s

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

Clinical 3D Imaging –
Has Its Time Finally Arrived?

Case Reports
on Volume Imaging

8
FROM THE EDITOR
This is the eighth issue of Siemens SOMATOM® Sessions.
It provides insights from clinical 3D imaging together with
case reports from Siemens SOMATOM Volume Zoom users.
This issue focuses on the many improvements made
possible through volume imaging.

As always we would appreciate your suggestions and

comments.

Xiaoyan Chen, M.D.

Editor of SOMATOM Sessions

CONTENTS
Letter from the Editor Page 2

Clinical 3D Imaging –
Has Its Time Finally Arrived? Page 3

An arteriovenous malformation involving

the second and third digits of the left foot Page 10

MSCT diagnosis on conductive hearing loss Page 12

Pancreatic Carcinoma Page 14

Chronic Intestinal Ischemia:

Superior and Inferior Mesenteric Artery
Stenosis Depicted by Multislice CT Page 16

Axillary Deep Venous Thrombosis after

PORT-A-CATH® Insertion Page 19

Multislice Spiral CT: Phlebography of the upper

extremity in a patient with shunt thrombosis Page 21

The drugs and doses mentioned herein are consistent with the approval
labeling for uses and/or indications of the drug. The treating physician bears
the sole responsibility for the diagnosis and treatment of patients, including
but not limited to the parameters selected during image acquisition and
postprocessing and any drugs and doses prescribed in connection with
such use.

2
Clinical 3D Imaging – Has Its Time Finally Arrived?
Three-dimensional imaging (3D) for CT applications was
introduced shortly after clinical CT scanning became a reality
in the late 1970s. Whether through work done by Gabor
Herman and associates at the University of Pennsylvania or
Mike Vannier and associates at the Mallinckrodt Institute
of Radiology, 3D imaging was viewed as a way of extract-
ing more information from a series of transaxial CT scan
slices. Not surprisingly early applications involved bone espe-
cially in areas like the skull and craniofacial regions (regions
of high CT contrast and anatomic zones less affected by
patient motion or breathing). Although most radiologists
at the time were not enthusiastic about 3D reconstructions,
our referring physicians found them extremely helpful in
patient management decisions in complex cases. Over the
next 15 or so years, 3D imaging continued to evolve with
the introduction of faster computer processing times, lower
priced workstations with better price/performance profiles,
and new rendering algorithms (i. e., volume rendering).
Yet, despite these and many other advances, 3D imaging
continued to be a study performed in a select group of
institutions for a limited set of applications.
It is debatable why the progress of 3D imaging in the
radiologic environment was so slow but a number of reasons
have been suggested including:
• High cost of workstations.
• Perceived notion that 3D had limited clinical applications.
• 3D was felt to be of value only to the referring physician
but not to the radiologist.
• Difficulty in using 3D workstations due to poor system
design and limited functionality.
• A “killer app” (application) had not been developed to
drive 3D imaging into the mainstream.
• Major equipment vendors like Siemens Medical Systems
and GE did not push 3D as a mainstream product.
• Poor reimbursement for 3D studies (especially the
physician component).
What really began to change the equation was the devel-
opment of spiral CT and the ability to obtain true volume
data sets which were ideal for 3D or volume imaging. With
the continued development of spiral CT scanning from a
technology where one could acquire 12 seconds of data to
a technology that could acquire up to 100 seconds of data,
things really began to change. New applications for CT
began to develop based on these new technologies and
capabilities. The role of 3D imaging was becoming more
of a core function of CT and inseparable especially with
applications like CT angiography and virtual endoscopy. The
introduction of multidetector CT and its advances for vas-
cular imaging continued this development cycle which has
been driving 3D imaging to become more of a standard
exam rather than a unique procedure. In fact, every scanner
manufacturer now recommends or ships a workstation
capable of 3D imaging with their high-end scanners (multi-
detector CT scanners (MDCT). Yet, there is still the feeling
among some radiologists that 3D imaging is not yet suitable
for their practice. This seeming contradiction may seem
hard to explain but is based in great part on the resistance
of radiology and radiologists to change.
In our experience, the biggest limitations to the use of
3D imaging (and other postprocessing tools) in the clinical
environment include:
• A lack of understanding of the advantages provided by
these techniques both from a clinical and patient care
perspective.
• A lack of understanding of how to use these new
techniques including a lack of understanding on how to
use the workstation.
• A lack of understanding of how to merge new technolo-
gies into a busy clinical practice that already may be
overwhelmed by the volume of work and/or a staffing
shortage (both radiologists and technologists).
• Resistance to change especially changes in work
distribution and flow.
3
Clinical 3D Imaging – Has Its Time Finally Arrived?
These limitations can be translated into a need for:
• Education
• Training
• Clarification of workflow issues
• Staffing
None of these problems however is insurmountable.
I believe that education can come from any of several
sources including:
• CME courses including courses with hands-on sessions.
For example, the RSNA as part of its annual meeting
has hands-on sessions on the use of computers including
medical workstations. Siemens Medical Systems has
sponsored a hands-on course using the 3DVirtuoso work-
station the past two years in Orlando and will have a third
meeting May 18-20, 2001, also in Orlando, Florida.
• Reading the radiologic literature (and pertinent literature
from other subspecialties) and noting the clinical role of 3D
imaging especially as it applies to CT angiography.
• Getting information from the vendor of your workstation
including detailed hands-on training on the use of the work-
station and better system documentation. The Somatom
Sessions is an example of vendor supplied information that
is valuable for your daily clinical practice.
• Web-based educational sites like www.CTISUS.com
where all of the 3D protocols are available including a large
teaching file of illustrated 3D cases.
Training reflects more on the ability to obtain technical
expertise on a 3D imaging system. Although every work-
station vendor provides some form of hands-on training
it usually is but two-days duration and this may be unsatis-
factory for either the radiology technologist or radiologist.
It is not suprising that the most common complaint about
4
a workstation and its use is lack of sufficient training. This
problem can be solved by either the 3D vendors providing
enhanced training (including through web-based training)
on or off-site or for the interested parties to go to sites with
similar equipment and learn in a more hands-on method.
Unless there is improvement in the training available the
use of 3D imaging will continue to lag other technologies.
Progress has been made as for example Siemens Medical
Systems has begun to focus 3D training in a centralized
location in Cary, North Carolina, USA.
Workflow issues and staffing are both separate but closely
intertwined problems. The decision as to who does the
3D imaging (radiologist vs. technologist) and where the
workstation is located are decisions that are made by indi-
vidual institutions. Although my experience is one where
the radiologists do the actual 3D imaging (including creat-
ing the images and filming them), other sites have found
a dedicated technologist (with radiologist supervision) to
be an ideal strategy. The advantages of the radiologist only
works in cases where the radiologist(s) is dedicated to
committing the necessary time and effort to the enterprise.
This is becoming more of an issue where most institutions
are understaffed and trying to cope with the clinical load
without adding new studies. However, this is shortsighted
as using a technique like CT angiography will decrease the
staffing (both radiologist and technologist) needed for more
invasive procedures like classic angiography. In addition,
our view that the future of imaging revolves around direct
3D viewing replacing axial CT scanned based imaging,
which will require primary radiologist participation. One
factor that will increase the radiologist’s willingness to be
the primary person for the 3D-image analysis is the avail-
ability of true real-time volume rendering. The Siemens
3DVirtuoso with the VolumePro upgrade will make this
wish a reality. The real-time rendering of this system allows
the radiologist to analyze even the most complicated cases
in a matter of minutes.
Other sites have found that a dedicated technologist can
perform most of the routine studies and the radiologist
works in a more supervisory role as well as doing the more
difficult/complex cases. Advantages of this workflow relate
to less of a commitment of the radiologist’s time and may
provide more continuity especially in those groups where
a radiologist is not based at any one hospital or office. In
this model selection of the technologist is critical as they
should be an individual who is willing to learn what the pur-
pose of each study is and is committed to continuing edu-
cation. The person must be self-motivated and committed
to the project. The technologist will also need people-skills
to deal with both the radiologist and the referring physician.
This workflow issue is critical to the success of any 3D
program and will need to be decided on a case to case basis.
Although it would be ideal to have multiple workstations
connected over a high-speed network capable of doing 3D
imaging this is rarely the case today. The decision as to
where to physically place the workstation is therefore
critical. I have found that it is ideal to have the workstation
away from the scanner suite in a separate room or office.
This allows consultation with referring physicians without
interrupting the primary function of the CT scanner which
is to scan patients.
This separate 3D suite or lab allows for the centralization
of function especially when a number of different scanners
and/or modalities are networked to a single workstation.
For example, at Hopkins our 3D lab is connected by a
100 megabyte backbone to scanners in the hospital, the
adjacent outpatient center, the adjacent oncology center,
the emergency room and a remote site 10 miles away.
All images seamlessly reach the workstation for postpro-
cessing. However, with our 3D volumes increasing to over
10 cases per day as well as the need for rapid image turn-
around (minutes rather than days), the location of the
workstation will soon have to be closer to the scanners and
reading room.
Workflow issues are obviously a critical factor in the
success of a 3D operation. The timely performance of a
CT scan will be negated if there is a time lag until the 3D
images are generated. Although many 3D studies do not
require an immediate turnaround, other applications are
very time-sensitive. These applications include acetabular
fracture repair (in select cases), suspected mesenteric
ischemia, and suspected aortic dissection. Training of enough
staff members to cover these off-hours cases is needed
to provide the 24/7 coverage demanded today. The use of
3D imaging in the acute setting is rapidly increasing.
Another problem with placing a workstation in a single
central location as 3D visualization becomes a primary
interpretation tool is that it would need to be located in the
scanner suite or in the area where films are interpreted.
This would potentially require a number of workstations
which would be cost-effective if used to enhance the
primary interpretation. Implementation of this paradigm is
beginning especially with the new design of the 3DVirtuoso
and its increased capabilities as a primary display and
analysis center.
Multidetector CT is probably the final brick that will push
3D imaging into the mainstream. Although I will not dis-
cuss the specific clinical advantages of MDCT, it is easy to
conclude that any 3D application that could be done pre-
viously can be done better due to a combination of factors
including narrower collimation, higher resolution imaging
and faster scan times.
MDCT also has resulted in many new applications for
CT now becoming a clinical reality. These include topics like
mesenteric angiography for ischemia, coronary artery
angiography and peripheral CT angiography. However, even
more than that is the practical reality of MDCT. While in
the prespiral era, a scan sequence of 35-50 images were
the rule, with multidetector spiral CT a typical study may be
anywhere from 150-600 slices.
5
Clinical 3D Imaging – Has Its Time Finally Arrived?
Even if film cost and storage were not an issue, the radio-
logist may become fatigued from looking at so many
images. 3D imaging or volume imaging may prove to be an
alternative. Viewing the entire data set as a volume with
an interactive 3D real time display may be ideal. The ability
to interactively segment out organs or organ systems will
help with more accurate detection of disease as well as
quantification of disease volumes. The use of an interactive
mode will also speed up the viewing process for both the
radiologist and the referring physician. Another practical
factor is that studies like CT angiography cannot be truly
evaluated as axial images. The CT display must be more
like a classic angiogram and display the vessels in the for-
mat that show the vessels in a true vascular map. Volume
rendering is ideal for this task and provides breath-taking
images using the 3DVirtuoso.
a b
Fig. 1: Pancreatic cancer with vessel displacement:
3D CT angiograms demonstrate displacement of both
the gastroduodenal artery and the celiac axis.
6
Although a detailed analysis of specific 3D applications is
beyond the scope of the article, a brief listing of the direction
we are going will give you the feel of how 3D imaging will
become not only mainstream but a central part of imaging
in the 21st century. Although classic 3D imaging tended
to focus on orthopedic imaging like acetabular fractures or
tibial plateau fractures the hottest areas of interest focus
on vascular imaging. The applications include:
• Oncologic imaging – 3D mapping of tumors for better
staging of disease as well as for surgical planning. Specific
applications include staging pancreatic cancer (figure 1),
renal cell carcinoma (figure 2), primary liver tumors as well
as lung cancer.
This is shown both with volume rendering technique
(a) and MIP (b) techniques.
 a b
Fig. 2: Renal cell carcinoma: dates for a partial nephrectomy. The patient’s right
CT angiography is used to determine eligible candi- renal cell carcinoma was successfully resected.

a b
Fig. 3: Mesenteric ischemia: (a-b)
This CT angiogram demonstrates occlusion of the axis and gastroduodenal artery through the artery of
SMA and IMA and collateralization through the celiac Drummond.

7
Clinical 3D Imaging – Has Its Time Finally Arrived?
• Vascular imaging – in addition to the evaluation of aortic
aneurysms and dissection we are now doing CT angio-
grams for mesenteric ischemia (figure 3) and to look at
bowel activity in Crohns disease. Evaluation of carotid or
renal artery stenosis are two other strong applications.
CT is at least 40% cheaper than a conventional angiogram.
• Organ donor imaging – 3D CT angiography is the gold
standard for the preoperative evaluation of potential renal
donors (figure 4). It is also our study of choice for evaluat-
ing patients who are potential living related organ donors
or transplant recipients.
a b
Fig. 4: Renal donor:
This dual phase CT angiogram provides definition of
both the potential donors renal artery(s) (a) as well as
the venous anatomy (b).
8
Conclusion
The modification of an established workflow pattern is
difficult and at times will seem impossible. This is especially
true if the old system worked well and its members are
satisfied with its performance. To paraphrase an old saying
“everyone wants progress but no one wants change”. It
is only when the system becomes unworkable or unsatis-
factory that the window for change opens. The introduction
of MDCT and the new real-time capabilities and functio-
nality of the 3DVirtuoso will provide the impetus by creating
an environment where a new paradigm will be needed.
We look forward to these changes and the potential inno-
vative solutions that will be its result.
This study is used as the guide for laparoscopic
nephrectomy. Note the two left renal arteries.
Table 1
The factors, which are driving 3D imaging into the realm
of a commonly used and accepted clinical study (by the
radiologic community) include:
• A better understanding of the clinical value added
by 3D imaging.
References
www.CTISUS.com contains all the CT protocols for single
and multidetector CT as well as complete references for
all of the clinical applications. A lecture series on volumetric
3D imaging and Siemens MDCT is also available on the
site.

• The growth of CT angiography and the demand for

clinical studies by the referring physicians.
• Better reimbursements for 3D.
• Wealth of supporting data in the radiologic literature.
• Easier to use 3D workstations.

Table 2
3D CT Imaging: WorkFlow Issues.
Where Should the 3D Image Processing be Done?

• A dedicated 3D lab.
• Anywhere there is space to put a workstation.
• In the CT reading area.
• In the referring physicians office, clinic and/or the O.R.
• Near the CT scanner.

Table 3
The biggest limitations to the use of 3D imaging and other
post-processing tools are:

• A lack of understanding of the advantages provided

by these techniques.
• A lack of understanding of how to use these new
techniques. Elliot K. Fishman, M.D.
• A lack of understanding of how to merge new techno- Professor of Radiology and Oncology
logies into a busy clinical practice that already may be Johns Hopkins University School of Medicine
overwhelmed by the volume of work and/or a staffing Baltimore, Maryland
shortage (both radiologists and technologists). U.S.A.

9
An arteriovenous malformation involving the
second and third digits of the left foot

History
55-year-old female patient with painful swelling of the
left lower foot. A CT angiogram was performed to assess
for a vascular malformation.
Results
Computed tomography confirms the presence of an arterio-
venous malformation involving the second and third digits of
the left foot. Digital subtraction arteriography demonstrated
two major feeders from the dorsalis pedis artery as well
as multiple smaller feeders from the posterior tibial artery.

Technical Data The CT angiogram demonstrates the complex arteriovenous

malformation with tremendous clarity when compared to
Scan digital subtraction arteriography.The CT angiogram is limited
Region Foot by the simultaneous visualization of the feeding arteries
Scan length 480 mm and draining veins, however there is less staining of the nidus
Slice collimation 4 x 1.0 mm of the AVM. Volume rendered views facilitate appreciation
Table Feed/rotation 6 mm of the three-dimensional relationships of this complex lesion
Pitch 6 and were useful in planning embolotherapy.
Scan direction craniocaudal
Rotation time 0.5 s
kV 140
Comments
mAs 120
Multislice spiral CT combined with 0.5 second gantry
Kernel uncertain
rotation allowed imaging of the arterial supply of the left
Scan time 40 s
leg from the knee through the toes with near isotropic
Image Reconstruction spatial resolution. As a result, small arteries and veins can
Reconstruction slice width 1.25 mm be visualized that were previously not identifiable by CT
Reconstruction increment 0.5 mm scanning.

Postprocessing Maximum intensity projections provide a similar appearance

Maximum intensity projections and volume rendering to that of the digital subtraction angiogram, while volume
rendering facilitates appreciation of three dimensional
relationships.

Geoffrey D. Rubin, M.D.

Associate Professor, Radiology
Stanford University School of Medicine,
Stanford, California, USA

10
 Fig. 2: Detailed view comparing DSA and MIP-CTA
views of the forefoot. The AVM nidus is clearly seen on
the DSA examination involving the second and third
digits. Although the nidus is not opacified to the same
level on the CTA, its position is inferred by the many
small vessels observed over the entire second digit in
the region of the metatarsal head as well as over the
medial aspect of the third digit. The DSA view is a com-
pilation of two views acquired five seconds apart show-
ing during the arterial and venous phases of the study.
The two views were added together to create a view
that is comparable to the CT, showing both arterial and
venous anatomy.
Fig. 1: AP and lateral maximum intensity projections
with an inverted gray scale demonstrate the entire
scan volume.The popliteal artery and the branches of
its trifurcation are demonstrated to enhance intensely
in the lateral aspect of the upper leg while early filling
of the saphenous venous system is observed medially.

3a 3b
Fig. 3: Left and right lateral and AP volume renderings
of the forefoot demonstrate the three dimensional
relationships of this complex AVM. Vessels with grea-
test enhancement are encoded in white, followed
by intermediately enhancing vessels in red and less
enhancing vessels encoded in magenta.

3c

11
MSCT diagnosis on conductive hearing loss
History
A 13-year-old girl, who had a cardiac surgery because of
ventricular septal defect and subvalvular pulmonary stenosis
at the age of three. The surgery was successful and the
patient was asymptomatic afterwards.
At the age of six, she was referred to an otorhinolaryngology
clinic because of hearing impairment.The clinical investiga-
tion showed transudate in the middle ear, bilaterally. Audio-
metry demonstrated a major conductive hearing loss on the
right side, while there was a less aggravated similar finding
on the left side.
The patient was operated on the right side, where a
tympanic membrane retraction was noted. The tympanic
membrane was found to reach the promontorium. The
otosurgeon evacuated plenty of thick fluid from the middle
ear, and inserted a grommet. The conductive hearing im-
pairment has, however, persisted on the right side, whereas
the patient’s hearing on the left side is normal after para-
centesis followed by grommet insertion.
In order to search for other causes of persisting conductive
hearing loss, a computed tomography was performed using
multi-slice CT (MSCT) equipment.
Technical Data
Equipment: Siemens SOMATOM Volume Zoom
• Patient position: Supine & head first
• Axial scan only
• 140 kV
• 100 mAs
• Rotation time: 0.75 sec
• Slice width: 0.5 mm
• Slice collimation: 2 x 0.5 mm
• Feed/rot.: 1 mm
• Kernel: U90u
• Image reconstruction increment: 0.1 mm
12
Postprocessing
At first, MPR was performed on the axial slices, using
the second console – Volume Wizard. MPR images were
reviewed at 0.1 mm increment and transferred to the
Virtuoso workstation, where the dataset was analyzed with
Real Time Volume Rendering Technique (VRT) in the RT3D
application program.
Diagnosis
Suspected interruption between the incus and stapes,
causing conductive hearing loss.
Remarks
Performing only axial instead of both axial and coronal
MSCT reduces examination time and patient radiation dose.
The interruption of the ossicular chain is easily recognized
in real time volume rendering in stereoscopic mode, where-
as it is difficult to demonstrate on the two-dimensional
slices. Furthermore, volume rendering with stereoscopic
display in real time gives a good view of normal and patho-
logic anatomy of the middle ear. In this way, the otosurgeon
can explore the region interactively and view it in 3-dimen-
sions, which is very valuable for discussion and surgical
planning. By performing MPR before VRT, the so-called step
artifacts can be reduced, and the dataset is reduced in
size by 50%. The examination is very quick and can be well
tolerated by the patients. The total time from examination
to diagnosis is around 10 minutes.
Anders Persson, M. D.
Head of Radiology Clinic
The Hospital of Hälsingland
Söderhamn, Sweden
Fig. 1: Axial image Fig. 2: MPR image

Fig. 3: VRT image Fig. 4: VRT image

Fig. 5: VRT image Fig. 6: VRT image

Fig. 1-4: Ossicular interruption. Fig. 5-6: Normal anatomical structure of the inner ear.
VRT images were generated from MPR images.

13
Pancreatic Carcinoma

History Patient preparation

65-year-old female patient with painless jaundice and
back pain for ten days. Ultrasound revealed stones in the
gallbladder, an extra- and beginning intrahepatic cholestasis
and an enlarged head of the pancreas with suspected
hypodense formation in the head of the pancreas. Lab works:
slightly incrased amylase and lipase, elevated phosphatase
and bilirubin and CA 19-9.
Oral contrast medium:
1000 ml iodinated oral contrast material 1 h prior to
the examination, 500 ml water 10 minutes prior to the
examination.
Right side position for 5 minutes before scanning;
Spasmolysant immediately before scanning;
Supine position during scanning.

ERCP: Filiform stenosis of the common bile duct in the head

of the pancreas indicates carcinoma of pancreatic head.
Dilated pancreatic duct. Results
T1 carcinoma of the pancreatic head (histologically con-
firmed). Dilated common bile duct, slightly dilated pancreatic

Technical Data duct. Small circular hyperdensity in the head of pancreas

surrounded by a small hypodense mass, which can not be
Scan delineated from the portal vein and the superior mesenteric
Region upper abdomen vein on tansverse images. Coronal and sagittal MIP and
Scan length 156 mm MPR confirm that the circular hyperdensity is the enhancing
Slice collimation 4 x 1 mm wall of the bile duct, surrounded by a small hypodense
Table feed / rotation 4 mm T1-tumor. Sagittal plane demonstrates the encasement of
Pitch 4 the portal vein of less than one quarter of the circumference.
Scan direction caudocranial
Therefore according to the criteria published by Lu et al.
Rotation time 0.5 s
1997 infiltration of the portal vein can be excluded. These
kV 120
findings (T1 stage; no infiltration of the peripancreatic
mAs 165
vessels) were confirmed intraoperatively.
Kernel B30
Scan time 23 s

Contrast Injection
Volume 120 ml (non-ionic contrast medium)
References
Lu DSK, Reber HA, Krasny RM, Kadell BM, Sayre J (1997)
Concentration 370 mg iodine/ml
Local staging of pancreatic cancer: criteria for unresectability
Flow rate 4 ml/s
of major vessels as revealed by pancreatic-phase,
Start delay 35 s
thin-section helical CT. AJR 1997; 168:1439-1443.
Image Reconstruction
Reconstructed slice width 1.25 mm/3 mm
Reconstruction increment 1 mm/3 mm

Postprocessing
Multiplanar reformations +

14
Fig. 1: Axial image
This image shows a hypodense tumor in the head
of the pancreas, the enhancing common bile duct, the
slightly dilated pancreatic duct and the encasement of
the superior mesenteric vein for less than one quarter
of the circumference.
Fig. 3: Sagittal MPR
This image shows the tumor in the pancreatic head
and the encasement of the portal vein for less than one
quarter of the circumference. Slight irregularity of the
lumen of the portal vein.
Fig. 2: Coronal MIP-reconstruction
This image shows normal calibre of the superior
mesenteric vein and the portal vein, the dilatation and
the enhancing wall of the common bile duct.
Pay attention to the small line of fatty tissue between
the portal vein and the carcinoma.
No suspicion of vascular infiltration on coronal MIP’s.
Ulrich Baum, MD
Institute of Diagnostic Radiology
University of Erlangen-Nuremberg
Maximiliansplatz 1
D-91054 Erlangen
Tel. ++49/91 31/8 53-60 66
Fax ++49/91 31/8 53-60 68
e-mail: Ulrich.Baum@idr.imed.uni-erlangen.de
15
Chronic Intestinal Ischemia: Superior and Inferior
Mesenteric Artery Stenosis Depicted by Multislice CT

History Clinical comments and summary

A 64-year-old woman has complained of chronic perium-
bilical pain for six months. The pain appeared half an hour
after each meal. She had a history of hypertension, heavy
smoking and right carotid bifurcation surgery. The pain was
also diffusing to her back. She lost 10 kg in 6 months. No
abnormality was detected by the sonography of the upper
abdomen, gastroscopy and coloscopy and the biology.
A multislice CT of the abdomen was performed to rule out
vascular mesenteric lesions.
The angiographic criteria of a chronic mesenteric ischemia
consist in the presence of significant stenosis or obliteration
of 2 of the 3 main gastrointestinal arteries. For this patient,
the only large and safe artery of the intestine is the celiac
trunk. This case illustrates the ability of the Volume Zoom
to provide a precise vascular mapping and detect the arterial
lesions in the intestinal arteries. The 3D reconstructions
obtained with the Volume Wizard (MIP, MPR, SSD) superbly
demonstrate the collateral vascular supply. Since the effi-
cacy of CT in the diagnosis of acute intestinal ischemia has
been demonstrated in comparison to angiography, further

Technical Data studies will have to determine its performance and role in
the diagnosis of chronic intestinal ischemia for which angio-
The spiral CT was acquired with a multislice spiral CT
graphy is still the imaging modality of choice.
(SOMATOM Volume Zoom, Siemens Medical Engineering,
Forchheim, Germany).
The following scan parameters were used:
References
KV 120
[1] Klein, H. M., Lensing, R., Klosterhalfen, B., Tons, C.,
mAs 90
Gunther, R. W.: Diagnostic imaging of mesenteric infarc-
Slice collimation 4 x 1 mm
tion. Radiology 1995 Oct; 197(1):79-82
Slice thickness 1.5 mm
FOV 37.9 cm [2] Yamada, K., Saeki, M., Yamaguchi, T., Taira, M., Ohyama,Y.,

Recon increment 1 mm Ashida, H., Sakuyama, K., Ishikawa, T.: Acute mesenteric

Rotation time 0.5 s ischemia. CT and plain radiographic analysis of 26 cases.

Feed per rotation 8 mm Eur Radiol 1999;9(7):1267-76

Total acquisition time 19.7 s [3] Boley, S. J., Brandt, L. J., Veit, F. J.: Ischeémic disorders
Reconstruction algorithm B20 of the intestine. Curr Prob Surg, 1978, 15: 1-85.
Total number of images 313
[4] Rogers, A. L., Cohen, J. L.: Ischemic bowel disease.
Injection protocol: brachial vein,
Gastroenterology, 4°ed., vol.3, Editor: J. E. Berk. Philadelphia,
Nonionic contrast medium at
350 mg I/100 ml. Injection volume 100 ml Saunders, 1915-1935.
Injection rate 4 ml/s
Start delay 40 s

16
 1a
1b
Fig. 1: Maximum Intensity Projection (MIP, Fig. 1a)
and Volume Rendering Technique (VRT, Fig. 1b) images
in a saggital oblique orientation demonstrating a
superior mesenteric artery stenosis.
2a
2b
Fig. 2: Left obliquely oriented coronal MIP (Fig. 2a)
and VRT (Fig. 2b) views showing collateral vascular
supply to the superior and inferior mesenteric arteries
originating from the celiac trunk and its branches.
17
Chronic Intestinal Ischemia: Superior and Inferior
Mesenteric Artery Stenosis Depicted by Multislice CT

Fig. 3: Obliquely oriented axial multiplanar reconstruc- Fig. 4: Saggital oblique MPR showing a stenosis at the
tion (MPR) at the level of the origin of the superior origin of the inferior mesenteric artery (white arrow).
mesenteric artery. A luminal interruption is observed
with an intramural blood clot (white arrow).

Denis Tack, M. D.
Department of Radiology – C.H.U. de Charleroi
Boulevard Janson 92
B-6000 CHARLEROI/BELGIUM
Phone: (32 71) 25 15 25
Fax: (32 71) 25 17 09
E-mail: denis.tack@skynet.be

18
Axillary Deep Venous Thrombosis after
PORT-A-CATH®Insertion

History Clinical comments and summary

A 53-year-old woman complained of swelling of the left
arm for 24 hours. One week before, a Port-A-Cath®
device had been inserted in her left jugular vein. She was
treated with chemotherapy for a gastric carcinoma.
Central venous access devices are often essential for the
administration of chemotherapy to patients with malignancy,
but its use has been associated with a number of compli-
cations, mainly thrombosis (1). Its sequelae include septic
thrombophlebitis, loss of central venous access and pulmo-
nary embolism. Phlebography is the imaging modality of

Technical Data choice to demonstrate the venous thrombosis. However,

it is not appropriate to delineate precisely innominatal vein
The spiral CT was acquired with a multislice spiral CT
compressions that occur in the antero-posterior direction
(SOMATOM Volume Zoom, Siemens Medical Engineering,
as lymphadenopathies do in the anterior upper mediastinum
Forchheim, Germany).
(Figure 1).This case shows the ability of multislice CT to
The following scan parameters were used:
depict the venous thrombosis and its causes, the insertion
Region of interest: from the diaphragm to the of a catheter in a compressed left innominatal vein.The
hyoid bone MIP images obtained with the Volume Wizard perfectly
Acquisition direction caudo-cranial demonstrate the collateral vascular supply to the chest
KV 120 wall and obviate the need for venography. Essential to the
mAs 77 technique is the injection of an iodine contrast of low
Slice collimation 4 x 1 mm concentration in both forearms.This allows opacification of
Slice thickness 1.5 mm the bilateral thoracic veins simultaneously. The dilution is
FOV 36.7 cm essential to avoid artifacts in the superior vena cava. Some
Recon increment 1 mm authors recommend a preventive treatment of venous
Rotation time 0.5 s thrombosis related to Port-A-Cath® device with a low mole-
Feed per rotation 8 mm cular weight heparin (2).
Total acquisition time 17 s
Reconstruction algorithm B20
Total number of images 229
References
Injection protocol: Nonionic contrast medium [1] Lersch, C., Eckel, F., Sader, R., Paschalidis, M.,
at 350 mg I/100 ml Zeilhofer, F., Schulte-Frohlinde, E., Theiss, W.:
Dilution of the contrast 1/4 Initial experience with Healthport miniMax and other peri-
Injection volume pheral arm ports in patients with advanced gastrointestinal
in the left arm 50 ml at a rate of 2 ml/s
malignancy. Oncology 1999; 57(4):269-75
Injection volume
in the right arm 150 ml at a rate of 4 ml/s [2] Monreal, M., Alastrue, A., Rull, M., Mira, X., Muxart, J.
Start delay 20 s Rosell, R., Abad, A.: Upper extremity deep venous
thrombosis in cancer patients with venous access devices
– prophylaxis with a low molecular weight heparin
(Fragmin). Thromb Haemost 1996;75(2):251-3.

19
Axillary Deep Venous Thrombosis after
PORT-A-CATH®Insertion

1 2
Fig. 1, 2: Coronal MPR (Fig. 1) and VRT (Fig. 2)
at the level of the left jugular vein and the catheter.
Mediastinal and cervical bilateral lymphadenopathies,
and left axillary vein thrombosis.

3 4

Fig. 3, 4: Maximum intensity projection with 10 cm

Denis Tack, M. D.
Department of Radiology – C.H.U. de Charleroi
Boulevard Janson 92, B-6000 CHARLEROI/BELGIUM
Phone: (32 71) 25 15 25, Fax: (32 71) 25 17 09
E-mail: denis.tack@skynet.be
thickness (Fig.4) and VRT (Fig. 3) images demonstrating
the normal right thoracic veins, the position of the
PORT-A-CATH device and the venous collaterals from
the left axillary region to the intercostal and mid vertical
thoracic vein.

20
Multislice Spiral CT: Phlebography of the
upper extremity in a patient with shunt thrombosis

History
A 38-year-old patient with end stage renal disease presented
with massive swelling of the right forearm and a history
of repeated shunt thrombosis. Physical examination on
admission revealed normal perfusion of the dialysis shunt
on the right upper arm.
Spiral CT was performed on suspicion of central thrombosis
and to exclude mediastinal mass.
Technical Data
Scanner: SOMATOM Volume Zoom, Siemens, Germany
Diagnosis
Acute central thrombosis of the right subclavian vein is
evident, without apparent anatomical reason (mass or
muscular hypertrophy). On the left side thrombosis of the
subclavian and axillary vein due to ipsilateral shunt throm-
bosis is shown. Multiple varicoid bypasses drain the left
upper extremity. Extensive opacification in vessels with
reduced blood flow is seen on the left arm because of cen-
tral vein thrombosis, whereas lower opacification is seen
in the shunt on the right side due to high, arterialized blood
flow. A filiform stenosis of the right brachiocephalic vein is
demonstrated proximal to the confluence of the superior
cava vein.

Slice collimation 4 x 1 mm
Table feet 8 mm/s Comments
Rotation time 0.5 s With MSCT an isotropic volume data set can be acquired
Reconstructed slice width 1.25 mm in a single breathold. Out of this data set, views from arbitrary
Reconstruction increment 1 mm chosen directions can be processed. Only little contrast
Total scan time 22 s material (50 ml) was needed to achieve sufficient contrast
Thin slice MIP + enhancement of both brachiocephalic veins due to the
Contrast material Optiray 300, Schering, Germany short acquisition time. The administration of contrast mate-
Total volume 50 ml, diluted with 50 ml NaCl 0.9% rial is a central issue for the assessment of vessels. Amount
Injection rate 2.0 ml/s and concentration of contrast material, flow rate and start
Start delay 50 s delay are important parameters for homogenous opacifi-
Injection was performed in the left antebrachial vein and cation without inflow- or high contrast artifacts. In this
the shunt on the right arm simultaneously with a power patient, the delay between the start of contrast material
injector. injection and the spiral scan was chosen empirically.To
have visual control of optimal opacification, semiautomatic
bolus triggering techniques can be used to optimize the
start delay. With such techniques a further reduction of con-
trast material volume is possible at the expense of a slight
increase of radiation dose. Dilution of the contrast material
is necessary to avoid high contrast artifacts. Both luminal
and extraluminal pathology (i. e. tumor mass, anatomical
variants) can be assessed and information of both venous
and arterial vessels is provided. Details of thrombus mor-
phology are availible and exact planning of an interventional
procedure is possible.

21
Multislice Spiral CT: Phlebography of the
upper extremity in a patient with shunt thrombosis

In addition to the axial images, 3D postprocessing can help

visualize pathology within one image and in orientations
used from DSA.Thin slice MIP is an easy and quick method
to display the vascular anatomy without time consuming
editing procedures. Cross sectional images help to differen-
tiate adherent from floating thrombus and measurements
of the diameter of the vessel help choosing the correct
dimension of angioplasty catheter and stent.

The patient was treated interventionally with dilatation and

stent implantation.

Michael Lell, M.D.

Institute of Diagnostic Radiology
University of Erlangen-Nuremberg
Erlangen, Germany
Fig. 1a-d: Axial images show the central thrombosis
of the right subclavian vein.

Fig. 2: Axial MPR image shows the thrombosis of the left Fig. 3: Oblique axial MPR image shows the thrombosis
subclavian vein. of both right and left subclavian veins.

22
4 5
Fig: 4, 5: MIP images show different views of the filiform
stenosis of the right brachiocephalic vein proximal to the
confluence of the superior cava vein.

6 7
Fig: 6, 7: MPR (Fig. 6) and MIP (Fig. 7) images show the
thrombosis of the left subclavian and axillary vein due to
ipsilateral shunt.

23
THIS ISSUE’S AUTHORS
“Clinical 3D Imaging –
Has Its Time Finally Arrived?”
Elliot K. Fishman, M.D.
Professor of Radiology and Oncology
Johns Hopkins University School of
Medicine, Baltimore, Maryland, USA
“An arteriovenous malformation
involving the second and third digits of
the left foot”
Geoffrey D. Rubin, M.D.
Associate Professor,
RadiologyStanford University School
of Medicine, Stanford, California, USA
IMPRESSUM
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“MSCT diagnosis on conductive
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Anders Persson, M.D.
Head of Radiology Clinic
The Hospital of Hälsingland Söderhamn
Sweden
“Pancreatic Carcinoma ”
Ulrich Baum, M.D.
Institute of Diagnostic Radiology
University of Erlangen-Nuremberg
Erlangen, Germany
“Chronic Intestinal Ischemia: Superior
and Inferior Mesenteric Artery Stenosis
Depicted by Multislice CT”
Denis Tack, M.D.
Department of Radiology
C.H.U. de Charleroi
CHARLEROI, BELGIUM
International Distribution
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CT Product Creation
Siemens AG, Medical Engineering
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eMail Loke-Gie.haw@med.siemens.de
“Axillary Deep Venous Thrombosis after
PORT-A-CATH® Insertion”
Denis Tack, M.D
Department of Radiology
C.H.U. de Charleroi
CHARLEROI, BELGIUM
“Multislice Spiral CT: Phlebography
of the upper extremity in a patient with
shunt thrombosis”
Michael Lell, M.D.
Institute of Diagnostic Radiology
University of Erlangen-Nuremberg
Erlangen, Germany
George Savatsky, B.A., M.A.
CT Marketing
Siemens AG, Medical Engineering
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