plied by the collateral circulation, which is Intravenous thrombolysis: Patients receive
extremely variable. Brain tissue that receives intravenous injection of a clot-busting drug (com-
sufficient perfusion from the collateral vessels monly Alteplase, also known as t-PA or rt-PA).
is more responsive to treatment and more This treatment is most effective when given
likely to return to normal function if the within the first few hours after the stroke and has
obstructed artery is recanalized (opened). better outcomes for recanalizing small distal
However, brain cells with poor collateral cerebral arteries (Konstas et al. 2009a; Menon
blood are more susceptible to further injury et al. 2013; Menon et al. 2015a). The success rate
during treatment (e.g. haemorrhage) and are for large arteries such as the internal carotid and
more likely to die (infarct), resulting in perma- proximal middle cerebral arteries is relatively
nent brain damage. low (10–30%) (Lee et al. 2007). Thrombolysis is
contraindicated for haemorrhage stroke and for
patients at risk for bleeding. Up to 7% of isch-
emic stroke patients without bleeding risk who
K. Dobeli (*) receive IV Alteplase will develop intracranial
Royal Brisbane and Women’s Hospital, haemorrhage (Yaghi et al. 2017).
Herston, QLD, Australia
80 K. Dobeli
Intra-arterial thrombectomy (clot retrieval): within the acute treatment window because
This procedure is performed in the angiography changes to the brain do not produce large dif-
suite by specialist neuro-interventionalists. A ferences in CT attenuation compared to unaf-
catheter is navigated to the site of the arterial fected brain until days or weeks later.
blockage in the brain, and the clot is mechani- However, an acute stroke may be suspected if
cally removed or dissolved with intravenous there is loss of grey-white matter differentia-
thrombolytics (Chung et al. 2013). Although only tion in the basal ganglia or cortical or insular
1 in 10 patients are eligible for thrombectomy, ribbons (Barrett and Meschia 2013) (Fig. 2).
the chances of a good therapeutic outcome in Occlusion of the middle cerebral artery
patients who undergo the procedure are increased (MCA) may be obvious on NCCT as a hyper-
by more than 50% (Goyal et al. 2016). dense ribbon called the ‘hyperdense MCA
Thrombectomy is usually performed in combina- sign’ (Barrett and Meschia 2013) (Fig. 3).
tion with intravenous thrombolysis. This sign is best appreciated on thin slice
Decompressive hemicraniectomy: Occlusion of (<2 mm) images (Mair et al. 2015).
the middle cerebral artery can result in significant
brain oedema, which increases intracranial pressure The CTA can be performed using an institu-
and poses a risk of small blood vessel compression, tion’s standard protocol for CTA of the head and
leading to cell death in parts of the brain not origi- neck, extending from the aortic arch to the skull
nally affected by the stroke. Decompressive hemi- vertex (Rudd et al. 2017). This coverage demon-
craniectomy is a life-saving procedure, in which the strates the level of arterial obstruction in the
skull overlying the side of the stroke is removed and brain, can provide information on the quality of
the dura is opened to release intracranial pressure. collateral flow (Fig. 4), allows assessment of
The procedure is usually performed within 48 hours underlying causes for stroke in the neck (e.g.
of a stroke (Świat et al. 2010). carotid artery atherosclerosis or dissection) and
An estimated 1.9 million neurons die every provides anatomical information about the ori-
minute a stroke remains untreated (Stroke gins and tortuosity of the neck vessels, which
Association 2018); thus, rapid diagnosis of stroke aids the planning and performance of endovascu-
is of paramount importance. CT is the initial and lar clot retrieval (Byrne et al. 2017). Because
major imaging modality involved in the diagno- rapid decisions are critical in stroke, post-
sis of stroke because it is fast and readily avail- processing should be kept to a minimum, for
able, it can detect mimics for stroke such as example standard thin slice axial images and
tumour and subdural haemorrhage, and it can thick slice axial maximum intensity projection
provide critical information required to deter- (MIP) reformats only.
mine the most appropriate treatment for the A potential pitfall of the CT angiogram is slow
patient (Shetty and Lev 2005). blood flow in the major arteries on the same side
A basic CT stroke protocol (Table 1) consists as the stroke. Thus, the level of the occlusion may
of a non-contrast scan (NCCT) of the head and a appear to be more proximal than it really is (Lev
CT angiogram (CTA) of the head and neck. The et al. 2001), which may cause delays in a clot
NCCT serves several purposes: retrieval procedure because the selection of
approach and catheters is made for the incorrect
• To rule out haemorrhagic stroke or other cere- level (Chung et al. 2013). If a vessel appears to be
bral bleed (Fig. 1). occluded on the CTA, a repeat scan from just
• To rule out other causes for the patient’s symp- below the level of the perceived occlusion to the
toms and to demonstrate long-standing brain vertex (with no additional contrast) can confirm
abnormalities, which may aid the interpreta- the true level of the occlusion (Chung et al. 2013).
tion of brain perfusion imaging. The basic CT stroke protocol can be supple-
• To confirm ischemic stroke: CT is not particu- mented by specialized CT stroke techniques,
larly sensitive for detecting ischemic stroke namely multiphase CTA, and/or CT perfusion.
Stroke Imaging Protocols 81
Table 1 Stroke protocol

Patient Head first, supine, arms down.
position If performing CT perfusion: tilt the chin down to position the glabellomeatal line as parallel to the
gantry as possible.
Immobilize the patient well.
Topogram AP and lateral to include mid chest to the vertex.
Non-contrast Scan region Foramen magnum to skull vertex
head Contrast N/A
Breath hold N/A
Recons Axial, sagittal and coronal MPRs.
CTA head and Scan region Pre-monitoring: Aortic arch
neck Main acquisition: Aortic arch to vertex.
Notes:
• May be performed in the cranio-caudal direction to reduce venous
contamination. When using this technique, the pre-monitoring scan can be
positioned at the level of the mandible.
• If using a very wide coverage CT unit, the CTA head may be obtained from
the CT perfusion acquisition; thus, the CTA can be limited to coverage of
the neck.
Contrast 50–75 ml of low or iso-osmolar non-ionic intravenous contrast administered by
power injector at 4–5 ml/s, followed by 40–50 ml of normal saline injected at
the same rate.
Breath HOLD N/A
Recons For rapid image reconstruction and diagnosis, reconstructions can be limited
to:
• Thin, overlapping axial MPR
• Thick, overlapping axial MIP, e.g. 10@5
Delayed scans Perform 1 or 2 scans of the brain at 8–12 s intervals after the completion of the
(if multiphase CTA head and neck. No further contrast is required.
CTA is used Reconstructions can be limited to thick, overlapping MIP.
instead of CT
perfusion)
CT perfusion Scan region 8 cm or greater slab with the inferior extent level with the base of the pituitary
fossa.
Contrast 30–50 ml of low or iso-osmolar non-ionic intravenous contrast administered by
power injector at 6–8 ml/s, followed by 30–50 ml of normal saline injected at
the same rate.
Breath hold N/A
Recons • Thick (5–10 mm) axial reconstructions (thickness may be determined by
the postprocessing perfusion software to be used).
Two features of stroke that have important impli- fusion of the brain tissue via collateral circulation.
cations for treatment, particularly thrombolysis, Evidence suggests addition of either of these tech-
are the ‘core’ and ‘penumbra’. The core of a stroke niques to the standard stroke protocol increases
describes brain tissue that is irreversibly damaged, confidence with decision-making on thrombec-
while brain tissue that is damaged but can poten- tomy (Khumtong et al. 2020).
tially be salvaged through treatment is called the Multiphase CT is a simple examination; it
penumbra. Collateral supply to the damaged brain involves two repeat CT scans of the brain imme-
is the key difference; tissue within the penumbra diately following the CTA of the head and neck.
has good collateral supply, while poor collateral The delay between the CTA and the first repeat,
supply usually indicates non- salvageable tissue and between the first and second repeats is quite
(Menon et al. 2015a). Multiphase CTA and CT short, about 8–12 s (Byrne et al. 2017). The
perfusion can both provide information about per- delayed scans can be reconstructed as thick slab
82 K. Dobeli
Fig. 1 This 86-year-old female was brought to hospital

by ambulance with stroke symptoms. She was immedi-
ately transferred to the imaging department for a CT
stroke exam. The non-contrast scan demonstrates a large,
left cerebellar haemorrhage (white arrow heads) with
Fig. 2 Non-contrast scan of the head on this 48-female
extension into the cerebral ventricles (black arrow heads).
(Patient X), who woke with right-sided facial droop,
A CT angiogram was performed, which showed an aneu-
expressive dysphasia and right-sided weakness shows
rysm of the left posterior inferior carotid artery (PICA).
subtle loss of grey-white matter differentiation involving
The patient was then taken to the angiography suite for
the left insular cortex, left lentiform nucleus and left cau-
coiling of the aneurysm
date nucleus (ellipse)
MIPs as for the CTA to enable easy comparison of

the three arterial scans and reduce processing the HU values against time to create a time-density
time. When the three arterial phases are viewed curve for each pixel. Because contrast is delivered
side-by-side, the rate and amount of collateral cir- to the tissue via the blood, these curves can pro-
culation to the ischemic area can be compared to vide information about the volume of blood that is
the unaffected side (Fig. 5). Regions of infarcted delivered to each voxel of the brain represented by
(core) tissue and penumbra can be estimated, the pixels, as well as how quickly the blood passes
which can help determine which patients would through each brain voxel (Khumtong et al. 2020;
benefit from early treatment (Menon et al. 2015b). Ramalho and Fragata 2014). The results demon-
The multiphase CT protocol also improves the strate the perfusion of the brain tissue and, impor-
localization of occlusions for the same reason a tantly for stroke, which tissue may be salvageable
delayed CT does (Byrne et al. 2017). and which may not.
CT perfusion is based on the principle that after Accuracy of the CT perfusion calculations
an injection of iodinated contrast, the CT density relies on:
within a tissue is directly related to the amount of
contrast contained within that tissue. CT perfusion • A compact contrast bolus and high level of
is performed by scanning the brain at regular inter- contrast enhancement in the brain (Konstas
vals after the injection of iodinated contrast. The et al. 2009b).
images are loaded into postprocessing software, • Adequate sampling (scanning) rate to gener-
which measures the CT density in Hounsfield ate precise time-density curves.
units (HU) of each pixel in every image within the • Measurements across the entire first pass con-
scan volume for each scan acquisition and plots trast bolus transit time through the brain tissue
a b
Fig. 3 5 mm (a) and 2 mm (b) thick images of the non- contrast difference between the MCA and the surrounding
contrast CT brain from Patient X. There is a hyperdense brain on the thinner slice (b)
MCA sign on the patient’s left (arrows). There is greater
(i.e. from just before the contrast first reaches

the brain tissue through the arteries, to just
after it passes out of the brain tissue via the
veins).
A typical CT perfusion protocol consists of

rapid injection (e.g. 6–8 ml/s) of 40–50 ml of
high-concentration iodinated contrast (e.g. 350 or
370 mg I/ml) followed by a 20–40 ml ‘saline
chaser’ via power injector through a wide bore
(e.g. 18 gauge) venepuncture catheter in a large
vein (e.g. antecubital vein) (Konstas et al. 2009b;
Khumtong et al. 2020). The perfusion scan series
is initiated 3–5 s after the start of the contrast
injection, and scans are acquired every 1–3 s for
60–90 s. To reduce radiation dose while provid-
ing for accurate time-density curves, scans may
Fig. 4 Coronal maximum intensity projection (MIP) be acquired at short intervals during the arterial
from the head and neck Patient X demonstrating absent
left middle cerebral artery enhancement (arrow) and col-
phase but at longer intervals during the venous
lateral supply to the ischemic area of the brain (arrow outflow stage. Although the contrast bolus transit
heads) time may be relatively short (e.g. 35 s) in many
84 K. Dobeli
a b c
Fig. 5 Thick slab MIPs from the head and neck CTA (a), middle cerebral artery territory (box); however, there
8 s delayed scan (b) and 16 s delayed scan (c) of Patient appears to be a small region that does not show arterial
X. There is collateral supply to the majority of the left enhancement across all three scans (arrow head)
patients, extended scanning is often required To reduce radiation dose to the lens of the eyes,
because some patients with stroke may have and to include as much of the critical brain regions
delayed flow due to arterial occlusion or poor within the scan range, the patient’s head can be
cardiac output (Konstas et al. 2009b). tilted with the chin down to position the glabello-
The brain perfusion scan can be performed meatal line (GML) as parallel to the gantry as pos-
after the CT angiogram or prior to it. If performed sible (Fig. 6). Immobilization of the patient’s head
after, a delay of 3–5 min is required to allow the is very important for CT perfusion postprocessing,
contrast from the angiogram to reach equilibrium as motion within or between scan acquisitions can
within the brain. reduce the accuracy of the results or even make it
The volume of brain coverage for CT perfu- impossible to obtain the perfusion information,
sion is highly variable across different scanner and patients who have suffered a stroke are often
makes and models. Some CT units provide full confused and disorientated (de Lucas et al. 2008).
brain coverage through wide detector coverage, Perfusion scans are acquired at low tube volt-
fast helical shuttle (continuous helical scanning age (e.g. 80 kVp) and low tube current; radiation
as the table moves quickly in and out), or jog doses from CT perfusion are in the order of 3.5–5
mode (non-helical scanning with fast movement millisieverts (mSv) (Konstas et al. 2009b; Lev
between two table locations). Others are only et al. 2001; Menon et al. 2015b; Wintermark and
able to provide limited coverage; however, if Lev 2010). Data are reconstructed in thick slices
extended coverage is required, two separate con- (e.g. 5–10 mm) to provide adequate contrast-to-
tiguous perfusion scans can be performed with a noise and signal-to-noise ratios.
delay of 3–5 min in between. The most important After reconstruction, the CT perfusion images
anatomical areas to be included within the perfu- are loaded into dedicated post-processing soft-
sion scan range are the basal ganglia, internal ware. Typically, initial processing involves sub-
capsule, and more distal territories supplied by traction of the skull, and corrections for any
the middle cerebral artery as these are the most motion (Konstas et al. 2009b). Perfusion calcula-
common sites for stroke (Hui et al. 2020). tions require identification of an artery (e.g.
a b
Fig. 6 Head positioning for CT perfusion. (a) Ideally, the scan plane. If the patient’s head is tilted backwards (b),
head should be tilted forward to position the base of skull some of the territory of the anterior cerebral artery will be
as parallel to the gantry plane as possible as this will excluded
increase the amount of brain at risk that lies within the
a nterior cerebral) and a vein (e.g. superior sagit- low. In potentially salvageable tissue, the brain
tal sinus), for which time-density curves are cre- tissue will be receiving sufficient blood volume
ated (Fig. 7). The time-density curves are from the collateral arteries (normal, or even ele-
analysed using mathematical techniques to gen- vated CBV), but the delivery of blood will be
erate parameters that describe perfusion. slower (reduced CBF). In both infarcted tissue
Commonly used perfusion parameters to assess and salvageable tissue, the MTT will be longer
ischemic stroke are (Carroll et al. 2008; Konstas compared to normal brain tissue.
et al. 2009a; Ramalho and Fragata 2014): Two other perfusion parameters frequently
used are time to peak (TTP) and Tmax. TTP is the
• Cerebral blood volume (CBV): This is the time from the first scan to when enhancement in
total volume of blood in a given volume of the the arterial input reaches maximum HU (Ramalho
brain. and Fragata 2014; Wouters et al. 2017). Tmax is
• Cerebral blood flow (CBF): This is the volume the time between the contrast reaching the arterial
of blood flowing through a given volume of input to when it reaches the brain tissue. Longer
the brain tissue per unit of time. TTP or Tmax indicates delayed flow, for example
• Mean transit time (MTT): This is the average due to thrombus. Tmax is more complex to calcu-
time in seconds it takes for blood to move late but it is better at accounting for delayed flow
through a given volume of brain tissue. due to other factors, such as poor cardiac output
MTT = CBV/CBF. (Calamante et al. 2010; Wouters et al. 2017).
Colour maps are assigned to the perfusion
In infarcted (non-salvageable) tissue, there is parameters to provide visual display of areas of
little, if any, perfusion of the injured brain tissue abnormal perfusion. Infarct core and penumbra
from collateral vessels. Thus, the blood flow can also be highlighted, based on user-selectable
(CVF) and blood volume (CBV) will both be values (Fig. 8).
86 K. Dobeli
a b
c
550
500
450
400 Venous input
350
HU
300
250 Arterial input
200
150
100
50
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50
Times(s)
Fig. 7 Arterial and venous inputs for CT perfusion calcu- often used for the venous input (b). Time-density curves
lations for Patient X. The anterior or middle cerebral are created for these inputs (c). The venous curve should
artery on the unaffected side is typically used for the arte- have a higher, but later peak than the arterial curve
rial input (a), while the posterior superior sagittal sinus is
a b
c d
Fig. 8 Perfusion maps for Patient X. There is decreased most CT perfusion post-processing software, which
cerebral blood flow (a) and increased mean transit time allows the creation of core/penumbra summary maps. The
(b) in the region of the middle cerebral artery (MCA) on summary map for Patient X (d) suggests a large infarct
the patient’s left. The cerebral volume map (c) suggests core even though the CBV map does not seem to demon-
increased blood volume in the distal MCA territory, which strate reduced CBV in this region. Patients with a large
is a normal phenomenon believed to be caused by dilata- infarct core are at higher risk of haemorrhagic stroke
tion of veins in the hypo-perfused region (Konstas et al. transformation (Bivard et al. 2015)
2009b). Thresholds for perfusion parameters can be set in
88 K. Dobeli
References bectomy in acute ischemic stroke. Neuroradiology.

2020;62(3):399–406. https://doi.org/10.1007/
s00234-019-02351-5.
Barrett KM, Meschia JF. Stroke. 2nd ed. Chichester:
Konstas A, Goldmakher G, Lee T-Y, Lev M. Theoretic
Wiley; 2013.
basis and technical implementations of CT perfu-
Bivard A, Levi C, Krishnamurthy V, McElduff P, Miteff
sion in acute ischemic stroke, part 1: theoretic basis.
F, Spratt NJ, Bateman G, Donnan G, Davis S, Parsons
Am J Neuroradiol. 2009a;30(4):662–8. https://doi.
M. Perfusion computed tomography to assist deci-
org/10.3174/ajnr.A1487.
sion making for stroke thrombolysis. Brain J Neurol.
Konstas A, Goldmakher G, Lee T-Y, Lev M. Theoretic
2015;138(Pt 7):1919–31. https://doi.org/10.1093/
basis and technical implementations of CT perfusion
brain/awv071
in acute ischemic stroke, part 2: technical implementa-
Byrne D, Sugrue G, Stanley E, Walsh JP, Murphy S,
tions. Am J Neuroradiol. 2009b;30(5):885–92. https://
Kavanagh EC, MacMahon PJ. Improved detec-
doi.org/10.3174/ajnr.A1492.
tion of anterior circulation occlusions: the “delayed
Lee K-Y, Han SW, Kim SH, Nam HS, Ahn SW, Kim
vessel sign” on multiphase CT angiography. Am
DJ, Seo SH, Kim DI, Heo JH. Early recanaliza-
J Neuroradiol. 2017;38(10):1911–6. https://doi.
tion after intravenous administration of recombinant
org/10.3174/ajnr.A5317.
tissue plasminogen activator as assessed by pre-and
Calamante F, Christensen S, Desmojd PM, Østergaard L,
post-thrombolytic angiography in acute ischemic
Davis SM, Connelly A. The physiological significance
stroke patients. Stroke. 2007;38(1):192–3. https://doi.
of the time-to-maximum (Tmax) parameter in perfu-
org/10.1161/01.STR.0000251788.03914.00.
sion MRI. Stroke. 2010;41(6):1169–74. https://doi.
Lev MH, Farkas J, Gonzalez RG, Rodriguez VR,
org/10.1161/STROKEAHA.110.580670.
Schwamm LH, Huner GJ, Putman CM, Rordorf GA,
Carroll TJ, Horowitz S, Shin W, Mouannes J, Sawlani
Buonanno FS, Budzik R, Koroshetz WJ. CT angi-
R, Ali S, Raizer J, Futterer S. Quantification of cere-
ography in the rapid triage of patients with hyper-
bral perfusion using the “bookend technique”: an
acute stroke to intraarterial thrombolysis: accuracy
evaluation in CNS tumors. Magn Reson Imaging.
in the detection of large vessel thrombus. J Comput
2008;26(10):1352–9. https://doi.org/10.1016/j.
Assist Tomogr. 2001;25(4):520–8. https://doi.
mri.2008.04.010.
org/10.1097/00004728-200107000-00003.
Chung HJ, Lee BH, Hwang YJ, Kim SY, Lee JY, Kim
Mair G, Boyd EV, Chappell FM, von Kummer R,
YS, Hong K-S, Cho Y-J, Park J-H. Delayed-phase
Lindley RI, Sandercock P, Wardlaw JM. Sensitivity
CT angiography is superior to arterial-phase CT angi-
and specificity of the hyperdense artery sign for
ography at localizing occlusion sites in acute stroke
arterial obstruction in acute ischemic stroke.
patients eligible for intra-arterial reperfusion therapy.
Stroke. 2015;46(1):102–7. https://doi.org/10.1161/
J Clin Neurosci. 2013;21(4):596–600. https://doi.
STROKEAHA.114.007036.
org/10.1016/j.jocn.2013.06.021.
Menon BK, O’Brien B, Bivard A, Spratt NJ, Demchuk
de Lucas EM, Sánchez E, Gutiérrez A, Mandly AG, Ruiz
AM, Miteff F, Lu X, Levi C, Parsons MW. Assessment
E, Flórez AF, Izquierdo J, Arnáiz J, Piedra T, Valle N,
of leptomeningeal collaterals using dynamic CT angi-
Bañales I, Quintana F. CT protocol for acute stroke:
ography in patients with acute ischemic stroke. J
tips and tricks for general radiologists. Radiographics.
Cereb Blood Flow Metab. 2013;33(3):365–71. https://
2008;28(6):1673–87. https://doi.org/10.1148/
doi.org/10.1038/jcbfm.2012.171.
rg.286085502.
Menon BK, Campbell BC, Levi C, Goyal M. Role of
Goyal M, Menon BK, van Zwam WH, Dippel DWJ,
imaging in current acute ischemic stroke workflow for
Mitchell PJ, Demchuk AM, Dávalos A, Majoie
endovascular therapy. Stroke. 2015a;46(6):1453–61.
CBLM, van der Lugt A, de Miquel MA, Donnan GA,
https://doi.org/10.1161/STROKEAHA.115.009160.
Roos YBWEM, Bonafe A, Jahan R, Diener H-C, van
Menon BK, d’Esterre CD, Qazi EM, Almekhlafi M, Hahn
den Berg LA, Levy EI, Berkhemer OA, Pereira VM,
L, Demchuk AM, Goyal M. Multiphase CT angiogra-
Rempel J, Millán M, Davis SM, Roy D, Thornton J,
phy: a new tool for the imaging triage of patients with
Román LS, Ribó M, Beumer D, Stouch B, Brown S,
acute ischemic stroke. Radiology. 2015b;275(2):510–
Campbell BCV, van Oostenbrugge RJ, Saver JL, Hill
20. https://doi.org/10.1148/radiol.15142256.
MD, Jovin TG. Endovascular thrombectomy after
Ramalho, JN, Fragata, IR, 2014, Computed tomography
large-vessel ischaemic stroke: a meta-analysis of indi-
(CT) perfusion: basic principles and clinical applica-
vidual patient data from five randomised trials. Lancet
tions. In: Ramalho, JN, Castillo, M, Semelka, RC, edi-
(British Edition). 2016;387(10029):1723–31. https://
tors. Vascular imaging of the central nervous system:
doi.org/10.1016/S0140-6736(16)00163-X.
physical principles, clinical applications and emerging
Hui, C, Tadi, P, Patti, L, 2020, Ischemic stroke. In:
techniques, Wiley-Blackwell, Hoboken.
StatPearls [internet], Treasure Island (FL): StatPearls
Rudd AG, Bowen A, Young G, James MA. National clini-
Publishing. https://www.ncbi.nlm.nih.gov/books/
cal guideline for stroke. Fifth edition 2016. Clin Med.
NBK499997/. Accessed 7 Nov 2020.
2017.
Khumtong R, Krings T, Pereira VM, Pikula A, Schaafsma
Shetty SK, Lev MH. CT perfusion in acute stroke. Semin
JD. Comparison of multimodal CT scan protocols
Ultrasound CT MRI. 2005;26(6):404–21. https://doi.
used for decision-making on mechanical throm-
org/10.1053/j.sult.2005.09.001.
Stroke Association. State of the nation. Stroke statistics; peak and Tmax for mismatch-based patient selection.
2018. https://www.stroke.org.uk/sites/default/files/ Front Neurol. 2017;8:539. https://doi.org/10.3389/
state_of_the_nation_2018.pdf. Accessed 23 Jan 2021. fneur.2017.00539.
Świat M, Targosz-Gajniak M, Arkuszewski M, Pięta Yaghi S, Willey JZ, Cucchiara B, Goldstein JN, Gonzales
M, Gamrot J, Wojtacha M, Bażowski P, Opala. NR, Khatri P, Kim LJ, Mayer SA, Sheth KN, Schwamm
Decompressive hemicraniectomy in ischaemic stroke. LH. Treatment and outcome of hemorrhagic transfor-
Neurol Neurochir Pol. 2010;44(2):131–8. https://doi. mation after intravenous alteplase in acute ischemic
org/10.1016/S0028-3843(14)60004-9. stroke: a scientific statement for healthcare profession-
Wintermark M, Lev MH. FDA investigates the safety of als from the American Heart Association/American
brain perfusion CT. Am J Neuroradiol. 2010;31(1):2– Stroke Association. Stroke. 2017;48(12):e343–61.
3. https://doi.org/10.3174/ajnr.A1967. https://doi.org/10.1161/STR.0000000000000152.
Wouters A, Christensen S, Straka M, Mlynash M,
Liggins J, Bammer R, Thijs V, Lemmens R, Albers
GW, Lansberg MG. A comparison of relative time to
Responses to Trauma and Stroke
Karen Dobeli
Abstract 1 Introduction
In major trauma, replacement of blood and body Although patients with significant blood loss
fluids is vital to patient survival. However, attain- have usually been stabilised with fluid resuscita-
ing venous access in a patient who has suffered tion before coming to the CT department, their
significant blood loss can be difficult. Intraosseous haemodynamics may still be abnormal (Leidel
(IO) access is an alternative method for obtaining et al. 2010; Winkler et al. 2017; Elwan et al.
vascular access in such patients. In this method, a 2017). Using a standard CTA injection protocol
large gauge needle is inserted into the bone mar- can result in poor contrast opacification because
row space, usually of a long bone such as the patients may have excess fluid, which dilutes the
tibia, femur or humerus. The medullary cavity contrast, and/or reduced cardiac output, which
has a rich network of blood vessels, which can affects contrast transit times (Fig. 1). A dedicated
quickly deliver injected fluids to the central vas- major trauma injection protocol which uses a
cular system. IO contrast media injections can be larger volume of (high-strength) contrast and a
made using a power injector with injection rates higher injection rate can reduce the risk of
up to 4 ml/s. Confirming the position of the ‘washed out’ contrast. Determination of the
intraosseous device before administering IV con- appropriate scan start time can be made through a
trast is recommended, as is a small test injection test injection or bolus tracking; bolus tracking is
of saline to check the injection pressure, because quicker to perform than a test injection so is pref-
these devices are often inserted by first respond- erable for trauma imaging.
ers in the field and there is a risk of dislodgement Radiation dose for a full body polytrauma CT
as the patient is moved between the field, ambu- is relatively high, being in the order of 20–30 mSv
lance, emergency department and CT scanner. (Gordic et al. 2015), which falls into the dose
range reported to increase the risk of certain can-
Keywords cers (Australian Radiation Protection Nuclear
Safety Agency n.d.). However, the principle of
Trauma imaging · IV contrast · Alternate ‘risk versus benefit’ must be applied, and consid-
positioning · Alternate technique ering the high potential for multiple serious inju-
ries, the radiation dose will be justified for
K. Dobeli (*) patients who have individual risks for polytrauma
Royal Brisbane and Women’s Hospital, Herston, (such as advanced age) and/or have experienced a
QLD, Australia high-risk mechanism of injury. Furthermore, the
92 K. Dobeli
use of CT as the primary imaging modality may when the scan is performed at the standard portal
improve survival rates for polytrauma patients venous delay (Eichler et al. 2015). These tech-
due to its ability to rapidly screen for a wide spec- niques reduce radiation dose by eliminating the
trum of injuries from the head to the toes (Huber- overlap from the diaphragm to the iliac crests/
Wagner et al. 2009). On the other hand, careful symphysis pubis between the arterial and portal
consideration of the benefit of a full polytrauma venous phase scans. However, there is some con-
CT should be made for young patients with lower cern regarding the ability of a single pass trauma
risk injury mechanism and without strong clini- protocol to detect vascular injuries due to reduced
cal suspicion of serious injury. intraluminal contrast density (Iacobellis et al.
Lower dose protocols that combine arterial 2020).
and portal venous enhancement phases for trauma Attention to patient position and preparation of
imaging of the chest and abdomen have been the scan region can also reduce radiation dose.
developed and reported in the literature. The spe- Most MDCT scanners feature automatic exposure,
cifics of the contrast injection protocol and scan which adjusts the standard protocol dose based on
delay vary between institutions but overall there patient density measurement from the scout scans.
are two main methods: split bolus and long injec- The patient’s arms should be lifted above their
tion time. The split bolus technique essentially head whenever possible when imaging the torso
combines a portal venous abdomen injection because this will reduce radiation dose and avoid
with an arterial injection. The portal venous con- streak artefact, which may otherwise obscure solid
trast volume makes up the first phase of the injec- organ haemorrhage (Iacobellis et al. 2020) (Fig. 1).
tion; a pause follows so that the second (arterial) If the patient’s arms cannot be abducted, improved
phase of the injection commences about 40 s image quality can be obtained by lifting and sup-
after the injection is first started. The scan is per- porting the patient’s elbows so they are no longer
formed at approximately 60 s (Beenen et al. in the same horizontal plane as the spine (Fig. 2).
2015). In the long injection time method, contrast High-density objects such as metal clamps, oxy-
is injected at a low infusion rate (e.g. 2 ml/s) so gen cylinders and ECG control boxes should also
that contrast is still present in the arterial system be positioned outside the scan field.
a b
Fig. 1 Poor contrast enhancement in a 23-year-old male extra abdominal fat, which are indicators of high fluid
who was involved in a motorcycle accident in a regional load. These images also demonstrate horizontal streak
area. (a) CT Chest. (b) CT Abdomen/Pelvis. He was sta- artefact, which is caused by the patient’s arms lying by
bilised at a local hospital before being airlifted to the clos- their side. There is increased X-ray absorption when the
est tertiary level hospital. The patient had suffered X-ray tube is in the 3 o’clock and 9 o’clock positions
significant blood loss and was given aggressive fluid because the long bones of the arms lie in the same plane as
resuscitation. Note the loss of definition in the abdominal the spine
musculature and apparent increase in CT density of the
Responses to Trauma and Stroke 93
a b
Fig. 2 Alternate positioning of the arms if they are unable above the level of the spine (a) can reduce streak artefact
to be raised above the patient’s head. Lifting the elbows through the kidneys, spleen and liver (b)
off the table with the use of pads and straps to raise them
Patients with stroke or head injury may be CT of the brain and can be used in combina-
confused and agitated. However, delaying the tion with the ‘no scout view’ method explained
examination or sedation of the patient may not be above. A dedicated ‘fast’ head protocol could
desirable. In these circumstances, the following be set up on the scanner for quick access if the
techniques could be considered in conjunction situation arises.
with the use of the scanner’s immobilisation • Scanning the patient however they are com-
devices such as straps and cushions: fortable. Patients, particularly elderly ones,
may be uncomfortable lying supine on the CT
• Elimination of the scout scans to reduce over- couch. Alert patients can verbalise this and
all scan time. This technique voids the use of request to change position, but patients with
dose modulation and can lead to under- reduced consciousness may not be able to.
scanning, which risks missing important find- Instead, they attempt to reposition themselves
ings and/or negating the time saving by having to a more comfortable position, and because
to repeat the scan, or over-scanning, which they are also not able to understand com-
increases patient radiation dose. Consequently, mands, they often move while the scan is in
this technique should only be considered for progress despite the radiographer asking them
CT of the head because the required scan to keep still. Placing a pillow under the
extent is easily determined from external ana- patient’s knees, and/or soft padding under the
tomical landmarks and CT of the brain is less buttocks or shoulders, can be all that is
dependent on dose modulation to balance required to achieve patient compliance, par-
radiation dose with image quality. ticularly for emaciated patients. Placing very
• Modification of the CT technique to reduce restless patients on their side is often effective
the scan time. Significantly reducing the scan as this is comfortable for patients with back
time can be achieved by increasing the pitch pain and it is easier for many patients to breath
and/or using the shortest rotation time and/or on their side compared to on their back. This
the highest kVp. This will usually result in a technique requires attention to how the
low-quality scan through reduction of projec- patient’s position is entered into the scanner
tion data and/or exposure; however, image when registering the patient as the scanner
quality can be sufficient to rule out major software will assign left, right, anterior and
pathology. This technique is also best suited to posterior based on this information.
94 K. Dobeli
References care nursing: science and practice, 3rd ed. Oxford:

Oxford University Press, 2017.
Avey G, Blackmore CC, Wessells H, Wright JL, Talner
Australian Radiation Protection Nuclear Safety Agency.
LB. Radiographic and clinical predictors of bladder
Ionising radiation and health. n.d.. https://www.
rupture in blunt trauma patients with pelvic frac-
arpansa.gov.au/understanding-r adiation/radiation-
ture. Acad Radiol. 2006;13(5):573–9. https://doi.
sources/more-radiation-sources/ionising-radiation-
org/10.1016/j.acra.2005.10.012.
and-health. Accessed 7 Nov 2020.
Baadh AS, Singh A, Choi A, Baadh PK, Katz DS, Harcke
Beenen LFM, Sierink JC, Kolkman S, Nio CY, Saltzherr
HT. Intraosseous vascular access in radiology: review
TP, Dijkgraaf MGW, Goslings JC. Split bolus technique
of clinical status. Am J Roentgenol. 2016;207(2):241–
in polytrauma: a prospective study on scan protocols
7. https://doi.org/10.2214/AJR.15.15784.
for trauma analysis. Acta Radiol. 2015;56(7):873–80.
Barrett KM, Meschia JF. Stroke. 2nd ed. Chicester: Wiley;
https://doi.org/10.1177/0284185114539319.
2013.
Eichler K, Marzi I, Wyen H, Zangos S, Mack MG, Vogl
Bivard A, Levi C, Krishnamurthy V, McElduff P, Miteff
TJ. Multidetector computed tomography (MDCT):
F, Spratt NJ, Bateman G, Donnan G, Davis S, Parsons
simple CT protocol for trauma patient. Clin Imaging.
M. Perfusion computed tomography to assist deci-
2015;39(1):110–5. https://doi.org/10.1016/j.
sion making for stroke thrombolysis. Brain J Neurol.
clinimag.2014.09.011.
2015;138(Pt 7):1919–31. https://doi.org/10.1093/
Elwan MH, Roshdy A, Elsharkawy EM, Eltahan SM,
brain/awv071
Coats TJ. The haemodynamic dilemma in emer-
Blackmore CC, Emerson SS, Mann FA, Koepsell
gency care: is fluid responsiveness the answer? a
TD. Cervical spine imaging in patients with
systematic review. Scandinavian J Trauma Resusc
trauma: determination of fracture risk to optimize
Emerg Med. 2017;25(1):25. https://doi.org/10.1186/
use. Radiology. 1999a;211(3):759–65. https://doi.
s13049-017-0370-4.
org/10.1148/radiology.211.3.r99jn22759.
Gordic S, Alkadhi H, Hodel S, Simmen H-P, Brueesch
Blackmore CC, Ramsey SD, Mann FA, Deyo
M, Frauenfelder T, Wanner G, Sprengel K. Whole-
RA. Cervical spine screening with CT in trauma
body CT-based imaging algorithm for multiple
patients : a cost-effectiveness analysis. Radiology.
trauma patients: radiation dose and time to diagnosis.
1999b;212(1):117–25. https://doi.org/10.1148/radiolo
Br J Radiol. 2015;88(1047):20140616. https://doi.
gy.212.1.r99jl08117.
org/10.1259/bjr.20140616.
Bloom, BA, Gibbons, RC, 2020, Focused assessment
Huber-Wagner S, Lefering R, Qvick L-M, Körner M,
with sonography for trauma. In: StatPearls [inter-
Kay MV, Pfeifer K-J, Reiser M, Mutschler W, Kanz
net]. Treasure Island (FL): StatPearls Publishing.
K-G. Effect of whole-body CT during trauma resus-
https://www.ncbi.nlm.nih.gov/books/NBK470479/.
citation on survival: a retrospective, multicentre study.
Accessed 7 Feb 2021.
Lancet (British Edition). 2009;373(9673):1455–61.
Byrne D, Sugrue G, Stanley E, Walsh JP, Murphy S,
https://doi.org/10.1016/S0140-6736(09)60232-4.
Kavanagh EC, MacMahon PJ. Improved detec-
Iacobellis F, Romano L, Rengo A, Danzi R, Scuderi MG,
tion of anterior circulation occlusions: the “delayed
Brillantino A, Scaglione M. CT protocol optimization
vessel sign” on multiphase CT angiography. Am
in trauma imaging: a review of current evidence. Curr
J Neuroradiol. 2017;38(10):1911–6. https://doi.
Radiol Rep (Philadelphia, PA). 2020;8(6) https://doi.
org/10.3174/ajnr.A5317.
org/10.1007/s40134-020-00351-5.
Calamante F, Christensen S, Desmojd PM, Østergaard L,
Leidel BA, Kirchhoff C, Braunstein V, Bogner V,
Davis SM, Connelly A. The physiological significance
Biberthaler P, Kanz K-G. Comparison of two intraos-
of the time-to-maximum (Tmax) parameter in perfu-
seous access devices in adult patients under resusci-
sion MRI. Stroke. 2010;41(6):1169–74. https://doi.
tation in the emergency department: a prospective,
org/10.1161/STROKEAHA.110.580670.
randomized study. Resuscitation. 2010;81(8):994–9.
Carroll TJ, Horowitz S, Shin W, Mouannes J, Sawlani
https://doi.org/10.1016/j.resuscitation.2010.03.038.
R, Ali S, Raizer J, Futterer S. Quantification of cere-
Winkler M, Talley C, Woodward C, Kingsbury A, Appiah
bral perfusion using the “bookend technique”: an
F, Elbelasi H, Landwher K, Li X, Fleischmann
evaluation in CNS tumors. Magn Reson Imaging.
D. The use of intraosseous needles for injection of
2008;26(10):1352–9. https://doi.org/10.1016/j.
contrast media for computed tomographic angiog-
mri.2008.04.010.
raphy of the thoracic aorta. J Cardiovasc Comput
Chand, R, 2019, ‘Chest trauma’, in Eltorai, AEM,
Tomogr. 2017;11(3):203–7. https://doi.org/10.1016/j.
Hyman, CH, & Healey, TT, Essential radiology
jcct.2017.03.001.
review a question and answer guide, 1st ed., Springer
International Publishing, Champions. https://doi.
org/10.1007/978-3-030-26044-6.
Chung HJ, Lee BH, Hwang YJ, Kim SY, Lee JY, Kim
Bibliography YS, Hong K-S, Cho Y-J, Park J-H. Delayed-phase
CT angiography is superior to arterial-phase CT angi-
Adam, S, Osboorne, W, Welch, J. Neurological problems. ography at localizing occlusion sites in acute stroke
In: Adam, S, Osborne, W, Welch, J, editors. Critical patients eligible for intra-arterial reperfusion therapy.
J Clin Neurosci. 2013;21(4):596–600. https://doi. Fusco MR, Harrigan MR. Cerebrovascular dissec-
org/10.1016/j.jocn.2013.06.021. tions: a review. part II: blunt cerebrovascular injury.
Coleman, JJ. Blunt abdominal trauma. In Saclarides, TJ, Neurosurgery. 2011;68(2):517–30. https://doi.
Myers, JA, Millikan, KW, editors. Common surgical org/10.1227/NEU.0b013e3181fe2fda.
diseases: an algorithmic approach to problem solving, Geyer LL, Linsenmaier U. MDCT of chest trauma. In:
New York, NY: Springer, 2015. Multidetector-row CT of the thorax, 2016. Springer
Como JJ, Diaz JJ, Dunham CM, Chiu WC, Duane TM, International Publishing, Cham, pp. 525–544. doi:
Capella JM, Holevar MR, Khwaja KA, Mayglothling https://doi.org/10.1007/978-3-319-30355-0_25.
JA, Shapiro MB, Winston ES. Practice management Goyal M, Menon BK, van Zwam WH, Dippel DWJ,
guidelines for identification of cervical spine injuries Mitchell PJ, Demchuk AM, Dávalos A, Majoie
following trauma: update from the eastern Association CBLM, van der Lugt A, de Miquel MA, Donnan GA,
for the Surgery of trauma practice management guide- Roos YBWEM, Bonafe A, Jahan R, Diener H-C, van
lines committee. J Trauma. 2009;67(3):651–9. https:// den Berg LA, Levy EI, Berkhemer OA, Pereira VM,
doi.org/10.1097/TA.0b013e3181ae583b. Rempel J, Millán M, Davis SM, Roy D, Thornton J,
Daffner RH. Helical CT of the cervical spine for Román LS, Ribó M, Beumer D, Stouch B, Brown S,
trauma patients: a time study. Am J Roentgenol. Campbell BCV, van Oostenbrugge RJ, Saver JL, Hill
2001;177(3):677–9. https://doi.org/10.2214/ MD, Jovin TG. Endovascular thrombectomy after
ajr.177.3.1770677. large-vessel ischaemic stroke: a meta-analysis of indi-
de Lucas EM, Sánchez E, Gutiérrez A, Mandly AG, Ruiz vidual patient data from five randomised trials. Lancet
E, Flórez AF, Izquierdo J, Arnáiz J, Piedra T, Valle N, (British Edition). 2016;387(10029):1723–31. https://
Bañales I, Quintana F. CT protocol for acute stroke: doi.org/10.1016/S0140-6736(16)00163-X.
tips and tricks for general radiologists. Radiographics. Grossbach AJ, Dahdaleh NS, Abel TJ, Woods GD,
2008;28(6):1673–87. https://doi.org/10.1148/ Dlouhy BJ, Hitchon PW. Flexion-distraction injuries
rg.286085502. of the thoracolumbar spine: open fusion versus per-
de Vries R, Reininga IHF, Pieske O, Lefering R, El cutaneous pedicle screw fixation. Neurosurg Focus.
Moumni M, Wendt K. Injury mechanisms, pat- 2013;35(2):E2. https://doi.org/10.3171/2013.6.FO
terns and outcomes of older polytrauma patients: an CUS13176.
analysis of the Dutch trauma registry. PLoS One. Hanson JA, Blackmore CC, Mann FA, Wilson
2018;13(1):e0190587. https://doi.org/10.1371/jour- AJ. Cervical spine injury: a clinical decision rule to
nal.pone.0190587. identify high-risk patients for helical CT screening.
Demetriades D, Karaiskakis M, Toutouzas K, Alo K, Am J Roentgenol. 2000;174(3):713–7. https://doi.
Velmahos G, Chan L. Pelvic fractures: epidemiology org/10.2214/ajr.174.3.1740713.
and predictors of associated abdominal injuries and Hayes CW, Conway WF, Walsh JW, Coppage L, Gervin
outcomes. J Am Coll Surg. 2002;195(1):1–10. https:// AS. Seat belt injuries: radiologic findings and clinical
doi.org/10.1016/S1072-7515(02)01197-3. correlation. Radiographics. 1991;11(1):23–36. https://
Dreizin D, Munera F. Blunt polytrauma: evalua- doi.org/10.1148/radiographics.11.1.1996397.
tion with 64-section whole-body CT angiography. Hertz AM, Hertz NM, Johnsen NV. Identifying bladder
Radiographics. 2012;32(3):609–31. https://doi. rupture following traumatic pelvic fracture: a machine
org/10.1148/rg.323115099. learning approach. Injury. 2020;51(2):334–9. https://
Eid HO, Abu-Aidan FM. Biomechanics of road traffic doi.org/10.1016/j.injury.2019.12.009.
collision injuries: a clinician’s perspective. Singapore Hildreth AM, Martin RS, Meredith JW. Introduction to
J Med. 2007;48(7):693–700. trauma care. In: Peitzman AB, Schwab CW, Yealy
Eisenberg, RL, 2019, Aorta. In: Eisenberg RL, editor. What DM, editors. The trauma manual: trauma and acute
radiology residents need to know: chest radiology, care surgery. 4th ed. Philadelphia: Wolters Kluwer
pp. 247–255, Springer International Publishing, Cham. Health; 2012. p. 1–9.
https://doi.org/10.1007/978-3-030-16826-1_18. Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective
Fadl SA, Sandstrom CK. Pattern recognition: a cervical spine radiography in blunt trauma: meth-
mechanism- based approach to injury detection odology of the National Emergency X-radiography
after motor vehicle collisions. Radiographics. utilization study (NEXUS). Ann Emerg Med.
2019;39(3):857–76. https://doi.org/10.1148/ 1998;32(4):461–9. https://doi.org/10.1016/
rg.2019180063. S0196-0644(98)70176-3.
Fassett DR, Dailey AT, Vaccaro AR. Vertebral artery inju- Hui, C, Tadi, P, Patti, L. Ischemic stroke. In: StatPearls
ries associated with cervical spine injuries: a review of [internet], Treasure Island (FL): StatPearls Publishing.
the literature. J Spinal Disord Tech. 2008;21(4):252–8. 2020. https://www.ncbi.nlm.nih.gov/books/
https://doi.org/10.1097/BSD.0b013e3180cab162. NBK499997/. Accessed 7 Nov 2020.
Friesen B, Brownlee R. The role of CT and MRI in Institute of Neurological Sciences, Glasgow. The Glasgow
suspected acute cervical spine trauma. Hong Kong structured approach to assessment of the Glasgow
J Emerg Med. 2014;21(6):368–72. https://doi. Coma Scale; n.d.. https://www.glasgowcomascale.
org/10.1177/102490791402100605. org/what-is-gcs/. Accessed 7 Nov 2020.
96 K. Dobeli
Jabbour P, Fehlings M, Vaccaro AR, Harrop JS. Traumatic and specificity of the hyperdense artery sign for
spine injuries in the geriatric population. Neurosurg arterial obstruction in acute ischemic stroke.
Focus. 2008;25(5):E16. https://doi.org/10.3171/ Stroke. 2015;46(1):102–7. https://doi.org/10.1161/
FOC.2008.25.11.E16. STROKEAHA.114.007036.
Joshi G, Kim EY, Hanna TN, Siegel CL, Menias CO. CT Mathen R, Inaba K, Munera F, Teixeira PGR, Rivas L,
cystography for suspicion of traumatic urinary bladder McKenney M, Lopez P, Ledezma CJ. Prospective
injury: indications, technique, findings, and pitfalls in evaluation of multislice computed tomography versus
diagnosis: RadioGraphics fundamentals | online pre- plain radiographic cervical spine clearance in trauma
sentation. Radiographics. 2018;38(1):92–3. https:// patients. J Trauma. 2007;62(6):1427–31. https://doi.
doi.org/10.1148/rg.2018170125. org/10.1097/01.ta.0000239813.78603.15.
Kaewlai R, Avery LL, Asrani AV, Novelline Mathews WA, Arguelles CS. The cervical spine. In:
RA. Multidetector CT of blunt thoracic trauma. Daniels JM, editor. Common musculoskeletal prob-
Radiographics. 2008;28(6):1555–70. https://doi. lems : a handbook. 2nd ed. Cham: Springer; 2015.
org/10.1148/rg.286085510. Mayberry JC. Imaging in thoracic trauma: the
Khumtong R, Krings T, Pereira VM, Pikula A, Schaafsma trauma Surgeon’s perspective. J Thorac
JD. Comparison of multimodal CT scan protocols used Imaging. 2000;15(2):76–86. https://doi.
for decision-making on mechanical thrombectomy in org/10.1097/00005382-200004000-00002.
acute ischemic stroke. Neuroradiology. 2020;62(3):399– Menon BK, O’Brien B, Bivard A, Spratt NJ, Demchuk
406. https://doi.org/10.1007/s00234-019-02351-5. AM, Miteff F, Lu X, Levi C, Parsons MW. Assessment
Konstas A, Goldmakher G, Lee T-Y, Lev M. Theoretic of leptomeningeal collaterals using dynamic CT angi-
basis and technical implementations of CT perfu- ography in patients with acute ischemic stroke. J
sion in acute ischemic stroke, part 1: theoretic basis. Cereb Blood Flow Metab. 2013;33(3):365–71. https://
Am J Neuroradiol. 2009a;30(4):662–8. https://doi. doi.org/10.1038/jcbfm.2012.171.
org/10.3174/ajnr.A1487. Menon BK, Campbell BC, Levi C, Goyal M. Role
Konstas A, Goldmakher G, Lee T-Y, Lev M. Theoretic of imaging in current acute ischemic stroke
basis and technical implementations of CT perfusion workflow for endovascular therapy. Stroke.
in acute ischemic stroke, part 2: technical implementa- 2015a;46(6):1453–61. https://doi.org/10.1161/
tions. Am J Neuroradiol. 2009b;30(5):885–92. https:// STROKEAHA.115.009160.
doi.org/10.3174/ajnr.A1492. Menon BK, d’Esterre CD, Qazi EM, Almekhlafi M, Hahn
Lateef Wani M, Gani Ahangar A, Ahmad Ganie F, Nabi L, Demchuk AM, Goyal M. Multiphase CT angiogra-
Wani S, Wani N. Vascular injuries: trends in manage- phy: a new tool for the imaging triage of patients with
ment. Trauma Mon. 2012;17(2):266–9. https://doi. acute ischemic stroke. Radiology. 2015b;275(2):510–
org/10.5812/traumamon.6238. 20. https://doi.org/10.1148/radiol.15142256.
Lee K-Y, Han SW, Kim SH, Nam HS, Ahn SW, Kim Mesfin FB, Gupta N, Hays Shapshak A, Tayor R. Diffuse
DJ, Seo SH, Kim DI, Heo JH. Early recanalization axonal injury. In: StatPearls [internet], StatPearls
after intravenous administration of recombinant tis- Publishing, Treasure Island, Florida. 2020. https://
sue plasminogen activator as assessed by pre-and w w w. n c b i . n l m . n i h . g ov / b o o k s / N B K 4 4 8 1 0 2 /.
post-thrombolytic angiography in acute ischemic Accessed 29 Aug 2020.
stroke patients. Stroke. 2007;38(1):192–3. https://doi. Montmany S, Rebasa P, Luna A, Hidalgo JM, Cánovas G,
org/10.1161/01.STR.0000251788.03914.00. Navarro S. Source of bleeding in trauma patients with
Leichtle SW, Poulos NG, Whelan J, Aboutanos M. Field pelvic fracture and Haemodynamic instability. Cirugia
triage of motor vehicle crashes: which factors predict Española (English Ed). 2014;93(7):450–4. https://doi.
high injury severity? Am Surg. 2019;85(7):764–7. org/10.1016/j.cireng.2015.01.005.
https://doi.org/10.1177/000313481908500740. Mulkens T, Marchal P, Daineffe S, Salgado R, Bellinck
Lev MH, Farkas J, Gonzalez RG, Rodriguez VR, P, te Rijdt B, Kegelaers B, Termote J-L. Comparison
Schwamm LH, Huner GJ, Putman CM, Rordorf GA, of low-dose with standard-dose multidetector
Buonanno FS, Budzik R, Koroshetz WJ. CT angi- CT in cervical spine trauma. Am J Neuroradiol.
ography in the rapid triage of patients with hyper- 2007;28(8):1444–50. https://doi.org/10.3174/ajnr.
acute stroke to intraarterial thrombolysis: accuracy A0608.
in the detection of large vessel thrombus. J Comput National Institute for Health and Care Excellence.
Assist Tomogr. 2001;25(4):520–8. https://doi. Clinical Guideline [CG176] Head injury: assess-
org/10.1097/00004728-200107000-00003. ment and early management; 2019. https://
Lomoschitz FM, Blackmore CC, Mirza SK, Mann www.nice.org.uk/guidance/cg176/chapter/1-
FA. Cervical spine injuries in patients 65 years old and Recommendations#assessment-i n-t he-e mergency-
older: epidemiologic analysis regarding the effects of department-2. Accessed 2 Jan 2021.
age and injury mechanism on distribution, type, and sta- National Institute for Health and Care Excellence. Spinal
bility of injuries. Am J Roentgenol. 2002;178(3):573– injury: assessment and initial management; 2021.
7. https://doi.org/10.2214/ajr.178.3.1780573. https://www.nice.org.uk/guidance/ng41/resources/
Mair G, Boyd EV, Chappell FM, von Kummer R, spinal-i njury-a ssessment-a nd-i nitial-m anagement-
Lindley RI, Sandercock P, Wardlaw JM. Sensitivity pdf-1837447790533. Accessed 2 Jan 2021.
Neschis DG, Scalea TM, Flinn WR, Griffith BP. Blunt The American College of Radiology. American College
aortic injury. N Engl J Med. 2008;359(16):1708–16. of Radiology Appropriateness Criteria; 2020.
https://doi.org/10.1056/NEJMra0706159. https://www.acr.org/Clinical-R esources/ACR-
Ramalho JN, Fragata IR. Computed tomography (CT) Appropriateness-Criteria. Accessed 7 Feb 2021.
perfusion: basic principles and clinical applications. Thesleff T, Kataja A, Öhman J, Luoto TM. Head injuries
In: Ramalho JN, Castillo M, Semelka RC, editors. and the risk of concurrent cervical spine fractures.
Vascular imaging of the central nervous system: Acta Neurochir. 2017;159(5):907–14. https://doi.
physical principles, clinical applications and emerging org/10.1007/s00701-017-3133-0.
techniques. Hoboken, New Jersey: Wiley-Blackwell; Trauma Victoria. Major trauma guidelines & education;
2014. 2021. www.trauma.reach.vic.gov.au. Accessed 2 Jan
Raptis C. Chest trauma: nonvascular injuries. In: Rosado 2021.
de Christenson ML, Bhalla S, Abbott GF, Martinez- Urry R, Clarke D, Bruce J, Laing G. The incidence, spec-
Jimenez S, editors. Chest imaging. New York: Oxford trum and outcomes of traumatic bladder injuries within
University Press; 2019. the Pietermaritzburg metropolitan trauma service.
Shah LM, Ross JS. Imaging of spine trauma. Injury. 2016;47(5):1057–63. https://doi.org/10.1016/j.
Neurosurgery. 2016;79(5):626–42. https://doi. injury.2016.01.020.
org/10.1227/NEU.0000000000001336. Wahlberg E, Goldstone J. Vascular injuries to the neck.
Shetty SK, Lev MH. CT perfusion in acute stroke. Semin In: Wahlberg E, Goldstone J, editors. Emergency vas-
Ultrasound CT MRI. 2005;26(6):404–21. https://doi. cular surgery: a practical guide. Berlin, Heidelberg:
org/10.1053/j.sult.2005.09.001. Springer; 2017a.
Singh A, Tetreault L, Kalsi-Ryan S, Nouri A, Fehlings Wahlberg E, Goldstone J. Abdominal vascular injuries.
MG. Global prevalence and incidence of traumatic In: Wahlberg E, Goldstone J, editors. Emergency vas-
spinal cord injury. Clin Epidemiol. 2014;6:309–31. cular surgery: a practical guide. Berlin, Heidelberg:
https://doi.org/10.2147/CLEP.S68889. Springer; 2017b.
Skinner DV, Driscoll PA. ABC of major trauma. 4th ed. Wang H, Zhou Y, Ou L, Li C, Liu J, Xiang L. Traumatic
London: Wiley; 2013. vertebral fractures and concomitant fractures of the rib
Sliker CW, Shanmuganathan K, Mirvis SE. Diagnosis in Southwest China, 2001 to 2010: an observational
of blunt cerebrovascular injuries with 16-MDCT: study. Medicine (Baltimore). 2015;94(44):e1985.
accuracy of whole-body MDCT compared with https://doi.org/10.1097/MD.0000000000001985.
neck MDCT angiography. Am J Roentgenol (1976). Wardrope J, Mackenzie R. The system of assessment and
2008;190(3):790–9. https://doi.org/10.2214/ care of the primary survey positive patient. Emerg
AJR.07.2378. Med. 2004;21:216–25. https://doi.org/10.1136/
Steenburg SD, Ravenel JG. Acute traumatic thoracic emj.2003.013524.
aortic injuries: experience with 64-MDCT. Am Wintermark M, Lev MH. FDA investigates the safety of
J Roentgenol. 2008;191(5):1564–9. https://doi. brain perfusion CT. Am J Neuroradiol. 2010;31(1):2–
org/10.2214/AJR.07.3349. 3. https://doi.org/10.3174/ajnr.A1967.
Stein DM, Pineda JA, Roddy V, Knight WA IV. Emergency Wirth GJ, Peter R, Poletti P, Iselin CE. Advances
neurological life support: traumatic spine injury. in the management of blunt traumatic blad-
Neurocrit Care. 2015;23(S2):155–64. https://doi. der rupture: experience with 36 cases.
org/10.1007/s12028-015-0169-y. BJU Int. 2010;106(9):1344–9. https://doi.
Stiell IG, Wells GA, Vandemheen KL, Clement CM, org/10.1111/j.1464-410X.2010.09377.x.
Lesiuk H, De Maio VJ, Laupacis A, Schull M, Wouters A, Christensen S, Straka M, Mlynash M,
McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Liggins J, Bammer R, Thijs V, Lemmens R, Albers
Eisenhauer MA, Greenberg GH, MacPhail I, Morrison GW, Lansberg MG. A comparison of relative time to
L, Reardon M, Worthington J. The Canadian C-spine peak and Tmax for mismatch-based patient selection.
rule for radiography in alert and stable trauma patients. Front Neurol. 2017;8:539. https://doi.org/10.3389/
J Am Med Assoc. 2001;286(15):1841–8. https://doi. fneur.2017.00539.
org/10.1001/jama.286.15.1841. Yaghi S, Willey JZ, Cucchiara B, Goldstein JN, Gonzales
Stroke Association. State of the nation. Stroke statistics; NR, Khatri P, Kim LJ, Mayer SA, Sheth KN, Schwamm
2018. https://www.stroke.org.uk/sites/default/files/ LH. Treatment and outcome of hemorrhagic transfor-
state_of_the_nation_2018.pdf. Accessed 23 Jan 2021. mation after intravenous alteplase in acute ischemic
Świat M, Targosz-Gajniak M, Arkuszewski M, Pięta stroke: a scientific statement for healthcare profession-
M, Gamrot J, Wojtacha M, Bażowski P, Opala. als from the American Heart Association/American
Decompressive hemicraniectomy in ischaemic stroke. Stroke Association. Stroke. 2017;48(12):e343–61.
Neurol Neurochir Pol. 2010;44(2):131–8. https://doi. https://doi.org/10.1161/STR.0000000000000152.
org/10.1016/S0028-3843(14)60004-9. Young CC, Chiarelli PA, Hofstetter CP. In: Ellenbogen
Teasdale G, Jennett B. Assessment of coma and RG, Sekhar LN, Kitchen ND, editors. Principles
impaired consciousness: a practical scale. Lancet of neurological surgery. 4th ed. Philadelphia, PA:
(British Edition). 1974;304(7872):81–4. https://doi. Elsevier; 2019. p. 475–92.
org/10.1016/S0140-6736(74)91639-0.
Whole-Body CT
Elio Arruzza and Shayne Chau
Abstract Keywords
Trauma is a leading cause of death globally. Whole-body computed tomography · WBCT

Early and accurate diagnosis in the emergency · Trauma · Full-body computed tomography ·
department (ED) is crucial in maximizing Pan-scan
health outcomes for trauma patients. The utili-
zation of Computed Tomography (CT), owing
to its superior imaging capabilities and rapid 1 Background & History
scanning speeds, has significantly increased in
recent years in the initial assessment of these Trauma takes the life of 4.4 million people every
patients. A protocol which surveys the entire year, accounting for 8% of global deaths (World
head, thorax and abdomen in a single scan, fit- Health Organisation 2021). This is more than the
tingly named ‘Whole Body CT’ (WBCT), has combination of fatalities resultant from HIV/
been recently implemented in many centres as AIDS, malaria and tuberculosis. For every fatal-
a way of reducing mortality and time spent in ity, several thousand more people are injured,
the ED/hospital. Aside from these possible leading to emergency department (ED) visits and
advantages, the obvious risk sourced from long-stay hospitalizations, sometimes resulting
excessive exposure to radiation makes a con- in permanent disabilities and necessitating long-
troversial topic. This chapter will exhibit the term healthcare and rehabilitation.
many facets pertaining to the viability of In Australia particularly, over eight million
WBCT for trauma patients in the ED setting, presentations were made to public hospital
with exploration of its advantages, drawbacks emergency departments in 2017–2018. Of these
and implications for radiographers. numbers, roughly 61,000 individuals were cat-
egorized as resuscitation patients, needing to be
treated immediately (Australian Institute of
Health and Welfare 2018). These presentations
E. Arruzza (*) have included: (1) motor vehicle accident,
University of South Australia, motor bike accident, (2) pedestrian crossing,
Adelaide, SA, Australia
e-mail: [email protected] (3) accidental falls, (4) exposure to inanimate
mechanical forces, (5) exposure to animate
S. Chau
University of Canberra, mechanical forces, (6) exposure to electric cur-
Canberra, ACT, Australia rent/smoke/animals/nature, (7) accidental poi-
100 E. Arruzza and S. Chau
soning, (8) intentional self-harm, (9) assault, quarters of the effective radiation dose delivered
(10) complications of medical and surgical from all imaging procedures (Fazel et al. 2009).
care, (11) acute respiratory infections including More recently, international increases in CT use
influenza and pneumonia, (12) intestinal infec- in the ED have been reported in Canada, Taiwan,
tious diseases, (13) hypertensive disease, (14) South Korea and Australia (Maxwell et al.
ischaemic heart diseases/ STEMI, (15) out of 2021).
hospital collapses and (16) cerebrovascular dis- Global uptake of CT has necessitated and cor-
eases (Pointer 2018). When a patient who has related with the rapid advancement of imaging
experienced trauma arrives to the emergency technology, particularly entailing faster scan
department (ED), two components of health- times, 3D reconstruction capabilities and dose
care are required to provide the most optimum reduction. Initial scanners offered inferior image
health outcome that the patient is provided the quality and acquisition times, leading to poor
correct diagnosis, and that the diagnosis is diagnostic accuracies and unreliability in the
made quickly. Regrettably, misdiagnosis and time-dependent environment of the ED. CT’s
time delay are two of the greatest barriers inhib- now dominance in these areas has accelerated
iting patient survival and quality of life since the advent of multi-slice CT in 1998 (Wang
thereafter. et al. 2019). Concurrently, the use of whole-body
Conventionally, diagnosis of trauma patients CT (WBCT) has spawned and developed from
presenting to the ED is informed by the Advanced the need to rapidly evaluate and treat patients in
Trauma Life Support (ATLS) protocol, which the ED.
emphasis the principle of treating first what is WBCT, which is interchangeably used with
likely to kill first (Kool and Blickman 2007). The the terms ‘pan-scan’, ‘full-body CT’ (FBCT) or
radiological component of the guidelines encom- ‘total-body CT’ (TBCT), is generally defined
passes a combination of fast and priority-based as a CT scan of the head, cervical spine, chest,
physical examination, plain X-ray of the chest abdomen and pelvis. Though WBCT has
and pelvis and focused assessment with sonogra- become a more widely used part of the trauma
phy for trauma (FAST) (American College of evaluation protocol in many centres interna-
Surgeons 2018). Though these modalities offer tionally, its use is a highly debated topic in the
little or no radiation doses and are relatively inex- field of radiology and emergency medicine.
pensive, their low diagnostic accuracies for This is principally due to the radiation dose
severe injuries mean that CT of selective body imparted during a single scan, though other
regions is often called upon. Using the ATLS has aspects like potentially excessive cost and the
resulted in missed injuries and delayed diagnosis promotion of self-referred WBCT to screen
in up to 39% of cases, with even higher rates healthy patients during the early 2000’s (Berlin
observed in the more severely injured (Beal et al. 2003) have undoubtedly added fuel to the fire.
2016). A plethora of methodologically sound studies
Since its inception in the early 1970s, CT has have been performed demonstrating both
evolved to become the cornerstone of imaging advantages and drawbacks of WBCT in the
hemodynamically stable trauma patients that trauma setting. A breakthrough article by
present to the emergency department (Tsutsumi Weninger et al. (2007) discovered a clear and
et al. 2017). ED physicians continually depend substantial time benefit in favour of WBCT
on CT’s ability to rapidly diagnose life- over conventional protocols. Positive findings
threatening conditions; so much so, that from were echoed by Huber-Wagner (2009) which
1995 to 2007, the number of ED visits featuring supplemented their findings of more rapid time
a CT scan increased from 2.7 million to 16.2 spent in the ED, with an increase in the proba-
million, a near six-fold increase (Larson et al. bility of survival in patients who received a
2011). In terms of patient dose, it is estimated WBCT scan compared to those who received
that CT is responsible for approximately three no CT scan or a selective CT scan.
Whole-Body CT 101
2 Time In light of these advantages, the link between

an alleviation of time spent in the ED and crucial
Much like the phrase ‘time is brain’ for stroke patient-related outcomes is not clear-cut in the
patients, time plays a crucial role in the context of context of WBCT. That is to say, it is still incon-
trauma patients. Prolonged diagnosis and treat- clusive whether the time saved in the ED by per-
ment of trauma patients are a contributor to ED forming WBCT saves more lives compared to
overcrowding; inability of the ED to meet the conventional protocols. However, where EDs are
demands for patient triage, medical imaging, busy and overcrowded, it is only logical to con-
pathological testing and specialty consultations, clude that such an environment is not conducive
negatively impact the patient flow in ED to safe, quality and economical healthcare. The
(Yarmohammadian et al. 2017). impact of high occupancy and limitation of phy-
Overwhelmingly, WBCT has been observed sician access have resulted in increased mortality
to reduce ED times. Palm et al. (2018) followed a rates, hospital length of stay (LOS), hospital
substantial sample size of 16,000 patients to readmission and even infection transmission
demonstrate a significant improvement of rates (Yarmohammadian et al. 2017).
approximately 17 less minutes spent in the ED
(84.3 vs 67.6). This trend has been reinforced by
Hutter et al. (2011) (144.7 vs 83.5), Hong et al. 3 Radiation Dose
(2016) (186.3 vs 108.6) and James et al. (2017)
(459.1 vs 390.9). It is believed that these benefits Like most applications of CT, the most critically
stem from technological advances relating to opposing argument against more widespread use
acquisition and reconstruction algorithms, which is excessive radiation dose. Originally and cur-
allows rapid acquisition of information from one rently where scanners do not possess modern
conclusive scan; as WBCT does not entail time- low-dose capabilities, a WBCT scan exposes a
consumption associated with X-ray and ultra- patient to greater than 20 mSv of effective radia-
sound, these findings have implications entailing tion dose (Arora and Arora 2019). A dose of
faster diagnosis time for definitive treatment and 20 mSv will increase the risk of dying from can-
lessening the impact of ED overcrowding. cer by 1 in 1250 in an average 45-year patients
Furthermore, the approach limits re-evaluation whilst a higher dose of 24 mSv increases this risk
and re-examination procedures, which may also by 1 in 900 in a 35-year-old male (Brenner and
be linked to reductions in overall time spent in Hall 2007).
hospital, radiation dose and cost of imaging and Several studies have compared dose levels of
healthcare over time (Sierink et al. 2016). trauma patients experiencing WBCT compared
Reductions in time spent in the ED and hospital to traditional protocols, and expectedly, these
permits for rapid clearance of patients with sub- studies indicated lower radiation dose levels for
stantial mechanisms of injury who require prompt the latter. The starkest discrepancy between
surgical interventions such as craniotomies and WBCT and non-WBCT was discovered by
spine procedures, who would otherwise require a Gordic et al. (2015) which showed WBCT expe-
lengthy period of observation lengthy and physi- rienced doubled the dose. This is reinforced in
cal examination before entering the operating other settings which showed an increase in dose
theatre (American College of Surgeons 2018). A of up to a third (James et al. 2017), and the the
further benefit is that when a WBCT protocol is proportion of patients exposed to a greater than
implemented, alterations in departmental design 20 mSv dose increasing significantly (from 19.6
and CT scanner location are often co-introduced. vs 11.6%) after introduction of a WBCT protocol
This was seen in Weninger’s study (2007) which (Asha et al. 2012). Nevertheless, the recent
decreased ED time from 104 to 70 min, after REACT-2 trial by Sierink et al. (2016) suggests
patients could be transported directly to the new that because WBCT may eliminate the need for
scanner located in the ED. further imaging, this could potentially lower dose
if the entire patient pathway is considered. The their institution increased by US$4971 after a
trial demonstrated that although dose was higher WBCT protocol was introduced. Conversely,
during the primary survey in the WBCT cohort, Hong et al. (2016) and Sierink et al. (2016) sug-
doses were more comparable as time proceeded gested that cost associated with WBCT was not
and patients required more scans. significantly greater than conventional imaging
protocols. In a recent multicentre RCT where
trauma patients experienced either WBCT or the
4 Overdiagnosis ATLS, mean costs of hospital care were €25,809
and Incidental Findings for the WBCT group and €26,155 (€23,050 to
€29,344) the latter, a per-patient and significant
Incidental findings are a ‘double-edged sword’. difference of €346 in favour of the former
On the one hand, they yield a positive impact on (p = 0.876) (Treskes et al. 2021).
future management, providing early diagnosis of
pathologies, particularly malignancy or vascular
disease. Conversely however, when clinical sig- 6 Tips for CT Radiographer
nificance is absent, these findings also result in When Resuscitation Room
potentially unwarranted investigations, overex- Calls
posure to radiation, patient anxiety and excessive
costs (Lumbreras et al. 2010). So profound these Generally, when a patient arrives to the resuscita-
disadvantages, the term ‘incidentaloma’ has been tion room, the first point of call is the ED consul-
used to describe incidental findings as a disease tant requesting an urgent CT to the CT department.
in itself. As modern CT produces images of supe- Another method may be via a hospital trauma
rior quality and by virtue of the vast anatomical pager system (or via the public announcement
region surveyed by WBCT, incidental findings throughout the department) with an estimated
are significantly higher in these scans compared time of arrival. For instance, the CT radiographer
to other modalities. Incidental findings are might receive a page noting ‘L1 Trauma ETA
reported in up to 75% of patients experiencing 1400’ or ‘pan-scan arriving in 5’.
WBCT, primarily in the abdomen region When the page is sent, an estimated arrival time
(Kroczek et al. 2017). In the recent REACT-2 will be conveyed to the CT radiographer. The
trial, 1 in 24 of findings were found to be a neo- radiographer should also be informed whether the
plasm pathology, and nearly half of these could patient is intubated or not, and whether the patient
have resulted in considerable morbidity. is coherent. This information is then communi-
cated to all staff involved, including the radiologist
on-site and the nursing staff. If there is only one
5 Cost CT machine in the department, the non-urgent
scans or outpatient scans are placed on hold and
As controversy surrounding radiation dose con- the room is then prepared for the pan-scan, includ-
tinues, and patient-related outcomes like mortal- ing preparation of the power/contrast injector, and
ity are justifiably prioritized by researchers, room set-up for patient transfer.
limited exploration has been undertaken regard- The second most important component of the
ing cost-effectiveness. Furthermore, cost is process is patient consent. The CT radiographer
dependent on several variables based on the indi- should note whether the patient can provide ver-
vidual institution’s capacity to implement and bal consent. For instance, if the patient suffers
maintain a new protocol, and longer research from confusion or altered mental state, language
periods are needed to determine true savings or barrier, unconsciousness, intubation, or intoxica-
expenses. tion, third party consent or two-doctor consent
James et al. (2017) discovered that the average should be organized. At times, if the examination
cost of hospital stay for a blunt trauma patient at is critical, consenting may be overridden by the
Whole-Body CT 103
ED consultation. In this case, documentation of • Proximal amputation.

the event should be performed and in the patient
notes, for future reference. (Treskes et al. 2016)
A typical WBCT protocol may consist of both
non-contrast and contrast-enhanced scans includ-
7 Protocols ing any of the following, but not limited to:
Uptake of WBCT has increased widely particu- • Non-contrast CT https://www.radiopaedia.

larly across developed nations; however, there org/articles/ct-brain?lang=us head.
exists a lack of consensus and standardization • Non-contrast CT cervical spine.
of protocols, and indications which warrant • CT thorax and upper abdomen (in arterial or
these protocols. Pregnant patients and paediat- venous phase).
rics are the exception, where non-ionizing • CT abdomen/pelvis in portal venous phase.
modalities are preferred in nearly every case.
Ultimately, a pan- scan protocol is justified If the following injuries are diagnosed in real
when it is deemed clinically necessary to scan time, the following phases may be added:
the body in a single episode, to improve the
ability to accurately report the images in trauma • CT Carotid/COW for neck injuries https://
centres and reduce the need for repeat scan- w w w. r a d i o p a e d i a . o rg / a r t i c l e s /
ning. Generally, findings from physical exami- missing?article%5Btitle%5D=ct-angiogram-
nation in the ED that suggest injury to multiple neck&lang=ushttps://radiopaedia.org/articles/
areas or systems in a hemodynamically stable blunt-cerebrovascular-injury?lang=us
patient generally warrant a WBCT scan. These • Delayed phase of the abdomen/pelvis: useful
findings stem from three general criteria includ- to assess for contrast pooling/contrast extrava-
ing mechanism of injury, type of injury and sation indicative of active bleeding.
physiologic status: • Excretory phase of the kidneys or CT cysto-
Mechanism of Injury may include, but are\ not gram useful in patients with traumatic kidney or
limited to, the following events: bladder https://radiopaedia.org/articles/renal-
trauma-1?lang=usinjuries https://radiopaedia.
• Vehicle collision. org/articles/urinoma?lang=ushttps://radiopae-
• Explosion. dia.org/articles/renal-trauma-1?lang=us
• Crush injury.
• Fall from a significant height. Furthermore, variations to protocols may be
added depending on radiologist and/or ED physi-
Physiologic Status may differ by institution, cian preferences. These additions may entail:
but common quantitative measurements include:
• Multiplanar reconstructions of the spine.
• Glasgow Coma Scale <10. • Additional non-contrast CT of the upper
• Systolic BP <80 mmHg. abdomen.
• RR <10 or >29. • CT angiogram of the lower limbs in the setting
• O2 sat. <90%. of suspected major haemorrhage and/or pel-
vic/lower limb fractures.
Types of Injuries may include, but are not lim- • Triphasic injection single pass CT of the chest,
ited to, the following presentations: abdomen and pelvis.
• Flail or open chest. Considering these points, two specific exam-

• Unstable pelvic fracture. ples of a suitable protocol with contrast timings
• Fractures >1 long bone. and reconstruction techniques are detailed below:
7.1 Patient Preparation –– 70 ml contrast @ 3–4 ml/s followed by

50 ml normal saline @ 3 ml/s. Wait 50 s
• No fasting. from start of contrast injection.
• No water oral filling. –– 70 ml contrast @ 3–4 ml/s followed by
• Supine. 50 ml normal saline @ 3 ml/s.
• OM baseline parallel to scan plane if possible. –– 15 s delay (65 s from start of first contrast
injection) then bolus tracking ROI during
second contrast bolus on aortic arch and
7.2 Dual Intravenous Contrast trigger @150HU.
Bolus
• Non-Contrast Head (from top of vertex to base 7.3 Single Intravenous Contrast
of skull) and Non-Contrast Cervical Spine Phase with Two Scan Ranges
(from EAM to T2) performed first (Fig. 1).
• Raise arms above head. • Non-Contrast Head (from top of vertex to base
of skull) and Non-Contrast Cervical Spine
Scan Range: Top of Acromions to Lesser (from EAM to T2) performed first (Fig. 1).
Trochanters (Fig. 2) • Raise arms above head.
Contrast: Scan Range: Top of Acromions to Lesser

• A total of 140 mls Omnipaque 350 contrast Trochanters (Fig. 2).
and 100 ml of normal saline @ 3-4 ml/s is A CT angiogram from top of the acromions to
administered. the pubic symphysis and a portal venous abdo-
men and pelvis is obtained.
Fig. 1 AP & lateral topogram of head

Whole-Body CT 105
Contrast: • Post-contrast (portal venous phase) abdomen

• 70–100mls contrast @ 3–4 ml/s followed by and pelvis.
50 ml normal saline @ 3 ml/s.
• Post-contrast (arterial phase) chest, abdo-
men and pelvis bolus tracking ROI after 7.4 Image Reconstruction
contrast bolus on aortic arch and trigger (Table 1):
@100HU.
Fig. 2 AP and lateral

topogram of chest,
abdomen & pelvis with
monitoring slice at the
level of the pulmonary
trunk. Images courtesy
of SC
Table 1 Image reconstruction parameters for head, c-spine, chest and chest/abdomen/pelvis (Hassam 2020)
Head C-Spine
1/1 mm soft tissue Axial 2/2 mm soft tissue Axial
1/0.8 mm bone Axial 2/2 mm soft tissue Sagittal
3/3 mm soft tissue Axial 2/2 mm soft tissue Coronal
3/3 mm soft tissue Coronal 2/2 mm bone Axial
3/3 mm soft tissue Sagittal 2/2 mm bone Coronal
2/2 mm bone Sagittal
Chest Chest/abdomen/pelvis
1/0.8 mm lung Axial 3/2 mm soft tissue Axial
8/8 mm lung Axial 8/8 mm soft tissue Axial
3/3 mm lung Coronal 1/0.8 mm bone Axial
3/3 mm soft tissue Coronal
3/3 mm soft tissue Sagittal
8 Conclusion Surg. 2019;9(4):636–41. https://doi.org/10.21037/

qims.2019.04.02
Asha S, Curtis KA, Grant N, Taylor C, Lo S, Smart R,
It can be argued that given the superior diagnostic Compagnoni K. Comparison of radiation exposure of
capability of CT, the undeniable fact that WBCT trauma patients from diagnostic radiology procedures
delivers greater radiation dose actually holds lim- before and after the introduction of a pan-scan proto-
col. Emerg Med Australas. 2012;24(1):43–51.
ited clinical applicability; rather, it is the degree Australian Institute of Health and Welfare. Emergency
by which WBCT produces greater dose that is department care 2017–18. Canberra: Australian
most relevant. Considering the vast benefits of Institute of Health and Welfare; 2018.
WBCT, ED physicians are faced with a question Beal L, Ahrendt MN, Irwin ED, Lyng JW, Turner SV,
Beal CA, Byrnes MT, Beilman GA. Prediction of
not uncommon in many aspects of radiology in blunt traumatic injuries and hospital admission based
emergency medicine: on history and physical exam. World J Emerg Surg.
How much inferior can traditional diagnostic pro- 2016;11(1):46.
tocols afford to be in terms of diagnostic accuracy Berlin L. Potential legal ramifications of whole-body CT
and imaging time, until its benefit of dose- screening: taking a peek into Pandora's box. Am J
minimization becomes no longer relevant? Or, how Roentgenol. 2003;180(2):317–22.
much more dose can WBCT afford to produce, until Brenner DJ, Hall EJ. Computed tomography: an increas-
its benefits over conventional protocols become no ing source of radiation exposure. N Engl J Med.
longer justified? 2007;357:2277–84.
Fazel R, Krumholz HM, Wang Y, Ross JS, Chen J, Ting
HH, Shah ND, Nasir K, Einstein AJ, Nallamothu
Though a solution to this issue can be informed BK. Exposure to low-dose ionizing radiation
by statistical evaluation of outcomes such as sen- from medical imaging procedures. N Engl J Med.
sitivity, specificity, radiation dose, cost and other 2009;361:849–57.
Gordic S, Alkadhi H, Hodel S, Simmen HP, Brueesch M,
patient-related factors, a significant role will Frauenfelder T, Wanner G, Sprengel K. Whole-body
always be played by clinical expertise, and pro- CT-based imaging algorithm for multiple trauma
fessional subjectivity, in determining the most patients: radiation dose and time to diagnosis. Br J
necessary diagnostic pathway for trauma patients. Radiol. 2015;88(1047):1–8.
Hassam S. CTI148 CT trauma CHEST abdomen pelvis.
Thus, it is challenging for researchers to devise a South Australia: Dr Jones & Partners; 2020.
threshold for outcomes such as mortality and ED Hong ZJ, Chen CJ, Yu JC, Chan DC, Chou YC, Liang CM,
times by which it can be confidently stated that Hsu SD. The evolution of computed tomography from
lower or nil-radiation dose modalities become organ-selective to whole-body scanning in managing
unconscious patients with multiple trauma a retrospec-
less clinically relevant. Nevertheless, it is esti- tive cohort study. Medicine. 2016;95(37):1–5.
mated that the risk of death from intermediate Hutter M, Woltmann A, Hierholzer C, Gärtner C, Bühren
level trauma is six times higher than the risk of a V, Stengel D. Association between a single-pass
cancer death from a CT-related radiation expo- whole-body computed tomography policy and survival
after blunt major trauma: a retrospective cohort study.
sure (Laack et al. 2011). With technological Scand J Trauma Resusc Emerg Med. 2011;19:1–9.
advancement and exploration of low-dose Huber-Wagner S, Lefering R, Qvick LM, Körner M, Kay
scanning, this risk is expected to decrease.
MV, Pfeifer KJ, Reiser M, Mutschler W, Kanz KG.
Currently, it is sensible to prefer WBCT in seri- Effect of whole-body CT during trauma resuscita-
tion on survival: a retrospective multicentre study.
ously injured multi-trauma patients but we need The Lancet. 2009;373(9673):1455–61. https://doi.
further studies defining seriously injured patients org/10.1016/S0140-6736(09)60232-4.
and strong rule-out criteria for decision of WBCT. James MK, Schubl SD, Francois MP, Doughlin GK, Lee
SW. Introduction of a pan-scan protocol for blunt
trauma activations: what are the consequences? Am
J Emerg Med. 2017;35(1):13–9. https://www.facs.
References org/-/media/files/quality-programs/trauma/tqip/imag-
ing_guidelines.ashx.
American College of Surgeons. Advanced trauma life sup- Kool D, Blickman J. Advanced Trauma Life Support®.
port student course manual, 10th ed. USA: American ABCDE from a radiological point of view. Emerg
College of Surgeons, 2018. Radiol. 2007;14(3):135–41.
Arora R, Arora AJ. Justification of whole-body CT Kroczek E, Wieners G, Steffen I, Lindner T, Streitparth F,
in polytrauma patients, can clinical examina- Hamm B, Maurer M. Non-traumatic incidental find-
tion help selecting patients? Quant Imaging Med ings in patients undergoing whole-body computed
Whole-Body CT 107
tomography at initial emergency admission. Emerg Treskes K, Saltzherr T, Luitse J, Beenen L, Goslings
Med J. 2017;34(10):643–6. J. Indications for total-body computed tomography
Laack T, Thompson K, Kofler J, Bellolio M, Sawyer M, in blunt trauma patients: a systematic review. Eur J
Issa Laack N. Comparison of trauma mortality and Trauma Emerg Surg. 2016;43(1):35–42.
estimated cancer mortality from computed tomog- Treskes K, Sierink J, Edwards M, Beuker B, Van Lieshout
raphy during initial evaluation of intermediate-risk E, Hohmann J, Saltzherr T, Hollmann M, Van Dieren
trauma patients. J Trauma Injury Infect Crit Care. S, Goslings J, Dijkgraaf M, Luitse J, Schepers
2011;70(6):1362–5. T, Beenen L, Tromp T, Brink M, El Moumni M,
Larson D, Johnson L, Schnell B, Salisbury S, Forman Harbers J, Patka P, den Hartog D, Hagenaars T. Cost-
H. National Trends in CT use in the emergency depart- effectiveness of immediate total-body CT in patients
ment: 1995–2007. Radiology. 2011;258(1):164–73. with severe trauma (REACT-2 trial). Br J Surg.
Lumbreras B, Donat L, Hernandez-Aguado I. Incidental 2021;108(3):277–85.
findings in imaging diagnostic tests: a systematic Tsutsumi Y, Fukuma S, Tsuchiya A, et al. Computed
review. Br J Radiol. 2010;83:276–89. tomography during initial management and mortal-
Maxwell S, Ha NT, Bulsara MK, et al. Increasing use of ity among hemodynamically unstable blunt trauma
CT requested by emergency department physicians patients: a nationwide retrospective cohort study.
in tertiary hospitals in Western Australia 2003–2015: Scand J Trauma Resusc Emerg Med. 2017;25:74.
an analysis of linked administrative data. BMJ Open. https://doi.org/10.1186/s13049-017-0396-7
2021;11(3):e043315. Published 2021 Mar 4. https:// Wang, G, Zhang Y, Ye X, Mou X, 2019. X-ray computed
doi.org/10.1136/bmjopen-2020-043315. tomography. In: Machine learning for tomographic
Palm HG, Kulla M, Wettberg M, Lefering R, Friemert imaging. Institute of Physics Publishing: Bristol.
B, Lang P. Changes in trauma management follow- Weninger P, Mauritz W, Fridrich P, Spitaler R, Figl M, Kern
ing the implementation of the whole-body computed B, Hertz H. Emergency room management of patients
tomography: a retrospective multi-Centre study based with blunt major trauma: evaluation of the multislice
on the trauma registry of the German trauma society computed tomography protocol exemplified by an
(TraumaRegister DGU((R))). Eur J Trauma Emerg urban trauma center. J Trauma. 2007;62(3):584–91.
Surg. 2018;44(5):759–66. World Health Organisation. Injuries and violence; 2021.
Pointer SC. Trends in hospitalised injury, Australia 1999– [online] https://www.who.int/news-room/fact-sheets/
00 to 2014–15. Injury research and statistics series no. detail/injuries-a nd-v iolence#:~:text=Injuries%20
110. Cat. no. INJCAT 190; 2018. Canberra: AIHW. %E2%80%93%20both%20unintentional%20and%20
Sierink JC, Treskes K, Edwards MJ, Beuker BJ, den violence,traffic%20injuries%2C%20homicide%20
Hartog D, Hohmann J, Dijkgraaf MG, Luitse JS, and%20suicide. Accessed 9 Dec 2021.
Beenen LF, Hollmann MW, Goslings JC. Immediate Yarmohammadian MH, Rezaei F, Haghshenas A, Tavakoli
total-body CT scanning versus conventional imag- N. Overcrowding in emergency departments: a review
ing and selective CT scanning in patients with severe of strategies to decrease future challenges. J Res Med
trauma (REACT-2): a randomised controlled trial. Sci. 2017;22(1):23.
Lancet (London, England). 2016;388(10045):673–83.
Part III
CT Guided Interventions
Indications, Technique and Pitfalls
Abstract vided by CT to minimise the associated risks or

complications to the patient will usually out-
In addition to serving as a diagnostic imaging weigh the radiation-related risks. Radiographers
modality, the use of Computed Tomography are an integral part of the multidisciplinary
(CT) to guide interventional procedures has team (MDT) when interventional CT proce-
increased dramatically in the past decade. This dures are being performed. Therefore, it is vital
is linked to more sophisticated technology to the success of the MDT that radiographers
available on CT scanners, including interven- understand the aim of the procedure and the
tional options, allowing for ‘live’ 3-dimen- associated risks so that they can provide opti-
sional data to guide the interventionalist to mal imaging in a timely manner whilst mini-
perform the procedure more safely. mising the radiation dose to both the patient
Interventional CT includes a wide range of pro- and the members of the MDT who may have to
cedures such as musculoskeletal joint injec- remain in the CT scan room during exposure.
tions, nerve root corticosteroid injections,
aspirations, biopsies, drainages, radiofrequency Keywords
ablations and transarterial chemoembolisa-
tions. The ALARA principle requires consider- Intervention · CT-guided · Injection · Biopsy ·
ation of the benefits and risks associated with Fluoroscopy
the use of ionising radiation when performing
such interventional procedures. When deciding
on the most appropriate modality to guide an 1 Indications
intervention, radiation dose and potential com-
plications are two major concerns to be consid- Computed Tomography (CT) uses ionising radia-
ered. CT fluoroscopy may deliver higher tion (X-rays) to produce images from 360° which
radiation dose than conventional fluoroscopy, assists the interventional radiologist to accurately
but the value of the 3-dimensional data pro- position a needle to deliver medication or biopsy
a lesion. In most cases, the radiation dose in a
E. Doyle (*) CT-guided interventional case will often be lower
Lumus Imaging, Melbourne, Australia than conventional fluoroscopy, as less imaging
may be performed. The procedure may be quicker
P. J. Ratnakanthan than under conventional 2D fluoroscopy-
Lumus Imaging, Melbourne, Australia
guidance, as 3D imaging is provided when CT
Capitol Health, Melbourne, Australia fluoroscopy is utilised.
112 E. Doyle and P. J. Ratnakanthan
Procedures include spinal injections such as 1.1 Technique

epidurals, facet joint or nerve root exits, and
shoulder hydrodilatation, arthroscopies and biop- Depending on the type of interventional proce-
sies may be performed with CT-guidance. The dure being performed, there are three different
indications for commonly performed CT-guided techniques that the radiologist may choose to use
interventional procedures are outlined in Table 1. to guide them:
Table 1 CT-guided interventional procedures

Procedure Indication(s) and brief outline
Arthrogram (pre-MRI) Used to introduce contrast into the joint capsule (i.e. arthrogram) prior to MRI scan
with intra-articular contrast.
The patient should be screened by the MRI staff prior to being consented by the
radiologist. An MR-compatible wheelchair should be brought to CT to transfer the
patient from CT to MRI.
The gadolinium contrast is introduced into the joint capsule under CT-guidance
following the intra-articular administration of iodinated contrast.
Biopsy Radiological imaging is used to guide the insertion of the needle of the biopsy gun
into the target lesion so a sample can be taken and sent to pathology for analysis. CT
is the preferred modality of choice when involuntary movement is likely (e.g.
respiration) or when vital anatomy is located close by.
Drainage Radiological imaging is used to guide the insertion of a drain into a collection of
fluid from an abscess or cavity. Using CT, the drainage catheter is advanced within
the fluid collection site, where it is secured, and a drainage bag attached to the
catheter. Depending on the volume of fluid, the drainage catheter can be left in situ
for a number of days before being removed.
Epidural injection Used to treat central disc protrusion or spinal canal stenosis.
The steroid and local anaesthetic are injected into the (epidural) space between the
dura and the spinal cord.
Facet joint injection / Used to treat localised neck or back pain often caused by arthritis, injury or
medial branch block mechanical stress.
The steroid is injected into the capsule at the facet (zygapophyseal) joint in the
cervical or lumbosacral spine. The aim is to reduce inflammation and provide long
lasting pain relief from 3–6 months.
Medial branch nerves are small nerves that exit through the facet joints and are
responsible for transmitting pain signals from these joints. A medial branch block
temporarily interrupts the pain signal from a specific facet joint. The anaesthetic is
injected proximal to the medial nerves related to a specific facet joint. Typically
several levels of the spine are injected in one procedure.
Hip injection Used to treat osteoarthritis and labral tear.
Hydrodilatation of the Used to treat osteoarthritis and adhesive capsulitis (i.e. ‘frozen shoulder’).
shoulder The capsule of the shoulder joint is extended (or ruptured) using air by the radiologist
to relieve the symptoms of a ‘frozen shoulder’. The aim is to stretch the joint capsule,
thereby improving function.
Knee injection Used to treat osteoarthritis.
Nerve root (perineural)/ Used to treat radiculopathy due to disc protrusion or foraminal stenosis.
foraminal injection The steroid and/or anaesthetic are injected into fat around the nerve where it exits
through the spinal foramen. A nerve root injection can assist in diagnosing the
vertebral level where the impingement or compression has occurred as it may not be
visualised on the MRI scan, and may also provide some pain relief.
Radiofrequency ablation Used to deliver targeted heat to a specific tumour or nerve. Most commonly used to
(RFA) treat metastatic lesions in the liver or damaged nerves. For hepatic RFA, CT scans will
include the acquisition of triphasic liver scans 2–3 times during the interventional
procedure to see if the tumour is still enhancing. The patient may be under general
anaesthetic so liaison with a team external to radiology will be required.
Transarterial Used to administer chemoembolisation to a vascularised tumour in the liver. Will
chemoembolisation (TACE) often involve coordination with the team in the angiography suite.
Indications, Technique and Pitfalls 113
1. Injection/Biopsy mode = intermittent fluoros- into the patient’s file on the Radiology Information
copy, e.g. iSequence (Siemens), ONE Shot System.
(Canon), SmartView (GE). CT radiographers must be familiar with the
2. Repeat Scan Range. side effects of both contrast agents used, as well as
3. CT fluoro = intermittent fluoroscopy, e.g. the medications administered so that they can
CARE Vision (Siemens), Continuous SURE identify an adverse reaction and alert the radiolo-
Fluoro (Canon) and SmartStep (GE). gist immediately. Particularly when the patient is
sedated, the signs and symptoms may not be
The complexity of the case should determine noticed by those concentrating on performing the
which technique the radiologist will use and they procedure so the CT radiographers should be
may have to change during the case. observing the patient at all times (Royal Australian
and New Zealand College of Radiologists 2018b).
In order to be valid, consent must be provided
1.2 Patient Preparation voluntarily by the patient, having been given suf-
ficient information to make a decision and the
The patient may be required to fast if having patient must be competent to make the decision
sedation and the radiology nurse will usually (The Royal Australian and New Zealand College
liaise with the patient in advance if this is the of Radiologists 2019). Even if they have signed
case. If a general anaesthetic is involved, the this form, the patient can still decline to proceed at
anaesthetics team will liaise with the patient any point during the procedure and their decision
regarding preparation and fasting times. must be respected—they should not be pressured
Depending on the procedure, recent blood test to proceed. For this reason, it is advised that the
results may be required, particularly for patients patient is ‘consented’ outside the CT scan room so
who take anticoagulants. Most departments will they have time to ‘consider the information given’
have a checklist that the radiology nurse will prior to the interventional procedure starting.
complete with the patient when booking the Where available, ‘Patient Information’ leaflets
CT-guided procedure. The results of any blood for the procedure should be provided to the
tests and previous imaging should always be patient to read in advance and sign on the day. If
checked prior to the interventional procedure as they have any queries, the radiologist can address
part of a ‘Time Out’ protocol. these prior to commencing the interventional
procedure. The Royal Australian and NEw
Zealand College of Radiologists’ ‘Inside
1.3 Consent Radiology’ website (2018a) is an excellent
resource for both patients and healthcare profes-
The radiologist who will perform the interven- sionals to review to further their understanding of
tional procedure is responsible for explaining to interventional procedures: https://www.insidera-
the patient what the procedure will involve and diology.com.au/interventional-radiology.
what the likely risks are. This discussion will
include the potential radiation risks and those
associated with the contrast agent which may be 1.4 Positioning the Patient
administered intrathecally, intra-articularly or
intravenously. The patient should also be Positioning of patients is the responsibility of the
informed of the benefits and risks of the interven- CT radiographer but may involve guidance from
tional procedure planned, as well as any alterna- the radiologist, depending on their individual pref-
tive options available to them. Having explained erences. For the common CT interventional proce-
the procedure thoroughly and answered any dures, the preferences for each radiologist should
questions, the radiologist should ask the patient be recorded locally to ensure that the procedure is
to sign the Consent form which is later scanned as time-efficient as possible for all involved. For
Fig. 1 Example of
set-up for interventional
CT procedure. Image
Courtesy of Canon
Medical and Dr. Smit,
Radboudumc, the
Netherlands (Canon
Medical Systems ANZ,
2021)
Fig. 2 Webb medical fast find grid. Image courtesy of

Webb Medical (2020)
Fig. 3 Beekley Medical Guidelines with laser cross-
more complicated procedures, e.g. biopsy, this hairs. Image courtesy of Beekley Medical (2020)
will vary depending on the location of the lesion.
The position of the patient in the CT scanner is
directly linked to the radiation dose that they
receive so accurate positioning to minimise the
radiation dose to the patient is desired (i.e. the
ALARA Principle—As Low As Reasonably
Achievable). With multislice CT scanners, the
body part of interest must be positioned in the
isocentre (i.e. the direct centre of the gantry) in
order to optimise image quality. Sometimes this
is not possible, as adequate space to work must
be available for the interventional equipment Fig. 4 Webb medical fast find grid. Image courtesy of
within the gantry but the radiographer must be Webb Medical (2020)
aware of the impact on subsequent radiation dose
and therefore, image quality. An example of the It is important that the lead lines within the
set-up for a CT-guided interventional procedure grid are perpendicular to the z-axis of the scan
is shown in Fig. 1. field to ensure they are visible on the pre-planning
The adhesive single-use interventional grid scan. There are two main types of grids available
should be placed on the patient’s skin over the as shown below in Figs. 3 and 4.
region of interest prior to the topogram (Fig. 2).
1.5 Pre-Planning CT Scan Once an appropriate needle insertion slice has

been planned, the CT radiographer will then
The patient will already have had a diagnostic CT mark that spot on the patient’s skin using a surgi-
or an MRI scan prior to the interventional proce- cal marker (or equivalent). It is important that the
dure. Therefore, the pre-planning scan can be radiographer checks that the needle entry site has
limited to a small range, e.g. ½ vertebral body been clearly marked on the patient’s skin prior to
above the inter-vertebral disc space to ½ verte- removing the grid, as this can be erased by anti-
bral body below (Fig. 5). septic solution whilst creating a sterile environ-
Allow the images to reconstruct prior to ask- ment for the procedure (Figs. 7 and 8).
ing the radiologist to review—if the radiologist
measures/marks the spot on the ‘Real Time’
images instead of the reconstructed images, the 1.6 Procedure
line will disappear. The radiologist uses the grid
on these images to decide where s/he will insert All CT-guided interventional procedures are per-
the needle (Fig. 6). formed in a sterile environment. When the radi-
ologist has donned sterile gloves, they will open
the sterile pack on a trolley. They will clean the
Vertebral body patient’s skin at the marked region of interest. A
sterile drape may be used to cover the patient to
preserve the sterile field and minimise the risk of
Scan Range
Fig. 5 Scan range for pre-planning scan
Fig. 7 Marking the spot on the patient’s skin using the

laser light for guidance with the Webb Medical Fast Find
Grid. Image courtesy of Webb Medical (2020)
Fig. 6 Beekley Medical Guidelines on the skin allowing Fig. 8 Confirming the spot is visible on the patient’s skin
radiologist to plan entry site and direction of needle inser- whilst gently removing the Webb Medical Fast Find Grid.
tion. Image courtesy of Beekley Medical (2020) Image courtesy of Webb Medical (2020)
infection. Local anaesthetic may be administered hand controls should be attached to the side of
subcutaneously. If a nurse is not available to assist the CT table that the radiologist will work from
the radiologist, it is vital that the CT radiographer and the foot pedal moved into position. The TV
double-checks all vials of medication and expiry monitor should be moved into position on the
dates with the radiologist prior to administration. opposite side of the CT table so that it is easily
Batch numbers and expiry dates should be seen by the radiologist whilst performing the pro-
recorded in the patient’s file on RIS in case of an cedure (Fig. 10).
adverse reaction or re-call by the manufacturer. There is usually a Soft and a Bone CT Fluoro
protocol to choose from:
1.7 Acquisition Option 1: • Use ‘Soft’ for Nerve Root.

Injection/Biopsy Mode • Use ‘Bone’ for Facets and Epidurals.
(I.E. Intermittent CT Fluoro)
Remember, the windows can be changed to
The radiologist will use the overhead TV screen Bone on the Soft protocol but not vice versa.
(i.e. monitor) in the CT scan room to gauge the Different vendors offer a variety of options
depth of penetration of the needle. This should be and may display 3, 5 or 7 images with:
positioned on the opposite side to where s/he will
be working from. The CT table can be moved out • 3 images of the same size, centred on the
for the radiologist remotely by the CT radiogra- needle
pher to allow for repositioning by the radiologist. • 1 large image (centre) and 2 smaller images
The CT radiographer should ensure that the table (head & foot).
is returned to the needle entry position before any
further acquisitions are undertaken. The central Figure 11 shows three images of the same
image should be centred on the needle tip with an size, along with a reference line (pink) on the
image shown at levels above and below (Fig. 9). topogram to localise the scan position
anatomically.
1.8 Acquisition Option 2:

Scanning a Range 1.10 Summary of Technique for CT
Radiographer
This option is often used to increase the scan
range or display field of view (DFOV) so the As the procedure is quite similar from the radiog-
radiologist can see the extravasation of intra- rapher’s perspective, only patient positioning will
articular contrast, it is easiest to close the be discussed for musculoskeletal (MSK) injec-
INJECTION/BIOPSY protocol & open up a tions which includes all spinal, shoulder, hip and
RANGE (same FOV, X- & Y co-ordinates). The knee injections. An example will also be pro-
shortest scan range possible should be acquired vided for a lung biopsy and a biopsy of the
to see where the contrast is. Depending on the CT abdomen.
scanner, it may be possible to change between For all patients, patient preparation is the
scanning a range and the INJECTION/BIOPSY same:
protocol if needed.
• Confirm patient ID.
• Confirm pregnancy status of female patients
1.9 Acquisition Option 3: CT of child-bearing age.
Fluoroscopy • Radiologist completes consent form.
• Change patient into gown.
This is a continuous CT fluoroscopy technique • Remove radiopaque artefacts from the area of
which allows the radiologist to screen ‘live’. The interest.
Fig. 9 Example of iSequence from Siemens demonstrating three slices, centred upon the needle tip. Images Courtesy
of Siemens Healthineers (2021)
Fig. 10 Room set-up

for CT-guided
interventional procedure.
Personal photo
If any breathing instructions are required, affected by sedation. Where the radiographer
these should be practiced with the patient in remains at the console outside the CT room, the
advance, particularly if they are sedated. It must microphone should be turned on to communicate
be appreciated that patient compliance may be with the radiologist during the procedure.
Fig. 11 Example of three images for CT-guided interventional procedure. Images Courtesy of Siemens Healthineers (2021)
1.11 Lumbar Spine Injections prolapsed disc and the compressed nerve.
Correct location of the needle tip (i.e. inferior
When performing a facet joint injection or medial and lateral to the ipsilateral pedicle) is con-
branch block, there is no clinically significant differ- firmed with a test injection of iodinated contrast
ence in terms of effectiveness based upon the injec- agent which should outline the extraforaminal
tion being administered into the facet joint or the nerve roots. Care must be taken not to inject
pericapsular soft tissues. However, if treating a neu- accidentally into a spinal artery, and the risk of
ral compression, then the injection must be adminis- this occurring should be discussed with the
tered intra-articularly (Watson and Jones 2018). patient as part of the consent process. In rare
Nerve root injections are generally adminis- cases, it can cause paraplegia. Alleviation of
tered to more complex patients. It is very impor- symptoms can be slow and may take 2–3 months
tant that recent MRI scans are reviewed to (Watson and Jones 2018).
confirm the correct side and vertebral level(s) to Table 2 summarises the procedure for a CT
be injected. The objective is to locate the needle radiographer when providing CT-guidance for a
tip outside the nerve root sheath so when the lumbar spine injection. The technique is similar
injection is administered, it passes between the for all types of injections.
Table 2 Lumbar spine injection procedure

Patient • Patient lies head first prone on scan table
position • Position laser lights (topogram/scanogram):
– X-axis: In the midline, at level of diaphragm
– Z-axis: Midway between anterior & posterior skin margins
• Apply radiopaque CT interventional grid over area of interest (with grid lines parallel to Z-axis)
• Explain the importance of staying still to the patient
Scan range Topo direction: Cranio-caudal
topo From: T11
To: S3
Scan range Pre-planning scan to include:
pre-plan ½ vertebral body above & below inter-vertebral level, as guided by radiologist
Recons Creating: Series description: To include:
pre-plan Thick –axial softs L-Sp_Pre-Plan 2 mm [spine] ½ vertebral body above &
below inter-vertebral inj level
Thick –axial bones L-Sp_Pre-Plan 2 mm [bone] ½ vertebral body above &
below inter-vertebral inj level
Procedure • If the radiologist is screening from inside the CT scan room using CT Fluoro:
– Attach the joystick to the side of the CT table & position the foot pedal on the side they will be
working from. Position the monitor on the opposite side.
– Switch on HAND CARE if available
– Turn on the speaker on CT control panel so you can hear the radiologist!
• Adjust the DFOV to include the L-spine, as well as the skin markers. Note the FOV, X & Y
co-ordinates.
• Recon both the soft & bone pre-planning scans, then call the radiologist.
• Radiologist reviews the pre-planning scan & selects the point of entry by measuring angle/distance
from grid on the skin surface.
• Document slice position [SP].
• Move the CT table to that position. Go into the CT scan room, turn on laser light and mark the
spot using a permanent marker. Then move the patient out of the gantry ready for the radiologist to
start.
Scan range • This mode usually acquires three slices of 2-3 mm thick—Centre, head & feet.
injection • On the pre-planning images, select the slice of interest where the radiologist marked the angle of
entry. Then move the table to that position. This table position will be the centre image. EXPOSE.
• Select head, centre or foot image where tip of needle is demonstrated & move the table to that
position. EXPOSE.
Recon’s Creating: Series description: To include:
injection Thick –axial soft L-spine_Inj 2–3 mm [Spine] Needle tip
Scan range If the needle is being inserted at an angle, the radiologist may choose to angle/tilt the gantry OR to
Range1 ‘Repeat range’ from pre-planning scan:
• When reconstructing, enter the FOV, X & Y co-ordinates from the reconstructed pre-planning
images
• Set a short scan range & REPEAT as required
Range1 Thick –axial soft LSpInj_Range1 2.0 [spine] Needle tip
Thick –axial bone LSpInj_Range1 2.0 [bone] Needle tip
Scan range • Radiologist may choose to use this mode if it is a challenging patient
CT Fluoro • This mode acquires three slices of 5–7 mm thick—centre, head & feet.
• When reconstructing, enter the FOV, X & Y co-ordinates from the reconstructed pre-planning
images
• The radiologist will position the table using the joystick and screen using the foot pedal.
• Different radiologists like different viewing—1 big box, 2 small & 1 big, three equal size…check
radiologist’s preferences.
(continued)
Table 2 (continued)
CT Fluoro Thick –axial soft CTF_Soft 2-3 mm [spine] Needle tip
Thick –axial soft CTF_bone 2-3 mm [Bone] Needle tip
Post- • Select image with needle tip where injection was given. Note series & image number.
processing • Add reference line & SAVE
• There should be two images—topo/scano (with reference line) & image with tip of biopsy
needle
• Zoom up the topo if necessary
• SAVE AS…“Inj site”
• Document radiation dose (CTDIvol & DLP), patient’s height and weight.
• CLOSE exam.
Archive to • Topo/Scano
PACS • Pre-planning scans
• Injection site
• Dose report
Medicare 57341 CT interventional
billing 104 consultation
And…
• 39013 facet
• 18232 epidural
• 18276 nerve root block
Fig. 12 L4/5 epidural

injection. Example of Topo with grid Topo with reference line Injection site
images sent to
PACS. Images
reproduced with
permission
Figure 12 shows the final images that are com- to avoid both the vertebral blood vessels and the
monly sent to PACS for an epidural injection into nerve root (Watson and Jones 2018).
the lumbar spine.
1.13 Shoulder Hydrodilatation ±

1.12 Cervical Spine Injections Injection ± Arthrogram
When performing nerve root injections of the cer- If the needle is correctly located within the shoul-
vical spine, extreme care must be taken to ensure der joint capsule, a test injection of contrast will
that the needle tip is located correctly. The risk of disperse from the needle tip around the joint
accidental intravascular injection, particularly to within the capsule (Fig. 13).
the vertebral artery, is higher than in the lumbar If the needle is not correctly located, the con-
spine. When inserting the needle, the radiologist trast media remains concentrated at the tip of the
should ensure that it passes posterior to the carotid needle. Iodinated contrast is usually absorbed
and jugular vessels, aiming towards the outer bony from the joint and excreted from the body within
rim of the posterior aspect of the foramen in order a few hours. However, if air is injected to dilate
Fig. 13 Patient positioned supine with anterior approach

and contrast injected. Image reproduced with permission
Fig. 14 Patient positioned lateral decubitus with poste-

rior approach and air injected. Image reproduced with
permission
Fig. 15 CT image

showing needle entering
shoulder joint and
contrast media
dispersed. Topogram
with reference line is
present in bottom right
corner. Image
reproduced with
permission
the joint capsule, not only can this be quite pain- to the glenohumeral joint. For the anterior
ful for the patient at the time, it may also take up approach, the patient lies supine on the CT table
to 4 days to be absorbed (Fig. 14). with the affected arm externally rotated. The
If the patient is going for an MRI arthrogram other arm may be raised above their head if the
immediately following the CT scan, it is impor- patient can tolerate it. This approach offers two
tant that any air bubbles within the shoulder joint main advantages:
are removed, as they will cause an artefact on the
MRI images. Approximately 15 ml of diluted low 1. Removes long head of the biceps tendon away
osmolar contrast agent is injected into the shoul- from the region of interest and
der (Watson and Jones 2018) (Fig. 15). 2. Facilitates a vertical needle entering the gle-
Patient positioning can vary and may involve nohumeral joint without damaging the gle-
anterior, modified anterior or posterior approach noid labrum.
Table 3 Shoulder injection procedure

Patient • Posterior approach—patient lies on
position scan table with head first
• Position laser lights:
– X-axis: Superior skin border of
shoulder
– Z-axis: Along axis of humeral head
• Apply radiopaque CT interventional
grid over lateral aspect of shoulder distal
to coracoid process (with grid lines
parallel to Z-axis)
Scan Topo direction: Cranio-caudal
range From: Skin borders superiorly
topo To: Inferior angle of scapula
Scan Pre-planning scan to include:
Fig. 16 Patient lateral decubitus positioning for posterior range Region of interest, as guided by the
approach. Personal photo pre-plan radiologist.
• Usually AC joint to inferior border of
glenoid fossa
The posterior approach may be favoured by Recons Creating: Series To include:
pre-plan description:
the patient if they don’t want to watch. The
Thick–axial Shoulder Skin
patient is prone or in the lateral decubitus posi- bone bone superiorly
tion with the affected shoulder raised on the CT 2–3 mm to inferior
table with a sponge under the affected shoulder to [bone] angle of
scapula,
raise it slightly (Fig. 16).
including
The affected arm is relaxed (half-way between skin
pronation and supination) so that the posterior margins and
capsule is relaxed. This approach requires the medial end
of clavicle
needle to go through less soft tissue (Watson and
Recon’s Creating: Series To include:
Jones 2018). Table 3 summarises the procedure injection description:
for a CT radiographer when providing Thick–axial Shoulder Shoulder
CT-guidance for a shoulder injection using the soft bone joint
posterior approach. 2–3 mm capsule
[bone]
Figure 17 shows the final images that are com-
monly sent to PACS for an injection into the CTF_ description:
shoulder. Bone Thick–axial Shoulder Needle tip
soft bone
5–7 mm
[bone]
1.14 Hip Injection
billing
When injecting into the hip, a test injection of
iodinated contrast may be administered after the
radiologist has felt a ‘give’ as the needle passes Figure 18 shows the final images that are com-
through the joint capsule. The contrast should be monly sent to PACS for an epidural injection into
seen to disperse away from the needle tip, thereby the lumbar spine.
confirming that the needle is correctly located at
the level of the femoral neck, immediately below
the junction with the femoral head. Table 4 sum- 1.15 Knee Injection
marises the procedure for a CT radiographer when
providing CT-guidance for a hip injection. The In accordance with the ALARA principle, knee
technique is similar for all types of musculoskele- injections may be performed under ultrasound
tal injections. guidance with no exposure to ionising radia-
Fig. 17 Right shoulder

injection. Example of Topo with grid Topo with reference line Injection site
images sent to
PACS. Image
reproduced with
permission
Table 4 Hip injection procedure

Indications To introduce steroid into the hip joint
Patient • Patient lies supine/prone on scan table with feet first
position • Arms overhead
– X-axis: Iliac crests
– Y-axis: Mid-sagittal plane
– Z-axis: Midway between anterior & posterior skin surfaces of pelvis
• Apply radiopaque CT interventional grid over antero-lateral aspect of hip at level of ASIS (with
grid lines parallel to Z-axis)
• Explain the importance of staying still to the patient
Scan range Insert RIGHT or LEFT into ‘comment’ field
topo Topo direction: Cranio-caudal
From: Iliac crest
To: Lesser trochanter
pre-plan ASIS to inferior aspect of acetabulum
pre-plan description:
Thick–axial bone Hip_Pre-Plan ASIS superiorly to inferior aspect of
3 mm [bone] acetabulum inferiorly, including skin
margins laterally
Recon’s Thick–axial soft Hip inj 2–3 mm Needle tip
injection [bone]
Thick–axial soft HipInj_Range1 Hip joint capsule
3 mm [bone]
billing
tion or using fluoroscopy where the radiation anatomical structures. The patient should be
exposure is expected to be lower than using sedated and their vital signs monitored through-
CT. out the procedure by a nurse. The radiographer
should be aware of any leads (or drains) attached
to the patient that may be dislodged when the
1.16 Lung Biopsy table moves during the procedure, particularly if
they are hidden by the sterile drape. The biopsy
Lung biopsies should only be performed in a needle should be advanced upon suspended res-
hospital environment with a resuscitation team piration, having practiced in advance with the
available on-site. The patient should be fasting patient. There should also be a familiarisation
for sedation. The patient will be positioned opportunity for the patient to hear the biopsy
according to the location of the lesion in order gun being triggered as it can be an unexpected
to provide the shortest access to the lesion from noise causing the patient to move which is
the skin surface, avoiding any major internal highly undesirable. A common complication of
Fig. 18 Left hip

injection. Example of Topo with metallic strip to
images sent to PACS Topo with reference line Injection site
use as a grid/guide
Table 5 Lung biopsy/drainage procedure

Indications Lesion identified on previous imaging—lung, mediastinum…
Patient • Patient lies supine/prone on scan table with head first
– X-axis: Apices
– Y-axis: Mid-sagittal plane if supine/spinous processes if prone
– Z-axis: Midway between anterior & posterior skin surfaces of chest
topo From: Apices
To: Diaphragm (lower posteriorly)
OR region of interest, as specified by radiologist
chest C- Region of interest ONLY, as guided by radiologist
chest C- Thin–axial softs Chest C- 0.5–1 mm soft [med] ROI superiorly to inferiorly,
including skin margins laterally
Thin–axial lungs Chest C- 0.5–1 mm sharp ROI superiorly to inferiorly,
[lung] including skin margins laterally
Thick–axial softs Chest C- 5 mm soft AX ROI superiorly to inferiorly,
Thick–axial bones Chest C- 5 mm bone AX ROI superiorly to inferiorly,
Thick–axial lungs Chest C- 5 mm lung AX ROI superiorly to inferiorly,
biopsy 3 thick images Biopsy 2.4 < body medium Tip of needle/biopsy gun on
smooth +soft> [med] Centre image
billing 38812 lung biopsy
104 consultation
a lung biopsy is a pneumothorax which occurs CXR 2–4 h post-procedure. Table 5 summarises
in ~20% of cases. Therefore the patient should the procedure for a CT radiographer when pro-
be monitored closely after the procedure. The viding CT-guidance for a lung biopsy/drainage
patient may require a non-contrast CT chest and Table 6 for a biopsy/drainage within the
immediately following the biopsy to rule out a abdominal cavity. The technique is similar for
pneumothorax. They will most likely require a all types of biopsies and drainages. Figures 19
Table 6 Abdomen biopsy/drainage procedure

Indications Lesion identified on previous abdominal imaging—liver, renal, spine…
Patient • Patient lies supine/prone on scan table with head first
– X-axis: Nipples
– Y-axis: Mid-sagittal plane
– Z-axis: Midway between anterior & posterior skin surfaces of abdomen
topo From: Diaphragm
To: Symphysis pubis & skin margins laterally
Abdo C- Region of interest ONLY, as guided by radiologist
Abdo C- Thin –axial softs Abdo C- 0.5–1 mm soft ROI, including skin margins
[Abdo] laterally
Thick–axial softs Abdo C- 5 mm AX [Abdo] ROI superiorly to inferiorly,
including skin margins
laterally
biopsy Three thick images Biopsy 2–3 mm soft [Abdo] Tip of needle/biopsy gun on
Centre image
Medicare • 57341 CT interventional
billing • 30094 aspiration biopsy—this may be a different code, depending on what is being biopsied
• 104 consultation
Fig. 19 Lung biopsy of

left upper lobe mass. Topo Axial slice showing LUL lesion
Examples of images sent
to PACS. Images
reproduced with
permission
Biopsy site Pneumothorax

Fig. 20 Biopsy
abdominal mass. Topo with grid Pre-Planning (Soft Tissue) Biopsy site (Bone)
Examples of images sent
to PACS. Images
reproduced with
permission
Canon Medical Systems ANZ. Computed tomogra-

and 20 show the final images that are commonly phy; 2021. https://anz.medical.canon/products/
sent to PACS for a lung biopsy and an abdomi- computed-tomography
nal biopsy. Siemens Healthineers Australia/New Zealand. Computed
tomography; 2021. https://www.siemens-healthineers.
com/en-au/computed-tomography
The Royal Australian and New Zealand College of
2 Pitfalls Radiologists. Inside Radiology -Interventional
Radiology; 2018a. https://www.insideradiology.com.
The biggest risk when performing CT-guided au/interventional-radiology/
The Royal Australian and New Zealand College of
interventional procedures is that the patient may Radiologists. Iodinated contrast media guideline.
move. The CT radiographer must be familiar RANZCR Iodinated Contrast Guidelines; 2018b.
with the CT scanner to get the scan centred back https://www.ranzcr.com/college/document-library/
on the needle as quickly as possible. It is very ranzcr-iodinated-contrast-guidelines
The Royal Australian and New Zealand College
helpful to practice breathing instructions with the of Radiologists. Medical Imaging Informed
patient to ensure that they take the same sized Consent Guidelines. Medical imaging
breath each time. informed consent guidelines; 2019. https://
w w w. r a n z c r. c o m / c o l l eg e / d o c u m e n t -l i b r a r y /
medical-imaging-informed-consent-guidelines
Watson N, Jones H, editors. Chapman & Nakielny's
References guide to radiological procedures. 7th ed. Amsterdam:
Elsevier; 2018.
Beekley Medical. 2020. https://beekley.com/ Webb Medical. 2020. https://beekley.com/product-details/
product-details/guidelines/ct-biopsy-grid-217 guidelines/ct-biopsy-grid-217
Tips, Tricks, Radiation Dose
and Protection
Abstract 1 Tips and Tricks
Once the patient is set up on the CT table in The radiologist scrubs up, cleans and drapes the
the most suitable position with the radio- patient, and begins the procedure. To track the
opaque grid placed on their skin, a ‘Pre- needle position throughout the procedure, we
Planning’ scan over the area of interest is usually use the ‘Injection/Biopsy’ protocol which
acquired. The radiologist uses this scan to gives the radiologist three images with the central
assess the anatomy and decide the best access one centred on the needle tip. Occasionally, CT
point and direction for the needle. It is very fluoro may be used or a ‘low dose’ helical range
important to try and get the patient as comfort- acquired. It does not cover a large scan range, but
able as possible (this can sometimes be diffi- is adequate for checking needle positions. A lon-
cult to achieve) to ensure the patient can ger range may be requested by the radiologist if
remain still for the entire duration of the pro- there is a complication and a larger anatomical
cedure. This is very important for maintaining area needs to be visualised, but this is usually
sterility, and also so the planned entry site and only required at the end of a lung biopsy to rule-
direction of needle are consistent with the ini- out a pneumothorax.
tial planning scans, thereby minimising any
complications.
2 Radiation Dose
Keywords and Radiation Protection
Low dose · Dose limitation · Radiation If CT fluoroscopy is not available on the CT

protection · Tips and tricks · CT imaging scanner, local protocols will require a short
‘range’ to be acquired and then repeated. This is
not ideal as the radiation dose is significantly
higher for the patient. If a department is intend-
ing to perform interventional procedures regu-
E. Doyle (*)
larly, a CT scanner with the appropriate
e-mail: [email protected] technology should be procured.
P. J. Ratnakanthan
Capitol Health, Melbourne, Australia
2.1 Clinical Example of Dose from the ‘Pre Planning’ scan should not be
Reduction for CT-Guided included. This data can then be used to calculate
Lumbar Spine Injections a facility DRL (fDRL) and should be reviewed
regularly to optimise radiation dose, ensuring
• CARE Vision is Siemens ‘live’ continuous that patients receive the lowest radiation dose
fluoroscopy screening mode, whereas possible whilst providing adequate image quality
‘Repeating the range’ literally involves repeat- that the radiologist can safely perform the
ing the Pre-Planning scan (2 mm slices). It CT-guided interventional procedure (Fig. 2).
presumed that the CT radiographer would With support from a medical physicist, radiation
reduce the exposure parameters in accordance doses from CT can be compared to fluoroscopy
with the ALARA principle. One way of for similar procedures.
achieving a lower dose is by reducing kV Following a dose reduction initiative for
instead of mA. interventional CT procedures, an audit in one
• ‘New’ injection = Biopsy mode is an intermit- particular department showed that the
tent fluoroscopy mode = 3 images: 1 at needle ‘Injection/Biopsy’ protocol used the lowest
tip, 1 (2.4 mm) above & 1 (2.4 mm) below. radiation dose. Since introducing this technique
in May 2015, the facility (fDRL) for a
Figure 1 shows the different options offered CT-guided injection of the lumbar spine was
by Canon CT scanners. reduced by 70% compared to scanning a range
Radiation dose in CT is measured by CTDIvol and is 90% lower than when using CARE
(per slice) and DLP (CTDIvol x scan range/ Vision. CT fluoro (CARE Vision) was reserved
length). These are estimations based on scanning for more complex cases, and Repeat Range was
a phantom. They are calculations of the radiation only used when required to view a longer scan
dose emitted by the CT scanner but are not equal length but this is associated with an increased
to the dose received by the patient. In order to DLP due to the definition of DLP. This example
calculate local Diagnostic Reference Levels demonstrates how radiographers can lead a
(DRLs), the CTDIvol, DLP, height & weight dose reduction strategy in a CT department in a
should be recorded for the interventional proto- collaborative project with the multidisciplinary
col that was utilised by the radiologist, i.e. dose team within radiology.
Fig. 1 CT fluoroscopy options on a Canon CT scanner. Image Courtesy of Canon Medical (Canon Medical Systems
ANZ, 2021)
Tips, Tricks, Radiation Dose and Protection 129
CT-guided L-spine injection (DLP)

600
500
400
pDRL (May-Nov ‘14)
May-14
mGy-cm
300 Nov-14
pDRL (>May 2015)
May-15
200 Aug-15
100
0
Planning CT-guided Inj CARE Vision Repeat Range Injection
Technique
Fig. 2 Chart comparing DLP for departmental lumbar spine injections following a change in protocol. Figure repro-
duced with permission
2.2 Radiation Protection of Staff SHIELDING FOR DIAGNOSTIC RADIOLOGY

Rear of Gantry
Where possible, staff not required to be in the CT
room during exposure should leave. If the radi-
ologist and/or nurse must remain in the CT room 40º
during exposure, they must wear appropriate per-
Shielding
sonal protective equipment and should be by Gantry Shielding
shielded using mobile lead screens. Use of the by Gantry
inverse square law should be applied. Staff should 20º
position themselves where radiation dose is low-
est in accordance with the dose map for the local
CT scanner (Figs. 3, 4, and 5).
Front of Gantry
2.3 Methods to Reduce 0.1 µGy/mGy cm 0.02 µGy/mGy cm

Occupational Radiation Dose 0.005 µGy/mGy cm 0.001 µGy/mGy cm
Calculated 0.02 µGy/mGy cmcontour
Where available, technological dose reduction

Fig. 3 Isodose map for CT scanner (Martin 2015) show-
options such as Siemens HAND Care or Canon
ing that the lowest radiation dose will be received when
Partial Exposure should be turned on when the standing beside the gantry
radiologist is operating the CT scanner and
remaining next to the patient during the proce-
dure. This feature turns off the radiation on the For procedures that will have longer screen-
side that the radiologist is located in order to ing/scan times, a mobile or ceiling-suspended
reduce the scatter radiation from the patient in lead shield should be provided for the staff
that area (Figs. 6 and 7). remaining in the CT room (Fig. 8).
20
10 40 10
100
200
200
100 5
50
20
10
1m
5 5
(Unit µGy)
Standing ( ) is recommended
Fig. 4 Recommendation from Canon Medical demon-

stating area of lowest radiation dose to staff. Image
Courtesy of Canon Medical
Fig. 5 Horizontal local

dose distribution map
for Siemens Definition
AS 128-slice CT scanner
showing that the lowest
radiation dose will be
received when standing
beside the gantry
(measurement values in
microGy /mAS). Images
Courtesy of Siemens
Healthineers Australia
New Zealand (2021)
Fig. 6 Siemens
HandCARE. Images
Courtesy of Siemens
Healthineers
Fig. 7 Canon Partial

Exposure when the
radiologist should stand
on the blue side, in this
example the left side.
Images Courtesy of
Canon Medical (Canon
Medical Systems ANZ,
2021)
Fig. 8 Photograph of interventional CT set-up with

ceiling-mounted protective lead screen. Image Courtesy
of Tallaght University Hospital, Dublin
References Siemens Healthineers Australia/New Zealand. Computed

tomography; 2021. https://www.siemens-healthineers.
com/en-au/computed-tomography
Canon Medical Systems ANZ. Computed tomogra-
phy; 2021. https://anz.medical.canon/products/
computed-tomography
Martin C. Radiation shielding for diagnostic radiology.
Radiat Prot Dosim. 2015;165(1–4):376–81.
Part IV
CT Forensic Imaging
CT Forensic Imaging
Edel Doyle and Anthony J. Buxton
Abstract immigration officers or medical doctors.

These are not ‘medical’ referrals so the justifi-
Forensic CT involves the utilisation of com- cation process for these ‘medico-legal’ imag-
puted tomography (CT) to answer questions ing procedures requires a higher level of
of law and can be used in investigations of the consideration as the individual does not
living or deceased. With the advent of low- directly benefit them and therefore informed
dose protocols, the use of CT in forensic consent is required. It is important that any
imaging of the living is increasing. Post- radiographers undertaking forensic CT should
mortem CT is frequently used to supplement be appropriately trained in the medico-legal
the invasive autopsy post-mortem examina- aspects, including local legislation. Training
tion. It is appreciated that the coroner is ulti- should also be provided so forensic radiogra-
mately responsible for the post-mortem phers can recognise the signs and symptoms
investigation of all deceased and their permis- of post-traumatic stress disorder in themselves
sion must be granted for any imaging to occur, and in colleagues.
as well as for the images to be used in any
subsequent publications. Often the agreement Keywords
of the next of kin is also sought. There are a
number of approaches to acquiring post- Forensic CT · Legal · Law · Living cases ·
mortem CT scans, depending on the presenta- Deceased cases
tion of the deceased. As the availability and
use of post-mortem CT are increasing, addi-
tional information can be acquired using 1 Introduction
advanced imaging techniques to assist the
post-mortem investigation such as angiogra- The autopsy is the gold standard in death investi-
phy, CT-guided biopsies or CT ventilation. In gation with imaging used to supplement this
living cases, there can be multiple referrers examination (Roberts et al. 2012). Whilst it has
such as the police, border control officers, been proposed that imaging could replace the
invasive post-mortem autopsy, this has not been
implemented in the majority of jurisdictions and
E. Doyle (*) · A. J. Buxton will not occur in cases where criminal charges
International Association of Forensic Radiographers, may be brought about without further supporting
Melbourne, Australia research (Varela Morillas et al. 2020).
138 E. Doyle and A. J. Buxton
The use of post-mortem computed tomogra- Virtopsy group in Switzerland introduced the
phy (PMCT) within the field of forensic medi- concept of using CT in virtual autopsy proposing
cine was first reported in 1977 for the study of that it could potentially replace the conventional
gunshot injuries to the head (Wullenweber et al. autopsy (Dirnhofer et al. 2006). In 2012, Roberts
1977). The use of PMCT is evolving and it is et al. concluded that whilst CT was more accurate
becoming a common tool for forensic patholo- than MRI in establishing cause of death com-
gists investigating the cause of death in coronial pared to autopsy, there was no suggestion that
cases. The 3-dimensional imaging capabilities of imaging should replace the conventional autopsy.
PMCT offer many benefits, one of which is the Today, CT is often used in forensic cases to assist
fact that PMCT images are well accepted in court in answering questions of law, which can relate to
as they can portray the extent of injuries that are either living patients or deceased subjects. CT is
not as confronting as forensic photographs of the often used to triage post-mortem cases to help the
case. forensic pathologist to decide if an autopsy is
Involvement of radiographers in a forensic CT necessary and may help to limit the extent of the
service requires detailed knowledge of the image invasive autopsy. For example, if the CT scans of
acquisition process to provide images that con- the head and abdomen do not raise any suspi-
tribute to the medico-legal investigation and a cions, the autopsy may be limited to the thoracic
comprehensive understanding of medico-legal cavity with the option available to extend the
principles including, but not limited to, consent, autopsy if needed.
integrity, continuity of evidence and scope of
practice. The CT images produced may be pre-
sented as evidence in court and a radiographer 3 Future of Forensic Imaging
may be called to court as a Witness of Fact.
Radiographers may also be required to provide a Research groups are constantly testing new
Preliminary Image Evaluation (PIE) or profes- technological advances to forensic applications.
sional review of the CT images to assist the In specialist forensic centres, PMCT angiogra-
pathologist. phy may be undertaken, as it is particularly ben-
PMCT has proven particularly valuable in eficial in identifying some pathologies that will
mass disaster situations providing large datas- not be visualised on the invasive post-mortem
ets of imaging information that can be recon- autopsy such as air emboli. Targeted PMCT cor-
structed for use by odontologists or onary angiography is also an option (Roberts
anthropologists to assist in Disaster Victim et al. 2011), as opposed to whole-body PMCT
Identification (DVI) and assist pathologists in angiography. When undertaking whole-body
establishing the Cause of Death. This all con- PMCT angiography, there are a number of tech-
tributes to the final report submitted to the coro- niques currently in use to administer contrast,
ner (Dorries 2020; Brough et al. 2015; Mentink including resuscitation, clinical injector pump
et al. 2020). or a VIRTangio(T) injector pump (Morgan et al.
2014). However, PMCT angiography is not rou-
tinely performed in Australia at this time. There
2 History of Forensic Imaging are specific considerations when selecting a
contrast medium including dilution, water-
Roentgen discovered the “invisible ray” on 8 based contrast or oily-based contrast (Grabherr
November 1985 and radiography was first used et al. 2015). The decision to undertake PMCT
in a first forensic case on 24 December 1895. CT angiography will be strongly influenced by the
was first used clinically in 1972 and was used to next steps in the death investigation process, as
describe a gunshot wound to the head in 1977 the contrast media may affect toxicology results
which is acknowledged as the first forensic use of (Robinson et al. 2019a). However, it has not
CT (Wullenweber et al. 1977). In the 2000s, the been shown to influence further tests if a tar-
CT Forensic Imaging 139
geted PMCT coronary angiography is per- 4 Living Versus Deceased

formed (Rutty et al. 2013). Since the literature Cases
review published by (Jayasooriya and Doyle
2019), in the same year (Robinson et al. 2019b) CT may be used in living cases for medico-legal
concluded that a PMCT angiography does not purposes, and this requires special consideration
add any additional value to the death investiga- of the justification, as there is not a direct health
tion process in a deceased person with a high benefit for the individual. Forensic imaging in the
PMCT calcium score. It must be noted that these living may include non-accidental injury, age
are advanced forensic imaging techniques and estimation or the identification of concealed
additional education is recommended and there- objects, e.g. drugs, diamonds or weapons. Many
fore is beyond the scope of this book (Grabherr radiographers will undertake forensic CT when
et al. 2016). imaging potential injuries following an alleged
PMCT pulmonary ventilation of adults and assault or road traffic crash. Viner (2006) clari-
children is also undertaken at some specialist fied that it is not necessarily known at the time of
centres but requires additional equipment (Rutty imaging that the examination may be the ‘subject
et al. 2016). This technique is used to expand the of a legal action’ in the future and that the images
lung tissue to assist in the detection of subtle lung produced or the radiologist’s report may be
pathologies (Germerott et al. 2012). It is acknowl- required to be presented in court as evidence.
edged that this approach is not appropriate for Best practice guidelines have been published by
use in cases with suspected airborne or droplet the International Association of Forensic
diseases. In a situation where there is an outbreak Radiographers (IAFR) to ensure that any images
of an airborne disease pandemic, e.g. the produced maintain the chain of evidence and
COVID- 19 pandemic, this technique was therefore are admissible in court (Doyle et al.
suspended. 2020).
CT may also be used to guide biopsies or Imaging to assist with the estimation of
specimen retrieval (Bolliger et al. 2010); again skeletal age may be requested in immigration
whilst this is not yet common practice in cases to help identify if an individual should be
Australia, it is another technique that may be considered an adult or a child, particularly
used to help provide additional information to when birth records may not be available. The
assist in establishing the cause of death use of CT when estimating skeletal age has
(Higgins et al. 2016). CT-guided biopsies can been considered and is not generally recom-
even be performed by robots (Martinez et al. mended in the guidelines published by the
2014). IAFR due to the radiation dose implications
Dual energy imaging was proposed for use in (Doyle et al. 2019).
forensic imaging in 2013 (Alkadhi and Leschka Low-dose abdominal CT is recommended
2013) with multiple potential applications. It over abdominal X-ray as a screening tool for sus-
may be used to assist with identifying illicit drugs pected body packers due to its superior sensitiv-
(Leschka et al. 2013) in the living (Platon et al. ity, specificity and ability to accurately localise
2016; Flach et al. 2011). Spectral imaging will drug packets (Lan and Doyle 2019). However, it
also introduce new opportunities in the forensic should be remembered that what may start as a
setting. medico-legal case could become a medical emer-
However, all new techniques must be accept- gency should the drug packets rupture. The pro-
able in court and therefore, it can take time to be cess of obtaining informed consent from the
accepted in the medico-legal context as the evi- individual must be thoroughly considered in both
dence presented in court must meet the required of these scenarios. Radiographers involved in
burden of proof, e.g. ‘beyond all reasonable forensic CT must be aware of the medico-legal
doubt’, as well as ensuring continuity of the chain principles and local legislation in respect to the
of evidence. imaging undertaken.
Permission to use PMCT images must be as it was concluded that due to his clinical
obtained from the coroner so publication of symptoms, it was highly likely that the packag-
forensic case studies is often rare. As with all ing had ruptured and that he was at a high risk of
medico-legal and forensic cases, details pertain- poisoning. The packages were provided to the
ing to the case should not be discussed with peo- police for testing and it is presumed that the
ple who are not directly involved in the patient was prosecuted for the associated crimi-
investigation. This is to ensure that justice is nal charges.
achieved, as well as respecting the confidentiality CT brain imaging may be undertaken as part
of the deceased and their family. of the investigation of non-accidental injury
Figure 1 shows an example of a patient in (NAI) or suspected physical abuse in children to
police custody who was admitted to the ward from identify a subdural haematoma that could be
the Emergency Department with abdominal pain. associated with rapid acceleration/deceleration
He was arrested and detained following a pursuit as the result of shaking the child (Radiologists
by police when the car turned back from a routine 2017). The detection of post-mortem rib fractures
police checkpoint. When the car was apprehended, is improved with CT compared to chest X-rays
it was suspected that there was a quantity of drugs (Shelmerdine et al. 2018). To date, there is no
in the possession of the patient. However, he was evidence to support the use of CT to replace the
unable to answer questions when first stopped, as traditional series of X-rays in a skeletal survey in
his mouth was full. He was taken to the local living children as part of the NAI investigation,
police station for further questioning, where he with the exception of the aforementioned CT
complained of a pain in his stomach. A doctor was brain scan.
called to the police station and advised that the Radiation protection is a very important
detainee be taken to the Emergency Department so consideration when using CT to provide foren-
the cause of his abdominal pain could be thor- sic imaging in living people. CT can also be
oughly investigated. The patient was referred for performed post-mortem, with or without the
an abdominal X-ray and CT. use of intravenous contrast, to help the pathol-
The patient was transferred from CT to the- ogist and coroner to establish the cause of
atre to remove the suspicious packages urgently, death. In Australia, the coroner is legally
responsible for the identification of the
deceased, as well as the investigation surround-
ing their death. Whilst consent from the next of
kin is always sought, if withheld, the coroner
may over ride and order that the post-mortem
examination proceed. The family can object to
the coroner’s ruling but this may require a
Supreme Court challenge which they would be
required to fund and it can be extremely expen-
sive, so generally all efforts are made to sup-
port the next of kin to agree. It is important to
remember that religious and cultural consider-
ations are always considered but sometimes the
law can take precedence, e.g. in the case of
homicide. Whilst radiation protection may not
be a primary consideration when performing a
Fig. 1 CT scan of police detainee who developed abdom-
CT scan of the deceased, radiation output
inal pain whilst in custody. The yellow arrow identifies an
area of high attenuation density in the distal ileum. should be considered in terms of extending the
Reproduced with permission (Doyle 2009) lifetime of the equipment.
5 Advantages an adjunct to the invasive autopsy, rather than as a

and Disadvantages of Post- replacement (Roberts et al. 2012; Higginbotham-
Mortem CT (PMCT) Jones and Ward 2014). Recently, PMCT has been
utilised to increase the speed and accuracy of
As a cross-sectional imaging modality, post- imaging in the forensic investigation of a Mass
mortem CT offers many benefits to forensic Fatality Incident (MFI) (Rutty et al. 2007; Levy
investigations. PMCT is non-invasive compared and Harcke 2011). It has been stated that ‘today
to the traditional autopsy so that the body is not cross-sectional imaging has an established role in
damaged during the imaging process; this can be mass fatality incidents across the world’ (NHS
important to some cultural or religious groups. Implementation Sub-Group of the Department of
PMCT provides images that are objective with Health Post Mortem 2012, p. 35) but the post mor-
evidence documented in situ prior to the invasive tem, forensic and disaster imaging (PMFDI)
and destructive autopsy. The CT scans can be Group did not describe or quantify the extent of
reviewed many times, including retrospective the role of PMCT in the DVI process. In Australia,
review by an independent expert, even after the PMCT is routinely used in Victoria and New South
autopsy has been performed. The acquisition of Wales with access to PMCT facilities available in
PMCT scans is relatively quick compared to the Queensland, South Australia, Tasmania, Western
time taken to perform an autopsy, making it quite Australia, the Australian Capital Territory and the
useful in the identification of deceased in mass Northern Territory.
disasters such as the MH17 terrorist incident
(Hofman et al. 2019).
Forensic imaging is accepted and recognised 5.1 Strengths of PMCT
internationally as an integral part of the DVI pro-
cess (Interpol 2009) and includes radiography, A cross-sectional imaging modality such as CT
dental x-rays, fluoroscopy and CT (Doyle et al. allows for complex data to be acquired in minutes
2020). Forensic imaging involves the application and then to be reviewed in an easy and interactive
of diagnostic imaging techniques to answer ques- format (Thali et al. 2003a). The acquisition of a
tions of law. Forensic imaging techniques have whole-body PMCT scan takes ‘10–15 min per
been stated to benefit the post-mortem investiga- body’ (Sidler et al. 2007). From a forensic per-
tion because the techniques are ‘minimally inva- spective, Webster (2010) emphasised that the
sive, objective, permanent and comparatively contents of the body bag can undergo PMCT
cost-effective’ (Viner 2008). As much research has scanning without the bag being opened, thus
focussed on the effectiveness of PMCT as a ensuring the integrity of the chain of evidence.
replacement for the traditional autopsy, it has been This also facilitates the exploration of both anat-
argued that that PMCT can successfully acquire all omy and injury patterns in a non-invasive and
necessary radiological information, thus eliminat- non-destructive manner (Thali et al. 2003a; O
ing the need for radiography (Sidler et al. 2007; Donnell 2010; Morgan 2010). The detailed infor-
Rutty et al. 2007; Rutty et al. 2009). Other authors mation that can be acquired by PMCT may
(Jeffery et al. 2008; Roberts et al. 2012) have reduce the number of cases where resection of
stated that PMCT cannot provide the same level of body parts such as the mandible are considered
information compared to a traditional post-mor- necessary, thereby avoiding further distress for
tem examination and that the detailed information the bereaved families (Forrest 2012).
provided by PMCT cannot replace the ‘external The CT raw data provides permanent docu-
inspection and internal examination of the mentation as well as facilitating the reconstruc-
deceased by an experienced observer’ (Thali et al. tion of 3-dimensional (3D) images, compared to
2003b). While PMCT is being used more fre- the limited 2-dimensional (2D) images produced
quently (Mahmood 2013; Thornton 2013), it is as by conventional radiography. PMCT generates
digital data that is observer-independent and non- eral regions examined using PMCT that are of
subjective (Thali et al. 2003b). This data can be areas where metal artefacts seriously degrade the
efficiently and effectively stored and is easily resultant images, such as the pelvis when the
transferred electronically if a second opinion is patient has a hip/s replacement. The most diffi-
required (Thali et al. 2003b; Leth 2009), thereby cult area to examine using PMCT is dental recon-
minimising the number of professionals required structions as part of the process of patient
in the Emergency Mortuary (PMFDI Group identification in the severely decomposed and
2012). In forensic scenarios, the security of the DVI incidents.
storage system must be assured so the data can be Imaging can be obtained using very thin slice
produced in court as evidence in the form of acquisition and the application of single energy
‘photos’ or ‘videos’. The post-processing steps metal artefact reduction or dual energy metal
performed must have been reproducible and there artefact reduction post-processing software pack-
must have been an audit trail of any changes. ages (Kawahara et al. 2019; Chandrasekar et al.
Reconstructed multi-planar images from PMCT 2020). Some CT scanners are capable of under-
have the advantage over photographs of being taking DEMAR with a single tube which switches
more visually acceptable for non-medical per- kV or by using a scanner with dual X-ray tubes.
sonnel, including family members and the jury in Access to this technology or even the software
court (Gibb 2008). for SEMAR may not be available to all centres so
the use of multiple pixel thickness Multi-Planar
Reconstructions (MPR), generally as a pseudo
5.2 Limitations of PMCT OPG is often the most helpful approach espe-
cially if the volume used contains information
The disadvantages associated with the use of about the sinus outlines (Forrest 2019). In the
PMCT include limited access to CT scanners and scenario where MAR software or algorithms are
the cost of purchasing or leasing such equipment not available on the local CT scanner, if the gan-
in the event of a mass fatality incident (MFI) or try can be angled to exclude the metallic objects
mass disaster (PMFDI Group 2012). PMCT doc- from the scan field of view, this is an alternative
umentation of dental restorations is inferior to the option of reducing streak artefacts.
description acquired from the visual dental sur-
vey, particularly due to the lack of colour infor-
mation required to differentiate types of 6 PMCT Protocol
restorations (Kirchhoff et al. 2008). The experi- Considerations
ence of radiologists in reviewing post-mortem
changes and of pathologists in reviewing cross- 6.1 Equipment
sectional images is improving but is still a limit-
ing factor in maximising the potential of forensic Technical parameters of the scanner being used is
CT imaging (Royal College of Radiologists beyond the scope of this chapter, however con-
(RCR) and Royal College of Pathologists sideration of the optimal parameters is an essen-
(RCPath) 2012). tial aspect of the scanning capability of the
When required for a medico-legal case, the scanner being used for PMCT (Gascho et al.
raw data for the relevant PMCT scans has to be 2018). The important consideration is that the
stored in a manner that will permit further data scanner must be capable of reconstructing images
reconstruction to be performed at a later date in the axial, coronal and sagittal planes, so the
(The Society and College of Radiographers and reconstructions should be made with overlapping
The International Association of Forensic slice thicknesses. If the scanner is not capable of
Radiographers 2010). isotropic image acquisition (considered to be
Streak artefacts may be caused by metallic 0.5 mm), then the use of a negative pitch is rec-
artefacts in the scan field of view. There are sev- ommended (Tsukagoshi et al. 2007).
6.2 Reconstruction role should be clearly identified when setting up

Considerations the PMCT service.
The use of PMCT which may be only to pro-
All images should be reconstructed using both a vide information relevant to the case presentation
contrast (soft) and spatial resolution (hard) algo- or as a formal record forming part of the final
rithm for all three planes, in order to visualise case record. The use of a targeted study of imag-
both soft tissue and bone structures. Thick slices ing only the relevant region/s of the body to con-
stored on a PACS system should be a minimum firm the cause of death has the advantage of
of 5 mm thick with 5 mm spacing, however reducing wear and tear on the scanner in particu-
3 mm × 3 mm is preferable if storage capacity is lar the tube life. The disadvantage of this approach
not an issue. The availability of surface shaded is that comorbidities, which may be relevant in
rendering of the region is also an advantage to the patient demise, are not identified and there is
enable an overview of the anatomy being investi- no permanent record of soft tissue anatomy of the
gated. It is recommended that each volume data- case.
set is saved to the PACS due to the possibility that The overriding consideration in regard to the
the raw datasets may be subpoenaed for a court of use of the PMCT delivery is always governed by
law. the Coronial Act of the service jurisdiction, and
The most relevant consideration in the pur- the most fundamental concept here is the adop-
chase of a scanner dedicated to PMCT is the bore tion of the least invasive approach to the identifi-
size and to this end, the larger the better, to allow cation of the identity, time and cause of death.
for cases that are hypersthenic, extensively The minimum recommend approach of a study
dilated due to decomposition or disfigured such would be a head, neck and torso examination
as a burns presentation. The consideration of with only the limbs excluded.
extended field of view reconstruction often used
in radiation therapy and dual energy capabilities 6.3.2 Study Approaches
are also important (Cheung et al. 2019). Other
important considerations are maximum weight of Head, Neck and Torso
a case and the length of table travel. This examination involves a volume acquisition
from above the vertex of the skull to the sterno-
clavicular joints and then another volume acqui-
6.3 Scanning Approaches sition from above the shoulders to mid femur.
The consideration being to ensure all abdominal
6.3.1 General Considerations contents are included along, where possible, with
The extent of imaging undertaken depends on the skin line being visible, and for males to
an established departmental protocol, and the include the external genitalia. An important con-
information provided here addresses ways to sideration here is the location of the arms for the
address this consideration. The primary consid- torso acquisition. Ideally the arms should be
eration is the service expectations of the role of raised above the head but this may not be possi-
PMCT in the service delivery, for example it is ble due to department protocol about opening
to be used just to image a specific region of the body bags and if the case must be scanned closed
body to assist in diagnosis/confirmation of a due to a suspicious nature of presentation. There
cause of death or as a permanent record of the is always a risk of post-mortem trauma to the
case to be kept on file. Ideally, the scan should body in “breaking rigor” incorrectly. The disad-
be used to provide assistance to the forensic vantage of scanning the case with the arms by the
pathologist in regard to the identification and side is the possibility of beam hardening artefacts
cause of the death of the presenting case, how- from arms outside the scanned field of view. The
ever it can also be used to identify comorbidity use of a large bore scanner can alleviate this to
conditions that add to the clinical picture. This some degree as can the use of mummification
(tightly wrapping the bag to the body with tape) torso parameters of thin slice acquisition. A
or carefully placing the arms as anteriorly over modification that can be undertaken is to only
the torso as possible (even through the bag). scan from above the shoulders to below the toes.
The scan acquisition for the head and neck The head acquisition is not to be used for diag-
should use the minimum slice thickness available nosis, but it is often appreciated by the forensic
in conjunction with a negative pitch and recon- pathologists due to the ability to obtain a full
structions performed with a minimum of 30% body 3D render of the case, especially if serious
slice overlap. For example, in the case of an iso- disfiguration has occurred. This acquisition does
tropic capable scanner, the acquisition should be result in a very heavy heat load to the scanner
0.5 mm slice thickness with a 0.3 mm slice inter- and over time will reduce tube life. Tube cooling
val and the images reconstructed at a minimum between acquisitions and or cases also becomes
of 3 mm × 3 mm in all three planes. For the torso, a consideration apart from the fact that poten-
images 1 mm thick with a 0.8 mm interval should tially up to 8000 slices will need reconstructing.
be acquired and reconstructed with the same slice Again, arm placement is a consideration and the
thickness, e.g. 1 mm × 1 mm. Figures 2 and 3 are recommendation is that if possible the arms are
soft tissue reconstruction examples. kept by the side or on the abdomen (to reduce
beam hardening artefact). It is generally not pos-
Whole-Body Approach No 1 sible to scan the entire body with the arms above
The study starts with the head and neck protocol the head.
previously described. The second acquisition The acquisition is acquired with a slice thick-
which is very dependent on the table travel ness of 1 mm and a 0.8 mm interval with recon-
length is to scan from above the head to below structions for reporting being 3 mm × 3 mm.
the toes, which some scanners may not be capa- Figure 4 demonstrates the soft tissue reconstruc-
ble of performing. This acquisition is using the tion example.
Fig. 2 Soft tissue MPRs for CT head & neck

Fig. 3 Soft tissue MPRs for CT torso
Fig. 4 Soft tissue MPRs including SSD for CT whole body

Whole-Body Approach No 2 Table 1 NSW health pathology, forensic medicine CT

scanning guideline
(Recommended)
This study again starts with the recommended Case presentation and recommended study approach
head and neck acquisition. This is then followed Full body Head, neck and torso
Death in custody Sudden death of a
by the torso study; however, the arms must be
presumed natural
beside the body or over the abdomen, so they are causes
included as part of the study. A third acquisition Homicide/suspicious Complex hospital
is then undertaken from above the acetabulum to referral
below the toes. A major advantage of this acqui- SIDS/SUDI (include full Morbidly obese
body X-rays)
sition is that if the case is too long for the table
Decomposed (with or Maternal deaths
movement to cover the entire body in a single without dental scan)
run, the case can be moved along the table (some Incinerated (include dental Hospital deaths with
turn the body around on the table, but this is not scan) extensive medical
recommended). The distal limb acquisition is history
obtained using a slice thickness of 2 mm and Industrial accident Suicides—hanging,
self-inflicted GSW,
1.5 mm interval with reconstructions for report- CO poisoning
ing being 3 mm × 3 mm. Diving accident Drug overdose
(excluding suspected
6.3.3 Dental Acquisition IV drug user)
Most scanners have a protocol for metal artefact Aviation accident (with or Witnessed drownings
without dental scan)
reduction reconstruction (optional cost gener-
Other paediatric cases
ally). A scan acquisition using the thinnest pos- Transport related incidents
sible slice thickness with at least a 30% overlap is (with or without dental scan)
recommended and employing an ultra-high spa- Skeletal remains with
tial resolution reconstruction algorithm. The scan residual soft tissue
range is from above the mandibular fossa to Suspected intravenous drug
user (possibly include bag
below the mandibular symphysis with the isocen- looking for sharps)
tre mid-way between the angles of the mandible. Unwitnessed drownings
Curved MPRs to simulate an OPG are ideal with ©—Copyright—NSW Health Pathology for and on behalf
reformations starting at 1 mm thick up to 20 mm. of the Crown in right of the State of New South Wales.
Dental package acquisitions and reformations are Adapted with permission of NSW Health Pathology
not necessary as such antemortem imaging is less
likely available compared to OPG and/or bite-
wing imaging. Mobile dental imaging using a 7 Image Storage, Retrieval &
Nomad hand-held dental X-ray unit is usually Archiving
performed if dedicated intra-oral imaging is
required. However, pseudo bite-wings made be As CT may be used for the forensic imaging of
reconstructed using a curved MPR approach. live or deceased subjects, the international best
practice guidelines published by the International
6.3.4 Choice of Scan Approach Association of Forensic Radiographers (IAFR)
The decision to proceed with PMCT is driven by aim to outline the role of radiographers involved
the clinical presentation of the case and the foren- in such situations and to ensure that correct pro-
sic pathologist triaging the case. The individual cedures are followed without compromising the
forensic pathologist may have a specific examina- voluntary nature of the work Doyle et al. (2020).
tion approach. It is recommended that a consistent Even though it is not necessarily known at the
service approach for the development of a recom- time of imaging that the examination may be the
mended scan guideline per case presentation pro- “subject of a legal action” in the future, radiogra-
vides more uniformity across the service (Table 1). phers should be aware that the images produced
or the radiologist’s report may be required to be explain the results of the CT scan to the court and
presented in court as evidence. Brogdon (1998) jury in layman’s terms. The radiographer who
noted that X-ray images were presented in court produced the images, on which the radiologist’s
and admitted as evidence, as early as 1896. He report was based, may also be summoned to
stated that the ‘admissibility of the product of a explain the process involved in acquiring the
radiological examination is unlikely to be ques- images and to confirm the continuity of the chain
tioned in a modern courtroom. There may be a of evidence (i.e. the images) from the time they
requirement to show that it was obtained by an were taken to the time they were given to the
accurate and generally recognised methodology police.
and accurately represents the object investigated’. The IAFR guidelines clearly describe proce-
Blitzer et al. (2008) discuss that ‘digital photo- dures to ensure continuity of evidence when pro-
graphs offer a new set of authentication issues for ducing digital images Doyle et al. (2020). The
the court, since they can be more easily manipu- IAFR guidelines clearly state that in order for
lated, altered or enhanced’. Therefore, it should evidence to be admissible, it must be.
be realised that it may be necessary that the
properly authenticated and continuity of evidence
radiographer attend the court as an expert witness must be demonstrated. The Radiographer, sup-
and describe the processes involved in acquiring ported by an appropriate witness should be able to
the CT scan. attest in court of law that any specific image was
produced by them at the date and time indicated,
that the image is of the identified evidence and has
not been tampered with during, or as the result, of
7.1 Discussion of Medico-Legal the image production process.
Concepts
Viner stated that it may be argued that digital
Evidence presented in a legal case could include images are more secure because ‘any change to
the CT images themselves, or the report issued by image data is/or can be recorded so that any evi-
the radiologist and either, or both, of these may dence of tampering can be detected’ (The Society
be produced in court as evidence. The court may and College of Radiographers 2006). PACS
summon expert witnesses, which in this case records some manipulations that are made to the
could be the radiologist and/or the radiographer. images (e.g. rotating an image 90°) but not all
The purpose of an expert witness has been out- (e.g. flipping an image from right to left) which
lined by the Federal Court of Australia (n.d.) in means that there is an incomplete electronic
the ‘Expert Evidence Practice Note’ record of changes made to the image. Berg (2000)
(GPN-EXPT): stated that ‘any enhancement applied to an image
the use of expert evidence in proceedings, often in must take place on a copy of the original’.
relation to complex subject matter, is for the Court Therefore, the original image (i.e. the Master
to receive the benefit of the objective and impartial copy) acts as a ‘control’ and documented
assessment of an issue from a witness with special- enhancements can be easily reproduced. This
ised knowledge (based on training, study or expe-
rience - see generally s 79 of the Evidence Act). process is clearly described in the IAFR
Guidelines when undertaking forensic imaging
Whilst the Federal Court of Australia acknowl- examinations (Doyle et al. 2020). It should be the
edges that aim of
An expert witness’ opinion evidence may have little any effective image-tracking procedure to elimi-
or no value unless the assumptions adopted by the nate the opportunity for unauthorized persons to
expert (i.e. the facts or grounds relied upon) and access images, thus avoiding the argument that
his or her reasoning are expressly stated in any someone could have altered or substituted an
written report or oral evidence given. image (Berg 2000)
Even in this scenario, the radiologist who pro- The department thus needs to demonstrate
duced the radiology report may be required to that a
robust and secure method of image storage, trans- complex nature, that may result in a coronial
mission and control of access to images is in place,
and normal procedures that exist for medical con-
enquiry, are generally the only cases referred for
fidentiality should be sufficient (The Society and a formal radiology report. There is also a strong
College of Radiographers 2006) belief that forensic pathologists have the skills
and knowledge to evaluate the PMCT
(International Society of Forensic Radiology and
8 Radiographer Review/ Imaging 2020). This combination of circum-
Impressions in PMCT stances has resulted in an ad hoc approach to just
how the images obtained in PMCT are managed.
8.1 Background There is no doubt that PMCT provides valu-
able information on the anatomy and pathology
Most of the literature available on radiographer of a deceased person, however there is a discon-
reporting is addressing the current clinical envi- nect between how the anatomy and pathology
ronment and in Australia the objection to such appear in imaging compared to the actual ana-
practice by the RANZCR (Woznitza et al. 2021). tomical structure at post-mortem. Imaging relies
Indeed, this role extension has been a topic of on the density of anatomical/pathological struc-
debate and discussion for over 30 years. There is tures to provide information on what is seen, and
support for this role from the radiographers and a this appearance is not so evident on anatomical
majority lack of support from radiologists, cer- specimens. Imaging appearances post-mortem
tainly in Australia (The Royal Australian and must be learned so that post-mortem artefacts can
New Zealand College of Radiologists 2018). The be identified from pathology (Sutherland and
UK, with the NHS, has a different structure to O'Donnell 2018). In PMCT a brain tumour, even
Australia (even North America, USA and without contrast, is often very easily identified
Canada) whereby advanced practitioner report- due to subtle tissue density changes and possible
ing radiographers, with a clearly defined scope of surrounding oedema, however the gross anatomy
practice, are recognised. appearance is considerably different. Similarly,
In Australia, the MRPBA has stated in its pro- many subtle cranial abnormalities, not identified
fessional capabilities document that offering an on PMCT, are clearly identified during a post-
opinion on imaging obtained by the radiographer mortem examination. Therefore, this correlation
is not only within their scope of practice but is between actual anatomical/pathological appear-
also a professional responsibility in regard to a ance and the representation of the same informa-
quality service delivery (Medical Radiation tion on a PMCT are very dissimilar, and there is
Practice Board (AHPRA) 2020). A major consid- a steep learning curve for the forensic pathologist
eration, certainly in Australia, is the fact there is to correlate their gross anatomy visual skills to
no rebatable item number from Medicare (Health PMCT appearances. Many enjoy this challenge
Insurance Commission) for a PMCT study, and and become expert in the role. The majority how-
therefore radiologists employed by forensic ser- ever do not have the time or the necessary regular
vices are remunerated on a sessional basis or on a exposure to PMCT to gain the confidence to cor-
negotiated set fee per study basis. There is also a relate the clinical information, which includes
shortage of radiologists resulting in a limited PMCT, into their workload. To them the addition
pool of them with specialist forensic radiology of the availability of an impression of the PMCT,
skills. The international position is most likely by someone with imaging experience, as part of
reflective of this situation. The reliance of the use the medical records they review is of greater ben-
of IV contrast in clinical practice and the changes efit and less time consuming.
that take place in the human body after death add The next issue that needs to be addressed is
to the complications in reporting on PMCT cases. the justification of allocating limited radiology
This results in the need to selectively refer cases reporting time to all PMCT cases. There is anec-
for a radiology report and that means cases of a dotal evidence to suggest that coroners are
increasingly relying on the information provided develop the ability to identify normal from abnor-
in a PMCT to support the forensic pathologist mal anatomical structures as they appear in medi-
recommendation for the allocation of a coroner’s cal imaging. This skill can be translated to a more
certificate without the need to proceed to autopsy, formalised structure whereby the radiographer
or indeed the need for only a limited post-mortem provides a written comment on the PMCT to
examination. Most centres currently rely on spe- assist the forensic pathologist correlate other
cific cases going directly to a formal radiology clinical information in order to progress the triag-
report and the remainder having a limited “skim” ing and final management of a case.
by the forensic pathologist who may have suffi- The arrangement needs to be structured and
cient information to identify a legally acceptable supported by all parties, up to and including the
identity and cause of death in a case. The PMCT coroner. The review then becomes a part of the
then just becomes a part of the case file along final case record. Although having no legal stand-
with other clinical tests, both ante and ing, the information can be used for the forensic
post-mortem. pathologist to decide whether a radiology report
Finally, radiologists may not necessarily be should be requested. The major advantage of the
interested in reporting on all PMCT cases for a implementation of radiographer review is that all
number of reasons: cases presenting to the coronial service can be
imaged, and a review forwarded to the triaging
1. There are just too many and insufficient hours forensic pathologist in a very short time frame to
allocated to the task thus impacting on allow for the case to move potentially more
addressing more important case reports. swiftly through the coronial process.
2. A formal report, which is legally binding,
must address the entire anatomy/pathology of
the case and not just describe a cause of death 8.3 The Structure and Approach
pathology so potentially are time consuming. for Radiographer Reviewing/
3. The majority of cases may present with obvi- Impressions
ous pathology which would not require a
detailed radiology report and basically an The primary role of the radiographer review is to
inappropriate use of radiologist time. identify a likely Cause of Death (CoD) in a
patient. In the case of an obvious cause not being
With this background, the extension of the identified by the radiographer, comment should
role of a radiographer in supporting the forensic be made regarding any potential abnormality,
pathologist by providing a review or impression which in conjunction with the detailed clinical
of the PMCT provides a valuable service and history the forensic pathologist has, may assist in
increased job satisfaction for the radiographer. formulating the management strategy. For exam-
This approach is described by the Australian ple, the identification of the absence or presence
Society of Medical Imaging and Radiation of coronary artery calcification which may or may
Therapy as ‘Preliminary Image Interpretation’ not have resulted in the patient’s death. A role in
and is not intended to replace a radiologist’s patient identification can also assist the coroner.
report. A suggested approach is to divide the case into
regions. Prior to making any comment, the
radiographer should look at all images in the
8.2 What Is a Radiographer axial, coronal and sagittal plane, often starting by
Review/Impression? looking at a 3D rendered image of the skull and
cervical vertebrae and then the entire body. A
One of the strengths of a radiographer is their basic understanding of why the case has become
ability to pattern recognise. From daily observa- a coronal referral gives an insight into the possi-
tion of the imaging they produce, radiographers ble pathology that may be identified.
8.3.1 Head and Neck

The head and neck are viewed in all three planes
using two window settings: soft tissue (contrast
algorithm) and bone (spatial resolution). Careful
observation of the vascular structures looking for
vessel calcification or dilatation. The symmetry
of the brain and ventricles as well as identifica-
tion of atrophy inconsistent with age. The pres-
ence of air (decomposition or trauma), blood
traumatic or spontaneous and other incidental
findings such as basal ganglia calcification. Basal
ganglia microcalcification is a frequently identi-
fied anomaly, such as the identification of calcifi-
cation in, or near, the falx. However, mentioning
this fact may be relevant to the forensic patholo-
gist who has a clinical history of the patient suf-
fering from Fahr’s syndrome and this information Fig. 5 Screenshot using ‘blue metal’ algorithm which
can assist in several ways, including confirmation highlights ballistic material present, as well as the ECG
leads that are still in situ
of the case’s identity. The radiographer then
looks at all three scan planes using a high spatial
resolution (bone) window to identify any bony generally the body bag will then have a warning
abnormality. In the case of a substantial head sticker applied, if not already there. The hilar
injury, the radiographer can simply indicate structures and the pleural walls are examined
‘extensive trauma to the majority of the bones of looking for lymph node enlargement, calcifica-
the vault (and neck)’ whereas a radiology report tion plaques and any lung soft tissue or fluid col-
would be obliged to provide more detailed lections. Hounsfield unit readings (looking for
description if there is a possibility of the case comparison between soft tissue collapse/consoli-
being part of a coronial judicial enquiry. Cervical dation and fluid which are similar to antemortem
alignment, medical intervention appliances and non-contrast studies) are taken of pleural collec-
any artefact not necessarily expected to be seen tions to exclude the likelihood of blood or infec-
should be documented. In the situation of a gun- tive material.
shot wound, the track and location of projectile It is important to recognise the changes that
fragments are helpful, along with any other soft- occur in the accuracy of HU readings over time.
ware manipulation that can provide more detailed Zech et al. (2014) identified that during 1–4 days
information on the projectile fragments (Fig. 5). post death interval, the HU reading was similar
to the known values for those regions in the liv-
8.3.2 Chest ing. However, once putrefaction is a factor this
The chest is viewed in all three planes using three makes the reliability of these HU readings vari-
different window settings: soft tissue, bone and able, as the influence of putrefaction fluids
lung (spatial resolution with a wide window and reduces reliability. They also stated that the
lung tissue level). The heart is observed for car- beam energies used, and the body temperature
diac size and the level, if any, of calcification, had only minor influence on HU value ranges
both vascular and cardiac valves. The pericar- and therefore in the early stages of post-mortem
dium and thoracic aorta are also reviewed, and should not complicate the differentiation and
the level of vascular calcification noted. Indication characterisation of body fluid and blood.
of the presence of an implanted medical device Andrews (2016) also stated how important it is
(pacemaker or defibrillator, the exact type is not to consider the influence of purification when
important just the existence) is important and interpreting PMCT imaging.
The location in situ of and medical devices pathologist. Any foreign material (e.g. projec-
such as an intubation/endotracheal tube or naso- tiles or surgical intervention) and the integrity
gastric tube are checked for correct position, par- of the skin should be noted. The uterus and
ticularly the end of the intubation tube to be prostate should be noted as unremarkable. For
located within the trachea and above the carina. A the uterus if bulky, indicate the level of homo-
hiatus hernia of clinical significance should be geneity and for the prostate, indicate if hyper-
noted. The lung window is used to identify the plastic and the level of calcification, if any.
presence of a pneumothorax, small interstitial Ascites, fresh and/or old blood and air identi-
abnormalities such as infiltrative disease, the fied or excluded. The spine is viewed for any
presence of any Chronic Pulmonary Obstructive abnormality and level of degeneration can be
Disease (COPD), including bullae and air bron- noted.
chograms or entrapment. The bone window is
used to identify any calcium in consolidated 8.3.4 Limbs
areas of the thoracic aorta, lung and/or the pleural The value of CT of the limbs is still being evalu-
wall, rib fractures, sternal integrity and thoracic ated, and certainly projectional radiography pro-
spine degeneration/trauma. vides a higher level of spatial resolution to
CT. The limbs should be view in all three planes
8.3.3 Abdomen using both the soft tissue and bone algorithms/
The abdomen is viewed in all three planes using windows (contrast and spatial algorithms and
three different windows settings: soft tissue, viewing window and level). Any disruption of
bone and lung. The choice of using a lung win- the skin, e.g. burns or trauma, should be noted
dow is dependent upon case presentation, for and identification of any obvious skeletal dam-
example identification of level of decomposi- age or disease documented. In the case of intra-
tion or possibility of perforation. In the case of venous (IV) drug presentations, care is taken to
suspected liver disease often the liver is viewed ensure no obvious sharps are present. The
in a narrow window (WW80/WL80) looking absence or presence of any should be noted in
for subtle liver disease. HU readings should be the review.
taken of the liver and spleen in any case where When writing a radiographer review, it is
the two structures appear to have differing den- important to remain within the scope of practice
sities on first review. The organs of the abdo- as defined by the MRPBA professional capabili-
men are observed for size, composition and ties (2020). For example, in the case of a possible
location. The identification of gallstones or oral drug overdose, the review should describe
cholecystectomy clips is an important observa- ‘high attenuation residue is noted in the stomach,
tion, which may assist in confirming the identi- some of which is rounded and most layering pos-
fication of the deceased. Any medical devices teriorly’, rather than stating ‘Tablet residue is
need to be identified and if correctly is situ, noted in the stomach’ as many food products, e.g.
such as NG tubes, drains from surgery, feeding chick peas, are rounded and appear as high atten-
tubes, supra-pubic and direct bladder catheters, uation material in the stomach. The fact the
and stomas. Vascular size and level of calcifica- radiographer has identified the stomach contents
tion should be noted along with incidental find- contain high attenuation material allows the
ings such renal calculi/cysts and high forensic pathologist to decide if this is consistent
attenuation residue in the stomach or bowel with the ingested products or whether examina-
(N.B. Identify as high attenuation residue and tion of the stomach contents at PM is warranted.
not try and be specific). Stomach and bladder A more common example is the noting of calcific
size should be commented upon if distended. pleural and pericardial plaques. This may repre-
Bowel distention and numerous fluid levels sent asbestosis, but it also may be related to cal-
should be identified but not stated as obstruc- cification from tuberculosis, information that the
tive, this will be correlated by the forensic forensic pathologist may have access to which
will confirm the diagnosis, or again proceed to References

PM, therefore the review just identifies the pres-
ence of the calcific plagues and where they are Alkadhi H, Leschka S. Dual-energy CT: principles, clini-
cal value and potential applications in forensic imag-
located. ing. J For Radiol Imaging. 2013;1:180–5.
Andrews SW. Postmortem changes as documented in
postmortem computed tomography scans. Acad For
9 Education and Training Pathol. 2016;6:63–76.
Berg EC. Legal ramifications of digital imaging in law
enforcement. For Sci Commun. 2000;2
The International Association of Forensic Blitzer H, Stein-Ferguson K, Huang J, Jacobia
Radiographers recognise that forensic CT is not a J. Introduction to forensic use of digital imaging.
graduate competency (Doyle et al. 2020). It is Understanding forensic digital imaging. Burlington:
Academic Press, 2008.
highly recommended that additional education Bolliger SA, Filograna L, Spendlove D, Thali MJ,
and training are completed prior to undertaking Dirnhofer S, Ross S. Postmortem imaging-guided
any forensic imaging. A thorough knowledge and biopsy as an adjuvant to minimally invasive autopsy
understanding of medico-legal principles, as well with CT and postmortem angiography: a feasibility
study. Am J Roentgenol. 2010;195:1051–6.
as relevant legislation, are required. This includes Brogdon BG. Forensic radiology. Florida: CRC Press;
understanding the challenges associated with 1998.
maintaining continuity of evidence and obtaining Brough AL, Morgan B, Rutty GN. Postmortem computed
consent in living patients. tomography (PMCT) and disaster victim identifica-
tion. Radiol Med. 2015;120:866–73.
Forensic CT may be distressful for some peo- Chandrasekar S, Colak C, Obuchowski NA, Primak AN,
ple and should only be performed on a voluntary Karim W, Subhas N. Combined dual-energy and single-
basis, unless specifically employed in that role. It energy metal artifact reduction techniques versus sin-
is very important that forensic radiographers are gle-energy techniques alone for lesion detection near
an arthroplasty. Am J Roentgenol. 2020;215:425–32.
trained to recognise and identify the signs and Cheung JP, Shugard E, Mistry N, Pouliot J, Chen
symptoms of post-traumatic stress disorder J. Evaluating the impact of extended field-of-view CT
(PTSD). This is a significant consideration for reconstructions on CT values and dosimetric accu-
managers, as a timely debrief and on-going sup- racy for radiation therapy. Medi Phys (Lancaster).
2019;46:892–901.
port processes must be available, even long after Dirnhofer R, Jackowski C, Vock P, Potter K, Thali
critical events, as unrelated situations may trigger MJ. VIRTOPSY: minimally invasive, image-guided
PTSD. virtual autopsy. Radiographics. 2006;26(5):130–3.
Dorries C. Autopsy CT scanning: a coroner's viewpoint.
Diagn Histopathol. 2020;26:341–2.
Doyle E. Casebook of 10 cases submitted for module 3
of the UCD graduate diploma in medicine (forensic
10 Conclusion medicine). Dublin: University College Dublin; 2009.
Doyle E, Márquez-Grant N, Field L, Holmes T, Arthurs
OJ, Van Rijn RR, Hackman L, Kasper K, Lewis J,
The use of CT in forensic and medico-legal cases, Loomis P, Elliott D, Kroll J, Viner M, Blau S, Brough
especially PMCT, continues to develop. PMCT A, de Las M, Heras S, Garamendi PM. Guidelines for
plays a role in death investigation and often helps best practice: imaging for age estimation in the living.
reduce the need for invasive autopsies. It also J For Radiol Imaging. 2019;16:38–49.
Doyle E, Hunter P, Viner MD, Kroll JJK, Pedersen CC,
provides an opportunity for radiographers to Gerrard CY. IAFR guidelines for best practice: prin-
extend and apply their knowledge and skills in ciples for radiographers and imaging practitioners
helping to answer questions of law whilst remain- providing forensic imaging services. For Imaging.
ing within their scope of practice. One of the 2020;22:200400.
Federal Court of Australia. Court evidence & expert
most important aspects of radiographer review- witnesses [Online]; n.d.. https://www.fed-
ing is to act within the scope of practice by court.gov.au/law-a nd-p ractice/guides/expert-
describing what possible abnormality is identi- evidence-:~:text=In%20some%20cases%20a%20
fied and not try and classify it as a specific party,expertise%2C%20training%20and%20special-
ised%20knowledge. Accessed 9 Feb 2021.
condition.
Flach PM, Ross SG, Ampanozi G, Ebert L, Germerott T, Kawahara D, Ozawa S, Yokomachi K, Higaki T,
Hatch GM, Thali MJ, Patak MA. “Drug mules” as a Shiinoki T, Saito A, Kimura T, Nishibuchi I,
radiological challenge: sensitivity and specificity in Takahashi I, Takeuchi Y, Imano N, Kubo K, Mori
identifying internal cocaine in body packers, body push- M, OHNO Y, Murakami Y, Nagata Y. Metal artifact
ers and body stuffers by computed tomography, plain reduction techniques for single energy CT and dual-
radiography and Lodox. Eur J Radiol. 2011;81:2518–26. energy CT with various metal materials. BJR Open.
Forrest AS. Collection and recording of radiologi- 2019;1(1):20180045.
cal information for forensic purposes. Aust Dent J. Kirchhoff S, Fischer F, Lindemaier G, Herzog P, Kirchhoff
2012;57:24–32. C, Becker C, Bark J, Reiser M, Eisenmenger W. Is
Forrest A. Forensic odontology in DVI: current practice post-mortem CT of the dentition adequate for correct
and recent advances. For Sci Res. 2019;4:316–30. forensic identification? Comparison of dental com-
Gascho D, Thali MJ, Niemann T. Post-mortem computed puted tomography and visual dental record. Int J Legal
tomography: technical principles and recommended Med. 2008;122:471–9.
parameter settings for high-resolution imaging. Med Lan K, Doyle E. Is abdominal x-ray (AXR) or computed
Sci Law. 2018;58:70–82. tomography (CT) of the abdomen the most appro-
Germerott T, Flach PM, Preiss US, Ross SG, Thali priate imaging modality for the detection of illegal
MJ. Postmortem ventilation: a new method for substances concealed, taking into consideration the
improved detection of pulmonary pathologies in sensitivity, specificity and radiation dose? J For Radiol
forensic imaging. Leg Med (Tokyo). 2012;14:223–8. Imaging. 2019;16:50–6.
Gibb IE. Computed tomography of projectile injuries. Leschka S, Fornaro J, Laberke P, Blum S, Hatem A,
Clin Radiol. 2008;63:1167–8. Niederer I, Meile C, Hibbeln D, Hausmann R,
Grabherr S, Grimm J, Baumann P, Mangin P. Application Wildermuth S, Eisenhart D. Differentiation of cocaine
of contrast media in post-mortem imaging (CT and from heroine body packs by computed tomography:
MRI). Radiol Med. 2015;120:824–34. impact of different tube voltages and the dual-energy
Grabherr S, Grimm JM, Heinemann A. Atlas of post- index. J For Radiol Imaging. 2013;1:46–50.
mortem angiography. Berlin: Springer International Leth PMP. Computerized tomography used as a routine
Publishing; 2016. procedure at postmortem investigations. Am J For
Higginbotham-Jones J, Ward A. Forensic radiology: the Med Pathol. 2009;30:219–22.
role of cross- sectional imaging in virtual post-mortem Levy AD, Harcke HT. Essentials of forensic imaging.
examinations. Radiography. 2014;20:87–90. Florida: CRC Press; 2011.
Higgins S, Parsons S, Woodford N, Briggs C, Cauchi Mahmood S. Scalpel-free post-mortem UK launch
D, O’Donnell C. Choice of biopsy devices for post- [online]. BBC; 2013. http://www.bbc.co.uk/news/
mortem CT-guided biopsy. J For Radiol Imaging. health-25086941. Accessed 27 Nov 2013.
2016;5:15–9. Martinez RM, Ptacek W, Schweitzer W, Kronreif G,
Hofman P, Alminyah A, Apostol M, Boel LWT, Brough Fürst M, Thali MJ, Ebert LC. CT-guided, mini-
A, Bouwer H, O'Donnell C, Fujimoto H, Iino M, Kroll mally invasive, postmortem needle biopsy using the
J, Lee CT, Levey DS, Makino Y, Oesterhelweg L, Ong B-rob II needle- positioning robot. J Forensic Sci.
B, Ranson D, Robinson C, Rutty G, Singh MKC, Villa 2014;59:517–21.
C, Viner M, Woodford N, Watkins T, Wozniak K. Use Medical Radiation Practice Board (AHPRA).
of post-mortem computed tomography in disaster Professional capabilities for medical radiation
victim identification. Updated positional statement practice [Online]; 2020. https://www.medicalradia-
of the members of the disaster victim identification tionpracticeboard.gov.au/registration/professional-
working group of the International Society of Forensic capabilities.aspx.
Radiology and Imaging; July 2019. J For Radiol Mentink MG, Latten BGH, Bakers FCH, Mihl C,
Imaging. 2019;19:100346. Rennenberg RJMW, Kubat B, Hofman PAM. Clinical
International Society of Forensic Radiology and Imaging. relevance of unexpected findings of post-mortem
ISFRI Education sub-committee [Online]; 2020. computed tomography in hospitalized patients: an
http://isfri.org/sub-committees/education/ observational study. Int J Environ Res Public Health.
Interpol. Disaster victim identification guide [Online]; 2020;17:7572.
2009. http://www.interpol.int/Public/DisasterVictim/ Morgan B. Initiating a post-mortem computed tomog-
guide/guide.pdf. Accessed 13 Mar 2010. raphy service: the radiologist's perspective. Diagn
Jayasooriya O, Doyle E. Is PMCT-calculated coronary Histopathol. 2010;16:556–9.
artery calcium score (PMCT CaSc) a predictor of sud- Morgan B, Sakamoto N, Shiotani S, Grabherr
den death due to coronary ischaemia in younger per- S. Postmortem computed tomography (PMCT)
sons i.e. males <50years of age and females <60years scanning with angiography (PMCTA): a descrip-
of age? J For Radiol Imaging. 2019;18:40–6. tion of three distinct methods. In: Rutty GN, editor.
Jeffery AJ, Rutty GN, Robinson C, Morgan B. Computed Essentials of autopsy practice: advances, updates
tomography of projectile injuries. Clin Radiol. and emerging technologies. London: Springer;
2008;63:1160–6. 2014.
NHS Implementation Sub-Group of the Department Al-Ali YS, Jerew S, Kirby A, Choi S, Gaunt T, Dodd
of Health Post Mortem, F. A. D. I. G. P. Can cross- C, Halliday K, Hartley L, MacDonald K, Preston
sectional imaging as an adjunct and-or alterna- L, Duncan KA, Sethi BA, Quigley AJ, Amarnath J,
tive to the invasive autopsy be implemented Barber JL, Ashwin CJ, Keaney C, Lam CZ, Marie E,
within the NHS? [online]. Crown; 2012. https:// Perez Matta MM, Williams MC. Chest radiographs
www2.le.ac.uk/departments/emfpu/media/ versus CT for the detection of rib fractures in children
CanCrossSectionalImagingasanAdjunctandor (DRIFT): a diagnostic accuracy observational study.
AlternativetotheInvasiveAutopsybe Lancet Child Adolesc Health. 2018;2:802–11.
ImplementedwithintheNHSOctober12FinalTRV.pdf/ Sidler M, Jackowski C, Dirnhofer R, Vock P, Thali
view. Accessed 21 Dec 2020. MJ. Use of multislice computed tomography in disas-
O Donnell C. An image of sudden death: utility of rou- ter victim identification -advantages and limitations.
tine post-mortem computed tomography scanning in Forensic Sci Int. 2007;169:118–28.
medico-legal autopsy practice. Diagn Histopathol. Sutherland T, O'Donnell C. The artefacts of death: CT
2010;16:552–5. post-mortem findings. J Med Imaging Radiat Oncol.
Platon A, Becker M, Becker CD, Lock E, Wolff H, 2018;62:203–10.
Perneger T, Poletti P-A. Illegal intra-corporeal pack- Thali MJ, Schweitzer W, Yen K, Vock P, Ozdoba C,
ets: can dual energy CT be used for the evaluation of Spielvogel E, Dirnhofer R. New horizons in foren-
cocaine concentration? a cross sectional study. BMC sic radiology: the 60-second digital autopsy - full-
Med Imaging. 2016;16:3. body examination of a gunshot victim by multislice
Roberts ISD, Benamore RE, Peebles C, Roobottom C, computed tomography. Am J Forensic Med Pathol.
Traill ZC. Diagnosis of coronary artery disease using 2003a;24:22–7.
minimally invasive autopsy: evaluation of a novel Thali MJ, Yen K, Schweitzer W, Vock P, Ozdoba C,
method of post-mortem coronary CT angiography. Dirnhofer R. Into the decomposed body - forensic dig-
Clin Radiol. 2011;66:645–50. ital autopsy using multislice-computed tomography.
Roberts IS, Benamore RE, Benbow EW, Lee SH, Harris Forensic Sci Int. 2003b;134:109–14.
JN, Jackson A, Mallett S, Patankar T, Peebles C, The Royal Australian and New Zealand College of
Roobottom C, Traill ZC. Post-mortem imaging as an Radiologists. Image interpretation by radiographers –
alternative to autopsy in the diagnosis of adult deaths: not the right solution [Online]. Sydney: RANZCR;
a validation study. Lancet. 2012;379:136–42. 2018. https://www.ranzcr.com/college/document-
Robinson C, Deshpande A, Richards C, Rutty G, Mason library/image-interpretation-by-radiographers-not-
C, Morgan B. Post-mortem computed tomogra- the-right-solution-position-statement.
phy in adult non-suspicious death investigation— The Royal College of Radiologists. The radiological
evaluation of an NHS based service. BJR|Open. investigation of suspected physical abuse in children
2019a;1:20190017. [Online]. RCR; 2017. https://www.rcr.ac.uk/publica-
Robinson C, Deshpande A, Rutty G, Morgan B. Post- tion/radiological-investigation-suspected-physical-
mortem CT: is coronary angiography required in the abuse-children.
presence of a high coronary artery calcium score? Clin The Royal College of Radiologists (RCR) & Royal
Radiol. 2019b;74:926–32. College of Pathologists (RCPATH), A. A. A. RCR/
Rutty GN, Robinson CE, Bouhaidar R, Jefferson AJ, RCPath statement on standards for medico-legal post-
Morgan B. The role of Mobile computed tomog- mortem cross- sectional imaging in adults [online].
raphy in mass fatality incidents. J Forensic Sci. London: RCPath; 2012. https://www.rcr.ac.uk/
2007;52(6):1343–9. publication/rcrrcpath-statement-standards-medico-
Rutty GN, Robinson CE, Morgan B, Black S, Adams C, legal-post-mortem-cross-sectional-imaging-adults.
Webster P. FIMAG: the United Kingdom disaster/ Accessed 17 Apr 2020.
forensic identification imaging system. J Forensic Sci. The Society and College of Radiographers. The film-
2009;54(6):1438–42. less department: use of images as evidence in legal
Rutty GN, Smith P, Visser T, Barber J, Amorosa J, Morgan proceedings [online]. London: SCOR; 2006. http://
B. The effect on toxicology, biochemistry and immu- www.sor.org/members/documentlibrary/sor_filmless_
nology investigations by the use of targeted post- department_images_evidence.pdf.
mortem computed tomography angiography. Forensic The Society and College of Radiographers & the
Sci Int. 2013;10:42–7. International Association of Forensic Radiographers.
Rutty GN, Morgan B, Germerott T, Thali M, Athurs Guidance for radiographers providing forensic radiog-
O. Ventilated post-mortem computed tomography – a raphy services. London: SCoR; 2010.
historical review. J For Radiol Imaging. 2016;4:35–42. Thornton, P. Chief coroner guidance no. 1. The use of
Shelmerdine SC, Langan D, Hutchinson JC, Hickson post-mortem imaging (adults) [online]; 2013. https://
M, Pawley K, Suich J, Palm L, Sebire NJ, Wade A, www.judiciary.uk/wp-c ontent/uploads/2013/09/
Arthurs OJ, Johnson K, McLoughlin E, Lacroix C, guidance-n o-1 -u se-o f-p ort-m ortem-i maging.pdf.
Sutaria P, Logan P, Verhagen MV, Arfeen F, Ljutikov Accessed 17 Apr 2020.
A, Anjari M, Gupta A, Soo MJ, Corral Guajardo G, Tsukagoshi S, Ota T, Fujii M, Kazama M, Okumura M,
Alsabban Z, Majeed NM, Cuscaden C, Abdeen M, Johkoh T. Improvement of spatial resolution in the
longitudinal direction for isotropic imaging in helical port post-mortem imaging. Diagn Histopathol.
CT. Phys Med Biol. 2007;52:791–801. 2010;16:578–80.
Varela Morillas Á, Nurgaliyeva Z, Gooch J, Frascione Woznitza N, Steele R, Groombridge H, Compton E,
N. A review on the evolution and characteristics Gower S, Hussain A, Norman H, O'Brien A, Robertson
of post-mortem imaging techniques. For Imaging. K. Clinical reporting of radiographs by radiogra-
2020;23:200420. phers: policy and practice guidance for regional
Viner, M. The Filmless Department: use of images as imaging networks. Radiography. 2021;27(2):645–9.
evidence in legal proceedings; 2006. https://www.sor. https://doi.org/10.1016/j.radi.2020.08.004.
org/system/files/document-library/members/sor_film- Wullenweber R, Shneider V, Grummer T. A computer-
less_department_images_evidence.pdf. Accessed 3 tomographical examination of cranial bullet wounds.
Dec 2020. Z Rechtsmed. 1977;80:227–46.
Viner MD. The use of radiology in mass fatality events. Zech W-D, Jackowski C, Buetikofer Y, Kara
In: Adams BJ, Byrd JE, editors. Recovery, analysis L. Characterization and differentiation of body fluids,
and identification of commingled human remains. putrefaction fluid, and blood using Hounsfield unit in
New York: Humana Press; 2008. postmortem CT. Int J Legal Med. 2014;128:795–802.
Webster P. Exchanging information: current United
Kingdom developments in the infrastructure to sup-
Part V
CT Education
Education in CT
Andrew Kilgour
Abstract the principle of assessment for learning, rather

than assessment of learning. Assessments of
Optimising education of medical radiation capability in CT can be designed to be imple-
science practitioners in the art and science of mented as a learning experience for these
Computed Tomography (CT) requires an practitioners, rather than just a requirement to
understanding of the fundamental principles allow them to be considered capable.
of education. These generic principles of CT is considered part of a radiographer’s
learning include andragogy (adult learning) scope of practice; however, students do not
and pedagogy (the method and practice of graduate from undergraduate radiography
teaching). When applied, these principles give degrees fully capable in CT. They may under-
a platform to the principles which are specific stand the theory and have some experience of
to medical radiation science education. This clinical practice under supervision, but they
platform can be built on to teach the skills that are not capable of working independently as a
are specific to becoming a proficient and capa- CT radiographer. As these graduates are
ble CT practitioner. These educational princi- adults, a self-directed learning program,
ples must be seamlessly integrated with the acknowledging prior experiences and knowl-
professional practice of CT, so that adult edge, will maximise the learning program
learners can absorb them in an authentic offered.
environment.
Integral to teaching is assessment, deter- Keywords
mining whether the knowledge imparted has
been absorbed, and importantly, whether the Adult education · Andragogy · Pedagogy ·
learner can apply this knowledge to their prac- Competence · Capability · Dynamic ·
tice. It is important that we assess capability Interactional · Contextual
rather than competence, so the fundamental
differences between capability and compe-
tence will be discussed. Assessing a practitio- 1 Introduction
ner’s capability in the requisites of CT involves
Computed Tomography (CT) is increasingly
becoming part of the scope of practice for quali-
A. Kilgour (*) fied radiographers. Indeed, in Australia, capability
RMIT University, Melbourne, Australia in CT is one of the primary capabilities required
160 A. Kilgour
for a graduate to be registered with the Australian tems and peculiarities of the particular brand of
Health Practitioner Regulation Agency (AHPRA) scanner installed in their workplace.
(Australian Health Practitioner Regulation Agency All of the above reveals that education in CT
2016). As a result of this progression in scope of has two distinct phases: undergraduate education
practice, CT has been included in undergraduate and postgraduate training. Of course, a radiogra-
radiographer education for many years. pher can also choose to undertake formal post-
To explain the broad background of undergraduate studies in CT, but the principles of these
graduate education, it is necessary to understand educational programs are similar to those
some of the history behind its genesis. The era of employed in undergraduate education, only at a
schooling, as we know it today, arose largely more advanced level. This chapter will examine
from the industrial revolution. Prior to this, insti- postgraduate training in CT, and how to best
tutionalised education was limited to a few occu- develop the CT skills of qualified radiographers.
pations, including medicine, law, military, and By way of introduction to this chapter, the
philosophy (Billett 2014). Most other occupa- various sub-areas of knowledge that are required
tions were learned by observing skilled trades- to be a capable CT radiographer must be consid-
men, or skilled practitioners. However, the boom ered. These sub-areas are as follows:
in employment opportunities brought about by
the industrial revolution and rapid advances in 1. CT theory—the principles of CT image cap-
technology meant that opportunities to work with ture and data manipulation.
and learn from skilled workers became in 2. Radiographic anatomy and pathology—par-
demand, and substitutes had to be found. Thus, ticularly cross-sectional anatomy.
the first textbooks were written, as a substitute for 3. Equipment and instrumentation—variations
actually learning from practice (Billett 2014). between terminology and operating systems
Radiography has developed from a career between the different vendors.
learned on the job to being acknowledged as a pro- 4. CT protocols—the scanning sequences, con-
fession requiring degree level education. In the trast rates, delay times, and image reconstruc-
process, it has transitioned from being learned tion sets required by the reporting radiologists,
almost solely in a hands-on environment, to being and how these vary or need to be modified for
learned in a traditional tertiary education environ- different presentations and suspected
ment, with occasional forays into the clinical envi- pathologies.
ronment known as, among other titles, Workplace 5. Physiology—particularly the use of intrave-
Learning (WPL) (Kilgour 2018). This has meant nous contrast agents, their possible contrain-
that undergraduate education in CT is largely theo- dications and side-effects, and what to do in
retical, with practical training in the course of the case of anaphylaxis.
study limited to whatever opportunities students
are given access to in their WPL placements. Before considering each of the above aspects
It goes without saying that these opportunities of CT education, it is important to describe some
in WPL are highly variable in quality of instruc- educational theories and principles. Once the
tion, length of time allotted for training, and the attributes of these have been discussed, the most
amount of “hands-on” experience provided. appropriate principles can be matched with the
Thus, when graduates enter the workplace for various sub-areas as described.
their first paid employment, although it is manda-
tory that they meet the professional capabilities
as referred to above, their actual capability will 2 Andragogy: Adult Learning
be highly variable. In addition, a large part of
their assimilation into the CT work environment Although first described in the literature in 1921,
will involve learning the specific protocols of the Knowles popularised the term andragogy in the
department they work in, and the operating sys- 1960s. It was later defined as “…the art and sci-
Education in CT 161
ence of helping adults learn” (Knowles 2015) classroom and relates the information that stu-
(p. 61). Andragogy is a broad term, encompass- dents are meant to learn. SDL turns this around
ing a multitude of different variations and activi- so that the learner is in charge of their learning.
ties that are designed to engage the adult learner Because all adult learners approach their
and to help them absorb and retain the knowledge learning with different prior experience, levels of
and skills that they are learning. theoretical knowledge, and learning styles, SDL
King (2017) describes four basic principles is suitable because it allows the adult learner to
that are key to successful andragogy: learning identify their learning needs, and prioritises the
must be self-directed; the learners’ experiences content, strategies, and resources which will best
must be used as a resource for learning; learning meet their personal needs (Brockett 1991). Thus,
should grow out of the social tasks integral in adult learners have to develop the ability to iden-
adult life; learning must be applied immediately. tify the strategies and resources, as well as the
When these principles are translated into actual learning style, that best suits them.
educational practices, some of the learning tech- One of the most prominent environments
niques that are used are demonstrating respect to which exemplifies andragogical principles is
adult learners, engaging adult learners in active workplace learning (WPL) (Candy 1991). The
learning, incorporating their prior life experi- way in which self-directed learning is applied in
ences into learning, and applying the learning to CT education is a direct example of WPL. While
their life needs. a qualified and experienced CT radiographer will
These learning techniques, according to supervise the learner, they are generally doing so
Blondy (2007), lead to three positive outcomes in a busy work environment with a full case-load.
for adult learners. Firstly, use of andragogical The supervising radiographer has certain expec-
principles cultivates lifelong learning in students. tations of the learner’s prior knowledge, and if
This is an essential attribute of a CT radiogra- the learner does not meet these expectations, they
pher, as equipment and techniques continue to have the responsibility to gain that knowledge in
advance at a very great rate, and the radiographer their own time.
needs to keep abreast of these rapid changes. When operating the CT scanner under super-
Secondly, educational programs employing vision, the learner has the responsibility to ask
andragogical teaching and learning foster critical for clarification of any aspect of the examination
thinking in learners. Critical thinking is vital for they don’t understand. The learner is expected to
a CT radiographer, as this is needed for functions identify the areas where they lack the required
such as designing scan protocols to best demon- knowledge. Because the learner is an adult, and
strate particular conditions, analysing scanning therefore has an expected level of maturity, the
errors to determine if they are due to machine or supervisor should be able to safely assume that
operator error, and many other aspects of the role. the learner will not carry out any examination
Thirdly, learning in the digital age requires where they are not very certain they know exactly
becoming familiar with ever-changing technol- what to do.
ogy, self-directed learning, and the flexibility of Another way in which the WPL environment
distance learning. The applications of these out- is ideal for the self-directed learner is that they
comes in educating CT radiographers are clear. can immediately apply their learning in the envi-
Some of the educational practices associated ronment where they will be using this new knowl-
with andragogy will now be explored in the con- edge (King 2017). Very few adults learn by just
text of educating CT radiographers. One of the observation. When an adult learner can actively
most prominent and universal principles of apply their learning within a very short time of
andragogy is self-directed learning (SDL). All having learned it, they are able to apply Gibbs
will be familiar with the traditional teacher- Reflective Cycle (see Fig. 1) by testing, practis-
controlled or teacher-centred model of learning. ing, and reinforcing what they have learned, and
The teacher or instructor stands at the front of the check up in a practical way their own understand-
162 A. Kilgour
Description
What happended?
Action plan Feelings
If it arose again, what would you do? What were you thinking and feeling?
Gibbs’
Reflective
Cycle
Conclusion Evaluation
What else could you have done? What was good and bad about the experience?
Analysis
What sense can you make of the situation?
Fig. 1 Gibbs reflective cycle
ing of the new knowledge and skills (Begley tions. Along the way, teachers point out the won-
2007). A trainee CT radiographer will retain the ders, ambiguities, and inconsistencies of the
content. (p. 100)
new knowledge and its application by undertak-
ing CT examinations under supervision as soon The supervising CT radiographer is the guid-
as possible. ing hand who advises the learner how to apply the
The number of ways in which the principles of theoretical content they already know in a real-
andragogy can be applied in CT education is world situation, and stands back as far as possible,
beyond the scope of this chapter to discuss. allowing the learner to actually implement that
However, one more merits inclusion: using the knowledge. The author remembers his own expe-
experiences of the adult learner as a learning rience when first learning CT. He had been a prac-
resource in itself. Boud and Walker (1990) tising radiographer for 8 years at this stage, and
enlarge on how this concept connects adult learn- the senior charged with his education in CT had a
ers to their learning, enhances their retention of teaching style which consisted of “do this, press
knowledge, builds on their ability to apply that this button, then this one and that one”, without
knowledge, and improves performance and letting the learner actually do it for himself. The
productivity. learner became disheartened and wondered
An experienced radiographer who is new to whether or not he had a learning disability, until a
CT will have a history of dealing with patients in new supervising radiographer came on board and
the radiological environment and also of radio- followed andragogical principles as outlined
graphic anatomy. They will also undoubtedly above. The difference it made was undeniable.
have learned at least some CT theory in their Adults generally learn more effectively if they
undergraduate studies. These prior experiences know why the learning is important, if they can
can be drawn on in assimilating the new knowl- maintain responsibility for their own learning, if
edge into their practice as a CT radiographer. their life experiences are valued as part of the
Gitterman (2004) describes the andragogical learning journey, and if they can learn in real-life
process of learning very well: situations rather than contrived or artificial ones
A primary teaching function is to structure the stu- (Mews 2020). Incorporating these principles into
dents’ learning opportunities to interact with the CT education is a win-win situation for all
subject and to personally experience its abstrac- involved.
Education in CT 163
3 Pedagogy: Method range of other healthcare practitioners. Healthcare

and Practice of Teaching provision is at its best when medical, nursing,
allied health, and ancillary staff teams interact
In contrast to andragogy, pedagogy is more with the well-being of their patients at the centre
teacher centred than learner centred. It is a con- of their interactions.
tent model whose primary aim is to transmit The literature enlarges on this, with published
information and employing that information in evidence that this kind of care centred around the
the development and application of skills. In a patient enhances their recovery, and engenders
pedagogical teaching model, the teacher has pre- ongoing health after recovery (Boudreau et al.
conceived ideas of the information and specific 2007). A CT radiographer is responsible for man-
skills essential for transmission. They then aging complex equipment, determining imaging
arrange these into chapters or topics in sequence protocols, and communicating with patients,
which seems orderly and logical to them, and family / carers, and medical / nursing staff simul-
decide on a method of passing this on to learners taneously (Björkman et al. 2013). All of this
(Holmes and Abington-Cooper 2000). emphasises the interactions required of CT
At first, the concept of pedagogy as outlined radiographers going about their daily business.
above seems contradictory to the thoughts on CT practice steps this interactional complexity
andragogical learning and teaching already up to another level over projection radiography,
expressed in this chapter. However, if viewed as not only is the equipment more complex, but
correctly, pedagogy and andragogy can be seen often the patients have more complex pathologies
to complement each other. What is required is the requiring more intervention from nursing / medi-
correct selection of pedagogy to allow andragogy cal staff.
to co-exist. Billett (2014) suggests that the best By working as part of a healthcare team, a CT
pedagogy for adult learners is “… learning in the radiographer can enhance their knowledge and
circumstances of practice …” (p. 674). This will capabilities in patient care by absorbing best
continue to be referred to as workplace learning practice from others in the team. This directly
(WPL). enhances the quality of care received by patients
How applicable then is the WPL paradigm as undergoing CT examination (Martin et al. 2005).
a pedagogy for radiographers learning CT? To When a patient trusts the CT radiographer, they
explore this, we first need to look at the nature of are much more likely to cooperate. This coopera-
CT practice. While there can be no argument that tion is essential to achieving a diagnostic CT
CT practice has a large technical element, it also examination (Ehrlich 2009).
is part of a healthcare profession. Therefore, by Not only do CT radiographers work in a mul-
nature, it is also interactional, dynamic, and con- tidisciplinary team, they also are part of an intra-
textual (Kilgour 2018). It is possible to learn at professional team. In a busy department, it is not
least some technical skills in a traditional, didac- uncommon to have one radiographer getting
tic setting, but the interactional, dynamic, and patients changed, cannulated, and positioned on
contextual nature of any healthcare profession the table, one scanning, and one doing image
cannot be effectively learned in a classroom. reconstruction and other associated tasks. This is
Next, the nature of CT practice as outlined above part of the culture of the profession. Different
will be unpacked. professions have different standards and expecta-
tions, which reflect the collective beliefs, cus-
toms, behaviours, attitudes, professional
3.1 Interactional Practice language, and problem-solving methodology of
that profession (Feuz 2014).
In the course of a normal day, a CT radiographer All of the interactions thus far described are
will work cohesively with not only their patients part of the role of a CT radiographer and cannot
and the patients’ family and / or carers, but also a be taught in a classroom. The WPL paradigm,
164 A. Kilgour
however, allows a radiographer learning CT to be Progress in technology is a result of the nature

continually immersed in the interactions that are of science—scientists are always exploring new
integral to the role. and potentially better ways of achieving goals
(Flick and Lederman 2004). This same overarch-
ing scientific principle of enquiry also applies to
3.2 Dynamic Practice disease and injury and their treatments (Cohen
2012). Scientists are constantly making new dis-
CT practice is never static and is always search- coveries about disease and its treatment, and this
ing for what constitutes best practice. Aspects of leads to new imaging techniques to diagnose and
CT practice which often exhibit change in them- treat. There are countless examples of CT proce-
selves, or which encourage change, include tech- dures being developed and refined for new diag-
nological advances, new developments in nostic and interventional requirements. In order
understanding and treatment of injury and pathol- to be a professional practitioner in this rapidly
ogy, and public educational programs leading to developing field, radiographers must be assessed
increased patient awareness. Practice is not only as to their ability to adapt and progress with the
“fluid, dynamic and changeable”, but is charac- procedures they will be an integral part of as
terised by its “alterability, indeterminacy and practising professionals. Clearly, WPL assess-
particularity”(Boud 2009). Fortune et al. (2013) ment in CT must be flexible and adaptable to
emphasise that health practitioner graduates must accommodate such progress.
have “… capacity to manage contestable, unpre- Because of this changing technological land-
dictable, and highly complex situations” (p. 32). scape, CT practitioners must be prepared to be
Progress in technology has more effect on the dynamic in their adaptation to the changes.
practice of radiography, including CT, than other However, this dynamism is not restricted to
less technology-dependent professions. CT scan- adapting to technological change. Every situation
ning technology has progressed from just being practitioners come across require them to be
able to produce axial scans of the brain, to a dynamic in adapting their practice to the unique
modality capable of imaging virtually any body requirements of that situation. Professional prac-
system in any plane. Producing CT images on tice requires practitioners to exercise reasoning,
film which is difficult to archive, difficult to judgement, and decision-making in a dynamic
transmit and subject to deterioration, has been environment (Govaerts et al. 2011). In order to
replaced by a fully digital environment which is facilitate learning in such a clinical environment,
faster, safer, and productive of a more permanent the CT learning process must be supervised and
medical record (Okada and Blankstein 2009). assessed, acknowledging that facilitation is in
As a consequence of this dynamism in CT, itself a dynamic process, where supervisors and
WPL programs have had to adapt to this ava- students work together in an environment of
lanche of new technology, in that radiographers mutual respect (Dickson et al. 2006).
learning the modality are, and need to be, exposed As technology and knowledge of disease and
to these advances as part of their learning experi- injury have progressed, so has education for
ence. However, the assessment of radiographers health science practitioners (Juanes and Ruisoto
learning in this rapidly changing environment has 2014). Even within postgraduate courses, there
not kept pace with these developments. In par- has been changed to accommodate evolving cir-
ticular, the ability of radiographers to adapt to cumstances, with academic staff needing to keep
changes in the profession brought about by tech- current with rapidly evolving technology and
nological advances is not currently assessed. procedures. However, this has not been reflected
Clearly, the dynamic nature of the technology in concomitant changes in the way the perfor-
involved in CT must be incorporated into its mance of a radiographer learning CT is assessed
assessment if the assessment is to be meaningful (Kilgour 2011). Indeed, in many settings where
and authentic (Solomon 2007). radiographers learn CT, there is no formal assess-
Education in CT 165
ment undertaken at all. Tertiary postgraduate CT Therefore, determining learners’ capability to

education assesses theoretical knowledge, but undertake CT practice must take these contextual
cannot of itself assess the learner’s actual capa- factors into account in order to be a reflection of
bility, which incorporates adaptation to the their actual capability.
dynamic nature of CT practice. Whether the exercise of skills should be clas-
Practice is always transformative (Kemmis sified as an achievement depends very much on
2009), meaning that it produces changes in peo- the context of the situation in which it was exer-
ples’ understanding, physical circumstances and cised (Sadler 2010). A fundamental aspect of the
social interactions. The ability of practitioners’ efficient and capable performance of professional
actions to produce these changes is a reflection of activities relates to situational understanding,
how well their practice implements the dynamic which involves taking the context of the perfor-
nature of professional practice. In order for WPL mance into account. Because of the variations in
assessment to capture this feature of learners’ the contexts of clinical performance, no single
performance, the assessment process must be assessment method can evaluate the entirety of a
sufficiently broad and flexible to ensure that student’s professional capabilities (Hager et al.
changes in practice are reported on and consid- 1994).
ered as part of their professional capabilities as a CT radiographers’ performance in the work-
CT radiographer. place is moulded by a variety of external factors,
including the context of the situation, as well as
the interactional, social, and dynamic features of
3.3 Contextual Practice professional practice already discussed.
Therefore, the assessment of CT workplace per-
The practice of CT does not exist in isolation. On formance should be based on their practice capa-
a micro level, it exists as part of the radiology bility, rather than theoretical achievement (Trede
department, and the CT radiographer is an inte- and Smith 2014). The skills that radiographers
gral part of the overall team of radiographers. On develop in handling these external factors in real
a macro level, the CT radiographer, particularly practice contexts create confidence for them to
in a hospital environment, is a part of several dif- work in other contexts which are previously
ferent healthcare teams. For example, in the case unencountered (Walsh 2007). The situations into
of trauma, the medical team responsible for the which a radiographer learning CT is placed in
management of the patient depends on the CT order to develop these skills should be deliber-
radiographer to provide not only a diagnosis, but ately designed to promote transferability from
also detail of any injuries sustained. An oncology one context to another (Orrell et al. 2010). This
team is dependent on the CT radiographer for argument emphasises a vital feature of CT prac-
staging of the patient’s malignancy. Mobile CT tice, that is, practitioners must be able to under-
units are increasingly being utilised in orthopae- take their practice irrespective of the context of
dic and neurological surgery. their practice. They must be able to adapt to
All of the above examples are different con- whatever circumstances are present and remain
texts for CT practice. CT practice is influenced competent and capable.
by so many factors outside of the core profession When these general principles are followed in
specific skills, and the context of the assessed planning and implementing the program that a
performance must always be taken into consider- radiographer learning CT undergoes, learners are
ation. The way skills are practised depends on enabled to encounter a wide variety of contexts.
existing resources, the time available to exercise Therefore, due to the wide variety of contexts
the skill, the nature of the patients for whom the which learners experience in such programs,
skill is practised, the culture of the workplace in adopting traditional assessment methods will
which it is carried out and the ability of the prac- result in questionable credibility of the assess-
titioner who is carrying out the task (Trede 2015). ments produced. These traditional methods
166 A. Kilgour
attempt to apply the scientific, psychometric determined to be ready for independent practice
assessment processes used in traditional educa- in CT, a formalised assessment should be under-
tion to the constantly changing context of CT taken. Before the nature of this assessment can be
practice. The world of CT practice requires a dif- determined, the question must be asked, “What is
ferent assessment paradigm to that of theoretical, actually to be assessed?”
on-campus academic assessment of learning
(Coll and Zegwaard 2011). This paradigm is not
so much about measurement, as it is about rea- 4.1 Competence and Capability
soning, judgement, and decision-making in the
variety of contexts encountered (Govaerts et al. The pertinent literature often uses the terms
2011). “competence” and “capability” interchangeably
(Kilgour 2018), therefore it should not be unex-
pected that practitioners often do not understand
4 Assessment of the Learning the difference between the two terms. However,
CT Radiographer Fraser and Greeenhalgh (2001) provide clarifica-
tion, defining competence as “…what individuals
As has been previously stated, in many depart- know or are able to do in terms of knowledge,
ments where radiographers are trained in CT skills, attitude”, and capability as the “…extent to
practice, there is no formalised assessment of which individuals can adapt to change, generate
their achievements, which means that there is no new knowledge, and continue to improve their
measurable way to determine whether or not they performance” (p. 799). These definitions make it
are ready to practice independently. In a hospital clear that whilst assessing the technical prowess
setting at least, a CT radiographer often has to of a CT radiographer can determine their compe-
work independently of other radiographers. This tence, a determination of competence cannot
is often the case when on call or working a mid- measure their actual capability in CT practice.
night to dawn shift. These situations are anecdot- In the light of what has been discussed thus
ally when the most challenging and complex far, a model of capability in CT practice is pro-
patient presentations occur, and the radiographer posed below (Fig. 2):
must adapt to these presentations. Whilst the No radiographer or radiography educator
technical aspects of CT practice are vital, they are would argue that technical competence is unim-
more easily learned than is the ability to adapt to portant, however, this model shows competence
the interactional, dynamic, and contextual nature to be a subset of capability. Therefore, in order to
of practice. Therefore, before a radiographer is assess a CT radiographer’s readiness for indepen-
Fig. 2 Model of
capability in CT practice
(Kilgour 2018).
interactional dimension dynamic dimension
professional
practice capability
technical skill dimension contextual dimension

Education in CT 167
dent practice, an assessment of capability incor- enhanced as the principles of professional prac-
porates an assessment of competence by default. tice are inculcated in future practitioners.
Assessing capability is a far more reliable method The question must now be asked as to the
for determining readiness to practice as a CT most effective way to assess CT capability.
radiographer than simply assessing competence,
as it determines the ability of the practitioner to
accommodate not only the inherent technical 4.3 Professional Judgement
complexities, but also their ability to adapt to
changes, use problem-solving skills to find solu- Although at face value professional judgement
tions to problems they have never before been may seem subjective, by necessity it plays an
confronted with, and interact as part of the health- essential role in the assessment of practice capa-
care team, regardless of circumstances. bility and is no less reliable than so-called objec-
tive assessment (Hager et al. 1994). It typically
has a high degree of credibility, dependability,
4.2 Assessment for Learning confirmability, and transferability, and its validity
and Assessment of Learning is assured because a sample observation of a
learner’s practice is the most direct basis for mak-
One widely accepted educational principle is that ing a judgement about professional capability
assessment drives learning (Dijkstra et al. 2010). (Hager et al. 1994). Clinical assessors can almost
According to this principle, when capability in universally identify good performance when they
professional practice is assessed as an integral see it, but if one was to ask an experienced asses-
part of CT radiographer education, skill in pro- sor exactly what they are looking for to classify
fessional practice will be enhanced. performance as capable, they may have a deal of
It can also be argued that assessment drives difficulty doing so (Sadler 1989). Sadler (2009)
behaviour, in that students exhibit the behaviours refers to the concept of holistic grading, where
they believe will allow them to pass assessment the primary influence is the supervisor’s emerg-
tasks, without necessarily obtaining the deep ing global judgement of the learner’s perfor-
learning and understanding that develops the mance. Of course, this judgement must be
characteristics of a professional practitioner. referenced to accepted standards for the relevant
Tennant et al. (2009) reflect that the tension profession.
between assessment for certification and Contemporary assessment literature (Boud
assessment for learning traditionally has led edu- and Dochy 2010; Sadler 2005) often refers to the
cators to set assessment tasks that promote role of standards in assessment. However, using
assessment of learning, rather than making their pre-determined professional capability standards
assessment a learning process in itself. They as the measure for assessment of professional
assert that the type of quality assessment which capability does not prescribe that professionals’
motivates students to engage with the task, and actions should be the same as the next person in a
use it to learn for their future practice, needs to given situation. Application of these standards
foster deep learning that can only be facilitated should allow for professional discretion (Feuz
during WPL by dialogue, reflection, and collab- 2014). When assessing capability, the context of
orative learning in the clinical environment. the performance needs to be integrated into the
Either way, incorporating assessment of pro- considerations (Johnsson and Boud 2010).
fessional practice capability into assessment of Therefore, assessing capability of a CT radiogra-
CT radiography performance will in time facili- pher is not really a process of measurement, but
tate the dissemination of understanding the nature rather the application of judgement, reasoning,
of professional practice throughout the profes- and decision-making in a dynamic environment
sion. The recognition in the healthcare commu- (Govaerts et al. 2011). This is a qualitative
nity of radiography as a profession will be process.
168 A. Kilgour
It is not constructive to try and force profes- Psychometric measurement models are suitable
sional qualitative judgements into some type of to assess technical domains but they are not suf-
artificial quantitative format. We should recog- ficient to credibly assess for student capability
nise and value these judgements for what they which should include interactional, dynamic, and
are—an accurate, professional reflection of learn- contextual features. Yet current models for
ers’ practice capability. assessment of performance for radiographers
Professional judgement of clinical assessors learning CT are largely psychometric (Kilgour
provides not only the most meaningful informa- 2011). The professional judgement of experi-
tion regarding practice capability, but also a supe- enced practitioners has been shown to be trust-
rior approach to assessment methods commonly worthy in determining the capability of learners
thought to be objective. At least one assessment they are assessing (Yorke 2011), and yet in cur-
component of the assessment framework devel- rent assessment models, this is largely ignored.
oped should be based on the professional judge- The past focus on assessment of technical
ment of experienced supervising CT skills has meant that clinical CT supervisors feel
radiographers. under-equipped to assess learners’ broader pro-
From the discussion above the following fessional skills. They either use their own ideas
propositions can be drawn: of what constitutes good performance, without
reference to standards or assessment criteria, or
1. An assessment framework for CT practice write an incomplete report, feeling that this
should allow supervisors to exercise their pro- makes them less likely to be “wrong” (Burchell
fessional judgement in assessing practice et al. 1999). The result is a superficial approach to
capability of radiographers learning CT. WPL-based assessment in the radiography pro-
2. Technical competence should be assessed, but fession in general, and CT in particular (Kilgour
this is just one part of the skillset that affords et al. 2014), with a focus on what is measurable
practice capability. and visible.
3. A CT assessment framework should include This superficial approach to assessing profes-
actions that facilitate and enhance student sional skills is reflected in the assessment strate-
learning, not just assessments that measure it. gies employed by supervising CT radiographers,
One proven method for attaining this is to use if indeed any formal assessment is carried out.
a reflective portfolio (Pinsky and Fryer- These typically report rigorously on technical
Edwards 2004). skills, and when other skills are included in
4. There should be more than one method of assessment, the assessment strategy is psycho-
assessment of CT practice capability contrib- metrically based. Psychometric assessment strat-
uting to the developed assessment egies are broadly suitable for assessing technical
framework. competence—in that many highly technical skills
are either “can do” or “can’t do” (Yorke 2011).
It should also be pointed out that assessment However, such an approach is not sufficient for
of CT practice capability needs to align with pro- assessment of more complex professional prac-
fessional and accreditation body standards. tice capability such as is required in CT. From the
point of view that capability is not the sum of
separate entities but an integrated whole, it is
4.4 Application to Assessment only logical to conclude that no single instru-
of CT Capability ment, no matter how psychometrically sound,
can provide all the information for a comprehen-
Many different models of assessment exist, and sive evaluation of competence in a health-related
for assessment to be credible and transparent, the domain (Dijkstra et al. 2010). Different aspects
models employed need to have a good match of capability therefore require different assess-
with the purpose of what is being assessed. ment strategies.
Education in CT 169
Whilst it is not in the scope of this chapter to accept changes in technology, is slow to accept
propose a specific assessment model for CT changes in education and its assessment.
capability, the literature as discussed demon-
strates that the technical skills required of a CT
radiographer can be assessed by a psychometric References
or scientific (quantitative) scale, but that the other
aspects of professional practice in CT need to be Australian Health Practitioner Regulation Agency.
Professional capabilities for medical radiation practice
assessed by qualitative means, such as a narrative [Online]; 2016. http://www.medicalradiationpractice-
comparing learner performance to professional board.gov.au/Registration/Professional-Capabilities.
standards, and targeted reflective portfolios kept aspx. Accessed 23 Sept 2016.
by learners. Begley S. How the brain rewires itself. Time (Chicago,
Ill.). 2007;169:72.
Billett S. Learning in the circumstances of practice. Int J
Lifelong Educ. 2014;33:674–93.
5 Conclusion Björkman B, Golsäter M, Simeonson RJ, Enskär K. Will
it hurt? verbal interaction between child and radiogra-
pher during radiographic examination. J Pediatr Nurs.
As radiographers learning CT are invariably adult 2013;28:e10–8.
learners, the principles of andragogy as set out in Blondy LC. Evaluation and application of andragogical
this chapter are clearly applicable, suggesting assumptions to the adult online learning environment.
that a self-directed learning program, acknowl- J Interact Online Learn. 2007;2:116–30.
Boud D. How can practice reshape assessment? In:
edging the learner’s prior experiences and knowl- Joughin G, editor. Assessment, learning and judge-
edge as part of the learning, will be efficacious in ment in higher education. Dordrecht, London:
maximising the learning and resulting capability Springer; 2009.
of those involved. Boud D, Dochy F. Assessment 2020. Seven propositions
for assessment reform in higher education. Status:
This chapter also highlights the importance of published; 2010.
hands-on, contextual learning, rather than a focus Boud D, Walker D. Making the most of experience. Stud
on theoretical knowledge, in developing CT prac- Contin Educ. 1990;12:61–80.
tice capability. Boudreau JD, Cassell E, Fuks A. A healing curriculum.
Med Educ. 2007;41:1193–201.
Current practice in CT capability assessment Brockett RG. Self-direction in adult learning: perspectives
remains fragmented and heavily psychometric on theory, research, and practice. London: Routledge;
based with a focus on assessing technical skills, 1991.
and little consideration given to either the profes- Burchell H, Higgs T, Murray S. Assessment of compe-
tence in radiography education. Assess Eval High
sional judgement of learners’ supervisors, or the Educ. 1999;24:315–26.
interactional, dynamic, and contextual dimen- Candy PC. Self-direction for lifelong learning: a compre-
sions of clinical practice that together with the hensive guide to theory and practice. San Francisco:
technical skill dimension make up professional Jossey-Bass; 1991.
Cohen LA. (2012). Disease prevention: Experiments in
practice capability. The concepts of education nature (Science (883)). Science (American Association
and assessment presented in this chapter are for the Advancement of Science), 338(6112), 1287.
informed by theoretical ideas of professional https://doi.org/10.1126/science.338.6112.1287
practice and how such practice capability can be Coll RK, Zegwaard K. International handbook for coop-
erative & work-integrated education; 2011
learned. Drawing on the theories and research Dickson C, Walker J, Bourgeois S. Facilitating under-
findings discussed above will require a cultural graduate nurses clinical practicum: the lived expe-
shift for CT assessment practices because it rience of clinical facilitators. Nurse Educ Today.
would mean embracing the interactional, 2006;26:416–22.
Dijkstra J, Vleuten CPM, Schuwirth LWT. A new frame-
dynamic, and contextual dimensions of practice work for designing programmes of assessment. Adv
that together with technical skills make a capable Health Sci Educ. 2010;15:379–93.
CT radiographer. Past evidence demonstrates that Ehrlich RA. Patient care in radiography: with an introduc-
radiography as a profession, while quick to tion to medical imaging. Mosby Elsevier: St. Louis,
Mo; 2009.
170 A. Kilgour
Feuz C. The role of the keyworker in breaking down pro- Knowles MS. The adult learner: the definitive classic in
fessional culture barriers to providing high-quality adult education and human resource development.
palliative care: a literature review. J Radiother Pract. Oxfordshire, England: Routledge; 2015.
2014;13:465–72. Martin DR, O’Brien JL, Heyworth JA, Meyer NR. The
Flick LB, Lederman NG. (2004). Scientific inquiry and collaborative healthcare team: tensive issues warrant-
nature of science: implications for teaching, learning, ing ongoing consideration. J Am Acad Nurse Pract.
and teacher education (L. B. Flick & N. G. Lederman, 2005;17:325–30.
Eds.; 1st ed. 2006.). Kluwer Academic Publishers. Mews J. Leading through andragogy. Coll Univ.
https://doi.org/10.1007/978-1-4020-5814-1 2020;95:65–8.
Fortune T, Ryan S, Adamson L. Transition to practice in Okada DR, Blankstein R. Digital image processing for
supercomplex environments: are occupational therapy medical applications. Perspect Biol Med. 2009.
graduates adequately prepared? Aust Occup Ther J. Orrell J, Cooper L, Bowden M. Work integrated learn-
2013;60:217–20. ing: a guide to effective practice. London: Routledge;
Fraser SW, Greeenhalgh T. Coping with complexity: edu- 2010.
cating for capability. Br Med J. 2001;323:799. Pinsky LEMD, Fryer-Edwards K. Diving for PERLS. J
Gitterman A. Interactive andragogy: principles, methods, Gen Intern Med. 2004;19:582–7.
and skills. J Teach Soc Work. 2004;24:95–112. Sadler DR. Formative assessment and the Design of
Govaerts MJB, Schuwirth LWT, van der Vleuten CPM, Instructional Systems. Instr Sci. 1989;18:119–44.
Muijtjens AMM. Workplace-based assessment: Sadler DR. Interpretations of criteria-based assessment
effects of rater expertise. Adv Health Sci Educ. and grading in higher education. Assess Eval High
2011;16:151–65. Educ. 2005;30:175–94.
Hager P, et al. General issues about assessment of compe- Sadler DR. Indeterminacy in the use of preset criteria
tence. Assess Eval High Educ. 1994;19:3–16. for assessment and grading. Assess Eval High Educ.
Holmes G, Abington-Cooper M. Pedagogy vs. andra- 2009;34:159–79.
gogy: a false dichotomy? J Technol Studies. Sadler DR. Fidelity as a precondition for integrity in grad-
2000;26:50–5. ing academic achievement. Assess Eval High Educ.
Johnsson MC, Boud D. Towards an emergent view of 2010;35(6):727–43.
learning work. Int J Lifelong Educ. 2010;29:359–72. Solomon N. (2007). Reality bite(s): Bringing the ‘real’
Juanes J, Ruisoto P. Technological advances and teach- world of working to educational classrooms. In
ing innovation applied to health science education. J M. Osborne, M. Houston, & N. Toman (Eds.), The
Inform Technol Res. 2014;7:1–6. pedagogy of lifelong learning: Understanding effec-
Kemmis S. Understanding professional practice: a syn- tive teaching and learning in diverse contexts. (pp.
optic framework. In: Green B, editor. Understanding 115–126). London and New York: Routledge.
and researching professional practice. Rotterdam, The Tennant M, McMullen C, Kaczynski D. Teaching, learn-
Netherlands: Sense Publishers; 2009. ing, and research in higher education : a critical
Kilgour A. Assessment of competency in radiography stu- approach. New York, NY: Routledge; 2009.
dents - a new approach. Radiographer. 2011;58:32–7. Trede F. Introduction to WPL [Online]; 2015. http://www.
Kilgour A. Radiography assessment for practice: a critical csu.edu.au/efpi/home/wpl-professional-development.
practice enquiry. Bathurst: Charles Sturt University; Accessed 1 Oct 2016.
2018. Trede F, Smith M. Workplace educators’ interpretations
Kilgour AJ, Kilgour PW, Gerzina T, Christian of their assessment practices: a view through a critical
B. Assessment of work-integrated learning: com- practice lens. Assess Eval High Educ. 2014;39:154–67.
parison of the usage of a grading rubric by supervis- Walsh A. An exploration of Biggs’ constructive alignment
ing radiographers and teachers. J Med Radiat Sci. in the context of work-based learning. Assess Eval
2014;61:22–9. High Educ. 2007;32:79–87.
King KP. Technology and innovation in adult learning. Yorke M. Summative assessment: dealing with the ‘mea-
San Francisco, CA: Jossey-Bass; 2017. surement fallacy’. Stud High Educ. 2011;36:251–73.

Computed Tomography: Advanced Clinical Applications Shayne Chau Christopher Hayre

Uploaded by

Computed Tomography: Advanced Clinical Applications Shayne Chau Christopher Hayre

Uploaded by

Computed

ISBN 978-981-19-9345-9 ISBN 978-981-19-9346-6 (eBook)

Computed Tomography is a dynamic technology and as such it keeps evolv-

It is my sincere prediction that this book Computed Tomography: Advanced

Part I Radiobiology and Patient Care

Part II CT in an Emergency Setting

 in an Emergency Setting ������������������������������������������������������������������ 39

Part III CT Guided Interventions

Indications, Technique and Pitfalls�������������������������������������������������������� 111

Part IV CT Forensic Imaging

CT Forensic Imaging ������������������������������������������������������������������������������ 137

Part V CT Education

Education in CT �������������������������������������������������������������������������������������� 159

Abstract 1 Radiobiology and Radiation

Keywords Radiation, an energy packet traveling in space at

wavelength, h is the Planck constant Beer (1852) exponential attenuation law

Fig. 1 Total mass

attenuation coefficients Soft tissue

Fig. 2 Rayleigh scattering—the orbiting electrons and

1.1.2 Compton Scattering

1.2 Effects of Ionizing Radiation 1.2.2 Stochastic Effects

where HU is the Hounsfield number, and μtissue 2 Radiation Dose in CT

Table 3 Tissue weighting factors

a Relative dose b Relative dose

a Relative dose b Relative dose

a small focal spot) and lack of scattered radiation.

Fig. 8 Distribution of radiation along the scan length

Fig. 9 CT cylindrical acrylic phantom for head and torso

Fig. 11 Illustration of

Resultant dose distribution

CTDI does not standardize the width for the inte-

variations in dose measurements owing to the 2.11 CTDIvol

energy deposited in the scan volume as the scan References

Abstract on common scenarios seen in a CT depart-

2 Clinical Considerations the yearly background radiation received is

Table 1 Classification of allergic reactions to IV contrast media

If contrast extravasation occurs, the following Breastfeeding

2.2.5 Pregnancy and Breastfeeding 3 Patient Interaction

Pregnancy 3.1 Values & Biases in Patient

3.2.1 Language Barriers 3.4 Patients with Specific Needs

Trilemma of CT Workflow thetic. However this statement alone can lead to

Fig. 2 Patient care—each individual healthcare profes-

3. Encourage staff to take a walk during their level—something healthcare professionals

mented memory of the events and often dis- References

Abstract ples of a few of many variations in current

for detection of acute hemorrhages (Hemphill medical departments (Nayebaghayee and

Table 1 Risk classification for TBI (indications)

As a result, stroke is regarded as one of the effective treatment of ischemic cerebrovascular

function history due to the acute presentation in

5.1 Epidural Hematoma

Epidural hematoma (Fig. 6) is an acute arterial

Table 2 Common Findings in CT scan for TBI and nTBI

hematoma with associated midline shift and sub- 5.3 Subarachnoid/Intraventricular

According to Parizel and Philips (2020), injury

5.4 Intra-Axial Hemorrhage

According to Ullah et al. (2015), “Intra-axial

Fig. 8 Subarachnoid/intraventricular (a & b) (Milpark Radiology 2020)

5.5 Intraparenchymal Hematoma • A is the largest hemorrhage diameter on the

5.7 Skull Fractures

Skull fractures are caused by high energy impact

Fig. 10 (a and b): ABC/2 method (Milpark Radiology 2020)

recommended if there is a high suspicion for

6.1 Hemorrhagic Stroke 6.2 Transient Ischemic Attack

Fig. 13 Brain herniation (Milpark radiology 2020)

Despite the lack of standardized protocols, the 9 Responses to Trauma,

Coutts SB. Diagnosis and management of transient www.hst.org.za/publications/South%20African%20

CT is a key imaging modality in the diagnosis Trauma imaging · Brain perfusion ·

other, and there is no consensus on which rule

Table 1 Glasgow Coma Scale 3 Thorax, Abdomen & Pelvis

4 Penetrating and Vascular trauma can also result in damage to arteries and/or

feature is available, a single acquisition of the

system and to distinguish between urinoma and

JA, Shapiro MB, Winston ES. Practice management

A stroke occurs when blood flow to a portion Stroke · Intra-arterial thrombectomy ·

Table 1 Stroke protocol

Fig. 1 This 86-year-old female was brought to hospital

Part I Radiobiology and Patient Care

Part II CT in an Emergency Setting

in an Emergency Setting �� 39

Part III CT Guided Interventions

Indications, Technique and Pitfalls�� 111

Part IV CT Forensic Imaging

CT Forensic Imaging �� 137

Part V CT Education

Education in CT �� 159

Abstract 1 Radiobiology and Radiation

1.1.2 Compton Scattering

1.2 Effects of Ionizing Radiation 1.2.2 Stochastic Effects

where HU is the Hounsfield number, and μtissue 2 Radiation Dose in CT

variations in dose measurements owing to the 2.11 CTDIvol

2 Clinical Considerations the yearly background radiation received is

2.2.5 Pregnancy and Breastfeeding 3 Patient Interaction

Pregnancy 3.1 Values & Biases in Patient

3.2.1 Language Barriers 3.4 Patients with Specific Needs

5.1 Epidural Hematoma

hematoma with associated midline shift and sub- 5.3 Subarachnoid/Intraventricular

5.4 Intra-Axial Hemorrhage

5.5 Intraparenchymal Hematoma • A is the largest hemorrhage diameter on the

5.7 Skull Fractures

6.1 Hemorrhagic Stroke 6.2 Transient Ischemic Attack

Despite the lack of standardized protocols, the 9 Responses to Trauma,

Table 1 Glasgow Coma Scale 3 Thorax, Abdomen & Pelvis

4 Penetrating and Vascular trauma can also result in damage to arteries and/or

2 Time In light of these advantages, the link between

7.1 Patient Preparation –– 70 ml contrast @ 3–4 ml/s followed by

8 Conclusion Surg. 2019;9(4):636–41. https://doi.org/10.21037/

Procedures include spinal injections such as 1.1 Technique

1.5 Pre-Planning CT Scan Once an appropriate needle insertion slice has

1.7 Acquisition Option 1: • Use ‘Soft’ for Nerve Root.

1.8 Acquisition Option 2:

1.13 Shoulder Hydrodilatation ±

Abstract 1 Tips and Tricks

2.2 Radiation Protection of Staff SHIELDING FOR DIAGNOSTIC RADIOLOGY

2.3 Methods to Reduce 0.1 µGy/mGy cm 0.02 µGy/mGy cm

geted PMCT coronary angiography is per- 4 Living Versus Deceased

5 Advantages an adjunct to the invasive autopsy, rather than as a

6.2 Reconstruction role should be clearly identified when setting up

8.3.1 Head and Neck

3 Pedagogy: Method range of other healthcare practitioners. Healthcare