SOMATOM Sessions. Cover Story. News. Business. Clinical Results. Science. Answers for life in Computed Tomography

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1 SOMATOM Sessions SOMATOM Sessions Answers for life in Computed Tomography International Edition November Issue Number 29 / November 2011 International Edition Cover Story A Critical Edge When Seconds Count Page 6 News syngo.via: New Clinical Opportunities with Brand New CT Software Applications Page 12 Business Value Added Max Page 26 Clinical Results Flash Scanning of Coronary CTA with just 0.3 msv Page 38 Science From Mannheim to Shanghai: a Viable Model for Future International Research Collaborations Page 68 29

2 Editorial With the introduction of two completely new systems at this year s RSNA conference, we have shown our strength in innovation and that we listen carefully to our customers. Walter Märzendorfer, Chief Executive Officer, Business Unit Computed Tomography and Radiation Oncology, Siemens Healthcare, Forchheim, Germany Cover page: Courtesy of German Heart Center, Departments of Cardiology and Radiology, Munich, Germany 2 SOMATOM Sessions November

3 Editorial Peter Seitz, Vice President Marketing, Computed Tomography, Siemens Healthcare, Forchheim, Germany Dear Reader, In all healthcare systems around the world, hospitals and clinics are facing the challenge of minimizing spiraling costs without compromising on patient care. Our vision, to create CT innovations that lift clinical practice to the next level of excellence and enable wide access to better patient care, has to meet those challenges. By working closely with the physicians and physicists who use our systems in clinical routine, we are convinced that this balance can be achieved. The outcome are products, that meet today s demands in modern patient care, and add innovations that help control costs and make your CT operations economically sound. The latest result of our extensive research and development in this direction is the SOMATOM Perspective 1, which is presented at this year s RSNA conference. This new 128-slice Single Source CT scanner showcases a wide range of CT technologies at an affordable price, and is also suitable for smaller clinics. It scans an adult thorax in about 3 seconds and supports our state-of-the-art iterative reconstruction SAFIRE 2 at a speedy 15 images/second. At the same time, its all-new emode allows you to operate the scanner in an outstanding patient-friendly and financially efficient way. This thoughtful balance will help you to manage your financial performance which is why we call it the business class in CT. For added benefits in workflow optimization, we have enhanced syngo.via 3 with a wide range of applications designed to streamline your clinical efficiency. These will help you to assess chronic obstructive pulmonary disease and offer you dedicated TAVI workflows to name just two examples. In addition, we carefully listened to your feedback and implemented many of your suggestions to make our paradigm-changing thin-client solution more intuitive than ever. But we also remain focused on innovations powered by high-end technology, such as the SOMATOM Definition Edge 4 a completely new and extremely fast single source scanner developed for highresolution, low noise imaging. Its core technology is the unique Stellar Detector, 4 the first fully-integrated detector in the industry, featuring the highest routine spatial resolution and dose-optimized Dual Energy applications. The SOMATOM Definition Edge is ideal for clinics introducing premium CT services, as well as institutions that want to maintain a leading edge in their offerings. For utmost performance, the Stellar Detector will also be available on our flagship scanner, the Dual Source SOMATOM Definition Flash. 1 Its unique scan speed and temporal resolution will be brought to a new level with ultra-high spatial resolution, for finer and sharper image details than ever. The Stellar Detector also marks another step in our endeavor to reduce dose in CT. Its capability to minimize noise makes it highly suited for your efforts to scan with the lowest possible dose, at levels that were thought unachieveable just a few years ago. As such, it perfectly blends with our raw data-based iterative reconstruction SAFIRE, two unique tools to help you implement the ALARA principle in your institution for best possible patient care. By working closely with our customers, we have recognized future trends and brought cutting-edge technology and cost-effective solutions to the present. See for yourself how close we are to achieving our vision in this issue of SOMATOM Sessions. Feedback in the form of criticisms or suggestions will be gladly received. Sincerely, Peter Seitz 1 Under FDA review. Not available for sale in the U.S. 2 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. 3 syngo.via can be used as a stand-alone device or together with a variety of syngo.via-based software options, which are medical devices in their own rights. 4 Under development. Not available for sale in the U.S. SOMATOM Sessions November

4 Content Content 18 International CT Image Contest Value Added Max Cover Story 6 When it comes to diagnosing critical injuries like in acute care or cardiology settings, radiologists need fast, highquality CT images at a low dose. Siemens listened to radiologists needs and developed a revolutionary new detector generation: the Stellar Detector. 1 Two renowned imaging experts, the radilogist Savvas Nicolaou, MD and the cardiologist Jörg Hausleiter, MD share their expectations and potential applications for the new detector technology. Cover Story 6 A Critical Edge When Seconds Count News 12 syngo.via 2 : New Clinical Opportunities with Brand new CT Software Applications 15 Significant Dose Reduction with SAFIRE 3 at Wexford General Hospital, Ireland 16 Boosting Cardiovascular Reading with syngo.via at this Year s CTA Academy 17 Stroke Management Education and Information Exchange Online 18 International CT Image Contest Iterative Reconstruction is Now Available for SOMATOM Emotion and Sensation 22 FAST CARE Meets DSCT 23 High-End CT is on the Move 24 CT Examinations Tailored Precisely to Individual Patient Needs Business 26 Value Added Max 30 Accelerated Cardiovascular Assessment Powered by syngo.via 31 Minimizing Scan Time Loss with TubeGuard 32 Versatility at High Speed Clinical Results Cardio-Vascular 34 SOMATOM Definition Flash: Ruling out Coronary Artery Disease and Diagnosing Coronary Arteritis with 1.3 msv 36 Fast and Precise Imaging of Aortic Intimal Flap Using High Pitch Flash Scan Protocol without ECG-Triggering or -Gating 38 Flash Scanning of Coronary CTA with just 0.3 msv 40 Flash Scanning for Pediatric Aortic Abnormalities without Sedation at 0.6 msv Oncology 42 Examination of a Patient with Lung Cancer with SOMATOM Definition AS Open to Evaluate Treatment and Calculate Dose 4 SOMATOM Sessions November

5 Content 58 Flash CT Pulmonary Angiography in a Freely Breathing Patient 64 Stellar Detector Performance in Computed Tomography 70 An Aura of Sucsess: The 10 th SOMATOM World Summit Science 44 Low Dose Pediatric Flash CT Scanning with IRIS 4 A Follow-up Study after Neuroblastoma Relapse 46 Dose Reduction Combining CARE Dose4D, CARE kv and SAFIRE Techniques 48 Lung Ventilation Imaging with Dual Energy Xenon CT in Single Breath Technique Neurology 50 SOMATOM Definition AS 40: VPCT Pre- and Post-Recanalization of the Internal Carotid Artery 52 Dual Energy CT Myelography Used to Detect Spontaneous Spinal Cerebrospinal Fluid Leaks Acute Care 54 SOMATOM Definition Flash: Low Dose Chest Follow-up Scanning with IRIS 56 SOMATOM Definition Flash: Metal Artifact Reduction with Mono Energetic Dual Energy Imaging in a Critical Trauma Case 58 Flash CT Pulmonary Angiography in a Freely Breathing Patient 60 The First Single Source Dual Energy Scan Mode with Optimized Dose 62 itrim a New Method for Improving Temporal Resolution in Cardiac Computed Tomography 64 Stellar Detector Performance in Computed Tomography 67 Pediatric Imaging in the Spotlight 68 From Mannheim to Shanghai: a Viable Model for Future International Research Collaborations Customer Excellence 70 An Aura of Success: The 10 th SOMATOM World Summit 72 Garmisch CT Symposium 2012 The Congress 72 Hands-on Tutorials at ESC FAST CARE Boosted with Expert Advice 73 Keep Track of Developments with Clinical Webinars 74 New Software for the SOMATOM Emotion The 3 rd Definition Symposium held by Siemens Japan in Tokyo 76 Frequently Asked Question 76 Upcoming Events & Congresses 77 Clinical Workshops Subscription 79 Imprint 1 Under development. Not available for sale in the U.S. 2 syngo.via can be used as a stand-alone device or together with a variety of syngo.via-based software options, which are medical devices in their own rights. 3 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. In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task. 4 In clinical practice, the use of IRIS may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task. SOMATOM Sessions November

6 Cover Story 1 With the unique combination of high spatial resolution at uncompromised temporal resolution, the SOMATOM Definition Edge 1 gives radiologists the perfect balance of clear diagnostic images with less patient radiation. Courtesy of German Heart Center, Departments of Cardiology and Radiology, Munich, Germany 6 SOMATOM Sessions November

7 Cover Story A Critical Edge When Seconds Count When it comes to diagnosing critical injuries like in acute care or cardiology settings, radiologists need fast, high-quality CT images at a low dose. Siemens listened to radiologists needs and developed a revolutionary new detector generation: the Stellar Detector 1. Two renowned imaging experts, the radiologist Savvas Nicolaou, MD and the cardiologist Jörg Hausleiter, MD share their expectations and potential applications for the new detector technology. By Amy K. Erickson Surrounded by cold deep ocean waters famous for whale spotting, Vancouver, British Columbia, located on Canada s western coast, is a cosmopolitan haven for adventure seekers and foodies alike. The city s sleek skyscrapers compete with the jagged mountain peaks beyond, creating an interesting juxtaposition of nature and urban culture. Situated in the heart of this vibrant metropolis is Vancouver General Hospital. Home to one of the largest research institutes in Canada, Vancouver General is a teaching hospital as well as a busy level 1 trauma center, where seconds can often mean the difference between life and death. At Vancouver General, radiologists use CT images to provide information that is critical to making a proper diagnosis in an acute care setting. CT images are used for a variety of clinical scenarios in the emergency department, such as identifying blocks in the coronary arteries or rips in the bowel, or finding small, subtle fractures in the spine, that if undiscovered, could result in patient paralysis. In a trauma setting, you want to obtain the best image quality possible, because we often have to make decisions very quickly about catastrophic injuries, says Savvas Nicolaou, MD, Director of Emergency/Trauma imaging at Vancouver General Hospital. Modern CT technology allows me to differentiate between patients who need to be treated with coronary stent placement and those patients who don t need it. Jörg Hausleiter, MD, German Heart Center, Munich, Germany A diagnostic necessity According to Nicolaou, there has been an explosion in the utilization of CT imaging in the acute care setting, and CT use has increased eight-fold in recent years. Trauma physicians work together with radiologists to make the right diagnoses and clinical decisions to provide the best and safest care to our patients, explains Nicolaou. At the German Heart Center in Munich, Jörg Hausleiter, MD, also relies on CT images to provide critical information about patients who present with chest pain or have a history of coronary heart disease. The recent 2011 WHO report states that cardio vascular diseases (CVDs) are the leading causes of death 1 Under development. Not available for sale in the U.S. SOMATOM Sessions November

8 reduction is at the forefront of patient care. For example, if you have a 23-year-old woman with chest pain, you need to do a CT scan to exclude aortic dissection, a pulmonary embolism, or a coronary artery stenosis (i.e. the Triple- Rule-Out Exam), explains Nicolaou. However, we want to minimize the radiation dose to that young woman because the breasts, thyroid, and other organs are very sensitive to the effects of radiation. He acknowledges that there is a lot of pressure to do low-dose imaging from within the radiology community and from physicians and patients as well. The challenge is to do it without compromising image integrity, so we can provide the appropriate diagnoses for our patients, says Nicolaou. In a trauma setting, you want to obtain the best image quality possible, because we often have to make decisions very quickly about catastrophic in juries. Savvas Nicolaou, MD, Vancouver General Hospital, Vancouver, Canada and disability in the world. A large proportion of CVDs is preventable but obesity and diabetes mellitus with atherosclerosis - that are often linked to CVD - makes CT imaging a challenge in that population. CT imaging allows me to differentiate between patients who need to be treated with coronary stent placement and those patients who don t need it, says Hausleiter. Advances in CT imaging provide radiologists with more opportunities than ever before to image unstable trauma patients. We have the ability to put people who are actively bleeding, whose blood pressures are greatly decreased, who are in a critical situation, into the CT scanner and use the high-speed acquisition technology to quickly tell the trauma surgeon whether a patient has a large hematoma that is crushing the brain that needs to be evacuated urgently or if they have a tear in the thoracic aorta that is actively bleeding in their chest, says Nicolaou. However, one of the biggest hot button issues in radiology today is the desire to minimize the radiation dose. Even in the acute setting where high quality images undoubtedly save lives, dose Quick response in the golden hour For patients in Vancouver, Munich and everywhere in between, trauma is the the leading cause of death under the age of 45. With fast and precise imaging radiologists can offer a therapeutic advantage to patients by providing an accurate diagnosis within the critical golden hour, the time period after an insult during which there is the highest likelihood that medical treatment will prevent death. For instance in acute stroke, the findings on the CT are very subtle and hard to detect in the early stages, says Nicolaou. High-speed acquisition is critical in stroke imaging so we can very quickly tell our neurology colleagues to administer the drugs to dissolve the clots. CT can also be used to look at ischemia of the bowel and to look for acute blood in the abdomen. We also need to identify traumatic tears of the bowel within minutes so that the surgeons can make the appropriate interventions, explains Nicolaou. CT also comes into play when looking at subtle fractures in the cervical spine. In addition, CT can be used in an acute setting to characterize the composition of kidney stones, which can determine the course treatment, such as having the stones broken down by an ultrasound machine, or dissolved with medical therapy Nicolaou remarks. Dual 8 SOMATOM Sessions November

9 Cover Story Vancouver General Hospital (VGH) is a leading institution in trauma imaging. Energy information can add the respective tissue information to the morphology to support this decision. Chest imaging and beyond One of the most common and critically important issues of CT images in an acute setting is for chest injuries and cardiac emergencies. At the German Heart Center, Hausleiter relies on CT images to identify any narrowing or atherosclerotic plaques in a patient s coronary arteries. The normal coronary artery is only 3 millimeters in diameter, so we are talking about very, very tiny structures, says Hausleiter. We often want to assess the coronary arteries to see if there is any narrowing or stenosis and to detect atherosclerotic plaques. Once the coronary arteries are imaged, cardiologists like Hausleiter can determine whether a patient needs to be rushed to the cath lab to have a stent inserted or if the patient can be medically managed and safely discharged. Other causes of chest pain can include a thrombotic clot within a coronary artery, a pulmonary embolism, or pneumonia in the lung. Whether it is imaging a motorcycle accident victim or an individual with chest pain, radiologists and cardiologists need CT technology that maintains image quality while minimizing the dose. As a radiologist, you can t forget that ultimately you need to make a diagnosis based on the images, says Nicolaou. I need detector technology that is highly efficient, while providing excellent clinical images. I also need to obtain diagnostic images at a low radiation dose. It is incumbent upon us as radiologists to minimize the dose, since we are using CT at such a rapid pace to optimize patient care. From a cardiology standpoint, Hausleiter points out that over time, stents can renarrow and the stenosis can come back. In this case, we need to assess the inside of the stent, and this requires a high spatial resolution, he says. The higher the spatial resolution, the higher our capability to detect these changes. Radiologists also need to benefit from a detector that provides an extremely high dynamic range of data preventing potential artifacts in the image. Currently it is very difficult to be able to identify and utilize information at very low contrast levels, says Nicolaou. He notes that in a trauma setting, patients often come in with numerous tubes and access lines. A lot of artifacts can occur when you image patients with these extra tubes, which can preclude you from obtaining good diagnostic images, says Nicolaou. However, if we have a detector that can take care of the noise and get rid of the artifacts, then we can SOMATOM Sessions November

10 Cover Story obtain better diagnostic images. In the emergency department, patients come in all shapes and sizes. It is often more difficult to obtain good images for our bariatric patients. The larger a patient is, the higher the dose of radiation that is needed in order to characterize the tissue to obtain high-quality diagnostic images. Noise is a problem in every patient, says Hausleiter, but we often have a problem with noise in obese patients compared to slim patients. The Edge is here To comply with these needs of leading radiologists and cardiologists like Nicolaou and Hausleiter, Siemens is launching a revolutionary new detector generation: The Stellar Detector 1. Introduced for the SOMATOM Definition Flash Dual Source systems, Siemens launches it also with the new SOMATOM Definition Edge 1. Based on the technology of the SOMATOM Definition Flash 2 with the Stellar Detector this Single Source CT system. Debuting at the 2011 RSNA annual meeting in Chicago, the new Stellar Detector and the innovative Edge Technology 1, is designed to generate ultra-thin slices to deliver the highest spatial resolution in CT. In the past, thinner slices delivered more image detail, but also higher image noise. With the Stellar Detector for the SOMATOM Definition Flash and the SOMATOM Definition Edge, electronic noise and cross-talk are minimized. Hausleiter believes that the new system will offer cardiologists a significant advantage in the field of cardiology. When imaging the heart, high spatial resolution only makes sense when it is combined with high temporal resolution. Hausleiter points out that a primary challenge in imaging the heart is that the muscle is constantly beating and moving, which means the coronary arteries are also constantly moving. CT images need to be obtained at a high temporal resolution to make coronary arteries sharp, says Hausleiter, and the sharper they are, the better ability we have to detect the coronary stenosis and atherosclerotic changes in plaque formations. With the unique combination of high spatial resolution from the Stellar Detector with uncompromised temporal resolution, both the SOMATOM Definition Edge and SOMATOM Definition Flash offer the most advanced solution for this clinical Doctors can t forget that ultimately he or she need to make a diagnosis based on images. Of course CT technology with high-speed, high-quality, low-dose CT images is preferred. challenge. We need a CT technology that gives us the possibility to safely detect in-stent restenosis of stents smaller than 3 mm in diameter or to differentiate the three plaque-components more precisely, explains Hausleiter. The new detector system offers improved spatial resolution. In addition, the new gantry on the SOMATOM Definition Edge allows a rotation speed of 0.28 seconds like the SOMATOM Definition Flash. This reduces motion significantly and offers cardiologists like Hausleiter a solution for precisely imaging a beating heart. The new detector generation is also perfectly suited for the acute care setting. One of the many clinical advantages offered by the SOMATOM Definition Flash and SOMATOM Definition Edge is SAFIRE 3 (Sinogram Affirmed Iterative Reconstruction). SAFIRE is a method of raw databased iterative reconstruction that reduces noise so precisely, that dose can be reduced by up to 60%, without compromising the image quality. When you decrease the dose or improve the resolution, explains Nicolaou, it inherently leads to an increase in noise. With iterative reconstruction, we can potentially reduce the dose while having the advantage of improved image quality. This is critical when it comes to imaging vital structures in the body. The minimized noise level of the Stellar Detector and the technology of SAFIRE are the perfect match for ultra-low dose high resolution imaging, eliminating the contradiction of outstanding image quality with minimal dose. The Stellar Detector may be ideal for bariatric imaging, where obese patients may attenuate a large portion of the signal, often resulting in a signal that is too low for diagnosis. By eliminating electronic noise, the signal-to-noise ratio (SNR) can be increased, giving it much more flexibility to handle low signals. The system s TrueSignal Technology significantly minimizes electronic noise in the detector and the resulting SNR at low signal levels is increased, so that even very low signals are sufficiently strong for the detector to pick up. Lowsignal images benefit from increased clarity, because the detector can now 10 SOMATOM Sessions November

11 Cover Story With fast image acquisition, good diagnostic image quality, and high spatial resolution, the SOMATOM Definition Edge enables radiologists to provide an accurate diagnosis, especially within the critical golden hour. differentiate the diagnostic information of an individual voxel much better compared to the surrounding image data. Especially bariatric patients are often at a higher risk for heart disease, stroke and high blood pressure, and these conditions must be evaluated safely, even in these challenging patients. I expect that this technology will help us with noise reduction, especially in obese patients, says Hausleiter. Additionally, Dual Energy becomes available for Single Source CT imaging with the SOMATOM Definition Edge. With the novel capabilities of the Stellar Detector and the dose-optimized, Single Source Dual Energy scan mode, the Definition Edge enables doctors to add tissue characteristics to morphology, allowing for the specification of formerly unspecific information for a higher diagnostic outcome. Inspiring confidence Radiologists and cardiologists across the world have spoken, and Siemens has answered with the Stellar Detector in the SOMATOM Definition Flash and in the new SOMATOM Definition Edge. The new detector generation provides the solutions that radiologists in acute care, cardiology and other fields have been looking for, with improved spatial resolution, reduced noise in obese patients, improved soft tissue characterization, and improved image quality in low signal examinations. When these features are added together, the new detector may allow radiologists and cardiologists to be more secure in their diagnoses. I expect that it will give me more confidence in my diagnoses and when deciding if a patient has advanced disease or minimal disease, says Hausleiter. With the development of the Stellar Detector, Siemens has once again looked into the future and brought cuttingedge technology to the present. The future of radiology is heading toward optimizing low-dose imaging while maintaining or even improving diagnostic image quality, says Nicolaou. This technology will allow us to do both: providing excellent diagnostic images at extremely low-dose radiation with SAFIRE s iterative reconstruction and the new Stellar Detector. Amy K. Erickson is a widely published medical journalist with more than a decade of experience in the health and biotech industries. Based in the San Francisco bay area, Amy s work has appeared in numerous publications including Nature Medicine, Cure magazine, the Washington Post and CNN.com. SOMATOM-Definition-Edge 1 Under development. Not available for sale in the U.S. 2 Under FDA review. Not available for sale in the U.S. 3 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. In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task. The following test method was used to determine a 60% dose reduction when using the SAFIRE reconstruction software. Noise, CT numbers, homogenity, low-contrast resolution and high contrast resolution were assessed in a Gammex 438 phantom. Low dose data reconstructed with SAFIRE showed the same image quality compared to full dose data based on this test. Data on file. SOMATOM Sessions November

12 News syngo.via: New Clinical Opportunities with Brand new CT Software Applications 1 By Susanne Hölzer, Philip Stenner, PhD, Jochen Dormeier, MD, Karin Barthel Computed Tomography, Siemens Healthcare, Forchheim, Germany With the launch of a new syngo.via 1 version at the RSNA 2011, Siemens is opening a new era for routine diagnostics in CT imaging. With four additional CT workflows, six freshened-up Dual Energy applications, and many other additional helpful features and applications, even for other imaging modalities, it is designed to further diagnostic speed and accuracy. Dual Energy Going beyond visualization The SOMATOM Definition Flash has brought Dual Energy examination into routine clinical practice and has shown the diagnostic benefits of going beyond visualization. With the new version the basic functionality of syngo.via has been enriched with well-established features such as Optimum Contrast for automatically calculating contrast-optimized images and a new Dual Energy applications now available on syngo.via: syngo.ct DE Lung Analysis syngo.ct DE Heart PBV syngo.ct DE Calculi Characterization syngo.ct DE Brain Hemorrhage syngo.ct DE Virtual Unenhanced syngo.ct DE Direct Angio functionality for generating monoenergetic images at a range of kev to optimize the image quality. Furthermore the assessment of kidney stones is facilitated with the new syngo.ct DE Calculi Characterization. The Siemens unique Kidney Stone Navigator makes it easy to navigate through findings without scrolling through the whole volume. Another new application syngo.ct DE Lung Analysis utilizes Siemens unique Dual Source Dual Energy data for simultane- ous assessment of both pulmonary function and of the lung vessels. After the evaluation all diagnostic information is being displayed in one view, allowing pulmonary embolism to be ruled out. Cardiovascular CT accuracy for TAVI planning and boosted sensitivity in triple rule-out examinations Aortic stenosis is one of the most common forms of cardiovascular valve disorder. It is conventionally treated by replacing the aortic valve with an artificial valve through invasive open chest surgery. However, patients affected usually suffer from several co-morbidities and are therefore denied surgery. Since a couple of years, these patients may undergo a minimally invasive replacement of the aortic valve, known as transcatheter aortic valve implantation (TAVI). Crucial for a successful TAVI procedure syngo.ct DE Lung Analysis in syngo.via 2 Curved planar reformations of the aorta and iliac arteries facilitate the assessment of the vessel diameters for pre-procedural TAVI planning. 12 SOMATOM Sessions November

13 News is accurate pre-procedural planning, where the access path for the catheter is assessed and the optimum device type and size are determined. From now on, the post-processing powers of syngo.ct Vascular Analysis and syngo.ct Cardiac Function will be combined to form a dedicated workflow for streamlined CT TAVI planning. In the first step of this workflow, the smallest possibly detected diameter of the iliac arteries is localized with a single click in syngo.ct Vascular Analysis. Quantification is easily performed with the Stenosis Measurement Tool. The cardiologist can now determine the optimum access route for the catheter. Calcification removal helps radiologists to visualize calcifications in the entire aorta. An accurate assessment of the aortic annulus is crucial for selecting the correct implant. syngo.ct Cardiac Function displays the aortic valve plane with a single click, allowing the short and long axes of the aortic annulus to be measured more quickly. The length of the device is determined by the distances of the coronary ostia, which are obtained in a matter of seconds. Finally, the angulation for the C-arm guided intervention is calculated and can be transferred to the cath lab. Predicting the optimal angulation with CT has been proven to help reducing the amount of contrast agent syngo.via combines all evaluation tools in one single workflow. This is a real advantage because we need less time to evaluate all anatomic structures relevant for the TAVI procedure. Tobias Pflederer, MD, University of Erlangen-Nuremberg, Erlangen, Germany applied in the cath lab by 48%. [1] This streamlined workflow leads to sounder decisions in TAVI planning. Patients exhibiting chest pain in the emergency department often undergo a triple rule-out examination to distinguish between coronary artery disease, aortic dissections, or pulmonary embolisms. The new syngo.via version introduces the new application syngo.ct PE CAD 3 which automatically detects pulmonary filling defects and which may be particularly helpful if no Dual Source Dual Energy data is available. Combined with the CT Coronary and CT Vascular tasks, the workflow CT Chest Pain + PE CAD 3 boosts sensitivity [2] in challenging triple rule-out cases. Improved automated preprocessing in syngo.ct Coronary Analysis is beneficial for such cases. In addition to the main coronaries, major coronary branches and saphenous vein grafts are now also automatically segmented and labeled. Dynamic Vessel Evaluation redefined A great step forward in terms of dynamic vessel evaluation has been made by introducing the new application syngo. CT Dynamic Angio. 2 For stroke patients or patients showing transient ischemic attack symptoms, syngo.ct Dynamic Angio 2 helps to inspect time-resolved CT images reconstructed from dynamic studies. It provides a temporal maximum intensity projection (tmip) and a temporal average volume (tavg) for enhanced vessel and soft tissue visualization. For evaluating local vessel or tissue enhancement, syngo.ct Dynamic Angio displays ROI-specific time attenuation curves, as well as curve and statistical parameters, such as time to peak and peak enhancement. For a phase-specific evaluation, for example of the arterial or venous phase, the Twin Slider can restrict calculation of new CT volumes to any userdefined time range within the dynamic The automated detection of pulmonary filling defects in syngo.ct 4 For an evaluation of local vessel or tissue enhancement, syngo.ct Dynamic PE CAD 3 allows for a safer evaluation of triple rule-out cases. [2] Angio 2 displays ROI-specific time attenuation curves, as well as curve and statistical parameters, such as time to peak and peak enhancement. References [1] T. Pflederer, S. Achenbach, Journal of Cardiovascular Computed Tomography (2010) 4, [2] Blackmon et al., European Radiology, January syngo.via can be used as a stand-alone device or together with a variety of syngo.via-based software options, which are medical devices 2 The information about this product is being provided for planning purposes. The product requires 510(k) review and is not commercially available in the U.S. 3 The product is not commercially available in the U.S.

14 syngo.ct Coronary Analysis now provides zeroclick tracking and labeling of the main coronaries (RCA, LM, CX), major coronary branches, and saphenous vein grafts. 6 The CT Oncology Engine now supports RECIST 1.1 and Choi criteria which add valuable clinical information for correct diagnosis by the radiologist. 7 syngo.ct Pulmo 3D is the new syngo.via application for assessment and therapy monitoring of COPD. Users can define default visualization options, such as the emphysema index display, according to their preferred workflow. scan. This means that the application may also be used for examining the liver, or abdominal aortic stent patency and endovascular leakage. Oncology fully featured and even more applications The new syngo.via version enhances the CT Oncology Engine and CT Oncology Engine Pro packages, as well as adding promising new applications for diagnosis and therapy. Radiologists can now select whether the time-saving automated segmentation algorithms for lung and liver lesions and lymph nodes utilize RECIST 1.0 or 1.1, thanks to added functionality for current oncological standards. Choi criteria are also evaluated and displayed in the report for each lesion. This additional clinical information helps the radiologist to differentiate between progressive disease (PD), stable disease (SD), complete response (CR) and partial response (PR). To facilitate diagnosis of cases with multiple prior examinations, syngo.pet&ct Onco Multi-Timepoint supports simultaneous visualization of up to eight timepoints and synchronous scrolling through all datasets. Especially in cases with many prior examinations and multimodality acquisitions such as PET/CT, radiologists will benefit from keeping track of the complete patient history visually, and the ability to compare these data with the current examination. Even more automation is provided through the improvements in our second reader tools syngo.ct Colonography PEV and syngo.ct Lung CAD both part of the CT Oncology Engine Pro. These tools now provide automated detection of lung nodules or colon polyps with revised algorithms. 3 In addition, syngo.ct Lung CAD now not only detects solitary pulmonary nodules but also partial-solid nodules 3 and ground-glass nodules (GGN). 3 Lung CAD findings are sorted by size in syngo.via s findings navigator. 3 The syngo.ct Colonography Advanced package features the new Stool Removal function, allowing the radiologist to remove residual stool from the visualization in the 3D endoluminal view and multi-planar reconstruction (MPR). By toggling quickly between Stool Removal and the standard display, physicians can

15 News detect potential polyps which might be hidden in residual stool cavities. Two new applications are optional to the CT Oncology Engine. Using the syngo.rt Interface, physicians can register CT or multi-modality datasets such as PET/CT with a radiotherapy planning CT. Segmented lesions, e.g. PET hotspots, can be copied from the diagnostic datasets to the planning CT and be exported as DICOM RT 1 structure sets. This allows accurate functional diagnostic imaging and morphological image processing to be used during radiotherapy planning. syngo.ct Pulmo 3D focuses on clinical assessment and monitoring treatment of chronic obstructive pulmonary disease (COPD). Based on the user s preference, the application provides different automated 3D quantifications for assessment of emphysema and lung airways utilizing non-enhanced CT chest scans. Using spatial details, healthcare professionals can differentiate between emphysemadominant and airway-dominant COPD subtypes, which can be used for planning further treatment, such as lung volume reduction surgery. Overall, the new syngo.via version further supports fast and precise oncological reading and reporting with exciting new features. Significant Dose Reduction with SAFIRE at Wexford General Hospital, Ireland By Tony de Lisa and Tiago Campos* *Computed Tomography, Siemens Healthcare, Forchheim Germany Wexford General Hospital serves a population in excess of 135,000 in County Wexford, Ireland. Recently replaced their 10-year-old 4-slice system was replaced with the SOMATOM Definition AS 64 with the FAST CARE platform. The CT team in Wexford has always been dose conscious and the dose reduction techniques available with the new system (especially SAFIRE 1,2 ) have greatly assisted them in achieving substantial reduction in dose. SAFIRE (Sinogram Affirmed Iterative Reconstruction) is the 1st raw data-based iterative reconstruction technique that allows up to 60% reduction in dose while preserving image quality as can be seen in the comparison shown in Fig. 1. Liz D Arcy, CT Clinical Specialist, commented: From day one, the CT team at Wexford decided to test the capabilities of SAFIRE in terms of image quality, workflow, and dose reduction. Our immediate finding was that the fast reconstruction speed and the ease of use meant no effect on throughput or workflow when compared to FBP. Our next step was to select an image quality acceptable to our consultant radiologists while continuing to reduce the dose. Neurological head scans are often regarded as a benchmark for diagnostic value in CT. The consultant radiologists have been very pleased with both the We have seen a very impressive reduction in dose. With SAFIRE we are achieving a very impressive dose reduction of up to 75% dose reduction in head scans (14.74 mgy vs 60 mgy) with excellent image quality. Richard Deignan, MD, Consultant Radiologist 1A 1A Standard WFBP. Standard weighted filtered back projection reconstruction using an H40 kernel. levels of dose and the image quality. Wexford has extended SAFIRE to all examinations and is achieving similar levels of dose reduction across the clinical spectrum. Liz D Arcy: The level of dose reduction is much more significant than we felt possible. The key 1B 1B This image visualizes image quality based on SAFIRE achieved with only mgy. Significantly decreased image noise without loss of resolution or gray-white matter differentiation can be seen. point is that we can, and do, use SAFIRE in our normal daily clinical routine, not just for special cases. Therefore the total CT dose to our patient population has fallen substantially. Tony de Lisa is an external writer based in Nuremberg, Germany. 1 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. 2 In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultationwith a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task. The following test method was used to determine a 60% dose reduction when using the SAFIRE reconstruction software. Noise, CT numbers, homogenity, low-contrast resolution and high contrast resolution were assessed in a Gammex 438 phantom. Low dose data reconstructed with SAFIRE showed the same image quality compared to full dose data based on this test. Data on file. 15

16 News Boosting Cardiovascular Reading with syngo.via at this Year s CTA Academy At SCCT 2011, syngo.via facilitated the evaluation of ccta and invasive angiography data sets. Philip Stenner, PhD, Computed Tomography, Siemens Healthcare, Forchheim, Germany During the SCCT CTA Academy Stephan Achenbach, MD, Gießen, Germany and John Lesser, MD, Minneapolis, USA offered expert hands-on training to interested physicians. Based on last year s huge success, the Society of Cardiovascular Computed Tomography (SCCT) has again organized a CTA Academy to train cardiovascular reading in The program is aimed at both radiologists and cardiologists, and provides a unique opportunity to practice the evaluation of coronary CT Angiography (ccta) data sets with an international expert faculty. This year s Academy comprises five courses, of which the most recent was held at the annual meeting of the SCCT in Denver, CO, USA. Stephan Achenbach, MD, from the Department of Cardiology at the University of Gießen, Germany, and John Lesser, MD, from the Minneapolis Heart Institute in Minneapolis, MN, USA, teamed up to teach this two-day course and offered expert hands-on training for the 20 cardiologists taking part. To assess the cctas and invasive angiography images, 11 workplaces had been equipped with syngo.via clients provided. In addition to the basic reading functionalities, the CT Cardio-Vascular Engine enabled the participants to evaluate the cases with advanced functionalities such as automatically generated center lines, curved planar reformations (CPR), and the image sharpening filter. To make full use of syngo.via s dual monitor support, all workplaces were equipped with two monitors and the presenter s screen was shown with a dualprojector set-up. The participants improved their cardiovascular reading skills by evaluating 50 ccta data sets, I have to say that the advanced functions, such as the curved planar reconstructions, are extremely stable and the results are really good and reliable. Stephan Achenbach, MD, Department of Cardiology, University of Gießen, Germany and verified their diagnoses with the corresponding invasive angiography images for each case. The main goal is really to learn how to interpret cardiac CT extremely carefully, look for the difficult findings, and cope even with difficult situations such as severe calcifications says Achenbach. According to him, the biggest challenge of this course was the mixed level of experience, as both beginners and experienced readers worked on the cases. What Achenbach likes about syngo.via is the ease of use which allowed the beginners to quickly catch on and immediately get started with cardiovascular reading. He further states with regard to syngo.via: I have to say that the advanced functions, such as the curved 16 SOMATOM Sessions November

17 News planar reconstructions, are extremely stable now and the results are really good and reliable. Quynh Truong, MD MPH, from the Division of Cardiology at Massachusetts General Hospital in Boston, MA, USA, who also helped the participants with reading the cases, believes this course to be a good opportunity to gain experience. Since the volume of CT scans being performed is fairly low at some participants institutions, it is important to practice on CT and cath correlations in order to maintain the required competency level. One of the participants, Cristiana Scridon, MD, from the Indian River Medical Center in Vero Beach, Fl, USA, already I am typically not a big advocate of curved planar reformations (CPR), but this workstation actually does a really good job of outlining the CPRs. Quynh Truong, MD MPH, Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA attended a previous CTA Academy. Her main goal was to learn from the experts and refresh her skills in cardiovascular reading. With regard to syngo.via, she states that Practically everything works very well and it s very smooth. The measurements go easily, and the adjustment of the image is easy to make. So it s great. Will she be coming again? Absolutely every year! Stroke Management Education and Information Exchange Online By Monika Demuth, PhD, Computed Tomography, Siemens Healthcare, Forchheim, Germany Siemens Healthcare has recently launched a new CT stroke management online resource for healthcare professionals. Here, a platform is provided for introducing and discussing new diagnostic opportunities to save brain and quality of life, synergized with information on the latest Siemens CT scanners and post-processing solutions. After a stroke, the brain loses as many neurons as it does in almost 3.6 years of normal aging [1] each hour it remains untreated. Therefore, the need for faster diagnosis and faster treatment is central to effective stroke management. Thanks to a dynamic brain perfusion coverage, Siemens Computed Tomography has clearly improved the stroke workflow and added value to stroke management. The new information platform for stroke management has been published to share these approaches and clinical outcomes. Peter Schramm, MD, from the certified stroke unit at the University of Göttingen, Germany, for example, shares his workflow from the arrival of a stroke patient in the emergency department until the decision for further treatment. In his institution, the door-to-needle time is less than 20 minutes. Furthermore, leading stroke specialists share their experience and protocols in webinars and presentations on the platform. Trial versions for Siemens latest software solutions are available for testing developments in stroke imaging in actual clinical practice. This educational website was launched to improve the knowledge of stroke References [1] Time is brain-quantified. Saver JL. Stroke Jan;37(1): Siemens has launched a CT stroke management website for healthcare professionals. diagnosis with extended brain coverage and is designed to integrate the experiences of physicians worldwide. The online resource can be visited via the following link. CT-stroke- management SOMATOM Sessions November

18 News International CT Image Contest 2011 By Tiago Campos, Computed Tomography, Siemens Healthcare, Forchheim, Germany In 2009, Siemens Healthcare surprised the healthcare industry with an original idea that was well received by the worldwide radiology community, the International CT Image Contest, encouraging radiologists to reduce dose by using CT hardware and software efficiently. Participants submitted their best clinical images achieved at a very low radiation dose according to the contest philosophy Highest diagnostic image quality at the lowest possible radiation dose and shared best practice throughout the industry. The 2010 International CT Image Contest was an extraordinary success, with around 300 submissions from over 30 different countries. On Facebook, the contest attracted over 1,500 fans and page views at the Siemens Low Dose website reached 17,000 between November 2009 and May 2010 alone. Continuing the success This year s contest even beat last year s success with massive 627 submissions from 43 different countries from all 5 continents, showing that low dose practices have no borders. Siemens customers who work with a SOMATOM Spirit, Emotion, Sensation, Definition, Definition AS or Definition Flash were given the opportunity to compete for the title of the best image in seven categories. The submissions were evaluated by an international jury consisting of acknowledged experts in the following categories: Cardiac, Vascular, Dual Energy, Pediatrics, Trauma, Neuro and areas of clinical routine including Thorax, Abdomen Pelvis and Extremities. During the entry phase, members of the jury chose an image each month for the Pick of the Month (Figs. 1 3) which ran from March through September. After entry deadline, a winning image of the highest quality at the lowest radiation dose was chosen from each category. The winners were announced in a ceremony at this year s RSNA in Chicago. 1 To see all of more than the 600 cases from 40 different countries featured in this year s Image Contest, or to become a fan on Facebook, visit the following websites Picture of the Month March Title: Dual Energy Carotid Angio Paraganglioma Author: Joao Carlos Costa, MD, Diagnóstico por Imagem, Lda System: SOMATOM Definition Flash 1 Jury statement: This is a beautiful case example for the use of Dual Energy CT techniques for non-invasive imaging of vessel-related tumors and surgical planning. The low radiation protocol selected and successfully applied here is of particular importance in the investigation of young, otherwise healthy individuals, as in this case. Prof. Uwe Joseph Schoepf, MD Medical University of South Carolina, USA 18 SOMATOM Sessions November The winners were not yet known at editorial deadline.

19 News 2 2 Picture of the Month April Title: SA Compression Stenosis Author: Volodymyr Mytchenok, MD, Poltava Regional Hospital, Ukraine System: SOMATOM Emotion Jury statement: Nice demonstration of functional lesion at a low dose, very illustrative post processing. Prof. Stephan Achenbach, MD University of Giessen, Germany 3 3 Picture of the Month June Title: Aorta Bypass Graft Author: Eder Quadros, MD, Hospital Beneficencia Portuguesa, Sao Paulo, Brazil System: SOMATOM Definition AS Jury statement: Very nice dataset of axillo-bifemoral bypass graft, achieved at a very reasonable dose. Very elegant and tasteful choice of rendering parameters results in visually appealing images! Prof. Dominik Fleischmann, MD Stanford University Medical Center, USA SOMATOM Sessions November

20 News Iterative Reconstruction is Now Available for SOMATOM Emotion and Sensation By Tiago Campos*, Sebastian Vogt, PhD** *Computed Tomography, Siemens Healthcare, Germany **Siemens Medical Solutions USA, Malvern PA, USA Siemens has recently added IRIS (Iterative Reconstruction in Image Space) to its new SOMATOM Emotion 16 scanners, as well as existing SOMATOM Emotion 16 (2007), SOMATOM Sensation 40, 64, and Open systems. Retrofitting this key technology into such a vast installed base emphasizes Siemens commitment to reducing patient dose by updating legacy systems for even better patient care. IRIS is available for these systems for delivery since September One of the largest and most diverse academic medical centers in the United States, the Ohio State University Medical Center (OSUMC) was among the first sites worldwide to evaluate IRIS on the SOMATOM Emotion. Professor Richard D. White, MD, and his team of radiologists welcomed the opportunity of upgrading the OSUMC s installed base of SOMATOM Emotion 16, SOMATOM Sensation 64, SOMATOM Definition AS 64, and SOMATOM Definition AS+ scanners with iterative reconstruction. This represented another important and greatly appreciated form of collaboration with Siemens through investigative interest, positive return-on-investment implications, and image quality gains, and clinical growth potential with market differentiating technologies for OSUMC, remarks Professor White. Although IRIS was not directly installed at OSUMC during the pilot phase, the datasets were reconstructed remotely to assess the feasibility of IRIS compared with weighted filtered back projection 1A 1B 1A Standard WFBP reconstruction using an B41 kernel. Courtesy of Ohio State University Medical Center, Columbus, OH, USA 1B This figure demonstrates the high image quality achieved with IRIS. Image noise is decreased without losing sharpness. Courtesy of Ohio State University Medical Center, Columbus, OH, USA 20 SOMATOM Sessions November

21 News (WFBP). Dozens of datasets were assessed from routine examinations of the head, thorax and abdomen. Experts then analyzed the image quality based on image noise, image quality, dose effectiveness, and lesion conspicuity. OSUMC s team gave positive feedback in all areas of the evaluation, highlighting noise reduction, edge recovery, impressive detail and sharpness among the prominent benefits of IRIS. Professor White concluded that across the board in this pilot project, there was unequivocal gain in image quality thanks to the application of IRIS. Artifact and noise were consistently reduced, while low contrast and edge definition were enhanced, leading to improved visualization of pathology. It is exciting to realize that this can be achieved with significant dose reduction. This is a tremendous advancement! At the time of editorial deadline, OSUMC were already preparing for the installation of IRIS. The Friedrich-Alexander-University of Erlangen-Nuremberg in Germany has also evaluated IRIS. The university currently has a SOMATOM Definition Flash, a SOMATOM Definition AS+, and a SOMATOM Sensation 64. Prof. Michael Lell, MD, was an early adopter of iterative reconstruction when it was initially released on the SOMATOM Definition Flash in 2009, and has also worked with the latest iterative reconstruction method SAFIRE 1 (Sinogram Affirmed Iterative Reconstruction). Although Prof. Michael Lell, MD and his team were already familiar with IRIS, the pilot study provided a good opportunity to assess its performance against the SOMATOM Definition systems. Following the same approach as OSUMC, datasets were reconstructed remotely and compared with conventional WFBP. Multiple patient datasets were reconstructed, focusing on specific examinations, such as cardiac, and routine examinations of the head, thorax and abdomen. Once again, experts rated the images based on image noise, image quality, dose effectiveness, and lesion conspicuity. Lell and his team commented that we highly appreciate that iterative reconstruction, which is fully integrated in our clinical workflow with the SOMATOM Definition scanners, is now available for existing CT systems like our SOMATOM Sensation. The excellent results with IRIS significantly reduce dose while maintaining image quality and lesion conspicuity. [1] With the successful launch of IRIS for the SOMATOM Emotion 16 (2007), SOMATOM Sensation 40, 64, and Open, Siemens, continues its commitment to reducing radiation exposure for all routine CT examinations below 2.4 msv. Bringing IRIS to the SOMATOM Emotion and Sensation offers low dose to the widest possible patient population, says Peter Seitz, Head of Marketing, Computed Tomography, Siemens Healthcare. References [1] May MS, Wüst W, Brand M, Stahl C, Allmendinger T, Schmidt B, Uder M, Lell MM. Dose reduction in abdominal computed tomography: intraindividual comparison of image quality of full-dose standard and half-dose iterative reconstructions with dual-source computed tomography. Invest Radiol Jul; 46(7): The information about this product is being provided for planning purposes. The product requires 510(k) review and is not commercially available in the U.S. 2A 2B 2A Standard WFBP reconstruction using a B40 kernel. Courtesy of Ohio State University Medical Center, Columbus, OH, USA 2B This figure demonstrates the high image quality achieved with IRIS. An improved image noise and better delineation of the liver lesion can be achieved compared to Fig. 2A. Courtesy of Ohio State University Medical Center, Columbus, OH, USA SOMATOM Sessions November

22 News FAST CARE Meets DSCT Technology platform FAST CARE is now also compatible with the Dual Source scanner SOMATOM Definition, giving CT users the opportunity to leverage untapped potential in patient-centric productivity. By Ingrid Horn, PhD Over SOMATOM Definition scanners have been installed globally since 2006, and are located in both community and university hospitals. Besides its utilization in diagnostic imaging centers, the scanner is deployed primarily in cardiology departments and emergency centers. A convincing technical concept is at the root of many modern success stories in the field. This one is called Dual Source. Simultaneous scanning with two X-ray tubes convinces in the case of cardiac CT, for example, providing high diagnostic accuracy irrespective of heart rate, without the use of beta blockers and with a radiation dose 50 percent lower than the norm. Combined with the Dual Energy principle, tissue and deposits can be characterized chemically by selecting different voltages for the two X-ray tubes. The device proves particularly efficient in emergency cases, facilitating a comprehensive, reliable diagnosis in a single examination procedure, irrespective of the patient s constitution and condition. The benefits of Dual Source Technology can now be combined with those of the FAST CARE platform. The Fully Assisting Scanner Technologies (FAST) make timeconsuming and complex procedures faster as well as far more intuitive. This ensures that the results remain reliably reproducible even in the event of a rotational workforce. FAST Planning simplifies the preparation of scan and recon ranges. Be it heart, lungs, spinal column or brain one click suffices to automatically adjust the optimal scan range on the basis of anatomical landmarks. This not only eases the workflow at the scanner, but prevents inaccurate setting of scan ranges and higher reproducibility of similar examinations. FAST Cardio Wizard gives users a step-by-step guide to cardiac scanning. The program provides guidance on the optimal choice of parameters and settings and allows The benefits of SOMATOM Definition's Dual Source Technology can now be combined with those of the FAST CARE platform. establishing individual quality standards. FAST Spine facilitates a fully automated preparation for reconstructions of the spinal column. The program identifies and marks each vertebra and disc within the scan range automatically, and alignes the reconstruction layers anatomically correct along the curvature of the spine. FAST Adjust guarantees safe scan parameter adjustment to the patient s habitus, even by less experienced personnel. The CARE software package reduces radiation dose considerably. Several publications have already scientifically proven that a potential reduction of up to 50 percent is possible. This is due principally to CARE kv. The program sets the appropriate kv for the selected examination type and thus optimizes radiation dose in line with pertinent diagnostic issues and the patient s anatomy. Other programs, including the CARE Dose Configurator, support this optimization process and make it transparent for users. Together with FAST CARE. SAFIRE 2 was introduced, joining the latest generation of iterative image reconstruction. Departments equipped with the SOMATOM Definition can retrofit their device with FAST CARE. Everyone the hospital enterprise, personnel and patients benefits from the advantages of this upgrade. Ingrid Horn, PhD, studied biology and biochemistry. She is an expert in science communications and an experienced medical writer. 1 Based on the number of systems sold. Data on file. 2 The information about this product is being provided for planning purposes. The product requires 510(k) review and is not commercially available in the U.S. 22 SOMATOM Sessions November

23 News High-End CT is on the Move With the introduction of the SOMATOM Definition AS in 2007, Siemens began a unprecedented success story. Now, Siemens is moving onto the next chapter of this success story with new sliding gantry configurations for the SOMATOM Definition AS. By Jan Freund, Computed Tomography, Siemens Healthcare, Forchheim, Germany The SOMATOM Definition AS with sliding gantry adds a new dimension in flexibility. Following its release in 2007, the SOMATOM Definition AS the world s first adaptive scanner was already in a class of its own. As the first CT scanner offering true 128-slice acquisition, it pushed the boundaries of CT imaging, providing new diagnostic options, including high-speed and high-resolution examinations, as well as 3D-guided CT interventions. In 2010, FAST CARE was introduced on the SOMATOM Definition AS, making it the ideal choice to increase patientcentric productivity. Being fully onsite upgradeable from 20 up to 128 slices, customers could tailor the system perfectly to their environment, and for example grow from routine to cardiac or acute care imaging. With over 1,500 systems installed, the SOMATOM Definition AS resembles the fastest ramp up in the history of Siemens CT. Clearly, the philosophy of offering one CT for all has shown to be the right answer to CT users requirements. In 2011, Siemens continues to evolve this success by adding a sliding gantry option to the SOMATOM Definition AS. Mounting a CT scanner on rails for moving it to a specific clinical area, such as acute care or between radiology and radiation therapy planning (RTP) departments is not a new idea. But the previous scanner generation considered midrange or even entry-level today. Now also the latest high-end CT scanner generation is back on rails. Customers have already benefited from the highest standards of flexibility with the SOMATOM Definition AS and the sliding gantry now allows the scanner to literally move in line with their clinical needs. The benefits are obvious: Clinical set-ups and processes can be designed much more efficiently. In acute care, the patient does not have to be transferred to the scanner anymore the scanner can be moved to the patient. Furthermore, institutions with RTP departments that do not utilize the full capacity of the system due to low patient volume can share resources with conventional radiology. The SOMATOM Definition AS sliding gantry will be available as a single-room and all AS scanner solution at the end of 2011 for all scanner configurations. SOMATOM Sessions November

24 News CT Examinations Tailored Precisely to Individual Patient Needs Individual patient characteristics and the clinical question need to be considered when choosing parameters and settings for a CT examination. The latest scientific papers [1-4] clearly demonstrate that SOMATOM scanners ensure CT scans are tailored to individual patient needs. By Heidrun Endt, MD, Computed Tomography, Siemens Healthcare, Forchheim, Germany. In the past few years, many new technologies have been introduced in computed tomography for increasingly automatic and individual settings of CT scan procedures. CARE kv tube voltage tailored for each examination CARE kv is one of these new technologies. With CARE kv the tube voltage is adjusted automatically depending on the clinical question on a per-patient basis. Researchers from Zurich, Switzerland, conducted a study for body CT Angiography (CTA) examinations using CARE kv on a SOMATOM Definition AS 64. [1] In the study 40 patients were examined and the reference setting for the tube voltage was set to 120 kv. CARE kv suggested the tube voltage for each scan based on the examination type and the topogram. This produced the following kv settings: 80 kv (1 patient), 100 kv (23 patients), 120 kv (15 patients), and 140 kv (1 patient). When changing the kv, the tube current must also be adjusted. As CARE kv works in combination with CARE Dose4D, this could be achieved simultaneously and automatically.throughout the study image quality was maintained, and applying CARE kv led to an overall dose reduction of 25.1% in the entire patient population, compared to a standard 120 kv protocol. The mean CTDI vol decreased from 10.6 mgy to 7.9 mgy. For the subgroup of 24 patients where the tube voltage was reduced to either 80 kv or 1 1 Fig. 1 shows a CT Angiography examination with the SOMATOM Definition AS 64 in an 82-year-old patient after endovascular aortic aneurysm repair. The scan was obtained using CARE kv and 120 kv was chosen as reference kv setting. As the patient had a low body mass index of 19 kg/m² CARE kv proposed 80 kv for this examination. The scan could be carried out with a CTDI vol of 2.88 mgy and 2.7 msv effective dose. Courtesy of University Hospital Zurich, Switzerland 24 SOMATOM Sessions November

25 2A 2B 2 Fig. 2A shows a coronary CT Angiography examination with the SOMATOM Definition Flash from the study conducted at MUSC. The reconstruction was done using FBP. For image 2B data from one tube of the Dual Source system were used corresponding to a 50% reduction in dose. With SAFIRE image quality is maintained in Fig. 2B and blooming artifacts could be reduced allowing for a more precise diagnosis. Courtesy of Medical University of South Carolina, USA 100 kv, the dose reduction was 39.3%. The authors conclude that they [ ] could demonstrate the beneficial effect of this technique for body CTA [ ]. [1] SAFIRE 1 designed to reduce radiation dose for every patient Radiation dose should always be considered when performing a CT examination, as the benefit to potential risk ratio should be as high as possible. Iterative reconstruction algorithms such as IRIS and SAFIRE 1 are powerful tools for reducing dose and following the ALARA (As Low As Reasonably Achievable) principle. An international group of researchers evaluated the potential of SAFIRE for coronary CTA examinations at the Medical University of South Carolina (MUSC). [2] In this study 65 patients were examined with a SOMATOM Definition Flash. The examinations were obtained with the protocols established at MUSC. The first reconstruction used the conventional method of filtered back projection (FBP). Afterwards, a second reconstruction with SAFIRE was performed using data from one tube of the Dual Source system, corresponding to a 50% reduction in radiation dose. When applying new reconstruction algorithms the diagnostic accuracy must be taken into account. Both reconstructions and coronary catheter angiography examinations were used for the assessment of diagnostic accuracy. The results show that [...] the application of this algorithm resulted in incrementally improved diagnostic accuracy for stenosis detection, [2] despite the lower dose that was used. The obese patient population of this study had a mean body mass index of 32.4 kg / m 2. The CT scans were acquired in either retrospectively-gated mode or prospectivelytriggered mode. The effective dose was 6.4 msv for FBP, and 3.2 msv for reconstructions with SAFIRE. Overall, the authors conclude that the results indicate [ ] the potential for substantial radiation dose savings [ ], which likely exceed the 50% margin set forth in this current investigation. [2] At the University Hospital in Zurich, [3] 25 patients underwent a body CTA examination on a SOMATOM Definition Flash. The data were reconstructed twice: once using FBP and once with SAFIRE. As above, only data acquired with one of the two tubes were analyzed for the SAFIRE reconstructions. By comparing two reconstructions of the examination with different reconstruction techniques, the researchers could determine diagnostic accuracy. A key finding of the study includes the following statement: In body CTA a dose reduction of >50% might be possible when using raw databased iterative reconstructions, while image quality can be maintained. [3] TAVI planning less contrast agent for multimorbid patients Transcatheter aortic valve implantation (TAVI) is an emerging technique and provides an alternative for patients who need a replacement of the aortic valve but cannot be referred to open surgery because of other pre-existing diseases. Whether a patient is suitable for TAVI needs to be decided based on the anatomy of the aortic root and the vessels used to gain access for the procedure. The amount of contrast agent is an important issue as many multimorbid patients suffer from an impaired renal function. An interdisciplinary group of researchers from Erlangen examined the potential of CT scans in 42 patients using the high-pitch mode on the SOMATOM Definition Flash with 40 ml of contrast agent. [4] The mean radiation dose for these examinations was 4.5 msv. The conclusion highlights the benefits: High-pitch spiral DSCTA [Dual Source CT Angiography] can be used to assess the entire aorta and iliac arteries in TAVI candidates with a low volume of contrast agent while preserving diagnostic image quality. [4] These scientific papers prove the benefits of innovative CT technology in contributing to individualized patient care. References [1] Winklehner A et al. Automated Attenuation- Based Tube Potential Selection for Thoracoabdominal Computed Tomography Angiography: Improved Dose Effectiveness. Invest Radiol Jul 1. [Epub ahead of print] [2] Moscariello A et al. Coronary CT angiography: image quality, diagnostic accuracy, and potential for radiation dose reduction using a novel iterative image reconstruction technique-comparison with traditional filtered back projection. Eur Radiol Oct;21(10): Epub 2011 May 25. [3] Winklehner A et al. Raw data-based iterative reconstruction in body CTA: evaluation of radiation dose saving potential. Eur Radiol Aug 6. [Epub ahead of print] [4] Wuest W et al. Dual source multidetector CTangiography before Transcatheter Aortic Valve Implantation (TAVI) using a high-pitch spiral acquisition mode. Eur Radiol Aug 17. [Epub ahead of print] 1 The information about this product is being provided for planning purposes. The product requires 510(k) review and is not commercially available in the U.S. SOMATOM Sessions November

26 Business Value Added Max About to debut in Hamburg, a scanner for an optimized return on investment: Get ready for the new SOMATOM Perspective. 1 By Eric Johnson What a difference a few years make. Since he began practicing radiology in 1994, Johann-C. Steffens, MD, has watched an astonishing improvement in computed tomography. The speed at which images are generated, the number of images per scan, the resolution of those images, their orientations, the elimination of artifacts all of these have progressed far beyond what could have been imagined at the time. Based on experience, I m sure CT performance will continue to improve, he says, but it has already reached a level that was still in our dreams only a few years ago. Soon those dreams will become reality for Steffens, when his Radiology Clinic in Hamburg (see sidebar) takes delivery of Siemens SOMATOM Perspective 1. This CT promises not only the latest innovations that deliver speed, quality, and efficient workflow to the people in scrubs and gowns the radiologists, operators, and patients. It also offers incentives to those in business suits the business and financial managers of radiology practices. The magic word starts with an e, for efficiency. Johann-C. Steffens, MD, Radiology Clinic in Hamburg, Germany, has watched an astonishing improvement in computed tomography during the past few years. Savings in your hands Steffens is quick to point out that cost consciousness has soared in recent years. Even in relatively prosperous Germany, he notes that spending is getting tighter and tighter, reimbursements are shrinking and shrinking. At his own clinic, the budgeting pencil is always kept sharp. More than ever before, he says, we are really keen 26 SOMATOM Sessions November

27 Business to assess costs and benefits of everything we do. Of course, Steffens is not alone. Witness a recent letter to the New England Journal of Medicine (2010; 363: ) by a trio of professors from Stanford University s School of Medicine. Physicians have a near-universal ignorance of actual costs associated with the delivery of medical care, contended Homero Rivas, John M. Morton, and Thomas M. Krummel. This lack of cost awareness affects all other components of the price equation, rendering us incapable of understanding the true economic value of medical care. With that kind of writing on the wall, it might seem a no-brainer to guess what Steffens chose to do about his current CT, an Emotion 16 from Siemens that he describes as very good, pretty much faultless. But rather than deciding to cut spending, instead he opted to cut a check. By bringing in a brandnew SOMATOM Perspective (which will be his fourth scanner from Siemens), he expects to sink the clinic s total cost of ownership (TCO) in computed tomography. Economy is so central to the new scanner that it is built right into its dashboard. The so-called emode allows operation of the scanner in an outstanding patient-friendly and financially-efficient way with a single click. An analysis of the scan is made in real time and the system is instantly fine-tuned to provide the exact scan the user wants, while simultaneously reducing wear and tear on the system. Coupled with this is a new service plus approach from Siemens: for customers who run the SOMATOM Perspective in emode for more than 80 percent of its operating time the institution will be rewarded with emode Service Benefits such as maintenance scheduling out of core working time or even a reduction of service fees for the next contracted year. We think our costs of maintenance are going to decline, says Steffens, and that is a good thing to see. By bringing in a brand-new SOMATOM Perspective, Johann-C. Steffens, MD, expects to sink the clinic s total cost of ownership in computed tomography. The new SOMATOM Perspective CT scanner Options Interleaved Volume Reconstruction (IVR) emode emode Service Benefits SAFIRE 2 (Iterative Reconstruction) itrim Lower waste heat and electricity Illumination Moodlight TM Small footprint, 18.5 m 2 Ultra Fast Ceramic (UFC ) Detector Benefit 128 slices to improve spatial resolution Efficient scanner usage with automated parameter setting Consequent emode usage will be rewarded with valuable emode Service Benefits Dose reduction and superior image quality Improved temporal resolution for cardiac imaging Cuts electric and air-conditioning bills Comfortable scanning environment Easy installation in one day. Leaves more valuable, clinical space available Better images from less radiation 1 Under FDA review. Not available for sale in the U.S. 2 The information about this product is being provided for planning purposes. The product requires 510(k) review and is not commercially available in the U.S. 27

28 Business And there will be other efficiencies and savings. Thanks to emode's automated approach to scanning, scan parameters will be automatically adjusted with a clear focus on efficient scanner usage. Operating costs will also be reduced. The SOMATOM Perspective s 1 small size a footprint of 18.5 square meters takes up less clinical space, and allows it to be fully installed in just one day. It consumes less power and radiates less Israelitisches Krankenhaus Together with three other physicians and ten support staff, Johann-C. Steffens, MD. Treats some 10,000 patients each year at the Radiology Clinic of the Israelitsches Krankenhaus in Hamburg, Germany. A relatively small operation in a metro area of some 4 million residents, about half of its patients come from the hospital, which specializes in gastroenterology, while the other half comprises ambulant cases of all types. Run as a private practice since 2004, the clinic uses computer tomography for intracranial, cervical, thoracic, abdominal, and extremities examinations. heat than most scanners, which in turn cuts bills for electricity and air-conditioning. A look at the technology In the SOMATOM Perspective, costconsciousness is combined with a full palette of features. It incorporates Siemens technologies that provide speed and quality at low-dosage. The SOMATOM Perspective can be equipped with Siemens innovative itrim to increase temporal resolution as low as 195 milliseconds for cardiac imaging, thereby reducing motion artifacts. This novel iterative image reconstruction algorithm improves the overall image quality and reduces image noise for obtaining accurate diagnosis in demanding situations, for example, in rapidly beating hearts. Then there is the Interleaved Volume Reconstruction (IVR) to detect even the smallest diagnostic detail by using the information of 128 slices, which for Steffens s clinic will be a major step up from its current 16-slice model. Thanks to this and itrim, the SOMATOM Perspective is suited for any clinical field including cardiac studies. In addition, the scanner can acquire longer scan ranges in a shorter period of time, for example 50 centimeter scan coverage at highest image quality in only 5.2 seconds. Dose reduction, also a key feature, comes to the SOMATOM Perspective as a trifecta. One element of this is CARE Dose4D that adapts the X-ray tube current for the entire scan range, aiming for constant image quality for all organs, patient shapes, and sizes all in real time. It overcomes the most common challenges in CT imaging that arise because: a) the applied dose in antero posterior and lateral positions need to be different; b) each slice needs different dose values; and c) patients are quite heterogeneous (young/elderly, small/large), so the applied dose must vary according to the individual patient. The second element of dose reduction is the use of Iterative Reconstruction (IR). Until recently, to use IR with CT imaging in conventional clinical medicine was too time-consuming: the computer took too long to reconstruct the images. With SAFIRE 2 (Sinogram Affirmed Iterative Reconstruction), Siemens introduced the industry s first raw data-based iterative reconstruction algorithm. SAFIRE achieves up to 60 percent dose reduction for a wide range 28 SOMATOM Sessions November

29 Business We think our costs of maintenance are going to decline, and that is a good thing to see. Johann-C. Steffens, MD, Radiology Clinic of Israelitisches Krankenhaus, Hamburg, Germany of applications and delivers superior image quality. Due to an excellent reconstruction speed of up to 15 images per second, SOMATOM Perspective allows SAFIRE in daily routine. The third element in dose-reduction comes from Ultra Fast Ceramic (UFC ) Detectors, which already have become a key feature in CTs that predate the SOMATOM Perspective. UFCs ensure smaller X-ray doses and still radiate with high luminance. So they outperform conventional detectors, which require more radiation to generate an equal-quality image. breath, he notes, and fewer scans are required. All in all, he says, the SOMATOM Perspective adds serious value to his clinic s offering. We ll offer CT scans that are faster, better, with less radiation and not least, more patient comfort. Eric Johnson, based in Zurich, Switzerland, writes about technology, science, and business. SOMATOM-Perspective Inside job Alongside features that optimize cost and maximize performance, the SOMATOM Perspective also has a perspective for those who use it every day, the operators and patients. For the former, ease your workday accessories are standard, such as FAST Adjust, Workstream 4D, a storage box and a fast reconstruction speed with up to 20 images per second. For patients the ultimate end-users the SOMATOM Perspective provides more comfort. Its gantry can be equipped with an Illumination Moodlight TM, which helps to banish the sterile, clinical look and feel of most examination rooms. Beyond that, says Steffens, the SOMATOM Perspective s speed and accuracy makes life easier for patients. They spend less time holding their The SOMATOM Perspective can acquire longer scan ranges in a shorter period of time, for example 50 centimeter scan coverage at highest image quality in only 5.2 seconds. 1 Under FDA review. Not available for sale in the U.S. 2 The information about this product is being provided for planning purposes. The product requires 510(k) review and is not commercially available in the U.S.. SOMATOM Sessions November

30 Business Accelerated Cardiovascular Assessment Powered by syngo.via SOMATOM Definition Flash and syngo.via 1 ensure fast workflows and efficient image management for cardiovascular reading. By Ruth Wissler, MD Specialists at the Cardiology Department of Aarhus University Hospital, Skejby, Denmark and the Department of Radiology, University of Brescia, Italy, appreciate the user-friendly and efficient reading system in their daily cardiac imaging and therapy routines. The Cardiology Department at Aarhus University Hospital has seven angio suites and performs between 2,500 and 3,000 cardiovascular readings per year with the SOMATOM Definition Flash. A five-license configuration allows simultaneous access to syngo.via in the scanner and the PACS reading room for streamlined cardiovascular evaluations. With a three-license syngo.via configuration and the SOMATOM Definition Flash, the Department of Radiology at the University of Brescia performs at least 20 to 25 vascular, coronary and oncological scans per day. With accelerated automated pre-processing, syngo.via reduces the time needed for full cardiac assessment or aortic stent planning. As soon as a cardiac case is opened, automatically pre-processed images are displayed, and the coronary vessels, the functional parameters, and the prepared calcium score can be evaluated immediately. Robust functional assessment Morten Bøttcher, MD, PhD, (Cardiology Department at Aarhus University Hospital), particularly appreciates the quick overall cardiac assessment, the accurate detection of ventricular borders, and the For functional imaging the important thing is to detect the (ventricular) borders. And syngo.via does that really well. Morten Bøttcher, MD, PhD, Aarhus University Hospital, Skejby, Denmark syngo.via is an excellent tool for planning placement of prosthesis for abdominal aneurysms. Roberto Maroldi, MD, Dept. of Radiology, University of Brescia, Italy precise visualization and rapid quantification of calcified coronary lesions. For functional imaging the important thing is to detect the (ventricular) borders. And syngo.via does that really well, says Bøttcher. The combination of SOMATOM CT s MinDose functionality and the syngo.ct Cardiac Function represent a highly dosesaving symbiosis for assessing complete global and local cardiac function. Fast planning and placement of aortic prosthesis With syngo.via, aortic stent planning is a matter of seconds, says Roberto Maroldi, MD, Head of the Department of Radiology at the University of Brescia. The automatic pre-processing features remove table and rib cage and thus ensure that the case is ready for review when opened. The automatic segmentation, labeling, and calculation of curved planar reformatted images 2 of the aorta, runoffs and renal arteries help to immediately assess the status of the general vessels. The stent planning template guides the user through all measurements necessary for planning of Abdominal Aortic Aneurism (AAA) stents. The specialists experience with the SOMATOM Definition Flash scanner and syngo.via at Aarhus University Hospital Skejby, Denmark and the Department of Radiology, University of Brescia, Italy confirm the unique symbiosis of scanner and software in modern diagnostic imaging and therapy. Ruth Wissler, MD, studied veterinary and human medicine. She is an expert in science communications and medical writing. 1 syngo.via can be used as a stand-alone device or together with a variety of syngo.via-based software options, which are medical devices in their own rights. 2 Available with syngo.ct Vascular Analysis Autotracer

31 Business Minimizing Scan Time Loss with TubeGuard By Tony de Lisa Normally, an automobile owner is not aware that his dealer has checked the profile of his auto s tires at every major service visit. This simple control, that requires only a few minutes to complete, actually delivers a lot of information: are the tires presently safe to use, how much longer before new tires are required (based upon use and driving habits) and what danger points such as split side-walls can be observed that indicate the possibility even probability of a blow-out. An intelligent driver understands that tires are consumable items that are subject to wear and tear and therefore, have a maximum life expectancy. Three factors primarily effect these results, i.e. the quality of the tire manufacture in the first place. the driving habits of the auto owner over time and mileage. At this point, the normal reader would suggest that comparing tires to X-ray tubes such as Siemens STRATON is banal. But is it really? Why not take a three minute diversion from your daily routine and re-read the previous paragraph substituting the word, X-ray tube for tire. This information begs the question, Who would not insist on having this inspection done regularly? At this point, our tire/tube comparison ends. With a flat tire, one mounts the spare tire and resumes driving to the next dealer. But the financial and organizational results of a CT X-ray tube breakdown are enormous in comparison. Just consider a radiology department that does 50 CT scans per day. There a tube breakdown can mean a financial loss that runs into the thousands. One hospital director informs us that Everything must be re-scheduled (in event of a breakdown) including the arrival of a helicopter. And we have not yet dis- cussed the danger to seriously injured or sick patients where time is critical. Rejecting the inevitability of such breakdowns, Siemens scientists and engineers have designed the Guardian Program including TubeGuard for all systems of the SOMATOM Definition family, a remote service that continuously (24/7) monitors ten important functions of the STRATON X-ray tube and warns days in advance of possible breakdowns. A tube replacement can then be scheduled at a time convenient for the hospital if necessary at two or three a.m. causing little or no interruption to the radiology routine the next morning. Siemens promise: With the Guardian Program including Tube- Guard, Siemens will predict nearly all potential tube failures on time. Should it fail a fair compensation policy (as determined in the users home country) takes effect to minimize any scan-time loss incurred. The local Siemens representative will provide more details. Workflow assurance: 1A I was very impressed when Siemens contacted me recommending a tube replacement based on proactive realtime system monitoring with the Siemens Guardian Program including Tube- Guard, said Terakado Hideji, MD, Chief Radiologist, Jichi Medical University 1B If there is any tube malfunction in a SOMATOM Definition scanner (Fig. 1A), TubeGuard, included in the Guardian Program, can detect it proactively (Fig. 1B) and tube replacement can then be scheduled at a time convenient for the hospital. Hospital, Shimotsuke-shi, Tochigi-ken, Japan. This new cutting-edge service enables us to plan the tube replacement at a convenient time based on our clinical workflow. As patients and staff are scheduled accordingly, patient satisfaction can also be significantly increased. Tony de Lisa is an external writer and based in Nuremberg, Germany. SOMATOM Sessions November

32 Business Versatility at High Speed SOMATOM Definition Flash CT scanners are a quantum leap in terms of diagnostic capabilities and patient-safety. At the same time, they offer a uniquely wide range of applications, from sophisticated scientific use to routine work. By Justus Krüger The PUMC Hospital in Peking is among the best and largest medical institutions in China. The hospital was founded in 1921 by the Rockefeller Foundation and is known internationally as the Peking Union Medical College Hospital (PUMC). It has a long tradition of excellence and of serving the public benefit: as a teaching institution, as an outstanding centre of scientific research, and as a clinic for the general public. It houses 1,800 hospital beds; every day, more than 12,000 outpatients go through its gates near Dongdan in the Wangfujing area in downtown Peking. With this throughput of truly enormous proportions, it is not surprising that the patients not only come from the Chinese capital alone. Nor are they exclusively Chinese. Attracting patients from abroad Ours is a university hospital, and our prime considerations are of course social factors, says Professor Jin Zhengyu, MD, who knows the hospital and the city of Peking like the back of his hand. He was born and raised in the Chinese capital, and he studied at the PUMC. What we do here is provide solutions for population-based problems. Yet, the fact that the Xiehe Hospital has a reputation as a technically sophisticated centre of medical excellence attracts patients from far beyond the boundaries of the city and even from abroad. Professor Jin is the Director of the Radiology Department at PUMC Hospital, as well as the doctoral supervisor and Vice Chairman of the Chinese Society of Radiology. People come to our hospital from many different countries, he says. Not only from Asia, but also from all over the world. Part of the global pull exercised by the hospital is its state-ofthe-art radiology department. It goes without saying, that the PUMC Hospital and its radiology department use the best medical equipment available. Part of this is a set of six Siemens CT scanner, including three SOMATOM Definition Flash CTs. Professor Jin is so convinced of the benefits of Flash CT that his hospital has just ordered another one. The optimal diagnosis The reason why Professor Jin and his hospital opted for no less than four Flash CTs is that they offer a variety of advantages over all other CT scanners. They are superior in virtually every respect, ranging from their diagnostic versatility and speed to image accuracy, radiation levels and patient comfort. These two aspects accuracy and patient comfort are really the same thing, says Professor Jin. From my perspective, of course, the imaging capabilities of the equipment usually are the key consideration: you have to be able to make the optimal diagnosis. Whether it s comfortable or not is a second consideration. But in this case, accuracy and patient comfort are internally connected. This is largely due to the scan speed of the renowned Flash Spiral mode. A complete scan of the heart for instance only takes quarter of a second with the Flash Spiral. And still with the Flash, scans can be made at all heart rates without using beta-blockers. Additionally, patients do not need to hold their breath during lung scans. This improves the imaging quality, says Professor Jin, because patients are not able to hold their breath. In such a case, you would get a poor imaging result with a slower scanner. For the same reason the exceptional scanning speed young infants do not need to be sedated when scanned, without compromising the image quality. The high speed of Flash Spiral CT also means a low dose of radiation of below one millisievert in cardiac CT. This is of great benefit for CT heart examinations in younger individuals that are yet still of a lower risk of cardiac disease. In all these respects lung scans without holding the breath, heart scans at all heart rates without the use of beta blockers, the capability to perform a scan on infants without sedation, and radiation levels below one millisievert in daily practice the SOMATOM Definition Flash is the only CT to deliver. A further unique feature of the SOMATOM Definition Flash CT is its capacity in dynamic imaging whole organ perfusion. Covering an area of up to 48 centimeters the Flash offers the longest 4D scan range in the market. We use the Adaptive 4D Spiral for a variety of areas, such as liver-, kidneyand pancreas-perfusion, says Professor 32 SOMATOM Sessions November

33 Business From my perspective, the imaging capabilities of the equipment usually are the key consideration: you have to be able to make the optimal diagnosis. Professor Jin Zhengyu, MD, Peking Union Medical College Hospital, Peking, China Jin. Also, we use it more and more for tumor diagnosis and follow-up studies. Patient safety The lowest exposure to radiation The superior capabilities of Siemens SOMATOM Definition Flash CT is also connected to its Dual Energy approach. By using two tubes instead of one like in conventional CT systems, two datasets at different energy level can be aquired simultaneously. The resulting Dual Energy image adds tissue characteristics to morphological information. But this does not mean patients are exposed to additional dose as all dose-saving techniques are fully utilized. In some applications, the dose is even lower than in conventional scans, when compared to conventional 120 kv examinations. For abdominal applications, for instance, you can use the data from the Dual Energy scan to produce a non-contrast (VNC) image, says Professor Jin. So if you scan only one phase, you can enhance the phase using Dual Energy and thus you can produce two-phase images. That means we have to com- pare the dose of a single Dual Energy scan with that emitted by two separate Single Source CT scans. And in such cases, we remain far below the radiation dose produced by single-energy scanners. From scientific use to medical routine work Low radiation dose combined with superior image quality make the SOMATOM Definition Flash the most versatile CT scanner available. What this means is that we have more diagnostic tools at our disposal than before, says Professor Jin. The result is above all a benefit for the patient. CT neuro imaging, for instance, is very often a matter of life-and-death therapeutic decision-making. SOMATOM Definition Flash provides tools and workflows that help deliver a complete and accurate status of the vascular structures and the brain tissue for these patients from scanning to diagnosis in less than ten minutes. In addition, Flash substantially reduces the necessity for invasive diagnoses. The diagnosis of gout is such a case, as is Flash s capability to visualize chemical differences in kidney stones. Flash CT can reliably identify those patients who can benefit from medical treatment alone and avoid unnecessary interventional procedures. This was an important consideration for us when we purchased Flash scanners, says Professor Jin. Although ultimately it is up to the doctor how to use the tools at his disposal. You can come up with far more applications in practice. It is precisely these benefits for the patient which bring about economical advantages for hospitals and radiologists as well. This is because unnecessary interventions can be singled out and avoided and because the diagnostic superiority and financial efficiency of Flash CT are a powerful argument both for patients and for allocators. This means that due to their unrivaled clinical capabilities, Flash scanners make sense economically as well. So much so that institutions with a large throughput of patients such as the Xiehe Hospital in Peking are opting for several SOMATOM Definition Flash. Thanks to this incomparable versatility, Professor Jin is convinced that the Flash is the best routine scanner available. At the same time, Flash scanners are at the top of the pack when it comes to scientific work, as they cover a wider range of applications than any other device. This makes them superior to other Dual Energy devices, as well as to conventional single source high-end scanners, both for everyday radiological work and for more sophisticated usage. This is really suitable for an extraordinarily wide range of applications, says Professor Jin. Justus Krüger is a freelance journalist based in Hong Kong. He has written for the Financial Times Deutschland, Geo, the South China Morning Post, the Berliner Zeitung, and McK Wissen. SOMATOM Sessions November

34 Clinical Results Cardio-Vascular Case 1 SOMATOM Definition Flash: Ruling out Coronary Artery Disease and Diagnosing Coronary Arteritis with 1.3 msv By J. Matthias Kerl, MD, Martin Beeres, MD, Boris Schell, MD, Thomas J. Vogl, MD, Ralf W. Bauer, MD Department of Diagnostic and Interventional Radiology, Clinic of the Goethe University, Frankfurt, Germany HISTORY A 52-year-old male patient with an intermediate coronary risk profile (cigarette smoking and hypercholesterolemia) was referred to the Department of Radiology on account of two collapses in the past two weeks. Cardiac enzyme-levels were normal. The patient reported transient typical chest pain. The coronary CT Angiography (ccta) was performed with a prospective triggered sequence technique with a mean heart rate of 65 bpm. DIAGNOSIS During ccta, coronary artery disease was excluded as a reason for the atypical chest pain. However, a soft tissue mass was found in the area of the bifurcation of the left coronary artery which also enclosed the proximal and mid part of the left anterior descending coronary artery and the circumflex coronary artery. Additionally, this same soft tissue entity was seen in the mid part of the right coronary artery. After performing curved multiplanar reformations, it was suspected that these soft tissue masses VRT of the left coronary artery shows the soft tissue mass surrounding the vessel (arrow). 2 VRT of the right coronary artery shows the soft tissue mass surrounding the vessel (arrow). 34 SOMATOM Sessions November

35 Cardio-Vascular Clinical Results EXAMINATION PROTOCOL not only enclosed the coronary arteries but also infiltrated them. Based on the findings in the ccta, a biopsy of these masses was performed. The pathological result was a coronary arteritis. COMMENTS Coronary CT Angiography is a wellestablished method to rule out coronary artery disease. The ongoing CT technique development, with doses below 1.5 msv for a complete diagnostic coronary CT Angiography, has helped to implement cardiac CT in the clinical routine. In this case, the cardiac CT allowed the visualization of the soft tissue masses surrounding the coronary arteries as well as establishing the coronary arterial morphology. Scanner Scan area Scan length Scan direction Scan time Tube voltage Tube current Dose modulation CTDI vol DLP Rotation time Pitch Slice collimation Slice width Spatial resolution Reconstruction increment Reconstruction kernel Contrast Volume Flow rate Start delay SOMATOM Definition Flash Heart 17 cm Cranio-caudal 8 s 100 kv with CARE kv 280 mas CARE Dose4D 5.90 mgy 81 mgy cm 0.28 s Sequence 128 x 0.6 mm 0.75 mm 0.33 mm 0.4 mm B26f 80 ml 5 ml/s Test Bolus Curved multiplanar reformations of the bifurcation of the left coronary artery demonstrate enclosure of the coronary artery (arrow). 4 MIP of the bifurcation of the left coronary artery visualizing the narrowing of the left coronary artery and the surrounding soft tissues. SOMATOM Sessions November

36 Clinical Results Cardio-Vascular Case 2 Fast and Precise Imaging of Aortic Intimal Flap Using High Pitch Flash Scan Protocol without ECG-Triggering or -Gating By Garrett Rowe, MD, Joseph U. Schoepf, MD Department of Radiology and Radiologic Science, Medical University of South Carolina, Charlston, SC, USA HISTORY A 55-year-old female patient, with status post aortic arch replacement via redo sternotomy, suffered a complicated postoperative course which included distal embolism with right foot ischemia and significant renal failure. An aortic CTA scan was performed prior and after a thoracoabdominal aneurysm repair, in which an interval descending thoracic aortic graft was placed extending from the proximal descending thoracic aorta to just cranial to the renal arteries. DIAGNOSIS Prior to the thoracoabdominal aneurysm repair, the aortic CTA scan showed evidence of a new intimal flap in the proximal descending thoracic aorta with extensive surrounding intramural hematoma of the aortic arch, a small anterior mediastinal hematoma (Fig. 1) and a small pseudoaneurysm adjacent to the aortic root (Fig. 2). The descending thoracoabdominal aortic aneurysm with a maximum diameter of 5.2 cm at the level of the diaphragmatic hiatus and the extensive formation of wall-adherent thrombus remained (Fig. 1). Other unchanged findings also included aneurysmal dilatation of the innominate artery, subclavian arteries and common iliac arteries, and the tight stenosis of the celiac axis at its origin (Fig. 3) with adjacent wall-adherent thrombus. The renal arteries were normal in caliber with there being three right renal arteries and a single left artery. Of note, the distal most right renal artery originated off the right common iliac artery (Fig. 3). EXAMINATION PROTOCOL Scanner SOMATOM Definition Flash Scanner SOMATOM Definition Flash Study date Jan 11, 2011 Study date Feb 22, 2011 Scan area Thorax Abdomen Scan area Thorax Abdomen Scan length 519 mm Scan length 552 mm Scan direction Cranio-caudal Scan direction Cranio-caudal Scan time 1.2 s Scan time 2.08 s Tube voltage 120 kv / 120 kv Tube voltage 120 kv / 120 kv Tube current 320 mas Tube current 131 mas Dose modulation CARE Dose4D Dose modulation CARE Dose4D CTDI vol 5.5 mgy CTDI vol 7.30 mgy DLP 312 mgy cm DLP 446 mgy cm Rotation time 0.28 s Rotation time 0.28 s Pitch 3.2 Pitch 1.95 Slice collimation 128 x 0.6 mm Slice collimation 128 x 0.6 mm Slice width 1.5 mm Slice width 1.5 mm Reconstruction kernel B30f Reconstruction kernel B30f 36 SOMATOM Sessions November

37 Cardio-Vascular Clinical Results After the interval repair of the descending thoracic aorta dissection, the follow up aortic CTA scan revealed no evidence of complication. The pararenal abdominal aortic aneurysm was without significant interval change and its maximum diameter was reduced to 3.7 cm (Fig. 4). The ascending thoracic aorta and aortic arch repair were unchanged with a small pseudoaneurysm again noted (Fig. 5). The celiac axis and the superior mesenteric arteries appeared to have been reimplanted (Fig. 6). COMMENTS Aortic CTA scanning is routinely applied to demonstrate vascular changes and to help in surgical planning. Previously, one of the challenges was the blurring or double contour effect due to motion artifacts caused by the aortic pulsation which often presented difficulties in visualizing the intimal flaps, especially in the ascending aorta and aortic arch. This was improved when the ECG-gated spiral scanning was introduced. However, it had to be performed at the costs of slower scanning and associated higher radiation dose. A new scanner with a new scanning technique improved that the SOMATOM Definition Flash scanner and its Flash scanning protocols. In this case it provided the possibility of scanning at a pitch of 3.2 (43 cm/s), meaning the acquisition time is dramatically shortened and therefore the temporal resolution is highly increased. This makes the ECGtriggering and -gating unnecessary. In combination with the excellent high contrast resolution provided with the scanner, a fast and precise imaging of the aortic intimal flap is made possible as shown in this case An intimal flap in the proximal descending thoracic aorta (solid arrow) with extensive surrounding intramural hematoma of the aortic arch (arrow head), and the descending thoracoabdominal aortic aneurysm with extensive formation of walladherent thrombus (dashed arrow). 2 A small pseudo-aneurysm adjacent to the aortic root (arrow). 3 A tight stenosis of the celiac axis at its origin (arrow). Three right renal arteries with the most distal originate off the right common iliac artery (arrow head) Abdominal aortic aneurysm after repair. 5 A remaining small pseudo-aneurysm adjacent to the aortic root (arrow). 6 The re-implanted celiac axis and the superior mesenteric arteries. SOMATOM Sessions November

38 Clinical Results Cardio-Vascular Case 3 Flash Scanning of Coronary CTA with just 0.3 msv By Kai Sun, MD, Rui Juan Han, MD, Li Jun Ma, MD, Wang Gang, MD, Li Gang Li, MD Department of Radiology, Baotou Central Hospital, Inner Mongolia, P. R. China HISTORY A 53-year-old male patient, a former smoker with a history of diabetes, was admitted to the hospital with paroxysmal chest distress. ECG revealed a sinus rhythm with no significant ST-T changes. Coronary CTA was performed to rule out cardiac disease. 1A DIAGNOSIS Curved reformation of the obtuse marginal artery demonstrated a severe stenosis in the proximal segment. COMMENTS The second generation of Dual Source CT, the SOMATOM Definition Flash, provides an ultra-fast scanning mode (Flash Spiral mode) using a pitch of 3.4 for coronary CTA examinations. Due to the wider detector width of 38.4 mm, it is now possible to examine the entire heart (128 mm) within one cardiac cycle in a time period of 207 ms. Moreover, the radiation dose has been significantly reduced. There have been reports of coronary CTAs with an effective dose of less than 1 msv. In this case, the Flash mode was applied using 80 kv to further reduce the effective dose to just 0.3 msv. The acquired image quality was excellent to establish the relevant diagnosis. 1 VRT (Fig. 1A) and MIP image (Fig. 1B) show the obtuse marginal artery with severe stenosis (arrows) in the proximal segment. 38 SOMATOM Sessions November

39 Cardio-Vascular Clinical Results EXAMINATION PROTOCOL Scanner SOMATOM Definition Flash Scan area Heart Pitch 3.4 Heart rate 60 bpm Slice collimation 128 x 0.6 mm Scan length 128 mm Slice width 0.75 mm Scan direction Cranio-caudal Spatial resolution 0.33 mm Scan time 0.2 s Reconstruction increment 0.4 mm Tube voltage 80 kv / 80 kv Reconstruction kernel B26f Tube current 312 mas Contrast Dose modulation CARE Dose4D Volume 60 ml CTDI vol 1.43 mgy Flow rate 5 ml/s DLP 22 mgy cm Start delay 8 s Effective dose 0.3 msv Rotation time 0.28 s 1B SOMATOM Sessions November

40 Clinical Results Cardio-Vascular Case 4 Flash Scanning for Pediatric Aortic Abnormalities without Sedation at 0.6 msv By Mannudeep K. Kalra, MD, Brian Ghoshhajra, MD, MBA Department of Radiology, Massachusetts General Hospital, Boston, USA HISTORY A 5-year-old girl was presented with a history of nausea upon exertion. Echocardiography revealed a right sided aortic arch. The patient was referred to cardio vascular CT examination to assess the presence of a vascular ring as a cause of her exertional nausea. helped clinch the diagnosis without the need of sedation. CARE kv and CARE Dose4D techniques applied in the exam helped select the appropriate kv and mas settings automatically to achieve the lowest possible radiation dose of 0.6 msv. Dose reduction for this child started with acquisition of just one AP Topogram at 80 kv and lowest possible tube current of 20 mas. The same low dose setting was also applied to the pre-monitoring and monitoring scans using bolus tracking technique. DIAGNOSIS Cardiac and aortic CT Angiography (CTA) confirmed the right sided aortic arch. In addition, an aberrant retro-esophageal left subclavian artery with a 2.3 cm Kommerell s diverticulum at its origin was displayed. The presence of a small patent ductus arteriosus connecting the diverticulum and the proximal left pulmonary artery indicated a complete vascular ring. The cardiac morphology as well as the origin and course of the coronary arteries showed no abnormality. COMMENTS The cardiovascular CTA was performed with Flash scanning mode triggered by ECG to acquire the entire scan range in 0.43 seconds. The child laughed during scanning, despite instructions to hold her breath and lie still. Her heart rate during scanning varied between 93 and 104 bpm. Despite these distractions, CTA EXAMINATION PROTOCOL Scanner SOMATOM Definition Flash Scan area Thorax Scan length 132 mm Scan direction Cranio-caudal Scan time 0.43 s Tube voltage 80 kv with CARE kv Tube current 200 mas Dose modulation CARE Dose4D CTDI vol 0.80 mgy DLP 15 mgy cm Rotation time 0.28 s Pitch 3.4 Slice collimation 128 x 0.6 mm Slice width 0.75 mm Spatial resolution 0.33 mm Reconstruction increment 0.4 mm Reconstruction kernel B26f Contrast Volume 40 ml Flow rate 2.8 ml/s Start delay 12 s with bolus tracking technique 40 SOMATOM Sessions November

41 1A 1B 1 Lowest possible radiation dose was used as shown in the patient protocol (Fig. 1A) for acquiring monitoring scans (Fig. 1B) in bolus tracking. 2A 2B 2C 2D 2 MPR image shows right-sided aortic arch (arrow, Fig. 2A). MIP (Fig. 2B) and VRT (Fig. 2C) images show a Kommerell s diverticulum (arrow) at the origin of the retroesophageal left subclavian artery. Please also note that there is a complete vascular ring as evidenced by additional presence of a small patent ductus arteriosus (arrowhead, Fig. 2C-2D) between the diverticulum and the left pulmonary artery. SOMATOM Sessions November

42 Clinical Results Oncology Case 5 Examination of a Patient with Lung Cancer with SOMATOM Definition AS Open to Evaluate Treatment and Calculate Dose By Jean Meyskens, MD, Katrien Geboers, MD, Sally Gysbrechts, Medical Physics, MSc, Iwan Scheelen, Medical Physics, MSc Department of Radiation Oncology, AZ Turnhout, Turnhout, Belgium HISTORY A 75-year-old male patient, with known restrictive lung disease, was diagnosed with squamous cell carcinoma ct1 pn0 M0 in December The CT exam showed a coin lesion in the upper lobe of the left lung. The patient was considered medically inoperable and was therefore submitted for radiation therapy. DIAGNOSIS Virtual simulation of the treatment was done with both arms up on a lung board. CT scanning was performed using the Anzai system (CT Respiratory Gating System). An average MidVent (Middle of Ventilation) and 20% phase-based CT images were reconstructed (Fig. 1). Virtual simulation of the treatment isocenter was based on the MidVent image. The average CT image (Fig. 2) 1 was used for dose calculation in the treatment planning system. The GTV (Gross Target Volume) of the lesion and the organs at risk were contoured on the MidVent image (Fig. 3). The breathing-correlated motion of the lesion was defined by the 20% phases, and an ITV (Internal Target Volume) was constructed. After evaluation of the target volume and organs at risk, the patient was considered a good candidate for stereotactic radiotherapy with 3 fractions of 18 Gy administered with an interval of at least 40 hrs (in this case treatment on Wednesday, Friday, and Monday). The treatment was given with coplanar intensity modulated photon beams on a Siemens ARTISTE linear accelerator with MV CBCT (Mega Voltage Cone Beam CT) guidance. The average CT image was used as the reference CT image to directly correct the patient position before the beginning of treatment. The patient subsequently suffered no side effects due to the radiotherapy. EXAMINATION PROTOCOL Scanner Scan mode Scan area Scan length Scan direction Scan time Tube voltage Tube current Rotation time Slice collimation Slice width Reconstruction increment Reconstruction kernel CTDI vol DLP SOMATOM Definition AS Open Thorax Resp Gating Thorax 270 mm Caudo-cranial 80 s 120 kv 40 mas 0.5 s COMMENTS Without respiratory correlated CT images, standard margins for tumor motion have to be used, resulting in a larger target volume. In this case, the target volume would be too close to the chest wall to apply a stereotactic dose. An alternative would have been to apply a lower biological equivalent dose at a longer overall treatment time, which would have not been not optimal for this patient. With the help of the respiratory-gated CT imaging, the treatment plan can be individually optimized. 16 x 1.2 mm 3 mm 1.5 mm B30f mgy 826 mgy cm 1 Using the TSpace View functionality. 42 SOMATOM Sessions November

43 Oncology Clinical Results 1A 1B 1C MidVent 20 % 20 % 1 CT images reconstructed at the middle of the ventilation (Fig. 1A), 20% (Fig. 1B) and 20% (Fig. 1C) demonstrate the motion of the lesion (arrow) on grid. 2 3 Average 2 An average CT image was used for dose calculation. 3 Dose and volume were calculated for stereotactic radiotherapy. SOMATOM Sessions November

44 Clinical Results Oncology Case 6 Low Dose Pediatric Flash CT Scanning with IRIS A Follow-up Study after Neuroblastoma Relapse By Harald Seifarth, MD, Ruth Lim, MD Department of Pediatric Radiology, Massachusetts General Hospital, Boston, MA, USA HISTORY A 5-year-old boy, with known stage IV Neuroblastoma, underwent tumor resection with left-sided nephrectomy and lymphadenectomy 14 months ago, followed by radiotherapy. He suffered from intermittent abdominal pain which had progressed over the past 2 weeks. A CT exam was ordered for restaging. DIAGNOSIS Relapse of Neuroblastoma with new soft tissue masses in the retroperitoneum, displacing and compressing the inferior vena cava, was diagnosed. COMMENTS As the patient was very ill, the Flash scanning protocol was used which enabled a very short scan time of 0.73 s to cover the entire abdomen and pelvis. The use of an 80 kv protocol in combination with IRIS (Iterative Reconstruction in Image Space) allowed a very low dose scan, resulting in a DLP of 33 mgy cm. While comparing the previous CT scans performed 14 months ago on another scanner (from Vendor A ) with a DLP of 212 mgy cm (Fig. 1), it was observed that despite the lower radiation dose (15.6% of the baseline scan DLP), the images acquired with the present scan on SOMATOM Definition Flash (Fig. 2) were excellent for diagnosis. The baseline scan was acquired in 5.9 s and the patient was mildly sedated to avoid motion artifacts. Using the Flash scanning protocol, sedation was not necessary due to the short acquisition time. EXAMINATION PROTOCOL Scanner SOMATOM Definition Flash Scanner Vendor A Scan area Abdomen Pelvis Scan area Abdomen Pelvis Scan length 298 mm Scan length 270 mm Scan direction Cranio-caudal Scan direction Cranio-caudal Scan time 0.73 s Scan time 5.9 s Tube voltage 80 kv / 80 kv Tube voltage 100 kv Tube current 56 mas CTDI vol 4.32 mgy Dose modulation CARE Dose4D DLP mgy cm CTDI vol 0.89 mgy Rotation time 0.5 s DLP 33 mgy cm Slice width 2.5 mm Rotation time 0.28 s Reconstruction increment 2.5 mm Pitch 3.0 Slice collimation 128 x 0.6 mm Slice width 3 mm Reconstruction increment 3 mm Reconstruction kernel I30f / B30f 44 SOMATOM Sessions November

45 Oncology Clinical Results Baseline CT Scan (Vendor A) 1A Follow-up CT Scan (SOMATOM Definition Flash) 2A 1B 2B 1C 2C 1 Images acquired on a scanner from Vendor A with a DLP of 212 mgy cm. Fig. 1A demonstrated a left-sided supra-renal soft tissue mass, Figs. 1B and 1C were reconstructed for comparison with Figs. 2B and 2C. 2 Images acquired on the SOMATOM Definition Flash with a DLP of 33 mgy cm. Figs. 2B and 2C revealed soft tissue masses in the retroperitoneum displacing and compressing the inferior vena cava. Fig. 2A was reconstructed for comparison with Fig. 1A. SOMATOM Sessions November

46 Clinical Results Oncology Case 7 Dose Reduction Combining CARE Dose4D, CARE kv and SAFIRE Techniques By Richard Deignan, MD, Liz D Arcy, DCR CT Department, Wexford General Hospital, Wexford, Ireland HISTORY An elderly male patient was diagnosed with laryngeal carcinoma and treated with radiotherapy in He was admitted to the hospital with symptoms of hoarseness, progressive dysphasia, anorexia and weight loss over a period of eight weeks. DIAGNOSIS A thorax and abdomen contrast CT scan was performed, which demonstrated an ill-defined soft tissue mass in the supra- sternal region, anterior to the sternum (Fig. 1A) with asymmetrical thickening of the major pectoral muscle (Fig. 1B). In the clinical exam, bilateral enlarged axillary lymph nodes, measuring as large as 3 cm in diameter, were found (Fig. 2). An ill-defined and slightly enhanced mass in the sub-carinal area was shown (Fig. 3), as well as diffuse abnormal soft tissue infiltration in the mediastinum (Fig. 4). A malignant process was suspected and a biopsy followed. This showed features of a high grade lymphoma, most likely a diffuse large B-cell lymphoma. COMMENTS To achieve optimal image quality with the lowest possible dose, various CT techniques have been established. CARE Dose4D modulates the tube current (ma) automatically based on the diameter of various body regions to produce constant image quality over the entire scan range. CARE kv uses 1A 1B 1 Sagittal MPR demonstrates an ill-defined soft tissue mass in the supra sternal region, anterior to the sternum (Fig. 1A). Axial image shows asymmetrical thickening of the major pectoral muscle (Fig. 1B). 46 SOMATOM Sessions November

47 Oncology Clinical Results information gathered by the topogram to optimize kv and mas settings so that a user-selected contrast-to-noise ratio is maintained. SAFIRE 1 is Siemens raw data-based iterative reconstruction technique. In this case, CT scanning was performed with a combination of CARE Dose4D, and CARE kv and then reconstructed with the use of SAFIRE to remove noise and possible artifacts from the low dose scan. This enabled an individualized low dose scan with only 2.4 msv for the entire thorax and abdomen. 2 2 Coronal MPR image displays bilateral enlarged axillary lymph nodes. EXAMINATION PROTOCOL Scanner SOMATOM Definition AS 64 Scan area Scan length Scan direction Scan time Tube voltage Tube current Dose modulation CTDI vol DLP Rotation time Slice collimation Slice width Reconstruction kernel Contrast Phase 1 Phase 2 Start delay Thorax Abdomen 476 mm Cranio-caudal 15 s 100 kv with CARE kv 78 mas CARE Dose4D 3.48 mgy 170 mgy cm 0.5 s 64 x 0.6 mm 5 mm I30f 2 phase injection 70 ml at 3 ml/s and 40 ml saline flush 30 ml at 2 ml/s and 25 ml saline flush 70 s 1 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. In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task. The following test method was used to determine a 60% dose reduction when using the SAFIRE reconstruction software. Noise, CT numbers, homogenity, lowcontrast resolution and high contrast resolution were assessed in a Gammex 438 phantom. Low dose data reconstructed with SAFIRE showed the same image quality compared to full dose data based on this test. Data on file Coronal MPR image shows an ill-defined and slightly enhanced mass in the subcarinal area. 4 Sagittal MPR image demonstrates diffuse abnormal soft tissue infiltration in the mediastinum. SOMATOM Sessions November

48 Clinical Results Oncology Case 8 Lung Ventilation Imaging with Dual Energy Xenon CT in Single Breath Technique By Prof. Norinari Honda, MD, Hisami Yanagita Department of Radiology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan HISTORY A 75-year-old male patient was referred to the radiology department for detailed imaging, after a mass was seen on his chest radiography. He is an ex-smoker with 53 pack years who quit two years ago. He has been taking anti-hypertensive medication for the past 20 years. The lung auscultation sounded normal and superficial lymph nodes were not palpable. Focal neurological deficits were not found. A Dual Energy xenon ventilation CT scan using single breath technique and a lung perfusion scintigraphy by SPECT examination were ordered for detailed examination of the lung mass and lung function. Brain MRI was ordered to detect occult brain metastases. DIAGNOSIS The lung perfusion scintigraphy and SPECT showed a defect corresponding to the mass. Perfusion of the other areas of the lung was homogeneous and normal. The ratio of the sum of the pixel counts of the left upper lobe to that of the whole lung was On unenhanced CT, the lung mass measured 6 cm at its greatest diameter. Enlarged lymph nodes, pleural nodules and pulmonary nodes other than the mass were not noted. Dual Energy Xenon CT showed a ventilation defect corresponding to the mass. And the ratio of the sum of the pixel values of the xenon images covering the left upper lobe to that of the whole lung was 0.83, which was in accordance with the scintigraphy results. The patient was diagnosed with T2b M0 N0 (UICC 7 th edition) primary lung cancer (poorly differentiated squamous cell carcinoma) and was scheduled for left upper lobectomy. MRI revealed an occlusion of the right intracranial internal carotid artery. Brain perfusion SPECT revealed hypoperfusion of the right frontal and parietal lobe. COMMENTS Xenon ventilation mapping using Dual Energy CT single breath technique [1] depicted the ventilation defect at the mass and also showed normal ventilation in other portions of the lungs. Risk of peri-operative cerebral infarction was estimated as high due to the presence of the right carotid artery occlusion. The patient underwent a left upper lobectomy. Metastases were absent in the intra-operative pathological examination. Post-operative pathological analysis of the sampled nodes revealed metastases in one out of fourteen dissected lymph nodes. The patient was staged as pt2b N1 M0. He recovered uneventfully. EXAMINATION PROTOCOL Scanner Scan mode Scan area Scan length Scan direction Scan time Tube voltage Tube current Dose modulation CTDI vol DLP Rotation time Slice collimation Slice width Reconstruction increment Reconstruction kernel SOMATOM Definition Flash Dual Energy Thorax 348 mm Cranio-caudal 5 s 80 kv / 100 kv 190 mas / 81 mas CARE Dose4D 6.60 mgy 247 mgy cm 0.33 s 40 x 0.6 mm 1.5 mm 0.7 mm D30f [1] N. Honda et al, Radiology 2011 in press 48 SOMATOM Sessions November

49 Oncology Clinical Results Coronal (Fig. 1) and sagittal MPR (Fig. 2) showed the mass in the left upper lobe Xenon ventilation mapping by Dual Energy CT depicted the ventilation defect at the mass and also showed normal ventilation in other portions of the lungs Xenon ventilation mapping by Dual Energy (Fig. 5) in comparison to SPECT (Fig. 6) both showed a defect corresponding to the mass. SOMATOM Sessions November

50 Clinical Results Neurology Case 9 SOMATOM Definition AS 40: VPCT Pre- and Post-Recanalization of the Internal Carotid Artery By PD Georg Mühlenbruch, MD, Prof. Martin Wiesmann, MD Department of Diagnostic and Interventional Neuroradiology, University Hospital Aachen, RWTH-Aachen, Germany HISTORY An 81-year-old male patient arrived in the emergency room of the university hospital, approximately ½ hour after the onset of acute left hemiparesis. His cardiovascular risk factors included hypertension and obesity. DIAGNOSIS A non-enhanced sequential CT scan was immediately performed and demon- strated no evidence of an early ischemia (Fig. 1). The subsequently performed Volume Perfusion CT (VPCT) clearly showed a delayed and reduced blood perfusion in the entire right frontal cerebral circulation. The blood volume in the corresponding area was maintained with the exception of the right putamen and the right caudate nucleus (Fig. 2). These mismatched findings indicated an acute reversible ischemia of the subtotal right frontal cerebral circulation. In the area of the right putamen and the right caudate nucleus, decreased blood volume could be seen, suggesting a partial irreversible impairment. The additionally performed carotid CT Angiography presented a proximal occlusion of the right internal carotid artery (ICA) (Fig. 4). A lengthy ICA occlusion was suspected and it was decided to perform an interventional recanalization. A thrombus, which occluded the ICA from its origin to the petrous segment, was mechanically extracted using a 6x30 mm SOLITAIRE retriever. Next, a stent PTA (percutaneous 1 2A 2B 2C 2D Neurology Clinical Results 1 Non-enhanced CT image showed no evidence of an early ischemia. 2 VPCT images showed the extent of tissue at risk (Fig. 2A), the reduced blood flow (Fig. 2B), the maintained blood volume (Fig. 2C) and the delayed time to peak (Fig. 2D) in the right hemisphere. 50 SOMATOM Sessions November

51 Neurology Clinical Results transluminal angioplasty) using a 7x30 mm Carotid WALLSTENT was performed. The final angiographic control demonstrated a complete recanalization (Fig. 5) with no further occlusion of the intracranial cerebral arteries. Immediately after the intervention, a VPCT was repeated and this showed a symmetrical and timely restored cerebral perfusion (Fig. 3). 15 minutes after extubation, the patient was able to move his left side again without restrictions. The patient was released 5 days later. COMMENTS When an acute stroke occurs, time is brain. As shown in this case, a combination of non-enhanced CT, Perfusion CT and CT Angiography allows quick and comprehensive imaging which supports optimal treatment selection to the benefit of the patient. The non-enhanced CT is primarily applied to rule out hemorrhagic stroke and to detect early signs of ischemia. The Perfusion CT displays type and extent of the ischemic process as well as the quality of the collateral flow. CT Angiography provides information concerning vascular pathology which improves the EXAMINATION PROTOCOL Scanner Scan mode Scan area Scan length Scan direction Scan time Tube voltage Tube current Rotation time Slice collimation Slice width Spatial resolution CTDI vol DLP Effective dose Contrast Volume Volume Flow rate SOMATOM Definition AS 40 VPCT Head 56 mm Caudo-cranial 53 s 80 kv 180 mas 0.33 s 16 x 1.2 mm 10 mm 0.33 mm mgy 2697 mgy cm 5.6 msv 40 ml contrast 20 ml NaCl 6 ml/s planning of potential interventions. The scanning protocols and the evaluation procedures are designed to run automatically to facilitate a fast and smooth workflow. 4 4 VRT fused with Coronal MPR image showed the occluded right ICA Follow up VPCT showed the symmetrically and timely restored blood perfusion of the right hemisphere. 5 Post stenting angiography demonstrated the re-canalized ICA with residual vasospasm after mechanical thrombectomy. SOMATOM Sessions November

52 Clinical Results Neurology Case 10 Dual Energy CT Myelography Used to Detect Spontaneous Spinal Cerebrospinal Fluid Leaks By Qiao-wei Zhang, MD, Prof. Shi-zheng Zhang, MD Department of Radiology, Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, P.R. China HISTORY A 35-year-old female patient was referred to the Department of Radiology complaining of headaches and neck stiffness for the past 17 days. The headaches were relatively mild in the supine position and became severe in an upright position. She denied any history of recent trauma and had received two weeks of conservative treatment in the local hospital with no relief. Neurological exams were normal at admission. Contrast-enhanced cerebral MRI showed bilateral dural thickening (Fig. 1). The lumbar puncture revealed a low cerebrospinal fluid (CSF) pressure of 40 mmh 2 O in lateral decubitus position. 10 ml Omnipaque (300 mg J/ml) was then injected and a Dual Energy CT myelography (DECTM) of the entire spine was performed. In accordance with the DECTM results, targeted epidural blood patch followed and the patient was discharged 3 days later with total pain relief. images. Both the virtual non-contrast (VNC) image and the iodine map were generated to display the precise point of leakage and both showed consistent results. COMMENTS Spontaneous intracranial hypotension (SIH) is an increasingly recognized cause in cases of newly occurent, daily persistent headaches. This is due to low CSF volume, usually secondary to an occult spinal leak. The most common presenting symptom is orthostatic headaches. DECTM has been shown to be the method of choice to accurately define the location and extent of the CSF leak. The visual demonstration of DECTM is superior to the traditional CTM and therefore can improve diagnostic confidence and better the communication between patients and physicians Contrast-enhanced head MRI image revealed bilateral dural thickening. DIAGNOSIS The DECTM images showed bilateral CSF leaks at the cervicothoracic junction extending into the paraspinal soft tissues. The contrast media and the bones could be easily distinguished by DECT 2 Axial CT image showed bilateral CSF leaks at the cervicothoracic junction extending into the paraspinal (C6 7) soft tissue (arrows). 52 SOMATOM Sessions November

53 Neurology Clinical Results EXAMINATION PROTOCOL Scanner SOMATOM Definition Flash Scan area Spine Slice collimation 40 x 0.6 mm for thoracic & lumbar segments 32 x 0.6 mm for cervical segment Scan length 221 mm for cervical segment Slice width 1 mm Scan direction Cranio-caudal Reconstruction increment 0.7 mm Scan time 10 s Reconstruction kernel D26f Tube voltage 100 kv / 140 kv Contrast Tube current 150 mas / 92 mas Volume 10 ml Dose modulation CARE Dose4D Flow rate Manual injection CTDI vol mgy Start delay 30 min DLP 304 mgy cm Rotation time 0.5 s Pitch 0.9 3A 3B 3C 3 CT myelogram demonstrated an extensive retrospinal CSF collection (Fig. 3A, arrows) at the C1 2 level. In 100 kv & 140 kv mixed image, the DECTM iodine map (Fig. 3B), presented clearly the iodine in blue (arrows) and the cortical bone in red. The virtual non-contrast image (Fig. 3C) showed the complete removal of the contrast. Please note that retrospinal fluid collection at the C1 2 level does not necessarily indicate the site of the CSF leak but a result of a large-volume CSF leak originating from the lower cervical spine. 4A 4B 4C 4 Cervical CTM images demonstrated the accumulation of extra-arachnoid contrast material along the bilateral root sleeve. In the iodine map image (Fig. 4A), the iodine is marked in blue and the cortical bone in red. In standard VRT reconstruction (Fig. 4B anterior view and Fig. 4C posterior view, transparent mode), the iodine leak along the nerve root was shown in 3D with the vertebrae removed. SOMATOM Sessions November

54 Clinical Results Acute Care Case 11 SOMATOM Definition Flash: Low Dose Chest Follow-up Scanning with IRIS By Dany Jasinowodolinski, MD, Arthur Borgonovi, MD Hospital do Coração, São Paulo, Brazil HISTORY A 62-year-old female patient, a former smoker with a prior history of coronary artery bypass grafting and a CT exam in 2010, returned to the hospital for a follow-up, complaining about anterior chest wall pain adjacent to the surgical scar. Her cardiac status was good, and her physical exam was normal. DIAGNOSIS Both CT exams revealed no significant findings, with the exception of a small calcified granuloma in the right upper lung lobe (Fig. 1) which showed no evidence of change in size or density (Fig. 2 and 3). COMMENTS The prior exam was performed on a SOMATOM Sensation 64 scanner with a low dose (2.5 msv) chest protocol. When the follow-up exam was requested, a new SOMATOM Definition Flash Scanner equipped with Iterative Reconstruction in Image Space (IRIS) technique was available. A further reduction of the 1 effective dose down to 1 msv, while retaining the high image quality for diagnosis was possible. Furthermore IRIS has an improved signal to noise ratio resulting in reduced image noise. These findings encouraged a routine implementation of low dose scanning with good image quality in the department. 1 Prior CT exam showed a small calcified granuloma in the right upper lobe (arrow). 54 SOMATOM Sessions November

55 Acute Care Clinical Results EXAMINATION PROTOCOL Scanner SOMATOM Sensation 64 SOMATOM Definition Flash Scan area Thorax Thorax Scan length 351 mm 351 mm Scan direction Caudo-cranial Caudo-cranial Scan time 6 s 3 s Tube voltage 120 kv 120 kv Tube current 58 mas 27 mas Dose modulation CARE Dose4D CARE Dose4D CTDI vol 4.44 mgy 1.86 mgy DLP 176 mgy cm 72 mgy cm Rotation time 0.5 s 0.5 s Slice collimation 64 x 0.6 mm 128 x 0.6 mm Slice width 3 mm 1 mm Reconstruction kernel B60 I The follow-up CT exam revealed no evidence of change in the small calcified granuloma (arrow). 3 The presentation of 3D image fused with MPR image affirms the results shown in Fig. 2. SOMATOM Sessions November

56 Clinical Results Acute Care Case 12 SOMATOM Definition Flash: Metal Artifact Reduction with Mono Energetic Dual Energy Imaging in a Critical Trauma Case By Florian Fintelmann, MD, Laura Avery, MD, Rajiv Gupta, MD PhD Department of Radiology, Massachusetts General Hospital, Boston, MA, USA HISTORY A young male arrived in the emergency department with a sudden onset of severe right-sided eye pain while using a weed whacker. A nail was protruding from the right orbit, and CT was ordered to evaluate intracranial injury. Imaging was performed on a 64-slice CT, and subsequently on the 2x128-slice Siemens Dual Source CT scanner the SOMATOM Definition Flash. COMMENTS Dual Energy CT allows the simulation of high-kv mono energetic images. In our case, the monochromatic CT image was derived from a Dual Energy acquisition with tube A at 80 kv and tube B at 140 kv. The advantage lies in the reduction of streak artifacts surrounding metallic foreign bodies. Our patient was spared open surgery, once injury to optic nerve and internal carotid artery had been ruled out. In summary, Dual Energy CT is helpful in delineating the exact relationship of metallic foreign bodies to vital structures. DIAGNOSIS The volume rendered image acquired at 120 kv on a conventional CT demonstrated a nail lodged in the inferior/ medial right orbit, penetrating the right lamina papyracea and extending through the right ethmoid air cells into the left sphenoid sinus. However, the relationship of the nail to the optic nerve and the internal carotid artery was unclear due to extensive streak artifact surrounding the tip of the nail (Fig. 1). Mono energetic CT image at 190 kev (Fig. 2) demonstrated that the tip of the nail terminated inferior to the left optic groove (solid arrow) and abut the left anterior clinoid process superior to the internal carotid artery (dashed arrow). No intracranial hemorrhage was seen. EXAMINATION PROTOCOL Scanner Scan area Scan length Scan direction Scan time Tube voltage A/B Tube current Dose modulation CTDI vol DLP Rotation time Slice collimation Slice width Reconstruction kernel Postprocessing SOMATOM Definition Flash DE Head 191 mm Cranio-caudal 8 s 80 kv / 140 kv 400 eff. mas / 200 eff. mas CARE Dose4D mgy 718 mgy cm 0.5 s 32 x 0.6 mm 1 mm D45f syngo Dual Energy 56 SOMATOM Sessions November

57 Acute Care Clinical Results 1A 1B 1 MPR (Fig. 1A) and VRT images (Fig. 1B) from conventional CT scanning show extensive metal artifacts along the course and surrounding the tip of the nail. 2A 2B 2 Mono energetic images acquired by Dual Energy scanning (Fig. 2A MPR and Fig. 2B VRT) with significantly reduced metal artifacts demonstrate clearly that the tip of the nail terminates inferior to the left optic groove (solid arrow) and abuts the left anterior clinoid process superior to the internal carotid artery (dashed arrow). SOMATOM Sessions November

58 Clinical Results Acute Care Case 13 Flash CT Pulmonary Angiography in a Freely Breathing Patient By Ralf W. Bauer, MD, Martin Beeres, MD, Boris Schell, MD, Prof. Thomas J. Vogl, MD, J. Matthias Kerl, MD Clinic of the Goethe University, Department of Diagnostic and Interventional Radiology, Johann Wolfgang von Goethe University, Frankfurt, Germany HISTORY A 58-year-old female patient with dyspnea, deep vein thrombosis and signs of right heart strain in echocardiography, was referred to CT pulmonary angiography (CTPA) with suspected pulmonary embolism (PE). CTPA was conducted in Dual Source high-pitch mode without the use of a breathing command and with only 40 ml of contrast medium. DIAGNOSIS The CT pulmonary angiography showed a partially occlusive massive bilateral pulmonary embolism and signs of right heart strain. Consolidations in the upper left lobe, as indicative for an infarct pneumonia, were present. The high-pitch mode enabled motion-free imaging of the pulmonary structures, even while the patient was breathing. No double contours of the diaphragm or pulmonary vessels were seen. The pulmonary arteries showed excellent enhancement to the periphery, at 100 kv with an effective dose of as low as 1.96 msv. COMMENTS During CTPA, regular Single Source CT scanners require at least a short period of breath-hold to ensure motion-free imaging of the pulmonary anatomy. However, breath-hold is associated with changes in hemodynamics of the intrathoracic venous system induced by Valsalva s maneuver. Despite adequate bolus timing, this may lead to a loss of contrast enhancement within the pulmonary arteries even though the aorta is perfectly enhanced and contrast medium is still flowing in through the superior vena cava. As shown in the present case, with a pitch of 3.0, patient motion can be virtually frozen. This allows CTPA to be performed in a freely breathing patient and, avoids breath-hold induced interruptions of the contrast column. Further, this technique allows the use of significantly lower amounts of contrast medium. Where usually ml are necessary for CTPAs, for this scan, excellent PA enhancement with only 40 ml was achieved. This is possible due to the fact that a snapshot of the pulmonary arteries is virtually made at the moment of maximum enhancement using the Flash mode Bilateral severe emboli can be shown in para-coronal VRT. 2 Bilateral severe emboli can be shown in coronal MIP as well. 58 SOMATOM Sessions November

59 Acute Care Clinical Results With optimal bolus timing, excellent contrast 2A enhancement can be shown in the pulmonary arteries: note almost contrast-free aorta. 4 An enlarged right ventricle and atrium with clearly definable AV valves can be revealed (RV/LV ratio of 1.2) Coronal reformation of CTPA in lung window: note motion-free delineation of the diaphragm, pulmonary vessels and infarction in the left upper lobe, although the patient was breathing. 6 Coronal reformation at the same level as in Fig. 5 but in venous phase in inspiratory breath hold: Note comparable image quality. EXAMINATION PROTOCOL Scanner SOMATOM Definition Flash Scan area Thorax Pitch 3.0 Scan length 273 mm Slice collimation 128 x 0.6 mm Scan direction Cranio-caudal Slice width 1.0 mm Scan time 0.68 s Reconstruction increment 0.5 mm Tube voltage 100 kv Reconstruction kernel B26f Tube current 180 reference mas Contrast Dose modulation CARE Dose4D Volume 40 ml CTDI vol 4.06 mgy Flow rate 4 ml/s DLP 140 mgy cm Start delay bolus tracking Rotation time 0.28 s SOMATOM Sessions November

60 Science The First Single Source Dual Energy Scan Mode with Optimized Dose When the SOMATOM Definition was introduced in 2005, Siemens Healthcare Computed Tomography unveiled the concept of Dual Energy, based on unique Dual Source Technology. Since then, attempts have been made to utilize Dual Energy in Single Source CT, but due to technical limitations they were never suitable for clinical practice, mainly due to unreasonably high dose. Siemens now tackles this with the SOMATOM Definition Edge. 1 By Jan Freund, Computed Tomography, Siemens Healthcare, Forchheim, Germany Dual Energy has opened the door to a new world of characterization, visualizing the chemical composition of material. In a Dual Energy CT scan, the region of interest is acquired at two different energy (or kv) levels to combine further tissue information with morphology data. The selected kv value determines the average energy level of the photons in the X-ray beam used for the examination. Changing the tube voltage alters the photon energy level and the attenuation of the X-ray beam in the scanned tissue. Dual Energy CT exploits this effect: Scanning the same region at two different voltages delivers two datasets showing different attenuation levels. Depending on the clinical question, these datasets are processed using specific software algorithms in the syngo Dual Energy application. In the resulting images, the difference in attenuation between materials can be used to classify the chemical composition of the scanned tissue. However, to produce a final Dual Energy image, the two datasets must be anatomically aligned. Dual Source images can easily be aligned for the final images, as both images are scanned at the same time and anatomical position. Aligning 1 1 Single Source Dual Energy scan reveals the chemical composition of a kidney stone. 60 SOMATOM Sessions November

61 Science single source scans is much more complicated, and despite efforts to solve this problem, technical limitations have prevented potential solutions from being used in clinical practice. One suggestion for solving the difficulties of aligning single source images is to acquire two different energy levels by changing the tube voltage several times during one rotation. This approach comes with several drawbacks. Firstly, only half the number of projections or fewer is available for each image. Secondly, this approach is only feasible at very slow rotation speeds. These two restrictions significantly reduce image quality. Finally, the most crucial limitation is that rapidly changing the tube voltage requires setting the current to a fixed value. And to penetrate large body regions this value has to be very high. This exposes patients to a higher dose than necessary and is contrary to the ALARA (As Low As Reasonably Achievable) principle. Siemens has never perceived fast kv-switching as a potential solution due to the high dose associated with it. A new dose optimized technique in Single Source Dual Energy scanning Despite such challenges, Siemens now introduces a dose-optimized Single Source Dual Energy scan mode with the SOMATOM Definition Edge, finally making this technology accessible for a larger number of institutions. This scan mode consists of two consecutive spiral scans, each acquiring a different energy level. A scan range of 30 centimeters can be covered with both energy levels in 15 seconds. The first spiral scan is carried out with a pitch of 0.6, followed immediately by a spiral scan with a pitch of 1.2 at the second energy level. Both datasets are perfectly aligned using a dedicated non-rigid image registration method. To avoid doubling the dose administered to the patient, the spirals are set at approximately half of the total value. Both spirals combined produce the necessary signal level to deliver a diagnostic Dual Energy image. With this Single Source Dual Energy scan mode, the entire range of dose-saving techniques can be applied, including modulating the tube current in real time using CARE Dose4D, and reducing image noise and accordingly, radiation dose, with SAFIRE. 2 The image quality of the new Single Source Dual Energy scan mode delivers impressive results: A scientific study presented at this year s RSNA demonstrates that the image quality of Single Source CT scans for kidney stone evaluation was considered similar to that of the Dual Source scans for all patients. [1] As the study was performed using a SOMATOM Definition AS+, not only the SOMATOM Definition Edge benefits from the new scan mode; the entire SOMATOM Definition AS Family can access this innovative examination method. The Stellar Detector detects very low signals Unique to the SOMATOM Definition Edge, the Stellar Detector 1 provides an exclusive benefit: Its revolutionary TrueSignal Technology is designed to minimize electronic noise with the first fully-integrated detector elements in the industry. This makes the detector especially suitable for low-signal imaging, as the signal-to-noise ratio is significantly increased. With both spiral sets at much lower dose levels than regular spirals, this is of even greater importance, as it increases the ability of the CT scanner to detect very low signals. The Stellar Detector covers an extended dynamic range. This new feature is called HiDynamics. It is designed to increase the sensitivity of the detector for visualizing finer structures especially for the low kv dataset. The first Single Source Dual Energy applications that will be available are syngo.ct DE Calculi Characterization, syngo.de Gout and syngo.de Monoenergetic 2. The characterization of kidney stones with syngo.ct DE Calculi Characterization is a good example of how tissue characterization can support physicians in determining appropriate treatment. Depending on the type of kidney stone, treatment can vary from medication only to an invasive procedure. A Dual Energy scan can add the tissue information to the morphology to aid this decision process. Gout is the most widespread form of crystal arthropathy and a common inflammatory joint disease. But diagnosis can prove difficult as there are various forms of arthritis with similar symptoms. Using syngo.de Gout, the disease can be detected in regions that are often overlooked and distinguished from similar illnesses. Finally, syngo.de Monoenergetic reconstructs images as if they were acquired at a specific energy level between 40 kev and 190 kev. This means that radiologists can reduce metal artifacts, such as clamps in spine images. Single Source Dual Energy is available for the SOMATOM Definition AS family and will be available for SOMATOM Definition Edge with its release in mid References [1] Leng S, et al. Renal Stone Composition Differentiation using Two Consecutive CT Scans and a Non-Rigid Registration Algorithm (abstr). In: Radiological Society of North America scientific assembly and annual meeting program. Oak Brook, Ill: Radiological Society of North America, Under development. Not available for sale in the U.S. 2 The information about this product is being provided for planning purposes. The product requires 510(k) review and is not commercially available in the U.S. SOMATOM Sessions November

62 Science itrim a New Method for Improving Temporal Resolution in Cardiac Computed Tomography Iterative techniques can be used to increase temporal resolution, a key parameter in cardiac imaging. On Siemens SOMATOM Perspective, 1 itrim is used to obtain an effective temporal resolution as low as 195 milliseconds. By Harald Schöndube, PhD*, Sebastian Vogt, PhD**, Thomas Allmendinger, PhD*, Stefan Ulzheimer, PhD* *Computed Tomography, Siemens Healthcare, Forchheim, Germany **Siemens Medical Solutions USA, Malvern, PA, USA High temporal resolution is one of the most important parameters in cardiac imaging. Utilizing conventional cardiac image reconstruction algorithms, the highest achievable temporal resolution in the isocenter of a CT image is determined by the time the scanner needs to acquire 180º of CT projections, [1] i.e. a half-rotation of a single source scanner. High-end Single Source CT scanners thus owe their good cardiac imaging performance and high temporal resolution to sophisticated and expensive scanner hardware that allows the acquisition system to be rotated faster. As an alternative to sophisticated hardware designs, image reconstruction algorithms can be used to improve temporal resolution. A long-known method of improving the temporal resolution in slower scanners is multi-segment image reconstruction, utilizing data from more than one cardiac cycle. Taking data from up to two heart beats (bi-segment approaches) is still a reasonable option for improving temporal resolution. For multi-segment approaches that use data from more than two heart cycles, the disadvantages clearly outweigh the benefits. Disadvantages are a sub-optimum dose efficiency, higher overall scan times, and unreliable performance, since even slight motion irregularities between heartbeats can cause image artifacts. Siemens has therefore developed itrim (Iterative Temporal Resolution Improve- 1 N HU 1 For each image pixel, a local histogram is generated, which is virtually unaffected by the presence of motion artifacts and which functions as a constraint during the iterations in itrim. 62 SOMATOM Sessions November

63 Science ment Method), which is designed to further reduce the temporal resolution of cardiac CT images on systems not offering the highest possible rotation speeds. [4] This novel iterative image reconstruction algorithm improves the temporal resolution by 20%, effectively reducing motion artifacts in CT images while maintaining a very good overall image quality and low image noise. itrim is based on the observation that the presence of motion artifacts does not significantly change the histogram of a CT image. This information is used to reconstruct an image from less than half a turn of data. [2] First, a partial cardiac scan is performed with weighted filtered back projection (WFBP), resulting in a temporal resolution equivalent to 180º of CT data. For each pixel, the system then computes a histogram within a quadratic region centered on the pixel, as shown in Fig. 1. An iterative reconstruction algorithm is then started, using only a subset of the full 180 cardiac dataset. The size of this subset (e.g. 140 ) is adapted to the target temporal resolution. In order to expedite convergence, a normal WFBP image is used as a start image for this iterative algorithm. The iterative loop then consists of two steps: Firstly, the image is updated with the projection data subset defined above using the SART (Simultaneous Algebraic Reconstruction Technique) iterative reconstruction framework. [3] After each SART iteration, an additional step is performed in which the HU value of each pixel is adjusted according to the respective histogram of the lower temporal resolution image: Pixels with an HU value close to a maximum of the histogram are left unchanged. Pixels with an HU value far from any maximum are adjusted slightly towards the closest maximum. After the iteration has finished, a motion detection technique is used in the final step. The itrim image from the final iteration of the iterative reconstruction is combined with the conventional 180º WFBP image. In regions that exhibit motion, the itrim image is used as the final image, whereas in static regions the WFBP image is used. 2A 2B WFBP 2 Axial images using conventional cardiac WFBP (left column) and itrim (right column). The effective temporal resolution is increased by 20%, completely eliminating motion artifacts in the right coronary artery. [4] Raw dataset courtesy of Shanghai Jiangong Hospital, Shanghai, People s Republic of China Fig. 2 shows image examples of a cardiac dataset, reconstructed with the typical cardiac WFBP, in direct comparison to an itrim reconstruction of the same dataset. The reduction in motion artifacts using the itrim algorithm is clearly visible, while maintaining the same noise level and overall image quality (Fig. 2). As scientifically validated, [4] the temporal resolution of the itrim reconstruction technique can enhance the temporal resolution by 20%. On Siemens SOMATOM Perspective 1 with a rotation time of 480 ms, this yields an equivalent rotation speed of 390 ms and an effective temporal resolution of 195 ms, far superior to the temporal resolution of 240 ms of the corresponding standard cardiac WFBP reconstruction. In summary, itrim is designed to improve image quality in cardiac imag- 2C 2D itrim ing for systems not offering the highest rotation speeds by providing a superior temporal resolution compared to conventionally reconstructed CT images, while maintaining the same overall image impression. References [1] Ohnesorge B et al. Multi-slice and Dual-source CT in Cardiac Imaging, Springer Verlag, Berlin, second ed. (2007). [2] Kunze H et al. Iterative extended field of view reconstruction, in Medical Imaging: Physics of Medical Imaging, Hsieh J and Flynn M J (eds.), Proc. SPIE 6510(1), 65105X (2007). [3] Kak, AC and Slaney M Principles of Computerized Tomographic Imaging, IEEE Press (1998), ( [4] Schöndube H et al. Evaluation of a novel CT image reconstruction algorithm with enhanced temporal resolution, Proc. SPIE 7961, 79611N (2011). 1 Under FDA review. Not available for sale in the U.S. SOMATOM Sessions November

64 Science Stellar Detector Performance in Computed Tomography The first fully-integrated detector in the CT industry sets a new reference in image quality with HiDynamics, TrueSignal and Ultra Fast Ceramics. By Stefan Ulzheimer, PhD, Siemens Healthcare, Computed Tomography, Forchheim, Germany Siemens has continually evolved its technology for the most critical components in the CT scanner, including the X-ray tube, detector array and efficient image reconstruction algorithms. Back in 2002, Siemens introduced a revolutionary concept for a new X-ray tube. The STRATON tube s compact design led to the development of fast rotation speeds and Dual Source Technology. STRATON X-ray tubes have a high power output, small focal spot sizes and virtually no cooling delays, thanks to unique technology that cools the anode directly. Siemens has also improved its image reconstruction methods continuously. While other vendors still use single-slice techniques which require compromises between image quality and speed, Siemens has developed SureView TM for the first generation of multi-slice detectors, offering optimal dose utilization and excellent image quality at arbitrary pitch values. Such extensive research and development has fueled the latest generation of iterative reconstruction approaches, which include IRIS, and SAFIRE 1 Siemens raw-data-based iterative reconstruction application available commercially. High absorption, fast decay and low afterglow CT scanner detectors convert the attenuated X-ray beam into a digital signal that can be processed by computers. To achieve very high dose efficiency, the detector s capacity for X-ray absorption must be as high as possible. After decades of using Xenon gas detectors in CT, Siemens introduced the first solidstate detector in 1999 (Fig. 1). Based on the proprietary scintillator material, Ultra Fast Ceramics (UFC ), the detector offered high X-ray absorption, short decay times, and extremely low afterglow. The UFC layer used in Siemens CT scanners converts almost 100% of the X-rays into visible light, whereas Xenon detectors can only convert between 60% and 90% of the X-ray into a usable signal. A direct comparison of Xenon detectors and UFC-based detectors indicated an increase of 23% in dose efficiency. [1] Decay time and afterglow are two other important properties of scintillator materials that characterize the light output of the scintillator after the X-rays are switched off. Decay refers to the shortterm behavior of the signal directly after the X-ray is switched off and afterglow is the longer-term composition of the signal output due to luminescence. UFC 1 100% Detector performance Siemens Xenon Gas Vendor A Xenon Siemens UFC Solid State Vendor A Scintillator I Vendor A Scintillator II Full electronic integration Siemens Stellar Detector 1st generation 2nd generation 3rd generation Time? 1 First generation detectors still used Xenon gas under high pressure to convert the incoming X-rays into electric current. Second-generation detectors use solid-state ceramic scintillators to convert X-rays into light, photodiodes to convert the light into current, and analog-to-digital converters (ADC) to digitize the signal. The Stellar Detector 2 is the first third-generation detector that combines the photodiode and the ADC in one Application- Specific Integrated Circuit (ASIC), dramatically reducing electronic noise, power consumption, and heat dissipation. 1 The information about this product is being provided for planning purposes. The product requires 510(k) review and is not commercially available in the U.S. 2 Under development. Not available for sale in the U.S.

65 Science has set an industry standard with a consistent decay time of 2.5 microseconds, and an afterglow below 10-4 after 1 millisecond and 10-5 after 10 milliseconds. Until recently, other vendors still had to use afterglow correction mechanisms [2] since long decay time and high afterglow can completely ruin spatial resolution. Siemens has continued this trend of innovation by developing the first fully-integrated detector, which is designed to dramatically reduce electronic noise, extend the dynamic range and increase spatial resolution in combination with new reconstruction methods. Revolutionary new detector design Detector performance is not only measured by fast and high X-ray absorption, short decay times, and low afterglow; low electronic noise levels and a high dynamic range are also key to designing effective detectors. With the new Stellar Detector, 2 Siemens is pioneering the first fully-integrated CT detector. Conventional solid-state detectors consist of a scintillator layer that converts the incoming X-rays into visible light, a photodiode array that converts the visible light into an electric current and an analog-to-digital converter (ADC) which digitizes the signal on a separate electronic board (Fig. 2). The number of electronic components and relatively long conducting paths increase power consumption, and add to the electronic noise produced by the detector. In the Stellar Detector, Siemens has combined the photodiode and the ADC in one application-specific integrated circuit (ASIC) for the first time in the history of CT, reducing the path of the signal. Fig. 3A shows a schematic of the new Stellar Detector configuration. The light from the UFC scintillator reaches the back-illuminated photodiode on top of the CMOS wafer, which houses the ADC. A digital signal is then produced on the other side of the wafer. This geometry consists of a 3D package of electronic circuits in a through-silicon via (TSV); a high performance technique for creating vertical connections that pass completely 2 through the silicon wafer. Fig. 3B shows the complete configuration of the compact Stellar Detector array with the ADC positioned entirely underneath the photodiode array. This small module replaces all the boards and electronic components shown in Fig. 2. Stellar Detectors transfer the digitized signal without any losses and the electronic noise produced by the detector is reduced by a factor of two (TrueSignal Technology). The new ASIC consumes 85% less power and dissipates less heat, further reducing electronic noise. Fig. 4 shows the reduced noise produced by the new Stellar Detector compared to a conventional second-generation detector. 2 Prototype configuration of a second-generation detector module includes anti-scatter collimator, scintillator layer, photodiode array and a separate electronic board with ADCs. 3A Light SiO2 Back-illuminated photodiode SiO2 3B Through-silicon via CMOS wafer (ADC) Stud bump Ceramics substrate Fully digital signal (20 bit) Schematic drawing shows the configuration of the new Stellar Detector. The light from the UFC scintillator reaches the back-illuminated photodiode on top of the CMOS wafer that contains the ADC. The digital signal is then produced on the other side of the wafer (Fig. 3A). A picture of the compact Stellar Detector array with the ADC positioned entirely underneath the photodiode array (Fig. 3B). SOMATOM Sessions November

66 Science 4 5A 6A Tube 120 kv Noise Detector Noise Measured in a 40 cm Water Phantom Tube current / ma 4 Reduced noise of the new Stellar Detector 3 measured with a 40 cm water phantom and compared to a conventional second-generation detector. Stellar produces almost no electronic noise (green line), benefiting low dose applications and large patient scans where signals are very low. 5 Simulation of a hip phantom with resolution insert, conventional detector technology and the new Stellar Detector. Using conventional technology, low signal levels in projections with high attenuation cause streak noise patterns in clinical images (left). With the Stellar Detector and TrueSignal Technology these unwanted noise patterns are eliminated (right). 6 A foot has been scanned and reconstructed with conventional technology (Fig. 6A) and Stellar technology with optimized SAFIRE model-based reconstruction (Fig. 6B). 1 The information about this product is being provided for planning purposes. The product requires 510(k) review and is not commercially available in the U.S. 2 Data on file. 3 Under development. Not available for sale in the U.S. 4 Under FDA review. Not available for sale in the U.S. 5B 6B Typical 2nd generation Detector Stellar detector 66 SOMATOM Sessions November Ideal detector without any electronic noise Low electronic noise and high dynamics In clinical CT, the attenuation of the measured object varies dramatically and so do the signal levels at the detector. The dynamic range describes the range of the input signal levels that can be reliably measured simultaneously without saturation. 2 HiDynamics has an exceptionally high dynamic range of 120 db, 15% more than conventional detector systems, eliminating the need to modify amplification and avoiding detector saturation. Combined with the noise reduction provided by TrueSignal, Stellar Detectors can measure smaller signals over a wider dynamic range which directly enhances CT image quality (Fig. 5). Applications with extremely low signal levels at the detector benefit especially from HiDynamics and True Signal, such as scanning large patients and lowdose scans, as well as the low-kv datasets of Dual Energy examinations. Model-based and detectoroptimized reconstruction With SAFIRE 1 (Sinogram Affirmed Iterative Reconstruction), Siemens introduced the first model-based and raw data-based iterative reconstruction application capable of reducing noise and artifacts, suited for a broad range of applications in clinical routine. SAFIRE can thus model the Stellar Detector precisely, including the cross talk between detector elements, detector aperture, detector grid, and the focal spot of the STRATON X-ray tube, reconstructing true 0.5 mm slices and unmatched spatial resolution in routine clinical protocols with excellent dose efficiency (Fig. 6). SOMATOM Definition Edge 3 and SOMATOM Definition Flash 4 now equipped with next-generation detector technology Siemens high-end scanners are now equipped with the latest Stellar Detector 1 in Single Source and Dual Source configurations. References [1] Fuchs TOJ et al. Direct comparison of a xenon and a solid-state CT detector system: measurements under working conditions. IEEE Trans Med Imaging Sep;19(9): [2] Hsieh J, Gurmen OE, King KF. Investigation of a solid-state detector for advanced computed tomography. IEEE Trans Med Imaging Sep;19(9):

67 Science Pediatric Imaging in the Spotlight In May 2011, more than 1000 delegates attended IPR, the International Paediatric Radiology Congress. Siemens Computed Tomography highlighted the latest innovations for individualized patient care, which were very well received by the community. By Heidrun Endt, MD, Computed Tomography, Siemens Healthcare, Forchheim, Germany. Societies focusing on pediatric radiology joined to organize the IPR 2011 in London. Experts from all over the world attended to present and discuss the latest research results in the field. The congress addressed all modalities relevant to pediatric radiology, so computed tomography was also part of the program. Studies carried out on SOMATOM scanners were covered in the scientific sessions, and in addition, Siemens CT presented its product portfolio on the exhibition floor, where visitors could view the latest technologies leading to individualized dose management for every patient. During the Siemens symposium SOMATOM Definition Flash: changing paradigms in pediatric CT imaging, three experts in the field of pediatric radiology reported on how these technologies are applied in their respective institutions. High-pitch CT Angiography in children Children with congenital heart disease were examined at the Minneapolis Heart Institute in Minnesota, USA, Kelly Han, MD, demonstrated how the high-pitch mode of the SOMATOM Definition Flash eliminates the need for general anesthesia for most of the patients, and how the dose can be lowered in these examinations. One study [1] about the results has already been published, and further studies will follow. In addition, a very interesting collection of cases was presented showing different anomalies and pathologies. CARE kv and CARE Child Marilyn Siegel, MD, from the Mallinckrodt Institute of Radiology USA, supported the clinical evaluation phase of CARE kv and CARE Child, the latest features contributing to dose reduction in pediatric CT imaging. In her presentation, she provided in-depth technical background information about the adjustment of tube voltage [2] and how CARE kv leads to optimized tube voltage settings for each examination, taking the individual patient and the clinical task into consideration. CT images from various cases were shown, proving the benefit that the technologies bring. CARE Child and Flash Spiral CT imaging The Radiology Department of the University Hospital Erlangen, Germany, was also one of the first institutions to have access to the latest technologies. Michael Lell, MD, presented cases scanned with a tube voltage setting of 70 kv, which is now possible with CARE Child. In addition, he shared his experiences with the high-pitch mode: results of a study [3] were presented in which even the youngest patients could be scanned without sedation or breath-hold. Information about the workflow, scan parameter settings, and contrast media protocols provided a best-practice reference for this scan mode. The symposium was very well received, and the three presentations clearly showed that these new technologies can benefit the youngest patients in clinical routine. Kelly Han,MD, Marylin Siegel,MD, and Michael Lell, MD, (from left to right) presented their experiences with the SOMATOM Definition Flash in pediatric CT imaging during the Siemens symposium at IPR. Marylin Siegel, MD, gave insight into CARE kv and how the technology is applied in her institution. References [1] Han BK et al. Accuracy and safety of high-pitch computed tomography imaging in young children with complex congenital heart disease. Am J Cardiol May 15;107(10): [2] Siegel MJ et al. Radiation dose and image quality in pediatric CT: effect of technical factors and phantom size and shape. Radiology Nov;233(2): [3] Lell MM et al. High-pitch spiral computed tomography: effect on image quality and radiation dose in pediatric chest computed tomography. Invest Radiol Feb;46(2): SOMATOM Sessions November

68 Science From Mannheim to Shanghai: a Viable Model for Future International Research Collaborations As China s scientific community strives for more international participation, Siemens Healthcare is looking at the emerging possibilities for cross-boarder collaborations between top institutes. By Bo Liu, PhD*, Christianne Leidecker, PhD**, Ulrike Haberland** *Healthcare Sector, Siemens Ltd. China, Shanghai, China **Computed Tomography, Siemens Healthcare, Forchheim, Germany In China, the healthcare system is rapidly developing and high-end CT systems are already commonplace. At the same time, Chinese radiologists are entering the research arena with enthusiasm, innovations and impressive results. Seven years ago, Siemens founded a dedicated team to support CT research in China. This global CT research collaboration team offers the Chinese partners direct access to the technical knowledge, education, and advice from leading international researchers that Chinese radiologists need to meet their scientific goals. An excellent example for this international clinical research collaboration is a current project between the Shanghai Pulmonary Hospital and the University Medical Center Mannheim. The Shanghai Pulmonary Hospital, which is affiliated to the Tongji University Medical School, is a famous hospital dedicated to lung disease. It has over 1000 inpatient beds, and annually they treat more than 20,000 new lung cancer patients. Jingyun Shi, MD, the vice president of the radiology department of Shanghai Pulmonary Hospital, planned for years to be able to employ the latest imaging technology for diagnosing patients with lung cancer. CT perfusion examinations promise to improve biological tumor characterization and therefore allow patients with lung cancer to be treated on an individual basis in the era of personalized medicine. In 2010 the hospital purchased the new SOMATOM Definition AS+ with the capability for whole tumor perfusion using Adaptive 4D Spiral Technology. With the The global research collaboration gives us great opportunity to work with top research scientists and radiologists in the world, which enables us to exchange new ideas. This collaboration not only benefits the research in China, but also gives us more confidence in solving clinical problems. Prof. Jingyun Shi, MD, Shanghai Pulmonary Hospital, Shanghai, China initiation of a research collaboration between the University Medical Center Mannheim, Heidelberg University, and Tongji University s Shanghai Pulmonary 1A 1B 1C 68 SOMATOM Sessions November

69 Project meeting at the University Medical Center Mannheim, Germany From left to right: Prof. Jingyun Shi, MD, Prof. Christian Fink, MD, Thomas Henzler, MD Hospital in the field of thoracic oncology. Prof. Shi was able to get in contact with colleagues from the University Medical Center Mannheim during a scientific meeting organized by both institutions in Shanghai. Professor Christian Fink, MD, associate chair and section chief of cardiothoracic imaging of the Institute of Clinical Radiology and Nuclear Medicine at the University Medical Center Mannheim and his colleague Thomas Henzler, MD, both experienced chest radiologists and researchers, realized the value of collaboration with the Shanghai Pulmonary Hospital. They were not only able to transfer their experience to an emerging scientific community in China, but also expand the current knowledge of lung cancer perfusion CT from small feasibility studies to a high volume clinical study. The latter may finally prove the clinical impact of this technique for diagnosing patients with lung cancer. The protocol of the collaborative research project was finalized with the help of local Siemens support at both ends of the collaboration. This included organizing the recruitment of local patients, scanning protocol, contrast media application protocol, patient consent, institutional review board approval and data collection by Prof. Shi with the help of the local CT collaboration scientist, Liu Bo, PhD, Siemens Ltd. China. A dedicated CT technician was assigned to run the research protocol on every patient recruited to ensure data consistency. With the bulk of the study design and preparations taken care of remotely, the next phase was to plan the first patient exams. For this, the whole group met in Shanghai for further optimization of the protocol initial patient examinations of the clinical study. The result of the detailed preparation of the project from Mannheim and Shanghai resulted in a very successful start to the project. From March to August 2011, Prof. Shi had already collected CT perfusion data of over 200 patients with lung cancer for the study. After another international scientific meeting on lung cancer in Shanghai in September 2011, Prof. By initiating the cooperation between Mannheim, Shanghai and Siemens we all went beyond borders on a scientific and personal level. Bringing together highly motivated researchers from China, high volume data from a large specialized hospital for pulmonary diseases, the latest scanner technology, and European research experience provides new opportunities for radiology research worldwide. Thomas Henzler, MD, University Medical Center Mannheim, Mannheim, Germany We see this project with Shang - hai Pulmonary Hospital as a role model for future research collaborations in a globalized world. Gaining further insights of the clinical value of perfusion CT only is possible with evidence from large volume studies, which could not have been achieved this way in Europe. Prof. Christian Fink, MD, University Medical Center Mannheim, Mannheim, Germany Shi will spend six months at the Institute of Clinical Radiology and Nuclear Medicine of the University Medical Center Mannheim to analyze the data with support from Fink and Henzler and prepare a scientific publication which is aimed for release in D 1E 1 Fig. 1A: Patient s topogram. Fig. 1B: Maximum intensity projection (MIP) of the upper thorax. The tumor volume is delineated in green, and the arterial region of interest in red. In the lower right segment the respective time attenuation curves are shown in white (mean tumor enhancement) and red (arterial input function). Figs. 1C 1E: Whole tumor perfusion image of the flow-extraction product (permeability) fused with the MIP in axial, sagittal, and coronal view. SOMATOM Sessions November

70 Customer Excellence Walter Märzendorfer, CEO, Busniness Unit CR, opened the 10 th World Summit. An Aura of Success: The 10 th SOMATOM World Summit To honor the tenth SOMATOM World Summit, 400 visitors participated in a special anniversary event for sharing the latest medical and technical developments, and networking with other healthcare professionals. By Tony de Lisa The great number of physicians participating in the summit in Hong Kong made the event the largest CT customer event in Siemens medical imaging history. Hong Kong one of Asia s most progressive and inspirational cities was selected for the venue and it was the first time the summit was held in Asia. In retrospect, it is not difficult to explain that this sudden surge of interest was caused by the number of exciting new products, such as SAFIRE 1, FAST CARE (including CARE kv, CARE Child) and the already well established high-end scanners, (SOMATOM Definition Flash and SOMATOM Definition AS+) introduced by Siemens in the last years. In short, there was enthusiasm and an aura of success about the bi-annual, tenth SOMATOM Summit, even before the event began. This aura continued throughout the entire event as witnessed from the positive comments of all participants. During the whole term of the summit, participants seized the chance to meet colleagues, to exchange opinions and experiences, and to socialize and network. The meeting was partly sponsored by Bayer Healthcare Pharmaceuticals reflecting the importance of contrast media for optimum diagnostic confidence. 70 SOMATOM Sessions November

71 Customer Excellence Martine Remy-Jardin, MD, PhD, Head of Department of Thoracic Imaging of University Hospital Lille, Cedex Lille, France, talked about Iterative Reconstruction and tube voltage adaptation in thoracic imaging to an interested audience. At the beginning, Walter Märzendorfer, CEO, Business Unit, CR, gave a short, inspiring speech, setting the tone and tempo for the activities immediately following. The actual working sessions covered the following subjects in two days: 1. Low dose imaging 2. Pediatrics 3. Oncology 4. Therapy 5. Acute Care 6. Cardiology 7. Dose and Contrast Media 8. Neuro 9. Functional imaging The latest medical and technical status of these themes was analyzed, explained and discussed by three to five experts experienced and competent in a sub-division of the main subject. Then the floor was opened to a panel discussion that could be joined by all persons present. These panel discussions were actually question and answer sessions making for an efficient networking forum unequaled in the CT world. All participants found it highly interesting and helpful to know how radiologists from around the world handle their daily routine and, more particularly, how they approach and solve problems such as pediatric examinations and low-dose scanning in general. The following statement by Peter Schramm, MD, chief radiologist at the University of Göttingen Clinic, Göttingen, Germany, is typical of comments received: The SOMATOM World Summit is an outstanding and unequaled meeting where leading CT experts and users share their experiences. Participants learned about modern CT imaging techniques and optimized workflows for diagnostic excellence and patient safety. Last, but certainly not least, is the question of feedback from the customers to Siemens. A significant amount of Siemens success in the medical imaging field has always been due to the fact that Siemens listens and is serious about feedback from practicing radiologists and other medical specialists in the field. And the 400-plus attendees to the 10 th SOMATOM World Summit were not sparing with their suggestions. Nothing is so good that it cannot be improved upon and this seemed to be the attitude of those present. Suggestions ranged from performance improvements to ideas for the next summit due in two years indicating that many of those present intended to visit the next summit as well. Peter Seitz, Head of Marketing, Computed Tomography, and Axel Lorz, Head of Customer Excellence, Computed Tomography, are convinced of the success of the event: We hope and expect that the summit inspires our customers to even further efforts to serve our patients healthcare needs. We are convinced, however, that not only our customers have profited from the summit, but also Siemens employees returned home with a great gain of knowledge and valuable customer feedback. Tony de Lisa is an external writer and based in Nuremberg, Germany Joon Beom Seo, Associate Professor at the University of Ulsan College of Medicine, Asan Medical Center in Seoul, Korea talked about diagnosing of pulmonary embolism with CT using Dual Energy. The get together took place over the roofs of Hong Kong. 1 The information about this product is being provided for planning purposes. The product requires 510(k) review and is not commercially available in the U.S. SOMATOM Sessions November

72 Customer Excellence Garmisch CT Symposium 2012 The Congress By Monika Demuth, PhD, Computed Tomography, Siemens Healthcare, Forchheim, Germany From January 11 14, 2012, the 7 th International Symposium for Multislice CT will take place in Garmisch, Germany. More than 1300 participants are expected to attend the congress, to be held in the Garmisch-Partenkirchen Congress House. Since the last CT Symposium two years ago, where 1200 participants from eight countries were in attendance, great steps in the technological development of computed tomography have led to significant advances in its diagnostic capabilities. And CT users have also realized that methodical enhancements need to have clear and measureable advantages. The congress program includes interesting talks in which technical innovations, diagnostic advancements, and opportunities to use MDCT in interventional radiology will be discussed. As always, the focus is on the patient. Scientificallybased and practical high-level training is the motto of the conference in Garmisch, so excellent speakers will be pre- senting clinically-oriented expert lectures, refresher courses and face-off sessions. The meeting structure for 2012 has been developed in the format of practical relevant and scientific lecture sessions. Friday January 13, 2012 will focus on oncology, with talks presented by colleagues from diagnostic and interventional radiology, therapeutic radiology, nuclear medicine, oncology, and surgery, who will provide in-depth knowledge about current standards and innovations in diagnostic and follow-up evaluation. The symposium is geared towards all who are interested in CT, as well as established radiologists, health physicists, physicians, and physicists from industry and research. The symposium is accredited by the Bavarian Landesärztekammer and the German Academy for Advanced Training in Radiology, so participants will have the option of registering for CME credits. The conference language is German. From January 11 14, 2012, the 7 th International Symposium for Multislice CT will take place in Garmisch-Partenkirchen, Germany. Further information on the CT 2012 web site and online registration: cms/ct2012/ct2012-home.html Hands-on Tutorials at ESC 2011 By Susanne v. Vietinghoff, Computed Tomography, Siemens Healthcare, Forchheim, Germany During the European Society of Cardiology (ESC) 2011, customers were able to join clinical hands-on workshops for computed tomography, magnetic resonance, angiography and ultrasound. Each of the sixteen sessions was fullybooked, providing 560 participants the opportunity to learn about and experience new developments in cardiac imaging. Tobias Pflederer, MD from the University of Erlangen, Germany, gave a talk on Cardiac CT Angiography, presenting scanning methods, dose-reduction techniques and guidelines. The participants then had the opportunity to experience syngo.via by themselves during the case reviews. After the session Siemens received the following positive feedback: The tips and short-cuts shown are very helpful, says Marjolein Kamphuis Menses, MD, from the ERASMUS University Medical Center in Rotterdam. It is absolutely fascinating to see the potential offered by on-screen image processing. Alexander Frank, MD, Klinik am Eichert, Göppingen, Germany: It was very interesting to get to know the new post-processing application and to learn something about the latest trends in CT. The hands-on tutorials will be offered again at ESC 2012 in Munich. Once again, Siemens organized hands-on tutorials at the European Society of Cardiology Congress SOMATOM Sessions November

73 Customer Excellence FAST CARE Boosted with Expert Advice By Heidrun Endt, MD, Computed Tomography, Siemens Healthcare, Forchheim, Germany With FAST CARE, new and innovative features for dose reduction, such as CARE kv and CARE Child, are brought into clinical practice. Three new flyers out of a series provide expert advice from Siemens Research and Development Department on how to use these technologies to the fullest extent. How to scan with CARE kv : CARE kv makes automated tube voltage adjustment possible, and CARE Child even allows scanning at 70 kv. This flyer includes information about the prerequisites and workflow, and information about the technology of tube voltage adaption. How to scan with CARE Dose4D : CARE Dose4D adjusts the tube current automatically for the individual patient and examination. This flyer provides information about the settings and how they can be customized to match the clinical needs of the institution based on the technology implemented in the latest scanner software syngo CT How to scan children with FAST CARE : The new dose management features will be especially beneficial to the youngest patients due to their increased sensitivity to radiation dosage. To meet special requirements in pediatric CT imaging, this flyer summarizes tips and tricks for The three new flyers from the series provide expert advice about CARE Dose4D, CARE kv and pediatric CT imaging with syngo CT scanning children with FAST CARE. Copies of all the flyers from this series can be ordered via the Customer Information Portal, Siemens Internet. Training & Education, Order your training materials Keep Track of Developments with Clinical Webinars By Susanne v. Vietinghoff, Computed Tomography, Siemens Healthcare, Forchheim, Germany For every healthcare professional who is interested in being connected with leading clinicians all over the world, Siemens Healthcare offers live clinical webinars, where the latest news in medical imaging can be followed. Many clinical webinars have already been held since the launch of the first session in December 2010 on Low dose in cardiac CT imaging. Past webinar topics include MR: emergencies in neuro imaging, Multi-modality reading in oncology and CT: stroke management. Each month, a new clinical modality will be in the spotlight, including a discussion of topics relevant to the field. The next webinars will cover the following topics: The role of MRI in breast imaging TAVI planning using advanced visualization On January 19, 2012 at 3:30 p.m. CET Martine Remy-Jardin, MD, will talk about CT-based diagnosis of lung disease. Each webinar will be recorded and made available online for viewing at a later date. The clinical webinars are free of charge. Siemens Healthcare offers live clinical webinars, where latest news in medical imaging can be followed. SOMATOM Sessions November

74 Customer Excellence New Software for the SOMATOM Emotion 16 By Katharina Linseisen and Marion Meusel, Computed Tomography, Siemens Healthcare, Forchheim, Germany As the demand for faster and more precise diagnosis increases, optimized workflow concepts and clinical applications become more and more important. Siemens constantly works on advancing its CT technologies and syngo Evolve, Siemens non-obsolescence program for SOMATOM CT scanners, provides the opportunity to benefit from these enhancements. A new syngo Evolve upgrade 1 is scheduled for 2012 for SOMATOM Emotion scanners running syngo CT 2007E which are subject to a syngo Evolve contract. After upgrading the latest software version and the required hardware, the user can access enhanced functionality and new features within the daily workflow. Dedicated application training for the new software enables healthcare professionals to fully utilize the capabilities of the scanner. Enhanced functionalities with the syngo Evolve upgrade: Siemens comprehensive approach for dose reduction in all areas of diagnostic and interventional imaging has resulted in a new DICOM Dose Structured Report (DICOM SR). For each examination, a DICOM SR is created in the Patient Browser and can be easily exported or send to PACS. It summarizes examination data and dose information according to the current DICOM standard. DICOM SR can be used with CARE Analytics, one of the latest CARE (Combined Applications to Reduce Exposure) applications. CARE Analytics analyzes and documents the dose received by patients during an examination with Siemens CT systems, X-ray and fluoroscopy devices and angiography systems. Accordingly, CARE Analytics can help clinicians to optimize their scan protocols and to Customers with an installed SOMATOM Emotion 16 scanner and syngo Evolve contract will get a software and hardware upgrade and have access to new clinical capabilities. work with reduced dose, allowing for greater dose transparency. To maximize workflow efficiency, the new software has also been refined with features which make the workday easier and clinically more successful, such as: New Move buttons on the Routine Subtask Card move the table up or down and in or out, directly via the user interface. Auto Delete deletes user-defined data automatically at specified time points depending on criteria such as free disk space. This ensures that the required storage capacity is always available. Features to expand the clinical capabilities: In addition, the syngo Evolve upgrade now offers the possibility to expand clinical capabilities. The new features available for purchase are IRIS, syngo CT Oncology, syngo InSpace Lung Parenchyma, syngo InSpace4D EP and syngo Expert-i for the acquisition console. A further key effort for improving patient care comes from Siemens leadership position in reducing dose. With the introduction of Iterative Reconstruction in Image Space (IRIS) in 2011 for the SOMATOM Emotion, the most popular CT scanner in the world is set to further reduce noise, deliver increased image quality, and make significant dose savings for a wide range of clinical applications. 2 syngo CT Oncology is a comprehensive software solution designed to fast-track routine diagnostic oncology, staging, and follow-up. syngo CT Oncology provides a range of fully automated tools specifically designed to support physicians in the detection, segmentation, 74 SOMATOM Sessions November

75 Customer Excellence 1A 1B and evaluation of suspicious lesions including dedicated tools for lung, liver, and lymph node assessment. It also offers a fully-automated follow-up protocol and features LungCAD (computer assisted detection). syngo CT Oncology also facilitates functional imaging offering fusion of PET with CT data. Furthermore syngo InSpace Lung Parenchyma Evaluation allows 3D evaluation of lung parenchyma in the case of chronic obstructive pulmonary disease (COPD). As an addition to InSpace4D, the InSpace EP application provides 3D cardiac visualization including automated segmentation of the left atrium and pulmonary veins. InSpace EP supports the electrophysiologist during planning, performing and follow-up of ablations for atrial fibrillation treatment. syngo Expert-i enables the physician to interact with the syngo Acquisition Workplace from virtually anywhere in the hospital. Questions that may arise 1A This head was scanned with a SOMATOM Emotion 16 and reconstructed with standard filtered back projection (FBP), using a H41 kernel. at the syngo Acquisition Workplace can be addressed quickly and efficiently from a network PC without having to go to the workplace. More detailed information, videos, case studies and how to order free trial licenses can be found on the Siemens online portal Discover. Try. Get a Quote. 1B IRIS improves image quality by significantly decreasing image noise without loss of resolution or gray-white matter differentiation. 1 This upgrade contains software version VB40. 2 In clinical practice, the use of IRIS may reduce CT patient dose depending on the clinical task, patient size, anatomical location and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular task. The 3rd Definition Symposium held by Siemens Japan in Tokyo By Katharina Otani, PhD and Eri Hirayama, Siemens Japan Healthcare, Tokyo, Japan Over three hundred participants attended the 3 rd Definition Symposium in Tokyo on August 27, 2011 to share information on Dual Source CT, Dual Energy CT, and volume perfusion CT with the SOMATOM Definition family. Fifteen doctors and technologists from university and private hospitals chaired and presented the sessions. In the first session, the speakers focused on technological aspects of CT, with three presentations on temporal resolution, spatial resolution, and dose. The radiological technologists discussed phantom measurements, and shared tips and tricks for increasing image quality and lowering dose in clinical routine. Afterwards, radiologists gave four presentations on cardiovascular CT in the second session. Starting with two talks on SOMATOM Definition Flash for pediatric CT and acute care, the next two speakers went on to inform the audience on perfusion CT for stroke care, and liver perfusion CT with the Definition AS. Siemens Japan also delivered a short lecture on Iterative Reconstruction. The last session on Dual Energy CT (DECT) covered a wide area of applications including DECT brain hemorrhage, virtual non-contrast and iodine distribution images for gastrointestinal cancers, monoenergetic DECT, and plaque removal in coronary DE CTA. Each session was followed by lively discussions. SOMATOM Sessions November

76 Customer Excellence Frequently Asked Question By Ivo Driesser, Computed Tomography, Siemens Healthcare, Forchheim, Germany How can the patient model dialog be cleaned up, if it is unnecessarily cluttered and confusing? Tube voltage (kv value) is an important parameter for the quality of each scan. In previous software versions, the patient model dialog listed separate protocols for different patient sizes, as large patients require a higher tube voltage than slim patients. Frequently, the same scan protocols were stored with different kv values while all other parameters remained unchanged, cluttering up the patient model dialog (Fig. 1). With the latest software version syngo CT2011A/B with CARE kv 1 on the SOMATOM Definition AS and SOMATOM Definition Flash, users no longer have to search for the right protocol. Default reference values are used as a basis for every scan protocol with CARE kv. The software considers the reference kv value, the reference ma value, patient size and examination type to define the best kv value for the scan. Instead of requiring the protocol with the correct kv value to be selected manually, the scanner sets the right kv value automatically. As the default protocols already have the right settings, the redundant scan protocols can be removed from the patient model dialog. The result is an organized and uncluttered patient model dialog (Fig. 2) which streamlines the workflow by making the right protocol easy to find Frequently, the same scan protocols are stored with only different kv values, cluttering up the patient dialog. 2 With the latest software syngo CT2011A/B with CARE kv on the SOMATOM Definition AS and SOMATOM Definition Flash, the default protocols already have the right kv settings. Redundant scan protocols can be removed from the patient model dialog. 1 Available as an option Upcoming Events & Congresses Title Dates Short Description Location Contact Euro SCCT Dec 16, 2011 Euro Society of Cardiovascular Computed Tomography Munich, Germany CT Symposium Jan 11 14, 2012 International symposium Garmisch Partenkirchen, Germany Arab Health Jan 23 26, 2012 Arab Health Dubai, UAE ECR Mar 1 5, 2012 China Med Mar 23 25, 2012 European Congress of Radiology Vienna, Austria en/about_esr_ecr.htm International Medical Instruments and Equipment Exhibition Beijing, China Cardiac MRI & CT Apr 1 3, 2012 Cardiac magnetic resonance imaging & computed tomography Cannes, France cannes2012.medconvent.at/ 76 SOMATOM Sessions November

77 Customer Excellence Life CMEF Apr 16 19, 2012 China International Medical Equipment Fair Shenzhen, China en.cmef.com.cn/ WCC Apr 18 21, 2012 World Congress of Cardiology Dubai, UAE ECIO Apr 25 28, 2012 European Conference on Interventional Oncology Florence, Italy Africa Health May 9 11, 2012 Africa Health Johannesburg, South Africa ESPR May 28 June 1, 2012 European Society for Paediatric Research Athens, Greece ISCT June 17 20, 2012 International Symposium on Multidetector Row CT San Francisco, USA SCCT July 19 22, 2012 Society of Cardiovascular Computed Tomography Baltimore, USA AOCR Aug 29 Sept 2, 2012 Asian Oceanian Congress of Radiology Sydney, Australia ESC Aug 29 Sept 2, 2012 European Society of Cardiology Munich, Germany Clinical Workshops 2012 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 Date Location Course Language Course Director ESGAR CT-Colonography Workshop Feb 8 10, 2012 Rome, Italy English / Italian Prof. Andrea Laghi, MD Franco Iafrate, MD Clinical Workshop on Cardiac CT Feb 15 17, 2012 July 4 6, 2012 Munich, Germany English Prof. Christoph Becker, MD Hands-on Workshops at ECR 2012 Mar 1 5, 2012 Vienna, Austria Clinical Workshop on Dual Energy Mar 30 31, 2012 Forchheim, Germany English English Siemens Healthcare PD Thorsten Johnson, MD Coronary CTA Interpretation Workshop Mar 15 16, 2012 June 21 22, 2012 Erlangen, Germany English Prof. Dieter Ropers, MD Hands-on at the ESGAR Congress June 12 15, 2012 Edinburgh, UK English Steve Halligan Hands-on Tutorial at ESC 2012 Aug 25 29, 2012 Munich, Germany English Siemens Healthcare In addition, you can always find the latest CT courses offered by Siemens Healthcare at SOMATOM Sessions November

78 Subscription Siemens Healthcare Publications Our publications offer the latest information and background for every healthcare field. From the hospital director to the radiological assistant here, you can quickly find information relevant to your needs. SOMATOM Sessions Online This website is a digital equivalent to the existing print magazine, including news from the world of computed tomography. With its reports and case studies, it is primarily designed for physicians, physicists, and medical technical personnel. enews Register for the global Siemens Healthcare Newsletter at com/healthcareenews to receive monthly updates on topics that interest you. Medical Solutions Innovations and trends in healthcare. The magazine is designed especially for members of hospital management, administration personnel, and heads of medical departments. MAGNETOM Flash Everything from the world of magnetic resonance imaging. The magazine presents case reports, technology, product news, and howto articles. It is primarily designed for physicians, physicists, and medical technical personnel. AXIOM Innovations Everything from the worlds of interventional radiology, cardiology, fluoroscopy, and radiography. This semiannual magazine is primarily designed for physicians, physicists, researchers, and medical technical personnel. IMAGING Life Everything from the world of molecular imaging innovations. This biannual magazine presents clinical case reports, customer experiences, and product news, and is primarily designed for physicians, hospital management and researches. For current and past issues and to order the magazines, please visit 78 SOMATOM Sessions November