Somatom session 28

Answers for life in Computed TomographySOMATOM Sessions

28

Issue Number 28 / June 2011Stanford-Edition | June 13th – 16th 2011

Cover Story Iterative ReconstructionGoes MainstreamPage 6

News FAST CARE Hits the Bull’s Eye2

Business syngo.via with the SOMATOM Defi nition-Flash: “A Technical Revolution”Page 32

Clinical ResultsNew 70 kV Protocol Ensures Low RadiationDose in Pediatric Patients with CongenitalHeart DiseasePage 54

Science CARE kV – How to Opti-mize Individualized DosePage 62

On account of certain regional limitations of sales rights and service availability, we cannot guarantee that all products included in this brochure are available through the Siemens sales organization worldwide. Availability and packaging may vary by country and is subject to change without prior notice. Some/All of the features and products described herein may not be available in the United States.

The information in this document contains general technical descriptions of specifications and options as well as standard and optional features which do not always have to be present in individual cases.

Siemens reserves the right to modify the design, packaging, specifications and options described herein without prior notice. Please contact your local Siemens sales representative for the most current information.

Note: Any technical data contained in this document may vary within defined tolerances. Original images always lose a certain amount of detail when reproduced.

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SOMATOM Sessions · June 2011 · www.siemens.com/healthcare-magazine 77

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2 SOMATOM Sessions · June 2011 · www.siemens.com/healthcare-magazine

Editorial

“Our success with FAST CARE fully supports our visionary perspective and sense of responsibility to make CT a diagnostic measure with broad acceptance and availability to almost all patients – worldwide.”

Walter Märzendorfer, Chief Executive Officer,Business Unit Computed Tomography and Radiation Oncology, Siemens Healthcare, Forchheim, Germany

Cover Page: Courtesy of University Hospital Zurich, Zurich, Switzerland

SOMATOM Sessions is also available on the internet: www.siemens.com/SOMATOMWorld

SOMATOM Sessions – IMPRINT© 2011 by Siemens AG, Berlin and MunichAll Rights Reserved

Publisher:Siemens AGHealthcare SectorBusiness Unit Computed TomographySiemensstraße 1, 91301 Forchheim, Germany

Chief Editors:Monika Demuth, PhD([email protected])Stefan Ulzheimer, PhD([email protected])

Clinical Editor:Andreas Blaha([email protected])

Project Management: Sandra Kolb

Responsible for Contents: Peter Seitz

Editorial Board:Andreas BlahaMonika Demuth, PhDHeidrun EndtAndreas FischerTanja GassertJulia HölscherSandra KolbAxel LorzPeter SeitzStefan Ulzheimer, PhD

Authors of this issue:Hatem Alkadhi, MD, University Hospital Zuerich, Switzerland

Andreas Artmann, MD, Radiologie im GHZ and Klinikum Wels-Grieskirchen, Wels, Austria

Philipp Blanke, MD, Department of Radiology, University of Freiburg, Germany

Stefan Bulla, MD, Department of Radiology, University of Freiburg, Germany

Filippo Del Grande, MD, Ospedale Civico, Lugano, Switzerland

Dieter Fedders, MD, Department of Radiology Hubertusburg, Wermsdorf, St. Georg group of companies, Leipzig, Germany

Yutaka Imai, MD, PhD, Department of Radiology, Tokai University, Kanagawa, Japan

Shuichi Kawada, MD, Department of Radiology, Tokai University, Kanagawa, Japan

Tadashi Kobayashi, MD, Department of Surgery, Kabayashi Hospital, Tokyo, Japan

Wolfgang Köhler, Department of Neurology Hubertusburg, Wermsdorf, St. Georg group of companies, Leipzig, Germany

Mathias Langer, MD, Department of Radiology, University of Freiburg, Germany

Michael Lell, MD, PD, Radiology Department, University of Erlangen-Nuremberg, Erlangen, Germany

Irene Noszian, MD, Radiologie im GHZ and Klinikum Wels-Grieskirchen, Wels, Austria

Gregor Pache, MD, Department of Radiology, University of Freiburg, Germany

Markus Ratzenböck, MD, Radiologie im GHZ and Klinikum Wels-Grieskirchen, Wels, Austria

Ermidio Rezzonico, Ospedale Civico, Lugano, Switzerland

Johannes Rixe, MD, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany

Andres Rolf, MD, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany

Oliver Rompel, MD, Radiology Department, University of Erlangen-Nuremberg, Erlangen, Germany

Tomoaki Shinkai, RT, Department of Radiology, Kabayashi Hospital, Tokyo, Japan

Kim Smith, MD, Radiology SA Central Districts Hospital, Elisabeth Vale, Australia

Piotr Sokolowski, MD, Department of Neurology Hubertusburg, Wermsdorf, St. Georg group of companies, Leipzig, Germany

Klemens Trieb, MD, Radiologie im GHZ and Klinikum Wels-Grieskirchen, Wels, Austria

Peter Wilson, MD, Department of Radiology, Coffs Harbour, Australia

Gao Yong, MD, Department of Radiology, Shanghai Jiangong Hospital, Shanghai, China

Irène Dietschi, Science editor, Olden, SwitzerlandIngrid Horn, Scientific writer, GermanyEric Johnson, external Journalist, GermanyManuel Meyer, Freelance Jounalist, SpainMichaela Spaeth-Dierl, Medical editor, Spirit Link Medical, Erlangen, Germany

Peter Aulbach, Florian Belohlavek, Andreas Blaha, Tiago Campos, Robert Dittrich, Tiago da Silveira Jaques, Jochen Dormeier, MD, Ivo Driesser, Heidrun Endt, Ute Feuerlein, Jan Freund, Larry Gallone, Benjamin Gutheil, Sandra Kolb, Rami Kusama, Janine Krebs, Katharina Linseisen, Christianne Leidecker, PhD, Marion Meusel, Sayoko Miyanishi, Jakub Mochon, Katharina Otani, PhD, Johann Russinger, Philip Stenner, PhD, Stefan Ulzheimer, PhD, Susanne von Vietinghoff, Li Chen Wei

Photo Credits: Thomas Schmidt, TM Studios, Nürnberg; Thorsten Rother; Jez Coulson/insight-visual; istock; Juan Pablo Moreiras / Agentur Focus

Production and PrePress: Norbert Moser, Kerstin Putzer, Siemens AG, Healtchare Sector

Printer: Mediahaus Biering GmbH, Freisinger Landstrasse 21, 80939 Munich, Germany

Desing and Editorial Consulting: Independent Medien-Design, Munich, Germany In cooperation with Primafi la AG, Zurich, Switzerland Managing Editor: Christa KrickPhoto Editor: Anja KellnerLayout: Claudia Diem, Mathias Frisch, Julia Hollweck, Elke Irnstetter, Luitgard SchüllerAll at: Widenmayer straße 16, 80538 Munich, Germany

The entire editorial staff here at Siemens Healthcare extends their appreciation to all the experts, radiologists, scholars, physicians and technicians, who donated their time and energy – without payment – in order to share their expertise with the readers of SOMATOM Sessions.


Dear Reader,

Somatom28_Content.indd Abs2:3 31.05.11 10:58

Cover Story

Contents

Cover Story

News

Business

Somatom28_Content.indd Abs2:4 31.05.11 10:58


Content

Acute Care 52 Dual Energy CT: Virtual Non-Con-

trast Imaging of a Complicated Renal Cyst

54 New 70 kV Protocol Ensures Low Radiation Dose in Pediatric Patients with Congenital Heart Disease

56 Diagnosing Pulmonary Embolism Using High Pitch Protocols

Orthopedics 58 Reliable Detection and Diagnoses of

Gout Using Dual Energy Acquisition Technique

60 Dual Energy CT: Virtual Non-Calcium Technique Detects Posttraumatic Bone Bruise of the Knee

Science

62 CARE kV – How to Optimize Individualized Dose

65 Choosing the kV is Now an Easy Equation – a First In-practice Report on CARE kV

66 Dose Neutral Dual Energy Scanning with Dual Source CT

Clinical Results

Cardio-Vascular 38 Thoracic Triple Rule-Out in Low

Dose Acquisition Technique Using Prospective ECG-Triggering

40 SOMATOM Definition AS+ Scanning: Coronary Artery Anomaly

42 Retrograde Filling of Occluded Proximal Coeliac Trunk – Confirmed by CTA

Oncology 44 CT Examination Reveals Extremely

Small Stone in the Kidney with SAFIRE

46 4-Phase Liver Examination with SOMATOM Emotion 16 Unveiled Liver Haemangioma

48 SOMATOM Emotion 16 Chest Imaging: Ground Glass Opacity in the Upper Right Lung

Neurology 50 SOMATOM Emotion 16: Intracranial

Head CTA – Dolichoectasia of the Basilar Artery

Life

68 Free Trial Licenses for syngo.via are now available

69 Experience Lounge: Hands-on Workshops at ECR 2011

69 Clinical Workshop on Cardiac CT at Munich University

70 New Series of Live Clinical Webinars70 FAST CARE for All Patients of syngo

Evolve Customers71 Investment Protection for

SOMATOM CT Scanners72 Frequently Asked Questions:

How can Dose be Reduced with syngo.via

73 Upcoming Events & Congresses73 Clinical Workshops 201174 Siemens Healthcare Publications75 Imprint

60 DECT: Virtual Non-Calcium Technique Detects Posttraumatic Bone Bruise

28 Growing Demand for Postmortem Imaging

58 Reliable Detection and Diag noses of Gout Using Dual Energy Acquisition Technique

Session28_Inhalt.indb Abs2:5Session28_Inhalt.indb Abs2:5 27.05.11 09:3527.05.11 09:35

Coverstory

Iterative Reconstruction Goes MainstreamIterative Reconstruction (IR) offers radiologists the choice: lower the radiation dose or get better image quality. IR is now becoming part of radiological routine.

By Eric Johnson


“It moves us well along the path of ALARA, but it ensures that we still can do our primary job, which is to capture an excellent diagnostic image.”

Bob McGregor, MD, Winkler’s Boundary Trails Health Centre, Manitoba, Canada

Flat as an ironing board, flanked by fields of waving wheat and canola, the 10,000-person town of Winkler could be Central Casting’s selection for Anytown USA, even though it sits a 15 minute’s drive north of the border in Canadian Manitoba. Typical, average, middle-of- the-road, with a whiff of ‘Lake Wobegone’ – the fictional setting made world-famous by (almost) local author Garrison Keillor.

Just west of town in a former farming field, Winkler’s Boundary Trails Health Centre fits the mould. It is a general hospital, treating the range of ailments that afflict a regional population of some 65,000. “We’re not a specialized institu-tion as such,” comments radiologist Bob McGregor, MD, “here we treat all kinds of patients, all kinds of diseases and all regions of the body.” Ordinary as that seems on the outside, McGregor has

since last September been using a tech-nology that clearly is extraordinary: iterative reconstruction. IR used to be the exclusive preserve of molecular imaging and nuclear medicine, but thanks to ongoing increases in comput-ing power, now it is routinely available for CT imaging. IR is up and running in day-to-day practice, not just here in mid-dle America, but also in middle Europe and middle South America as well. Join-ing McGregor in mainstreaming IR are two other radiologists: Hatem Alkadhi, MD of Switzerland’s University Hospital Zurich, and Dany Jasinowodolinski, MD of Brazil’s Hospital do Coração in São Paulo.

Down with DosageBetween the three resides some 45 years of radiological experience, much of it logged on what is still the industry workhorse and standard for image creation: filtered back projection (FBP). And good as FBP is at generating quality images – which of course is the radiolo-gists’ primary mission – all three of them recognize the rising pressure of ALARA. “As low as reasonably achievable” has

Session28_Inhalt.indb 6Session28_Inhalt.indb 6 27.05.11 09:3527.05.11 09:35

Coverstory


1 The dataset of a patient with urinary stones is acquired with SAFIRE and a very low radiation dose of 1.6 mSv. Obviously the image does not appear noisy in spite of the low dose usage. Courtesy of University Hospital Zurich, Zurich, Switzerland

1


become their byword, especially in the wake of the notorious 2008–09 overdosing of brain-scan patients in the US.“People fear radiation,” observes Alka-dhi, “partly because it’s so mysterious, something they cannot feel or see.” He personally believes that the public’s angst has been hyped, not least by sensational media reports and pseudo-scientific claims. Still, he takes a ‘better-safe-than-sorry’ view toward low-dos-age. “In the case of, say, a 50-year-old male who has lower abdominal pain

and needs a one-off scan, the exposure is really not a significant health risk,” he notes. “On the other hand we have many patients – for instance, those with a lymphoma or urinary stones – who are younger and who need repeated scans over relatively long periods. Especially for these we should, as a priority, keep doses as low as we can.”Since coming online last November, this is precisely what University Hospital Zurich has been doing with its new Sinogram Affirmed Iterative Recon-struction, better known as SAFIRE.*,**


Alkadhi says that doses for chest scans have tumbled nearly ten-fold from 5–7 to 0.6–0.8 mSv; for abdominal images the exposure has been dropped from 8–10 to about 1.6 mSv. With its IRIS** system (Iterative Reconstruction in Image Space), Canadian Boundary Trails has also dropped exposure mightily: McGregor reports declines of 45 percent in abdominal-pelvic scans and 55 percent in chest imaging. Also using IRIS, Hospital do Coração is achieving radiation reduction of 50 percent that, according to Jasino-

Coverstory

“People fear radiation, partly because it’s so mysterious, something they cannot feel or see.”

Hatem Alkadhi, MD, MPH, University Hospital Zurich, Switzerland

* The information about this product is being provided for planning purposes. The product is pending 510(k) review, and is not yet commercially available in the U.S.** In clinical practice, the use of SAFIRE or IRIS may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A

consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task.


Coverstory


wodolinski, are accompanied by 35 per-cent less noise.

Business as UsualDosage drop has come at no sacrifice to image quality. McGregor has cataloged same-patient images taken first with FBP and then with IRIS, and concluded that images are equivalent. The doctors do find that IR changes the texture of the body views, rendering them dif-ferently than conventional FBP. “But after a short adjustment period, one gets used to this change,” Alkadhi notes,

“IRIS is a big step forward for us.”

Dany Jasinowodolinski, MD, Hospital do Coracao, Sao Paolo, Brazil



Coverstory

Data recycling: the nous behind IRIterative reconstruction (IR) is the latest in a long line of innovations to reduce radiation dose. Reconstruction refers to the task of building an image out of a scan’s projection raw data. Iterative refers to the method. Calculations are repeated over and over, to zero in on the best possible image, minus artifacts and noise. The fundamentals of IR have long been

known and applied in other fields, but until recently, to use it with CT imaging in conventional clinical medicine was simply too time-consuming: the com-puter took too long to reconstruct the images. In 2009, that changed. Newly-launched IRIS (Iterative Reconstruction in Image Space) was powerful enough to plough through the iterations within acceptable cost and time limits. SAFRIE

More powerful dose reduction than image-based methodsWell-established image impressionSuperior image qualityReady for clinical routine use with fast image reconstruction performance of up to 20 images per second

Dose reduction** or image quality improvementWell-established image impressionFast reconstruction in image space

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(Sinogram Affirmed Iterative Reconstruc-tion),* released shortly afterwards, is even more powerful. Whereas IRIS first reconstructs a master image and then iterates on that, SAFIRE also iterates back through the raw data itself (see graphic), allowing even greater reductions** in radiation-exposure and eliminating conventional CT artifacts.

* The information about this product is being provided for planning purposes. The product is pending 510(k) review, and is not yet commercially available in the U.S.** In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task.



Coverstory

adding that quality is retained with IR, just in a slightly different way.Although the three doctors are using IR to slash dose, it can also be used to improve image quality. In cases where imaging is typically difficult – say, bariatric patients – IR can raise results, notes Alkadhi. Depending on the spe-cific circumstances, quality can still be hiked with a dose decline.Either way, IR is quickly integrated into radiological routine. After a short set-tling-in period, McGregor’s day-to-day work with IRIS is much the same as it

Leading hospitals in their countries

was with its FBP predecessor. So, too, is Alkadhi’s with SAFIRE. “Generating images for an abdominal dataset might take an extra 30 seconds or so,” he notes. Jasinowodolinski’s IRIS takes about one minute longer to create images than the previous FBP system. All the doctors expect that ever-rising computation power will in due course eliminate that extra processing time altogether.IR is definitely a worthwhile investment, they conclude. “IRIS is a big step forward for us,” offers Jasinowodolinski.

“It moves us well along the path of ALARA,” says McGregor, “but it ensures that we still can do our primary job, which is to capture an excellent diagnos-tic image.” Ordinary aims, extraordinary dose-reduction – that will be IR.

Eric Johnson writes about technology, business and the environment from Zurich. Formerly he headed what is now a Thompson-Reuters bureau and corresponded for McGraw-Hill World News.

Boundary Trails Health CentreAcute services to the community are provided by the 94-bed Boundary Trails Health Centre, Canada. This facility, which also acts as a regional

Hospital do CoraçãoThe HCor – Hospital do Coração is located in the Paraiso neighborhood in the city of São Paulo, Brazil. It diversified its scope of services and offers treatment in 37 medical spe-cialties today, such as orthopedics,

UniversitätsSpital ZürichThe University Hospital Zurich is located in the center of Zurich, opposite the University of Zurich and the Federal Technical High School (ETHZ). Comprised of 40 depart-ments and institutes, both special-ised and comprehensive, University Hospital Zurich incorporates all medical disciplines. University

health centre providing primary, sec-ondary, and community health care to the residents of South Central Manitoba, is located between Win-kler and Morden and serves a popu-lation of about 65,000 in the area. It

traumatology, oncology, neurology, urology, gastroenterology, surgery in diverse specialties, image diagnosis, sports medicine, and nutriology, among others. In order to accomplish its social mission as philanthropic hospital, the HCor offers the most

Hospital Zurich is serving approxi-mately 200,000 patients a year. With 850 beds and more than 270,000 hospital days, University Hospital Zurich is one of the largest hospitals in Switzerland. The Institute of Diag-nostic and Interventional Radiology offers the full spectrum of general diagnostic and interventional radiol-ogy and features sub-specialization

is an integral part of the services offered by Regional Health Authority – Central Manitoba Inc. Currently, there are approximately 450 employees working at the Boundary Trails Health Centre.

advanced technology in cardiologic procedures to needy children. The HCor has the most advanced technol-ogy within the health care area in Latin America, with a highlight for the Diag-nosis Center – which performs more than 1,2 million exams annually.

expertise. It combines excellence in research and outstanding education with the highest quality health care. The number of inpatient and outpa-tient radiology procedures totals over 100,000 annually, which are carried out at the request of medical special-ists and general physicians. The hos-pital’s expert radiologists work with skilled technologists and nurses.



News

FAST CARE Hits the Bull’s EyeFAST CARE ushers in a new era in computed tomography. After the market launch at the RSNA 2010, the new technology platform has been up and running in clinical institutions for several months. Experiences in Zurich, London and Tacoma prove that FAST simplifi es and accelerates workfl ows, and reduces radiation dose even further – thanks, in particular, to the new CARE kV technology.

By Ingrid Horn, PhD

The latest generation SOMATOM Defini-tion AS – the high-end, single-source CT scanner from Siemens – has been deliv-ered with the innovative technology platform FAST CARE since March 2011. “CARE” (Combined Applications to Reduce Exposure) unite all technologies currently used by Siemens to reduce radi-ation doses in a unique manner. Although enormous progress in terms of radiation

protection and dose reduction has been made in the last 15 years, reducing radiation doses in computed tomogra-phy even further remains an issue for Hatem Alkadhi, MD. “It is assumed that all additional radiation is unhealthy for patients. As a result, we aim to con-tinue avoiding unnecessary radiation, exploiting the technical potential to reduce doses for patients to its fullest,”

explains the Zurich-based radiologist. He researches at the Institute for Diag-nostic Radiology based at the University Hospital Zurich, Switzerland, a selected test center for CARE.Over a six month period, Alkadhi and his team have performed an in-depth analy-sis of CARE kV technology in clinical con-text. CARE kV is a breakthrough addition to CARE Dose4DTM, a tool which already

1 FAST Spine delivers an automatic segmentation of the spinal canal and automatic labeling of the vertebrae.Courtesy of University Hopspital of Zurich, Switzerland

1



allows maximum image quality with minimum dose for each patient, thanks to real-time dose modulation. So what’s the advantage of CARE kV? The answer is clear: in addition to the current modulation familiar from CARE Dose4D, CARE kV also optimizes CT examinations and the administered dose via the auto-matic selection of suitable voltage in line with pertinent diagnostic issues and the patient’s physique. The radiologist explains the situation as follows: “We used to be confronted frequently with the problem of whether we should reduce the tube voltage or not, and to what extent. And, if so, whether the reduced image quality jeopardizes a reli-able diagnosis. We often used parame-ters such as body weight or body mass index to assist us in the decision-making process. However, the question of which body weight should necessitate a reduc-tion in tube voltage and radiation dose, and the extent of the said reduction proved divisive. By contrast, CARE kV plans the examination for us in advance with an optimized radiation dose, usu-ally decreasing this so that the patient ultimately receives less radiation.”Meanwhile, the radiologists in Zurich have found scientific evidence for the reduction in radiation dose via CARE kV. They carried out a study of vascular patients who require repeated CT scans within the context of follow-up treat-ment. Material pre-dating the launch of CARE kV is available concerning these patients. This permits an effective comparison of radiation dose and image

quality with and without the use of CARE kV. They are also currently collect-ing relevant data for the CT examination of the neck region with regard to bone and soft tissue. Alkadhi summarizes: “The additional dose reduction is huge in the case of all patient groups exam-ined.” He indicates a dose reduction of between 20 and 30 percent for all evaluated patients. If circumstances are favorable, reductions of up to 50 percent in scans of the neck region are even possible in isolated cases.

Olivia Egan in London, England, is also a fan of the CARE package. She holds the post of CT Superintendent Radiogra-pher at the Chelsea and Westminster Hospital and views the issue from a dif-ferent perspective, commenting: “CARE gives my technical team a high degree of security as regards dose reduction.” Olivia Egan views the easy compatibility of CARE kV with FAST as an additional benefit. “FAST” (Fully Assisting Scanner Technologies) stand for all programs designed to simplify scanning work-flows. She goes on to outline a further benefit of FAST Adjust, namely that it allows less experienced technicians on the roster to achieve the highest quality images with the lowest radiation dose possible. FAST Adjust ensures that scan parameters such as scan time, pitch or tube current can be set correctly with just a single click. In just a few weeks, these simple operations have become routine for the technologists in London.

Employees at MultiCare’s Tacoma Gen-eral Hospital trauma service in Tacoma, Washington, USA, highly appreciate how FAST (Fully Assisting Scanner Technolo-gies) takes care of the finer details at the CT and accelerates workflows in the pro-cess. MultiCare Imaging Manager, Joe Larson is full of praise for the FAST Spine tech nology: “FAST Spine gives us an enormous time advantage in the case of suspected spinal column injuries.” The program marks the vertebrae within a predetermined scan area of the spine automatically and calculates the posi-tion of vertebrae and disks for an ana-tomically correct image reconstruction. Up until now, this process was per-formed manually by a technologist ver-tebra by vertebra, which easily took a half-hour or more. Larson explains, “FAST Spine accelerates the entire pro-cess automatically and naturally. The images are produced immediately, so that the surgeon can evaluate them in real time. This allows the trauma sur-geon to decide more quickly whether to operate.” FAST Spine also reduces the time normally placed on CT technolo-gists, because quick action is essential in trauma cases. Both physicians and CT technologists at Tacoma General Hospi-tal point to FAST CARE as essential to improving their working environment.

2 These two images show the abdomen scan in 2009 (Fig. 2A) with 140 kV and as follow-up examination in 2011 (Fig. 2B) with CARE kV and only 100 kV. Both images have the same image quality although using lower kV in 2011.

Ingrid Horn, PhD, studied biology and bio-chemistry. She is an expert in science communi-cations and an experienced medical writer.

www.siemens.com/fastcare

2B2A


News

New SIERRA Expert Sub-Committee Focusing on Pediatric Dose Reduction Established

Within SIERRA, Siemens’ expert panel on dose reduction, a new group, concentrating on dose savings in pediatric radiology, has been formed.

By Stefan Ulzheimer, PhD, and Heidrun Endt, Computed Tomography, Siemens Healthcare, Forchheim Germany

The Siemens Radiation Reduction Alliance (SIERRA) was founded in June 2010. Six-teen radiologists, physicists and cardiolo-gists, renowned for their scientific research on dose in medical imaging, joined the expert panel to set up tasks to determine how dose can be further reduced. When imaging children, dose becomes even more important as children are more sensitive to radiation. Researchers in this special field of radiology have joined together in a SIERRA sub-commit-tee. This sub-committee will not only concentrate on new technologies but – equally important – on education for pediatric imaging. Siemens’ scanners pro-vide a lot of innovative technologies to reduce dose, so education should focus on these technologies, their functionality and optimal application in daily clinical practice. Marilyn Siegel, MD, Mallinck-

rodt Institute of Radiology, St. Louis, U.S., will head this new group within SIERRA. Siegel joined the SIERRA panel in June 2010 as did Elliot Fishman, MD, Johns Hopkins University Hospital, Baltimore, U.S . Additionally both will now support the efforts concerning pediatric radiol-ogy. CARE kV and CARE Child, the most recent technologies that come with Sie-mens’ SOMATOM Scanners, were devel-oped and tested in close collaboration together with Siegel.For Siemens, dose reduction, while deliv-ering excellent image quality in radiology and during interventional procedures, has always been a top priority. Innovative CARE (Combined Applications to Reduce Exposure) features are an integral part of all Siemens systems. Using lower tube voltages in CT can dramatically reduce dose, especially in small patients and children1. However, this potential has not

been widely exploited because a lot of related conditions have to be observed. As defining the ideal tube voltage for each patient was not an easy step to make, this parameter was seldom adapted to the current patient and exam-ination in clinical practice. Now CARE kV automatically selects the optimal tube voltage based on the individual patient and application. Furthermore, with CARE Child, Siemens provides the industry’s first-ever scans with voltage as low as 70 kV. Combining both, CARE kV and CARE Child, leads to a dramatic reduction of dose, especially in pediatric patients. Fishman states: “The latest dose reduc-tion features like a 70 kV mode will espe-cially benefit our youngest patients. But it is also important that the equipment is used in an optimal fashion. Therefore, I’m happy to work with Siemens and my peers on optimizing protocols and on


“The latest dose reduction features like a 70 kV mode will especially benefi t our youngest patients. But it is also important that the equipment is used in an optimal fashion (…).”

Elliot Fishman, MD, Johns Hopkins University Hospital, Baltimore, U.S.


Expert Advice on Dose Reduction Always at Your Fingertips By Heidrun Endt, Computed Tomography, Siemens Healthcare, Forchheim, Germany

Siemens SOMATOM scanners come with innovative technologies for dose reduc-tion, making low dose CT examinations possible for every patient. Now a new series of flyers is available which includes advice on how to reduce dose even further: experts from Siemens CT Research & Development department share their knowledge about using these technologies in the most efficient way. “How to reduce dose in Pediatric CT imaging” is one of the first flyers out of this series. As children are more sensi-tive to radiation than adults, it is of utmost importance to pay attention when imaging pediatric patients. This flyer includes tips and tricks* to guide the user from patient preparation to protocol selection and application of features such as CARE Dose4D.Two more flyers are available: “How to reduce dose in Cardio CT,” suitable for

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www.siemens.com/low-dose-CT

www.siemens.com/CT-infoportalTraining & Education; Order your training material

the SOMATOM Definition AS Family and another one for the SOMATOM Definition Flash, both with syngo CT 2011. Which is the most appropriate scan mode for the patient and which reconstruction parameters should be chosen? These flyers provide all the information necessary in daily clinical practice. As the series continues, more flyers will be available on the latest technologies, for example CARE kV.To have expert advice on dose reduction always at the fingertips, flyers can be ordered via the Customer Information Portal, Siemens Internet.

education programs to make sure that new technology is not only developed but also adopted as fast and as broadly as possible.”One of the first steps of the newly estab-lished sub-committee will be a publica-tion that summarizes the possibilities of dose reduction for pediatric patients. Other activities in terms of best practice sharing are planned, in order to transfer the expert advice to as many radiologists as possible who perform CT examinations in children.

How to reduce dose in Pediatric CT imaging and Cardio CT: three flyers out of a new series are available providing expert advice on dose reduction.

The members of the SIERRA sub-group focusing on pediatric imaging are Marilyn Siegel, MD, Elliot Fishman, MD, and Joseph Foss, MD, (Arnold Palmer Hospital for Children & Women, Orlando, U.S.). Additionally, Cynthia Rigsby, MD, (Children’s Memorial Hospital, Chicago, U.S.) and Robert Gilkeson, MD, (University Hospital Case Medical Center, Cleveland, U.S.) have joined the sub-committee. They will all help to optimize the use of leading edge technology in daily clinical practice, sharing their knowledge in this special field of radiology. The formation and follow-up of this expert panel with its sub-committee indicates once more, Siemens’ ongoing efforts to reduce dose to the lowest extent possible.

n

[1] Siegel MJ et al. Radiation dose and image quality in pediatric CT: effect of technical factors and phantom size and shape. Radiology. 2004, Nov; 233(2):515–22.


*Appropriate for syngo CT 2010 or earlier.

Somatom28_News_Sierra_Dose.indd 15Somatom28_News_Sierra_Dose.indd 15 31.05.11 11:0731.05.11 11:07


Faster Abdominal Aortic Stent Planning with syngo.via and the CT Cardio-Vascular EngineBy Philip Stenner, PhD, Computed Tomography, Siemens Healthcare, Forchheim, Germany

Abdominal aortic aneurysms (AAA) pose a serious threat to patients as a rupture will cause abdominal bleeding which is a life-threatening condition. Ruptured aneurysms are responsible for roughly 9,000 annual deaths in the US.1 With an occurrence of 4%-7% in adults of 65 years and older, AAAs are a common disease worldwide.2 Up until the late 80s, the conventional treatment was an open repair of the aorta. The treatment of AAAs was revolutionized in 1991 by the first endovascular aortic repair (EVAR).3 With this technique, a stent is inserted through a catheter to the place of the aneurysm and expanded to stabi-lize the surrounding vessel. Today, com-pared to an open repair, the risks for the

patient are dramatically reduced, lead-ing to 30-day mortality rates of only 1.2%.4

Crucial for the success of an EVAR proce-dure is correct pre-procedural planning to assess the anatomy and optimal stent size for each patient. With its high spa-tial resolution, Computed Tomography (CT) is the method of choice. With SOMATOM Scanners on the scanner side and syngo.via on the post-processing side, Siemens Healthcare provides an excellent solution for the planning of EVAR procedures. The software syngo.CT Vascular Analysis* provides an efficient and reliable assessment of the abdominal aortic anatomy. Due to comprehensive automated pre-

processing, like automated bone and table removal, an immediate vascular-only view is provided. The Autotracer** automatically segments and labels the vessels even before the case is opened. The aorta is displayed in a curved planar reformation and the centerline is auto-matically created providing the basis for important length measurements.Since 95% of aortic aneurysms are infra-renal, i.e. below the ostia of the renal arteries, syngo.CT Vascular Analysis provides a dedicated stent planning template for these cases (Fig. 1). The template guides the user through mea-suring the length and diameters of the aneurysm, the aorta, and the left and right illiac arteries. The distance of the aneurysm to the renal arteries and to the illiac bifurcation are also included. Along with the registration of all mea-surements in the Findings Navigator, all diameter measurements are automati-cally saved in the stent planning tem-plate which is easily accessed in the report editor. The automation greatly facilitates the workflow and allows for a reliable assessment of abdominal aortic stent parameters thus providing a sound basis for EVAR procedures.

www.siemens.com/ct-cardiology

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1 Macari M, et al. Radiology 2006, Vol. 241, No. 3, 908–914.

2 Katzen BT, et al. Circulation 2005; 112: 1663–1675.

3 Parodi JC, et al. Ann Vasc Surg. 1991; 5: 491–499.

4 Prinssen M, et al. N Engl J Med 2004; 351:1607–1618.

1 The success of endovascular aortic repair strongly depends on correct pre-procedural planning. syngo.via and the CT Cardio-Vascular Engine provide a powerful means for efficient and reliable assessment of the abdominal aortic anatomy and all parameters necessary for stent planning.

1

*syngo.CT Vascular Analysis is available either as a stand-alone software package or as one of several software and hardware features in the CT Cardio-Vascular and Acute Care Engines.

**Available in the Acute Care Engine Pro and CT Cardio-Vascular Engine Pro


syngo.via Powers CT Oncology Engine for Oncological Assessment By Jochen Dormeier, MD, Computed Tomography, Siemens Healthcare, Forchheim, Germany

Oncological diagnosis and assessment of effectiveness of cancer therapeutics make use of standards like RECIST 1 (response evaluation criteria in solid tumors) and standards set by the WHO (World Health Organization).2 Therefore, easy access to the right measurement tools as well as dedicated reporting capa-bilities are essential to report on response or progression comparing the most cur-rent with the baseline examination. Either in parallel to conventional report-ing from PACS or by reporting directly using the CT Oncology Engine, syngo.via facilitates this assessment by bundling a variety of dedicated functionalities for oncological reading.Even before the case is opened, syngo.via works in the background to pre-fetch relevant patient image data from previous examinations. In addition, for lung cases, computer aided detection, and for virtual colonoscopy cases, polyp-enhanced viewing algorithms prepare the cases as second reader tools – its

www.siemens.com/ct-oncology

results being immediately available.For comparison with previous examina-tions, the current and baseline images are loaded into the reading physician’s preferred layout. The datasets are auto-matically registered so that the same anatomical areas are displayed in both datasets while scrolling through the scans. If measurements have already been performed with syngo.via for the baseline, these measurements are avail-able in the findings navigator for easy call-up and comparison with the specific lesion in the current scan. As soon as the lesion in the baseline and the current examination are measured and linked, the report provides relevant information about RECIST and volumetric changes of the tumor size.In contrast to conventional 2-dimensional PACS based reading, syngo.via’s approach of working with data volumes and utiliz-ing automated segmentation algorithms provides access to reproducible results for volumetric assessment of tumor burden.


1 Eisenhauer EA et al. New response evaluation criteria in solid tumors: revised RECIST guideline (version 1.1). J. Eur J Cancer. 2009 Jan; 45(2): 228-47

2 World Health Organization, WHO Handbook for Reporting Results of Cancer Treatment, Offset Publication No. 48, Geneva, 1979

3 Prasad SR, et. al. CT tumor measurement fortherapeutic response assessment: comparisonof uni-dimensional, bi-dimensional, and volumetric techniques-initial observations. Radiology 2002; 225(2): 416–419

1 Assessment of tumor change over time is essential for efficient oncological follow up. Being able to decide about response, stable or progres-sive disease determines the decision for therapy continuation or change in the oncological regimen. Radiologists can benefit vastly from having the right diagnostic software like syngo.via and the CT Oncology Engine at their disposal.

Especially for volumetric approaches, scientific publications have shown significant deviations in disease assess-ment compared to RECIST and WHO and requests for large studies have been formulated.3 Here the CT Oncology Engine immediately provides the right tools at the fingertips.

1



SOMATOM Emotion – The Most Popular CT in the World* – Now with IRIS**By Rami Kusama, Computed Tomography, Siemens Healthcare, Forchheim, Germany

The success story of over 7,000 SOMATOM Emotion installations con tinues. To meet present and future demands for higher quality and cost-efficient healthcare, Siemens has intro-duced IRIS – Iterative Reconstruction in Image Space – at this year’s ECR 2011 on the SOMATOM Emotion 16 as well as the SOMATOM Emotion Excel Edition. With the introduction of IRIS on the world’s biggest installed base, this compact scanner is set to offer not only improved image quality or lower dose** for better patient care, but will

also help users to stay at the forefront in an increasingly competitive and rapidly changing healthcare market.There is no doubt that medical imaging saves lives and thus its utilization has increased immensely over the years. With its increased utilization, radiation dose and radiation dose reduction have become one of the most discussed topics in and outside of the imaging community. As an innovation leader in dose reduc-tion, Siemens has long applied CARE (Combined Applications to Reduce

Exposure), a comprehensive approach to all areas of diagnostic and inter-ventional imaging. Today, the Siemens CARE standard brings together a wide variety of advanced technologies and applications to meet the needs of patients and physicians for appropriate radiation dose with the best possible outcomes for diagnoses and interven-tions.In addition, depending on the system configuration, IRIS can also be added retrospectively for already installed SOMATOM Sensations as well as SOMATOM Emotion 16-slice configu-rations.“Bringing IRIS on the Emotion, our widest installed base, means offering low dose to the widest possible patient population,” says Peter Seitz, Vice President Marketing CT.The SOMATOM Emotion produces clini-cally excellent results, while reducing ongoing costs, and protecting business through superb system reliability. Siemens also continues to offer a consistent software platform, syngo®, throughout all product lines to make training faster, more efficient, and less expensive to facilities worldwide. If you are a radiologist, technologist, or finan-cial administrator, you will also enjoy the knowledge that you own the world’s most popular CT scanner*, now with IRIS.

www.siemens.com/SOMATOMEmotion

* Based on the number of systems worldwide.** Expected availability summer 2011.

In clinical practice, the use of Iterative Reconstruc-tion IRIS may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiolo-gist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task.

IRIS

Image data recon

Image correction

Raw data recon

Standard FBP

Limited dose reduction Ultra-fast recon without iterations Well-established image impression

Significant dose reduction Image quality improvement Fast recon in image space Well-established image impression

Dose reduction with CT has been limited by the currently used filtered back projection reconstruc-tion algorithm as displayed on the left. Using IRIS results in increased image quality or dose savings for a wide range of clinical applications.

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Dose savings may vary according to body region. Data on file.


The New SOMATOM Spirit – Modern. Easy. Reliable. By Florian Belohlavek, Computed Tomography, Siemens Healthcare, Forchheim, Germany

The new SOMATOM Spirit sets standards in the segment of entry-level CT. Siemens´ sub-second, multi-slice CT scanner stands out due to simplicity and excellent reliability without loss of quality. “Making state-of-the-art CT affordable is one of the key goals in the Siemens CT vision. With the SOMATOM Spirit – a modern, easy-to-use and reli-able multi-slice CT, Siemens provides an adequate answer for day-to-day examina-tions in clinical practice,” says Peter Seitz, Vice President Marketing, Business Unit CT, Siemens Healthcare. “A combination of well-proven components and modern features like a gantry-front display, fast computer hardware and an adjustable patient table are setting new standards in the entry-level segment.”

ModernThe SOMATOM Spirit is a synonym for efficient system design. This philosophy is easily recognized in the slim and highly efficient gantry that has become the benchmark in the CT industry. And, starting with the 2011 models, the SOMATOM Spirit comes equipped with a gantry-front display showing parameters

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www.siemens.com/SOMATOMSpirit

such as tube current, tube voltage, scan time, table position and gantry tilt, all particularly useful, for example, for interventional and other procedures. Equipped with the industry leading detector material UFC,TM the SOMATOM Spirit offers a segment-leading, high-contrast resolution of 15.5 lp/cm at 0% modulation transfer function (MTF). The SOMATOM Spirit offers a compre-hensive spectrum of CT applications to perform all the 2D and 3D functions that are required in daily routine. Addition-ally, a wide selection of optional features is available to equip the scanner for spe-cial needs, for example Neuro Perfusion, Dental CT or automated bone removal.

EasySiemens has designed a tailor-made, ease-of-use, syngo user interface for the SOMATOM Spirit. A “follow-me” approach is used that quickly takes the user – step by step – through all the procedures required for a successful scan. The user is logically guided through procedures for patient registration, protocol selection and patient positioning in preparation for the scan. Standardized procedures and

The new SOMATOM Spirit is equipped with a gantry-front display.

* Results may vary. Data on file.


protocols make it easy for all staff mem-bers to achieve standardized results. Also important for rapid and reliable workflow is the state-of-the-art computer hardware with an excellent recon speed of five images per second. In addition, the new patient table facilitates easy patient posi-tioning and contributes to efficient and profitable workflow.

ReliableSiemens believes that the only time that can be afforded is UPTIME, so engineering and production efforts emphasize this goal. Results from the almost 2,000 sys-tems installed around the globe indicate that the SOMATOM Spirit has a 99.6%* UPTIME rate and regularly achieves 10,000 scans – and more – without a single glitch.

Addressing all needs of an affordable multi-slice CT used in daily routine, the SOMATOM Spirit is modern, easy and reli-able. A system that can be trusted.



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SOMATOM Defi nition Flash – the Gold Standard in CT

By Peter Aulbach, Computed Tomography, Siemens Healthcare, Forchheim, Germany

A system or device is called the “gold standard,” if it is the best and most suc-cessful for the required task. The ECRI is an US non-profit organization that researches quality, cost effectiveness and patient safety of medical equipment. They serve more than 5,000 members including hospitals, public and private payers and government agencies. In the case of CT, they assessed all relevant competing technologies in the market and compared their capabilities for the most common tasks in CT.Their conclusion was that only the

SOMATOM Definition Flash provides fast, low-dose scanning that minimizes the effects of patient movement, making it especially valuable in trauma, pediatric and cardiac cases. Special advantages are amongst many others:■ A Cardiac Flash mode requiring very

low dose■ Excellent, reliable image quality at all

heart rates■ Tripe rule-out examination for chest

pain, in less than one second■ The Flash scan mode is a viable alter-

native, particularly for patients unable to hold their breath or those at low cardiac risk

■ The combination of fast imaging for uncooperative children (Flash mode) and dose reduction makes the system a very useful tool for pediatric imaging

■ The Adaptive 4D Spiral that enables

good brain and excellent body perfusion imaging with widest coverage of any evaluated systems of up to 48 cm

■ The effective dose for a Dual Energy scan that is the same as for a conven-tional single energy scan

■ Excellent image quality and dose management

■ Noise reduction, with iterative recon-struction techniques for dose reduction

■ Whole-body studies that are completed in under five seconds

Studying the ECRI1 results one could conclude that the SOMATOM Definition Flash is the best and most successful technology for CT routine and advanced tasks thus rightly defining the “gold standard” in CT imaging.

www.ecri.org

1 ECRI Institute Report, HEALTH DEVICES, MARCH 2011

Successful RSNA 2010 for Siemens’ Research Partners

Researchers from the Medical University of South Carolina (MUSC) were especially successful and received three awards from the conference committee.By Heidrun Endt and Stefan Ulzheimer, PhD, Computed Tomography, Siemens Healthcare, Forchheim Germany

MUSC was awarded trainee research prizes in three different categories: chest radiology, emergency imaging and cardiac. The research for these three outstanding contributions was done on Siemens SOMATOM scanners. Triple-rule-out examinations obtained in patients with acute chest pain were further analyzed. Matthias Renker, BSC, presented a study where an evaluation with an automated detection algorithm for lung nodules was added to the clini-cal reading as some of these lesions are overseen during emergency imaging.

Thomas Henzler, MD, is working at the University hospital of Mannheim and currently visiting MUSC as a research fellow. He presented that CT examina-tions in cases of acute pulmonary embo-lism can additionally be used to assess signs of right ventricular strain. Thus the expensive measurement of a specific biomarker for right ventricular dys-function might no longer be necessary. Cardiac CT with the SOMATOM Definition Flash enables an overall assessment in patients with coronary artery disease: morphology of the ves-

www.rsna.org

sels, cardiac function and perfusion. Markus Weininger, MD, concluded that one examination may provide all the information that is necessary for the diagnosis of coronary artery disease.

Thus SOMATOM scanners are used for scientific research very successfully pro-viding innovative technology and soft-ware features that improve patient care.

Thomas Henzler, MD, Prof. Joseph Schoepf, MD, (Director of Cardiovascular Imaging and CT Research and Development, MUSC) and Markus Weininger, MD, presenting the cer-tificates for their successful, prize-winning research.


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International CT Image Contest 2011 – Siemens Repeats a Previous SuccessExcellent image quality is essential for accurate clinical diagnostics. Additionally, another important ambition should be the lowest possible radiation exposure for the patient. By Michaela Spaeth-Dierl, medical editor, Spirit Link Medical, Erlangen, Germany

Siemens Healthcare wants to support its customers in making efficient use of hardware and software to reduce dose on CTs and in sharing their experiences with colleagues and other interested audi-ences. Therefore, the first International CT Image Contest was inaugurated in 2010 with great success. Almost 300 users of Siemens CT scanners from about 30 countries submitted their best clinical images taken with the lowest possible radiation dose. There was even a fan community on Facebook with more than 1600 members, who discussed the images submitted. In addition, internet users were able to publically vote for their favorite picture. The internet page devoted to the contest received 17,000

hits within 6 months. Following up on this amazing interest, Siemens Healthcare has now announced the “International CT Image Contest 2011.” The contest was officially launched at the European Con-gress of Radiology (ECR) 2011 in Vienna on March 3rd. Siemens customers who work with a Siemens SOMATOM CT scan-ner of any performance class will have the opportunity to compete for the title of the best image in seven categories. The submissions will be evaluated by an international top-class jury made up of acknowledged experts in the following categories: Cardiology, Angiography, Dual Energy, Pediatrics, Trauma, Neu rology and areas of clinical routine including Thorax, Abdomen and Pelvis.

www.siemens.com/image-contest You can be a fan of the Interna-tional CT Image Contest 2011 at www.facebook.com/imagecontest

Images can be submitted until Sep tember 18th, 2011. The contest will close with an award-winning ceremony at the RSNA in Chicago at the end of November. In addition, monthly winners will be picked by the expert jury. Each monthly category winner will receive a certifi cate as “low-dose CT expert”.Terms and conditions of entry for the “International CT Image Contest 2011“ can be obtained here:

Following up on the amazing interest in the first International CT Image Contest in 2010, Siemens Healthcare has now announced the “International CT Image Contest 2011.”


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Data Analysis Aids Dose Reduction with the New CARE AnalyticsBy Tiago Campos, Computed Tomography, Siemens Healthcare, Forchheim, Germany

The measurement and calculation of radiation dose is an important topic for efficient dose management, not only in computed tomography (CT) but also for all areas where X-ray exposure is uti-lized. Siemens provides tools such as DICOM Dose Structured Reports (DICOM SR) and CARE Analytics.* The DICOM SR contains comprehensive data for each irradiation event, the accumulated dose (CTDI and DLP) in CT,

and information about the context of the exposure. The data is provided in DICOM standard format that can be sent to any system which receives, stores and/or processes dose information, such as conventional PACS or workstations.In order to evaluate and analyze the information contained in the DICOM SR files, Siemens provides a new, free tool: CARE Analytics. CARE Analytics allows dose received by

patients during an examination with computed tomography systems, X-ray and fluoroscopy devices as well as angiography systems, to be analyzed and evaluated. Hence, it can help radiologists and other clinicians, for example, to optimize their scan proto-cols, and to work with reduced dose. This software tool can be installed on any office computer connected to the hospital network and is able to retrieve and query SRs from DICOM nodes directly or import them from a USB device. Dose reporting data can then be exported and analyzed with standard tools, such as Microsoft Excel™.With the use of CARE Analytics, medical staff is able to compare dose given during different examinations in order to further optimize the scan protocols. In addition, it is possible to ascertain the dose a patient has received on dif-ferent systems over a series of examina-tions. Dose reporting between multiple hospitals is also possible. The increased transparency lets clinicians improve their working practices and be more sparing with the dose given than in the past. Contact your local Siemens representative in order to obtain CARE Analytics.

www.siemens.com/ihe

* further details in: SOMATOM Sessions 27, page 68–71

At Siemens, one of the core responsibilities is to provide medical institutions with solu-tions that enable them to further lower radiation dose. CARE Analytics is yet another tool to help achieve that goal.


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CARE Contrast IIIBy Florian Belohlavek and Ute Feuerlein, Computed Tomography, Siemens Healthcare, Forchheim, Germany

One of the biggest challenges in com-puted tomography is a high quality con-trast scan. In the year 2005, Siemens Healthcare took an important step by introducing a solution for bolus injection coupling. By synchronizing the scan and contrast media injection, the bolus injec-tor workflow could be simplified and adapted to the needs of the clinical envi-ronment. Even if only one technician is present, the reading physician is able to perform high quality contrast scans on the one hand and handle the simultane-ous bolus injection on the other. This unique CARE solution is based on the international standard for the communi-cation between CT and injector – the CANopen application profile for medical diagnostic add-on modules.In 2009, another important milestone was passed with the introduction of the second version of CARE Contrast. CARE Contrast II facilitates contrast enhanced

clinical workflow by synchronizing CT scan and contrast media injection using a single button control from either the scanner or the injector. In addition, the injection parameters are automatically transferred to the patient protocol, the e-logbook and to the Modality Per-formed Procedure Step (MPPS) thus completing the data for the examina-tion. With this, no separate documenta-tion is needed, resulting in significant workflow improvements: e.g. the injec-tor information is available from the pic-ture archiving and communication sys-tem (PACS) when reading the images or accessible from the hospital information system (HIS) / radiology information system (RIS). A new and higher level of injector cou-pled scanning has now been reached with the latest Siemens innovation – CARE Contrast III. It is based upon the highly integrated CANopen, class-4 standard

for bi-directional communications that can reach a new level of improved con-trast workflow. In addition to all features of the earlier versions, CARE Contrast III is equipped with the latest innovations: For the first time, contrast protocols can be defined and managed on the scanner console and transferred to the injector. By operating contrast management on the scanner console, a combination of scan and contrast protocols in inte-grated examination protocols is possi-ble. Protocols on the scanner can be adjusted to cover the frequently used cases in the clinical environment and can be transferred to other scanners with the same setup. CARE Contrast III is available for the SOMATOM Definition AS and Definition Flash family with the latest scanner software version.

“ The coupling of scan-ner and injector in combination with pre-defi ned contrast protocols promotes fast and effective workfl ow. The handling, com-bined with the Medrad injector, is simple and dependable.”

Prof. Christoph Becker, MD, and Barbara Wieser, Department of Radiology, Ludwig-Maximilians-University, Campus- Grosshadern, Munich, Germany

SYNC.START



Synergies in CT – For Better Patient CareBy Stefan Ulzheimer, PhD, Computed Tomography, Siemens Healthcare, Forchheim, Germany

SOMATOM Sessions – Only One Click AwayBy Sandra Kolb, Computed Tomography, Siemens Healthcare, Forchheim, Germany

Medical progress very often relies on teamwork. Both Bayer Healthcare and Siemens Healthcare continuously strive to improve CT quality at the lowest possi-ble radiation levels. This happens by combining technological and pharmaceu-tical expertise. Both companies are pro-moting the exchange of knowledge among the most experienced CT users worldwide and through researching and working together. This is done by sharing relevant research results, joint scan protocol development, attendance at expert panels, by organiz-ing joint symposia and by publishing pod-casts with medically interesting cases.

Reading magazines attentively is time consuming and difficult for a radiologist in an active, successful practice.Would it not be great to read about the exciting possibilities with Siemens CT on an iPad? Scrolling through the latest news on the Blackberry at the airport? Or discussing an exceptional case study with a colleague directly at the office PC? Now we have the answer: the online version of SOMATOM Sessions. The online magazine is now only one mouse click away for reading or refer-ence 24/7.All articles and case studies can be browsed by specialty and a smart over-view of all the hot topics like low dose in computed tomography and training

Almost 800 participants attended the Bayer-Siemens Lunch Symposium at ECR 2011.

Siemens Computed Tomography magazine, SOMATOM Sessions, is now available as online version: www.siemens.com/somatom-sessions.

Furthermore courses at the Imaging Science Institute in Berlin (part of the Charité, the biggest University Hospital in Europe) are offered where radiologists receive hands-on training as well as STAR (Specialized Training in Advances in Radiology) Workshops, an international educational forum for practizing radiolo-gists. So far, STAR meetings have been held in 36 countries with more than 26,000 radiologists attending.A recent highlight of these joint activities was the lunch symposium at ECR 2011. Here experts like Michael Lell, MD, Marilyn Siegel, MD, Joseph U. Schoepf, MD, and Andreas Mahnken, MD, shared

their extensive research on iterative reconstruction, pediatric dose optimiza-tion, and contrast media administration with almost 800 medical specialists attending. Even the exhibition at the Bayer Communication Center in Leverkusen was a winner with over 5,000 visitors from the general public.

possibilities is offered. And readers can now leave a comment, so it’s feasible to interact with the editorial team or other readers. It is also possible to subscribe and get the latest news via email and – if desired – forward interesting articles to a friend by email or through social networks.The printed Sessions will continue to be published twice a year. The printed copies can be ordered on the online sessions homepage.Visit us now and enjoy.

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www.star-program.com

www.siemens.com/somatom-sessions



Five Areas of Ecological Improvements in CTBy Johann Russinger, Computed Tomography, Siemens Healthcare, Forchheim, Germany

Siemens has a long history of ecological improvements. Recently Siemens targeted primarily five areas: ecological manufac-turing, radiation minimization, life-cycle extension, refurbishing and recycling.

Ecological ManufacturingSiemens’ concern for environmental safety begins long before the first scan in the planning phase together with R&D and during prototype development. One example is taken, lead is no longer used as counter-weights and has been eliminated in many other areas in newer models. All materials are selected keeping ecological aspects in mind. In short, potential eco-logical “burdens” are eliminated for the entire life-cycle of the system.

Radiation MinimizationSiemens’ SOMATOM Definition Flash was designed primarily to make CT exams much healthier for patients using less radiation dosage than previous systems – e.g. less than 1 mSv for cardiac examina-tions. In this context, the SOMATOM Definition Flash requires 45% less energy for a standard thorax scan and 85% less energy for a cardiac Flash scan compared to previous models.

Life-cycle ExtensionThe third area of ecological responsibility involves life-cycle extension – in other words, extending the useful life of the scanner before it needs to be replaced with a newer model. Along with a wide selection of software updates, Siemens offers Evolve, a long-term and financially attractive update program designed to keep existing systems up-to-date and therefore extending their useful lives.

RefurbishingWhen a customer becomes ready for a new system for his radiology department, Siemens offers a trade-in program for their existing scanner. Complete CT systems and their components are dismantled and

shipped back to the factory where they are refurbished and re-sold with a new equipment warranty.

RecyclingLast but not least, recycling systems at the end of their life-cycle are very impor-tant. A possibility for responsible conduct comes when a system simply must be recycled. And here our story has come full circle. All possible measures were taken into account in the beginning when the system was designed to make recycling easy years later:■ All substances contained in the product

and its packaging are documented.

■ Plastic parts are labeled for recycling.■ Disassembly instructions for high-

quality recycling are available.■ Product take-back is carried out

according to strict EU directives.■ More than 97% of the used materials

can be recycled.■ The environmental product declara-

tion is available for download via internet.

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1 A two-month-old child underwent sur-gery to correct trans-position of the great arteries. Due to the short scan time of 0.3 seconds there was no need for sedation or breath-hold in this CT exami-nation. The image shows a narrowing of the tracheal lumen (arrow). Courtesy of Friedrich-Alexander University Erlangen-Nuremberg, Germany

The SOMATOM Defi nition Flash Helps to Deal with Everyday Clinical ChallengesWith the SOMATOM Defi nition Flash, highest clinical requirements can be met. Six recently published scientifi c papers show the capabilities of the system in pediatric imaging and when using iterative reconstruction.

By Heidrun Endt, Computed Tomography, Siemens Healthcare, Forchheim, Germany

Imaging pediatric patientsIn the field of pediatric radiology, special conditions and clinical needs have to be considered. Three scientific papers report on CT examinations obtained with children, proving the capabilities now brought into routine clinical practice with the system.A group of researchers from France examined 30 children up to six years old, suffering from congenital heart disease (CHD). Different anatomic structures such as the heart, the coronary arteries and thoracic vessels had to be assessed

while dose should be kept down. This is especially important in this patient population as follow-up examinations after therapy and further observation might be necessary in the coming years. Applying a prospectively ECG-triggered scan mode, known as step-and-shoot mode, the physicians achieved impres-sively low-dose values with a mean radiation dose of 0.26 mSv. Image qual-ity was rated 4.7 on a scale from 1 to 5. All examinations provided diagnostic image quality. According to the authors, the study “ [...] demonstrates that tech-

nological im pro vements in CT allow the acquisition of high-quality images with very low radiation doses in pediatric patients with CHD”.1

CT examinations of 32 children also suffering from CHD, were analyzed in terms of image quality, radiation dose and diagnostic accuracy by a group of researchers in Minnesota. The images were obtained applying different pitch values from 2.25 up to 3.4. In addition the results were compared to CT scans acquired with a conventional multi-slice-CT scanner. Those examinations obtained with a pitch of 3.4 with the SOMATOM Definition Flash could be car-ried out with the lowest possible radia-tion dose. In addition, the young patients were breathing normally during the examinations. The diagnostic quality of the CT examinations acquired under dif-ferent clinical conditions was not influ-enced by the scan speed and free breath-ing. So the authors conclude that the high pitch scan mode “[...] may be the preferred mode of imaging for specific pediatric patient subsets for definition of combined cardiac and extracardiac anatomy”.2

At the University of Erlangen, 30 children diagnosed with CHD or cardiovascular malformation, underwent CT examina-tion with the SOMATOM Definition Flash. The physicians performed these scans in high-pitch mode. This scan mode enabled them to obtain the diagnostic images with a mean scan time of 0.49

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1


2 Two CT examinations of the thorax obtained at different time points from a patient diagnosed with lung cancer to monitor chemotherapy. With IRIS, a significant reduction of radiation dose from 2.8 mSv* to 1.4 mSv* could be achieved while maintaining excellent image quality. CT examination of the thorax without IRIS, CTDIvol = 5.11 mGy, DLP = 199 mGy cm, eff.dose = 2.8 mSv* (Fig. 2A). CT examination of the thorax with IRIS, CTDIvol = 2.54 mGy, DLP = 98 mGy cm, eff. dose 1.4 mSv* (Fig. 2B). Courtesy of Hospital Calmette, Lille, France


seconds. Despite patient motion, due to the speed of the scan there was neither need to sedate the young patients nor for controlled ventilation. On the one hand, this improves the workflow, as personnel specialized in sedation and anesthesia in children are not necessary. On the other hand, even more importantly, the patients are not exposed to additional risks because of these anesthetic proce-dures. The conclusion by the authors: “High-pitch chest CT is a robust method to provide highest image quality making sedation or controlled ventilation [...] unnecessary, whereas maintaining low radiation dose values”.3

IRIS as a powerful tool to reduce doseSOMATOM scanners offer a wide spec-trum of technologies developed to reduce radiation exposure to the lowest possible dose. IRIS, Siemens’ Iterative Reconstruction in Image Space, has meanwhile been repeatedly scientifically validated. A study published by Bittencourt et al. reports about 55 coronary CT Angiogra-phy examinations that were recon-structed twice, applying filtered back projection as the conventional recon-struction method and in a second step applying IRIS: image noise decreased and higher signal to noise ratios could be achieved with iterative reconstruction.

This was true for all three scan modes which were chosen due to different clinical conditions.4 Thus, dose can be reduced for coronary CT Angiography examinations without compromising image quality.Researchers from France carried out a study that was divided in two parts. In the first part they assessed 32 chest CT examinations obtained with the estab-lished scan protocol settings of their institution. They reconstructed the imag-ing datasets twice, once with filtered back projection and once with IRIS. Objective and subjective image noise could be clearly reduced and the image quality scores increased when images were reconstructed with IRIS. Based on a detailed analysis of lesion conspicuity, the authors state that IRIS enables “[...] significant reduction of image noise without loss of diagnostic information [...]”.5

For the second part of their study the researchers evaluated chest CT examina-tions of 80 patients. These patients underwent a first CT examination in a conventional mode, without IRIS. As all of them needed a follow-up scan, a second CT examination was performed. The follow-up scans were obtained with reduced dose and with the use of IRIS. This led to a mean effective dose of 1.5 mSv* compared to 2.3 mSv* for the conventional mode. The authors con-

clude that IRIS enables “dose reduction without loss of diagnostic information” and that “even higher dose reductions than 35% may be feasible”.6

Scientifi cally validatedThese publications provide an unbiased proof: Highest clinical requirements are met with the SOMATOM Definition Flash, opening new possibilities for CT in daily clinical practice.

News2A 2B

1 Paul JF et al. Radiation dose for thoracic and coro-nary step-and-shoot CT using a 128-slice dual-source machine in infants and small children with congenital heart disease. Pediatr Radiol. 2011 Feb; 41(2):244-9.

2 Han BK et al. Accuracy and safety of high pitch com-puted tomography imaging in young children with complex congenital heart disease. Am J Cardiol. 2011 May 15;107(10):1541-6.

3 Lell MM et al. High-pitch spiral computed tomography: effect on image quality and radiation dose in pediatric chest computed tomography. Invest Radiol. 2011 Feb; 46(2):116-23.

4 Bittencourt MS et al. Iterative reconstruction in image space (IRIS) in cardiac computed tomography: initial experience. Int J Cardiovasc Imaging. 2010 Dec 1. [Epub ahead of print]

5 Pontana F et al. Chest computed tomography using iterative reconstruction vs filtered back projection (Part 1): Evaluation of image noise reduction in 32 patients. Eur Radiol. 2011 Mar;21(3):627-35.

6 Pontana F et al. Chest computed tomography using iterative reconstruction vs filtered back projection (Part 2): image quality of low-dose CT examinations in 80 patients. Eur Radiol. 2011 Mar;21(3):636-43.

*calculated using published conversion factors: 0.014 mSv/mGy cm (McCollough C et al. Strategies for Reducing Radiation Dose in CT. Radiol Clin North Am. 2009 January; 47(1): 27–40.)



Growing Demand for Postmortem ImagingPostmortem examination by means of computed tomography and other imaging techniques is still a novelty in many countries. But at the forensic institute of the University of Zurich, Switzerland, scanning the bodies is daily routine.

By Irène Dietschi

The man’s body, after being exhumed from the cemetery in the early morning hours, was brought to the Institute of Legal Medicine at the University of Zurich around 9 a.m. The coffin was admitted through the wide entering

gates on a trolley, pushed through the hall, where mortuary fridges are arrayed along the wall, and brought straight to the adjoining imaging section of the institute. There, the body underwent a complete CT scan. It took no more than

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ten minutes to push it through the wide opening of the SOMATOM Definition Flash, thereby virtually cutting the body into thousands of razor-thin slices. All this while the man’s body remained in the coffin (Fig. 1).

1 The wide bore of 78 cm allows scanning of larger objects such as coffins too.

1


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The Dose Report – New Feature of Utilization Management

Typically, dose data are available to operators during every examination, but these data are sometimes not documented afterwards for later reference or analysis. With Siemens service offering, Utilization Management, dose information can be accessed for SOMATOM Defi nition systems.*

By Benjamin Gutheil and Janine Krebs, Customer Service, Siemens Healthcare, Erlangen, Germany

Siemens Utilization Management (UM) includes dose reports as a new feature. UM is a proactive service offered from Siemens UPTIME Services that provides system-specific usage data. Access to these detailed data enables users to leverage their systems’ full potential. They receive extensive equipment utili-zation analyses and anonymous bench-mark information about comparable systems at other facilities operating in similar environments, as well as dose infor mation on a regular basis.With the new dose report, operators obtain an overview of the total number

and the percentage split of scan ranges per selected protocol, as well as the available dose information for the selected month. They can see if any specific values have been exceeded.

What are the key benefits?■ Visibility of dose usage data on a

monthly or multi-monthly period ■ Increased awareness of radiation

exposure among clinicians■ Easy way to track system and dose

utilization details at the point of care■ Increased patient safety

How does the user obtain access to these data?With regards to Computed Tomography, dose reports are made available through the LifeNet UPTIME Services Portal. This is Siemens’ secure web portal pro-viding users with the information needed to manage the productivity of their Siemens diagnostic equipment. In the dose report, users obtain an overview of all selected protocols, indicating if any specific values have been exceeded and what radiation dose has been administered.

* from software version VA20

1 All important figures are collected in the dose report. The user gets additional information about system utilization.

1



The radiologist is particularly impressed by syngo.via: “The software is a techni-cal revolution.” While patient diagnosis used to take between 20 and 30 min-utes, he can now perform the same task in less than five minutes with syngo.via.This is chiefly due to the software’s auto-mated preparation of cases, which allows him to concentrate more closely on diagnosis. Carlos Delgado explains that syngo.via segments and labels the coronary vessels, removes ribs from images and displays the corresponding

As soon as talk turns to the new SOMATOM Definition Flash® and syngo.via®, Carlos Delgado, MD, cardiac radiologist at the Povisa private hospital in Northern Spain, goes into raptures. In September 2009, the hospital, located in Vigo, Galicia, substituted its 64-slice CT scanner for the new SOMATOM Definition Flash and installed the imaging software syngo.via. Says Carlos Delgado: “Since then, we’ve been working faster and more accurately and have also reduced radiation doses considerably.”

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syngo.via with the SOMATOM Defi nition Flash: “A Technical Revolution”Povisa hospital was Spain’s fi rst private clinic to introduce syngo.via with the SOMATOM Defi nition Flash CT scanner in 2009. Since then, work has become faster and more accurate, and patient fi gures have increased.

By Manuel Meyer

Francisco Tardáguila, MD, Head of the Department of Radiology with his team next to the SOMATOM Definition Flash which allows the acquisition of MinDose data for full functional evaluation with syngo.via, even at minimum dose.

Povisa Hospital, Vigo. Main entrance.

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cardiac CT automatically, performing preparatory tasks which once had to be done by the radiologists. “I can now dis-play clinical images on the screen within seconds and with a single mouse click.” The time saved is particularly significant in emergencies. Accident victims’ diag-noses reach the emergency room just 15 minutes after scanning.

Greater Diagnostic SafetyHowever, the time reduction is not the most important benefit. “Besides improved workflows, syngo.via generally boosts diagnostic safety.” This also proves significant in emergencies, as attending physicians or radiologists are not always familiar with cardiac CT imag-ing. Although Delgado believes there are too many ways to process a CT image in general, he finds syngo.via easy to learn and very intuitive. Above all, the online system means users are no longer tied to a single workplace, but can access the CT images anywhere in the hospital and even from home via the internet.This constitutes a “qualitative leap” which, according to the radiologist, should nonetheless be regarded in conjunction with the new SOMATOM Definition Flash CT scanner and its unique Dual Source technology. With its split-second scanning function, the Flash mode allows him to scan the entire heart in just a quarter of a heartbeat.

Reduced Radiation DoseThe new Siemens CT scanners offer patients an extra advantage in terms of pediatric radiology. “The increased scan speed as well as dedicated algorithms

drastically reduce the radiation dose”, comments the radiologist. Carlos Del-gado emphasizes that CT scans which continue to transmit radiation doses of 15 millisieverts with some conventional 64-slice CT scanners generate just 0.9 millisieverts with the new Definition Flash scanner. And with the new syngo.CT Cardiac Function, it is now possible to use MinDose data for a full functional assessment. The syngo.CT Cardiac Function software defines “landmarks” in images taken dur-ing a diastole and adapts these anatomic regions for images taken during other phases of the cardiac cycle. These intelli-gent algorithms can perform highly reliable cardiac anatomy segmentation even with noisy low-dose data. So in effect, not a single image is wasted. Thorax radiologist Concha Martínez, MD, adds: “The new Dual Energy imaging, which permits improved characteriza-tion of in juries and pathological tissue changes, facilitates a more precise diagnosis.”However, realizing the device’s full po ten tial took time. Povisa hospital was the first clinic in Spain to introduce syngo.via with the new CT scanner in 2009.“We were testing the beta version of syngo.via, and no one had any experi-ence with it at the time. That means that we could experience the very first ver-sion of the system and consult Siemens CT in improving the prototype with addi-tional features and tools. And whenever we had an issue or question, Siemens’ service was outstanding. And it still is.

“Besides improved workfl ows, syngo.via generally boosts diagnostic safety.”Carlos Delgado, MD, cardiac radiologist, Povisa private hospital, Vigo, Spain

Above: Carlos Delgado, MD, radiologist (left) and Concepción Martínez, MD (right), radiologist and Head of TAC Section, at the main entrance of Povisa Hospital. Below Francisco Tardáguila, MD, Head of Radiology Department, next to his syngo.via reading workplace.



More Patients Thanks to the Latest Technology“The physicians are so impressed with the new technology that they’re sending us more and more patients. We used to perform a couple of scans daily in cardiac CT, and now we do up to five,” confirms Francisco Tardaguila, MD, Head Radiologist. The low radiation doses mean that an increasing number of pedi-atricans throughout Galicia are sending patients, affirms the former president of the Spanish Radiology Association.As a Spanish reference clinic in the field of radiology, “being equipped with the latest radiology technology was a matter of prestige,” says Francisco Tardaguila. The decision not only increased the pro-ductivity and medical opportunities within his radiology department, but also proved economically advantageous, as the new CT scanner attracts wealthy private patients from across Spain.This is an important economic growth factor for a private hospital, which is,

Of course, now working on a released product we do not have many issues. “But if I have a problem nowadays, it’s solved by Siemens the same day,” enthuses Carlos Delgado.Siemens offers a 24/7 hotline support if wished. Technical questions as well as application questions will be answered. Thereby the dedicated application spe-cialist can support online via desktop sharing, after the customer gives access to the syngo.via server.In general, however, the Povisa radiolo-gist’s verdict is thoroughly positive: “Since the acquisition of the new CT scanner with syngo.via, we’ve not only had to work more due to the increase in information, but, above all, because we treat more patients,” he jokes.

Freelance journalist Manuel Meyer lives and works in Madrid. He regularly reports on scien-tific and medical issues for various media.

Left: SOMATOM Definition Flash examination of the abdomen. Above: Automatic pre-processing with syngo.via enables quick and easy evaluation of the entire colon. Below: With syngo.via a CT series is compared with an MR dataset whereby the lesion is quantified with a volume measurement tool.

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with 600 beds, considerably smaller than Vigo’s two state hospitals. How-ever, if Povisa was one of Spain’s “major league” clinics specializing in radiology before the introduction of the new Siemens CT scanner, it certainly became the “FC Barcelona of Spanish radiology” afterwards, says the Head Radiologist, playfully comparing his department’s new image and abilities with the famous Spanish soccer club.



In recent years, medical practice has sig-nifi cantly changed. New applications have been introduced that allow a safer and more sustainable diagnosis and treatment. But the changes did not affect only the medical side. More and more institutions are confronted with eco-nomic challenges resulting from reim-bursement cuts, competition and, in the end, the requirement to perform medical services profi tably. So what for-merly was mainly the fi eld of business driven enterprises has now become an important aspect in the decision making and operation of many medical institu-tions.The battle for referrals has intensifi ed as many limiting conditions have changed

as well. The progress in medical technol-ogy has made high-end imaging – includ-ing CT – affordable to a larger number of institutions. This is, in general, a favor-able development as, in the end, it is of benefi t for the patients. But along with this improvement came many new regu-lations, limited resources or cost increases and, fi nally, the competitor right across the street. Consequently, hospitals, clinical practices and imaging centers have to make sure that they are perceived as the fi rst choice for referrers and patients for their services. In busi-ness, this is known as marketing.Many institutions have already recog-nized this as an important part of their business and have started to market

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Surviving in the Battle for ReferralsMarketing is becoming a more and more important topic for medical institutions. No matter whether it is compensating for the new competition down the street or simply the need to get enough patients to cover the running costs, promoting one’s services can be a decisive factor. For this, Siemens has launched a new customer marketing toolkit.

By Jan Freund

Computed Tomography, Siemens Healthcare, Forchheim, Germany

As one kind of marketing, the MSHA is showing online waiting times for their patients.

www.msha.com/www.siemens.com/CT-toolkit

themselves. One example is Franklin Woods Community Hospital, an institu-tion of Mountain States Health Alliance (MSHA), USA. The vast majority of Emer-gency Department examinations here are walk-in patients. So obviously, waiting time is a big factor. Therefore, MSHA has put much focus on this and is now actively marketing it by posting Emer-gency Department waiting times for their institutions online.Because the importance of marketing is growing for customers, Siemens has put together a very comprehensive set of tools to actively support their marketing activities. This toolkit, which helps to promote CT practice by providing the tools necessary, consists of examples for all typical marketing channels like print, online and social media as well as scripts for radio and TV advertisement. Now, customers can simply download the clearly structured templates. To set up an advertisement in a magazine for exam-ple, the respective image and text sec-tions of the template just need to be exchanged by the customer and the ad is ready to use. Siemens offers this service free of charge to its customers. To get an overview of the customer marketing toolkit, just visit:



What Prompts Customers to buy Multiple SOMATOM Defi nition Flash ScannersIf someone trades his common CT scanner for a high-end device in times of a global economic crisis, one is surprised. But if, instead, they buy not only one but fi ve high-end scanners, there must be a good reason.

By Michaela Spaeth-Dierl, medical editor, Spirit Link Medical, Erlangen, Germany

The SOMATOM® Definition Flash is con sidered by many to be the “Porsche” among CT scanners. But high quality com bined with speed comes at a price. Still, many customers have recently taken advantage of so-called Multi-Unit Deals. This means that some SOMATOM Def i nition Flash customers bought not only one SOMATOM Definition Flash scan ner, but up to six or even nine at a time.What prompted them to do that, despite the tense economic situation, the high in vestment and the fact that typical char-ges for CT examinations are de creasing?

SOMATOM Sessions talked to Gilbert Raff, MD of the Royal Oak Hospital in Michigan, Elliot Fishman, MD of the Johns Hopkins Hospital in Baltimore, Maryland, and Vinay Malhotra, MD from Tacoma, Washington, who were all in vol ved in the purchasing decision for more than one SOMATOM Definition Flash.

SOMATOM Sessions: What was your intention in buying multiple SOMATOM Definition Flash scanners? And in what way would you say it was a worthwhile investment?

FISHMAN: We’ve been working with our first SOMATOM Definition Flash scan-ners for roughly two years, now. We have a new hospital opening in 2012 and we needed five new scanners. We decided on SOMATOM Definition Flash, looking at what the best scanner was for our patients from a dose-saving perspective and with regard to tech-nology. From that perspective, it was the best we were able to do for our money. It’s an outstanding product across all modalities, whether it’s car-diac CT or oncological imaging for low-dose pancreas or liver exams. We are very, very happy with the product. RAFF: We have three hospitals and we wanted to offer equivalent coronary and cardiothoracic care to all our

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patients at all three hospitals, whether they are young and therefore require lowest possible doses, or suffer from high and irregular heart rates.

MALHOTRA: The reason why we chose the Flash systems is their versatility. In the past, systems have been geared either to work for cardiology, cardio-vascular or general radiology. And it increases the costs if you put multiple systems in the hospital and you have to decide each time where to send your patient depending on what information you need. Now, for the first time, we’re able to get it all from one scanner with-out putting too much money into multi-ple systems and not putting too many systems in one place. Now you can per-form cardiac and trauma CT as well as oncological, neurological or acute care exams or examine children – all with one CT system. And you can do it with a high degree of safety, with lowest radi-ation doses, and still get great results.

“Now, for the fi rst time, we’re able to get it all from one scanner without putting too much money into multiple systems and not putting too many systems in one place.”

Gilbert Raff, MD, Royal Oak Hospital, Michigan, USA


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the entire hospital system. Using the Flash we are now talking about a radia-tion dose which is less than 25% of it was four years ago, even without using any iterative reconstruction dose-saving tech-nologies such as IRIS* or SAFIRE**. This dose-saving aspect is very important for our patients. To me, anything that can improve images while decreasing dose is where we need to be moving in the future and the Flash is already there.

SOMATOM Sessions: Why did you invest in syngo.via in addition to the SOMATOM Definition Flash?

MALHOTRA: Because with syngo.via there is no IT- or connectivity issue. We’re based in different locations, but we’re con-nected centrally. That means we can do everything on one platform, nobody’s reading on different platforms and get-ting into disagreements over what this looks like or what that looks like. With one system that connects easily, I can focus on one particular problem instead of having to focus on many problems at a time. And it helps all physicians because you only have to train them once, not over and over again. That’s why we picked syngo.via to complement the Flash, for the ease of use, its uniformity across the system and the cost and time savings. Years ago everyone was focusing on new systems with only the following in mind: cardiology and number of slices. What they didn’t realize: Here was a sys-tem that was able to do everything effec-tively and properly with low radiation doses. So I think this is something that people are taking a while to catch on to since other vendors are still propagating the old paradigms. SOMATOM Sessions: Thank you very much. To sum up: With the SOMATOM Definition Flash you get fast scanning at lowest dose without the need for breath-hold or sedation in case of pediatric patients, and even for patients with high and irregular heart rates. A detailed con-sideration shows that buying multiple SOMATOM Definition Flash scanners is a reasonable and worthwhile investment that pays off in the end. With the pur-chase and use of multiple scanners, the

“It’s an outstanding product across all modalities, whether it’s car-diac CT or oncolog-ical imaging for low-dose pancreas or liver exams.”

Elliot Fishman, MD, Johns Hopkins Hospital, Baltimore, Maryland, USA

“Here was a system that was able to do everything effec-tively and properly with low radiation doses.”

Vinay Malhotra, MD, Tacoma, Washington, USA

advantages of the single unit multiply. And working with a uniform, efficient system simplifies workflows and so saves time and money.

SOMATOM Sessions: And are there any further advantages?

RAFF: Yes, absolutely. There is the high throughput and the automated functions. It’s a very fast scanner, and it quickly delivers results from all the modalities you talked about. And that means reduc-ing the waiting time and eliminating coordination efforts since all patients can be examined with the Definition Flash. Another important issue is patient safety: For example, if you wanted to do a scan of a baby or small child in the past, an anesthetist was required hours before, during and even after the scan. With the SOMATOM Definition Flash, a full pediat-ric scan can be done in less than one sec-ond, independent of breathing move-ment. This system makes sedation and forced breathing obsolete. We made this investment so that we would be able to deliver a superior result uniformly across

www.siemens.com/SOMATOM-Definition-Flash

* In clinical practice, the use of Iterative Reconstruc-tion IRIS may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiolo-gist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task.

** The information about this product is being provi-ded for planning purposes. The product is pending 510(k) review and not available in the U.S..In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appro-priate dose to obtain diagnostic image quality for the particular clinical task.


Clinical Results Cardio-Vascular

Case 1Thoracic Triple Rule-Out in Low Dose Acquisition Technique Using Prospective ECG-TriggeringBy Johannes Rixe, MD,* Andreas Rolf, MD,* Andreas Blaha**

*Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany **Siemens AG, Healthcare Sector, Business Unit CT, Forchheim, Germany

HISTORYA 28-year-old female patient weighting 55 kg at a height of 175 cm (Body Mass-Index 18) presented with chest pain and shortness of breath under exertion. Additionally, she complained about backache that had initially occurred a few hours before admission.She had an elevated blood pressure of 160/100 mmHg. D-Dimer testing showed very slightly elevated values

(1.1 times upper-normal value), Tropo-nin T was negativ. The ECG documented no relevant ST-T elevations. Because of the multiple but typical symptoms and the equivocal laboratory and ECG find-ings, we referred the patient for ECG-triggered CT to rule out pulmonary embolism (PE), aortic dissection and cor-onary artery disease (CAD).

DIAGNOSISThe investigation was performed using a SOMATOM Definition CT scanner. In order to obtain optimal image quality at a preferably low radiation dose, nitro-glycerine was given sublingually imme-diately prior to the examination. At a heart rate of 61 bpm, a prospec-tively ECG-triggered scan was performed from the aortic arch to the diaphragm at a tube voltage of 80 kV and a tube


1A VRT discovered a regular course of LAD and no stenosis.

1B MIP of LAD showed no calcifica-tion or stenosis.

2A VRT of RCA depicted a regular course and no stenosis.

1A

2B MIP displayed RCA without calcifications or stenosis.

2A

1B 2B


Cardio-Vascular Clinical Results


current of 215 mAs. With an estimated radiation dose of only 0.94 mSv (using published conversion factor of 0.014) outstanding image quality could be achieved. With the CT Angiography a coronary artery disease could be ruled out and additionally a pulmonary embo-lism could be excluded as well as an aor-tic dissection. Due to these results from the CT scan, no further medical treatment was declared to be necessary and the patient was discharged from hospital a few hours later.

COMMENTSUsing an individually adapted scan pro-tocol with prospective ECG-triggering, the SOMATOM Definition CT scanner allows accurate assessment of coronary arteries and intra-thoracic vessels with excellent image quality at a very reason-able radiation dose. Therefore a SOMATOM Definition Dual Source CT scanner can reliably rule out CAD, pulmonary embolism and aortic dis-section at very low radiation exposure.

3 The right pulmonary artery did not show any signs of pulmonary embolism.

4

4 Even the left pulmonary artery did not show any signs of PE and no aortic arch dissection was visible.

5

5 Axial MIP of pulmonary arteries did not discover any thrombus.

6

6 Curved MIP of aortic arch and descend-ing aorta showed no aortic dissection.

EXAMINATION PROTOCOLScanner SOMATOM DefinitionScan mode Triple Rule Out Slice collimation 64 x 0.6 mmScan area Thorax Slice width 0.75 mmScan length 186 mm Spatial Resolution 0.33 mmScan direction Cranio-caudal Reconstruction increment 0.4 mmScan time 14 s Reconstruction kernel B26fTube voltage 80 kV ContrastTube current 356 mAs/Rot Volume 140 mlCTDIvol 3.58 mGy Flow rate 7 ml/sDLP 67 mGy cm Start delay 20 sEff. dose 0.94 mSv Postprocessing syngo CirculationRotation time 0.33 s

3



Case 2

SOMATOM Defi nition AS+ Scanning: Coronary Artery AnomalyBy Peter Wilson, MD,* Robert Dittrich **

*Department of Radiology, Northside Medical Imaging, Coffs Harbour, Australia **Siemens Healthcare Australia and New Zealand

HISTORYA 72-year-old male patient was initially referred to the hospital due to chest pain. Anomalous left main coronary artery origin was found on coronary angiography. The coronary anatomy was clarified in more detail with a retrospec-tively gated coronary CT Angiography.

DIAGNOSISAn anomalous left main coronary artery origin from the right sinus of Valsalva in conjunction with the origin of the right coronary artery was found with CT Angiography. The left main coronary artery subsequently had an unusual

course anterior to the pulmonary trunk. Patent stenting in the left coronary artery was detected to pass the ostium of a second diagonal branch. A branch stent had been placed proximal of the second diagonal artery. Both stents were discovered to be patent. Small plaque formations were found in the coronary arteries elsewhere without significant stenosis. No infarction was visible. The left ventricular function (ejection frac-tion, EF) was detected to be normal (EF: 55 %) and the calcium score moderate.Totally applied radiation dose including Calcium Scoring was 4.17 mSv (using the published conversion factor of 0.014 mSv/mGy cm).

COMMENTSCoronary artery anomalies are difficult to characterize on catheter angiography. CT coronary angiography is ideal to demonstrate the course of anomalous arteries and the anatomy of their ori-gins. This helps in deciding whether the anomaly places the patient at higher cardiac risk or if it is a benign variant. An assessment of coronary stents is now feasible by this method. In this case the anomaly seemed benign. These complex stents were shown to be patent.


EXAMINATION PROTOCOLScanner SOMATOM Definition AS+Scan mode Coronary CTA Effective dose 2.28 mSvScan area Heart Slice collimation 128 x 0.6 mmScan length 137 mm Slice width 0.6 mmScan direction Cranio-caudal Spatial Resolution 0.33 mmScan time 7.87 s Reconstruction increment 0.3 mmTube voltage 100 kV Reconstruction kernel 126 / 146Tube current 57 mAs ContrastRotation time 0.3 s Volume 70 mlDose modulation CARE Dose4D Flow rate 5 ml/sCTDIvol 10.04 mGy Start delay Bolus trackingDLP 163 mGy cm Postprocessing syngo 3D



1 VRT overview showed the course of the left coronary artery (LAD). 2 VRT overview showed the distal right coronary artery (RCA).

1 2

3 Curved multiple planar reformation of the LAD and diagonal branch showed two stents after bifurcation.

4 Patent in-stent lumen of the LAD stent was visualized by curved MPR.

3 4

5 MIP overview highlighted the common ostium of left and right coronary artery.

6 Curved MPR discovered the region from the posterior descending artery (PDA arrow) to the distal left circumflex coronary artery (LCX arrowhead).

5 6



Case 3Retrograde Filling of Occluded Proximal Coeliac Trunk – Confi rmed by CTABy Kim Smith, MD

Radiology SA Central Districts Hospital, Elisabeth Vale, Australia

HISTORYA 64-year-old male presented with chronic (> 5 years) abdominal pain, especially after meals. Contrast enhanced CT, plain films, barium meal and ultra-sound had, over that period of time, not determined a cause for his pain. Mesenteric angina was suspected and a CT mesenteric angiogram performed.

DIAGNOSISA particular feature of this man’s pain was that it was primarily post-prandial. Mesenteric angina was suggested after most other possibilities had been excluded. It was an unlikely cause and is responsible for as little as 5% of intesti-nal ischemia.1 It is more commonly found in the elderly and often of acute onset. Other than pain, there were very few indicators to help the clinician. There was no sign of small bowel obstruction and few episodes of vomit-ing. The following is quoted from the report written by the radiologist who supervised the examination:“There is a significant abnormality of the foregut blood supply. There is a small stump origin of the coeliac with a 2 cm length of occlusion of the coeliac axis. The coeliac axis fills retrograde (inferior pancreaticoduodenal to gastroduodenal as well as gastroepiploic to left gastric arcade). The very horizontal nature of the proximal occluded coeliac axis suggests that the occlusion is thought to be due to

long-standing diaphragmatic crus com-pression. As a result, the superior mesen-teric artery (SMA) is hypertrophied and is of generous caliber – measuring 7 mm in diameter for the first 5 cm of its length with large caliber collaterals involving the duodenum and pancreas.”

COMMENTSCT Angiography proved to be the defini-tive examination for this case. For some years this man had debilitating pain which had been virtually impossible to diagnose. The following images clearly show the coeliac artery obstruction and abnormal re-filling which allowed the gut to function despite an otherwise life-threatening vascular abnormality. Despite its long standing nature, the chances of an acute event are quite high and chronic mesenteric vessel disease has a mortality rate of 40%.1 In addition to this catastrophic possibility, mesen-teric ischemia can cause weight loss, a fear of eating (sitophobia) due to the severity of post prandial pain, gastric ulcers and ischemic gastritis.2, 3

CTA has a good resolution of distal, small caliber vessels. In addition to this benefit, CTA is readily accessible to general practitioners. The low proba-bility of a positive examination result means this condition is most likely going to be investigated by a local clinician exhausting possibilities.

Once diagnosed the primary treatment is surgical intervention. Whether it is by open or endoluminal method, the blood supply to the affected region of gut needs to be restored. Grafting man-made material or vessels harvested from the patient’s leg are well established means of bypassing the obstruction. Great strides have been made in re-can-alizing stenosed vessels without open surgery. However, in the case under dis-cussion, it was the opinion of the report-ing radiologist that the complete obstruction of the coeliac artery at its origin would require open surgery.


1 Jayaprakash Sreenarasimhaiah Chronic mesen-teric ischemia. Best Practice & Research Clinical Gastroenterology. April 2005 (Vol. 19, Issue 2, Pages 283–295)

2 Musil F, Kouhout P, Eliás P, Krajina A, Podhola M. Chronic mesenteric ischemia. Vnitr Lek. 2000 Jul; 46(7):418–22. [Article in Czech]

3 Barry D. Toombs, MD and James M. Jing, MD. Current Concepts in the Evaluation of Vascular Disease: Magnetic Resonance & Computed Tomo-graphic Angiography. Tex Heart Inst J. 2000; 27(2): 170–192.



1 20 mm sagittal slab MIP shows normal a SMA but the coeliac artery immediately superior does not fill from the aorta.

2 3 mm axial MIP reveals the coeliac artery root and filled artery but no connection between the two (arrowhead).

3 VRT image demonstrates the unenhanced area of obstruction and abnormal re-filling and hypertrophic SMA (arrow ahead).

5 Fused VRT and MPR shows regular enhancement of the right kidney.

6 MIP technique highlights the vascular status of the SMA.

3

5 6

4 Full thickness MIP shows the same region as Fig. 3 but more clearly identify-ing calcific plaques which may influence treatment (arrowhead).

EXAMINATION PROTOCOLScanner SOMATOM Definition AS 64Scan area Abdomen and Pelvis Slice collimation 64 x 0.6 mmScan length 370 mm Slice width 0.75 mmScan direction Cranio-caudal Spatial Resolution 0.6 mmScan time 6 s Reconstruction increment 0.5 mmTube voltage 120 kV Reconstruction kernel B20fTube current 160 eff. mAs ContrastDose modulation CARE Dose4D Volume 100 mlCTDIvol 10.16 mGy Flow rate 5 ml/sDLP 399 mGy cm Start delay 12 sRotation time 0.5 s Postprocessing syngo InSpace4DPitch 1.5

21

4

Cardio-Vascular Clinical Results


Clinical Results Oncology

Case 4CT Examination Reveals Extremely Small Stone in the Kidney with SAFIREBy Hatem Alkadhi, MD, MPH*, Andreas Blaha**

*University Hospital Zurich, Zurich, Switzerland **Computed Tomography, Siemens Healthcare, Forchheim, Germany


HISTORYA 39-year-old, male patient showed up in the emergency room with severe, persisting abdominal pain while continu-ously seeking a more comfortable position to lay down. Immediate observations indicated most likely an acute renal colic. The patient did not report a family history of kidney stones. He was imme-diately hydrated intravenously and transferred to the radiology department.

DIAGNOSISStandard imaging methods for this group of patients is a conventional abdominal X-ray image, followed by a non-contrast CT examination. Utilizing SAFIRE* (Sinogram Affirmed Iterative Reconstruction) together with an espe-cially adapted, low dose acquisition pro-tocol developed by Siemens, 1.6 mSv was sufficient to get good image quality and diagnostic accuracy.No kidney cysts, no pyelectasis could be detected but, using the series recon-structed with SAFIRE*, a small stone could be seen in the right kidney.

EXAMINATION PROTOCOLScanner SOMATOM Definition AS 64Scan area Abdomen Eff. dose 1.6 mSvScan length 435 mm Rotation time 0.5 sScan direction Cranio-caudal Pitch 0.6Scan time 18 s Slice collimation 64 x 0.6 mmTube voltage 120 kV Slice width 2 mmTube current 30 eff. mAs Spatial Resolution 0.33 mmDose modulation CARE Dose4D Reconstruction increment 1.4 mmCTDIvol 2.41 mGy Reconstruction kernel B30 / I30DLP 108 mGy cm Postprocessing syngo.via

1

1

*The information about this product is being provided for planning purposes. The product is pending 510(k) review and not available in the U.S.. In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task.


Oncology Clinical Results


COMMENTSSAFIRE* allowed to reliably identify a small stone in the right kidney. The diameter of the calculi was measured to be 0.3 x 0.2 mm. Due to it’s small size the likelihood that the stone will pass

without further treatment is very high.Although the dataset is acquired with a very low radiation dose of 1.6 mSv, it does not appear noisy.

1 syngo.via with SAFIRE image reconstruction shows the small stone and also offers size measurement.


1 Iris-diaphragm phenomena is visible in axial image (arrow; arrowhead in sagittal image reconstruction.)


Case 5 4-Phase Liver Examination with SOMATOM Emotion 16 Unveiled Liver HaemangiomaBy Gao, Yong, MD*, Li, Chen Wei**, Andreas Blaha***

*Department of Radiology, Shanghai Jiangong Hospital, Shanghai, China**Computed Tomography, Siemens Healthcare, SLC, China***Computed Tomography, Siemens Healthcare, Forchheim, Germany


HISTORYThe patient presented in the hospital complaining of occasional abdominal pain. Ultrasound showed signs of a lesion measuring approximately 3 cm in size in segment VIII of the liver. Therefore we transferred the patient with suspected haemangioma to theSOMATOM Emotion 16 CT scanner for further clarification.Haemangiomas are the most common liver lesions, accounting for nearly 5-7 % of all benign tumors.1 They are con-genital, vascular malformations. Due to the increasing age of the patient, there was the suspicion, that the tumor size may have increased with the growth of the liver.

1

Somatom28_Case5_Hemangioma.indd 46Somatom28_Case5_Hemangioma.indd 46 31.05.11 11:2731.05.11 11:27


DIAGNOSISWe performed a 4-phase liver examina-tion, non-contrast, arterial, portal venous and the equilibrium phase (approximately 5 minutes after initial contrast injection) to evaluate the potential enhancement of the lesion.A lesion measuring 3.4 cm in diameter and 12 ml in volume could be confir-med. The non-contrast series showed a hypodense structure, the late contrast enhancement in the late phase showed isodense values (56HU), a haeman-gioma was diagnosed.The initial peripheral nodular contrast enhancements continuously become isodense, also known as iris-diaphragm phenomena (Fig 1).

Oncology Clinical Results

EXAMINATION PROTOCOLScanner SOMATOM Emotion 16Scan area AbdomenScan length 181 mmScan direction Cranio-caudalScan time 6 sTube voltage 110 kVTube current 137 eff. mAsCTDIvol 7.65 mGyDLP 138.5 mGy cmRotation time 0.6 sPitch 1.0Slice collimation 16 x 1.2 mmSlice width 1.5 mmReconstruction kernel B41sPostprocessing syngo.via

COMMENTSA 4-phase CT examination is a feasible method to diagnose haemangioma. With focus on low radiation dose applied to the patient, customized SOMATOM Emotion acquisition protocols achieve low radiation values.To keep track of possible changes in growth, the patient was kept on a follow-up, latest in one year period.

1 Ishak KG, Rabin L.Benign tumors of the liver. Med Clin North Am 1975 ; 59 : 995-101



Case 6SOMATOM Emotion 16 Chest Imaging: Ground Glass Opacity in the Upper Right LungBy Tadashi Kobayashi MD,* Tomoaki Shinkai RT,** and Katharina Otani, PhD***

*Department of Surgery , Kobayashi Hospital, Tokyo, Japan; **Department of Radiology, Kobayashi Hospital, Tokyo, Japan; ***Research & Collaboration Development Marketing Department, Marketing Division, Healthcare Sector, Siemens Japan K.K., Tokyo, Japan

HISTORYA 78-year-old male was referred to the hospital for a detailed chest examination after an anomaly was seen in the chest radiography that he underwent for screening. A CT of the thorax was ordered to further check the patient’s lungs.

DIAGNOSISThe CT images clearly revealed a ground glass opacity (GGO) of increased attenu-ation in the upper lobe of the right lung. GGO is defined as hazy, increased atten-uation of the lung, but with preservation of bronchial and vascular margins, i.e. caused by partial filling of air.1 The GGO had an irregular shape and measured about 12x12 mm. The bronchi and arteries could clearly be seen, as well as a slightly pulled-in area of the visceral pleura. Small nodules were also seen in

the peripheral right middle lobe, but their size was too small to make a confi-dent diagnosis. Neither lymph node enlargement nor pleural effusion could be detected. Lung cancer was sus-pected. The patient was referred to a hospital specialized in cancer treatment.

COMMENTSThe patient experienced no discomfort during the CT scan. Images were ready and of excellent quality soon after the scan. GGO was clearly seen and a diag-nosis could be forwarded to the refer-ring hospital. The diagnosis of primary lung cancer was confirmed at the referred hospital and the patient under-went surgery.


EXAMINATION PROTOCOLScanner SOMATOM

Emotion 16Scan area ThoraxScan length 333 mmScan direction Cranio-caudalScan time 10 sTube voltage 130 kVTube current 110 eff mAsCTDIvol 12.23 mGyDLP 449 mGy cmRotation time 0.6 sSlice collimation 16 x 1.2 mmSlice width 1.5 mmReconstruction kernel B80Postprocessing syngo InSpace4D

1 JH Austin, Glossary of terms for CT of the lung: recommendations of the Nomenclature Committee of the Fleischner Society, Radiology August 2996 200:327–331



1 Coronal view in VRT of the lungs.

3 Coronal MIP of the lungs. 4 Ground glass opacity in axial MIP.

5 Ground glass opacity in the right upper lung lobe. 6 Axial view of ground glass opacity shows pulled-in area of visceral pleura.

2

2 Ground glass opacity in VRT.

1

3 4

5 6



Case 7 SOMATOM Emotion 16: Intracranial Head CTA – Dolichoectasia of the Basilar ArteryBy Dieter Fedders, MD,* Piotr Sokolowski, MD,** Wolfgang Köhler**

*Department of Radiology Hubertusburg, Wermsdorf, St. Georg group of companies, Leipzig, Germany**Department of Neurology Hubertusburg, Wermsdorf, St. Georg group of companies, Leipzig, Germany

Clinical Results Neurology

HISTORYThis 57-year-old male patient has been complaining of dizziness and diplopia for approximately one year. He was referred for Ear Neck Throat (ENT) con-sultation, which did not reveal any path-ological clinical findings. On subsequent MRI of the head in 2009, a megadolicho-shaped basilar artery (i.e. a dolichoecta-sia of the basilar artery) was diagnosed. Over the past several months, the patient has complained of an increase in dizziness, at times with falls and ataxia on standing and walking. At present he also complains of a numb sensation and decreased strength of the left arm and foot, which have been present since October 2010. He had trigeminal neural-gia approximately 2 years ago. He was admitted to the hospital because of an increase in his known symptoms of dizziness and a left-sided hemi-symp-toms since October 2010. A review of his medical history confirmed that he has a megadolicho-shaped basilar artery (i.e. dolichoectasia of the basilar artery) and an intra-cranial aneurysm.

DIAGNOSISThe presence of a posterior cerebral artery aneurysm on the left side at the junction of P1- to the P2-line could be confirmed. As suspected in the previous examination, there was no evidence of a posterior communicating artery branch.The origin of the right posterior cerebral artery is located to the right of the aneu-rismal sac.

The left vertebral artery aneurysm with dolichoectasia of the basilar artery dilates approximately 1.1 cm in diameter.

Arising from the head of the basilar artery, a nose shaped aneurysm sac measuring largest diameter of 1.3 cm could be outlined. Other parts of the aneurysm measured 0.9 cm in diameter.An internal carotid artery ectasia on the right at the origin of the middle cerebral artery could be confirmed as well.

COMMENTSThe CT Angiography clearly confirmed the segments of the vessel with per-fused lumen. An interventional follow-up procedure could then be considered. With the acquisition of thin slices with the SOMATOM Emotion 16, the former diagnosis of left posterior communicat-ing artery aneurysm could be reliably excluded. It showed the origin of the

EXAMINATION PROTOCOLScanner SOMATOM

Emotion 16Scan area Carotid Head CTAScan length 159 mmScan direction Caudo-cranialScan time 13 sTube voltage 110 kVTube current 70 eff. mAsCTDIvol 12.52 mGyDLP 218.14 mGy cmRotation time 0.6 sSlice collimation 16 x 0.6 mmSlice width 0.75 mmReconstruction increment 0.5 mmReconstruction kernel H31sContrastVolume 95 mlFlow rate 4 ml/sStart delay Bolus tracking

(Aorta ascendens)Postprocessing syngo 3D

right posterior cerebral artery out of a saccular aneurysm of the left posterior cerebral artery. The anatomical condi-tions could be reliably determined.


1 VRT view shows the aneurysm of the left vertebral artery, the basilar artery aneurysm and the aneurysm of the left posterior cerebral artery (PCA) with the branching of the right PCA from the aneurysm sac.

2 T2w coronar MRI shows an aneurysm sac and lumen of the basilar artery. Note mesencephal compression and oedema in the right peduncle of the brain as well as in the right subthalamic region. Mild hydrocephalus.


Neurology Clinical Results3, 4 In the VRT superior view, a pos-terior communicat-ing artery (PcoA) is not detectable (source images deci-sive for diagnosis) (Fig. 3). The same can be revealed in the posterior view (Fig. 4).

5, 6 In the MIP view, branching of the P1 segment of the left PCA from the basilar artery aneurysm to the aneurysm sac can be shown as well as further branching of both PCA from the aneurysm. Ectasia of the right internal carotid artery can be revealed above the cavernous segment.

3 4

5 6

1 2


Clinical Results Acute Care

Case 8Dual Energy CT: Virtual Non-Contrast Imaging of a Complicated Renal CystBy Shuichi Kawada MD,* Yutaka Imai MD PhD,* Sayoko Miyanishi**

*Department of Radiology, Tokai University, Kanagawa, Japan **Siemens Japan K.K., Imaging & Therapy Systems Division, Tokyo, Japan

HISTORYA 40-year-old female came to the emer-gency department with lower abdominal pain. Her anamnesis included systemic lupus erythematosus with chronic renal impairment caused by lupus nephritis. She had been on hemodialysis for about 10 years after going through peritoneal dialysis. A Dual Energy CT scan for detailed examination was ordered. From the Dual Energy CT data, an iodine map and a virtual non-enhanced (VNC) image was generated for comparison with a true non-enhanced CT that was taken one month ago.

DIAGNOSISThe CT images revealed kidney atrophy on both sides and multiple cystic lesions. Inside the left upper kidney, a uniform region with slightly higher density than the surrounding tissue was seen. A com-plicated cyst was suspected, but it could not be determined on the contrast enhanced CT images whether the region showed higher density due to contrast medium uptake. The iodine map and the fused iodine and VNC images showed that the high density region did not con-tain contrast medium. From the compar-ison of VNC and true non-enhanced CT

images, it could be confirmed that the lesion was a complicated cyst of homo-geneously high attenuation correspond-ing to a category II cystic lesion according to Bosniak Criteria. No treatment was required. The patient remained in the hospital for observation and could be released three days later.

COMMENTSComplicated cysts of category II accord-ing to Bosniak Criteria show homoge-neously high attenuation without iodine uptake. They are therefore difficult to distinguish from iodine enhancing lesions on contrast enhanced CT. Dual Energy CT was found very useful for this case since with one single CT scan two data sets are available after Dual Energy CT post-processing with the LiverVNC application: virtual non-contrast images and iodine maps. In addition, the Selec-tive Photon Shield introduced with the SOMATOM Definition Flash proved use-ful for the further separation of the two tube’s X-ray spectra during acquisition. It leads to an improved material decompo-sition. Furthermore, the patient did not receive additional dose from the Dual Energy CT scan compared to a conven-tional Single Energy CT scan.


EXAMINATION PROTOCOLScanner SOMATOM Definition FlashScan mode Dual Energy VNCScan area Abdomen PelvisScan length 435 mmScan direction Cranio-caudalScan time 19 s Tube Voltage 100 kV / 140 kVTube current 140 mAs / 119 mAsDose modulation CARE Dose4D CTDIvol 11.57 mGyDLP 523 mGy cmRotation time 0.5 sSlice collimation 32 x 0.6 mmSlice width 1.5 mmReconstruction Increment 1.5 mmReconstruction kernel D30fContrastVolume 100 ml (300 mg/ml)Flow Rate 1.5 ml/sStart delay 120 s


Acute Care Clinical Results


1 Fused 100 kV and 140 kV images give a mixed image that corresponds to a 120 kV single energy image. A high density region can be seen in the left kidney (arrow).

2 With fused iodine and VNC images of a 50/50 ratio, it can be shown that the high density region inside the left kidney does not contain iodine (arrow).

3 The pure iodine image shows a region of higher density (arrow) but no iodine uptake.

1 2 3

4

4 A true non-contrast image was taken one month before.

6

6 The fused iodine and VRT image also show nicely that there is no contrast medium in the high density region.

5 Even the virtual non-enhanced image showed that the high density region did not contain contrast medium.

5

7

7 Coronal fused iodine and VNC images of a 50/50 ratio visualized the dense region well (arrow).

8

8 The same can be shown in the coronal iodine image (arrow).

9

9 The same can be shown in the coronal VNC image (arrow).



Case 9New 70 kV Protocol Ensures Low Radiation Dose in Pediatric Patients with Congenital Heart DiseaseBy Michael Lell, MD, PD,* Oliver Rompel, MD,* Andreas Blaha**

*Radiology Department, University of Erlangen-Nuremberg, Erlangen, Germany**Computed Tomography, Siemens Healthcare, Forchheim, Germany

HISTORYA 10-month-old male baby underwent surgery for multiple ventricular septal defects (VSD) as well as a secundum-type atrial septal defect (ASD). Partially anomalous pulmonary venous return, insufficiency of the tricuspid valve and a

patent ductus arteriosus were corrected in prior surgical procedures, as was banding of the pulmonary artery. The post-operative phase, after closure of the VSDs and ASD, was complicated with infection and secretion from the


1 VRT gave an overview of the 70 kV chest acquisition. 2 Fused VRT and MPR image showed the location of the ductus arteriosus botalli clip (arrow).

1 2

sternotomy wound appeared. Before re-thoracotomy, a low-dose chest CT was performed as planning base for the following surgery.



5 Sagittal view of the pediatric chest. 4 In this axial slice, a retrosternal fluid depot is well visible.

EXAMINATION PROTOCOLScanner SOMATOM Definition AS+Scan area ThoraxScan length 129 mmScan direction Caudo-cranialScan time 1.21 sTube voltage 70 kVTube current 130 eff. mAsDose modulation CARE Dose4DCTDIvol 0.24 mGyDLP 4 mGy cmRotation time 0.5 sPitch 1.4Slice collimation 32 x 1.2 mmSlice width 1.5 mmSpatial Resolution 0.33 mmReconstruction kernel B30f / I30ContrastVolume 5 mlFlow rate Injection per handStart delay after injection completedPostprocessing InSpace4D

3 4


DIAGNOSISThe scan on a SOMATOM Definition AS+ revealed the proper location of the ductus-arteriosus clip. A sickle shaped retrosternal fluid collection could be demonstrated as well as interstitial edema and dystelectasis. The right ventricle was enlarged and the right ventricular wall significantly thickened.

COMMENTSWith the fast acquisition time of 1.21 seconds covering 129 mm, precise diag-nosis could be established in mild seda-tion. Children with congenital heart dis-ease usually require multiple imaging studies in the follow-up. Therefore, it is critical to keep the cumulating radiation dose as low as possible. A dedicated low-dose pediatric acquisition protocol, with auto selection and adjustment of kV and mAs is very useful in this patient group to ensure consistently high image quality at reasonably low dose.



Case 10Diagnosing Pulmonary Embolisms Using High Pitch ProtocolsBy Ermidio Rezzonico, Filippo Del Grande, MD, Ospedale Civico, Lugano, Switzerland

HISTORYA young woman, aged 22 years, pre-sented in the Emergency Department with right-sided, para-vertebral pain. The patient complained of progressively worsening pain for the past six weeks. At this stage, the pain was also respira-tion dependent. The patient did not show any further symptoms. The tho-racic X-ray demonstrated an effusion in the right lung and the left costo-phrenic angle was collecting fluid. The Poly-merase Chain Reaction Test (PCR) and D-dimer were elevated. The patient was then transferred to the radiology depart-ment for a thoracic CT Angiography to rule out the presence of a pulmonary embolism.

DIAGNOSISThe examination was performed accord-ing to our CT protocol for the evaluation of a pulmonary embolism, which includes a CT Flash Thorax acquisition. The examination showed a left-sided pulmonary embolism located at the level of the bifurcation medial of the lingula and the basal lateral segment of the left inferior lobe. There was a minimal increase in parenchyma density in shape of a triangle corresponding to the basal medial lobe of the left inferior lobe. A further small pleuritic effusion was visi-ble on the right, extending from the wing of the great fissure.

COMMENTSTwo fundamental advantages are pro-vided when using the CT Flash Thorax protocol to rule out pulmonary embo-lism. 1) Due to the extremely rapid acquisition time, there is no need for breath-hold. 2) A low radiation dose is required – of particular interest for younger patients. The pulmonary artery tree was shown in high quality, the exact contrast enhancement timing was ensured by using Bolus Tracking. While using high pitch examination pro-tocols, the system ensures very high image quality even in a less cooperative patient group.In this case, low radiation dose (esti-mated effective radiation dose 1.9 mSv) and continuous breathing during acquisi-tion resulted in very good image quality.


EXAMINATION PROTOCOLScanner SOMATOM Definition FlashScan area Flash Thorax Slice collimation 0.6 mmScan length 307 mm Slice width 3 mmScan direction Cranio-caudal Spatial Resolution 0.33 mmScan time 1 s Reconstruction increment 3 mmTube voltage 100 kV Reconstruction kernel B31Tube current 112 eff. mAs ContrastDose modulation CARE Dose4D Volume 100 mlCTDIvol 4.3 mGy Flow rate 4.5 ml/sRotation time 0.28 s Start delay Bolus trackingPitch 2.0 Postprocessing syngo 3D


SOMATOM Sessions · June 2011 · www.siemens.com/healthcare-magazine

1 The coronal reconstructions demonstrate a filling defect of the left pulmonary artery.

2 The sagittal reconstructions demonstrate a filling defect of the left pulmonary artery.

3 The axial image also allows visualization of the pleural effusion.

3

4 The evaluation of the pulmonary parenchyma demonstrates the pleural effusion on the right lung.

2


1

4


Clinical Results Orthopedics

Case 11Reliable Detection and Diagnoses of Gout Using Dual Energy Acquisition TechniqueBy Andreas Artmann, MD, Markus Ratzenböck, MD, Irene Noszian, MD, Klemens Trieb, MD

Radiologie im GHZ and Klinikum Wels-Grieskirchen, Wels, Austria

HISTORYUsually, rheumatologic diseases are of many kinds, numerous and varied, mak-ing a quick diagnosis sometimes difficult.Siemens Computed Tomography, using Dual Energy acquisition techniques, allows the visualization of uric acid deposits. These urate crystal deposits are most often located in peripheral joints or near the surrounding soft tissues. The question, which had to be clearified in this investigation was whether the urate crystal deposits must have a minimum size to trigger clinical symptoms.76 peripheral joints were examined and evaluated using Dual Energy CT tech-niques. The size of the uric crystal deposits were correlated to the presence of pain at the exact location of these deposits. Additionally, the correlation between serum uric acid blood levels

and the final diagnosis, including the results of all available examinations, was established.

DIAGNOSISUrate crystal deposits > 2 mm correlated to 100 % with pain at the exact given location. All patients with urate crystal deposits > 2 mm had increased uric acid blood levels, either actually or reported. These patients were then finally diag-nosed with gout, taking all performed examinations into consideration.Urate crystal deposits ≤ 2 mm did not correlate in any instance with pain exactly at the deposit site. The uric acid blood levels in these patients at the time of the examination were partly elevated (43 %) partly normal (57 %).

In patients with no detectable urate crystal deposits, the uric acid blood lev-els were normal. The existing symptoms were explained through differential diagnosis (some of which were found during the Dual Energy CT examination).

COMMENTSDual Energy CT allows the quantitative imaging of urate crystal deposits. A minimum size of the urate crystal depos-its > 2 mm seems to be the pre-requisite for inducing clinical symptoms. Taking into consideration the size of the urate crystal deposits, the diagnosis of clinically manifested gout can be reliably made.Patients, of course, prefer the non-inva-sive acquisition protocol in comparison to invasive punctures.


EXAMINATION PROTOCOLScanner SOMATOM Definition 1. Scan area DE Hand, Elbow, Foot, Ankle 2. Scan area DE Knee

Scan length Adjusted to anatomy Scan length Adjusted to anatomyScan direction Cranio-caudal Scan direction Cranio-caudalScan time Depending on Scan Length Scan time Depending on Scan LengthTube voltage A 140 kV / B 80 kV Tube voltage A 140 kV / B 80 kVTube current A 55 eff mAs / B 233 eff mAs Tube current A 70 eff mAs / B 298 eff mAsDose modulation CARE Dose4D Dose modulation CARE Dose4DSlice collimation 32 x 0.6 mm Slice collimation 32 x 0.6 mmSlice width 0.75 mm Slice width 0.75 mmReconstruction increment 0.5 mm Reconstruction increment 0.5CTDIvol 8.5 mGy CTDIvol 9.4 mGyDLP 203 mGy cm DLP 175 mGy cmRotation time 0.5 s Rotation time 1 sReconstruction kernel D30f Reconstruction kernel D30s smoothPostprocessing syngo DE Gout Postprocessing syngo DE Gout



1 Advanced stage of gout with numerous tophi, urate deposits are visualized in green colour.

2 The localization of the urate deposits > 2 mm correlated to 100% with pain.

3

3 DECT allows specific and quantitative visualization of urate deposits.

4 Patient with wrist pain: with the help of DECT the diagnosis gout could be made.

4

5

5 Urate deposits > 2 mm, typical for clinical manifest gout.

6

6 Tophus with osteodestruction.

1 2



Case 12 Dual Energy CT: Virtual Non-Calcium Technique Detects Posttraumatic Bone Bruise of the KneeBy Gregor Pache, MD, Stefan Bulla, MD, Philipp Blanke, MD and Prof. Mathias Langer, MD

Department of Radiology, University of Freiburg, Germany

Clinical Results Orthopedics

1 Axial image taken with Dual Energy CT bone window shows intact osseous structures at this height of the tibial plateau (Fig. 1A). Gray-scale virtual non-calcium (VNCa) image reveals bilateral bone marrow edema (Fig. 1B, arrows). Corresponding T2-weighted MR image of posttraumatic bone bruises in the posteromedial and posterolateral tibia plateau (Fig. 1C, arrows). Colour-coded virtual non-calcium image makes the bone bruises more obvious (Fig. 1D, arrows).

1A 1B

1C 1D



2 Coronal image taken with Dual Energy CT bone window dis-covers a small fracture in the posteromedial tibia plateau (arrow).

3 Sagittal T2-weighted MR image rereveals a complete tear of the anterior cruciate ligament (arrow).

2 3

HISTORYA 49-year-old male patient, with sus-tained, high-energy knee trauma due to a skiing accident, was referred to the radiology department. As the radiogra-phy result was equivocal, a CT scan of the knee was performed to rule out a fracture.

DIAGNOSISCT revealed a small circumscribed frac-ture in the posteromedial tibia plateau (Fig.2). Additionally a Dual Energy CT (DECT) virtual non-calcium image (VNCa) (Fig.1B) was calculated (r value = 1.43) discovering bone marrow edema in the

posteromedial and posterolateral tibia plateau. Although the edema appeared subtle on the gray-scale VNCa, the color-coded VNCa image made the bone bruises obvious (Fig.1D). In light of these findings, subsequently performed corresponding T2-weighted MR image confirmed both bone bruises (Fig.1C). Sagittal T2-weighted image revealed a complete anterior cruciate ligament tear (Fig.3).

COMMENTSThe DECT virtual non-calcium technique subtracts calcium from cancellous bone, making post-traumatic bone bruises of the knee potentially detectable with CT.

It is well known that the bone bruise pattern can predict associated soft-tissue injuries. Typically, as seen in this case, bone bruises of the posterolateral tibial plateau are associated with ante-rior cruciate ligament tears. Although DECT will not replace MRI in the evalua-tion of knee trauma, DECT might be helpful to guide further diagnostic work-up. DECT might also constitute an option for those patients who have contra-indications to MR imaging or for whom MR imaging is not available. Most importantly, as compared with the CTDIvol of 8.71 mGy required for a single energy CT scan, it was possible to obtain this extra information without additional radiation dose.

EXAMINATION PROTOCOLScanner SOMATOM Definition Scan area Knee Rotation time 1 sScan length 139 mm Pitch 0.7Scan direction Cranio-caudal Slice collimation 20 x 0.6 mmScan time 34 s Slice width 2 mmTube voltage (A/B) 140/80 kV Spatial Resolution 0.33 mmTube current (A/B) 43/183 mAs Reconstruction increment 1.0Dose modulation none Reconstruction kernel D30CTDIvol 8.69 mGy Contrast noneDLP 131 mGy cm Postprocessing Dual Energy

Orthopedics Clinical Results



CARE kV – How to Optimize Individualized DoseAn important aspect in patient care is reducing dose. Tube current and tube voltage play a central role in this regard.

By Stefan Ulzheimer, PhD, Heidrun Endt, and Christianne Leidecker, PhD

Computed Tomography, Siemens Healthcare, Forchheim, Germany

Science

Tube current modulation with CARE Dose4DSiemens’ SOMATOM scanners provide a wide spectrum of technologies to reduce radiation exposure to the patient. One of these technologies is CARE Dose4D, the automated, real-time tube current modulation. Dose savings of up to 68% are possible when adjust-ing the tube current to the patient’s size and shape.1,2

Based on an user specified image qual-

ity, the system determines the mean tube current based on the topogram and subsequently modulates the tube cur-rent in real time during the examination. To specify image quality, the user sets a reference value, the so-called “Quality Reference mAs”. This has to be done only once for each protocol. The values should be based on those for a standard patient of 75 kg.CARE Dose4D enables constant image quality over the entire scan range. As

Modulating the tube current with CARE Dose4D is a well-known method for Siemens’ customers to reduce patient radiation exposure. To further explore dose reduction potential by adjusting the tube voltage, Siemens’ SOMATOM scan-ners feature an additional innovative technology, CARE kV. Combining CARE Dose4D and CARE kV enables an opti-mized, automatic adjustment of tube cur-rent and tube voltage – individualized for each patient and the clinical indication.

1 Iodine contrast (1A), noise (1B) and, most importantly, the contrast-to-noise ratio (CNR) (1C) in CT depend strongly on the tube voltage but also the patient size when the dose is kept constant. The lower the tube voltage the higher the iodine contrast in the image because the average energy of the spectrum gets closer to the k-edge of iodine (33.2 keV) (1A). In small patients, lowering the tube voltage at constant dose has almost no effect on image noise. Larger objects absorb a significant amount of low energy photons and therefore the noise can rise dramatically (1B). The CNR as a measure for the resulting image quality behaves accordingly. For small patients the CNR increases when going to lower kV, for bigger patients it has a maximum and drops again when lowering the tube voltage (1C). CARE kV takes all these effects into account and suggests the optimum kV for each patient also taking into account the power limits of the CT scanner for the different kV settings.

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Science


exams, there is no additional benefit from contrast improvement at lower kV. However, CARE kV will still recommend the optimal scan settings to the individ-ual patient, for example by suggesting low kV-settings for pediatric patients.There is one important caveat, though: simply lowering the tube voltage with-out adjusting tube current can result in too high an image noise and therefore a reduced image quality despite increased contrast. Thus, it is essential to adjust tube current when changing the kV-set-ting and this task is automatically accomplished with CARE kV (Table 1).Taking into account patient size and the clinical indication, CARE kV automati-cally recommends the optimal tube voltage and tube current. In doing so, it also considers system limits when deter-mining the individual patient and exam settings. Thus, low kV-settings will be typically observed for small patients, where the range of tube current is suffi-

cient because of the overall smaller X-ray attenuation. For larger patients, the optimal setting may be reached at higher tube voltage.The combination of CARE kV and CARE Dose4D enables an individualized patient care by optimizing scan para-meters for each individual patient and clinical question.

How to use CARE kVSimilar to CARE Dose4D, when using CARE kV, the first step is to specify a ref-erence. This reference value should be set for a standard patient of 75 kg and should be exam specific. If the user already works on a Siemens system, the previously used combination of mAs- and kV-settings can be kept and set as quality reference mAs and reference kV. Alternatively, the Siemens standard scan protocols available on the scanner can be used as a recommended starting point.

the patient’s diameter varies between different parts of the body, the tube current is automatically adjusted during the examination. This is true not only for different body regions, but also for different angles during rotation.

Tube voltage adjustment with CARE kVAdjusting the tube current is a well-established method to reduce radiation exposure. While the dose reduction potential when optimizing the tube voltage is known and has been previ-ously shown,3, 4 it is in fact, rarely real-ized in daily clinical practice. The rela-tionship between tube current, tube voltage and image quality (contrast, noise and contrast-to-noise ratio (CNR)) in CT is an intricate procedure (Fig. 1) and thus, adjusting the tube voltage to each individual patient and exam is challenging and mostly too time con-suming. To overcome these challenges, Siemens has developed a new tool, CARE kV, which automatically recom-mends the optimal tube voltage for the individual patient and clinical indica-tion. Simultaneously, CARE Dose4D will adjust the tube current.As with CARE Dose4D, the goal is to maintain a specified image quality while minimizing dose. While image quality may be characterized by many parame-ters, two important ones are contrast and noise. Image quality is considered constant when the contrast-to-noise ratio (CNR) is kept constant. Herein lies the potential of tube voltage adjust-ment: lowering kV typically leads to an increase in contrast and thus potentially allows more noise and therefore less dose while image quality (CNR) is kept constant.Because the extent of this increase is different for various materials such as, for example, iodine (high increase) and soft tissue (small increase), the optimal tube voltage will depend on the clinical indication. Typically, studies which will benefit most from tube voltage adjust-ment are vascular exams such as CT angiograms, CT enterographies, and CT urograms. Abdominal and pelvis exams will benefit as well. In non-contrast

Table 1: Tube voltage adjustment with CARE kV

kV mAs Pitch CTDI 80 462 1.00 – 100 297 1.00 -20% 120 210 1.00 11.00 140 147 1.00 +5%

In this example exam, 120 kV at 210 mAs with a pitch of 1.0 was the routine protocol, and the user selected a “Liver” contrast setting along the slider bar. The information gathered from the topogram, along with the user-provided contrast information, allowed the optimal kV to be selected for this patient and exam. CARE kV chose 100 kV. Despite the increase in mAs the reduced kV allowed for a 20% dose reduction at constant image quality. The first selection (80 kV) could be achieved under different parameters, such as lower pitch, but at the current settings it exceeded the tube limits.

2 The CARE kV user interface: The quality reference mAs and reference kV of the specific exam are used to determine and maintain image quality for each exam in conjunction with the CARE kV slider, which is used to indicate the type of exam being performed, allowing the tool to optimize dose for each specific exam. The optimal kV and mAs settings are now shown on the left panel and will be implemented in the scan. The semi mode allows the user to force a specific kV while the tube current is still adjusted according to the defined quality reference mAs value.

2



scan. For each protocol one defines, these settings should be adjusted once. CARE kV will then adjust for the individ-ual patient characteristics. Additionally, for each exam, a minimum and maxi-mum kV-setting can be specified to be used, if necessary.For routine scanning, three different operation modes of CARE kV are avail-able. When CARE kV is set to “On,” the system will recommend optimized kV- and mAs-settings. When CARE kV is set to “Semi,” a user specified kV setting will be used and mAs-values will be adjusted based on the specified reference values. This is particularly helpful for multi-phase or follow-up exams where a constant kV-setting enables comparisons between the different scans and/or exams of the same patient. Last but not least, when CARE kV is set to “Off”, the scan is performed with the reference kV-setting defined in the respective scan protocol.As an additional feature, Siemens now offers five kV-settings, ranging from 70 kV, 80 kV, 100 kV, and 120 kV to 140 kV. All available settings are consid-ered when determining the optimal setting for the individual patient and clinical question.Especially for pediatric examinations with

CARE Child, Siemens now makes it possi-ble to scan with a tube voltage as low as 70 kV. This will particularly benefit chil-dren with their smaller body size in terms of reduced radiation. Depending on patient size CARE kV can save up to 60% of patient dose compared to a 120 kV scan at comparable image quality (Fig. 4).

Big step towards individual patient care in CTWith CARE kV, Siemens’ SOMATOM scan-ners are the first in the medical imaging industry to provide a tool for an auto-mated adjustment of tube voltage. Addi-tionally, they are the first to provide the possibility to scan with 70 kV. These innovative features bring patient care a big step further towards an individual-ized level of care.

Most importantly, the position of the dose optimization slider has to be set according to the clinical indication (Fig. 2). The symbols on the CARE kV settings dialogue will help to define the exam type; a slider on the far right side indi-cates a vascular exam, moving the slider to the left will optimize settings for less iodine content until, at the far left, the settings are optimized for a non-contrast

www.siemens.com/low-dose

References1 Greess H et al. Rofo. 2004 Jun;176(6):862-9.2 Greess H et al. Eur Radiol. 2004 Jun;14(6):995-9.3 Siegel MJ et al. Radiology. 2004 Nov;233(2):

515-22.4 McCollough CH et al. Radiol Clin North Am. 2009

Jan;47(1):27-40.5 Katharine Grant, PhD et al. White Paper, Siemens

Healthcare, 2011.

3 Follow-up case with CARE kV. The baseline scan (3A) was done with the standard protocol with 120 kV. For the follow-up scan CARE kV suggested the optimal tube voltage of 100 kV for the individual patient and the specific application (3B). In combination with CARE Dose4D, Siemens’ automatic online tube current modulation, this led to a 35% dose reduction (CTDIvol of 15 mGy vs. 9.8 mGy). Courtesy of University Hospital of Munich, Großhadern, Germany

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4 The smaller the patient the higher the dose saving potential with CARE kV. This graph shows how much dose can be saved in contrast enhanced scans compared to a standard 120 kV scan. The dose saving potential is up to 60%.

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120 kV, CTDIvol=15.0 mGy 100 kV, CTDIvol=9.8 mGy3A 3B



Science

Choosing the kV is Now an Easy Equation – a First In-practice Report on CARE kVBy Jan Freund, Computed Tomography, Siemens Healthcare, Forchheim, Germany

Taking a closer look into what changing the tube voltage means for CT and con-sequently how CARE kV works, it also becomes clear why it is not as trivial as it sounds. When changing the kV value, many other parameters have to be re-adjusted as well. For example, in vascu-lar studies using contrast media, lower kV values are favorable. Due to its higher attenuation, iodine then becomes much brighther, resulting in increased contrast of the vessels. But switching to a lower kV value requires that the mAs value also have to be changed in order to maintain the same contrast-to-noise ratio (CNR). Unfortunately, this correla-tion is not linear and thus requires com-plicated calculations (see also page 63). Typically, in clinical practice, neither knowledge nor time for this is at hand. As a result, tube voltages are typically not adjusted and remained mostly at 120 kV (Fig.1), the established standard.

Dose saving with CARE kVBut this will now change with CARE kV. User defined reference values describe the expected image quality in terms of

It sounds so easy: Introduce a function-ality that automatically suggests the appropriate voltage setting for each scan. But reality is often – unfortunately – not so easy and it took until RSNA 2010, before Siemens could introduce the industry’s first automated kV setting functionality. Now, a few months after its introduction, CARE kV proves its capa-bilities and potential in clinical practice.

CARE kV – the fi rst automated voltage settingThe right tube voltage value, measured in kV, is one of the essential parameters in CT scanning. Together with the tube current, measured in mAs, it directly affects the image quality and the associ-ated dose. While the tube current can be seen as the amount of photons cre-ated by the X-ray tube, the chosen tube voltage value defines their energy. With CARE kV, Siemens introduced the first automated, exam-specific voltage set-ting. It is one of the many highlights of the FAST CARE technology platform and, with regards to dose reduction, perhaps the most important.

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With CARE kV 1 The evaluation of applied kV shows a clear shift toward lower kV values using CARE kV.Source: Internal data evalua-tion based on anonymous assessment on SRS connected scanners.

CNR. CARE kV then takes the patient’s habitus from the topogram and the cho-sen examination type into consideration, proposes the appropriate kV and sets all other parameters accordingly to get the defined CNR. And this pays off: Siemens monitored CARE kV during the first months after its introduction and evalu-ated the results. After having scanned more than 12,000 patients, there was a clear shift towards 100 kV and 80 kV scans (see Figure 1B). With this, dose could be saved in more than two thirds of these patients, compared to the initial protocols. And the dose reduction itself was significant. For example, abdomen scans could be reduced to below 10 mGy using 100 kV, down from 14.1 mGy with the former standard protocol set at 120 kV. And this dose reduction of around 30% came with no compromise in image quality, as CNR could be main-tained.So, in the end, it has become as easy as it sounds. With CARE kV, CT users can make use of the full potential of their system while patients benefit from significantly reduced dose.

1A 1B



Dose Neutral Dual Energy Scanning with Dual Source CTBy Peter Aulbach, Computed Tomography, Siemens Healthcare, Forchheim, Germany

Science

t

X-CARE

Iterative Reconstruction in Image Space (IRIS)

Sinogram-Affirmed Iterative Reconstruction (SAFIRE)*

*The information about this product is being provided for planning purposes. The product is pending 510(k) review, and is not yet commercially available in the U.S

Selective Photon Shield

Adaptive Dose Shield

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Dose Shield

With Siemens’ unique Dual Source technology, all renowned dose-saving techniques can be applied, including Ultra Fast Ceramic (UFC), CARE Dose4D, Adaptive Dose Shield, X-CARE, IRIS and SAFIRE.* Together with the Selective Photon Shield, this makes Dual Energy as dose-efficient as conventional 120 kV scans. So all the diag-nostic and image quality improving advantages of Dual Energy imaging are available with the same dose as a Single Energy scan – without a dose penalty.


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Somatom28_Science_Dose_Neutrality.indd 67 31.05.11 11:32


Siemens Healthcare’s CT online portal, “Discover. Try. Get a Quote.” for clinical applications now offers the possibility to learn more about CT specific applications for syngo.via. Key feature descriptions give you a first impression, and trial license orders can be placed immediately.

syngo.CT Colonography is one of the new features available on syngo.via. CT-based colonography has become a routine clinical tool for oncological assess-ment of the colon. Especially in the case of failed or incomplete conventional colonoscopy, as well as occlusive cancer

Life

www.siemens.com/DiscoverCT

that prevents assessment of the proxi-mal part of the colon, risk of bleeding, or wall perforation, virtual colonoscopy is the appropriate clinical method.syngo.CT Colonography offers a dedi-cated non-invasive evaluation of the entire colon based on low-dose, high-resolution spiral CT scans. The application combines the advantages of 2D and 3D reading strategies for time efficient analysis of the colon and provides fully automated path finding and fast real-time fly-through navigation with a high-quality virtual endoscopic viewing technique.syngo.CT Vascular Analysis allows the

evaluation and quantification of angiog-raphy images of the general vessels with a vascular-specific set of display func-tions. Due to automatic pre-processing steps, an immediate view of the extracted vessels is provided as soon as the case is opened. The automatic side-by-side layout, e.g. to display both carotid arteries, helps to better assess and evaluate complex lesions. In the case of abdominal aortic aneurysms (AAA) syngo.CT Vascular Analysis provides a dedicated stent planning template. The automatic pre-processing features ensure that the case is immediately ready for review when opened, thus sav-ing many manual workflow steps to bring more efficiency into emergency situa-tions. One of the causes of acute chest pain can be aortic dissection. As part of triple rule-out protocols syngo.CT Vascular Analysis allows the immediate assessment of the aorta and the vascular walls. The aortic arch is easily evaluated in a curved planar reformation. The software thus facilitates life-saving decisions when every second counts.syngo.CT Vascular Analysis further facili-tates pre-procedural planning, e.g. for transcatheter aortic valve implantation. The automatic side-by-side layout allows for a quick assessment of the peripheral arteries to check for an optimal access path. The cross sections enable a reli-able calculation of the vessel diameters. The manual plane functionality yields a visualization of the aortic arch and the curvature is calculated with dedicated evaluation tools.To find out more about these features and many more syngo.via applications, free trial licenses can be ordered online.

Free Trial Licenses for syngo.via are Now AvailableBy Marion Meusel, Computed Tomography, Siemens Healthcare, Forchheim, Germany

1 Fig. 1A: CT-based colonography combines the advantages of 2D and 3D reading strategies for time-effective analysis of the colon and provides high-quality virtual endoscopic viewing.Fig. 1B: The “vascular-only view” allows the immediate evaluation and quantification of angio-graphy images of the general vessels.

1A

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www.siemens.com/life-courses

Siemens’ Hands-on Workshops at the Experience Lounge are becoming an established learning forum as they have now been held for the 7th time at ECR.More than 250 participants had the opportunity to read cases from CT, MR as well as nuclear medicine under the guid-ance of experienced experts. As part of the Breast Care Day at ECR 2011, there were sessions on Thursday dedicated to MR breast reading and reporting held by Prof. Werner A. Kaiser, MD, from the Insti-tute of Diagnostic and Interventional Radi-ology I, Friedrich-Schiller-University Hospi-tal Jena, Germany. CT Oncology courses were held by PD Anno Graser, MD, Assis-tant Professor at the Department of Clini-cal Radiology at the University Hospital in

Munich-Campus Grosshadern. At the beginning of each 1.5-hour session the speaker gave a introduction of the topic and an update on state-of-the-art scan-ning techniques. During his session on cardiology, Prof. Dieter Ropers, MD, from the Medical Institute for Cardiology and Angiography at the University Hospital Erlangen, Germany pointed out the dif-ferent possibilities on how to perform a cardiac examination from basic sequence scanning to the most advanced Flash Spiral data acquisition. After the short introduction, it was time for the participants to experience Siemens imaging software for them-selves. One workstation and monitor were available for each team of two par-

ticipants to follow and interact with the instructors. PD Rolf Janka, MD, from the Department of Radiology at the Univer-sity Hospital of Erlangen, Germany, took the participants along a flight through the colon explaining the multiple advan-tages of syngo.via. Participants during the CT Dual Energy session held by Ralf Bauer, MD, from the Institute for Diag-nostic and Interventional Radiology Johann Wolfgang Goethe-University at Frankfurt/ Main, Germany, highly appre-ciated that post-processing of Dual Energy data is so fast and easy to use. The next possibility to join one of our Workshops is the annual meeting of the European Society of Cardiology (ESC) from 27–31 August 2011 in Paris.

Cardiac CT is a rapidly evolving field that provides a clinically valid method for non-invasive assessment of coronary artery disease and structural cardiac pathology. In 2011, Siemens Healthcare will offer two workshops for radiologists who would like to deepen their clinical

knowledge and practical skills on cardiac CT. The workshops will be offered in cooperation with Christoph Becker, MD, Professor of Radiology and Section Chief of CT and PET/CT at the University Hospi-tal in Munich - Campus Grosshadern, Germany.The three-day training will cover scientific lectures, clinical presentations, live exam-inations as well as hands-on sessions with advanced syngo evaluation software. All aspects of cardiac CT imaging (calcium scoring, CTA, functional imaging, viability imaging and valve imaging) will be addressed in comprehensive lectures that support the hands-on training sessions. University Hospital in Munich

Opportunities for advanced training and observation of live CT cases on the SOMATOM Definition Flash will be part of the course. Up to 50 clinical CTA cases will be reviewed during the course with cross correlations (invasive angiography and IVUS).Date Details: July, 20–22, 2011 November, 9–11, 2011 More details about the course and how to book can be found via the following link:


Hands-on Workshop at this year European Radiology Congress (ECR) in Vienna

Clinical Workshop on Cardiac CT at Munich University

By Susanne von Vietinghoff, Computed Tomography, Siemens Healthcare, Forchheim, Germany

Experience Lounge: Hands-on Workshops at ECR 2011

By Susanne von Vietinghoff, Computed Tomography,Siemens Healthcare, Forchheim, Germany


NEW Series of Live Clinical Webinars

By Susanne von Vietinghoff, Computed Tomography, Siemens Healthcare, Forchheim, Germany

Radiologists are busy people. Scanning, processing and diagnosing 30 or more patients each workday leaves little timeand opportunity to look for informationto remain up-to-date in their profession. Therefore, bringing education and train-ing to the medical imaging specialists has always been given high priority at Siemens. Siemens’ newest efforts are live, cross-modality, clinical webinars. Each month

www.siemens.com/clinical-webinars

there will be presented and discussed what is new and exiting in one of the different modalities.A live webinar is more than just infor-mation, medical imaging specialists can learn from some of the world’s ren owned clinicians and also have the opportunity to interact live with them.The first of these webinars on December 16th 2010, conducted by Prof. Stephan Achenbach, MD, from the University Hospital of Erlangen/Germany, was dedicated to “Low Dose in Cardiac CT Imaging.”During his presentation, he explained the motivation as well as need to in crease dose only very cautiously, espe-cially when it comes to coronary CTA. Potential strategies on how to lower dose were outlined in a clear way, ranging from basic technologies like ECG-based, tube-current modulation (pulsing) for spiral acquisitions to more

advanced, techniques like the Flash Spiral scan mode.After this first very positive experience, the following webinars are planned for the near future:■ MR: Emergencies in Neuro Imaging■ Interventional Imaging: Hybrid Surgery■ Multi-modality Reading in Oncology■ IQ-SPECT: Maximize Speed and Mini-

mize Dose

The next clinical webinar for CT will be on Thursday 09th of June at 15:30 CET. The topic will be “CT Stroke Manage-ment” and the webinar will be held by Prof. Bernd Tomandl, MD.To register for any of the above or to view recorded past webinars, please use the following link:

FAST Adjust: Direct adjustment of all parameters can be done with a single click.

syngo Evolve, Siemens’ non-obsolescence program consists of software and hard-ware upgrades. Together with the new FAST CARE Platform, it provides innova-tive enhancements and access to new features for SOMATOM Definition AS scanners. To give medical professionals

A seminar can be joined via webinar without leaving the office.

FAST CARE for All Patients of syngo Evolve Customers

By Katharina Linseisen, Computed Tomography, Siemens Healthcare, Forchheim, Germany


Life


International: www.siemens.com/DiscoverCTUSA only: www.usa.siemens.com/webShop/CT

With syngo Evolve, customers get access to innovative clinical and diagnostic applica-tions to expand the capabilities of their system. A well-planned software and hardware upgrade with syngo Evolve will bring the system to the next level of performance.

Without syngo Evolve, a system remains at the same performance level over its entire life cycle.

Investment Protection for SOMATOM CT Scanners

By Katharina Linseisen, Computed Tomography, Siemens Healthcare, Forchheim, Germany

Up-to-date, powerful software and hard-ware are key factors for maximizing the performance and diagnostic quality of CT systems. syngo Evolve, Siemens’ non-obsolescence program, contains well-planned upgrades of the existing soft-ware and hardware. It helps to keep pace with rapidly developing technology. With syngo Evolve, SOMATOM scanners that have been installed for 3 to 5 years, get

new, state-of-the-art hardware and the latest software pro viding improved performance and access to the latest innovations. Thus, syngo Evolve ensures increased investment protection for CT scanners. And, because it is an option which can be included in the Siemens service contract, it allows eco-nomical and accurate budget planning.With the upgrade, customers benefit

from feature enhancements for the existing software solutions, allowing higher productivity and improved com-petitiveness. Additionally, new clinical applications that can be purchased after the upgrade, promote new business opportunities.With syngo Evolve, SOMATOM scanners are prepared for the innovations which are yet to come.

www.siemens.com/ct-evolve

more time for their patients, the new FAST CARE technology accelerates work-flow and lowers radiation exposure to previously unseen levels. Thus, it levers untapped potential in patient-centric productivity.Definition AS scanners with a syngo Evolve contract will automatically get the new FAST CARE platform. It includes the following innovative enhancements that allow delivering FAST CARE to all patients:■ CARE kV: first automated, exam-spe-

cific tube voltage setting to optimize contrast-to-noise-ratio and reduce dose by up to 60%

■ CARE Child: dedicated pediatric CT imaging, including industry’s first 70 kV scan modes and dedicated proto-cols to significantly lower radiation*

■ CARE Dose Configurator: more precise and simplified dose modulation, allowing more accurate parameter adjustments to the patient’s anatomy

■ CARE Profile: visualization of the dose distribution along the topogram prior to the scan

■ CARE Dashboard: visualization of activated dose reduction features to analyze and manage the dose to be applied in the scan

■ FAST Adjust: intuitive scan parameter adjustment at the push of a button

In addition to the syngo Evolve upgrade, FAST CARE offers a range of optional features to utilize the scanner even more efficiently, e.g. FAST Planning allows a safer, faster and more standard-ized workflow at the scanner via imme-diate, organ-based settings of scan and recon ranges.

System capabilities

Time

Technological development

Access to new applications with syngo Evolve

System performance upgrade with syngo Evolve

syngo Evolve helps to keep pace with rapidly developing technology.

System performance without syngo Evolve

* license must be ordered separately, requires new STRATON X-ray tube


Life


72 Titel Magazine · February 2008 · www.siemens.com/healthcare-magazine72 SOMATOM Sessions · June 2011 · www.siemens.com/healthcare-magazine

Frequently Asked Questions: How can Dose be Reduced with syngo.via?

By Ivo Driesser, Computed Tomography, Siemens Healthcare, Forchheim, Germany

Since the introduction of cardiac scan-ning many different features have been introduced to minimize radiation dose. ECG-pulsing is one of them. For a full cardiac evaluation, including functional assessment, it was previously necessary to scan with normal pulsing. This has changed with improved algo-rithms in syngo.via. They detect the shape of the ventricles

even when the scan is performed with MinDose. MinDose pulsing reduces the dose in the systolic phase even more. Only 4% of the normal dose is used in the systolic phase. On the trigger subtask “MinDose – auto” or “MinDose – manual” can be selected (Fig. 1). Where can I find my results? After opening the study in syngo.via, the

results are displayed correctly in the CT Cardiac Function Workflow step. The noise of the images does not influence the calculations (Fig. 2). The calculation of ejection fraction, car-diac output and more are now possible with low dose.

Conclusion: syngo.via makes virtually full cardiac function assessment possible with low dose.

2 Adequate results with lowest possible dose are directly accessi-ble without any clicks.

1 “Pulsing: MinDose – auto” (marked in red).

1

2

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SOMATOM Sessions · November 2010 · www.siemens.com/healthcare-magazine 73

Title Dates Short Description Location Contact

DRK Jun 1 – 4, 2011 92. Deutscher Röntgenkongress Hamburg, Germany www.roentgenkongress.de

DEGRO Jun 2 – 5, 2011 17. Jahreskongress der Deutschen Gesellschaft für Radioonkologie

Wiesbaden, Germany

http://congress.cpb.de/2/Startseite.degro-2011.0.html

ISCT Jun 13 – 16, 2011 International Symposium on Multidetector Row CT

San Francisco, USA www.isct.org

SCCT Jul 14 – 16, 2011 6. Annual Scientific Meeting of the Society of Cardiovascular Computed Tomography

Denver, USA www.scct.org

ESC Aug 27 – 31, 2011 European Society of Cardiology Congress 2011

Paris, France www.escardio.org/ congresses/esc-2011

RSNA Nov 27 – Dec 2, 2011 97. Annual Meeting of Radiologi-cal Society of North America

Chicago, USA www.rsna.org

Upcoming Events & Congresses

Clinical Workshops 2011As 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 Language

Course Director

Coronary CTA Interpretation Workshop

Jun 30 – Jul 1, 2011Dec 15 – 16, 2011

Erlangen, Germany

English Prof. Dieter Ropers, MD

Clinical Workshop on Cardiac CT

Jul 20 – 22, 2011Nov 09 – 11, 2011

Munich, Germany

English Prof. Christoph Becker, MD

Hands-on Tutorials at ESC 2011 Aug 27 – 30, 2011 Paris, France English Siemens Healthcare

Clinical Training Course on Cardiac CT

Sept 10 – 11, 2011 Kuching, Malaysia

English Prof. Sim Kui Hian, MDOng Tiong Kiam, MD

ESGAR CT Colonography Workshop Sept 14 – 16, 2011 Dublin, Ireland English Prof. Helen Fenlon, MDMartina Morrin, MD

Clinical Workshop on Dual Energy Sept 30 – Oct 1, 2011 Forchheim, Germany

English PD Thorsten Johnson, MD

In addition, you can always fi nd the latest CT courses offered by Siemens Healthcare at www.siemens.com/SOMATOMEducate

Life



Siemens Healthcare PublicationsOur publications offer the latest information and background for every healthcare fi eld. From the hospital director to the radiological assistant – here, you can quickly fi nd information relevant to your needs.

For current and prior issues and to order the magazines, please visit www.siemens.com/healthcare-magazine

Medical SolutionsInnovation and trends in healthcare. The magazine, published three times a year, is designed especially for members of the hospital management, administration per-sonnel, and heads of medical departments.

AXIOM InnovationsEverything from the worlds of interventional radiology, cardiology, fluoroscopy, and radiography. This semi-annual magazine is primar-ily designed for physicians, physicists, researchers, and medical technical personnel.

MAGNETOM FlashEverything from the world of magnetic resonance imaging. The magazine presents case reports, technology, product news, and how-to’s. It is primarily designed for physicians, physicists, and medical technical personnel.

SOMATOM SessionsEverything from the world of computed tomography. With its innovations, clinical applications, and visions, this semiannual magazine is primarily designed for physicians, physicists, researchers, and medical technical personnel.

NewsOur latest topics such as product news, reference stories, reports, and general interest topics are always available at www.siemens.com/healthcare-news

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Note in accordance with § 33 Para.1 of the German Federal Data Protec-tion Law: Despatch is made using an address file which is maintained with the aid of an automated data processing system.SOMATOM Sessions with a total circulation of 35,000 copies is sent free of charge to Siemens Computed Tomography customers, qualified physicians and radiology departments throughout the world. It includes reports in the English language on Computed Tomography: diagnostic and therapeu-tic methods and their application as well as results and experience gained with corresponding systems and solutions. It introduces from case to case new principles and procedures and discusses their clinical potential.The statements and views of the authors in the individual contributions do not necessarily reflect the opinion of the publisher.The information presented in these articles and case reports is for illustra-tion only and is not intended to be relied upon by the reader for instruc-tion as to the practice of medicine. Any health care practitioner reading this information is reminded that they must use their own learning, train-ing and expertise in dealing with their individual patients. This material does not substitute for that duty and is not intended by Siemens Medical Solutions to be used for any purpose in that regard. The drugs and doses mentioned herein are consistent with the approval labeling for uses and/

or indications of the drug. The treating physician bears the sole responsi-bility for the diagnosis and treatment of patients, including drugs and doses prescribed in connection with such use. The Operating Instructions must always be strictly followed when operating the CT System. The sources for the technical data are the corresponding data sheets. Results may vary.Partial reproduction in printed form of individual contributions is permit-ted, provided the customary bibliographical data such as author’s name and title of the contribution as well as year, issue number and pages of SOMATOM Sessions are named, but the editors request that two copies be sent to them. The written consent of the authors and publisher is required for the complete reprinting of an article.We welcome your questions and comments about the editorial content of SOMATOM Sessions. Manuscripts as well as suggestions, proposals and information are always welcome; they are carefully examined and submit-ted to the editorial board for attention. SOMATOM Sessions is not respon-sible for loss, damage, or any other injury to unsolicited manuscripts or other materials. We reserve the right to edit for clarity, accuracy, and space. Include your name, address, and phone number and send to the editors, address above.


Imprint


Editorial

“Our success with FAST CARE fully supports our visionary perspective and sense of responsibility to make CT a diagnostic measure with broad acceptance and availability to almost all patients – worldwide.”

Walter Märzendorfer, Chief Executive Officer,Business Unit Computed Tomography and Radiation Oncology, Siemens Healthcare, Forchheim, Germany

Cover Page: Courtesy of University Hospital Zurich, Zurich, Switzerland

SOMATOM Sessions is also available on the internet: www.siemens.com/SOMATOMWorld

SOMATOM Sessions – IMPRINT© 2011 by Siemens AG, Berlin and MunichAll Rights Reserved

Publisher:Siemens AGHealthcare SectorBusiness Unit Computed TomographySiemensstraße 1, 91301 Forchheim, Germany

Chief Editors:Monika Demuth, PhD([email protected])Stefan Ulzheimer, PhD([email protected])

Clinical Editor:Andreas Blaha([email protected])

Project Management: Sandra Kolb

Responsible for Contents: Peter Seitz

Editorial Board:Andreas BlahaMonika Demuth, PhDHeidrun EndtAndreas FischerTanja GassertJulia HölscherSandra KolbAxel LorzPeter SeitzStefan Ulzheimer, PhD

Authors of this issue:Hatem Alkadhi, MD, University Hospital Zuerich, Switzerland

Andreas Artmann, MD, Radiologie im GHZ and Klinikum Wels-Grieskirchen, Wels, Austria

Philipp Blanke, MD, Department of Radiology, University of Freiburg, Germany

Stefan Bulla, MD, Department of Radiology, University of Freiburg, Germany

Filippo Del Grande, MD, Ospedale Civico, Lugano, Switzerland

Dieter Fedders, MD, Department of Radiology Hubertusburg, Wermsdorf, St. Georg group of companies, Leipzig, Germany

Yutaka Imai, MD, PhD, Department of Radiology, Tokai University, Kanagawa, Japan

Shuichi Kawada, MD, Department of Radiology, Tokai University, Kanagawa, Japan

Tadashi Kobayashi, MD, Department of Surgery, Kabayashi Hospital, Tokyo, Japan

Wolfgang Köhler, Department of Neurology Hubertusburg, Wermsdorf, St. Georg group of companies, Leipzig, Germany

Mathias Langer, MD, Department of Radiology, University of Freiburg, Germany

Michael Lell, MD, PD, Radiology Department, University of Erlangen-Nuremberg, Erlangen, Germany

Irene Noszian, MD, Radiologie im GHZ and Klinikum Wels-Grieskirchen, Wels, Austria

Gregor Pache, MD, Department of Radiology, University of Freiburg, Germany

Markus Ratzenböck, MD, Radiologie im GHZ and Klinikum Wels-Grieskirchen, Wels, Austria

Ermidio Rezzonico, Ospedale Civico, Lugano, Switzerland

Johannes Rixe, MD, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany

Andres Rolf, MD, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany

Oliver Rompel, MD, Radiology Department, University of Erlangen-Nuremberg, Erlangen, Germany

Tomoaki Shinkai, RT, Department of Radiology, Kabayashi Hospital, Tokyo, Japan

Kim Smith, MD, Radiology SA Central Districts Hospital, Elisabeth Vale, Australia

Piotr Sokolowski, MD, Department of Neurology Hubertusburg, Wermsdorf, St. Georg group of companies, Leipzig, Germany

Klemens Trieb, MD, Radiologie im GHZ and Klinikum Wels-Grieskirchen, Wels, Austria

Peter Wilson, MD, Department of Radiology, Coffs Harbour, Australia

Gao Yong, MD, Department of Radiology, Shanghai Jiangong Hospital, Shanghai, China

Irène Dietschi, Science editor, Olden, SwitzerlandIngrid Horn, Scientific writer, GermanyEric Johnson, external Journalist, GermanyManuel Meyer, Freelance Jounalist, SpainMichaela Spaeth-Dierl, Medical editor, Spirit Link Medical, Erlangen, Germany

Peter Aulbach, Florian Belohlavek, Andreas Blaha, Tiago Campos, Robert Dittrich, Tiago da Silveira Jaques, Jochen Dormeier, MD, Ivo Driesser, Heidrun Endt, Ute Feuerlein, Jan Freund, Larry Gallone, Benjamin Gutheil, Sandra Kolb, Rami Kusama, Janine Krebs, Katharina Linseisen, Christianne Leidecker, PhD, Marion Meusel, Sayoko Miyanishi, Jakub Mochon, Katharina Otani, PhD, Johann Russinger, Philip Stenner, PhD, Stefan Ulzheimer, PhD, Susanne von Vietinghoff, Li Chen Wei

Photo Credits: Thomas Schmidt, TM Studios, Nürnberg; Thorsten Rother; Jez Coulson/insight-visual; istock; Juan Pablo Moreiras / Agentur Focus

Production and PrePress: Norbert Moser, Kerstin Putzer, Siemens AG, Healtchare Sector

Printer: Mediahaus Biering GmbH, Freisinger Landstrasse 21, 80939 Munich, Germany

Desing and Editorial Consulting: Independent Medien-Design, Munich, Germany In cooperation with Primafi la AG, Zurich, Switzerland Managing Editor: Christa KrickPhoto Editor: Anja KellnerLayout: Claudia Diem, Mathias Frisch, Julia Hollweck, Elke Irnstetter, Luitgard SchüllerAll at: Widenmayer straße 16, 80538 Munich, Germany

The entire editorial staff here at Siemens Healthcare extends their appreciation to all the experts, radiologists, scholars, physicians and technicians, who donated their time and energy – without payment – in order to share their expertise with the readers of SOMATOM Sessions.


Answers for life in Computed TomographySOMATOM Sessions

28

Issue Number 28 / June 2011Stanford-Edition | June 13th – 16th 2011

Cover Story Iterative ReconstructionsGoes MainstreamPage 6

News FAST CARE Hits the Bull’s EyePage 12

Business syngo.via with the SOMATOM Defi nition-Flash: “A Technical Revolution”Page 32

Clinical ResultsNew 70 kV Protocol Ensures Low RadiationDose in Pediatric Patients with CongenitalHeart DiseasePage 54

Science CARE kV – How to Opti-mize Individualized DosePage 62

On account of certain regional limitations of sales rights and service availability, we cannot guarantee that all products included in this brochure are available through the Siemens sales organization worldwide. Availability and packaging may vary by country and is subject to change without prior notice. Some/All of the features and products described herein may not be available in the United States.

The information in this document contains general technical descriptions of specifications and options as well as standard and optional features which do not always have to be present in individual cases.

Siemens reserves the right to modify the design, packaging, specifications and options described herein without prior notice. Please contact your local Siemens sales representative for the most current information.

Note: Any technical data contained in this document may vary within defined tolerances. Original images always lose a certain amount of detail when reproduced.

www.siemens.com/healthcare-magazine

Global Business Unit

Siemens AGHealthcare SectorComputed Tomography & Radiation OncologySiemensstrasse 191301 ForchheimGermanyPhone: +49 9191 18 - 0www.siemens.com/healthcare

Local Contact Information

Asia/Pacific:Siemens Medical SolutionsAsia Pacific HeadquartersThe Siemens Center60 MacPherson RoadSingapore 348615Phone: +65 9622-2026www.siemens.com/healthcare

Canada:Siemens Canada LimitedHealthcare Sector6865 Century Avenue, Suit 3001Mississauga ON L5N 2E2CanadaPhone: +1 905 819 5800www.siemens.com/healthcare

Europe/Africa/Middle East:Siemens AGHealthcare SectorHenkestrasse 12791052 ErlangenGermanyPhone: +49 9131 84-0www.siemens.com/healthcare

Latin America:Siemens S.A.Medical SolutionsAvenida de Pte. Julio A. Roca No 516, Piso 7C1067ABN Buenos Aires ArgentinaPhone: +54 11 4340-8400www.siemens.com/healthcare

USA:Siemens Medical Solutions U.S.A., Inc.51 Valley Stream ParkwayMalvern, PA 19355-1406USAPhone: +1-888-826-9702www.siemens.com/healthcare

Global SiemensHealthcare Headquarters

Siemens AGHealthcare SectorHenkestrasse 12791052 ErlangenGermanyPhone: +49 9131 84 - 0www.siemens.com/healthcare

Global Siemens Headquarters

Siemens AGWittelsbacherplatz 280333 MuenchenGermany

Order No. A91CT-41013-69M1-7600 | Printed in Germany | CC CT 41013 ZS 0611/35. | © 06.2011, Siemens AG

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28

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Somatom session 28

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