Neuro CT

Last updated: 11/13/2021

General

  • Brain Standard Reformations
    • Axial brain 5 mm
    • True Axial brain 5 mm: Reformations are parallel to the infra-orbital line and skull base
    • Coronal brain 2 mm
    • Sagittal brain 2 mm
    • Axial bone 0.6 mm
  • Dual Energy Brain Reformations
    • Axial (AX) F_0.5
    • True Axial (TR AX) F_0.5
    • Coronal (COR) F_0.5
    • Sagittal (SAG) F_0.5
    • True Axial (TR AX) Bone F_0.5
    • A+B A_80kV
    • A+B Sn150kV
    • A+B Monoenergentic Plus 190 keV
  • Cervical spine “multi-spine” reformat angels the axial images to a true axial on patients with a curved spine

Brain

  • Without Intravenous Contrast Indications
    • Suspected intracranial hemorrhage
    • Severe headache
    • Follow up bleed or stroke
    • ER patient with new onset seizure
    • Altered mental status
    • Trauma
    • Hydrocephalus
  • With Intravenous Contrast Indications
    • Some indications with same day or recent non-contrasted CT
    • Brain lab or treatment planning
  • Without & With Intravenous Contrast Indications
    • MRI contraindicated and
      • Brain tumor or metastatic disease
      • CNS infection/abscess/meningitis/AIDS
  • Acquisition Phases
    • Brain Without: Noncontrast
    • Brain With: 5 minute Delay
    • Brain Without and With: Noncontrast and 5 minute Delay
  • Anatomical Coverage: Skull Vertex to C1 Vertebral Body
  • Reformations: Standard
  • Note: MUST specify the bolded acquisition phase name above and add any additional phases needed to ensure correct phases are obtained

Brain and Face Trauma

  • Indication: Head/Face Trauma
  • Acquisition Phase: Noncontrast
  • Anatomical Coverage: Skull Vertex through Mandible
  • Brain Reformations: Standard
  • Face Reformations
    • Axial, coronal, and sagittal soft tissue 2 mm
    • Axial, coronal, and sagittal bone 2 mm
    • 3-Dimensional reconstructions

Brain CT Angiography

  • Indications
    • Subarachnoid hemorrhage
    • Aneurysm follow-up
    • Rule out vasospasm
  • Acquisition Phase: Noncontrast, Arterial
  • Anatomical Coverage: Skull Vertex to C1 Vertebral Body
  • Reformations
    • Non-contrasted axial brain 5 mm
    • Non-contrasted coronal brain 2 mm
    • Non-contrasted sagittal brain 2 mm
    • CTA Brain axial 0.6 mm
    • Axial, coronal, and sagittal MIPS 10 mm slab
    • 3D: Cranial view (Circle of Willis), Bilateral lateral views (ACA), Anterior view (Carotid terminus), Posterior view (Basilar and distal vertebral arteries)

Brain Attack

  • Indication: Acute stroke
  • Acquisition Phases: Non-contrast, Arterial, Perfusion
  • Anatomical Coverage
    • Non-contrast: Skull Vertex to C1 Vertebral Body
    • Arterial: Pulmonary Arteries to Skull Vertex
    • Perfusion: Skull Vertex to C1 Vertebral Body
  • Reformations
    • Non-contrasted axial brain 5 mm
    • Non-contrasted coronal brain 2 mm
    • Non-contrasted sagittal brain 2 mm
    • CTA Brain axial 0.6 mm
    • Axial, coronal, and sagittal MIPS 10 mm slab
    • Carotid canal 0.6 mm (right & left)
    • Carotid bifurcation MIPs (right & left)
    • 3D: Cranial view (Circle of Willis), Bilateral lateral views (ACA), Anterior view (Carotid terminus), Posterior view (Basilar and distal vertebral arteries)
    • Cerebral blood flow, cerebral blood volume, mean transit time, and time to peak maps

Brain and Neck CT Angiography

  • Indications
    • Suspected dissection
    • Vertigo/ataxia
    • Syncope
    • Transient ischemic attack (TIA)
  • Acquisition Phases: Noncontrast, Arterial
  • Anatomical Coverage: Skull Vertex to Aortic Arch
  • Reformations
    • Non-contrasted axial brain 5 mm
    • Non-contrasted coronal brain 2 mm
    • Non-contrasted sagittal brain 2 mm
    • CTA Brain axial 0.6 mm
    • Axial, coronal, and sagittal MIPS 10 mm slab
    • Carotid canal 0.6 mm
    • Carotid bifurcation sagittal 3 mm bilaterally
    • 3D: Cranial view (Circle of Willis), Bilateral lateral views (ACA), Anterior view (Carotid terminus), Posterior view (Basilar and distal vertebral arteries)

Neck CT Angiography

  • Indications
    • Trauma with suspected vascular injury
    • Vascular anomaly
    • Arterial Stenosis
  • Acquisition Phase: Arterial
  • Anatomical Coverage: Mid Orbits through Aortic Arch
  • Standard CTA Reformations
    • Axial soft tissue 0.6 mm
    • Carotid canal 0.6 mm (right & left)
    • Carotid bifurcation sagittal 3 mm bilaterally
    • 3D Vascular
  • Trauma CTA Reformations
    • Axial soft tissue 0.6 mm
    • Coronal and sagittal soft tissue 2 mm
    • Axial, coronal, and sagittal bone 2 mm
    • 3-Dimensional Vascular
  • Notes
    • Must specify CTA Neck vs Trauma CTA Neck to ensure correct reformations are performed
    • Either performed as a true CTA (CTANNWWO) or as a trauma CTA neck (CNNTRAUMAW)
    • Almost always perform as the true CTA (not trauma) due to better image quality
    • Trauma CTA Neck is most commonly performed when the trauma team orders a “Single Pass” trauma CT

Soft Tissue Neck

  • Without Intravenous Contrast Indications
    • Subglottic stenosis
    • Thyroid pathology in patients who cannot receive iodinated contrast (reaction vs plan for treatment)
  • With Intravenous Contrast Indications
    • Malignancy/Mass
    • Infection
  • Acquisition Phases
    • Soft Tissue Neck Without: Noncontrast
    • Soft Tissue Neck With: 90 second delay
  • Anatomical Coverage: Frontal Sinuses through Aortic Arch
  • Reformations
    • 3 mm axial, coronal, and sagittal soft tissue
    • 3 mm axial, coronal, and sagittal bone
    • Laryngology patients also get 1 mm soft tissue axial through larynx
  • Notes
    • MUST specify the bolded acquisition phase name above and add any additional phases needed to ensure correct phases are obtained
    • If the order is for without and with, look to see if it’s for a parathyroid abnormality and if so use that specific protocol. Otherwise, both without and with contrast is not performed.

Cervical Spine

  • Without Intravenous Contrast Indications
    • Spinal canal stenosis and MRI contraindicated
    • Trauma, compression fracture
    • Osseous metastatic disease
    • Post myelogram
  • With Intravenous Contrast Indications
    • Metastasis and MRI contraindicated
    • Epidural tumor and MRI contraindicated
    • Intraspinal abscess
    • Surgical planning (vertebral artery)
  • Acquisition Phase
    • Cervical Spine Without: Noncontrast
    • Cervical Spine With: 60-70 second delay (basically same as PVP)
  • Anatomical Coverage: Skull Base to T1 Vertebral Body
  • Reformations
    • 2 mm axial, coronal, and sagittal soft tissue
    • 2 mm axial, coronal, and sagittal bone
  • Note
    • MUST specify the bolded acquisition phase name above and add any additional phases needed to ensure correct phases are obtained
    • Never perform without and with contrast
    • “Multispine”: Angles the axial images to the true axials on patients with curved spines

Face

  • Without Intravenous Contrast Indication: Trauma
    • Sinus CT (does not cover mandible): sinusitis (see below for sinus protocol)
    • Face CT (does cover the mandible): trauma
  • Face With Intravenous Contrast Indications
    • Malignancy
    • Infection (Invasive sinusitis, cellulitis, abscess, etc.)
  • Acquisition Phases
    • Face Without: Noncontrast
    • Face With: 60-70 second delay (basically same as PVP)
  • Anatomical Coverage: Frontal Sinuses through Mandible
  • Reformations
    • 2 mm axial, coronal, and sagittal soft tissue
    • 2 mm axial, coronal, and sagittal bone
  • Notes
    • MUST specify the bolded acquisition phase name above and add any additional phases needed to ensure correct phases are obtained
    • Face includes mandible (vs sinus)
    • Never perform without and with contrast
    • Also have a noncontrast “Face/Sinus Brain Lab” protocol which includes 1 mm soft tissue and bone reformations and is used for surgical planning

Parathyroid

  • Indications
    • Suspected parathyroid lesion
    • Abnormal parathyroid glands
  • Acquisition Phases: Noncontrast, Arterial (25 seconds from injection), Delay (80 seconds from injection)
  • Anatomical Coverage: Frontal Sinus through Carina
  • Reformations
    • 2 mm axial noncontrast phase
    • 2 mm axial, coronal, and sagittal soft tissue arterial and delayed phases
  • Note: Should be ordered and coded as CT neck without and with

Sinus

  • Indication: Non-invasive sinusitis
  • Acquisition Phases: Noncontrast
  • Anatomical Coverage: Frontal through Maxillary Sinuses
  • Reformations
    • 2 mm axial, coronal, and sagittal soft tissue
    • 2 mm axial, coronal, and sagittal bone
  • Notes
    • Sinus CT’s are not performed with contrast. If the indication needs contrast, then a Face CT should be performed instead
    • Sinus doesn’t include mandible (vs face)
    • Also have a noncontrast “Face/Sinus Brain Lab” protocol which includes 1 mm soft tissue and bone reformations and is used for surgical planning

Orbit/Sella

  • Without Intravenous Contrast Indication: Trauma
  • With Intravenous Contrast Indications
    • Intra-orbital tumor
    • Infection
  • Acquisition Phases
    • Orbit/Sella Without: Noncontrast
    • Orbit/Sella With: 60-70 second delay (basically same as PVP)
  • Anatomical Coverage: Frontal through Maxillary Sinuses
  • Reformations
    • 2 mm axial, coronal, and sagittal soft tissue
    • 2 mm axial, coronal, and sagittal bone
  • Notes
    • MUST specify the bolded acquisition phase name above and add any additional phases needed to ensure correct phases are obtained
    • Never perform without and with contrast

Temporal Bone

  • Without Intravenous Contrast Indications
    • Trauma
    • Conductive or sensorineural hearing loss
    • Semicircular canal dehiscence
    • Surgical planning for mastoidectomy and cochlear implant placement
  • With Intravenous Contrast Indication
    • Neoplasms (e.g. Glomus tympanicum or jugulare)
    • Infection (Ear/Mastoid, Rule out Bezold’s abscess)
  • Acquisition Phases
    • Temporal Bone Without: Noncontrast
    • Temporal Bone With: 60-70 second delay (basically same as PVP)
  • Anatomical Coverage: Mastoid air cells
  • Without Reformations (All bone window and bilateral)
    • Axial 0.6 mm (Bilateral and individual coned down)
    • Coronal 0.6 mm (Bilateral and individual coned down)
    • Oblique Poschl and Stenvers 0.6 mm
  • With Reformations
    • Axial bone 0.6 mm (Bilateral and individual coned down)
    • Coronal bone 0.6 mm (Bilateral and individual coned down)
    • Oblique bone Poschl and Stenvers 0.6 mm (Individual coned down only)
    • Axial 0.6 mm soft tissue (Bilateral only)
    • Coronal soft tissue 0.6 mm (Bilateral and individual coned  down)
  • Notes
    • MUST specify the bolded acquisition phase name above and add any additional phases needed to ensure correct phases are obtained
    • Never perform without and with contrast
    • Bilateral= wider field of view able to see both sides
    • Individual= smaller field of view focused in on either the right or left side
    • Remind techs to send soft tissue reconstructions on the “with contrast” exams