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SOMATOM Sessions

Answers for life in Computed Tomography

Issue Number 31 / November 2012


RSNA Edition

Cover Story
New Clinical Insights
Faster Diagnosis
Page 06

News
FAST Dual Energy
Boosts Comprehensive
Imaging and Treatment
in Oncology
Page 16

Business
We Are Family
Page 22

Clinical
Results
Diagnosis of CoronaryVertebral Subclavian
Steal Syndrome using
iTRIM Technique
Page 34

Science
CARE kV Allows
a Reduction of
Radiation Dose
Page 52

Editorial

Due to its broad benefits to the


healthcare system, image guided
therapy is now a major trend in
medicine.
Together with our network of
outstanding clinical and industrial
partners, we will continue to
lead the way in this exciting field.
Walter Mrzendorfer, Chief Executive Officer, Business Unit Computed Tomography and Radiation O
ncology,
Siemens Healthcare, Forchheim, Germany

Cover page: Courtesy of Clinique Pasteur, Toulouse, France

2 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

Editorial

Peter Seitz,
Vice President Marketing,
Computed Tomography,
Siemens Healthcare,
Forchheim, Germany

Dear Reader,
Over the last few years, dose reduction
in CT has become a highly considerably
issue. The result is that considerably lower
dose levels on average are applied to
our patients. For some body regions, the
improvements are spectacular. Who would
have thought 10 years ago, in the early
days of cardiac CT, that a coronary CT
Angiography would be possible for an
adult patient using an effective dose of
less than 1 mSv?
At some point we have to ask ourselves
whether the battle for the lowest dose
makes sense beyond the second digit.
Clearly, a 50 or 60% dose reduction is
great when you start at 5 or 10 mSv.
Yet, below 1 mSv it could be argued that
the best possible image quality might be
more relevant than another 0.1 mSv in
dose reduction. And equally important:
even with the latest technologies many
examinations still require a couple of mSv
in adult patients, e.g. around 3 to 4 mSv
for a typical abdomen. So below 1 mSv

Finally, we will work to further improve


access to state-of-the-art imaging with
the SOMATOM Perspective 64-slice configuration. Featuring the latest technologies already introduced to the 128-slice
configuration, this scanner includes
a footprint of only 18 m2. Its versatility
covers single-click reconstruction and
labeling of the entire spine through
to advanced intervention.3 Our tailored
solution for advanced visualization in
this segment come with a dedicated
set of applications to join the world of
syngo.via.

might not be the right dose for every


patient, too.
We will therefore shift the focus of our
efforts in dose reduction from low dose
to right dose. We will advise on absolute
dose values whenever possible. We will
continue to develop highly innovative
dose reduction technologies, such as
CARE kV or SAFIRE.1 We will continue to
work together with experts, for example
in our Siemens Radiation Reduction Alliance (SIERRA), to optimize protocols and
improve training. However, we will not
exclusively promote dose levels of below
1 mSv. Because we believe our patients
deserve the right dose for the best possible diagnosis.

I do hope you enjoy reading more about


these topics and catching up on a broad
range of clinical and business news in
this latest edition of SOMATOM Sessions.

We will also release the latest version


of syngo.via,2 introducing a wider range
of applications and features designed
to make reading easier than ever. One
example is Bone Reading,2 where images
now show the entire spine and rib cage
unfolded. In TAVI planning, the all-new
syngo.CT Cardiac Function Valve Pilot2
supports the assessment of the annulus
plane.

With best regards,

Peter Seitz

In clinical practice, the use of SAFIRE may reduce CT


patient dose depending on the clinical task, patient size,
anatomical location, and clinical practice. A consultation
with a radiologist and a physicist should be made to
determine the appropriate dose to obtain diagnostic
image quality for the particular clinical task.
2
Under FDA review. Not available for sale in the U.S.
3
These features are not commercially available in the
U.S. Due to regulatory reasons their future availability
cannot be guaranteed. Please contact your local Siemens
organization for further details.
1

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

Content

Content
Cover Story

06 syngo.via now fulfills


many established computed
tomography functions.
Whether working on oncological,
neurological or cardiac cases,
radiologists can save time
and may potentially improve the
quality of their findings.

06

New Clinical Insights


Faster Diagnosis

18

A New Course for


CT Scanning Suggested
by the Latest Research

Cover Story

Business

06 
New Clinical Insights
Faster Diagnosis

22 We Are Family
26 IRIS and Emotion in Daily Practice

News

Clinical Results

12 Precision and Flexibility on Rails


16 FAST Dual Energy Boosts Comprehensive Imaging and Treatment in
Oncology
18 
A New Course for CT Scanning
Suggested by the Latest Research
20 
C ARE Right. Committed to the Right
Dose in CT


Cardiovascular
28 
Low Dose CT Scanning with
70 kV in Congenital Heart Disease of
a 3-month-old Infant
30 
Low Dose CT Diagnosis of Pediatric
Aortic Coarctation using CARE kV,
SAFIRE and Flash Mode
32 
Unroofed Coronary Sinus
Syndrome Diagnosis with Dual
Source CT using Flash Mode
34 
Diagnosis of Coronary-Vertebral
Subclavian Steal Syndrome using
iTRIM Technique

4 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

Content

20

CARE Right. Committed to


the Right Dose in CT

52

CARE kV Allows a Reduction of


Radiation Dose

Science
Oncology
36 
Minimally Invasive Treatment
of Hepatocellular Carcinoma using
a Siemens Miyabi System

Acute Care
38 
Aortic Dissection Follow-Up using
Fast Mode with SOMATOM Definition
Edge
Orthopedics
40 
Metal Artifact Reduction by
Energetic Extrapolation in Single
Source Dual Energy CT1
42 
Metal Artifact Reduction using Dual
Energy CT Monoenergetic Imaging

44 
Research Clusters Enable Transfer
of Basic Research to Clinical Routine
Part II. Concentrated Expertise
Against Coronary Heart Disease
48 
Image Quality in Computed
Tomography Part I. Low Contrast
Detectability
52 
C ARE kV Allows a Reduction of
Radiation Dose

Customer
Excellence

55 
New Dual Energy Technology for
SOMATOM Definition
55 
Flash Imaging A Book Full of Flash
Expertise
56 Frequently Asked Question
56 Clinical Workshops 2012/2013
57 
Upcoming Events & Congresses
2012/2013
58 Subscriptions
59 Imprint

54 
Clinical Fellowships: Localized
Learning from the Experts
54 ESC Hands-on Tutorials (HoTs)

Under FDA review. Not available for sale in the U.S.

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

Cover Story

New Clinical Insights


Faster Diagnosis
syngo.via now fulfills many established computed tomography (CT)
functions. Whether working on oncological, neurological or cardiac cases,
radiologists can save time and may potentially improve the quality of
their findings.
By Oliver Klaffke

Late on Friday afternoon, and the groundfloor radiology department of the


Maussins-Nollet clinic in Paris is alive with
activity. Radiologist Catherine Radier,
MD, is still on duty in her tiny ground-floor
office. Dedicated to her work, she prefers
to deal with her patients face-to-face
rather than stare endlessly at screens:
Radiology is all about people, she states.
For Radier, any technological advance
that allows her to spend more time with
her patients is a welcome development.
This is precisely why she uses a syngo.via
system from Siemens.

Personally, I have benefited


greatly from the advances that
syngo.via and the CT Oncology
Engine have brought to radiology.
Catherine Radier, MD, Radiologist, Maussins-Nollet clinic, Paris, France

6 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

Personally I have benefited greatly


from the advances that syngo.via and
the CT Oncology Engine have brought to
radiology, Radier says. Both the Siemens
SOMATOM Definition AS and the CT
Oncology Engine are in use at her clinic.
Thanks to the data pre-processing and
retrieval capabilities of these systems,
images are instantly available and records
are always at hand. In addition, computeraided detection of lesions has opened
up a new diagnostic dimension for the
radiologist.

Cover Story

1 Rib and spine assessment are redefined with syngo.CT Bone Reading.
Courtesy of Medical University of Vienna, Department of Radiology, Vienna, Austria

Recently, Ms. Radier had the chance to


test one of Siemens latest additions:
syngo.CT Bone Reading.1 This is an application designed to support the visual
identification of bone metastases or
fractures.1 Detecting them in ribs and
vertebrae can be a tedious task for radiologists: One can become easily confused, wading through stacks of twodimensional images, Radier explains.

A palette of oncology functions


The new application for bone assessment
opens the entire chest cavity virtually;
providing unfolded rib and spine views,
so that three dimensions become two,
and the whole region is displayed as a
single layer. Furthermore, ribs and vertebrae are numbered automatically to aid
future reference.
Once findings are noted, they are automatically remembered by syngo.vias
Findings Navigator and can be easily
retrieved. As a core tool, this facility is an

 he option is pending 510(k) clearance, and is not yet


T
commercially available in the United States.

aid to radiologists day-to-day work and


is particularly useful when they need to
share findings with other physicians,
I can easily walk them through a case,
going from finding to finding, Radier
explains.
Another valuable functionality has been
added to syngo.CT Segmentation, which
has been designed to segment lesions in
the lung, liver, and the lymphatic systems.
Advanced Hounsfield Unit Statistics1
are collated to lesions for assessment of
hypodense areas of tumors, which might
be an indicator of necrosis. These are
then color-coded to provide an overview.
In addition, volume and percentage
compared to complete tumor volume is
calculated and displayed. Determining
changes in tumor size as well as changes
in tumor density is essential both in
assessing the progress of the disease,
and in evaluating its treatment.
The CT Oncology Engine also provides
a clear overview of tumor loads and
dimensions clearly over time. Thanks to
its pre-retrieval function, syngo.PET&CT
Cross-Timepoint Evaluation automatically
makes existing data available. By show-

ing this in a so called trending table or


graph, measurements from up to eight
examinations can be compared: Building such a table takes less than a second,
Radier notes.

Fast access to lifesaving


diagnostic information about
stroke patients
Meanwhile in northern Germany,
an emergency helicopter is landing at
Goettingen University Hospital with
a patient suffering an acute stroke.
Over 1,000 stroke patients are treated
here every year: Our aim is to restore
the blood supply to affected tissue as
soon as possible, says neuroradiologist
PD Peter Schramm, MD. This is essential
if neurological damage is to be kept to
a minimum, as up to two million brain
cells can be lost every minute following
a stroke: time is brain.
Three key diagnostic questions are
need to be answered in acute stroke:
How large are the areas of core infarct
and tissue that could potentially be saved
(penumbra) with further treatment in

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

Cover Story

the brain tissue? Is the stroke caused by


bleeding or a clot? And what is the size
and location of the clot? All three questions can be addressed with CT.
As the stroke patient is rushed from the
helicopter to the radiology unit Schramm
turns to his SOMATOM Definition AS+
CT scanner with the CT Neuro Engine.
The new perfusion imaging application
syngo.CT Neuro Perfusion1 is now available on the thin client-server platform
syngo.via. Treatment without precise
knowledge of core infarct size and penumbra may do more harm than benefit,
says Schramm. Therefore, diagnostic
imaging tools are required to see the size
of the core infarct and penumbra. These
need to be able to cover the whole brain,
safely, accurately and fast.
The syngo.CT Neuro Perfusion includes
a Tissue at Risk model that is based on
the mismatch between blood volume and
blood flow, Schramm says. However,
users can also select a custom mismatch,
based on user-defined perfusion metrics.
Schramm is investigating the Siemens
unique metric, Time To Drain (TTD), to
look for signs of early ischemia. Important,
but often overlooked are differences
in the hemodynamics of gray vs. white
matter: therefore the penumbra analysis
can be restricted not only to the affected

hemisphere. On top of that it can per


selection be limited to the brain gray
matter. For whole brain perfusion imaging, the Adaptive 4D Spiral technology
moves the table of the CT smoothly back
and forth, providing coverage beyond
the width of the detector.
The acute therapy varies according to
what caused the stroke: thrombolytics
need to be administered when a clot is
responsible; however, they are contraindicated when bleeding is the cause. A
native head scan will answer the question is it bleeding or is it a clot quickly.
Excellent image quality is required here
as the subtle nuances indicative of the
early signs of ischemic stroke can be
difficult to see. I routinely use Neuro
BestContrast, says Schramm.
If the result discovers a clot as the reason for the stroke, treatment can include
the administration of thrombolytic drugs
to dissolve the clot on the one hand and,
increasingly, interventional techniques
for clot retrieval. With modern neurointerventional techniques, such as catheters and clot retrieval devices, theres
practically no proximal intracranial artery
we cant open up, says Schramm. To do
this, it is vital to see exactly where the
vessel is obliterated. Generally, one can
determine the location of the clot by

We need
a reliable
stroke diagnosis
within
10 minutes.
PD Peter Schramm, MD,
Neuroradiologist,
University Hospital Goettingen, Germany

8 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

Dual Energy
opens new
dimensions in
diagnosis.
Prof. Michael Lell, MD,
Radiologist, University Hospital
Erlangen-Nuremberg, Germany

scrolling through axial CT Angiography


(CTA) source images. However, estimating
the size of the clot is somewhat cumbersome and often not possible, since the
images are taken at a single point in time.
This is where syngo.CT Dynamic Angio
comes into play. Dynamic CTA appears to
be a solution to this limitation. Movies
of blood flow, from arterial to venous
phases can be created and temporal
Maximum Intensity Projections (tMIP)
especially seem to better characterize
the clot size due to retrograde collateral
filling.
With my SOMATOM Definition AS+ and
the CT Neuro Engine, I am able to identify
core and penumbra, exclude bleeding
and determine the size and location
of the clot, says Schramm. Routinely,

Cover Story

patients are ready for stroke intervention


in less than 10 minutes. This gives me
confidence in better selecting patients
that may benefit from interventional
stroke treatment, concludes Schramm.

Overcome limitations of conventional methods


As radiologists we live in exciting times,
says Prof. Michael Lell, MD, radiologist at
Erlangen-Nuremberg University Hospital
in southern Germany. He has also had
the chance to explore some of the new
syngo.via applications resulting from
the Dual Energy functionality which,
he believes, opens up new dimensions
in diagnosis.
One of these applications is syngo.CT
DE Gout,2 an application that detects the
build-up of uric acid crystals: the cause
of gout. We expect an improvement in
treatment, as this application will help
us differentiate between the apparently
similar symptoms of gout and other forms
of arthritis, Lell observes. To date, CT
imaging has not been standard procedure in the diagnosis of gout. In traditional clinical practice, the presence
of increased levels of uric acid and salt
crystals in joints has been seen as an indication of gout. However, it is not always
so simple. In an acute phase, the levels
of uric acid might actually be quite low,
giving a false negative reading. Puncturing the joints is not always feasible and
not always diagnostic. Furthermore, in
some gout patients, the crystals only form
in the fibres not the joints. To further
complicate matters, the blood levels of
uric acid associated with some other
arthritic diseases can be as high as those
with gout.

 he option is pending 510(k) clearance, and is not yet


T
commercially available in the United States.
2
syngo.CT DE Gout is not commercially available in
the U.S. Due to regulatory reasons its future availability
cannot be guaranteed.

2 Infarct (red) and penumbra (yellow) with the tissue at risk model.
Courtesy of University Hospital Goettingen, Germany

3 syngo.CT DE Gout color-codes uric acid crystals to easily diagnose gout.


Courtesy of Nan Xi Shan Hospital, Guilin, China

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

Cover Story

Every year rheumatologists refer between


50 and 100 patients to Lell and his colleagues for CT examinations: It is essential to have a reliable way of judging
whether the salts are present or not, he
says. This is exactly what syngo.CT DE
Gout does, through its ability to clearly
show any salt crystals on the CT images.

Bringing clarity to gout


diagnosis and treatment
Clear visuals also make communication
easier with the patients, Lell notes.
Normally, two-dimensional CT images
can leave patients more confused than
enlightened; whereas three-dimensional
images of a joint with the salts highlighted in color make the situation
much clearer.
A further advantage of CT scans comes
from their ability to assist the physician
in assessing the success of gout therapy:
Tracking the presence of uric acid salts
with CT over time is a good way of
telling whether any improvements have
taken place, says Lell. syngos preretrieval feature assists with this. Even
before a scan has started, any previous
images will have been identified and
readied for comparison with the most
recent findings. One can then spot easily
whether the disease has advanced or
not, Lell adds.
In some cases, using Dual Energy can be
especially helpful: Think of uric acid and
of calcium pyrophosphate as indicators
of different diseases, says Lell. With Dual
Energy, one can tell them apart. They
are marked in different colors; in no
time, the radiologist can tell exactly what
disease the patient is suffering from.

Evaluating myocardial perfusion is one of


Feuchtners regular jobs. She has already
been using CT for this task; however, now
she has had the chance to test the new
features of syngo.CT Cardiac Function.
The Enhancement extension shows the
perfusion of the heart on an AHA-conform, 17-segment polar map it therefore provides a swift overview of vital
details.
Looking at perfusion to get an idea of
the state of the myocardium has many
advantages over simply identifying stenoses: With the improved enhancement
functionality, I can overcome the shortfalls of purely anatomical imaging as it
helps me to assess the hemodynamic
relevance of a stenosis, Feuchtner says.
With syngo.CT Cardiac Function, she can
track physiological changes within the

myocardium, It is far easier to identify


a perfusion defect on a 17-segment
map, she adds.
The Hybrid View offers a particularly
elegant way of presenting results, by
providing a three-dimensional display of
the heart. Besides the coronary arteries,
it shows an overlay of left ventricular
function and perfusion whether intact
or dysfunctional: The Hybrid View
allows a clear judgment of the diseased
vessels, says Feuchtner.
In the course of her examinations in
Innsbruck Feuchtner gets yet more valuable information by using syngo.CT
Cardiac Function. Besides evaluating first
pass enhancement, she also applies the
technique of late enhancement imaging
to CT. By waiting 68 minutes after contrast agent administration, a second scan

Boosting myocardial perfusion


analysis
At Innsbruck University Hospital in
Austria, matters of the heart are at the
core of the daily work of radiologist
Gudrun Feuchtner, MD. She performs
up to eight coronary CT Angiographies
a day: Time is a precious commodity,
she says. syngo.via is helping her to get
more from her images in less time.
4 The Hybrid View helps to correlate the perfusion defect with the supplying
coronary artery. Courtesy of Clinique Pasteur, Toulouse, France

10 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

Cover Story

allows the radiologist to differentiate


viable from scarred tissue.[1] Information about the still-functioning regions
of the heart muscle is vital for planning
pacemaker surgery. It makes no sense
to place electrodes in regions that are
no longer working properly. Normally,
MRI is used for late enhancement assessment, but in certain circumstances it is
contra-indicated, e.g. if the patient has
a cardiac pacemaker.[2] In these cases,
computed tomography may be the
method of choice: syngo.CT Cardiac
Function-Enhancement is therefore
particularly useful in planning revascularisation procedures, Feuchtner states.
Its images are proving a great help for
the cardiac surgeon.

Saving time in cardiology


Displaying perfusion within the myocardium in this way makes interpretation
much easier. Until now, this task
demanded considerable amounts of an
individuals time, concentration and
endurance. Thanks to the Automatic Preprocessing in syngo.via, all the necessary data is now made readily available.
With syngo.via we observe a reduction
of read-out time and time-to-diagnosis,
says Feuchtner. By introducing Rapid
Results Technology1 Siemens takes image
evaluation a step further and combines
efficient reading with increased standardization. The generation of images
now is not only automated, but also
reproducible. The design of individual
protocols helps to drive the evaluation
of coronary and general vessels and may
help to establish a constant quality of
care.
When it comes to Transcatheter Aortic
Valve Implantation (TAVI) planning,
syngo.CT Cardiac Function Valve Pilot2
supports the quantitative assessment of
the annulus plane. The annulus plane is
displayed and the minimum, maximum,
and effective diameters of the aortic
annulus are provided as the case is
opened.

Oliver Klaffke is a science and business writer,


who lives in Switzerland and France. Publications
for which he has written previously include the
New Scientist and Nature, among others.

It is far easier to identify


a perfusion defect
on a 17-segment map.
Gudrun Feuchtner, MD, Radiologist,
University Hospital Innsbruck, Austria

 apid Results Technology is not commercially available


R
in the U.S. Due to regulatory reasons its future availability
cannot be guaranteed.
2
The option is pending 510(k) clearance, and is not yet
commercially available in the United States.
1

References
[1] Hamilton-Craig C, et al. JACC Cardiovasc Imaging.
2011 Feb; 4(2):207-8.
[2] Schroeder S, et al. Eur Heart J. 2008
Feb; 29(4):531-56.

The statements by Siemens customers described herein


are based on results that were achieved in the customers
unique setting. Since there is no typical hospital and
many variables exist (e.g., hospital size, case mix, level
of IT adoption) there can be no guarantee that other
customers will achieve the same results.

Further Information
www.siemens.com/syngo.via

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

11

News

Precision and
Flexibility on Rails
Austria and Japan not only share a passion for classical music. The field
of X-ray diagnostics reveals more common ground: clinics in both countries
are trailblazers as far as the use of SOMATOM Definition AS systems with
sliding g
antry configurations is concerned.
By Regina Sailer, PhD

Be it pain management, tumor therapy,


or trauma classification, the SOMATOM
Definition AS with Sliding Gantry masters
a diverse range of clinical applications, as
events in Japan and Austria convincingly
disclose. The nascent system has now
been put through its paces in both countries, and has been in operation at the
Wels Clinic in Grieskirchen, Upper Austria,
since February 2012. Experiences of the
system in Osaka, where the worlds first
SOMATOM Definition AS with Sliding
Gantry was installed at the Toyonaka

Municipal Hospital in November 2011,


date back even further.

Multiple applications for


diagnosis and therapy
The high-end system has created a host
of new opportunities for diagnosis and
intervention in both countries. The conventually-run hospital in Wels demonstrates exactly how clinic resources can
be used more effectively as a result. With
approximately 1,200 beds, the hospital
serves Upper Austrias entire central

region. The system is deployed primarily


in the clinics trauma division, concurrently coping with an additional daily
workload of 35 to 50 routine CTs.
Senior physician Thomas Muhr, MD, radiologist and the clinics acting medical
director, explains: A major focus of our
clinical activities is CT controlled pain
management of the spine. With over
6,000 cases of intervertebral disk infiltration annually, Wels leads the national
field as far as treatment for this condition is concerned.

The resultant precision


which can be attained is
absolutely phenomenal,
and the images are
excellent.
Thomas Muhr, MD, Radiologist and medical director,
Wels Clinic in Grieskirchen, Austria

12 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

Wels hospital is equipped with a sliding gantry solution designed for use in two rooms, namely in both the trauma room and a second room
in which routine CT scans are carried out. Both of these rooms are equipped with a stationary, height-adjustable table. The gantry itself can be moved
to any desired position via the rail system.

Cardiac examinations are also increasing


in frequency at the Wels Clinic, which has
a very active cardiac surgery department,
gradually becoming part of the hospitals
daily routine. Here, the CT scanner is
currently used chiefly for exclusion diagnostics and clarification during bypass
operations, Muhr explains. The resultant precision which can be attained is
absolutely phenomenal, and the images
are excellent, adds the radiologist.
Smaller interventions, including facet
joint blocks in the lumbar region, lung
punctures, and biopsies are also part of
the clinics routine.
Its proximity to the trauma division
results in the systems additional use in
the diagnosis of whiplash injuries, joint
injuries, fractures or shoulder injuries,
and frequently for CT brain scans. It is
also implemented in the examination of

oncology patients during comparative


tumor evaluations, for instance. CT-controlled radiofrequency therapy is also
offered. Although the latter counts as
one of the Wels Clinics specialist fields,
the corresponding case numbers are
low, in strong contrast to the situation
at Osakas 650-bed municipal hospital,
where tumor therapy is at the very heart
of the SOMATOM Definition AS systems
activities.

Focus on oncological therapy


in Osaka
At the Toyonaka Municipal Hospital,
the rail-guided SOMATOM Definition AS
flexes its muscles primarily in the field
of precision oncological therapy. Taku
Yasumoto, MD, uses the technology to
perform between 50 and 60 interventions
on a monthly basis. Barring emergency

procedures, standard examinations


include lung biopsies and treatment of
hepatocellular carcinomas, which have a
high incidence rate in Japan, using radiofrequency ablation (RFA). Yasumoto favors
a combined technique of transcatheter
arterial chemoembolization (TACE),
followed by RFA. Here, the SOMATOM
Definition AS with Sliding Gantry is
teamed with an AXIOM Artis angiography
system from Siemens. Both procedures
are performed in a single location on
a treatment couch. This saves space, an
important factor in Japan. Patients and
clinic personnel alike benefit as a result,
as TACE plus RFA can now be carried out
conveniently without location transfers.
During these interventions, imaging
quality is particularly crucial. Yasumoto
emphasizes that, above all, minimally
invasive therapy must be highly selective,

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

13

News

and that optimal real-time imaging is


absolutely essential in consequence.
According to Yasumoto, this is where the
scanner comes into its own, offering clear
benefits during treatment, as both the
needle tips, Lipiodol and microbubbles
can be visualized perfectly with the CT.
In addition, the 3D-visualization also helps
less experienced personnel with the
precise localization of organs and tissue,
while, on the other hand, experienced
radiologists benefit greatly from the siximage display.

A customized system
The system in Osaka has been adapted
in line with Yasumotos specifications
in order to function with even greater
precision. The screens are now stacked
vertically on top of one another on a
small trolley and positioned above the
board with the joystick. The trolley fits
perfectly between CT construction and
retracted C-arm, allowing the physician
to view the screen and operate the joystick with his left hand without having
to let go of the needle shaft with his
right hand.

Yasumoto has developed two additional


special devices to assist him during examinations, which he has integrated effectively within the existing system. Besides
the glove, he uses a personal invention
in the shape of a type of cage which
surrounds the needle while he holds it.
He has also replaced the conventional
protective CT shields with a personally
designed Kamakura (Japanese for
igloo). This contraption is draped directly
over the gantry. The upper section consists of leaded crystal, while the lower
section forms a lead cover, two millimeters thick, which protects Yasumotos
arms and chest while still permitting
him to reach through into the gantrys
interior.

One CT for two rooms


Osaka Toyonaka Municipal Hospital
witnessed the first ever global use of the
SOMATOM Definition AS with Sliding
Gantry. Although the Wels Clinic was the
fifth to be equipped with the system,
it is revolutionary in another respect. It
was the worlds first hospital to be fitted
with a sliding gantry solution designed

for use in two rooms, namely in both the


trauma room and a second room in which
routine CT scans are carried out. Both of
these rooms are equipped with a stationary, height-adjustable table. The gantry
itself can be moved to any desired position via the rail system serving both rooms
with a single click from the control room.
This allows the team at Wels to use the
CT scanner in both rooms as required,
either routinely for daily business or for
emergency patients in the trauma room.
When severely injured individuals are
admitted, an event which occurs approximately every three days, the lead-lined
partition between the adjacent rooms is
simply opened, allowing the SOMATOM
Definition AS to slide into the emergency
area via the rail system, where the patient
waits on a special treatment couch
equipped with a carbon plate.
Both the CT and the diagnostic process
can be completed easily and conveniently
on this special couch. A considerable
benefit, explains Thomas Muhr, as, after
conveying the patient from the ambulance to the carbon plate, no more transfers are required until the time comes to

1 Computed tomography during arterial portography


(CTAP) was performed to confirm a hepatocellular
carcinoma diagnosis and to aid the physician in deciding
on the access path to this challenging tumor location
(see also case 5, page 36).
Courtesy of Toyonaka Municipal Hospital, Osaka, Japan

2 Polytrauma cases are routine in Wels, Austria.


Courtesy of Wels Clinic, Grieskirchen, Austria

14 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

News

move the individual to a hospital bed.


Up to nine transfers used to be required
to complete the diagnostic process. Problems involving obese patients, for whom
the old examination table had to be stabilized with an extra support, are now
also a thing of the past. The new system
receives top marks from the team at Wels
for both its larger bore and improved
hygiene. Muhr comments: The technically optimized water-cooling system
means that we benefit from less pathogen contamination during interventions
and polytrauma. And the reduced heat
loss heralds further improvements in
energy efficiency.

Speedy post-processing with


syngo.via
The trauma patients at Wels not only
benefit from increased efficacy as far as
transport and diagnosis are concerned.
In addition, the visualization software
syngo.via, which is fully integrated at
Wels, facilitates significantly faster CT
post-processing in the field of trauma
care. Thomas Muhr reports: syngo.via
is a great support, as we can use it to
reconstruct images and create 3D-reconstructions in a matter of seconds. This
is particularly advantageous for trauma
patients: We used to require around
an hour from the patients arrival to the
completion of the final image. The new
CT has allowed us to reduce this to 35
minutes, adds the Wels-based radiologist.
Not only emergency admissions have
been experiencing faster diagnostic
procedures since the new equipments
arrival oncological patients have also
benefited. We are now in a position to
measure tumors and calculate their volumes immediately with a simple click.
This has simplified things considerably,
explains Muhr, who also underlines the
systems user-friendliness and the advantageous impact of automatic preparation
on cases.

A giant step forward for


patients and colleagues
All these new options represent a giant
step forward for both patients and colleagues, reports Thomas Muhr, summa-

The trolley allows Taku Yasumoto, MD, to view the screen and operate the joystick with his left
hand without having to let go of the needle shaft with his right hand.

rizing experiences to date as follows: It


is impossible to rate the acceleration of
our work triggered by this new technology highly enough, particularly in the
field of trauma care. According to Muhr,
this progress also goes hand in hand
with pleasingly high stability. Downtime
is the exception to the rule, despite the
systems novelty. And what happens if
the system should malfunction? In this
case, Siemens reacts immediately. The
support provided is excellent, says Muhr.
Colleagues at Wels particularly appreciate this dedicated service, adds the physician, and are always happy to participate
in new projects involving Siemens.
The new SOMATOM Definition AS has
also established itself as an extremely
valuable tool in Japan during its first year
in service. According to Yasumoto, the
outstanding image quality has successfully enhanced minimally invasive therapy, particularly when combined with
ultra-precise table motion.

Regina Sailer, PhD, is a communications


scientist. She writes for German print and online
media as a freelance journalist. Her specialist
topics include the fields of medicine, health,
new therapies, and research. She lives and works
in Salzburg, Austria.

The products/features (here mentioned) are not commercially available in all countries. Due to regulatory
reasons their future availability cannot be guaranteed.
Please contact your local Siemens organization for
further details.

www.siemens.com/sliding-gantry

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

15

News

FAST Dual Energy Boosts Comprehensive


Imaging and Treatment in Oncology
SOMATOM Definition Siemens first generation Dual Source CT boosted
by FAST Dual Energy now offers valuable functional parameters helping to
answer critical oncological questions fast and without increasing radiation
dose or contrast media consumption. Specialists at the Institute of Clinical
Radiology and Nuclear Medicine at the University Medical Center Mannheim,
Germany, appreciate the user-friendly system in their daily imaging and
therapy routines.
By Ruth Wissler, MD

The Institute of Radiology and Nuclear


Medicine at the University Medical Center
Mannheim, Germany, performs between
100 and 120 CT readings per day. An
increasing number of outpatients are supplied with telemedical services and teleradiology, respectively. Six hospitals rely
on the comprehensive radiology service
during the night, and a smaller satellite
hospital uses the entire IT infrastructure
for telemedical purposes. Since the institutes SOMATOM Definition was equipped
with FAST Dual Energy about six months

ago, its utilization has reached approximately 50% of the Dual Source CT readings, with an upward trend.
Besides cardiovascular, neurological
and trauma readings, the Mannheim
Radiology Department provides the entire
spectrum of oncological imaging and
interventional oncological therapies, e.g.
Transcatheter Arterial Chemoembolization (TACE), Selective Internal Radiation
Therapy (SIRT), and Radiofrequency
Ablation (RFA). The embedded Centre
of Rare Tumors focuses on special

Meanwhile I dont ask


myself when to use Dual
Source CT with FAST
Dual Energy, but rather
when not to use it.
Thomas Henzler, MD,
Head of computed tomography at the Institute
of Clinical Radiology and Nuclear Medicine at
the University Medical Center Mannheim, Germany

16 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

tumor entities such as sarcoma and


Gastrointestinal Stromal Tumors (GIST).

Oncological challenges in
radiology
We are faced with growing requirements
from referring oncologists, and we have
to supply them with functional parameters, says Thomas Henzler, MD, Head of
computed tomography at the Institute of
Clinical Radiology and Nuclear Medicine
at the University Medical Center Mannheim, Germany. Increasingly individualized diagnostics, personalized intervention planning, and therapy monitoring
call for sophisticated imaging technologies. Combining Dual Energy CT and MRI
with PET-CT provides better functional
information.
For example, the progress in targeted
therapies requires a new quality of therapy monitoring. Functional imaging
shows us, that there is imaging beyond
Response Evaluation Criteria in Solid
Tumors (RECIST), says Thomas Henzler.
We see that patients receiving targeted
therapies live longer, even without reduction of tumor size. So this may partially
indicate an improper classification of
malignancies if we just use morphological
criteria.
The aim is not only to state the presence
and the changes in size of tumors during

1 57-year-old patient with large peritoneal GIST metastasis. Low keV monoenergetic iodine maps allowed significantly better assessment
of metastatic contrast enhancement, which is an important marker for therapy response evaluation under targeted therapy with Imatinib.
Courtesy of University Medical Center Mannheim, Germany

therapy, but also to assess the tumor


vascularization or status before and after
chemoembolization.

Dual Energy CT provides better


functional information
Currently, a large variety of functional
imaging solutions are available. But Dual
Energy CT according to Henzler, is probably the most commonly available and
cost-efficient imaging method. Dual
Energy CT will increasingly gain significance because medical imaging has to
take into account the advantage for the
patient as well as the incremental efficiency cost ratio. One very important
aspect of using SOMATOM Definition with
Dual Energy CT is to get functional information quickly without increasing the
radiation dose or the amount of contrast
agent. In therapy monitoring, for example, the low kV monoenergetic selective
iodine contrast enhancement allows significantly better assessment of metastases
(see Fig. 1).
With an optimal composition of low and
high kV data the contrast-to-noise ratio
can be improved. This optimal composition is provided with the Dual Energy
composition slider included in FAST Dual
Energy; consequently the amount of
contrast agent used may potentially be
optimized. During the last few years the
discussion has focussed on reducing the

radiation dose, but not reducing the contrast agent. As we found out in a study,
dose neutrality can only be confirmed
for Dual Source Dual Energy CT, emphasizes Henzler.

Clinical advantages: FAST Dual


Energy reconstruction
Considerable timesaving is one prominent clinical feature. Henzler: I would
assume that for 3D reconstruction, data
transmission and storage we can save
three to five minutes per case. During
a normal working day this adds up to a
considerable acceleration of workflow.
This is an important aspect for the technicians, too, because there is no additional workload.
The use of FAST Dual Energy right from
the start allows generation of additional
information such as functional data, if
needed, without having to store three
times the amount of data, because unused
datasets are eliminated and the Picture
Archiving and Communication System
(PACS) is not jam-packed. The specialists
experience with SOMATOM Definition
boosted by FAST Dual Energy at the Institute of Clinical Radiology and Nuclear
Medicine at the University Medical Center
in Mannheim, represents state of the
art practice in acceleration of workflow,
lean data sets and excellent acceptance
by technicians.

low kV
data

high kV
data

recon
part 1

recon
part 1

recon
part 2

3D
recon

FAST Dual
Energy image

2 FAST Dual Energy can use statistical


information from both images simultaneously and provides a combined filter for
improved mixed images at low and high
Dual Energy composition value.

Ruth Wissler, MD, studied veterinary and


human medicine. She is an expert in science
communications and medical writing.

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

17

News

A New Course for CT Scanning


Suggested by the Latest Research
Two recently published scientific studies show how CT scanning might
change established guidelines in the case of acute coronary syndrome
and in preventive medicine. Siemens SOMATOM CT scanners are well
equipped to set a new course.
By Heidrun Endt, MD
Computed Tomography, Siemens Healthcare, Forchheim, Germany
Since the 1970s, when CT became commercially available for the first time, it has
become a key imaging tool to approach
a range of clinical questions. Two large
clinical trials have recently been published
showing how CT scanning might have an
even greater impact and change established guidelines in the future.

Patient management in
the case of acute coronary
syndrome
The New England Journal of Medicine,
one of the most renowned medical
journals, published a multi-center study
on the use of coronary CT Angiography
(cCTA) examinations in the emergency
department. The authors included in their
study 1,370 patients who had presented
1A

with suspected acute coronary syndrome.


All of these patients had a low to intermediate risk of acute coronary syndrome.
The patients were then assigned to two
groups; one receiving traditional care
management as it is performed and established at the study location, the other
receiving cCTA as the initial imaging test.
A follow-up was conducted within 30 days
of the event. The researchers concluded
that cCTA in these patients [] appears
to allow the safe, expedited discharge
from the emergency department of many
patients who would otherwise be admitted[1] and that this approach is therefore [] more efficient than traditional
care.[1] Efficient workflow is important,
especially in the emergency department.
There would clearly not be enough time

to adjust the CT scan protocol manually


for each patient. Two studies[2, 3] published recently evaluated the potential
for the use of CARE kV, the automated
tube voltage adjustment from Siemens,
for cCTA examinations. In both studies,
one part of the examinations was carried
out with a manually-adjusted tube voltage based on the BMI of the patient; for
the second group of patients CARE kV
was used to determine the optimal tube
voltage. With CARE kV, the selection of
tube voltage resulted in a changed setting in 17 out of 38 patients in the first
study and the mean CTDIvol decreased
from 12.4 mGy to 8.7 mGy.[2] In the
second study, Park et al. conclude that
they were able [] to reduce radiation
exposure while maintaining diagnostic

1B
1 CARE kV proposed the
use of 80 kV as optimal tube
voltage setting for this CT
examination of the heart.
A 0.7 mSv effective dose
was applied for the coronary
CT Angiography (Figs. 1AB).
Within their study[2] the
authors from Massachusetts
General Hospital evaluated
the use of CARE kV for this
application.
Courtesy of Massachusetts
General Hospital, Boston,
USA

18 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

News

image quality [].[3] Further dose


reduction can be achieved with iterative
reconstruction. An international group of
researchers evaluated the use of SAFIRE
in an obese patient population for cCTA.
Compared with their standard protocol
with 120 kV, the low dose protocol with
100 kV and SAFIRE [] can reduce the
radiation requirements by 50% while
maintaining diagnostic image quality in
the obese patient population.[4]

Low-dose CT for persons at


high-risk of lung cancer
The New England Journal of Medicine
published a large clinical trial with more
than 53,000 persons at high-risk of lung
cancer.[5] The persons were assigned
to one of two groups. Each participant
underwent three annual examinations for
several years; either with conventional
X-ray examination (group 1) or a low-dose
CT scan (group 2). Afterwards, there was
a follow-up phase that showed that mortality from lung cancer was reduced in
the low-dose CT scan group.
Scanning these persons in a preventive
context requires special attention to
radiation dose. Baumueller et al. assessed
the use of SAFIRE for low dose examinations of the lung. The authors conclude
that the radiation dose of non-enhanced
lung CT can be lowered to a submillisievert level, while image quality still
remains diagnostic when data are reconstructed with SAFIRE.[6] Special organsensitive dose protection can be achieved
2A

with X-CARE; here the tube current is


lowered for certain angles of the rotation
of the X-ray beam. Ketelsen et al. evaluated thoracic CT examinations in 30
patients.[7] These patients were given
an initial CT scan without X-CARE and
had to undergo a second scan as followup. For this second examination, X-CARE
was used to lower the radiation dose to
the female breast and the thyroid gland.
Based on their measurements, the authors
recommend that X-CARE [] should
be used in thoracic CT examinations in
male and female patients with a possible
decrease in organ equivalent doses of
sensitive organs by about 30%.[7]

The impact of these large


clinical trials
Cardiovascular diseases are on the rise
and lung cancer is the most common
cause of cancer-related deaths. Consequently, research into how to manage
these diseases in an optimal fashion is
of great importance. Studies such as the
two large clinical trials presented above
[1, 5] help lead the way to optimized
management. Of course, until results
find their way into practical guidelines,
more studies are needed to further support their findings and subjects need to
be looked at from different angles. The
technologies implemented in Siemens
SOMATOM CT scanners would be of great
benefit in both cases: For scanning in the
case of suspected acute coronary syndrome, when there is no time to adjust

the protocol for each patient manually;


for scanning persons at high-risk of lung
cancer in the context of preventive medicine, where it is especially important to
keep the radiation dose low.

References
[1] Litt HI, et al. N Engl J Med.
2012 Apr 12;366(15):1393-403.
[2] Ghoshhajra BB, et al. Cardiac Computed
Tomography Angiography With Automatic Tube
Potential Selection: Effects on Radiation Dose
and Image Quality. J Thorac Imaging.
2012 Jul 27. [Epub ahead of print]
[3] Park YJ, et al. J Cardiovasc Comput Tomogr.
2012 May;6(3):184-90.
[4] Wang R, et al. Eur J Radiol.
2012 Nov;81(11):3141-5.
[5] National Lung Screening Trial Research Team.
N Engl J Med. 2011 Aug 4;365(5):395-409.
[6] Baumueller S, et al. Low-dose CT of the lung:
potential value of iterative reconstructions.
Eur Radiol. 2012 Jun 15. [Epub ahead of print]
[7] Ketelsen D, et al. Invest Radiol.
2012 Feb;47(2):148-52.

In clinical practice, the use of SAFIRE may reduce CT


patient dose depending on the clinical task, patient
size, anatomical location, and clinical practice. A
consultation with a radiologist and a physicist should
be made to determine the appropriate dose to obtain
diagnostic image quality for the particular clinical
task. The following test method was used to determine
a 54 to 60% dose reduction when using the SAFIRE
reconstruction software. Noise, CT numbers, homogeneity, low-contrast resolution and high contrast
resolution were assessed in a Gammex 438 phantom.
Low-dose data reconstructed with SAFIRE showed the
same image quality compared to full-dose data based
on this test. Data on file.

2B
2 A 55-year old patient
suffering from scleroderma
had to undergo a CT examination of the thorax. A lesion
in the left upper lobe (arrow,
Fig. 2A) was diagnosed as
well as lung fibrosis (arrows,
Fig. 2B). Due to the use of
SAFIRE, the examination could
be carried out with an effective dose of 0.35 mSv on the
SOMATOM Definition AS 64.
The examination was included
in the scientific study written
by Baumueller et al.[6]
Courtesy of University
Hospital Zurich, Switzerland

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

19

News

CARE Right. Committed to


the Right Dose in CT
In CT, achieving reliable clinical results with the greatest patient safety does
not mean reducing radiation at all costs. Experts recommend absolute values.
By Ivo Driesser, Computed Tomography, Siemens Healthcare, Forchheim, Germany

The guiding principle in applying radiation


is As Low As Reasonably Achievable, or
ALARA. In computed tomography this
means applying not just the lowest, but
also the right dose for sound diagnostic
imaging. Siemens has, therefore, made a
commitment to delivering the right dose
in CT with CARE Right. CARE Right summarizes Siemens efforts in the areas of
dose reduction technology, finding the
right dose levels for individual exams and
managing patient dose throughout the
institution.
Reference values

Right dose technology


In order to get to the right dose and to
reduce it to as low as reasonably achievable for the clinical task, the clinical staff
need to have the right dose technology.
From the beginning of the CT era, developing highly innovative dose reduction
technologies was one of Siemens main
goals. Back in the 1990s, Siemens introduced CARE the Combined Applications
to Reduce Exposure. In CT scans, three
aspects are crucial: individual size and
stature of the patient, examination type,

and, finally, applied radiation dose. They


are all the key drivers for the resulting
image quality.

Individual patient and examination types


First, the patients habitus both in-plane
and along the longitudinal axis influences
the dose that needs to be applied.
Siemens CARE Dose4D is unique in adjusting modulation in real time during the
scan based on only one topogram so that
the right dose is always applied accord-

Switzerland1

Germany2

European Union3

USA4

Head Routine

CTDIvol [mGy]

65

65

60

75

Thorax Routine

CTDIvol [mGy]

15

12

30

Abdomen Routine

CTDIvol [mGy]

15

20

35

Standard values*

Standard SAFIRE***
values*/**

Study values**

Default Siemens
Protocol
Head Routine

CTDIvol [mGy]

59.8

41.4

455

Thorax Routine

CTDIvol [mGy]

7.4

4.4

1.56

Abdomen Routine

CTDIvol [mGy]

14.2

10.1

6.57

25

1 Bundesamt fr Gesundheit (Merkblatt R-06-06, Diagnostische Referenzwerte in der Computertomographie, 01.04.2010)


2 Bundesamt fr Strahlenschutz (Bekanntmachung der aktualisierten diagnostischen Referenzwerte fr diagnotische und interventionelle Rntgenuntersuchungen. Vom 22. Juni 2010)
3 European Guidelines on Quality Criteria for Computed Tomography (http://www.drs.dk/guidelines/ct/quality/htmlindex.htm)
4 American College of Radiology (CT Accreditation Program Requirements, Clinical Image Quality Guide, 13.04.2012)
5 Becker HC, et al. Radiation exposure and image quality of normal computed tomography brain images acquired with automated and organ-based tube current modulation multiband filtering and
iterative reconstruction. Invest Radiol. 2012 Mar;47(3):202-7.
6 Baumueller S, et al. Low-dose CT of the lung: potential value of iterative reconstructions. Eur Radiol. 2012 Jun 15. [Epub ahead of print] CTDIvol for the protocol using 100 kV.
7M
 ay MS, et al. Dose reduction in abdominal computed tomography: intraindividual comparison of image quality of full-dose standard and half-dose iterative reconstructions with dual-source computed
tomography. Invest Radiol. 2011 Jul;46(7):465-70. CTDIvol for abdominal CT calculated according to the conclusion.

Tab. 1: Absolute values which can be obtained with default protocols on the SOMATOM Definition Flash in comparison with reference values
from different regions.
*** V
 alues are based on the default protocols of the SOMATOM Definition Flash with syngo CT 2012B and an average sized patient of 1.75 m and 75 kg
*** Iterative Reconstruction is used
*** In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with
a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task. The following test method
was used to determine a 54 to 60% dose reduction when using the SAFIRE reconstruction software. Noise, CT numbers, homogenity, low-contast resolution and high contrast
resolution were assessed in a Gammex 438 phantom. Low dose data reconstructed with SAFIRE showed the same image quality compared to full dose data based on this test.
Data on file.

20 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

News

ing the right dose for each examination.


In order for users to know, whether they
apply the right dose levels, absolute dose
values are a pre-requisite. Therefore
Siemens provides them along with its protocols and they are confirmed in external
peer-reviewed publications (see references
5-7 in Tab.1). Users can apply these values as a reference to compare their current dose level with regional recommendations and with the dose delivered by
Siemens CT scanners (see Tab. 1).

Documenting dose a basis


for management, compliance
and improvement
1 Siemens CT updated free-of-charge the SOMATOM Definition AS family for their

customers to SAFIRE, the latest evolution in iterative reconstruction. With SAFIRE, it


was possible to achieve excellent image quality with a low dose value (CTDIvol:10 mGy).

ing to the strongly varying attenuation


in x-, y- and z-direction during one scan.
Second, also the tube voltage should be
adapted to the individual patient and
examination type. In a CTA, for example,
lower kV is beneficial as the contrast
media enhanced vessels can be depicted
with a better contrast-to-noise-ratio (CNR).
However in non-contrast scans or in
obese patients higher kV may be better
to provide enough power to obtain good
and diagnostic image quality. Siemens
CARE kV is still the only solution on the
market that automatically determines the
appropriate kV and scan parameters to
deliver the right dose for the particular
scan and the required image quality.
Third, iterative reconstruction approaches
proved to be beneficial in reconstructing
images of the same diagnostic quality
acquired with a lower dose compared
to the established filtered backprojection
technique. With outstanding clinical
results, SAFIRE Sinogram Affirmed
Iterative Reconstruction enables a dose
reduction potential of up to 60%.***
Siemens has also introduced new image
reconstruction systems that allow itera-

tive reconstructions of up to 20 images


per second, fast enough for clinical
routine. As a result, many Siemens sites
across the globe use SAFIRE consistently
for every examination, even in time
crucial environments like acute care.

Absolute dose values


essential for the right dose
But next to having access to the right technology, it is essential to know the right
dose levels to perform an examination
according to ALARA. There is an ongoing
debate about the balance between
image quality and amount of radiation.
On this issue, Siemens, together with key
opinion leaders, founded SIERRA the
Siemens Radiation Reduction Alliance.
Feedback from this and other panels of
experts provides input for a dedicated
development team. That produces the
various Siemens protocols needed to
comply with the full range of patient
types, disease types, examination procedures, and with the expectations of
reading physicians with regard to image
quality. The result is a sophisticated
library of scan protocols focused on apply-

Finally, organizations need to manage


dose across their institutions. Regional
regulations sometimes require that radiation given to patients is documented.
Other CT administrators like to have an
overview as a basis for dose optimization.
Both cases require structured access to
dose data. With DoseMAP Siemens new
Dose Management Program data can
be accessed from various sources, such
as scanners, PACS or RIS and aggregated
to the type of report required. With
EduCARE, Siemens also offers specialized
trainings focussing on applications to
reduce dose. CME-accredited tutorials
and webinars can be booked by users for
specific topics. Furthermore, Siemens has
introduced a new cross-modality consultancy program, called Optimize CARE.
Siemens professionals work with the
customer on site to analyze the current
situation, define and implement improvement measures to reasonably reduce
radiation and then monitor the progress
with the customer to finally hit the right
dose.

Commitment to the right dose


Siemens efforts in optimizing dose
have also been recognized by others. An
impartial organization, KLAS, stated in
its report CT 2011: Focused on Dose
that Siemens was the leader to catch,
honoring Siemens commitment to delivering the right dose.

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

21

Business

We Are Family
Only 12 months after the debut of the SOMATOM Perspective 128-slice
configuration, its sibling is on its way this time in 64-slice configuration.
The SOMATOM Perspective family brings plenty of new features along with
its great economics.
By Eric Johnson

The SOMATOM Perspective scanners are


ideal for larger private practices and midsize hospitals, offering them a first step
towards the upper-end of computed
tomography (CT).
One-size-fits-all has never been the
Siemens approach to CT or to medical
equipment in general, because we know
that requirements vary from clinic to clinic
and practice to practice, comments
Florian Belohlavek, Siemens Global Product Marketing Manager for the SOMATOM
Perspective, CT. So, to meet these needs,
we now offer the SOMATOM Perspective

family. The machines share quite a number of unique functionalities, but differ
in their scan coverage capabilities and
thus clinical applications. Such is their
similarity that customers can buy this
64-slice machine as a starter system from
the high-end segment, and in time,
upgrade directly to a 128-slice model. The
main difference between the two is a
matter of clinical performance. The 128slice has a powerful cardiac and vascular
package; the 64-slice addresses customers that only face cardiac questions once
in a while and focus on having a strong

Only one year after the debut of the 128-slice SOMATOM Perspective,
another is on its way this time in 64-slice configuration.

22 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

workhorse for everyday clinical tasks.


The new SOMATOM Perspective was
unveiled in November, at the 2012 Radiological Society of North America (RSNA)
conference, and featured a host of
upgraded components. However, one
element definitely remains unchanged:
the positioning as the most economical
CT in its class.

Born this way. So, whats new?


The first new addition to the FAST CARE
platform is a feature already available in
SOMATOM Definition scanners: FAST
Spine.1 This speedier system for recons of
the spine is an option for the SOMATOM
Perspective family. By preparing anatomically aligned reconstruction ranges,
as well as the labeling of all acquired
vertebrae and discs, FAST Spine1 may
potentially reduce time needed for preparing spine recons, which is important
in time-crucial cases in acute care.Then
there is the introduction of tilted spiral
scanning2 for analyses of the head and
spine. While the previous SOMATOM
Perspective offered tilted sequential scanning, this now can be done in spiral mode.
Also new is i-Control,3 an in-room
remote control for interventions. It
transfers all scanner controls into the
scan room, e.g. for the patient table
movement, or remote command for the
gantry and scanner functions.
Dose protection has been boosted, too.
A new password system enables scan protocols to be changed only by authorised
people at a practice or clinic, not just by
anybody with access to the machine. In
addition, the integrated gantry display

1 This case of liver tumor was examined with SOMATOM Perspective. The VRT image highlights multiple liver lesions and fine details
of the mesenteric arteries. Courtesy of Diagnosezentrum Favoriten, Vienna, Austria

has been upgraded. More information is


reported, in a larger format, making it
easier to both read and use.4

Practice made perfect


As would be expected in a high-end
system, the SOMATOM Perspective family

offers some of the latest innovations in


CT. Dose reduction is achieved in three
ways. The first of these is through the
application of CARE Dose4D, which adapts
the X-ray tube current throughout the
duration of scan, helping to create images
of consistent quality for all organs, patient

shapes, and sizes in real time. This overcomes the most common challenges of
CT imaging: a) the applied dose in anterior, posterior, and lateral positions needs
to be different; b) each slice requires
different dose values, and c) patients
are quite heterogeneous (young/elderly,

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

23

Business

(IVR) helps to visualize even very small


diagnostic details using a sophisticated
reconstruction algorithm.

Taking care of business

2 A case of lymphoma VRT image shows multiple enlarged lymph nodes in the mediastinum
and great anatomical details in the lungs. Courtesy of Clinique Sainte Marie, Paris, France

small/large), so the applied dose must


be adapted to the individual patient;
d) patients can move after the initial
topogram was acquired, thus a real-time
adjustment is needed during the scan.
Secondly, iterative reconstruction (IR)
further aids dose reduction. Until recently,
using IR with CT imaging in conventional
clinical medicine was simply too timeconsuming: reconstructing images with
iterative algorithms required too much
computational power. With Sinogram
Affirmed Iterative Reconstruction
(SAFIRE), Siemens has introduced rawdata-based iterative reconstruction that
can achieve a dose reduction of up to
60%5 across a wide range of applications. It also delivers excellent image
quality. Due to its reconstruction speed
of up to 15 images/second, SOMATOM
Perspective brings SAFIRE into the daily
routine.
The final element of dose reduction

comes from Ultra Fast Ceramic (UFC)


detectors, which have already become
a key feature in CTs predating the
SOMATOM Perspective. UFCs enable the
capture of smaller X-ray doses, yet they
still respond with high luminance. This
means that they outperform conventional
detectors, which require more radiation
to generate an image of equal quality.
Besides this comprehensive dose portfolio, the new scanner also features new
functionalities like iTRIM and IVR, improving its diagnostic capabilities. The first,
Iterative Temporal Resolution Improvement Method (iTRIM) improves temporal
resolution, which is essential in cardiac
imaging. This novel algorithm analyzes
the image for fast moving sections and
applies an iterative image reconstruction
when required. This supports diagnosis
in demanding situations, for example
when imaging hearts with rapid movements. Interleaved Volume Reconstruction

24 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

Money, time, space the SOMATOM


Perspective family saves all, which brings
down both capital and operating costs.
The speed of installation represents a
major plus for the SOMATOM Perspective
family. Since the scanner and control
room have the smallest footprint of any
comparable CT system just 18.5 square
meters (199 square feet) a SOMATOM
Perspective will easily fit into the space
of an existing CT, with room to spare. Its
also lightweight: tipping the scales at
1,719 kg (3,790 lbs), whereas conventional CTs can weigh anything from just
over two, to nearly three metric tonnes
(4,409-6,613 lbs). Existing CT power
sources rated at 75-150 kVA can be
used because the SOMATOM Perspective
requires only 70 kVA. This allows installation in an existing scan room, without
the need for extending, floor reinforcement or rewiring. All this means that
instead of the 3-4 days downtime usually needed to fit a conventional CT, the
SOMATOM Perspective can be up and
running within 48 hours.
In operation, these CTs run at lower
temperatures and use less energy. Cooling requirements and total electricity
consumption are around half those of a
conventional scanner. Then comes the
masterstroke: eMode. Built into the user
interface, eMode allows operation of the
scanner in a patient-friendly and financially efficient way with a single click. An
analysis of the scan is made in real time,
and the system is instantly fine-tuned
according to the requirements of the user.
This reduces wear and tear on the system. Coupled with this it comes a new
service plus approach from Siemens:
for customers who run the SOMATOM
Perspective in eMode for more than 80
percent of its operating time, their institution will be rewarded with dedicated
eMode service benefits.6

Taking care of people


Of course, money isnt everything. The
SOMATOM Perspective is also simple to

Both the 64-slice and the 128-slice configuration offer the Illumination Moodlight.

use. Operators will appreciate easeyour-workday accessories such as FAST


Planning, FAST Cardio Wizard, the newly
introduced FAST Spine,1 Workstream4D,
the storage box and a standard reconstruction speed of up to 20 images per
second. The gantry also offers Siemens
unique Illumination MoodlightTM, which
helps to banish the sterile, clinical lookand-feel of most examination rooms. As
they are so fast and accurate, the scanners may allow patients to undergo fewer
scans altogether, and during those scans
to spend less time holding their breath,
rolling or stretching. That is a bonus for
patients.
So in addition to clinical advancements
and significantly reduced overall costs,
patients may also benefit from the patient
friendly features. This is what makes up

the cumulative strength of this family:


It enhances patient care and business.

 he features (here mentioned) are not comT


mercially available in the U.S. Due to regulatory
reasons their future availability cannot be
guaranteed. Please contact your local Siemens
Eric Johnson writes about technology,
organization for further details.
business and the environment from Zurich.
5
In clinical practice, the use of SAFIRE may reduce
Previously he headed what is now a ThompsonCT patient dose depending on the clinical task,
Reuters bureau and corresponded for McGrawpatient size, anatomical location, and clinical
Hill World News.
practice. A consultation with a radiologist and
a physicist should be made to determine the
appropriate dose to obtain diagnostic image
www.siemens.com/
quality for the particular clinical task. The followSOMATOM-Perspective
ing test method was used to determine a 54
to 60% dose reduction when using the SAFIRE
reconstruction software. Noise, CT numbers,
1
homogeneity, low-contrast resolution and high
FAST Spine is not commercially available in the
contrast resolution were assessed in a Gammex
U.S. Due to regulatory reasons its future avail438 phantom. Low-dose data reconstructed with
ability cannot be guaranteed.
2
SAFIRE showed the same image quality compared
Tilted spiral scanning is not commercially availto full-dose data based on this test. Data on file.
able in the U.S. Due to regulatory reasons its
6
future availability cannot be guaranteed.
Individual service benefit availability is subject
3
i-Control is not commercially available in the
to country-specific offerings.
U.S. Due to regulatory reasons its future availability cannot be guaranteed.
4

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

25

Business

IRIS and Emotion in Daily Practice


Technical modernization proves particularly challenging for small
radiology practices. It is essential to strike the right balance between
technical progress, patient expectations, personal aspirations, and
costs. Radiologist Christoph Voigt, who runs his own practice based
in the Protestant Hospital in Hattingen, Germany, is well on track
with the Siemens package, consisting of SOMATOM Emotion and IRIS.
By Ingrid Horn, PhD

Back then, when the issue of a new CT


system cropped up, we decided on an
ideal combination, says Christoph Voigt.
A SOMATOM Emotion 16 scanner, an
unpretentious yet high-quality computed
tomography scanner from Siemens, has
graced his practice since March 2012.
The most popular model in the compact
class is equipped with the high-performance Ultra Fast Ceramic (UFC) detector
technology. As a result, the SOMATOM
Emotion generates premium-quality
images while helping to minimize radia-

tion exposure for patients. However,


Christoph Voigt, who had prior experience of Siemens CT technology, decided
to go a step further in the knowledge
that appropriate image reconstruction
methods can produce an additional
reduction in patient dose. The Hattingenbased radiologist chanced upon IRIS
while researching this topic. Iterative
Reconstruction in Image Space successfully reduces image noise to such an
extent that the radiation dose used to
generate the images can be decreased

significantly without impairing image


quality. In the meantime, many CT
models produced by Siemens can be
upgraded with iterative reconstruction.
Christoph Voigt explains his decision as
follows: We wanted to purchase a reliable, modern and economically efficient
device with genuinely good prospects.

Raised competitive profile


IRIS is en vogue. The radiologist and his
partners are aware that following current
trends is key to remaining competitive.

The team at the Protestant Hospital in Hattingen, Germany, is proud to work with SOMATOM Emotion in combination with IRIS.
Main tasks include colonographies, tumor and nervous system imaging.

26 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

Business

Hattingen lies on the periphery of the


Wuppertal conurbation in the German
federal state of North Rhine-Westphalia.
The practice owners decided to invest in
IRIS to raise their competitive profile and
set themselves apart from other radiology institutions. Above all, it is a way to
counteract patient migration to radiology centers. As a result, they spread the
good news of their practices technical
upgrade via local newspaper. And attention was certainly paid by patients. As
Christoph Voigt discovered during ensuing discussions, the dose reduction facilitated by IRIS was the most important
aspect in their eyes. Meanwhile, he has
realized exactly how much the SOMATOM
Emotion and IRIS combination achieves.
When compared to his previous images
and external images of patients, he puts
the average dose savings at 50%.1

Dose reduction as top priority


Patients at the joint practice are referred
by both local practitioners and the hospital. Approximately 25 patients with a
wide range of clinical diagnoses receive
CT scans daily. Christoph Voigt explains:
We do everything the device permits
with the exception of cardiac CTs. Applications in focus include colonographies
and tumor and nervous system imaging.
Voigt places great emphasis on an optimized balance of image quality and radiation dose. In some cases, such as muscleskeletal system imaging, he retains the
conventional dose in order to benefit
from increased image quality with IRIS. In
general, however, dose reduction is the
top priority. Voigt says: This method is
particularly beneficial for young people
with testicular carcinomas or lymphomas,
as the total radiation load in the face of
the frequent checkups decreases. The
thorax CT of a patient suffering from a
bronchial carcinoma convincingly demonstrates the way in which outstanding
images can be achieved with a reduced
radiation dose and via the use of IRIS.
Although the radiation load is just as high
as in the case of the two-plane X-ray, the
CT provides more information than the
classic radiograph, which may aid the
physician in making decisions regarding
possible surgical interventions. As a result,

1 Thorax CT of a patient suffering from a bronchial carcinoma.


Courtesy of RSN Hattingen, Germany

paranasal sinuses are only scanned with


the CT scanner and IRIS technology in
Hattingen.
Christoph Voigt believes that his practice
now provides standard examinations at
university level thanks to the new device
configuration. He is equally impressed
by the fact that, after just a brief familiarization phase, the use of IRIS and the
interpretation of the resultant images
have quickly become routine. IRIS is
always an asset in the eyes of Christoph
Voigt, whether a small radiology practice is debating a new acquisition or an
upgrade.

Ingrid Horn, PhD, studied biology and


biochemistry. She is an expert in science communications and an experienced medical writer
with an emphasis on biomedical topics in fields
including medical engineering, neuroscience,
oncology, and pediatrics.

I n clinical practice, the use of IRIS may reduce


CT patient dose depending on the clinical task,
patient size, anatomical location, and clinical
practice. A consultation with a radiologist and
a physicist should be made to determine the
appropriate dose to obtain diagnostic image
quality for the particular clinical task. The following test method was used to determine a up to
60% dose reduction when using the IRIS reconstruction software. Noise, CT numbers, homogeneity, low-contrast resolution and high
contrast resolution were assessed in a Gammex
438 phantom. Low-dose data reconstructed
with SAFIRE showed the same image quality
compared to full-dose data based on this test.
Data on file.
The statements by Siemens customers described
herein are based on results that were achieved
in the customers unique setting. Since there
is no typical hospital and many variables exist
(e.g., hospital size, case mix, level of IT adoption)
there can be no guarantee that other customers
will achieve the same results.

www.healthcare.siemens.com/
computed-tomography/
clinical-applications/iris

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

27

Clinical Results Cardiovascular

Case 1
Low Dose CT Scanning with
70 kV in Congenital Heart Disease
of a 3-month-old Infant
By Martin Wong,* Wai Leng Chin**
** Paediatric Cardiology Unit, Pusat Jantung Hospital Umum Sarawak, Malaysia
** Siemens Healthcare, Regional RHQ, Singapore
1

HISTORY

DIAGNOSIS

A 3-month-old male infant was admitted


with central cyanosis and a heart murmur.
An echocardiography revealed complex
cyanotic heart disease (situs inversus,
dextrocardia, tricuspid atresia, univentricular heart and pulmonary atresia). The
pulmonary artery anatomy could not be
clearly delineated in echocardiography.

A CT Angiography (CTA) revealed a


confluent central pulmonary artery, unifocally supplied by a ductus arteriosus
(Figs. 13, arrows). The ductus arteriosus
originated from the descending aorta
and ran a tortuous S-shape course before
inserting into the right pulmonary artery.
There was a long segment narrowing
of the proximal right pulmonary artery
(Fig. 3, dashed arrow) between the pul-

28 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

monary artery confluence and the ductal


insertion site. Otherwise, both distal
pulmonary arteries were of average size.
The univentricular heart (Fig.4, asterix)
and dextrocardia were also seen in the
CTA.
The infant successfully underwent
a left modified Blalock-Taussig shunt
as the first step in the single ventricle
repair pathway.

Cardiovascular Clinical Results

COMMENTS
70 kV CTA clearly demonstrated the
complex pulmonary artery anatomy
and enabled a prompt diagnosis and
pre-operative planning. Invasive cardiac
catheterization became unnecessary.
The combined effect of the low kilovoltage setting of 70 kV and the auto-

matic tube current dose modulation


for low radiation dose is feasible in
small-size pediatric patients, without
impairing image quality.

13 VRT (Fig.1),
thin MIP 7 mm
(Fig. 2) and 5 mm
(Fig. 3) images show
a confluent central
pulmonary artery,
unifocally supplied by
a ductus arteriosus
(Figs. 13, arrows).
The ductus arteriosus
originated from the
descending aorta
and ran a tortuous
S-shape course before
inserting into the
right pulmonary
artery. A long segment narrowing of
the right pulmonary
artery (Fig. 3, dashed
arrow) could also be
visualized between
the pulmonary artery
confluence and the
ductal insertion site.

4 Thin MIP 10 mm
shows univentricular
heart (asterix), and
dextrocardia.

examination protocol
Scanner

SOMATOM
Definition Flash

Scan area

Thorax

Scan length

147 mm

Scan direction

Cranio-caudal

Scan time

0.35 s

Tube voltage

70 kV

Tube current

132 eff. mAs

Dose
modulation

CARE Dose4D

CTDIvol

1.29 mGy

DLP

19 mGy cm

Rotation
time

0.28 s

Pitch

2.0

Slice collimation

0.6 mm

Slice width

0.6 mm

Spatial
Resolution

0.33 mm

Reconstruction
increment

0.4 mm

Reconstruction
kernel

B26

Contrast
Volume

8 mL

Flow rate

1.0 mL/s

Start delay

CARE Bolus

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

29

Clinical Results Cardiovascular

Case 2
Low Dose CT Diagnosis of
Pediatric Aortic Coarctation using
CARE kV, SAFIRE and Flash Mode
By Pei Nie, MD,* Ximing Wang, MD,* Zhaoping Cheng, MD,* Yanhua Duan, MD,* Xiaopeng Ji, MD,*
Jiuhong Chen, MD, PhD**
** Shandong provincial key laboratory of diagnosis and treatment of cardio-cerebral vascular diseases,
Shandong Medical Imaging Research Institute, Shandong University, Jinan, Shandong, P. R. China
** CT Research Collaboration, Siemens Ltd. China, Beijing, P. R. China

HISTORY

A 4-year-old boy was presented with a


history of hypertension. A physical examination revealed upper extremity hypertension and diminished femoral pulses.
A systolic ejection murmur, at the left
upper sternal border, radiated to the
interscapular area. A cardiovascular CT
examination was requested to evaluate
the aortic anatomy prior to surgery.

1 Flash Mode enables data acquisition within one cardiac cycle.

DIAGNOSIS
A thoracic CT Angiography (CTA) scan with
ECG triggering confirmed the coarctation
of the aorta (Figs. 3, 5-8). The coarctation
was distal to the left subclavian artery and
measured 15 mm in diameter proximal
to the obstruction, 5 mm at the smallest
diameter, 16 mm distal to the obstruction
and 10 mm in length. Additionally, a small
patent ductus arteriosus (Figs. 4, 7-8)
was found, connecting the main pulmonary artery and the upper descending
aorta. The cardiac structures, as well as
the origins and the courses of the coronary arteries, showed no abnormalities.

COMMENTS
Flash Mode enables an ECG-triggered
spiral scan starting at 10% of the R-R interval with a high pitch of 3.4. The heart rate

2 The parameters of CT scanning and contrast injection were recorded in the patient protocol.

30 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

Cardiovascular Clinical Results

varied between 78 to 100 bpm (Fig. 1),


however, the image acquisition of the
entire thorax was completed within one
cardiac cycle in only 0.46 s. Therefore
neither sedation nor breathhold was
necessary.
A combination of various techniques
was applied to lower the radiation dose
to 0.35 mSv CARE Dose4D (automatic
tube current modulation), CARE kV (automatic tube voltage optimization) and
SAFIRE (raw data-based iterative reconstruction).
The amount of contrast medium used
could also be reduced to 18 mL (1.2 mL
per kg body weight) thanks to the
Flash scanning speed and the intensive
enhancement achieved at 70 kV.

examination protocol
Scanner

SOMATOM
Definition Flash

Scan area

Thorax

Scan length

144 mm

Scan direction

Caudo-cranial

Scan time

0.32 s

Tube voltage

70 kV with CARE kV

Tube current

130 eff. mAs

Dose modulation

CARE Dose4D

CTDIvol

0.37 mGy

DLP

8 mGy cm

Effective dose

0.35 mSv

Rotation time

0.28 s

Pitch

3.4

Slice collimation

128 x 0.6 mm

Slice width

0.75 mm

Spatial Resolution

0.33 mm

Reconstruction
increment

0.5 mm

Reconstruction
kernel

I26f, SAFIRE

Heart rate

78 100 bpm

Contrast

350 mg/mL,
Ultravist, Iopromide

Volume

18 mL (contrast)
+ 15 mL (saline)

Flow rate

1.5 mL/s

Start delay

25 s

38 Maximum Intensity Projection (MIP) images (Figs. 34) and volume-rendered images
(Figs. 58) demonstrated the coarctation of the aorta (arrows) and the patent ductus arteriosus
(dashed arrows) between the main pulmonary artery and the upper descending aorta.

In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task,
patient size, anatomical location, and clinical practice. A consultation with a radiologist and
a physicist should be made to determine the appropriate dose to obtain diagnostic image quality
for the particular clinical task. The following test method was used to determine a 54 to 60% dose
reduction when using the SAFIRE reconstruction software. Noise, CT numbers, homogeneity, lowcontrast resolution and high contrast resolution were assessed in a Gammex 438 phantom. Low
dose data reconstructed with SAFIRE showed the same image quality compared to full dose data
based on this test. Data on file.

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

31

Clinical Results Cardiovascular

Case 3
Unroofed Coronary Sinus Syndrome
Diagnosis with Dual Source CT using
Flash Mode
By Hongliang Zhao, MD,* Minwen Zhen, MD,* Yi Huan, MD,* Fu Fu Chen, MD,** Hong Tao Liu, MD**
** Department of Radiology, Xijing Hospital, the Fourth Military Medical University, Xian, P.R. China
** Healthcare Sector, Siemens Ltd. China, Shanghai, P. R. China

HISTORY

COMMENTS

A 70-year-old female patient with a known


history of hypertension presented herself
to the hospital complaining of stuffiness
in the chest for the past two months.
A Dual Source Coronary CT Angiography
(CTA) was performed to rule out coronary
heart disease.

Unroofed coronary sinus syndrome


(URCS), also called coronary sinus septal
defect, is a rare congenital cardiac anomaly. The roof of the CS is either partially
or completely absent resulting in a communication between the CS and the left
atrium (LA). Trans-thoracic echocardiography is the most widely used imaging
modality for suspected unroofed CS, but
is limited in its ability to visualize the
posterior cardiac structures such as the CS.
Dual Source CT, with its excellent spatial
and temporal resolution, allows for the
visualization and the evaluation of the

DIAGNOSIS
The CTA images clearly showed an atrial
septal defect (ASD, Figs.13) with leftto-right shunting. The coronary sinus (CS)
opened into the left atrium (Figs.14),
and the great and middle cardiac veins
were enlarged before they joined the
coronary sinus. An anomalous vascular
structure, running in the right atrioventricular groove, along with the right
coronary artery connected the right
atrium and the coronary sinus (Figs.15).
Mixed plaques were present in the
proximal left anterior descending (LAD)
artery with less than 50% luminal stenosis (Fig.6). The other coronary vessels
appeared to be normal.

posterior structures of the heart. With


its widespread use for coronary artery
assessment, Dual Source CT is emerging
as a potentially useful non-invasive imaging modality for the evaluation of the
coronary venous system. A variety of new
techniques can be combined to reduce
the radiation dose and to achieve better
image quality. In this case, CARE Dose4D,
tube voltage of 100 kV and Flash Mode
using a pitch of 3.4 were jointly used to
lower the patient radiation dose to only
0.94 mSv.

examination protocol
Scanner

SOMATOM Definition Flash

Scan area

Heart

Pitch

3.4

Scan length

195 mm

Slice collimation

128 x 0.6 mm

Scan direction

Cranio-caudal

Slice width

0.75 mm

Scan time

0.42 s

Temporal Resolution

75 ms

Tube voltage

100 kV

Reconstruction increment

0.4 mm

Tube current

266 eff. mAs

Reconstruction kernel

B26f

Dose modulation

CARE Dose4D

Heart rate

58 bpm

CTDIvol

2.6 mGy

Contrast

DLP

67 mGy cm

Volume

60 mL

Rotation time

0.28 s

Flow rate

4 mL/s

Effective dose

0.94 mSv

Start delay

19 s

32 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

16 The ASD and jet of dense contrast (left-to-right shunt) entering the right atrium (arrowhead), as well as the site of the unroofing
(dashed arrows) are shown in Figs. 13. An anomalous vascular structure running within the right atrio-ventricular groove along with the
right coronary artery connecting the right atrium and the coronary sinus (arrows) are presented in Figs. 15. A mixed plaques in the
proximal LAD with less than 50% luminal stenosis (double arrows) is visualized in Fig. 6.

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

33

Clinical Results Cardiovascular

Case 4
Diagnosis of Coronary-Vertebral
Subclavian Steal Syndrome using
iTRIM Technique
By PG Pedro, MD,* P Oliveira, RT,* P Coelho, RT,* L Pereira, RT,* D Jesus, RT,* H Pereira, RT,* J Ramalho, RT,*
J Costa, RT,* A Chaves, RT**
** Department of Radiology and Cardiology, SAMS Hospital, Lisbon, Portugal
** Siemens Healthcare, Portugal

HISTORY
A 59-year-old female patient with multiple
cardiovascular risk factors (type II diabetes, hypertension, hypercholesterolemia,
smoker) had suffered an anterior myocardial infarction (AMI) 5 years ago and
later developed a CCS class II angina
pectoris. Catheterization disclosed an
occluded mid-segment in the left anterior
descending artery (LAD) and an 80%
lesion in the circumflex artery (Cx).
A coronary artery bypass graft (CABG)
was then performed with a left internal

1A

mammary anastomosis (LIMA) to LAD


and a radial free graft, from LIMA to an
obtuse marginal (OM) branch. The patient
remained asymptomatic until recently,
in spite of the severe risk factors. Three
months later, moderate angina reappeared as well as episodes of dizziness,
mainly during upper limb exercise. One
month later, a new AMI in the lateral
wall occurred. An urgent femoral catheterization revealed thrombotic occlusion
of the Cx artery. The LAD artery had an

1B

old occlusion and the LIMA graft could


not be catheterized. The right coronary
artery (RCA) was normal. Primary angioplasty of the culprit Cx was performed
and a bare metal coronary stent was
successfully deployed. Rest chest pain
was resolved, but mild effort angina
and dyspnea resumed one week later.
A physical examination disclosed absent
pulses in the left arm. A cardiac CT
Angiography (CTA) was then performed.

1C

1 Heart and great vessels isolated volume rendering reconstructions (VRT) show occluded left subclavian artery and retrograde filling of the
axillary artery, through the patent LIMA and left vertebral artery. The radial artery bypass graft is occluded and a coronary Cx stent is patent.

34 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

2A

2B

2C

examination protocol
Scanner

SOMATOM Perspective

Scan area

Middle neck to diaphragm

Slice width

0.75 mm

Scan length

250 mm

Temporal Resolution

195 ms

Scan direction

Cranio-caudal , Feet first

Reconstruction increment

0.5 mm

Scan time

12 s

Reconstruction kernel

B26s and B46s

Tube voltage

130 kV

Heart rate

60 bpm

Tube current

289 mAs

Contrast

Iopromide 370

Volume

100 mL contrast
+ 60 mL saline

Dose modulation

CARE Dose4D

CTDIvol

32.09 mGy

DLP

974 mGy cm

Flow rate

6 mL/s

Start delay

5 s (Bolus
tracking,
triggered
at 70 HU)

Effective dose

13.6 mSv

Rotation time

0.48 s

Pitch

0.27

Slice collimation

64 x 0.6 mm

2 Curved multiplanar reformations


(cMPR) of the LIMA/LAD (Fig.2A),
RCA (Fig.2B) and Cx (Fig.2C).

3A

DIAGNOSIS
A total occlusion of the left subclavian
artery was demonstrated, 1.8 cm from its
origin, proximal to the LIMA and ipsilateral
vertebral artery. Both of these supply a
scant axillary artery flow (Fig.1). In spite
of this fact, the LIMA was well enhanced,
with a good anastomosis to the mid LAD
(Figs.1 A, C and Fig.2). The radial (LIMA
to OM) anastomosis was totally occluded,
only a metal clip path could be seen
(Fig.1C). The Cx stent was patent, with
no signs of restenosis and the RCA was
normal (Figs.1 and 2). The right brachiocephalic and left carotid arteries were
also normal (Fig.1). The left ventricular
ejection fraction was 53%, with lateral
wall and apical akinesis (Fig.3). The left
atrium was enlarged (Figs.1B and 3A).
A complementary triplex Doppler scan
disclosed reversal of the left vertebral
artery flow. A diagnosis of coronaryvertebral subclavian steal syndrome was
confirmed.

COMMENTS
Coronary and/or vertebral subclavian steal
syndrome is a well-known late complication of CABG, occurring in patients with
pre-existent mild to moderate subclavian

atherosclerotic disease. It is unclear


whether the surgical procedure itself
accelerates the growth of the lesions in
the subclavian artery. This is mainly due
to the enhanced local flow and consequent endothelial shear stress. In the
patient described, pre-operative upper
limb arterial pressures were symmetrical
and poor risk factors might also have
contributed to the subclavian disease
progression.
In this well-documented case, a large
acquisition window, ranging from the
middle neck region to the diaphragm,
was used to ensure good anatomical
coverage; primarily that of the proximal
supra-aortic vessels to prepare for a future
surgical decision. Since the left carotid
artery is disease free, a left carotid-axillary
shunt is being proposed.
Siemens SOMATOM Perspective with
iTRIM technique allowed for fast cardiac
CTA acquisition with a higher temporal
resolution. Together with the fast volume
rendering technique (VRT) on syngo.via,
superb anatomic details could be yielded
to avoid further invasive studies.

3B

3C

3 Four chamber (Fig. 3A) and short axis


(Fig. 3B) views depict left ventricular wall
thinning. Polar map of the left ventricular
wall motion (Fig.3C).

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

35

Clinical Results Oncology

Case 5
Minimally Invasive Treatment
of Hepatocellular Carcinoma using
a Siemens Miyabi System
By Taku Yasumoto, MD, PhD,* Katharina Otani, PhD**
** Toyonaka Municipal Hospital, Department of Radiology, Osaka, Japan
** Siemens Japan K.K., Healthcare H IM, Research & Collaborations Department, Tokyo, Japan

HISTORY
A 71-year-old male patient, with known
hepatitis C, came to the hospital for
an annual follow-up. A 4-phase liver CT
examination revealed a hepatocellular
carcinoma (HCC) with a diameter of
3 cm. The patient was scheduled for
transarterial chemoembolization (TACE)
to be followed by radiofrequency ablation (RFA).

DIAGNOSIS AND
TREATMENT
All procedures were performed on a
Miyabi system that consists of a CT sliding
gantry (SOMATOM Definition AS) and
an angiography system (Artis zee ceilingmounted system). An arterial portography
(CTAP, Fig. 3C) was performed to confirm the HCC diagnosis before treatment
began. The contrast media was injected
through a catheter that was advanced
into the superior mesenteric artery (SMA).
The feeding arteries of the tumor came
off both the left (LHA, Fig.1A) and the
right hepatic arteries (RHA, Fig. 2A). A
super-selective angiogram as well as an
embolization was performed at the level
of segment 4 in both arteries (Figs.1B
and 2B). The follow-up confirming angiogram was performed through the common hepatic artery (CHA, Figs.1C and
2C). The whole procedure was successfully completed within 120 minutes.
A non-contrast CT was performed to confirm the retention of the Lipiodol in the

entire tumor (Fig. 4). The RFA procedure


was carried out one week later (Fig. 5),
successfully completed within 75 minutes.
The patient recovered without complications.

COMMENTS
The Miyabi system is an integrated system with an angiography unit and a CT
sliding gantry unit. Both units share a
common patient table, facilitating quick
transportation of the patient from one
unit to the other without risking dislodgment of the catheter. Whereas the angiography offers higher spatial resolution
necessary for detailed imaging of the
blood vessels, the CT offers better low
contrast resolution which is necessary for
imaging the extension of the tumor and
to confirm the retention of the Lipiodol
in the entire tumor after TACE. The CTAP
can obtain much better portal venous
enhancement using less contrast media
(total volume of 50 mL of 150 mg/mL of
iodine at 2.5 mL/s, patient dependent,
with a start delay of 25 s, injected through
a dual injector as a mixture of contrast
medium and saline solution) in comparison to a standard contrast CT scan (100
mL of 370 mg/mL of iodine at 4 mL/s).
The other challenge presented in this case
was caused by the special location of the
tumor directly below the diaphragm and
above the gallbladder. A critical decision
had to be made regarding the access path

36 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

of the RFA procedure, necessary to avoid


potential complications occurring to
the lung or to the gallbladder. The views
displayed on the CT monitor and the
three dimensional imaging were helpful
to ensure a minimally invasive procedure.

examination protocol
Scanner

SOMATOM Definition
AS Sliding Gantry

Scan area

Abdomen

Scan mode

CTAP

Scan length

206 mm

Scan time

4.5 s

Scan direction

Cranio-caudal

Tube voltage

120 kV

Tube current

126 eff. mAs

CTDIvol

10.46 mGy

DLP

240 mGy cm

Effective dose

3.6 mSv

Rotation time

0.5 s

Slice collimation

64 x 0.6 mm

Reconstructed

1 mm

slice thickness
Increment

1 mm

Kernel

I30f, SAFIRE

Contrast

150 mg/mL iodine

Volume

50 mL

Flow Rate

2.5 mL/s

Start delay

25 s

1A

1B

1C

1 A CHA angiogram (Fig. 1A) shows the feeding artery from the LHA. Super-selective angiogram and embolization were performed at the
level of segment 4 (Fig. 1B), and confirmed by a CHA angiogram (Fig. 1C, arrow).

2A

2B

2C

2 A RHA angiogram (Fig. 2A) showed another feeding artery from the RHA. Super-selective angiogram and embolization were performed
at the level of segment 4 (Fig. 2B). The embolization of both feeding arteries at the level of segment 4 (LHA, Fig. 2C, arrow and RHA, Fig. 2C,
dashed arrow) was confirmed by a CHA angiogram.

3A

3B

3C

3 CT images of non-contrast (Fig. 3A), arterial phase (Fig. 3B) and CTAP (Fig. 3C) showed the extension of the tumor.
The CTAP image showed soft tissue contrast much better.

4 Non-contrast CT image
confirmed the retention of the
Lipiodol in the entire tumor.

5 CT images discovered
the critical access path for
the RFA procedure.

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

37

Clinical Results Acute Care

Case 6
Aortic Dissection Follow-Up using Fast
Mode with SOMATOM Definition Edge
By Prof. Hans-Christoph R. Becker, MD
Department of Clinical Radiology, Grosshadern Clinic, Ludwig-Maximilians-University (LMU) Munich, Germany

38 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

Acute Care Clinical Results

HISTORY
A 62-year-old male patient suffering from
an aortic dissection (Stanford type A)
underwent surgical repair. A CT scan was
ordered for post-operative control.

DIAGNOSIS
The hematoma around the ascending
aorta was successfully removed by
surgery, whereas the dissection in the

COMMENTS
descending aorta remained. The tear
originated in the aortic arch, continued
into the origin of the left subclavian
artery, down the whole descending aorta,
and ended at the iliac bifurcation. The
left renal artery originated from the false
lumen and resulted in a hypo-perfusion
of the left kidney. An arterio-venous fistula was suspected in the right femoral
artery.

15 MPR
(Figs. 1, 5) and
VRT (Figs. 2, 4)
images show that
the hematoma
around the ascending aorta has been
removed (Fig. 1),
while the dissection
in the descending
aorta (Figs. 24)
remained. The tear
originated in the
aortic arch, continued into the
origin of the left
subclavian artery
(Figs. 13, dashed
arrows), down the
whole descending
aorta, and ended
at the iliac bifurcation. The left renal
artery originated
from the false
lumen (Figs. 2,
45, arrows)
and resulted in a
hypoperfusion
of the left kidney.

Fast mode, combining a pitch of 1.7 and


a rotation time of 0.28 s, is ideal for longrange CT Angiography (CTA). The image
acquisition speed provides, with only a
single CT scan, all the relevant information concerning the patients vascular
status with a reasonably low radiation
exposure and less contrast media. This
mode has been routinely performed in
our department both for aortic CTA and
transcatheter aortic valve implantation
(TAVI) planning and control.

examination protocol
Scanner

SOMATOM
Definition Edge

Scan area

Thorax-pelvis

Scan length

593 mm

Scan direction

Cranio-caudal

Scan time

3s

Tube voltage

100 kV

Tube current

54 eff. mAs

Dose modulation

CARE Dose4D

CTDIvol

2.17 mGy

DLP

137 mGy cm

Effective dose

1.9 mSv

Rotation time

0.28 s

Pitch

1.7

Slice collimation

128 x 0.6 mm

Slice width

0.75 mm

Reconstruction
increment

0.7 mm

Reconstruction
kernel

I26f, SAFIRE

Contrast
Volume

60 mL

Flow rate

4 mL/s

Start delay

10 s

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

39

Clinical Results Orthopedics

Case 7
Metal Artifact Reduction
by Energetic Extrapolation in
Single Source Dual Energy CT1
By Felix G. Meinel, MD, and PD Thorsten R. C. Johnson, MD
Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Germany

DIAGNOSIS

HISTORY
A 77-year-old female patient with
multiple vertebral metastases from a
renal cell carcinoma, which had been
stabilized with several spinal fusion
operations, presented herself to the
emergency room complaining of weakness in her left leg. A CT examination
1

was performed to assess the degree of


osteolytic destruction, the integrity and
position of the osteosynthetic material
and to rule out an infiltration or compression of the spinal canal and the neuroforamina by metastases or hematoma.

The CT scan showed a complete collapse


of the 9th and 10th thoracic vertebrae
(Fig. 1). Advanced osteolytic metastases
were also noted in the 11th and 12th
thoracic and in the 2nd and 4th lumbar
vertebrae (Fig. 1). The osteosynthetic
material itself was intact. However, the

Under FDA review. Not available for sale in the U.S.


1A

1B

E = 70 keV

1C

E = 110 keV

1D

E = 130 keV

1E

E = 150 keV

E = 180 keV

1 Sagittal MPR images at extrapolated photon energies of 70, 110, 130, 150 and 180 keV show a marked reduction in metal artifacts
with increased extrapolated photon energy.

40 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

2A

2B

2C

2 The effective reduction of metal artifacts at high extrapolated photon energies allows for highly accurate volume rendering
technique (VRT) images.

screws had broken through the base


plates of the 11th and 12th thoracic
vertebral bodies (Fig. 2). There was no
evidence of a hematoma or metastatic
mass in the spinal canal or in the neuroforamina.

COMMENTS
Appearing as bright and dark streaks originating from the metallic implants, metal
artifacts can greatly hamper accurate CT

interpretation, including the diagnosis


of fractures, implant loosening, or to rule
out inflammation or hematoma in the
surrounding soft tissue. These artifacts
can be effectively reduced in Dual Energy
CT by generating images extrapolated
to higher photon energies. These extrapolated photon energies, with the highest diagnostic quality, usually fall in the
range of 100-130 keV. This technique
can be applied for the examination of
metallic implants of various types and

alloys and their surrounding tissues.


Pathologies of the spine can be extremely
challenging to assess in patients after
spinal fusion surgery, due to substantial
metal artifacts in both CT and MRI scans.
Energetic extrapolation effectively reduces
metal artifacts in Dual Energy CT and
allows for an accurate assessment of the
spine, the spinal canal and the neuroforamina in such patients.

examination protocol
Scanner

SOMATOM Definition Edge

Scan Mode

Single Source Dual Energy

DLP

482 mGy cm / 629 mGy cm

Scan area

Spine

Effective dose

7.2 mSv / 9.4 mSv

Scan length

415 mm

Rotation time

0.5 s

Scan direction

Cranio-caudal

Pitch

0.5 / 1.2

Scan time

11 s

Slice collimation

128 x 0.6 mm

Tube voltage

80 kV / 140 kV

Slice width

1 mm

Tube current

600 mAs / 142 mAs

Reconstruction increment

1 mm

Dose modulation

CARE Dose4D

Reconstruction kernel

Q40f

CTDIvol

11 mGy / 14 mGy

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

41

Clinical Results Orthopedics

Case 8
Metal Artifact Reduction using Dual
Energy CT Monoenergetic Imaging
By Qiaowei Zhang, MD,* Prof. Shizheng Zhang, MD,* Chenwei Li, MD**
** Department of Radiology, Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, P. R. China
Sir Run Run Shaw Hospital School of Medicine of Zhejiang University, P. R. China
** Healthcare Sector, Siemens Ltd. China, Shanghai, P. R. China

HISTORY

DIAGNOSIS

COMMENTS

A 65-year-old male patient, who had


undergone an ORIF (Open Reduction
Internal Fixation) procedure for a lateral
femoral neck fracture the previous year,
was referred to the CT department for a
follow-up assessment. A Dual Energy CT
scan was performed using monoenergetic
imaging to reduce the metal artifacts.

The metal artifacts were pronounced at


70 keV (proximately equivalent to 120 kV
setting, Fig.1A), but were substantially
reduced by increasing the energy level,
e.g. to 110 keV (Fig.1B) and 150 keV
(Fig.1C). A transversal break through the
proximal section of the implant was also
found (Figs. 2 and 3).

In ORIF follow-up examinations, it is


important to assess the metal implant, the
interface between the implant and the
bone structures, as well as the surrounding tissues. Metal artifacts, however,
represent a significant limitation in CT
assessment. Structures are sometimes
not interpretable even when using hard

1A

1B

1C

1 Axial images present significant metal artifact reduction from 70 keV (Fig.1A), to 110 keV (Fig.1B) and 150 keV (Fig.1C) settings.

42 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

Orthopedics Clinical Results

3A

2 VRT image shows the location of the implant in the left femur.

convolution kernels and widened CT


window settings. Dual Energy CT with
monoenergetic imaging method allows
dose-neutral acquisition at 100 kV and
140 kV simultaneously. It provides a wider
range of energy settings (50 to 190 keV)
which the users can freely apply to
achieve the optimal level for substantial
metal artifact reduction. Thus, the image
quality can be greatly improved for diagnosis.

3B

3 VRT images demonstrate the transversal break in the proximal


section of the implant.

examination protocol
Scanner

SOMATOM Definition Flash

Scan area

Hip

DLP

303.6 mGy cm

Scan length

253 mm

Effective dose

4.6 mSv

Scan direction

Cranio-caudal

Rotation time

0.5 s

Scan time

18 s

Pitch

0.6

Tube voltage

100 kV / Sn 140 kV

Slice collimation

40 x 0.6 mm

Tube current

95231 eff. mAs /


85163 eff. mAs

Slice width

1 mm

Dose modulation

CARE Dose4D

Reconstruction increment

1 mm

CTDIvol

12 mGy

Reconstruction kernel

D40f

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

43

Science

Research Clusters Enable Transfer


of Basic Research to Clinical Routine
Part II. Concentrated Expertise Against Coronary Heart Disease
By Monika Demuth, PhD
Computed Tomography, Siemens Healthcare, Forchheim, Germany

For men over 50, the risk of suffering


from a heart attack in the next 10 years
due to coronary heart disease (CHD) is
510%.[1]
Behind these numbers lie human tragedies, but also immense costs for the
healthcare system. These were sufficient
reasons for the University of ErlangenNuremberg (Cardiology and Radiology)
and Siemens Healthcare to jointly participate in the Leading Edge Cluster
competition organized by the German
Federal Government within the Medical
Valley European Metropolitan Region
Nuremberg cluster.

The Leading Edge Cluster


competition
Between 2007 and 2010, the German
Federal Government initiated three competitions. The aim was for science and
business to co-operate and co-ordinate
closely to apply for funding with concepts
which, based on the strengths of the
cluster, pointed to untapped development potential. The fundamental idea
behind the thematically unrestricted
Leading Edge Cluster competition was to
strengthen Germany, for the long term,
as a location for innovation and business.
Among those Leading Edge Clusters that
were selected in the second round is, for
instance, m4 personalized medicine and
goal-oriented therapies a new dimension in medical development (see part 1
of the report in SOMATOM Sessions 30).
Another medical technology cluster
selected from the second round is the
cluster Medical Valley European
Metropolitan Region Nuremberg. The

members of this Leading Edge Cluster


have taken on the task of improving the
quality of healthcare, while simultaneously lowering the costs.

Improve coronary CT
One project within the cluster is dedicated
to developing new technologies and procedures for non-invasive examination of
the coronary arteries. New procedures for
computed tomography are to be developed and validated, procedures that will
improve the obtained images of the coronary arteries and enable the detection
and quantification of atherosclerotic
plaques with improved spatial and temporal resolution, while also reducing
exposure to radiation. The ultimate goal
of the project is to improve prevention
of CHD, which would potentially include
preventive care approaches.
When the joint project was designed and
initiated, Dual Source CT had been introduced and, for carefully selected patients,
high quality imaging of the coronary vessels was possible with a radiation dose
below 1 mSv. One of the project aims is
to develop and validate techniques which
will allow low-dose imaging in all patients,
in order to be able to more broadly apply
coronary CT Angiography potentially
including asymptomatic individuals with
an increased risk.

Close cooperation to optimize


dose and image quality
Several equally important components
are required to optimize image quality
while reducing dose: Clinically, fundamental information on the relationship

44 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

between patient characteristics and


image quality must be collected. On the
technical side, detector design and reconstruction algorithms mainly must be
further developed in a targeted manner.
Finally, new technology must be validated.
Within the joint project, technology
development is undertaken by Siemens
Healthcare, while clinical aspects are
covered by a cooperation between the
Department of Cardiology and the Institute of Radiology at University Hospital
Erlangen-Nuremberg.
Cardiology and radiology research groups
at the University Hospital, led by Prof.
Stephan Achenbach, MD, Prof. Dieter
Ropers, MD and Prof. Michael Lell, MD,
have been working together especially
closely for many years. It is based on
this long-standing cooperation that substantial progress in cardiac and coronary
imaging using CT has been made.
In cardiac imaging there has been a move
away from the retrospectively ECG-gated
spiral scan, towards prospectively ECGtriggered step-and-shoot scan, on the one
hand, and high-pitch scan on the other.
Using this latter method, it was possible
to conduct the heart scans of all the
patients examined at under 1 mSv.
Previously, image noise had been a problem with the extremely low radiation
doses used but the Leading Edge Cluster
project solved this by developing patient
adapted scan protocols using new technologies such as iterative reconstruction,
automatic tube voltage setting and new
detector designs. This combination results
in very good image quality at minimal
X-ray doses. Many of the new techniques

Science

are already available as products.


A major success was the broad introduction of iterative reconstruction procedures
(SAFIRE) and automatic tube voltage
setting (CARE kV).

Scan protocols individualized


Here, the advantage of individually optimized scan protocols for each patient
was evident: the kV value can be adjusted
to the optimum level for each case.
Patients with a high BMI are particularly
problematic. In such cases, by means of
the software component CARE kV, the
CT scanner software offers aid in decision
making. Based on the patients topogram,
the first very low-dose overview scan
included in every CT scan for planning
purposes suggests the optimum kV value.
Thus, individualized examination proto-

1A

cols are created. Similar problems must


be dealt with in patients with a broad
thorax-wall cross-section. To deal with
such a fundamental, complex problem
and in order to identify the crucial parameters, comprehensive basic data was
gathered in the first 3 years of the project.
These data led the clinicians to a better
understanding of the factors that influence the image quality and the correlated
sensitivity and specificity of the methods.
Additionally, they achieved a significantly improved dose to image quality
relationship which permitted reliable
clinical diagnoses.

Further project steps


With respect to this, more advanced technologies such as iterative reconstruction
based on raw data proved to be helpful,

1B

as did new detector technology. The prerequisite conditions for pursuing further
sub-goals have thus now been established. In the next phase of the project,
post-processing software will be further
developed and validated. This would make
the automatic analysis of atherosclerotic
plaques possible to avoid individual variations on the part of the evaluator, and
could achieve even better reproducibility.
The clinical data must, of course, also be
further validated. Here, improved image
quality achieved by means of iterative
reconstruction and plaques characterization based on low-dose data sets should
be the focus.
New detectors that are currently being
developed will be able to count individual
X-ray photons and determine their individual energy and increase spatial reso-

1C

1 One of the project aims is to develop and validate techniques which will allow high-quality imaging of the coronary vessels
with a radiation dose below 1 mSv. In this case an extremely low radiation dose of 0.078 mSv was sufficient.
Courtesy of University Hospital Erlangen-Nuremberg, Germany

2A

2B

2 A major success on the


way to significantly reducing
image noise by using very
low radiation doses was the
broad introduction of SAFIRE
(Sinogram Affirmed Iterative
Reconstruction): without
SAFIRE (Fig. 2A), with SAFIRE
(Fig. 2B).
Courtesy of University Hospital
Erlangen-Nuremberg,
Germany

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

45

Science

As part of the Leading Edge


Cluster project we developed scanconditions to obtain high-quality
images with less than 1 mSv in all
heart patients examined.
Prof. Dieter Ropers, MD, Dept. of Cardiology,
University Hospital Erlangen-Nuremberg, Germany

We expect the data compiled during


the project prospectively affecting
the course of CT imaging for the
diagnosis and prevention of CHD.
Prof. Stefan Achenbach, MD, Dept. of Cardiology,
University Hospital Erlangen-Nuremberg, Germany

Leading Edge Cluster funding


like this allows excellent collaboration
between scientific institutes and
industry and reinforces the advancement of innovation and business
in a country in the long run.
Prof. Michael Lell, MD, Dept. of Radiology, University Hospital Erlangen-Nuremberg, Germany

46 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

Science

lution even further. These new detectors


have the potential to drive patient dose
down even further and increase image
quality which could result in an even
higher specificity for the evaluation of
early signs of coronary artery disease.
Results gained by the three experts
Stefan Achenbach, Dieter Ropers and
Michael Lell during the cooperation
described (within the framework of the
Cutting-Edge project at the University
of Erlangen-Nuremberg) included new
data acquisition protocols, new detector
technologies, new image reconstruction
techniques and the opportunity to use
patient-specific optimized scan-parameters. These results should allow an
optimization of image quality and, moreover, considerably reduced radiation
exposure. The results, which will be collated at the end of the project, will influence the direction that CT imaging for
the diagnosis and prevention of CHD will
take in the future.
Based on the achievements in the first
phase of the project, the jury of renowned
experts decided during the extensive
project review phase also to fund the
second phase of the project until 2015.

3A

3B

70,0

Image Noise (HU)

60,0
50,0
40,0
30,0
20,0
10,0
0,0
0

10

15

20

25

30

35

Body Mass Index (kg/m2)


3C

In clinical practice, the use of SAFIRE may reduce CT


patient dose depending on the clinical task, patient size,
anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made
to determine the appropriate dose to obtain diagnostic
image quality for the particular clinical task.
The product/feature (mentioned herein) is currently
under development; is not for sale in the U.S. Its future
availability cannot be guaranteed.

70,0
60,0

Image Noise (HU)

[1] Conroiy et al, Estimation of ten-year risk of fatal


cardiovascular disease in Europe: the SCORE
project. Eur Herat J 2003.

50,0
40,0
30,0
20,0
10,0
0,0
0,00

150,00

300,00

450,00

600,00

750,00 900,00

Chest Area (mm )


2

3 N = 165, Schuhbck A, et al (Invest Radiol in press)


The kV value can be adjusted to the optimum for each case
even for patients with a broad thorax-wall cross-section
(Figs. 3A, 3C) or with a high BMI (Fig. 3B).

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

47

Science

Image Quality in Computed Tomography


Part I. Low Contrast Detectability
By Stefan Ulzheimer, PhD
Computed Tomography, Siemens Healthcare, Forchheim, Germany

Image quality in computed tomography


(CT) can be described using several parameters such as image noise, high contrast spatial resolution and low artifact
content. Low contrast detectability, sometimes also called low contrast resolution,
is often considered a key parameter as
well.
For low contrast detectability (LCD), however, there is decisive difference compared
to other image quality parameters: as
opposed to, for example, high contrast
spatial resolution, it is not a well-defined
image metric and cannot easily be measured objectively. This article explains the
concept of low contrast detectability, how

it can be measured and what the pitfalls


in the assessment are.

Low contrast detectability and


image noise
In general, every measurement is associated with a certain margin of error and
all measured values fluctuate around the
true value. In CT the value that is measured is the attenuation caused by the
object, represented by its Hounsfield
(HU) value. Each volume element (voxel)
of a CT image is a measurement of the
respective attenuation caused by the
scanned object. Therefore, if a CT scan
of the same object is repeated, the scan

will always yield a slightly different CT


value for this voxel. If a homogeneous
object such as a water phantom is
scanned, each voxel in the image can be
interpreted as an independent measurement of the same material. Thus, a CT
scan of a homogeneous object can be
interpreted as many independent measurements of the same material carried
out at the same time. All voxel values
will fluctuate around the true value of,
for example, water.
The measurement error is directly visible
in the image and is usually called image
noise. If a sufficiently large amount of
measurements are carried out, the aver-

1B

1A

1A The CATPHAN phantom (The Phantom Laboratory, New York)


or a similar phantom with a respective low contrast test insert can be used
to determine the low contrast detectability.
(Images courtesy of The Phantom Laboratory, New York, USA)

48 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

1B The low contrast insert of the CATPHAN phantom


with a 200 mm diameters; and periodic inserts with
diameter and contrasts in the range of 2 to 15 mm and
3 to 10 HU, respectively, as an example of a low contrast
detectability test phantom.

Science

age of the measured values is close to the


true value. In a CT image the image noise
and the true HU value can be estimated
by evaluating a sufficiently large homogeneous region of interest (ROI) in the
image and calculating the standard deviation and the average in that ROI. Small
attenuation differences can only be
detected when the image noise is sufficiently small.
In general, LCD aims to describe the performance of a CT system in detecting
objects of low contrast against the background. Ideally, one would define an
objective test method, for example, using
phantoms, to assess LCD for scanner
characterization.
In current practice, LCD is typically specified by measuring a low contrast phantom with objects of different sizes and
different densities. Fig. 1 shows a typical
test phantom with a respective low contrast (LC) insert. One then specifies which
insert can presumably be seen at a certain dose level with a certain scan protocol. A sample specification may look like
this: 5 mm, 3 HU @ 11.0 mGy CTDIvol
(200 mm CATPHAN phantom, 10 mm
slice width, 120 kV, typical body mode).
This means that when the 200 mm
CATPHAN phantom with the LC insert
at a dose of 11.0 mGy is scanned (in
terms of CTDIvol in the 32 cm phantom)
with a standard body protocol, the person assessing should be able to see the
5 mm, 3 HU insert.
The crux lies in the presumed ability to
see a certain low contrast structure, since
for an individual this is a highly subjective task. It makes it difficult to obtain
statistically objective data with some level
of confidence using visual methods.

Radiologists do not evaluate


images statistically
Statistical performance parameters are
often considered to be an indication of
the systems LCD performance [1, 2] and
respective criteria have been formulated.
However, the LCD not only depends on
the noise in relation to the contrast difference, but also on the size and shape of the
lesion and the surrounding tissue. In daily
practice it all boils down to what a human
reader can see in the image the diag-

Table 1: Parameters that influence LCD

Observer

Experience; How well can he or she eliminate


bias; What are his or her goals

Scan Parameters

Dose and dose distribution; Collimation

Reconstruction Parameters

Slice Thickness; Reconstruction kernel;


In-Plane Resolution

Reading Conditions

Ambient Light; Monitor; Ability to window

Evaluation

How many readers; How many have to detect


the insert; Do they have to detect only the
smallest or all bigger inserts

Phantom

Manufacturing quality; Reproducibility;


Patterns of inserts

Scanner

Detector; Dose efficiency; Artifact


suppression; Scatter radiation

Low Contrast Object

Density; Size; Shape; Background material

nosis will be based on what the reader can


recognize. If image noise is too high, low
contrast objects or lesions are hidden
behind that curtain of noise. Experienced
readers can see through noise better than
inexperienced readers. Therefore, the
experience of the reader affects the LCD
in addition to the level of image noise.[3]
Reader experience, however, is only one
of the many parameters that influence
LCD (Table 1).
To be able to carry out a valid comparison
of the LCD performance of a CT scanner
all parameters that influence LCD, besides
the scanner itself, have to be kept constant. It is clear that this is a rather challenging task, if possible at all.

Various approaches to LCD


specification
One reason for the lack of a well-defined
objective method to assess LCD is that
various manufacturers use different methods to specify LCD performance of their

systems. These approaches can be summarized in three different categories:


The conservative approach
The optimistic approach
Monkey Business

So, LCD involves the specification of a


certain object being seen by an observer.
As discussed above, the measurement
itself is a statistical process and, especially
when pushing the limits of detectability,
it automatically follows that not every
reader will see the lesion in every image.
There will even be images acquired with
the very same scanner and same scanning
parameters where the same reader will
see the insert in one scan but not in the
other.
Different manufacturers have different
ideas of what it means to see the lesion.
Siemens uses a very conservative
approach. Ten experienced readers read
ten independently acquired data sets

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

49

Science
2B

2A

2A The LC insert of the CATPHAN phantom scanned with


a standard body protocol on a SOMATOM Definition AS+ with
a CTDIvol of 11.0 mGy reconstructed with a 10 mm slice width.
50% of readers could detect the 5 mm, 3 HU insert (orange arrow)
in more than 50% of the data sets. Therefore, Siemens specifies
LCD for the SOMATOM Definition AS+ as 5 mm, 3 HU @ 11.0 mGy.

measured with the same parameters. For


the specified dose level, at least 50% of
the readers must detect the low contrast
object in at least 50% of the data sets.
Additionally, Siemens exclusively uses
standard clinical protocols exactly as specified in the System Owner Manual to determine the LCD.
Optimistic approaches which may be
applied by other manufacturers typically
use much softer criteria to determine the
LCD for their systems. If fewer readers
are included who are more optimistic and
also use softer criteria for the evaluation,
the result would consequently lead to
much better specifications.
Of course, one has to keep in mind that
by measuring the LCD in well-defined
phantoms, the same lesion patterns are
always in the same location so that readers already know where to look and what
for. Even for a reader with the best intentions, it is very hard to eliminate bias.
The manner in which the measurements

2B The LC insert of the CATPHAN phantom scanned with


a standard body protocol on a SOMATOM Definition AS+ now with
a CTDIvol of 17.0 mGy again reconstructed with a 10 mm slice width.
It is obvious that the noise level is reduced and this time 50% of the
readers could detect the 3 mm, 3 HU insert (arrow head) in more
than 50% of the data sets.

are evaluated can even dramatically influence the results. Even stricter rules than
Siemens currently uses can be applied,
for example, that all consecutive inserts
from 15 mm down to the desired one
have to be detected by all readers in all
cases. That requirement alone would lead
to dramatically lower LCD specs for all
scanners without changing anything else.
On the other hand, simply relaxing some
of the rules can result in much better LCD
values. Based on Fig. 3, Siemens could
also specify a LCD of 2 mm, 3 HU @ 11.0
mGy just by relaxing the rules so that
only at least one observer has to detect
the insert without changing anything
else.
While the optimistic approach could
still be justified by at least specifying the
evaluation method in datasheets, taking
the optimization of LCD one step further
leads to Monkey Business. Acquisition
protocols and reconstruction parameters
can always be tweaked in such a way that

50 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

LCD values are dramatically improved but


with an outcome that is completely irrelevant clinically.
One example is to use scan protocols that
are never used in clinical routine and are
designed only to give good LCD at very
low doses. This can be done by introducing special X-ray filters or collimators that
are adapted only to measure good LCD in
the established CTDIvol and LCD test phantoms. Another way is to design special
reconstruction kernels optimized for this
particular task that are never used in a
clinical setting.
In the end, it is important to keep in mind
that all tricks to optimize LCD work only
in defined phantoms, but these numbers
will be meaningless when looking at real
patients.

The devil is in the detail


In data sheets often only a couple of
values specifying LCD can be found without telling exactly how these values were

obtained. The goal of this article is to


explain what LCD is, how it can be measured, as well as its limitations and potential pitfalls. It needs to be considered
that there is no generally accepted and
well-defined method of determining LCD
given the difficulty of obtaining statistically objective data with some level of
confidence. There are many parameters
that influence LCD and not all of them are
related to the CT system. If parameters
are not kept constant, it is false to compare the performance of CT systems based
on these values. The bottom line is that as
long as a manufacturer does not explain
how exactly he determines the LCD and
as long as CT users do not ask the right
questions these specs will be completely
meaningless. Efforts are currently being
made at national and international levels
to standardize some of the methods used
in practice. One approach is to standardize evaluation by using mathematical
model observer studies [4] to eliminate
this uncertainty from the equation at
least.

smallest insert size detected (mm)

Science

15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
0

10

11

observer number
3 Minimum low contrast insert size in the 200 mm CATPHAN phantom detected by 10 different experienced readers for 3 HU density with data from the SOMATOM Definition AS (typical
body protocol, 120 kV, 11.0 mGy). There is a huge variation even between experienced readers
depending on how well they eliminate bias because all readers know where the inserts are.
Two readers could detect the 2 mm insert and one reader could only see the 8 mm insert.

References
[1] ICRU Report 54: 1995, Medical Imaging The
Assessment of Image Quality (7910 Woodmont
Ave., Bethesda, Maryland USA 20814)
[2] ASTM E 1695 95: 1995, American Society for
Testing and Materials ASTM
[3] Thilander-Klang A, et al. Evaluation of subjective
assessment of the low-contrast visibility in constancy control of computed tomography. Radiat
Prot Dosimetry. 2010 Apr-May;139(1-3):449-54.

[4] Hernandez-Giron I, et al. Automated assessment


of low contrast sensitivity for CT systems using
a model observer. Med Phys. 2011 May;38
Suppl 1:S25.

Data on file.

Table 2: LCD for different insert sizes


SOMATOM
Definition Flash

SOMATOM
Definition AS

SOMATOM
Perspective

SOMATOM
Emotion

SOMATOM
Spirit

5 mm, 3 HU

11.0 mGy

10.7 mGy

11.2 mGy

11.8 mGy

11.9 mGy

4 mm, 3 HU

13.3 mGy

13.8 mGy

14.1 mGy

14.3 mGy

14.5 mGy

3 mm, 3 HU

16.2 mGy

16.8 mGy

17.1 mGy

17.5 mGy

17.9 mGy

2 mm, 3 HU

23.6 mGy

24.4 mGy

25.2 mGy

25.3 mGy

25.0 mGy

In most Siemens data sheets only LCD values for the 5 mm, 3 HU insert of the 200 mm CATPHAN phantom are specified. Of course, that does not
mean that smaller inserts cannot be detected. This table shows at roughly what dose levels smaller inserts can be reliably detected based on Siemens
conservative rules for five different systems.1

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

51

Science

CARE kV Allows a Reduction of


Radiation Dose
At Erasmus Medical Center in Rotterdam, the Netherlands, the work of CT
technologists has been made easier thanks to CARE kV. This unique software
tool reduces radiation by optimizing tube voltage.
By Irne Dietschi
The baby was just five weeks old when
it was admitted to the Erasmus Medical
Center (MC) radiology department in
Rotterdam for a thorax scan. The radiologist required a visualization of the childs
aorta and vascular system; however,
because it was a neonate patient, the
technologists put special emphasis on
reducing radiation to very low levels
(Fig. 1).
It was thanks to CARE kV the unique
Siemens tool that determines the ideal
tube voltage according to the individual
patient and clinical situation that technologists were able to perform the procedure on such a young patient. With CARE
kV they chose a tube voltage of just 70 kV:

The resulting dose was so low, it was


almost unbelievable, says technologist
Ronald Booij, coordinator of the departments Research & Innovation CT unit.

Tiny dose for a tiny patient


We calculated a DLP Dose Length Product of just 2.8 mGy cm, which is very
low, his colleague, Specialized Research
CT technologist Marcel Dijkshoorn adds.
Nevertheless, they produced an impeccable vascular exam with the aorta, the
lungs and the heart clearly defined.
In a small patient, lowering the tube
voltage has almost no effect on image
noise, and the iodine gives you a good
contrast, Booij explains. This means

you can choose a low kV, and the software will provide the lowest possible
ref. mAs.
The infants examination was carried out
at the beginning of May 2012, at the
same time that CARE kV was introduced
in the Erasmus MC radiology department.
With more than 11,000 employees and
1,300 beds, the hospital is the largest
of eight university hospitals in the
Netherlands. Since that exam, Booij and
Dijkshoorn have gained considerable
experience with the new software tool.
Moreover, they have passed this knowledge on to their colleagues. They explain
that once you have learned a few basic
rules, it is easily implemented. As of the
end of August, they had been running
CARE kV on two of the departments six
Siemens scanners. Booij and Dijkshoorn
are delighted with the software and intend
to roll it out on two further scanners in
the near future: Thanks to CARE kV, we
are able to reduce doses and still achieve
better images, Booij says. It has made
our lives a lot easier. Because their
patients receive smaller doses while image
quality was not impaired, the technologists have less to worry about.

A balancing act

At Erasmus Medical Center in Rotterdam the patients receive smaller doses thanks to
CARE kV. So technologists Marcel Dijkshoorn (left) and Ronald Booij (right) are happy to have
less to worry about.

52 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

Booij and Dijkshoorn have been modulating tube voltages in their practice for
years because they know that this helps
to reduce radiation doses. However, they
had to do it manually before no easy
task within a daily routine. The relationship between tube current, tube voltage
and image quality (contrast, noise and
CNR, the contrast-to-noise ratio) in CT
makes it an intricate procedure; therefore,

adjusting the tube voltage for each individual patient and exam is a challenge:
Every kV adaptation requires an appropriate mAs adaptation as well, Dijkshoorn
explains, and the adaptations must differ
for native arterial or venous scans, parenchyma, vessel or bone studies and, of
course, according to the patients body
habitus. This is a very time-consuming
process, which requires significant expertise from all the CT technologists.
At Erasmus MC, which conducts more
than 200,000 diagnostic radiological
exams annually, technicians would concentrate on protocols where either image
quality improvement or dose savings
were greatest: Performing this manually
conflicts with workflow optimization,
says Dijkshoorn. Either the number of
protocols or their complexity increases,
with specific low and high kV settings
relative to the patients weight or BMI.
CARE kV eliminates the need for these
protocols. In general, a standard scan
protocol for a clinical situation is now
sufficient, regardless of the size of the
patient whether pediatric or adult:
Implementing CARE kV, along with our
use of SAFIRE and the new Stellar Detector, were the reasons behind our decision
to completely rework our protocols and
configure them in the best possible way,
says Booij. And whereas kV modulation
was formerly an option that depended on
the experience of CT technicians, CARE kV
has made it much easier to handle. The
tube voltage is now optimized automatically for almost any patient or clinical situation, says Ronald Booij. Patients benefit from lower doses, and the technicians
from less stress. Because things are
easier, you are more relaxed conducting
your examination.

Benefits in Pediatrics
In pediatric CT especially, this is highly
beneficial, where it is a delicate balancing
act between good quality images and
acceptable doses: Pediatric CT is very
demanding for both the doctor and the
technician, Dijkshoorn states. At the same
time it is clear that the developing bodies
of children should be exposed to as little
radiation as possible. CARE kV simplifies
the scanning process significantly:

Excellent

images and dose reductions


of up to 60%.
At Erasmus Medical Center, more
patients are now referred for CT
instead of MRI and angiography,
which means the same information
can be rendered in an exam taking
only a few seconds.
Since more pediatric patients are now
referred to CT, and because the procedures have become more simple, the CT
technicians can clearly gain as a group in
their routines, Dijkshoorn says. There
is now sufficient expertise not only to
make good scans during office hours, but
also in the evening and during night
shifts.
Dijkshoorn and Booij are keen to point
out that despite these advantages, every
CT scan must have a clinical indication
justifying the radiation and contrast
media regardless of how low it is: But
with doses decreasing, we notice a shift
from MRI to CT because the possible complications in MRI exam may outweigh
convenience.

When every second counts


What applies to pediatric CT is similarly
true within the emergency setting, where
CARE kV also brings benefits: In situations where every second counts, you
dont have time to think of dozens of
protocols, Booij explains. You need to
work as fast as you can often by yourself, without the advice of a colleague
so it is a great relief to have a robust
protocol and reliable software to obtain
optimal results.
Booij recalls the case of an 18-year-old
female cystic fibrosis patient, who was
referred to radiology with haemoptysis
and a light fever. Considering embolization, the doctors urgently needed to know
the cause of the bleeding and asked for
a detailed visualization of all the vessels
in the lung: This scan is usually done
with 100 kV, which results in a DLP of
80 mGy cm; however, in this case, the
DLP was just 28 mGy cm, while CARE kV
had chosen 80 kV. The scan revealed
a sequester in the right lower lobe, and
no treatment was necessary.
CARE kV also offers a semi mode. This
allows a user-specified kV setting to be

1 A five-week-old baby was admitted to


the Erasmus Medical Center (MC) radiology
department in Rotterdam for a thorax scan.
A visualization of the childs aorta and vascular system was required. CARE kV allowed
the radiologist to conduct the scan using
the lowest possible radiation dose (CTDIvol
0.1 mGy, DLP 2 mGy cm, eff. dose 0.078
mSv).

used, with the software adjusting mAs


values according to the specified reference values. This is particularly helpful
for multi-phase follow-up exams, such as
the wash out measurement of an adrenal gland, Dijkshoorn notes. A constant
kV setting allows comparison between
multiple scans and/or exams conducted
on the same patient.
At Erasmus MC, the education element
of CARE kV started long before the software was installed. Although it is quite
simple to use, understanding the background is more sophisticated: We wanted
the whole group to know that something
big was coming that would change their
work tremendously, Booij recalls. We
found it extremely important for everybody to be aware of the scope of the new
tool. In his and Dijkhoorns view, the
training of technicians and radiologists
should be done simultaneously, allowing
them to create new protocols together:
You get the most benefit from training
when doctors and technicians join
forces.
Irne Dietschi is an award-winning Swiss
science and medical writer. She writes for the
public media, such as the Neue Zrcher Zeitung
and has published several books.

The statements by Siemens customers described


herein are based on results that were achieved in the
customers unique setting. Since there is no typical
hospital and many variables exist (e.g., hospital size,
case mix, level of IT adoption) there can be no guarantee that other customers will achieve the same results.

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

53

Customer Excellence

Clinical Fellowships:
Localized Learning from the Experts
By Susanne von Vietinghoff, Computed Tomography, Siemens Healthcare, Forchheim, Germany

Ralf Bauer, MD, (left) and Matthias Kerl, MD,


(right) are in charge of the CT fellowship
program at the Johann Wolfgang Goethe
University in Frankfurt, Germany.

During a clinical fellowship, Siemens


Healthcare provides customers with the
opportunity to learn from clinical experts
at their institute about their typical
proven workflows. A clinical expert guides
participants through their daily workflow
and shows how examinations are conducted (including choice of protocols or
contrast injection timing). Furthermore,
users can learn how to do post-processing and how to write reports. In addition,
numerous tips and tricks straight out of
clinical routine are given directly at the
fellowship location. This hands-on training moves at the pace of the hospital,
creating an authentic practical experience.
Currently, there are sixteen different
fellowship locations available globally

with scanners ranging from SOMATOM


Emotion 6 to SOMATOM Definition Flash.
Fellowship training takes place at private
institutes as well as at university hospitals.
Siemens offers dedicated sites for scanning in the Emergency Room and in the
Neuroradiology and Cardiology Departments. So there are fellowship locations
available for every field of interest.
Please dont miss this excellent training
opportunity contact your local sales
representative.
An up-to-date list of fellowship locations
can be found here:

www.siemens.com/
SOMATOMEducate

ESC Hands-on Tutorials (HoTs)


By Susanne von Vietinghoff, Computed Tomography, Siemens Healthcare, Forchheim, Germany
In 2012 Siemens once again provided
HoTs for Cardiovascular CT and MR, Cardiac Molecular Imaging, Interventional
Cardiology, Echocardiography and Cardiac
Lab testing. The aim of the six CT sessions held by Matthias Kerl, MD, from the
University of Frankfurt, Germany, was
to discuss with the attendees most of
them cardiologists the opportunities
that CT offers for cardiac scanning.
Matthias Kerl presented everything from
scanning techniques to contrast media
injection protocols. After the short
introduction it was time to experience
syngo.via live while evaluating cardiac
datasets. Keerthi Prakash, MD, from the

University of Leeds, UK commented


after attending the HoT: I received a
good introduction to the basic principles
of scanning and post-processing. It was
a really good hands-on experience and
an enjoyable session, allowing great
interaction with the speaker. Nik Abidin,
MD, from Salford Royal Hospital NHS FT
in Manchester, UK, commented: Very
good introductory lectures aiming to
present the strength of the modality.
Good case presentations, demonstrating
the utility of CT in cardiac scanning. The
cases demonstrated helped our understanding of how the investigative tools
support clinical decision making.

54 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

The next chance to attend one of these


workshops is at ECR 2013 in Vienna, Austria.

www.siemens.com/
SOMATOMEducate

Customer Excellence

New Dual Energy Technology


for SOMATOM Definition
By Katharina Linseisen, Computed Tomography, Siemens Healthcare,
Forchheim, Germany
As the first Dual Source scanner, the
SOMATOM Definition revolutionized
the world of CT.
Now, it will take another evolutionary
step. The new software syngo CT 2012B
provides FAST Dual Energy1 and the
innovative FAST CARE Platform. All customers with a syngo Evolve contract,
Siemens non-obsolescence program,
benefit from a software-only upgrade
delivering innovative technology.

FAST Dual Energy1


To date, SOMATOM Definition customers
worldwide enjoy using Dual Energy (DE)
in daily practice. FAST DE now is designed
to speed up workflow by enabling easy
and intuitive direct 3D-reconstructions

of acquired DE data. Time consuming,


error prone, manual reconstruction steps
have been eliminated. In addition, the
data volume is reduced, saving filming
and archiving resources.

FAST CARE platform


FAST CARE technology may give medical
professionals more time for their patients.
FAST features like FAST Adjust accelerate
the workflow via intuitive scan parameter adjustment at the push of a button.
These features are combined with CARE
functionalities such as CARE kV, the first
automated kV-setting, that reduces dose
by up to 60%.2
Thus, the new software levers untapped
potential in patient-centric productivity.

The new software for the SOMATOM


Definition may give clinical professionals more
time to concentrate on patient care.

 elivered to all customers with Dual Energy and


D
a syngo Evolve contract.
2
Data on file.
1

Flash Imaging A Book Full of Flash Expertise


Flash Imaging

Topics. In each chapter authors from


different countries in Asia, Europe and
America give detailed information about
how SOMATOM Definition Flash is used
in their departments. With its unique
technologies, such as Dual Source Dual
Energy or the Flash Spiral high-pitch
mode, the SOMATOM Definition Flash
opens up new possibilities for CT scanning. This book provides an excellent
overview of these new uses. It allows
the reader to look behind the scenes of
well-known clinical departments and
offers a guide to an optimized use of the
scanner in daily routine. Free copies can
be ordered via the Customer Information
Portal on the Siemens Internet.

This compendium
provides a comprehe
nsive source of scan
information for all
and contrast protocols
important indication
as well as additiona
s for the second-g
l
Denition Flash.
eneration DSCT scanner,
the Siemens SOMATOM

Flash Imaging
brings together
clinical expertise
and experience
from all over the
world regarding
CT scanning with
the SOMATOM
Definition Flash.

The focus of all contribut


ing centers has been
on the optimization
since contrast media
of both scan and
delivery has become
contrast paramete
an increasingly critical
rs,
in modern CT imaging.
element of contrastThe protocols also
enhanced procedur
aim to achieve excellent
es
radiation exposure
images with the lowest
by exploiting the
possible
unique features of
the SOMATOM De
nition Flash.
Reecting expertise
and experience from
across
the
globe, contributions
from renowned radiology
to this volume have
centers in Europe,
been elicited
America, and Asia.

Flash Imaging

The book Flash Imaging, published by


Springer in May 2012, reports on clinical
expertise gained using the SOMATOM
Definition Flash. The authors from all
over the world share their best practices
as regards scan and contrast protocols
and provide additional helpful hints as
well as clinical cases.
In this comprehensive compendium an
introductory section describes the technology of the scanner and new insights
into the use of contrast medium in computed tomography scanning. Editors
renowned for their outstanding research
contributed to one of the following
clinical chapters: Sub-mSv Cardiac, Dual
Energy CT, Flash Thorax and Special Flash

Achenbach Johnson
Lee Lengsfeld
Ulzheimer (Eds.)

By Heidrun Endt, MD, Computed Tomography, Siemens Healthcare, Forchheim, Germany

Flash Imaging

springer.de

Achenbach
Johnson
Lee
Lengsfeld
Ulzheimer
(Eds.)

www.siemens.com/CT-Infoportal
Then navigate to Recommended
CT Literature; Protocols

SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

55

Customer Excellence

Frequently Asked Question


By Ivo Driesser, Computed Tomography, Siemens Healthcare, Forchheim, Germany
How can you speed up the workflow
in intervention and still save on dose?
Since the syngo CT 2011A software version was introduced for the SOMATOM
Definition Flash, SOMATOM Definition and
SOMATOM Definition AS, it has become
possible to significantly speed up the
workflow and use a lower dose in 3D
Interventions.*
Maximum image quality can be achieved
using minimum dose for each patient
by a combination of the Adaptive Dose
Shield, which eliminates over-radiation in
every spiral scan, and the real-time dose
modulation offered by CARE Dose4D.
In clinical routine, an ad hoc situation
sometimes requires a CT intervention.
Prior to the intervention a normal spiral

or 3D sequence scan is performed and


then an intervention scan is added. The
thin slices from the first scan can easily
be used for 3D planning of the intervention.
Select a 3D layout, select the recon job
with the thin slices (Fig. 1, marked in red),
and drag and drop them onto one of the
MPR segments (Fig. 1). Now it is possible
to plan the intervention immediately,
for instance to obtain an overview of the
situation and anatomical structures.
Thus, one extra scan (for example, an
i-Spiral) of the affected body area can be
eliminated, and therefore less dose is
applied. Time can even be saved: by
clicking somewhere in one of the three
MPR segments there is an automatic

alignment with the images in the tomosegment.


Another option to speed up the workflow during intervention is to load a
series from the Patient Browser or a
prior scanned series and use them as a
reference. To do this, open the Patient
Browser, select the series (for example,
CT or MR) and then drag and drop them
to the reference segment onto the intervention card.
Dragging and dropping onto the reference segment can also be used to load
images straight from the scans prior to
the intervention.

* Option

1 Select the
recon job with
the thin slices
(marked in
red) and drag
and drop them
onto one of the
MPR Segments.
The images
from the prior
scan can then
be used for
planning or
orientation.

Clinical Workshops 2012/2013


As a cooperation partner of many leading 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/Special Interest

Date

Location

Course Director

Link

Clinical Workshop on
Cardiac CT/Cardiac

Dec, 1214, 2012

Munich,
Germany

Siemens Healthcare
Prof. Becker, MD

www.siemens.com/
SOMATOMEducate

Clinical Workshop on
DE/Dual Energy

Feb, 89, 2013

Forchheim,
Germany

Siemens Healthcare
PD Johnson, MD

www.siemens.com/
SOMATOMEducate

Clinical Workshop on
Cardiac CT/Cardiac

Feb, 2022, 2013

Munich,
Germany

Siemens Healthcare
Prof. Becker, MD

www.siemens.com/
SOMATOMEducate

56 SOMATOM Sessions November 2012 www.siemens.com/healthcare-magazine

Customer Excellence

Hands-on Workshop at
ECR 2013/Multiple

Mar, 711, 2013

Vienna, Austria Siemens Healthcare

www.myESR.org

CTA Interpretation Course/Cardiac

Mar, 1415, 2013

Erlangen,
Germany

Siemens Healthcare
Prof. Achenbach, MD

www.siemens.com/
SOMATOMEducate

Hands-on at the
ESGAR Workshop/Colonography

Apr, 1820, 2013

Copenhagen,
Denmark

ESGAR P. Lefere, MD
C. Lauridsen, MD

www.esgar.org

Hands-on at the
ESGAR Congress/Colonography

June, 47, 2013

Barcelona,
Spain

ESGAR
Prof. Carmen Ayuso, MD

www.esgar.org

Clinical Workshop on
Cardiac CT/Cardiac

June, 1214, 2013

Munich,
Germany

Siemens Healthcare
Prof. Becker, MD

www.siemens.com/
SOMATOMEducate

Oncology Imaging
Course 2013/Oncology

June, 2729, 2013

Dubrovnik,
Croatia

OIC Prof. M. Reiser, MD

www.oncoic.org

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

Upcoming Events & Congresses 2013


Title

Dates

Short Description

Location

Contact

Arab Health

Jan, 2831

Arab Health

Dubai, UAE

www.arabhealthonline.com

ECR

Mar, 711

European Society of Radiology

Vienna, Austria

www.myesr.org

Cardiac MRI & CT

Apr, 1921

Cardiac Magnetic Resonance


Imaging & Computed Tomography

Cannes, France

http://cannes2013.medconvent.at

Africa Health

May, 79

Africa Health

Johannesburg,
South Africa

www.africahealthexhibition.com

EuroPCR

May, 2124

European Association of Percutaneous Paris, France


Cardiovascular Interventions

www.europcr.com

esc

May, 2831

European Stroke Conference

London, England

www.eurostroke.eu

ESPR

June, 37

European Society of Paediatric


Radiology

Budapest,
Hungary

www.espr.org

ESTI

June, 811

European Society of Thoracic Imaging

Seoul, Korea

www.myesti.org

ISCT

June, 1720

International Society for


Computed Tomography

Washington DC,
USA

www.mdctcourse.com

ECIO

June, 1922

European Conference on
Interventional Oncology

Budapest,
Hungary

www.ecio.org

SCCT

July, 1114

Society of Cardiovascular
Computed Tomography

Montreal,
Canada

www.scct.org

ESC

Aug, 31
Sept, 4

European Society of Cardiology

Amsterdam,
The Netherlands

www.escardio.org

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2012 by Siemens AG,
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All Rights Reserved
Publisher:
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Research Institute, Shandong University, Jinan,
Shandong, P. R. China
Thorsten R. C. Johnson, MD, LudwigMaximilians-University Hospital Munich,
Germany
Felix G. Meinel, MD, Ludwig-MaximiliansUniversity Hospital Munich, Germany
Zhen Minwen, MD, Xijing Hospital, the Fourth
Military Medical University, Xian, P. R. China
Pei Nie, MD, Shandong Medical Imaging
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J. Ramalho, RT, SAMS Hospital, Lisbon, Portugal

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Ximing Wang, MD, Shandong Medical Imaging


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L. Pereira, RT, SAMS Hospital, Lisbon, Portugal


H. Pereira, RT, SAMS Hospital, Lisbon, Portugal

Martin Wong, Pusat Jantung Hospital Umum


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Taku Yasumoto, MD, PhD, Toyonaka Municipal
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P. Coelho, RT, SAMS Hospital, Lisbon, Portugal


J. Costa, RT, SAMS Hospital, Lisbon, Portugal
Yanhua Duan, MD, Shandong Medical Imaging
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Yi Huan, MD, Xijing Hospital, the Fourth
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