CT Protocols

BASE OF BRAIN FOR NEURAL FORAMINA AND CRANIAL NERVE DISORDERSREGION OF INTEREST:SCOUT FILM:SLICE THICKNESS:SLICE INTERVALINFERIOR EXTENT:SUPERIOR EXTENT:INTRAVENOUS CONTRAST:BASE OF BRAIN FOR NEURAL FORAMINA AND CRANIAL NERVE DISORDERSLATERAL1 mm1 mmBOTTOM OF FORAMEN MAGNUMTHIRD VENTRICLENON-IONIC 100mlCOMMENTS:1. HARD PALATE PERPENDICULAR WITH BASE OF SKULL (CHIN-UP) FOV 25, SOFT TISSUE AND BONE ALGORITHMS.2. PATIENTS WITH FACIAL NERVE DISORDERS ALSO REQUIRE THESE VIEWS. EVEN IF ROUTINE HEAD ORDERED.3. GIVE VERY SPECIFIC HXINDICATION: FACIAL NUMBNESS, PAIN, TASTE ALTERATIONS, AND BELL’S PALSYSliceScanSeries Description16Ax (Bone)Cor (Bone)Ax (Soft)Cor (Soft)1X1WITHAX BONE C1x1WITHCOR BONE C1x1WITHAX SOFT C1x1WITHCOR SOFT C

LARYNXREGION OF INTEREST:SCOUT FILM:SLICE THICKNESS:SLICE INTERVAL:SUPERIOR EXTENT:INFERIOR EXTENT:INTRAVENOUS CONTRAST:LARYNXLATERAL1 mm (3mm for Neck)1 mm (Coronal & Sagittal thru Larynx) 3mm thru neckOrbitsAP windowNon-Ionic 135ml maximumCOMMENTS:1.2.3.4.5.6.THE NECK SHOULD BE HYPEREXTENDED.THE PATIENT SHOULD BE INSTRUCTED NOT TO SWALLOW DURING IMAGING.A SMALL FOV (200mm) FOR LARYNX ONLYREMOVE DENTAL WORK IF POSSIBLE.THIS STUDY DONE IN CONJUNCTION WITH A NECK STUDYPHONATION (“E”) CAN BE USED FOR DISTENDING THE PYRIFORM SINUSES, SUPRAGLOTTIC TUMOR AROUND THE SINUSES,AND EPIGLOTTIC ZED VOCAL CORD, HOARSENESSAx (Bone)1X1W/OAX BONESag (Bone)1x1W/OSAG BONECor (Bone)1x1W/OCOR BONEAX (Soft)1x1W/OAX SOFTSag (Soft)1x1W/OSAG SOFTCor (Soft)1x1W/OCOR SOFT

NECK FOR PRIMARY HYPERPARATHYROIDISMREGION OF INTEREST:SCOUT:PHASE OF RESPIRATION:SLICE THICKNESS:SLICE INTERVALSUPERIOR EXTENT:INFERIOR EXTENT:INTRAVENOUS CONTRAST:NECK AND MEDIASTINUMLATERAL OR A/P. BOTH IF NEEDED“STOP BREATHING, DON’T BREATHE OR SWALLOW “3 mm3 mm (Coronal/Sagittal MPR)Mid OrbitsCarinaNON-IONIC – 75 ml or 135 ml maximum if orderedScan 1: W/O contrastScan 2: 25 sec DelayScan 3: 80 sec DelayComments: SAGITTAL AND CORONAL REFORMATS REQUIRED.INDICATION: Parathyroid Adenoma, Ectopic parathyroid gland, 3x3W/OAXAx3x3WITHAX CSag (Bone)2x2W/OSAG BONECor (Bone)2x2W/OCOR BONESag (Soft)2x2W/OSAG SOFTCor (Soft)2x2W/OCOR SOFT

NECK AND MEDIASTINUMREGION OF INTEREST:SCOUT:NECK AND MEDIASTINUMLATERAL AND A/P IF NEEDEDPHASE OF RESPIRATION:“STOP BREATHING, DON’T BREATHE OR SWALLOW “SLICE THICKNESS:3 mmSLICE INTERVAL3 mm (Coronal/Sagittal MPR)SUPERIOR EXTENT:Mid OrbitsINFERIOR EXTENT:AP WindowINTRAVENOUS CONTRAST:NON-IONIC – 75 ml or 135 ml maximum IF STONE SUSPECTED DO W/WO STUDYALL SWELLING, MASS OR OTHER PALPABLE AREAS NEED MARKED OR DOCUMENTED NOT ABLE TO PALPATE.NECK SOFT TISSUE SHOULD ALWAYS BE DONE WITH IV CONTRAST TO DIFFERENTIATE BETWEEN LYMPH NODES ANDVESSELS.45 SECOND DELAYFOR VOCAL CORD PARALYSIS; INFERIOR ASPECT OF SCAN; AP WINDOW/BRONCHI (see Larynx CK PAIN/SWELLING, DIFFICULTY SWALLOWING, NECK MASS, SALIVARY STONEAx3x3W/OAXAx3x3WITHAX CSag (Bone)3x3W/OSAG BONECor (Bone)3x3W/OCOR BONESag (Soft)3x3W/OSAG SOFTCor (Soft)3x3W/OCOR SOFT

TRAUMA SPINEREGION OF INTEREST:CONTRAST:INSPIRATION:SLICE THICKNESS:SLICE INTERVAL:SUPERIOR EXTENT:INFERIOR EXTENT: CERVICAL, THORACIC, AND LUMBARNo oral or IVQUIET BREATHING2 mm2 mmAPPROX, 1 ½ - 2-disc spaces ABOVE AREA OF CONCERNAPPROX. 1 ½ - 2-disc spaces BELOW AREA OF CONCERN* Usually entire spineSCAN CONTINUOUS THROUGH AREA OF INTEREST.Reconstruction:o Axial – Bone & Soft tissueo Coronal – Boneo Sagittal – Bone & Soft tissueMPR’S ARE DONE IN BONEOff Axial Reformat (follow the spine, not the table)3D IMAGES ARE TO BE DONE IF ORDERED ON SCRIPT OR AT RADIOLOGISTS MA, PAIN, FRACTUREAx (Bone)2x2W/OAX BONESag (Bone)2x2W/OSAG BONECor (Bone)2x2W/OCOR BONEAx (Soft)2x2W/OAX SOFTSag (Soft)2x2W/OSAG SOFT

SPINE NON-TRAUMA (CERVICAL, THORACIC, AND LUMBAR)REGION OF INTEREST:CONTRAST:SCOUTS:SLICE THICKNESS:SLICE INTERVAL:SUPERIOR EXTENT:INFERIOR EXTENT: SPINE, CERVICAL, THORACIC, LUMBARNo oral or IVLATERAL & AP IF NEEDED2 mm2 mmAPPROX, 1 ½ - 2-disc spaces ABOVE AREA OF CONCERNAPPROX. 1 ½ - 2-disc spaces BELOW AREA OF CONCERNUSE PILLOW OR PAD UNDER KNEE FOR LUMBAR TO DECREASE ANGULATION OF L5-S1.ADULT OR CHILD WITH HISTORY OF SPONDYLOLYSIS DO L3-S1DISCOGRAM STUDIES START JUST ABOVE CONTRAST IN DISC AND END JUST BELOW CONTRAST.Off Axial Reformat (follow the spine, not the table)3D IMAGES TO BE DONE ON SPINES IF ORDERED ON SCRIPT OR REQUESTED BY RADIOLOGISTS.Reconstruction: Axial, Sagittal, & Coronal – Soft Tissue and BoneINDICATION:SliceScanSeriesDescription21BACK PAIN, SPONDYLOSIS, SPINAL STENOSISAx (Bone)2x2W/OAX BONESag (Bone)2x2W/OSAG BONECor (Bone)2x2W/OCOR BONEAx (Soft)2x2W/OAX SOFTSag (Soft)2x2W/OSAG SOFTCor (Soft)2x2W/OCOR SOFT

HEAD CT With & Without PERFUSIONREGION OF INTEREST:IV CONTRAST:SLICE THICKNESS:BRAIN AND VESSELS IF ORDEREDISOVUE 370 VISIPAQUE 320 OMNI 3505 MM CONES 8i CINE 1 SECOND SCAN X 45-50 SECONDSFOR PERFUSION IMAGES 700 IMAGESPROCEDURE: Scan must be completed and dictated within 45 minutes of order. (1) Routine head without iv contrast for most code stroke orders. If MDwants WITH AND WITHOUT study Perfusion and Angio1. Routine head without (2) Angio head using no more than 100 ml of contrast. (3) Perfusion head study using 50 ml of contrast. (4) Reprocess headfrom Angio to regular head or brain cuts (5MM).2. Send Angio Head images and 700 perfusion head images to workstation. Work up angio brain and then work up perfusion images.3. Send Head without, Reprocessed head with, and finished perfusion 4-5 images to PACS don’t send all of perfusion raw images to PACS.4. Contrast is injected at 4-5ml second (follow angio protocol rates for perfusion study) use 150 ml of contrast 100ml on angio then use 50ml onPerfusion study.5. Work up Procedure for Perfusion6. Click Perfusion images7. Pick Perfusion 38. 3 Click on CT Perfusion (2nd) box9. Apply Registration10. Next11. Adjust thresholds air and bone12. Next13. Create ellipse ROI adjust to size and put over artery Next14. Same as above on vein put 2 additional ROI in brain tissue Next Adjust post enhancement images move back one number Next15. Compute, close and save images 4 in all send to PACS22

CTA HEAD WO & WITH (Angiography 3D)REGION OF INTEREST:INTRAVENOUS CONTRAST:SCOUT:RESPIRATION:SLICE THICKNESS:RECONSTRUCTION:SUPERIOR EXTENT:INFERIOR EXTENT:CIRCLE OF WILLIS135 ml max of ISOVUE 370AP & LATERAL if needed.QUIET BREATHING IN HEAD HOLDER1 x 1 mm1 x 1 mmTOP OF HEADBASE OF SKULL. Bolus tracking region of interest in Aortic archReconstruction:Axial, Sagittal, and Coronal 1 mm with separate FOV limited to head and neckAxial, Sagittal, and Coronal MIP for head STUDY DONE WO/W IVAcute Stroke: If Non-contrasted head has already been complete it does not need OWN ANEURYSM, STROKE, CIRCULATORY DISEASEAx1x1W/OAXAx1x1WITHAX CSag1x1WITHSAG CCor1x1WITHCOR CAx MIP HeadSag MIP HeadCor MIP HeadWITHAX MIPHEAD CWITHSAG MIPHEAD CWITHCOR MIPHEAD C

CT ANGIOGRAPHY OF THE CAROTIDSREGION OF INTEREST:ORAL CONTRAST:INTRAVENOUS CONTRAST:SUPERIOR EXTENT:INFERIOR EXTENT:POST PROCESSING:CAROTIDSNONENon-Ionic 135 ml maximumThe bolus tracking region of interest in the Aortic arch.AP & LATERAL IF NEEDEDStop breathing1 mm1 mm for Axial, Sagittal, & CoronalSagittal & Coronal MIPsJUST INFERIOR TO THE CIRCLE OF WILLIS.AORTIC ARCH AT ORIGIN OF GREAT VESSELS.SAGITTAL AND CORONAL REFORMATS.INDICATION:CAROTID STENOSIS, STROKESCOUT FILM:PHASE OF RESPIRATION:SLICE THICKNESS:RECONSTRUCTION:SliceScanSeries Description24Ax1x1W/OAXAx1x1WITHAX CSag1x1WITHSAG CCor1x1WITHCOR CSag MIP NeckCor MIP NeckWITHSAG MIP NECK CWITHCOR MIP NECK C

CTV HEAD W CONTRASTREGION OF INTEREST;ORAL CONTRAST;SCOUT/TOPOGRAM;INTRAVENOUS CONTRAST;SLICE THICKNESS;SLICE INTERVAL;RECONSTRUCTION;COMMENTS;ENTIRE BRAIN, VEINSNONELATERALNon-Ionic 100ml maximum1 mm1 mm1 mm for Axial, Sagittal, & CoronalSagittal & Coronal MIPsMRV OF THE HEAD IS PREFERRED BY RADIOLOGISTINDICATION:DURAL SINUS THROMBOSISAxAxSagCorAx MIP HeadSag MIPHeadCor HWITHSeriesDescriptionAXAX CSAG CCOR CAX MIPHEAD CSAG MIPHEAD CCOR MIPHEAD C25

STEALTH BRAIN CTREGION OF INTEREST:CONTRAST:SCOUT IMAGES:PATIENT POSITION:HEAD HOLDER USED.SLICE THICKNESS:SUPERIOR EXTENT:INFERIOR EXTENT:ENTIRE HEAD INCLUDING SOFT TISSUENon-IonicLATERALSUPINE, HEAD IS FLAT AND STRAIGHT. NO ANGLED. SPONGE IF SURGICAL2 X 2 mm with NO ANGLEABOVE SKIN AND FIDUCIALS (MARKERS)BELOW BASE OF SKULLCOMMENTS: 1-3 IS DONE BY SURGERY!1.2.3.4.5.6.PT NEEDS 10 FIDUCIAL MARKER IN RANDOM ON HD, 2 WILL BE OVER TUMOR (REFER TO PREVIOUS EXAM)PT NEEDS TO HAVE 10 SMALL AREAS OF HAIR SHAVED THEN CLEAN SKIN WITH ALCOHOL PREP PAD. APPLY FIDUCIALSAND PUT A BLACK DOT IN the CENTER WITH MAGIC MARKER.GIVE PATIENT A SURGERY CAP AND SENT PATIENT EITHER TO SURGERY OR ROOM. FADUCIALS MUST STAY ONPATIENT.SEND AXIAL IMAGES TO THE STEALTH MACHINE.MAKE SURE SURGERY HAS STEALTH TURNED ON PRIOR TO STUDY.DO NOT SHAVE ENTIRE HEAD.INDICATION:SliceScanSeries Description26BRAIN TUMORAx2x2W/OAXAx2x2WITHAX C

Adrenal Washout Oral Contrast: NoneIV Contrast:o Rate: 3cc/seco HyperlinkScan Range: Above dome of liver to iliac crestTiming: Without, 75 seconds and 15 minSlice (mm)ScanSeries Description 3x3w/oAXAx3x375 secAX C3x315 minAX DEL3x3w/oCORCor3x375 secCOR C3x315 minCOR DEL3x3w/oSAGSag3x375 secSAG C3x315 minAX DELReconstructions:All scans, all phases are to be reconstructed in three planes: axial, coronal, sagittal lined up with the patient (not the table) using a 3 mm slicewidth (or 3.75 mm if the scanner cannot create 3 mm) and 3 mm slice increment. If the patient is lying oblique (RPO or LPO) on the table,sagittal and coronal images must be aligned with the patient.27

CT Urogram: 2 Phase with Furosemide Ask about allergies to Lasix or sulfa drugs. If yes, skip to without furosemide protocol.Patients who are receiving hydration for GFR may still receive Lasix.Preparation for Scan:o For patients without fluid restrictions: Oral: water 3 (12 oz) cups over 45 to 60 minutes 1080 mL total (if fluids restricted see next bullet point). This can be done prior to arrival indepartment.o For people with fluid restrictions: If receiving Lasix and can walk one block without shortness of breath, may give 150cc NS before entering the CT suite. You will still give the100ml of normal saline listed below. This is a total of 250 mL of normal saline administered.**Split administration of bolus** Administer normal saline 100 ml IV. Administer furosemide 10 mg IV. Scan abdomen without. Administer 1/2 of the Isovue 370 at 2 ml/sec IV Wait 6 minutes Administer 1/2 of the Isovue 370 at 2 ml/sec Wait 2 minutes Scan abdomen. Use 100 kVp or less, if possible. Reconstructions:o All scans, all phases are to be reconstructed in three planes: axial, coronal, sagittal lined up with the patient (not the table) using a 3 mm slice width (or3.75 mm if the scanner cannot create 3 mm) and 3 mm slice increment. If the patient is lying oblique (RPO or LPO) on the table, sagittal and coronalimages must be aligned with the patient.SliceScanSeries Description28AxAxCorCorSagSag3x3W/OAX3x3WithAX C3x3W/OCOR3x3WithCOR C3x3W/OSAG3x3WithSAG C

CT Urogram: 2 Phase without Furosemide (Note longer delay and dosing change 1/3 early, 2/3 later compared to Lasix protocol)Preparation for scan.o For patients without fluid restrictions: Oral water 3 (12 oz) cups over 45 to 60 minutes 1080 mL total For people with fluid restrictions: No oral or IV fluid.** Split administration of bolus** Scan abdomen without.Administer 1/3 of the Isovue 370 at 2 ml/ sec IV.Wait 8 minutesAdminister 2/3 of the Isovue 370 at 2 ml/secWait 2 minutesScan abdomen. Use 100 kVp or less, if possibleReconstructions:o All scans, all phases are to be reconstructed in three planes: axial, coronal, sagittal lined up with the patient (notthe table) using a 3 mm slice width (or 3.75 mm if the scanner cannot create 3 mm) and 3 mm slice increment. Ifthe patient is lying oblique (RPO or LPO) on the table, sagittal and coronal images must be aligned with thepatient.SliceScanSeries Description29AxAxCorCorSagSag3x3W/OAX3x3WithAX C3x3W/OCOR3x3WithCOR C3x3W/OSAG3x3WithSAG C

CT Abdomen and Pelvis with Contrast (Trauma) Ask patient if they have hematuria.Contrast:Rate: 3 ml/secScan abdomen and pelvis at 70 secondsIf patient has hematuria or if the CT technologist sees kidney injury on 75 second scan, scan abdomen and pelvis at 8-10 minutes.Reconstructions:o All scans, all phases are to be reconstructed in three planes: axial, coronal, sagittal lined up with the patient (not the table)using a 3 mm slice width (or 3.75 mm if the scanner cannot create 3 mm) and 3 mm slice increment. If the patient is lying oblique (RPOor LPO) on the table, sagittal and coronal images must be aligned with the patient.SliceScanSeries Description30Ax3x375 secAX CAx3x3DelayDELCor3x375 secCORCor3x3DelayCOR DELSag3x375 secSAGSag3x3DelaySAG DEL

CT Abdomen and Pelvis without and with (Acute GI Bleeding) Scan abdomen and pelvis without contrast media firstContrastRate: 4ml/secScan abdomen and pelvis at 35 secondsScan abdomen and pelvis at 90 secondsReconstructions:o All scans, all phases are to be reconstructed in three planes: axial, coronal, sagittal lined up with the patient (not the table) using a 3mm slice width (or 3.75 mm if the scanner cannot create 3 mm) and 3 mm slice increment. If the patient is lying oblique (RPO orLPO) on the table, sagittal and coronal images must be aligned with the x3W/OCORSag3x3W/OSAGAx3x335 secAX EARLYARTERIALAx3x390 secAX PORTALVENOUSCor3x335 secCOR EARLYARTERIALCor3x390 secCORPORTALVENOUSSag3x335 secSAG EARLYARTERIALSag3x390 secSAGPORTALVENOUS

Cystogram 20 ml of Isovue 370 in 500 ml saline bag (do not remove any saline from bag)Scan Range: Top of bladder to below perineumFull bladderAxCorSagSlice3x33x33x3Series DescriptionAX CCOR CSAG CAxCorSagSlice3x33x33x3Series DescriptionAX DELCOR DELSAG DELPost void:Reconstructions:o All scans, all phases are to be reconstructed in three planes: axial, coronal, sagittal lined up with the patient (not the table) using a 3mm slice width (or 3.75 mm if the scanner cannot create 3 mm) and 3 mm slice increment. If the patient is lying oblique (RPO orLPO) on the table, sagittal and coronal images must be aligned with the patient.32

Enteroclysis: Procedure: Nasojejunal tube placed in fluoroscopy and small bowel infused with negative contrasto Some sites will infuse positive contrast.IV Contrast: optionalo Rate: 3cc/secScan Range: Dome diaphragm to pubic symphysisSliceSeries Description Ax3x3AX CCor3x3COR CSag3x3SAG CReconstructions:o All scans, all phases are to be reconstructed in three planes: axial, coronal, sagittal lined up with the patient (not the table) using a 3 mmslice width (or 3.75 mm if the scanner cannot create 3 mm) and 3 mm slice increment. If the patient is lying oblique (RPO or LPO) on thetable, sagittal and coronal images must be aligned with the patient.33

Enterography Patient Prep: Clear liquids after midnight.Oral Contrast: 450 ml volume (or local negative contrast agent) 60, 45 and 30 min prior to scan. 500 ml water 15 min prior to scan, if patient cantolerate.IV Contrast:Rate: 3mL/secTiming: 70 secScan Range: Dome diaphragm to pubic symphysisAxCorSagSlice3x33x33x3Series DescriptionAX CCOR CSAG CReconstructions:o All scans, all phases are to be reconstructed in three planes: axial, coronal, sagittal lined up with the patient (not the table) using a 3 mmslice width (or 3.75 mm if the scanner cannot create 3 mm) and 3 mm slice increment. If the patient is lying oblique (RPO or LPO) on thetable, sagittal and coronal images must be aligned with the patient.34

Liver (Multi-Phase) IV Contrast: .65 ml/pound with 135 ml maxo Rate 4 cc/seco Saline flush: 50 ml at 4 cc/seco IV access: 20 gauge or largerScan Range: Above dome of liver to iliac crestReconstructions:o All scans all phases are to be reconstructed in three planes: axial, coronal, sagittal lined up with the patient (not the table) using a3mm slice width (or 3.75 mm if the scanner cannot create 3 mm) and 3 mm slice increment. If the patient is lying oblique (RPO or LPO)on the table, sagittal and coronal images must be aligned with the patient.Pelvis: If a pelvis is ordered, please go through the pelvis on the 75 second (Portal Venous phase) only.If order includes Chest (i.e. Chest/Abdomen/Pelvis) scan times can be 25 sec / 75 sec / and 5-minute delay, if scanner cannot accommodate 35 sec.If patient is status post Interventional Radiology ablation therapy, then also ADD CT WITHOUT through the same area.SliceScanSeries Description3x335 sec or BolusAX LATEARTERIALAx3x375 sec orBolusAXPORTALVENOUS3x335 sec or BolusSAG LATE ARTERIAL Without Bolus TrackerScan abdomen at 35 seconds (arterial phase)Scan abdomen at 75 seconds (portal phase)Scan abdomen at 5 minutes (delayed phase)353x35 min or Bolus3x335 sec or BolusCor3x375 sec or BolusAX DELCORLATEARTERIALCORPORTALVENOUSSag3x375 sec or BolusSAG PORTAL VENOUS3x35 min or BolusCORDEL3x35 min or BolusSAG DELWith Arterial Bolus TrackerPlace Tracker at aorta at the diaphragms18 seconds after tracker reaches 120 HU, scan abdomen (arterial phase)48 seconds after tracker reaches 120 HU, scan abdomen (portal phase)5 minutes after tracker reaches 120 HU, scan abdomen (delayed phase)

Pancreas Oral Contrast: WaterIV Contrast: .65 ml/pound with 135 ml maxRate: 4 - 5cc/sec.Scan at 40 and 80 sec.Scan Range: Above dome of liver to iliac crestAxAxCorCorSagSagSlice3x33x33x33x33x33x3Scan40 sec80 sec40 sec80 sec40 sec80 secSeries DescriptionAX EARLYARTERIALAX PORTALVENOUSCOR EARLYARTERIALCOR PORTALVENOUSSAG EARLYARTERIALSAG PORTALVENOUS Recons

Chest o Chest/Abdomen/Pelvis (Routine) 43 o Chest with or without contrast (Routine) 44 o High Resolution Chest 45 o Chest Angio Protocol (PE) 46 o Coronary Artery Calcium Score 47 o Cardiac (Heart) Score (coronary artery or pulmonary vein) 48 Overread (Addendum) o Aortic Dissection – Chest w/o & CTA