Computed Tomography of the Coronary Arteries - 2nd Edition

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COMPUTED TOMOGRAPHY OF THE

CORONARY
ARTERIES
Second Edition

EDITORS

Pim J de Feyter
Gabriel P Krestin

CO-EDITORS
Filippo Cademartiri

Carlos van Mieghem

Bob Meijboom

Nico Mollet

Koen Nieman

LAYOUT
Denise Vrouenraets
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© 2008 Informa UK Ltd

First edition published in the United Kingdom in 2005

Second edition published in the United Kingdom in 2008 by Informa Healthcare, Telephone House, 69-77 Paul Street, London EC2A
4LQ. Informa Healthcare is a trading division of Informa UK Ltd. Registered Office: 37/41 Mortimer Street, London W1T 3JH.
Registered in England and Wales number 1072954.

Tel: +44 (0)20 7017 5000

Fax: +44 (0)20 7017 6699
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would be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention.

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Library of Congress Cataloging-in-Publication Data

Data available on application

ISBN-10: 1 84184 657 0

ISBN-13 978 1 84184 657 6

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9781841846576-FM 5/9/08 9:30 PM Page v

Contents

Preface vii
Acknowledgments ix
1. Basic principles 1
2. Image post-processing 28
3. Radiation issues 53
4. Coronary imaging: normal coronary anatomy 60
5. Coronary angiogram evaluation 67
6. Coronary pathology relevant to coronary imaging 77
7. Coronary stenosis: description and quantification 83
8. Coronary stenosis 91
9. Coronary plaque imaging 124
10. Coronary calcification 137
11. Assessment of coronary stents 148
12. Coronary bypass graft imaging 156
13. Pre-percutaneous coronary intervention assessment: chronic total occlusions
and magnetic navigation 168
14. Coronary artery anomalies in the adult 175
15. Cardiac masses, intracardiac thrombi, and pericardial abnormalities 186
16. The great thoracic vessels 193
17. Computed tomography in the emergency department 201
18. Preoperative assessment of the coronary tree before cardiac valve surgery 210
19. Assessment of left ventricular function and viability 221
20. Computed tomography and electrophysiology 229
21. Non-cardiac findings on cardiac computed tomography 236
22. Artifacts 242

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CONTENTS

23. Contrast enhancement in coronary angiography 269

24. The future 277
Index 289

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Preface

Since the first edition of Computed Tomography of Cardiac CT has matured significantly and has
the Coronary Arteries was published in 2005, attracted many radiologists and cardiologists to
knowledge about CT technology has significantly begin a cardiac CT program in their departments.
increased, which prompted us to provide an We also believe that cardiac CT has a bright
updated version of the book. future and may become the most important
Non-invasive coronary imaging using multi- non-invasive modality for the visualization of the
slice CT has rapidly evolved as a diagnostic coronary arteries.
modality to detect or exclude the presence of The CT technique, although relatively straight
significant coronary artery disease. In addition, forward, requires thorough understanding of the
multislice CT is able to provide important infor- basic principles for accurate interpretation and
mation about non-obstructive plaques and their clinical application of CT coronary images.
tissue composition, including whether they are non- Many cardiologists and radiologists are not
calcified, calcified, or mixed coronary plaques. familiar with cardiac CT, and we believe that our
The technological improvements of CT scan- book provides easy and understandable informa-
ners have been impressive and 64-slice CT has tion about cardiac CT. The book is the result of
largely superseded four- and 16-slice CT scanners, close collaboration between both cardiologists
while prototype 256- or 320-slice CT scanners and radiologists, and the contents are a reflection
have been introduced very recently. of the specific insights of each discipline. We
Many reports have been published about the clearly believe that for optimal interpretation and
diagnostic performance of CT coronary angiography implementation of cardiac CT teamwork between
to detect significant coronary stenosis compared radiologists and cardiologists is essential.
with invasive coronary angiography. These We hope that the second edition will again
reports unanimously agree that CT coronary serve its goal as a concise, quick reference for
angiography can reliably exclude the presence of understanding and interpreting CT coronary
significant coronary artery disease but that the images.
accurate detection of coronary obstructions,
Pim J de Feyter
i.e. extent, location, and distribution, is still
Gabriel P Krestin
somewhat limited, and requires improvement in
spatial and temporal resolution.

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Acknowledgments

The editors wish to express their gratitude to the Medical Books, with special thanks to Alan
many individuals employed in both radiology Burgess and Kathryn Dunn.
and cardiology departments of Erasmus MC We would also like to thank Marcel Dijkshoorn
Rotterdam, who have supported us. Their help and Berend Koudstaal for their assistance in
was indispensable to compile Computed patient preparation, data acquisition, and post-
Tomography of the Coronary Arteries. processing.
This book would not have become a reality Finally, we would like to thank Denise
without the much appreciated skilful help of Vrouenraets for her excellent secretarial assis-
the members of the staff of Informa Healthcare tance, enthusiasm, and encouragement.

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CHAPTER 1

Basic principles

Cardiac imaging is currently one of the most rap- reconstruction, whole-body scanners, improved
idly advancing fields in clinical cardiology. image quality, and dynamic imaging protocols. In
Continuing technical innovations are expanding the interest of cardiovascular imaging, electron
the applicability and usefulness of non-invasive beam CT (EBCT) was introduced in the mid-
imaging modalities such as ultrasound, nuclear 1980s. EBCT is a non-mechanical CT technique
imaging, positron emission tomography, magnetic that provides high temporal resolution owing to
resonance imaging and, most recently, computed the absence of rotating scanner parts. In the
tomography (CT). While CT became an essential early 1990s spiral CT allowed continuous data
imaging tool in general medicine early on, for a acquisition while the patient was moved through
long time it was considered an unsuitable tech- the gantry. In 1998 the first multislice spiral CT
nique for imaging moving structures. However, scanners with four detector rows were intro-
current multislice spiral CT scanners, with rapid duced. Because of their thin detectors, volumet-
gantry rotation, are able to provide detailed and ric acquisition of data, and fast coverage, these
motion-free imaging of the heart and coronary scanners resulted in a breakthrough as regards
arteries. It is undeniable that spiral CT has angiographic applications and further propelled
entered the arena of non-invasive cardiac imag- the development of advanced three-dimensional
ing, and while its exact role in the clinical setting image processing applications. High temporal
is still under investigation, expansive employ- resolution, which is essential for imaging moving
ment of cardiac spiral CT is anticipated by both objects, was facilitated by accelerated rotation
cardiologists and radiologists. rates combined with dedicated reconstruction
algorithms, and allowed almost motion-free imag-
ing of the heart. Electrocardiogram (ECG)-gated
DEVELOPMENT OF CARDIAC COMPUTED contrast-enhanced CT angiography of the heart
TOMOGRAPHY and coronary arteries improved with further devel-
opment of faster rotation and shorter scan times
Computed tomography is one of the many appli- by extending the number of detector rows, and
cations of X-ray radiation in clinical medicine. The further decreasing the thickness of the detectors.
technique was developed in the early 1970s
by Godfrey N Hounsfield, and together with
Dr Allan MacLeod Cormack, who contributed COMPUTED TOMOGRAPHY BASICS
mathematical solutions, he received the
Nobel Prize in Medicine for his work in 1979. The process of (cardiac) CT can be divided into
These first computed axial tomography (CAT) the following steps: data acquisition, image
scanners required long scan and reconstruction reconstruction, post-processing, evaluation and
times to provide crude images (of the brain). reporting, and data storage and exchange
Technical advancement led to faster imaging and (Figure 1.1).

1
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COMPUTED TOMOGRAPHY OF THE CORONARY ARTERIES

Data acquisition transmission, which is called attenuation,

depends on the atomic composition and density
of the traversed tissues, as well as on the energy
Analog–digital
conversion of the photons. After passing through an object
Digital the partially attenuated X-rays are collected by
X-ray detectors on the opposite side and con-
Image reconstruction
verted from X-ray photons to electrical signals
Storage Post-processing
(Figure 1.3). These signals are then converted
archiving quantification into digital data, after which the attenuation value
is calculated. While the X-ray tube and detectors
Digital–analog rotate around the patient, a large number of pro-
conversion jections are collected from consecutive angular
orientations.
Display

X-ray beam
Evaluation and reporting

Figure 1.1 Schematic overview of the CT acquisition

process.

Data acquisition

Data acquisition refers to the collection of X-ray

transmission measurements through the patient.
It requires an X-ray source that produces an X-ray
beam, which is collimated into the shape of a fan
or cone (Figure 1.2). When an X-ray beam passes
through an object some of the photons are
absorbed or scattered. The reduction of X-ray

Detectors

Anode
Cathode
Attenuation
profile
e-

Image
reconstruction

Figure 1.2 Roentgen tube. Within the electrical field

electrons are released from the cathode and travel through
the vacuum housing of the roentgen tube towards the Figure 1.3 Depending on the traversed material, emitted
anode. When the high-energy electrons collide with the photons are partially absorbed or scattered. The remaining
anode, photons are emitted. The anode and the location of photons are collected and measured by the detectors on
electron impact rotate to avoid overheating. Low-energy the opposite side. To calculate the attenuation throughout
photons, which do not contribute to the image formation, the plane, and reconstruct a CT image, a large number of
are filtered out. The remaining photons are then collimated attenuation profiles from consecutive rotational angles are
to form a fan- or cone-shaped beam. required.

2
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BASIC PRINCIPLES

Image reconstruction interpolation of adjacent measurements in the

longitudinal direction (Figure 1.5). The final step
The reconstruction of images from the X-ray is to calculate the variation of regional attenua-
measurements involves the following steps tion within the image plane based on the collec-
(Figure 1.4). First, the measured X-rays are pre- tion of angular projections using back-projection
processed, which is necessary to correct for reconstruction technique. The selected ‘field
beam hardening and scattered radiation. After of view’ is divided into small image elements,
pre-processing the raw data are filtered using called pixels. The density value of each pixel
convolution kernels. The filtering can result in depends on the composition of the tissue it
very smooth to very sharp images based on the represents and is expressed in Hounsfield units
selected kernel. Depending on the reconstruc- (HU). The Hounsfield units are calculated from
tion algorithm, projections from a 180∞ or the attenuation measurements relative to the
360∞ rotation are used for image reconstruction. attenuation of water and range from –1024 to
Because spiral CT continuously acquires meas- +3071 HU
urements at slightly varying longitudinal posi-
Hounsfield unit (x,y) = 1000 × µ (x,y) – µwater /
tions, an additional step is required before
µwater (µ = attenuation coefficient)
reconstruction. A complete set of projections
at the selected plane position is created by The result is a two-dimensional matrix of pre-
selected size and detail, with each element rep-
resenting the average attenuation of that location
relative to water.
Measurements

Image display
Pre-processing
Contrary to continuous analog images (conven-
tional X-ray), CT images are digital or numerical
images (Figure 1.6). The attenuated X-ray that
Raw data
Desired plane position

Filtering
−180° Gantry position +180°

Filtered data

Interpolation

Longitudinal z-axis
Back-projection
Figure 1.5 Interpolation of the spiral data. Because in spiral
CT the table moves continuously, all projections are acquired
at slightly different table positions. By weighted interpolation
of the measurements adjacent to the plane position,
Axial source images weighted by the distance of the actual measurement to the
reconstruction plane, a complete set of measurements is
created and an image can be reconstructed using back-
Figure 1.4 CT image reconstruction. projection algorithms.

3
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COMPUTED TOMOGRAPHY OF THE CORONARY ARTERIES

reaches the detector is transformed into an The window level indicates the density value at
analog electrical signal and then converted into a the center of the displayed gray scale, which deter-
discrete digital format that can be processed by mines the brightness of the image. The window
computer. The CT images on screen are an width indicates which density values around the
analog visual representation of binary values that window level are within the gray scale display.
have been digitally processed. The image con- Therefore, the width determines the image con-
sists of a matrix of discrete attenuation values trast. All matrix elements with attenuation values
that are the result of sampling and computer pro- beyond the window limits appear as either satu-
cessing. Theoretically this entire range of attenu- rated white or black on the screen. The density
ation values (−1024 to +3071 HU) could be value of water is predefined at 0 HU. The density
displayed in a gradually sliding scale from black value of soft tissues, such as non-enhanced
to white. Unfortunately, the human eye is inca- muscle and blood, varies between approximately
pable of distinguishing these fine nuances. –100 and +200 HU, while fat tissue is at the
Therefore, it is important to adjust the display lower end of that scale and bone or other calci-
setting in such a way that the range of density fied tissues have higher attenuation values.
values of the structure of interest are displayed Using routine intravenous contrast-enhancement
with optimal contrast (Figures 1.7 and 1.8). protocols and contrast media, the attenuation

Figure 1.6 Digitization. Digitization of an (analog) image results in a numerical matrix.

4
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BASIC PRINCIPLES

Maximum

Bone 800 to 1200

Stent 700 to 1000
Coronary calcium 200 to 1200

Aortic root 300 to 500

Coronary lumen 200 to 400
Myocardium 100 to 200

Fat −200 to 0

Lung −1000 to −800

Air −1000
Minimum

Figure 1.7 Tissue densities and window level and width settings. The tissue attenuation ranges of the various tissues in contrast-
enhanced CT angiography are arranged on the first density scale. By setting the window level at a high-density level, structures
such as bone tissue can be evaluated. An intermediate level around 200 HU allows differentiation of the vessels and their relation
to the vessel wall and calcifications. A low window level setting allows appreciation of the lungs. Tissues with density values
beyond the boundaries of the window width appear as either saturated white (higher density) or black (lower density).

value of the arterial blood is increased to a level containing more than 250 slices each, will
between +200 and +400 HU. Metal has density require at least 500 MB. Data can be archived on
values that overlap and exceed bone. Air and various magnetic and optical media. Alternatively,
lung tissue have very low attenuation values. digital archiving using a picture archiving and
Taking the attenuation characteristics of the dif- communication system (PACS) may be preferred
ferent tissue types into consideration, the for convenient exchange and retrieval of data. To
window level of a contrast-enhanced CT image is assure communication of imaging data between
set at around +250 HU and the window width at various imaging modalities, digital archives, eval-
400 HU. This allows appreciation of the contrast- uation workstations, printers, etc. from different
enhanced blood and its relation to the surround- manufacturers, a standard called DICOM (Digital
ing tissues, with bone and other high-density Imaging and Communication in Medicine) has
structures displayed as saturated white, and fat been developed.
and air displayed as saturated black. Depending
on the users’ interests and preferences, as well
as the scanning conditions, these settings can COMPUTED TOMOGRAPHY SYSTEMS AND
be altered to allow optimal appreciation of the ACQUISITION MODES
coronary luminal integrity.
Sequential and spiral CT

Data storage Originally, all CT scanners sequentially acquired

axial slices according to the stop-and-shoot princi-
Data can be stored on film but, particularly if addi- ple. In sequential scanning, during acquisition of a
tional post-processing is anticipated in the future, slice (or more slices with multidetector systems),
digital storage is preferable. The size of a single the table remains stationary. After completion of the
CT image is approximately 500 kB. A complete acquisition the table moves to a new (consecutive
cardiac study, including several reconstructions or overlapping) position to perform the next scan

5
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COMPUTED TOMOGRAPHY OF THE CORONARY ARTERIES

(a) (Figure 1.9). The disadvantage of this method is

the relatively long scan time (Table 1.1). Spiral CT
scanners allow for continuous tube-detector
rotation and fast acquisition of data. This was
made possible by the use of slip-ring technology.
Sequential CT scanners rely on a physical connec-
(b) tion in the form of cables between the rotating
elements containing the roentgen tube and detec-
tors and the stationary base, which necessitates
unwinding of the wires after each acquisition.
Spiral CT systems transmit energy and data
between the rotating and stationary scanner
parts via electrically conductive brushes and rotat-
(c) ing rings. Instead of the stop-and-shoot (and
rewind) principle of conventional, sequential scan-
ners, spiral CT scanners are able to rotate contin-
uously. During acquisition the table moves at a
constant speed through the gantry (Figures 1.9
and 1.10). The path of the acquisition relative
(d) to the subject resembles that of a helix or

(a)

(e)

Figure 1.8 Window level and width settings. Display of a

digital image can be manipulated by altering the window
level and width. The histogram, which displays the
pixel–density distribution, roughly consists of four tissue (b)
types: air and lung tissue, fat tissue, soft tissue, and dense
tissue (a). The window settings determine how a measured
and reconstructed density value is displayed on screen. To
evaluate the coronary arteries the level is set around the
density value of the enhanced blood in the coronary
arteries (a). Using a wide window results in low-contrast
images, the entire range of density values are displayed
with a slightly different shade (b). Because the human eye
is incapable of distinguishing these fine nuances, the
structures of interest are not clearly recognized. Selecting a
very narrow width results in high-contrast images with
completely saturated shading of the densities above and
below the selected level (c). Increasing the level results in
display of high-density structures, i.e. the contrast- Figure 1.9 Sequential and spiral CT scanning. Sequential
enhanced structures and calcified tissue (d), and a low scanners acquire one (set of) slices, after which the table is
level results in brighter images and display of the low-density advanced to the next plane position (a). Spiral scanners
structures, i.e. the lungs (e), and completely saturated acquire data continuously while the table moves at a
display of the other tissues. constant speed (b).

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BASIC PRINCIPLES

Table 1.1 Triggered versus gated image acquisition and reconstruction

ECG synchronization Prospective triggering Retrospective gating

Reconstruction of multiple cardiac – Available
phases

Multisegmental reconstruction – Available

algorithms

Vulnerability to arrhythmia Severe Modest

Retrospective ECG editing − Available

Overlapped slice reconstruction − Available

ECG, electrocardiogram

spiral, hence the names: helical and spiral CT. Electron beam CT
Continuous acquisition of data allows coverage of
larger sections in the same amount of time. In par- In mechanical CT, including multislice spiral CT, the
ticular angiographic applications, which demand roentgen tube and detector array physically rotate
temporary contrast enhancement, have bene- around the table. The extrafugal forces created
fited from this improvement in acquisition during rotation restrict the rotation speed, and
speed. Because the X-ray tube generates energy thereby the temporal resolution of mechanical CT.
for an extended period more heat storage The electron beam CT (EBCT) was developed to
capacity is required. Also, the large amount of image the heart. Instead of a physically rotating
data that is being produced in a very short period tube detector unit, EBCT generates and directs
requires expanded storage and processing electrons along a stationary tungsten ring
capacity. (Figure 1.11). Emitted X-rays from the target ring

X-ray tube
X-ray tube
X-ray beam
Collimator Collimated
fan beam

Table

Collimator

Detectors
Detectors

Longitudinal view Short-axis view

Figure 1.10 Multislice spiral CT. The X-ray tube and the detectors rotate in an opposing position on the gantry around the
patient. During continuous X-ray emission a collimated roentgen beam is passed through the patient and the attenuated
radiation is collected while the patient on the couch is advanced continuously through the gantry. Instead of one detector row,
several parallel detector rows acquire data, which allows accelerated scanning and a short scan time.