SoMaTom Sessions Computed Tomography November 2008

The Difference in Computed Tomography

SOMATOM Sessions

Cover Story SOMATOM Defi nition Flash Dual Source CT:Leaving Dose BehindPage 6

News Dual Source CT on Scientifi c Center Stage4

Business As Radiation Dose Goes Down, Attractiveness of CT RisesPage 20

Clinical Outcomes Coronary CTA with Flash Spiral Scanning in 300 msec Scan TimePage 26

Science CT put to the TestPage 56

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Through a combi-nation of unprece-dented speed and innovative dose-reduction features, the new SOMATOM Defi nition Flash offers patients a healthier CT scan.

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Issue Number 23/November 2008RSNA Edition | November 30th – December 05th, 2008

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.

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“The new scanner is a true revolution. We never before dared to scan with such a low dose and such a high speed.”

Willi Kalender, PhD, Director of the Institute of Medical Physics, 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 Zimmer-mann

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

B. Beyer, MD, Department of Surgery, University of Munich, Campus Großhadern, Munich, Germany

J. Fielding, Department of Radiology, Angliss Hospital, Upper Ferntree Gully, Melbourne VIC, Australia

R. Finzel, Department of Neuroradiology, Univer-sity of Göttingen, Göttingen, Germany

M. Godoy, MD, Department of Radiology, New York University Medical Center, New York, USA

J. Hausleiter, MD, Department of Radiology and Nuclear Medicine, German Heart Center, Mu-nich, Germany

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 au-tomated 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 applica-tion as well as results and experience gained with corresponding systems and so-lutions. It introduces from case to case new principles and procedures and dis-cusses 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 remind-ed 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.

E. Hendrich, MD, Department of Radiology and Nuclear Medicine, German Heart Center, Munich, Germany

M. Higashi, MD, Department of Radiology and Nuclear Medicine, National Cardiovascular Cen-ter, Osaka, Japan

R. Hoffmann, MD, Department of Clinical Radiol-ogy, University of Munich, Campus Großhadern, Munich, Germany

T. Jakobs, MD, Department of Clinical Radiology, University of Munich, Campus Großhadern, Mu-nich, Germany

S. Kanzaki, MD, Department of Radiology and Nuclear Medicine, National Cardiovascular Cen-ter, Osaka, Japan

K. Kichikawa, MD, PhD, Department of Radiolo-gy, Nara Medical University, Nara, Japan

S. Kitano, MD, Department of Radiology, Nara Medical University, Nara, Japan

A. Kohli, MD, Department of Radiology, Breach Candy Hospital Trust, Mumbai, India

T. Löffler, MD, Department of Surgery, University of Munich, Campus Großhadern, Munich, Germany

S. Martinoff, MD, Department of Radiology and Nuclear Medicine, German Heart Center, Mu-nich, Germany

N. Marugami, MD, Department of Radiology, Nara Medical University, Nara, Japan

A. Megibow, MD, MPH, FACR, New York University Medical School, New York, USA

D. Naidich, MD, Department of Radiology, New York University Medical Center, New York, USA

H. Naito, MD, PhD, Department of Radiology and Nuclear Medicine, National Cardiovascular Cen-ter, Osaka, Japan

K. Nikolaou, MD, Department of Clinical Radiolo-gy, University of Munich, Campus Großhadern, Munich, Germany

M. Reiser, MD, Department of Clinical Radiology, University of Munich, Campus Großhadern, Mu-nich, Germany

J. Remy, MD, University of Center Lille, Depart-ment of Thoracic Imaging, Hospital Calmette, Lille, France

M. Remy-Jardin, MD, PhD, University Center of Lille, Department of Thoracic Imaging, Hospital Calmette, Lille, France

P. Schramm, MD, Department of Neuroradiology, University of Göttingen, Göttingen, Germany

W. Sommer, MD, Department of Clinical Radiolo-gy, University of Munich, Campus Großhadern, Munich, Germany

T. Taoka, MD, PhD, Department of Radiology, Nara Medical University, Nara, Japan

Catherine Carrington, freelance authorMelanie J. Davis, medical writerTony DeLisa, freelance authorSameh Fahmey, medical and scientific journalistHildegard Kaulen, PhD, freelance scientific journalistOliver Klaffke, freelance scientific journalistTim Schröder, freelance scientific journalist Rita Wellens, PhD, medical writer and clinical research consultant

Photo Credits: Peter Rigaud/Shotview, Jez Coul-son, Tina Ruisinger, Stephan Sahm, Chris De Bode

Peter Aulbach; Steven Bell; Andreas Blaha; Joachim Buck, PhD; Jan Chudzik; Ulrike Dräger-Klar; Ivo Driesser; Carolin Emmert; Inga Fötsch; Tanja Gassert; Christoph Hachmöller, MD; Carolin Knecht; Rami Kusama; Claudia Lindner; Reto Merges; Marion Meusel; Kerstin Putzer; Rainer Raupach, PhD; Holger Reinsberger; Peter Seitz; Katja Stöcker; Heike Theessen; Stefan Wünsch, PhD; Claudette Yasell; all Siemens Healthcare

Production: Norbert Moser, Siemens AG, Healthcare

Layout: independent Medien-DesignWidenmayerstrasse 16, 80538 Munich

Printers: Farbendruck Hofmann, Gewerbestraße 5, 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 responsi-bility for the diagnosis and treatment of patients, including drugs and doses pre-scribed 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, provid-ed the customary bibliographical data such as author’s name and title of the contri-bution 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 consent 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 SOMA-TOM Sessions. Manuscripts as well as suggestions, proposals and information are always welcome; they are carefully examined and submitted to the editorial 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© 2008 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 · November 2008 · www.siemens.com/healthcare-magazine 77

Imprint

2 SOMATOM Sessions · November 2008 · www.siemens.com/healthcare-magazine

Editorial

“Lowest radiation dose is important to physicians and patients. It’s important to us.”Sami Atiya, PhD, Chief Executive Officer, Business Unit CT, Siemens Healthcare, Forchheim, Germany



Editorial

Dear Reader, For the Siemens Healthcare Sector, be-ing the industry’s innovative leader in medical technology – year after year – has become almost routine. But innova-tion leadership in pioneering new clini-cal terrain with unmatched technology alone is not sufficient: From the very beginning, we have maintained a strict focus on patient safety as well. And in computed tomography (CT), patient safety translates primarily into dose re-duction. For this reason, we have, from the earliest days, always given dose reduction top priority.The actual danger caused by X-ray radia-tion in rather low amounts as required for CT scanning is difficult to measure since there exists almost no adequate information or scientific stud-ies on the problem. We have therefore committed ourselves to the ALARA (i. e. As Low As Reasonably Achievable) principle of exposing patients only to the minimum amount of radiation absolutely necessary to achieve the best possible diagnosis. Consequently, in recent years, we have developed many significant products and protocols to conform to the ALARA principle, for example, Adaptive Dose Shield and others that reduce radiation dose to the lowest possible level. Following closely on the development and introduction of Dual Source CT (DSCT) in 2005, we have once again achieved a new milestone in CT dose

reduction with the new SOMATOM® Definition Flash scanner. This scanner delivers greatly improved diagnostic quality with levels of dose lower than ever before possible because its modern and future oriented technology effi-ciently utilizes the next generation DSCT. With its revolutionary Flash Spiral mode resulting in very high speed, the SOMATOM Definition Flash scanner is not only the lowest dose scanner known today, it is also the fastest, being able to virtually eliminate the need for breath holds and do a whole body scan in four seconds or to scan an entire thorax in less than one second. And it accomplish-es these breath-taking performances with the lowest dose known world-wide.Flash speed plus lowest dose are the core of the new scanners’ advantages. Even under unfavorable conditions, the patient’s dose exposure is less than what is required for diagnostic cardiac cath. And triple rule-out examinations are possible with doses below 5 mSv, up to four times lower than any other scanner available on the market. Furthermore the SOMATOM Definition Flash can selectively reduce sensitive-area exposure up to 40% without loss of image quality by turning down the X-ray tube while scanning dose-sensitive body areas such as female breasts. The SOMATOM Definition Flash opens new dimensions for functional 4D imaging

by combining the unique Adaptive 4D Spiral with Flash speed, thereby intro-ducing Adaptive 4D Spiral Plus for long-range dynamic imaging of up to 48 cm, enabling dynamic imaging with half the dose. An additional dose-saving feature is the Selective Photon Shield, filtering out unnecessary photons of the high energy X-ray tubes resulting in a better separation of 80/140 kV images by simul-taneously providing dose-neutral, Spiral Dual Energy. In addition to the advanced technology required for lowest dose imaging, ade-quate training is provided by our highly competent application team so that you and your medical team will be able to take full advantage of both the superior scanning performance and the dose-reducing features of the new scanner. With the SOMATOM Definition Flash all patients benefit from the extremely low dose levels, thus making CT a healthier examination than ever before. And your work will be easier and faster, your diag-noses more accurate with completely new clinical applications that only Dual Source CT can provide.

Enjoy reading,

André Hartung, Vice President

Marketing and Sales

André Hartung

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Cover Story

6 SOMATOM Definition Flash Dual Source CT: Leaving Dose Behind

News

14 Dual Source CT on Scientific Center Stage

15 First U.S. Payor Reimburses CT Colonography (CTC) for Screening

16 The SOMATOM Definition AS 20-Slice Configuration

16 4D Noise Reduction: New Filter Setting for Dose Decrease and Image Enhancement

17 The Success Story of the SOMATOM Emotion Continues

17 3D on the fly with new syngo Web-Space 2008B

18 Proactive Tube Failure Prediction: Siemens Guardian Program now Includes TubeGuard for the SOMATOM Definition Family

19 Molecular CT – Imaging in Living Colors

Cover Story


Content

Content

The new SOMATOM® Definition Flash Dual Source CT scanner can sweep through the entire thorax in 0.6 seconds and speed through cardiac scans in less than half a heartbeat. But the talk will be about more than speed alone. That’s because the new scanner also promises an impressive reduc-tion in radiation dose for all patients and all types of scans. In a word, the SOMATOM Definition Flash has been designed to be a healthier CT scanner.

6 SOMATOM Definition Flash

42Visualization of Brain Vessel Connection



Neurology 38 Acute Left Hemispheric Ischemic

Stroke: Comprehensive Stroke Imag-ing Using Neuro Volume Perfusion CT

40 SOMATOM Definition AS+: Neuro Volume Perfusion CT of Intracerebral Metastatic Disease

42 Dual Source CT: Visualization of Brain Vessel Connection of Siamese Twins

44 A Rare Anomaly of the Middle Cere-bral Artery Detected by Three-Dimen-sional Subtraction CT-Angiography

Acute Care 46 Complete Thorax with Flash Spiral 48 Dual Source CT: Carotid Stenosis

Diagnosed with Dual Energy

Orthopedics 50 Screw Placement and Pelvic

Osteoplasty Under CT – Fluoroscopic Guidance

Science

52 CT-Guided Osteosynthesis in Instable Pelvic Fractures

54 Clinical Advantages of Automated CT Tumor Measurement

Business

20 As Radiation Dose Goes Down, Attractiveness of CT Rises

22 Making a Case for the SOMATOM Emotion

24 syngo WebSpace: Command Central for Fast and Efficient Image Processing

Clinical Results

Cardiovascular 26 Coronary CTA with Flash Spiral

Scanning in 300 msec Scan Time 28 Low Dose Coronary CTA Reveals

High Grade Stenosis 30 Dual Source CT:

Pediatric Congenital Heart Disease 32 Identification of Vessel Stenosis

of the Lower Leg by Dynamic CT-Angiography Using the SOMATOM Definition AS+

Oncology 34 SOMATOM Definition Dual Energy

Scanning: Liver Imaging with Optimum Contrast

36 Lung Parenchyma Analysis Software with Automated Three-Dimensional Quantification of Emphysema

56 CT put to the Test 60 Virtual Histology with Dual Source CT

Life

64 Proactive Services for and by Radiologists

68 Customer Report: Upgrade from SOMATOM Plus 4 to SOMATOM Definition Delivers a new Picture of Health

70 syngo CT 2008G – New Software Release for SOMATOM Definition

70 CT Research Collaborations in China: a True Win-Win Situation

71 Recording of Hands-on Workshops at ECR 2008

71 New E-Learning for CARE Dose4D 72 Free 90-Day Trial Licenses for

Clinical Applications 73 Clinical CT Posters 73 Frequently Asked Questions 74 Clinical Workshops 2009 75 Scientific Photography Prize for

Anders Persson 75 Upcoming Events & Congresses 76 Siemens Healthcare –

Customer Magazines 77 Imprint

Content

64 Siemens Guardian Program Supports Clinical Workflow

60 Virtual Histology with DSCT



Cover Story

SOMATOM Definition Flash Dual Source CT: Leaving Dose BehindThrough a combination of unprecedented speed and innovative dose-reduction features, the new SOMATOM Defi nition Flash offers patients a healthier CT scan.

By Catherine Carrington

Flash speed. Lowest dose: The new SOMATOM Definition Flash Dual Source CT Scanner is the healthier CT System.

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How can CT scanning become healthier for your patients?

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Cover Story

“Our goal was to build the most patient-friendly CT by signifi cantly reducing dose

through faster speed.” Sami Atiya, PhD, Chief Executive Officer,

Business Unit CT, Siemens Healthcare

Flash. It’s a word that grabs your atten-tion, immediately evoking speed or bril-liance.

The new SOMATOM® Definition Flash Dual Source CT scanner hits the mark on both counts. With an acquisition speed and the ability for low dose-scans never before equaled in CT, it outpaces all rivals. It can sweep through the entire thorax in 0.6 seconds and speeds through cardiac scans in less than half a heartbeat. Still, when Siemens Healthcare unveils the SOMATOM Definition Flash at the 2008 annual meeting of the Radiological Society of North America, the talk will be about more than speed alone. That’s because the new scanner also promises an impressive reduction in radiation dose for all patients and all types of scans. In a word, the SOMATOM Defini-tion Flash has been designed to be a healthier CT scanner.“We have a strong focus on putting the patient in the center of all we do,” says Sami Atiya, PhD, chief executive officer of the CT Business Unit of Siemens Health-care. “Our goal was to build the most patient-friendly CT by significantly reduc-ing dose through faster speed. Lowest radiation dose is important to physicians and patients. It’s important to us.”

How it WorksDual Source technology was introduced by Siemens in 2005 with the launch of the SOMATOM Definition CT scanner. With two X-ray sources and two detec-tors, the scanner not only enabled an unprecedented improvement in tempo-ral resolution to 83 msec, it also made Dual Energy scanning possible.But the ability of Dual Source CT to push data acquisition speeds to new levels went relatively unrecognized until recently. In one of those “light bulb”

moments, Siemens scientists and engi-neers realized that with two detectors, it was no longer necessary for the patient table to inch forward during data acquisition. Instead, a Dual Source scanner could achieve gapless z-sam-pling, even with the wide-open spiral created by a pitch of above 3. That’s because the two detectors create two complementary data spirals that, when put together, include all the information that would be found in a single spiral





Cover Story

acquired at a much lower table speed. “The new scanner is a true revolution,” says Willi Kalender, PhD, director of the Institute of Medical Physics at the University of Erlangen-Nuremberg in Erlangen, Germany. “It picks up on the well established concept of Dual Source CT but improves it in several ways. We never before dared to scan with such a low dose and such a high speed.”Not only can the patient table travel at more than 43 cm/sec, the SOMATOM Definition Flash is equipped with two 4 cm detectors that each acquire 128 slices of image data. Gantry rotation time has dropped to 0.28 s, which trans-lates into a temporal resolution of just 75 msec. X-ray tube power has been increased to 2 x 100 kW to accommo-date even the most obese patients. Sophisticated technical features further lower radiation dose.All of these features are available merely on the SOMATOM Definition Flash. “The fastest scan is only possible through Dual Source,” Atiya says. “That’s why it’s unique. Unless you have Dual Source technology, you can’t do all these other things.”

Split-Second ThoraxIf you want to picture just how fast the SOMATOM Definition Flash is, consider a full thoracic scan that takes about 0.6 seconds. That means, for the first time, that patients will no longer have to hold their breath during scanning. Not only will this be a welcome relief for patients who are sick or injured, it will shorten patient preparation time, an im-portant plus in any busy CT department. “This will save time for the tech,” says Konstantin Nikolaou, MD, an associate professor of radiology and CT section chief at Ludwig Maximilian University of Munich, Großhadern, Germany. “With a very fast scan, you don’t have to train anyone to hold his breath or be concerned about motion artifacts. We will just tell the patient to use shallow breathing, and that should be fine.” Pediatric scanning will also be easier and safer with the SOMATOM Definition Flash.

The new scanner is of even greater ben-efit for trauma patients, who are often in too much pain to lie still. With its abil-ity to scan 120 cm in less than three seconds, the SOMATOM Defintion Flash will not only reduce motion and breath-ing artifacts, but will get the patient out of the CT scanner and into surgery much more quickly. “For the trauma surgeon, the faster you’re done with your scans,

the better,” Nikolaou says. Triple rule-out examinations are also likely to enjoy renewed interest. These all-in-one scans evaluate patients for three common causes of chest pain – pulmonary embolism, aortic dissection, and coronary artery disease. However, their popularity has been hampered by a radiation dose of 15 to 20 mSv, a direct consequence of a lengthy, electro-

1 Triple rule-out without breath hold in less than one second – at a dose below 5 mSv.

1



Cover Story

2 Rule-out coronary artery disease for early detection and prevention – Flash Spiral CTA with 0.9 mSv.

cardiographic (ECG) gated exams that use a pitch of 0.2 to 0.4. But with the SOMATOM Definition Flash running at a pitch of above 3, a triple rule-out scan will take no more time than a standard thorac-ic study and expose the patient to no more radiation, approximately 5 mSv. Less contrast material may also be needed.“This protocol facilitates the diagnostic procedure in chest pain patients, as the

scan can be performed very fast and with low dose, while still potentially providing substantial information on the heart and the coronary arteries,” Nikolaou adds. The speed of the SOMATOM Definition Flash promises to boost CT dynamic im-aging as well. With its 4 cm detector and a shuttle mode that continuously glides the patient table back and forth, the

SOMATOM Definition Flash is capable of a dynamic scan range of 48 cm, the lon-gest available today. This lengthy 4D spiral opens the possi-bility of scanning the entire thorax in a time-resolved way. In patients with aortic dissection, the radiologist could watch contrast material flowing in and out of the true and false lumens and observe how various vessels and organs

2



Cover Story

1A

1 Flash speed. Lowest dose: SOMATOM Definition Flash

Split-second thorax: Scanning heart/thorax needs 0.6 s, taking the burden of breath-holding off the patient and allowing functional imaging for body regions up to 48 cm (Fig. 1A).

Sub-mSv heart: temporal resolution of 75 msec and scan speed of up to 43 cm/s make heart-scanning without beta-blockers possible or without breath hold a standard with dose levels below 1 mSv (Fig. 1B).

Single dose Dual Energy: now dose neutral with the Selective Photon Shield and the widest range of FDA-cleared applications (Fig. 1C).

Organ-sensitive dose protection: The SOMATOM Definition Flash pre-vents clinically irrelevant dose for spiral examinations and introduces organ-sensitive dose protection (Fig. 1D).

1D

< 1 mSv

SelectivePhoton Shield

80 kV Attenuation B

140 kV Attenuation A

Tube 1 Tube 2

Vol

< 1 sec

X-ray off

X-ray on

1C1B



Cover Story

are supplied. It also offers the option of dynamically scanning the entire abdo-minal/pelvic region, for example, in a patient with renal cell carcinoma that has metastasized throughout the mes-entery. An exciting further development, 4D Noise Reduction, makes it possible to significantly improve image quality with no increase in dose or, alternately, reduce dose up to 50% without compro-mising image quality.But Nikolaou is also intrigued by the pos-sibility of using the extended dynamic scan range to improve run-off studies of the lower leg. He is already using a hybrid, two-injection technique to achieve a true arterial phase of the low-er leg, even in patients with advanced

peripheral arterial disease. Still, the smaller detector on his existing scanner permits viewing of only about two-thirds of the lower leg. That will change with the SOMATOM Definition Flash. “With 48 cm coverage, you could really have a lower leg CTA with time-resolved imaging,” stresses Nikolaou. “This will definitely change our protocol.”

Sub-mSv HeartDual Source CT took cardiac imaging to new heights. Now, the SOMATOM Definition Flash goes even further, scanning the heart in about 250 msec at a temporal resolution of 75 msec and with a radiation dose of < 1 mSv. With specs like that, Flash scanning has the potential to stretch cardiac CT applications to include everything from screening to stress myocardial perfusion imaging.Consider the use of CT coronary angio-graphy for preventive screening. It has the potential to unmask a silent killer, but until now, radiation dose has been a significant stumbling block. “If we could detect coronary disease earlier, it might have a tremendous im-pact on prognosis,” says Jörg Hausleiter, MD, an associate professor of medicine at the German Heart Center in Munich. “But with currently available CT tech-nology, a CT-Angiography of the heart delivers a dose of approximately 13 mSv, which is not acceptable for early detec-tion. Anything less than 2 to 3 mSv would be great.”In addition to the ultra low-dose Flash protocol – which uses a pitch of above 3 – the SOMATOM Definition Flash also offers the Flash Cardio Sequence. This “intelligently triggered” step-and-shoot method is not only suited to higher heart rates, it automatically adapts to variations in cardiac rhythm, ensuring that images are always acquired during diastole. On top of coronary imaging it also allows, for the first time ever, to calcu-late ejection fraction to the new dual-step pulsing approach. “We’re already doing step-and-shoot with Adaptive Cardio Sequence on our current system, but with the larger

“If we could detect coro-nary disease earlier, it might have a tremendous impact on prognosis.”

Jörg Hausleiter, MD, Cardiologist, Associate Professor of Medicine, German Heart Center, Munich, Germany“For the trauma

surgeon, the faster you’re done with your scans, the better.”

Konstantin Nikolaou, MD, Associate Professor of Radiology and Section Chief of CT Department, Ludwig Maximilian University, Campus Großhadern, Munich, Germany

detector and the higher temporal reso-lution of the SOMATOM Definition Flash, we expect to have even better image quality,” Hausleiter says. “It’s probably the most attractive alternative to the pitch 3 Flash mode.”CT myocardial perfusion imaging is another application that is catching the attention of cardiologists. Today, it is possible to do such functional imaging at resting heart rates using Dual Energy. The SOMATOM Definition Flash, thanks to a temporal resolution of 75 msec and a shuttle mode that covers the entire



Cover Story

myocardium, offers the possibility of doing perfusion imaging at high heart rates, even during exercise or pharma-cologic stress. “The role of CT myocardial perfusion imaging is still evolving, but it is intrigu-ing,” Hausleiter says. “This would give us additional information on the severity of the lesion and the hemodynamic impact of that lesion. If we could deter-mine that while the patient is still on the table of the CT scanner, that would be very beneficial.”

Single Dose Dual Energy Dual Energy imaging is made possible by the simultaneous operation of two X-ray sources at different energy levels, which enables differentiation of fat, soft tissue, and contrast material on the basis of their unique energy-dependent attenuation profiles. The SOMATOM Definition introduced Dual Energy in 2005. Since then, the Food and Drug Administration has cleared 10 Dual Energy clinical appli-cations, an achievement only Siemens can claim. Still, Dual Energy imaging is underutilized in everyday clinical prac-tice, in part because of a dose penalty of about 20 percent in some scans e.g. in the case of obese patients.The SOMATOM Definition Flash could change all that. A new Selective Photon Shield pre-filters high kV X-rays, re-moving low-energy photons. This has two beneficial effects. First, it improves energy separation and, therefore,

Baltimore, MD, USA. “If you come up with something new and it has the same or lower dose – and yet provides all sorts of additional information – that becomes very exciting. This new scanner has the potential for raising the bar.”At the same time, new features will make Dual Energy scanning easier to

3 Fast and reliable removel of calcifications in the entire vasculature with syngo Dual Energy Direct Angio: VRT (Fig. 3A), MIP (Fig. 3B).

“The availability of a dose-neutral scan is likely to spark renewed interest in Dual Energy.”

Elliot Fishman, MD, Director of Diagnostic Imaging and Body CT, Johns Hopkins Medical Institutions, Baltimore, MD, USA

ma terial differentiation by 80 percent. Second, it markedly reduces dose. “The availability of a dose-neutral scan is likely to spark renewed interest in Dual Energy,” says Elliot Fishman, MD, a professor of Radiology and director of Diagnostic Imaging and Body CT at Johns Hopkins Medical Institutions,

3A 3B



use in everyday routine. For example, better image processing, including zero-delay bone removal, will save time. Increased tube power and a wider field of view on the second detector will also expand the possible range of patients and applications. Making Dual Energy images available on syngo WebSpace will enable radiologists to interpret Dual Energy scans from any PC anywhere. “This new scanner has new capabilities that could allow Dual Energy to become a robust study that is part of a routine examination,” Fishman says. “And that this system is better, that it lowers the radiation dose, and speeds up work-flow – that will make a tremendous difference.”

Organ-Sensitive Dose Protection

The SOMATOM Definition Flash is de-signed with dose savings in mind. Besides the reduced radiation exposure

that automatically results from the high table speed, the scanner has several other dose-conscious features. The Se-lective Photon Shield and the ECG-puls-ing in the Flash Cardio Sequence are just two. In addition, the new scanner is equipped with Adaptive Dose Shield, which blocks X-rays from the portion of the spiral that will not be used in im-age reconstruction. This amounts to a half-detector’s width at the beginning and end of each acquisition. In the case of cardiac scans, Adaptive Dose Shield cuts radiation dose by as much as 25 percent. The scanner also features organ-specific dose protection, a technique that en-ables the radiologist to turn off the X-ray tube during the portion of the gantry ro-tation that would directly expose radia-tion sensitive organs, such as the breast, thyroid gland, or eyes.Siemens is already looking to the future, developing iterative reconstruction tech-niques that promise to further reduce

Cover Story

Further Information

www.siemens.com/somatom-definition-flash

4 X-CARE reduces direct exposure of dose sensitive organs, e.g. minus 40% for breast tissue – while maintaining a homogeneous image quality over the entire scan field of view.

dose. The idea is to acquire the dataset at a low dose, which results in noisy images. Through repeated reconstruc-tion steps, image artifact and noise are removed, and quality is improved. “I’m impressed by the concept,” Kalender says. “You can scan at a lower dose, and make up for the additional image noise using this new reconstruction method.”“For now, the main limitation to iterative reconstruction is its need for massive com-puting power,” Atiya says. “But we believe that the iterative reconstruction holds po-tential and we will be coming up with a first set of applications in the near future.”

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

4A 4B


Dual Source CT on Scientifi c Center StageBy Peter Seitz

Business Unit CT, Siemens Healthcare, Forchheim, Germany

Seldom does a new technology find its way to a leading role in the world of scientific publications within only a few months. But after Dual Source CT was announced at the RSNA 2005 and made available commercially in summer 2006, it took over center stage almost immedi-ately. In the 2 years since then, more than 100 peer-reviewed articles have already been published. Dual Source CT virtually introduced the topic of Dual Energy CT into most major congresses – and scientific discussions regarding Cardiac CT were brought to a whole new level. This impressive success was crowned by the offer to devote an entire issue of the European Journal of Radio-logy on Dual Source CT, resulting in 12 new publications featured in the December 2008 issue.

DSCT in CardiologyThe foremost capability responsible for this development is, without doubt, the ability of Dual Source CT to utilize 2 X-ray tubes to achieve a true temporal

More than 400 Dual Source installations worldwide More than 100 peer-reviewed publications

resolution of 83 ms and thereby, for the first time, allowing robust cardiac imag-ing without beta-blockers. The clinical effect of this improvement has been best demonstrated by Achenbach et al1 in a randomized study of 200 patients. 100 patients were examined using single source, 64-slice CT and the other 100 with Dual Source CT. Within both sub-groups around half of the patients received oral and intravenous beta-blockade for a target heart rate ≤ 60 beats/min, whereas the other half did not receive any pre-medication. Results confirmed a clear advantage of Dual Source CT, no matter if the analysis was performed per-patient, per-vessel or per-segment. In the case of single source CT, with beta-blockers 91-93% of all studies proved evaluable. Without beta-blockers this number dropped to 69-82%, depending on the analysis approach. On the other hand, imaging with or without beta-blockers didn’t show a significant impact on the num-ber of evaluable patients, vessels or

Faster than every beating heart – with 83 ms true temporal resolution and no need for beta-blockers, proven by more than 25 publications.

Full cardiac detail at half the dose – down to 2.5 mSv average dose, proven by 5 publications.

One-stop shop in Acute Care – fast diagnosis to save time, lives and money, proven by 4 publi cations.

Beyond visualization with Dual Energy – with 10 released applications and Optimum Contrast, proven by 14 publi cations.

etc.

segments when using Dual Source CT. In all cases results remained above 96%.First studies even suggest that Dual Source CT allows for robust diagnosis of significant stenosis in patients with atrial fibrillation2,3, in the past a common rule-out criteria on single source CT.But while the impact of DSCT on in-creased temporal resolution is unques-tioned, the more robust cardiac CT imaging gets the more it is brought into the spotlight on the topic of radiation exposure. Recently a special focus has been put to the question: What dose values can be reached reliably with a low-dose approach such as a step-and-shoot mode?In their study on 120 patients, Scheffel et al.4 from the University of Zurich found that DSCT allows mean effective doses of 2.5 mSv, while 98% of all seg-ments provided diagnostic image quality and 97% of significantly obstructed segments were classified correctly, compared with conventional coronary


More than 400 SOMATOM Definitions are in clinical use worldwide, not only for daily clinical routine, but also for cutting-edge research. Meanwhile, more than 100 peer-reviewed publications have been released, documenting Dual Source CT, focusing on DSCT´s unique strengths.



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angiography. While further improve-ments on dose reduction are clearly warranted, these results confirm that effective DSCT doses below average diagnostic catheter doses are becoming more and more common.

DSCT in Acute CareA completely different approach is taken by recent publications on DSCT in Acute Care, where, next to clinical effective-ness, economical aspects are considered increasingly important for the everyday question of evaluating patients with suspected acute coronary syndrome. Researchers from the University of Penn-sylvania compared conventional ap-proaches, e.g. serial cardiac markers as well as stress testing, with the outcome of an immediate CT coronary angiogra-phy5. While the immediate CTA approach was as safe and able to identify as many patients with coronary artery disease as the other approaches, it resulted in the lowest cost and shortest length of stay. Overall, an immediate CTA reduced aver-age costs to $1,240 vs. $2,318 - $4,024.

Sources1 Achenbach S et al. – JACC, VOL 1, NO. 2, Jan

2008.

2 Oncel D et al. – Radiology 2007 Dec; 245(3):703-

11.

3 Wang Y et al. – Eur J Radiol Nov 2008.

4 Scheffel H et al. – Heart Jun 2008.

5 Chang AM et al. – ACADEMIC EMERGENCY MEDI-

CINE 2008; 15:649-655.

6 Ruzsics B et al. – Eur Radiol 2008 June.

First U.S. Payor Reimburses CT Colono-graphy (CTC) for Screening

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

According to the ACRIN* 6664 trial, CT Colonography (CTC) – respectively Virtu-al Colonoscopy (VC) – was comparable to the gold standard colonoscopy for screening intermediate and large-sized polyps. Based on these results, VC has been validated as a screening test for

colorectal cancer and detection of large and medium-sized polyps. Results from other VC trials (IMPACT, Munich Colorec-tal Cancer Prevention Trial and Wiscon-sin Trial) have also shown positive re-sults for VC. Thus, the American Cancer Society (ACS) recently added virtual colonoscopy to their new colorectal can-cer screening guidelines. This decision is, for the first time, triggering reim-bursement for colon cancer screening in the U.S. Colon Health Centers of Ameri-ca (CHC), a provider of VC services for gastroenterology specialists, has signed a contract with Blue Cross Blue Shield of Delaware (BCBSDE). This agreement rep-resents the first major commercial payor

in the United States to reimburse VC screening. BCBSDE has agreed to reim-burse CHC of America’s patent-pending, integrated colon screening model, fol-lowed by therapeutic colonoscopy for those with discovered polyps. They pro-vide a single, bundled, episode-of-care payment ‘per screening event’. The pay-or believes that it is essential to have the capability to provide same-day, same-prep therapeutic colonoscopy for pa-tients who need it. This is the first step toward future reimbursements in the U.S.

*ACRIN (American College of Radiology Imagin

Network).

The average length of stay could be shortened to 8.1 hours vs. 20.9 – 30.3 hours for the other strategies. As the number of CT systems in dedicated emer-gency department environments is in-creasing, further studies with larger pa-tient groups are under preparation.

DSCT and Dual EnergyFinally, a whole new field of research was opened with the introduction of DSCT Dual Energy, made possible by applying different energy spectra (of 80 kV and 140 kV) to the two X-ray tubes simultaneously. The results are two spiral data sets acquired simultane-ously in a single scan providing diverse information that permits differentiation or characterization of the imaged tissue and material. Possible applications are, e.g. an accurate subtraction of bone in CTAs or iodine removal from liver scans to generate a virtual unenhanced image. A brand-new application, the visualiza-tion of iodine content in the myocardial blood-pool to diagnose perfusion de-fects, has just been evaluated by Ruzsics

et al. from Medical University of South Carolina6. They evaluated this approach on 35 patients, and correlated the results with SPECT. Initial results are promising, proving 91% accu racy in comparison with SPECT (per-segment) for detecting any type of myocardial ischemia.In the meanwhile, more than 400 Dual Source scanners have been installed worldwide, generating a rising number of publications on the cutting-edge of CT imaging.

VC has been validated as a screening test for colorectal cancer and detection of large and medium-sized polyps.



News

4D Noise Reduction: New Filter Setting for Dose Decrease and Image Enhancement

By Rainer Raupach, PhD, Business Unit CT, Siemens Healthcare, Forchheim, Germany

The SOMATOM Defi nition AS 20-Slice Confi guration

By Jan Chudzik, Business Unit CT, Siemens Healthcare, Forchheim, Germany

With the introduction of multi-slice CT making scans with large volume cover-age possible, dynamic CT examinations have stepped into clinical routine. With modes like organ perfusion or 4D CT, angiography time series* can be taken, exposing a large part of the body to time-dependent X-rays. Therefore, pa-tient dose has to be considered carefully.4D image data are routinely acquired by means of multi- or adaptive 4D spiral

Since its introduction at RSNA 2007, the SOMATOM® Definition AS, the world’s first adaptive scanner, has already be-come the fastest selling single source CT in Siemens history with 200 installations worldwide within the first months from market introduction. In its multiple con-figurations (40-, 64- and 128-slice), it describes another success story for Siemens Healthcare. At this year’s RSNA, the Definition AS platform introduced a further expansion with its new 20-slice configuration attracting the interest of a wide range of healthcare facilities by providing easier and more economical access to the latest innovations of high- end CT. This enables a broad spectrum of clinical applications at a great price-performance ratio. And, with its full,

scans. Applying a newly developed, elaborate filtering technique, the radia-tion dose of dynamic CT exams can be reduced by a substantial amount, while retaining equivalent diagnostic informa-tion. The procedure is as follows: At a fixed time point, the data from the time series mentioned above are separated into soft contents and sharp edge infor-mation, containing the major amount of image noise. By combining the sharp

onsite upgradeability, the 20-slice con-figuration is able to grow with clinical needs, allowing a continuous expansion of radiology offerings in the future, im-proving the services for referring physi-cians and patients. The new SOMATOM Definition AS 20-slice configuration, with its large 31 inch (78 cm) gantry bore, the optional 660 lbs (300 kg) patient weight capacity and its high scan speed, is designed perfectly for high patient throughput, even for obese pa-tients. With this new SOMATOM Definition AS family member, clinicians have access to excellent image quality and clinical capabilities in a very afford-able and compact unit, greatly improv-ing patient care.

portion of different time points, the dose can be used more efficiently, thereby leading to an image with significantly reduced noise and improved image quality.The effect of this method can, on the one hand, be utilized to reduce radiation dose while obtaining the same image quality as without 4D Noise Reduction. On the other hand, the spatial resolution of the CT perfusion images can be in-creased or the reliability of the perfusion parameters improved while maintaining the same dose (Fig. 1). In the perfusion study shown, the perfusion parameters of many pixels cannot be evaluated due to noise (Fig. 1A). Using 4D Noise Reduction mode, these pixels can be reduced, yielding tissue perfusion infor-mation with higher quality (Fig. 1B).

1 CT perfusion evalua-tion (blood volume) of the orig inal images (Fig. 1A) and results after image enhancement (Fig. 1B). The number of pixels where perfusion parameters could not be deter mi ned due to noise (violet) is significantly reduced.

The new SOMATOM Definition AS 20-slice configuration

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* Images from a defined body region or organ

during a defined period of time.



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In June 2008, the Portsmouth Imaging Centre in Rhode Island installed the 6,000th SOMATOM® Emotion system – making this system the most popular CT in the World. The success of the SOMATOM Emotion continues with installations now heading towards 6,500. “At our new Portsmouth Imaging Centre, we use a Siemens SOMATOM Emotion CT scanner because it pro-vides speed and extremely high re-solution that is essential for fast and accurate diagnoses,” said Todd Cipriani, vice president, Professional Services, Newport Hospital.

Simon Shaw (US Product Marketing Manager for SOMATOM Emotion, right) hands a plaque commemorating the 6,000th SOMATOM Emotion installation to David Card (CT/MR Manager, Portsmouth Imaging Center, left).

Previously, radiologists who were seek-ing additional reconstructions in coro-nal, sagittal or other planes to support their diagnosis, needed to call the tech-nologist at the scanner and request them. The technologist then needed to manually start the recon jobs and send the images to the PACS – a time con-suming and cumbersome procedure, not to mention the additional amount of data that needed to be archived in the PACS. Now, with the latest function-al enhancements of syngo WebSpace 2008B, this annoying work step can be eliminated. The time consuming, traditional “image reconstructions on demand” are being replaced by the interactive “3D on the fly”. With a click on the syngo WebSpace button in the PACS environment, the same case opens in 3D at the very same work-place. The interactive 3D functionality

of syngo WebSpace can provide a coro-nal, a sagittal or any other view on the image data. These views do not need

to be prepared beforehand. They are dynamically created on the fly by syngo WebSpace.

“Both patients and physicians like knowing that image clarity is excellent.” With the SOMATOM Emotion, the combination of high-end image quality, efficient gantry design, low running costs, high reliability and the smallest installation space re-quirements, underpin the success. These factors were some of the driving forces behind Newport Hospital’s purchasing decision and the decisions of over 6,000 other SOMATOM Emotion customers.

Interactive 3D on the fly

Image Reconstructions on Demand

syngo WebSpace Interactive 3D on the fly

Manually create and send additional image reconstructions

Auto send images

Call for additional image reconstructions 2

2

3

1

Auto send images1

The Success Story of the SOMATOM Emotion Continues

By Steven Bell


3D on the fl y with new syngo WebSpace 2008B

By Christoph Hachmöller, MD




News

Proactive Tube Failure Prediction: Siemens Guardian Program now Includes TubeGuard for the SOMATOM Defi nition FamilyBy Ulrike Dräger-Klar and Holger Reinsberger

Business Unit CS, Siemens Healthcare, Erlangen, Germany

CT systems are crucial for clinical diag-nosis and important to support emer-gency processes like trauma patient examinations. Doctors as well as patients are dependent upon the reliable avail-ability of their systems. The CT tube is a component with a usage-dependent life span. It is absolutely vital to system

including TubeGuard for the SOMATOM® Definition family is Siemens’ new pro-active solution that allows prediction of potential tube and system failure in advance.

How does it work?Cooling, vacuum, filament, anode, rotation, focal spot and high voltage all have a significant impact on the opera-tion of the CT tube. Once TubeGuard has been installed, sensors proactively monitor the tube functions via real-time data flow with Siemens Remote Service (SRS) – the efficient and comprehensive infrastructure for medical-equipment-related remote services. By doing this, deviations can be detected before prob-lems occur. One example of sensor monitoring is the measurement of cool-ing performance. The measurement via SRS is based on sensor data of oil tem-perature, gantry temperature and oil pressure. If the cooling performance falls under defined limits, the tube could possibly fail, Siemens will schedule a tube change at a convenient time for the customer before the failure occurs.This program brings it all together: state-of-the-art technology to assess and transfer information to the Siemens Service Center, expert analysis through our support engineers, and the develop-ment of a plan together with the cus-tomer to convert system downtime into a planned service visit. With the Guardian Program including TubeGuard, the majority of all tube failures are predicted well in advance, proactively and efficiently.

measured and calculated lifetime [rel. units]

Measurement of Cooling Performance

time [rel. units]

Continuous Examination

Tube failure – without Siemens Guardian Program™ including TubeGuard

Tube failure – with Siemens Guardian Program™ including TubeGuard

Reactive service

Continuous Examination

Proactive service – continuous monitoring of various sensor data

k unpredicted tube failure and tube replacement

Tube break down services request Hard-down of system

kplanned and scheduled downtime

Soft-down of systemScheduled tube exchange

triggered by Siemens

availability. But a tube can also fail, causing a hard-down of the CT system. This can lead to disruptions of the clini-cal workflow, and the immediate need for patient rescheduling or transfer to another department. This was the moti-vation for a new and innovative idea: the Siemens Guardian Program™

1,2

0,8

0,4

00 20 40 60 80 100 120 140

proactive triggered tube change



The recent past has seen monumental advances in CT technology, proving the clinical value of multislice capabilities, speed and resolution. But even exquisite CT images can leave unanswered clini-cal questions and could benefit from the addition of molecular contrast to add metabolic information. Using the most advanced PET (positron emission tomography) technology combined with Siemens adaptive CT technology (known from SOMATOM Definition AS) makes Biograph mCT the crossover scanner that is destined to change the way radiology looks at integrated diagnostics.To move oncology forward, the next innovation in CT should include a “smart” contrast agent. The concept of using molecular contrast with PET and CT has already been applied in the molecular imaging arena with unprece-dented success. With this knowledge in hand, together with the increasing demand for PET, asserting that every CT can have molecular imaging capabilities clearly addresses the need for more effective imaging in oncology. Mole-cular CT makes this technology more

widely available, offering personalized and very specific information about patients’ diseases. Patients will benefit from higher quality diagnostic information that can lead to definitive changes in disease manage-ment. Providers could benefit from the potential cost savings from the purchase of one all-encompassing scanner like the Biograph mCT instead of two, a PET scanner and a CT.Biograph mCT was specifically devel-oped for an integrated imaging environ-ment – designed to obtain functional, anatomical and molecular information from one non-invasive diagnostic exam. Using Siemens premium CT technology, it adapts to virtually any patient and clinical need for higher resolution, con-trast and speed. Biograph mCT comes in a powerful, small package. It boasts a large bore, short tunnel and a very small footprint for unparalleled patient care and comfort. Biograph mCT is available with up to 128 slices and a table that can accommodate patients up to 500 pounds (227 kilograms).In addition to cutting-edge CT techno-logy, Biograph mCT maximizes the most

1 Biograph mCT (Fig. 1A) offers excellent resolution and contrast in PET•CT imaging, such as in this pri-mary squamous cell carcinoma in the left lung with hilar lymph metastases (Fig. 1B).

advanced PET technology available, in-cluding features such as unique PET extended field of view and ultra high-definition imaging technology with time of flight reconstruction, enabling the possibility of a routine, five-minute PET scan. It offers the ultimate in PET image quality and count rates for faster, more comprehensive scanning, and provides maximum patient comfort and work-flow efficiency. Latest applications in oncology from CT and PET include the ability to delineate target volumes for diagnosis, staging and re-staging of cancer, providing exquisite anatomical detail plus a measurement of cell metabolism. Future functionalities may include correlation of information about organ perfusion derived from CT and tumor metabolism derived from PET. Physicians as well as patients will bene-fit from the valuable information pro-vided by molecular CT.

Molecular CT – Imaging in Living ColorsSiemens Biograph mCT opens doors to earlier disease detection and inte-grated diagnostics in radiology.

By Claudette Yasell, Business Unit MI, Siemens Healthcare, Hoffman Estate, USA

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Business

As Radiation Dose Goes Down, Attractiveness of CT Rises In recent years, Siemens scanners have steadily decreased radiation dose in CT exams, making CT use in everyday diagnostics all the more interesting. Now, for example, cardiac CT can be performed with doses as low as the “gold-standard”, cardiac catheterization and below, as studies at the Univer-sity Hospital Zurich have shown.

By Oliver Klaffke

“Excellent images and low dosage is what physicians have always wanted.” Hatem Alkadhi, MD,Radiologist and Associate Professor, University Hospital Zurich

Hatem Alkadhi, MD, radiologist and associate professor at the University Hospital Zurich, is excited. Together with his colleagues he performed tests on patients with cardiac computed tomography (CT) utilizing two of Siemens newest high-end scanners, the SOMATOM® Dual Source Definition and the SOMATOM Definition AS. The radiation doses required were no higher than cardiac catheterization or scintigraphy. “This opens totally new perspectives for cardiac diagnostics with CT,” Alkadhi says. “Excellent ima-ges and low dosage is what physicians have always wanted,” he adds.

His findings are in line with the general trend in CT in recent years. The radia-tion dose needed for reliable diagnoses was considerably reduced when Siemens, the leader in the field of CT, pushed the frontier of progress forward with new Siemens dose-saving technol-ogies such as the Adaptive Dose Shield, CARE Dose4D, ECG-Pulsing and Adaptive Cardio Sequence that are used today to deliver optimal images with as low dosage as possible. This, of course, is of great benefit for patients. “Dosage is always an issue, especially for children and patients who need a number of consecutive CTs,” says Prof. Borut

Marincek, MD, head of radiology at the University Hospital in Zurich. “For the sake of our patients, we will always opt for the latest technology that offers the best results with the lowest possible dosage,” he says. This was one of the main reasons why he and the hospital decided to purchase two Siemens high-end CT scanners, the Dual Source SOMATOM Definition and the SOMATOM Defintion AS. Both of them provide unique technologies to signifi-cantly reduce patient exposure in both clinical routine and advanced applica-tions and, therefore, assure better pa-tient care.

Economic benefi ts of using CTIn addition to the main health issues criteria such as dose reduction, there are significant financial reasons for in-vesting in CT. This is especially true for cardiac diagnostics. ”Through the in-creased use of CT for cardiac diagnos-tics, a large hospital can clearly reduce costs,” says Marincek. The increased use of computed tomography has a great number of advantages for hospitals. “With a stronger emphasis on CT, it’s possible to save on expensive invest-ments for the procurement and mainte-nance of various other equipment that, so far, has been primarily used for diag-nostics,” he points out.



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For his department at the University Hospital in Zurich, Marincek calculates that CT represents lower procurement and infrastructure costs than an addi-tional gamma chamber or further installations for cardiac catheterization testing. His conclusion: “The costs of the individual tests are much lower with CT than with the other procedures.”

As in other fields of CT, the dosage needed in cardiac diagnostics can now be kept very low. “Radiation exposure is no longer a reason to refrain from using CT for cardiac testing,” asserts Alkadhi.

The Zurich-based physicians completed their tests using very low doses. On average, only 2.5 mSv were required to obtain high-quality, meaningful images. As a result, the radiation expo-sure remained well under the values that have previously been typical with CT-Angiography. Depending on the test conditions, these have ranged between 9 and 21 mSv. “The radiation doses of our tests are below those currently necessary with cardiac catheterization,” says Alkadhi. He and his colleagues applied CT to 120 patients suspected of coronary heart disease. They were able to obtain diagnostically valuable and unrivaled data at minimal radiation exposure.

This was possible as the result of tech-nical advances in Siemens’ CT techno-logy and through the development of intelligent software applications for CT. The tests in Zurich used the Siemens SOMATOM Definition, a CT equipped with two X-ray tubes functioning simul-taneously. “It is a significant advance-ment that dose can be kept so low using for example the step-and-shoot procedure,” says Alkadhi. This and also other new features, such as the Adap-tive Dose Shield, are implemented as well in the SOMATOM Definition AS, offering dose reduction in every spiral exam. This means that the patient is not subjected to radiation not needed for the diagnosis. “Using the lowest possible dose is of definite benefit to the patient,” Alkadhi says. Because computed tomography technology will surely be more fre-quently used in the future, dose reduc-tion becomes a more compelling issue. This is one of the reasons Zurich Univer-sity Hospital always opts for the latest technology in computed tomography. It should not be assumed that dose reduc-tion has been accomplished only in this area. Such Siemens innovations are used today to deliver optimal images with as low dosage as possible. All together, they bring CT into the

mainstream of clinical routine making the SOMATOM Definition and the SOMATOM Definition AS scanners intelligent buying decisions. “With future purchases, dose will be one of the most important criteria when deciding in what system to invest,” Marincek says.

Oliver Klaffke is a science journalist in Switzerland.

“ Dosage is always an issue, especially for children and

patients who need a number of consecutive CTs.”

Prof. Borut Marincek, MD,Head of Radiology,

University Hospital Zurich

“With future pur-chases, dose will be one of the most important criteria when deciding in what system to invest.” Prof. Borut Marincek, MD,Head of Radiology, University Hospital Zurich



Business

Making a Case for the SOMATOM EmotionThe long list of benefi ts reported by the staff at Northside Hospital in Atlanta, Georgia, since fi ve new SOMATOM Emotion scanners were installed in January 2008 reads like a testimonial – from exceptional images and increased throughput to patient satisfaction and fi nancial benefi ts.

By Sameh Fahmy

With 14 imaging facilities spread across a large metropolitan area, Northside Hos-pital in Atlanta, GA, needed a CT solution that would reliably and efficiently 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 health-care is convenient and patient focused, while also providing our referring physi-cians with high-quality imaging, regard-less of location,” says director of radiology services Deidre Dixon.Northside originally had a variety of single-, four- and six-slice CT scanners at its facilities and sought to upgrade with a solution that would provide superior image quality, rapid workflow, and maxi-mum return on investment. In January 2008, after a collaborative decision pro-cess, they chose to install five Siemens SOMATOM® Emotion CT scanners. As a result, Northside has been able to expand its imaging services while gain-ing efficiencies and measurable financial benefits from faster workflow. “We were looking for a workhorse scanner,” says radiologist Carolyn J. Weaver, MD, “and the SOMATOM Emotion has proven to be just that.”

The 16-Slice ChoiceWeaver says the hospital’s previous scan-ners limited the protocols that Northside could offer at some locations. “Configu-rations greater than 16 slices allow for cutting-edge applications,” she says, but Northside needed a scanner that could

“16-slice is a confi guration that of-fers all the necessary protocols and offers them effi ciently and with good diagnostic capabilities.” Carolyn J. Weaver, MD, Radiologist at the Northside Hospital in Atlanta



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“Our goal is to make sure that our healthcare is convenient

and patient focused, while also providing our referring physi-cians with high-quality imag-

ing regardless of location.” Deidre Dixon, Director of Radiology Services

at the Northside Hospital in Atlanta

Sameh Fahmy, is an award-winning freelance medical and technology journalist based in Athens, Georgia, USA.

Further Information

www.siemens.com/somatom-emotion

capably handle their day-to-day needs. “For basic outpatient scanning, 16-slice is a configuration that offers all the necessary protocols and offers them efficiently and with good diagnostic capabilities,” Weaver says.In addition to superb image quality, Northside wanted a system that would efficiently handle its large volume of CT procedures. In 2007 alone, Northside performed more than 78,000 CT exams.The expansion of services after installa-tion of the SOMATOM Emotion 16 sys-tems has also resulted in a financial ben-efit to the group by increasing patient volumes. One imaging center, for exam-ple, increased patient capacity by 71 per-cent after upgrading from a single-slice scanner to the SOMATOM Emotion 16.The ability to expand services and increase throughput aren’t the only features that boost return on invest-ment. Another reason is that the SOMATOM Emotion has an economical price/performance ratio and minimum lifecycle costs. The SOMATOM Emotion has the industry’s lowest power supply demand, requiring 70 kVA versus 90 to 100 kVA for other vendor’s 16-slice scan-ners. Its low heat dissipation of less than 6.8 kW also reduces cooling costs com-pared to competition.

Fast Installation and Minimal Down TimeNorthside Hospital clearly isn’t alone in choosing the SOMATOM Emotion. As

of July 2008, more than 6,000 customers have installed the system, making it the most popular CT scanner in the world. In many cases the SOMATOM Emotion can be installed in only three days while, in contrast, many other scanners require more than a week to install. Longer installation results in greater patient rescheduling and inconvenience.The ease of installation is facilitated by the remarkably small, 18 square meter (194 cubic feet) footprint of the system. Weaver says the compact gantry design also creates a more relaxing environment for patients. “Anytime a patient sees something that is overwhelming in size, particularly in proportion to the room it’s in, it creates anxiety,” Weaver says. “And that could make it more difficult to get an IV and make the whole experience more difficult.”Downtime can be costly for hospitals, but Dixon points out that it is also a major inconvenience for patients. “If a pa-tient has taken a day off work to have a CT and comes in to find that there’s a machine issue, it not only impacts us but, subsequently, also the patient,” Dixon says. “Even if we’re able to get the machine up that same day, we’re left with customer dissatisfaction.” The SOMATOM Emotion was built with reli-ability in mind, and has not disappointed the staff at Northside. “We’ve never had any problems with it since we’ve had it here,” says radiology supervisor Regi-nald Moultrie. “It’s great.”

Advice to Other FacilitiesWith their purchase behind them, ad-ministrators and technicians at North-side Hospital are now realizing the benefits of a decision that was truly collaborative. Dixon recommends visit-ing many sites and asking users about downtime and how well scanners per-form day-to-day. Image quality must meet the expectations of radiologists, and she recommends choosing one vendor so that technologists can easily share information and support each other. The amount of support a vendor offers in optimizing applications is im-portant, too, she says.“We feel that partnership is a key com-ponent of the vendor selection process,” Dixon says. “We want to feel that the vendor has knowledge of our core busi-ness strategy and based on that knowl-edge can suggest products that fit with-in our organization to make sure patients receive the best care possible. We’re very pleased with our collabora-tive relationship with Siemens.”



Business

syngo WebSpace: Command Central for Fast and Effi cient Image ProcessingIn a recent interview with SOMATOM Sessions at the Hospital Notre-Dame in Tournai, Belgium, Jacques Kirsch, MD, head of the Department of Radiology, shared his insights on the impact of syngo WebSpace on his facility’s diag-nostic capabilities and workfl ow processes.

By Rita Wellens, PhD

syngo WebSpace is the latest innovation in client-server solutions for image pro-cessing. Any personal computer or laptop is turned into a diagnostic command center when linked up with syngo Web-Space. It allows for real-time access to image data – from anywhere*.

Radiology Department with Cutting-Edge TechnologyThe Hospital Notre-Dame is a general

hospital located in the city of Tournai, about 85 kilometers southwest of Brussels. The hospital provides – consid-ering its size, with 300 acute hospital beds – a respec t able spectrum of radio-logical services and is equipped with state-of-the-art technology. The radiology department covers the entire spectrum of con ven tional radiology and CT. This includes very sophisticated computed tomography such as cardiac CTA and CT

colonography. In addition, many CT inter-ventions, especially for pain therapy, are per formed in the department. The radiol-ogy department operates a SOMATOM Definition Dual Source CT scanner and a SOMATOM Definition AS scanner.The latest innovation in the department of radiology is the syngo WebSpace client-server solution, which the head of the department, Jacques Kirsch, MD, uses together with four staff radiologists.

Jaques Kirsch, MD, reading at his integrated PACS / syngo WebSpace workplace of the Hospital Notre-Dame.

“The essential workflow advan-tage of syngo WebSpace is centralizing and making available all diagnostic solutions from any workplace.”

Jaques Kirsch, MD, Head of the Department of Radiology, Hospital Notre-Dame, Tournai, Belgium



Business

Rita Wellens, PhD, is a medical writer and clini-cal research consultant residing in Belgium.

Further Information

www.syngo-webspace.com

Easy Access to Image Data – EverywhereThe obvious benefit that Kirsch enjoys while using syngo WebSpace is the fact that many time-consuming steps have been eliminated, especially for the manipulation, retrieval and distribution of thin-slice CT data. The radiologist no longer has to walk to his 3D work-station, and patient data no longer has to be physically moved to another location for accessing at a particular workstation. In addition, everyone always knows where to find the thin-slice data sets: on the syngo WebSpace server.“The essential workflow advantage of syngo WebSpace is centralizing and mak-ing available all diagnostic solutions from any workplace,” Kirsch emphasizes. ”The fact that syngo WebSpace allows the transfer of reconstructed thin-slice CT volume data to the central server in real time offers radiologists the unique possi-bility of accessing the complete patient CT imagery – thick and thin slices – from any connected workstation, and to have all of the software wizardry at hand. This immediate availability of CT images speeds up workflow and strengthens diagnostic capabilities as well as inter-vention planning. Multiple users can in parallel access 3D diag nostics and may even hold 3D interactive sessions through the internet.” Of course, thin-slice data was already being used by the radiologists before syngo WebSpace was in place, for exam-ple, to evaluate very small lesions. How-ever, another dedicated thin-slice server had to be used to temporarily – eight to nine months – store the large-volume thin-slice CT data. syngo WebSpace has clearly done away with the previously existing restrictions tied into scanners and their networking. “We do not need to switch to another workstation or room – we have every-thing right at our fingertips. In other words, once syngo WebSpace was con-nected to the network, it started func-tioning as a ‘central dispatch.’ syngo WebSpace is totally integrated into PACS – I rate that as a feat of genius,” Kirsch says.

Interactive 3D for Referring PhysiciansKirsch explains this syngo WebSpace advantage while beaming up 3D images at the PACS console: “In pre-syngo times, the diagnostic reconstructions of thick slices would be transmitted through the central PACS and thus would be available to all clinicians.” Radiologists performed 3D reconstructions at a separate worksta-tion. When the pathology was obvious in the 3D image, they created a screenshot and sent it back to the PACS. Other clini-cians could retrieve and review only this screenshot, which of course could no lon-ger be manipulated.“Totally new is not having to forward clinicians those flat, static images any-more,” says Kirsch. “Thanks to syngo WebSpace, we can send real-time, dynamic volumes! This is truly a spec-tacular innovative feature. Typically – pre-syngo WebSpace – only radiologists worked with volumes, and clinicians worked with images. Now, clinicians have full access to the fascinating world of volumes.” Radiologists working in 3D on syngo WebSpace can save a bookmark when the pathology becomes obvious on the screen. Later other clinicians just need to click the bookmark in “their” syngo WebSpace environment and immedi ately get the same image that the radi ologist prepared for them. They now have an interactive 3D image. The difference is that the clinician can further manipulate the image in order to get a better under-standing of the pathology.One can think about a comminuted fracture. The orthopedic surgeon highly appreciates the ability to turn the fracture around to get an estimation of the spatial situation of the bone fragments.

on the fl y ReconsSo far, radiologists who were seeking additional reconstructions in coronal, sagittal or other planes to support their diagnosis, needed to call the technologist at the scanner and ask for additional reconstructions. The technologist needed to manually start the recon jobs and then send the images to the PACS – a time

consuming and cumbersome pro cedure. Not to mention the additional amount of data that needed to be archived in the PACS.With syngo WebSpace this annoying work step can be almost entirely eliminated. The time-consuming traditional “recons on demand” can be replaced by the inter-active “3D on the fly.” With a click on the syngo WebSpace button in the PACS envi-ronment, not only the same case and the same image series open in 3D at the very same workplace, but additionally, each data set can now be presented in an indi-vidual, pre-defined screen layout which contains the planes to display such as coronal, sagittal or any other plane, as well as the favorite hanging protocols and window settings. Kirsch adds that being able to share these incredibly fast diagnostic capabilities with colleagues anywhere has boosted overall efficiency, patient care and staff satisfac-tion. In order to size up the positive impact of syngo WebSpace as suggested by the many superlatives he uses to describe it, Kirsch is asked whether he could envi-sion operations at his department now without the syngo WebSpace solution. He sighs heavily and answers, “It would be very, very difficult – such a huge step backward! syngo WebSpace has facili-tated so many aspects of our work. It has seamlessly integrated with PACS and other existing IT applications, and it has given us such diagnostic flexibility. Not being able to use this resource anymore is quite unthinkable.” Even after such a short period of time in routine use, syngo WebSpace’s impact is already being felt in countless positive ways at the Hospital Notre-Dame.

*internet connection required.



Clinical Results Cardiovascular

Case 1Coronary CTA with Flash Spiral Scanning in 300 msec Scan TimeBy Stefan Achenbach, MD* and Andreas Blaha**

*Department of Cardiology, University of Erlangen-Nuremberg, Erlangen, Germany**Business Unit CT, Siemens Healthcare, Forchheim, Germany

HISTORY

A 58-year-old male patient with atypical chest pain and a family history of pre-mature coronary artery disease was referred to the cardiology department to rule out coronary artery disease.Coronary CT-Angiography (CTA) was performed with a Dual Source CT in low dose technique using prospective

triggering in combination with Flash Spiral Cardio. This new heartbeat-controlled scan mode allows ultrafast spiral acquisition as a direct result of having 2 X-ray tubes, simultaneously collecting information. The entire scan was acquired in just 300 ms.

DIAGNOSIS

After determination of the contrast transit time using a test bolus approach, coronary CTA was performed in cranio-caudal direction after injecting 60 ml iodine contrast agent followed by a 50 ml saline chaser, both at 6 ml/s.The mean heart rate of the patient was 52 beats per minute, which allowed

Neurology Clinical Results

1 Volume Rendered Image of the heart shows artifact free course of the right coronary artery (RCA) including side branches.

2 Zoomed VRT of left main coronary artery (LM, white arrow) including left circumflex (LCX, blue arrow) and left artery descending (LAD, green arrow).

1 2



3 Curved Planar Reformation (CMPR) of the RCA. A series of crossectional recon-structions of the artery shows no lumen narrowing; only minor calcified plaques proximal.

Cardiovascular Clinical Results

EXAMINATION PROTOCOL

Scanner Flash Spiral mode

Scan area heart Spatial resolution 0.33 mm

Scan length 138 mm Slice width 0.6 mm

Scan time 300 ms Reconstruction increment 0.5 mm

Scan direction cranio-caudal Reconstruction kernel B26f

Heart rate 52 bpm Contrast

Tube voltage 100 kV Volume 60 ml

Tube current 280 mAs/rot. Flow rate 6 ml/s

Dose 0.9 mSv Start delay 26 s

for a particularly sharp visualization of the coronary tree. Tube voltage was set at 100 kV, with a tube current of 280 mAs, which resulted in a very low dose of 0.9 mSv. Coronary vessels were visualized free of artifacts. The left anterior descending coronary artery (LAD) and the right coronary artery (RCA) showed minor calcified and non-calcified plaques without lumen narrowing. The left main coronary artery (LM) and left circumflex coronary artery (LCX) did not show any abnormalities.

COMMENTS

Scanning with Flash Spiral Cardio allowed accurate and artifact-free visu-alization of the coronary arteries in one ultrafast acquisition of 0.3 seconds.The Flash Spiral Cardio scan mode com-bined with the simultaneously working two X-ray tubes results in significantly faster scan time, reducing the applied dose to the patient.

The RCA and LAD revealed minor calci-fied plaques and non-calcified plaques without vessel stenosis. No further diagnostic method was needed to de-termine an adequate diagnosis for the patient. The new scan mode allows to rule out coronary stenosis at an extremely low dose, making further diagnostic assessment unnessesary.

3A 3B 3C

3D 3E




HISTORY

A 38-year-old female patient with a his-tory of former nicotine abuse, arterial hypertension, and family history of pre-mature coronary artery disease, hyper-lipidemia, and apoplectic stroke was referred to the Cardiology Department with atypical chest pain to rule out coronary artery disease.Coronary CT-Angiography (CTA) was performed with a SOMATOM Definition Dual Source CT in low dose technique using prospective triggering (Adaptive Cardio Sequence), with a temporal reso-lution of 83 ms and spatial resolution of 0.33 mm.

Case 2Low Dose Coronary CTA Reveals High Grade StenosisBy Stefan Achenbach, MD

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

1 VR visualization of the left circumflex (LCX) artery shows the stenotic segment (arrow).

1

2 syngo Circulation provides angio-graphic like view of the entire heart.

2



DIAGNOSIS

After determination of the contrast tran-sit time using a test bolus approach, cor-onary CT-Angiography was performed in cranio-caudal direction injecting 75 ml of iodine contrast agent followed by a 50 ml saline chaser, both at 6 ml/s. Due to the relatively low heart rate of 50 bpm, a sequential scan was chosen. Tube voltage was set at 100 kV, with a tube current of 215 mAs, which resulted in a very low dose (1.6 mSv). Total scan time was 8 seconds. Coronary vessels were visualized free of artifacts. The left circumflex coronary artery (LCX) revealed a high grade stenosis. The left anterior descending coronary artery (LAD) and the right coro-nary artery (RCA) showed no relevant plaques or stenosis.

COMMENTS

SOMATOM Definition Dual Source CT allowed accurate and artifact-free visual-ization of LM, LAD and RCA without showing any stenosis or plaques, while a high grade stenosis was demonstrated in the left circumflex coronary artery, at a total dose of 1.6 mSv. The patient was referred to the angiography suite for revascularisation of the circumflex artery by percutaneous coronary intervention (PCI).


Scanner SOMATOM Definition

Scan area heart

Scan length 104 mm

Scan direction cranio-caudal

Scan time 8 s

Heart rate 50 bpm

Tube voltage 100 kV

Tube current 215 mAs

Dose 1.6 mSv

Spatial resolution 0.33 mm

Rotation time 0.33 s

Slice collimation 0.6 mm

Reconstructed

slice thickness 0.75 mm

Increment 0.6

Kernel B30f

4A Conventional angiography prior to percutaneous coronary intervention (PCI).

4B Conventional angiography after PCI.

4B

4A


3 Multi Planar Refor-mation (MPR) of left circumflex artery (LCX) and a crossectional view of LCX.

3




HISTORY

A 10-day-old newborn was referred to the pediatric cardiology department for treatment of his congenital heart disease. Examination by transthoracic echocardiography led to a diagnosis of right isomerism, complex cardiac type of total anomalous pulmonary venous

Case 3Dual Source CT: Pediatric Congenital Heart DiseaseBy Suzu Kanzaki, MD, Masahiro Higashi, MD, Hiroaki Naito, MD, PhD

Department of Radiology and Nuclear Medicine, National Cardiovascular Center, Osaka, Japan

connection with obstruction, double outlet right ventricle with complete atrioventricular septal defect, coarcta-tion of the aorta and bilateral superior vena cava. An ECG gated cardiac Dual Source CT scan was taken to help con-firm the diagnosis.

The patient’s height was 43.5 cm, body weight was 2.4 kg, and mean heart rate during the scan was 142 bpm. Due to the fast scan time of only 3 seconds, he had to be sedated only by oral medi-cation before the scan.

1 Volume rendered display of the pediatric cardiac scan reveals aortic coarctation (Fig. 1A) and a complex cardiac type of anomalous pulmonary venous connection even at a mean heart rate of 142 bpm (Fig. 1B).

1B1A






Scan area thorax

Scan length 80 mm

Scan time 3 s


Tube voltage 100 kV

Tube current 280 mAs

Rotation time 0.33 s



Reconstructed slice thickness 0.6 mm

Increment 0.5 mm

Kernel B25f

DIAGNOSIS

The aortic coarctation and the anoma-lous pulmonary venous connection to the abnormal site of the atrium are shown in the DSCT (Dual Source CT) images above. DSCT could confirm the morphologies of these great vessels, which were difficult to discern by echocardiography alone. The morphol-ogy of the cardiac chambers was also well detected as diagnosed by echo-cardiography. Based on these findings, palliative surgical correction was planned.

COMMENTS

The Dual Source CT images were of diag-nostic quality despite the small size of the patient’s heart and despite his high heart rate of 142 bpm. The patient could not hold his breath, but scan time was short enough to suppress the influenceof banding artifacts. The high CT im-

2 Maximum Intensity Projection (MIP) of the aortic coarctation (Fig. 2A) and double outlet right ventricle (Fig. 2B).

2A 2B

age quality made precise surgery planning possible. This scan was per-formed shortly after installation of the Dual Source CT at the radiation center. With more experience, it’s possible to reduce the dose to pedi-atric patients by about 2/3.

20 mm

40 mm




Case 4Identifi cation of Vessel Stenosis of the Lower Leg by Dynamic CT-Angiography Using the SOMATOM Defi nition AS+By Wieland H. Sommer, MD and Konstantin Nikolaou, MD

Department of Clinical Radiology, University of Munich, Campus Großhadern, Munich, Germany

HISTORY

A 82-year-old man presented with peri-pheral occlusive disease. A previous occlusion of his left superficial femoral artery had been treated by a femoro-popliteal bypass. A second bypass became necessary after occlusion of the first. The patient now presented with an advanced stage of disease with rest pain of his left lower leg and foot

1 Contrast enhancement of the lower leg at different points of time. The initial enhancement of the left and right lower leg differs by 12.5 seconds. Without the venous overlay, it can be seen, that only the fibular artery is contrasted in the left lower leg.

(Fontaine stage III). He was referred to our radiology department to undergo imaging of the vessels of the lower ex-tremity.

DIAGNOSIS

Performing a standard peripheral run-off CT-Angiography, significant disease in

the proximal parts of the lower extremity and stenotic or occluded bypass vessels may lead to asymmetric contrast enhancement of the lower leg, which may cause a reduced diagnostic accuracy in the region of the calf, either by insuffi-cient contrast enhancement of one side or by venous overlay of the contra-lateral side.To overcome this problem, an additional time-resolved CT-Angiography of the lower leg can be performed before the standard lower-extremity run-off. In the time-resolved examination, we cover a range of 27 cm including the distal popliteal artery, the trifurcation and the proximal part of the three arteries of the lower leg. Twelve phases are used, one every 2.5 seconds. This enables a clear depiction of the contrast dynamics and there will always be a truly arterial phase on either side that is perfect for diagnos-tic purposes.In this patient, the standard peripheral CTA protocol, covering the peripheral run-off from the renal arteries down to the feet, proved that the femoro-popliteal bypass on the left side was not occluded. The right superficial femoral artery showed no significant stenosis, but was rather aneurysmatic. However, in the standard lower-extremity run-off, the contrast enhancement of the lower leg was asymmetric. On the left side, venous overlay made an evaluation of the calf ar-teries difficult. On the right side, the low-er leg was not yet sufficiently contrasted.Adding the dynamic information of the

1A 1B

1C 1D

33 s*

45.5 s*

40.5 s*

50.5 s*

*After contrast media injection.




time-resolved CTA revealed an asymmet-ric enhancement of the lower leg. The initial enhancement of the left and right popliteal artery differed by 12.5 seconds. On the left side, only the fibular artery was continuous, while the other two ves-sels were not contrasted. On the right side, the anterior tibial artery only showed proximal enhancement and was then occluded in the distal vessel seg-ments.

COMMENTS

In case of asymmetric proximal stenosis or bypass grafts, the dynamic of the blood flow of the lower leg may be influ-enced such that at the time of image acquisition, vessels of one side are not yet enhanced or the other side shows venous overlay. This problem can be overcome by dynamic CT-Angiography, using multiple phases in image acquisi-tion. A further advantage of dynamic CT-acquisition is the evaluation of ste-nosis. Especially in patients with periph-eral arterial disease, multiple confluent or circular calcifications make it difficult to estimate the residual lumen. The time-resolved information of the arterial enhancement provides additional infor-mation for radiologists and vascular surgeons. In patients with peripheral arterial dis-ease, therefore a first dynamic scan covering the lower leg was performed including the lower popliteal artery, the trifurcation and the proximal and middle portions of the fibular artery, as well as the anterior and posterior tibial artery. In order to lower the radiation exposure the range was limited to 27 cm and the tube current and the tube voltage were low-ered to 165 mAs and 80 kV, respectively. Dynamic CT-Angiography, as it is rendered possible by the SOMATOM Definition AS+, is therefore a helpful tool for the evaluation of the lower leg arteries in patients with known peri-pheral occlusive disease.

2 VRT of lower extremity run-off: The aneurysmatic right superficial femoral artery leads to a delayed contrast enhancement of the right lower leg. While the left lower leg already shows venous overlay, the right side is not sufficiently con-trasted.

2A

2B


Scanner SOMATOM Definition AS+ SOMATOM Definition AS+

CT-Angiography Adaptive 4D Spiral

Scan area run-off lower leg

Scan length 1335 mm 270 mm

Scan phases 12

Scan time 27 s 25 s

Scan direction cranio-caudal cranio-caudal

Tube voltage 120 kV 80 kV

Tube current 130 mAs 165 mAs

Dose modulation CARE Dose4D on CARE Dose4D off

Rotation time 0.5 s 0.3 s

Pitch 0.6 Adaptive 4D Spiral

Slice collimation 0.6 mm 0.6 mm

Slice width 0.75 mm 1.5 mm

Reconstruction increment 0.5 mm 1 mm

Reconstruction kernel B20f B30f

Contrast

Volume 100 ml 50 ml

Flow rate 5.0 ml/s 5.0 ml/s

Post processing syngo InSpace 4D syngo InSpace 4D



Clinical Results Oncology

HISTORY

A 55-year-old male was referred for a Dual Source CT follow-up scan after transcatheter arterial chemoembo-lization (TACE) of his hepatocellular carcinoma (HCC) 6 years ago. A contrast enhanced, dynamic CT scan of the abdo-men was performed on the SOMATOM Definition using Spiral Dual Energy for screening for recurrences after chemoembolization.

Case 5SOMATOM Defi nition Dual Energy Scanning: Liver Imaging with Optimum ContrastBy Satoru Kitano, MD, Nagaaki Marugami, MD, Toshiaki Taoka, MD, PhD, Kimihiko Kichikawa, MD, PhD

Department of Radiology, Nara Medical University, Nara, Japan

DIAGNOSIS

The hepatic arterial-dominant phase im-ages revealed numerous hyper-attenu-ating lesions (Fig. 1B). In the virtual non-contrast image, the lesions showed almost iso-density with the liver paren-chyma (Fig. 1A). From syngo Dual Ener-gy (DE) Optimum Contrast images – im-proved even more after post-processing – a clear analysis of the visible lesions was possible (Fig. 1C). The patient was then diagnosed with multiple HCC recurrence with liver cirrhosis.

COMMENTS

In the Dual Energy mode, two X-ray sourc-es can be operated simultaneously at dif-ferent kV levels: 140 kV/80 kV. The results are two spiral data sets acquired in a sin-gle scan, providing diverse information that allows one to differentiate, character-ize, isolate, and distinguish the imaged tis-sue and material. Enhanced patterns of liver lesions can be visualized with the syngo Dual Energy Liver VNC (Virtual Non-Contrast) application. With the VNC-mode,

1A 1B



Oncology Clinical Results



Scan area Abdomen Slice collimation 0.6 mm

Scan length 268 mm Slice width 1 mm

Scan direction cranio-caudal Reconstruction increment 0.5 mm

Scan time 10 s Reconstruction kernel 30 D

Tube voltage A/B 140 kV/80 kV Contrast

Tube current A/B 80 Eff. mAs/345 Eff. mAs Volume 100 ml

Dose modulation CARE Dose4D on Flow rate 3 ml/s Iodine 370 mgl/ml

Rotation time 0.5 s Postprocessing syngo DE Virtual Unenhanced

Pitch 0.8 Bolustracking

any contrast-medium generated contrast disappears, with the remaining images in-dicating just tissue related differences (Fig.1A). The standard mixed view shows iodine-contrasted structures (light-col-

ored) against non-contrast enhanced structures (dark-colored) (Fig. 1B). With Optimum Contrast, an image that com-bines the high contrast of the 80 kV image and the low noise of the mixed image can

1 Virtual Non-Contrast mode: any contrast-medium gener-ated contrast disappears with the remaining images indicat-ing just tissue related differences (Fig. 1A).

Standard mixed view: shows iodine-contrasted structures against non-contrast enhanced structures (Fig. 1B).

Optimum contrast: an optimized noise-to-contrast ratio can be reached, resulting in clearer and better contrasted image quality (Fig. 1C).

1C

be generated (Fig. 1C). Optimized differ-entiation of contrasted and non-contrast-ed regions allows an even more detailed and clearer diagnosis compared to the standard mixed view.



Clinical Results Oncology

HISTORY

A 72-year-old male, a former smoker on home oxygen with history of severe COPD, was referred for a DSCT scan of the thorax for follow-up due to worse-ning dyspnea. The patient had bilateral upper lobe lung volume reduction sur-gery 8 years ago.

DIAGNOSIS

The DSCT scan with lung window setting showed diffuse severe emphysema and bullous changes were identified throughout the upper lobes. Severe cen-trilobular emphysema was also identi-fied inclu ding the lower lobes (Fig.1A). Surgical clips and architectural distortion from prior bullectomy were noted in the upper lobes.syngo InSpace Lung Parenchyma Analy-sis software was then used to quantify the amount of emphysema, characte-rized by lung attenuation below -950 HU1. Results were stratified by lung thirds (upper, middle and lower) to evalu-ate the distribution of the disease. As illustrated in Figs.1B and 1C, the soft-ware allowed the automatic three-di-mensional quantification of total lung volume and relative volume percen-tages, mean lung density, and low and high attenuation volumes. The low at-tenuation volume (LAV) corresponds to the volume of emphysematous lung and is displayed as a percentage of the total lung volume. In this case, the analysis showed that 51.5% of the left lung and 38.4% of the right lung volume corres-

Case 6Lung Parenchyma Analysis Software with Automated Three-Dimensional Quantifi cation of EmphysemaBy Myrna C.B. Godoy, MD and David P. Naidich, MD

Department of Radiology, New York University Medical Center, New York, USA

ponded to emphysema (Fig. 1C, arrows). It also confirmed the upper lobe pre-dominance of the disease. Emphysema cluster analysis was auto-matically performed, showing clusters class 1 (> 2mm3), class 2 (> 8mm3), class 3 (> 65mm3), and class 4 (>187mm3) co-lored in blue, green, yellow, and red, respectively (Figs. 2A-B). The vast major-ity of the emphysema in this patient was classified as cluster class 4, which involved 50.3% of the left lung volume and 37.0% of the right lung volume (Fig. 2C).

COMMENTS

The syngo Lung Parenchyma Analysis software enables automated evaluation of emphysema. It permits not only pre-cise quantification of the amount of dis-ease, but also classification of the foci of emphysema by size and distribution of the disease. The importance of these pa-rameters resides in the preference for ac-curate quantification of disease when compared with routine pulmonary func-tional testing for assessing potential ther-apeutic options in patients with emphy-sema. While characterization of large bullae indicates the possibility of treat-ment with bullectomy, in fact, most pa-tients present with either predominant centrilobular or panlobular emphysema. Over the past several years, a number of innovative therapeutic options have been developed for treating patients with pre-dominant upper lobe centrilobular em-

physema. In addition to routine lung vol-ume reduction surgery (LVRS),2,3 newer interventional bronchoscopic techniques have emerged as potential alternatives, including the placement of one-way en-dobronchial valves and bronchial fenes-tration.4,6 As emphasized in this case, in addition to preoperative evaluation, it is equally important to monitor disease pro-gression following surgery. For this pur-pose, quantitative CT offers a potential alternative to less precise measurements of disease severity, including routine ex-ercise testing and PFTs. In addition, CT al-lows identification of potential complica-tions (including the development of lung cancer in this especially predisposed pop-ulation). In this regard, the availability of a “user-friendly” CT application will be of critical importance in establishing quanti-tative CT as the gold standard for both pre- and post-operative assessment of pa-tients with emphysema. In this case, the degree of residual emphysema following lung volume reduction surgery estab-lished this patient as a candidate for lung transplantation.

References1 Gevenois PA et al. Am J Respir Crit Care Med

1996; 154:187-192.

2 Lederer DJ et al. Clin Chest Med 2007; 28:639-

653, vii.

3 Fishman A et al. N Engl J Med 2003; 348:2059-

2073.

4 Wan IY et al. Chest 2006; 129:518-526.

5 Reilly J et al. Chest 2007; 131:1108-1113.

6 Cardoso PF et al. J Thorac Cardiovasc Surg 2007;

134:974-981.



Oncology Clinical Results

1 Lung parenchyma analysis: general analysis stratified into upper, middle and lower lung thirds. Axial CT scan at the level of the carina showing severe emphysema with bullous changes in the upper lobes and centrilobular emphysema in the superior segments of the lower lobes (Fig. 1A). Histogram showing severe emphysema bilaterally with upper third predominance in both lungs (Fig. 1B). Quantitative three-dimensional analysis of lung volume, mean lung density, low and high attenuation volumes are displayed (Fig. 1C). The low attenuation volume (LAV %) indicates the percentage of the lung with emphysema.

2 Lung Parenchyma Analysis: Cluster classification stratified by thirds in the left and right lung. Axial and coronal reformats (Figs. 2A-2B) showing emphysematous clusters, color-coded by size. The red color corresponds to the largest clusters (Class 4, ≥ 187 mm3). Results displayed in the table (Fig. 2C) show the percentage of lung volume involved by specific cluster’s size. In this case there is severe emphysema characterized by Class 4 clusters involving 50.3% of the left lung volume and 37% of the right lung volume.

2A1A

2A 2B

1B 1C

2C



Scan area thorax Slice width 0.75 mm

Scan length 348 mm Reconstruction increment 0.5 mm

Scan direction cranio-caudal Reconstruction kernel B40

Scan time 8.2 s Slice collimation 0.6 mm

Tube voltage 120 kV Pitch 0.8

Tube current 160 qual. ref. eff. mAs Rotation time 0.33 s

CTDIvol 11.5 mGy Postprocessing syngo InSpace Lung

Parenchyma Analysis

1C



Clinical Results Neurology

Case 7Acute Left Hemispheric Ischemic Stroke: Comprehensive Stroke Imaging Using Neuro Volume Perfusion CTBy Ramona Finzel and Peter Schramm, MD

Department of Neuroradiology, University of Göttingen, Göttingen, Germany

HISTORY

A 75-year-old female patient with histo-ry of arterial hypertension, diabetes mellitus and absolute arrhythmia was admitted to the neurological clinic with symptoms of acute stroke. Two hours prior, the patient had developed an acute, right-sided hemiplegia and a right-sided facial palsy. On physical examination the patient was global aphasic, showed a left-sided eye and head deviation and recurrent emesis (NIHSS 26).*

DIAGNOSIS

On initial non-enhanced cranial CT (NECT), intracranial hemorrhage and tumor were ruled out. A hyperdense media sign on the left side was visible as an early sign of ischemic stroke (Fig.1A). However, grey and white brain matter appeared normal (Fig. 1B).Volume perfusion CT (VPCT) indicated large areas of restricted brain perfusion in the left hemisphere. A substantial reduction of values of cerebral blood flow (CBF, Fig. 2A) as well as reduction of cerebral blood volume (CBV, Fig. 2B) were detected in the anterior and middle parts of the left middle cerebral artery (MCA) territory and in parts of the left anterior cerebral artery (ACA) territory.

Furthermore, a significant prolongation of the mean transit time (MTT, Fig. 2C) and the time to peak (TTP) in both the complete MCA and ACA territories were found. On CT-Angiography (CTA), occlusion of the main stems of the left MCA (Fig. 3) and ACA were detected. Due to the presence of a large penum-bra volume, it was decided to perform

intra-arterial thrombolysis and to start a bridging therapy with 20 mg rt-PA immediately. Unfortunately, both throm-bolysis therapies were unsuccessful (Fig. 4). Two days later, the follow-up NECT showed the delineation of com-plete territory infarctions of the MCA and ACA, brain edema and severe mid-line herniation (Fig. 5).


Scanner SOMATOM Definition AS+ SOMATOM Definition AS+

CT -Perfusion CTA Vessel analysis

Scan area head head

Scan length 96 mm (VPCT) 300 mm

Scan direction cranio-caudal cranio-caudal

Scan time 40 s, one scan every 1.5 s 2.91 s

Tube voltage 80 kV 120 kV

Tube current 200 Eff. mAs 120 Eff. mAs

Scan mode Adaptive 4D Spiral Spiral

eff. dose 5.2 mSv 3.1 mSv

Rotation time 0.3 s 0.3 s

Slice collimation 0.6 mm 0.6 mm

Slice width/Increment 5 mm/3 mm 1.5 mm/1 mm

Reconstruction kernel H20f H20f

Contrast

Volume/Flow rate 35 ml Iomeprol 350 @ 5 ml/s 40 ml Iomeprol 350@ 5 ml/s

20 ml NaCl @ 5 ml/s 25 ml Iomeprol 350@ 2,5 ml/s

20 NaCl @ 2,5 ml

Start delay 4s 4s

Postprocessing syngo Volume Perfusion CT – Bolus tracking

Neuro (VPCT-Neuro) syngo Neuro DSA* NIHSS 26 (National Institute of Health

Stroke SCORE 26).



COMMENTS

With VPCT, analysis of the brain perfu-sion parameters of the whole brain is possible. Contrary to standard perfusion CT, which allows analysis only of restrict-ed areas of the brain depending on the

detector width, even smallest areas of hypo-perfusion can now be analyzed throughout the whole brain with VPCT. Therefore, the advent of VPCT renders important information about the com-

plete volume of tissue at risk of infarc-tion and should be implemented in a comprehensive stroke CT protocol.

1 A hyperdense media sign on the left side was visible as an early sign of ischemic stroke (Fig.1A, arrow). However, the differentiation of grey and white brain matter appeared normal (Fig. 1B).

2 Volume perfusion CT (VPCT) indicated substantial reduction of values of cerebral blood flow (CBF, Fig. 2A) as well as reduction of cerebral blood volume (CBV, Fig. 2B) were detected in the anterior and middle parts of the left MCA territory and in parts of the left ACA territory. Further-more, a significant prolongation of the mean transit time (MTT Fig. 2C) could be observed. A large penumbra could be detected (yellow) in regards to a smaller core infarct (red, Fig. 2D). Therefore intra-arterial lysis was indicated.

1B

1A

2D

2B

2C

2A

4 Intraarterial thrombolyses failed to open left MCA.

3 Due to complete stroke assessement the CTA revealed an occlusion of the main stem of the left MCA.

5

5 Follow-up NECT showed the delineationof complete territory infarctions of the MCA and ACA, brain edema and severe midline herniation.

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Case 8SOMATOM Defi nition AS+: Neuro Volume Perfusion CT of Intracerebral Metastatic DiseaseBy Ramona Finzel and Peter Schramm, MD

Department of Neuroradiology, University of Göttingen, Göttingen, Germany

HISTORYA 69-year-old female patient with a his-tory of bronchial carcinoma presented to the Department of Neurology with a dis-crete left-sided, arm-accented, hemipa-resis since the evening. She was fully orientated but very cachectic and in poor general condition.

DIAGNOSIS

Neuroradiologic examination consisted of a cranial, non-enhanced CT (NECT) scan followed by Volume Perfusion CT (VPCT). NECT revealed a tumor in the subcortical white matter of the right parietal lobe (Fig. 1A). The tumor showed a rim-like hyperdensity with a central loss of density on NECT and was surrounded by an ede-ma. A second small cortical lesion was visible in the right anterior lobe (Fig. 1B).

Assuming that the patient was suffering from multiple metastasis, we performed VPCT. The calculated permeability maps of VPCT showed multiple lesions with disrupted blood-brain-barrier through-out the whole brain (Figs. 2A–F), indi-cating the presence of numerous brain metastasis. The lesions showed an ele-vation of cerebal blood volume (CBV, Fig. 3) and contrast enhancement on the MIP images. In addition, we detected a severe prolongation of the mean transit time (MTT, Figs. 4A-C) and time to peak (TTP) in parts of the right MCA territory.The follow-up MRI examination on the same day visualized various metastasis supra- and infratentorial. In addition, we found subacute ischemic lesions on diffu-sion-weighted images in the area sup-plied by the right MCA which were al-

ready indicated by the prolongated MTT and TTP on VPCT.

COMMENTS

This case illustrates that VPCT can depict disturbances of the blood-brain-barrier even within smallest lesions that are not visible on NECT. Therefore VPCT is a meaningful method to reveal smallest metastasis within the scope of a CT examination. Further, this example dem-onstrates the multi-modality of VPCT. Although the examination and the postprocessing were focussed on the assumed diagnosis “tumor”, we were able to uncover the supplemental isch-emic lesion on the parameter maps.

1 NECT revealed a tumor in the subcorti-cal white matter of the right parietal lobe (Fig. 1A, arrow). The tumor showed a rim-like hyperdensity with a central loss of den-sity surrounded by an edema. A second small cortical lesion was identified in the right anterior lobe (Fig. 1B, arrow).

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2B

2E

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2 VPCT showed multiple lesions with disrupted blood-brain-barrier throughout the whole brain (Figs. 2A–F, arrows), indicating the presence of numerous brain metastasis.

4 3D evaluation of the brain detected an infarct seen as severe prolongation of the mean transit time (MTT) in parts of the right MCA territory.

3 Additionally VPCT showed an ele-vation of cerebal blood volume (CBV) of the tumor.


Scanner SOMATOM Definition AS+

Scan area head Spatial resolution 0.33 mm

Scan length 96 mm (VPCT) Slice width/Increment 5 mm & 3.0 mm increment

Scan time 40 s, one scan every 1.5 s Reconstruction kernel H20f

(27 scans) Contrast

Scan direction cranio-caudal Volume/Flowrate 35 ml Iomeprol 350 @ 5 ml/s

Tube voltage 80kV 20 ml NaCI @ 5 ml/s

Tube current Eff. 200 mAs Start delay 4 s

Scan mode Adaptive 4D Spiral Postprocessing syngo Volume Perfusion CT –

eff. dose 5.2 mSv Neuro (VPCT-Neuro)

Rotation time 0.3 s

3 4A 4B



Case 9Dual Source CT: Visualization of Brain Vessel Connection of Siamese TwinsBy Anirudh Kohli, MD, Head

Department of Radiology, Breach Candy Hospital Trust, Mumbai, India

1A Overview with volume rendering technique (VRT) showing the connec-tion of both skulls.

1B Blood-flow through the con-nected head-vessel system of the conjuncted twins, demonstrated by VRT during administering contrast medium into the artery system of twin one (left person). Venous drain-age can be found in the brain of twin two (right person).

1A

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HISTORY

Two children, 3½-year-old female twins, fused at the cranium since birth (cranio-phagus), were transferred to the depart-ment of radiology for prearrangement of separation. For the pre-operative diag-nosis and surgery planning, a CT-Angio-graphy was performed to evaluate the vascular communications between the connected brain tissues of both children.The dissection of these communications was the key challenge for the separation procedure. In preparation for the CT scan and for brain vessel visualization, twin one was injected before twin two and finally, both were injected simulta-neously.

DIAGNOSIS

The CT imaging revealed both venous communications as well as arterial connections. The arterial communica-tions were well visualized in the super-ficial cranial branches of the external carotid. The superficial temporal and frontal artery of twin one and the super-ficial temporal and occipital artery of twin two were found to be communi-cating. This brain vessel anomaly was recognized to be the reason for volume overload in the brain tissue of twin two, thus resulting in hypertensity.

COMMENTS

The results of the CT imaging provided excellent orientation for the surgical team to prepare a safe separation of the twins.A CT-Angiography was preferred over an MR-Angiography due to the very short scan time required. This allowed a short sedation time, lowering the sedation risks for the children while concurrently delivering excellent image quality.With Dual Energy CT-Angiography, small vascular communications could be visu-alized that are critical in a pre-operation-al workup. This information is important to know exactly – before starting a sur-gery of this difficulty and severity.



Scan area head

Scan length 500 mm

Scan time 16 s


Tube voltage A/B 140/80 kV

Tube current A/B 70/297 quality ref. mAs

Rotation time 0.5 s



Slice width 0.6 mm

Kernel H10f

2 MIP visualiza-tion of vessel-connection: in-flow of contrast media into the arteries of twin one (left) with drainage via the venous vessel system of twin two (right, Fig. 2A) and vice versa in a second CT-scan afterwards (Fig. 2B).

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Case 10A Rare Anomaly of the Middle Cerebral Artery Detected by Three-Dimensional Subtraction CT-AngiographyJacqui Fielding

Department of Radiology, Angliss Hospital, Upper Ferntree Gully, Melbourne VIC, Australia

HISTORY

A 66-year-old woman with a history of hypertension and recent headaches pre-sented at the hospital with an acute on-set of vertigo, fatigue and severe head-ache. On examination and questioning of the patient, it was found that her mother died at an early age from com-plications of a cerebral aneurysm. The patient was referred for a brain CT and brain CTA to rule out sub-arachnoid hemorrhage and aneurysm.

DIAGNOSIS

The non-enhanced brain CT shows no sign of subarachnoid bleeding. Using the functionality of digital subtraction CT-Angiography, automatically subtract-ing a non-contrast from a contrast enhanced study, the complete cerebro-vascular tree could be demonstrated and two progressed aneurysms in the middle cerebral arteries could be detected.

COMMENTS

In this 66-year-old woman, preoperative angiography and 3-dimensional com-puted tomography angiography re-vealed a double aneurysm at the right middle cerebral artery (Circle of Willis).

Both aneurysms were clipped and su-perficial temporal artery-DMCA* anas-tomosis was performed. She was dis-charged with no neurologic deficits.


Scanner SOMATOM Emotion 16

Scan area Circle of Willis

Scan length 80 mm

Scan direction caudo-cranial

Scan time 7 s

Tube voltage 100 kV

Tube current 100 Eff. mAs

Dose modulation CARE Dose off

CTDIvol 15 mGy

Rotation time 0.6 s

Pitch 0.8

Slice collimation 16 x 0.6 mm

Slice width 0.75 mm

Reconstruction increment 0.5 mm

Reconstruction kernel H31

Contrast Ultravist 370

Volume 50 ml

Flow rate 4 ml/s

Iodine delivery rate 4 ml/s

Start delay CARE Bolus *Duplication of the middle cerebral artery.




1 View into the brain via Volume Rendering Technique (VRT), showing the position of the double aneurysm in the Circle of Willis.

3 View on the two aneurysms in the Circle of Willis, virtually separated from brain tissue in VRT (Fig. 3A) and in comparison in MIP (Fig. 3B).

2 Detailed VRT image, showing both aneurysms, located consecutively in an aortic brain vessel.

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Clinical Results Acute Care

1 Even without ECG-triggering, sharp delineation of aortic valve leaflets is possible.

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Case 11Complete Thorax with Flash Spiral By Martine Remy-Jardin, MD, PhD and Jacques Remy, MD

University Center of Lille, Department of Thoracic Imaging, Hospital Calmette, Lille, France

HISTORYA 64-year-old male patient was referred to the department of radiology for eval-uation of abnormal chest radiographic findings in March 2006. This patient was an ex-smoker (smoking cessation 18 years ago) with a cigarette consump-tion of 20 pack-years. At the time of first referral, chest CT revealed the pres-ence of a spiculated nodule in the right middle lobe. This was associated with hilar and mediastinal adenopathies with a final diagnosis, in June 2006, of right middle lobe adenocarcinoma with lymph node metastases. This diagnosis, ob-tained after atypical resection of the right middle lobe nodule and lymph node sampling, indicated chemotherapy followed by radiotherapy at the level of the tumoral zones. In 2008, this patient was also diagnosed with bone and cere-bral metastases.

DIAGNOSIS

The present CT examination was indicat-ed for the follow-up of the chest lesions in a patient in poor general condition. This examination showed sequellae of right middle lobe resection and areas of airspace consolidation in the lung paren-chyma located close to the right hilum, caused by radiotherapy. Furthermore multiple areas of non-specific ground glass attenuation in both lung lobes were discovered, predominantly on the right side, resulting from radio therapy or an infection. In addition to hilar and subcarinal adenopathies, osteolytic le-sions of the thoracic spine and the ster-num were found.

COMMENTSThis examination was obtained with an ultra fast Flash Spiral mode which made the overall examination very comfort-able for this patient in poor general con-dition. The optimization of data acquisi-tion and administration of contrast medium generates high quality images of the mediastinum that are devoid of respiratory motion artifacts. This kind of

acquisition makes the analysis of the coronary arteries at the same time possi-ble. In this case, the patient’s heart rate was 65 bpm. The delineation of aortic and pulmonary valves was excel-lent. The only limitation was the pres-ence of interpolation artifacts around the ribs, noticeable on lung images.



Acute Care Clinical Results

2 3

2 Coverage of the entire lung in ultra-short breath hold time of < 3 sec. Note the apparent right lower lobe consolidation secondary to lung resection.

3 Sagittal view of the right lung highlights the high quality of lung images from top to bottom of the volume scanned.


Scanner Flash Spiral mode

Scan area whole chest Reconstruction increment 1 mm

Scan length 345 mm Reconstruction kernel BB20f (mediastinum); B50f (lung)

Scan direction cranio-caudal Contrast 350 mg of iodine/mL

Tube voltage 120 kV

Tube current 52 Eff. mAs Volume 80 ml

Heart rate 65 bpm Flow rate 4 ml/s

Pitch 3.2 Start delay 18 s (ROI within descending aorta)

Spatial resolution 0.33 mm Postprocessing syngo InSpace

Slice width 1 mm



Case 12Dual Source CT:Carotid Stenosis Diagnosed with Dual EnergyBy Eva Hendrich, MD and Stefan Martinoff, MDDepartment of Radiology and Nuclear Medicine, German Heart Center, Munich, Germany

HISTORY

A 65-year-old woman presented with complaints about recurring dizziness. Weeks previously, she has been stented in the right carotis interna. During a rou-tinely conducted ultrasound examina-tion, a stenosis was discovered in the left arteria carotis interna. To confirm this result and for a correct planning of stent positioning and PTA (percutanuous transluminal angioplasty), a CT examina-tion with Dual Energy technology was subsequently performed.

DIAGNOSIS

With CTA (CT-Angiography), indicated by the ultrasound survey, a quite severe stenosis in the branch of the left arteria carotis interna with cranio-caudal exten-sion of 13 mm could be confirmed. Furthermore, the CTA delivered addi-tional information that an expanded semi-circular atheromatous plaque was the cause for the stenosis. In the area surrounding the implanted stent, in the proximal right arteria carotis interna, a stenosis could be ruled out. Moreover other profound arteriosclerotic alterations in the region of the basal brain arteries could also be ruled out by the CTA survey.

COMMENTS

syngo Dual Energy Bone Removal deliv-ers credible information about vessel status. Therefore, the non-overlapping imaging of the vessels plays an impor-tant role, as well as the option of hard-plaque visualization that affords a de-tailed conclusion about vessel lumen and plaque. A very positive effect is the uncomplicat-ed integration of Dual Energy into the post processing procedure. Hence syngo Dual Energy Bone Removal has become an inherent part of our vascular workflow.

Clinical Results Acute Care



Scan area carotis Rotation time 0.33 s

Scan length 281 mm Spatial resolution 0.33 mm

Scan time 6 s Slice collimation 0.6

Scan direction cranio-caudal Reconstructed slice thickness 0.75 mm

Tube voltage A/B 140/80 kV Increment 0.6

Tube current A/B 204/48 Eff. mAs Kernel D30f



1 VRT Visualization of syngo Dual Energy scan shows earlier PTA result in right carotid artery (Fig. 1A).Inverted Maximum Intensity Projection (MIP) of the same scan (DE) (Fig. 1B).

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2 syngo InSpace advanced vessel analysis (InSpace AVA) measured accurately the grade of the stenosis for use of later PTA (Fig. 2A).syngo Hard Plaque unveiled the calcified plaque (red) versus remaining lumen of the carotid arteries (blue) (Fig. 2B).

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Acute Care Clinical Results



Clinical Results Orthopedics

Case 13Screw Placement and Pelvic Osteoplastie Under CT – Fluoroscopic Guidance By Ralf-Thorsten Hoffmann, MD*, Bianca Beyer, MD**, Tobias F. Jakobs*, Maximilian F. Reiser, MD*

*Department of Clinical Radiology, University of Munich, Campus Großhadern, Munich, Germany**Department of Surgery, University of Munich, Campus Großhadern, Munich, Germany

HISTORYA 68-year-old male patient with a history of renal cell carcinoma 4 years prior, pre-sented in the department of radiology. Due to pelvic pain occurring during his follow-up, a MSCT of the pelvis was ob-tained.

DIAGNOSIS

The examination showed a large osteo-lysis in the sacrum and the adjacent iliac bone (Fig. 1). Furthermore, a pathologi-cal fracture was detected as stigmata of the recurring tumor. After an inter-disciplinary case discus-sion, the decision was made to treat the patient with a combination of angio-graphic embolization of the strongly vas-cularized tumor, followed by CT guided placement of two screws supported by



Scan area pelvis Rotation time 0.5 s

Scan length 4.8 mm Slice collimation 12 x 1.2 mm

Scan time i-Fluoro Slice width 4.8 mm

Tube voltage 120 kV Reconstruction kernel B50s

Tube current 25 Eff. mAs Postprocessing Intervention Pro

CTDI vol 289 mGy Adaptive 3D Intervention

a CT guided osteoplasty during the same treatment session.

COMMENTS

After placing the patient in a stable lat-eral position with the help of a vacuum bed, a CT scan was performed using the i-Spiral mode. The correct positioning of the screws was planned on axial images. Furthermore, path planning and calculation of the screw length was performed on the automatically ob-tained 3D images using the needle ori-ented view. The following procedure was monitored by repeated control with i-Fluoro mode. By using Hand CARE mode, K-wires were positioned through small skin incisions by the interventional radiologist under CT fluoroscopic guid-

ance using the i-Fluoro mode (Fig. 2). The screws were placed via K-wires by the surgeon in order to avoid a too deep insertion of the screw head into the weakened bone (Figs. 3A-B). A major support for these control scans is the One Click Table Position, bringing the patient back to the exact same position, avoiding additional fluoroscopic CT ex-amination. Procedure times and radia-tion exposures are thereby significantly reduced. After the insertion of two screws, (Fig. 4) the next step was the in-sertion and positioning of two vertebro-plasty canulas into the osteolysis and ap-plication of the PMMA cement under CT fluoroscopic guidance by the radiologist using the needle artefact reduction tool i-Needle Sharp (Figs. 5A-B).



4 Two screws were inserted into the broken pelvic bone.

5 Two vertebroplasty canulas were inserted and positioned into the osteolysis (Fig. 5A) and PMMA cement was supplied under CT fluo-roscopic guidance using i-Needle Sharp (Fig. 5B).

5A 5B

3A 3B

1 The CT examination showed a large osteolysis in the sacrum and the adjacent iliac bone.

2 K-wires were positioned under CT fluoroscopic guid-ance using the i-Fluoro mode.

3 The screws were placed via K-wires in order to avoid a too deep insertion of the screw head into the weak-ened bone.

4

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Science

1 CT-guided osteosynthesis in instable pelvic fractures

CT-Guided Osteosynthesis in Instable Pelvic FracturesBy Tobias F. Jakobs, MD*, Ralf-Thorsten Hoffmann, MD*, Thomas Löffler, MD**

*Department of Clinical Radiology, University of Munich, Campus Großhadern, Munich, Germany

**Department of Surgery, University of Munich, Campus Großhadern, Munich, Germany

Recent improvements in mortality due to high-energy trauma can be attributed to the progress made in modern critical care medicine including early fracture stabilization.Most of the complications of classical stabilization techniques are related to the surgical exposure itself, rather than to the initial injury. It therefore seems reasonable to consider less invasive

treatment options. The most frequent percutaneous application is the trans-iliosacral screw fixation using only fluo-roscopy guidance. Given the anatomical complexity of the pelvic structures, this surgical procedure remains a challeng-ing task.An 18-year-old woman was presented at the CT unit for a whole-body scan after having experienced a severe car acci-

dent. The CT scan revealed – beside a right sided lung contusion – an instable fracture of the pelvic bone involving the superior ramus of the pubic bone and the wing of the sacral bone on the left side (Figs. 2A-B). On day 5 after the trauma the patient was referred to the interventional radiology unit for CT-guided osteosynthesis.

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2 CT scan revealed an instable fracture of the pelvic bone involving the superior ramus of the pubic bone and the wing of the sacral bone on the left side (Fig. 2A). VRT supports surgi-cal planning planning (Fig. 2B).

Science

Procedure

The procedure was performed under general anaesthesia in cooperation with trauma surgeons (Figs. 1A-C). The patient was placed in a strict lateral position using a vacuum mattress with the fractured pelvis pointing to the

top. A planning CT was performed to identify the most appropriate position for the screw. Using a Siemens SOMATOM Definition AS+ CT scanner and the new Siemens Interventional Suite for 3D-guided interventions, plan-ning procedures have been dramatically

improved. Additionally, a 78 cm large bore allows convenient work within the gantry. The innovative table-side control module “i-Control” enables operating all table and scanner movements from inside the scan room (Fig. 1B, arrow), improving the workflow as well on such complex procedures. For this patient, the correct positioning of the screw was planned on axial images. Furthermore, path planning and calculation of the screw length were performed on the automatically obtained 3D images using the needle oriented views. A combina-tion of CT Fluoroscopy with the new i-Fluoroscopy mode and a sequential ap-proach with 3D i-Sequence mode was used to securely drive a wire through the iliac bone and the sacral wing into the first sacral vertebral body. Especially the 3D i-Sequence mode with instant display of the wire in an axial, coronal and sagittal view (MPR) permitted excel-lent visualization and increased the in-terventional radiologist’s confidence not to harm, e.g. the neuro-foramen, or to protrude outside the first sacral verte-bral body. This enables a safe place-ment of the screw even in complex anatomy (Fig. 3).With the guide wire in place, the screw could be advanced into the target area to provide compression on the fractured sacral wing (Fig. 3). Then, the guide wire was withdrawn. Before the patient was removed from the CT-table, a con-trol scan was conducted and MPR as well as VRT were reconstructed (Fig. 4).

CommentsWith the availability of the new 3D-guid-ed Interventional Suite, we have chosen the approach of CT-guided osteosynthe-sis. In comparison to classic surgical techniques of internal fixation, the new interventional procedure brings advan-tages for both patients and the hospital. Less complications, due to less exten-sive soft tissue damage associated with long bed rest, reduce the likelihood for pneumonia, deep vein thrombosis etc., facilitate a faster recovery of the patient and finally an earlier discharge.

3 With the 3D approach, the placement of the screw into the target area can be perfectly monitored using a guide wire.

4 Using CT guided interventions, the screw can be placed in the target area without providing compression of the fractured sacral wing.

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Science

Clinical Advantages of Automated CT Tumor Measurement Lesion measurement has long been an inexact science. Yet, judging the patient’s disease regression or progression is, to a large extent, based on documentation of exact changes in tumor size. Currently, when tumor masses are encountered in daily clinical practice, manual measurements made with electronic calipers are utilized. These are quite time consuming and not reliably exact from examination to examination.

By Alec J. Megibow, MD, MPH, FACR

New York University Medical School, New York, USA

Because tumors are complex shapes, the axis of measurement chosen over serial time points may vary. RECIST (Response Evaluation Criteria in Solid Tumors) has been widely adopted in the U.S. and WHO (World Health Organization) crite-ria elsewhere as the standard reporting parameters for lesion size. Among many problems with these methods, con-straining measurements into the axial plane may under- or overestimate the longest diameter of the lesion. If software could be developed to segment the 3D volume from an MDCT data set, the truest approximation of the maximal diameter (RECIST diameter) could be determined. Additionally, such software should be able to “store” this information so that the same exact le-sion could be followed over the course of the patient’s treatment, thereby elimi-nating variances in manual measure-ment. Finally, converting these observa-tions onto a spreadsheet would aid institutional compliance in clinical trial, with benefits not only to improved pa-tient care, but also increased opportuni-

1 All segmentation and measurement results are stored and reported. The list in-cludes the most important lesion information, such as WHO and RECIST diameters, Volumes and their changes since the last examination. A comprehensive report, including key images, can be generated and stored.

1



2 Example of a 73 year old female patient with known carcinoid on treatment. Follow up is performed in a 3 month interval (Figs. 3A-B). The datasets are automatically registered and displayed synchronously for easy follow-up comparison. The lesion is then identified in both studies and is automatically segmented and evaluated. Sagittal and 3D reformats are shown (Figs. 2A-B – base exam, Figs. 3A-B – 3 month follow up).

Science

main consistent while volume changes. Clearly, the ability to measure volume is an asset, even if it has not yet been clini-cally validated. We are currently in the process of comparing changes in volume against diameter changes as measured with RECIST criteria. With its ability to record and evaluate all tumor parameters, syngo CT Oncology is an advantageous tool for the radiologist. This software helps solidify the role of the radiologist as someone who goes beyond simple diagnosis, but rather, a physician who, through the use of a wide variety of image processing tools, can provide information that directly im-pacts therapeutic decisions.

ty for ongoing funding, since it improves the institution’s ability to record data in a usable format. Siemens syngo CT Oncology is a clinical-ly available suite of tools that provides all these capabilities (Fig. 1).

Algorithm Refi nementIn preliminary testing of the syngo CT Oncology algorithm, 27 hepatic metas-tases in 13 patients were evaluated us-ing prototype software that defined the edges, maximal and orthogonal diame-ters of the targeted lesion. The auto-segmented measurements were com-pared to manual measurements made by electronic calipers, and the difference between the two was recorded. As a prototype, this algorithm performed well: Using 4 mm slices, long diameters of 67 percent of metastases of less than 5 mm were correctly measured within 2 mm of the manual measurement. With this information, the algorithm was fur-ther refined. In our next evaluation of the actual, clin-ical application, it performed exception-ally well. Eighty-seven hepatic masses from 33 patient studies were evaluated. Here, we sought to compare the tool’s ability to obtain RECIST diameters of hepatic metastases against manual eval-uation of the same lesion. There was a high degree of concordance between RECIST diameters obtained using auto-mated segmentation versus manual measuring. In fact, 74 percent of lesions differed by less than 5 mm. A finding of particular importance: the syngo CT On-cology segmentation algorithm is inde-pendent of absolute HU measurements. Thus, there is no dependence on the quality of the contrast injection, which makes the tool particularly valuable for serial observations of lesions in patients where it is difficult to obtain a good in-jection (such as those undergoing che-motherapy).

Comprehensive Evaluation and ReportingWith syngo CT Oncology, the lesion is presented in axial, coronal and sagittal displays with RECIST and WHO measure-

ments, and volume. The radiologist can decide whether to accept the results or edit, if necessary. Evaluation results are comprehensively presented and the im-ages stored to PACS, ensuring that any follow-up measurements are conducted with a consistent approach to the cor-rect lesion(s). This is particularly helpful in following tumor progress.

Future DirectionsRECIST and WHO criteria do not currently include volume; it is the next, expected step in comprehensive tumor measure-ment. It is theorized that volume may be more sensitive to tumor growth than di-ameter because lesion diameter can re-

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Science

CT put to the TestCT units from various manufacturers were recently put through practical tests at the German Heart Center in Munich in order to determine radiation exposure levels for patients during everyday operations. The results indicate that applied doses depend not only on the specifi c device, but are also sig-nifi cantly infl uenced by the operator. The study further shows that Siemens has developed particularly effi cient radiation-saving equipment.

By Tim Schröder

Computed Tomography (CT) has estab-lished itself in the past few years as a non-invasive procedure for obtaining medical imagery. With every new product generation, manufacturers have paid considerable attention to reducing the levels of radiation to which patients are exposed. Never the less, the question of dose is becoming increasingly important as CT-technology becomes more wide-spread. Not only the technical data pro-vided by manufacturers is of interest, but especially the actual radiation doses to which patients are exposed during treat-ment. To this end, the German Heart Center in Munich, in cooperation with the American Mayo Clinics in Rochester and Jacksonville, and the Friedrich-Alex-ander University in Erlangen-Nuremberg,

“It’s clear to see that Siemens has quite evidently developed a very radiation-saving system.”

Jörg Hausleiter, MD, Cardiologist, associated Professor of Medicine, German Heart Center Munich, Germany

Sessions23_S58-61.indd 56Sessions23_S58-61.indd 56 17.11.2008 8:58:01 Uhr17.11.2008 8:58:01 Uhr

1 49-year-old patient, former smoker with high cholesterol, who repeatedly developed symp-toms of dyspnea in combination with a difficult to adjust hypertension. SOMATOM Definition with Adaptive Cardio Sequence revealed with a quick 1.8 mSv low dose cardiac examination a high grade lesion in the right coronary artery. The patient was transferred from CT directly to the cath lab for a percutaneous intervention.


Germany, conducted an International Prospective Multicenter Study on Radiation Dose Estimates of Cardiac CT-Angiography in Daily Practice (PROTEC-TION-I). The study compared five CT units from four different manufacturers. The basis of the study was 1,965 cardiac CT scans that were carried out in a total of 50 clinics and heart centers. The study showed clear differences in radiation doses depending upon both the CT system manufacturer and the behavior of the operator. The study especially under-lines that radiation can be significantly reduced by more consistently using already existing technologies for dose reduction in CT systems.“Until now the only information available for evaluating individual devices has been to use systematic phantom measure-ments or physical readings provided by the manufacturers,” said Jörg Hausleiter, cardiologist and associate professor of medicine, German Heart Center in Munich. “Conversely, the new study deliv-ers, for the first time, data obtained from individual patients, including abundant patient data such as size and weight.” As was shown, the radiation dose varies considerably, by as much as a factor of six. Hausleiter: “An emphasis of our work was to test the effectiveness of the different software tools for reducing radi-ation.” This included the so-called “Automatic Exposure Control,” which automatically adjusts the CT radiation intensity to the anatomy of the patient. Generally more radiation must be used when conducting tests of larger bodies. The Automatic Exposure Control is already well established for noncardiac scanning, but it was not specifically developed for cardiac CTs. All of the devices tested were equipped with it. “ECG-Pulsing” is also implemented in all devices. This synchronizes CT radiation to the ECG, so that the image is recorded during the late diastolic phase, when the heart is not moving. It is only at this time that the apparatus increases the radiation intensity to the necessary high level. During the in-between phases, X-ray emission is kept to a minimum. Addition-ally, Hausleiter’s team researched the influence of the 100 kV Scan Protocol.

1B

1A



Science

This protocol is not integrated by all man-ufacturers, but is available, for example, with the Siemens systems. Until now, it was unclear as to how much of a reduc-tion of dose came with the 100 kV tech-nology in comparison to the conventional 120 kV protocol. As a further tool, the re-searchers evaluated the so-called, step-and-shoot method. In contrast to Spiral-Scan, this procedure does not expose the entire heart area to radiation through the entire test. Once again, thanks to syn-chronization with the ECG, exposure is limited to the diastolic phase. Then the CT device moves the patient forward so that the next heart segment can be ex-amined. At the time the study was enroll-ing patients, this low dose scan mode was only available in a preliminary re-search version at selected Dual Source Computed Tomograph (DSCT) SOMATOM Definition sites. Thus, this mode had been used infrequently on DSCT systems in PROTECTION I and patients could not benefit from the tremendous dose saving potential of the system at that time. However, shortly after the publication of the study, the Siemens proprietary step-and-shoot mode, “Adaptive Cardio Sequence,” and the software upgrade syngo 2008G has become available for all DSCT customers.

100 kV Tube Reduces Dose by HalfHausleiter primarily noted during the analysis of the data how often the indi-vidual software solutions were imple-mented. It became evident that the es-tablished Automatic Exposure Control was employed in more than a third of all cases, but, ultimately, hardly contribut-ed at all to dose reduction. ECG-Pulsing was employed in 78.7 percent of the cas-es and reduced the dose by about 20 per-cent. This is minor though, in comparison to the effect of the 100 kV tube that re-duced dose by half – while providing the same image quality in adequately select-ed, non-obese patients. However, this technology has so far been used in only 5.8 percent of all cases. “When testing pa-tients, physicians want to be secure and are afraid that by using the 100 kV mode the image quality will be inadequate for

confident findings,” said Haus-leiter. The situation is similar with the step-and-shoot technology. In comparison to the spiral-scan, this method reduces the dose by 68 percent, but so far has only been used in 6.2 percent of all cases. According to Hausleiter, the multivariate analysis of the PROTECTION-I study does not permit a direct comparison of devices, since op-erator behavior has an influence. Howev-er, the Siemens 64-slice scanner was as-sociated with the lowest radiation dose in cardiac CT-Angiography and served as the reference value for assessing the other systems. Close behind, in third place, was the DSCT SOMATOM Definition. Despite this, in comparable clinical situations in the study, the average radiation dose of the DSCT SOMATOM Definition was con-siderably lower than that of the compet-ing scanners ranked in fourth and fifth place. “It’s clear to see that Siemens has quite evidently developed a very radia-tion-saving system,” said Hausleiter. The multivariate data additionally allows an-other interpretation: satisfactory dose val-ues were only attained in the PROTEC-TION-I study when the radiation reduction software was frequently em-ployed. “Based on the available results we can conclude that Siemens evidently be-longs to those manufacturers, that pro-vide especially good systems training for their customers, so that operators can take advantage of the total radiation re-duction potential of the device.”

Dual Source-Scanner Unique WorldwideThomas Flohr, head developer of the SOMATOM Definition Dual Source CT at Siemens Healthcare in Forchheim, Ger-many, believes that, “the DSCT would have performed even better if it had al-ready been equipped with current, im-proved version of the step-and-shoot technology during the study.” At any rate, the Dual Source scanner is worldwide the only CT equipped with two X-ray tubes and two detectors, that are connected to one another at an angle of 90 degrees. This means that the heart is simultane-ously scanned from two different angles. With a gantry rotation speed of only 0.33 seconds, one achieves a temporal resolu-

tion of 83 milliseconds – so quick that sharp images are possible from even rapidly beating hearts. Despite having two X-ray sources, the total dose is less than that of conventional single source devices, thanks to the extremely short exposure time.“In discussions about radiation reduc-tions, one should not get carried away,” said Hausleiter. “To date, the level of radiation of cardiac CT-Angiography is very comparable with other diagnostic CT studies, such as multiphase abdomi-nal and pelvic CTs, which we perform in daily routine without worrying so much about radiation exposure.” Naturally, Hausleiter knows that, despite this, caution is required, especially when testing children and youths. “To this ex-tent, it makes sense that manufacturers continue to reduce the dose. Though par-ticularly in applications such as cardiac CT, the advantages of the method and the superior image quality weighs much more positively than any possible radia-tion risks.”

Immense PotentialHausleiter is currently advancing the follow-up studies, PROTECTION-II and PROTECTION-III. PROTECTION-II systemati-cally compares the image quality when using 100 and 120 kV tubes. PROTEC-TION-III studies the influence of step-and-shoot technology in the same way. At the end, Hausleiter wants to provide physi-cians with clear suggestions, with which the technologies can be used without any loss of image quality – up to approximate body volumes or weights. The goal is clear: In the future, radiologists and cardiologists should be less hesitant to use the technologies. Hausleiter: “Never-theless, the potential is immense. Until now with conventional CT technology the average radiation dose during a CT test was in the average 13 to 15 mSv. By consistently using dose reduction tools, today we can already achieve an average of less than 3 mSv.”

Tim Schröder is a biologist and former editor of the science section of the Berliner Zeitung. He is now a freelance writer in Oldenburg, Germany, and publishes regularly in scientific journals such as the german edition of Scientific American, Max-Planck-research and Fraunhofer-Magazin.



Science

Siemens benchmarks in low dose

2 Conventional Step & Shoot is vulnerable for extrasystolic heart beats. Adaptive Cardio Sequence, with arrhythmia compensation enables the system to react on extra systoles. In clinical routine, dose levels of 1.2 – 2.6 mSv can be reliably achieved.

Adaptive Cardio Sequence: – 68% dose compared to conventional ECG-Spiral dose

2

Three of Siemens’ latest and most effective dose saving features – and with the SOMATOM Defi nition Flash the further development in dose reduction technology continuously proceeds (see Cover Story).

extra-systole

Scan Scan Table

MoveMove

Table React Scan

1B Adaptive Dose Shield: The SOMATOM Definition AS is the first commercially available CT-scanner that addresses the problem of over-radiation with a dynamic collimation technique reducing spiral over-radiation up to 25% for a heart scan.

Adaptive Dose Shield: – 25% dose for spiral acquisition1B STRATON with Adap-

tive Dose Shield

No Post-Spiral DoseNo Pre-Spiral Dose

1A Spiral Acquisition: MinDose reduces the tube current from 20% to 4% during the systolic phase of an RR interval to lower the dose to the patient leading to a dose reduction of about 30%. In combination with reduced tube current of 100 kV dose levels of 3.9 mSv can be achieved in routine clinical use.

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MinDose: – 30% dose compared to conventional ECG-Spiral dose

MinDose

4%

Tub

e C

urr

ent

20%

Advanced Pulsing with Dual Source CT



Science

Virtual Histology with Dual Source CTIn Tübingen, Germany, the partnership between radiologists and cardiologists at the University Clinic at Schnarrenberg – aided by Siemens imaging technology – is making great strides in the identifi cation of vulnerable plaques.

By Hildegard Kaulen, PhD



Science

Every fourth heart attack comes com-pletely unexpected and cannot be ex-plained by classic risk factors such as hypertension, hyperlipidemia, smoking, diabetes mellitus or genetic factors. Usually, the cause is the rupture of a vulnerable plaque. The exact risk of some atherosclerotic plaques has, until now, been very unpredictable. A study with the Dual Source SOMATOM Definition CT, at the clinic of the University of Tübingen in Germany indicates that this situation could soon change.It’s not uncommon that a fruitful collab-oration stands at the beginning of an interesting new development. At Schnar-renberg, a hill that offers an unobstruct-

ed view over the surrounding country-side, radiologists working with Prof. Claus D. Claussen, MD, and cardiologists working with Prof. Meinrad P. Gawaz, MD, came together to perform an illumi-nating study. The goal was to use com-puted tomography to more accurately determine the extent and composition of atherosclerotic plaques. For this pur-pose, two procedures were compared: virtual histology using intravascular ultrasound (IVUS), and virtual histology using Dual Source CT. IVUS histology has been the gold stan-dard for characterizing atherosclerotic plaques for the past three years. Histolo-gy based on Dual Source CT is, in con-

trast, a new development. The assess-ment of plaque volume and composition rests upon Hounsfield Unit (HU)-based color mapping. With the comparison, the two responsible physicians, radiolo-gist Harald Brodoefel, MD, and cardiolo-gist Christof Burgstahler, MD, entered new territory and obtained some fasci-nating results. With plaque volume as-sessment, the methods delivered almost identical results. With the determination of plaque composition, there were dis-crepancies that have apparent causes. Visual assessment, which is typically in use, almost always resulted in an overes-timation of the plaque burden and an underestimation of vascular lumen.

Histology based on Dual Source CT is a new development.


Topic


Despite many advances in treatment, cardiovascular disease remains the number-one cause of death in western, industrialized nations. However, myocar-dial infarctions are often not the result of high levels of coronary stenosis, but rather stem from the rupture of a vulner-able plaque. Burgstahler says: “Stable lesions with high degrees of luminal constriction typically lead to exercise induced angina pectoris. Should the cor-onary vessel gradually be blocked, col-lateral vessels often arise, so that not every vascular blockage necessarily leads to an acute heart attack. In con-trast, when a vulner able plaque rup-tures, it usually results in an acute vas-cular blockage, and thus in a heart attack. The patient may have been com-pletely free of symptoms until this point. The identification of vulnerable plaques can therefore be an important parame-ter for risk stratification.” In order to estimate the threat of plaque rupture, one needs to know the plaque composition. The most dangerous are those with thin fibrous caps and large fatty cores, not the highly calcified plaques. Vascular calcification is simply a measure of the general vascular plaque burden. For a qualitative analy-sis, it is therefore necessary to be able to differentiate between fibrous tissue, lipids, calcification and necrotic tissues. This is where virtual histology comes into play. The team from Tübingen in-vestigated whether Dual Source CT and the Plaque Analysis Program of the latest syngo Circulation Package represented a reasonable alternative.With IVUS histology, the discrimination between different tissue types is not based on the conventional grey-scale image, but rather on the spectrum anal-ysis of radio frequency data. Every histo-logical class is assigned a color; thus there is one each for fibrous, necrotic, fatty-fibrous, and calcified material. The classification was previously validat-ed by comparison with autopsy material. The fact that Dual Source CT can be con-sidered for virtual histology has to do with its high level of spatial and tempo-ral resolution. In both disciplines, the SOMATOM Definition sets industry stan-

Science

“We can well determine plaque volumes using DSCT based virtual histology.”

Prof. Claus D. Claussen, MD, University of Tübingen, Department of Radiology, Tübingen, Germany



Science

Hildegard Kaulen, PhD, is a molecular biolo-gist. Following positions at Rockefeller Universi-ty in New York and Harvard Medical School in Boston, she has been writing as a freelance sci-ence journalist for prestigious newspapers and science magazines since the mid 1990s.

The study appears in: Brodoefel H, Reimann A, Heu-schmid M, Tsiflikas I, Kopp AF, Schroeder S, Claussen CD, Clouse ME, Burgstahler C. Characterization of coronary atherosclerosis by dual-source computed tomography and HU-based color mapping: a pilot study. Eur Radiol. 2008 Nov; 18(11):2466-74. Epub 2008 May 20.

dards with 83 ms temporal resolution to freeze any cardiac motion and 0.33 mm spatial resolution to visualize the coronar-ies and plaque in the vessel wall.” Since it records images within a tenth of a sec-ond, produces hardly any motion artifacts from partial-volume effects and has high-ly homogenous Hounsfield Units, it pos-sesses the technical prerequisites for virtual histology. “Until now, intravascular ultrasound has been the gold standard for assessing vascular lumen, vascular wall and plaque burden,” says Brodoefel. “Coronary an-giography only gives information about the degree of stenosis. As an invasive procedure, IVUS has clear disadvantages. Every invasive procedure brings with it the risk of complications, and in addition, it is labor and cost intensive. Moreover, it is not possible to bring the ultrasound probe into every coronary vessel; some are too small and others have too high a level of stenosis. With Dual Source CT, the entire vascular tree with lumen and walls is represented. One can consequently ob-serve the entire plaque situation. Finally, CT offers the opportunity to perform a more wide-ranging analysis than does intravascular ultrasound.”For Dual Source CT-based virtual histo-logy, Burgstahler and Brodoefel first

determined thresholds for the Hounsfield Unit based on IVUS data. For this, the doctors matched the determined color maps of some plaques with the spectrum analysis of the corresponding radio fre-quency data, and obtained the following thresholds: 10 to 69 HUs stand for the fatty compartment of an atherosclerotic plaque, 70 to 158 HUs for the fibrous compartment, 159 to 436 HUs for the vascular lumen, and 437+ for calcifica-tion. Additional plaques were subse-quently analyzed using both procedures and the results compared. Burgstahler notes: “We found a good correlation with volumes. The sizes of plaques can thus be equally well determined with both Dual Source CT and intravascular ultrasound. With plaque composition, however, there was only limited correspondence. A pos-sible reason is the lower spatial resolu-tion in relation to IVUS. Calcification also presents a problem, since it respectively leads to excessive overexposure with CT and loss of ultrasound waves due to in-terference when using IVUS. Dual Energy mode possibly brings some advantages for determining the plaque composition. We have not yet evaluated this mode on the coronary vessels.” The SOMATOM Definition can be used in Dual Source and Dual Energy mode. With Dual Source

mode, both tubes run with the same energy level. Dual Energy mode allows better differentiation of tissues by sub-tracting two different energy levels, but re sults in reduced temporal resolution.Noteworthy with this study was the high level of reproducibility of results. “The high inter-observer variability is a big prob lem with visually evaluating and manually segmenting atherosclerotic plaques,” explains Brodoefel. “In contrast, a HU-based plaque analysis eliminates many investigator-dependent steps. In our work, high inter-observer variability could not only be achieved for plaque volume but also for plaque composition. It remains questionable, however, how robust the results for possible serial CT investigations of the same plaques will be. Here the always-different contrast of the vascular lumens presents us with great challenges.”Prof. Claussen also attributes great signif-icance to the study. “We can well deter-mine plaque volumes using Dual Source CT based virtual histology,” he says. “The reproducibility is also high. For plaque composition analysis, we need improve-ments. In order to use virtual histology for screening or follow up controls, long-term studies are necessary anyway. They must demonstrate that there actually is a correlation between plaque composi-tions, determined using CT, and the risk of heart attack. We also need studies that show whether a specific intervention – such as statin therapy – changes plaque composition and thus positively influenc-es risk. Furthermore, the levels of radia-tion exposure are still too high for screen-ing or regular follow-up controls.”

SOMATOM Definition sets industry standards to visualize coronaries and plaque in the vessel wall.



Proactive Service for and by RadiologistsA system failure not only brings throughput to a stop but it’s, above all, a nightmare when interventions are in process. The Medical Director of the Diagnostic and Interventional Radiology Department at the Tübingen Uni-versity Hospital, Germany, Professor Claus D. Claussen, MD and various team members speak about the challenges of radiology and why proactive services such as the Siemens Guardian Program support clinical workfl ow.

By Katja Stöcker, Siemens Healthcare, Erlangen, Germany

A smooth workflow in CT is important for any hospital to realize optimized capacity utilization.



Life

Anja Reimann, MD, resident assistant physician, describes the rare but always possible event of a system failure as nerve-wracking: If, for example, the computed tomograph (CT) should go down during aspiration of an abscess, it could be unpleasant for the patient who might at that very moment have the guide canula in his or her body. If the system can be restarted quickly, there is only a small shift in the schedule. How-ever, in the event of a relatively long fail-ure, the patient must be called in again and the intervention must be repeated. She discusses some findings with Profes-sor Andreas Kopp, MD, senior physician. “A system failure would be difficult for us here in radiology also because we cannot use the time for other productive activities. Our colleagues on the wards, for example, could take the case history of another patient or discuss a surgical procedure,” says Professor Kopp.Today, purchasing decisions are no lon-ger made solely on the basis of product features. System availability and service are other important criteria that help decide the competitiveness of supplying companies. “We are under massive pressure to de liver competent diagnoses to our colleagues in the hospital or to the refer-ring physicians with ever-faster turn-around times,” says Medical Director, Professor Claussen, describing an essential challenge for radiology. To

realize optimized capacity utilization, appointments are scheduled tightly. A system failure would immediately dis-rupt the workflow in his department and would also have ramifications for the workflow of the University Hospital Tübingen (UKT – Universitätsklinikum Tübingen), as a whole. “Therefore, in the event of a malfunction, technical service must be prompt and competent,” continues Claussen. For the various Siemens systems, in-cluding the high-end, Dual Source CT scanner SOMATOM® Definition, and the SOMATOM Sensation 64 CT system in Professor Claussen’s department, Siemens supports the workflow with a broad pallet of proactive services. Virus Protection for example is a service that protects Siemens systems from viruses, worms and trojan horses. System-spe-cific usage and capacity-utilization data can be called up through the service Utilization Management. “It is important to recognize errors as early as possible – not only after the system shuts down,” says Claussen. The Siemens Guardian ProgramTM efficiently provides this pro-active service.

Prompt Remote Repair Saves TimeThrough the Siemens Remote Service (SRS) platform, the medical device reports deviations of important system parameters to the Siemens Service Cen-

ter. Siemens experts are not only able to call the customers proactively and alert them to an impending problem, but can often immediately solve it remotely. Andrea Ganter, a technical assistant in Diagnostic and Intervention-al Radiology, tells of one such proactive telephone call: “Due to this call, we knew that our CT would work only for approximately another two days.” This gave the team enough time to shift patient appointments and program the necessary time for repairs without an involved onsite fault search. “Thanks to Guardian, the CT scanner was available again after four hours of repair time,” reports Ganter. Another advantage of remote monitoring is that Siemens can determine in advance, via SRS, which spare parts are required, so that the Customer Service Engineer (CSE) can bring the proper replacement parts with him. A few doors away, Ayser Birinci-Aydogan, a radiological assistant, is monitoring the scan of a 58-year-old man using the high-end, SOMATOM Definition Dual Source CT scanner. On the screen in the control room, the coro-nary vessels can be clearly recognized. The man came to UKT due to his family predisposition for coronary disease. Throughout all clinical operations, Guardian works unobtrusively in the background: through the pro ac tive real-time monitoring of important system components such as X-ray tubes, detec-

“It is important to recognize errors as early as possible

and not only after the system has gone down.”

Professor Claus D. Claussen, MD, Medical Director, Diagnostic and Interventional Radiology,

University Hospital Tübingen, Germany



tor and image computer, system failures can often be avoided. “Our nightmare would be if our SOMATOM Definition were to go down in the core time of 10 a.m. to 2 p.m.,” says Birinci-Aydogan. Around 3 p.m. at the latest, the sur-geons need the images in order to plan their procedures for the following morn-ing. “For me, proactive service means predictability,” continues Birinci-Aydo-gan, as she glances away from the screen for a moment to clinic technician Jürgen Bahls, who hurries by. “Here in the hospital we have excellent techni-cians, and we are also very satisfied with

the Siemens service technicians and the remote support from the Siemens Service Center.” “So far, the Siemens service technicians have often gone the ‘extra mile’ for us – that is not something that one should take for granted,” Birinci-Aydogan reports. Often she already knows what to do as a result of her experience and involvement in the introduction of the SOMATOM Definition, but she also praises the knowledgeable contact per-sons at the other end of the telephone line and the possibility of remote support and repair. In the event of a

“Siemens service technicians have often gone the ‘extra mile’ for us.”

Ayser Birinci-Aydogan, Radiological Assistant,Diagnostic and Interventional Radiology, University Hospital Tübingen, Germany

difficult situation, a Siemens service technician quickly comes to UKT. “It is an advantage that the Siemens service organization is set up very well in the region and their technicians have a shorter distance to travel than other pro-viders,” confirms her colleague, techni-cal assistant Andrea Ganter. Based on the service agreement, the hospital’s own service technicians are not only trained by Siemens but also, for exam-ple, work together with Siemens service technicians in installing replacement parts. Thus, special technical knowledge is developed onsite, so a system can be restarted quickly in a serious situation.

Outstanding Remote Support and Onsite Service“Not only are we called back quickly by the UPTIME Service Center, but we also appreciate that the Siemens service technicians are committed and work competently,” says Ganter, who has worked at UTK for 13 years. “Due to the combination of proactive services and the onsite Siemens service technicians, planning reliability was greatly impro-ved,“ stresses Ganter. Predictability is not only crucial for smooth workflow in radi-ology, but also for all further steps in the treatment: “And that applies not only to emergencies such as a patient with a lung embolism in intensive care,” says the technical assistant. “Every shift in our schedule as a result of a system failure results in 15 people waiting at the door. And follow-up appointments in the outpatient clinic, for example, must be rescheduled.” Then surgery schedules and the ordering of anesthesiologists as well as further treatments must be delayed. “Service is critical for workflow in radi-ology, from admission of the patient all the way to dismissal,” Ayser Birinci-Aydogan also adds. “If that service per-formance is proactive and competent as is the case with Siemens, that is all better,” she emphasizes.



Life

“Thanks to Guardian, the CT scanner

was available again after only four

hours of repair time.”

Andrea Ganter, Technical Assistant.Diagnostic and Interventional Radiology,

University Hospital Tübingen, Germany

Monitoring of potential system malfunctions and possible devia-tions from predefined values.

Telephone call from Siemens UPTIME Service Center in the event of deviations.

Problems often eliminated ‘remotely’ through the Siemens Remote Service platform.

In the event of onsite deploy-ment, Siemens service techni-cians can bring the proper replacement part on the initial visit.

Reduction of unplanned system down time to a minimum.

Improved appointment sche-duling within and outside of the radiology department.

Proactive Real-time System Monitoring: Siemens Guardian Program

“Intelligent Handling” of Immense Quantities of Data

SOMATOM CT systems provide UKT radi-ologists with a large number of data sets with high definition images. Those im-ages support the radiologists with con-tinuously more precise and reliable diag-nostics, but in doing so, also supply large numbers of image data sets in order to facilitate more precise and reli-able diagnostics. Professor Claussen sees “intelligent handling” of immense quan-tities of data as another essential condi-tion of smooth workflow. During the past year, around 200,000 diagnostic examinations and more than 2,500 interventions were carried out in his department on CT and MR scanners as well as angiography systems. “On many days we generate close to 40 gigabytes of images,” says Horst Bock, who is responsible for the picture archiving and communication system (PACS) of the department. “Workflow must be inte-grated; it does not stop with the systems themselves or the PACS or the radiology information system. Above all, what counts today is medical know-how as well as workflow organization and opti-

mization in order to avoid long wait times and fast, competent diagnostics,“ summarizes Claussen. The professor sees radiology as a ‘service provider’ carrying out a service role. Innovative systems alone are by no means sufficient. In an increasingly in-tense and competitive environment, the development of a service culture is key – such as his team’s interaction with patients and colleagues in the hospital and also within the department. The medical director also expects excellent service from the medical technology providers and is not disappointed: „Here, we all appreciate the competent, preven-tive Siemens service.“

Further Information

www.siemens.com/guardian-program



Life

Customer Report: Upgrade from SOMATOM Plus 4 to SOMATOM Defi nition Delivers a new Picture of HealthIn 1998, the single-slice SOMATOM Plus 4 CT offered Saint Barnabas Ambula-tory Care Center the most advanced imaging possible. Over the years, the unit’s capabilities were far surpassed, limiting its usefulness. But it remained a valuable trade-in for a SOMATOM Defi nition Dual Source CT.

By Melanie J. Davis

“After we bought a second device, a SOMATOM® Sensation 16-slice scanner, the SOMATOM Plus 4 was simply taking up expensive floor space. When we had an opportunity to get even greater im-aging capabilities with the SOMATOM Definition, we used the Siemens Elevate program to upgrade affordably by trad-ing in the Plus 4. A third-party dealer wouldn’t have given us much for it, but we were very satisfied with the arrange-ments we made with Siemens,” says Barbara Richardson, Administrative Di-rector of the Radiology Department at

Saint Barnabas Ambulatory Care Center, Livingston, NJ.

A Smart Business DecisionThe upgrade to the SOMATOM Defini-tion Dual Source CT (DSCT) is part of the center’s efforts to provide state-of-the-art imaging solutions. She says, “We constantly ask, ‘What’s the most we can do for our physicians? For our patients? For our employees?’ Having the best equipment is one answer to those ques-tions. Dual Energy is emerging and we want to be part of the growth of that

technology. We can now offer physi-cians that ‘special extra’, so we have a competitive edge.”Saint Barnabas Ambulatory Care Center provides outpatient services for nearby Saint Barnabas Hospital and other refer-ring physicians, and is responsible for more than 90,000 imaging procedures a year.The decision to upgrade from the Plus 4 to the SOMATOM Definition was made after the staff extensively researched their options. They evaluated other ven-dors, and made the decision to lease the Siemens unit.“We’ve been with Siemens for a long time, and we have a great relationship with sales personnel and technicians. The SOMATOM Definition is not just a piece of equipment – it’s a great rela-tionship,” says Richardson.Maureen Lowe, CT Supervisor, says the center is extremely pleased with the outcome. “You go back and forth on the dollars to make the best choice that will give you the payback that you want, and we’re happy with what we’re see-ing. The Board of Directors is very excit-ed with what the unit can do, and they realize that in diagnostic imaging, the new technology makes a difference.”

“The SOMATOM Defini-tion is not just a piece of equipment – it’s a great relationship between Siemens and us.”

Barbara Richardson, Administrative Director of

the Radiology Department at Saint Barnabas

Ambulatory Care Center, Livingston, NJ



Life

Transition & Training

Installing the SOMATOM Definition was both inexpensive and easy, with the work limited to “spiffing up” the room and making some electrical upgrades. Staff training consisted of Lowe and a senior evening staff member making two visits to the Siemens training center in Cary, NC so they could return and, led by a Siemens Clinical Education Specialist who was on-site in New Jer-sey for two weeks, train their own staff.“Two weeks was a lot of time for the specialist to be available to us, and it was helpful. I think the transition was very easy for us also because we were familiar with Siemens units and the syngo platform,” says Lowe. “Post-processing is so much simpler now because the raw data quality is so high that you’re not doing as much reconstruct-ing. The amount of time we save in that aspect alone is impressive,” she adds.

New Clinical Applications Increase Patient CountSince the upgrade to the SOMATOM Definition, the center’s volume of proce-dures has steadily increased as word has spread among physicians about the system. Richardson says insurers’ reti-cence to approve multiple diagnostic CTs per patient will be offset by the in-creased type and quantity of procedures the center can conduct.The SOMATOM Definition’s speed ac-commodates many more patients dur-ing premium peak hours, and Siemens’ radiology information system made it easy to accommodate the increased pa-tient load.Thanks to the upgrade, Lowe also anticipates an increase in the number of bariatric patients being scanned be-cause the SOMATOM Definition’s large bore and increased power. Medical Director David Wilson, MD, adds: “Cardiology patients benefit be-cause the Definition scans so quickly, it captures the heart’s action without the need for beta-blockers. We’re less de-pendent on the patient’s heart rate to get high-quality images. Before, those patients would have been told they

couldn’t be scanned or had to go some-place else.”

Dual Energy ImpressesAs important as the cardiology applica-tions are with the SOMATOM Definition, Richardson says they were just a small part of the imaging center’s upgrade decision: “We bought it for the emerg-ing technology we expect to see from Dual Energy. Now we can expand into a lot of areas.”Relatively little time has passed since the system was installed, yet Dual Energy is being used on a regular basis. One of the most successful of those

protocols has been scanning kidney stones, which the imaging center does at least once each day.“We are excited about this application because we can quickly determine whether the patient should be treated with medication or other interventions,” says Wilson.

Wilson and his team all agree that the SOMATOM Definition has provided many benefits to Saint Barnabas Ambu-latory Care Center.

Melanie J. Davis, Medical Writer

The decision to upgrade to the SOMATOM Definition was made after the staff

extensively researched their options.



The latest enhancement for SOMATOM® Definition CT scanners is the new soft-ware version syngo CT 2008G. This new software will bring improved usability and the following new functionalities for the SOMATOM Definition. The high-lights range from new Dual Energy ap-plications to all new solutions for perfu-sion imaging and interventions:* The new syngo Dual Energy applications (Heart PBV, Brain Hemorrhage, Lung Vessels and Gout) will open new clinical fields.* With these applications, custom-ers can take advantage of our 90 day free trial licenses.

syngo CT 2008G – New Software Release for SOMATOM Defi nitionBy Marion Meusel, Business Unit CT,

Siemens Healthcare, Forchheim, Germany

In China, the healthcare system is devel-oping at a rapid rate alongside the eco-nomic growth. Innovative healthcare concepts are being implemented in all major cities of the country, therefore high-end CT systems are not a rarity any-more. At the same time, the scientific community strives for more international participation. Three years ago, Siemens

CT Research Collaborations in China: a True Win-Win Situation

By Reto Merges, CT Research Collaborations, Siemens Healthcare, Shanghai, China

A group of young researchers at the annual seminar on scientific writing.

Life

The new Adaptive 4D Spiral* scan mode allows for whole organ coverage in per-fusion CT as well as phase-resolved imag-ing up to 21 cm. Enabled by the volume projector, it applies a continuously re-peated bi-directional table movement, moving the patient smoothly in and out of the gantry over the desired scan range.Interventional procedures are supported by i-Fluoro.* Fluoroscopic scans can be acquired with low-dose techniques and displayed in real time. For fastest workflow during interventions, scan modes can be switched on the fly with a single click. Key features are configurable layout screens,

*Optional components that need to be purchased separately.

**Customers will be contacted by customer service.

founded a dedicated team to support CT research in China. To be able to cater to the diverse needs of our Chinese part-ners, the team today consists of two radi-ologists and two engineers. It is a typical win-win situation because Siemens gets a unique insight into the customers’ needs in China and the collab-oration partners gain direct access to the

technical knowledge, education and ad-vice that they need in order to raise the scientific capabilities of their institutes.The activities extend from supporting research projects aimed at international publications to workshops on hot topics in radiology and scientific writing. Re-search topics cover a broad field of inno-vative CT applications, from Cardiac Im-aging and CT Perfusion to Dual Energy CT. “The key is to help educate young re-searchers so that innovative healthcare delivery and research will go hand in hand in the future!” says Prof. Zheng Yu Jin, MD, Peking Union Medical College Hospital.

an all-new Interventional Toolbar* and HandCARETM* for i-Fluoro to avoid direct X-ray exposure of the surgeon’s or radi-ologist’s hand during the intervention.SOMATOM Definition systems running on syngo CT 2007C will automatically receive the new software syngo CT 2008G** accompanied with comprehen-sive training on-site and supporting training material via e-learning CD.



Life

At this year’s European Congress of Radi-ology (ECR) in Vienna, more than three hundred customers participated in the Hands-on Workshops organized by Siemens Healthcare. Clinical presenta-tions by leading experts were followed by demonstrations of clinical cases dur-ing which participants were guided through the processing tools available for the syngo MultiModality Workplace platform. Sitting at one of the sixteen worksta-tions, radiologists and technologists from over fifty countries had the oppor-tunity to discover the capabilities of thesyngo software.

Recording of Hands-on Workshops at ECR 2008By Heike Theessen, Business Unit CT, Siemens Healthcare, Forchheim, Germany

http://www.siemens.com/somatomeducate

CARE Dose4D™ and its real-time mA adjustment provide best image quality at the lowest possible dose. Every patient is different in terms of size, weight, and anatomy. Therefore CARE Dose4D was developed to provide fully automated, real-time, anatomy-based dose regula-tion. CARE Dose4D adapts the dose automatically to the specific anatomical characteristics of each individual patient to consistently deliver a user defined

New e-Learning for CARE Dose4DBy Claudia Lindner, Business Unit CT, Siemens Healthcare, Forchheim, Germany

and customizable noise level.But how does it work exactly? With the new CARE Dose4D e-learning, CT-users can easily learn how to utilize CARE Dose4D most efficiently. The web based version can be accessed or the CD ver-sion can be ordered via the link below.This is only one e-learning tool out of many others offered by Siemens Healthcare. As part of the SOMATOM® Educate program “Life“, users benefit

Michael Lell, MD, University Hospital of the Friedrich-Alexander-University Erlan-gen-Nuremberg who led the session on Neuro-CT, rates these workshops to be very important, because they also serve to train the user with knowledge beyond application training. More about the clinical value of Siemens Hands-on work-shops can be read under the link below.There you can also order the DVD with the recording of the ECR Hands-on work-shops.

http://www.siemens.com/somatomeducate

from Siemens’ clinical e-learning oppor-tunities – and experience the latest clinical results in the various fields of CT imaging.

81 mAs 210 mAs800 mA

20 mA



Free 90-Day Trial Licenses for Clinical ApplicationsBy Rami Kusama, Business Unit CT, Siemens Healthcare, Forchheim, Germany

Trial License: Adaptive 4D Spiral

Siemens’ unique Adaptive 4D Spiral moves beyond fixed detector limitations to provide full coverage of any organ in 4D. This overcomes the coverage limita-tion of a static detector design so the perfusion and dynamic coverage can be adapted to exactly the range needed. In stroke assessment, it provides the per-fusion information, not just for a limited section of the disease, but for the whole brain,* so the physician is assured of a reliable assessment of the type and ex-tent of cerebral perfusion disturbances. In addition, it allows tumor perfusion studies over the entire organ in both head and body,* enabling the radiolo-gist to assess the perfusion and vascular-ization of tumors. Additionally, the Adaptive 4D Spiral en-ables the visualization and evaluation of

complex vascular structures by perform-ing time-resolved angiographies with multiple phases. With this feature, for example, arterial and venous phases can be captured in a single acquisition and can then be evaluated time-resolved. The benefits of the Adaptive 4D Spiral can be experienced with a 90-day free trial. **

Trial License: Intervention Pro & Adaptive 3D InterventionFor 90 days, at no cost, “Intervention Pro” can be tried, supporting guidance for interventional procedures with maxi-mal flexibility and with minimal, single-click effort. In addition, spiral sequence and fluoroscopic scan modes can be switched on the fly during interventions. A dedicated interventional toolbar sup-ports the workflow with respect to table control and 2D/3D measurements. The additional option, Adaptive 3D Interven-

1 2 Adaptive 4D Spiral provides perfusion information not just for a limited section of the disease, but for the whole brain (Figs. 1A–C).”Intervention Pro” supports spiral and sequential acquisition for interventional procedures with maximal flexibility (Fig. 2).

tion, further overcomes the limitations of conventional 2D-CT guidance, allow-ing for 3D visualization (MPR, VRT) and needle path planning.*** Thus, a more comprehensive visualization of needle position, needle path, and surrounding organs supports in difficult procedures. This is especially helpful when using oblique needle paths, for example, during RF ablation. Intervention Pro and Adaptive 3D Inter-vention can be tested risk free with a 90-day free trial.**

* Maximum perfusion coverage depends on system configuration.**Minimum system requirements need to be fulfilled for these options to be available. There-fore the related Siemens representative should be asked to check the system configuration.***Dual Monitor for in-room support highly recommended.

1B

1A 2

1C



Life

Q: How can I reduce my reading time in syngo Oncology?A: By using the powerful CAD tool in syngo Oncology after an automated detection of lung lesions, for example, several markers are listed which need to be reviewed.All the marked structures are numbered and listed in the Marker List. It is also possible to have several lesions from previous examinations or lesions

Frequently Asked Questions

that are marked by the user him/herself.To save time, the space bar can easily be used to jump from one marker to the next (or the button “B” can be used to go back to the previous marker). After starting with marker number one, for instance, you only have to press the space bar to go straight to marker number two (Fig.1).Q: Can I change the default display for the Global Result Segment?A: Depending on your preference, it is

possible to convert the default display in the Global Result Segment from the VRT image to a MPR image.Under Options -> Configuration, you will find the “syngo CT Oncology” icon. Dou-ble click to open the configuration menu. On the second subtask card, you can select 2D for “Default Representation”. Then press “OK”. The next time when you open the syngo Oncology application the changes are applied (Figs. 2-3).

Clinical CT PostersThanks to the excellent cooperation with our clinical partners, we now have a growing number of posters in the Clini-cal Poster Gallery.Perfect for the patient waiting room, the staff lounge or the reading room, these posters illustrate the wide range of im-ages that are possible from a CT exami-

nation. They will help to educate staff and patients about the human anatomy as seen through a CT scanner. Key anat-omy is clearly labeled, typical pathologi-cal findings are described and key fea-tures of the application are noted. To date we have the following posters available: www.siemens.com/ct-poster

1 2 3 In the result view, the markers can easily be found to review tissue lesions (Fig. 1). In the configuration menu, the default display can easily be changed for the Global Result Segment (Figs. 2-3).

CT Cardiac Anatomy CT Neuro Anatomy CT Colonography

Using the link, below a personal copy free of charge can be ordered.

1 32



Life

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

In addition, you can always fi nd the latest CT courses offered by Siemens Medical Solutions at www.siemens.com/SOMATOMEducate

Workshop Title Dates Location Course Course language director

Clinical Workshop on Cardiac CT 21.–23.01.09 Erlangen/Germany English Prof. Stephan Achenbach, MD

Clinical Workshop on Cardiac CT 15.–16.05.09 Paris/France English Jean-Francois Paul, MD 11.–12.09.09

Clinical Workshop on Cardiac CT 04.–06.02.09 Munich/Germany English PD Christoph Becker, MD 08.–10.07.09 Alexander Becker, MD 09.–11.11.09

Clinical Coronary CTA 12.–13.03.09 Erlangen/Germany English Prof. Stephan Achenbach, MDInterpretation Course 14.–15.05.09

Clinical Training Course 21.–22.03.09 Kuching/Malaysia English Prof. Sim Kui Hianon Cardiac CT 25.–26.07.09 Ong Tiong Kiam, MD 21.–22.11.09

Hands-on Workshop Cardio-CT 03.–04.07.09 Zürich/Schweiz German PD Hatem Alkadhi, MD

Clinical Workshop on 27.–30.04.09 Münster/Germany English PD Johannes Wessling, MDState-of-the-Art Applications 21.–24.09.09

Virtual CT-Colonography 27.–28.03.09 Berlin/Germany German Prof. Bernd Lünstedt, MD 25.–26.09.09 20.–21.11.09

Dual Energy Workshop 20.–21.02.09 Forchheim/Germany English Thorsten Johnson, MD 17.–18.04.09

Cardiac-CT Basics for Technologists 19.–20.03.09 Forchheim/Germany German Heike Theessen 06.–07.04.09 English

Clinical Coronary CTA Workshop 05.-06.04.09 Munich/Germany English PD Christoph Becker, MD 21.-22.06.09 Alexander Becker, MD

ESGAR CT-Colonography 02.–04.02.09 Harrogate/ English David Burling, MD Workshop United Kingdom Clive Kay, MD Stuart Taylor, MD

ESGAR CT-Colonography Workshop 17.–19.09.09 Stresa/Italy English Daniele Regge, MD

Clinical Workshop on Cardiac CT, CMIV 22.–24.04.09 Linköping/Sweden Swedish Anders Persson, MD

Clinical CT Colonography Workshop, CMIV 18.–20.03.09 Linköping/Sweden Swedish Ulf Björnlert, MD

Clinical PET/CT Basic Course 04.–06.11.09 KS Stockholm/Sweden Swedish

Clinical Radiology Optimization 13.–15.05.09 Norrköping/Sweden Swedish Pia Björk/ Elisabeth Olsson Course, Norrköping

Clinical Workshop Advanced 23.–26.09.09 Linköping/Sweden Swedish Petter Quick/ Peter HolmqvistCT Application, CMIV

Workshop SOMATOM Definition 18.–20.02.09 Stockholm/Sweden Swedish Lars Karlssonfor Hospital Physicist



Life

Upcoming Events & Congresses

The annual Lennart Nilsson Award this year goes to Professor Anders Persson, MD (Linköping University). The Swedish radiologist is honoured for his innova-tive 3D images depicting the human body internally. Using CT technology, he has provided new possibilities in forensic pathology.

The commendation is considered to be the world’s most prestigious award in scientific and medical photography.Read more about Persson’s methodology in the SOMATOM Sessions Magazine 22.

Scientifi c Photography Prize for Anders Persson


Title Location Short Description Date Contact

Moscow Moscow, International Dec. 08 –12, 2008 www.zdravo-expo.ru/enHealthcare Russia Exhibition

Arab Health Dubai, Exhibition and Jan. 26 –29, 2009 www.arabhealthonline.com UAE Scientific Congress

25th Annual Orlando, CME Course Feb. 12 –15, 2009 www.hopkinscme.eduComputed USA Tomography 2009: The Cutting Edge

ECR Vienna, Exhibition and March 06 –10, 2009 www.ecr.org Austria Scientific Congress

ACC Orlando, Exhibition and March 29 –31, 2009 www.acc09.acc.org USA Scientific Congress

GEST Paris, France Global Embolization April 15 –18, 2009 www.gest09.eu Symposium and Technologies

ITEM Yokohama, Internat. Tech. April 16 –19, 2009 www.j-rc.org Japan Exhib. of Med. Imaging

Deutsche Mannheim, 75th Annual Meeting April 16 –18, 2009 www.dgk.orgGesellschaft für Germany Kardiologie

ICNC Barcelona, Nuclear Cardiology May 10 –13, 2009 www.icnc9.org Spain and Cardiac CT

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

DRK Berlin, National Scientific May 20 –23, 2009 www.roentgenkongress.de Germany Congress

2nd World Congress Valencia, Scientific Congress May 30 –June 02, 2009 www.2wcti.orgof Thorac. Imag. and SpainDiagn. in Chest Disease(WCTI)

In addition, you can always fi nd the latest CT courses offered by Siemens Medical Solutions at www.siemens.com/SOMATOMEducate



Subscription

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.

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

Medical SolutionsInnovation and trends in healthcare. The magazine, published three times a year, is designed especially for members of the hospital management, administration per-sonnel, and heads of medical departments.

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’s. 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.

NewsOur latest topics such as product news, reference stories, reports, and general interest topics are always available at www.siemens.com/healthcare-news




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

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

B. Beyer, MD, Department of Surgery, University of Munich, Campus Großhadern, Munich, Germany

J. Fielding, Department of Radiology, Angliss Hospital, Upper Ferntree Gully, Melbourne VIC, Australia

R. Finzel, Department of Neuroradiology, Univer-sity of Göttingen, Göttingen, Germany

M. Godoy, MD, Department of Radiology, New York University Medical Center, New York, USA

J. Hausleiter, MD, Department of Radiology and Nuclear Medicine, German Heart Center, Mu-nich, Germany

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 au-tomated 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 applica-tion as well as results and experience gained with corresponding systems and so-lutions. It introduces from case to case new principles and procedures and dis-cusses 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 remind-ed 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.

E. Hendrich, MD, Department of Radiology and Nuclear Medicine, German Heart Center, Munich, Germany

M. Higashi, MD, Department of Radiology and Nuclear Medicine, National Cardiovascular Cen-ter, Osaka, Japan

R. Hoffmann, MD, Department of Clinical Radiol-ogy, University of Munich, Campus Großhadern, Munich, Germany

T. Jakobs, MD, Department of Clinical Radiology, University of Munich, Campus Großhadern, Mu-nich, Germany

S. Kanzaki, MD, Department of Radiology and Nuclear Medicine, National Cardiovascular Cen-ter, Osaka, Japan

K. Kichikawa, MD, PhD, Department of Radiolo-gy, Nara Medical University, Nara, Japan

S. Kitano, MD, Department of Radiology, Nara Medical University, Nara, Japan

A. Kohli, MD, Department of Radiology, Breach Candy Hospital Trust, Mumbai, India

T. Löffler, MD, Department of Surgery, University of Munich, Campus Großhadern, Munich, Germany

S. Martinoff, MD, Department of Radiology and Nuclear Medicine, German Heart Center, Mu-nich, Germany

N. Marugami, MD, Department of Radiology, Nara Medical University, Nara, Japan

A. Megibow, MD, MPH, FACR, New York University Medical School, New York, USA

D. Naidich, MD, Department of Radiology, New York University Medical Center, New York, USA

H. Naito, MD, PhD, Department of Radiology and Nuclear Medicine, National Cardiovascular Cen-ter, Osaka, Japan

K. Nikolaou, MD, Department of Clinical Radiolo-gy, University of Munich, Campus Großhadern, Munich, Germany

M. Reiser, MD, Department of Clinical Radiology, University of Munich, Campus Großhadern, Mu-nich, Germany

J. Remy, MD, University of Center Lille, Depart-ment of Thoracic Imaging, Hospital Calmette, Lille, France

M. Remy-Jardin, MD, PhD, University Center of Lille, Department of Thoracic Imaging, Hospital Calmette, Lille, France

P. Schramm, MD, Department of Neuroradiology, University of Göttingen, Göttingen, Germany

W. Sommer, MD, Department of Clinical Radiolo-gy, University of Munich, Campus Großhadern, Munich, Germany

T. Taoka, MD, PhD, Department of Radiology, Nara Medical University, Nara, Japan

Catherine Carrington, freelance authorMelanie J. Davis, medical writerTony DeLisa, freelance authorSameh Fahmey, medical and scientific journalistHildegard Kaulen, PhD, freelance scientific journalistOliver Klaffke, freelance scientific journalistTim Schröder, freelance scientific journalist Rita Wellens, PhD, medical writer and clinical research consultant

Photo Credits: Peter Rigaud/Shotview, Jez Coul-son, Tina Ruisinger, Stephan Sahm, Chris De Bode

Peter Aulbach; Steven Bell; Andreas Blaha; Joachim Buck, PhD; Jan Chudzik; Ulrike Dräger-Klar; Ivo Driesser; Carolin Emmert; Inga Fötsch; Tanja Gassert; Christoph Hachmöller, MD; Carolin Knecht; Rami Kusama; Claudia Lindner; Reto Merges; Marion Meusel; Kerstin Putzer; Rainer Raupach, PhD; Holger Reinsberger; Peter Seitz; Katja Stöcker; Heike Theessen; Stefan Wünsch, PhD; Claudette Yasell; all Siemens Healthcare

Production: Norbert Moser, Siemens AG, Healthcare

Layout: independent Medien-DesignWidenmayerstrasse 16, 80538 Munich

Printers: Farbendruck Hofmann, Gewerbestraße 5, 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 responsi-bility for the diagnosis and treatment of patients, including drugs and doses pre-scribed 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, provid-ed the customary bibliographical data such as author’s name and title of the contri-bution 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 consent 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 SOMA-TOM Sessions. Manuscripts as well as suggestions, proposals and information are always welcome; they are carefully examined and submitted to the editorial 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© 2008 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

“Lowest radiation dose is important to physicians and patients. It’s important to us.”Sami Atiya, PhD, Chief Executive Officer, Business Unit CT, Siemens Healthcare, Forchheim, Germany


The Difference in Computed Tomography

SOMATOM Sessions

Cover Story SOMATOM Defi nition Flash Dual Source CT:Leaving Dose BehindPage 6

News Dual Source CT on Scientifi c Center StagePage 14

Business As Radiation Dose Goes Down, Attractiveness of CT RisesPage 20

Clinical Outcomes Coronary CTA with Flash Spiral Scanning in 300 msec Scan TimePage 26

Science CT put to the TestPage 56

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Through a combi-nation of unprece-dented speed and innovative dose-reduction features, the new SOMATOM Defi nition Flash offers patients a healthier CT scan.

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Issue Number 23/November 2008RSNA Edition | November 30th – December 05th, 2008

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.


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Local Contact Information

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

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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

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SoMaTom Sessions Computed Tomography November 2008

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