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Bellingham, Washington USA
Library of Congress Cataloging-in-Publication Data
Hsieh, Jiang.
Computed tomography : principles, design, artifacts, and recent advances / Jiang Hsieh.
-- 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8194-7533-6
1. Tomography. I. SPIE (Society) II. Title.
[DNLM: 1. Tomography, X-Ray Computed. 2. Tomography Scanners, X-Ray
Computed--trends. 3. Tomography, X-Ray Computed--instrumentation. 4. Tomography,
X-Ray Computed--trends. WN 206 H873c 2009]
RC78.7.T6H757 2009
616.07'572--dc22
2009004797
Published by

SPIE
P.O. Box 10
Bellingham, Washington 98227-0010 USA
Phone: +1 360.676.3290
Fax: +1 360.647.1445
Email: [email protected]
Web: http://spie.org
and
John Wiley & Sons, Inc.
111 River Street
Hoboken, New Jersey 07030
Phone: +1 201.748.6000
Fax: +1 201.748.6088
ISBN: 9780470563533
Copyright © 2009 Society of Photo-Optical Instrumentation Engineers
All rights reserved. No part of this publication may be reproduced or distributed in any
form or by any means without written permission of the publisher.
The content of this book reflects the work and thought of the author(s).
Every effort has been made to publish reliable and accurate information herein, but the
publisher is not responsible for the validity of the information or for any outcomes
resulting from reliance thereon.
Printed in the United States of America.
Contents
Preface xi

Nomenclature and Abbreviations xiii

1 Introduction 1
1.1 Conventional X-ray Tomography 2
1.2 History of Computed Tomography 7
1.3 Different Generations of CT Scanners 14
1.4 Problems 19
References 19

2 Preliminaries 23
2.1 Mathematics Fundamentals 23
2.1.1 Fourier transform and convolution 23
2.1.2 Random variables 27
2.1.3 Linear algebra 30
2.2 Fundamentals of X-ray Physics 33
2.2.1 Production of x rays 33
2.2.2 Interaction of x rays with matter 36
2.3 Measurement of Line Integrals and Data Conditioning 42
2.4 Sampling Geometry and Sinogram 46
2.5 Problems 48
References 52

3 Image Reconstruction 55
3.1 Introduction 55
3.2 Several Approaches to Image Reconstruction 57
3.3 The Fourier Slice Theorem 61
3.4 The Filtered Backprojection Algorithm 65
3.4.1 Derivation of the filtered back-projection
formula 68
3.4.2 Computer implementation 71
3.4.3 Targeted reconstruction 85
3.5 Fan-Beam Reconstruction 88
3.5.1 Reconstruction formula for equiangular
sampling 89

v
vi Contents

3.5.2 Reconstruction formula for equal-spaced

sampling 95
3.5.3 Fan-beam to parallel-beam rebinning 97
3.6 Iterative Reconstruction 101
3.6.1 Mathematics verses reality 102
3.6.2 The general approach to iterative
reconstruction 103
3.6.3 Modeling of the scanner’s optics and physics 105
3.6.4 Updating strategy 109
3.7 Problems 112
References 114

4 Image Presentation 119

4.1 CT Image Display 119
4.2 Volume Visualization 123
4.2.1 Multiplanar reformation 123
4.2.2 MIP, minMIP, and volume rendering 128
4.2.3 Surface rendering 136
4.3 Impact of Visualization Tools 137
4.4 Problems 140
References 142

5 Key Performance Parameters of the CT Scanner 143

5.1 High-Contrast Spatial Resolution 143
5.1.1 In-plane resolution 144
5.1.2 Slice sensitivity profile 150
5.2 Low-Contrast Resolution 154
5.3 Temporal Resolution 160
5.4 CT Number Accuracy and Noise 167
5.5 Performance of the Scanogram 172
5.6 Problems 174
References 176

6 Major Components of the CT Scanner 179

6.1 System Overview 179
6.2 The X-ray Tube and High-Voltage Generator 180
6.3 The X-ray Detector and Data-Acquisition Electronics 190
6.4 The Gantry and Slip Ring 197
6.5 Collimation and Filtration 199
6.6 The Reconstruction Engine 202
6.7 Problems 203
References 205
Contents vii

7 Image Artifacts: Appearances, Causes, and Corrections 207

7.1 What Is an Image Artifact? 207
7.2 Different Appearances of Image Artifacts 209
7.3 Artifacts Related to System Design 214
7.3.1 Aliasing 214
7.3.2 Partial volume 226
7.3.3 Scatter 231
7.3.4 Noise-induced streaks 235
7.4 Artifacts Related to X-ray Tubes 239
7.4.1 Off-focal radiation 239
7.4.2 Tube arcing 242
7.4.3 Tube rotor wobble 244
7.5 Detector-induced Artifacts 244
7.5.1 Offset, gain, nonlinearity, and radiation
damage 244
7.5.2 Primary speed and afterglow 248
7.5.3 Detector response uniformity 253
7.6 Patient-induced Artifacts 258
7.6.1 Patient motion 258
7.6.2 Beam hardening 270
7.6.3 Metal artifacts 280
7.6.4 Incomplete projections 283
7.7 Operator-induced Artifacts 288
7.8 Problems 291
References 295

8 Computer Simulation and Analysis 301

8.1 What Is Computer Simulation? 301
8.2 Simulation Overview 303
8.3 Simulation of Optics 305
8.4 Computer Simulation of Physics-related Performance 316
8.5 Problems 323
References 324

9 Helical or Spiral CT 327

9.1 Introduction 327
9.1.1 Clinical needs 327
9.1.2 Enabling technology 331
9.2 Terminology and Reconstruction 332
9.2.1 Helical pitch 332
9.2.2 Basic reconstruction approaches 333
9.2.3 Selection of the interpolation algorithm and
reconstruction plane 339
9.2.4 Helical fan-to-parallel rebinning 343
9.3 Slice Sensitivity Profile and Noise 348
viii Contents

9.4 Helically Related Image Artifacts 355

9.4.1 High-pitch helical artifacts 355
9.4.2 Noise-induced artifacts 360
9.4.3 System-misalignment-induced artifacts 364
9.4.4 Helical artifacts caused by object slope 368
9.5 Problems 371
References 372

10 Multislice CT 375
10.1 The Need for Multislice CT 375
10.2 Detector Configurations of Multislice CT 378
10.3 Nonhelical Mode of Reconstruction 385
10.4 Multislice Helical Reconstruction 396
10.4.1 Selection of interpolation samples 398
10.4.2 Selection of region of reconstruction 402
10.4.3 Reconstruction algorithms with 3D
backprojection 405
10.5 Multislice Artifacts 410
10.5.1 General description 410
10.5.2 Multislice CT cone-beam effects 411
10.5.3 Interpolation-related image artifacts 413
10.5.4 Noise-induced multislice artifacts 416
10.5.5 Tilt artifacts in multislice helical CT 416
10.5.6 Distortion in step-and-shoot mode SSP 419
10.5.7 Artifacts due to geometric alignment 420
10.5.8 Comparison of multislice and single-slice
helical CT 422
10.6 Problems 422
References 425

11 X-ray Radiation and Dose-Reduction Techniques 433

11.1 Biological Effects of X-ray Radiation 434
11.2 Measurement of X-ray dose 436
11.2.1 Terminology and the measurement
standard 436
11.2.2 Other measurement units and methods 442
11.2.3 Issues with the current CTDI 443
11.3 Methodologies for Dose Reduction 445
11.3.1 Tube-current modulation 446
11.3.2 Umbra-penumbra and overbeam issues 448
11.3.3 Physiological gating 451
11.3.4 Organ-specific dose reduction 454
11.3.5 Protocol optimization and impact of the
operator 456
11.3.6 Postprocessing techniques 461
Contents ix

11.3.7 Advanced reconstruction 462

11.4 Problems 463
References 465

12 Advanced CT Applications 469

12.1 Introduction 469
12.2 Cardiac Imaging 471
12.2.1 Coronary artery calcification (CAC) 472
12.2.2 Coronary artery imaging (CAI) 476
12.2.2.1 Data acquisition and
reconstruction 478
12.2.2.2 Temporal resolution improvement 485
12.2.2.3 Spatial resolution improvement 492
12.2.2.4 Dose and coverage 493
12.3 CT Fluoroscopy 497
12.4 CT Perfusion 503
12.5 Screening and Quantitative CT 512
12.5.1 Lung cancer screening 512
12.5.2 Quantitative CT 516
12.5.3 CT colonography 519
12.6 Dual-Energy CT 522
12.7 Problems 532
References 534

Glossary 545

Index 551
Preface
Since the release of the first edition of this book in 2003, x-ray computed
tomography (CT) has experienced tremendous growth thanks to technological
advances and new clinical discoveries. Few could have predicted the speed and
magnitude of the progress, and even fewer could have predicted the diverse
nature of the technological advancement. The second edition of this book
attempts to capture these advances and reflect on their clinical impact.
The second edition provides significant changes and additions in several
areas. The first major addition is a new chapter on radiation dose. In the last few
years, significant attention has been paid to this subject by academic researchers,
radiologists, the general public, and the news media. An increased awareness of
the impact of radiation dose on human health has led to the gradual adoption of
the “as low as reasonably achievable” (ALARA) principle, the implementation of
American College of Radiology (ACR) accreditation and other dose reference
levels, and the development of many advanced dose-saving features for CT
scanners. The new Chapter 11 briefly describes some of the known biological
effects of radiation dose, then presents different dose definitions and
measurements, and concludes with an illustration of various dose-reduction
techniques.
At the time the first edition was published, the term “multislice” CT was an
accurate description of state-of-the-art scanners. Sixteen-slice scanners had just
been introduced commercially, and their clinical utilities and advantages had just
begun to be discovered. Since then, the “slice war” has continued, and now 64-,
128-, 256-, and 320-slice scanners are the new state of the art. These scanners
can be easily labeled as “cone-beam” CT. They require not only a detector with
wider coverage, but also other technologies such as new calibration techniques
and reconstruction algorithms. Chapter 10 has been significantly expanded to
discuss the technologies associated with these scanners and the new image
artifacts created by them.
Since the first edition, CT advancement has not been limited to the technology.
Advances also have been made in many areas of clinical applications, including the
rapid development of cardiac CT imaging and new applications inspired by the
reintroduction of dual-energy CT. Chapter 12 presents these advances and the
fundamental physics and technologies behind them.
Image artifacts have accompanied x-ray CT ever since its birth over 30 years
ago. Some artifacts are caused by the characteristics of the physics involved,
some are caused by technological limitations, some are created by new

xi
xii Preface

technologies, some are related to the patient, some result from suboptimal design,
and some are introduced by the operator. Chapter 7 has been expanded to reflect
the ever-evolving nature of these artifacts and various efforts to overcome them.
Historically, CT advances were driven by the development of new hardware.
However, it has become increasingly clear that hardware alone cannot solve all
of the technical and clinical problems that CT operators face. The second edition
includes significant updates to the section on statistical iterative reconstruction
technology and presents some of the exciting new developments in this area.
To enhance readers’ understanding of the material and to inspire creative
thinking about these subjects, a set of “problems” concludes each chapter. Many
problems are open-ended and may not have uniquely correct solutions. Hopefully
readers will find these problems useful and will develop new problems of their own.
At the time of this writing, the world is experiencing an unprecedented
financial crisis—that some call a financial “tsunami.” It is impossible to estimate
or predict the impact of this crisis on the market for x-ray CT. However, CT
technology is unlikely to remain stagnant. Many new exciting advances will take
place in both the technology and its clinical applications.

Acknowledgments
Many of the ideas, principles, results, and examples that appear in this book stem
from thoughts provoked by other books and research papers, and the author
would like to take this opportunity to acknowledge those sources. The author
would like to express his appreciation to Prof. Jeffrey A. Fessler of the
University of Michigan for his review of this text. His expert critical opinions
have significantly strengthened and enhanced the manuscript. The author owes a
debt to two people for supplying materials for both editions of this book: Dr.
Ting-Yim Lee of the Robarts Research Institute for providing reference materials
on CT perfusion, and Mr. Nick Keat of the ImPACT group in London for
supplying historical pictures on early CT development. The author would also
like to thank Dr. T. S. Pan of the M.D. Anderson Cancer Research Center for
providing some of the positron emission computed tomography (PET-CT)
images, and Dr. P. Kinahan of the University of Washington for providing
research results on patient motion artifacts. The author would like to thank many
current and former colleagues at GE Healthcare Technologies and the GE Global
Research Center for useful discussions, joint research projects, inspiration, and
many beautiful images. Finally, the most significant acknowledgment of all goes
to the author’s spouse, Lily J. Gong, for her unconditional support of the project,
and to his children, Christopher and Matthew, for their forgiveness of the missed
vacation.

Jiang Hsieh
August 2009
Nomenclature and Abbreviations
2D: two-dimensional
3D: three-dimensional
AAPM: American Association of Physicists in Medicine
ACR: American College of Radiology
ALARA: as low as reasonably achievable
ART: algebraic reconstruction technique
ASIC: application-specific integrated circuit
BMD: bone mineral density
bpm: beats per minute (heart rate)
CAC: coronary artery calcification
CAI: coronary artery imaging
CAT: computer-aided tomography
CBF: cerebral blood flow
CBV: cerebral blood volume
CDRH Center for Devices and Radiological Health (FDA)
CG: conjugate gradient
COPD: chronic obstructive pulmonary disease
CT: computed tomography
CTDI: CT dose index
DAS: data acquisition system
DECT: dual-energy CT
DFT: discrete Fourier transform
DLP: dose-length product
DSP: digital signal processing
EBCT: electron-beam computed tomography
EBT: electron-beam tomography
EC: European Commission
ECG / EKG: electrocardiogram
FBP: filtered backprojection
FDA: US Food and Drug Administration
FDK: Feldkamp-Davis-Kress (cone beam reconstruction algorithm)
FFT: fast Fourier transform
FOV: field of view
FWHM: full width at half maximum
FWTM: full width at tenth maximum
GDE: geometric detection efficiency

xiii
xiv Nomenclature and Abbreviations

GPU: graphic processor unit

HCT: helical computed tomography
HU: Hounsfield unit
IAC: inner auditory canal
IAEA: International Atomic Energy Agency
ICD: iterative coordinate decent
ICRP: International Commission on Radiological Protection
IFFT: inverse fast Fourier transform
IR: iterative reconstruction
LCD: low-contrast detectibility
LSF: line spread function
MIP: maximum intensity projection
minMIP: minimum intensity projection
ML: maximum likelihood
MPR: multiplanar reformation
MSAD: multiple-scan average dose
MTF: modulation transfer function
MTT: mean transit time
NPS: noise power spectrum
OS: ordered subset
PET: positron emission computed tomography
PSF: point spread function
QA: quality assurance
QDE: quantum detection efficiency
rad: radiation absorbed dose
RCA: right coronary artery
rem: Roentgen equivalent man
ROI: region of interest
SPECT: single-photon-emission computed tomography
SSP: slice sensitivity profile
Sv: sieverts
TAT: transverse axial tomography
VR: volume rendering
WL: (display) window level
WW: (display) window width
Chapter 1
Introduction
According to Webster’s dictionary, the word “tomography” is derived from the
Greek word “tomos” to describe “a technique of x-ray photography by which a
single plane is photographed, with the outline of structures in other planes
eliminated.”1 This concise definition illustrates the fundamental limitations of the
conventional radiograph: superposition and conspicuity due to overlapping
structures. In conventional radiography, the three-dimensional (3D) volume of a
human body is compressed along the direction of the x ray to a two-dimensional
(2D) image, as shown in Fig. 1.1(a). All underlying bony structures and tissues
are superimposed, which results in significantly reduced visibility of the object of
interest. Figure 1.1(b) shows an example of a chest x-ray study. The
superposition of the ribs, lungs, and heart is quite evident. Consequently, despite
the image’s superb spatial resolution (the ability to resolve closely placed high-
contrast objects), it suffers from poor low-contrast resolution (the ability to
differentiate a low-contrast object from its background). A recognition of this
limitation led to the development of conventional tomography.

Figure 1.1 Illustration of conventional x ray. (a) Acquisition setup and (b) example of a
chest study.
1
2 Chapter 1

1.1 Conventional X-ray Tomography

Conventional tomography is also known as planigraphy, stratigraphy,
laminagraphy, body section radiography, zonography, or noncomputed
tomography.2 One of the pioneers of conventional tomography was A. E. M.
Bocage.3 As early as 1921, Bocage described an apparatus to blur out structures
above and below a plane of interest. The major components of Bocage’s
invention consisted of an x-ray tube, an x-ray film, and a mechanical connection
to ensure synchronous movement of the tube and the film. The principle of
conventional tomography is illustrated in Fig. 1.2. For convenience, consider two
isolated points, A and B, located inside a patient. Point A is positioned on the
focal plane and point B is off the focal plane. The shadows cast on the x-ray film
by points A and B are labeled A1 and B1, respectively, as shown in Fig. 1.2(a).
The image produced on the film at this instant is not at all different from a
conventional radiograph. Next, we move both the x-ray source and the x-ray film
synchronously in opposite directions (for example, the x-ray source moves to the
left and the film moves to the right, as shown in the figure) to reach a second
location. We want to make sure that the shadow A2 produced by the stationary
point A overlaps with the shadow A1 produced by point A in the first position.
This can be easily accomplished by setting the distance traveled by the x-ray
source and the x-ray film to be proportional to their respective distances to point
A, as shown in Fig. 1.2(b). However, the shadow B2 produced by the stationary
point B at the second position does not overlap B1. This is due to the fact that
point B is off the focal plane, and the distance ratio from point B to the x-ray
source and to the film deviates significantly from that of point A. When the x-ray
tube and the film move continuously along a straight line (in opposite directions,
of course), the shadow produced by point B forms a line segment. This property
holds for any point located above or below the focal plane. Note that the
intensities of the shadows produced by the off-focus points are reduced, since the
shadows are distributed over an extended area. On the other hand, any point
located at the focal plane retains its image position on the film. Its shadow
remains a point and the corresponding intensity is not degraded.
Conventional tomography has several problems. Although the focal plane in
conventional tomography is theoretically a true plane, planes close to the focal
plane undergo little blurring. If we use the amount of blurring to judge whether a
point belongs to the focal plane, the slice thickness based on this definition
depends on the sweep angle , as shown in Fig. 1.3. In fact, the slice thickness is
inversely proportional to tan(). Clearly,  must be fairly large to obtain a
reasonable slice thickness.
Another problem associated with conventional tomography is the fact that
little blurring takes place in the direction perpendicular to the movement of the x-
ray source and the film. The net effect is that for structures parallel to the
direction of the source motion, the sharpness of the shadow boundaries is not
significantly reduced as desired. These structures appear to be elongated only
Introduction 3

Figure 1.2 Illustration of conventional tomography principle. (a) X-ray source and film
produce shadows A1 and B1 of points A and B at a first position. (b) X-ray source and film
are moved reciprocally such that shadow A2 of point A overlaps shadow A1, but shadow
B2 of point B does not overlap B1.

Figure 1.3 Illustration of slice thickness as a function of the scan angle.

4 Chapter 1

along the direction of motion. This effect is illustrated with a computer

simulation shown in Fig. 1.4. The imaged object was made of two long ellipsoids
and two spheres with a 2:1 density ratio in favor of the ellipsoids. The goal was
to enhance the visibility of the spheres. In the first simulation, the ellipsoids were
placed such that their long axes were perpendicular to the direction of the source
motion. For comparison, a conventional radiography image (stationary source
and detector) is shown in Fig. 1.4(a) and a conventional tomography image is
shown in Fig. 1.4(b). Compared to the conventional radiograph, the ellipsoids in
the conventional tomography image were blurred by the source motion because
the ellipsoids were placed away from the focal plane. (The spheres were located
on the focal plane.) The improvement in sphere visibility is obvious. When the
ellipsoids were rotated 90 deg so their long axes became parallel to the source
motion direction, little blurring took place, since the path lengths through the
ellipsoids at different source locations were virtually unchanged. Consequently,
no improvement in sphere visibility was obtained.
To partially compensate for the lack of tomographic effect in certain
directions, pluridirectional tomography has been proposed.2 For these devices,
the x-ray source and the film synchronously undergo more complicated motion

Figure 1.4 Simulated images of conventional tomography. The phantoms are made of two
long ellipsoids and two spheres. The top row depicts the scenario in which the long axes
of the ellipsoids are perpendicular to the direction of source-detector motion, and the
bottom row depicts the scenario in which the ellipsoids’ long axes are parallel to the
motion. (a) and (c) show conventional radiography images of the phantoms; (b) and (d)
show conventional tomography images of the phantoms.
Introduction 5

patterns, such as circular, ellipsoidal, sinusoidal, hypocycloidal, or spiral. Figure

1.5 depicts an example of an elliptical motion pattern that produces more uniform
blurring of the structures outside the focal plane. Disadvantages of
pluridirectional tomography include higher cost, increased procedure time, and a
larger x-ray dose to the patient.
Instead of forming a focal plane parallel to the patient long axis, axial
transverse tomography (also known as transverse axial tomography or TAT)
defines a cross-sectional plane that is perpendicular to the patient long axis, as
shown in Fig. 1.6. In this apparatus, the x-ray source is stationary and is oriented
at a shallow angle  with respect to the x-ray film. Both the patient and the film
rotate about their vertical axes synchronously at an identical direction and speed.
Because the geometric relationship between the x-ray source, the patient, and the
film remains unchanged, the magnification factor for each point located inside
the tomographic plane is constant (the magnification factor is defined as the
distance between the source and the shadow on the film over the distance
between the source and the point in the tomographic plane).
During the imaging process, structures inside the tomographic plane remain
in sharp focus, since structures inside the plane remain in the field of view (FOV)
at all times, and the shadow locations produced by these structures do not change
relative to the film. On the other hand, structures outside the tomographic plane
do not always stay inside the FOV, and their shadows move around relative to
the film during the scan. Thus, these shadows do not appear as sharp. Strictly
speaking, the tomographic plane is actually a volume. The thickness of the
volume decreases with the angle  between the center ray of the source and the
film. Since  is limited by many practical factors, the minimum thickness of the
tomographic volume is also limited. For example, for an extremely small , the

Figure 1.5 Illustration of pluridirectional tomography.

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