CT Accreditation Program Clinical Image Quality Guide

CT Accreditation Program
Clinical Image Quality Guide
INTRODUCTION ................................................................................... 2
BASIC ASSUMPTIONS ........................................................................ 2
CT ACCREDITATION DOSE REQUIREMENTS .................................. 3
CT EVALUATION CATEGORIES ......................................................... 4
ADULT HEAD/NECK MODULE ............................................................ 7
ADULT CHEST MODULE ................................................................... 10
ADULT CARDIAC MODULE ............................................................... 16
ADULT ABDOMEN MODULE ............................................................. 23
PEDIATRIC STUDIES ........................................................................ 31
PEDIATRIC HEAD/NECK MODULE ................................................... 32
PEDIATRIC CHEST MODULE ........................................................... 38
PEDIATRIC CARDIAC MODULE ....................................................... 41
PEDIATRIC ABDOMEN MODULE ..................................................... 43
This document is copyright protected by the American College of Radiology. Any attempt to reproduce, copy, modify, alter or otherwise change or use this document without the
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INTRODUCTION
Read this entire document carefully. This document provides guidance for interpreting physicians and
technologists on the criteria evaluated by reviewers for the accreditation program. Although all
interpreting physicians performing CT must assume responsibility for the quality of images produced by
the facility, the primary responsibility for image quality and for implementing an effective QA program
belongs to the lead interpreting physician. The lead interpreting physician must understand the
program and demonstrate an interest in the results. Successful facilities are often those where the
staff’s commitment to high quality is a reflection of the interests of the lead interpreting physician.
Criteria for quality image evaluation are continual and should be critiqued on a routine basis.
Some of the examinations are considered “specialty” examinations, and these are marked with an
asterisk (*) in the Examination Specific Parameters section of this document.
Prior to submission of any images for evaluation, the interpreting physicians and technologists at your
facility must review the accreditation criteria contained in this document. Note: Although some
aspects of CT examinations are requirements for accreditation, other aspects in this document
are only intended as a guide. We realize that each facility will have its own protocols. Your own
exam protocols should be used for images submitted for accreditation purposes. Technique
factors should be consistent with your written protocols. However, all protocols should stress
the importance of keeping radiation doses as low as reasonably achievable (ALARA).
BASIC ASSUMPTIONS
It is presumed that the images submitted by the facility are the best available. The facility should
take sufficient interest in the accreditation process to have the submitted films selected by an individual
who is knowledgeable about image quality. As a practical manner, the ACR recognizes that in some
cases images may be of adequate diagnostic-quality but are less than optimal. For example, body
habitus or patient cooperation may limit the ability to maximize image quality. However, the intention of
accreditation is to provide guidelines on what constitutes optimal image quality above that which is
normally acceptable and to promote the best practice at all times.
Every unit must apply for all patient types performed on that unit and modules routinely
performed on that unit for a facility to be accredited.
Facilities cannot submit examinations performed on models or volunteers. The images submitted
for each individual examination must be from the same patient (i.e., all brain images must be from the
same brain study).
Note: The purpose of the accreditation evaluation is to review the quality of the practice of MRI
at applicant facilities and not to comment on abnormal findings. The ACR is not responsible for
clinical findings shown on the images. Submitting abnormal examinations except when
specified may significantly delay the accreditation process.
CT ACCREDITATION DOSE REQUIREMENTS
In order to be accredited with the ACR, a CT unit must pass both the clinical and phantom image
quality tests. The phantom will fail (and, the unit will fail ACR accreditation) if the dose from the CT unit
exceeds the pass/fail criteria. The facility must repeat the entire phantom portion of the accreditation
testing, and pass, for the unit to be granted accreditation.
ACR CT Accreditation Dose Pass/Fail Criteria and Reference Levels:
Pass/Fail Criteria Reference Levels

Examination CTDIvol (mGy) CTDIvol (mGy)
Adult Head 80 75
Adult Abdomen 30 25
Pediatric Abdomen (5 year 25 20
old)
All sites applying for CT accreditation must comply with CT dose pass/fail criteria established by the
ACR Committee on CT Accreditation. The CT Accreditation Program also revised their reference
levels.
Reference levels help identify situations where doses are above expected values and should be
investigated. Units exceeding these reference levels (but remaining below the pass/fail criteria) will not
fail accreditation. However, even if the unit is granted accreditation, the ACR will strongly urge the
facility to consult with its medical physicist to determine if it is possible to reduce the examination dose
without sacrificing image quality.
These new pass/fail criteria and reference levels are based on a detailed analysis of the dose data and
image quality collected during the first three years of the accreditation program. The new requirements
and recommendations consider the amount of radiation necessary for adequate image quality.
Because multislice CT scanners are more prevalent since the accreditation program started, the new
dose criteria and levels also incorporate a more appropriate dose descriptor (CTDIvol). These changes
help facilities reduce unnecessary radiation dose to patients undergoing CT examinations while still
maintaining sufficient radiation levels necessary for appropriate diagnoses.
It is important to be aware that there may be significant differences between the dose estimates
reported by some CT scanners for pediatric scans and what is actually measured using pediatric
dosimetry phantoms. Depending on the field of view selected, the scanner may assume an adult-size
phantom, which is 32 cm in diameter; the pediatric phantom is 16 cm in diameter. This assumption
results in a dose estimate that is approximately 2.4 times lower for a pediatric study than the same
scan technique would actually produce in a pediatric phantom. In general, pediatric abdomen
techniques should be reduced by approximately a factor of 3 to achieve similar image quality to an
adult abdomen scan.
Currently, there is no reference level or pass/fail criterion for Pediatric Head. Data from this
portion of the phantom submission will be used in the future to create a reference level and
pass/fail criterion for this examination.
CT EVALUATION CATEGORIES
The categories for scoring examinations submitted for ACR CT Accreditation are:
A. Technique Parameters
B. Anatomic Coverage/Display
C. Filming Technique (for hard copy film submissions only)
D. Artifacts
E. Examination Identification: Missing Information
F. Examination Protocols
Criteria for categories C, D, E and F (filming technique, artifacts, examination identification and
examination protocols) apply generically to both specialty and basic exams, and are thus listed first in
this document. Descriptions of evaluation criteria specific to Categories A and B (technique parameters
and anatomic coverage and display) for each examination follow in the examination specific criteria
section of this document.
Category C: Filming Technique (Hard copy submission only)
 Images must be photographed large enough to be evaluated.
 Films must be formatted at no more than 20 on 1 for a 14 x 17 film. (For high resolution chest
CT and pulmonary embolism and all cardiac examinations formats no greater than 12 on
1 should be used.)
 Each image should be numbered sequentially and photographed in anatomic order.
 The films may also be numbered sequentially with a grease pencil or stick-on label, but this is
not a requirement.
 There should be no missing images or images photographed out of numerical sequence.
 If applicable, non-contrast scans should be photographed in sequence separate from contrast-
enhanced scans.
 Delayed scans should also be photographed in a separate series in anatomic order.
 The overall film density should be appropriate to display anatomic structures.
 Gaps in the alphanumeric information may suggest that the density is set too low, while loss of
definition or blooming may suggest density is set too high.
 The film should not exhibit variation in density across the film or between individual films.
 There should be no areas of the film where the images or alphanumerics appear blurry.
 Two digital scout (topogram, etc.) images must be included for each study: one of which should
be annotated.
 The digital scout radiograph should be displayed either as an image the same size as the axial
images or in a larger format.
 It may be on the same film as the axial images or on a separate film. The scan locations (as
indicated by an image number or location) should be displayed on the scout radiograph.
 The films should be free of fog, roller marks or other artifacts.
Category D: Artifacts
 The images should be free of artifacts that would hinder interpretation. If such artifacts are
present, images should be repeated.
 The repeated images may be inserted in the sequence of images either after the images
containing artifacts or at the end of the series.
 Motion artifacts that result in indistinct or "double" contours to organs should be repeated if they
significantly degrade the exam quality on multiple sections.
 Misregistration is more difficult to quantitate, but if it appears to result in more than a 2-cm gap
in anatomic coverage, images should be repeated in the area of the gap.
 The image should not appear visually grainy; if graininess is present it may be a function of
insufficient exposure or the combination of exposure, window width/level, and film density.
 Streak artifacts that compromises diagnostic quality with sections not repeated would be a
deficiency. If streak artifacts are present, the images should have been repeated after
attempting to eliminate the cause of the artifact (such as overlying lines or metallic devices).
 In some cases, internal metallic surgical clips are responsible for the streak artifact; if so, the
images should not be considered deficient.
Category E: Exam Identification
All labels should be easily readable and placed so they do not overlap with the relevant anatomy on the
image.
Film submission: The following exam information should be printed on films. If all of the information is
not available on the filmed images, you must include a screen print or demographics page on the films
you submit. If there are images from more than one pulse sequence on a single sheet of film, the
sequence used to obtain each image should be easily identifiable.
Electronic submission: If you are submitting your images electronically, the information should be on
the images, or readily assessable by the reviewer.
 Patient name (First and last) (Note: All patient information annotated on clinical examinations
will be kept confidential by the ACR, as stated in the Practice Site Survey Agreement.)
 Patient age (or date of birth)
 Patient identification number
 Gender of patient, date of exam
 Time of exam (this refers to the time of the first axial image acquired in helical or non-helical
mode), and institution name
 The technologist's name, initials, or other means of identifying the technologist who performed
the study should be indicated at least once on the study
 Left/right labeling
 mA
 kVp
 Pitch or rate of table feed
 Scan time (duration)
 Image number (numbered consecutively based on anatomic location)
 Series number (if applicable)
 Size (distance) scale as scored lines indicating centimeters
 Slice thickness or slice width
 Table position (scan location)
 Window width and level
 Presence or absence of contrast
 Field of view
 Reconstruction algorithm
Category F: Examination Protocol
Facilities are required to submit a copy of their scanning protocols with the images. The facility should
submit its protocols in the format that it normally uses on site, but they need to be readily
understandable by a reviewer charged with correlating those protocols with the submitted images. The
ACR does not provide forms for the site’s protocols. These protocols must be submitted on paper
(hand written or typed) with the provided label affixed to the protocol.
A typical protocol should at least include the following elements:
Indication
Scanner settings (routine kVp, mA, rotation time, etc.)
Phase of respiration
Slice thickness
Table speed (pitch)
Reconstruction algorithm
Reconstruction interval
Cranio-caudal extent
IV contrast (with injection rate and scan delay)
Necessity for preliminary non-contrast scans
It is important that scanning protocols be designed specifically to optimize visualization of pathologic

processes and take full advantage of the capabilities of the scanner in use. Protocols will vary from site
to site but still share common attributes, e.g., the need to scan prior to contrast equilibration when
evaluating the liver. The protocol should not just be a summary of the submitted examination, but
generalized, clear instructions for the technologist which describe how to perform that type of
examination.
Refer to the exam-specific technique parameters section for specific protocol requirements and
recommendations.
Your own exam protocols should be used for images submitted for accreditation purposes.
Technique factors on submitted images should be consistent with your written protocols.
However, all protocols should stress the importance of keeping radiation doses as low as
reasonably achievable (ALARA). Accredited facilities must always meet the minimum
requirements for all examinations in the Examinations Specific Parameters section below.
All items in bold and italics are accreditation requirements. Failure to

meet these requirements will result in failure.
ADULT HEAD/NECK MODULE
Adult Head (such as for headaches or to exclude neoplasm)
Technique Parameters (Items in bold and italics are accreditation requirements. Failure to meet these requirements will result in failure)
Scan Parameter Parameter Specification Comments
Required Series Unenhanced and IV
Contrast enhanced study
mAs  The mAs selected should result in diagnostic-quality images.
 Should take into account the patient’s body habitus and age, slice width, kVp, and unique attributes of the scanner
and acquisition mode.
Max.Tube Rotation Time ≤ 2 seconds
kVp 120 – 140 kVp
Collimation ≤ 6 supratentorial
≤ 5 infratentorial
Pitch (IEC definition) Between 1.0 and 1.5
Respiration Suspension N/A
Oral Contrast N/A
IV Contrast 80-150 ml  300 – 350 mg/ml non-ionic contrast for an average-size adult
 Higher or lower volumes may be used if the protocol states that the volume may be adjusted for patient weight.
Injection rate 1.5 – 3.0 ml/seconds  For routine oncologic survey exams of the head, rates in excess of 3 ml/sec are unnecessary.
(standardized)
Scan delay  Computer assisted or  Scan should be completed prior to visual evidence of near complete washout of the Circle of Willis arterial contrast.
empiric standardized  If standardized, 20 – 30 second delay
Reconstruction algorithm Standard

Reconstruction spacing
CTDIvol Reference value: 75 mGy Facilities must submit CTDIvol information on dose received by the patient on the examination submitted. Either
Pass/Fail Criteria: 80 mGy include a screen save of the dose with the images, or place the post scanning dose displayed on the Clinical Test
Image Data Sheet. The CTDIvol should be appropriate for the examination.
Anatomical Coverage/Display
Coverage Base of the skull to the vertex  Include entire head with visualization of the entire bony cranium.
Gantry tilt (reconstruction 25 degrees caudad to Reid’s  Superimpose the supraorbital ridge and the inner table of the skull at the foramen magnum along a line.
angle) base line
Display FOV Between 20 – 24 cm
Display window width/level Soft tissue and bone  Soft tissue Infratentorial WW = 80 – 140 HU WL = 35 – 50 HU
 Soft tissue Supratentorial WW = 40 – 100 HU WL = 35 – 50 HU
 Bone: WW = 2000 – 3000 HU WL = 200 – 300 HU
The submission of both soft tissue and bone windows is required. The ww/wl range is recommended
This document is copyright protected by the American College of Radiology. Any attempt to reproduce, copy, modify, alter or otherwise change or use this document without the express written permission of the American College of
Radiology is prohibited.
Adult Temporal Bones*
Parameter
Scan Parameter Comments
Specification
Required Series Axial and Coronal  With multiple detector helical scanners, coronal images may be reconstructed from axial images.
 Image quality and resolution must be similar to those acquired in the axial plane.
 There should be no more than 2 sequential series acquired through the body part.
 Should take into account the patient’s body habitus and age, slice width, kVp, and unique attributes of the scanner and
acquisition mode.
kVp 120 – 140 kVp
Collimation ≤ 2 mm
Pitch (IEC Definition) ≤1
Respiration N/A
IV Contrast medium N/A
Oral Contrast N/A
Injection rate N/A
Scan delay N/A
Reconstruction algorithm Edge or other high  Soft tissue may be used in addition to, but not instead of edge algorithm for a routine exam.
spatial frequency
CTDIvol There are no reference Facilities must submit CTDIvol information on dose received by the patient on the examination submitted if the unit is
values for this capable. Either include a screen save of the dose with the images, or place the post scanning dose displayed on the
examination Clinical Test Image Data Sheet. The CTDIvol should be appropriate for the examination.
Coverage  Axials: mastoid tip through petrous bone
 Coronals: mandibular condyles through mastoid bone
Gantry tilt Axials – angle to superimpose the base of the skull and acanthion
Coronals- gantry is angled perpendicular to the petrous bone
Scan FOV 18 – 20 cm
Display FOV Approximately 9.6 cm  Sufficient magnification to allow clear visualization of the ossicular chain and
inner ear structures
Display window Soft Tissue and bone The submission of both soft tissue and Soft Tissue: WW: 150 – 200 HU WL = 50 – 75 HU
width/level bone windows is required. The ww/wl range is recommended.
Bone: WW: 3000 – 4000 HU WL = 300 – 400 HU
Adult C-spine (Such as for trauma)*
Required Series Axial, reformatted in the sagittal  Both sagittal and coronal reformations are required.
and coronal planes
 Should take into account the patient’s body habitus and age, detector configuration, kVp, and
unique attributes of the scanner and acquisition mode.
kVp 120 – 140 kVp
Collimation ≤ 3 mm
Pitch (IEC definition) Between 1.0 and 1.5
Respiration N/A
Oral Contrast N/A
Injection rate N/A
Scan delay N/A
Reconstruction algorithm Bone
Reconstruction spacing ≤ 3 mm
CTDIvol There are no reference values for Facilities must submit CTDIvol information on dose received by the patient on the examination
this examination submitted if the unit is capable. Either include a screen save of the dose with the images, or place the
post scanning dose displayed on the Clinical Test Image Data Sheet. The CTDIvol should be
appropriate for the examination.
Coverage Cranio-cervical junction to the T1  Include the spine and immediate adjacent soft-tissues
vertebra
Gantry tilt N/A
Display FOV 14 – 16 cm  Appropriate for the patient’s body habitus to include the spine and immediate adjacent soft-
tissues.
Display window width/level Soft Tissue and Bone The Soft Tissue: WW = 450 – 650 HU WL = 80 – 100 HU
submission of both soft tissue
and bone windows is required. Bone: WW = 2000 – 3000 HU WL = 200 – 300 HU
The ww/wl range is recommended
ADULT CHEST MODULE
Adult Chest (Such as for lung cancer or cough)
Required Series IV contrast may be used, but is not required
 Should take into account the patient’s body habitus and age, slice width, kVp, and unique attributes of the scanner
and acquisition mode.
Max.Tube Rotation Time ≤ 1 second
kVp 120 – 140
Slice width ≤ 5 mm
Pitch (IEC Definition) Between 1.0 and 1.5
Respiration
IV Contrast medium 80 – 150 cc of 300 – 350  Higher or lower volumes may be used if the protocol states that the volume may be adjusted for patient weight.
mg/ml non-ionic
Oral Contrast N/A
Injection rate 2 – 4 ml/sec  For routine chest CT for staging lung cancer, rates in excess of 4 ml/seconds are unnecessary.
 Rates below 2 ml/seconds may not result in sufficient hilar and mediastinal vascular opacification, but may be
adequate in patients with diminished cardiac output, and subjective evaluation of the adequacy of hilar and
mediastinal vascular opacification based on the reference images is recommended when the injection rate falls
outside the recommended range.
Scan delay Computer-assisted or  If standardized delay is used, it should be coordinated with the contrast injection rate such that at 2 ml/sec rate, a
empiric standardized delay of 20- 45 seconds is used.
 Use shorter delay for faster rates.
 The scan should be completed prior to visual evidence suggesting that the contrast has left the hilar and mediastinal
vasculature and cardiac chambers.
 Examples of such evidence would include inability to distinguish attenuation differences between normal or enlarged
mediastinal nodes and adjacent vasculature and an inability to visualize the interventricular septum of the heart.
Reconstruction algorithm Standard (mediastinum)
or high spatial frequency
(lung parenchyma)
Reconstruction spacing  For helical scans the reconstruction interval should at least equal the slice thickness.
 Overlapping reconstructions are not necessary for helical scans but are acceptable.
 For incremental scanners, the images should be reconstructed at contiguous intervals.
CTDIvol There are no reference Facilities must submit CTDIvol information on dose received by the patient on the examination submitted if the unit is
values for this capable. Either include a screen save of the dose with the images, or place the post scanning dose displayed on the
examination Clinical Test Image Data Sheet. The CTDIvol should be appropriate for the examination.
Coverage Lung apex to below the lung bases  The site will not be penalized for extending the scan down through the adrenal glands or liver.
Gantry tilt N/A
Display FOV Edge of the patient  Not be so small that a portion of the chest wall is excluded or so large that the edge of the image
lies well beyond the edge of the patient’s body.
Display window width/ level Lung and Mediastinum The Lung: Allow adequate visualization of the lung parenchyma and intraparenchymal airways and vessels.
submission of both lung and WW = 1200 – 1500 HU WL = -550 – -700 HU
mediastinum windows is required. The Mediastinum: Allow visualization of the mediastinal and hilar vessels and allow distinction of the chest
ww/wl range is recommended wall musculature from subcutaneous fat. WW = 250 – 450 HU WL = 40 – 80 HU
Adult Aortic Dissection*
Required Series IV contrast enhance study An IV contrast series is required. Some sites perform pre-contrast scans – this is acceptable.
 Should take into account the patient’s body habitus and age, slice width, kVp, and unique attributes
of the scanner and acquisition mode.
Max.Tube Rotation Time ≤ 1second
kVp 120 – 140 kVp
Slice width ≤ 3mm
IV Contrast medium 80 – 150 cc  350 - 370 mg/ml non-ionic contrast (The facility will not be penalized if 300 -350 mg/ml is used.)
 Dense enhancement of the thoracic aorta that is sustained throughout the sequence of scans may
suggest an excessive contrast dose for the patient’s weight.
 Higher or lower volumes may be used if the protocol states that the volume may be adjusted for
patient weight.
Oral Contrast N/A  Oral contrast is not required. The site will not be penalized if oral contrast is used. If used, oral
contrast should not produce streaking artifact.
Injection rate 3 – 5 ml/sec 4 – 5 ml/sec is recommended
Scan delay Computer assisted or empiric  The scan should be completed prior to visual evidence or significant washout of intraaortic contrast.
standardized  This is best assessed in the chest by noting little or no difference between intraaortic density and
muscle attenuation.
Reconstruction algorithm Standard or soft tissue
Reconstruction spacing Should overlap at least 50% of the In situations where helical scans are reconstructed at overlapping intervals (e.g., every 1.25 mm) for
slice thickness for helical scans if cine viewing on a workstation and to obtain high-quality reconstructions, it is reasonable for every
the capability of the scanner used is second or third image to be photographed in an attempt to reduce the number of films required to
less than 64 slices. The display the entire study. If you decide to submit only every second or third image, please include a
reconstruction spacing should not letter of explanation with your submission.
exceed the collimation.
Coverage Above the aortic arch to the level of
the aortoiliac bifurcation
Gantry tilt N/A
Display FOV Should not be so small that a portion
of the aorta is excluded or so large that
edge of the image lies well beyond the
edge of the patient’s body.
Display window width/level Lung and Mediastinum The The settings should allow adequate visualization of the aortic lumen and should not display an
submission of both lung and aorta so dense that it is indistinguishable from cortical bone, or so hypodense that it is virtually
mediastinum windows is required. The indistinguishable from normal soft-tissue (i.e., chest wall musculature). The site will not be
ww/wl range is recommended penalized if a third set of windows is submitted to better visualize the aorta.
 Lung: WW = 1200 – 1500 HU WL = -550 – -700 HU
 Mediastinum: WW = 250 – 450 HU WL = 40 – 80 HU
Adult Pulmonary Embolus*
Required Series IV contrast enhanced study
 Should take into account the patient’s body habitus and age, slice width, kVp, and unique
attributes of the scanner and acquisition mode.
kVp 120 – 140 kVp
Pitch (IEC Definition) ≤1 Slices must be contiguous
Respiration
IV Contrast medium 80 – 150 ml  300 - 370 mg/ml non-ionic contrast.
 Higher or lower volumes may be used if the protocol states that the volume may be adjusted for
patient weight.
Oral Contrast N/A
Injection rate 3 – 5 ml/sec  Rates above 5 ml/sec are rarely necessary unless the patient has a high cardiac output.
 Rates below 3 ml/sec may not result in sufficient pulmonary arterial opacification.
Scan delay Computer assisted or empiric  If standardized delay, use 10-20 seconds.
standardized  The scan should be completed prior to visual evidence of significant washout of pulmonary arterial
contrast.
 This is best assessed in the chest by noting minimal or no difference between pulmonary arterial
density and muscle attenuation.
Reconstruction algorithm Standard or soft Tissue
Reconstruction spacing Contiguous or overlapping sections There should be no gaps (i.e., the reconstruction spacing should not exceed the collimation). If
overlapping sections are used, the overlap should be approximately 50%.
Coverage Enhanced scans: top of right  At least one scan (enhanced, unenhanced, or a combination of both) should extend from the
diaphragm to top of aortic arch, lung apices to the bases.
including proximal aspects of all  Enhanced scans should be acquired in no more than a single helical acquisition.
segmental pulmonary artery
branches.
Gantry tilt N/A
Display FOV Lung settings: include entirety of
lung, do not extend beyond the edge
of the patient.
Enhanced mediastinum settings:

include peripheral pulmonary
vessels; do not extend beyond the
edge of the patient.
Display window width/level Lung and Mediastinum The  The settings should allow adequate visualization of the pulmonary artery lumen and should not
submission of both lung and display the pulmonary arteries as so dense that they are indistinguishable from cortical bone, or so
mediastinum windows is required. hypodense that they are only mildly enhanced or virtually compared to normal soft-tissue (i.e.,
The ww/wl range is recommended. chest wall musculature).
 As compared to the grading of vascular opacification of mediastinal and hilar vessels in a CT of the
chest for lung cancer evaluation, a greater degree of intra-arterial enhancement should be
expected in assessing adequacy of pulmonary arterial opacification for a CT pulmonary embolism
study.
 The site will not be penalized for submitting an additional wider window to better visualize the
pulmonary arteries for filling defects.
 Lung: WW = 1200 – 1500 HU WL = -550 – -700 HU
 Mediastinum: WW = 250 – 450 HU WL = 40 – 80 HU
Adult HRCT of Chest*
Required Series Non-enhanced study  While it is not required, the performance of prone scans in patients with posteriorly situated lung
disease is desirable. This should be limited to relevant areas, such as the lung bases.
 The performance of expiratory scans to detect air trapping is encouraged, but not required.
 When using Helical mode, there should be no more than 3 complete acquisitions through the body
part, such as baseline, expiration and prone sequences, all performed helically. Ideally, 2 sequences
plus a limited acquisition will be performed.
mAs 40 - 200  A mAs of 40-200 should be used, although higher doses may be necessary for larger patients.
 In thin patients and those who have follow-up HRCT examinations, a low-dose technique (40-80
mAs) may produce diagnostic-quality images and is acceptable providing image noise is not
excessive.
kVp 120 – 140 kVp The mAs and kVp should be sufficient so that the images do not appear excessively noisy or grainy.
Slice width ≤ 1.5 mm
Respiration
Oral Contrast
Injection rate
Scan delay
Reconstruction algorithm Bone or High Spatial Frequency
Algorithm
Reconstruction spacing ≤ 10 mm 10 mm reconstruction spacing is ideal. The site will not be penalized if , 10 mm is used.
CTDIvol There are no reference values for Facilities must submit CTDIvol information on dose received by the patient on the examination submitted
this examination if the unit is capable. Either include a screen save of the dose with the images, or place the post
scanning dose displayed on the Clinical Test Image Data Sheet. The CTDIvol should be appropriate for
the examination.
Coverage Lung apex through lung bases. It is important to make certain that lung in the lateral and posterior costophrenic sulci are included on the
most inferior scan.
Gantry tilt N/A
Display FOV Wide enough to include the lungs but not so large that the edge of the image lies well beyond the margin
of the patient’s body.
Display window width/level Lung and Mediastinum The  The lung settings should provide a uniform appearance of normal lung parenchyma and allow
submission of both lung and visualization of intraparenchymal airways and vessels.
mediastinum windows is  WW = 1200 – 2000 HU WL = -550 – -700 HU
required. The ww/wl range is  The mediastinal settings should allow visualization of the mediastinal and hilar vessels and allow
recommended reasonable distinction of the chest wall musculature from subcutaneous fat.
 WW = 250 – 450 HU WL = 40 – 80 HU
ADULT CARDIAC MODULE
Adult Coronary CTA*
Required Series Submit the best phase of  Curved reformats may be re-registered/phase corrected.
contrast enhanced axial  Coronal and axial images must be from the same phase.
slices, and screen shots  Low-dose pre-contrast images are acceptable.
of reconstructions for  See Anatomical Coverage/Display section below for complete list of required screen shots.
relevant segments
mAs 140-160 recommended  The mAs selected should result in diagnostic-quality images.
 Should take into account the patient’s body habitus and age, slice width, kVp, and unique attributes of the
scanner and acquisition mode.
 Dose reduction techniques (such as dose modulation, prospective gating or automatic dose
reduction) are required.
Max. Tube Rotation Time ≤ 0.4 sec The scan temporal resolution should be less than 0.2 sec
kVp 120 The mAs and kVp should be sufficient so that the images do not appear excessively noisy or grainy.
Nominal Slice Thickness (z-axis) ≤ 1.0 mm
Pitch (IEC Definition) < 1.0
Respiration Breath Hold (inspiration recommended if patient able to cooperate)
IV Contrast medium 80 – 150 ml  300 - 370 mg/ml non-ionic contrast. Saline flushor blended contrast flush is required
Higher or lower volumes may be used if the protocol states that the volume may be adjusted for patient weight.
Oral Contrast N/A
Injection rate Between 4 and 7 cc/sec
Scan delay Must use test injection or automatic triggering
 venous contamination with inadequate coronary or LV opacification indicates a late injection
 right heart too dense with inadequate coronary or LV opacification indicates an early injection
Reconstruction spacing Reconstruction interval less than or equal to the effective slice thickness
DLP < 1400 mGy-cm for The use of dose reduction techniques (such as dose modulation, prospective gating manually adjusted
retrospective gating or < 700 mA/kVp or automatic dose reduction) are required for this examination. Facilities must submit CTDIvol
mGy-cm for prospective gating information on dose received by the patient on the examination submitted. Either include a screen shot of
the dose with the images, or place the post scanning dose displayed on the Clinical Test Image Data Sheet.
The CTDIvol should be appropriate for the examination.
Coverage Scan must cover the entire coronary circulation and heart
Gantry tilt N/A
Display FOV Wide enough to include all relevant structures, but not so large that the edge of the image lies
well beyond the margin of the patient’s body.
Display window width/level Window width and level should be appropriate for display of intravascular contrast.
Window width 600-1000 Window Level 80-200
Required Screen Shots Coronal and axial images must  CTDIvol and DLP if the facility has the capability to save on screen shot
be from the same best phase of  Scout with locations displayed
images.  Curved or straight reformat of 2 cm of LAD
 Curved or straight reformat of 2 cm of LCX
 Curved or straight reformat of 2 cm of OM1 or first large OM

Adult Calcium Scoring for risk stratification

Required Series Non-contrast images  The facility will not be penalized if submitting pre and post contrast images
 Facilities must provide the score table, in whatever format they normally use. (Screen shot, word
document, etc.)
 The Calcium Threshold must be ≥ 2-3 pixels
 The Calcium Threshold must be equal to 130 HU
 ECG Gating must be used
 Dose reduction technique (prospective gating) is required.
Scan Temporal Resolution ≤ 0.8 sec The scan Temporal Resolution should be less than 0.8 sec
kVp 120 The mAs and kVp should be sufficient so that the images do not appear excessively noisy or grainy.
Nominal Slice Thickness ≤ 3 mm
Oral Contrast N/A
Injection rate N/A
Scan delay N/A
CTDIvol There are no reference values for this The use of dose reduction techniques (prospective gating) is required for this examination. Facilities
examination must submit CTDIvol information on dose received by the patient on the examination
submitted. Either include a screen shot of the dose with the images, or place the post scanning dose
displayed on the Clinical Test Image Data Sheet. The CTDIvol should be appropriate for the
examination.
Coverage The entire circulation and heart
Gantry tilt N/A
Display FOV Wide enough to include all relevant structures, but not so large that the edge of the image lies well
beyond the margin of the patient’s body.
Display window width/level Window and level must be sufficient for coronary calcium
Required Screen Shots  Score diagonals with LAD  Axial sections
 Score PDA with RCA or LCX  CTDIvol and DLP
 ROIs must be reviewed post  Scout view with locations displayed
scoring with commercial  Three representative axial views through the aorta with distance measurements
methodology  Submission must include scores for:
o LM
o LAD
o RCA
o LCX
o Total score
Adult Cardiac Function and Morphology, such as for tumor, congenital heart disease, aortic valve or
cardiomyopathy
Required Series  Submit the best phase  Movies must be cine reformatted images across the phases of the cardiac cycle (as
contrast enhanced axial required of screen shot images – see Anatomical Coverage/Display section below)
images and o horizontal long position
 short axis movie in .mpg or o vertical long position
.avi format showing wall o single short axis movie at the level of the mid left ventricle
motion covering apex to  ECG gating must be used (gating must be retrospective when ventricular function
base of heart and is relevant)
 Screen shots (See  If examination is performed for Aortic Valve:
Anatomical o Images of aortic valve both open and closed must be submitted by either cine or
Coverage/Display below) screen shot.
o Valve measurement
 Should take into account the patient’s body habitus and age, slice width, kVp, and
 Dose reduction techniques (such as dose modulation, prospective gating,
manually adjusted mA/kVp or automatic dose reduction) are required.
Scan Temporal Resolution ≤ 0.25 sec.
kVp 120-140
Nominal Slice Thickness ≤ 1.3 mm
Pitch (IEC Definition) <1
IV Contrast medium  300 - 370 mg/ml non-ionic  Use saline flush or dilute contrast flush to clear the SVC and reduce the right heart
contrast. Higher or lower density
volumes may be used if the 
protocol states that the
volume may be adjusted for
patient weight.
Oral Contrast N/A
Injection rate Between 4-6 ml/sec Test bolus or automatic triggering must be used
Scan delay  A contrast delay that is too late will result in venous contamination with inadequate
coronary or LV opacification
 A contrast delay that is too early will result in right heart too dense with inadequate
coronary or LV opacification
Reconstruction spacing ≤ effective slice thickness
DLP >1400 mGy-cm for retrospective The use of dose reduction techniques (such as dose modulation, or automatic dose
gating reduction) are required for this examination. Facilities must submit CTDIvol information
on dose received by the patient on the examination submitted. Either include a screen shot
of the dose with the images, or place the post scanning dose displayed on the Clinical Test
Coverage Must cover coronary
circulation and heart
Gantry tilt N/A
Display FOV Should not be so small that relevant structures are excluded or so large that edge of the
image lies well beyond the edge of the patient’s body.
Display window width/level Appropriate for display of intravascular contrast
Required Screen Shots  CTDIvol and DLP
 Scout with locations displayed
 Coronal reformat through left ventricle anterior to mitral valve plane (soft tissue
windows)
 Axial section through plane of mitral valve (soft tissue windows)
 Horizontal long axis (4 chamber view) reformat through the AV valve plane
 Vertical long axis (2 chamber view) reformat through the mitral valve plane
 Images of aortic valve both open and closed must be submitted by either cine or
screen shot if examination submitted is for valve assessment
 Valve area measurement if examination submitted is for valve assessment
Adult Pulmonary Vein Mapping such as for pre-ablation planning for treatment of atrial fibrillation
Required Series  Best phase or non-gated helical Required screen shots of reformatted images (see Anatomical Coverage/Display section
or axial images below.
 Dose reduction techniques (such as dose modulation, prospective gating, manually
adjusted mA/kVp or automatic dose reduction) are required.
Max.Tube Rotation Time ≤ 0.5 sec
kVp 80 – 120
Nominal Slice Thickness ≤ 1.5 mm
Pitch (IEC Definition) If helical, 1 – 1.5
IV Contrast medium  300 - 370 mg/ml non-ionic contrast.
 Saline flush is required
Oral Contrast N/A
Injection rate Between 4-6 ml/sec Test bolus or automatic triggering must be used
Scan delay  The scan should be performed during the peak of contrast in the pulmonary veins.
 A contrast delay that is too late will result in excessive washout of left atrium
 A contrast delay that is too early will result in inadequate contrast in left atrium with right heart
significantly denser than left heart
Reconstruction spacing ≤ effective slice thickness
DLP >1400 mGy-cm for retrospective The use of dose reduction techniques (such as dose modulation, prospective gating,
gating or . >700 mGy-cm for manually adjusted mA/kVp or automatic dose reduction) are required for this examination.
prospective gating or non-gated Facilities must submit CTDIvol information on dose received by the patient on the examination
images submitted. Either include a screen shot of the dose with the images, or place the post scanning dose
displayed on the Clinical Test Image Data Sheet. The CTDIvol should be appropriate for the
examination.
Coverage Pulmonary viens craniocaudally at
least 2 cm beyond their orifices
Gantry tilt N/A
Display FOV Should not be so small that relevant structures are excluded or so large that edge of the image lies
well beyond the edge of the patient’s body.
Required Screen Shots  CTDIvol and DLP
 Axial section through plane of mitral valve (soft tissue windows)
 Axial section through mi-left ventricle 2-4 cm above apex (soft tissue windows)
 Coronal oblique reformat RUL pulmonary vein (at least one)
 Coronal oblique reformat RLL pulmonary vein (at least one)
 Coronal oblique reformat LUL pulmonary vein (at least one)
 Coronal oblique reformat LLL pulmonary vein (at least one)
ADULT ABDOMEN MODULE
Adult Abdomen (such as for detection of possible liver metastases or lymphoma)
Required Series IV contrast enhanced study  Contrast enhanced images are required.
 While delayed or repeat images may be necessary, excessive sequential images through the
abdomen should not be obtained.
Max.Tube Rotation Time ≤ 1 sec
kVp 120 – 140 kVp
IV Contrast medium 80 – 150 cc of 300 - 370 mg/ml non-  Higher or lower volumes may be used if the protocol states that the volume may be adjusted for
ionic contrast for an average size patient weight.
adult.  Dense enhancement of all the major arteries and veins that is sustained throughout the
sequence of scans and "white out" of the renal parenchyma may suggest an excessive contrast
dose for the patient's weight.
Oral Contrast Oral contrast material must be  Alternatively, the stomach and duodenum may be distended with gas-producing agent or neutral
present with good distension of contrast.
the stomach and opacification of  There may or may not be contrast in the visualized portions of the colon.
most small bowel loops.  The stomach should be well distended. If it is not, the scan should show evidence of repeat
sections with either additional oral contrast or a gas-producing agent.
 Neutral contrast agents such as water are acceptable, so long as good distension has resulted.
Injection rate 2 – 4 ml/sec  Rates below 2 ml/second may not result in sufficient hepatic opacification.
 It is understood that in oncology patients, venous access may be limited, and slower rates may
be necessary.
Scan delay Computer assisted or empiric  It is essential that images be obtained through the liver during the peak of portal venous
standardized enhancement to optimize lesion detection.
 If a standardized delay is used, it  The portal vein contrast level should visually be as great as or greater than the arterial contrast
should be coordinated with the level with good discrimination of the portal vein from the surrounding liver parenchyma.
contrast injection rate such that  For possible metastatic disease, a single set of portal venous phase images is required, but you
at 2 ml/sec, a delay of 60 to 75 will not be penalized for doing pre-contrast or arterial phase scans in addition. This will be highly
seconds should be used. dependent on whether the underlying tumor and other issues Is hypervascular.
 The delay should be  If a multi-phase exam for hypervascular metastasis is performed, the indication must be
appropriately shortened for faster specifically given in the test image data sheet describing the underlying tumor.
rates.
 The scan should be completed
prior to visual evidence
suggesting that the contrast has
entered the equilibrium phase.
CTDIvol Reference value = 25mGy Facilities must submit CTDIvol information on dose received by the patient on the
Pass/Fail Criteria = 30 mGy examination submitted if the unit is capable. Either include a screen save of the dose with the
(per single series or uniphasic exam) images, or place the post scanning dose displayed on the Clinical Test Image Data Sheet. The
CTDIvol should be appropriate for the examination.
Coverage Diaphragm to Iliac crest to include The site will not be penalized for extending the scans down to the iliac bifurcation as part of an
the entire liver. abdominal scan.
Gantry tilt N/A
Display FOV There should be no portions of the body outside the field of view. The field of view should be small
enough so that its edge lies just beyond the edge of the patient’s body.
Display window width/level Soft tissue, liver, and lung.  Liver windows are required on one set of the contrast-enhanced images if submitting by
hard copy film.
Soft tissue:  Both liver and lung windows through the lung bases are required if submitting by hard
 WW = 350 – 500 HU copy film.
 WL = 10 – 40 HU
Liver:
 WW = 150 to 200 HU with the
level adjusted to provide an
acceptable overall density.
Lung:
 WW = 1200 – 1500 HU
 WL = -550 – -700 HU
Adult Known Cirrhosis (r/o hepatoma)*
Required Series IV contrast enhanced study Should perform three series of images: non contrast, arterial and portal venous phase series.
 Should take into account the patient’s body habitus and age, collimation, kVp, and unique
Max. Tube Rotation Time ≤ 1 sec
kVp 120 – 140 kVp
Pitch (IEC Definition) ≤1.5
Respiration
IV Contrast medium 120 – 150 cc of 300 – 350 mg/ml  Higher or lower volumes may be used if the protocol states that the volume may be adjusted for
non-ionic contrast for an average size patient weight.
adult.  Lower volumes may be used if 320 -370 mg/ml contrast is used.
Oral Contrast Not mandatory Neutral contrast agents, such as water, are acceptable so long as good distension of the stomach
and proximal bowel are demonstrated.
Injection rate 3 – 5 ml/sec 4 ml/sec should be minimum unless venous access is a problem.
Scan delay Computer assisted or empiric  A hepatic arterial phase set of images must be obtained starting approximately 25 – 30
standardized seconds after the initiation of the injection.
 The second acquisition should occur at the time of peak hepatic parenchymal enhancement
(portal vein phase), usually 45 – 65 seconds following the initiation of the bolus at the rate of 4 to
5 ml/second.
Reconstruction algorithm Standard or soft tissue (or
appropriate body-kernel)
CTDIvol There are no reference values for this Facilities must submit CTDIvol information on dose received by the patient on the
examination examination submitted if the unit is capable. Either include a screen save of the dose with the
images, or place the post scanning dose displayed on the Clinical Test Image Data Sheet. The
Coverage Top of the right hemidiaphragm to
the iliac crest or to the lower edge
of the right lobe of liver, whichever
is more caudal.
Gantry tilt N/A
Display FOV Appropriate to patient’s body habitus. Should be large enough to include at least all anatomic areas within the abdominal wall musculature.
Display window width/level Soft tissue, liver and lung The submission of soft tissue, lung and liver windows is required. The ww/wl range is
recommended if submitting by hard copy film.
Liver:Nonenhanced or hepatic arterial phase:
 WW = ~150 HU WL = ~45 HU
Portal venous phase:
 WW = 300 – 450 HU WL = 40 – 50 HU
Lung:
 WW = 1200 – 1500 HU WL = -550 – -700 HU
Adult Renal Mass*

Required Series IV contrast enhanced and  This exam requires unenhanced pre-contrast scans and medullary (nephrographic)
unenhanced study phase scans, and possibly delayed scans. Optimized renal mass evaluation should be
performed when the kidneys display a homogeneous tubular nephrogram. The site may
obtain scans during both the cortical-medullary phase and tubular nephrogram phase,
but scans submitted from only the cortico-medullary phase are not acceptable. The site
will be penalized if the contrast within the kidneys is an early cortico-medullary phase.
Some sites may also submit late collecting-system phase images, but these are not a
substitute for nephrogram phase images.
 For renal mass evaluation, a site will not be penalized for submitting images acquired in
a step-and-shoot mode.
kVp 120 – 140 kVp
Slice width ≤ 5 mm over entire kidney and
mass
Pitch (IEC Definition) ≤ 1.5
Respiration
IV Contrast medium 100 – 150 cc of 300 – 350 mg/ml  Higher or lower volumes may be used if the protocol states that the volume may be
non-ionic contrast for an average adjusted for patient weight. Lower volume may be used if higher concentration is used.
size adult.
Oral Contrast No oral contrast is preferred.  Neutral contrast agents such as water are acceptable, so long as good distension has
resulted.
 If used, oral contrast material should provide uniform distension of the stomach and
opacification of most small bowel loops.
Injection rate 2 – 4 ml/sec
Scan delay Computer assisted or empiric  If a standardized delay is used, it should be coordinated with the contrast injection rate
standardized of 2-4 ml/sec., a delay of 90 to 120 seconds should be used.
 The delay should be appropriately shortened for faster rates.
 If delayed scans are performed to visualize the collecting system, 3 – 7 minute delay is
recommended.
appropriate body-kernel)
CTDIvol There are no reference values for Facilities must submit CTDIvol information on dose received by the patient on the
this examination examination submitted if the unit is capable. Either include a screen save of the dose
with the images, or place the post scanning dose displayed on the Clinical Test Image Data
Sheet. The CTDIvol should be appropriate for the examination.
Coverage Must encompass the entire  Many centers will incorporate the renal evaluation within the whole abdomen and pelvis
length of both kidneys and the CT.
full cephalo-caudad extent of  It is recommended that the bladder not be imaged during the nephrographic phase.
the mass being evaluated.
Gantry tilt N/A
Display FOV Appropriate to patient’s body There should be no portions of the body outside the field of view. The field of view should be
habitus. small enough so that its edge lies just beyond the edge of the patient’s body.
Display window width/level Soft tissue and lung Liver windows are optional
Soft tissue:
 WW = 350 – 500 HU
 WL = 10 – 40 HU
Lung:
 WW = 1200 – 1500 HU
 WL = -550 – -700 HU
ROIs Placement and size of region of  Circular or square cursors may be employed.
interest cursors (ROI) are  Magnified views “coning down” over the affected kidney with ROI cursors may be
critical components of included.
competent renal mass  Measurements must be shown on both unenhanced and enhanced images.
evaluation.
Adult Pancreatic Carcinoma*
Required Series IV contrast enhanced study  Adequacy of intravenous contrast enhancement should be evaluated for the dose, rate,
and timing of contrast administration.
 The submitted protocols should verify that the site adhered to its protocol, and they
should verify the visual assessment of the contrast parameters.
 The protocols are an important part of the review process to be used in conjunction with
the images.
 No more than 3 sequential acquisitions through the body part.
kVp 120 – 140 kVp
Respiration
IV Contrast medium 125 – 150 cc of 300 – 350 mg/ml  Higher or lower volumes may be used if the protocol states that the volume may be
non-ionic contrast for an average adjusted for patient weight.
size adult.  The overall enhancement should be pleasing to the eye.
 Dense enhancement of all the major arteries and veins that is sustained throughout the
sequence of scans and "white out" of the renal parenchyma may suggest an excessive
contrast dose for the patient's weight.
 Lesser volumes of contrast may be used if higher concentrations are used.
Oral Contrast Oral contrast material must be  There may or may not be contrast in the visualized portions of the colon.
present with good distension  The stomach should be well distended. If it is not, the scan should show evidence of
of the stomach and repeat sections with either additional oral contrast or a gas-producing agent.
opacification of proximal  Neutral contrast agents such as water are acceptable, so long as good distension has
small bowel loops. resulted.
 Alternatively, the stomach and duodenum may be distended with the gas-producing
agent.
Injection rate 3 – 5 ml/sec  Rates below 2 ml/sec may not result in dense peripancreatic vascular enhancement. 4 –
5 ml/sec is preferred.
Scan delay Computer assisted or empiric  Pancreatic phase images should image the kidneys in a “cortico-medullary” pattern of
standardized enhancement, approximately 35 – 45 seconds after initiation of the contrast.
 Portal vessels within the liver may be enhanced; however, the parenchymal
enhancement should be less than that seen on the subsequent portal venous phase.
 The second phase of the exam should be in the portal venous phase approximately 60-
75 seconds after initiation of contrast.
 Optimized liver phase images will show less cortico-medullary differences in contrast
enhancement in the kidney than in the pancreatic phase

appropriate body-algorithm)
CTDIvol There are no reference values Facilities must submit CTDIvol information on dose received by the patient on the
for this examination examination submitted if the unit is capable. Either include a screen save of the dose
Coverage  Pancreatic phase scans  Some practices extend scans down to the iliac bifurcation as part of an abdominal
must extend from the porta scan. Some sites include the pelvis in their studies.
hepatis through the  The whole pancreas must be covered on the pancreatic phase.
transverse duodenum.
 The second (liver/portal
phase) images must extend
from the diaphragm to the
superior margin of the
sacroiliac joints to include
the entire liver.
Gantry tilt N/A
Display FOV Appropriate to patient’s body  There should be no portions of the body outside the field of view.
habitus.  The field of view should be small enough so that its edge lies just beyond the edge of
the patient’s body.
 Some sites use targeted reconstructions restricted to the pancreas and peripancreatic
vessels. These could substitute for full field of view images in the pancreatic phase
Display window Soft tissue, liver, and lung if  It is not necessary to include 3-D reformatted or rendered images.
width/level submitting by hard copy film  Specifications as to the data set used to render such images should be included in the
site’s protocol.
Soft tissue:
 WW = 350 – 450 HU
 WL = 10 – 40 HU
Liver:
 WW = 150 – 200 HU
 WL = Adjusted to provide an acceptable overall density
Lung:
 WW = 1200 – 1500 HU
 WL = -550 – -700 HU
PEDIATRIC STUDIES
Special attention must be paid to milliamperes (mA) for pediatric studies. The facility will not receive a pass if the radiation dose is perceived to be too
high, regardless of whether the rest of the CT study conforms to satisfactory criteria. Recommendations for maximum exposures are shown below.
Suggested Tube Current (mA) is by weight and type of examination.
References are included to help in selecting the appropriate dose.
Weight (kg) mA (Chest) mA (Abdomen/Pelvis)

< 10 40 60
10-25 60 80
26-50 80 120
51-70 100-120 140-150
> 70 > 140 > 160
Donnelly LF, Emery KH, Brody AS, et al. Minimizing radiation dose for pediatric body applications for single-detector helical CT: strategies at a large
children’s hospital. AJR 2001; 176:303-306.
Pediatric Doses – It is very important for you to be aware of the differences between the dose observed for the pediatric abdomen portion of the phantom
submission (when a child sized phantom is used) and pediatric doses reported on the scanner (which assume an adult sized phantom). The scanner
reported doses (i.e. assuming an adult dose phantom) are approximately 2.4 times lower than the same exact x-ray technique would produce in a
pediatric dose phantom . In other words, a dose reported on a pediatric abdomen should ideally be reduced by a factor of 3 or more as compared to adult
doses.
PEDIATRIC HEAD/NECK MODULE
Pediatric Head (such as for headaches, seizures, or suspected mass)
Required Series Nonenhanced study An IV contrast study is not necessary but may be submitted.
 Should take into account the patient’s body habitus and age, slice width, kVp, and unique attributes of
the scanner and acquisition mode.
kVp 80 – 140 kVp Reduced kVp may be used
Slice width ≤5
Pitch(IEC Definition) Between 1.0 and 1.5  In general, a pitch of less than one (“over scanning”) is not recommended in pediatric patients.
 Some multi-slice scanners limit the choices of pitch. If this results in the site having to use a pitch of less than
one in children, the mAs should be appropriately adjusted downward, either by protocol design or by
automated software on the scanner.
Respiration Suspension N/A

Oral Contrast N/A
IV Contrast 80-150 ml  If IV contrast is used, it should be adjusted based on the child’s weight. 300 mg/ml or it’s equivalent
should be used.
Injection rate 1.5-3.0 ml/sec (standardized) For routine oncologic survey exams of the head, rates in excess of 3 ml/sec are unnecessary.
Scan delay  Computer assisted or Scan should be completed prior to visual evidence of significant washout of the Circle of Willis arterial
empiric standardized contrast. This is best assessed in the brain by noting minimal or no difference between Circle of Willis arterial
density and brain attenuation.
 If standardized, 20-30
second delay
Reconstruction algorithm Standard All heads with and without IV contrast
CTDIvol There are no reference values Facilities must submit CTDIvol information on dose received by the patient on the examination
for this examination submitted if the unit is capable. Either include a screen save of the dose with the images, or place the post
scanning dose displayed on the Clinical Test Image Data Sheet. The CTDIvol should be appropriate for the
examination.
Coverage Base of the skull to the vertex Include entire head with visualization of the entire bony cranium.
Gantry tilt 25 degrees caudad to Reid’s base Superimpose the supraorbital ridge and the inner table of the skull at the foramen magnum along a line.
line
Display FOV Between 20 – 24 cm
Display window width/level Soft tissue and bone Soft tissue:
The submission of both soft tissue  Posterior fossa
and bone windows is required if WW = 40 – 140 HU WL = 35 – 50 HU
submitting on hard copy film. The  Supratentorial
ww/wl range is recommended WW = 80 – 100 HU WL = 35 – 50 HU
Bone:
WW = 2000 – 3000 HU WL = 200 – 300 HU
Pediatric Sinuses
Required Series Coronals  The site will not be penalized if both axial and coronal sections are obtained, as primary
acquisitions, so long as image quality is adequate. Axials may be reformatted from coronals, or
coronals from axials, but at a minimum a coronal set of images is required.
 No more than 2 sequential acquisitions through the body part.

 Should take into account the patient’s body habitus and age, collimation, kVp, and unique
kVp 80 – 140 kVp
Collimation ≤ 3 mm from the frontal
through the anterior
ethmoid sinuses
≤ 5 mm from the posterior
ethmoid through the
sphenoid sinuses
Pitch (IEC Definition) Between 1.0 and 1.5  In general, a pitch of less than one (“over scanning”) is not recommended in pediatric patients.
 Some multi-slice scanners limit the choices of pitch. If this results in the site having to use a
pitch of less than one in children, the mAs should be appropriately adjusted downward, either
by protocol design or by automated software on the scanner.
Respiration N/A
Oral Contrast N/A
Injection rate N/A
Scan delay N/A
Reconstruction Detail or other high spatial
algorithm frequency
CTDIvol There are no reference Facilities must submit CTDIvol information on dose received by the patient on the
values for this examination examination submitted if the unit is capable. Either include a screen save of the dose with the
images, or place the post scanning dose displayed on the Clinical Test Image Data Sheet. The
Coverage Scans should extend from the
frontal through the sphenoid
sinuses.
Gantry tilt For coronal images, the gantry is
angled perpendicular to the face.
Scan FOV 13 – 15 cm With multiple-detector helical scanners, axial images may be reconstructed from coronal
images; however, image quality and resolution must be similar to those acquired in the
coronal plane.
Display window width/level Soft Tissue and bone The submission of both soft tissue and bone windows is required if submitting by hard copy
film. The ww/wl range is recommended.
Soft Tissue:
 WW = 300 – 350 HU WL = 35 – 45 HU
Bone:
 WW = 3000 – 4000 HU WL = 300 – 400 HU
Pediatric Temporal Bones*
Required Series Axial and Coronal With multiple detector helical scanners, coronal images may be reconstructed from axial
images. Image quality and resolution must be similar to those acquired in the axial plane.
kVp 80 – 140 kVp
Collimation ≤ 1.5 mm
Respiration N/A
Oral Contrast N/A
Injection rate N/A
Scan delay N/A
Reconstruction algorithm Edge or other high spatial A soft-tissue or standard reconstruction algorithm is inappropriate; however it may be
frequency used in conjunction with the routine exam.
with the images, or place the post scanning dose displayed on the Clinical Test Image
Data Sheet. The CTDIvol should be appropriate for the examination.
Coverage Scans should extend from the
mastoid tip through petrous bone
Gantry tilt Axials – angle to superimpose the base of the skull and acanthion
Coronals- gantry is angled perpendicular to the petrous bone

Scan FOV 18 – 20 cm
Display FOV Approximately 9.6 cm Sufficient magnification to allow clear visualization of the ossicular chain and inner ear
structures
Display window width/level Soft Tissue and bone The submission of both soft tissue and bone windows is required if submitting by hard
copy film. The ww/wl range is recommended.
Soft Tissue:
 WW = 150 – 250 HU WL = 50 – 75 HU
Bone:
 WW = 3000 – 4000 HU WL = 300 – 400 HU
Pediatric C-spine*
Required Series Axial, reformatted in at least Both sagittal and coronal reformations are required.
the Sagittal plane
Max.Tube Rotation Time ≤ 2 sec.
kVp 80 – 140 kVp
Respiration N/A
Oral Contrast N/A
Injection rate N/A
Scan delay N/A
Reconstruction algorithm Bone
Reconstruction spacing An interval less than or equal
to the slice thickness.
this examination examination submitted if the unit is capable. Either include a screen save of the dose with
the images, or place the post scanning dose displayed on the Clinical Test Image Data
Coverage Entire spine from the cranio- Include the spine and immediate adjacent soft-tissues
cervical junction to the T1
vertebra
Gantry tilt N/A
Display FOV 9 – 14 cm Appropriate for the patient’s body habitus to include the spine and immediate adjacent soft-
tissues.
Display window width/level Soft Tissue and Bone The submission of both soft tissue and bone windows is required if submitting by
hard copy film. The ww/wl range is recommended.
Soft Tissue: WW = 450 – 650 HU WL = 80 – 100 HU
Bone: WW = 2000 – 3000 HU WL = 200 – 300 HU
PEDIATRIC CHEST MODULE
Pediatric Chest (such as for metastatic disease, trauma, infection, or cough)
Required Series Non-enhanced study Intravenous or oral contrast enhancement is not necessary, but may be used at the
discretion of the radiologists if clinically indicated.
kVp 80 – 140
Pitch (IEC Definition) Between 1.0 and 1.5  In general, a pitch of less than one (“overscanning”) is not recommended in pediatric
patients.
 Some multi-slice scanners limit the choices of pitch. If this results in the site having to
use a pitch of less than one in children, the mAs should be appropriately adjusted
downward, either by protocol design or by automated software on the scanner.
Respiration N/A
Oral Contrast N/A
Injection rate N/A
Scan delay N/A
Reconstruction algorithm Standard or high spatial
frequency
Reconstruction spacing At least equal the slice thickness. Overlapping reconstructions are not necessary for helical scans but are acceptable.
Coverage Lung apex to below the lung bases. The site will not be penalized for extending the scan down through the adrenal glands.
Gantry tilt N/A
Display FOV Edge of the patient Not be so small that a portion of the chest wall is excluded or so large that the edge of
the image lies well beyond the edge of the patient’s body.
Display window width/ Lung and mediastinum Lung: WW = 1200 – 1500 HU WL = -550 – -700 HU
level The submission of both lung and  Allow adequate visualization of the lung parenchyma and intraparenchymal
mediastinum windows is required if airways and vessels.
submitting by hard copy film. The
ww/wl range is recommended Mediastinum: WW = 250 – 400 HU WL = 40 – 80 HU
 Allow visualization of the mediastinal and hilar vessels and allow distinction of the
chest wall musculature from subcutaneous fat.
Pediatric HRCT of Chest*
Required Series Non-enhanced scan  The performance of expiratory scans to detect air trapping is encouraged, but not
required.
 In a child, no more than 2 complete scans of the chest should be performed.
mAs 80 – 140  The mAs selected should result in diagnostic-quality images.
kVp 80 – 140 kVp The mAs and kVp should be sufficient so that the images do not appear excessively
noisy or grainy.
Slice width ≤ 1.5 mm
Pitch (IEC Definition) Between 1.0 and 1. 5
Respiration N/A
Oral Contrast N/A
Injection rate N/A
Scan delay N/A
Reconstruction algorithm Bone or high spatial frequency
Algorithm
Reconstruction spacing ≤ 20 mm
CTDIvol There are no reference values for this Facilities must submit CTDIvol information on dose received by the patient on the
examination examination submitted if the unit is capable. Either include a screen save of the
dose with the images, or place the post scanning dose displayed on the Clinical Test
Coverage Lung apex through lung bases. It is important to make certain that lung in the lateral and posterior costophrenic sulci
are included on the most inferior scan.
Gantry tilt N/A
Display FOV Wide enough to include the lungs but
not so large that the edge of the image
lies well beyond the margin of the
patient’s body.
Display window Lung and mediastinum  The lung settings should provide a uniform appearance of normal lung parenchyma
width/level The submission of both lung and and allow visualization of intraparenchymal airways and vessels.
mediastinum windows is required if  The mediastinal settings should allow visualization of the mediastinal and hilar
submitting by hard copy film. The vessels and allow reasonable distinction of the chest wall musculature from
ww/wl range is recommended subcutaneous fat.
Lung: WW = 1200 – 2000 HU WL = -550 – -700 HU
Mediastinum: WW = 250 – 400 HU WL = 40 – 80 HU
PEDIATRIC CARDIAC MODULE
Pediatric Cardiac Examination such as for Congenital Disease
Required Series Single phase contrast  Usually only one phase (arterial if for CTA)
enhanced  Multiple phases must be justified due to increased radiation dose
o Complicated post operative heart where arterial and venous phase needed
o Masses
mAs mAs inappropriate for  The mAs selected should result in diagnostic-quality images.
examination/ patient weight  Should take into account the patient’s body habitus and age, slice width, kVp, and unique attributes
Weight (Kg) mA of the scanner and acquisition mode.
<10 40  Dose reduction techniques (such as dose modulation, prospective gating, manual
10-15 50 manipulation mA/kVp or automatic dose reduction) are required.
15-24 60
25-34 70
35-44 80
>45 100
Max.Tube Rotation Time ≤1.0 sec (0.5 recommended)
kVp 80 – 120 Appropriate for patient body habitus and age.
Slice width <1.5 mm
Pitch (IEC Definition) > 1.0
IV Contrast medium 280 – 320 mg I non-ionic 2 mL/kg (max. 4 mL/kg or 125 mL)
Oral Contrast N/A
Injection rate Variable with catheter size  22g – 1.5 -2.0 mL/sec
(antecubital)  20g – 2.0 – 3.0 mL/sec
 24g or central line – 1.0 mL/sec
 Hand inject
Scan delay Computer assisted or empiric  If standardized empiric delay for CTA , use 12-15 seconds for children under 10 kg, 20-25 seconds if
standardized > 10 kg.
 The scan should be completed prior to visual evidence of significant washout of pulmonary arterial
contrast.
CTDIvol There are no reference values for The use of dose reduction techniques (such as dose modulation, prospective gating, manual
this examination manipulation mA/kVp or automatic dose reduction) are required for this examination. Facilities
must submit CTDIvol information on dose received by the patient on the examination submitted.
Either include a screen shot of the dose with the images, or place the post scanning dose displayed on
the Clinical Test Image Data Sheet. The CTDIvol should be appropriate for the examination.
Coverage From the inlet to the diaphragm
Gantry tilt N/A
Display FOV Should not be so small that relevant structures are excluded or so large that edge of the image lies
well beyond the edge of the patient’s body.
PEDIATRIC ABDOMEN MODULE
Pediatric Abdomen (Such as for trauma, suspected appendicitis, or abdominal pain)
kVp 80 – 140 kVp
Pitch (IEC Definition) Between 1.0 and 1.75  In general, a pitch of less than one (“overscanning”) is not recommended in
pediatric patients.
 Some multi-slice scanners limit the choices of pitch. If this results in the site having
to use a pitch of less than one in children, the mAs should be appropriately adjusted
Respiration
IV Contrast medium The recommended IV contrast dose is  The overall enhancement should be pleasing to the eye.
2 ml/kg of 300 – 350 mg/ml non-ionic  Dense enhancement of all the major arteries and veins that is sustained throughout
contrast or it’s equivalent not to exceed the sequence of scans and "white out" of the renal parenchyma may suggest an
150 ml or 4 ml/kg (whichever is the excessive contrast dose for the patient's weight.
lower amount).  Hypovolemic shock could cause a similar appearance, but in this condition, there
should also be bowel wall enhancement, and the caliber of the aorta and vena cava
should also be small.
Oral Contrast Oral contrast material must be  Oral contrast is required except for acute trauma and appendicitis, and in these
present with good distension of the cases used at the discretion of the physician.
stomach and opacification of most
small bowel loops. 
Injection rate 1.2 – 3 ml/sec if contrast is given via a  The rates will vary with the catheter size.
power injector through an indwelling  If hand injecting, push as rapidly as possible. The reviewer will refer to the
catheter in the antecubital region. submitted protocols to verify that the site adhered to its protocol, and to verify the
visual assessment of the contrast parameters.
Scan delay Computer assisted or empiric  The standardized administration will vary among institutions.
standardized  The reviewer will refer to the submitted protocols to verify that the site adhered to its
protocol, and to verify the visual assessment of the contrast parameters.
 The scan should be completed prior to visual evidence suggesting that the contrast
has entered the equilibrium phase in the liver. Examples of such evidence would
include loss of cortico-medullary differences in contrast enhancement in the kidney,
, barely perceptible portal vein contrast, or no difference in density between the
aorta and the inferior vena cava.
 It is essential that images be obtained through the liver during the peak of portal
venous enhancement to optimize lesion detection. The portal vein contrast level
should visually be as great or greater than the arterial contrast level, with good
discrimination of the portal vein from the surrounding liver parenchyma.

CTDIvol Reference value = 20 mGy Facilities must submit CTDIvol information on dose received by the patient on the
Pass/Fail Criteria = 25 mGy examination submitted if the scanner is capable. Either include a screen save of the
dose with the images, or place the post scanning dose displayed on the Clinical Test
It is important to be aware that there may be significant differences between the dose
estimates reported by some CT scanners for pediatric scans and what is actually
measured using pediatric dosimetry phantoms. Depending on the field of view selected,
the scanner may assume an adult-size phantom, which is 32 cm in diameter; the
pediatric phantom is 16 cm in diameter. This assumption results in a dose estimate that
is approximately 2.4 times lower for a pediatric study than the same scan technique
would actually produce in a pediatric phantom. In general, pediatric abdomen
techniques should be reduced by approximately a factor of 3 to achieve similar
image quality to an adult abdomen scan.
Coverage For routine trauma abdominal CT the The entire liver should be included, i.e., the sections should begin just above the
scan should extend from the uppermost aspect of the liver.
diaphragm to the symphysis pubis.
For other examinations, clinical
indications indicate extent of scan.
Gantry tilt N/A
Display FOV Appropriate for the patient's body There should be no portions of the body outside the field of view. The field of view
habitus. should be small enough so that its edge lies just beyond the edge of the patient’s
body.
Display window width/level Soft tissue, liver, and lung. The submission of soft tissue, lung and liver windows is required if
submitting by hard copy film. The ww/wl range is recommended
Soft tissue: WW = 300 – 400 HU WL = 10 – 40 HU
Lung: WW = 1200 – 1500 HU WL = -550 – -700 HU
Pediatric Adrenal or Renal Mass*
kVp 80 – 140 kVp
Pitch (IEC Definition) Between 1.0 and 1. 5  In general, a pitch of less than one (“overscanning”) is not recommended in pediatric
patients.
 Some multi-slice scanners limit the choices of pitch. If this results in the site having to
use a pitch of less than one in children, the mAs should be appropriately adjusted
Respiration N/A
IV Contrast medium The recommended IV contrast  The overall enhancement should be pleasing to the eye.
dose is 2 ml/kg of 300 – 350  Dense enhancement of all the major arteries and veins that is sustained throughout
mg/ml non-ionic contrast not to the sequence of scans and "white out" of the renal parenchyma may suggest an
exceed 150 ml or 4 ml/kg excessive contrast dose for the patient's weight.
(whichever is the lower amount).
Oral Contrast Oral contrast is required and
should be adequate to opacify
bowel (varies with age).
Injection rate 1.2 and 3 ml/sec if contrast is  The rates will vary with the catheter size.
given via a power injector through  If hand injecting, push as rapidly as possible. The reviewer will refer to the submitted
an indwelling catheter in the protocols to verify that the site adhered to its protocol, and to verify the visual
antecubital region. assessment of the contrast parameters.
Scan delay Computer assisted or empiric  The standardized administration will vary among institutions. The reviewer will refer to
standardized the submitted protocols to verify that the site adhered to its protocol, and to verify the
visual assessment of the contrast parameters.
 The scan should be completed prior to visual evidence suggesting that the contrast
has entered the equilibrium phase.
 Optimized adrenal or renal mass evaluation should be performed when the kidneys
display a homogeneous tubular nephrogram.
 The portal vein contrast level should visually be as great or greater than the arterial
contrast level, with good discrimination of the portal vein from the surrounding liver
parenchyma.
 It is essential that images be obtained through the liver during the peak of portal
venous enhancement to optimize lesion detection.
 The portal vein contrast level should visually be as great or greater than the arterial
contrast level, with good discrimination of the portal vein from the surrounding liver
parenchyma.
with the images, or place the post scanning dose displayed on the Clinical Test Image
Data Sheet. The CTDIvol should be appropriate for the examination.
Coverage Extend from the diaphragm to the  The entire liver should be included, i.e., the sections should begin just above the
symphysis pubis. uppermost aspect of the liver.
 The kidneys must be studied with thin slice width during the tubular nephrogram
phase of contrast enhancement.
Gantry tilt N/A

Display FOV Appropriate to patient’s body habitus. There should be no portions of the body outside the field of view. The field of view
should be small enough so that its edge lies just beyond the edge of the patient’s
body.
Display window width/level Soft tissue and lung Liver windows are optional
The submission of both soft tissue Soft tissue: WW = 300 – 400 HU WL = 10 – 40 HU
and lung windows is required if
submitting by hard copy film. The Lung: WW = 1200 – 1500 HU WL = -550 – -700 HU
ww/wl range is recommended.

CT Accreditation Program Clinical Image Quality Guide

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CT Accreditation Program Clinical Image Quality Guide

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CT Accreditation Program

Clinical Image Quality Guide

ACR CT Accreditation Dose Pass/Fail Criteria and Reference Levels:

Pass/Fail Criteria Reference Levels

It is important that scanning protocols be designed specifically to optimize visualization of pathologic

All items in bold and italics are accreditation requirements. Failure to

Reconstruction algorithm Standard

Enhanced mediastinum settings:

Adult Calcium Scoring for risk stratification

Adult Renal Mass*

mAs  The mAs selected should result in diagnostic-quality images.

Reconstruction algorithm Standard or soft tissue (or

Weight (kg) mA (Chest) mA (Abdomen/Pelvis)

Respiration Suspension N/A

mAs  The mAs selected should result in diagnostic-quality images.

Coronals- gantry is angled perpendicular to the petrous bone

mAs  The mAs selected should result in diagnostic-quality images.

Reconstruction algorithm Standard or soft tissue

Lung: WW = 1200 – 1500 HU WL = -550 – -700 HU

Gantry tilt N/A

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