Somatom sessions 24

The Difference in Computed Tomography

SOMATOM Sessions

Cover Story SOMATOM Defi nition Flash: Impressive PerformancePage 6

News Functional Imaging Widens the Clinical Spectrum for CT2

Business Chest Pain: Clarity with CTPage 20

Clinical Results SOMATOM Defi nition Flash: The Entire Heart Scanned in Just 270 ms with 0.95 mSvPage 32

Science Iterative Image Reconstruction Moves into Clinical PracticePage 65

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The SOMATOM Defi nition Flash delivers excellent improved diagnostic quality with levels of dose lower than ever before possible. It can be summa-rized in four words: Flash speed. Lowest dose.

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Issue Number 24/May 2009Stanford-Edition I May 19th – 22th, 2009

On account of certain regional limitations of sales rights and service availability, we cannot guarantee that all products included in this brochure are available through the Siemens sales organization worldwide. Availability and packaging may vary by country and is subject to change without prior notice. Some/All of the features and products described herein may not be available in the United States.

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Note: Any technical data contained in this document may vary within defined tolerances. Original images always lose a certain amount of detail when reproduced.

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“The SOMATOMDefi nition Flashis the scannerthat gives you alloptions.”

Stephan Achenbach, MD, Department of Cardiology, University of Erlangen-Nuremberg, Erlangen, Germany

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Responsible for Contents: André Hartung

Editorial Board: Andreas Blaha, Andreas Fischer, Thomas Flohr, PhD, Klaudija Ivkovic, Axel Lorz, Jens Scharnagl, Heiko Tuttas, Alexander Zimmermann

Authors of this Issue: S. Achenbach, MD, Department of Cardiology, University of Erlangen-Nuremberg, Erlangen, Germany

J. Aigner, Department of Diagnostic Radiology, University Hospital, Salzburg, Austria

R. Bauer, MD, Department of Diagnostic and Interventional Radiology, Johann Wolfgang Goethe-University, Frankfurt, Germany

M. Das, MD, Department of Diagnostic Radiology, University Hospital, RWTH-Aachen University, Germany

E. Egin, MD, Department of Radiology, Cardio Center, Volgograd, Russia

W. Eicher, MD, Department of Radiology, Landeskrankenhaus Klagenfurt, Klagenfurt am Wörthersee, Austria

Note in accordance with § 33 Para.1 of the German Federal Data Protection Law: Despatch is made using an address file which is maintained with the aid of an automated data processing system.SOMATOM Sessions with a total circulation of 35,000 copies is sent free of charge to Siemens Computed Tomography customers, qualified physicians and radiology departments throughout the world. It includes reports in the English language on Computed Tomography: diagnostic and therapeutic methods and their application as well as results and experience gained with corresponding systems and solutions. It introduces from case to case new principles and procedures and discusses their clinical potential.The statements and views of the authors in the individual contributions do not necessarily reflect the opinion of the publisher.The information presented in these articles and case reports is for illustration only and is not intended to be relied upon by the reader for instruction as to the prac-tice of medicine. Any health care practitioner reading this information is reminded that they must use their own learning, training and expertise in dealing with their individual patients. This material does not substitute for that duty and is not intended by Siemens Medical Solutions to be used for any purpose in that regard.

J. Ferda, MD, PhD, Clinic of Radiodiagnostics, University Hospital Pilsen, Pilsen, Czech Republic

M. Gerl, Department of Diagnostic Radiology, University Hospital, Salzburg, Austria

R. Gilkeson, MD, University Hospital, Case Medical Center, Cleveland, Ohio, USA

K. Hausegger, MD, Department of Radiology, Landeskrankenhaus Klagenfurt, Klagenfurt am Wörthersee, Austria

K. Hergan, MD, Department of Diagnostic Radiology, University Hospital, Salzburg, Austria

B. Hettegger, Department of Diagnostic Radiology, University Hospital, Salzburg, Austria

F. Hinkmann, MD, Institute of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany

R. Janka, MD, Institute of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany

T. Kau, MD, Department of Radiology, Landeskrankenhaus Klagenfurt, Klagenfurt am Wörthersee, Austria

M. Kerl, MD, Department of Diagnostic and Interventional Radiology, Johann Wolfgang Goethe-University, Frankfurt, Germany

H. Korkusuz, MD, Department of Diagnostic and Interventional Radiology, Johann Wolfgang Goethe-University, Frankfurt, Germany

B. Kreuzberg, MD, PhD, Clinic of Radio-diagnostics, University Hospital Pilsen, Pilsen, Czech Republic

A. Küttner, MD, Institute of Diagnostic Radiology, University of Erlangen-Nuremberg, Erlangen, Germany

M. Lauschmann, MD, Department of Diagnostic Radiology, University Hospital, Salzburg, Austria

M. Lell, MD, Department of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany

D. Perdieus, MD, Department of Radiology, Imelda Ziekenhuis, Bonheiden, Belgium

M. Schlager, Department of Diagnostic Radiology, University Hospital, Salzburg, Austria

A. Schneider, MD, Department of Diagnostic Radiology, University Hospital, Salzburg, Austria

S. Shaid, MD, Department of Medicine, Goethe-University Hospital Frankfurt, Germany

E. Uysal, MD, Department of Radiology, Sisli Etfal Training and Research Hospital, Istanbul, Turkey

U. Valeti, MD, Department of Cardiology, St. Paul Heart Clinic, Saint Paul Minnesota, USA

T. Vogl, MD, Department of Diagnostic and Interventional Radiology, Johann Wolfgang Goethe-University, Frankfurt, Germany

P. Weisser, MD, Department of Diagnostic and Interventional Radiology, Johann Wolfgang Goethe-University, Frankfurt, Germany

E. Wenkel, MD, Institute of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany

Catherine Carrington, freelance author Tony DeLisa, freelance author Ron French, medical writer Louisa Kasdon, medical writer

Photo Credits: Jez Coulson

Peter Aulbach; Karin Barthel; Andreas Blaha; Herbert Bruder, PhD; Joachim Buck, PhD; Steven Bell; Ivo Driesser; Kerstin Fellenzer; Thomas Flohr, PhD; Jan Freund; Inga Fötsch; Tanja Gassert; Christoph Hachmöller, MD; Christiane Iwert; Takumi Katsuya; Carolin Knecht; Bernhard Krauss, PhD; Rami Kusama; Oliver Meissner, MD; Marion Meusel; Tetsuo Onishi; Katharina Otani, PhD; Kerstin Putzer; Rainer Raupach, PhD; Karl Stierstorfer; Heike Theessen; Peter Seitz; Susanne von Vietinghoff; Stefan Wünsch, PhD; all Siemens Healthcare

Production: Norbert Moser, Siemens AG, Healthcare

Design and Editorial Consulting: independent Medien-Design, Munich, Germanyin cooperation with Primafila AG, Zurich, SwitzerlandManaging Editor: Christa LöberbauerPhoto Editor: Susanne NipsLayout: Claudia Diem, Mathias FrischAll at: Widenmayerstrasse 16, D-80538 Munich,Germany

PrePress: Kerstin Putzer, Siemens AG, Healthcare; Reinhold Weigert, Typographie und mehrSchornbaumstraße 7, D-91052 Erlangen

Printers: Farbendruck Hofmann, Gewerbestraße 5, D-90579 Langenzenn, Printed in Germany

SOMATOM Sessions is also available on the internet: www.siemens.com/SOMATOMWorld

The drugs and doses mentioned herein are consistent with the approval labeling for uses and/or indications of the drug. The treating physician bears the sole responsibility for the diagnosis and treatment of patients, including drugs and doses prescribed in connection with such use. The Operating Instructions must always be strictly followed when operating the CT System. The sources for the technical data are the corresponding data sheets. Results may vary.Partial reproduction in printed form of individual contributions is permitted, pro-vided the customary bibliographical data such as author’s name and title of the contribution as well as year, issue number and pages of SOMATOM Sessions are named, but the editors request that two copies be sent to them. The written con-sent of the authors and publisher is required for the complete reprinting of an article.We welcome your questions and comments about the editorial content of SOMATOM Sessions. Manuscripts as well as suggestions, proposals and informa-tion are always welcome; they are carefully examined and submitted to the edito-rial board for attention. SOMATOM Sessions is not responsible for loss, damage, or any other injury to unsolicited manuscripts or other materials. We reserve the right to edit for clarity, accuracy, and space. Include your name, address, and phone number and send to the editors, address above.

SOMATOM Sessions – IMPRINT© 2009 by Siemens AG, Berlin and MunichAll Rights Reserved

Publisher:Siemens AGHealthcare SectorBusiness Unit Computed TomographySiemensstraße 1, 91301 Forchheim, Germany

Chief Editors:

Monika Demuth, PhD ([email protected])

Stefan Wünsch, PhD([email protected])

SOMATOM Sessions · May 2009 · www.siemens.com/healthcare-magazine 77

Imprint

2 SOMATOM Sessions · May 2009 · www.siemens.com/healthcare-magazine

Editorial

“With developing the SOMATOM Definition Flash, our company has once again set a new standard for radiation dose reduction in CT.”Sami Atiya, PhD, Chief Executive Officer, Business Unit Computed Tomography, Siemens Healthcare, Forchheim, Germany

Cover Page: A thorax scan for triple-rule out with the SOMATOM Defi nition Flash is possible in less than one second. Courtesy of University of Erlangen-Nuremberg, Erlangen, Germany


Editorial

Dear Reader,

In the broad spectrum of diagnostic methods and equipment available to the medical industry today, computed tomog-raphy has assumed more and more impor-tance. The number of exams worldwide is increasing, not only because CT offers extremely high diagnostic certainty but also because the acquisition method is simple and results are permanent and reproducible. And because of CT’s versa-tility (cardiology, oncology, trauma, etc.), it is rapidly becoming a standard exam-ination at medical facilities around the globe – therefore it contributes to a sig-nificant amount of overall radiation expo-sure in the entire population. Other sources are natural background radiation (on average 2-4 mSv per year) and other diagnostic/therapeutic procedures, like X-ray, radiotherapy as well as long dis-tance flights. Because of this factor, all CT facilities and vendors assume a heavy and unavoidable responsibility to mini-mize radiation and maximize safety for their patients.The justification for the existence of the entire medical field is, of course, better healthcare for all patients. Siemens has always been a visionary company, believing that even the farthest techni-cal horizons were temporary and could be surpassed with consistent dedication

to improved healthcare. This visionary approach has made Siemens the undis-puted innovation leader in CT over the last 35 years. But our innovative philoso-phy is based solidly upon the assumption that achieving the highest technical per-formance is only important when it meets the needs of the patient. And meeting the needs of the patient means respon-sible dose considerations. Our newest developments clearly illus-trate our commitment to lower dose exposure: for example, our UFC (Ultra-FastCeramic) detector, CARE Dose4D, organ-sensitive dose protection and our revolutionary, new Adaptive Dose Shield, introduced with the SOMATOM® Definition AS adaptive scanner.And with the SOMATOM Definition Flash, we made dose reduction the centerpiece of our research. Its core innovation – the unique low-dose Flash Spiral – can be summarized in four words: Flash speed. Lowest dose. Conventional, single source cardiac CT requires up to 30 mSv dose, except with extremely stable, low heart rates. Siemens’ introduction of Dual Source CT in 2005 radically improved this situation by reducing dose requirements regardless of heart rate. Now, Dual Source technology is combined with Flash speed making possible the industry’s fastest

true temporal resolution of 75 ms and, most important, it reduces dose to an absolute minimum – for example, com-pleting a cardiac scan in less than 300 milliseconds with dose as low as below 1 mSv.For this issue of SOMATOM Sessions, we have been in constant contact and dis-cussions with our customers – medical experts in clinical practice who are faced every day with an unlimited variety of conditions and CT applications. We are therefore able to bring you the first clini-cal results of the SOMATOM Definition Flash, as well as reports and updates of our entire portfolio. Read in this issue and see for yourself how Siemens’ com-mitment to dose management compli-ments our technological and diagnostic excellence, significantly improving healthcare.

Enjoy reading.Sincerely,

André Hartung, Vice President

Marketing and SalesBusiness Unit CT

Siemens Healthcare Forchheim, Germany

André Hartung


Content

Cover Story

6 SOMATOM Definition Flash: Impressive Performance

News

12 syngo 2009 – Functional Imaging Widens the Clinical Spectrum for CT

13 Private Payers Reimburse for CT Colonography in the U.S.

13 500 SOMATOM Definition Dual Source Installations Prove Clinical Success

14 The syngo CT 2009E Software for the SOMATOM Emotion Further Increases the Clinical Capabilities of the Most Popular Scanner

15 Win with Excellent Image Quality at Lowest Dose

15 SOMATOM Definition Flash Intro-duced During ECR 2009

Business

16 The St. Paul Heart Clinic: A Model of Efficiency

20 Chest Pain: Clarity with CT 24 SOMATOM Emotion Around

the Globe 28 Economical Benefits Drive

Thin-Client Server Technology

Cover Story

Content6 SOMATOM Definition Flash CT

6 It’s said that experience is what separates promise from reality. But when it comes to the SOMATOM Definition Flash Dual Source CT scanner, experience shows that promise is reality. As the innovative new scanner is tested in daily clinical practice, it is exceeding nearly every expectation. Split-second thoracic scanning: proven. Sub-milliSievert cardiac scans: confirmed. Superb image quality: no question.

16The St. Paul Heart Clinic: A Model of Efficiency


Content

Acute Care 52 SOMATOM Definition AS+:

Polytrauma Patient Scanned in Seven Seconds

54 Triple Rule-Out in Flash Speed: Entire Thorax Scanned in less than a Second

Orthopedics 56 High Resolution Follow-up of a Wrist

Fracture of the Os Triquetrum with SOMATOM Definition AS+ and z-UHR

Gastroenterology 58 Difficult Drainage After

Cholecystectomy

Science

60 Dual Energy in Clinical Routine with syngo CT Oncology

62 Dual Energy CT in Pulmonary Embolism

65 Iterative Image Reconstruction Moves into Clinical Practice

66 Okinawa Churaumi Aquarium: Imaging Marine Animals with the SOMATOM Spirit

Clinical Results

Cardiovascular 30 Dual Source CT Unveils Several High-

Grade Stenoses of Coronary Arteries 32 SOMATOM Definition Flash: The

Entire Heart Scanned in Just 270 ms with 0.95 mSv

34 Low Dose 3D Evaluation of a Child’s Heart with Anomalous Venous Return with the SOMATOM Sensation

36 Cardiac Scan Prior to Bariatric Surgery 38 Detection of Unusual Case of

Aorto-Leftventricular Tunnel with Dual Source CT

Oncology 40 Dual Source CT Kidney Tumor

Imaging with VNC Dual Energy 42 Lung Perfused Blood Volume Imaging

with Dual Energy 44 syngo WebSpace in Imelda Zieken-

huis in Bonheiden, Belgium

Neurology 48 SOMATOM Definition: Head CTA

Brain Hemorrhage Examination with Dual Energy

50 SOMATOM Sensation: Subtracted 3D CT-Angiography for Evaluation of Arteriovenous Malformation

69 Spatiotemporal Multi-Band Filter for Reducing Artifacts and Dose

Life

70 Clinical Workshops at the Pulse of CT Technology

71 Now is the Time to Elevate SOMATOM AR and SOMATOM Plus 4 Scanners

71 Free 90 Day Trial Licenses for Clinical Applications

72 Clinical Poster on CT-guided Vertebroplasty

72 GEST 2009: Siemens Healthcare Demonstrated Innovation Leader-ship in Interventional Oncology

73 ESGAR Workshops on CT Colonography

73 Frequently Asked Questions 74 News in the CT World 74 Clinical Workshops 2009 75 Upcoming Events & Congresses 75 Experience Lounge at ECR 2009 76 Siemens Healthcare – Customer

Magazines 77 Imprint

66 Imaging Marine Animals in Okinawa Churaumi Aquarium

54 Entire Thorax Scan in Less Than a Second


SOMATOM Definition Flash: Impressive PerformanceIn everyday clinical use, the SOMATOM Defi nition Flash Dual Source CT scanner is proving to be innovative and versatile.

By Catherine Carrington

The SOMATOM Definition Flash makes a thorax scan for triple rule-out possible in less than one second.

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Cover Story

scan with Dual Energy. The Definition Flash does it all.”

Thorax and BeyondAt the University of Erlangen, radiologist Michael Lell, MD, has used the Definition Flash to perform thoracic imaging in approximately 40 patients. Typically, he is able to image the entire thorax in just 0.6 to 0.9 seconds.“This is definitely a breakthrough,” Lell says. “The scan is so fast, we can examine patients who don’t hold their breath, and we get perfect images.”The speed of the Definition Flash trans-lates to better patient safety and comfort. For trauma patients, the ability to scan the entire body in less than five seconds not only reduces motion and breathing artifacts, it has the potential to reduce delays in getting to surgery. Pediatric scanning promises to be easier and safer. And eliminating the need for breath-holding offers comfort to patients who are very sick or injured.“The scan speed is so fast that it’s really unnecessary to switch a respirator on and off in order to get sharp images,” Lell says. “We can just keep on with the respirator and do the fast scan, and we get perfect image quality.”Lell is especially pleased with both the efficiency and effectiveness of the Definition Flash in evaluating patients who come from the emergency room with chest pain. For these patients, he uses a triple rule-out protocol. It includes electrocardiographic gating, but avoids the low pitch and high radiation dose that once burdened triple rule-out studies on single source CTs.“We can do a single scan and rule out three major killers from chest disease: pulmonary embolism, aortic dissection, and coronary occlusion,” he says. “And with the new system, we just fly over the heart and thorax very fast. We don’t have redundant data anymore.”As a result, Lell has found that the radia-tion dose for a triple rule-out study per-formed on the SOMATOM Definition Flash amounts to just 1.6 to 1.9 mSv. “It’s really changing thoracic imaging,” he says. “On the one hand we have an extremely fast scan that offers outstand-

It’s said that experience is what separates promise from reality. But when it comes to the SOMATOM® Definition Flash Dual Source CT scanner, experience shows that promise is reality. As the innovative new scanner is tested in daily clinical practice, it is exceeding nearly every expectation. Split-second thoracic scanning: proven. Sub-milliSievert cardiac scans: confirmed. Superb image quality: no question.“This is the scanner that gives you all options,” says cardiologist Stephan Achen-bach, MD, a professor of medicine at the University of Erlangen-Nuremberg in Erlangen, Germany. “You can scan at unprecedented low doses. You can scan at both low and high heart rates. You can

“We can examine patients who don’t hold their breath, and we get perfect images.”

Michael Lell, MD, PD, Department of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany

“The SOMATOM Defi nition Flash is the scanner that gives you all options.”

Prof. Stephan Achenbach, MD, Department of Cardiology, University of Erlangen-Nuremberg, Erlangen, Germany

ing image quality – and we get the coro-naries for free. On the other hand, we have the ability to perform Dual Energy studies. That’s very exciting.”

Cardiac ImagingStephan Achenbach has also been scan-ning patients on the Definition Flash since mid-February. So far, some 100 patients have been imaged using the new low-dose Flash Spiral mode, that acquires data in a single heart beat, during a 250 ms- pause in the cardiac cycle when the heart is in diastole. The results have been impressive.“The Flash scanner is superb,” says Achen-bach. “In cardiac imaging, what really counts is temporal resolution, and this is the fastest scanner on the market. The image quality is excellent.”


edented radiation dose of less than 1 mSv. Early testing focused on patients weigh-ing less than 90 kg (200 lbs) and used settings of 100 kV and 320 mAs. The result was an average dose of just 0.94 mSv. Stephan Achenbach is now evaluating whether dose can be reduced even further in thin patients and how settings might need to be adjusted in heavier patients.A sub-milliSievert radiation dose has the potential to expand the horizons of cardiac CT to include screening for pre-vention of cardiovascular disease. “We are now at a dose for CT angiography that is less than it used to be for calcium scoring,” Achenbach says. “This low dose could allow us to use cardiac CT for screening. The question is a medical one: Does it make sense to do screen-ing?”Preliminary data published in the Journal of the American College of Cardiology in 2007 and 2008 suggest that findings of non-calcified, non-obstructive plaque on CT angiography add new information that can be used in determining a patient’s cardiovascular risk and prognosis. But the clinical value of cardiac CT screening needs to be confirmed in larger studies, Achenbach says. It is a project he and his colleagues are already undertaking.“It’s possible we are going to find that there are specific patient groups who benefit from this test – patients who have diabetes or a strong family history of heart disease, for example,” Achenbach

The Definition Flash, a second-generation Dual Source scanner, is equipped with two detectors and two X-ray sources set at an angle of approximately 95 degree to one another. With a gantry rotation time of 0.28 s, the scanner boasts a temporal resolution of just 75 ms. Moreover, an innovation introduced with the Definition Flash eliminates the need for the patient table to slowly inch forward during data acquisition. Instead, in low-dose Flash Spiral mode, the scanner achieves gap-less z-sampling even with the wide-open spiral created by a pitch of 3.2 and a table speed of more than 40 cm/s. This is because the two detectors create two complementary data spirals that together include all the information that would be found in a single spiral acquired at a much slower table speed – but without redundant, overlapping data and unnec-essary radiation exposure.During the first weeks of gathering clinical experience at the University of Erlangen-Nuremberg, the Flash mode has been used primarily to scan cardiac patients. This approach has produced flawless images free of motion artifacts. “This scanner allows us to do cardiac imaging at the lowest dose with the highest

image quality,” says Prof. Willi Kalender, PhD, director of the Institute of Medical Physics at the University of Erlangen-Nuremberg. “We actually measured both spatial and temporal resolution in the Flash mode, and they are uncompro-mised. For cardiac imaging, no question, this is the best.”Equally important, both patient exami-nations and physics measurements con-clusively show that the Definition Flash can scan the complete heart at an unprec-

The worldwide first SOMATOM Definition Flash, installed at the University of Erlangen-Nuremberg, Erlangen, Germany.

“This scanner allows us to do cardiac imaging at the lowest dose with the highest image quality.”

Prof. Willi Kalender, PhD, Director of the Institute of Medical Physics of the University of Erlangen-Nuremberg, Erlangen, Germany


Cover Story

says. “We don’t have that data yet, but we now have a scan mode that would allow us to use this technology for screening if we find that it makes sense for the patient.”

Dual EnergyDual Energy studies are a special interest of Hatem Alkadhi, MD, who heads both body CT and cardiovascular imaging at the Institute of Diagnostic Radiology, University Hospital Zurich, Switzerland. He has performed hundreds of Dual Energy exams using the first-generation Dual Source scanner, the SOMATOM Definition, and now the new Definition

Flash scanner as well.“Dual Energy gives radiologists additional information that we don’t have when making single energy scans,” says Alkadhi. “This is a great benefit of this technique.”Dual Energy imaging involves the simul-taneous operation of two X-ray sources at different energy levels. This enables differentiation of fat, soft tissue and contrast material on the basis of their unique energy-dependent attenuation profiles. As impressive as early versions of Dual Energy imaging have been, the Definition Flash brings new strengths to the table. An important new feature is the selective

photon shield that pre-filters high kV X-rays, removing low-energy photons. This improves separation of the 80 kV and 140 kV images and, therefore, improves material differentiation by about 80%. In addition, the photon filter consistently reduces image noise and substantially cuts radiation dose. “With the second generation of Dual Energy, we’re finally able to deliver additional diagnostic infor-mation with dose levels comparable to a single energy scan. That’ll make the decision to use Dual Energy even easier for us,” Alkadhi says.An improved ability to separate materials has important clinical implications. It

With the latest DSCT technology, the heart can be visualized artifact free and with an ultra-low dose of 0.95 mSv in Flash speed.2

2


The improved ability to separate materials with Dual Energy makes it easier to characterize the composition of urinary stones.

ing another important application of Dual Energy CT – evaluation of suspected pul-monary embolism. Dual Energy imaging enables the radiologist to not only detect a blood clot that is cutting off blood flow through the pulmonary artery, but also to show the effect of the obstruction on perfusion of the lung tissue itself.In the past, the use of Dual Energy imag-ing was limited to the center of the lung because of the smaller size of the second detectors. A similar problem hampered Dual Energy imaging in the liver, where observing contrast uptake can aid in determining whether a lesion is hepato-cellular carcinoma or a hemangioma. To realize its full potential, Dual Energy must be able to image even lateral seg-ments of this large organ.“When we make a Dual Energy scan,

makes it easier to characterize the com-position of urinary stones, for example, and guide clinical decisionmaking. If a stone is composed of uric acid, the urol-ogist has the option to try medical ther-apy, rather than immediately referring the patient for shock wave lithotripsy.“This is better for the patient,” Alkadhi says. “And our ability to use Dual Energy to separate materials of similar density is what makes it possible.”Similarly, Dual Energy imaging makes it simple to differentiate iodinated contrast material from bone, two materials with similar densities on standard CT. With a click of a button, bones can be removed from an image, leaving only the opaci-fied arteries for examination. In other circumstances, iodine can be subtracted from an image, creating virtual nonen-

hanced images without need for a sepa-rate scan prior to contrast injection. This approach is helpful in reducing radiation dose when performing studies that would normally involve more than one imaging phase. It is also helpful when a suspicious inci-dental finding is noted on a contrast-enhanced scan, Alkadhi says. With stan-dard CT, it is impossible to determine in retrospect whether the lesion is simply a hyperdense mass or has the propensity to take up contrast, a worrisome clue that suggests malignancy. With Dual Energy imaging, a virtual “do-over” is possible. By subtracting iodine from the image, it is possible to create a precontrast image and evaluate lesion density in the absence of contrast enhancement.The SOMATOM Definition Flash is improv-

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Cover Story

we want to cover the whole organ of interest – the whole lung, the whole liver, the whole abdomen,” Alkadhi says. “If you can’t, it limits the practicability of your technique and the willingness of the radiologist to use it. Obviously Siemens understood this. The Definition Flash is a big step forward with the large Dual Energy field of view.”Now the Definition Flash is outfitted with two 4-cm detectors, and the field of view is no longer a limitation in large organs like the lung and liver. “With the new system the field of view is so large we can cover the entire lung,” Alkadhi says. “The lung parenchyma is completely displayed with Dual Energy properties, including the periphery.”

Dose Dose savings are built into the SOMATOM Definition Flash. Besides the reduced radiation exposure that directly results from the high table speed, the scanner has several other dose-sparing features. Previously, Dual Energy imaging typically exposed patients to between 10% and 20% more radiation than a corresponding single energy scan. Now, the photon shield eliminates the dose penalty in most types of Dual Energy studies, Kalender says.In addition, the new scanner is equipped

applies to shorter scan ranges, such as for the heart or the brain, or in pediatric imaging. We can expect a higher percent reduction as compared to standard scan-ning.”“For example, the radiation dose could be reduced by as much as 50% for a scan of the heart performed at high pitch on the Definition Flash, when compared to the same type of scan without the dose shield,“ Kalender says.Another dose-saving feature designed for the Definition Flash is X-CARE. This technique, which provides organ-specific dose reduction, enables the radiologist to turn off the X-ray tube during the por-tion of the gantry rotation that would directly expose radiation-sensitive organs, such as the breast, thyroid gland, or eye. According to a study Kalender published in European Radiology last year, the X-CARE technique can cut radiation dose to the breast by 50% during thoracic imaging.“It’s the best way to reduce dose to the female breast,” Kalender says. “It’s an exciting prospect.”

Further Information

www.siemens.com/somatom-definition-flash

“With the second generation of Dual Energy the fi eld of view is so large we can cover the entire lung.”

Hatem Alkadhi, MD, PD, Institute of Diagnostic Radiology, University Hospital Zurich, Switzerland

Direct exposure of dose sensitive organs can be significantly reduced by using X-CARE.

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with adaptive dose shielding, which blocks the X-rays at the beginning and end of each spiral acquisition that will not be used in image reconstruction. In the case of cardiac scans, adaptive dose shielding cuts radiation dose by as much as 25% when the studies are performed using a conventional pitch. However, the dose savings are expected to be much greater when patients are scanned using the Flash mode.“The percent dose reduction with the adaptive dose shield is greater the higher the pitch and the shorter the scan range,” Kalender says. “That means as we go to even higher pitch values, the effect of shielding on dose is greater. The same

Catherine Carrington is a medical writer and holds a master’s degree in journalism from the University of California Berkeley. She is based in Vallejo, CA.

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Low dose

High dose


News

syngo 2009 – Functional Imaging Widens the Clinical Spectrum for CTBy Karin Barthel and Stefan Wünsch, PhD, Business Unit CT, Siemens Healthcare, Forchheim, Germany

Siemens is further strengthening its commitment to deliver software products that can significantly increase diagnostic speed and confidence in everyday radi-ology as well as maintaining the innova-tion leadership for functional CT. The latest syngo 2009 software focuses on the new era of functional imaging in CT. With the launch of new applications such as syngo Dual Energy Lung Nodules, syngo Dual Energy Xenon, syngo Volume Perfusion Myocardium* and major improvements in syngo Volume Perfusion CT, more functional aspects are added to the classical morphological information of CT images.Applying a newly developed 4D Noise Reduction technique implemented in syngo Volume Perfusion CT Neuro, the radiation dose of dynamic CT exams can be reduced by a substantial amount with-out compromising on diagnostic image quality.*syngo DE Lung Nodules permits visualiz-ing the contrast agent concentration in the lung nodules without the use of an additional non-contrast scan (Fig. 1). It may support the differentiation of lung

tumors. The new syngo Dual Energy Xenon sets a new trend in the evaluation of chronic and acute lung diseases. With the latest advances in CT imaging tech-nologies, the clinical evaluation of, for instance, COPD (chronic obstructive pul-monary disease), is rapidly moving from pure visualization to quantitative analysis of lung parenchyma abnormalities. The acquired information may contribute to a more accurate planning of a surgery. Furthermore, the application provides information about the effectiveness of medication in a very early stage of the treatment.The syngo Volume Perfusion Myocar-dium** allows the display and analysis of dynamic CT data of the heart utilizing the heart perfusion scanning mode of the SOMATOM® Definition Flash after contrast injection. The application not only helps to determine hemodynamic relevance of a myocardial infarction, it further provides information that can help to distinguish whether the myocardial infarction is old or fresh (Fig. 2). In addi-tion, syngo 2009 supports the fusion of dynamic data of other modalities e.g.

dynamic angiographic data from Dyna CT with 4D CT data, thereby obtaining further functional information.Of course, since the last major software version was released, many more improvements in routine and advanced applications e.g. in Expert-i, syngo CT Oncology, syngo InSpace as well as in syngo Neuro DSA have also been made.To benefit from the latest enhancements within existing applications only a soft-ware upgrade is needed.***To test the dedicated applications in advance, 90 days trial licenses can be ordered. In case of interest, the local Siemens sales representative should be contacted.

www.siemens.com/ct-applications

* requires syngo 2009B.** a prerequisite is syngo VPCT Body.

*** dependent on workstation configuration.

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1 Solitary pulmonary nodule in an adult patient displayed with DECT: iodine enhancement is shown as colored overlay to a virtual non-contrast image; the semi-automatic segmentation result is indicated in blue. Courtesy of Asan Medical Center, Seoul, Korea.

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2 SOMATOM Definition Flash Heart Perfusion: Minor perfused myocardium (arrows) scanned with spatial resolution 0.33 mm, rotation 0.28 s, 2 x detector coverage .


News

Private Payers Reimburse for CT Colonography in the U.S.

By Joachim Buck, Business Unit CT, Siemens Healthcare, Forchheim, Germany

500 SOMATOM Defi nition Dual Source Installations Prove Clinical Success

By Rami Kusama, Business Unit CT, Siemens Healthcare, Forchheim, Germany

Stunning results of several CT Colonog-raphy (CTC) trials (e.g. ACRIN1 6664) have motivated the American Cancer Society (ACS) to add CTC to its five-year colon screening guidelines in 2008. Despite this fact, CMS (Centers for Medi-care and Medicaid Service) announced a proposed non-coverage decision for CTC, at least for the time being. However this proposed decision won’t discontinue the success story of CTC.Two major commercial payers, Blue Cross Blue Shield of Delaware (BCBSDE) and Philadelphia region’s largest health insurer, Independence Blue Cross (IBC), have started to reimburse for CTC. BCB-SDE has agreed to reimburse the patent-

With currently 500 installations world-wide, the SOMATOM® Definition has redefined the face of CT. Within three years, DSCT has proven itself in clinical routine as state-of-the-art with more than 1,500,000 coronary CTAs performed, 250 peer-reviewed papers, and 200,000 Dual Energy scans. Together with the SOMATOM Definition Flash, introduced in 2008, the SOMATOM Definition family will continue to define – and redefine – the expanding world of CT.

pending Integrated Virtual Colonoscopy™ model from Colon Health Centers (CHC)2 of America, a Philadelphia-based company that partners with pre-eminent gastro-intestinal physician groups in a region, enabling them to provide CTC as an option to traditional colonography for colon cancer screening. BCBSDE is providing a single, bundled, episode-of-care payment “per screening event” for CTC and believes that it is essential to have the capability to provide same-day, same-prep thera-peutic colonography for patients who undergo CTC. CHC of America is expecting several Mid-Atlantic region Blue Cross plans and other commercial insurers to begin to reimburse CTC within the next several months. Payers are encouraged and positively responding to the high sensitivity, safety and convenience that CTC offers patients, as well as the signifi-

cantly lower ”per screening event” costs. With colorectal cancer (CRC) screening rates hovering in the dismal 50% range, payers are looking for other screening options to get their members off the ‘screening sidelines’. CTC is that new option. For example, nearly 50% of the patients screened at CHC of America sites report that the availability of patient-friendly CTC was the force motivating them to receive life-saving CRC screen-ing. CT Colonography will definitely play a large role in CRC screening for the fore-seeable future. With this, CTC is definitely the wave of the future and it is highly expected that other private payers will follow in the near future.

This map shows where SOMATOM Definition DSCT scanners are installed worldwide in Diagnostic Imaging Centers (red dots), Community Hospitals (blue dots), Departments of Cardiology (deep red dots), Emergency Departments (yellow dots) and University Hospitals (deep blue dots).

www.siemens.com/dsct

References1 ACRIN (American College of Radiology Imaging

Network)

2 www.colonhealthcenters.com

Enhanced diagnostic confidence using syngo Colonography PEV as a second reader option for colon polyp detection.


News

The syngo CT 2009E Software for the SOMATOM Emotion Further Increases the Clinical Capabili-ties of the Most Popular ScannerBy Steven Bell, Business Unit CT, Siemens Healthcare, Forchheim, Germany

The release of the syngo CT 2009E software version for all new SOMATOM® Emotion systems further reinforces Siemens Healthcare’s dedication to con-tinuously increase clinical capabilities throughout the product portfolio.syngo CT 2009E makes remote access to the scanner workplace available for the first time through the introduction of syngo Expert-i. Siemens’ leading applications, such as syngo CT Oncology, are available for the first time on the SOMATOM Emotion CT Workplace, and a number of leading syngo applications have been even further enhanced.

Additional capabilities on Acquisition WorkplaceWith the syngo CT 2009E release, Expert-i will allow physicians or senior CT technol-ogists to connect remotely to the scan-ning workplace. This functionality enables the CT users to seek an expert clinical

opinion quickly and efficiently without the need to physically go to the CT suite, resulting in improved workflow and better clinical outcomes for patients. In interven-tional CT, the simple and efficient work-flow for which the SOMATOM Emotion is known is further enhanced with the addition of a laser grid to increase the speed and accuracy of CT interventional procedures.With the release of this software Siemens also continues the philosophy of reduc-ing dose in CT. To assist users in this con-tinual process, a comprehensive and exportable dose report is now available on the SOMATOM Emotion with the syngo CT 2009E release.

Additional capabilities on CT WorkplaceThrough the introduction of the syngo CT 2009E software, leading applications, including syngo CT Oncology, are now

available on the CT Workplace with the additional convenience of a linked data-base with the CT system. syngo CT Oncol-ogy increases the speed and accuracy of CT oncology imaging through the use of automated lesion measurements, routine volume calculations, and auto-matic lesion matching for follow-up staging studies.In addition to syngo CT Oncology, syngo Neuro Perfusion Weighted Map, e-Logbook, and InSpace Circulation PE Detection are now also available on the CT Workplace with the potential to significantly improve workflow in acute care imaging.syngo CT 2009E has been available on all new Emotion 6- and 16-slice configu-rations since the beginning of April 2009.


News

Win with Excellent Image Quality at Lowest DoseBy Jan Freund, Business Unit CT, Siemens Healthcare, Forchheim, Germany

SOMATOM Defi nition Flash Introduced During ECR 2009By Carolin Knecht and Peter Seitz, Business Unit CT, Siemens Healthcare, Forchheim, Germany

Seeing is better than believing. Therefore Siemens CT will launch a global contest to underline that the Definition family is the choice for achieving the best results when it comes to image quality. In 2005, Siemens CT introduced its Dual Source Technology with the highly successful SOMATOM® Definition. Since then, more than 500 systems have been installed, proving that Dual Energy has become a routine application and thus making the SOMATOM Definition the proven Dual Source CT. In 2007, Siemens then launched the most flexible scanner sys-tem in the market, the SOMATOM Defini-tion AS which adapts to any patient, while at the same time also adapts for complete dose protection with innova-tive technologies. Since its introduction, the SOMATOM Definition AS has achieved the fastest ramp-up in Siemens CT history.But these cutting edge systems were

Themed, “Ask the Ultimate Power in Imaging,” Siemens Healthcare intro-duced its latest imaging innovation, the SOMATOM® Definition Flash, at the European Congress of Radiology (ECR) 2009 from March 6 to March 10 in Vienna, Austria.This latest computer tomograph is designed to be the industry’s most patient friendly CT by requiring less dose through faster speed. During the congress, dose reduction was obviously of universal interest for the visitors. Many wanted to know more details about technical features of the SOMATOM Definition Flash that enable users to scan with highly reduced radia-

not the end of CT’s innovation potential: Last year, CT continued its Dual Source success story with the introduction of the SOMATOM Definition Flash, allowing scanning the entire thorax in less than one second and imaging the heart with a radiation exposure of less than 1 mSv, only a fraction of the natural background radiation.Consequently, the time has come to prove the superior image quality of the SOMATOM Definition family obtained with significantly reduced dose. As the best proof is customers’ voice, Siemens CT will host a contest for all Definition users addressing highest image quality at low-est dose which will be introduced in June 2009. Participants are welcome to send in cases scanned on any Definition scanner (single and Dual Source). A jury of highly qualified experts and medical advisers will discuss each case and deter-mine the finalists. Therefore, beginning

immediately, all Definition customers are invited to participate in this contest and start collecting their outstanding low dose cases and demonstrate their achievements in cutting-edge CT.

The new SOMATOM Definition Flash was introduced to the European market during the European Congress of Radiology (ECR) 2009 featuring a special “healthy” version of the low-dose scanner.

www.siemens.com/CT-IQcontest

tion dose, for example, heart scan with less than 1 mSv. The fast scan speed of 43 cm/s and the temporal resolution of 75 ms were also subjects of great gener-al interest at the Siemens booth.At a Joint Satellite Symposium of Siemens Healthcare and Bayer Schering Pharma, first clinical results of the SOMATOM Definition Flash were presented, together with updates on the entire range of SOMATOM Definition scanners. According to the theme “For better patient care: What’s new in CT,” leading clinical experts once again complimented the innovative power of Siemens CT and made it one of the most visited symposia at ECR 2009.

The SOMATOM Definition Family: Revolutionizing CT imaging since its intro-duction in 2005.


Business

The St. Paul Heart Clinic: A Model of EfficiencyThe leading physician overseeing the construction and equipping of a new clinic in the State of Minnesota (USA) has found that making a big investment in state-of-the-art technology for cardiac imaging pays big dividends for patient care.

By Ron French

The cardiovascular imaging center in the St. Paul Heart Clinic (St. Paul, Minnesota, USA) is unique in more ways than one. It is the first independent cardiology prac-tice in the world to incorporate both

St. Paul Heart Clinic, Saint Paul, Minnesota, USA.

Siemens MRI and SOMATOM® Definition Dual Source CT scanning technology, thereby offering state-of-the-art imaging and unprecedented patient and customer efficiencies. And what’s even more unique

is that the clinic has designed a success-ful business model around these cutting edge technologies.At the heart of this success story is Uma Valeti, MD, Director of Cardiovascular


Business

of Siemens sites and talked to the engi-neers in detail. Siemens offered a well integrated cardiovascular imaging solu-tion with these two modalities that was unparalleled by other vendors at the time. Since our installation of Siemens equip-ment we have been able to compare our efficiencies and workflow – as well as the satisfaction of our patients, nursing staff and technologists – and we’ve been extremely happy with our choice.

A limitation of most cardiac CT scan-ning technology has been its inability to capture clear images of a beating heart. Some patients had to be placed on beta-blockers to slow their hearts to 60 beats a minute and had to wait for an hour for the medication to kick in. And the chests of obese patients were too dense to permit a clear image. As many as 10 percent of the images were non-diagnostic. How has the SOMATOM Definition improved imag-ing efficiencies?What we found with Dual Source CT was that there were very few exclusions, for previously common reasons like high heart rate, asthma or large body habitus. Patients didn’t have to take beta-blockers mandatorily to reach a heart rate below 60 beats/minute, and the system was better able to deal with irregular heart rates, so there was no need to wait for hours prior to the scan. We saw that it would be advantageous and improve workflow. The patients are happy due to the ease of the exams, the physicians

are happy because they did not need to exclude many patients that were previ-ously excluded, and finally our staff is happy due to less work involved in pre-paring a patient for the study.

And the improved workflow cut costs?The improved workflow meant more efficient patient throughput. The non-diagnostic scan rate is now less than three percent, which is less than half of what it was before with regular 64-slice scanners. Additionally, the time and dol-lar savings on mandatory beta-blocker administration and aftercare are not tak-en into account in this consideration.

Siemens SOMATOM Definition Dual Source CT also offers a low-dose option – reducing patient radiation from the industry standard of up to 30 mSv per scan to below 3 mSv, without compro-mising image quality. And with the new SOMATOM Definition Flash you can even reach levels of below 1 mSv. Was that a selling point?Yes, it was a big selling point. The one big knock against CT was always the radiation level. It’s important to lower the radiation dose as much as possible, without compromises in image quality. This fits into our goals of patient first, safety first. Being able to offer low dose cardiac CT is a clear differentiator and a competitive advantage. And the latest DSCT is setting a new benchmark in this dose battle among CT vendors, strongly reducing concerns about dose.

CT/MRI, at the St. Paul Heart Clinic (SPHC). Four years ago, Valeti moved from the Mayo Clinic in Rochester, Minnesota, to SPHC to build the Cardio-vascular MRI/CT imaging center. He oversaw not only the selection and pur-chasing of the imaging technology, but also the communications and customer service that have been integral to the center’s growth. Valeti shares the steps St. Paul Heart Clinic took to build the advanced imaging practice in an inter-view with SOMATOM Sessions – steps that other physician groups could emu-late.

It’s unusual for an independent cardi-ology practice to have both MRI and CT imaging. Why did you choose to include both in your practice and what were some of the challenges you anti-cipated when you were building the advanced imaging program?Our practice has 38 cardiologists and we are a tertiary care facility. We get a lot of complex cases referred to us in addition to the usual mix of cardiac pathology. We were convinced that cardiac CT and MR imaging were leading a paradigm shift in the future of general cardiac imaging and not just limited to complex cardiac diseases. We wanted to have all the ad-vanced modalities to diagnose and man-age the routine and complex patients re-ferred to us not only for patient care but also to enhance our ability to recruit highly talented physicians looking to in-tegrate cutting edge clinical care and re-search into their professional careers.

Your clinic is designed so that, if needed, patients can go seamlessly from the MRI lab to the CT lab. Your imaging rooms are separated by a glassed-in control room, which is the nerve center of both imaging labs. There were many choices for equip-ment. Why did you pick SOMATOM Definition Dual Source CT and Siemens Avanto MRI?We had no previous experience with Siemens. We had worked with CT and MR scanners from different vendors and went out and looked at a number

The SOMATOM Definition scanner delivers clear images for save diagnoses – even in patients with fast or irregular heart beats or with an obese body habitus.


Business

at various small and large group confer-ences. The message was simple and consistent. We kept saying, “Here are all the imaging modalities and clinical solu-tions we have, and here’s what they can offer. If you feel they can benefit your patient, here’s the number to call.” We also made it very simple for them to re-fer patients. Everybody in the group had extensive education about each modality, appropriate indications as defined by the guidelines including the scheduler, the technologists, the nurses and the pro-gram administrator in addition to being aware of the unique Siemens technologi-cal benefits. At first, we turned down many referring providers who were order-ing studies that did not meet the appro-priateness criteria, at the risk of offending them. However, the initial emphasis was on letting our referring providers realize that our program was a credible patient centric program and if they know we were being very careful to prevent un-necessary utilization eventually we would get more appropriate studies. In addition, we had a constant line of com-munication with all the referring provid-ers with access to an imaging physician at all times for any question related to the appropriate use of advanced imag-ing modalities.

It sounds as if you have to be as good as a businessman as a physician.We are fortunate to have an outstanding administrative leadership team for busi-ness planning. Therefore the credit goes to them. From my perspective, what the doctors and third-party payers really want to know is: Is this a layered test? Are you just adding another test to patients already getting stress tests and MRIs or an angiogram? Even before we began the program, we engaged all the parties involved – all the cardiologists, the pri-mary care providers and the third-party payers – and informed them that we are going to start this program, and shared our pilot data with them to reassure them that there would not be layering of tests. On the contrary, we shared data about the large cost savings to the system based on our initial pilot of 250 patients. We also informed them that every year we

Full cardiac evaluation possible with syngo Circulation which is automatically included in CT Cardiac and Acute Care Engine.

What were some of the challenges you anticipated and what did you do to build market share to the point that the clinic could work economically? What was your marketing plan?Because this is new technology, we real-ized the biggest hurdle would be aware-ness and education. Although we are a tertiary care practice, most physicians

within our practice and in the community were not aware of the benefits and appro-priate use of these advanced technolo-gies and how they can improve clinical diagnoses, management and treatment of their patients, as well as decreasing the overall costs of working up patients. Members of my group gave about 200 formal and informal talks in the first year

Anterior-oblique volume rendered view of the heart of an obese patient depicting the right coronary artery (RCA) and left artery descending (LAD) with the Dual Source CT SOMATOM Definition.

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Business

would come back and show the data to the third-party payers.

And what happened?At the end of the first year, we invited all the major payers to come to our practice. The data was remarkable. In a study of more than 1,000 cardiac CT scans, only 15 percent of patients went on to have angiograms. Normally, if CT was not in the picture, more than 50 percent of these patients would go on to have angiograms based on previous studies of patients with equivocal or mildly positive stress tests. However, invasive angiograms carry a higher procedural risk and are 5 to 10 times more expensive than CT scans.

You are a busy interventional cardiol-ogist. What is your perspective on cardiac CT?Being an interventional cardiologist, I am very skeptical of anything that is por-trayed in the media as a replacement to an invasive angiogram. But I can’t argue with the fact that for 30 to 40 percent of patients that are currently referred for diagnostic angiography, cardiac CT is in fact a safer and equally effective proce-dure in addition to being cost effective for the health system due to its very high negative predictive value. What would really help in convincing decision makers like cardiologists, primary care

“The improved workfl ow means greater patient throughput and the non-diagnostic scan rate is now three percent, less than half of what it was before.”

Uma Valeti, MD,Director of Cardiovascular CT/MRI, St. Paul Heart Clinic, St. Paul, Minnesota, USA.

Further Information

www.siemens.com/ct-cardiology

physicians and the third-party payers is data from large multicenter trials, prov-ing the benefit of the cardiac CT in a wide patient population.

Your equipment was installed in 2006. In those three years, your market share has grown to 90 percent of cardiac MRI and CT imaging in your region. There are more than 20 clinics referring to your center. How do you account for that rapid growth?The key has been good, relevant informa-tion that was immediately conveyed to the referring providers along with the outstanding patient experiences during the process of scheduling, scanning and follow up. Consequently our program has been growing steadily for the past three years with a wide range of clinical pathol-ogy. Our advanced imaging program sup-ports several sub-speciality clinics and helped in their growth (for example: vas-cular clinic, adult congenital clinic, CHF clinic, Hypertrophic Cardiomyopathy clin-ic, Pulmonary Hypertension clinic etc). We were also very successful in educating our referring providers about the techno-logical benefits offered by our CT and MR imaging equipment. For instance, the low dose cardiac CT protocols, the high image quality even in difficult patients, the lack of a mandatory need for oral beta-block-ers and lack of a large list of exclusion

criteria was very attractive for them.We were also able to recruit eight highly talented physicians in the last three years, at a time when most practices in the re-gion had trouble recruiting and retaining cardiologists. An important reason is be-cause St. Paul Heart Clinic offered them advanced imaging modalities that provide exciting and unique capabilities and ser-vices.

Do you have any advice for other clinics that are considering investing in SOMATOM Definition CT technology?We believed in the technology and believed that it would inevitably move to mainstream modality in a few years. You have to spend a lot of time in educating the people who will be using it and pay-ing for it. This is a long-term strategy and you will need to believe in the para-digm shifts occurring in cardiac imaging. That’s why we invested in it.

Ron French is a senior writer and award-winning journalist for the Detroit News, where he specializes in coverage of health care and the economy.


Topic

Chest Pain: Clarity with CTIt’s not an insignifi cant problem, nor a cheap one. With more than six million patients a year presenting at emergency departments with chest pain, costing an estimated eight billion dollars, the importance of an accurate, effi cient and quick way to determine which patients need inter-ventional treatment and follow-up is hard to ignore. Dual Source CT scan-ners meet these criteria perfectly. They are enhancing diagnostic capacity for adult and pediatric patient populations that would have formerly been excluded from CT scans because of conditions such as obesity, high heart rates, atrial fi brillation or contra-indications to beta-blockers.

By Louisa Kasdon

Business“You can do the ‘triple rule-out’

in real time, confi rming three diagnoses with one scan.”

Udo Hoffmann, MD, MPH, Director of Cardiac MR PET CT Program, Massachusetts General Hospital, Boston, MA, USA

“With the new SOMATOM Defi nition Flash technology, you will be able to image the entire chest in less than one second.”

Harold I. Litt, MD, PhD, Assistant Professor of Radiology and Medicine, Chief, Cardiovascular Imaging Section, Department of Radiology, University of Pennsylvania Health System, Philadelphia, PA, USA


Topic

The “Holy Grail” in the emergency depart-ment, according to Gilbert Raff, MD, of William Beaumont Hospital in Royal Oak, Michigan, USA, is figuring out which patients to send home, and which to keep for further observation and treatment. Raff, a cardiologist with more than thirty years of clinical experience, says that misdiagnosing a patient and sending him or her home with a potentially fatal heart attack, is the nightmare scenario for every ER doctor. The tricky part is to identify the 10 to 20%, out of the patient cohort, who really do need immediate treatment.

A Roundtable at the University of PennsylvaniaA group of prominent American inter-ventional radiologists and cardiologists, specialists at the forefront of their pro-fessions, suggest that immediate triaging to a CT scan for patients presenting with chest pain has the potential to radically streamline the diagnostic process and speed up the door-to-balloon interval. SOMATOM Sessions recently met with three of these experts for a roundtable discussion at the University of Pennsyl-vania – Harold I. Litt, MD, PhD, Assistant Professor of Radiology and Medicine, Chief, Cardiovascular Imaging Section,

Department of Radiology, University of Pennsylvania Health System in Philadel-phia; Udo Hoffmann, MD, MPH, Director of Cardiac MR PET CT Program at the Massachusetts General Hospital (MGH) of Harvard University in Boston; and Gilbert Raff, MD, Director, Ministrelli Cen-ter for Advanced Cardiovascular Imag-ing, William Beaumont Hospital, Royal Oak, Michigan – and listened in as they revealed their vision for a new “gold standard” for the diagnosis of chest pain.These clinicians believe that scanning patients with a Dual Source CT (DSCT) SOMATOM® Definition can save billions of dollars in healthcare costs annually. “The work-up of those patients who do end up not having a heart attack costs us about eight billion dollars a year. A big chunk, with the potential for big health-care savings,” says Hoffmann. Litt con-curs, “we conducted a large trial, with more than 640 individuals, about the actual financial comparison of different strategies to evaluate patients with potential acute coronary syndrome.“*“Herein we compared the CTA group (A) with the two groups being treated the standard or current way,” describes Litt. These two groups are the clinical decision unit group with serials of biomarkers and stress test (B) and the usual care group

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which was defined as admission with serial biomarkers and hospital-directed evaluation (C).The main outcomes were actual cost of care (facility direct and indirect fixed, facility variable direct labor and supply costs), length of stay, the 30-day read-mission rate as well as safety measured in 30-day death or myocardial infarction rate.The study showed an overwhelming result. The standard of care group B and the usual care group C revealed median costs of $2,913 – $4,024 per patient and an average length of stay of 26.2 to 30.2 hours. The rate of myocardial infarction and death was 0.7 to 3.1%. The readmission rate was between 2.3 and 12.2% here, which means that addi-tional cost has to be considered for the patients coming back for further test and treatment. Those results were com-pared with the new CTA strategy. The cost per patient in the CTA group A were found to be only $1,240 which was a 57% to 69% saving. Similar results been revealed for length of stay with eight hours in CTA group, which was a time advantage of 69 – 73%. Interestingly the rate of myocardial infarction or death in the CTA group (A) was 0%, which can be explained with the high negative predic-

Topic “With the CT of the heart

being less than one milliSievert, radiation will basically no longer be an issue.”

Gilbert Raff, MD, Director, Ministrelli Center for Advanced Cardiovascular Imaging, William Beaumont Hospital, Royal Oak, MI, USA


Business

tive value of almost 100% of the DSCT. Also the 30 day readmission rate was 0% which means no patients coming back for additional testing or treatment, which saves additional time and money. Litt and his group found that, using total facility cost in their analysis, immediate CTA was the least costly method of eval-uation. It also resulted in reduced length of stay, decreased rate of admission, lower rate of return visits, and at least equivalent 30-day outcomes. Other strategies that required inpatient or ob-servation unit admission were more costly, had more prolonged length of stay, and did not detect any more dis-ease than the immediate CTA strategy.

The subset of patients who received ’usu-al care’ accompanied by cardiac testing (stress echo, treadmill testing, or cardiac catheterization) had a mean cost of $4,154 compared to $1,239.

A Unique Tool for a Better ImageBeyond economic and efficiency issues, any new technology has to support better patient care. These three doctors feel strongly that the new generation of Dual Source CT scanners enables them to iden-tify cardiac issues with more clarity, and yields diagnostic information to prevent future disease. There is a big impact on patient care. “We now have a unique tool

with the spatial and temporal resolution that can help us noninvasively visualize the disease,” Hoffmann explains.At MGH, Udo Hoffmann is conducting a randomized trial where both low-risk and high-risk patients are put into a CT scanner. For the high-risk patients with a suspicion of pulmonary embolism, aortic dissection, or acute coronary syn-drome, he is finding the Dual Source scanners high-image-quality, even at high heart rates or with obese patients, extremely helpful. “You can do the ‘triple rule-out’ in real time, confirming three separate diagnoses with one scan,” says Hoffmann. For the low-risk patient sub-clinical disease can be captured also and treatment can be started that could pre-vent a heart attack in the future.”

The Heart is a Moving TargetAnother advantage of the Dual Source CT scan seems to be speed. “Because the heart is moving, in order to get images of it that don’t have motion artifacts, you need to be able to scan as quickly as possible,” says Litt. He enthuses that a DSCT scanner like the SOMATOM Definition Flash scanner “can freeze the heart’s motion twice as fast as other com-peting technologies. This is a particularly important benefit for patients who come to the emergency room and cannot take a beta-blocker to lower their heart rate so that the heart beats more slowly. “In our patient population,” Litt explains, “we have patients with asthma or suspi-cion of other lung problems like pulmo-nary embolism, people who have taken cocaine recently – and you can’t use these types of drugs on them. With the new Dual Source CT, it is possible to do a thorax scan in a split second without holding breath. We can scan patients with higher heart rates and have confi-dence that we’re going to get good image quality.”Obese patients represent another clinical challenge. Litt says: “With the Dual Source CT technology, we’re able to get better image quality at lower radiation doses in

Dual Source scanners deliver high image quality, even at high heart rates.


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With sub-milliSievert heart scanning, the SOMATOM Definition Flash raises the bar higher in terms of cardiac dose saving.

obese patients, even those who weigh more than 350 pounds.” At Raff’s hospi-tal in Michigan, using a new software package, that he terms the cardio obese model, in combination with the Dual Source CT allows him to scan 90% of obese patients and get a diagnostic image.

Next Steps for CT Scanners?As the technology continues to improve, the doctors look ahead to a new era of even greater clinical utility as equipment like the Flash scanner comes into clinical use. When they see that one could now image at 83 milliseconds, they understand immediately that this is a tremendous improvement, really a quantum leap from the 64-slice CT. It opens up their

patient population to patients who were previously considered not suitable – for example, those with calcification – and lets a diagnosis become even more quan-titative. Litt concurs, that with SOMATOM Definition Flash it is possible to image very quickly. “Typically a chest CT on an average high-end scanner might take five to ten, perhaps twenty seconds. With the new technology, you will be able to image the entire chest in less than one second. That will allow us to get very clear images of the heart, the pulmonary arteries, and the aorta without the patient needing to hold his breath. Similarly, in children and infants who can’t understand the direction to take a deep breath and hold it, you will be able to get motion-free images of the entire chest or the

body in a time frame where the patient can remain still.”With sub-milliSievert heart scanning, the SOMATOM Definition Flash raises the bar even higher in terms of cardiac dose saving. Raff pronounces, “that with the CT of the heart being below 1 milliSievert, radiation will basically no longer be an issue.” Hoffmann says that, due to its low dose, it is even conceiv-able that, in the future, this technology could be used for early detection and prevention of acute myocardial infarc-tion.Another priority for the future is collect-ing better clinical data. The physicians are working together to launch several, large, multi-center trials to get demon-strable data and validation of the new triage pattern for their colleagues, for the NIH, and for the large public and private insurers such as Medicare in the USA, all of whom will have to be convinced of the CT scanner’s superiority as a diagnostic tool as well as its ability to increase work-flow and efficiency in emergency depart-ments all across the country. Other pri-orities for the doctors are education and training. Unless young physicians and radiological technicians are trained to use and interpret CT scans, the benefits of the technological advances will be limited to the most sophisticated medi-cal centers.

Further Information

www.siemens.com/somatom-definition

Louisa Kasdon is a Cambridge, Massachusetts-based writer who specializes in health, medi-cine, nutrition, food and business. She writes about health issues for Fortune magazine, the Boston Globe and the Christian Science Monitor.

* Chang AM, Litt HI et al.: Actual Financial Comparison of Four Strategies to Evaluate Patients with Potential Acute Coronary Syndromes. ACADEMIC EMERGENCY MEDICINE. 2008; 15: 649-655.


Topic

SOMATOM Emotion Around the GlobeWorldwide sales of the SOMATOM Emotion CT system recently exceeded 6,500 units, making it globally the most popular CT system. SOMATOM Sessions asked eight clinics why they chose the Emotion system and how it has been put to use in their clinical environments.

By Steven Bell, Business Unit CT, Siemens Healthcare, Forchheim, Germany

“We are very pleased with the performance of the SOMATOM Emotion 16. The system reliability has been excellent.”

Holly Klein, RT(R)(M), Director of Imaging/Cardiolab Services, Shannon Clinic, San Angelo, Texas, USA

6

“We were looking for a workhorse scanner, and the SOMATOM Emotion has proven to be that. We’ve never had any problems with the system – it’s great!”

Reginald Moultrie, MD, Radiology Supervisor, Northside Hospital, Atlanta, Georgia, USA

“The system has an extraordinary image quality – in fact, we have the best images in the entire city!”

Ramírez Calderón, MD, Centro Médico de Diagnóstico Hermanos Ramírez Calderón, San Cristóbal, Táchira, Venezuela

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Business

The SOMATOM® Emotion has proven itself over and over again as a leading work-horse CT in almost all global CT markets. The SOMATOM Emotion has achieved this outstanding success through a com-bination of excellent image quality, lead-ing-edge clinical applications, efficient CT workflow and Siemens’ continued focus on system uptime. These factors offer Siemens customers enhanced clinical capabilities that translate into better clini-cal and financial outcomes. The success

of this philosophy is easily recognized with over 6,500 satisfied and knowledge-able customers worldwide.On these pages, SOMATOM Sessions has put together a selection of quotes and stories from many successful SOMATOM Emotion installations from all corners of the globe. These sites are varied in nature, from outpatient clinics, to comprehen-sive trauma hospitals, and offer superb examples of why the SOMATOM Emotion is the world’s most popular CT system and

“The image quality is excep-tional. The system enables us to scan and process patients’ images very fast. For emer-gency cases at night, we use only this system.”

Yu Kang Chang, MD, CT Section Chief, Chie Mei Medical Center, Luiying, Tainan, Taiwan

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“We examine practically the complete non-cardiac spectrum of patients on our SOMATOM Emotion 6 – from patients with diffuse lung disease to those with cerebral ischemia.”

Pavel Elias, MD, PhD, Professor of Radiology, University Hospital Hradec Králové, Czech Republic

“All examinations – head, whole body, thorax, abdomen and pelvis – are performed with the SOMATOM Emotion 16. The postprocessing is extremely fast.”

Prof. Kunihiko Fukuda, MD, Tokyo Jikei University Hospital, Japan

why it is the right choice for CT service installation.

1 Tokyo Jikei University Hospital, Japan.

The Tokyo Jikei University Hospital is one of four hospitals associated with the Jikei School of Medicine. The hospital is large, with over 1,050 beds and 3,000 outpatient visits per day, six days a week. It has four CT systems to service both in- and outpatients. In 2006, the hospital

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installed a SOMATOM Emotion 16 to ser-vice all routine examinations and emer-gency cases. Professor Kunihiko Fukuda says that up to 70 patients are examined with the Emotion 16 per day: “All exam-inations – head, whole body, thorax, abdomen and pelvis – are performed with the SOMATOM Emotion 16 at our hospital. The postprocessing is extremely fast. The techs create MPR, MIP and 3D images in no time at all.”

2 University Hospital Hradec Králové Czech Republic.

The Department of Radiology at the Uni-versity Hospital Hradec Králové is associ-ated with the Charles University in Prague. This facility ranks among the most significant healthcare facilities in the Czech Republic. The hospital serves a population of approximately 1,000,000 residents and many departments attract patients from the entire Czech Republic. The hospital is an important training cen-ter for physicians and secondary school educated medical workers. Every year, about 42,000 patients are admitted to 21 clinics with about 1,500 beds, and ap-proximately 660,000 patients are treated as outpatients. Since 2004, the lead CT system has been a SOMATOM Emotion. Pavel Elias, MD, PhD, from the University Hospital Hradec Králové says: “There are two CT scanners working in our facility. We examine practically the complete non-cardiac spectrum of patients on our SOMATOM Emotion 6 – from patients with diffuse lung disease to those with

cerebral ischemia. Perfusion studies or CT angiography are crucial for treatment pa-tients with cerebral ischemia, subarach-noid hemorrhage, or for patients with an-eurysmal dilation of aorta. We exam up to 50 patients per day.”

3 Chi Mei Medical Center, Luiying, Tainan, Taiwan.

The Chi Mei Medical Center in Luiying, Taiwan, installed the SOMATOM Emotion 6 in mid-2004. Initially, the system was used to examine over 1,400

patients per month until a second CT system was installed. The SOMATOM Emotion system provides 24-hour ser-vices for all routine and emergency cases. “The image quality of the SOMATOM Emotion is exceptional, even when com-pared to the 64-slice systems in our department,” says CT Section Chief Yu-Kang Chang, MD. “The workflow of the SOMATOM Emotion 6 enables us to scan and process patients’ images very fast. It’s the reason why we only use SOMATOM Emotion 6 for emergency cases at night instead of the other CT systems in the department.”

4 Treviso Santa Maria Cà Foncello Hospital, Italy.

The workload at the Neuroradiology Department of Treviso Santa Maria Cà Foncello Hospital can be very heavy. Over 13,000 CT procedures were performed on the SOMATOM Emotion 6 during 2008. “The Emotion 6 performance in neuro-radiology is without any doubt satisfying as far as image quality and scanning speed are concerned,” says the chairman of the department, Francesco Di Paola, MD. Moreover, he praises the versatility of the system. At his hospital, the

“The SOMATOM Emotion 6 performance in neuroradiology is without any doubt satisfying. It offers the quality-to-price ratio the hospital was looking for.”

Francesco Di Paola, MD, Chairman Neuroradiology Department, Treviso, Santa Maria Cà, Italy

The SOMATOM Emotion has proven itself as a leading workhorse CT.


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SOMATOM Emotion is used not only for neurological-related exams (brain, head, maxillo-facial, CT angiography of the carotids and intracranic vessels) but also for general radiology (thorax and abdo-men). “The SOMATOM Emotion,” says Di Paola, “offers the quality-to-price ratio the hospital was looking for.”

5 Centro Médico de Diagnóstico Hermanos Ramírez Calderón,

San Cristóbal, Táchira, Venezuela.Since the opening of the Centro Médico de Diagnóstico Hermanos Ramírez Calderón in 2007, the CT department’s patient traffic has grown to around 35 examinations per day. “We are a family of physicians and decided to build this center for the benefit of the city of San Cristóbal. Since I have four children who are radiologists, we decided on the field of diagnostics,” says Ramírez Calderón, MD. From the onset, the team of doctors was convinced that this center should offer the highest technology with state-of-the-art equipment. “When we started, we decided to work only with the best systems available on the market,” says Ramírez Calderón. “The Emotion is a very good CT system, it has extraordinary images – in fact, we have the best images in the entire city!”

6 Shannon Clinic, San Angelo, Texas, USA.

Shannon Clinic is a large, multi-speciality outpatient clinic with around 120 physi-cians. In 2000, the hospital purchased a Siemens SOMATOM Emotion single slice system. “The system was easy to use and very reliable,” says Holly Klein, RT(R)(M), Director of Imaging/Cardiolab Services. “Our technologists loved it. Due to the higher quality and performance, Shannon Clinic decided to upgrade to the Siemens SOMATOM Emotion 6 in 2004.” Then, in 2008, a decision was taken to upgrade the Emotion 6 scanner to the SOMATOM Emotion 16. Since the decision the num-ber of CT examinations has steadily been growing from a base of around 300 cases per month. “We are very pleased with the performance of the SOMATOM Emotion 16. The system reliability has been excel-

lent. We use the scanner to perform high-quality routine examinations such as abdomen, pelvis, head, and chest,” says Holly Klein. “Feedback from our radiology staff has been very positive about the image quality of the SOMATOM Emotion 16,” Klein continues. “Furthermore, our patients are particularly happy with the shorter scan times.”

7 Northside Hospital, Atlanta, Georgia, USA.

With imaging facilities spread across a large metropolitan area, Northside Hospital in Atlanta, Georgia, needed a CT solution that would reliably and effi-

of CT procedures. In 2007 alone, North-side performed more than 78,000 CT exams. The SOMATOM Emotion was built with reliability in mind and has not dis-appointed the staff at Northside. “We’ve never had any problems with it since we’ve had it here,” says radiology super-visor Reginald Moultrie. “It’s great.”

8 Yunus Emre State Hospital, Eskisehir, Turkey.

The Yunus Emre State Hospital was first opened under the name Eskis̨ehir SSK District Hospital on the 4th of April 1963. In early 2005, the hospital has been handed over to the Ministry of Health.

“We have optimized our hospital workfl ow with the fast scan protocols of the SOMATOM Emotion.”

Alper Yurdasiper, MD, Yunus Emre State Hospital, Eskisehir, Turkey

Further Information

www.siemens.com/somatom-emotion

ciently allow its staff to image a large volume of patients with a broad range of medical needs. “Our goal is to make sure that our care is convenient and patient-centric while also providing our referring physicians with high-quality imaging – regardless of location,” says director of Radiology Services, Deidre Dixon. In January 2008, Northside chose to install five Siemens SOMATOM Emotion CT scanners across their network. As a result, Northside has been able to expand its imaging services while gaining effi-ciencies and measurable financial bene-fits from faster workflow. “We were looking for a workhorse scanner,” says radiologist Carolyn J. Weaver, MD, “and the SOMATOM Emotion has proven to be that.” In addition to superb image quality, Northside wanted a system that would efficiently handle its large volume

The SOMATOM Emotion 16 was installed in February 2008. “With the SOMATOM Emotion CT, we are able to scan 90 patients per day on average,” says Alper Yurdasiper, MD. “Especially in periphal angiography studies, the diagnostic sharpness has increased due to the great image quality of our SOMATOM Emotion. Radiologists in our hospital are grateful to achieve such high-quality CT images. Moreover, we optimized our hospital workflow with the fast scan protocols of the SOMATOM Emotion.’’


Topic

Economical Benefi ts Drive Thin-Client Server TechnologyBy Joachim Buck, PhD

Business Unit CT, Siemens Healthcare, Forchheim, Germany

CT is making 3D post-processing and advanced clinical applications a necessity for daily routine in radiology depart-ments. Large volumes of data with thou-sands of images per study require 3D imaging for faster diagnosis. 3D as diag-nostic tool increases reading efficiency and saves time. Due to the CT data explo-sion and the increasing spectrum of clinical applications, hospitals and other

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clinical enterprises are searching for technologically and economically feasible solutions to access and utilize CT volume data. Consequently, in recent years, Siemens has developed more powerful clinical applications for cardiac, oncology, neuro, and acute care CT. The availability of high quality CT volume data and the development of new clinical applications deliver more and better information to

clinicians for their treatment choices. However, the delivery of huge CT volume data sets to the individual workstations of the involved physicians is a heavy bur-den for the IT system and performance can, and often does, slow down con-siderably. In addition, the purchase of several stand-alone workstations, each fully packed with clinical applications, puts heavy pressure on the hospital’s

Emilio Vega, Manager, Image Processing Lab at NYU Langone Medical Center, integrated syngo WebSpace, Siemens’ thin-client server technology, into clinical workflow.


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budget. In view of the increased aware-ness of IT infrastructure, and its potential impact on the organization’s business success, the strong trend from stand-alone workplaces to thin-client, server-based solutions, such as Siemens’ syngo WebSpace, is very natural and driven primarily by the following economic benefits:

3D reconstructions immediately available anywhere: Several thousand images per CT exam are no longer an exception. Referring physicians, neuro and orthopedic surgeons, oncologists etc., cannot view and diagnose all these images. They need 3D reconstructions and the functionality to interactively modify the 3D representations according to the specific details they are interested in. A thin-client, server-based system centralizes the complete 3D volume pro-cessing at the server. The 3D results are immediately available to the physicians on their personal viewing stations. They can make use of basic viewing features such as MPR, MIP or VRT and advanced clinical applications for cardiac, oncology, neuro, and acute care CT.

Usage of existing IT infrastructure: For image processing, volume data sets are sent from the CT scanner to the central server where all the image processing software (e.g. vessel analysis) is up and

running. From each unit (e.g. PACS view-ing station) connected to the server via the IT network, the clinician can start the processing of a CT volume data set. Thus thin-client server technology does not place any additional burden on the local hospital’s IT infrastructure. Large amounts of CT data are no longer distributed across the entire IT network to several work-stations. Therefore, 3D image processing does not slow down the system for other image transfer purposes. Expensive upgrades of the whole IT infrastructure are avoided.

Cost-effective maintenance: A thin-client, server-based solution reduces time and cost of keeping data and soft-ware up-to-date and consistent across the healthcare enterprise. It saves a lot of technical man-hours required for both the installation and maintenance.

Faster workflow and patient through-put: Within the radiology department, thin-client server technology significantly increases productivity. Technologists no longer need to run pre-processing at the scanner’s acquisition console. Radiology departments are able to shift higher salaried personnel from time-consuming, routine tasks to more com-plex and demanding duties, resulting in faster and better diagnosis for the patient.

Increased revenue: Thin-client, server-based technology makes 3D post-pro-cessing and advanced clinical applications available to other departments within the hospital or to referring physicians. Therefore hospitals can significantly increase reimbursement and revenue.

Shorter reading times: 3D reading soft-ware provides significant added value for the patient’s diagnosis. Compared to stand-alone workplaces, thin-client, server-based solutions are capable of speeding up the 3D reading process by easily integrating into existing PACS installations. The end result of being able to access the very same case in 3D applications with just one click, can lead to an earlier therapy decision for the patient.

Competitive edge for the hospital/department: Ongoing cost pressure due to shrinking healthcare budgets is com-mon to all healthcare facilities. As this fact drives the competition among hos-pitals and healthcare providers, thin-client server technology can provide a competitive edge in attracting referring physicians and patients as well as recruiting qualified medical staff to join the hospital or department.

Significant cost reduction: 3D thin-client images are instantaneously avail-able on virtually any clinical-quality PC, PACS workstation etc. Hospitals no longer have to incur additional costs of adding hardware for 3D post-processing throughout the hospital or in remote locations.

Investment protection and flexibility: Investment into thin-client server technology enables hospitals and other healthcare enterprises to gradually invest, depending on varying needs, and thus spread costs over several budget cycles. Investment protection programs, such as Siemens’ exclusive e-Tune, are the key to keeping hospitals and other healthcare enterprises economically on the safe side.

“syngo WebSpace allows our clinicians to access advanced post-processing tools from any computer at the offi ce or even at home. This has given us fl exibility thus becoming more effi cient.”

Emilio Vega, Manager, Image Processing Lab at NYU Langone Medical Center


Clinical Results Cardiovascular

VRT of the LM, CX and RCA revealed calcified lesions in LAD (arrow, Fig. 1A). Lateral VRT shows the entire course of the RCA (arrow, Fig. 1B).

approximately 8 mm from the ostium. Significant calcified plaques in the proximal part of the right coronary artery (RCA) and the left coronary artery descending (LAD) causing high-grade stenoses with hemodynamic relevance were observed. An additional high-grade stenosis was found in D1.

COMMENTS

With the high temporal resolution of the Dual Source CT, it was possible to perform a reliable and quick diagnosis even with this extreme arrhythmic heart rate.

Case 1Dual Source CT Unveils Several High-Grade Stenoses of Coronary ArteriesBy Evgeny Egin, MD* and Andreas Blaha**

HISTORY

A 77-year-old male patient presented with chest pain at the radiology depart-ment of the Cardio Center, Volgograd, Russia, in preparation for aortic femoral bypass surgery. The patient had a known history of several atherosclerotic arteries, without hemodynamic relevant stenoses and atrial fibrillation. The patient also suffered from chronic iron deficiency, cerebral atherosclerosis with temperate Parkinson’s Syndrome and inter-vertebral osteochondrosis with neurovascular dis-orders.

DIAGNOSIS

Prior to the contrast enhanced scan, a calcium scoring native cardiac scan was performed. Almost every segment showed coronary artery calcifications. The coronary CTA was performed with an arrhythmic heart rate of 65–181 bpm, on average 94 bpm. Aorta and pulmo-nary artery trunk and branches were not dilated.The scan revealed a right dominant heart, wide left main coronary artery (LM), left circumflex artery (CX) and its marginal branch as well as the right ventricular branch, all without hemodynamic rele-vant stenoses. A high-grade stenosis was detected in first diagonal branch (D1),

* Department of Radiology, Cardio Center, Volgograd, Russia

** Business Unit CT, Siemens Healthcare, Forchheim, Germany

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Cardiovascular Clinical Results

EXAMINATION PROTOCOL

Scanner SOMATOM Definition

Scan mode Spiral Spatial resolution 0.33 mm

Scan area Heart HR Independent Temporal

Scan length 149 mm Resolution 83 ms

Scan direction Cranio-caudal Slice collimation 0.6 mm

Scan time 13 s Slice width 0.75 mm

Heart rate 65 – 181 bpm, 94 avrg. Reconstruction increment 0.6 mm

Tube voltage 120/120 kV Reconstruction kernel B26f

Tube current 198 mAs/rot. Postprocessing CT Cardiac Engine

Rotation time 0.33 s

Crossectional cut of LAD (Fig. 3A); Curved Planar Reformats of RCA, with syngo Circulation QCA (Fig. 3B).

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Curved Planar Reformats of RCA including plaque analysis (Fig. 2A); curved LAD, with syngo Circulation plaque analysis (Fig. 2B).

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Case 2SOMATOM Defi nition Flash: The Entire Heart Scanned in Just 270 ms with 0.95 mSvBy Stephan Achenbach, MD* and Andreas Blaha**

HISTORY

A 70-year-old female patient was referred to the cardiology department because of recurrent episodes of atrial fibrillation accompanied by typical chest pain. Prior to catheter ablation, coronary CT angiog-raphy was scheduled to assess pulmo-nary vein anatomy and to rule out coro-nary artery stenoses.

DIAGNOSIS

During coronary CT angiography, which was performed using a SOMATOM® Definition Flash Dual Source CT system, the patient was in sinus rhythm (52 bpm). In order to achieve accurate contrast timing, contrast agent transit time was determined using a test bolus approach after injection of 10 ml contrast agent

(Ultravist 370), followed by 60 ml of saline solution. Coronary CT angiography was performed in Flash Spiral mode (prospectively ECG-triggered spiral acqui-sition, 0.28 ms rotation time, pitch 3.2), with a 270 ms scan in cranio-caudal direction, triggered at 55% of the RR interval. 60 ml of contrast agent was followed by 60 ml saline chaser, both injected with 6 ml/s flow to keep the bolus as compact as possible.CT angiography was able to clearly demonstrate the absence of coronary artery stenoses as well as the absence of calcified and non-calcified plaques.A minor calcified lesion was located at the aortic valve. Anatomy of the left atri-um and pulmonary veins was normal.For coronary CT angiography, using the

prospectively ECG-triggered Flash Spiral mode, the dose length product was 68 mGy/cm, corresponding to an estimated effective dose of 0.95 mSv.

COMMENTS

With a fast rotation time of 0.28 seconds and two X-ray tubes, the SOMATOM Definition Flash system allows a new, prospectively ECG-triggered spiral scan mode that uses a very high pitch value. This fast scan mode requires only 270 ms of data acquisition time within one single cardiac cycle and provides a temporal resolution of 75 ms. It there-fore allows ultra-low dose, artifact free visualization of the heart and coronary arteries.


Scanner SOMATOM Definition Flash

Scan mode Flash Spiral Cardio Pitch 3.2

Scan area Heart DLP 68 mGy/cm

Scan length 120 mm Slice collimation 128 x 0.6 mm

Scan direction Cranio-caudal Slice width 0.75 mm

Scan time 270 ms Spatial resolution 0.33 mm

Tube voltage 100/100 kV Reconstruction increment 0.4 mm

Tube current 320 mAs/rot Reconstruction kernel B26f

CTDIvol 3.29 mGy Volume 60 ml contrast

Effective Dose 0.95 mSv Start delay 24 s

Rotation time 0.28 s Postprocessing CT Cardiac Engine

** Department of Cardiology, University of Erlangen-Nuremberg, Erlangen, Germany



Curved planar reformation in MIP technique depicts the entire course of the RCA (Fig. 2A). The “angio like view” in MIP from ante-rior oblique direc-tion shows the entire coronary tree (Fig. 2B); image processing with syngo Circu-lation.

Volume rendered image of the heart, highlighting the coronary arteries in the foreground as well as the left atrium in the background (LA in red).

Volume rendered image of the heart show-ing the right coro-nary artery (RCA, arrow) and right ventricular branch (RVB, arrowhead, Fig. 3A). Volume rendered image of the posterior descending artery (PDA, arrowhead) and the left artery descending (LAD, arrow, Fig. 3B).

Curved planar reformation with syngo Circulation in MIP technique shows the entire course of the LCX (Fig. 4A) and the LAD (Fig. 4B) for interactive lesion evaluation.

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Case 3Low Dose 3D Evaluation of a Child’s Heart with Anomalous Venous Return with the SOMATOM SensationBy Robert Gilkeson, MD

University Hospital, Case Medical Center, Cleveland, Ohio, USA

HISTORY

A 19-month-old male patient presented with failure to thrive. An echocardiogram demonstrated a markedly enlarged right ventricle and findings consistent with total anomalous venous return. A mark-edly enlarged common draining vein entering the superior vena cava (SVC) was identified. The echocardiogram was limited in delineating the full course of this anomalous vein. For pre-surgical eval-uation, a three dimensional evaluation was needed. A CT scan was requested by the surgical team. The patient’s weight was 14 kg (31lbs) with a heart rate of 132 bpm. A “feed and bundle” technique


Scanner SOMATOM Sensation 40-slice configuration

Scan mode Spiral, Care Dose4D, MinDose Spatial resolution 0.33 mm

Scan area Chest Reconstruction increment 0.4 mm

Scan length 130 mm Reconstruction kernel B20f

Scan direction Cranio-caudal Volume 28 ml

Scan time 5 s Start delay No actual “scan delay”.

Heart rate 132 bpm Because of the small size of

Tube voltage 80 kV these patients, a pressure

Tube current 10 mAs/rot. injector was not used. Begin of

Dose modulation Retrospective ECG gating with imaging as soon as approxi-

MinDose technique mately ¾ of the contrast medium

Rotation time 0.33 s has been infused.

Slice collimation 0.6 mm Postprocessing syngo 3D

Slice width 0.75 mm

was performed, where the performance of the CT was coordinated with the last bottle-feeding. There was no need for patient sedation, the IV contrast was hand injected at a dose of 2cc/kg. A low-dose CT angiographic technique was performed with a protocol used to evalu-ate infants with congenital heart dis-ease. The X-ray dose that had to be ap-plied was 0.102 mSv with DLP 6 mGycm.

DIAGNOSIS

Volumetric and MIP reconstructions demonstrate a markedly enlarged anom-

alous common draining vein emptying into the SVC. The right ventricle was markedly dilated.

COMMENTS

Due to the 0.33 s fast rotation time and corresponding high temporal resolution, the pediatric patient’s heart could be vi-sualized without motion artifacts despite the high heart rate of 132 bpm. These images were important in the surgical planning, and surgical redirection of the large anomalous vein into the left atri-um has been successfully performed.


Cardiovascular Clinical Results

Axial image demonstrates anomalous drainage of pulmonary veins (orange arrows) into common draining vein (white arrow).

Coronal MIP image demonstrates large anomalous draining vein emptying into SVC (white arrows). Marked enlargement of right ventricle (RV) is clearly visible.

Low dose (0.1 mSv) axial image demonstrates the anomalous common vein draining into the SVC (white arrows).

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Case 4Cardiac Scan Prior to Bariatric Surgery By Uma Valeti, MD

Department of Cardiology, St. Paul Heart Clinic, Saint Paul, Minnesota, USA

HISTORY

A 57-year-old obese female patient with a body mass index (BMI) of 52, weight 305 lbs (138.6 kg), presented for a pre-operative evaluation to undergo a bar-iatric surgery. The patient had cardiac risk factors of hypertension (HTN), hyper-lipidemia and diabetes mellitus. An exer-cise cardiolite stress test was performed with equivocal results due to the pres-ence of attenuation and splanchnic arti-facts due to the large body habitus.

DIAGNOSIS

The patient, presented with a heart rate of 78 beats per minute, was given 0.4 sublingual nitroglycerin (NTG) prior to the scan. The contrast flow rate was increased to 7 ml/s for improved contrast to noise ratio, total volume of contrast was set to 100 ml.The start of the coronary CTA was trig-gered by the Bolus Tracking approach, placing a region of interest in the aorta ascending.During the fast scan time of only eight seconds the scan revealed mild to moder-ate stenoses associated with mixed plaque in the proximal left artery descending (LAD, Figs. 4–5).

COMMENTS

The cardiac obese protocol done with combining information in 165 ms of the cardiac circle shows improvement in the signal to noise ratio compared to the standard of using 82 ms (Figs. 3A–3B).

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volume rendered image of the heart (VRT) embedded in thoracic cage.

VRT of the heart showing the entire course of LAD and first diagonal (D1) branch lesion marked with arrow.

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Improved signal to noise ratio using 165 ms data acquisition (Fig. 3A) versus 82 ms data acquisition (Fig. 3B).

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Moderate stenosis in proximal segment of LAD (mixed plaque).

Cross-sectional cut of the stenotic area perpendicular to the centerline of curved LAD path.

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Scan mode Obese Cardio Protocol Pitch 0.32

Scan area Heart Spatial resolution 0.33 mm

Scan length 124 mm Slice collimation 64 x 0.6 mm

Scan direction Cranio-caudal Slice width 0.75 mm

Scan time 8 s Reconstruction increment 0.4 mm

Heart rate 78 bpm Reconstruction kernel B26f

Tube voltage 120 kV Volume 100 ml

Tube current 205 mAs/rot. Flow rate 7 ml/s

Start delay Bolus Tracking Effective dose 6.2 mSv

Rotation time 0.33 s Postprocessing CT Cardiac Engine

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Case 5Detection of Unusual Case of Aorto-Leftventricular Tunnel with Dual Source CTBy Wolfgang Eicher, MD, Thomas Kau, MD, Klaus Armin Hausegger, MD

Department of Radiology, Landeskrankenhaus Klagenfurt, Klagenfurt am Wörthersee, Austria

HISTORY

A 16-year-old patient appeared at the department of radiology suffering with fever for the past week. A Magnetic Resonance Tomography (MRT) and an echocardiographic investigation showed a thickened bicuspid aortic valve and a perfused tissue structure, seeming to arise from left-ventricular outflow tract. A coronary fistula could not be diagnos-tically excluded with these methods due to the extreme adjacency to left cir-cumflex coronary artery (LCX) and left main coronary artery (LMCA). To clarify whether or not there was a coronary aneurysm or an endocarditic based paravalvular aneurysmatic aorto-leftventricular tunnel (ALVT), a Dual Source CT was conducted under the fol-

lowing conditions: DLP 120, 2.04 mSv, slice 7 x 0,6 x 32 x 2 mm, RECON, Saline flush mix 5 ml KM and 40 ml NaCl, flow 6 ml/s. The heart rate during the examination was 75 bpm.

DIAGNOSIS

In the cardio CT, a close relation between the inflammatory ALVT and the LM could be observed (distance 1–2 mm), whereas the LM itself and their lumen were not affected. Additionally, a small left ventricular perforation adjoining the bicuspid aortic valve was visible. The tiny hole in the aortic root could be only supposed. These findings seemed to be accordable with



Scan mode Adaptive Cardio Sequence Rotation time 0.33 s

Scan area Heart Slice collimation 0.4 mm

Scan length 175 mm Slice width 0.6 mm

Scan direction Cranio-caudal Spatial resolution 0.33 mm


Heart rate 75 bpm Reconstruction kernel B26f

Tube voltage 100 kV Volume 80 ml

Tube current 190 mAs/rot. Flow rate 6 ml/s

Dose modulation ECG-pulsing on, Start delay 2 s

from 70–74%, MinDose off Postprocessing CT Cardiac Engine

CTDIvol 7.09 mGy

an inflammatory ALVT, based on endo-carditis of the bicuspid aortic valve, which could be confirmed by thorax surgery and histological findings.

COMMENTS

Afterwards, the etiopathology was controlled by transoesophageal echo-cardiography. The patient was treated by a two-step surgery. After closure of the left ventricular defect, the sac of the tunnel was growing and compressed the LCA leading to significant ischemic ECG abnormalities and elevated CK-MB. In a second step, the aortic hole was closed by a patch-plastic and the ALVT was obliterated by using fibrin adhesive.


Cross-sectional cut in left ventricle and ALTV above aortic valve (arrow).

With VRT calculation (yellow) the size of the lesion (arrow) can be measured.

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Extraction of left coronary artery (LM) and circumflex coronary artery left neighboured by the ALTV visualized with syngo Circulation (Fig. 4A). The ALTV is nicely visible in the cross-sectional axial slice (Fig. 4B).

4A 4B

Cross-sectional cut in left ventricle and ALTV above aortic valve showing inverted VRT. Arrows indicate relevant region on each image.

1A 1B

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Clinical Results Oncology

Case 6Dual Source CT Kidney Tumor Imaging with Virtual Non-Contrast Dual EnergyBy Jiri Ferda, MD, PhD and Boris Kreuzberg, MD, PhD

Clinic of Radiodiagnostics, University Hospital Pilsen, Pilsen, Czech Republic

HISTORY

A 56-year-old male patient was referred to the University Hospital Pilsen with abdominal pressure pain near the right kidney region. The patient also experi-enced fever and weight loss. A hematuria exists and has been proven by the gen-eral practitioner. The proximate ultra-sound showed a right kidney infiltration.

DIAGNOSIS

After a Dual Energy scan performed on the SOMATOM® Definition, the post pro-cessing of the images in VNC (Virtual Non-Conrast) displayed a color-coded iodine distribution map. The Dual Energy iodine assignment confirmed a tumor infiltra-tion of the right kidney and, emphasized by color-coding, the hypervascularized tumor tissue with involvement of the renal vein. The same SOMATOM Definition scan verified metastases in retroperitoneal lymph nodes.

COMMENTS

In the Dual Energy mode, two X-ray sources can be operated simultaneously at different kV levels. The results are two spiral data sets, acquired in a single scan, providing diverse information that

allows one to differentiate, characterize, isolate, and distinguish the imaged tissue and material. Enhancement patterns of kidney regions can be clearly visualized with the Dual Energy VNC application.



Scan mode Spiral

Scan area Abdomen

Scan length 500 mm

Scan direction Cranio-caudal

Scan time 17 s

Tube voltage A/B 140/80 kV

Tube current A/B 60/360 Eff. mAs

Rotation time 0.5 s

Spatial resolution 0.33 mm

Slice collimation 0.6 mm

Slice width 0.6 mm

Reconstruction increment 0.4 mm

Reconstruction kernel D20f

Postprocessing syngo DE Virtual Unenhanced (VNC)


1

Dual Energy Virtual Non-Contrast (VNC) scan. Dual Energy scan shows vascularisation of tumor, composed data with contrast (arrows).

Mixed visualization of VNC and iodine concentration. Dual Energy application highlights iodine concentration.

65

VRT with Bone Removal shows vascular status of the tumor (arrow).

Coronal reformation of the right kidney using Optimum Contrast.

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Case 7Lung Perfused Blood Volume Imaging with Dual EnergyBy Ralf W. Bauer, MD, Matthias Kerl, MD, Thomas J. Vogl, MD

Department of Diagnostic and Interventional Radiology, Johann Wolfgang Goethe-University, Frankfurt, Germany

HISTORY

A 61-year-old woman with known advanced lung cancer presented to the emergency department with sudden onset of shortness of breath, chest pain, and dropped arterial oxygen-saturation. She was referred to pulmonary CT angiog-raphy for clinically suspected pulmonary embolism.

DIAGNOSIS

Pulmonary CTA was performed utilizing the Dual Energy Lung Perfused Blood Volume (PBV) protocol that ruled out

pulmonary embolism. Instead, a large lymph node mass in the upper mediasti-num was identified. This mass caused encasing of the superior vena cava, the right pulmonary artery, and major ob-struction of the right upper lobe branch.Analysis of the iodine distribution map with Dual Energy revealed a huge perfu-sion defect of the whole upper lobe of the right lung, explaining the woman’s symptoms. The patient was then imme-diately referred to the Department of radiation oncology of our hospital for emergency irradiation.

COMMENTS

Analysis of pulmonary iodine distribution with Dual Energy can provide important information, not only about the signifi-cance of intravascular obstruction, such as pulmonary embolism, but also about vascular obstruction in general. The influence of vascular obstruction identified with the conventional morpho-logical information of CT on hemody-namics can be assessed using different information of the same scan. Thus, Dual Energy CT can provide both morpho-logical and functional information with-in one scan.

1

Conventional gray scale 3D reformates show a huge lymphatic mass in the upper right mediastinum in coronal (Fig. 1) and axial (Fig. 2, arrow) plane encasing the right main pulmonary artery and the branches of the upper right lobe.

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Oncology Clinical Results



Scan mode Spiral

Scan area Thorax

Scan length 180 mm

Scan direction Caudo-cranial

Scan time 5 s


Tube current A/B 70/298 ref. Quality mAs

Dose modulation CARE Dose4D on

CTDIvol 11.8 mGy


Pitch 0.7

Slice collimation 1.2 mm

Slice width 1.5 mm

Reconstruction increment 1 mm


Volume 60 ml KM + 100 ml NaCl-Chaser-Bolus

Flow rate 4 ml/s

Start delay 7 s

Postprocessing syngo DE Lung PBV

Subtotal vessel obstruction results in a malperfusion of the whole right upper lobe (Fig. 3 and Fig. 5, arrow), displayed as well in a volu-metric visualisation (Fig. 4, arrow). Note the significantly reduced iodine content (black) of lung parenchyma compared to the rest of the lung (blue).

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5

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Case 8syngo WebSpace in Imelda Ziekenhuis in Bonheiden, BelgiumBy Dirk Perdieus, MD* and Karin Barthel**

The Imelda Ziekenhuis in Bonheiden, Bel-gium, is a 502 bed hospital, with 1,200 employees. In the hospital surgery, neuro surgery, internal medicine, nephrology with renal dialyses, pediatrics, orthope-dics, oncology, cardiology as well as an emergency department are available with a specialized focus on cardiology, cardiac surgery, cardiac intervention and oncolo-gy. Within the radiology department 38 employees, 10 radiologists and 28 radio-graphers cover daily requests. They all

rotate using the following Siemens sys-tems: four ultrasound systems, two digital X-ray cameras, one digital intervention system, one digital mammography sys-tem, one MRI and one CT scanner. The SOMATOM® Definition is used in combination with syngo WebSpace and a syngo MultiModality Workplace. Both are seamlessly integrated in an Agfa PACS.Dirk Perdieus, MD, is one of the radiolo-gists at Imelda. He and his colleagues cover the requested CT examinations.

“In the future, the radiographers in our depart-ment will also be trained in using syngo WebSpace. Then they will be able to prepare standard 3D reconstructions and 3D bookmarks. This will then be the basis for radiologists to start reading the case. And that will save even more time in our clinical routine.”Dirk Perdieus, MD, Department of Radiology, Imelda Ziekenhuis, Bonheiden, Belgium.

The radiographers perform the acquisi-tions at the CT scanner and the radiolo-gists evaluate and report the cases in the PACS reading room.Before having syngo WebSpace integrated in their workflow, the radiologists usually started evaluating the cases in PACS. Whenever they wanted to have a more detailed look, they had to walk from their PACS reading room to the workstation next to the CT scanner. In lucky cases, the Multi Modality Workplace (MMWP) was

* Department of Radiology, Imelda Ziekenhuis, Bonheiden, Belgium



Oncology Clinical Results

Data Flow

Order Plan & Prepare Distribute

Patient Preparation Scan Patient 2D/3D/4D Processing

syngo MultiModality Workplaces + CT Clinical Engines + syngo Expert-i

Home PC/Laptop

Offi cePC/Laptop

PACS ReadingWorkstations

Archiving/Reporting/2D Reading

Shared Database

syngo Acquisition workplace

syngo CT workplace

Scanner Control and Reconstruction

syngo WebSpace Server

PACS Archive

Auto delete

Auto-sendAuto processing

Thin slices Applications

3D/4D

2D

Thin slices

Thick slices

Auto delete

2D, 3D, 4D and Applications, all in one place

Prefetching

Internet

Scan & Reconstruct Process Read & Report

1

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not busy and they could search for the appropriate patient, open the dedicated application, save the resulting images, make notes and then walk back to the PACS reading room to continue with the reporting of the patient. Having installed

syngo WebSpace, client-server access to the entire CT functionality is now possible from all remote locations and Perdieus can finalize everything at his PACS Work-stations (WS). He can use all necessary tools that are needed in order to do the

diagnoses and finally report the cases without moving between his PACS WS and his 3D WS. The following case describes a typical workflow scenario from scan-ning to diagnosis using syngo WebSpace in the Imelda Ziekenhuis.

syngo WebSpace reading workflow and data management: Auto functions between the scanner and workplaces to speed up the workflow available; thick slices protect PACS from data overflow; Entire CT functionality is available from anywhere within the hospital. It is not necessary to change workplaces. Fast Data link offers immediate access to CT data from anywhere; no waiting time between sending and receiving images from a CT scanner to a workplace.

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CAD markers in the syngo CT Oncology application. Volume measurement of a lung nodule in syngo CT Oncology.

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HISTORY

A 65-year-old female patient presented during the oncology consultation hour for follow-up of breast carcinoma. She was referred to the CT division and a MDCT examination of the thorax for sus-pected lung nodules was ordered.

DIAGNOSIS

The patient was scanned with the SOMATOM Definition. The radiographers chose the standard “Oncology Thorax” protocol and performed the examination in inspiration. Three reconstruction jobs were done automatically by the system: one thin-slice series with a high resolu-tion lung kernel, one thin-slice series with a mediastinum kernel, and one thick-slice series with a lung kernel. The two thin-slice series were automatically sent to the WebSpace server and MMWP (Fig. 1). The thick-slice series was sent to PACS for archiving. After the recon job was finished, approximately two

minutes after examination, Dirk Perdieus started to evaluate the data in his PACS reading room. He opened the series and viewed the 2D images revealing various lung nodules in the right lung. In order to have a more detailed look and not to miss anything, he opened the same series in syngo WebSpace by clicking a single button in his PACS User Interface. The same series automatically opened in a 3D format on a second monitor. Thereby the entire volume could be evaluated by using clip planes, in an MPR, MIP and VRT approach. Since he was sure that the patient had several lesions present in the lung, the same series was opened in syngo CT Oncology in order to quantify the nodules and to run the integrated CAD algorithm as a second reader (Figs. 2–3). Finally, Perdieus reported all his findings and saved the images in the Agfa PACS.

COMMENTS“In this particular patient, three small lung nodules have been detected and con-firmed by CAD which, in 2D, seems to be an orthogonal cut through a vessel. Results in MIP and 3D are more detailed and precise, which increased the reading accuracy tremendously. You simply see more,” Perdieus says. “So, all this has been done within a few minutes without changing seats or workplaces. I could remain sitting in my PACS reading room and concentrate on my evaluation.It is no longer necessary to leave the PACS reading room and to walk to the MMWP that, in our case, is installed next to the CT scanner. Since syngo WebSpace and Expert-i offer all available tools, this means the entire CT functionality on one screen, we can save much time com-pared to the previous workflow.” At the same time, the quality of work improves by using more 3D evaluation tools than before. “Looking at 2D images only is sometimes very difficult and can lead

2 3


to incomplete or incorrect results. By using syngo WebSpace and Expert-i, the radiologists in our department get 3D reformations automatically, simply by pressing a single button,” Perdieus stresses. “And looking at 3D information is important in order not to lose infor-mation. 3D evaluation not only saves time; it also eliminates a cumbersome



Scan mode Spiral Pitch 1.2

Scan area Thorax Spatial resolution 0.33 mm

Scan length 313 mm Slice collimation 0.6 mm

Scan direction Cranio-caudal Slice width 3 mm

Scan time 6.9 s Reconstruction increment 1 mm

Tube voltage 120 kV Reconstruction kernel B60f sharp

Tube current 130 Eff. mAs Start delay Bolus Tracking

CTDIvol 9.37 mGy Postprocessing syngo InSpace 4D and syngo CT

Rotation time 0.5 s Oncology via syngo WebSpace

2D reading approach. Clicking through the whole volume slice by slice can be very difficult. Also, having everything available in different planes and via CT Oncology which is CAD and workflow supported, makes the work easier.”Depending on a hospital’s needs, syngo WebSpace is available in four configura-tions:

The syngo WebSpace “Trend” allows access for three concurrent users. This means that three radiologists can use the 3D evaluation tool at the same time.syngo WebSpace “Expert” is for 5 con-current users, syngo WebSpace “Depart-ment” is for 10 concurrent users, syngo WebSpace “Clinic” is for 20 concurrent users.

syngo WebSpace client integrated into the PACS.

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Clinical Results Neurology

Case 9SOMATOM Defi nition: Head CTA Brain Hemorrhage Examination with Dual EnergyBy Jiri Ferda, MD, PhD and Boris Kreuzberg, MD, PhD

Clinic of Radiodiagnostics, University Hospital Pilsen, Pilsen, Czech Republic

HISTORYDue to suddenly occurring and continu-ing loss of consciousness during a sojourn in the forest, a 71-year-old female was admitted to the University Hospital in Pilsen for a suspected brain aneurysm rupture. Her past medical history showed a thromboembolism treated with anti-coagulant therapy. A brain CT was con-ducted immediately.

DIAGNOSISA non-contrast brain CT showed an acute subarachnoidal bleeding in the left hemisphere. In order to affirm or disprove a ruptured aneurysm, a head CTA with Dual Energy was performed. This technology allows better visualiza-tion and easier localization of brain hemorrhages. The virtual non-contrast image showed acute extensive bleeding with same high quality as conventional non-contrast CT. An examination with Dual Energy scanning, using both tubes with different kV-settings (140 kV/80 kV) makes it possible to accurately detect and localize the origin of the bleeding.

COMMENTSFor an angiographic coiling treatment, knowing the exact localization of bleed-ing in the brain is a life and tissue saving advantage.Due to the different tube voltages of 140 kV and 80 kV, it is possible to ascer-tain the exact Houndsfield (HU)-values. syngo Dual Energy color codes the iodine enhancement and a virtual unenhanced can always be generated from a contrast enhanced study.The application may make pre-contrast scans unnecessary in the future.



Scan mode Spiral Rotation time 0.33 s

Scan area Head-neck Spatial resolution 0.33 mm

Scan length 339 mm Slice collimation 0.6 mm

Scan direction Caudo-cranial Slice width 0.6 mm


Tube voltage A/B 140/80 kV Reconstruction kernel B30f

Tube current A/B 59/250 Eff. mAs Postprocessing syngo DE Virtual Unenhanced (VNC)


Neurology Clinical Results

1A

Virtual Non-Contrast (VNC) image axial, coronal, axial (Figs. 1A–1C), showing exact localization of bleeding.

Bildartefakte retuschieren

1C

Pure iodine contrasted image axial, coronal, axial (Figs. 3A–3C), showing exact localization of bleeding.

3C

Dual Energy mixed image axial, coronal, axial (Figs. 2A–2C), showing exact localization of bleeding.

1B

2B

3B

2A

3A

2C

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Clinical Results Neurology

Case 10SOMATOM Sensation: Subtracted 3D CT-Angiography for Evaluation of Arteriovenous MalformationBy Ender Uysal, MD

Department of Radiology, Sisli Etfal Training and Research Hospital, Istanbul, Turkey

HISTORY

A 35-year-old man who underwent emer-gency surgery for a left frontal intracere-bral hematoma was referred to the radiol-ogy department for further assessment of underlying pathology. The motivation for this decision were positive findings of neurological examination and sensory deficits on the contralateral side. Volume subtracted 3D CT-Angiography (VS-3D CTA) was performed with a SOMATOM® Sensation 40 using syngo Neuro DSA soft-ware. VS-3D CTA images were obtained.

DIAGNOSIS

A left frontal arteriovenous malforma-tion (AVM) was found that had one feeder artery from middle cerebral artery (MCA). Nidus size was 10 x 15 mm. Drainage vein was the cortical vein which drains to superior sagittal sinus (Figs. 1A–B). VS-3D CTA images depicted ecta-sia of the drainage vein as well. Conven-tional catheter angiography showed the same findings as the CTA (Figs. 2A–B).

COMMENT

Conventional digital subtraction angiog-raphy (DSA) is the current gold standard for the diagnosis and characterization of arteriovenous malformations.1, 2 However, non-invasive computed tomo-graphic angiography (CTA) has become a useful tool for this purpose because of its ability to visualize simultaneously both the arterial and venous components and the nidus. Moreover, it is a non-inva-sive imaging technique that does not

Selective conventional digital subtraction angiography (DSA) confirmed the arteriovenous malformation (AVM, arrows) and the feeding artery (arrowhead) depicted with CTA. Courtesy of Levent Onat, MD, Department of Radiology, Sisli Etfal Training and Research Hospital, Istanbul, Turkey.

1B1A

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Neurology Clinical Results


2A 2B

Arteriovenous malformations (arrows) shown in volume rendered technique (VRT) using syngo Neuro DSA.


Scanner SOMATOM Sensation 40-slice configuration

Scan mode Spiral Spatial resolution 0.33 mm

Scan area Head Slice collimation 40 x 0.6 mm


Scan direction Caudo-cranial Reconstruction kernel H20f smooth

Scan time 11.41 s Volume 100 ml

Tube voltage 120 kV Flow rate 4 ml/s

Tube current 120 Eff. mAs Start delay 4 s

Dose modulation CARE Dose4D off Postprocessing syngo Neuro DSA

CTDIvol 20.3 mGy

require arterial puncture or catheter manipulation. It can be easily performed immediately after the initial non-en-hanced CT with a single bolus of intrave-nous contrast medium.3 Furthermore, it provides more accurate information about localization of the nidus, adjacent brain anatomy and overlying osseous structures allowing rapid diagnosis and treatment planning in the acute setting.4 Nevertheless, CTA may show complexity

in display due to overlying large veins. Recently, syngo Neuro DSA is being used as a novel alternative to DSA for pre-op-erative examination of aneurysms which are close to the skull base.5 syngo Neuro DSA images may help to depict AVM com-ponents with better image quality and in a very short time compared to MIP and shaded surface methods. Under life threatening conditions, such as intracra-nial hemorrhage, syngo Neuro DSA may

help to understand underlying vascular pathology before the emergency sur-gery.

References1 Anzalone N et al., Eur Radiol 1998; 8:685–690.

2 Tanaka H et al., J Comput Assist Tomogr 1997;

21:811–817.

3 Uysal E, Interv Radiol. 2005 Jun; 11(2):77–82.

4 Yoon DY et al., AJNR Am J Neuroradiol. 2007 Jan;

28(1):60–7.

5 Sakamoto S et al., AJNR Am J Neuroradiol.

2006 Jun–Jul; 27(6):1332–7.

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Clinical Results Acute Care

Case 11SOMATOM Defi nition AS+: Polytrauma Patient Scanned in Seven SecondsBy Astrid Schneider, MD, Marcus Lauschmann, MD, Jutta Aigner, Markus Schlager, Monika Gerl, Bernhard Hettegger, Prof. Klaus Hergan, MD

Department of Diagnostic Radiology, University Hospital, Salzburg, Austria

HISTORY

A 40-year-old male patient was referred to the emergency department after fall-ing approximately 20 m in a severe skiing accident. An immediate CT scan was ini-tiated to evaluate and confirm multiple rib and skull fractures.

DIAGNOSIS

The head scan was performed on the SOMATOM® Definition AS+ and revealed multiple skull fractures, fracture of right petrous bone, a subluxation of both temporomandibular joints and fracture of right sphenoid sinus wall as well as fracture of right zygomatic bone. A subarachnoid hemorrhage (SAH) that required immediate action was also found in the head scan.A contrast enhanced scan of thorax and abdomen using a thin collimation of 128 x 0.6 mm and a slice width of 0.75 mm was appended and confirmed the suspected multiple rib fractures and spinal fractures with vertebral sublux-ation. The comminute fracture of tho-

racic vertebral body eight was noted along with fractures of both transverse processes.A pleural effusion on the patients’ right side, pulmonary dystelectasis and a con-tusion of the right upper and lower lobe were also diagnosed.

COMMENTS

During the following surgery, the frac-tured vertebral body was stabilized and a probe was implanted to equalize the patients brain pressure.Due to availability of the multi-slice CT scanner, SOMATOM Definition AS+ in the emergency department, the entire trauma scan procedure, inclusive patient positioning, was done in just six minutes. This is extremely fast. Polytrauma man-agement is usually a very extensive and time-consuming activity. Using this new 128-slice technology makes it possible to cut down the time to diagnosis tremen-dously and patients can be referred to the operating room much faster.

Thorax and abdomen scan captured in only 7 seconds in volume rendering technique (VRT).


Scanner SOMATOM Definition AS+

Scan area Head, thorax, abdomen Pitch 1.25

Scan length 70 cm Slice collimation 128 x 0.6 mm


Scan time 7 s thorax/abdomen Reconstruction increment 0.7 mm

Tube voltage 120 kV Spatial resolution 0.33 mm

Tube current 104 eff.mAs Reconstruction kernel B31f

Dose modulation CARE Dose4D on Volume 100 ml

CTDIvol 12.59 mGy Start delay Fixdelay 40 s

Rotation time 0.33 s Postprocessing CT Acute Care Engine

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Acute Care Clinical Results

Sagittal planar reformation of the spine, showing dislocated comminute fracture of thoracic vertebral body eight (arrow, Fig. 2A). In volume rendering technique (VRT, arrow, Figs. 2B–2C) posterior-anterior view in VRT of both (fractured) transverse processes.

2A 2B 2C

Pulmonary dystelectasis and contusion of the right lung in VRT, maximum intensity projection (MIP) coronal and sagittal (arrows, Figs. 3A–3C).

3A 3B 3C

CT scan of the skull unveils multiple fractures (arrow, Fig. 4A) and subluxation of both temporomandibular joints (arrow, Figs. 4B–4C); axial cut shows fracture of right zygomatic bone (arrow, Fig. 4D).

4A 4B 4C 4D

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Clinical Results Acute Care

Case 12Triple Rule-Out in Flash Speed: Entire Thorax Scanned in less than a SecondBy Michael Lell, MD*, Fabian Hinkmann, MD*, Andreas Blaha**

HISTORY

A 64-year-old male patient was referred to the radiology department with acute chest pain. ECG and lab tests did not suggest myocardial infarction. An ECG triggered triple rule-out protocol was selected to evaluate coronary artery disease, pulmonary embolism, aortic dissection, and other thoracic disease.

DIAGNOSIS

The ultra-fast scan speed of up to 43 cm per second allowed a reduction of i.v. contrast injection down to 80 ml followed

Bilateral pulmonary artery emboli in MIP and VRT visualization with syngo Circulation PE Detection acquired in only 0.6 seconds.

Volume rendered technique of the thorax, highlighting RCA and left artery descending (LAD, arrow). A non-calcified plaque can be detected in LAD proximal part.

by a saline chaser bolus. The chosen scan direction was caudo-cranial to assure a homogenous contrast distribution in the coronary and pulmonary arteries. No high-grade stenoses, only minor calcified plaques at the aortic root, next to the ostium of the right coronary artery (RCA) and a non-calcified plaque of the LAD were shown by the curved planar recon-structions of the coronary arteries. The entire thoracic aorta did not show any signs of dissection. Bilateral pulmonary emboli were detected as well as emboli in subsegmental arteries of the lower lobe.

COMMENTS

Split-second thorax imaging provides a very fast, non-invasive visualization of coronary arteries with simultaneous evaluation of the pulmonary arteries, thoracic aorta, and other intra-thoracic structures. Applying only 1.9 mSv dose (conversion factor 0.014) to the patient in this case, CT becomes even more the first-line imaging test for assessing patients with suspected acute pulmo-nary embolism.

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*Department of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany

**Business Unit CT, Siemens Healthcare, Forchheim, Germany

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Acute Care Clinical Results


Scanner SOMATOM Definition Flash

Scan mode Flash Spiral ChestPain Rotation time 0.28 s

Scan area Thorax Pitch 3.2

Scan length 29 cm Slice collimation 128 x 0.6 mm


Scan time 0.6 s Spatial resolution 0.33 mm

Tube voltage 100/100 kV Reconstruction increment 0.4 mm

Tube current 370 mAs/rot Reconstruction kernel B20f

Dose modulation CARE Dose4D on Volume 80 ml contrast

Effective dose 1.9 mSv dose Start delay Test bolus

(conversion factor 0.014) Postprocessing CT Acute Care Engine

3

Display of the aortic arch (sagittal), coronal and axial bilateral curved maximum intensity projection and VRT of the thorax, showing RCA and left coronary artery descending (LAD), using single screen for display.

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Clinical Results Orthopedics

Case 13High Resolution Follow-up of a Wrist Fracture of the Os Triquetrum with SOMATOM Defi nition AS+ and z-UHRBy Axel Küttner, MD and Rolf Janka, MD

Institute of Diagnostic Radiology, University of Erlangen-Nuremberg, Erlangen, Germany

HISTORY

A 46-year-old patient presented in the emergency department after a fall during an ice hockey game. Clinically, a scaphoid fracture was suspected. X-ray revealed a normal scaphoid. However, a potential fracture of the os triquetrum was sus-pected due to an inhomogenous spon-giosa structure. Also, a small bone frag-ment was observed in the X-ray image (Fig. 1). In order to clarify the dislocation of the fragment, a conventional CT was ordered.

DIAGNOSIS

The initial CT scan clearly excluded a scaphoid fracture as well as fractures of all other carpal bones. It confirmed a fracture of the triquetral bone consisting of a non-dislocated dorsal aspect (Fig. 2). The patient was treated with cast immo-bilization for five weeks. The follow-up CT examination was performed with Siemens unique z-UHR (Ultra High Reso-lution) mode in order to rule out second-ary dislocation and osseous consolidation of the fragment (Fig 3). The VRT as well

as the z-UHR display that a slight second-ary dislocation occurred. In combination with the z-UHR, it could be confirmed that the contact area shows a beginning osseous consolidation (Fig. 4).

COMMENTS

Most wrist fractures and dislocations are a result of axial loading on the out-stretched palm and extended wrist, usually from a fall on outstretched hand

1

A conventional X-ray imaging identified a small bone fragment near the triquetral bone.

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2

CT of left wrist, indicating a fracture of dorsal aspect of z-UHR clearly shows a slightly secondary dislocation and identifies

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Orthopedics Clinical Results



Scan mode Spiral Rotation time 0.5

Scan area Wrist Slice collimation 16 x 0.3 mm


Tube voltage 120 kV Spatial resolution 0.24 mm

Tube current 83 eff mAs Reconstruction kernel U70u

Dose modulation CARE Dose4D on Postprocessing syngo InSpace

Pitch 0.85

(FOOSH), motor vehicle accident, or sports contact injury. Most result in frac-tures of distal radius, scaphoid, and other carpal bones. Higher-impact injuries from falls or severe motor vehicle accidents can lead to more complex fracture/dislo-cation patterns of the wrist (for example, perilunate fracture/dislocation).According to a US study, approximately 14% of all hand fractures are carpal frac-tures. Scaphoid fractures are by far the most common of the carpal fractures, estimated at 70–79%. Fractures of the triquetrum make up an estimated 14% of all carpal fractures, trapezial fractures make up 2.3%, and hamate fractures make up 1.5%. Lunate, pisiform, and capitate fractures combine for 3% of all

carpal fractures. Trapezoid fractures are rare, encompassing 0.2% of all carpal fractures.Triquetral fractures are the second most common carpal fractures. These frac-tures are usually not seen in isolation and the most common presentation is with other carpal injuries that are boney, ligamentous, or both (for example peri-lunate fracture dislocation). Triquetral fractures may be divided into three types based on radiographs, dorsal cortical fractures (most common), body frac-tures and volar avulsion fractures.*Especially for fractures of the wrist, CT is the diagnostic gold standard. It can depict the entire anatomy without any overlapping osseous structures as often

revealed in X-ray exams. Especially with the unique z-Ultra High Resolution mode – which is intended for ultra-high reso-lution bone imaging, in particular for wrists, joints, and inner ear studies – even the tiniest fractures and fissures can be detected. Also in non-dislocated fractures the spongiosa inhomogenity is the only sign of a fracture which can be optimally highlighted with the z-UHR mode. In the present case, the spongiosa is not as clearly depicted with standard CT mode compared to the z-UHR scan.

*Source: http://emedicine.medscape.com/article/1285825-overview ultra high resolution

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the os triquetrum without dislocation of the fractured fragment (Fig. 2). an osseous consolidation of the fragment (Fig. 3). VRT displays a slight, secondary dislocation (Fig. 4).


Clinical Results Gastroenterology

Diagnostic CT of the upper abdomen. Fluid collection with an air-fluid level indicates suspected abscess (arrows) in the gallbladder bed.

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Case 14Diffi cult Drainage After CholecystectomyBy Rolf M. Janka, MD, Fabian Hinkmann, MD, Evelyn Wenkel, MD

Institute of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany

HISTORY

A 74-year-old female patient underwent open cholecystectomy due to acute cholecystis. Five days after surgery the laboratory exam showed signs of inflam-mation and an ultrasound of the abdo-men indicated a suspected abscess for-mation in the gallbladder bed. The patient was sent to the CT unit to confirm the suspected diagnosis. In the case of a positive result, CT-guided percutaneous abscess drainage should be performed.

DIAGNOSIS

Contrast enhanced CT revealed a fluid collection at the previous gallbladder site with a maximum diameter of three cm (Fig. 1). The abscess was verified by punctation of the fluid collection as the color of aspirated material was purulent yellowish. In the next step, a 12G drain-age was placed in Seldinger technique in the abscess. The control scan after drainage placement showed an optimal position of the drainage system.

COMMENTS

The easiest way to puncture a lesion is to place the incision alongside a suitable slice position. In that case, the needle can be followed in realtime using the Siemens i-Fluoro application. The diag-nostic CT scan indicated a fluid collection surrounded by liver tissue. The drainage should not be placed through the liver parenchyma. Therefore, a position for the incision had to be found below the liver. The surgery scar was located at the cau-dal liver edge and the drainage shouldn’t go through the scar either. Therefore, the punction site was chosen beneath the scar which resulted in a challenging puncture route. With Siemens newly developed Adaptive 3D Interventional Suite for CT Interventions, this puncture route could be easily planned. With the integrated path planning tool, the inci-sion site can be exactly placed to define a puncture route to avoid crossing critical anatomical structures. In our case the incision site was 10 cm below the abscess position and the angles of the puncture route were in x-direction -31 degrees and z-direction -58 degrees: The needle was correctly placed in the abscess on the first attempt under fluoroscopic con-trol using 3D and VRT visualization (Figs. 2–3). The whole procedure took only 18 minutes.

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Gastroenterology Clinical Results



Scan mode i-Sequence Pitch 0.8

Scan area Abdomen Slice collimation 32 x 1.2 mm

Scan length 44 mm Slice width 5 mm

Scan direction Cranio caudal Reconstruction kernel B30f

Tube voltage 120 kV Volume 100 ml (Imeron 350)

Tube current 78 Eff. mAs Flow rate 3 ml/s

Rotation time 0.5 s Postprocessing Adaptive 3D Intervention

Dual monitor layout for path planning: the dual monitor layout of the Siemens Adaptive 3D Suite allows direct control of the needle during CT interventions using the i-Fluoro display (right side) and on the other hand allows controlling the interventions in 3D (left side).

VRT reconstructions after drainage placement indicates a good positioned drainage with an entrance below the post-operative scar and without touching the transverse colon or the liver parenchyma.

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Science

In the past, functional information on lesions that were detected in a CT scan were the clear domain of nuclear medi-cine. But since the introduction of the SOMATOM® Definition, the world’s first

Single Source – Single Energy Dual Source – Dual Energy

Native scan native unenhanced images virtual non-contrast (VNC) images

Arterial/venous/late phase enhanced images virtual 120 kV images (mixed 80/140 kV) 80 kV images, 140 kV images, Iodine images

two single energy one Dual Energy scan

CT Oncology Imaging. Comparison of Single and Dual Source Scanning.

Liver lesion with Dual Energy. VNC (upper left), mixed image (upper right), iodine image (lower left), overlay mixed and iodine image (lower right) in syngo CT Oncology.

Dual Energy in Clinical Routine with syngo CT OncologyBy Marco Das, MD

Department of Diagnostic Radiology, University Hospital, RWTH-Aachen University, Germany

Dual Source CT, significant progress has been made in the direction of functional imaging by using the unique capabilities of Dual Energy. Recent studies have shown that Dual Energy extends CT’s

diagnostic possibilities by providing functional information. For example, in oncology CT, the evaluation of the io-dine uptake of lesions seems to have a correlation with malignancy.Cancer is by far the most frequent indi-cation for CT exams in clinical routine and tools like syngo CT Oncology are necessary to support an accurate and ef-ficient reading workflow. The key factor in oncology CT is the ability to compare different phases of a contrast enhance-ment, like the native scan, the arterial phase, the venous phase and sometimes also a late phase. Images taken during different phases need to be displayed side-by-side and synchronized scrolling must be available in order to enable si-multaneous reading. For efficient and accurate tumor evaluation, automated tools are also needed for tumor segmen-tation, measurements and reporting. Baseline and follow-up examinations need to be directly available without un-necessary and time consuming searches in databases. Additionally, fusion of functional images like PET and CT imag-es should be available. Dual Energy accomplishes every func-tion described in this reading scenario. Instead of loading multi-phase images

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Solitary pulmonary nodule in an adult patient with DECT: Iodine enhancement is shown as colored overlay to a virtual unenhanced (VNC) image; the semi-auto-matic segmentation result is indicated in blue. Courtesy of Asan Medical Center, Seoul, Korea.

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Enhanced syngo Dual Energy SoftwareBernhard Krauss, PhD, Business Unit CT, Siemens Healthcare, Forchheim, Erlangen

from conventional single energy scans into the application, “virtual” Dual Energy images are used. Instead of native non-contrast images of a single source sys-tem, syngo Dual Energy generates vir-tual unenhanced (VNC) images, which contain the necessary diagnostic image information. The arterial phase of single source scans corresponds to the virtual 120 kV Dual Energy images. But Dual Energy can do more: besides virtual 120 kV images it provides 80 kV and 140 kV images as well as iodine images. All images can be loaded into syngo CT Oncology thus delivering additional diagnostic information.syngo CT Oncology’s tool set, including automatic tumor evaluation, can then be used exactly in the same way with Dual Energy as for conventional CT im-

Spiral Dual Energy CT exploits the effect that X-ray absorption is energy-depen-dent: Two X-ray sources running simulta-neously at different voltages acquire two data sets showing different attenuation levels. In the resulting images, the mate-rial-specific difference in attenuation makes a classification of the elementary chemical composition of the scanned tissue feasible. The new software version of syngo Dual Energy which will be available in 2009 allows:■ determining the absolute iodine

concentration (in mg/ml) in the appli-cation class Liver VNC.

■ semi-automatic segmentation of lung nodules: After marking a lesion, parameters like volume and RECIST-diameter as well as the iodine uptake are calculated from the Dual Energy data. Published studies on solitary pulmonary nodules indicate usefulness of this quantity in assessing the benign or malignant character of the nodule.

ages. The combination of Dual Energy and syngo CT Oncology software makes it possible to report oncology related results directly from the reporting en-vironment available within syngo CT Oncology.Furthermore the user can utilize the Dual Energy iodine images with syngo CT Oncology’s fusion functionality in the same familiar way used in fusing PET images. The ratio between the iodine image and the VNC image, for example, can be continuously mixed with a simple slider bar, providing a combination of functional and anatomical information within the CT-modality.Not to forget another practical aspect of Dual Energy in oncology imaging: Dual Energy overcomes a difficulty that often occurs when performing the native and

the contrast scan separately. With Dual Energy, the registration of the different image series is always perfect as all image data is acquired simultaneously.

Conclusionsyngo CT Oncology accomplishes another step towards using Dual Energy data in clinical routine, providing exciting per-spectives to the reading physician. Dual Energy adds functional information to CT Oncology imaging with approximately the same dose level as single source scan protocols do. All of syngo CT Oncology’s automatic tools are also available for Dual Source data, i.e. there is no learn-ing curve to deal with. The virtual multi-phase data generated from Dual Energy are always perfectly registered.

■ improved application class “Optimum Contrast”: better visualization of weakly enhanced lesions.

■ ”Monoenergetic”: visualization of iodine contrast with an equivalent X-ray beam energy as low as 40 keV.

■ visualization of Xenon gas in the lungs of a patient after applying it by a ven-tilation system. In addition, this appli-cation is already being discussed in published articles for animal models and patients.

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Dual Energy CT in Pulmonary EmbolismBy Ralf W. Bauer, MD, Philipp Weisser, MD, Huedayi Korkusuz, MD, Prof. Thomas J. Vogl, MD and J. Matthias Kerl, MD

Both computed tomography (CT) and ventilation/perfusion single photon emission computed tomography (SPECT V/Q) have been used for years as estab-lished methods for the diagnosis of pul-monary embolism (PE). While CT uses morphological information, i.e. the di-rect visualization of clot for making the diagnosis, V/Q scan utilizes functional, in-direct information of located ventilation/perfusion mismatch in the lungs. For a variety of reasons, in recent years, CT angiography of the pulmonary arteries has become more and more the primary modality for diagnosing PE. Compared to early generation CTs, the new multi-detector-row CT scanners with sub-milli-

meter collimation now allow accurate imaging of pulmonary artery branches down to the sub-segmental level with constantly highly improved sensitivity for detecting emboli, but often with unsatis-factory positive predictive value in terms of discordant clinical findings.1 There-fore, concerns have been raised about a) false positive diagnosis, b) “over-diagnos-ing” very small PE without hemodynamic and clinical relevance that would not have been diagnosed with a V/Q scan, and c) the impact of these findings on therapy.2

As a further step in CT evolution, a Dual Source system has become available with two X-ray tubes and two detector arrays

mounted on the gantry at 90° offset.3 The tubes can be operated at different voltages and can therefore create differ-ent X-ray spectra. As the X-ray absorption characteristics (represented as Hounsfield Units, HU) of each material vary at dif-ferent X-ray spectra, this fact can be used to differentiate tissue.4 The Dual Energy characteristic of iodine, which is typically used as contrast medium in CT, is very unique, and its distribution in different tissues of the body can be preferably analyzed.We used a Dual Source CT scanner, the Siemens SOMATOM® Definition, in Dual Energy mode (DECT) for pulmonary CT angiography in a 71-year-old, male

On the mixed series with 70/30% ratio of the 140/80 kV series, the impression of a virtual 120 kV image is created. On the multi-planar reformats (axial view) multiple emboli in both lungs are documented. A and B: extensive clot formation (arrows) in the right upper and lower as well as in the left upper and lower lobar arteries down to the sub-segmental level with total or subtotal occlusion of the vessel lumen.

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Department of Diagnostic and Interventional Radiology, Johann Wolfgang Goethe-University Hospital, Frankfurt, Germany

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Multiplanar reformats (MPR; Fig. 2A) and maximum intensity projections (MIP; Figs. 2B–2C) with the super-imposed iodine distribution map of the lung parenchyma generated on the basis of the Dual Energy characteristic of iodine at 140 and 80 kV. Iodine concentration is color-coded: light green = high, blue = average, dark purple = significantly reduced con-centration; black = no iodine. Figures 2D–2F show the cor-responding perfusion SPECT images. Ventilation scan was normal (not shown). Excel-lent correlation was found between Dual Energy CT and V/Q scan (arrows) in terms of depicting perfusion deficits. As an advantage of CT, mor-phological information to explain observed perfusion deficits is contained in the same images: in Figures 2B and 2C, occlusive emboli (arrow heads) are displayed together with the resulting lack of iodine in their respec-tive vascular supply area, whereas on the respective V/Q scan images only the ventilation-perfusion mis-match can be appreciated (Figs. 2E–2F). Note the elevated right diaphragm (Fig. 2C) generating the impression of perfusion defect on SPECT.

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Patient placement Central on the patient table

Scan direction Caudo-cranial


Tube current A/B 70/298 ref. mAs

Dose modulation CARE Dose4D on


Pitch 0.7

Slice collimation 14 x 1.2 mm

Slice thickness 1.5 mm and 5 mm

Reconstruction increment 1 mm


Contrast

Volume 60 ml iodine + 100 ml NaCl-Chaser-Bolus

Flow 4 ml/s

Timing Bolus tracking

ROI in Truncus pulmonalis

Trigger +100 HU

Scan delay 7 s

Breath Scan in expiration

Postprocessing syngo DE Lung PBV

patient with suspected pulmonary embolism. After lung resection in 2006 for non-small, cellular lung cancer, he relapsed in January 2008 with two pulmo-nary metastases and has been receiving chemotherapy since then. This patient recently presented to our emergency department with dyspnea, tachypnea, and tachycardia. The initial D-dimer test was positive. Ultrasound of the legs did not show deep venous thrombosis. The following scan protocol was used: tube A was operated with 50 mAs at 140 kV, tube B with 215 mAs at 80 kV, collimation on both detectors 14 x 1.2 mm, 0.33 s gantry rotation time, pitch 0.7. The scan was contrast enhanced with 60 ml of contrast medium (400 mg iodine/ml; Imeron 400, Bracco) followed by a 100 ml NaCl chaser bolus, injected at 4 ml/s. Bolus tracking was used for automated scan start. Three regular axial gray-scale

image series were reconstructed with a section width of 1.5 mm and 1 mm increment: each one series of the 140 kV and 80 kV spectrum alone and finally a mixed series with 70% of information of the 140 kV spectrum and 30% of the 80 kV spectrum that generates the impression of a 120 kV scan. This mixed series was used for regular diagnostic reading on axial images and 3D multi-planar reformats (MPR) or maximum intensity projections (MIP) (Fig. 1). The iodine content of the lung parenchyma was determined from its typical absorp-tion characteristics at the different kV levels using dedicated software imple-mented on the scanner workstation. The result was color-coded (“iodine map”) and could be superimposed on the regu-lar MPRs and MIPs.In this patient, DECT pulmonary angiog-raphy revealed multiple bilateral PE from

the lobar level to the periphery (Fig. 1). The iodine map showed large, partially wedge-shaped areas of lung parenchyma with reduced or lacking iodine content (Figs. 2A–C). During his further clinical work-up, the patient also underwent V/Q scanning, because of the very high emboli burden to assess the extent of perfusion deficit with the gold standard method. The areas of reduced iodine con-tent on DECT correlated well with areas of perfusion defect and ventilation/per-fusion mismatch, respectively, at V/Q scanning (Figs. 2D–F). Further, a large perfusion deficit situated in the right lower lobe on V/Q scan could be identi-fied as elevated diaphragm.In the underlying case, both the morpho-logical correlate of suspected pulmonary embolism and its hemodynamic signifi-cance could be successfully demonstrated at the same time with the data acquired with a single DECT scan. Dual Energy CT may thereby help to eliminate the initial decision of either imaging the clot or the perfusion defect by combining patho-anatomical and patho-physiological findings. Likewise, other morphological findings that may generate perfusion defects at V/Q scan, as in this case an elevated diaphragm, or emphysema, are documented by CT. Regarding the per-petual discussion about the best imag-ing modality for diagnosing pulmonary embolism and how to deal with test results, Dual Energy CT can add benefit for diagnosis and therapy. Further research will have to validate this new technique.

References1 Stein PD et al., Curr Opin Pulm Med. 2007;

13: 384-388

2 Anderson DR et al., JAMA. 2007; 298: 2743-2753

3 Flohr T., Eur Radiol. 2ww006; 16: 256-268

4 Johnson TR et al., Eur Radiol. 2007;

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Science

Iterative Image Reconstruction Moves into Clinical PracticeBy Herbert Bruder, PhD, Rainer Raupach, PhD, Karl Stierstorfer, PhD, Thomas Flohr, PhD


In the last 20 years, a variety of iterative reconstruction approaches were devel-oped. But introduction into clinical prac-tice has been handicapped due to slow convergence of reconstruction and, consequently, the demand for extensive computer power. Furthermore, the noise texture of the images was often different from standard Filtered Backprojection (FBP) reconstruction, and the users had to get used to working with unfamiliar image impressions. Due to most recent scientific results showing artifact and noise reduction, increased image sharp-ness and dose savings, iterative image reconstruction technique is now at the advent into clinical practice.In contrast to conventional image recon-struction based on FBP, iterative image reconstruction optimizes image quality by modeling the signal generation pro-cess (Fig. 1). Synthesized projection data are compared to real measurement data in an iterative manner: the update image is refreshed by a correction image and prior knowledge is imposed onto image data. Application of prior knowledge smoothes the virtual image within homo-geneous regions, whereas contrast edges are preserved. The corrected image has

removed all artifacts produced by non-exact FBP reconstruction. Convergence of the reconstruction is drastically accel-erated by filtering the projection data with a pre-selected (very sharp) convolu-tion kernel prior to backprojection.Additionally, image noise can be substan-tially reduced or, alternatively, the radia-

tion exposure to the patient can be lowered while maintaining image quality. Fig. 2 presents a preliminary result of a 2-phase liver study at full dose and 60% dose reduction (simulated by adding noise to CT raw data). Obviously, image quality can be fully restored with iterative reconstruction.

Axial thin slice images of a 2-phase liver scan (SOMATOM Definition AS+). Fig. 2A: FBP-image with B31 convolution kernel. Fig. 2B: FBP-image with B31 con-volution kernel, 60% less dose simulated by adding noise. Fig. 2C: Iterative Recon-struction of data of Fig. 2B after two iterations, 60% less dose (center 40 HU, width 400 HU). Even using less dose, image noise is reduced while maintain-ing image sharpness, comparable with image quality of Fig. 2A.

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Conventional CT reconstruction (iterative reconstruction loop n = 0, blue path) is done with Standard Filter Backprojection (FBP). Iterative reconstruction delivers a corrected image: all artifacts which have been created by non-exact FBP reconstruction are removed.

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References 1) J. Sunnegårdh, Thesis No 1301, Institute of Technology, Linkøping, 2007; 2) J. Sunnegårdh, et al., Med. Phys. 35 (2008), pp. 4173.

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TopicScience

Okinawa Churaumi Aquarium is one of the few aquariums that successfully keep whale sharks and the first to breed manta rays in captivity. Little is known about computed tomography of marine animals. For scientific purposes, a SOMATOM® Spirit scanner was installed at Churaumi

Aquarium in January 2008. Drying and conditioning the CT room was a major challenge as it is located next to changing rooms where staff members keep their wet suits. In addition, a door – used to bring in living fish in water tanks into the CT room – connects directly to the out-

side – and the weather is usually humid and warm in tropical Okinawa. The CT scanner also needed extra protection as marine animals are usually dripping seawater. To prevent corrosive seawater leaking into the gantry electronics, all joints were insulated with extra silicon

Okinawa Churaumi Aquarium: Imaging Marine Animals with the SOMATOM SpiritOkinawa Churaumi Aquarium ranks among the fi ve largest in the world and has achieved a long list of “bests” and “fi rsts”. Now Churaumi Aquarium has become the fi rst aquarium in Japan to use a CT scanner, specifi cally to diagnose marine animals.

By Katharina Otani, PhD, Tetsuo Onishi, Takumi Katsuya

Siemens-Asahi Medical Technologies, Tokyo, Japan

Members of the Fish and Aquatic Mammal Section (from left to right): Haruka Suzuki, veterinary nurse, Sayuri Shimoyama, veterinary nurse,Ikue Hamasaki, assistant veterinarian, Makio Yanagisawa, veterinarian and Keiichi Ueda, veterinarian.


Science

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Contrast enhanced CT images (VRT) of Chiloscyllium punctatum (often called “brown-banded bamboo shark”) showing blood volume.

tape and a cover, made from wet suit material, protects both the patient table and mat from water and turtle’s claws. The veterinarians Keiichi Ueda and Makio Yanagisawa at Churaumi Aquarium to-gether with Tetsuo Onishi from Siemens Asahi Medical Technologies adjusted the scan protocols by comparing fish to human sizes and shapes. After several trial and error scans of dead fish, they were able to save suitable scan protocols. Ikue Hamasaki recently joined the team as an assistant to the veterinarians. She earned a radiotechnologist license before studying marine biology at the University of North Carolina at Wilmington. “Scan-ning fish with a CT is easier than taking X-rays,” she says, “because positioning is less critical. But unexpected artifacts appear in the CT images, for example, because shark skin is very thick. Also, immobilizing marine animals is challeng-ing.”Time is critical when scanning living fish since some fish survive only a few minutes outside of water.Veterinarian Yanagisawa recently suc-ceeded in confirming the blood circula-tion of a Chiloscyllium punctatum (often

called “brown-banded bamboo sharks”). After sedating the shark, he injected 20 ml of iodinated contrast bolus directly into the shark’s two-chambered heart. The shark was lifted onto the patient table, positioned, and fixed before being scanned. The scan revealed that blood is pumped into the arteries and then flows to the gills. From there, it spreads directly into the shark’s whole body. The venous blood flowing back to the heart is faster than the arterial blood spreading into the body. Not all fish can be sedated, but Chiloscyllium punctatum are robust marine animals that tolerate anesthesia and contrast injections well. After the scan, the sedated shark was cradled inside seawater until it woke up and could soon be put back into the main tank.

Development of Treatment PlansVeterinarian Ueda also uses CT for diag-nosing and healing sick marine animals. Dissections and virtual autopsies help in understanding the cause of death of an animal, if organisms could be routinely scanned, treatment plans could be

decided to save animals. This became possible with a CT installed on the Aquar-ium premises. Last year, Ueda could diag-nose pneumonia on the CT images of a Steno bredanensis (often called “rough-toothed dolphin”) that fell ill. Unfortu-nately, this dolphin did not survive but the CT images obtained have helped in determining treatment plans for other sick marine animals.One of the Chelonia mydas (often called “green turtle”) in the aquarium was in bad shape, but the veterinarians were unable to tell whether it had a lung or visceral organ or peritoneum problem, so they scanned it. From the CT images, it became clear that the turtle had ingested foreign substances that were blocking its intes-tines. Direct intervention was not needed but the turtle was kept under observa-tion. It lost some weight initially, and then slowly recovered. A follow-up scan one month later revealed that the foreign substances in the intestines had been eliminated and that the turtle would sur-vive.Most of the scans, about three to five per week, are done as virtual autopsies for research purposes. The veterinarians have

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Foreign bodies of unknown origin were seen in the turtle’s intestines (Fig. 4C). Follow-up scan one month later showed that the ingested substances were eliminated (Fig. 4D).

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A Steno bredanensis (often called “rough-toothed dolphin”) diagnosed with pneumonia: positioning of the dolphin (Fig. 3A), axial CT image of the dolphin’s lung (Fig. 3B).

Chelonia mydas (often called “green turtle”) in Okinawa Churaumi Aquarium (Fig. 4A). Foreign bodies in turtle’s intestines detected with VRT (Fig. 4B).

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already assembled an amazing amount of data ranging from dolphin’s digestive systems and locations of air leakages when deep-sea fish are brought to the surface, to the morphology of Zoanthids (often called “colonial anemones”). They have presented posters at several Japa-nese workshops such as last year’s Meet-ing of the Japanese Society of Zoo and Wildlife Medicine. This year they plan to report results at the Spring Meeting of the Japanese Society of Fishery Science

and at the Biennial Conference on the Biology of Marine Mammals. A discus-sion on CT of marine animals has been started.The team agrees that CT is very useful in the aquarium. “Dissection of marine animals and sketching results take many hours. Additionally organs shift when opening the animals. With CT, we can see the location of bones and organs in their original position at once,” Yanagisawa and Hamasaki agrees. “Living marine

Standard Dual Energy cardio mixed image (Fig. 1A) and optimized reconstruction utilizing 4D Noise Reduction (Fig. 1B). Motion artifacts are clearly reduced with simultaneously enhanced contrast.

Spatiotemporal Multi-Band Filter for Reducing Artifacts and DoseBy Rainer Raupach, PhD


Siemens AG has developed a new algo-rithm – spatiotemporal Multi-band Filter called 4D Noise Reduction – for use with modern CT scanners when performing routine dynamic CT examinations, such as organ perfusion or 4D CT-Angiography. With 4D Noise Reduction, dose can be drastically reduced without any subse-quent loss of image quality. On the other hand, when superior image quality is the highest priority, the spatial resolution of

the CT perfusion images can be increased or the reliability of the perfusion para-meters improved utilizing the same dose that would be required when not using 4D Noise Reduction, i.e. the “standard” dose.4D Noise Reduction can be utilized for many investigational purposes: for example, artifacts in cardio CT images can be reduced significantly by maximizing temporal resolution which affects the

stability of CT values over a period of time. Therefore, images of unique quality for detecting perfusion-parameters can be achieved. By applying other modifica-tions, visualization of Dual Energy data can be improved and Dual Energy cardio scans can be optimized, offering Dual Energy information as well as delinea-tion of coronary arteries with maximum temporal resolution from a single scan (Fig. 1).

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animals can also be scanned now that we have a CT scanner in-house, which will help determining illnesses and treat-ment plans,” Ueda adds.

Further Information

http://www.kaiyouhaku.com/en/index.html

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Clinical Workshops at the Pulse of CT TechnologyBy Heike Theessen, Business Unit CT, Siemens Healthcare, Forchheim, Germany

Learning with well-known clinical experts in Europe: Attending clinical workshops in Paris/France to get started with Cardiac CT or coming to Münster/Germany to learn about state-of-the-art applications in DSCT.Due to long-term cooperation with key users, Siemens Healthcare is able to pro-vide high quality, peer-to-peer training with experts in Cardiac CT and DSCT. Clinical workshops are offered in various locations throughout Europe and through-out the year.

Clinical Workshop on Cardiac CT in Paris/FranceA very small group – maximum six par-ticipants – will be the core of this work-shop, which offers in-depth education in Cardiac CT. Jean-Francois Paul, MD, will guide the participants through the basics of Cardiac CT and provide plenty of tips and tricks along the way. During the first day, the participants will experience live patient examinations. Going from patient preparation to contrast optimization and

acquisition, a strong focus will be on radiation dose reduction. After that, the “work” comes back into the workshop. Most of the afternoon and during the second day, participants will work on syngo MultiModality Workstations to review datasets and re-evaluate images with coronary stenosis, plaque imaging and left ventricular function. Each case will be discussed in the group, sharing the challenges and complexity of each individual patient.The workshop will be held at the Marie Lannelongue Surgical Centre, an inter-nationally recognized, 200-bed hospital that specializes in thoracic and cardio-vascular diseases in adults and children. The team of the radiology department is developing new applications for cardio-vascular CT. The interest in using DSCT for congenital heart disease is particu-larly high and the team already has con-siderable experience in this emerging area. Technical aspects, especially radia-tion dose issues and contrast protocols are their main field of interest.

View to the University Hospital of Münster.

State-of-the-Art Applications Workshop in Münster/GermanyTheory and practice are combined in this four-day workshop. Johannes Wessling, MD, Harald Seifarth, MD, and their col-leagues will familiarize the participants with state-of-the-art applications and show how to use DSCT in the most effi-cient way. The first two days will focus on Cardiac CT. The participants will be familiarized with scanning techniques on two different scanners (SOMATOM Definition and SOMATOM Definition AS+) with live examinations on each scanner. The following days will focus on virtual colonography and detection and charac-terization of pulmonary nodules as well as modern concepts for the imaging of patients suffering from ischemic stroke. Clinical lectures will summarize exami-nation technique, patient selection and preparation as well as image interpreta-tion and processing techniques. The main focus will be on hands-on training and interactive interpretation of case studies using syngo MultiModality Workstations.The workshop will be held at the Uni-versity Hospital of Münster (UKM). With more than 7,500 highly qualified employ-ees and a capacity of over 1,500 beds, the University Hospital of Münster is one of the largest hospital complexes for specialized medical care in northern Ger-many. Approximately 420,000 patients per year receive inpatient or outpatient treatment in 33 clinics.Research closely linked to patient care has contributed largely to the international reputation of the University Hospital of Münster. Thanks to interdisciplinary co-operation, innovative new methods and findings in fields such as inflammatory process, strokes, heart and vascular dis-eases and transplantation medicine are progressively created and developed.

Life

www.siemens.com/life-courses


Topic

Trial License: Dual Energy CTFor 90 days, the unique Dual Energy ap-plications can be tried at no cost. It has always been Siemens’ aim to collect as much information as possible for the dif-

Free 90 Day Trial Licenses for Clinical Applications

ferentiation of tissues. Providing Spiral Dual Energy scanning, SOMATOM® Definition and SOMATOM Definition Flash open the door to a new world of characterization, visualizing the chemi-cal composition of material.Many applications are already available for daily clinical use, such as an accu-rate subtraction of bone in CTAs, assess-ment of pulmonary and myocardial perfusion, characterization of kidney stones or atherosclerotic plaque and iodine removal from liver scans to gen-erate a virtual unenhanced image.By enabling not only faster and more reliable diagnoses, but also by further broadening the application spectrum of CT, Spiral Dual Energy makes a difference in everybody’s daily work.

Dual Energy trial applications available: ■ syngo DE Direct Angio■ syngo DE Hardplaque Display■ syngo DE Lung PBV■ syngo DE Virtual Unenhanced (VNC)■ syngo DE Calculi Characterization■ syngo DE Musculoskeletal■ syngo DE Lung Vessels■ syngo DE Gout■ syngo DE Brain Hemorrhage■ syngo DE Heart PBV

The local Siemens representative can be contacted for system requirements and ordering details.

syngo DE lung PBV

Life

Now is the Time to Elevate SOMATOM AR and SOMATOM Plus 4 ScannersBy Marion Meusel, Business Unit CT, Siemens Healthcare, Forchheim, Germany

The first SOMATOM® AR and Plus 4 scan-ners left the Siemens CT factory back in the 90s. Since then, even though modern CT technology has evolved rapidly from single row, single source scanners to multi-slice Dual Source systems, many AR and Plus 4 scanners still do a pretty good imaging job. But after more than 10 years of reliable service, these products are now reaching the end of their useful life-span.Generally, Siemens Healthcare supports its imaging products for 10 years after the last system is produced. As equipment

www.siemens.com/ct-elevate

ages, however, it is much more difficult to maintain support because some sup-pliers discontinue the production of needed components.The SOMATOM AR and Plus 4 scanners will reach the end of their feasible servic-ing period by the end of this year. For AR or Plus 4 owners, advantageous upgrade programs exist to switch over smoothly to a new SOMATOM CT scanner from the current Siemens CT portfolio. The new technologies help to reduce dose, im-prove workflow, increase procedures and enhance patient comfort.


Clinical Poster on CT-guided VertebroplastyIn recent years, there has been a steady rise in the use of CT for biopsy and for image-guided, minimally-invasive thera-pies. Thanks to the excellent cooperation between Ralf Hofmann, MD, from the University of Munich, Campus Großhad-ern, Germany and Siemens a new clini-cal poster was designed. Based on 600 CT-guided interventions, vertebroplasty has been identified as a key area. The poster informs both, physicians and pa-tients about state-of-the-art intervention-al procedures in vertebroplasty, offering

www.siemens.com/ct-posters

GEST 2009: Siemens Healthcare Demonstrated Innovation Leadership in Interventional OncologyBy Stefan Wünsch, PhD*, Susanne von Vietinghoff*, Oliver Meissner, MD**

*Business Unit CT / **Business Unit AX, Siemens Healthcare, Forchheim, Germany

Siemens used the opportunity at the GEST 2009 meeting (Global Embolization Symposium and Technologies) in Paris April 15th-18th to demonstrate their latest developments in CT and angiographic guided interventional oncology.The congress focused on embolization, hands-on workshops and training courses, as well as highly focused industry sympo-sia. At the Siemens booth, presentations on 3D advanced applications, the Artis zee and the SOMATOM CT families were shown. At workplaces, interventional opportunities with CT and the latest guided technologies from angiography – iGuide CAPPA1, an electromagentic needle guidance system – were demonstrated.

Additionally, the customers were invited to join the symposium “Siemens Innova-tions in Interventional Oncology”.Mike Wallace, MD, M.D. Anderson Cancer Center, Houston, TX, USA, presented first results with the new needle guidance system, syngo iGuide and iGuide CAPPA, offering electromagnetic needle tracking.Tobias Jakobs, MD, University of Munich, Campus Großhadern, Germany, demon-strated Siemens’ leadership in CT-guided interventions using the latest Adaptive 3D Intervention Suite for SOMATOM Definition CT systems,2 thus highlighting the fast and efficient 3D guided treat-ment of various tumors with full in-room control. The symposium showed Siemens’

unique strenghts and gave a compre-hensive overview of latest imaging tech-niques in interventional oncology.

1 Skalej M, MD et.al., AXIOM Innovations 08 p22-23.2 Hoffmann RT, MD et al., SOMATOM Sessions 23 p50-51; Jakobs TF, MD et al., SOMATOM Sessions 23 p52-53.

information regarding indications, con-tra-indications as well as access paths and results. Hence, it is perfectly de-signed for the scanning room and the patient waiting room.With this new member, a total of 4 clini-cal posters will be available in the Clinical Poster Gallery. A free copy can be ordered via www.siemens.com/ct-posters in late summer 2009.

Tobias Jacobs, MD, University of Munich, Germany, demonstrates 3D guided treatment of tumors at the GEST symposium.

NEW


Topic

How can I reduce dose in cardiac scans?The following tips can help to reduce dose up to 50% in cardio scans.*■ Use 100 kV protocols instead of

120 kV for patients lighter than 80 kg (175 lbs) and adapt the mAs/rot by a factor of 1.28.

With 100 kV, the contrast to noise is much better and you can therefore reduce the dose up to 25%. A default

Frequently Asked Questions

scan protocol with 100 kV is available on your scanner.

■ When you change the scan length from an average of 17 cm to 14 cm, the dose saving is up to 15%.

■ Use the smallest possible ECG-pulsing window and MinDose if functional imaging is not desired.

When the heart rate is < 75 bpm, use a pulsing window of 70 to 70% (Fig.1),

saving up to 40% dose** in compari-son to a window of 60 to 80%.

When the heart rate is > 75 bpm, use a pulsing window of 35 to 70%, saving up to 20% dose** in comparison to a window of 30 to 80%.

With an ECG-pulsing window of 70 to 70%, you still have the possibility to shift the reconstruction window for +3% or -3% to obtain the best image quality.

■ For lowest possible dose, use the Adaptive Cardio Sequence scan proto-col that is by default installed on your scanner. With this protocol, the system will react when there is an extra-systolic heartbeat and set the Flexpadding to 0.

Fig. 1: Example of the SOMATOM Definition scanner trigger card.

Life

ESGAR Workshops on CT Colonography

CT-Colonography (CTC) has proven to be a viable alternative to conventional colon examinations like double contrast barium enema and colonography.However, CTC scanning and especially the evaluation of CTC results, require specific knowledge and skills.Therefore, ESGAR, the European Society of Gastro-intestinal and Abdominal Radiology, frequently offers CTC workshops across Europe. Siemens, a long-term partner in these workshops, was pleased to be part

http://www.esgar.org

of the 10th ESGAR hands-on workshop on CT-Colonography, which took place in February 2009 in Harrogate/UK. Dur-ing one day of lectures, over 100 partici-pants learned fundamental clinical de-tails on CTC.During the second day, more than 30 datasets were reviewed on the worksta-tions provided. This review started with easy cases, going to more difficult ones, ending with cases that showed typical pitfalls of CTC.

The next CTC workshop from ESGAR will take place in Stresa/Italy in September 2009. Registering is possible via the ESGAR website.

* All numbers and facts are based on a SOMATOM Definition with software version syngo CT 2008G.** For non-arrhythmic patients.

Logo of European Society of Gastrointestinal and Abdominal Radiology.

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Topic

Healthcare industry is constantly subject to rapid changes. Remaining up-to-date is of vital importance. The Siemens’ CT e-Newsletter brings targeted information on the latest developments and impor-tant events.The monthly CT e-Newsletter provides:■ Highlights on business, clinical

outcomes, science and customer care topics,

News in the CT World

Clinical Workshops 2009As a cooperation partner of many renowned hospitals, Siemens Healthcare offers continuing CT training programs. A wide range of clinical workshops keep participants at the forefront of clinical CT imaging.

Workshop Title Location Dates Course Course language director

Clinical CTA Interpretation Course Erlangen/Germany May 14 – 15, 2009 English Prof. Stephan Achenbach, MD Oct. 01 – 02, 2009 Nov. 26 – 27, 2009

Clinical Workshop on Cardiac CT Paris/France May 15 – 16, 2009 English Jean-Francois Paul, MD Sept. 11 – 12, 2009

Hands-on Workshop Cardiac CT Zurich/Schweiz June 12 – 13, 2009 German PD Hatem Alkadhi, MD

Dubai CT-Workshop Dubai/UAE June 21 – 22, 2009 English Alexander Becker, MD PD Christoph Becker, MD

Clinical Workshop on Cardiac CT Munich/Germany July 08 – 10, 2009 English PD Christoph Becker, MD Nov. 09 – 11, 2009 PD Konstantin Nikolaou, MD Alexander Becker, MD

Clinical Training Course on Cardiac CT Kuching/Malaysia July 25 – 26, 2009 English Prof. Sim Kui Hian, MD Nov. 21 – 22, 2009 Ong Tiong Kiam, MD

Hands-on Workshops during ESC 2009 Barcelona/Spain Aug. 29 – Sept. 01, 2009 English TBD

Basics on Cardiac CT for MTRA Forchheim/Germany Sept. 03 – 04, 2009 German TBDTechnologists

Dual Energy Workshop Forchheim/Germany Sept. 11 – 12, 2009 English Thorsten Johnson, MD

11th ESGAR CT-Colonography Workshop Stresa/Italy Sept. 17 – 19, 2009 English Daniele Regge, MD

Clinical Workshop on State-of-the-Art Münster/Germany Sept. 21 – 24, 2009 English PD Johannes Wessling, MDApplications

Virtual CT-Colonography Berlin/Germany Sept. 25 – 26, 2009 German Prof. Bernd Lünstedt, MD Nov. 20 – 21, 2009

Clinical Workshop on Cardiac CT Erlangen/Germany Oct. 21 – 23, 2009 English Prof. Stephan Achenbach, MD

www.siemens.com/ct-news

In addition, the latest CT courses offered by Siemens Healthcare can be found at www.siemens.com/SOMATOMEducate

■ Upcoming CT events and courses,■ Answers to frequently asked questions,■ Selection of tips and tricks on “how

to …” efficiently use Siemens CT scan-ners and applications in daily clinical practice.

Registration online:


At this year’s European Congress of Radiology (ECR) in Vienna, Siemens once again invited customers to visit the Experience Lounge and join clinical hands-on Workshops for Computed Tomogra-phy (CT), Magnetic Resonance (MR) and Molecular Imaging (MI). More than 400 participants from 49 countries joined the sessions and could enjoy an update on state-of-the-art techniques for these modalities.At the beginning of each session, a theo-retical introduction was given by a clini-cal expert. Radiologists from well known

By Heike Theessen, Business Unit CT, Siemens Healthcare, Forchheim, Germany

Siemens cooperation partners shared tips and tricks and explained how certain procedures are done in their environment. These were followed by demonstrations of clinical cases during which participants were guided through the processing tools available for the syngo MultiModality Workplace platform.Siemens will also offer the Experience Lounge at the upcoming RSNA 2009 in

Chicago. The ECR hands-on workshops in 2008 have been recorded. This DVD can be ordered via the following link (click on E-Learning):

Experience Lounge at ECR 2009

www.siemens.com/somatomeducate

Upcoming Events & Congresses

Siemens Experience Lounge during ECR 2009.

Title Location Short Description Date Contact

11th International San Francisco/ Stanford CME Course May 19 – 22, 2009 radiologycme.stanford.eduSymposium on USA and ExhibitionMultidetector-Row CT

Deutscher Röntgen- Berlin/Germany National Scientific Congress May 20 – 23, 2009 www.roentgenkongress.dekongress (DRK) and Exhibition

2nd World Congress of Valencia/Spain Scientific Congress May 30 – www.2wcti.orgThorac. Imag. and Diagn. June 02, 2009in Chest Disease (WCTI)

SCCT Orlando/USA 4th Annual Scientific Meeting July 16 – 19, 2009 www.scct.org of the Society of Cardiovascular Computed Tomography

ESC Barcelona/ Annual Congress of European Aug. 29 – www.escardio.org Spain Society of Cardiology Sep 02, 2009

ESNR Athens/ Annual Congress of European Sept. 17 – 20, 2009 www.esnr.org Greece Society of Neuroradiology

CIRSE Lisbon/ Scientific Congress Sept. 19 – 23, 2009 www.cirse.org Portugal

German Society of Cologne/ 44th Annual Meeting Oct. 08 – 10, 2009 www.dgnr.orgNeuroradiology (DGNR) Germany

Medica Duesseldorf/ MEDICA 2009 Nov. 18 – 21, 2009 www.medica.de Germany

RSNA Chicago/ Annual Meeting of Radiological Nov. 29 – www.rsna.org USA Society of North America Dec. 04, 2009

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Siemens Healthcare – Customer MagazinesOur customer magazine family offers the latest information and background for every healthcare fi eld. From the hospital director to the radiological assistant – here, you can quickly fi nd information relevant to your needs.

Medical SolutionsInnovations and trends in healthcare. The magazine is designed especially for members of hospital manage-ment, administration personnel, and heads of medical depart-ments.

AXIOM InnovationsEverything from the worlds of interventional radiology, cardiology, fluoroscopy, and radiography. This semi-annual magazine is primar-ily designed for physicians, physicists, researchers, and medical technical personnel.

MAGNETOM FlashEverything from the world of magnetic resonance imaging. The magazine presents case reports, technology, product news, and how-to articles. It is primarily designed for physicians, physicists, and medical technical personnel.

SOMATOM SessionsEverything from the world of computed tomography. With its innovations, clinical applications, and visions, this semi-annual magazine is primarily designed for physicians, physicists, researchers, and medical technical personnel.

PerspectivesEverything from the world of clinical diagnostics. This semi-annual publication pro-vides clinical labs with diag-nostic trends, technical inno-vations, and case studies. It is primarily designed for laboratorians, clinicians, and medical technical personnel.

eNewsRegister for the Siemens Healthcare global eNewsletter at www.siemens.com/healthcare-eNews to receive monthly updates on topics that interest you.

For current and former issues and to order the magazines, please visit www.siemens.com/healthcare-magazine

“The SOMATOMDefi nition Flashis the scannerthat gives you alloptions.”

Stephan Achenbach, MD, Department of Cardiology, University of Erlangen-Nuremberg, Erlangen, Germany

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Responsible for Contents: André Hartung

Editorial Board: Andreas Blaha, Andreas Fischer, Thomas Flohr, PhD, Klaudija Ivkovic, Axel Lorz, Jens Scharnagl, Heiko Tuttas, Alexander Zimmermann

Authors of this Issue: S. Achenbach, MD, Department of Cardiology, University of Erlangen-Nuremberg, Erlangen, Germany

J. Aigner, Department of Diagnostic Radiology, University Hospital, Salzburg, Austria

R. Bauer, MD, Department of Diagnostic and Interventional Radiology, Johann Wolfgang Goethe-University, Frankfurt, Germany

M. Das, MD, Department of Diagnostic Radiology, University Hospital, RWTH-Aachen University, Germany

E. Egin, MD, Department of Radiology, Cardio Center, Volgograd, Russia

W. Eicher, MD, Department of Radiology, Landeskrankenhaus Klagenfurt, Klagenfurt am Wörthersee, Austria

Note in accordance with § 33 Para.1 of the German Federal Data Protection Law: Despatch is made using an address file which is maintained with the aid of an automated data processing system.SOMATOM Sessions with a total circulation of 35,000 copies is sent free of charge to Siemens Computed Tomography customers, qualified physicians and radiology departments throughout the world. It includes reports in the English language on Computed Tomography: diagnostic and therapeutic methods and their application as well as results and experience gained with corresponding systems and solutions. It introduces from case to case new principles and procedures and discusses their clinical potential.The statements and views of the authors in the individual contributions do not necessarily reflect the opinion of the publisher.The information presented in these articles and case reports is for illustration only and is not intended to be relied upon by the reader for instruction as to the prac-tice of medicine. Any health care practitioner reading this information is reminded that they must use their own learning, training and expertise in dealing with their individual patients. This material does not substitute for that duty and is not intended by Siemens Medical Solutions to be used for any purpose in that regard.

J. Ferda, MD, PhD, Clinic of Radiodiagnostics, University Hospital Pilsen, Pilsen, Czech Republic

M. Gerl, Department of Diagnostic Radiology, University Hospital, Salzburg, Austria

R. Gilkeson, MD, University Hospital, Case Medical Center, Cleveland, Ohio, USA

K. Hausegger, MD, Department of Radiology, Landeskrankenhaus Klagenfurt, Klagenfurt am Wörthersee, Austria

K. Hergan, MD, Department of Diagnostic Radiology, University Hospital, Salzburg, Austria

B. Hettegger, Department of Diagnostic Radiology, University Hospital, Salzburg, Austria

F. Hinkmann, MD, Institute of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany

R. Janka, MD, Institute of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany

T. Kau, MD, Department of Radiology, Landeskrankenhaus Klagenfurt, Klagenfurt am Wörthersee, Austria

M. Kerl, MD, Department of Diagnostic and Interventional Radiology, Johann Wolfgang Goethe-University, Frankfurt, Germany

H. Korkusuz, MD, Department of Diagnostic and Interventional Radiology, Johann Wolfgang Goethe-University, Frankfurt, Germany

B. Kreuzberg, MD, PhD, Clinic of Radio-diagnostics, University Hospital Pilsen, Pilsen, Czech Republic

A. Küttner, MD, Institute of Diagnostic Radiology, University of Erlangen-Nuremberg, Erlangen, Germany

M. Lauschmann, MD, Department of Diagnostic Radiology, University Hospital, Salzburg, Austria

M. Lell, MD, Department of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany

D. Perdieus, MD, Department of Radiology, Imelda Ziekenhuis, Bonheiden, Belgium

M. Schlager, Department of Diagnostic Radiology, University Hospital, Salzburg, Austria

A. Schneider, MD, Department of Diagnostic Radiology, University Hospital, Salzburg, Austria

S. Shaid, MD, Department of Medicine, Goethe-University Hospital Frankfurt, Germany

E. Uysal, MD, Department of Radiology, Sisli Etfal Training and Research Hospital, Istanbul, Turkey

U. Valeti, MD, Department of Cardiology, St. Paul Heart Clinic, Saint Paul Minnesota, USA

T. Vogl, MD, Department of Diagnostic and Interventional Radiology, Johann Wolfgang Goethe-University, Frankfurt, Germany

P. Weisser, MD, Department of Diagnostic and Interventional Radiology, Johann Wolfgang Goethe-University, Frankfurt, Germany

E. Wenkel, MD, Institute of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany

Catherine Carrington, freelance author Tony DeLisa, freelance author Ron French, medical writer Louisa Kasdon, medical writer

Photo Credits: Jez Coulson

Peter Aulbach; Karin Barthel; Andreas Blaha; Herbert Bruder, PhD; Joachim Buck, PhD; Steven Bell; Ivo Driesser; Kerstin Fellenzer; Thomas Flohr, PhD; Jan Freund; Inga Fötsch; Tanja Gassert; Christoph Hachmöller, MD; Christiane Iwert; Takumi Katsuya; Carolin Knecht; Bernhard Krauss, PhD; Rami Kusama; Oliver Meissner, MD; Marion Meusel; Tetsuo Onishi; Katharina Otani, PhD; Kerstin Putzer; Rainer Raupach, PhD; Karl Stierstorfer; Heike Theessen; Peter Seitz; Susanne von Vietinghoff; Stefan Wünsch, PhD; all Siemens Healthcare

Production: Norbert Moser, Siemens AG, Healthcare

Design and Editorial Consulting: independent Medien-Design, Munich, Germanyin cooperation with Primafila AG, Zurich, SwitzerlandManaging Editor: Christa LöberbauerPhoto Editor: Susanne NipsLayout: Claudia Diem, Mathias FrischAll at: Widenmayerstrasse 16, D-80538 Munich,Germany

PrePress: Kerstin Putzer, Siemens AG, Healthcare; Reinhold Weigert, Typographie und mehrSchornbaumstraße 7, D-91052 Erlangen

Printers: Farbendruck Hofmann, Gewerbestraße 5, D-90579 Langenzenn, Printed in Germany

SOMATOM Sessions is also available on the internet: www.siemens.com/SOMATOMWorld

The drugs and doses mentioned herein are consistent with the approval labeling for uses and/or indications of the drug. The treating physician bears the sole responsibility for the diagnosis and treatment of patients, including drugs and doses prescribed in connection with such use. The Operating Instructions must always be strictly followed when operating the CT System. The sources for the technical data are the corresponding data sheets. Results may vary.Partial reproduction in printed form of individual contributions is permitted, pro-vided the customary bibliographical data such as author’s name and title of the contribution as well as year, issue number and pages of SOMATOM Sessions are named, but the editors request that two copies be sent to them. The written con-sent of the authors and publisher is required for the complete reprinting of an article.We welcome your questions and comments about the editorial content of SOMATOM Sessions. Manuscripts as well as suggestions, proposals and informa-tion are always welcome; they are carefully examined and submitted to the edito-rial board for attention. SOMATOM Sessions is not responsible for loss, damage, or any other injury to unsolicited manuscripts or other materials. We reserve the right to edit for clarity, accuracy, and space. Include your name, address, and phone number and send to the editors, address above.

SOMATOM Sessions – IMPRINT© 2009 by Siemens AG, Berlin and MunichAll Rights Reserved

Publisher:Siemens AGHealthcare SectorBusiness Unit Computed TomographySiemensstraße 1, 91301 Forchheim, Germany

Chief Editors:

Monika Demuth, PhD ([email protected])

Stefan Wünsch, PhD([email protected])


Imprint


Editorial

“With developing the SOMATOM Definition Flash, our company has once again set a new standard for radiation dose reduction in CT.”Sami Atiya, PhD, Chief Executive Officer, Business Unit Computed Tomography, Siemens Healthcare, Forchheim, Germany

Cover Page: A thorax scan for triple-rule out with the SOMATOM Defi nition Flash is possible in less than one second. Courtesy of University of Erlangen-Nuremberg, Erlangen, Germany

The Difference in Computed Tomography

SOMATOM Sessions

Cover Story SOMATOM Defi nition Flash: Impressive PerformancePage 6

News Functional Imaging Widens the Clinical Spectrum for CTPage 12

Business Chest Pain: Clarity with CTPage 20

Clinical Results SOMATOM Defi nition Flash: The Entire Heart Scanned in Just 270 ms with 0.95 mSvPage 32

Science Iterative Image Reconstruction Moves into Clinical PracticePage 65

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sThe SOMATOM Defi nition Flash delivers excellent improved diagnostic quality with levels of dose lower than ever before possible. It can be summa-rized in four words: Flash speed. Lowest dose.

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Issue Number 24/May 2009Stanford-Edition I May 19th – 22th, 2009

On account of certain regional limitations of sales rights and service availability, we cannot guarantee that all products included in this brochure are available through the Siemens sales organization worldwide. Availability and packaging may vary by country and is subject to change without prior notice. Some/All of the features and products described herein may not be available in the United States.

The information in this document contains general technical descriptions of specifications and options as well as standard and optional features which do not always have to be present in individual cases.

Siemens reserves the right to modify the design, packaging, specifications and options described herein without prior notice. Please contact your local Siemens sales representative for the most current information.

Note: Any technical data contained in this document may vary within defined tolerances. Original images always lose a certain amount of detail when reproduced.

www.siemens.com/healthcare-magazine

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Siemens AGMedical SolutionsComputed TomographySiemensstraße 191301 ForchheimGermanyPhone: +49 9191 18 - 0www.siemens.com/healthcare

Local Contact Information

Asia/Pacific:Siemens Medical SolutionsAsia Pacific HeadquartersThe Siemens Center60 MacPherson RoadSingapore 348615Phone: +65 9622 - 2026www.siemens.com/healthcare

Canada:Siemens Canada LimitedMedical Solutions2185 Derry Road WestMississauga ON L5N 7A6CanadaPhone: +1 905 819 - 5800www.siemens.com/healthcare

Europe/Africa/Middle East:Siemens AGMedical SolutionsHenkestraße 127D-91052 ErlangenGermanyPhone: +49 9131 84 - 0www.siemens.com/healthcare

Latin America:Siemens S.A.Medical SolutionsAvenida de Pte. Julio A. Roca No 516, Piso 7C1067ABN Buenos Aires ArgentinaPhone: +54 11 4340 - 8400www.siemens.com/healthcare

USA:Siemens Medical Solutions U.S.A., Inc.51 Valley Stream ParkwayMalvern, PA 19355-1406USAPhone: +1-888-826 - 9702www.siemens.com/healthcare

Global SiemensHealthcare Headquarters

Siemens AGHealthcare SectorHenkestraße 12791052 ErlangenGermanyPhone: +49 9131 84 - 0www.siemens.com/healthcare

Global Siemens Headquarters

Siemens AGWittelsbacherplatz 280333 MuenchenGermany

Order No. A91CT-00872-41M1-7600 | Printed in Germany | CC CT 00872 ZS 0509/35. | © 05.2009, Siemens AG

Somatom sessions 24

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