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  • 1. Global Siemens Headquarters Global Siemens SOMATOM Sessions SOMATOM Sessions Rapid evaluation is Healthcare Headquarters Siemens AG critical after trauma and Wittelsbacherplatz 2 Siemens AG with symptoms such as 80333 Muenchen Healthcare Sector weakness, headache, Germany Henkestraße 127 and dizziness, which is why CT is the modality 91052 Erlangen Germany The Difference in Computed Tomography of choice in these Phone: +49 9131 84 - 0 scenarios. Exceptional www.siemens.com/healthcare image quality is key to optimize diagnosis, and lower dose imaging Issue Number 26 / May 2010 www.siemens.com/healthcare-magazine ISCT- / ASNR-Edition I May 18th – May 21st, 2010 26 minimizes risk to the patient. Order No. A91CT-41011-14M1-4A00 | Printed in Germany | CC CT 41011 ZS 0510/8. | © 05.2010, Siemens AG May 2010 Cover Story On account of certain regional limitations of Global Business Unit Local Contact InformationSUBS CRIBE NOW! sales rights and service availability, we cannot The Best of Both Worlds guarantee that all products included in this Siemens AG Asia/Pacific: in Neuro Imaging– and get your free copy of future brochure are available through the Siemens Medical Solutions Siemens Medical Solutions Page 6SOMATOM Sessions! Interesting information sales organization worldwide. Availability and Computed Tomography Asia Pacific Headquarters packaging may vary by country and is subject Siemensstraße 1 The Siemens Centerfrom the world of computed tomography – gratis to change without prior notice. Some/All of the features and products described herein may 91301 Forchheim Germany 60 MacPherson Road Singapore 348615 Newsto your desk. Send us this postcard, or subscribe not be available in the United States. Phone: +49 9191 18 - 0 Phone: +65 9622 - 2026 Best Balance Betweenonline at www.siemens.com/ct-news www.siemens.com/healthcare www.siemens.com/healthcare Image Quality The information in this document contains general technical descriptions of specifications Canada: and Reduced Dose and options as well as standard and optional Siemens Canada Limited Page 18 features which do not always have to be present Medical Solutions in individual cases. 2185 Derry Road West Mississauga ON L5N 7A6 Business Siemens reserves the right to modify the design, Canada packaging, specifications and options described Phone: +1 905 819 - 5800 New Feature: Neuro herein without prior notice. www.siemens.com/healthcare Image Quality Surpasses Please contact your local Siemens sales representative for the most current information. Europe/Africa/Middle East: all Expectations Siemens AG Page 26 ISCT-Edition Note: Any technical data contained in this Medical Solutions document may vary within defined tolerances. Original images always lose a certain amount Henkestraße 127 D-91052 Erlangen Clinical of detail when reproduced. Germany Results Henkestraße 127 Halthcare Sector 91052 Erlangen Phone: +49 9131 84 - 0 www.siemens.com/healthcare SOMATOM Definition AS+: Siemens AG CT Perfusion With Germany Latin America: H CC 11 Siemens S.A. Extended Coverage for Medical Solutions Acute Ischemic Stroke Avenida de Pte. Julio A. Roca No 516, Piso 7 C1067ABN Buenos Aires Argentina Page 46 Phone: +54 11 4340 - 8400 www.siemens.com/healthcare Science USA: CT in Pediatrics: Easier Siemens Medical Solutions U.S.A., Inc. and Safer With the FlashSOMATOM 51 Valley Stream Parkway Malvern, PA 19355-1406 Page 58 USASessions Phone: +1-888-826 - 9702 www.siemens.com/healthcare
  • 2. Editorial Imprint “Neuro BestContrast SOMATOM Sessions – IMPRINT © 2010 by Siemens AG, Berlin and Munich A. Becker, MD, Department of Clinical Radiology, University of Munich, Campus Großhadern, F. Schoth, MD, RWTH Aachen University Hospital, Aachen, Germany allows radiologists to All Rights Reserved Munich, Germany C. R. Becker, MD, Department of Clinical Radiology, F. Schwarz, MD, Department of Clinical Radiology, University of Munich, Campus Großhadern, better visualize subtle Publisher: Siemens AG Healthcare Sector University of Munich, Campus Großhadern, Munich, Germany Munich, Germany H. Seifarth, MD, Department of Clinical Radiology, edemas as well as Business Unit Computed Tomography Siemensstraße 1, 91301 Forchheim, Germany G. Feuchtner, MD, Institute of Diagnostic Radiolo- gy, University Hospital Zurich, Zurich, Switzerland University Hospital, Münster, Germany K. Takada, MD, Department of Radiology, subtle signs of stroke, Chief Editors: M. Fischer, MD, Institute of Diagnostic Radiology, Sakakibara Heart Institute, Tokyo, Japan and to better delineate “Our new neurological University Hospital Zurich, Zurich, Switzerland T. J. Vogl, MD, Department of Diagnostic and R. Goetti, MD, Institute of Diagnostic Radiology, University Hospital Zurich, Zurich, Switzerland Interventional Radiology, Clinic of the Goethe Uni- versity, Frankfurt, Germany the cortical margin.” W. Heindel, MD, Department of Clinical Radiology, P. Weisser, MD, Department of Diagnostic and In- software combined with University Hospital, Münster, Germany terventional Radiology, Clinic of the Goethe University, Frankfurt, Germany David S. Enterline, MD, J. M. Kerl, MD, Department of Diagnostic and Duke University Medical Center in Durham, North Carolina, USA Interventional Radiology, Clinic of the Goethe M. Wieser, MD, Clinic of Cardiovascular Surgery, University, Frankfurt, Germany University Hospital Zurich, Zurich, Switzerland the SOMATOM Definition M. Lell, MD, Department of Radiology and C. Wyss, MD, Cardiology Division, University Monika Demuth, PhD Stefan Wünsch, PhD the Imaging Science Institute (ISI), University Hospital Zurich, Zurich, Switzerland (monika.demuth@ (stefan.wuensch@ of Erlangen-Nuremberg, Erlangen, Germany Sameh Fahmy, freelance medical and technology siemens.com) siemens.com) S. Leschka, MD, Institute of Diagnostic Radiology, journalist Tony DeLisa, freelance author University Hospital Zurich, Zurich, Switzerland Wiebke Kathmann, PhD, freelance scientific journalist line of scanners repre- Responsible for Contents: André Hartung Hildegard Kaulen, PhD, freelance scientific journalist K. Lin, MD, Department of Radiology, New York Oliver Klaffke, freelance scientific journalist Editorial Board: University Langone Medical Center, New York, Annette Tuffs, MD, medical journalist Andreas Blaha NY, USA Helge Bohn Peter Aulbach; Karin Barthel; Andreas Blaha; A. H. Mahnken, MD, RWTH Aachen University sents a quantum leap Andreas Fischer Steven Bell; Ivo Driesser; Kerstin Fellenzer; Tomoko Hospital, Aachen, Germany Thomas Flohr, PhD Fujihara; Jan Freund; Tanja Gassert; Toshihide Julia Hoelscher Y. Mizutani, MD, Department of Radiology, Itoh; Christiane Koch, Rami Kusama; Marion Klaudija Ivkovic Sakakibara Heart Institute, Tokyo, Japan Meusel; Jakub Mochon; Katharina Otani, PhD; Axel Lorz Kerstin Putzer; Heike Theessen; Peter Seitz; Ste- K. Nikolaou, MD, Department of Clinical Radiology, Please enter your business address in speed, low dose and fan Ulzheimer PhD; Fernando Vega-Higuera; Country State City Postal Code Street Name Title Function Department Institution Peter Seitz University of Munich, Campus Großhadern, Stefan Ulzheimer, PhD Stefan Wünsch, PhD; all Siemens Healthcare Munich, Germany Alexander Zimmermann Photo Credits: Greg Morris, Yohanne Lamoulére/ J.-F. Paul, MD, Centre Chirurgical Marie Authors of this Issue Agentur Focus, Harald Krieg, Thorsten Rother Lannelongue, Le Plessis-Robinson, France H. Alkadhi, MD, Institute of Diagnostic Radiology, diagnostic accuracy.” Production: Norbert Moser, Siemens AG, University Hospital Zurich, Zurich, Switzerland A. Plass, MD, Clinic of Cardiovascular Surgery, Medical Solutions University Hospital Zurich, Zurich, Switzerland F. Bamberg, MD, Department of Clinical Radiology, Design and Editorial Consulting: University of Munich, Campus Großhadern, B. Policeni, MD, Radiology Faculty, Neuroradiology, Independent Medien-Design, Munich, Germany Munich, Germany University of Iowa Hospitals and Clinics, Iowa In cooperation with Primafila AG, Zurich, City, Iowa, USA R. W. Bauer, MD, Department of Diagnostic and Switzerland; Interventional Radiology, Clinic of the Goethe H. Scheffel, MD, Institute of Diagnostic Radiology, Managing Editor: Christa Löberbauer; University, Frankfurt, Germany University Hospital Zurich, Zurich, Switzerland Photo Editor: Susanne Nips; Layout: Claudia Diem, Mathias Frisch; All at: Widenmayerstraße 16, 80538 Munich, Germany SOMATOM Sessions is also available on the internet: www.siemens.com/SOMATOMWorld Subscription Sami Atiya, PhD, Chief Executive Officer, Business Unit Computed Tomography, Siemens Healthcare, Forchheim, Germany Note in accordance with § 33 Para.1 of the German Federal Data Protection Law: The drugs and doses mentioned herein are consistent with the approval labeling Despatch is made using an address file which is maintained with the aid of an for uses and/or indications of the drug. The treating physician bears the sole automated data processing system. responsibility for the diagnosis and treatment of patients, including drugs and Register for: Stay up to date with the latest information following Siemens Healthcare customer magazine(s): Please include me in your mailing list for the E-mail SOMATOM Sessions with a total circulation of 35,000 copies is sent free of charge doses prescribed in connection with such use. The Operating Instructions must unsubscribe from info service Yes, I consent to the above information being used important news from Siemens. for future contact regarding product updates and other the monthly healthcare e-newsletter AXIOM Innovations SOMATOM Sessions MAGNETOM Flash Medical Solutions to Siemens Computed Tomography customers, qualified physicians and radiology always be strictly followed when operating the CT System. The sources for the departments throughout the world. It includes reports in the English language technical data are the corresponding data sheets. Results may vary. on Computed Tomography: diagnostic and therapeutic methods and their applica- Partial reproduction in printed form of individual contributions is permitted, pro- tion as well as results and experience gained with corresponding systems and vided the customary bibliographical data such as author’s name and title of the solutions. It introduces from case to case new principles and procedures and dis- contribution as well as year, issue number and pages of SOMATOM Sessions are cusses their clinical potential. named, but the editors request that two copies be sent to them. The written consent The statements and views of the authors in the individual contributions do not of the authors and publisher is required for the complete reprinting of an article. necessarily reflect the opinion of the publisher. We welcome your questions and comments about the editorial content of The information presented in these articles and case reports is for illustration only SOMATOM Sessions. Manuscripts as well as suggestions, proposals and informa- and is not intended to be relied upon by the reader for instruction as to the prac- tion are always welcome; they are carefully examined and submitted to the edito- Cover Page: With Volume Perfusion CT Neuro fused with carotid CT Angiography the perfusion status of the brain tissue tice of medicine. Any health care practitioner reading this information is remind- rial board for attention. SOMATOM Sessions is not responsible for loss, damage, can be observed. Courtesy of University Hospital Göttingen, Germany. ed that they must use their own learning, training and expertise in dealing with or any other injury to unsolicited manuscripts or other materials. We reserve the their individual patients. This material does not substitute for that duty and is not right to edit for clarity, accuracy, and space. Include your name, address, and intended by Siemens Medical Solutions to be used for any purpose in that regard. phone number and send to the editors, address above.2 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 73 Please print clearly!
  • 3. Editorial André Hartung, Vice President Marketing and Sales Business Unit CT, Siemens HealthcareDear Reader,Imagine an emergency room only a With syngo.via, Siemens’ new work- sure. CT is steadily moving into the firstfew short years ago: in the middle of place software, all time consuming line of emergency and stroke imagingthe night, a 55-year-old, unconscious pre- and post-processing steps are mainly because of the wide diagnosticpatient is wheeled in. All neurologic eliminated and all diagnostic infor- spectrum, speed and diagnostic pre-observations indicate stroke. But mation – including information from cision. Providing all the advantages inhow severe? Is it an occlusion or a other modalities such as MR, MI and CT imaging aligned with measures tohemorrhage and where is it located? PET – are available in almost real time. minimize the radiation exposure hasAll crucial questions that demand fast Best possible image quality is pro- always been one of Siemens key goals.answers! The physician on duty could vided with sophisticated “signal boost” Therefore we have recently introducedrequest a head CT examination that technologies or image-optimizing new technical developments like IRIS tocould possibly involve two scans at 15 techniques resulting in definitive reduce radiation exposure to the lowestto 30 mSv radiation dose. The physician grey and white tissue differentiation level in the CT industry. In functionalwould then begin with extensive post- in neuro imaging. Excellent image imaging, e.g. for CT brain perfusion, theprocessing – possibly using a PACS quality and fast processes are bene- dose can be reduced by up to 50 % withWorkstation before the CT results could ficial for both physicians and patients 4D Noise Reduction, without compro-provide life the necessary clinical infor- as they are preconditions for highest mising image quality. And our Adaptivemation required. Not a very pleasant diagnostic accuracy and, at the same Dose Shield completely eliminates pre-alternative for the physicians or the time, low dose safety for the patient. and post-spiral radiation that cannot bepatient. utilized for image reconstruction. These In all patient groups, including difficult are only a few examples from dozens ofNow imagine the same situation in a obese and pediatric patients, as well as additional large and small improvementsmodern emergency room equipped with emergency room situations, safety is developed by our dedicated employeesSiemens cutting-edge technology such strongly linked to ALARA (As Low As to make the radiologist’s life easier andas SOMATOM Definition Flash scanner – Reasonably Achievable) radiation ex- the patient’s healthcare better. You willthat scans faster than all other CT posure. In the past, especially in acute find many of these reported in this, andscanners on the market – with latest clinical cases, lowering the radiation in future editions of SOMATOM Sessions.neuro imaging software and syngo.via exposure when utilizing CT for diagnosissoftware that “post-process on-the-fly” was not the primary focus. In stroke Good reading,Within minutes, the physician would cases, “minutes equaled mind” and for Sincerelyhave access to the head scan results with accident victims, minutes could meanall post-processing completed at lowest life or death. Today, thanks to Siemens’possible dose, including non-enhanced significant leadership in bringing lowCT for exclusion of hemorrhage, com- dose CT into clinical routine, image André Hartungplete vascular status plus functional quality is not necessarily tied to a slowerinformation. diagnosis path and higher dose expo-* syngo.via can be used as a standalone device or together with a variety of syngo.via based software options, which are medical devices in their own rights.. SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 3
  • 4. Content 6 22 Content The Best of Both Worlds International CT Image Contest at Lowest DoseCover Story Cover Story 6 Exciting advances in computed 6 The Best of Both Worlds in Neuro tomography (CT) examination Imaging methods, including low dose protocols, technical innovations such as whole brain CT Perfusion, News Dual Energy or Neuro Best Contrast applications and groundbreaking 16 Affordable Performance in 16- and radiological research have drama- 64-slice CT tically changed the diagnostic 18 Best Balance Between Image Quality approach for reading physicians and Reduced Dose by enabling new indications and 19 IRIS Now Extended to SOMATOM improved timing in the examination Definition AS 20 and SOMATOM of patients with acute neurological Definition AS 40 deseases. SOMATOM Sessions 20 syngo CT 2010B Now Available: discussed with five experienced New Software Version for the physicians how CT can routinely be SOMATOM Definition AS Launched used as the key diagnostic modality 21 Worldwide Dose Counter in neuro imaging before the start 22 International CT Image Contest – of appropriate treatment. Highest Image Quality at Lowest Dose4 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 5. Content 48 60– Highest Image Quality Vasospasm After Subarachnoid Hemorrhage: Study Finds Atherosclerosis in 3,500 Volume Perfusion CT Neuro Year old Egyptian Mummies Business Science 26 New Feature: Neuro Image Quality Oncology 58 CT in Pediatrics: Easier and Safer Surpasses all Expectations 42 3D Guided RF Ablation and CT With the Flash Perfusion – a New Combination for 60 Study Finds Atherosclerosis in Monitoring of Treatment Response 3,500 Year old Egyptian Mummies Clinical Results 44 SOMATOM Definition Flash: 61 Independent Validation of Perfusion Routine Re-staging of Oesophageal Evaluation Software Cardio-Vascular Carcinoma Utilizing IRIS Technology 62 Reduced Procedure Time and 28 Adenosine Myocardial Stress Radiation Dose in Interventional Imaging Using SOMATOM Neurology CT Workflow Definition Flash 46 SOMATOM Definition AS+: CT 64 Scientific Validation of the 30 SOMATOM Definition Flash: Perfusion With Extended Coverage SOMATOM Definition Flash Visualization of the Adamkiewicz for Acute Ischemic Stroke Artery by IV-CTA in Dual Power Mode 48 Vasospasm After Subarachnoid 32 Dynamic Myocardial Stress Perfusion Hemorrhage: Volume Perfusion CT Life 34 Pre-operative Exclusion of Coronary Neuro Artery Stenosis With Less Than 66 Behind the Scenes: CT Scan Protocols 1 mSv Dose Acute Care 68 First syngo.via Hands-on Workshops 36 Utilizing Ultra Low Dose of 0.05 mSv 52 Dual Energy Scanning: Diagnosis at ECR 2010 for Premature Baby With Congenital of Ruptured Cocaine Capsule 68 Upcoming Events & Congresses Heart Disease 54 Progressive Kidney Hematoma 69 Training Website for Knowledge 38 SOMATOM Definition Flash: Pediatric Post-interventional Biopsy Improvement Patient Without Sedation and 56 SOMATOM Definition Dual Source 69 Free Trial Licenses for Neuro Imaging Breath-Holding High Pitch vs. Routine Pitch Scanning 70 Frequently Asked Questions 40 SOMATOM Definition Flash: Dual in a Pediatric Lung Low Dose 70 Dual Energy CT: Learning From the Energy Coronary CT Angiography for Examination Experts Evaluation of Chest Pain After RCA 71 Clinical Workshops 2010 Revascularization 72 Siemens Healthcare – Customer Magazines 73 Imprint SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 5
  • 6. Coverstory6 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 7. CoverstoryThe Best of Both Worlds inNeuro ImagingExceptional Image Quality Meets Lowest Dosein NeuroradiologyAt Duke University Medical Center in Durham, North Carolina, USA andelsewhere, Siemens equipment is helping radiologists combine exceptionalimage quality in neuro imaging with innovative dose-reducing featuresto maximize diagnostic confidence.By Sameh FahmyExciting advances in computed tomo- Perfusion imaging with Siemens’ uniquegraphy (CT) examination methods, in- Adaptive 4D Spiral and the use of CTcluding low dose protocols, technical Angiography from the aortic arch to theinnovations such as whole brain CT cranium are further expanding possibili-Perfusion, Neuro BestContrast or Dual ties, increasing the diagnostic confidenceEnergy applications and groundbreaking of neurologists and potentially enablingradiological research have dramatically more appropriate treatment decisions.changed the diagnostic approach for “By providing really good image quality,reading physicians by enabling new indi- we are able to improve the efficiency ofcations and improved timing in the ex- care,” says David S. Enterline, MD, Asso-amination of patients with acute neuro- ciate Professor of Radiology and Divisionlogical deseases. CT is routinely used as Chief of Neuroradiology at Duke Uni-the key diagnostic modality in neuro versity Medical Center in Durham, Northimaging before the start of appropriate Carolina, USA. “And through dose sav-treatment to detect or exclude intracra- ings, we can minimize the risk to pa-nial hemorrhage, either traumatic or tients.” “Neuro BestContrastnon-traumatic, or to detect other causes allows radiologistsof acute onset of neurological disease, Neuro BestContrastsuch as stroke, intracerebral tumors, or Although newer techniques are revolu- to better visualizehematoma. Rapid evaluation is critical tionizing stroke assessment, the gold the gray/white mat-after trauma and with symptoms such standard for the initial diagnosis ofas weakness, headache, and dizziness, stroke and intracranial hemorrhage is ter interface to seewhich is why CT is the modality of still non-contrast imaging of the brain.choice in these scenarios. Siemens has always placed emphasis on subtle edema andExceptional image quality is key to opti- providing the highest image quality on signs of stroke, andmize diagnosis, and lower dose imaging all of their scanners for this challenginghelps to minimize the risk to the patient. application. Now, Siemens has taken to better delineateIt is often said that the price of improved image quality to the next level. Last the cortical margin.”image quality with CT is increased radia- year, Duke became the first hospital intion dose, but Siemens has shown that the United States to install Siemens’ David S. Enterline, MD, Division Chief Neuroradiology, Duke University Medicalhigh quality, low dose imaging is possi- Neuro BestContrast, an application that Center in Durham, North Carolina, USAble in even the most challenging neuro- dramatically increases gray/white matterradiology applications. Whole brain CT differentiation in non-contrast head CT SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 7
  • 8. Coverstory1A 1B 1C 1 Comparing conventional head CT imaging (Fig. 1A) with the new IRIS technology (Fig. 1B) shows decreased image noise. Combining IRIS with Neuro BestContrast technology provides very high image quality with decreased noise by utilizing reduced radiation dose (Fig. 1C).exams using the SOMATOM Definition experience of radiologists in Europe. In At the University Hospital in Göttingen,line of scanners. Enterline says that Neuro a blinded study whose results were pre- Germany, Peter Schramm, MD, DeputyBestContrast allows radiologists to sented at the 2009 scientific assembly Head of the Department of Neuro-better visualize subtle edemas as well and annual meeting of the Radiological radiology, was able to compare imagesas subtle signs of stroke, and to better Society of North America, neuroradiolo- acquired before and after the implemen-delineate the cortical margin, adding, gists preferred Neuro BestContrast data tation of Neuro BestContrast in a patient“My colleagues and I uniformly feel that sets in 97 % of cases.1 Other readers, with head trauma whose hospitalizationwith better image quality, our comfort who viewed the Neuro BestContrast coincided with the hospital’s transitionlevel and our ability to make diagnoses data set side-by-side with the traditional to the new software. “We were able toare significantly increased.” images, also rated image quality better perform an exact comparison intra-The improved image quality experienced in more than 90 % of the cases and individually, and in that case it was reallyby Enterline and his colleagues at Duke lesion conspicuity higher in more than impressive to see the improvement thatis also evidenced by clinical data and the 50 % of the cases. came along with Neuro BestContrast,” “I think Neuro BestContrast and IRIS work perfectly with each other and have additive value in reducing dose.” Christoph Becker, MD, Professor of Radiology and Section Chief of CT and PET/CT at Munich University Hospital, Munich, Germany8 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 9. CoverstorySchramm says. “The delineation of the 2edema and the margins of the edema Iterative Reconstruction in Image Space (IRIS)were definitely better visualized usingNeuro BestContrast, and the same ap-plies to the changes that occur in acutestroke.”Neuro BestContrast improves non-con-trast head images by taking advantage Fast Image Data Spaceof the fact that clinically important infor-mation from CT scans is contained in me-dium and low frequencies, while high fre-quencies are dominated by image noise.The software processes high-frequency Image data Imagedata differently than the low-to-medium recon correctionfrequency data, resulting in improvedtissue contrast without the amplificationof image noise. CompareEnterline says the use of Neuro BestCon-trast has the potential to reduce radiationdose as well. His preliminary data hasdocumented a 15 to 20 % improvement Masterin gray/white matter differentiation that Slow Raw Data Space reconcan allow for image acquisition at a lowerdose than is currently used. “Our institu-tion has traditionally fought for lowerdose,” he says, “and I think this will nowallow us to further reduce our dose.”IRISNeuro BestContrast can be combinedwith another new Siemens technologyknown as Iterative Reconstruction in Strong artifact and dose reductionImage Space (IRIS) to reduce dose and Well-established image impressionimprove image quality even further. Fast reconstruction in image space“I think they work perfectly with eachother and have additive value,” says 2 IRIS takes all of the data, which contains fine details as well as significant amountsChristoph Becker, MD, Professor of Radi- of noise, combines it in a master image and cleans it up in the fast-processing image spaceology and Section Chief of Computed rather than in the slow-processing raw data area. The result is that that high spatial resolu-Tomography and PET/CT at Ludwig-Maxi- tion is preserved and noise is reduced – without disrupting workflow.milians-University in Munich, Germany.Iterative reconstruction uses a correctionloop to improve image quality in severalsteps, or iterations. The idea was first bines it in a master image and cleans it of dense structures such as bone andintroduced in the 1970s, but the com- up in the fast-processing image space calcium, making it easier to visualizeputing power and time required for the rather than in the slow-processing raw or rule out subarachnoid hemorrhage.reconstruction made it impractical for data area. The result is that high spatial Preliminary data from Becker show thatuse in clinical settings. An alternative resolution is preserved and noise is re- IRIS reduces dose by 25 % in head CTknown as statistical image reconstruction duced – without disrupting workflow. exams yet achieves the same level ofreduced the time associated with itera- Becker says the combination of Neuro noise as filtered back projection, the tra-tive reconstruction but produced a tex- BestContrast and IRIS, which is available ditional method for image reconstruc-ture that radiologists found unaccept- on the SOMATOM Definition line of tion. Becker notes that clinicians canable. With IRIS, Siemens took a different scanners, allows him and his colleagues also choose to use the same dose as fil-approach. The algorithm takes all of the to better differentiate the basal ganglia tered back projection yet deliver signifi-data, which contains fine details as well and to see subtle signs of stroke. He cantly better image quality using IRIS.as significant amounts of noise, com- adds that IRIS also reduces the blooming In the United States, Ridgeview Medical SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 9
  • 10. CoverstoryCenter in Waconia, Minnesota, USA in- CT while the patient is still in the scanner,stalled IRIS on its SOMATOM Definition allows improved detection of acuteAS 40-slice CT and its Definition AS+ stroke, which has been substantiated in128-slice scanner early in 2010. Chief several studies,” says Ke Lin, MD, Assis-of Radiology, David Gross, MD, directly tant Professor of Radiology at New Yorkcompared images produced using IRIS University Langone Medical Center inwith traditional filtered back projection New York City, USA. In a study of 100images and then enthusiastically adopt- patients presenting to the emergencyed IRIS. “After two or three days, we department within three hours of strokedecided that there’s no sense in even onset, Lin and his colleagues found thatcomparing anymore,” Gross says. “With CT Perfusion provided significantly im-the improvement in radiation dose, the proved sensitivity and accuracy in acuteimage quality is not changed, so we stroke detection over non-contrast CT.just switched right over to it.” Specifically, the researchers found thatNeuro BestContrast and IRIS build upon “With the improve- CT Perfusion revealed 64.6% of acuteother Siemens innovations in neuro infarctions compared to 26.2 % for non-imaging that maximize diagnostic confi- ment in radiation contrast CT. CT Perfusion also had an ac-dence. The “Posterior Fossa Optimization” dose using IRIS, curacy of 76 % compared to an accuracyalgorithm, which was introduced in 2001 of 52 % for non-contrast CT.2and is implemented in all SOMATOM the image quality Lin and his colleagues obtained CT Per-Sensation and Definition scanners, is not changed, so fusion data from a z-direction coveragesignificantly reduces streaks and dark of 24 mm centered at the mid-basalbands, known as Hounsfield Bars, to we just switched ganglia which maximizes the visualiza-allow for better resolution with less right over to it.” tion of the middle cerebral artery terri-artifact. Siemens’ z-Sharp Technology tory. Still, the researchers noted thatprovides routine isotropic resolution of David Gross, MD, Chief of Radiology they missed ten infarcts that were out-0.33 mm, one of the industry’s highest, Ridgeview Medical Center, Waconia, side of this volume of coverage. The ad-enabling the visualization of small Minnesota, USA vent of whole brain CT Perfusion usinganatomical details such as fine vascular Siemens’ unique Adaptive 4D Spiral, how-structures. For ultra-high-resolution bone ever, further increases the value of CTimaging for inner ear structures, Siemens’ Perfusion by expanding the scan range.z-UHR Technology provides 0.24 isotro- The revolutionary scan mode, which ispic resolution. hemorrhage and ischemic stroke mimics, available on the SOMATOM Definition the use of perfusion CT imaging is in- line of scanners, overcomes the limita-Perfusion CT and CTA creasingly being adopted. “Dynamic CT tions of a static detector design by ap-While non-contrast head CT exams are Perfusion imaging, which can be acquired plying a continuously repeated bi-direc-still important for excluding intracranial immediately after the non-contrast head tional table movement that smoothly “Dynamic CT Perfusion imaging, which can be acquired immediately after the non- contrast head CT while the patient is still in the scanner, allows improved detection of acute stroke, which has been substantiated in several studies.”2, 4 Ke Lin, MD, Assistant Professor of Radiology, Department of Radiology, New York University Langone Medical Center, New York, USA10 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 11. Coverstory3 3 Perfusion CT imaging is in- creasingly be- ing adopted in daily routine. This function overcomes the limitations of a static detector design, which provides full brain coverage, and the poten- tial for improve- ment in diag- nostic accuracy for acute stroke.moves the patient in and out of the a smooth, fast, and user-friendly work- graphy adds approximately 10 minutesgantry over the desired scan range. Lin flow. A number of steps are automated, to the acute stroke workflow. “That’s nothas recently switched to a SOMATOM including motion correction, bone seg- a lot of time considering that the addi-Definition AS+ Scanner with all the mentation, arterial input function deter- tional information provided by the CTadvantages of full brain coverage. “With mination, and vascular pixel elimination. Perfusion and the CT Angiography maythe increased coverage, we now expect The software allows for simultaneous have very important implications for thefurther improvement in acute stroke visualization of functional parametric patient’s treatment and management,”detection accuracy, as well as the full maps of cerebral blood flow, cerebral Lin says.delineation of the ischemic penumbra blood volume, time to peak, mean tran-and the infarct core,” Lin says. sit time and other clinically important Reducing Dose in CT PerfusionThe stroke imaging workflow at NYU information. With the click of a button, Lin recognizes that, while the use of CTLangone Medical Center also includes clinicians can toggle between axial, Perfusion is moving from academica CT Angiography immediately following sagittal and coronal reformations. medical centers to community hospitals,the CT Perfusion exam to evaluate clot Lin and his colleagues acquire the CT some barriers to its widespread adoptionlocation, clot burden, and collateral re- Perfusion data for the whole brain in remain. Chief among them is a concerncruitment. Lin adds that the information just 45 seconds. Next, CT Angiography about the radiation dose associated withis also used for planning interventional data from the aortic arch through the the acquisition of CT Perfusion and CTprocedures such as mechanical throm- whole brain, a scan range of typically Angiography data. The use of Siemensbectomy. more than 30 cm, is acquired in a couple 4D Noise Reduction, however, can re-Lin says the fast image acquisition of of seconds to deliver valuable infor- duce the radiation noise of dynamic CTthe SOMATOM Definition AS+ 128-slice mation about the feeding vessels that Perfusion. The reconstruction techniquescanner, combined with the rapid post- are not covered by the initial perfusion treats the static anatomical informationprocessing of the Siemens syngo Volume scan. Post-processing takes an additional differently from the dynamically chang-Perfusion CT Neuro software, allows three to five minutes. In total, when ing perfusion information that resultsreading physicians to arrive quickly at an time for interpretation is accounted for, from the in and outflow of the contrastappropriate treatment decision through the use of CT Perfusion and CT Angio- agent. By sampling multiple passes over SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 11
  • 12. Coverstory4 the same volume it allows for the reduc- 4 With Volume Perfusion CT (VPCT) tion of image noise. So the initial scan fused with carotid can be performed with a lower tube CTA the perfusion current, thus saving dose. The result status of the brain is that radiation dose is reduced by tissue can be re- up to 50 % while retaining equivalent vealed. This patient presented after diagnostic information. onset of stroke and Although such dose-saving features can underwent lysis benefit patients, Lin cautions that the therapy. The follow- issue of dose must be kept in context up examination during an acute stroke. “The acute criti- showed a complete revascularization cal ischemic event that could kill the of the previously patient takes priority over the slight in- hypoperfused area. crease in radiation dose that is imparted Courtesy of Uni- to the patient in order to arrive at a versity Hospital Göt- tingen, Germany. more accurate diagnosis, a clearer understanding of the patient’s patho- physiology, and a broader understand- ing of the acute event,” he emphasizes. Lin points out that only 2 % of acute stroke patients receive intravenous tissue plasminogen activator (tPA), the only U.S. Food and Drug Administration approved drug for acute stroke. He says this low rate is largely because of the restrictive three-hour time window in which the drug is approved for use. An additional factor is that an unknown5 5 With Dual Energy time of onset, which occurs in up to (DE) Bone Removal 25 % of acute stroke patients, disqualifies vascular structures patients from receiving the drug. can quickly be sepa- rated from the bones In Europe, the University of Göttingen, even in difficult areas Germany has established stroke units such as the base of where patients are examined in an elon- the skull. This clearly gated time window of 4.5 hours after the proves the clinical onset of stroke, based on results from the benefit of DE for clinical routine. Third European Cooperative Acute Stroke Courtesy of University Study3 (ECASS III), so that more patients Hospital Munich, can benefit from tPA treatment. Campus Großhadern, Rather than making treatment decisions Germany. based on the clock, the use of perfusion CT and CT Angiography can help deliver truly personalized medicine for acute stroke patients. The adage “time is brain” still applies, Lin says, but technology can enable a new paradigm that says that “physiology is brain.” “The rallying cry of ‘physiology is brain’ is really a summation of the proposal to use a patient’s own pathophysiology, his own cerebral hemodynamics, to deter- mine whether he still has significant amounts of salvageable tissue at risk and therefore should be a candidate for acute stroke therapy within the confines 12 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 13. Coverstory “We were able to perform an exact com- parison intra-individually, and in that case it was really impressive to see the improvement that came along with Neuro BestContrast.” Peter Schramm, MD, Deputy Head of the Department of Neuroradiology, University of Göttingen, Germany of the safety profile of the various treat- as the SOMATOM Definition and neously at different energies can acquire ments,” Lin says. Definition Flash “syngo Dual Energy two data sets with different attenuation Direct Angio” offers a similar technique levels. A Range of Neuro Imaging which permits direct removal of bone “DSA is susceptible to any motion that Options using only one scan. It uses the fact occurs between the exams,” Becker Of course, the use of CT in neuroradio- that two X-ray sources running simulta- points out, “whereas with Dual Energy logy is not limited to patients with acute there are never any motion artifacts stroke. syngo Volume Perfusion CT when we extract the bone from the Neuro software provides a rapid and dataset.” The scan speed of up to automated evaluation of brain tumors 45,8 cm per second and the temporal that enhances the ability to grade resolution of 75 milliseconds that is tumors, plan biopsies, and monitor possible with the SOMATOM Definition therapy. The use of MRI to image brain Flash can be particularly helpful in tumors is well established, but Schramm scanning the carotid arteries, Becker notes that the use of CT Perfusion can says, since they quickly fill with contrast be advantageous in some cases. Intra- media. He says the high-pitch Flash cerebral lymphomas, for instance, can mode makes it easy to accurately time be difficult to differentiate using MRI but the scan so that pure arterial phase can can be easily identified using perfusion be achieved without venous overlay that CT. “My prognosis is that CT will gain can impair visualization. Additionally, even more ground in the coming years, “Siemens is commit- the information from dynamic CTAs and this is due to the fact that it is using the Adaptive 4D Spiral technology ted to reducing broadly available, less expensive than offers new insights in cerebral hemo- MRI, and, in many cases, offers better radiation dose to dynamics to evaluate endoleaks, Takayasu spatial resolution,” he says. disease, or complex hemodynamics of Another tool that significantly improves the lowest possible dural arteriovenous fistula. Becker adds workflow and diagnostic confidence in level. Innovations that Siemens’ latest imaging software, the assessment of vascular structures of syngo.via*, speeds workflow by allowing the head and neck is syngo.via* CT such as IRIS are him and his colleagues to access and Neuro DSA (Digital Subtraction Angio- evidence of this share data from anywhere** within the graphy), which automates the removal network. of bone from images, even in difficult commitment as is areas such as the base of the skull. The X-CARE” As Low as Reasonably very robust technique uses a non-con- Achievable trast, low-dose scan that is acquired be- Sami Atiya, PhD, Chief Executive “In developing advances that aim to im- fore the actual CT Angiography and is Officer, Business Unit Computed prove the diagnostic confidence of phy- then used to automatically remove all Tomography, Siemens Healthcare, sicians and patient outcomes, Siemens the bone structures in the scanned re- Forchheim, Germany. is committed to reducing radiation dose gion. On Dual Source CT scanners such to the lowest possible level following the * syngo.via can be used as a standalone device or together with a variety of syngo.via based software options, which are medical devices in their own rights. ** Prerequisites include: internet connection to clinical network, DICOM compliance, meeting of minimum hardware requirements, and adherence to local data security regulations.Somatom_26_Inhalt_USA.indd Abs2:13 10.05.10 09:39
  • 14. Coverstory 6A 6B 6 X-CARE is especially important in CT for protecting dose sensitive tissue, e.g. the lenses of the eyes (Fig. 6A). To further reduce the radiation dose for the lenses, additional safety devices like an eye protector (Fig. 6B) can be used.7 Dose Shield Selective Photon Shield 80 kV 140 kV Attenuation B Attenuation A Dose Shield 2007 2008 2008 Adaptive Dose Shield Selective 4D Noise Photon Reduction Shield Up to 25 % dose reduction No dose penalty Up to 50 % dose reduction 7 Siemens has been a pioneer in creating a host of innovative technical features that significantly reduce radiation exposure in CT scans. Using these features may result in variant values of dose reduction. 14 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 15. Coverstory‘as low as reasonably achievable’ Definition AS and Definition Flash scan- news media. Enterline and others say(ALARA) principle. Innovations such as ners. With traditional spiral CT exams, that, as a result, patients increasinglyIRIS are evidence of this commitment, patients are exposed to unnecessary ask about the potential consequencesas is Siemens X-CARE”, says Sami Atiya, radiation at the beginning and the end of their exposure to medical imaging.PhD, Chief Executive Officer, Business of the exam. The Adaptive Dose Shield Discussing the risks and benefits asso-Unit Computed Tomography, Siemens automatically moves collimators into ciated with CT imaging with patientsHealthcare in Forchheim, Germany. The place to block this unnecessary exposure, helps reassure them, Enterline says, andapplication protects sensitive organs by thereby reducing dose by up to 25 %. so does having technology that minimizeslowering the tube current during the Becker notes that the proportion of over- dose. “It’s our responsibility to do whatportion of the rotation in which the area beaming is especially significant over we can to minimize dose and to makeof concern would otherwise be near the small scan ranges, so pediatric patients sure that the studies are appropriate,”X-ray source. Enterline, at Duke University and those requiring head CT exams he adds. “It’s the right thing to do forMedical Center in Durham, USA, points stand to gain the most. patients.”out that X-CARE is especially important Becker and his colleagues further reducefor protecting the lenses of the eyes, radiation dose with Siemens CARE Sameh Fahmy is an award-winning freelancewhich are particularly radiosensitive. He Dose4D, which provides real-time mo- medical and technology journalist based in Athens, Georgia, USAsays the technology has allowed him and dulation of dose, based on patient sizehis colleagues to reduce dose to the lens and the anatomy being imaged. “I totally 1 Diehn F, et al. – RSNA 2009 presentation SSE23-up to 30 % in preliminary data without insist on using it,” Becker says. “We 03: A Preliminary Study of Novel Post-processinga reduction in image quality. They don’t switch this option on and off – Tool: Multi-Band Filtration of Noncontrast Head CTs.routinely use X-CARE in their practice. we use it for every CT scan.” 2 Lin K, et. al. – Cerebrovascular Diseases 2009;Another technology that minimizes dose Concerns about radiation dose have 28:72-79to patients is the Siemens Adaptive moved from the medical journals and 3 Hacke W, et al. – NEJM 2008;359 (13) 1317-1329Dose Shield, available on the SOMATOM conference halls into the mainstream 4 Thomandl B, et al. – RadioGraphics, 23:565-592 X-ray low Image data Image recon correction X-ray on 2008 2008 2009 Neuro BestContrast X-C ARE Iterative Reconstruction in Image Space (IRIS) Up to 30 % dose reduction Up to 40 % dose Up to 60 % dose reduction reduction SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 15
  • 16. NewsAffordable Performancein 16- and 64-slice CTAt the European Congress of Radiology in March 2010, Siemensintroduced new 16- and 64-slice systems to the market: The SOMATOMEmotion Excel Edition and the SOMATOM Definition AS Excel Edition.By Jan Freund, Steven Bell and Rami Kusama, Business Unit CT, Siemens Healthcare, Forchheim, GermanyThe new Excel Editions from Siemensare especially cost-effective versionsof the SOMATOM Emotion 16-slice andSOMATOM Definition AS 64-slice scan-ners. The Excel Edition is the result ofSiemens’ commitment to developmentsthat bring new technology to morepeople through reducing the costs ofthese innovations. These new additionsto the Emotion and Definition AS fami-lies offer customers access to 16-sliceand 64-slice Siemens technology inscanners that include many of the ad-vantages that existing Emotion andDefinition AS customers know, at asignificantly more advantageous price.On the one side, the SOMATOM EmotionExcel Edition is especially designed tomake it easier for small and medium-sizedhospitals and practices to enter theworld of 16-slice computed tomography.It continues the success story of theEmotion platform that remains the mostpopular CT in the world.The success of the SOMATOM Emotionplatform to date has been due to superbimage quality, a simplified and efficientworkflow, and the ability to save moneyover the life of the CT system. To date,there are around 7000 systems installedworldwide. The 16-slice SOMATOMEmotion Excel Edition builds on the priorsuccess of this imaging platform to bringthese advantages to more customersand patients. It offers the smallest focal- The new Excel Editions from Siemens are especially affordable versions of the SOMATOM Emotionspot size and a high number of effective 16-slice and SOMATOM Definition AS 64-slice scanners.16 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 17. Newsdetector channels for increased image ness is the unprecedented adaptability the scanner offers the highest degree ofclarity and resolution. It continues to any patient and any clinical question, flexibility with its 78 cm gantry and aSiemens’ focus on dose reduction with making it an expert in virtually any table load capacity of up to 300 kg thusthe exclusive CARE Dose4D algorithm clinical field. With the introduction of avoiding delays and patient exclusions.offering dose reduction of up to 68 % in the SOMATOM Definition AS Excel Combined with the industry’s highestroutine scanning. Customers will also Edition, Siemens continues to lead the sub-mm resolution and coverage speedcontinue to benefit from the easy-to-use world of innovation by making two ends in its segement, a rotation speed of 0.33syngo user interface that Siemens meet: bring outstanding imaging tech- seconds and unique applications like 3D-customers across all imaging modalities nology and advanced clinical applica- guided CT interventions, the SOMATOMare familiar with. tions to budget-minded customers. Definition AS Excel Edition deliversOn the other side, the SOMATOM The SOMATOM Definition AS Excel state-of-the-art CT imaging and canDefinition AS Excel Edition introduces Edition addresses the growing market for cope with literally every need in clinicala high-end, yet affordable 64-slice work- entry-level 64-slice scanners. Especially routine. At the same time, it sets stan-horse for both everyday clinical routine this segment is currently facing a very dards in patient safety by providing aand advanced imaging. It will broaden strong trend towards commoditization, unique composition of dose protectionthe portfolio of the SOMATOM Definition demanding a reliable, cost-efficient features like CARE Dose4D, the innova-AS family and continue its legacy as the 64-slice system to realize high through- tive Adaptive Dose Shield, which avoidsworld´s first adaptive scanner. Its unique- put in everyday clinical routine. For this, unnecessary overradition in every spiral scan, or IRIS – the Iterative Reconstruc- tion in Image Space which allows a dose reduction of up to 60 %. With its onsite upgradeability to the standard AS 64-slice and AS+ 128-slice configura- tions and with the smallest footprint in its segment, the new Edition is the ideal system for customers that are both performance and budget-minded. Finally, together with syngo.via* – Siemens’ new imaging software – the SOMATOM Definition AS Excel Edition grants access to a whole new world of workflow improvement. By moving from post-processing of image data to having it pre-processed and ready to review, it sets new standards in ease-of-use and thus clinical efficiency. The SOMATOM Emotion Excel Edition was released on the first of April 2010 and the SOMATOM Definition AS Excel Edition on the first of May. For more information about the new Excel Editions, the local Siemens representative can be contacted. www.siemens.com/ somatom-emotion www.siemens.com/ somatom-definition-as* syngo.via can be used as a standalone device or together with a variety of syngo.via based software options, which are medical devices in their own rights. SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 17
  • 18. 1NewsBest Balance BetweenImage Qualityand Reduced DoseIterative Reconstruction in ImageSpace (IRIS) provides individual choicesand benefits for all patients. 1 Since autumn 2009 in the University Hospitals Munich and Erlangen-Nuremberg all CT scan protocols have been changed to use IRIS in clinical routine.By Annette Tuffs, MDIt is a difficult choice for physicians time and enormous computing capacity recounts. Which patients will benefitto decide what benefits the patient most, and therefore – before IRIS – was not most from the use of IRIS? “All patientsthe highest resolution with best image feasible for use in clinical routine. Now, should have the benefit,” says Lell, “andquality and diagnostic confidence – Siemens engineers and scientists have therefore we changed all our protocolsor the lowest radiation level to reduce optimized the process and developed to include IRIS.” However, there are spe-the long-term risks for their patients. IRIS, where time and computing capacity cific patient groups that should benefitModern CT technology like IRIS cannot are no longer an issue. even more, for instance children, sinceentirely overcome this dilemma, of “We are enthusiastic about this innova- they demand the smallest possible dosecourse, but it provides flexible solutions tive method in CT scanning, that´s why because of long-term, higher potentialthat allow choices for the individual we use it in our greatly improved daily radiation risks and, at the same time,patient according to age, condition, routine,” says Professor Joseph Schoepf, have smaller body structures, which aresuspected pathology and the specific CT MD, whose Department of Radiology at more difficult to visualize in CT scanninginvestigation being performed, thereby the Medical University of South Carolina, procedures.permitting the reading physician to Charleston, USA, was one of the first Lell specifically mentions the group ofcarefully weigh the benefits of highest to gain clinical experience with IRIS. children and juvenile patients with muco-possible resolution against the advan- His department has been using IRIS on viscidosis, an unstable condition that cantages of minimized radiation exposure. a routine basis since autumn 2009 for require frequent CT scans. He is optimistic about 15 patients per day. that, with the ongoing fine-tuning of IRIS,IRIS – A Success Story further dose reductions will be possibleThe peak of these impressive develop- All Patients Benefit and he is confident that the magic thresh-ments is IRIS, which stands for Iterative Several university hospitals, in Germany old of up to 70 % reductions can beReconstruction in Image Space. It had and abroad, have already been able to reached.its debut at the 2009 RSNA meeting in gather extensive clinical experience withChicago and has proven to be another IRIS. One of them is the University Special Object:Siemens success story in substantially Hospital, Erlangen in Germany, where Cardiovascular Stentreducing radiation dose. It is based upon Michael Lell, MD, Senior Physician at the Another group of patients that especially“iterative reconstruction,” a method first Radiology Institute, has been involved in benefit from IRIS is the increasing num-developed in the 1970s to reduce noise studies concerning the potential of IRIS ber of obese patients of both gendersin CT images. in reducing radiation dosage. In one of his and all ages. Even when the smaller ofIterative reconstruction includes a “cor- studies, that he will submit for publica- these morbidly obese patients are able torection loop,” in which images are repeat- tion in the next months, more than 70 squeeze through the CT gantries, theedly calculated by assumptions. The patients have been evaluated with and resulting images are often substandard,image becomes softer in homogenous without IRIS. The radiologists in Erlangen sometimes strikingly so.tissue regions while, at the same time, were looking specifically at the abdo- “The diagnostic results can be greatlyhigh-contrast tissue boundaries are main- men. “As a preliminary result, we can say improved with IRIS in obese patients,”tained. Image resolution and image noise that we were able to achieve a 50 % says Schoepf. His hospital mainly caresare no longer closely inter-dependant. dosage reduction while maintaining for patients with either digestive diseaseHowever, this process required a lot of high standards of image quality,” Lell or cardiovascular disease. His special18 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 19. Newsinterest is testing IRIS in patients with of the liver, especially when searching to prove this effect. “IRIS has improvedheart stents that are supposed to keep for small metastases of malignant tumors our daily routine because of higher im-the coronary arteries open. elsewhere in the body. “With IRIS, we age quality or lower dose.” The Munich“Coronary stents are the Achilles’ heels have a much better chance of finding radiologists are currently running studiesof radiological heart diagnostics,” says these lesions,” says Schoepf. where the diagnostic results from IRISSchoepf. With IRIS, it is easier to detect Konstantin Nikolaou, MD, Prof. of images are compared with conventionalwhether there is a true obliteration of Radiology, Associate Chair of the Depart- images, and their recent finding havethe stent or the so-called, “beam harden- ment of Radiology, Munich University shown that an experienced radiologisting,” that only simulates closure of the Hospital, Germany, also agrees that all can easily adjust to the new kind ofstent. Preliminary results of a study at patients can profit from the use of IRIS, image impressions. “A trained eye canthe Medical University of South Carolina some of them more than others. Since benefit from the IRIS specific images –have already shown that IRIS will help last autumn, he and his colleagues have the improved spatial image resolution into make this important distinction, that changed all the protocols to use IRIS. By high contrast areas, with less noise inhas a major impact on therapeutic deci- April 2010, more than 3.000 patients of the low contrast areas.”sions and results. all ages and conditions profited from improved IRIS image quality or doseSearching for Small Liver reduction. Overall dose reductions in all Annette Tuffs, MD, is a medical journalistMetastases body regions of about 30 % were based in Heidelberg, Germany. The former medical editor of the daily Die Welt hasAnother important area with far-reaching achieved, and current scientific studies been contributing to the Lancet and thetherapeutic consequences is the imaging at the University of Munich are designed British Medical Journal since 1990.IRIS Now Extended to SOMATOM Definition AS 20and SOMATOM Definition AS 40By Rami Kusama, Business Unit CT, Siemens Healthcare, Forchheim, GermanyBecause at Siemens dose reduction has increases the ability to see the smallestcontinued to be given top priority, assur- detail; however, it is directly correlated Iterative Reconstuction in Image Space (IRIS)ing both patients and medical personnel with increased image noise.the best in medical care with the least In an iterative reconstruction, a correc-possible risk, the availiability of IRIS with tion loop is introduced into the image Fast Image Data Spacethe SOMATOM Definition, SOMATOM generation process. To avoid long recon-Definition Flash, and SOMATOM struction times, IRIS first applies a rawDefinition AS+ and AS 64, will be ex- data reconstruction only once. During this Image data Imagetended to the SOMATOM Definition AS initial raw data reconstruction, a so- correction recon40, as well as AS 20. Now all scanners called and newly developed masterfrom the SOMATOM Definition family* volume is generated that contains the full Comparewill benefit from excellent diagnostic amount of raw data information, but atimage quality with levels of dose lower the expense of significant image noise. Masterthan ever before. With IRIS, Siemens’ During the following iterative correc- Slow Raw Data Space reconsmart approach to iterative reconstruc- tions, the image noise is removed with-tion, up to 60% additional dose reduction out degrading image sharpness. Thecan be achieved in a wide range of daily new technique results in increased im-routine CT applications. age quality or dose savings of up to 60 %Dose reduction with CT has been limited for a wide range of clinical applications.by the currently used filtered back projec- 90 day, free trial licenses for IRIS aretion reconstruction algorithm. When now also available. The local sales Up to 60 % dose reduction Image quality improvementusing this conventional reconstruction of representative can be contacted for Fast recon in image spaceacquired raw data, a trade-off between details. Well-established image impressionspatial resolution and image noise has to 90 day, free trial licensebe considered. Higher spatial resolution *requires syngo CT 2010A or syngo CT 2010B SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 19
  • 20. News syngo CT 2010B Now Available: New Software Version for the SOMATOM Definition AS Launched By Jan Freund, Business Unit CT, Siemens Healthcare, Forchheim, Germany The new syngo software version, CT quency data, it specificly optimizes the Reduction and the Adaptive Signal Boost 2010B, for SOMATOM Definition AS tissue contrast without amplifying the will be available free of charge. CARE scanners, was released in April 2010. image noise, resulting in an improve- Contrast II synchronizes CT scan and It makes IRIS (Iterative Reconstruction ment of signal to noise ratio of up to contrast media injection. With its open in Image Space) available to SOMATOM 30 %. In dynamic studies, such as CT interface technology, it is ready for Definition AS customers. With IRIS, a Perfusion images, noise can be signifi- future applications. The syngo CT 2010B dose reduction of up to 60% is possible cantly reduced. As a result, radiation will be delivered with all new systems without compromising image quality. dose can be lowered without compro- beginning in May 2010 and as a field In addition, native head-image quality mising image quality. The Adaptive roll-out to the complete installed base can be significantly improved with Signal Boost optimizes lower signals, of the SOMATOM Definition AS. Neuro BestContrast without an increase e.g. when low dose or obese protocols in dose. By separating low and high fre- are used. Neuro BestContrast, 4D Noise 20 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazineSomatom_26_Inhalt_USA.indd Abs2:20 10.05.10 09:39
  • 21. NewsWorldwide Dose CounterWith the SOMATOM Definition Flash, coronary CTAs become routinelyavailable at dose levels below 1 mSv. Now everybody can check dose valuesfor themselves, in daily routine, worldwide, and in almost real-time.By Peter Seitz, Business Unit CT, Siemens Healthcare, Forchheim, GermanyWith the SOMATOM Definition Flash, Spiral Cardio scans – our all-new high- every 30 minutes by statistical datacoronary CTAs become routinely available pitch mode for scan speeds up to 458 analysis that is sent from SOMATOMat dose levels below 1 mSv. Now every- mm/s – publicly available. With this ultra- Definition Flash installations worldwide.body can check dose values for them- fast scanning, the SOMATOM Definition In addition latest news and furtherselves, in daily routine, worldwide, and Flash acquires the entire heart in only information are available on Siemensin almost real-time. Being able to image around 270 ms, reducing radiation expo- Low Dose CT.the coronary arteries with a radiation sure to the minimum, all the while main-dose of below 1 mSv is impressive in taining the excellent image quality thatitself, but it becomes even more impres- previously was only possible at muchsive when this happens everyday, all higher dose levels.around the globe and not just in a few At www.siemens.com/low-dose anyonespecialized cases. That’s why Siemens can observe the current average dose on www.siemens.com/low-dosedecided to make average doses of Flash the installed base. This value is updated View on the Siemens Healthcare dose counter homepage. SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 21
  • 22. NewsInternational CT ImageContest – Highest ImageQuality at Lowest DoseBy Rami Kusama, Business Unit CT, Siemens Healthcare, Forchheim, GermanyExcellent image quality is an essential ences with other users. For this reason, than 30 countries were submitted andrequirement in computed tomography Siemens initiated the International CT were evaluated by a jury of internation-(CT). At the same time, the patient’s Image Contest from October 1, 2009 to ally renowned professors.radiation exposure should be kept as low February 1, 2010 asking physicians fromas possible. Siemens wants to motivate around the world to send in their work The Juryits users to utilize all dose reduction to compete for the best image quality at Professor Stephan Achenbachfeatures available on their CT scanners the lowest possible radiation dose. University of Erlangen, Germanyto the full extent and share their experi- Around 300 low dose cases from more Professor Dominik Fleischmann 1 1 Winner in CardiacModerate Atherosclerosis(SOMATOM Definition Flash /0.97 mSv dose), Yuko Utanohara,MD and co-authors:Nobuo Iguchi, MD, PhD; KenjiHorie; Tatsunori Niwa; SakakibaraHeart Institute, JapanHistory:A 68-year-old female, non-smoker,with a 3-year history of hyperlipid-emia, shortness of breath and chesttightness on exertion was referredfor detailed examination to our de-partment after heart murmur wasdetected for the first time.Diagnosis:The coronary arteries showedmoderate atherosclerosis on CT. Jury statement:“This case study is not only aestheti- cally pleasing, but in addition, it demonstrates that supreme diag- nostic accuracy can be achieved at very low doses, with unambiguous visualization of the coronary artery lumen up to the very distal seg- ments of the coronary artery tree.”22 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 23. Stanford University Medical Center, USA Flash, in the categories of: cardiac,Professor Elliot K. Fishman neuro, abdomen and pelvis, vascular,Johns Hopkins University Hospital, USA thorax, as well as Dual Energy. EveryProfessor Yutaka Imai internet viewer could select theirTokai University School of Medicine, “favorite image” in a public voting.JapanProfessor Zengyu Jin Winner AnnouncementPeking Medical Union College, China The winner announcement took placeProfessor Borut Marincek at the ECR 2010 in Vienna during theUniversity Hospital Zurich, Switzerland Bayer Schering Pharma and SiemensProfessor Maximilian Reiser Healthcare joint Satellite Symposium.Ludwig-Maximilians-University Munich, Winning images (Figs. 1–6) were ex- Winner in public voting: Interrupted AorticGermany hibited at the Grand CT Image Gallery. Arch (SOMATOM Definition/ 0.45 mSv dose), Pannee Visrutaratna, MD, Maharaj NokornProfessor Uwe Joseph Schoepf For those who could not attend the Chiangmai Hospital, ThailandMedical University of South Carolina, ECR, the winners were announced atUSA the same time on the contest website History: A five-month old girl has suffered from tachypnea, poor feeding, and poor weight gain and via press release.Participation since she was one month old.Images could be submitted online on www.siemens.com/Image-Contest Diagnosis: Interrupted Aortic Arch. The arch The free contest poster can be interruption occurs distal to the origin of thea contest website by users of the ordered at: left subclavian artery. The descending thoracicSOMATOM Definition, SOMATOM Defini- aorta is supplied by a large patent ductus www.siemens.com/ct-postertion AS, as well as SOMATOM Definition arteriosus.2 2 Winner in Neuro Perfusion after Occluded Stent (SOMATOM Definition AS / 7.55 mSv dose), Robert McGregor, MD; Bound- ary Trails Health Centre; Canada History: Carotid CTA and perfusion imaging was obtained in a 55-year-old female post SILK stent for right internal carot- id aneurysm. Diagnosis: CTA revealed occlusion of the stented right internal carotid artery. Perfusion imaging demonstrated decreased CBF, increased MTT, but maintained CBV, indicating a large perfusion defect without significant infarction. Jury statement: “The case nicely presents the potential of comprehensive stroke assessment by CT Perfusion. CT Perfusion may suffer from image noise with unsharp margins of the infarcted territory. In this example, the margins of the infarct are clearly displayed allowing determination of the extent of the <<bitte überall mitmit Dosis-Tacho>> <<bitte überall Dosis-Tacho>> infarction precisely.” SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 23
  • 24. News 3 3 Winner in Abdomen and PelvisCancer of Pancreas (SOMATOM Definition/ 6.34 mSv dose), Prof. Dan Han, MDand Yu-Hui Chen, MD; Hospital of Kun-ming Medical College; P.R. ChinaHistory:A 59-year-old male had experienced up-per abdominal pain for four years. A massin the head and neck of pancreas wasidentified in both Ultrasound and MRI.Diagnosis:The advanced cancer of pancreas resultedin a significant narrowing in the portalvein and the collateral circulation wasestablished. Jury statement:“This CTA shows the encasement of the portal vein / SMV confluence making the patient unresectable. The case with the highest image quality is the one that pro- vides the most information content for the radiologist and the referring physician. This case fulfills these criteria completely at a very low radiation dose.” 4 4 Winner in VascularChild Aortic Transposition (SOMATOMDefinition Flash / 0.25 mSv dose), GregoryNicaise, MD and co-author: Philippe Ever-arts, MD, Centre Hospitalier de Jolimont,BelgiumHistory:A 2-year-old child with chronic dyspnea andpulmonary infection was presented for a CTexamination.Diagnosis:Aortic transposition, left bronchial stenosis,atelectasy, pulmonary clarity and air trap-ping were detected. Jury statement:“This case demonstrates excellent image quality achieved at ultra-low dose permit- ting a comprehensive and accurate diag- nosis in a complex congenital heart de- fect.”24 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 25. News5 5 Winner in Thorax Flash ECG Thorax (SOMATOM Definition Flash / 0.82 mSv dose), Petter Quick; CMIV Linköping University; Sweden History: A 47-year-old woman was presented to the CT-department with unspecific chest pain. Diagnosis: The CT examination showed no pathology and could successfully rule out coronary disease, pulmonary embolism as well as lung tumor. Jury statement: “This case represented everything that chest CT can be – a high quality, volume data set that can provide information for vascular imaging as well as the lung parenchyma. High quality imaging re- quires the right scanner, the right proto- cols and the right execution of these protocols. This image tells that story very nicely.”6 6 Winner in Dual Energy Carotid and Circle of Willis (SOMATOM Definition Flash / 1.12 mSv dose), João Carlos Costa, MD, Diagnóstico por Imagem, Lda, Portugal History: A healthy 75-year-old female was presented to the CT-department with a family history of carotid artery stenosis. Diagnosis: Small atherosclerotic plaques in the emergence of braquiocephalic trunk and left carotid artery were identified. Jury statement: “This case illustrates the power of Dual Energy CT for tissue differentiation. In a single image and at tremendously low doses, all tissue layers in the human body can be simultaneously and intuitively displayed and provide the anatomic con- text of the target structure, the carotid circulation.” SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 25
  • 26. BusinessNew Feature: NeuroImage Quality Surpassesall ExpectationsA better and quicker workflow that leads to more time for patient care anddiagnosis – this is the bottom line for Peter Schramm, MD, of the Universityof Göttingen, Germany, after testing the new features of syngo CT 2010B.But specifically for him, as neuroradiologist, the new dimension in neuroimage quality is also a main improvement and a very impressive one.By Wiebke Kathmann, PhDThe new software version, syngo CT physicians worldwide to test the new Neuro BestContrast absolutely fulfilled2010B, offers several new features in- features in the clinical environment on a Schramm’s expectations. „Simply bycluding Neuro BestContrast, 4D Noise SOMATOM Definition AS+ scanner. As a looking at the images in our digitalReduction, Iterative Reconstruction in neuroradiologist, he was especially im- Picture Archiving and CommunicationImage Space (IRIS), CARE Contrast II and pressed by Neuro BestContrast because System (PACS), we could recognize theAdaptive Signal Boost. Together they it achieves a very substantial improve- point in time at which the new softwaretruly improve the diagnostic precision ment in image contrast, thereby signifi- had been installed. A lot of our patientsand workflow as could be clearly demon- cantly improving the distinction be- get a follow-up CT scan, so we couldstrated during the Market Entrance tween gray and white matter in the also compare scans from before andPhase (MEP) by Peter Schramm, MD, brain – a very important feature in the after the software was implemented.Deputy Head of the Neuroradiology diagnosis of acute stroke patients where When Siemens told us that they wereDepartment at the University of tissue changes on the scale of 5 to 10 aiming at improving the differentiationGöttingen. He was among the first HU can decide between life and death. of brain tissue, we were wondering how A better and quick- er workflow that leads to more time for patient care and diagnosis – this is the bottom line for Peter Schramm, MD, of the Univer- sity of Göttingen.
  • 27. Business rial sequence. For the patient that would search, or clinical purposes – saves time,“ mean one instead of three CT scans, explains Schramm.”This makes it a very consequently a shorter examination interesting feature for both research time and, in the end, less radiation.“ and in clinical routine.“ Less Radiation Benefit for the Obese Patient With the Iterative Reconstruction in As for the Adaptive Signal Boost, Image Space (IRIS), Siemens recently Schramm is convinced that it will im-“At some point in the introduced a new approach to addition- prove diagnostic precision and reliability, ally reduce dose by up to 60 % and, at for example in CT imaging of the spine. future, neuroradiolo- the same time, improve image quality for “This application is on the rise due to gists may no longer a wide range of clinical applications. Af- improvements in CT technology and the ter an initial raw-data reconstruction, a growing number of bariatric patients need to perform newly developed master image is gener- who simply do not fit into the MRT and the complete stroke ated followed by several iterative correc- where it is crucial to provide the re- tions that remove image noise without quired image quality for clinical evalua- CT protocol.” degrading image sharpness. With this tion.” Here the Adaptive Signal BoostPeter Schramm, MD, approach, IRIS achieves a similar image improves the diagnostic accuracy in softUniversity of Göttingen, Germany quality as with true iterative reconstruc- tissue imaging, especially of paraverte- tions but avoids the long reconstruction bral and intra-spinal structures. “In rou- times, as multiple translations from and tine examinations, these features do notthey would be able to achieve an im- to the raw data are not needed. Forprovement in contrast without losing Schramm, the main promise IRIS holdsspatial resolution. But they did – by with this new method is a reduction ofprocessing low and high frequencies radiation dose. So far, he and his team “Most likely, IRIS willseparately.“ have worked with the regular dose. After allow for a reduction testing IRIS, they will now commenceOne-Stop-Shopping with a controlled, stepwise dose reduc- of radiation doseFor clinicians performing perfusion im- tion during the next few weeks. In 10 % by 20-30 % in neuro-aging, 4D Noise Reduction is the most steps with about 500 neuroradiologicalinteresting feature. Static and dynamic cases each, they hope to prove that IRIS radiology.”components are treated separately as allows a reduction of radiation dose while Peter Schramm, MD, University of Göttingen, Germanya means to reduce noise, thus improving keeping the image quality at the samethe image quality and clinical outcome. level. “Most likely, IRIS will allow for aSchramm could confirm this in acute reduction by 20 % in neuroradiology. Instroke patients, who are frequently quite spinal CT, I expect a reduction by 25 toagitated. 30 % without any loss of image quality,”The main advantage, however, that says Schramm. “In very obese patientsSchramm sees with 4D Noise Reduction and abdominal CT applications, I canis a reduction in radiation dose while realize a dose reduction of up to 60 %.“still being able to get all the diagnosticinformation from one 4D volume perfu- Saving Timesion scan. “At some point in the future, Regarding the use of CARE Contrast II –neuroradiologists may no longer need the new coupling interface for scannerto perform the complete stroke CT and bolus injector – Schramm experi-protocol consisting of a non-contrast CT, enced two advantages: first, the im- necessitate changes in the workflow fora whole brain perfusion CT including 4D proved workflow for the technician due the technician,” says Schramm, “Theyspiral scans and a CT Angiography of the to the synchronization of injector and hardly notice the changes, whereas thebrain vessels. Due to the precision with scanner and therefore improved patient clinical results are very impressive for4D Noise Reduction, there could be ‘one- care; second, and more important, the the radiologist at the end of the line.”stop-shopping’, the non-contrast CT time saved due to the automatic and Wiebke Kathmann, PhD, is a frequent contributorcould be skipped by using the first of the digital transfer of the whole dataset on to medical magazines in the German-speakingmulti-spiral CT images before the con- contrast media, flow rate etc. to the world. She holds a Master in biology and a PhD in theoretical medicine and was employed as an edi-trast medium arrives and the angio-in- patient protocol. ”This archiving of the tor for many years before becoming a freelancer information could be taken from one arte- complete data set – be it for legal, re- 1999. She is based in Munich, Germany. SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 27
  • 28. Clinical Results Cardio-VascularCase 1Adenosine Myocardial Stress ImagingUsing SOMATOM Definition FlashBy Gudrun Feuchtner,1, 4 Robert Goetti,1 André Plass,2 Monika Wieser,2 Christophe Wyss,3Fernando Vega-Higuera,5 Hans Scheffel,1 Michael Fischer,1 Hatem Alkadhi,1 Sebastian Leschka11 Institute of Diagnostic Radiology, University Hospital Zurich, Switzerland2 Clinic of Cardiovascular Surgery, University Hospital Zurich, Switzerland3 Cardiology Division, University Hospital, Zurich, Switzerland4 Department of Radiology II, Innsbruck Medical University, Austria5 Business Unit CT, Siemens Healthcare, Forchheim, Germany.HISTORY COMMENTSA 51-year-old male with atypical chest defect indicating ischemia anteroseptal Adenosine stress-imaging of reversiblepain and intermediate coronary risk pro- at midventricular level (Figs. 1A–1B) myocardial ischemia is feasable withfile (cigarette smoking and hypercholes- corresponding to left artery descending 128-slice Dual Source CT with compre-terolemia) underwent two coronary (LAD) stenosis. No defect was found in- hensive evaluation of coronary arteries.128-slice Dual Source CT Angiographies: ferior of right coronary artery (RCA) vas- Assessment of PBV reversible ischemiathe first under adenosine myocardial cular territory. Invasive angiography with CT is helpful to improve accuracy ofstress-imaging, the second at rest. confirmed a significant 90 % stenosis at coronary CT Angiography, especially in mid LAD and a patent RCA bare-metal cases of severe coronary calcification or stent. Total radiation dose was 2.2 mSv limited in-stent lumen visibility.DIAGNOSIS for adenosine stress and rest CT scansHigh-pitch CT Angiography showed using high-pitch Flash Spiral mode atseverely calcified left coronary artery 3.4 pitch factor. The delay between both(Fig. 1C) with significant stenosis, and scans was 5 minutes. Scan time wasbare-metal stent in the RCA. 0.44 seconds for each study, tube set-Adenosine CT stress imaging showed tings were 100 kV and 320 mAs, gantrya reversible myocardial perfusion rotation time was 0.28 s.EXAMINATION PROTOCOL Scanner SOMATOM Definition Flash Scan mode Flash Spiral Pitch 3.4 Scan area Heart Slice collimation 128 x 0.6 mm Scan length 135 mm Slice width 0.75 mm Scan direction Cranio-caudal Reconstruction increment 0.4 mm Scan time 0.44 s Reconstruction kernel B 26f Tube voltage 100 kV / 100 kV Volume 80 ml Tube current 320 mAs/rot. Flow rate 5 ml/s Dose modulation CARE Dose4D Start delay 10 s CTDIvol 3.09 mGy Postprocessing syngo CT Cardiac – Effective Dose 2.2 mSv (in total) Function prototype* Rotation time 0.28 s*The product is not commercially available in the US.28 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 29. Cardio-Vascular Clinical Results First CTA under adenosine stress Second CTA at rest1A 1B 1 By injecting adenosine under stress, a perfusion defect anteroseptal was shown (arrow, Fig. 1A), which was reversible after 5 minutes Rest Scan (arrow, Fig. 1B). A significant mid LAD stenosis was detected by CT, and quantified as 90 % by invasive 1C angiography. Distal after steno- sis a severely calcified artery was found (arrow, Fig. 1C).2A 2B 2 Short axis at midventri- cular level showed antero- septal myocardial perfusion defect during adenosine stress (Fig. 2A, arrow), which was reversible at rest (Fig. 2B, arrow).3A 3B 3 Color maps of the myo- cardium showed black/dark areas (Fig. 3A, arrow) indicating ischemic myocardium during stress. There was no defect at the inferior myocardial region supplied by RCA corresponding to patent RCA stent (Fig. 3B, arrow).4A 4C 4 Automated quantifi- cation of hypo-attenuating perfusion defect antero- septal midventricular during stress (Fig. 4A, arrow) re- presented with the prototype of the syngo CT Cardiac Function software,* including 3D segmentation (Fig. 4B). 4B No perfusion defect inferior of RCA vascular territory could be detected (Fig. 4C, arrow). *The product is not commercially available in the US.
  • 30. Clinical Results Cardio-VascularCase 2SOMATOM Definition Flash:Visualization of the Adamkiewicz Arteryby IV-CTA in Dual Power Mode By Yoshiyuki Mizutani, MD* and Tomoko Fujihara** *Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan**Application Department CT Team, Customer Service Division, Siemens-Asahi Medical Technologies, Tokyo, JapanHISTORY DIAGNOSISA 75-year-old female was referred to had been diagnosed with TAA (descend- TAA was clearly seen on the Dual Sourcethe radiology department of Sakakibara ing aorta of 5.6 cm diameter) by com- CT images. An artery originating from aHeart Institute to examine where her puted tomography and echography as lumbar artery was detected, bifurcatingAdamkiewicz artery originated before well as right coronary artery (RCA) steno- from the aorta at the upper level of thetreatment of her thoracic descending sis by conventional angiography. She 4th lumbar vertebra, entering into theaortic aneurysm (TAA). The patient was was referred to Sakakibara Heart Insti- spinal canal from the intervertebral fora-scanned with Dual Source CT in dual tute for surgical vessel replacement and men between the 4th and 5th lumbarpower mode. coronary artery bypass grafting with vertebrae and running along the spinalAt the referring hospital, the patient saphenous vein graft to RCA. cord on the ventral side up to the lower 1 2 1 TAA was clearly seen on the Dual Source CT images (VRT). 2 TAA was clearly seen on the Dual Source CT images (thin MIP).30 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 31. Cardio-Vascular Clinical Results3A 43B 3 Adamkiewicz artery entering into the spinal canal (Fig. 3A) 4 Adamkiewicz artery connected into the anterior spinal artery. from the intervertebral foramen between the 4th and 5th lumbar vertebrae and running along the spinal cord on the ventral side up to the lower level of the 12th thoracic vertebra where it changed direction forming a hairpin shaped structure (Fig. 3B).level of the 12th thoracic vertebra where Adamkiewicz artery is a tiny vessel, a EXAMINATION PROTOCOLit changed direction forming a hairpin fair amount of contrast media needs toshaped structure. It connected into the be injected at reasonably high rates to Scanner SOMATOManterior spinal artery. According to these ensure that this tiny vessel is enhanced. Definition Flashcharacteristics this artery was identified In addition, since the Adamkiewicz Scan area Thorax-abdomenas the Adamkiewicz artery. artery runs partially inside the spinal Scan length 280 mmThe true lumen of the aorta was highly canal, enough dose needs to be applied Scan direction Cranio-caudalenhanced, reaching a CT value of 746 to achieve a high signal to noise ratio Scan time 8.41 sHU at the level between the 4th and 5th (SNR) in an area surrounded by bones. Tube voltage 100 kV / 100 kVlumbar vertebrae whereas the Adam- Dual Source CT in the dual power mode Tube current 600 eff. mAskiewicz artery reached a maximum CT combines the power of two X-ray tubes Dose modulation CARE Dose4Dvalue of only 140 HU. and two generators and can therefore Rotation time 0.5 s provide twice as much X-ray output as Slice collimation 128 x 0.6 mm a single source CT at the same pitch. As Reconstruction 0.3 mmCOMMENTS a result, areas that need additional dose incrementThe course of the Adamkiewicz artery can be scanned at high scan speed and Reconstruction B36needs to be determined before surgery appropriate tube current for a high SNR. kernelfor TAA repair to ensure that it is not The high scan speed was essential for Volume 100 mldamaged during surgery and to reduce visualizing the Adamkiewicz artery, Flow rate 5.0 ml/sthe risk of postoperative paraplegia. since it required several seconds after Postprocessing syngo InSpaceHowever, visualizing the Adamkiewicz enhancement of the aorta until theartery with intravenous (IV) CTA is a small arteries were enhanced, thenchallenging task as injection and scan quickly scan over the required long scanprotocols need to be tailored to the loca- range while the small arteries were stilltion and size of this artery. Since the enhanced. SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 31
  • 32. Clinical Results Cardio-VascularCase 3Dynamic Myocardial Stress PerfusionBy Florian Schwarz, MD, Fabian Bamberg, MD, MPH, Christoph R. Becker, MD,Alexander Becker, MD, Konstantin Nikolaou, MDDepartment of Clinical Radiology, University of Munich, Campus Großhadern, Munich, Germany1 2 1 Maximum intensity display of the right coronary artery, demon- 2 Curved multiplanar reformation of the left anterior descending strating heavy calcified plaque in the proximal segment and calcified coronary artery with minor calcified and non-calcified plaque in the and non-calcified plaque in the intermediate segment, causing proximal segment of the vessel (arrow). a mild to moderate stenosis (arrow).HISTORY DIAGNOSIS COMMENTSA 71-year-old male was referred for eval- Coronary CTA revealed heavy calcified Non-invasive myocardial perfusion imag-uation of stable chest pain syndrome plaque and a mild to moderate lesion of ing by CT may represent an attractiveand enrolled in a prospective cohort study the right coronary artery (RCA, Figs. 1 option to determine the hemodynamicto evaluate the diagnostic accuracy and and 2). Dynamic adenosine stress perfu- relevance of obstructive coronary lesions,clinical feasibility of dynamic myocardial sion imaging revealed homogeneous or lesions with limited evaluability duestress perfusion imaging by cardiac CT. perfusion of the myocardium without to heavy calcification. However, furtherCoronary CT Angiography (CTA) and defined perfusion defect (Figs. 4 and 5). validation using appropriate gold stan-CT-based assessment of myocardial per- dards is warranted.fusion under adenosine stress was per- After undergoing the CT Perfusion scan,formed prior to cardiac catheterization. the patient received conventional medical therapy.32 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 33. Cardio-Vascular Clinical Results3A 3B CT [HU] CT [HU] 80 100 60 80 60 40 40 20 20 time [s] time [s] 0 0 0 5 10 15 20 25 30 0 5 10 15 20 25 30 3 Principle: dynamic volumetric myocardial stress perfusion to quantify Myocardial Blood Flow (MBF). Comparison of different time attenuation curve (TCA) pattern with a slower and lower peak (86 ml / 100 ml / min) in an ischemic segment (Fig. 3A) and normal blood flow (MBF 159 ml / 100 ml / min) in an healthy segment (Fig. 3B).4 5 4 Systolic reconstruction display of long axis, color-coded myo- 5 Short axis color-coded perfusion map of the left ventricle cardial stress perfusion image of the left ventricle indicating homo- demonstrating homogeneous perfusion (green) under geneous perfusion (green) and the absence of a circumscribed adenosine stress. perfusion defect.EXAMINATION PROTOCOL Scanner SOMATOM Definition Scan mode Dynamic Stress Perfusion Mode Dose modulation no Scan area Left ventricular myocardium CTDIvol 94.15 mGy Scan length 72 mm Rotation time 0.28 s Scan direction Cranio-caudal Slice collimation 32 x 1.2 mm Scan time 31 s Slice width 3 mm Heart rate 72 bpm Reconstruction increment 2 mm Tube voltage 100 kV Reconstruction kernel B23f Tube current 350 mAs/rot. Post processing syngo VPCT Body Myocardium SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 33
  • 34. Clinical Results Cardio-Vascular Case 4 Pre-operative Exclusion of Coronary Artery Stenosis With Less Than 1 mSv Dose By Sebastian Leschka, MD* and Andreas Blaha** * Institute of Diagnostic Radiology, University Hospital Zurich, Zurich, Switzerland** Business Unit CT, Siemens Healthcare, Forchheim, Germany HISTORY DIAGNOSIS COMMENTS A 71-year-old male patient with a history In total, ten calcified lesions could be In combination with the CaSc (0.35 mSv) of cerebral infarction caused by a high- detected in the CaSc. Diffuse distribution and the CTA (0.8 mSv), an effective grade stenosis of the left internal carotid of calcified deposits was observed in dose* of 1.1 mSv was applied to the artery and lysis therapy was now re- the right coronary artery (RCA), the left patient to detect coronary artery disease. ferred to the radiology department to artery descending (LAD) and the left cir- The entire acquisition time of the CTA rule out coronary artery disease. cumflex coronary artery (CX). The total was 280 ms; calcium scoring was In addition to the coronary CT Angio- Agatston score was 130. acquired in 120 ms. graphy (CTA) examination a non-en- CTA unveiled a normal coronary artery The Flash Spiral cardio method quickly hanced calcium-scoring scan (CaSc) anatomy, right dominant coronary supply and reliably combines low radiation was performed. type with regular sized lumen of the dose values with the accurate display of The CTA was acquired with a fast pitch coronary arteries. RCA and LAD showed the coronary arteries in all segments. spiral technique (Flash Spiral Cardio) no hemodynamic relevant lesions. CX while a mean heart rate of 56 bpm was coronary artery unveiled a stenosis present. smaller than 50% in its proximal seg- ment. A deep myocardial bridging of the LAD could also be depicted. Threshold = 130 HU (102.7 mg/cm3 CaHA) Artery Numbers of Calcium Score (2) Volume [mm3] (3) Equiv. Mass Lesions (1) [mg CaHA] (4) LM 0 0.0 0.00 0.0 LAD 2 27.5 29.3 4.89 CX 3 48.3 50.5 8.57 RCA 5 53.6 66.2 10.81 Total 10 129.5 146.0 24.27 (1) Lesion is volume based, (2) Equivalent Agatston score, (3) Isotropic interpolated volume, (4) Calibration Factor: 0.790 *Effective Dose was calculated using the published conversion factor for an adult chest of 0.014 mSv (mGy cm)-1 [1]. [1] McCollough CH et al. Strategies for Reducing Radiation Dose in CT, Radiol. Clin. N. Am. 47: (2009) 27-40. 34 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 35. Cardio-Vascular Clinical ResultsEXAMINATION PROTOCOL Scanner SOMATOM Definition Scan mode Flash Spiral CorCTA Rotation time 0.28 s Scan area Thorax Pitch 3.4 Scan length 130 mm Spatial Resolution 0.33 mm Scan direction Cranio-caudal Slice collimation 128 x 0.6 mm Scan time 0.28 s Slice width 0.75 mm Heart rate 56 bpm Reconstruction increment 0.7 Tube voltage 100 kV / 100 kV Reconstruction kernel B26f Tube current 320 mAs/rot. Volume 60 ml Dose modulation CARE Dose4D Flow rate 6 ml/s CTDIvol 3.10 mGy Start delay Test Bolus DLP 57 mGy cm Postprocessing syngo Circulation Effective Dose 0.8 mSv syngo InSpace1 2 31 VRT of the Coronary arteries shows deep 2 MIP of the LAD shows myocardial bridging 3 MIP of the first diagonal branch (D1) of themyocardial bridging of LAD (arrow). (arrow). LAD, discovers plunge into myocardium.4 5 6 4 MIP of the coronary artery tree with 5 A stenosis is present in the proximal 6 Cross-sectional view displays theremoved blood pool of the left ventricle segment of CX artery (arrow). stenotic area of CX artery.reveals calcifications (arrow). SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 35
  • 36. Clinical Results Cardio-Vascular Case 5 Utilizing Ultra Low Dose of 0.05 mSv for Premature Baby With Congenital Heart Disease By Jean-Francois Paul, MD1 and Andreas Blaha2 1 Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France 2 Business Unit CT, Siemens Healthcare, Forchheim, Germany1 course of right pulmonary artery (RPA). Therefore a low dose CT examination was requested, utilizing low kilovoltage (kV) and low milliampere seconds (mAs) to achieve ultra low dose radiation values. DIAGNOSIS A mild stenosis present at the ostium of the right pulmonary artery could be observed. Although the RPA showed an irregularity it had a normal anatomical course. The ventricular septum defect as well as the still open atrial septum could be clearly revealed by using oblique pla- nar reformations. The right coronary ar- tery was well depicted despite a heart rate of 157 bpm. COMMENTS The data acquisition was performed with a SOMATOM Definition Flash using the ECG-triggered sequential mode 1 CT imaging with VRT technique shows ventricular septal defect (arrows) (Flash Cardio Sequence) which resulted and persistent foramen ovale (PFO, arrowheads). in an ultra low dose value. Calculated with the dose length product (DLP) of 0.7, an estimated dose of 0.05 mSv could HISTORY be achieved.* Using the Definition Flash low dose ac- A premature baby was referred to the left ventricular septum defect could be quisition technique it was possible to de- radiology department with diagnosis of detected with echocardiography but tect this congenital heart disease (CHD) congenital heart disease. An atrial and with a doubt about the exact origin and in a very early stage of the patients life. *Effective Dose was calculated using the published conversion factor for a pediatric (newborn) chest of 0.039 mSv (mGy cm)-1 [1]. To take into account that Siemens calculates the CTDI in a 32 cm CTDI phantom an additional correction factor of 2 had to be applied. [1] McCollough CH et al. Strategies for Reducing Radiation Dose in CT, Radiol. Clin. N. Am. 47: (2009) 27-40. 36 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 37. Cardio-Vascular Clinical Results2 3 2 Ventricular septal defect in MIP technique (caudo-cranial view, arrow); PFO (arrowhead). 3 Caudo-cranial view MIP shows mild stenosis and irregularity of the RPA (arrow).4 5 4 Cranio-caudal view in VRT-tech- nique. 5 Fused VRT and MIP highlighting RPA (arrow).EXAMINATION PROTOCOL Scanner SOMATOM Definition Flash Scan mode Flash Cardio Sequence Effective Dose 0.05 mSv Scan area Thorax Rotation time 0.28 s Scan length 33 mm Feed/Rotation one rotation Scan direction Cranio-caudal Slice collimation 128 x 0.6 mm Scan time 0.18 s Slice width 0.75 mm Tube voltage 80 kV / 80 kV Reconstruction increment 0.4 mm Tube current 22 mAs / rot. Reconstruction kernel B26f CTDIvol 0.18 mGy Postprocessing CT Cardiac Engine DLP 0.7 mGy cm SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 37
  • 38. Clinical Results Cardio-Vascular Case 6 SOMATOM Definition Flash: Pediatric Patient Without Sedation and Breath-Holding By Kaori Takada, MD* and Tomoko Fujihara** *Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan**Application Department CT Team, Customer Service Division, Siemens-Asahi Medical Technologies, Tokyo, Japan HISTORY shunt surgeries (therefore the subclavi- CT images revealed a tortuous artery A 4-year-old boy with Tetralogy of Fallot an artery is connected with the pulmo- originating from a right subclavian ar- (TOF, Fig.1), pulmonary atresia (PA) nary artery) within 9 months. Then, at tery that supplied the right and left infe- and major aorto-pulmonary collateral the age of 3, an artificial vessel was con- rior lung lobes. The left lung was per- arteries (MAPCAs) was referred to the structed from the right ventricle (RV) fused mainly by the left central pulmo- radiology department of Sakakibara to the pulmonary artery by palliative nary artery. The right middle lung lobe Heart Institute for a follow-up examina- Rastelli procedure. was perfused by the large right inferior tion using a SOMATOM Definition Flash, The patient now underwent a percu- diaphragmatic artery (its distal end was Dual Source CT in Flash Spiral mode tanous transluminal angioplasty (PTA) connected to an artery originating from following treatment of his pulmonary of pulmonary artery. A low dose, Dual the central pulmonary artery). artery stenosis. Source CT scan in the Flash Spiral mode Incidentally, the right coronary artery The patient was diagnosed shortly after was ordered to confirm his postopera- (RCA) was found to originate from the birth with TOF, PA, MAPCA. When he tive condition, in particular concerning aorta at the upper level of left coronary was 10 months old, a stent was inserted the pulmonary circulation. The patient’s artery, the left coronary cusp (Fig. 4), in the largest MAPCA and a central shunt weight was 15.6 kg (34.39 lb). which could neither be seen in the previ- was placed when he was 16 months old. He was not sedated and no breath-hold ously performed catheter angiography When he was 2 years old, he underwent was needed during the scan. His mean nor in a 16-MSCT examination. right and left modified Blalock-Taussig heart rate was 95 bpm. Based on these findings a catheter PTA of the pulmonary artery stenosis at the distal part of the stent was planned. 1 DIAGNOSIS The Dual Source CT images showed that COMMENTS the RV-pulmonary artery conduit was patent and that the anastomosis site Dual Source CT Angiography has had no stenosis. Neither the right nor emerged as an essential diagnostic tool the left pulmonary arteries (about for the assessment of complex congeni- 4 mm diameter) presented any signifi- tal heart disease. Nevertheless, dose has cant stenosis (Fig. 2). remained a concern, in particular when A stent was confirmed in the biggest referring pediatric patients for cardiac MAPCA, which bifurcated from the CT. With the Flash Spiral mode of the descending aorta at the level of the left second generation Dual Source CT, atrium. It went to the right superior and pediatric patients can be scanned at inferior lung lobes, and connected one ultra low dose, as in this case at 1.63 artery originating from right central pul- mGy (effective dose 0.644 mSv). Apart 1 Ventricular septal defect that is one monary artery. Although the stent itself from dose concerns, additional chal- characteristic of TOF. was patent, a stenotic part was seen dis- lenges have been associated with imag- tal of the stent (Fig. 3). The Dual Source ing pediatric congenital heart disease 38 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 39. Cardio-Vascular Clinical Resultspatients: the patients have high heart length was taken in only 0.51 seconds 95 bpm. Pulmonary artery in-stent ste-rates, the cardiac vessels are tiny, seda- without sedation or breath-hold. Vessels nosis could also be evaluated. The Dualtion often presents a risk and most pa- were clearly visualized without artifacts. Source CT Flash images were extremelytients cannot hold their breath. This Even coronary anomaly could be seen helpful for further treatment planning.Dual Source CT Flash scan of 211 mm despite the patient’s high heart rate of2A 3A2B 3B 2 Both, right and left pulmonary arteries (about 4 mm diameter) 3 Stent was embedded in largest MAPCA that showed had now significant stenosis. a stenosis (arrow) distal of stent (arrowhead).4A EXAMINATION PROTOCOL Scanner SOMATOM Definition Flash Scan mode Flash Spiral Scan area Thorax / Chest Scan length 211 mm Scan direction Cranio-caudal Scan time 0.52 s4B Tube voltage 80 kV Tube current 104 eff. mAs CTDIvol 1.63 mGy Effective Dose 0.644 mSv Rotation time 0.28 s Pitch 3.4 Slice collimation 128 x 0.6 mm Slice width 0.6 mm Reconstruction increment 0.3 mm Spatial resolution 0.33 mm Reconstruction Kernel B26f, B46f (stent) Contrast Flow Rate 2.5 ml/s 4 RCA originated from left coronary cusp (arrows). Start delay 17 s Volume 30 ml SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 39
  • 40. Clinical Results Cardio-VascularCase 7SOMATOM Definition Flash:Dual Energy Coronary CT Angiographyfor Evaluation of Chest Pain After RCARevascularizationBy Ralf W. Bauer, MD, J. Matthias Kerl, MD, Thomas J. Vogl, MDDepartment of Diagnostic and Interventional Radiology, Clinic of the Goethe University, Frankfurt, GermanyHISTORYA 54-year-old female patient underwent pressure and had an event of syncope branch were found (Fig. 1). Recanaliza-coronary stent percutaneous translumi- three weeks ago. Invasive coronary angi- tion was performed with placement of 2nal coronary angioplasty (PTCA) of ography was performed to assess stent drug-eluting stents in the distal and midthe right coronary artery (RCA) four patency. In-stent occlusion of the mid RCA. During intervention, a small con-months ago for acute ST-elevation and distal RCA with moderate collateral- trast material extravasation was seenmyocardial infarction of the inferioseptal ization from the left anterior descending near the ostium in the proximal RCA.wall. Now, the patient suffered from (LAD) and left circumflex artery (LCX) A small intima dissection was suspectedreduced physical power and labile blood and a patent right ventricular (RV) and another stent was placed to close1 2 3 1 Prior to recanalization: Cardiac catheteri- 2 Curved multiplanar reformates showed 3 Dual Energy iodine mapping showed a zation showed a prominent RV branch and instent thrombosis with occlusion beginning large area with decreased perfusion in in-stent occlusion of the mid and distal RCA in the proximal RCA. In the RV branch, which the arterial phase in the inferoseptal wall (arrow). was clearly visible on pre-interventional cath extending from the base to the apex of the images, no contrast material filling could be heart (arrow). delineated (arrows).40 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 41. Cardio-Vascular Clinical Results the leakage. Three hours after interven- area inferoseptal extending from the proximally in the RCA. The new hybrid tion, the patient developed chest tight- base down to the apex (Fig. 3). Low reconstruction algorithm for coronary ness and retrosternal pain. ECG showed dose step-and-shoot late enhancement CTA images preserves the high temporal signs of the known old infarction images 7 minutes after contrast injec- resolution of 75 ms of the Dual Source inferiorseptally (Q waves in II, III and tion showed corresponding delayed system and allows for motion-free imag- aVF) but no signs of acute ischemia. contrast material washout (Fig. 4). On ing of the vascular structures. According She was sent to CT to rule out aortic regular anatomical multiplanar refor- to the clinical history of the patient, dissection. mates, a moderate thinning of the left assessment of the myocardium with ventricular myocardium was present Dual Energy first-pass perfusion and in that area (Fig. 5). late enhancement imaging showed signs DIAGNOSIS of chronic infarction in the inferoseptal Cardiac CT was performed in Dual Energy wall of the left ventricle. Increased tube COMMENTS mode with retrospective ECG-gating. power as well as improved separation of There was no sign of contrast material In this case, Dual Energy coronary the spectra by using a tin filter (140 kV extravasation or aortic dissection. Dual CT Angiography was used to image a + Sn filter) allowed for artifact-free im- Energy CT Angiography revealed in-stent complication of interventional recanali- aging of myocardial perfusion. Complete thrombosis with occlusion of the RCA zation, i.e. acute in-stent thrombosis, diagnostic work-up of the coronary 13 mm after its origin (Fig. 2). While while the initial clinical diagnosis of arteries and the myocardium was on cardiac cath the RV branch was still acute aortic dissection could reliably achieved with a total dose length product open, DECT showed an occlusion of the be ruled out. of only 294 mGy cm (227 mGy cm CTA + vessel due to the thrombus in the proxi- A further complication was the occlu- 67 mGy cm late enhancement). mal RCA, explaining the patient’s symp- sion of the RV branch (which was patent toms. Dual Energy myocardial iodine prior to intervention) due to the large mapping showed a large hypoperfused thrombus formation beginning very EXAMINATION PROTOCOL Scanner SOMATOM Definition Flash4 5 Scan mode Dual Energy Scan area Heart Scan length 170 mm Scan direction Cranio-caudal Scan time 4.8 s Tube voltage A/B 100 kV/140 kV+Sn filter Tube current A/B 165 mAs/140 mAs CTDIvol 13.29 mGy Rotation time 0.28 s Pitch 0.17 Slice collimation 64 x 0.6 mm Slice width 0.75 mm Reconstruction increment 0.4 mm 4 Late enhancement was present in the in- 5 Regular anatomical multiplanar reformates Reconstruction feroseptal wall corresponding to the perfusion showed moderate thinning of the interoseptal kernel D26f defect in arterial phase. wall consistent with chronic ischemia (arrow). Volume 70 ml contrast media Flow rate 5 ml/s Start delay Test bolus Post processing syngo Dual Energy SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 41
  • 42. Clinical Results Oncology Case 8 3D Guided RF Ablation and CT Perfusion – a New Combination for Monitoring of Treatment Response By Hatem Alkadhi, MD*,** and Jan Freund*** * Institute of Diagnostic Radiology, University Hospital Zurich, Zurich, Switzerland; ** Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA*** Business Unit CT, Siemens Healthcare, Forchheim, Germany Today, there is a significant trend for cedures, especially when using oblique RF ablation of a renal cell carcinoma more routine biopsies, as well as an in- needle positions in both fluoroscopic with a combined monitoring of treat- creasing volume of more complex inter- and non-fluoroscopic procedures. ment response by Adaptive 4D Spiral ventional procedures such as radio fre- Strongly motivated by the increased vol- volume perfusion CT. quency (RF) ablations and minimally ume of these interventions, radiologists invasive surgical procedures. In addition, have been looking for a solution that PATIENT HISTORY the need for large perfusion ranges is in- adds precision while reducing procedure creasing with the demand for complete time, freeing up the CT suite for more An 80-year-old female patient presented and comprehensive assessments of the patients and procedures and, in addition, to the emergency department with mac- whole disease in the entire organ. The bringing new revenue opportunities. rohematuria. A CT of the abdomen current challenge in CT interventions is At University Hospital Zurich, radiologists revealed a mass in the left kidney that to overcome the limitations of conven- are working on an impressive and prom- was suspicious of a renal cell carcinoma tional 2D CT guidance where, especially ising solution utilizing Siemens’ real- (Fig. 1). Because severe co-morbidities in difficult cases, the safe navigation time 3D image guidance for minimally prevented open surgery, the patient was of the needle is a challenge. invasive procedures and CT Perfusion scheduled to undergo radio frequency A more accurate overview of the needle in combination with the innovative ablation (RFA). Considering the large size position and surrounding organs has Adaptive 4D Spiral technology. The fol- of the tumor, embolization of the mass often been lacking during difficult pro- lowing case demonstrates a 3D guided was performed prior to RFA (Fig. 3). 1 2 3 1 Contrast-enhanced abdominal CT shows 2 The image shows the RFA procedure of 3 Selective catheter angiography of the left an exophytic mass in the left kidney (arrow). the left kidney tumor. renal artery demonstrating the hyper-vascu- larized tumor of the lower pole (left). Angi- ography after embolization shows subtotal devascularization of the tumor (right). 42 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 43. Oncology Clinical Results4 5 4 Blood volume map shows a largely devascularized tumor after 5 Blood volume map shows complete devascularization of the kidney embolization treatment, however, also a strongly perfused area tumor (purple, blue) after RF treatment. in the medial, lower part of the tumor (red, yellow). path planning, a fast and precise needle It gives a more accurate overview of the DIAGNOSIS navigation was ensured. Radiation expo- needle position and surrounding organs Due to the large size of the tumor, con- sure could be kept very low by applying during difficult procedures, such as ventional CT Perfusion studies are nor- an interventional sequence scan mode oblique needle positions of RFAs. This mally unable to capture the entire tumor for needle navigation. ensures a higher success rate of RF treat- and therefore deliver only partial perfu- A CT Perfusion study performed the ments. In addition, the automated needle sion information. To circumvent this day after RFA shows complete devascu- guidance and tracking tool significantly limitation, the patient was sent for a larization of the tumor (Fig. 5) indicating helps to speed up the insertion and volume perfusion scan to the SOMATOM a successful treatment of the patient. needle placement with a reduced pa- Definition AS offering the Adaptive 4D With the ability to perform perfusion tient exposure. Spiral scan modes. This allows CT Perfu- studies over the entire region of interest, The 3D minimal invasive suite in parti- sion coverage of up to 7 cm. The Adap- it is now possible to assess the extent of cular now offers the freedom to direct tive 4D Spiral scan was performed one the disease and visualize the function of the entire procedure with just the touch day after embolization. It showed the potential metastases. The combination of a button – without ever leaving the tumor to be largely devascularized. of CT Perfusion studies and CT guided patient’s side. No ongoing, extensive However, a small proportion in the me- RFAs allows the reading physician to communication with the technician for dial lower part of the tumor still showed more precisely assess the treatment additional distance measurements, blood flow (Fig. 4). success after RFA in a timely manner. This windowing and image adjustments is Two days later, a CT-guided RFA was per- makes it possible to monitor devascular- necessary. Since the user is now able formed using the Adaptive 3D Interven- ization of the kidney tumors only one to easily switch between fluoroscopic, tion Suite with its needle path planning day after RFA. sequential and spiral examinations and on-line tracking mode. Particularly without time-consuming scan protocol the perfused tumor part as demonstrat- manipulation, the physician saves COMMENTS ed by perfusion CT was targeted (Fig. 2). additional time reducing the overall In order to safely reach the dedicated The increased precision of the 3D visual- interventional procedure time. This areas, a 3D visualization of axial, coronal ization especially helps to more precisely frees up the valuable CT suite more and sagittal slices during the intervention position RF needles to ensure the correct quickly for waiting patients and proce- was used. In combination with a 2-click placement in the perfused tumor area. dures. SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 43
  • 44. Clinical Results Oncology Case 9 SOMATOM Definition Flash: Routine Re-staging of Oesophageal Carcinoma Utilizing IRIS Technology By Michael Lell, MD*and Andreas Blaha** *Department of Radiology and the Imaging Science Institute (ISI), University of Erlangen-Nuremberg, Erlangen, Germany**Business Unit CT, Siemens Healthcare, Forchheim, Germany HISTORY The 55-year-old male patient presented lymph nodes in the mediastinum. In iterative reconstruction in image space with a history of oesophageal cancer. addition, a small pericardial effusion, technology (IRIS) were utilized, which He previously underwent combined radio- most probably a side effect of radio- lead to a significant reduction in dose chemotherapy. CT was requested for therapy, was visualized. There was no and noise as compared to conventional re-staging to discuss further therapy evidence of liver or lung metastases and CT, improving image quality. This exa- options for the patient. there were no enlarged lymph nodes at mination reliably demonstrated the the level of the celiac trunk. An isolated possibility of acquiring excellent image solitary cyst (Bosniak I) was located in quality at reduced dose levels (3.9 mSv / DIAGNOSIS the upper left kidney. DLP: 260 mGy cm). A contrast enhanced CT revealed bilateral well-perfused lung, also the port catheter COMMENTS was well positioned in the vena cava superior. Following treatment, there was Several measures to reduce dose were still prominent thickening of the wall employed with this patient. Online tube of the distal oesophagus und enlarged current modulation (CARE Dose4D) and EXAMINATION PROTOCOL Scanner SOMATOM Definition Flash Scan mode Thorax DLP 260 mGy cm Scan area Thorax-Abdomen Effective Dose 3.9 mSv Scan length 656 mm Rotation time 0.33 s Scan direction Cranio-caudal Slice collimation 128 x 0.6 mm Scan time 21 ms Slice width 0.75 mm Tube voltage 120 kV Reconstruction increment 0.4 mm Tube current Ref.mAs 100 eff. mAs Reconstruction kernel I41 Dose modulation CARE Dose4D Postprocessing syngo CT 3D 44 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 45. Oncology Clinical Results1 2 1 VRT and fused MPR show the extension of oesophageal 2 Coronal cut demonstrates the solitary cyst (left kidney, arrow), and wall thickening. distal oesophageal wall thickening (arrowhead, IRIS reconstruction).3 4 3 Axial slice highlights wall thickening of the oesophagus 4 Low and homogenous noise in the entire dataset using IRIS (arrowhead), and pericardial effusion (arrows). (coronal slice) reveals oesophageal thickening (arrows). SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 45
  • 46. Clinical Results NeurologyCase 10SOMATOM Definition AS+:CT Perfusion With Extended Coveragefor Acute Ischemic StrokeBy Ke Lin, MDDepartment of Radiology, New York University Langone Medical Center, New York, USAHISTORYA 53-year-old male with history of hyper- 12 months. He arrived to the emergency head CT (NCCT), dynamic CT Perfusiontension presented with sudden onset department of NYU Langone Medical (CTP) of the brain, and CT Angiographyof expressive aphasia and weakness. Center within 1 hour of symptom onset (CTA) of the cervical and intracranialThe patient had experienced two similar and was immediately evaluated for arterial vasculature.but transient episodes in the previous acute ischemic stroke by non-contrast1 1 Dynamic CT Perfusion (CTP) cerebral blood flow (CBF) map shows markedly decreased CBF to the left frontal operculum. CTP cerebral blood volume (CBV) map shows matched decreased CBV in this region indicating irrevers- ible infarct core. A penumbra-core map generated by using thresholds of CBV ≤ 1.2 ml / 100 ml for core (red) and CBF ≤ 35 ml / 100 ml / min and CBV >1.2 ml / 100 ml for penum- bra (yellow) shows little salvageable tissue at this level.46 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 47. Neurology Clinical Results2 2 The penumbra-core maps from selected slices above and below the level shown in Fig. 1: the extents of both the salvageable ischemic penumbra (yellow) and the irreversible infarct core (red) are fully de- picted.DIAGNOSISWhile NCCT showed only subtle blurring indicative of salvageable tissue at risk In this case, the setting with 96 mm ofof the normal gray/white matter inter- (Fig. 2). CTA showed embolic occlusion z-direction coverage (and 1.5 secondsface at the left frontal operculum, CTP of the frontal opercular division of the temporal resolution) covered nearly thewith extended coverage revealed the full left MCA secondary to plaque rupture entire supratentorial brain. syngo VPCTextent of the acute ischemia in the ante- at the left carotid bulb. The patient was Neuro extracts first-pass data from therior left middle cerebral artery (MCA) then rapidly treated with intravenous 45 seconds dynamic acquisition en-territory. There was severe compromise thrombolytic therapy with mild improve- abling a rapid exam. The extents of bothof cerebral blood flow (CBF) to the mid ment of symptoms. the salvageable ischemic penumbra andand inferior left frontal lobe. At the level the irreversible infarct core were fullyof the operculum (Broca’s area), there depicted. Rescue of ischemic penumbra COMMENTSwas a matched defect in low CBF and is the main rationale for aggressivelow cerebral blood volume (CBV) indica- The SOMATOM Definition AS+ scanner stroke intervention, and its identificationtive of irreversible infarct core (Fig. 1). with 128-slice configuration and Adaptive through perfusion imaging may form theHowever, there was appreciable CBF/CBV 4D Spiral technology allows larger CTP basis of patient selection for therapy inmismatch on the other acquired slices, coverage with a single bolus of contrast. the near future.EXAMINATION PROTOCOL Scanner SOMATOM Definition AS+ Scan mode Adaptive 4D Spiral Rotation time 0.3 s Scan area Head Slice collimation 64 x 0.6 mm Scan length 96 mm Slice width 10 mm Scan direction Caudo-cranial and cranio-caudal Reconstruction increment 5 mm Scan time 45 s Reconstruction kernel H20f Tube voltage 80 kV Contrast Volume 50 ml iodine Tube current 200 eff. mAs Flow rate 5 ml/s Dose modulation CARE Dose4D off Start delay 4s CTDIvol 218.8 mGy Postprocessing syngo VPCT Neuro SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 47
  • 48. Clinical Results NeurologyCase 11Vasospasm After SubarachnoidHemorrhage:Volume Perfusion CT NeuroBy Bruno A. Policeni, MDRadiology Faculty, Neuroradiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA1 angiography, confirming the right MCA aneurysm (Fig. 3). She underwent im- mediate aneurysm coil embolization. On day four after the intervention, her neu- rologic exam attested deterioration and she showed a left facial palsy, indicating suspected vasospasm. The patient was referred to the radiology department for comprehensive stroke imaging, includ- ing CT Angiography and Volume Perfu- sion CT (VPCT) of the brain to rule out vasospasm. L R DIAGNOSIS Using the Adaptive 4D Spiral technology a 9.6 cm volume perfusion scan cover- 1 3D CT Angiography shows a right mid cerebral artery (MCA) bi-lobed aneurysm ing the entire brain was performed and (arrow). No other aneurysms were found. the resulting perfusion parameter maps were qualitatively and quantitatively evaluated in 3D. They demonstrated anHISTORY impaired brain perfusion in the rightA 36-year-old female with a history of rhage. The temporal horns were mildly MCA and ACA vascular territory distribu-migraine developed a sudden onset of dilated due to early obstructing hydro- tion with prolonged Mean Transit Timethe worst headache of her life, lost con- cephalus and a small amount of intra- (MTT), reduced Cerebral Blood Flowtrol of the entire right side of her body ventricular blood was present in the left (CBF) in the same area and slightlyand fell to the floor. However she had occipital horn. A CT Angiography was increased Cerebral Blood Volume (CBV,no trauma to her head and did not lose performed and showed a 7 mm x 4 mm Fig. 4). CT Angiography images were ob-consciousness. She was admitted to the bi-lobed berry aneurysm with a narrow tained from the dynamic VPCT data andemergency department where a head CT neck arising from the M1 segment of the showed areas of narrowing in the right(Fig. 2) showed right sylvian fissure and right mid cerebral artery (MCA, Fig.1). MCA and anterior cerebral artery (ACA,inter-hemispheric fissure hyperdensity The patient was transferred to the Fig. 6). The following angiography con-consistent with subarachnoid hemor- angiography suite for conventional firmed the vasospasm findings consis-48 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 49. Neurology Clinical Results2 3 2 Head CT without contrast demonstrates right sylvian fissure and interhemispheric fissure hyperdensity consis- tent with subarachnoid hem- orrhage (arrows). The tempo- ral horns are mildly dilated due to early obstructing hydrocephalus (arrowhead). 3 Conventional angiography demonstrates the right MCA aneurysm in the right internal carotid artery injection (ar- row).4 4 VPCT axial multi-parameter view showing a Maximum Intensity Projection (MIP), Cerebral Blood Flow (CBF), Cerebral Blood Volume (CBV), Time To Peak, Time To Drain (TTD) and Mean Transit Time (MTT), MTT and TTD (time to drain, a Siemens origin parameter) being the most useful parameters in this case. SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 49
  • 50. Clinical Results Neurology5 5 3D view of the Time To Drain (TTD) parameter map of the entire brain. Time to drain is a Siemens unique deconvolution based parameter de- scribing the time of the earliest washout of contrast medium in seconds. It is a very sensitve parameter to detect perfusion asymetries like MTT.tent with segmental narrowing in the facial droop, well-controlled pain and sion CT through the base of skull. Thusright MCA/ACA and delayed capillary ambulating without assistance. She was syngo VPCT Neuro in combination withtransit time (Fig. 7A). The patient was scheduled for a follow-up exam in the the Adaptive 4D Spiral technology is en-immediately treated with 8 mg intra- clinic 6 weeks later. hancing the diagnostic application. Thearterial nicardipine for a period of 10 ability to obtain a CT Angiography withminutes and balloon angioplasty was the same data acquisition is crucial for COMMENTSperformed in the right MCA. Immediate the correlation to the vascular territoryfollow-up confirmed a successful treat- syngo VPCT Neuro offers dynamic perfu- showing prolonged MTT. Temporal pa-ment (Fig. 7B) and there was also an im- sion analysis of the entire brain. That, rameter maps like MTT in 2D and 3Dprovement in the neurologic exam, as in this case, enables the detection of delivered by syngo VPCT Neuro may actspecifically in the left facial palsy. The vasospasms – even those located in as a sensible tool to detect perfusionpatient was discharged on day 17, neu- upper brain regions or in the posterior asymmetries in the two hemispheres asrologically stable with resolution of the fossa, not covered by traditional Perfu- an indicator for vasospasm.50 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 51. Neurology Clinical Results6 6 Coronal CTA MIP reconstruction from the dynamic series demonstrates areas of severe vasospasm (arrows) in the right ICA and MCA compared to the normal left MCA (arrowhead).7A 7B 7 Conventional angiography confirmed severe vasospasm (arrows): segmental narrowing in the right MCA/ACA and a delayed capillary transit time (Fig. 7A). Follow up demonstrates resolution of the vasospasm after nicardipine injection and balloon angioplasty (Fig. 7B, arrows).EXAMINATION PROTOCOL Scanner SOMATOM Definition AS+ Scan mode Adaptive 4D Spiral (spiral shuttle mode) Rotation time 0.3 s Scan area Head Slice collimation 128 x 0.6 mm Scan length 96 mm Slice width 5 mm for perfusion, 1 mm for CTA Scan direction Cranio-caudal and caudo-cranial Reconstruction kernel H20f Scan time 45 s; 30 scans total Volume 40 cc Isovue-370 and 50 cc normal saline Tube voltage 80 kV Flow rate 8 ml/s Tube current 200 mAs Start delay No delay CTDIvol 218 mGy Post processing syngo Volume Perfusion CT Neuro SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 51
  • 52. Clinical Results Acute CareCase 12Dual Energy Scanning:Diagnosis of Ruptured Cocaine CapsuleBy Ralf W. Bauer, MD, J. Matthias Kerl, MD, Thomas J. Vogl, MD, Philipp Weisser, MDDepartment of Diagnostic and Interventional Radiology, Clinic of the Goethe University, Frankfurt, GermanyHISTORY DIAGNOSISA 32-year-old male passenger on a flight A contrast-enhanced, Dual Energy CT sule was secured. The patient recoveredfrom South America landed at Rhein- (DECT) scan of the abdomen was per- on the intensive care unit without fur-Main International Airport in Frankfurt. formed. 24 capsules with an average ther major medical treatment and couldHe showed a conspicuous and slightly size of 2.5 x 3.5 cm and hyperdense be relieved from the rest of his freightdelirious behavior. The customs and content were found, confirming the with the use of laxatives.border police were alert and questioned patient’s story. Average CT values of thehim whether he was carrying or had hyperdense content were 203 HU at COMMENTSconsumed drugs. At first, he denied, but 80 kV and 140 HU at 140 kV. The cap-as his medical condition dramatically sules were spread all through the small With the use of DECT, a reliable diagnosisworsened, he admitted that he had bowel and colon. However, there was of the ruptured cocaine capsule couldswallowed 24 self-packed capsules with one capsule in the rectum, that was sig- be performed and immediate medicalcolumbian cocaine. The patient devel- nificantly larger than the others and its help provided. To our knowledge thisoped heavy attacks of abdominal cramps content showed lower attenuation val- is the first report on the Dual Energyand became more and more apathetic. ues of 139 HU at 80 kV and 77 HU at behaviour of columbian cocaine. ThisHe was transferred to the hospital to lo- 140 kV. DECT further revealed a thin hy- might be of future relevance for in vivocalize the capsules, to confirm the num- perdense layer-like structure that peeled differentiation of cocaine or heroin ofber, and to check, if one of the capsules off from that capsule, therefore the sus- different origin in uncommunicativehad opened and cocaine had come into picion arose that the capsule actually body packers. However, further researchthe bowel lumen – or if the capsules had ruptured. Rectoscopy was per- in this field is needed to confirm ourhad caused an ileus. formed immediately and the torn cap- results.EXAMINATION PROTOCOL Scanner SOMATOM Definition Flash Scan mode Dual Energy Rotation time 0.5 s Scan area Abdomen Pitch 0.55 Scan length 464 mm Slice collimation 14 x 1.2 mm Scan direction Cranio-caudal Slice width 1.5 mm Scan time 24 s Reconstruction increment 1.0 mm Tube voltage A/B 140 kV / 80 kV Reconstruction kernel D30f Tube current A/B 49 eff. mAs / 212 eff. mAs Contrast Volume 90 ml Dose modulation CARE Dose4D Flow rate 3 ml/s CTDIvol 9.14 mGy Postprocessing syngo Dual Energy52 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 53. 1 2 Neuroradiology Clinical Results 1 Cocaine capsules distributed throughout the whole intestine. 2 Virtual colonoscopy view.3 4 3 Color-coding of cocaine capsules facilitates detection and 4 Ruptured cocaine capsule. Arrows point at the loose outer layer. counting.5 6 5 ROI measurements demonstrate typical Dual Energy values of 6 The coronal reformate shows large amounts of fluid in the columbian cocaine. colon lumen. However, no ileus was present. SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 53
  • 54. Clinical Results Acute Care Case 13 Progressive Kidney Hematoma Post-interventional Biopsy By Sebastian Leschka, MD * and Andreas Blaha ** *Institute of Diagnostic Radiology, University Hospital Zurich, Zurich, Switzerland**Business Unit CT, Siemens Healthcare, Forchheim, Germany HISTORY DIAGNOSIS COMMENTS To determine further therapy, the 21- In the native phase, an accumulation of Despite the low quantity of applied con- year-old patient, status after hepatitis B, liquid at the lower left renal pole was trast media, a contrast media enhance- was referred to the radiology depart- seen. The arterial phase showed an ment in the left kidney could be identi- ment. Here a biopsy of the renal paren- extravasation of contrast media out of fied due to a quick acquisition time of chyma was performed upon which a the left kidney. An inhomogeneous 0.7 seconds. The SOMATOM Definition haemorrhage occurred, accompanied by hematoma measuring 15 x 7.5 x 5 cm Flash allowed a precise and rapid the formation of a hematoma. A 3-phase was detected around the left kidney. diagnosis with a reduced given patient kidney CT was performed. Due to the Both kidneys were perfused symmetri- radiation dose of 3.3 mSv. nephritic syndrome only 60 ml of con- cally, unique renal arteries were seen trast media with a flow rate of 4 ml/s bilaterally. In the venous phase a normal followed by a 60 ml NaCl bolus (4 ml/s) renal calyx developed on both sides. was injected for the kidney CTA. 1 1 Fused VRT/MPR highlight kidney hematoma.
  • 55. Acute Care Clinical ResultsEXAMINATION PROTOCOL Scanner SOMATOM Definition Flash Scan mode 3-phase kidney Rotation time 0.28 s Scan area Abdomen Pitch 2.1 Scan length 218 mm Slice collimation 128 x 0.6 mm Scan direction Cranio-caudal Slice width 2 mm Scan time 0.7 s Reconstruction increment 1 mm Tube voltage 120 kV / 120 kV Reconstruction kernel B30f Tube current 100 eff. mAs Contrast Volume 60 ml Iodine Dose modulation CARE Dose4D Flow rate 4 ml/s CTDIvol 7.71 mGy Postprocessing syngo CT 3D syngo InSpace2A 2B 2C2 Axial non-enhancement multiplanar reformation (MPR, Fig. 2A); axial early enhancement MPR shows haemorrhages in thekidney hematoma (arrow, Fig. 2B). Axial late state MPR shows persistent bleeding (arrow, Fig. 2C).3A 3B 3C 3 Sagittal non-enhancement MPR (Fig. 3A); sagittal early enhancement MPR shows hemorrhages in the kidney hematoma(arrow, Fig. 3B); sagittal late state MPR shows persistent bleeding (arrow, Fig. 3C). SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 55
  • 56. Clinical Results Acute Care Case 14 SOMATOM Definition Dual Source High Pitch vs. Routine Pitch Scanning in a Pediatric Lung Low Dose Examination By Harald Seifarth, MD,* Walter Heindel, MD,* Andreas Blaha ** *Department of Clinical Radiology, University Hospital, Münster, Germany**Business Unit CT, Siemens Healthcare, Forchheim, Germany HISTORY 1 2 A 5-year-old male patient with a history of neutropenia after stem-cell trans- plantation was referred to the radiology department. The patient presented with persistent fever despite ongoing treat- ment with antibiotics. A CT examination was scheduled to exclude the presence of pulmonary mycosis. The CT examination was performed with a high pitch proto- col (pitch = 3.0), resulting in a scan time of only 0.9 seconds. 1 High pitch scan – axial slice of high pitch 2 Regular scan – axial slice acquisition, no motion artifacts (arrow) of high resolution regular scan. due to breathing. DIAGNOSIS 3 4 The present CT examination showed no signs of any fungal pulmonary infection or other inflammatory changes. Minor bilateral, subpleural dystelectases could be observed. In the previous examination (pitch 1.4, scan time 4.5 seconds, scan length 189 mm, 50 ref mAs), artifacts due to respiratory motion during the acquisi- tion hampered the evaluability of the exam. The study showed small pulmo- nary infiltrates. 3 High pitch scan – entire lung in low 4 Regulars scan – artifacts due dose technique (10 eff. mAs), no motion to respiratory motion (arrows). artifacts are visible.56 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 57. Acute Care Clinical Results 5 6 COMMENTS Because of motion, the previous CT scan made diagnosis more difficult (Figs. 2, 4, 6). The fast acquisition speed made it possible to reliably rule out the presence of pulmonary infiltrations and mycosis. Although only 10 mAs were utilized, a high diagnostic image quality was pre- served. Using the new high pitch scanning technique a significant re- duction of radiation dose is feasible. 5 High pitch scan – sharp delineation 6 Regular scan – sagittal image shows of pulmonary segments. motion artifact of the diaphragm due to breathing during the acquisition. 7 EXAMINATION PROTOCOL Scanner SOMATOM Definition Scan mode Thorax HiPitch Scan area Thorax Scan length 159 mm Scan direction Cranio-caudal Scan time < 1s Tube voltage A/B 120 kV / 120 kV Tube current A/B 10 eff. mAs Dose modulation CARE Dose4D CTDIvol 0.56 mGy DLP 9 mGy cm Effective Dose 0.37 mSv* Rotation time 0.33 s Pitch 3.0 Slice collimation 64 x 0.6 mm Slice width 1.0 mm Reconstruction increment 0.5 mm Reconstruction 7 Volume rendered image of the thorax, showing regular bronchial tree. kernel B60f Postprocessing syngo CT 3D syngo InSpace*Effective Dose was calculated using the published conversion factor for an 5-year-old pediatric chest of 0.082 mSv (mGy cm)-1 [1]. To take into account that Siemens calculates the CTDI in a 32 cm CTDI phantom an additional correction factor of 2 had to be applied. [1] McCollough CH et al. Strategies for Reducing Radiation Dose in CT, Radiol. Clin. N. Am. 47: (2009) 27-40. SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 57
  • 58. ScienceCT in Pediatrics: Easierand Safer With the FlashThe SOMATOM Definition Flash allows even squirming infants and smallchildren to be scanned with maximum image quality at lightning speed,without movement artifacts, anesthesia, or ventilation. This makescomputed tomography increasingly interesting for pediatric diagnostics,solely in the event of clear indications.By Hildegard Kaulen, PhDBeing able to “freeze” movements in longer have to hold their breath or lie attained without sedation impresses usorder to scan small children without seda- still for protracted periods. Sedation is time and again. This is particularly strik-tion is every radiologist’s dream. Anesthe- no longer necessary either, and, as a ing during a direct comparison betweensia transforms what would be a compar- result, the entire imaging process is re- the Flash and another CT. We examinedatively fast scan into a time-consuming, duced to a few minutes. Lell has been a 15-month-old child with Down’s syn-possibly risky affair. Therefore, Michael working with the Flash for 16 months. drome and cystic fibrosis using a 10-rowLell, MD, Assistant Professor at the Uni- During this period, he has successfully CT. The images contained movementversity Hospital in Erlangen, is extremely scanned 50 infants and toddlers, and artifacts despite sedation. We examinedsatisfied with the various pediatric the same number of children and ado- the child once more at 27 months, thisoptions offered by the new SOMATOM lescents, without sedation or anesthe- time using the Flash. The results? Razor-Definition Flash. As small patients are sia. His experience with the Flash in sharp images without sedation (Fig.1).moved through the tube at a speed of the field of pediatric diagnostics is out- One child even attempted to sit up dur-almost half a meter per second, they no standing. Says Lell: “The image quality ing the scan. Everyone was convinced1A 1B 1 Thorax CT scan for lung investigation of a 15-month-old child with cystic fibrosis with a 10-slice CT (Fig. 1A) and for follow-up 12 months later with the SOMATOM Definition Flash (Fig. 1B) showing artifact-free lung tissue.58 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 59. Sciencethat the images would be blurred, but ventilation are not used. If it’s a choicethis wasn’t the case.” between performing CT with anesthesiaYoung patients are usually examined or not, then the answer in the case ofusing ultrasound or MRI devices. Children the Flash is a definite no.”undergoing an MRI must be sedated.Lell comments: “Anesthesia and ventila- Setting New Standardstion necessitate considerable time and The SOMATOM Definition Flash is ableeffort. We are dependent on assistance to freeze movements due to its uniquefrom other specialist disciplines. The an- speed. Scanning speeds of up to 45.8 cmesthetic must be induced, controlled and per second with a temporal resolutionreversed by an anesthetist, and the chil- of 75 ms ensure that complete chestdren have to be monitored for several scans of young patients can be recordedhours afterward. Whereas scanning time in 0.4 to 0.5 seconds. No other deviceis relatively short, outpatient care is nec- is as fast. The Flash also sets new stan-essary for hours.” Medical treatment, dards when it comes to radiation expo-care and logistics result in substantial sure. The Adaptive Dose Shield reducescosts, and the associated risks can also radiation exposure in every single spiralbe considerable. Anesthesia is an inva- scan. But the most impressive dose re-sive procedure. Complications may arise duction is possible in the field of cardiol-at any time. Says Lell: “Ventilation also ogy where ultrafast Flash Spiral cutsleads to anesthesia-related pulmonary down radiation compared to conventional Assistant Professor Michael Lell,atelectasis, a condition which causes ECG-gated examinations by up to 90 %. MD, completed his medical studiesparts of the lungs to collapse, impeding Lell believes that the Flash will make CT at the universities of Regensburg andgas exchange. It is difficult to assess these scans an increasingly attractive option Munich with subsequent qualifica-areas accurately during imaging. This is- for younger patients. The radiologist tion as a consultant in radiology andsue becomes irrelevant if anesthesia and considers indications to be the decisive habilitation. Employed by the Univer- factor. In pediatrics, a CT would only be sity Hospital in Erlangen since 1999. considered in the event of medical indi- Promoted to Chief Physician in 2009. Indications for cations with few or no alternatives, such One-year residency at the David Pediatric CT Scans: as polytrauma or tumor staging. In the Steffen School of Medicine at UCLA. Polytrauma case of multiple injuries, it is more im- Member of national and international Congenital heart disease portant to clarify the extent of the trauma professional associations; reviewer Serious lung diseases such suffered than to contemplate a statistical for various journals. as cystic fibrosis or atypical increase in cancer risk in the distant pneumonias future. Says Lell: “Some indications neces- Tumor staging sitate a CT examination, even if we are Hildegard Kaulen, PhD, is a molecular biolo- aware of the effective dose. We don’t gist. After stints at the Rockefeller University in New York and the Harvard Medical School in know exactly how this dose may affect Boston, she moved to the field of freelance Benefits of Flash CT the cancer risk in any case as no long- science journalism in the mid-1990s and contrib- in Pediatrics: term data is available based on medical utes to numerous reputable daily newspapers and scientific journals. Images free of movement arti- imaging exposure levels.” Lell already facts, even in the case of insists on reduced dose protocols. He squirming children and his team have developed protocols No sedation or deep general like these for all pediatric indications. In anesthesia Erlangen, children are always scanned Imaging possible without assis- with a tube voltage of 80 or 100 kV. tance from other disciplines Special anatomy adapted cushions are such as anesthesia or nursing used to fix the small patients during the No outpatient care or aftercare examination. Contrast agents are used No complications as a result very sparingly. Lell also ensures that the of anesthesia examination area is kept to a minimum, and strives to achieve the attention to detail necessary for diagnosis. SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 59
  • 60. ScienceThrough the use of a SOMATOM Emotion 6 from Siemens Healthcare, an international research team discoveredatherosclerosis in 3500 year old Egyptian mummies.Study Finds Atherosclerosis in3,500 Year old Egyptian MummiesBy Steven Bell, Business Unit CT, Siemens Healthcare, Forchheim, GermanyA team of cardiologists led by Drs. The imaging for this project was under- the study was shown to be of an elevatedGregory S. Thomas of the University of taken on a SOMATOM Emotion 6-slice nature, which may have contributedCalifornia, Irvine and Adel H. Allam of configuration that was donated to the to the process of disease due to lifestyleAl Azhar University, Cairo, found that Museum as part of an earlier study in issues. The main aim of this project wasatherosclerosis is not only a disease conjunction with National Geographic to identify the presence or absence ofof modern man, but was present in to image the famous mummified remains atherosclerosis in an ancient patienthumans as far back as 1,530 BC. of King Tutankhamun. population, however, the study alsoThe team of cardiologists working The researchers were able to locate and offered prominent Egyptologists theclosely with a team of Egyptologists identify vascular tissue in 16 out of the opportunity to view the mummifiedundertook the most comprehensive CT 22 mummies imaged in this study. Of remains of these patients in a way thatstudy of vascular disease in Egyptian these 16, 9 had visible signs of arterial was not damaging to these ancientmummies to date by scanning 22 mum- calcification, considered to be pathogno- artifacts, the protection of which ismies over a four-day period in the Cairo monic of atherosclerosis, from which the central to the thinking of all membersMuseum of Antiquities. The study was researchers were able to conclude that of this research study.co-sponsored by Siemens Healthcare and atherosclerosis is not a disease exclusive The results of this project were pub-aimed to investigate whether atheroscle- to modern humans. Findings of calcifica- lished in the November 18, 2009 editionrosis, the precursor of heart disease, is an tion were made in men and women who of the JAMA and also presented at theaffliction of modern man or whether this lived between 1570 BC and 364 AD. The November AHA Meeting in Orlando,disease existed thousands of years ago. social status of most patients included in Florida, USA.60 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 61. ScienceIndependent Validation ofPerfusion Evaluation SoftwareBy Katharina Otani, PhD and Toshihide ItohResearch Collaboration Development, Siemens Asahi Medical Technologies, Tokyo, JapanA study by an independent Japanese obtained with bSVD (B, D). Abnormal acute stroke patients reported higher posi-research group reported that Siemens CT MTT/TTP areas appeared larger than tive predictive values for infarction byPerfusion software syngo VPCT Neuro, those in bSVD for maps of all commercial using maximum slope-derived parametersusing the maximum slope model to de- software (A, C, D, E) except for one ven- (first moment, TTP), versus both delay-rive cerebral blood flow (CBF), delivered dor’s software (B). An editorial in the sensitive and delay-insensitive deconvolu-among the most accurate results in the same journal issue commented:2 “The tion-derived parameters. These resultsassessment of stroke infarct size com- results of the study by Kudo et al.1 also highlight the delay-insensitive nature ofpared to other commercial software.1 support the use of the maximum slope perfusion maps derived from maximum-Kohsuke Kudo, MD, PhD, from Iwate method for CT perfusion post-processing. slope algorithms. At present, however,Medical University and his colleagues Indeed, a recent MR imaging study3 of there remains insufficient evidence to sug-from five other universities in Japan used gest whether maximum-slope methodsdata of 10 stroke patients acquired with a outperform delay-insensitive deconvolu-four-detector-row scanner and applied tion algorithms.” Kudo started working ondifferent algorithms to generate CT Per- standardization of perfusion softwarefusion maps, in particular CBF, cerebral after he programmed his own softwareblood volume (CBV) and mean transit and discovered that his results differed nottime (MTT) or time to peak (TTP) maps: only from the results of one commercialA – singular-value decomposition (SVD, software but that the results from all soft-CT Perfusion 3, GE Healthcare) ware packages also differed from eachB – inverse filter IF (Version 2.0, Hitachi other. With Makoto Sasaki, MD, he set upMedical Systems) ASIST Japan supported by a grant from theC – singular-value decomposition (SVD, Japanese governement. ASIST Japan hasVersion 1.201, Philips Healthcare) introduced a color look-up table for perfu-D – maximum slope (MS, VA70A, sion maps. Kudo emphasizes that “trueSiemens Healthcare) multicenter trials on stroke assessment byE – box modular transfer function (bMTF, CT Perfusion and optimization of patientPh 7, Toshiba Medical Systems). “True multi-center management will only be possible onceKudo compared the perfusion maps with trials on stroke every vendor’s software delivers the samethe results from free software (Perfusion perfusion maps”.Mismatch Analyzer, PMA) distributed assessment by CT In his study, Kudo used earlier perfusionby the Acute Stroke Imaging Standard- Perfusion and opti- software versions such as Siemens “Neuroization Group (ASIST) Japan that applies PCT”. In the meantime however, Siemenstwo well-documented deconvolution mization of patient has developed “syngo VPCT Neuro”, a vol-algorithms: standard singular-value de- management will ume perfusion software that gives the op-composition (sSVD) and block-circulant tion to also apply a new tracer delay insen-singular-value decomposition (bSVD). only be possible sitive deconvolution algorithm in additionsSVD and bSVD algorithms differ with re-spect to their sensitivity to contrast tracer once every ven- to the as well delay insensitive maximum slope model used in this study. Kudo isdelay effects. bSVD is considered the dor’s software de- currently working on further multi-vendor“gold standard” since it is relatively insen- comparison studies.sitive to tracer delay. livers the sameKudo found that commercial software perfusion maps.” 1 Kudo K, et al . Radiology. 2010 Jan; 254(1):200-9 2 Konstas A A, et al. Radiology, 2010; 254(1):22-25could be classified in two groups: those 3 Christensen S, et al. Stroke 2009, 40 : 2055 – 2061giving similar results to the CBF maps Kohsuke Kudo, MD, PhD, Iwate Medical Universityobtained with sSVD (A, C, E) and those http://asist.umin.jp/index-e.htmgiving similar results to the CBF maps SOMATOM Sessions · Mai 2010 · www.siemens.com/healthcare-magazine 61
  • 62. ScienceReduced Procedure Timeand Radiation Dose in Inter-ventional CT WorkflowBy Prof. A.H. Mahnken, MD and F. Schoth, MDRWTH Aachen University Hospital, Aachen, GermanyPercutaneous lung biopsy is one of the ing during in- and expiration. For many the radiologists’ accuracy and confidencemost common CT-guided procedures. patients, it is virtually impossible to re- with needle biopsy of the lung. A simpleThis technique can be performed using peatedly come back to the same breath light display allows the patients to moni-sequential CT-scanning or CT-fluoroscopy. hold position. Therefore, small lesions tor their breathing level and consistentlyBecause CT-fluoroscopy may result in in particular, will often move out of return to their reference breath-holdsignificant radiation exposure to the plane. This problem is particularly pro- position during their biopsies. The IBCpatient as well as the interventionalist, nounced in the basal sections of the was developed to assist with CT inter-repeated sequential CT-scanning is com- lung and is a major issue when dealing ventional procedures, but may also bemon practice due to the minimal radia- with small lesions of 1 cm or less. very useful for PET CT, radiation therapy,tion exposure to the operating physician. Combining CT-guided procedures with ultrasound, fusion imaging, and otherHowever, this approach requires several the Interactive Breath-Hold Control procedures and modalities where respi-breath holds, with the target lesion mov- device (IBC) has been shown to increase ratory motion is an issue. At the depart-1A 1B 60 45 15 30 1 The IBC system brings down the total procedure time. In this example, the time from placing the reference grid to harvesting three samples from a small lung nodule was less than 50 seconds.62 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 63. Science2 2 Combining CT-guided procedures with the Interactive Breath-Hold Control device (IBC) has been shown to increase the radiologists’ accuracy and confidence with needle biopsy of the lung.ment of Diagnostic Radiology, RWTH sure in CT-guided biopsy of pulmonary CT-guided examinations with such appli-Aachen University Hospital in Germany, nodules while reducing the procedure cations as CARE Dose4D and HandCARE,a study was conducted to evaluate the steps. protecting patients and physicians fromIBC system in CT-guided lung biopsy. In combination with optimized planning radiation exposure during CT interven-Schoth and colleagues assessed the effect using the new Adaptive 3D Intervention tions.of an IBC system on procedure time and software from Siemens for 3D CT-guided Schoth F, Plumhans C, Kraemer N, Mahnken A,technical success in trans-thoracic CT- interventions, biopsy of smaller nodules Friebe M, Günther RW, Krombach G. – Evaluationguided lung biopsies. In 36 patients with becomes much easier, resulting in a of an Interactive Breath-Hold Control System in CT-Guided Lung Biopsy. Rofo. 2010 Feb 8.a pulmonary nodule, CT-guided biopsy higher technical success rate. With thewas done using a SOMATOM Definition early detection and histological proof of 3scanner, the Adaptive 3D Intervention lung cancer, treatment is more effective.Suite from Siemens and the breath-hold Prognosis significantly improves whendevice. In a two-arm study with and lung cancer is detected and treated be-without the device, the biopsy was visu- fore metastases occur. Therefore, a highally successful in all patients. The diame- success rate of diagnostic puncturester of the target lesion was comparable during the diagnostic workup greatlyin both groups (IBC: 30 +/– 19 mm; con- supports therapy. Moreover, IBC is a rele-trol: 28 +/– 15 mm). But the number of vant support to therapeutic proceduresimaging steps was significantly smaller such as radiofrequency ablation or ste-(p < 0.05) and the intervention time was reotactic radiation therapy of small lungsignificantly shorter (p < 0.05) in the IBC tumors.group (IBC: 9 +/– 5 steps, 17 +/– 10 min; Regarding dose reduction, the IBC inte- 3 Interactive Breath-Hold Control System wascontrol: 13 +/– 5 steps, 26 +/– 12 min). grates and supplements perfectly into developed by Mayo Clinic Rochester, USA to assistApplication of the IBC unit reduced the the huge expertise that Siemens has CT-guided interventional procedures.*intervention time and radiation expo- accumulated to reduce radiation dose in* The device will be distributed by Medspira (USA) (www.medspira.com) and Siemens AG. SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 63
  • 64. ScienceScientific Validation of theSOMATOM Definition FlashOne of the cornerstones of Siemens CT activities has always been thescientific validation of Siemens’ products and solutions. Independent peer-review of publications in scientific journals provides an unbiased andobjective assessment of the capabilities of the systems.By Stefan Ulzheimer, PhD, and Peter SeitzBusiness Unit CT, Siemens Healthcare, Forchheim, GermanySince the introduction of the Siemens The dose saving potential of the high- due to its unmatched temporal resolu-SOMATOM Definition Flash at RSNA pitch scan mode of SOMATOM Definition tion and high volume coverage even at2008, and its commercial availability in Flash was also evaluated by Sommer et high heart rates in stressed patients.July 2009, the CT scanner has been cov- al. in a study using an anthropomorphic Bastarrika et al. showed that “[…] thisered in 15 presentations at the annual phantom and the data of 31 patients.2 technique can demonstrate subendocar-meeting of the Radiological Society The average scan time for the complete dial infarction not seen on SPECT butof North America in 2009 and ten peer- thorax was 0.7 seconds, the average confirmed by MRI and can detect isch-reviewed publications in renowned dose 4.1 mSv, only one fifth of the dose emia in good correlation with stress-journals. of a conventional gated chest scan. perfusion MRI and SPECT.” 6 Fig. 1 showsThese presentations and publications a short axis view of the myocardiumprominently feature the notable advan- Sub-mSv Heart – The robust visualiza- comparing stress perfusion measuredtages of the SOMATOM Definition Flash tion of the coronary arteries with excel- with the SOMATOM Definition Flashthat enhance efficiency and significantly lent image quality at ultra low doses of (Fig. 1A) and SPECT (Fig. 1B).improve patient care. below 1 mSv was the focus of three pub- lications by researchers from Zurich, Single Dose Dual Energy – The latestSplit-second Thorax – Lell et al. from Switzerland3 and Erlangen, Germany.4,5 innovation in the area of Dual Energy CTthe University Hospital of Erlangen dem- The latest study from Erlangen used the (DECT), the Selective Photon Shield, isonstrated the SOMATOM Definition Flash Spiral scan mode in 50 consecutive based on an additional tin filter (TF)Flash’s capabilities with its high-pitch patients with body weight up to 100 kg for the high energy spectrum on thescan mode in thorax examinations.1 and heart rates up to 60 beats per min- SOMATOM Definition Flash. The Selec-Twenty-four consecutive patients who ute with an average effective dose of tive Photon Shield allows for the acquisi-presented with chest pain received a 0.78 to 0.99 mSv and excellent image tion of Dual Energy data without anyhigh-pitch thorax scan (Pitch 3.2) to quality.5 The average dose was 0.87 dose penalty compared to standard singleexclude coronary artery disease, pulmo- mSv. In a similar study from Zurich, energy scans and significantly improvesnary embolism and aortic dissection. Leschka et al. found an average dose of the separation of the energy spectra.The average dose was 1.6 mSv for pa- 0.9 mSv in 35 consecutive patients.3 In A group of scientists from Zurich con-tients who were scanned with a 100 kV both studies 99% of all coronary seg- firmed this for the syngo application,protocol and 3.2 mSv for patients who ments could be evaluated3,5 and the im- “Calculi Characterization,” using it for thewere scanned with a 120 kV protocol. age quality was rated excellent in 94 % differentiation of uric acid (UA) and non-The authors conclude that the “[…] high- of the segments or as, “at least good,” in UA stones and concluded: “DECT with TFpitch scan mode allows motion artifact 5 % of the segments.5 and 80-140 kV tube voltage settingsfree and accurate visualization of the significantly improves the discriminationthoracic vessels and diagnostic image Assessment of Myocardial Perfusion – between UA-containing and non-UAquality of the coronary arteries in pa- The SOMATOM Definition Flash offers containing urinary stones as comparedtients with low and stable heart rates at completely new possibilities to assess with DECT without using the TF […].”7a very low radiation exposure.” perfusion deficits in the myocardium Lell et al. from the University of Erlangen64 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 65. Science1A 1B 1 New frontiers in cardiac diagnosis with CT: stress-perfusion images of the heart using the unmatched temporal resolution of the SOMATOM Definition Flash compared to SPECT. A stress perfusion scan on the SOMATOM Definition Flash nicely depicts a perfusion defect in the myocardium (Fig. 1A). The perfusion defect could be confirmed using SPECT (arrows, Fig. 1B). Courtesy of Joseph Schoepf, MD, Medical University of South Carolina, USA.evaluated the application of DECT to tages. For example, a special issue of Uder M, Lell MM. Coronary computed tomogra- phy angiography with a consistent dose belowcreate bone-free data sets to assess the “Investigative Radiology” on “Advances 1 mSv using prospectively electrocardiogram-supraaortic arteries.8 Automatic bone in CT technology,” specifically focusing triggered high-pitch spiral acquisition. Eur Heartremoval allows for a faster and more re- on Dual Source, Dual Energy CT and J. 2010 Feb;31(3):340-6.liable diagnosis of vessels close to boney multi-slice CT with 128 or more slices, 6 Bastarrika G, Ramos-Duran L, Schoepf UJ, Rosen- blum MA, Abro JA, Brothers RL, Zubieta JL, Chia-structures. The authors conclude that is scheduled for this summer. ramida SA, Kang DK Adenosine-stress dynamic“[…] excellent bone suppression could 1 Lell M, Hinkmann F, Anders K, Deak P, Kalender myocardial volume perfusion imaging with sec-be achieved” using the improved scan WA, Uder M, Achenbach S. High-pitch electro- ond generation dual-source computed tomogra-modes and evaluation methods on the cardiogram-triggered computed tomography of phy: Concepts and first experiences. JCCT 2010SOMATOM Definition Flash. the chest: initial results, Invest Radiol. 2009 DOI: 10.1016/j.jcct.2010.01.015. Nov;44(11):728-33. 7 Stolzmann P, Leschka S, Scheffel H, Rentsch K,By combining multi-phase protocols to 2 Sommer WH, Schenzle JC, Becker CR, Nikolaou Baumüller S, Desbiolles L, Schmidt B, Marincekone Dual Energy exam, the dose-saving K, Graser A, Michalski G, Neumaier K, Reiser MF, B, Alkadhi H. Characterization of Urinary Stonespotential of DECT was evaluated by Johnson TR. Saving Dose in Triple-Rule-Out Com- With Dual-Energy CT: Improved DifferentiationSommer et al. in patients after endovas- puted Tomography Examination Using a High- Using a Tin Filter. Invest Radiol. 2010 Jan;cular aneurism repair using virtual non- Pitch Dual Spiral Technique. Invest Radiol. 2010 45(1):1-6. Feb;45(2):64-71. 8 Lell M, Hinkmann F, Nkenke E, Schmidt B,contrast images. They achieved a dose Seidensticker P, Kalender WA, Uder M, Achenbach 3 Leschka S, Stolzmann P, Desbiolles L, Baumuellerreduction of 44 % compared to a bi- S, Goetti R, Schertler T, Scheffel H, Plass A, Falk V, S. Dual energy CTA of the supraaortic arteries:phase protocol. In 70 examinations, all Feuchtner G, Marincek B, Alkadhi H. Diagnostic Technical improvements with a novel dual24 endoleaks were detected and correctly accuracy of high-pitch dual-source CT for the source CT system. Eur J Radiol. 2009 Oct 8 assessment of coronary stenoses: first experience. [Epub ahead of print].classified.9 Eur Radiol. 2009 Dec;19(12):2896-903. 9 Sommer WH, Graser A, Becker CR, Clevert DA, 4 Lell M, Marwan M, Schepis T, Pflederer T, Anders Reiser MF, Nikolaou K, Johnson TR. Image qualityMore to Come – In addition to the K, Flohr T, Allmendinger T, Kalender W, Ertel D, of virtual noncontrast images derived from dual-above mentioned publications, many Thierfelder C, Kuettner A, Ropers D, Daniel WG, energy CT Angiography after endovascularothers are in the pipeline, promising to Achenbach S. Prospectively ECG-triggered high- aneurysm repair. J Vasc Interv Radiol. 2010 Mar; pitch spiral acquisition for coronary CT Angiogra- 21(3):315-21.validate the technical advancements of phy using dual source CT: technique and initial 10 Johnson TR, Schenzle JC, Sommer WH, Michalskithe SOMATOM Definition Flash and, experience. Eur Radiol. 2009 Nov;19(11):2576-83. G, Neumaier K, Lechel U, Nikolaou K, Becker H-C,even more importantly, how this trans- 5 Achenbach S, Marwan M, Ropers D, Schepis T, Reiser MF. Dual energy CT: How about the dose?lates into clinical and workflow advan- Pflederer T, Anders K, Kuettner A, Daniel WG, Invest Radiol. 2010 (in press). SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 65
  • 66. LifeBehind the Scenes:CT Scan ProtocolsStandard scan protocols are by far more sophisticated than CT users mightrealize. Christiane Koch is the scan protocol designer for Siemens Healthcare,Computed Tomography and knows what is important in this field.By Heike TheessenBusiness Unit CT, Siemens Healthcare, Forchheim, GermanyHow would you describe your job This is all done before new scanners are What is important to know whenas a scan protocol designer? delivered to any customer. Then, during users want to change parameters inKoch: My task is to create scan protocols the so-called “Market Entrance Phase”, a default scan protocol?for all scanners and all software ver- our collaboration partners begin scan- Koch: Around 50% of all scan protocolsions. Together with colleagues from ning patients and the scan protocols are parameters run in the background.departments of physics, product defini- clinically tested. The results are reviewed These parameters are, for example, dosetion, marketing, development and the and validated by radiologists and physi- modulation types and additional recon-application specialists, I design and set cists. Before the new CT system is finally struction algorithms. It would be ideal ifup Siemens default scan protocols. released, scan protocols are adapted our customers would use the default pro-In doing so, dose and other guidelines according to the results of all prior tests. tocols. In this manner, following theof various radiological societies fromdifferent countries need to be observed.Scan protocols have to be comparablethrough different software versions andscanner models. For example a protocolcalled “AbdomenRoutine” on aSOMATOM Emotion is similar to theprotocol on a SOMATOM Definition.I consolidate the data for the scan proto-cols in a comprehensive data base.These files become translated to a data-base called, “ModeLibrary”, and after-wards as usable scan protocol to theuser interface.I am in close collaboration with custom-ers and application specialists world-wide, both during the developmentphase and after systems are installed.How do you validate scan protocolsbefore a new scanner is released?Koch: Functionality and performance aretested with phantoms in our laboratoryduring the development phase. For intui-tive tests, we do invite Radiographers inorder to simulate a real live scenario. Christiane Koch is the scan protocol designer for Siemens CT.66 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 67. Life “The best possible image quality at the lowest dose can be achieved by using the default scan protocols.” Christiane Koch, Business Unit CT, Siemens Healthcare, Forchheim, Germany.Data for the scan protocols are being consolidated in a comprehensivedata base.ALARA principle, the best possible image teristics. However, children older thanquality at the lowest possible dose can 6 years or heavier than 55 kg can be Tips from the expert:be achieved. But, of course, all users need examined with regular adult protocols.to adapt certain parameters to fit their Fast scan times are very helpful when Do not use a protocol from a cer-individual needs such as breathing scanning children since they probably tain body region and change it toinstructions for the patient or transfer will not, or cannot, hold still for the a protocol to fit another bodyrules indicating where images should duration of the scan. An increased pitch region.be sent. value or faster rotation time also sup- When comparing dose values ofIf the operator wants to change any port fast acquisitions. Repeated scan- different scanner models andparameters within a scan protocol, it is ning can be avoided. different vendors, it is importantimportant to select the correct base pro- to compare CTDIvol values, nottocol. For example an “AbdomenRou- Where can users find more informa- tube current values. Tube currenttine” protocol should not be changed to tion about CT scan protocols? values are related primarily tofit a neck examination and vice versa. Koch: The Workflow Assistant is included filter settings and the scannerAlso, if an institute has scanners from within the CT Life Card. It is available for geometry.different vendors or different scanner the SOMATOM Definition family starting Customized scan protocols can bemodels, tube current values can not be with software version syngo CT 2007B exported through the Scan Proto-compared when it comes to dose. Only (VA11). Application Guides do exist for col Assistant to Excel to be used onthe CTDIvol value represents a compara- older scanner models. These media a PC for further documentation,ble figure. The CTDIvol is a measured include valuable facts about scan proto- e.g. documentation of dose values.value of the dose absorbed during a cols, physical fundamentals, dose mea- All or certain scan protocols canCT examination. sures and practical tips and tricks. be copied from one scanner to another scanner via the Scan Pro-Dedicated children protocols are pro- tocol Assistant. Pre-conditions arevided on all Siemens CT scanners. What the same scanner model and iden-is so special about these protocols? tical software version.Koch: Children scan protocols are devel-oped in cooperation with pediatricradiologists in order to ensure evenlower dose values as compared to adultprotocols. By using children protocols,the user does not have to adjust dosevalues to the age or weight of the child.In these protocols, CARE Dose4D auto-matically adapts the tube current to the www.siemens.com/life-coursesindividual patient’s anatomical charac- SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 67
  • 68. LifeFirst syngo.via Hands-onWorkshops at ECR 2010By Heike Theessen, Business Unit CT, Siemens Healthcare, Forchheim, Germany T. Mang, MD, hold the session on CT Colonography using syngo.viaFor the 6th consecutive year, Siemens Mang, MD, from Vienna University, dem- participants could experience SiemensHealthcare offered hands-on workshops onstrated how they can use syngo.via new imaging software for themselves.in the experience lounge at ECR 2010. for their daily reporting. The instructing physicians guided themParticipants could benefit from very At the beginning of each session, a theo- step-by-step through the applications,comprehensive sessions for CT, MR as retical introduction into the topic was explaining the benefits of syngo.via.well as PET and SPECT CT. given by the speakers. Pflederer pointed Customers particularly liked the auto-Unlike previous years however, the new out the various dose reduction possibili- mated case preparation, where all coro-imaging software syngo.via* was used ties for Cardiac CT while Mang gave an nary arteries are automatically labelledfor the sessions CT Cardiology, CT Oncol- overview of patient preparation and and functional evaluations for left andogy and CT Colonography. During the 90 reading techniques for CT Colonography. right ventricle are already done.minute sessions, Tobias Pflederer, MD, After a brief demonstration of syngo.via Next workshops with syngo.via arefrom Erlangen University and Thomas by Siemens application specialists, the planned for ESC 2010 in Stockholm.* syngo.via can be used as a standalone device or together with a variety of syngo.via based software options, which are medical devices in their own rights. Upcoming Events & Congresses Title Location Short Description Date Contact ASNR Boston, USA 48th Annual Meeting May 15-20, 2010 www.asnr.org ISCT San Francisco, 12th International May 18–21, 2010 www.isct.org USA Symposium on Multidetector-Row CT WCC Bejing, China World Congress of June 16–19, 2010 www.worldheart.org Cardiology Scientific Sessions 2010 SCCT Las Vegas, USA 5th Annual July 14–15, 2010 www.scct.org Scientific Meeting ESC Stockholm, Cardiology August 28 – www.escardio.org Sweden Congress September 01, 2010 ESNR Bologna, Italy Neuroradiology October 04–09, 2010 www.esnr.org Congress RSNA Chicago, USA Annual Meeting of November 28– www.rsna.org Radiological Society December 03, 2010 of North America68 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 69. LifeTraining Website for Knowledge ImprovementBy Jakub Mochon, Computed Tomography Division, Siemens Medical Solutions, Malvern, Pennsylvania, USARecent years have brought significant has launched a dedicated website: role and utility of CT imaging inprogress to the area of ischemic stroke https://www.med.usa.siemens.com/ stroke care.therapy. Equally important develop- stroke. Particularly beneficial is the threements have taken place on the diagnos- part Webcast presented by Ke Lin, MD,tic side. With availability of Adaptive4D from New York University: https://www.Spiral on all SOMATOM Definition scan- med.usa.siemens.com/stroke/webcast/ners, coverage for perfusion imaging Part 1: Appropriateness of perfusion inhas been extended beyond the limita- stroke diagnosis: Where and when totion of the detector size. Physicians can use it.now adjust the coverage to the specific Part 2: Workflow, Acquisition and Postneeds of the patient and the indications Processing.of the neurological exam. New syngo Part 3: How to read and interpret studies.Volume Perfusion CT Neuro software Siemens is also working closely with Ap-offers improved guided workflow and plied Radiology: http://www.appliedradi-enables rapid sharing of perfusion data ology.com/ on an educational strokeand maps utilizing syngo Expert-i. In or- forum that will further discuss the diverse In order to improve the knowledge on Siemensder to improve the knowledge on Sie- needs of the stroke teams at the clinics offerings, Siemens USA has launched a dedicatedmens offerings in this area, Siemens USA and particularly emphasize the beneficial website https://www.med.usa.siemens.com/strokeFree Trial Licenses for Neuro ImagingBy Marion Meusel, Business Unit CT, Siemens Healthcare, Forchheim, GermanySiemens’ newest application for neuro- tions. All relevant perfusion parameters Similar free-trial licenses are availablelogical imaging, syngo Volume Perfusion (CBF, CBV, TTP, MTT) are shown in one for many more clinical applications.CT Neuro, can now be tried for 90 days view. The integrated “3D Tissue at Riskat no cost. Evaluation” gives confidence in the dif- International:syngo Volume Perfusion CT Neuro facili- ferentiation between cerebral tissue at www.siemens.com/DiscoverCTtates quantitative 3D volume evaluation risk and core infarct. All these features USA only: www.usa.siemens.com/for differential diagnosis of brain tumors make syngo Volume Perfusion CT Neuro webShop/CTand ischemic stroke. In combination night shift and 24/7 service ready.with Adaptive 4D Spiral technology, ex- syngo Volumetended brain coverage is feasible.* It is Perfusion CT Neuro –the most complete 3D stroke evaluation All dynamic informa-software on the market and the only ap- tion in one view.plication with both maximum slope anddeconvolution models integrated, sup-porting diagnostic results even in criticalsituations. With the 3D Auto Stroke func-tionality, therapeutic decisions can be *Available for themade without complex user interac- SOMATOM Definition family only.
  • 70. “Options”, “Configuration” and “Scan Protocol Assistant”. Step 1: Select “Change Protocols.” Step 2: Select all protocols. Step 3: Go to “scan” where you see all Example of the scan parameters. Click on the config- the Trigger uration icon (marked in red on the im- card of age). Select the “CTDIvol” box and place in SOMATOM the menu bar via the arrow (marked in Definition scanner. green). Click on the configuration icon again. If desired the“CTDIvol” entry can be selected in the menu bar and moved toFrequently Asked Questions the preferred location. 2. For 3D reconstructions it is preferableBy Ivo Driesser, Business Unit CT, Siemens Healthcare, Forchheim, Germany to have a non-square matrix. Select in Step 2 all the affected protocols by using the filter “3D recon jobs”. In in Step 3In the Scan Protocol Assistant (SPA), card, which makes it easy to find the you can change the matrix size. Selectthe user has access to all scan protocols. entries which should be changed. the column “Matrix size” and in the lowerThese protocols can be adapted, changed How can SPA help in daily routine? part, make your changes. All selectedor deleted. Everything is clearly listed 1. The entry “CTDIvol”, for example, can protocols will now be changed.as in the patient model dialog. The be added for all scan protocols as follows: In this way, protocols are easily and quicklylayout is comparable to the examination First the SPA has to be opened, via adapted to the users preferences.Dual Energy CT: Learning From the ExpertsBy Heike Theessen, Business Unit CT, Siemens Healthcare, Forchheim, GermanySiemens Healthcare will offer a work- utilizing the potential of Dual Energy CT. have been used reliably in daily routineshop on Dual Energy CT in cooperation The two-day training session will include for years. Some others are only a couplewith Thorsten Johnson, MD, Associate presentations on both the physical princi- of months old. Upon completion of theProfessor of Radiology and Head of Com- ples and the clinical benefits of Dual workshop, participants will be at the fore-puted Tomography at Munich University Energy CT. A hands-on session at a front of Dual Energy technology,” saysHospital, Campus Großhadern, Germany. SOMATOM Definition scanner, as well as course director Johnson.The course will take place in Forchheim, on a workstation for extended case re-Germany from September 10th to Sep- view is also part of the workshop. “Some www.siemens.com/life-coursestember 11th 2010. of the things covered in the workshopThe field of Dual Energy CT scanning During a workshopis expanding incredibly fast. Twelve dif- Thorsten Johnson, MDferent FDA cleared Dual Energy applica- will present both thetions have already been introduced since physical principlesthe launch of Dual Source CT in 2005, and clinical benefitscreating both clinical and educational of Dual Energy CT.demand. Siemens Healthcare will providea comprehensive overview to those whoare just starting to integrate Dual EnergyCT into their daily routine with emphasison understanding the principles and fully70 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 71. LifeClinical Workshops 2010 As a cooperation partner of many renowned hospitals, Siemens Healthcare offers continuing CT training programs. A wide range of clinical workshops keeps participants at the forefront of clinical CT imaging. Workshop Title Dates Location Course Course language director Clinical Workshop on July, 28–30 2010 Erlangen, English Prof. Stephan Achenbach, MD Cardiac CT / Erlangen Germany Clinical Workshop on July, 07–09 2010 Munich, English PD Konstantin Nikolaou, MD Cardiac CT / Munich December, Germany Prof. Christoph Becker, MD 15 –17 2010 Alexander Becker, MD Clinical CTA Interpretation November, Erlangen, English Prof. Stephan Achenbach, MD Course / Erlangen 18–19 2010 Germany Hands-on Workshop September, St. Gallen, German PD Hatem Alkadhi, MD Cardiac CT 23–25 2010 Switzerland PD Sebastian Leschka, MD Clinical Training Course June, 26–27 2010 Kuching, English Prof. Sim Kui Hian, MD on Cardiac CT October, 30 –31 2010 Malaysia Ong Tiong Kiam, MD Virtual CT-Colonography June, 11–12 2010 Berlin, German Prof. Bernd Lünstedt, MD November, 05– 06 2010 Germany Dual Energy Workshop September, Forchheim, English PD Thorsten Johnson, MD 10 –11 2010 Germany ESGAR CT-Colonography September, Lisbon (Cascais), English Workshops 23–24 2010 Portugal Prof. Filippe Caseiro-Alves, MD April Dublin, Prof. Helen Fenlon, MD 13–15, 2011 Ireland Martina Morrin, MD September Gothenburg, Prof. Mikael Hellström, MD 14 –16, 2011 Sweden Cardiac-CT Workshop/ Autumn 2010 Dubai, UAE English PD Christoph Becker, MD Dubai Alexander Becker, MD Hands-on Workshops August, Stockholm, English n.a. during ESC 2010 28 –31 2010 Sweden Experience Lounge November, 28 – Chicago, English n.a. at RSNA 2010 December, 2 2010 USAIn addition, you can always find the latest CT courses offered by Siemens Healthcare at www.siemens.com/SOMATOMEducate SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 71
  • 72. LifeSiemens Healthcare – Customer MagazinesOur customer magazine family offers the latest information and background for everyhealthcare field. From the hospital director to the radiological assistant – here, you canquickly find information relevant to your needs. Medical Solutions Medical Solutions Innovation and trends News The Magazine for Healthcare Leadership in healthcare. The Our latest topics May 2010 magazine, published such as product three times a year, is news, reference designed especially stories, reports, for members of the and general hospital management, interest topics are administration per- always available at sonnel, and heads of www.siemens.com/ medical departments. healthcare-news Medicine in 2050 How today’s babies will grow into the future of healthcare Inhalt_May_10_eng.indd 1 23.04.10 09:10 AXIOM Innovations MAGNETOM Flash SOMATOM Sessions Perspectives Everything from the worlds Everything from the world Everything from the world Everything from the world of interventional radiology, of magnetic resonance of computed tomography. of clinical diagnostics. This cardiology, fluoroscopy, imaging. The magazine With its innovations, clinical semi-annual publication pro- and radiography. This semi- presents case reports, applications, and visions, vides clinical labs with diag- annual magazine is primar- technology, product news, this semiannual magazine nostic trends, technical inno- ily designed for physicians, and how-to’s. It is primarily is primarily designed for vations, and case studies. physicists, researchers, and designed for physicians, physicians, physicists, It is primarily designed for medical technical personnel. physicists, and medical researchers, and medical laboratorians, clinicians and technical personnel. technical personnel. medical technical personnel. For current and prior issues and to order the magazines, please visit www.siemens.com/healthcare-magazine72 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
  • 73. Editorial Imprint “Neuro BestContrast SOMATOM Sessions – IMPRINT © 2010 by Siemens AG, Berlin and Munich A. Becker, MD, Department of Clinical Radiology, University of Munich, Campus Großhadern, F. Schoth, MD, RWTH Aachen University Hospital, Aachen, Germany allows radiologists to All Rights Reserved Munich, Germany C. R. Becker, MD, Department of Clinical Radiology, F. Schwarz, MD, Department of Clinical Radiology, University of Munich, Campus Großhadern, better visualize subtle Publisher: Siemens AG Healthcare Sector University of Munich, Campus Großhadern, Munich, Germany Munich, Germany H. Seifarth, MD, Department of Clinical Radiology, edemas as well as Business Unit Computed Tomography Siemensstraße 1, 91301 Forchheim, Germany G. Feuchtner, MD, Institute of Diagnostic Radiolo- gy, University Hospital Zurich, Zurich, Switzerland University Hospital, Münster, Germany K. Takada, MD, Department of Radiology, subtle signs of stroke, Chief Editors: M. Fischer, MD, Institute of Diagnostic Radiology, Sakakibara Heart Institute, Tokyo, Japan and to better delineate “Our new neurological University Hospital Zurich, Zurich, Switzerland T. J. Vogl, MD, Department of Diagnostic and R. Goetti, MD, Institute of Diagnostic Radiology, University Hospital Zurich, Zurich, Switzerland Interventional Radiology, Clinic of the Goethe Uni- versity, Frankfurt, Germany the cortical margin.” W. Heindel, MD, Department of Clinical Radiology, P. Weisser, MD, Department of Diagnostic and In- software combined with University Hospital, Münster, Germany terventional Radiology, Clinic of the Goethe University, Frankfurt, Germany David S. Enterline, MD, J. M. Kerl, MD, Department of Diagnostic and Duke University Medical Center in Durham, North Carolina, USA Interventional Radiology, Clinic of the Goethe M. Wieser, MD, Clinic of Cardiovascular Surgery, University, Frankfurt, Germany University Hospital Zurich, Zurich, Switzerland the SOMATOM Definition M. Lell, MD, Department of Radiology and C. Wyss, MD, Cardiology Division, University Monika Demuth, PhD Stefan Wünsch, PhD the Imaging Science Institute (ISI), University Hospital Zurich, Zurich, Switzerland (monika.demuth@ (stefan.wuensch@ of Erlangen-Nuremberg, Erlangen, Germany Sameh Fahmy, freelance medical and technology siemens.com) siemens.com) S. Leschka, MD, Institute of Diagnostic Radiology, journalist Tony DeLisa, freelance author University Hospital Zurich, Zurich, Switzerland Wiebke Kathmann, PhD, freelance scientific journalist line of scanners repre- Responsible for Contents: André Hartung Hildegard Kaulen, PhD, freelance scientific journalist K. Lin, MD, Department of Radiology, New York Oliver Klaffke, freelance scientific journalist Editorial Board: University Langone Medical Center, New York, Annette Tuffs, MD, medical journalist Andreas Blaha NY, USA Helge Bohn Peter Aulbach; Karin Barthel; Andreas Blaha; A. H. Mahnken, MD, RWTH Aachen University sents a quantum leap Andreas Fischer Steven Bell; Ivo Driesser; Kerstin Fellenzer; Tomoko Hospital, Aachen, Germany Thomas Flohr, PhD Fujihara; Jan Freund; Tanja Gassert; Toshihide Julia Hoelscher Y. Mizutani, MD, Department of Radiology, Itoh; Christiane Koch, Rami Kusama; Marion Klaudija Ivkovic Sakakibara Heart Institute, Tokyo, Japan Meusel; Jakub Mochon; Katharina Otani, PhD; Axel Lorz Kerstin Putzer; Heike Theessen; Peter Seitz; Ste- K. Nikolaou, MD, Department of Clinical Radiology, Please enter your business address in speed, low dose and fan Ulzheimer PhD; Fernando Vega-Higuera; Country State City Postal Code Street Name Title Function Department Institution Peter Seitz University of Munich, Campus Großhadern, Stefan Ulzheimer, PhD Stefan Wünsch, PhD; all Siemens Healthcare Munich, Germany Alexander Zimmermann Photo Credits: Greg Morris, Yohanne Lamoulére/ J.-F. 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