SoMaTom Sessions Computed Tomography November 2008

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Editorial Imprint
“The new scanner is a

true revolution. We
“Lowest radiation dose
SOMATOM Sessions – IMPRINT E. Hendrich, MD, Department of Radiology M. Remy-Jardin, MD, PhD, University Center of
© 2008 by Siemens AG, Berlin and Munich and Nuclear Medicine, German Heart Center, Lille, Department of Thoracic Imaging, Hospital
All Rights Reserved Munich, Germany
M. Higashi, MD, Department of Radiology and
Calmette, Lille, France
P. Schramm, MD, Department of Neuroradiology,
never before dared to
Publisher: Nuclear Medicine, National Cardiovascular Cen- University of Göttingen, Göttingen, Germany
scan with such a low
is important to
Siemens AG ter, Osaka, Japan
Healthcare Sector W. Sommer, MD, Department of Clinical Radiolo-
R. Hoffmann, MD, Department of Clinical Radiol- gy, University of Munich, Campus Großhadern,
Business Unit Computed Tomography
Siemensstraße 1, 91301 Forchheim, Germany ogy, University of Munich, Campus Großhadern,
Munich, Germany
Munich, Germany dose and such a high
T. Taoka, MD, PhD, Department of Radiology,
Chief Editors:
speed.”
physicians and patients.
T. Jakobs, MD, Department of Clinical Radiology, Nara Medical University, Nara, Japan
University of Munich, Campus Großhadern, Mu- Catherine Carrington, freelance author
nich, Germany Melanie J. Davis, medical writer
S. Kanzaki, MD, Department of Radiology and Tony DeLisa, freelance author
Willi Kalender, PhD, Director of the Institute
Nuclear Medicine, National Cardiovascular Cen- Sameh Fahmey, medical and scientific journalist
It’s important to us.”

ter, Osaka, Japan Hildegard Kaulen, PhD, freelance scientific of Medical Physics, University of Erlangen-Nuremberg,
journalist Erlangen, Germany
K. Kichikawa, MD, PhD, Department of Radiolo-
gy, Nara Medical University, Nara, Japan Oliver Klaffke, freelance scientific journalist
Tim Schröder, freelance scientific journalist
S. Kitano, MD, Department of Radiology, Nara Rita Wellens, PhD, medical writer and clinical
Medical University, Nara, Japan research consultant
Monika Demuth, PhD Stefan Wünsch, PhD A. Kohli, MD, Department of Radiology, Breach Photo Credits: Peter Rigaud/Shotview, Jez Coul-
Sami Atiya, PhD, Chief Executive Officer, (monika.demuth@ (stefan.wuensch@ Candy Hospital Trust, Mumbai, India son, Tina Ruisinger, Stephan Sahm, Chris De
Business Unit CT, Siemens Healthcare, Forchheim, Germany siemens.com) siemens.com) T. Löffler, MD, Department of Surgery, University Bode
of Munich, Campus Großhadern, Munich, Peter Aulbach; Steven Bell; Andreas Blaha;
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Editorial Board: Andreas Blaha, Andreas Fischer, S. Martinoff, MD, Department of Radiology and Klar; Ivo Driesser; Carolin Emmert; Inga Fötsch;
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Jens Scharnagl, Heiko Tuttas, Alexander Zimmer- nich, Germany Knecht; Rami Kusama; Claudia Lindner; Reto
mann Merges; Marion Meusel; Kerstin Putzer; Rainer
N. Marugami, MD, Department of Radiology,
Raupach, PhD; Holger Reinsberger; Peter Seitz;
Authors of this Issue: Nara Medical University, Nara, Japan
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S. Achenbach, MD, Department of Cardiology, A. Megibow, MD, MPH, FACR, New York PhD; Claudette Yasell; all Siemens Healthcare
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Editorial
André Hartung,
Vice President
Marketing and Sales
Dear Reader,
For the Siemens Healthcare Sector, be- reduction with the new SOMATOM® by combining the unique Adaptive 4D
ing the industry’s innovative leader in Definition Flash scanner. This scanner Spiral with Flash speed, thereby intro-
medical technology – year after year – delivers greatly improved diagnostic ducing Adaptive 4D Spiral Plus for long-
has become almost routine. But innova- quality with levels of dose lower than range dynamic imaging of up to 48 cm,
tion leadership in pioneering new clini- ever before possible because its modern enabling dynamic imaging with half the
cal terrain with unmatched technology and future oriented technology effi- dose. An additional dose-saving feature
alone is not sufficient: From the very ciently utilizes the next generation is the Selective Photon Shield, filtering
beginning, we have maintained a strict DSCT. out unnecessary photons of the high
focus on patient safety as well. And in With its revolutionary Flash Spiral energy X-ray tubes resulting in a better
computed tomography (CT), patient mode resulting in very high speed, the separation of 80/140 kV images by simul-
safety translates primarily into dose re- SOMATOM Definition Flash scanner is taneously providing dose-neutral, Spiral
duction. For this reason, we have, from not only the lowest dose scanner known Dual Energy.
the earliest days, always given dose today, it is also the fastest, being able In addition to the advanced technology
reduction top priority. to virtually eliminate the need for breath required for lowest dose imaging, ade-
The actual danger caused by X-ray radia- holds and do a whole body scan in four quate training is provided by our highly
tion in rather low amounts as required seconds or to scan an entire thorax in competent application team so that you
for CT scanning is difficult to measure less than one second. And it accomplish- and your medical team will be able to
since there exists almost no es these breath-taking performances take full advantage of both the superior
adequate information or scientific stud- with the lowest dose known world-wide. scanning performance and the dose-
ies on the problem. We have therefore Flash speed plus lowest dose are the reducing features of the new scanner.
committed ourselves to the ALARA core of the new scanners’ advantages. With the SOMATOM Definition Flash all
(i. e. As Low As Reasonably Achievable) Even under unfavorable conditions, the patients benefit from the extremely low
principle of exposing patients only to the patient’s dose exposure is less than what dose levels, thus making CT a healthier
minimum amount of radiation absolutely is required for diagnostic cardiac cath. examination than ever before. And your
necessary to achieve the best possible And triple rule-out examinations are work will be easier and faster, your diag-
diagnosis. possible with doses below 5 mSv, up to noses more accurate with completely
Consequently, in recent years, we have four times lower than any other scanner new clinical applications that only Dual
developed many significant products available on the market. Source CT can provide.
and protocols to conform to the ALARA Furthermore the SOMATOM Definition
principle, for example, Adaptive Dose Flash can selectively reduce sensitive- Enjoy reading,
Shield and others that reduce radiation area exposure up to 40% without loss
dose to the lowest possible level. of image quality by turning down the
Following closely on the development X-ray tube while scanning dose-sensitive
and introduction of Dual Source CT body areas such as female breasts. The
(DSCT) in 2005, we have once again SOMATOM Definition Flash opens new
achieved a new milestone in CT dose dimensions for functional 4D imaging André Hartung
SOMATOM Sessions · November 2008 · www.siemens.com/healthcare-magazine 3
Sessions23_Inhalt.indd Abs1:3 17.11.2008 8:50:53 Uhr

Content
6 42
Content SOMATOM Definition Flash Visualization of Brain Vessel
Connection
Cover Story Cover Story

The new SOMATOM® Definition Flash Dual 6 SOMATOM Definition Flash Dual
Source CT scanner can sweep through the Source CT: Leaving Dose Behind
entire thorax in 0.6 seconds and speed
through cardiac scans in less than half a
heartbeat. But the talk will be about more News
than speed alone. That’s because the new
scanner also promises an impressive reduc- 14 Dual Source CT on Scientific
tion in radiation dose for all patients and all Center Stage
types of scans. In a word, the SOMATOM 15 First U.S. Payor Reimburses CT
Definition Flash has been designed to be a Colonography (CTC) for Screening
healthier CT scanner. 16 The SOMATOM Definition AS
20-Slice Configuration
16 4D Noise Reduction:
New Filter Setting for Dose Decrease
and Image Enhancement
17 The Success Story of the SOMATOM
Emotion Continues
17 3D on the fly with new syngo Web-
Space 2008B
18 Proactive Tube Failure Prediction:
Siemens Guardian Program
now Includes TubeGuard for the
SOMATOM Definition Family
19 Molecular CT –
Imaging in Living Colors
4 SOMATOM Sessions · November 2008 · www.siemens.com/healthcare-magazine

Content
60 64
Virtual Histology Siemens Guardian Program
with DSCT Supports Clinical Workflow
Business
20 As Radiation Dose Goes Down, Neurology 56 CT put to the Test
Attractiveness of CT Rises 38 Acute Left Hemispheric Ischemic 60 Virtual Histology with Dual Source CT
22 Making a Case for the SOMATOM Stroke: Comprehensive Stroke Imag-
Emotion ing Using Neuro Volume Perfusion CT
24 syngo WebSpace: Command 40 SOMATOM Definition AS+: Life
Central for Fast and Efficient Image Neuro Volume Perfusion CT of
Processing Intracerebral Metastatic Disease 64 Proactive Services for and by
42 Dual Source CT: Visualization of Brain Radiologists
Vessel Connection of Siamese Twins 68 Customer Report: Upgrade from
Clinical Results 44 A Rare Anomaly of the Middle Cere- SOMATOM Plus 4 to SOMATOM
bral Artery Detected by Three-Dimen- Definition Delivers a new Picture of
Cardiovascular sional Subtraction CT-Angiography Health
26 Coronary CTA with Flash Spiral 70 syngo CT 2008G – New Software
Scanning in 300 msec Scan Time Acute Care Release for SOMATOM Definition
28 Low Dose Coronary CTA Reveals 46 Complete Thorax with Flash Spiral 70 CT Research Collaborations in China:
High Grade Stenosis 48 Dual Source CT: Carotid Stenosis a True Win-Win Situation
30 Dual Source CT: Diagnosed with Dual Energy 71 Recording of Hands-on Workshops
Pediatric Congenital Heart Disease at ECR 2008
32 Identification of Vessel Stenosis Orthopedics 71 New E-Learning for CARE Dose4D
of the Lower Leg by Dynamic 50 Screw Placement and Pelvic 72 Free 90-Day Trial Licenses for
CT-Angiography Using the Osteoplasty Under CT – Clinical Applications
SOMATOM Definition AS+ Fluoroscopic Guidance 73 Clinical CT Posters
73 Frequently Asked Questions
Oncology 74 Clinical Workshops 2009
34 SOMATOM Definition Dual Energy Science 75 Scientific Photography Prize for
Scanning: Liver Imaging with Anders Persson
Optimum Contrast 52 CT-Guided Osteosynthesis in 75 Upcoming Events & Congresses
36 Lung Parenchyma Analysis Software Instable Pelvic Fractures 76 Siemens Healthcare –
with Automated Three-Dimensional 54 Clinical Advantages of Automated Customer Magazines
Quantification of Emphysema CT Tumor Measurement 77 Imprint

Cover Story
SOMATOM Definition Flash

Dual Source CT:
Leaving Dose Behind
Through a combination of unprecedented speed and innovative
dose-reduction features, the new SOMATOM Definition Flash offers
patients a healthier CT scan.
By Catherine Carrington
Flash speed. Lowest dose: The new SOMATOM Definition Flash Dual Source CT Scanner is the healthier CT System.
Sessions23_S6-13_Cover.indd Abs1:6 17.11.2008 8:55:30 Uhr

How can CT scanning become
healthier for your patients?
Session23_Klappseite Inhalt.indd 1 14.11.2008 11:39:12 Uhr

Cover Story
“Our goal was to build the

most patient-friendly CT by
significantly reducing dose
through faster speed.”
Sami Atiya, PhD, Chief Executive Officer,
Business Unit CT, Siemens Healthcare
Flash. It’s a word that grabs your atten- How it Works

tion, immediately evoking speed or bril- Dual Source technology was introduced moments, Siemens scientists and engi-
liance. by Siemens in 2005 with the launch neers realized that with two detectors,
of the SOMATOM Definition CT scanner. it was no longer necessary for the
The new SOMATOM® Definition Flash With two X-ray sources and two detec- patient table to inch forward during
Dual Source CT scanner hits the mark on tors, the scanner not only enabled an data acquisition. Instead, a Dual Source
both counts. With an acquisition speed unprecedented improvement in tempo- scanner could achieve gapless z-sam-
and the ability for low dose-scans never ral resolution to 83 msec, it also made pling, even with the wide-open spiral
before equaled in CT, it outpaces all Dual Energy scanning possible. created by a pitch of above 3. That’s
rivals. It can sweep through the entire But the ability of Dual Source CT to push because the two detectors create two
thorax in 0.6 seconds and speeds data acquisition speeds to new levels complementary data spirals that, when
through cardiac scans in less than half went relatively unrecognized until put together, include all the information
a heartbeat. recently. In one of those “light bulb” that would be found in a single spiral
Still, when Siemens Healthcare unveils
the SOMATOM Definition Flash at the
2008 annual meeting of the Radiological
Society of North America, the talk will
be about more than speed alone. That’s
because the new scanner also promises “The new scanner is a true
an impressive reduction in radiation
dose for all patients and all types of revolution. We never before
scans. In a word, the SOMATOM Defini- dared to scan with such a
tion Flash has been designed to be a
healthier CT scanner. low dose and such a high
“We have a strong focus on putting the speed.”
patient in the center of all we do,” says
Sami Atiya, PhD, chief executive officer of
the CT Business Unit of Siemens Health- Willi Kalender, PhD, Director of the Institute
care. “Our goal was to build the most of Medical Physics, University of Erlangen-Nuremberg,
Erlangen, Germany
patient-friendly CT by significantly reduc-
ing dose through faster speed. Lowest
radiation dose is important to physicians
and patients. It’s important to us.”

Cover Story
acquired at a much lower table speed. The new scanner is of even greater ben- the better,” Nikolaou says.
“The new scanner is a true revolution,” efit for trauma patients, who are often Triple rule-out examinations are also
says Willi Kalender, PhD, director of in too much pain to lie still. With its abil- likely to enjoy renewed interest. These
the Institute of Medical Physics at the ity to scan 120 cm in less than three all-in-one scans evaluate patients for
University of Erlangen-Nuremberg seconds, the SOMATOM Defintion Flash three common causes of chest pain –
in Erlangen, Germany. “It picks up on will not only reduce motion and breath- pulmonary embolism, aortic dissection,
the well established concept of Dual ing artifacts, but will get the patient out and coronary artery disease. However,
Source CT but improves it in several of the CT scanner and into surgery much their popularity has been hampered
ways. We never before dared to scan more quickly. “For the trauma surgeon, by a radiation dose of 15 to 20 mSv, a
with such a low dose and such a high the faster you’re done with your scans, direct consequence of a lengthy, electro-
speed.”
Not only can the patient table travel at
more than 43 cm/sec, the SOMATOM
1
Definition Flash is equipped with two
4 cm detectors that each acquire 128
slices of image data. Gantry rotation
time has dropped to 0.28 s, which trans-
lates into a temporal resolution of just
75 msec. X-ray tube power has been
increased to 2 x 100 kW to accommo-
date even the most obese patients.
Sophisticated technical features further
lower radiation dose.
All of these features are available merely
on the SOMATOM Definition Flash. “The
fastest scan is only possible through
Dual Source,” Atiya says. “That’s why it’s
unique. Unless you have Dual Source
technology, you can’t do all these other
things.”
Split-Second Thorax
If you want to picture just how fast the
SOMATOM Definition Flash is, consider
a full thoracic scan that takes about
0.6 seconds. That means, for the first
time, that patients will no longer have
to hold their breath during scanning.
Not only will this be a welcome relief for
patients who are sick or injured, it will
shorten patient preparation time, an im-
portant plus in any busy CT department.
“This will save time for the tech,” says
Konstantin Nikolaou, MD, an associate
professor of radiology and CT section
chief at Ludwig Maximilian University
of Munich, Großhadern, Germany.
“With a very fast scan, you don’t have
to train anyone to hold his breath or
be concerned about motion artifacts.
We will just tell the patient to use
shallow breathing, and that should
be fine.” Pediatric scanning will also 1 Triple rule-out without breath hold in less than one second – at a dose below 5 mSv.
be easier and safer with the SOMATOM
Definition Flash.

Cover Story
cardiographic (ECG) gated exams that scan can be performed very fast and SOMATOM Definition Flash is capable of
use a pitch of 0.2 to 0.4. But with the with low dose, while still potentially a dynamic scan range of 48 cm, the lon-
SOMATOM Definition Flash running at a providing substantial information on gest available today.
pitch of above 3, a triple rule-out scan will the heart and the coronary arteries,” This lengthy 4D spiral opens the possi-
take no more time than a standard thorac- Nikolaou adds. bility of scanning the entire thorax in
ic study and expose the patient to no The speed of the SOMATOM Definition a time-resolved way. In patients with
more radiation, approximately 5 mSv. Less Flash promises to boost CT dynamic im- aortic dissection, the radiologist could
contrast material may also be needed. aging as well. With its 4 cm detector and watch contrast material flowing in and
“This protocol facilitates the diagnostic a shuttle mode that continuously glides out of the true and false lumens and
procedure in chest pain patients, as the the patient table back and forth, the observe how various vessels and organs
2 Rule-out coronary artery disease for early detection and prevention – Flash Spiral CTA with 0.9 mSv.

Cover Story
1A
< 1 sec
Vol
Tube 1 Tube 2
1B 1C
Selective
Photon
Shield
80 kV 140 kV
Attenuation B Attenuation A
< 1 mSv
1D
1 Flash speed. Lowest dose: SOMATOM Definition Flash
X-ray off
Split-second thorax: Scanning heart/thorax needs 0.6 s, taking the
burden of breath-holding off the patient and allowing functional
imaging for body regions up to 48 cm (Fig. 1A).
Sub-mSv heart: temporal resolution of 75 msec and scan speed of up

to 43 cm/s make heart-scanning without beta-blockers possible or
without breath hold a standard with dose levels below 1 mSv (Fig. 1B).
Single dose Dual Energy: now dose neutral with the Selective Photon
Shield and the widest range of FDA-cleared applications (Fig. 1C).
Organ-sensitive dose protection: The SOMATOM Definition Flash pre-

vents clinically irrelevant dose for spiral examinations and introduces
X-ray on organ-sensitive dose protection (Fig. 1D).

Cover Story
are supplied. It also offers the option of peripheral arterial disease. Still, the
dynamically scanning the entire abdo- smaller detector on his existing scanner
minal/pelvic region, for example, in a permits viewing of only about two-thirds
patient with renal cell carcinoma that of the lower leg. That will change with
has metastasized throughout the mes- the SOMATOM Definition Flash.
entery. An exciting further development, “With 48 cm coverage, you could really
4D Noise Reduction, makes it possible have a lower leg CTA with time-resolved
to significantly improve image quality imaging,” stresses Nikolaou. “This will
with no increase in dose or, alternately, definitely change our protocol.”
reduce dose up to 50% without compro-
mising image quality. Sub-mSv Heart
But Nikolaou is also intrigued by the pos- Dual Source CT took cardiac imaging
sibility of using the extended dynamic to new heights. Now, the SOMATOM
scan range to improve run-off studies Definition Flash goes even further,
of the lower leg. He is already using a scanning the heart in about 250 msec
hybrid, two-injection technique to at a temporal resolution of 75 msec
achieve a true arterial phase of the low- and with a radiation dose of < 1 mSv.
er leg, even in patients with advanced With specs like that, Flash scanning
has the potential to stretch cardiac CT
applications to include everything from
screening to stress myocardial perfusion “If we could
imaging.
Consider the use of CT coronary angio- detect coro-
graphy for preventive screening. It has
the potential to unmask a silent killer,
nary disease
but until now, radiation dose has been
a significant stumbling block.
earlier, it
“If we could detect coronary disease might have
earlier, it might have a tremendous im-
pact on prognosis,” says Jörg Hausleiter, a tremendous
MD, an associate professor of medicine
at the German Heart Center in Munich.
impact on
“But with currently available CT tech-
nology, a CT-Angiography of the heart
prognosis.”
delivers a dose of approximately 13 mSv,
which is not acceptable for early detec- Jörg Hausleiter, MD, Cardiologist,
tion. Anything less than 2 to 3 mSv Associate Professor of Medicine,
German Heart Center, Munich,
would be great.” Germany
“For the trauma In addition to the ultra low-dose Flash
protocol – which uses a pitch of above
surgeon, the 3 – the SOMATOM Definition Flash also
offers the Flash Cardio Sequence. This detector and the higher temporal reso-
faster you’re “intelligently triggered” step-and-shoot lution of the SOMATOM Definition Flash,
done with your method is not only suited to higher
heart rates, it automatically adapts to
we expect to have even better image
quality,” Hausleiter says. “It’s probably
scans, the better.” variations in cardiac rhythm, ensuring the most attractive alternative to the
that images are always acquired during pitch 3 Flash mode.”
diastole. CT myocardial perfusion imaging is
Konstantin Nikolaou, MD, Associate On top of coronary imaging it also another application that is catching the
Professor of Radiology and Section Chief
allows, for the first time ever, to calcu- attention of cardiologists. Today, it is
of CT Department, Ludwig Maximilian
University, Campus Großhadern, Munich, late ejection fraction to the new dual- possible to do such functional imaging
Germany step pulsing approach. at resting heart rates using Dual Energy.
“We’re already doing step-and-shoot The SOMATOM Definition Flash, thanks
with Adaptive Cardio Sequence on to a temporal resolution of 75 msec and
our current system, but with the larger a shuttle mode that covers the entire

Cover Story
myocardium, offers the possibility of 3A 3B

doing perfusion imaging at high heart
rates, even during exercise or pharma-
cologic stress.
“The role of CT myocardial perfusion
imaging is still evolving, but it is intrigu-
ing,” Hausleiter says. “This would give
us additional information on the severity
of the lesion and the hemodynamic
impact of that lesion. If we could deter-
mine that while the patient is still on the
table of the CT scanner, that would be
very beneficial.”
Single Dose Dual Energy

Dual Energy imaging is made possible
by the simultaneous operation of two
X-ray sources at different energy levels,
which enables differentiation of fat,
soft tissue, and contrast material on the
basis of their unique energy-dependent
attenuation profiles.
The SOMATOM Definition introduced
Dual Energy in 2005. Since then, the
3 Fast and reliable removel of calcifications in the entire vasculature with syngo
Food and Drug Administration has
Dual Energy Direct Angio: VRT (Fig. 3A), MIP (Fig. 3B).
cleared 10 Dual Energy clinical appli-
cations, an achievement only Siemens
can claim. Still, Dual Energy imaging is
underutilized in everyday clinical prac-
tice, in part because of a dose penalty
of about 20 percent in some scans e.g. material differentiation by 80 percent. Baltimore, MD, USA. “If you come up
in the case of obese patients. Second, it markedly reduces dose. with something new and it has the same
The SOMATOM Definition Flash could “The availability of a dose-neutral scan or lower dose – and yet provides all
change all that. A new Selective Photon is likely to spark renewed interest in sorts of additional information – that
Shield pre-filters high kV X-rays, re- Dual Energy,” says Elliot Fishman, MD, becomes very exciting. This new scanner
moving low-energy photons. This has a professor of Radiology and director has the potential for raising the bar.”
two beneficial effects. First, it improves of Diagnostic Imaging and Body CT at At the same time, new features will
energy separation and, therefore, Johns Hopkins Medical Institutions, make Dual Energy scanning easier to
“The availability of a dose-

neutral scan is likely to
spark renewed interest
in Dual Energy.”
Elliot Fishman, MD, Director of Diagnostic Imaging and Body CT,
Johns Hopkins Medical Institutions, Baltimore, MD, USA

Cover Story
4A 4B
4 X-CARE reduces direct exposure of dose sensitive organs, e.g. minus 40% for breast tissue – while maintaining a homogeneous
image quality over the entire scan field of view.
use in everyday routine. For example, that automatically results from the high dose. The idea is to acquire the dataset
better image processing, including zero- table speed, the scanner has several at a low dose, which results in noisy
delay bone removal, will save time. other dose-conscious features. The Se- images. Through repeated reconstruc-
Increased tube power and a wider field lective Photon Shield and the ECG-puls- tion steps, image artifact and noise are
of view on the second detector will also ing in the Flash Cardio Sequence are removed, and quality is improved.
expand the possible range of patients just two. In addition, the new scanner “I’m impressed by the concept,” Kalender
and applications. Making Dual Energy is equipped with Adaptive Dose Shield, says. “You can scan at a lower dose, and
images available on syngo WebSpace which blocks X-rays from the portion make up for the additional image noise
will enable radiologists to interpret Dual of the spiral that will not be used in im- using this new reconstruction method.”
Energy scans from any PC anywhere. age reconstruction. This amounts to a “For now, the main limitation to iterative
“This new scanner has new capabilities half-detector’s width at the beginning reconstruction is its need for massive com-
that could allow Dual Energy to become and end of each acquisition. In the case puting power,” Atiya says. “But we believe
a robust study that is part of a routine of cardiac scans, Adaptive Dose Shield that the iterative reconstruction holds po-
examination,” Fishman says. “And that cuts radiation dose by as much as 25 tential and we will be coming up with a
this system is better, that it lowers percent. first set of applications in the near future.”
the radiation dose, and speeds up work- The scanner also features organ-specific
flow – that will make a tremendous dose protection, a technique that en- Medical writer Catherine Carrington holds
difference.” ables the radiologist to turn off the X-ray a master’s degree in journalism from the
University of California Berkeley and is based
tube during the portion of the gantry ro- in Vallejo, CA.
Organ-Sensitive Dose tation that would directly expose radia-
Protection tion sensitive organs, such as the breast,
Further Information
thyroid gland, or eyes.
The SOMATOM Definition Flash is de- Siemens is already looking to the future, www.siemens.com/somatom-
signed with dose savings in mind. developing iterative reconstruction tech- definition-flash
Besides the reduced radiation exposure niques that promise to further reduce

More than 400 Dual Source
installations worldwide
More than 100 peer-reviewed publications
Q Faster than every beating heart – with 83 ms true temporal resolution and
no need for beta-blockers, proven by more than 25 publications.
Q Full cardiac detail at half the dose – down to 2.5 mSv average dose,
proven by 5 publications.
Q One-stop shop in Acute Care – fast diagnosis to save time,
lives and money, proven by 4 publications.
Q Beyond visualization with Dual Energy – with 10 released applications and
Optimum Contrast, proven by 14 publications.
Q etc.
More than 400 SOMATOM Definitions are in clinical use worldwide, not only for daily clinical routine, but also for cutting-edge research. Meanwhile,
more than 100 peer-reviewed publications have been released, documenting Dual Source CT, focusing on DSCT´s unique strengths.
Dual Source CT on Scientific Center Stage

By Peter Seitz
Business Unit CT, Siemens Healthcare, Forchheim, Germany
Seldom does a new technology find its resolution of 83 ms and thereby, for the segments when using Dual Source CT.
way to a leading role in the world of first time, allowing robust cardiac imag- In all cases results remained above 96%.
scientific publications within only a few ing without beta-blockers. The clinical First studies even suggest that Dual
months. But after Dual Source CT was effect of this improvement has been Source CT allows for robust diagnosis
announced at the RSNA 2005 and made best demonstrated by Achenbach et al1 of significant stenosis in patients with
available commercially in summer 2006, in a randomized study of 200 patients. atrial fibrillation2,3, in the past a
it took over center stage almost immedi- 100 patients were examined using common rule-out criteria on single
ately. In the 2 years since then, more single source, 64-slice CT and the other source CT.
than 100 peer-reviewed articles have 100 with Dual Source CT. Within both But while the impact of DSCT on in-
already been published. Dual Source CT sub-groups around half of the patients creased temporal resolution is unques-
virtually introduced the topic of Dual received oral and intravenous beta- tioned, the more robust cardiac CT
Energy CT into most major congresses – blockade for a target heart rate ≤ 60 imaging gets the more it is brought into
and scientific discussions regarding beats/min, whereas the other half did the spotlight on the topic of radiation
Cardiac CT were brought to a whole not receive any pre-medication. Results exposure. Recently a special focus has
new level. This impressive success was confirmed a clear advantage of Dual been put to the question: What dose
crowned by the offer to devote an entire Source CT, no matter if the analysis was values can be reached reliably with a
issue of the European Journal of Radio- performed per-patient, per-vessel or per- low-dose approach such as a step-and-
logy on Dual Source CT, resulting in segment. In the case of single source shoot mode?
12 new publications featured in the CT, with beta-blockers 91-93% of all In their study on 120 patients, Scheffel
December 2008 issue. studies proved evaluable. Without beta- et al.4 from the University of Zurich
blockers this number dropped to 69- found that DSCT allows mean effective
DSCT in Cardiology 82%, depending on the analysis doses of 2.5 mSv, while 98% of all seg-
The foremost capability responsible for approach. On the other hand, imaging ments provided diagnostic image quality
this development is, without doubt, with or without beta-blockers didn’t and 97% of significantly obstructed
the ability of Dual Source CT to utilize show a significant impact on the num- segments were classified correctly,
2 X-ray tubes to achieve a true temporal ber of evaluable patients, vessels or compared with conventional coronary

News
angiography. While further improve- The average length of stay could be et al. from Medical University of South
ments on dose reduction are clearly shortened to 8.1 hours vs. 20.9 – 30.3 Carolina6. They evaluated this approach
warranted, these results confirm that hours for the other strategies. As the on 35 patients, and correlated the
effective DSCT doses below average number of CT systems in dedicated emer- results with SPECT. Initial results are
diagnostic catheter doses are becoming gency department environments is in- promising, proving 91% accuracy in
more and more common. creasing, further studies with larger pa- comparison with SPECT (per-segment)
tient groups are under preparation. for detecting any type of myocardial
DSCT in Acute Care ischemia.
A completely different approach is taken DSCT and Dual Energy In the meanwhile, more than 400 Dual
by recent publications on DSCT in Acute Finally, a whole new field of research Source scanners have been installed
Care, where, next to clinical effective- was opened with the introduction of worldwide, generating a rising number
ness, economical aspects are considered DSCT Dual Energy, made possible by of publications on the cutting-edge
increasingly important for the everyday applying different energy spectra (of of CT imaging.
question of evaluating patients with 80 kV and 140 kV) to the two X-ray
suspected acute coronary syndrome. tubes simultaneously. The results are
Researchers from the University of Penn- two spiral data sets acquired simultane-
sylvania compared conventional ap- ously in a single scan providing diverse
proaches, e.g. serial cardiac markers as information that permits differentiation
well as stress testing, with the outcome or characterization of the imaged tissue
Sources
of an immediate CT coronary angiogra- and material. Possible applications are,
1 Achenbach S et al. – JACC, VOL 1, NO. 2, Jan
phy5. While the immediate CTA approach e.g. an accurate subtraction of bone in 2008.
was as safe and able to identify as many CTAs or iodine removal from liver scans 2 Oncel D et al. – Radiology 2007 Dec; 245(3):703-
patients with coronary artery disease as to generate a virtual unenhanced image. 11.
3 Wang Y et al. – Eur J Radiol Nov 2008.
the other approaches, it resulted in the A brand-new application, the visualiza-
4 Scheffel H et al. – Heart Jun 2008.
lowest cost and shortest length of stay. tion of iodine content in the myocardial 5 Chang AM et al. – ACADEMIC EMERGENCY MEDI-
Overall, an immediate CTA reduced aver- blood-pool to diagnose perfusion de- CINE 2008; 15:649-655.
age costs to $1,240 vs. $2,318 - $4,024. fects, has just been evaluated by Ruzsics 6 Ruzsics B et al. – Eur Radiol 2008 June.
First U.S. Payor Reimburses CT Colono-

graphy (CTC) for Screening
By Joachim Buck, PhD, Business Unit CT, Siemens Healthcare, Forchheim, Germany
colorectal cancer and detection of large in the United States to reimburse VC

and medium-sized polyps. Results from screening. BCBSDE has agreed to reim-
other VC trials (IMPACT, Munich Colorec- burse CHC of America’s patent-pending,
tal Cancer Prevention Trial and Wiscon- integrated colon screening model, fol-
sin Trial) have also shown positive re- lowed by therapeutic colonoscopy for
sults for VC. Thus, the American Cancer those with discovered polyps. They pro-
VC has been validated as a screening test for Society (ACS) recently added virtual vide a single, bundled, episode-of-care
colorectal cancer and detection of large and colonoscopy to their new colorectal can- payment ‘per screening event’. The pay-
medium-sized polyps. cer screening guidelines. This decision or believes that it is essential to have the
is, for the first time, triggering reim- capability to provide same-day, same-
According to the ACRIN* 6664 trial, CT bursement for colon cancer screening in prep therapeutic colonoscopy for pa-
Colonography (CTC) – respectively Virtu- the U.S. Colon Health Centers of Ameri- tients who need it. This is the first step
al Colonoscopy (VC) – was comparable ca (CHC), a provider of VC services for toward future reimbursements in the
to the gold standard colonoscopy for gastroenterology specialists, has signed U.S.
screening intermediate and large-sized a contract with Blue Cross Blue Shield of
polyps. Based on these results, VC has Delaware (BCBSDE). This agreement rep- *ACRIN (American College of Radiology Imagin
been validated as a screening test for resents the first major commercial payor Network).

News
The SOMATOM Definition AS 20-Slice Configuration

By Jan Chudzik, Business Unit CT, Siemens Healthcare, Forchheim, Germany
Since its introduction at RSNA 2007, the onsite upgradeability, the 20-slice con-
SOMATOM® Definition AS, the world’s figuration is able to grow with clinical
first adaptive scanner, has already be- needs, allowing a continuous expansion
come the fastest selling single source CT of radiology offerings in the future, im-
in Siemens history with 200 installations proving the services for referring physi-
worldwide within the first months from cians and patients. The new SOMATOM
market introduction. In its multiple con- Definition AS 20-slice configuration,
figurations (40-, 64- and 128-slice), it with its large 31 inch (78 cm) gantry
describes another success story for bore, the optional 660 lbs (300 kg)
Siemens Healthcare. At this year’s RSNA, patient weight capacity and its high scan
the Definition AS platform introduced a speed, is designed perfectly for high
further expansion with its new 20-slice patient throughput, even for obese pa-
configuration attracting the interest of a tients. With this new SOMATOM
wide range of healthcare facilities by Definition AS family member, clinicians
providing easier and more economical have access to excellent image quality
access to the latest innovations of high- and clinical capabilities in a very afford-
end CT. This enables a broad spectrum able and compact unit, greatly improv-
of clinical applications at a great price- ing patient care. The new SOMATOM Definition AS 20-slice configuration
performance ratio. And, with its full,
4D Noise Reduction: New Filter Setting for

Dose Decrease and Image Enhancement
By Rainer Raupach, PhD, Business Unit CT, Siemens Healthcare, Forchheim, Germany
With the introduction of multi-slice CT scans. Applying a newly developed, portion of different time points, the dose
making scans with large volume cover- elaborate filtering technique, the radia- can be used more efficiently, thereby
age possible, dynamic CT examinations tion dose of dynamic CT exams can be leading to an image with significantly
have stepped into clinical routine. With reduced by a substantial amount, while reduced noise and improved image
modes like organ perfusion or 4D CT, retaining equivalent diagnostic informa- quality.
angiography time series* can be taken, tion. The procedure is as follows: At a The effect of this method can, on the
exposing a large part of the body to fixed time point, the data from the time one hand, be utilized to reduce radiation
time-dependent X-rays. Therefore, pa- series mentioned above are separated dose while obtaining the same image
tient dose has to be considered carefully. into soft contents and sharp edge infor- quality as without 4D Noise Reduction.
4D image data are routinely acquired by mation, containing the major amount On the other hand, the spatial resolution
means of multi- or adaptive 4D spiral of image noise. By combining the sharp of the CT perfusion images can be in-
creased or the reliability of the perfusion
1A 1B parameters improved while maintaining
1 CT perfusion evalua-
the same dose (Fig. 1). In the perfusion
tion (blood volume) of the
original images (Fig. 1A) study shown, the perfusion parameters
and results after image of many pixels cannot be evaluated
enhancement (Fig. 1B). due to noise (Fig. 1A). Using 4D Noise
The number of pixels where Reduction mode, these pixels can be
perfusion parameters could
not be determined due to
reduced, yielding tissue perfusion infor-
noise (violet) is significantly mation with higher quality (Fig. 1B).
reduced. * Images from a defined body region or organ
during a defined period of time.

News
The Success Story of the

SOMATOM Emotion Continues
By Steven Bell
In June 2008, the Portsmouth Imaging “Both patients and physicians like
Centre in Rhode Island installed the knowing that image clarity is
6,000th SOMATOM® Emotion system – excellent.”
making this system the most popular With the SOMATOM Emotion, the
CT in the World. The success of the combination of high-end image
SOMATOM Emotion continues with quality, efficient gantry design, low
installations now heading towards running costs, high reliability and
6,500. “At our new Portsmouth Imaging the smallest installation space re-
Centre, we use a Siemens SOMATOM quirements, underpin the success.
Emotion CT scanner because it pro- These factors were some of the
vides speed and extremely high re- driving forces behind Newport
solution that is essential for fast and Hospital’s purchasing decision and Simon Shaw (US Product Marketing Manager
for SOMATOM Emotion, right) hands a
accurate diagnoses,” said Todd Cipriani, the decisions of over 6,000 other plaque commemorating the 6,000th SOMATOM
vice president, Professional Services, SOMATOM Emotion customers. Emotion installation to David Card (CT/MR
Newport Hospital. Manager, Portsmouth Imaging Center, left).
3D on the fly with new syngo WebSpace 2008B

By Christoph Hachmöller, MD
Previously, radiologists who were seek-

ing additional reconstructions in coro- Image Reconstructions on Demand
nal, sagittal or other planes to support 1 Auto send images
their diagnosis, needed to call the tech-
nologist at the scanner and request Call for additional image reconstructions 2
them. The technologist then needed to
3 Manually create and send additional
manually start the recon jobs and send image reconstructions
the images to the PACS – a time con-
suming and cumbersome procedure,
not to mention the additional amount Interactive 3D on the fly
of data that needed to be archived in
the PACS. Now, with the latest function- 1 Auto send images
al enhancements of syngo WebSpace
2008B, this annoying work step can
be eliminated. The time consuming,
traditional “image reconstructions on syngo WebSpace 2 Interactive 3D on the fly
demand” are being replaced by the
interactive “3D on the fly”. With a click
on the syngo WebSpace button in the
PACS environment, the same case of syngo WebSpace can provide a coro- to be prepared beforehand. They are
opens in 3D at the very same work- nal, a sagittal or any other view on the dynamically created on the fly by syngo
place. The interactive 3D functionality image data. These views do not need WebSpace.

News
Proactive Tube Failure Prediction: Siemens

Guardian Program now Includes TubeGuard for
the SOMATOM Definition Family
By Ulrike Dräger-Klar and Holger Reinsberger
Business Unit CS, Siemens Healthcare, Erlangen, Germany
including TubeGuard for the SOMATOM®

Reactive service
Definition family is Siemens’ new pro-
Tube failure – without Siemens Guardian Program™ including TubeGuard
active solution that allows prediction of
Tube break down
potential tube and system failure in
services request Hard-down of system advance.
k unpredicted tube failure
Continuous and tube replacement How does it work?
Examination
Cooling, vacuum, filament, anode,
rotation, focal spot and high voltage all
have a significant impact on the opera-
Proactive service – continuous monitoring of various sensor data
tion of the CT tube. Once TubeGuard
Tube failure – with Siemens Guardian Program™ including TubeGuard
has been installed, sensors proactively
monitor the tube functions via real-time
Scheduled tube exchange
triggered by Siemens Soft-down of system data flow with Siemens Remote Service
k planned and (SRS) – the efficient and comprehensive
Continuous scheduled
Examination downtime infrastructure for medical-equipment-
related remote services. By doing this,
deviations can be detected before prob-
CT systems are crucial for clinical diag- availability. But a tube can also fail, lems occur. One example of sensor
nosis and important to support emer- causing a hard-down of the CT system. monitoring is the measurement of cool-
gency processes like trauma patient This can lead to disruptions of the clini- ing performance. The measurement via
examinations. Doctors as well as patients cal workflow, and the immediate need SRS is based on sensor data of oil tem-
are dependent upon the reliable avail- for patient rescheduling or transfer to perature, gantry temperature and oil
ability of their systems. The CT tube is a another department. This was the moti- pressure. If the cooling performance
component with a usage-dependent life vation for a new and innovative idea: falls under defined limits, the tube
span. It is absolutely vital to system the Siemens Guardian Program™ could possibly fail, Siemens will schedule
a tube change at a convenient time for
the customer before the failure occurs.
Measurement of Cooling Performance
This program brings it all together:
measured and calculated lifetime [rel. units]
1,2
state-of-the-art technology to assess and
transfer information to the Siemens
Service Center, expert analysis through
proactive triggered tube change
0,8 our support engineers, and the develop-
ment of a plan together with the cus-
tomer to convert system downtime into
0,4 a planned service visit.
With the Guardian Program including
TubeGuard, the majority of all tube
0
0 20 40 60 80 100 120 140 time [rel. units] failures are predicted well in advance,
proactively and efficiently.

1A 1B
1 Biograph mCT
(Fig. 1A) offers
excellent resolution
and contrast in
PET•CT imaging,
such as in this pri-
mary squamous cell
carcinoma in the
left lung with hilar
lymph metastases
(Fig. 1B).
Molecular CT – Imaging in Living Colors

Siemens Biograph mCT opens doors to earlier disease detection and inte-
grated diagnostics in radiology.
By Claudette Yasell, Business Unit MI, Siemens Healthcare, Hoffman Estate, USA
The recent past has seen monumental widely available, offering personalized advanced PET technology available, in-
advances in CT technology, proving the and very specific information about cluding features such as unique PET
clinical value of multislice capabilities, patients’ diseases. extended field of view and ultra high-
speed and resolution. But even exquisite Patients will benefit from higher quality definition imaging technology with time
CT images can leave unanswered clini- diagnostic information that can lead to of flight reconstruction, enabling the
cal questions and could benefit from definitive changes in disease manage- possibility of a routine, five-minute PET
the addition of molecular contrast to ment. Providers could benefit from the scan. It offers the ultimate in PET image
add metabolic information. Using the potential cost savings from the purchase quality and count rates for faster, more
most advanced PET (positron emission of one all-encompassing scanner like comprehensive scanning, and provides
tomography) technology combined the Biograph mCT instead of two, a PET maximum patient comfort and work-
with Siemens adaptive CT technology scanner and a CT. flow efficiency. Latest applications in
(known from SOMATOM Definition AS) Biograph mCT was specifically devel- oncology from CT and PET include the
makes Biograph mCT the crossover oped for an integrated imaging environ- ability to delineate target volumes
scanner that is destined to change ment – designed to obtain functional, for diagnosis, staging and re-staging of
the way radiology looks at integrated anatomical and molecular information cancer, providing exquisite anatomical
diagnostics. from one non-invasive diagnostic exam. detail plus a measurement of cell
To move oncology forward, the next Using Siemens premium CT technology, metabolism. Future functionalities may
innovation in CT should include a it adapts to virtually any patient and include correlation of information about
“smart” contrast agent. The concept of clinical need for higher resolution, con- organ perfusion derived from CT and
using molecular contrast with PET and trast and speed. Biograph mCT comes tumor metabolism derived from PET.
CT has already been applied in the in a powerful, small package. It boasts Physicians as well as patients will bene-
molecular imaging arena with unprece- a large bore, short tunnel and fit from the valuable information pro-
dented success. With this knowledge a very small footprint for unparalleled vided by molecular CT.
in hand, together with the increasing patient care and comfort. Biograph mCT
demand for PET, asserting that every CT is available with up to 128 slices and
can have molecular imaging capabilities a table that can accommodate patients
clearly addresses the need for more up to 500 pounds (227 kilograms).
effective imaging in oncology. Mole- In addition to cutting-edge CT techno-
cular CT makes this technology more logy, Biograph mCT maximizes the most

Business
As Radiation Dose Goes Down,

Attractiveness of CT Rises
In recent years, Siemens scanners have steadily decreased radiation dose
in CT exams, making CT use in everyday diagnostics all the more interesting.
Now, for example, cardiac CT can be performed with doses as low as the
“gold-standard”, cardiac catheterization and below, as studies at the Univer-
sity Hospital Zurich have shown.
By Oliver Klaffke
Hatem Alkadhi, MD, radiologist and His findings are in line with the general Marincek, MD, head of radiology at
associate professor at the University trend in CT in recent years. The radia- the University Hospital in Zurich. “For
Hospital Zurich, is excited. Together tion dose needed for reliable diagnoses the sake of our patients, we will always
with his colleagues he performed tests was considerably reduced when opt for the latest technology that offers
on patients with cardiac computed Siemens, the leader in the field of CT, the best results with the lowest possible
tomography (CT) utilizing two of pushed the frontier of progress forward dosage,” he says. This was one of the
Siemens newest high-end scanners, with new Siemens dose-saving technol- main reasons why he and the hospital
the SOMATOM® Dual Source Definition ogies such as the Adaptive Dose Shield, decided to purchase two Siemens high-
and the SOMATOM Definition AS. CARE Dose4D, ECG-Pulsing and Adaptive end CT scanners, the Dual Source
The radiation doses required were no Cardio Sequence that are used today SOMATOM Definition and the
higher than cardiac catheterization or to deliver optimal images with as low SOMATOM Defintion AS. Both of them
scintigraphy. “This opens totally new dosage as possible. This, of course, is provide unique technologies to signifi-
perspectives for cardiac diagnostics of great benefit for patients. “Dosage is cantly reduce patient exposure in both
with CT,” Alkadhi says. “Excellent ima- always an issue, especially for children clinical routine and advanced applica-
ges and low dosage is what physicians and patients who need a number of tions and, therefore, assure better pa-
have always wanted,” he adds. consecutive CTs,” says Prof. Borut tient care.
Economic benefits of using CT

In addition to the main health issues
criteria such as dose reduction, there
“Excellent images are significant financial reasons for in-

vesting in CT. This is especially true for
and low dosage cardiac diagnostics. ”Through the in-
creased use of CT for cardiac diagnos-
is what physicians tics, a large hospital can clearly reduce
costs,” says Marincek. The increased use
have always of computed tomography has a great
wanted.” number of advantages for hospitals.

“With a stronger emphasis on CT, it’s
possible to save on expensive invest-
Hatem Alkadhi, MD,
Radiologist and Associate Professor, ments for the procurement and mainte-
University Hospital Zurich nance of various other equipment that,
so far, has been primarily used for diag-
nostics,” he points out.

Business
“ Dosage is always an issue,

especially for children and
patients who need a number
of consecutive CTs.”
Prof. Borut Marincek, MD,
Head of Radiology,
University Hospital Zurich
For his department at the University This was possible as the result of tech- mainstream of clinical routine making
Hospital in Zurich, Marincek calculates nical advances in Siemens’ CT techno- the SOMATOM Definition and the
that CT represents lower procurement logy and through the development of SOMATOM Definition AS scanners
and infrastructure costs than an addi- intelligent software applications for CT. intelligent buying decisions. “With
tional gamma chamber or further The tests in Zurich used the Siemens future purchases, dose will be one
installations for cardiac catheterization SOMATOM Definition, a CT equipped of the most important criteria when
testing. His conclusion: “The costs of with two X-ray tubes functioning simul- deciding in what system to invest,”
the individual tests are much lower with taneously. “It is a significant advance- Marincek says.
CT than with the other procedures.” ment that dose can be kept so low
using for example the step-and-shoot
As in other fields of CT, the dosage procedure,” says Alkadhi. This and also Oliver Klaffke is a science journalist in
needed in cardiac diagnostics can now other new features, such as the Adap- Switzerland.
be kept very low. “Radiation exposure is tive Dose Shield, are implemented as
no longer a reason to refrain from using well in the SOMATOM Definition AS,
CT for cardiac testing,” asserts Alkadhi. offering dose reduction in every spiral
exam. This means that the patient is not
The Zurich-based physicians completed subjected to radiation not needed for
their tests using very low doses. On the diagnosis.
average, only 2.5 mSv were required
to obtain high-quality, meaningful “Using the lowest possible dose is of “With future pur-
images. As a result, the radiation expo- definite benefit to the patient,” Alkadhi
sure remained well under the values says. Because computed tomography chases, dose will
that have previously been typical with
CT-Angiography. Depending on the test
technology will surely be more fre-
quently used in the future, dose reduc-
be one of the most
conditions, these have ranged between
9 and 21 mSv. “The radiation doses of
tion becomes a more compelling issue.
This is one of the reasons Zurich Univer-
important criteria
our tests are below those currently sity Hospital always opts for the latest when deciding in
necessary with cardiac catheterization,” technology in computed tomography. It
says Alkadhi. He and his colleagues should not be assumed that dose reduc- what system to
applied CT to 120 patients suspected of
coronary heart disease. They were able
tion has been accomplished only in
this area. Such Siemens innovations are
invest.”
to obtain diagnostically valuable and used today to deliver optimal images Prof. Borut Marincek, MD,
unrivaled data at minimal radiation with as low dosage as possible. Head of Radiology,
exposure. All together, they bring CT into the University Hospital Zurich

Business
Making a Case
for the SOMATOM Emotion
The long list of benefits reported by the staff at Northside Hospital in
Atlanta, Georgia, since five new SOMATOM Emotion scanners were installed
in January 2008 reads like a testimonial – from exceptional images
and increased throughput to patient satisfaction and financial benefits.
By Sameh Fahmy
With 14 imaging facilities spread across

a large metropolitan area, Northside Hos-
pital in Atlanta, GA, needed a CT solution
that would reliably and efficiently allow its
staff to image a large volume of patients
with a broad range of medical needs.
“Our goal is to make sure that our health-
care is convenient and patient focused,
while also providing our referring physi-
cians with high-quality imaging, regard-
less of location,” says director of radiology
services Deidre Dixon.
Northside originally had a variety of
single-, four- and six-slice CT scanners at
its facilities and sought to upgrade with
a solution that would provide superior
image quality, rapid workflow, and maxi-
mum return on investment. In January
2008, after a collaborative decision pro-
cess, they chose to install five Siemens
SOMATOM® Emotion CT scanners. As
a result, Northside has been able to
expand its imaging services while gain-
ing efficiencies and measurable financial
benefits from faster workflow. “We were
looking for a workhorse scanner,” says
radiologist Carolyn J. Weaver, MD, “and
the SOMATOM Emotion has proven to
“16-slice is a configuration that of- be just that.”
fers all the necessary protocols and The 16-Slice Choice

Weaver says the hospital’s previous scan-
offers them efficiently and with ners limited the protocols that Northside
good diagnostic capabilities.” could offer at some locations. “Configu-
rations greater than 16 slices allow for
Carolyn J. Weaver, MD, Radiologist at the Northside Hospital in Atlanta cutting-edge applications,” she says, but
Northside needed a scanner that could

Business
“Our goal is to make sure that

our healthcare is convenient
and patient focused, while also
providing our referring physi-
cians with high-quality imag-
ing regardless of location.”
Deidre Dixon, Director of Radiology Services
at the Northside Hospital in Atlanta
capably handle their day-to-day needs. of July 2008, more than 6,000 customers Advice to Other Facilities
“For basic outpatient scanning, 16-slice have installed the system, making it the With their purchase behind them, ad-
is a configuration that offers all the most popular CT scanner in the world. ministrators and technicians at North-
necessary protocols and offers them In many cases the SOMATOM Emotion side Hospital are now realizing the
efficiently and with good diagnostic can be installed in only three days while, benefits of a decision that was truly
capabilities,” Weaver says. in contrast, many other scanners require collaborative. Dixon recommends visit-
In addition to superb image quality, more than a week to install. Longer ing many sites and asking users about
Northside wanted a system that would installation results in greater patient downtime and how well scanners per-
efficiently handle its large volume of CT rescheduling and inconvenience. form day-to-day. Image quality must
procedures. In 2007 alone, Northside The ease of installation is facilitated by meet the expectations of radiologists,
performed more than 78,000 CT exams. the remarkably small, 18 square meter and she recommends choosing one
The expansion of services after installa- (194 cubic feet) footprint of the system. vendor so that technologists can easily
tion of the SOMATOM Emotion 16 sys- Weaver says the compact gantry design share information and support each
tems has also resulted in a financial ben- also creates a more relaxing environment other. The amount of support a vendor
efit to the group by increasing patient for patients. “Anytime a patient sees offers in optimizing applications is im-
volumes. One imaging center, for exam- something that is overwhelming in size, portant, too, she says.
ple, increased patient capacity by 71 per- particularly in proportion to the room it’s “We feel that partnership is a key com-
cent after upgrading from a single-slice in, it creates anxiety,” Weaver says. “And ponent of the vendor selection process,”
scanner to the SOMATOM Emotion 16. that could make it more difficult to get an Dixon says. “We want to feel that the
The ability to expand services and IV and make the whole experience more vendor has knowledge of our core busi-
increase throughput aren’t the only difficult.” ness strategy and based on that knowl-
features that boost return on invest- Downtime can be costly for hospitals, but edge can suggest products that fit with-
ment. Another reason is that the Dixon points out that it is also a in our organization to make sure
SOMATOM Emotion has an economical major inconvenience for patients. “If a pa- patients receive the best care possible.
price/performance ratio and minimum tient has taken a day off work to have a We’re very pleased with our collabora-
lifecycle costs. The SOMATOM Emotion CT and comes in to find that there’s tive relationship with Siemens.”
has the industry’s lowest power supply a machine issue, it not only impacts us
demand, requiring 70 kVA versus 90 to but, subsequently, also the patient,”
100 kVA for other vendor’s 16-slice scan- Dixon says. “Even if we’re able to get Sameh Fahmy, is an award-winning
ners. Its low heat dissipation of less than the machine up that same day, we’re freelance medical and technology journalist
based in Athens, Georgia, USA.
6.8 kW also reduces cooling costs com- left with customer dissatisfaction.” The
pared to competition. SOMATOM Emotion was built with reli-
ability in mind, and has not disappointed
Fast Installation and Minimal Further Information
the staff at Northside. “We’ve never had
Down Time any problems with it since we’ve had www.siemens.com/somatom-
Northside Hospital clearly isn’t alone it here,” says radiology supervisor Regi- emotion
in choosing the SOMATOM Emotion. As nald Moultrie. “It’s great.”

Business
syngo WebSpace: Command Central for

Fast and Efficient Image Processing
In a recent interview with SOMATOM Sessions at the Hospital Notre-Dame in
Tournai, Belgium, Jacques Kirsch, MD, head of the Department of Radiology,
shared his insights on the impact of syngo WebSpace on his facility’s diag-
nostic capabilities and workflow processes.
By Rita Wellens, PhD
“The essential
workflow advan-
tage of syngo
WebSpace is
centralizing and
making available
all diagnostic
solutions from
any workplace.”
Jaques Kirsch, MD, Head of the
Department of Radiology, Hospital
Notre-Dame, Tournai, Belgium
Jaques Kirsch, MD, reading at his integrated PACS / syngo WebSpace

workplace of the Hospital Notre-Dame.
syngo WebSpace is the latest innovation hospital located in the city of Tournai, colonography. In addition, many CT inter-
in client-server solutions for image pro- about 85 kilometers southwest of ventions, especially for pain therapy, are
cessing. Any personal computer or laptop Brussels. The hospital provides – consid- performed in the department. The radiol-
is turned into a diagnostic command ering its size, with 300 acute hospital ogy department operates a SOMATOM
center when linked up with syngo Web- beds – a respectable spectrum of radio- Definition Dual Source CT scanner and a
Space. It allows for real-time access to logical services and is equipped with SOMATOM Definition AS scanner.
image data – from anywhere*. state-of-the-art technology. The radiology The latest innovation in the department
department covers the entire spectrum of radiology is the syngo WebSpace
Radiology Department with of conventional radiology and CT. This client-server solution, which the head
Cutting-Edge Technology includes very sophisticated computed of the department, Jacques Kirsch, MD,
The Hospital Notre-Dame is a general tomography such as cardiac CTA and CT uses together with four staff radiologists.

Business
Easy Access to Image Data – Interactive 3D for Referring consuming and cumbersome procedure.
Everywhere Physicians Not to mention the additional amount of
The obvious benefit that Kirsch enjoys Kirsch explains this syngo WebSpace data that needed to be archived in the
while using syngo WebSpace is the fact advantage while beaming up 3D images PACS.
that many time-consuming steps have at the PACS console: “In pre-syngo times, With syngo WebSpace this annoying work
been eliminated, especially for the the diagnostic reconstructions of thick step can be almost entirely eliminated.
manipulation, retrieval and distribution slices would be transmitted through the The time-consuming traditional “recons
of thin-slice CT data. The radiologist central PACS and thus would be available on demand” can be replaced by the inter-
no longer has to walk to his 3D work- to all clinicians.” Radiologists performed active “3D on the fly.” With a click on the
station, and patient data no longer has to 3D reconstructions at a separate worksta- syngo WebSpace button in the PACS envi-
be physically moved to another location tion. When the pathology was obvious in ronment, not only the same case and the
for accessing at a particular workstation. the 3D image, they created a screenshot same image series open in 3D at the very
In addition, everyone always knows and sent it back to the PACS. Other clini- same workplace, but additionally, each
where to find the thin-slice data sets: cians could retrieve and review only this data set can now be presented in an indi-
on the syngo WebSpace server. screenshot, which of course could no lon- vidual, pre-defined screen layout which
“The essential workflow advantage of ger be manipulated. contains the planes to display such as
syngo WebSpace is centralizing and mak- “Totally new is not having to forward coronal, sagittal or any other plane, as
ing available all diagnostic solutions from clinicians those flat, static images any- well as the favorite hanging protocols
any workplace,” Kirsch emphasizes. ”The more,” says Kirsch. “Thanks to syngo and window settings.
fact that syngo WebSpace allows the WebSpace, we can send real-time, Kirsch adds that being able to share these
transfer of reconstructed thin-slice CT dynamic volumes! This is truly a spec- incredibly fast diagnostic capabilities with
volume data to the central server in real tacular innovative feature. Typically – colleagues anywhere has boosted overall
time offers radiologists the unique possi- pre-syngo WebSpace – only radiologists efficiency, patient care and staff satisfac-
bility of accessing the complete patient worked with volumes, and clinicians tion.
CT imagery – thick and thin slices – from worked with images. Now, clinicians In order to size up the positive impact
any connected workstation, and to have have full access to the fascinating world of syngo WebSpace as suggested by the
all of the software wizardry at hand. of volumes.” many superlatives he uses to describe
This immediate availability of CT images Radiologists working in 3D on syngo it, Kirsch is asked whether he could envi-
speeds up workflow and strengthens WebSpace can save a bookmark when sion operations at his department now
diagnostic capabilities as well as inter- the pathology becomes obvious on the without the syngo WebSpace solution.
vention planning. Multiple users can in screen. Later other clinicians just need He sighs heavily and answers, “It would
parallel access 3D diagnostics and may to click the bookmark in “their” syngo be very, very difficult – such a huge step
even hold 3D interactive sessions through WebSpace environment and immediately backward! syngo WebSpace has facili-
the internet.” get the same image that the radiologist tated so many aspects of our work. It
Of course, thin-slice data was already prepared for them. They now have an has seamlessly integrated with PACS and
being used by the radiologists before interactive 3D image. The difference is other existing IT applications, and it has
syngo WebSpace was in place, for exam- that the clinician can further manipulate given us such diagnostic flexibility. Not
ple, to evaluate very small lesions. How- the image in order to get a better under- being able to use this resource anymore
ever, another dedicated thin-slice server standing of the pathology. is quite unthinkable.”
had to be used to temporarily – eight to One can think about a comminuted Even after such a short period of time
nine months – store the large-volume fracture. The orthopedic surgeon highly in routine use, syngo WebSpace’s impact
thin-slice CT data. appreciates the ability to turn the fracture is already being felt in countless positive
syngo WebSpace has clearly done away around to get an estimation of the spatial ways at the Hospital Notre-Dame.
with the previously existing restrictions situation of the bone fragments.
tied into scanners and their networking.
*internet connection required.
“We do not need to switch to another on the fly Recons
workstation or room – we have every- So far, radiologists who were seeking Rita Wellens, PhD, is a medical writer and clini-
thing right at our fingertips. In other additional reconstructions in coronal, cal research consultant residing in Belgium.
words, once syngo WebSpace was con- sagittal or other planes to support their
nected to the network, it started func- diagnosis, needed to call the technologist
Further Information
tioning as a ‘central dispatch.’ syngo at the scanner and ask for additional
WebSpace is totally integrated into reconstructions. The technologist needed www.syngo-webspace.com
PACS – I rate that as a feat of genius,” to manually start the recon jobs and then
Kirsch says. send the images to the PACS – a time

Clinical Results Cardiovascular
Case 1
Coronary CTA with Flash Spiral Scanning
in 300 msec Scan Time
By Stefan Achenbach, MD* and Andreas Blaha**
*
Department of Cardiology, University of Erlangen-Nuremberg, Erlangen, Germany
**
HISTORY DIAGNOSIS
A 58-year-old male patient with atypical triggering in combination with Flash After determination of the contrast
chest pain and a family history of pre- Spiral Cardio. This new heartbeat- transit time using a test bolus approach,
mature coronary artery disease was controlled scan mode allows ultrafast coronary CTA was performed in cranio-
referred to the cardiology department spiral acquisition as a direct result of caudal direction after injecting 60 ml
to rule out coronary artery disease. having 2 X-ray tubes, simultaneously iodine contrast agent followed by a
Coronary CT-Angiography (CTA) was collecting information. The entire scan 50 ml saline chaser, both at 6 ml/s.
performed with a Dual Source CT in was acquired in just 300 ms. The mean heart rate of the patient was
low dose technique using prospective 52 beats per minute, which allowed
1 2
Neurology Clinical Results
1 Volume Rendered Image of the heart shows artifact free course of 2 Zoomed VRT of left main coronary artery (LM, white arrow) including left
the right coronary artery (RCA) including side branches. circumflex (LCX, blue arrow) and left artery descending (LAD, green arrow).

Cardiovascular Clinical Results
3A 3B 3C
3D 3E 3 Curved Planar Reformation (CMPR) of

the RCA. A series of crossectional recon-
structions of the artery shows no lumen
narrowing; only minor calcified plaques
proximal.
COMMENTS
for a particularly sharp visualization of Scanning with Flash Spiral Cardio The RCA and LAD revealed minor calci-
the coronary tree. Tube voltage was allowed accurate and artifact-free visu- fied plaques and non-calcified plaques
set at 100 kV, with a tube current of alization of the coronary arteries in without vessel stenosis. No further
280 mAs, which resulted in a very one ultrafast acquisition of 0.3 seconds. diagnostic method was needed to de-
low dose of 0.9 mSv. Coronary vessels The Flash Spiral Cardio scan mode com- termine an adequate diagnosis for the
were visualized free of artifacts. bined with the simultaneously working patient. The new scan mode allows
The left anterior descending coronary two X-ray tubes results in significantly to rule out coronary stenosis at an
artery (LAD) and the right coronary faster scan time, reducing the applied extremely low dose, making further
artery (RCA) showed minor calcified dose to the patient. diagnostic assessment unnessesary.
and non-calcified plaques without
lumen narrowing.
The left main coronary artery (LM) and
left circumflex coronary artery (LCX)
did not show any abnormalities.
EXAMINATION PROTOCOL
Scanner Flash Spiral mode
Scan area heart Spatial resolution 0.33 mm
Scan length 138 mm Slice width 0.6 mm
Scan time 300 ms Reconstruction increment 0.5 mm
Scan direction cranio-caudal Reconstruction kernel B26f
Heart rate 52 bpm Contrast
Tube voltage 100 kV Volume 60 ml
Tube current 280 mAs/rot. Flow rate 6 ml/s
Dose 0.9 mSv Start delay 26 s

Case 2
Low Dose Coronary CTA Reveals
High Grade Stenosis
By Stefan Achenbach, MD
Department of Cardiology, University of Erlangen-Nuremberg, Erlangen, Germany
1 HISTORY
A 38-year-old female patient with a his-
tory of former nicotine abuse, arterial
hypertension, and family history of pre-
mature coronary artery disease, hyper-
lipidemia, and apoplectic stroke was
referred to the Cardiology Department
with atypical chest pain to rule out
coronary artery disease.
Coronary CT-Angiography (CTA) was
performed with a SOMATOM Definition
Dual Source CT in low dose technique
using prospective triggering (Adaptive
Cardio Sequence), with a temporal reso-
lution of 83 ms and spatial resolution
of 0.33 mm.
1 VR visualization of the left circumflex (LCX) artery shows the stenotic segment (arrow). 2 syngo Circulation provides angio-
graphic like view of the entire heart.

DIAGNOSIS
After determination of the contrast tran- 3
3 Multi Planar Refor-
sit time using a test bolus approach, cor- mation (MPR) of left
onary CT-Angiography was performed in circumflex artery (LCX)
cranio-caudal direction injecting 75 ml and a crossectional
view of LCX.
of iodine contrast agent followed by a
50 ml saline chaser, both at 6 ml/s.
Due to the relatively low heart rate of
50 bpm, a sequential scan was chosen.
Tube voltage was set at 100 kV, with a
tube current of 215 mAs, which resulted
in a very low dose (1.6 mSv). Total scan
time was 8 seconds.
Coronary vessels were visualized free
of artifacts. The left circumflex coronary
artery (LCX) revealed a high grade
stenosis. The left anterior descending
coronary artery (LAD) and the right coro-
nary artery (RCA) showed no relevant
plaques or stenosis.
4A
4A Conventional
COMMENTS angiography prior to
percutaneous coronary
SOMATOM Definition Dual Source CT intervention (PCI).
allowed accurate and artifact-free visual-
ization of LM, LAD and RCA without
showing any stenosis or plaques, while
a high grade stenosis was demonstrated
in the left circumflex coronary artery,
at a total dose of 1.6 mSv. The patient
was referred to the angiography suite for
revascularisation of the circumflex artery
by percutaneous coronary intervention
(PCI).
Scanner SOMATOM Definition 4B 4B Conventional
Scan area heart angiography after PCI.

Scan length 104 mm
Scan direction cranio-caudal
Scan time 8s
Heart rate 50 bpm
Tube voltage 100 kV
Tube current 215 mAs
Dose 1.6 mSv
Spatial resolution 0.33 mm
Rotation time 0.33 s
Slice collimation 0.6 mm
Reconstructed
slice thickness 0.75 mm
Increment 0.6
Kernel B30f

Case 3
Dual Source CT:
Pediatric Congenital Heart Disease
By Suzu Kanzaki, MD, Masahiro Higashi, MD, Hiroaki Naito, MD, PhD
Department of Radiology and Nuclear Medicine, National Cardiovascular Center, Osaka, Japan
HISTORY
A 10-day-old newborn was referred to connection with obstruction, double The patient’s height was 43.5 cm, body
the pediatric cardiology department outlet right ventricle with complete weight was 2.4 kg, and mean heart rate
for treatment of his congenital heart atrioventricular septal defect, coarcta- during the scan was 142 bpm. Due to
disease. Examination by transthoracic tion of the aorta and bilateral superior the fast scan time of only 3 seconds,
echocardiography led to a diagnosis of vena cava. An ECG gated cardiac Dual he had to be sedated only by oral medi-
right isomerism, complex cardiac type Source CT scan was taken to help con- cation before the scan.
of total anomalous pulmonary venous firm the diagnosis.
1A 1B
1 Volume rendered display of the pediatric cardiac scan reveals aortic coarctation (Fig. 1A) and a complex cardiac type of anomalous pulmonary
venous connection even at a mean heart rate of 142 bpm (Fig. 1B).

2A 2B
40 mm
20 mm
2 Maximum Intensity Projection (MIP) of the aortic coarctation (Fig. 2A) and double outlet right ventricle (Fig. 2B).
DIAGNOSIS COMMENTS
The aortic coarctation and the anoma- The Dual Source CT images were of diag- age quality made precise surgery
lous pulmonary venous connection to nostic quality despite the small size of planning possible. This scan was per-
the abnormal site of the atrium are the patient’s heart and despite his high formed shortly after installation of
shown in the DSCT (Dual Source CT) heart rate of 142 bpm. The patient could the Dual Source CT at the radiation
images above. DSCT could confirm the not hold his breath, but scan time was center. With more experience, it’s
morphologies of these great vessels, short enough to suppress the influence possible to reduce the dose to pedi-
which were difficult to discern by of banding artifacts. The high CT im- atric patients by about 2/3.
echocardiography alone. The morphol-
ogy of the cardiac chambers was also
well detected as diagnosed by echo- EXAMINATION PROTOCOL
cardiography. Based on these findings,
palliative surgical correction was Scanner SOMATOM Definition
planned. Scan area thorax
Scan length 80 mm
Scan time 3s
Tube voltage 100 kV
Tube current 280 mAs
Rotation time 0.33 s
Reconstructed slice thickness 0.6 mm
Increment 0.5 mm
Kernel B25f

Case 4
Identification of Vessel Stenosis of the
Lower Leg by Dynamic CT-Angiography
Using the SOMATOM Definition AS+
By Wieland H. Sommer, MD and Konstantin Nikolaou, MD
Department of Clinical Radiology, University of Munich, Campus Großhadern, Munich, Germany
HISTORY
A 82-year-old man presented with peri- (Fontaine stage III). He was referred to the proximal parts of the lower extremity
pheral occlusive disease. A previous our radiology department to undergo and stenotic or occluded bypass vessels
occlusion of his left superficial femoral imaging of the vessels of the lower ex- may lead to asymmetric contrast
artery had been treated by a femoro- tremity. enhancement of the lower leg, which
popliteal bypass. A second bypass may cause a reduced diagnostic accuracy
became necessary after occlusion of the in the region of the calf, either by insuffi-
DIAGNOSIS
first. The patient now presented with cient contrast enhancement of one
an advanced stage of disease with Performing a standard peripheral run-off side or by venous overlay of the contra-
rest pain of his left lower leg and foot CT-Angiography, significant disease in lateral side.
To overcome this problem, an additional
time-resolved CT-Angiography of the
1A 1B
lower leg can be performed before the
standard lower-extremity run-off. In the
time-resolved examination, we cover a
range of 27 cm including the distal
popliteal artery, the trifurcation and the
proximal part of the three arteries of the
lower leg. Twelve phases are used, one
every 2.5 seconds. This enables a clear
depiction of the contrast dynamics and
there will always be a truly arterial phase
33 s* 40.5 s* on either side that is perfect for diagnos-
1C 1D
tic purposes.
In this patient, the standard peripheral
CTA protocol, covering the peripheral
run-off from the renal arteries down to
the feet, proved that the femoro-popliteal
bypass on the left side was not occluded.
The right superficial femoral artery
showed no significant stenosis, but was
rather aneurysmatic. However, in the
standard lower-extremity run-off, the
contrast enhancement of the lower leg
45.5 s* 50.5 s*
was asymmetric. On the left side, venous
1 Contrast enhancement of the lower leg at different points of time. The initial enhancement of overlay made an evaluation of the calf ar-
the left and right lower leg differs by 12.5 seconds. Without the venous overlay, it can be seen, teries difficult. On the right side, the low-
that only the fibular artery is contrasted in the left lower leg.
er leg was not yet sufficiently contrasted.
Adding the dynamic information of the
*After contrast media injection.

time-resolved CTA revealed an asymmet- 2A

2 VRT of lower extremity run-off:
ric enhancement of the lower leg. The The aneurysmatic right superficial
initial enhancement of the left and right femoral artery leads to a delayed
popliteal artery differed by 12.5 seconds. contrast enhancement of the right
On the left side, only the fibular artery lower leg. While the left lower leg
already shows venous overlay, the
was continuous, while the other two ves-
right side is not sufficiently con-
sels were not contrasted. On the right trasted.
side, the anterior tibial artery only
showed proximal enhancement and was
then occluded in the distal vessel seg-
ments.
2B
COMMENTS
In case of asymmetric proximal stenosis
or bypass grafts, the dynamic of the
blood flow of the lower leg may be influ-
enced such that at the time of image
acquisition, vessels of one side are not
yet enhanced or the other side shows
venous overlay. This problem can be
overcome by dynamic CT-Angiography,
using multiple phases in image acquisi-
tion. A further advantage of dynamic
CT-acquisition is the evaluation of ste-
nosis. Especially in patients with periph-
eral arterial disease, multiple confluent
or circular calcifications make it difficult EXAMINATION PROTOCOL
to estimate the residual lumen. The
time-resolved information of the arterial Scanner SOMATOM Definition AS+ SOMATOM Definition AS+
enhancement provides additional infor- CT-Angiography Adaptive 4D Spiral
mation for radiologists and vascular Scan area run-off lower leg
surgeons. Scan length 1335 mm 270 mm
In patients with peripheral arterial dis- Scan phases 12
ease, therefore a first dynamic scan Scan time 27 s 25 s
covering the lower leg was performed Scan direction cranio-caudal cranio-caudal
including the lower popliteal artery, the Tube voltage 120 kV 80 kV
trifurcation and the proximal and middle Tube current 130 mAs 165 mAs
portions of the fibular artery, as well as Dose modulation CARE Dose4D on CARE Dose4D off
the anterior and posterior tibial artery. In Rotation time 0.5 s 0.3 s
order to lower the radiation exposure the Pitch 0.6 Adaptive 4D Spiral
range was limited to 27 cm and the tube Slice collimation 0.6 mm 0.6 mm
current and the tube voltage were low- Slice width 0.75 mm 1.5 mm
ered to 165 mAs and 80 kV, respectively.
Reconstruction increment 0.5 mm 1 mm
Dynamic CT-Angiography, as it is
Reconstruction kernel B20f B30f
rendered possible by the SOMATOM
Contrast
Definition AS+, is therefore a helpful
Volume 100 ml 50 ml
tool for the evaluation of the lower leg
Flow rate 5.0 ml/s 5.0 ml/s
arteries in patients with known peri-
Post processing syngo InSpace 4D syngo InSpace 4D
pheral occlusive disease.

Clinical Results Oncology
Case 5
SOMATOM Definition Dual Energy
Scanning: Liver Imaging
with Optimum Contrast
By Satoru Kitano, MD, Nagaaki Marugami, MD, Toshiaki Taoka, MD, PhD, Kimihiko Kichikawa, MD, PhD
Department of Radiology, Nara Medical University, Nara, Japan
HISTORY DIAGNOSIS COMMENTS

A 55-year-old male was referred The hepatic arterial-dominant phase im- In the Dual Energy mode, two X-ray sourc-
for a Dual Source CT follow-up scan ages revealed numerous hyper-attenu- es can be operated simultaneously at dif-
after transcatheter arterial chemoembo- ating lesions (Fig. 1B). In the virtual ferent kV levels: 140 kV/80 kV. The results
lization (TACE) of his hepatocellular non-contrast image, the lesions showed are two spiral data sets acquired in a sin-
carcinoma (HCC) 6 years ago. A contrast almost iso-density with the liver paren- gle scan, providing diverse information
enhanced, dynamic CT scan of the abdo- chyma (Fig. 1A). From syngo Dual Ener- that allows one to differentiate, character-
men was performed on the SOMATOM gy (DE) Optimum Contrast images – im- ize, isolate, and distinguish the imaged tis-
Definition using Spiral Dual Energy proved even more after post-processing sue and material. Enhanced patterns of
for screening for recurrences after – a clear analysis of the visible lesions liver lesions can be visualized with the
chemoembolization. was possible (Fig. 1C). The patient was syngo Dual Energy Liver VNC (Virtual Non-
then diagnosed with multiple HCC Contrast) application. With the VNC-mode,
recurrence with liver cirrhosis.
1A 1B

Oncology Clinical Results
any contrast-medium generated contrast ored) against non-contrast enhanced be generated (Fig. 1C). Optimized differ-
disappears, with the remaining images in- structures (dark-colored) (Fig. 1B). With entiation of contrasted and non-contrast-
dicating just tissue related differences Optimum Contrast, an image that com- ed regions allows an even more detailed
(Fig.1A). The standard mixed view shows bines the high contrast of the 80 kV image and clearer diagnosis compared to the
iodine-contrasted structures (light-col- and the low noise of the mixed image can standard mixed view.
Scanner SOMATOM Definition
Scan area Abdomen Slice collimation 0.6 mm
Scan length 268 mm Slice width 1 mm
Scan direction cranio-caudal Reconstruction increment 0.5 mm
Scan time 10 s Reconstruction kernel 30 D
Tube voltage A/B 140 kV/80 kV Contrast
Tube current A/B 80 Eff. mAs/345 Eff. mAs Volume 100 ml
Dose modulation CARE Dose4D on Flow rate 3 ml/s Iodine 370 mgl/ml
Rotation time 0.5 s Postprocessing syngo DE Virtual Unenhanced
Pitch 0.8 Bolustracking
1C
1 Virtual Non-Contrast mode: any contrast-medium gener-
ated contrast disappears with the remaining images indicat-
ing just tissue related differences (Fig. 1A).
Standard mixed view: shows iodine-contrasted structures

against non-contrast enhanced structures (Fig. 1B).
Optimum contrast: an optimized noise-to-contrast ratio can

be reached, resulting in clearer and better contrasted image
quality (Fig. 1C).

Clinical Results Oncology
Case 6
Lung Parenchyma Analysis Software
with Automated Three-Dimensional
Quantification of Emphysema
By Myrna C.B. Godoy, MD and David P. Naidich, MD
Department of Radiology, New York University Medical Center, New York, USA
HISTORY
A 72-year-old male, a former smoker on ponded to emphysema (Fig. 1C, arrows). physema. In addition to routine lung vol-
home oxygen with history of severe It also confirmed the upper lobe pre- ume reduction surgery (LVRS),2,3 newer
COPD, was referred for a DSCT scan of dominance of the disease. interventional bronchoscopic techniques
the thorax for follow-up due to worse- Emphysema cluster analysis was auto- have emerged as potential alternatives,
ning dyspnea. The patient had bilateral matically performed, showing clusters including the placement of one-way en-
upper lobe lung volume reduction sur- class 1 (> 2mm3), class 2 (> 8mm3), class dobronchial valves and bronchial fenes-
gery 8 years ago. 3 (> 65mm3), and class 4 (>187mm3) co- tration.4,6 As emphasized in this case, in
lored in blue, green, yellow, and red, addition to preoperative evaluation, it is
respectively (Figs. 2A-B). The vast major- equally important to monitor disease pro-
DIAGNOSIS
ity of the emphysema in this patient gression following surgery. For this pur-
The DSCT scan with lung window setting was classified as cluster class 4, which pose, quantitative CT offers a potential
showed diffuse severe emphysema and involved 50.3% of the left lung volume alternative to less precise measurements
bullous changes were identified and 37.0% of the right lung volume of disease severity, including routine ex-
throughout the upper lobes. Severe cen- (Fig. 2C). ercise testing and PFTs. In addition, CT al-
trilobular emphysema was also identi- lows identification of potential complica-
fied including the lower lobes (Fig.1A). tions (including the development of lung
COMMENTS
Surgical clips and architectural distortion cancer in this especially predisposed pop-
from prior bullectomy were noted in the The syngo Lung Parenchyma Analysis ulation). In this regard, the availability of
upper lobes. software enables automated evaluation a “user-friendly” CT application will be of
syngo InSpace Lung Parenchyma Analy- of emphysema. It permits not only pre- critical importance in establishing quanti-
sis software was then used to quantify cise quantification of the amount of dis- tative CT as the gold standard for both
the amount of emphysema, characte- ease, but also classification of the foci of pre- and post-operative assessment of pa-
rized by lung attenuation below -950 emphysema by size and distribution of tients with emphysema. In this case, the
HU1. Results were stratified by lung the disease. The importance of these pa- degree of residual emphysema following
thirds (upper, middle and lower) to evalu- rameters resides in the preference for ac- lung volume reduction surgery estab-
ate the distribution of the disease. As curate quantification of disease when lished this patient as a candidate for lung
illustrated in Figs.1B and 1C, the soft- compared with routine pulmonary func- transplantation.
ware allowed the automatic three-di- tional testing for assessing potential ther-
mensional quantification of total lung apeutic options in patients with emphy-
volume and relative volume percen- sema. While characterization of large References
1 Gevenois PA et al. Am J Respir Crit Care Med
tages, mean lung density, and low and bullae indicates the possibility of treat-
1996; 154:187-192.
high attenuation volumes. The low at- ment with bullectomy, in fact, most pa- 2 Lederer DJ et al. Clin Chest Med 2007; 28:639-
tenuation volume (LAV) corresponds to tients present with either predominant 653, vii.
the volume of emphysematous lung and centrilobular or panlobular emphysema. 3 Fishman A et al. N Engl J Med 2003; 348:2059-
is displayed as a percentage of the total Over the past several years, a number of 2073.
4 Wan IY et al. Chest 2006; 129:518-526.
lung volume. In this case, the analysis innovative therapeutic options have been
5 Reilly J et al. Chest 2007; 131:1108-1113.
showed that 51.5% of the left lung and developed for treating patients with pre- 6 Cardoso PF et al. J Thorac Cardiovasc Surg 2007;
38.4% of the right lung volume corres- dominant upper lobe centrilobular em- 134:974-981.

Oncology Clinical Results
1A
2A 1B 1C
1 Lung parenchyma analysis: general analysis stratified into upper, middle and lower lung thirds. Axial CT scan at the level of the carina showing
severe emphysema with bullous changes in the upper lobes and centrilobular emphysema in the superior segments of the lower lobes (Fig. 1A).
Histogram showing severe emphysema bilaterally with upper third predominance in both lungs (Fig. 1B). Quantitative three-dimensional analysis
of lung volume, mean lung density, low and high attenuation volumes are displayed (Fig. 1C). The low attenuation volume (LAV %) indicates the
percentage of the lung with emphysema.
2A 2B 2C
2 Lung Parenchyma Analysis: Cluster classification stratified by thirds in the left and right lung. Axial and coronal reformats (Figs. 2A-2B) showing
emphysematous clusters, color-coded by size. The red color corresponds to the largest clusters (Class 4, ≥ 187 mm3). Results displayed in the table
(Fig. 2C) show the percentage of lung volume involved by specific cluster’s size. In this case there is severe emphysema characterized by Class 4
clusters involving 50.3% of the left lung volume and 37% of the right lung volume.

Scan area thorax Slice width 0.75 mm
Scan length 348 mm Reconstruction increment 0.5 mm
Scan direction cranio-caudal Reconstruction kernel B40
Scan time 8.2 s Slice collimation 0.6 mm
Tube voltage 120 kV Pitch 0.8
Tube current 160 qual. ref. eff. mAs Rotation time 0.33 s
CTDIvol 11.5 mGy Postprocessing syngo InSpace Lung
Parenchyma Analysis

Clinical Results Neurology
Case 7
Acute Left Hemispheric Ischemic Stroke:
Comprehensive Stroke Imaging Using
Neuro Volume Perfusion CT
By Ramona Finzel and Peter Schramm, MD
Department of Neuroradiology, University of Göttingen, Göttingen, Germany
HISTORY
A 75-year-old female patient with histo- Furthermore, a significant prolongation intra-arterial thrombolysis and to start
ry of arterial hypertension, diabetes of the mean transit time (MTT, Fig. 2C) a bridging therapy with 20 mg rt-PA
mellitus and absolute arrhythmia was and the time to peak (TTP) in both the immediately. Unfortunately, both throm-
admitted to the neurological clinic with complete MCA and ACA territories bolysis therapies were unsuccessful
symptoms of acute stroke. Two hours were found. On CT-Angiography (CTA), (Fig. 4). Two days later, the follow-up
prior, the patient had developed an occlusion of the main stems of the left NECT showed the delineation of com-
acute, right-sided hemiplegia and MCA (Fig. 3) and ACA were detected. plete territory infarctions of the MCA
a right-sided facial palsy. On physical Due to the presence of a large penum- and ACA, brain edema and severe mid-
examination the patient was global bra volume, it was decided to perform line herniation (Fig. 5).
aphasic, showed a left-sided eye and
head deviation and recurrent emesis
(NIHSS 26).*
DIAGNOSIS EXAMINATION PROTOCOL

On initial non-enhanced cranial CT Scanner SOMATOM Definition AS+ SOMATOM Definition AS+
(NECT), intracranial hemorrhage and CT -Perfusion CTA Vessel analysis
tumor were ruled out. A hyperdense
Scan area head head
media sign on the left side was visible as
Scan length 96 mm (VPCT) 300 mm
an early sign of ischemic stroke (Fig.1A).
Scan direction cranio-caudal cranio-caudal
However, grey and white brain matter
Scan time 40 s, one scan every 1.5 s 2.91 s
appeared normal (Fig. 1B).
Tube voltage 80 kV 120 kV
Volume perfusion CT (VPCT) indicated
Tube current 200 Eff. mAs 120 Eff. mAs
large areas of restricted brain perfusion
Scan mode Adaptive 4D Spiral Spiral
in the left hemisphere. A substantial
eff. dose 5.2 mSv 3.1 mSv
reduction of values of cerebral blood
Rotation time 0.3 s 0.3 s
flow (CBF, Fig. 2A) as well as reduction
Slice collimation 0.6 mm 0.6 mm
of cerebral blood volume (CBV, Fig. 2B)
Slice width/Increment 5 mm/3 mm 1.5 mm/1 mm
were detected in the anterior and middle
Reconstruction kernel H20f H20f
parts of the left middle cerebral artery
Contrast
(MCA) territory and in parts of the left
Volume/Flow rate 35 ml Iomeprol 350 @ 5 ml/s 40 ml Iomeprol 350@ 5 ml/s
anterior cerebral artery (ACA) territory.
20 ml NaCl @ 5 ml/s 25 ml Iomeprol 350@ 2,5 ml/s
20 NaCl @ 2,5 ml
Start delay 4s 4s
Postprocessing syngo Volume Perfusion CT – Bolus tracking
*NIHSS 26 (National Institute of Health
Neuro (VPCT-Neuro) syngo Neuro DSA
Stroke SCORE 26).

1A 2A 2B
1B 2C 2D
1 A hyperdense media sign on the left 2 Volume perfusion CT (VPCT) indicated substantial reduction of values of cerebral blood flow
side was visible as an early sign of ischemic (CBF, Fig. 2A) as well as reduction of cerebral blood volume (CBV, Fig. 2B) were detected in the
stroke (Fig.1A, arrow). However, the anterior and middle parts of the left MCA territory and in parts of the left ACA territory. Further-
differentiation of grey and white brain more, a significant prolongation of the mean transit time (MTT Fig. 2C) could be observed. A large
matter appeared normal (Fig. 1B). penumbra could be detected (yellow) in regards to a smaller core infarct (red, Fig. 2D). Therefore
intra-arterial lysis was indicated.
3 4 5
3 Due to complete stroke assessement 4 Intraarterial thrombolyses failed to 5 Follow-up NECT showed the delineation
the CTA revealed an occlusion of the main open left MCA. of complete territory infarctions of the MCA and
stem of the left MCA. ACA, brain edema and severe midline herniation.
COMMENTS
With VPCT, analysis of the brain perfu- detector width, even smallest areas of plete volume of tissue at risk of infarc-
sion parameters of the whole brain is hypo-perfusion can now be analyzed tion and should be implemented in a
possible. Contrary to standard perfusion throughout the whole brain with VPCT. comprehensive stroke CT protocol.
CT, which allows analysis only of restrict- Therefore, the advent of VPCT renders
ed areas of the brain depending on the important information about the com-

Case 8
SOMATOM Definition AS+: Neuro
Volume Perfusion CT of Intracerebral
Metastatic Disease
By Ramona Finzel and Peter Schramm, MD
Department of Neuroradiology, University of Göttingen, Göttingen, Germany
HISTORY
A 69-year-old female patient with a his- Assuming that the patient was suffering ready indicated by the prolongated MTT
tory of bronchial carcinoma presented to from multiple metastasis, we performed and TTP on VPCT.
the Department of Neurology with a dis- VPCT. The calculated permeability maps
crete left-sided, arm-accented, hemipa- of VPCT showed multiple lesions with
COMMENTS
resis since the evening. She was fully disrupted blood-brain-barrier through-
orientated but very cachectic and in out the whole brain (Figs. 2A–F), indi- This case illustrates that VPCT can depict
poor general condition. cating the presence of numerous brain disturbances of the blood-brain-barrier
metastasis. The lesions showed an ele- even within smallest lesions that are not
vation of cerebal blood volume (CBV, visible on NECT. Therefore VPCT is a
DIAGNOSIS
Fig. 3) and contrast enhancement on the meaningful method to reveal smallest
Neuroradiologic examination consisted of MIP images. In addition, we detected a metastasis within the scope of a CT
a cranial, non-enhanced CT (NECT) scan severe prolongation of the mean transit examination. Further, this example dem-
followed by Volume Perfusion CT (VPCT). time (MTT, Figs. 4A-C) and time to peak onstrates the multi-modality of VPCT.
NECT revealed a tumor in the subcortical (TTP) in parts of the right MCA territory. Although the examination and the
white matter of the right parietal lobe The follow-up MRI examination on the postprocessing were focussed on the
(Fig. 1A). The tumor showed a rim-like same day visualized various metastasis assumed diagnosis “tumor”, we were
hyperdensity with a central loss of density supra- and infratentorial. In addition, we able to uncover the supplemental isch-
on NECT and was surrounded by an ede- found subacute ischemic lesions on diffu- emic lesion on the parameter maps.
ma. A second small cortical lesion was sion-weighted images in the area sup-
visible in the right anterior lobe (Fig. 1B). plied by the right MCA which were al-
1A 1B
1 NECT revealed a
tumor in the subcorti-
cal white matter of
the right parietal lobe
(Fig. 1A, arrow). The
tumor showed a rim-
like hyperdensity with
a central loss of den-
sity surrounded by an
edema. A second
small cortical lesion
was identified in the
right anterior lobe
(Fig. 1B, arrow).

2A 2B 2C
2D 2E 2F
2 VPCT showed multiple lesions with disrupted blood-brain-barrier throughout the whole brain (Figs. 2A–F, arrows),
indicating the presence of numerous brain metastasis.
3 4A 4B 4C
3 Additionally VPCT showed an ele- 4 3D evaluation of the brain detected an infarct seen as severe prolongation of the mean transit time
vation of cerebal blood volume (CBV) (MTT) in parts of the right MCA territory.
of the tumor.
Scanner SOMATOM Definition AS+
Scan area head Spatial resolution 0.33 mm
Scan length 96 mm (VPCT) Slice width/Increment 5 mm & 3.0 mm increment
Scan time 40 s, one scan every 1.5 s Reconstruction kernel H20f
(27 scans) Contrast
Scan direction cranio-caudal Volume/Flowrate 35 ml Iomeprol 350 @ 5 ml/s
Tube voltage 80kV 20 ml NaCI @ 5 ml/s
Tube current Eff. 200 mAs Start delay 4s
Scan mode Adaptive 4D Spiral Postprocessing syngo Volume Perfusion CT –
eff. dose 5.2 mSv Neuro (VPCT-Neuro)
Rotation time 0.3 s

Case 9
Dual Source CT:
Visualization of Brain Vessel
Connection of Siamese Twins
By Anirudh Kohli, MD, Head
Department of Radiology, Breach Candy Hospital Trust, Mumbai, India
1A
1A Overview with volume rendering
technique (VRT) showing the connec-
tion of both skulls.
1B 1B Blood-flow through the con-

nected head-vessel system of the
conjuncted twins, demonstrated by
VRT during administering contrast
medium into the artery system of
twin one (left person). Venous drain-
age can be found in the brain of twin
two (right person).

HISTORY 2A
2 MIP visualiza-
tion of vessel-
Two children, 3½-year-old female twins, connection: in-
fused at the cranium since birth (cranio- flow of contrast
phagus), were transferred to the depart- media into the
ment of radiology for prearrangement of arteries of twin
one (left) with
separation. For the pre-operative diag- drainage via the
nosis and surgery planning, a CT-Angio- venous vessel
graphy was performed to evaluate the system of twin
vascular communications between the two (right, Fig.
2A) and vice versa
connected brain tissues of both children.
in a second CT-
The dissection of these communications scan afterwards
was the key challenge for the separation (Fig. 2B).
procedure. In preparation for the CT
scan and for brain vessel visualization,
twin one was injected before twin two
and finally, both were injected simulta-
neously. 2B
DIAGNOSIS
The CT imaging revealed both venous
communications as well as arterial
connections. The arterial communica-
tions were well visualized in the super-
ficial cranial branches of the external
carotid. The superficial temporal and
frontal artery of twin one and the super-
ficial temporal and occipital artery of
twin two were found to be communi-
cating. This brain vessel anomaly was
recognized to be the reason for volume
overload in the brain tissue of twin two,
thus resulting in hypertensity.
COMMENTS
The results of the CT imaging provided
excellent orientation for the surgical
team to prepare a safe separation of the
twins. Scanner SOMATOM Definition
A CT-Angiography was preferred over an
Scan area head
MR-Angiography due to the very short
Scan length 500 mm
scan time required. This allowed a short
Scan time 16 s
sedation time, lowering the sedation
risks for the children while concurrently
Tube voltage A/B 140/80 kV
delivering excellent image quality.
Tube current A/B 70/297 quality ref. mAs
With Dual Energy CT-Angiography, small
Rotation time 0.5 s
vascular communications could be visu-
alized that are critical in a pre-operation-
al workup. This information is important
Slice width 0.6 mm
to know exactly – before starting a sur-
Kernel H10f
gery of this difficulty and severity.

Case 10
A Rare Anomaly of the Middle Cerebral
Artery Detected by Three-Dimensional
Subtraction CT-Angiography
Jacqui Fielding
Department of Radiology, Angliss Hospital, Upper Ferntree Gully, Melbourne VIC, Australia
HISTORY COMMENTS
A 66-year-old woman with a history of In this 66-year-old woman, preoperative Both aneurysms were clipped and su-
hypertension and recent headaches pre- angiography and 3-dimensional com- perficial temporal artery-DMCA* anas-
sented at the hospital with an acute on- puted tomography angiography re- tomosis was performed. She was dis-
set of vertigo, fatigue and severe head- vealed a double aneurysm at the right charged with no neurologic deficits.
ache. On examination and questioning middle cerebral artery (Circle of Willis).
of the patient, it was found that her
mother died at an early age from com-
plications of a cerebral aneurysm. The
patient was referred for a brain CT and
brain CTA to rule out sub-arachnoid
hemorrhage and aneurysm. EXAMINATION PROTOCOL
Scanner SOMATOM Emotion 16
DIAGNOSIS Scan area Circle of Willis
The non-enhanced brain CT shows no Scan length 80 mm
sign of subarachnoid bleeding. Using Scan direction caudo-cranial
the functionality of digital subtraction Scan time 7s
CT-Angiography, automatically subtract- Tube voltage 100 kV
ing a non-contrast from a contrast Tube current 100 Eff. mAs
enhanced study, the complete cerebro- Dose modulation CARE Dose off
vascular tree could be demonstrated CTDIvol 15 mGy
and two progressed aneurysms in Rotation time 0.6 s
the middle cerebral arteries could be Pitch 0.8
detected. Slice collimation 16 x 0.6 mm
Slice width 0.75 mm
Reconstruction increment 0.5 mm
Reconstruction kernel H31
Contrast Ultravist 370
Volume 50 ml
Flow rate 4 ml/s
Iodine delivery rate 4 ml/s
*Duplication of the middle cerebral artery. Start delay CARE Bolus

1 2
1 View into the brain via Volume Rendering Technique (VRT), 2 Detailed VRT image, showing both aneurysms, located consecutively
showing the position of the double aneurysm in the Circle of Willis. in an aortic brain vessel.
3A 3B
3 View on the two aneurysms in the Circle of Willis, virtually separated from brain tissue in VRT (Fig. 3A) and in comparison in MIP (Fig. 3B).

Clinical Results Acute Care
Case 11
Complete Thorax with Flash Spiral
By Martine Remy-Jardin, MD, PhD and Jacques Remy, MD
University Center of Lille, Department of Thoracic Imaging, Hospital Calmette, Lille, France
HISTORY COMMENTS
A 64-year-old male patient was referred This examination was obtained with an acquisition makes the analysis of the
to the department of radiology for eval- ultra fast Flash Spiral mode which made coronary arteries at the same time possi-
uation of abnormal chest radiographic the overall examination very comfort- ble. In this case, the patient’s heart
findings in March 2006. This patient able for this patient in poor general con- rate was 65 bpm. The delineation of
was an ex-smoker (smoking cessation dition. The optimization of data acquisi- aortic and pulmonary valves was excel-
18 years ago) with a cigarette consump- tion and administration of contrast lent. The only limitation was the pres-
tion of 20 pack-years. At the time of medium generates high quality images ence of interpolation artifacts around
first referral, chest CT revealed the pres- of the mediastinum that are devoid of the ribs, noticeable on lung images.
ence of a spiculated nodule in the right respiratory motion artifacts. This kind of
middle lobe. This was associated with
hilar and mediastinal adenopathies with
a final diagnosis, in June 2006, of right
middle lobe adenocarcinoma with lymph
node metastases. This diagnosis, ob-
tained after atypical resection of the 1
right middle lobe nodule and lymph
node sampling, indicated chemotherapy
followed by radiotherapy at the level of
the tumoral zones. In 2008, this patient
was also diagnosed with bone and cere-
bral metastases.
DIAGNOSIS
The present CT examination was indicat-
ed for the follow-up of the chest lesions
in a patient in poor general condition.
This examination showed sequellae of
right middle lobe resection and areas of
airspace consolidation in the lung paren-
chyma located close to the right hilum,
caused by radiotherapy. Furthermore
multiple areas of non-specific ground
glass attenuation in both lung lobes
were discovered, predominantly on the
right side, resulting from radio therapy
or an infection. In addition to hilar and 1 Even without ECG-triggering, sharp delineation of aortic valve
subcarinal adenopathies, osteolytic le- leaflets is possible.

sions of the thoracic spine and the ster-
num were found.

Acute Care Clinical Results
Scanner Flash Spiral mode
Scan area whole chest Reconstruction increment 1 mm
Scan length 345 mm Reconstruction kernel BB20f (mediastinum); B50f (lung)
Scan direction cranio-caudal Contrast 350 mg of iodine/mL
Tube voltage 120 kV
Tube current 52 Eff. mAs Volume 80 ml
Heart rate 65 bpm Flow rate 4 ml/s
Pitch 3.2 Start delay 18 s (ROI within descending aorta)
Spatial resolution 0.33 mm Postprocessing syngo InSpace
Slice width 1 mm
2 3
2 Coverage of the entire lung in ultra-short breath hold time of 3 Sagittal view of the right lung highlights the high quality of lung
< 3 sec. Note the apparent right lower lobe consolidation secondary images from top to bottom of the volume scanned.
to lung resection.

Clinical Results Acute Care
Case 12
Dual Source CT:
Carotid Stenosis Diagnosed
with Dual Energy
By Eva Hendrich, MD and Stefan Martinoff, MD
Department of Radiology and Nuclear Medicine, German Heart Center, Munich, Germany
HISTORY DIAGNOSIS COMMENTS

A 65-year-old woman presented with With CTA (CT-Angiography), indicated by syngo Dual Energy Bone Removal deliv-
complaints about recurring dizziness. the ultrasound survey, a quite severe ers credible information about vessel
Weeks previously, she has been stented stenosis in the branch of the left arteria status. Therefore, the non-overlapping
in the right carotis interna. During a rou- carotis interna with cranio-caudal exten- imaging of the vessels plays an impor-
tinely conducted ultrasound examina- sion of 13 mm could be confirmed. tant role, as well as the option of hard-
tion, a stenosis was discovered in the Furthermore, the CTA delivered addi- plaque visualization that affords a de-
left arteria carotis interna. To confirm tional information that an expanded tailed conclusion about vessel lumen
this result and for a correct planning of semi-circular atheromatous plaque was and plaque.
stent positioning and PTA (percutanuous the cause for the stenosis. In the area A very positive effect is the uncomplicat-
transluminal angioplasty), a CT examina- surrounding the implanted stent, in the ed integration of Dual Energy into the
tion with Dual Energy technology was proximal right arteria carotis interna, a post processing procedure. Hence syngo
subsequently performed. stenosis could be ruled out. Moreover Dual Energy Bone Removal has become
other profound arteriosclerotic alterations an inherent part of our vascular workflow.
in the region of the basal brain arteries
could also be ruled out by the CTA survey.
Scan area carotis Rotation time 0.33 s
Scan length 281 mm Spatial resolution 0.33 mm
Scan time 6s Slice collimation 0.6
Scan direction cranio-caudal Reconstructed slice thickness 0.75 mm
Tube voltage A/B 140/80 kV Increment 0.6
Tube current A/B 204/48 Eff. mAs Kernel D30f

Acute Care Clinical Results
1A 1B
1 VRT Visualization of syngo Dual Energy scan shows earlier PTA result in right carotid artery (Fig. 1A).
Inverted Maximum Intensity Projection (MIP) of the same scan (DE) (Fig. 1B).
2A 2B
2 syngo InSpace advanced vessel analysis (InSpace AVA) measured accurately the grade of the stenosis for use of later PTA (Fig. 2A).
syngo Hard Plaque unveiled the calcified plaque (red) versus remaining lumen of the carotid arteries (blue) (Fig. 2B).

Clinical Results Orthopedics
Case 13
Screw Placement and Pelvic Osteoplastie
Under CT – Fluoroscopic Guidance
By Ralf-Thorsten Hoffmann, MD*, Bianca Beyer, MD**, Tobias F. Jakobs*, Maximilian F. Reiser, MD*
*
Department of Clinical Radiology, University of Munich, Campus Großhadern, Munich, Germany
**
Department of Surgery, University of Munich, Campus Großhadern, Munich, Germany
HISTORY
A 68-year-old male patient with a history a CT guided osteoplasty during the same ance using the i-Fluoro mode (Fig. 2).
of renal cell carcinoma 4 years prior, pre- treatment session. The screws were placed via K-wires by
sented in the department of radiology. the surgeon in order to avoid a too deep
Due to pelvic pain occurring during his insertion of the screw head into the
COMMENTS
follow-up, a MSCT of the pelvis was ob- weakened bone (Figs. 3A-B). A major
tained. After placing the patient in a stable lat- support for these control scans is the
eral position with the help of a vacuum One Click Table Position, bringing the
bed, a CT scan was performed using the patient back to the exact same position,
DIAGNOSIS
i-Spiral mode. The correct positioning of avoiding additional fluoroscopic CT ex-
The examination showed a large osteo- the screws was planned on axial images. amination. Procedure times and radia-
lysis in the sacrum and the adjacent iliac Furthermore, path planning tion exposures are thereby significantly
bone (Fig. 1). Furthermore, a pathologi- and calculation of the screw length was reduced. After the insertion of two
cal fracture was detected as stigmata of performed on the automatically ob- screws, (Fig. 4) the next step was the in-
the recurring tumor. tained 3D images using the needle ori- sertion and positioning of two vertebro-
After an inter-disciplinary case discus- ented view. The following procedure plasty canulas into the osteolysis and ap-
sion, the decision was made to treat the was monitored by repeated control with plication of the PMMA cement under CT
patient with a combination of angio- i-Fluoro mode. By using Hand CARE fluoroscopic guidance by the radiologist
graphic embolization of the strongly vas- mode, K-wires were positioned through using the needle artefact reduction tool
cularized tumor, followed by CT guided small skin incisions by the interventional i-Needle Sharp (Figs. 5A-B).
placement of two screws supported by radiologist under CT fluoroscopic guid-

Scan area pelvis Rotation time 0.5 s
Scan length 4.8 mm Slice collimation 12 x 1.2 mm
Scan time i-Fluoro Slice width 4.8 mm
Tube voltage 120 kV Reconstruction kernel B50s
Tube current 25 Eff. mAs Postprocessing Intervention Pro
CTDI vol 289 mGy Adaptive 3D Intervention

1 2
1 The CT examination
showed a large osteolysis in
the sacrum and the adjacent
iliac bone.
2 K-wires were positioned

under CT fluoroscopic guid-
ance using the i-Fluoro mode.
3A 3B
3 The screws were placed
via K-wires in order to avoid a
too deep insertion of the
screw head into the weak-
ened bone.
4
4 Two screws were
inserted into the broken
pelvic bone.
5A 5B
5 Two vertebroplasty
canulas were inserted
and positioned into the
osteolysis (Fig. 5A) and
PMMA cement was
supplied under CT fluo-
roscopic guidance
using i-Needle Sharp
(Fig. 5B).

Science
CT-Guided Osteosynthesis in
Instable Pelvic Fractures
By Tobias F. Jakobs, MD*, Ralf-Thorsten Hoffmann, MD*, Thomas Löffler, MD**
*Department of Clinical Radiology, University of Munich, Campus Großhadern, Munich, Germany

**Department of Surgery, University of Munich, Campus Großhadern, Munich, Germany
Recent improvements in mortality due treatment options. The most frequent dent. The CT scan revealed – beside a
to high-energy trauma can be attributed percutaneous application is the trans- right sided lung contusion – an instable
to the progress made in modern critical iliosacral screw fixation using only fluo- fracture of the pelvic bone involving the
care medicine including early fracture roscopy guidance. Given the anatomical superior ramus of the pubic bone and
stabilization. complexity of the pelvic structures, this the wing of the sacral bone on the left
Most of the complications of classical surgical procedure remains a challeng- side (Figs. 2A-B). On day 5 after the
stabilization techniques are related to ing task. trauma the patient was referred to
the surgical exposure itself, rather than An 18-year-old woman was presented at the interventional radiology unit for
to the initial injury. It therefore seems the CT unit for a whole-body scan after CT-guided osteosynthesis.
reasonable to consider less invasive having experienced a severe car acci-
1A 1B
1C
1 CT-guided osteosynthesis in instable pelvic fractures

Science
Procedure
top. A planning CT was performed to improved. Additionally, a 78 cm large
The procedure was performed under identify the most appropriate position bore allows convenient work within the
general anaesthesia in cooperation with for the screw. Using a Siemens gantry. The innovative table-side control
trauma surgeons (Figs. 1A-C). The SOMATOM Definition AS+ CT scanner module “i-Control” enables operating
patient was placed in a strict lateral and the new Siemens Interventional all table and scanner movements from
position using a vacuum mattress with Suite for 3D-guided interventions, plan- inside the scan room (Fig. 1B, arrow),
the fractured pelvis pointing to the ning procedures have been dramatically improving the workflow as well on such
complex procedures. For this patient,
2A 2B the correct positioning of the screw was
planned on axial images. Furthermore,
path planning and calculation of the
screw length were performed on the
automatically obtained 3D images using
the needle oriented views. A combina-
tion of CT Fluoroscopy with the new i-
Fluoroscopy mode and a sequential ap-
proach with 3D i-Sequence mode was
used to securely drive a wire through
the iliac bone and the sacral wing into
the first sacral vertebral body. Especially
2 CT scan revealed an instable fracture of the pelvic bone involving the superior ramus of the 3D i-Sequence mode with instant
the pubic bone and the wing of the sacral bone on the left side (Fig. 2A). VRT supports surgi- display of the wire in an axial, coronal
cal planning planning (Fig. 2B). and sagittal view (MPR) permitted excel-
lent visualization and increased the in-
3 terventional radiologist’s confidence not
to harm, e.g. the neuro-foramen, or to
protrude outside the first sacral verte-
bral body. This enables a safe place-
ment of the screw even in complex
anatomy (Fig. 3).
With the guide wire in place, the screw
could be advanced into the target area
to provide compression on the fractured
sacral wing (Fig. 3). Then, the guide
wire was withdrawn. Before the patient
was removed from the CT-table, a con-
trol scan was conducted and MPR as
3 With the 3D approach, the placement of the screw into the target area can be perfectly
monitored using a guide wire.
well as VRT were reconstructed (Fig. 4).
Comments
4
With the availability of the new 3D-guid-
ed Interventional Suite, we have chosen
the approach of CT-guided osteosynthe-
sis. In comparison to classic surgical
techniques of internal fixation, the new
interventional procedure brings advan-
tages for both patients and the hospital.
Less complications, due to less exten-
sive soft tissue damage associated with
long bed rest, reduce the likelihood for
pneumonia, deep vein thrombosis etc.,
facilitate a faster recovery of the patient
4 Using CT guided interventions, the screw can be placed in the target area without
and finally an earlier discharge.
providing compression of the fractured sacral wing.

Science
Clinical Advantages
of Automated CT Tumor
Measurement
Lesion measurement has long been an inexact science. Yet, judging the
patient’s disease regression or progression is, to a large extent, based
on documentation of exact changes in tumor size. Currently, when tumor
masses are encountered in daily clinical practice, manual measurements
made with electronic calipers are utilized. These are quite time consuming
and not reliably exact from examination to examination.
By Alec J. Megibow, MD, MPH, FACR
New York University Medical School, New York, USA
1
Because tumors are complex shapes, the
axis of measurement chosen over serial
time points may vary. RECIST (Response
Evaluation Criteria in Solid Tumors) has
been widely adopted in the U.S. and
WHO (World Health Organization) crite-
ria elsewhere as the standard reporting
parameters for lesion size. Among many
problems with these methods, con-
straining measurements into the axial
plane may under- or overestimate the
longest diameter of the lesion.
If software could be developed to
segment the 3D volume from an MDCT
data set, the truest approximation of the
maximal diameter (RECIST diameter)
could be determined. Additionally, such
software should be able to “store” this
information so that the same exact le-
sion could be followed over the course
of the patient’s treatment, thereby elimi-
nating variances in manual measure-
ment. Finally, converting these observa-
tions onto a spreadsheet would aid 1 All segmentation and measurement results are stored and reported. The list in-
cludes the most important lesion information, such as WHO and RECIST diameters,
institutional compliance in clinical trial,
Volumes and their changes since the last examination. A comprehensive report,
with benefits not only to improved pa- including key images, can be generated and stored.
tient care, but also increased opportuni-

Science
2A 2B
ty for ongoing funding, since it improves
the institution’s ability to record data in
a usable format.
Siemens syngo CT Oncology is a clinical-
ly available suite of tools that provides
all these capabilities (Fig. 1).
Algorithm Refinement
In preliminary testing of the syngo CT
Oncology algorithm, 27 hepatic metas-
tases in 13 patients were evaluated us-
ing prototype software that defined the
edges, maximal and orthogonal diame-
ters of the targeted lesion. The auto-
segmented measurements were com-
pared to manual measurements made 3A 3B
by electronic calipers, and the difference
between the two was recorded.
As a prototype, this algorithm performed
well: Using 4 mm slices, long diameters
of 67 percent of metastases of less than
5 mm were correctly measured within
2 mm of the manual measurement. With
this information, the algorithm was fur-
ther refined.
In our next evaluation of the actual, clin-
ical application, it performed exception-
ally well. Eighty-seven hepatic masses
from 33 patient studies were evaluated.
Here, we sought to compare the tool’s
ability to obtain RECIST diameters of
hepatic metastases against manual eval- 2 3 Example of a 73 year old female patient with known carcinoid on treatment. Follow up
uation of the same lesion. There was is performed in a 3 month interval (Figs. 3A-B). The datasets are automatically registered and
displayed synchronously for easy follow-up comparison. The lesion is then identified in both
a high degree of concordance between
studies and is automatically segmented and evaluated. Sagittal and 3D reformats are shown
RECIST diameters obtained using auto- (Figs. 2A-B – base exam, Figs. 3A-B – 3 month follow up).
mated segmentation versus manual
measuring. In fact, 74 percent of lesions
differed by less than 5 mm. A finding of ments, and volume. The radiologist can main consistent while volume changes.
particular importance: the syngo CT On- decide whether to accept the results or Clearly, the ability to measure volume is
cology segmentation algorithm is inde- edit, if necessary. Evaluation results are an asset, even if it has not yet been clini-
pendent of absolute HU measurements. comprehensively presented and the im- cally validated. We are currently in the
Thus, there is no dependence on the ages stored to PACS, ensuring that any process of comparing changes in volume
quality of the contrast injection, which follow-up measurements are conducted against diameter changes as measured
makes the tool particularly valuable for with a consistent approach to the cor- with RECIST criteria.
serial observations of lesions in patients rect lesion(s). This is particularly helpful With its ability to record and evaluate all
where it is difficult to obtain a good in- in following tumor progress. tumor parameters, syngo CT Oncology is
jection (such as those undergoing che- an advantageous tool for the radiologist.
motherapy). Future Directions This software helps solidify the role of
RECIST and WHO criteria do not currently the radiologist as someone who goes
Comprehensive Evaluation and include volume; it is the next, expected beyond simple diagnosis, but rather, a
Reporting step in comprehensive tumor measure- physician who, through the use of a
With syngo CT Oncology, the lesion is ment. It is theorized that volume may be wide variety of image processing tools,
presented in axial, coronal and sagittal more sensitive to tumor growth than di- can provide information that directly im-
displays with RECIST and WHO measure- ameter because lesion diameter can re- pacts therapeutic decisions.

Science
CT put to the Test

CT units from various manufacturers were recently put through practical
tests at the German Heart Center in Munich in order to determine radiation
exposure levels for patients during everyday operations. The results indicate
that applied doses depend not only on the specific device, but are also sig-
nificantly influenced by the operator. The study further shows that Siemens
has developed particularly efficient radiation-saving equipment.
By Tim Schröder
Computed Tomography (CT) has estab-

lished itself in the past few years as a
non-invasive procedure for obtaining
medical imagery. With every new product
generation, manufacturers have paid
considerable attention to reducing the
levels of radiation to which patients are
exposed. Never the less, the question of
dose is becoming increasingly important
as CT-technology becomes more wide-
spread. Not only the technical data pro-
vided by manufacturers is of interest, but
especially the actual radiation doses to
which patients are exposed during treat-
ment. To this end, the German Heart
Center in Munich, in cooperation with
the American Mayo Clinics in Rochester
and Jacksonville, and the Friedrich-Alex-
ander University in Erlangen-Nuremberg,
“It’s clear to see

that Siemens has
quite evidently
developed a very
radiation-saving
system.”
Jörg Hausleiter, MD, Cardiologist, associated
Professor of Medicine, German Heart Center
Munich, Germany
Sessions23_S58-61.indd 56 17.11.2008 8:58:01 Uhr

1A
Germany, conducted an International

Prospective Multicenter Study on
Radiation Dose Estimates of Cardiac CT-
Angiography in Daily Practice (PROTEC-
TION-I). The study compared five CT units
from four different manufacturers. The
basis of the study was 1,965 cardiac CT
scans that were carried out in a total of
50 clinics and heart centers. The study
showed clear differences in radiation
doses depending upon both the CT
system manufacturer and the behavior of
the operator. The study especially under-
lines that radiation can be significantly
reduced by more consistently using
already existing technologies for dose
reduction in CT systems.
“Until now the only information available
for evaluating individual devices has been
to use systematic phantom measure-
ments or physical readings provided by
1B
the manufacturers,” said Jörg Hausleiter,
cardiologist and associate professor of
medicine, German Heart Center in
Munich. “Conversely, the new study deliv-
ers, for the first time, data obtained from
individual patients, including abundant
patient data such as size and weight.”
As was shown, the radiation dose varies
considerably, by as much as a factor of
six. Hausleiter: “An emphasis of our
work was to test the effectiveness of the
different software tools for reducing radi-
ation.” This included the so-called “
Automatic Exposure Control,” which
automatically adjusts the CT radiation
intensity to the anatomy of the patient.
Generally more radiation must be used
when conducting tests of larger bodies.
The Automatic Exposure Control is
already well established for noncardiac
scanning, but it was not specifically
developed for cardiac CTs. All of the
devices tested were equipped with it.
“ECG-Pulsing” is also implemented in all
devices. This synchronizes CT radiation
to the ECG, so that the image is recorded
during the late diastolic phase, when the
heart is not moving. It is only at this time
that the apparatus increases the radiation
1 49-year-old patient, former smoker with high cholesterol, who repeatedly developed symp-
intensity to the necessary high level.
toms of dyspnea in combination with a difficult to adjust hypertension. SOMATOM Definition with
During the in-between phases, X-ray Adaptive Cardio Sequence revealed with a quick 1.8 mSv low dose cardiac examination a high
emission is kept to a minimum. Addition- grade lesion in the right coronary artery. The patient was transferred from CT directly to the cath
ally, Hausleiter’s team researched the lab for a percutaneous intervention.
influence of the 100 kV Scan Protocol.

Science
This protocol is not integrated by all man- confident findings,” said Haus-leiter. The tion of 83 milliseconds – so quick that
ufacturers, but is available, for example, situation is similar with the step-and- sharp images are possible from even
with the Siemens systems. Until now, it shoot technology. In comparison to the rapidly beating hearts. Despite having
was unclear as to how much of a reduc- spiral-scan, this method reduces the dose two X-ray sources, the total dose is less
tion of dose came with the 100 kV tech- by 68 percent, but so far has only been than that of conventional single source
nology in comparison to the conventional used in 6.2 percent of all cases. According devices, thanks to the extremely short
120 kV protocol. As a further tool, the re- to Hausleiter, the multivariate analysis of exposure time.
searchers evaluated the so-called, step- the PROTECTION-I study does not permit “In discussions about radiation reduc-
and-shoot method. In contrast to Spiral- a direct comparison of devices, since options, one should not get carried away,”
Scan, this procedure does not expose the erator behavior has an influence. Howev- said Hausleiter. “To date, the level of
entire heart area to radiation through the er, the Siemens 64-slice scanner was as- radiation of cardiac CT-Angiography is
entire test. Once again, thanks to syn- sociated with the lowest radiation dose in very comparable with other diagnostic
chronization with the ECG, exposure is cardiac CT-Angiography and served as the CT studies, such as multiphase abdomi-
limited to the diastolic phase. Then the reference value for assessing the other nal and pelvic CTs, which we perform in
CT device moves the patient forward so systems. Close behind, in third place, was daily routine without worrying so much
that the next heart segment can be ex- the DSCT SOMATOM Definition. Despite about radiation exposure.” Naturally,
amined. At the time the study was enroll- this, in comparable clinical situations in Hausleiter knows that, despite this,
ing patients, this low dose scan mode the study, the average radiation dose of caution is required, especially when
was only available in a preliminary re- the DSCT SOMATOM Definition was con- testing children and youths. “To this ex-
search version at selected Dual Source siderably lower than that of the compet- tent, it makes sense that manufacturers
Computed Tomograph (DSCT) SOMATOM ing scanners ranked in fourth and fifth continue to reduce the dose. Though par-
Definition sites. Thus, this mode had place. “It’s clear to see that Siemens has ticularly in applications such as cardiac
been used infrequently on DSCT systems quite evidently developed a very radia- CT, the advantages of the method and
in PROTECTION I and patients could not tion-saving system,” said Hausleiter. The the superior image quality weighs much
benefit from the tremendous dose saving multivariate data additionally allows an- more positively than any possible radia-
potential of the system at that time. other interpretation: satisfactory dose val- tion risks.”
However, shortly after the publication ues were only attained in the PROTEC-
of the study, the Siemens proprietary TION-I study when the radiation Immense Potential
step-and-shoot mode, “Adaptive Cardio reduction software was frequently em- Hausleiter is currently advancing the
Sequence,” and the software upgrade ployed. “Based on the available results we follow-up studies, PROTECTION-II and
syngo 2008G has become available for can conclude that Siemens evidently be- PROTECTION-III. PROTECTION-II systemati-
all DSCT customers. longs to those manufacturers, that pro- cally compares the image quality when
vide especially good systems training for using 100 and 120 kV tubes. PROTEC-
100 kV Tube Reduces Dose their customers, so that operators can TION-III studies the influence of step-and-
by Half take advantage of the total radiation re- shoot technology in the same way. At the
Hausleiter primarily noted during the duction potential of the device.” end, Hausleiter wants to provide physi-
analysis of the data how often the indi- cians with clear suggestions, with which
vidual software solutions were imple- Dual Source-Scanner Unique the technologies can be used without any
mented. It became evident that the es- Worldwide loss of image quality – up to approximate
tablished Automatic Exposure Control Thomas Flohr, head developer of the body volumes or weights. The goal is
was employed in more than a third of SOMATOM Definition Dual Source CT at clear: In the future, radiologists and
all cases, but, ultimately, hardly contribut- Siemens Healthcare in Forchheim, Ger- cardiologists should be less hesitant to
ed at all to dose reduction. ECG-Pulsing many, believes that, “the DSCT would use the technologies. Hausleiter: “Never-
was employed in 78.7 percent of the cas- have performed even better if it had al- theless, the potential is immense. Until
es and reduced the dose by about 20 per- ready been equipped with current, im- now with conventional CT technology the
cent. This is minor though, in comparison proved version of the step-and-shoot average radiation dose during a CT test
to the effect of the 100 kV tube that re- technology during the study.” At any rate, was in the average 13 to 15 mSv. By
duced dose by half – while providing the the Dual Source scanner is worldwide the consistently using dose reduction tools,
same image quality in adequately select- only CT equipped with two X-ray tubes today we can already achieve an average
ed, non-obese patients. However, this and two detectors, that are connected to of less than 3 mSv.”
technology has so far been used in only one another at an angle of 90 degrees.
Tim Schröder is a biologist and former editor of
5.8 percent of all cases. “When testing pa- This means that the heart is simultane- the science section of the Berliner Zeitung. He is
tients, physicians want to be secure and ously scanned from two different angles. now a freelance writer in Oldenburg, Germany,
are afraid that by using the 100 kV mode With a gantry rotation speed of only 0.33 and publishes regularly in scientific journals such
as the german edition of Scientific American,
the image quality will be inadequate for seconds, one achieves a temporal resolu- Max-Planck-research and Fraunhofer-Magazin.

Science
Siemens benchmarks in low dose

Three of Siemens’ latest and most effective dose saving features – and with
the SOMATOM Definition Flash the further development in dose reduction
technology continuously proceeds (see Cover Story).
MinDose: – 30% dose compared to conventional ECG-Spiral dose

1A
Advanced Pulsing with Dual Source CT
Tube Current
20%
4%
MinDose
1A Spiral Acquisition: MinDose reduces the tube current from 20% to 4% during the systolic phase of an RR
interval to lower the dose to the patient leading to a dose reduction of about 30%. In combination with reduced
tube current of 100 kV dose levels of 3.9 mSv can be achieved in routine clinical use.
Adaptive Dose Shield: – 25% dose for spiral acquisition

1B STRATON with Adap-
tive Dose Shield
No Pre-Spiral Dose
No Post-Spiral Dose
1B Adaptive Dose Shield: The SOMATOM Definition AS is the first commercially available CT-scanner
that addresses the problem of over-radiation with a dynamic collimation technique reducing spiral over-
radiation up to 25% for a heart scan.
Adaptive Cardio Sequence: – 68% dose compared to conventional

ECG-Spiral dose
2 Scan Table Scan Table React Scan
Move Move
extra-systole
2 Conventional Step & Shoot is vulnerable for extrasystolic heart beats. Adaptive Cardio Sequence, with
arrhythmia compensation enables the system to react on extra systoles. In clinical routine, dose levels of
1.2 – 2.6 mSv can be reliably achieved.

Science
Virtual Histology with

Dual Source CT
In Tübingen, Germany, the partnership between radiologists and
cardiologists at the University Clinic at Schnarrenberg – aided
by Siemens imaging technology – is making great strides in the
identification of vulnerable plaques.
By Hildegard Kaulen, PhD

Science
Histology based on Dual Source CT is a new development.
Every fourth heart attack comes com- ed view over the surrounding country- trast, a new development. The assess-
pletely unexpected and cannot be ex- side, radiologists working with Prof. ment of plaque volume and composition
plained by classic risk factors such as Claus D. Claussen, MD, and cardiologists rests upon Hounsfield Unit (HU)-based
hypertension, hyperlipidemia, smoking, working with Prof. Meinrad P. Gawaz, color mapping. With the comparison,
diabetes mellitus or genetic factors. MD, came together to perform an illumi- the two responsible physicians, radiolo-
Usually, the cause is the rupture of a nating study. The goal was to use com- gist Harald Brodoefel, MD, and cardiolo-
vulnerable plaque. The exact risk of some puted tomography to more accurately gist Christof Burgstahler, MD, entered
atherosclerotic plaques has, until now, determine the extent and composition new territory and obtained some fasci-
been very unpredictable. A study with the of atherosclerotic plaques. For this pur- nating results. With plaque volume as-
Dual Source SOMATOM Definition CT, at pose, two procedures were compared: sessment, the methods delivered almost
the clinic of the University of Tübingen virtual histology using intravascular identical results. With the determination
in Germany indicates that this situation ultrasound (IVUS), and virtual histology of plaque composition, there were dis-
could soon change. using Dual Source CT. crepancies that have apparent causes.
It’s not uncommon that a fruitful collab- IVUS histology has been the gold stan- Visual assessment, which is typically in
oration stands at the beginning of an dard for characterizing atherosclerotic use, almost always resulted in an overes-
interesting new development. At Schnar- plaques for the past three years. Histolo- timation of the plaque burden and an
renberg, a hill that offers an unobstruct- gy based on Dual Source CT is, in con- underestimation of vascular lumen.

Topic
Science
Despite many advances in treatment,

cardiovascular disease remains the
number-one cause of death in western,
industrialized nations. However, myocar-
dial infarctions are often not the result
of high levels of coronary stenosis, but
rather stem from the rupture of a vulner-
able plaque. Burgstahler says: “Stable
lesions with high degrees of luminal
constriction typically lead to exercise
induced angina pectoris. Should the cor-
onary vessel gradually be blocked, col-
lateral vessels often arise, so that not
every vascular blockage necessarily
leads to an acute heart attack. In con-
trast, when a vulnerable plaque rup-
tures, it usually results in an acute vas-
cular blockage, and thus in a heart
attack. The patient may have been com-
pletely free of symptoms until this point.
The identification of vulnerable plaques
can therefore be an important parame-
ter for risk stratification.”
In order to estimate the threat of plaque
rupture, one needs to know the plaque
composition. The most dangerous are
those with thin fibrous caps and large
fatty cores, not the highly calcified
plaques. Vascular calcification is simply
a measure of the general vascular
plaque burden. For a qualitative analy-
sis, it is therefore necessary to be able
to differentiate between fibrous tissue,
lipids, calcification and necrotic tissues.
This is where virtual histology comes
into play. The team from Tübingen in-
vestigated whether Dual Source CT and
the Plaque Analysis Program of the latest
syngo Circulation Package represented
a reasonable alternative.
“We can well determine With IVUS histology, the discrimination
between different tissue types is not
plaque volumes using DSCT based on the conventional grey-scale
image, but rather on the spectrum anal-
based virtual histology.” ysis of radio frequency data. Every histo-
logical class is assigned a color; thus
Prof. Claus D. Claussen, MD, University of Tübingen, there is one each for fibrous, necrotic,
Department of Radiology, Tübingen, Germany fatty-fibrous, and calcified material.
The classification was previously validat-
ed by comparison with autopsy material.
The fact that Dual Source CT can be con-
sidered for virtual histology has to do
with its high level of spatial and tempo-
ral resolution. In both disciplines, the
SOMATOM Definition sets industry stan-

Science
mode, both tubes run with the same

energy level. Dual Energy mode allows
better differentiation of tissues by sub-
tracting two different energy levels, but
results in reduced temporal resolution.
Noteworthy with this study was the
high level of reproducibility of results.
“The high inter-observer variability is
a big problem with visually evaluating
and manually segmenting atherosclerotic
plaques,” explains Brodoefel. “In contrast,
a HU-based plaque analysis eliminates
many investigator-dependent steps. In
our work, high inter-observer variability
could not only be achieved for plaque
volume but also for plaque composition.
It remains questionable, however, how
robust the results for possible serial CT
investigations of the same plaques will
be. Here the always-different contrast of
the vascular lumens presents us with
SOMATOM Definition sets industry standards to visualize coronaries and plaque in the vessel wall. great challenges.”
Prof. Claussen also attributes great signif-
dards with 83 ms temporal resolution to determined thresholds for the Hounsfield icance to the study. “We can well deter-
freeze any cardiac motion and 0.33 mm Unit based on IVUS data. For this, the mine plaque volumes using Dual Source
spatial resolution to visualize the coronar- doctors matched the determined color CT based virtual histology,” he says. “The
ies and plaque in the vessel wall.” Since it maps of some plaques with the spectrum reproducibility is also high. For plaque
records images within a tenth of a sec- analysis of the corresponding radio fre- composition analysis, we need improve-
ond, produces hardly any motion artifacts quency data, and obtained the following ments. In order to use virtual histology
from partial-volume effects and has high- thresholds: 10 to 69 HUs stand for the for screening or follow up controls, long-
ly homogenous Hounsfield Units, it pos- fatty compartment of an atherosclerotic term studies are necessary anyway. They
sesses the technical prerequisites for plaque, 70 to 158 HUs for the fibrous must demonstrate that there actually is a
virtual histology. compartment, 159 to 436 HUs for the correlation between plaque composi-
“Until now, intravascular ultrasound has vascular lumen, and 437+ for calcifications, determined using CT, and the risk
been the gold standard for assessing tion. Additional plaques were subse- of heart attack. We also need studies that
vascular lumen, vascular wall and plaque quently analyzed using both procedures show whether a specific intervention –
burden,” says Brodoefel. “Coronary an- and the results compared. Burgstahler such as statin therapy – changes plaque
giography only gives information about notes: “We found a good correlation with composition and thus positively influenc-
the degree of stenosis. As an invasive volumes. The sizes of plaques can thus be es risk. Furthermore, the levels of radia-
procedure, IVUS has clear disadvantages. equally well determined with both Dual tion exposure are still too high for screen-
Every invasive procedure brings with it Source CT and intravascular ultrasound. ing or regular follow-up controls.”
the risk of complications, and in addition, With plaque composition, however, there
it is labor and cost intensive. Moreover, it was only limited correspondence. A pos- The study appears in: Brodoefel H, Reimann A, Heu-
schmid M, Tsiflikas I, Kopp AF, Schroeder S, Claussen
is not possible to bring the ultrasound sible reason is the lower spatial resolu-
CD, Clouse ME, Burgstahler C. Characterization of
probe into every coronary vessel; some tion in relation to IVUS. Calcification also coronary atherosclerosis by dual-source computed
are too small and others have too high a presents a problem, since it respectively tomography and HU-based color mapping: a pilot
study. Eur Radiol. 2008 Nov; 18(11):2466-74. Epub
level of stenosis. With Dual Source CT, the leads to excessive overexposure with CT 2008 May 20.
entire vascular tree with lumen and walls and loss of ultrasound waves due to in-
is represented. One can consequently ob- terference when using IVUS. Dual Energy
serve the entire plaque situation. Finally, mode possibly brings some advantages
CT offers the opportunity to perform a for determining the plaque composition. Hildegard Kaulen, PhD, is a molecular biolo-
more wide-ranging analysis than does We have not yet evaluated this mode on gist. Following positions at Rockefeller Universi-
ty in New York and Harvard Medical School in
intravascular ultrasound.” the coronary vessels.” The SOMATOM Boston, she has been writing as a freelance sci-
For Dual Source CT-based virtual histo- Definition can be used in Dual Source and ence journalist for prestigious newspapers and
logy, Burgstahler and Brodoefel first Dual Energy mode. With Dual Source science magazines since the mid 1990s.

A smooth workflow in CT is important for any hospital to realize optimized capacity utilization.
Proactive Service for and

by Radiologists
A system failure not only brings throughput to a stop but it’s, above all, a
nightmare when interventions are in process. The Medical Director of the
Diagnostic and Interventional Radiology Department at the Tübingen Uni-
versity Hospital, Germany, Professor Claus D. Claussen, MD and various
team members speak about the challenges of radiology and why proactive
services such as the Siemens Guardian Program support clinical workflow.
By Katja Stöcker, Siemens Healthcare, Erlangen, Germany

Life
Anja Reimann, MD, resident assistant realize optimized capacity utilization, ter. Siemens experts are not only able
physician, describes the rare but always appointments are scheduled tightly. A to call the customers proactively and
possible event of a system failure as system failure would immediately dis- alert them to an impending problem,
nerve-wracking: If, for example, the rupt the workflow in his department but can often immediately solve it
computed tomograph (CT) should go and would also have ramifications for remotely. Andrea Ganter, a technical
down during aspiration of an abscess, it the workflow of the University Hospital assistant in Diagnostic and Intervention-
could be unpleasant for the patient who Tübingen (UKT – Universitätsklinikum al Radiology, tells of one such proactive
might at that very moment have the Tübingen), as a whole. “Therefore, in telephone call: “Due to this call, we
guide canula in his or her body. If the the event of a malfunction, technical knew that our CT would work only for
system can be restarted quickly, there is service must be prompt and competent,” approximately another two days.” This
only a small shift in the schedule. How- continues Claussen. gave the team enough time to shift
ever, in the event of a relatively long fail- For the various Siemens systems, in- patient appointments and program the
ure, the patient must be called in again cluding the high-end, Dual Source CT necessary time for repairs without an
and the intervention must be repeated. scanner SOMATOM® Definition, and involved onsite fault search. “Thanks to
She discusses some findings with Profes- the SOMATOM Sensation 64 CT system Guardian, the CT scanner was available
sor Andreas Kopp, MD, senior physician. in Professor Claussen’s department, again after four hours of repair time,”
“A system failure would be difficult for Siemens supports the workflow with a reports Ganter. Another advantage of
us here in radiology also because we broad pallet of proactive services. Virus remote monitoring is that Siemens can
cannot use the time for other productive Protection for example is a service that determine in advance, via SRS, which
activities. Our colleagues on the wards, protects Siemens systems from viruses, spare parts are required, so that the
for example, could take the case history worms and trojan horses. System-spe- Customer Service Engineer (CSE) can
of another patient or discuss a surgical cific usage and capacity-utilization data bring the proper replacement parts with
procedure,” says Professor Kopp. can be called up through the service him. A few doors away, Ayser Birinci-
Today, purchasing decisions are no lon- Utilization Management. “It is important Aydogan, a radiological assistant, is
ger made solely on the basis of product to recognize errors as early as possible – monitoring the scan of a 58-year-old
features. System availability and service not only after the system shuts down,” man using the high-end, SOMATOM
are other important criteria that help says Claussen. The Siemens Guardian Definition Dual Source CT scanner. On
decide the competitiveness of supplying ProgramTM efficiently provides this pro- the screen in the control room, the coro-
companies. active service. nary vessels can be clearly recognized.
“We are under massive pressure to The man came to UKT due to his family
deliver competent diagnoses to our Prompt Remote Repair predisposition for coronary disease.
colleagues in the hospital or to the refer- Saves Time Throughout all clinical operations,
ring physicians with ever-faster turn- Through the Siemens Remote Service Guardian works unobtrusively in the
around times,” says Medical Director, (SRS) platform, the medical device background: through the proactive real-
Professor Claussen, describing an reports deviations of important system time monitoring of important system
essential challenge for radiology. To parameters to the Siemens Service Cen- components such as X-ray tubes, detec-
“It is important to recognize

errors as early as possible
and not only after the
system has gone down.”
Professor Claus D. Claussen, MD,
Medical Director, Diagnostic and Interventional Radiology,
University Hospital Tübingen, Germany

difficult situation, a Siemens service
technician quickly comes to UKT. “It is
an advantage that the Siemens service
organization is set up very well in the
region and their technicians have a
shorter distance to travel than other pro-
viders,” confirms her colleague, techni-
cal assistant Andrea Ganter. Based on
the service agreement, the hospital’s
own service technicians are not only
trained by Siemens but also, for exam-
ple, work together with Siemens service
technicians in installing replacement
parts. Thus, special technical knowledge
is developed onsite, so a system can be
restarted quickly in a serious situation.
Outstanding Remote Support

and Onsite Service
“Not only are we called back quickly by
the UPTIME Service Center, but we also
appreciate that the Siemens service
“Siemens service technicians have technicians are committed and work
competently,” says Ganter, who has
often gone the ‘extra mile’ for us.” worked at UTK for 13 years. “Due to the
combination of proactive services and
Ayser Birinci-Aydogan, Radiological Assistant, the onsite Siemens service technicians,
Diagnostic and Interventional Radiology, University Hospital Tübingen, Germany planning reliability was greatly impro-
ved,“ stresses Ganter. Predictability is not
only crucial for smooth workflow in radi-
ology, but also for all further steps in the
treatment: “And that applies not only to
emergencies such as a patient with a
lung embolism in intensive care,” says
tor and image computer, system failures the Siemens service technicians and the technical assistant. “Every shift in
can often be avoided. “Our nightmare the remote support from the Siemens our schedule as a result of a system
would be if our SOMATOM Definition Service Center.” failure results in 15 people waiting at
were to go down in the core time of “So far, the Siemens service technicians the door. And follow-up appointments in
10 a.m. to 2 p.m.,” says Birinci-Aydogan. have often gone the ‘extra mile’ for us – the outpatient clinic, for example, must
Around 3 p.m. at the latest, the sur- that is not something that one should be rescheduled.” Then surgery schedules
geons need the images in order to plan take for granted,” Birinci-Aydogan and the ordering of anesthesiologists
their procedures for the following morn- reports. Often she already knows what as well as further treatments must be
ing. “For me, proactive service means to do as a result of her experience and delayed.
predictability,” continues Birinci-Aydo- involvement in the introduction of the “Service is critical for workflow in radi-
gan, as she glances away from the SOMATOM Definition, but she also ology, from admission of the patient
screen for a moment to clinic technician praises the knowledgeable contact per- all the way to dismissal,” Ayser Birinci-
Jürgen Bahls, who hurries by. “Here in sons at the other end of the telephone Aydogan also adds. “If that service per-
the hospital we have excellent techni- line and the possibility of remote formance is proactive and competent
cians, and we are also very satisfied with support and repair. In the event of a as is the case with Siemens, that is all
better,” she emphasizes.

Life
“Thanks to Guardian,
the CT scanner
was available again
after only four
hours of repair
time.”
Andrea Ganter, Technical Assistant.
Diagnostic and Interventional Radiology,
University Hospital Tübingen, Germany
“Intelligent Handling” of mization in order to avoid long wait

Immense Quantities of Data times and fast, competent diagnostics,“
summarizes Claussen. Proactive Real-time
SOMATOM CT systems provide UKT radi- The professor sees radiology as a ‘service
ologists with a large number of data sets provider’ carrying out a service role.
System Monitoring:
with high definition images. Those im- Innovative systems alone are by no Siemens Guardian
ages support the radiologists with con- means sufficient. In an increasingly in- Program
tinuously more precise and reliable diag- tense and competitive environment,
nostics, but in doing so, also supply the development of a service culture is Q Monitoring of potential system
large numbers of image data sets in key – such as his team’s interaction with malfunctions and possible devia-
order to facilitate more precise and reli- patients and colleagues in the hospital tions from predefined values.
able diagnostics. Professor Claussen sees and also within the department. The Q Telephone call from Siemens
“intelligent handling” of immense quan- medical director also expects excellent UPTIME Service Center in the
tities of data as another essential condi- service from the medical technology event of deviations.
tion of smooth workflow. During the providers and is not disappointed: „Here, Q Problems often eliminated
past year, around 200,000 diagnostic we all appreciate the competent, preven- ‘remotely’ through the Siemens
examinations and more than 2,500 tive Siemens service.“ Remote Service platform.
interventions were carried out in his Q In the event of onsite deploy-
department on CT and MR scanners as ment, Siemens service techni-
well as angiography systems. “On many cians can bring the proper
days we generate close to 40 gigabytes replacement part on the initial
of images,” says Horst Bock, who is visit.
responsible for the picture archiving and Q Reduction of unplanned system
communication system (PACS) of the down time to a minimum.
department. “Workflow must be inte- Q Improved appointment sche-
grated; it does not stop with the systems duling within and outside of the
Further Information
themselves or the PACS or the radiology radiology department.
information system. Above all, what www.siemens.com/
counts today is medical know-how as guardian-program
well as workflow organization and opti-

Life
Customer Report: Upgrade from

SOMATOM Plus 4 to SOMATOM Definition
Delivers a new Picture of Health
In 1998, the single-slice SOMATOM Plus 4 CT offered Saint Barnabas Ambula-
tory Care Center the most advanced imaging possible. Over the years, the
unit’s capabilities were far surpassed, limiting its usefulness. But it remained
a valuable trade-in for a SOMATOM Definition Dual Source CT.
By Melanie J. Davis
“After we bought a second device, a Saint Barnabas Ambulatory Care Center, technology. We can now offer physi-
SOMATOM® Sensation 16-slice scanner, Livingston, NJ. cians that ‘special extra’, so we have a
the SOMATOM Plus 4 was simply taking competitive edge.”
up expensive floor space. When we had A Smart Business Decision Saint Barnabas Ambulatory Care Center
an opportunity to get even greater im- The upgrade to the SOMATOM Defini- provides outpatient services for nearby
aging capabilities with the SOMATOM tion Dual Source CT (DSCT) is part of the Saint Barnabas Hospital and other refer-
Definition, we used the Siemens Elevate center’s efforts to provide state-of-the- ring physicians, and is responsible for
program to upgrade affordably by trad- art imaging solutions. She says, “We more than 90,000 imaging procedures
ing in the Plus 4. A third-party dealer constantly ask, ‘What’s the most we can a year.
wouldn’t have given us much for it, but do for our physicians? For our patients? The decision to upgrade from the Plus 4
we were very satisfied with the arrange- For our employees?’ Having the best to the SOMATOM Definition was made
ments we made with Siemens,” says equipment is one answer to those ques- after the staff extensively researched
Barbara Richardson, Administrative Di- tions. Dual Energy is emerging and we their options. They evaluated other ven-
rector of the Radiology Department at want to be part of the growth of that dors, and made the decision to lease
the Siemens unit.
“We’ve been with Siemens for a long
time, and we have a great relationship
“The SOMATOM Defini- with sales personnel and technicians.
tion is not just a piece of The SOMATOM Definition is not just a
piece of equipment – it’s a great rela-
equipment – it’s a great tionship,” says Richardson.
relationship between Maureen Lowe, CT Supervisor, says the
center is extremely pleased with the
Siemens and us.” outcome. “You go back and forth on the
dollars to make the best choice that will
Barbara Richardson, Administrative Director of give you the payback that you want,
the Radiology Department at Saint Barnabas and we’re happy with what we’re see-
Ambulatory Care Center, Livingston, NJ ing. The Board of Directors is very excit-
ed with what the unit can do, and they
realize that in diagnostic imaging, the
new technology makes a difference.”

Life
Transition & Training

Installing the SOMATOM Definition was
both inexpensive and easy, with the
work limited to “spiffing up” the room
and making some electrical upgrades.
Staff training consisted of Lowe and a
senior evening staff member making
two visits to the Siemens training center
in Cary, NC so they could return and,
led by a Siemens Clinical Education
Specialist who was on-site in New Jer-
sey for two weeks, train their own staff.
“Two weeks was a lot of time for the
specialist to be available to us, and
it was helpful. I think the transition
was very easy for us also because we
were familiar with Siemens units and
the syngo platform,” says Lowe.
“Post-processing is so much simpler now
because the raw data quality is so high
that you’re not doing as much reconstruct-
ing. The amount of time we save in that
aspect alone is impressive,” she adds.
New Clinical Applications

Increase Patient Count
Since the upgrade to the SOMATOM
Definition, the center’s volume of proce-
dures has steadily increased as word
has spread among physicians about the
system. Richardson says insurers’ reti-
cence to approve multiple diagnostic
CTs per patient will be offset by the in-
creased type and quantity of procedures
the center can conduct.
The SOMATOM Definition’s speed ac- The decision to upgrade to the SOMATOM Definition was made after the staff
commodates many more patients dur- extensively researched their options.
ing premium peak hours, and Siemens’
radiology information system made it couldn’t be scanned or had to go some- protocols has been scanning kidney
easy to accommodate the increased pa- place else.” stones, which the imaging center does
tient load. at least once each day.
Thanks to the upgrade, Lowe also Dual Energy Impresses “We are excited about this application
anticipates an increase in the number As important as the cardiology applica- because we can quickly determine
of bariatric patients being scanned be- tions are with the SOMATOM Definition, whether the patient should be treated
cause the SOMATOM Definition’s large Richardson says they were just a small with medication or other interventions,”
bore and increased power. part of the imaging center’s upgrade says Wilson.
Medical Director David Wilson, MD, decision: “We bought it for the emerg-
adds: “Cardiology patients benefit being technology we expect to see from Wilson and his team all agree that the
cause the Definition scans so quickly, it Dual Energy. Now we can expand into a SOMATOM Definition has provided
captures the heart’s action without the lot of areas.” many benefits to Saint Barnabas Ambu-
need for beta-blockers. We’re less de- Relatively little time has passed since latory Care Center.
pendent on the patient’s heart rate to the system was installed, yet Dual
get high-quality images. Before, those Energy is being used on a regular basis.
patients would have been told they One of the most successful of those Melanie J. Davis, Medical Writer

Life
syngo CT 2008G – New

Software Release for
SOMATOM Definition
By Marion Meusel, Business Unit CT,
Siemens Healthcare, Forchheim, Germany
The latest enhancement for SOMATOM® The new Adaptive 4D Spiral* scan mode an all-new Interventional Toolbar* and
Definition CT scanners is the new soft- allows for whole organ coverage in per- HandCARETM* for i-Fluoro to avoid direct
ware version syngo CT 2008G. This new fusion CT as well as phase-resolved imag- X-ray exposure of the surgeon’s or radi-
software will bring improved usability ing up to 21 cm. Enabled by the volume ologist’s hand during the intervention.
and the following new functionalities projector, it applies a continuously re- SOMATOM Definition systems running
for the SOMATOM Definition. The high- peated bi-directional table movement, on syngo CT 2007C will automatically
lights range from new Dual Energy ap- moving the patient smoothly in and out receive the new software syngo CT
plications to all new solutions for perfu- of the gantry over the desired scan range. 2008G** accompanied with comprehen-
sion imaging and interventions:* Interventional procedures are supported sive training on-site and supporting
The new syngo Dual Energy applications by i-Fluoro.* Fluoroscopic scans can be training material via e-learning CD.
(Heart PBV, Brain Hemorrhage, Lung acquired with low-dose techniques and
Vessels and Gout) will open new clinical displayed in real time. For fastest workflow
fields.* With these applications, custom- during interventions, scan modes can be
*Optional components that need to be
ers can take advantage of our 90 day switched on the fly with a single click. Key purchased separately.
free trial licenses. features are configurable layout screens, **Customers will be contacted by customer service.
CT Research Collaborations in China: a True Win-Win Situation

By Reto Merges, CT Research Collaborations, Siemens Healthcare, Shanghai, China
In China, the healthcare system is devel- founded a dedicated team to support CT technical knowledge, education and ad-
oping at a rapid rate alongside the eco- research in China. To be able to cater to vice that they need in order to raise the
nomic growth. Innovative healthcare the diverse needs of our Chinese part- scientific capabilities of their institutes.
concepts are being implemented in all ners, the team today consists of two radi- The activities extend from supporting
major cities of the country, therefore ologists and two engineers. research projects aimed at international
high-end CT systems are not a rarity any- It is a typical win-win situation because publications to workshops on hot topics
more. At the same time, the scientific Siemens gets a unique insight into the in radiology and scientific writing. Re-
community strives for more international customers’ needs in China and the collab- search topics cover a broad field of inno-
participation. Three years ago, Siemens oration partners gain direct access to the vative CT applications, from Cardiac Im-
aging and CT Perfusion to Dual Energy
CT. “The key is to help educate young re-
searchers so that innovative healthcare
delivery and research will go hand in
hand in the future!” says Prof. Zheng Yu
Jin, MD, Peking Union Medical College
Hospital.
A group of young researchers at
the annual seminar on scientific writing.

Life
Recording of Hands-on Workshops at ECR 2008

By Heike Theessen, Business Unit CT, Siemens Healthcare, Forchheim, Germany
At this year’s European Congress of Radi- Michael Lell, MD, University Hospital of
ology (ECR) in Vienna, more than three the Friedrich-Alexander-University Erlan-
hundred customers participated in the gen-Nuremberg who led the session on
Hands-on Workshops organized by Neuro-CT, rates these workshops to be
Siemens Healthcare. Clinical presenta- very important, because they also serve
tions by leading experts were followed to train the user with knowledge beyond
by demonstrations of clinical cases dur- application training. More about the
ing which participants were guided clinical value of Siemens Hands-on work-
through the processing tools available shops can be read under the link below.
for the syngo MultiModality Workplace There you can also order the DVD with
platform. the recording of the ECR Hands-on work-
Sitting at one of the sixteen worksta- shops.
tions, radiologists and technologists
from over fifty countries had the oppor-
tunity to discover the capabilities of the http://www.siemens.com/
syngo software. somatomeducate
New e-Learning for CARE Dose4D

By Claudia Lindner, Business Unit CT, Siemens Healthcare, Forchheim, Germany
CARE Dose4D™ and its real-time mA and customizable noise level. from Siemens’ clinical e-learning oppor-
adjustment provide best image quality at But how does it work exactly? With the tunities – and experience the latest
the lowest possible dose. Every patient new CARE Dose4D e-learning, CT-users clinical results in the various fields of CT
is different in terms of size, weight, and can easily learn how to utilize CARE imaging.
anatomy. Therefore CARE Dose4D was Dose4D most efficiently. The web based
developed to provide fully automated, version can be accessed or the CD ver-
real-time, anatomy-based dose regula- sion can be ordered via the link below.
tion. CARE Dose4D adapts the dose This is only one e-learning tool out
automatically to the specific anatomical of many others offered by Siemens http://www.siemens.com/
characteristics of each individual patient Healthcare. As part of the SOMATOM® somatomeducate
to consistently deliver a user defined Educate program “Life“, users benefit
800 mA
81 mAs 210 mAs
20 mA

1A 2
1B
1C
1 2 Adaptive 4D Spiral provides perfusion information not just for a limited section of the disease, but for the whole brain (Figs. 1A–C).
”Intervention Pro” supports spiral and sequential acquisition for interventional procedures with maximal flexibility (Fig. 2).
Free 90-Day Trial Licenses for

Clinical Applications
By Rami Kusama, Business Unit CT, Siemens Healthcare, Forchheim, Germany
Trial License: Adaptive complex vascular structures by perform- tion, further overcomes the limitations
4D Spiral ing time-resolved angiographies with of conventional 2D-CT guidance, allow-
multiple phases. With this feature, for ing for 3D visualization (MPR, VRT) and
Siemens’ unique Adaptive 4D Spiral example, arterial and venous phases can needle path planning.*** Thus, a more
moves beyond fixed detector limitations be captured in a single acquisition and comprehensive visualization of needle
to provide full coverage of any organ in can then be evaluated time-resolved. position, needle path, and surrounding
4D. This overcomes the coverage limita- The benefits of the Adaptive 4D Spiral organs supports in difficult procedures.
tion of a static detector design so the can be experienced with a 90-day free This is especially helpful when using
perfusion and dynamic coverage can be trial. ** oblique needle paths, for example,
adapted to exactly the range needed. during RF ablation.
In stroke assessment, it provides the per- Trial License: Intervention Pro Intervention Pro and Adaptive 3D Inter-
fusion information, not just for a limited & Adaptive 3D Intervention vention can be tested risk free with a
section of the disease, but for the whole For 90 days, at no cost, “Intervention 90-day free trial.**
brain,* so the physician is assured of a Pro” can be tried, supporting guidance
reliable assessment of the type and ex- for interventional procedures with maxi- * Maximum perfusion coverage depends on
system configuration.
tent of cerebral perfusion disturbances. mal flexibility and with minimal, single-
**Minimum system requirements need to be
In addition, it allows tumor perfusion click effort. In addition, spiral sequence fulfilled for these options to be available. There-
studies over the entire organ in both and fluoroscopic scan modes can be fore the related Siemens representative should
head and body,* enabling the radiolo- switched on the fly during interventions. be asked to check the system configuration.
gist to assess the perfusion and vascular- A dedicated interventional toolbar sup- ***Dual Monitor for in-room support highly
recommended.
ization of tumors. ports the workflow with respect to table
Additionally, the Adaptive 4D Spiral en- control and 2D/3D measurements. The
ables the visualization and evaluation of additional option, Adaptive 3D Interven-

Life
Clinical CT Posters
Thanks to the excellent cooperation with nation. They will help to educate staff Q CT Cardiac Anatomy
our clinical partners, we now have a and patients about the human anatomy Q CT Neuro Anatomy
growing number of posters in the Clini- as seen through a CT scanner. Key anat- Q CT Colonography
cal Poster Gallery. omy is clearly labeled, typical pathologi-
Perfect for the patient waiting room, the cal findings are described and key fea- Using the link, below a personal copy
staff lounge or the reading room, these tures of the application are noted. free of charge can be ordered.
posters illustrate the wide range of im- To date we have the following posters
ages that are possible from a CT exami- available: www.siemens.com/ct-poster
Frequently Asked Questions
Q: How can I reduce my reading time that are marked by the user him/herself. possible to convert the default display in
in syngo Oncology? To save time, the space bar can easily be the Global Result Segment from the VRT
A: By using the powerful CAD tool in used to jump from one marker to the next image to a MPR image.
syngo Oncology after an automated (or the button “B” can be used to go back Under Options -> Configuration, you will
detection of lung lesions, for example, to the previous marker). After starting find the “syngo CT Oncology” icon. Dou-
several markers are listed which need with marker number one, for instance, ble click to open the configuration menu.
to be reviewed. you only have to press the space bar to go On the second subtask card, you can
All the marked structures are numbered straight to marker number two (Fig.1). select 2D for “Default Representation”.
and listed in the Marker List. Q: Can I change the default display for Then press “OK”. The next time when you
It is also possible to have several lesions the Global Result Segment? open the syngo Oncology application the
from previous examinations or lesions A: Depending on your preference, it is changes are applied (Figs. 2-3).
1 2 3
1 2 3 In the result view, the markers can easily be found to review tissue lesions (Fig. 1). In the configuration menu, the default
display can easily be changed for the Global Result Segment (Figs. 2-3).

Life
Clinical Workshops 2009

As a cooperation partner of many renowned hospitals, Siemens Healthcare offers continuing CT training programs.
A wide range of clinical workshops keeps participants at the forefront of clinical CT imaging.
Workshop Title Dates Location Course Course

language director
Clinical Workshop on Cardiac CT 21.–23.01.09 Erlangen/Germany English Prof. Stephan Achenbach, MD
Clinical Workshop on Cardiac CT 15.–16.05.09 Paris/France English Jean-Francois Paul, MD
11.–12.09.09
Clinical Workshop on Cardiac CT 04.–06.02.09 Munich/Germany English PD Christoph Becker, MD
08.–10.07.09 Alexander Becker, MD
09.–11.11.09
Clinical Coronary CTA 12.– 13.03.09 Erlangen/Germany English Prof. Stephan Achenbach, MD
Interpretation Course 14.– 15.05.09
Clinical Training Course 21.–22.03.09 Kuching/Malaysia English Prof. Sim Kui Hian
on Cardiac CT 25.–26.07.09 Ong Tiong Kiam, MD
21.–22.11.09
Hands-on Workshop Cardio-CT 03.–04.07.09 Zürich/Schweiz German PD Hatem Alkadhi, MD
Clinical Workshop on 27.–30.04.09 Münster/Germany English PD Johannes Wessling, MD
State-of-the-Art Applications 21.–24.09.09
Virtual CT-Colonography 27.–28.03.09 Berlin/Germany German Prof. Bernd Lünstedt, MD
25.–26.09.09
20.–21.11.09
Dual Energy Workshop 20.–21.02.09 Forchheim/Germany English Thorsten Johnson, MD
17.–18.04.09
Cardiac-CT Basics for Technologists 19.–20.03.09 Forchheim/Germany German Heike Theessen
06.–07.04.09 English
Clinical Coronary CTA Workshop 05.-06.04.09 Munich/Germany English PD Christoph Becker, MD
21.-22.06.09 Alexander Becker, MD
ESGAR CT-Colonography 02.–04.02.09 Harrogate/ English David Burling, MD
Workshop United Kingdom Clive Kay, MD
Stuart Taylor, MD
ESGAR CT-Colonography Workshop 17.–19.09.09 Stresa/Italy English Daniele Regge, MD
Clinical Workshop on Cardiac CT, CMIV 22.–24.04.09 Linköping/Sweden Swedish Anders Persson, MD
Clinical CT Colonography Workshop, CMIV 18.–20.03.09 Linköping/Sweden Swedish Ulf Björnlert, MD
Clinical PET/CT Basic Course 04.–06.11.09 KS Stockholm/Sweden Swedish
Clinical Radiology Optimization 13.–15.05.09 Norrköping/Sweden Swedish Pia Björk/ Elisabeth Olsson
Course, Norrköping
Clinical Workshop Advanced 23.–26.09.09 Linköping/Sweden Swedish Petter Quick/ Peter Holmqvist
CT Application, CMIV
Workshop SOMATOM Definition 18.–20.02.09 Stockholm/Sweden Swedish Lars Karlsson
for Hospital Physicist
In addition, you can always find the latest CT courses offered by Siemens Medical Solutions at www.siemens.com/SOMATOMEducate

Life
Scientific Photography Prize

for Anders Persson
The annual Lennart Nilsson Award this The commendation is considered to be
year goes to Professor Anders Persson, the world’s most prestigious award in
MD (Linköping University). The Swedish scientific and medical photography.
radiologist is honoured for his innova- Read more about Persson’s methodology
tive 3D images depicting the human in the SOMATOM Sessions Magazine 22.
body internally. Using CT technology, he
has provided new possibilities in forensic www.siemens.com/
pathology. healthcare-magazine
Upcoming Events & Congresses

Title Location Short Description Date Contact
Moscow Moscow, International Dec. 08 –12, 2008 www.zdravo-expo.ru/en
Healthcare Russia Exhibition
Arab Health Dubai, Exhibition and Jan. 26 –29, 2009 www.arabhealthonline.com
UAE Scientific Congress
25th Annual Orlando, CME Course Feb. 12 –15, 2009 www.hopkinscme.edu
Computed USA
Tomography 2009:
The Cutting Edge
ECR Vienna, Exhibition and March 06 –10, 2009 www.ecr.org
Austria Scientific Congress
ACC Orlando, Exhibition and March 29 –31, 2009 www.acc09.acc.org
USA Scientific Congress
GEST Paris, France Global Embolization April 15 –18, 2009 www.gest09.eu
Symposium and
Technologies
ITEM Yokohama, Internat. Tech. April 16 –19, 2009 www.j-rc.org
Japan Exhib. of Med.
Imaging
Deutsche Mannheim, 75th Annual Meeting April 16 –18, 2009 www.dgk.org
Gesellschaft für Germany
Kardiologie
ICNC Barcelona, Nuclear Cardiology May 10 –13, 2009 www.icnc9.org
Spain and Cardiac CT
11th International San Francisco, Stanford CME Course May 19 –22, 2009 radiologycme.stanford.edu
Symposium on USA and Exhibition
Multidetector-Row CT
DRK Berlin, National Scientific May 20 –23, 2009 www.roentgenkongress.de
Germany Congress
2nd World Congress Valencia, Scientific Congress May 30 –June 02, 2009 www.2wcti.org
of Thorac. Imag. and Spain
Diagn. in Chest Disease
(WCTI)
In addition, you can always find the latest CT courses offered by Siemens Medical Solutions at www.siemens.com/SOMATOMEducate

Subscription
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Our customer magazine family offers the latest information and background for every
healthcare field. From the hospital director to the radiological assistant – here, you can
quickly find information relevant to your needs.
Medical Solutions
Innovation and trends News
in healthcare. The Our latest topics
magazine, published such as product
three times a year, is news, reference
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AXIOM Innovations MAGNETOM Flash SOMATOM Sessions Perspectives

Everything from the worlds Everything from the world Everything from the world Everything from the world
of interventional radiology, of magnetic resonance of computed tomography. of clinical diagnostics. This
cardiology, fluoroscopy, imaging. The magazine With its innovations, clinical semi-annual publication pro-
and radiography. This semi- presents case reports, applications, and visions, vides clinical labs with diag-
annual magazine is primar- technology, product news, this semi-annual magazine nostic trends, technical inno-
ily designed for physicians, and how-to’s. It is primarily is primarily designed for vations, and case studies.
physicists, researchers, and designed for physicians, physicians, physicists, It is primarily designed for
medical technical personnel. physicists, and medical researchers, and medical laboratorians, clinicians and
technical personnel. technical personnel. medical technical personnel.
For current and older issues and to order the magazines, please visit www.siemens.com/healthcare-magazine

Editorial Imprint
“The new scanner is a

true revolution. We
“Lowest radiation dose
SOMATOM Sessions – IMPRINT E. Hendrich, MD, Department of Radiology M. Remy-Jardin, MD, PhD, University Center of
© 2008 by Siemens AG, Berlin and Munich and Nuclear Medicine, German Heart Center, Lille, Department of Thoracic Imaging, Hospital
All Rights Reserved Munich, Germany
M. Higashi, MD, Department of Radiology and
Calmette, Lille, France
P. Schramm, MD, Department of Neuroradiology,
never before dared to
Publisher: Nuclear Medicine, National Cardiovascular Cen- University of Göttingen, Göttingen, Germany
scan with such a low
is important to
Siemens AG ter, Osaka, Japan
Healthcare Sector W. Sommer, MD, Department of Clinical Radiolo-
R. Hoffmann, MD, Department of Clinical Radiol- gy, University of Munich, Campus Großhadern,
Business Unit Computed Tomography
Siemensstraße 1, 91301 Forchheim, Germany ogy, University of Munich, Campus Großhadern,
Munich, Germany
Munich, Germany dose and such a high
T. Taoka, MD, PhD, Department of Radiology,
Chief Editors:
speed.”
physicians and patients.
T. Jakobs, MD, Department of Clinical Radiology, Nara Medical University, Nara, Japan
University of Munich, Campus Großhadern, Mu- Catherine Carrington, freelance author
nich, Germany Melanie J. Davis, medical writer
S. Kanzaki, MD, Department of Radiology and Tony DeLisa, freelance author
Willi Kalender, PhD, Director of the Institute
Nuclear Medicine, National Cardiovascular Cen- Sameh Fahmey, medical and scientific journalist
It’s important to us.”

ter, Osaka, Japan Hildegard Kaulen, PhD, freelance scientific of Medical Physics, University of Erlangen-Nuremberg,
journalist Erlangen, Germany
K. Kichikawa, MD, PhD, Department of Radiolo-
gy, Nara Medical University, Nara, Japan Oliver Klaffke, freelance scientific journalist
Tim Schröder, freelance scientific journalist
S. Kitano, MD, Department of Radiology, Nara Rita Wellens, PhD, medical writer and clinical
Medical University, Nara, Japan research consultant
Monika Demuth, PhD Stefan Wünsch, PhD A. Kohli, MD, Department of Radiology, Breach Photo Credits: Peter Rigaud/Shotview, Jez Coul-
Sami Atiya, PhD, Chief Executive Officer, (monika.demuth@ (stefan.wuensch@ Candy Hospital Trust, Mumbai, India son, Tina Ruisinger, Stephan Sahm, Chris De
Business Unit CT, Siemens Healthcare, Forchheim, Germany siemens.com) siemens.com) T. Löffler, MD, Department of Surgery, University Bode
of Munich, Campus Großhadern, Munich, Peter Aulbach; Steven Bell; Andreas Blaha;
Responsible for Contents: André Hartung Germany Joachim Buck, PhD; Jan Chudzik; Ulrike Dräger-
Editorial Board: Andreas Blaha, Andreas Fischer, S. Martinoff, MD, Department of Radiology and Klar; Ivo Driesser; Carolin Emmert; Inga Fötsch;
Thomas Flohr, PhD, Klaudija Ivkovic, Axel Lorz, Nuclear Medicine, German Heart Center, Mu- Tanja Gassert; Christoph Hachmöller, MD; Carolin
Jens Scharnagl, Heiko Tuttas, Alexander Zimmer- nich, Germany Knecht; Rami Kusama; Claudia Lindner; Reto
mann Merges; Marion Meusel; Kerstin Putzer; Rainer
N. Marugami, MD, Department of Radiology,
Raupach, PhD; Holger Reinsberger; Peter Seitz;
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