Somatom sessions 30

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 or 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.

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Issue Number 30 / July 2012International Edition – Not for distribution in the US.

Cover Story Performance is Becoming More AccessiblePage 6

News SOMATOM Defi nition Edge: Low Dose, Quality ImagesPage 16

Business Low Dose, High Resolution for Pediatric CardiologyPage 34

Clinical ResultsDiagnosis of an Intracranial Dual-Aneurysm using the new SOMATOM PerspectivePage 54

Science Beating Cancer – Treating IndividualsPage 69

2 SOMATOM Sessions · July 2012 · www.siemens.com/healthcare-magazine

Editorial

“Our strategy at Siemens is to apply our trendsetting technologies not only to leading high-end CT Systems, such as the new SOMATOM Defi nition Edge, but also in widely accessible and highly innovative CT products like the SOMATOM Perspective.

Based on this strategy we are able to offer to our customers extremely attractive sustainable products, with a strong focus on optimizing the total cost of ownership.”

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

Cover page: Courtesy of Sainte-Marie Clinic, Osny, France

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

SOMATOM Sessions · July 2012 · www.siemens.com/healthcare-magazine 79

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SOMATOM Sessions – IMPRINT© 2012 by Siemens AG, Berlin and MunichAll Rights Reserved

Publisher: Siemens AGMedical SolutionsComputed Tomography & Radiation OncologySiemensstraße 1, 91301 Forchheim, Germany

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

Clinical Editor:Xiaoyan Chen, MD([email protected])

Project Management: Sandra Kolb

Responsible for Contents: Peter Seitz

Editorial Board:Xiaoyan Chen, MD; Andreas Fischer; Jan Freund; Tanja Gassert; Sandra Kolb; Axel Lorz; Heidrun Endt; Julia Hölscher; Monika Demuth, PhD; Peter Seitz; Stefan Ulzheimer, PhD

Authors of this issue:Andre Kemmling, MD,University Hospital Münster, Germany A. Nchanduca, RT, Clinica Girassol, Luanda, AngolaBorek Foldyna, MD, University of Leipzig, Heart Center, Leipzig, GermanyChristian Fink, MD, University of Mannheim, GermanyChristian Lücke, MD, University of Leipzig, Heart Center, Leipzig, Germany Christoph Schülke, MD, University of Muenster, Muenster, Germany Claudia Andres, MD, University of Leipzig, Heart Center, Leipzig, Germany Constança Palma Borges, MD, Clinica Girassol, Luanda, Angola Erdie Q. Dizon, Radiographer, Tan Tock Seng Hospital, SingaporeFahim H. Jafary, MD, FACC, FSCAI, Tan Tock Seng Hospital, Singapore Fumiaki Ishida MD, Toho University Omori Medical Center, Tokyo, JapanGang Wang, MD, Baotou Central Hospital, Inner Mongolia, P. R. China Gang-feng Hu, MD, Wuxi People’s Hospital Affi liated to Nanjing Medical University, Wuxi, P.R. China Go Sano MD, Toho University Omori Medical Center, Tokyo, JapanHailiang Jia, MD, Baotou Central Hospital, Inner Mongolia, P. R. ChinaHarald Seifarth, MD, University of Muenster, Muenster, GermanyHeather Gill-Frerking, Reiss-Engelhorn Museums, Mannheim, Germany

Hong-wei Chen, MD, Wuxi People’s Hospital Affi liated to Nanjing Medical University, Wuxi, P.R. ChinaHui-jun Lu, MD, Wuxi People’s Hospital Affi liated to Nanjing Medical University, Wuxi, P.R. ChinaJagajothi Devadoss, Senior Radiographer, Tan Tock Seng Hospital, Singapore Jian Cao, MD, Peking Union Medical College, Beijing, P.R. China Joana Costa, MD, Institut Jules Bordet João Carlos Costa, MD, Hospital Particular de Viana do Castelo, Viana do Castelo, Portugal Johann Steffens, MD, Israelitisches Krankenhaus, Hamburg, Germany Johannes Wessling, MD, University of Muenster, Muenster, Germany Jyoji Nakagawara, MD, Nakamura Memorial Hospital, Sapporo, Japan Kai Sun, MD, Baotou Central Hospital, Inner Mongolia, P. R. China Kazutoshi Isobe MD, PhD, Toho University Omori Medical Center, Tokyo, Japan Keishi Sugino MD, PhD, Toho University Omori Medical Center, Tokyo, Japan Keita Sato MD, Toho University Omori Medical Center, Tokyo, Japan Kianoush Ansari Gilani, MD, University Hospital Radiology, Cleveland, Ohio, USA Leslie Ciancibello, RT, University Hospital Radiology, Cleveland, Ohio, USA Lijun Ma, MD, Baotou Central Hospital, Inner Mongolia, P. R. China Ludger Feyen, MD, University Hospital Münster, Germany Lukas Lehmkuhl, MD, University of Leipzig, Heart Center, Leipzig, GermanyM. Reis, RT, Hospital Particular de Viana do Castelo, Viana do Castelo, Portugal M. Sozinho, RT, Clinica Girassol, Luanda, Angola Marisa Gonçalves, RT, Hospital Particular de Viana do Castelo, Viana do Castelo, Portugal Masahiro Kobayashi MD, Toho University Omori Medical Center, Tokyo, Japan Matthias Gutberlet, MD, University of Leipzig, Heart, Center, Leipzig, Germany Nao Hirota MD, Toho University Omori Medical Center, Tokyo, Japan Naoshi Kikuchi MD, Toho University Omori Medical Center, Tokyo, Japan Nobuyuki Shiraga MD, PhD, Toho University Omori Medical Center, Tokyo, Japan P. Miguel, RT, Clinica Girassol, Luanda, Angola Ping-yan Qian, MD, Wuxi People’s Hospital Affi liated to Nanjing Medical University, Wuxi, P.R. China Prof. Robert C. Gilkeson, MD, University Hospital Radiology, Cleveland, Ohio, USA C. Rosa, RT, Clinica Girassol, Luanda, Angola Ruijuan Han, MD, Baotou Central Hospital, Inner Mongolia, P. R. China S.Bastos, RT, Clinica Girassol, Luanda, Angola

Sakae Homma MD, PhD, Toho University Omori Medical Center, Tokyo, Japan Savvas Nicolaou, MD, Vancouver General Hospital, Vancouver, Canada Susumu Sakamoto MD, PhD, Toho University Omori Medical Center, Tokyo, Japan Thomas Henzler, MD, University of Mannheim, Germany Vasco Silva, MD, Clinica Girassol, Luanda, Angola. Wilfried Rosendahl, PhD, Reiss-Engelhorn Museums, Mannheim, Germany Xiang-ming Fang, MD, Wuxi People’s Hospital Affi liated to Nanjing Medical University, Wuxi, P.R. China Xiao-yun Hu, MD, Wuxi People’s Hospital Affi liated to Nanjing Medical University, Wuxi, P.R. China Yingning Wang, MD, Peking Union Medical College, Beijing, P.R. China Yujiro Takai MD, PhD, Toho University Omori Medical Center, Tokyo, Japan Zhou Li, MD, Peking Union Medical College, Beijing, P.R. China

Christian Rayr freelance journalist, Paris, France; Irène Dietschi science and medical writer, Switzerland; Martina Lenzen-Schulte, MD, medical journalist, Germany; Robert L. Bard medical writer, Michigan, USA

Ana Chaves; Chenwei Li, MD; Christiane Torres; Christine Dehm, PhD; Heidrun Endt, MD; Holger Reinsberger; Ivo Driesser; Jan Feund; Jennifer Powell; Karl Krzymyk; Katharina Otani, PhD; Ligang Li, MD; Monika Demuth, PhD; Peter Aulbach; Philip Stenner, PhD; Sandra Kolb; Silvia Meyer; Stefan Ulzheimer, PhD; Susanne v. Vieting-hoff; Tiago Campos; Wynne Chia; Christian Weiss

Photo Credits: Franck Ferville Agence Vu Paris; Jan Averwerser; Christian Grund; independent Medien-Design; Sara Jorde; plainpicture/fStop; Johannes Krömer

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

Editorial

Dear Reader,

Over the past few months, several break-throughs in CT have been implemented in clinical practice. These innovations address an increasing demand for effi-ciency in diagnostic imaging, as well as the possibility to individualize imaging for each patient.

When investing in high-end technology, such as 128-slice CT scanners, the bal-ance between performance and cost has become the key criterion in many buying decisions. The Sainte-Marie Hospital near Paris is an example of where high expec-tations in imaging quality have to be matched with the need to manage high patient numbers. In this issue, read how the SOMATOM Perspective was rapidly implemented at this hospital providing the perfect balance for both requirements.

At the German Heart Center in Leipzig, syngo.via has helped to reduce the time required for vessel segmentation tenfold, a considerable difference – especially when handling complicated cases. Its automatic pre-processing also speeds up TAVI planning significantly.

In addition to performance and cost effectiveness, high-end quality remains essential in daily CT clinical use. In Switzerland, at the Inselspital in Bern full use is made of the Stellar Detector which provides the high resolution at the lowest possible dose required in clinical imaging of children awaiting cochlea implants. The hospital has an international reputation in this field and was among the first to implement the Stellar Detector and SOMATOM Definition Edge.

High resolution is also key for the German Heart Center in Munich, where the Stellar Detector is used in their Flash Dual Source scanner. When assessing the relevance of a stenosis in a small coronary artery, the remaining diameter that needs to be depicted can be as small as 1 millimeter or even less. A remarkable new achieve-ment.

CT has come a long way in meeting many challenges in resolution, quality and dose. Today, Siemens is celebrating the 1000th delivery of a Dual Source scanner world-wide. This confirms DSCT as the leading CT technology around the globe. Read in this issue about how Dual Source CT is used at the Minneapolis Heart Institute to individualize imaging for each patient.

And about how smart algorithms, such as CARE kV, help to individualize para-meters, e.g. the amount of radiation applied to each patient.

Because that’s what Siemens focuses its entire innovative energy on: helping to manage financial performance whilst offering individualization at the most demanding levels. For this reason, Siemens developed the smallest 128-slice scanner – and is continuously improving the capabilities of unmatched Dual Source technology.

Discover for yourself in this latest issue of SOMATOM Sessions how these inno-vations can impact clinical practice.

Any feedback in the form of comments, criticisms or suggestions will be gladly received.

Yours,

Peter Seitz,Vice President Marketing,

Computed Tomography, Siemens Healthcare, Forchheim, Germany


Peter Seitz


Cover Story

Content

6 Sainte-Marie Clinic in Osny, France was one of the first places, to have the recently introduced SOMATOM Perspective CT scanner installed at the beginning of 2012. SOMATOM Sessions visited the medical imaging team there to talk about their first experiences in diagnostic, economic and ecological respects and how performance is becoming more accessible.

22Siemens International CT Image Contest 2011

Content

34Low Dose, High Resolution for Pediatric Cardiology

Cover Story

06 Performance is Becoming More Accessible

News

12 Stellar Detector: Lower Radiation Dose, Increased Precision

16 SOMATOM Definition Edge: Low Dose, Quality Images

20 Iterative Reconstruction – Lower Dose in Clinical Routine

22 Siemens International CT Image Contest 2011

26 syngo.via Brings Improved Automa-tion and Additional Functionality to Clinical Routine

28 App now Available for SOMATOM Sessions Online

29 KLAS Report 2011 Honors Siemens Commitment to Low-Dose CT

30 Pushing Boundaries in CT – Latest Research in Functional Imaging

Business

32 Straton X-ray Tube: High-Performance under Challenging Conditions

34 Low Dose, High Resolution for Pediatric Cardiology

38 eMode on SOMATOM Perspective – a Chance to Optimize Total Cost of Ownership in Clinical Routine

Clinical Results

Cardio-Vascular40 Adaptive 4D Spiral CT Angiography

for the Diagnosis of a Capillary Hemangioma

42 Diagnosis of Coronary-Ventricular Fistula with Giant Coronary Aneurysm using Flash Mode

44 Diagnosis of Truncus Arteriosus using Flash CT Scanning

46 Follow-up on CABG using iTRIM Method for Coronary CTA


Content

62Diagnosis of Sub-acute Pulmonary Emboli using Flash mode, SAFIRE and 100 kV

74Siemens Hands-on Workshops at the ECR and ESC

72Education and Awareness Brings Confidence to Decision-making in Medical Imaging

62 Diagnosis of Sub-acute Pulmonary Emboli using Flash Mode, SAFIRE and 100 kV

Pulmonology64 Dynamic Volumetric Expiratory

Imaging for Diagnosis of Tracheo-bronchomalacia using Flash CT Scanning

Science

66 Lung Ventilation Imaging with Xenon Dual Energy CT

68 Discovering the Mysteries of Our Ancestors With Dual Energy CT

69 Research Clusters Enable Transfer of Basic Research to Clinical Routine

72 Education and Awareness Brings Confidence to Decision-making in Medical Imaging

48 Diagnosis and Follow-up of RCA Aneurysm using Flash Scanning at 0.3 mSv

Oncology50 Xenon Ventilation Imaging using

Dual Energy CT in Combined Pulmonary Fibrosis and Emphysema

52 Non-Hodgkin Lymphoma with Rare Metastases in the Pancreas

Neurology54 Diagnosis of an Intracranial

Dual-Aneurysm using the new SOMATOM Perspective

56 Whole Brain Perfusion CT Reveals Acute Misery Perfusion

Acute Care58 CT Perfusion Identifies Delayed

Cerebral Ischemia after Subarachnoid Hemorrhage

60 Time Resolved CT Angiography in Patients after EVAR

Customer Excellence

74 Siemens Hands-on Workshops at the ECR and ESC

75 Clinical Webinar: Highly Topical Information Presented by Specialists

75 Coronary CTA Interpretation Workshop Level II

76 Frequently Asked Question77 Clinical Workshops 201277 Upcoming Events & Congresses

2012

78 Subscription79 Imprint


1 In the Sainte-Marie Clinic in Osny, France, about 800 patients have been already examined with the new SOMATOM Perspective. Almost all pathologies have been successfully investigated. This follow-up study of a spine fracture is an example of osteoarticular imaging. Courtesy of Sainte-Marie Clinic, Osny, France

1


Performance is Becoming More AccessibleAt the beginning of 2012, the Sainte-Marie Clinic in Osny, France, was one of the fi rst places in the world to have the SOMATOM® Perspective CT scanner installed. The event was welcomed by the whole medical imaging team, which received the new piece of Siemens equipment and which has already noticed its diagnostic, economic, and ecological performance.

By Christian Rayr

Cover Story

Between Paris and Pontoise, roads and motorways pass through a string of indus-trial suburbs, then towns and villages, which are generally green and welcoming, without interrupting the urban network. It is in Osny, in the uplands of Pontoise, that you can begin to imagine that you are in the countryside. “On the one hand we are in Paris, we are an extension of the capital. On the other hand, beyond us, the countryside really begins,” explains Franck Lamesa, General Charge Nurse for Medical Imaging at the Sainte-Marie Clinic.The medical imaging centre was founded by a group of radiologists in the 1960s to meet the health requirements of a con-tinuously growing population. “It was initially located in the town of Pontoise itself and the centre grew over time, with doctors and radiologists all practicing in very different specialties,” says Alexandre Fuchs, MD, co-director of the Sainte-Marie medical imaging center. As a result of development, the centre had to grow and relocate. The medical imaging centre is now located primarily in Osny. It is associated with the Sainte-Marie Clinic (see box next page) and is responsible for a large part of the care offered to a town of 500,000 residents, of which the socio-economic status is very mixed.Fuchs remembers, “in 1999 we became the first establishment in France to have the first multi-slice Siemens CT scanner

(4 slices), which was revolutionary at the time. This was within the framework of a partnership with Siemens, one of the world leaders in imaging.” From this time, the partnership has only become stronger and several devices have arrived to complete the equipment. The SOMATOM Definition AS, with 128 slices, was installed in 2010, again one of the first in France. Two MRIs arrived as well as syngo.via, the new multi-modality imaging software. At the end of January 2012, as one of the first worldwide, the all-new SOMATOM Perspective scanner was installed, having been introduced officially at the Radiological Society of North America (RSNA) congress in Chi-cago at the end of November 2011.

800 Patients already examinedFuchs says, “after six weeks of using the CT scanner, we are only just beginning to see all its possibilities, but it has already met all of our expectations. We have examined about 800 patients and have been able to study almost all pathologies without any problem: oncology, pediat-rics, cardiac, vascular, osteoarticular, cerebral etc. We are very satisfied with the results.”It is 11.20 am on this Monday morning in Osny. Already eighteen patients have been through the SOMATOM Perspective tunnel this morning. “One every ten min-utes,” explains Guillaume Hamel, the

operator who works with the two scan-ners, SOMATOM Definition AS and SOMATOM Perspective. “Perspective is a little bit slower than SOMATOM Definition AS. With the SOMATOM Perspective, we can do a thorax examination in 3 seconds (1.5 seconds with SOMATOM Definition AS), pelvic abdominal examination in 8 seconds, and lumbar rachis in 10 sec-onds. The device is extremely easy to use. And the reconstruction module means

Alexandre Fuchs, MD is co-director of the Sainte-Marie Clinic near Paris

Cover Story


that the images can be smoothed very quickly.”

High-quality images, radiation cut by halfHigh-quality images are obtained very quickly, confirms Fuchs. The syngo® interface and the syngo.via imaging soft-ware allows the images to be transferred quickly to the internal network, with complete fluidity. The images are very easy to read. Depending on the pro-grammed examination and the pathology being looked for, the images can be seen instantly and in accordance with the adapted slice. Both operators and doctors think that the workflow is remarkably easy. The fact that an examination can be carried out so quickly is an important asset. Fuchs says that this is because “we do a lot of pediatric work here and children have a natural tendency to move during

The use of the eMode software allows the team in Osny to work at more or less 80 percent of the system’s maximum intensity, which guarantees a longer life cycle.

Sainte-Marie in Osny: A Health Center with Advanced Medical ImagingSince it was founded, the Sainte-Marie Clinic has relocated and expanded several times. Today it is made up of several buildings covering an area of around 14,000 square meters. It specializes in surgery and oncology and is fitted with the highest quality technical equipment. It has an accident

Entrance of the Sainte-Marie Clinic, Osny, France

and emergency department, which is open 24 hours a day, seven days a week. For run of the mill consultations, the Sainte-Marie Clinic has also opened a versatile medical service that brings together several specialist surgeries.Composed of two buildings facing each other – the medi-cal imaging centre and the institute of radiology – the Sainte-Marie Clinic is involved in the care of in-patients but also receives a large number of external patients. Franck Lamesa explains: “We are open ten hours per day and see approximately 300 patients a day. About three percent of these are emergency patients, five to ten per-cent are patients in the hospital and the others are patients with outpatient appointments.” All kinds of examinations are carried out: standard or very low dosage radiology, echography, mammogram, and osteodensitometry, amongst others. They also include interventional proce-dures, macro and micro biopsies, infiltrations, and infusions. Working in partnership with Siemens, the Sainte-Marie Clinic has devices from each of the previous generations: a digital Siemens mammogram, two Siemens MRIs (1.5T Aera and 1.5T Essenza), two Siemens CT scanners (SOMATOM Definition AS and SOMATOM Perspective) and syngo.via as mutli-modality imaging software. The SOMATOM Perspective, the newest one, was installed in Osny as one of the first worldwide.


Cover Story

The atmosphere in the examination room can be softened thanks to the Illumination Moodlight. This lighting system can be adjusted in terms of color and intensity.

“ Ease of use, speed of acquisition, image quality, decrease in radiation doses – SOMATOM Perspective has a larger number of advanced options.”

Alexandre Fuchs, MD, Sainte-Marie Clinic, Osny, France

examinations. We also do a lot of oncol-ogy work, with patients who have had to undergo numerous repetitive examina-tions. Thanks to this new CT scanner and Sinogram Affirmed Iterative Reconstruc-tion – SAFIRE* in short –, which we also use with SOMATOM Definition AS, we have observed that the radiation doses are markedly reduced.” After four to six weeks of use, the team believes that the reduction of the doses is around 50 per-cent, which they think is very significant.

A quick, less stressful examinationThe arrival of the SOMATOM Perspective also has another benefit for patients:

* In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A con-sultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task.

Cover Story


it means that waiting times are con-siderably reduced. “On average we do 40 examinations a day with SOMATOM Perspective,” explains Franck Lamesa. “Today we could do up to 50. And if there was not a shortage of radiologists, may-be even 80. But already, instead of wait-ing three weeks or a month, our patients can get an appointment within 48 hours.”Even the atmosphere in the examination room is softened thanks to the Illumina-tion Moodlight. This lighting system can be adjusted in terms of color and inten-sity, which is very useful when working with children everyday. Their attention can be drawn to an external stimulus and can make a possibly stressful examination less of a big deal. Some claustrophobic patients also seem to be more at ease with Moodlight. SOMATOM Perspective appears to be suitable for any indication and any patient – from the calmest to the most anxious. For those who have a tendency to move either voluntarily or involuntarily.

Economic installation and functioningAlexandre Fuchs and Franck Lamesa both think that the device has benefits other

than the medical ones, for example organizational and economic benefits. SOMATOM Perspective is a smaller scan-ner that has been designed particularly carefully in respect of actual demands for medical equipments and is amazingly compact in comparison to traditional devices. Franck Lamesa and Guillaume Hamel were both amazed by its genera-tor: a small “box” measuring 70 by 30

centimeters that can be run from a tiny storage cupboard at the side of the examination room and does not require a refrigerated place. In total, a room measuring less than 20 square meters is big enough for the scanner. In addition to this, it is easy to install. As it is ultra light, the SOMATOM Perspective does not need a reinforced floor. It has its own air-cooling system and therefore does not require air conditioning: it can operate in a room where the temperature fluctu-ates between 18 and 30 degrees Celsius. Finally, it can be installed in just one day, whereas conventional scanners require a minimum of three to four days for instal-lation, on average.The SOMATOM Perspective is also cost effective, which is important in times where healthcare institutions are sub-ject to pressure from multiple sources to provide that their care is profitable. Another advantage of the new CT scan-ner is a kind of automatic saving. “The use of the eMode allows us to economize scanner operation, working at more or less 80 percent of its maximum power, which prolongs the life cycle,” explains Fuchs. An automated parameter setting uses less power and enables more profit-able material management.“We have started on an active evalua-tion process of the eMode,” says Franck Lamesa. “We do at least 95 percent of examinations using this software feature.

At the end of January 2012, as one of the first worldwide, the all-new SOMATOM Perspective scanner was installed in Sainte-Marie imaging center.

With the SOMATOM Perspective, Alexandre Fuchs, MD can obtain high-quality images very quickly. After that the images can be reviewed immediately at the syngo.via workplace.


Cover Story

Christian Rayr is a freelance journalist based in Paris, France. He writes for various medical publications and covers medical topics for the general media.

Value for MRIBy Eric Johnson

More for less – this is technology’s history lesson. Take mobile phones: not only have they shrunk from paving brick to billfold size, they have gained massive functionality while declining in real price. Ditto the trend for automo-biles, personal computers, refrigerators, and just about any gadget you can name.That includes medical-imaging devices. Siemens is taking seriously both the economic pressures on global health-care systems and its attendant responsibility to innovate and invest in premium products that also are cost-efficient. So here come a new array of accessible innovations: the SOMATOM® Perspective CT, the ACUSON S1000™ ultrasound system, and the MAGNETOM® Spectra* MRI.MAGNETOM® Spectra proves the point. Until its com-mercial launch in early 2012, 3 Tesla MRI was beyond reach of most non-research hospitals and clinics. Of course 3T delivers higher signal-to-noise, more detail and the ability to shorten scan time, but until now, budgets of small and medium-sized hospitals and practices typically stretched only as far as 1.5T. With MAGNETOM Spectra, those budgets recalculate, and not just due to outstand-ing image quality and lower capital outlay. Compared to high-end research 3T system approximately five years ago, MAGNETOM Spectra cuts the total cost of ownership just about in half.A crucial factor for those savings, and the systems clinical success is the excellent usability, making 3T MRI less complex. In the past, 3Ts often required full-time medical physicists to keep them working properly. These highly-skilled technicians sort the settings and planar positioning, and they screen scans for artifacts, quantum effects, and other negatives. Clinics, by contrast, generally lack the work-volume to justify hiring such an employee. But they

Eric Johnson writes about business, the environment, medicine and technology from Zurich, Switzerland. He studied chemistry, and prior to working independently, headed what is now a Thompson-Reuters bureau and corresponded for McGraw-Hill World News.

can employ two virtual staff members: Siemens’ Tim (total imaging matrix) and Dot (day optimizing through-put) systems. These allow an easy and fast patient setup and organize the work for the MRI operator, allowing an easy, intuitive operation of MAGNETOM Spectra with excellent, reproducible results. According to the customer, a typical cardiac exam on a 1.5T scanner with conventional software takes an hour. With 3T and Tim and Dot, this time can be significantly reduced.

Every year a usage analysis is carried out with Siemens: if the eMode is used for at least 80 percent of scans, the imaging centers can benefit from various advan-tages e.g. training days, specific applica-tions, re-evaluation of the maintenance contract, and so on. This leads to another financial gain. One should not forget that these savings also have an ecologi-cal effect, adds Franck Lamesa.

A scanner for all radiology centersFranck Lamesa: “Ease of use, speed of acquisition, image quality, decrease in

www.siemens.com/SOMATOM-Perspective

With MAGNETOM Spectra comes a new member of the array of Siemens’ accessible innovations.

* This product is not commercially available in all countries. Due to regulatory reasons, its future availability cannot be guaranteed. Please contact your local Siemens organization for further details.

radiation doses – SOMATOM Perspective, which is a high-end device, has a larger number of advanced options. This scan-ner even makes non-routine procedures in the majority of radiology sites possible: interventional procedures, infusions, emergencies … It’s a flagship machine that responds to the current requirements of all radiology centers.”

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As a rule, innovations can only be achieved if one ventures away from pre-defined paths of thinking. This is often easier said than done, but it is nonetheless true. The first big step in the develop-ment of CT solid-state detectors was the introduction of a highly efficient detector material. Now, Siemens has also taken a new approach in a different area – the improvement of the detector electronics. And behold, the fine tuning of this new element has paid off. At the German Heart Center Munich, Stefan Martinoff, MD, Director of the Radiology Institute, and Jörg Hausleiter, MD, Head of the Cardio-

Stellar Detector: Lower Radiation Dose, Increased PrecisionThe new CT detector technology from Siemens wins over users immediately, as an interview conducted by SOMATOM Sessions with doctors at the German Heart Center in Munich, Germany reveals.

By Martina Lenzen-Schulte, MD

logical Intensive Care Unit have already been amongst the first to work with the new technology.

SOMATOM Sessions: You are now already utilizing the full performance of the new Stellar Detector in the SOMATOM® Definition Flash CT. What has been your experience?

MARTINOFF: Here we are dealing with an apparently better image quality com-pared to previous detector generations. On the one hand, this is due to reduced electronic noise, because naturally, every-

thing that generates noise is a disruptive factor. One immediately notices in the images how well they have been able to reduce the noise with the new detector. The members of our staff also confirm this. Moreover, the resolution is notice-ably higher, as we have already been able to determine.

HAUSLEITER: We particularly like the fact that these advantages are not offset by disadvantages. On the heart, which is constantly moving, it is not only a matter of morphologically analyzing the coro-nary vessels and their alterations. We

1 Example of a bypass follow-up study done with the Stellar Detector. Courtesy of German Heart Center Munich, Munich, Germany

1B 1C 1A

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would also like to exclude any distortion that is due to movement. With the new Stellar Detector, we can continue to use the SOMATOM Definition Flash’s tried and tested highest heart rate indepen-dent temporal resolution – a compelling argument with the beating heart.

SOMATOM Sessions: What in your view are the diagnostic advantages resulting from this?

HAUSLEITER: It is our job to inform coronary patients about their prognoses as precisely as possible. We know that a stenosis of the coronary vessels is hemo-dynamically relevant if more than a 70 percent restriction exists, which means that the cardiac muscle’s blood circulation is impaired. In order to be capable of determining this with a vascular diameter of approximately three millimeters, we would have to be capable of determining whether a residual lumen of at least one millimeter is still open. Even for an angiography, this is a challenge. The new detector that breaks the barrier of below three millimeters could provide a true advantage in cases like that.

MARTINOFF: In addition, we would like to be better able to evaluate the quality of a plaque and to describe its position in relation to the vascular wall more pre-cisely, which means: How calcified is it, and is it possibly “only” in the coronary artery’s wall? Here, the limited spatial resolution, which leads to so-called blooming, has always presented us with interfering artifacts, which we sometimes cannot classify correctly. If the interfer-ence is prevented, it could contribute to an enormous clinical precision. Based on the Stellar Detector’s initial images, it looks as if this could be achieved. At the moment we are in the process of quanti-fying it with larger samples.

HAUSLEITER: Actually, the improved spatial resolution and the prevention of artifacts are important in many vessels, not least of which are the carotid arteries. Additionally, there is the evaluation of stents, which have an even smaller lumen than the vessels that they are designed

to keep open. It is not only an advantage that one can possibly evaluate lumina of less than three millimeters. It is also help-ful if – as we can already see – a verifica-tion of the very small branching becomes discernible, which indicates the reduced perfusion of an entire area.

MARTINOFF: As radiologists, we espe-cially appreciate the increase in precision in cases in which we would like to pro-vide the surgeon or cardiologist with the most precise details possible about anatomic conditions before an operation or an intervention – for example, before

a valve intervention by means of TAVI (Transcatheter Aortic Valve Implantation). Or if we want to rule out an aortic disease in a young patient, for example in the case of Marfan syndrome. Such examples also show that there are many inter-disciplinary issues for which radiologists and cardiologists feel jointly responsible – for the good of the patients.

SOMATOM Sessions: Less blooming and fewer artifacts are one side of the improvement, and the reduced electronic noise through the use of TrueSignal technology is the other.

Stefan Martinoff, MD, and Jörg Hausleiter, MD, are talking about the new Stellar Detector technology in their SOMATOM Definition Flash and how it creates a win-win situation for them and their patients.

“ As radiologists, we especially appreciate the increase in precision we see with the new detector.”

Stefan Martinoff, MD, Institute for Radiology and Nuclear Medicine, German Heart Center, Munich, Germany

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evaluations by means of imaging, for example if stitch leakages are suspected. In these cases, it can be vital to receive information about the child’s condition quickly and without complications. Using the new Stellar Detector with the 70 kV scan mode, we recently managed to eval-uate a special case after very complex surgery with unprecedented precision.

HAUSLEITER: In the future, this will give us a significant advantage, especially with overweight patients. These patients often have – in addition to lipometabolic disorders, high blood pressure and dia-betes – a so-called metabolic syndrome, which makes them even higher risk candidates for coronary cardiac disease. The fatty tissue strongly reduces radia-tion, which allows the electronic noise to dominate and makes it a disruptive problem with these patients. This com-plicates the diagnostics, so we are espe-cially glad of the improved image quality in such cases.

MARTINOFF: This is also true for other indications with these patients, for example if one has to evaluate the organs’ parenchyma in adiposity cases, which used to be difficult because of high elec-tronic noise. One has to consider that this will affect an increasing clientele in future. While patients with over 150 kilograms of body weight used to be the exception, they are now coming for an assessment increasingly often. For the first time with this new system, we are seeing very good images, even with very adipose patients with a body mass index of over 35.

SOMATOM Sessions: Do all these advantages have an effect on work-flow?

MARTINOFF: Doctors save time in imme-diately seeing top images after scanning, also during post-processing. In addition, readers can diagnose much more reliably when everything is so well-depicted – the radiologist is visibly more relaxed. If, as a diagnostician, you are seeing even the branches of branches, you have a very good feeling.

The entrance of the German Heart Center in Munich, Germany

The German Heart Center in Munich is now utilizing the full performance of the new Stellar Detector in their SOMATOM Definition Flash CT.

What advantages does this have with respect to the dose?

HAUSLEITER: We already see that we can get by with a lower X-ray dose on a broad front and the image quality has improved at the same time. Up to now, one could practically only reduce the noise by increasing the dose. Or one had to accept the noise, if one aimed for the lowest possible exposure. Now only 80 instead of 100 kilovolts are required for a CT

scan of the heart, or just 100 instead of 120 kilovolts for carotid arteries.

MARTINOFF: This is extremely beneficial in pediatric cardiology, since with the Flash in most situations we do not need to worry about motion artifacts, con-trolled breathing or sedation in young children and babies. Here at the Heart Center, many children with heart condi-tions are surgically treated. We are regu-larly required to perform post-surgical

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HAUSLEITER: This also applies to digital post-processing, and when we want answers to particular questions. We can access much more precise basic data with the new device. For the first time, we can now access a dataset with a layer thickness of only 0.5 millimeters instead of 0.6 millimeters, which allows a sig-nificantly higher spatial resolution of 0.3 millimeters.

MARTINOFF: The breaking of this barrier has been anticipated for a long time. The physics departments always said that this could only be done with a trade-off of a higher dose, but as we have seen now, it does work. In the future, medical facilities that have to answer special questions will not be able to avoid the use of such high-end precision imagery. I can definitely recommend the use of the Stellar Detector to everyone.

HAUSLEITER: After all, the new technol-ogy creates an absolute win-win situation for every patient and his or her attend-ing physician, because all the patients may benefit from the dose reduction and the increase in imaging precision.

“ We already see that we can get by with a lower X-ray dose on a broad front, and the image quality has improved at the same time.”

Jörg Hausleiter, MD, Cardiological Intensive Care Unit, German Heart Center, Munich, Germany

Martina Lenzen-Schulte, MD, is a physician, medical journalist, author and moderator. She writes for medical journals and the consumer media.

Jörg Hausleiter, MD:He is a cardiologist and medical specialist for internal medicine. Hausleiter is head of the Cardiological Intensive Care Unit at the German Heart Center in Munich. His scientific focus includes non-invasive coronary diagnostics and interventional valve and stent therapies.

Stefan Martinoff, MD: For more than a decade, radiologist Martinoff has directed the Institute for Radiology and Nuclear Medicine at the German Heart Center in Munich and is currently also its Deputy Medical Director. He played a leading role in installing the first completely digital X-ray department in the German State of Bavaria.

The statements by Siemens’ customers described herein are based on results that were achieved in the customer’s unique setting. Since there is no “typical“ hospital and many variables exist (e.g., hospital size, case mix, level of IT adoption) there can be no guarantee that other customers will achieve the same results.

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SOMATOM Definition Edge: Low Dose, Quality ImagesThe Inselspital Bern in Switzerland was the fi rst hospital to introduce the SOMATOM® Defi nition Edge CT in clinical application. The team’s judgment after a short period of practice: “cutting-edge!”

By Irène Dietschi

The new SOMATOM Definition Edge, the first single source CT to use the newly developed Stellar Detector is the latest acquisition by the Inselspital in Bern.

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The 86-year-old lady had all the symp-toms of a wake-up stroke when she was admitted to the Institute of Neuro-radiology at Bern University hospital, the so-called Inselspital, one morning at the end of March 2012. Suffering from hemiplegia on her left, she was in a bad clinical condition. “That’s why we decided not to have her examined by MRI, which we usually recommend for strokes, but to do the diagnostics by CT instead,” explains PD Christoph Ozdoba, MD, senior neuroradiologist at the Insel-spital. Given the seriousness of the case, Ozdoba and his team were able to test in full the capacity of the institute’s latest acquisition: the new SOMATOM Definition Edge, the first single source CT to use the newly developed Stellar Detector by Siemens.While the patient lay on the table, anaes-thetized, Ozdoba and head technologist Nadja Feusi ran through almost all the features provided by the new tomograph, including the possibility to visualize the perfusion of the entire brain – a crucial parameter in stroke diagnostics. “When the first images appeared on the screen, displaying the infarct of this patient in its entire dimension, we were immediately convinced that our CT diagnosis would be accurate,” says Ozdoba. Chief physician Prof. Gerhard Schroth is pleased beyond expectations: “The images yielded by this CT are cutting-edge,” he says. “The speed of the machine is quite astonishing,” adds Nadja Feusi, who is becoming more familiar with the Definition Edge every day she operates it.

Decisive argument: dose reductionBern University hospital is the very first clinic worldwide where the single source CT SOMATOM Definition Edge has been introduced into clinical application. Apart from the machine at the Institute of Neuroradiology, a second scanner will be provided for the new emergency room, due at the beginning of July. “When we evaluated the system in October 2011 we were soon convinced that we wanted to have it, although we didn’t foresee at that time that we would be the first ones to actually operate it,” says Ozdoba.

1–2 In neuroradiology excellent images and sharp resolution, combined with an advanced post-processing software are key. The SOMATOM Definition Edge comprises all of that, like in this stroke investigation of a patient who presented in Bern University hospital.

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defining the neuro-protocols: stroke exam-inations, the post-operative controlling and pre-operative planning of neurosurgi-cal interventions (hemorrhages, tumors), the planning of stereotactic interventions such as deep brain stimulation, the plan-ning and controlling of spinal surgery, the visualization of aneurysms, stenoses in the carotis etc. Stroke examinations are of special relevance here because the Inselspital is one of the major stroke centers in Switzerland, treating up to 1,000 patients per year. And even though MRI is regarded as the standard exami-nation by many, CT could become more significant in this field owing to the extensive qualities of the new scanner.

Promising for the pediatric fi eldAn important partner of the institute is the Ear, Nose and Throat clinic. The Inselspital Bern has an international

The installation of the scanner, supported by a Siemens engineer during the first few days after delivery, went surprisingly smoothly. “In fact, we were so amazed at its stability that we decided to run it routinely after only four days.”The decisive argument in losing no time was dose reduction. “I admit I was quite critical about this point at the beginning, suspecting that this was pure marketing, but now, we reckon to save no less than 30 to 40 percent of the radiation formerly used,” says Christoph Ozdoba. “The qual-ity of the images is at least the same, the resolution better than with our prede-cessor.“ This major improvement is due to the revolutionary Stellar Detector, the first fully-integrated detector with TrueSignal Technology which allows for 0.3 millimeter spatial resolution. Thus, even fine lesions and previously hidden vessels are visible. Moreover, the Definition Edge is very fast, the gantry

rotating at 0.28 seconds rotation speed and thus scanning up to 23 centimeters per second becomes possible. Clinically, this means scanning the whole heart in half a second, a 50 centimeter thorax in roughly two seconds or performing a two-meter scan of the entire body in nearly eight-and-a-half seconds.

Advanced post-processing softwareWhat is even more important than speed in neuroradiology are excellent images and sharp resolution, combined with an advanced post-processing software such as an advanced vascular program – all of which the Definition Edge comprises. “The system must cover the whole scope of neurological CT diagnostics where microstructures are just as important as whole brain visualizations,” says Ozdoba. In the first phase after the installation he and his team have mainly been busy

The SOMATOM Definition Edge includes the possibility to visualize the perfusion of the entire brain – a crucial parameter in stroke diagnostics.

Head technologist Nadja Feusi already ran through almost all the features provided by the new computed tomograph and is becoming more familiar with it every day she operates it.

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reputation for cochlea implantations, and the institute of neuroradiology does all the preparative examinations of the hearing system, especially of the petrosal bone. “The SOMATOM Definition Edge is fantastic for visualizing those miniature structures in high resolution,” says Christoph Ozdoba. “Considering that most of the patients destined for a cochlea implant are children, whose developing brain should be exposed to as little radi-ation as possible, another advantage of the scanner becomes apparent: with its minimal doses the SOMATOM Definition Edge meets children’s needs especially well.“ It is therefore hardly surprising Ozdoba regards the application of the scanner as “very promising” for a large pediatric field.No doubt it will take several months to tap the maximum of the machine and to define all the protocols conceivable in clinical use. However, one thing seems to be certain: in Bern the SOMATOM Definition Edge has already been worth the investment after only one week.

“ We were so amazed at its stability that we decided to run it routinely after only four days. The decisive argument in losing no time was dose reduction.”

PD Christoph Ozdoba, MD, senior neuroradiologist, Inselspital Bern, Switzerland

Irène Dietschi is an award-winning Swiss science and medical writer.

PD Christoph Ozdoba, MD, was immediately convinced that CT diagnosis will be accurate with the SOMATOM Definition Edge.

The statements by Siemens’ customers described herein are based on results that were achieved in the customer’s unique setting. Since there is no “typical“ hospital and many variables exist (e.g., hospital size, case mix, level of IT adoption) there can be no guarantee that other customers will achieve the same results.

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Iterative Reconstruction – Lower Dose in Clinical RoutineSiemens Iterative Reconstruction solutions prove their dose reduction value in facilities worldwide. Now the dose reduction potential is explicitly approved by the FDA for the US Market.[1]

By Jan Freund


Iterative reconstruction (IR) has been a topic of interest in computed tomography for decades. Initially, the main limitation was the available computing power. Trans-ferring the data from a reconstructed image back into the raw data space by modeling the scan parameters for the next reconstruction loop was time-consuming. Long calculation times prohibited the use of iterative imaging in clinical routine, as this could take up to several hours for large datasets.

IRIS makes IR interesting in clinical lifeWith the introduction of IRIS – Iterative Reconstruction in Image Space – at RSNA 2009, Siemens launched iterative recon-struction for the SOMATOM® Definition family. It is mathematically proven that noise reduction can be completely sepa-rated from artifact reduction.* By avoiding computing intensive forward projections back to the raw data, Siemens found an intelligent approach to leverage dose reduction with iterative reconstruction. Thereby image noise was reduced con-siderably with iterative loops in image space. The reduction in image noise can be converted into patient dose reduction. Noisy images acquired with lower dose could be cleaned up using IRIS, restoring the initial image quality at a reduced

dose of up to 60%. [2, 3] Performing the iteration loops in image space compen-sated for the lack of computing power and made iterative reconstruction feasible in CT.

Further improved image quality with SAFIREIn 2010, Siemens introduced SAFIRE – the Sinogram Affirmed Iterative Recon-struction and new image reconstruction systems (IRS) hardware explicitly designed to support iterative reconstruction algo-rithms. SAFIRE not utilizes forward projec-tions into raw data for the image improve-ment process. Now, CT images can be converted back into the raw data space which validates the reconstructed data-set using the raw dataset. The iteration loops in the raw data space correct geo-metrical imperfections and further reduce image artifacts.SAFIRE has the potential to reduce dose by up to 60% and to improve image qual-ity with regards to artifacts, contrast, and sharpness – further enhancing the image quality already realized with IRIS. [4, 5] To provide IRIS customers with their full range of IR advantages, Siemens delivered SAFIRE free of charge to existing IRIS users.Certainly the new single source CT systems SOMATOM Definition Edge and the 128-slice SOMATOM Perspective – both introduced at RSNA 2011 – were

equipped with SAFIRE. Furthermore Siemens released IRIS for the SOMATOM Emotion and SOMATOM Sensation 64 installed bases.On top of that new image reconstruction hardware accelerated the introduction of iterative reconstruction into clinical routine. Dedicated hardware solutions delivered a reconstruction speed of up to 20 images per second on SOMATOM Definition scanners, boosting perfor-mance to a level comparable to conven-tional CT systems without IR capabilities. With this, SAFIRE can be utilized in acute care and other time-sensitive clinical applications.

Siemens’ IR is independently validatedAnother critical milestone for SAFIRE was the US market approval – the 510(k) issued by the Food and Drug Administra-tion (FDA). In their approval, the FDA con-firmed the potential of SAFIRE “to reduce dose by up to 54–60%”. [1] An approval by the FDA including a quantitative dose reduction potential is currently unique in the market. This potential was also recognized by the scientific community. Many publications on IRIS and SAFIRE have shown the dose reduction potential for various body regions and their clini-cal suitability. [2–5]The distribution of SAFIRE increased to approximately 1,000 installations world-* Data on file.


wide as of mid-2012, covering more than a third of the installed SOMATOM Definition AS and SOMATOM Definition Flash systems. The unique combination of proven dose reduction with a perfor-mance suitable for everyday use was key to introducing iterative reconstruction in clinical routine. Many institutions all over the world now perform all their examinations using SAFIRE and achieve consistently low dose values for all patients.These affirmative developments encour-age Siemens to pursue a goal: all CT examinations with the latest Siemens scanners could soon be performed below the average natural background radiation of 2.4 mSv. The introduction of IRIS and SAFIRE was a major step in this direction: More than 70% of all Siemens’ standard protocols with iterative reconstruction for the SOMATOM Definition Flash are now below the average annual natural background radiation of 2.4 mSv (based on syngo CT 2011A and draft of syngo CT 2012B). And the CT community is already looking forward to Siemens’ next cutting-edge innovations such as the Stellar Detector.

References[1] FDA clearance letter for SAFIRE dated November

22, 2011; 510(k) number K103424 [2] Bulla S et al. Eur J Radiol. 2011 Jun 8.

[Epub ahead of print][3] Hu XH et al. Clin Radiol. 2011 Nov;66(11):1023-9. [4] Moscariello A et al. Eur Radiol. 2011

Oct;21(10):2130-8. [5] Winklehner A et al. Eur Radiol. 2011

Dec;21(12):2521-6.

2 VRT image of the same patient which also clearly illustrates the correct place-ment of the prosthesis. Courtesy of University Hospital Zurich, Switzerland

1 MIP image of a 47-year-old patient after therapy of an aortic dissection type B with an intra-aortic prosthesis from a SAFIRE validation study. [5] Images were scanned with 50% dose reduction compared to the institution’s established standard protocol and reconstructed with SAFIRE strength 3. The dose-length product of the scan was 368 mGy cm, the estimated effective dose is 5.3 mSv. Courtesy of University Hospital Zurich, Switzerland

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In clinical practice, the use of SAFIRE and IRIS may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consul-tation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task. The fol-lowing test method was used to determine a 60% dose reduction when using the IRIS reconstruction software and a 54% to 60% dose reduction when using SAFIRE reconstruction software: Noise, CT numbers, homoge-neity, low-contrast resolution and high contrast resolu-tion were assessed in a Gammex 438 phantom. Low dose data reconstructed with SAFIRE and IRIS showed the same image quality compared to full dose data based on this test. Data on file.

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Siemens International CT Image Contest 2011At the start of last year’s congress of the Radiological Society of North America (RSNA), Siemens Healthcare announced the winners of the “International CT Image Contest 2011”. More than 160 institutes and hospitals from 43 countries from all continents had submitted over 600 clinical cases, acquired using Siemens CT scanners with low radiation dose.

Monika Demuth, PhD, and Tiago Campos, Computed Tomography, Siemens Healthcare, Forchheim, Germany

Spurred on by the success of the first competition for computed tomography (CT) images in 2010, Siemens announced the “International CT Image Contest 2011”. Customers using a CT scanner from the SOMATOM Definition family or a SOMATOM Emotion, SOMATOM Sensation or SOMATOM Spirit had the opportunity to present an international jury of recog-nized experts with clinical images in seven medical categories: Cardiac, Routine, Vascular, Dual Energy, Trauma, Neuro, Pediatrics.For the first contest in 2010, the jury received around 300 clinical images from over 30 countries. More than twice as many clinical images were submitted the second time around – a clear indication that dose reduction is a key issue for CT users on all continents around the world. Peter Seitz, Vice President Marketing CT, Siemens Healthcare awarded the prizes to the winners at the RSNA 2011. The seven winners, selected by an interna-

tional jury of experts, hail from China, England, France, Ireland, Macau, Singa-pore, USA and the public vote winner from Taiwan. As well as exhibiting a high quality standard, the images are impres-sive examples of how valuable diagnostic information can be obtained even at low dose.The members of the jury were Professor Stephan Achenbach, MD, from the Giessen-Marburg University (Germany), Professor Dominik Fleischmann, MD, from the Stanford University Medical Center (U.S.A.), Professor Elliot K. Fishman, MD, from the Johns Hopkins Hospital in Balti-more (U.S.A.), Professor Yutaka Imai, MD, from the Tokai University School of Medicine (Japan), Professor Zengyu Jin, MD, from the Peking Union Medical Col-lege (China), Professor Borut Marincek from the University Hospital’s Case Medi-cal Center in Cleveland (U.S.A.), Professor Maximilian Reiser, MD, from the Ludwig-Maximilians-University in Munich

(Germany), and Professor Uwe Joseph Schoepf, MD, from the Medical Univer-sity of South Carolina (U.S.A.).For the duration of the contest, between March and September 2011, a fan com-munity comprising more than 4,000 members discussed the submitted images on Facebook. In addition, Image Contest fans could vote for their favorite picture in a public vote. The internet page devoted to the contest received over 50,000 hits within just eight months. The aim was to raise public awareness of the responsi-bility that manufacturers and radiologists have in relation to diagnostic radiation. More information on the International CT Image Contest including all clinical details and respective protocols are avail-able at:

www.siemens.com/image-contest

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1 Winner of Category “Cardiac”:

Submitter: Carolyn Young, RT,Great Ormond Street Hospital for Children NHS Trust, UKPatient’s History: A 3-day-old baby, with a Tetralogy of Fallot and absent pulmonary valve variant, was referred to CT imaging for evaluation of the degree of pulmonary artery enlargement and of bronchial com-pression for surgical planning.Diagnosis: A perimembranous VSD (Ventricular Septum Defect), RV (Right Ventricle) hypertrophy and overinflated left lung were shown using CT imaging. The main pulmonary artery measured 1.9 cm in diameter and its proximal branches were grossly dilated. Both right and left main bronchi were completely collapsed resulting from their location behind the dilated pulmonary arteries.Scanner: SOMATOM DefinitionDose: 0.7 mSv

2 Winner of Category “Routine”:

Submitter: Yang Guo-Qing, MD, Center People’s Hospital of Suining, P. R. ChinaPatient’s History: A 63-year-old female patient had been suffering from asymptomatic recurrent melena for the past year. Fecal occult blood test was positive. However, endoscopic examinations of the stomach and colon revealed no positive findings.Diagnosis: A non-contrast CT showed a soft tissue lesion with calcification in the distal segment of the ileum. The lesion was enhanced and supplied by feeding vessels in the contrast scan followed. The patient underwent surgery and the pathology results confirmed a stromal tumor.Scanner: SOMATOM Sensation 16Dose: 1.3 mSv

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3 Winner of Category “Vascular”:

Submitter: Liz D’Arcy, RT, Wexford General Hospital, IrelandPatient’s History: A 43-year-old male patient, non-smoker, complaining about chest and back pains as well as numbness and weakness of the legs, was referred for CT evaluation of the complete aorta to rule out a dissection or other vascular pathology.Diagnosis: CT Angiography demonstrated coarctation of the aorta with extensive collateral supply arising from the superior segment.Scanner: SOMATOM Definition ASDose: 2.4 mSv

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4 Winner of Category “Dual Energy”:

Submitter: Teh Hui Seong, MD, and Trishna Sumer Shikhare, MD, Khoo Teck Puat Hospital, SingaporePatient’s History: A 69-year-old male patient presented with a pulsating abdominal mass and an acute onset of lower abdominal pain. CT Angiography was performed and an abdominal aortic aneurysm was detected for which the patient underwent Endovascular Aortic Aneurysm Repair (EVAR) and aorto- iliac stent implantation.Diagnosis: Post EVAR CT Dual Energy (DE) imaging showed neither evidence of a contrast leak or haemorrhage, nor haemoperitoneum or retroperitoneal collection.Scanner: SOMATOM Definition FlashDose: 5.9 mSv

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5 Winner of Category “Trauma”:

Submitter: Wen Chao Bai, MD, Macau University Hospital, MacauPatient’s History: A 55-year-old male patient suffered a left lower tibial fracture in a traffic accident 9 years ago. Internal immobiliza-tion followed and was then removed 2 years later. Recently, the patient complained of pain in his left ankle combined with limping. CT imaging was required for evaluation.Diagnosis: An immobilization screw remaining in the left distal tibial extremity was clearly demonstrated. Changes due to traumatic arthritis were additionally visualized.Scanner: SOMATOM Definition ASDose: 0.1 mSv

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6 Winner of Category “Neuro”:

Submitter: Robert Kufchak, RT,Buffalo Women’s and Children Hospital, USAPatient’s History: A 10-year-old boy was presented to the hospital with a projectile penetrating the forehead.Diagnosis: A non-contrast CT examination showed that the tip of the projectile ended intracranially, just above the anterior left ethmoid after breaching the anterior left frontal sinus and the left cribriform plate. A small pneumocephalus was seen underlying the frontal bone. There was no evidence of either extra-axial or intraparenchymal hemorrhage, nor direct injury to the orbit or globe.Scanner: SOMATOM Definition ASDose: 0.1 mSv

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7 Winner of Category “Pediatrics”:

Submitter: Jean Francois Paul, MD, Centre Chirurgical Marie Lannelongue, FrancePatient’s History: A 13-month-old baby in respiratory distress was referred for a CT check-up after an ultrasound examination evoking an aortic aneurysm.Diagnosis: CT Angiography revealed a voluminous thoracic aortic aneurysm.Scanner: SOMATOM Definition FlashDose: 1.0 mSv

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8 Winner of Category “Public Vote”:

Submitter: Tsai Yi-Shan, MD, Chou Chen-Miao, National Cheng Kung University Hospital, TaiwanPatient’s History: CHDDiagnosis: Intra-cardiac TAPVR with small ASD. Left upper pulmonary vein drainage into the ASD region shows flow into LA and RA.Scanner: SOMATOM Definition FlashDose: 0.8 mSv

8

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The Heart Center Leipzig in Germany, is equipped with a SOMATOM® Defini-tion Flash scanner and a five-user set-up of syngo.via. “We have been testing syngo.via VA11 for four months now. As the automation helps us greatly in clinical routine almost all colleagues in my team use the CT Cardio-Vascular Engine on a regular basis”, says Lukas

Lehmkuhl, MD, senior radiologist in cardiac CT. Around 1,200 cardiac CT scans are performed each year at the Heart Center Leipzig.

Automation of recurring steps in cardiovascular evaluationsLehmkuhl uses syngo.via for routine purposes, but sees its main advantages

in dealing with cases that previously required intensive segmentation, i.e. all cardiovascular studies and functional exams. “syngo.via takes a lot of work off our hands as recurring steps are auto-mated, such as calculating curved planar reformations or labeling vessels.” In com-parison with other software, syngo.via has reduced the amount of time for ves-

“syngo.CT Dynamic Angio makes it possible to classify different types of endoleaks in follow-up examinations of endovascular aneurysm repair procedures.”

Lukas Lehmkuhl, MD, Heart Center Leipzig, Germany

syngo.via Brings Improved Automation and Additional Functionality to Clinical RoutineThe Heart Center Leipzig, Germany, stands to benefi t from improvements that further boost the reading of cardiovascular cases and allow for functional assessment of pulmonary arteries based on Dual Source CT (DSCT) Dual Energy data. The clinic is one of the fi rst sites to evaluate syngo.via VA11 in clinical routine.

By Philip Stenner, PhD


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1 EVAR: Endovascular aortic repair. The statements by Siemens’ customers described herein are based on results that were achieved in the customer’s unique setting. Since there is no “typical“ hospital and many variables exist (e.g., hospital size, case mix, level of IT adoption) there can be no guarantee that other customers will achieve the same results.

syngo.CT Dynamic Angio helps Lukas Lehmkuhl, MD with the evaluation of AAA stent patency based on 4D image data.

sel segmentation tenfold at the Heart Center Leipzig. syngo.via VA11 worked especially well for one complicated case: A patient with mitral valve endocarditis underwent a cCTA. Since he was sched-uled for urgent surgery there was not enough time for a cardiac catheter. How-ever, the advanced features in syngo.CT Coronary Analysis helped to detect a sig-nificant coronary stenosis which could then be adequately treated during the operation with a bypass graft.As Automated Preprocessing is also part of syngo.CT Vascular Analysis, Lehmkuhl also profits from tremendous time-savings for all studies including the aorta, such as pre-procedural planning scans for trans-catheter aortic valve implantations (TAVI).

Boosting assessment of 4D EVAR1 follow-upsLehmkuhl further appreciates new diagnostic possibilities with syngo.CT Dynamic Angio. Since this application

www.siemens.com/ct-clinical-engines

provides 4D analysis of time-resolved CT studies, it helps with follow-up studies of stent grafts and allows the detection of endovascular leakages. “syngo.CT Dynamic Angio makes it possible to classify different types of endoleaks in follow-up examinations of endovascular aneurysm repair studies,” says Lehmkuhl. “As the handling of several time points is now straight forward, the sensitivity has significantly increased allowing for confident evaluations.”

Morphological and functional analysis with Dual Energy CTLehmkuhl regards the new Dual Energy (DE) application syngo.CT DE Lung Analysis as a potential game changer when it comes to evaluating pulmonary emboli. The challenge here is to assess the impact of thrombi in peripheral ves-sels in addition to a purely morphological detection. “With syngo.CT DE Lung Analysis we have the means to close the

gap between CTA of pulmonary arteries and scintigraphy,” says Lehmkuhl. It is now possible to detect thrombi in the peri-pheral vessels due to a reduced iodine enhancement. And at the same time it is possible to judge whether a more central occlusion is actually hemodynamically relevant. According to Lehmkuhl, the rate of false negatives can be significantly lowered for the CTA of pulmonary arteries.

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App now Available for SOMATOM Sessions OnlineBy Sandra Kolb


In keeping with today's age of digital information, the SOMATOM Sessions magazine has been available online since June 2011.Siemens CT has now launched an app that makes the content of the latest arti-cles available for reading on the iPhone or iPad. SOMATOM Sessions readers can download this app free-of-charge from the App Store (an Android app is due for release in August 2012). The SOMATOM Sessions app optimizes content to be read easily on either device and also enables offline browsing of articles. Just as on the

website, the articles are conveniently sorted by category within the app and readers can opt to receive alerts via push notifications when new content is pub-lished. An exclusive feature not available on the website allows users to bookmark articles for later reading.In the established online version of SOMATOM Sessions, readers benefit from the easy to read blog style, articles sorted according to subject, and links to inter-esting topics on training. Each article now contains links to related articles and further online resources. As a feature-

packed alternative to the print edition, the new online format also includes engaging videos which are linked directly to related content for easy navigation with a single click. SOMATOM Sessions online has a host of social features: readers can com-municate with authors via the contact form or comment on articles directly.To check out the new SOMATOM Sessions app for iPhone and iPad, go to:

SOMATOM Sessions online, now available for mobile devices


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KLAS Report 2011 Honors Siemens Commitment to Low-dose CTBy Christiane Torres* and Peter Aulbach**

** Computed Tomography, Siemens Healthcare, Malvern, USA** Computed Tomography, Siemens Healthcare, Forchheim, Germany

Siemens was recognized as the industry low-dose leader in the most recent KLAS “CT 2011: Focused on Dose“ report. In the same report, the SOMATOM® Definition Flash took first place in the high-end CT space and the SOMATOM Definition AS+ (128-slice)¹ earned first kudos from cus-tomers. KLAS is an independent organi-zation based in Utah, USA that publishes reports measuring vendor performance in the healthcare sector. During the sur-vey, healthcare providers were asked to evaluate the systems in use at their insti-tution according to a standard set of questions and interviews.

Siemens – A real partner in dose reductionKLAS found that Siemens was chosen as the low-dose leader by their own customers almost 100% of the time. In addition, about 14% to 23% of non Siemens users in the study also describe Siemens as the low-dose leader, and these percentages are significantly higher than those of any other vendor. According to the KLAS report, the over-whelming theme was an appreciation for Siemens’ dedicated resources to develop new technology that helps pro-viders reduce dose and can be summa-rized in one simple sentence: The “over-all, industry perception is that Siemens is the low-dose leader to catch.”Siemens also received highest ranking for physician education offerings, an important factor in achieving consistently low dose exams for patients. Further-more, providers felt that Siemens is lead-ing in terms of the ability to adapt exist-ing customer protocols to incorporate and utilize new dose-saving technologies.The KLAS study applauded: “Overall, pro-

viders felt that Siemens is really a partner in helping them reduce dose.”

Siemens – Innovations at workThe SOMATOM Definition Flash took first place in the high-end CT space ratings. It remains the undisputed winner with the highest recommendation rate (Fig. 1) in the KLAS survey, along with the highest rankings for product reliability/uptime, ease of use, functionality, and quality of training.Dual Source CT capabilities such as the Flash Spiral scanning for cardiac scans routinely below 1 mSv or dose neutral Dual Energy CT are still unique in the market.Preliminary results show good satisfaction ratings for the SOMATOM Definition AS+ with 100% satisfaction ratings when it comes to functionality that makes this a true price-performance system. The

SOMATOM Definition AS+ features a rota-tion time as fast as 0.30 s, stroke imag-ing of the entire brain, plus the recently added sequential Dual Energy scanning. Plus it also ships with state-of-the-art dose-saving features such as CARE kV, IRIS (Iterative Reconstruction in Image Space) and SAFIRE (Sinogram Affirmed Iterative Reconstruction), the Adaptive Dose Shield and X-CARE.The SAFIRE algorithm is currently rolled out free-of-charge to the international installed base of SOMATOM Definition customers who already use IRIS, showing Siemens’ commitment to making low dose CT as widely available as possible for optimum patient care.

1 This chart compiled by KLAS researchers compares Evangelists and Naysayers for a range of CT scanners in active use: The blue bars in the chart represent the percentage of users who would recommend and actively speak in favor of the product. The orange bar represents the number of users who would actively speak against the CT system.

SiemensSOMATOMDefinition Flash

Vendor A64-slice CT

Vendor B64-slice CT

Vendor B320-slice CT

SiemensSOMATOMDefinition AS 64

Vendor C256-slice CT

Vendor A64-slice “HD” CT

Vendor C64-slice CT

10% 9% 11%8% 7%

18%

0%

78%

67%

21%

67% 67% 65% 64%

55%

45%

0%

1

Evangelist Naysayer

¹ Information about the product was taken from less than fifteen provider organizations. Readers should only consider the measurement as an early indicator of performance from a small sample of clients.

KLAS “CT 2011: Focused On Dose” report, 11/2011, www.KLASresearch.com, © 2011 KLAS Enterprises, LLC. All rights reserved.

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Pushing Boundaries in CT – Latest Research in Functional ImagingGround-breaking research published in a special edition of Investigative Radiology reveals insights into new functional imaging methods.

By Heidrun Endt, MD


Functional CT imaging is currently attract-ing considerable interest in scientific research. Investigative Radiology pub-lished a special issue [e.g. 1-5] dedicated to this emerging field with a focus on oncology and cardiovascular medicine. Eight of the thirteen clinical studies included in this edition used Siemens SOMATOM® CT scanners.

Perfusion CT imaging as a quantitative imaging methodWhen evaluating new therapy methods in oncology, a change of thinking is required. New drugs or treatments may trigger other reactions in the tumor tissue that cannot be measured at an early stage with current criteria (e.g. tumor size). Perfusion CT needs to be assessed comprehensively to prove its worth as a reliable biomarker.A group of researchers from Zurich, Switzerland, analyzed perfusion patterns of primary malignant liver tumors and hepatic metastases in 30 patients with computed tomography (CT) and ultra-sound examinations. [1] A SOMATOM Definition Flash was used for the CT part of the study. With the Adaptive 4D Spiral a scan range of 14.8 cm was covered enabling perfusion imaging of the whole organ. By using this technology repeatly, bi-directional table movements are per-formed. As many patients may not be able to hold their breath for the duration required, motion correction is crucial for

gathering reliable data. The study found that “quantitative analysis of tumor per-fusion was feasible in all patients […]” [1] after motion correction. The perfusion evaluation with syngo Volume Perfusion CT Body included arterial liver perfusion, portal-venous perfusion and total perfu-sion.Another study published in this special issue details research into CT perfusion imaging of the kidneys. [2] The perfu-sion patterns of renal cell carcinomas were evaluated in 21 patients with the SOMATOM Definition Flash and the Adaptive 4D Spiral. After motion correc-tion all examinations could be assessed and a reliable evaluation of the renal perfusion was possible. “Considerable tumor heterogeneity was found in both qualitative and quantitative analyses reinforcing the use of volumetric techni-ques for both perfusion imaging and per-fusion analysis.” [2] Such tumor hetero-geneity may become the salient point in the assessment of therapy response for new drugs.

Dual Energy CT for evaluation of body perfusionIodine-related attenuation (IRA) can be depicted with Dual Energy CT (DECT). As the amount of contrast medium respec-tively iodine enhancing a tumor, or more general a tissue – depends on the status of vascularization IRA can be used for evaluation of perfusion. [3] Researchers

from the University Medical Center Mannheim, University of Heidelberg, Germany, evaluated hepatic metastases in 24 patients with gastrointestinal stromal tumors (GIST) with a SOMATOM Definition. 23 patients received tyrosine kinase inhibitors as therapy and 11 under-went several DECT studies for follow-up. The CT data were also evaluated accord-ing to the Choi criteria, where the density of the tumor is assessed. The authors concluded: “DECT is a promising imaging method for the assessment of treatment response in GIST, as IRA might be a more robust response parameter than the Choi criteria.” [3]

Cardiovascular imaging with Dual Energy CTResearchers from the University Medical Center Mannheim, University of Heidel-berg, Germany, and Medical University of South Carolina, USA, collaborated for a study to optimize the contrast material injection protocol for DECT in patients with suspected pulmonary embolism. [4] The study included the CT examina-tions of 100 patients with a SOMATOM Definition. Four different contrast injec-tion protocols were evaluated. The iodine delivery rate (IDR) and the iodine con-centration were set to different values whereas the total iodine delivery was kept constant. The protocol with the highest concentration of iodine and the highest IDR (400 mg I/mL; 1.6 g I/s) “[…] maxi-


mizes the attenuation in the structures of interest […]”. [4] DECT in case of pul-monary embolism delivers “[...] a tradi-tional CTPA [CT pulmonary angiography] and visualization of blood perfusion in a single acquisition and may therefore provide incremental value to pulmonary angiography alone.” [4]

The need for proof and evaluationIn the foreword, the editors of this special issue of Investigative Radiology empha-size the need for studies evaluating func-tional CT imaging: “Clinical radiology is increasingly confronted with clinicians’ demands for quantitative information to better characterize and stratify disease, or to evaluate treatment response.” [5] New imaging methods need to be assessed in terms of feasibility and quan-titative parameters gained in clinical tests used up to now. These results and future quantitative studies will make an important contribution toward fulfilling this request so that functional CT imag-ing is ready for wider use in the future.

http://journals.lww.com/investigativeradiology/toc/2012/01000

References[1] Goetti R et al. Quantitative perfusion analysis

of malignant liver tumors: dynamic computed tomography and contrast-enhanced ultrasound. Invest Radiol. 2012 Jan;47(1):18-24.

[2] Reiner CS et al. CT perfusion of renal cell carcinoma: impact of volume coverage on quantitative analysis. Invest Radiol. 2012 Jan;47(1):33-40.

[3] Apfaltrer P et al. Contrast-enhanced dual-energy CT of gastrointestinal stromal tumors: is iodine-related attenuation a potential indicator of tumor response? Invest Radiol. 2012 Jan;47(1):65-70.

[4] Nance JW et al. Optimization of contrast material delivery for dual-energy computed tomography pulmonary angiography in patients with suspected pulmonary embolism. Invest Radiol. 2012 Jan;47(1):78-84.

[5] Fink C et al., Functional Computed Tomography Imaging. Invest Radiol. 2012 Jan;47(1):1

2 A 57-year-old male patient with a gastro-intestinal stromal tumor (GIST) and hepatic metastases underwent Dual Energy CT. Fig. 2A: virtual 120 kV image, Fig. 2B: virtual noncontrast image, Fig. 2C: iodine map, Fig. 2D: fused iodine map. The examination was part of a study [3] that was set up to evaluate iodine-related attenuation as an indicator of tumor response in GIST. Courtesy of University Medical Center Mannheim, Germany

2A 2B

2D2C

1 A 47-year-old male patient suffering from colon cancer with hepatic metastases was included in a scientific study. [1] The CT perfusion examination was performed to evaluate therapy response to chemotherapy (Avastin®, FOLFOX). Fig. 1A: maximum intensity projection, Fig. 1B: arterial liver perfusion, Fig. 1C: portal-venous perfusion, Fig. 1D: time-intensity curve. The measurements show a central-necrotic metastasis with enhanced perfusion at its margins.Courtesy of University Hospital Zurich, Switzerland

1A 1B

1C 1D

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STRATON X-ray TubeHigh performance under Challenging Conditions

By Christine Dehm, PhD,* and Holger Reinsberger**

**Clinical Products, Siemens Healthcare, Erlangen, Germany**Customer Services, Siemens Healthcare, Erlangen, Germany

Siemens developed the STRATON® X-ray tube for high-performance CT scanning in extreme operating conditions.

Benefi ts of the STRATON designThe STRATON tube differs significantly from a standard tube. Unlike conventional tubes, the anode in the STRATON tube is cooled directly, creating a powerful tube which is much smaller than conven-tional designs (Fig. 2). This means that two X-ray tubes can be installed in dual source platforms for scans at high tem-poral resolution, which is essential espe-cially for cardiac imaging. As the anode is cooled directly, long runoff scans or perfusion studies are not interrupted by cooling processes.

Technology and operating conditionsX-ray tubes are subject to high voltages of up to 140 kV and high currents. The materials used in the tube design must be able to withstand a high vacuum, extreme temperatures and permanent temperature changes. New technology had to be developed for the STRATON tube design, including the deflection coils which shape the electron beam. The new design can shape different focal spot sizes with just one emitter. In each X-ray tube 1% of electrical energy applied results in an X-ray beam. The rest of the electrical energy is converted into heat. When the electron beam hits the anode, the energy density reaches values up to half the energy density on the surface of the sun. A power of 100 kW is directly applied to the focal spot by the generator (Fig. 1). While the power is

applied, the temperature in the focal spot reaches 2,500 °C, and the temperature on the focal track hits 2,000 °C. The back of the anode has – due to the direct cooling – a temperature of only 200 °C, resulting in a temperature gradient of more than 1,800 °C/cm. Emitter temper-atures reach up to about 2,500 °C, and must also be kept very stable at high temperatures.The STRATON tube components must also endure other extreme conditions

like significant centrifugal forces. The tube rotation frequency is 160 Hz. With the additional scanner rotations, the STRATON tube has to grapple with 40 times the gravity (40 g), which is about 10 times higher than the centrifugal force a passenger is exposed to in a roller coaster.Even though these extreme conditions put the tube under enormous stress, continuous technical improvements have made the Straton tube one of the most

1 Schematics of the STRATON tube with anode directly attached to the tube envelope.

1

Oil for cooling

Emitter

MotorAnode

Electron beam

Deflection coils

Focal spotX-rays

Rotation Cathode

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reliable and long-lasting tubes in the industry.

Wear and tear affecting an X-ray tubeAll X-ray tubes are consumables and the wear caused during operation will sooner or later lead to failure. One example of deterioration is emitter erosion. Over time, the cathode material becomes thin-ner until it melts. Physical stress caused by the temperature changes can cause micro leaks. The constant bombardment of the anode with electrons leads to a rough surface which eventually results in insufficient dose.

The need to increase tube lifeIn an ideal world, a technical system should survive for its designed service life and fail after this period as illustrated in Fig. 3 (blue line). As the variables affect-ing wear are hard to predict, the service life of an X-ray tube cannot be ensured and a tube failure may occur at any time. By examining a large number of tubes, the failure rate and the average time until a tube will fail can be measured. The failure distribution over time can be expressed in a linear relationship Fig. 3 (red line). Siemens constantly monitors the quality, investigates the reasons for tube failure and continuously improves clinical capabilities and the quality of its X-ray tubes. With tube optimization, physi-cal conditions will still affect the service life of the tube, however the tube failure will decrease as illustrated in Fig. 3 (green line). The area between the red line and the green line represents the average increased tube life.

Siemens service solutionSiemens offers a unique service for remotely determining the remaining life span of a tube. Thanks to the Guardian program including TubeGuard, a replace-ment tube is ordered before a failure occurs. To cover the financial risk, Siemens provides a warranty for its tubes and offers a service contract during the life cycle.

www.siemens.com/TubeGuard

10 cm

2 The compact design of the STRATON tube (Fig. 2A) allows two acquisition systems within one scanner for dual source and dual energy scanning. A conventional tube is shown for comparison (Fig. 2B).

2A 2B

100%

Distribution of failure

time

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

ideal

x-ray tube

x-ray tube withquality improvement

3 Distribution of failure versus time for an ideal case with only one cause of failure (blue line). In case of multiple failure causes which can occur at different times (like wear caused in an X-ray tube) a linear relationship results (red line). With continuous tube optimization the failure rate over time can be decreased (green line).

3


Low Dose, High Resolution for Pediatric Cardiology The Dual Source computed tomography (CT) scanner from Siemens, the SOMATOM® Defi nition Flash, is winning the hearts of both pediatric cardiology patients and their doctors at a Minnesota children’s hospital. The reason: lower radiation doses, higher temporal resolution, and unmatched patient comfort.

By Robert L. Bard

The SOMATOM Definition Flash from Siemens is changing the clinical care of pediatric cardiology patients at the Minneapolis Heart Institute and Children’s Hospital and Clinics of Minnesota – for the better. Pediatric cardiologist Kelly Han, MD, who serves as Director of Congenital Cardiac Imaging at the hospital, says the capabilities of the SOMATOM Definition Flash are unique because its isovolumetric resolution is outstanding, meaning it is the same resolution regardless of the plane. “In comparison to magnetic reso-

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nance imaging (MRI),” Han explains, “the plane you are focused on with MRI is very good, but the other planes are not as clear. Thanks to the SOMATOM Definition Flash’s Dual Source approach, the tempo-ral resolution of 75 msec “freezes” cardiac motion during the acquisition time frame.” That robustly prevents motion artifacts.The temporal resolution is an extremely important concern in pediatric cardiology because of babies’ high heart rates, babies’ inability to perform breath hold-ing on command, and the radiation expo-

sures from imaging. Imaging risks are lower today, according to Han, because by using the dose-efficient Flash Spiral scan mode in combination with SAFIRE, the radiation dose is just a fraction of previous generation scanners. Addition-ally, today’s CT scan may eliminate the need for diagnostic heart and thus further decrease radiation exposure. John Lesser, MD, Director of Cardiovascu-lar Computed Tomography and Magnetic Resonance Imaging at the Minneapolis Heart Institute, talks about the changing

1 3-day-old baby with an interrupted aortic arch. Courtesy of Minneapolis Heart Institute and Children’s Hospital and Clinics of Minnesota, Minneapolis, USA

2 An anomalous RCA from ascending aorta from a 17-year-old child weighing 200 lb. Courtesy of Minneapolis Heart Institute and Children’s Hospital and Clinics of Minnesota, Minneapolis, USA

21

clinical practice resulting from the Dual Source CT SOMATOM Definition Flash’s high temporal resolution and decreased radiation. “Because the radiation dose is so low, we can do multiple scans for different purposes now if necessary –without increased risk,” he says. “For instance, we can look at the anatomy and function by doing two different scans with a minimal increase in radiation, allowing us to answer multiple questions in one small time frame and limit the radiation exposure.”

Individualizing patient care and imaging modality selectionImaging has become individualized at the Minneapolis Heart Institute. As Han says, “It takes a lot of physician inter-action, and every single scan has to be tailored to the question that needs to be answered for that patient; it is not some-thing that can be rigidly protocolized.”The individualized approach limits radiation exposure by imaging only the necessary structures rather than using standardized protocols that image more anatomy than is clinically relevant. The recently introduced FAST CARE platform helps individualize the protocols. For example, the CARE kV function auto-matically selects the optimum kV step to save the maximum amount of dose without compromising image quality.One of the greatest benefits of the

benefit, because recovery time is elimi-nated.The choice of imaging modality is also highly individualized. Advanced modali-ties are required in neonatal patients who have complex anatomy, and CT is a desirable option because it will not damage these patients’ small blood vessels. “Patients with congenital heart disease are living longer and longer,” says Han, “and they need to have healthy blood vessels in case a heart catheteri-

SOMATOM Definition Flash is that seda-tion may not be indicated in all cases because of the Flash’s extraordinary high speed. It can allow for some patient movement and may not require a breath-holding sequence due to its scan speed of up to 458 mm/s. There is also a defi-nite increase in patient friendliness and patient comfort with the Flash technol-ogy. When sedation is not used, parents can take their child home right after the scan is finished. This is a significant

The experts David Dassenko, MD, Kelly Han, MD, and John Lesser, MD, (from left to right) were discussing about lower radiation doses, higher temporal resolution and patient comfort for their cardiology patients during the interview with SOMATOM Sessions.

“ If you are going to translate into a major shift from traditional diagnostic heart catheterization to CT scans you could potentially see a signifi cant staff savings to the institution.”

David Dassenko, MD, Director of the Cardiovascular Care Center, cardiac intensivist and anesthesiologist at Children’s Hospitals and Clinics of Minnesota

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zation is vital later in life.” Lesser simpli-fies the diagnostic decision tree to two simple questions: “Number one: What do I need? And number two: What is the least risk?” According to Han, “The SOMATOM Definition Flash CT is a much better answer to those questions than the older generation scanners used to be.”

Effi ciency and cost savings

David Dassenko, MD, Director of the Cardiovascular Care Center, who is a cardiac intensivist and an anesthesiolo-gist at Children’s Hospitals and Clinics of Minnesota, says that the speed of the testing process and the reduced need for sedation are two more reasons why Flash CT imaging is the desirable imaging choice. Dassenko notes that anesthesia charges by the hour, and the use of CT is a much faster diagnostic test. “For example, a diagnostic heart catheteri-zation takes approximately one to two hours to complete,” he explains, “and the staff time typically includes an anes-thesiologist and a resident physician or a nurse anesthetist – and the cost that that implies. Typically, an hour’s worth of operating room time plus our time is in the thousands of dollars, so if we can minimize the time down to a few minutes, the obvious cost savings are there.”

Scanning is exceptionally more efficient without the need for a breath hold. Says Dassenko, “In the past, a pediatric CT almost always required intubating the baby and putting the baby to sleep so that an anesthesiologist could hold the baby’s breath. With the Dual Source Technology of the SOMATOM Definition Flash, the paradigm has been dramati-cally changed.” Changes in sedation have caused the CT scanner turnaround to be faster. Lesser points out that an MRI in a patient who requires a breath hold and thus sedation and intubation takes up 2–3 slots (scheduling units for the scanner), but a CT takes up only one slot. MRI may also be contraindicated in patients who have metal implants, especially in congenital heart patients who commonly have coils, stents, pace-makers or internal cardiac defibrillators. Furthermore, both MRI and heart cathe-terization typically require contrast, and Flash CT does not.Since CT commonly eliminates or decreases anesthesia, the recovery times are also eliminated or decreased. In patients where sedation is indicated, such as those with anxiety, the doses are lower and the recovery times are shorter than they used to be, reports Dassenko. “Many of our patients have congenital heart disease and are therefore considered

to be relative high risk for complications associated with anesthesia, so eliminating or minimizing sedatives decreases the risk of adverse events,” he says.The decreased role and costs of anesthesia in pediatric cardiology with the use of SOMATOM Definition Flash represent a major shift in clinical care and have freed up the anesthesia team for other needs throughout the medical center. Dassenko concludes, “If you are going to translate into a major shift from traditional diag-nostic heart catheterization to CT scans that are much, much less time involved, you could potentially see a significant staff savings to the institution.” Lesser adds that eliminating catheterizations dramatically decreases expenses, because CT can provide the desired information for the same diagnostic indications and does not have the costly complications associated with diagnostic heart cathe-terization.

New imaging paradigm requires teamworkHan, Lesser, and Dassenko all agree that the new imaging paradigm is changing the process of diagnosing patients, and

“ The Flash CT is a much better answer to those questions than the older gener-ation scanners used to be.”

Kelly Han, MD, Director of Congenital Cardiac Imaging, Children’s Hospitals and Clinics of Minnesota

The Minneapolis Heart Institute and Children’s Hospital and Clinics of Minnesota.

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they emphasize that teamwork is vital to the success of the paradigm. Lesser, commenting on the Minneapolis Heart Institute’s experience, says “There is some-thing very unique to our team approach: it is an adult cardiology unit that has a pediatric cardiologist associated with it (Han), and I don’t know of any other place that has such an adult-child interaction.” This arrangement is beneficial because the pediatric specialists have expertise related to unusual cases, and the CT technicians are likely to have special skills in order to manipulate the images of the small babies while imaging at the lowest possible radiation dose. Lesser adds that adult cardiology brings forth the benefit of technicians’ tremendous experience, because of the high volume of patients. Han concurs, adding, “In order to do CT well, it is a team approach: You have to have techs who are well-trained and an anesthesiologist who understands the risks of sedation and knows exactly what the ordering physician is trying to accomplish with the scan.”The Dual Source CT SOMATOM Definition Flash has improved communication and teamwork between physicians. Lesser

Robert L. Bard is a freelance medical writer certified by the American Medical Writer’s Association who also conducts clinical research at the University of Michigan’s Division of Cardiovascular Medicine.

“ Because the radia-tion dose is so low, we can do multiple scans for different pur poses now if necessary – with-out increased risk.”

John Lesser, MD, Director of Cardiovascular Computed Tomography and Magnetic Resonance Imaging at the Minneapolis Heart Institute

Kelly Han, MD, explains to the patient what will happen during the imaging procedure.

notes that teamwork was not well estab-lished with the use of the older genera-tion scanners. Han is currently using Flash CT clinically to diagnose children with complex anatomy who are less than eight years of age, because of its favorable risk profile.


www.siemens.com/SOMATOM-Definition-Flash

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eMode on SOMATOM Perspective – a Chance to Optimize Total Cost of Ownership in Clinical RoutineBy Silvia Meyer

Customer Services, Siemens Healthcare, Erlangen, Germany

In a tough financial climate and faced by increasing competitive challenges, health-care institutions have to maintain a high level of diagnostic excellence and treat-ment quality. On the other hand, there are more budget restrictions than ever before and reimbursement rates are decreasing globally.Siemens is offering a new service benefit program called eMode for SOMATOM Perspective that delivers answers to these challenges. A SOMATOM Perspective service contract can be ordered optional to the scanner purchase. If a medical institution then is running their SOMATOM Perspective with eMode in 80% of their scans, several additional service compo-nents like the following examples can be made use of.1

syngo Remote Assist2, 3 – for excellent application support in CT imagingWhenever customers need support in clinical applications, they can call their local Siemens Uptime Service Center for immediate support from an Application Specialist. With the customer’s permission, the system is connected with Siemens Remote Service via an encrypted broad-band connection to provide secure data transfer. Ms. Bak, executive technician from the radiology department in Mut-langen, Germany, had already the chance to experience the ease of use of syngo Remote Assist. “I trust Remote Assist Services completely. The Siemens appli-cation expert sees what I’m doing and I can see what Siemens is doing. It’s almost like having the expert watching

over my shoulder.” Once the customer has shared their desktop and handed over mouse control, the Application Specialist can provide instant support in any appli-cation queries. This means that the cus-tomer can work productively and benefits from CT expertise. Data protection is assigned the highest priority: Siemens Remote Services are based on a certified

IT infrastructure and secure VPN con-nections.Ms. Bak was impressed with the initial ease of use of syngo Remote Assist and became a clear promoter of the tool: “Remote support from an experienced Siemens application specialist is extremely helpful in the daily routine, e. g. for changing protocol settings or when pre-

The Application Specialist can provide instant support for any application.

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1 Further details can be collected from the local service organization

2 eMode service benefits are subject to country-specific availability

3 syngo Remote Assist is based on Siemens Remote Services (SRS) which is an efficient and comprehensive infrastructure for medical equipment-related remote services. Siemens provides SRS-based services via a reliable bidirectional infrastructure based on a powerful and secure Virtual Private Network (VPN). syngo Remote Services are ISO 27001 certified.

paring a special CT examination – espe-cially for things that need to be done less often – this saves me lots of time. Having now worked on a Siemens system for the first time, I’m extremely happy as a new user that the Siemens expert can connect to the system remotely and immediately help me with all my questions. I feel more secure.”

Service contract adjustment2 – actively optimizes total cost of ownershipAnother lever to improve operational cost of the SOMATOM Perspective for the medical institution is the “Service contract adjustment” benefit option.When using the scanner with eMode in 80% of scans, customers can earn a discount on their annual service con-tract price. As an example, Siemens Uptime Services in Germany is offering a business model where the monetary benefit shows an even higher positive impact on the total cost of operation,

the longer the scanner lifecycle of the customer is.“With the choice of different eMode service benefits we can not only save time through efficient workflows when choosing syngo Remote Assist, we can even save real money by having an opti-mized cost-benefit-ratio by choosing ser-vice contract adjustments,” says Johann Steffens, MD, who has chosen this bene-fit for his private clinic in Hamburg for the first operating year.More information on how customers can benefit from the SOMATOM Perspective and eMode service benefits, as well as country-specific information on eMode service benefit programs is available from local Siemens Uptime Services represen-tatives.

eMode is designed to get the most out of SOMATOM Perspective.

eMode and a respective service benefit program allows operating the SOMATOM Perspective in a patient friendly and financially efficient way.

The statements by Siemens’ customers described herein are based on results that were achieved in the customer’s unique setting. Since there is no “typical” hospital and many variables exist (e.g., hospital size, case mix, level of IT adoption) there can be no guarantee that other customers will achieve the same results.

Clinical Results Cardio-Vascular


HISTORY

A 29-year-old female patient presented herself to the hospital with a tumor on the ulnar side of her left ring finger. The tumor had appeared a month earlier, small and asymptomatic. It however

progressed in size and caused discom-fort and occasional bleeding. Physical examination revealed a firm, non-pulsa-tile subcutaneous tumor near the distal interphalangeal joint. The capillary

return and the movement of the finger were normal. The skin covering the tumor appeared normal and there was no sensory loss.

1 The VRT image shows that the tumor (arrow) is well defined and clearly separated from the phalanx.

1 2

2 The VRT image shows one of two draining veins (arrow).

Case 1Adaptive 4D Spiral CT Angiography for the Diagnosis of a Capillary Hemangioma By Xiang-ming Fang, MD,* Xiao-yun Hu, MD,* Hong-wei Chen, MD,* Ping-yan Qian, MD,* Gang-feng Hu, MD,* Hui-jun Lu, MD,* Chenwei Li, MD**

**Department of Radiology, Wuxi People’s Hospital Affiliated to Nanjing Medical University, Wuxi, P. R. China**Healthcare Sector, Siemens Ltd. China, Shanghai, P. R. China


Cardio-Vascular Clinical Results

DIAGNOSIS

Non-contrast CT images showed a soft tissue tumor, measuring 1.8 x 1.7 cm, on the ulnar side of the distal left ring finger. The tumor was well defined and clearly separated from the phalanx (Fig. 1). CT Angiography (CTA) images acquired with the Adaptive 4D Spiral demonstrated significant and homo-geneous enhancement of the tumor with its feeding artery, along with two draining veins (Fig. 2–3). These results suggested a vascular tumor or a vessel-originated tumor. The patient under-went surgery and the pathology report confirmed a capillary hemangioma.

COMMENTS

Vascular abnormalities of the hand are infrequent and capillary hemangiomas of digital arteries are particularly rare. It is difficult to differentiate a hemangioma from a soft tissue lesion, such as an abscess, cyst, or neuroma, when the tumor is non-pulsatile, and the typical symptoms of arterial insufficiency (pain, pallor, no pulse, and paresthesia) are not present. Normal radiographs are usually not helpful unless erosive bone changes are suspected. Although angiography and nuclear scanning have proved to be helpful, they are considered invasive with possible complications. Contrarily,

a CTA examination is noninvasive and easily available. In this case, the advanced 4D Spiral CTA with dynamic scanning technique was used to demonstrate the feeding artery and draining veins, thus providing valuable information not only for the diagnosis but also for surgery.

3 The VRT image demonstrates the feeding artery (arrowhead) and two draining veins (arrows).

EXAMINATION PROTOCOL

Scanner SOMATOMDefinition Flash

Scan area Hand

Scan length 150 mm

Scan Mode Adaptive 4D Spiral

Scan direction Caudo-cranial and cranio-caudal

Scan time 24 s

Tube voltage 100 kV

Tube current 120 mAs

CTDIvol 100 mGy

DLP 1520 mGy cm

Effective Dose 1.2 mSv

Rotation time 0.285 s

Slice collimation 32 x 1.2 mm

Slice width 1.5 mm

Reconstructionincrement

1.0 mm

Reconstruction kernel B20f

Contrast

Volume 50 ml

Flow rate 3.5 ml/s

Start delay Bolus tracking

3



HISTORY

A 44-year-old female patient presented herself to the hospital with paroxysmal chest distress after exertion for the past 10 days. The duration of the distress varied between 10 minutes and several hours. There was no history of hyper-tension or diabetes. An electrocardio-gramm showed a sinus rhythm without significant ST-T changes. A coronary CTA was requested for further evaluation.

DIAGNOSIS

A coronary CT Angiography (cCTA) using Flash mode with a high pitch and an ECG-triggered spiral scanning revealed an extremely rare combination of coro-nary anomalies. These included a giant coronary aneurysm originating off a fis-tula connecting the left coronary artery and the right ventricle, an anomalous single coronary artery arising from the left sinus of Valsalva, and the absence of the right coronary artery (RCA) as well as of the left circumflex coronary artery (LCx).

COMMENTS

The combination of such coronary anomalies is extremely rare. cCTA imag-ing provided a comprehensive overview of the anomalies, thus offering informa-tion necessary to aid the physician in diag-nosis. Dual Source CT with Flash mode and ECG-triggering, using single spiral scanning and a very high pitch, not only shortens the acquisition time but also reduces the radiation exposure to the patient. In this case, the entire heart was scanned in just 0.23 s with a dose of only 0.8 mSv.

Case 2Diagnosis of Coronary-Ventricular Fistula with Giant Coronary Aneurysm using Flash Mode By Kai Sun, MD,* Ruijuan Han, MD,* Lijun Ma, MD,* Ligang Li, MD,** Gang Wang, MD,* Hailiang Jia, MD*

** Department of Radiology, Baotou Central Hospital, Inner Mongolia, P. R. China** Healthcare Sector, Siemens Ltd. China, Shanghai, P. R. China


Scanner SOMATOM Definition Flash

Scan area Heart Rotation time 0.28 s

Scan length 13 cm Pitch 3.4

Scan direction Cranio-caudal Slice collimation 128 x 0.6 mm

Scan time 0.23 s Slice width 0.75 mm

Tube voltage 100 kV Reconstruction increment 0.4 mm

Tube current 375 ref. mAs Reconstruction kernel B26f

Dose modulation CARE Dose4D Contrast

CTDIvol 3.59 mGy Volume 60 mL

DLP 59 mGy cm Flow rate 5 mL/s

Effective Dose 0.8 mSv Start delay 8 s



1–6 Images show a giant coronary aneurysm (Figs. 3–5, solid arrows) originating off a fistula (Figs. 1, 2, 5, dashed arrows) connecting the left coronary artery and the right ventricle, and an anomalous single coronary artery arising from the left sinus of Valsalva (Figs. 1–2, arrowheads). The right coronary artery (RCA) and the left circumflex coronary artery (LCx) are absent.

6

21

3 4

5



HISTORY

A 4-year-old girl, weighing 7.5 kg with a provisional diagnosis of congenital heart disease, was transferred by the National Board of Health from Angola to the Girassol private practice in Luanda. Despite the previous administration of beta-blockers, her heart rate remained at 93 bpm when CT was performed to evaluate the complex structure of the heart.

DIAGNOSIS

The cardiac CT Angiography confirmed the diagnosis of a truncus arteriosus with ventricular septal defect (Collett and Edwards type I; Van Praagh type 1A). A common arterial trunk arised from both ventricles, which communicated via a large perimembranous ventricular septal defect (VSD) (Fig. 1). The arterial trunk divided into the aorta and the main pulmonary artery. The main pulmonary artery subsequently divided into the left and right branched pulmonary arteries. (Figs. 2 and 3). Both coronary arteries arised from the common arterial trunk proximal to the main pulmonary arteries (Fig. 4). The anatomical abnormalities were confirmed and repaired in subse-quent surgery.

COMMENTS

Truncus arteriosus is a congenital heart disease resulting from the failure of

truncoconal septation. It occurs in 1% to 2% of infants with congenital heart defects. CT provides excellent charac-terization of the anatomy and levels of anatomic detail which are especially useful for surgical planning. Flash CT features a high temporal resolution which allows diagnosis at a high heart



Scan mode ECG triggered sequential scan

Scan area Heart

Scan length 98 mm

Scan direction Cranio-caudal

Scan time 4 s

Tube voltage 100 kV

Tube current 99 eff. mAs



Slice width 0.75 mm

Reconstruction increment 0.4 mm

Temporal Resolution 75 ms


CTDIvol 4.11 mGy

DLP 57 mGy cm

Effective Dose 2.26 mSv

Contrast

Volume 10 mL contrast media

Flow Rate 2 mL/s

Start delay 6 s

Case 3Diagnosis of Truncus Arteriosus using Flash CT ScanningBy Vasco Silva, MD,* João Carlos Costa, MD,** Constança Palma Borges, MD,* Joana Costa, MD,*** Marisa Gonçalves, RT,**M. Reis, RT,** P. Miguel, RT,* M. Sozinho, RT,* A. Nchanduca, RT,* C. Rosa, RT,* S.Bastos, RT,* Ana Chaves ****

**** Radiology Department, Clinica Girassol, Luanda, Angola**** Radiology Department, Hospital Particular de Viana do Castelo, Portugal**** Radiology Department Institut Jules Bordet, Brussels**** CT Application Specialist, Siemens Healthcare, Portugal

rate, reduced exposure dose and mini-mizes the necessary amount of contrast media (in this case, 93 bpm, 0.8 mSv and 10 mL). This is particularly important for pediatric cardiac CT examinations of congenital heart disease where the patients normally have a higher heart rate and incompatibility with beta-blockers.



1 MPR image shows a common arterial trunk arising from both ventricles, which communicate via a large perimembranous ventricular septal defect (arrow).

2–3 MIP (Fig. 2) and VRT (Fig. 3) images demonstrate the arterial trunk which divides into the aorta and main pulmonary artery, and the main pulmonary artery subsequently divides into the left and right branch pulmonary arteries.

4 MIP image reveals both coronary arteries arising from the common arterial trunk proximal to the main pulmonary arteries.

1 2

3 4



HISTORY

A 55-year-old male patient, who had undergone a Coronary Artery Bypass Graft (CABG) 8 years ago, was referred to the CT department for a follow-up evaluation.

DIAGNOSIS

The CT images demonstrated two bypasses – Left Internal Mammary Artery – Left Anterior Descending Artery (LIMA-LAD) and Aorta-Saphenous Vein – Diagonal 1 (AO-SV-D1). The LIMA graft was left intact at its origin off the subclavian artery and was grafted to the LAD artery, distal to the occlusion (Figs. 1, 2 and 4). A left Saphenous Vein Graft (SVG) was laid over the pulmonary artery, and originated proximally off the anterior wall of the ascending aorta. It was anastomosed to the first diagonal branch of the LAD, distal to the stenosed site (Figs. 1 and 4). Both grafts remained patent, with no evidence of stenosis.The following findings were seen for the original coronary arteries: A mild stenosis, from soft plaque, in the mid-Right Coronary Artery (mid-RCA, Fig. 3), a severe stenosis, from soft plaque, in the Left Main Artery (LMA, Fig. 5), occlusion, from both soft and calcified plaque, in the proximal LAD (Fig. 5), and a severe stenosis, from soft plaque, in the proximal D1 (Fig. 5). The Circumflex (CX) was small in caliber but showed no evidence of stenosis (Fig. 6).

Case 4Follow-Up on CABG using iTRIM Method for Coronary CTABy Yingning Wang, MD, Jian Cao, MD, Zhou Li, MD

Department of Radiology, Peking Union Medical College, Beijing, P.R. China

1 VRT image demonstrates an overview of both LIMA and SVG grafts which are patent. LIMA graft remains intact at its origin (arrow) off the subclavian artery and is grafted to

the LAD artery (dashed arrow). A left SVG was laid over the pulmonary artery and origi-nated proximally off the anterior wall of the ascending aorta. A mild stenosis in mid-RCA (arrowhead) can also be visualized.

1


COMMENTS

In CABG follow-up studies, especially those with saphenous vein grafts, cathe-ter angiography is often difficult. Cardiac CT can obtain both 2D and 3D images, to depict in detail the course and status of the grafts. Generally, to avoid motion artifacts, a high temporal resolution is required. This involves sophisticated hardware to speed up the rotation time. Alternatively, image reconstruction algo-rithms, such as the iterative Temporal Resolution Improvement Method (iTRIM) can be used to improve the temporal resolution. iTRIM enhances temporal resolution by 20% [1], allowing temporal resolution to be improved to 192 ms potentially aiding the physician in making a reliable diagnosis.


Scanner SOMATOM Perspective

Scan area Heart

Scan length 250 mm


Scan time 12 s

Tube voltage 130 kV


CTDIvol 28.35 mGy

DLP 877.82 mGy cm

Effective dose 12.3 mSv


Pitch 0.27


Slice width 0.75 mm

Temporal Resolution 192 ms

Reconstruction increment 0.5 mm

Reconstruction kernel B31s

Patient heart rate 35 – 53 bpm

Contrast

Volume 80 mL (370 mgL/mL contrast media)

+50 mL saline

Flow rate 5 mL/s

Start delay 23 s

2 Curved MPR image presents the entire course of the LIMA graft and its patent anasto-mosis to the LAD.

3 Curved MPR shows RCA with mild stenosis from soft plaque (arrowheads).

4 VRT image shows the full extent of LIMA graft from its proximal origin (arrow) off the subclavian artery to its distal anastomosis with the LAD (dashed arrow). The SVG connected to D1 (double arrows) is patent.

5 Curved MPR shows severe stenosis, from non-calcified plaque in LM, occlu-sion from both soft and calcified plaque in proximal LAD and severe stenosis from non-calcified plaque in proximal D1.

6 Curved MPR shows CX is small in caliber with no evidence of stenosis.

2 3 4 5 6

References[1] Schöndube H et al. Evaluation of a novel CT

image reconstruction algorithm with enhanced temporal resolution, Proc. SPIE 7961, 79611N (2011).



HISTORY

An 18-year-old male patient, with known Kawasaki’s disease, had a prior diagnosis of a right coronary artery (RCA) aneu-rysm by invasive angiography in 2007. The aneurysm was reported measuring 7.38 mm. He presented himself to the hospital for an assessment and to estab-lish a baseline CTA (Computed Tomogra-phy Angiography) to follow the progres-sion of the aneurysm.A coronary CTA scan was performed using a high pitch Flash Spiral mode, and six months later a follow-up examination was conducted.50 mg of oral Atenolol was administered to the patient an hour prior to the study. Nitroglycerine spray was also adminis-tered prior to scanning. The patient’s heart rate was 63–66 beats per minute at the time of both studies, and the patient tolerated the procedures with no compli-cations.The effective radiation dose was 0.34 mSv and 0.32 mSv, respectively in both studies.

DIAGNOSIS

This is a limited study to determine the progression of a previously identified proximal RCA aneurysm. Prior CT images showed a large aneurysm in the proximal RCA that arose 2 mm beyond the ostium measuring 8.3 mm in diameter (Figs. 1–2), with a mild layering of thrombus at the inferior margin (Fig. 3). All find-ings were unchanged in the image review on the follow-up CT exam (Fig. 4).

COMMENTS

A coronary aneurysm is rare, especially in young patients. Follow-up CT scans are necessary to monitor the progress of the aneurysm. Therefore, it is important to minimize the exposure dose to the patient. Flash scanning uses an ECG-triggered spiral scan to acquire the entire heart in one heart cycle. This provides a very short scan time (0.3 s) and a very low, consistent dose (0.3 mSv), as seen in these two follow-up CT examinations of the patient.

Case 5Diagnosis and Follow-up of RCA Aneurysm using Flash Scanning at 0.3 mSvBy Fahim H. Jafary, MD, FACC, FSCAI, Senior Consultant Cardiologist,* Jagajothi Devadoss, Senior Radiographer,* Erdie Q. Dizon, Radiographer,* Wynne Chia, Senior Application Specialist, CT**

** Department of Cardiovascular Medicine, Tan Tock Seng Hospital, Singapore** Siemens Healthcare, Regional Headquarters, Asia, Australia



Scan area Heart

Scan length 138 mm


Scan time 0.3 s

Tube voltage 80 kV


CTDIvol 1.26 mGy

DLP 24 mGy cm



Pitch 3.4


Slice width 0.6 mm

Temporal Resolution

75 ms

Reconstructionincrement

0.3 mm

Reconstruction kernel

B26f

Contrast

Volume 60 mL

Flow rate 6 mL/s

Start delay Test Bolus Peak Trigger + 15 secs


1 VRT images show a large aneurysm in the proximal RCA (baseline, arrow).

1

2 VRT images show a large aneurysm in the proximal RCA (baseline, arrow).

2

3 MPR image reveals a mild layering of thrombus at the inferior margin (arrow).

3

4 RCA aneurysm was unchanged in the follow-up examination.

4


Clinical Results Oncology


HISTORY

A 76-year-old man was admitted to our hospital complaining of progressive dys-pnea during exertion. He had a 50-year smoking history averaging 20 cigarettes per day. He had no known exposure to

asbestos. The chest auscultation revealed bilateral fine crackles in the lung bases. Laboratory data upon admission showed high levels of KL-6 (1283 U/mL) and SP-D (168 ng/mL). The results of an arterial

blood gas analysis were as follows: pH, 7.44; PaCO2, 34.8 Torr; and PaO2, 88.1 Torr on room air. The pulmonary function test revealed mixed-ventilatory impairment (FVC, 2.22 L, 69.6% of

Case 6Xenon Ventilation Imaging using Dual Energy CT in Combined Pulmonary Fibrosis and EmphysemaKeishi Sugino, MD, PhD,* Masahiro Kobayashi, MD,** Fumiaki Ishida, MD,* Naoshi Kikuchi, MD,* Nao Hirota, MD,* Keita Sato, MD,* Go Sano, MD,* Kazutoshi Isobe, MD, PhD,* Susumu Sakamoto, MD, PhD,* Yujiro Takai, MD, PhD,* Nobuyuki Shiraga, MD, PhD,** and Sakae Homma, MD, PhD*

**Department of Respiratory Medicine, Toho University Omori Medical Center, Tokyo, Japan**Department of Radiology, Toho University Omori Medical Center, Tokyo, Japan

1 Chest CT revealed paraseptal and centrilobular emphysematous lesions significantly in both upper lobes and reticular lesions with honeycombing formations bilaterally in the sub-pleural lower lobes.

1A 1B


Oncology Clinical Results



Scan area Chest

Scan length 345.0 mm

Scan time and delay 10.09 s


kV 80 kV / 140 kV

Effective mAs 230 / 95 mAs



Reconstructed slice thickness

2 mm

Increment 1.5 mm

Kernel D30f

predicted, FEV1 1.46 L, 65.2% of predicted, FEV1%, 65.8%,) with decreased diffusing capacity (DLco, 7.79 mL/min/mm Hg, 51.2% of predicted, DLco/VA, 2.11 L/s, 49.9% of predicted) and increased resi-dual volume (RV, 2.23 L, 123.2% of pre-dicted). A chest X-ray showed reticular shadows bilaterally in the lower lung fields. A chest CT revealed paraseptal and centrilobular emphysematous lesions, significantly in both upper lobes, and reticular lesions with honeycombing formations bilaterally in the sub-pleural lower lobes (Fig. 1).

DIAGNOSIS

Based upon the results of the increased serum inflammatory markers (KL-6 and SP-D), the mixed-ventilatory impairment with decreased diffusing capacity and the chest CT results, the patient was diag-

nosed with pulmonary emphysema asso-ciated with idiopathic pulmonary fibrosis (IPF), the so-called combined pulmonary fibrosis and emphysema (CPFE).

COMMENTS

3D Xenon-CT imaging showed large focal xenon ventilation defects in the upper lobes, and in contrast, slightly decreased xenon ventilation with several defects and volume loss with diffuse hypoventi-lation in the fibrotic lesions in the lower lobes. These results clearly demonstrated that the areas of ventilatory failure were to be found not only in the upper lobes, but also in the middle and lower lobes (Fig. 2, 3). The xenon-enhanced areas accumulated to 64.2% in the whole lungs (Fig. 2). Xenon-CT Imaging may be use-ful for differentiating lesions in cases of CPFE.

2, 3 3D Xenon-CT imaging and coronal MPR showed large focal xenon ventilation defects in the upper lobes, and in contrast, slightly decreased xenon ventilation with several defects and volume loss with diffuse hypoventilation in the fibrotic lesions in the lower lobes.

2 3

Clinical Results Oncology


Case 7Non-Hodgkin Lymphoma with Rare Metastases in the PancreasBy Harald Seifarth, MD, Christoph Schülke, MD, Johannes Wessling, MD

Department of Clinical Radiology, University of Muenster, Germany

HISTORY

A 24-year-old female patient was pre-sented to the emergency department with superior vena cava (SVC) syndrome. The thoracic CT scan showed a hypodense mass surrounding and compressing the SVC. The biopsy revealed a highly aggres-sive B-cell non-Hodgkin lymphoma (NHL). An abdominal CT was then performed for lymphoma staging.

DIAGNOSIS

The thoracic CT scan revealed a large, hypodense mediastinal mass, extending from the sternal notch to below the bifur-cation of the trachea. The left anonymous vein was occluded and stenoses of the right anonymous vein, the SVC (Figs.1 and 3), the right superior pulmonary vein and both pulmonary arteries (Fig. 2) were seen. The mass encased the supra aortic vessels, the aortic arch, the trachea and the esophagus. The trachea (Fig. 1) was stent-expanded.The abdominal CT scan revealed multiple extranodal involvements of both kid-neys (stage IV, Figs. 5 and 6). Addition-ally, several hypodense lesions could be detected in the pancreas (Fig. 4), result-ing in pancreatic duct distension in the corpus and tail. There was no apparent affliction of the retroperitoneal lymph nodes.


Scanner SOMATOM Definition Flash SOMATOM Definition Flash

Scan area Thorax Abdomen

Scan length 286 mm 420 mm

Scan direction Caudo-cranial Cranio-caudal

Scan time 4 s 9 s

Tube voltage 120 kV 120 kV

Tube current 86 mAs 104 mAs

Dose modulation CARE Dose4D CARE Dose4D

CTDIvol 5.8 mGy 8.5 mGy

DLP 177 mGy cm 307 mGy cm

Effective dose 2.48 mSv 4.6 mSv

Rotation time 0.28 s 0.5 s

Pitch 0.6 0.6

Slice collimation 128 x 0.6 mm 128 x 0.6 mm

Slice width 1.0 mm 1.5 mm

Reconstruction increment 0.5 mm 0.7 mm

Reconstruction kernel B30 B20

Contrast

Volume 90 mL 100 mL

Flow rate 2.5 mL/s 3 mL/s

Start delay 45 s 85 s

COMMENTS

B-cell NHL is the most common lymphoma histotype. The affliction of the retroperi-toneal lymph nodes and the kidneys is commonly seen during staging. However an involvement of the pancreas is rare and reported in only 2% of patients with NHL. CT imaging, especially with multi-

planar reformations, can clearly demon-strate the multiple lesions and structures involved. In this case, the metastases in the parenchyma of the pancreas and the slight ectasia of the distal duct could be clearly visualized.


2 An oblique MPR image showed the stenoses of both pulmonary arteries (arrows).

1 An axial image showed a mediastinal mass encasing the aorta, the trachea and the SVC. The SVC was nearly occluded (arrow) and the trachea is stented.

6 An oblique MPR image demonstrated multiple hypodense lesions in the left kidney (arrows), consistent with the NHL-manifestation.

5 An axial image presented the lymphoma manifestation in the pancreas (arrow) and in the right kidney (dashed arrow).

5 6

1 2

3 An oblique MIP image demonstrated the stenosis of the SVC (arrow) and the azygos vein (dashed arrow).

4 An oblique MPR image showed the lymphoma manifestation in the pancreas (arrow).

3 4

Clinical Results Neurology


Case 8Diagnosis of an Intracranial Dual-Aneurysm using the new SOMATOM PerspectiveBy Johann Steffens, MD

Department of Radiology, Israelitisches Krankenhaus, Hamburg, Germany

HISTORY

An 84-year-old female patient with a known small left internal carotid aneurysm was admitted to the hospital due to a sudden onset of ptosis and a lack of right eye abduction.

DIAGNOSIS

CT images showed a large aneurysm, measuring 2.9 cm in diameter, at the right internal carotid artery (ICA) siphon, compressing the right orbital apex.

A smaller aneurysm, measuring 1 cm in diameter, was also seen at the left internal carotid artery siphon. There was no evidence of intracranial bleeding.

COMMENTS

CT Angiography (CTA) is accurate and reliable for the detection and character-ization of intracranial aneurysms. In this case, CTA demonstrated that the newly developed large aneurysm of the right

carotid artery siphon compressing the orbital apex was responsible for the symptoms. The complete head and neck region was acquired in just 4 seconds using the new 128-slice SOMATOM Perspective. The CT data set could be clearly visualized and demonstrated in any desired plane in VRT (Volume Rendered Technique) or curved MPR (Multiple Planar Reformation) images.


Scanner SOMATOM Perspective

Scan area Head and neck Rotation time 0.6 s

Scan length 316 mm Slice collimation 64 x 0.6 mm

Scan direction Caudo-cranial Slice width 0.75 mm

Scan time 4 s Reconstruction increment 0.4 mm

Tube voltage 110 kV Reconstruction kernel I 30

Tube current 68 eff. mAs Contrast

CTDIvol 5.08 mGy Volume 50 mL

DLP 224.45 mGy cm Flow rate 3 mL/s

Effective dose 1.5 mSv Start delay 12 s


Neurology Clinical Results

1 2

3 VRT image reveals a small aneurysm at the left ICA siphon (arrow).

3

1 Curved MPR image shows a large aneurysm at the right ICA siphon.

4

4 Oblique MPR image presents the right orbital apex compressed by the aneurysm.

2 Curved MPR image reveals a small aneurysm at the left ICA siphon (arrow).

Clinical Results Neurology


Case 9Whole Brain Perfusion CT Reveals Acute Misery PerfusionBy Jyoji Nakagawara, MD

Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan

1–6 CBF, MTT and CBV images acquired before (Figs. 1–3) and after (Figs. 4–6) treatment.

1 2 3

4 5 6


HISTORY

An 84-year-old patient was referred to the hospital with transient left-sided hemiparesis. A cervical echo-arteriogram revealed a stenosis of the right cervical carotid artery. The hemi-paresis gradu-ally progressed after admission. MRI was contra-indicated, since the patient had a pacemaker. Instead a whole brain perfusion CT and an IMP-SPECT1 were ordered.

DIAGNOSIS

The cervical CT Angiography showed severe stenosis of the right internal carotid artery (ICA, Fig. 8A). The whole brain perfusion CT demonstrated a criti-cal perfusion state of the right cerebral hemisphere – a decrease of Cerebral Blood Flow (CBF, Fig. 1), an increase of Cerebral Blood Volume (CBV, Fig. 3) and a prolongation of Mean Transit Time (MTT, Fig. 2), which definitely suggested an acute misery perfusion state. The patient was diagnosed with a progressing stroke due to severe stenosis of the right ICA. The IMP-SPECT also showed reduced blood flow to the same area (Fig. 7). An emergency carotid artery stenting (CAS) was performed. After the CAS treatment, the left-sided hemiparesis immediately improved and then disappeared. An emergency treatment of the left internal


Scanner SOMATOM Definition AS+

Scan area Whole brain

Scan length 96 mm

Scan time 45 s

Scan direction Caudo-cranial and cranio-caudal

Tube voltage 80 kV


Rotation time 0.3 s


Reconstructed slice thickness

5 mm

Increment 5 mm

Kernel H22f

CTDIvol 198.7 mGy


Contrast

Volume 30 mL iodine + 20 mL saline

Flow Rate 6 mL/s

Start delay 5 s

carotid artery stenosis was considered unnecessary at the time. The follow-up whole brain perfusion CT, on day one after CAS treatment, demonstrated marked improvement of the cerebral perfusion of the right cerebral hemisphere (Figs. 4–6). The patient was discharged one month later, and scheduled for out-patient fol-low-ups.

COMMENTS

Patients suffering from an ischemic penumbra with abrupt occlusion of the cerebral arteries in embolic stroke and acute misery perfusion with hemody-namic cerebral ischemia could be candi-dates for acute revascularization proce-dures. Up to now, image modality was not sufficient to confirm the diagnosis of an acute misery perfusion with hemody-namic cerebral ischemia in routine clinical practice. In patients with progressing strokes, whole brain perfusion CT allows the identification of a critical perfusion state such as an acute misery perfusion of the affected cerebral hemisphere.Emergency CAS treatment has not yet been established in the Japanese stroke management guidelines. However, whole brain perfusion CT could reveal a critical perfusion state, such as an acute misery perfusion, and could therefore be useful

for the indication of emergency thera-peutic intervention within a narrow time window.

7 IMP-SPECT1 confirms perfusion CT findings. 8 Stenosis could be visualized in both right (Fig. 8A) and left (Fig. 8B) internal carotid arteries.

7 8A 8B

1 IMP-SPECT: single photon emission computed tomography (SPECT) using N-isopropyl-(iodine-123)p-iodoamphetamine (123I-IMP)

Clinical Results Acute Care

HISTORY

A 61-year-old female patient was admit-ted to the hospital suffering from a thun-derclap headache, followed by a rapid deterioration of her consciousness level and then coma. Non-enhanced CT (Fig. 1) and CT Angiography (CTA), upon admis-sion, showed an acute subarachnoid hemorrhage (SAH) due to an anterior communicating aneurysm (Hunt-Hess grade 3, Fisher grade 3). The aneurysm was promptly secured by surgical clipping; however, the intubated patient remained in a deep coma after the initial event. Therefore, a neurological evaluation of her consciousness level and the detection of new focal deficits were not possible.

DIAGNOSIS

An initial CT Perfusion (CTP, Fig. 3A) scan was performed on day 4 for the evaluation of delayed cerebral ischemia (DCI) and vasospasm. There was severe reduction in tissue perfusion in the anterior watershed white matter of the right hemisphere (mean transit time

[MTT] > 7 s, cerebral blood flow [CBF] < 47 mL/100 mL/min). Digital subtrac-tion angiography (DSA, Fig. 2A) showed severe proximal vasospasms. Endovas-cular therapy was initiated with an intra-arterial nimodipine infusion (Fig. 2B). A follow-up CTP scan (Fig. 3B) revealed a normalized perfusion of the former ischemic right hemisphere (MTT < 4 s, CBF > 65 mL/100 mL/min). The patient subsequently recovered while retaining minor deficits.

COMMENTS

It is necessary to monitor patients with SAH to promptly identify treatable and reversible causes of neurological deterio-ration. DCI is defined as the delayed development of a focal neurological deficit and/or cerebral infarction due to SAH.[1] Clinical monitoring for DCI con-sists of repeated neurological assess-ments, however, not all ischemic events are detectable during a clinical examina-tion.

Case 10CT Perfusion Identifi es Delayed Cerebral Ischemia after Subarachnoid HemorrhageBy Andre Kemmling, MD, Ludger Feyen, MD

Department of Clinical Radiology, University Hospital, Muenster, Germany

DSA is considered the gold standard for the detection of arterial vasospasm. CTA has a high specificity and a negative pre-dictive value of 95–99%, and is therefore an increasingly useful screening tool to limit the use of DSA. Unlike CT perfusion, it does not allow quantitative assessment of brain perfusion required for metabolic demands of the tissue. Also, not all patients with angiographic vasospasm manifest clinical symptoms.[2] A combi-nation of CT protocols (non-enhanced + CTA + CTP) has the highest predictive value for DCI monitoring. The combina-tion of delayed MTT (> 7 s) and visible vasospasms on CTA is highly accurate in selecting patients that need an endovas-cular intervention for vasospasm. [3, 4] Furthermore, CBF asymmetry between hemispheres is an independent predictor of DCI. [5] Early deficits in CT perfusion identify patients with subsequent DCI and their detection constitute image-guided management of SAH patients. [6, 7]Dynamic CT perfusion imaging allows sen-sitive evaluation of DCI and vasospasms

1 Non-enhanced CT on admission showed subarachnoid hemorrhage.

2 DSA image showed severe proximal vasospasm before treatment (Fig. 2A). Follow-up DSA demonstrated normalized perfusion after treatment (Fig. 2B).

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in the whole brain of patients with SAH. It is increasingly feasible due to drasti-cally lowered radiation doses, achievable with the latest available CTP protocols and modern CT scanners. The thin slice (1.5 mm) 4-dimensional dataset (96 mm brain coverage) in this case allowed sharp multiplanar reformatting within the syngo VPCT Neuro application. A newer syngo.via application (CT Dynamic Angio) can process the same VPCT dataset to screen-time resolved maximum intensity projections and to assess arrival time of enhanced collaterals (Fig. 4).Multimodal CT imaging and particularly CT perfusion have become valuable tools for detecting and monitoring vasospasms and delayed cerebral ischemia. CT per-fusion may become pivotal for image-guided decision making for interventional therapy.

References[1] Vergouwen MDI, Hemorrhage PitIM-DCCotCCMoS.

Neurocritical Care 2011;15:308-311.[2] Greenberg ED, et al. American Journal of Neuroradiology

2010;31:1853-1860.[3] Wintermark M et al. Cerebrovascular diseases

(Basel, Switzerland) 2008;26:163-170.[4] Wintermark M,et al. AJNR American Journal of Neuroradiology

2006;27:26-34.[5] Washington CW, Zipfel GJ, Hemorrhage PitIM-DCCotCCMoS.

Neurocritical Care 2011;15:312-317.[6] Sanelli PC et al.Neuroradiology 2011;53:425-434.[7] van der Schaaf et al. Stroke 2006;37:409-413.



Scan mode Adaptive 4D Spiral

Scan area Head

Scan length 96 mm

Scan direction Cranio-caudal / caudo-cranial

Scan time 45 s

Tube voltage 80 kV



Slice collimation 32x 1.2mm

Slice width 10 mm

Reconstruction

kernel H20f

CTDIvol 256.38 mGy

DLP 3036 mGy/cm

Effective Dose 6.4 mGy cm

Contrast Ultravist® 370

Volume 30 mL contrast agent + 50 mL NaCl

Flow 6 mL/s

3 Initial CTP images showed severe DCI in the right hemisphere (Fig. 3A).A follow-up CTP scan revealed a normalized perfusion of the former ischemic right hemisphere (Fig. 3B).

4 CT Dynamic Angio collateral assessment: time resolved collateral filling in early arterial phase (right vs. left hemisphere).

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Case 11Time Resolved CT Angiography in Patients after EVARBy Claudia Andres, MD, Borek Foldyna, MD, Christian Lücke, MD, Matthias Gutberlet, MD, Lukas Lehmkuhl, MD

Department of Diagnostic and Interventional Radiology, University of Leipzig, Heart Center, Leipzig, Germany

HISTORY

The patient presented himself for a follow-up examination after an endo-vascular implantation of an aorto-biiliacal Y-stentgraft due to an extant infrarenal aortic aneurysm in June 2004. The pre-vious examination showed an increase in the size of the aneurysm sac (to max. 57 mm) and an endoleak type IB. The endoleak was then shut out with an

atrium stentgraft of the left common iliac artery. In the current contrast media duplex ultrasound, there was no hint of an endoleak or a perforation. For further assessment, a dynamic CT Angiography of the abdominal aorta was performed.

DIAGNOSIS

The dynamic CT Angiography of the abdominal aorta demonstrated an un-obtrusive stent prosthesis. Compared to the examination before stent implan-tation, the aneurysm sac showed a con-stant width with its maximal diameter being 57 mm. In the ventral part of the aneurysm sac, a type IIA endoleak was clearly defined, fed from the inferior mesenteric artery.

1–2 Axial (Fig. 1) and VRT (Fig. 2) images showing the different points in time after reaching the bolus tracking threshold. (Fig. 1A/2A) 12 s p.t.: significantly enhanced stentgraft, no endoleak visible.(Fig. 1B/2B) 17 s p.t.: well-enhanced stentgraft, and a type IIA endoleak in the ventral aneurysm sac could be visualized. (Fig. 1C/2C) 32 s p.t.: no longer enhanced stentgraft, however a well-enhanced endoleak.

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Acute Care Clinical Results

References[1] Lehmkuhl et al., Dynamic computed tomogra-

phy angiography (dCTA) after abdominal aortic endovascular aneurysm repair (EVAR): Differ-ences in contrast agent dynamics in the aorta and endoleaks – Preliminary results J Vasc Interv Radiol. 2012 Apr 9. [Epub ahead of print]



Scan area Abdomen

Scan length 283 mm

Scan direction Cranio-caudal / caudo-cranial

Scan time 54 s

Total scan phase s/steps 10

Temporal resolution 5 s

Tube voltage 80 kV


CTDIvol 28.47 mGy

DLP 629 mGy cm




Slice width 1.5 mm


Contrast

Volume Contrast 80 mL

Flow rate 4 mL/s

Volume Saline 40 mL

COMMENTS

Contrary to the contrast media ultrasound examination, the dynamic CT Angiography helped determine the existence of an endoleak and delivered an explanation for the missing reduction in size of the aneurysm sac. Dynamic CTA may aid the physician in detecting the flow patterns of the different endoleaks by using mul-tiple acquisitions at different time points and thereby increases both the sensitivity and the specificity for the detection of endoleaks. The gathered information concerning the dynamic of endoleaks considerably eases classification.[1]

3 Relative time density curves in the aorta (curve 1, yellow), the endoleak (curve 3, orange) and the aneurysm sac (curve 2, green) together with the respective cross-sections where the ROIs were placed: aorta (Fig. 3B), endoleak (Fig. 3C), aneurysm sac (Fig. 3D).

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HISTORY

A 44-year-old male patient presented himself to the hospital due to worsening shortness of breath on exertion for the past 6 months. A CT scan with contrast was requested to rule out pulmonary emboli (PE).

DIAGNOSIS

The post-contrast CT scan revealed good opacification of the pulmonary arteries. The images showed extensive right-sided pulmonary emboli involving the posterior segment of the right upper lobe (arrow, Fig. 1A) and all segments of the

right lower lobe (arrowheads, Figs. 1–2). Further thrombus could be visualized in the posterior segment of the left upper lobe (dashed arrow, Fig. 2B). These areas of thrombus are incompletely occlusive and are slightly eccentric, which may

Case 12Diagnosis of Sub-acute Pulmonary Emboli using Flash Mode, SAFIRE and 100 kVBy Savvas Nicolaou, MD,* Jennifer Powell**, Karl Krzymyk***

*** Vancouver General Hospital, Department of Emergency Trauma Radiology, Vancouver, Canada*** CS Applications, Siemens Healthcare, Canada*** CT Collaborations USA, Siemens Healthcare, USA

1–2 Images showed extensive bilateral pulmonary emboli involving the posterior segment of the right upper lobe (arrow, Fig. 1A), all segments of the right lower lobe (arrowheads, Figs. 1–2) and the posterior segment of the left upper lobe (dashed arrow, Fig. 2B).

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Acute Care Clinical Results

represent sub-acute pulmonary emboli. There was no evidence of right heart strain nor of any mediastinal adenopathy or pericardial effusion.

COMMENTS

PE can be life threatening, and PE patients generally have difficulties hold-ing their breath during a CT scan. Using Flash mode, the image acquisition of the entire thorax can be completed in less than one second (in this case 0.6 sec-onds). Therefore, motion artifacts can be avoided even without breath-hold. Since regular follow-up CT scans are necessary for PE patients, radiation dose reduction is essential. In this case, the patient’s effective dose was reduced to 1.46 mSv by combining the Flash mode, SAFIRE (Sinogram Affirmed Iterative Reconstruction) and 100 kV.

3 Volume-rendered images demonstrated good opacification of the pulmonary arteries which clearly revealed the thrombus in the posterior segments of the right lower lobe (arrows).



Scan area Thorax Pitch 3.2

Scan length 287 mm Slice collimation 128 x 0.6 mm

Scan direction Cranio-caudal Slice width 0.75 mm

Scan time 0.67 s Reconstruction increment 0.5 mm

Tube voltage 100 kV Reconstruction kernel I26f

Tube current 289 eff. mAs Contrast

Dose modulation CARE Dose4D Volume 70 mL (Optiray 350)

CTDIvol 3.01 mGy + 30 mL saline

DLP 104 mGy cm Flow rate 4.5 mL/s

Effective dose 1.46 mSv Start delay 18 s


3

Clinical Results Pulmonology


HISTORY

An 82-year-old female patient with a long history of asthma was presented to the radiology department complaining of a persistent cough, which did not respond to inhalers and standard asthma therapy. A High Resolution CT (HRCT) was requested to evaluate bronchiectasis and interstitial lung disease.A standard non-contrast volumetric CT was performed, followed by a dynamic volumetric expiratory imaging to evaluate a suspected tracheomalacia.

DIAGNOSIS

The dynamic volumetric expiratory imaging demonstrated significant

dynamic airway collapse (Figs. 1–3) throughout the visualized airways, thus establishing the diagnosis of tracheo-bronchomalacia.

COMMENTS

Expiratory collapse of the central airways, termed tracheomalacia, is an important and often unrecognized cause of chronic cough. Traditional airway imaging assess-ment includes a series of selected axial images taken in end-expiration to evalu-ate parenchymal air trapping and tracheo-bronchial airway collapse. End-expiratory imaging is limited in the evaluation of airway collapse as it fails to capture the

important dynamic nature of an airway collapse. The markedly improved tempo-ral resolution of the Flash CT technology enables volumetric evaluation of the chest and central airways in imaging times of less than 1 second. When synchronized with the beginning of the patient’s active expiratory phase, Flash CT scanning enables low dose (0.66 mSv) volumetric imaging of the airways in the times used for a FEV-1(Forced Expiratory in 1 second), a standard metric for pulmonary function testing.In this case, the ultra fast acquisition and low dose imaging capabilities of the Flash CT technology enabled the dynamic physiologic evaluation of the airways.

Case 13Dynamic Volumetric Expiratory Imaging for Diagnosis of Tracheobronchomalacia using Flash CT ScanningBy Kianoush Ansari Gilani, MD, Leslie Ciancibello, RT, and Prof. Robert C. Gilkeson, MD

University Hospital Radiology, Cleveland, Ohio, USA


Scanner SOMATOM Definition Flash Scanner SOMATOM Definition Flash

Scan area Thorax (standard) Scan area Thorax (expiratory)

Scan length 24.2 mm Scan length 14 mm, thoracic inlet to carina

Scan direction Cranio-caudal Scan direction Cranio-caudal

Scan time 3 s Scan time 0.9 s

Tube voltage 120 kV Tube voltage 120 kV

Tube current 273 eff. mAs Tube current 40 Eff. mAs

Dose modulation CARE Dose4D Dose modulation CARE Dose4D

CTDIvol 17.96 mGy CTDIvol 2.2 mGy

DLP 532 mGy cm DLP 47 mGy cm

Rotation time 0.5 s Rotation time 0.28 s

Pitch 1.2 Pitch 3

Slice collimation 128 x 0.6 mm Slice collimation 128 x 0.6 mm

Slice width 2 mm Slice width 2 mm

Spatial Resolution 0.33 mm Spatial Resolution 0.33 mm

Reconstruction increment 1 mm Reconstruction increment 1 mm

Reconstruction kernel B31f Reconstruction kernel B31f


Pulmonology Clinical Results

1–3 Comparison of images acquired in inspiratory phase (A) and expiratory phase (B) demonstrates the normal airways (A) and the tracheomalacia (B) in axial images (Fig. 1), fly-through images (Fig. 2) and VRT images (Fig. 3).

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Lung Ventilation Imaging with Xenon Dual Energy CTDue to the high prevalence of lung disease worldwide, specialists are always looking for new simple and patient-friendly methods for lung imaging.

By Katharina Otani, PhD, R&C Department, HIM, Siemens Japan KK, Tokyo, Japan

Chronic obstructive pulmonary disease (COPD) is a serious, incurable disease. Yet, treatment can slow its course. Prof. Norinari Honda, Chairman of the Depart-ment of Radiology, Saitama Medical Cen-ter, Saitama Medical University proposed that Xenon Dual Energy CT (DECT) ven-tilation imaging of the whole lung in the single-breath technique may be faster than the multiple-breath technique and a useful diagnostic tool for early detection of COPD and other lung diseases.

Imaging methods using xenon gasIn Japan, repeated inhalation of stable xenon-oxygen mixtures with up to 35% xenon for xenon-enhanced CT brain imag-ing is approved by Japanese pharmaceu-tical law and covered by national health insurance for cerebral blood flow mea-surement. Radioactive isotopes of xenon have been used in molecular imaging as a radiotracer for the evaluation of pul-monary ventilation such as in dynamic pulmonary Single Photon Emission Com-puted Tomography (SPECT) imaging. For this, the patient usually inhales a xenon-oxygen mixture in a closed circuit for several minutes (wash-in) to reach equi-librium and finally exhales the xenon mixture through a one-way valve inhaling ambient air for several minutes (wash-out). A gamma camera continuously acquires data during wash-in, equilibrium and wash-out phases. Maps of ventilation rate can be obtained based on the Kety model, as long as the lung function is not too severely impaired. In Dual Energy

CT multiple-breath technique, stable non-radioactive xenon is used as a contrast medium. By scanning a single slice of the lung, wash-in and wash-out of xenon is monitored similarly to SPECT imaging. The whole lung is only scanned once during breathhold after equilibrium is reached. Several studies have demonstrated that this technique may be useful for evaluat-ing COPD and asthma.

Single-breath technique for Xenon Dual Energy CTSaitama Medical University, Saitama Medi-cal Center, Kawagoe, Saitama prefecture

in Japan installed a SOMATOM Definition Flash CT scanner in March 2010. Prof. Norinari Honda, who specializes in chest radiology and nuclear medicine, thought that a single-breath technique may be applicable to Xenon DECT for obtaining pulmonary ventilation images. This tech-nique would have the advantage of short-ening the examination time and reduc-ing the patient’s exposure to xenon gas, reducing side effects and increasing xenon concentration to improve image quality above the multiple-breath tech-nique. Prof. Honda designed two phan-tom experiments to evaluate the tech-

Prof. Norinari Honda, Chairman of the Department of Radiology, Saitama Medical Center, Saitama Medical University reported that Xenon Dual Energy CT ventilation of the whole lung in single-breath technique may depict ventilation.

1 Xenon Dual Energy CT ventilation images acquired in single-breath technique after inhalation of 41% (Figs. 1 A, B), 60% (Figs. 1 C–E), 80% (Figs. 1 F–H) xenon mixed with 59, 40, 20% oxygen respectively. A maximum enhancement was measured for the highest xenon concentration.

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nique and confirmed feasibility in four volunteer scans. [1] In the first phantom experiment, a bag filled with xenon-oxygen mixtures of various concentra-tions was scanned to confirm the linear dependence of xenon concentration and Hounsfield (HU) values. In a second phantom experiment Prof. Honda’s group demonstrated that one time simultane-ous inspiration of a xenon-oxygen mix-ture with 35% xenon injected into tubes with different apertures appears on CT images as inhomogeneous xenon distri-bution, similar to how xenon may dis-tribute in the lung.

Beyond 35% Xenon concentrationsSince the air that we breathe contains only 20% oxygen, Prof. Honda presumed that mixtures of up to 80% xenon and 20% oxygen may be feasible for Xenon DECT. At the 4th Japanese Society of Pulmonary Functional Imaging meeting, [2] Prof. Honda et al presented the case report of a healthy volunteer who under-went Xenon DECT scans in single-breath

References[1] Honda N et al. Radiology 2012; 262: 262-268[2] The 4th Japanese Society of Pulmonary Func-

tional Imaging meeting, 10-12 February 2012, Otsu, Shiga, Japan, http://jspfi4.umin.ne.jp/ (Japanese)

[3] Yanagita H, et al. Prediction of postoperative pulmonary function by single-breath dual energy xenon CT: a preliminary report. Insight into imaging (ECR2012 Book of abstracts) 2012:3 Suppl 1;B-0030

[4] The 4th Japanese Society of Pulmonary Func-tional Imaging meeting, 10-12 February 2012, Otsu, Shiga, Japan, http://jspfi4.umin.ne.jp/ (Japanese)

www.saitama-med.ac.jp/kawagoe/ (Japanese)

technique after inhalation of five xenon-oxygen mixtures containing 35, 41, 61 and 80% xenon. Prof. Honda measured a maximum enhancement of 49.2 HU (standard deviation SD 9.31) for the high-est xenon concentration compared to 36.2 HU (SD 6.84), and 40.2 HU (SD 9.23) after 41 and 60% xenon inhalation respec-tively as shown in Fig. 1. No side effects were reported except for a transient mild dizziness, but a rigorous clinical study would be needed to confirm the safety before xenon mixtures of more than 35% could be used in clinical routine.

Clinical applicationsXenon DECT in single-breath technique gathered much attention at the 4th Japa-nese Society of Pulmonary Functional Imaging meeting. [2] Ms. Hisami Yanagita working with Prof. Honda presented preliminary results of a clinical study on whether lung function after lobectomy of lung cancer patients scheduled for surgery could be estimated on Xenon DECT images before surgery [3] and received a poster prize. Another poster

prize went to Keishi Sugimoto, MD et al, Toho University Omori Medical Center, Tokyo, for his report on Xenon DECT for differential diagnosis of combined pulmonary fibrosis and emphysema. [4] More studies are expected to be reported soon.

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Discovering the Mysteries of Our Ancestors With Dual Energy CTThomas Henzler, MD,* Heather Gill-Frerking,** Wilfried Rosendahl, PhD,** and Christian Fink, MD*

** Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany

** Reiss-Engelhorn Museums, Mannheim, Germany

Why was a nail driven into a person’s skull 2000 years ago? How can we learn about the diseases suffered by South American women in the past millennia? By scanning mummies with Dual Energy Computed Tomography (CT), a group of researchers in Mannheim has been able to unlock some of the mysteries of how our ances-tors lived.Scientists were only first able to unwrap the secrets of mummified bodies without destroying them in the nineteenth cen-tury. In 1895, Wilhelm Conrad Röntgen discovered “a new kind of ray” [1] which we now refer to as the X-ray; and X-ray images of mummies were published a year later. [2]Since then, different medical imaging techniques have been used to gather vast quantities of data on mummies and the embalming process. Researchers from Mannheim, Germany used the SOMATOM Definition with Dual Energy CT technique to divulge the past of the mummies examined in the German Mummy Project. To date, this group of researchers has scanned 20 mummies and skulls from regions around the world.Dual Energy CT performs the scan at two different energy levels which helped the scientists to differentiate between the materials of the body, bandages and burial objects and create an impression of how our ancestors looked many years ago.Beyond material differentiation, Dual Energy CT can reduce metal artifacts. Fig. 1 shows a Roman skull penetrated by a long nail, which was presented as a Celtic trophy. More than 2000 years later, the skull was found filled with pebbles in a fountain of a Celtic farm near Koblenz in Germany. Researchers used mono-energetic images at energy levels from

40 kV to 180 kV to analyze the skull.Although information on the culture and habits of our ancestors is intriguing for anthropologists, medical researchers can also learn more about pathologies from

a specific period. Dual Energy CT images showed calcifications typical of arterio-sclerosis in the femoral vessels of an approximately 1000-year-old female mummy found in South America (Fig. 2).

1E

1 This trophy – a skull penetrated by a long nail – was scanned with Dual Energy CT. Among the monoenergetic images generated (Figs. 1A–D) the image at 180 kV (Fig. 1D) delivered a precise image of the object despite the metallic implant (Fig. 1E).Courtesy of University Medical Center Mannheim, Germany

2 These Dual Energy CT images show calcifications (arrows) in the femoral vessels of a mummy found in South Africa (Figs. 2A–B). With Dual Energy plaque identification soft-ware these calcifications could be characterized as typical of arteriosclerosis (Fig 2B).Courtesy of University Medical Center Mannheim, Germany

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20 kV 40 kV

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160 kV 180 kV

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www.umm.uni-heidelberg.de/inst/ikr/pdf/2011_12_Anthropologie.pdf (German)

www.g-o.de/dossier-detail-570-4.html (German)

www.rem-mannheim.de[1] Röntgen W. Ueber eine neue Art von Strahlen. Sitzungsberichte der Wuerzburger Physik.-medic. Gesellschaft, Wuerzburg, 1895.

[2] König C., 14 Photographien von Röntgen-Strahlen aufgenommen im Physikalischen Verein zu Frankfurt a. M., Frankfurt, 1896.

Research Clusters Enable Transfer of Basic Research to Clinical RoutinePart I. Beating Cancer – Treating Individuals

By Monika Demuth, PhD, Computed Tomography, Siemens Healthcare, Forchheim, Germany

At the time, risk factors such as lack of exercise or high-fat diet correlated with arteriosclerosis today were not present, which can help us to understand modern diseases in pathophysiological research.Dual Energy CT is also used in clinical routine today to differentiate soft-tissue masses or calculate virtual non-contrast CT images based on scans using contrast medium. As can be seen in the example of arteriosclerosis, the research by the

German Mummy Project not only helps us to understand our ancestors’ past but also establishes correlations between historic and modern diseases.

People and diseases have something in common: no two individuals are identical. As our knowledge of specifi c diseases, such as tumors, improves it is becoming increasingly apparent that often gener-alized oncological treatment regimes do not serve the individual patient well enough. Diseases and their prescribed treatments can trigger discrete effects in different patients. This is because the effects of a particular cancer therapy depend on a host of factors, including the tumor’s individual biological charac-teristics (biomarkers), the stage of the disease, patient age and physical condi-tion, and many others. These factors inform the development of modern, indi-vidualized cancer therapies. The goal is to achieve the optimal balance for each patient; in other words, a compromise including a highly effective treatment for the individual with the lowest possible level of side effects. An ambitious goal for modern medical research.

Combining Professional ExpertiseThe German Federal Government offers structural funding for leading-edge tech-

nology in the country, in so-called “clus-ters”, to facilitate the optimal networking of professional expertise. The intention is to produce additional scientific benefits and accelerate market launches of inno-vative products, processes, and services. The Government has already organized several competitions to encourage leading-edge clusters to develop novel approaches to a long-term, regional or national cluster strategy. Prof. Konstantin Nikolaou, MD and Clemens Cyran, MD, radiologists at the University Clinic affili-ated to the Ludwig Maximilian University (LMU) of Munich, are involved in a pro-ject run by the Munich Biotech Leading-Edge Cluster, known as “m4”. The “m4” project is one of several high-end clusters in Bavaria and is funded by the Federal Ministry of Education and Research and by the Bavarian State Ministry for Trade, Transport and Technology. The key focus of the Munich cluster is the dedicated development of medical treatments for personalized oncological medicine. The cluster itself is a collaboration between biotechnology and pharmaceutical com-panies, research institutes and institutions affiliated to Munich’s two leading univer-

sities, LMU and TUM (Technical University of Munich) and their University Clinics, the Munich Helmholtz Center and the city’s Max Planck Institute. The “m4” pro-ject is coordinated by BioM Biotech Cluster Development GmbH.In 2009, the “m4” initiative won one such leading-edge cluster competition enab-ling its various research groups to start work on over 30 projects centered around the theme of “Personalized Medicine in Oncology”. One of the medical projects run by “m4” – “Non-invasive Monitoring of Molecular Therapies in Oncology:

University Clinic Munich, Campus Großhadern plays a main role within the “m4” project.

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Bench to Bedside Establishment of Bio-markers in Therapy Response” – is super-vised by the aforementioned physicians at the Institute for Clinical Radiology, part of the University Hospital in Großhadern Munich (Director: Prof. Reiser, MD). Siemens always advocates the importance of such fundamental research. As a result, the company has made significant con-tributions to this influential, prestigious project and supports the concerted efforts through the provision of technical exper-tise and considerable financial assistance.

The ProjectIn the past, the efficacy of traditional, cytotoxic tumor therapies, such as chemo-therapy and radiotherapy, was usually monitored exclusively on the basis of changes in tumor size and morphology. Precisely defined algorithms are applied in order to describe tumor response based on its size change during therapy. How-ever, molecular cancer therapies, which effectively inhibit tumor growth and restrict blood circulation to the tumor as opposed to destroying it cytotoxically,

are now becoming increasingly popular. Conventional tumor monitoring, which measures possible size alterations, is no longer sufficient in many cases when so-called anti-angiogenic pharmaceutical therapies are prescribed. Since these therapies are not primarily cytotoxic, instead reducing the microcirculation and metabolism of tumor tissue, the success of a treatment can be determined chiefly via an analysis of these two effects. As a result, when assessing therapeutic success, it is advisable to use functional and molecular imaging procedures in addition to established morphological imaging. This allows the rating of factors such as oxygen supply, perfusion and diffusion in the tumor tissue for an early-stage evaluation of therapy response (ideally a few days after start of the treat-ment in question). Responders can, therefore, be differentiated from non-responders effectively. Functional imaging procedures appear better suited to the presentation of the therapeutic success of molecular treatments and the devel-opment of various imaging biomarkers

(prognostic imaging biomarkers, predic-tive imaging biomarkers, and therapy response imaging biomarkers) than their established, purely morphological coun-terparts.Animal experiments performed to date by researchers at the University Hospital in Großhadern as part of the “m4” project emphasize the potential of functional imaging procedures with dynamic, con-trast-enhanced magnetic resonance imaging (MRI), computed tomography (CT) and contrast-enhanced ultrasound for tumor imaging. Still, further studies are needed to apply the technology to actual clinical practice. With this in mind, the project is currently focusing on the standardization of perfusion imaging, the systematic, reproducible analysis of kinetic data, and the highly accurate definition of the “region of interest” in which tissue microcirculation is measured. One project, for example, assesses the validation of recorded non-invasive MRI and CT imaging biomarkers against immunohistochemical assessment. The aim is to investigate the individual biological significance of perfusion parameters compared with the actual mechanisms at cellular level. Ultimately, the results of the animal experiments will be applied in a clinical setting. Here, the consideration of personalized molecular therapies already approved for human use and the reduction of costs and risks in applying this new treatment form are essential. Should the pharmaceutical prove ineffective, the use of correct imag-ing procedures and techniques could result in a swifter termination of treat-ment than is normally the case with cur-rent conventional morphological follow-ups. This could reduce adverse side effects for patients. Ideally, in the future it will be possible to evaluate the success or failure of molecular tumor therapies at an early stage so as to be able to adjust and complement the various treat-ment concepts quickly and individually.Unsurprisingly, high-function, dynamic, contrast-enhanced screenings of this nature require state-of-the-art equipment. Researchers working on the leading-edge cluster project use Siemens MAGNETOM® Verio 3 Tesla MRI scanners and the high-

1 MR perfusion maps (plasma flow, mL/100mL/min). Experimental, subcutaneous prostate carcinomas in rats with sorafenib therapy prior to treatment (day 0) and after seven days of therapy. A significantly reduced plasma flow in the prostate carcinoma allograft with sorafenib therapy was observed between days 0 and 7.

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end ultrasound system, Siemens ACUSON S3000™, which are used for both animal experiments and patient screenings. CT screenings use the Siemens SOMATOM® Definition Flash scanner.

Project ObjectivesIn the first three-year project phase, Prof. Konstantin Nikolaou, MD, Clemens Cyran, MD, and their scientific team will conduct pre-clinical trials on tumor models in rats. In one model, for example, a colon carcinoma implanted subcutaneously is treated with regorafenib, an angiogenesis inhibitor. The tumor is examined via CT perfusion before and after treatment and the results correlated with an immu-nohistochemical tumor analysis. This initial project phase aims to optimize both CT methods and the standardized quantification of tumor perfusion as a non-invasive imaging biomarker of ther-apy response.The second project phase runs parallel to the first. Methods established in the experimental model will be made more rapidly available in the clinic, e.g. for patients with colon carcinomas under-

going anti-angiogenic therapies. Prof. Christoph Becker, MD, and associate Prof. Anno Graser, MD, senior consultants in the CT department at the University Hospital in Großhadern, provide a crucial interface in the transfer of research findings to clinical practice. The second phase of the project will focus on certain clinical aspects, for instance workflows relating to new research methods and large data volumes. Investigations will seek to determine the sections of the patient’s body that require scanning and the required parameters in the affected physical area to achieve the optimal bal-ance between radiation dose, contrast agent dose and screening validity. It is also essential to identify this area again in the follow-up examination by taking the underlying scan parameters from the previous scan and configuring the scan settings precisely (protocol retention).Furthermore, it is important to determine how the extremely high data volumes incurred during dynamic, time-resolved screenings can be processed and opti-mally saved (improving data handling). It is crucial to ascertain how radiation

2 CT perfusion maps of a patient with pleural metastases of a renal cell carcinoma (red arrow, top row: before treatment, bottom row: after treatment). The perfusion screening with CT pro-vides proof of therapy response showing a significant decline in the perfusion of this metastasis after just two weeks of treatment (bottom row) with a tyrosine-kinase inhibitor (TKI).

2A 2B 2C

2D 2E 2F

dose, which accumulates during CT per-fusion screenings, particularly in the event of multiple scans, can be reduced using the SOMATOM Definition Flash. In addition to these core aspects, perfusion imaging with Dual Energy CT is a further project theme that may offer a possible approach to reducing radiation dose, particularly in sequential screenings. The research findings will also cover post-processing, e.g. in connection with motion correction in respiratory move-ments. Moreover, the cost efficiencies of modern tumor therapy monitoring are to be determined and the benefits offered by Siemens technologies identi-fied, such as the Adaptive 4D Spiral or the shuttle mode for multi-phase imag-ing of an entire organ.The initial pre-clinical and clinical research findings described show that personalized and individualized treatment concepts are set to shape the medical world, and oncology in particular, decisively in the coming years. Non-invasive radiological and nuclear medical imaging, an impor-tant diagnostic tool for clinical disciplines, will play an increasingly significant role in primary diagnostics and therapy moni-toring. Great challenges remain for all medical and industrial participants as they seek to establish functional and molecular tumor imaging as an effective complement to tumor morphology in meaningful clinical algorithms.


Education and Awareness Brings Confi dence to Decision-making in Medical ImagingSurvey sponsored by SIERRA, the Siemens Radiation Reduction Alliance, exposes Americans’ concerns, infl uences, and levels of basic awareness about medical imaging tests.

By Stefan Ulzheimer, PhD, Computed Tomography, Siemens Healthcare, Forchheim, Germany

The Siemens Radiation Reduction Alliance (SIERRA), an expert panel established to advance the cause of dose reduction in medical imaging, sponsored a recentsurvey that evaluates the decision-making process of potential patients in response to situations where a medical scan is recommended by a physician.

Scrutiny is increasing over medical imag-ing scans and the use of radiation. The study reveals that awareness and famil-iarity with medical imaging tests leads to clearer decisions for American adults about their healthcare.In the survey of more than 1000 Ameri-can adults, several questions were asked

about the use of medical imaging tests, followed by five real-life scenarios of varying severity where each respondent was asked to decide whether to go ahead with a specific medical imaging test for themselves or a loved one. The results show a direct correlation between the familiarity with a medical imaging test

Science

Science

www.siemens.com/US-Dose-Survey

“ This survey sponsored by SIERRA provides perspective on the patient concerns that doctors deal with at the practice level every day when it comes to medical imaging.”

Marilyn Siegel, MD, Mallinckrodt Institute of Radiology, St. Louis, USA

and the likelihood that they will go ahead with that test at the recommendation of a physician.

Familiarity with a medical technology correlates with consumer’s attitudeThe technologies most familiar to con-sumers – defined as those who have either heard of or have had the test – cor-respond to the percentage of consumers who would go ahead with the test in the survey scenarios. Of the technologies highlighted in the survey, consumers are most aware of X-rays (96%) and would go ahead with a physician’s recommen-dation for an X-ray in the survey scenario (88%). Consumers were least familiar with nuclear heart scan technology, with just over one-third (39%) of surveyed consumers having received or heard of the test, and only 28% of respondents indicating they would follow a physician’s recommendation for a nuclear heart scan.

Lack of knowledge on specifi c technologiesThe study found that 90% of American adults could correctly identify the primary use of medical imaging tests, citing use as a diagnostic tool to find out what’s wrong, to see internally what can’t be seen otherwise, and as a non-invasive procedure instead of exploratory surgery as the top reasons.Further, roughly two in five respondents (41%) identify radiation exposure as a risk associated with medical imaging tests. Yet, when asked which medical imaging

the deciding factors when making an informed decision about their care.The survey shows that information and understanding are critical for patients when assessing the benefits and perceived risks of these tests. As a longtime pioneer in radiation dose reduction, Siemens Healthcare is committed to working with clinical staff to provide the resources they need to help patients make informed decisions about their care. As a conse-quence of the survey results, Siemens also launched a new internet portal for patient education on medical imaging (www.medicalradiation.com).SIERRA intends to publish the survey results in a peer-reviewed journal to draw the attention of the medical community to the importance of not only the edu-cation of professionals but also patient education.More details about the survey results can be found under:

tests use radiation, the survey shows that many American adults are unfamiliar with what technologies utilize radiation to produce images, and which do not. Twenty-three percent of respondents cite ultrasound technology and 60% cite MRI when asked “which of the following tech-nologies use ionizing radiation to produce images?”.Despite the perceived risk of radiation exposure, when respondents reviewed all the options in the five survey scenarios, including the physician’s recommenda-tion, almost 80% of the time consumers went with the physician’s advice, which entailed proceeding with a medical imag-ing scan for themselves or a loved one. These results reinforce how the benefits of medical imaging far outweigh radiation concerns for a majority of Americans.

Information and options are key for patientsThe results illustrate that for many consumers who opt not to have the test in a potentially critical medical scenario, the information and available options are

Marilyn Siegel, MD, from the Mallinckrodt Institute of Radiology in St. Louis is a SIERRA panel physician.

Customer Excellence


Siemens Hands-on Workshops at the ECR and ESCBy Susanne v. Vietinghoff, Computed Tomography, Siemens Healthcare, Forchheim, Germany

Siemens hands-on workshops offer detailed instruction on the latest techni-ques in computed tomography. Each course is conducted in a classroom setting and covers topics from image acquisition to processing and interpretation.

During the Siemens hands-on workshops at the European Congress of Radiology (ECR) and the European Society of Car-diology (ESC) attendees learnt to get the most from Siemens advanced visualiza-tion tools with case-based demonstrations by clinical experts. These workshops are free of charge for registered attendees and are fully CME accredited.

Workshops during ECR:During the CT workshops the presenters focused on optimizing reading criteria as well as image quality and postprocessing.CT workshops:■ CT Oncology presented by

Anno Graser, MD■ CT Colonography presented by

Thomas Mang, MD■ CT Dual Energy presented by

Ralf Bauer, MD■ CT Neurology presented by

Peter Schramm, MD■ CT Cardiology presented by

Matthias Kerl, MDThe program also included workshops for MR Mammography, advanced reading in PET/CT and 3D Breast Tomosynthesis. With ten workplaces available on the course, participants benefited from an individual learning environment.

Workshops during ESC:For the upcoming ESC 2012 in Munich, Siemens is hosting workshops on com-puted tomography, magnetic resonance, molecular imaging, ultrasound, angiog-raphy and laboratory diagnostics.

Due to the high demand last year, the number of sessions has been increased and two workshop rooms are available for parallel sessions. Attendees can register onsite for the workshops at the ESC.The six CT sessions on technical prin-ciples, clinical indications and analysis of cardiac CT datasets will be held by Matthias Kerl, MD from the University Hospital in Frankfurt. During these 90-minute sessions he will talk in detail about triaging patients with suspected coronary artery disease (CAD). The goal of the non-invasive CT examination is to differentiate between patients with and without significant stenosis.Matthias Kerl will also demonstrate why coronary CT Angiography (CTA) is often perceived as the most promising tech-nique for non-invasive CT and how far coronary CTA has become part of clinical routine. This hands-on session includes the latest dose-saving techniques, main indications, and tips and tricks. Multiple cases will also be presented and discussed during an introduction to the syngo.via advanced visualization software. A statement from one of last year’s participants underlines the success of the Siemens hands-on workshops:“The tips and short-cuts shown during the workshop are very helpful. It is fas-cinating to see the possibilities offered by on-screen image processing,” says Marjolein Kamphuis-Menses, MD, ERASMUS University Medical Center, Rotterdam. Further information at:

www.siemens.com/SOMATOMEducate

ECR 2012 Hands-on workshop:

CT Dual Energy presented by Ralf Bauer, MD

ESC 2011 Hands-on tutorial:

CT Cardiology presented by Tobias Pflederer, MD

Customer Excellence


Siemens webinars are held by clinical experts.

Clinical Webinar: Highly Topical Information Presented by SpecialistsBy Susanne v. Vietinghoff, Computed Tomography, Siemens Healthcare, Forchheim, Germany

Coronary CTA Interpretation Workshop Level IIBy Susanne v. Vietinghoff, Computed Tomography, Siemens Healthcare, Forchheim, Germany

Siemens clinical webinars feature the latest information in healthcare imaging and new medical imaging technologies. Each of the webinars is held by clinical experts and can be watched anytime from anywhere.The following topics which are currently available:■ “Low Dose Cardiac CT” by Prof. Stephan

Achenbach, MD, PhD. Stephan Achenbach presents his experiences of cardiac CT scanning and explains how excellent imaging is achievable at lowest possible dose values.

■ “CT Stroke Management” by Prof. Bernd Tomandl, MD. Bernd Tomandl shows the combination of non-enhanced CT, CT Perfusion and CT Angiography

scanning for patients with acute ischemic strokes.

The most current webinar is:■ “High-resolution CT (HRCT) scans for

patients referred for interstitial lung diseases” with Martine Remy-Jardin, MD, PhD. During the presentation, Martine Remy-Jardin discusses the clinical disease pattern of interstitial lung diseases including potential diag-nostic methods while demonstrating the value of HRCT scanning for such patients. Further information at:

www.siemens.com/ SOMATOMEducate

www.siemens.com/ SOMATOMEducate

Periodically, Siemens offers workshops for clinical personnel to share experiences on how to get the most out of their tech-nology. One offer is a cardiac interpreta-tion workshop held at the University of Erlangen-Nuremberg, Germany where participants collect hands-on experiences in the interpretation of coronary CT Angiography datasets. Over the two days, attendees use syngo.via to evaluate 50 original coronary CT Angiography scans which help them to get towards Level II certification. The cases range from easy, introductory cases to more advanced cases with difficult diagnoses and typical pitfalls. Invasive coronary angiography

correlation is available for the CT Angi-ography cases. The faculty will be avail-able to provide help and guidance during the whole course.This course is most suited for cardiolo-gists and radiologists who have basic knowledge of cardiac computed tomo-graphy, who want to improve their inter-pretation skills and gather experience in recognizing typical and more complex findings.Patrizia Pernter, MD from Bolzano/Italy: “I enjoyed the Cardio Workshop in Erlangen completely because it fulfilled my expectations. The practical exercises are exactly what is needed to learn the

everyday tools. Prof. Ropers answered all the questions during the course and solved all issues that were raised in a helpful manner. I have learned a lot that is very important for my daily practice.”The next course date is scheduled for September 27–28, 2012.

The statements by Siemens’ customers described herein are based on results that were achieved in the customer’s unique setting. Since there is no “typical” hospital and many variables exist (e.g., hospital size, case mix, level of IT adoption) there can be no guarantee that other customers will achieve the same results.


Customer Excellence

Why are two different Quality Refer-ence Tube Current Values Displayed?Since 2011, CARE kV has been available on Siemens high-end scanners.* CARE kV can set the tube voltage (kV) automati-cally for individual examinations which optimizes contrast-to-noise ratio and reduces dose by up to 60%. CARE kV sets the correct kV values based on patient size and examination type. When changing the kV value manually, the tube current (mAs) needs to be re-cal-

culated to ensure the best image quality. CARE kV adapts the kV value and calcu-lates a new quality reference mAs value for the new kV value.The original and the new values can always be verified easily. In the scan protocol, the original value is marked in green on the scan subtask card. In the left lower corner of the tomosegment, the new calculated tube current value (ref. mAs) is highlighted in green (Fig. 1).The reason for this is simple: When a

follow-up scan is performed on a scanner that is not equipped with CARE kV, the radiographer can manually set the new kV and quality ref. mAs values. That means the best dose for the patient and optimum image quality can be set, even on a scanner which is not equipped with CARE kV.

Frequently Asked Question By Ivo Driesser, Computed Tomography, Siemens Healthcare, Forchheim, Germany

* SOMATOM Definition AS, SOMATOM Definition Flash

1 The original tube current value is marked in green on the scan subtask card (arrowhead). In the left lower corner of the image, the new calculated tube current value (ref.mAs) is highlighted in green (arrow).

1

Customer Excellence

Clinical Workshops 2012As a cooperation partner of many renowned hospitals, Siemens Healthcare offers continuing CT training programs. A wide range of clinical workshops keeps participants at the forefront of clinical CT imaging.

Title Dates Short Description Location Contact

ESTI June 22 – 24 European Society of Thoracic Imaging London, GB www.esti2012.org/

SCCT July 19 – 22 Society of Cardiovascular Computed Tomography

Baltimore, Maryland

www.scct.org/

ESC Aug 29 – Sept 2 European Society of Cardiology Munich, Germany www.escardio.org

AOCR Aug 30 – Sept 2 Asian Oceanian Congress of Radiology

Sydney, Australia www.aocr.org/

ASTRO Oct 28 – 31 Annual Meeting of the American Society of Radiation Oncology

Boston, U.S. www.astro.org/

Medica Nov 14 – 17 World Forum for Medicine Dusseldorf, Germany www.medica-tradefair.com/

RSNA Nov 25 – 30 Annual Meeting of Radiological Society of North America

Chicago, U.S. www.rsna.org/

Workshop Title / Special Interest Date Location Course Director Link

Hands-on at the ESGAR Congress / Colonography

June 12 – 15 Edinburgh, UK ESGAR – S. Halligan, MD www.esgar.org

Oncology Imaging Course 2012 / Oncology

June 28 – 30 Dubrovnik, HR OIC – Prof. M. Reiser, MD www.oncoic.org

Clinical Workshop on Cardiac CT / Cardiac

July 4 – 6 Munich, GER Siemens Healthcare – Prof. C. Becker, MD


Cardiac CT Level II Training / Cardiac July 17 – 20 London, UK British Institute of Radiology www.bir.org.uk

Hands-on Tutorial at ESC 2012 / Cardiac

Aug 25 – 29 Munich, GER Siemens Healthcare www.siemens.com/ESC

Cardiac CT Level II Training / Cardiac Sept 11 – 14 London, UK British Institute of Radiology www.bir.org.uk

CT Neuro Perfusion Workshop Sept 14 – 15 Göttingen, GER P. Schramm, MD www.kelcon.de/_d-upl/Programm_Hands_on_Workshop_Goettingen.pdf

Hands-on at the ESGAR Workshop / Colonography

Sept 19 – 21 Valencia, S ESGAR – L. Marti-Bonmati www.esgar.org

CTA Interpretation Course / Cardiac Sept 27 – 28 Erlangen, GER Siemens Healthcare – Prof. D. Ropers, MD



Oct 17 – 19 Munich, GER Siemens Healthcare – Prof. C. Becker, MD


Clinical Workshop on DE / Dual Energy

Nov 2 – 3 Forchheim, GER

Siemens Healthcare – Prof. T. Johnson, MD



Dec 12 – 14 Munich, GER Siemens Healthcare – Prof. C. Becker, MD


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

Upcoming Events & Congresses 2012


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

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

Medical SolutionsInnovations and trends in healthcare. The magazine is designed especially for members of hospital manage-ment, administration personnel, and heads of medical departments.

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

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IMAGING LifeEverything from the world of molecular imag-ing innovations. This bi-annual magazine presents clinical case reports, cus-tomer experiences, and product news, and is pri-marily designed for phy-sicians, hospital manage-ment and researchers.

SOMATOM Sessions Online This website is a digital equivalent to the existing print magazine, including news from the world of computed tomography. With its reports and case studies, it is primarily designed for physicians, physicists, and medical technical personnel. www.siemens.com/SOMATOM-Sessions


Editorial

“Our strategy at Siemens is to apply our trendsetting technologies not only to leading high-end CT Systems, such as the new SOMATOM Defi nition Edge, but also in widely accessible and highly innovative CT products like the SOMATOM Perspective.

Based on this strategy we are able to offer to our customers extremely attractive sustainable products, with a strong focus on optimizing the total cost of ownership.”

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

Cover page: Courtesy of Sainte-Marie Clinic, Osny, France

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


Imprint

SOMATOM Sessions – IMPRINT© 2012 by Siemens AG, Berlin and MunichAll Rights Reserved

Publisher: Siemens AGMedical SolutionsComputed Tomography & Radiation OncologySiemensstraße 1, 91301 Forchheim, Germany

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

Clinical Editor:Xiaoyan Chen, MD([email protected])

Project Management: Sandra Kolb

Responsible for Contents: Peter Seitz

Editorial Board:Xiaoyan Chen, MD; Andreas Fischer; Jan Freund; Tanja Gassert; Sandra Kolb; Axel Lorz; Heidrun Endt; Julia Hölscher; Monika Demuth, PhD; Peter Seitz; Stefan Ulzheimer, PhD

Authors of this issue:Andre Kemmling, MD,University Hospital Münster, Germany A. Nchanduca, RT, Clinica Girassol, Luanda, AngolaBorek Foldyna, MD, University of Leipzig, Heart Center, Leipzig, GermanyChristian Fink, MD, University of Mannheim, GermanyChristian Lücke, MD, University of Leipzig, Heart Center, Leipzig, Germany Christoph Schülke, MD, University of Muenster, Muenster, Germany Claudia Andres, MD, University of Leipzig, Heart Center, Leipzig, Germany Constança Palma Borges, MD, Clinica Girassol, Luanda, Angola Erdie Q. Dizon, Radiographer, Tan Tock Seng Hospital, SingaporeFahim H. Jafary, MD, FACC, FSCAI, Tan Tock Seng Hospital, Singapore Fumiaki Ishida MD, Toho University Omori Medical Center, Tokyo, JapanGang Wang, MD, Baotou Central Hospital, Inner Mongolia, P. R. China Gang-feng Hu, MD, Wuxi People’s Hospital Affi liated to Nanjing Medical University, Wuxi, P.R. China Go Sano MD, Toho University Omori Medical Center, Tokyo, JapanHailiang Jia, MD, Baotou Central Hospital, Inner Mongolia, P. R. ChinaHarald Seifarth, MD, University of Muenster, Muenster, GermanyHeather Gill-Frerking, Reiss-Engelhorn Museums, Mannheim, Germany

Hong-wei Chen, MD, Wuxi People’s Hospital Affi liated to Nanjing Medical University, Wuxi, P.R. ChinaHui-jun Lu, MD, Wuxi People’s Hospital Affi liated to Nanjing Medical University, Wuxi, P.R. ChinaJagajothi Devadoss, Senior Radiographer, Tan Tock Seng Hospital, Singapore Jian Cao, MD, Peking Union Medical College, Beijing, P.R. China Joana Costa, MD, Institut Jules Bordet João Carlos Costa, MD, Hospital Particular de Viana do Castelo, Viana do Castelo, Portugal Johann Steffens, MD, Israelitisches Krankenhaus, Hamburg, Germany Johannes Wessling, MD, University of Muenster, Muenster, Germany Jyoji Nakagawara, MD, Nakamura Memorial Hospital, Sapporo, Japan Kai Sun, MD, Baotou Central Hospital, Inner Mongolia, P. R. China Kazutoshi Isobe MD, PhD, Toho University Omori Medical Center, Tokyo, Japan Keishi Sugino MD, PhD, Toho University Omori Medical Center, Tokyo, Japan Keita Sato MD, Toho University Omori Medical Center, Tokyo, Japan Kianoush Ansari Gilani, MD, University Hospital Radiology, Cleveland, Ohio, USA Leslie Ciancibello, RT, University Hospital Radiology, Cleveland, Ohio, USA Lijun Ma, MD, Baotou Central Hospital, Inner Mongolia, P. R. China Ludger Feyen, MD, University Hospital Münster, Germany Lukas Lehmkuhl, MD, University of Leipzig, Heart Center, Leipzig, GermanyM. Reis, RT, Hospital Particular de Viana do Castelo, Viana do Castelo, Portugal M. Sozinho, RT, Clinica Girassol, Luanda, Angola Marisa Gonçalves, RT, Hospital Particular de Viana do Castelo, Viana do Castelo, Portugal Masahiro Kobayashi MD, Toho University Omori Medical Center, Tokyo, Japan Matthias Gutberlet, MD, University of Leipzig, Heart, Center, Leipzig, Germany Nao Hirota MD, Toho University Omori Medical Center, Tokyo, Japan Naoshi Kikuchi MD, Toho University Omori Medical Center, Tokyo, Japan Nobuyuki Shiraga MD, PhD, Toho University Omori Medical Center, Tokyo, Japan P. Miguel, RT, Clinica Girassol, Luanda, Angola Ping-yan Qian, MD, Wuxi People’s Hospital Affi liated to Nanjing Medical University, Wuxi, P.R. China Prof. Robert C. Gilkeson, MD, University Hospital Radiology, Cleveland, Ohio, USA C. Rosa, RT, Clinica Girassol, Luanda, Angola Ruijuan Han, MD, Baotou Central Hospital, Inner Mongolia, P. R. China S.Bastos, RT, Clinica Girassol, Luanda, Angola

Sakae Homma MD, PhD, Toho University Omori Medical Center, Tokyo, Japan Savvas Nicolaou, MD, Vancouver General Hospital, Vancouver, Canada Susumu Sakamoto MD, PhD, Toho University Omori Medical Center, Tokyo, Japan Thomas Henzler, MD, University of Mannheim, Germany Vasco Silva, MD, Clinica Girassol, Luanda, Angola. Wilfried Rosendahl, PhD, Reiss-Engelhorn Museums, Mannheim, Germany Xiang-ming Fang, MD, Wuxi People’s Hospital Affi liated to Nanjing Medical University, Wuxi, P.R. China Xiao-yun Hu, MD, Wuxi People’s Hospital Affi liated to Nanjing Medical University, Wuxi, P.R. China Yingning Wang, MD, Peking Union Medical College, Beijing, P.R. China Yujiro Takai MD, PhD, Toho University Omori Medical Center, Tokyo, Japan Zhou Li, MD, Peking Union Medical College, Beijing, P.R. China

Christian Rayr freelance journalist, Paris, France; Irène Dietschi science and medical writer, Switzerland; Martina Lenzen-Schulte, MD, medical journalist, Germany; Robert L. Bard medical writer, Michigan, USA

Ana Chaves; Chenwei Li, MD; Christiane Torres; Christine Dehm, PhD; Heidrun Endt, MD; Holger Reinsberger; Ivo Driesser; Jan Feund; Jennifer Powell; Karl Krzymyk; Katharina Otani, PhD; Ligang Li, MD; Monika Demuth, PhD; Peter Aulbach; Philip Stenner, PhD; Sandra Kolb; Silvia Meyer; Stefan Ulzheimer, PhD; Susanne v. Vieting-hoff; Tiago Campos; Wynne Chia; Christian Weiss

Photo Credits: Franck Ferville Agence Vu Paris; Jan Averwerser; Christian Grund; independent Medien-Design; Sara Jorde; plainpicture/fStop; Johannes Krömer

Production and PrePress: Norbert Moser, Kerstin Putzer, Siemens AG, Healthcare SectorReinhold Weigert, Typographie und mehr ..., 91052 Erlangen, Schornbaumstr. 7

Proof-Reading: Sheila Regan

Design and Editorial Consulting: independent Medien-Design, Munich, Germany In cooperation with Primafi la AG, Zurich, Switzerland Managing Editor: Christa KrickPhoto Editor: Florencia SerrotLayout: Andreas Brunner, Claudia Diem, Mathias Frisch, Heidi KralAll at: Widenmayer straße 16, 80538 Munich, Germany

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

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 or all of the features and products described herein may not be available in the United States.

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

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

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

www.siemens.com/healthcare-magazine

Global Business Unit

Siemens AGMedical SolutionsComputed Tomography& Radiation OncologySiemensstraße 191301 ForchheimGermanyPhone: +49 9191 18-0www.siemens.com/healthcare

Local Contact Information

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

Canada:Siemens Canada LimitedHealthcare Sector2185 Derry Road WestMississauga ON L5N 7A6CanadaPhone: +1 905 819-5800www.siemens.com/healthcare

Europe/Africa/Middle East:Siemens AGHealthcare SectorHenkestraße 127D-91052 ErlangenGermanyPhone: +49 9131 84-0www.siemens.com/healthcare

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

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

Global SiemensHealthcare Headquarters

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

Global Siemens Headquarters

Siemens AGWittelsbacherplatz 280333 MuenchenGermany

Order No. A91CT-41016-16M1-7600 | Printed in Germany | CC CT 41016 ZS 0712/25. | © 07.2012, Siemens AG

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Answers for life in Computed Tomography

SOMATOM Sessions

Issue Number 30 / July 2012International Edition – Not for distribution in the US.

Cover Story Performance is Becoming More AccessiblePage 6

News SOMATOM Defi nition Edge: Low Dose, Quality ImagesPage 16

Business Low Dose, High Resolution for Pediatric CardiologyPage 34

Clinical ResultsDiagnosis of an Intracranial Dual-Aneurysm using the new SOMATOM PerspectivePage 54

Science Beating Cancer – Treating IndividualsPage 69

Documents

Somatom sessions 30