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Answers for life in Computed Tomography

Issue Number 27/ November 2010


RSNA-Edition / November 28th December 03rd, 2010

Cover Story
Be FAST, take CARE
Page 6

Iterative Reconstruction
Reloaded
Page 14

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SOMATOM Sessions

News

Business
syngo.via: Ready for
Prime Time in Clinical
Practice
Page 34
RSNA-Edition

Global Siemens Headquarters

Clinical
Results
SOMATOM Denition
Flash: Rule-Out of Coronary Artery Disease,
Aortic Dissection and
Cerebrovascular Diseases
in a Single Scan
Page 60

Science
Dose Parameters
and Advanced Dose
Management on
SOMATOM Scanners
Page 68

27

Editorial

Imprint

SOMATOM Sessions IMPRINT


2010 by Siemens AG,
Berlin and Munich
All Rights Reserved
Publisher:
Siemens AG
Healthcare Sector
Business Unit Computed Tomography
Siemensstrae 1, 91301 Forchheim,
Germany

With FAST CARE we address


todays challenges of our
customers, accelerate CT
workows and reduce patient
exposure even further.
Sami Atiya, PhD, Chief Executive Office,
Business Unit Computed Tomography, Siemens Healthcare, Forchheim, Germany

Chief Editors:
Monika Demuth, PhD
(monika.demuth@siemens.com)
Stefan Ulzheimer, PhD
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Clinical Editor:
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of Radiology, Ludwig-MaximiliansUniversity, Munich, Germany
Philipp Glitz, MD, Department of
Neuroradiology, University of ErlangenNuremberg, Erlangen, Germany

Project Management: Sandra Kolb


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Editorial

Andr Hartung,
Vice President
Marketing and Sales
Business Unit CT,
Siemens Healthcare

Dear Reader,
Recent improvements in healthcare have
created a serious backlog of patients at
many medical facilities, creating a contradictory situation: the medical care is
better but it has become more difficult
to be treated as medical facilities stagger
under an ever-increasing workload.
Adding to the contradictory matrix is a
medically well-informed public concerned with radiation exposure. An efficient, faster throughput of patients while
maintaining quality care has become
the critical issue in modern health care.
The creative and innovative products
developed by Siemens to deal with this
situation are truly amazing. The revolutionary, single-source SOMATOM
Definition AS (and AS+) scanner that
reduces many scans to a one click operation at extremely low dose. The
second noteworthy is the unique
SOMATOM Definition Flash scanner that
scans an entire thorax in less than one
second with sub-mSv dose and can
freeze even the fastest beating heart,
producing diagnostic quality cardiology
images in minutes.
We then introduced the syngo.via*,
multi-modality imaging software. With
syngo.via*, the reading physician can
observe and analyze CT, MR, PET,
Radiography, Fluroscopy and Angiography simultaneously on a single
monitor eliminating many trips from
the regular reading workplace to various
workstations. Another great advantage
of syngo.via* is the pre-processing

system. When a case is opened, many


pre-processing tasks such as table removal, bone removal, curved planar reformatting, naming of vessels, ejection
fraction calculations and orthogonal cuts
are already done. The reading physician
can start the interpretation and diagnosis
immediately.
The challenge now became combining
these (and many other) systems to relieve pressure on hospitals and clinics by
increasing throughput while maintaining
quality medical care. This goal resulted in
the introduction of our new FAST CARE
platform at the recent RSNA convention
in Chicago. When it comes to the FAST
CARE platform, incorporating Fully
Assisting Scanner Technology (FAST) and
Combined Applications to Reduce Exposure (CARE), the name says it all.
This new platform for the SOMATOM
Definition family, guides the user through
a CT scan in just a few intuitive steps,
starting with planning, through the actual scanning process, to reconstruction
and evaluation of clinical images. In this
way, FAST prioritizes considerations of
efficiency and focuses on patient-centric
productivity.
The CARE standard combines a variety of
Siemens innovations, like CARE kV, CARE
Child or the next generation of Iterative
Reconstruction, SAFIRE** that we have
introduced at this years RSNA.
Using these powerful tools enables you
to quickly examine your most challenging

patients including trauma or young


children from head to toe without
having to repeat the scan. In addition you
now have the possibility to reduce dose
even further.
Additionally, in keeping with our traditional cooperation with out-of-house
experts, radiologists and others who
are confronted daily with challenges
in their daily scanning practice we have
launched the Siemens Radiation Reduction Alliance (SIERRA). This panel of
highly respected experts in the medical
imaging field will track and provide
valuable feedback and make recommendations on dose-related subjects to
Siemens, information that will mean
even healthier examinations for your
patients. Our ultimate goal with this
prestigious group is to reduce dose
exposure in CT to a level below 2.4 mSv,
the annual natural level of radiation
always present in our environement.
More complete information and valuable
links on all these new and exciting developments can be found in the pages of
this SOMATOM Sessions issue. And
invisibly embedded in every page is a
factor that is not new here at Siemens
better health care for all patients.
We wish you enjoyable and profitable
reading.
Sincerely,

Andr Hartung

** syngo.via can be used as a standalone device or together with a variety of syngo.via based software options, which are medical devices in their own rights.
** The information about this product is being provided for planning purposes. The product is pending 510 (k) review, and is not yet commercially available in the U.S.

Content

Contents
Cover Story

20

Be FAST, Take CARE

A Pediatric Breakthrough

Cover Story
6 Be FAST, Take CARE

News

6 Technology should serve


the physician, not vice
versa. The true task of the
doctor is caring for the
patient, not handling
apparatus. Therefore,
FAST CARE is set to raise
the standard for patientcentric productivity and
introduces innovations for
patient dose reduction.
The result: safe, reproducible examinations that
involve less exposure and
are therefore more
effective and efficient.

12 CEO Corner: Excellence in Clinical


Practice
12 Working with syngo.via an
In-Practice Report
14 Iterative Reconstruction Reloaded
16 Flash Spiral Dual Source CT for
Precise and Patient-Friendly
Transcatheter
Aortic Valve Implantation (TAVI)
Procedure Planning.
18 Siemens Launches SIERRA, the
Siemens Radiation Reduction
Alliance
19 Siemens CT Stroke Management:
Helping to Save Brain and Quality
of Life
20 A Pediatric Breakthrough: Automated Adaptation of CT Dose Levels
22 Expanding Radiodiagnostics:
University Hospital Hradec Krlov,
Czech Republic
24 Full Cardiac Assessment with
syngo.via Maximal Significance,
Minimal Dose

4 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

26 Advanced Imaging for Four-Legged


Patients
27 SOMATOM Definition AS Open
Dedicated High-end CT for Radiation
Therapy Planning
27 Among Europes Best
28 SOMATOM Scanners: Ahead of the
Innovative Curve

Business
30 1,000th SOMATOM Definition AS
Installed A Success Story
32 Time is Brain A Comprehensive
Stroke Program at the University
of Utah Considerably Improves
Patients Outcome
34 syngo.via: Ready for Prime Time in
Clinical Practice
36 SOMATOM Spirit: A Choice That
Paid Off

All articles mentioned on the cover are


designated in orange.

Content

32

60

Time is Brain

SOMATOM Definition Flash:


Rule-Out of Coronary Artery Disease

Clinical Results
Cardio-Vascular
38 SOMATOM Definition Flash Ruling
out Coronary Artery Disease with
0.69 mSv
40 SOMATOM Definition Flash:
Low-Dose Abdomen Pediatric Scan:
Follow-Up Study of Fibromuscular
Dysplasia
42 CT Dynamic Myocardial Stress
Perfusion Imaging Correlation
with SPECT
Oncology
44 SOMATOM Definition Flash: Motionfree Thoracic Infant Scan: Follow-Up
Study After Chemotherapy
46 SOMATOM Definition Flash:
Dual Energy Carotid Angiography
for Rapid Visualization of
Paraganglioma
48 Total Occlusion of the Left Superior
Pulmonary Vein by a Metastasis
Detected with Dual Energy CT
50 SOMATOM Spirit: Follow-Up Examination of Cerebral Meningioma
Neurology
52 SOMATOM Definition Flash: Improving Image Quality of Brain Scans
With IRIS, X-CARE and Neuro
BestContrast

Science
54 Volume Perfusion CT Neuro as a Reliable Tool for Analysis of Ischemic
Stroke Within Posterior Circulation
Acute Care
56 Dual Source, Dual Energy CT:
Improvement of Lung Perfusion
Within 5 Hours in a Patient With
Acute Pulmonary Embolism
58 Differentiation of Pulmonary Emboli
and Their Effect on Lung Perfusion
Determined With a Low-Dose Dual
Energy Scan
60 SOMATOM Definition Flash: Rule-Out
of Coronary Artery Disease, Aortic
Dissection and Cerebrovascular
Diseases in a Single Scan
62 SOMATOM Definition Flash: RIPIT to
the Rescue Fast CT Examination
for Trauma Patients
Pulmonology
64 Xenon Ventilation CT Scan Demonstrates an Increase in Regional
Ventilation After Bullectomy in a
COPD Patient

68 Dose Parameters and Advanced


Dose Management on SOMATOM
Scanners
72 IRIS and Flash: Cardio CT with
Minimum Radiation Exposure
Delivers Precise Images

Life
74 Clinical Fellowship: Learning From
the Experts in the Field
76 STAR: Specialized Training in
Advances in Radiology
76 Evolve Update Facilitates Dose
Savings
77 Frequently Asked Questions
77 Siemens Healthcare is Proud to
Present a New Series of Live Clinical
Webinars
78 News at Educate Homepage:
Recommended CT Literature
78 Clinical Workshops 2011
79 Upcoming Events & Congresses
80 Corporate Magazines
81 Imprint

Orthopedics
66 SOMATOM Definition: Dual Energy
Locates Progressive Wrist Arthritis

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

Coverstory

Be FAST, Take CARE


FAST CARE reduces the complexity of
CT scans to just a few clicks and facilitates
even more reduction of dosage.
Technology should serve the physician, not vice versa. The true task of the
doctor is caring for the patient, not handling apparatus. Therefore, FAST
CARE is set to raise the standard for patient-centric productivity and introduces
several innovations for patient dose reduction. The result: safe, reproducible
examinations that involve less exposure and are therefore more effective and
efcient. Dr. Michael Lell shared his observations and expectations with us.
By Hildegard Kaulen, PhD

The new generation of the FAST CARE software will be availabe for all SOMATOM Definition scanners spring 2011.

Coverstory

The medical profession is changing.


As patient numbers increase, budgets
are ever-decreasing. At the same time,
patients seek the assurance and the
advice of the physician. In the University
Clinic at Erlangen, Germany, too, the
numbers of examinations have been
skyrocketing, while the residence time
at the clinic has been going down. Less
and less resources for diagnostics are
available. Associate Professor Dr. med.
Michael Lell, Senior Physician at the Institute of Radiology, feels the pinch, especially when it comes to staff. This is why
he is particularly appreciative of software solutions that not only leave him
more time for his obligations as a doctor
and researcher, but also optimizes the
utilization of staff. When it comes to
Siemens new FAST CARE technology,
incorporating Fully Assisting Scanner
Technologies (FAST) and Combined
Applications to Reduce Exposure (CARE),
the name says it all. The new platform
for the SOMATOM Definition product
family guides the user through a CT scan
in just a few intuitive steps, starting with
planning, through the actual scanning
process, to reconstruction and evaluation of clinical images. In this way, FAST
prioritizes considerations of efficiency
and focuses on patient-centered productivity. Standardization ensures that all
examinations follow the same pattern,
avoiding errors and uncertainty. So,
scans that erroneously fail to depict
parts of the target organ can be avoided
in the future. At the same time, FAST
CARE also offers the user new solutions
for reducing the applied radiation dose
and supports the consistent use of
already available solutions. The entire CT
scan thus not only becomes more intuitive and reproducible, but also safer for
the patients.

Reducing users workloads


FAST Planning, one of the new functionalities of FAST CARE, provides suggestions for the scan and reconstructions
that are appropriate for the selected
mode based on the characteristics of the
organ, including the length of the examination volume. Thus, for example, in
the case of a cranial CT, the isocenter is

A program that
guides users intuitively through
the entire CT scan
makes the task
simpler, safer,
more reproducible and more
efcient.
Michael Lell, MD, PD, Departement
of Radiology, University of
Erlangen-Nuremberg, Erlangen,
Germany

automatically adapted to the position of


the skull. CT scans are complex procedures and operating the equipment is
demanding, even with standardized protocols. Lell agrees: there will always be
situations where the standard protocol
must be adapted to the stature of the
patient or the problem being investigated. Also, the technical staff operates
not just one, but many modalities. The
constant back and forth between individual applications makes high demands
of staff members expertise and concentration. A program that guides users
intuitively through the entire CT scan
makes the task simpler, safer, more reproducible and more efficient. In view of
the fact that well-trained staff is increasingly difficult to find, Lell continues,
this is an important aspect. He has
high expectations for the automatic coupling of the contrast agent injection
with the scanning protocol, which will
be offered as a special add-on feature
for the standard package under the designation CARE Contrast III. Currently,
two staff members work on examinations involving contrast agents, says
Lell. One of them injects the contrast
agent, while the other prepares the scan
. If the injection and the scan are linked,

we can do the same work with one less


staff member. Since we have less and
less staff available due to cost reasons,
that would be a major economization.
If the selected scan parameters create
conflicts, FAST CARE resolves them
through a single click on the FAST Adjust
button. On occasion, Dr. Lell explains,
a selected scan protocol could combine
different parameters in such a manner,
that scanner will prevent the scan
in order to avoid a faulty result. Currently,
University of Erlangen-Nuremberg,
Erlangen, Germany.

Coverstory

If the new algorithm


is faster and offers
better image quality,
it is ready for routine
application.
Michael Lell, MD, PD, Departement of Radiology,
University of Erlangen- Nuremberg, Erlangen, Germany

such situations have to be resolved manually, which costs time. With FAST CARE,
the FAST Adjust function suggests the
ideal solution. But the focus is also on
faster diagnostics. This is where the
strengths of syngo.via,* Siemens new,
leading-edge imaging software, come
into effect. The software automatically
loads the images into the appropriate
application and segments them in such
a way that they can be adjudged without further ado. The physician can arrive
at a final diagnosis with just a few clicks
of the mouse as the images have already
been pre-processed for him. The application is determined by the disease-specific
criteria of the case at hand and no longer
needs to be independently selected.
Since syngo.via handles all preparatory
steps, the physician can focus completely on his actual task, namely diagnostics. This, too, saves time and
enhances diagnostic reliability.

Improved image reconstruction


FAST CARE also introduces SAFIRE,**
Siemens first raw-data-based iterative
reconstruction. This technique removes
noise and artifacts in iterative steps in
the image and raw data domain, without compromising image sharpness. The
procedure can be used in two different

ways. Either the image quality of the


standard reconstruction is maintained,
and the dose can be reduced, or the dose
level is maintained and clinical images
of noticeably higher quality are generated. Until now, however, calculation of
the projection data required significantly
more time than the standard reconstruction. For FAST CARE, the image space
algorithm was enhanced and a new
reconstruction computer was specially
developed for this purpose. This now
also allows use of raw data in the reconstruction process to further enhance
image quality and reduce dose. In this
way, users can take advantage of the
potential for dose reduction in a noticeably greater number of examinations
during routine clinical application, significantly reducing the average dose. (For
further information, see the article Iterative Reconstruction Reloaded on page
14 in this issue.) Using the potential of
SAFIRE, 72% of all Siemens standard protocols apply dose of below the average
annual natural background radiation of
2.4 mSv.***
Michael Lell has performed clinical
studies with the previous version of the
software. He describes the results: For
research purposes, we always perform
both the standard reconstruction and the

iterative reconstruction. With the previous algorithm, iterative reconstruction


takes about four to five times longer than
standard reconstruction. Here, I expect
a clear improvement with the new algorithm. With the previous algorithm an
abdominal CT can be performed using
half the dosage without compromising
image quality. Our work on thoracic CT
has not yet been concluded, but the
potential for dosage reduction is expected to be of a similar order of magnitude. These are considerable reductions
of dose that should be used. If the new
algorithm is faster and offers better
image quality, it is ready for routine
application.

Optimal scan parameters


for everyone
When it comes to the sensitive issue
of radiation exposure, Siemens follows
the ALARA principle: As Low As Reasonably Achievable. FAST CARE comes
with CARE kV, an expansion of CARE
Dose4D, which modulates the tube current according to the patients anatomy.
In addition, CARE kV now automatically
identifies the optimal tube voltage and
adapts the tube current accordingly.
This change is useful, for instance,
when contrast agents are used. Because

*** syngo.via can be used as a standalone device or together with a variety of syngo.via based software options, which are medical devices in their own rights.
*** SAFIRE: The information about this product is being provided for planning purposes. The product is pending 510 (k) review, and is not yet commercially available in the U.S.
*** Data on le.

the higher iodine contrast more than


makes up for the higher absorption of
iodine, a lower tube voltage can be
applied. In this case, however, the mAs
value should be adapted. This requires
quite a bit of familiarity with the technology. Many users are not confident
enough to make that adaptation and
therefore do not exploit the potential to
be gained from changing the tube voltage. CARE kV takes this insecurity out by
preparing the appropriate kV and mAs
value, thus taking the burden off the
user. Also, CARE Dashboard can be used
to display which dose-reducing measures are available for the scan regions
selected in the scanning protocol and
whether these have been activated. Lell
explains: We have a legal and moral
obligation to protect patients from
unnecessary radiation. The Medical Service, tasked with providing the radiation
protection of supervisors and physicians
involved with suggestions for improving
radiation protection, reducing radiation
exposure and enhancing image quality,
routinely checks whether we adhere to
this obligation. CARE kV and CARE Dashboard give us further support in this
area. Many users, however, do not use
the available solutions consistently
enough. Automation is useful, but we
also need better training. The various
options for dose reduction must be chosen suitably. For instance, Lell has
found that caution is required when
using specific solutions on children.
Therefore, new parameter sets were
developed for CARE Dose4D that take
into account the specific anatomy of the
child. Also, the STRATON tube
was developed further so that in case
of pediatric scans, the voltage can be
reduced to 70 kV.
The issue of dose cannot be discussed
independently of the diagnostic evaluation when it comes to CT. A clear decision is always required as to when the
clinical necessity of a CT examination is
greater than the potential risks of radiation exposure. Lell believes dose can
also be reduced by ensuring that the
selected examination area is defined as
narrowly as possible, which FAST CARE
does automatically. Furthermore, the

1 Manually setting the scan range too


short in the topogram can cut off relevant
parts of the examined organ.

2 Manually setting the scan range too


long in the topogram could potentially
over-radiate the patient

3 FAST Planning uses the defined anatomical landmarks to set the correct ranges. When
applied manually without FAST CARE, only based on the coronal view the lower part of the
lung could be easily be missed (indicated by the reference line).

4 Direct setting of the scan range in with FAST Planning assures covering the entire
organ without overscanning

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

Coverstory

5 FAST Cardio

Wizard: It is an
intuitive guidance software,
integrated
in the Cardio
workflow.

requirements for image detail should be


limited to what is necessary for resolving
the problem at hand. In planning a lung
biopsy, less detail is required than when
searching for metastases. Therefore,
emphasizes Dr. Lell, all radiologists
should ask themselves what degree of
quality is in the best interests of the
patient. This, too, is an important contribution to reducing radiation exposure.

Improving visualization and


management of dose

6 Anatomically

correct spine
reconstructions
are typically
very time consuming procedures, as every
spinal cord and
disc needs to
have an own
recon layer
depending on
its individual
position. With
FAST Spine,
these manual
steps can be
simplified to
ideally just a
single click.

FAST CARE also offers a number of


functionalities that serve to visualize the
radiation given to the patient during
the scan. Before the start of the examination, CARE Profile displays the course
of the dose to be applied according
to the patients anatomy. The user can
also determine reference values and
upper limits for the individual protocols
and request notification when the scan
approaches these limits, as required
under a new IEC standard. Furthermore,
the software includes applications for
quality control. Currently, the CTDIvol
and DLP data specified in the patient
protocol must still be entered manually
into a quality control monitoring program. This is arduous and time-consuming work. FAST CARE stores the data into
the DICOM Dose SR with CARE
Analytics that then can be evaluated.
Lell explains: Automatic data export
offers unforeseen opportunities for quality control. It would be possible to review
the average dosage distribution values
for every day and to check which scans
exceed or fall below a certain value.
Currently, such a degree of quality control is still unattainable.

Assistant Professor Dr. med. Michael Lell studied at the University of Regensburg and Technische
Universitt Mnchen. He is specialized in diagnostic radiology. Currently, he is Senior Physician at
the Institute of Radiology, Erlangen University Clinic, Erlangen, Germany, where he has been working
since 1997. He was a visiting researcher at the David Geffen School of Medicine at the University
of California, Los Angeles, and is a member of various national and international professional bodies.
He is also a peer reviewer of several medical journals.

10 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

Coverstory

We Need Better
Default Protocols.
Dr. Aaron Sodickson, MD, PhD, Assistant Director of
Emergency Radiology, Brigham and Womens Hospital,
Harvard Medical School, Boston, spoke to journalist
Dr. Hildegard Kaulen for SOMATOM Sessions:
Dr. Sodickson, in the past three years,
concerns have been raised about
cumulative exposure by repetitive CT
imaging. How serious is the problem?
SODICKSON: There is persistent controversy over the risk models that exist for
radiation exposure of the magnitude
used in CT. We attempted to quantify the
levels of risk using the most common
Linear-No-Threshold risk model used in
the 7th Biological Effects of Ionizing
Radiation (BEIR-VII) report. We studied
32,000 patients undergoing CT at our
institution, using the BEIR-VII model to
estimate cumulative cancer risks from
CT exposures. We found that 7% of our
cohort had undergone enough previous
CT radiation exposure to increase their
cancer risk by at least 1% or more above
baseline. As a result, we believe that
patients undergoing recurrent imaging
over time warrant heightened radiation
protection efforts.
Many CT users dont take full advantage of the available dose reduction
tools and work with protocols that are
not fully optimized. Is active assistance, such as that provided by FAST
CARE, the key to a more universal
adoption?
SODICKSON: Active assistance is one of
many excellent solutions. Any automation that makes scanning easier and
helps to create reproducible results
across the wide range of patient sizes
and technologist skill levels is extremely
valuable. But we also need better default
protocols that are dose-optimized and

robust in order to ensure adequate diagnostic image quality for every patient.
We need close collaboration between CT
manufacturers, radiologists, technologists, and medical physicists. By combining our different areas of expertise,
we can best reach consensus about
what works and what doesnt, and what
represents adequate image quality for
the particular diagnostic task at hand.
What are the essentials for a radiation
risk assessment program?
SODICKSON: We should routinely review
the imaging history of our patients. We
are working to implement a decision
support system that alerts ordering physicians in real time of the magnitude of
a patients radiation risk. Our goal is to
bring appropriate perspective to the risk/
benefit decision by providing the best
risk estimates possible. We hope this will
enhance an active and critical review of
the imaging order and an assessment of
how the scan fits into the longitudinal
medical history of the patient.
Will risk assessment interfere with
the workflow and lengthen the decision making and scanning process?
SODICKSON: That depends on how it is
implemented. We need solutions that
create an efficient workflow without
frustrating delays. Otherwise they might
not be accepted in clinical routine.
An exciting feature for dose reduction
is lowering kV. You had the chance to
test CARE kV, which is a part of FAST

CARE. Did the tool meet your expectations?


SODICKSON: We assessed an early prototype, which worked quite nicely. Based
on the patients size, the system automatically suggests kV and effective mAs settings that minimize the applied dose
without compromising image quality.
This tool takes a great deal of guesswork
out of low kV scanning, making it feasible for all technologists.
As Assistant Director of Emergency
Radiology, where do you see additional potential for increasing patient
care further, besides the ever-present
topic of continuous dose reduction?
SODICKSON: We need dose-optimized
default protocols that work in fastpaced, sometimes chaotic settings such
as the ED, and can be used reliably by
technologists of all skill levels. We need
streamlined workflow to scan even our
sickest patients with reliably low dose
and high quality results every time. We
need improved education to ensure that
every user is aware of the excellent
dose-reduction tools that are available,
and knows how to use them correctly.
And finally, we need improved methods
to capture patient- and exam-specific
dose information from every scan, both
for real-time quality control and for
longitudinal dose-monitoring efforts.
Dr. Hildegard Kaulen is a molecular biologist.
After sojourns at the Rockefeller University in
New York and Harvard Medical School in Boston,
USA, she has been working as a freelance science journalist for prestigious daily newspapers
and science journals since the mid-1990s.

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

11

News

CEO Corner: Excellence in Clinical Practice

Dr. Sami Atiya, CEO Business Unit CT,


Siemens Healthcare, Forchheim, Germany

Excellence in Clinical Practice through


innovation & responsibility remains the
cornerstone of Siemens leadership in
the CT medical imaging field. A constant
source of strength as aging markets in
industrial countries, and dynamic markets in rapidly developing countries,
demand better health care at lower cost.
We help you meet these challenges in
four key areas:

You can depend on us, as undisputed


trendsetter in CT technology, for the
industrys fastest and healthiest single
and Dual Source scanners today and
into the future.
To improve your clinical efficiency, we
support you with workflow excellence,
ease of use and high reliability.
As your caring partner, we maintain
highest industrial standards in customer relationship & care.
To make state-of-the-art CT affordable
and financeable for you, we have
introduced the new Excel Editions of
our highly efficient 16- and 64- slice
scanners.

uously sets the trend in an always


changing environment providing
answers for life.
We are looking forward, that in the years
ahead, you will continue to work with us
in our efforts to uphold excellence in CTs
clinical practice.

Reducing our vision to its essence:


As a caring partner of our customers, we
create CT-innovations that lift clinical
practice to a higher level of excellence
and enable wide access to better patient
care. Our ambitious global team contin-

Working with syngo.via an In-Practice Report


Physicians and technologists at the department of radiology at the University
of Pennsylvania Hospital (HUP) have been evaluating the syngo.via*
software for two years now. Harold I. Litt, MD, PhD, assistant professor of
radiology and chief of the cardiovascular imaging section, reports on his
experiences with syngo.via in his daily routine.
By Michaela Spaeth-Dierl, medical editor, Spirit Link Medical, Erlangen

The Hospital of the University of Pennsylvania has a reputation as a world


leader in medical research and clinical
care. Since 1765, it has been dedicated
to the care of patients, the education of
physicians and development and imple-

mentation of new medical knowledge.


HUP therefore seemed to be the right
place to evaluate one of the first
research systems of the new syngo.via
software from Siemens, and the radiology department there has now been

12 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

evaluating it for two years. All cardiovascular CT and MRI exams, neurovascular
CT, and body CT studies requiring additional processing (e.g. CT urography and
colonography) are automatically routed
to the syngo.via server, and six radiolo-

News

gists and four 3D technologists regularly


work with the system. In his section,
Harold Litt mainly interprets cardiovascular studies with syngo.via. With
syngo.via, the daily routine has changed.
Compared to a stand-alone workstation,
a thin-client system like syngo.via* has
benefits for both workflow and time,
he summarizes his experiences.
A great advantage of syngo.via is the
automated pre-processing. When a case
is opened, many pre-processing tasks
such as table removal, bone removal,
curved planar reformatting, naming of
vessels, ejection fraction calculations
and orthogonal cuts are already done.
So, the radiologists can start their interpretation immediately.
My experience with syngo.via* in cardiac CT is that the pre-processing of data
is very accurate and requires few edits.
This means fewer corrections and faster
reading, says Dr. Litt. Compared to
other thin client technology, there are
also differences. Previously the workflow
involved the following: the data from
the scanners was sent to dedicated
workstations, where the cases were
post-processed by dedicated 3D technologists. The techs captured screenshots
of their results, saving them on the PACS
and manually transcribing any numeric
results into a web-based system. Radiologists would review the captured images
on PACS, another workstation, or a
thin-client system, then copy and paste
results from the web-based system to
their reports in the RIS. If the radiologist
wanted to review the technologists
work directly, it would mean a walk to
the 3D lab and reloading the case on a
workstation.
Now, and in the future with syngo.via,
all users access the same database.
Technologists prepare the cases and
forward their results to the radiologists
through shared reading. Radiologists
can start reviewing each case where
they are sitting and do not need to walk
to the workstations anymore, and technologists no longer need to type their
measurements into a separate system.
Furthermore, syngo.via allows its users
to load cases from different modalities
such as echocardiography or CT angio-

Looking at curved MPRs used


to take a lot of clicks and usually
wasnt worth it. Since you now get it
automatically, Im looking at them
in almost every case.
Harold I. Litt, MD, PhD, Assistant Professor of Radiology and Medicine,
Chief, Cardiovascular Imaging Section, Department of Radiology,
University of Pennsylvania School of Medicine, Philadelphia, PA, USA

graphy. The series navigator shows all


images related to the opened patient, so
radiologists dont have to search for the
right series from the right patient in the
entire patient list.
Concerning several of the dedicated
features available, the right ventricular
analysis (RVA) within the syngo.CT
Cardiac Function Right Ventricle** is
very much appreciated. says Harold I.
Litt. We study many patients with
congenital heart disease as well as those
undergoing electrophysiology ablation
procedures. Being able to calculate RV
ejection fraction without manual contouring saves half an hour per case.

Now you get the LV and RV wall motion


analysis and EF automatically as soon as
you open a case without any waiting
or interaction.
Experience that testers of syngo.via have
gained in the department of radiology at
HUP shows that the use of this software
provides a simplification of clinical workflows and time savings.
** syngo.via can be used as a standalone device or
together with a variety of syngo.via based software
options, which are medical devices in their own
rights.
** syngo.CT Cardiac Function- Right Ventricle is not
commercially available in the US.
Dr. Litt has received grant funding from Siemens
for research related to this product.

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

Somatom_News_CC.indd 13

13

10.11.10 11:36

News

Iterative Reconstruction
Reloaded
For the rst time, SAFIRE* introduces the usage of raw-data information
within iterative reconstruction for everyday use in clinical practice.
By Jan Freund, Business Unit CT, Siemens Forchheim, Germany

For quite some time, iterative reconstruction has been heavily discussed in
the CT community as a highly promising
method to achieve significant dose
reduction without compromising image
quality. Essentially, iterative reconstruction introduces a correction loop in
the image generation process that
cleans up artifacts and noise in low-dose
images. The proposed approach is, that
after the initial reconstruction using the
weighted filtered back projection
(WFBP), the measured data of the
acquired image (in the so-called image
space) is compared to the data (raw-

1A

1A Plain FBP

data). But until now, the implementation of this method for clinical practice
was limited as the necessary re-transformation of data from the image to the
raw-data space was very time-consuming
and the computational power required
to make it feasible for everyday use was
not available. Therefore, vendors found
several different approaches to handle
this limitation in their first individual
solutions.

The rst step IRIS


At RSNA 2009, Siemens introduced its
solution IRIS. Like all other vendors,

it had to conquer the challenge of performance. In order not to do so at the


expense of image quality a plasticlike image impression was one of the
major drawbacks of other solutions
Siemens found a smart alternative:
The innovative first step was the reconstruction of a super-high resolution
image that had virtually no image loss.
This was achieved by not applying the
filtering that typically reduced image
noise, taking into account that the
resulting image was then accordingly
very noisy, but contained all information. The iteration loops to reduce the

1B

1C

1D

1B Standard Siemens WFBP

1C IRIS

1D SAFIRE

14 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

News

2 Improved noise reduction and workflow with SAFIRE*

noise in the image were then per formed


completely in image space, which was
the key to achieve the reconstruction
performance and keep a well-known
image impression. This unique approach
then even found its way into the product
name: IRIS Iterative Reconstruction in
Image Space. Several publications
proved IRIS to be highly effective when
it comes to reducing dose while maintaining diagnostic image quality. The
University of Erlangen for example,
achieved average dose reductions of
50%** for abdomen examinations by
taking Dual Source datasets done with
the SOMATOM Definition Flash and
reconstructing the images based only
on data from one source. The resulting
images now naturally utilizing only
half the dose showed the same image
quality after being reconstructed with
IRIS compared to those reconstructed
without IRIS and utilizing the data from
both sources.

The next generation SAFIRE


But now, Siemens actually shifted into a
higher gear and introduced the successor
at this years RSNA: SAFIRE (Sinogram
Affirmed Iterative Reconstruction)*. For
the first time, the use of raw data (which
is visualized in the so-called sinogram) is
actually being utilized in the image

improvement process. Here, the current


set of CT images is transformed back into
raw data which models all relevant geometrical properties of the CT scanner.
This step produces a CT raw-data set that
again resembles a virtual CT system. By
comparing the synthetic raw data with
the acquired data, differences are identified. This procedure can be regarded as
validating (or affirming) the current
images compared with the measured raw
data. The detected deviations are then
again reconstructed using WFBP, yielding
an updated image.
With this step, the images can be analyzed, subtracting image noise from the
previous images without loss of sharpness. The same applies for potential artifacts that every vendor is confronted with
when using the WFBP and which often
remain in conventional CT images. Using
multiple iterations of these steps, geometrical imperfections of the WFBP are
corrected in addition to incrementally
reducing image noise. With this, SAFIRE
Sinogram Affirmed Iterative Reconstruction can achieve a radiation dose reduction of up to 60%** at improved
image quality (contrast, sharpness and
noise), even surpassing the already
impressive image quality realized with
IRIS. This amazing achievement resulted
mainly from two measures: First, the

algorithms used in the iterations were


redesigned to make them more efficient.
And second, new image reconstruction
systems (IRS) were developed and
introduced parallel now finally providing
the computational means for the complex
calculations required. SAFIRE of course
also works with the former IRS but
naturally at a reduced performance.
With the new high performance IRS
the FAST IRS the performance is enhanced even further. The result: With
SAFIRE, the potential to reduce radiation
dose is up to 60%,** but at an significantly improved image quality. The big
difference is now, that this potential is
accessible to a much larger number of
examinations, meaning that the average
dose saving over all examinations will be
significantly higher. Using the potential
of SAFIRE* 72% of all Siemens standard
protocols, apply dose of below the
average annual natural background
radiation of 2.4 mSv.** SAFIRE will be
commercially available for all SOMATOM
Definition AS in March 2011 and for
SOMATOM Definition Flash in May 2011.

** The information about this product is being provided for planning purposes. The product is pending 510 (k) review, and is not yet commercially
available in the U.S.
** Results may vary. Data on file.

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

15

1B

1A

Topic

Flash Spiral for Precise and Patient Friendly


Transcatheter Aortic Valve Implantation (TAVI)
Planning.
By Peter Aulbach
Business Unit CT, Siemens Healthcare, Forchheim, Germany

Transcatheter heart valve implantation is


considered a technology with enormous
clinical potential. The percutaneous
implantation of a pulmonary valve was
reported for the first time in 2000. Since
then, these procedures have recorded
constant double-digit annual growth,1
since it presents a new option to candidates for whom conventional surgery
was not suitable.

Clinical needs and challenges


The recent PARTNER trial, published in
the New England Journal of Medicine,2
demonstrates that transcatheter aortic
valve implantation (TAVI), in comparison
with standard therapy, resulted in significantly lower rates of death among
those patients. Patients who undergo
TAVI show a 45% reduction in the rate of
death in comparison with those receiving standard therapy.
Exact knowledge of the aortic root anatomy, including the proximal coronary
arteries, and the entire aorta up to the
femoral artery bifurcation, is necessary to
allow accurate pre-procedural planning.
After scanning with conventional proto-

cols, CT imaging requires relatively large


amounts of contrast which can be a problem in older patients, especially those
with concomitant renal disease. Prospectively triggered high-pitch Flash Spiral
Dual Source CT (Flash Spiral), with up to
458 mm/s table feed, is able to obtain all
important anatomic information in one
single scan. Because of the extremely
rapid data acquisition, completed in less
than 2 seconds (Fig. 1B), the amount of
contrast agent can be reduced significantly.
In conventional aortic valve surgery, the
access route to the aortic valve is standardized. Normally the sizing of the
utilized valve prosthesis is done directly
under visual control at the surgical site.
In contrast, in TAVI procedures all these
points need to be meticulously addressed during pre-operative planning, since
annulus size, access route or distance of
the coronary ostia to the aortic root will
influence the procedural strategy and
the appropriate selection of the artificial
heart valve.
Moreover, large amounts of contrast
agent have to be used in addition to the

16 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

contrast exposure during the aortic


valve implantation itself. In the TAVI
population, more than 50% of patients
show impairment of renal function
(elevated serum creatinine levels).
It is known that up to one third of all
patients undergoing catheter-based
aortic valve implantation develop acute
renal failure in the shortly following
post-operative course.3 Therefore the
application of contrast dye needs to be
reduced to a minimum.

Benets of Flash Spiral CT


The latest Dual Source CT system, the
SOMATOM Definition Flash, allows the
use of prospectively triggered high-pitch
spiral data acquisition, called Flash
Spiral. This mode allows a significant
reduction of radiation dose compared to
other CT technologies. Effective radiation doses of only 3-5 mSv are now only
needed to visualize all relevant thoracoabdominal structures (Fig. 1). Even
more importantly, within this patient
population, this new scan mode allows
an extremely rapid data acquisition in
less than 2 seconds (other CT technolo-

1C

News
Topic

1 80-year old patient with severe aortic valve stenosis prior to transcatheter aortic valve implantation (TAVI). Pre-procedural Flash Spiral
angiography was performed using high-pitch spiral data acquisition prospectively triggered at 60% of the R-R interval (128 x 0.6 mm slices,
100 kV, 320 mAs, SOMATOM Definition Flash). For thoraco-abdominal
angiography including the coronary arteries (Arrowhead) only 40 ml of
contrast agent was used (flow rate 4 ml /s). Estimated effective radiation
dose was 4.3 mSv. at a scan time of 1.7 seconds.
Images show assessment of aortic annulus diameters in syngo.via (Fig.
1A dotted line) as well as distances between the aortic annulus and the
coronary ostia. In addition, peripheral arteries have been evaluated for
significant stenosis (Fig. 1B). The red arrow indicates an occluded iliac
artery, making transfemoral access impossible here. The same data also
shows pronounced calcification along the whole thoracic aorta (Fig. 1C).

Accurate and fast planning


with syngo.via
The decision whether a patient is suitable for a catheter-based procedure and
the pre-operative planning with the
selection of the access route are based
upon results of the CT angiography. The
size of the aortic annulus for selection of
the valve prosthesis and the angulation
of the invasive fluoroscopy which allows
for simulating the optimal projection of
the aortic valve during the TAVI procedure can be predicted from the same
DSCT angiography data with the support
of syngo.via.* This leads to further contrast media savings during the invasive
procedure since the syngo.via* software
automatically provides the corresponding C-arm position.
On the basis of this protocol and anatomical measurements by Flash Spiral
CT, physicians are able to quickly perform more patient friendly and precise
catheter-based procedures.
The time consuming planning of the
procedure is very well supported by the

many automated pre-processing steps


in the new syngo.via* software which
in early tests could show to reduce planning time by more than 33% (10 min.
versus 15 min.).

In a nutshell: Flash Spiral


and syngo.via
In conclusion the Definition Flash,
combined with the highly automated
syngo.via* workflow modules, provide
the most possible patient friendly and
accurate pre-operation planning solution
available. The high potential for cost
reduction coming from fewer patients
suffering acute CIN and therefore
requesting less of the expensive aftercare
is not yet taken into account herein.

1 Cardiovascular News, Transcatheter heart valve


replacement: A European perspective,
www.cxvascular.com, Jan 2010
2 Valve Implantation for Aortic Stenosis in Patients
Who Cannot Undergo Surgery, N Engl J Med
2010
3 Aregger F, Wenaweser P, Hellige GJ, et al. Risk of
acute kidney injury in patients with severe aortic
valve stenosis undergoing transcatheter valve
replacement. Nephrol Dial Transplant 2009; 24:
21752179.
4 Vahanian A, Alfieri OR, Al-Attar N, et al. Transcatheter valve implantation for patients with aortic
stenosis: a position statement from the European
Association of Cardio-Thoracic Surgery (EACTS)
and the European Society of Cardiology (ESC), in
collaboration with the European Association of
Percutaneous Cardiovascular Interventions
(EAPCI). EuroIntervention 2008; 4: 193-199.

* syngo.via can be used as a standalone device or


together with a variety of syngo.via based software options, which are medical devices in their
own rights.

SOMATOM Definition Flash:


www.siemens.com/SOMATOMDefinition-Flash
CT Cardiovascular Engine:
www.siemens.com/CT-cardiology

160

140 ml*
Amount of Contrast Agent [mL]

gies need about 69 seconds). This permits a tremendous reduction of contrast


agent by 5060%, which is crucial for
patients with renal insufficiency undergoing a subsequent TAVI procedure.
Compared to approximately 100140 ml
of contrast agent needed in the past for
a CT angiography of the entire aorta, it
is now possible to use only 40 ml (flow
rate 4 ml/s) for the same examination,
which poses a significantly reduced risk
of Contrast Induced Nephropathy (CIN)
in this patient population (Fig. 2).

140
120

100 ml#
100
80
60

40 ml
40
20
0

Single-Source CT
for Abdominal
Aorta

Single-Source CT
for Triple Rule Out

Dual Source CT
SOMATOM
Definition Flash

2 Up to 60%
less contrast
media by use of
high-pitch spiral
DSCT angiography of the
complete aorta
compared to
other CT technologies.

Courtesy of
University
of ErlangenNuremberg,
Erlangen,
Germany

*Loewe C, Eur Radiol 2010; #Wu W, AJR 2009; Flash Thorax Protocol

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

17

I am happy and proud to embark on this initiative together


with Siemens and my colleagues from around the globe in
order to ensure that Siemens powerful tools for dose reduction are used to their fullest extent.
U. Joseph Schoepf, MD, Medical University of South Carolina, U.S.

Siemens Launches SIERRA, the Siemens


Radiation Reduction Alliance
SIERRAs expert panel proposes its rst recommendations
on patient care and radiation reduction
By Stefan Ulzheimer, PhD, Business Unit CT, Siemens Healthcare, Forchheim, Germany

In a continual commitment to patient


care and radiation reduction in Computed Tomography (CT), Siemens Healthcare has launched SIERRA, the Siemens
Radiation Reduction Alliance and has
established an expert panel to advance
the cause of dose reduction in CT. The
new Low Dose Expert Panel includes 16
specialists in radiology, cardiology and
physics, who are internationally recognized for their publications on the subject of CT dose. The panels objective is
to generate proposals on how Siemens
can continue to develop their technology
and to help users better adapt their procedures in order to bring about further
dose reduction in CT. One of the most
important suggestions from the first
meeting of the Low Dose Expert Panel in
May 2010 concerns methods to recognize and increase utilization in clinical
practice of the many CT dose reduction
technologies that are already available.
Siemens will pursue the following,
concrete, first recommendations
together with its partners:
Q To establish a baseline of dose levels
for the 10 most commonly performed
CT exams, the group agreed to establish and contribute to an international,
multi-institutional dose registry.

The participating, renowned institutions will share their CT scan protocols


for the 10 most commonly performed
examinations on a central web site as
a first step to promote best practice
sharing in the field.
Siemens will develop a dedicated low
dose educational program in close
collaboration with the involved institutions.

The Panel will meet twice a year to discuss new ideas and investigate whether
measures already agreed upon are having a positive impact. The next meeting
takes place at RSNA 2010.

www.siemens.com/low-dose-CT

Current Members of SIERRAs expert panel:


Hatem Alkadhi, MD, University Hospital Zrich, Switzerland
Christoph Becker, MD, Ludwig Maximilians University, Germany
Elliot Fishman, MD, Johns Hopkins University, U.S.
Donald Frush, MD, Duke University, U.S.
Jrg Hausleiter, MD, German Heart Center, Munich, Germany
Brian Herts, MD, Cleveland Clinic Foundation, U.S.
Willi Kalender, PhD, Erlangen University, Germany
Harold Litt, MD, PhD, Pennsylvania University, U.S.
Cynthia McCollough, PhD, Mayo Clinic, U.S.
Alec Megibow, MD, NYU-Langone Medical Center, U.S.
Michael Recht, MD, NYU-Langone Medical Center, U.S.
Dushyant Sahani, MD, Harvard Medical School, MGH, U.S.
U. Joseph Schoepf, MD, South Carolina Medical University, U.S.
Marilyn Siegel, MD, Mallinckrodt Institute of Radiology, U.S.
Aaron Sodickson, MD, PhD, Brigham and Womens Hospital, U.S.
Kheng-Thye Ho, MD, Tan Tock Seng Hospital, Singapore

18 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

News

Siemens CT Stroke Management


Siemens Healthcare recently has started a new CT Stroke Management
Online Resource for healthcare professionals highlighting new diagnostic
opportunities by synergizing with latest Siemens CT scanners and postprocessing solutions Helping to Save Brain and Quality of Life.
By Stefan Wnsch, PhD, Business Unit CT, Siemens Healthcare Forchheim, Germany

When diagnosing and treating stroke


patients, time is critical. Stroke is one of
the diseases where diagnosis, prognosis
and treatment drastically changes within
a short period of time. Every minute in
which a large vessel ischemic stroke is
untreated, the average patient loses 1.9
million neurons, 14 billion synapses, and
12 km (7 miles) of axonal fibers. Each
hour in which treatment fails to occur,
the brain loses as many neuron as it does
in almost 3.6 years of normal aging*.
Therefore, the need for faster diagnosis
and faster treatment is central to acute
stroke management care. Providing the
right information in every step of the
treatment is crucial in order to save
brain and thus save quality of life for
stroke patients. Siemens CT Stroke
Management moves beyond just ruling
out the bleed by helping to establish a
personalized treatment plan. Using the
possibilities of extended brain coverage,
Siemens has radically improved the
stroke workflow uniquely adding value
to stroke management. In order to share
these approaches, Siemens has published a new information platform www.
siemens.com/CT-stroke-management to
share clinical outcomes. Dr. Schramm
from the University of Gttingen, Germany, for example, shares his workflow

of a certified stroke unit from the arrival


of a stroke patient in the emergency
department until the decision for further
treatment is made together with the
neurologist. In his institute, the door-toneedle time is less than 20 min. Furthermore, leading stroke specialists share
their experience and protocols in webinars and presentations. Trial versions are
offered to Siemens customers to test
the latest software solutions in stroke
imaging in actual clinical practice.
This campaign is meant to improve the
knowledge of stroke diagnosis with

extended brain coverage and Siemens


CT solutions and is also designed to integrate experiences of other customers
worldwide.
If you are interested in sharing your
results with other colleagues on this
homepage, please contact
stefan.wuensch@siemens.com
www.siemens.com/CT-strokemanagement
* Time is brain-quantified. Saver JL. Stroke. 2006
Jan;37(1):263-6.

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

19

News

A Pediatric Breakthrough: Automated


Adaptation of CT Dose Levels
If only Siemens could re-engineer people like it does CT scanners. For
more than a decade, Siemens has been at the forefront of dose reduction
in computed tomography. New technology is coming on the market at
breakneck speeds, with each generation making scans safer and faster.
By Ron French
Dose levels of CT scans have fallen
dramatically in recent years and will
continue to drop with Siemens latest
scanners. Yet even as CT scans become
safer for patients, the variation of dose
from facility to facility can still be
unacceptably high, says Dr. Marilyn
Siegel, Professor of Radiology and
Pediatrics at Washington University
School of Medicine in St. Louis, Missouri
(USA) and Pediatric Radiologist at the
affiliated St. Louis Childrens Hospital.
Siegel is delighted at the advancements
in CT technology, allowing individual
organs to be shielded and automatically
adjusting the dose level in real time as
the patient moves through the scanner.
That technology must now be coupled
with education, to assure that radiologists and technologists across the globe
are aware of and using proper protocols for each patient.
A decade ago, the average CT dose was
15 to 20 mSv. As the use of CTs exploded (more than 70 million scans are performed annually in the U.S. alone),

radiation exposure to the population,


especially in industrialized countries,
increased. The National Council on
Radiation Protection and Measurements
reported in March 2009 that radiation
exposure per capita more than doubled
in the United States in the past two
decades, largely due to increased use
of CT, nuclear medicine imaging and
interventional radiology.
Because the potential risk of repeated
radiation exposure accumulates over
time, and because the tissues of children
are particularly sensitive to radiation,
dose levels are an even bigger concern
for pediatric radiologists like Siegel.
Effective dose in children is 35 times
greater than in adults at comparable
exposure levels, and you have very
sensitive tissues, especially the breasts
and gonads, in children who are
growing, Siegel clarifies. The younger
the patient, the more is the potential
risk from radiation. There are two things
you can do when there is a challenge:
You can hide and hope somebody else

does it, or you move and you do it


yourself, Siegel explains. Siemens,
she adds, has been at the forefront
of dose reduction.

SOMATOM Denition AS:


The Adaptive Scanner
At St. Louis Childrens Hospital, the
volume of CT scans is declining, but it
is still the tool of choice for many neurological exams, chest and abdominal
scans including lung transplants,
tumors, trauma and abscess infection.
To limit radiation exposure, the hospital
invests in the latest CT technology.
The newest scanner at St. Louis Childrens
Hospital is a SOMATOM Definition AS.
The AS is the first scanner to intelligently
adapt to the patient, changing dose
levels automatically as it scans thicker
and thinner parts of the body. Instead of
setting a dose level that will offer clear
images in a thick part of the body such
as the shoulders and maintaining that
level throughout the scan, dose levels
rise and fall throughout the scan.

Siemens has been in the forefront of dose-reduction. Marilyn J. Siegel, MD, Pediatric Radiologist, Washington University School of Medicine and
St. Louis Childrens Hospital, Missouri, USA

News

1 6 weeks old pediatic case after congenital heart surgery (utilizing 3 mSv)

The Definition AS also reduces dose level


in spiral scanning by eliminating radiation in pre- and post-spiral areas that
wont be reconstructed.
Siegel watches on a computer monitor
as a CT scan is performed on a young
cancer patient. Before, wed set one
dose level for the entire body, Siegel
says, a dose level high enough for good
image quality in the thickest part of the
body. Now, the automated adaption of
dose level cuts radiation.
The scanner also incorporates an Adaptive Dose Shield to limit radiation to
clinically relevant parts of the body. The
result is an average dose of 2 mSv to
3 mSv in young pediatric patients, a 10fold decrease in dose from a decade ago.
Though the St. Louis Childrens Hospital
installed the SOMATOM Definition AS in
January 2010, the hospital already has
on order the next generation of Siemens
CT scanner the SOMATOM Definition
Flash. The Flash will offer scans at less
than 1 mSv possibly as low as 0.5 mSv.
Thats incredible, Siegel explains.
With the Flash, we can lower the dose
without the need of sedation for patients
under five (because of the speed of the
scan). Its a win-win situation. The older
scanners yes, they were fast, and yes,
you could reduce the dose, but not like

you can now, Siegel says. Its really


about patient care and affecting patient
outcomes, reducing the risk, and
increasing the benefit for these kids.
Siegel also published groundbreaking
work on how dose can be reduced,
especially in children and small patients,
by not only adapting the tube current
but also the tube voltage. Siemens has
been providing dedicated pediatric protocols using low tube voltages of 80 kV
since 2002 but now they take this
method to the next level. The latest
scanners will come with CARE kV, a feature that automatically recommends the
ideal tube voltage for the individual.
Additionally, Siemens will be the first CT
vendor to offer a tube voltage setting of
70 kV which allows for additional dose
savings in the youngest patients.

Education and certication


is key
Siemens willingness to listen to the needs
of physicians and continue to improve
their scanners is why Siegels pediatric
radiology department uses Siemens
equipment.
Siegel was instrumental in the development of CT protocols for Siemens, and
serves on an expert panel organized by
the company to brainstorm ways to reduce

dose levels in CT. One of the things that


we discussed and that Siemens already
implemented is a warning system that
alerts the user if certain pre-set dose
limits are exceeded, Siegel emphazies.
If you choose a protocol and its really
way off, you get a warning to reconsider
your choices.
Siegel does CT accreditation for the
American College of Radiology. I am
sometimes surprised at what I see out
there, she says. There is a lot of variation in radiation dose among sites. One
published study found a dose variation
of 13-fold. There is a lot of education to
do, not only for radiologists but also
technologists, Siegel says.
We know were not there yet, but were
making progress.
Newer dose reduction scanner technology
is one part of the solution for dose reduction, Siegel says, but another important
factor is education. Siegel is sold on
Siemens scanners, but also on the companys commitment to education.
Siemens personnel are always available
to answer questions and have helped
train the hospitals technologists.
While the number of CT scans continues
to rise for adult patients, scan levels
have stabilized among children and are
actually going down at academic centers
such as St. Louis Childrens Hospital.
Siemens has been a pioneer in reducing
CT dose level for more than a decade,
with each new generation of scanners
breaking barriers. At St. Louis Childrens
Hospital, Siemens helps train technologists to operate the scanners in ways
to get the best possible images and keep
radiation dose as low as reasonably
achievable (the ALARA principle), which
is what is all about when scanning
children.
Whats the future for pediatric radiology
at St. Louis Childrens Hospital? Faster
scans. Safer scans. Lower radiation
doses. More arm-in-arm innovation with
Siemens. I feel like Im lucky to work
with them, says Siegel.

Ron French is a healthcare writer based


in Detroit, Michigan (USA).

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

21

Topic

Dr. Pavel Ryska performs up to 40 patients a day on the SOMATOM Emotion 6.

Expanding Radiodiagnostics: University


Hospital Hradec Krlov, Czech Republic
The University Hospital in the Czech district capital Hradec Krlov has been
able to increase its radiodiagnostic activities considerably, thanks to the installation of a Siemens CT scanner from the SOMATOM Emotion 6 range. Dr. Pavel
Ryska, principally highlights the devices performance: reliability, application
range and image quality.
By Rudolf Hermann

With 23 clinical departments, 1,500


beds and an annual volume of around
40,000 patients, the University Hospital
(Fakultni nemocnice) in Hradec Krlov,
the capital of Eastern Bohemia, is one of
the most important healthcare facilities

in the Czech Republic. Although, as a


university hospital, research forms a
prime focus of activity, the establishment also fulfills the function of a
general hospital as Hradec Krlov
has no separate city clinic. This results

22 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

in slightly different requirements and


prerequisites in the day-to-day running
of the hospital, setting it apart from
traditional university hospitals which
are not obliged to fulfill this additional
function.

News

The radiodiagnostics department at


Hradec Krlov has been using a
Siemens SOMATOM Emotion 6 CT scanner for around six years. The scanner
replaced a previous model, also by
Siemens, from the HiQ range. The
hospital also recently installed another
CT scanner the SOMATOM Definition AS+,
which is used in the emergency department.

Highly cost-effective
According to Dr. Pavel Ryska, responsible
for the SOMATOM Emotion 6, the decision to purchase Siemens scanners was
based both upon positive experiences
with the previous range and on the high
service level offered. Ryska values the
Emotion 6 range as it facilitates a high
examination density in line with mandatory medical standards for a large number of applications, making procedures
extremely cost-effective. Moreover, the
device is easy to install and has no
specific spatial demands. In Ryskas
view, a further benefit is the systems
reliability, which results in high economic efficiency.
The head of department particularly
appreciates the syngo user interface,
which not only facilitates fast orientation, but also functions in a manner
similar to other radiological devices
from the same manufacturer (such as
magnetic resonance), with the result
that staff from other departments
quickly become familiar with its
operation (so-called multi-modality
workplaces).
In the light of the fact that Czech
hospitals conclude fixed fee contracts
with health insurance providers, the

market for self-paying private patients


is virtually non-existent and it is thus
impossible to receive extra remuneration
for additional services. The SOMATOM
Emotion 6 CT scanners increased
efficiency over its HiQ predecessor is
used primarily for better, more complex
diagnostic assessments as opposed to
more examinations. We could certainly
utilize another CT device to capacity on
the basis of potential patient figures
alone. At present, we treat patients from
our catchment area only. The SOMATOM
Emotion 6 is so efficient that we are able
to reduce waiting periods for examinations during day-to-day operations, says
Dr. Ryska.

Indispensable workhorse
Ryska believes that, as a university
hospital, his establishment should be at
the forefront of technical progress.
However, he knows only too well that,
the Czech healthcare system has limited
resources. With its excellent speed- and
examination quality ratio, the highly
efficient SOMATOM Emotion 6 blends
into this medical landscape with consummate ease. In fact, it could be
termed the indispensable workhorse,
while the Definition AS+ is called on to
perform more challenging tasks.
A particular benefit of the CT devices at
the hospital in Hradec Krlov highlighted by Ryska is the variable and
therefore reduced patient radiation
exposure, achieved by state-of-the-art
technology (ultra-fast ceramic detectors
and CARE Dose4D technology). Exposure
is reduced by between 30 and 40 percent on average in comparison with
earlier models. Physicians are

particularly pleased by this development


since patients do not tend to address the
issue as frequently. However, parents of
children undergoing examinations are
displaying increasing interest in the
question of radiation exposure.

Improvements made via the use


of the SOMATOM Emotion 6
Clinical:
Q broader, more complex diagnostics for
routine examinations
Q a clear reduction in radiation dose by
an average of 3040%
Workflow:
its outstanding capability to combine
high througput with high quality for a
large range of applications makes the
SOMATOM Emotion 6 a workhorse
for the majority of mainstream examinations
Q a user-friendly interface permits
synergies with other radiological
facilities at the hospital
Q high system reliability without significant downtime or maintenance
periods
Q

Patient contact:
the highly efficient SOMATOM
Emotion 6 allows patient needs at a
public hospital funded by health
insurance firms to be met to the
required quality standards without
significant waiting periods.

Rudolf Hermann is a journalist based in Prague


with extensive experience of political and
economic developments in Central and Eastern
Europe.

The scanner is an indispensable workhorse.


We examine up to 40 patients a day with
3040% lower dose on average than before.
Dr. Pavel Ryska

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

23

News

Evaluation of cardiac function based on high quality images.*

Full Cardiac Assessment with syngo.via


Maximal Signicance, Minimal Dose
Siemens has once again succeeded in taking another step forward in the eld
of CT diagnostics. By combining SOMATOM Scanners with the new syngo.via**
imaging software, cardiac function assessments can now be carried out
using very low radiation doses.
By Michaela Spaeth-Dierl, medical editor, Spirit Link Medical, Erlangen

Assessment of cardiac function with CT


is still a challenging procedure for radiologists. Siemens has now managed to
solve some critical issues. A full cardiac
function evaluation requires multi-phase
CT data which previously led to high
patient doses.
Engineers at Siemens took up the challenge. Aiming at turning a difficult procedure into a routine task, they developed MinDose and syngo.CT Cardiac
Function*.

MinDose about 50% reduction of radiation exposure


Conventional ECG multi-phase datasets
are usually acquired with a radiation
dose of 810 mSv. MinDose mode has

now reduced this dose by half. This


means that a full cardiac function
assessment is available with approx.
4 mSv.
The dose-saving effect of MinDose
mode is achieved by ECG-controlled
tube current modulation. Sharp images
are most likely to be obtained during
the diastolic phase, when there is minimal movement in the heart. Therefore,
the tube output is raised to the maximum level during these intervals.
During the remaining, predominant
phase of the cardiac cycle, the tube
current can be reduced to 4%. This is
a unique plus for Siemens tubes since
other tubes only allow a current decrease down to 20%.

24 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

This benefit, however, can only be


achieved by combining SOMATOM CT
scanner MinDose data with syngo.CT
Cardiac Function,* an application running on the basis of the syngo.via**
imaging software.

syngo.CT Cardiac Function


optimally handles MinDose
data
During a multi-slice CT examination of
the heart, large amounts of data are
obtained, but only very few of them are
used for image reconstruction. With
the new syngo.CT Cardiac Function, it
is now possible to use MinDose data for
a full functional assessment.
The syngo.CT Cardiac Function software

News

The assessment of cardiac function also works with noisy MinDose images.
(30% dose savings in comparison with normal ECG Pulsing with 20% plateau)*

defines landmarks in images taken


during a diastole and adapts these anatomic regions for images taken during
other phases of the cardiac cycle. These
intelligent algorithms can perform
highly reliable cardiac anatomy segmentation even with noisy low-dose
data. So in effect, not a single image is
wasted.

CT Cardio-Vascular Engine
offers automated workows
Siemens looked at the concerns of
SOMATOM CT users and has also
addressed clinical challenges such as
time management, cost pressure and
work sharing. Based on syngo.via,**
Siemens has released a completely renewed CT Cardio-Vascular Engine that
almost entirely automates clinical workflows. Radiologists can immediately
start diagnosing thanks to automated
performing pre-processing, the clear
arrangement of physiological parameters. In cardiac function evaluation,
these pre-settings and supportive
evaluation tools enable the user to skip

Having the possibility to quantify


and evaluate a stenosis with one
click while moving through axial
slices tremendously improves my
workow.
Prof. Stephan Achenbach, MD, Erlangen University Hospital, Erlangen, Germany

17 manual steps with a single click and


to complete a full cardiac assessment
within four minutes.

SOMATOM CT scanners with


syngo.via more than the sum
of its parts
The combination of Siemens SOMATOM
CT scanners and syngo.via** adds a
new dimension to cardiac assessment.
For the first time ever, radiologists can
perform full, highly precise zero click

full cardiac assessments with MinDose


CT data. This unique combination allows
them to reduce the dose by up to 50%
and to save a great amount of time and
effort. Thus, workflow optimization has
been taken a step further benefitting
both the radiologist and the patient.
** syngo.CT Cardiac Function Right Ventricle is not
commercially available in the US.
** syngo.via can be used as a standalone device or
together with a variety of syngo.via based software
options, which are medical devices in their own
rights.

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

25

News

Advanced
Imaging for
Four-Legged
Patients
Installing the SOMATOM
Spirit has brought a new
level of patient care to Croft
Veterinary Hospital in Cramlington, Northumberland,
UK, while also increasing
referrals.
In 2008 Croft Vets has opened the doors to its state-of-the-art flagship
veterinary hospital.

In the same way that tertiary care hospitals provide the most advanced medical
care for humans, Croft Veterinary Hospital
in Cramlington, Northumberland, UK,
provides companion animals with
specialized care using state-of-the-art
equipment. Co-founder Malcolm Ness,
BVetMed, says that he and his colleagues wanted to build a referral center
where patient care would not be compromised by technological limitations.
This is why they chose to install Siemens
SOMATOM Spirit multi-slice CT scanner
when they moved to a new and larger
facility in 2008. We just wanted to do
things better and to continue to improve,
largely for the good of the patients,
but also for our own academic and intellectual satisfaction, Mr. Ness says.
While the use of CT in veterinary practices is still relatively rare, Mr. Ness
explains that the Spirit technology has
allowed him and his colleagues to work
more efficiently while improving patient
outcomes. Metastases from mammary
cancers in dogs that were once visual-

By Sameh Fahmy

ized with conventional radiography


taken from three different views are
now rapidly imaged using CT. Mr. Ness
points out that, in addition to saving
time, CT is much more sensitive and
routinely detects tumors less than
1 millimeter in diameter. Cases that
were really quite complex and challenging from a diagnostic imaging point of
view are now very straightforward,
quick and affordable, he says. Planning
spinal surgeries using radiographic
myelography used to require multiple
views and routinely took up to an hour,
whereas a single CT myelography scan
can give surgeons all of the information
they need in minutes. CT also improves
surgical planning for severely comminuted fractures and allows for the visualization of stress fractures in complex
anatomy, such as the hock (the equivalent of the human ankle) in greyhounds.
One feature of the Spirit that is particularly useful, Mr. Ness reports, is the
ability to create three-dimensional
reconstructions almost instantaneously.

26 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

In addition to helping plan surgeries


such as pelvis reconstruction following
a vehicle collision, three-dimensional
images allow him and his colleagues to
better communicate treatment needs
and goals to their clients, the pets owners. He says the Spirit offers the ideal
combination of image quality, reliability
and ease of use.
Leasing through Siemens Financial
Services allowed Mr. Ness to reduce his
upfront financial investment and made it
easier to plan his cash flow, and his
investment has already resulted in
increased referrals. We get a number of
cases specifically because we have the
CT, Mr. Ness says, and when were out
talking to referring veterinarians, they
never cease to be amazed by the images
and are intensely jealous of the fact that
we have something that can give us such
brilliant pictures at the drop of a hat.
Sameh Fahmy is an award-winning freelance
medical and technology journalist based in
Athens, Georgia, USA

News

SOMATOM Denition AS Open*


Dedicated High-end CT for
Radiation Therapy Planning
By Jan Freund, Business Unit CT, Siemens Healthcare, Forchheim, Germany

At this years annual meeting of the


American Society for Therapeutic Radiology and Oncology (ASTRO), Siemens
introduced the new SOMATOM Definition AS Open* the first and only dedicated, high-end CT system to efficiently
cover both diagnostic radiology and
Radiation Therapy (RT) needs. Because of
its base in diagnostic CT, it delivers cutting edge radiation image quality. In RT,
a precise diagnosis and location of the
tumor is key to an accurate planning,
positioning of the patient and finally to
a successful therapy. For example, the
capability to freeze motion is of highest
importance in order to easily and accurately contour the tumor. The SOMATOM
Definition AS Open is now a fully dedi-

cated RTP system due to its new, specific


RT options and modifications: its bore
diameter was increased to 80 cm. Next
to the regular Field of View (FOV) of
50 cm and the extended FOV of 80 cm,
it now also features an innovative HighDefinition (HD) FOV of 65 cm delivering
the required accuracy to reliably plan
radiation treatments. The dedicated,
multi-purpose table offers a patient load
capacity of 227 kg with a deflection of
less than 2 mm and the new ReferenceFix function takes care of aligning the
relation between the different coordinate systems of the CT system and the
Linac. And even more so, the SOMATOM
Definition AS Open is available as a sliding gantry solution,* so that the patient

The new SOMATOM Definition AS Open*


with its extra large bore.

can be kept on the table at all times.


In addition, Tspace View allows proper
motion management for safe, fast and
easy contouring for non-gated conventional treatments and an open interface
for respiratory gating is also available.
The SOMATOM Definition AS Open will
be available starting March 2011.

* The information about this product is being provided for planning purposes. The product is pending 510 (k) review, and is not yet commercially available in the U.S.

Among Europes Best


By Doris Pischitz, Corporate Communications, Siemens Healthcare,
Erlangen Germany

Siemens Healthcare offers a variety of publications tailored to the customers needs.

Siemens Healthcare Publications received


the Silver Award in the category Best
Crossmedia Solution at the BCP Best of
Corporate Publishing Congress in Hamburg, Germany. Under the topic Healthcare Publications, Siemens Healthcare
submitted its crossmedia publications
portfolio, which consists of the businessto-business magazine Medical Solutions,
the expert magazines SOMATOM Sessions
(computed tomography), AXIOM Innovations (angiography, radiography, and fluoroscopy), MAGNETOM Flash (magnetic
resonance imaging), Perspectives (laboratory diagnostics), and the Healthcare
Newsletter.

The jury of the largest corporate publishing contest in Europe honored the best
publications out of over 600 entries. We
hope you are just as satisfied with our
media as the jury. Dont hesitate to tell us
your opinion at editor.medicalsolutions.
healthcare@siemens.com.
If you would like to subscribe to any of
our periodicals, please visit our websites.

www.siemens.com/healthcaremagazine
www.siemens.com/healthcareeNews

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

27

News

SOMATOM Scanners Ahead of


the Innovative Curve
New Siemens technologies in Computed Tomography lead
to a wider spectrum of indications, providing additional information for generating a more precise diagnosis. Advantages
of these new developments have been scientically validated:
Investigative Radiology published two special issues
dedicated to Advances in CT Technology.
By Heidrun Endt and Stefan Ulzheimer, PhD , Business Unit CT, Siemens Healthcare,
Forchheim, Germany

Investigative Radiology, a worldrenowned journal, published two special


issues in June and July 2010 titled,
Advances in CT Technology. In these
two special issues, 16 out of the 21
studies were done on SOMATOM Scanners which once more exemplifies
Siemens continuous commitment to
improve patient care and highlights
Siemens innovation leadership.

Perfusion Imaging and CT


Angiography
The Adaptive 4D Spiral allows for whole
organ perfusion studies and long-range,
phase-resolved CT-Angiography (CTA). In
a phantom study, the tissue flow values
measured with the use of the Adaptive
4D Spiral correlated very well with those
measured with the standard dynamic
scan modes.1 Morhard et al. from Grosshadern, Munich report on the advantages
of the Adaptive 4D Spiral for brain perfusion CT with the SOMATOM Definition
AS+ in 72 patients. The coverage was
extended to 9.6 cm. Using this new technique, resulted in a different final diagnosis in 34.7% of all exams2 and led to
an augmentation of clinically important
information in the imaging of acute
stroke.2 Helck et al. assessed morphology
and function in kidney grafts with the
SOMATOM Definition AS+ simultaneously.3 Qualitative and quantitative per-

fusion information was acquired


in 21 patients with liver metastases
by researchers from Zurich with the
SOMATOM Definition AS and the
SOMATOM Definition Flash.4 A future
indication could be the evaluation
of perfusion patterns after anti-angiogenetic treatment.

Dual Energy CT
Dual Energy CT (DECT) allows for the
acquisition of a virtual non-enhanced
image and an iodine image with a single
scan, whereas the conventional method

1A

1B

1C

1D

28 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

would need a dual-phase scan: a true


non-enhanced scan and one with the
application of contrast media. Researchers from Grosshadern, Munich evaluated
CT examinations of 202 patients with
renal masses comparing these two examination modes. DECT allows for fast and
accurate characterization of renal masses
in a single-phase acquisition.5 A total
radiation dose of 4.95 mSv was applied
for the DECT enabling a 48.9% 7.0%
dose reduction over the dual-phase protocol.5 The Selective Photon Shield for
the SOMATOM Definition Flash makes an

1 Dual Energy CT
provides all the information needed for the
characterization of
renal masses in a singlephase scan. Diagnosis of
angiomyolipoma in the
left kidney:
1A: information of both
tubes;
1B: virtual non-contrast
image;
1C: iodine image;
1D: overlay of B and C

News

improved separation of the energy spectra


possible and allows for DECT scanning without additional dose. With this technique
Thomas et al. from Tuebingen differentiated
urinary calculi reliably, while Dual Energy contrast was increased.6 The authors suggest:
Also other applications as bone and plaque
removal from DECT-angiographic datasets can
be expected to benefit () because a higher
DE contrast will be advantageous for the separation of iodine and calcium.6

Myocardial Perfusion
Myocardial perfusion imaging is one indication to which the spectrum of Computed
Tomography is extended due to the innovative technology of the SOMATOM Definition
Flash. Mahnken et al. from Aachen report on
initial experience in quantitative whole heart
stress perfusion CT imaging7 in an animal
model. They assume that this technique is
able to show the hemodynamic effect of high
grade coronary stenosis7 and that it exceeds
the present key limitation of cardiac computed tomography.7 First clinical experience
is shown in a study by Bastarrika et al.:

Scanning with the SOMATOM Definition


Flash allows for the evaluation of qualitative and semi quantitative parameters
of myocardial perfusion in a comparable
fashion as with MRI.8

Outlook
Further publications are expected to
come, showing how these new techniques are applied in clinical practice.
The editors of these two special issues
are convinced and conclude: , For sure,
innovative research on imaging technology () will contribute to advances in
clinical medicine and patient care.9
Siemens Computed Tomography will
proceed and will stay committed to its
innovation leadership.
1 Haberland U. et al. Performance assessment of
dynamic spiral scan modes with variable pitch
for quantitative perfusion computed tomography. Invest Radiol. 2010 Jul;45(7):378-86.
2 Morhard D. et al. Advantages of extended brain
perfusion computed tomography: 9.6 cm coverage
with time resolved computed tomography-angiography in comparison to standard stroke-computed
tomography. Invest Radiol. 2010 Jul;45(7):363-9.

3 Helck A. et al. Determination of glomerular filtration rate using dynamic CT-angiography: simultaneous acquisition of morphological and functional
information. Invest Radiol. 2010 Jul;45(7):387-92.
4 Goetti R. et al. Quantitative computed tomography liver perfusion imaging using dynamic spiral
scanning with variable pitch: feasibility and initial results in patients with cancer metastases.
Invest Radiol. 2010 Jul;45(7):419-26.
5 Graser A. et al. Single-phase dual-energy CT allows
for characterization of renal masses as benign or
malignant. Invest Radiol. 2010 Jul;45(7):399-405.
6 Thomas C. et al. Differentiation of urinary calculi
with dual energy CT: effect of spectral shaping
by high energy tin filtration. Invest Radiol. 2010
Jul;45(7):393-8.)
7 Mahnken AH. et al. Quantitative whole heart
stress perfusion CT imaging as noninvasive
assessment of hemodynamics in coronary artery
stenosis: preliminary animal experience. Invest
Radiol. 2010 Jun;45(6):298-305.
8 Bastarrika G. et al. Adenosine-stress dynamic
myocardial CT perfusion imaging: initial clinical
experience. Invest Radiol. 2010 Jun;45(6):306-13.
9 Fink C. et al. Advances in CT technology. Invest
Radiol. 2010 Jun;45(6):289.

http://journals.lww.com/
investigativeradiology

Dual Energy CT with the SOMATOM


Denition on the Cover of Radiology
By Heidrun Endt and Bernhard Krauss,
Business Unit CT, Siemens Healthcare, Forchheim, Germany

A new approach to bone imaging with


Dual Energy CT (DECT) is reported in an
article published in the August 2010
issue of Radiology. The internationally
recognized journal chose the cover
image for this issue from the study
done by Pache et al. on the SOMATOM
Definition.1 Researchers from Freiburg
revealed specific lesions of the bone
marrow, also known as bone bruise, with
a DECT virtual non-calcium technique.
Until now, the diagnosis, bone bruises,
was acquired only from magnetic resonance (MR) imaging. Bone bruise is discussed, to predict associated soft-tissue
injuries1 and to, be a precursor of early
degeneration changes.1
Twenty-one patients with acute knee
traumas, were scanned with an MR as

well as a DECT scan. The applied postprocessing algorithms enabled the


scientists to subtract calcium from the
DECT images so that the marrow space
of the bones could be assessed.
The authors concluded that DECT
might constitute an option for those
patients who have contraindications
to MR imaging or for whom MR imaging
will not be available.1 Potentially, other
pathologic processes (...), such as metastatic spread, could also be detected by
using DECT with higher accuracy or in
earlier stages than with single-energy
CT alone.1
This study shows once again that Dual
Energy CT on SOMATOM Scanners provides a lot of new possibilities waiting
to be discovered.

A new approach to bone imaging with


Dual Energy CT on the SOMATOM
Definition is shown on the cover of
Radiology, August 2010.

1 Pache G. et al. Dual-energy CT virtual noncalcium


technique: detecting posttraumatic bone marrow
lesions-feasibility study. Radiology. 2010 Aug;
256(2):617-24.

http://radiology.rsna.org/
content/256/2.toc

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

29

Business

1,000th SOMATOM Denition AS


Installed A Success Story
Following its introduction at the RSNA 2007, the rst SOMATOM Denition AS
was installed in May 2008. Since then, this unique, single-source CT system
the worlds rst Adaptive Scanner has written an unparalleled success story.
In September 2010, it was crowned with the 1,000th installation. And there
are many more to come.
By Jan Freund, Business Unit CT, Siemens Healthcare, Forchheim, Germany

The updated appearence of the new SOMATOM Definition AS, now with a clear resemblence that it inherited together with multiple features from
the SOMATOM Definition Flash.

Business

With the introduction of the SOMATOM


Definition AS the worlds first Adaptive
Scanner in 2007, Siemens opened
a new chapter in single-source CT technology. The revolutionary idea was to
combine high-end CT imaging for any
clinical task at lowest possible dose with
a scanner design that didnt exclude
patients because of the systems geometry. And all this with a footprint small
enough to fit it into literally minimum
space. The result: for the first time, a
system actively adapts itself to virtually
every clinical situation. Offering a 128slice CT system with a pitch-independent
isotropic resolution of 0.33 mm, a rotation time of 0.3 seconds and 100 kW
generator power, it delivers enough
reserves to meet virtually all clinical
tasks. With a 78 cm bore diameter, a scan
range of 200 cm that can be acquired in
approximate 10 seconds at highest resolution and a table load capacity of up to
300 kg, whole body examinations in
acute care or bariatric imaging were
turned into clinical routine. Groundbreaking innovations introduced new dimensions in CT: the Adaptive 4D Spiral overcame the limitations of a static detector
design and allowed covering whole
organs in 4D and the still unique 3D
interventional suite provided 3D guided
intervention support. This was all realized
within a system that could be fit nearly
everywhere with only an 18 m footprint,
freely selectable air or water cooling and
full on-site upgradeability.
After the first installations, users were
immediately excited. Among the first was
Prof. Joe Schoepf from the Medical University of South Carolina. In an interview,
he commented that the Definition AS
will effectively overcome a number of
limitations we face today. [] All the
guess work is taken out and it has all
the power [] to capture clear images
unmarred by excess noise, even in obese
patients. Following this excitement,
many publications proved that the
SOMATOM Definition AS kept the promises given. In 2009, a new software version was rolled out to all customers,
underlining Siemens dedication to customer care. With innovative features like
Neuro BestContrast, it boosted the

Right after its introduction, the manufacturing lines of the SOMATOM Definition AS
were filled and have remained filled since then.

already outstanding image quality even


further and made IRIS the Iterative
Reconstruction in Image Space available for the SOMATOM Definition AS.
Naturally, this convinced the market and
the result was the fastest ramp-up in
Siemens CTs history. After the first
installation in May 2008, the SOMATOM
Definition AS surpassed 500 installations,
in September 2009, and then achieved
the 1,000th installation in September
2010 in Washington DC, USA.
Now, Siemens has taken the SOMATOM
Definition AS to the next level with the
introduction of FAST CARE at this years
RSNA. For decades, Siemens has spearheaded dose reduction and has introduced many innovations following the
As Low as Reasonably Achievable
(ALARA) principle. For this, Siemens initiated its CARE (Combined Applications to
Reduce Exposure) philosophy more than
15 years ago. Additionally, the SOMATOM
Definition AS brought many innovations
like the Adaptive Dose Shield that, for the
first time, virtually eliminated unnecessary over-radiation in every spiral scan.
The new FAST (Fully Assisting Scanner
Technologies) philosophy now aims to
give customers the possibility to maximize clinical outcome meaning to

achieve best clinical results, but with


significantly less resources bound to the
CT system. The ultimate goal: provide
medical professionals more time for
patients or patient-centric productivity.
The new FAST features, like FAST Planning or FAST Spine, simplify typically time
consuming and complex procedures. The
scanning process gets more structured
and results become more reproducible.
Integrating the capabilities of syngo.via,*
Siemens revolutionary, new imaging
software, the complete examination
from scan preparation to data evaluation
is streamlined. This gives medical professionals significantly more time for
what is of utmost importance: the diagnosis and interaction with their patients,
leading ultimately to improved clinical
results with less patient burden. This
combination of highest image quality at
lowest dose and highest patient-centric
productivity is the lever to maximizing
clinical outcomes. The new SOMATOM
Definition AS with FAST CARE will be
available from March 2011.

* syngo.via can be used as a standalone device or


together with a variety of syngo.via based software options, which are medical devices in their
own rights.

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

31

Business

Time is Brain A Comprehensive Stroke


Program at the University of Utah Helps
Improve Patients Outcome
In the event of a stroke, every minute counts. Therefore, recognizing a stroke
and treating it quickly and properly takes top priority. With its comprehensive
stroke program, the University of Utah is leading the way.
By Michaela Spaeth-Dierl, Medical Editor, Spirit Link Medical, Erlangen, Germany
and Jakub Mochon, Business Unit CT, Siemens Healthcare, Malvern, PA, USA

Stroke is the second leading cause of


death worldwide and the most common
cause for serious, long-term disability
and care dependency. On average,
795,000 persons suffer a new or a
recurrent stroke every year and every
three minutes someone dies of a stroke.

Saving lives and time through


close collaboration
The more time that elapses between
the event of a stroke and the beginning
of therapy, the more brain tissue is
destroyed with corresponding consequences for the affected person,
explains neuro-interventionalist Edwin
A. Steve Stevens, professor and chairman of the department of radiology at
the University of Utah Health Sciences
Center. Thus, an initially small team

consisting of a neuro-interventionalist
Steve Stevens a neuro-surgeon and a
stroke neurologist committed to saving
precious time, developed a stroke program that provides fast and appropriate
treatment of the stroke patient. Part of
this program is the foundation of a
stroke center with a Brain Attack Team
available 24/7. This multi-disciplinary
team now consists of emergency physicians, neurologists, neurosurgeons,
radiologists, and specially trained nurses
and medical staff. This team is notified
as soon as a stroke is suspected, often
even before the patient reaches the
hospital.

Staying ahead of the stroke


A crucial factor for activating the Brain
Attack Team is recognizing a stroke for

what it is. Thus, the stroke program


aims at educating people who are
involved with stroke in order to raise
awareness for its symptoms. This
includes training programs for physicians, rescue workers and nurses, as
well as information events for lay
people since the latter are often the
first to arrive at the scene.

Advanced capabilities for


an accurate diagnosis and
effective therapy
A great advantage of the stroke center
is that it provides the latest in stroke
technology, including CT angiography
as well as diffusion and perfusion MR
imaging for an accurate diagnosis.
Therapies include interventional radiology and advanced neurosurgical

CT perfusion plays a tremendous


role in assessing what tissue is at risk,
which is why performing the study
quickly is so important.
Edwin A. Steve Stevens, MD, Professor and Chairman of Radiology

32 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

Topic

techniques such as removing and dissolving clots or reconstructing ruptured


blood vessels. In order to provide the
best possible care anywhere, and not
just at the University Hospital, the stroke
center has established a TeleStroke
capability that allows the specialized
team to review CT scans performed in
remote counties.

Fast diagnosis, timely therapy


and dose reduction
Once the patient has arrived at the
hospital and the vital functions have
been secured, the next step is to quickly
determine whether the brain attack was
caused by an ischemic or a hemorrhagic
infarction. The time window for initiating a thrombolytic therapy after the
onset of a stroke is currently three
hours. Therefore, the first course of
action is a non-contrast CT.
Those initial few minutes make a tremendous difference in the outcomes
and thats why we streamline the procedure and the process and why we
have real-time interpretation to help us
in those decisions, says Steve Stevens.
The topic of radiation exposure is often
mentioned when talking about CT
imaging. But in contrast to MR, for
example, CT is usually accessible even
in small and rural hospitals, and it
doesnt take much time to perform.
After a therapy decision has been made,
further evaluation by CT angio and
perfusion imaging or MR may follow.
So we want to minimize dose, and we
also want to make sure that were
getting the information we need to
appropriately take care of our patients,
summarizes Stevens.

Success becomes apparent


The success of the stroke program is
evidenced by a better outcome for the
patients. Our patients are now arriving
much earlier than when we initially
started, says Steve Stevens.
Its success is reflected in the higher
level of education for residents and
fellows as well as in additional members
of the team who come from other parts
of the country to participate in this
program.

The University of Utah stroke unit is equipped with latest CT scanner technology using
a SOMATOM Definition AS+ and the Adaptive 4D spiral technology in order to provide
whole brain perfusion in stroke patients. Having a brain attack protocol in place,
In-house stroke neurologists, residents, or fellows from the department of Neurology
quickly assess the patient and immediately proceed with a CT study to determine
the nature of the stroke: ischemic or hemorrhagic.

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

33

Business

syngo.via: Ready for Prime


Time in Clinical Practice
syngo.via,* the revolutionary new medical imaging software, has arrived
in France. The Centre dImagerie Mdicale de lOuest Parisien (CIMOP)
is discovering the benets of this sophisticated yet easily accessible visualization tool, for both routine as well as advanced reading. We met with
Dr. Yves Martin-Bouyer, radiologist at CIMOP.
By Christian Rayr

Its not a long way from Val dOr to


Bizet (see our insert), but for the five
radiologists at the Centre dImagerie
Mdicale de lOuest Parisien (CIMOP),
the West Paris medical imaging centre,
and the doctors who work there, the
journey hasnt been necessary for a long
time. CIMOP has set up a computer and
telephone link to unify patient care
between its two sites in Saint-Cloud and
Paris. In 1998, this centre, which receives
80,000 patients a year and has the
newest image acquisition methods in
every field, equipped itself with a Picture
Archiving and Communication System
(PACS) and a Radiology Information System (RIS) that archives all patient cases.
Radiologist Dr. Martin-Bouyer explains:
Due to the portability of images and the
fact that they can be read on a console,

we can now make use of the best skills


within a team and the geographical location of the practitioner or technician is no
longer an issue. The new syngo.via*
software has played a part in this set-up
in recent months. It is a considerable
plus due to its remarkably quick and
advanced innovative capacities for image
processing and preparation, which are
revolutionizing the diagnostic approach.

No manual intervention
A patient comes to CIMOP for a vascular
scan. Once the image acquisition has
been done, it is transferred to the PACS
where Dr. Martin-Bouyer could do a
simple reconstruction in manual mode.
But with syngo.via*, he can use the case
preparation function instead. A vascular
application is selected and the images

Due to the portability of images


and the fact that they can be read
on a console, we can now make
use of the best skills within a team
and the geographical location of
the practitioner or technician is
no longer an issue.
Dr. Yves Martin-Bouyer, radiologist at CIMOP

34 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

are processed. syngo.via* does the


reconstruction according to the exam
programmed and the pathology looked
for, automatically and without manual
intervention. If I have axial images with
a view of the bones, explains Dr. Martin-Bouyer, syngo.via* automatically
removes the elements not useful for
diagnosis and only displays the images
Im interested in according to the appropriate section. I can see the coronary
arteries directly in 3D, as with an angiogram. I simply click to do a detailed analysis of the vessels, and their trajectory is
displayed. I can revolve around a vessel
with a 360 degree view, measure a narrowing syngo.via* instantly calculates
the percentage and so on.
Heres another example in oncology,
Dr. Martin-Bouyer continues, the acquisition is done with the cancer application, which prompts syngo.via* to do all
the corresponding post-processing.
Hepatic metastases are detected. Now,
syngo.via* automatically measures the
exact volume of each lesion. The data is
then made available to the practitioner
for reading: if he confirms this data, it
is stored in the memory. During the
next exam, this data is displayed on the
screen and the therapeutic results and/
or development of the disease can be
monitored.

Business

it is ready for reading. In Val dOr, the


technicians confirm the time saved. For
a lower limb exam, it used to take them
10 minutes to process the image; they
now need 3 minutes.
Easier and quicker to use and more reliable, syngo.via,* which you can connect
to a standard PC, can be integrated into
all imaging machines and all PACS. We
can expect that such a diagnostic tool
will gradually become a necessity,
predicts Dr. Martin-Bouyer. In autumn
2010, CIMOP will be setting up a dedicated unit for interpretation and postprocessing, where the best skills and best
equipment will be on hand.

syngo.via,* which can connect to a standard PC, can be integrated into all
imaging machines and all PACS.

Reconstruction time halved


The images of various exams, such as
whole body MRI scans (where the series
of images are automatically organized
by stages and sorted into successive
sections), and echograms etc. become
accessible and comparable with a few
clicks. Dr. Martin-Bouyer sums up: In
oncology, the detection and monitoring

of changes in lesions and the quality and


reliability of reporting are significantly
improved now. In vascular, cardiac or
peripheral diseases, it is much quicker
and easier to analyze lesions. The reconstruction time has been halved for the
technician and a coronary scan that took
20 to 25 minutes now takes 10 minutes.
When the technician sends me the exam,

Christian Rayr, an independent journalist


specialized in health and medicine, lives and
works in Paris. He contributes to a number of
professional medical journals and various
health columns in the general press.

* syngo.via can be used as a standalone device or


together with a variety of syngo.via based software
options, which are medical devices in their own
rights.

CIMOP From Saint-Cloud to Paris


The Centre dImagerie Mdicale de lOuest Parisien (CIMOP)
is a professional health facility dedicated to imaging. ISO 9001/
V2000 certified for all of its activities, it is based in two medical/surgery clinics (the Clinique Chirurgicale du Val dOr in SaintCloud and the Clinique Bizet in Paris 16th district) and offers
a whole range of medical examinations: X-rays, echograms,
mammograms, osteodensitometry, scans, magnetic resonance
imaging (MRI), scintigraphy, cardiovascular and interventional
radiology and positron emission tomography (PET). The main
specialties concerned are cardiovascular medicine, oncology
and neurology.
Patient care is computerized from the appointment stage. The
time spent in the clinic is half an hour if the patient doesnt wait
for the results, an hour if he or she discusses the results with
the doctor who has analyzed them, an hour and a half if he or
she waits for the report and copies. Certain exams, vascular
exams in particular, take extra time and are available as soon
as possible on an approved website.

The Centre dimagerie Mdicale de lOuest Pariseien (CIMOP) is based


in two medical/surgery clinics (the Clinique Chirurgicale du Val dOr in
Saint-Cloud and the Clinique Bizet in Paris 16th district)

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

35

Business

SOMATOM Spirit: A Choice That Paid Off


UMDI Medicina Diagnstica, in Mogi das Cruzes, Brazil, was the rst
purchaser of a SOMATOM Spirit in Latin America, a choice that it now
recommends to other healthcare centers in the region.
By Reinaldo Jos Lopes

Almost as soon as the SOMATOM Spirit


was available in the market, Nitamar
Abdala, MD, and his colleagues at UMDI
Medicina Diagnstica in Mogi das Cruzes, a major diagnostic clinic in the
Greater So Paulo area, decided to purchase the new system. In fact, they were
the first in Latin America to do so, a
choice that they have never regretted.
The Spirits capabilities sounded interesting from the start, says Abdala. We
had already had excellent previous experiences with devices produced by Siemens. The cost was pretty reasonable,
even low, one could say, if you take into
account the standard in the market. And
both speed and spatiotemporal resolution
were very good. UMDI is now building
its first hospital, with the intention of
keeping its main focus on diagnosis
while also targeting some treatments.
According to Abdala, the SOMATOM
Spirit was instrumental in helping the
clinic to take this next step.
I have already recommended the Spirit
to five or six small hospitals with which
we have been in touch, he says. It is
ideally adapted to clinics that are starting up. If youre not sure about how big
your demand for exams is going to be, it
is a great machine for routine work. You
can do nearly anything you need to do
with it, leaving just the more complicated imaging involving coronary
arteries, for example, where you need to
image a big area in nearly real time to
more powerful machines.
SOMATOM Spirit in daily routine; in a typical day about 50 exams can be done, although this
number can be as high as 70.

36 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

1A

1B

Topic

1C

1D

Integrated tools add versatility


With the SOMATOM Spirit, the 25 physicians at UMDI in Mogi das Cruzes manage to cover 95 percent of the exams
that their patients require. The remaining 5 percent we basically choose not to
do ourselves, and we forward those
patients to other clinics, says Abdala.
He estimates that, among the exams
that are done with the Spirit, around 20
percent involve imaging of the abdomen;
the other major applications involve the
thorax (15 percent), brain (20 percent)
and head and neck (10 percent).
For all those kinds of cases, he says, the
SOMATOM Spirit was a step forward for
UMDI. Before Spirit, you didnt have tools
like perfusion analysis for tomography,
for example. Its the kind of tool that normally is only available for high-performance equipment, but we can do these
beautifully with Spirit.
Abdala notes that the perfusion tools in
Spirit are especially useful when looking
into a cerebral vascular incident, like ischemia involving the occlusion of the carotid
artery. Of course, in those kinds of cases
you need to know where to look for the
problem. You need to have someone with
clinical expertise, someone who is able to
interpret the clinical signs of the stroke.
But once you know more or less where to
look, the perfusion tool gives you a very
good picture of the lesion thats causing
the problem. (Fig. 1C)
He also says that the Dental Scan tool
has been very useful. It has helped to
bring to the clinic patients that normally
wouldnt be there those who need to
be checked for the feasibility of a dental
implant. Its a simple tool, but very
effective, says Abdala. Basically, what

1 A, B: Nitamar Abdala, MD, is convinced that SOMATOM Spirit fulfills the expectations of small
hospitals and furthermore offers a wide range of capabilities. C: Perfusion: Hypoperfused area
right frontal in this axial slice. D: Dental: Mandibula and molars in volume rendered technique

it does is to give you a very good sense


of the width of the bone, so that you
can say, with a great degree of confidence, whether theres enough space for
an implant there, and what is the best
way to place it while taking into account
the width of the bone. (Fig. 1D)

Quick return on investment


SOMATOM Spirits capabilities of volume
rendering are also very useful for many
kinds of cerebral vascular diagnosis, says
Abdala, especially when it comes to
imaging the Circle of Willis, a well-known
hotspot for aneurysms. When a patient
is being prepared for angiography, Spirits CARE Bolus is a valuable pre-tool, as
he puts it. It helps you to time, quite
precisely, the injection of the contrast
with the imaging of brain arteries, for
example.
All of Spirits features have made workflow at UMDI twice to three times as
fast, according to Abdala. The machine
itself is quite easy to work with, and
the software is very user-friendly, he
says. From the time you enter the room

until the time you exit it, you need


only minutes for each patient. Technician
Marcelo Francisco Cardoso agrees: In a
very short time, the patient can have the
procedure and leave the clinic with his
or her exam in hand. Theres no need for
the patient to come back to pick up the
results later.
In a typical day, says Abdala, about 50
exams can be done, although this number can be as high as 70. With the
demand for exams that we have, the
equipment has paid for itself in two to
three years, he explains.
Abdala reports that the increased speed
in workflow was the main factor behind
the quick return on the investment that
UMDI reaped from the SOMATOM Spirit.
He also notes that the useful life of Spirits components is quite long when compared to other machines, which has also
helped the clinic to save money in the
long term. That was another good surprise, he concludes.
Reinaldo Jos Lopes is the science editor
at Folha de S.Paulo, Brazils largest daily
newspaper.

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

37

Clinical Results Cardio-Vascular

Case 1
SOMATOM Denition Flash:
Ruling out Coronary Artery Disease
with 0.69 mSv
By Ralf W. Bauer, MD, J. Matthias Kerl, MD and Thomas J. Vogl, MD
Goethe University Clinic, Department of Diagnostic and Interventional Radiology, Frankfurt, Germany

HISTORY
A 68-year-old patient with atypical
chest pain and known, year-long arterial
hypertension presented at the radiology
department in order to rule out coronary
artery disease. Ultrasound showed concentric left ventricular (LV) hypertrophy
and aortic valve stenosis, grade 1. The
resting heart rate was 50 bpm and no
beta-blockers were injected.

DIAGNOSIS
Coronary CT angiography using the prospectively ECG-gated Flash Spiral was
performed utilizing only 0.69 mSv radia-

tion dose. Mild concentric LV hypertrophy and minor calcifications of the aortic
valve were found. There was no sign of
macroangiopathic arteriosclerotic changes
in the main coronary arteries and their
major branches. Coronary artery disease
could be ruled out in this patient.

ease in this normal-sized adult patient


(185 cm / 86 kg) with a DLP of 49. The
smallest myocardial branches of the
right coronary artery (RCA), left anterior
descending artery (LAD) and left circumflex coronary artery (LCX) could be visualized, underlining best image quality
at lowest dose values.

COMMENTS
In only 0.29 seconds scan time without
the use of beta-blockers, Coronary CT
angiography using 100 kV tube voltage
and the Flash Spiral acquisition mode
allowed ruling out coronary artery dis-

1 Volume rendered
display of the major
coronary arteries
was underlined with
multi-planar reconstruction (MPR).
2 Caudo-cranial
view of the distal
part of the right coronary artery (RCA)
and patent ductus
arteriosus (PDA).

38 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

Cardio-Vascular Clinical Results

3 Curved planar
reformatted (CPR)
display of the RCA.
4 90 degree
angulated view of
the RCA (compared
with Fig.3).

5 Curved planar
reformatted (CPR)
display of the left
anterior descending artery LAD.
6 CPR display of
the entire course
of the LAD.

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition Flash

Scan mode

Flash Spiral

Rotation time

0.28 s

Scan area

Heart

Pitch

3.4

Scan length

135 mm

Slice collimation

128 x 0.6 mm

Scan direction

Cranio-caudal

Slice width

0.75 mm

Scan time

0.29 s

Reconstruction increment

0.4 mm

Heart rate

50 bpm

Reconstruction kernel

B26f

Tube voltage

100 kV / 100 kV

Contrast

Tube current

370 mAs/rot.

Volume

70 ml

Dose modulation

CARE Dose4D

Flow rate

5 ml/s

CTDIvol

2.59 mGy

Start delay

Test bolus

DLP

49 mGy cm

Postprocessing

syngo InSpace4D

Effective Dose

0.69 mSv

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

39

Clinical Results Cardio-Vascular

Case 2
SOMATOM Denition Flash:
Low-Dose Abdomen Pediatric Scan: Follow-Up
Study of Fibromuscular Dysplasia
By Pia Sfstrm, MD, Nils Dahlstrm, MD and Petter Quick
Department of Radiology and Center for Medical Image Science and Visualization (CMIV),
Linkping University Hospital, Linkping, Sweden

40 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

1 Fused volumerendered view showed


variant vascular anatomy consisting of
the common hepatic
artery (arrow).

Cardio-Vascular Clinical Results

HISTORY

DIAGNOSIS

COMMENTS

A seven-year-old boy who had been


diagnosed two years prior with fibromuscular dysplasia (FMD) of a right
renal segmental artery causing severe
hypertension, presented at our department for a follow-up study. After successful balloon angioplasty, the blood
pressure normalized. On a follow-up CT
angiography, small caliber changes in
the superior mesenteric and gastro-duodenal arteries were suspected. Later
follow-up CTA showed no progression of
these findings but new, minute changes
in the renal arteries were noted. Further
monitoring with CTA is warranted.

A fibromuscular dysplasia (FMD) of the


renal arteries caused the hypertension.
This led to the suspicion of FMD in
visceral arteries. CT imaging showed
variant vascular anatomy consisting of
the common hepatic artery arising
from the superior mesenteric artery
(Fig. 1 and Fig. 3).

CTA provides accurate visualization


of the visceral and renal arteries.
Low-dose CT technique is advocated
in pediatric patients, especially when
repeated follow-up examinations are
expected. In this case the total effective dose was 0.88 mSv using the
published conversion factor from DLP
to effective dose of 0.02 mSv /
(mGy cm) for a five-year-old abdomen
exam.

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition Flash

Scan mode

Flash Spiral

Rotation time

0.28 s

Scan area

Abdomen

Pitch

Scan length

240 mm

Slice collimation

128 x 0.6 mm

Scan direction

Cranio-caudal

Slice width

0.75 mm

Scan time

0.6 s

Reconstruction increment

0.6 mm

Tube voltage

80 kV

Reconstruction kernel

B31f

Tube current

88 mAs

Contrast

Dose modulation

CARE Dose4D

Volume

20 ml, 320 mg/ml

CTDIvol

1.4 mGy

Flow rate

2 ml/s

DLP

44 mGy cm

Start delay

CARE Bolus, trigger 130 HU

Eff. Dose

0.88 mSv

Postprocessing

syngo 3D Basic

2 A coronal curved inverted maximum intensity


projection (MIP) view discovered both renal arteries

3 A curved inverted maximum


intensity projection (MIP) allowed
this view on the hepatic artery
(arrow).

4 Coronal inverted MIP showed


superior mesenteric artery

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

41

Clinical Results Cardio-Vascular

Case 3
CT Dynamic Myocardial Stress Perfusion
Imaging Correlation with SPECT
Kheng-Thye Ho, FACC,* Kia-Chong Chua, MSC,*
Ernst Klotz,** and Christoph Panknin,**
*Department of Cardiology, Tan Tock Seng Hospital, Singapore, Republic of Singapore
**Business Unit CT, Siemens Healthcare, Forchheim, Germany

1A

1B

2A

2B

1 CT dynamic stress MPI with SPECT


correlation in the mid-ventricular short
axis (1A) and the horizontal long axis
view (1B). Stress are images in the
upper quadrants, rest images below;
CT perfusion to the left of the corresponding SPECT.

2 Invasive angiography findings:


Total occlusion of the proximal LAD
and a 90% lesion in OM3 (2A, arrow),
and 75% lesion in the RPDA branch
of the otherwise normal RCA (2B,
arrowhead).

HISTORY
A 61-year-old male with cardiac risk factors of hypertension and hyerlipidemia
presented with symptoms of atypical
chest pain. Resting ECG was unremarkable. Dipyridamole-stress nuclear myocardial perfusion imaging (NMPI) had demonstrated a very large, reversible defect
involving the apex, anterior wall and septum. The total defect size was quantified

as 34% of the left ventricle. Left ventricular ejection fraction was estimated as
65% in the post-stress images by gating.
Post-stress dilatation was noted in the
scan, which is an adverse prognostic sign
in the presence of coronary artery disease. Invasive coronary angiography
demonstrated total occlusion of the proximal LAD, with collaterals arising from

42 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

both the LCx and RCA. There was also a


90% lesion in the third obtuse marginal
branch (OM3) and a 75% lesion in the
right posterior descending artery (RPDA)
branch of the right coronary artery
(RCA). CT myocardial perfusion imaging
(MPI) was performed prior to CABG.[1]
The patient underwent successful coronary bypass surgery, with a left internal

3A

3B

3C

Topic

3 Good correlation of CT MPI and


SPECT for apex (3A), mid-ventricular
(3B), and base short axis views (3C) as
well as vertical (3D) and horizontal
(3E) long axis views. Arrangement of
Stress/Rest/CT/SPECT as in image 1.

3D

3E

mammary artery (LIMA) to the mid-left


artery descending (LAD), saphenous
vein graft (SVG) to RPDA and OM.

myocardium was 0.90 cc/cc/min and


0.81 cc/cc/min at stress and rest, respectively.

DIAGNOSIS

COMMENTS

CT dynamic stress MPI demonstrated a


reversible defect in the apex, anterior
wall, and septum as seen in NMPI. The
myocardial blood flow (MBF) of the
anterior wall and septum during application of dipyridamole-stress was 0.57
cc/cc/min (blue), whereas the normal
tissue, i.e., the inferior wall and lateral
wall, had an MBF of 1.09 cc/cc/min
(red). In the rest-scan, the defect
resolved and MBF was similar to that of
the normal myocardium at rest, 0.82 cc/
cc/min and 0.81 cc/cc/min (yellowgreen). The mean MBF of the normal

Another relevant finding was the reduction of MBF in the defect area at stress
even below its MBF at rest. This is evidence of a horizontal myocardial steal
occurring during vasodilator stress. These
findings are compatible with the angiographic findings of severe, complete
occlusion of the proximal LAD, and the
presence of collaterals from the left circumflex coronary artery (LCx) and right
coronary artery (RCA). In the normal resting situation, collaterals form LCx and RCA
supply the myocardium in the occluded
LAD territory. During vasodilator stress,

vascular resistance in the LCx and RCA


bed drops, and blood preferentially flows
into these territories, even from the LAD
territory, resulting in reduction of MBF in
septum and anterior wall below that in
the rest scan (0.57 cc/cc/min compared to
0.82 cc/cc/min). The LAD bed is already
maximally vasodilated due to the pre-existing complete occlusion of LAD, and the
vascular resistance is unable to be reduced
further. Hence the steal phenomenon.
The absence of a perfusion defect in the
LCx territory in both CT MPI and NMPI
suggests that flow reserve is maintained
there despite the presence of stenosis in
the LCx.
1 Stress and Rest Dynamic Myocardial Perfusion Imaging by Evaluation of Complete Time-Attenuation
Curves With Dual-Source CT. JACC Imaging 2010;
3: 81120. KT Ho, KC Chua, E Klotz, C Panknin.

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition Flash

Scan length

73 mm

Slice collimation

128 x 0.6 mm

Scan time

30 s

Reconstruction increment

2 mm
B25

Heart rate

82 bpm for stress image, 73 bpm for rest image

Reconstruction kernel

Tube voltage

100 kV

Contrast

Ultravist 370 mg iodine / ml

Tube current

300 mAs/rot

Volume

60 ml

Flow rate

6 ml/s

CTDIvol

653 mGy (stress), 649 mGy (rest)

Start delay

Scan start 4 s before arrival


of contrast in left ventricle

Rotation time

285 ms

Postprocessing

syngo VPCT Body Myocardium

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

43

Clinical Results Oncology

Case 4
SOMATOM Denition Flash
Motion-free Thoracic Infant Scan: Follow-Up
Study After Chemotherapy
By Susann Skoog, MD, Nils Dahlstrm MD, and Petter Quick
Department of Radiology and Center for Medical Image Science and Visualization (CMIV),
Linkping University Hospital, Linkping, Sweden

HISTORY

DIAGNOSIS

A three-year-old boy with small


(7-8 mm diameter) lung metastases
from a germ-cell tumor, successfully
treated with chemotherapy, was
referred for follow-up CT of the thorax.
In a previously acquired CT-examination
without sedation, utilizing DLP 51.95
mGycm, 3.28 mGy CTDi vol / scan
length 140 mm, the patient had been
cooperative.
In the present Flash scan, no remaining
metastases were identified and the
serum tumor marker Alpha Fetoprotein
(AFP) levels were normal.

The ultra-fast thoracic scan mode, using


pitch value of 3, did not reveal any metastatic lesions or other pathological findings in the thorax. Both lungs were well
perfused and there was no sign of any
enlarged lymph nodes. The size of the
thymus was increased moderately.
Inverted maximum intensity projection
(MIP) showed a regular bronchial tree.

COMMENTS
Continuous follow-up CT examinations
are necessary to monitor the treatment
effect and determine the complete

patient response. Using the high-pitch


spiral acquisition of the SOMATOM
Definition Flash CT, patients can always
be examined with greatly reduced radiation dose in comparison to standard CT
protocols. In this case only 0.54 mSv*
were necessary to be applied.
The fast scan mode which acquired the
patients thorax in only 0.42 seconds
avoided the need to sedate this pediatric
patient. The resulting images were
obtained motion free and delivered excellent and valuable data for a safe diagnosis without the need of a second scan.

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition Flash

Scan mode

Flash Spiral Thorax

Eff. Dose

0.54 mSv

Scan area

Thorax CTA

Pitch

Scan length

172 mm

Slice collimation

128 x 0.6 mm

Scan direction

Cranio-caudal

Slice width

0.75 mm

Scan time

0.42 s

Reconstruction increment

0.6 mm

Tube voltage

120 kV

Reconstruction kernel

B31f

Tube current

20 mAs

Contrast

Dose modulation

CARE Dose4D

Volume

30 ml Ultravist 370 mg / ml

CTDIvol

1.23 mGy

Flow rate

1 ml/s

Rotation time

0.28 s

Start delay

30 s

DLP

30 mGy cm

Postprocessing

syngo InSpace4D

*Effective Dose was calculated using the published conversion factor for a pediatric (5 year old) chest of 0.036 mSv (mGy cm)-1 [1].
To take into account that Siemens calculates the CTDi in a 32 cm CTDi phantom, an additional correction factor of 2 had to be applied.
[1] McCollough CH et al Strategies for Reducing Radiation Dose in CT.

44 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

2 A sagittal view highlights the absence of motion,


especially visible in the patients diaphragm (arrow).

1 CT imaging resulted in a fused volume rendered view


of the entire chest.

3 Inverted Maximum Intensity Projection (MIP)


shows a regular bronchial tree.

4 Bilateral well-perfused lung in this coronal view


could be recognized.

5 Coronal view from previous CT Scanner (51.95 DLP,


arrows) showed motion caused by breathing.

6 Sagittal view from previous CT Scanner (arrows) of


breathing patient made diagnosis more difficult.

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

45

Clinical Results Oncology

Case 5
SOMATOM Denition Flash: Dual Energy
Carotid Angiography for Rapid Visualization
of Paraganglioma
By Joo Carlos Costa, MD;* J. Oliveira, MD;* J. Dinis, MD;* R. Duarte, MD;* O. Borlido, RT;* M. Gonalves, RT;*
D. Martins, RT;* S. Silva, RT;* D. Teixeira, RT,* A. Chaves,** and Andreas Blaha**
* Radiology Department, Hospital Particular de Viana do Castelo, Viana do Castelo, Portugal
** Business Unit CT, Siemens Healthcare, Forchheim, Germany

HISTORY

DIAGNOSIS

A 30-year-old female patient with a oneyear history of progressive growth of a


right cervical mass was referred to the CT
department. There were no associated
local symptoms. The patient did not complain of pain but reported physical weakness. An echo-doppler study revealed a
well-defined solid mass between the
internal and external right carotid arteries with intense arterial irrigation being
suggestive of a paraganglioma.

A Dual Energy CT angiography examination confirmed a solid mass with the size
of 2.5 cm in diameter, located in the right
carotid bulb which could lead to carotid
paraganglioma. The arterial enhancement of the carotid arteries did not show
any signs of stenoses or occlusions.
There is no vascular abnormity present in
the Circle of Willis. Due to exact contrast
timing, venous contamination could be
avoided.

A typical sharp delineation of the lesion


in the right carotid artery confirmed the
suspicion of paraganglioma. The patient
was referred to surgery where the initial
diagnosis could be confirmed.
A complete isolation and resection of the
paraganglioma could be achieved.
Convalescence of the patient was short
and no complications arose.

1 Dual Energy VRT of


the right carotid artery
shows a cervical mass.

2 Dual Energy VRT


view of right carotid
artery, focusing on
carotid bifurcation
(arrow).

46 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

Oncology Clinical Results

COMMENTS
The SOMATOM Definition Flash allows
the acquisition of Dual Energy examination at a low-dose level of 0.84 mSv.
Using syngo DE Direct Angio, the

cervical spine could be immediately


hidden and the vascular status was
immediately visible.
Vascular examinations are acquired in
Dual Energy technique allowing fast

diagnosis and the additional benefit


from second contrast for tissue characterization or virtual non-contrast (VNC)
that eliminates the need for an additional non-contrast scan.

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition Flash

Scan mode

Dual Energy

Slice width

1 mm

Scan area

Carotid CTA

Reconstruction increment

0.5 mm

Scan length

185 mm

Spatial Resolution

0.33 mm

Scan direction

Cranio-caudal

Reconstruction kernel

D26f

Scan time

5s

DLP

68 mGy cm

Tube voltage

140 kV / 100 kV

Effective Dose

0.84 mSv

Tube current

139 / 139 eff. mAs

Contrast

Dose modulation

CARE Dose4D

Volume

CTDIvol

3.29 mGy

Flow rate

5 ml/s

Rotation time

0.28 s

Start delay

6s

Slice collimation

64 x 0.6 mm

PostProcessing

syngo Dual Energy Direct Angio

70 ml contrast

3 Axial MPR highlights vascular status of the paraganglioma (arrow).

4 Coronal MPR of
the paraganglioma
(arrow).

5 Coronal angio
view compares both
carotids.

6 Lateral angio
view focusing on
paraganglioma in
carotid bulb
(arrow).

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

47

Clinical Results Oncology

Case 6
Total Occlusion of the Left Superior
Pulmonary Vein by a Metastasis Detected
with Dual Energy CT
By Luca Flors, MD, Carlos Leiva-Salinas, MD, Klaus D. Hagspiel, MD
Department of Radiology, University of Virginia, VA, USA

DIAGNOSIS

HISTORY
A 58-year-old male patient with history of
metastatic melanoma (pulmonary, pleural mediastinal and brain metastases),
recurrent malignant pleural effusion that
required multiple episodes of thoracocentesis and recent right thoracoscopic talc

pleurodesis (specific form of chemical


pleurodesis), was presented with acute
onset of shortness of breath and tachycardia. He was referred to our department for CT angiography in order to rule
out pulmonary thromboembolism.

The Dual Energy CT images showed multiple bulky mediastinal, bilateral hilar
and right pleural metastases. The left
mediastinal lesions produced encasement and occlusion of the left superior
pulmonary vein. The Dual Energy
perfused blood volume (PBV) images
revealed a severe perfusion defect in the
left upper lobe, caused by the complete
tumoral occlusion of the left upper pulmonary vein. Smaller caliber of vessels
were noted in the low-attenuating portion of the under-perfused lung.

COMMENTS

1 CTPA coronal sub-volume, Maximum Intensity Projection (MIP) shows right and left hilar,
mediastinal as well as right pleural metastases. The left hilar mass encases and occludes the
left superior pulmonary vein (arrow). The left upper pulmonary artery remains permeable
(arrowhead).

48 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

One of the main pulmonary applications


of PBV Dual Energy CT is the assessment
of perfusion defects due to pulmonary
embolism. However, alterations in pulmonary perfusion are not caused only
by disruption of the arterial supply but
also by problems with venous drainage.
The simultaneous evaluation of the
iodine perfusion map and the morphological CT angiographic images allows
precise evaluation of the derangements
in the pulmonary vascular supply or
drainage and their resulting perfusion
defects. This information is obtained
from one single scan and thus without
dose penalty.

2A

2B

2 Axial (Fig. 2A) and coronal (Fig. 2B) images in lung window setting show relative hypodensity of the left upper lobe, a large left pulmonary effusion and a right hilar mass with near complete occlusion of the superior vena cava. Smooth septal thickening is also seen in the right
upper lobe, most likely due to interstitial edema. Chest drainage tubes are seen in the right arrow pleural space as well as a small amount of
pleural air related to the recent pleurodesis.

3A

3B

3C

3 Coronal (Fig. 3A and 3B) and axial (Fig. 3C) Dual Energy Lung PBV images demonstrate near complete loss of perfusion of the left upper
lobe caused by metastasis occluding the left superior pulmonary vein. Alteration of the perfusion is also noted within the right upper lobe
due to septal thickening.

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition

Scan mode

Dual Energy Lung

Scan area

Thorax

Slice collimation

0.6 mm

Scan length

308 mm

Slice width

1.5 mm

Scan direction

Cranio-caudal

Reconstruction increment

1 mm

Scan time

10 s

Reconstruction kernel

B30f

Tube voltage A/B

140 kV / 80 kV

Contrast

Tube current A/B

93 eff. mAs / 382 eff. mAs

Volume

100 ml of 350 mg/ml

Dose modulation

CARE Dose4D

Flow rate

4 ml/s

CTDIvol

16.90 mGy

Start delay

17 s

Rotation time

0.5 s

Postprocessing

syngo DE Lung PBV

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

49

Clinical Results Oncology

Case 7
SOMATOM Spirit: Follow-Up Examination
of Cerebral Meningioma
By Wolfgang Gerlach, MD,* Andreas Blaha**
*Private Practice, Heidenheim, Germany,
**Business Unit CT, Siemens Healthcare, Forchheim, Germany

HISTORY
This 74-year-old female patient underwent a regular follow up procedure
of the known meningioma located
in the ventral part of the clivus. To
exclude progress of the meningioma
a CT-Angiography was ordered.

timing an automatic contrast bolus


tracking software (CARE Bolus CT) was
utilized. CT provides the exact measurement and location in the very dense

region of the patients meningioma and


makes it the preferred visualization
method for detecting and monitoring
cerebral meningioma.

DIAGNOSIS
The cerebral CT-Angiography (CTA) was
performed with 80 ml of contrast media
to achieve a good delineation of the
meningioma. A homogeneous opacification of the lesion needed to be achieved
(Mean density could be measured with
110 Hounsfield units, HU). The meningioma is situated at the clivus, almost
extending to the foramen magnum. The
size was measured with 2.9 x 2.5 cm.
The sagittal view of the CTA shows the
extension towards the spinal cord, but no
derogation of the spinal cord could be
seen. No abnormity of the cerebral vascular system could be detected.

COMMENTS
The patient requires continuous monitoring to detect early signs of progression
of the lesion. Therefore a low dose protocol was selected 0.5 mSv*. No progression could be observed, so the next
monitoring examination is recommended
in 12 months.
To achieve the pure arterial contrast
*Effective Dose was calculated using the published conversion factor for an adult head of
0.0021mSv (mGy cm)-1 [1].
[1] McCollough CH et al. Strategies for Reducing Radation Does in CT, Radiol. Clin. N. Am. 47:
(2009) 27-40.

1 Cranio-caudal view of the CTA, good opacification of the meningioma (arrow).

50 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

Oncology Clinical Results

EXAMINATION PROTOCOL
Scanner

SOMATOM Spirit

Scan mode

Spiral

Pitch

1.5

Scan area

Head

Slice collimation

1.5 mm

Scan length

66 mm

Slice width

2 mm

Scan direction

Caudo-cranial

Reconstruction increment

1 mm
H31s

Scan time

22 s

Reconstruction kernel

Tube voltage

130 kV

Contrast

Tube current

165 eff. mAs

Volume

80 ml

CTDIvol

33 mGy

Flow rate

2 ml/s

Rotation time

1.5 s

Start delay

CARE Bolus

DLP

239 mGy cm

Postprocessing

syngo InSpace4D

Eff. Dose

0.5 mSv

3 Caudo-cranial view of the meningioma, mean


densitiy values of 110 HU.

2 View of the meningioma showing (arrow) arteria communis posterior exiting.

4 Sagittal view of meningioma, no spinal cord


disturbance (arrows).

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

51

Clinical Results Neurology

Case 8
SOMATOM Denition Flash:
Improving Image Quality of Brain Scans With
IRIS, X-CARE and Neuro BestContrast
By Dominik Augart, Barbara Wieser and Christoph Becker, MD
Department of Radiology, Ludwig-Maximilians-University, Munich, Germany

HISTORY

COMMENTS

A 76-year-old female patient with a


chronic dural hematoma following a fall
presented at our department. The first
scan was performed 24 hours after the
fall with a SOMATOM Sensation, 64-slice
scanner utilizing CARE Dose4D. To check
progress of the wound, a follow-up scan
of the skull was requested. An additional
exam was taken 7 days later with a
SOMATOM Definition Flash utilizing IRIS,
X-CARE, and Neuro BestContrast.

Due to the newest scan and reconstruction technologies, a significantly better


image quality resulted making a better
delineation of bleeding possible. The
differentiation between old and new
blood was also substantially improved.
A further significant advantage of these
new procedures is not only better image
quality but also dose reduction. In our

follow-up study, we were able to determine, in addition to an overall dose


reduction, close to 40% less dose
applied to the eye lens. This is particularly important in order to minimize
the possibility of long-term damage to
the eye lens for young patients who
must undergo repeated scans.

EXAMINATION PROTOCOL
DIAGNOSIS
The first scan revealed a chronic subdural hematoma with old as well as
fresh blood. There was no indication of
intra-cerebral, subarachnoid or intraventricular bleeding. Additionally, there
was no indication of an ischemic event.
A significantly better judgment of the
spread and differentiation between old
and new blood as well as the chronic
subdural hematoma was first possible
with the second examination one week
later. This clearly showed additional
hypodense structure indicating fresh
bleeding that could not be detected in
the previous examination.

Scanner

SOMATOM Definition Flash

Scan area

Head

Head

Scan length

150 mm

150 mm

Scan direction

Cranio-caudal

Cranio-caudal

Scan time

9s

30 s

Tube voltage

120 kV

120 kV

Tube current

320 mAs

306 mAs

Rotation time

1.0 s

1.0 s

Dose modulation

CARE Dose 4D, X-CARE

CARE Dose4D

CTDIvol

42.21 mGy

49.80 mGy

DLP

661 mGy cm

761,88 mGy cm

Effective Dose

1.4 mSv

1.6 mSv

Slice collimation

128 x 0.6 mm

40 x 0.6 mm

Slice width

5 mm

5 mm

Reconstruction
kernel

J37s

H37

52 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

SOMATOM Sensation 64

1B

1A

Flash

S64

1 Significantly improved image quality to delineate the bleeding (arrow). Chronic dural hematoma (Fig. 1B arrow).

2A

2B

Flash

S64

2 Fresh bleeding could be outlined by the hypodense structure (arrow) that couldnt be clearly seen in the initial examination (Fig. 2B arrow).

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

53

Clinical Results Neurology

Case 9
Volume Perfusion CT Neuro as a Reliable Tool
for Analysis of Ischemic Stroke Within Posterior
Circulation
By Philipp Glitz, MD
Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany

HISTORY

A 90-year old male patient was brought


to our hospital with a right-sided hemiparesis and aphasia existing for two and
a half hours. Physical examination
showed an NIHSS (National Institute of
Health stroke score) of 18. No history of
neurological disorders or absolute
arrhythmia was known. From the clinical
appearance it was suspected that the
symptoms could be caused by an infarction within the left middle cerebral
artery territory.

DIAGNOSIS

1 Delayed Time to peak (TTP) and prolonged mean transit time (MTT) show a delay of blood
flow in the whole left PCA-territory including the thalamus and the left cerebral peduncle
whereas cerebral blood volume (CBV) and cerebral blood flow (CBF) were unchanged.

54 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

The neuro-radiologic examination


started with a cranial, non-enhanced CT
(NECT) scan for ruling out intracranial
hemorrhage or tumor. A short segment
of the proximal part of the left posterior
cerebral artery (P1-segment of PCA) was
found to be hyperdense as a sign of
thrombembolic occlusion. The grey and
white matter distinction was not altered.
Next a volume perfusion CT (VPCT) was
performed. It revealed a delayed time to
peak (TTP) of the whole left PCA-territory including the thalamus and the left
cerebral peduncle. Also the mean transit
time (MTT) was prolongated. On the
other hand there was no definable
reduction of the cerebral blood volume
(CBV) and the cerebral blood flow within
the PCA-territory. Additionally, measure-

Neurology Clinical Results

2 CT-angiography (CTA) detected the P1-segment occlusion


(arrow) on the left side.

ment of the permeability was performed, which was slightly increased


only in a few cortical parts. This could be
interpreted as a predictor of a reduced
risk of developing a hemorrhagic stroke
transformation.
In correlation to the early stroke sign of
the NECT the CT-angiography (CTA)
detected the P1-segement occlusion on
the left side. The P2- and P3-segment of
the PCA were regularly contrasted, pre-

3 Fusion of CTA and TTP delay indicate the occlusion (arrow) and
the corresponding perfusion delay in the PCA-territory (arrowhead).

sumably via the (also in the CTA visible)


left posterior communicating branch
from the anterior circulation. The parameter constellation of the VPCT indicated a large penumbra volume and so it
was decided to start an intravenous lysis
therapy. The therapy was successful and
the patient recovered remarkably. The
follow-up NECT on next day showed no
delineation of any infarction.

COMMENTS
This case illustrates, that VPCT allows a
reliable analysis concerning ischemic
stroke changes also within the posterior
circulation territory including thalamus
and midbrain. Moreover, the VPCT can
be used as a quick, feasible tool for the
assessment of the tissue at risk and
thereby the patient management could
be influenced.

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition AS+

Scan mode

Adaptive 4D Spiral

Slice collimation

0.6 mm

Scan area

Head

Slice width

3 mm

Scan length

96 mm

Reconstruction increment

1 mm

Scan direction

Caudo-cranial and cranio-caudal

Reconstruction kernel

H20f

Scan time

46 s

Contrast

Ultravist 370 mg/ml

Tube voltage

80 kV

Volume

30 ml

Tube current

200 mAs

Flow rate

5 ml/s

CTDIvol
Rotation time

218 mGy
0.3 s

Postprocessing

syngo Volume Perfusion CT Neuro

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

55

Clinical Results Acute Care

Case 10
Dual Source, Dual Energy CT:
Improvement of Lung Perfusion Within 5 Hours
in a Patient With Acute Pulmonary Embolism
By Tetsuro Nakazawa, MD; Masahiro Higashi, MD, PhD; Hiroaki Naito, MD, PhD
Department of Radiology, National Cardiovascular Center, Osaka, Japan

HISTORY

DIAGNOSIS

A 70-year-old woman complained about


dyspnea and chest discomfort on exertion.
The symptoms gradually worsened and she
was referred to our center with suspicion
of acute coronary syndrome. An ECG was
almost normal, but laboratory test results
showed mild, increased fibrinogen, and
Ultrasound Cardiography (UCG) showed
right ventricle dilatation and tricuspid
regurgitation. From these results, we
suspected pulmonary thromboembolism
and ordered a Dual Energy CT scan.

The first Dual Source CT examination


in the Dual Energy mode was taken at
11:30. The mixed images revealed
thrombi in both pulmonary artery trunks
reaching into the branches and the
patient was diagnosed with pulmonary
embolism. Dual Energy lung perfused
blood volume (PBV) images showed
perfusion defects in the right lung and
the left lingular and lower lobe corresponding to the location of the thrombus.

Heparin therapy was started. Thrombolytic therapy was planned, and then
an Inferior Vena Cava (IVC) filter was
placed. The patient felt instant relief
from dyspnea and therefore a follow-up
Dual Energy CT scan was performed at
16:30. The mixed CT images revealed
that the thrombus was unchanged compared to five hours earlier. Yet, the Dual
Energy lung PBV images showed that
the patients lung perfusion had
improved.

1A

1B

2A

11:30
1C

11:30
1D

11:30

2C

11:30

1 CT at 11:30 shows thrombus located in both pulmonary arteries (Fig. 1A and 1B).The Lung
PBV Dual Energy data revealed a significant reduction of pulmonary perfusion (Fig. 1C and 1D).

56 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

16:30

16:30
2 After initiating heparin therapy no
reduction of thrombus could be observed
(Fig. 2A and 2B),

Acute Care Clinical Results

Considering the patients age and physical condition, a wait-and-see approach


was decided and anti-coagulation with
heparin and warfarin were continued.
The patients symptoms gradually
improved. One week later we confirmed
on Dual Energy Lung PBV images that
perfusion had improved in large parts,
but slightly decreased perfusion was still
seen in the mid-right lobe and upper left
and left lingular segments. The thrombus
had disappeared on the mixed CT images.
Two weeks later, the patient underwent
perfusion and ventilation scintigraphy.

Now, only a small mismatch between the


images was seen at the periphery of the
middle lobe of the right lung and the lingular segment of the left lung.

COMMENTS
In the past, scintigraphy was used for PE
diagnosis. In recent years however MDCT
has replaced scintigraphy for PE diagnosis. The diagnosis can be done by confirming clots in vessels with CT. In the
case of this patient, PE could be diagnosed on single Energy CT, but the rea-

son for the improvement of clinical symptoms could not be confirmed. Only with
PBV images acquired by Dual Energy CT
could we presume that pulmonary perfusion improvement was the cause for the
relief of the symptoms. Perhaps this was
the result of an increased blood flow
around the thrombus, which was too small
to be seen from the state of the thrombus
itself. Only functional images (meaning
perfusion images) could reveal it. We were
able to see this small change with only one
Dual Energy CT scan. Dual Energy Lung
PBV was extremely helpful in this case.

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition

Scan mode

Dual Energy Lung PBV

Pitch

0.8

Scan area

Thorax

Slice collimation

0.6 mm

Scan length

290 mm

Slice width

1 mm

Scan direction

Cranio-caudal

Reconstruction increment

1 mm

Scan time

6.9 s

Reconstruction kernel

D30f

Tube voltage A/B

80 kV / 140 kV

Contrast

Tube current A/B

45 mAs / 225mAs

Volume

60 ml

Dose modulation

CARE Dose4D

Flow rate

2 ml/s

Rotation time

0.33 s

Postprocessing

Dual Energy Lung PBV

3A

2B

16:30

1 week later
3C

2D

16:30

but a considerable improvement of lung


perfusion (Fig. 2C and 2D).

3B

2 weeks later

1 week later
3D

2 weeks later

3 CT Dual Energy Lung PBV one week later showed almost complete perfusion recovery
(Fig. 3A and 3B). 2 weeks later perfusion and ventilation scintigraphy unveiled only a small
remaining defect (Fig. 3C and 3D).

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

57

Clinical Results Acute Care

Case 11
Differentiation of Pulmonary Emboli and
Their Effect on Lung Perfusion Determined
With a Low-Dose Dual Energy Scan
By Luca Flors, MD, Carlos Leiva-Salinas, MD, Klaus D. Hagspiel, MD
Department of Radiology, University of Virginia, VA, USA

HISTORY
A 48-year-old male patient, status post
right lung transplant with history of coal
workers pneumoconiosis, emphysema
and left upper lobe lobectomy, presented with acute onset of shortness of
breath. He was referred to our department for CT angiography in order to rule
out pulmonary thromboembolism.

sity in areas of severe emphysema and


bullous disease as revealed in the lung
window setting. A hemodynamically,
probably not significant, narrowing of
the pulmonary arterial anastomosis relative to the donor main pulmonary artery
was also noted. The venous and bronchial anastomoses were normal.

DIAGNOSIS

COMMENTS

On the Dual Energy CT images, an acute


pulmonary embolus was noted within
the right lower lobe pulmonary artery,
involving the segmental and sub-segmental arteries. The Dual Energy Perfusion Blood Volume (PBV) images
revealed perfusion defects in lung areas
matching the location of the thrombi.
Scattered perfusion defects were also
seen throughout the left lung parenchyma due to decreased pulmonary den-

One of the key advantages of Dual


Energy CT PBV is the ability to differentiate between occlusive and non-occlusive
pulmonary emboli. Functional information is added to the otherwise purely
morphological assessment provided by
standard CT Pulmonary Angiography
and thus makes it possible to custom tai- *Pausini V, Remy-Jardin M, Faiure JB, et al.
Assessment of Lobar perfusion in smokers
lor therapy in certain high risk patients.
according to the presence and severity of of
Because the Dual Energy CT PBV algoemphysema: preliminary experience with DE;
European Radiology 2009, 19: 2834-2843
rithm is optimized for the detection of

pulmonary emboli, most pulmonary


parenchymal diseases cause tissue densities outside the standard range and
thus are displayed as perfusion or
pseudo-perfusion defects. In the case of
emphysema, the cause of the perfusion
defects is a true decrease in pulmonary
circulation secondary to lung destruction, and it has been reported that the
degree of decreased perfusion is correlated with the severity of emphysema.*
This case also nicely illustrates that high
quality, Dual Energy lung scans can be
obtained with relatively low radiation
dose. The CTDIvol for this exam was
3.79 mGy, resulting in an estimated
effective dose of approximately 1.9 mSv.

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition

Scan mode

DE Lung

Pitch

0.8

Scan area

Thorax

Slice collimation

0.6 mm

Scan length

328.5 mm

Slice width

1.5 mm

Scan direction

Cranio-caudal

Reconstruction increment

1 mm

Scan time

11 s

Reconstruction kernel

B30f

Tube voltage A/B

140 kV / 80 kV

Contrast

Tube current A/B

21 eff. mAs / 83 eff. mAs

Volume

Dose modulation

CARE Dose4D

Flow rate

4 ml/s

CTDIvol
Rotation time

3.79 mGy
0.5 s

Start delay
Postprocessing

17 s
syngo DE LungPBV

58 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

100 ml of 350 mg/ml

1A

1B

2A

2B

2C

2D

3A

3B

1 CTPA sagittal-oblique subvolume maximum intensity


projection (MIP) (Fig. 1A) and
sagittal DE CT PBV (Fig. 1B)
show large thrombus involving
the right lower lobe pulmonary
artery (arrow), and near complete loss of perfusion of the
matching parenchyma with
mild narrowing of the pulmonary arterial anastomosis
(arrowhead).

2 Axial images in lung window


setting (Fig. 2A and 2C) and corresponding Dual Energy CT PBV
images (Fig. 2B and 2D) show
thrombus within the right lower
lobe artery with the corresponding lung perfusion defect (Fig.
2A and 2B). Severe emphysematous changes are present in the
left lung. Perfusion is normal
within the right upper lobe (Fig.
2C and 2D). Right loculated pleural effusions and diffuse ground
glass opacities with septal thickening of unknown etiology are
also noted.

3 Coronal color-coded iodine


perfusion map (Fig. 3A) and
lung window (Fig. 3B) images
show decreased perfusion in
the right lower lobe due to
acute pulmonary embolism.
Scattered perfusion defects in
the left lung due to severe
emphysematous changes. Also
note changes post left upper
lobectomy.

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

59

Clinical Results Acute Care

Case 12
SOMATOM Denition Flash: Rule-Out of
Coronary Artery Disease, Aortic Dissection and
Cerebrovascular Diseases in a Single Scan
Junichiro Nakagawa, MD,* Osamu Tasaki, MD, PhD,* Tomoko Fujihara**and Katharina Otani, PhD**
*Trauma and Acute Critical Care Center, Osaka University Hospital, Osaka, Japan
**Marketing Division, Healthcare Sector, Siemens Japan K.K., Tokyo, Japan

1 The Dual Source CT images showed


heart enlargement, pericardial effusions
and left ventricle myocardial hypertrophy.

3A

HISTORY

2 None of the three major coronary arteries had stenoses.

3B

An 89-year-old female patient with disturbance of consciousness (DOC) and


respiratory arrest was brought to the
Trauma and Acute Critical Care Center
of Osaka University Hospital. She was in
shock, her level of consciousness (LOC)
was E1V1M2 (Glasgow Coma Scale, GCS)
her heart rate was 74 bpm and her blood
pressure was unmeasureable. Her anamnesis included hypertension, and she
was on oral medication for diabetes. Her
spontaneous breathing was coming
back, but her DOC continued, prompting
us to perform tracheal intubation and to
administer an infusion of vasopressors.
She was pulled out of shock.
Chest X-ray showed marked enlargement
of the cardiac silhouette and a mediastinal shadow suggesting congestive heart
failure. For a multiple rule-out of coronary disease, aortic disease and cerebrovascular lesions, we performed a Dual
Source CT scan in Flash Spiral mode
(non-ECG-triggered) from head to thoracic region.

DIAGNOSIS

3 None of the major cerebral arteries were affected.

60 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

The Dual Source CT images showed


heart enlargement, pericardial effusions
and left ventricle myocardial hypertrophy (Fig. 1). None of the three major

4 No significant abnormity of the


aorta.

coronary arteries had stenoses (Fig. 2)


and no significant abnormity of the aorta
or cerebrovascular region (Fig. 3 and 4)
was found. With these results, acute coronary syndrome, aortic dissection and
stroke could be ruled out. The pericardial effusion was diagnosed as chronic
on echocardiography. Based on the
left ventricle myocardial hypertrophy
finding, we suspected hypertrophic
obstructive cardiomyopathy.
A diuretic worked well to improve cardiac function and respiratory condition.
After performing tracheotomy, the
patients respiratory status gradually
improved and she could be weaned from
ventilatory support after 43 days in
the hospital. Her level of consciousness
(LOC) came back to E4VTM6 (GCS)
and oxygenation could be stopped. On
the 48th day, the patient was transferred
to another hospital to receive rehabilitation.

COMMENTS
Dual Source CT Flash Spiral was used
for long range CT-Angiography (Fig. 5).
It gave us necessary information to rule
out critical acute coronary syndrome,
thoracic aortic dissection and cerebrovascular lesions. The Flash Spiral mode is

5 Dual Source CT Flash Spiral was used


for long range CT angiography.

6 The fast pitch of 2.3 allows acquiring motion


free images in patients who cannot hold their
breath.

an extremely useful tool, in particular


for ruling out life-threatening disorders
at initial treatment phase without having to subject the patient to additional
invasive examinations such as cardiac
catheterization. As the Flash Spiral scan

mode has a fast pitch of 2.3 (up to pitch


3.4), diagnostic images can be acquired
even of patients who cannot hold their
breath which is especially useful at
Trauma and Acute Critical Care Centers
(Fig. 6).

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition Flash

Scan mode

Flash Thorax

Scan area

Head to Thorax

Scan length

570.5 mm

Scan direction

Caudo-cranial

Scan time

2.07 s

Tube voltage

120 kV / 120kV

Tube current

162 eff. mAs

Dose modulation

CARE Dose4D

CTDIvol

9.06 mGy

DLP

574 mGy cm

Rotation time

0.28 s

Pitch

2.3

Slice collimation

0.6 mm

Slice width

0.75 mm

Reconstruction increment

0.6 mm

Reconstruction kernel

B35f

Contrast
Volume

95 ml

Flow rate

4.0 ml/s

Start delay

28 s Bolus Tracking

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

61

Clinical Results Acute Care

Case 13
SOMATOM Denition Flash: RIPIT
to the Rescue Fast CT Examination
for Trauma Patients
Savvas Nicolaou, MD
Vancouver General Hospital, Department of Emergency Trauma Radiology, Vancouver, Canada

HISTORY
A 70-year-old female was involved in
a high-speed motor vehicle collision.
An auto launch was triggered immediately and the patient was transferred
by helicopter to Vancouver General
Hospital (VGH).
Immediate imaging was required to
quickly ascertain the patients condition.
A RIPIT FLASH was performed (Rapid
Imaging Protocol In Trauma).*

DIAGNOSIS
The brain demonstrated subarachnoid
hemorrhage and small hemorrhagic

contusion. A complex LEFORT TYPE 3


VARIANT facial fracture was identified
instantaneously. The globes were intact.
In addition there was ground glass density in both lower lobes with centrilobular
nodular tree in bud appearance, signifying aspiration of blood. The abdomen
was normal.

COMMENTS
Given the age and frailty of the patient,
an immediate assessment of the patients
condition was required and this was
provided in a matter of seconds with the
FLASH RIPIT protocol.

The brain findings were not surgical and


the complex facial fracture was quickly
repaired. The lung findings ensured that
the patient was observed with diligence,
as this could lead to ARDS.** In the
trauma setting, the golden hour is
critical. If appropriate therapy is instituted
then, this can have an important impact
on improving patient outcomes by decreasing morbidity and mortality. The
FLASH RIPIT scan can provide critical,
life-saving information in a matter of
seconds.

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition Flash

Scan area

Head to Pelvis

Pitch

1.8

Scan length

911 mm

Slice collimation

128 x 0.6 mm

Scan direction

Cranio - caudal

Slice width

3 mm

Scan time

3.8 s

Spatial Resolution

0.33 mm

Tube voltage

140 kV

Reconstruction increment

1.5 mm

Tube current

149 mAs

Reconstruction kernel

B36f

Dose modulation

CARE Dose4D

Contrast

370 mg/ml

CTDIvol

16.53 mGy

Volume

150 ml

DLP

1596 mGy cm

Flow rate

5.0 ml/s

Rotation time

0.28 s

Start delay

6s

*The RIPID protocol has been introduced in SOMATOM Sessions # 25 by Savvas, Nicolaou in November 2009
**Acute Respiratory Distress Syndrome

62 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

1, 2 Volume
Rendered (VRT)
view showing
vascular status
of this trauma
patient.

3, 4 Fast pitch
of 1.8 allows
long range
scanning from
head to pelvis.
The sagittal
view (Fig. 4)
shows artifact
free aortic
angiogram.

5 Subarachnoid hemorrhage delineated with a


fused MPR
(Multi Planar
Reformation)
and VRT visualization technique (arrow).
6 Coronal
MPR of the
brain (calculated out of the
full body scan)
shows the
extension of
the bleeding
(arrow).

Clinical Results Pulmonology

Case 14
Xenon Ventilation CT Scan
Demonstrates an Increase in Regional
Ventilation After Bullectomy
in a COPD Patient
By Calvin Yeung W.H., MD and Gladys G. Lo, MD
Department of Diagnostic and Interventional Radiology, Hong Kong Sanatorium and Hospital

HISTORY

DIAGNOSIS

A 70-year-old male (ex-smoker) was


referred to the hospital with a history of
severe Chronic Obstructive Pulmonary
Disease (COPD) with emphysema. A
Xenon CT-scan of the thorax was performed to assess regional ventilation
and plan bullectomy (either bronchoscopic or video assisted surgery).

Prior to the examination, a Xenon gas


inhalation was initiated. Xenon was also
applied during the acquisition to highlight perfusion defects in the lungs.
The Xenon Dual Energy examination of
the thorax (Figs. 1 and 2) showed diffuse emphysema and a large, 9 cm bulla
in the left lower lobe. There was a signif-

icant decrease in ventilation seen in


left lower lobe due to the bulla. Xenon
enhancement measurements in left
upper lobe showed 44% and in comparison to the left lower lobe nearly 0%
enhancement (Xenon enhancement at
trachea is at 100% for reference measurements).

1 Coronal section of Xenon CT scan of the thorax before bullectomy


shows marked decrease in regional ventilation in left lower lobe due
to large bulla.

2 Axial section of Xenon CT scan of thorax shows Xenon


enhancement in left upper lobe.

64 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

Pulmonology Clinical Results

EXAMINATION PROTOCOL

COMMENTS
With an Xenon CT examination of the
thorax, it is possible to demonstrate,
in addition to the morphologic assessment, the functional state of the lung.
In this case it showed less ventilation in
the left lower lobe which the bronchoscopist and surgeon used to plan the
site for lung volume reduction surgery.
Bronchoscopic lung volume reduction
surgery was attempted, but failed due
to significant collateral flow, detected
during the placement of endobronchial
valve (one-way valve placed in bronchius).
A video-assisted thoracoscopic bullectomy was performed. The bulla in the
left lower lobe was surgically resected
with no complications and the patient
recovered well. After surgery there was
a significant subjective improvement
in dyspnoea that was confirmed by pulmonary function testing. The Forced
Expiratory Volume in 1 second (FEV1)
increased from 0.62 l to 0.87 l (25% to
38% of predicted value); FEV1/ Forced

Vital Capacity (FVC) ratio increased from


36% to 40%. A value larger than 75% is
considered to be normal. In a follow up
Xenon CT scan of the thorax (Figs. 3 and
4) a significant improvement of the ventilation and function in the left upper
lobe was detected. Xenon enhancement
measurements in the left upper lobe
increased from 44% to 64%. (for reference Xenon enhancement at trachea
was 100%). The extremely low dose CT
examination utilizing only 1.7 mSv radiation dose showed the effect of lung volume reduction surgery with significant
improvement in regional ventilation.
Bullectomy is a significant treatment in
this patient group. Improvements in
exercise capacity, pulmonary function
and quality of life have been observed in
this emphysematous patient, and are
attributed to a decrease of (dynamic)
hyperinflation.

Scanner

SOMATOM
Definition Flash

Scan mode

Dual Energy Lung

Scan area

Thorax

Scan length

310 mm

Scan direction

Cranio - caudal

Scan time

9s

Tube voltage

80kV/140kV

Tube current

80 eff. mAs/
48 eff.mAs

Dose modulation

CARE Dose4D

CTDIvol

3.82 mGy

Eff. Dose

1.7 mSv

Rotation time

0.26 s

Slice collimation

64 x 0.6 mm

Slice width

1 mm

Spatial Resolution

0.33 mm

Reconstruction
increment

0.8 mm

Reconstruction
Kernel

D30

Contrast

Xenon gas
inhalation

Start delay

90 s

Postprocessing

syngo DE Xenon

3 Coronal section of Xenon CT scan of thorax after bullectomy


shows increase in volume and ventilation of left upper lobe.
Atelectasis and effusion is noted at the bullectomy site. (arrow)

4 Axial section of Xenon CT scan of thorax after bullectomy


shows Xenon enhancement in left upper lobe increased to 64%.
(vs.44% prior to bullectomy)

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

65

Clinical Results Orthopedics

Case 15
SOMATOM Denition:
Dual Energy Locates Progressive Wrist Arthritis
By Philipp Weisser, MD, Ralf W. Bauer, MD, J. Matthias Kerl, MD and Thomas J. Vogl, MD
Department of Diagnostic and Interventional Radiology, Goethe University Clinic, Frankfurt, Germany

HISTORY

1A

Swelling and pain symptoms in the right


hand started 3 months prior to our
involvement. Initially there were no
pathologic findings in conventional radiography and, unfortunately, even a histopathologic examination was unspecific. As the previous radiography to this
CT showed massive erosive changes in
the wrist, but unclear changes in the
MCP (metacarpophalangeal joint) and
PIP (proximal interphalangeal joint),
we performed a CT scan to search for
possible further erosions and synovitis.

DIAGNOSIS
1B

Rapid progressive wrist arthritis in the


right hand. The CT scan revealed massive erosive destruction of the right
wrist, accompanied by synovitis and
joint effusion. Within the phalanges we
found subcortical osteolytic changes
(which were not visible in the left hand)
with intact cortical structures. With
Dual Energy technique, we could easily
visualize the synovitic tissue.

COMMENTS
1 Massive, destructive erosions in the

wrist, subcortical pre-erosive changes in


the MCP-joints (arrow).

In rheumatic imaging, when the verification of erosive changes is the most


important question, synovitic tissue can
still be easily detected in Dual Energy
technique. As the 80/140kV-ratio is quite
high, after iodine contrast application it
is very easy to visualize this tissue.

66 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

EXAMINATION PROTOCOL
Scanner

SOMATOM
Definition

Scan mode

DE Extremity

Scan area

Dual Energy Wrist

Scan length

282 mm

Scan direction

Cranio - caudal

Scan time

21 s

Tube voltage A/B

140 kV / 80 kV

Tube current A/B

68 mAs / 292 mAs

Dose modulation

CARE Dose4D

CTDIvol

12.97 mGy

eff. Dose

0.32 mSv

Rotation time

1s

Slice collimation

64 x 0.6 mm

Slice width

2 mm

Spatial Resolution

0.33 mm

Reconstruction
increment

1 mm

Contrast
Volume

90 ml

Flow rate

4 ml/s

Start delay

360 s

Postprocessing

syngo DE Gout

2A

2B

Acute Care Clinical Results


Topic

2 Distinctive demarcation of synovitis in the right wrist, pronounced Dual Energy characteristics and impressive visualization of the synovitis (arrow).

3A

3B

3 3D Fusion rendering, showing the destructions and synovitis of the right wrist (arrow).

4A

4B

4 Difference of density in synovitis after application of iodine contrast agent at 80 and 140 kV. We measured around 140 HU in 80 kV,
and around 90 HU in 140 kV (arrow).

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

67

Science

Dose Parameters and Advanced Dose


Management on SOMATOM Scanners
The measurement and calculation of radiation dose in CT is an important
topic for an efcient dose management. Quantities such as the CTDI, DLP
and effective dose are useful when used appropriately. Now Siemens takes
dose management to a new level by providing tools such as Dose Structured
Reports and CARE Analytics.
By Stefan Ulzheimer, PhD, Christianne Leidecker, PhD, and Heidrun Endt
Business Unit CT, Siemens Healthcare, Forchheim, Germany

The assessment and management of


patient dose has become one of the most
frequently discussed topics in Computed
Tomography. On SOMATOM Scanners,
the reporting of established dose parameters like Computed Tomography Dose
Index (CTDI) and Dose Length Product
(DLP) has been implemented since 1999.
For each exam, the information is available in the patient protocol, and can be
viewed and archived as a DICOM image.
With Dose Structured Reports (Dose SR)
Siemens is taking the next step to enable
more transparency in terms of radiation

dose. Furthermore, tools like CARE


Analytics provide an easy means to evaluate Dose SR.

Technical dose parameters


CTDIvol and DLP
The CTDI is the primary dose measurement concept in CT and is defined by
the International Electrotechnical Commission (IEC) [1] and adopted by various
national bodies such as for example by
the US Food and Drug Administration
(FDA). The weighted volume CT Dose
Index, CTDIvol represents the average

absorbed dose within the scan volume


for standardized phantoms. Their diameters are 16 and 32 cm, to approximate
conditions for head and body examinations so the phantoms do not adequately
represent patient cross-sections. However the CTDIvol is an objective technical
dose parameter based on a directly measured quantity. It takes into account protocol-specific parameters and is useful to
compare different scan protocols across
various CT scanners. Thus, IEC standards
require the prospective display of the
CTDIvol on the console of the CT scanner.

Calculating effective dose from scanner dose information.


1

1 Calculating effective
dose for adults. From the
Patient Protocol of this
abdominal scan, the DLP is
obtained:

DLP = 274 mGycm


Using the conversion factor
for abdominal exams,
0.015 mSv/(mGycm) [3],
effective dose E is estimated
to be E = 274 mGycm
0.015 mSv/(mGycm) =
4.1 mSv

68 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

Science

Calculating effective dose from scanner dose information for a pediatric body exam.
2

2 Calculating effective dose for children. Using the same values as in the first example, the DLP is: DLP = 274 mGycm. First you have to
determine if the DLP refers to a 32 cm or 16 cm CTDI phantom. In this case, the DLP is reported in the 32 cm body CT dose phantom. This value
has to be converted to the head CT dose phantom if pediatric conversion factors published in [table 1] shall be used to compute the effective
dose: DLP = 2.0 * 274 mGycm = 548 mGycm. Note: Typical values are between 2.0 and 2.4 for Siemens scanners. Values can be found in the
System Owner Manual. Since the method of using conversion factors to determine the effective dose is a very rough method usually using a correction factor of 2.0 is sufficiently accurate for all scanners. For a 5-year old child, a factor of 0.02 mSv/(mGycm) for abdominal exams is used
[table 1] to estimate E. E = 548 mGycm 0.02 mSv/(mGycm). = 11 mSv. If the DLP was already measured in the 16 cm head phantom like it is
the case on new scanners the conversion factors from table 1 can be used directly without applying an additional factor of 2.0 to 2.4.

Table 1
Region of body

Conversion factor from DLP to Effective Dose in [mSv / (mGy cm)]


0 year old

1 year old

5 year old

10 year old

Adult

Head and neck

0.013

0.0085

0.0057

0.0042

0.0031

Head

0.011

0.0067

0.0040

0.0032

0.0021

Neck

0.017

0.012

0.011

0.0079

0.0059

Chest

0.039

0.026

0.018

0.013

0.014

Abdomen and pelvis

0.049

0.030

0.020

0.015

0.015

Trunk

0.044

0.028

0.019

0.014

0.015

To represent the overall dose of a given


scan protocol, the CTDIvol is multiplied
with the examination range which then
yields the DLP.

Towards assessing
patient dose
When asking the question of what is
the radiation dose, one really is inter-

ested in what is the risk of this exam?


However, information on individual
patient dose depends on multiple parameters, such as patient specific characteristics and in addition to the technical
parameters of the system and exam.
The International Commission on Radiation Protection (ICRP) has introduced the
concept of effective dose which repre-

One practical method to calculate effective dose: Conversion


factors from DLP to effective
dose for children and adults;
for different body regions as
published in [2, 3]. Please note
that the conversion factors for
children refer to a DLP measured
in a 16 cm phantom. On older
scanners or software versions
the DLP in pediatric protocols
often refers to a 32 cm phantom.
Then an additional correction
factor has to be applied.

sents a risk-related quantity for the control of radiation exposure and optimization of protection. It cannot be measured
directly, but rather is calculated using
defined dosimetric models. Hence, it
applies to a reference person and does not
provide risk information for the individual.

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

69

Science

3 The Dose SR can

be viewed on the
scanner console,
sent to PACS or to
an independent
server used to monitor dose data.

Practical ways to determine


effective dose for CT exams
Several approaches to estimate effective
dose for CT exams have been investigated. A generic method was proposed
to estimate effective dose from the DLP
of an exam [2], with the DLP being
reported on most systems. Conversion
factors for normalized effective dose per
DLP were obtained from Monte Carlo
calculations of effective dose for various
clinical exams. These conversion factors
depend only on the region of the body
being scanned (head, neck, thorax,
abdomen, or pelvis).
It is important to understand that calculating effective dose using this method
can always only be a rough estimate of
effective dose because many parameters
that influence effective dose are not
taken into account. The body size and

the exact location of the scanned area in


relation to the dose sensitive organs are
only two of those parameters. However,
usually this method is sufficiently exact
for the purpose the effective dose concept was developed for: Radiation protection and getting an estimate on the total
exposure that is also comparable with
other sources of radiation.
As an example, Figure 1 illustrates the
calculation of the effective dose of an
abdominal scan using conversion factors
published by Shrimpton et al. [table 1].

Special considerations
for children
Conversion factors are also available for
children of various ages [table 1].
Special attention has to be paid to the fact
that the conversion factors published
apply to values reported in the head CT

70 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

dose phantom.
In the past scanners, CTDI values were
reported in the head CT dose phantom
for head exams and the body CT dose
phantom for body exams, irrespective of
the patient age. This was in line with the
original IEC standards, which did not
provide instructions for pediatric exams.
Thus, for calculations regarding pediatric
body exams, an additional calculation
step has to be performed, as illustrated
in Figure 2.
The example shown illustrates that the
same exposure leads to an effective dose
that is almost three times higher for a
five year old than an adult. While being
purely theoretical, the example shows
that, it is of utmost importance to pay
special attention when imaging pediatric
patients, in particular to use dedicated
pediatric protocols in combination with

Science

CARE Dose4D.
To standardize dose reporting for pediatric patients, future editions of IEC standards will require dose reporting in the
head CT dose phantom for pediatric
exams, irrespective of the body region
imaged. Starting with software version
syngo CT 2011A, Siemens will implement
this new requirement. As a consequence,
the conversion factors [table 1] can be
directly applied also in pediatric protocols. To ease the transition, the CT dose
phantom size was added to the user
interface and it is also reported in the
Dose SR.

A new standard:
Dose Structured Reports
As the first CT manufacturer Siemens
now provides the new Dose SR almost
across its complete CT product portfolio.

The Dose SR contains comprehensive


data for each irradiation event, the accumulated dose and information about the
context of the exposure. The data is provided in electronic format that can be
sent to any system which receives, stores
or processes dose information, such as
conventional PACS or workstations.

A new tool to evaluate


Dose Structured Reports:
CARE Analytics
The Dose SR can serve as the center
piece of an institution wide dose quality
control. To evaluate and analyze the
information, Siemens provides a new
free tool, CARE Analytics. It is a standalone tool and can be installed on an
office computer.
With CARE Analytics, one can query Dose
SR from DICOM nodes directly. Dose

reporting data can be exported and analyzed with standard tools, such as Microsoft Excel.
With the prompt implementation of
Dose SR and the new tool CARE Analytics
Siemens provides the customer with all
the information needed for a transparent dose management.
References
1 IEC 61223-2-6 Evaluation and routine testing in
medical imaging departments Part 2-6: Constancy tests Imaging performance of computed
tomography X-ray equipment
2 Jessen KA, Panzer W, Shrimpton PC, et al. EUR
16262: European Guidelines on Quality Criteria
for Computed Tomography. Paper presented at:
Office for Official Publications of the European
Communities; Luxembourg. 2000.
3 Shrimpton PC, Hillier MC, Lewis MA, Dunn M.
National survey of doses from CT in the UK:
2003. Br J Radiol Dec;2006 79(948):968980.
[PubMed: 17213302]

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

71

Science

IRIS and Flash:


Cardio CT with Minimum Radiation
Exposure Delivers Precise Images
Iterative Reconstruction in Image Space (IRIS) in connection with the
SOMATOM Denition Flash can provide extremely high speed CT examinations of the heart, with a radiation dose of less than 0.5 mSv. A recent study
of the German Heart Centre Munich demonstrates the high image quality
of this method. This opens up the prospect of using CT more extensively in
cardiological investigations than has been the case to date.
By Matthias Manych

The coronary vessels of the heart have


a diameter of just a few millimeters.
In order to study these vessels and to
diagnose and quantify arteriosclerotic
changes in CT, images with high resolution in space and time are required. Until
a few years ago, however, these could
only be obtained with relatively high
doses of radiation. The challenge of combining brilliant diagnostic images with
a minimum of radiation exposure for
patients has now been met successfully
with new scanner technologies. In particular at cardiology centers with a great
deal of expertise, these developments

PD Hausleiter, MD, is physician for internal


medicine and cardiology and director at the
German Heart Center in Munich.

have brought about a marked improvement for Cardio CT, according to Dr. Jrg
Hausleiter, specialist in non-invasive,
cardiac CT diagnostics at the German
Heart Centre Munich. He explains: The
data at our center shows that three or
four years ago, we had an average effective radiation exposure of 10 mSv; now,
we are at under 2 mSv.

New dimension of low-dose CT


using IRIS
A number of approaches to image data
processing have been developed as part
of the quest to reduce radiation exposure without loss in image quality. Among
other approaches, these efforts involved
feeding the raw data measured by the
scanner back into a mathematical corrective loop in order to reconstruct the
best possible image through incremental
approximations. Siemens has now supplied IRIS as an innovative reconstruction
option, which has been analyzed by Hausleiter (together with Dr. Bettina Gramer
and Dr. Bernhard Bischoff). With this
study, the medical scientist aimed to
establish the level of image quality that
can be achieved with IRIS in low-dose
Cardio CT. To this end, the method was
compared to Filtered Back Projection
(FBP), the standard in CT image recon-

72 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

struction. Hausleiter describes the initial


situation: You have to consider that
the quality of conventional image reconstruction has already reached a level
of perfection where it is essentially difficult to raise the standard any higher.
First of all, the lung arteries of 56 patients
were depicted. In a subgroup of 36
patients who had a heart rate of less
than 60 beats per minute, the coronary
vessels were also assessed. The physicians did so using the specific capabilities of the SOMATOM Definition Flash,
which they had helped develop. The Flash
mode operates with extreme rapidity;
temporal resolution amounts to just
75 ms, and scanning of the entire chest
takes only 0.6 s. In this way, even the
fine structures of the beating heart can
be captured in precise images.
IRIS has proven its worth. Despite the
remarkably low radiation level of only
0.5 mSv, the assessibility of the CT
images was evaluated at 100 per cent.
As far as diagnostics is concerned, the
new reconstruction technique is just
as good as FBP. In terms of the quantitative quality criteria such as image noise
and signal-to-noise ratio, IRIS even
showed statistically significant superiority. Jrg Hausleiter is very satisfied with
the outcome of the study, which was

Science
1

1 A 55-year old man underwent coronary CT Angiography


with the SOMATOM Definition
Flash to exclude a stenosis of the
pulmonary vein before cardiac
electrophysiology examination.
In combination with IRIS the CT
scan could be carried out with an
extremely low dose of 0.5 mSv
(DLP 39 mGy cm). (Courtesy of
PD Hausleiter, MD, German Heart
Center, Munich, Germany)

presented in May this year at the International Symposium on Multi-detector Row


CT in San Francisco: IRIS and Flash provide us with very potent instruments for
keeping radiation exposure as low as
possible. At the same time, the resulting
images are of high diagnostic value. The
two methods complement one another
very well, and our results are very promising. Also, as the cardiologist points
out, IRIS can be used with a less powerful
CT scanner, which nevertheless will
deliver better images than have been
available to date.

A new perspective for


cardiac diagnostics
IRIS reduces image noise and artifacts
very effectively without loss in spatial
resolution. Together with state-of-the-

art scanner technology, radiation exposure in Cardio CT can be reduced to


levels well below those in scintigraphy
and cardiac catheterization. This removes
one of the main points of criticism against
CT, which may now take on a new importance in cardiac diagnostics. Cardiac
catheterization is still quite widespread;
in Germany alone, the method is
employed about 700.000 to 800.000
times a year. As Hausleiter points out,
however, many cases are without pathological findings, and only 25 to 30 per
cent of patients must undergo balloon
dilatation during invasive cardiac imaging. Thus, it should certainly be possible
to replace part of these catheterization
procedures with CT diagnosis.
High radiation exposure has been an
obstacle to cardiological screening so far.

Now, with the possibilities offered by IRIS


and Flash, the discussion should receive
a fresh impetus. Against the background
of cardiovascular diseases as the leading
cause of death, Hausleiter says: This is
certainly worth considering as a concept
for employing such technologies in
screening in selected patient groups
with a higher risk of coronary events.
Matthias Manych has a masters degree in
Biology and is a freelance scientific journalist
and editor with a focus on medicine. In addition
to other topics, he regularly covers developments in imaging technology.

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

73

Life

Clinical Fellowship: Learning


From the Experts in the Field
You are eagerly awaiting the arrival of a new CT scanner and are a little nervous about the new options and features? Then this is the perfect moment
to attend a Clinical Fellowship program, an educational format Siemens
Healthcare offers to users of their CT scanners and applications. They provide the opportunity to improve your skills while being guided through the
daily clinical workow at an institution.
By Wiebke Kathmann, PhD

Dr. Ralf Bauer (left) and Dr. Matthias Kerl (right) are in charge of the CT fellowship program at Johann Wolfgang Goethe University in Frankfurt/ Germany.

74 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

Application training and clinical handson workshops are valuable opportunities


to learn more about the features of a
new CT scanner. But they do not represent the clinical reality. Choice of protocol, critical determinants of the workflow or contrast injection timing were
some of the questions that remain open
even for an experienced radiologist like
Naama Bogot, MD, Jerusalem, Israel.
That is why she decided to register for a
Clinical Fellowship at Siemens once it
was sure that her department would be
getting a SOMATOM Definition Flash. At
the time, she had been working for nine
years as a radiologist specialized in cardio thoracic imaging and was employed
at a private institute that is affiliated
with the Hebrew University.

The fellows perspective


Bogot had a clear agenda on her mind
when arriving at the radiology department of the Johann Wolfgang Goethe
University in Frankfurt Main, Germany:
My aim was not to use the fantastic
new scanner like any other scanner but
to get the most out of it, to use it in an
educated way. I also wanted to understand when to choose a single or a dual
source mode and when to use flash scanning. How to avoid mistakes in using the
technical features and protocols and how
to best perform Dual Energy CT imaging.
There was more on her list. Bogot also
wanted to deepen her understanding of
the chemical and physical properties of
tissues when applying two levels of
energy as in Dual Energy CT and on how
to use different levels of radiation in cardiac CT imaging. Timing of contrast injection was another issue on her agenda.
With the SOMATOM Definition Flash
scanner being so fast there is little time
for planning the injection. Besides, she
felt she needed to learn about dose in
cardiac CT imaging, as the radiation dose
needed with the SOMATOM Definition
Flash is far lower than with any other
scanner. Dosing aspects and safe dosing
are a hot topic for me. I learned a lot.

Good learning experience


Frankfurt was the center of choice for
Bogot as it is very versatile, offering

tumor diagnosis and intervention as well


as cardiac imaging and other applications. Besides, the academic point of
view and innovative applications had
sparked her interest when meeting Ralf
Bauer, MD, and Matthias Kerl, MD, at a
hands-on workshop earlier in the year.
Bogot came to Frankfurt for a week. The
stay fulfilled all of her expectations. She
managed to look into all the aspects she
had wanted to study and even set up a
research collaboration with Bauer and
Kerl. Bogot very much appreciated the
enthusiasm of both experts in Frankfurt.
Being at the beginning of their career
they were both very enthusiastic about
the scanner, eager and open to share
and skilled in their teaching while I
could contribute my clinical experience
as a radiologist. The learning atmosphere was good and reciprocal.
Upon leaving Frankfurt, Bogot felt confident and competent about working with
the new scanner back in Israel. Her conclusion: The learning curve was a lot
faster than if I had had to figure it all out
by myself. Bogot would recommend fellow radiologist to take advantage of this
option, provided they are motivated and
have some background.

The experts perspective


For Bauer and Kerl, Bogot was not the
first Clinical Fellow. By now they have
shared their expertise with ten attendees. Both enjoy this format and appreciate the insights they get into the work,
workflow or applications used in other
hospitals or the health system in other
countries. Upon arrival of a fellow, Bauer
and Kerl first discuss the fellows expectations and find out about his or her clinical
focus back home. Both can differ quite a
bit as Frankfurt offers this format to technicians as well as radiologists. Some of
our fellows are already experienced in
working with Siemens CT scanners, most
have already done the Application Training. Others want to learn about post processing after buying a new software.
Bauers and Kerls goal is to send attendees home with a set of robust protocols
for routine applications, to provide them
with tips and tricks for daily clinical practice and to teach them subtle nuances

I want to get the most


out of the new scanner and use it in the
most educated way.
Dr. Naama Bogot, Department of Radiology,
Shaare Zedek Medical Center Jerusalem,
Israel and Department of Radiology,
University of Michigan Hospital, Ann Arbor
Michigan, USA

for more refined examinations. Last, but


not least, the radiation dose is a big
issue: We teach fellows how to get the
maximum result with the least radiation
dose, because dose has become a big
issue for patients. In Frankfurt, fellows
can learn a wide array of applications of
Dual Energy scanning, be it cardiovascular imaging, diagnosis of lung emboli,
cardiac diagnosis with flash, sequence
or dual energy modus, angio CT or oncological issues. We do the whole spectrum of diagnostic radiology from headneck scans to trauma diagnosis to angio
CT from head to toe, says Kerl. That
way, the fellow can experience the scanner as an all-round-machine.
Looking back, Bogot would recommend
other fellows to plan on two visits. One
5-day and another 3- to 5-day visit some
months later after trying out the protocols back home. The second time one is
more focused on what to ask and
observe. She herself would love to go
back in two months.
Wiebke Kathmann, PhD, is a frequent contributor to medical magazines. She holds a Master in
Biology and a PhD in Theoretical Medicine and
was employed as an editor for many years
before becoming a freelancer in 1999. She is
based in Munich, Germany.

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

75

Life

STAR: Specialized Training


in Advances in Radiology
By Axel Lorz, Business Unit CT, Siemens AG, Healthcare Sector, Forchheim, Germany
STAR is an international educational
forum jointly sponsored by Bayer Schering
Pharma and Siemens and was launched
way back in 1993. Its aim is to train
practicing radiologists by offering a wide
range of topics ranging from refresher
type courses to cutting-edge developments in radiology. The program symposia are held as regular forums in the
respective country in conjunction with
local radiological societies. The meetings
typically last two days and consist of
45-minute faculty lectures followed by
90 to 120-minute workshops by five

eminent leaders in their field who have


hands-on expertise . The lecture topics
are jointly selected by the local representatives and are tailored to countryspecific requirements. STAR s unique
approach is that it is run without commercial overtones, which is guaranteed
by the close cooperation with independent advisors. For the past six years,
Prof. Hans Ringertz from Linkping University, Sweden and Stanford University,
USA, has successfully headed the program
as Scientific Director. By the end of 2010,
close to 140 STAR events were held in

35 different countries with more than


23,000 radiologists attending. STAR is
one example of Siemens ongoing support for the professional education of
radiologists. To learn more on STAR, the
following link can be consulted.
www.star-program.com

Evolve Update Facilitates Dose Savings


By Marion Meusel, Business Unit CT, Siemens Healthcare, Forchheim, Germany
1A

1B

syngo Evolve, Siemens non-obsolescence program, ensures latest software


and hardware upgrades for your medical
equipment.
Currently SOMATOM Definition customers with an Evolve contract enjoy
the upgrade to syngo CT 2010A. Those
customers will benefit from enhancements such as Neuro BestContrast
integrated in the head and neuro scan

The image shows standard reconstruction using


conventional body kernel
scanned at 1.4 mSv.
(Fig. 1A). Here, the initial
1.4 mSv scan was reconstructed with IRIS. Curved
planar reformation of
the right coronary artery
(RCA) showing significantly sharper visualization of calcifications
with IRIS (Fig. 1B).

protocols to improve gray-white matter


differentiation and therefore to achieve
better contrast without an increase in
noise or dose. Furthermore syngo CT
2010A offers new purchasable features
like IRIS (Iterative Reconstruction in
Image Space), X-CARE and the Hi-Pitch
Spiral scan mode. IRIS uses multiple
iteration steps for the reconstruction of
CT data while reducing image noise with

76 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

every step and thus allowing up to 60 %


lower radiation dose and/or improving
image quality. X-CARE enables organsensitive dose protection by reducing
sensitive area exposure up to 40% without loss of image quality. The Hi-Pitch
Spiral scan mode for a maximum pitch
of 3.2 at a maximum scan speed of
96 mm/s will drastically shorten the scan
time and eliminate motion artefacts,
thus being very useful in paediatric
scanning.
To discover more on the CT clinical
application portfolio visit:

International:
www.siemens.com/DiscoverCT
USA only:
www.usa.siemens.com/
webShop/CT

Life
1

Frequently
Asked
Questions
By Ivo Driesser, Business Unit CT,
Siemens Healthcare, Forchheim,
Germany

1 On the subtask card, the X-CARE zone is visualized on the watermark.

X-CARE is an organ-sensitive dose protection feature. With X-CARE, organs


which are more sensitive to radiation,
like eye lenses and breast tissue, receive
a lower dose.
This feature is introduced by Siemens
Healthcare in the latest software update
(syngo CT 2010A) for SOMATOM
Definition and SOMATOM Definition
Flash.
How does it work?
X-CARE intelligently changes the dose
distribution during a rotation. It lowers
the tube current, and therefore dose, in
the area of a sensitive organ (anterior)

and provides a slightly higher dose in


the posterior part of the body.
The dose distribution is changed in favor
of the dose sensitive organ.
How to use X-CARE?
The dedicated, default scan protocols
in the patient model dialog are marked
with the suffix XCARE (for example:
Thorax_XCARE or Head_XCARE).
How to know if X-CARE is used?
On the Routine subtask card there is a
watermark displaying the gantry. A green
zone visualizes the area of the dose
protection (Fig. 1). When the patient
position is changed in the Patient Model

Dialog, the X-CARE zone adapts automatically. That means that the X-CARE
zone is always placed on the anterior part
of the body. In the comment line there is
also the entry X-CARE.
What about obese patients?
X-CARE checks the patient size for every
individual patient and creates the best
dose distribution so that the best possible
image quality is guaranteed.
How to get X-CARE?
Your Siemens contact representative will
be happy to help you arrange for free
trial licenses.

Siemens Healthcare is Proud to Present


a New Series of Live Clinical Webinars
By Heike Theessen, Business Unit CT, Siemens Healthcare, Forchheim, Germany

Siemens Healthcare is proud to present


a new series of live clinical webinars.
These Webinars are ideal for CT users who
are interested in finding the latest information in healthcare imaging, discovering new technologies and gaining access
to some of the worlds most renowned
clinicians. And all of this is possible without the need to travel and completely free
of charge. Every month a different clinical
modality will be featured to show what
is new in the exciting field of medical
imaging. The opportunity can be taken
to interact with the expert clinicians.

In the first session, Prof. Stephan Achenbach, MD from Erlangen University will
present a current status report on low
dose imaging in the field of cardiac CT.
Prof. Achenbach will present many clinical cases with excellent image quality
acquired with a minimum of radiation
dose. Each webinar session is recorded
and available online for later review.
More clinical webinars are planned so
dont wait and please register now for
further information.
www.siemens.com/webinars

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

77

Life

News at Educate Homepage:


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

A new section on Siemens CTs Educate


Homepage supports users with recommendations about CT literature.
When it comes to clinical training,
Siemens strongly relies on an independent network of CT professionals. These
collaboration partners support fellowships and workshops throughout the
year and many of them are very active
in the CT scientific arena as well. As a
result of this scientific work, numerous
books have been published recently by
well-known CT luminaries, sharing their
knowledge and experience. As part of
the education offerings, Siemens would

like to recommend these books to physicians and technologists who want to get
a more detailed insight into the technology of CT, cardio-vascular or oncologic
CT applications.
With this comprehensive overview,
which will grow over time and be constantly updated, you will always have
the latest CT-related book publications
to further improve clinical know-how
right at your finger tips.
On the Educate Homepage, the authors
names can be found as well as book
titles and order numbers with a forwarding link for convenient online ordering.

www.siemens.com/
SOMATOMeducate

Clinical Workshops 2011


As 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.

Workshop Title

Date

Location

Course Language

Course Director

Clinical Workshop on Cardiac CT/


Munich

April 6 8, 2011
July 20 22, 2011
October 4 6, 2011

Munich,
Germany

English

Prof. Christoph Becker, MD


PD Thorsten Johnson, MD
Alexander Becker, MD
Fabian Bamberg, MD

Clinical CTA Interpretation Course/


Erlangen

January 13 14, 2011


March 24 25, 2011
June 30 July 1, 2011

Erlangen,
Germany

English

Prof. Stephan Achenbach,


MD

Clinical Training Course on Cardiac CT March 12 13, 2011


September 10 11, 2011

Kuching,
Malaysia

English

Prof. Sim Kui Hian, MD


Ong Tiong Kiam, MD

Dual Energy Workshop

Forchheim,
Germany

English

PD Thorsten Johnson, MD

May 6 7, 2011
September 16 17, 2011

78 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

Life

ESGAR CT-Colonography Workshops

April 13 15, 2011

Dublin, Ireland

September 14 16, 2011

Gothenburg,
Sweden

Experience Lounge at ECR 2011

March 3 7, 2011

Vienna, Austria English

Siemens Healthcare

Hands-on Tutorials at ESC 2011

August 27 31, 2011

Paris, France

Siemens Healthcare

English

English

Prof. Helen Fenlon, MD


Martina Morrin, MD
Prof. Mikael Hellstrm, MD

In addition, you can register and nd the latest CT courses offered by Siemens Healthcare at www.siemens.com/SOMATOMEducate

Upcoming Events & Congresses


Title

Dates

Short Description

Location

Contact

RSNA

November 28
December 3, 2010

Annual Meeting of Radiological


Society of North America

Chicago, USA

www.rsna.org

Arab Health

January 24 27, 2011

Arab Health Congress

Dubai, UAE

www.arabhealthonline.
com

International
Stroke Conference

February 9 11, 2011

Present recent scientific work


related to stroke and cerebrovascular disease

Los Angeles, USA

http://strokeconference.
americanheart.org/portal/
strokeconference/sc/

ECR

March 3 7, 2011

European Society of
Radiology

Wien, Austria

www.myesr.org

AHA

March 22 25, 2011

Cardiovascular Epidemiology and Atlanta, USA


Prevention Scientific Sessions

www.americanheart.org

ACC

April 3 5, 2011

American College of
Cardiology

www.acc.org

ITEM

April 8 10, 2011

International Technical Exhibition Yokohama, Japan


of Medical Imaging

www.jira-net.or.jp

AOCR

April 11 15, 2011

American Osteopathic College of


Radiology

Palm Beach, USA

www.aocr.org

DGK

April 27 30, 2011

German Cardiac Society


Annual Meeting

Mannheim, Germany

www.dgk.org

DRK

June 1 4, 2011

German Radiology Congress


Annual Meeting

Hamburg, Germany www.roentgenkongress.de

ASNR

June 4 9, 2011

49th Annual Meeting of


the National Society of
Neuroradiology

Seattle, USA

www.asnr.org

ISCT

June 13 16, 2011

International Symposium on
Multidetector Row CT

San Francisco, USA

www.isct.org

SCCT

July 14 16, 2011

Society of Cardiovascular
Computed Tomography

Denver, USA

www.scct.org

New Orleans, USA

SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

79

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of computed tomography.
With its innovations, clinical
applications, and visions,
this semiannual magazine
is primarily designed for
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researchers, and medical
technical personnel.

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80 SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine

Editorial

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2010 by Siemens AG,
Berlin and Munich
All Rights Reserved
Publisher:
Siemens AG
Healthcare Sector
Business Unit Computed Tomography
Siemensstrae 1, 91301 Forchheim,
Germany

With FAST CARE we address


todays challanges of our
customers, accelerate CT
workows and reduce patient
exposure even further.
Sami Atiya, PhD, Chief Executive Office,
Business Unit Computed Tomography, Siemens Healthcare, Forchheim, Germany

Chief Editors:
Monika Demuth, PhD
(monika.demuth@siemens.com)
Stefan Ulzheimer, PhD
(stefan.ulzheimer@siemens.com)
Clinical Editor:
Andreas Blaha
(andreas.blaha@siemens.com)

Wolfgang Gerlach, MD, Private Practice,


Heidenheim, Germany
Luca Flors, MD, Klaus D. Hagspiel, MD,
Carlos Leiva-Salinas, MD, Department of
Radiology, University of Virginia, VA; USA
Joo Carlos Costa, MD, J. Dinis, MD,
R. Duarte, MD, J. Oliveira, MD, O. Borlido,
RT, M. Gonalves, RT, D. Martins, RT,
S. Silva, RT, D. Teixeira, RT, Radiology
Department, Hospital Particular de Viana
do Castelo, Viana do Castelo, Portugal
Dominik Augart, MD, Christoph Becker,
MD, Barbara Wieser, MD, Department
of Radiology, Ludwig-MaximiliansUniversity, Munich, Germany
Philipp Glitz, MD, Department of
Neuroradiology, University of ErlangenNuremberg, Erlangen, Germany

Project Management: Sandra Kolb


Responsible for Contents: Andr Hartung
Editorial Board:
Andreas Blaha
Andreas Fischer
Stefan Ulzheimer, PhD
Peter Seitz
Stefan Wnsch, PhD
Axel Lorz
Julia Hlscher
Jan Freund
Heidrun Endt

Junichiro Nakagawa, MD, Osamu Tasaki,


MD, PhD, Trauma and Acute Critical Care
Center, Osaka University Hospital, Osaka,
Japan

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freelance journalist; Michaela SpaethDierl, medical editor, Spirit Link Medical;
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Answers for life in Computed Tomography

Issue Number 27/ November 2010


RSNA-Edition / November 28th December 03rd, 2010

Cover Story
Be FAST, take CARE
Page 6

Iterative Reconstruction
Reloaded
Page 14

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SOMATOM Sessions

News

Business
syngo.via: Ready for
Prime Time in Clinical
Practice
Page 34
RSNA-Edition

Global Siemens Headquarters

Clinical
Results
SOMATOM Denition
Flash: Rule-Out of Coronary Artery Disease,
Aortic Dissection and
Cerebrovascular Diseases
in a Single Scan
Page 60

Science
Dose Parameters
and Advanced Dose
Management on
SOMATOM Scanners
Page 68