Somatom sessions 26

SOMATOM Sessions
The Difference in Computed Tomography
26 Issue Number 26/May 2010
International Edition
Cover Story
The Best of Both Worlds
in Neuro Imaging
Page 6
News
Best Balance Between
Image Quality
and Reduced Dose
Page 18
Business
More for Less in Monaco
Page 28
Clinical
Results
SOMATOM Defi nition AS+:
CT Perfusion With
Extended Coverage for
Acute Ischemic Stroke
Page 50
Science
CT in Pediatrics: Easier
and Safer With the Flash
Page 62
26

Editorial
2 “Our new neurological
software combined with
the SOMATOM Defi nition
line of scanners repre-sents
a quantum leap
in speed, low dose and
diagnostic accuracy.”
Sami Atiya, PhD, Chief Executive Officer,
Business Unit Computed Tomography, Siemens Healthcare, Forchheim, Germany
Cover Page: With Volume Perfusion CT Neuro fused with carotid CT Angiography the perfusion status of the brain tissue
can be observed. Courtesy of University Hospital Göttingen, Germany.
SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine

Editorial
Dear Reader,
Imagine an emergency room only a
few short years ago: in the middle of
the night, a 55-year-old, unconscious
patient is wheeled in. All neurologic
observations indicate stroke. But
how severe? Is it an occlusion or a
hemorrhage and where is it located?
All crucial questions that demand fast
answers! The physician on duty could
request a head CT examination that
could possibly involve two scans at 15
to 30 mSv radiation dose. The physician
would then begin with extensive post-processing
– possibly using a PACS
Workstation before the CT results could
provide life the necessary clinical infor-mation
required. Not a very pleasant
alternative for the physicians or the
patient.
Now imagine the same situation in a
modern emergency room equipped with
Siemens cutting-edge technology such
as SOMATOM Definition Flash scanner –
that scans faster than all other CT
scanners on the market – with latest
neuro imaging software and syngo.via
software that “post-process on-the-fly”
Within minutes, the physician would
have access to the head scan results with
all post-processing completed at lowest
possible dose, including non-enhanced
CT for exclusion of hemorrhage, com-plete
vascular status plus functional
information.
André Hartung,
Vice President
Marketing and Sales
Business Unit CT,
Siemens Healthcare
With syngo.via, Siemens’ new work-place
software, all time consuming
pre- and post-processing steps are
eliminated and all diagnostic infor-mation
– including information from
other modalities such as MR, MI and
PET – are available in almost real time.
Best possible image quality is pro-vided
with sophisticated “signal boost”
technologies or image-optimizing
techniques resulting in definitive
grey and white tissue differentiation
in neuro imaging. Excellent image
quality and fast processes are bene-ficial
for both physicians and patients
as they are preconditions for highest
diagnostic accuracy and, at the same
time, low dose safety for the patient.
In all patient groups, including difficult
obese and pediatric patients, as well as
emergency room situations, safety is
strongly linked to ALARA (As Low As
Reasonably Achievable) radiation ex-posure.
In the past, especially in acute
clinical cases, lowering the radiation
exposure when utilizing CT for diagnosis
was not the primary focus. In stroke
cases, “minutes equaled mind” and for
accident victims, minutes could mean
life or death. Today, thanks to Siemens’
significant leadership in bringing low
dose CT into clinical routine, image
quality is not necessarily tied to a slower
diagnosis path and higher dose expo-
sure. CT is steadily moving into the first
line of emergency and stroke imaging
mainly because of the wide diagnostic
spectrum, speed and diagnostic pre-cision.
Providing all the advantages in
CT imaging aligned with measures to
minimize the radiation exposure has
always been one of Siemens key goals.
Therefore we have recently introduced
new technical developments like IRIS to
reduce radiation exposure to the lowest
level in the CT industry. In functional
imaging, e.g. for CT brain perfusion, the
dose can be reduced by up to 50 % with
4D Noise Reduction, without compro-mising
image quality. And our Adaptive
Dose Shield completely eliminates pre-and
post-spiral radiation that cannot be
utilized for image reconstruction. These
are only a few examples from dozens of
additional large and small improvements
developed by our dedicated employees
to make the radiologist’s life easier and
the patient’s healthcare better. You will
find many of these reported in this, and
in future editions of SOMATOM Sessions.
Good reading,
Sincerely
André Hartung
* 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

Content
Content
4 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
Cover Story
6 The Best of Both Worlds in Neuro
Imaging
News
16 Affordable Performance in 16- and
64-slice CT
18 Best Balance Between Image Quality
and Reduced Dose
19 IRIS Now Extended to SOMATOM
Definition AS 20 and SOMATOM
Definition AS 40
20 syngo CT 2010B Now Available:
New Software Version for the
SOMATOM Definition AS Launched
20 Worldwide Dose Counter
21 syngo.via Workstation Face-off
Sessions
22 syngo.via CT Speedometer
24 International CT Image Contest –
Highest Image Quality at
Lowest Dose
Cover Story
6 Exciting advances in computed
tomography (CT) examination
methods, including low dose
protocols, technical innovations
such as whole brain CT Perfusion,
Dual Energy or Neuro Best Contrast
applications and groundbreaking
radiological research have drama-tically
changed the diagnostic
approach for reading physicians
by enabling new indications and
improved timing in the examination
of patients with acute neurological
deseases. SOMATOM Sessions
discussed with five experienced
physicians how CT can routinely be
used as the key diagnostic modality
in neuro imaging before the start
of appropriate treatment.
24
International CT Image Contest
at Lowest Dose
6
The Best of Both Worlds

Content
64
Study Finds Atherosclerosis in 3,500
Year old Egyptian Mummies
Oncology
46 3D Guided RF Ablation and CT
Perfusion – a New Combination for
Monitoring of Treatment Response
48 SOMATOM Definition Flash:
Routine Re-staging of Oesophageal
Carcinoma Utilizing IRIS Technology
Neurology
50 SOMATOM Definition AS+: CT Perfu-sion
With Extended Coverage for
Acute Ischemic Stroke
52 Vasospasm After Subarachnoid
Hemorrhage: Volume Perfusion CT
Neuro
Acute Care
56 Dual Energy Scanning: Diagnosis
of Ruptured Cocaine Capsule
58 Progressive Kidney Hematoma
Post-interventional Biopsy
60 SOMATOM Definition Dual Source
High Pitch vs. Routine Pitch Scanning
in a Pediatric Lung Low Dose
Examination
Business
28 More for Less in Monaco
30 New Feature: Neuro Image Quality
Surpasses all Expectations
Clinical Results
Cardio-Vascular
32 Adenosine Myocardial Stress
Imaging Using SOMATOM
Definition Flash
34 SOMATOM Definition Flash:
Visualization of the Adamkiewicz
Artery by IV-CTA in Dual Power Mode
36 Dynamic Myocardial Stress Perfusion
38 Pre-operative Exclusion of Coronary
Artery Stenosis With Less Than
1 mSv Dose
40 Utilizing Ultra Low Dose of 0.05 mSv
for Premature Baby With Congenital
Heart Disease
42 SOMATOM Definition Flash: Pediatric
Patient Without Sedation and
Breath-Holding
44 SOMATOM Definition Flash: Dual
Energy Coronary CT Angiography for
Evaluation of Chest Pain After RCA
Revascularization
Science
62 CT in Pediatrics: Easier and Safer
With the Flash
64 Study Finds Atherosclerosis in
3,500 Year old Egyptian Mummies
65 Independent Validation of Perfusion
Evaluation Software
66 Reduced Procedure Time and Radia-tion
Dose in Interventional CT Work-flow
68 Scientific Validation of the SOMATOM
Definition Flash
Life
70 Behind the Scenes: CT Scan Protocols
72 First syngo.via Hands-on Workshops
at ECR 2010
72 Upcoming Events & Congresses
73 Training Website for Knowledge
Improvement
73 Free Trial Licenses for Neuro Imaging
74 Frequently Asked Questions
74 Dual Energy CT: Learning From the
Experts
75 Clinical Workshops 2010
76 Siemens Healthcare – Customer
Magazines
77 Imprint
– Highest Image Quality
52
Vasospasm After Subarachnoid Hemorrhage:
Volume Perfusion CT Neuro

Coverstory

Coverstory
The Best of Both Worlds in
Neuro Imaging
Exceptional Image Quality Meets Lowest Dose
in Neuroradiology
At Duke University Medical Center in Durham, North Carolina, USA and
elsewhere, Siemens equipment is helping radiologists combine exceptional
image quality in neuro imaging with innovative dose-reducing features
to maximize diagnostic confi dence.
By Sameh Fahmy
Exciting advances in computed tomo-graphy
(CT) examination methods, in-cluding
low dose protocols, technical
innovations such as whole brain CT
Perfusion, Neuro BestContrast or Dual
Energy applications and groundbreaking
radiological research have dramatically
changed the diagnostic approach for
reading physicians by enabling new indi-cations
and improved timing in the ex-amination
of patients with acute neuro-logical
deseases. CT is routinely used as
the key diagnostic modality in neuro
imaging before the start of appropriate
treatment to detect or exclude intracra-nial
hemorrhage, either traumatic or
non-traumatic, or to detect other causes
of acute onset of neurological disease,
such as stroke, intracerebral tumors, or
hematoma. Rapid evaluation is critical
after trauma and with symptoms such
as weakness, headache, and dizziness,
which is why CT is the modality of
choice in these scenarios.
Exceptional image quality is key to opti-mize
diagnosis, and lower dose imaging
helps to minimize the risk to the patient.
It is often said that the price of improved
image quality with CT is increased radia-tion
dose, but Siemens has shown that
high quality, low dose imaging is possi-ble
in even the most challenging neuro-radiology
applications. Whole brain CT
Perfusion imaging with Siemens’ unique
Adaptive 4D Spiral and the use of CT
Angiography from the aortic arch to the
cranium are further expanding possibili-ties,
increasing the diagnostic confidence
of neurologists and potentially enabling
more appropriate treatment decisions.
“By providing really good image quality,
we are able to improve the efficiency of
care,” says David S. Enterline, MD, Asso-ciate
Professor of Radiology and Division
Chief of Neuroradiology at Duke Uni-versity
Medical Center in Durham, North
Carolina, USA. “And through dose sav-ings,
we can minimize the risk to pa-tients.”
Neuro BestContrast
Although newer techniques are revolu-tionizing
stroke assessment, the gold
standard for the initial diagnosis of
stroke and intracranial hemorrhage is
still non-contrast imaging of the brain.
Siemens has always placed emphasis on
providing the highest image quality on
all of their scanners for this challenging
application. Now, Siemens has taken
image quality to the next level. Last
year, Duke became the first hospital in
the United States to install Siemens’
Neuro BestContrast, an application that
dramatically increases gray/white matter
differentiation in non-contrast head CT
“Neuro BestContrast
allows radiologists
to better visualize
the gray/white mat-ter
interface to see
subtle edema and
signs of stroke, and
to better delineate
the cortical margin.”
David S. Enterline, MD, Division Chief
Neuroradiology, Duke University Medical
Center in Durham, North Carolina, USA

1A 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).
experience of radiologists in Europe. In
a blinded study whose results were pre-sented
at the 2009 scientific assembly
and annual meeting of the Radiological
Society of North America, neuroradiolo-gists
preferred Neuro BestContrast data
sets in 97 % of cases.1 Other readers,
who viewed the Neuro BestContrast
data set side-by-side with the traditional
images, also rated image quality better
in more than 90 % of the cases and
lesion conspicuity higher in more than
50 % of the cases.
“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, Germany
Coverstory
exams using the SOMATOM Definition
line of scanners. Enterline says that Neuro
BestContrast allows radiologists to
better visualize subtle edemas as well
as subtle signs of stroke, and to better
delineate the cortical margin, adding,
“My colleagues and I uniformly feel that
with better image quality, our comfort
level and our ability to make diagnoses
are significantly increased.”
The improved image quality experienced
by Enterline and his colleagues at Duke
is also evidenced by clinical data and the
At the University Hospital in Göttingen,
Germany, Peter Schramm, MD, Deputy
Head of the Department of Neuro-radiology,
was able to compare images
acquired before and after the implemen-tation
of Neuro BestContrast in a patient
with head trauma whose hospitalization
coincided with the hospital’s transition
to the new software. “We were able to
perform an exact comparison intra-individually,
and in that case it was really
impressive to see the improvement that
came along with Neuro BestContrast,”

Coverstory
Iterative Reconstruction in Image Space (IRIS)
Image data
recon
Master
recon
Compare
Strong artifact and dose reduction
Well-established image impression
Fast reconstruction in image space
Schramm says. “The delineation of the
edema and the margins of the edema
were definitely better visualized using
Neuro BestContrast, and the same ap-plies
to the changes that occur in acute
stroke.”
Neuro BestContrast improves non-con-trast
head images by taking advantage
of 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
data differently than the low-to-medium
frequency data, resulting in improved
tissue contrast without the amplification
of image noise.
Enterline says the use of Neuro BestCon-trast
has the potential to reduce radiation
dose as well. His preliminary data has
documented a 15 to 20 % improvement
in gray/white matter differentiation that
can allow for image acquisition at a lower
dose than is currently used. “Our institu-tion
has traditionally fought for lower
dose,” he says, “and I think this will now
allow us to further reduce our dose.”
IRIS
Neuro BestContrast can be combined
with another new Siemens technology
known as Iterative Reconstruction in
Image Space (IRIS) to reduce dose and
improve image quality even further.
“I think they work perfectly with each
other and have additive value,” says
Christoph Becker, MD, Professor of Radi-ology
and Section Chief of Computed
Tomography and PET/CT at Ludwig-Maxi-milians-
University in Munich, Germany.
Iterative reconstruction uses a correction
loop to improve image quality in several
steps, or iterations. The idea was first
introduced in the 1970s, but the com-puting
power and time required for the
reconstruction made it impractical for
use in clinical settings. An alternative
known as statistical image reconstruction
reduced the time associated with itera-tive
reconstruction but produced a tex-ture
that radiologists found unaccept-able.
With IRIS, Siemens took a different
approach. The algorithm takes all of the
data, which contains fine details as well
as significant amounts of noise, com-of
dense structures such as bone and
calcium, making it easier to visualize
or rule out subarachnoid hemorrhage.
Preliminary data from Becker show that
IRIS reduces dose by 25 % in head CT
exams yet achieves the same level of
noise as filtered back projection, the tra-ditional
method for image reconstruc-tion.
Becker notes that clinicians can
also choose to use the same dose as fil-tered
back projection yet deliver signifi-cantly
better image quality using IRIS.
In the United States, Ridgeview Medical
Slow Raw Data Space Fast Image Data Space
bines it in a master image and cleans it
up in the fast-processing image space
rather than in the slow-processing raw
data area. The result is that high spatial
resolution is preserved and noise is re-duced
– without disrupting workflow.
Becker says the combination of Neuro
BestContrast and IRIS, which is available
on the SOMATOM Definition line of
scanners, allows him and his colleagues
to better differentiate the basal ganglia
and to see subtle signs of stroke. He
adds that IRIS also reduces the blooming
Image
correction
2 IRIS takes all of the data, which contains fine details as well as significant amounts
of noise, combines it in a master image and cleans it up in the fast-processing image space
rather than in the slow-processing raw data area. The result is that that high spatial resolu-tion
is preserved and noise is reduced – without disrupting workflow.
2

“With the improve-ment
in radiation
dose using IRIS,
the image quality
is not changed, so
we just switched
right over to it.”
David Gross, MD, Chief of Radiology
Ridgeview Medical Center, Waconia,
Minnesota, USA
Coverstory
Center in Waconia, Minnesota, USA in-stalled
IRIS on its SOMATOM Definition
AS 40-slice CT and its Definition AS+
128-slice scanner early in 2010. Chief
of Radiology, David Gross, MD, directly
compared images produced using IRIS
with traditional filtered back projection
images and then enthusiastically adopt-ed
IRIS. “After two or three days, we
decided that there’s no sense in even
comparing anymore,” Gross says. “With
the improvement in radiation dose, the
image quality is not changed, so we
just switched right over to it.”
Neuro BestContrast and IRIS build upon
other Siemens innovations in neuro
imaging that maximize diagnostic confi-dence.
The “Posterior Fossa Optimization”
algorithm, which was introduced in 2001
and is implemented in all SOMATOM
Sensation and Definition scanners,
significantly reduces streaks and dark
bands, known as Hounsfield Bars, to
allow for better resolution with less
artifact. Siemens’ z-Sharp Technology
provides routine isotropic resolution of
0.33 mm, one of the industry’s highest,
enabling the visualization of small
anatomical details such as fine vascular
structures. For ultra-high-resolution bone
imaging for inner ear structures, Siemens’
z-UHR Technology provides 0.24 isotro-pic
resolution.
Perfusion CT and CTA
While non-contrast head CT exams are
still important for excluding intracranial
hemorrhage and ischemic stroke mimics,
the use of perfusion CT imaging is in-creasingly
being adopted. “Dynamic CT
Perfusion imaging, which can be acquired
immediately after the non-contrast head
“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, USA
CT while the patient is still in the scanner,
allows improved detection of acute
stroke, which has been substantiated in
several studies,” says Ke Lin, MD, Assis-tant
Professor of Radiology at New York
University Langone Medical Center in
New York City, USA. In a study of 100
patients presenting to the emergency
department within three hours of stroke
onset, Lin and his colleagues found that
CT Perfusion provided significantly im-proved
sensitivity and accuracy in acute
stroke detection over non-contrast CT.
Specifically, the researchers found that
CT Perfusion revealed 64.6% of acute
infarctions compared to 26.2 % for non-contrast
CT. CT Perfusion also had an ac-curacy
of 76 % compared to an accuracy
of 52 % for non-contrast CT.2
Lin and his colleagues obtained CT Per-fusion
data from a z-direction coverage
of 24 mm centered at the mid-basal
ganglia which maximizes the visualiza-tion
of the middle cerebral artery terri-tory.
Still, the researchers noted that
they missed ten infarcts that were out-side
of this volume of coverage. The ad-vent
of whole brain CT Perfusion using
Siemens’ unique Adaptive 4D Spiral, how-ever,
further increases the value of CT
Perfusion by expanding the scan range.
The revolutionary scan mode, which is
available on the SOMATOM Definition
line of scanners, overcomes the limita-tions
of a static detector design by ap-plying
a continuously repeated bi-direc-tional
table movement that smoothly

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.
3
Coverstory
a smooth, fast, and user-friendly work-flow.
A number of steps are automated,
including motion correction, bone seg-mentation,
arterial input function deter-mination,
and vascular pixel elimination.
The software allows for simultaneous
visualization of functional parametric
maps of cerebral blood flow, cerebral
blood volume, time to peak, mean tran-sit
time and other clinically important
information. With the click of a button,
clinicians can toggle between axial,
sagittal and coronal reformations.
Lin and his colleagues acquire the CT
Perfusion data for the whole brain in
just 45 seconds. Next, CT Angiography
data from the aortic arch through the
whole brain, a scan range of typically
more than 30 cm, is acquired in a couple
of seconds to deliver valuable infor-mation
about the feeding vessels that
are not covered by the initial perfusion
scan. Post-processing takes an additional
three to five minutes. In total, when
time for interpretation is accounted for,
the use of CT Perfusion and CT Angio-moves
the patient in and out of the
gantry over the desired scan range. Lin
has recently switched to a SOMATOM
Definition AS+ Scanner with all the
advantages of full brain coverage. “With
the increased coverage, we now expect
further improvement in acute stroke
detection accuracy, as well as the full
delineation of the ischemic penumbra
and the infarct core,” Lin says.
The stroke imaging workflow at NYU
Langone Medical Center also includes
a CT Angiography immediately following
the CT Perfusion exam to evaluate clot
location, clot burden, and collateral re-cruitment.
Lin adds that the information
is also used for planning interventional
procedures such as mechanical throm-bectomy.
Lin says the fast image acquisition of
the SOMATOM Definition AS+ 128-slice
scanner, combined with the rapid post-processing
of the Siemens syngo Volume
Perfusion CT Neuro software, allows
reading physicians to arrive quickly at an
appropriate treatment decision through
graphy adds approximately 10 minutes
to the acute stroke workflow. “That’s not
a lot of time considering that the addi-tional
information provided by the CT
Perfusion and the CT Angiography may
have very important implications for the
patient’s treatment and management,”
Lin says.
Reducing Dose in CT Perfusion
Lin recognizes that, while the use of CT
Perfusion is moving from academic
medical centers to community hospitals,
some barriers to its widespread adoption
remain. Chief among them is a concern
about the radiation dose associated with
the acquisition of CT Perfusion and CT
Angiography data. The use of Siemens
4D Noise Reduction, however, can re-duce
the radiation noise of dynamic CT
Perfusion. The reconstruction technique
treats the static anatomical information
differently from the dynamically chang-ing
perfusion information that results
from the in and outflow of the contrast
agent. By sampling multiple passes over

Coverstory
4 With Volume
Perfusion CT (VPCT)
fused with carotid
CTA the perfusion
status of the brain
tissue can be re-vealed.
This patient
presented after
onset of stroke and
underwent lysis
therapy. The follow-up
examination
showed a complete
revascularization
of the previously
hypoperfused area.
Courtesy of Uni-versity
Hospital Göt-tingen,
Germany.
the same volume it allows for the reduc-tion
of image noise. So the initial scan
can be performed with a lower tube
current, thus saving dose. The result
is that radiation dose is reduced by
up to 50 % while retaining equivalent
diagnostic information.
Although such dose-saving features can
benefit patients, Lin cautions that the
issue of dose must be kept in context
during an acute stroke. “The acute criti-cal
ischemic event that could kill the
patient takes priority over the slight in-crease
in radiation dose that is imparted
to the patient in order to arrive at a
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 unknown
time of onset, which occurs in up to
25 % of acute stroke patients, disqualifies
patients from receiving the drug.
In Europe, the University of Göttingen,
Germany has established stroke units
where patients are examined in an elon-gated
time window of 4.5 hours after the
onset of stroke, based on results from the
Third European Cooperative Acute Stroke
Study3 (ECASS III), so that more patients
can benefit from tPA treatment.
Rather than making treatment decisions
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
5 With Dual Energy
(DE) Bone Removal
vascular structures
can quickly be sepa-rated
from the bones
even in difficult areas
such as the base of
the skull. This clearly
proves the clinical
benefit of DE for
clinical routine.
Courtesy of University
Hospital Munich,
Campus Großhadern,
Germany.
4
5

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-ments,”
Lin says.
A Range of Neuro Imaging
Options
Of course, the use of CT in neuroradio-logy
is not limited to patients with acute
stroke. syngo Volume Perfusion CT
Neuro software provides a rapid and
automated evaluation of brain tumors
that enhances the ability to grade
tumors, plan biopsies, and monitor
therapy. The use of MRI to image brain
tumors is well established, but Schramm
notes that the use of CT Perfusion can
be advantageous in some cases. Intra-cerebral
lymphomas, for instance, can
be difficult to differentiate using MRI but
can be easily identified using perfusion
CT. “My prognosis is that CT will gain
even more ground in the coming years,
and this is due to the fact that it is
broadly available, less expensive than
MRI, and, in many cases, offers better
spatial resolution,” he says.
Another tool that significantly improves
workflow and diagnostic confidence in
the assessment of vascular structures of
the head and neck is syngo.via* CT
Neuro DSA (Digital Subtraction Angio-graphy),
which automates the removal
of bone from images, even in difficult
areas such as the base of the skull. The
very robust technique uses a non-con-trast,
low-dose scan that is acquired be-fore
the actual CT Angiography and is
then used to automatically remove all
the bone structures in the scanned re-gion.
On Dual Source CT scanners such
as the SOMATOM Definition and
Definition Flash “syngo Dual Energy
Direct Angio” offers a similar technique
which permits direct removal of bone
using only one scan. It uses the fact
that two X-ray sources running simulta-neously
at different energies can acquire
two data sets with different attenuation
levels.
“DSA is susceptible to any motion that
occurs between the exams,” Becker
points out, “whereas with Dual Energy
there are never any motion artifacts
when we extract the bone from the
dataset.” The scan speed of up to
45,8 cm per second and the temporal
resolution of 75 milliseconds that is
possible with the SOMATOM Definition
Flash can be particularly helpful in
scanning the carotid arteries, Becker
says, since they quickly fill with contrast
media. He says the high-pitch Flash
mode makes it easy to accurately time
the scan so that pure arterial phase can
be achieved without venous overlay that
can impair visualization. Additionally,
the information from dynamic CTAs
using the Adaptive 4D Spiral technology
offers new insights in cerebral hemo-dynamics
to evaluate endoleaks, Takayasu
disease, or complex hemodynamics of
dural arteriovenous fistula. Becker adds
that Siemens’ latest imaging software,
syngo.via*, speeds workflow by allowing
him and his colleagues to access and
share data from anywhere** within the
network.
As Low as Reasonably
Achievable
“In developing advances that aim to im-prove
the diagnostic confidence of phy-sicians
and patient outcomes, Siemens
is committed to reducing radiation dose
to the lowest possible level following the
“Siemens is commit-ted
to reducing
radiation dose to
the lowest possible
level. Innovations
such as IRIS are
evidence of this
commitment as is
X-CARE”
Sami Atiya, PhD, Chief Executive
Officer, Business Unit Computed
Tomography, Siemens Healthcare,
Forchheim, Germany.
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.
*
**

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.
2008
4D N oise
Reduction
Up to 50 % dose reduction
2007
Adaptive Dose Shield
Selective
Photon
Shield
2008
Selective
Photon
Shield
No dose penalty
140 kV
Attenuation A
80 kV
Attenuation B
Dose Shield
Dose Shield
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.
7

1 Diehn F, et al. – RSNA 2009 presentation SSE23-
03: A Preliminary Study of Novel Post-processing
Tool: Multi-Band Filtration of Noncontrast Head
CTs.
2 Lin K, et. al. – Cerebrovascular Diseases 2009;
2009
Coverstory
Iterative
Reconstruction in
Image Space (IRIS)
X- ARE
Up t 40 % dose
2008
Neuro BestContrast
C
o
reduction
2008
X-ray low
X-ray on
Image data
recon
Image
correction
28:72-79
3 Hacke W, et al. – NEJM 2008;359 (13) 1317-1329
4 Thomandl B, et al. – RadioGraphics, 23:565-592
‘as low as reasonably achievable’
(ALARA) principle. Innovations such as
IRIS are evidence of this commitment,
as is Siemens X-CARE”, says Sami Atiya,
PhD, Chief Executive Officer, Business
Unit Computed Tomography, Siemens
Healthcare in Forchheim, Germany. The
application protects sensitive organs by
lowering the tube current during the
portion of the rotation in which the area
of concern would otherwise be near the
X-ray source. Enterline, at Duke University
Medical Center in Durham, USA, points
out that X-CARE is especially important
for protecting the lenses of the eyes,
which are particularly radiosensitive. He
says the technology has allowed him and
his colleagues to reduce dose to the lens
up to 30 % in preliminary data without
a reduction in image quality. They
routinely use X-CARE in their practice.
Another technology that minimizes dose
to patients is the Siemens Adaptive
Dose Shield, available on the SOMATOM
Definition AS and Definition Flash scan-ners.
With traditional spiral CT exams,
patients are exposed to unnecessary
radiation at the beginning and the end
of the exam. The Adaptive Dose Shield
automatically moves collimators into
place to block this unnecessary exposure,
thereby reducing dose by up to 25 %.
Becker notes that the proportion of over-beaming
is especially significant over
small scan ranges, so pediatric patients
and those requiring head CT exams
stand to gain the most.
Becker and his colleagues further reduce
radiation dose with Siemens CARE
Dose4D, which provides real-time mo-dulation
of dose, based on patient size
and the anatomy being imaged. “I totally
insist on using it,” Becker says. “We
don’t switch this option on and off –
we use it for every CT scan.”
Concerns about radiation dose have
moved from the medical journals and
conference halls into the mainstream
news media. Enterline and others say
that, as a result, patients increasingly
ask about the potential consequences
of their exposure to medical imaging.
Discussing the risks and benefits asso-ciated
with CT imaging with patients
helps reassure them, Enterline says, and
so does having technology that minimizes
dose. “It’s our responsibility to do what
we can to minimize dose and to make
sure that the studies are appropriate,”
he adds. “It’s the right thing to do for
patients.”
Sameh Fahmy is an award-winning freelance
medical and technology journalist based in
Athens, Georgia, USA

News
Affordable Performance
in 16- and 64-slice CT
At the European Congress of Radiology in March 2010, Siemens
introduced new 16- and 64-slice systems to the market: The SOMATOM
Emotion Excel Edition and the SOMATOM Defi nition AS Excel Edition.
By Jan Freund, Steven Bell and Rami Kusama, Business Unit CT, Siemens Healthcare, Forchheim, Germany
The new Excel Editions from Siemens
are especially cost-effective versions
of the SOMATOM Emotion 16-slice and
SOMATOM Definition AS 64-slice scan-ners.
The Excel Edition is the result of
Siemens’ commitment to developments
that bring new technology to more
people through reducing the costs of
these innovations. These new additions
to the Emotion and Definition AS fami-lies
offer customers access to 16-slice
and 64-slice Siemens technology in
scanners that include many of the ad-vantages
that existing Emotion and
Definition AS customers know, at a
significantly more advantageous price.
On the one side, the SOMATOM Emotion
Excel Edition is especially designed to
make it easier for small and medium-sized
hospitals and practices to enter the
world of 16-slice computed tomography.
It continues the success story of the
Emotion platform that remains the most
popular CT in the world.
The success of the SOMATOM Emotion
platform to date has been due to superb
image quality, a simplified and efficient
workflow, and the ability to save money
over the life of the CT system. To date,
there are around 7000 systems installed
worldwide. The 16-slice SOMATOM
Emotion Excel Edition builds on the prior
success of this imaging platform to bring
these advantages to more customers
and patients. It offers the smallest focal-spot
size and a high number of effective
The new Excel Editions from Siemens are especially affordable versions of the SOMATOM Emotion
16-slice and SOMATOM Definition AS 64-slice scanners.

News
www.siemens.com/
somatom-emotion
www.siemens.com/
somatom-definition-as
detector channels for increased image
clarity and resolution. It continues
Siemens’ focus on dose reduction with
the exclusive CARE Dose4D algorithm
offering dose reduction of up to 68 % in
routine scanning. Customers will also
continue to benefit from the easy-to-use
syngo user interface that Siemens
customers across all imaging modalities
are familiar with.
On the other side, the SOMATOM
Definition AS Excel Edition introduces
a high-end, yet affordable 64-slice work-horse
for both everyday clinical routine
and advanced imaging. It will broaden
the portfolio of the SOMATOM Definition
AS family and continue its legacy as the
world´s first adaptive scanner. Its unique-ness
is the unprecedented adaptability
to any patient and any clinical question,
making it an expert in virtually any
clinical field. With the introduction of
the SOMATOM Definition AS Excel
Edition, Siemens continues to lead the
world of innovation by making two ends
meet: bring outstanding imaging tech-nology
and advanced clinical applica-tions
to budget-minded customers.
The SOMATOM Definition AS Excel
Edition addresses the growing market for
entry-level 64-slice scanners. Especially
this segment is currently facing a very
strong trend towards commoditization,
demanding a reliable, cost-efficient
64-slice system to realize high through-put
in everyday clinical routine. For this,
the scanner offers the highest degree of
flexibility with its 78 cm gantry and a
table load capacity of up to 300 kg thus
avoiding delays and patient exclusions.
Combined with the industry’s highest
sub-mm resolution and coverage speed
in its segement, a rotation speed of 0.33
seconds and unique applications like 3D-guided
CT interventions, the SOMATOM
Definition AS Excel Edition delivers
state-of-the-art CT imaging and can
cope with literally every need in clinical
routine. At the same time, it sets stan-dards
in patient safety by providing a
unique composition of dose protection
features like CARE Dose4D, the innova-tive
Adaptive Dose Shield, which avoids
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.
* 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.

News
Best Balance Between
Image Quality
and Reduced Dose
Iterative Reconstruction in Image
Space (IRIS) provides individual choices
and benefi ts for all patients.
By Annette Tuffs, MD
It is a difficult choice for physicians
to decide what benefits the patient most,
the highest resolution with best image
quality and diagnostic confidence –
or the lowest radiation level to reduce
the long-term risks for their patients.
Modern CT technology like IRIS cannot
entirely overcome this dilemma, of
course, but it provides flexible solutions
that allow choices for the individual
patient according to age, condition,
suspected pathology and the specific CT
investigation being performed, thereby
permitting the reading physician to
carefully weigh the benefits of highest
possible resolution against the advan-tages
of minimized radiation exposure.
IRIS – A Success Story
The peak of these impressive develop-ments
is IRIS, which stands for Iterative
Reconstruction in Image Space. It had
its debut at the 2009 RSNA meeting in
Chicago and has proven to be another
Siemens success story in substantially
reducing radiation dose. It is based upon
“iterative reconstruction,” a method first
developed in the 1970s to reduce noise
in CT images.
Iterative reconstruction includes a “cor-rection
loop,” in which images are repeat-edly
calculated by assumptions. The
image becomes softer in homogenous
tissue regions while, at the same time,
high-contrast tissue boundaries are main-tained.
Image resolution and image noise
are no longer closely inter-dependant.
However, this process required a lot of
time and enormous computing capacity
and therefore – before IRIS – was not
feasible for use in clinical routine. Now,
Siemens engineers and scientists have
optimized the process and developed
IRIS, where time and computing capacity
are no longer an issue.
“We are enthusiastic about this innova-tive
method in CT scanning, that´s why
we use it in our greatly improved daily
routine,” says Professor Joseph Schoepf,
MD, whose Department of Radiology at
the Medical University of South Carolina,
Charleston, USA, was one of the first
to gain clinical experience with IRIS.
His department has been using IRIS on
a routine basis since autumn 2009 for
about 15 patients per day.
All Patients Benefi t
Several university hospitals, in Germany
and abroad, have already been able to
gather extensive clinical experience with
IRIS. One of them is the University
Hospital, Erlangen in Germany, where
Michael Lell, MD, Senior Physician at the
Radiology Institute, has been involved in
studies concerning the potential of IRIS
in reducing radiation dosage. In one of his
studies, that he will submit for publica-tion
in the next months, more than 70
patients have been evaluated with and
without IRIS. The radiologists in Erlangen
were looking specifically at the abdo-men.
“As a preliminary result, we can say
that we were able to achieve a 50 %
dosage reduction while maintaining
high standards of image quality,” Lell
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.
recounts. Which patients will benefit
most from the use of IRIS? “All patients
should have the benefit,” says Lell, “and
therefore we changed all our protocols
to include IRIS.” However, there are spe-cific
patient groups that should benefit
even more, for instance children, since
they demand the smallest possible dose
because of long-term, higher potential
radiation risks and, at the same time,
have smaller body structures, which are
more difficult to visualize in CT scanning
procedures.
Lell specifically mentions the group of
children and juvenile patients with muco-viscidosis,
an unstable condition that can
require frequent CT scans. He is optimistic
that, with the ongoing fine-tuning of IRIS,
further dose reductions will be possible
and he is confident that the magic thresh-old
of up to 70 % reductions can be
reached.
Special Object:
Cardiovascular Stent
Another group of patients that especially
benefit from IRIS is the increasing num-ber
of obese patients of both genders
and all ages. Even when the smaller of
these morbidly obese patients are able to
squeeze through the CT gantries, the
resulting images are often substandard,
sometimes strikingly so.
“The diagnostic results can be greatly
improved with IRIS in obese patients,”
says Schoepf. His hospital mainly cares
for patients with either digestive disease
or cardiovascular disease. His special
1

News
IRIS Now Extended to SOMATOM Defi nition AS 20
and SOMATOM Defi nition AS 40
By Rami Kusama, Business Unit CT, Siemens Healthcare, Forchheim, Germany
Because at Siemens dose reduction has
continued to be given top priority, assur-ing
both patients and medical personnel
the best in medical care with the least
possible risk, the availiability of IRIS with
the SOMATOM Definition, SOMATOM
Definition Flash, and SOMATOM
Definition AS+ and AS 64, will be ex-tended
to the SOMATOM Definition AS
40, as well as AS 20. Now all scanners
from the SOMATOM Definition family*
will benefit from excellent diagnostic
image quality with levels of dose lower
than ever before. With IRIS, Siemens’
smart approach to iterative reconstruc-tion,
up to 60% additional dose reduction
can be achieved in a wide range of daily
routine CT applications.
Dose reduction with CT has been limited
by the currently used filtered back projec-tion
reconstruction algorithm. When
using this conventional reconstruction of
acquired raw data, a trade-off between
spatial resolution and image noise has to
be considered. Higher spatial resolution
increases the ability to see the smallest
detail; however, it is directly correlated
with increased image noise.
In an iterative reconstruction, a correc-tion
loop is introduced into the image
generation process. To avoid long recon-struction
times, IRIS first applies a raw
data reconstruction only once. During this
initial raw data reconstruction, a so-called
and newly developed master
volume is generated that contains the full
amount of raw data information, but at
the expense of significant image noise.
During the following iterative correc-tions,
the image noise is removed with-out
degrading image sharpness. The
new technique results in increased im-age
quality or dose savings of up to 60 %
for a wide range of clinical applications.
90 day, free trial licenses for IRIS are
now also available. The local sales
representative can be contacted for
details.
*requires syngo CT 2010A or syngo CT 2010B
Iterative Reconstuction in Image Space (IRIS)
Slow Raw Data Space Fast Image Data Space
Image data
recon
Master
recon
Compare
Image
correction
Q Up to 60 % dose reduction
Q Image quality improvement
Q Fast recon in image space
Q Well-established image impression
Q 90 day, free trial license
interest is testing IRIS in patients with
heart stents that are supposed to keep
the coronary arteries open.
“Coronary stents are the Achilles’ heels
of radiological heart diagnostics,” says
Schoepf. With IRIS, it is easier to detect
whether there is a true obliteration of
the stent or the so-called, “beam harden-ing,”
that only simulates closure of the
stent. Preliminary results of a study at
the Medical University of South Carolina
have already shown that IRIS will help
to make this important distinction, that
has a major impact on therapeutic deci-sions
and results.
Searching for Small Liver
Metastases
Another important area with far-reaching
therapeutic consequences is the imaging
of the liver, especially when searching
for small metastases of malignant tumors
elsewhere in the body. “With IRIS, we
have a much better chance of finding
these lesions,” says Schoepf.
Konstantin Nikolaou, MD, Prof. of
Radiology, Associate Chair of the Depart-ment
of Radiology, Munich University
Hospital, Germany, also agrees that all
patients can profit from the use of IRIS,
some of them more than others. Since
last autumn, he and his colleagues have
changed all the protocols to use IRIS. By
April 2010, more than 3.000 patients of
all ages and conditions profited from
improved IRIS image quality or dose
reduction. Overall dose reductions in all
body regions of about 30 % were
achieved, and current scientific studies
at the University of Munich are designed
to prove this effect. “IRIS has improved
our daily routine because of higher im-age
quality or lower dose.” The Munich
radiologists are currently running studies
where the diagnostic results from IRIS
images are compared with conventional
images, and their recent finding have
shown that an experienced radiologist
can easily adjust to the new kind of
image impressions. “A trained eye can
benefit from the IRIS specific images –
the improved spatial image resolution in
high contrast areas, with less noise in
the low contrast areas.”
Annette Tuffs, MD, is a medical journalist
based in Heidelberg, Germany. The former
medical editor of the daily Die Welt has
been contributing to the Lancet and the
British Medical Journal since 1990.

News
syngo CT 2010B Now Available:
New Software Version for the
SOMATOM Defi nition AS Launched
By Jan Freund, Business Unit CT, Siemens Healthcare, Forchheim, Germany
The new syngo software version, CT
2010B, for SOMATOM Definition AS
scanners, was released in April 2010.
It makes IRIS (Iterative Reconstruction
in Image Space) available to SOMATOM
Definition AS customers. With IRIS, a
dose reduction of up to 60% is possible
without compromising image quality.
In addition, native head-image quality
can be significantly improved with
Neuro BestContrast without an increase
in dose. By separating low and high fre-quency
Worldwide Dose Counter
By Peter Seitz, Business Unit CT, Siemens Healthcare, Forchheim, Germany
data, it specificly optimizes the
tissue contrast without amplifying the
image noise, resulting in an improve-ment
of signal to noise ratio of up to
30 %. In dynamic studies, such as CT
Perfusion images, noise can be signifi-cantly
reduced. As a result, radiation
dose can be lowered without compro-mising
image quality. The Adaptive
Signal Boost optimizes lower signals,
e.g. when low dose or obese protocols
are used. Neuro BestContrast, 4D Noise
Reduction and the Adaptive Signal Boost
will be available free of charge. CARE
Contrast II synchronizes CT scan and
contrast media injection. With its open
interface technology, it is ready for
future applications. The syngo CT 2010B
will be delivered with all new systems
beginning in May 2010 and as a field
roll-out to the complete installed base
of the SOMATOM Definition AS.
With the SOMATOM Definition Flash,
coronary CTAs become routinely available
at dose levels below 1 mSv. Now every-body
can check dose values for them-selves,
in daily routine, worldwide, and in
almost real-time. Being able to image the
coronary arteries with a radiation dose of
below 1 mSv is impressive in itself, but it
becomes even more impressive when this
happens everyday, all around the globe
and not just in a few specialized cases.
That’s why Siemens decided to make av-erage
doses of Flash Spiral Cardio scans –
View on the Siemens Healthcare
dose counter homepage.
analysis that is sent from SOMATOM
Definition Flash installations worldwide.
In addition latest news and further infor-mation
are available on Siemens Low
Dose CT.
www.siemens.com/low-dose
our all-new high-pitch mode for scan
speeds up to 458 mm/s – publicly avail-able.
With this ultrafast scanning, the
SOMATOM Definition Flash acquires the
entire heart in only around 270 ms, re-ducing
radiation exposure to the mini-mum,
all the while maintaining the excel-lent
image quality that previously was
only possible at much higher dose levels.
At www.siemens.com/low-dose anyone
can observe the current average dose on
the installed base. This value is updated
every 30 minutes by statistical data

News
syngo.via
Workstation
Face-off Sessions
By Karin Barthel, Business Unit CT,
Siemens Healthcare, Forchheim, Germany
At RSNA 2009, Siemens Healthcare
introduced their new imaging software,
syngo.via,* a client-server based soft-ware
solution which allows to display
most used applications across various im-aging
modalities – dedicated not only to
general radiology but tailored to specific
clinical fields such as oncology, neurology,
vascular imaging and cardiology as well.
Since then, syngo.via has participated at
2 major face-offs. At a face-off, several
industry vendors enter the arena to dem-onstrate
cases live on their respective
workplaces, permitting the audience to
make an immediate, direct comparison of
the software versions and results.
First, syngo.via met the challenge at the
6th International MDCT Symposium 2010
in Garmisch-Partenkirchen, Germany,
where about 1.600 CT experts were reg-istered.
Thomas Mang, MD, from the Uni-versity
Hospital in Vienna demonstrated
the cases for Siemens. The first was a
vascular case where an aneurysm needed
to be evaluated. With syngo.via, Mang
could fulfill all tasks ahead of time in out-standing
clinical quality. Only 2 minutes
were required since many steps, like table
removal, bone removal, naming of vessels,
curved MPRs and orthogonal views, were
automatically calculated by syngo.CT
Vascular Analysis.** The second case was
an oncology case in which multiple liver
lesions had to be measured. The auto-matic
synchronization of datasets, the
propagation of previous results and the
unique Findings Navigator helped to
speed up the workflow tremendously.
The contouring algorithm worked per-fectly
and measured reliably, even for the
very complex liver lesions that, in compari-son
to the surrounding tissue, showed
very similar density.
With syngo.via, a vascular case, demonstrated during the face-off in Vienna,
was completed with only a few steps due to automated tools.
The second competition was the work-station
face-off at the ECR in March 2010
in Vienna, Austria. There, 3 cases where
demonstrated by Marco Das, MD, from
the University Hospital in Maastricht, The
Netherlands. The first case was a vascular
case whereby a high-grade stenosis in
the common carotid artery needed to be
quantified and an occlusion in the MCA
segment had to be displayed. The case
was completed with syngo.via with only
a few steps. Due to all the automated
tools, Das only had to click into the areas
of interest and could show the results.
The second case was a brain perfusion in
which the MTT, CBF and CBV parameters
had to be measured. Here it was only
necessary to open the syngo Volume
Perfusion CT Neuro application to accept
the results and to place a ROI into the in-farction.
Everything else was automati-cally
calculated by the system. All in all,
this took only 45 seconds.
The third case was a PET/CT case in which
the assessment of response to treatment
between 3 time-points had to be done
with an volumetric assessment according
to RECIST, WHO and volume, including
percentual change between examina-tions
as well as an metabolic SUV assess-ment
based on PET data. With the Find-ings
Navigator it was very simple to jump
from finding to finding. And the compari-son
of findings was easy to use since all
images such as CT, PET, Fused and MIP
images were displayed next to each
other. Due to the dedicated lung, liver
and lymph algorithms, all kinds of le-sions,
no matter if large or small were
contoured and measured precisely. These
results showed that syngo.via currently
will be an industry standard for state-of-the-
art imaging solution.
Thomas Mang, MD,
AKH, Vienna, Austria
“Due to the automated
features within syngo.via,
manual preparation of
cases is no longer necessary.
Now, a radiologist can
start working where he
wants to start, with reading
the case.”
Marco Das, MD,
Maastricht University
Medical Center,
The Netherlands
“I saw the syngo.via face-off
in Garmisch and was very
impressed. So, when I was
asked to demonstrate it in
Vienna, I agreed immediately.
Although the software was
new for me, it was easy to
learn and I was proud to
demonstrate it at the ECR.”
*
**
The information about this product is being provided for planning purposes. The product is pending 510 (k) review, and is not yet commercially available in the U.S.

News
syngo.via CT Speedometer
In November 2009, Siemens Healthcare introduced syngo.via, a new
client-server based imaging solution concept to improve quality
of patient care, to cut costs for healthcare and to help hospitals and
practices optimize their workfl ows.
By Karin Barthel, Business Unit CT, Siemens Healthcare, Forchheim, Germany
syngo.via* is a new imaging software
that supports the physician’s diagnostic
work with indication-specific workflows,
layouts, and tools. Unlike typical radiolog-ical
workplace setups – often equipped
with multiple, isolated workstations –
syngo.via is a server-based imaging soft-ware
that can be seamlessly integrated
in PACS or RIS-based working scenarios,
accessible from any** PC within a clinical
network.
To give an overview of the many oppor-tunities
for saving time in CT, an easy
to use tool has now been created: the
syngo.via CT Speedometer. The CT Speed-ometer
shows exactly how utilizing
syngo.via can save time during the whole
workflow, from patient registration over
reading the cases up to distributing the
report. Many time-consuming steps
which previously had to be done manually
can now be avoided.
The following illustrates just a few of the
time-saving features that are quickly locat-ed
and explained with the CT Speedometer:
will also be created automatically
(Fig. 1A).
Summary: There is no need to prepare
the data set before being able to read
the case.
One Click Stenosis –
Measurement Straight Away
In cardiac evaluations, three reference
points are automatically placed before,
in and after a stenosis by syngo.CT
Coronary Analysis.*** The entire vessel
lumen can be controlled with a dedicated
profile curve displayed next to the vessel.
By accepting the measurement, the
results – including the images – are
documented in the Findings Navigator
(Fig. 1B).
Summary: There is no need to go
through the entire case manually.
Multimodality Oncology –
Holistic Oncology Imaging
Because syngo.via provides multimodality
imaging, it can provide additional and
Image Prefetching –
Up-to-date imaging History
As soon as the patient is registered or
data arrives, syngo.via automatically
initiates a query in all connected archives
(e.g. PACS) for previous exams or reports.
Any reasonable previous examinations
of a patient from CT, MR, AX or other
moda-lities are prefetched. Thus, a com-plete
imaging history is available before
the physician starts reading the case.
Summary: Manual, time-consuming
querying and loading data is history
with syngo.via.
Preprocessing – Reading can be
Started Faster Than Ever Before
For example, as soon as a vascular case
arrives at the server, syngo.via automati-cally
starts to preprocess the data set. In
this case, the table removal, bone removal
and the labeling of main vessels will be
automatically done by syngo.CT Vascular
Analysis.*** Curved MPR reformations
and orthogonal views of the main vessels
1A 1B
Prerequisites includes: internet connection to clinical network, DICOM compliance, meeting of minimum hardware requirements, and adherence to local data security regulations.
The syngo.CT Vascular Analysis and syngo.CT Coronary Analysis options are pending 510(k) review and are not yet commercially available in the U.S.
*
**
***

News
“With syngo.via, I can cut the time for my cardio-vascular
diagnosis from 25 minutes to only 4 minutes.”
Stéphane Rusek, PhD, Centre Cardio-Thoracique de Monaco, Monaco
“In an acute care case, e.g. a whole body scan
with multiple fi ndings – syngo.via can save up to
23 minutes to diagnosis.”
Marco Das, MD, University Hospital, Maastricht, The Netherlands
“Due to the automatic pre-processing of syngo.via a
substracted case of CT Neuro DSA can be seen imme-diately
instead of waiting up to 5–12 min post-processing
time with a traditional CT Neuro DSA software.”
Jacques Kirsch, MD, Department of Radiology, Hospital Notre-Dame, Tournai, Belgium
“When reading an oncology follow-up examination such
as a PET/CT which demonstrates multiple foci of cancer,
comparison with prior appearance is essential to
report response of therapy, syngo.via can reduce this
total interpretation time by 65 %.”
James Busch, MD, Specialty Networks, USA
The speedometer shows exactly how much
time can be saved with syngo.via.
www.siemens.com/ct-speedometer
potentially decisive diagnostic information
in oncology cases. Any image data, in
addition to CT, from PET, MRI or ultra-sound
available for the patient, can easily
be integrated into the oncology reading
layout with drag and drop (Fig. 1C).
Summary: There is no need to switch
between different data-sets or interfaces.
Lesion Picking – One Click
Synchronization
In Neuro Cases, syngo.via offers a one-click
aneurysm evaluation. By simply
clicking on the finding, e.g., in the VRT
view, the same finding will be centered
in the axial, coronal and sagittal views,
and the other way round (Fig. 1D).
Summary: No manual update of corre-sponding
windows is necessary.
Findings Navigator –
Reproducible Results
While reading the patient, findings
and measurements can be created, for
example, the grade of stenoses or
lengths of aneurysms. These are auto-matically
saved in the Findings Navigator.
Whenever a user opens a case, the last
findings are still there. By clicking on a
finding, the image will again be displayed
as it was before the last save.
Summary: No difficult reproduction of
old measurements is necessary.
Reporting – Complete
Summary Automatically
Finally, when the reading physician is ready
to close a case, a summary including all
image findings and measurements will be
created and saved to the PACS system.
Work can be finished with a few easy clicks.
There is no need to fax or mail results.
1 Time saving opportunities with
syngo.via:
In preprocessing alone, up to 7 min
can be saved (1A). In cardiac evalua-tion,
one-click stenosis measurement
(1B) saves an additional 4 min. This
also applies to multimodality onco-logy
reading (1C), and with CT Neuro
DSA aneurysm evaluation (1D), up
to 1 min can be saved (results may
vary; data on file).
More time saving features can be
found in the CT Speedometer.
www.siemens.com/ct-speedometer
1C 1D

News
International CT Image
Contest – Highest Image
Quality at Lowest Dose
By Rami Kusama, Business Unit CT, Siemens Healthcare, Forchheim, Germany
Excellent image quality is an essential
requirement in computed tomography
(CT). At the same time, the patient’s
radiation exposure should be kept as low
as possible. Siemens wants to motivate
its users to utilize all dose reduction
features available on their CT scanners
to the full extent and share their experi-
1 Winner in Cardiac
Moderate Atherosclerosis
(SOMATOM Definition Flash /
0.97 mSv dose), Yuko Utanohara,
MD and co-authors:
Nobuo Iguchi, MD, PhD; Kenji
Horie; Tatsunori Niwa; Sakakibara
Heart Institute, Japan
History:
A 68-year-old female, non-smoker,
with a 3-year history of hyperlipid-emia,
shortness of breath and chest
tightness on exertion was referred
for detailed examination to our de-partment
after heart murmur was
detected for the first time.
Diagnosis:
The coronary arteries showed
moderate 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.”
ences with other users. For this reason,
Siemens initiated the International CT
Image Contest from October 1, 2009 to
February 1, 2010 asking physicians from
around the world to send in their work
to compete for the best image quality at
the lowest possible radiation dose.
Around 300 low dose cases from more
than 30 countries were submitted and
were evaluated by a jury of internation-ally
renowned professors.
The Jury
Professor Stephan Achenbach
University of Erlangen, Germany
Professor Dominik Fleischmann
1

Winner in public voting: Interrupted Aortic
Arch (SOMATOM Definition/ 0.45 mSv dose),
Pannee Visrutaratna, MD, Maharaj Nokorn
Chiangmai Hospital, Thailand
History: A five-month old girl has suffered from
tachypnea, poor feeding, and poor weight gain
since she was one month old.
Diagnosis: Interrupted Aortic Arch. The arch
interruption occurs distal to the origin of the
left subclavian artery. The descending thoracic
aorta is supplied by a large patent ductus
arteriosus.
Stanford University Medical Center, USA
Professor Elliot K. Fishman
Johns Hopkins University Hospital, USA
Professor Yutaka Imai
Tokai University School of Medicine,
Japan
Professor Zengyu Jin
Peking Medical Union College, China
Professor Borut Marincek
University Hospital Zurich, Switzerland
Professor Maximilian Reiser
Ludwig-Maximilians-University Munich,
Germany
Professor Uwe Joseph Schoepf
Medical University of South Carolina,
USA
Participation
Images could be submitted online on
a contest website by users of the
SOMATOM Definition, SOMATOM Defini-tion
AS, as well as SOMATOM Definition
<<b<i<ttbei tüteb eürbaellr malli tm Diot sDiso-sTiasc-Thaoc>h>o>>
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.
Flash, in the categories of: cardiac,
neuro, abdomen and pelvis, vascular,
thorax, as well as Dual Energy. Every
internet viewer could select their
“favorite image” in a public voting.
Winner Announcement
The winner announcement took place
at the ECR 2010 in Vienna during the
Bayer Schering Pharma and Siemens
Healthcare joint Satellite Symposium.
Winning images (Figs. 1–6) were ex-hibited
at the Grand CT Image Gallery.
For those who could not attend the
ECR, the winners were announced at
the same time on the contest website
and via press release.
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
infarction precisely.”
2
www.siemens.com/Image-Contest
The free contest poster can be
ordered at:
www.siemens.com/ct-poster

News
3 Winner in Abdomen and Pelvis
Cancer of Pancreas (SOMATOM Definition
/ 6.34 mSv dose), Prof. Dan Han, MD
and Yu-Hui Chen, MD; Hospital of Kun-ming
Medical College; P.R. China
History:
A 59-year-old male had experienced up-per
abdominal pain for four years. A mass
in the head and neck of pancreas was
identified in both Ultrasound and MRI.
Diagnosis:
The advanced cancer of pancreas resulted
in a significant narrowing in the portal
vein and the collateral circulation was
established.
Jury statement:
“This CTA shows the encasement of the
portal vein / SMV confl uence 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 fulfi lls these criteria completely
at a very low radiation dose.”
4 Winner in Vascular
Child Aortic Transposition (SOMATOM
Definition Flash / 0.25 mSv dose), Gregory
Nicaise, MD and co-author: Philippe Ever-arts,
MD, Centre Hospitalier de Jolimont,
Belgium
History:
A 2-year-old child with chronic dyspnea and
pulmonary infection was presented for a CT
examination.
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.”
3
4

News
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 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.”
5
6

Business
Stéphane Rusek, PhD, is convinced that syngo.via radically transforms the use of CT even for his colleagues, turning it into an all’round
tool for all doctors: (from left to right) Filippo Civaia, MD, Philippe Rossi, MD, Stéphane Rusek, PhD, Laura Iacuzio, MD.
More for Less in Monaco
At Monaco’s Centre Cardio-Thoracique, Siemens’ latest groundbreaking
image-processing software, syngo.via, is boosting the productivity of the
cardio-vascular team.
Only a few meters up from the harbor,
yet still within sight of the multi-million-dollar
fleet resting in the sun, is located
Monaco’s Centre Cardio-Thoracique
where Stéphane Rusek, PhD, head of the
hospital’s IT department, is trying to
extract as much diagnostic information
as he can for as little cost and time as
possible.
Rusek’s goal is to boost the productivity
of radiologists and cardiologists by using
computed tomography (CT) images to
diagnose cardiac cases. And syngo.via,*
Siemens’ groundbreaking imaging
software, he’s convinced, is the answer.
syngo.via has the capacity to help
medical professionals use CT images
more easily and efficiently, thus freeing
such examinations delivered around
50 images; nowadays they generate
thousands – far too many for anyone
to handle promptly and effectively.
Rusek is convinced that syngo.via radi-cally
transforms the use of CT, turning
it into an useful tool for all doctors.
“We are on the brink of a boom in cardio-vascular
CT that will see it become
standard and routinely used in every
hospital,” he says. And the time seems
ripe. Health authorities around the
world appear increasingly willing to
fund cardiac CT. They have been fun-ded
in the USA since early 2010, and, in
Europe, German health authorities are
now looking into authorizing payment
for cardiac related examinations. The
up more time for actual diagnosis.
Stéphane Rusek is personally responsible
for implementing Siemens’ latest break-through
in image processing at the
Monaco clinic. “A new era in image pro-cessing
and CT diagnosis has dawned,”
he says. “What the iPhone did for mobile
computing, syngo.via is doing for CT. It
offers a user-friendly interface that gets
the most out of the technology without
users even being aware of the sophis-ticated
software responsible, let alone
having to learn to manipulate it.”
syngo.via has been specifically designed
to free medical professionals from the
burden of having to process the vast
amount of images made available by
today’s CT examinations. Ten years ago,
By Oliver Klaffke

Business
certain result will be to make such
exams more widely available.
“The enormous benefit of the cardio-vascular
applications in syngo.via
is that they save time,” says Rusek.
“Cardiologists no longer need to carry
out tasks that can be done faster and
better by software.” Preparing scans
for diagnosis can be extremely time-consuming,
especially in cardiac cases.
For example, manually deleting the
bony rib cage from images and high-lighting
the arteries takes a lot of effort.
In Monaco, before syngo.via, cardio-logists
often needed up to half an hour
just to prepare the images for diagnosis.
Fortunately, time consuming and
numerous mouse clicks to diagnosis may
soon be no more than a distant memory.
Today, cases can be automatically pre-pared
and presented using syngo.via.
“My guess is that five out of the six
clicks that you once had to make with
the mouse are no longer necessary,”
smiles Rusek. As soon as his medical
colleagues click to open a case in their
inbox, syngo.via lets them get straight
down to diagnosis. It will already have
prepared the cases automatically and
identified a process to meet the specific
diagnostic needs. Images are imme-diately
displayed in disease-related
layouts along with the appropriate tools
for deeper investigation. The medical
professionals are then carefully guided
through a series of steps that they
predefined in the software for their
institution.
“The syngo.via Cardio-Vascular appli-cation
package** now cuts the time
for cardio-vascular diagnosis from
25 to only 4 minutes – a factor of six.”
Information Available – Quality
and Effi ciency
“Here in Monaco, we have benefited
greatly from these disease-related work-flows,”
says Rusek. For each diagnosis,
syngo.via presents a to-do list to help
professionals get all the necessary infor-mation
reliably and in shortest time.
Simply following these procedures is a
great way to maintain the high stan-dards
that are increasingly the norm
in medicine. In Monaco, the cardiology
team has completely redefined its
standards and processes, thanks to
syngo.via. “Now everybody working here
uses the same processes,” says Rusek.
“This greatly reduces the risk of errors
and omissions during diagnosis.
And since all relevant related data are
stored along with the case and are re-trievable
at the click of a mouse, writing
reports has become much easier. “It’s
the perfect way to organize patient
documentation, so that the physician in
charge can work efficiently on the case,”
says Rusek.
In the past, cardiologists at Centre
Cardio-Thoracique often had to switch
between workstations to retrieve older
data stored on different computers.
No longer. “In our radiology department,
that’s a thing of the past,” says Rusek.
Using syngo.via, cases can be easily
accessed from any computer linked to
the hospital’s network. Gone is the need
to wait until a workstation becomes
available. At the PCs on their office
desks, medical professionals can imme-diately
and conveniently view any case
they want. Even specialists working at a
distance can log in utilizing a broadband
internet connection and get the infor-mation
they need quickly and efficiently.
Siemens Healthcare is dedicated to
making these benefits available every-where,
not just for Stéphane Rusek and
his colleagues on the beautiful shores
of the Mediterranean Sea.
1
Oliver Klaffke is a science and business
writer based in Switzerland. He has been
on assignment for New Scientist and
Nature in the past.
1 syngo.via CT Cardio-Vascular applications** for full cardiac assessment in less than 4 min: the automated case preparation, that saves up to
12 typical steps together with advanced visualization tools, like the Image Sharpening Filter for calcified lesions or stents, saves up to 21 min for
a full cardiac assessment (results may vary; data on file).
The syngo.CT Vascular Analysis and syngo.CT Coronary Analysis options are pending 510(k) review and are not yet commercially available in the U.S.
*
**

Business
New Feature: Neuro
Image Quality Surpasses
all Expectations
A better and quicker workfl ow that leads to more time for patient care and
diagnosis – this is the bottom line for Peter Schramm, MD, of the University
of Göttingen, Germany, after testing the new features of syngo CT 2010B.
But specifi cally for him, as neuroradiologist, the new dimension in neuro
image quality is also a main improvement and a very impressive one.
By Wiebke Kathmann, PhD
The new software version, syngo CT
2010B, offers several new features in-cluding
Neuro BestContrast, 4D Noise
Reduction, Iterative Reconstruction in
Image Space (IRIS), CARE Contrast II and
Adaptive Signal Boost. Together they
truly improve the diagnostic precision
and workflow as could be clearly demon-strated
during the Market Entrance
Phase (MEP) by Peter Schramm, MD,
Deputy Head of the Neuroradiology
Department at the University of
Göttingen. He was among the first
physicians worldwide to test the new
features in the clinical environment on a
SOMATOM Definition AS+ scanner. As a
neuroradiologist, he was especially im-pressed
by Neuro BestContrast because
it achieves a very substantial improve-ment
in image contrast, thereby signifi-cantly
improving the distinction be-tween
gray and white matter in the
brain – a very important feature in the
diagnosis of acute stroke patients where
tissue changes on the scale of 5 to 10
HU can decide between life and death.
Neuro BestContrast absolutely fulfilled
Schramm’s expectations. „Simply by
looking at the images in our digital
Picture Archiving and Communication
System (PACS), we could recognize the
point in time at which the new software
had been installed. A lot of our patients
get a follow-up CT scan, so we could
also compare scans from before and
after the software was implemented.
When Siemens told us that they were
aiming at improving the differentiation
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.

“At some point in the
future, neuroradiolo-gists
may no longer
need to perform
the complete stroke
CT protocol.”
Peter Schramm, MD,
Business
Wiebke Kathmann, PhD, is a frequent contributor
to medical magazines in the German-speaking
world. She holds a Master in biology and a PhD in
theoretical medicine and was employed as an edi-tor
for many years before becoming a freelancer in
1999. She is based in Munich, Germany.
they would be able to achieve an im-provement
in contrast without losing
spatial resolution. But they did – by
processing low and high frequencies
separately.“
One-Stop-Shopping
For clinicians performing perfusion im-aging,
4D Noise Reduction is the most
interesting feature. Static and dynamic
components are treated separately as
a means to reduce noise, thus improving
the image quality and clinical outcome.
Schramm could confirm this in acute
stroke patients, who are frequently quite
agitated.
The main advantage, however, that
Schramm sees with 4D Noise Reduction
is a reduction in radiation dose while
still being able to get all the diagnostic
information from one 4D volume perfu-sion
scan. “At some point in the future,
neuroradiologists may no longer need
to perform the complete stroke CT
protocol consisting of a non-contrast CT,
a whole brain perfusion CT including 4D
spiral scans and a CT Angiography of the
brain vessels. Due to the precision with
4D Noise Reduction, there could be ‘one-stop-
shopping’, the non-contrast CT
could be skipped by using the first of the
multi-spiral CT images before the con-trast
medium arrives and the angio-in-formation
could be taken from one arte-rial
sequence. For the patient that would
mean one instead of three CT scans,
consequently a shorter examination
time and, in the end, less radiation.“
Less Radiation
With the Iterative Reconstruction in
Image Space (IRIS), Siemens recently
introduced a new approach to addition-ally
reduce dose by up to 60 % and, at
the same time, improve image quality for
a wide range of clinical applications. Af-ter
an initial raw-data reconstruction, a
newly developed master image is gener-ated
followed by several iterative correc-tions
that remove image noise without
degrading image sharpness. With this
approach, IRIS achieves a similar image
quality as with true iterative reconstruc-tions
but avoids the long reconstruction
times, as multiple translations from and
to the raw data are not needed. For
Schramm, the main promise IRIS holds
with this new method is a reduction of
radiation dose. So far, he and his team
have worked with the regular dose. After
testing IRIS, they will now commence
with a controlled, stepwise dose reduc-tion
during the next few weeks. In 10 %
steps with about 500 neuroradiological
cases each, they hope to prove that IRIS
allows a reduction of radiation dose while
keeping the image quality at the same
level. “Most likely, IRIS will allow for a
reduction by 20 % in neuroradiology. In
spinal CT, I expect a reduction by 25 to
30 % without any loss of image quality,”
says Schramm. “In very obese patients
and abdominal CT applications, I can
realize a dose reduction of up to 60 %.“
Saving Time
Regarding the use of CARE Contrast II –
the new coupling interface for scanner
and bolus injector – Schramm experi-enced
two advantages: first, the im-proved
workflow for the technician due
to the synchronization of injector and
scanner and therefore improved patient
care; second, and more important, the
time saved due to the automatic and
digital transfer of the whole dataset on
contrast media, flow rate etc. to the
patient protocol. ”This archiving of the
complete data set – be it for legal, re-search,
or clinical purposes – saves time,“
explains Schramm.”This makes it a very
interesting feature for both research
and in clinical routine.“
Benefi t for the Obese Patient
As for the Adaptive Signal Boost,
Schramm is convinced that it will im-prove
diagnostic precision and reliability,
for example in CT imaging of the spine.
“This application is on the rise due to
improvements in CT technology and the
growing number of bariatric patients
who simply do not fit into the MRT and
where it is crucial to provide the re-quired
image quality for clinical evalua-tion.”
Here the Adaptive Signal Boost
improves the diagnostic accuracy in soft
tissue imaging, especially of paraverte-bral
and intra-spinal structures. “In rou-tine
examinations, these features do not
“Most likely, IRIS will
allow for a reduction
of radiation dose
by 20-30 % in neuro-radiology.”
Peter Schramm, MD,
necessitate changes in the workflow for
the technician,” says Schramm, “They
hardly notice the changes, whereas the
clinical results are very impressive for
the radiologist at the end of the line.”

Clinical Results Cardio-Vascular
Case 1
Adenosine Myocardial Stress Imaging
Using SOMATOM Defi nition Flash
By Gudrun Feuchtner,1, 4 Robert Goetti,1 André Plass,2 Monika Wieser,2 Christophe Wyss,3
Fernando Vega-Higuera,5 Hans Scheffel,1 Michael Fischer,1 Hatem Alkadhi,1 Sebastian Leschka1
1 Institute of Diagnostic Radiology, University Hospital Zurich, Switzerland
2 Clinic of Cardiovascular Surgery, University Hospital Zurich, Switzerland
3 Cardiology Division, University Hospital, Zurich, Switzerland
4 Department of Radiology II, Innsbruck Medical University, Austria
5 Business Unit CT, Siemens Healthcare, Forchheim, Germany.
HISTORY
A 51-year-old male with atypical chest
pain and intermediate coronary risk pro-file
(cigarette smoking and hypercholes-terolemia)
underwent two coronary
128-slice Dual Source CT Angiographies:
the first under adenosine myocardial
stress-imaging, the second at rest.
DIAGNOSIS
High-pitch CT Angiography showed
severely calcified left coronary artery
(Fig. 1C) with significant stenosis, and
bare-metal stent in the RCA.
Adenosine CT stress imaging showed
a reversible myocardial perfusion
COMMENTS
Adenosine stress-imaging of reversible
myocardial ischemia is feasable with
128-slice Dual Source CT with compre-hensive
evaluation of coronary arteries.
Assessment of PBV reversible ischemia
with CT is helpful to improve accuracy of
coronary CT Angiography, especially in
cases of severe coronary calcification or
limited in-stent lumen visibility.
defect indicating ischemia anteroseptal
at midventricular level (Figs. 1A–1B)
corresponding to left artery descending
(LAD) stenosis. No defect was found in-ferior
of right coronary artery (RCA) vas-cular
territory. Invasive angiography
confirmed a significant 90 % stenosis at
mid LAD and a patent RCA bare-metal
stent. Total radiation dose was 2.2 mSv
for adenosine stress and rest CT scans
using high-pitch Flash Spiral mode at
3.4 pitch factor. The delay between both
scans was 5 minutes. Scan time was
0.44 seconds for each study, tube set-tings
were 100 kV and 320 mAs, gantry
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.

Cardio-Vascular Clinical Results
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
angiography. Distal after steno-sis
a severely calcified artery
was found (arrow, Fig. 1C).
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).
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).
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).
No perfusion defect inferior
of RCA vascular territory could
be detected (Fig. 4C, arrow).
1A
2A
3A
First CTA under adenosine stress Second CTA at rest
1B
2B
3B
4A
4B
4C
1C
* The product is not commercially
available in the US.

Case 2
SOMATOM Defi nition Flash:
Visualization of the Adamkiewicz Artery
by 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, Japan
HISTORY
A 75-year-old female was referred to
the radiology department of Sakakibara
Heart Institute to examine where her
Adamkiewicz artery originated before
treatment of her thoracic descending
aortic aneurysm (TAA). The patient was
scanned with Dual Source CT in dual
power mode.
At the referring hospital, the patient
had been diagnosed with TAA (descend-ing
aorta of 5.6 cm diameter) by com-puted
tomography and echography as
well as right coronary artery (RCA) steno-sis
by conventional angiography. She
was referred to Sakakibara Heart Insti-tute
for surgical vessel replacement and
coronary artery bypass grafting with
saphenous vein graft to RCA.
DIAGNOSIS
TAA was clearly seen on the Dual Source
CT images. An artery originating from a
lumbar artery was detected, bifurcating
from the aorta at the upper level of the
4th lumbar vertebra, entering into the
spinal canal from the intervertebral fora-men
between the 4th and 5th lumbar
vertebrae and running along the spinal
cord on the ventral side up to the lower
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).
1

4 Adamkiewicz artery connected into the anterior spinal artery.
Scanner SOMATOM
Definition Flash
Scan area Thorax-abdomen
Scan length 280 mm
Scan direction Cranio-caudal
Scan time 8.41 s
Tube voltage 100 kV / 100 kV
Tube current 600 eff. mAs
Dose modulation CARE Dose4D
Rotation time 0.5 s
Slice collimation 128 x 0.6 mm
Reconstruction 0.3 mm
increment
Reconstruction B36
kernel
Volume 100 ml
Flow rate 5.0 ml/s
Postprocessing syngo InSpace
4
3B
level of the 12th thoracic vertebra where
it changed direction forming a hairpin
shaped structure. It connected into the
anterior spinal artery. According to these
characteristics this artery was identified
as the Adamkiewicz artery.
The true lumen of the aorta was highly
enhanced, reaching a CT value of 746
HU at the level between the 4th and 5th
lumbar vertebrae whereas the Adam-kiewicz
artery reached a maximum CT
value of only 140 HU.
COMMENTS
The course of the Adamkiewicz artery
needs to be determined before surgery
for TAA repair to ensure that it is not
damaged during surgery and to reduce
the risk of postoperative paraplegia.
However, visualizing the Adamkiewicz
artery with intravenous (IV) CTA is a
challenging task as injection and scan
protocols need to be tailored to the loca-tion
and size of this artery. Since the
Adamkiewicz artery is a tiny vessel, a
fair amount of contrast media needs to
be injected at reasonably high rates to
ensure that this tiny vessel is enhanced.
In addition, since the Adamkiewicz
artery runs partially inside the spinal
canal, enough dose needs to be applied
to achieve a high signal to noise ratio
(SNR) in an area surrounded by bones.
Dual Source CT in the dual power mode
combines the power of two X-ray tubes
and two generators and can therefore
provide twice as much X-ray output as
a single source CT at the same pitch. As
a result, areas that need additional dose
can be scanned at high scan speed and
appropriate tube current for a high SNR.
The high scan speed was essential for
visualizing the Adamkiewicz artery,
since it required several seconds after
enhancement of the aorta until the
small arteries were enhanced, then
quickly scan over the required long scan
range while the small arteries were still
enhanced.
3A
3 Adamkiewicz artery entering into the spinal canal (Fig. 3A)
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).

Case 3
Dynamic Myocardial Stress Perfusion
By Florian Schwarz, MD, Fabian Bamberg, MD, MPH, Christoph R. Becker, MD,
Alexander Becker, MD, Konstantin Nikolaou, MD
Department of Clinical Radiology, University of Munich, Campus Großhadern, Munich, Germany
HISTORY
A 71-year-old male was referred for eval-uation
of stable chest pain syndrome
and enrolled in a prospective cohort study
to evaluate the diagnostic accuracy and
clinical feasibility of dynamic myocardial
stress perfusion imaging by cardiac CT.
Coronary CT Angiography (CTA) and
CT-based assessment of myocardial per-fusion
under adenosine stress was per-formed
prior to cardiac catheterization.
DIAGNOSIS
Coronary CTA revealed heavy calcified
plaque and a mild to moderate lesion of
the right coronary artery (RCA, Figs. 1
and 2). Dynamic adenosine stress perfu-sion
imaging revealed homogeneous
perfusion of the myocardium without
defined perfusion defect (Figs. 4 and 5).
COMMENTS
Non-invasive myocardial perfusion imag-ing
by CT may represent an attractive
option to determine the hemodynamic
relevance of obstructive coronary lesions,
or lesions with limited evaluability due
to heavy calcification. However, further
validation using appropriate gold stan-dards
is warranted.
After undergoing the CT Perfusion scan,
the patient received conventional medical
therapy.
1 Maximum intensity display of the right coronary artery, demon-strating
heavy calcified plaque in the proximal segment and calcified
and non-calcified plaque in the intermediate segment, causing
a mild to moderate stenosis (arrow).
1
2 Curved multiplanar reformation of the left anterior descending
coronary artery with minor calcified and non-calcified plaque in the
proximal segment of the vessel (arrow).
2

time [s]
CT [HU]
time [s]
CT [HU]
3B
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).
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
4 Systolic reconstruction display of long axis, color-coded myo-cardial
stress perfusion image of the left ventricle indicating homo-geneous
perfusion (green) and the absence of a circumscribed
perfusion defect.
4
5 Short axis color-coded perfusion map of the left ventricle
demonstrating homogeneous perfusion (green) under
adenosine stress.
5
3A
80
60
40
20
0
0 5 10 15 20 25 30
100
80
60
40
20
0
0 5 10 15 20 25 30

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
A 71-year-old male patient with a history
of cerebral infarction caused by a high-grade
stenosis of the left internal carotid
artery and lysis therapy was now re-ferred
to the radiology department to
rule out coronary artery disease.
In addition to the coronary CT Angio-graphy
(CTA) examination a non-en-hanced
calcium-scoring scan (CaSc)
was performed.
The CTA was acquired with a fast pitch
spiral technique (Flash Spiral Cardio)
while a mean heart rate of 56 bpm was
present.
COMMENTS
In combination with the CaSc (0.35 mSv)
and the CTA (0.8 mSv), an effective
dose* of 1.1 mSv was applied to the
patient to detect coronary artery disease.
The entire acquisition time of the CTA
was 280 ms; calcium scoring was
acquired in 120 ms.
The Flash Spiral cardio method quickly
and reliably combines low radiation
dose values with the accurate display of
the coronary arteries in all segments.
DIAGNOSIS
In total, ten calcified lesions could be
detected in the CaSc. Diffuse distribution
of calcified deposits was observed in
the right coronary artery (RCA), the left
artery descending (LAD) and the left cir-cumflex
coronary artery (CX). The total
Agatston score was 130.
CTA unveiled a normal coronary artery
anatomy, right dominant coronary supply
type with regular sized lumen of the
coronary arteries. RCA and LAD showed
no hemodynamic relevant lesions. CX
coronary artery unveiled a stenosis
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.
*
**

3
5 6
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 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 InSpace
2
2 MIP of the LAD shows myocardial bridging
(arrow).
3 MIP of the first diagonal branch (D1) of the
LAD, discovers plunge into myocardium.
1
1 VRT of the Coronary arteries shows deep
myocardial bridging of LAD (arrow).
5 A stenosis is present in the proximal
segment of CX artery (arrow).
6 Cross-sectional view displays the
stenotic area of CX artery.
4
4 MIP of the coronary artery tree with
removed blood pool of the left ventricle
reveals calcifications (arrow).

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
1Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France
2Business Unit CT, Siemens Healthcare, Forchheim, Germany
HISTORY
A premature baby was referred to the
radiology department with diagnosis of
congenital heart disease. An atrial and
left ventricular septum defect could be
detected with echocardiography but
with a doubt about the exact origin and
*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.
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
(Flash Cardio Sequence) which resulted
in an ultra low dose value. Calculated
with the dose length product (DLP) of
0.7, an estimated dose of 0.05 mSv could
be achieved.*
Using the Definition Flash low dose ac-quisition
technique it was possible to de-tect
this congenital heart disease (CHD)
in a very early stage of the patients life.
1 CT imaging with VRT technique shows ventricular septal defect (arrows)
and persistent foramen ovale (PFO, arrowheads).
1

2 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 Cranio-caudal
view in VRT-tech-nique.
5 Fused VRT and
MIP highlighting
RPA (arrow).
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 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
4
5

Case 6
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
A 4-year-old boy with Tetralogy of Fallot
(TOF, Fig.1), pulmonary atresia (PA)
and major aorto-pulmonary collateral
arteries (MAPCAs) was referred to the
radiology department of Sakakibara
Heart Institute for a follow-up examina-tion
using a SOMATOM Definition Flash,
Dual Source CT in Flash Spiral mode
following treatment of his pulmonary
artery stenosis.
The patient was diagnosed shortly after
birth with TOF, PA, MAPCA. When he
was 10 months old, a stent was inserted
in the largest MAPCA and a central shunt
was placed when he was 16 months old.
When he was 2 years old, he underwent
right and left modified Blalock-Taussig
CT images revealed a tortuous artery
originating from a right subclavian ar-tery
that supplied the right and left infe-rior
lung lobes. The left lung was per-fused
mainly by the left central pulmo-nary
artery. The right middle lung lobe
was perfused by the large right inferior
diaphragmatic artery (its distal end was
connected to an artery originating from
the central pulmonary artery).
Incidentally, the right coronary artery
(RCA) was found to originate from the
aorta at the upper level of left coronary
artery, the left coronary cusp (Fig. 4),
which could neither be seen in the previ-ously
performed catheter angiography
nor in a 16-MSCT examination.
Based on these findings a catheter PTA
of the pulmonary artery stenosis at the
distal part of the stent was planned.
COMMENTS
Dual Source CT Angiography has
emerged as an essential diagnostic tool
for the assessment of complex congeni-tal
heart disease. Nevertheless, dose has
remained a concern, in particular when
referring pediatric patients for cardiac
CT. With the Flash Spiral mode of the
second generation Dual Source CT,
pediatric patients can be scanned at
ultra low dose, as in this case at 1.63
mGy (effective dose 0.644 mSv). Apart
from dose concerns, additional chal-lenges
have been associated with imag-ing
pediatric congenital heart disease
shunt surgeries (therefore the subclavi-an
artery is connected with the pulmo-nary
artery) within 9 months. Then, at
the age of 3, an artificial vessel was con-structed
from the right ventricle (RV)
to the pulmonary artery by palliative
Rastelli procedure.
The patient now underwent a percu-tanous
transluminal angioplasty (PTA)
of pulmonary artery. A low dose, Dual
Source CT scan in the Flash Spiral mode
was ordered to confirm his postopera-tive
condition, in particular concerning
the pulmonary circulation. The patient’s
weight was 15.6 kg (34.39 lb).
He was not sedated and no breath-hold
was needed during the scan. His mean
heart rate was 95 bpm.
DIAGNOSIS
The Dual Source CT images showed that
the RV-pulmonary artery conduit was
patent and that the anastomosis site
had no stenosis. Neither the right nor
the left pulmonary arteries (about
4 mm diameter) presented any signifi-cant
stenosis (Fig. 2).
A stent was confirmed in the biggest
MAPCA, which bifurcated from the
descending aorta at the level of the left
atrium. It went to the right superior and
inferior lung lobes, and connected one
artery originating from right central pul-monary
artery. Although the stent itself
was patent, a stenotic part was seen dis-tal
of the stent (Fig. 3). The Dual Source
1 Ventricular septal defect that is one
characteristic of TOF.
1
*
**

2A 3A
2B 3B
2 Both, right and left pulmonary arteries (about 4 mm diameter)
had now significant stenosis.
3 Stent was embedded in largest MAPCA that showed
a stenosis (arrow) distal of stent (arrowhead).
4 RCA originated from left coronary cusp (arrows).
4A
4B
Scan mode Flash Spiral
Scan area Thorax / Chest
Scan length 211 mm
Scan time 0.52 s
Tube voltage 80 kV
Tube current 104 eff. mAs
CTDIvol 1.63 mGy
Effective Dose 0.644 mSv
Pitch 3.4
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
Start delay 17 s
Volume 30 ml
patients: the patients have high heart
rates, the cardiac vessels are tiny, seda-tion
often presents a risk and most pa-tients
cannot hold their breath. This
Dual Source CT Flash scan of 211 mm
length was taken in only 0.51 seconds
without sedation or breath-hold. Vessels
were clearly visualized without artifacts.
Even coronary anomaly could be seen
despite the patient’s high heart rate of
95 bpm. Pulmonary artery in-stent ste-nosis
could also be evaluated. The Dual
Source CT Flash images were extremely
helpful for further treatment planning.

Case 7
Dual Energy Coronary CT Angiography
for Evaluation of Chest Pain After RCA
Revascularization
By Ralf W. Bauer, MD, J. Matthias Kerl, MD, Thomas J. Vogl, MD
Department of Diagnostic and Interventional Radiology, Clinic of the Goethe University, Frankfurt, Germany
HISTORY
A 54-year-old female patient underwent
coronary stent percutaneous translumi-nal
coronary angioplasty (PTCA) of
the right coronary artery (RCA) four
months ago for acute ST-elevation
myocardial infarction of the inferioseptal
wall. Now, the patient suffered from
reduced physical power and labile blood
pressure and had an event of syncope
three weeks ago. Invasive coronary angi-ography
was performed to assess stent
patency. In-stent occlusion of the mid
and distal RCA with moderate collateral-ization
from the left anterior descending
(LAD) and left circumflex artery (LCX)
and a patent right ventricular (RV)
branch were found (Fig. 1). Recanaliza-tion
was performed with placement of 2
drug-eluting stents in the distal and mid
RCA. During intervention, a small con-trast
material extravasation was seen
near the ostium in the proximal RCA.
A small intima dissection was suspected
and another stent was placed to close
1 Prior to recanalization: Cardiac catheteri-zation
showed a prominent RV branch and
in-stent occlusion of the mid and distal RCA
(arrow).
1
2 Curved multiplanar reformates showed
instent thrombosis with occlusion beginning
in the proximal RCA. In the RV branch, which
was clearly visible on pre-interventional cath
images, no contrast material filling could be
delineated (arrows).
3 Dual Energy iodine mapping showed a
large area with decreased perfusion in
the arterial phase in the inferoseptal wall
extending from the base to the apex of the
heart (arrow).
2 3

Scan mode Dual Energy
Scan area Heart
Scan length 170 mm
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
Pitch 0.17
Slice width 0.75 mm
Reconstruction
increment 0.4 mm
Reconstruction
kernel D26f
Volume 70 ml contrast media
Flow rate 5 ml/s
Start delay Test bolus
Post processing syngo Dual Energy
the leakage. Three hours after interven-tion,
the patient developed chest tight-ness
and retrosternal pain. ECG showed
signs of the known old infarction
inferiorseptally (Q waves in II, III and
aVF) but no signs of acute ischemia.
She was sent to CT to rule out aortic
dissection.
DIAGNOSIS
Cardiac CT was performed in Dual Energy
mode with retrospective ECG-gating.
There was no sign of contrast material
extravasation or aortic dissection. Dual
Energy CT Angiography revealed in-stent
thrombosis with occlusion of the RCA
13 mm after its origin (Fig. 2). While
on cardiac cath the RV branch was still
open, DECT showed an occlusion of the
vessel due to the thrombus in the proxi-mal
RCA, explaining the patient’s symp-toms.
Dual Energy myocardial iodine
mapping showed a large hypoperfused
area inferoseptal extending from the
base down to the apex (Fig. 3). Low
dose step-and-shoot late enhancement
images 7 minutes after contrast injec-tion
showed corresponding delayed
contrast material washout (Fig. 4). On
regular anatomical multiplanar refor-mates,
a moderate thinning of the left
ventricular myocardium was present
in that area (Fig. 5).
COMMENTS
In this case, Dual Energy coronary
CT Angiography was used to image a
complication of interventional recanali-zation,
i.e. acute in-stent thrombosis,
while the initial clinical diagnosis of
acute aortic dissection could reliably
be ruled out.
A further complication was the occlu-sion
of the RV branch (which was patent
prior to intervention) due to the large
thrombus formation beginning very
proximally in the RCA. The new hybrid
reconstruction algorithm for coronary
CTA images preserves the high temporal
resolution of 75 ms of the Dual Source
system and allows for motion-free imag-ing
of the vascular structures. According
to the clinical history of the patient,
assessment of the myocardium with
Dual Energy first-pass perfusion and
late enhancement imaging showed signs
of chronic infarction in the inferoseptal
wall of the left ventricle. Increased tube
power as well as improved separation of
the spectra by using a tin filter (140 kV
+ Sn filter) allowed for artifact-free im-aging
of myocardial perfusion. Complete
diagnostic work-up of the coronary
arteries and the myocardium was
achieved with a total dose length product
of only 294 mGy cm (227 mGy cm CTA +
67 mGy cm late enhancement).
4 Late enhancement was present in the in-feroseptal
wall corresponding to the perfusion
defect in arterial phase.
4
5 Regular anatomical multiplanar reformates
showed moderate thinning of the interoseptal
wall consistent with chronic ischemia (arrow).
5

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
Today, there is a significant trend for
more routine biopsies, as well as an in-creasing
volume of more complex inter-ventional
procedures such as radio fre-quency
(RF) ablations and minimally
invasive surgical procedures. In addition,
the need for large perfusion ranges is in-creasing
with the demand for complete
and comprehensive assessments of the
whole disease in the entire organ. The
current challenge in CT interventions is
to overcome the limitations of conven-tional
2D CT guidance where, especially
in difficult cases, the safe navigation
of the needle is a challenge.
A more accurate overview of the needle
position and surrounding organs has
often been lacking during difficult pro-cedures,
especially when using oblique
needle positions in both fluoroscopic
and non-fluoroscopic procedures.
Strongly motivated by the increased vol-ume
of these interventions, radiologists
have been looking for a solution that
adds precision while reducing procedure
time, freeing up the CT suite for more
patients and procedures and, in addition,
bringing new revenue opportunities.
At University Hospital Zurich, radiologists
are working on an impressive and prom-ising
solution utilizing Siemens’ real-time
3D image guidance for minimally
invasive procedures and CT Perfusion
in combination with the innovative
Adaptive 4D Spiral technology. The fol-lowing
case demonstrates a 3D guided
RF ablation of a renal cell carcinoma
with a combined monitoring of treat-ment
response by Adaptive 4D Spiral
volume perfusion CT.
PATIENT HISTORY
An 80-year-old female patient presented
to the emergency department with mac-rohematuria.
A CT of the abdomen
revealed a mass in the left kidney that
was suspicious of a renal cell carcinoma
(Fig. 1). Because severe co-morbidities
prevented open surgery, the patient was
scheduled to undergo radio frequency
ablation (RFA). Considering the large size
of the tumor, embolization of the mass
was performed prior to RFA (Fig. 3).
2
2 The image shows the RFA procedure of
the left kidney tumor.
1
3
3 Selective catheter angiography of the left
renal artery demonstrating the hyper-vascu-larized
tumor of the lower pole (left). Angi-ography
after embolization shows subtotal
devascularization of the tumor (right).
1 Contrast-enhanced abdominal CT shows
an exophytic mass in the left kidney (arrow).
*
**
***

Oncology Clinical Results
5
DIAGNOSIS
Due to the large size of the tumor, con-ventional
CT Perfusion studies are nor-mally
unable to capture the entire tumor
and therefore deliver only partial perfu-sion
information. To circumvent this
limitation, the patient was sent for a
volume perfusion scan to the SOMATOM
Definition AS offering the Adaptive 4D
Spiral scan modes. This allows CT Perfu-sion
coverage of up to 7 cm. The Adap-tive
4D Spiral scan was performed one
day after embolization. It showed the
tumor to be largely devascularized.
However, a small proportion in the me-dial
lower part of the tumor still showed
blood flow (Fig. 4).
Two days later, a CT-guided RFA was per-formed
using the Adaptive 3D Interven-tion
Suite with its needle path planning
and on-line tracking mode. Particularly
the perfused tumor part as demonstrat-ed
by perfusion CT was targeted (Fig. 2).
In order to safely reach the dedicated
areas, a 3D visualization of axial, coronal
and sagittal slices during the intervention
was used. In combination with a 2-click
path planning, a fast and precise needle
navigation was ensured. Radiation expo-sure
could be kept very low by applying
an interventional sequence scan mode
for needle navigation.
A CT Perfusion study performed the
day after RFA shows complete devascu-larization
of the tumor (Fig. 5) indicating
a successful treatment of the patient.
With the ability to perform perfusion
studies over the entire region of interest,
it is now possible to assess the extent of
the disease and visualize the function of
potential metastases. The combination
of CT Perfusion studies and CT guided
RFAs allows the reading physician to
more precisely assess the treatment
success after RFA in a timely manner. This
makes it possible to monitor devascular-ization
of the kidney tumors only one
day after RFA.
COMMENTS
The increased precision of the 3D visual-ization
especially helps to more precisely
position RF needles to ensure the correct
placement in the perfused tumor area.
It gives a more accurate overview of the
needle position and surrounding organs
during difficult procedures, such as
oblique needle positions of RFAs. This
ensures a higher success rate of RF treat-ments.
In addition, the automated needle
guidance and tracking tool significantly
helps to speed up the insertion and
needle placement with a reduced pa-tient
exposure.
The 3D minimal invasive suite in parti-cular
now offers the freedom to direct
the entire procedure with just the touch
of a button – without ever leaving the
patient’s side. No ongoing, extensive
communication with the technician for
additional distance measurements,
windowing and image adjustments is
necessary. Since the user is now able
to easily switch between fluoroscopic,
sequential and spiral examinations
without time-consuming scan protocol
manipulation, the physician saves
additional time reducing the overall
interventional procedure time. This
frees up the valuable CT suite more
quickly for waiting patients and proce-dures.
4 Blood volume map shows a largely devascularized tumor after
embolization treatment, however, also a strongly perfused area
in the medial, lower part of the tumor (red, yellow).
4
5 Blood volume map shows complete devascularization of the kidney
tumor (purple, blue) after RF treatment.

Clinical Results Oncology
Case 9
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
with a history of oesophageal cancer.
He previously underwent combined radio-chemotherapy.
CT was requested for
re-staging to discuss further therapy
options for the patient.
DIAGNOSIS
A contrast enhanced CT revealed bilateral
well-perfused lung, also the port catheter
was well positioned in the vena cava
superior. Following treatment, there was
still prominent thickening of the wall
of the distal oesophagus und enlarged
lymph nodes in the mediastinum. In
addition, a small pericardial effusion,
most probably a side effect of radio-therapy,
was visualized. There was no
evidence of liver or lung metastases and
there were no enlarged lymph nodes at
the level of the celiac trunk. An isolated
solitary cyst (Bosniak I) was located in
the upper left kidney.
COMMENTS
Several measures to reduce dose were
employed with this patient. Online tube
current modulation (CARE Dose4D) and
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 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
iterative reconstruction in image space
technology (IRIS) were utilized, which
lead to a significant reduction in dose
and noise as compared to conventional
CT, improving image quality. This exa-mination
reliably demonstrated the
possibility of acquiring excellent image
quality at reduced dose levels (3.9 mSv /
DLP: 260 mGy cm).

Oncology Clinical Results
1
2 Coronal cut demonstrates the solitary cyst (left kidney, arrow), and
distal oesophageal wall thickening (arrowhead, IRIS reconstruction).
2
3 Axial slice highlights wall thickening of the oesophagus
(arrowhead), and pericardial effusion (arrows).
3
4 Low and homogenous noise in the entire dataset using IRIS
(coronal slice) reveals oesophageal thickening (arrows).
4
1 VRT and fused MPR show the extension of oesophageal
wall thickening.

Clinical Results Neurology
Case 10
SOMATOM Defi nition AS+:
CT Perfusion With Extended Coverage
for Acute Ischemic Stroke
By Ke Lin, MD
Department of Radiology, New York University Langone Medical Center, New York, USA
HISTORY
A 53-year-old male with history of hyper-tension
presented with sudden onset
of expressive aphasia and weakness.
The patient had experienced two similar
but transient episodes in the previous
12 months. He arrived to the emergency
department of NYU Langone Medical
Center within 1 hour of symptom onset
and was immediately evaluated for
acute ischemic stroke by non-contrast
head CT (NCCT), dynamic CT Perfusion
(CTP) of the brain, and CT Angiography
(CTA) of the cervical and intracranial
arterial vasculature.
1
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.

Neurology Clinical Results
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.
indicative of salvageable tissue at risk
(Fig. 2). CTA showed embolic occlusion
of the frontal opercular division of the
left MCA secondary to plaque rupture
at the left carotid bulb. The patient was
then rapidly treated with intravenous
thrombolytic therapy with mild improve-ment
of symptoms.
COMMENTS
The SOMATOM Definition AS+ scanner
with 128-slice configuration and Adaptive
4D Spiral technology allows larger CTP
coverage with a single bolus of contrast.
In this case, the setting with 96 mm of
z-direction coverage (and 1.5 seconds
temporal resolution) covered nearly the
entire supratentorial brain. syngo VPCT
Neuro extracts first-pass data from the
45 seconds dynamic acquisition en-abling
a rapid exam. The extents of both
the salvageable ischemic penumbra and
the irreversible infarct core were fully
depicted. Rescue of ischemic penumbra
is the main rationale for aggressive
stroke intervention, and its identification
through perfusion imaging may form the
basis of patient selection for therapy in
the near future.
DIAGNOSIS
While NCCT showed only subtle blurring
of the normal gray/white matter inter-face
at the left frontal operculum, CTP
with extended coverage revealed the full
extent of the acute ischemia in the ante-rior
left middle cerebral artery (MCA)
territory. There was severe compromise
of cerebral blood flow (CBF) to the mid
and inferior left frontal lobe. At the level
of the operculum (Broca’s area), there
was a matched defect in low CBF and
low cerebral blood volume (CBV) indica-tive
of irreversible infarct core (Fig. 1).
However, there was appreciable CBF/CBV
mismatch on the other acquired slices,
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 4 s
CTDIvol 218.8 mGy Postprocessing syngo VPCT Neuro
2

Case 11
Vasospasm After Subarachnoid
Hemorrhage:
Volume Perfusion CT Neuro
By Bruno A. Policeni, MD
Radiology Faculty, Neuroradiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
1 3D CT Angiography shows a right mid cerebral artery (MCA) bi-lobed aneurysm
(arrow). No other aneurysms were found.
HISTORY
A 36-year-old female with a history of
migraine developed a sudden onset of
the worst headache of her life, lost con-trol
of the entire right side of her body
and fell to the floor. However she had
no trauma to her head and did not lose
consciousness. She was admitted to the
emergency department where a head CT
(Fig. 2) showed right sylvian fissure and
inter-hemispheric fissure hyperdensity
consistent with subarachnoid hemor-
rhage. The temporal horns were mildly
dilated due to early obstructing hydro-cephalus
and a small amount of intra-ventricular
blood was present in the left
occipital horn. A CT Angiography was
performed and showed a 7 mm x 4 mm
bi-lobed berry aneurysm with a narrow
neck arising from the M1 segment of the
right mid cerebral artery (MCA, Fig.1).
The patient was transferred to the
angiography suite for conventional
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.
DIAGNOSIS
Using the Adaptive 4D Spiral technology
a 9.6 cm volume perfusion scan cover-ing
the entire brain was performed and
the resulting perfusion parameter maps
were qualitatively and quantitatively
evaluated in 3D. They demonstrated an
impaired brain perfusion in the right
MCA and ACA vascular territory distribu-tion
with prolonged Mean Transit Time
(MTT), reduced Cerebral Blood Flow
(CBF) in the same area and slightly
increased Cerebral Blood Volume (CBV,
Fig. 4). CT Angiography images were ob-tained
from the dynamic VPCT data and
showed areas of narrowing in the right
MCA and anterior cerebral artery (ACA,
Fig. 6). The following angiography con-firmed
the vasospasm findings consis-
1
L R

3 Conventional angiography
demonstrates the right MCA
aneurysm in the right internal
carotid artery injection (ar-row).
4
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).
2 3
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.

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
right MCA/ACA and delayed capillary
transit time (Fig. 7A). The patient was
immediately treated with 8 mg intra-arterial
nicardipine for a period of 10
minutes and balloon angioplasty was
performed in the right MCA. Immediate
follow-up confirmed a successful treat-ment
(Fig. 7B) and there was also an im-provement
in the neurologic exam,
specifically in the left facial palsy. The
patient was discharged on day 17, neu-rologically
stable with resolution of the
facial droop, well-controlled pain and
ambulating without assistance. She was
scheduled for a follow-up exam in the
clinic 6 weeks later.
COMMENTS
syngo VPCT Neuro offers dynamic perfu-sion
analysis of the entire brain. That,
as in this case, enables the detection of
vasospasms – even those located in
upper brain regions or in the posterior
fossa, not covered by traditional Perfu-sion
CT through the base of skull. Thus
syngo VPCT Neuro in combination with
the Adaptive 4D Spiral technology is en-hancing
the diagnostic application. The
ability to obtain a CT Angiography with
the same data acquisition is crucial for
the correlation to the vascular territory
showing prolonged MTT. Temporal pa-rameter
maps like MTT in 2D and 3D
delivered by syngo VPCT Neuro may act
as a sensible tool to detect perfusion
asymmetries in the two hemispheres as
an indicator for vasospasm.
5

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).
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
6

Clinical Results Acute Care
Case 12
Dual Energy Scanning:
Diagnosis of Ruptured Cocaine Capsule
By Ralf W. Bauer, MD, J. Matthias Kerl, MD, Thomas J. Vogl, MD, Philipp Weisser, MD
Department of Diagnostic and Interventional Radiology, Clinic of the Goethe University, Frankfurt, Germany
HISTORY
A 32-year-old male passenger on a flight
from South America landed at Rhein-
Main International Airport in Frankfurt.
He showed a conspicuous and slightly
delirious behavior. The customs and
border police were alert and questioned
him whether he was carrying or had
consumed drugs. At first, he denied, but
as his medical condition dramatically
worsened, he admitted that he had
swallowed 24 self-packed capsules with
columbian cocaine. The patient devel-oped
heavy attacks of abdominal cramps
and became more and more apathetic.
He was transferred to the hospital to lo-calize
the capsules, to confirm the num-ber,
and to check, if one of the capsules
had opened and cocaine had come into
the bowel lumen – or if the capsules
had caused an ileus.
DIAGNOSIS
A contrast-enhanced, Dual Energy CT
(DECT) scan of the abdomen was per-formed.
24 capsules with an average
size of 2.5 x 3.5 cm and hyperdense
content were found, confirming the
patient’s story. Average CT values of the
hyperdense content were 203 HU at
80 kV and 140 HU at 140 kV. The cap-sules
were spread all through the small
bowel and colon. However, there was
one capsule in the rectum, that was sig-nificantly
larger than the others and its
content showed lower attenuation val-ues
of 139 HU at 80 kV and 77 HU at
140 kV. DECT further revealed a thin hy-perdense
layer-like structure that peeled
off from that capsule, therefore the sus-picion
arose that the capsule actually
had ruptured. Rectoscopy was per-formed
immediately and the torn cap-
sule was secured. The patient recovered
on the intensive care unit without fur-ther
major medical treatment and could
be relieved from the rest of his freight
with the use of laxatives.
COMMENTS
With the use of DECT, a reliable diagnosis
of the ruptured cocaine capsule could
be performed and immediate medical
help provided. To our knowledge this
is the first report on the Dual Energy
behaviour of columbian cocaine. This
might be of future relevance for in vivo
differentiation of cocaine or heroin of
different origin in uncommunicative
body packers. However, further research
in this field is needed to confirm our
results.
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
CTDIvol 9.14 mGy Postprocessing syngo Dual Energy

4 Ruptured cocaine capsule. Arrows point at the loose outer layer.
2
1 Cocaine capsules distributed throughout the whole intestine.
3 Color-coding of cocaine capsules facilitates detection and
counting.
5 ROI measurements demonstrate typical Dual Energy values of
columbian cocaine.
1
3
5
Neuroradiology Clinical Results
2 Virtual colonoscopy view.
6 The coronal reformate shows large amounts of fluid in the
colon lumen. However, no ileus was present.
4
6

Case 13
Progressive Kidney Hematoma
Post-interventional Biopsy
By Sebastian Leschka, MD * and Andreas Blaha **
*Institute of Diagnostic Radiology, University Hospital Zurich, Zurich, Switzerland
HISTORY
To determine further therapy, the 21-
year-old patient, status after hepatitis B,
was referred to the radiology depart-ment.
Here a biopsy of the renal paren-chyma
was performed upon which a
haemorrhage occurred, accompanied by
the formation of a hematoma. A 3-phase
kidney CT was performed. Due to the
nephritic syndrome only 60 ml of con-trast
media with a flow rate of 4 ml/s
followed by a 60 ml NaCl bolus (4 ml/s)
was injected for the kidney CTA.
1 Fused VRT/MPR
highlight kidney
hematoma.
DIAGNOSIS
In the native phase, an accumulation of
liquid at the lower left renal pole was
seen. The arterial phase showed an
extravasation of contrast media out of
the left kidney. An inhomogeneous
hematoma measuring 15 x 7.5 x 5 cm
was detected around the left kidney.
Both kidneys were perfused symmetri-cally,
unique renal arteries were seen
bilaterally. In the venous phase a normal
renal calyx developed on both sides.
COMMENTS
Despite the low quantity of applied con-trast
media, a contrast media enhance-ment
in the left kidney could be identi-fied
due to a quick acquisition time of
0.7 seconds. The SOMATOM Definition
Flash allowed a precise and rapid
diagnosis with a reduced given patient
radiation dose of 3.3 mSv.
1

Acute Care Clinical Results
2C
3C
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
CTDIvol 7.71 mGy Postprocessing syngo CT 3D
syngo InSpace
2A 2B
2 Axial non-enhancement multiplanar reformation (MPR, Fig. 2A); axial early enhancement MPR shows haemorrhages in the
kidney hematoma (arrow, Fig. 2B). Axial late state MPR shows persistent bleeding (arrow, Fig. 2C).
3B
3A
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).

Case 14
SOMATOM Defi nition 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
HISTORY
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.
DIAGNOSIS
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.
1 2
3
2 Regular scan – axial slice
of high resolution regular scan.
1 High pitch scan – axial slice of high pitch
acquisition, no motion artifacts (arrow)
due to breathing.
3 High pitch scan – entire lung in low
dose technique (10 eff. mAs), no motion
artifacts are visible.
4
4 Regulars scan – artifacts due
to respiratory motion (arrows).

Acute Care Clinical Results
5 6 COMMENTS
Scanner SOMATOM
Definition
Scan mode Thorax HiPitch
Scan area Thorax
Scan length 159 mm
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*
Pitch 3.0
Slice width 1.0 mm
Reconstruction
increment 0.5 mm
Reconstruction
kernel B60f
Postprocessing syngo CT 3D
syngo InSpace
7 Volume rendered image of the thorax, showing regular bronchial tree.
7
6 Regular scan – sagittal image shows
motion artifact of the diaphragm due to
breathing during the acquisition.
5 High pitch scan – sharp delineation
of pulmonary segments.
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.
*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.

Science
CT in Pediatrics: Easier
and Safer With the Flash
The SOMATOM Defi nition Flash allows even squirming infants and small
children to be scanned with maximum image quality at lightning speed,
without movement artifacts, anesthesia, or ventilation. This makes
computed tomography increasingly interesting for pediatric diagnostics,
solely in the event of clear indications.
By Hildegard Kaulen, PhD
Being able to “freeze” movements in
order to scan small children without seda-tion
is every radiologist’s dream. Anesthe-sia
transforms what would be a compar-atively
fast scan into a time-consuming,
possibly risky affair. Therefore, Michael
Lell, MD, Assistant Professor at the Uni-versity
Hospital in Erlangen, is extremely
satisfied with the various pediatric
options offered by the new SOMATOM
Definition Flash. As small patients are
moved through the tube at a speed of
almost half a meter per second, they no
longer have to hold their breath or lie
still for protracted periods. Sedation is
no longer necessary either, and, as a
result, the entire imaging process is re-duced
to a few minutes. Lell has been
working with the Flash for 16 months.
During this period, he has successfully
scanned 50 infants and toddlers, and
the same number of children and ado-lescents,
without sedation or anesthe-sia.
His experience with the Flash in
the field of pediatric diagnostics is out-standing.
Says Lell: “The image quality
1A 1B
attained without sedation impresses us
time and again. This is particularly strik-ing
during a direct comparison between
the Flash and another CT. We examined
a 15-month-old child with Down’s syn-drome
and cystic fibrosis using a 10-row
CT. The images contained movement
artifacts despite sedation. We examined
the child once more at 27 months, this
time using the Flash. The results? Razor-sharp
images without sedation (Fig.1).
One child even attempted to sit up dur-ing
the scan. Everyone was convinced
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.

Science
Assistant Professor Michael Lell,
MD, completed his medical studies
at the universities of Regensburg and
Munich with subsequent qualifica-tion
as a consultant in radiology and
habilitation. Employed by the Univer-sity
Hospital in Erlangen since 1999.
Promoted to Chief Physician in 2009.
One-year residency at the David
Steffen School of Medicine at UCLA.
Member of national and international
professional associations; reviewer
for various journals.
that the images would be blurred, but
this wasn’t the case.”
Young patients are usually examined
using ultrasound or MRI devices. Children
undergoing an MRI must be sedated.
Lell comments: “Anesthesia and ventila-tion
necessitate considerable time and
effort. We are dependent on assistance
from other specialist disciplines. The an-esthetic
must be induced, controlled and
reversed by an anesthetist, and the chil-dren
have to be monitored for several
hours afterward. Whereas scanning time
is relatively short, outpatient care is nec-essary
for hours.” Medical treatment,
care and logistics result in substantial
costs, and the associated risks can also
be considerable. Anesthesia is an inva-sive
procedure. Complications may arise
at any time. Says Lell: “Ventilation also
leads to anesthesia-related pulmonary
atelectasis, a condition which causes
parts of the lungs to collapse, impeding
gas exchange. It is difficult to assess these
areas accurately during imaging. This is-sue
becomes irrelevant if anesthesia and
ventilation are not used. If it’s a choice
between performing CT with anesthesia
or not, then the answer in the case of
the Flash is a definite no.”
Setting New Standards
The SOMATOM Definition Flash is able
to freeze movements due to its unique
speed. Scanning speeds of up to 45.8 cm
per second with a temporal resolution
of 75 ms ensure that complete chest
scans of young patients can be recorded
in 0.4 to 0.5 seconds. No other device
is as fast. The Flash also sets new stan-dards
when it comes to radiation expo-sure.
The Adaptive Dose Shield reduces
radiation exposure in every single spiral
scan. But the most impressive dose re-duction
is possible in the field of cardiol-ogy
where ultrafast Flash Spiral cuts
down radiation compared to conventional
ECG-gated examinations by up to 90 %.
Lell believes that the Flash will make CT
scans an increasingly attractive option
for younger patients. The radiologist
considers indications to be the decisive
factor. In pediatrics, a CT would only be
considered in the event of medical indi-cations
with few or no alternatives, such
as polytrauma or tumor staging. In the
case of multiple injuries, it is more im-portant
to clarify the extent of the trauma
suffered than to contemplate a statistical
increase in cancer risk in the distant
future. Says Lell: “Some indications neces-sitate
a CT examination, even if we are
aware of the effective dose. We don’t
know exactly how this dose may affect
the cancer risk in any case as no long-term
data is available based on medical
imaging exposure levels.” Lell already
insists on reduced dose protocols. He
and his team have developed protocols
like these for all pediatric indications. In
Erlangen, children are always scanned
with a tube voltage of 80 or 100 kV.
Special anatomy adapted cushions are
used to fix the small patients during the
examination. Contrast agents are used
very sparingly. Lell also ensures that the
examination area is kept to a minimum,
and strives to achieve the attention to
detail necessary for diagnosis.
Hildegard Kaulen, PhD, is a molecular biolo-gist.
After stints at the Rockefeller University in
New York and the Harvard Medical School in
Boston, she moved to the field of freelance
science journalism in the mid-1990s and contrib-utes
to numerous reputable daily newspapers
and scientific journals.
Indications for
Pediatric CT Scans:
Q Polytrauma
Q Congenital heart disease
Q Serious lung diseases such
as cystic fibrosis or atypical
pneumonias
Q Tumor staging
Benefits of Flash CT
in Pediatrics:
Q Images free of movement arti-facts,
even in the case of
squirming children
Q No sedation or deep general
anesthesia
Q Imaging possible without assis-tance
from other disciplines
such as anesthesia or nursing
Q No outpatient care or aftercare
Q No complications as a result
of anesthesia

Science
Through the use of a SOMATOM Emotion 6 from Siemens Healthcare, an international research team discovered
atherosclerosis in 3500 year old Egyptian mummies.
Study Finds Atherosclerosis in
3,500 Year old Egyptian Mummies
By Steven Bell, Business Unit CT, Siemens Healthcare, Forchheim, Germany
A team of cardiologists led by Drs.
Gregory S. Thomas of the University of
California, Irvine and Adel H. Allam of
Al Azhar University, Cairo, found that
atherosclerosis is not only a disease
of modern man, but was present in
humans as far back as 1,530 BC.
The team of cardiologists working
closely with a team of Egyptologists
undertook the most comprehensive CT
study of vascular disease in Egyptian
mummies to date by scanning 22 mum-mies
over a four-day period in the Cairo
Museum of Antiquities. The study was
co-sponsored by Siemens Healthcare and
aimed to investigate whether atheroscle-rosis,
the precursor of heart disease, is an
affliction of modern man or whether this
disease existed thousands of years ago.
The imaging for this project was under-taken
on a SOMATOM Emotion 6-slice
configuration that was donated to the
Museum as part of an earlier study in
conjunction with National Geographic
to image the famous mummified remains
of King Tutankhamun.
The researchers were able to locate and
identify vascular tissue in 16 out of the
22 mummies imaged in this study. Of
these 16, 9 had visible signs of arterial
calcification, considered to be pathogno-monic
of atherosclerosis, from which the
researchers were able to conclude that
atherosclerosis is not a disease exclusive
to modern humans. Findings of calcifica-tion
were made in men and women who
lived between 1570 BC and 364 AD. The
social status of most patients included in
the study was shown to be of an elevated
nature, which may have contributed
to the process of disease due to lifestyle
issues. The main aim of this project was
to identify the presence or absence of
atherosclerosis in an ancient patient
population, however, the study also
offered prominent Egyptologists the
opportunity to view the mummified
remains of these patients in a way that
was not damaging to these ancient
artifacts, the protection of which is
central to the thinking of all members
of this research study.
The results of this project were pub-lished
in the November 18, 2009 edition
of the JAMA and also presented at the
November AHA Meeting in Orlando,
Florida, USA.

Independent Validation of
Perfusion Evaluation Software
By Katharina Otani, PhD and Toshihide Itoh
Research Collaboration Development, Siemens Asahi Medical Technologies, Tokyo, Japan
“True multi-center
trials on stroke
assessment by CT
Perfusion and opti-mization
of patient
management will
only be possible
once every ven-dor’s
software de-livers
the same
perfusion maps.”
Kohsuke Kudo, MD, PhD, Iwate Medical
University
Science
1 Kudo K, et al . Radiology. 2010 Jan; 254(1):200-9
2 Konstas A A, et al. Radiology, 2010; 254(1):22-25
3 Christensen S, et al. Stroke 2009, 40 : 2055 – 2061
SOMATOM Sessions · Mai 2010 · www.siemens.com/healthcare-magazine 65
A study by an independent Japanese
research group reported that Siemens CT
Perfusion software syngo VPCT Neuro,
using the maximum slope model to de-rive
cerebral blood flow (CBF), delivered
among the most accurate results in the
assessment of stroke infarct size com-pared
to other commercial software.1
Kohsuke Kudo, MD, PhD, from Iwate
Medical University and his colleagues
from five other universities in Japan used
data of 10 stroke patients acquired with a
four-detector-row scanner and applied
different algorithms to generate CT Per-fusion
maps, in particular CBF, cerebral
blood volume (CBV) and mean transit
time (MTT) or time to peak (TTP) maps:
A – singular-value decomposition (SVD,
CT Perfusion 3, GE Healthcare)
B – inverse filter IF (Version 2.0, Hitachi
Medical Systems)
C – singular-value decomposition (SVD,
Version 1.201, Philips Healthcare)
D – maximum slope (MS, VA70A,
Siemens Healthcare)
E – box modular transfer function (bMTF,
Ph 7, Toshiba Medical Systems).
Kudo compared the perfusion maps with
the results from free software (Perfusion
Mismatch Analyzer, PMA) distributed
by the Acute Stroke Imaging Standard-ization
Group (ASIST) Japan that applies
two well-documented deconvolution
algorithms: standard singular-value de-composition
(sSVD) and block-circulant
singular-value decomposition (bSVD).
sSVD and bSVD algorithms differ with re-spect
to their sensitivity to contrast tracer
delay effects. bSVD is considered the
“gold standard” since it is relatively insen-sitive
to tracer delay.
Kudo found that commercial software
could be classified in two groups: those
giving similar results to the CBF maps
obtained with sSVD (A, C, E) and those
giving similar results to the CBF maps
obtained with bSVD (B, D). Abnormal
MTT/TTP areas appeared larger than
those in bSVD for maps of all commercial
software (A, C, D, E) except for one ven-dor’s
software (B). An editorial in the
same journal issue commented:2 “The
results of the study by Kudo et al.1 also
support the use of the maximum slope
method for CT perfusion post-processing.
Indeed, a recent MR imaging study3 of
acute stroke patients reported higher posi-tive
predictive values for infarction by
using maximum slope-derived parameters
(first moment, TTP), versus both delay-sensitive
and delay-insensitive deconvolu-tion-
derived parameters. These results
highlight the delay-insensitive nature of
perfusion maps derived from maximum-slope
algorithms. At present, however,
there remains insufficient evidence to sug-gest
whether maximum-slope methods
outperform delay-insensitive deconvolu-tion
algorithms.” Kudo started working on
standardization of perfusion software
after he programmed his own software
and discovered that his results differed not
only from the results of one commercial
software but that the results from all soft-ware
packages also differed from each
other. With Makoto Sasaki, MD, he set up
ASIST Japan supported by a grant from the
Japanese governement. ASIST Japan has
introduced a color look-up table for perfu-sion
maps. Kudo emphasizes that “true
multicenter trials on stroke assessment by
CT Perfusion and optimization of patient
management will only be possible once
every vendor’s software delivers the same
perfusion maps”.
In his study, Kudo used earlier perfusion
software versions such as Siemens “Neuro
PCT”. In the meantime however, Siemens
has developed “syngo VPCT Neuro”, a vol-ume
perfusion software that gives the op-tion
to also apply a new tracer delay insen-sitive
deconvolution algorithm in addition
to the as well delay insensitive maximum
slope model used in this study. Kudo is
currently working on further multi-vendor
comparison studies.
http://asist.umin.jp/index-e.htm

Science
Reduced Procedure Time
and Radiation Dose in Inter-ventional
CT Workflow
By Prof. A.H. Mahnken, MD and F. Schoth, MD
RWTH Aachen University Hospital, Aachen, Germany
Percutaneous lung biopsy is one of the
most common CT-guided procedures.
This technique can be performed using
sequential CT-scanning or CT-fluoroscopy.
Because CT-fluoroscopy may result in
significant radiation exposure to the
patient as well as the interventionalist,
repeated sequential CT-scanning is com-mon
practice due to the minimal radia-tion
exposure to the operating physician.
However, this approach requires several
breath holds, with the target lesion mov-ing
during in- and expiration. For many
patients, it is virtually impossible to re-peatedly
come back to the same breath
hold position. Therefore, small lesions
in particular, will often move out of
plane. This problem is particularly pro-nounced
in the basal sections of the
lung and is a major issue when dealing
with small lesions of 1 cm or less.
Combining CT-guided procedures with
the Interactive Breath-Hold Control
device (IBC) has been shown to increase
1A 1B
45
60
15
30
the radiologists’ accuracy and confidence
with needle biopsy of the lung. A simple
light display allows the patients to moni-tor
their breathing level and consistently
return to their reference breath-hold
position during their biopsies. The IBC
was developed to assist with CT inter-ventional
procedures, but may also be
very useful for PET CT, radiation therapy,
ultrasound, fusion imaging, and other
procedures and modalities where respi-ratory
motion is an issue. At the depart-
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.

Science
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
Aachen University Hospital in Germany,
a study was conducted to evaluate the
IBC system in CT-guided lung biopsy.
Schoth and colleagues assessed the effect
of an IBC system on procedure time and
technical success in trans-thoracic CT-guided
lung biopsies. In 36 patients with
a pulmonary nodule, CT-guided biopsy
was done using a SOMATOM Definition
scanner, the Adaptive 3D Intervention
Suite from Siemens and the breath-hold
device. In a two-arm study with and
without the device, the biopsy was visu-ally
successful in all patients. The diame-ter
of the target lesion was comparable
in both groups (IBC: 30 +/– 19 mm; con-trol:
28 +/– 15 mm). But the number of
imaging steps was significantly smaller
(p 0.05) and the intervention time was
significantly shorter (p 0.05) in the IBC
group (IBC: 9 +/– 5 steps, 17 +/– 10 min;
control: 13 +/– 5 steps, 26 +/– 12 min).
Application of the IBC unit reduced the
intervention time and radiation expo-sure
in CT-guided biopsy of pulmonary
nodules while reducing the procedure
steps.
In combination with optimized planning
using the new Adaptive 3D Intervention
software from Siemens for 3D CT-guided
interventions, biopsy of smaller nodules
becomes much easier, resulting in a
higher technical success rate. With the
early detection and histological proof of
lung cancer, treatment is more effective.
Prognosis significantly improves when
lung cancer is detected and treated be-fore
metastases occur. Therefore, a high
success rate of diagnostic punctures
during the diagnostic workup greatly
supports therapy. Moreover, IBC is a rele-vant
support to therapeutic procedures
such as radiofrequency ablation or ste-reotactic
radiation therapy of small lung
tumors.
Regarding dose reduction, the IBC inte-grates
and supplements perfectly into
the huge expertise that Siemens has
accumulated to reduce radiation dose in
CT-guided examinations with such appli-cations
as CARE Dose4D and HandCARE,
protecting patients and physicians from
radiation exposure during CT interven-tions.
Schoth F, Plumhans C, Kraemer N, Mahnken A,
Friebe M, Günther RW, Krombach G. – Evaluation
of an Interactive Breath-Hold Control System
in CT-Guided Lung Biopsy. Rofo. 2010 Feb 8.
2
3 Interactive Breath-Hold Control System was
developed by Mayo Clinic Rochester, USA to assist
CT-guided interventional procedures.*
3
* The device will be distributed by Medspira (USA) (www.medspira.com) and Siemens AG.

Science
Scientifi c Validation of the
SOMATOM Defi nition Flash
One of the cornerstones of Siemens CT activities has always been the
scientifi c validation of Siemens’ products and solutions. Independent peer-review
of publications in scientifi c journals provides an unbiased and
objective assessment of the capabilities of the systems.
By Stefan Ulzheimer, PhD, and Peter Seitz
Since the introduction of the Siemens
SOMATOM Definition Flash at RSNA
2008, and its commercial availability in
July 2009, the CT scanner has been cov-ered
in 15 presentations at the annual
meeting of the Radiological Society
of North America in 2009 and ten peer-reviewed
publications in renowned
journals.
These presentations and publications
prominently feature the notable advan-tages
of the SOMATOM Definition Flash
that enhance efficiency and significantly
improve patient care.
Split-second Thorax – Lell et al. from
the University Hospital of Erlangen dem-onstrated
the SOMATOM Definition
Flash’s capabilities with its high-pitch
scan mode in thorax examinations.1
Twenty-four consecutive patients who
presented with chest pain received a
high-pitch thorax scan (Pitch 3.2) to
exclude coronary artery disease, pulmo-nary
embolism and aortic dissection.
The average dose was 1.6 mSv for pa-tients
who were scanned with a 100 kV
protocol and 3.2 mSv for patients who
were scanned with a 120 kV protocol.
The authors conclude that the “[…] high-pitch
scan mode allows motion artifact
free and accurate visualization of the
thoracic vessels and diagnostic image
quality of the coronary arteries in pa-tients
with low and stable heart rates at
a very low radiation exposure.”
The dose saving potential of the high-pitch
scan mode of SOMATOM Definition
Flash was also evaluated by Sommer et
al. in a study using an anthropomorphic
phantom and the data of 31 patients.2
The average scan time for the complete
thorax was 0.7 seconds, the average
dose 4.1 mSv, only one fifth of the dose
of a conventional gated chest scan.
Sub-mSv Heart – The robust visualiza-tion
of the coronary arteries with excel-lent
image quality at ultra low doses of
below 1 mSv was the focus of three pub-lications
by researchers from Zurich,
Switzerland3 and Erlangen, Germany.4,5
The latest study from Erlangen used the
Flash Spiral scan mode in 50 consecutive
patients with body weight up to 100 kg
and heart rates up to 60 beats per min-ute
with an average effective dose of
0.78 to 0.99 mSv and excellent image
quality.5 The average dose was 0.87
mSv. In a similar study from Zurich,
Leschka et al. found an average dose of
0.9 mSv in 35 consecutive patients.3 In
both studies 99% of all coronary seg-ments
could be evaluated3,5 and the im-age
quality was rated excellent in 94 %
of the segments or as, “at least good,” in
5 % of the segments.5
Assessment of Myocardial Perfusion –
The SOMATOM Definition Flash offers
completely new possibilities to assess
perfusion deficits in the myocardium
due to its unmatched temporal resolu-tion
and high volume coverage even at
high heart rates in stressed patients.
Bastarrika et al. showed that “[…] this
technique can demonstrate subendocar-dial
infarction not seen on SPECT but
confirmed by MRI and can detect isch-emia
in good correlation with stress-perfusion
MRI and SPECT.” 6 Fig. 1 shows
a short axis view of the myocardium
comparing stress perfusion measured
with the SOMATOM Definition Flash
(Fig. 1A) and SPECT (Fig. 1B).
Single Dose Dual Energy – The latest
innovation in the area of Dual Energy CT
(DECT), the Selective Photon Shield, is
based on an additional tin filter (TF)
for the high energy spectrum on the
SOMATOM Definition Flash. The Selec-tive
Photon Shield allows for the acquisi-tion
of Dual Energy data without any
dose penalty compared to standard single
energy scans and significantly improves
the separation of the energy spectra.
A group of scientists from Zurich con-firmed
this for the syngo application,
“Calculi Characterization,” using it for the
differentiation of uric acid (UA) and non-
UA stones and concluded: “DECT with TF
and 80-140 kV tube voltage settings
significantly improves the discrimination
between UA-containing and non-UA
containing urinary stones as compared
with DECT without using the TF […].”7
Lell et al. from the University of Erlangen

Science
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.
tages. For example, a special issue of
“Investigative Radiology” on “Advances
in CT technology,” specifically focusing
on Dual Source, Dual Energy CT and
multi-slice CT with 128 or more slices,
is scheduled for this summer.
evaluated the application of DECT to
create bone-free data sets to assess the
supraaortic arteries.8 Automatic bone
removal allows for a faster and more re-liable
diagnosis of vessels close to boney
structures. The authors conclude that
“[…] excellent bone suppression could
be achieved” using the improved scan
modes and evaluation methods on the
SOMATOM Definition Flash.
By combining multi-phase protocols to
one Dual Energy exam, the dose-saving
potential of DECT was evaluated by
Sommer et al. in patients after endovas-cular
aneurism repair using virtual non-contrast
images. They achieved a dose
reduction of 44 % compared to a bi-phase
protocol. In 70 examinations, all
24 endoleaks were detected and correctly
classified.9
More to Come – In addition to the
above mentioned publications, many
others are in the pipeline, promising to
validate the technical advancements of
the SOMATOM Definition Flash and,
even more importantly, how this trans-lates
into clinical and workflow advan-
1 Lell M, Hinkmann F, Anders K, Deak P, Kalender
WA, Uder M, Achenbach S. High-pitch electro-cardiogram-
triggered computed tomography of
the chest: initial results, Invest Radiol. 2009
Nov;44(11):728-33.
2 Sommer WH, Schenzle JC, Becker CR, Nikolaou
K, Graser A, Michalski G, Neumaier K, Reiser MF,
Johnson TR. Saving Dose in Triple-Rule-Out Com-puted
Tomography Examination Using a High-
Pitch Dual Spiral Technique. Invest Radiol. 2010
Feb;45(2):64-71.
3 Leschka S, Stolzmann P, Desbiolles L, Baumueller
S, Goetti R, Schertler T, Scheffel H, Plass A, Falk V,
Feuchtner G, Marincek B, Alkadhi H. Diagnostic
accuracy of high-pitch dual-source CT for the
assessment of coronary stenoses: first experience.
Eur Radiol. 2009 Dec;19(12):2896-903.
4 Lell M, Marwan M, Schepis T, Pflederer T, Anders
K, Flohr T, Allmendinger T, Kalender W, Ertel D,
Thierfelder C, Kuettner A, Ropers D, Daniel WG,
Achenbach S. Prospectively ECG-triggered high-pitch
spiral acquisition for coronary CT Angiogra-phy
using dual source CT: technique and initial
experience. Eur Radiol. 2009 Nov;19(11):2576-83.
5 Achenbach S, Marwan M, Ropers D, Schepis T,
Pflederer T, Anders K, Kuettner A, Daniel WG,
Uder M, Lell MM. Coronary computed tomogra-phy
angiography with a consistent dose below
1 mSv using prospectively electrocardiogram-triggered
high-pitch spiral acquisition. Eur Heart
J. 2010 Feb;31(3):340-6.
6 Bastarrika G, Ramos-Duran L, Schoepf UJ, Rosen-blum
MA, Abro JA, Brothers RL, Zubieta JL, Chia-ramida
SA, Kang DK Adenosine-stress dynamic
myocardial volume perfusion imaging with sec-ond
generation dual-source computed tomogra-phy:
Concepts and first experiences. JCCT 2010
DOI: 10.1016/j.jcct.2010.01.015.
7 Stolzmann P, Leschka S, Scheffel H, Rentsch K,
Baumüller S, Desbiolles L, Schmidt B, Marincek
B, Alkadhi H. Characterization of Urinary Stones
With Dual-Energy CT: Improved Differentiation
Using a Tin Filter. Invest Radiol. 2010 Jan;
45(1):1-6.
8 Lell M, Hinkmann F, Nkenke E, Schmidt B,
Seidensticker P, Kalender WA, Uder M, Achenbach
S. Dual energy CTA of the supraaortic arteries:
Technical improvements with a novel dual
source CT system. Eur J Radiol. 2009 Oct 8
[Epub ahead of print].
9 Sommer WH, Graser A, Becker CR, Clevert DA,
Reiser MF, Nikolaou K, Johnson TR. Image quality
of virtual noncontrast images derived from dual-energy
CT Angiography after endovascular
aneurysm repair. J Vasc Interv Radiol. 2010 Mar;
21(3):315-21.
10 Johnson TR, Schenzle JC, Sommer WH, Michalski
G, Neumaier K, Lechel U, Nikolaou K, Becker H-C,
Reiser MF. Dual energy CT: How about the dose?
Invest Radiol. 2010 (in press).
1A 1B

Life
Behind the Scenes:
CT Scan Protocols
Standard scan protocols are by far more sophisticated than CT users might
realize. Christiane Koch is the scan protocol designer for Siemens Healthcare,
Computed Tomography and knows what is important in this fi eld.
How would you describe your job
as a scan protocol designer?
Koch: My task is to create scan protocols
for all scanners and all software ver-sions.
Together with colleagues from
departments of physics, product defini-tion,
marketing, development and the
application specialists, I design and set
up Siemens default scan protocols.
In doing so, dose and other guidelines
of various radiological societies from
different countries need to be observed.
Scan protocols have to be comparable
through different software versions and
scanner models. For example a protocol
called “AbdomenRoutine” on a
SOMATOM Emotion is similar to the
protocol 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 the
user interface.
I am in close collaboration with custom-ers
and application specialists world-wide,
both during the development
phase and after systems are installed.
How do you validate scan protocols
before a new scanner is released?
Koch: Functionality and performance are
tested with phantoms in our laboratory
during the development phase. For intui-tive
tests, we do invite Radiographers in
order to simulate a real live scenario.
What is important to know when
users want to change parameters in
a default scan protocol?
Koch: Around 50% of all scan protocol
parameters run in the background.
These parameters are, for example, dose
modulation types and additional recon-struction
algorithms. It would be ideal if
our customers would use the default pro-tocols.
In this manner, following the
Christiane Koch is the scan protocol designer for Siemens CT.
By Heike Theessen
This is all done before new scanners are
delivered to any customer. Then, during
the so-called “Market Entrance Phase”,
our collaboration partners begin scan-ning
patients and the scan protocols are
clinically tested. The results are reviewed
and validated by radiologists and physi-cists.
Before the new CT system is finally
released, scan protocols are adapted
according to the results of all prior tests.

Tips from the expert:
ALARA principle, the best possible image
quality at the lowest possible dose can
be achieved. But, of course, all users need
to adapt certain parameters to fit their
individual needs such as breathing
instructions for the patient or transfer
rules indicating where images should
be sent.
If the operator wants to change any
parameters within a scan protocol, it is
important to select the correct base pro-tocol.
For example an “AbdomenRou-tine”
protocol should not be changed to
fit a neck examination and vice versa.
Also, if an institute has scanners from
different vendors or different scanner
models, tube current values can not be
compared when it comes to dose. Only
the CTDIvol value represents a compara-ble
figure. The CTDIvol is a measured
value of the dose absorbed during a
CT examination.
Dedicated children protocols are pro-vided
on all Siemens CT scanners. What
is so special about these protocols?
Koch: Children scan protocols are devel-oped
in cooperation with pediatric
radiologists in order to ensure even
lower dose values as compared to adult
protocols. By using children protocols,
the user does not have to adjust dose
values to the age or weight of the child.
In these protocols, CARE Dose4D auto-matically
adapts the tube current to the
individual patient’s anatomical charac-teristics.
However, children older than
6 years or heavier than 55 kg can be
examined with regular adult protocols.
Fast scan times are very helpful when
scanning children since they probably
will not, or cannot, hold still for the
duration of the scan. An increased pitch
value or faster rotation time also sup-port
fast acquisitions. Repeated scan-ning
can be avoided.
Where can users find more informa-tion
about CT scan protocols?
Koch: The Workflow Assistant is included
within the CT Life Card. It is available for
the SOMATOM Definition family starting
with software version syngo CT 2007B
(VA11). Application Guides do exist for
older scanner models. These media
include valuable facts about scan proto-cols,
physical fundamentals, dose mea-sures
and practical tips and tricks.
Life
Q Do not use a protocol from a cer-tain
body region and change it to
a protocol to fit another body
region.
Q When comparing dose values of
different scanner models and
different vendors, it is important
to compare CTDIvol values, not
tube current values. Tube current
values are related primarily to
filter settings and the scanner
geometry.
Q Customized scan protocols can be
exported through the Scan Proto-col
Assistant to Excel to be used on
a PC for further documentation,
e.g. documentation of dose values.
Q All or certain scan protocols can
be copied from one scanner to
another scanner via the Scan Pro-tocol
Assistant. Pre-conditions are
the same scanner model and iden-tical
software version.
www.siemens.com/life-courses
Data for the scan protocols are being consolidated in a comprehensive
data base.
“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.

Life
For the 6th consecutive year, Siemens
Healthcare offered hands-on workshops
in the experience lounge at ECR 2010.
Participants could benefit from very
comprehensive sessions for CT, MR as
well as PET and SPECT CT.
Unlike previous years however, the new
imaging software syngo.via* was used
for the sessions CT Cardiology, CT Oncol-ogy
and CT Colonography. During the 90
minute sessions, Tobias Pflederer, MD,
from Erlangen University and Thomas
Mang, MD, from Vienna University, dem-onstrated
how they can use syngo.via
for their daily reporting.
At the beginning of each session, a theo-retical
introduction into the topic was
given by the speakers. Pflederer pointed
out the various dose reduction possibili-ties
for Cardiac CT while Mang gave an
overview of patient preparation and
reading techniques for CT Colonography.
After a brief demonstration of syngo.via
by Siemens application specialists, 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.
participants could experience Siemens
new imaging software for themselves.
The instructing physicians guided them
step-by-step through the applications,
explaining the benefits of syngo.via.
Customers particularly liked the auto-mated
case preparation, where all coro-nary
arteries are automatically labelled
and functional evaluations for left and
right ventricle are already done.
Next workshops with syngo.via are
planned for ESC 2010 in Stockholm.
First syngo.via Hands-on
Workshops at ECR 2010
By Heike Theessen, Business Unit CT, Siemens Healthcare, Forchheim, Germany
T. Mang, MD, hold the session on CT Colonography using syngo.via
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 America

Life
Training Website for Knowledge Improvement
By Jakub Mochon, Computed Tomography Division, Siemens Medical Solutions, Malvern, Pennsylvania, USA
Recent years have brought significant
progress to the area of ischemic stroke
therapy. Equally important develop-ments
have taken place on the diagnos-tic
side. With availability of Adaptive4D
Spiral on all SOMATOM Definition scan-ners,
coverage for perfusion imaging
has been extended beyond the limita-tion
of the detector size. Physicians can
now adjust the coverage to the specific
needs of the patient and the indications
of the neurological exam. New syngo
Volume Perfusion CT Neuro software
offers improved guided workflow and
enables rapid sharing of perfusion data
and maps utilizing syngo Expert-i. In or-der
to improve the knowledge on Sie-mens
offerings in this area, Siemens USA
role and utility of CT imaging in
stroke care.
Free Trial Licenses for Neuro Imaging
By Marion Meusel, Business Unit CT, Siemens Healthcare, Forchheim, Germany
Siemens’ newest application for neuro-logical
imaging, syngo Volume Perfusion
CT Neuro, can now be tried for 90 days
at no cost.
syngo Volume Perfusion CT Neuro facili-tates
quantitative 3D volume evaluation
for differential diagnosis of brain tumors
and ischemic stroke. In combination
with Adaptive 4D Spiral technology, ex-tended
brain coverage is feasible.* It is
the most complete 3D stroke evaluation
software on the market and the only ap-plication
with both maximum slope and
deconvolution models integrated, sup-porting
diagnostic results even in critical
situations. With the 3D Auto Stroke func-tionality,
therapeutic decisions can be
made without complex user interac-has
launched a dedicated website:
https://www.med.usa.siemens.com/
stroke. Particularly beneficial is the three
part Webcast presented by Ke Lin, MD,
from New York University: https://www.
med.usa.siemens.com/stroke/webcast/
Part 1: Appropriateness of perfusion in
stroke diagnosis: Where and when to
use it.
Part 2: Workflow, Acquisition and Post
Processing.
Part 3: How to read and interpret studies.
Siemens is also working closely with Ap-plied
Radiology: http://www.appliedradi-ology.
com/ on an educational stroke
forum that will further discuss the diverse
needs of the stroke teams at the clinics
and particularly emphasize the beneficial
tions. All relevant perfusion parameters
(CBF, CBV, TTP, MTT) are shown in one
view. The integrated “3D Tissue at Risk
Evaluation” gives confidence in the dif-ferentiation
between cerebral tissue at
risk and core infarct. All these features
make syngo Volume Perfusion CT Neuro
night shift and 24/7 service ready.
In order to improve the knowledge on Siemens
offerings, Siemens USA has launched a dedicated
website https://www.med.usa.siemens.com/stroke
Similar free-trial licenses are available
for many more clinical applications.
International:
www.siemens.com/DiscoverCT
USA only: www.usa.siemens.com/
webShop/CT
syngo Volume
Perfusion CT Neuro –
All dynamic informa-tion
in one view.
*Available for the
SOMATOM Definition
family only.

Frequently Asked Questions
By Ivo Driesser, Business Unit CT, Siemens Healthcare, Forchheim, Germany
In the Scan Protocol Assistant (SPA),
the user has access to all scan protocols.
These protocols can be adapted, changed
or deleted. Everything is clearly listed
as in the patient model dialog. The
layout is comparable to the examination
Dual Energy CT: Learning From the Experts
By Heike Theessen, Business Unit CT, Siemens Healthcare, Forchheim, Germany
Siemens Healthcare will offer a work-shop
on Dual Energy CT in cooperation
with Thorsten Johnson, MD, Associate
Professor of Radiology and Head of Com-puted
Tomography at Munich University
Hospital, Campus Großhadern, Germany.
The course will take place in Forchheim,
Germany from September 10th to Sep-tember
11th 2010.
The field of Dual Energy CT scanning
is expanding incredibly fast. Twelve dif-ferent
FDA cleared Dual Energy applica-tions
have already been introduced since
the launch of Dual Source CT in 2005,
creating both clinical and educational
demand. Siemens Healthcare will provide
a comprehensive overview to those who
are just starting to integrate Dual Energy
CT into their daily routine with emphasis
on understanding the principles and fully
card, which makes it easy to find the
entries which should be changed.
How can SPA help in daily routine?
1. The entry “CTDIvol”, for example, can
be added for all scan protocols as follows:
First the SPA has to be opened, via
utilizing the potential of Dual Energy CT.
The two-day training session will include
presentations on both the physical princi-ples
and the clinical benefits of Dual
Energy CT. A hands-on session at a
SOMATOM Definition scanner, as well as
on a workstation for extended case re-view
is also part of the workshop. “Some
of the things covered in the workshop
“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
the scan parameters. Click on the config-uration
icon (marked in red on the im-age).
Select the “CTDIvol” box and place in
the menu bar via the arrow (marked in
green). Click on the configuration icon
again. If desired the“CTDIvol” entry can be
selected in the menu bar and moved to
the preferred location.
2. For 3D reconstructions it is preferable
to have a non-square matrix. Select in
Step 2 all the affected protocols by using
the filter “3D recon jobs”. In in Step 3
you can change the matrix size. Select
the column “Matrix size” and in the l ower
part, make your changes. All selected
protocols will now be changed.
In this way, protocols are easily and quickly
adapted to the users preferences.
have been used reliably in daily routine
for years. Some others are only a couple
of months old. Upon completion of the
workshop, participants will be at the fore-front
of Dual Energy technology,” says
course director Johnson.
During a workshop
Thorsten Johnson, MD
will present both the
physical principles
and clinical benefits
of Dual Energy CT.
www.siemens.com/life-courses
Example of
the Trigger
card of
SOMATOM
Definition
scanner.

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

Life
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and how-to’s. It is primarily
designed for physicians,
physicists, and medical
technical personnel.
SOMATOM Sessions
of computed tomography.
With its innovations, clinical
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this semiannual magazine
is primarily designed for
physicians, physicists,
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technical personnel.
Perspectives
of clinical diagnostics. This
semi-annual publication pro-vides
clinical labs with diag-nostic
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and case studies.
It is primarily designed for
laboratorians, clinicians and
medical technical personnel.
The Magazine for Healthcare Leadership
May 2010
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
News
Our latest topics
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and to better delineate
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Duke University Medical Center in Durham, North Carolina, USA
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Alexander Zimmermann
Authors of this Issue
H. Alkadhi, MD, Institute of Diagnostic Radiology,
University Hospital Zurich, Zurich, Switzerland
F. Bamberg, MD, Department of Clinical Radiology,
University of Munich, Campus Großhadern,
Munich, Germany
R. W. Bauer, MD, Department of Diagnostic and
Interventional Radiology, Clinic of the Goethe
University, Frankfurt, Germany
A. Becker, MD, Department of Clinical Radiology,
Munich, Germany
C. R. Becker, MD, Department of Clinical Radiology,
Munich, Germany
G. Feuchtner, MD, Institute of Diagnostic Radiolo-gy,
M. Fischer, MD, Institute of Diagnostic Radiology,
R. Goetti, MD, Institute of Diagnostic Radiology,
W. Heindel, MD, Department of Clinical Radiology,
University Hospital, Münster, Germany
J. M. Kerl, MD, Department of Diagnostic and
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M. Lell, MD, Department of Radiology and
the Imaging Science Institute (ISI), University
of Erlangen-Nuremberg, Erlangen, Germany
S. Leschka, MD, Institute of Diagnostic Radiology,
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University Langone Medical Center, New York,
NY, USA
A. H. Mahnken, MD, RWTH Aachen University
Hospital, Aachen, Germany
Y. Mizutani, MD, Department of Radiology,
Sakakibara Heart Institute, Tokyo, Japan
K. Nikolaou, MD, Department of Clinical Radiology,
Munich, Germany
J.-F. Paul, MD, Centre Chirurgical Marie
Lannelongue, Le Plessis-Robinson, France
A. Plass, MD, Clinic of Cardiovascular Surgery,
B. Policeni, MD, Radiology Faculty, Neuroradiology,
University of Iowa Hospitals and Clinics, Iowa
City, Iowa, USA
H. Scheffel, MD, Institute of Diagnostic Radiology,
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H. Seifarth, MD, Department of Clinical Radiology,
University Hospital, Münster, Germany
K. Takada, MD, Department of Radiology,
Sakakibara Heart Institute, Tokyo, Japan
T. J. Vogl, MD, Department of Diagnostic and
Interventional Radiology, Clinic of the Goethe Uni-versity,
Frankfurt, Germany
P. Weisser, MD, Department of Diagnostic and In-terventional
Radiology, Clinic of the Goethe
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Rapid evaluation is
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