s

S O M ATO M S E S S I O N S

Multislice CT

Quarter Second CT

Spiral CT

Case Study

Top 10 Q & A

6
 Overline

FROM THE EDITOR

This is the sixth issue of Siemens SOMATOM® Sessions,
which features novel applications of our new multislice CT
– the SOMATOM Plus 4 Volume Zoom. This issue provides
basic information on multislice CT technology, discusses
the advanced applications of cardiac imaging with Quarter
Second CT, and presents the clinical benefits and inter-
relationships of Spiral CT. Other articles include a case study
on pulmonary emboli and responses to the 10 most
frequently asked questions.

As always we would appreciate your suggestions and

comments.

Xiaoyan Chen, M.D.

Editor of SOMATOM Sessions

CONTENTS
Letter from the Editor Page 2

Multislice CT Page 3

Quarter Second CT Page 9

Spiral CT Page 16

Case Study Page 21

The Top 10 Q & A Page 22

2
 Multislice CT
BASICS AND APPLICATIONS
Since Hounsfield and Ambrose presented the first clinical
CT image in 1972, the improvements in image quality
and scan performance have been dramatic. More than any
other development, spiral CT scanning, introduced by
Siemens in 1989 has extended the clinical applications of
CT diagnosis and helped CT to mature to a true volume
imaging modality. The second quantum leap in CT history
occurred recently with the introduction of multislice CT in
1998. The SOMATOM Plus 4 Volume Zoom from Siemens
with a rotation time of 500 ms and simultaneous acquisition
of 4-slice offers an 8-fold increase in performance com-
pared to single slice, one second scanners. This opens up
a whole range of new applications, including Cardiac CT.
In the following, we will discuss the basic concepts, as
well as the clinical applications of multislice CT.
X-ray Tube
Tube Collimator
Collimated Slice
Detector Collimator
Adaptive Array Detector
Single Row Detector
Graphic 1: Side view of the gantry and 3D model
of single row and multirow detectors.
What is Multislice CT?
Conventional CT scanners use a single row of detector
elements and acquire a single slice per rotation. A multi-
slice CT system, in contrast, uses multiple detector rows
and can therefore acquire multiple slices per rotation.
With the SOMATOM Plus 4 Volume Zoom, introduced by
Siemens at RSNA 1998, the improvement is not just 4-slice
acquisition per rotation, but also the gantry rotation has
been sped up to 500 ms. This concept offers tremendous
clinical advantages:
• More speed
A given volume can be scanned in a fraction of the time.
With the SOMATOM Plus 4 Volume Zoom, taking advantage
of the simultaneous acquisition of four slices and the high
rotation speed of 0.5 sec, even high resolution protocols
covering the whole chest can be accommodated in a single
breathhold.
• More volume
The volumes that can be covered in a given time at
a certain resolution are eight times larger than with a single
slice scanner.
• More detail
The z-axis resolution of any protocol can be increased
up to a factor of 8 enabling a tremendous improvement in
the image quality of postprocessing.
• More productivity
The number of images that can be acquired per second
has been increased from one to eight.This results in a
more productive tube usage, since the warranty is given in
scan seconds.
Detector Design
There are essentially two possible approaches to designing
a multislice detector, the Fixed Matrix Detector (FMD) and
the Adaptive Array Detector (AAD).
3
 Multislice CT
4 x 1.25 mm
4 x 2.5 mm
4 x 3.75 mm
4 x 5 mm
Fig. 1a: Available collimations and read-out schemes
for the Fixed Matrix Detector (FMD). The highlighted
bar indicates the collimation at the detector. For
each detector configuration, prepatient collimation is
adjusted correspondingly.
• Fixed Matrix Detector (FMD)
The Fixed Matrix Detector consists of a matrix of detector
elements of fixed width. As an example consider Figure 1a.
The detector consists of 16 rows 1. An electronic switch
in the data acquisition system allows the combination of
several rows to obtain thicker slices. As an example con-
sider a pixel width of 1.25 mm at the center of rotation. Then,
the slice collimations 2 that can be acquired are 1.25 mm,
2.5 mm, 3.75 mm and 5 mm. However, the outer detector
rows of the array will never be used individually, but will
always be combined by the electronic switch.
1
We refer to the sets of detector pixels as rows.The output of the data
acquisition system can be a combination of several rows by means of an
electronic switch.The result is called a slice.
2
With the slice collimation we refer to the width of one of the multiple
slices, scaled to the center of rotation.
4
2 x 0.5 mm
4 x 1.0 mm
4 x 2.5 mm
2 x 8.0 mm
4 x 5.0 mm
Fig. 1b: Available collimations and read-out schemes
for the Adaptive Array Detector (AAD). The highlighted
bar indicates the collimation at the detector. For
each detector configuration, prepatient collimation is
adjusted correspondingly.
Therefore, the septa between the outer detector rows
are unnecessary and undesirable since they deteriorate the
efficiency of the detector by introducing dead spaces.
• Adaptive Array Detector (AAD)
The Adaptive Array Detector, used in the SOMATOM Plus 4
Volume Zoom, optimizes detector efficiency at all slice
collimation settings by using varying row widths. Figure 1b
gives a schematic overview. The widths of the detector
rows increase towards the outer edges. Specifically 1 mm,
1.5 mm, 2.5 mm and 5 mm are combined symmetrically,
allowing for slice collimation of 2 x 0.5 mm, 4 x 1 mm,
4 x 2.5 mm, 4 x 5 mm and 2 x 8 mm. It is evident that the
geometrical design minimizes the dead space in between
the detector rows. The detector in the SOMATOM Plus 4
Volume Zoom uses the Ultra Fast Ceramic (UFC) scintillator
material, which provides the fast response required for
obtaining high resolution images at 500 msec gantry rotation.
Overline

For a given volume, the higher the pitch, the shorter the
Why four slices? scan time.The lower the pitch, the longer the scan time.
All multislice CT systems available today acquire four slices
When the pitch value is fixed, a compromise between z-axis
from one of the two detector designs described above.
coverage and scan time will occur. With the SOMATOM
But why can a detector made up of 16 rows not acquire 16
Plus 4 Volume Zoom, pitch value can be adapted freely
slices? The reason lies in the image reconstruction process.
from 1 to 8 by the software according to the clinical required
In CT image reconstruction, it is usually assumed that all
z-axis coverage and scan time, thus overcoming today’s
rays lie within a common image plane.This is the case
limitations of spiral scanning.
in single slice CT using “stop and go“ mode. In single slice
spiral CT, this condition can be met after an interpolation
step. In multislice CT, however, the outermost rays are not
perpendicular to the axis of rotation but are tilted with
respect to an axial plane by what is called the cone angle.
Hence the rays nutate, or wobble like a top but in a con-
trolled manner.This effect causes cone beam artifacts in
the image.The artifact level depends on the ratio of cone
angle and slice collimation. A detailed analysis shows that,
as a rule of thumb, the cone beam artifacts can be neglected
using up to four slices of detector data. When going to
a higher number of detector rows, visible artifacts appear.
The detector design of the SOMATOM Plus 4 Volume
Zoom is therefore optimized to the acquisition of four slices.

Graphic 2: Pitch Model

Spiral Scanning Pitch in variable from 1 to 3 for single slice CTs (left).
In spiral scanning, pitch is an important factor, as it in- With the SOMATOM Plus 4 Volume Zoom, it can be
fluences the z-axis coverage and spiral scan time. In single freely adapted from 1 to 8 (right).

slice CT, pitch is the ratio of table movement per rotation

In single slice spiral CT, the user typically selects the
over collimated slice thickness, while in multislice CT, pitch
collimation, pitch and tube current.The resulting slice width
is the ratio of table movement per rotation over single
of the reconstructed image, given by its Full Width at Half
collimated slice thickness.
Maximum (FWHM) value, was dependent on the selected
collimation, pitch and the spiral algorithm (i.e. slim or wide).
When the pitch is increased for a given mA setting, the dose
is decreased. However, the image noise stays constant
Slice Table movement Pitch since the slice width is broadened. This results in a differ-
collimation per rotation
ence between the selected slice collimation and the
Single slice CT 5 mm 5 mm 1
obtained slice width for the reconstructed image, and the
Multi slice CT 4 x 5 mm 20 mm 4
z-axis resolution.

5
Multislice CT
Slice Thickness (effective)
3.5
3 4
2.5
2 Wide
1.5
Slim
1
0.5
0 1
0 0.5 1 1.5 2 2.5
Pitch
Graphic 3: Pitch, Algorithm and Eff. Slice Width.
In single slice spiral scanning, the true width of the
reconstructed image is influenced by the pitch
and algorithm applied – what you select may not be
what you get.
In multislice CT, although the technology behind it is so
much more advanced, spiral scanning with the SOMATOM
Plus 4 Volume Zoom has been simplified dramatically.
This is achieved by an innovative spiral interpolation con-
cept from Siemens, the Adaptive Axial Interpolator (AAI).
• What you select is what you get
Rather than selecting a slice collimation and getting a
random slice width of the reconstructed image, the user
chooses the desired slice width together with a collimation
setting. Several collimation settings can produce a desired
slice width. The following rules of thumb apply:
1.The reconstructed slice width can never be smaller than
the slice collimation.
2.The slice collimation determines the z-axis coverage
per rotation.
3. Thinner collimations will improve image quality (reduce
partial volume artifacts), but at the cost of longer scan time.
• Same mAs, same dose, same pixel noise
Instead of selecting tube current (mA) and getting a pitch
dependent dose, the user now selects the mAs in com-
bination with the desired slice width. The software then will
6
4.5
3.5
Slice Width
3
2.5
2
1.5
3 1 2 3 4 5 6 7 8
Pitch
Graphic 4: With the Adaptive Axial Interpolator of the
SOMATOM Plus 4 Volume Zoom, the true width of the
reconstructed image (slice width) is independent of
pitch and algorithm – what you select is always what
you get.
adapt the mA in order to achieve the required dose and
image quality. The user no longer has to distinguish between
different kinds of algorithms. Also, for a given mAs, the
dose applied will be the same as in a sequence scan, inde-
pendent of the pitch. The radiation overlap that decreases
with increasing pitch values is corrected for by increasing
the tube curent for larger pitch values.The pitch-dependent
tube current adjustment is given by
mA (tube current) = mAs per image/Rotation time x Pitch/4.
At a certain rotation time, large pitch means short scan
time but also high tube load. Small pitch means longer
scan time but reduced tube load.
Clinical Applications
In single slice spiral CT, users often had to compromise
between the scan time, the volume coverage, and the slice
collimation. The SOMATOM Plus 4 Volume Zoom has
harmonized these aspects for routine clinical applications,
and opened up new applications.
Overline

• Routine applications With the SOMATOM Plus 4 Volume Zoom, clinical routine
Let’s take one of the routine studies as an example. applications benefit in the following ways:
" Anatomical regions can be acquired in a very short time
Example 1: The same volume can be covered with the with 4 x 5 mm collimation as the fast mode.
same slice collimation in a very short scan time. " Anatomical regions can be acquired in a shorter time
with 4 x 2.5 mm collimation as the routine mode.
Single slice Multi slice " Anatomical regions can be acquired in a reasonable time
Volume coverage (cm) 20 20 with 4 x 1 mm collimation as the thin slice mode.
Rotation time (s) 1 0.5
Slice collimation (mm) 5 4x5 • New Applications
Pitch 1.5 6 " Combi Scan
Scan time (s) 27 3.3 With the SOMATOM Plus 4 Volume Zoom, the data
acquired by narrow slice collimation can be used for both
narrow and thick slice reconstructions thereby avoiding
multiple exposure to the patient. The diagnostic informa-
Example 2: The same volume can be covered with even
tion for both high contrast resolution (e.g. bone structure)
thinner slice collimation in a shorter scan time.
and low contrast resolution (e.g. soft tissue) are obtained
Single Multi Multi from a single scan. This feature is called “Combi Scan“.
slice slice slice
Volume
The clinical examples*:
coverage (cm) 20 20 20
One thorax scan (4 x 1 mm) for both HiRes lung (Fig. 2b)
Rotation time (s) 1 0.5 0.5
and mediastinum study (Fig. 2a).
Slice
collimation (mm) 5 4 x 2.5 4x1 * Clinical example provided by Erlangen University, IMP.
Pitch 1.5 6 7
Scan time (s) 27 7 14
" Cardiac CT imaging
Cardiac CT studies require the following elements:
1) Synchronization of data acquisition to the
Example 3: With the same scan time and even a thinner
cardiac cycle
slice collimation, an even larger volume can be covered.
To achieve this, two methods can be applied which are

Single Multi Multi Multi related to the mode of data acquisition.

slice slice slice slice – Prospective triggering: For sequential scanning a trigger
Volume is derived from the ECG-signal to initiate the CT scan
coverage (cm) 20 162 81 37.8 with a given, user selectable point in time with respect to
Rotation time (s) 1 0.5 0.5 0.5 the R-wave.
Slice – Retrospective gating: For spiral scanning, the ECG signal
collimation (mm) 5 4x5 4 x 2.5 4x1
and the CT data are acquired simultaneously. And then,
Pitch 1.5 6 6 7
the data will be used for image reconstruction relative to
Scan time (s) 27 27 27 27
a selected heart phase.

7
Multislice CT
Fig. 2a: Axial image – 5 mm slice width for soft tissue
study.
2) The fast speed of data acquisition to freeze the
heart motion.
The 500 ms full rotation with the SOMATOM Plus 4 Volume
Zoom allows 250 ms temporal resolution per image to
freeze heart motion. In order to achieve the 250 ms a partial
scan technique is used in combination with an optimized
half scan reconstruction using parallel x-ray geometry.
For detailed information on Cardiac CT imaging with
SOMATOM Plus 4 Volume Zoom see “Quarter Second CT“
– also included in this issue.
Summary
The key benefit of multislice spiral imaging in combination
with 500 ms rotation time is a significantly improved z-axis
resolution relative to volume coverage.
For clinical applications this opens up the possibility to:
• Scan long volumes in practical times
8
Fig. 2b: MPR – 1 mm slice width for HiRes lung study.
• Scan given volumes in extremely short times and
• Scan given volumes with narrow collimation for
excellent 3D-resolution within practical scan times.
Particularly this last feature is crucial to optimizing image
quality of transaxial slices as well as of 3D-renderings.
The huge number of images, generated with such spiral
protocols, also calls for intelligent approaches to viewing
and diagnosis. Volume rendering methods, as provided on
the 3DVirtuoso, will become a more standard procedure
to approach the diagnostic process in a manner oriented
towards volume viewing. Similarly cine viewing and MPRs
are expected to become a more integral part of the diag-
nostic process.
An attractive procedure, also derived from narrow collima-
tion scanning, is the combination examination, which let
one obtain low and high contrast information from the same
scan and thereby avoids multiple exposures to a patient.
 Quarter Second CT
CARDIAC IMAGING
Introduction
For the diagnosis of coronary artery disease, the Electron
Beam CT (EBCT) used to be considered as the non-invasive
imaging modality, which has the potential to image the
coronary arteries for diagnostic and follow-up purposes in
addition to the common application of calcium scoring
([1], [2], [3], [4]).
However, clinically the reproducibility in the visualization
of coronary plaque including non-calcified atherosclerotic
plaques and optimized 3D visualization of the coronary
arteries has been questioned ([5]). Because of the restric-
tion to non-spiral scanning in ECG supported cardiac
investigations, 3D calcium scoring and contrast enhanced
visualization of the coronary arteries using EBCT suffers
from sub-optimal volume coverage and restricted z-reso-
lution within a single breath-hold scan.
The advent of “Subsecond Cardio CT“ with the SOMATOM
Plus 4, in combination with prospective ECG-triggering
and retrospective ECG-gating, has challenged EBCT in the
domain of cardiac imaging ([5], [6]).
The introduction of the SOMATOM Plus 4 Volume Zoom
– the multislice CT acquires 4 slices simultaneously with
500 ms rotation speed and 250 msec temporal resolution
opens new horizons for the cardiac CT imaging. With sig-
nificantly faster volume coverage the total examination for
quantification of coronary calcium is completed in a single
breath-hold. The detection accuracy is improved due to
the significant decrease of interscan misregistration.The
improvement in scan speed can be invested in a reduction
of the collimated slice width in order to approach the
isotropic image data acquisition with gap-less coverage of
the entire heart and excellent z-resolution for CT Angio-
graphy of the coronary arteries.
This article will explain the principles of prospective
ECG-triggered sequential scanning and retrospective ECG-
gated spiral scanning with SOMATOM Plus 4 Volume
Zoom. To indicate the potential of “Quarter Second CT“ for
the current and future cardiac imaging applications, the
first clinical results of calcium imaging and high resolution
CT Angiography examinations of the coronary arteries will
be presented.
Principals
To freeze-frame the heart, there are two important aspects
of cardiac CT imaging: the synchronization of the data
acquisition or reconstruction to the cardiac cycle, and the
high temporal resolution. In addition, the data has to be
acquired within a single breath-hold with high 3D-resolution.
To achieve this, there are two different approaches des-
cribed as follows:
• Prospectively ECG-Triggered Sequential Scanning
For sequential scanning, a prospective trigger is derived
from the ECG-trace to initiate the scan with a certain user
selectable delay time after the R-wave (Figure 1a). Usually,
the delay is defined such that the scans are acquired
during the diastolic phase of the heart.
Such procedures are well known from using EBCT ([7])
and the SOMATOM Plus 4 with “Subsecond Cardio CT“.
The clinical investigations have clearly indicated the equi-
valency of these two modalities with respect to coronary
calcium scoring ([6]).
With the SOMATOM Plus 4 Volume Zoom, the full rotation
time has been accelerated up to 500 ms. And a special
algorithm has been optimized using parallel x-ray beam
geometry for half scan reconstruction. In combination with
the partial scan technique, the temporal resolution is
improved to 250 ms, which can virtually freeze the heart
motion.
9
Quarter Second CT

ECG R R R
ECG R R R

(a) Delay Recon Delay Recon Spiral Scan

(a) Delay Scan Delay Scan Table Feed

“3D“ Image data

Sequential nuous ed

Recon
t i

Z-Position
images Con an & Fe
(b) al Sc

Recon
Spir
Z-Position

(b)
Scan

Recon
Recon
Delay ECG
10 mm Feed
Scan

Delay
R R R R
R R R R ECG

Time Time

Fig. 1a: Principle of Prospectively ECG-Triggered Fig. 2a: Principle of Retrospectively ECG-Gated
Sequential Scanning. Spiral Scanning.
Fig. 1b: Multislice CT with Prospectively ECG-Triggered Fig. 2b: Multislice CT with Retrospectively ECG-Gated
Sequential Scanning. Spiral.

Compared to single slice CT and EBCT, the SOMATOM
Plus 4 Volume Zoom acquires simultaneously 4 slices per
prospective ECG-trigger. This provides two important
clinical advantages: The scan time to cover heart anatomy
over a 120 mm volume is reduced to about 15 sec, i.e. well
within a single breath-hold (the exact time depends on
the cardiac frequency). Further, the simultaneous acquisition
of 4 adjacent slices effectively reduces the misregistration
of lesions (e.g. calcifications) due to significant motion of
the heart in the z-direction.
The principle of sequential volume acquisition using a
4-slice system combined with ECG-triggering is illustrated
in Figure 1b.
• Retrospectively ECG-Gated Spiral Scanning
With this technique a continuous spiral scan is acquired with
the ECG-signal recorded simultaneously. The scan data
is selected for image reconstruction with respect to a pre-
defined heart phase. Similar to ECG-triggered sequential
scanning a certain R-peak delay defines the start point of
data that is used for image reconstruction (Figure 2a).
This has already been applied to conventional single slice
CT scanners such as the SOMATOM Plus 4 with Sub-
second Cardio CT, and recent studies clearly indicated
the clinical validity of the method to study heart anatomy
virtually free of motion artifacts ([8]). The method was
observed to improve cardiac image quality compared to
prospective ECG-triggering techniques due to reduced
sensitivity to heart rate arrhythmia. However, in order to
get gap-less image reconstruction in Z-direction for diastolic
phase, an overlapping acquisition during spiral scan has to
be applied. For a single slice system, it is difficult to cover
the entire heart within a practical scan time.
With multislice spiral scanning, this has been improved.
The increased volume scan speed compared to a single
slice system easily limits the scan time to a single breath-
hold. Overlapping images (increment < slice width) that
are reconstructed at arbitrary z-positions provide volume
images with improved z-resolution in predefined but
selectable heart phases. From the continuous multislice

10
Overline
spiral data set, data is retrospectively selected for recon-
struction by definition of a certain phase specific time delay
relative to the R-peaks. 3D images can be reconstructed
in incrementally shifted heart phases from the same spiral
data set to produce a “4D“ series that covers a complete
heart cycle.
For the SOMATOM Plus 4 Volume Zoom, a new spiral
reconstruction algorithm dedicated for Cardiac imaging has
been developed for multislice scanning, and this is opti-
mized to improve the temporal resolution and image quality
of the beating heart. For cardiac multislice investigations,
a low spiral pitch value is required in order to produce gap-
less volume reconstruction for a dedicated cardiac phase.
This may result in a degradation of temporal resolution.
Therefore we developed a new partial scan based spiral
reconstruction approach optimized for multislice techno-
logy which provides appropriate temporal resolution.
To reduce spiral artifacts due to table movement and to
provide a well-defined slice sensitivity profile, a spiral
weighting operation is applied to multislice fan beam data
to produce a “planar“ partial scan data set for each image.
The optimized “half-scan“ partial scan algorithm that is also
used for sequential cardiac imaging is applied to this data.
Hence, the temporal resolution of 250 ms is maintained for
cardiac spiral images.
An example for the accumulation of volume image data
from stacks of axial images (shaded stacks) in consecutive
heart cycles is shown in Figure 2b. All image stacks are
reconstructed in the same relative heart phase. It shows
the 4 slices relative to the patient with increasing time. In
each stack, images are generated equidistantly in the z-axis
according to the selected image reconstruction increment.
Figure 2b also indicates that for continuous volume cover-
age the spiral pitch needs to be adapted to the heart rate in
order to avoid gaps in between the image stacks of differ-
ent cycles.The pitch has to be selected according to the
minimum heart rate that is expected during the scan. We
define the spiral pitch as table feed per full rotation norma-
lized to the width of one slice of the multi slice detector
(e.g. if the slice collimation is 4 x 1 mm, and the table feed
per rotation is 2 mm, then pitch = 2). For normal heart
rates (~ 60-100 bpm) pitch values in the range of 1.5 to 2.5
have to be used.
The significant improvement in scan speed with multi slice
technology can be used for a reduction of the slice colli-
mation for high z-resolution imaging. With 4 x 1 mm colli-
mation and 500 msec rotation time the usual scan time for
a high resolution cardiac spiral scan is 25-30 sec – still
within a single breath-hold. With these parameters, retro-
spective spiral ECG-gating is a well-suited scan technique
for CT angiography of the coronary arteries.
Clinical Experience
Prospective ECG-triggering and retrospective ECG-gating
are installed as “work-in-progress“ versions with the
SOMATOM Plus 4 Volume Zoom at several clinical sites.
Extensive studies are in work to investigate and confirm
the relevance of the cardiac package for clinical application.
• Calcium scoring
Based on the experience with EBCT, the evaluation of cal-
cified plaques in the coronary arteries using the established
“Agatston“ scoring procedure is considered to be the “tra-
ditional“ cardiac CT application. Multislice scan technology
in combination with volume based evaluation methods
([10]) now promises to provide a highly reproducible and
reliable tool for quantification of coronary atherosclerosis.
Coronary calcium scoring can be performed with both
presented scan techniques – ECG-triggered sequence and
ECG-gated spiral.
11
Quarter Second CT
An appropriate scan protocol for sequential cardiac CT
is as following:
• 4 x 2.5 mm collimation
• 2.5 mm slice width
• 500 msec rotation
• 250 ms temporal resolution
• 140 kV
• 20-40 mAs (depending on patient obesity)
• 1.5 sec cycle time (actual value depends on heart rate)
• Z-coverage of 120 mm in 18 sec.
Due to the very fast scan times, the entire heart can be
conveniently covered within a single breath-hold. 250 msec
temporal resolution combined with advanced trigger
algorithms provide virtually motion-free images also for
patients with accelerated heart rates (Figure 3).
a b
Fig. 3: Examples of Coronary Calcium Imaging with
ECG-Triggered Sequential Scanning.
(a): Heart Rate 120 bpm, (b): Heart Rate 70 bpm
Data from Institute of Diagnostic Radiology, Erlangen
ECG-triggered multislice CT shows 2 major advantages
over single slice EBCT. First, multislice acquisition promises
improved calcium quantification and reproducibility as
misregistration is largely eliminated. Due to the complex
3 dimensional motion of the heart, single slice sampling
faces a considerable probability to miss calcifications or to
12
count them twice. 4-slice imaging considerably reduces
this probability. Moreover, EBCT is restricted to fixed mAs
setting (67 mAs). With multislice CT the mAs setting can
be adjusted to the patient’s obesity in order to provide
appropriately low image noise for accurate calcium evalua-
tion for all patients. Figure 4 shows in a representative
example that only the SOMATOM Plus 4 Volume Zoom
can provide appropriate image data for obese patients.
a b
Fig. 4: Comparison of EBCT and the SOMATOM Plus 4
Volume Zoom with ECG-Triggered Sequential Scanning.
(a): EBCT Image
(b): SOMATOM Plus 4 Volume Zoom Image
Data from Institute of Diagnostic Radiology, Klinikum Großhadern
ECG-gated spiral CT is also well suited for coronary calcium
imaging. Non-overlapping sequential scanning contributes
to the inter-scan variability of Agatston- and 3D-based
Ca-scores due to partial volume errors in plaque registration.
This is no longer true for ECG-gated volume data acquisition
with multislice spiral CT and overlapping image recon-
struction. Continuous image data with improved z-coverage
presents the possibility to quantitatively evaluate calcified
plaques individually in terms of volume, mass and density
with high reproducibility. This will be of high value for
coronary calcium scoring and follow-up calcium of coronary
calcium load of patients with transplanted hearts.
Overline
For calcium imaging with ECG-gated spiral CT the following
scan parameters are usually used:
• 4 x 2.5 mm collimation
• 3 mm slice width
• 1 mm reconstruction increment
• 500 msec rotation
• 250 ms temporal resolution
• 140 kV
• 20-40 mAs per slice (depending on patient obesity)
• Pitch 1.5-2.5 (actual value depends on heart rate)
• Z-coverage of 120 mm in 10-15 sec
Figure 5 shows an image example in comparison with the
corresponding EBCT result.
a b
Fig. 5: Comparison of EBCT and the SOMATOM Plus 4
Volume Zoom with ECG-Gated Spiral.
(a): EBCT Image
(b): SOMATOM Plus 4 Volume Zoom
Data from Institute of Diagnostic Radiology, Klinikum Großhadern
• Coronary CTA and cardiac functional imaging
ECG triggered multi slice sequential scanning can be applied
to coronary CT Angiography. The entire heart can be
acquired with 4 x 2.5 mm collimation in a single breath-hold,
however the resolution is not optimal. To improve the reso-
lution, the 4 x 1 mm collimation would be optimal but the
entire heart can barely be acquired in a single breath-hold.
ECG-gated multislice spiral CT represents a quantum leap
in image quality of CT angiography of the coronary arteries.
Volume images based on 3 mm slice width are already of
higher quality than sequential CT data due to overlapping
reconstruction with 1 mm slice increment.The fast scan
speed even allows covering the heart with 4 x 1 mm colli-
mation within a single breath-hold time (10 cm in 25-35 sec).
3D reconstructions with 1.25 mm slice width and sub-
millimeter increment provide data of unique quality for
visualisation of the coronary arteries.
Figure 6 proves the gain in z-resolution with 1 mm colli-
mation versus 2.5 mm collimation. Figure 6a represents a
sagital MPR generated in diastole from 3 mm slices with
1 mm increment. For comparison the MPR in Figure 6b
shows an equivalent plane for a different patient with com-
parable heart rate. This MPR is also generated in diastole
but is now based on 1.25 mm slices and 0.5 mm increment.
A significant improvement in z-resolution can be observed,
e.g. in the calcified LADs and in the valves.
a
b c
Fig. 6: Coronary CT Angiography with the
SOMATOM Plus 4 Volume Zoom with ECG-Gated Spiral
(a): 3mm slice width, Diastole
Data from Institute of Diagnostic Radiology, Erlangen
(b): 1.25 mm slice width, Diastole,
(c): 1.25 mm slice width, Systole,
Data from Institute of Diagnostic Radiology, Klinikum Großhadern
13
Quarter Second CT

Figure 6c illustrates the “4D“ series imaging capabilities

of the technique. It represents an MPR in the same sagital
plane and for the same scan as Figure 6b but generated
from a 3D image volume that was reconstructed in the
systolic phase. The excellent contrast of the left ventricle in
relaxation (Figure 6b) and contraction (Figure 6c) indicates
that the method is also well suited for advanced evaluation
of functional parameters.

From first clinical experience, the proposed scan

parameters for coronary CT Angiography are as follows:
• 4 x 1 mm collimation
• 1.25 mm slice width
• 0.5 mm reconstruction increment
• 500 msec rotation
• 250 ms temporal resolution
Fig. 7a: Coronary CT Angiography –
• 140 kV Two stents in the LAD and RCA.
• 100-150 mAs (depending on patient obesity) Data from Institute of Diagnostic Radiology, Klinikum Großhadern

• pitch 1.5-2.5 (actual value depends on heart rate)

• Z-coverage of 100 mm in 20-30 s.
The main application fields of non-invasive visualization
of the coronary arteries are visualization of stenosis
and post-interventional follow-up investigations (e.g. stent,
bypass patency). For best visualization, advanced 3D
postprocessing techniques such as Volume Rendering
Technique (VRT), Surface Shaded Display (SSD) or
Fly through have to be applied to the 3D image data.
Figure 7a and b show VRT images that were generated
on a Siemens workstation – “3DVirtuoso“. In addition
to the main coronary artery branches, the images also
resolve many of side branches with smaller diameter.
Figure 7c and d are the corresponding screen shot of the
“fly-through“ on the 3DVirtuoso.

Fig. 7b: Coronary CT Angiography –

The LAD and its origin.
Data from Institute of Diagnostic Radiology, Klinikum Großhadern

14
Quarter Second CT
Fig. 7c: Fly through the left coronary artery –
The VRT image (left), the MPR reference guidance
(right upper) and the inner view of coronary artery
(right lower).
Data from Institute of Diagnostic Radiology, Klinikum Großhadern
Fig. 7d: Fly through the right coronary artery –
The stent patency in the RCA.
Data from Institute of Diagnostic Radiology, Klinikum Großhadern
In conclusion, “Quarter-second CT“ for cardiac imaging
with the SOMATOM Plus 4 Volume Zoom delivers multi-
slice acquisition and 250 msec temporal resolution with
superior image quality. Present clinical studies under
evaluation being conducted will evaluate the suitability of
this new cardiac imaging tool to evaluate calcified plaques
as part of a for non-invasive diagnosis of coronary artery
disease in comparison with EBCT and “gold-standard“
coronary angiography.
References
[1]: Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M, Detrano R (1990)
Quantification of Coronary Artery Calcium Using Ultrafast Computed Tomography.
J Am Coll Cardiol 15:827-832.
[2]: S. Achenbach, W. Moshage, D. Ropers, K. Bachmann (1998) Curved Multiplanar
Reconstructions for the Evaluation of Contrast-Enhanced Electron-Beam CT of the
Coronary Arteries. AJR 1998 170:895-899.
[3]: S. Achenbach, W. Moshage, D. Ropers, J. Nössen, WG. Daniel (1998) Value of
Electron-Beam Computed Tomography for the Non-Invasive Detection of High-Grade
Coronary Artery Stenoses and Occlusions. N Engl J Med 339:1964-71.
[4]: PA. Wielopolski, RJM. van Geuns, PJ. de Feyter, M. Oudkerk (1998) Coronary
Arteries. Eur. Radiol. 8:873-885.
[5]: SD. Flamm (1998) Coronary Artery Calcium Screening: Ready for Prime Time?
Radiology 208:571-572.
[6]: CR. Becker, A. Knez,TF. Jakobs, S. Aydemir, A. Becker, UJ. Schöpf, R. Brüning,
R. Haberl, MF. Reiser (1999) Detection and Quantification of Coronary Artery Calcification
with Electron-Beam and Conventional CT. Eur Radiol 9:620-624.
[7]: Ultrafast CT for Coronary Calcification (1991). Lancet 337:1449-50.
[8]: M. L. Bahner, J. Boese, A. Lutz, H. Wallschlaeger, J. Regn, K. Klingenbeck-Regn,
G. van Kaick (1999) Retrospectively ECG-gated Spiral CT of the Heart and Lung.
Eur Radiol 9:106-109.
[9]: K. Klingenbeck, S. Schaller,T. Flohr, B. Ohnesorge (1999) Subsecond Multi-Slice
Computed Tomography: Basics and Applications.To be published in Eur J Radiol.
[10]: TQ. Callister, B. Cooil, SP. Raya, NJ. Lippolis, DJ. Russo, P. Raggi (1998) Coronary
15
 Spiral CT

CLINICAL BENEFITS
Unfortunately this increased speed was neither fast enough
Conventional CT to allow an entire anatomic region to be acquired in a single
In conventional CT, images are acquired on a slice-by-slice
breath hold nor sufficiently quick to enable differentiation of
basis, typically during a 360° rotation of the x-ray tube
contrast enhancement phases.
and detector. This was originally due to the need to supply
power to the rotating part of the CT gantry and to transfer
scan data from the gantry to the image processor. The
length of the high voltage and data cables required for this
represented a limitation to rotation of only slightly more
Spiral CT
With the advent of Spiral CT, introduced with the
than 360°.
SOMATOM Plus in 1989, a full 360° scan was slashed to
only 1 second and interscan delay was eliminated.
Throughout the history of CT, there has been a constant
Spiral CT was undoubtedly the most important innovation
striving to reduce the time required for each image and for
in CT since CT’s introduction in the early 70’s.
the entire examination so as to acquire as many images as
possible per unit of time. This has resulted in ever-decreas-
In this mode of operation, the patient is continuously moved
ing scan times and shorter and shorter interscan delays
through the scan plane while the x-ray tube and detector
(i.e. the time lapse between the end of one scan and the
constantly rotate about the patient, emitting radiation and
beginning of the next).The restriction of having to rewind
collecting scan data. Slip rings are employed for power
power and data cables following each 360° rotation pre-
supply and data transfer. Special algorithms are utilized for
vented a reduction of the interscan delay beyond 1 second.
image reconstruction, which will be discussed in some
Still, even prior to Spiral CT, this did allow about 20 images
detail below.
to be acquired in only one minute in dynamic mode, as
opposed to, say, 10 images in standard mode.

Standard vs. Dynamic Scanning in Conventional CT Conventional CT vs. Spiral CT

Conventional CT Spiral CT
Standard:
– Longer cycle time
but instant display I.S.D* I.S.D

*Inter Scan Delay

Dynamic:
– Fast acquisition
but delayed display
w/ I.S.D* w/o I.S.D

I.S.D I.S.D I.S.D I.S.D *Inter Scan Delay

Fig.1: The use of dynamic scan modes permitted Fig. 2: Spiral CT eliminated interscan delay, allowing
interscan delay to be shortened to only 1 second. more images to be acquired per unit of time.

16
Spiral CT

Arterial phase Venous phase

Fig. 3: Acquisition of images in different phases of

contrast enables differential diagnosis.

A number of clinical benefits derive from the use of the • Slice misregistration (i.e. double acquisition of the same
Spiral CT technique: anatomy or gaps) cannot occur, assuming acquisition is
• Longer anatomic regions can be acquired during a single limited to single breath hold.
breath hold, decreasing the probability of patient motion,
which would degrade image quality. In addition thinner
slices may be acquired in the same time (due to “pitch“
which will be discussed below) and freely definable The Next Slice May Not Be The Next Slice
overlapping images can be reconstructed, improving the
detection of small lesions and the quality of post-pro-
cessed images.
• Smaller volumes of contrast media are required, a large
number of images can be acquired during each contrast
enhancement phase, and the differentiation of these
phases is facilitated.

Deep Inspiration Moderate Inspiration

Fig. 4: Changes in breath hold can easily place

anatomy and pathology outside the scan plane of
non-spiral acquisitions.

17
Spiral CT
The Interrelationships of
Spiral CT
To truly comprehend how Spiral CT really works, it is
necessary to understand the interrelationships of a number
of factors:
• Nominal slice thickness
• Table movement
• Pitch
• Effective slice thickness
• Wide and slim spiral reconstruction algorithms
• Noise
• Rotation time
• Temporal resolution
• Reconstruction increment
• Image and patient dose
Setting up Spiral CT and conventional CT exams is iden-
tical in many ways. For instance, slice thickness must be
selected in advance in both modes.
In contrast to conventional CT, however, the table is con-
tinuously moved during Spiral CT. As one can imagine, this
movement results in a widening of the selected, or nomi-
nal, slice thickness to what is referred to as the effective
slice thickness.The degree to which the slice is widened
depends on the speed with which the table is moved
through the scan plane during each rotation.This brings us
to the next concept: pitch.
Pitch is the relationship between table movement per rota-
tion and nominal slice thickness. For example, let’s assume
a slice thickness of 2 mm and a table movement of 3 mm
per rotation. That results in a pitch of 1.5. With state of the
art single detector Spiral CT scanners, one can employ a
pitch of up to three.
18
But, you may ask, doesn’t that result in an extremely wide
effective slice thickness? That brings us to the next point:
wide (360°) and slim (180°) reconstruction algorithms.
Let’s first discuss the wide algorithm. Since in Spiral CT
the patient is continuously being moved through the scan
plane, the scan data acquired during the rotation, say at
the 12, 3, 6 and 9 o’clock positions, are not obtained from
one and the same table position. Fortunately, the slices
employed in CT are sufficiently narrow and the human
anatomy within these narrow slices is uniform enough to
permit interpolation of two data points measured in the
vicinity of the slice and separated by 360° of rotation.The
data point closest to the slice receives more weight, or
counts more, in the reconstruction.
Data
Table position
Weighted Slice Interpolation
Fig. 5: Data from two 360° rotations are interpolated
and then used to reconstruct an image at the desired
table position.
As compared to conventional CT, image noise is reduced
and image contrast is increased when wide algorithms are
utilized.This is because data points from a greater volume
are being used. Unfortunately, some of the data points
are located quite some distance from the slice being recon-
structed. This results in a widening of the effective slice
thickness of 27% at pitch 1and 120% at pitch 2! For that
reason, one should not generally employ a wide algorithm
when pitch greater than one is used.
Spiral CT
Slim algorithms take advantage of the fact that attenuation,
or the weakening of x-rays, is the same whether the x-ray
originates from the 12 or 6 o’clock or the 3 or 9 o’clock posi-
tions, for instance. Slim algorithms also involve the inter-
polation of two data points measured in the vicinity of the
slice to be reconstructed. To permit the distance between
the measured data and the slice to be reduced, however,
“complementary“ data are generated by assuming that the
same data would have been obtained had the measure-
ment taken place 180° later. Complementary data are just
the mirrored image of measured data.
Measured
data
Comple-
mentary
data
Table position
Slice
Fig. 6: Complementary data are generated from
measured data. Then the data from two half rotations
are interpolated and used to reconstruct an image
at the desired table position.
As a result, the effective slice thickness of images recon-
structed with slim algorithms is virtually the same at pitch
one and only 27% greater at pitch two, as compared to
conventional CT images. For this reason, use of slim algo-
rithms is to be recommended when pitch greater than
one is employed and when images are being acquired for
post-processing purposes, i.e. MPR, 3D SSD, MIP, VRT
and virtual endoscopy.
Slim vs. Wide Spiral Reconstruction Algorithms
Slice Thickness (effective)
3.5
3
2.5
2 Wide
1.5
Slim
1
0.5
0
0 0.5 1 1.5 2 2.5 3
Pitch
Fig.7: The use of “Slim“ permits slice widening to be
limited to only 27% at pitch 2!
A minor disadvantage of slim algorithms is that noise is
increased by 16%. Offsetting this disadvantage is the fact
that, since the data points are only 180° apart, the tem-
poral, or time, resolution is half that of the rotation time.
So for a rotation time of 750 ms, the temporal resolution is
375 ms when a slim algorithm is employed.
A benefit inherent to Spiral CT for post-processing is the
ability to reconstruct freely definable overlapping images.
For instance, 3 mm slices may be reconstructed with 1 mm
reconstruction increments, so images are reconstructed
every 1 mm, i.e. with an overlap of 67%. Such an overlap
will eliminate the “steps“ sometimes seen in the highly
absorbent anatomic structures of post-processed images.
This inherent capability dramatically improves such clinical
tools as cinematic image review, multiplanar reformatted
images, and 3D shaded surface display images. The ability
to acquire and reconstruct a large number of thin images
at peak contrast enhancement has also led to a number
of clinical methods not available prior to the introduction
of Spiral CT, such as maximum intensity projection and
the volume rendering technique for the visualization of the
vasculature and virtual intra-lumenal procedures.
19
Spiral CT

An often overlooked advantage of Spiral CT is the ability

to freely define pitch.This allows users to take advantage
of an interesting characteristic of spiral reconstruction algo-
rithms. By increasing both the mA setting and the pitch,
one is able to both increase the dose in the image and
decrease patient dose. To illustrate this, let’s assume a slice
thickness of 10 mm and a table movement of 17 mm per
rotation. Spiral reconstruction algorithms utilize the dose
No Overlap
applied over the entire 17 mm, “moving“ the quanta in
effect into the 10 mm slice, wherever it may be located
along the z-axis. Since only a portion of the dose was
actually applied within the 10 mm slice, however, the patient
receives less dose.

Summary
Spiral CT, introduced with the SOMATOM Plus in 1989,
was the most important innovation in CT since its invention
50% Overlap
in the early 70s. Numerous clinical benefits can be derived
from Spiral CT, and these benefits can be increased through

Fig. 8: The quality of postprocessed images is dramati- a more thorough understanding of a number of interrelated
cally improved through the use of overlapping images. spiral parameters.

20
 Case Study
PULMONARY EMBOLUS
Patient History
A 72 years old female was admitted for Drainage of Hepatic
Abscess following surgery for Cholecystectomy, suddenly
happened an Acute onset of Shortness of breath,
Tachycardia and Hypoxia. The patient had a previous history
of Pulmonary Embolus following a Total Knee Replacement.
The Provision Diagnosis was Acute Pulmonary Embolism.
Techniques:
We use Siemens SOMATOM Plus 4 CT Scanner, and a
BIOTEL Power Injector for contrast medium injection.
* The drugs and doses mentioned herein are consistent with the approval
• Patient position: Supine & Head first (her head was
raised considerably due to her shortness of breath).
• 140 kV/240 mA/1 sec
• 3 mm Slice Thickness
• 4.5 mm Feed (Pitch of 1.5)
• AB40
• Scanned Caudo-cranially (bottom to top)
• Images reviewed at 1.5 mm increment for MPR’s
• Contrast injection*: start delay 15 s, 120 mls I.V at
a flow rate of 2.5 ml/s (the patient had dreadful veins).
Result:
• Extensive clot was seen at the division of both Main
Pulmonary Arteries.
• The clot extended into Segmental Branches of the
Mid & Lower zones bilaterally.
• Large Right Pleural Effusion
• Evidence of thrombus in the IVC just below the level
of the Left Renal Vein.
Remarks:
The patient was unable to hold her breath at all, and we
were unable to inject at a higher rate due to the patient’s
lack of venous access. However, due to the fast speed of
Spiral CT, we were still able to obtain a reasonably “good“
study although it was not “Text Book“ perfect but still
provided us with the diagnosis required in a minimal time.
Treatment with Heparin was started immediately the
patient returned to the ward. And the patient was rescanned
one week later and the emboli had reduced markedly.
She was discharged 3 weeks later.
labeling for uses and/or indications of the drug.The treating physician bears
the sole responsibility for the diagnosis and treatment of patients, including
but not limited to the parameters selected during image acquisition and
postprocessing and any drugs and doses prescribed in connection with
such use.
21
 FAQ

TOP TEN Q & A

Q Is it possible to use CARE Vision with a gantry tilt? Q What do the numbers in the lower left corner of
A Plus 4 – Yes, you can angle the gantry as long as x-ray the images mean?
is off. A Plus 4/AR Spiral –
Second to the Last Row:
Q How can I change the default Field of View for the AB**- Kernel
scan modes and CARE Vision? Focal Spot – S = small, L = large (Focal spot size is
A Plus 4 – In the Scan Mode Window, click the Image applied automatically, only on a 1 mm or 2 mm slice)
softkey on the left. Change the FOV and click Store. MCA – M = on, 0 = off

Q When using DXP, why does the scan cancel
automatically?
A Plus/S – If the tube cooling delay exceeds 300 seconds,
the system will cancel the mode. This gives you the
opportunity to adjust the scan parameters to reduce
the cooling delay.
Q Why doesn’t the system print my last film sheet?
A Plus 4/AR Spiral – Go to Film/Settings Platform and be
sure that Auto Change is answered YES. The film will
change when a new patient is registered.
Plus/S/HiQS – Use the command EXP/END to close
the job and send the last sheet to the camera.
Last Row:
Adaptive Filter – 1 = on, 0 = off
MBH – 1 = on, 0 = off
Balancing – 1 = on, 0 = off
Z-Profile Algorithm – W = wide, S = slim, I = slim 2
Tube Position at Start of Scan – “Clock Hour Count“
Time Since Last Calibration – Hourly Count
Image Display Format –
0 = Original, 1 = Compressed, 2 = Briefed,
3 = Briefed & Compressed
Q Why don’t the procedures run after the VB31F
software upgrade?
A Plus/S – Go into the procedure using PROC/MOD,
then remove any “Wait“ commands that are in the
procedure.

22
 Overline

Q How can I have a Reference Topogram in the
images?
A Plus 4/AR Spiral – First acquire the topogram, then put
the active segment on the topogram. Go into Filming/
Interactive and click the RefTopo softkey. Scan the
patient and be sure auto-filming is turned ON during
scanning.The images will be filmed with a small
topogram, the topogram will not be displayed on the
monitor. This will also work when reviewing the raw
data after the scanning is completed.
Plus/S/HiQ – Go into DISPLAY, SET the Permanent
Topogram, the images will appear with a small topo-
gram in the upper right corner on the monitor and
the film.
Q Can I delete selected patients or images
from the MOD?
A All Systems – It is only possible to delete the entire
side of an MOD, not individual patients.
Q The system is not sending my films to the camera,
how can I correct this without rebooting.
A Plus 4/AR Spiral – Go to System/Run, click expo_init,
then GO. Go into the Job/Control and click Continue.*
Plus/S/HiQ – Type EXP/INIT, then type
EXP/CONTINUE.*
Lisa Reid
CT Application Manager

Q If I Filter an image, how can it be stored

permanently in the image list?
A Plus 4/AR Spiral – Display the image in the active
segment, then do a Copy/Seg*
Plus/S/HiQ – Display the image on the monitor, then
do a COPY/SCREEN.*

* NOTE: This will work for any images you would like to save. For example; * NOTE: This may also need to be done it for some reason the camera is
images with ROI or Distance,Topograms with the lines, Magnified images, turned off, and then on again without re-booting the system.
etc..

23
THIS ISSUE’S AUTHORS
For “Multislice CT –
Basics and Applications”
Xiaoyan Chen, Stefan Schaller,
Thomas Flohr
CT Product Creation
Siemens AG
Medical Engineering
Siemensstrasse 1
91301 Forchheim, Germany
For “Quarter Second CT – Cardiac
Imaging with the SOMATOM Plus 4
Volume Zoom”
Bernd Ohnesorge
CT Product Creation
Siemens AG
Medical Engineering
Siemensstrasse 1
91301 Forchheim, Germany
IMPRESSUM
Published by
CT Marketing
Siemens AG
Medical Engineering
Siemensstrasse 1
91301 Forchheim, Germany
Correspondence
and U.S. Distribution
Barbara Cammisa
Siemens Medical Systems, Inc.
186 Wood Avenue South
Iselin, NJ, 08830, USA
Phone +01 412 351 0803
Fax +01 732 321 3291
eMail barbara.cammisa@
exchange.sms.siemens.com
For “The Clinical Benefits and For “Case Study: Pulmonary Emboli”
Interrelationships of Spiral CT”
Donna Press
George Savatsky Chief Radiographer
CT Marketing
RAYSCAN IMAGING
Siemens AG The Hills Private Hospital
Medical Engineering 499 Windsor Road
Siemensstrasse 1 Baulkham Hills NSW 2153
91301 Forchheim, Germany Sydney, Australia.
For “Top 10 Q & A”
Lisa Reid, B. S., R.T. (R)
CT Application Manager
Siemens AG
Medical Engineering
Siemensstrasse 1
91301 Forchheim, Germany
International Distribution
Xiaoyan Chen, M.D. George Savatsky, B.A., M.A.
CT Product Creation CT Marketing
Siemens AG, Medical Engineering Siemens AG, Medical Engineering
Siemensstrasse 1 Siemensstrasse 1
91301 Forchheim, Germany 91301 Forchheim, Germany
Phone +49-9191-18-9652 Phone +49-9191-18-8142
Fax +49-9191-18-9998 Fax +49-9191-18-9998
eMail xiao-yan.chen@med.siemens.de eMail george.savatsky@med.siemens.de
Lisa Reid, B.S., R.T. (R)
CT Application Manager
Siemens AG, Medical Engineering
Siemensstrasse 1
91301 Forchheim, Germany
Phone +49-9191-18-8405
Fax +49-9191-18-9998 Order No. A91100-M2100-E946-01-7600
Printed in Germany
eMail lisa.reid@med.siemens.de CC 61946 WS 0901X.