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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
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
Peter Seitz
Content
Content
Cover Story
06
18
Cover Story
Business
06
New Clinical Insights
Faster Diagnosis
22 We Are Family
26 IRIS and Emotion in Daily Practice
News
Clinical Results
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
Content
20
52
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)
Cover Story
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
Cover Story
We need
a reliable
stroke diagnosis
within
10 minutes.
PD Peter Schramm, MD,
Neuroradiologist,
University Hospital Goettingen, Germany
Dual Energy
opens new
dimensions in
diagnosis.
Prof. Michael Lell, MD,
Radiologist, University Hospital
Erlangen-Nuremberg, Germany
Cover Story
2 Infarct (red) and penumbra (yellow) with the tissue at risk model.
Courtesy of University Hospital Goettingen, Germany
Cover Story
Cover Story
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.
Further Information
www.siemens.com/syngo.via
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
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.
13
News
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.
News
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.
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
15
News
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
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
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.
low kV
data
high kV
data
recon
part 1
recon
part 1
recon
part 2
3D
recon
FAST Dual
Energy image
17
News
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
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
News
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.
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
19
News
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
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.
News
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
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.
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
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,
23
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
Both the 64-slice and the 128-slice configuration offer the Illumination Moodlight.
25
Business
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.
Business
www.healthcare.siemens.com/
computed-tomography/
clinical-applications/iris
27
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
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-
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
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
29
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
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.
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
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.
31
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
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.
examination protocol
Scanner
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
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
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.
33
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
1B
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.
2A
2B
2C
examination protocol
Scanner
SOMATOM Perspective
Scan area
Slice width
0.75 mm
Scan length
250 mm
Temporal Resolution
195 ms
Scan direction
Reconstruction increment
0.5 mm
Scan time
12 s
Reconstruction kernel
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
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
3B
3C
35
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
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
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
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
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.
37
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
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.
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
39
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
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.
2A
2B
2C
2 The effective reduction of metal artifacts at high extrapolated photon energies allows for highly accurate volume rendering
technique (VRT) images.
COMMENTS
Appearing as bright and dark streaks originating from the metallic implants, metal
artifacts can greatly hamper accurate CT
examination protocol
Scanner
Scan Mode
DLP
Scan area
Spine
Effective dose
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
Reconstruction increment
1 mm
Dose modulation
CARE Dose4D
Reconstruction kernel
Q40f
CTDIvol
11 mGy / 14 mGy
41
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
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.
3A
2 VRT image shows the location of the implant in the left femur.
3B
examination protocol
Scanner
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
Slice width
1 mm
Dose modulation
CARE Dose4D
Reconstruction increment
1 mm
CTDIvol
12 mGy
Reconstruction kernel
D40f
43
Science
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.
Science
1A
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
45
Science
Science
3A
3B
70,0
60,0
50,0
40,0
30,0
20,0
10,0
0,0
0
10
15
20
25
30
35
70,0
60,0
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
47
Science
1B
1A
Science
Observer
Scan Parameters
Reconstruction Parameters
Reading Conditions
Evaluation
Phantom
Scanner
49
Science
2B
2A
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
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.
Data on file.
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
51
Science
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.
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
53
Customer Excellence
Clinical Fellowships:
Localized Learning from the Experts
By Susanne von Vietinghoff, Computed Tomography, Siemens Healthcare, Forchheim, Germany
www.siemens.com/
SOMATOMEducate
www.siemens.com/
SOMATOMEducate
Customer Excellence
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.
Flash Imaging
Achenbach Johnson
Lee Lengsfeld
Ulzheimer (Eds.)
Flash Imaging
springer.de
Achenbach
Johnson
Lee
Lengsfeld
Ulzheimer
(Eds.)
www.siemens.com/CT-Infoportal
Then navigate to Recommended
CT Literature; Protocols
55
Customer Excellence
* 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.
Date
Location
Course Director
Link
Clinical Workshop on
Cardiac CT/Cardiac
Munich,
Germany
Siemens Healthcare
Prof. Becker, MD
www.siemens.com/
SOMATOMEducate
Clinical Workshop on
DE/Dual Energy
Forchheim,
Germany
Siemens Healthcare
PD Johnson, MD
www.siemens.com/
SOMATOMEducate
Clinical Workshop on
Cardiac CT/Cardiac
Munich,
Germany
Siemens Healthcare
Prof. Becker, MD
www.siemens.com/
SOMATOMEducate
Customer Excellence
Hands-on Workshop at
ECR 2013/Multiple
www.myESR.org
Erlangen,
Germany
Siemens Healthcare
Prof. Achenbach, MD
www.siemens.com/
SOMATOMEducate
Hands-on at the
ESGAR Workshop/Colonography
Copenhagen,
Denmark
ESGAR P. Lefere, MD
C. Lauridsen, MD
www.esgar.org
Hands-on at the
ESGAR Congress/Colonography
Barcelona,
Spain
ESGAR
Prof. Carmen Ayuso, MD
www.esgar.org
Clinical Workshop on
Cardiac CT/Cardiac
Munich,
Germany
Siemens Healthcare
Prof. Becker, MD
www.siemens.com/
SOMATOMEducate
Oncology Imaging
Course 2013/Oncology
Dubrovnik,
Croatia
www.oncoic.org
In addition, you can always find the latest CT courses offered by Siemens Healthcare at www.siemens.com/SOMATOMEducate
Dates
Short Description
Location
Contact
Arab Health
Jan, 2831
Arab Health
Dubai, UAE
www.arabhealthonline.com
ECR
Mar, 711
Vienna, Austria
www.myesr.org
Apr, 1921
Cannes, France
http://cannes2013.medconvent.at
Africa Health
May, 79
Africa Health
Johannesburg,
South Africa
www.africahealthexhibition.com
EuroPCR
May, 2124
www.europcr.com
esc
May, 2831
London, England
www.eurostroke.eu
ESPR
June, 37
Budapest,
Hungary
www.espr.org
ESTI
June, 811
Seoul, Korea
www.myesti.org
ISCT
June, 1720
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
Amsterdam,
The Netherlands
www.escardio.org
57
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Editorial Board:
Xiaoyan Chen, MD; Monika Demuth, PhD;
Heidrun Endt, MD; Andreas Fischer;
Jan Freund; Julia Hlscher; Axel Lorz;
Peter Seitz; Stefan Ulzheimer, PhD
The drugs and doses mentioned herein are consistent with the approval labeling
for uses and/or indications of the drug. The treating physician bears the sole
responsibility for the diagnosis and treatment of patients, including drugs and
doses prescribed in connection with such use. The Operating Instructions must
always be strictly followed when operating the CT System. The sources for the
technical data are the corresponding data sheets. Results may vary.
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59
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