Somatom Sessions 20

SOMATOM Sessions
The Difference in Computed Tomography
Issue no. 20 / June 2007

Stanford-Edition
June 13th–16th, 2007
Cover Story
Dual Source CT Reshapes
Clinical Imaging
Page 4
News
syngo CT Oncology
Page 14
Clinical
Outcomes
Acute Care: New Insight
Into Kidney Stone Detec-
tion and Treatment With
Spiral Dual Energy
Page 44
Science
Half-Scan vs. Multi-Seg-
ment Reconstruction for
CT Coronary Angiography
Page 54
Education &
Events
New: Cardiac CT Poster
Page 60
Editor’s Letter
André Hartung,
Vice President Marketing
and Sales.
Dear Reader,
To provide the world’s population with no patient must ever again be turned needed - even from a home PC or a lap-
the best possible, economically solid, away. A major benefit is the ability to top while traveling. Instead of purchasing
medical care is the challenge faced by all avoid unnecessary and expensive diag- and installing multiple workstations,
healthcare systems today. This places the nostic heart catheterization procedures. medical facilities today can install an im-
responsibility squarely upon medical doc- syngo® Dual Energy (DE) transforms aging center with an application server
tors, clinics and other healthcare institu- black and white anatomical imaging into that is constantly updated and simultane-
tions to cost-efficiently provide faster and highly functional color imaging, making ously available for up to 20 viewers at all
more reliable diagnoses and treatments. many pathologies visible that were previ- times. The savings in both investment
Given the pressure to constantly reduce ously not detectable – such as, for only and expensive professional time are con-
costs, it is no longer practical to expect one example, gout related urate deposits. siderable.
the investment in high-end imaging The probability that syngo DE will soon It has always been Siemens‘ ambition to
equipment to be amortized from imaging become a standard CT application is establish sweeping, innovative mega-
patients alone: the entire clinical process, obvious. trends and consistently follow these up
whether in hospitals or practices, must The trend is clearly visible today towards with unique products.
be accelerated while improving health- automatically processing large data vol-
care quality. In everyday practice, this ume rather than manually viewing and As you will read in this issue of the
means reducing the time required from post-processing layers and slices. This SOMATOM Sessions, we are not relaxing
”suspicion” to diagnosis, reducing the procedure is perhaps best illustrated by our dedication to this principle and to
number of examinations and shortening syngo CT Oncology**, an application that providing you with new, intelligent solu-
the length of hospital stays – all improve- supports the complete diagnostic work- tions that make a positive difference in
ments that can be ideally supplemented flow. Rough approximations of tumor all your professional activities.
by computed tomography (CT). CT offers dimensions are now replaced by precise
an incredibly broad spectrum of examina- measurements. Because oncology ac-
tions, is widely available, – usually counts for approximately 60% of CT use*,
around the clock – with minimum per- improvements in this area will speed up
sonnel requirements. New clinical appli- and simplify routine throughput in many
André Hartung
cations and ease-of-use promise a bright practices.
future for CT in improved patient care The necessity for data to be available to
while further reducing costs. many departments within a medical
The recent introduction of Dual Source facility, as well as to external locations, * Results may vary. Data on file.
CT with the SOMATOM® Definition repre- has been solved by Siemens with the ** Pending 510(k): The information about this
sents a break-through in the entire medi- introduction of syngo WebSpace. 3D data product is being provided for planning purposes
cal imaging industry. Beta-blockers are no can now be called up for viewing and only. This product is pending 510(k) review, and
longer necessary for heart CT scans and processing wherever and whenever it is is not yet commercially available in the U.S.
Cover Page: Volume rendered image of a dual energy examination of the hands of an adult patient with acute gout. With the dual energy information, deposits of uric
acid can be detected within the tophi. Areas of active inflammation additionally show an increased contrast enhancement. By Drs. T. Johnson, S. Weckbach, H. Kellner,
M. Reiser and C. Becker, University of Munich – Grosshadern, Munich/Germany. Cf. ‘Molecular Imaging of Gout‘ (Arthritis & Rheumatism; in press)
2 SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine

Content
Cover Story
4 Dual Source CT Reshapes Clinical Imaging
News
10 Maximum CT Capabilities in Minimum Space
14 Fully Automated Tumor Tracking With syngo CT Oncology
16 syngo Circulation – Siemens Scientifically Validated
Cardiac CT Software
Business
17 Flexibility for the Future – Now
22 Big Progress for a Small Clinic
25 Cardiac CT Takes Off
4 Clinical Outcomes
Dual Energy For Clinical Routine
Cardiovascular:
30 Heterotopic Heart Transplant With Arrhythmic
Heart Rate of 45 –125 bpm
32 Reliable In-Stent Lumen Visualization With
Dual Source CT Coronary Angiography
34 Abdominal CTA With Direct Dual Energy Bone Subtraction
Oncology:
36 New: syngo CT Oncology
38 Improved Evaluation and Follow-up of Routine
Diagnostic Oncology Exams With syngo CT Oncology
Neurology:
40 Utilizing the SOMATOM Emotion 16 for a Neuro DSA CTA
Evaluation of a Suspected PICA Aneurysm
Acute Care:
42 Dual Source CT Triple Rule Out Without ß-Blocker
25 44 New Insight Into Kidney Stone Detection and Characterization
With Spiral Dual Energy
Cardiac CT Takes Off
Science
46 Detecting Coronary Atherosclerosis by DSCT Images With
Color Maps
48 Coronary CT Angiography With DSCT – Implications for
Contrast Media Delivery
52 Nefertiti´s Bust – An Inside View
54 Half-Scan vs. Multi-Segment Reconstruction for CT Coronary
Angiography
Education & Events

59 CT Life Card: Clinical Education at Your CT Workplace /
E-Logbook: Eliminate Cumbersome Paperwork
60 New: Cardiac CT Poster / New: CTA Interpretation Workshops
61 Free 90 Day Trial Licenses for Clinical Applications /
32 Frequently Asked Questions
DSCT Coronary Angiography 62 E-Newsletter / Upcoming Events & Courses
63 Imprint
SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine 3

Cover Story
Dual Source CT Reshapes

Clinical Imaging
When dual source technology burst on the scene in 2005, it did more
than change the look of CT. It changed the future of medicine, not only sur-
mounting critical barriers in cardiac imaging, but also introducing an entirely
new way of characterizing body tissues using dual energy techniques.
By Catherine Carrington
From the start, it was clear that cardiac 1

imaging would win big with Dual Source
CT. With a temporal resolution of just
83 milliseconds, Siemens’ SOMATOM®
Definition Dual Source CT scanner can
freeze cardiac motion in even the most
challenging patients. Nowhere is this
more important than in the emergency
department (ED), where the Definition is
revolutionizing the diagnosis of patients
with acute chest pain. “Dual Source CT
has overcome many of the obstacles we
had with the 64-slice scanner,” says
Michael Gallagher, MD, a cardiologist at
William Beaumont Hospital in Royal Oak,
Michigan. “We have fewer artifacts, less
dependency on heart rate, less depen-
dency on the regularity of the heart
rhythm, and overall, a much higher per-
centage of diagnostic scans.”
Gallagher has been deeply involved
in research into the role of multislice CT
for the evaluation of patients with acute
chest pain. In a study in the February
2007 issue of the Annals of Emergency
Medicine, he showed that 64-slice CT was
at least as accurate as conventional stress
nuclear testing for determining the cause
of chest pain in low-risk patients, if not
more so. A negative CT scan was 99 % ac-
curate for eliminating coronary artery
disease as the cause of chest pain, while
1 Large aneurysm of ascending aorta.
a negative nuclear stress test was 97 %
accurate*.
*Results may vary. Data on file.

Cover Story
No Need for Beta-Blockers
The SOMATOM Definition Dual Source CT “It is important to note that we have 15 hours, on average, to reach a diagnosis
is a further leap forward. “Image quality scanned patients with heart rates of 90, in low-risk patients with acute chest pain.
on the Dual Source CT is excellent. In 100 and 110 beats per minute on the The use of 64-slice CT cut that time to
fact, it’s as good without the use of beta- Definition, with very positive results,” 3.4 hours.
blockers as it was on the 64-slice CT when Gallagher says. “The standard work-up can be long
patients were premedicated with beta- The ability to eliminate beta-blockers from and complicated. Patients can spend an
blockers,” Gallagher says. The ability to the scan protocol has more than clinical entire day in the emergency room,” says
eliminate beta-blockers in most patients benefits. It streamlines patient diagnosis Gilbert L. Raff, MD, director of the Mines-
has had an enormous impact on the eval- from beginning to end, saving both time trelli Center for Advanced Cardiovascular
uation of acute chest pain, expanding and money. Imaging at William Beaumont. “This is
the range of patients who are eligible for the first study in which emergency physi-
CT scanning, streamlining patient prepa- Shorter Stays, Reduced Costs cians used CT to make clinical decisions
ration in both the ED and the CT suite, about the management of patients with
speeding the time to diagnosis, freeing Researchers at William Beaumont pub- chest pain. It represents a major change.”
up resources for additional patients, and lished a groundbreaking study in the Today, the Definition is speeding patient
cutting healthcare costs. February 27, 2007, issue of the Journal care still more. Much of the improvement
In the past, as many as 20 % of patients of the American College of Cardiology. takes place even before the patient arrives
simply could not have a cardiac CT scan, It showed that with a standard nuclear in the CT suite. “There used to be a lot of
as they could not safely take beta-block- stress testing protocol, it took more than phone calls back and forth between the
ers to slow the heart rate to 65 to 70
beats per minute, a rate necessary to 2
achieve high-quality images on a 64-slice
CT scanner. This group includes, among
others, patients with asthma or left ven-
tricular dysfunction, and those who have
used cocaine within the previous few
days. With the Definition, such patients
can be routinely scanned without the
need for beta-blockers.
At the University of Pennsylvania, for
example, patients with a heart rate as high
as 85 beats per minute undergo cardiac
CT scanning without beta-blockers. In the
past, 70 % of patients were given oral
beta-blockers and 20 % needed additional
intravenous beta-blockers; today very few
patients take any medication to slow the
heart rate.
“The Dual Source CT has dramatically re-
duced the percentage of patients getting
beta-blockers to about 10 %,” says Harold
Litt, MD, Chief of Cardiovascular Imaging
and an Assistant Professor of Radiology
and Medicine at the University of Penn-
sylvania in Philadelphia. “And it’s likely
that most of those patients are getting
beta-blockers not because of the CT scan,
but because their care in the emergency
department dictates it. We’re not giving
any intravenous beta-blockers on the CT
table.”
William Beaumont Hospital also now
eschews beta-blockers until the heart rate 2 Triple rule-out examination with artifact-free visualization
of right and left coronary arteries and aortic arch.
exceeds 85 beats per minute. They have
successfully stretched that limit, however.

Cover Story
emergency physician and the radiologist,” 3

says Litt. “‘Is the patient eligible for the
study? Can he be given beta-blockers? Is
the heart rate response adequate? Does
the patient need intravenous beta-block-
ers? Will a nurse need to go to radiology
to monitor the patient?’ The Definition
has made things much less complicated
because we don’t have to talk about those
issues now.”
In addition, waiting for the patient’s heart
rate to slow to the target range typically
took an hour or more. Today, if the elec-
trocardiogram is normal and the first set
of cardiac enzymes shows no signs of a
heart attack, the patient can immediately
go for CT scanning. If the second set of
cardiac enzymes is normal, the patient
can be safely discharged home, potentially
within only a few hours of arriving at
the ED.
Although neither William Beaumont nor
the University of Pennsylvania has
tracked the improvement in time from
patient arrival in the ED to the initiation
of scanning, both Litt and Gallagher
believe the savings have been substantial.
In addition, Gallagher estimates that it
now takes only about two hours from the
time the ED physician orders the CT scan
3
until the final results are available, a sav-
ings of one-and-a-half hours that is at-
tributable to the Definition. Similarly, 3 Pulmonary embolism (arrow).
at the University of Pennsylvania, the
time from CT order to final report during
daytime hours averages about two-and-
a-half hours, but it is often closer to one
hour, Litt says. In a separate cost analysis, pain unit. By comparison, the estimated charged immediately after the CT scan,
Litt found that determining the cause of cost of using a DSCT-based protocol was avoiding the cost of further testing and
chest pain in low-risk patients using a pro- $3,000 to $3,500. intervention. In addition, relieving the
tocol of serial electrocardiograms, serial In addition to immediate cost savings, Dual beta-blocker bottleneck means that more
cardiac enzymes, and nuclear stress test- Source CT offers other economic benefits. patients can be scanned in the CT suite
ing cost $11,000 to $13,000 per patient For example, up to three-quarters of low- and more patients can be treated in the
in the hospital and $6,500 in the chest risk patients with chest pain can be dis- ED in the course of a day. “Our ED is full
almost all of the time, so sending patients
home more quickly frees up resources for
other patients,” says Litt.
“It is important to note that we have scanned
Scans for a Wider Range
patients with heart rates of 90, 100 and of Patients
110 beats per minute on the Definition with
The Definition successfully images other
very positive results.” challenging cardiac patients as well –
for example, those with atrial fibrillation
Michael Gallagher, MD, Cardiologist, William Beaumont Hospital, Royal Oak, Michigan. and other irregular heart rhythms. Dual
Source CT has several advantages over
a 64-slice scanner in such patients. First,
scan times are so much shorter, it is less
likely that variations in heart rate will

Cover Story
4 artifact, an inadequate signal-to-noise ra-

tio as a result of obesity, and other tech-
nical factors. Because the Definition pro-
duces fewer nondiagnostic scans, fewer
patients require nuclear stress testing or
cardiac catheterization to determine the
physiologic significance of a questionable
finding.
And although using two x-ray sources
might suggest an increase in radiation
dose, Dual Source CT can substantially re-
duce patient exposure for cardiac applica-
tions. As the Definition images the heart
twice as fast, an adaptive ECG-controlled
pulsing can apply the dose necessary in
less than half the time. In addition, DSCT
adapts the table speed according to the
heart rate of the patient, thus automati-
cally reducing cardiac dose at higher
heart rates. Besides, the resulting improve-
ment in diagnostic confidence is likely to
reduce radiation exposure over the long
term. According to Litt, about 20 % of pa-
tients who come to the ED with chest
pain return to the hospital within a
month with the same symptoms. Because
emergency physicians have confidence
in the reliability of cardiac CT, they are
less likely to repeat the scan than they
might be with nuclear imaging.
“By doing CT, which gives a lot of confi-
dence in a negative study, you’re avoiding
4 Volume rendered image of a dual energy examination of the hands of an adult patient with the need for further studies down the
acute gout. With the dual energy information, deposits of uric acid can be detected within the
road and perhaps decreasing the overall
tophi. Areas of active inflammation additionally show an increased contrast enhancement.
radiation that that patient will be exposed
to in a lifetime,” Litt says.
occur during the scan. Second, because ages were typically too noisy. Today they Dual Energy Imaging Enables
the Definition does not rely on multiseg- are considering relaxing that standard. new CT Applications
ment reconstruction, it produces high- “With the Definition we get a better signal-
quality images even in patients with to-noise ratio in obese patients,” says Everyone knew that cardiac imaging
irregular heart rhythms. And perhaps Gallagher. “In particular, we’ve noted im- would leap forward with Dual Source CT.
most important, a temporal resolution of provements in those who have both a The surprise was how important dual
83 milliseconds is fast enough to accom- high BMI and a high heart rate – patients energy imaging would become. Once
modate any heart rate. “We’ve certainly who were very difficult to image with the considered by some to be an intriguing
found the dual source scanner to be very 64-slice scanner,“ says Litt. “We’re scan- bonus of Dual Source CT, dual energy
useful in allowing us to freeze cardiac ning pretty much anybody they throw at imaging is quickly becoming a workhorse
motion, even with a variable heart rate,” us now, and getting good-quality studies application in its own right.
Litt says. Obese patients are no longer a in almost everybody. The big difference is The ability to simultaneously operate two
major challenge to image with the Defini- that we’re much more confident in the di- x-ray sources at different energy levels –
tion. The ability to use a combined total agnoses we make in obese patients.” and therefore differentiate materials like
of 160 kW of power from two indepen- Increased diagnostic confidence trans- fat, soft tissue, and contrast agent on the
dent x-ray sources enables Dual Source lates into less radiation exposure to the basis of their unique energy-dependent
CT to overcome tissue attenuation in the patient. In the Journal of the American attenuation profiles – is opening the door
chest. In the past, cardiologists at William College of Cardiology study, William to a host of clinically useful applications.
Beaumont didn’t scan patients with a Beaumont researchers found that approx- “We’re ramping up and doing more scans
body mass index (BMI) of 39 or greater – imately 11 % of studies performed on the with dual energy every day,” says
think of a person 5 feet 11 inches tall and 64-slice CT scanner were uninterpretable Johnny Vlahos, MD, an assistant profes-
weighing 280 pounds – because the im- as a result of motion artifact, respiratory sor of radiology at NYU Medical Center in

Cover Story
New York City. “I suspect we’ll soon be 5A 5B

doing the majority of our studies with 5 With dual energy it
the dual energy technique.” is possible to differ-
Since August 2006, Vlahos and his col- entiate kidney stones
that require different
leagues have scanned perhaps 120
ways of therapy.
patients using dual energy. One of the Calcium Oxalate
most useful dual energy applications in Stone (Blue) has to
the chest and abdomen is the creation be treated by inter-
of virtual noncontrast images. This is vention. Uric Acid
accomplished by acquiring data at both Stone (Red) has to be
80 kV and 140 kV. Because iodine has its treated with drug
therapy.
maximum attenuation at low energy, the
80 kV dataset can be used to subtract
contrast material from the image, creat-
ing a virtual noncontrast image, and to
compare before and after images to
highlight areas of contrast enhance-
ment.
5B
This technique has many uses. For exam-
ple, in an area of the liver that shows
increased density on contrast-enhanced
studies, differentiation of an abnormal
lesion from focal fatty sparing may be
difficult. Virtual noncontrast images
show the density of the liver before con-
trast administration, while virtual con-
trast images depict areas of iodine up-
take. Both aid in diagnosis. The NYU
team routinely uses a similar technique
to assess hyperdense kidney cysts and to
differentiate benign and malignant nod-
ules and masses in the liver and kidneys.
They are currently evaluating the use of
dual energy virtual non-contrast imaging
both to simplify CT follow-up of patients
who have had treatment for aortic dis-
section and to reduce radiation expo-
sure. Instead of imaging before contrast on peripheral run-off studies, he says, enhancement of the lung parenchyma.
administration and during both arterial taking a laborious and time-consuming This use of lung perfusion mapping in
and delayed phases of contrast enhance- manual chore and transforming it into combination with CT pulmonary angiog-
ment, they are studying whether it is an easy step that takes less than a min- raphy can assist in pinpointing pulmo-
sufficient to acquire only postcontrast ute to perform. nary emboli and, perhaps, guiding ther-
delayed-phase images using a dual “The results are amazingly good,” says apy. “This technique goes beyond direct
energy protocol, subsequently creating Becker, an Associate Professor of Radiol- visualization of the pulmonary artery. It
virtual noncontrast images at the work- ogy and Section Chief of body CT and has the potential to improve our physio-
station. PET CT. “Dual energy really helps us to logical understanding of pulmonary em-
“There is the potential to move from two create images of the entire vascular ter- bolism,” he says.
to three acquisitions in a single patient ritory, from the diaphragm to the toe, Becker has found dual energy techniques
to only one acquisition,” says Vlahos. without any bony overlay. We are now very useful for visualizing tendons and
“The 80 kV images are very, very sensi- getting many more demands for this ligaments, particularly in trauma pa-
tive to iodine. We’ve had cases where a particular application from our referring tients, who will undergo CT scanning in
contrast leak has been picked up only on physicians.” Similarly, dual energy tech- any case. He is also taking advantage
the delayed-phase 80 kV images.” niques simplify bone removal from the of dual energy findings to determine the
At the University Hospital of Munich- base of the skull, a critical step that en- composition of kidney stones. Those
Grosshadern, Christoph Becker, MD, rou- ables clear display of the carotid arteries primarily composed of uric acid are best
tinely uses another dual energy tech- during CT angiography. treated conservatively with medication,
nique: bone removal from CT angio- In patients with suspected pulmonary while other stones need more aggressive
graphic studies. Dual energy techniques embolism, Vlahos has begun to routinely management. Uric acid crystals can also
have markedly simplified bone removal perform dual energy imaging to evaluate accumulate in the joints of patients with

Cover Story
6A 6B
6 Long distance peripheral
run-off examination
with dual energy tech-
nique. The ability to
show (Fig. 6A) or hide
(Fig. 6B) calcified plaque
(arrow) allows asess-
ment of the remaining
lumen.
gout. Dual energy imaging is now pro- “I’m pretty amazed at the progress in dual ener-
viding new information on the source of
soft tissue swelling and the extent of gy techniques in just the last year. I believe
joint destruction in advanced gout.
Many other dual energy applications are
dual energy will become a substantial part of
nearing clinical use. Plaque imaging is routine scanning for a number of different
perhaps the most intensely anticipated.
Increasingly sophisticated plaque remov- applications we can’t even conceive of yet.”
al tools can be used to mask calcification
and minimize blooming artifact, making Christoph Becker, MD, Associate Professor of Radiology and Section Chief of body CT and PET CT,
Department of Clinical Radiology, University Hospital of Munich, Munich-Grosshadern, Germany
it much easier to evaluate the severity of
arterial stenosis. Perhaps even more in-
triguing is the possibility for dual energy
techniques to detect inflammation,
thereby distinguishing stable from un-
stable plaques.
“I’m pretty amazed at the progress in
dual energy techniques in just the last
year,” Becker says. “I believe dual energy
will become a substantial part of routine Medical writer Catherine Carrington holds a
scanning for a number of different appli- master’s degree in journalism from the University
cations we can’t even conceive of yet.” of California Berkeley and is based in Vallejo, CA.

News
Professor Gerhard Mostbeck,

MD, Department of Radiology,
Otto Wagner Hospital and
Medical Center, Vienna, Austria.

News
Maximum CT Capabilities
in Minimum Space
In a discussion with SOMATOM Sessions, Professor Gerhard Mostbeck, MD,
Department of Radiology, Otto Wagner Hospital and Medical Center, Vienna,
Austria, describes how daily workflow has improved with their new SOMATOM
Emotion 16-slice configuration.
Interview by Robert Harsieber, PhD
Professor Mostbeck, you selected the the scan data, a very practical archiving Which applications are particularly
new SOMATOM® Emotion 16 for your feature. important for you?
department. What were your criteria? We also have night shifts that are staffed Except for heart examinations, which are
Image quality, of course, is always the to some extent by colleagues who come not within the capabilities of our hospi-
primary consideration. But an important from other clinical backgrounds. In these tal, we conduct a large volume and large
issue was also the small space require- cases, the “syngo® Expert-i” software is variety of computed tomography scans
ment. At our location we have a lot of CT important, because it allows a user on an here. Our emphasis is on the lungs, abdo-
activity, but very restricted space, so we external computer to access the monitor men, neuropsychiatry, orthopedics and
were pleased that we did not need a larg- of the CT. The night operators use this similar areas.
er room for the new scanner. Another de- feature to quickly get external, expert Our pulmonary center – including thorax
ciding factor was air-cooling. If we were opinion when needed. surgery and two lung departments – is
to convert to water-cooling, we would one of our largest. These need special
have to run water pipes through these software tools to analyze CT data. We do
old walls and then have to deal with the How important are workflow and many biopsy procedures in the chest and
waste water as well, involving a lot of ex- speed? pre-operative wire markings of small pul-
tra costs. With its air-cooling, the Emo- The elevation from a 6- to 16-slice config- monary nodules before they are removed
tion saved us much expense. We were uration means a very great improvement by thoracic surgeons using video assisted
also positively influenced by our previous in image quality, of course, and, thanks thoracic surgery (VATS).
experience with the Emotion 6-slice con- to the new applications, also in diagnos- CT-guided biopsy or wire marking of
figuration that proved to be extremely ro- tic workflow. This is something we have small pulmonary nodules less than 1 cm
bust. Many different people operated it now grown accustomed to, and we in diameter is challenging. Respiratory
and there were hardly ever any problems. would surely miss this efficiency if it were movements of the nodule make place-
We also like the new practical storage box no longer available for any reason. ment of a biopsy needle a demanding
for clinical accessories located close to For example, the biopsy mode and the CT task. Probing with a needle several times
the patient. transillumination (CT fluoroscopy) are for a pulmonary lesion increases the risk
substantial improvements. And the fact of complications like pneumothorax or
that the scanner reconstructs very rapidly bleeding. Thus, exact placement of the
To what extent has the new interface is also an important feature. needle tip in a single step is extremely
influenced your operations? One can process data and, on a second important.
Our radiology technicians now work with workstation, inspect, analyze and recon- This biopsy mode of the Emotion 16-slice
pretty much the same interface that they struct it at the same time. Our clinical configuration supports us and shortens
already know from magnetic resonance. routine and throughput are greatly facili- examination times substantially. It also
On the other hand, Siemens has added a tated when we can take the 1,000 or helps us to reduce the number of X-rays,
few things that significantly improve pa- 1,500 image datasets that we make dur- compared to what we used to do.
tient throughput. For example, there is a ing a routine examination of the thorax We were able to determine this after our
menu list that gives the operator the op- and abdomen, and reconstruct them eas- first 40 or 50 biopsies. Furthermore,
tion of saving a patient’s data alongside ily and quickly. there is a new function that helps us to

News
“With the SOMATOM Emotion 16 today’s resolution

achieves new dimensions. Today we actually see, for
example, things in the lungs that previously we could
not detect at all.”
Professor Gerhard Mostbeck, MD, Department of Radiology, Otto Wagner Hospital and Medical Center, Vienna, Austria
recognize the number and origin of nod- graphically bring out and highlight the point in the diagnostic framework is to
ules in the lungs. Radiologists are not vessels. That has worked very well in clin- look for colon cancer via a virtual exami-
perfect – we make mistakes – but now ical routine, alongside an existing CT per- nation of the colon. Another one is to
we have new computer aided detection fusion procedure that provides us with make a “virtual flight” within the bronchi-
(CAD) software that automatically recog- hemodynamic information about isch- al system. With this technology we can
nizes and marks suspicious structures for emic brain areas. offer simulations to our colleagues who
us. A stroke is an illness that requires imme- later perform the actual surgeries, and
diate clinical treatment, but does not they know in advance what they will find
In what other ways has the SOMATOM necessarily show up as a change in a rou- when they get there.
Emotion 16-slice configuration been tine CT. Another impressive feature of the
useful? With CT-perfusion, we can recognize SOMATOM Emotion 16-slice configura-
The Emotion provides high image quality problems very early. While a conventional tion is that we can select automatic
as well as software for special applica- CT is still negative, suspicions surface multi-planar reconstructions – coronal
tions. For example, neuro-radiology plays that possible permanent damage is and sagittal – from these data. This is,
a key role in our work here. We support a occurring, so we can immediately begin in comparison to the predecessor model,
stroke unit that encounters, on average, lysis therapy. This is quite significant and a substantial improvement.
one stroke per day. So of course, it is im- practical. One has a better spatial conception
portant to be able to image the vessels of Furthermore, the new Emotion 16 is very through scrolling various planes. When
the brain. effective for virtual representations. In ra- imaging lung cancer, there is definite
There is also a new solution with which diology today, we try to replace demand- improvement in the ability to assess tu-
we can subtract the skull bones, and ing examinations with procedures that mor infiltration of the lobar fissures or
then, from what is left on the scan, are less stressful and invasive. A starting the chest wall. And an additional capabil-
Axial thin section

CT and coronal
MIP: Multiple tree-
in-bud configura-
tions representing
small airway dis-
ease. Mycoplasma
pneumoniae was
diagnosed.

News
“Another novelty of the SOMATOM Emotion 16-slice configuration is that we can select
automatic multiplanar reconstructions – coronal and sagittal,” says Prof. Mostbeck.
ity that is important is that we can fuse forward with great expectations for people who must be examined again
PET data from the Department of Nuclear future developments. Through modern CT and again, this is clearly important.
Medicine at the Wilhelminen Hospital technology, we have also learned that With low-dose CT solutions like CARE
here in Vienna with our CT data. This co- radiologists are humans and therefore, Dose4DTM, the dose level can be fine
operation has a crucial influence on on- not 100% perfect. The expectation that tuned to the lowest level possible for the
cology because we often prevent unnec- we spot every nodule is, in practice, image quality required in the patients’
essary operations, which certainly results impossible. best interest.
in better healthcare for the patients. As humans, we are incapable of filtering
crucial information from these huge data On the other hand, today’s resolution
How has rapid technical progress sets that we acquire daily. We are inclined achieves important and useful new di-
changed your clinical routine? to agree contentedly. Therefore, today’s mensions.
Tremendously. CT is one of the most inno- computer-aided diagnostic systems are That’s true. Today we actually see, for ex-
vative techniques now in existence. From important. Diagnosis can be improved ample, things in the lungs that previously
development of the conventional CT to substantially by the interaction of humans we could not detect at all. With 10 –12
the single slice spiral CT to multi-detector and technology. mm layers of resolution, a 3 mm nodule
CT, we are constantly achieving better res- In this sense, technology is incorruptible. went unnoticed; we simply did not see it.
olutions and shorter examination times. And with the SOMATOM Emotion, not Today the spatial resolution is increasingly
CT will continue to get better and faster only is the technology mature, but better, and this is a crucial help to our di-
until, one day, it will replace conventional Siemens also has seriously considered agnoses. On the other hand, this creates
lung X-rays completely because the CT how such questions can be answered. some additional challenges. The Ameri-
scan, at some point, will take no longer From our point of view, this is the criteria cans have a name for it: “things you wish
than two seconds. How-ever, this also cre- for a well-designed product. you never had seen.” Not everything that
ates a communications problem. It is no one sees is directly responsible for illness.
longer a simple matter, when conferring What are your thoughts about cumula- One must say to the patient, you have
with our clinical colleagues, of hanging tive radiation? three nodules, 3 to 5 mm in size, and
up the images and saying, “There is your The history of low-dose CT covers only such nodules are with 95% certainty be-
tumor.” We have enormous datasets, so the last seven or eight years. There is a re- nign. You tell the patient not to worry, but
we need solutions that allow these data thinking going on in the radiological that he nevertheless must return in six
to be presented as simply and as three-di- world. One increasingly asks oneself, “Do months for another examination to check
mensionally as possible, –offering a us- I need the best image quality for each whether or not the nodules have grown.
able view of the pathology. diagnosis?” I think not. I need image qual- Patients must learn to deal with this. The
That is the essence of CT progress, to be ity that permits me to make a diagnosis, process must also be computer assisted,
able to reduce the huge volume of data to but not always the optimum, which, due because, with the human eye alone,
a simple illustration that I can view, com- to physical laws, also is the one that such developments cannot be accurately
prehend and diagnose on a computer requires the highest dose. With older measured.
monitor and then pass on. The applica- patients in oncology, this is not such a
Robert Harsieber, PhD, is a freelance business
tions that we already have available are major concern. But with children, with journalist, author, publisher and editor-in-chief of
important in this regard and I am looking young women, and with chronically ill Ärzte EXKLUSIV. He is based in Vienna, Austria.

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Vahid Yaghmai, MD, Associate Professor of Radiology at Northwestern University-Feinberg School of Medicine, Illinois.
Let the Computer do it!

Fully Automated Tumor Tracking With
syngo CT Oncology
By David J. Tenenbaum
Before data becomes information, it must measurement, and even brings volume the largest oncology units in the United
be thoroughly examined and analyzed. calculation into routine tumor evaluation. States.
And as CT scanners produce a growing In May, he reported to the American
torrent of data, radiologists confront a Quick, Accurate and Consistent Roentgen Ray Society that manual and
data-or-information question every day: automatic segmentation and measure-
how to obtain the maximum patient ben- In preliminary tests, Vahid Yaghmai, MD, ment of abdominal and pelvic lymph
efit from the hundreds of slices that an Associate Professor of Radiology at the nodes corresponded closely, according to
advanced CT scanner produces from each Northwestern University Feinberg School both RECIST and WHO criteria. Similarly,
patient scan? of Medicine, Chicago, Illinois, says the he reported to the Society of Gastrointes-
Rigorous, accurate and repeatable analysis software matched the best human mea- tinal Radiologists that the software suc-
of CT scans is a matter of life and death surements. “In our experience, we have cessfully segmented and measured 22
in oncology, but the sheer quantity of seen an excellent correspondence be- liver lesions on contrast-enhanced CT
data raises the potential for operator fa- tween a manual measurement of lymph scans from 12 patients.
tigue and even error. And these dangers node and most liver tumors, and the Fast, accurate and repeatable tumor seg-
are multiplied by the regular follow-up automatic software measurement. mentation and measurement are signifi-
studies needed to track tumor response It’s very quick, accurate and consistent cant advances, but syngo’s new ability to
to treatment. in measuring lesions using the RECIST automatically calculate tumor volume
But wading through data is precisely why (Response Evaluation Criteria in Solid could have equal importance. Studies
computers were invented. Several years Tumors) and WHO (World Health Organi- have already shown that the volume of
ago, Siemens CT software gained the zation) standards.” Yaghmai is Medical lung tumors may be valuable for assess-
capability to automatically detect tumors. Director of CT at Northwestern Memorial ing progression or regression; similar
And now the new syngo® CT Oncology Hospital - Northwestern University, a ter- studies for liver, bone and brain tumors
has the capability to automate lesion tiary care hospital in Chicago with one of remain to be done. Although the role of

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Greater accuracy may also help resolve

long-standing questions about the relative
value of RECIST and WHO standards.
There is a lot of debate, but a lot of that
stems from the issue of human error in
manual segmentations.
syngo CT Oncology also offers workflow
improvements. “In a large oncology center,
measuring lymph nodes in multiple dimen-
sions and reporting on multiple lesions in
every study is a very time-consuming pro-
cess,” Yaghmai says. “An automated way of
measuring lesions would really improve,
the workflow. You decide which lesions to
evaluate, and click on as many as you
want. Theoretically, somebody who is not
a radiologist can look at lesions on a fol-
low-up study.”
Volume as a Standard Modality?

In the longer term, automated tumor mea-
surement can take radiology firmly into
One click 3D-segementation and size evaluation of liver lesions with syngo CT Oncology. the third dimension. While each compo-
nent of a CT scan is a two-dimensional
slice of the patient’s anatomy, tumors
themselves are three-dimensional objects,
volume in determining tumor status measurement that can occur when doing and the new-found ability to measure
remains subject to further research. “Intu- it manually,” says Yaghmai. “Despite ad- volume will allow comparisons to see
itively, we think it should be important,” vances in technology, consistency remains whether volume, RECIST or WHO is most
says Yaghmai. “But until now, the difficul- a problem in radiology. There have been appropriate for evaluating treatment.
ty of performing volume measurements many studies showing that measurements Already, data regarding the volume of lung
has limited our ability to validate this.“ of the same lesion by two observers will cancer nodules “suggests that volume
be different. syngo CT Oncology eliminates should be the way to follow treatment,”
Simplified Follow-Ups that part of the inconsistency.” This im- Yaghmai says. “However, nobody knows
provement may be particularly important what volume means in terms of patient
To obtain automated measurements in irregular tumors, with poorly defined management for tumors of the liver or
from the syngo CT Oncology*, a radiolo- margins that are difficult to measure. lymph nodes. Even before the precise role
gist clicks on the lesion on the display, and of volume measurements is determined,
immediately receives a readout of x, y, Better Patient Care accuracy and repeatability have value in
and z dimensions, RECIST and WHO mea- improving patient care,” says Yaghmai. “We
surements, and lesion volume. If the On the practical level, automated measure- do not want the human factor to be a com-
scan is a follow-up, the system displays ment can improve the accuracy of compar- ponent of these measurements. It’s better
previous data on the same lesion, and isons when patients change hospitals. for patient to have realistic information.
calculates any dimensional change during “Many patients are first imaged at a small Whether or not volume becomes a stan-
the interim. community hospital, and we want to standard modality for evaluating treatment,”
A simplified follow-up is one of the biggest dardize the way we are following these tu- Yaghmai says, “software like this will be
benefits of this new syngo software; there mors; it’s really about better patient care,” eventually standard for any follow-up of
is no need to “find” the same tumor on says Yaghmai. oncology patients. Previously, the technol-
previous images, and then determine Automated measurement can also advance ogy was not available, and now it is.”
which slice shows the greatest single the state-of-the-art in oncology, by improv-
dimension for RECIST or WHO measure- ing the accuracy of tumor assessment dur- *Pending 510(k): The information about this
ments – those repetitive functions are now ing clinical trials, he adds. There is much product is being provided for planning purposes
all embedded in the software. “When you push from the National Cancer Institute to only. This product is pending 510(k) review, and
follow patients based on these measure- standardize the way we follow up tumors. is not yet commercially available in the U.S.
ments, you want consistent and reliable There is a lot of variability in how different
David J. Tenenbaum, reports on science, health
data, and this software gives reliable and centers do follow-up, and we want to stan-
and environment, and is co-author of Visualizing
consistent information. It virtually elimi- dardize how we acquire images and mea- Human Biology, published by John Wiley and
nates human error and the variations in sure these tumors. Sons (2007).

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syngo Circulation - Siemens Scientifically

Validated Cardiac CT Software.
By Lars Hofmann, MD, Global Clinical Marketing Manager, Cardiac and Acute Care CT, Siemens Medical Solutions, Forchheim, Germany
Modern post-processing software tools Circulation the first coronary analysis improvements include the completion of
have gained increasing significance in software to be scientifically validated. the functional and myocardial evaluation
routine diagnosis over the past years. It The group of Busch et al. concluded that, as well as improved accuracy and flexibility
is of high importance to offer not only “the automatic segmentation of the for quantitative coronary analysis. New
a variety of software features, but at the whole coronary artery tree has become plug-ins allow the automatic detection of
same time, to validate accuracy and func- routinely feasible and has eased post-pro- pulmonary emboli** and the fusion of
tionality against existing gold standards. cessing.” Additionally it is important to cardiac CT data with SPECT and PET data.
Researchers at the University of Munich, note that, “the diagnostic accuracy of CTA syngo Circulation is the only cardiac CT
Departments of Clinical Radiology and can be improved with this software,” software that allows the complete cardiac
Cardiology, evaluated the accuracy of which “makes the software a very helpful morphology and function evaluation in
syngo® Circulation as a quantitative coro- tool to improve diagnostic accuracy one single software.
nary CTA analysis tool in reference to with the quantitative grading of stenosis.” * The study of Busch et al. was pre-published as online
quantitative coronary analysis in conven- syngo Circulation has reached its third issue in European Radiology on December 16, 2006.
tional angiography*. This makes syngo development stage in two years. Major **Not commercially available in the US.
syngo Circulation Plaque Analysis.

Flexibility for the Future – Now
One significant advantage of the SOMATOM Sensation Web Selection is its
combination of state-of-the-art 64-slice CT imaging capabilities with the
dedication to provide an exceptionally streamlined CT workflow. This makes
it the premium solution to fulfill todays high end CT expectations.
By Tim Friend
Radiology workflow at Alamance Regional Web Selection as the world’s first Web- bed hospital has upgraded the 40-slice
Medical Center (ARMC) in Burlington, N.C., enabled CT, providing “Zero Delay” Work- machine to a SOMATOM Sensation 64
has entered the jet stream. The vehicle flow Solution with instant accessibility Web Selection – complete with new hard-
whisking this remarkable community hos- of 3D volume data to users at any loca- ware and software, and protection against
pital on a wickedly fast ride into the future tion, 24 hours a day. Getting onboard obsolescence. But what DeAngelo says is
is SOMATOM® Sensation Web Selection. with SOMATOM Sensation Web Selection most noteworthy about the upgrade is
According to ARMC’s RIS/PACS administra- marks the second time in two years that that it was done “without a forklift,” using
tor Chris DeAngelo, this new ride is a ARMC has become first in the world to the existing SOMATOM Sensation 40.
fully-loaded package with medical imag- obtain brand-new CT technology and The entire upgrade, which gives Almance
ing technology and IT features few people IT workflow solutions from Siemens. In the ability to conduct full cardiac CT angi-
have seen before. 2005, ARMC was first to receive the ography with the fastest gantry available
Siemens describes its SOMATOM Sensation SOMATOM Sensation 40. Now the 238- on the market, was completed in a day

Business
“Now we can say we have a

whole brand-new CT scanner
with excellent image quality
and the sizzling gantry
speed of 0,33 s at minimal
investment.”
Chris DeAngelo, RIS/PACS administrator, Alamance Regional
Medical Center, Burlingtion, N.C.
and at a fraction of the cost of buying a first customer to use it. Alamance per- ties such as syngo® Circulation software
new 64-slice machine. forms CT for all medical indications, but that enables cardiologists to analyze
“When Web Selection came onto the it has had its eye on cardiac CT angiogra- coronary blood vessels in a very high tech
horizon, we immediately put it into our phy. With the SOMATOM Sensation 40 but easy manner. After the CT scan is ac-
crosshairs,” DeAngelo says. “We were able scanner obtained in 2005, the hospital quired, the radiologists can do post-pro-
to do the upgrade to Web Selection very began expanding into cardiovascular cessing, analyze their data to generate
economically with minimal effort. It was imaging, primarily for peripheral arteries special cardiac images, and make screen
easy on the wallet and an easy install. and carotids. Now the hospital is planning shots or reports. As techs, we will look at
This made it possible to continue with our for cardiac CT angiography, expanding it the images, isolate blood vessels, calcu-
initial investment while keeping up with patient base as the place to be for diag- late the percentage of stenosis, and send
latest technology and with a minimal nosing coronary artery disease. those images to PACS,“ says DeAngelo.
amount of downtime. Now we can say SOMATOM Sensation Web Selection Besides its superb imaging capabilities,
we have a whole brand-new CT scanner addresses exactly these needs, with its the SOMATOM Sensation Web Selection
with excellent image quality and the advanced imaging capabilities. It offers is designed to deliver a streamlined CT
sizzling gantry speed of 0.33 s at minimal industry’s highest rotation speed of workflow with Zero-Delay from the very
investment.” 0.33 s which is essential to freeze the car- beginning of patient preparation to the fi-
It seems safe to say that ARMC Senior diac motion. At the same time the high- nal diagnosis. It starts with a “smart” fea-
Vice President Carol Hudson, as well as est isotropic resolution of 0.33 mm en- ture, CARE Contrast, that allows the tech-
the radiology department she oversees, is abled by Siemens unique z-Sharp nologist to initiate the CT Scan right at
enjoying life at the leading edge. “We are technology gives the user the ability to the injector in the scan room at one click
very excited. The upgrade to the 64 gives see smallest detail such as the entire cor- of a button without having to leave the
us the increased clinical functionality we onary artery tree or even coronary in- room. This saves time and increases pa-
needed to move into full cardiac imaging, stent lumen. tient care. It continues with a minimal
which all of the big medical centers offer The combination of both, speed and processing time of images realized by
now and whose technology the local resolution is key in cardiac imaging. Not an option called Workstream4D, enabling
community is beginning to ask for,” only to freeze motion and make smallest the direct reconstructions of multiplanar
Hudson says. “But we’re particularly excit- details clearly visual for the physicians but images. A feature, that helps busy depart-
ed about how images can now be ac- especially to image calcified plaques with ments to get valuable additional informa-
quired. This is certainly going to improve as little blooming artifacts as possible. tion in less time. Even beyond the CT
workflow and turnaround for patient Combined with the latest evaluation soft- Department the Web Selection offers
results and reporting. We are seeing im- ware, the SOMATOM Sensation is a pow- tools to provide a so called “Zero-Delay”
mediate benefits.” erful tool in Cardiac CT. CT workflow. To enable physicians to call
What´s more. DeAngelo says the for a second opinion or to have a CT Tech
Cutting Edge in CT Imaging SOMATOM Sensation Web Selection’s call for advice for reconstruction of imag-
and Workflow Multimodality workplace is set up with es, syngo Expert-i is the perfect tool to es-
sophisticated post-processing software tablish a connection between the work-
Alamance is the first hospital in the US for a wide variety of functions. station and any remote PC instead of
to receive the SOMATOM Sensation Web- “We have a new Multimodality Workplace having the expert physically come to the
Selection. DeAngelo is delighted to be the with advanced post-processing capabili- workplace.

Order Plan & Prepare Scan & Reconstruct Process Read & Report Distribute
Patient Preparation Scan Data
MultiModality Workplaces +
CT Clinical Engines + syngo Expert-i (Remote)
syngo Expert-i syngo WebSpace (Clients)
Office PC
Acquisition CT WebSpace
Workplace Workplace Server
Home
PC/Laptop
Shared Database
Fast Data Link PACS PACS Reading

Archive Workstations
With syngo WebSpace 3D data are available anytime and anywhere.*
Remote Technology Brings ing images from a PACS archive for post- “From the administrative perspective,
Images Closer processing at the Multimodality workplace Web Selection gives us the ability to
can now be used in more productive continue to be out there on the innova-
Any outside observer at Alamance’s ways. Radiologists and surgeons no lon- tive and up-to-date use of technology,
radiology department can see that all is ger have to wait in line for the Multimo- not only for the patient, but for the staff
in motion – fluid, linear, traveling at the dality workplace to view the highest and their work time and input. This gives
speed of light – from the moment a CT quality CT images, nor must they waste us efficiency in both arenas. We are fairly
technician pushes the button on the time and effort switching between the sophisticated with technology already,
64-slice scanner, to the automatic post- workstation and a personal computer but this takes us up another notch in the
processing of 3D volume data in a dedi- when viewing images in 3D. And that technological world.”
cated two-terabyte server, to a physician’s midnight drive from the radiologist’s home The SOMATOM Sensation Web Selection,
click of a mouse only moments later to to the hospital simply to spend ten min- which was introduced by Siemens at
access the images from any remote loca- utes reading an image? That’s history, too. RSNA 2006 contains a number of vital
tion with an Internet connection. “We will see significant costs savings in components. Perhaps the most glamor-
According to Hudson, the time patients the long term, but the benefits are imme- ous one beside the excellent image quality
spend waiting to be scanned and to re- diate. Physicians are able now to access is a technology called syngo WebSpace.
ceive a diagnosis is diminishing. The time images over the Internet, which is saving DeAngelo says WebSpace has made it
technicians previously spent download- everyone time and money,” Hudson says. possible to transform any personal com-
* Internet connection required.

Business
SOMATOM Sensation Web Selection.
puter or laptop into a “thin-client” clinical “Like InSpace on Steroids” could do on that workstation with
workstation with high-end CT imaging InSpace – on the Multimodality workplace
and post-processing capabilities similar to As a former CT technician and now – at a fixed location we can now do
the Multimodality workplace. Rather than Alamance’s RIS/PACS guru, DeAngelo is anywhere, anytime.* What that means
having to sit down at a dedicated work- most excited about what most people in practical terms is that WebSpace is
station to access 3D volume data, users never see – Web Selection’s hardware making 3D data practical for the common
gain access from any location over the server infrastructure and the new imag- man.”
Internet using a standard broadband con- ing software. The state of the art for Hudson says SOMATOM Sensation Web
nection. Making life even simpler, DeAn- image processing has been InSpace, Selection is transforming the radiology
gelo notes, the system uses the same fa- which operates with the Multimodality department. While syngo WebSpace
miliar syngo platform as all Siemens workplace. InSpace, which became avai- resolves a key bottleneck in radiology,
imaging systems. This makes WebSpace lable in 2003, changed the landscape namely limited access to Multimodality
easy to learn, because the language is the from 2D axial images to 3D volume workplaces, the SOMATOM Sensation
same and the computer screens are fa- images. In the 19th issue of Siemens’ WebSpace server has resolved issues with
miliar in appearance. Training is a matter SOMATOM Sessions magazine, Elliot the massive amount of 3D volume data
of learning a few extra keystrokes, he Fishman said, “WebSpace is sort of like and heavy computing power needed
says. InSpace on steroids. Everything we for post-processing and image storage.
* Internet connection required.

Business
“We will see significant costs savings in the

long term, but the benefits are immediate.
Physicians are able now to access images
over the Internet, which is saving everyone
time and money.”
Carol Hudson, Senior Vice President of the Alamance
Regional Medical Center, Burlington, N.C.
Radiologists at Alamance recognized facilities that provide cardiac surgery the ed ER admissions,” says Jan Chudzik, Prod-
early on the value of 3D imaging for many cardiac surgeons can view the images on uct Marketing Manager for the SOMATOM
medical indications compared to standard a computer screen in the OR while they Sensation. “The thin client-based accessi-
axial images. The dedicated two-terabyte operate. DeAngelo says WebSpace also is bility of 3D images to the physicians any-
WebSpace server that DeAngelo oversees becoming popular with the hospital’s where and anytime will help to shorten
receives information instantaneously orthopedic surgeons, who rely on 3D the overall process of patient diagnosis by
via a Fast Data Link from the SOMATOM volume data as much as cardiologists. But cutting out the typical delays of a worksta-
Sensation. New software instantly does new applications for WebSpace are essen- tion/PACS-bounded workflow.”
the post-processing and makes it available tially limitless. Hudson adds that having For any institution purchasing expensive
to users via the server’s Web connection. access to 3D images over the Web makes imaging equipment, flexibility for the
Typically, technicians must download the the hospital more attractive to patients future is an important consideration, adds
raw CT volume data onto a workstation and to new referring physicians. A patient Hudson. The rapid pace of technological
from an archival server and do post-pro- and physician can view images together evolution can cause million-dollar imaging
cessing, which takes time and “chews up on the physician’s computer when discuss- systems to become outdated in just three
an enormous amount on space on my ing a diagnosis and treatment options. to five years. Purchasing the Sensation 40
PACS archive,” DeAngelo says. “With the with knowledge that it could be upgraded
WebSpace server, we have an additional Investing in Flexibility to a 64-slice system gave Alamance the
two terabytes worth of space. For me, this in the Future flexibility it needed. Siemens’ e-Tune is
will keep the cost of maintaining the main packaged with Web Selection to offer pro-
PACS archive down by not overloading it “We were already a filmless radiology tection against technological obsoles-
with data. We can store our most current department and fairly state of the art. But cence. e-Tune guarantees that Alamance
images on the new server and keep our with SOMATOM Sensation Web Selection receives software and even hardware up-
overall costs low.” we see multiple advantages for us,” dates for the next several years.
syngo WebSpace can accommodate five, DeAngelo says. “There is a huge workflow DeAngelo is confident that the hospital
ten or twenty simultaneous users, de- benefit for everyone, including our radiol- made the right choice, saying, “This will
pending on an institution’s needs. Ala- ogists and referring physicians – particu- carry us quite some time into the future.
mance’s package provides access for 10 larly orthopedic and vascular surgeons.” The Web Selection with e-Tune extends
users at any given time. As Alamance “ARMC’s continued trust and investment our original investment in 2005 in the
becomes a local leader in cardiac CT into the SOMATOM Sensation product line Sensation 40 to a total of five years.”
angiography with its 64-slice scanning shows the success of the technological
capability, DeAngelo sees this as a premi- and clinical capabilities of the system.
um value for cardiologists and heart Alamance’s decision to optimize its busy
surgeons. DeAngelo says physicians and CT program with the SOMATOM Sensation
surgeons will be able to access 3D images Web Selection will accelerate the way they Tim Friend, a USA Today reporter for 17 years,
of a patient’s coronary arteries from their can deliver patient care. The ability to scan is now a freelance science and medical writer
based in Alexandria, Virginia. He is the author of
personal computers. The images are avail- and post-process patients faster will have
Animal Talk: Breaking the Codes of Animal Lan-
able almost instantly after they are taken a positive impact on patient throughput, guage, and The Third Domain: The Untold Story
in the radiology suite. Likewise, in those especially at peak times or with unexpect- of the Archaea and the Future of Biotechnology.

Business
Karl Engelhard, MD, Chief of the Department of Radiology Although the Martha-Maria Hospital is a confessional clinic with
at the Martha-Maria Hospital in Nuremberg, Germany. only 330 beds, it is able to compete with much larger hospitals.
Big Progress for a Small Clinic

Elevating to a new SOMATOM Sensation scanner has paid off
for a hospital in southern Germany, delivering more patients, more
revenues and better, faster diagnoses.
By Frank A. Miltner
“In CT diagnostics, we are clearly a step grading their existing Siemens single slice tics on this for another few months,”
ahead,” says Karl Engelhard, MD, Chief of CT to a new multislice, spiral, computed notes Engelhard, “but the trend in num-
Radiology at the Martha-Maria Hospital tomography scanner, the SOMATOM® bers of scans is clearly rising.” Also help-
in Nuremberg, Germany. Since the begin- Sensation 40-slice configuration from Sie- ing the trend climb is the small radiology
ning of 2007, this small, confessional mens Medical Solutions.” team’s new ability to continuously further
clinic of only 330 beds has been able to Word traveled fast about the acquisition extend its diagnostic spectrum.
compete with much larger hospitals. And of the 40-slice CT. Just three months
competition is fierce: about a dozen other after installation of this high-end system, Money (Also) Talks
small hospitals, a university clinic, and an the number of CT scans had risen nearly
urban hospital with 2,000 beds are avail- 20 % to the present level of about 1,600 Healthcare, of course, is the primary con-
able to patients in the Nuremberg metro- per year. Primarily private patients come sideration but no clinic today can afford
politan area, with its some two million in- to the small hospital, some from as far as to ignore financial matters.
habitants. “This significant progress for a 100 kilometers away, for complex pre-clini- “Siemens helped to make our move to
small hospital was made possible by up- cal diagnoses. “We won’t have firm statis- multislice CT happen through their

Business
The diagnosed ureteral tumor stands out (arrow) as do the contrasting white areas in the kidney and the ureter. “Only this
morning we discovered a ureter tumor that we would not have recognized with our old equipment,” Engelhard says.
attractive offering including the buy-back scanner is a fraction of what it used to be. “Thanks to multi-planar reconstruction
of our old scanner.“ And the investment This eases discomfort for the many pa- with thin collimation and temporally
of several hundred thousand euros – ob- tients who come for scans with breathing highly-resolved contrast dynamics,” he
viously still a significant sum for a small difficulties and other problems. For says. “Only this morning, we discovered
hospital, amortizes itself at various levels. example, where the old single slice a ureter tumor that we would not have
There are already cooperative agree- system needed five or six minutes for a recognized with our old equipment.”
ments with established physicians who chest cage CT, the new one needs only Early discovery gives the patient a critical
now send their patients to Martha-Maria 15 seconds – and it delivers markedly advantage, because this sort of tumor is
instead of to the large urban hospital in better results. aggressive and spreads easily. The
Nuremberg or to the University Clinic at SOMATOM Sensation 40’s industry‘s high-
Nuremberg-Erlangen. True to the Mission of its est spatial resolution, its fast, accurate
And of course the diagnostic spectrum Benefactor localization allows a rapid, low-risk surgi-
has been greatly extended, compared to cal plan to remove it.
that of the previous scanner, an eight- Not surprisingly, this cuts costs. The new Political reform of the healthcare system
year-old, single slice, spiral CT. In Martha- CT does not require additional personnel. has, in the past few years, intensified
Maria Hospital, the main benefactors of the On the contrary – the four physicians and competition among German hospitals.
new scanner are oncology, gastroenterol- seven technicians in the radiology depart- While some hospitals respond by cutting
ogy, urology, orthopedics and cardiology. ment now have more time for other back on services, Martha-Maria is trying
All benefit from temporally and spatially diagnostic procedures and for their pa- another approach: it is positioning itself
highly-resolved oncological and cardio- tients. For the Martha-Maria Hospital, as a specialist where quality comes first –
logical diagnostics, for example, and with this brings an ethical bonus: its benefactor and the SOMATOM Sensation 40 plays a
virtual colonoscopy and three-dimensional is the Protestant Mission Martha-Maria, central role. “The marketing effect of this
representations of arthritic changes. The which operates on the principal of broth- scanner generates a positive influence on
new equipment brings additional revenues erly love and puts people at the center the economics of the entire hospital,”
as well as better conditions for patients. of its clinical work. The chief of radiology’s contends Engelhard. The improved pre-
Radiation exposure is clearly reduced, delight in his new clinical capability is clinical diagnostics even bring in extra
and the time a patient must spend in the clearly noticeable. patients on their own initiative.

Business
Custom-Made Advantages increase from 16 % to 19 %. This was a pleted within a few days. “One must
literal case of “time is money.” strongly emphasize: as a small hospital
“The choice of a Siemens CT also turned So Siemens Medical Solutions installed with limited resources, we were very glad
out to be a great advantage when it came the new equipment during the week be- that Siemens could offer us such a cus-
to installation,“ says Engelhard. In this in- tween Christmas and New Year, a time tom-made solution.”
stance, Martha-Maria had some very ex- when little business is conducted and
acting, demanding requirements. Plan- when most other service companies are
ning was to begin only in late summer on holiday. “The hospital administration
2006, yet installation and full functional- could not afford to have long down times Frank A. Miltner is a Munich-based media con-
sultant and a scientific and medical journalist. He
ity had to be completed by December 31 – in CT diagnostics,” notes Engelhard.
is a former editor of the German magazine Focus
because on the next day, January 1st, Moreover, Siemens purchased the old and editor-in-chief for Lifescience.de and Netdok-
2007, Germany’s value-added tax would equipment and user training was com- tor.de as well as the author of several books.
A Workhorse as well for Cardiology

Interview with Falk Karsten Pohle, MD, Chief of Cardiology, Martha-Maria Hospital, Nuremberg, Germany
Dr. Pohle, you strongly supported the purchase of the non-invasive heart diagnostics, not only for our patients and for
SOMATOM Sensation 40-slice configuration. Why this partic- our small hospital, but also for the whole region. Among non-
ular scanner? university clinics, at present we have no competition.
I have worked for many years with Siemens CTs, and I know
very well that I can rely on them and their high image quality in What has changed for the patients?
addressing cardiological questions. This CT is a true workhorse. We can, for example, rule out coronary diseases, conduct
Of course, it is obvious that this 40-slice CT, compared to our artery hardening analyses, recognize soft plaques, and diagnose
old single slice system, represents a quantum transition for our patients with small and middle pre-test probability or middle
PROCAM risk to the extent that preventive measures can then be
introduced. With this CT, we not only work more accurately,
but also spare many patients the discomfort of a heart-catheter
examination.
What has changed for your cardiology department?

Our reputation has grown noticeably, patient numbers have in-
creased, and we now have a cooperative program with estab-
lished cardiologists. Word spread about our cardio CT, and pa-
tients have begun to ask about it. This CT not only improves the
quality and thus the reputation of our Department of Cardiology,
it also provides for significant hospital revenues. It has been
only three months since we introduced the new equipment,
and we are fully on budget with our financial plans. The invest-
ment was worthwhile for us in all respects.
Falk Karsten Pohle, MD: “With this CT,

we not only work more accurately, but also
spare many patients the discomfort of a
heart-catheter examination.“

Business
Cardiac CT Takes Off

Detecting coronary artery disease in its asymptomatic stage is one
of the greatest challenges a cardiologist faces. The flight surgeons of the
German Air Force have had tremendous success in this area, as they
have developed a method using computed tomography for early diagnosis
of the disease in pilots. This unique method has gained increasing
recognition in aeromedicine worldwide.
By Sonja Fischer, Siemens Medical Solutions, Erlangen, Germany
Just as the captain of the Boeing 757 has tion with the control tower operators, was able to safely land the aircraft and
safely taken off, he feels a sharp pain in he collapses and is not able to continue none of the passengers was harmed. The
his chest. He is panting for air. In his field navigating the aircraft. What sounds like captain, however, died from the conse-
of vision, the controls blur with the de- a real horror-scenario actually took place quences of his heart attack. Coronary ar-
creasing landscape below, and before he in February of this year in a Continental tery disease (CAD) is still the most fre-
has a chance to set up radio communica- Airlines aircraft. Fortunately, the copilot quent cause of death in the industrialized

this reason, diagnosing CAD at an early,
asymptomatic stage is important for us as
flight surgeons so that we can prevent
any acute coronary syndrome that could
have immediate consequences for the pilot
and aircraft.”
Extraordinary Exposure
for Jet Pilots
For jet pilots, a “sudden incapacitation
in flight” can be particularly dangerous.
They often fly alone and, in case of a
heart attack, there would be no one to
safely land the aircraft. In addition, spe-
cific conditions in the cockpit further
cause physical stress: extreme heat,
hypoxia, and high accelerating forces
that push blood from the head into the
legs and can shift internal organs up to
15 centimeters. These conditions increase
the danger of an acute coronary event
in persons with arteriosclerosis.
However, within the clinical aeromedicine
department in Fürstenfeldbruck, Wonhas
is responsible for more than just the
aeromedical assessment of military pilots.
As Assistant Director of the German Air
Force’s ‘Aeromedical Center,’ which has
been accredited for civil aviation, he also
assesses pilots from major German air-
lines on behalf of the German Federal
Thanks to its high sensivity and specificity, DSCT has become increasingly recognized Office for Civil Aeronautics. He is currently
in international aviation medicine when diagnosing CAD in asymptomatic pilots at the stationed at the US Air Force School of
German Heart Center, Munich, Germany. Aerospace Medicine in Texas, taking part
in continuing aeromedical education.
There, the significance of CAD for aero-
medicine has been confirmed for Wonhas.
“In terms of accelerated Statistics from the Federal Aviation Admin-
istration (FAA), the civil aviation authority
temporal resolution, in the US, indicate that pilot autopsies

have shown a higher-than-average per-
centage of coronary heart disease. From
SOMATOM Definition sets 1980 to 1982, the agency examined 710
deceased pilots. Of those, 3 % showed se-
groundbreaking standards.” vere, and 66 % showed minimal to mod-
erate coronary heart disease. Only 31 %
Stefan Martinoff, MD, had no indications of arteriosclerosis of
Director, Institute for Radiology and Nuclear Medicine, the coronary arteries. “In Germany, we do
German Heart Center, Munich, Germany not have such large sets of statistics, be-
cause fewer people are actively flying.
Therefore, there are far fewer fatalities,”
says Wonhas. “However, forensic doctors
world, and can cause what in aviation is at the German Air Force Institute of at the German Air Force Institute of Avia-
feared as ‘sudden incapacitation in flight’. Aviation Medicine in Fürstenfeldbruck, tion Medicine have observed a similar sit-
Now, a specialized strategy should prevent Germany, sees as his most important uation, and several autopsies have found
these events in both military and civil task. “The prevention of fatal occurrences more or less severe CAD or stenosis.” As a
aviation. This is what Christoph Wonhas, or sudden incapacitation is critical to result, the flight surgeons began to
MD, an internal specialist and cardiologist ensuring flight safety,” he stresses. “For search for a reliable method of detecting

Business
the disease early to help prevent sudden disease hit rate of only 21 %. In addition, method for displaying the coronary arter-
inflight incapacitation. the European JAR-FCL3 guidelines (Joint ies of asymptomatic pilots in suspicious
Aviation Requirements for Flight Crew Li- cases without having to risk an invasive
Cardiac Health: censing) can disqualify pilots with a lu- catheter examination. This was a method
Strict Guidelines for Pilots men occlusion of 30 %. As such, for avia- we wanted to use,” he remembers.
tion it is very important to be able to
In aeromedicine, bicycle ergometrics is determine CAD in asymptomatic subjects Effective Cooperation
recognized as the essential stress test without high-degree stenosis. Until now, in Cardiac CT
for the health and fitness of pilots. With invasive coronary angiography has been
respect to CAD, however, ergometrics do the gold standard. However, physicians For this reason, the German Air Force
not enable diagnosis until a stage that do not want to subject asymptomatic pa- Institute of Aviation Medicine looked for
shows changes in the electrocardiogram tients to the risks associated with this ex- a suitable cooperation partner in diag-
(ECG) due to ischemia. Yet before the cor- amination every time there is a new, but nostic cardiology and high-resolution car-
onary blood flow becomes insufficient, insignificant conspicuity in a stress ECG. diac CT, and found that partner in the
the stenosis diameter has to reach 50 %. “Furthermore, we have found myocardial German Heart Center in Munich (DHM).
This means that ergometrics are of signif- scintigraphy, which is used regularly in The DHM is one of the leading cardiac
icant value for assessing patients at risk. American aeromedicine, to be unsuitable centers in Europe, and was one of the
However, during routine screening of for detecting CAD in our pilots because it first facilities to use MSCT technology on
young, asymptomatic patients with a low does not enable display of the coronary the heart. The center has been equipped
coronary risk score like Framingham and arteries,” says Wonhas. “However, with with state-of-the-art CT scanners from
PROCAM Score, as is the case of most pi- multislice computed tomography (MSCT), Siemens since 2002. The first MSCT sys-
lots, this method has a coronary heart we found a fast, secure, and cost-effective tem that the center used was SOMATOM®
German Air Force Institute

of Aviation Medicine
The German Air Force Institute of Aviation Medicine in Fürsten-
feldbruck is the central aeromedical facility for the German
Army, Air Force, and Navy. Its job encompasses the selection,
examination, and aerophysiological instruction of aircraft crews
for the German Armed Forces. It is also responsible for investi-
gating aviation accidents, ergonomics, aerophysiology, and ment. It is an interdisciplinary, polyclinical diagnostic center
dealing scientifically with aeromedical problems. The primary with eight specialist groups: Internal Medicine, Orthopedics,
tasks are performed in the following six departments: Neurology and Psychiatry, Ophthalmology, Ear-Nose-Throat,
Dentistry, Diagnostic Radiology, and Central Lab. Their task is to
■ Research, Science and Education, Air and Space Medicine examine and assess the medical suitability of all candidates for
■ Clinical Aeromedicine military flight service. This includes follow-up examinations on
■ Forensic Medicine and Aviation Accident Medicine approximately 3,300 army, navy, and air force pilots and weap-
■ Flight Psychology on systems officers for deployment on military aircraft. The in-
■ Ergonomics stitute uses equipment of the highest standard. Since 2003, the
■ Aerophysiology German Air Force Institute of Aviation Medicine has also served
as the Aeromedical Center (AMC) for civil aviation on the order
The Clinical Aeromedicine Department, where MSCT diagnostics of the German Federal Office for Civil Aeronautics. As a result,
are used as a noninvasive cardiac examination procedure under frequent fliers such as Lufthansa captains, hobby pilots, and
the direction of Christoph Wonhas, MD, is the largest depart- flight attendants now round off the patient spectrum.
Source: German Air Force

Business
“MSCT is a fast, secure, and cost-

effective method for displaying the
coronary arteries of asymptomatic
pilots in suspicious cases, without
having to risk an invasive catheter
examination.”
Christoph Wonhas, MD, Internist and Cardiologist,
Air Force Institute of Aviation Medicine, Fürstenfeldbruck, Germany
Sensation 16, which was later upgraded greater certainty.” after ergometrics to rule out structural
to a 64-slice system. This was then re- From a cardiological perspective, Haus- heart diseases such as cardiomyopathy or
placed by the latest high-end CT system leiter particularly stresses the advantages cardiac valve disease. On the same day,
from Siemens in the summer of 2006: of CTA as a noninvasive method to identify the colleagues at DHM perform the MSCT
SOMATOM Definition. plaque-accumulation in the coronary examination on the affected pilot. This
Stefan Martinoff, MD, Director of the arteries. “Due to the high spatial and tem- procedure has proven to be extremely ef-
Institute for Radiology and Nuclear Medi- poral resolution of CTA imaging, we can fective. From 2003 to 2004, exactly 3,409
cine at DHM, and Jörg Hausleiter, MD, show calcified as well as noncalcified flight crew members were examined and
cardiologist at the Department of Cardio- plaque.” During plaque rupture, blood clots retrospectively evaluated in a study. In
vascular Diseases, both helped to develop occur which can consequently cause a 1.73 % of cases (59 pilots), results proved
this innovative method for using MSCT in heart attack. Therefore, Hausleiter as- to be suspicious and required further ex-
aeromedical assessments. Martinoff is sumes that these deposits – especially the amination. “Fortunately, we were able to
impressed by the new SOMATOM Defini- noncalcified – will, in the future, be in- rule out coronary heart disease in 85 % of
tion. “With this system, we took the op- creasingly considered for the diagnosis of them. However, we did find coronary ar-
portunity to accelerate cardiac imaging in arteriosclerosis in asymptomatic patients tery disease in nine persons, with steno-
terms of temporal resolution. In this area, with low to intermediate risk to suffer ses up to 90 %, and these were all asymp-
the new Dual Source CT sets a ground- from CAD like the pilots. tomatic pilots with a PROCAM Score of
breaking standard. The system is much about only 5 %,” says Wonhas. This per-
easier on the patient, and it is easier for Reliable Diagnosis spective of the physician comes from 20
us to perform significant, high quality in Asymptomatic Pilots years clinical experience as an internal
coronary CT examinations,” states the ra- specialist in an intensive care unit. In
diologist. “In addition to the resolution, Since 2003, Wonhas and his colleagues 2003, during his flight certification (flight
which at 82 milliseconds is twice as fast, have been using MSCT in aeromedical surgeons in the German Air Force are re-
there is a whole range of hightech fea- assessments with the support of DHM. As quired to fly on a case-by-case basis),
tures that make the Definition an excel- in the past, they routinely perform ergo- Wonhas, too, had suspicious ergometrics
lent system for vascular and cardiac ex- metrics at the Institute of Aviation Medi- while being asymptomatic. CTA was per-
aminations.” For Wonhas, computed cine once annually as a screening method. formed, and the findings were normal.
tomography angiography (CTA) using Now, however, if changes are noted in “Therefore, I have a different perspective.
SOMATOM Definition is the method of the ECGs and ergometrics when compared I understand the problem as an invasive
choice for aeromedical assessments: “The to those from the previous year – for ex- cardiologist, but also as a patient,” says
primary advantage is the high negative ample, a new, higher-grade arrhythmia or Wonhas. Martinoff of DHM can confirm
predictive value of almost 100 %. With new ST segment changes – the physi- that Wonhas makes sensible patient se-
respect to flight safety, we can now rule cians authorize additional, noninvasive lections for the examination based on his
out whether an asymptomatic pilot is suf- examinations. This means that a transtho- experience: “Given the hundreds of pilots
fering from coronary heart disease with racal echocardiogram (TTE) is performed in the German Air Force, the small num-

Business
1A 2
1B 1C 1D 1E
1 If irregularities occur in the resulting electrocardiogram (Fig. 1A), 2 Routine investigation at the Institute of Aviation
CTA is performed on the same day at the German Heart Center Medicine includes bicycleergometrie as indispensable
(Figs. 1B - 1E). Exemplary findings (above) from Wohnas‘ CTA test stress test.
in 2003 which ruled out CAD for him.
ber that Wonhas sent to us to be exam- Treaty Organization) has begun working Armed Forces or civilian airline will contin-
ined in 2003 and 2004 had a relatively with MSCT to diagnose CAD. Wonhas is ue to benefit from his expertise. As a re-
high hit rate. The subsequent procedure convinced of the value of MSCT in aero- sult, our method makes a lot of sense.”
confirmed that the approach we are us- medical assessments, and hopes it will be
ing makes sense.“ quickly implemented in aviation interna-
tionally to prevent harm. “To date, in
International Recognition in 85 % of asymptomatic patients with a
Aeromedicine newly occurring higher-grade ventricular
arrhythmia or non-conclusive new ST de-
Based on the results presented by Wonhas pression, our examination has clearly
and colleagues, the German Armed Forces demonstrated that their hearts are
have since recognized CTA with MSCT as healthy. On the other hand, in 15 % of
the diagnostic procedure for their flying cases, we discovered coronary artery
service, and use it as routine. The Federal disease at an early stage. All of these pa-
Office for Civil Aeronautics, the highest tients were able to receive special ap-
monitoring agency for aviation in Germa- proval to fly once they began treatment.
ny, has also accepted this method be- For the pilot, this means minimizing the
cause of its high negative predictive value. risk of a heart attack before it happens.
Internationally, NATO (North Atlantic He can be there for his family, and the

Clinical Outcomes Cardiovascular
Case 1
Heterotopic Heart Transplant With
Arrhythmic Heart Rate of 45 –125 bpm1,2
and Post-Surgical Control with Cardiac CT
By Shu-Hsun Chu, MD, Cardiovascular Center, Far Eastern Memorial Hospital, Taipei, Taiwan
HISTORY
A 52-year-old man suffered for two years 48-year-old head injury donor with good in the ambulance. When the donor ar-
from dyspnea on exertion and chest cardiac function passed the brain-death rived at the hospital, his blood pressure
tightness. Because progressive symptoms examination. During transport of the do- was 60/30 mm Hg, and heart rate 36 bpm.
failed to respond to medical treatment, nor to the Far Eastern Memorial Hospital, An immediate sternotomy revealed that
the patient was admitted for heart trans- cardiac arrest occurred. Cardiopulmonary the heart was already arrested, distended
plantation evaluation. In April 2001, a resuscitation was performed immediately and cyanotic. The donor was soon put on
1
1 VRT display shows
the heterotopic
transplanted heart
on the patient’s
right side and the
native heart on
the left.

Cardiovascular Clinical Outcomes
3
2 ECG trace shows 3 Maximum Intensity
patient’s very high and Projection (MIP) image
irregular heart rate of shows the artifacts
45–125bpm. Despite free coronary arteries
the unfavourable heart of the native heart
rate, both hearts and (arrow heads) and the
coronary arteries could right coronary artery
be displayed free of of the transplanted
motion. heart (arrow).
cardio-pulmonary bypass (CPB). After EXAMINATION PROTOCOL

that, the heart started to beat again and
could maintain a stable hemodynamic Scanner SOMATOM Definition
status even when CPB was weaned off. Scan area Aortic arch to diaphragm
Since the suitability of the resuscitated Scan length 205 mm
heart as orthotopic heart transplant was Scan time 16.3 s
unclear, the hospital decided to do a het- Scan direction Cranio-caudal
erotopic heart transplantation. Five years Heart rate Arrhythmic 45–125 bpm
after successful surgery the patient is in
kV 120 kV
good condition.
Effective mAs 400 mAs/rot
Rotation time 0.33 s
COMMENTS AND DIAGNOSIS Temporal resolution HR independent 83 msec
Using the SOMATOM® Definition for a re- Slice collimation 0.6 mm

cent follow-up exam, it could be clearly Spatial resolution 0.33 mm
determined that both hearts were func- Slice width 0.75 mm
tional, but with different heart rates and Pitch 0.22
rhythms. SOMATOM Definition’s high Reconstruction increment 0.4 mm
temporal resolution of 83 msec in combi- Kernel B26
nation with reliable ECG-editing function-
References
ality was of crucial importance in obtain- 1 Cp. Chiu KM, Lin TY, Chu SH. Successful Heterotopic Heart Transplantation after Cardiopulmonary Bypass
ing diagnostic images of the rapidly Rescue of Arrested Donor Heart. Transplantation Proceedings 2006; 38: 1514–1515.
changing heart rates between 45 and 2 Cp. Chiu KM, Lin TY, Li SJ, Chan CY, Chu SH. Hybrid Pulmonary Artery Conduit Angioplasty for Heterotopic
125 bpm. Heart Transplantation. Transplantation Proceedings 2006; 38: 1538–1540.

Case 2
Reliable In-Stent Lumen Visualization
With Dual Source CT Coronary Angiography
By Annick C. Weustink, MD, and Nico R. Mollet, MD, PhD,
Departments of Radiology and Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
HISTORY
A 58-year-old man with a history of hy- rate-independent temporal resolution of stents with excellent visualization of
pertension and hypercholesterolemia was 83 ms. As a result, high-quality images of the in-stent lumen without the need for
admitted to the hospital with symptoms the rapidly-moving coronary arteries are pre-scan beta-blockers in a patient with
of suspected stable angina pectoris. obtained even with higher heart rates. a heart rate of 76 beats/minute. It dem-
The patient was referred to conventional Moreover, the adaptive pitch and onstrates the potential of DSCT coronary
coronary angiography after a positive use of prospective ECG-tube modulation angiography to rule out the presence of
exercise-ECG test. Conventional angiogra- allows significant reduction of the radia- in-stent restenosis in follow-up patients
phy showed significant stenoses at the tion exposure during cardiac CT scanning, after percutaneous intervention proce-
level of the proximal right coronary artery especially with higher heart rates. This dures.
(RCA) and the proximal left anterior de- example shows clear delineation of the
scending coronary artery (LAD). Percuta-
neous intervention was undertaken and
one bare-metal stent in the RCA and two
overlapping bare-metal stents in the LAD EXAMINATION PROTOCOL
were successfully implanted. The patient
was referred to follow-up CT coronary Scanner SOMATOM Definition
angiography after 18 months. Scan area Heart
Scan length 103 mm
DIAGNOSIS Scan time 7,3 sec
Scan direction Caudo-cranial
The patient was scanned on a Dual
Heart rate 76 bpm
Source CT (DSCT) scanner. Nitroglycerine
kV 120 kV
was administered prior to the CT scan;
mAs / Rot 400 mAs/rot
however, the patient did not receive pre-
scan beta-blockers. The patient had a Rotation time 0.33 sec
heart rate of 76 beats/minute during the Temporal resolution HR independent 83 msec
CT scan. DSCT coronary angiography was Slice collimation 0.6 mm
able to reliably rule out the presence of Spatial resolution 0.33 mm
in-stent restenosis in both the RCA and Pitch 0.32
LAD stents. Reconstructed slice thickness 0.75 mm
Increment 0.4 mm
COMMENTS Prospective ECG-tube modulation On, window: 30 – 60%
CTDIvol 45,31 mGy
The SOMATOM® Definition CT scanner
Kernel B46f
uses two X-ray sources and two detectors
Contrast material volume 90 ml
at the same time. This is one of the im-
Flow rate 5,5 ml/s
portant features for cardiac CT scanning. It
Bolus tracking On
allows scanning of the heart with a heart-

1 Volume Rendered CT image showing the stents in the proximal-to-mid LAD and the mid part of the RCA.
2 3
2 3 Curved multiplanar CT images showing excellent visualization of the in-stent lumen of both the RCA
(Fig. 2) and LAD (Fig. 3) stents, thereby reliably ruling out the presence of in-stent restenosis.

Case 3
SOMATOM Definition Abdominal CTA
With Direct Dual Energy Bone Subtraction
By Alec J. Megibow MD, MPH, FACR and Johnny Vlahos, MD, Department of Radiology, NYU Medical Center, New York, USA
HISTORY DIAGNOSIS COMMENTS

A 75-year-old man was referred for pre- The acquisition parameters allowed pre- The scanning protocol (outlined below)
surgical MDCT evaluation of a known ab- cise localization of the origin of the aneu- utilized the Definition’s dual x-ray sources,
dominal aortic aneurysm that had been rysm with respect to the renal arteries each operating at a different kVp thereby
detected on screening abdominal ultra- and allowed for necessary measurements resulting in a simultaneous dual energy
sound. A contrast enhanced CTA scan of of the neck of the aneurysm, the distance acquisition. Two spiral data sets are
the abdomen was performed on the from the renal arteries to the aortic bifur- acquired in a single acquisition; each data
SOMATOM® Definition. cation and to each common iliac bifurca- set contains unique spectral information,
tion to be calculated, and the adequacy of which allows differentiation and charac-
the run-off to the lower extremities to be terization of imaged structures and tissue
assessed. Finally, a small accessory (Fig.1). In this dual energy application,
renal artery supplying the upper pole of the direct subtraction of bone can be
the right kidney was detected. Based on achieved almost instantly with a high
this single study, the patient was consid- degree of accuracy as compared with
ered a candidate for endovascular repair. conventional bone removal techniques.
1
1 Precise visualization of the abdominal
aneurysm and their relations to
skeletal landmarks is possible with
the SOMATOM Definition.

EXAMINATION PROTOCOL
Additionally, critical small vessels such as Scanner SOMATOM Definition
an accessory right upper pole renal artery Scan area Abdominal CT Angiography
can be easily preserved. Using dual ener-
Scan length 410 mm
gy acquisitions, abdominal CTA segmen-
Scan time 12 sec
tations can be performed, eliminating
Scan direction Caudo-cranial
manual post processing steps and there-
kV 140 kV and 80 kV
by significantly reducing reporting time.
The degree of bone segmentation is at Effective mAs 66 eff. mAs and 190 eff. mAs
the discretion of the radiologist; in this Rotation time 0.5 sec
example, the dual display allows the vas- Slice collimation 0.6 mm
cular map to be superimposed over the Spatial resolution 0.33 mm
skeletal structures. This aids the surgeon Slice width 2 mm
in establishing landmarks that can aid in Reconstructed slice thickness 2 mm
the fluoroscopic based endovascular re- Increment 1.5 mm
pair. The success of the bone removal is CTDIvol 10.7 mGy
illustrated in the MIP image (Fig. 2). Kernel D20f
Contrast material volume 100 ml
Flow rate 4 ml/s
Bolus tracking On
2 3
2 Dual Energy MIP of the abdominal vasculature allows 3 Dual Energy VRT, excellent visualization of the abdominal skeleton.
immediate rule out of aneurysms, stenosis or embolism.
Notice the lack of interference from bones.

Clinical Outcomes Oncology
NEW: syngo CT Oncology

Designed to Take the Guesswork out of Routine
Oncology Imaging!
By Louise A. McKenna, PhD, MBA, Global Clinical Marketing Manager, CT Oncology,
Siemens Medical Solutions, Forchheim, Germany
Siemens’ newest software for routine CT uation parameters such as RECIST, WHO suspicious. Automated lesion matching
oncology imaging, syngo® CT Oncology, and tumor burden, plus the 3D volume. assisted in the rapid identification of the
has radiologist’s daily needs in mind. De- The DICOM SR (and RT) compatible report same, very much smaller lymph node in
signed to take the guesswork out of rou- can be saved to PACS for follow-up. For the previous exam. The automated mea-
tine lesion evaluation, syngo CT Onco- follow-up exams, automated lesion mat- surement should also help to further re-
logy** offers automated tools for tumor ching helps the clinician to locate previ- duce reader variability, enabling us to
evaluation including automated measure- ously identified lesions quickly and easily. achieve even better diagnostic outcomes”.
ment of RECIST and WHO criteria, lesion Previously generated lesion size parame- The evaluation and follow-up of liver
volume plus tumor burden. Fully auto- ters are instantly available for compari- lesions follows the same automated work-
mated lesion matching speeds up the fol- son, growth is automatically calculated flow as for lung lesions and lymph nodes,
low-up process with automatic generation and the results are presented in an intui- helping to ensure easy integration of this
of percentage-growth and doubling time tive tabular form (Fig.1). software into daily clinical routine diag-
helping to improve reliability and confi- syngo CT Oncology lymph node evalua- nostic oncology imaging, staging
dence. The new software offers dedicated tion uniquely offers clinician a fully auto- and follow-up (Fig.3).
workflows, so called autopilots, for the mated workflow for the evaluation of syngo CT Oncology also incorporates
evaluation of lung and liver lesions, plus lymph nodes. One-click 3D-segmentation image fusion functionality for example for
lymph nodes. of user identified lymph nodes results in PET-CT imaging, with fully automated im-
For the identification and evaluation of automatic calculation of the RECIST, WHO age registration, clinicians can readily
lung lesions, the lung autopilot incorpo- and volume measurements. Lesion details match form with function helping to
rates Siemens’ clinically proven Lung are automatically saved to a DICOM SR achieve more confident diagnostic deci-
CAD* software with auto-preprocessing. and can be used for fast, accurate follow- sions.
This means that as soon as the recon- up for staging and treatment monitoring syngo CT Oncology will be available with
structed image data arrives at the syngo (Fig.2). syngo 2008A software in September 2007.
workplace, potential lesions are automati- “This software presents considerable op-
cally detected off-line and the results are portunities for improvement of diagnostic *syngo Lung CAD is not designed to be used as a
ready to review when the radiologist outcomes”, explains Axel Küttner MD, first-reader.
opens the exam, saving valuable time and Department of Diagnostic Radiology, Uni- **Pending 510(k): The information about this
enhancing diagnostic confidence. One- versity of Erlangen-Nuremberg, Erlangen, product is being provided for planning purposes
click lesion segmentation results in auto- Germany. “In a recent follow-up exam, an only. This product is pending 510(k) review, and
matic generation of standard tumor eval- enlarged lymph node was identified as is not yet commercially available in the U.S.
1
1 Follow-up of a
lung lesion. Growth
parameters are
generated at the
touch of a button.
A comprehensive results
table includes growth
parameter for all lesions
including doubling time
and tumor burden.
Courtesy of Marco Das, MD,
RWTH Aachen, Germany.

Oncology Clinical Outcomes
2 2
2
2 Identification and follow-up of lymph nodes
(follow-up exam on the left).
Courtesy of Axel Küttner, MD, University of Erlangen-Nuremberg,
Erlangen, Germany.
3 Follow-up of a liver lesion.

Courtesy of Anno Graser, MD, University Hospital of Munich-
Grosshadern, Munich,, Germany.
3 3

Clinical Outcomes Oncology
Case 4
Improved Evaluation and Follow-up
of Routine Diagnostic Oncology Exams
With syngo CT Oncology*
By Axel Küttner, MD, and Alexander Aplas, MD, Institute of Diagnostic Radiology, University of Erlangen-Nuremberg,
Erlangen, Germany
Diagnostic, staging and follow-up exams Recently a number of automated or semi- the 3D evaluation and follow-up of tumors
for tumors are among the most frequent automated 2D/3D, and CAD software in the liver and in the lung, incorporating
CT exams performed in many radiology tools have become available to assist in lung CAD. There is also a dedicated algo-
departments. For the University of Erlan- the evaluation, reporting and follow-up rithm for lymph nodes, plus a generic
gen, oncology related imaging represents of lung and colon lesions. These have algorithm for other tumors throughout
approximately 60% of the daily CT work- proved extremely useful in improving di- the body – such as malignant melanoma,
load. To date, exams are read and evalu- agnostic outcomes, delivering reliable as in the case presented here.
ated in 2D, employing manual measure- performance in everyday clinical routine
ment and reporting of lesions. For – increasing reader confidence and short- HISTORY
follow-up exams, previously reported le- ening evaluation time.1–3 However, these
sions must be manually located, and are automated tools do not cover the evalua- A 70-year-old man underwent a routine
often re-measured for size comparison tion of lymph nodes and liver nodules, follow-up CT exam at three months while
with the current exam. This relatively for example, which together with the undergoing chemotherapy for malignant
time-consuming manual process is there- evaluation of lung lesions are the bread melanoma. The software facilitates 3D
fore prone to intra- and inter-reader vari- and butter imaging of clinical routine. lesion segmentation and delivers stan-
ability, with the potential for sub-optimal syngo® CT Oncology* is a new software, dard lesion parameters: RECIST, WHO and
outcomes. which offers automated workflows for volume (Fig. 1). The automated lesion
1 1B
1 Identification of 3 intra-
abdominal lesions
and 1 of 2 lung lesions
marked for 3 month
follow-up. Lesions can
be viewed in axial,
coronal, sagittal and
VRT views. Basic lesion
parameters are
presented in a DICOM
SR compatible report.
Lung lesions were
identified in the same
dataset by switching to
a lung window.
38
Oncology Clinical Outcomes
3 EXAMINATION PROTOCOL
Scanner SOMATOM Sensation 64-slice configuration

Scan area Thorax-Abdomen Pitch 1.2
Scan length 686 mm Reconstruction increment 0.8 mm
Scan time 15 s Kernel B4If
Scan direction cranio-caudal Contrast
kV 120 kV Volume 100 ml
Effective mAs 150 mAs Flow rate 3 ml / s
Rotation time 0.5 s Postprocessing
Slice collimation 0.6 mm syngo CT Oncology
Spatial resolution 0.33 mm
3 Significantly increased tumor burden is Slice width 1 mm
marked in red in the report. The percen-
tal change in RECIST, WHO, 3D volume
and doubling time of all lesions are lesions (Fig. 3). A great time saver is the follow-up measurements which are less
automatically calculated and included ability to switch between lung and soft tis- prone to inter- and intra-reader variabili-
in the DICOM SR compatible report.
sue windows, for example, which means ty, allowing us to deliver a more stan-
that lung nodules (Figs. 1 and 2) can be dardized output. Additionally, the auto-
easily evaluated at the same time, without mated lesion matching could help to save
loading a new data set. All lesion parame- valuable time in follow-up exams.
matching marked previously reported le- ters are included in the same report.
1 Graser, A. and Becker, C. R. (2005)
sions in the follow-up exam and the per-
SOMATOM Sessions 17.
cental change in lesion parameters were
DIAGNOSIS AND COMMENTS 2 Das, M. et al (2006) SOMATOM Sessions 19.
automatically calculated and sent to the 3 Mang, T. et al (2007) Eur Radiol Mar 10.
DICOM SR (Fig. 2). Doubling time and Preliminary experiences with syngo CT * syngo CT Oncology will be available with the
tumor burden are also automatically cal- Oncology** suggest a great potential for release of syngo 2008A.
** Pending 510(k): The information about this
culated and as a useful eye catcher, tu- improving all aspects of routine workflow product is being provided for planning purposes
mor burden is highlighted in red, demon- by allowing us to deliver objective, reli- only. This product is pending 510(k) review, and
strating significant growth of marked able and consistent tumor evaluation and is not yet commercially available in the U.S.
2
2 Automated lesion
matching identified the
previously identified
lesions in the follow-up
exam. The percental
change in basic tumor
parameters were auto-
matically calcu-lated and
presented in the report.
39
Clinical Outcomes Neurology
Case 5
Utilizing the SOMATOM Emotion 16-slice
configuration for a Neuro DSA CTA Evaluation
of a Suspected PICA Aneurysm
By Adam J. Davis, MD, Hartsdale Imaging, Hartsdale, New York, USA
HISTORY DIAGNOSIS AND COMMENTS corresponding to the area of suspicion

on the MRA. The fully automated CT DSA
The patient, a 13-year-old female pre- A left posterior inferior cerebellar artery application easily allowed VRT visualiza-
sented in our Imaging Center with loop was diagnosed and no aneurysm tion of the origin of the PICA from the lat-
acute onset persistent left hemicranial demonstrated. eral aspect of the vertebral artery, nor-
and left supraorbital headache. Neuro- MRA is an excellent screening technique mally obscured by the adjacent occipital
logic examination was unremarkable. for the presence of intracranial aneurysms, bone. Of interest, differing algorithms
A non-gadolinium 3D TOF MRA of the although the inherent resolution and provide a different visualization of the
brain was performed to evaluate for the presence of flow artifacts may make the anatomy. The use of a higher kernel algo-
possibility of a vascular abnormality. technique insufficient for smaller and rithm for the pre- and post-masks allows
The exam was suspicious for a left poste- more tortuous intracranial vessels. The for a more definitive evaluation of the
rior inferior cerebellar artery (PICA) sac- MRA imaging is suspicious, but not defin- luminal contour, although the image
cular aneurysm. CTA of the brain was itive, for a proximal left PICA aneurysm. quality may be less pleasing to the eye.
requested for a further evaluation. An elongated 2.9 mm posterior projecting It should be remembered that the luminal
outpouching could not be clearly delin- diameter of this PICA measures approxi-
eated from the parent vessel. The Neuro mately 0.6 mm; emphasizing the excel-
DSA CTA of the brain clearly defined the lent inherent resolution of Neuro DSA
anatomy of the vessel, demonstrating a CTA performed with the SOMATOM®
tight, posteriorly oriented C-shaped loop, Emotion 16-slice configuration.
1 EXAMINATION PROTOCOL
Scanner SOMATOM Emotion 16-slice configuration

Scan area Head Slice collimation 0.6 mm
Scan length 138 mm Slice width 0.75 mm
Scan time 10 s Pitch 0.9
L R Scan direction Caudo Cranial Reconstruction increment 0.5mm
kV 120 kV Kernel H20 / H70
Effective mAs 176 mAs Postprocessing
Rotation time 0.6 s syngo Neuro DSA
1 PA view of the non-gadolinium 3D TOF

MRA demonstrates the abnormality
at the origin of the left PICA (arrow).

Neurology Clinical Outcomes
2 3
2 A more magnified MRA image utilizing clip planes iso- 3 CTA utilizing a closely applied clip plane from the left
lates the left PICA. The best view orientation gives a side eliminates much of the obscuring occipital
hint as to the true nature of the finding, although calvarium, and allows improved visualization of the
the vessel course and origin are not clearly defined lateral aspect of the vessel. While still somewhat
on the MRA, and the outpouching cannot be entirely obscured, this view demonstrates the origin of the
eliminated in any view. The study remains non-diag- PICA and a tight posterior C-shaped loop, not an
nostic. aneurysm (H20 S Kernel setting).
4 5
4 Neuro DSA CTA provides a rapid and easy to acquire 5 Neuro DSA CTA utilizing a higher kernel algorithm
visualization of the lateral aspect of the left PICA. (H70s) provides substantially better visualization of
A clip plane in the orientation of the view was the the origin of the left PICA. A well defined proximal
only additional post processing required once the segment is now seen prior to the tight posterior
VRT was created. The vessel loop is clearly defined, C-shaped loop (arrow). The contralateral right PICA is
and the possibility of a saccular aneurysm is defini- also clearly defined (arrowhead).
tively excluded (arrow).

Clinical Outcomes Acute Care
Case 6
Dual Source CT Triple Rule Out
Without Beta-Blocker
By Christoph R. Becker, MD, Section Chief, Computed Tomography
Department of Clinical Radiology, University Hospital of Munich-Grosshadern, Munich, Germany
HISTORY
A 60-year-old male patient, suffering the major causes of chest pain in a one- a cardio scan and a thorax scan. The dose
from a severe chest pain, arrived in the stop diagnosis without the compromise modulation along the patient axis is per-
Department of Radiology of the Univer- of beta-blockers. Now we can accurately formed with an optimized dose for each
sity Hospital in Munich, Großhadern. In triage chest-pain patients within 10 min- of the corresponding regions. In combi-
order to rule out the major causes of utes after presenting to our department. nation with a simple contrast injection
chest pain (such as myocardial infarction, With the SOMATOM Definition, a special protocol of 80 ml with a flow rate of
pulmonary embolism, and aortic dissec- Chest Pain protocol can be used, apply- 4,5 ml/s, Dual Source CT enabled us to
tion) in a one stop diagnosis, the patient ing reduced dose to the patient through establish the chest pain evaluation into
was transferred directly to the CT depart- the combination of two scan ranges, our daily routine.
ment. A gated scan of chest was per-
formed on the SOMATOM® Definition,
without the use of beta-blockers.
DIAGNOSIS
Scanner SOMATOM Definition
The gated chest pain protocol of the Scan area Chest
SOMATOM Definition enabled the imme-
Scan length 285 mm
diate visualization of the entire thorax
Scan time 16 sec
as well as the coronary arteries without
Scan direction Cranio-caudal
motion artifacts. As shown in the images
Heart rate 65–70 bpm
below, a Stanford type B aortic dissection
was identified. The patient was referred kV 120 kV
to Vascular Surgery Department for stent mAs/Rot 320 mAs/Rot
placement. Rotation time 0.33 sec
Temporal resolution HR independent 83 msec
Slice collimation 0.6 mm
COMMENTS Spatial resolution 0.33 mm
Slice width 0.6 mm
Chest pain is one of the most common Pitch 0.30
and complex symptoms for which patients Reconstruction increment 0.75
seek medical care. With standard diag-
Effective dose 9,2 mSv
nostic evaluation, patients with chest pain
Kernel B26
undergo multiple serial tests and long
Volume 80 ml
observation periods. This ties up staff as
Flow rate 4,5 ml/s
well as space for up to a whole day. Dual
Source CT enables us to quickly rule out Start delay CareBolus+5s

Acute Care Clinical Outcomes
1 2
3
1 Motion free visualization of coronary
arteries rule out myocardial infarction.
2 Due to excellent imaging of patient’s aorta,

Stanford type B aortic dissection can be precisely
shown.
3 Accurate display of pulmonary arteries

rule out pulmonary embolism.

Clinical Outcomes Acute Care
Case 7
SOMATOM Definition: New Insight Into
Kidney Stone Detection and Characterization
With Spiral Dual Energy
By Anno Graser, MD, Thorsten Johnson, MD, and Christoph R. Becker, MD,
Department of Clinical Radiology, University Hospital of Munich-Grosshadern, Munich, Germany
HISTORY DIAGNOSIS
A 34-year-old male (Fig. 1A) and a 55- The dual energy acquisition allowed pre- tient for drug therapy treatment. Subse-
year-old male with latent gout (Fig. 1B) cise localization of the kidney stones. quently, the stone passed spontaneously
separately visited our Acute Care unit In addition Patient B showed dilatation and was analysed. The analysis confirmed
with flank pain. They had been presen- of the right ureter proximal to the calcu- that the concrement consisted of 100%
ted after multiple occurrence of neph- lus. Moreover, dual energy analysis uric acid.
rolithiasis and urolithiasis. Both patients permitted a characterization of the The blue color-code shown in Patient B
were referred to our Dual Source CT scanned tissue or material. The red color- (Fig. 2B) characterizes a calcium oxalate
for evaluation of abdominal stones. coding of the urethral stone shown in stone. Based on this dual energy study,
Contrast enhanced CTA scans of the Patient A (Fig. 2A) indicates an uric acid the stone was removed in an interven-
abdomen were performed on the stone. In contrast, the vertebrae can be tional procedure. The lab analysis of the
SOMATOM® Definition using spiral dual identified as blue-colored structure. After removed stone confirmed the calcium
energy. Dual Energy CT, we could transfer the pa- oxalate composition.
1A 1B
1 Using conventional MDCT imaging, urethral stones (arrows) can clearly be visualized in both patients
(Fig. 1A and 1B). However, they cannot be characterized based on a conventional CT single source image.
44
Acute Care Clinical Outcomes
Scanner SOMATOM Definition SOMATOM Definition
Patient Patient A Patient B
Scan area Abdominal Scan Abdominal Scan
Scan length 377 mm 215 mm
Scan time 44 sec 25 sec
Scan direction Craniocaudal Craniocaudal
kV 140 kV and 80 kV 140 kV and 80 kV
Effective mAs 64 eff. mAs and 352 eff. mAs 69 eff. mAs and 351 eff. mAs
Rotation time 0.5 sec 0.5 sec
Slice collimation 0.6 mm 0.6 mm
Spatial resolution 0.33 mm 0.33 mm
Slice width 0.75 mm 0.75 mm
Reconstructed slice thickness 2.0 mm 2.0 mm
Increment 1.5 mm 1.5 mm
CTDIvol 18.07 mGy 15.4 mGy
Kernel D30 D30
CareDose4D on on
COMMENTS
The majority of kidney stones can be tation and enables us to differentiate the ize, isolate, and distinguish the imaged tis-
grouped as either calcium oxalate stones scanned tissue. The SOMATOM Definition sue and material as shown in Fig. 2A and
(80%) or uric acid material (9%). Conven- permits the use of two sources at two dif- 2B. In our case, dual energy scanning of-
tional CT imaging helps to locate and visu- ferent kV levels simultaneously. The result fers new insights into the characterization
alize kidney stones. However, a fast and is two spiral data sets acquired in a single of urolitis. A corresponding treatment deci-
secure characterization is not possible. scan providing diverse information, mak- sion can be reached immediately, avoiding
Dual energy scanning overcomes this limi- ing it possible to differentiate, character- unnecessary hospitalization.
2A 2B
2A Patient A: Spiral dual energy enables the characterization of 2B Patient B: Spiral dual energy enables the characterization of
tissue. The kidney stone could be identified as uric acid stone, tissue. The kidney stone could be identifies as calcium oxalate
color-coded in red (arrow). stone, color-coded in blue (arrow).
45
Science
Dual Source CT
Detecting Coronary Atherosclerosis
by Dual Source Computed Tomography Images
With Color Maps
By Sei Komatsu1,2, Dieter Ropers1, Axel Küttner3, Ulrike Ropers1, Martin Wechsel1, Tobias Pflederer1, Alexander Kuhlmann1,
Katharina Anders3, Werner Bautz3, Werner G. Daniel1, Atsushi Hirayama2, Kazuhisa Kodama2, Stephan Achenbach1
1
Department of Internal Medicine 2, University of Erlangen-Nuremberg, Erlangen, Germany
2
Cardiovascular Division, Osaka Police Hospital, Osaka, Japan
3
Institute of Diagnostic Radiology, University of Erlangen-Nuremberg, Erlangen, Germany
Recently, Dual Source computed tomog- Color-coded Coronary comprehensive method of analysis,
raphy (DSCT) has become available. Due Analysis Plaque Map, which converts DICOM-for-
to its high temporal resolution, coronary matted files to color-coded images based
arteries can now be visualized with re- Multi-detector row CT (MDCT) coronary on CT attenuation5. Vulnerable plaque of
duced motion artifacts. Spatial resolution angiography allows noninvasive visualiza- coronary 6,7 and peripheral arteries8 can be
of DSCT reaches 0.33 mm allowing more tion not only of coronary stenosis but also demonstrated by MDCT using Plaque Map
precise visualization of the coronary of coronary atherosclerosis 3–5. Plaque as IVUS-like visualization tool. Fig. 1 dem-
arteries. However, the grade of stenosis composition such as lipid-rich plaque, fi- onstrates a typical example. Fig. 1A is a
does not predict an acute coronary syn- brous plaque, and calcified plaque can be cross-sectional image of a vessel without
drome 1 due to positive remodeling (com- characterized based on the CT values 4,5. plaque. Concentric graduation from red to
pensatory enlargement of lumen area 2). Region of interest (ROI) and profile curve yellow spreads outwards the vessel. Fig.
are traditional methods to measure CT 1B is a cross-sectional image of the culprit
values. However, they do not cover the lesion in a patient with acute coronary
entire vessel at one time. We developed a syndrome. Yellow area (dotted arrow)
1A 2
50 200
1A Cross-sectional image of
vessel without plaque (Left). 0 100 350*
1A 1C
Plaque Map (Right). Concen-
tric graduation from red to White
yellow spreads outside the 0 68 136 205 273 341 409
vessel.
*Maximum CT number of
1B (Quoted ref 7) The cross-sec- Contrast Media
tional image of acute corona
1B areas drawn green to blue Lipid-rich Plaque (LP)
(arrow) are ranged -25 to 25
HU, suggesting lipid-rich Fibrous Plaque (FP)
plaque.
Calcified Plaque (CP)
1C (Quoted ref 7) Intravascular
ultrasound image. Plaque
Map corresponded to the 2 Color Map for
findings of intravascular detecting plaque
ultrasound (IVUS). characteristics.
1C 500 –(HU) 50 – 70
350 – 500 25 – 50
300 – 350 0 – 25
250 – 300 -25 ~ 0a
200 – 250 -50 ~ -25
150 – 200 ~ -50
70 – 150

3A 4A 4B 5A 5B
b
c
d
LP
lipid pool
3B 4C 5C 5D
FP
LP
CP
branch
LP+FP
3 Color Map of curved 4 An example of non-calcified 5 An example of various plaque types. Color Map of curved MPR
MPR of normal coronary plaque. Fig. 4A: Curved MPR. (Fig. 5A). The points b, c and d in Fig. 5A are shown as Fig. 5B,
artery (Fig. 3A). Cross- Fig. 4B: Color-coded curved MPR. Fig. 5C, and Fig. 5D, respectively. LP: lipid-rich plaque, FP: fibrous
sectional image of Fig. Fig. 4C: Color-coded cross-sec- plaque, CP: calcified plaque.
3A arrow (Fig. 3B). tional image at Q1 (Fig. 4B dot).
0–50 100–200 0–50 100–200 0 –50 100–200

50–100 200–500 50–100 200–500 50 –100 200–350
represents residual lumen area which Interpretation of Coronary Futures of Color Analysis
indicates a severe stenosis. Three areas Plaque with Color Analysis using DSCT
with green to blue color (arrow) ranging
from -25 to 25 HU, suggest lipid-rich A typical vessel without plaque is demon- Previously, analysis of CT attenuation
plaque. The observation of predominant- strated in Fig. 3A. Areas of orange, light within coronary atherosclerotic plaques
ly lipid-rich plaque corresponds well to green and green are demonstrated as was limited by the relatively poor spatial
IVUS (Fig. 1C). Recently the syngo Circula- concentric circles (Fig. 3B). A typical resolution of CT. CT attenuation was used
tion software package has been equipped example of lipid-rich plaque is shown in for “organ-level” analysis. The improve-
with color-coded analysis based on CT Fig. 4. The curved MPR of left anterior ment of spatial and temporal resolution
attenuation 9 (syngo Circulation Plaque descending coronary artery shows a non- of DSCT minimizes partial volume effects
Analysis). We describe one application calcified plaque with positive remodelling and “Pixel analysis in silico”7 becomes
for detecting coronary plaque. in the proximal segment of the coronary possible. The term “in silico”, referring to is
artery (Fig. 4A). Fig. 4B and 4C, respec- commonly used in the fields of life science
Screening Coronary Plaque tively, demonstrate color maps of the and computer medicine. In the era of
using syngo Circulation curved MPR and cross-sectional image at DSCT, we can analyze plaque at “tissue-
the level of the atherosclerotic lesion. level” using a workstation with color cod-
The integrated color coding allows the Green, which ranges from 0 to 50 HU, ing software such as syngo Circulation.
four colors, green, light green, orange, and light-green, which ranges from 50 to
and pink. The ranges and thresholds 100 HU, are dominant. This suggests that
can be individually changed. We set the the plaque consists of predominantly
borders of the scale to distinguish maxi- lipid-rich components.
mum six borders through coronary We also show another example of various
artery; transparent (below 0 HU), green plaque types. The left anterior descend-
(0–50 HU), light green (50–100 HU), ing artery of an asymptomatic patient References
1 Ambrose JA et al. J Am Coll Cardiol 1988: 12(1):
orange (100 –200 HU), pink (200-“maxi- was analyzed (Fig. 5). Cross-sectional im-
56–62.
mum CT number of contrast media on ages at the points b, c and d in Fig. 5A 2 Glagov S et al. N Engl J Med. 1987: 316(22):
coronary artery”), and white (above “max- are shown as Fig. 5B, Fig. 5C, and Fig. 5D, 1371–5.
imum CT number of contrast media”) respectively. In Fig. 5B, lipid-rich plaque 3 Schroeder S et al. J Am Coll Cardiol. 2001: 37(5):
(Fig. 2). The upper limit of pink area is the as light green is present at 3–6 o‘clock 1430–5.
same as contrast media. Light green and position of the vessel. In the vessel, area 4 Achenbach S et al. Circulation. 2004: 109(1): 14–7.
orange correspond to fibrous plaque. Green less than 0 HU (transparent) is found at 5 Komatsu S et al. Circ J 2005: 69(1): 72–7.
6 Komatsu S et al. Int J Cardiol 2007: 117(3): 423-9.
shows lipid-rich plaque. Lipid-pools are sus- 5–6 o’clock, suggesting a lipid-pool.
7 Komatsu S et al. Vascular Disease Prevention 2006:
pected of areas with a density below 0 HU Fig. 5C demonstrates calcified plaque in 3(4): 319–325.
inside the vessel area. CT density of calci- white. Fig. 5D shows mixed plaque in light 8 Komatsu S et al. Int J Cardiol 2007: 117(3):423-9.
fication is above the maximum CT number green and green, suggesting a mixture 9 syngo Circulation: The Next generation.
of contrast media, appearing white. of fibrous and lipid-rich plaque. SOMATOM Session 18. 8–9, 2006.

Science
Coronary CT Angiography With DSCT

Implications for Contrast Media Delivery
By Joachim Ernst Wildberger, MD1, Andreas Horst Mahnken, MD, MBA1, and Peter Reinhardt Seidensticker, MD2
1
Department of Diagnostic Radiology, RWTH Aachen University, Aachen, Germany
2
Global Medical Affairs Diagnostic Imaging, Bayer Schering Pharma AG, Berlin, Germany
Implications for imaging and has already replaced a signifi-

Contrast Media Delivery cant number of diagnostic catheter Contrast Media Administration
angiographies. Fundamental advantages
Multi-detector row computed tomography of the new DSCT scanners are provided In general, optimized contrast injection
(MDCT) has substantially improved over by three cornerstones, i.e., improved is an important issue for achieving high
the past years with faster gantry rotation, spatial resolution, better temporal resolu- quality CT scans with homogeneous at-
more powerful X-ray tubes, dedicated in- tion and shorter scan time. tenuation and high contrast throughout
terpolation algorithms and – last but not With DSCT, imaging of the coronaries the entire data set. In particular CT angio-
least – the introduction of Dual Source can easily be performed in a single breath- graphy, including cardiac CT, will benefit
CT (DSCT) with the SOMATOM Definition hold providing sub-millimeter isotropic from homogeneous and compact bolus
(Siemens Medical Solutions, Forchheim, resolution and minimized motion artifacts. geometry1. High and constant iodine con-
Germany) in 2006. High quality assessment of the coronary trast should be maintained throughout
As one of the consequences of this tech- vessels highly irrespective of the under- the whole data set to achieve diagnostic
nical evolution, CT angiography (CTA) lying heart rate of the patient is an evolu- opacification by providing optimal contrast
of the coronaries has become an estab- tionary milestone that significantly im- between the vessel lumen and the sur-
lished technique for minimally invasive proves the clinical robustness of cardiac CT. rounding soft tissue.
Scanner SOMATOM Definition
Collimation 2 x 64 [2 x 32] x 0.6 mm
Pitch Dependent on patient’s heart rate (0.2 – 0.43)
kVp 120
mAsrot 400*
Rotation time 330 ms
Slice thicknesseff 0.75 mm
Increment 0.4 mm
Kernel Siemens B26f (HeartView smooth ASA)
Contrast media injection protocol
IDR (Iodine Delivery Rate) biphasic (5 s @ 2 gJ/s + (x-5) s @ 1.5 gJ/s)**
(e.g. Iopromide 370: 27 ml @ 5.4 ml/s + y ml @ 4 ml/s
Iopromide 300: 33 ml @ 6.6 ml/s + y ml @ 5 ml/s)
Amount Individually adapted: Injection duration = Scan duration + 10%
Saline chaser 50 ml @ 4 ml/s (370) and 5 ml/s (300), respectively
Bolus timing Bolus-Trigger in the ascending aorta; Threshold: 180 HU
Scan parameters, reconstruction parameters and contrast injection parameters for a suggested cardiac scan protocol
with the SOMATOM Definition (Siemens).
* In addition, a dose modulation concept is recommended (e.g. Care Dose 4D; ECG-pulsing).
** x = (Scan duration + 10%); Clinical example: Contrast material will be injected with 2g iodine/s , followed by a 6s injection at 1.5g iodine/s, if the scan lasts 10s.
The latter can be calculated from the overall injection duration; e.g. overall scan duration +10% = 11s, minus 5s for the first (fixed) injection phase. Therefore,
using iopromide 300, 33 mL will be injected with 6.6 mL/s followed by 30 mL iopromide 300 with 5 mL/s.

Science
1A 1B
1 Male patient with intermittent atypical chest pain and an increased cardio-vascular risk profile. He has a history of smoking (30 pack years)
and moderate hyperlipidaemia. Contrast-enhanced DSCT of the coronary arteries was performed to rule out coronary artery disease.
Fig. 1A: 3D-VRT (Volume Rendering Technique) shows the left coronary artery without pathological findings.
Fig. 1B: Curved multiplanar reformat (MPR) of the right coronary artery shows an eccentric, non-calcified plaque without relevant lumen
narrowing (arrows).

Science
2A 2B
2 74-year-old male patient with

a history of coronary bypass
surgery: He presented with
acute chest pain and suspected
bypass graft occlusion. Con-
trast-enhanced cardiac DSCT
revealed two patent CABG (co-
ronary artery bypass grafts)
to the LCX (left circumflex
artery) and the LAD (left an-
terior descending artery) (Fig.
2A). Distal anastomoses were
patent (arrows), as exemplari-
ly shown for the LAD (Fig. 2B).

Science
Sophisticated injection protocols such dium and its viscosity is exponential. This dividualized approach to the injection reg-
as biphasic injection protocols have been means that the pressures that are built up imen as compared to automated bolus
advocated for coronary CT applications and by the power injector and the resulting tracking.5
have been incorporated into the clinical pressures in the patient‘s veins might be
workflow. However, many complex multi- even higher with highly concentrated Saline Chaser
phasic contrast delivery protocols for ideal agents despite the fact that they are inject-
enhancement patterns are still based on ed with slower flow rates. The clinical ef- The use of double-power injectors has
extensive mathematical equations and fect of different flow rates and contrast been advocated for automated saline
have not yet undergone sufficient clinical medium viscosities on the incidence of flushing at the injection site, especially for
evaluation.2 paravasation is not fully understood and CTA examinations. Otherwise, approxi-
Numerous factors affect the geometry of will require large prospective population mately 20 ml – 30 ml of contrast material
the contrast medium bolus in CTA.3 These studies. However, the benefit of large ac- will be retained in the “dead space” be-
factors may be divided into intrinsic pa- cess lines (e.g., 18G needles) and of pre- tween the brachial vein and the superior
tient related factors and extrinsic contrast heating the contrast material to mean vena cava. In consequence, performing
material and injection technique associat- body temperature of 37° Celsius in order to saline flush improves arterial enhance-
ed parameters, and include: bring down the viscosity appears obvious. ment and reduces the amount of contrast
■ Patient cardiac output, individual pathol- needed for a diagnostic examination. This
ogy, specific parameters (e.g. body mass Scan Timing has a positive impact on patient safety
index, blood pressure, heart rate and and costs.6
even gender) In any case, using empiric scan delays
■ Specific pharmacologic features of the cannot be recommended with modern In summary, optimal contrast bolus
contrast material itself (e.g. concentra- MDCT or DSCT. With 16- (or more) slice shaping with special emphasis on bolus
tion, viscosity and temperature of the MDCT, the start delay of a CTA has to be design and timing is a key issue in modern
contrast medium injected) chosen individually. In the clinical setting, DSCT imaging of the coronary arteries. The
■ Injection technique (dual-head power in- two modes are currently available for op- IDR is the most important factor for
jector; flow rate, total volume, mono-, timal enhancement after intravenous con- achieving this goal and can be optimized
bi-, or multiphasic; use of saline chaser). trast delivery1,4: Automated bolus tracking by adapting the flow rate of the injector to
provides a sufficiently robust, easy to use the iodine concentration of the chosen
Iodine Delivery Rate (IDR) method. A pre-monitoring scan is per- contrast medium. Typical IDRs lie between
formed at the upper level of the heart us- 1.5 g l/s and 2.0 g I/s. The test-bolus
The overall iodine load is the main deter- ing a low-dose scanning technique (120 methodology and automated bolus
minant for parenchymal organ studies. kVp; 20 mAs (effective)). A region-of-in- tracking are widely used as an adjunct to
However, the overall amount of contrast terest is placed in the ascending aorta and the regular CTA scan and help to increase
material administered to the patient is of attenuation values (in Hounsfield units; the robustness of this examination
minor importance for a CTA study. The io- HU) are continuously measured during method.
dine delivery rate (IDR; given in g iodine/s) the contrast injection. When the trigger
is the determining factor for the quality threshold level (e.g. 140 HU) is reached,
of the bolus and can easily be calculated an automated start of the spiral scan is 1 Cademartiri F., van der Lugt A, Luccichenti G,
Pavone P, Krestin GP. Parameters affecting bolus
by multiplying the iodine concentration initialized.
geometry in CTA: A review. J Comput Assist Tomogr
of the contrast material (g iodine/ml) Alternatively, a test-bolus methodology 2002; 26: 598 – 607.
with the flow rate of the injector (ml/s). can be applied. A small additional volume 2 Bae KT. Peak contrast enhancement in CT and MR
Usually the IDR will be in the range of of contrast material (usually 15 ml – 20 angiography: When does it occur and why? Pharma-
1.5 – 2.0 g iodine/s for CTA applications. ml) is injected at the same flow rates as cokinetic study in a porcine model. Radiology 2003;
This can be realized by using a highly con- used for the contrast enhanced scan pro- 227: 809 – 816
centrated contrast medium (350 – 400 mg tocol. By repeat acquisition of serial scans 3 Fleischmann D. High-concentration contrast media
in MDCT angiography: Principles and rationale.
iodine) in combination with moderate flow (monitoring scans every 2 s from approxi-
Eur Radiol 2003; 13 Suppl 3: N39 – N43
rates. On the other hand, the same IDR can mately 10 s – 40 s; usually at the level of 4 Bae KT. Test-bolus versus bolus-tracking techniques
also be achieved by increasing the flow the heart), individual flow dynamics can for CT angiographic timing. Radiology 2005; 236:
rates for contrast material with 300 mg of be assessed more precisely: From the en- 369 – 370.
iodine per ml (or even less). Normalizing hancement over time within the target 5 Mahnken AH, Klotz E, Hennemuth A, Jung B, Koos
the IDR is a straightforward means of mak- vessel lumen, the time-to-peak enhance- R, Wildberger JE, Günther RW. Measurement of car-
ing different injection protocols compara- ment can be calculated. The latter is cho- diac output from a test-bolus injection in multislice
computed tomography.
ble. It seems obvious that the choice of a sen as start delay. The test-bolus data also
Eur Radiol 2003; 13: 2498 – 2504.
highly concentrated agent could keep the allows estimation of the bolus geo-metry 6 Schoellnast H, Tillich M, Deutschmann HA,
flow rates lower and potentially could help with a given amount of contrast material Deutschmann MJ, Fritz GA, Stessel U, Schaffler GJ,
to avoid local complications such as parav- at a selected flow rate. Moreover, this Uggowitzer MM. Abdominal multidetector row com-
asation. However, in this context it should technique allows determination of cardiac puted tomography. Reduction of cost and contrast
be kept in mind that the relation between output from the contrast enhancement material dose using saline flush. J Comp Assist
the iodine concentration of a contrast me- curve and therefore constitutes a more in- Tomogr 2003; 27: 847 – 853.

Science
Nefertiti’s Bust – An Inside View

For decades, Nefertiti’s beauty has captivated museum visitors. But what is
behind the perfect surface? Modern CT technology increasingly becomes inter-
esting for historical, non-destructive investigations. So plaster layers and the
limestone core of the world-famous bust can now easily be virtually separated
and evaluated.
By Andreas Blaha and Monika Demuth, PhD, Siemens Medical Solutions, Computed Tomography, Forchheim, Germany
The name of the Egyptian queen means 1

exactly what the bust shows: “the beauti-
ful one has arrived.” And she has arrived –
or much better said, under extreme safety
precautions has been brought – in the
true sense of the word, to the Imaging
Science Institute (ISI) at Siemens Medical
Solutions in Berlin in order to be scanned
by the SOMATOM® Sensation 64-slice
computed tomography (CT) scanner. The
examination was part of a research for
documentation by the broadcaster, Na-
tional Geographic, in cooperation with
Prof. Dietrich Wildung, Director of the
Egyptian Museum in Berlin. Thanks to
modern CT technology, the researchers
could make many inner details visible.
Because CT technology has realized such
tremendous advances since 1992 (when
the bust was last scanned) the research-
ers expected a much more detailed sepa-
ration of the limestone core and plaster
surface of the bust revealing much more
detail due to the improved image quality
with 0,24 mm isotropic resolution of the
SOMATOM Sensation 64. The state of the
art volume rendering technique which
was used created 1660 thin axial cuts of
the bust. This enormous number of slices
have been put together to display a 3 di-
mensional object. This method is typically
used to view objects from all viewing an-
gles to get a 3D impression of the object.
By adjusting the Houndsfield scale accord-
ing to the scanned material it is possible
to show and hide the plaster layer over
the limestone and vice versa. In addition
it is possible to assign certain Houndsfield
values to colors for easy differentiation
between the displayed layers. Therefor 1 CT-image from a SOMATOM Sensation 64 showing the pristine surface
with help of CT software, it was possible of the bust of Nefretete (without painting).
to virtually “remove” the plaster layer and

Science
then, step by step, dissect the limestone composition of the materials. The re- husband, in their function as priests, rep-
core. The procedure revealed, in amazing- search with CT scans firmly established resented the important God, Aton. During
ly fine resolution, the rough limestone that the composition consisted of a sculp- their rule, the royal couple often allowed
core showing slanting, asymmetric shoul- tured limestone core layered with plaster. various portrayals of themselves with
ders and a thin throat (Figs. 2 and 3). Plaster was used here and in other details their children.
Discovering and establishing the practice to modify the sculpture to the familiar Results and interpretations about the CT-
of non-damaging examinations of Egyp- form known today. scan of Nefertitis bust will soon appear in
tian antiques has been described by Nofretete’s bust was discovered in 1912 at appropriate scientific publications.
Dietrich Wildung in 1992.1 He conducted the Egyptian desert village of Tell el-Ama-
research according to the then-modern rna. Thanks to this world famous work by
archeological standards. Quite an unusual the sculptor Thutmosis, the queen enjoys Reference:
idea at the time: spectacular findings worldwide recognition, not only by art ex- 1
Dietrich Wildung, “Einblicke – Zerstörungsfreie
were then seldom thoroughly investigat- perts, but also by the general public. As Untersuchungen an altägyptischen Objekten“,
ed by fine arts experts to the different wife of Pharaoh Echnaton, she and her 1992, p 133–156.
2 3
2 This image shows the plaster layer over the shoulder area of the 3 The limestone core of the bust, without plaster covering.
limestone sculpture of the queen.

Science
CT Coronary Angiography
Half-Scan vs. Multi-Segment
Reconstruction for Computed Tomography
Coronary Angiography
Considerations on the effects on image quality
By Stephan Achenbach, MD, Department of Internal Medicine 2, University of Erlangen-Nuremberg, Erlangen, Germany
Coronary artery visualization by multi- segment of the coronary cycle as possi- struct one single image. Theoretically,
detector row (or better, multi-slice) com- ble. In order to reconstruct one cross-sec- the window of data used for image recon-
puted tomography (“coronary CT angiog- tional image, data acquired from 180° struction in each cardiac cycle can be
raphy,“ “coronary CTA”) is rapidly entering of parallel data projections are necessary. substantially shorter than in half-scan
mainstream cardiology. High accuracies Most computed tomography systems con- reconstruction algorithms. However,
have been reported for the detection tain one x-ray tube, so that one-half rota- multi-segment reconstruction algorithms
of coronary artery stenoses by 16- and tion of the gantry is necessary to acquire use data from several heart beats to re-
64-slice CT and especially a high negative data from 180°. construct one image so that the generated
predictive value makes coronary CTA a image is an “average” of several cardiac
useful tool in the assessment of certain Half-Scan Reconstruction cycles. Since slight differences from one
patient populations with chest pain 1. In heart beat to the next can be assumed
a joint statement by several professional Reconstruction algorithms that use even in regular heart rhythms, and since
societies, led by the American College of data from one continuous 180° sweep of substantial differences between consecu-
Cardiology, the use of CT coronary angi- the x-ray tube for image reconstruction tive heart beats must be assumed in situ-
ography has been labeled an “appropri- are called “half-scan” reconstruction algo- ations e.g. of arrhythmia, the averaging
ate” indication to rule out or establish the rithms. Thus, the temporal resolution of of several cardiac cycles has severe draw-
presence of coronary artery stenoses in these half-scan reconstruction algorithms backs from a theoretical point of view
several clinical situations 2. corresponds to approximately one-half (Fig. 1). A definite benefit of multi-seg-
of the gantry rotation time (e.g. 330 ms ment reconstruction over half-scan re-
Cardiac Motion gantry rotation time = 165 ms temporal construction has not been proven for the
resolution). All x-ray data used for recon- detection of coronary artery stenosis.
Rapid motion of the heart and coronary struction of a single cross-sectional image However, regarding the use of multi-seg-
arteries and ensuing impairment of im- are acquired contiguously during the ment reconstruction for coronary artery
age quality are the major problems that image acquisition window in one single visualization, potential issues of concern
may exist in CT coronary angiography. In- heart beat. exist. They will be outlined below.
sufficient image quality can lead to false-
positive or false-negative findings, with Multi-Segment Reconstruction 1. Variability of the
the consequence of unnecessary further (Multi-Phase Reconstruction) Cardiac Cycle
testing in the first case and of missed
diagnoses in the latter. In order to avoid Alternative approaches are so-called Coronary artery visualization and analysis
artifacts caused by motion, two aspects “multi-segment” reconstruction algo- requires sub-millimeter resolution. How-
are important. rithms. These algorithms use less than ever, from one cardiac cycle to the next,
Firstly, with widely used single source 180° of data from a single heart beat. To it cannot be expected that the coronary
computed tomography systems it is compensate for the missing projections, arteries return to exactly the same posi-
important to use data for image recon- data acquired in the next cardiac cycles tion, within a fraction of a millimeter.
struction that was acquired during a is used to fill in the missing projections. Thus, multi-segment reconstruction, which
cardiac phase of relatively little motion This is done under the assumption that uses averaging, may slightly blur the im-
of the coronary arteries. one cardiac cycle is absolutely equal ages and thus reduce image quality.
Secondly, it is essential to limit data used to the next and data from several heart
for image reconstruction to as short a beats can thus be combined to recon-

Science
1A 1B 1C 1D
1 Fig. 1A to Fig. 1C: Angiography image of a right coronary artery (RCA) and colored outline in three subsequent heartbeats, pro-
jected on top of each other (Fig. 1D), clearly showing that variations of the position of coronary arteries in each subsequent
1E 1F 1 Fig. E to Fig. G: Cross-section

of a coronary artery including
a calcified plaque with multi-
segment
reconstruction in three fused
projections. Small dimensioned
outlines can not be clearly de-
picted and information is lost in
the process (Fig. 1H).
1G 1H

Science
2. Changes in Heart Rate During the Scan

Variability in the position of the coronary the diagnostic filling period is longer and age of several, non-identical cardiac cy-
arteries from one cardiac cycle to the next the heart will be more “expanded“ than cles. With higher true temporal resolution
will be especially evident if heart rate with faster heart rates. Thus, the end-dia- of CT scanners using half-scan (or single-
changes during the scan. Slight changes stolic position of the coronary arteries may segment) reconstruction, heart rate vari-
in heart rate during image acquisition are change and images reconstructed with ations are not a limitation and motion-
frequent. In slightly longer cardiac cycles, multi-segment algorithms will be an aver- free imaging becomes possible (Fig 2).
2A 2B 2C
2 Example of a patient in whom the rate of

normal sinus rhythm changes during the
scan. It drops from 75/min to 63/min dur-
ing the initial phase of data acquisition
(Fig. 2A). Such changes in heart rate will
lead to differences in the position of the
coronary arteries from one cardiac cycle
to the next – a disadvantage for multi-
segment reconstruction. With half-scan
reconstruction and a temporal resolution
of 83 ms (SOMATOM Definition, Siemens
AG), clear and motion-free visualization
of the heart (right coronary artery) is
achieved in spite of the heart rate varia-
tion (Figs. 2B and 2C).
3. Arrhythmias During Data Acquisition

Not only can the heart rate change arrhythmias occur in the form of supra- half-scan reconstruction because it is not
during data acquisition (even if there is ventricular or ventricular ectopic beats. necessary to average data from several
sinus rhythm throughout), it also is possi- Image quality of the single reconstructed heart beats (Fig. 3).
ble – and, in fact, not infrequent – that image remains unaffected in the case of
3A 3B 3C
3 78-year-old patient with previous bypass

surgery. Substantial supraventricular
arrhythmia occurred during the scan (Fig.
3A). Half-scan reconstruction with a tem-
poral resolution of 83 ms remains unaf-
fected from the arrhythmia and allows
precise delineation of bypass grafts and a
stenosis in the venous graft to the left an-
terior descending coronary artery (Fig. 3B,
arrow). Angiography confirms the finding
(Fig. 3C, arrow).

Science
4. Reduced Pitch for 4A

Multi-Segment Reconstruction
In order to be able to use data from several
cardiac cycles to reconstruct a cross-sec-
tional image at any given z-axis position,
the x-ray detector has to cover that posi- 4B 4C
tion during several consecutive cardiac cy-
cles. The more cardiac cycles are to be
used for reconstruction, the slower the
movement of the patient relative to the
detector has to be. Thus, the pitch which is
defined as the table movement during a
360° rotation divided by the collimated de-
tector width has to be chosen low and in
each given z-axis position, the patient will
be exposed to radiation several consecu-
tive times. This leads to increased radiation
exposure compared to single-segment re-
construction approaches. In addition, since
the overall scan time will be longer, more
contrast agent must be given to the pa-
tient to ensure full enhancement of the
blood pool during the longer period of 4D
data acquisition.
A further effect of this issue is that exclu-
sion of ectopic beats from the reconstruc-
tion process may not be possible. Occa-
sionally, ectopic beats will require
excluding one or several heart beats from 4E 4F
reconstruction in order to avoid misalign-
ment artifacts. However, in that case, it
may occur that the z-axis position inques-
tion will not be covered by the detector
in enough “regular” heart beats to allow
multi-segment reconstruction (Fig 4).
5. Examples
Multi-segment reconstruction may theoret-
ically lead to shorter data windows used
for image reconstruction (compensated for
by using data from several consecutive car-
diac cycles), but it does not in all cases
lead to elimination of motion artifact or
improved image quality. In fact, Magnetic 4 Exclusion of an ectopic beat to avoid artifact in 64-slice CT. In the ECG trace, gray bars
Resonance coronary angiography uses ex- indicate the times during which data is used for image reconstruction (Fig. 4A). Because
tensive averaging of heart beats in their of the ectopic beat, one of these data windows is in systole (arrow). This leads to arti-
data acquisition and reconstruction pro- facts which can be seen in the CT images at the level of the mid to distal right coronary
cess, but even though the theoretical reso- artery (arrows, Figs. 4A and 4C). After exclusion of the data acquired during the ectopic
lution of magnetic resonance coronary ar- beat from image reconstruction in Fig. 4D (marked in blue), the right coronary artery is
sharply delineated (arrows, Figs. 4E and 4F).
tery imaging is below 0.5 mm, images
never reach the crispness and sharpness
seen in cardiac CT. This is the consequence
of blurring which is caused by the averag-
ing of usually eight to 16 cardiac cycles.

Science
5A
5A 57-year-old female.
Heart rate 68/min.
Half-scan reconstruc-
tion yields good im-
age quality of the
right coronary artery.
Multi-segment recon-
struction at the same
cardiac phase (40 %
of cardiac cycle)
shows obvious mo-
tion artifact of the
right coronary artery
(right, arrow).
5B 73-year-old male. 5B
Heart rate 72/min.
Half-scan reconstruc-
tion (left) yields
good image quality
of the right coronary
artery. Multi-seg-
ment reconstruction
at the same cardiac
phase (70 % of cardi-
ac cycle) shows obvi-
ous motion artifact of
the right coronary ar-
tery (right, arrow).
In coronary CT angiography, multi-seg- be combined to make up for the missing resolution in combination with half-scan
ment reconstruction does not reliably projections constitutes a drawback that reconstruction allows reliable imaging of
lead to elimination of motion artifacts. may have negative influence on image the coronary arteries even with high
In fact, new artifacts may be introduced. quality. “Blurring” may occur because the heart rates.
Two examples are shown here (Fig. 5). coronary arteries do not return to exactly
the same position from one cardiac cycle
Summary to the next. The reduced pitch may cause
higher radiation dose and may require a
Even though multi-segment reconstruc- larger amount of contrast agent. Irregu-
tion, as compared to half-scan recon- larities of the heart rate and arrhythmias
References
struction, offers nominally shorter data may be more difficult to compensate for 1 Budoff MJ, Achenbach S, Blumenthal RS, et al.;
windows during each cardiac cycle used than with half-scan reconstruction. Finally, Circulation 2006; 114(16): 1761–91.
for image reconstruction, the fact that the initial experience with Dual Source CT 2 Hendel RC, Patel MR, Kramer CM, et al.;
data from several cardiac cycles need to demonstrates that high, true-temporal J. Am. Coll. Cardiol. 2006; 48(7): 1475– 97.

Education & Events
CT Life Card: Clinical Education at Your CT Workplace

There is an easy way to increase your skills
at the CT workplace: exclusively for the
SOMATOM® Definition, Siemens Medical
Solutions introduces the CT Life Card, a
portal for a wide spectrum of information
and services at your scanner. The CT Life
Card combines the Operator Manual,
LifeNet and the new Workflow Assistant
on one modern education and communi-
cation platform. The Workflow Assistant is
a state-of-the-art CT examination guide
that takes you from patient preparation,
through scan acquisition to data evalua- CT Life Card – a portal to a wide spectrum A workflow guide for cardiac imaging – how
tion. It expands your clinical knowledge by of information and services at your workplace. to perform left ventricular functional evaluation
with syngo Circulation.
offering best practice examples including
clinical background, current indications cation tools such as syngo® Circulation
and fascinating case-studies. It provides and others. The Workflow Assistant is also
useful workflow tips that enhance the available on DVD as a convenient tool for
confidence of the unexperienced user general staff education. In addition, via
when performing advanced CT procedures the LifeNet portal on the Life Card, you
such as cardiovascular imaging. It illus- will find current information on CT edu- * The DVD will be provided to all customers working
trates the quickest path to excellent clini- cation and gain access to helpful services with the software version syngo CT 2007C. For
cal results using workflow movies that such as ordering of trial licenses for the additional copies, please contact your local Siemens
demonstrate the clinical utility of CT appli- latest clinical applications. representatives
E-Logbook: Eliminate Cumbersome Paperwork

The E-Logbook* is a very handy tool that The E-logbook input fields are individual- patient examination on a certain date is
automatically records necessary data to ly configurable to include what really now only a matter of a few clicks. Addi-
be saved. You only have to enter specific matters in the department. Parameters tionally, the files can be transferred to
additional information when needed. that are already available within the any PC, e.g. for statistical evaluations in
In many clinics, it is still common use to system (e.g. patient name, Patient ID, Microsoft Excel. A print-out of the data is
note patient examination data in a so- dose values) will be transferred to the possible directly from the scanner. “With
called “paper logbook.” With the newly E-Logbook automatically after completing the E-Logbook, we can quickly check
developed E-Logbook you save time and the examination. Other parameters can what examinations we have done over
will be guaranteed an error-free reporting then be typed in manually if desired. All the whole lifetime of our SOMATOM CT
compared to the conventional, handwrit- recorded examination data are saved to system. The system records all parame-
ten patient logbook. a local database. Searching for a certain ters automatically, which saves us time
compared to a paper logbook”, says
Michaela Henkel, technician of the Radio-
logical Institute at the Werner-Wicker
Klinik, Bad Wildungen, Germany.
* The E-Logbook option is now available for all

SOMATOM Sensation, Emotion and Spirit scanners
with the syngo CT 2007 software.

Education & Events
New: Cardiac CT Poster for

all Siemens Customers
Siemens Medical Solutions announces a new Cardiac CT Anatomy poster.
A special offer to all our customers: This high-gloss poster shows detailed CT
images of main cardiac structures including all coronary vessels, cardiac
valves, standard Myocardial Segmentation (AHA 17-Segment Model), differ-
ent cardiac planes and standard views compared to conventional Angio
(size: 84 cm x 119 cm; 33,11 x 46,81 inches). The images were provided by
the University Hospital of Munich-Grosshadern (Department of Radiology
and Cardiology) and the University Hospital of Erlangen-Nuremberg in Ger-
many and were acquired with the SOMATOM Sensation 64 slice scanner and
the SOMATOM Definition. Order your poster free of charge via this link:
www.siemens.com/
ct-cardiac-poster
New: CTA Interpretation Workshops

The Friedrich-Alexander University Hospi- stations and evaluate 50 original coro- 2007 was very successful. “This is the
tal and Siemens Medical Solutions offer nary CT angiography scans, which leads most interesting course I’ve ever partici-
clinical workshops specifically for image towards Level II certification. These cases pated in,” says Miclaus Gratian, MD, from
evaluation. range from easy, introductory to more the Neuromed Center of Diagnostic Imag-
Conducted by Stephan Achenbach, MD, advanced cases with difficult diagnoses ing in Timisoara, Rumania.
FESC, FACC, from the Friedrich-Alexander and typical pitfalls. The course is most suited for Cardiolo-
University Hospital Erlangen-Nuremberg, Invasive coronary angiography correla- gists and Radiologists with basic know-
Germany, these courses focus on provid- tion are available for every CT angiogra- ledge of cardiac CT.
ing the participants with hands-on expe- phy case. Two participants work on one
rience in the interpretation of coronary CT workstation jointly, and a faculty is avail- Upcoming Dates:
angiography data sets. able to provide help and guidance. In 19–20 July 2007 (Course ID: ERL5)
For two days, participants have the oppor- addition, two lectures are given during 20–21 Sept. 2007 (Course ID: ERL6)
tunity to use image interpretation work- the lunch breaks.The first course in March
For online registration please go to the
following link and select: ‘Professional
Clinical Education’ and ‘Course schedule.’
Here you will also find information about
all upcoming courses for 2007. Educate,
stay up-to-date!
www.siemens.com/
somatomeducate
Exclusively during this clinical workshop: The participants could evaluate more than 50 datasets.

Education & Events
Free 90 Day Trial

Licenses* for
Clinical Applications
Try the following advanced clinical appli-

cations: syngo® Neuro DSA and syngo
Circulation 90 days for free! The clinically
proven syngo Neuro DSA CT provides an
easy, fast and fully automated method to
improve the detection of intracranial an- in less than ten minutes. The intelligently
eurysms and subsequent therapy plan- designed, guided workflow will lead you
ning**. It facilitates optimal visualization effortlessly to a confident diagnosis, from
and evaluation of complex intracranial quantitative coronary assessment and
and extracranial vascular structures, espe- plaque analysis to left ventricular and
cially at the base of the skull, and helps to myocardial analysis, ultimately fusing all
delineate aneurysms, stenoses, and other your diagnostic findings into a single
* Minimum system requirements need to be fulfilled
vascular diseases. comprehensive report. For details regard- for these options to be available. Ask your Siemens
syngo Circulation is your fast track to a ing trial licenses, please consult your representative to check your system configuration.
complete, noninvasive cardiac evaluation Siemens representative. ** Tomandl et al. AJNR 2006, 27: 55–59.
Frequently Asked Questions

How to turn mAs/ rot at the SOMATOM Definition into How can I display the cardiac phase information
effective mAs? in the Browser?
Please use the following formula: mAs/ rotation = 2 x mA x rotation To display the cardiac phase, please open the Browser and dese-
time. When placing the mouse cursor over the mAs setting in the lect under Viewing the entry Image Stamps. Select Options –
routine subtask card, you can see the corresponding value from the Configure Browser – Tree View – Instance. There you will find
SOMATOM® Sensation 64-slice configuration. Further information under Data Type CT Image. Select the entry Image Comment
can be found in the online help (F1 key). and add this via a click on the down arrow to Heading Settings.

Education & Events
E-Newsletter
The CT monthly e-newsletter from in the world of computed tomography
Siemens Medical Solutions includes high- with the Siemens Medical CT Newsletter.
lights on clinical outcomes, business, Subscribe via the following link, or with
science and customer care topics. As the postcard attached to the back cover
subscriber, you will receive latest infor- of this magazine.
mation on upcoming Siemens CT events
and courses. Answers to frequently asked
questions will be given, along with a sec-
tion with tricks and tips on “how to …”
efficiently use Siemens CT scanners and www.siemens.com/
applications in daily clinical practice. medicalnews
Stay up-to-date with what is happening Latest information with the monthly CT e-newsletter.
Upcoming Events & Courses

Title Location Short Description Date Contact
ESC Vienna, Austria European Society of Sep. 1–5, 2007 www.escardio.org
Cardiology Congress 2007
9th Biennial Barcelona, Spain European Society for Sep. 8–13, 2007 www.estroweb.org
ESTRO Meeting Therapeutic Radiology
and Oncology
ESNR Genova, Italy European Society of Sep. 20–23, 2007 www.esnr.org
Neuroradiology Congress
ESCR Rome, Italy Annual Scientific Meeting Oct. 18–20, 2007 www.escr.org
JFR Paris, France Société Française Oct. 20 –24, 2007 www.sfrnet.org
de Radiologie Congrès
TCT Washington, USA Transcatheter Cardiovascular Oct. 20–25, 2007 www.tct2007.com
Therapeutics Symposium
AHA Orlando, USA American Heart Association Nov. 3–7, 2007 www.scientificsessions.org
Scientific Sessions
Medica Duesseldorf, Germany MEDICA 2006 Nov. 14–17, 2007 www.medica.de
RSNA Chicago, USA Radiological Society of Nov. 25–30, 2007 www.rsna.org
North America
Moscow Moscow, Russia 17th international Exhibition Dec. 5–9, 2007 www-eng.expocentr.ru
Healthcare of Health Care, Medical
Engineering and Pharmaceutics
In addition, you can always find the latest CT courses offered by Siemens Medical Solutions at www.siemens.com/SOMATOMEducate

Imprint
SOMATOM Sessions – Imprint

© 2007 by Siemens AG, Berlin and Munich, All rights reserved
Publisher A. Davis, MD, Hartsdale Imaging, Hartsdale, A. Weustink, MD, Departments of Radiology and
Siemens AG New York, USA Cardiology, Erasmus Medical Center, Rotterdam, the
Medical Solutions Netherlands
A. Graser, MD, Department of Clinical Radiology,
Computed Tomography Division
University Hospital of Munich-Grosshadern, Munich, J. Wildberger, MD, Department of Diagnostic Radiolo-
Siemensstraße 1
Germany gy, RWTH Aachen University, Aachen, Germany
D-91301 Forchheim
A. Hirayama, MD, Cardiovascular Division, Catherine Carrington, freelance author
Responsible for Contents
Osaka Police Hospital, Osaka, Japan Tim Friend, freelance author
André Hartung
T. Johnson, MD, Department of Clinical Radiology , Robert Harsieber, PhD, freelance author
Chief Editors Frank Miltner, freelance author
University Hospital of Munich-Grosshadern, Munich,
Monika Demuth, PhD Germany David J. Tenenbaum, freelance author
(monika.demuth@siemens.com) Tony DeLisa, freelance author
Stefan Wünsch, PhD K. Kodama, MD, Cardiovascular Division, Osaka Police
(stefan.wuensch@siemens.com) Hospital, Osaka, Japan Karin Barthel; Nina Bastian; Dagmar Birk; Andreas
Blaha; Wai Leng Chin; Jan Chudzik; Monika Demuth,
Editorial Board S. Komatsu, MD, Department of Internal Medicine 2, PhD; Sonja Fischer; Tanja Gassert; Murat Guengoer;
Nina Bastian University of Erlangen-Nuremberg, Erlangen, Germany
Christoph Hachmöller, MD; Loke-Gie Haw; Lars Hof-
Thomas Flohr, PhD and Cardiovascular Division, Osaka Police Hospital,
mann, MD; Julia Kern-Stoll; Rami Kusama; Karin Lad-
Osaka, Japan
Murat Guengoer enburger; Per-Anselm Mahr; Louise McKenna, PhD,
Louise McKenna, PhD A. Küttner, MD, Institute of Diagnostic Radiology, MBA; Marion Meusel; Hiroshi Nakatsuji; Doris Pischitz;
Julia Kern-Stoll University of Erlangen-Nuremberg, Erlangen, Germany Gitta Schulz; Peter Seitz; Stefan Wünsch, PhD; Alexan-
Axel Lorz der Zimmermann; all Siemens Medical Solutions
A. Kuhlmann, MD, Department of Internal Medicine 2,
Jens Scharnagl
University of Erlangen-Nuremberg, Erlangen, Germany Production
Bernhard Schmidt, PhD
Norbert Moser, Siemens Medical Solutions
Heiko Tuttas A. Mahnken, MD, Department of Diagnostic Radio-
Alexander Zimmermann logy, RWTH Aachen University, Aachen, Germany Layout
A. Megibow, MD, MPH, FACR, Department of Radio- independent Medien-Design
Authors of this Issue
logy, NYU Medical Center, New York, USA Widenmayerstrasse 16
S. Achenbach, MD, Department of Internal Medicine
D-80538 Munich
2, University of Erlangen-Nuremberg, Erlangen, Ger- N. Mollet, MD, PhD, Departments of Radiology and
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SOMATOM Sessions

The Difference in Computed Tomography

Issue no. 20 / June 2007

2 SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine

Education & Events

SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine 3

Dual Source CT Reshapes

From the start, it was clear that cardiac 1

*Results may vary. Data on file.

4 SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine

No Need for Beta-Blockers

SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine 5

emergency physician and the radiologist,” 3

6 SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine

4 artifact, an inadequate signal-to-noise ra-

SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine 7

New York City. “I suspect we’ll soon be 5A 5B

8 SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine

SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine 9

Professor Gerhard Mostbeck,

10 SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine

SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine 11

“With the SOMATOM Emotion 16 today’s resolution

Axial thin section

12 SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine

SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine 13

Let the Computer do it!

14 SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine

Greater accuracy may also help resolve

Volume as a Standard Modality?

SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine 15

syngo Circulation - Siemens Scientiﬁcally

syngo Circulation Plaque Analysis.

16 SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine

SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine 17

“Now we can say we have a

18 SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine

Patient Preparation Scan Data

Fast Data Link PACS PACS Reading

With syngo WebSpace 3D data are available anytime and anywhere.*

* Internet connection required.

SOMATOM Sensation Web Selection.

* Internet connection required.

“We will see signiﬁcant costs savings in the

SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine 21

Big Progress for a Small Clinic

22 SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine

SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine 23

A Workhorse as well for Cardiology

What has changed for your cardiology department?

Falk Karsten Pohle, MD: “With this CT,

24 SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine

Cardiac CT Takes Off

SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine 25

temporal resolution, in the US, indicate that pilot autopsies

26 SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine

German Air Force Institute

Source: German Air Force

SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine 27

“MSCT is a fast, secure, and cost-

28 SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine

SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine 29

30 SOMATOM Sessions · June 2007 · www.siemens.com/medical-magazine