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SOMATOM
Sessions
No 17/December 2005RSNA-Edition
Nov. 27th
Dec. 2nd, 2005
www.siemens.com/medical
COVER STORYDual Source CT Imaging A New Era in ComputedTomographyPage 4
NEWSCT Clinical Engines Speedand Confidence
Page 19
BUINESSSOMATOM Emotion Excel-lent Price-Performance RatioPage 25
Revenue InvestmentPays OffPage 27
CLINICAL OUTCOMESOncology Respiratory Gating
Page 34
Acute Care Diagnosis andSurgical Planning in TraumaticParaplegiaPage 42
SCIENCEIncreased Speed and Resolu-tion Make a Difference inCoronary Artery ImagingPage 46
CUSTOMER CAREEDUCATE Free CME-Credited CD-SetPage 49
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The number of slices acquired per rotation has doubled every 18 months in the last years,
with Siemens being an innovation leader in both technical concepts and clinical applications.
At RSNA 2003, Siemens set another landmark as the first company to introduce 64-slice CT.
Only two years later, our SOMATOM Sensation 64 is installed in over 500 institutions
world-wide the largest installed base in this segment.
At Siemens, we continue to challenge the future view on CT technology and clinical applica-
tions. We understand that supplying our users with innovative hardware is not enough. Intro-
ducing our new CT Clinical Engines, we provide perfect clinical CT solutions in neurology, diag-
nostic oncology, cardiovascular and acute care available across Siemens' CT product line and
based on Siemens' unique syngo platform.
The time has come to explore totally new CT concepts and to move beyond the simple adding
of more detector slices. At RSNA 2005, Siemens moves CT into a new era with the introduction
of the world's first Dual Source CT, the SOMATOM Definition a breath-taking innovation that
started with a simple scribble and was designed in cooperation with the world's leading clinical
experts. Experience completely new dimensions of CT. Redefine the clinical role of CT in car-
diac imaging and acute care. Explore new clinical frontiers with dual energy scanning. Join us
to reach new levels of excellence in CT.
Now, enjoy reading this 17th issue of the SOMATOM Session magazine. It is the introduction
to another great CT year in a year in which Siemens will once again set the trend.
Sincerely,
Dear Reader,
Bernd Ohnesorge, PhD, Vice President CT Marketing and Sales
2 SOMATOM Sessions17
EDITORS LETTER
DeutscherZukunftspreis/
AnsgarPudenz
Bernd Ohnesorge, PhD,
Vice President
CT Marketing and Sales
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SOMATOM Sessions 17 3
CONTENT
COVER STORY4 Dual Source CT Imaging A New Era in Computed Tomography
12 Dual Source CT Imaging The Idea behind the Technology
NEWS19 Speed and Confidence
21 Leader in Customer Care
21 NEW Advanced Vessel Analysis
22 Proven Leadership
22 Trendsetting Injector Coupling Device
23 Enhanced Workflow
BUSINESS24 Virus Protection Shields Medical Systems
24 The Easy Way from Sequential to Multislice CT
25 Excellent Price-Performance Ratio
26 Reimbursement in the US
27 Investment Pays Off
CLINICAL OUTCOMES28 Cardiovascular: CT Angiography of Chest, Abdomen, Pelvis and Upper Extremities
with CARE Dose4D and z-Sharp
30 Cardiovascular: Peripheral Runoff
32 Oncology: Computer Assisted Reading - More Speed. Enhanced Confidence
34 Oncology: Respiratory Gated CT-Imaging in Radiation Therapy of Lung Cancer
36 Oncology: Restaging Bronchial Carcinoma after Radiotherapy Treatment
38 Oncology: Making a Difference with PET and CT in Complex Cases
40 Neurology: Bone Subtraction CTA for Vascular Mapping in Head and Neck Imaging
42 Acute Care: 40-Slice CT for Diagnosis and Surgical Planning in Traumatic Paraplegia
SCIENCE44 Head and Neck Imaging
46 Increased Speed and Resolution Make a Difference in Coronary Artery Imaging
CUSTOMER CARE48 Customer Event
48 Cardiac CT Live Case Workshop
48 First High-end Users Meeting
49 Free CME-Credited CD-Set
49 Service: Frequently Asked Questions
50 Service: CT News on the Web
50 Service: Upcoming Events and Courses
51 Imprint
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4 SOMATOM Sessions 17
Dual Source CT Imaging
A New Era inComputed Tomography
Four prominent medical specialists from radiology, cardiologyand medical physics sat down together recently to discussa revolutionary innovation in CT technology: dual source CT imaging.Here is how the experts assessed the new technology.
By Catherine Carrington
COVER STORY
Buzz. Its what fills the air when people take note of an
exciting new trend, a technological revolution that
promises to change the future, an innovation so creativeit defines out of the box thinking.
Buzz. Its what energized the room when four computed
tomography (CT) experts gathered in Cleveland, Ohio, to
envision the future of imaging, and how it will change
with the introduction of a revolutionary new technology:
dual source CT.
The first system worldwide to contain this new technology
is Siemens SOMATOM Definition. Overcoming the
convention of thinking in terms of numbers of slices, it is
equipped with two X-ray source/detector systems that
rotate in synchrony, simultaneously capturing image data
in half the time required with conventional technology.Two X-ray sources, two detectors, a multitude of clinical
possibilities.
At the table were neuroradiologist Michael Modic, M.D.,
chairman of radiology at the Cleveland Clinic Foundation;
radiologist Richard White, M.D., head of the section of
cardiovascular imaging at the Cleveland Clinic Foundation;
cardiologist Gilbert Raff, M.D., director of CT and MRI
research at William Beaumont Hospital, Royal Oak,
Michigan; and medical physicist Cynthia McCollough,
Ph.D., director of the CT Clinical Innovation Center at Mayo
Clinic, Rochester, Minnesota.
Coronary CTAexamination with83 ms temporal
resolution ofa patient withvarying heart
rate of 85-93 bpmduring the scan.
MIP LAD DiastoleCourtesy: University Hospital Erlangen
MIP LAD Diastole
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SOMATOM Sessions 17 5
MICHAEL MODIC, M.D.,chairman of radiology at the
Cleveland Clinic Foundation
RICHARD WHITE, M.D.,radiologist, head of the
section of cardiovascular
imaging at the Cleveland
Clinic Foundation
GILBERT RAFF, M.D.,cardiologist, director of CT
and MRI research at William
Beaumont Hospital, Royal
Oak, Michigan
CYNTHIA MCCOLLOUGH,Ph.D., medical physicist,
director of the CT Clinical
Innovation Center, Mayo
Clinic, Rochester, Minnesota
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6 SOMATOM Sessions 17
COVER STORY
SOMATOM Sessions: 64-slice CT scanner have been a
remarkable innovation, but we are wondering what
challenges still remain. Are there ways in which CT can
become even better?
DR. RAFF: Cardiac CT has extremely high accuracy in finding
a lesion and in excluding significant stenosis. However, it
is very important to both, the patients management andinterventional planning, to discover exactly how severe the
lesion is whether it is a 25 percent stenosis or a 75 percent
stenosis. Any move in that direction is key.
The second issue is patient preparation. I have an entire
holding area staffed with nurses and equipped with
monitors, all dependent on having to give patients beta
blockers to slow the heart rate. We could save a lot of time,
work and cost if we didnt need to give patients these beta
blockers.
DR. WHITE: The leap from 16- to 64-slice technology really
made it possible for us to do coronary CT angiography. But
were still dependent upon picking the right patients. With
future CT technology improvements, we need to be able to
do an examination on any patient.
DR. MODIC: CT is the ideal modality for imaging acute
stroke. The first decision for us is blood no blood, and
CT is very good at answering that question. But we alsoneed to evaluate the intracranial vessels, including fast and
accurate separation of vessels and bone. Moreover, calcified
plaque in the carotid arteries has been a limiting factor in
applying CT to the evaluation of stroke. We need a tool that
is better able to differentiate tissues.
DR. MCCOLLOUGH: Radiation dose has become of
increasing concern. With present multislice CT technology,
as temporal resolution improves, the radiation dose goes
up. Its a concern that hangs over the technology and makes
everyone worry.
Four CT experts from the US gathered in Cleveland to envision the future of imaging, and how it will change with the
introduction of dual source CT.
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Dual source CT meets all of these challenges. Consider cardiac
imaging: Each of the two source/detector systems must travel
only 90 degrees to acquire image data, resulting in a doubling
of temporal resolution. It provides a temporal resolution of 83
ms a factor of two better than the 165-ms temporal
resolution of the best single source CT scanners. Together with
a spatial resolution of less than 0.4 mm, it enables SOMATOM
Definition to visualize the smallest anatomical structures with
exceptional quality without the compromises associated with
beta blockers and ECG-gated, multisegment reconstruction.
SOMATOM SESSIONS: How will dual source CT solve some of
the challenges you continue to face in cardiac imaging?
DR. RAFF: Even in patients that we consider ideal today, there
is always cardiac motion and subtle amounts of blurring at thelevel of the stenosis. The only way were going to push coronary
CTA to achieve the quality we need to make key clinical
decisions is with higher temporal resolution.
DR. WHITE: Any opportunity to capture that coronary artery
as its flying by is a major gain. With 83-ms temporal resolution,
independent of the heart rate, youre also getting away from
the need for segmented reconstruction approaches.
SOMATOM SESSIONS: Lets talk about multisegment
reconstruction. Its said to improve temporal resolution and
overcome problems associated with a high heart rate. Are the
images of consistently high quality?
DR. WHITE: Mult isegmental
reconstruction is not a panacea, and
quite often its detrimental rather than
beneficial. Youre averaging data from
multiple cardiac cycles, and thats not
the most desirable approach.
Multisegment reconstruction should
not be relied upon as the answer to
temporal resolution.
DR. MCCOLLOUGH: If you average
two cardiac cycles and the heart
doesnt come back to exactly the samespot on a submillimeter level, youve
just blurred out that 1- or 2-mm artery
youre trying to see.
SOMATOM SESSIONS: High temporal
resolution eliminates the need to give
beta blockers. We have discussed the
operational benefits, but is there also
a clinical benefit?
SOMATOM Sessions 17 7
DR. RAFF: A considerable number of patients cant take beta
blockers. For example, patients with asthma are not
candidates for cardiac CT today. And some patients are beta
blocker resistant. If dual source CT means that fewer patients
are rejected beforehand, and more of the patients we do
image have diagnostic results, thats quite important in the
scheme of things.
DR. WHITE: Theres another aspect to consider. Lets say,
based on the CT study, youre concerned about athero-
sclerosis and want to determine its functional importance.
Having beta blockers on board may preclude immediately
doing a functional assessment with stress testing. Thats a
problem that dual source CT can solve.
Cardiac Imaging
Gilbert Raff, MD, director of CT and MRI research,
William Beaumont Hospital, Royal Oak, Michigan
Better coronary imaging at thislevel is going to revolutionize
the treatment of coronarydisease, and coronary disease is
the most commmon serioushealth problem in
the developed world.
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SOMATOM Definition delivers the lowest possible radiation
exposure in cardiac CT imaging today, despite using two
X-ray sources instead of one. How? Dual source CT images
the heart twice as fast; therefore, Adaptive ECG-pulsingTM
delivers the dose necessary for cardiac imaging in less than
half the time as the most dose-efficient single source CT
scanner. In addition, dual source CT easily acquires images
even at the highest
heart rates, thus allowing for scanning at higher table speed.
Higher table speed results in lower radiation exposure
compared to single-source CT.
SOMATOM SESSIONS: Is dose exposure a big issue in
cardiac CT?
DR. RAFF: Yes, its a concern. When the dose gets to behigher than for a coronary angiogram, theres a
psychological barrier, and everyone from patients to
government regulators become reluctant.
DR. MCCOLLOUGH: Radiation dose becomes a very hot-
button topic because people dont understand it. If someone
comes to the emergency room and its clearly important to
evaluate them with CT, then the dose risk is negligible in
comparison to the medical necessity of the exam. But in
those patients that come for rule-out examinations,
minimizing radiation exposure is very important. Reducing
the dose in cardiac CT by a factor of two will be an important
prerequisite for further establishing the technique in clinical
practice.
DR. RAFF: Im concerned about the patient who has CT after
equivocal results on a stress test. Theyve had a nuclear
procedure with radiation, a CT scan with radiation, and they
may go on to cardiac catheterization, with more radiation.
Anything we can do along that pathway to minimize
radiation exposure is critically important.
SOMATOM SESSIONS: Does radiation dose resonate with
your patients? Could you draw patients to your center by
emphasizing that dual source CT offers excellent image
quality at half the dose?DR. MODIC: Absolutely.
DR. WHITE: Why not put it out there as a mandate? We
should tell patients: This is one of our core values, to reduce
dose without sacrificing image quality. Lowering dose is the
right thing to do for multiple reasons.
Acute CareA combination of the highest temporal resolution and the
highest power available in the industry enables dual source
CT to easily image critical and challenging acute care
patients. This includes not only patients who are short of
breath or have a high heart rate, but also obese patients.
SOMATOM Definition has a wide, 78-cm gantry bore, a
200-cm scan range, and a combined 160-kW of power from
two independent X-ray sources. Together, these ensure
excellent image quality and enable scanning at high speed
for pure arterial-phase imaging, even in the heaviest of
patients.
SOMATOM SESSIONS: How important is it to be able toimage obese patients with adequate power and at an
optimal table speed?
DR. MODIC: Any time you can match dose with body mass,
youre better off. With dual source CT, youve got enough
power to take care of the patient.
DR. RAFF: In obese patients, the deterioration of image
quality can be so substantial with conventional CT scanners
that many of these patients have undiagnosable lesions.
Based on our experience with heavier patients, we dont
examine cardiac patients with a body mass index over
38 kg/m2.
DR. MCCOLLOUGH: We have successfully done abdominal
8 SOMATOM Sessions 17
COVER STORY
Michael Modic, M.D., chairman of radiology,
Cleveland Clinic Foundation
If you have a strong,premier cardiac program,youll have to have a dual
source CT. A health systemlike ours should
probably have several.
Radiation Dose
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resolution of 165 ms, there is still going to be motion blur.
So I think dual source CT could be a huge benefit for
imaging of pediatric patients without sedation, or for
imaging an injured patient who is in pain and cant hold
still, or a patient who is agitated for some other reason.
Dual Source CT Allows Dual Energy ImagingDual energy imaging possible only with dual source CT
leverages differences in attenuation that depend on the
types of tissues being scanned, as well as on the energy
level. Scanning an object with 80 kV results in a different
attenuation than scanning an object at 140 kV. This raises
the possibility of direct subtraction of either vessels or bone
during scanning, as well as characterization of other tissues.
By using two X-ray sources simultaneously at different
energies, SOMATOM Definition can acquire two data sets with different information from a single scan. This may
offer the possibility of going beyond mere visualization of
anatomy to differentiation and characterization of tissues.
SOMATOM SESSIONS: What clinical opportunities does
dual energy scanning offer?
DR. MCCOLLOUGH: One of the most important challenges
in cardiovascular CTA is calcium. If a patient has a lot of
calcium in the coronaries, you cant see through that bright
spot to make a good diagnosis. Thats one of the things
were hoping dual energy will help us deal with.
SOMATOM Sessions 17 9
studies on a patient weighing more than 500 pounds, using
a 64-slice scanner. But we have to make compromises. We
have to lower the table speed and, therefore, we cant
optimize the exam from a contrast perspective, as we would
with a regular patient. So if dual source CT allows us to scan
obese patients using the dose and the table speed we prefer,
there will be fewer trade-offs. And, in cardiac CT of obese
patients, lowering the table speed is not sufficient. You
simply need more X-rays for those patients.
SOMATOM SESSIONS: Should physicians be concerned
about the extra radiation dose to the obese patient?
DR. MCCOLLOUGH: The target organs that you worry about
for cancer are buried inside all that tissue, which absorbs a
lot of the radiation. It turns out that the effective dose,
which is an indicator of cancer risk from ionizing radiation,
only goes up by 10 to 20 percent, even though the scanneris cranking out double or quadruple the usual dose.
SOMATOM SESSIONS: Are there other types of acute care
patients for whom dual source CT could make an important
difference?
DR. MCCOLLOUGH: Weve done imaging of non-sedated
kids for a decade and a half because weve had an electron-
beam CT in our practice. Weve recently replaced that
scanner with a 64-slice scanner, and weve been doing well
with kids, but we still have to spend a long time in the exam
room calming them down if theyre agitated. At a temporal
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COVER STORY
DR. MODIC: The whole issue of calcium isnt just in the
heart. It could be in the lungs. It could be in peripheral
angiography, even in the hands and feet. Well be able to do
bone subtraction, not in postprocessing, but based on the
dual energy source.
SOMATOM SESSIONS: Dr. Modic, youre a neuroradiologist.
Would it be helpful to you to be able to discriminate bone
and vascular tissue when imaging the brain?
DR. MODIC: Absolutely, especially given the emergence of
CT and CTA in the evaluation of patients with subarachnoidhemorrhage and acute stroke. The high cervical carotids
and the skull base those are difficult areas. Were very
eager to see the quality of the images we can achieve using
dual energy. Its likely to have a profound effect on the use
of CT in neuroradiology.
DR. WHITE: Dual energy is the big unknown for dual source
CT thats going to take it into an entirely different dimension.
We dont know what the prospects are for smarter contrast
agents, for example. We might adjust energies according to
the agent. There are probably opportunities we havent even
begun to anticipate.
Financial JustificationSOMATOM SESSIONS: From an operational or economic
standpoint, how would each of you justify investing in a
dual source CT scanner?
DR. MODIC: If you have a strong, premier cardiac program,
youll have to have a dual source CT. A health system like
ours should probably have several. If you have the patient
demand, the throughput that you can achieve through these
devices more than justifies the cost.
DR. MCCOLLOUGH: I can see dual source CT in the
emergency room, taking care of acute care and traumatizedpatients. Also in a big pediatric hospital. These are the places
where sub-100 milliseconds should be a clear win, and
where it may be worth paying the price differential.
DR. RAFF: For a cardiac program like ours, dual source CT is
an obvious choice. Its very important for us to be the best.
In addition, our emergency room sees six thousand patients
a year with chest pain, and their average length of stay is
over 24 hours. Were finishing up a series of studiesRichard White, M.D.,
head of the section of cardiovascular
imaging, Cleveland Clinic Foundation
Any opportunity to capturethat coronary artery
as its flying by is a major gain.With 83-ms temporal resolution,independent of the heart rate,youre also getting away from theneed for segmentedreconstruction approaches.
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showing a dramatic decrease in length of stay when CT is
used to evaluate chest pain patients. If we could eliminate
beta blockers, we could probably reduce the length of stay
by another two hours. Those are the kind of compelling
numbers that hospital administrators with busy emergency
rooms are going to look at. Also, if a hospital is competing
with other institutions, it will be a distinguishing feature.
Patients will like the convenience.
Evolution or Revolution?SOMATOM SESSIONS: Many of the advances in CT over the
last several years have been evolutionary. The increasing
number of slices with each new scanner is the most obvious
example. Is dual source CT another evolutionary change, or
is it revolutionary?
DR. MCCOLLOUGH: This scanner jumps off the curve,because its not about the slices, its about rotation time.
We went from a half-second to 0.42 seconds to 0.37 seconds
to 0.33 seconds, and the gains were 0.08 and 0.05 and 0.04
seconds. Now we jump off a curve thats reaching its upper
limit and virtually cut rotation time in half, thats a big deal.
DR. WHITE: I think its both. You can count on it being
evolutionary on day one as we learn how to use it. But then,
the prospects for this technology to set a whole new
direction are amazing, and it will sustain that for quite some
time.
DR. RAFF: We have to consider the potential impact on
cardiology, and, through it, on medicine in general and the
healthcare system. Better coronary imaging at this level is
going to revolutionize the treatment of coronary disease,
and coronary disease is the most common serious health
problem in the developed world.
Author: Catherine Carrington is a medical editor in Vallejo,
California.
Cynthia McCollough, Ph.D.,
director of the CT Clinical
Innovation Center, Mayo Clinic,
Rochester, Minnesota
Dual source CT could be ahuge benefit for imaging of
pediatric patients withoutsedation, or for imaging an
injured patient who is in pain andcant hold still, or a patient
who is agitated
for some other reason.
SOMATOM Sessions 17 11
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SOMATOM Sessions 17 13
Dual Source
CT Imaging The Idea behindthe Technology
With the introduction of the DualSource CT technology at this years RSNA,
Siemens once again demonstrates its
leadership in technology and clinical
applications, moving beyond the simple
adding of more detector rows a race
that had dominated CT technology for
the past couple of years.
SOMATOM Definition is the worlds first CT scanner to
incorporate this new technology with which Siemens is
once again pushing technical and clinical boundaries to a
higher level by adding a second X-ray source and detector
to the CT system. The results are unprecedented image
quality and detail at lowest patient exposure while ensuring
substantially increased diagnostic speed and confidence.
Patient table
Gantry
Detector 1
X-ray unit 2
X-ray unit 1
Rotation ofX-ray unitand detector
Detector 2
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COVER STORY
SOMATOM Definitions heart rate independent resolution
is 83 milliseconds, permitting scans of virtually every heart
and any heart rate from acute chest pain evaluation to
coronary visualization to functional analysis of the heart.
Together with the high spatial resolution of below 0.4 mm, it
makes the visualization of the smallest anatomical structures
possible with exceptional quality.
In combination with a 78-cm large gantry bore and field of
view, 200-cm scan range, and its high generator power, the
system allows most accurate scans or acute patients,
independent of size or condition. And all this at the lowest
possible dose. Additionally, SOMATOM Definition offers the
widest range of clinical applications, allowing fast and most
confident diagnoses to comprehensive reporting in only amatter of minutes. Intuitive and computer-assisted reading
tools also assist physicians in early detection, fast evaluation,
and precise follow up of malignant diseases, sometimes even
enabling them to review results before the patient is off the
table. Whats more, SOMATOM Definitions capabilities promote
pioneering new clinical opportunities at the highest level.
How Does it Work?The use of two X-ray sources and two detectors at the same
time result in double the temporal resolution, double speed and
twice the power, while even further lowering radiation dose.
Cardiac ImagingOptimal cardiac imaging can be best achieved in the diastolic
phase of the heartbeat. The faster the heart rate, the shorter
this phase becomes. With a single source CT scanner, the
X-ray source/detector system has to obtain data projections of
180 degrees to take an image within the diastolic phase. With
Dual Source CT, each of the two source/detector combinationsneeds to travel only 90 degrees to acquire an exceptional
cardiac image. Based on 0.33 s rotation time, this concept
provides an unprecedented temporal resolution of 83 ms,
independent of the heart rate.
Advantages at a Glance
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SOMATOM Sessions 17 15
100 bpm Dual Source CT
60 bpm single source CT 60 bpm Dual Source CT
100 bpm single source CT
At a low and stableheart rate, the time asingle source CT
scanner needs forimaging is sufficient.Nevertheless, the
substantially highertemporal resolution ofDual Source CT
eliminates residualmotion.
At higher or varyingheart rates, the diastolicphase is too short
for a single source CTscanner, resulting inpoor image quality.
Dual Source CT, on theother hand, deliverssharp and detailed
cardiac images in ashort diastolic phaseand even in the systolic
phase.
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Heartbeat-controlled
dose modulation
Heartbeat-controlled
dose modulation
60 bpm single source CT
100 bpm Dual Source CT
60 bpm Dual Source CT
100 bpm single source CT
Dose Reduction
Dual Source CT images
the heart twice as fastas single source CT
scanners, reducing theECG-pulsing window bymore than half.
To overcome insufficient
temporal resolution athigh heart rates, singlesource CT scanners use
multisegment recon-struction with high doseand limited reliability.
Dual Source CT, on theother hand, maintainsthe lowest dose, inde-
pendent of the heart rate.
At the same time, SOMATOM Definition offers the lowest
possible radiation exposure in cardiac CT. Thanks to Dual
Source CT, the CT gantry needs to travel only 90 degrees to
acquire an exceptional cardiac image with unprecedented
temporal resolution of 83 ms, independent of the heart
rate. Monitoring the ECG in real-time, Siemens Adaptive
ECG-pulsing instantly reacts to any changes of the heartrate. Now that cardiac acquisition is twice as fast, the time
of high exposure during the heart beat, controlled by dose
modulation, can be cut by more than half compared to
single source CT scanners.
Instead of using multisegment reconstruction at higher
heart rates, Dual Source CTs highest temporal resolution
allows to acquire cardiac images from single heartbeats, at
any heart rate. Using automated table speed adaptation,
SOMATOM Definition increases the pitch with higher heart
rates, resulting in a faster table speed and a corresponding
reduction of radiation exposure. In other words, the higher
the heart rate, the less time is required for imaging the
heart, and consequently lower dose is needed.
Obese PatientsScanning obese patients with single source CT usually results in
a trade-off between speed and image quality. Dual Source CTovercomes this limitation of restricted power reserves with a
second X-ray source. In other words, it accumulates the power
of the two independent sources, resulting in unprecedented
160 kW, providing sufficient X-ray power reserves for high quality
imaging of patients whether tall or small, thin or large at
maximum volume coverage speed and fastest rotation time.
And, because scan speeds can be increased, the higher power
is used to improve quality, while dose maintains the same as in
single source CT. And the large bore of SOMATOM Definition
makes patient positioning much easier.
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Scan speed
Quality
Power
Dose
SOMATOM Sessions 17 17
Scan speed
Quality
Power
Dose
SINGLE SOURCE CT WITH LIMITED KW.
Insufficient power for high-speed scanningof obese patients.
DUAL SOURCE CT WITH 160 KW*.
Dual Source CT accumulates the power of two
seperate sources resulting in unprecedented 160 kW*.
* Depends on system configuration.
When imaging obese patients at a high table speednecessary for pure arterial scanning, even astate-of-the-art, single source CT scanner may not have
sufficient power.
Dual Source CT, on the other hand, delivers sharp anddetailed images at any scan speed, because it
accumulates the power of two independent sources.
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Energy 1:
Iodine
296 HU
Bone 670 HU
80 kV
Iodine
144 HU
Energy 2:
Bone 450 HU
140 kV
As X-ray absorption is energy-dependent, changingthe tube's kilo voltage results in a material-specific
change of attenuation.
18 SOMATOM Sessions 17
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It has always been an aim to collect as much information
as possible for differentiation of tissues. Dual Source CT
assists in opening the door beyond visualization, moving
into a new world of characterization. Permitting the use of
two sources simultaneously at different energies, SOMATOM
Definition makes it possible to acquire two data sets
simultaneously from a single scan, running the tubes at two
different kV levels. The result are two data sets with diverse
information, which can allow the user to differentiate,characterize, isolate, and distinguish the imaged tissue and
material obtaining specific details about the scanned
object beyond morphology.
Spectacular research topics lie ahead, waiting to be explored,
as dual energy helps pave the way for a broad spectrum of
potential clinical uses. Possible application fields are: direct
subtraction of either vessels or bone during scanning,
classification of tumors in oncology, characterization of
plaques in vessels and the differentiation of body fluids in
emergency diagnostics.
Tissue Differentiation
Using a single source CT scanner,
diagnosing the circled area becomesdifficult, as insufficient informationdoes not allow a differentiation
between different tissue types.
Dual Source CT, on the other hand,
enables physicians to easilydifferentiate tissue types. The lesion
could be identified as a lipid
degeneration, color-coded in darkred.Object
140 kVAttenuation A
80 kVAttenuation B
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In order to enhance clinical workflow in
the computed tomography (CT) environ-
ment, Siemens CT Division is introduc-
ing a new generation of CT Clinical En-
gines. Supplying our customers with
hardware dedicated to their needs is not
enough, says Bernd Montag, PhD, Pres-
ident of the CT Division. We also want
to provide them with applications and
workflow tools that are specifically de-
signed to enhance image quality and
workflow efficiency in their particular
clinical departments. The CT Clinical En-
gines marry the world's most innovative
CT technology with syngo, Siemens
unique clinical applications solution.
Perfect synergy, designed to reliably se-
cure outstanding clinical outcomes
the new CT Clinical Engines bring togeth-er state-of-the-art CT scanner features
such as the industrys fastest rotation
speed, lowest possible dose scanning
modes and direct 3D data reconstruction
with exactly the right syngo solutions.
With our new CT Clinical Engines, we
take clinical application to the center of
our strategy, says Bernd Ohnesorge,
PhD, Vice President of CT Marketing and
Sales. The CT Clinical Engines will pro-
vide our framework to introduce further
innovations in the rapidly developingclinical fields of neurology, diagnostic
oncology, cardiovascular and acute care
that will drive the future of CT. They are
designed to enhance speed and diag-
nostic confidence by delivering excep-
tional image quality, fast access to im-
age data, and flexible access to intuitive
syngo clinical applications throughout
the radiology environment.
NEWS
The Complete Solution forCardiovascular CT
The CT Cardiac Engine offers the com-
plete solution for cardiovascular CT im-
aging. From scan to diagnosis, it covers
everything to achieve a streamlined car-
diovascular workflow. State-of-the-art
ECG-synchronized acquisition, image
reconstruction techniques and intuitive
ECG-editing to exclude extra beats be-
fore image reconstruction, ensure opti-
mal image quality. The lowest possible
dose for patients is provided with intelli-
gent adaptive ECG-pulsing. An innova-
By Louise McKenna, PhD, MBA, Global Product and Marketing Manager CT-Workplaces, and Stefan Wnsch, PhD, Global
Product and Marketing Manager Clinical Solutions, Siemens AG, Medical Solutions, CT Division, Forchheim, Germany
C T C L I N I C A L E N G I N E S
Speed and Confidence
SOMATOM Sessions 17 19
tive, dedicated cardiovascular imaging
user interface simplifies daily workflow
and ensures highest throughput. The CT
Cardiac Engine facilitates cardiovascular
diagnosis from vascular analysis with
accurate stenosis measurement to stent
planning, from cardiac morphology to
functional analysis, concluding in a
comprehensive report.
Full Confidencein Neuro CTThe CT Neuro Engine delivers the tech-
nology required to perform artifact-free
imaging with the high spatial and tem-
syngo Circulation as a
key component of the CT
Cardiac Engine offersphysicians the industrys
most comprehensive
software for cardiac CT,
setting a new benchmark
for improving clinical
outcomes through inno-
vative software solutions.
syngo Neuro DSA CT as
part of the CT NeuroEngine offers tools for
fast and easy assessment
of head and neck
images, including direct
bone subtraction CTA.
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Bernd Ohnesorge, PhD, Vice
President CT Marketing & Sales
of Siemens Medical Solutions,
receives the Frost & Sullivan
Award from Stephen Mohan, Vice
President Sales, Healthcare
Practice North America, Frost &
Sullivan, at the 6th international
conference on Cardiac CT in
Boston, MA, USA.
NEWS
22 SOMATOM Sessions 17
S O MATO M S e n sa t io n
Proven LeadershipWith well over 500 installations, the
SOMATOM Sensation 64 is the worlds
most widely installed 64-slice computed
tomography (CT) system. Its outstanding
capabilities are not only recognized by
physicians, but also by market analysts
and engineering experts.
Frost & Sullivan has awarded Siemens
Medical Solutions the 2005 Enabling
Technology of the Year award in recogni-
tion of being the first company to success-
fully introduce a 64-slice CT system.
Since the introduction of the SOMATOM
Sensation 64, healthcare professionals
consider it an industry standard in high-
quality imaging. On the basis of its tech-
nological capability, Siemens has set a
benchmark in the development and
adoption of high-end technologies in the
imaging industry, said Stephen Mohan,
Vice President Sales, Healthcare Practice
North America, Frost & Sullivan.
In recognition of its exceptional image
quality, speed, and ease-of-use, the
SOMATOM Sensation 64 was also hon-
ored with the gold award in the 2005
Medical Design of Excellence Awards
(MDEA). Judges in the eighth annual
MDEA competition recognized the sys-
tems excellent engineering such as
its revolutionary z-SharpTM Technology
identifying it as a paradigm shift in CT
scanning technology. Sponsored by Can-
non Communications, publishers of "Eu-
ropean Medical Device Manufacturer"
(EMDM) magazine, the MDEA program
honors design and engineering achieve-
ments within the medical industry.
www.frost.com;
www.devicelink.com/expo/awards02/
k
C A R E Co n tr a st C T
Trendsetting Injector Coupling DeviceSiemens Computed Tomography (CT)
customers can now profit from a unique
synergy of trendsetting scanner tech-
nology, the seamlessly integrated syngo
CARE Contrast CT, and contrast media
injector devices, resulting in the most
efficient contrast management on the
market. Siemens CARE solutions havebeen expanded with the new option
CARE Contrast CT, extending the func-
tionality of all Siemens SOMATOM CT
scanners and optimizing contrast en-
hanced CT examinations.
CARE Contrast CT connects the CT scan-
ner and the injector, therefore allowing
starting or stopping the scan from one
single entry point. This is a trendsetting
answer to the increasing demands of
fast contrast enhanced CT scanning. It
speeds up clinical workflow and allows
efficient and confident monitoring of
patients during contrast media injection
and scan start, even if only one techni-
cian is present.
CARE Contrast CT is the first scanner
interface using a new standard (namedCiA425) for injector coupling devices in
medicine. The interface is designed to
cover future communication tasks be-
tween scanner and injector and will
open up new fields of contrast-based ap-
plications. It is currently supported by
leading injector companies MEDRAD
and MEDTRON. Following this trend,
additional releases of injectors from oth-er companies are expected soon.
CARE Contrast
CT greatly
speeds up
workflow in
contrast-
enhanced
CT scans.
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SOMATOM Sessions 17 23
NEWS
s y n g o 2 0 0 6 A
Enhanced Workflowsyngo 2006A, Siemens newest work-
flow software, will be delivered on new
syngo MultiModality workplaces1 by the
end of January 2006. Continuing the
Think Clinical theme, it gives users ac-
cess to new features and functionalities
designed to enhance workflow and di-
agnostic confidence.
Key Clinical AreasThree key clinical areas have been the
focus: cardiovascular CT, neuro CT and
CT imaging in oncology and early detec-
tion, thus providing key building blocks
for the four new CT Clinical Engines just
introduced at RSNA namely CT Cardiac
Engine, CT Neuro Engine, CT Acute Care
Engine and CT Oncology Engine (see
page 19).
syngo Circulation, designed for one-
stop, fast, robust morphological and
functional cardiac evaluation, makes its
debut in syngo 2006A. In combination
with enhancements to syngo InSpace
4D, such as bone removal and advanced
vessel segmentation and analysis func-
tionalities, users have access to superior
tools for comprehensive cardiac assess-
ment, fast evaluation of chest pain,
complex vascular exams, and fractures.
In neuro CT, visualization of complex
cerebro-vascular structures has been
hindered by the dense bone at the base
of the skull. Siemens new syngo Neuro
DSA CT facilitates subtraction of bone
from contrasted vessels allowing excep-
tional visualization of these vessels. New
features in syngo Neuro Perfusion CT in-
clude automatic tissue-at-risk assess-
ment, offering enhanced speed and
confidence in tumor perfusion and
stroke workflow.
With syngo 2006A, Siemens adds an-
other computer assisted reading tool to
its portfolio. syngo Colonography with
PEV (Polyp Enhanced Viewing) is a sec-
ond reader tool for the automated de-
tection of colon lesions. Together with
syngo LungCARE CT with NEV (Nodule
Enhanced Viewing), Siemens offers its
users an exceptional level of confidence
for early detection and follow-up exams
of the colon and lung.
Another new addition to the oncology
portfolio, syngo Body Perfusion CT, en-
ables the user to obtain an accurate pic-
ture of a tumors dynamic profile, help-
ing to optimize treatment decisions. On
top of the new clinical functionalities,
syngo 2006A provides the user with sig-
nificant improvements of workflow per-
formance. DICOM transfer of up to 21
images per second can be achieved, as
well as loading capacity of up to 3,200
images.
syngo Colonography with PEV (Polyp Enhanced Viewing)
is among the new computer assisted reading tools for
early detection available with syngo 2006A.
The syngo Body Perfusion CT option allows for the
quantitative evaluation of dynamic CT data of organs and
tumors, following the injection of a compact bolus.
1
Formerly: LEONARDO
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BUSINESS
24 SOMATOM Sessions 17
S I E M E N S R E M O T E S E R V I C E
Virus Protection Shields
Medical SystemsRegular computers can easily be pro-
tected against viruses. But regular virus
protection software cannot be indis-
criminately used on medical equip-
ment. Without the corresponding vali-
dation and testing, a systems safety and
efficacy may be significantly impacted.
Siemens Virus Protection solves the
problem. The solution is designed to
handle virus-related security matters on
syngo-based systems. It is the first
on the market to address this issue for
medical systems, significantly support-
ing customers in keeping their medical
systems healthy.
Siemens Virus Protection is based on
a virus scanner by Trend Micro, Inc., a
global leader in antivirus and content
security software and services. It in-
cludes regular updates with the latest
engines and patterns, using a VPN
(Virtual Private Network) broadband
Siemens Remote Service connection. The
Virus Protection program has been de-
veloped, validated and thoroughly test-
ed in both Germany and the United
States and is now available for Siemens
computed tomography systems.* Virus
protection for medical systems has be-
come a necessity due to the common
usage of various data media and inter-
net connections. As long as our cus-
tomers did not optimize their workflow
through network connectivity, there
was no need for such services, says
Wolfgang Heimsch, PhD, head of
Siemens Medical Solutions Customer
Service Division. Now healthcare pro-
viders are increasingly using networked
systems, so the market needs a suitable
virus protection solution.
* depending on software configuration
S O MATO M S pi r i t
The Easy Way From Sequential
to Multislice CTTo support customers in advancing their
computed tomography (CT) perform-
ance, Siemens Life Customer Care Solu-
tion offers Elevate, a program dedicat-
ed to updating outdated systems with
new ones for example SOMATOM AR
sequential scanners from the 1990s
with the spiral, dual-slice CT SOMATOM
Spirit, a cost-effective system for clinical
routine. When comparing the two sys-tems, the SOMATOM Spirit offers many
advantages: Its spiral scan mode and
multislice technology broadens the clin-
ical spectrum. Concurrently, together
with its fast scan time, spiral scanning
speeds up data acquisition and thus re-
duces motion artifacts. With the syngo-
based, easy-to-operate user interface
and an image reconstruction time of
only one second, the SOMATOM Spirit
accelerates the whole diagnostic
process. Thanks to the SOMATOM Spir-
its multislice technology, users can re-
construct different slice thicknesses
based on one single scan for example,
thin slice, high-contrast images and
wider slices with soft tissue display at
low contrast resolution. The SOMATOM
Spirit offers better resolution in high-
contrast structures, and a better low-contrast detectability in soft tissue.
Siemens unique UltraFastCeramic
(UFCTM) detector material and dose
reduction software lower patient dose
while achieving better image quality.
All in all, a lot of reasons why SOMATOM
AR owners should consider converting
their system.
www.siemens.com/
SOMATOMElevate
k
Siemens Virus Protection handles
virus-related security matters on syngo
based systems.
Elevate Siemens managed
system upgrade program brings
clinical performance to a higher
level: from the sequential single-
slice SOMATOM AR to the new
spiral, multislice SOMATOM Spirit.
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SOMATOM Sessions17 25
BUSINESS
Interview
S O MATO M Emo t io n
Excellent Price-Performance RatioSiemens Medical Solutions recently
installed the first SOMATOM Emotion
16-slice computed tomography (CT)
system at the following locations: in
Germany, at the Israelitische Kranken-
haus, Hamburg and Klinikum Nurem-
berg Nord; in Belgium, at Clinique du
Sud-Luxembourg/St. Joseph, Arlon;
and in the US, at the Ohio State Uni-
versity, Columbus. SOMATOM Ses-
sions spoke with Johann-C. Steffens,
MD, Head of Radiology of the Israeliti-
sche Krankenhaus.
What are your first experiences with
the 16-slice SOMATOM Emotion?
The amazing fact for me was that the
new 16-slice SOMATOM Emotion
worked as a reliable scanner from the
very first day, replacing our 6-slice CTscanner. Installation took only two
days. The syngo user interface of the
16-slice SOMATOM Emotion is so sim-
ilar to the SOMATOM Emotion with six
slices that there were no changes in
how to operate the system, and no
need for additional training. We now
use the scanner for our daily routine
as well as for advanced applications
like CT Colonography.
Which clinical advantages and image
quality, compared to a 6-slice CT,does the 16-slice configuration of
the SOMATOM Emotion provide?
We appreciate the low image noise
and high resolution that the system
allows us to achieve. Because of the
faster rotation time and the higher
number of slices, we can perform sub-
millimeter lung examinations in one
single breath-hold, so that motion arti-
facts are reduced. In addition, run-offs
can be performed in better resolution
and with a longer range, giving us the
opportunity to see smaller details. We
achieve very good image quality inabdominal imaging and imaging of
bony structures. In addition, the im-
age quality of head scans is outstand-
ing.
With the 16-slice configuration of
the SOMATOM Emotion, the resolu-
tion and the number of slices in-
creased. How about patient dose?
Patient dose does not increase. Be-
cause of the efficient system design,
the effective patient dose is generally
very low. For most examinations theeffective patient dose is less than with
our former 6-slice system.
To which users would you recom-
mend the new configuration of the
SOMATOM Emotion?
I think this scanner provides radiolo-
gists the opportunity to perform rou-
tine and advanced applications. There-
fore it enables them to get more
patients from their referrals and also
increase the number of referrals. In
addition, the low investment and life-
cycle costs permit radiologists with
limited budgets to purchase a scannerwith excellent performance. Especial-
ly radiological departments in small
and mid-size hospitals and imaging
centers can profit from the excellent
price-performance ratio of the SO-
MATOM Emotions 16-slice configura-
tion.
www.israelitisches-krankenhaus.dek
Johann-C. Steffens,
MD: The SOMATOM
Emotion 16 enables
us to achieve low
image noise and high
resolution.
The Israelitische Krankenhaus in
Hamburg is a 205-bed hospital con-
sisting of the Medical Clinic and the
Surgery Clinic, plus an interdiscipli-nary intensive care unit and the De-
partment of Anesthesiology. The Radi-
ological Practice of Dr. Steffens, a
Cardiological Practice, a Neurological
Practice and the cancer research cen-
ter, Indivumed, are located on the
same premises and closely cooperate
with the hospital.
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NEWS SECTION
SOMATOM Sessions17 27
BUSINESS
R E V E N U E
Investment Pays OffModern equipment is one of the key
factors in providing more efficient and
higher quality healthcare today. Both clin-
ical community and patients benefit from
an improved clinical workflow and ad-
vances in medical diagnosis. In computed
tomography (CT), scan modes, scan and
image reconstruction times, resolution,
applications and user interfaces, as well as
dose reduction methods, have all devel-
oped quickly over the past few years.
Keeping a hospital up-to-date is a finan-
cially significant task. However, two re-
cent analyses show that it pays off.
A Giant LeapHospital Moinhos de Vento, Porto Alegre,
Brazil, took one giant leap forward when
it replaced two single-slice scanners with
one SOMATOM Sensation Cardiac 16 in
2004. When comparing the database of a
six-month period prior to the installation
to a six-month period after the installa-tion, they realized that the average time
for scheduling an examination was re-
duced from 26 to 11 minutes; that the
number of examination increased by
52 percent; that the average contrast vol-
ume was reduced by 25 percent; and that
the number of examinations with patient
sedation was reduced from 4 percent to
3.2 percent. Using modern, multislice
equipment dramatically streamlines the
workflow and increases patient care and
comfort, concludes J.A. Marconato, MD
at the hospital. He points out, however,
that this improvement is only possible if
the entire staff works together as a team
from scheduling the examinations to di-
agnosing the images: Today, the limita-
tions are no longer set by the equipment.
Step by StepOf course, one expects such savings from
a major upgrade step even if one new
scanner replaces two old ones. But it also
pays off to be among the early adopters
of new CT technology. The Chairman of
the Radiology Department at a huge US
hospital compared core data from several
systems, starting with the SOMATOM Plus
4, the SOMATOM Volume Zoom and the
SOMATOM Sensation 16, up to the SO-MATOM Sensation 64. One basic result:
Acquisition and reconstruction times de-
creased dramatically over the years, en-
abling higher patient throughput. The
clinic has increased its patient volume
from less than 20 patients per day with
the SOMATOM Plus 4 to well over 60
while enabling on demand examina-
tions instead of the long waiting lists com-
mon with the older systems. In spite of
higher staffing required to run the
SOMATOM Sensation 64, the expenses,
as a percentage of the revenue, trend
down. This is due to higher patient vol-
ume, and also to a different staffing skill
mix. Today, more aides are hired for tasks
that do not require the expertise of a tech-
nologist to ensure the same patient tran-
sit time and patient care. With this combi-
nation of measures, the clinic has been
able to continuously reduce expenses;
from more than 60 US$ per exam to 45,
despite rising market prices for the scan-
ners. As a result, expenses as a percent-
age of net revenue have decreased from
over 16 to only 9 percent. In summary, in-
creased coverage, speed, resolution, ap-
plications, indications and availability not
only increase patient care: When it comes
down to finances, these improvementsalso decrease spending. A detailed pres-
entation, now available on CD, was held
by the clinic's radiology chairman at the
7th SOMATOM CT User Conference
2005 (see page 49).
Results may vary. Data on File.
Abdominal CT Scan Total Exam Time
35
3025
20
15
10
5
0
Time(Minu
tes)
Plus4 Volume Zoom
Acquisition
Patient TransitRecon
Sens at ion 16 Sen sa ti on 64
An abdominal scan with the SOMATOM Plus 4
took more than 30 minutes total examination
time with the SOMATOM Sensation 64, every-
thing was done in five minutes.
Expense Trends
By continuously upgrading their CT equipment,
the US c linic has been able to increase patient
throughput while reducing costs.
18
1614
12
10
8
6
4
2
0
Perc
ent
Plus4 Volume Zoom Sensation 16 Sensation 64
Payroll & Benefits
Medical Supply & OtherDirect EquipExpenseTotal Expense
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28 SOMATOM Sessions 17
Case 1:CT Angiography of Chest, Abdomen, Pelvis andUpper Extremities with CARE Dose4D and z-SharpBy Dominik Fleischmann, MD, Jeffrey C. Hellinger, MD, and Geoffrey D. Rubin, MD, Department of Radiology,
Cardiovascular Imaging Section, Stanford University Medical Center, Stanford, CA, USA
HISTORY
A 34-year-old woman with right arm numbness was referred
for CTA of the upper extremities as well as the chest,
abdomen and pelvis. The patient's past medical history was
significant for a right brachial artery aneurysm presumably
caused by vasculitis which had been treated with a
reversed vein graft and secondary interventions over the
past 10 years. The patient also had a history of bilateral iliac
artery aneurysms.
The imaging goal in this particular case was to identify or
exclude a vascular cause for the patient's recent right arm
symptoms. Because of the patient's history and the known
iliac artery aneurysms, the large arteries of the body were
also imaged. We chose a single CTA acquisition with the
patients arms placed next to her body and a single contrast
medium injection into a left antecubital vein.
Care Dose4D Automated Dose Modulation
[ 1 ] Consistently excellent image quality throughout the entire scanning range in vascular territories
within the body and in the upper extremities off-center at an average of 180 effective mAs
0
50
100
150
200
250
300
350
400
450
500
550
600
650
700
750
800longitudinaldistanceinmm
Effective mAs (Houndsfield Units)
0 50 100 150 200 250 300
Eff. mAsRef mAs: 250, kVp 120
A
verage180mAs
73
245
93
160
106
252
158Image Noise(HU)
Dose Modulation(eff. mAs)
Oncology NeuroCardiovascular Acute CareCLINICAL OUTCOMES
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Scanner SOMATOM Sensation
64-slice configuration
Scan area From lower neck to finger-tips;arms by side of body
Scan length 77.5 mm
Scan time 29 s
Scan direction cranio-caudal
kV 120 kV
Effective mAs 180 at 250 Ref mAs
Rotation time 0.5 s
Slice collimation 0.6 mm
Slice width 1 mm
Pitch 0.7
Reconstruction increment 0.7 mm
CTDI 13.41 mGy
Kernel B25f
Contrast Omnipaque 350 mg iodine/ml
Volume 25 cc at 5 cc/s, 100 cc at 4 cc/s,
followed by 40 cc saline flush
Start delay 5 s
NEWS SECTIONCLINICAL OUTCOMES
SOMATOM Sessions17 29
EXAMINATION PROTOCOL
[ 2 ] A left vertebral artery origin
directly off the aortic arch is present.
Otherwise, the supraaortic vessels arewithin normal limits.
[ 3 ] Right common iliac artery
aneurysm and small left internal ili-
ac artery aneurysm. A high-gradestenosis of the celiac artery, due to
median arcuate ligament impinge-
ment is noted.
[ 4 ] Multiple mild focal dilata-
tions within the right brachial
artery, a reversed vein graft.The graft is patent with mild
stenosis distally. Several surgical
clips are also noted.
DIAGNOSIS
Incidentally noted is a left vertebral artery origin directly off
the aortic arch. Otherwise, the supraaortic vessels are within
normal limits. The right subclavian and axilary arteries are
patent. Multiple focal areas of mild dilatation (11 to 14 mm indiameter) are seen within the right brachial artery reversed
vein graft. The graft is patent with mild stenosis distally. The
radial, ulnar, and interossea arteries are patent.
A high-grade stenosis of the celiac artery origin, due to
median arcuate ligament impingement, is noted. The thora-
co-abdominal aorta and its visceral branches are otherwise
unremarkable. A 15 mm right common iliac artery aneurysm
and a small, 11 mm left internal iliac artery aneurysm are
seen in the pelvis.
COMMENTS
The patient was positioned in supine position with her arms
placed at the sides of her body, to enable coverage of the
entire chest-abdomen-pelvis and upper extremities vessel ter-
ritories within a single CTA acquisition, and with a single injec-
tion of contrast medium. Although such positioning may
cause streak artifacts in the shoulder region and excessive
noise within the upper extremities, the use of automated tube
current modulation (CARE Dose4DTM) and high spatial resolu-
tion using z-Sharp Technology resulted in virtually artifact-free
visualization of all clinically relevant vessels at unprecedented
image quality.
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Case 2:Peripheral RunoffBy Jean-Bernard DHarcour, MD, Cliniques du Sud-Luxembourg,
site St. Joseph, Arlon, Belgium
HISTORY
A 55-year-old patient with previous history of left femoral
bypass was presented for mild claudication of the right leg.
A CTA runoff with the SOMATOM Emotion was performed.
DIAGNOSISCTA shows severe aorto iliac athromatosis and complete
occlusion of the left iliac axis. Left aorto femoral bypass is
patent. On the left side, a short occlusion of the distal super-
ficial femoral artery (SFA) is disclosed. On the right side,
there is no significant stenosis of the iliac axis but a long
occlusion of the SFA is shown. On both sides, peripheral
arteries are patent.
[ 1 ] VRT showing occlusion of the left iliac artery
and patency of aorto femoral bypass. Bone removal
was performed with syngo InSpace4D.
COMMENTS
This case demonstrates the ability of the SOMATOM Emotion
with 16-slice configuration to achieve complete arterial map-
ping, thus enabling the physician to plan vascular therapy.
syngo InSpace4D with bone removal allows a quick overview
of the entire vascular tree and permits a reliable analysis of
heavily calcified segments. Complete evaluation should not
take more than 15 minutes.
[ 2 ] VRT of the complete examination
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32 SOMATOM Sessions 17
Case 3:Optimizing Clinical Workflow in CT ColonographyUsing syngo Colonography PEVBy Anno Graser, MD, and Christoph R. Becker, MD, Department of Clinical Radiology,
University Hospital Munich-Grosshadern, Munich, Germany
[ 2 ] Adenomatous polyp in the trans-
verse colon close to the hepatic flexure
[ 3 ] CAD identified several
additional small lesions.
At our center, the demand for colorectal cancer screening is
growing and the number of CT colonography (CTC) exami-
nations is increasing rapidly. We are constantly looking for
tools that help us to improve speed and enhance confidence
and offer our patients the highest possible level of care. A
study performed at our institution to be presented at this
years Radiologic Society of North America (RSNA) annual
meeting (Session SSG 10-07, Tuesday, November 29) shows
that PEV reaches 94% sensitivity in the detection of polyps inthe important 5-9 mm size range. In addition, the study
shows that PEV can be integrated into clinical routine due to
its short running time of 4 minutes per dataset. With PEV
running in the background, syngo Colonography PEVs per-
formance remains unrivalled, delivering excellent perform-
ance in everyday clinical routine increasing reader confi-
dence and shortening evaluation time.
The case presented here shows how PEV improves human
[ 1 ] Anastomosis of the descending
colon and the remaining sigmoid
Computer Assisted Reading More Speed.Enhanced ConfidenceThe use of computer assisted reading tools such as syngo
Colonography with PEV (Polyp Enhanced Viewing) and
syngo LungCARE CT with NEV (Nodule Enhanced Viewing)
can significantly enhance clinical workflow, adding speed
and diagnostic confidence. Two expert centers look at just
how much value second-reader products can add to their
clinical workflow.
reader performance and level of confidence in the detection
of polyps. The 62-year-old male patient had undergone par-
tial sigmoidectomy for resection of a stage T2 cancer in
2002. The patient underwent CTC, following incomplete
colonoscopy.
There is end-to-side anastomosis of the descending colon
and the remaining sigmoid [Fig. 1] and a 15-mm adenoma-
tous polyp in the transverse colon close to the hepatic flex-
ure [Fig. 2]. The PEV algorithm identified several additionalsmall polyps: one difficult to see hiding between two folds
[Fig. 3], another had been obscured by a puddle of fluid on
the supine scan and can only be seen on prone images where
there is slightly increased image noise seen as the character-
istic cobble stone pattern of the colonic mucosa which nev-
ertheless does not prevent detection of the lesion [Fig. 3]. In
summary, PEV shows an excellent performance in the detec-
tion of colonic lesions.
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Case 4:Improved Workflow for Detectionof Pulmonary NodulesBy Marco Das, MD, Andreas Horst Mahnken, MD, Georg Mhlenbruch, MD, Joachim Ernst Wildberger, MD,
Department of Diagnostic Radiology, Rolf. W Gnther, MD, Director, Department of Diagnostic Radiology, and
Thomas Kraus, MD, Department of Occupational Health, RWTH Aachen University, Aachen, Germany
[ 2 ] The NEV software
detected the nodule and
marked it as a potential
lesion with a red circle. The
mark has to be evaluated
by the radiologist to confirmthis finding as a true posi-
tive finding.
[ 3 ] The software allows a quantitative evaluation of
the nodule and gives information about diameters, volume,
and CT density values. It also allows a comprehensive view
of the anatomical location between the vessels in this 3D-
rendered scene of the finding (Volume Of Interest, VOI).
After identifying the nodule as a true positive finding, all
these parameters are stored in the final report.
Multidetector-row computed tomography (MDCT) is the
method of choice for detection of pulmonary nodules.
Increased spatial resolution with modern CT scanners facili-
tates the detection of nodules as small as one or two mil-
limeters. Overlooked pulmonary nodules, regardless of size,
may have potentially severe consequences for the patient.
Reasons for missing nodules may be perception errors or
misinterpretation. Double reading during clinical routine has
been suggested to reduce false negative diagnosis. In times
of increased workload and limited human capacity, this
goal is not always practicable. Moreover, quantification of
nodules is problematic due to inter- and intraobserver vari-
ability. Thus, computer algorithms have been developed to
aid the radiologist for the detection and quantification of pul-
monary nodules.
ENHANCED CONFIDENCE
syngo LungCare CT with NEV facilitates the detection work-
flow and provides easy objective quantification and reporting
of pulmonary nodules. Fig. 1 shows a routine low-dose chest
MDCT examination of a 66-year-old male patient (120 kV, 10
mAs eff., 16 x 0.75 mm collimation, rotation time 0.5 sec,
table feed/rotation 18 mm, 1 mm slice thickness, 0.5 mm
reconstruction). With initial standard reading using Maxi-
mum-Intensity-Projection (MIP technique; 5 mm thick sec-
tion), a pulmonary nodule was not detected, probably
because of its central location closely surrounded by largevessels. During initial standard reading, the NEV algorithm
runs in the background and marks potential lesion candidates
for reviewing after the initial read. The nodule was detected
and marked by the software automatically [Fig. 2] and was
confirmed by the reading radiologist. With one additional
mouse-click, quantification of the nodule was performed
[Fig. 3]. After final reporting, the patient underwent CT-guid-
ed, fine-needle aspiration biopsy and small-cell lung cancer
was finally diagnosed during cytopathological work-up.
[ 1 ] 66 year old male patient
who received a low-dose
MDCT chest examination for
the detection of pulmonary
nodules. Initial reading missed
the nodule located centrallybetween several surrounding
vessels in the left lower lobe.
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Case 5:Respiratory Gated CT-Imagingin Radiation Therapy of Lung CancerBy J. Dinkel, MD, A. Jensen, MD, U. Mende, MD, PhD, Department of Radiation Oncology, and J. Debus MD, PhD,
Director, Department of Radiation Oncology, University of Heidelberg, Germany
this patient, the breathing frequency was over 12 cycles/min.
CT data was collected in spiral mode, with simultaneous
acquisition of 24 parallel sections using a 1.2 mm collimation
and appropriate spiral pitch of 0.1. The respiratory signal
from the patient was synchronized and simultaneously
recorded during free-breathing CT data acquisition, using a
chest-belt with a pressure sensor. Virtually correlated 4D
phase volumes (with the time as the fourth dimension) were
reconstructed after the scan to form a model of anatomic
movement. 7 different reconstructions were performed cor-
responding to different phases of the breathing cycle.
In these CT scans, a 4 x 3.7 x 3.8 cm lobular mass was clearly
visible in the medial aspect of the left upper lobe extending
to the left hilus. Various nodular calcified lymph nodes as
well as an enlarged aorticopulmonary lymph node could beseen in the mediastinal region. Additionally, the CT scan
showed an extrathoracic metastasis in the left adrenal
gland. In our scans, the tumor mobility was about 2.1 mm in
[ 1 ] Nodular calcified lymph node as well as an
enlarged aorticopulmonary lymph node can be seen
in the mediastinal region.
[ 2 ] Metastasis in the left adrenal gland
HISTORY
A 62-year-old female patient under chemotherapy treatment
for a non-small-cell lung cancer and cerebral metastases
was examined using the SOMATOM Sensation Open with a
4D respiratory gated data acquisition protocol in order to
determine the full range of motion of critical internal struc-
tures and the lung cancer during respiration. This method
was used to achieve a more targeted radiation treatment.
DIAGNOSIS
Respiratory gating supplies information about tumor motion
during the patient's breathing cycle. The introduction of the
latest generation multislice CT systems with short acquisi-
tion times permits the evaluation of thoracic structures with
a temporal resolution of 250 ms. Short acquisition times inthis set-up are achieved by simultaneous acquisition of 24 or
40 transverse sections, half-second scanner rotation, and
advanced respiratory-gated reconstruction algorithms. In
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EXAMINATION PROTOCOL
Scanner SOMATOM Sensation Open
Scan area ThoraxScan length 300 mm
Scan time 51.85 s
Breathing frequency > 12 cycles/min.
kV 120 kV
Effective mAs 400 mAs
Rotation time 0.5 s
Slice collimation 1.2 mm
Slice width 1.5 mm
Pitch 0.1
Reconstruction increment 1 mm
CTDI 35.63 mGy
Kernel B10f
Postprocessing syngo Inspace4D
3A 3B
the x-axis (L-R), 6.2 mm in the y-axis (A-P) and 5.2 mm in the
z-axis. The mass, however, did not show a deformation dur-
ing the breathing cycle. Visualization of structure motion is
possible with dedicated software syngo Inspace4D.
COMMENTS
New approaches in radiation therapy with the use of more
and more conformal dose application in combination with
higher doses per fraction for irradiation treatment need
accurate delineation of tumor and critical structures espe-
cially in areas where artifacts distorting the geometric shape
and location of the organs cannot be tolerated. Motion arti-
facts usually occur at boundaries of anatomical structures
(both target volumes and organs at risk), resulting in the
image degradation and the inability to correctly delineateanatomical structures. This leads to erroneous position,
shape and volume information for target volumes and other
regions affected by motion.
The respiratory gated data acquisition in CT allows the plan-
ning physician to visualize and study the organ and tumor
motion in 3D coordinates and time, contributing to a better
understanding of the target area and potential sparing of
healthy tissue by minimization of treatment volume and
reduction of side effects. Respiratory gating is a promising
new tool to increase the quality of RT planning and patient
treatment.
[ 3A, 3B ] Two reconstructions corresponding to different phases of the breathing cycle demonstrate the
range of motion of critical internal structures and the lung cancer during respiration.
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[ 4 ] Tumoral encasement ofthe inferior pulmonic vein
[ 5 ] Post obstructive lung changeson the right side
[ 6 ] MPR views of the paramediastinal fibrotic changes
[ 3 ] Tumoral mass caudal inthe right hilum
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Case 7:Making a Difference with PET andCT in Complex Cases
Biograph High-Resolution Examination
The powerful functional imaging in Positron Emission Tomo-
graphy (PET) became even more powerful with the addition of
anatomical data from CT. The diagnostic limitations of stand-
alone PET and CT procedures are eliminated with combined
PET/CT imaging technology, which has become the gold
standard for tumor diagnosis and staging. Siemens Biograph
PET/CT hybrid-imaging scanners provide seamlessly matched
functional and anatomical images from a single non-invasive
procedure, enabling accurate tumor diagnosis, whole-body
staging, target definition and treatment planning. The Bio-
graph provides complete clinical information regarding the
exact location, size and metabolic activity of disease.
HISTORY
This 63-year-old female patient with severe scoliosis and his-
tory of surgically removed gallbladder cancer in 2004 was
seen for follow-up in March 2005. In this routine follow-up,
the patient was diagnosed with Non Small Cell Lung Cancer
(NSCLC), and a hybrid PET/CT was ordered for staging.
DIAGNOSIS
In addition to several pulmonary lesions and the NSCLC, the
PET/CT study, obtained on the Biograph 16 HI-REZ, identified
multiple bone lesions within the spine [Fig. 1, Fig. 2], two
intra-abdominal lesions [Fig. 3], as well as additional 6 mm
lesions in the thorax wall [Fig. 4, Fig. 5]. The metastatic and
some other bone lesions were almost undetectable in the CT
images.
COMMENTSPET has a major role in early detection, staging and treatment
planning of lung cancer and related metastases. FDG PET
influences patient management decisions, effecting treat-
ment outcomes and quality of life. Adding co-registered,
detailed anatomical data acquired with a diagnostic CT scan
increases the diagnostic accuracy and provides the reading
and referring physician with the possibility to assess func-
tional and structural changes in one exam.
Using hybrid PET/CT scanning was critical in diagnosing the
additional, unexpected bone metastases and lesions in the
thoracic wall. Some of these bone lesions would have beendifficult to detect using a stand-alone CT. However due to the
patients extreme case of scoliosis, an exact correlation of
stand-alone PET data to the corresponding vertebras was only
possible by using co-registered functional (PET) and anatomi-
cal (CT) information provided by the PET/CT hybrid imaging
scan. The HI-REZ PET imaging technology of the Biograph 16,
with its unmatched additional resolution, also played a signifi-
cant role in accurately identifying the smaller lesions in the
thorax wall, allowing greater diagnostic confidence to the
interpreting physician.[ 1 ] CT Spine image of patient with severe case of scoliosis
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Contrast
Volume 90 cc
Dual phase CT acquisition of the thorax and(arterial and portal venous) upper abdomen
[ 3 ] Fused PET/CT image identifies
two intra-abdominal lesions.
[ 4 ] CT image of the thorax wall [ 5 ] PET/CT image identifies 6 mm
lesions in the thorax wall.
[ 2 ] PET/CT image showing multiple
bone lesions within the spine
EXAMINATION PROTOCOL
Scanner Biograph 16
FDG 11mCi
Uptake time 62 min
Beds 7
Time per bed 3 min
HI-REZ yes
Scan area Whole body
Scan direction Cranial-caudal
Effective mAs 30 mAs
Rotation time 0.5 s
Slice collimation 1.5 mm
Slice width 5.0 mm
Table feed/rotation 24 mm
Pitch 1
Reconstruction increment 5.0 mm
Case courtesy of Martina Eschmann, MD, Tuebingen University, Tuebingen, Germany
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[ 1A ] Osteolysis of the mandible with
cortical destruction [ 1B and 1C ]; Fistula
of the bone in bone [ 1B ] and soft tissue
window [ 1C ]; Inflammation of the soft
tissue along the fistula with skin retraction
[ 2 ] BSCT-Angiogram: frontal view [ 2A ]
and left carotid artery from a lateral
[ 2B ] and medial [ 2C ] view
1A
1B
1C
2A
2B
2C
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Case 9:40-Slice CT for Diagnosis and SurgicalPlanning in Traumatic ParaplegiaBy Steffen Gnther, MD, and Markus F. Berger, MD, Institute of Diagnostic Radiology,
Swiss Paraplegic Center, Nottwil, Switzerland
HISTORY
A 22-year-old man was brought to our hospital by emergency
transport helicopter (REGA) with incomplete paraplegia sub
L2 (ASIA D) following a motorcycle accident. Prior to admis-
sion, the patient had been completely healthy. A vertebral
fracture was suspected and CT scanning of the lumbar spine
for diagnosis and surgical planning was performed. Following
initial posterior instrumentation, a follow-up examination
was performed to document the operative result and to
assess the need for additional anterior stabilisation.
DIAGNOSIS
CT scanning revealed a traumatic burst type vertebral body
fracture of L2 with loss of spinal stability. Bony compromise of
the spinal canal was present. An additional MR scan showedtraumatic injury to the conus medullaris, as the patient unfor-
tunately also had a tethered cord.
Follow-up CT after initial treatment by posterior USS-titanium
stabilisation from L1 to L3 demonstrated an exellent opera-
[ 2 ] Axial image showing postoperative
follow up after burst type fracture of vertebral
body L2. Note the minimal metal artefacts.
[ 1 ] VRT lateral view of the lumbar spine
showing fracture of vertebral body L2
with extension into the posterior column
tive result. Due to the intended straightening of the fracture
zone, there was a relatively large bony defect in the body of
L2 and the need for additional anterior intervertebral fusion
L1/L2 in a second intervention. After both successful opera-
tions the patient showed partial recovery of neural function.
COMMENTS
By using 1.0 s rotation and z-Sharp Technology's flying focal
spot, the SOMATOM Sensation scanner with 40 slices allows
us to achieve both extended coverage and the highest reso-
lution in one examination. Vertebral fractures can be
assessed from whole body datasets in multiple planes and
unprecedented detail. Due to the marked reduction of metal
artefacts, imaging of the postoperative spine has dramatical-ly improved. We can now see what was completely invisible
before. The volume rendered images created with the syngo
InSpace4D application on the CT workstation are simply stun-
ning.
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[ 3 ] VRT images showing postoperative results after posterior-lateral stabilisation;
different views with colour emphasis on the metal implants. Note the virtual absence
of streak artefacts and the excellent delineation of implanted bone chips.
EXAMINATION PROTOCOL
Scanner SOMATOM Sensation 40-slice configurationPre-surgery Post-surgery
Scan area Lumbar spine Lumbar spine
Scan length 250 mm 194 mm
Scan time 46 s 18 s
Scan direction Caudal-cranial Caudal-cranial
kV 120 kV 120 kV
Effective mAs 482 mAs 261 mAs Postprocessing InSpace4D InSpace4D
Rotation time 1.0 s 1.0 s
Slice collimation 0.6 mm 0.6 mm
Slice width 0.75 mm 0.75 mm
Pitch 0.45 0.9
Kernel B25s B25s
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SCIENCE
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Patients with carcinoma of the oral cavity that infiltrate bone
require resection of the involved part of the mandible. This
resection may be performed in a continuity-preserving or, in
more advanced cases, continuity-interrupting resection. To
cover larger defects in order to provide fixation of prosthetic
dentures and restore the ability to masticate, microvascular
grafts are required. Fibula- and radius-grafts are commonly
used. Before reconstructive surgery, detailed information of
the host region is essential for the surgeon [1]. Tumor recur-
rence has to be ruled out, the viability of surrounding bone
has to be assured, and the vascular situation in the host
region has to be assessed. Besides course and diameter of
the external carotid artery (ECA) and its branches, it is
mandatory to be aware of angiopathies. Nutritive-toxic and
age dependent vessel alterations can be encountered fre-
quently in this patient population. Prior resection or preoper-
ative radiation therapy seriously affects the vascularbed in thereceiver region. A decision for or against microvascular
reconstruction has to be made based on the results of the
angiography. Selective catheter angiography (digital sub-
traction angiography, DSA) is still the gold standard in the
diagnosis of the head and neck vasculature. Major drawbacks
of DSA for preoperative vascular mapping are the relatively
high costs and risks of neurological complications. Recently,
multislice spiral computed tomography angiography (CTA)
has emerged as an alternative technique to DSA in a large
Multislice CT AngiographyHead and Neck Imaging
By Michael Lell, MD, Institute of Radiology, University Erlangen-Nuremberg; Bernd F. Tomandl, MD, Department of
Neuroradiology, Klinikum Bremen; Axel Barth, Product Manager Applications, Siemens AG, Medical Solutions, CT Division,
Forchheim; Emeka Nkenke, MD, Department of Maxillofacial Surgery, University Erlangen-Nuremberg; all Germany
variety of indications [39]. In the following paragraphs, the
protocols and results for CTA used at the authors institution
will be reviewed.
Imaging ProtocolPrior to entering the CT suite, an 18-gauge intravenous
catheter is placed in the right antecubital vein, and all mobile
dentures are removed. The patient is placed in supine posi-
tion with the head bedded in a headrest. A biphasic CT scan
is performed with a 16-slice or 64-slice spiral CT scanner
(SOMATOM Sensation 16 or 64). The arterial phase study is
used to create 3D angiographic images, the delayed phase
study for tumor staging. CARE Bolus can be applied to deter-
mine the individual start delay (TimeDelay) for the arterial
phase. Alternatively, the test-bolus method (10 ml contrast
media, 30 ml NaCl 0.9%) can be used: the test-bolus
sequence is then loaded in the Dynamic Evaluation appli-cation, and contrast enhancement curves of the arterial and
venous system can be analyzed in detail. Time-to-peak plus
2s is used as the delay be