CT Protocol Guidelines: Duty Vetting Reference Document

Computed Tomography (CT) Protocol Guidlines

1 Scope

For local use within the CT scanning department.

2 Purpose

To ensure the best possible imaging for all CT examinations.

3 Definition of terms

Staging

In the context of this document refers to the follow-up of known cancers on a treatment pathway. ?

Any request to investigate a new diagnosis of cancer will be marked as ‘Query’ (?) in the protocol description.

Early Arterial 10 seconds delay from the point of trigger

Late Arterial 23 seconds delay from the point of trigger.  Some protocols will have a ‘fudge factor’ built-in to allow the chest to be scanned prior to the abdomen, keeping the abdomen in the late arterial phase. BW

Body Weight contrast volume 2 or 4 dose

Oral preparation, 5 mL Omnipaque 300 in 250mL of water

Chest

Apices of the lungs to costophrenic angles

Chest and Abdomen

Apices of the lungs to iliac crests

Abdomen

Dome of diaphragm to iliac crests

Abdomen and Pelvis

Dome of diaphragm to lesser trochanters

Chest, Abdomen and Pelvis

Apices of the lungs to lesser trochanters

Neck, Chest, Abdomen and Pelvis

Base of skull to lesser trochanters

Gated Study

Scanning with ECG electrodes to acquire images according to a set percentage of the patients R-R cardiac cycle

Thoracic Aorta

Apices to costophrenic angles

Abdominal Aorta

Dome of diaphragm to iliac crest

Whole Aorta

Apices of the lungs to lesser trochanters

Bastion

Single Acquisition, multi-dose contrast delivery ROI

Region of interest GG

Gastrograffin

4 Introduction

CT scanning procedures administer a particularly high dose of ionising radiation

to the patient. It is of paramount importance and part of the IR(ME)R guidelines

that patient radiation dose is kept to a minimum. To ensure this is adhered to, and that the type/dosage of contrast medium and acquisition timings are optimised to detect the pathologies of concern, a list of protocols have been created. This document also serves as an educational tool for the training of radiologists and radiographers.

5 Responsibilities

Radiologists



Ensuring that the CT protocols are up to date and adhered to, ensuring the correct protocol is requested on the relevant Epic request when vetting and provide relevant scanning information as required.

Radiographers

 Carrying out the correct scan following the CT protocols  Ensuring the correct protocol is requested on the relevant Epic request when vetting and provide relevant scanning information as required.  Review resultant images and perform additional scans/recons/injections of contrast media relevant to any found pathology.  Seek Consultant Radiologist/Senior SpR Radiologists opinion when necessary.

6 Weight-Based contrast

In most protocols, the volume of contrast medium to be administered will be based on bodyweight (BW) at a dose of 540 mg/kg . Exceptions are highlighted.

Rates of injection are to be those as per the chart in Appendix 1 . Omnipaque 350 is preferred in order to reduce injection times and flow rate. A maximum dose of 200mL is stated, although there are no published guidelines in this regard. A risk/benefit analysis should be performed on a case-by-case basis if a study is non-diagnostic or inadequate: if necessary, a study may be repeated with additional contrast medium following discussion with the clinical team in charge as appropriate. Periprocedural hydration may be considered.

Preparations are administered by CT administrative staff unless stated otherwise.

Scope ............................................................................................................................ 2

Purpose ......................................................................................................................... 3

Definition of terms.......................................................................................................... 4

Introduction .................................................................................................................... 5

Responsibilities ............................................................................................................. 6

Weight-Based contrast .................................................................................................. 7

Table of Contents .......................................................................................................... 8

Chest Protocols ........................................................................................................... 10

Abdomen & Pelvis Protocols ....................................................................................... 14

9.1

CT Oral Contrast Protocol – Preparation Guidance............................................... 15

9.2

GI Tract Protocols .................................................................................................. 16

9.3

Colonography Protocols ........................................................................................ 18

9.4

Adrenal, Endocrine, Lymphatic System Protocols ................................................. 20

9.5

Hepatobiliary (HPB) Protocols ............................................................................... 22

9.6

Pancreas Protocols ............................................................................................... 25

9.7

Urology and Gynae Protocols ................................................................................ 26

9.8

Miscellaneous ........................................................................................................ 29

9.9

Vascular Protocols ................................................................................................. 30

9.10

Muscular-Skeletal (MSK) .................................................................................... 35

Trauma – Adult ......................................................................................................... 37

10.1

Trauma East Manual of Proceedures and Operations (TEMPO) Guidelines ..... 38

Paediatrics ................................................................................................................ 40

11.1

Paediatric general/oncology scanning protocols ................................................ 41

Paediatric Trauma .................................................................................................... 45

12.1

CT Paediatric Trauma scanning parameters by weight: ..................................... 47

Neuro Protocols ........................................................................................................ 49

13.1

Standard Head Protocols ................................................................................... 50

13.2

Operative Navigation (Stealth) ........................................................................... 53

13.3

Facial Imaging .................................................................................................... 55

13.4

Temporal Bones ................................................................................................. 57

13.5

Spine .................................................................................................................. 59

13.6

Neck ................................................................................................................... 62

13.7

Vascular ............................................................................................................. 64

13.8

Neuro Intervention .............................................................................................. 66

13.9

Specialist Scanning ............................................................................................ 68

13.10

Standard Paediatric Head Protocols .................................................................. 70

13.11

Operative Navigation (Paediatric Stealth) .......................................................... 72

13.12

Standard Paediatric Spine Protocols .................................................................. 74

13.13

Standard Paediatric Crainofacial Protocols ........................................................ 76

13.14

Standard Paediatric Vascular Protocols ............................................................. 79

Paediatric Sedation and Vascular Access ................................................................ 81

14.1

Sedation ............................................................................................................. 82

14.2

Intravenous Contrast Administration for Paediatric Patients .............................. 83

References ............................................................................................................... 84

Associated documents .............................................................................................. 85

Appendix 1 Contrast, Dose & Injection Rates vs Bodyweight ............................................ 86

Appendix 2 DIEP Post-Processing Reconstruction Guide .................................................. 88

Appendix 3 CT Thoracic Aorta aneurysm surveillance protocolling flow chart .................... 89

Appendix 4 CT AAA surveillance protocolling flow chart .................................................... 90

Appendix 5 Bilateral Arm Injection Guide .......................................................................... 91

Appendix 6 CT Enterography Proceedure .......................................................................... 92

Appendix 7 Orthopaedic Reconstruction of Pelvic & Hip Fractures .................................... 93

Appendix 8 Skeletal Survey Protocol .................................................................................. 94

Appendix 9 CTC Protocolling Flow Chart ........................................................................... 95

Appendix 10 CTC After Intervention at Coloscopy Policy ................................................... 96

Appendix 11 CT Head Imaging Technique ......................................................................... 97

Appendix 12 Dementia Reformats .................................................................................... 102

Appendix 13 Brain Perfusion Maps .................................................................................. 105

Appendix 14 Max-Fax Facial Bones and Mandible reconstruction ................................... 112

Appendix 15 Sinus Reformats .......................................................................................... 116

Appendix 16 Spine Reformats .......................................................................................... 118

Appendix 17 Orbit Reformats ........................................................................................... 119

Appendix 18 Vasospasm Imaging .................................................................................... 122

Appendix 19 Temporal Bone Reformats ........................................................................... 127

Appendix 20 Cerebral Venography ................................................................................... 128

8 Chest Protocols

2WW Lung Cancer Referrals

The following is a general guide for Band 7 Radiographers vetting 2WW Cancer Pathway CT Chest referrals from the Lung Cancer

Specialist team.

If unsure, requests are to be vetted by a Consultant Thoracic Radiologist.

Normal CXR

 Unenhanced chest only  If definite haemoptysis = Arterial chest (25 sec delay)

Abnormal CXR



Arterial chest and portal venous abdomen o If specific pelvic bony symptoms then include contrast pelvis

o If appears metastatic disease in chest (or known malignancy elsewhere) then include contrast pelvis

Protocol

Prep

IV

Imaging

Timing

Notes

Bronchiectasis, Interstitial fibrosis, Emphysema, COPD,

Vasculitis, Sarcoid, Small airways disease, Bronchiolitis, Asthma

Protocol name: Chest_NonContrast

 Non-contrast Chest

? Lung Cancer

Lung Cancer Staging/Follow-up

Mediastinal Mass/Anatomy

Protocol name: ChestAbdo_LungCa_Contrast

BW  Arterial Chest  Portal Abdomen  25s  70s

Empyema

Protocol name: Chest_Contrast

BW  Arterial Chest  25s

Malignant pleural disease

Pleural Thickening

Mesothelioma

Protocol name: ChestAbdo_Portal

BW  Portal Chest and Abdomen (one run)  70s ? Interstitial lung disease (ILD) / Bronchiectasis

Protocol name: Chest_NonContrast

 Non-contrast chest

Shortness of breath post Stem Cell / Organ Transplant

Hypersensitive Pneumonitis

Rheumatoid Arthritis (RA)

Protocol name: Chest_Exps

 Non-contrast chest  Sequential Expiration Scans of the chest (1’s on 10mm)

? PE / Haemoptysis / Dyspnoea

Protocol name: PE_Scan

If abdomen and Pelvis required:

Protocol name: PE_AbdoPelvis

kV Dependant 5ml/Sec  Chest  Bolus tracked at the level of the carina. ROI to be placed on pulmonary artery.

Contrast Volumes:

80kV = 40mL 100kV = 60mL 120kV = 80mL

If scanning AbdoPelvis use BW contrast dose ? Asbestosis ? Drug Reaction

Protocol name: Chest_NonContrast

 Chest Prone  -

Send images as scanned (do not flip and mirror)

Oesophageal Ca Staging / follow-up

Protocol name: ChestAbdo_LateArterial

H 2 O BW  Late arterial Chest and Abdomen (To include Supraclavicular fossa)  Portal Abdomen & Pelvis  Bolus-tracked late arterial  70s

Triggered off abdominal Aorta at the level of the diaphragm

Oesophageal Perforation

Suspected Iatrogenic Perforation (e.g. post-surgery/endoscopy)

Protocol: Chest_NonContrast + ChestAbdo_LateArterial

BW  Unenhanced Chest/Abdo (i.e. Pre oral / IV)  On table – give 200-300 ml 10% water soluble low Osmolar contrast medium (e.g. Omnipaque).  Late arterial Chest & Abdomen  Portal Abdomen & Pelvis 



Oral Contrast 

Bolus-tracked late arterial  70s

Suspected Spontaneous Oesophageal Perforation

Protocol: ChestAbdo_LateArterial

BW  Late arterial Chest & Abdomen  Portal Abdomen & Pelvis 

Bolus-tracked late arterial  70s

No oral contrast medium or unenhanced required ? Thymoma / Graves’ Disease / Goitre

Protocol Name: ENT_NeckChest

70mL  ENT Neck and Chest protocol  80s – Neck 

Chest scanned shortly after

Separate body regions into correct accession numbers.

Scan with arms down

Lung nodule (Size check)

Protocol name: Chest_LowDose

 Low dose Chest

Ground Glass Nodule

Protocol name: Chest_NonContrast

 Chest

Breast Ca Staging and Follow Up

Protocol name: CAP_Portal

BW  Portal Chest, Abdomen and Pelvis (One run) (To include supraclavicular fossa to below lesser trochanter)  70s

Large Airways

Protocol name: Chest_NonContrast

+ Append another Chest_NonContrast

 (1) Chest Inspiratory  (2) Expiration from vocal cords to below carina

No longer need to instruct patient to breathe out slowly for duration of scan. Follow standard expiration instructions.

Fungal Chest / Infection

Protocol name: Chest_NonContrast

 Chest

Mediastinal abnormality Assessment

Acute bleeding (e.g. haemoptysis)

Mediastinal Lymph Nodes Assessment (e.g. TB, sarcoid, malignancy)

Protocol name: Chest_Contrast

BW  Chest  25s

Tracheobronchomalacia (TBM)

Protocol Name: Chest_NonContrast

 Non Contrast Chest  Dynamic Expiration from vocal cords to just below carina 

Inspiration 

Non contrast dynamic exps

(Volume NOT

Sequential)

Remove breathing instructions and ask patient to slowly breath out for the duration of the scan

Abdomen & Pelvis Protocols

9.1

CT Oral Contrast Protocol – Preparation Guidance

5mL of Omnipaque 300™ (Iohexol) mixed with approximately 250mL of water is equal to one oral dose; this is to be consumed over a

30 minute period. A 2 dose or 4 dose protocol will be specified in accordance with this protocol document.

2 Dose

 In the case of a 2 dose preparation, patients are instructed to arrive at the department one hour before their examination time

and consume two oral doses over one hour.

4 Dose

 In the case of a 4 dose preparation, patients are instructed to take the first dose at 20:00 hours on the day 48 hours prior to the

examination.

 A second dose at 12.00 (midday) hours the following day with a third dose at 20:00

 A fourth dose 1.5 hours prior to the patients scan time.

Water (H 2 0):

 Patient is to drink 1 litre (4 x 250mL cups) over 30 minutes prior to their CT scan.

Kleenprep:

 See Appendix 6.

9.2 GI Tract Protocols

Protocol

Prep

IV

Imaging

Timing

Notes

Gastric / Stomach Ca / Duodenal

Protocol name: ChestAbdo_LateArterial

H 2 O BW  Late arterial Chest and Abdomen (To include Supraclavicular fossa)  Portal Abdomen & Pelvis  Bolus-tracked late arterial  70s

Triggered off abdominal Aorta at the level of the diaphragm

Late arterial to detect early Ca. IDA – Iron deficiency anaemia CIBH – Change in Bowel Habit ?Diverticulitis

Protocol name: AbdoPelvis_Portal

H 2 O BW  Portal Abdo/Pelvis  70s ? Malignancy, Weight loss, general symptoms or restaging

Protocol name: CAP_Portal

H 2 O BW  Portal Chest, Abdomen & Pelvis (One Run)  70s

For any primary Ca that is

NOT listed in this document.

Follow Up Bowel Ca (Post surgery)

Basingstoke Protocol

Protocol name: CAP_Portal

2GG BW  Portal Chest, Abdomen & Pelvis (One Run)  70s

Basingstoke Protocol

Follow Up Bowel Ca

Protocol name: CAP_Portal

BW  Portal Chest, Abdomen & Pelvis (One Run)  70s

Enterography  Radiographers to protocol patients over 50 for: Abdominal pain,

Iron deficiency anaemia, Diarrhoea, Possible Crohn’s, Crohn’s.  Patient under 50 or any uncertainty please refer to GI

Consultant

Protocol name: Enterography

Kleen Prep BW  Portal Abdomen & Pelvis  70s

See Appendix 6 GIST (Gastrointestinal Stromal Tumour)

Protocol name: GIST_LateArterial

Protocol name: GIST_Chest_LateArterial

H 2 O BW  Late arterial Abdomen and Pelvis  Portal Abdo Only (+ Chest if initial staging)

• Bolus-tracked late arterial

• 70s

Triggered off abdominal Aorta at the level of the diaphragm

Due to rarity of lung metastasis, chest not required at follow up unless known metastases

GIST_Chest_LateArterial

9.3 Colonography Protocols

Please note: Lynch syndrome – not a precursor for CTC and requires consultant GI radiologis discussion

Protocol

Prep

IV

Imaging

Timing

Notes

Anaemia, CIBH, failed colonoscopy

Protocol name: Colonography_Contrast

Colon prep (high dose GG + low residue diet) BW  Supine enhanced Abdo/pelvis  Right lateral unenhanced low dose decubitus

Abdo/pelvis  Additional low dose left lateral decubitus required if right sided colon is under distended  70s

Reference Appendix 9 & 10

Bowel Cancer Screening Programme (BCSP)

Protocol name: BCSP_Colonography

Colon prep (high dose GG + low residue diet) BW  Right lateral Unenhanced Decube Abdomen and Pelvis  Left lateral Unenhanced Decube Abdomen and

Pelvis  *Review after each scan, if patient has Luminal

Cancer or Extra-luminal pathology please give IV contrast:

 Perform a Supine Portal Chest , Abdomen and

Pelvis, so scan like a symptomatic patient if extra colonic pathology present  70s CTC follow ups i.e. 6 months/3 years etc. for polyps

Protocol name: Colon_BCSP

Colon prep (high dose GG + low residue diet) BW  Right lateral Unenhanced Decube Abdomen and Pelvis  Left lateral Unenhanced Decube Abdomen and

Pelvis  *Review, if patient has Luminal Cancer or

Extra-luminal pathology please give IV contrast:  Perform a supine Portal Abdomen and Pelvis,

so scan as a symptomatic patient if known

extra colonic pathology  If extra colonic pathology detected on 1 st acquisition please perform the second position as a supine Portal Abdomen and Pelvis  70s

9.4 Adrenal, Endocrine, Lymphatic System Protocols

Protocol

Prep

IV

Imaging

Timing

Notes

? Adrenal mass ? Addison’s disease ? Conn’s syndrome ? Cushing’s disease

Protocol Name: Adrenal

Unenhanced and review  Unenhanced Abdomen + review

Delete scan phases as necessary

Adrenal lesion characterisation

Protocol Name: Adrenal

BW if lesion >15 HU  Unenhanced Abdomen only and review  Portal Abdomen  Delayed Abdomen only (washout)  -  70s  10 minutes

Delete scan phases as necessary

Adrenal follow up

Protocol Name: AbdoPelvis_NonCon

 Unenhanced Abdomen  -

N.B For completion characterisation of adrenal lesions seen on a previous portal phase study, ONLY pre and 10 min delayed phases are required if the same amount of contrast medium

is being administered as before.

Conn’s Syndrome (confirmed)

Cushing’s Disease follow up

Protocol Name : CAP_Portal

BW  Portal Chest, Abdomen and Pelvis (One run)  70s ? Phaeochromocytoma ? Paraganglioma, staging and follow up

Protocol Name: Adrenal

BW  Unenhanced Abdomen  Portal Abdomen and Pelvis  Delayed phase Abdomen only (washout)  -  70s  10 minutes

Adrenocortical carcinoma (ACC)

Protocol Name: ChestAbdo_LateArterial

BW  Late Arterial Chest and Abdomen  Portal Abdomen and Pelvis  Bolus-tracked  70s

Triggered off abdominal Aorta at the level of the diaphragm

Neuroendocrine tumours (NET)

Protocol name: CAP_LateArterial

H 2 O BW  Late arterial Chest/Abdo/Pelvis  Portal Abdomen  Bolus-tracked late arterial  70s

Trigger off abdominal aorta at the level of the diaphragm

Lymphoma (staging, mid cycle or end of treatment)

Protocol name: CAP_Portal

H 2 O BW  Portal Neck to Pelvis  70s

From base of skull to lesser trochanters.

Head in neutral position

Melanoma

Protocol name: CAP_LateArterial

2 Dose BW  Late arterial Chest/Abdo/Pelvis  Portal Abdomen  Bolus-tracked late arterial  70s

Trigger off abdominal aorta at the level of the diaphragm

9.5 Hepatobiliary (HPB) Protocols

Protocol

Prep

IV

Imaging

Timing

Notes

Cirrhosis surveillance (no previous locoregional treatment)

Protocol name: Liver_Untreated

BW  Late arterial Liver  Portal Abdomen and Pelvis  4 min delayed Liver  Bolus-tracked late arterial  70s  4 minutes

Trigger off abdominal aorta at the level of the diaphragm

Unenhanced not required unless there has been previous TAE, TACE, RFA, SIRT/radiotherapy or liver surgery

Liver lesion characterisation

Known HCC following locoregional treatment (TAE/TACE/SIRT) or surgical resection

Protocol name: Liver_Quad

BW  Unenhanced Liver  Late arterial Liver  Portal Abdomen and Pelvis (+/- Chest – see notes)  4 min delayed Liver  -  Bolus-tracked late arterial  70s  4 minutes

Trigger off abdominal aorta at the level of the diaphragm

Unenhanced required due to high density embolic or surgical material, and due to haemorrhage/necrosis within tissues following therapy

Staging / Restaging of confirmed HCC / Transplant for previous HCC/

Transplant assessment for HCC

If NO prior locoregional treatment:

Protocol name: Liver_Untreated_Chest

OR

If prior locoregional treatment revert to:

Protocol name: Liver_Quad_Chest

BW  Late arterial Liver  Portal Chest, Abdomen and Pelvis  4 min delayed Liver  Bolus-tracked late arterial  70s  4 minutes

Trigger off abdominal aorta at the level of the diaphragm

If previous locoregional therapy or surgery use protocol:

Liver_Quad_Chest

Liver metastases – Post Radio Frequency Ablation (RFA)

Protocol name: AbdoPelvis_Portal

BW  Portal Abdomen and Pelvis  70s

Liver metastases – post SIRT (radiotherapy)

Protocol name: Liver_LateArterial

BW  Unenhanced Liver  Late Arterial Liver  Portal Abdomen and Pelvis  -  Bolus-tracked late arterial  70s

Trigger off abdominal aorta at the level of the diaphragm

Cholangiocarcinoma – Initial staging

Protocol name: Liver_Quad_Chest

H2O BW  Unenhanced liver  Late Arterial Liver  Portal Chest, Abdomen and Pelvis  4 min delayed Liver  -  Bolus-tracked late arterial  70s  4 minutes

Trigger off abdominal aorta at the level of the diaphragm

Cholangiocarcinoma (follow up / on treatment)

Protocol name: Abdo_LateArterial

H2O BW  Late Arterial Abdo  Portal Chest, Abdomen and Pelvis  Bolus-tracked late arterial  70s

Trigger off abdominal aorta at the level of the diaphragm

Delayed phase not required

Follow up liver trauma - ? vascular injury/complications

Protocol name: Liver_PostTrauma

BW  Early Arterial Liver Only  Portal Liver Only  Bolus-tracked early arterial  70s

Trigger off abdominal aorta at the level of the diaphragm

Early arterial (angiogram) to assess for pseudo-aneurysms, AV fistulae etc.

Liver transplant assessment

Protocol name: Liver_Quad

BW  Unenhanced Liver  Late Arterial Liver  Portal Abdomen and Pelvis  4 min delayed Liver  -  Bolus-tracked late arterial  70s  4 minutes

Trigger off abdominal aorta at the level of the diaphragm

Liver transplant assessment requires identification of tumours

• > late arterial required

Post liver transplant complications / Cholangiopathy / Vascular concerns

Protocol name: Liver_Vascular

BW  Unenhanced Liver  Early arterial Liver  Portal Abdomen and Pelvis  -  Bolus-tracked early arterial  70s

Trigger off abdominal aorta at the level of the diaphragm

Early arterial (angiogram) required to assess for strictures, aneurysms, AV fistulae etc.

Live kidney donor assessment

Protocol name: LiveKidneyDonor

BW  Early arterial Abdomen  Portal Abdomen and Pelvis  Bolus-tracked early arterial  70s

Trigger off abdominal aorta at the level of the diaphragm

Post kidney transplant follow up

Post SPK (kidney + pancreas) follow up

Protocol name: SPK_Transplant

100mL@ 4mL/sec  Unenhanced umbilicus to ischium  Early arterial umbilicus to ischium  Portal Abdo/Pelvis  -  Bolus-tracked early arterial  70s

Trigger off abdominal aorta at the level of the diaphragm N.B Please trigger just above the bifurcation of the abdominal aorta. If ?thrombosis please discuss with Dr S. Upponi or other GI radiologists if unavailable.

Multivisceral transplant assessment/follow up

Discuss with Dr.Upponi/GI/HPB Consultant – if none available, early arterial Abdo/pelvis, followed by a Portal chest/Abdo/pelvis with no oral prep – Use

BW contrast dose

Pre-TIPSS (Transjugular Intrahepatic Portosystemic

Shunt)/TIPSS complication

Protocol name: AbdoPelvis_Portal

BW  Portal Abdomen and Pelvis  70s

9.6

Pancreas Protocols

Protocol

Prep

IV

Imaging

Timing

Notes

“Fishing expedition” CT request for ?pancreatic pathology – the vast majority (e.g. Abdo pain/weight loss or other more general complaints) H 2 o BW  Portal Abdomen and Pelvis  70s

Acute pancreatitis (presentation & follow up)

Protocol name: PancreatitisBastion

H 2 O

Multi-Phase Injection:

 Abdomen and Pelvis - with multi- phase contrast injection (kV dependent)  Bolus tracked scan triggered from the descending Aorta at the level of the diaphragm.  Bolus tracked  Trigger off abdominal aorta at the level of the diaphragm  Monitoring Delay for 100/120 kV = 65s  Monitoring Delay for 140 kV = 70s 100/120kV 90mL Omni + 20mL Saline @ 4mL/sec

• 32s Pause-

60mL Omni + 20mL Saline @ 4mL/sec 140 kV 100mL Omni + 20mL Saline @ 4mL/sec

• 35s Pause-

60mL Omni + 20mL Saline @ 4mL/sec ? Pancreatic lesion

Dilated bile ducts

Jaundice

Protocol name: Pancreas_Lesion

H 2 O BW  Late arterial abdomen  Portal abdomen and pelvis  Bolus-tracked late arterial  70s  Trigger off abdominal aorta at the level of the diaphragm

Pancreatic Ca – Staging/Follow up

Protocol name: Abdo_LateArterial

H 2 O BW  Late arterial Abdomen  Portal Chest, Abdomen and Pelvis  Bolus-tracked late arterial  70s  Trigger off abdominal aorta at the level of the diaphragm

Post Whipple’s

Protocol name: CAP_Portal

H 2 O BW  Portal Chest, Abdomen and Pelvis  70s IPMN (Intraductal Papillary Mucinous Neoplasm)

Pancreatic Cyst Follow up

AbdoPelvis_Portal

H 2 O BW  Portal Upper Abdomen  70s  Upper abdomen only

9.7 Urology and Gynae Protocols

Protocol

Prep

IV

Imaging

Timing

Notes

KUB / Renal Colic

Protocol name: KUB_Prone

 Prone unenhanced Abdo/Pelvis then review ?IV (Biphasic, see below)  -

Use Protocol: KUB_Supine if

pronation not possible

Haematuria

Protocol name: Haematuria_Prone

BW  Prone unenhanced Abdomen and Pelvis (Scan Caudo-cranially and stop the scan once past the kidneys)

• Inject 50mL contrast, sit patient up and wait for

10mins  Prone Portal Abdomen and Pelvis  -  10 minunte wait  70s

Use Protocol:

Haematuria_Supine if

pronation not possible

Use remaining BW contrast dose for the portal phase imaging (minimum dose = 70mL)

NB Patient bladder should be empty before starting haematuria studies. Perform prone if possible. DO NOT send the prone Topogram to PACS.

Renal lesion characterisation (any Bosniak cyst)

Protocol name: Kidney_Triple

BW  Unenhanced Abdomen  Late Arterial Kidneys  Nephrogenic phase Abdomen and Pelvis  -  Bolus tracked late arterial  100s

Trigger off abdominal aorta at the level of the diaphragm

Append Chest if renal pathology detected.

Staging known renal cell carcinoma (RCC)

Post nephrectomy for RCC

Protocol name: CAP_Late_Arterial

BW  Late arterial Chest, Abdomen and Pelvis  Portal Abdomen  Bolus-tracked late arterial  70s

Trigger off abdominal aorta at the level of the diaphragm

NB. If the urologist requests anatomy for partial nephrectomy, an early arterial phase of the abdomen to aortic bifurcation should be performed.

Post Kidney Ablation

Protocol Name: Kidney_Triple

BW  Unenhanced abdomen  Late Arterial kidneys  Nephrographic phase abdomen and Pelvis  -  Bolus-tracked late arterial  100s

Trigger off abdominal aorta at the level of the diaphragm

Encapsulating Peritoneal Sclerosis (EPS)

Discuss with Dr.Upponi/GI/HPB Consultant – if none available, 5 mL Gastrografin in 200 mL water x 2 with 90 min delay before imaging. If history of

obstruction included in request, please discuss with GI radiologist before giving oral contrast medium.

Staging bladder ca/follow up/recurrence

Protocol name: AbdoPelvis_Portal

BW  Inject 50mLs contrast, sit patient up for 10mins  Portal Abdomen and Pelvis  10 minute delay  70s

Chest if known disease

Protocol: CAP_Portal

Use remaining BW contrast dose for the portal phase (Minimum 70mls)

Testicular Ca – Germ cell, Seminoma, Teratoma - Initial staging / ?

Recurrence

Protocol name: CAP_Portal

BW  Portal Chest, Abdomen and Pelvis  70s

Testicular Ca – Routine Follow up / Surveillance

Protocol name: AbdoPelvis_NonCon

 Abdomen to mid Pelvis (ASIS)  Chest if known disease or abnormal CXR

Protocol: CAP_NonCon

 -

Testicular Ca – Retroperitoneal lymph node dissection (RPLND) planned or previous

Protocol name: AbdoPelvis_Portal

BW  Portal Abdomen and Pelvis  Chest if known disease or abnormal CXR

Protocol: CAP_Portal

 70s

Prostate Ca – Staging/Follow up

Protocol name: AbdoPelvis_Portal

BW  Portal Abdomen and Pelvis  Chest if known disease or abnormal CXR

Protocol: CAP_Portal

 70s

Ovarian Ca (elevated CA 125) – Staging/Follow up

Protocol name: CAP_Portal

4 Dose BW  Portal Chest, Abdomen and Pelvis  70s

Endometrial Ca

Protocol name: AbdoPelvis_Portal

4 Dose BW  Portal Abdomen and Pelvis  70s

Vulvar, cervical Ca

Protocol name: AbdoPelvis_Portal

BW  Portal Abdomen and Pelvis  70s

Sarcoma (gynae)

Malignant Mixed Mullerian Tumour (MMMT)

Staging/Follow up

Protocol name: CAP_Portal

4 Dose BW  Portal Chest, Abdomen and Pelvis  70s

9.8 Miscellaneous

Protocol

Prep

IV

Imaging

Timing

Notes

Sarcoma (non-gynae) – staging/follow up

Protocol name: CAP_Portal

BW  Portal Chest, Abdomen and Pelvis  70s

Myeloma – staging & follow up

Protocol name: Skeletal_Survey

 Skeletal Survey – Vertex of head to below Knees  -

Please refer to Appendix 8 for scanning timeframe

Abdominal pain (generalised, unknown cause)

Protocol name: AbdoPelvis_Portal

BW  Abdomen and Pelvis  70s

If concern regarding specific aetiology (e.g. pancreatic/gastric ca) please perform specific protocol.

9.9 Vascular Protocols

Protocol

Prep

IV

Imaging

Timing

Notes

(Contact for Vascular protocol uncertainties – contact IR consultant on-call, found on rota-watch)

NAAASP (National Abdominal Aortic Aneurysm Screening

Programme)

Protocol name: Whole_Aorta

90mL Omni + 50 mL saline @ 5mL/sec

Unenhanced whole aorta

Arterial whole aorta

Bolus tracked early arterial

Trigger off thoracic aorta at the level of the aortic arch NAAASP (National Abdominal Aortic Aneurysm Screening

Programme) UNABLE TO VISUALISE AORTA

Protocol name: Whole_Aorta

Unenhanced abdominal aorta

Post TEVAR follow up (For normal abdominal aorta. IF abnormal ->see notes)

Protocol name: Thoracic_Aorta

90mL Omni + 50mL saline @ 5mL/sec

Unenhanced Chest/Upper Abdo – apices to costophrenic angle

Arterial Chest/Upper Abdo – apices to costophrenic angle (finish around 5 cm below distal end of stent)

Bolus-tracked early arterial

If stents and or aneurysms/dissections are present in the abdominal aorta: unenhanced whole aorta + arterial whole aorta.

Whole_Aorta

Post TEVAR ?endoleak (Acute or Post abnormal USS) (For normal abdominal aorta. If abnormal  see notes)

Protocol name: Thoracic_Aorta_Triple

BW

Unenhanced Chest/Upper Abdo – apices to costophrenic angle. (finish around 5 cm below distal end of stent)

Arterial Chest/Upper Abdo – apices to costophrenic angle

Portal Chest/Upper Abdo – apices to costophrenic angle



Bolus-tracked early arterial  70s

Bolus tracked on from the Aortic

Arch

Right arm preferred to reduce artefact if possible

If stents are present in the abdominal aorta: whole aorta triple phase.

If there is an aneurysm/dissection in the abdominal aorta: whole aorta triple phase.

Post EVAR 1 ST follow up ONLY

Protocol name: Abdominal_Aorta

90mL Omni + 50mL saline @ 5mL/sec

Unenhanced Abdo/Pelvis to lesser trochanter

Arterial abdominal aorta to lesser trochanter 



Bolus-tracked early arterial

Trigger off abdominal aorta at the level of the diaphragm

If patient has already had 1 st follow up please discuss with vascular radiologist

Post EVAR – ? Endoleak (Acute or Post abnormal USS)

Protocol name: Abdominal_Aorta_Triple

BW

Unenhanced Abdo/Pelvis to lesser trochanter

Arterial abdominal aorta to lesser trochanter

Portal Abdomen and Pelvis to lesser trochanter

Bolus-tracked early arterial

70s

Trigger off abdominal aorta at the level of the diaphragm

Post FEVAR/BEVAR 1 st follow up ONLY

Protocol name: Abdominal_Aorta

90mL Omni + 50mL saline @ 5mL/sec

Long topogram from apices to

lesser trochanter

Unenhanced to cover the entire length of the graft down to lesser trochanter

Arterial phase to cover the entire length of the graft down to lesser trochanter 



Bolus-tracked early arterial

Trigger off abdominal aorta at the level of the diaphragm

If patient has already had 1 st follow up please discuss with vascular radiologist

NB : for inpatients –

unenhanced abdominal aorta only to cover stent for stent position.

Post FEVAR/BEVAR – ? Endoleak (Acute or Post abnormal USS)

Protocol name: Abdominal_Aorta_Triple

BW

Long topogram from apices to

lesser trochanter

Unenhanced to cover the entire length of the graft down to lesser trochanter

Arterial phase to cover the entire length of the graft down to lesser trochanter

Portal phase to cover the entire length of the graft down to lesser trochanter

Bolus-tracked early arterial

70s

Trigger off abdominal aorta at the level of the diaphragm

NB: if the stent is linked to

another stent in the thorax –

Whole aorta triple phase.

Post FEVAR/BEVAR linked to TEVAR follow up

Protocol name: Whole_Aorta

90mL Omni + 50 mL saline @ 5mL/sec

Unenhanced whole aorta to lesser trochanter

Early arterial whole aorta to lesser trochanter

Bolus tracked early arterial

Trigger off thoracic aorta at the level of the aortic arch

Thoracic Aorta Aneurysm Surveillance AAA Surveillance

Protocol name: See flowchart

90mL Omni + 50mL saline @ 5mL/sec

See Appendix 3

See Appendix 4

Bolus-tracked

See Appendix 3 & 4

For correct protocol selection

Aortic Dissection Follow Up

Protocol name: Flash_Aorta_NonGated

90mL Omni + 50mL saline @ 5mL/sec

Arterial whole aorta – apices to lesser trochanter

Bolus-tracked

No intervention, conservatively managed.

Thoracic aorta measurements

Aortic root dilatation

Dilated ascending aorta on echo

Dissection_ECG_Gated_Flash_HR_Above70

or

Dissection_ECG_Gated_Flash_HR_Below70

(Cut Unenhanced)

90mL Omni + 50mL saline @ 5mL/sec

ECG gated arterial chest

Bolus-tracked

Select appropriate protocol depending on heart rate

Unenhanced not required unless specifically requested

Embolisation follow up of

Renal, Splenic & Hepatic Arteries

Protocol name: AbdoPelvis _ Triple

BW

Unenhanced Abdomen and Pelvis

Early arterial Abdomen and Pelvis

Portal Abdomen and Pelvis

Bolus-tracked early arterial

70s

Trigger off abdominal aorta at the level of the diaphragm

Surveillance of aneurysm

Renal, Splenic & Hepatic Arteries

Vessel assessment for potential transplant

Protocol name: Abdominal_Aorta

(Cut pre contrast acquisition)

90mL Omni + 50mL saline @ 5mL/sec

Arterial abdominal aorta to lesser trochanter

Bolus-tracked early arterial

Trigger off abdominal aorta at the level of the diaphragm

Renal arteries stenosis

Protocol name: Abdominal_Aorta

(Cut pre contrast acquisition)

90mL Omni + 50mL saline @ 5mL/sec

Arterial abdominal aorta to iliac crests

Bolus-tracked early arterial

Trigger off abdominal aorta at the level of the diaphragm

Pre Breast Reconstruction.

Deep Inferior Epigastric Arteries (DIEP) or

Transverse Rectus Abdominis Myocutaneous (TRAM) Flap

Protocol name: DIEP

100mL Omni 350 @ 4mL/Sec

Caudo-cranial arterial Abdo/Pelvis from below lesser trochanter to above renal Arteries

Bolus tracked on abdominal aorta just above bifurcation 7sec delay

For Post Processing see

Appendix 2 : DIEP Post

Processing Reconstruction

Guide

N.B. If request states

Latissimus Dorsi Flap surgery, extend Topogram to include chest and scan whole aorta

BE AWARE!

If ALT flap/gluteal flap or GASTROC flap/fibular flap is

requested  LegRunOff

Requests from Dr Rusk or with details of vascular EDS/ehlers-danlos/Lois Deitz/vascular connective tissue disease

90mL Omni + 50mL saline @ 5mL/sec

Arterial phase of requested region

Bolus-tracked early arterial

If root/valve involvement:

Flash_Aorta_NonGated

Leg runoff – Lower limb ischemia

Protocol name: LegRunOff

100mL + 50mL saline @ 5mL/sec

Arterial above renal arteries to include toes

+/- 2 nd scan patella to toes – perform if can’t see 3 vessels on symptomatic side

Bolus tracked

Triggered off abdominal Aorta at the level of the diaphragm

Finish at lesser trochanter

Arm run off - Upper limb ischemia

Protocol name: Whole_Aorta

120mL + 50 mL saline @ 5mL/sec

Unenhanced whole aorta to incl. whole arm & fingers

Arterial whole aorta to incl. whole arm & fingers

Bolus tracked on

Thoracic Aorta at the level of the Aortic Arch IV access contralateral arm

Indicated arm(s) by side. ? Dissection

Dissection_ECG_Gated_Flash_HR_Above70

or

Dissection_ECG_Gated_Flash_HR_Below70

90mL Omni + 50mL saline @ 5mL/sec

Unenhanced Chest – apices to costophrenic angle

Arterial Gated whole aorta – apices to lesser trochanter

Bolus-tracked

ONLY TO BE PERFORMED

ON CT3

If CT3 is unavailable revert to

Whole_Aorta Protocol

Bolus tracked on from the Aortic

Arch

Right arm injection preferred to reduce artefact unless specific concern re right arm

Select appropriate protocol depending on heart rate

Aortic emergency e.g. AAA?

Protocol name: Abdominal_Aorta

90mL Omni + 50mL saline @ 5mL/sec

Unenhanced Abdomen and Pelvis to lesser trochanter

Arterial abdominal aorta to lesser trochanter

Bolus-tracked early arterial

Trigger off abdominal aorta at the level of the diaphragm

Ischaemic bowel GI bleed

Chronic mesenteric ischemia

Protocol name: AbdoPelvis _ Triple

BW

Unenhanced Abdomen and Pelvis

Early arterial Abdomen and Pelvis

Portal Abdomen and Pelvis

Bolus-tracked early arterial

70s

Trigger off abdominal aorta at the level of the diaphragm ? SVC Obstruction or great vein occlusion

- For upper limb & central chest veins

Protocol name: SVC_Obstruction

Bi-Lateral Arm Hand Injection

60mL on pump @ 2mL/sec & 20mL by hand @ 2mL/sec

OR

Bi-Lateral Arm Pump Injection

60mL on 1 ST pump @ 2mL/sec & 60mL on 2 ND pump @ 2mL/sec

Arterial Chest from supraclavicular fossa to costophrenic angles

Plus 

Venous Chest from supraclavicular fossa to costophrenic angles

25sec Delay &

70sec Acquisition

Bilateral IV access required

Arms down to avoid subclavian vein compression

Always try to use two pumps in the first instance. Only hand inject if a second pump is not available.

If hand injecting, pace the administration of contrast throughout the length of the scan delay, aiming to walk out of the room promptly before the scan starts.

MRI Venogram should be exam

of choice. Requests to be

vetted by a Suitable Consultant

See appendix 2 for scanning guidance

Thoracic outlet syndrome (TOS)

70ml @ 5mL/sec X 2

See notes for patient positioning

guidance ->

Arterial Chest from angle of mandible to costophrenic angles. 

Bolus-tracked early arterial

MRI Angiogram should be exam

of choice. Requests to be

vetted by a Suitable Consultant

Inject opposite side to symptomatic side if bilateral inject less symptomatic side.

Then the patient needs their arms up in provocation position second injection and second CT thoracic aorta arterial phase.

This has to be supervised to

ensure the patient gets their

symptom eg the pulse goes or

arm goes numb. Plan for Friday

am list with APW.

9.10

Muscular-Skeletal (MSK)

Protocol

Prep

IV

Imaging

Timing

Notes

Radiographer to Protocol

All Orthopaedic referrals for surgical planning/assessment of chronic issues / ? Bone Union

Protocol Name: Please select protocol according to relevant

body region

 As a general rule please include proximal 3rd of each bone of the joint in question OR  Entire bone with both joint spaces included

Please assess each case based on the clinical question i.e. fracture size / metalwork in-situ / injury in question. Scan range may vary from one patient to the next

See Appendix 7 for reformats

Vikas Khanduja Hips

Protocol Name: Khanduja_Hips

 ASIS to lesser trochanters  Scan distal femoral epicondyles

Topogram from iliac crest to include both knee joints

Provide 3D Recons of Hip scan only

Usually referred by Vikas

Khanduja, Andrew McCaskie and Sunil Kumar

Matija Krkovic team: external fixator/ Taylor spatial frame (TSF) for assessment of bone healing/docking site

Protocol Name: Please

select protocol according to relevant body region

 Entirety of Frame/metalwork

To assess whether frame can be removed CT skeletal surveys for myeloma

Protocol name: Skeletal_Survey

 Skeletal Survey – Vertex of head to below Knees

Please refer to Appendix 8 for scanning timeframe

MSK Consultant to Protocol

Infection queries

Protocol Name: Please select relevant body region

BW  As a general rule please include proximal 3rd of each bone of the joint in question OR  Entire bone with both joint spaces included  As requested by MSK

Consultant

Should be protocolled by MSK as may need contrast

Referrals for CT of bone lesions on XR

Protocol Name: Please select relevant body region

Reviewed by MSK in case CT could be avoided or MRI better

Acute ED/Inpatients

Protocol Name: Please select relevant body region

 As a general rule please include proximal 3rd of each bone of the joint in question OR  Entire bone with both joint spaces included

Discussed with the on-call CT team in case not necessary when they review the XR

Leg Length Scanogram

Protocol Name: Scanogram

 Topogram ONLY from Iliac crests to include both

knee joints

May require axial scans through Hips, Knees

and Ankles depending on Radiologist

protocol

Axial scans of Hips, Knees and

Ankles only when protocolled by MSK Consultant

Ankle replacement measurements-Stryker

Protocol Name: PROPHECY

 Topogram from knees down to include feet  Scan knees to include 5cm proximally and distally  Scan ankle and whole foot and extend to 10cm above ankle joint (please measure carefully!)  Ideal FOV is 28. Maximum is 40

Referrer should request PROPHECY when needed

Band 7 to accept request (No MSK Consultant needed to confirm)

ALL PAEDIATRIC MSK PROTOCOLS TO BE VETTED BY A CONSULTANT RADIOLOGIST

10 Trauma – Adult

Protocol

IV

Imaging

Timing

Notes

Standard Trauma Protocol

Protocol name: Trauma_Standard

 Unenhanced head & C-spine

100mL @ 4mL/sec  Arterial chest to pubic symphysis  Portal Abdomen and Pelvis to lesser trochanters  Bolus tracked  70 sec

Bolus tracked on from the Aortic

Arch

See Tempo guidelines, section 10.1

Bastion Trauma Protocol

Protocol name: Trauma_Bastion

Multi-Phase

Injection

 Multi-phase contrast injection  Bolus tracked scan triggered from the Aortic

Arch.  Scan from apices of the chest to below lesser trochanters  Bolus Tracked

Bolus tracked on from the Aortic

Arch

Scan and pump to be started together.

First injection of 60mL of contrast will be delivered, followed by a pause before the second inject of contrast begins and bolus tracking commences.  70mL @ 2mL/sec

• 25sec Pause –

 70mL @ 4mL/sec

The choice of Trauma Protocol is the responsibility of the reporting Radiologist and should be determined by their clinical judgement based on mechanism

of injury and ED’s initial assessment.

Trauma with poor IV Access

Protocol name: Trauma_OneRun

100mL @ best flow possible  One run scan from Apices to lesser trochanters  Manual start

Place bolus tracking Region of interest over air, manually trigger the scan when contrast is visualised.

In the event IV access cannot be obtained, a discussion between the ED team and reporting Radiologist is recommended to weigh up limited patient

assessment from an unenhanced CT vs delay in achieving central access.

10.1

Trauma East Manual of Proceedures and Operations (TEMPO) Guidelines

 Standard head CT – If Involved

Unenhanced axial head CT – either angled to orbito-meatal line or if suspected facial injury, spiral acquisition through brain and facial

bones. Bone reconstructions on thinnest possible with edge enhancement.

 Cervical Spine CT

Image from foramen magnum to T3–4. Sagittal 2mm and coronal 2mm reconstructions either on the scanner or using PACS

workstation.

Following head and neck imaging: if possible, the patient’s arms should be placed above their head (preferable), crossed over the

anterior lower abdomen or placed on a pillow over the abdomen.

 Arterial Phase – Chest and Abdomen

Image from C6 to pubic symphysis post IV contrast medium; trigger over ascending aorta, 100mls @ 4mls/sec. Acquire thin section

axial images on a soft tissue reconstruction.

Consider also imaging the neck in the arterial phase, following IV contrast medium, to assess vascular injury secondary to

penetrating injury.

 Portal Venous Phase – Abdomen and Pelvis

Image from domes of diaphragm to below symphysis pubis at 70 secs from the start of the contrast medium injection. Acquire thin

section axial images on a soft tissue reconstruction algorithm.

 Delayed Phase

The initial images should be reviewed whilst patient is on the CT table and delayed imaging performed through all areas suspicious for

active bleeding or where solid organ injury is detected or suspected (particularly renal injury). Image at approximately 5 mins post IV

injection, if clinically appropriate.

If bladder injury is suspected, CT Cystogram or formal Cystogram can be undertaken. If there is a bladder catheter in situ – fill bladder

under gravity with 50mls of contrast medium in 450mls of normal saline.

 Rectal Contrast Medium

In suspected penetrating trauma to the abdominal or pelvic cavity, rectal contrast medium can be helpful in the detection of bowel

injury.

50mls Omnipaque 300 in 1000mls sterile saline. Preferably delivered via a drip system with a ballooned Foley catheter inserted within

the rectum. Alternative is via hand injection using catheter syringe.

Taken from: TEMPO Guidelines, v2, December 2014, NHS East of England Trauma Network, www.eoetraumanetwork.nhs.uk/tempo

Paediatrics

11.1 Paediatric general/oncology scanning protocols

The need for sedation should be discussed at the time the request is accepted by a Consultant Paediatric Radiologist on a case by

case basis.

A 22G, blue cannula with bionector attatchment should be requested if the scan necessitates.

CT1, CT2, CT3 or CT4 must be used whenever possible in order to administer as lower dose as possible.

Intravenous Contrast Administration for Paediatric Patients

All paediatric contrast injections should be administered at 2mL/sec.

Only peripheral cannulas with bionector attachment may be used to administer IV contrast.

CENTRAL ACCESS LINES (PICC HICKMAN OR CENTRAL LINES) ARE NOT PERMITTED.

Hand Injections via cannula

A hand injection is preferred if:

 The child is under 10kgs  Small cannula (Yellow 24G) in situ.

Pump Injections

If the child has a 22G, blue cannula with bionector, and is above 10kgs the pump can be used.

If using the pump a Radiologist or a Radiographer who has completed Paediatric Injection Competencies should check the line using

the Trusts ANTT , Hand Hygiene Policy , and Administration of Medicines policy .

Pump injections must be supervised in the scanning room whilst the injection is being administered. The exception to this is a bolus

tracked scan or if X-rays are in process during injection.

Standard paediatric protocols

Radiology registrars and Band 7 CT radiographers can accept and protocol paediatric CT requests using the standard oral protocol

above and delays above in the chest imaging and abdomen/pelvis imaging above.

Clinical Criteria to be accepted for standard delays above include:

 Cystic Fibrosis  Fungal (first time to include contrast)  TB  Empyema  Cancer Staging (to include abdomen/pelvis where necessary)

 Anything vascular requires discussion with a paediatric consultant radiologist

Chest Imaging

Volume is calculated at 1.5mg of contrast per kilogram of warmed Omnipaque 300 up to 50mLs maximum volume (Low - Osmolar

Contrast Media), at a flow rate of 2mL/sec. The delay should be 5 seconds post end of contrast injection or the Consultant Paediatric

Radiologists protocol.

Fungal Chest Infection Imaging

If it is the patients first CT give IV contrast as stated in Contrast Injections for Paediatric Patients above, using the timings in Paediatric

Chest Imaging. Subsequent examinations to evaluate for fungal infection do not require IV contrast medium.

Abdomen and Pelvis Imaging

Volume is calculated at 1.5mg of contrast per kilogram of warmed Omnipaque 300 up to 70mLs maximum volume(Low - Osmolar

Contrast Media), at a flow rate of 2mL/sec. All children should receive oral contrast as per the Omnipaque™ Administration Protocol

below unless contraindicated. The portal venous delay should be 15 seconds post end of contrast injection or the Consultant

Paediatric Radiologists protocol.

All other phases require discussion with a Consultants Paediatric Radiologist

NB. Multi-phase imaging should be avoided wherever possible.

Omnipaque™ (Iohexol) Oral Contrast Administration Protocol:

Age

Dose & Dilution

Administration

0-1 Year 2mL Omnipaque TM / 120mL Water

Slowly over 1 hour 2-5 Years 4mL Omnipaque TM / 250mL Water

Slowly over 1 hour 6-12 Years 5.5mL Omnipaque TM / 350mL Water

Slowly over 1 hour 13 Years + 8mL Omnipaque TM / 500mL Water

Slowly over 1 hour

Prolonged Bowel Prep

0-1 Year  1 st Dose – 1mL Omnipaque TM / 60mL Water  2 nd Dose – 2mL Omnipaque TM / 120mL Water  First Dose – 2 hours before the scan  Second Dose – 1 hour before the scan 2-5 Years  1 st Dose – 2mL Omnipaque TM / 125mL Water  2 nd Dose – 4mL Omnipaque TM / 250mL Water  First Dose – 2 hours before the scan  Second Dose – 1 hour before the scan 6-9 Years  1 st Dose – 2.5mL Omnipaque TM / 175mL Water  2 nd Dose – 5mL Omnipaque TM / 350mL Water  First Dose – 2 hours before the scan  Second Dose – 1 hour before the scan 10-12 Years  1 st Dose – 2.5mL Omnipaque TM / 175mL Water  2 nd Dose – 5mL Omnipaque TM / 350mL Water  First Dose – 4 hours before the scan  Second Dose – 1 hour before the scan 13+ Years  1 st Dose – 4mL Omnipaque TM / 250mL Water  2 nd Dose – 8mL Omnipaque TM / 500mL Water  First Dose – 4 hours before the scan  Second Dose – 1 hour before the scan

In the event of prolonged bowel prep protocol please follow the guidance in the table above.

12 Paediatric Trauma

 Paediatric Bastion

Bastion protocols should be used for all paediatric trauma CT scans above 10 kg.

The Bastion paediatric trauma protocols are divided into weight categories of 10 kg.

The weight based protocol selected on the scanner must match the weight based protocol on the injector pump. (See

charts below).

The Bastion protocol will be used to scan paediatric trauma patients up to 70 kg. Any patient in excess of 70 kg will be

scanned using the standard adult CT Bastion trauma protocol (Section 10).

Where possible paediatric patients should be scanned on CT1, CT2 or CT3 to minimise the radiation dose.

Protocols available on CT1, 2, 3:

Paed_Bastion_AbdoPelvis – Select appropriate weight category.

Paed_Bastion_CAP – Select appropriate weight category. Chest only to be scanned on Radiologists approval.

The scanning protocols for paediatric trauma are as follows:

 Brain and c-spine – if clinically indicated

Further imaging should always be discussed with a Radiologist and be dictated by:

 Chest: CXR is the initial radiological investigation (to be performed in ED on patient arrival). This is to detect pneumothorax,

haemothorax, rib fractures, gross mediastinal abnormalities and diaphragmatic injuries.

 If CXR is normal, CT chest can be avoided as it is unlikely to change management. Indications for CT Chest:

The nature of the injury (penetrating trauma to chest)

The clinical condition of the child

The initial CXR findings

 Abdomen and pelvis: A Split dose IV contrast enhanced, single acquisition scan (Paediatric Bastion) in accordance with

child’s weight.

No oral contrast is required for paediatric trauma patients.

 On the table review

A radiologist hot report must be documented on EPIC as soon as the scan is completed.

If a bladder or ureteric injury is suspected an unenhanced CT abdomen/pelvis should be done at a 10 minute post IV

contrast interval.

12.1 CT Paediatric Trauma scanning parameters by weight:

10-14kg – Total Contrast = 24mL

1 st injection @ 0 seconds 18mL @ 2.0mL/s = 9 seconds

Pause 9 seconds 2 nd injection @ 68 seconds 6mL @ 1mL/s = 6 seconds

Delay 5 seconds

Scan 29 seconds

15-19kg – Total Contrast = 32mL

1 st injection @ 0 seconds 26mL @ 2.0mL/s = 13 seconds

Pause 9 seconds 2 nd injection @ 68 seconds 6mL @ 1mL/s = 6 seconds

Delay 5 seconds

Scan 33 seconds

20-24kg – Total Contrast = 47mL

1 st injection @ 0 seconds 33mL @ 2.0mL/s = 17 seconds

Pause 8 second 2 nd injection @ 68 seconds 14mL @ 2.0mL/s = 7 seconds

Delay 5 seconds

Scan 37 seconds

25-29kg – Total Contrast = 54mL

1 st injection @ 0 seconds 40mL @ 2.0mL/s = 20 seconds

Pause 8 seconds 2 nd injection @ 68 seconds 14mL @ 2.0mL/s = 7 seconds

Delay 5 seconds

Scan 40 seconds

30-34kg – Total Contrast = 68mL

1 st injection @ 0 seconds 48mL @ 2.0mL/s = 24 seconds

Pause 8 seconds 2 nd injection @ 61 seconds 20mL @ 2.7mL/s = 14 seconds

Delay 5 seconds

Scan 44 seconds

35-39kg – Total Contrast = 75mL

1 st injection @ 0 seconds 55mL @ 2.0mL/s = 28 seconds

Pause 8 seconds 2 nd injection @ 62 seconds 20mL @ 2.7mL/s = 7 seconds

Delay 5 seconds

Scan 48 seconds

45-49kg – Total Contrast = 97mL

1 st injection @ 0 seconds 71mL @ 2.0mL/s = 36 seconds

Pause 7 seconds 2 nd injection @ 62 seconds 26mL @ 2.5mL/s = 10 seconds

Delay 5 seconds

Scan 58 seconds

50-54kg – Total Contrast = 112mL

1 st injection @ 0 seconds 78mL @ 2.0mL/s = 39 seconds

Pause 5 seconds 2 nd injection @ 62 seconds 34mL @ 2.9mL/s = 12 seconds

Delay 5 seconds

Scan 61 seconds

55-59kg – Total Contrast = 120mL

1 st injection @ 0 seconds 86mL @ 2.0mL/s = 43 seconds

Pause 5 seconds 2 nd injection @ 62 seconds 34mL @ 2.9mL/s = 12 seconds

Delay 5 seconds

Scan 65 seconds

60-64kg – Total Contrast = 133mL

1 st injection @ 0 seconds 93mL @ 2.0mL/s = 47 seconds

Pause 4 seconds 2 nd injection @ 62 seconds 40mL @ 3.0mL/s = 13 seconds

Delay 5 seconds

Scan 69 seconds

65-69kg – Total Contrast = 140mL

1 st injection @ 0 seconds 100mL @ 2.0mL/s = 50 seconds

Pause 4 seconds 2 nd injection @ 62 seconds 40mL @ 3.0mL/s = 13 seconds

Delay 5 seconds

Scan 72 seconds

40-44kg – Total Contrast = 89mL

1 st injection @ 0 seconds 63mL @ 2.0mL/s = 30 seconds

Pause 7 seconds 2 nd injection @ 62 seconds 26mL @ 2.5mL/s = 10 seconds

Delay 5 seconds

Scan 54 seconds

Neuro Protocols

13.1 Standard Head Protocols

The following is a general guide for Neuro Band 7 Radiographers vetting requests to ensuring the correct protocol is applied.

If unsure, requests are to be vetted by a Consultant Neuro Radiologist.

Head without Contrast:

 Hydrocephalus  Headache  Stroke / CVA (including post treatment)  ? Intracranial haemorrhage (SAH, SDH, EDH, ICH)  SOL without history of cancer  Meningitis  Head Injury  Memory loss, dementia assessment  Post-surgical intervention (shunt, biopsy, EVD, tumour resection)  Post-thrombectomy (use Dual Energy if available)

Head without and with Contrast:

 ? Metastasis  Abscess / Empyema / Infection  Ventriculitis  Tumours

Head with Contrast only

 Pituitary (MRI Contraindicated)

Preparation

 Position the patient supine with the head supported by the carbon fibre headrest.

 Using the Z-axis laser, ensure the patient’s median sagittal plane is aligned parallel.

 Ensure the head is tilted caudal (chin down) to minimise gantry angulation and irradiation of the lens of the orbit.

 Use immobilisation aids in the event of imaging non-compliant patients (side wedges, forehead strap)

 Position the patient at the vertex using the internal laser light (Siemens).

Scan Process

 The Topogram will be performed by default cranio-caudal, with a lateral tube orientation.

 The scan field outlined by the magenta box (Siemens) should align to the infraorbital-meatal line avoiding primary irradiation of

the lens of the orbit.  Ensure the upper border of C1 to the Vertex is covered within the scan range.

Reconstruction

 Reduce the field of view to allow a small air gap around the surface of the skin.

 Reconstruct the thin slice as acquired (without straightening).

 Reconstruct the 5mm (3D) reconstruction aligned to the subcallosal plane ( Appendix 8 )

Where reconstruction from RAW data cannot be performed, align the patient using the system MPR tool

Contrast (if required)

 Use either a hand or injector to deliver the bolus of contrast  The volume of contrast should amount to 50mL in the adult patient.

Protocol

IV

Imaging

Notes

Hydrocephalus

Headache

Stroke / CVA ? Intracranial haemorrhage (SAH, SDH, EDH, ICH)

Meningitis

Head Injury

Post-surgery

Protocol name: HeadRoutine3D

 Non Contrast

Where the scan range is outside the typical

FoV please use

Protocol name: HeadLargeFoV (not

required in CT3)

Where patient movement is expected during acquisition please use

Protocol name: HeadFast

? Metastasis with known primary

Abscess / Empyema

Ventriculitis

Tumours

Protocol name: HeadContrast_PrePost

50mL  Non contrast  3 minutes post contrast

Pituitary

Protocol name: HeadContrastOnly

50mL  3 minutes post contrast

Memory loss, dementia assessment

Protocol name: HeadDementia

 Non contrast

Appendix 12 – Dementia Reformats

Post VP Shunt

Protocol name: HeadLowDose

 Non Contrast

Post Thrombectomy

Protocol name: DE_Head_Post_Thrombectomy

 Non Contrast  Dual energy scan CT3

Syngo.Via will automatically create iodine maps and archive to PACS. In the event that you should need to straighten your head anatomy please load your data into the 3D card straighten save and send to PACS.

13.2 Operative Navigation (Stealth)

Stealth compatible imaging requires contiguous thin (soft tissue kernel) slices with a zero gantry tilt.

Imaging is imported from PACS by the surgical team, to allow imaged guided surgical intervention.

Brain Volume without Contrast:

 Pre-Op Shunt / EVD  Deep Brain Stimulator insertion  Image guide sinus surgery (Medtronic Protocol)

Brain Volume with Contrast:

 Biopsy  Tumour resection

Preparation

 Position the patient supine with the head supported by the carbon fibre headrest.

 The table extension and square head-pad can be used also if appropriate.

 Using the Z-axis laser, ensure the patient’s median sagittal plane is aligned parallel.

 Ensure the head remains in a neutral position

 DO NOT use immobilisation aids that could distort the cranio-facial anatomy

 Position the patient at the vertex using the internal laser light (Siemens).

Scan Process

 The Topogram will be performed by default cranio-caudal with a lateral tube orientation.

 The scan field outlined by the magenta box (Siemens) should include:

 Superiorly: airspace beyond the vertex  Inferiorly: to just below the nose and whole cranium.

 Ensure ZERO gantry tilt

Reconstruction

 Reduce the field of view to allow a small air gap around the surface of the skin in all directions.

 Reconstruct the thin slice as acquired (without straightening).

 Reconstruct the 5mm (3D) reconstruction aligned to the subcallosal plane ( Appendix 8)

 Where reconstruction from RAW data cannot be performed, align the patient using the system MPR tool

Contrast (if required)

 Use either a hand or injector to deliver the bolus of contrast  The volume of contrast should amount to 50mL in the adult patient.

Protocol

IV

Imaging

Notes

Pre-Op Shunt / EVD

Deep Brain Stimulator insertion

Protocol name: HeadStealth



Non contrast

Biopsy

Tumour resection

Protocol name: HeadStealthContrast

50mL  3 minutes post contrast

Post contrast only is required

Medtronic Image Guided Sinus Surgery

Protocol name: SinusesStealth



Non contrast

This is a very low dose protocol and should only be used for this indication

13.3 Facial Imaging

Preparation

 Position the patient supine with the head supported by the carbon fibre headrest.

 The table extension and square head-pad can be used also if appropriate.

 Using the Z-axis laser, ensure the patient’s median sagittal plane is aligned parallel.

 Ensure the head remains in a neutral position  Use immobilisation aids if required  Position the patient at the vertex using the internal laser light (Siemens).

Scan Process

 The Topogram will be performed by default cranio-caudal with a lateral tube orientation.

 The scan field outlined by the magenta box (Siemens) should include: see protocol section below

Reconstruction

 Reduce the field of view to allow a small air gap around the surface of the skin in all directions.

 Reconstruct the thin slice as acquired (without straightening).

 Where reconstruction from RAW data cannot be performed, align the patient using the system MPR tool

 Coronal and Sagittal reformats should be archived to PACS

Contrast (if required)

 Use the contrast injector to deliver the bolus of contrast  The volume of contrast is indicated in the protocol below

Body Region

Protocol

IV

Imaging

Notes

Sinuses FESS

Chronic Sinusitis CSF Leak

Wegener’s Granulomatosis

Medtronic Protocol’ – see operative navigation

Protocol name: Sinuses

 Non contrast  Appendix 15 – Sinus Reformats

Tumor

Protocol name: SinusesContrast

70mL  80 Second delay 

Post Contrast only required

Orbits

Trauma (Blow-out fracture)

Foreign body

Protocol name: Orbits



Non contrast 

Ensure the eyes are closed 

Create reformats, Appendix 17

Tumor/Abcess

Cellulitis

Protocol name: OrbitsContrast

70mL  45 second delay 

Ensure the eyes are closed 

Post contrast only is required

Mandible

Dental pathology TMJ assessment

Trauma

Osteoradionecrosis

Protocol name: Mandible



Non contrast  1 mm oblique reconstructions across the body of the mandible 

Create VRT reformats, Appendix 14

13.4

Temporal Bones

Preparation

 Position the patient supine with the head supported by the carbon fibre headrest.

 The table extension and square head-pad can be used also if appropriate.

 Using the Z-axis laser, ensure the patient’s median sagittal plane is aligned parallel.

 Ensure the head remains in a caudal tilted position  Immobilisation aids should be used to ensure the patient head remains still  Position the patient at the vertex using the internal laser light (Siemens).

Scan Process

 The Topogram will be performed by default cranio-caudal with a lateral tube orientation.

 The scan field outlined by the magenta box (Siemens) should include:

 Superiorly: Upper mastoid air cells  Inferiorly: Just below the skull base  Tilt the scan range parallel to the skull base

Reconstruction

 Reduce the field of view to allow a small air gap around the surface of the skin side-to-side.

 Reconstruct the thin slice as acquired (without straightening).

 Where reconstruction from RAW data cannot be performed, align the patient using the system MPR tool

 Include bilateral small FoV (80mm) reconstructions on each side ( Appendix 16 )

Contrast (if required)

 Use a contrast injector to deliver the bolus of contrast  The volume of contrast should amount to 70mL in the adult patient.

Protocol

IV

Imaging

Notes

Cholesteatoma CSF leak

Erosion of tegmen, Attic perforation

Cochlear implant assessment

T_Bones_UHR

T_Bones_UHR_Sn (CT3)

 Non contrast

Performed only in CT1/CT3

Glomus Jugulare

Infection

Hearing loss? Vestibular schwannoma (when MRI not possible)

T_Bones_UHR_Contrast

70mL 3mL / sec  35 Second delay

Post contrast only

13.5

Spine

Preparation

C-Spine

 Position the patient supine with the head supported by the carbon fibre headrest

 Using the Z-axis laser, ensure the patient’s median sagittal plane is aligned parallel.

 Arms down by patient side  Position the patient at the EAM using the internal laser light (Siemens). T-Spine  Position the patient supine  Head supported by a pillow / headrest attachment

 Using the Z-axis laser, ensure the patient’s median sagittal plane is aligned parallel.

 Arms raised above head and supported

 Position the patient at the shoulders using the internal laser light (Siemens).

 AP Topogram, cranio-caudal L-Spine  Position the patient supine  Head supported by a pillow / headrest attachment

 Using the Z-axis laser, ensure the patient’s median sagittal plane is aligned parallel.

 Arms raised above head and supported

 Position the patient at Symphysis Pubis, using the internal laser light (Siemens).

 Lateral Topogram, caudo-cranial.

Scan Process

C-Spine  The Topogram will be performed with a lateral tube orientation, cranio-caudal  Ensure range is from base of skull down to T3 T-Spine  The Topogram will be performed with AP tube orientation, cranio-caudal.  Ensure the whole thoracic spine is covered with superior border of L1 L-Spine

 The Topogram will be performed with a lateral tube orientation, caudo-cranial.

 Ensure the whole lumbar spine is covered with inferior border of T12

Reconstruction

 Reduce the field of view to allow a small air gap around the surface of the skin side-to-side.

 Reconstruct the thin slice as acquired (without straightening).

 Where reconstruction from RAW data cannot be performed, align the patient using the system MPR tool

 Refer to Appendix 13 for parallel range reformats

Contrast (if required)

 Use a contrast injector to deliver the bolus of contrast  The volume of contrast should amount to 70mL in the adult patient.

Protocol

IV

Imaging

Notes

Trauma

Whole Spine

Post Op (pedicle screws)

Osteomyelitis

Rheumatoid

C-Spine

T-Spine

L-Spine



Non Contrast

Stenosis (MRI Contraindicated)

SpineStenosis



Non Contrast

Myelography

Myelogram



Non contrast

13.6 Neck

Note for Neck and Chest:

Ensure study has two accession numbers (orders) for both the neck and chest.

This will allow consultant verified reports to be made by a neuro and body specialist radiologist.

Use a multi-study registration where possible to eliminate the requirement to correct the accession number post scan

Preparation

 Position the patient supine with the head supported by the carbon fibre headrest

 Using the Z-axis laser, ensure the patient’s median sagittal plane is aligned parallel.

 Arms down by patient side  Position the patient at the EAM using the internal laser light (Siemens).

Scan Process

 The Topogram will be performed by default cranio-caudal with a lateral tube orientation.

 The scan field outlined by the magenta box (Siemens) should include:

Superiorly: Skull base

Inferiorly: Mediastinum  Tilt the scan range if required to minimise dental artefact

Reconstruction

 Reduce the field of view to allow a small air gap around the surface of the skin side-to-side.

 Reconstruct the thin slice as acquired (without straightening).  Coronal and Sagittal Soft tissue MPRs from RAW data

Contrast

 Use a contrast injector to deliver the bolus of contrast  The volume of contrast should amount to 70mL in the adult patient.

Protocol

IV

Imaging

Notes

Staging

Protocol name: ENT Neck Staging

70mL 1mL / sec  80 Second Delay

Abscess

Protocol name: ENT Neck Abscess

70mL 2mL / sec  50 Second Delay

Parathyroid Adenoma

Protocol name: Parathyroid4D

75mL 4mL / sec  25 Second Delay  80 Second Delay

13.7

Vascular

Preparation

 Position the patient supine with the head supported by the carbon fibre headrest.

 The table extension and square head-pad can be used also if appropriate.

 Using the Z-axis laser, ensure the patient’s median sagittal plane is aligned parallel.

 Ensure the head remains in a neutral position  Position the patient at the vertex using the internal laser light (Siemens).

Scan Process

 The Topogram will be performed by default cranio-caudal with a lateral tube orientation.

 Neck Angio will be an AP Topogram  Ensure ZERO gantry tilt

Reconstruction

 Reduce the field of view to allow a small air gap around the surface of the skin in all directions.

 Reconstruct the thin slice as acquired (without straightening).  Contrast (if required)  Use the contrast injector to deliver the bolus of contrast  Spinal Angio: Omnipaque 350

Protocol

IV

Imaging

Notes

SAH AVM

Protocol name: HeadAngio

70mL 

Vertex to C3

Bolus tracked on the descending aspect of the Aortic

Arch

Brain Death

Protocol name: CTABrainDeath

120mL 

Vertex to C3 unenhanced 

Vertex to C3 20 seconds delay 

Vertex to C3 60 seconds delay

120 mL Omnipaque 350 at

3mLs per second

Carotid Stenosis

Dissection

Vessel Occlusion

Protocol name: AngioCarinaVertex

70mL 

Vertex to Carina

Bolus tracked on the descending aspect of the Aortic

Arch DAVF

Protocol name: Angio_Spinal

150 mL 

Shoulders to Symphysis Pubis

Bolus tracked on the abdominal aorta just above the bifurcation

Omnipaque 350

Venous sinus thrombosis

Pulsatile tinnitus (Subjective)

Protocol name: HeadVenogram

100mL 

Vertex to C3

Idiopathic intracranial hypertension

Stents

Pulsatile tinnitus (Objective)

Specifically protocolled by JNPH

Protocol name: HeadVenogramJNPH

100mL 

Vertex to Carina

13.8

Neuro Intervention

The Operator will be the Radiologist performing the procedure.

Exposures will be initiated using the foot pedal or scanner button (in-room) or control pad.

Table movement will be controlled i-Control (affixes to the side of the CT table).

Note: i-Control can be hard wired into the scanner in the event of wireless failure.

Preparation

CT Guided Nerve Root Injection Cervical

 Prone position (or supine for Dr Scoffings)

 White wedge pad for head support using the carbon fibre head rest (or flat end with pillow for Dr Scoffings)

 Arms by the patient’s sides  A theatre cap may be useful with patients that have long hair  Topogram to be set to Craniocaudal

CT Guided Nerve Root Injection Lumbar

 Prone position  Flat table extension to be used  Arms preferably by the patient’s head  Select low dose as preference, based on operator discretion  CT Guided Biopsy Bone / CT Guided Biopsy

 Post contrast imaging may be useful and will be directed by the Radiologist prior to the procedure

Scan Process

 A lateral Topogram will be performed over the area of interest.  A scan volume will be placed over the level as identified by the Radiology.

 Once the injection level is established, i-sequence will be performed by the Radiologist in the scan-room.

Protocol

IV

Imaging

Notes

CT Guided Nerve Root Injection Cervical

Protocol name: NRI_Cervical

CT Guided Nerve Root Injection Lumbar CT Guided Biopsy Bone

Protocol name: NRI_Lumbar

Protocol name: NRI_Lumbar_LD

13.9

Specialist Scanning

CT Head Perfusions (CTP):

 Refer to the “Flowchart for acute Stroke Patients requiring CT Imaging”

Preparation

 Position the patient supine with the head supported by the carbon fibre headrest.

 The table extension and square head-pad can be used also if appropriate.

 Using the Z-axis laser, ensure the patient’s median sagittal plane is aligned parallel.

 Position the patient at the vertex using the internal laser light (Siemens).

Scan Process

 The Topogram will be performed by default cranio-caudal with a lateral tube orientation.

Reconstruction

 Reduce the field of view to allow a small air gap around the surface of the skin in all directions.

 Please refer to Appendix 13 for colour maps

Contrast

 Use the contrast injector to deliver the bolus of contrast

Protocol

IV

Imaging

Notes

Stroke Protocol

Protocol name: HeadPerfusion

50mL

Refer to the ‘Flowchart for Acute Stroke

Patients requiring CT Imaging’

Vasospasm

Protocol name: HeadPerfVasospasm

50mL

Note: First referral for vasospasm CTP will be accepted by the Radiographer.

Subsequent imaging referrals must be discussed with the Consultant Neuroradiologist 

Neurosurgical referrals only 

Refer to Appendix 15

13.10 Standard Paediatric Head Protocols

The following is a general guide for Neuro Band 7 Radiographers vetting requests to ensuring the correct protocol is applied.

If unsure, requests are to be vetted by a Consultant Neuro Radiologist.

Preparation

 Position the patient supine with the head supported by the carbon fibre headrest.

 Using the Z-axis laser, ensure the patient’s median sagittal plane is aligned parallel.

 Ensure the head is tilted caudal to minimise gantry angulation and irradiation of the lens of the orbit.

 Use immobilisation aids in the event of imaging non-compliant patients (side wedges, forehead strap)

 Position the patient at the vertex using the internal laser light (Siemens).

Scan Process

 The Topogram will be performed by default cranio-caudal with a lateral tube orientation.

 The scan field outlined by the magenta box (Siemens) should align to the infraorbital-meatal line avoiding primary irradiation of

the lens of the orbit.  Ensure the upper border of C1 to the Vertex is covered within the scan range.  The scan will be performed by default caudo-cranial.

Reconstruction

 Reduce the field of view to allow a small air gap around the surface of the skin.

 Reconstruct the thin slice as acquired (without straightening).  Reconstruct the 5mm (3D) reconstruction aligned to the subcallosal plane

 Where reconstruction from RAW data cannot be performed, align the patient using the system MPR tool

 Contrast (if required)  Use either a hand or injector to deliver the bolus of contrast

 The volume of contrast should amount to 1mL per kilo for a paediatric patient (not exceeding 50mL).

Protocol

IV

Imaging

Notes

Hydrocephalus

Headache ? haemorrhage

Meningitis

Post-surgical intervention

Trauma

Craniosynostosis

Protocol name: HeadRoutine3D_Paed



Non Contrast ? Metastasis with known primary

Abscess / Empyema

Protocol name: HeadContrast

1 mL per Kg* 

Non contrast 

Post contrast Hand/Pump inject 1mL per kilo (Scan at 3 minutes post contrast)

Not exceeding 50 mL

13.11 Operative Navigation (Paediatric Stealth)

Stealth compatible imaging requires contiguous thin (soft tissue kernel) slices with a zero gantry tilt.

Imaging is imported from PACS by the surgical team, to allow imaged guided surgical intervention.

Preparation

 Position the patient supine with the head supported by the carbon fibre headrest.

 Using the Z-axis laser, ensure the patient’s median sagittal plane is aligned parallel.

 Ensure the head is not over tilted.

 Ensure that the ears and nose are not touching anything or being clipped by anything.

 Position the patient at the vertex using the internal laser light (Siemens).

Scan Process

 The Topogram will be performed by default cranio-caudal with a lateral tube orientation.

 The scan field outlined by the magenta box (Siemens) should have a zero gantry tilt.

 Ensure the scan range covers the whole nose to just beyond the vertex.  The scan will be performed by default caudo-cranial.

Reconstruction

 Reduce the field of view to allow a small air gap around the surface of the skin.

 Reconstruct the thin slice as acquired (without straightening).  Reconstruct the 5mm (3D) reconstruction aligned to the subcallosal plane

 Where reconstruction from RAW data cannot be performed, align the patient using the system MPR tool

 Contrast (if required)  Use either a hand or injector to deliver the bolus of contrast

 The volume of contrast should amount to 1mL per kilo for a paediatric patient (not exceeding 50mL).

Protocol

IV

Imaging

Notes

Pre-Op Shunt Insertion/EVD

Protocol name: HeadStealth



Non Contrast

Scan from just above vertex to just below the nose. Very important to include the nose and above vertex for the stealth navigation system. The ears must not be touching anything or clipped.

Pre-Op for tumour removal

Pre-Op for abscess removal/Washout

Protocol name: HeadStealthContrast

1 mL per Kg* 

Post contrast Hand/Pump inject 1mL per kilo (Scan at 3 minutes post contrast)

Not exceeding 50 mL

13.12

Standard Paediatric Spine Protocols

The following is a general guide for Neuro Band 7 Radiographers vetting requests to ensuring the correct protocol is applied.

If unsure, requests are to be vetted by a Consultant Neuro Radiologist.

Preparation

 Position the patient supine with the head supported by the carbon fibre headrest when scanning the cervical spine or a pillow

for head support when scanning the thoracic or lumber spine.

 When scanning the cervical spine ensure the arms are down by the patient’s side and raised if patient is able to do so, when

scanning the thoracic or lumber spine.

 Using the Z-axis laser, ensure the patient’s spine is aligned to the median sagittal plane.

 Position the patient with the internal laser light (Siemens) just above the ear for cervical spine and at the symphysis for lumber

spine.

Scan Process

 The Topogram will be performed by default cranio-caudal for the cervical spine and caudo-cranial for the whole spine protocol

with a lateral tube orientation.

 The scan field outlined by the magenta box must cover the desired area (Siemens).

 Ensure the scan range for cervical spine covers from just above C1 down to T1 and for other areas of the spine ensure that

your scan range covers at least one level above and one below the asked for vertebra.

 The scan will be performed by default cranio-caudal.

Reconstruction

 Reduce the field of view to allow a small air gap around the surface of the skin.

 Reconstruct the first recon box as acquired (without straightening).  Then reconstruct the 3D thin sagittal and coronal reformats.

 Where reconstruction from RAW data cannot be performed, align the patient using the system MPR tool

Protocol

IV

Imaging

Notes

Trauma

Pre or Post surgery

Protocol name: C-Spine



Non contrast

Scan from C1 to T1

Trauma

Scoliosis

Pre or Post surgery

Protocol name: Spine0_6yr



Non contrast

Scan at least one level above and one below the desired region.

13.13

Standard Paediatric Crainofacial Protocols

The following is a general guide for Neuro Band 7 Radiographers vetting requests to ensuring the correct protocol is applied.

If unsure, requests are to be vetted by a Consultant Neuro Radiologist.

Preparation

 Position the patient supine with the head supported by the carbon fibre headrest.

 Using the Z-axis laser, ensure the patient’s median sagittal plane is aligned parallel.

 Ensure the head is not over tilted and in a neutral position.  Position the patient at the vertex using the internal laser light (Siemens).

Scan Process

 The Topogram will be performed by default cranio-caudal with a lateral tube orientation.

 The scan field outlined by the magenta box must cover the desired area (Siemens)

 For sinus scans ensure the scan range covers from the top of the frontal sinus to the bottom of the maxillary sinus. For orbit

scans ensure that just above and just below the whole orbit are covered and for inner ear scans please ensure the mastoid air

cells are all covered.  The scan will be performed by default caudo-cranial.

Reconstruction

 Reduce the field of view to allow a small air gap around the surface of the skin.

 Reconstruct the thin slice as acquired (without straightening).  Then reconstruct the 3D thin sagittal and coronal reformats.

 Where reconstruction from RAW data cannot be performed, align the patient using the system MPR tool

 Contrast (if required)  Use either a hand or injector to deliver the bolus of contrast

 The volume of contrast should amount to 1mL per kilo for a paediatric patient (not exceeding 50mL).

Protocol

IV

Imaging

Notes

Sinus

Sinusitis

Define bony anatomy for surgery

Protocol name: sinusesOrbit



Non Contrast

Scan from top of frontal sinus to bottom of maxillary sinus.

Tumour Evaluation

Protocol name: sinusesOrbit

1mL per Kg* 

Non contrast (Check protocol on request as non contrast scan not always needed) 

Contrast Hand/Pump inject 1mL per kilo

Please use sinusesOrbit

protocol and add the contrast used and volume.

Non contrast scan not always required please check protocol on request or with radiologist if unsure.

Orbits

Fractures

Protocol name: sinusesOrbits



Non contrast

Scan just above and just below the orbital socket.

Orbital Cellulitis/ Abscess

Tumour Evaluation

Protocol name: OrbitsContrast

1mL per Kg* 

Non contrast (Not always needed check protocol on request) 

Contrast Hand/Pump injection 1mL per kilo and scan 15 seconds after the end of the injection

Non contrast scan not always required please check protocol on request or with radiologist if unsure.

Please use OrbitsContrast protocol and add the contrast used and volume.

If child is able, ensure the eyes are closed. Create reformat

Appendix 17 .

Inner Ear

Semi-circular canal dehiscence

Cochlear Implants

Protocol name: InnerEar_UHR



Non Contrast

Scan to include all of the inner ear and mastoid air cells.

*Not exceeding 50mL

13.14

Standard Paediatric Vascular Protocols

The following is a general guide for Neuro Band 7 Radiographers vetting requests to ensuring the correct protocol is applied.

If unsure, requests are to be vetted by a Consultant Neuro Radiologist.

Preparation

 Position the patient supine with the head supported by the carbon fibre headrest.

 Using the Z-axis laser, ensure the patient’s median sagittal plane is aligned parallel.

 Ensure the head is not over tilted and in a neutral position.  Position the patient at the vertex using the internal laser light (Siemens).

Scan Process

 The Topogram will be performed by default cranio-caudal with a lateral tube orientation.

 The scan field outlined by the magenta box must cover the desired area (Siemens)

 For head angio scans ensure the scan range covers from the vertex to C3. For neck angio scans ensure that the scan range

covers from the vertex to carina. For venograms ensure that the scan range covers from vertex to C3 and for ENT neck scans

ensure that the scan range covers from base of skull to the arch.

 For head & neck angios as well as venograms the scan will be performed by default caudo-cranial. However for ENT neck

scans they are performed cranio-caudal by default.

Reconstruction

 Reduce the field of view to allow a small air gap around the surface of the skin.

 Reconstruct the thin slice as acquired (without straightening).  Then reconstruct the 3D thin sagittal and coronal reformats.

 Where reconstruction from RAW data cannot be performed, align the patient using the system MPR tool

 Contrast (if required)  Use either a hand or injector to deliver the bolus of contrast

 The volume of contrast should amount to 1mL or 1.5mL per kilo for a paediatric patient (not exceeding 70mL).

Protocol

IV

Imaging

Notes

Aneurysm AVM

Vascular Abnormality

Protocol name: HeadAngio0-6yr

1mL per kilo* 

Contrast 

If pump injecting trigger scan at arch of aorta 

If hand injecting the contrast volume. Inject, let the injecting person leave the scan room and scan immediately.

Scan from vertex to C3

Trigger off arch of aorta

Dissection

Vascular Abnormality

Protocol name: HeadNeckAngio0-6yr

1mL per kilo* 

Contrast 

If pump injecting trigger scan at arch of aorta 

If hand injecting the contrast volume. Inject, let the injecting person leave the scan room and scan immediately.

Scan from vertex to carina

Trigger off arch of aorta

Sinus Thrombus

Protocol name: HeadVenogram0-6yr

1.5mL per kilo* 

Contrast 

If pump injecting 2 or 3mL per second is preferable and scan 10 seconds after the end of the injection. 

If hand injecting the contrast volume. Inject the bolus and scan 10 seconds after the end of injection.

Scan from vertex to C3

Abscess

Tumour

Protocol name: ENTNeckContrast

1mL per Kilo* 

Contrast 

If pump injecting inject at 1mL per second and scan 15 seconds after the end of the injection. 

If hand injecting the contrast volume. Inject the bolus and scan 15 seconds after the end of injection.

Scan from base of skull to arch

*Not exceeding 70mL

Paediatric Sedation and Vascular Access

14.1 Sedation

The need for sedation should be discussed at the time the request is accepted by a Consultant Paediatric Radiologist on a case by

case basis.

A 22G, blue cannula or 20G pink cannula, should be requested if the scan necessitates.

CT1, CT2, CT3 or CT4 should be used whenever possible in order to administer as lower dose as possible.

14.2 Intravenous Contrast Administration for Paediatric Patients

All paediatric contrast injections should be administered at 1, 2 or 3mL/sec.

Only peripheral cannulas with a bionector may be used to administer IV contrast.

Central access lines (PICC, Hickman or Central Lines) are NOT permitted.

Hand Injections

A hand injection is preferred if:

• The child is under 10kgs.

• Small cannula (yellow) in situ.

Pump Injections

If the child has a 22G, blue cannula or 20G pink cannula, in situ the pump can be used above 10kgs

If using the pump a Radiologist or a Radiographer who has completed Paediatric Injection Competencies should check the line using

the Trusts ANTT, Hand Hygiene Policy, and Administration of Medicines policy.

Pump injections must be supervised in the scanning room whilst the injection is being administered. The exception to this is a bolus

tracked scan or if X-rays are in process during injection.

Standard paediatric protocols

Radiology registrars and Band 7 CT radiographers can accept and protocol paediatric CT requests.

References



1 Kambadakone AR et al. Abdom Radiol (NY). 2018 Jan;43(1):56-74. doi: 10.1007/s00261-017-1325-y.

 www.eoetraumanetwork.nhs.uk/tempo

16 Associated documents

 ANTT  Hand Hygiene Policy  Administration of Medicines policy

Equality and diversity statement

This document complies with the Cambridge University Hospitals NHS Foundation Trust service equality and diversity statement.

Disclaimer

It is your responsibility to check against the electronic library that this printed out copy is the most recent issue of this document.

Document management

The table below will be completed by the Trust documents team:

Approved by:

Kevin Mortimer

Approval date:

12 January 2022 JDTC approval date:

Owning department: CT Scanning - Imaging

Author(s):

David Bowden/Kevin Mortimer/Daniel Scoffings/David Biddle/Joanne

Loughnane/Claire Stanford

Pharmacist:

File name:

CT Scanning Protocol Document

Supersedes:

Version 13.0

Version number:

Version 14.0

Local reference:

Document ID:

Appendix 1 Contrast, Dose & Injection Rates vs Bodyweight

Omnipaque 300

Omnipaque 350

Weight

(kgs)

Omni 300

(mL)

Flow Rate

(mL/s)

Weight

(kgs)

Omni 300

(mL)

Flow Rate

(mL/s)

4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.1 4.0 4.1 4.0 4.2 4.0 4.3 4.0 4.3 4.0 4.4 4.0 4.4 4.0 4.5 4.0 4.6 4.0 4.6 4.0 4.7 4.0 4.7 4.0 4.8 4.0 4.9 4.1 4.9 4.1 5.0 4.2 5.0 4.2 5.1 4.3 5.2 4.3 5.2 4.4

Omnipaque 300

Omnipaque 350

Weight

(kgs)

Omni 300

(mL)

Flow Rate

(mL/s)

Weight

(kgs)

Omni 300

(mL)

Flow Rate

(mL/s)

5.3 4.4 5.3 4.5 5.4 4.5 5.5 4.6 5.5 4.6 5.4 4.7 5.4 4.7 5.74 4.8 5.8 4.8 5.8 4.9 5.9 4.9 5.9 5.0 6.0 5.0 6.1 5.1 6.1 5.1 6.2 5.2 6.2 5.2 6.3 5.3 6.4 5.3 6.4 5.4 6.5 5.4 6.5 5.5 6.6 5.5 6.7 5.6 5.6 5.7 5.7 5.8 5.8 5.9 5.9 6.0 6.0 6.1 6.1 6.2 6.2 6.3 6.3 6.4 6.4 6.5 6.5 6.6 6.6 6.7

Appendix 2 DIEP Post-Processing Reconstruction Guide

 Reproduce the following for deep inferior epigastric perforator flap pre-operative

breast reconstruction planning.

 Use the ‘Arterial Phase 1.0/0.7 B20f’ reconstruction to construct VRT in the 3D

card, or Syngovia®.

For Coronal Reformat:

1. Click / highlight axial view

2. Click ‘Parallel Ranges’ then click the horizontal ranges

3. Find the DIEP (Inferior Epigastric Artery)

4. Set the lines parallel to each other

5. Cover the anterior abdomen to both iliac arteries

6. Highlight the 4th box and click ‘MIP Thin’ [^^TYPE^^]

7. On ‘parallel ranges’ set up – image thickness = 35.0mm

8. Distance between images = 5.0mm (Approximately 26 images)

9. Click START

10. Then click SAVE AS then type Coronal MIP’s

For Axial Reformat:

1. On axial view, click the free mode, make sure that the green line is parallel to the

Inferior Epigastric Artery

1. Highlight the 2nd box (Coronal View)

2. Click ‘Parallel Ranges’ then click the horizontal ranges

3. Find the DIEP (Inferior Epigastric Artery)

4. Cover from the kidneys to the femoral head

5. Highlight the 4th box, and click ‘MIP Thin’ [^^TYPE^^]

6. On ‘parallel ranges’ set up – image thickness = 35.0mm

7. Distance between images = 5.0mm (Approximately 55 images)

8. Click START

9. Then click SAVE AS then type Axial MIP’s

Appendix 3 CT Thoracic Aorta aneurysm surveillance protocolling flow

chart

Appendix 4 CT AAA surveillance protocolling flow chart

Appendix 5 Bilateral Arm Injection Guide

2-Pump Method

1. Patient is placed on the scanning table with a minimum of 2, 22G (Blue) cannulas in the

ACF’s.

1. On the first pump in the scanning room select the patients name and enter the weight and

cannula type as normal. Select the 2.0ml/sec protocol and amend the volume to 50mls.

1. A second mobile pump is borrowed from another scanner and an anonymous patient is

selected and the same protocol is selected and amended as above.

1. On the scanner select the SVC_Obstruction protocol. (Includes a 25second delay chest and

70second delay chest)

1. Both pumps in the scanning room and the scan should be started at the same time.

Hand Injection Method

1. Patient is placed on the scanning table with a minimum of 2, 22G (Blue) cannulas in the

ACF’s.

1. On the first pump in the scanning room select the patients name and enter the weight and

cannula type as normal. Select the 2.0ml/sec protocol and amend the volume to 60mls.

1. 20mls of contrast should be drawn up.

2. On the scanner select the SVC_Obstruction protocol. (Includes a 25second delay chest and

70second delay chest)

1. The pump in the scanning room, the Radiographer hand injecting and the scan should be

started at the same time.

1. The radiographer hand injecting needs to pace the administration of contrast to last as long

as possible but ensuring all contrast is used before they leave the room at the last minute.

(Contrast needs to be in the vessels near the shoulder therefore injecting too quickly before

the scan starts means we will miss the contrast)

Appendix 6 CT Enterography Proceedure

Check all requests with Consultant GI Radiologist.

Ensure the patient has been starved for 6 hours prior to scan.  The patient should arrive 1.5 hours before their appointment time.  On arrival make up a solution of Kleenprep® powder (found in GG cupboard in reception) in 1L of water. Add cordial if preferred by patient.

 The patient is to drink 0.5L of the Kleenprep® solution over 15mins, followed by the

next 0.5L over the next 15mins.

 Once the patient has consumed the Kleenprep® solution they must be given 1L of

water. Again add cordial if required.  Again 0.5L to be drunk over 15mins and the rest over the following 15mins.  The scan should take place 1 hour from the START of drinking the Kleenprep®

solution; therefore, ideally cannulate the patient before entering the scan room.

 Once in the scanning room the patient is to be given 1mL of Buscopan, one final cup

of water and must be laid on their right hand side for a couple of minutes.  Perform a supine portal Abdo/Pelvis scan. Label the reconstructions as

‘Enterography’ and ensure the Kleenprep® details are recorded on the Notes section

of the patients’ Epic examination entry so that it is reported by the appropriate

Radiologist.  IF THE PATIENT HAS HAD BOWEL REMOVED PREVIOUSLY OR STARTS TO HAVE DIARRHOEA DURING/AFTER KLEENPREP BRING THE SCAN TIME FORWARD 10- 15MINS.

 Document any problems with drinking times or list unfinished drinks on under the

Notes section of the patients’ Epic examination entry.

Immediate side effects include:

 Abdominal distension and cramps; diarrhoea; bloating

Appendix 7 Orthopaedic Reconstruction of Pelvic & Hip Fractures

A. Load thin 1.0/0.6 soft tissue images of pelvis or extremity into InSpace / 3D

Card / Syngovia®

B. Access the ‘ Musculoskeletal ’ folder and apply the ‘ Transparent bone 2 ’

window/VRT construction, pictured as a skull, or implant transparent bone window. C. Straighten up the image if patient was rotated on the acquisition CT Scans.

D. Press the Radial Range button, this can be found under the ‘tools’ tab, at

the bottom right of the screen (image of a silhouetted head with a spoke wheel overlaid): E. A table will appear where angles of the recons can be manipulated. Total angle should be set at 360° F. Step angle at 10° G. Number of steps is automatic

H. Set the axis of recons to HF

I. Press start, save images

J. Set the axis of recons to LR

K. Press start, save images, send to PACS L. Repeat all of the above with an ‘Opaque Vessels’ window / VRT construction.

This can be found in the ‘Neuro’ folder of windows / VRT constructs.

N.B some windowing may be required to remove the soft tissue and scanning

table.

If reconstructing using Syngovia® please refer to guidelines on CT network

Any previous CT imaging from

vertex of the head to below

both Knees?

Yes

No

If a CT Skeletal

Survey has been

performed within

the last 6 months:

NOT for repeat

imaging.

Case must be

discussed with

MSK Radiologist

If CT Imaging

performed within

the last 3 months:

Complete staging

with

X-Ray.

If unsure discuss

case with

MSK Radiologist

Proceed to

CT Skeletal

Survey

If clinically

justified.

If unsure discuss

case with

MSK Radiologist

Appendix 8 Skeletal Survey Protocol

Symptomatic BCSP

Clinical details:

 CIBH  + FIT  weight loss LGI pathway  failed/unsuitable for colonoscopy BCSP means +FIT

Must be unsuitable for or had a failed colonoscopy.

Patient choice is NOT a justification for CTC for 1 st investigation

Recent colonoscopy?

No

Yes

Yes

Recent colonoscopy?

No

Biopsy/polypectomy/EMR (endoscopic mucosal resection)?

Yes

No for BCSP

Protocol as BCSP:



Colon prep  NO IV contrast  < 1 week CP 

Check allergies as normal

Protocol as symptomatic:



Colon prep  IV contrast – portal  < 1 week CP 

Check creatinine/eGFR as normal 

Check allergies as normal

No for symptomatic

Biopsy

NO delay required.

Protocol as for symptomatic or BCSP but with a low dose supine acquisition before insufflation (this is to check for perforation) (Low dose acquisition is required < 2 weeks for a *left sided biopsy and < 4 weeks for *right sided)

Polypectomy/EMR/ESD (endoscopic submucosal resection)

DELAY is required.

Protocol as for symptomatic or BCSP but with the following:

2 week delay for *left sided

4 week delay for *right sided

Symptomatic or BCSP request? * Left sided is rectum to mid transverse * Right sided is mid transverse to caecum

Appendix 9 CTC Protocolling Flow Chart

Appendix 10 CTC After Intervention at Coloscopy Policy

Following endoscopic mucosal biopsy ONLY

 No necessary delay following colonoscopy.

 Do ultralow / low dose supine CT abdomen / pelvis prior to insertion of rectal tube and

review.

Following polypectomy or combined biopsy / polypectomy procedures or EMR

 If left-sided polypectomy, two week delay prior to CTC.  If right-sided polypectomy, four week delay.

 If EMR (endoscopic mucosal resection) or ESD (endoscopic submucosal dissection), four

week delay.

 No need for pre-insufflation CT in cases where more than two weeks has elapsed post

procedure.

Views

 Right colon – caecum to mid transverse colon  Left colon – mid transverse colon to rectum

Review

 Each scan must be reviewed on “lung windows” before proceeding to the next stage to

check for free air.

Suspected perforation

If perforation is suspected the insufflator should be turned off and the duty Radiologist

informed immediately. Refer to Perforation of the Large Bowel during CT Colonography Policy.

Appendix 11 CT Head Imaging Technique

1. Align the scan range to avoid the lens

1. Start the 1 st and 2 nd reconstruction which are both thin slice

1. Once the 1 st reconstruction has completed, click on the 3 rd reconstruction.

2. Change the “Planning Base” to “Head 1.0 H40s” (or equivalent) indicated in yellow. The MRP will change into high quality.

1. Straighten the head (FAST 3D auto correction may be enabled on some scanners, all a few seconds for this to complete)

Note: auto correction will only apply once the Planning Base has been updated to the thin slice reconstruction.

1. Navigate to the midline and tilt the range using the blue line on the SAGITTAL image. Align the blue line across the inferior

genu and splenium of the corpus callosum.

Appendix 12 Dementia Reformats

Coronal and sagittal reformats (on-scanner post-processing)

1. Load 1.0 mm H30/J30 series into the 3D card.

2. Straighten up if necessary using the dashed coloured lines.

3. On the axial box, offset the red vertical line so it passes through a temporal horn of the lateral ventricles (Fig. 1).

4. Now go to the sagittal box (now offset) and angle the blue line so that it is parallel to the long axis of the hippocampus, which

lies in the inferior part of the temporal horn. You should see the temporal horn stretch out on the axial image (Fig 1).

1. When you are happy with the angulations return to the axial box and select parallel ranges.

2. Set to contiguous 3 mm slices.

3. Do not angle the parallel ranges (Fig 2).

4. Do the same with sagittal parallel ranges (Fig. 3).

5. ‘Save as’ after each set and name accordingly.

Fig. 1

Fig. 2

Fig. 3

Appendix 13 Brain Perfusion Maps

The following applies to on-scanner software only

Post processing is only available on CT2 (Siemens Definition AS+)

1. Load the scan data “VPCT DynMulti4D 10.0 H20f” into “VPCT Neuro” card on the Workstation.

2. The Organ selection box will display and the preferred preset is “Auto Stoke MTT”. This option provides the best method to

automate the processing of data.

1. There are 4 steps in the process of analysis. The software will proceed through each automatically and will only halt if it

requires user input. If the process halts, resolve the issue and click on the blue tick to proceed. The steps are as follows:

Step 1: Motion Correction

 The yellow boxes will appear next to the vertical scroll bar on the right at the levels where there is

movement detected.  You can select each one by the “Next/Previous Critical Time” Point button.  The centre button will remove the images at the current time point.

Step 2: Segmentation

 This step usually requires no intervention.  Click on the blue tick to proceed to the next step.

Step 3: Vessels

 Check the software has correctly located the midline.

 The software will attempt to find the best region of interest for an arterial and venous vessel.

 If the curves on the graph do not represent a bell shape then you will need to manually draw a region of interest.

 The best region for the arterial input function is the A2 segment of the anterior cerebral artery, which is what the

icon indicates.  Keep trying to achieve a good bell curve on the arterial and venous lines.

 The threshold must be adjusted to include the blood vessels only, for exclusion from the calculation.

 Count the red squares to the peak of the curve which will correspond to the strongest arterial “DynMulti4D 1.5 H20f xx ” series

for angiographic reconstructions (Unless you have removed time points from the series due to motion!).

Step 4: Normalisation



The software will normalise the data set. 

Click on the calculator. 

Once the perfusion maps have been produced, click on “Edit” and then “Select series” from the menu bar.

 To save click on “ Save RGB”.  Ensure the data below is sent to PACS

CT Brain Perfusion Post Processing using Syngo.Via

1. Launch Syngo.Via Client using the icon on the Desktop of a Standard Trust Computer

2. Login using the Trust Computer username and password

3. Enter the MRN into the Patient Browser (Red arrows)

1. Right click the study and select “Open With”, “CT Neuro Perfusion”

2. Verify the initial output by checking that you have “bell” curves in the TAC chart.

1. Confirm the calculations by clicking “confirm! (RED arrow)

2. Once confirmed, to make further adjustments you must reset the workflow.

1. To archive the results to PACS, click on the tick (RED ARROW)

Appendix 14 Max-Fax Facial Bones and Mandible reconstruction

Use Syngo.Via to perform volume rendered reformats. The following will guide you through using Syngo.Via.

1. Search for the patient using either name or MRN

2. The workflow should be “MM Reading”, if the field is blank, right click and “Open With”, selecting MM reading.

3. Ensure the soft tissue volume is loaded. To load an alternative volume, drag the series into the workspace

1. Select ‘Cinematic VRT ‘ by hovering the curser over the bottom left icon on the image.

1. Double click the VRT image to view the whole screen

Note:

 Right mouse (hold click) rotates the image

 Left clicking the orientation cube (yellow highlight) will snap to the view indicated.

 To save images, press ‘S’ on the keyboard.

 Saved images will appear as results in the series column on the right-hand-side.

1. Once finished, ‘Save and Send’ by clicking the tick (yellow highlight) or closing the patient

Appendix 15 Sinus Reformats

1.

Coronal and Sagittal reconstructions should be performed whilst in the Examination Card (Siemens) wherever possible.

If this is not available, Syngo.Via or an alternative should be used, using the sharp kernel bone volume only.

2.

If necessary straighten the images, prior to assessing landmarks for the reconstruction plane.

Coronal

Baseline: Perpendicular to the hard palate.

Coverage: Front of nose to the back of the sphenoid sinus.

Direction: Anterior to posterior

Slice thickness: 1mm

Sagittal

Baseline: Median sagittal plane

Coverage: Ethmoid sinus

Direction: Left to right

Slice thickness: 1mm 3.

Ensure any saved imaging is sent to PACS.

Appendix 16 Spine Reformats

1. Coronal and Sagittal reconstructions should be performed whilst in the Examination Card (Siemens) wherever possible. If this is

not available, Syngo.Via or alternative should be used, using the sharp kernel bone volume only.

1. If necessary straighten the images, prior to assessing landmarks for the reconstruction plane.

Coronal

Baseline: Parallel to the long axis of the spine

Coverage: Front vertebral body to end of spinous process

Direction: Anterior to posterior

Slice thickness: 2mm

Sagittal

Baseline: Median sagittal plane

Coverage: Lateral aspects of the bony spine

Direction: Left to right

Slice thickness: 2mm

Note

Depending on the clinical information and why you are scanning the spine sometimes soft tissue reconstructions may also be

needed. For example sagittal soft tissue recons for degenerative spines are desirable.

If scanning the spine as a myelogram study, coronal and sagittal recons (both bony and soft tissue) must be completed.

1. Ensure any saved imaging is sent to PACS

Appendix 17 Orbit Reformats

1. Load the 1mm thin H30 soft tissue or 1mm thin H70 bony reconstructions of the orbits into the 3D card depending on what you

are scanning for.

1. If necessary straighten the images.

2. Using the sagittal image by clicking on it to highlight the box surrounding it, place your recon lines on by clicking on the parallel

ranges icon on the right hand side of the screen.

1. Place your lines on the axial image starting from the front of the orbits and dragging your lines to the back of the optic nerve.

2. These recons must be reconstructed in 3mm width slices.

1. Click start, save images.

2. Sometimes bony coronal reconstruction will be needed, for example when looking for fractures.

3. Sagittal Orbit reconstruction may also sometimes be of value; again these images should be reconstructed in 3mm width slices.

To achieve this place your recon lines on the axial image parallel to the optic nerve and drag from left to right. These should be

done if soft tissue pathologies are found or fractures by using the bony recon images.

1. This time, place your parallel ranges lines on the axial image starting from the left and drag to the right creating some sagittal

images.

1. Click start, save images

1. If your axial images were not straight it may be worth creating and saving a straightened set. This time use the sagittal image to

plan from. Place your parallel ranges lines parallel to the optic nerve and drag to cover the whole of the orbital area.

1. These must again be in 3mm width slices.

2. Click start, save images.

Appendix 18 Vasospasm Imaging

Cerebral Vasospasm is the vasoconstriction of arterial vessels that can lead to brain ischaemia and haemorrhage. There is

specific pathway for treating patients with Vasospasm called ‘Triple H Therapy’

Induced Hypertension, Hypervolemia and Haemodilution form the ‘Triple H Therapy’

Imaging can be important with the diagnosis of vasospasm by defining defects within the pattern of cerebral perfusion

Scanning Protocol Methodology

The perfusion scan technique allows a quick and reliable assessment of the type and extent of perfusion disturbances in the brain.

Perfusion CT is a software application based on dynamic CT images acquired directly after contrast injection.

Perfusion CT analyses the increase of Hounsfield numbers caused by iodine enhancement, which is relatively small and appears

against a high background noise.

Image quality depends on iodine enhancement/noise ratio. Increasing the mAs will reduce the noise; however, will increase the

dose of radiation. Thick slices will decrease the noise and a compromise between this and the mAs is met.

High atomic number materials such as iodine show higher CT numbers at lower kV settings therefore 80 kV is used to exaggerate

this.

A fast rotation time of 1 sec or less will be used to achieve good temporal resolution therefore the accurate assessment of the

contrast bolus can be made pixel by pixel.

The contrast bolus will be given a saline chaser to optimize the contrast enhancement.

The extracted CTA will allow the assessment of the vessels within the head

Scanning Workflow

A non-contrast brain should always be performed in the first instance.

Ensure all imaged data is correctly archived to the PACS system and the patient’s attendance finalised on the RADIANT system

with the correct code.

Preparation

The multi-angle carbon fibre headrest should be used as gantry tilt is not available.

The patient will be cannulated preferably in the antecubital fossa.

Cannula no smaller than 20G, injection rate 5mL/sec

When appropriate, the patient must be reassured and put at ease due to the length of the scan, very rapid hot flush (table motion).

The dual head pump injector and will contain 50mL contrast and 50mL saline.

The injection rate is the same for both syringes.

Technique

1. Topogram

 Vertex to C3  Ensure the patient’s head is isocentred within the Gantry

1. CTH

 Supraorbitomeatal baseline

 Ensure the patient’s head is central within the blue shaded columns either side

 Scan range should include from Vertex down to the body of C1

 A second reconstruction should be added to provide 5mm contiguous slices in the axial plane if the patient is not

aligned straight.

1. CTP

 The perfusion scan range is 10cm

 Its placement on the Topogram should be sufficient to provide maximum coverage.

 As a guide, align the bottom pink line to the approximate inferior border of the pituitary fossa and verify your position

using the non-contrast scan.

 The second reconstruction provides the 4D Angio and should be processed as described further in this document

Do Not Reconstruct the Second Box Until You Have Processed the Perfusion

Post Processing

 As per Brain Perfusion workflow in Appendix 10

Extract CTA

1. On the Perfusion Card or the ‘Snapshot’ saved, look for the earliest peak on the Time Attenuation Curve (TAC)

2. To check, you can click on the two vertical white lines as shown in Fig. 2. This

will place a white line on the TAC

1. Each complete table movement will correspond to reconstructable range of 1.5s, therefore in the example, 20seconds is not

achievable directly. In this case; the Begin time should be 19.5 seconds and End time 21 seconds.

1. This will produce one series called “VPCT DynMulti 0.6 H20f 1”

ARCHIVE THIS TO PACS MANUALLY

Appendix 19 Temporal Bone Reformats

Reference AJNR 2019

Appendix 20 Cerebral Venography