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Abdominal CT Attenuation

This document discusses how computed tomography (CT) uses x-ray attenuation to provide information about tissue densities and characterize different structures and pathologies seen on abdominal CT scans. It explains that denser tissues block more x-rays, appearing brighter on scans. Attenuation is measured using Hounsfield units (HU). Common uses of HU measurements include distinguishing simple from complex fluids, characterizing fatty masses, and diagnosing fatty liver disease. The document provides examples to illustrate each concept.

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Yahya Salman
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68 views1 page

Abdominal CT Attenuation

This document discusses how computed tomography (CT) uses x-ray attenuation to provide information about tissue densities and characterize different structures and pathologies seen on abdominal CT scans. It explains that denser tissues block more x-rays, appearing brighter on scans. Attenuation is measured using Hounsfield units (HU). Common uses of HU measurements include distinguishing simple from complex fluids, characterizing fatty masses, and diagnosing fatty liver disease. The document provides examples to illustrate each concept.

Uploaded by

Yahya Salman
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Abdominal CT:

Attenuation
Michael P Hartung and Mike Cadogan ●
Apr 3, 2023

HOME MEDICAL SPECIALTY RADIOLOGY

Measuring attenuation
The density of a structure determines how well it
blocks x-rays from reaching the detector, which
determines its appearance on CT. Dense
structures like bone or contrast block more x-rays
and appear bright, whereas structures like air and
fat appear darker, even black, because they do
not block as many x-rays.

We can use attenuation to interrogate the images


for fluid, masses and fatty infiltration

The ability to block x-rays is also referred to as


attenuation, where high attenuation structures
appear brighter and low attenuation structures
appear darker.

Attenuation is represented both by the grey scale


appearance in the image and a numerical value
that you can measure. This value is called the
Hounsfield unit (HU). The higher the number, the
more x-rays the structure blocks. So, a high
attenuation structure like bone will have a higher
HU value than low attenuation structures like fat
or air.

Hounsfield Scale for different kinds of tissues (adapted


from Institut für Anatomie, Universität Bern) de
Alcântara et al

By drawing a region of interest (ROI) over the


structure, you can obtain the attenuation value
and more precise information about the
structure’s density. This can be thought of as a
radiology magnifying glass.

By convention, two structures are assigned values


that are used to calibrate all of the other values:

Air is –1000 HU
Water is 0 HU

Since water is the zero point, it can be used as the


starting point to characterize other fluid types. For
instance, a simple fluid such as ascites is within
the range of 0–20 HU, whereas a complex fluid
like blood, which might occur with trauma, is
within the range of 30–70 HU.

How do we use attenuation to


detect abnormalities?
We can use attenuation to interrogate the images
for fluid, masses and fatty infiltration

Fluid

Example 1: Fluid and attenuation

In the CT scan below, the pelvic fluid measures 10


HU. From this, we can infer the accumulation of a
simple fluid in the abdomen, also known as
ascites, which is commonly associated with
cirrhotic liver disease.

Simple fluid: Ascites

Example 2: Complex fluid and attenuation

In the next example, the fluid around the liver and


spleen has been measured to be 45 HU. This is
higher than simple fluid and indicates complex
fluid. Because this patient is presenting with
trauma, this fluid is suspicious for blood
products due to an intraabdominal injury,
prompting a careful review of the images to look
for the source of the bleeding.

Complex fluid: blood products due to an


intraabdominal injury

Masses

In addition to checking the fluid, measuring


attenuation can also be useful for masses. When
characterising adrenal, kidney, or ovarian masses,
you can check the attenuation value for fat or
enhancement. This can help determine if a lesion
is benign or possibly cancerous

Example 3: Ovarian mass

Below is an example of an ovarian mass. If we


draw a region of interest circle over the darkest
part of the mass, the attenuation measures –100
HU, which is consistent with fat. This information
helps us to confidently give the diagnosis of a
benign fat-containing mass of the ovary called a
mature teratoma.

Mass: Mature teratoma

Example 4: Renal mass

Non-contrast CT image from a patient with a large


mass in the left kidney. We want to look for
vascular flow which would indicate that it is not a
cyst and may be cancerous. To determine this,
you will need to acquire images both before and
after the patient is given contrast to see whether
the mass shows enhancement, which means it
should get brighter after contrast is given. As
contrast is carried by the blood, enhancement
would indicate blood flowing into the mass.

Mass: Renal mass

When we zoom in on the mass, we can see that


the density is variable, and coming to a diagnosis
using visual comparison may be challenging.
Checking the HU may help. By drawing a region of
interest over the mass in the same area on both
images, the HU value indicates increased
enhancement with contrast.

By subtracting the non-contrast HU value from


the post-contrast HU value, you can determine a
difference in perceived enhancement (i.e.,
brightness) with more accuracy.

If we subtract the non-contrast value of 30 HU


from the post-contrast value of 65 HU, we can
calculate an increase in brightness of 35 HU. An
increase of 20 HU or more generally means you
can be sure it is truly enhancing. Thus, we can say
that this is an enhancing mass and that it might be
cancerous, needing further evaluation such as a
biopsy.

Fatty infiltration

The evaluation of fatty infiltration of the liver is


another useful application of attenuation values.
This involves a comparison of the liver and spleen
and is most reliable on non-contrast images.

Example 5: Fatty infiltration

Non-contrast image showing the liver and the


spleen. By drawing a region of interest on both
structures, you can use the HU values to
determine the amount of fat in the liver tissue.

Non-contrast abdominal scan: fatty liver disease

For this you can consider two cutoff points that


indicate fat infiltration:

If the liver measures less than 40 HU


If the liver measures less than the spleen by at
least 10 HU

Note: this comparison only works on a non-


contrast CT.

In the example above, the liver measures 8 HU


and the spleen measures 50 HU. We know that 8
HU is less than 40, and 8 HU is 42 HU less than
the spleen. Therefore, both cutoffs have been
met, and you can confidently diagnose fatty liver
disease or hepatic steatosis.

This is an edited excerpt from the


Medmastery course Abdominal CT
Essentials by Michael P. Hartung, MD.
Acknowledgement and attribution to
Medmastery for providing course transcripts
for #FOAMed delivery.

Hartung MP. Abdominal CT Essentials.


Medmastery

References
Top 100 CT scan quiz. LITFL

Radiology Library: Abdominal CT Basics


Hartung MP. What is the role of Abdominal CT?
LITFL
Hartung MP. Abdominal CT: Basics. LITFL
Hartung MP. Abdominal CT: Common Terms.
LITFL
Hartung MP. Abdominal CT: Planes. LITFL
Hartung MP. Abdominal CT: Measuring
attenuation. LITFL
Hartung MP. Abdominal CT: Windows settings
(basics). LITFL
Hartung MP. Abdominal CT: Windows settings
(advanced). LITFL

Abdominal CT interpretation

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Michael P Hartung

Assistant Professor of Abdominal Imaging and


Intervention at the University of Wisconsin
Madison School of Medicine and Public Health.
Interests include resident and medical student
education, incorporating the latest technology
for teaching radiology. I am also active as a
volunteer teleradiologist for hospitals in Peru
and Kenya. | Medmastery | Radiopaedia |
Website | Twitter | LinkedIn | Scopus 

Mike Cadogan

Associate Professor Curtin Medical School,


Curtin University. Emergency physician MA
(Oxon) MBChB (Edin) FACEM FFSEM Sir
Charles Gairdner Hospital.  Passion for rugby;
medical history; medical education; and
asynchronous learning #FOAMed evangelist.
Co-founder and CTO of Life in the Fast lane |
Eponyms | Books | Twitter |

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