CT ABDOMEN (LIVER) MULTIPHASIC

IWAN SETIAWAN
APPLICATION SPECIALIST
SIEMENS HEALTHINEERS JAKARTA

Unrestricted age 1 Iwan Setiawan

DISCUSSION TOPIC

. UNDERSTANDING
. INDICATIONS FOR EXAMINATION
. PREPARATION FOR EXAMINATION
. PROTOCOL and PARAMETER SETTING
. POST PROCESSING
. TRICKS and TIPS

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I. DEFINITION

CT ABDOMEN MULTIPHASIC:

. CT Abdomen Biphasic

Biphasic spiral CT scanning includes the scanning process

with contrasting stinging on the arterial phase and followed by
with the portal vein phase.

. CT Abdomen Triphasic

Triphasic spiral CT has a different meaning.

difference

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CT ABDOMEN TRIPHASIC:

. Definition I

Indicating the scanning process includes non-contrast scan,

followed by a biphasic CT scan.

. Understanding II
Indicating the actual triphasic scanning,
namely arterial phase, venous phase, and delay phase.

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. Artery Phase
Early Artery
The scan was performed with bolus tracking and the scan was done 4-6 seconds.

after the trigger. Or set a fixed delay time: 25-35 seconds.

In the early arteries, the aorta and hepatic artery enhancement are observed.

Late Arteri
The scan was performed with bolus tracking and the scan was done 10 seconds.

after the trigger. Or set a fixed delay time: 30-40 seconds.

- In the late artery, portal vein enhancement is observed, but the hepatic vein
enhancement has not occurred yet.

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. Phase Vein
Vena Portal
The scan is performed after a delay time of about: 40-45 seconds

Portal vein enhancement, and also hepatic vein in the antegrade area
Hepatic Vein
The scan is performed after a delay time of about: 55-65 seconds.

Hepatic vein enhancement, and renal parenchyma enhancement but

excretion has not yet been observed.

Inferior Vena Cava

The scan is performed after a delay time of about: 70-90 seconds.
Contrast appears to fill the inferior vena cava.

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. Phase Delayed

Early Delayed
Scan 3-5 minutes after i.v is given
Identifying hemangiomas and small cysts

Late Delay
Scan 10-15 minutes after i.v. is given
Helps to detect small cysts and tumors with
extensive fibrotic components (e.g. cholangiocarcinoma), HCC
with capsules.

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Hepatic Vessel Moments

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II. INDICATIONS FOR EXAMINATION

A triphasic CT is helpful for the characterization of known.

hepatic lesion; Hemangiomas, Hepatocellular carcinoma
(HCC), Focal Nodal Hyperplasia (FNH). And can improve
the detection rate of Hepatocellular Carcinomas, especially in
cirrhotic patient.

Spiral and Multislice CT of The Body page 418

Mathias Prokop and Michael Galanski

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Characteristics of Hemangioma:
. Lesion with a clear boundary
. Rarely calcification is found in the lesion, only about 10% in the area.
large hemangioma.
. The enhancement is in all contrast phases.

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Characteristics of Hepatocellular Carcinoma (HCC):

. Tumor Capsule
. Lesions resemble a pattern of large stones, associated with chirrosis and fibrosis.
. The phase delay shows a long enhancement.

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Characteristics of Focal Nodular Hyperplasia (FNH):
. Relatively common benign hepatic tumor
. 100% FNH enhances the phase artery
. 95% FNH enhances homogeneously
. Central scar enhances pada phase equilibrium

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Typical Appearances of common pathology in the
liver

Hepatic Hemangioma Focal nodular

Carcinoma Hyperplasia

Plain Hypoattenuating Iso or hypo– Iso or hypo–

Attenuating Attenuating

Arterial Uniform and hyper attenuating hyper attenuating

hyper attenuating

Portal Venous Hyper Iso or hypo– Iso attenuating

attenuating Attenuating

Delayed Hyper/ Iso attenuating but Iso attenuating

Iso attenuating may show capsule

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Hemangioma

[Link]

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Hepatocellular Carcinoma–Small HCC

[Link]

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Hepatocellular Carcinoma–Typical Mosaic
Pattern

[Link]

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Focal Nodular Hyperplasia

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III. PREPARATION FOR INSPECTION

. PREPARATION OF CT MACHINE

. PATIENT PREPARATION

. PREPARATION OF TOOLS AND MATERIALS

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CTSCAN MACHINE PREPARATION

. Check-Up
After the CT machine is started up, the operator must
performing a Check-Up to ensure that the CT system is ready for use
If the CT is not used for more than 12 hours, perform a Check-Up.
Filament Adaptation, Defective Channels Correction, and Calibration.

. Calibration
After the CT machine is started up, the detector is not in
optimal temperature (>700K), calibration is needed.
Calibration can be done every 60 minutes.

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PATIENT PREPARATION
. Fasting for at least 3-4 hours before the examination
. Urea and Creatinine Examination
. Calculation of GFR or eGFR with eGFR Calculator
. Install the sureflow and Threeway on the right antecubital vein
. Check the patency by injecting NaCl + 15 ml through the Threeway.

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Urea-Creatinine VS GFR (eGFR)
. Urea
The final result of protein metabolism comes from amino acids that have been
the ammonia is transferred inside the heart and reaches the kidneys, and in

express an average of 30 grams per day.

Normal level 20-40mg in 100cc of blood
. Creatinine
Residual products of the breakdown of creatine phosphate that occurs in the muscles.

is a poison substance in the blood.

Normal levels max 1.6

As a metabolic waste that will be excreted by the kidneys, UREA.

and CREATININE as an indicator of the degree of health in the kidneys.

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Urea-Creatinine VS GFR (eGFR)
. GFR
GFR stands for glomerular filtration rate.
It is a blood test that provides an indication of how well the kidneys are functioning.

filtering for toxins.

Source: National Kidney Diseases Education Programs. [Link]. March 2012

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PREPARATION OF TOOLS and MATERIALS

. Abocath / Venflon / sureflow No. 18 or 20 : 1

. Threeway stopcock : 1
. Inject 20 cc: 1
. Syringe 1 cc : 1
. Syringe Connector : 1
. Syringe Injector : 1
. Contrast material (Iopamiro / Optiray / Ultravist / Omnipaque) = 80 cc
. Water for injection / NaCl: 50 cc
. Mineral water 500 cc

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IV. PROTOCOL AND PARAMETER SETTINGS

. PATIENT POSITION
Sleep Supine, feet first.
Both arms are raised and positioned upwards, above the head.
Oral contrast is not provided, unless evaluating an organ.
other intra-abdominal related to staging determination.

. SCAN RANGE
FOV Includes the area from the diaphragm level to the lower rim area.
liver/ mid level from the kidney, and can extend the scan range up to
the pubic symphysis area if it includes whole abdomen CT.
(Protocol for Multislice CT, 2ndedition, page 199.
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• CT Technique for Which Clinical Indications

Phase after intravenous contrast injection

Precontrast Arterial Portal Delayed
Screening for metastases
hypovascular .- (+) .++ .-
hypervascular (+) .++ .++ .-

Prior to resection (+) .++ .++ .+

Lesion of unknown dignity (+) .++ .++ .+

Suspected HCC (+) .++ .++ .+

Protected CCC (+) (+) .++ .+

Post Transplantation (+) .++ .++ .-

Trauma .+ (+) .++ .-

Description:
The arterial phase is always combined with the portal venous phase (biphasic spiral CT)
well suited
may provide additional information
(+) : may provide additional information in selected cases
not recommended

Spiral and Multi Slice CT of the Body, Page 414

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. SCAN PARAMETER

(Protocol for Multislice CT, 2nd edition, page 200).

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IV. PROTOCOL AND PARAMETER SETTINGS

. Phase Arteries
Place the triggering bolus in the aorta, at the height of the liver hilum.

Pre-monitoring

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IV. PROTOCOLS AND SETTING PARAMETERS

. Phase Artery
Set IV Bolus at a value of 100-150 HU
Scan Direction = CranioCaudal
Adjust Volume Contrast = 60-70cc.
- Flow Rate set = 3cc/second
Start Injection simultaneously with Start Scanning, if bolus trigger
If enhancements are seen, please perform a manual start.
aorta.

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IV. PROTOCOL AND SETTINGS PARAMETERS
. Vena Phase
Set delay vena time before the scan is performed, adjusted according to the formula:

DELAY VEIN = VEIN TIME - (ARTERY DELAY + SCAN

TIME ARTERI + DELAY MONITORING

The time of the vein can be replaced according to the provisions;

We suggest aortic triggering with a 40-45s delay for the portal venous.
phase, and 55-65s delay for the hepatic venous phase.
(Mathias Prokop and Michael Galanski, Spiral and Multislice CT of Body page.418)

Scan Direction: CaudoCranial

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IV. PROTOCOLS AND SETTING PARAMETERS

. Phase Delay
- The delay time setting for the delay phase can be adjusted according to the formula:

Phase Delay Delay = Phase Delay Time - (artery Delay + Scan

Time Artery + Delay Vein + Scan Time Vein + delay monitoring

Phase Delay Time Provision:

Early Delay: 3-5 minutes after contrast injection
Late Delay: 10-15 minutes after contrast injection

Repeat Scan was performed manually.

Scan direction: CranioCaudal

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IV. POST PROCESSING

. Arterial PHASE
Make the thinnest recon with slices width: 0.75-1.25mm
- Window: CT Angio, and Kernel: 30 Medium Smooth
Display 3D images in the form of MIP thin
Set the thickness of MIP between 10-25

Show an illustration: Celiac Artery, Renal Artery, and Hepatic A.

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. Early VS Late Arteri Phase

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IV. POST PROCESSING

. Vena Phase
Make the thinnest recon with slices width: 0.75-1.25mm
Window: CT Abdomen, and Kernel: 30 Medium Smooth
Display 3D images in MPR format.
Make a slice like a Routine Abdomen
The additional image shows the portal vein.

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. Vena Portal

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IV. POST PROCESSING

. FASE Delay
Make the thinnest recon with slices width: 0.75-1.25mm
- Window: CT Abdomen, and Kernel: 30 Medium Smooth
Display 3D images in MPR format
Create a slice like a Routine Abdomen

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. Phase Delayed

Delayed Liver (4 mins) showing

wash-out of haemangioma
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IV. POST PROCESSING

. FILMING
Axial Description: Artery, Vein and Delay Phase
MIP Axial and Coronal Image: Arterial Phase
- Axial Coronal MPR Description: Venous Phase and Delay
Measurement

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V. TRICKS and TIPS
. An unenhanced scan adds no value to the biphasic/triphasic scan and
can be omitted (note: if follow-up studies after transarterial chemo-
embolization, unenhanced scanning can be helpful to display lipiodol
storage and distribution). This way can reduce radiation doses.

. To adapt the scan time individually to the patient's cardiovascular circulation.

time, a bolus tracking devices should be used.

. To gain a higher intravascular contrast, 370 mgI/ml is recommended, if only

Contrast 300 mgI/ml is available, sufficient attenuation can be achieved by
increasing the volume to 150ml and the Flowrate up to 5 mL/s.

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V. TRICKS and TIPS

. In general, axial 4mm slices thickness reconstruction will be diagnostically

sufficient in most of the cases and are the best compromise between
diagnostic accuracy and low noise and good image quality.

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REFERENCE LIST

Spiral and Multislice Computed Tomography of the Body, Mathias Prokop MD

and Michael Galanski MD. Thieme, Stuttgart, Germany. 2003.

Protocol for Multislices CT, [Link] and [Link]. Springer, Berlin. Germany.
2006.

Multislice CT, A.L Baert Leuven, M Knauth Gottingen and K. Saltor Heidelbergh.
Berlin, Germany.

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