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No 19/November 2006

RSNA-Edition
Nov. 26th Dec. 1st, 2006

10.00

www.siemens.com/medical

Highlights
COVER STORY
syngo WebSpace: Leading
the Workflow Revolution in
Volume CT
Page 4
Two: The New
Arithmetic of CT
Page 8
NEWS
Clinically Proven: The
Benefit of syngo Lung CAD
Now PMA Approved
Page 12
BUSINESS
Life in the Global Village:
A Dialogue With
Prof. Michael Knopp, MD
Page 15
CLINICAL OUTCOMES
Oncology Improved Follow
up For Pulmonary Nodules
Page 22
Acute Care NEW: Comprehensive 3D Stroke Imaging
Page 26
SCIENCE
See the Whole Disease:
Neuro Perfused Blood
Volume Imaging
Page 32
EDUCATION & EVENTS
The Worlds First
SOMATOM Definition
Workshop
Page 35

SOMATOM
Sessions

EDITORS LETTER

Andr Hartung,
Vice President Marketing
and Sales

Dear Reader,
In recent years, developments in the computed tomography (CT) field have accelerated with
breath-taking speed and have radically improved medical imaging. Siemens was able to make a
decisive contribution to this fascinating, quantum leap in CT development. Our success is based
upon a simple principle: cooperation with the best clinical experts. We are proud to say that we
have for years maintained professional contacts to experts from around the world. From the very
earliest stages of research, product development and design, Siemens relies upon the advice and
recommendations of external medical experts to determine our focus and this focus has been on
the needs and demands of the end users. In this way, our products have been able to make a significant difference for our customers.
Our newest innovations underscore the clinical advantages of our products: The Dual Source CT
SOMATOM Definition completely eliminates the need for beta-blockers to reduce heartbeat
frequency during CT heart examinations. Image quality and speed remain outstanding under these
conditions, including emergency room and obese patients. The first clinical installations utilizing
our Dual Source CTs with two x-ray sources and two detectors permitting imaging at two different
energy levels simultaneously are already in use. And the previously difficult challenge of quickly
and efficiently managing large volumes of high-resolution images and making these images
available wherever you are has been elegantly solved with syngo WebSpace software. Efficient 3D
CT post-processing from remote computer around the world is now a reality. (For more information, see our Cover Stories). The intelligent interaction and high-performance post-processing of
diagnostic information has become increasingly more important in daily clinical routine.
The medical profession has hardly begun to utilize the full potential of computed tomography and,
as usual, Siemens is taking the lead. In teamwork with our internal and external experts, all things
are possible. And making the difference for you, our customers, is our passion!
Enjoy reading

Andr Hartung, Vice President Marketing and Sales

Cover Page: Real-time, spiral dual energy volume rendering technique (VRT) of a head and neck CTA shows
the precise cerebral vasculature status. Kindly provided by the University of Munich, Grosshadern, Germany.

SOMATOM Sessions 19

CONTENT

COVER STORY
4

syngo WebSpace: Leading the Workflow Revolution in Volume CT

Two: The New Arithmetic of CT

NEWS
12

Clinically Proven: The Benefit of syngo Lung CAD Now PMA Approved

14

The Results Are Ready When You Are

14

Improving Financial and Operational Outcomes With Utilization Management

BUSINESS
15

Life in the Global Village: A Dialogue With Prof. Michael Knopp, MD

19

Quality, Valuability and Flexibility

CLINICAL OUTCOMES
20

Cardiovascular: Improved Workflow and Speed Combining


SOMATOM Definition & AXIOM Artis dFC

22

Oncology: Improved Follow up For Pulmonary Nodules With syngo LungCARE


and syngo Lung CAD

24

Neurology: Child 11 Months: Visualization of a Choroid Plexus Papilloma

26

Acute Care: NEW Comprehensive 3D Stroke Imaging With syngo Neuro PBV

SCIENCE
28

CARE Dose4D: New Technique for Radiation Dose Reduction

32

See the Whole Disease: Neuro Perfused Blood Volume Imaging

EDUCATION & EVENTS


35

The Worlds First SOMATOM Definition Workshop

36

Continuous Updates in SOMATOM LifeNet

37

New Course Selector

37

Frequently Asked Questions

38

Efficient Tools to Explore New Clinical Opportunities

38

Upcoming Events and Courses

39

Imprint

SOMATOM Sessions 19

COVER STORY

syngo WebSpace:
Leading the Workflow
Revolution in Volume CT
Until now, the potential of volume CT imaging for diagnosis and treatment
has been limited due to workstation accessibility issues. But syngo WebSpace,
a new server / thin client technology, is rapidly meeting this challenge and
making access to 3D data available from everywhere*. SOMATOM Sessions
Tim Friend talked with Prof. Elliot Fishman about the workflow implications
of this new technology.

Elliot Fishman, MD, Professor of Radiology and Oncology, Johns Hopkins Medical Institutions, Baltimore, Maryland.

SOMATOM Sessions 19

COVER STORY

By Tim Friend
The most extraordinary feature of syngo WebSpace is how
ordinary it appears.
As I look on, Elliot Fishman, MD, Professor of Radiology and
Oncology at the Johns Hopkins Medical Institutions in Baltimore, chooses a desktop computer at random in an empty
cubicle across the hall from his office. He accesses Internet
Explorer and, with a brief flash of keystrokes, downloads a
syngo WebSpace client onto the computers hard drive. After
about a minute, a new icon appears on the desktop screen.
The program is loaded and ready to run.
Fishman clicks on the icon, which accesses the Internet and
connects to a server. Up pops a menu of patients who have
undergone CT scanning in the radiology department. One
more mouse click, and the screen displays a 3D state-ofthe-art CT image of a heart. The way someone might rev the
engine to display the power of a new Ferrari, he spins the
heart and manipulates the dramatically detailed image to
display the speed at which syngo WebSpace is able to operate
over a typical broadband internet connection.
A naive bystander would not realize what has just occurred.
But physicians accustomed to using a PACS workstation for
two-dimensional images and having to wait in line to log
onto a separate workstation for access to three-dimensional
images would immediately stop in their tracks and know they
were witnessing something remarkable and brand new.

Harnessing the Power of the


Internet for CT
Until now, the state of the art for Siemens Medical Solutions
has been syngo InSpace4DTM software for volume visualization of images made with Siemens scanners using the Multi
Modality Workplace (MMWP). syngo InSpace, which became
available in 2003, aided the paradigm shift from axial images
to volume images, Fishman says. With true volume imaging,
physicians began to realize the value of diagnostic and treatment information contained in such massive data sets. syngo
InSpace4D can remain state of the art for Siemens Medical
Solutions, but access is limited to dedicated workstations.

Elliot Fishman concentrating on the syngo WebSpace screen.

Everything we could do on that


workstation at a fixed location, we can
now do anywhere*, anytime.
What that means in practical terms
is that syngo WebSpace is making 3D
data practical for the common man.
Elliot Fishman, MD, Professor of Radiology and Oncology,
Johns Hopkins Medical Institutions, Baltimore, Maryland

What Fishman has just demonstrated with syngo WebSpace


is the beginning of a revolution that will make the clinical use
of 3D and 4D medical diagnostic CT imaging as common and
routine as logging onto the internet.
WebSpace is sort of like InSpace on steroids, says Fishman.
Everything we could do on that workstation on the MMWP
at a fixed location, we can now do anywhere, anytime.
What that means in practical terms is that syngo WebSpace is
making 3D data practical for the common man.
syngo WebSpace resolves one of the most important challenges to the broader clinical use of volume images today:
limited access to workstations. This has been the primary
bottleneck of workflow in the radiology departments of most
major medical centers. The bottleneck arose as demand for
volume imaging dramatically increased in recent years.
In the past, when no one really thought of 3D or post-processing as a critical part of CT, it wasnt so much of an issue,
explains Fishman. No one was clamoring for the information,
so there was no urgency to use the workstation. As someone

SOMATOM Sessions 19

COVER STORY

syngo WebSpace takes


a process that is really good
and really critical, which
is 3D post-processing, and
makes it available everywhere* so that it pushes
the process throughout
the enterprise.
syngo WebSpace allows fast examination of clinical images wherever you are.

who has taught 3D courses for ten years with Siemens, one
of the things we discovered was that, back in the beginning,
people would say, This 3D stuff is okay, but Im probably not
going to do it. Then, after a few years, people started saying
Well, its interesting. Ill have to keep my eye on it. Finally,
three to four years ago, with 16-slice CT, the real change
began, and people were saying, This 3D stuff is something I
probably should do. I noticed a big difference last year at the
64-slice level courses. Suddenly I was hearing, I agree with
you, we have to do it. The problem is, we cant do it, because
there are twenty people in my group and we only have one
workstation. Its not part of our workflow. We cant get to the
system. The system is down the hall from the scanner. Yes we
agree with you that this is a valuable tool, but how do we do
workflow? Thats really what syngo WebSpace does answer.

Movie Magic for Medical Applications


Back in Fishmans office, which is crowded with files of
thousands of antique hard-copy images, he outlines the
evolution of CT in recent history. He was instrumental in
developing 3D medical imaging in the early 1980s working
with animation legends Lucas Films and Pixar to adopt moviemagic computer graphics technology for medical applications.
As the software was being developed for medical imaging,
he began collaborating with Siemens.

SOMATOM Sessions 19

Elliot Fishman, MD, Professor of


Radiology and Oncology, Johns Hopkins
Medical Institutions, Baltimore, Maryland

At Hopkins, weve been Siemens users for more than twenty years. Weve been involved in CT and using Siemens scanners since 1982. Weve seen the technology change from the
DR3 scanner through single-slice spirals, through 4-slice spirals, through 16 to 64 slices, to literally the new Dual Source
CT, SOMATOM Definition, which is being installed at Hopkins
and expected to be operational within two weeks, Fishman
says. From the beginning, one of the things we have viewed
differently from many of our colleagues elsewhere is that CT
is more than slices. CT is volumes of data, and the best way
to get information from the CT scan was to use the volume
rather than the slices. Weve always been involved with
development and working with Siemens on workstations for
visualization. So whether it was with 3D Virtuoso or currently
with the MMWP and syngo InSpace4D, our concept was
always that CT is volume visualization. CT has gone from a
study of an abdomen lets say that was 30 slices to 100
slices
to 300 and now to thousands of slices. Because of those
capabilities, our abilities have changed over time. Yes, we have
always looked at the pancreas and the liver and lungs with CT,
but now we can do it better than ever more accurately
with higher sensitivity and higher specificity. Because of all
these important changes, we have been able to develop
new applications, from CT angiography to virtual bron-

COVER STORY

choscopy to virtual colonoscopy. The common theme that


everything has had is that you needed to look at information
as a volume. The development of powerful workstations
able to handle the amount of data generated by 16- and
64-slice CT scanners made physicians realize the potential
for diagnosing and treating diseases in their patients. They
started wanting more. But the new popularity also created
the workflow bottleneck. Over the past six months, Fishman,
together with other experts and Siemens Medical Solutions,
has collaborated to overcome this latest challenge. syngo
WebSpace is the result of that collaboration.

Anytime, Anywhere* Access


Speeds Workflow
A syngo WebSpace server receives information from scanners
in a radiology department instantly. With high-speed Internet
connections, anyone can log onto the syngo WebSpace
system and use their PC or laptop** just like a MMWP. After
spinning the 3D heart in his syngo WebSpace demonstration
via the Internet, Fishman notes that he perceives virtually no
difference in speed compared with the MMWP.
Initially, Siemens has created syngo WebSpace systems that
can accommodate five, ten or twenty simultaneous users.
But Fishman expects demand to increase rapidly. He says in
the past, busy physicians wouldnt bother coming to the radiology department to look at the volume images. It was simply
a question of time trips to other floors or buildings on a
large hospital campus were impractical. But now, physicians
can log onto the internet, download the syngo WebSpace
program one time, and use the system whenever it is convenient. Surgeons may even use the system while operating.
Radiologists can have access to all of their volume data at
their homes with a broadband internet connection. The new

applications are limitless. Fishman says syngo WebSpace will


reshape medical education as well. Currently, students, residents and fellows can view volume images during conferences
rather than look at static two-dimensional pictures. He also
sees syngo WebSpace as attractive to referring physicians.
Hospitals can offer access to such remarkable CT data to
physicians in their own offices. They can view studies of their
patients via syngo WebSpace within minutes of the images
being taken at a radiology unit. Physicians also may find the
service helpful during office visits to discuss diagnosis and
treatment plans with their patients.
Clearly, all roads with syngo WebSpace lead to everyday
practical use of the most advanced CT imaging information.
syngo WebSpace takes a process that is really good and really
critical, which is 3D post-processing, and just makes it available
everywhere so that it pushes the process throughout the
enterprise, says Fishman. The result is better patient care,
more efficient care, and better management of patients,
because it puts much more information into the hands of the
clinician quickly and easily.
Author: Tim Friend, a USA Today reporter for 17 years, is now a
freelance science and medical writer based in Alexandria, VA. He is
the author of Animal Talk: Breaking the Codes of Animal Language,
and has just finished a second book on the discovery of a new life form
on earth.
*internet connection required
**PC or laptop must meet minimum specifications

k www.siemens.com/syngo-WebSpace

The result is better patient care,


more efficient care, and better
management of patients, because
it puts much more information
into the hands of the clinician
quickly and easily.
Elliot Fishman, MD, Professor of Radiology and Oncology,
Johns Hopkins Medical Institutions, Baltimore, Maryland

Johns Hopkins Medical Institutions, Baltimore, Maryland.

SOMATOM Sessions 19

COVER STORY

Two: The New


Arithmetic of CT
Two sources, two detectors and the ability to operate two X-ray tubes at
different energy levels: These features of Dual Source Computed Tomography
have opened the way to a broad range of new applications.
By Hildegard Kaulen, PhD

Andreas H. Mahnken, MD, MBA, Senior Physician at the Clinic


for Diagnostic Radiology at the Aachen University Hospital,
Germany, knows what he wants. Integrated into the daily
routine of a major hospital, the radiologist is familiar with the
questions posed to him on a daily basis. How severe is the
stenosis? After therapy, is the tumor still vital? Are the ligaments still intact after the knee fracture? What fluids can be

detected: blood, abscess, ascites? Previously, many of these


questions could not be answered completely using computed
tomography. But Mahnken particularly values this modality.
CT is fast, robust, and requires almost no waiting time.
By increasing the number of detector rows, previous CT
developments dramatically increased the speed of acquisitions. However, he says, these days, acquisition speed is no
longer an issue. A further increase of slices would not help gain
the additional information required to improve diagnoses.
Since the introduction of the SOMATOM Definition, Mahnken
is not only convinced that the worlds first Dual Source CT
improves patient care by making non-invasive, cardiac CT
diagnosis routinely accessible for all patients, but also that
the new technology opens the door beyond simple visualization of Hounsfield values. Dual Source CT is not only an
excellent diagnostic device for daily routine exams, it is also
an interesting tool to discover completely new clinical applications. Mahnken has been working with the SOMATOM
Definition since May 2006.
In normal mode, for example both X-ray tubes run at the
same energy level, acquisition time is cut in half. The result: a
heart-rate independent temporal resolution of 83 ms that
eliminates the need for -blockers and reduces radiation
exposure in cardiac CT.

Dual energy provides


information that extends beyond
the actual imaging.
Andreas Mahnken considers utilizing xenon
as a contrast medium in ventilation studies.

SOMATOM Sessions 19

Andreas Mahnken, MD, MBA,


Senior Physician, Clinic for Diagnostic Radiology,
Aachen University Hospital, Aachen, Germany

COVER STORY

The Principle of Dual Energy

80 kV
Attenuation B

140 kV
Attenuation A

SOMATOM Definition permits the use of two


sources simultaneously at different kilovoltage
(kV) levels. This offers the possibility to acquire
two data sets simultaneously from a single
spiral scan, running the tubes at two energy
levels.
The X-ray tubes kV determines the average
energy level of the X-ray beam. Changing the
kV setting results in an alteration of photon
energy and a corresponding attenuation modification of the materials scanned. In other words,
X-ray absorption is energy-dependent, for
example, scanning an object with 80 kV results
in a different attenuation than with 140 kV.
Most important, this attenuation depends on
the type of tissue scanned.
syngo Dual Energy uses two X-ray sources
running at different energy levels and acquiring
two data sets of diverse information, which
allows to differentiate, characterize, isolate, and
distinguish the imaged tissue and material to
obtain specific details about the scanned object
beyond morphology.

Contrast Scans
In dual energy mode, on the other hand, each tube uses a
different X-ray energy. We are currently exploring the full
benefits of spiral dual energy, says Mahnken. When scanning an anatomical structure at 80 kV, one obtains a different
attenuation than that obtained at 140 kV. This provides information that extends beyond the actual imaging. syngo Dual
Energy should provide us with a new look at clinical questions.
For the first time, we are able to reliably separate cartilage
from tendons in a CT image. This is truly amazing. Dual energy
broadens the application spectrum we know from computed
tomography. The new technology also helps in the visualization of the hot problems of CT, the differentiation between
hard plaques and contrast agents. We can now display the
true vessel lumen without interfering plaques. A convincing
example of how important dual energy will be in everybodys
daily Radiology work.

Mahnken, who completed two years of training in healthcare management, knows how to calculate costs and sees
another advantage of syngo Dual Energy in the area of noncontrast scans. By using the X-ray tubes at two energy levels,
the contrast medium can be masked. Previously, two scans
were required to achieve this. We now perform only a single,
contrast enhanced, spiral dual energy scan, says Mahnken.
This provides two advantages: On the one hand, we can
subtract the contrast medium out of the images, avoiding
the non-enhanced examination and saving the corresponding radiation exposure. The resulting dual energy image
helps, on the other hand, to reliably characterize liver and
kidney lesions. Now, we can, for example, quickly differentiate between contrast enhanced and hypo-lipid areas, and
immediately identify possible tumors. In addition, through
distribution of the iodine, we also obtain information on
perfusion, which in turn provides a visualization of the vitality
SOMATOM Sessions 19

COVER STORY

Additional Voices: Christoph Becker, MD


Christoph Becker, MD, Section Chief CT at the Institute
for Diagnostic Radiology at Grosshadern University
Hospital in Munich, Germany:
SOMATOM Definitions breathtaking image quality
enables us to access completely new clinical applications,
setting new benchmarks in CT. In particular, the use of
syngo Dual Energy paves the way for a broad spectrum of
potential clinical uses, one of the most significant technology shifts since the introduction of Multislice CT. A very
promising application field is syngo Dual Energy Direct
Angio, the accurate subtraction of bone in CTAs even in

[ 1 ] Real-time, spiral dual energy volume


rendering technique (VRT)of a head and neck CTA
shows the precise cerebral vasculature status.

10

SOMATOM Sessions 19

complicated anatomical regions. Overcoming limitations


of conventional bone removal software, the dual energy
approach reliably isolates even complex vasculature, for
example, at the base of the skull where CTAs are difficult to
interpret. To quickly and without manual post processing
steps, see a narrowing in the carotid artery without the
skull blocking the view helps us to increase our diagnostic
efficiency. Another dual energy application we often perform is the evaluation of lung perfusion defects. A spiral
dual energy scan allows direct visualization of the local
iodine concentration in the lung parenchyma, clearly displaying the area of possibly affected tissue.

[ 2 ] The corresponding dual energy maximum


intensity projection (MIP) enables immediate ruleout of aneurysms or sub-arachnoidal-bleedings.

COVER STORY

For the first time, we are able to reliably


separate cartilage from tendons in a CT image.
This is truly amazing.
Andreas Mahnken, MD, MBA, Senior Physician, Clinic for Diagnostic Radiology,
Aachen University Hospital, Aachen, Germany

of the tissue. For example, if we use heat in treating a primary


liver cell carcinoma, we want to subsequently see whether
we were successful. If the tumor remains free of contrast
medium, it means that blood flow to the tumor has stopped
and it is no longer being supplied. He points to a liver scan
displayed on his monitor. This is a tumor where contrast
medium no longer deposits. We were successful with the
ablation. Mahnken always attaches great importance to
contrast medium. We currently use iodine almost exclusively.
We havent even started to consider intelligent dual energy
contrast medium. A new contrast medium that we could
consider, would be xenon, an inert gas. We could use xenon to
measure pulmonary ventilation. We have some experience
using this gas in anesthesiology, and know it is not harmful
to patients. Why shouldnt it be used as a contrast medium
for dual energy? Iodine for pulmonary perfusion, xenon for
ventilation that would produce a complete pulmonary
diagnostic evaluation.

Further Perspectives
Mahnken also sees potential for syngo Dual Energy in
characterizing body fluids. We are just at the very beginning
in this area. It will require additional research to be able to
differentiate between blood, pus, urine, or ascites with certainty, he explains, while keeping an eye on the workflows
in the department. To date, body fluids have only been
characterized via MRI or biopsy. A spiral dual energy scan
could provide comparable results. MRI and CT would come a
step closer, without arguing over competing application
areas. It is another interesting perspective of SOMATOM
Definitions syngo Dual Energy capabilities.

Author: Hildegard Kaulen, PhD, is a molecular biologist. After


positions at Rockefeller University in New York and Harvard Medical
School in Boston, she has worked since the mid-90s as a freelance
science journalist for well-known newspapers and scientific journals.

Additional Voices:
David P. Nadich, MD
David P. Naidich, MD, Professor of Radiology and
Medicine, NYU Medical Center and School of
Medicine, New York, USA:
The introduction of the SOMATOM Definition has been
particularly exciting for our department. The utilization
of syngo Dual Energy allows the possibility of evaluating the distinct material components of the body in a
way that was previously not possible. As an example, we
recently performed a spiral dual energy examination on
a patient with a metallic stent graft within a thoracic
aortic aneurysm. Heterogeneous high attenuation areas
within this aneurysm had caused previous evaluations
for an endoleak to be particularly difficult. However, on
the current scan the generation of virtual contrast and
noncontrast maps from the dual energy data allowed
us to confidently diagnose an enhancing endoleak
tract within pre-existing high attenuation thrombus.
Whats more, we are looking into the characterization
of solitary pulmonary nodules. With these lesions of
just a few millimeters, it is currently difficult to tell
whether they are malignant or benign. It should be
easier to clarify this question by subtracting the energy
levels, which is now possible for the first time. Calcium
is also important. We want to use syngo Dual Energy to
look at these deposits and the area behind them.
Perhaps one day, people will examine calcium deposits
in the breast with spiral dual energy scan. Who knows?
I think that many new applications will come to us
by chance. Essentially, every fundamental CT development has proven itself. I expect nothing less from Dual
Source CTs syngo Dual Energy.

SOMATOM Sessions 19

11

NEWS

COMPUTER AIDED DETEC TION ( CAD )

Clinically Proven: The Benefit of syngo


Lung CAD Now PMA Approved
Siemens once again confirms its trendsetting role in the dynamically-evolving
market of CT Computer-Aided Detection
(CAD) products by integrating new
CAD features into its applications syngo
LungCARE CT and syngo Colonography
CT. The seamless integration of CAD into
the reading workflow is intended to
speed up and enhance diagnostic confidence when interpreting large datasets
with hundreds of images. This clearly
illustrates Siemens focus on comprehensive healthcare solutions.
Siemens first automated detection
product for thoracic CT exams, syngo
LungCARE NEV (Nodule Enhanced Viewing), was introduced in December 2003
and now boasts more than 500 installa-

tions worldwide. Now, Siemens' latest


FDA approved computer-aided detection
product, syngo Lung CAD, is available.1

Increased Detection
Accuracy
syngo Lung CAD is based on proprietary
image processing and pattern recognition algorithms that have been trained
on a large database of thoracic CT studies. The software is designed to assist radiologists in the detection of solid pulmonary nodules during review of multidetector computed tomography (MDCT)
examinations of the chest. syngo Lung
CAD alerts the radiologist to regions of
interest (ROI) that may have been overlooked in the initial read.

Clinically proven, syngo Lung CAD has


been validated in the largest multi-center, multi-reader study performed
to date on the use of CAD in thoracic
CT examinations. The objective was to
demonstrate the added clinical value of
CAD in helping to detect more lung nodules. Each of the nearly 200 cases was
reviewed by 17 radiologists using data
from four leading medical centers in the
U.S. The use of syngo Lung CAD as a second reader helped all participating radiologists to increase their detection accuracy for clinically significant lung
nodules. The results represent important
confirmatory evidence for the clinical use
of CAD in detecting otherwise overlooked lung nodules in MDCT studies of
the thorax, said David Naidich, MD,
Professor of Radiology and Medicine at
New York University Medical Center, and
principal investigator of the study.

Detection and Tracking


of Lung Nodules

[ 1 ] Display of growth rate of nodules in a follow up setting.

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SOMATOM Sessions 19

syngo Lung CAD detects a range of nodule sizes, starting at 3 mm in diameter. The added value for the radiologist
using syngo Lung CAD in the second
read has been shown to be at different
nodule sizes, including nodules greater
than or equal to 3 mm as well as nodules
greater than or equal to 5 mm. The automatically detected nodules cover the
full range of locations and contours and
the CAD software works equally well in
the presence or absence of intravenous
contrast.
While syngo Lung CAD provides essential
support for the detection of lung nodules, the syngo LungCARE CT application facilitates interpretation as well as

NEWS

The results represent important confirmatory evidence


for the clinical use of CAD in detecting otherwise overlooked
lung nodules in MDCT studies of the thorax.
David Naidich, MD
New York University Medical Center

[ 2 ] Automated detection of potential nodules with syngo Lung CAD (red = CAD findings).

tracking of nodules in follow-up exams. In


particular, the auto correlation and auto
segmentation tools enable monitoring of
nodules, such as, tracking nodule volume
and density changes. With this user-

friendly CAD approach, syngo Lung CAD


can be integrated into day-to-day workflow and allows not only for the identification and evaluation of lesions of interest, it also bridges diagnostic decisions

with treatment planning, says Marco


Das, MD, RWTH Aachen University.
1

Requires a syngo MultiModality Workplace


(formerly LEONARDO), with Siemens latest software release, min. syngo 2006A.

SOMATOM Sessions 19

13

NEWS

AUTO - PROCESSI N G

The Results Are Ready When You Are


Auto-processing of CT data is Siemens
latest in a stream of innovative solutions
for improved workflow in CT. With its
pre-processing technology for Oncology,
Cardiac and Acute Care imaging, Siemens
is helping radiologists to get the images
they need to make diagnostic decisions
faster and more efficient than ever before.
In the area of Oncology, data acquired
on a Siemens SOMATOM CT scanner for
both lung and colon exams is automatically processed off-line as it arrives at
the syngo MultiModality Workplace.
When the radiologist accesses the exam

data using syngo Lung CAD1 or syngo


Colonography PEV 2, potential lesions
are already marked and ready for review,
saving valuable time and enhancing
diagnostic confidence.
syngo Circulation features* new autoprocessing tools3 for cardiac and acute
care exams. Siemens new Cardio BestPhase tool automatically selects and reconstructs the best cardiac phase for image review. With the new PE Detection
application, pulmonary emboli are
marked for review and are available
when the dataset is opened. These are
tools that have the potential to save

valuable time when making time-critical


diagnostic decisions.
1

syngo Lung CAD is an option for syngo


LungCARE and must be purchased separately.
2
syngo Colonography PEV is an option for syngo
Colonography and must be purchased separately.
3
PE Detection is an option for syngo Circulation
and must be purchased separately.
*510(k) pending

Please note: PE Detection application is


work in progress and is not commercially
available in the U.S., requires syngo 2007 C.

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

Improving Financial and Operational


Outcomes With Utilization Management
number of patient exams

Utilization Management Advanced Report


Number of Patient Exams per Day
40

30

20

10

10

11

12

13

14

days

customers system
benchmark system

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SOMATOM Sessions 19

CT customers can not only measure


various parameters of their system utilization, but also compare their utilization
performance with other CT users.
Improved patient and investment planning are only two of the challenges confronting customers today. Now Siemens
offers anonymous benchmark information that is electronically available in the
form of the Utilization Management
Advanced Report. With this report customers can benchmark their CT performance with the best of their peers.
With Siemens Utilization Management
CT customers already have access to
detailed utilization data that indicate
potential for better staff planning and

system scheduling, as well as continuously monitoring examination times. Via


electronic reports Siemens Utilization
Management provides detailed information about system efficiency and utilization. The reports are accessible via a personalized internet portal and contain, for
example, the number of patient examinations and the average examination
time.

k www.siemens.com/
utilizationmanagement
This is a service of Life
our customer care solution

BUSINESS

Interview
L I F E I N T H E G LO B A L V I L L A G E P E R F O R M A N C E , S P E E D , E F F I C I E N C Y

A Dialogue With Michael Knopp, MD,


Chairman and Professor of Radiology
Michael Knopp, MD, is a citizen of the world. According to
his birth certificate, he is German. But he spent his younger
days in the United States, earned his university and medical
degrees in Germany, and returned to the U.S. seven years
ago. Today, Knopp is Chairman and Professor of Radiology
at the University Medical Center of The Ohio State University
in Columbus. There he heads up a department with 300
employees and an annual budget of 180 million dollars.
SOMATOM Sessions spoke with Knopp about living between
two cultures, the differences in health insurance on each side
of the Atlantic, and why he twice purchased the SOMATOM
Emotion 16-slice configuration.
Professor Knopp, we are meeting you today in Jena,
Germany. What are you here for?
I am attending the Fourth International Congress on MRMammography and will be introducing the results of our
research on tissue differentiation with contrast media.
What keeps you going?
For one thing, the desire to achieve an even faster and
more precise diagnosis that leads to the right therapy. My
main concern is the patient. But I am also driven by basic
research. For example, the question of whether imaging is
a way to learn something about the molecular characteristics of a pathological structure, and whether we can use
this information for a personalized treatment. I want to
push the envelope.
Why are you, although born and educated in Germany,
pursuing these questions at Ohio State University?
To answer this question, I must give you a little background.
I lived in Columbus for a while back in the 1970s. My father,
also a doctor, did his specialist training in radiology at The
Ohio State University, and my uncle was a Professor of
Psychiatry there, so I have roots in that city. After I had
worked at the German Cancer Research Center for ten years,

Michael Knopp, MD, PhD, Chairman and Professor


of Radiology, Ohio State University Medical Center,
Ohio, USA.

I received the offer to chair the Department of Radiology


at the University of Greifswald. While I appreciated that
opportunity, the other opportunities on the horizon to join
the National Cancer Institute in Washington, D.C. and subsequently to join The Ohio State University were more
tempting and challenging.
What kind of conditions did you find there?
When I started in Columbus four-and-a-half years ago, many
things did not reflect the latest standards. Workflow,
image quality, and patient comfort did not live up to my
expectations of a modern radiology department. I therefore felt an urgent need to make several changes, but in the
beginning, the only budget equipment available was what
had been approved for my predecessor. Since then, my
team and I have brought in more than 35 million dollars of
grant revenue and started the Wright Center of Innovation

SOMATOM Sessions 19

15

BUSINESS

in Imaging, an academia-industry collaboration. Originally, I


was also very limited by the existing space. The best option I
had for replacing our old single-slice CT was to find a system
that had a small footprint so it would fit into the room
where the old system had been housed and that didnt
need an external cooling device outside the gantry. I recognized then that facility renovation can easily eat up a third of
the cost of the new equipment, and we naturally wanted to
save ourselves this expense. It did not take long for us to
make a decision to buy the SOMATOM Emotion 16-slice configuration. Our system was the very first one on American
soil. We had it installed even before it was introduced at the
European Congress of Radiology in March 2005. Today we
manage all of our routine work with it. That way, we can
keep our high-end scanners free for special jobs like, for
example, complicated cardiovascular procedures.

The modest space requirements, the high diagnostic image


quality, and the fast image
management convinced.
And then, soon afterward, you bought a second SOMATOM
Emotion 16?
Yes. A year later, when the single slice CT on the main
campus also had to be replaced, it was clear that the only
logical choice was a SOMATOM Emotion 16-slice configuration. The modest space requirements, the high diagnostic
image quality, and the fast image management with the
PACS system in other words, the entire workflow process
and the technical features convinced us.

16

SOMATOM Sessions 19

We are forced to find very


cost-effective ways of working
What do you see as the most significant differences
between what you were doing in Germany and what you
are now doing in the United States?
The demands on each side of the Atlantic are the same, and
while we practice more subspecialty Radiology in the US and
have a different training approach, there are not so many
differences. We must find better, faster, and more efficient
ways to diagnose and treat an ever-growing older population.
Whats different are the general conditions. In the U.S., there
is the old familiar problem of getting expenses refunded.
Many patients have no health insurance, or only a portion of
the cost will be paid. So we have to deal with the situation
that our charges may not be paid at all, or may not be paid
in full. Therefore we may end up carrying a considerable
portion of the cost ourselves. Subsequently, we are forced
to find very cost-effective ways of imaging and to manage
within our payer mix. Those who can pay their bills in full
compensate for those who cannot. Luckily, we have a very
reasonable payer and social structure in Ohio. Most patients
are reasonably insured. Nevertheless, cost efficiency will be
increasingly an important subject. It is, by the way, basically
the same situation in Germany now with the fee for a case
based system. Financial resources are in short supply all
over. That is why the SOMATOM Emotion 16 was also a
good choice from a cost point of view with service, for
example.
What differences are evident from the patients point
of view?
Thats also an interesting perspective. In both countries the
healthcare system plays an important role. In Germany,
however, people have until now thought very little about
where the money is coming from to pay for healthcare,
there is a strong feeling of entitlement. Contributions to a
health insurance plan are mandatory and linked to the salary
and employment. In the U.S., there is no mandatory health
insurance or coverage below age 65. U.S. citizens therefore

BUSINESS

have to think a lot more about who pays for health care and
what they can afford. This is one reason why Americans
attach great importance to it. So we have a kind of paradoxical
situation that there are very high expectations for the quality
of medical services, while a significant part of the population
cannot pay for it. For our routine CT-imaging it means that
we need a system that delivers top image quality while
being cost effective. Fast imaging allows not only excellent
throughput but also reduces motion artifacts. We have to
work very efficiently, which we can definitely do with the
SOMATOM Emotion.
Could you please describe the workflow at your institution from scanning to diagnosis?
Optimized image and work flow management is not just a
question of saving time but also has to do with the increasing specialization. Today we do all the imaging with the
SOMATOM Emotion 16 according to a standardized protocol. After the scan the images are sent automatically into the
PACS system, where everyone has access to them and that
includes both source data and the 3D reconstructions. Thus,

The number of CT images


has risen every year by 18 percent.
We have to be able to keep up
with the demand.

we have created a highly efficient and effective workflow


that goes beyond the individual departmental borders and
specializations. Only in this way are we able to keep up with
the increasing demands. Radiologists specialize more frequently in modalities in Germany, while in the U.S. theres
a very strong preference to specialize in anatomic areas such
as the chest, abdomen, musculo-skeletal, interventional
or neuro. Regardless of which approach is taken, everyone
involved needs fast access to the images. Another difference
in workflow within a teaching institution is that in the U.S.,
patient studies are frequently first discussed with the residents and then a diagnosis is made. In Germany, it is frequently an opposite workflow. Its amazing how different
approaches, environments and training at the end do create
the same needs and outcome.
What do you mean by increasing demands?
The number of CT images has been rising for years. In the
last calendar year, our rate of increase was 18 percent. That
has to do with the fact that we are taking much better
images today, and you can see much more detail on them
than ever before. For this reason, we decided we needed the
16 slice scanner and not the 4-slice scanner for our routine
work. The 16-slice offers improved diagnostic confidence,
which we would not want to withhold from our patients. In
Columbus, another factor plays a role: our overall population is growing at a rate of three percent every year, that is
certainly also different to Germany where it is shrinking
because of the low birthrate.

SOMATOM Sessions 19

17

BUSINESS

We manage all of our daily business with the two


SOMATOM Emotion 16 scanners. We can also easily use
both of them for emergencies if necessary.
What do you use the two SOMATOM Emotion 16 scanners
in your department for?
As I have already mentioned, we have one on both our
east campus and our main campus. Both of them are integrated into the full daily spectrum of routine clinical in- and
outpatient care. We manage all of our daily business with
them. We can also easily use both of them for emergencies
if necessary. For complicated cardiac questions, we fall
back on our 64-slice scanner. For routine imaging, however,
we usually dont need to use it. Not many patients have to
be examined with the high-end scanners. Our motto is:
use the best image quality possible for necessary examinations but dont do additional imaging unless there is a very
good reason. We always have to keep in mind that not
every exam request is indicated and is going to be paid for.

How does your family cope with life between two


cultures?
I never hid the fact that I could imagine myself working and
living in the U.S. My wife, while also German was open
minded and up for it, too. In addition, we have four children,
and they also feel right at home in both cultures. Its worth
noting, however, that the world has become smaller and
smaller in recent years. That was quite different in the
seventies. Back then, phoning long distance was an expensive undertaking and was limited to important calls. These
days, we communicate with the whole world over the
internet, listen to our favorite music and hometown news
on the Web radio, can watch German television shows via
podcasts, and read the online version of our any local
paper. The world has become a global village, and its exciting
to be working and living in it.
The interview with Prof. Michael Knopp, MD, was conducted
by medical journalist Hildegard Kaulen, PhD, in Jena, Germany.

SOMATOM Emotion

SOMATOM Emotion 16-slice configuration a synthesis of


advanced clinical performance and low life-cycle costs.

18

SOMATOM Sessions 19

Brain-CT: collimation 12 x 0.6 mm, rotation


time 1.5 sec, 130 kV, 270/280 effective mAs.

BUSINESS

Proven Excellence by R efur bishe d Syst ems

Quality, Valuability and Flexibility


The Proven Excellence process, in combination with an understanding of what
todays customers need, has made
Siemens Medicals Refurbished Systems
(RS) what it is today: a customer-oriented
solution provider for medical pre-owned
systems.
Siemens offers customers the Proven
Excellence program which makes the
companys refurbished business unique
in a highly competitive market. Worldwide there are already 585 RS-systems
installed.
The program is the centerpiece of a
strategy that emphasizes both the like
new quality as well as the favorable
price-performance ratio of its products.
From Siemens, customers can expect
professional service response, including
warranties typically equivalent to those
of new systems like flexible service
agreements, spare parts availability for
at least five years, and stringent quality
assurance standards.

After the System is cleaned, repainted, and brought up to the latest


technical standards, it is thoroughly tested. A Siemens engineer runs exactly
the same tests on the refurbished CT that a new system would have to
pass before being delivered to the customer.

Five Step Quality Check


All pre-owned systems entering the
Proven Excellence process undergo a
five-step quality check. The first step is
called Selection and includes a thorough assessment of age and condition
of the specific system. During the second
step, De-installation, professional service providers and Siemens engineers
perform an onsite inspection. Approved
systems are de-installed and transferred
to Forchheim, Germany. The third step,
Refurbishing, is the most comprehensive in the Proven Excellence program. It
includes the cleaning, disinfecting, and
repainting of each system to make it
look like new. Furthermore, worn parts
are replaced with original spare parts. All

components and sub-systems are then


thoroughly checked for proper functioning. Software updates to the latest version are performed. Afterwards, the
system is checked with original test
equipment and procedures. This means
that the system must pass exactly the
same tests that brand-new systems
have to pass. After successful completion of testing, the Proven Excellence
quality seal is applied.
In the fourth step, the Re-Installation,
the systems are installed and startedup by Siemens technicians. Repeated
performance tests follow and, upon
completition, the customer receives the
Proven Excellence quality certificate.

Warranty and services, the last step in


the process, is fulfilled by local Siemens
customer service engineers.
Additionally, Siemens Refurbished Systems can, with its world-wide locations
(including the U.S.), offer an interesting
choice of value-added solutions that
include service contracts with comprehensive spare parts coverage, flexible
financing and qualified support services
worldwide.
Siemens points to its stringent ProvenExcellence process as the companys
assurance of quality and reliability to its
Refurbished Systems customers globally.
k www.siemens.com/
proven-excellence

SOMATOM Sessions 19

19

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neurology

Acute Care

Case 1
Stenting of a Severe, Noncalcified Stenosis:
Combining SOMATOM Definition &
AXIOM Artis dFC to Improve Workflow and Speed
By Stephan Achenbach, MD, Associate Professor, and Josef Ludwig, PhD, Associate Professor, Department
of Internal Medicine II, University of Erlangen-Nuremberg, Germany

HISTORY

DIAGNOSIS AND COMMENTS

A 32 year-old Asian male suffering from chest pain was


admitted to the emergency room in the early morning. The
age of the patient was unusual for a cardiovascular event
and the fact that he apparently had an important university
exam the same day made the case even more dubious. The
patient was in good condition and the physical examination
did not reveal anything out of the ordinary. As for cardiovascular risk factors, he had mild hypercholesterolemia and
nicotine abuse. His ECG showed discrete signs of ST-Elevation
in II and III. Initial enzyme levels were normal. In order to
secure a diagnosis, he was transferred to the SOMATOM
Definition CT scanner to perform a non-invasive coronary CT
angiography.

His heart rate showed 81 beats per minute and scan parameters were automatically adapted to the heart rate resulting
in a six second scan. Betablockade was unnecessary due to
the high temporal resolution of the scanner. The evaluation
was performed using standard 3D evaluation software and
syngo Circulation as a dedicated cardiac CT evaluation tool.
High-resolution images revealed that RCA and LAD were
without pathology. However, a severe, non-calcified stenosis
was diagnosed in the mid segment of the left circumflex
a rather unusual finding for a 32 year-old man.
The patient was transferred to the angio suite for immediate
treatment. Using the advantages of a universal syngo Workplace, the CT data could be directly accessed and evaluated

[ 1 ] Showed with syngo Circulation: Detail of a


severe, non-calcified stenosis which was diagnosed in
the mid segment of the left circumflex (arrow).

20

SOMATOM Sessions 19

[ 2 ] Overview of vessel lumen, 2D and 3D data with


syngo Circulation. 3D reconstruction illustrates that the
left circumflex coronary artery lesion is immediately
distal to the origin of the obtuse marginal branch (arrow).

CLINICAL OUTCOMES

by the interventional cardiologist as well. The AXIOM Artis


dFC-system with the integrated 3D Quantification tool syngo
IC3D, allows accurate 3D planning for a more precise interventional treatment.

COMMENTS
With the AXIOM Sensis hemodynamic recording system connecting to the hospitals information system server, required
demographics were downloaded automatically. syngo online
IC3D measurement provided accurate values for vessel
dimensions as well as the geographic location of the stenosis
relative to the ostium of the obtuse marginal branch without
foreshortening effects. A 13 mm drug eluting stent was
deployed. In conclusion the combined use of both the Dual
Source CT and the AXIOM Artis dFC achieved positive results.

[ 3 ] Overview of vessel lumen, 2D and 3D data with IC3D.

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition

Scan area

Cardiac Scan

Scan length

125 mm

Scan time

6s

Scan direction

cranio caudal

Heart rate

81 bpm

kV

120 kV

Effective mAs

330 mAs/rot.

Rotation time

0.33 s

Slice collimation

0.6 mm

Slice width

0.75 mm

Pitch

0.36

Reconstruction increment

0.6 mm

CTDI

26.6 mGy

Kernel

B26f

Contrast
Volume

55 ml

Flow rate

5 ml / s

Start delay

21 s

[ 4 ] Detail of the stenosis, diagnosed in the mid


segment of the left circumflex.

SOMATOM Sessions 19

21

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neurology

Acute Care

Case 2:
Improved Follow up For Pulmonary Nodules With
syngo LungCARE and syngo Lung CAD
By Marco Das, MD, Georg Mhlenbruch, MD, Andreas H. Mahnken, MD, Rolf W. Gnther, MD, Joachim Ernst Wildberger, MD,
all from the Department of Diagnostic Radiology, RWTH Aachen University, Aachen, Germany

The detection of pulmonary nodules is one of the most


common exams in chest multidetector-row CT (MDCT).
Small pulmonary nodules can easily be overlooked and lead
to false negative results, which could have severe consequences for the patient. Improved visualization using maximum intensity projection (MIP) and computer-aided detection
(CAD) are beneficial for significant improvement of radiologists
detection rate for small pulmonary nodules. However, the
diagnostic challenge of how to characterize nodules remains.
Criteria like shape, density or enhancement are often used, but
1A

Delete Marker

Link To

1B

22

SOMATOM Sessions 19

Set Annotation

Get Counterpart

size and size change are the most effective way for characterization. New guidelines from the Fleischner Society1 address
this problem, for the first time providing radiologists with
practical follow up suggestions for small pulmonary nodules.
This guideline is based on recent lung cancer screening trials,
and suggests follow-up for pulmonary nodules depending
on nodule size and patient risk classification. Thus, objective
and reliable nodule detection and follow-up measurements
have become more and more important as manual measurements yield high intra- and interreader variability.

[ 1 ] A small
pulmonary nodule
(diameter 2.1 mm)
in the apical segment of the upper
lobe on the left lung
was found by the
CAD software and
marked after verification by the Radiologist. Using the
automated follow
up function [Fig. 1A],
the corresponding
counterpart in the
follow up examination is automatically
marked [Fig. 1B].

CLINICAL OUTCOMES

2A

[ 2 ] syngo Lung CAD soft-

ware was used for


the detection of additional
pulmonary nodules on
the follow up examination.
Findings of the software
(circled in red) indicating
the need for verification
by the radiologist.
Finally reported nodules
are marked in green.
2B

HISTORY
This case presents a 64 year old female with colorectal cancer,
who underwent chest MDCT for detection of pulmonary
metastasis.

EXAMINATION PROTOCOL
Scanner

SOMATOM Sensation
64-slice configuration

Scan area

Lung

Scan length

250-320 mm

DIAGNOSIS

Scan time

10 s

Scan direction

cranio-caudal

The initial read was negative for pulmonary nodules, but the
use of syngo Lung CAD indicated the presence of two very
small nodules (both with a nodule diameter about 2 mm).
Short term follow-up was performed to detect potential
growth of these two nodules, and assess the degree of
metastatic disease.

kV

120 kV

Effective mAs

10 (<80 kg); 20 (>80 kg) mAs

Rotation time

0.5 s

Slice collimation

64 X 0.6 mm

Slice width

1.0 mm

Table feed / rotation

18 mm

Reconstruction increment

0.5 mm

Kernel

B50f

COMMENTS
Using the automatic follow-up mode in syngo LungCARE,
previously marked nodules were automatically aligned with
the corresponding nodule (counterpart) in the follow-up
examination. Volumetry results were directly compared and
growth rate estimated. Additionally CAD was run on the
follow up examination, enhancing diagnostic confidence.
In our experience, syngo Lung CAD is a clinically valuable
tool, helping physicians to be sure that all potential lesions
are identified. The automatic follow-up feature of syngo
LungCARE CT helps to eliminate errors in assessing the growth
progression, or regression, of lesions, thereby enhancing our
diagnostic confidence for chest exams.

1 MacMahon H, Austin JH, Gamsu G, Herold CJ, Jett JR, Naidich DP, Patz
EF Jr, Swensen SJ; Fleischner Society. Guidelines for management of small
pulmonary nodules detected on CT scans: a statement from the Fleischner
Society. Radiology 2005; 237: 395 400.

SOMATOM Sessions 19

23

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neurology

Acute Care

1A

Case 3:
Child 11 Months:
Visualization of a Choroid
Plexus Papilloma
By Andrzej Kosciesza, MD, Piotr Nuzynski, MD, Department of
Radiology, Bogdanowicz Hospital, Warsaw, Poland

1B

HISTORY
A normally developing infant aged eleven months suffered a
minor trauma. Ultrasonographic examination disclosed
triventricular hydrocephalus and abnormal hyperechogenic
mass in midline partially involving the lateral ventricles and
the third ventricle.

DIAGNOSIS
On CT examination an abnormal mass of highly increased
density was seen, involving the lateral ventricles and the
third ventricle, associated with supratentorial hydrocephalus.
On histological examination choroid plexus papilloma was
found.

1C

COMMENTS
This case demonstrates the usefulness of CT in the assessment
of the character and precise location of well vascularized
congenital tumours in children. Short acquisition time and
secondary reconstructions of outstanding quality using a
SOMATOM Emotion 16-slice configuration enable correct
diagnosis and precise planning of surgical treatment.

[ 1 ] Supratentorial hydrocephalus: abnormal masses


involving the lateral ventricles [Fig. 1A] VRT sagittal,
[Fig. 1B] MIP axial and [Fig. 1C] VRT coronal.

24

SOMATOM Sessions 19

CLINICAL OUTCOMES

SOMATOM Emotion 16-slice configuration with a wide-open gantry in the children scan room,
all painted in a very colorful way so that the small patients are not afraid of examinations.

EXAMINATION PROTOCOL
SOMATOM Emotion
16-slice configuration

Slice width

1.5 mm

Pitch

0.55

Scan area

Head

Reconstruction increment

0.6 mm

Scan length

126 mm

Kernel

H40s medium

Scan time

22 s

kV

130 kV

Contrast

Effective mAs

240 mAs

Volume

12 ml

Rotation time

1.5 s

Flow rate

manual

Slice collimation

16 x 1.2 mm

Start delay

manual

Scanner

SOMATOM Sessions 19

25

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neurology

Case 4:
NEW: Comprehensive 3D Stroke Imaging
With syngo Neuro PBV

Acute Care

No
w

FD
AC

lea

re

By Jie Lu1, MD, Miao Zhang1, MD, Jiuhong Chen2, Prof. Kuncheng Li, MD1,
1

Xuanwu Hospital, Capital Medical University Beijing, China

SIEMENS Ltd., China

HISTORY
A 59 year old male was delivered to our stroke unit in the
Xuanwu hospital three hours after onset of right-sided
extremity weakness and a right-sided hemiparesis. On
examination in the emergency room, he was found to have
profound right extremity paresis, an expressive aphasia and
facial palsy on the left side. A complete stroke evaluation
was scheduled. In order to meet the demand of fast hemodynamic imaging of the entire brain, CT Perfusion and whole
brain perfused blood volume calculation using syngo Neuro
PBV (Perfused Blood Volume)* were performed. This new
approach allows for routine calculation of three-dimensional, color-coded whole brain images overcoming the
limited scan coverage of Perfusion CT.

DIAGNOSIS AND COMMENTS


After exclusion of hemorrhage with a non-contrast CT scan,
color maps of CT Perfusion demonstrated delayed Time to Peak
(TTP) and reduced cerebral Blood Flow (CBF) and Cerebral
Blood Volume (CBV) in the area of the arteria cerebri media.

1A

1B

Using syngo Neuro Perfusion CT, oligemic tissue that is near


the threshold for tissue at risk and regions of the core infarct
were indicated [Fig. 1].
To overcome the limited scan coverage of Perfusion CT, the
three-dimensional extend of the stroke area can now be
defined using the new software syngo neuro PBV [Fig. 2]
thus increasing the safety of treatment decision. Due to the
perfusion parameters, an occlusion of the main cerebral
artery was suspected which has been confirmed by a CT
angiography in the concurrent stroke workflow [Fig. 3].
Based on the differential diagnoses obtained with CT Perfusion
and 3D evaluation of perfused blood flow using syngo Neuro
PBV and the right therapeutic window 50 mg RTPA, anticoagulants and platelet anti-aggregates were administered. This
led to a relief of the symptoms by the next day, for example
partial words could be understood. The patient was released
from the hospital in a stable condition one week later.

*available 04/2007 with syngo 2007C

1C

1D

[ 1 ] CT Perfusion demonstrates a clear infarct of the left hemisphere with delayed TTP [marked areas, Fig. 1A]
reduced cerebral blood volume [Fig. 1B] and reduced cerebral blood flow [Fig. 1C]. The tissue at risk assessment
clearly indicated the core infarct [red areas, Fig. 1D] and with a large area of tissue at risk [yellow areas, Fig. 1D]
which might be rescued after intervention.

26

SOMATOM Sessions 19

CLINICAL OUTCOMES

[ 2 ] The three dimen-

sional extent of the


stroke area can be
displayed using a color
coded map of the perfused blood volume of
the whole brain
(arrows).

EXAMINATION PROTOCOL
Scanner

SOMATOM Sensation SOMATOM Sensation


64-slice configuration 64-slice configuration
Non-enhanced CT
CT angiography

Scan area

Head

Head

Scan length

133 mm

474 mm

Scan time

9.81 s

5.96 s

Tube voltage

120 kVp

120 kVp

Effective mAs

480 mAs

150 mAs

Rotation time

1.0 s

0.5 s

Slice collimation

64 x 0.6 mm

64 x 0.6 mm

Slice width

1.0 mm

1.0 mm

Reconstruction
increment

0.8 mm

0.8 mm

Kernel

H20 S

H20 S

[ 3 ] CTA revealed a stenoses in the left internal


carotid artery (arrow).

SOMATOM Sessions 19

27

SCIENCE

EDUCATION

CARE Dose4D
New Technique for Radiation Dose Reduction
Discussion of fundamental basis, clinical applications
and advantages of automatic exposure control techniques,
with particular emphasis on the CARE Dose4DTM technique
By Mannudeep K. Kalra, MD and Thomas J. Brady, MD, Division of Cardiac Imaging,
Department of Radiology, Massachusetts General Hospital, Boston, USA

The need to reduce radiation dose and optimize image quality


have spurred vendors to develop novel techniques1. In this
respect, automatic exposure control techniques represent
the most important and efficient method for reducing radiation
dose while maintaining desired image quality 2. The present
article discusses fundamental basis, clinical applications
and advantages of automatic exposure control techniques,
with particular emphasis on Siemens syngo CARE Dose4D
technique.
What are the Limitations of Manually Selected
Fixed Tube Current?
Manual selection of a fixed tube current remains the most
commonly used way of performing CT scanning1. With this
technique, the technologist prescribes a tube current value
for CT scanning and the entire scanning is done at the specified fixed tube current. The scanner does not change the
tube current based on patient size and/or attenuation.
Although radiation dose reduction can be achieved with
such fixed tube current technique, there are some limitations of this technique that can be addressed with use of
automatic exposure control technique. For example, surveys
suggest that many centers do not change the tube current
based on patient size1. As a consequence, patients might be
overdosed or image quality might not meet the clinical
needs. Rapid development in CT technology and newer clinical applications makes it difficult to adapt scanning protocols
with fixed tube current for different size patients and clinical
indications.
Moreover, unlike automatic exposure control techniques, the
fixed tube current technique cannot modulate tube current in
response to rapidly changing patient size or attenuation
within a slice position or from one slice position to the next.

28

SOMATOM Sessions 19

What is Automatic Exposure Control?


Automatic exposure control techniques used in CT are
analogous to photo timing in digital radiography. The latter
technique terminates the exposure once a pre-specified
radiographic density is obtained, which implies that exposure
is terminated earlier (lower radiation dose) for smaller
patients and longer exposure time (higher dose) is allowed
for larger patients 2. In this way, photo timing technique
allows optimization of radiation exposure while maintaining
desired or specified image quality. Likewise, automatic exposure techniques used in CT scanning adapt tube current in
the x-y plane (angular) or along the scanning direction in
z-axis or both (combined modulation) based on size and
attenu-ation of the body region (attenuation profile) being
scanned to obtain specified image quality or noise with
lowest possible radiation dose. The image noise, an important
determinant of image quality, is determined by x-ray beam
attenuation as it traverses through the patient.
Angular Modulation
During CT scanning, the x-ray tube continuously emits x-rays
from 360 degrees (projection angles) around the patient
over the entire scan length. Since image noise is dominated
by those projections, which have the highest attenuation,
tube current and with it also dose can be reduced for
those projections which have a low attenuation without
increasing overall image noise. Therefore, in asymmetric or
non-circular body parts, such as the shoulders, there is less
x-ray beam attenuation in the anteroposterior direction
compared to the lateral direction. Thus, within each slice
position, less photons or lower tube current would be necessary in anteroposterior direction than in the lateral direction.
Tube current modulation minimizes unnecessary x-rays in

SCIENCE

eff. mAs
(compared to Quality ref. mAs)

Effect of Modulation Strengths on Radiation Dose for Slim and Obese Patients
200
constant
image noise

180

obese patient/ region:


strong increase

160

average increase

140

weak increase

120

100
constant dose
slim patient/ region:
weak decrease

80

60

average decrease
strong decrease

40

20

50

100

150

slim patient

obese patient

slim region

obese region

200

250

300

350

400 %

X-ray attenuation
(compared to reference attenuation)

[ 1 ] The sophisticated algorithm provides desired image quality for all patients, slim to obese. Individual
preferences on tube current increase and decrease can be realized by choosing strong, moderate or weak.

the anteroposterior projection without any substantial effect


on image quality.
The technical implementation of angular modulation differs
from vendor to vendor. Some only offer sinusoidal modulation,
others are limited in the modulation range (min. to max ratio).
Siemens CARE Dose4D modulates the tube at all rotation
times without compromising the modulation range, comparable to an organ specific dose reduction.3
z-Axis Adaptation
With z-axis adaptation, the tube current changes from one
slice position to the other without optimization in the x-y axis.
The technique automatically selects higher tube current for
larger patients and anatomical regions with higher attenua-

tion and lower tube current for smaller patients and anatomical regions with low attenuation in order to maintain
desired image quality at optimum radiation dose2. Lastly,
combined modulation technique (CARE Dose4D), discussed
in the following section, combines benefits of angular and
z-axis modulation techniques.
How does CARE Dose4D technique work?
From a single topogram, the CARE Dose4D technique
measures attenuation profile in the z-axis in the direction of
projection and also in the perpendicular direction with a
sophisticated algorithm4. Tube current values are calculated
and adapted to the patient size and attenuation changes
based on these attenuation profiles. Tube current adjustment

SOMATOM Sessions 19

29

SCIENCE

2A

2B

[ 2 ] CT image acquired with CARE Dose4D techniques reveal excellent image quality with substantial dose reduction.
[Fig. 2A] Chest-CT with 20% mean dose reduction and [Fig. 2B] abdomen-liver with 38% mean dose reduction5.

depends on a user defined so-called image quality reference


mAs (z-axis modulation). Based on these tube current
levels, real-time tube current modulation during each tube
rotation according to patients angular attenuation profile
(angular modulation) is then performed.
The challenging part of automatic exposure techniques is how
to adapt the tube current to the different sizes of patients
and how to compensate for changes along the patients
length. The first and simplest approach would be a modulation
which keeps the noise constant from patient to patient and
over the whole scan. However, this approach has two limitations: Firstly, this is not possible from a technical perspective
since the range of attenuation changes from patient to
patient and also during a single scan (for example shoulder
to neck) is much larger than any tube can provide. Secondly,
studies have shown that, from a clinical perspektive, needs
are different. In smaller patients, lower noise levels are desired, whereas in obese patients more noise is often acceptable due to higher contrast . This indicates different requirements for automatic exposure techniques.
With CARE Dose4D, tube current is modulated so that both
limitations are overcome. The user selects a quality reference
mAs according to the diagnostic requirements and the

30

SOMATOM Sessions 19

individual preference of the user. For a given protocol, this


value reflects the effective mAs used in a certain body region
for a reference patient defined as a typical adult, weighing
70 kg to 80 kg (for adult protocols) or as a typical child
having the age of 6 years (for pediatric protocols).
The technique adapts the tube current to the individual
patient size based on the quality reference mAs value. It
determines whether the patient is slim or obese from the
topogram and adapts the tube current based on the preselected adaptation strengths (weak, average or strong). As
illustrated in Fig. 1 the system uses an advanced algorithm to
adapt tube current so that the user gets the desired image
quality. This means that for example for slim patients tube
current is reduced less than constant image noise would
require. For obese patients to get the desired image quality
tube current is increased less than constant image noise
would require.
The adaptation strengths are prospectively set for these
patient types and determine the extent of change in effective
mAs. Thus, image quality and radiation dose can be controlled
by selecting an appropriate modulation strength and/or quality
reference mAs value.

SCIENCE

Where Can CARE Dose4D Technique be Applied?


CARE Dose4D technique can be used for CT scanning of
neck, chest, abdomen, and pelvis [Fig. 2]. The technique is
commercially available on Siemens MSCT scanners with 1 to
64 detector configurations. It is also available on the Dual
Source CT, the SOMATOM Definition. CARE Dose4D can be
used in scans for all patients, including pediatric and obese
patients. It also can be used for patients with metal prostheses
without causing unnecessary increase in the radiation dose7.
This is due to the fact that a special detection algorithm is
implemented into CARE Dose4D8 [Fig. 3].
What is the Evidence Supporting CARE Dose4D?
Several large studies have evaluated CARE Dose4D technique its effect on image quality and radiation dose in clinical
routine4-6.
For instance Dr. Rizzo and colleagues4 have reported that,
compared with constant tube current technique, there was
a 19% (15.4/19.0) reduction in radiation dose for angular
modulation, a 42% (11.0/19.0) reduction with weak decrease
(slim) strong increase (obese) type of combined modulation
and a 44% (10.6/19.0) reduction with average decrease
(slim) average increase (obese) type of combined modulation.
Mulkens et al5 have also found that, mean dose reduction
for combined angular and z-axis modulation technique and
for the angular modulation technique alone was as follows:
thorax, 20% and 14%, respectively; abdomen-liver, 38% and
18%, respectively; abdomen-pelvis, 32% and 26%, respectively; lumbar spine, 37% and 10%, respectively; and cervical
spine, 68% and 16%, respectively.
For CT colonography, Graser et al6 have reported 33% (prone)
to 35% (supine) dose reduction with CARE Dose4D compared
to CARE Dose technique.

CT-Scan With CARE Dose4D

X-ray
dose
Scan with
constant mA

Reduced dose
level based on
topogram

Real-time
angular dose
modulation

Slice position

1332 mA

20 mA

[ 3 ] Instead of just taking into account the


patients external dimensions and apparent size,
CARE Dose4D analyzes the cross-secional anatomy
in real-time and adjust the emitted X-ray dose
accordingly providing excellent image quality with
minimized exposure.

References
1 Kalra MK et al. Radiology. 2004; 230: 61928.
2 Kalra MK et al. Radiology. 2004; 233: 64957.
3 Greess H et al. Eur Radiol 2002; 12: 157176.
4 Rizzo S et al. AJR Am J Roentgenol. 2006; 186: 6739.
5 Mulkens TH et al. Radiology. 2005; 237: 21323.
6 Graser A et al. Am J Roentgenol. 2006; 187: 695701.
7 Rizzo S et al. Am J Roentgenol 2005; 184: 491496.
8 Tejas Dalal et al. Radiology 2005; 236: 671675.

SOMATOM Sessions 19

31

SCIENCE

See the Whole Disease


Neuro Perfused Blood Volume Imaging
By Stephan P. Kloska1, MD, Tobias Fischer1, MD, and Roman Fischbach1, MD, Hendrik Ditt2, MSc,
1

Department of Clinical Radiology, Chairman: W. Heindel, MD, University of Muenster, Germany

Siemens AG, Medical Solutions, CT Division, Forchheim, Germany

Introduction
Computed tomography is still the most widely used imaging
modality in the evaluation of acute stroke as magnetic resonance imaging (MRI) is hampered by its relatively limited
availability. CT angiography and perfusion CT (PCT) improve
the diagnostic yield of non-enhanced CT (NECT) by direct
visualization of cerebral vessels and assessment of cerebral
hemodynamics. PCT is used to calculate color-coded maps
of the hemodynamic parameters cerebral blood flow (CBF),
cerebral blood volume (CBV) and time to peak enhancement
(TTP) and thus allows detailed evaluation of perfusion disturbances including delineation of brain tissue with irreversible
damage and tissue at risk1. In contrast to diffusion weighted
MRI or MRI perfusion measurement, PCT evaluation is

[ 1 ] Calculation of Neuro Perfused Blood Volume


(PBV) Imaging (NECT = non-enhanced computed tomography; CTA = computed tomography angiography).

32

SOMATOM Sessions 19

restricted to a subvolume of the brain due to the limited


width of the CT detector. Therefore, an ischemic area may
only be covered in part and infarctions outside of the selected
PCT level may be missed.
In order to meet the demand of fast hemodynamic imaging
of the entire brain, neuro perfused blood volume software
(Siemens Medical Solutions, Forchheim, Germany) presents a
practical approach that allows for routine calculation of threedimensional color-coded whole brain perfused blood volume
images thereby overcoming the limited scan coverage of PCT.

Imaging Protocol
CT imaging in patients with suspected acute stroke at our
institution consists of NECT followed by PCT and CTA2. The
scan delay for the CTA is derived from the time to peak
enhancement in the sagittal sinus in PCT to allow for combined arterial and venous vessel evaluation. NECT and CTA
cover the entire brain and both scans are acquired with identical detector collimation, section thickness and reconstruction increment. For the CTA, intravenous injection of
100 mL of a non-ionic high concentration contrast agent
(350 400 mg iodine/mL) followed by a saline flush of
50 mL with a flow rate of 4 mL/s is performed.
Images of the whole brain NECT and CTA data sets are loaded
into the syngo Neuro Perfused Blood Volume CT (PBV)* software for the calculation of the PBV. The software generates
PBV data sets by fully automatic registration and normalized
subtraction of the NECT data from the CTA data [Fig. 1].
The result of the subtraction operation reflects the overall
brain parenchymal enhancement. After filtering, PBV images
are displayed using a color code similar to perfusion CT maps.
In normal perfused brain parenchyma, the white matter
usually is coded in blue to dark green color corresponding to
the physiologically lower blood perfusion, whereas the basal
ganglia and cortex have higher normal perfusion values and
are displayed in yellow or green [Fig. 2].

SCIENCE

[ 2 ] Visualization
of Neuro Perfused
Blood Volume Imaging
in a patient without
perfusion abnormality.
The color-coded 3Ddataset displays regular levels of blood
volume in the white
and grey matter

Examination Protocol
Non-enhanced CT

CT angiography

Scanner

SOMATOM Sensation
16-slice configuration

SOMATOM Sensation
64-slice configuration

SOMATOM Sensation
16-slice configuration

SOMATOM Sensation
64-slice configuration

Scan area

Head

Head

Head

Head

kV

120 kV

120 kV

120 kV

120 kV

Effective mAs

360 mAs

480 mAs

130 mAs

175 mAs

Rotation time

1s

1s

1s

0.5 s

Slice collimation

16 x 0.75 mm

64 x 0.6 mm

16 x 0.75 mm

64 x 0.6 mm

Slice width

1 mm

1 mm

1 mm

1 mm

Reconstruction increment

0.8 mm

0.8 mm

0.8 mm

0.8 mm

Kernel

H20 S

H20 S

H20 S

H20 S

Tube voltage

120 kVp

120 kVp

120 kVp

120 kVp

Field of view

230 mm

230 mm

230 mm

230 mm

350400 mg iodine/mL

Contrast

100 ml (volume of contrast agent)

Volume

50 ml (volume of saline)
4 ml / s

Flow rate

Postprocessing

PBV -version

syngo Neuro PBV*

PBV -version

syngo Neuro PBV*

SOMATOM Sessions 19

33

SCIENCE

3A

3B

[ 3 ] 81 year-old

man with acute leftsided hemiplegia and


aphasia since 3 hours.
Non-enhanced CT
(NECT) revealed signs
of infarction in the left
middle cerebral artery
(MCA) territory
[Fig. 3A].
CT angiography (CTA)
excludes occlusion of
the proximal middle
cerebral artery (MCA)
on the left [Fig. 3B].
The three-dimensional
perfused blood volume
(PBV) calculation [Fig.
3C] demonstrated the
volume of perfusion
abnormality in close
correlation to the
magnetic resonance
imaging follow-up
with diffusion-weighted imaging (DWI)
sequence [Fig. 3D].

3C

3D

Neuro Perfused Blood Volume Imaging


The 3D-PBV datasets are viewed on a MMWP workstation
in multiplanar mode (MMWP, Siemens Medical Solutions,
Forchheim, Germany). The volume of the 3D-PBV covers
the whole brain. Areas of reduced perfusion have a blue to
purple color coding [Fig. 3].

Discussion and Perspective


Neuro perfused blood volume imaging is a new feature that
can be seamlessly integrated into a routine CT stroke imaging
protocol, as it does not require any additional scans beside
the usual NECT and CT angiography performed in patients
with suspected acute ischemic stroke. Since the entire brain
is covered, syngo Neuro PBV overcomes the limited volume
coverage of PCT and thus serves as a sensitive imaging tool

34

SOMATOM Sessions 19

to detect perfusion abnormalities. As PBV CT visualizes the


irreversibly damaged brain tissue3, 4 perfusion CT will remain
an important part of our CT protocol for prospectively assessing tissue at risk (mismatch imaging) especially in patients
where intravenous or local arterial fibrinolysis is discussed5.
syngo Neuro PBV is a valuable tool to visualize site and
extent of ischemic brain damage and to better select the
level of the brain subvolume to be assessed in more detail by
perfusion CT.
References
1 Murphy BD et al. Stroke. 2006; 37: 17711777.
2 Kloska SP et al. Radiology 2004; 233(1): 7986.
3 Hunter GJ et al., AJNR 1998; 19(1): 2937.
4 Hunter GJ et al. Radiology 2003; 227(3): 725730.
5 Schellinger PD et al. Stroke 2003; 34(2): 575583.
* available 04/2007, for SOMATOM and
Defintion only, requires syngo 2007C

EDUCATION & EVENTS

E D U C AT I O N

The Worlds First


SOMATOM Definition
Workshop
In October 2006 the Department of Radiology and the
Department of Cardiology at the University Hospital Munich
Grosshadern, Germany, hosted the worlds first Workshop for
the SOMATOM Definition Dual Source CT (DSCT) scanner.
The three-day course program covered scientific lectures,
clinical presentations, live examinations on the SOMATOM
Definition, and primarily hands-on sessions at the workstations. All aspects of cardiac CT imaging like calcium
scoring, CTA, functional-, viability- and valve imaging were
addressed in comprehensive lectures that supported the
hands-on training sessions. The workshop was held by both
radiologists and cardiologists.
A technically fully equipped course room and syngo MultiModality Workplaces were available. Siemens Medical
Solutions provided one workstation per two participants to
use throughout the entire training period. Maximum training
success was achieved in small groups with not more than ten
participants who could benefit from an interactive exchange
of experience away from their daily routine work. The Participants observed live CT cases on the SOMATOM Sensation in
its 64-slice configuration and the worlds first DSCT scanner,
the SOMATOM Definition.
The training was aimed at preparing participants to satisfy all
levels of certification according the ACC-AHA Guidelines. The
University of Munich Cardiac Imaging Group at Grosshadern
Clinic has one of the worlds largest coronary CTA databases
with cross correlations to invasive angiography and intravascular ultrasound. Up to 50 clinical CTA cases were reviewed

Location of the workshop:


University Hospital, Munich, Grosshadern, Germany.

during the course. By providing cross correlations (invasive


angiography and IVUS) in all cases, learning success was
enhanced.
The course attracted many more applicants than were able to
join and the feedback has been outstanding: Well organized,
richly illustrated live cases and practical tips and tricks usable

The Hospital Grosshadern in Munich


Since October 1999 both University
Hospitals in Munich, Grosshadern and
Innenstadt, belong to the LudwigMaximilian-University of Munich. Now,
with its 2,428 beds and 9,000 staff
members, the University of Munich

Hospital is aside from the University


Hospital in Berlin (Charit) the largest
facility of this kind in Germany. The University Hospital can look back to almost
200 years of history closely tied to the
development of the medical faculty.

This faculty is part of the University of


Ingolstadt, which opened its doors for
instruction in 1472. Ingolstadt remained the seat of the University until
1800. More Information about the hospital: www.klinikum.uni-muenchen.de

SOMATOM Sessions 19

35

EDUCATION & EVENTS

in my own clinical practice made this course absolutely worth


the trip, was the enthusiastic comment from Dimitri De
Vuyst, MD, AZ Sint-Maarten, Department of Radiology,
Mechelen, Belgium.
Dilek ncel, MD, Sifa Hospital, Department of Radiology,
Izmir, Turkey declared, This course was very well-organized
not only to improve application skills, but also widening our
clinical perspective.
The course has been contucted under direction of PD
Christoph Becker, MD, head of CT from the Department of
Radiology and collegues and PD Andreas Knez, MD, Head of
cardiac CT from the Department of Cardiology and collegues.
Because the workshop has been so successful, the hospital
has decided to offer additional courses in 2007. The dates will
be displayed in the CT Course Selector on the Siemens CT
webpage. To register online the following link can be used:

Participants of the SOMATOM Definition workshop


at interactive hands-on sessions.

k www.siemens.com/somatomeducate
This is a service of Life our customer care solution

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

Continuous Updates in SOMATOM LifeNet


Service, Support, and Information: SOMATOM LifeNet, the
information and service portal available directly at the
CT scanner consoles, not only comes in new colors it continuously offers more services and information. For instance,
Siemens informs a customer via a news ticker about new
and upcoming software applications. If the customer is interested in new applications, information and corresponding
(free of charge) 90 day trial licenses can be downloaded via
LifeNet.
SOMATOM LifeNet also offers application guides and
e-Training for software applications that can be downloaded
directly to the scanner. This way, getting started with the
application is uncomplicated and easy.
Designed to support customers in their daily work, SOMATOM
LifeNet offers fast and easy access to information, as well as
to a broad range of services using the Siemens Remote
Service (SRS) connection as a direct line to Siemens.
More information and updates with SOMATOM LifeNet.

k www.siemens.com/ct-LifeNet
This is a service of Life our customer care solution

36

SOMATOM Sessions 19

EDUCATION & EVENTS

C T- O N L I N E : C O U R S E S C H E D U L E

New Course Selector


Continuous education is becoming more and more important. But searching the web for specific medical courses is
time consuming and does not always produce the desired
results. Siemens Medical Solutions has designed a new tool
the Course Selector to give the customer an easier access to
the medical education he or she is looking for. Whether
searching globally or locally, whether searching for personal
training or e-learning, whether cardiology or radiology is the

focus. Just define dedicated criteria to find the right Siemens


offering. More information and registration on the web:
k www.siemens.com/somatomeducate
This is a service of Life our customer care solution

SERVICE

Frequently Asked Questions


Convolution Kernel for Stents and Calcifications
For a better visualization of stents and calcifications, you
can use the convolution kernel B46. This is available on all
SOMATOM Sensation and SOMATOM Definition scanners
with the HeartView CT option. B46 is an edge preserving
noise reduction kernel that has been optimized to display
small vessels and reduce the blooming effect for higher
density structures.
Why Do We Have Step Artifacts in Cardiac Images?
In these images [Fig. 1 and 2] one can clearly see breathing
artifacts. To recognize these artifacts, reconstruct a large
FoV, so that the whole chest is displayed. The spine is shown
without artifact, but the sternum and the heart show steps.
This is caused by breathing, where the patients chest moves
in an anterior direction. To avoid these artifacts, practice the
breathing instructions with the patient prior to the scan.

[ 1 ] Step artifacts in the lungs and in the liver (red arrow)


are only visible in anterior part.

Via LifeNet, the information and service portal available


directly at the CT-scanner consoles (see p. 36), find further
FAQs and learn how to easily use Siemens computed tomography scanners and applications in daily clinical practice.
This is a service of Life our customer care solution

[ 2 ] No step artifacts are visible in the spine (white arrow).

SOMATOM Sessions 19

37

EDUCATION & EVENTS

C T ONLINE

Efficient Tools to Explore


New Clinical Opportunities
Enabling customers to take full advantage of their CTs
post processing capabilities is the goal of Siemens Medical
Solutions. That is why Siemens provides their customers with
a new e-Learning program which will be available on CD.
This e-Learning is based on the latest software version syngo
2007 and comprises clinical post processing applications for
Computed Tomography.
The applications are available for newly purchased systems.
In the future, they will be also accessible for installed CT
systems for customers having a syngo Evolve contract.*
Evolve helps to stay up to date by regularly updating softand hardware. This syngo interactive e-Learning tool enables
the user to familiarize himself with new applications or to get
prepared for a 90 day trial. The syngo e-Learning CD is available
for order at the local Siemens Life Representative or at:
med.somatomlife@siemens.com.

Screenshot of syngo 2007 e-Learning:


Brought to the customer by Life Customer Care
from Siemens Medical Solutions.

This is a service of Life our customer care solution

* Availability of single applications depending on system prerequisites.

Upcoming Events & Courses


Title

Location

Short Description

Date

Contact

Arab Health

Dubai, UAE

Exhibition and Congress

Jan. 29Feb.1, 2007

www.arabhealthonline.com

ESGAR CTC
Workshop

Nice, France

Hands-on Workshop
on CT Colonography

Jan. 2527, 2007

www.esgar.org

23nd Annual Computed


Body Tomography 2007

Orlando, USA

JHU CME Course

Feb. 1518, 2007

www.ctisus.com

ECR

Vienna, Austria

Exhibition and
Scientific Congress

March 913, 2007

www.ecr.org

ACC

New Orleans, USA

Annual Scientific
Session and Exposition

March 2427, 2007

www.acc.org

Deutsche Gesellschaft
fr Kardiologie

Mannheim,
Germany

73. Jahrestagung

April 1214, 2007

www.dgk.org

ITEM

Yokohama, Japan

Trade fair

April 1315, 2007

www.j-rc.org

Advanced Topics
in CT Scanning:

Baltimore, USA

CT Angiography, 3D:
Current State of the Art,
focus: Cardiac CT

April 2022, 2007

www.hopkinscme.org/

Deutscher Rntgenkongress

Berlin, Germany

Exhibition and Congress

May 1619, 2007

www.drg.de

Stanford Symposium

San Francisco, USA

9th Annual International


Symposium on
Multidetector-Row CT

June 1316, 2007

radiologycme.stanford.edu

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

38

SOMATOM Sessions 19

CUSTOMER CARE

SOMATOM SESSIONS IMPRINT


2006 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:
Andr Hartung
Editors
Monika Demuth, PhD
(monika.demuth@siemens.com)
Stefan Wnsch, PhD
(stefan.wuensch@siemens.com)
Editorial Board
Nina Bastian
Thomas Flohr, PhD
Louise McKenna, PhD
Julia Kern-Stoll
Axel Lorz
Matthew Manuel
Jens Scharnagl
Bernhard Schmidt, PhD
Heiko Tuttas
Authors of this Issue
S. Achenbach, MD, Department of Internal Medicine II, University of Erlangen-Nrnberg, Germany
C. Becker, MD, Institute for Diagnostic Radiology at
Grohadern University Hospital in Munich, Germany
T. Brady, MD, Division of Cardiac Imaging, Department of Radiology, Massachusetts General Hospital
in Boston, MA, USA
M. Das, MD, Department of Diagnostic Radiology,
RWTH University Aachen, Germany

R. Fischbach, MD, Department of Clinical Radiology,


University Mnster, Germany
T. Fischer, MD, Department of Clinical Radiology,
University Mnster, Germany
R. Gnther, MD, Department of Diagnostic
Radiology, RWTH University Aachen, Germany
M. Kalra, MD, Division of Cardiac Imaging, Department of Radiology, Massachusetts General Hospital
in Boston, MA, USA
S. Kloska, MD, Department of Clinical Radiology,
University Mnster, Germany
A. Kosciesza, Department of Radiology,
Dr. Jan Bogdanowicz Independent Group of Public
Health Service, Warsaw, Poland
K. Li, MD, Prof. Xuanwu Hospital, Capital Medical
University, Beijing, China
J. Lu, MD, Xuanwu Hospital, Capital Medical University, Beijing, China
J. Ludwig, PhD, Department of Internal Medicine
II, University of Erlangen-Nuremberg, Germany
A. Mahnken, MD, Clinic for Diagnostic Radiology,
University Hospital in Aachen, Germany
G. Mhlenbruch, MD, Department of Diagnostic
Radiology, RWTH University Aachen, Germany
D. Naidich, MD, Department of Radiology and
Medicine, New York University Medical Center and
School of Medicine, New York, USA
P. Nuzynski, Department of Radiology,
Dr. Jan Bogdanowicz Independent Group of Public
Health Service, Warsaw, Poland

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

J. Vlahos, MD, Department of Radiology and


Medicine, New York University Medical Center and
School of Medicine, New York, USA
J. Wildberger, MD, Department of Diagnostic
Radiology, RWTH University Aachen, Germany
M. Zhang, MD, Xuanwu Hospital, Capital Medical
University, Beijing, China
Hildegard Kaulen, PhD, freelance author,
Tim Friend, freelance author,
Tony DeLisa, freelance author
Jessica Amberg; Karin Barthel; Nina Bastian;
Dagmar Birk; Andreas Blaha; Jiuhong Chen; Hendrik Ditt; Christoph Hachmller, MD; Larissa Heinrich; Lars Hofmann, MD; Julia Kern-Stoll; JohannGerhard Kreft; Per-Anselm Mahr; Louise McKenna,
PhD, MBA; Hansjrgen Lder; Doris Pischitz; Ingo
Schmcking, MD; Gitta Schulz; Stefan Wnsch,
PhD; Zimmermann Alexander; all Siemens
Medical Solutions
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No 19/November 2006
RSNA-Edition
Nov. 26th Dec. 1st, 2006

10.00

www.siemens.com/medical

SOMATOM
Sessions

Highlights
COVER STORY
syngo WebSpace: Leading
the Workflow Revolution in
Volume CT
Page 4
Two: The New
Arithmetic of CT
Page 8
NEWS
Clinically Proven: The
Benefit of syngo Lung CAD
Now PMA Approved
Page 12
BUSINESS
Life in the Global Village:
A Dialogue With
Prof. Michael Knopp, MD
Page 15
CLINICAL OUTCOMES
Oncology Improved Follow
up For Pulmonary Nodules
Page 22
Acute Care NEW: Comprehensive 3D Stroke Imaging
Page 26
SCIENCE
See the Whole Disease:
Neuro Perfused Blood
Volume Imaging
Page 32
EDUCATION & EVENTS
The Worlds First
SOMATOM Definition
Workshop
Page 35

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SOMATOM Sessions
Issue No.19/ November 2006

On account of certain regional limitations of sales


rights and service availability, we cannot guarantee
that all products included in this brochure are available
through the Siemens sales organization worldwide.
Availability and packaging may vary by country and is
subject to change without prior notice. Some/All of
the features and products described herein may not
be available in the United States.
The information in this document contains general
technical descriptions of specifications and options
as well as standard and optional features which do
not always have to be present in individual cases.
Siemens reserves the right to modify the design,
packaging, specifications and options described herein
without prior notice. Please contact your local Siemens
sales representative for the most current information.
Note: Any technical data contained in this document
may vary within defined tolerances. Original images
always lose a certain amount of detail when reproduced.
Please find fitting accessories:
www.siemens.com/medical-accessories

Siemens AG, Medical Solutions


Henkestr. 127, D-91052 Erlangen
Germany
Telephone: +49 9131 84-0
www.siemens.com/medical

Siemens AG, Medical Solutions


Computed Tomography
Siemensstr. 1, D-91301 Forchheim
Germany
Telephone: +49 9191 18-0

2006 Siemens SOMATOM Sessions


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