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No 17/December 2005

RSNA-Edition
Nov. 27th
Dec. 2nd, 2005

www.siemens.com/medical

COVER STORY
Dual Source CT Imaging
A New Era in Computed
Tomography
Page 4
NEWS
CT Clinical Engines Speed
and Confidence
Page 19
BUINESS
SOMATOM Emotion Excellent Price-Performance Ratio
Page 25
Revenue Investment
Pays Off
Page 27
CLINICAL OUTCOMES
Oncology Respiratory Gating
Page 34
Acute Care Diagnosis and
Surgical Planning in Traumatic
Paraplegia
Page 42
SCIENCE
Increased Speed and Resolution Make a Difference in
Coronary Artery Imaging
Page 46
CUSTOMER CARE
EDUCATE
Free CME-Credited CD-Set
Page 49

SOMATOM
Sessions

Deutscher Zukunftspreis/Ansgar Pudenz

EDITORS LETTER

Bernd Ohnesorge, PhD,


Vice President
CT Marketing and Sales

Dear Reader,
The number of slices acquired per rotation has doubled every 18 months in the last years,
with Siemens being an innovation leader in both technical concepts and clinical applications.
At RSNA 2003, Siemens set another landmark as the first company to introduce 64-slice CT.
Only two years later, our SOMATOM Sensation 64 is installed in over 500 institutions
world-wide the largest installed base in this segment.
At Siemens, we continue to challenge the future view on CT technology and clinical applications. We understand that supplying our users with innovative hardware is not enough. Introducing our new CT Clinical Engines, we provide perfect clinical CT solutions in neurology, diagnostic oncology, cardiovascular and acute care available across Siemens' CT product line and
based on Siemens' unique syngo platform.
The time has come to explore totally new CT concepts and to move beyond the simple adding
of more detector slices. At RSNA 2005, Siemens moves CT into a new era with the introduction
of the world's first Dual Source CT, the SOMATOM Definition a breath-taking innovation that
started with a simple scribble and was designed in cooperation with the world's leading clinical
experts. Experience completely new dimensions of CT. Redefine the clinical role of CT in cardiac imaging and acute care. Explore new clinical frontiers with dual energy scanning. Join us
to reach new levels of excellence in CT.
Now, enjoy reading this 17th issue of the SOMATOM Session magazine. It is the introduction
to another great CT year in a year in which Siemens will once again set the trend.
Sincerely,

Bernd Ohnesorge, PhD, Vice President CT Marketing and Sales

SOMATOM Sessions 17

CONTENT

COVER STORY
4
12

Dual Source CT Imaging A New Era in Computed Tomography


Dual Source CT Imaging The Idea behind the Technology

NEWS
19

Speed and Confidence

21

Leader in Customer Care

21

NEW Advanced Vessel Analysis

22

Proven Leadership

22

Trendsetting Injector Coupling Device

23

Enhanced Workflow

BUSINESS
24

Virus Protection Shields Medical Systems

24

The Easy Way from Sequential to Multislice CT

25

Excellent Price-Performance Ratio

26

Reimbursement in the US

27

Investment Pays Off

CLINICAL OUTCOMES
28

Cardiovascular: CT Angiography of Chest, Abdomen, Pelvis and Upper Extremities


with CARE Dose4D and z-Sharp

30

Cardiovascular: Peripheral Runoff

32

Oncology: Computer Assisted Reading - More Speed. Enhanced Confidence

34

Oncology: Respiratory Gated CT-Imaging in Radiation Therapy of Lung Cancer

36

Oncology: Restaging Bronchial Carcinoma after Radiotherapy Treatment

38

Oncology: Making a Difference with PET and CT in Complex Cases

40

Neurology: Bone Subtraction CTA for Vascular Mapping in Head and Neck Imaging

42

Acute Care: 40-Slice CT for Diagnosis and Surgical Planning in Traumatic Paraplegia

SCIENCE
44

Head and Neck Imaging

46

Increased Speed and Resolution Make a Difference in Coronary Artery Imaging

CUSTOMER CARE
48

Customer Event

48

Cardiac CT Live Case Workshop

48

First High-end Users Meeting

49

Free CME-Credited CD-Set

49

Service: Frequently Asked Questions

50

Service: CT News on the Web

50

Service: Upcoming Events and Courses

51

Imprint

SOMATOM Sessions 17

COVER STORY

Dual Source CT Imaging


A New Era in
Computed Tomography
Four prominent medical specialists from radiology, cardiology
and medical physics sat down together recently to discuss
a revolutionary innovation in CT technology: dual source CT imaging.
Here is how the experts assessed the new technology.
By Catherine Carrington

Buzz. Its what fills the air when people take note of an
exciting new trend, a technological revolution that
promises to change the future, an innovation so creative
it defines out of the box thinking.
Buzz. Its what energized the room when four computed
tomography (CT) experts gathered in Cleveland, Ohio, to
envision the future of imaging, and how it will change
with the introduction of a revolutionary new technology:
dual source CT.
The first system worldwide to contain this new technology
is Siemens SOMATOM Definition. Overcoming the
convention of thinking in terms of numbers of slices, it is
equipped with two X-ray source/detector systems that
rotate in synchrony, simultaneously capturing image data
in half the time required with conventional technology.
Two X-ray sources, two detectors, a multitude of clinical
possibilities.
At the table were neuroradiologist Michael Modic, M.D.,
chairman of radiology at the Cleveland Clinic Foundation;
radiologist Richard White, M.D., head of the section of
cardiovascular imaging at the Cleveland Clinic Foundation;
cardiologist Gilbert Raff, M.D., director of CT and MRI
research at William Beaumont Hospital, Royal Oak,
Michigan; and medical physicist Cynthia McCollough,
Ph.D., director of the CT Clinical Innovation Center at Mayo
Clinic, Rochester, Minnesota.

SOMATOM Sessions 17

Coronary CTA
examination with
83 ms temporal
resolution of
a patient with
varying heart
rate of 85-93 bpm
during the scan.

MIP LAD Diastole


MIP LAD Diastole
Courtesy: University Hospital Erlangen

COVER STORY

MICHAEL MODIC, M.D.,


chairman of radiology at the
Cleveland Clinic Foundation

RICHARD WHITE, M.D.,


radiologist, head of the
section of cardiovascular
imaging at the Cleveland
Clinic Foundation

GILBERT RAFF, M.D.,


cardiologist, director of CT
and MRI research at William
Beaumont Hospital, Royal
Oak, Michigan

CYNTHIA MCCOLLOUGH,
Ph.D., medical physicist,
director of the CT Clinical
Innovation Center, Mayo
Clinic, Rochester, Minnesota

SOMATOM Sessions 17

COVER STORY

Four CT experts from the US gathered in Cleveland to envision the future of imaging, and how it will change with the
introduction of dual source CT.

SOMATOM Sessions: 64-slice CT scanner have been a


remarkable innovation, but we are wondering what
challenges still remain. Are there ways in which CT can
become even better?
DR. RAFF: Cardiac CT has extremely high accuracy in finding
a lesion and in excluding significant stenosis. However, it
is very important to both, the patients management and
interventional planning, to discover exactly how severe the
lesion is whether it is a 25 percent stenosis or a 75 percent
stenosis. Any move in that direction is key.
The second issue is patient preparation. I have an entire
holding area staffed with nurses and equipped with
monitors, all dependent on having to give patients beta
blockers to slow the heart rate. We could save a lot of time,
work and cost if we didnt need to give patients these beta
blockers.
DR. WHITE: The leap from 16- to 64-slice technology really

SOMATOM Sessions 17

made it possible for us to do coronary CT angiography. But


were still dependent upon picking the right patients. With
future CT technology improvements, we need to be able to
do an examination on any patient.
DR. MODIC: CT is the ideal modality for imaging acute
stroke. The first decision for us is blood no blood, and
CT is very good at answering that question. But we also
need to evaluate the intracranial vessels, including fast and
accurate separation of vessels and bone. Moreover, calcified
plaque in the carotid arteries has been a limiting factor in
applying CT to the evaluation of stroke. We need a tool that
is better able to differentiate tissues.
DR. MCCOLLOUGH: Radiation dose has become of
increasing concern. With present multislice CT technology,
as temporal resolution improves, the radiation dose goes
up. Its a concern that hangs over the technology and makes
everyone worry.

COVER STORY

Cardiac Imaging
Dual source CT meets all of these challenges. Consider cardiac
imaging: Each of the two source/detector systems must travel
only 90 degrees to acquire image data, resulting in a doubling
of temporal resolution. It provides a temporal resolution of 83
ms a factor of two better than the 165-ms temporal
resolution of the best single source CT scanners. Together with
a spatial resolution of less than 0.4 mm, it enables SOMATOM
Definition to visualize the smallest anatomical structures with
exceptional quality without the compromises associated with
beta blockers and ECG-gated, multisegment reconstruction.
SOMATOM SESSIONS: How will dual source CT solve some of
the challenges you continue to face in cardiac imaging?
DR. RAFF: Even in patients that we consider ideal today, there
is always cardiac motion and subtle amounts of blurring at the
level of the stenosis. The only way were going to push coronary
CTA to achieve the quality we need to make key clinical
decisions is with higher temporal resolution.
DR. WHITE: Any opportunity to capture that coronary artery
as its flying by is a major gain. With 83-ms temporal resolution,
independent of the heart rate, youre also getting away from
the need for segmented reconstruction approaches.
SOMATOM SESSIONS: Lets talk about multisegment
reconstruction. Its said to improve temporal resolution and
overcome problems associated with a high heart rate. Are the
images of consistently high quality?
DR. WHITE: Multisegmental
reconstruction is not a panacea, and
quite often its detrimental rather than
beneficial. Youre averaging data from
multiple cardiac cycles, and thats not
the most desirable approach.
Multisegment reconstruction should
not be relied upon as the answer to
temporal resolution.
DR. MCCOLLOUGH: If you average
two cardiac cycles and the heart
doesnt come back to exactly the same
spot on a submillimeter level, youve
just blurred out that 1- or 2-mm artery
youre trying to see.
SOMATOM SESSIONS: High temporal
resolution eliminates the need to give
beta blockers. We have discussed the
operational benefits, but is there also
a clinical benefit?

DR. RAFF: A considerable number of patients cant take beta


blockers. For example, patients with asthma are not
candidates for cardiac CT today. And some patients are beta
blocker resistant. If dual source CT means that fewer patients
are rejected beforehand, and more of the patients we do
image have diagnostic results, thats quite important in the
scheme of things.
DR. WHITE: Theres another aspect to consider. Lets say,
based on the CT study, youre concerned about atherosclerosis and want to determine its functional importance.
Having beta blockers on board may preclude immediately
doing a functional assessment with stress testing. Thats a
problem that dual source CT can solve.

Better coronary imaging at this


level is going to revolutionize
the treatment of coronary
disease, and coronary disease is
the most commmon serious
health problem in
the developed world.
Gilbert Raff, MD, director of CT and MRI research,
William Beaumont Hospital, Royal Oak, Michigan

SOMATOM Sessions 17

COVER STORY

Radiation Dose
SOMATOM Definition delivers the lowest possible radiation
exposure in cardiac CT imaging today, despite using two
X-ray sources instead of one. How? Dual source CT images
the heart twice as fast; therefore, Adaptive ECG-pulsingTM
delivers the dose necessary for cardiac imaging in less than
half the time as the most dose-efficient single source CT
scanner. In addition, dual source CT easily acquires images
even at the highest
heart rates, thus allowing for scanning at higher table speed.
Higher table speed results in lower radiation exposure
compared to single-source CT.
SOMATOM SESSIONS: Is dose exposure a big issue in
cardiac CT?
DR. RAFF: Yes, its a concern. When the dose gets to be
higher than for a coronar y angiogram, theres a
psychological barrier, and everyone from patients to
government regulators become reluctant.
DR. MCCOLLOUGH: Radiation dose becomes a very hotbutton topic because people dont understand it. If someone
comes to the emergency room and its clearly important to
evaluate them with CT, then the dose risk is negligible in
comparison to the medical necessity of the exam. But in
those patients that come for rule-out examinations,
minimizing radiation exposure is very important. Reducing
the dose in cardiac CT by a factor of two will be an important
prerequisite for further establishing the technique in clinical
practice.
DR. RAFF: Im concerned about the patient who has CT after
equivocal results on a stress test. Theyve had a nuclear
procedure with radiation, a CT scan with radiation, and they
may go on to cardiac catheterization, with more radiation.
Anything we can do along that pathway to minimize
radiation exposure is critically important.
SOMATOM SESSIONS: Does radiation dose resonate with
your patients? Could you draw patients to your center by
emphasizing that dual source CT offers excellent image
quality at half the dose?
DR. MODIC: Absolutely.
DR. WHITE: Why not put it out there as a mandate? We
should tell patients: This is one of our core values, to reduce
dose without sacrificing image quality. Lowering dose is the
right thing to do for multiple reasons.

Acute Care
A combination of the highest temporal resolution and the
highest power available in the industry enables dual source
CT to easily image critical and challenging acute care
patients. This includes not only patients who are short of
breath or have a high heart rate, but also obese patients.

SOMATOM Sessions 17

If you have a strong,


premier cardiac program,
youll have to have a dual
source CT. A health system
like ours should
probably have several.
Michael Modic, M.D., chairman of radiology,
Cleveland Clinic Foundation

SOMATOM Definition has a wide, 78-cm gantry bore, a


200-cm scan range, and a combined 160-kW of power from
two independent X-ray sources. Together, these ensure
excellent image quality and enable scanning at high speed
for pure arterial-phase imaging, even in the heaviest of
patients.
SOMATOM SESSIONS: How important is it to be able to
image obese patients with adequate power and at an
optimal table speed?
DR. MODIC: Any time you can match dose with body mass,
youre better off. With dual source CT, youve got enough
power to take care of the patient.
DR. RAFF: In obese patients, the deterioration of image
quality can be so substantial with conventional CT scanners
that many of these patients have undiagnosable lesions.
Based on our experience with heavier patients, we dont
examine cardiac patients with a body mass index over
38 kg/m2.
DR. MCCOLLOUGH: We have successfully done abdominal

COVER STORY

studies on a patient weighing more than 500 pounds, using


a 64-slice scanner. But we have to make compromises. We
have to lower the table speed and, therefore, we cant
optimize the exam from a contrast perspective, as we would
with a regular patient. So if dual source CT allows us to scan
obese patients using the dose and the table speed we prefer,
there will be fewer trade-offs. And, in cardiac CT of obese
patients, lowering the table speed is not sufficient. You
simply need more X-rays for those patients.
SOMATOM SESSIONS: Should physicians be concerned
about the extra radiation dose to the obese patient?
DR. MCCOLLOUGH: The target organs that you worry about
for cancer are buried inside all that tissue, which absorbs a
lot of the radiation. It turns out that the effective dose,
which is an indicator of cancer risk from ionizing radiation,
only goes up by 10 to 20 percent, even though the scanner
is cranking out double or quadruple the usual dose.
SOMATOM SESSIONS: Are there other types of acute care
patients for whom dual source CT could make an important
difference?
DR. MCCOLLOUGH: Weve done imaging of non-sedated
kids for a decade and a half because weve had an electronbeam CT in our practice. Weve recently replaced that
scanner with a 64-slice scanner, and weve been doing well
with kids, but we still have to spend a long time in the exam
room calming them down if theyre agitated. At a temporal

resolution of 165 ms, there is still going to be motion blur.


So I think dual source CT could be a huge benefit for
imaging of pediatric patients without sedation, or for
imaging an injured patient who is in pain and cant hold
still, or a patient who is agitated for some other reason.

Dual Source CT Allows Dual Energy Imaging


Dual energy imaging possible only with dual source CT
leverages differences in attenuation that depend on the
types of tissues being scanned, as well as on the energy
level. Scanning an object with 80 kV results in a different
attenuation than scanning an object at 140 kV. This raises
the possibility of direct subtraction of either vessels or bone
during scanning, as well as characterization of other tissues.
By using two X-ray sources simultaneously at different
energies, SOMATOM Definition can acquire two data sets
with different information from a single scan. This may
offer the possibility of going beyond mere visualization of
anatomy to differentiation and characterization of tissues.
SOMATOM SESSIONS: What clinical opportunities does
dual energy scanning offer?
DR. MCCOLLOUGH: One of the most important challenges
in cardiovascular CTA is calcium. If a patient has a lot of
calcium in the coronaries, you cant see through that bright
spot to make a good diagnosis. Thats one of the things
were hoping dual energy will help us deal with.

SOMATOM Sessions 17

COVER STORY

DR. MODIC: The whole issue of calcium isnt just in the


heart. It could be in the lungs. It could be in peripheral
angiography, even in the hands and feet. Well be able to do
bone subtraction, not in postprocessing, but based on the
dual energy source.
SOMATOM SESSIONS: Dr. Modic, youre a neuroradiologist.
Would it be helpful to you to be able to discriminate bone
and vascular tissue when imaging the brain?
DR. MODIC: Absolutely, especially given the emergence of
CT and CTA in the evaluation of patients with subarachnoid
hemorrhage and acute stroke. The high cervical carotids
and the skull base those are difficult areas. Were very
eager to see the quality of the images we can achieve using
dual energy. Its likely to have a profound effect on the use
of CT in neuroradiology.
DR. WHITE: Dual energy is the big unknown for dual source
CT thats going to take it into an entirely different dimension.
We dont know what the prospects are for smarter contrast
agents, for example. We might adjust energies according to
the agent. There are probably opportunities we havent even
begun to anticipate.

Financial Justification

Any opportunity to capture


that coronary artery
as its flying by is a major gain.
With 83-ms temporal resolution,
independent of the heart rate,
youre also getting away from the
need for segmented
reconstruction approaches.
Richard White, M.D.,
head of the section of cardiovascular
imaging, Cleveland Clinic Foundation

10

SOMATOM Sessions 17

SOMATOM SESSIONS: From an operational or economic


standpoint, how would each of you justify investing in a
dual source CT scanner?
DR. MODIC: If you have a strong, premier cardiac program,
youll have to have a dual source CT. A health system like
ours should probably have several. If you have the patient
demand, the throughput that you can achieve through these
devices more than justifies the cost.
DR. MCCOLLOUGH: I can see dual source CT in the
emergency room, taking care of acute care and traumatized
patients. Also in a big pediatric hospital. These are the places
where sub-100 milliseconds should be a clear win, and
where it may be worth paying the price differential.
DR. RAFF: For a cardiac program like ours, dual source CT is
an obvious choice. Its very important for us to be the best.
In addition, our emergency room sees six thousand patients
a year with chest pain, and their average length of stay is
over 24 hours. Were finishing up a series of studies

COVER STORY

showing a dramatic decrease in length of stay when CT is


used to evaluate chest pain patients. If we could eliminate
beta blockers, we could probably reduce the length of stay
by another two hours. Those are the kind of compelling
numbers that hospital administrators with busy emergency
rooms are going to look at. Also, if a hospital is competing
with other institutions, it will be a distinguishing feature.
Patients will like the convenience.

Evolution or Revolution?
SOMATOM SESSIONS: Many of the advances in CT over the
last several years have been evolutionary. The increasing
number of slices with each new scanner is the most obvious
example. Is dual source CT another evolutionary change, or
is it revolutionary?
DR. MCCOLLOUGH: This scanner jumps off the curve,
because its not about the slices, its about rotation time.
We went from a half-second to 0.42 seconds to 0.37 seconds
to 0.33 seconds, and the gains were 0.08 and 0.05 and 0.04
seconds. Now we jump off a curve thats reaching its upper
limit and virtually cut rotation time in half, thats a big deal.
DR. WHITE: I think its both. You can count on it being
evolutionary on day one as we learn how to use it. But then,
the prospects for this technology to set a whole new
direction are amazing, and it will sustain that for quite some
time.
DR. RAFF: We have to consider the potential impact on
cardiology, and, through it, on medicine in general and the
healthcare system. Better coronary imaging at this level is
going to revolutionize the treatment of coronary disease,
and coronary disease is the most common serious health
problem in the developed world.
Author: Catherine Carrington is a medical editor in Vallejo,
California.

Dual source CT could be a


huge benefit for imaging of
pediatric patients without
sedation, or for imaging an
injured patient who is in pain and
cant hold still, or a patient
who is agitated
for some other reason.
Cynthia McCollough, Ph.D.,
director of the CT Clinical
Innovation Center, Mayo Clinic,
Rochester, Minnesota

SOMATOM Sessions 17

11

COVER STORY

12

SOMATOM Sessions 17

COVER STORY

X-ray unit 1

Rotation of
X-ray unit
and detector

X-ray unit 2

Gantry

Patient table

Detector 1

Dual Source
CT Imaging
The Idea behind
the Technology
With the introduction of the Dual
Source CT technology at this years RSNA,
Siemens once again demonstrates its
leadership in technology and clinical
applications, moving beyond the simple
adding of more detector rows a race
that had dominated CT technology for
the past couple of years.

SOMATOM Definition is the worlds first CT scanner to


incorporate this new technology with which Siemens is
once again pushing technical and clinical boundaries to a
higher level by adding a second X-ray source and detector
to the CT system. The results are unprecedented image
quality and detail at lowest patient exposure while ensuring
substantially increased diagnostic speed and confidence.

Detector 2

SOMATOM Sessions 17

13

COVER STORY

Advantages at a Glance
SOMATOM Definitions heart rate independent resolution
is 83 milliseconds, permitting scans of virtually every heart
and any heart rate from acute chest pain evaluation to
coronary visualization to functional analysis of the heart.
Together with the high spatial resolution of below 0.4 mm, it
makes the visualization of the smallest anatomical structures
possible with exceptional quality.
In combination with a 78-cm large gantry bore and field of
view, 200-cm scan range, and its high generator power, the
system allows most accurate scans or acute patients,
independent of size or condition. And all this at the lowest
possible dose. Additionally, SOMATOM Definition offers the
widest range of clinical applications, allowing fast and most
confident diagnoses to comprehensive reporting in only a
matter of minutes. Intuitive and computer-assisted reading
tools also assist physicians in early detection, fast evaluation,
and precise follow up of malignant diseases, sometimes even
enabling them to review results before the patient is off the

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SOMATOM Sessions 17

table. Whats more, SOMATOM Definitions capabilities promote


pioneering new clinical opportunities at the highest level.

How Does it Work?


The use of two X-ray sources and two detectors at the same
time result in double the temporal resolution, double speed and
twice the power, while even further lowering radiation dose.

Cardiac Imaging
Optimal cardiac imaging can be best achieved in the diastolic
phase of the heartbeat. The faster the heart rate, the shorter
this phase becomes. With a single source CT scanner, the
X-ray source/detector system has to obtain data projections of
180 degrees to take an image within the diastolic phase. With
Dual Source CT, each of the two source/detector combinations
needs to travel only 90 degrees to acquire an exceptional
cardiac image. Based on 0.33 s rotation time, this concept
provides an unprecedented temporal resolution of 83 ms,
independent of the heart rate.

COVER STORY

At a low and stable


heart rate, the time a
single source CT
scanner needs for
imaging is sufficient.
Nevertheless, the
substantially higher
temporal resolution of
Dual Source CT
eliminates residual
motion.
60 bpm single source CT

100 bpm single source CT

60 bpm Dual Source CT

100 bpm Dual Source CT

At higher or varying
heart rates, the diastolic
phase is too short
for a single source CT
scanner, resulting in
poor image quality.
Dual Source CT, on the
other hand, delivers
sharp and detailed
cardiac images in a
short diastolic phase
and even in the systolic
phase.

SOMATOM Sessions 17

15

COVER STORY

Dual Source CT images


the heart twice as fast
as single source CT
scanners, reducing the
ECG-pulsing window by
more than half.

Heartbeat-controlled
dose modulation
60 bpm single source CT

60 bpm Dual Source CT

To overcome insufficient
temporal resolution at
high heart rates, single
source CT scanners use
multisegment reconstruction with high dose
and limited reliability.
Dual Source CT, on the
other hand, maintains
the lowest dose, independent of the heart rate.

Heartbeat-controlled
dose modulation
100 bpm single source CT

100 bpm Dual Source CT

Dose Reduction
At the same time, SOMATOM Definition offers the lowest
possible radiation exposure in cardiac CT. Thanks to Dual
Source CT, the CT gantry needs to travel only 90 degrees to
acquire an exceptional cardiac image with unprecedented
temporal resolution of 83 ms, independent of the heart
rate. Monitoring the ECG in real-time, Siemens Adaptive
ECG-pulsing instantly reacts to any changes of the heart
rate. Now that cardiac acquisition is twice as fast, the time
of high exposure during the heart beat, controlled by dose
modulation, can be cut by more than half compared to
single source CT scanners.
Instead of using multisegment reconstruction at higher
heart rates, Dual Source CTs highest temporal resolution
allows to acquire cardiac images from single heartbeats, at
any heart rate. Using automated table speed adaptation,
SOMATOM Definition increases the pitch with higher heart
rates, resulting in a faster table speed and a corresponding

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SOMATOM Sessions 17

reduction of radiation exposure. In other words, the higher


the heart rate, the less time is required for imaging the
heart, and consequently lower dose is needed.

Obese Patients
Scanning obese patients with single source CT usually results in
a trade-off between speed and image quality. Dual Source CT
overcomes this limitation of restricted power reserves with a
second X-ray source. In other words, it accumulates the power
of the two independent sources, resulting in unprecedented
160 kW, providing sufficient X-ray power reserves for high quality
imaging of patients whether tall or small, thin or large at
maximum volume coverage speed and fastest rotation time.
And, because scan speeds can be increased, the higher power
is used to improve quality, while dose maintains the same as in
single source CT. And the large bore of SOMATOM Definition
makes patient positioning much easier.

COVER STORY

Scan speed
Quality
Power
Dose

SINGLE SOURCE CT WITH LIMITED KW.


Insufficient power for high-speed scanning
of obese patients.

When imaging obese patients at a high table speed


necessary for pure arterial scanning, even a
state-of-the-art, single source CT scanner may not have
sufficient power.

Scan speed
Quality
Power
Dose

DUAL SOURCE CT WITH 160 KW*.


Dual Source CT accumulates the power of two
seperate sources resulting in unprecedented 160 kW*.

Dual Source CT, on the other hand, delivers sharp and


detailed images at any scan speed, because it
accumulates the power of two independent sources.

* Depends on system configuration.

SOMATOM Sessions 17

17

COVER STORY

Using a single source CT scanner,


diagnosing the circled area becomes
difficult, as insufficient information
does not allow a differentiation
between different tissue types.

Dual Source CT, on the other hand,


enables physicians to easily
differentiate tissue types. The lesion
could be identified as a lipid
degeneration, color-coded in dark
red.

Object

80 kV
Attenuation B

140 kV
Attenuation A

Tissue Differentiation
It has always been an aim to collect as much information
as possible for differentiation of tissues. Dual Source CT
assists in opening the door beyond visualization, moving
into a new world of characterization. Permitting the use of
two sources simultaneously at different energies, SOMATOM
Definition makes it possible to acquire two data sets
simultaneously from a single scan, running the tubes at two
different kV levels. The result are two data sets with diverse
information, which can allow the user to differentiate,
characterize, isolate, and distinguish the imaged tissue and
material obtaining specific details about the scanned
object beyond morphology.
Spectacular research topics lie ahead, waiting to be explored,
as dual energy helps pave the way for a broad spectrum of
potential clinical uses. Possible application fields are: direct
subtraction of either vessels or bone during scanning,
classification of tumors in oncology, characterization of
plaques in vessels and the differentiation of body fluids in
emergency diagnostics.

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SOMATOM Sessions 17

Energy 2:

Energy 1:
Bone 670 HU

80 kV

Iodine
296 HU

Bone 450 HU

Iodine
144 HU

140 kV

As X-ray absorption is energy-dependent, changing


the tube's kilo voltage results in a material-specific
change of attenuation.

NEWS

C T CLINIC AL ENGINES

Speed and Confidence


By Louise McKenna, PhD, MBA, Global Product and Marketing Manager CT-Workplaces, and Stefan Wnsch, PhD, Global
Product and Marketing Manager Clinical Solutions, Siemens AG, Medical Solutions, CT Division, Forchheim, Germany

In order to enhance clinical workflow in


the computed tomography (CT) environment, Siemens CT Division is introducing a new generation of CT Clinical Engines. Supplying our customers with
hardware dedicated to their needs is not
enough, says Bernd Montag, PhD, President of the CT Division. We also want
to provide them with applications and
workflow tools that are specifically designed to enhance image quality and
workflow efficiency in their particular
clinical departments. The CT Clinical Engines marry the world's most innovative
CT technology with syngo, Siemens
unique clinical applications solution.
Perfect synergy, designed to reliably secure outstanding clinical outcomes
the new CT Clinical Engines bring together state-of-the-art CT scanner features
such as the industrys fastest rotation
speed, lowest possible dose scanning
modes and direct 3D data reconstruction
with exactly the right syngo solutions.
With our new CT Clinical Engines, we
take clinical application to the center of
our strategy, says Bernd Ohnesorge,
PhD, Vice President of CT Marketing and
Sales. The CT Clinical Engines will provide our framework to introduce further
innovations in the rapidly developing
clinical fields of neurology, diagnostic
oncology, cardiovascular and acute care
that will drive the future of CT. They are
designed to enhance speed and diagnostic confidence by delivering exceptional image quality, fast access to image data, and flexible access to intuitive
syngo clinical applications throughout
the radiology environment.

The Complete Solution for


Cardiovascular CT
The CT Cardiac Engine offers the complete solution for cardiovascular CT imaging. From scan to diagnosis, it covers
everything to achieve a streamlined cardiovascular workflow. State-of-the-art
ECG-synchronized acquisition, image
reconstruction techniques and intuitive
ECG-editing to exclude extra beats before image reconstruction, ensure optimal image quality. The lowest possible
dose for patients is provided with intelligent adaptive ECG-pulsing. An innova-

tive, dedicated cardiovascular imaging


user interface simplifies daily workflow
and ensures highest throughput. The CT
Cardiac Engine facilitates cardiovascular
diagnosis from vascular analysis with
accurate stenosis measurement to stent
planning, from cardiac morphology to
functional analysis, concluding in a
comprehensive report.

Full Confidence
in Neuro CT
The CT Neuro Engine delivers the technology required to perform artifact-free
imaging with the high spatial and temsyngo Circulation as a
key component of the CT
Cardiac Engine offers
physicians the industrys
most comprehensive
software for cardiac CT,
setting a new benchmark
for improving clinical
outcomes through innovative software solutions.

syngo Neuro DSA CT as


part of the CT Neuro
Engine offers tools for
fast and easy assessment
of head and neck
images, including direct
bone subtraction CTA.

SOMATOM Sessions 17

19

NEWS

poral resolution needed for fast and accurate visualization of complex neurological disorders of head, neck, and spine,
as well as injuries and stroke. Siemens
unique portfolio of syngo automated
software tools for neuro CT will help to
deliver excellent diagnostic outcomes
with bone subtraction in neuro CT DSA
studies for comprehensive evaluation of
complex vascular structures, with fast
brain perfusion for stroke patients and
differentiation of brain tumors.

Faster Diagnosis
in Acute Care
The Siemens CT Acute Care Engine
offers the complete solution for emergency and trauma imaging with CT. In
acute care, the requirements for CT
imaging are very challenging and
diverse from acute chest pain and
complex polytrauma to stroke assessThe CT Acute Care
Engine offers a fast onestop diagnostic confidence in all emergency
room situations.

syngo LungCare CT with


NEV (Nodule Enhanced
Viewing) as an element of
the CT Oncology Engine
identifies potential lung
lesions that were overlooked during the radiologists first read.

20

SOMATOM Sessions 17

Siemens CT Division not only takes care of the outer appearance of their existing
SOMATOM Emotion and SOMATOM Sensation product lines they also introduce
CT Clinical Engines that offer users the ultimate CT solution in key clinical areas.

ment, every second counts. The CT


Acute Care Engine delivers the complete solution to make fast and confident decisions. By combining state-ofthe-art functions for cardiac, vascular,
and neuro CT imaging, and adding innovative workflow features and high-resolution acquisition, the CT Acute Care
Engine provides the complete clinical
portfolio for imaging emergency patients
from head to toe. Using fast direct 3D
reconstruction, images can be reviewed
before the patient is off the table. syngo

streamlines the clinical workflow for


cardiac, vascular, musculoskeletal, and
stroke evaluation.

From Staging to
Follow-up in Oncology
CT Imaging
Siemens CT Oncology Engine offers a
unique combination of the most innovative scanner and syngo solutions for
diagnostic imaging, evaluation, and follow-up in any diagnostic oncology setting. syngos intuitive computer-assisted
reading tools, combined with intelligent
evaluation, automated follow-up, and
image guided intervention offer a new
level of confidence for preventive care,
staging, follow-up exams, and realtimeguided biopsies. Additionally, comprehensive tumor perfusion enables a fast
and easy visualization of tumor enhancement and aids in differentiating tumors. Fusing images from PET or SPECT
with high resolution CT images helps
not only to better localize tumors, but
also therapy planning. Siemens soltions
for interventional CT extend the clinical
spectrum towards differential diagnosis
and treatment.
These first generation CT Clinical Engines
offer Siemens users something very special: a totally unique combination of CT
technology and syngo, delivering a clinically optimized workflow, designed for
speed and diagnostic confidence for
every patient, every time. And this is only the beginning: with a keen eye on the
future, Siemens will continue to set new
trends for the next generation of clinical
CT solutions

NEWS

Life

Leader in Customer Care


Frost & Sullivan, a global growth consulting firm, has conferred Siemens
Medical Solutions the 2005 Customer
Care Leadership award.
Life is the embodiment of Siemens
Medical Solutions dedication to partnership with health care providers, its integrated service portfolio providing a highly
interactive forum for customer feedback,
says Siddharth Saha, Industry Manager,
Medical Imaging, Frost & Sullivan.
This award from Frost & Sullivan confirms Siemens leadership role in offering our customers a real lifecycle solution when purchasing our products,

said Volker Wetekam, President, Global


Solutions Division, Siemens Medical
Solutions. From the moment of purchase, Life surrounds our customers
with an array of programs and support,
that enable the continuous development of their skills, productivity and
technology, helping them to broaden
their capabilities, increase their profitability and take patient care to the next
level.
The Frost & Sullivan Customer Care
Leadership award is bestowed upon a
company that has demonstrated excellence in customer care leadership within

the industry. The recipient must have


shown tremendous responsiveness to
customer needs and must have continually focused on long- and short-term
customer profitability goals. In addition,
the recipient company must have
demonstrated flexibility in tailoring their
product offerings to suit customer businesses.
k www.frost.com

syngo InSpace4D

NEW Advanced Vessel Analysis


Advanced Vessel Analysis (AVA) is an
optional plug-in for syngo InSpace4DTM.
AVA features a fast and intuitive, guided
workflow for the segmentation of vascular structures, with dedicated algorithms for segmentation of carotids,
aorta, aortic arch, abdominal vessels,
run-off, cardiac vessels and bronchii.
Once the vessels of interest have been
segmented, the user can visualize and
assess stenotic lesions, including calcifications, applying curved MPR and orthogonal views. A wealth of automated
measuring tools allow for accurate
quantification and stent planning. AVA
will be available in syngo 2006A for new
syngo MultiModality workplaces1. Together with syngo InSpace4D advanced
bone removal, AVA provides users with
a comprehensive tool for assessment of
acute vascular conditions plus treatment follow-up.
1

syngo InSpace4D with Advanced Vessel Anaysis offers a portfolio


of dedicated algorithms for vascular segmentation.

Formerly: LEONARDO

k www.insideinspace.com

SOMATOM Sessions 17

21

NEWS

S O M AT O M S e n s a t i o n

Proven Leadership

Bernd Ohnesorge, PhD, Vice


President CT Marketing & Sales
of Siemens Medical Solutions,
receives the Frost & Sullivan
Award from Stephen Mohan, Vice
President Sales, Healthcare
Practice North America, Frost &
Sullivan, at the 6th international
conference on Cardiac CT in
Boston, MA, USA.

With well over 500 installations, the


SOMATOM Sensation 64 is the worlds
most widely installed 64-slice computed
tomography (CT) system. Its outstanding
capabilities are not only recognized by
physicians, but also by market analysts
and engineering experts.
Frost & Sullivan has awarded Siemens
Medical Solutions the 2005 Enabling
Technology of the Year award in recognition of being the first company to successfully introduce a 64-slice CT system.
Since the introduction of the SOMATOM
Sensation 64, healthcare professionals
consider it an industry standard in highquality imaging. On the basis of its technological capability, Siemens has set a
benchmark in the development and
adoption of high-end technologies in the
imaging industry, said Stephen Mohan,

Vice President Sales, Healthcare Practice


North America, Frost & Sullivan.
In recognition of its exceptional image
quality, speed, and ease-of-use, the
SOMATOM Sensation 64 was also honored with the gold award in the 2005
Medical Design of Excellence Awards
(MDEA). Judges in the eighth annual
MDEA competition recognized the systems excellent engineering such as
its revolutionary z-SharpTM Technology
identifying it as a paradigm shift in CT
scanning technology. Sponsored by Cannon Communications, publishers of "European Medical Device Manufacturer"
(EMDM) magazine, the MDEA program
honors design and engineering achievements within the medical industry.
k www.frost.com;
www.devicelink.com/expo/awards02/

C AR E Cont rast C T

Trendsetting Injector Coupling Device


Siemens Computed Tomography (CT)
customers can now profit from a unique
synergy of trendsetting scanner technology, the seamlessly integrated syngo
CARE Contrast CT, and contrast media
injector devices, resulting in the most
efficient contrast management on the
market. Siemens CARE solutions have
been expanded with the new option
CARE Contrast CT, extending the functionality of all Siemens SOMATOM CT
scanners and optimizing contrast enhanced CT examinations.
CARE Contrast CT connects the CT scanner and the injector, therefore allowing
starting or stopping the scan from one
single entry point. This is a trendsetting
answer to the increasing demands of

22

SOMATOM Sessions 17

fast contrast enhanced CT scanning. It


speeds up clinical workflow and allows
efficient and confident monitoring of
patients during contrast media injection
and scan start, even if only one technician is present.
CARE Contrast CT is the first scanner
interface using a new standard (named
CiA425) for injector coupling devices in

medicine. The interface is designed to


cover future communication tasks between scanner and injector and will
open up new fields of contrast-based applications. It is currently supported by
leading injector companies MEDRAD
and MEDTRON. Following this trend,
additional releases of injectors from other companies are expected soon.
CARE Contrast
CT greatly
speeds up
workflow in
contrastenhanced
CT scans.

NEWS

syngo 2006A

Enhanced Workflow
syngo 2006A, Siemens newest workflow software, will be delivered on new
syngo MultiModality workplaces1 by the
end of January 2006. Continuing the
Think Clinical theme, it gives users access to new features and functionalities
designed to enhance workflow and diagnostic confidence.

Key Clinical Areas


Three key clinical areas have been the
focus: cardiovascular CT, neuro CT and
CT imaging in oncology and early detection, thus providing key building blocks
for the four new CT Clinical Engines just
introduced at RSNA namely CT Cardiac
Engine, CT Neuro Engine, CT Acute Care
Engine and CT Oncology Engine (see
page 19).
syngo Circulation, designed for onestop, fast, robust morphological and
functional cardiac evaluation, makes its
debut in syngo 2006A. In combination

with enhancements to syngo InSpace


4D, such as bone removal and advanced
vessel segmentation and analysis functionalities, users have access to superior
tools for comprehensive cardiac assessment, fast evaluation of chest pain,
complex vascular exams, and fractures.
In neuro CT, visualization of complex
cerebro-vascular structures has been
hindered by the dense bone at the base
of the skull. Siemens new syngo Neuro
DSA CT facilitates subtraction of bone
from contrasted vessels allowing exceptional visualization of these vessels. New
features in syngo Neuro Perfusion CT include automatic tissue-at-risk assessment, offering enhanced speed and
confidence in tumor perfusion and
stroke workflow.
With syngo 2006A, Siemens adds another computer assisted reading tool to
its portfolio. syngo Colonography with
PEV (Polyp Enhanced Viewing) is a sec-

syngo Colonography with PEV (Polyp Enhanced Viewing)


is among the new computer assisted reading tools for
early detection available with syngo 2006A.

ond reader tool for the automated detection of colon lesions. Together with
syngo LungCARE CT with NEV (Nodule
Enhanced Viewing), Siemens offers its
users an exceptional level of confidence
for early detection and follow-up exams
of the colon and lung.
Another new addition to the oncology
portfolio, syngo Body Perfusion CT, enables the user to obtain an accurate picture of a tumors dynamic profile, helping to optimize treatment decisions. On
top of the new clinical functionalities,
syngo 2006A provides the user with significant improvements of workflow performance. DICOM transfer of up to 21
images per second can be achieved, as
well as loading capacity of up to 3,200
images.

Formerly: LEONARDO

The syngo Body Perfusion CT option allows for the


quantitative evaluation of dynamic CT data of organs and
tumors, following the injection of a compact bolus.

SOMATOM Sessions 17

23

BUSINESS

S I E M E N S R E M OTE S E RVI C E

Virus Protection Shields


Medical Systems
Regular computers can easily be protected against viruses. But regular virus
protection software cannot be indiscriminately used on medical equipment. Without the corresponding validation and testing, a systems safety and
efficacy may be significantly impacted.
Siemens Virus Protection solves the
problem. The solution is designed to
handle virus-related security matters on
syngo-based systems. It is the first
on the market to address this issue for
medical systems, significantly supporting customers in keeping their medical
systems healthy.

Siemens Virus Protection is based on


a virus scanner by Trend Micro, Inc., a
global leader in antivirus and content
security software and services. It includes regular updates with the latest
engines and patterns, using a VPN
(Virtual Private Network) broadband
Siemens Remote Service connection. The
Virus Protection program has been developed, validated and thoroughly tested in both Germany and the United
States and is now available for Siemens
computed tomography systems.* Virus
protection for medical systems has become a necessity due to the common

Siemens Virus Protection handles


virus-related security matters on syngo
based systems.

usage of various data media and internet connections. As long as our customers did not optimize their workflow
through network connectivity, there
was no need for such services, says
Wolfgang Heimsch, PhD, head of
Siemens Medical Solutions Customer
Service Division. Now healthcare providers are increasingly using networked
systems, so the market needs a suitable
virus protection solution.
* depending on software configuration

S O M AT O M S p i r i t

The Easy Way From Sequential


to Multislice CT

Elevate Siemens managed


system upgrade program brings
clinical performance to a higher
level: from the sequential singleslice SOMATOM AR to the new
spiral, multislice SOMATOM Spirit.

24

SOMATOM Sessions 17

To support customers in advancing their


computed tomography (CT) performance, Siemens Life Customer Care Solution offers Elevate, a program dedicated to updating outdated systems with
new ones for example SOMATOM AR
sequential scanners from the 1990s
with the spiral, dual-slice CT SOMATOM
Spirit, a cost-effective system for clinical
routine. When comparing the two systems, the SOMATOM Spirit offers many
advantages: Its spiral scan mode and
multislice technology broadens the clinical spectrum. Concurrently, together
with its fast scan time, spiral scanning
speeds up data acquisition and thus reduces motion artifacts. With the syngobased, easy-to-operate user interface
and an image reconstruction time of
only one second, the SOMATOM Spirit

accelerates the whole diagnostic


process. Thanks to the SOMATOM Spirits multislice technology, users can reconstruct different slice thicknesses
based on one single scan for example,
thin slice, high-contrast images and
wider slices with soft tissue display at
low contrast resolution. The SOMATOM
Spirit offers better resolution in highcontrast structures, and a better lowcontrast detectability in soft tissue.
Siemens unique UltraFastCeramic
(UFCTM) detector material and dose
reduction software lower patient dose
while achieving better image quality.
All in all, a lot of reasons why SOMATOM
AR owners should consider converting
their system.
k www.siemens.com/
SOMATOMElevate

BUSINESS

Interview
S O M AT O M E m o t i o n

Excellent Price-Performance Ratio


Siemens Medical Solutions recently
installed the first SOMATOM Emotion
16-slice computed tomography (CT)
system at the following locations: in
Germany, at the Israelitische Krankenhaus, Hamburg and Klinikum Nuremberg Nord; in Belgium, at Clinique du
Sud-Luxembourg/St. Joseph, Arlon;
and in the US, at the Ohio State University, Columbus. SOMATOM Sessions spoke with Johann-C. Steffens,
MD, Head of Radiology of the Israelitische Krankenhaus.
What are your first experiences with
the 16-slice SOMATOM Emotion?
The amazing fact for me was that the
new 16-slice SOMATOM Emotion
worked as a reliable scanner from the
very first day, replacing our 6-slice CT
scanner. Installation took only two
days. The syngo user interface of the
16-slice SOMATOM Emotion is so similar to the SOMATOM Emotion with six
slices that there were no changes in
how to operate the system, and no
need for additional training. We now
use the scanner for our daily routine
as well as for advanced applications
like CT Colonography.
Which clinical advantages and image
quality, compared to a 6-slice CT,
does the 16-slice configuration of
the SOMATOM Emotion provide?
We appreciate the low image noise
and high resolution that the system
allows us to achieve. Because of the
faster rotation time and the higher
number of slices, we can perform submillimeter lung examinations in one
single breath-hold, so that motion arti-

Johann-C. Steffens,
MD: The SOMATOM
Emotion 16 enables
us to achieve low
image noise and high
resolution.

facts are reduced. In addition, run-offs


can be performed in better resolution
and with a longer range, giving us the
opportunity to see smaller details. We
achieve very good image quality in
abdominal imaging and imaging of
bony structures. In addition, the image quality of head scans is outstanding.
With the 16-slice configuration of
the SOMATOM Emotion, the resolution and the number of slices increased. How about patient dose?
Patient dose does not increase. Because of the efficient system design,
the effective patient dose is generally
very low. For most examinations the
effective patient dose is less than with
our former 6-slice system.
To which users would you recommend the new configuration of the
SOMATOM Emotion?
I think this scanner provides radiologists the opportunity to perform routine and advanced applications. Therefore it enables them to get more

patients from their referrals and also


increase the number of referrals. In
addition, the low investment and lifecycle costs permit radiologists with
limited budgets to purchase a scanner
with excellent performance. Especially radiological departments in small
and mid-size hospitals and imaging
centers can profit from the excellent
price-performance ratio of the SOMATOM Emotions 16-slice configuration.
The Israelitische Krankenhaus in
Hamburg is a 205-bed hospital consisting of the Medical Clinic and the
Surgery Clinic, plus an interdisciplinary intensive care unit and the Department of Anesthesiology. The Radiological Practice of Dr. Steffens, a
Cardiological Practice, a Neurological
Practice and the cancer research center, Indivumed, are located on the
same premises and closely cooperate
with the hospital.
k www.israelitisches-krankenhaus.de

SOMATOM Sessions 17

25

BUSINESS

CARDIAC C T

Reimbursement in the US
New Current Procedural Terminology Category III codes
for Cardiac CT released by AMA to become effective January 1, 2006

Category III codes for Cardiac CT will be


effective January 1, 2006, potentially
leading to Category I coding by 2007.

Currently, computed tomography is


used by physicians as a diagnostic tool
for many conditions and symptoms.
Promising new indications are cardiac
CT and coronary CT angiography (CTA).
While specific procedure codes exist for
established CT applications, none currently exist for the new cardiac applications.
The absence of specific codes has not
prevented some Medicare contractors
from developing Local Coverage Determinations, permitting coverage. For example, since June 2004, Medicares local fiscal intermediaries or carriers in
South Carolina, Pennsylvania, New Jersey and New York have decided to cover
cardiac CTA services. As for coding, the
Local Carrier Decision Policies (LCD) in
these states currently specify CTA exams of the chest (with/without contrast,
plus post-processing) for cardiac CT procedures.
In a recent development, the South
Carolina Heart Center, a specialty heart

26

SOMATOM Sessions 17

clinic and Siemens refererence site, has


worked together with its local Medicare
carrier, Palmetto GBA, to expand its LCD
based upon the recently published
64-slice clinical trials (see page 46). As
for coverage by the private sector, cardiac CTA reimbursement from private
insurance providers (among them Blue
Cross/Blue Shield, United, Aetna, Kaiser
Permanente and others), is still limited
and mostly dependent upon individual
contracts between the healthcare provider and their local payers. There is currently no reimbursement allowed for
non-contrast based CT calcium scoring.
In general, this procedure is still a consumer directed (or retail) service.
As for coding, in mid-2005, the American College of Radiology (ACR) had recommended its members use unlisted
CT procedure code for cardiac CTA procedures. Despite this recommendation,
providers should understand that they
still need to obtain approval from local
payers for use of this code for cardiac
CTA reimbursement.
This situation will change in 2006. At
the American Medical Associations Editorial Panel meeting in June, the American College of Cardiology (ACC) and
the American College of Radiology
(ACR) co-sponsored a new coding proposal specific to cardiac CT and coronary CTA. The proposal included seven
temporary new Category III codes and
one add-on code. In July 2005, AMA
released these temporary new Category III codes; they will become effective January 1, 2006. Category III codes
were established by AMAs Editorial Panel to identify emerging technologies,

services and procedures. These codes


are intended to allow data collection
and to substantiate widespread usage a
criterion the Editorial Panel considers,
along with clinical effectiveness, before
assigning the new service or procedure
a Category I code. It should be noted
that Category III codes are not to be
referred to the AMA/Specialty RVS
Update Committee (RUC) for valuation.
Because no relative value units (RVUs)
are assigned to Category III codes, payment is determined by local payers in
Medicares case, by local carriers and fiscal intermediaries who cover the procedure identified by the Category III code,
not by the Medicare Physician Fee
Schedule. It should also be noted that
providers are required to utilize these
new codes when treating their patients.
In 2006, utilization and payment for
cardiac CTA will still need to be driven at
the local level by each provider of this
diagnostic tool, through dialogue with
their local payers. Physicians and key cardiac CT opinion leaders, including the
Society of Cardiovascular CT, hope that
widespread usage of the new Category
III codes will lead to a successful application to secure Category I code as soon as
2007. Securing a Category I code would
result in Cardiac CT receiving its own
RVU, and would allow the procedure to
become a truly routine test for noninvasive management of Cardiovascular
disease.

k www.ama-assn.org/ama/pub/
category/12850.html

NEWSBUSINESS
SECTION

REVENUE

Investment Pays Off

A Giant Leap
Hospital Moinhos de Vento, Porto Alegre,
Brazil, took one giant leap forward when
it replaced two single-slice scanners with
one SOMATOM Sensation Cardiac 16 in
2004. When comparing the database of a
six-month period prior to the installation
to a six-month period after the installation, they realized that the average time
for scheduling an examination was reduced from 26 to 11 minutes; that the
number of examination increased by
52 percent; that the average contrast volume was reduced by 25 percent; and that
the number of examinations with patient

sedation was reduced from 4 percent to


3.2 percent. Using modern, multislice
equipment dramatically streamlines the
workflow and increases patient care and
comfort, concludes J.A. Marconato, MD
at the hospital. He points out, however,
that this improvement is only possible if
the entire staff works together as a team
from scheduling the examinations to diagnosing the images: Today, the limitations are no longer set by the equipment.

Step by Step
Of course, one expects such savings from
a major upgrade step even if one new
scanner replaces two old ones. But it also
pays off to be among the early adopters
of new CT technology. The Chairman of
the Radiology Department at a huge US
hospital compared core data from several
systems, starting with the SOMATOM Plus
4, the SOMATOM Volume Zoom and the
SOMATOM Sensation 16, up to the SOMATOM Sensation 64. One basic result:
Acquisition and reconstruction times decreased dramatically over the years, enabling higher patient throughput. The
clinic has increased its patient volume
from less than 20 patients per day with
the SOMATOM Plus 4 to well over 60

Time (Minutes)

Abdominal CT Scan Total Exam Time


35
30
25
20
15
10
5
0

Acquisition
Patient Transit
Recon

Plus4

Volume Zoom

Sensation 16

Sensation 64

An abdominal scan with the SOMATOM Plus 4


took more than 30 minutes total examination
time with the SOMATOM Sensation 64, everything was done in five minutes.

while enabling on demand examinations instead of the long waiting lists common with the older systems. In spite of
higher staffing required to run the
SOMATOM Sensation 64, the expenses,
as a percentage of the revenue, trend
down. This is due to higher patient volume, and also to a different staffing skill
mix. Today, more aides are hired for tasks
that do not require the expertise of a technologist to ensure the same patient transit time and patient care. With this combination of measures, the clinic has been
able to continuously reduce expenses;
from more than 60 US$ per exam to 45,
despite rising market prices for the scanners. As a result, expenses as a percentage of net revenue have decreased from
over 16 to only 9 percent. In summary, increased coverage, speed, resolution, applications, indications and availability not
only increase patient care: When it comes
down to finances, these improvements
also decrease spending. A detailed presentation, now available on CD, was held
by the clinic's radiology chairman at the
7th
SOMATOM CT User Conference
2005 (see page 49).
Results may vary. Data on File.

Expense Trends
Percent

Modern equipment is one of the key


factors in providing more efficient and
higher quality healthcare today. Both clinical community and patients benefit from
an improved clinical workflow and advances in medical diagnosis. In computed
tomography (CT), scan modes, scan and
image reconstruction times, resolution,
applications and user interfaces, as well as
dose reduction methods, have all developed quickly over the past few years.
Keeping a hospital up-to-date is a financially significant task. However, two recent analyses show that it pays off.

18
16
14
12
10
8
6
4
2
0

Payroll & Benefits


Medical Supply & Other
Direct EquipExpense
Total Expense

Plus4

Volume Zoom

Sensation 16

Sensation 64

By continuously upgrading their CT equipment,


the US clinic has been able to increase patient
throughput while reducing costs.

SOMATOM Sessions 17

27

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neuro

Acute Care

Case 1:
CT Angiography of Chest, Abdomen, Pelvis and
Upper Extremities with CARE Dose4D and z-Sharp
By Dominik Fleischmann, MD, Jeffrey C. Hellinger, MD, and Geoffrey D. Rubin, MD, Department of Radiology,
Cardiovascular Imaging Section, Stanford University Medical Center, Stanford, CA, USA

HISTORY
A 34-year-old woman with right arm numbness was referred
for CTA of the upper extremities as well as the chest,
abdomen and pelvis. The patient's past medical history was
significant for a right brachial artery aneurysm presumably
caused by vasculitis which had been treated with a
reversed vein graft and secondary interventions over the
past 10 years. The patient also had a history of bilateral iliac
artery aneurysms.

The imaging goal in this particular case was to identify or


exclude a vascular cause for the patient's recent right arm
symptoms. Because of the patient's history and the known
iliac artery aneurysms, the large arteries of the body were
also imaged. We chose a single CTA acquisition with the
patients arms placed next to her body and a single contrast
medium injection into a left antecubital vein.

Care Dose4D Automated Dose Modulation


Eff. mAs

Ref mAs: 250, kVp 120


Effective mAs (Houndsfield Units)
0

50

100

150

200

250

300

73

0
50

245

100
150
200

93

250

Average 180 mAs

300
350
400
450
500

160

106

longitudinal distance in mm

550
600

252

650
700
750
800

Image Noise
(HU)

Dose Modulation
(eff. mAs)

158

[ 1 ] Consistently excellent image quality throughout the entire scanning range in vascular territories
within the body and in the upper extremities off-center at an average of 180 effective mAs

28

SOMATOM Sessions 17

NEWS
SECTION
CLINICAL
OUTCOMES

[ 2 ] A left vertebral artery origin


directly off the aortic arch is present.
Otherwise, the supraaortic vessels are
within normal limits.

[ 3 ] Right common iliac artery


aneurysm and small left internal iliac artery aneurysm. A high-grade
stenosis of the celiac artery, due to
median arcuate ligament impingement is noted.

DIAGNOSIS
Incidentally noted is a left vertebral artery origin directly off
the aortic arch. Otherwise, the supraaortic vessels are within
normal limits. The right subclavian and axilary arteries are
patent. Multiple focal areas of mild dilatation (11 to 14 mm in
diameter) are seen within the right brachial artery reversed
vein graft. The graft is patent with mild stenosis distally. The
radial, ulnar, and interossea arteries are patent.
A high-grade stenosis of the celiac artery origin, due to
median arcuate ligament impingement, is noted. The thoraco-abdominal aorta and its visceral branches are otherwise
unremarkable. A 15 mm right common iliac artery aneurysm
and a small, 11 mm left internal iliac artery aneurysm are
seen in the pelvis.

COMMENTS
The patient was positioned in supine position with her arms
placed at the sides of her body, to enable coverage of the
entire chest-abdomen-pelvis and upper extremities vessel territories within a single CTA acquisition, and with a single injection of contrast medium. Although such positioning may
cause streak artifacts in the shoulder region and excessive
noise within the upper extremities, the use of automated tube
current modulation (CARE Dose4DTM) and high spatial resolution using z-Sharp Technology resulted in virtually artifact-free
visualization of all clinically relevant vessels at unprecedented
image quality.

[ 4 ] Multiple mild focal dilatations within the right brachial


artery, a reversed vein graft.
The graft is patent with mild
stenosis distally. Several surgical
clips are also noted.

EXAMINATION PROTOCOL
Scanner

SOMATOM Sensation
64-slice configuration

Scan area

From lower neck to finger-tips;


arms by side of body

Scan length

77.5 mm

Scan time

29 s

Scan direction

cranio-caudal

kV

120 kV

Effective mAs

180 at 250 Ref mAs

Rotation time

0.5 s

Slice collimation

0.6 mm

Slice width

1 mm

Pitch

0.7

Reconstruction increment

0.7 mm

CTDI

13.41 mGy

Kernel

B25f

Contrast

Omnipaque 350 mg iodine/ml

Volume

25 cc at 5 cc/s, 100 cc at 4 cc/s,


followed by 40 cc saline flush

Start delay

5s

SOMATOM Sessions 17

29

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neuro

Acute Care

Case 2:
Peripheral Runoff
By Jean-Bernard DHarcour, MD, Cliniques du Sud-Luxembourg,
site St. Joseph, Arlon, Belgium

HISTORY

COMMENTS

A 55-year-old patient with previous history of left femoral


bypass was presented for mild claudication of the right leg.
A CTA runoff with the SOMATOM Emotion was performed.

This case demonstrates the ability of the SOMATOM Emotion


with 16-slice configuration to achieve complete arterial mapping, thus enabling the physician to plan vascular therapy.
syngo InSpace4D with bone removal allows a quick overview
of the entire vascular tree and permits a reliable analysis of
heavily calcified segments. Complete evaluation should not
take more than 15 minutes.

DIAGNOSIS
CTA shows severe aorto iliac athromatosis and complete
occlusion of the left iliac axis. Left aorto femoral bypass is
patent. On the left side, a short occlusion of the distal superficial femoral artery (SFA) is disclosed. On the right side,
there is no significant stenosis of the iliac axis but a long
occlusion of the SFA is shown. On both sides, peripheral
arteries are patent.

[ 1 ] VRT showing occlusion of the left iliac artery


and patency of aorto femoral bypass. Bone removal
was performed with syngo InSpace4D.

30

SOMATOM Sessions 17

[ 2 ] VRT of the complete examination

CLINICAL OUTCOMES

EXAMINATION PROTOCOL
Scanner

SOMATOM Emotion
16-slice configuration

Reconstruction increment

1 mm

Kernel

B20s smooth

Scan area

Lower extremity runoff

Scan length

1560 mm

Scan time

25 s

Contrast

Scan direction

Cranio-caudal

Volume

kV

110 kV

Effective mAs

90 mAs with CARE Dose4D

50 cc at 7 cc/s, 100 cc at 5 cc/s,


followed by 50 cc saline flush
at 5 cc/s

Rotation time

0.6 s

Start delay

5s

Slice collimation

16 x 1.2 mm

Slice width

1.5 mm

Pitch

1.5

Postprocessing

syngo InSpace4D with bone removal

[ 3 ] MIP image of SFAs shows short occlusion of the


left SFA and long occlusion of the right SFA.

[ 4 ] Despite proximal occlusions, distality is


clearly depicted on this MIP image. No significant
lesion shown

SOMATOM Sessions 17

31

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neuro

Acute Care

Computer Assisted Reading More Speed.


Enhanced Confidence
The use of computer assisted reading tools such as syngo
Colonography with PEV (Polyp Enhanced Viewing) and
syngo LungCARE CT with NEV (Nodule Enhanced Viewing)
can significantly enhance clinical workflow, adding speed

and diagnostic confidence. Two expert centers look at just


how much value second-reader products can add to their
clinical workflow.

Case 3:
Optimizing Clinical Workflow in CT Colonography
Using syngo Colonography PEV
By Anno Graser, MD, and Christoph R. Becker, MD, Department of Clinical Radiology,
University Hospital Munich-Grosshadern, Munich, Germany
At our center, the demand for colorectal cancer screening is
growing and the number of CT colonography (CTC) examinations is increasing rapidly. We are constantly looking for
tools that help us to improve speed and enhance confidence
and offer our patients the highest possible level of care. A
study performed at our institution to be presented at this
years Radiologic Society of North America (RSNA) annual
meeting (Session SSG 10-07, Tuesday, November 29) shows
that PEV reaches 94% sensitivity in the detection of polyps in
the important 5-9 mm size range. In addition, the study
shows that PEV can be integrated into clinical routine due to
its short running time of 4 minutes per dataset. With PEV
running in the background, syngo Colonography PEVs performance remains unrivalled, delivering excellent performance in everyday clinical routine increasing reader confidence and shortening evaluation time.
The case presented here shows how PEV improves human

[ 1 ] Anastomosis of the descending


colon and the remaining sigmoid

32

SOMATOM Sessions 17

reader performance and level of confidence in the detection


of polyps. The 62-year-old male patient had undergone partial sigmoidectomy for resection of a stage T2 cancer in
2002. The patient underwent CTC, following incomplete
colonoscopy.
There is end-to-side anastomosis of the descending colon
and the remaining sigmoid [Fig. 1] and a 15-mm adenomatous polyp in the transverse colon close to the hepatic flexure [Fig. 2]. The PEV algorithm identified several additional
small polyps: one difficult to see hiding between two folds
[Fig. 3], another had been obscured by a puddle of fluid on
the supine scan and can only be seen on prone images where
there is slightly increased image noise seen as the characteristic cobble stone pattern of the colonic mucosa which nevertheless does not prevent detection of the lesion [Fig. 3]. In
summary, PEV shows an excellent performance in the detection of colonic lesions.

[ 2 ] Adenomatous polyp in the transverse colon close to the hepatic flexure

[ 3 ] CAD identified several


additional small lesions.

CLINICAL OUTCOMES

Case 4:
Improved Workflow for Detection
of Pulmonary Nodules
By Marco Das, MD, Andreas Horst Mahnken, MD, Georg Mhlenbruch, MD, Joachim Ernst Wildberger, MD,
Department of Diagnostic Radiology, Rolf. W Gnther, MD, Director, Department of Diagnostic Radiology, and
Thomas Kraus, MD, Department of Occupational Health, RWTH Aachen University, Aachen, Germany

Multidetector-row computed tomography (MDCT) is the


method of choice for detection of pulmonary nodules.
Increased spatial resolution with modern CT scanners facilitates the detection of nodules as small as one or two millimeters. Overlooked pulmonary nodules, regardless of size,
may have potentially severe consequences for the patient.
Reasons for missing nodules may be perception errors or
misinterpretation. Double reading during clinical routine has
been suggested to reduce false negative diagnosis. In times
of increased workload and limited human capacity, this
goal is not always practicable. Moreover, quantification of
nodules is problematic due to inter- and intraobserver variability. Thus, computer algorithms have been developed to
aid the radiologist for the detection and quantification of pulmonary nodules.

ENHANCED CONFIDENCE
syngo LungCare CT with NEV facilitates the detection workflow and provides easy objective quantification and reporting
of pulmonary nodules. Fig. 1 shows a routine low-dose chest
MDCT examination of a 66-year-old male patient (120 kV, 10
mAs eff., 16 x 0.75 mm collimation, rotation time 0.5 sec,
table feed/rotation 18 mm, 1 mm slice thickness, 0.5 mm
reconstruction). With initial standard reading using Maximum-Intensity-Projection (MIP technique; 5 mm thick section), a pulmonary nodule was not detected, probably
because of its central location closely surrounded by large
vessels. During initial standard reading, the NEV algorithm
runs in the background and marks potential lesion candidates
for reviewing after the initial read. The nodule was detected
and marked by the software automatically [Fig. 2] and was
confirmed by the reading radiologist. With one additional
mouse-click, quantification of the nodule was performed
[Fig. 3]. After final reporting, the patient underwent CT-guided, fine-needle aspiration biopsy and small-cell lung cancer
was finally diagnosed during cytopathological work-up.

[ 1 ] 66 year old male patient


who received a low-dose
MDCT chest examination for
the detection of pulmonary
nodules. Initial reading missed
the nodule located centrally
between several surrounding
vessels in the left lower lobe.

[ 2 ] The NEV software


detected the nodule and
marked it as a potential
lesion with a red circle. The
mark has to be evaluated
by the radiologist to confirm
this finding as a true positive finding.

[ 3 ] The software allows a quantitative evaluation of


the nodule and gives information about diameters, volume,
and CT density values. It also allows a comprehensive view
of the anatomical location between the vessels in this 3Drendered scene of the finding (Volume Of Interest, VOI).
After identifying the nodule as a true positive finding, all
these parameters are stored in the final report.

SOMATOM Sessions 17

33

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neuro

Acute Care

Case 5:
Respiratory Gated CT-Imaging
in Radiation Therapy of Lung Cancer
By J. Dinkel, MD, A. Jensen, MD, U. Mende, MD, PhD, Department of Radiation Oncology, and J. Debus MD, PhD,
Director, Department of Radiation Oncology, University of Heidelberg, Germany

HISTORY
A 62-year-old female patient under chemotherapy treatment
for a non-small-cell lung cancer and cerebral metastases
was examined using the SOMATOM Sensation Open with a
4D respiratory gated data acquisition protocol in order to
determine the full range of motion of critical internal structures and the lung cancer during respiration. This method
was used to achieve a more targeted radiation treatment.

DIAGNOSIS
Respiratory gating supplies information about tumor motion
during the patient's breathing cycle. The introduction of the
latest generation multislice CT systems with short acquisition times permits the evaluation of thoracic structures with
a temporal resolution of 250 ms. Short acquisition times in
this set-up are achieved by simultaneous acquisition of 24 or
40 transverse sections, half-second scanner rotation, and
advanced respiratory-gated reconstruction algorithms. In

[ 1 ] Nodular calcified lymph node as well as an


enlarged aorticopulmonary lymph node can be seen
in the mediastinal region.

34

SOMATOM Sessions 17

this patient, the breathing frequency was over 12 cycles/min.


CT data was collected in spiral mode, with simultaneous
acquisition of 24 parallel sections using a 1.2 mm collimation
and appropriate spiral pitch of 0.1. The respiratory signal
from the patient was synchronized and simultaneously
recorded during free-breathing CT data acquisition, using a
chest-belt with a pressure sensor. Virtually correlated 4D
phase volumes (with the time as the fourth dimension) were
reconstructed after the scan to form a model of anatomic
movement. 7 different reconstructions were performed corresponding to different phases of the breathing cycle.
In these CT scans, a 4 x 3.7 x 3.8 cm lobular mass was clearly
visible in the medial aspect of the left upper lobe extending
to the left hilus. Various nodular calcified lymph nodes as
well as an enlarged aorticopulmonary lymph node could be
seen in the mediastinal region. Additionally, the CT scan
showed an extrathoracic metastasis in the left adrenal
gland. In our scans, the tumor mobility was about 2.1 mm in

[ 2 ] Metastasis in the left adrenal gland

CLINICAL OUTCOMES

3A

3B

[ 3A, 3B ] Two reconstructions corresponding to different phases of the breathing cycle demonstrate the
range of motion of critical internal structures and the lung cancer during respiration.

the x-axis (L-R), 6.2 mm in the y-axis (A-P) and 5.2 mm in the
z-axis. The mass, however, did not show a deformation during the breathing cycle. Visualization of structure motion is
possible with dedicated software syngo Inspace4D.

EXAMINATION PROTOCOL
Scanner

SOMATOM Sensation Open

Scan area

Thorax

Scan length

300 mm

COMMENTS

Scan time

51.85 s

Breathing frequency

> 12 cycles/min.

New approaches in radiation therapy with the use of more


and more conformal dose application in combination with
higher doses per fraction for irradiation treatment need
accurate delineation of tumor and critical structures especially in areas where artifacts distorting the geometric shape
and location of the organs cannot be tolerated. Motion artifacts usually occur at boundaries of anatomical structures
(both target volumes and organs at risk), resulting in the
image degradation and the inability to correctly delineate
anatomical structures. This leads to erroneous position,
shape and volume information for target volumes and other
regions affected by motion.
The respiratory gated data acquisition in CT allows the planning physician to visualize and study the organ and tumor
motion in 3D coordinates and time, contributing to a better
understanding of the target area and potential sparing of
healthy tissue by minimization of treatment volume and
reduction of side effects. Respiratory gating is a promising
new tool to increase the quality of RT planning and patient
treatment.

kV

120 kV

Effective mAs

400 mAs

Rotation time

0.5 s

Slice collimation

1.2 mm

Slice width

1.5 mm

Pitch

0.1

Reconstruction increment

1 mm

CTDI

35.63 mGy

Kernel

B10f

Postprocessing

syngo Inspace4D

SOMATOM Sessions 17

35

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neuro

Acute Care

Case 6:
Restaging Bronchial Carcinoma
after Radiotherapy Treatment
By Jan Capoen, MD, Radiologist, Jan Yperman Ziekenhuis, Ypres, Belgium

HISTORY
A 70-year-old female presented with increasing dyspnea and
general detoriation. She was known with an inoperable right
sided bronchial carcinoma, treated with radiotherapy. A CT
scan was performed in order to restage this carcinoma and
to look for any further complications or progression.

[ 1 ] Paramediastinal lungfibrosis and


enlarged
mediastinal
lymphnodes

DIAGNOSIS AND COMMENTS


The CT scan showed the typical post-radiotherapy changes
on the right side: sharply demarcated paramediastinal fibrotic
pathology. Multiple enlarged lymphnodes were detected:
ipsilateral, contralateral and infracarinal. Confluent hypodense lymphnodes were present paratracheal.
A central tumoral mass caudal in the right hilum encased the
inferior right pulmonic vein and abutted the esophagus. The
mass was larger in comparison to the prior CT scans.
Post obstructive lung changes were present in the right middle and lower lobe. Some free plural fluid was present on the
right and left side.
Due to subsecond scanning and high pitch, breathhold was
not an issue. CARE Dose and the 4 mm collimation reduced
the radiation dose significantly. MPR reconstructions, despite
the 4 mm collimation, had additional diagnostic value.

[ 2 ] Inhomogeneous enhancing tumoral


mass caudal in
the right hilum
and infracarinal
lymphnodes

EXAMINATION PROTOCOL
Scanner

SOMATOM Spirit

Reconstruction increment

2.8 mm

Scan area

Thorax

CTDIvol.

5.42 mGY

Scan length

288.5 mm

DLP

169 mGY

Scan time

17 s

Kernel

B41s

Scan direction

Caudo-cranial

kV

130 kV

Effective mAs

50 mAs (with CARE Dose)

Contrast

Iomeron 300

Rotation time

0.8 s

Volume

80 cc

Slice collimation

4.0 mm

Flow rate

2.6 cc/s

Slice width

5.0 mm

Start delay

25 s

Table feed/rotation

14.4 mm

Pitch

1.8

Postprocessing

MPR

36

SOMATOM Sessions 17

CLINICAL OUTCOMES

[ 3 ] Tumoral mass caudal in


the right hilum

[ 4 ] Tumoral encasement of
the inferior pulmonic vein

[ 5 ] Post obstructive lung changes


on the right side

[ 6 ] MPR views of the paramediastinal fibrotic changes

SOMATOM Sessions 17

37

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neuro

Acute Care

Case 7:
Making a Difference with PET and
CT in Complex Cases
The powerful functional imaging in Positron Emission Tomography (PET) became even more powerful with the addition of
anatomical data from CT. The diagnostic limitations of standalone PET and CT procedures are eliminated with combined
PET/CT imaging technology, which has become the gold
standard for tumor diagnosis and staging. Siemens Biograph

PET/CT hybrid-imaging scanners provide seamlessly matched


functional and anatomical images from a single non-invasive
procedure, enabling accurate tumor diagnosis, whole-body
staging, target definition and treatment planning. The Biograph provides complete clinical information regarding the
exact location, size and metabolic activity of disease.

Biograph High-Resolution Examination


HISTORY
This 63-year-old female patient with severe scoliosis and history of surgically removed gallbladder cancer in 2004 was
seen for follow-up in March 2005. In this routine follow-up,
the patient was diagnosed with Non Small Cell Lung Cancer
(NSCLC), and a hybrid PET/CT was ordered for staging.

DIAGNOSIS
In addition to several pulmonary lesions and the NSCLC, the
PET/CT study, obtained on the Biograph 16 HI-REZ, identified
multiple bone lesions within the spine [Fig. 1, Fig. 2], two

[ 1 ] CT Spine image of patient with severe case of scoliosis

38

SOMATOM Sessions 17

intra-abdominal lesions [Fig. 3], as well as additional 6 mm


lesions in the thorax wall [Fig. 4, Fig. 5]. The metastatic and
some other bone lesions were almost undetectable in the CT
images.

COMMENTS
PET has a major role in early detection, staging and treatment
planning of lung cancer and related metastases. FDG PET
influences patient management decisions, effecting treatment outcomes and quality of life. Adding co-registered,
detailed anatomical data acquired with a diagnostic CT scan
increases the diagnostic accuracy and provides the reading
and referring physician with the possibility to assess functional and structural changes in one exam.
Using hybrid PET/CT scanning was critical in diagnosing the
additional, unexpected bone metastases and lesions in the
thoracic wall. Some of these bone lesions would have been
difficult to detect using a stand-alone CT. However due to the
patients extreme case of scoliosis, an exact correlation of
stand-alone PET data to the corresponding vertebras was only
possible by using co-registered functional (PET) and anatomical (CT) information provided by the PET/CT hybrid imaging
scan. The HI-REZ PET imaging technology of the Biograph 16,
with its unmatched additional resolution, also played a significant role in accurately identifying the smaller lesions in the
thorax wall, allowing greater diagnostic confidence to the
interpreting physician.

CLINICAL OUTCOMES

[ 2 ] PET/CT image showing multiple


bone lesions within the spine

[ 3 ] Fused PET/CT image identifies


two intra-abdominal lesions.

[ 4 ] CT image of the thorax wall

[ 5 ] PET/CT image identifies 6 mm


lesions in the thorax wall.

EXAMINATION PROTOCOL
Scanner

Biograph 16

Slice width

5.0 mm

FDG

11mCi

Table feed/rotation

24 mm

Uptake time

62 min

Pitch

Beds

Reconstruction increment

5.0 mm

Time per bed

3 min

HI-REZ

yes

Scan area

Whole body

Scan direction

Cranial-caudal

Volume

Effective mAs

30 mAs

Rotation time

0.5 s

Dual phase
CT acquisition of the thorax and
(arterial and portal venous) upper abdomen

Slice collimation

1.5 mm

Contrast
90 cc

Case courtesy of Martina Eschmann, MD, Tuebingen University, Tuebingen, Germany

SOMATOM Sessions 17

39

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neuro

Acute Care

Case 8:
Bone Subtraction CTA for Vascular Mapping
in Head and Neck Imaging
By Michael Lell, MD and Ulrich Baum, MD, Institute of Radiology, University Erlangen-Nuremberg; Ernst Klotz and
Hendrik Ditt, Physics and Application Development, Siemens AG, Medical Solutions, CT Division, Forchheim; all Germany

Bone subtraction CTA (BSCTA) in neuro CTA proved to be a


valuable tool for delineation of complex intracranial structures and cranial aneurysms [Somatom Sessions No.
15/December 2004]. For bone subtraction, a non-enhanced
and contrast enhanced data set has to be acquired. Using
shape and CT value distribution of bony structures in both
data sets, the algorithm automatically matches the volumes
using a rigid transformation model. Then the bone removal
process is performed, which selectively eliminates bone,
while retaining both soft tissue and contrast-enhanced vessels. To determine the optimal contact interface between
vessels and bone, initially a global threshold for the segmentation of bony structures in the non-enhanced CT images is
used. The threshold is then locally adapted if vessels are in
the vicinity of bone to minimize creating artificial luminal
reduction. The resulting bone structures are then selectively
eliminated from the contrast-enhanced data. Thus subtraction of soft tissue is avoided. For subtraction purposes, a
non-enhanced CT scan in low dose technique is sufficient.
The following case has been evaluated using the new syngo
Neuro DSA CT software.

HISTORY

tissue reaction but without abscess formation. CTA did not


reveal relevant stenosis of the carotid arteries or the major
branches.

COMMENTS
To achieve good results, it is of great importance to carefully
instruct the patient not to move between the two scans. For
subtraction purposes, a low dose scan in addition to a regular contrast enhanced scan is sufficient to create threedimensional, volume-rendered images of the head and neck
vasculature, comparable to rotational angiography.

EXAMINATION PROTOCOL
Scanner

SOMATOM Sensation 64-slice configuration


Non-enhanced
Arterial phase

Scan area

C6 zygomatic arch

Scan length

150 mm

Scan time

3.4 s

Scan direction

Caudo-cranial

kV
Effective mAs

120 kV
50 mAs

Rotation time
Slice collimation

A 63-year-old patient with a history of successfully treated


laryngeal carcinoma presented with chronic osteomyelitis of
the mandible. A partial resection of the mandible was
planned and CT was performed to visualize the mandibular
lesion and the external carotid artery and its branches for
microvascular reconstruction.

64 x 0.6 mm

Slice width

0.75 mm

Pitch

0.9

Reconstruction
increment
CTDI

140 mAs
0.33 s

0.5 mm
7.87 mGy

Kernel

21.88 mGy
H20

Contrast

DIAGNOSIS
CT did not show recurrent tumor or lymph node metastasis.
Chronic osteomyelitis of the mandible and a bone fistula
could be detected on the left side, with inflammatory soft

40

SOMATOM Sessions 17

Volume

50 cc

Flow rate

5.0 cc/s

Start delay

individual (testbolus or CARE Bolus)

Postprocessing

syngo Neuro DSA CT, VRT

CLINICAL OUTCOMES

1A

2A

1B

2B

1C

2C

[ 1A ] Osteolysis of the mandible with


cortical destruction [ 1B and 1C ]; Fistula
of the bone in bone [ 1B ] and soft tissue
window [ 1C ]; Inflammation of the soft
tissue along the fistula with skin retraction

[ 2 ] BSCT-Angiogram: frontal view [ 2A ]


and left carotid artery from a lateral
[ 2B ] and medial [ 2C ] view

SOMATOM Sessions 17

41

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neuro

Acute Care

Case 9:
40-Slice CT for Diagnosis and Surgical
Planning in Traumatic Paraplegia
By Steffen Gnther, MD, and Markus F. Berger, MD, Institute of Diagnostic Radiology,
Swiss Paraplegic Center, Nottwil, Switzerland

HISTORY
A 22-year-old man was brought to our hospital by emergency
transport helicopter (REGA) with incomplete paraplegia sub
L2 (ASIA D) following a motorcycle accident. Prior to admission, the patient had been completely healthy. A vertebral
fracture was suspected and CT scanning of the lumbar spine
for diagnosis and surgical planning was performed. Following
initial posterior instrumentation, a follow-up examination
was performed to document the operative result and to
assess the need for additional anterior stabilisation.

DIAGNOSIS
CT scanning revealed a traumatic burst type vertebral body
fracture of L2 with loss of spinal stability. Bony compromise of
the spinal canal was present. An additional MR scan showed
traumatic injury to the conus medullaris, as the patient unfortunately also had a tethered cord.
Follow-up CT after initial treatment by posterior USS-titanium
stabilisation from L1 to L3 demonstrated an exellent opera-

[ 1 ] VRT lateral view of the lumbar spine


showing fracture of vertebral body L2
with extension into the posterior column

42

SOMATOM Sessions 17

tive result. Due to the intended straightening of the fracture


zone, there was a relatively large bony defect in the body of
L2 and the need for additional anterior intervertebral fusion
L1/L2 in a second intervention. After both successful operations the patient showed partial recovery of neural function.

COMMENTS
By using 1.0 s rotation and z-Sharp Technology's flying focal
spot, the SOMATOM Sensation scanner with 40 slices allows
us to achieve both extended coverage and the highest resolution in one examination. Vertebral fractures can be
assessed from whole body datasets in multiple planes and
unprecedented detail. Due to the marked reduction of metal
artefacts, imaging of the postoperative spine has dramatically improved. We can now see what was completely invisible
before. The volume rendered images created with the syngo
InSpace4D application on the CT workstation are simply stunning.

[ 2 ] Axial image showing postoperative


follow up after burst type fracture of vertebral
body L2. Note the minimal metal artefacts.

CLINICAL OUTCOMES

EXAMINATION PROTOCOL
Scanner

SOMATOM Sensation 40-slice configuration


Pre-surgery
Post-surgery

Rotation time

1.0 s

1.0 s

Slice collimation

0.6 mm

0.6 mm

Scan area

Lumbar spine

Lumbar spine

Slice width

0.75 mm

0.75 mm

Scan length

250 mm

194 mm

Pitch

0.45

0.9

Scan time

46 s

18 s

Kernel

B25s

B25s

Scan direction

Caudal-cranial

Caudal-cranial

kV

120 kV

120 kV

Effective mAs

482 mAs

261 mAs

Postprocessing

InSpace4D

InSpace4D

[ 3 ] VRT images showing postoperative results after posterior-lateral stabilisation;


different views with colour emphasis on the metal implants. Note the virtual absence
of streak artefacts and the excellent delineation of implanted bone chips.

SOMATOM Sessions 17

43

SCIENCE

Multislice CT Angiography
Head and Neck Imaging
By Michael Lell, MD, Institute of Radiology, University Erlangen-Nuremberg; Bernd F. Tomandl, MD, Department of
Neuroradiology, Klinikum Bremen; Axel Barth, Product Manager Applications, Siemens AG, Medical Solutions, CT Division,
Forchheim; Emeka Nkenke, MD, Department of Maxillofacial Surgery, University Erlangen-Nuremberg; all Germany

Patients with carcinoma of the oral cavity that infiltrate bone


require resection of the involved part of the mandible. This
resection may be performed in a continuity-preserving or, in
more advanced cases, continuity-interrupting resection. To
cover larger defects in order to provide fixation of prosthetic
dentures and restore the ability to masticate, microvascular
grafts are required. Fibula- and radius-grafts are commonly
used. Before reconstructive surgery, detailed information of
the host region is essential for the surgeon [1]. Tumor recurrence has to be ruled out, the viability of surrounding bone
has to be assured, and the vascular situation in the host
region has to be assessed. Besides course and diameter of
the external carotid artery (ECA) and its branches, it is
mandatory to be aware of angiopathies. Nutritive-toxic and
age dependent vessel alterations can be encountered frequently in this patient population. Prior resection or preoperative radiation therapy seriously affects the vascular bed in the
receiver region. A decision for or against microvascular
reconstruction has to be made based on the results of the
angiography. Selective catheter angiography (digital subtraction angiography, DSA) is still the gold standard in the
diagnosis of the head and neck vasculature. Major drawbacks
of DSA for preoperative vascular mapping are the relatively
high costs and risks of neurological complications. Recently,
multislice spiral computed tomography angiography (CTA)
has emerged as an alternative technique to DSA in a large

[ 1 ] Patient with prior reconstructive surgery


after tumor resection, scheduled for repeated
surgery because of fracture of the right
reconstructed mandible. DSA: Left carotid
angiogram; patent graft vessel (arrow)

[ 2 ] CTA: Corresponding CTA of the left carotid


artery. Patent graft vessel (arrow)

44

SOMATOM Sessions 17

variety of indications [39]. In the following paragraphs, the


protocols and results for CTA used at the authors institution
will be reviewed.

Imaging Protocol
Prior to entering the CT suite, an 18-gauge intravenous
catheter is placed in the right antecubital vein, and all mobile
dentures are removed. The patient is placed in supine position with the head bedded in a headrest. A biphasic CT scan
is performed with a 16-slice or 64-slice spiral CT scanner
(SOMATOM Sensation 16 or 64). The arterial phase study is
used to create 3D angiographic images, the delayed phase
study for tumor staging. CARE Bolus can be applied to determine the individual start delay (TimeDelay) for the arterial
phase. Alternatively, the test-bolus method (10 ml contrast
media, 30 ml NaCl 0.9%) can be used: the test-bolus
sequence is then loaded in the Dynamic Evaluation application, and contrast enhancement curves of the arterial and
venous system can be analyzed in detail. Time-to-peak plus
2s is used as the delay between injection of the full contrast
bolus and the scan.
100 ml of a non-ionic contrast agent are injected with a power
injector at a rate of 4-5 ml/s followed by a saline flush of 3050 ml. The scan volume includes the inferior margin of the
bottom of C6 to the zygomatic arch and the skull base to the
thoracic inlet for the late phase scan. The scanner settings are
2

SCIENCE

[ 3 ] CTA: Reconstruction of the


mandibula (dotted
arrows); graft vessel
(arrow), fracture
(dotted arrow with
round end)

given in the examination protocoll. The late phase scan is


performed 60s after the first scan during shallow breathing.

Review of Images
Axial 0.75 mm slices of the arterial phase are reconstructed at
an increment of 0.5 mm with a field of view (FOV) of 180 mm
and a matrix of 512x512, applying a soft tissue kernel. This
data set is transferred to a CT-workstation for 3D volume rendering. A default setting for volume rendering (syngo 3D
platform) is used to limit postprocessing. The analysis of the
vessels is done interactively. In selected cases, thin slab-maximum intensity projections (thin-MIP) or multiplanar reformations (MPR) may be applied.
The late phase scan is used for tumor staging and is routinely
reconstructed in contiguous 3 mm axial slices and 3 mm
coronal slices (direct 3D reconstruction). In unclear cases, thin
slice reconstruction may be performed for MPR evaluation.

Results of MSCT-Angiography
In a recently published study [9], we compared the ability of
16-slice CTA and selective carotid DSA in the evaluation of the
ECA and side-branches. For the complete number of vessel
branches detected in each of the two different imaging
modalities, a statistically significant difference could not be
found for the two examiners (PCTA = 0.59, PDSA = 0.41). DSA
was able to show more vessel segments than CTA, especially
vessels within narrow bony canals (infraorbital or inferior
alveolar artery), but considering vessels suitable for reconstructive surgery, no statistically significant difference
between CTA and DSA was found. All CTA studies were diagnostic; no examination had to be repeated.

CT Examination Protocol

Discussion
For preoperative vascular mapping of head and neck region,
CTA is a less invasive and more cost effective alternative to
DSA. Tumor staging and vascular mapping can be performed
with a biphasic CT protocol within a single session. No additional contrast agent injections are necessary, and catheter
associated risks can be avoided completely. The information
provided by CTA seems to be sufficient for the planning of
microvascular reconstructions. In addition, three-dimensional image reconstruction uniquely demonstrates anatomical relationships between blood vessels, bones, and soft tissue. Osseous pathology can be assessed in detail, and virtual
preoperative planning as well as computer-aided selection
or preparation of transplant material becomes possible.
1 Ehrenfeld M, Riediger D, Wolburg H, Thron A. Angiographic visualization
and morphology of anastomosed vessels in microsurgical tissue transplantation. Fortschr Kiefer Gesichtschir 1987; 32: 7174
2 Fleischmann D. Present and future trends in multiple detector-row CT
applications: CT angiography. Eur Radiol 2002; 12 Suppl 2: S1115
3 Herzog C, Dogan S, Wimmer-Greinecker G, Balzer JO, Mack MG, Vogl TJ. Multidetector-row CT: cardiosurgery indications. Eur Radiol 2003; 13 Suppl 5: M8287

Arterial phase

Delayed phase

Scanner

SOMATOM
Sensation
16-slice
configuration

SOMATOM
Sensation
64-slice
configuration

SOMATOM
Sensation 16
16-slice
configuration

SOMATOM
Sensation 64
64-slice
configuration

kV
Effective
mAs
Rotation
time
Slice
acquisition
Recon. slice
thickness
Reconstruction interval

120
110

120
140

120
150

120
150

0.5 s

0.33 s

0.5 s

0.33 s

16 x 0.75 mm 64 x 0.6 mm

16 x 0.75 mm 64 x 0.6 mm

0.75 mm

0.75 mm

3 mm

3 mm

0.5 mm

0.5 mm

3 mm

3 mm

Contrast
Volume
100 cc
Flow rate
4 cc/s
Postprocessing:

In a subsequent analysis of patients with prior reconstructive


surgery and the need of repeated surgery, all patent graft
vessels could be detected with CTA.

100 cc

5 cc/s

syngo Neuro DSA CT

4 Remy-Jardin M, Tillie-Leblond I, Szapiro D, et al. CT angiography of pulmonary embolism in patients with underlying respiratory disease: impact of
multislice CT on image quality and negative predictive value. Eur Radiol
2002; 12: 19711978
5 Wiesner W, Hauser A, Steinbrich W. Accuracy of multidetector row
computed tomography for the diagnosis of acute bowel ischemia in a nonselected study population. Eur Radiol 2004
6 Ropers D, Baum U, Pohle K, et al. Detection of coronary artery stenoses
with thin-slice multi-detector row spiral computed tomography and multiplanar reconstruction. Circulation 2003; 107: 664666
7 Catalano C, Napoli A, Fraioli F, Venditti F, Votta V, Passariello R. Multidetector-row CT angiography of the infrarenal aortic and lower extremities
arterial disease. Eur Radiol 2003; 13 Suppl 5: M8893
8 Lell M, Wildberger JE, Heuschmid M, et al. CT-angiography of the carotid
artery: First results with a novel 16-slice-spiral-CT scanner. Fortschr Rntgen
str 2002; 174: 11651169
9 Lell M, Tomandl BF, Anders K, Baum U, Nkenke E. Computed tomography
angiography versus digital subtraction angiography in vascular mapping for
planning of microsurgical reconstruction of the mandible. Eur Radiol 2005; 15:
15141520

SOMATOM Sessions 17

45

SCIENCE

SOMATOM Sensation
Increased Speed and Resolution Make a Difference
in Coronary Artery Imaging
By Stephan Achenbach, MD, Department of Internal Medicine II, University of Erlangen, Germany, President of the Society
of Cardiovascular CT (SCCT)

Non-invasive imaging of the coronary arteries is a holy


grail. Clinically, the need for a non-invasive tool to replace
some diagnostic invasive coronary angiograms is obvious,
but the technical challenges to achieve reliable imaging of
the coronary vessels are tremendous. The coronary arteries
are subjected to constant, rapid motion. Along with their
small dimensions as well as the necessity to achieve high
contrast between the vessel lumen and surrounding structures, this makes non-invasive coronary imaging an
extremely difficult task.
Around the year 2000, the first multi-detector computed
tomography (MDCT) systems with rotation times of 500 ms
were introduced. Dedicated image reconstruction methods
that required less than 360 of data and could correlate
image reconstruction to the electrocardiogram were developed. With these 4-slice scanners, it could be demonstrated
that non-invasive visualization of the coronary artery lumen
with mechanical CT is possible. However, it was soon recognized that in many cases both temporal and spatial resolution were insufficient and failed to provide diagnostic image
quality. The next step in the evolution of scanner technology
were 16-slice scanners which further increased spatial resolution (by providing sub-millimeter collimation) and temporal resolution (with rotation times of less than 500 ms). Consequently, high diagnostic accuracy for the detection of
coronary artery stenoses was reported by several experienced academic sites [15].

[ 1 ] Istotropic spatial resolution


permits multiplanar reconstructions of the coronary arteries without losing anatomic detail. Here,
a curved multiplanar reconstruction of a right coronary artery
(arrow) is shown. The data set
was acquired with 64-slice MDCT.

64-slice CT
Recently, 64 slice scanners have been introduced. What
advantages have they brought about? Clinically, the
improvements that can be attributed to the development of
64-slice scanners are very obvious. Increased gantry rotation
speed (now 330 ms) with higher temporal resolution makes
it easier to acquire images free of motion artifacts (even
though in most cases, lowering the heart rate is still
advised). The fact that data are acquired in 64 slices within
each rotation provides for coverage of the complete volume
of the heart in 912 seconds or less. This has proven to be a
tremendous clinical advantage breath holds of that duration are truly easy to perform for almost any patient, and the
amount of contrast agent needed can be decreased to less
than 60 ml. An especially important improvement is the fact
that the acquired data sets now provide practically isotropic
spatial resolution the ability to visualize small structures

[ Table 1 ]

Sensitivities and Specificities for the detection of coronary artery


stenoses by 64-slice MDCT in comparison to invasive coronary angiography
Author

Publication

Number of patients

Sensitivity

Leschka et al [5]

Eur Heart J 2005

67

94%

97%

Leber et al [6]

JACC 2005

59

87%*

91%*

Raff et al [7]

JACC 2005

70

86%+/91%++

95%+/92%++

*5 of 6 lesions that required revascularization were detected by MDCT


+

46

Per-segment analysis

++

SOMATOM Sessions 17

Per-artery analysis

Specificity

SCIENCE

within the coronary arteries in the axial imaging plane and in


reformatted images orthogonal to the axial plane is equally
high [Fig. 1]. This brings about a substantial improvement
and facilitation of postprocessing to assess the coronary
artery lumen in small vessels and at sites with coronary calcifications (potentially, also coronary stents). The first published studies that verified 64-slice MDCT against invasive
coronary angiography have confirmed the high diagnostic
accuracy of 64-slice MDCT in detecting coronary artery
stenoses in patients with various clinical presentations [Fig.
2, Table] [68]. Based on the experience that could be gathered so far, it can be expected that coronary artery visualization by CT will find a clinical role in certain subsets of symptomatic patients who require workup for coronary artery
disease. High negative predictive values (97%99%) observed
throughout all recent studies [18] make applications in the
context of ruling out coronary stenoses especially promising.

2A

2B

Future Developments
What future developments would translate into clinical advantages for coronary imaging? Clearly, simply adding more slices
will not solve the remaining problems. The only advantage
would be a decreased overall scan time, which, however, is no
longer an obstacle of any significance. Further decreasing slice
collimation would require a parallel, disproportionate increase
in x-ray tube current and radiation exposure to avoid excessive
image noise. The most desirable improvement would therefore be an increase in true temporal resolution, as it is possible
with the new Dual Source CT technology. This will make image
quality even more stable and predictable and will potentially
obviate the need to use medication in order to lower the
patients heart rate in preparation for the scan. Cardiac CT
scans are even easier to perform. Potentially, higher temporal
resolution might even permit prospective triggering of X-ray
tube output (instead of retrospective gating of image reconstruction) and thus effectively lower radiation exposure.

1 Kuettner A, Beck T, Drosch T, Kettering K, Heuschmid M, Burgstahler C,


Claussen CD, Kopp AF, Schroeder S. Image quality and diagnostic accuracy
of non-invasive coronary imaging with 16-detector slice spiral computed
tomography with 188 ms temporal resolution. Heart 2005; 91: 938941
2 Mollet NR, Cademartiri F, Krestin GP, McFadden EP, Arampatzis CA, Serruys
PW, de Feyter PJ. Improved diagnostic accuracy with 16-row multi-slice computed
tomography coronary angiography. J Am Coll Cardiol 2005; 45: 128132
3 Morgan-Hughes GJ, Roobottom CA, Owens PE, Marshall AJ. Highly accurate
coronary angiography with submillimetre, 16 slice computed tomography.
Heart 2005; 91: 308313
4 Hoffmann MHK, Shi H, Schmitz BL, Schmid FT, Lieberknecht M, Schulze
R, Ludwig B, Kroschel U, Jahnke N, Haerer W, Brambs HJ, Aschoff AJ.
Noninvasive coronary angiography with multislice computed tomography.
JAMA 2005; 293: 24712478

2C

[ 2 ] Stenosis of the left


anterior descending coronary
artery visualized by
64-slice MDCT.
[ A ] 5 mm maximum intensity projection in axial orientation shows the lumen
narrowing at the ostium of
the left anterior descending
coronary artery (large
arrow). A small intermediate
branch (*) and even the origin of the sinuatrial nodal
artery from the proximal left
circumflex coronary artery
(small arrow) can be appreciated.
[ B ] 3-dimensional reconstruction of the heart and
coronary arteries shows the
proximal stenosis of the left
anterior descending coronary artery (arrow). The left
atrium has been removed to
provide unobstructed view
on the left main bifurcation.
[ C ] The corresponding invasive coronary angiogram
confirms the stenosis
(arrow).

In summary, the development and clinical introduction of


64-slice MDCT has substantially enhanced clinical applicability, image quality, and accuracy of CT coronary angiography.
Isotropic spatial resolution has been found to greatly facilitate image evaluation. Further improvements are expected
from increased temporal resolution available with the new
Dual Source CT technology.

5 Achenbach S, Ropers D, Pohle FK, Raaz D, von Erffa J, Yilmaz A, Muschiol G,


Daniel WG. Detection of coronary artery stenoses using multi-detector CT with
16x0.75 mm collimation and 375 ms rotation. Eur Heart J 2005; Epub May 27, 2005

6 Leschka S, Alkadhi H, Plass A, Desbiolles L, Grnenfelder J, Marincek B,


Wildermuth S. Accuracy of MSCT coronary angiography with 64-slice technology: first experience; Eur Heart J 2005; 26: 14821487
7 Leber AW, Knez A, von Ziegler F, Becker A, Nikolaou K, Paul S, Wintersperger B, Reiser M, Becker CR, Steinbeck G, Boekstegers P. Quantification of
obstructive and nonobstructive coronary lesions by 64-slice computed
tomography. A comparative study with quantitative coronary angiography
and intravascular ultrasound. J Am Coll Cardiol 2005; 46: 147154
8 Raff GJ, Gallagher MJ, ONeill WW, Goldstein JA. Diagnostic accuracy
of noninvasive angiography using 64-slice spiral computed tomography.
J Am Coll Cardiol 2005; 46: 552557

SOMATOM Sessions 17

47

NEWS SECTION
CUSTOMER
CARE

S O M AT O M U S E R S M E E T I N G B R A Z I L

Customer Event
Aiming at partnership and exchange of
information among magnetic resonance
(MR), computed tomography (CT) and
molecular imaging (MI) users at MERCOSUR (Argentina, Bolivia, Brazil, Chile,
Paraguay and Uruguay), Siemens Medical
Solutions organized the second regional
users meeting in Brazil. 170 Siemens
users, among them nuclear physicians,

radiologists, neurologists and cardiologists, discussed clinical trends, and


shared experiences, studies and researches. The program included discussions on the use of diagnostic imaging
technologies in neurology; orthopedic;
oncology and screening; cardiovascular
examinations. Among the speakers
were Ricardo Cury, MD, Massachusetts

Brazilian Ricardo Cury, MD, introduced a study


on coronary CTA conducted at Massachusetts
General Hospital, Harvard Medical School.
General Hospital, Harvard Medical
School, Boston, MA, USA; Rodofo
Nunez, MD, Anderson Cancer Center
Houston, TX, USA; Henrik Michaelly,
MD, California University, Los Angeles,
CA, USA; and Carsten Figge, MD, Bad
Wildungen, Germany.

WO R KI N G WITH TH E EXPE RTS I N H O N G - KO N G

Cardiac CT Live Case Workshop


230 cardiologists, radiologists and referring physicians from Hong-Kong and the
neighboring countries participated in the
first 64-slice, cardiac Computed Tomography (CT) workshop at Sir Run Run Shaw
Heart Center at St. Teresas Hospital. The
clinic had installed Hong-Kong's first 64slice CT, a SOMATOM Sensation system,
last fall.
Seven cardiac CT examinations were
broadcast live. A panel board, moderated
by the head of the department and superintendent of the hospital, Dr. CM Wong,

and consisting of affiliated cardiologists


from the center as well as Stefan Achenbach, MD, Department of Internal Medicine II, University of Erlangen-Nuremberg, Germany, evaluated the cases on
the spot. Five patients were transferred to
the cathlab immediately, three to magnetic resonance imaging both departments utilizing Siemens state-of-the-art
equipment and technology.
Participants were impressed by noninvasive cardiac CT and the results delivered by the system. Image quality from

calcified lesions and stents was outstanding. Cardiologists, who had never been
in touch with cardiac CT before, are
now convinced of the robustness of the
new technology. Participants from other
SOMATOM Sensation 64-slice sites highly
appreciated the teaching aspect and the
hands-on session on the new CT workstations featuring syngo Circulation.
k www.sth.org.hk/e/index.html

S O M AT O M U S E R S M E E T I N G I N D I A

First High-end Users Meeting


The first SOMATOM Users Meeting in
India was held in Mumbai at the picturesque Hotel Renaissance overlooking
Konstantin
Nikolaou, MD,
elucidates on
the journey
from 16 to
64 slices.

48

SOMATOM Sessions 17

the Powai Lake. The event was attended by 110 radiologists and computed tomography (CT) technologists.
Recently, the interest in 64-slice CT in
India has increased dramatically and
more than ten Siemens 64-slice scanners have been installed in 2005.
International speakers were Konstantin Nikolaou, MD, University Hospital
Munich Grosshadern, Germany, and
a delegation from Siemens Medical
Solutions, CT Division, Germany. Invitees witnessed the power of SOMATOM

Sensation and the magic of z-Sharp


Technology at work. Bernd Ohnesorge,
PhD, Vice President CT Marketing and
Sales, delivered the keynote address
on 30 Years of Siemens CT and
Beyond, and Dr. Nikolaou spoke on
Advances in Cardiovascular and Body
Imaging. Further highlights were fabulous displays of coronary imaging techniques. The new syngo Circulation
package for cardiac imaging was met
with great enthusiasm and much positive comment.

CUSTOMER
NEWS SECTION
CARE

L i f e : E D U C AT E

Free CME-Credited CD-Set


Siemens Medical Solutions Computed
Tomography (CT) Division has captured
the 7th SOMATOM CT Users Conference
2005, held in Rome, Italy, on CD. The
complete package of six CDs is approved
for AMA PRA Category 1 credit through
Johns Hopkins University, School of
Medicine, and is ready to order free of
charge.
Physicians can benefit from 46 outstanding presentations given by an international faculty of leading experts.
Topics such as Technology Principles of
Multislice CT, Head and Neck CT,
Chest CT, Cardiac CT, Abdominal CT,
Vascular CT, and New Frontiers in CT
are covered. Live case demonstrations
of high-end clinical CT applications in
combination with case interpretations
are included as well. Professor Roberto

Passariello, MD, head of the Department


of Radiologic Sciences, acted as chairman of the conference, supported by
Carlo Catalano, MD, Associate Professor
at the same department (both University Hospital La Sapienza, Rome, Italy).
Professor Elliot Fishman, MD, Johns
Hopkins Hospital, Baltimore, MD, USA,
and Professor Yutaka Imai, MD, Tokai
University, Tokyo, Japan, were co-chairmen.
Customers benefit from Siemens clinical e-learning opportunities as part of
the SOMATOM Educate program within
Life and experience the latest clinical
results in the various fields of CT imaging. A preview of the CD is provided
in Siemens CT User Lounges at
www.siemens.com/SOMATOMWorld.
To obtain a free CD package, please send

SERVICE

Frequently Asked Questions


Via the SOMATOM World User Lounges, Siemens applications specialists answer your questions on how to easily
use Siemens Computed Tomography scanners and applications in daily clinical practice. Additionally, SOMATOM Sessions offers a regular column with frequently asked questions for offline reference.
How do I get reference lines on the topogram after the
exam has been closed?
Open the Patient Browser and double click on the patient's
raw data in the browser to reload the study into the examination card. With the topogram in the upper left segment of
the examination card, drag and drop the chronicle bar to be
posted onto the topogram in the image segment. Last,
select patient and save image. A new image of the
topogram with reference lines can be seen in the Patient
Browser.

A CME-credited set of six CDs is


available from the 7th SOMATOM
CT User Conference 2005.
an e-mail with your postal address to
med.somatomlife@siemens.com, subject
CD set: 7th SOMATOM CT User Conference 2005.

k www.siemens.com/SOMATOMEducate
k www.siemens.com/SOMATOMWorld
k www.ctisus.org

How can I save a list and/or print a copy of the scan protocols on the system?
On systems running VA70/VB10 software versions, this can be
accomplished by going to System->Run->List Scan Protocols.
Here you can save the list of the protocols (which includes site
specific protocols as well as Siemens default scan protocols)
onto a floppy disk. Insert floppy into A: drive, and then go to
File->Save As, and make sure the 3 _ floppy (A:) drive is selected at the dropdown in Save In field. Click Save to put a copy of
this protocol list to the floppy. Wait until the drive has stopped
activity to remove floppy. You can also print using Print at the
top of the platform if you have a network printer connected to
system. On systems starting with VA47/VA70, it is necessary to
press the <Ctrl> key and the <N> key together to get a second
window that has the command dropdowns at the top of it,
then accomplish the tasks above. In syngo CT 2006 A/G, this
function is in the Main Menu of the Scan Protocol Manager
(Options->Configuration) under View List. Close the List and
the Scan Protocol Manager, and open the File Browser
(Options->File Browser). You will find the html-file in the folder
H:\SiteData\offline.

SOMATOM Sessions 17

49

CUSTOMER CARE

C T ONLINE

CT News on the Web


k www.siemens.com/DualSource
This new microsite introduces the latest CT technology the
SOMATOM Definition and its trend-setting Dual Source concept. An intro movie and a 3D model lead to explanations of
the SOMATOM Definitions technical design and functionality. The system and its clinical outcomes are compared to
conventional CT technology. Also available are media information, event reviews and animations. An interactive presentation of the SOMATOM Definition and its application
area enhance the website.

k www.siemens.com/medicalnews
Siemens Computed Tomography (CT) Division has expanded
its customer information service, and started the Siemens
Medical CT Newsletter. The regular e-newsletter includes a
highlight article either on a business, clinical outcomes, science or customer care topic, as well as the latest information
on upcoming Siemens CT courses, answers to frequently
asked questions plus a section with tricks and tips on how to
efficiently use Siemens CT scanners and applications in
daily clinical practice. Customers can either subscribe via the
above link, or with the postcard attached to the back cover
of this issue of SOMATOM Sessions.

Upcoming Events & Courses


Title

Location

Description

Date

Contact

4th International
Multislice CT
Symposium

GarmischPartenkirchen,
Germany

Scientific talks and lectures

Jan.1821, 2006

www.ct2006.org

Arab Health

Dubai, UAE

Exhibition and Congress

Jan. 2225, 2006

www.arabhealthonline.com

22nd Annual
Computed Body
Tomography 2006:
The Cutting Edge

Orlando, USA

CME Course

Feb.1619, 2006

www.ctisus.com

ECR

Vienna, Austria

Congress

March 37, 2006

www.ecr.org

ACC

Atlanta, USA

Annual Scientific Session


and Exposition

March 1114, 2006

www.acc.org

The Charleston Course: Charleston,


Cardiovascular Imaging South Carolina

Scientific talks
and lectures

March 2023, 2006

www.ryalsmeet.com/

Advanced Topics
in CT Scanning

Las Vegas, USA

3D, CT Angiography, and


Virtual Imaging; CME Course

March 2427, 2006

www.ctisus.com

Advanced Topics
in CT Scanning

Baltimore, USA

3D, CT Angiography, and


Virtual Imaging; CME Course

March 31April 2, 2006 www.ctisus.com

ITEM

Yokohama, Japan

Trade fair

April 79, 2006

www.j-rc.org

Deutsche Gesellschaft fr Kardiologie

Mannheim,
Germany

72. Jahrestagung

April 2022, 2006

www.dgk.org

Deutscher
Rntgenkongress

Berlin, Germany

Kongress und Industrieforum

May 2427, 2006

www.drg.de

Stanford Symposium

San Francisco, USA

8th Annual International Symposium on Multidetector-Row CT

June 1417, 2006

radiologycme.stanford.edu

Society of Cardiovascular CT

Washington, DC, USA 1st Annual Scientific Meeting in cooperation with the 7th International Conference on Cardiac CT

July 1316, 2006

www.scct.org

Advanced Topics
in Multidetector
CT Scanning

Cruise to the
Mediterranean

July 29Aug. 5, 2006

www.ctisus.com

CME Course

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

50

SOMATOM Sessions 17

CUSTOMER CARE

SOMATOM SESSIONS IMPRINT


2005 by Siemens AG, Berlin and Munich, All rights reserved
Publisher
Siemens AG
Medical Solutions
Computed Tomography Division
Siemensstrae 1
D-91301 Forchheim
Responsible for Contents:
Bernd Ohnesorge, PhD
Editors
Doris Pischitz, M.A.
(doris.pischitz@siemens.com)
Stefan Wnsch, PhD
(stefan.wuensch@siemens.com)
Editorial Board
Joachim Buck, PhD
Thomas Flohr, PhD
Chad DeGraaff
Andr Hartung, MD
Julia Kern-Stoll
Matthew Manuel
Louise McKenna, PhD, MBA
Axel Lorz
Nicole Reyher
Jens Scharnagl
Authors of this Issue
S. Achenbach, MD,
Department of Internal Medicine II,
University of Erlangen, Germany
C. R. Becker, MD,
Department of Clinical Radiology,
University Hospital Grosshadern,
Munich, Germany
U. Baum, MD,
Institute of Radiology,
University Erlangen, Germany

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

G. Mhlenbruch, MD,
Department of Diagnostic Radiology,
RWTH University Aachen, Germany

J. Debus, MD, PhD,


Department of Radiation Oncology,
University of Heidelberg, Germany

E. Nkenke, MD,
Department of Maxillofacial Surgery,
University Erlangen, Germany

J.-B. D'Harcour, MD,


Cliniques du Sud-Luxembourg,
site St Joseph, Arlon, Belgium

B. F. Tomandl, MD,
Department of Neuroradiology,
Klinikum Bremen, Germany

J. Dinkel, MD,
Department of Radiation Oncology,
University of Heidelberg, Germany

J. E. Wildberger, MD,
Department of Diagnostic Radiology,
RWTH University Aachen, Germany

A. Graser, MD,
Department of Clinical Radiology,
University Hospital Grosshadern,
Munich, Germany

Cathrine Carrington, medical editor


Tony De Lisa, freelance author

R. W. Gnther, MD,
Department of Diagnostic Radiology,
RWTH University Aachen, Germany
A. Jensen, MD,
Department of Radiation Oncology,
University of Heidelberg, Germany
T. Kraus, MD
Department of Occupational Health,
RWTH University Aachen, Germany
M. Lell, MD,
Institute of Radiology,
University Erlangen, Germany
A. H. Mahnken, MD,
Department of Diagnostic Radiology,
RWTH University Aachen, Germany
U. Mende, MD, PhD,
Department of Radiation Oncology,
University of Heidelberg, Germany

Note in accordance with 33 Para.1 of the German Federal Data Protection


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

Gumurkh Advani; Jessica Amberg; Axel Barth, Karin


Barthel; Dagmar Birk; Joachim Buck, PhD; Chad
DeGraaff; Ana Paula Pieroni De Menezes; Hendrik
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