Somatom Sessions 18

Picture

SOMATOMSessions

No 18/June 2006Stanford-EditionJune 14th –June 17th, 2006

www.siemens.com/medical

COVER STORYSaving Time, Money and LivesPage 4

NEWS3D-Reading Wherever You Are0

BUSINESSUtilization Report Now AlsoAvailable for CT SystemsPage 15

CLINICAL OUTCOMESCardiovascular – Dual SourceCT after Left Main CoronaryArtery StentingPage 17

CLINICAL OUTCOMES

Neurology – Complete Occlusion of Left CarotidArtery and Stenosis at Right Carotid ArteryPage 29

SCIENCERadiation Dose with DualSource CT

Page 38

CUSTOMER CAREEvolve Update FacilitatesEnhanced CT FluoroscopyPage 45

Highlights

2 SOMATOM Sessions 18

EDITOR’S LETTER

Dear Reader,

Bernd Ohnesorge, PhD, Vice President CT Marketing and Sales

* Pending 510(k): The information about this product is being provided for planning purposes only.

This product is pending 510(k) review, and is not yet commercially available in the U.S.

Cover Page: syngo Neuro DSA delineates the complete vascular tree from aortic arch to the Circle of Willis

obtained with a SOMATOM Definition. Kindly provided by the University of Munich, Großhadern, Germany.

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Bernd Ohnesorge, PhD, Vice President CT Marketing and Sales

At RSNA 2005, Siemens moved CT into a new era. With the introduction of the world’s first Dual Source

CT, the SOMATOM Definition, the CT “slice race” is coming to an end. Now, only six months after its intro-

duction, the first ten systems are up and running in the world’s leading clinical institutions – ten out of

approximately 150 scanners that will be installed in the year 2006. In this issue, these Dual Source CT

users will share their excitement about their first clinical experiences with the new scanner, and our

technology experts will explain the miracle of dose reduction with two tubes running at the same time.

However, we at Siemens understand that supplying our users with innovative CT scanner technology is

not enough. Therefore, we have dedicated a significant part of this issue to explaining how you can

benefit from our CT Clinical Engines to continuously enhance your diagnostic performance in the key

clinical fields of cardiovascular CT, neuro CT, acute care CT and CT in diagnostic oncology. In the mean-

time, nearly 50 percent of our high-end CT customers decide to equip their system with one or more

CT Clinical Engine, customized to their clinical needs.

But we want to take CT workplace innovation even further. Have you ever thought about turning your

office PC or laptop computer into a high-performance CT workstation? Now you can. With syngo

WebSpace* Siemens is the first CT manufacturer to introduce a client-server solution for 3D reading –

wherever you are. While you are reading this, the first clinical installations of syngo WebSpace* are

being implemented and customized for very different clinical environments – from private imaging

centers to large hospital enterprises.

In this 18th SOMATOM Sessions customer magazine issue, you will discover that CT has gone beyond

innovative tube and detector technology. This issue's cover story from the chest pain unit of the Medical

University of South Carolina represents a great example that CT manufacturers have to think differently

today. New developments have to pay attention to all steps from the patient entering the CT room to

the clinical report. Now, we invite you to enjoy reading about today’s synthesis of innovations in CT

scanners and workplaces that enhance your clinical workflow.

Sincerely,

SOMATOM Sessions 18 3

CONTENT

COVER STORY4 Saving Time, Money and Lives

NEWS8 syngo Circulation – The Next Generation

10 3D-Reading – Wherever You Are

12 Siemens and BrainLAB Develop New Solutions for Neurosurgery

13 New Features with syngo CT 2006C

13 And the Winner is…

14 Individualized Head Image Reconstructions – Always Thinking (a)Head.

BUSINESS15 An Expert Opinion from Anywhere in Just a Few Seconds

15 Utilization Report Now Also Available for CT Systems

CLINICAL OUTCOMES16 Cardiovascular: Faster Diagnosis and Full Confidence in Cardiac CT

17 Cardiovascular: Dual Source CT after Left Main Coronary Artery Stenting

21 Cardiovascular: CT Angiography of the Chest

23 Oncology: Faster Diagnosis and Full Confidence in Oncology CT

24 Oncology: Silikoasbestosis of the Lung with Secondary Bronchial Carcinoma

26 Oncology: Improving Patient Outcomes with PET/CT

28 Neurology: Faster Diagnosis and Full Confidence in Neuro CT

29 Neurology: Complete Occlusion of Left Carotid Artery and Stenosis at Right Carotid Artery

31 Neurology: CTA of the Neck – Stenosis of Left Carotid Artery Evaluated with CT Digital Subtraction Angiography

33 Neurology: Cerebral Perfusion in a Patient with Dengue Hemorrhagic Fever

35 Acute Care: Faster Diagnosis and Full Confidence in Acute Care CT

36 Acute Care: Trauma Diagnosis in Seconds: 64-Slice Spiral Computed TomographyServing Full and Frank Image Acquisition

SCIENCE38 Radiation Dose with Dual Source CT

41 The Sarawak Experience – A Report After 18 Months in Clinical Practice

CUSTOMER CARE45 Evolve Update Facilitates Enhanced CT Fluoroscopy

45 Service: Frequently Asked Questions

46 Service: CT Education on the Web

46 Service: Upcoming Events and Courses

47 Imprint

COVER STORY


The scenario is a common one at the Medical University of

South Carolina (MUSC) and at hospitals around the globe: A

patient presents to the emergency department with acute

chest pain, but ECG and blood test results are inconclusive.

The current protocol for ruling out coronary syndromes as a

cause for the pain is time consuming, expensive and often

involves an invasive angiogram. MUSC’s U. Joseph Schoepf,

Looking into computed tomography as a diagnostic tool to quickly assess the cause of acute chest pain: Christian Thilo, MD, Eric Powers, MD, and U. Joseph Schoepf, MD (from left).

MD, associate professor of radiology and medicine, and his

colleagues are exploring an alternative that may provide

physicians and patients with a clear, definitive diagnosis that

saves time and money.

In 2004, the hospital was among the first in the United

States to install the Siemens SOMATOM Sensation 64-slice

computed tomography (CT) system. Schoepf, who is also

Saving Time, Money and LivesDiagnosing chest pain symptoms can be a costly, time-consuming process,often involving invasive tests and hospital admission. But new CT technologypromises welcome relief for both patients and hospital staff.

By Sameh Fahmy

COVER STORY


A SOMATOM Sensation 64-slice computed tomography scanneris installed directly adjacent to the emergency room at MUSC.

“Any type of post-processing

is much more diagnostic with

a 64-slice scanner.”U. Joseph Schoepf, MD, Associate Professor

of Radiology and Medicine, Medical University

of South Carolina, Charleston, SC

Director of CT Research and Development at MUSC, says the

benefits of the technology were immediately and intuitively

evident. “Because of the better temporal and spatial resolu-

tion, any type of post-processing, any type of 3D, looks much

better and is much more diagnostic with a 64-slice CT scan-

ner,” he says.

Using the technology to diagnose acute chest pain was both

a result of the strength of the 64-slice CT scanner and the

limitations of ECGs and blood tests as stand-alone diagnostic

tools. Cardiac enzyme tests do not reach diagnostic levels of

sensitivity until at least six hours after the onset of pain. This

necessitates a period of observation, often combined with

treadmill testing to help diagnose unstable angina. The

observation period for acute chest pain patients can take

several hours and may necessitate hospital admission, but

does not necessarily produce a clear diagnosis.

“The testing that we do and that we continue to do includes

tests which have limited sensitivity and specificity and limited

diagnostic value,” says Eric Powers, MD, professor of medi-

cine and Director of the Acute Coronary Syndrome Center at

MUSC. “So even after the testing we’d do, we’d frequently be

left with a question instead of a definite answer.”

Angiography is commonly used to rule out coronary artery

disease as the cause for chest pain, but the technique is costly,

invasive and carries risks such as bleeding and infection. “The

fact of the matter is, there are lots and lots of patients we’d

prefer not to take to cardiac catheterization – for whom we’d

rather settle the issue about the presence or absence of

coronary artery disease using a noninvasive test,” Powers says.

Promising Initial CT Trials To put the SOMATOM Sensation 64-slice system to the test,

Schoepf and his colleagues began a clinical trial that aims to

enroll 100 patients. Those patients who present to the emer-

gency department with chest pain and have a high likelihood

of coronary artery disease – positive ECG and cardiac mark-

ers – undergo conventional work-up that includes catheteri-

zation. Schoepf explains that in these patients, the addition

of a CT scan is likely to be detrimental, as it may delay the

onset of therapy.

Those patients who present with acute chest pain but have

non-diagnostic ECG results and initially negative cardiac

markers – and Schoepf says these are the vast majority of

patients – are given a chance to enroll in the trial in which

the 64-slice CT scan is used as a diagnostic tool.

CT has been shown to effectively rule out coronary artery

disease as a source of chest pain and has the further benefit

of ruling out non-cardiac causes such as acute pulmonary

embolism or aortic dissection.

“From a cardiologist’s point of view, the enthusiasm comes

from the excellent images that are taken,” Powers says. "The

excellent detail of the coronary vessels that allows us to

make the assessment.”

In addition to the SOMATOM Sensation in its vascular center,

MUSC has installed a second 64-slice system adjacent to its

emergency room to facilitate a smooth workflow. If a CT

scan is deemed necessary, hospital staff simply moves

patients through a single set of double doors to be scanned.

Although the CT trial is still enrolling patients, preliminary

results are promising. In patients where ECG and blood test

results were inconclusive, those who underwent CT imaging


COVER STORY

The SOMATOM Sensation 64-slice computed tomography scanner ensures immediate access and fast diagnosis forpatients with unclear causes of chest pain.

and were found not to have a coronary syndrome or other

acute pathology were discharged in an average of eight

hours. Those who did not undergo the CT scan were dis-

charged in an average of 17.6 hours.

The data suggest a marked cost savings as well. The average

cost of emergency department treatment for patients who

underwent the CT scan was 2,413 dollar compared to 3,438

dollar for those who did not undergo the scan – a saving of

over 1,000 dollar per patient.

But numbers don’t tell the whole story. Schoepf recalls a 22

year old patient who presented to the emergency depart-

ment with acute chest pain. The patient had a family history

of heart disease and his ECG results showed clear signs of

ischemia in the myocardium. But the patient’s relatively

young age made Schoepf doubtful that coronary artery dis-

ease was the cause and that an invasive test was warranted.

The CT scan revealed a congenital coronary abnormality in

which the patient had an aberrant artery between the root

of the aorta and the pulmonary artery. Every contraction of

the patient’s heart would squeeze the aberrant artery, pro-

ducing ECG results that looked like those of a heart attack.

Schoepf says diagnosing the patient’s anomaly using an

angiogram would have been difficult, and that the CT scan

was able to produce a better diagnosis with less risk to the

patient. “That was obviously very much of an eye opener,”

Schoepf says of the case. “I think that convinced pretty much

everybody involved about the particular value of the CT.”

In the case of another patient, a 66 year old man who pre-

sented to the emergency department with acute chest pain,

the CT scan determined significant atherosclerotic changes

– 60 percent stenosis – as well as an important incidental

finding: it revealed an early-stage squamous cell carcinoma

of the lung. “Such extra-cardiac findings are not too rare,"

says Christian Thilo, MD, research physician in the Depart-

ments of Radiology and Cardiology at MUSC. “We find pleural

effusions, pneumonia and sometimes tumor nodules in

the lungs.”

Another real benefit that’s difficult to qualify is how the

reduced wait time for patients can ease anxiety. “When you

tell patients within a very short period of time that you have

an answer and they are normal, what does that do?” Powers

asks. “That lifts a huge weight off their shoulders.”


COVER STORY

Further Benefits with Dual Source CT

MUSC has purchased and will soon install a Siemens

SOMATOM Definition, the world’s first Dual Source CT. By using

two X-ray source and detector systems that rotate in syn-

chrony, the SOMATOM Definition acquires image data in half

the time of conventional technology. The Dual Source scan-

ner has a temporal resolution of 83 milliseconds and a spatial

resolution below 0.4 millimeter, which Schoepf says will fur-

ther facilitate the emergency diagnosis of acute chest pain.

Even with a 64-slice scan, beta blockers are commonly used

to slow a patient’s heart rate so that physicians can get the

sharpest image possible. Some patients, such as those with

asthma, are not candidates for beta blockers, while others

are beta blocker resistant.

Schoepf anticipates that the better temporal resolution of

Dual Source CT will make giving patients beta blockers

unnecessary, saving time in the emergency department and

making the technology available to a wider group of patients.

He adds that the decreased scan times and other technical

advances mean that the patient’s radiation dose is cut sub-

stantially, and that patients breath-hold times are reduced,

which is of vital importance in critically ill patients.

Schoepf says the rate at which CT technology is progressing

exceeds the ability of academic medicine to assess its bene-

fits, but the trial currently underway demonstrates a com-

mitment to evidence-based medicine and a patient-centered

atmosphere.

“If you have to cut through a lot of red tape in order to make

the interdepartmental logistics work, that is not a very good

background for a speedy assessment of patients with acute

chest pain,” Schoepf says. “In this scenario, there needs to be

very good interaction between the departments of emer-

gency medicine, cardiology and radiology to make this test

as efficient as possible. Fortunately, at this institution, I believe

we are in that particular situation.”

And while the researchers await final results from their

study, they already grasp the potential of the technology and

its implications for cardiology.

“An accurate, non-invasive technique to evaluate coronary

artery disease has really been one of the holy grails of cardi-

ology forever, really,” Powers says. “This technology holds

the prospect that it really could be what we’ve been waiting

for throughout history. That sounds kind of grandiose, but the

fact of the matter is, a noninvasive test which is diagnostical-

ly accurate to assess the presence of coronary artery disease

is a crucial step in the development of cardiology.”

Author: Medical writer Sameh Fahmy holds a master’s degree in science and technology journalism from Texas A&M University and is based in Athens, GA.

“A non-invasive test

which is diagnostically

accurate to assess the

presence of coronary

artery disease is a cru-

cial step in the develop-

ment of cardiology.”Eric Powers, MD, Professor of Medicine,

Director of the Acute Coronary

Syndrome Center, Medical University

of South Carolina, Charleston, SC

A tumor in the left atrium has been identified with the SOMATOM Sensation 64(arrow).

An (sub) acute LAD occlusion(arrow) diagnosed in a patient pre-senting with atypical chest pain andinconclusive ECG and lab testing.


NEWS

s y n g o C I R C U L AT I O N

The Next GenerationThe entrance of CT into the world of

cardiovascular imaging has consider-

ably changed the research and clinical

environment over the past few years.

The advent of 64-slice CT-scanners has

brought the ability to perform reliable

and routine cardiovascular imaging to a

wide range of customers. Whereas it

was a mere research topic three to five

years ago, the majority of sites now rou-

tinely perform non-invasive CT imaging

to rule out cardiovascular disease.

Siemens CT division not only con-

tributed to this development by invent-

ing one of the most sophisticated scan-

ner technologies, but also by

engineering excellent software: syngoCirculation is the main pillar of the CT

Cardiac Engine. Developed in 2005 and

commercially available since the begin-

ning of this year, it combines morpho-

logical analysis of the coronary artery

tree with an easy and fast functional as-

sessment of the left ventricle. Only six

months after rolling out the first ver-

sion, the next generation of syngo Cir-

culation is on the horizon. This new ver-

sion will greatly enhance existing

functionality, and by adding a number

of new features, take syngo Circulation

to the top of cardiovascular evaluation

software.

While loading up to 3600 images in the

background, the diastolic phase is auto-

matically loaded first, so the user can

start performing an initial evaluation.

Additionally, an automatic segmenta-

tion of the whole heart is performed in

the background, so the user can easily

switch between a full thorax view and a

heart-only view.

The quantitative coronary analysis has

become faster and easier. A workflow

status indicates which coronaries have

been evaluated and which have not.

The addition of vessel segments be-

came possible by simply clicking into the

VRT image. The stenosis measurement

now includes an editable vessel contour

line to facilitate an accurate stenosis

measurement [Fig. 1]. The location of

the stenosis can now be defined by

clicking onto the respective location in

an AHA 15-segment model.

[ 1 ] The quantita-tive coronary analy-sis (QCA) of the NEWsyngo Circulation.The VRT can be easilyfaded out under thecoronary arteriesoverlay (lower right).An adaptable con-tour line makes thestenosis measure-ment even moreaccurate (upper left).The further simplifiedreporting dialogueallows quick report-ing (lower left).


NEWS

[ 2 ] The new Plaque Analysis (PA) allows the volumetric analysis of coronaryplaque. The histogram and color coding facilitate an easy visualization of thefindings.

One of the highlights of the new syngoCirculation software is a dedicated plaque

analysis tool1. The automatic color coding

of different HU values for three compo-

nents (calcified, intermediate, low) allows

a rapid visualization of coronary plaques.

The composition and volume of all com-

ponents can be defined and a histogram

simplifies the visualization of the distribu-

tion of the different components. The col-

or-coded overlay is visible in the cross-sec-

tional (IVUS-) views and the curved MPRs

[Fig. 2].

The functional analysis also features new

possibilities. The valvular plane of the left

ventricle is automatically defined. By set-

ting a clickpoint indicating the anterior

septum – endo- and epicard are outlined

and can be easily corrected using a three-

dimensional contouring tool. It takes less

than two minutes to edit contours for sys-

tole and diastole. Functional parameters

are automatically displayed including the

Cardiac Index. A Bulls Eye blot indicates

thickness and thickening and wall motion

abnormalities. A simple click into the AHA

17-segment Bulls Eye blot and short and

long axis views are automatically oriented

to the respective location. The movie

function allows the cine display of the my-

ocardium to accurately assess wall mo-

tion [Fig. 3].

At the end of the evaluation all findings,

including images, will end in a compre-

hensive report which can be either stored

as DICOM Structured Report or printed as

HTML or PDF file.

“The new syngo Circulation lets me save

even more time in my daily work, howev-

er facilitating a thorough analysis of the

coronaries and the myocardium. In partic-

ular, the new plaque tool and the compre-

hensive functional analysis greatly com-

plement the streamlined quantitative

coronary artery (QCA) evaluation,“ says

Andreas Knez, MD, Associate Professor

Cardiology, University Hospital of Munich-

Grosshadern.

1 Licensing fees may apply.

[ 3 ] The improved left ventricular analysis (LVA) enables a comprehensiveevaluation of myocardial function. A Bulls Eye blot with coronary artery overlaysimply visualizes any wall motion abnormality.


NEWS

N E W – s y n g o We b S p a c e *

3D-Reading – Wherever You Are

syngo WebSpace is Siemens Medical

Solution’s CT Division’s new client server

solution. A real pace setter, it offers in-

stant access to CT data plus state-of-the-

art 2D, 3D and 4D post-processing tools –

enterprise-wide and beyond.

syngo WebSpace is designed to offer

the ultimate speed and flexibility across

the entire clinical workflow. Real-time

streaming of reconstructed CT data to the

powerful server allows users instant

access to CT data via PACs or any PC client

throughout the institution, in their home

office or while traveling, by simply con-

necting to the network. Large thin-slice

data in sets up to 5000 slices per session

are immediately available for 2D, 3D and

4D interactive reading using a client serv-

er version of the highly popular syngoInSpace 4D clinical application, which is

also capable of supporting advanced

tools such as bone removal and advanced

vessel analysis. What’s more, with all

rendering taking place on the server,

users benefit from unprecedented pro-

cessing speed.

Up to 20 Concurrent Users“I am really excited about this new prod-

uct,” says Axel Kuettner, MD, University of

Erlangen in Germany. “Within a matter of

seconds I can connect my laptop to the

server and interact with a routine abdo-

minal or even multiphase cardiac dataset

using full 3D and 4D capabilities. And that

is something that is really going to speed

up our clinical workflow!”

”For us as cardiologists, the ability of the

new thin client server solution to provide

immediate availability of original CT data

in the cath lab, in the office, or in the

cardiac care unit plays a pivotal role,“ says

Stephan Achenbach, MD, University of

Erlangen. ”In addition, therapeutic deci-

sions in Cardiology often have to be made

very quickly. Therefore the possibility to

obtain immediate expert knowledge by

day and night will again substantial

importance.”

syngo WebSpace facilitates from 5 up to

20 concurrent users, depending on the

server configuration, from any number of

clients throughout the hospital network

and via secure access from the home

office or while traveling. Larger enter-

prises can access multiple servers to fur-

ther expand the possible number of con-

current sessions. This offers clinical facili-

ties of various size a very cost effective

solution for fast image distribution and

high availability routine clinical post-

processing, because once connected to

the central server, any PACS workplace or

PC can be turned into a CT processing

workplace.

“For a large institution such as Hopkins,

this client-server solution means that we

can offer all our staff access to CT data,

24/7. Now our physicians can have access

3D-Reading – Wherever You Are. Axel Küttner, MD, University of Erlangen. Screenshot syngo WebSpace (Login, evaluation with syngo InSpace 4D).

NEWS


Workflow with syngo WebSpace

OfficeComputer

HomeLaptop

PACS ReadingStation

syngo WebSpace PACS Archive

CT-Scanner with syngo Modality Workplaces

Datatransfer

Server access

Data transfer

Wor

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ces

Serv

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ity

Thin

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ter

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where and when they need it and not just

at the workstations in our 3D lab or at the

scanner. The client server solution ex-

pands our capabilities to deliver outstand-

ing patient care and improve workflow,”

explains Prof. Elliot Fishman of Johns Hop-

kins Medical Centers in Baltimore, USA.

“Plus it’s syngo, which means we don’t

have to invest time and resources in re-

training staff.”

Ideal Short Term StorageSolutionsyngo WebSpace is also ideally suited for

short term storage of thin-slice CT data.

Traditionally, large volume thin-slice data

has been stored for a matter of days on

the CT scanner, and only thick-slice data

has been archived. The short term stor-

age provided by this server solution will

give users instant access to thin slice data.

It avoids the need of sending all thin-slice

data sets directly to the PACS and frees up

the CT Scanner data base at the same

time.

“syngo WebSpace represents what CT im-

aging is demanding in a state-of-the-art

workplace solution today,“ says Dr. Bernd

Ohnesorge, Vice President CT Division at

Siemens Medical Solutions, respectively.

“It provides high speed access to CT data

combined with routine and advanced

reading tools, and can be fully integrated

into an existing PACS and IT environment.

The simple client-server architecture is

highly cost effective not only because of

its multi-user capability, but also because

it makes use of existing computer re-

sources. This should lead to higher pro-

ductivity and faster diagnosis.”

Siemens Medical Solutions is showcasing

syngo WebSpace for the first time at Stan-

ford’s 8th Annual Symposium on Multislice

CT, San Francisco, USA, 14–17th June

2006.* Pending 510(k): The information about this product is being provided for planning purposes only.

This product is pending 510(k) review, and is not yet commercially available in the U.S.


NEWS

Klaus Peter, MD, medical director of the University Hospital Munich (left) and Jörg-Christian Tonn, MD, (right)inaugurate the surgery room with the SOMATOM® Sensation Open sliding gantry.

The integrated solution works as fol-

lows: the position of the patient and the

surgical instruments are tracked in real

time and a dedicated software inte-

grates this information with the pre- and

intraoperative acquired CT images.

“Operations are less invasive and more

accurate," summarizes Jörg-Christian

Tonn, MD, director of the neurosurgery

department at Munich-Grosshadern.

www.klinikum.uni-muenchen.dek

Thanks to an integration of computed to-

mography (CT) images from the

SOMATOM Sensation Open and naviga-

tion from BrainLAB, Inc., the University

Hospital Munich-Grosshadern, Germany,

can operate more precisely and therefore

more patient-friendly. The neurosurgery

clinic inaugurated its new surgery room

with a so-called sliding gantry of the

SOMATOM Sensation Open. Because of

the bigger gantry bore of the SOMATOM

Sensation Open with 82 cm, patient posi-

tioning is more flexible, and also scanning

with a head clamp, which is regularlyused

in neurosurgery, becomes easier. Also,

the patient does not have to be moved

for imaging, because the CT gantry slides

over him. Therefore, SOMATOM Sensa-

tion Open is an ideal imaging solution for

use during surgery. A real novelty is the

cooperation with BrainLAB. It allowed an

integrated solution of CT imaging from

Siemens and the navigation system of

BrainLAB. “Through the joint work we

learned a lot about how to improve the

clinical workflow,” says Frank Engel-

Murke, MD, responsible product manag-

er at Siemens CT division.

S O M ATO M S e n s at io n O p e n

Siemens and BrainLAB Develop New Solutions for Neurosurgery


NEWS

S O M ATO M S p ir i t

And the Winner is…When it comes to design awards,

Siemens computed tomography (CT)

systems seem to have a regular sub-

Bernd Ohnesorge (left), PhD, Vice President CT Marketing and Sales, Karin Laden-burger, Product Manager CT Segments, and Klaus Thormann, Design Manager ofdesignafairs, received the "iF gold award 2006" for the SOMATOM Spirit.

S O M ATO M S p ir i t

New Features with syngo CT 2006CSince the end of January 2006 all SOMATOM Spirit scanners

are being delivered ex-factory with the latest software: syngoCT 2006C. This upgrade introduces several new workflow fea-

tures to further simplify system operation and to broaden the

clinical application spectrum of the SOMATOM Spirit.

CARE Dose has been upgraded to CARE Dose4D, enabling the

most sophisticated real time dose modulation with dose re-

duction up to 66 percent, without compromising diagnostic

image quality. The new Scan Protocol Assistant offers an easy

five-step interface to adjust protocols. Further optional fea-

tures are the new E-logbook, an efficient tool which helps to

manage patient information and includes a browser linked to

the patient image database. Additionally, syngo Neuro Perfu-

sion CT and syngo Body Perfusion CT are now supported. www.siemens.com/computed-tomographyk

scription. This year, the SOMATOM®

Spirit won an “iF gold award 2006“ at

the product design contest of the

International Forum Design GmbH in

Hannover, Germany. The jury bestowed

the price during the iF award ceremony

at the IT-fair CeBIT. The SOMATOM Spirit

convinced the jury by its attractive de-

sign, innovation and functionality. Each

year the International Forum Design

bestows the well-known iF product

design award. Fifty products won an iF

gold award in 2006, the iPod nano from

Apple and the new Passat from Volks-

wagen, too. About 1000 participants

from 37 countries had applied with 1952

products and concepts. The SOMATOM

Spirit was also shortlisted for the 2006

Design Award of the Federal Republic of

Germany.

syngo 2006C further enhances the clinical capabilities of the SOMATOM Spirit.

www.ifdesign.de,

www.designpreis.de

k


NEWS

H E A D I M AG I N G

Individualized Head Image Reconstructions – Always Thinking (a)HeadSiemens has now integrated new convo-

lution kernels settings and scan modes

which allow the user to individualize the

image impression in Neuro imaging.*

CT is usually considered the initial modal-

ity in routine and advanced head imag-

ing. Management of patients with stroke,

bleeding, acute trauma as well as visuali-

zation of sinuses and complex intracra-

nial structures like inner ear requires best

image quality for the reader.

Whether physicians prefer head images

with a smooth layout or extreme sharp

grey-white differentiation in their clinical

routine, Siemens now allows further indi-

vidualization of head images e.g. at the

level of the basal ganglia or the cortex.

Now various settings for image recon-

Enhanced filter setting allows for highest image quality in the head with individualized Kernels. A: Excellent grey-white differenciation. B: Excellent visualization of details with z-sharp.Courtesy Vancouver General Hospital, Canada

struction can be selected out of an

extended kernel list, leading to excellent

and customized image impression for

confident diagnosis in the head.

The new convolution kernels have com-

parable sharpness as conventional

Siemens kernels, but offer a different tex-

ture within the images, like en-hanced

edge visualization. They can be applied as

alternative reconstruction algorithms for

all head protocols. This allows now ven-

dor independent visualization of images.

Additional steps for head image acquisi-

tion and reconstruction (optimized scan

protocols, iterative beam hardening

correction) have been integrated. This

yields to improved grey-white matter

differentiation, particularly within the

parenchyma close to the bone/ brain

interface. Where ever a high signal to

noise ratio is clinically needed a 2x1s scan

mode can be used. Depending on the

clinical need scan modes can be freely

selected to always ensure excellent

image quality.

We thank Dr. Graeb Senior, Neuro Radio-

logist at the Vancouver General Hospital,

Dr. Hudon Neuro Radiologist Foothills

Medical Center, Calgary, and Dr. Emery

Neuro Radiologist University of Alberta,

Edmonton, for their valuable inputs and

collaboration in achieving these results.

A B

* Available with SOMATOM Definition and with software version syngo 2006A for all SOMATOMSensation 40/64 and Open, for Sensation 10/16 available Q1/2007.


BUSINESS

www.siemens.com/

utilizationmanagement

k

s y n g o EXP E RT- I *

An Expert Opinion from Anywhere in Just a Few Seconds

S I E M E N S R E M OT E S E R V I C E

Utilization Reports Now Also Available for CT SystemsTogether with Christoph Becker, MD, of

the University Hospital Munich-Gross-

hadern, Germany, Siemens has devel-

oped system utilization reports for com-

puted tomography (CT) systems. They

will support CT users with detailed data

that indicate potential for better staff

planning and system scheduling, as well

as continuously monitoring examination

times. These reports are accessible via a

personalized internet portal and are cur-

rently available on a monthly basis.

“Siemens Utilization Management helps

in a sensible way to reveal irregularities

in the CT workflow and to react accord-

syngo Expert-i saves time: From any networked PC consulting physicians can simply log on with a password as a remote user via web based access.

word. Consulting physicians can simply

log on with this password as a remote

user via web based access from any net-

worked PC. Full screen access to the

syngo CT Workplace*** is possible

(including total mouse control). Espe-

cially demanding CT applications like

cardiac CT will benefit from this solu-

tion. Requesting a second opinion on

how to edit the ECG or on how to recon-

struct the data is in your hands with a

simple mouse click. With an adequately

fast connection and VPN access to the

hospital network, this solution will even

work from home for expert on call

expertise. No matter what the need is,

the optional syngo Expert-i connects

the expert with the physician and tech-

nologist with the scanner.

ingly. In addition to the more efficient

usage of the system, patient waiting

time can be reduced. For the staff, Uti-

lization Management means a well-bal-

anced working routine throughout the

entire day,” says Becker.

Initially, utilization reports were only

available to magnetic resonance systems

users. After positive experiences, users

requested to expand this service to other

Siemens imaging systems. Today, imag-

ing systems are both established diag-

nostic tools and high-value investments

that must be deployed as cost-effectively

as possible. This is a challenge that many

universities as well as small practices face

every day. Radiology departments must

also achieve a positive performance bot-

tom line. That is why Siemens is now

working on extending the CT Utilization

Management portfolio. Following the

basic Utilization Management reports,

Siemens is already planning consulting

services, such as detailed benchmark

analyses of systems operating in similar

environments. There are also recom-

mendations for process improvements

to ensure optimum system utilization.

* Pending 510(k): 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.

**Option to be purchased separately.

***On SOMATOM Definition systems only, on other systems from early 2007 on.

Which radiologist or technologist does

not know the moments, where she or

he would like to have a second opinion

on how to reconstruct a CT scan? A pos-

sible scenario: the outpatient center

located on the other side of the road,

the CT attending or consulting physician

is paged, but is presently in the main

building and it takes him a while to get

to the scanner. All work has to be

stopped until clarification is reached.

Now Siemens can offer a much more

convenient solution for these problem-

atic situations – syngo Expert-i.** It

takes one phone call and a PC any-

where inside the hospital network to

receive an expert opinion. The person

requesting help simply starts syngoExpert-i and receives a connection pass-


CardiovascularFaster Diagnosis and Full Confidence in Cardiac CTBy Lars K. Hofmann, MD, Global Product and Marketing Manager Cardiovascular CT,

Siemens AG, Medical Solutions, CT Division, Forchheim, Germany

From scan to diagnosis, the CT Cardiac Engine offers a unique combination of innovative scanner technologyand syngo clinical applications.

A CT Cardiac Engine offers a complete solution for cardiac CT

imaging. From scan to diagnosis, it offers a unique combina-

tion of innovative scanner technology and syngo clinical

application solutions to optimize the CT system for cardiac

and vascular applications.

The CT Cardiac Engine delivers the technology for fastest

possible rotation speed, state-of-the-art ECG-synchronized

acquisition, image reconstruction techniques and intuitive

ECG-editing, always providing optimal image quality. With

ECG-pulsing the patient receives the lowest dose possible.

For Cardiac EvaluationThe completely guided cardiac evaluation with syngo Circu-

lation and syngo Calcium Scoring enables the physician to

make a diagnosis in under 10 minutes. Accurate stenosis

measurements are supported by automatically updated cross-

sectional views of the vessel (IVUS View) and display of

curved reformats. To further optimize lesion characteriza-

tion, a plaque measurement tool facilitates the volumetric

definition of different plaque components.

The fully automated cardiac function evaluation allows a

robust measurement of ejection fraction (EF), stroke volume

and cardiac index. Additional analysis of myocardial thick-

ness and wall motion can easily be performed and displayed

via Bull’s eye plot or cine function.

From cardiac morphology to coronary artery stenosis meas-

urement, this functional analysis results in a comprehensive

report that turns data into diagnostic outcomes.

For Vascular Evaluationsyngo InSpace4D Advanced Vessel Analysis stands for excep-

tional speed and image quality for quantitative vascular diag-

nosis and planning of interventions. With the Advanced

Vessel Analysis’ 1-click segmentation, the physician can auto-

matically extract any vessel from its surrounding tissue mak-

ing accurate stenosis quantification an easy task.

www.siemens.com/computed-tomographyk

Oncology NeurologyCardiovascular Acute CareCLINICAL OUTCOMES


CLINICAL OUTCOMES

Case 1: Dual Source CT after Left Main Coronary ArteryStenting in a Patient with ArrhythmiasBy Stephan Achenbach, MD1 ; Ulrike Ropers, MD1 ; Dieter Ropers, MD1; Katharina Anders, MD2; Axel Küttner, MD2;

Willi Kalender, PhD3; Werner Bautz, MD2 Werner G. Daniel, MD1

1Department of Internal Medicine 2 (Cardiology), University of Erlangen-Nuremberg, Erlangen, Germany 2Institute for Diagnostic Radiology, University of Erlangen-Nuremberg, Erlangen, Germany3Institue for Medical Physics, University of Erlangen-Nuremberg, Erlangen, Germany

HISTORY

A 63 year old male patient with known chronic occlusion of

the left anterior descending coronary artery and previous

bypass surgery (internal mammary artery graft to left anteri-

or descending coronary artery 15 years previously) experi-

enced an acute coronary syndrome (non-ST elevation myocar-

dial infarction). A high grade stenosis of the left main

coronary artery was found. Percutaneous coronary interven-

tion (PCI) and stent placement (Taxus® 5.0/12 mm) of the

left main coronary artery was performed to restore blood

flow to the left circumflex coronary artery and an intermedi-

[ 1A ] Angiography of the right coronary artery (arrow).

ate branch [Fig. 1]. The left internal mammary artery bypass

graft and right coronary artery were found patent at the time

of angiography and left main intervention.

Several days after stent placement, the patient experienced

non-typical chest pain at rest and a Dual Source CT scan was

performed to investigate stent patency. During the DSCT

scan, the patient developed arrhythmias (supraventricular

ectopic beats). Image reconstruction was performed in systole

(300 ms after R-wave), and half-scan reconstruction (heart

rate independent 83 ms temporal resolution) was used.

[ 1B ] Angiography of the intact internal mammaryartery graft (large arrow) to the left anterior descendingcoronary artery (small arrows).

1A 1B


[ 1C ] High-grade stenosis of left main coronaryartery (arrow).

[ 1D ] After PCI and stent placement into the left maincoronary artery, there is no residual stenosis in the leftmain coronary artery (large arrow). Diffuse disease ofthe left circumflex coronary artery remains (smallarrows; arrowhead = intermediate branch).

[ 2 ] ECG trace during DSCT data acquisition. Heart rate is highly irregular due to supraventricular ectopic beats,rapidly changing between 48 and 90 bpm.

COMMENTS

In spite of arrhythmias during scanning, Dual Source CT was

able to rule out the presence of in-stent narrowing or occlu-

sion of the newly implanted left main coronary artery stent.

In addition, patency of the internal mammary artery bypass

graft and absence of new stenosis in the right coronary

artery could be demonstrated.


DIAGNOSIS

In the systolic reconstructions, the heart, coronary arteries,

and the bypass graft were visualized free of motion artifacts

[Fig. 3-5], in spite of the presence of arrhythmias throughout

data acquisition. The left main coronary artery stent was

depicted in axial and frontal multiplanar reconstructions and

could clearly be demonstrated to be free of acute thrombotic

occlusion or restenosis [Fig. 3]. In addition, reconstructions of

the arterial bypass graft and of the right coronary artery

showed both vessels free of significant stenosis. Diffuse dis-

ease had remained in the left circumflex coronary artery after

the percutaneous intervention, and these stenoses were also

demonstrated by DSCT, without change to the angiographic

finding [Fig. 4 and 5]. Thus, a repeat invasive coronary

angiogram was not necessary.

1C 1D

[ 3 ] Reconstruction of the left main coro-nary artery stent in a frontal [ 3A ] and axialplane [ 3B ] and in a curved multiplanarreconstruction that shows the stent and theleft circumflex coronary artery [ 3C ]; (largearrow: patent stent, small arrows: diffusedisease in left circumflex coronary artery,compare to Fig. [ 1D ]).

[ 4 ] Curved multiplanar reconstruction of the right coronary artery [ 4A ] (arrow, no significantstenosis) and of the left main and left anterior descending coronary artery [ 4B ] (known to beoccluded; arrows = LAD, arrowhead = distal segment of IMA bypass graft and anastmosis to LAD).

CLINICAL OUTCOMES

3A 3B

4A 4B

3C



[ 5A, 5B ] 3-dimensional reconstruction of the heart and coronary arteries. The patent internal mammaryartery graft to the left anterior descending coronary artery can clearly be appreciated.

Scanner SOMATOM Definition Dual Source CT

Scan area Aortic arch to diaphragm

Scan length 137 mm

Scan direction cranio-caudal

Heart rate highly irregular between 48 and 90 bpm

kV 120 kV

Effective mAs 380 mAs/rot.

Temporal Resolution 83 ms

Rotation time 330 ms

Slice collimation 2 x 64 x 0.6 mm

Slice width 0.6 mm

EXAMINATION PROTOCOL

Pitch 0.22

Reconstruction increment 0.3 mm

Kernel B26f

5A 5B

Contrast 370 mg iodine/ml (Ultravist, Schering AG)

Volume 65 ml

Flow rate 5 ml / s

Start delay 23 s


CLINICAL OUTCOMES


Case 2: CT Angiography of the Chest – Triple Rule OutBy Lanett Varnell, MD, and Gordon D. Graham, MD, Imaging Center,

Chattanooga Heart Institute, Chattanooga, TN, USA

HISTORY

A 66 year old woman suffering shortness of breath was

examined. A performed echocardiography showed abnor-

mal findings.

An ECG-synchronized multi-slice CT of the chest was per-

formed to rule out pulmonary embolism or coronary artery

disease. Using a collimation setting of 0.6 mm resulted in a

spatial resolution 0.33 mm in order to get a detailed analysis

of coronary vessels.

DIAGNOSIS AND COMMENTS

No evidence of infiltrate or mass could be detected in the lung

window. The mediastinal windows did not show lym-

phadenopathy by size criteria. Also, the cardiothoracic ratio

remained within normal limits.

A pulmonary diagram demonstrates a pulmonary artery of 1.8

cm in diameter. No pulmonary arterial filling-defect through

third order branching could be detected. The thoracic

angiogram shows an artifact-free aortic root measuring

3.14 cm without evidence of aneurysm or dissection inside the

FOV. Wall thickness and motion were normal, the ejection

fraction 65 percent. The coronary arteries were displayed free

of motion artifacts. The left main artery (LM) with a length of

about 10 mm showed almost circumferential calcifications. The

left anterior descending coronary artery (LAD) showed a

non-calcified plaque in the proximal one third with possible,

clinically significant obstruction. The left circumflex coronary

artery (LCX) also suggested diffuse non-calcified plaque with

calcifications distally. A potentially significant obstruction was

noted in the mid segment of the vessel. Also the right coronary

artery (RCA) showed diffuse calcifications with soft plaque,

resulting in a diffuse mildly obstructive disease.

A structurally normal heart with intact left ventricular function

can be concluded. Diffuse atherosclerotic disease was noted

including significant calcified and non-calcified plaquing.

A triple vessel disease with clinically significant obstruction is

suggested. Patient subsequently underwent cardiac catheriza-

tion followed by coronary artery bypass graft (CABG).

[ 1 ] Normal origin and course of right coronaryartery seen.

[ 2 ] Diffuse plaque noted in the left coronary artery.


[ 3 ] Diffuse plaquing, both soft and calcific. [ 4 ] Normal origin of Left Main.

[ 5 ] Soft plaque probably with clinically significantobstruction.

[ 6 ] Calcified plaque noted three vessel disease noted.


Scanner SOMATOM Sensation 40-slice configuration

Scan area From arch to artery

Scan length 131.5 mm

Scan time 18 s

Scan direction cranio-caudal

kV 120 kV

Effective mAs 795 mAs

Rotation time 0.37 s


Slice collimation 0.6 mm

Slice width 0.75 mm

Pitch 0.24


Kernel B25f

Contrast 370 mg iodine/ml (Ultravist, Berlex)

Volume 120 ml

Flow rate 4 ml / s


OncologyFaster Diagnosis and Full Confidence in Oncology CT By Ken Field, Global Product and Marketing Manager Oncology CT, Siemens AG,

Medical Solutions, CT Division, Forchheim, Germany

Oncology NeurologyCardiovascular Acute Care CLINICAL OUTCOMES

The CT Oncology Engine provides a uniquecombination of innovative scanner solutionsand syngo clinical applications.

The CT Oncology Engine provides a complete solution for CT

imaging in oncology. For early disease detection, diagnosis,

intervention, reporting, and follow-up, the CT Oncology

Engine provides a unique combination of innovative scanner

solutions and syngo clinical applications, designed to achieve

a streamlined diagnostic oncology workflow.

For Lung and Colon Evaluationsyngo LungCARE CT with Nodule Enhanced Viewing (NEV)

and syngo CT Colonography with Polyp Enhanced Viewing

(PEV) provide state-of-the-art workflow for early detection,

visualization, reporting, and follow-up for the lung and colon

regions. Second-reader tools are integrated into the workflow

to ensure a comprehensive evaluation of CT study data.

For Tumor Evaluationsyngo Body Perfusion enables the functional analysis of body

tumors for tissue differentiation and staging. Intuitive tumor

perfusion enables fast, easy visualization of a tumor’s vascu-

larization profile and aids in differentiating tumors.

For Gaining better Insightsyngo Image Fusion allows the user to fuse two DICOM image

datasets acquired on different imaging modalities to form

a new image dataset that contains enhanced information.

With syngo Image Fusion, a physician can combine function-

al information obtained with SPECT or PET with anatomical

information obtained from CT.

For Interventional ProceduresCARE Vision CT optimizes interventional procedures by pro-

viding real-time visualization and scan protocols that signifi-

cantly reduce radiation exposure to patients and staff.


[ 1 ] VRT: miliary calcification of the lung, eggshell likelymph node calcification mediastinal and hilar.


Case 3: Silikoasbestosis of the lung with secondarybronchial carcinomaBy Manfred Oldendorf, MD, Medical Director,

Department of Radiology, Hospital Nuremberg North, Nuremberg, Germany

HISTORY

A 67 year old male patient shows fine particulate and

asbestos pollution of the lung for more than 30 years because

of professional reasons. He has suffered from accretive diffi-

culty in breathing with restrictive disorder of the ventilation

and pulmonary hypertension for 5 years.

DIAGNOSIS

The CT scan showed a Silikoasbestosis of the lung with sec-

ondary bronchial carcinoma of the lung (plate epithelium

carcinoma, histological firmed). Disseminated, military nod-

ules with calcification were detected, as well as an interstitial

lung deformation with emphysema bubbles, which were

caused by retraction. The images clearly show a solid tumor

on the right upper lobe without necrolysis and a calcified

medistinal lymphatic gland.

[ 2 ] Disseminated, miliary nodules with calcification,interstitial lung deformation with emphysema bub-bles caused by retraction. [ 2A ] Lung window setting.[ 2B ] Mediastinum window setting.

2B


1

2A

CLINICAL OUTCOMES


[ 3 ] Solid tumor on the right upper lobe withoutnecrolysis (hist.plate ephitelium carcinoma (arrow)) andCalcified mediastinal lymphatic gland (arrow head).

[ 4 ] VRT: fibrotic deformed lung structure (white).


Scanner SOMATOM Emotion 16-slice configuration

Scan area Thorax

Scan length 320 mm

Scan time 13.0 s

Scan direction Caudo-cranial

kV 130 kV

Effective ref. mAs 68 –158 mAs (Care Dose4D)

Rotation time 0.6 s

Slice collimation 16 x 1.2 mm

Slice width 1.5; 6.0 mm

Contrast

Volume 120 ml

Flow rate 2.0 ml / s

Start delay 60 s

Postprocessing MPR, MIP, VRT

Pitch 0.8

Reconstruction increment 1.2; 6.0 mm

CTDIvol 14.5

Kernel 3

3 4


Case 4: Improving Patient Outcomes with PET/CTBy John Myers, Diagnostic Services Director, Kansas City Cancer Center, Overland Park, Kansas, USA

The diagnostic capabilities of PET/CT technology in oncology

are substantially broadened when compared to those of

individual CT or PET studies and can have a significant effect

on patient outcomes. The Biograph hybrid imaging system

provides the powerful combination of functional and anatom-

ical information in a single diagnostic procedure, enabling

Metastatic Bladder Cancer

accurate tumor diagnosis, whole-body staging, target defini-

tion, and treatment planning. As hybrid PET/CT imaging

becomes the standard diagnostic tool in oncology cases,

patients are benefiting from earlier detection of disease and

metastases, as well as more accurate assessments during

and after treatments.

[ 1 ] CT scan of the pelvis shows the close proximity of the normal pelvic anatomy and abnormal lymph node.

HISTORY

A 64 year old male with a long history of cigarette smoking,

hypertension and hydronephrosis was referred for PET/CT to

follow-up on an initial diagnosis of invasive urothelial carci-

noma after a negative CT scan was performed.

DIAGNOSIS

The PET/CT study, performed on a Siemens Biograph 16 with

HI-REZ, detected a hypermetabolic lymph node of 1.2 cm,

located next to the iliac vein, iliac artery and ureter [Fig.

2–4]. The metastatic lesion was not detectable in the stand-

alone CT, due to its size and close relationship to the above

mentioned anatomy [Fig.1].


Lymph node

Iliac artery

Iliac vein

Ureter


CLINICAL OUTCOMES


Scanner Biograph 16

CT Protocol

Scan area Whole Body

kV 120 kV


Rotation time 0.5 s

Slice collimation 16 X 1.5 mm

[ 4 ] PET, CT and fused PET/CT sagittal, coronal andaxial slices demonstrate exact localization and relation-ship of the lesion with the surrounding anatomy.

COMMENTS

PET/CT plays a major role in the detection, staging and treat-

ment of oncology cases. In this particular case, the impor-

tance of using hybrid PET/CT technology was critical, as the

management, and ultimately the outcome of this patient’s

case would have been significantly different if he only under-

went a PET scan, or only had the CT scan during the diagnostic

evaluation. While the lymph node was not diagnosed at all in

the standalone CT, a dedicated PET scan could have poten-

tially misinterpreted the abnormal activity as FDG in the ureter.

Only the co-registered, detailed anatomical and functional

data illustrated the true diagnosis and changed the treat-

ment plan and overall outcome for this patient.

The HI-REZ PET imaging technology of the Siemens Biograph

16, in conjunction with the spectacular detail in the anatom-

ical imaging of the CT, makes it possible to see detailed

anatomy and functional processes in a single exam and can

make a difference in diagnoses and outcomes in complex

oncological cases.

[ 2 ] Fused PET/CT image shows the hypermetaboliclymph node situated in the pelvis (red spot).

[ 3 ] PET, CT and fused PET/CT axial slices through thepelvis, revealing the hypermetabolic lymph node.

Slice width 5 mm

Pitch factor 0.75

Reconstruction increment 3 mm

PET Protocol

Dosage 15.0 mCi FDG

Bed Times 3min/bed position

Recon Method Iterative


NeuroFaster Diagnosis and Full Confidence in Neuro CT By Stefan Wünsch, PhD, Global Product and Marketing Manager Neurology CT,


A CT Neuro Engine offers a complete solution for neuro CT

imaging. From scan to diagnosis, the CT Neuro Engine pro-

vides a unique combination of innovative scanner solutions

and syngo clinical applications, designed to achieve a

streamlined neuro workflow. The CT Neuro Engine delivers

the technology required to perform artefact-free imaging

with the high spatial and temporal resolution needed for fast

and accurate visualization of complex neurological disor-

ders, the head, neck, spine, and the evaluation of acute

ischemic stroke. Using Interactive 3D Volume reading, in

combination with dedicated scanner solutions, allows opti-

mal visualization and treatment planning of complex C spine

fractures. A diagnosis will be fast and confident, turning data

into a diagnostic outcome within minutes.

For Stroke Evaluation The fully automated syngo Neuro Perfusion CT ensures the

fastest differential diagnosis of ischemic stroke and tissue at

risk evaluation in less than 10 minutes at a flow rate of 5-8

ml/s. It allows the simultaneous calculation of diagnostic

images in less than 1 min.

For Vascular Evaluation syngo Neuro DSA CT is the first CT-based digital subtraction

angiography for non invasive assessment of intracranial vessels

and CTA data of the neck. It is ideally suited for the delineation

of aneurysms and other vascular diseases. syngo Neuro DSA CT

enables fully automated subtraction of vessels from bones,

thus enhancing the visualization of even the smallest cerebral

vessels and helping to improve diagnostic confidence.

For Brain Tumor EvaluationFully automated syngo Neuro Perfusion CT facilitates quanti-

tative evaluations of brain tumors. The fast quantitative eval-

uation enhances the ability to grade tumors, plan biopsies

and monitor therapy.


The CT Neuro Engine provides a unique combi-nation of innovative scanner solutions and syngoclinical applications.


Case 5: Complete Occlusion of Left Carotid Artery and Stenosis at Right Carotid ArteryBy Amit Mehta, MD, Chief Radiologist, and Susan Hall, CT Technologist,

St. Catharines General Site – Niagara Health System, Ontario, Canada

HISTORY

A 68 year old female admitted to our facility for a pre opera-

tive assessment for carotid endarterectomy. The patient has

experienced episodes of vision loss in the right eye over the

past 2 or 3 months, but had no speech difficulties and no

motor or sensory deficits have been detected. The patient

had a history of a carotid Doppler examination in 2003 at

which time she had severe stenosis of both internal carotid

arteries (ICA). A Doppler ultrasound in 2006 showed an

occluded left ICA and 80– 90 percent stenosis of the right

ICA. She also has a history of hypertension and smokes. The

CNS exam was grossly intact. A CTA of the carotids was per-

formed for pre-operative assessment.


The CTA data confirmed a complete occlusion of the left

common carotid and internal carotid arteries. The left exter-

nal carotid artery is partially reconstituted via a muscular col-

lateral artery. Additionally, a severe stenosis at the bifurca-

tion of the right internal and external carotid artery by a

mixed calcified and soft plaque was detected. With the high

resolution of SOMATOM Sensation 64 and syngo Neuro DSA

the CTA of the whole carotid artery could be displayed and

evaluated easily using the automated bone subtraction

functionality.


CLINICAL OUTCOMES

[ 1 ] VRT of the carotid arteries.

Scanner SOMATOM Sensation 64-sliceconfiguration

Scan area Carotids and Circle of Willis

Scan length 266 mm

Scan time 5.36 s

Scan direction Caudo-Cranial

kV 120 kV

Effective mAs 200 mAs (150 mAs for native scan)



Slice width 0.6 mm

Pitch 0.95


CTDI 15.33 mGy

Kernel B20f


Contrast 350 mg iodine/ml (Optiray)

Volume 70 ml

Flow rate 4 ml / s

Start delay 2 sec

Bolus Tracking trigger 100hu at aortic arch

Postprocessing syngo Neuro DSA, CT



[ 2 ] CT digital subtraction angiogram: frontal view.VRT display after automatic substraction of boneusing syngo (kursiv) Neuro DSA CT.

[ 3 ] MIP image obtained with the automated subtractionalgorithm of syngo Neuro DSA showing occlusion of the left common carotid and internal carotid arteries with severestenosis of the right internal carotid artery. A muscular colla-teral fills the left external carotid artery.


CLINICAL OUTCOMES

Case 6: CT-DSA of a Common Carotid Artery in a Young WomanBy Harald Görzer, MD, Diagnosezentrum Margareten, Vienna, Austria

DIAGNOSIS AND COMMENTSUsing the functionality of digital subtraction CT-angiogra-

phy, automatically subtracting a noncontrast from a con-

trast enhanced study, the complete vascular tree could be

demonstrated and the suspected 90 percent stenosis of the

[ 1 ] VRT of left carotid artery.

HISTORY A 46 years old woman with a history of hypertension presented an acute onset of vertigo, fatigue, severe headache and somno-

lence in our institution. CCT showed neither recent signs of supra- or infratentorial ischaemia, nor bleeding nor intracranial mass.

Colour coded Doppler ultrasound was not completely conclusive due to a high carotid bifurcation and a moderate elongation of

the internal carotid artery on both sides, as well as tachyarrythmia. A 60-90 percent stenosis of the left ICA was suspected, there-

fore the patient was scheduled for carotid CTA.

left internal carotid artery at its origin could be verified. The

right carotid artery was not affected. The patient is now on

aspirin therapy and endarterectomy is scheduled.



[ 2 ] The CTA demon-strates stenosis of the left internal carotid artery (arrow). The right carotid arteryis not affected.

[ 3 ] The CTA demon-strates a 90% stenosisof the left internal carotid artery ostiumwith slight calcifi-cations (arrow), the left external carotid was not affected.

Scanner SOMATOM Emotion 16-slice configuration

Scan area Carotids and Circle of Willis

Scan length 168 mm

Scan time 13.6 s

Scan direction Caudo Cranial

kV 130 kV


Rotation time 0.6 s

Slice collimation 16 x 0.6 mm


Contrast 370 mg iodine/ml

Volume 70 ml

Flow rate 4 ml / s

Start delay 2 s

Postprocessing Neuro CT-DSA, MPR, VRT

Slice width 0.75 mm

Pitch 0.8

Kernel B20s

[ 1 ] Overview of CTperfusion data. Upperleft MiP image, Upperright – Blood Flow,Lower left – Blood Volu-me, Lower right – TimeTo Peak data.


Case 7: Cerebral Perfusion in a Patient with Dengue Hemorrhagic Fever By Nitamar Abdala, MD, Radiology Professor, and Carolina Salazar, MD, Radiology Resident – UMDI – Unidade Mogiana

de Diagóstico por Imagem, São Paulo, Brazil

CLINICAL OUTCOMES

HISTORY

A 53 year old male patient with acute high intensity

headache episodes and syncope (nausea) one month ago,

left hemiplegics, and no more associated symptoms, was

referred to the hospital. The patient had a history of hyper-

tension with drug control and Dengue Hemorrhagic five

years ago.

Patients that suffer from Dengue Hemorrhagic can eventually

have low blood flow with hypo cerebral perfusion which can

cause cerebral infarction like “watershed”, which means,

stroke in the frontier areas. Most of these lesions occur

between the anterior and median cerebral arteries, as well

as in the basal ganglia. Since this patient had an old stroke

possibly caused by an ischemic event related to Dengue

Hemorrhagic five years ago and moreover the patient still

lives in the endemic area, it was suspected that the current

symptoms could be related to the cerebral hypo perfusion.


CT data acquired with the first SOMATOM Spirit in Brazil

shows a lesion detected at right basal ganglia interpreted as

encephalic scar from previous event. The current CT Perfu-

sion study shows signals that can be related to hypo perfu-

sion of left basal ganglia.



Dengue / Dengue Hemorrhagic Fever

Dengue and dengue hemorrhagic fever (DHF) are

acute febrile diseases, found in the tropics, with a geo-

graphical spread similar to malaria. Caused by Fla-

vivirus, the disease is transmitted to humans by the

mosquito Aedes aegypti. The disease is manifested by a

sudden onset of fever, with severe headache, joint

and muscular pains (myalgias and arthralgias, severe

pain gives it the name break-bone fever), leukopenia

and rashes. The dengue rash is characteristically bright

red and covers most of the body. DHF also shows

higher fever, hemorrhagic phenomena, thrombocyto-

penia, and hemoconcentration. In around 5 percent of

cases there is dengue shock syndrome (DDS) and hem-

orrhage, leading to death. There is no commercially

ready vaccine.


[ 2 ] MIP image shows an old lesion at right basal ganglia interpreted as encephalic scar from an old stroke (3). And suggested hypoperfused area in the left basal ganglia (3).

[ 3 ] Perfusion data of Blood Flow [ 3A ] and Blood Volume [ 3B ] from CT Perfusion study shows hypo perfused area of left basal ganglia (3) and the old lesion in the right basal ganglia (3).

Scanner SOMATOM Spirit

Scan area Basal ganglia

Scan length 10 mm

Scan time 40 s

kV 80 kV


Rotation time 1.5 s


3A 3B

Slice width 10 mm

Table feed / rotation 0 mm

Kernel H31s

Contrast 300 mg iodine/ml (Henetix)

Volume 40 ml

Flow rate 5 ml / s

Start delay 5 s

Postprocessing syngo Neuro Perfusion CT


Acute CareFaster Diagnosis and Full Confidence in Acute Care CT By Lars K. Hofmann, MD, Global Product and Marketing Manager Cardiovascular CT,


A CT Acute Care Engine provides a complete solution for CT

imaging in an emergency situation. The requirements for CT

imaging are challenging and diverse, from acute chest pain

patients to complex poly-trauma to stroke assessment –

every second counts.

The CT Acute Care Engine delivers a complete solution need-

ed to make fast and confident decisions. By combining state-

of-the-art functionality for cardiac, vascular and neuro CT

imaging, and adding innovative workflow features to high-

resolution acquisition, the CT Acute Care Engine provides a

complete clinical portfolio for imaging emergency patients

from head to toe.

Cardiovascular EvaluationThe CT Acute Care Engine provides the tools physicians need

to diagnose todays vascular emergency – from aortic dissec-

tion or pulmonary embolism to coronary artery disease and

acute vascular obstructions.

syngo Circulation’s fast-track non-invasive cardiac evaluation

enables fully automated segmentation of the coronary arter-

ies, fast and accurate stenosis quantification and reliable

wall motion and cardiac function analysis. syngo InSpace4D

Advanced Vessel Analysis stands for exceptional speed and

image quality for real-time diagnosis and interventional

planning.

Polytrauma Evaluation

syngo InSpace4D also enables exceptional visualization of

complex vasculature and fractures from head to toe. It

allows fast high quality imaging of full body scans with auto-

mated bone segmentation including transparency mode

allowing the rapid visualization of complex fractures.

Stroke and Neurovascular Evaluationsyngo Neuro DSA CT and syngo Neuro Perfusion CT lead to a

quantitative evaluation for differential diagnosis of stroke

and exclusion of subarachnoidal bleeding (SAB) in an emer-

gency situation. syngo Neuro Perfusion CT with its guided

workflow and automatic quantification of cerebral blood

flow (CBF), cerebral blood volume (CBV), time to peak (TTP),

allows the assessment of tissue-at-risk and the evaluation of

perfused blood volume in less than 10 min from scan to diag-

nosis. The fully automated workflow of syngo Neuro DSA CT

facilitates direct subtraction of native and contrast-enhanced

scans for optimal visualization and evaluation of complex

cranial vascular structures and supports interventional plan-

ning e. g. coiling or clipping of aneurysms in SAB patients.


Oncology NeurologyCardiovascular Acute Care CLINICAL OUTCOMES

The CT Acute Care Engine delivers the complete solution needed to make fast and confident decisions.

[ 1 ] Frontobasal contusions on both sides and mixedsubarachnoid and subdural bleeding in the left hemis-phere (arrows).

[ 2 ] The viscerogenic cranium endured a tripoidal frac-ture on the right and an ipsilateral blow-out fracture ofthe orbital base.



Case 8: Trauma Diagnosis briefly: 64-Slice Spiral Computed TomographyBy Florian T. Schmid, MD, Björn Stinn, MD, Jörg-Thomas Kluckert, MD, Thomas Chlibec, MD, and Simon Wildermuth, MD, PhD,

Institute of Radiology, Kantonsspital St. Gallen, Switzerland

HISTORY

A 52 year old male fell off a 7 m high roof during mainte-

nance work. After the arrival of the med-evac helicopter, the

emergency physician diagnosed an initial Glasgow-Coma-

Score (GCS) of 3, hypotonia and tachycardia. The left pupil

was fixed under direct light. An asymmetric mydriasis existed

in both eyes. A periorbital hematoma developed quickly on

the left side and there was visible blood flow out of the nose

and left ear. The patient was hemodynamically stabilized by

transfusion, intubated on site and afterwards airlifted to our

clinic. At the emergency room the patient received a right-

sided pleural drain (Buelau) and a CT examination of the head

and body was performed as per standard trauma protocol.

DIAGNOSIS

The initial native CCT-scan showed frontobasal contusions on

both sides and in the right basal ganglias. A mixed subarach-

noid and subdural bleeding in the left hemisphere lead to a

consecutive shift of the centerline and to an initial, tentorial

herniation. The aqueduct was free. The thin-slice reconstruc-

tion showed singular, pontine and cerebellar shear-lesions.

The frontal base was ambilaterally fractured and emanated

into the right temporal bone and pneumencaphalon.

A hematotympanon on the left was probably caused by a

longitudinal fracture of the petrous bone which sphenoidally

emanated.

The viscerogenic cranium endured a tripoidal fracture on the

right and an ipsilateral blow-out fracture of the orbital base

without herniation of orbital soft tissue. The diagnosis was a

consecutive hematosinus.

A ventral right pneumothorax without relevant collapse of

lung tissue could be found after insertion of the “Buelau”-

drainage. The bilateral postobasal lung contusions were cor-

responding with the costal fractures of ribs three and four on

the right. According to the trauma mechanism, a liver lacera-

tion of segment five and six could also be found, with a large

Scanner SOMATOM Sensation 64-slice configuration

Head Scan Protocol

Scan area Head

Scan length 242.5 mm

Scan time 17.41 s

Scan direction caudocranial

kV 120 kV


Rotation time 1 s


Slice width 1 mm

Pitch 0.8


CTDI 59.43 mGy

Kernel H21s / H70h

Body Scan Protocol

Scan area Body

Scan length 641 mm

Scan time 21.51 s

Scan direction craniocaudal

kV 120 kV

Ref mAs 200 mAs (Care Dose 4D)



Slice width 1.5 mm

Pitch 0.6


CTDI 10.84 mGy

Kernel B10f / B30f / B60f

Contrast 350 mg iodine/ml (Iomeron)

Volume 150 ml (polyphasisch)

Flow rate 3.5 ml / s

Start delay Care Bolus Tracking

Postprocessing InSpace 4D

SCIENCE


hematoma and active, portal-venous hemorrhage. Little peri-

hepatic and interenteric liquid with an attenuation of 40 HU

correlate with a caudal liver capsule lesion. Mesenteric, hepatic

and gastric edema matched the patient’s initial shock state.

Despite a small, v-shaped perfusion defect of the left kidney,

there were no further abdominal pathologies. An arterial injury

as a cause of the perfusion defect could be reliably excluded.

The spine did not show any injuries – only degenerations.

A little Pipkin 3 impact fracture of the right femur was detected.

Together with a non-dislocated fracture of the frontal pelvic

ring, including the advocated anterior acetabulum, it marked

the power vectors. A fracture of the right dorsal pelvic ring

caused instability while striding the right iliosacral joint.

COMMENTS

Already in 1976, Cowley influenced the concept of “golden

hour”1 and illustrated that trauma management always

means time management. The mortality of traumatized

patients increases significantly after the first hour, and

includes not only first aid and quick transport. The time

before therapy is essential. A fast and comprehensive diag-

nosis became the solution for a successful triage and therapy.2

Today’s multislice CT with slice configurations of 40 and more

slices, short rotation times and high-performance tubes

allow a diagnosis with detailed information about the neuro-

surgical, traumatological, thoracic- and abdominal surgical

state of the patient.

In this case, the initial prognostic detection of shear lesions in

brainstem and cerebellum already indicated a possible lethal

outcome. Nevertheless, the perceptibility of such minimal

changes of the modern spiral CT of the brain indicates a

huge progress in technology. The findings were not only

quantitative, in terms of short examination times of large

volumes, but also qualitative with continuously better spatial

resolutions down to 0.33 mm in isotropic voxels.

A modern dose modulation method like Care Dose 4D con-

siderably reduces the necessary dose exposure.

1 Cowley RA (1976) The resuscitation and stabilization of major multiple trauma patients in a trauma center environment. Clin Med 83: 14.2 A.Beck, F.Gebhard, Th. Fleiter, E. Pfenninger, L.Kinzl: [Time optimized modern shock room management using digital techniques]; Unfallchirurg. 2002Mar; 105(3): 292–6.


[ 3 ] A liver laceration was found with a hematomaand active portal-venous hemorrhage.

[ 4 ] Fractures of the right femur (3) and of the frontalpelvic ring (3) were detected.


Temporal resolution better than 100 ms in combination with

sub-mm spatial resolution and examination times below 10 s

to cover the entire heart volume are considered pre-requisi-

tes for a successful implementation of cardiac CT into routi-

ne clinical algorithms. SOMATOM Definition is a Dual Source

CT (DSCT) scanner with a 0.33 s gantry rotation time and

2 x 32 x 0.6 mm collimation in combination with z-SharpTM

Technology for the simultaneous acquisition of 2 x 64 over-

lapping 0.6 mm slices. With these technical specs, it can ful-

fill these requirements: temporal resolution is as good as 83

milliseconds independent of the heart rate for coronary CTA

and functional evaluation. 0.33 mm through-plane resolu-

tion can be routinely achieved for the evaluation of stents

and severely calcified coronary arteries. The scan time for a 120

mm scan volume ranges between 5 and 9 s, depending on the

patient’s heart rate. First clinical experience has already demon-

strated a considerably increased robustness of the method

for the imaging of patients with high heart rates [Fig. 1].

In addition to their benefits for cardiac examinations, DSCT

scanners also show promising properties for general radiology

applications. First, both X-ray tubes can be operated simulta-

neously in a standard spiral or sequential acquisition mode,

in this way providing up to 160 kW X-ray peak power. These

power reserves are not only beneficial for the examination of

morbidly obese patients, whose numbers are dramatically

growing in western societies, but also to maintain adequate

X-ray photon flux for standard protocols when very high

volume coverage speed is necessary. Among them are acute

care situations, where the scanner has to be operated with

fast gantry rotation (0.33 s) and at high pitch (p = 1.5). Addi-

tionally, both X-ray sources can be operated at different kV-

settings and/or different pre-filtrations, in this way allowing

dual energy acquisitions.

A major concern in cardiac CT is high radiation dose to the

patient, which is mainly caused by the highly overlapping

data acquisition due to the low spiral pitch required for

gapless volume coverage in each phase of the cardiac cycle.

In cardiac DSCT, both X-ray sources have to be simultaneous-

ly operated at the power level needed for single source CT, sin-

ce each of them contributes only a quarter rotation to an

image slice. Without further optimization, DSCT would incre-

ase radiation dose to the patient by almost a factor of two.

With dedicated dose reduction mechanisms, however, radia-

tion dose can be efficiently reduced to a level well below that

of single source cardiac CT. The three major steps to radiation

dose reduction are:

EDUCATIONSCIENCE

SOMATOM DefinitionRadiation Dose with Dual Source CTReducing radiation dose is a major concern in cardiac CT. With dedicated dose reduction mechanisms, however, radiation dose in Dual Source CT canbe efficiently reduced to a level well below that of single source CT.

By Thomas Flohr, PhD, Head of Physics and Application Development, Herbert Bruder, PhD, Karl Stierstorfer, PhD,

Physics and Application Development, Siemens AG, Medical Solutions, CT Division Forchheim, Germany,

and Cynthia McCollough, PhD, Director of the CT Clinical Innovation Center, Mayo Clinic, Rochester, Minnesota, USA

[ 1 ] VRT renderings of a 59 year old male patient with suspicion of RCA stenosis. The mean heart rate of the patient during the scan was 85 bpm. Left: diastolic reconstruction at 65 % of the cardiac cycle. Right: end-systolic reconstruction at 28 % of thecardiac cycle. In both cases, the coronary arteries are clearly depicted with little or no motion artifacts.

100%690 x 490

Time

Recon

single source CT

Dual Source CT

Recon

Curr

ent

20%


� use of a new optimized ECG-pulsing with shorter exposure

windows that can be reliably applied even in the presence

of arrhythmia� use of single-segment reconstruction at all heart rates that

enables efficient adaptation of the spiral pitch to the heart

rate� use of an optimized cardiac beam-shaping filter that avoids

unnecessary exposure outside the central heart region

Efficient ECG-Controlled Tube Current ModulationIn cardiac CT, ECG-controlled modulation of the X-ray tube

current is applied to restrict the time interval of maximum

exposure to those cardiac phases where diagnostic image

quality is required [Fig. 2]. The plateau of high dose must

extend over the data range needed for image reconstruc-

tion, as well as additional ranges for retrospective optimiza-

tion of the cardiac phase used for image reconstruction. In

single source CT, image reconstruction requires a high dose

plateau of at least half the gantry rotation time at iso-center,

and the data range needed for phase optimization has to be

larger than in DSCT due to the lower temporal resolution. In

DSCT, image reconstruction requires a high dose plateau of

only a quarter of the gantry rotation time at iso-center.

Consequently, the time interval with full dose can be much

shorter, which results in reduced radiation exposure com-

pared with single source CT. The potential for dose reduction

depends on the heart cycle length and, hence, on the

patient’s heart rate.

For ECG-controlled modulation of the tube current, a pro-

spective method is needed to estimate the time of the R-

peak for the next cardiac cycle. Using conventional approa-

ches, the mean value of some preceding heart cycles is used

to estimate the next RR-interval. This method fails if the

patient’s heart beat is arrhythmic. For DSCT, a much more

robust algorithm for prospective estimation of the cardiac

cycle length by refined analysis of the patient’s ECG has been

developed and implemented. This algorithm takes non-

rhythmic heart beats, such as extra-systoles, into account

and can be applied also in case of arrhythmia.

Adaptation of Spiral Pitch to thePatient’s Heart RateIn single source CT, improved temporal resolution is obtained

at the expense of limited spiral pitch and correspondingly

increased radiation dose to the patient. For a so-called single-

segment reconstruction, the table has to travel so slowly

that each z-position of the heart is seen by a detector slice

during each phase of the cardiac cycle. Consequently, the

patient’s heart rate determines the spiral pitch: if the heart

rate goes up, the spiral pitch can be increased, too. If multi-

segment reconstructions are applied at higher heart rates to

improve temporal resolution, the spiral pitch has to be redu-

ced again: for a 2-segment reconstruction, each z-position of

the heart has to by seen be a detector slice during two con-

secutive heart beats; for a 3-segment reconstruction during

three consecutive heart beats; and so on. In general, manu-

facturers of single source CT scanners recommend an adap-

tive approach for ECG-gated cardiac scanning: the pitch of

the ECG-gated spiral scan is kept constant at a relatively low

value of 0.2– 0.25, and more segments are used for image

reconstruction at higher heart rates to improve temporal

resolution. Up to a certain threshold heart rate, a single-seg-

ment reconstruction is performed, if the heart rate increases

this threshold, two or even more segments are used. Even if

a certain adaptation of the pitch is available, as proposed by

some manufacturers, the range of variation is very small, e. g.

between 0.2 and 0.25.

Using a DSCT-system, a temporal resolution of a quarter of the

gantry rotation time is achieved independent of the patient’s

SCIENCE

ECG-controlled Tube Current Modulation

[ 2 ] ILLUSTRATION OF ECG-controlled tube current modulationfor the evaluated DSCT system. For coronary CT angiography, theimage reconstruction window should be located within the windowof maximum tube current. The temporal width of the image recon-struction window is 83 ms for the DSCT; it is 165 ms for a singlesource CT at 0.33 s gantry rotation time. For the DSCT, the temporalwidth of the window of maximum tube current can be selected bythe user. It can be much shorter than for a single source CT system,thereby reducing radiation dose to the patient.


SCIENCE

Comparison of Relative Radiation Dose

[ 4 ] RELATIVE RADIATION DOSE for ECG-gated scanning withsingle source CT and DSCT, with ECG-controlled dose modulation,using the same scaling as in Figure 3. For single source CT, the win-dow of full dose is 400 ms, for DSCT it is 210 ms. The relative dosewith single source CT increases with increasing heart rate, due to thedecreasing dose reduction effect of ECG-controlled dose modulationand the constant spiral pitch. The relative dose with DSCT decreaseswith increasing heart rate. At clinical relevant heart rates between70 and 90 bmp, the radiation exposure with DSCT is only about 50%of the radiation exposure with the single source CT system , whenECG controlled dose modulation is applied.

[ 3 ] RELATIVE RADIATION DOSE for ECG-gated scanning withsingle source CT and DSCT, assuming equivalent image noise. Forboth systems, no ECG-controlled dose modulation is used. The sin-gle source CT system is operated at a pitch of 0.2, a typical valuefor ECG-gated coronary CTA. The non-optimized DSCT system (alsooperating at a pitch of 0.2) increases radiation dose by almost afactor of 2.With an optimized cardiac bowtie-filter, the dose increase is reducedto a factor of 1.53. With additional pitch adaptation, the radiationdose for the DSCT system is only 80 percent of the radiation expo-sure with single source CT at clinical relevant heart rates of 70 – 90bpm, when ECG controlled dose modulation is not used.

ray beam can be attenuated by shaped filters to reduce radi-

ation intensity in the scan-plane (in the fan-angle direction)

with increasing distance from the iso-center. In cardiac CT,

the region of interest, the heart, is centered within the thorax,

and radiation can, in principle, be restricted to a cardiac field

of view (FOV) of about 25 cm in diameter. Thus, the radiation

dose outside the cardiac FOV can be reduced by an optimi-

zed beam-shaping filter and by the smaller scan field of view

of the second X-ray tube-detector system.

The effects of the three dose saving steps are summarized in

Fig. 3 and 4. In Fig. 3, the relative radiation dose for ECG-

gated cardiac CTA with DSCT is compared with the dose for a

corresponding single source CT-system, both without ECG-

pulsing. Dose reduction for DSCT comes from the cardiac

bowtie-filter and the adaptation of the pitch to the patient’s

heart rate. In Fig. 4, the effect of ECG-gated dose modulation

is additionally taken into account for both systems. Applying

the three dose saving steps, dose reduction up to a factor of

two compared with single source CT can be demonstrated

Further ReadingFlohr, T., et. al.: First performance evaluation of a dual-source CT (DSCT)

system, Eur Radiol. 2006 Feb; 16(2): 256–68.

Achenbach, S., et al.: Contrast-enhanced coronary artery visualization

by dual-source computed tomography – Initial experience. Eur J Radiol.

2006 Mar; 57(3): 331–5.

heart rate. Single-segment reconstruction using data from

one cardiac cycle for image reconstruction can be applied at

all heart rates. Since multi-segment reconstruction will not

be required, the spiral pitch can be efficiently adapted to the

patient’s heart rate and significantly increased at elevated

heart rates, compared with single source CT systems that

have to use multi-segment reconstruction at higher heart

rates. Pitch values ranging from 0.25 at lower heart rates up

to 0.5 at high heart rates are possible, resulting in coverage

of the entire heart volume within 5–9 s with 2 x 32 x 0.6 mm

collimation. The increased pitch at higher heart rates does

not only reduce the examination time, but reduces the radi-

ation dose to the patient. At constant tube output (constant

mA) and fixed gantry rotation time, higher pitch is directly

equivalent to reduced patient dose: an ECG-gated examina-

tion that is performed at a pitch of 0.4 instead of 0.2 results

in only 0.2/0.4 = 0.5 times the radiation dose. Using the eva-

luated DSCT scanner, the patient’s heart rate is monitored

before the examination, the lowest heart rate observed during

the monitoring phase is taken and an additional safety mar-

gin of 10 bpm is subtracted to automatically adjust the pitch.

Optimized Cardiac Beam-Shaping FilterBecause patient thickness decreases at the periphery, the X-

< 55

single source CT+ ECG-pulsing

+ Pitch adaptation

DSCTNonoptimized

+ Cardiacbowtie

singlesource CT

Dual Source CT

100%

50%

200%

150%

100%

50%

55 - 70 70 - 90 > 90 bpm

< 55 55 - 70 70 - 90 > 90 bpm


SCIENCE

The Sarawak General Hospital (SGH) is the largest hospital in

East Malaysia, situated on the island of Borneo. It is a tertiary

referral centre for the population of Sarawak, which in terms

of land area is the largest state in Malaysia. It has all the major

surgical and medical disciplines and it also functions as a

teaching hospital for the medical faculty of the state university.

The Department of Cardiology, headed by Professor S. K.

Hian, was set up as a separate entity from Internal Medicine

in 2000. Within five years, it has established itself as one of

the top cardiac units in this part of the world. The depart-

ment has state-of-the-art facilities such as a fully integrated

cardiac information archiving system, cardiac MR and cardiac

CT. It provides a comprehensive range of diagnostic and

therapeutic cardiovascular interventions which include 3-D

echocardiography, cardiac catheterization, IVUS and catheter-

based coronary, cardiac and other vascular interventions.

Whereas the hospital’s main purpose is to serve the public

health of the state, it is also active in cardiovascular research.

Between 2003 and 2005, more than 60,000 volunteers have

been registered in a state-wide cardiovascular disease risk

database to asses the ten-year risk for the development of

CHD (Myocardial Infarction and Coronary Death) [presented

at the ASEAN Congress of Cardiology, September 2004,

Bangkok, Thailand].

Furthermore, the department participates in several interna-

tional multi-center clinical trials, including the recently con-

cluded OASIS-5, OASIS-6 and TIMI-EXTRACT therapeutic tri-

als of patients with acute coronary syndrome, as well as new

drug-eluting stent registries such as e-Cypher, Taxus Olympia,

E-Five (Endeavour) and e-Healing (Genius).

Getting Started with Cardiac CTWith a fund from the state-owned Sarawak Heart Foundation,

the SGH purchased a SOMATOM Sensation 64 Cardiac CT

scanner in December 2004, which was installed January 2005

in the radiology department of the hospital. Since then the

scanner has been jointly used by the Departments of Radiology

and Cardiology. At present, every patient with a medical indi-

cation can undergo a cardiac CT scan free of charge.

The utilization of CT for the assessment and evaluation of

coronary vessels in South East Asia, in general, has been rather

low prior to 2004. Since the emergence of 64-slice CTs in

2004, coronary CTA has become more feasible on a routine

level for many hospitals, even though very few of them had

previous experience in coronary CTA. To overcome this limi-

tation, two cardiologists from SGH attended a clinical work-

shop in late 2004 in Erlangen, Germany, and two others were

sent to Rotterdam, The Netherlands, to receive formal train-

ing in cardiac CT. This proved to be an invaluable experience

and served as the basis for the center’s entrance into the car-

diac CT business. To date, the hospital has performed approx-

imately 1,300 cardiac CT scans, around 370 of which have

been correlated with an invasive cathlab procedure. In 2005,

one additional cardiologist spent four weeks as a fellow at

the Department of Cardiology at the Erlangen University.

Being the first 64-slice CT in a public hospital in South East

Cardiac CTThe Sarawak Experience – A Report After 18 Months in Clinical PracticeBy Sim Kui Hian, MD, Head of Cardiology, Sarawak General Hospital, Kuching, Malaysia,

and Tobias Seyfarth, MD, CT Marketing Manager Asia Pacific, Siemens Medical Solutions, Singapore

[ 1 ] Percentage of coronary artery disease on CTA& CCA under different clinical presentations (n=261).

� 3+VD � 2VD � 1VD � NS CAD

STEMI NSTEMI/CAD

KnownCAD

+ ETT/EAP

Equivocal ETT/ Atypical CP

High-riskAsympto-matic

Symptomatic Patients

100

80

60

40

20

0

77,8

56,7

46,2

13,3

21,1

7,1

92,9 86,7 43,8 22,278,9 33,3

SCIENCE


10 Year CVD Risk Assessment*

N = 70 ‘Normal’ scan ‘Abnormal’ scan

Framingham ‘Low Risk’ (<10 %) 43 (61.4%) 35 (81.4%) 8 (18.6%)

PROCAM ‘Low Risk’ (<10 %) 59 (84.3%) 46 (78.0 %) 13 (22.0%)

Framingham ‘Medium-High Risk’ 27 (38.6%) 18 (66.7%) 9 (33.3%)

PROCAM ‘Medium-High Risk’ 11 (15.7%) 7 (63.6%) 4 (36.4%)

*Source: Ang CK, et al. J Geriatr Cardiol 2006; 3(1): 17–21).

Asia, with a high number of patients scanned in a short time,

inspired the Department of Cardiology to investigate the

possibility of utilizing this large amount of patient data for

research purposes.

After thorough analyses of the collected patient data and

previously published articles from other sites, SGH’s first pub-

lication in a major journal discussed the feasibility and accu-

racy of 64-slice CT from a center with limited experience1. In

a further study involving 301 patients, an increase in sensi-

tivity, specificity, negative and positive predictive value could

be shown over each quarter of the first year (2005), with a

sharp increase in the first six months (which is considered the

initial learning time), while reaching a stable plateau after

nine months. This report – from a hospital with no previous

experience in cardiac CT – might be more applicable to a

large number of first-time CT users than the figures pub-

lished mainly in international journals by those centers with

a long history of cardiac CT. A major finding was that a mini-

mum time frame of six months should be assigned as a start-

ing phase in a center with high volume caseload until the

interpretation skills of the physicians reached an acceptable

confidence level in daily routine. The chance of receiving a

transfer of knowledge by clinical workshops and fellowships

at renowned hospitals proved to be very important, while

facilities to confirm the CT diagnoses by a subsequent inva-

sive cathlab procedure during the learning curve is beneficial

(where indicated or in a research environment).

In addition to the pure correlation of cardiac CT data to inva-

sive cathlab images, the Department of Cardiology has also

been focusing on redefining cardiovascular risks for certain

patient subgroups.

Clinical Studies

The prelude to this was the identification of significant coro-

nary disease among clinical subsets of 261 patients with car-

diac symptoms2. One-third of the patients with atypical chest

pain and over 20 % of asymptomatic patients were found to

have significant coronary disease on CTA, which correlates

closely (over 95 %) with conventional angiography.

Subsequently, 70 patients at the clinic with atypical ‘cardiac’

chest pain (ACCP) were selected over a one month period

and offered a coronary CT scan. CTA confidently excluded

significant coronary disease as the cause of the chest pain for

76 % of the patients3. When the 10-year CVD risk was calcu-

lated using PROCAM and Framingham algorithms, the gen-

eral finding was that despite getting a low risk profile in

PROCAM and Framingham, around 20 % (22%; 18.6% respec-

tively) of the patients with ACCP had an abnormal CT scan (as

defined by a lumen stenosis of 50 % or more or significant

coronary calcification (CaSC >400)) [see table]. On the other

hand, around 65 % of patients with a mid to high risk by

PROCAM and Framingham (63.6 %; 66.7% respectively) had

normal CT scans (defined as absence of any lesion ≥50 %

and CaSC of <400). This would suggest that patients might

benefit from non invasive risk stratification with the utili-

zation of CT in addition to the current algorithms. CTA of the

coronaries can help to identify low risk patients who might

benefit from a more aggressive treatment. With coronary CTA

readily available in many centers around the world, it has the

potential to become the non-invasive investigation tool of

choice for evaluation of atypical chest pain and also helps to

enhance the risk stratification of CVD.

More interesting results have been found in the coronary

CTAs of the asymptomatic patient group. In this subgroup of

66 patients (all of them with a Diabetes mel. Type II), around

20 % of the patients showed a stenosis of 50–75 %, and in

around 30% of the patients a stenosis greater than 75% in at

least one major coronary vessel was present.

What is the clinical value of these findings? It will allow physi-

cians to redefine and estimate the relative importance of estab-

lished and putative risk factors of cardiovascular disease. And

because the low sensitivity and specificity of existing algo-

rithms is understood, CTA will help to alert physicians about

patients whose overall cardiovascular risk (by present modes of

calculation) was low but who nevertheless harbor underlying

coronary disease, thus requiring further intensive therapy.

To further broaden the scientific scope of the center, the

Department of Cardiology at SGH has established ties with the

Radiology Department of Aachen University (RWTH Aachen)

for a co-operation on various clinical questions involving car-

diac CT. With this, an enlarged patient cohort might be studied,

SCIENCE

Clinical Images: Patient with Coronary Stenosis

45 year old male, diabetic patient with concurrent hypertension and obesity. CT angiography was done to screen for coronary artery disease,in view of his multiple risk factors.CTA revealed a significant stenosis in the proximal LAD. The patientunderwent conventional coronary angiography which confirmed thelesion in the LAD. The patient opted for medical therapy.

Prox and mid LAD stenosis.

Cross section of prox LCx lesion.Prox and mid LCx stenosis.

47 year old man, Coronary riskfactors Asymptomatic. Exercisetreadmill test in 2004 was negative.CTA revealed a moderate stenosis(40–50%) in the proximal LCx anda significant stenosis (60–70%) inthe mid segment of the left circum-flex artery. Patient declined any further invasive investigation, wasstarted on aspirin and aggressivelipid lowering therapy.


[ 2 ] Prevalence of coronary disease in 66 asymptomatic type II diabetes patients.

Sig. Stenosis Present

No. of patients

Sig. Stenosis Absent

Symptomatic Patients

35

30

25

20

15

10

5

0

>75%

28,8%

21,2%

50 –75%


SCIENCE

thus overcoming the largest limitation encountered in single

site research.

An exciting collaboration is the study of right ventricular func-

tion. At SGH, a report has been published on the accuracy of

left ventricular function by cardiac CT while using the dedi-

cated syngo Circulation software when compared to cardiac

MRI4. The department has also embarked on a novel method

to evaluate plaque vulnerability5.

To share the knowledge gained in cardiac CT, the hospital

opened its doors to the clinical public, inviting them to their

first clinical training program (four times annually) in Febru-

ary 2006 under the umbrella of the world-wide Siemens

Medical Solutions Life Educate program. This might repre-

sent a cheaper, more convenient alternative to the overseas

training centers in Europe and North America for Asian

physicians. Additionally, the center now facilitates its own

DICOM database with more than 150 interesting cardiac CT

cases with the respective cathlab correlation for interactive

teaching. A sufficient number of state-of-the-art worksta-

tions are available, all of which feature the latest in cardiac

CT evaluation software, syngo Circulation.

In summary, after 18 months it can be said that the center

has established itself as a strong provider of routine coronary

CTAs to the public with a high diagnostic confidence (around

8–11 scans per day). Furthermore, it has been able to suc-

cessfully submit several scientific contributions in the field of

cardiac CT highlighting the clinical use of the newly emerged

imaging option6, 7. The opportunity to collaborate with

renowned medical institutions is surely a great one. Hopeful-

ly, such clinical achievements can be maintained and contin-

ued on a different level. With the start of clinical training pro-

grams, SGH will share its knowledge regionally and help to

bring medical personnel new to cardiac CT quickly to a high

level of confidence and experience.

From left to right: Annuar R, MD;Prof A. Mahnken, MD (University of Aachen); radiographer; Prof. HKSim, MD; TK Ong, MD; Fong A, MD;radiographer; T. Seyfarth, MD, (Siemens Medical Solutions).

References1 Ong TK et al. Feasibility and Accuracy of 64-Row MDCT Coronary Imaging

From A Centre With Early Experience: A Review And Comparison With Estab-

lished Centers. Med J Malaysia 2005; 60(5): 625–632.

2 Chin SP et al. 64 Slice MDCT accurately detects a high prevalence of

coronary artery disease among high-risk symptomatic and asymptomatic

patients. Oral abstract TCT 2005 (Washington, USA) Am J Cardiology Suppl

2005: (96): H21–22.

3 Ang CK et al. High-resolution computed tomography in patients with

atypical ‘cardiac’ chest pain: a study investigating patients at 10-year cardio-

vascular risks defined by the Framingham and PROCAM scores; J Geriatr

Cardiol 2006; 3(1): 17–21.

4 Liew CK et al. Assessment of left ventricular ejection fraction: comparison

of two dimensional echocardiography, cardiac magnetic resonance imaging

and 64-row multi-detector computed tomography; J Geriatr Cardiol 2006;

3(1): 2–8.

5 Chin SP et al. Vessel Density Ratio: A Novel Approach to Identifying “Culprit”

Lesions in Acute Coronary Syndrome by MDCT; ACC 2006 (Atlanta, USA).

6 Ong TK et al. Accuracy Of 64 Multi Row Detector Computed Tomography

In Detecting Coronary Artery Disease in 134 Symptomatic Patients: Influence

of Calcification; American Heart Journal (In Press).

7 Chan WL at al. Feasibility And Accuracy Of Coronary Imaging In Elderly

Patients Using The Multi Detector Row Computed Tomography; J Geriatr

Cardiol 2006; 3(1): 9–14.

With the necessary opera-

tional requirements in place,

in addition to a highly moti-

vated medical staff, this success story will be surely seen

around the world. Cardiac CT is a valuable clinical tool that

everybody can benefit from.

The research results represented in this article are the com-

bined effort of the research team in SGH including: Ong

Tiong Kiam, MD, Chin Sze Piaw, MD, Ang Choon Kiat, MD,

Annuar Rapaee, MD, Chan Wei Ling, MD, Liew Chee Khoon,

MD, Liew Houng Bang, MD, Alan Fong, MD, Martin Wong,

MD, and Prof. Sim Kui Hian, MD.

www.cardiacsgh.health.gov.myk

From left to right: Dr. Ang CK; Dr. Chan WL; Dr. Chin SP


CUSTOMER CARE

LI F E : N E W C LI N I C A L A P P LI C AT I O N S F O R I N STA LLE D SYST E M S

Evolve Update Facilitates Enhanced CT Fluoroscopy

syngo Evolve is Siemens’ non-obsoles-

cence program that always ensures the

latest software and hardware updates

for medical equipment. The latest Evolve

update, syngo CT 2006G, is now avail-

able for all SOMATOM Sensation 10, 16

and 16 Cardiac CT systems covered by

a syngo Evolve contract. It provides

significant workflow improvements and

access to new optional clinical applica-

tions such as syngo InSpace 4DTM with

bone removal1, 2, CARE Contrast CT2 for

optimized contrast agent application,

syngo Body Perfusion2, and CARE Vision

CT2, which now features a new screen

layout for enhanced needle navigation.

Computed tomography (CT) fluoroscopy

allows precise needle guidance for in-

terventional procedures such as drain-

age, biopsy and pain therapy. CARE Vi-

sion CT is Siemens’ solution for minimally

invasive interventional procedures and

offers maximum dose reduction. “The

speed of the intervention, in comparison

with other modalities, makes it often the

method of choice,” says Jaques Kirsch,

MD, Head of Radiology Department,

Clinique Notre-Dame in Tournai, Belgium.

The in-room monitor and X-ray control

facilitate easy and fast operation, and

the HandCARETM feature reduces X-ray

for the patient and the operator’s hand.

CT fluoroscopy case studies of vertebro-

plasty and percutaneous sympathectomy

can be found under the link below.1 Bone removal requires VolPro graphics card.

2 Option to be purchased separately.

www.siemens.com/CT-Fluoroscopyk

CARE Vision CT, among other features,permits the additional display of the slicesadjoined with the area of operation.Courtesy Clinic Notre Dame, Belgium

Via the SOMATOM World User Lounges, Siemens applica-

tions specialists answer your questions on “how to …” easily

use Siemens Computed Tomography scanners and applica-

tions in daily clinical practice. Additionally, SOMATOM Sessions

offers a regular column with frequently asked questions for

offline reference.

How do I change the default window/level settings forspecific protocols?Select “options/configuration/viewer/evaluation general” and

the protocol in question, and set the window and levels for

windows 1 & 2 to your organ-specific preferences.

What is the reason for the CD-“device not mounted“ error?The last CD was ejected manually from the CD drive. Restart

the system to re-establish communication between the

scanner and drive. To prevent this error, always use the soft

key in the “transfer” drop-down to eject a CD.

S E R V I C E

Frequently Asked Questions

Can I get the entire patient-relevant scan data combinedin one report?Yes. The patient protocol is available after the examination is

closed. This protocol is listed in the patient browser and can

be loaded to the viewing card to read the values, e.g. dose

length product or total mAs applied to the patient. You can

enable the patient protocol in “options/configuration/exami-

nation.” If the checkbox is selected, the protocol will auto-

matically be added to the patient study after the examina-

tion is finished.

How can I get full image quality of syngo InSpace imagesdisplayed in the viewing card?When saving images with the “save as”-button in syngoInSpace, check the entry in the “image size” field. 1024x1024

should be selected in the “save to database”-window. After

loading the saved images to the syngo viewing card, the best

image quality is available.

www.siemens.com/SOMATOMWorldk


CUSTOMER CARE

C T O N LI N E

CT Education on the Web

www.star-program.comSTAR is an international educational forum sponsored by

Siemens Medical Solutions and Schering AG, aimed at pre-

senting cutting-edge developments in radiology. The program

is held as a regular forum on a regional basis involving emi-

nent and independent experts from all fields of radiology.

The meetings typically last two days and consist of 45-

minute faculty lectures followed by 90 to 120-minute work-

shops or panel discussions. The communication of radiologi-

cal advances at a high level contributes to an intensive

exchange of experience between the lecturers and the physi-

cians of the host country. Abstracts of the lectures are avail-

able on the STAR internet site. Over the 12 years of its exis-

tence, STAR has conducted 89 symposia in 26 countries all

over the world with more than 11,000 radiologists attending.

Often, more than 80 percent of a country's practising radiol-

k

In addition, you can always find the latest CT courses offered by Siemens Medical Solutions at www.siemens.com/SOMATOMEducate.

Upcoming Events & Courses

ogists were present. Schering and Siemens are perfect part-

ners in this educational enterprise: Much of the meeting’s

success is due to the close links both companies maintain

with radiologists around the world.

Title Location Short Description Date Contact

Society of Washington DC, USA 1st Annual Scientific Meeting July 13–16, 2006 www.scct.org Cardiovascular CT in cooperation with the 7th

International Conference on Cardiac CT

Advanced Topics Cruise to the CME Course July 29–Aug. 5, 2006 www.ctisus.comin Multidetector MediterraneanCT Scanning

ESC Barcelona, Spain World Congress Sept. 2–6, 2006 www.escardio.orgof Cardiology 2006

ESTRO Leipzig, Germany European Society for Oct. 8–12, 2006 www.estroweb.orgTherapeutic Radiology and Oncology Estro

JFR Paris, France Société Française de Oct. 21–25, 2006 www.sfrnet.orgRadiologie Congrès

TCT Washington, USA Transcatheter Cardiovascular Oct. 22–27, 2006 www.tct2006.comTherapeutics Symposium

ASTRO Philadelphia, PA, USA American Society for Nov. 5–9, 2006 www.astro.orgTherapeutic Radiology and Oncology Annual Meeting

AHA Chicago, USA American Heart Association Nov.12–15, 2006 www.scientificsessions.orgScientific Sessions

Medica Düsseldorf, Germany MEDICA 2006 Nov.15–18, 2006 www.medica.de

RSNA Chicago, USA Radiological Society Nov. 26–Dec.1, 2006 www.rsna.orgof North America

CUSTOMER CARE

SOMATOM SESSIONS – IMPRINT

PublisherSiemens AGMedical SolutionsComputed Tomography DivisionSiemensstraße 1D-91301 Forchheim

Responsible for Contents:Bernd Ohnesorge, PhD

Chief EditorsMonika Demuth, PhD([email protected])Doris Pischitz, M.A.([email protected])Stefan Wuensch, PhD([email protected])

Editorial BoardNina BastianJoachim Buck, PhDChad DeGraaffThomas Flohr, PhDAndré HartungJulia Kern-StollAxel LorzMatthew ManuelLouise McKenna, PhDJens Scharnagl

Authors of this IssueN. Abdala, MD, Department of Radiology, UMDI,Sao Paulo, Brazil

S. Achenbach, MD, Department of Internal Medi-cine II, University of Erlangen-Nuremberg, Germany

K. Anders, MD, Institute for Diagnostic Radiology,University of Erlangen-Nuremberg, Germany

W. Bautz, MD, Institute for Diagnostic Radiology,University of Erlangen-Nuremberg, Germany

T. Chlibec, MD, Institute of Radiology, Kantons-spital St. Gallen, Switzerland

C. McCollough, PhD, CT Clinical Innovation Center,Mayo Clinic, Rochester, Minnesota, USA

W. G. Daniel, MD, Department of Internal MedicineII, University of Erlangen-Nuremberg, Germany

H. Görzer, MD, Department of Radiology Hart-mannspital Vienna, Austria

G. D. Graham, MD, Imaging Center, ChattanoogaHeart Institute, Chattanooga, TN, USA

S. Hall, Niagara Health Region, St. CatharinesGeneral Site Ontario, Canada

W. Kalender, PhD, Institue for Medical Physics,University of Erlangen-Nuremberg, Germany

J.-T. Kluckert, MD, Institute of Radiology, Kantons-spital St. Gallen, Switzerland

A. Küttner, MD, Institute for Diagnostic Radiology,University of Erlangen-Nuremberg, Germany

A. Mehta, MD, Niagara Health Region, St. Catharines General Site Ontario, Canada

J. Myers, Kansas City Cancer Center, Overland Park, Kansas, USA

M. Oldendorf, MD, Medical Director Department ofRadiology, Klinikum Nuremberg North, Germany

E. Powers, MD, Department of Radiology andmedicine, Medical University of South Carolina,Charleston, USA

D. Ropers, MD, Department of Internal MedicineII, University of Erlangen-Nuremberg, Germany

U. Ropers, MD, Department of Internal Medicine II,University of Erlangen-Nuremberg, Germany

© 2006 by Siemens AG, Berlin and Munich, All rights reserved

C. Salazar, MD, UMDI – Unidade Mogiana deDiagóstico por Imagem; São Paulo, Brazil

F. T. Schmid, MD, Institute of Radiology, Kantons-spital St. Gallen, Switzerland

U. J. Schoepf, MD, Department of Radiology andmedicine, Medical University of South Carolina,Charleston, USA

K. H. Sim, MD, Department of Cardiology,Sarawak General Hospital, Kuching, Malaysia

B. Stinn, MD, Institute of Radiology, KantonsspitalSt. Gallen, Switzerland

L. Varnell, MD, Imaging Center, ChattanoogaHeart Institute, Chattanooga, TN, USA

S. Wildermuth, MD, PhD, Institute of Radiology,Kantonsspital St. Gallen, Switzerland

Sameh Fahmy, freelance author

Jessica Amberg; Nina Bastian; Andreas Blaha; Her-bert Bruder, PhD; Jan Chudzik; Ana P. Pieroni DeMenezes; Ken Field; Thomas Flohr, PhD; Lars Hof-mann, MD; Julia Kern-Stoll; Louise McKenna, PhD,MBA; Doris Pischitz; Rainer Raupach, PhD; GittaSchulz; Peter Seitz; Tobias Seyfarth; Karl Stierdorfer,PhD; Stefan Wünsch, PhD; Claudette Yaselle; Zim-mermann Alexander; all Siemens Medical Solutions

ProductionNorbert Moser, Siemens Medical Solutions

Layoutindependent Medien-DesignWidenmayerstrasse 16, D-80538 Munich

PrintersFarbendruck HofmannGewerbestraße 5, D-90579 LangenzennPrinted in Germany

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

Note in accordance with § 33 Para.1 of the German Federal Data Protection

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 therapeutic

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 instruction

as to the practice of medicine. Any health care practitioner reading this

information is reminded that they must use their own learning, training 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 responsibility for the diag-

nosis 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 permitted,

provided the customary bibliographical data such as author’s name and title

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SOMATOMSessions

No 18/June 2006Stanford-EditionJune 14th –June 17th, 2006

www.siemens.com/medical

COVER STORYSaving Time, Money and LivesPage 4

NEWS3D-Reading Wherever You ArePage 10

BUSINESSUtilization Report Now AlsoAvailable for CT SystemsPage 15

CLINICAL OUTCOMESCardiovascular – Dual SourceCT after Left Main CoronaryArtery StentingPage 17

CLINICAL OUTCOMES

Neurology – Complete Occlusion of Left CarotidArtery and Stenosis at Right Carotid ArteryPage 29

SCIENCERadiation Dose with DualSource CT

Page 38

CUSTOMER CAREEvolve Update FacilitatesEnhanced CT FluoroscopyPage 45

Highlights

SOM

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MSe

ssio

ns

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, pack-

aging, 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 18

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Transcript of Somatom Sessions 18