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SOMATOM Sessions

The Difference in Computed Tomography


Issue no. 21 / November 2007
RSNA-Edition
November 25th 30 th, 2007

Cover Story
Growth of Denition
Family Signals New
Era in CT
Page 6

News
syngo 2008A Automating Routine Workow
Page 14

Clinical
Outcomes
The SOMATOM
Denition AS With the
CT Oncology Engine
Page 28

Science
Adaptive 4D Spiral
a Flexible Solution for
Dynamic Scanning
Page 46

Life
Life Behind the Scenes
Page 55

Editorial

A SOMATOM Definition CT is
much more about delivering
healthcare than delivering
images, its a tool for
managing the whole patient.
Bernd Montag, PhD, President of Computed Tomography,
Siemens Medical Solutions, Forchheim, Germany

Cover Page: Follow-up examination (7 s) of a patient with thoracic carcinoma, scanned with the SOMATOM Denition AS.
The artefact free visualization of detailed tissue structures shows, amongst others, the complete course of the aortic-arch.
Courtesy of Department of Diagnostic Radiology, University of Erlangen-Nuremberg, Erlangen, Germany

2 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Editors Letter

Andr Hartung,
Vice President Marketing and Sales

Dear Reader,
Every hospital, physician and medically
related organization wants to deliver the
best patient care possible. Yet increasingly,
theyre faced with the clear mandate to
shorten hospital stays, reduce time-todiagnosis and trim costs. Additionally,
as innovations develop faster and faster,
patients have become more knowledgeable. They expect and demand more
from healthcare. We asked ourselves
what role CT could and should play
in meeting these difficult demands.
Our conclusion: a paradigm shift in
thinking from what CT has always been
to what it should be in the current
medical environment. We call this The
SOMATOM Definition Era, where we
change CT from almost to always. We
have gone beyond fixed components to
engineering a smart dynamic architecture
for true adaptability. Now you can scan
virtually any patient, even the most
challenging, without compromise. Chest
care, stroke, or polytrauma patients will
need only a single CT scan to determine
next steps. From where to what - we
go beyond grey-scaled images that only
visualize anatomical detail, to seeing
functionality and tissue differentiation
that enable characterization of disease.
From there to everywhere - we go
beyond CT as a stand-alone imaging
procedure to a completely integrated,
digital exam readily available to the
entire clinical team, whenever and

wherever they need it. We began realizing our vision the SOMATOM Definition
Era in 2005 with the SOMATOM Definition, the worlds first Dual Source CT.
We continue today with the introduction
of the SOMATOM Definition AS, the
worlds first Adaptive CT Scanner. Introducing a fundamentally new way to use
single source CT, it intelligently adapts,
on the fly, to virtually every clinical situation, producing more than just clear
images, but also clear solutions to clinical
questions. It is the only CT to adept to
any patient - even the most challenging
pediatric, obese, cardiac or trauma.
The SOMATOM Definition AS actively
manages dose in 100% of all exams. Its
Adaptive Dose Shield dynamically
removes clinically irrelevant dose, in
every exam, for every patient.
With its unique Adaptive 4D Spiral,
SOMATOM Definition AS moves beyond
fixed detector limitations to provide
full coverage of any organ in 4D. In stroke
or tumor assessment, this gives invaluable functional information. And, with its
built-in 3D minimally invasive suite,
SOMATOM Definition AS makes routine
and complex procedures easier.
In our SOMATOM Definition Era, CT
has become more than just a clinically
efficient imaging modality, but a
critical tool to acquire and manage a
complete patient story. Utilizing our
vast experience with classical clinical

knowledge as the guiding principle, we


have gone beyond and transformed CT
into an analytical thinking platform that
adapts dynamically to virtually every
clinical situation and patient. Thus allowing e.g. to scan nearly every bariatric patient up to 300 kg / 660 lbs or patients in
acute situations with a scan range of 200
cm / 79 as one-stop shop with excellent
outcomes. CT has finally become a part
of the entire diagnostic and therapeutic
process, delivering a whole new level of
workflow efficiency through reductions
in time-consuming processes from data
handling and storage to post-processing
while opening up new worlds of diagnostic and economic possibilities. In this
issue of SOMATOM Sessions, you will read
more about the new era in computed tomography and the SOMATOM Definition
AS. We hope that you will become just as
enthusiastic as we are about these remarkable developments.
Enjoy!

Andr Hartung

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Content

Content

17

SOMATOM Definition AS

3D/4D images any time and

Cover Story

Cover Story
The Definition family of CT scanners
now consists of the original Definition
Dual Source scanner and the new
Definition AS, the worlds first adaptive
scanner. Together they offer an
impressive combination of strength and
flexibility, successfully imaging even
the most challenging patients,
replacing multiple diagnostic tests with
a single CT examination, adding new
information to CT images, and
distributing images and information to
the point of clinical decision-making. In
an interview with SOMATOM Sessions,
four experts discuss how the SOMATOM
Definition AS expands the SOMATOM
Definition Era by adapting to any
patient, for complete dose protection,
for new dimensions and to your space.

4 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Growth of Definition Family Signals


New Era in CT
Going Beyond Imaging to Managing
a Complete Patient Story

News
14 syngo 2008A Automating Routine
Workflow
16 The SOMATOM Spirit Provides new
Options: More Power for Corpulent
Patients
16 Dose Efficiency and Robustness

Business
17

Through the Eyes of the Radiologist

Content

everywhere

24

52

Clinical Outcomes:
Detection of an excentric plaque

CT of sediment cores

Clinical Outcomes
Cardiovascular
20 Assessment of a Coronary Anomaly
and a Huge Myocardial Bridge by
Dual Source CT-Angiography
22 SOMATOM Definition: Ultra low
Dose Cardiac CTA-Sequence
24 Detection of an Excentric Plaque
Causing a Relevant Stenosis of
Proximal Right Coronary Artery
Using Dual Source CT
26 Acute Myocardial Infarction and
Complication of Non-Calcified Plaque
in Left Anterior Descending
Coronary Artery
Oncology
28 The SOMATOM Definition AS With the
CT Oncology Engine Outstanding
Clinical Outcomes From Diagnosis to
Treatment for Everyday Oncology
32 Hide and Seek CT Colonoscopy
Solves the Riddle
34 Follow-up of Pediatric Patient With
Lymphoma Enhanced Diagnostic
Confidence With syngo CT Oncology
36 Quantitative Measurement of Emphysema Using the Automated Lung
Parenchyma Analysis Software of
syngo InSpace

Science
Neurology
38 Dual Energy for Ruling out Sinus
Thrombosis or Cerebral Abscess From
Acute Parenchymal Hemorrhage at
Right Parietal Lobe
40 Multisection CT for Complete Evaluation of Patients With Subarachnoid
Hemorrhage (SAH)
Acute Care
42 Dual Source CT Perfusion Defect
Visualization With Spiral Dual Energy
Scanning
44 Trauma Scan: Active Areas of Contrast
Extravasation Detect Active
Hemorrhage

46 Adaptive 4D Spiral a Flexible Solution for Dynamic Scanning


49 Dual Source CT: Detecting Urinary
Stones by Spiral Dual Energy
CT With Virtual Non-Enhanced
Images
52 Cold-Water Corals as Climate Archives in the Ocean Depths

Life
55 Life Behind the Scenes
57 Free 90 Day Trial Licenses for
Clinical Applications
58 In Step With the Future
58 SOMATOM World Summit 2007
59 Clinical Workshops 2008
60 Virtual CTA Course
60 SOMATOM Sessions Online
61 Clinical Poster Gallery
61 Frequently Asked Questions
62 New CT Customer Information Portal
62 Upcoming Events & Courses
63 Imprint

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Cover Story

Growth of Denition Family Signals


New Era in CT
Going Beyond Imaging to Managing
a Patient Story
The Denition Era is characterized by the ability to image even the most
challenging patients with ease, to develop new opportunities in functional
imaging and tissue characterization and to make healthcare information
available wherever and whenever its needed.
By Catherine Carrington

1
1 CT plays an

increasingly important role


in diagnosis,
staging and
intervention.
SOMATOM Definition AS is designed to scan
any patient
with exceptional scan range
and scan speed.

6 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Cover Story

SOMATOM Definition AS

In any family, welcoming a new member


is cause for celebration. At Siemens Medical Solutions, the recent expansion of the
Definition family of elite CT scanners is
especially notable, as it signals a new era
in medical imaging.
Launched in 2005 with the introduction
of the SOMATOM Definition Dual Source
CT scanner, the Definition family now
welcomes the SOMATOM Definition AS.
Together, they define a critical new trend:
going beyond seeing sharp pictures in CT
to seeing the big picture in healthcare.
We believe that CT today is much more
than an imaging test, says Bernd Montag,
PhD, president of Siemens CT division.
CT is a tool for managing the whole patient. Its more about delivering healthcare
than delivering images.
The Definition family of CT scanners consists of the original Definition Dual Source
scanner and the new SOMATOM Definition AS, the worlds first adaptive scan-

ner. Together they offer an impressive


combination of strength and flexibility,
successfully imaging even the most challenging patients, replacing multiple diagnostic tests with a single CT examination,
adding new information to CT images,
and distributing images and information
to the point of clinical decision-making.
A SOMATOM Definition CT scanner transforms itself into a stroke unit, a noninvasive cath lab, a therapy management tool
for the cancer patient, or an interventional suite all according to the need of the
individual patient, says Montag. We
have paid attention to the smallest detail,
even keeping siting requirements as low
as possible. All of these advances work to
improve the quality and efficiency of
healthcare while keeping the costs
down.
The Definition Era is defined by three
broad trends, according to Montag:
From Almost to Always. Patients come in

Adapts to Any Patient


Any patient, any organ or
clinical need without compromise.

Adapts for Complete Dose


Protection
Active dose management in
100% of exams. Clinically irrelevant dose is removed for
the patients.

Adapts for
New Dimensions
Full coverage of any organ
in 4D. Real-time 3D image
guidance in minimally invasive procedures.

Adapts to Your Space


The extremely compact
design of the SOMATOM
Definition AS boasting an
18 m2 footprint means
that it perfectly adapts to
room and installation needs.

all shapes, sizes, and clinical conditions


and frankly, some are difficult, if not impossible, to image on a conventional CT
scanner. The Definition family of scanners is designed to scan virtually any patient and do it well. A temporal resolution
surpassing any on the market means that
cardiac imaging is successful even in patients with rapid or irregular heart rates.
A combination of extra tube power, a large
gantry bore, and a heavy-duty scan table
means that even extremely obese patients can be reliably imaged. In addition,
superior scan range and scan speed benefit victims of multiple trauma as well
as squirmy, frightened children.
Clinicians can be sure when they send
a patient with a particular clinical problem
to a Definition scanner, theyll get an
answer, says Montag.
From Where to What. CT excels in depicting structure, shape, and location of normal and diseased tissue. What most CT

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Cover Story

SOMATOM Definition
Faster

Than Every
Beating Heart
It performs reliable cardiac
imaging, independent of heart
rate, with no beta-blockers, no
multi-segment reconstruction,
no exceptions.

Full

Cardiac Detail at
Half the Dose
The heart can be imaged twice
as fast, with the lowest possible
radiation exposure 50% lower
dose in cardiac CT.

One-Stop

Diagnosis
in Acute Care
Accurate triage of chest-pain patients in ten minutes. Easy routine
scanning regardless of size and
condition of patient.

Beyond

Visualization
with Dual Energy
In a single scan, differentiation,
characterization, isolation and
distinguishing the imaged tissue
and material is possible.

scanners cant do is elucidate function or


tissue composition of entire organs.
Definition scanners can. They provide a
colorful display of information to guide
clinical decision-making when its most
critical. Using dual energy techniques,
the Definition Dual Source CT scanner
can determine the composition of kidney
stones (Fig. 3A, 3B), for example, and aid
in the automated removal of bone from
angiographic images. The Definition AS
scanner, through a new Adaptive 4D
Spiral scan mode with continuous bidirectional table movement, depicts full
organ perfusion over time (Fig. 4A, 4B).
That means, just to cite one example,
that in a patient with suspected stroke,
blood flow in the entire brain can be
evaluated in less than a minute, speeding both diagnosis and treatment.
We are moving from morphology to
function, explains Montag, while
maintaining the classic strengths of CT:
easy to use, robust, and always reliable.

From There to Everywhere. In the past,


CT film sheets were tucked away in a film
library. Even when CT went digital, information was typically available only at
a limited number of dedicated workstations. Today, clinicians want information
and images to be available anywhere
and everywhere. Siemens syngo WebSpace makes that possible, using clientserver technology to deliver CT images
and information throughout the hospital
and to a physicians office or home.
Were switching to a world in which you
dont have to go to the CT information
the CT information comes to you, says
Montag.

Denition AS: No Limits


The Definition AS got the name Adaptive
Scanner the old-fashioned way: It earned
it. Designed and built with numerous
architectural and engineering improvements, it outperforms even the best single

8 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

source MDCT scanners on the market


today. As a result, the SOMATOM Definition AS has the ability to adapt to any
patient and virtually every clinical task,
every physician, and every healthcare
institution.
Im very excited about the introduction
of this new technology, says Joseph
Schoepf, MD, an associate professor of
radiology and medicine at the Medical
University of South Carolina, Charleston,
USA. It will enable us to address any clinical question in any situation.
Challenging patients. Take, for example,
patients with multiple traumas. With so
many injuries, trauma patients are unable
to lie still or hold their breath for extended
periods, if at all. At the same time, they
often are not medically stable enough for
sedation. Despite the scan speed with our
64-slice Siemens Sensation which is truly
exceptional we still see a fair amount
of motion artifact as a result of breathing

Cover Story

2
2 Whole brain

perfusion study
for comprehensive tissue at
risk classification in the entire organ.

and patient motion, says Schoepf.


These patients are in extreme pain.
In addition, the full extent of the patients
injuries may not be known, which makes
a head-to-toe scan essential. Given the
scan range of a conventional CT scanner,
it is difficult to position such a patient
precisely enough to accomplish a headto-toe scan in a single pass. The Definition
AS meets both of these needs. In addition
to 40- and 64-slice configurations, the
Definition AS offers a 128-slice configuration. Coupling the larger detector with a
200-cm scan range means that polytrauma
patients can be imaged rapidly, head-totoe, without difficulty.
All the guesswork is taken out, says
Schoepf. You position the patient without
all sorts of special maneuvers and do the
scan, which takes just seconds.
Another feature of the Definition AS that
is useful in trauma imaging is the 78-cm
gantry opening. Not only does such a
large bore accommodate even the hefti-

est patients, it also allows room for the


jumble of intravenous bags, monitoring
devices, and life support equipment that
arrive with trauma patients from the
emergency room.
Obese patients, whether the victims of
trauma or suffering from a medical emergency, benefit from two additional features of the Definition AS: an x-ray source
capable of delivering 100 kW of power
when needed no more dose-starved
studies and a scan table capable of supporting up to 660 pounds.
This combination of features, coupled with
a gantry rotation time of just 300 ms,
comes in especially useful when imaging
patients with chest pain or other cardiac
conditions. Schoepf estimates that roughly
half of the cardiac patients he sees at
MUSC are obese. Many also have diabetes
and are prone to repeated episodes of
equivocal chest pain. Not only would invasive cardiac catheterization often produce negative findings in such patients,

it would carry added risk because of the


patients size. The Definition AS has all
the power it needs to capture clear images unmarred by excess noise, even in
obese patients, Schoepf says.
Adaptive Dose Shield. The Definition AS
is characterized by a commitment not
just to scanning the most challenging patients, but to protecting all patients from
unnecessary radiation exposure. Of
course, all manufacturers have instituted
dose-reduction features in recent years.
Electrocardiographic dose modulation
and automatic dose reduction for pediatric
patients are two examples. The Definition
AS takes it much further, however, solving
a problem that has been widely recognized but, until now, little talked about:
the unnecessary radiation exposure of
non-target tissue at the beginning and end
of each spiral acquisition.
Such overscanning has been considered
a necessary evil of spiral CT, one that en-

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Cover Story
3

3A

From Where to
What: the
SOMATOM Definition Era adds vital
information to CT
images and helps
diagnosing not
only where the
disease is located
(Figs. 3A, 4A) but
also characterizing
the disease , e.g.
the chemical composition of kidney
stones with dual
energy (Fig. 3B) or
3D perfusion of a
neck-tumor with
Adaptive 4D Spiral
(Figs. 4B, 4C, 4D).

3B

Courtesy of University Hospital of


Munich-Grohadern,
Munich, Germany
and University of
Erlangen-Nuremberg, Erlangen,
Germany

4A

4C

4B

4D

10 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

sures that data acquisition includes the


entire region of interest. With single-slice
CT scanners, the over-radiated tissue
amounted to just a half-slice width at
each end, a negligible amount. But as
detectors have become larger and larger
over the years, the issue has become
more worrisome.
Overbeaming and overscanning have
become topics of critical interest with the
advent of multidetector CT, says Willi
Kalender, PhD, director of the Institute of
Medical Physics at the University of
Erlangen-Nuremberg, Erlangen, Germany.
Wide cone beams are a blessing they
allow the exam to proceed very quickly, in
just a few seconds but the disadvantage
is that they also expose regions that are
not imaged.
The unnecessary radiation exposure is
particularly worrisome when the region of
interest is relatively small, as it is in cardiac imaging. In such a case, the percentage increase in radiation dose can be
substantial. It is also of special concern
in patients who undergo lengthy or
repeated examinations, for example during CT interventions or perfusion imaging. The Definition AS, through its unique
Adaptive Dose Shield, eliminates worries
about over-radiation. With a press of a
button, collimators move into place to
physically block the x-ray beam from
reaching tissue outside the region of
interest. According to Kalenders calculations, the adaptive dose shield can reduce
the total radiation dose by in average 10
percent.
One of the credos of radiation protection
is that you never expose tissue unless
youll see an image, says Kalender.
That problem has now been solved.
New Dimensions. The SOMATOM Definition AS scanner moves CT beyond its
traditional focus on tissue location and
morphology to a new and exciting focus
on function. In doing so, it not only opens
the door to new applications, it also helps
radiologists use todays applications in
new, more effective ways.
Perfusion imaging is a perfect example.
The Definition AS sets a new standard in
CT perfusion imaging with Adaptive 4D
Spiral scan mode applying a continuous
bidirectional table movement. Its as if
the patient were gliding back and forth
beneath the detector on a gentle swing
no stops, no bumps, just constant image

Cover Story

CT is a tool for managing the whole patient.


Its more about delivering healthcare than
delivering images.
Bernd Montag, PhD, President of Computed Tomography, Siemens Medical Solutions, Forchheim, Germany

acquisition spanning an entire organ.


Its not hard to imagine what this might
mean in diagnosing a patient with suspected stroke. Instead of preselecting a
narrow section of the brain to evaluate for
perfusion defects and hoping to hit
the mark the radiologist can see a far
more complete picture.
With the new bidirectional table movement, you can cover the entire brain
for whole-organ perfusion, says Werner
A. Bautz, MD, professor and chair of
diagnostic radiology and director of the
Radiological Institute at the University
Erlangen-Nuremberg, Erlangen, Germany.
When you deliver contrast, you see
perfusion of the brain over time.

Whole-organ perfusion imaging is also


useful in the evaluation of tumors.
Increased perfusion and vascularity may
signal more aggressive tumors. CT
perfusion imaging can also be used to
gauge the effectiveness of treatment,
with a reduction in vascularity signaling
improvement.
At the same time, SOMATOM Definition
AS turns into an interventional suite,
enabling real-time 3D-guided interventions that overcome the limitations of
2D imaging.
With the CT scanners now available, a
biopsy needle must be placed in-plane
to see its tip and the direction of movement, says Bautz. But in a biopsy of the

The new Adaptive Scanner, Denition AS, enables us to address any clinical question in any
situation.
Joseph Schoepf, MD, Department of Radiology,
Medical University of South Carolina, Charleston, USA

Perfusion differences between the left


and right sides of the brain help to identify
stroke. The ability to examine individual
vessels throughout the brain is also
critical. We hope we can diagnose stroke
earlier than with current state-of-the-art
CT scanners, says Bautz. Time is brain.
The earlier we get the patient to therapy,
the better.

lung, for example, you must puncture


between two ribs and go out of the axial
plane. In many cases, you cannot safely
do the biopsy with 2D imaging.
Real-time 3D guidance enables the interventionalist to reconstruct the image in
any direction or view, and visualize the
biopsy needle in the context of the entire
organ.

It makes every procedure safer and


faster, says Bautz. I can plan my intervention better. I can localize the point of
puncture and I can localize the mass I
want to biopsy. I get the information I
need faster.
Wireless in-room controls also speed
interventions by eliminating the need to
leave the room to adjust scanner settings.
And the large gantry bore proves useful in
another way, by giving interventionalists
extra room to work and manipulate large
biopsy needles and other instruments.
You need space to do these procedures.
Anything that makes it easier to work
saves time, notes Bautz.
Practicality. Radiologists may be most
impressed with the clinical advantages of
the Definition AS, but radiology managers
will sit up and take notice of its practical
advantages. Simply put, the Definition AS
has been designed to adapt to any space.
With a footprint of just 18 m2, it fits in
rooms that are often too small for other
high-end scanners. In addition, it can be
air-cooled or water-cooled, depending
on how the room is already equipped, a
feature that reduces remodeling costs.
The Definition AS displays its practical
nature going forward as well. Available in
40-, 64-, and 128-slice configurations, the
Definition AS can be upgraded on site,
without need to remove the scanner. This
type of future-proofing may be the ultimate sign of adaptability in a healthcare
system always looking to raise quality
while lowering costs.

Denition Dual Source CT


As impressive as the Definition AS is, the
Definition Dual Source sets a standard of
performance that no other CT scanner

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

11

Cover Story

One of the credos of radiation


protection is
that you never
expose tissue
unless youll
see an image.
That problem
has been solved.
Willi Kalender, PhD, Director of the Institute of Medical Physics, University of Erlangen-Nuremberg, Erlangen, Germany

can match. Its not surprising, then, that


leading healthcare institutions around the
world have embraced this new technology
with enthusiasm. Indeed, since its market
release in August 2006, more than 250
Definition Dual Source CT scanners have
been installed worldwide, and early reports of clinical results have drawn intense
interest at medical meetings and in leading
scientific journals.The dual source scanner
is designed with two x-ray source/detector
pairs that rotate in synchrony, simultaneously capturing image data in half the time
of a single source scanner. The result is a
temporal resolution of just 83 ms and a
unique ability to use two different energy
levels to characterize tissue composition
and function. Both capabilities are driving
innovative applications in CT.

With the new


bidirectional
table movement,
you can cover
the entire brain
for whole-organ
perfusion.
Werner A. Bautz, MD, Director of the
Institute of Diagnostic Radiology,
University of Erlangen-Nuremberg,
Erlangen, Germany

At the Ludwig-Maximilians-University of
Munich, the Definition Dual Source CT
scanner is fueling a busy cardiac imaging
program. In the last 18 months, more than
500 patients have undergone cardiac studies on the dual source scanner, says Konstantin Nikolaou, MD, associate professor
of radiology, associate chair for clinical operations, and section chief for body CT at
the Grosshadern campus.
Most patients are referred for exclusion of
coronary artery disease, a bread-andbutter application. However, Dual Source
CT is opening up entirely new imaging
opportunities as well, for example, evaluation of patients with atrial fibrillation,
either to determine the cause of the
arrhythmia or to prepare for an electrophysiologic procedure.

12 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

With the improved temporal


resolution of
the Dual Source
CT, we consistently get higher
image quality
at high heart
rates.
Konstantin Nikolaou, MD, Department
of Clinical Radiology, University Hospital of
Munich-Grosshadern, Munich, Germany

Were getting more and more referrals for


these patients, says Nikolaou. Historically,
CT has had great difficulty in getting
decent image quality in patients with atrial
fibrillation. With the improved temporal
resolution of the Dual Source CT, we
consistently get higher image quality at
high heart rates.
Cardiac surgical patients are also being
referred in greater numbers, and from an
increasingly broad spectrum of surgeons.
They see Dual Source CT as useful both
before surgery, for surgical planning, and
after surgery, to follow-up patients for
complications calcification and narrowing of a replacement aortic valve, for
example. I think this is a good sign that
the robustness of the technique is making
it acceptable as a clinically widely useful

Cover Story

method, says Nikolaou.


Dual Energy. Spiral Dual Energy applications are also reshaping referral patterns
at the University of Munich, markedly
increasing, for example, the number of
patients undergoing CT imaging for
suspected kidney tumors or kidney stones.
With the Definition Dual Source CT scanner, it is possible to simultaneously operate
the two x-ray sources at different energy
levels and, therefore, to differentiate fat,
soft tissue, and contrast material on the
basis of their unique energy-dependent
attenuation profiles. Because iodine has its
maximum attenuation at low energy, it
can be subtracted from an image to create
a virtual non-contrast image, without
having to do a separate non-contrastenhanced scan. Comparing before-andafter images highlights areas of contrast
enhancement. In kidney studies, this technique is used to differentiate solid tumors
from cysts, on the basis of contrast uptake.
Similarly, kidney stones can be detected
using a single acquisition during delayed
enhancement, when the ureters are filled
with contrast material. Dual energy tech-

niques can be used to remove the contrast


material from the image, revealing the kidney stone. At the same time, dual-energy
imaging can characterize the composition
of the stone, revealing whether it is a calcified stone requiring lithotripsy, or a uric
acid stone that may respond to oral medication. Says Nikolaou: This is totally new:
Now we can not only tell the urologist why
the patient has abdominal pain, we can
identify the type of stone and recommend
a course of treatment. Now, every patient
with a kidney tumor or a stone is coming
to us for imaging.
Nikolaou is also using Spiral Dual Energy
techniques in, for instance, the evaluation
of liver tumors, to gauge perfusion in
patients with suspected pulmonary embolism, to evaluate the effectiveness of antiangiogenesis therapy in cancer patients, to
quickly remove bone from angiographic
images, and to evaluate arterial plaque.
Some of these are research applications,
but theyre quickly moving into clinical
practice, he says.
With the addition of the SOMATOM Definition AS, the Definition family of CT scan-

ners has secured its exceptional reputation


on the market. Together, dual source technology and adaptive scanning capabilities
not only meet virtually every clinical and
logistical challenge, they stretch to new
frontiers never before attained by CT.
But for all of its strength and innovation,
notes Siemens Montag, the Definition Era
has just begun. We have accomplished
a great deal, but this is a pathway characterized by dynamic motion. We are continuing to move forward, and the family
will continue to grow.
www.siemens.com/
somatom-denition-as

Medical writer Catherine Carrington writes


for Applied Radiology, Diagnostic Imaging, the
American College of Cardiology, and the Society
for Cardiovascular Angiography and Interventions, and provides web-based audio broadcasts
from major medical meetings for an international
audience of physicians. She holds a masters
degree in journalism from the University of
California Berkeley and is based in Vallejo, CA.

*configuration of the single source SOMATOM Definition AS


SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

13

News

syngo 2008A Automating


Routine Workow
Louise A. McKenna, PhD, MBA, Stefan Wnsch, PhD,
CT Division, Siemens Medical Solutions, Forchheim, Germany

syngo 2008A heralds a new era for routine


diagnostic oncology imaging. With the
launch of syngo CT Oncology, syngo
InSpace4D Lung Parenchyma Analysis,
auto-preprocessing for syngo Neuro DSA
and new features for dual energy imaging,
Siemens is further strengthening its commitment to deliver software products that
can significantly increase diagnostic speed
and confidence in everyday radiology.

Oncology
syngo CT Oncology is the industrys first
software product to offer fully automated

workflow support for tumor evaluation.


From diagnostics through staging and follow-up, dedicated workflow autopilots
offer automated 3D segmentation of identified lesions and computer generated lesion dimensions (including RECIST, WHO
and 3D volume) that are instantly available in the DICOM SR report. Previously
identified lesions are automatically
matched in follow-up exams. And with
percent change in tumor parameters
including the total tumor burden and doubling time only one click away, clinicians
save valuable time normally spent manually identifying and matching target le-

sions in successive exams. Whats more,


the automation of parameter evaluation
helps to reduce the potential inaccuracies
arising from inter-reader variability. With
Siemens clinically proven syngo Lung CAD
adding an extra layer of confidence by automatically identifying potential lung lesions for evaluation by the clinician, users
of syngo CT Oncology can look forward to
less guesswork in routine oncology exams.

Lung Disease
Another growth area for clinical software
is evaluation of chronic lung diseases.

1
1 Follow-up of liver

lesions with syngo


CT Oncology
provides autopilots
for automated
lesion matching and
3D segmentation of
e.g. lymph nodes.
Furthermore, tumor
growth is automatically measured.

14 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

News

With advances in CT imaging technologies, clinical evaluation of lung disease


such as COPD (chronic obstructive pulmonary disease) is rapidly moving from
pure visualization to quantitative analysis
of lung parenchyma abnormalities.
InSpace4D Lung Parenchyma Analysis,
Siemens newest plug-in for syngo sets
a new trend in this clinical area with an
automated workflow for 3D analysis of
the lung parenchyma. The software
features automatic segmentation and
density evaluation of the complete lung
parenchyma in 3D, facilitating reproducible lung volume measurements for early
evaluation and follow-up of diffuse lung
diseases. It offers automatic generation
of statistical evaluation results, including
sub-range and percentile analysis as
well as 3D low attenuation value (LAV)
cluster analysis with a graphical and numerical display of lung density. With its
3D approach, this software should also
help in the clinical evaluation of new
therapeutic approaches such as lung
volume reduction surgery (LVRS) valve
insertion and will also help in the
evaluation of new potential pharmaceutical treatments.

Neurology

2 Clinical evaluation of lung disease with syngo InSpace4D Parenchyma Analysis.

In addition, the most popular application


for the automated vascular evaluation
of the head and neck, syngo Neuro DSA,
has been updated with auto-preprocessing functionality. This speeds up the evaluation of intracranial and extracranial
vessels, and the screening of aneurysms.
Data are automatically pre-processed
off-line when sent from the SOMATOM
CT scanner to the syngo workplace.
Therefore CT DSA results are ready for
diagnosis as soon as the data are needed.
In addition, post-processed data can be
sent automatically to other DICOM nodes,
e.g. the syngo WebSpace server or PACS
archives, providing access to the data
from multiple entry points.

3 Automated vascular evaluation of the head and neck with auto-preprocessing.

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

15

News

The SOMATOM Spirit Provides new Options:


More Power for Corpulent Patients
By Dagmar Birk, CT Division, Siemens Medical Solutions, Forchheim, Germany

Axial view of the thorax of an obese patient,


high resolution image with detailed and
clearly displayed lung structure.
Courtesy of Zhongshawwn Hospital Fudan University.

Obesity, one of the fastest growing public


health problems, has found its way into
radiological job routine: More and more
corpulent people need to be scanned.
This requires radiologists as well as CT
systems to adapt to those patients. For
this purpose, the SOMATOM Spirit now
offers a new option for overweight
patients. A new, more powerful generator (up to 40 kW) and an accompanying
x-ray tube (3.5 MHU) routinely acquire
excellent image quality for higher
diagnostic confidence with more
corpulent patients.
Dose exposure is, however, not increased
unnecessarily. Siemens proprietary
CAREDose4D automatically reduces dose

to the minimum while maintaining


maximum image quality.
Optionally, a RTP-function is available to
support the radiologist during radiation
therapy planning. Providing precise
location-CTs, the function allows a more
detailed planning of treatment and
ensures an exact determination of radiation-planes. Another innovation is the
increase in gantry tilt from 25 to 30.
This considerably simplifies some
examinations such as shoulder orthography and sub-cranial scans.
Latest technology, high performance
and low life cycle costs make the
SOMATOM Spirit a most economical
all-round scanner.

Dose Efficiency and Robustness


By Rainer Raupach, PhD, CT Division, Siemens Medical Solutions, Forchheim, Germany

The prospectively triggered cardio


sequence was introduced with the
SOMATOM VolumeZoom in 1998, the
first cardiac CT on the market. This technique optimizes patient dose, but does
not offer the same phase optimization
flexibility and reliability compared to retrospectively gated spiral scans. Therefore,
spiral scanning has established itself as
the standard in cardiac CT to date.
The SOMATOM Definition and SOMATOM
Definition AS with syngo 2008G provide
the new Adaptive Cardio Sequence
Technique, combining both dose efficiency
and robustness. The scan can be automatically repeated at the current table
position (Arrhythmia Compensation) to

avoid stairstep artifacts, even in the case


of ectopic beats or extra systoles.
Furthermore, FlexPadding is available
to allow for optimizing the reconstruction
phase retrospectively. The best phase
for imaging the coronary arteries can be
adjusted. Optimal image quality is also
achieved by means of the new Volume
Projector including z-Sharp Technology
and an effective cone correction for
maximum spatial resolution and artifactfree images.
The SOMATOM Definition offers the best
temporal resolution for prospectively
triggered sequential scans. Radiation
dose to the patient can be reduced by up
to 80 percent.

16 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Coronary CTA Sequence of a 59-year-old


male patient

Business

Professor Dr. Anders Persson, Director, of the Center for Medical Image Science Visualization (CMIV)

Through the Eyes of the Radiologist


When vascular surgeons at the University Hospital in Linkping, Sweden,
wanted to see 3D images of CT acquisitions the same as radiologists, they had
to sit at a workstation. Now however, the syngo WebSpace server technology
sends the 3D/4D images where they need them to their ofces,
to conference rooms, or even to a laptop while traveling.
By Katja Stcker, Siemens Medical Solutions, Erlangen, Germany

Professor Anders Persson, MD, the Director


of the Center of Medical Image Science
Visualization (CMIV), is justifiably proud
of his inter-disciplinary research center.
Accompanying him on a tour through the

CMIV at the University Hospital in Linkping, he speaks enthusiastically of the


numerous research activities of his 70
researchers and 31 doctoral candidates. All
are focused on the big picture. Persson

and his team are researching imaging


and reconstruction, image analysis, visualization and processing, as well as the
transfer of comprehensive image data
such as generated with the high-end

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

17

Business

SOMATOM Definition Dual Source CT


system. The CMIV master plan hangs on
the wall: a Nobel Prize within the next
25 years.

3D/4D Images
Anytime and Everywhere
Professor Persson sees good cooperation
with clinicians in the adjacent rooms of the
University Hospital Linkping as an important key to the success of the CMIVs research projects. We listen carefully to
where clinical applications can be improved. In return, we receive feedback from
the clinicians on our efforts, explains Persson. Previously, he discussed radiological
reports, for example, with vascular surgeons at morning case meetings using 2D
images from PACS. In order to plan operations better, surgeons want to see what we
see, and not simply imagine it, explains
Persson. This is now possible anytime
and from anywhere. Using syngo
WebSpace, we can call up 3D CT images
from a standard computer or laptop this
provides us with a completely different
way of working, says Persson enthusiastically.
The easy, password-protected Internet connection to a syngo WebSpace server enab-

les up to 20 users to work simultaneously


with 3D/4D post-processing tools without
having to sit at a workstation. The images
are sent directly from the CT system to the
syngo WebSpace server. This happens
much faster than from a CT system to
PACS, reports Persson. Speed is playing
an increasingly important role in modern
medical care.

Enormous Storage Capacity


for Thin-Slice Acquisitions
syngo WebSpace is also the optimum
solution for short-term storage of thinslice (less than 5 millimeters) CT data. The
servers storage capacity is enormous, from
800 Gigabytes to 4.9 Terabytes, depending
on the configuration. As a result, from 1.6
million to almost 10 million thin-slice
acquisitions can be stored. The need for
3D/4D image data from volume CT images
has grown enormously, but purchasing
new or upgrading existing workstations is
expensive. CMIV employees currently work
at four workstations. Naturally, they are
always fully booked, says Persson. syngo
WebSpace makes detailed CT information
available everywhere, is password protected and significantly improves workflow. This saves money and improves the

Speed is playing
an increasingly
important role
in modern
medical care.
Professor Anders Persson, MD

Prof. Anders Persson, MD and Gunnar


Wiklund, MD discussing a patients diagnosis. Data can be sent directly from the
CT system to the syngo WebSpace server
which makes detailed CT information
available everywhere.

18 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

quality of treatment. Thoracic radiologist


and senior physician Gunnar Wiklund, MD,
noted an additional benefit:
If a patient sees how advanced calcification is in his coronary vessels, he will take
our advice to quit smoking and get into
exercise more seriously than if we were to
simply show him 2D images from PACS.

Detecting the Exact Position,


Extent, and Length of Stenoses
Since the syngo WebSpace client-server
technology works with the proven syngo
InSpace4D post-processing software, no
additional training is necessary for users of
the workstation based InSpace 4D. All
post-processing functions can be used
from a PACS workstation, as well as a PC or
laptop. syngo WebSpace even enables for
example, more precise preparation for
vascular intervention. In this 76-year-oldman, we see a somewhat unusual position
for the LIMA [left internal mammary
artery], which runs under the thorax. In
addition, the 4D view shows us how the
vessel moves, says Persson, explaining the
images on the screen in the CMIV training
room (Fig. 2). Using this detailed information, surgeons are able to more precisely
plan the opening in the thorax to reach the

Business

1 With syngo WebSpace even criminal cases can be

solved more easily: concerned police stations


have simplified access to virtual autopsies.

coronary vessels. Vascular surgeon Claes


Forssell, MD, agrees and adds: We need,
for example, very precise details regarding the position, length, and extent of
stenoses. The ability to look at 3D/4D
images, even in my office or during surgery, simplifies my work and improves
treatment for my patients. Enhanced
vascular analytical functions such as automatic stenosis measurement and lumen to vessel evaluation are additional,
critical pieces of information that Forssell
and his colleagues can call up anywhere,
even outside the hospital.
Another focus of the CMIV is cardiac examinations. The Dual Source SOMATOM
Definition CT system provides Persson
and his colleagues with high-resolution
real-time images of the beating heart,
using a low dose of contrast agent
without beta blockers. For Professor Persson, syngo WebSpace also plays a critical
role in training: Here in the CMIV training room, I show my students the 3D/4D
images from the computer directly on the
screen. Persson also trains colleagues
from throughout Sweden on working
with 3D post-processing tools such as
syngo InSpace4D, and shows them how
to design more efficient workflows with
syngo WebSpace. The next course will

2 A 76-year-old man with LIMA (left internal mammary artery),

running under the thorax.

take place in early 2008 (see page 59).

Virtual Autopsies
Clarify Criminal Cases
Because of its modern equipment, the
CMIV also works on solving criminal cases.
According to Persson, since the centers
founding in 2003, it has performed almost
200 virtual autopsies. In some of the
cases, with our modern imaging capabilities we came up with a cause of death
different than the obvious one, reports
Persson proudly. High-resolution 3D imaging provides fast, precise information on
injuries and fractures. Using syngo
WebSpace, the information is sent just
as quickly to the corresponding police
stations and district attorneys offices.
Professor Persson is very satisfied with
the capabilities that syngo WebSpace and
syngo InSpace4D offer his radiology team
and the clinicians at the university hospital, especially in vascular analysis and the
planning for surgery, as well as in training.
I hope that we will also be able to view
3D/4D images from other applications
at our morning meetings, such as blood
flow and oncology. By keeping a focus
on the big picture, Perssons research and
that of the CMIV do not stop with imaging.

Overview: Center of
Medical Image Science
Visualization (CMIV),
Linkping, Sweden

Founded in 2003 at Linkping


University Hospital, Sweden
Research and training center
with 70 researchers and 31 doctoral candidates
Four areas of research: Imaging
and reconstruction, image analysis and description, image visualization and processing, as well
as transfer of comprehensive image data
Selection of projects: Studies on
cardiac and vascular blood flow,
vascular morphology, segmentation and transfer of CT and MR
data, including volume rendering
for clinical application

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

19

Clinical Outcomes Cardiovascular

Case 1
Assessment of a Coronary Anomaly and
a Huge Myocardial Bridge With Dual Source
CT-Angiography
By W. Alexander Leber, MD, Konstantin Nikolaou, MD, Christoph Becker, MD,
Department of Clinical Radiology, University Hospital of Munich-Grosshadern, Munich, Germany

HISTORY
A 77-year-old patient was admitted to
the hospital with stable angina during
stress and apical hypokinesia under
dobutamine stress echocardiography.

DIAGNOSIS
Dual Source CT- Angiography delineated
a coronary anomaly with the left coronary artery (LCA) originating from the
ostium of the right coronary artery (RCA).

The course of the LCA is completely


intramyocardialy over a 46 mm section
to the origin of the Left Circumflex (LCX).
A stenotic atherosclerotic lesion was be
ruled out.

COMMENTS
The symptoms as well as the stress induced wall motion abnormality are
explained by this large myocardial bridge.

1A

This pathology remained clinically silent


until the patient subsequently developed dysfunctional diastolic relaxation
due to hypertension and aging with a
subsequent increase in diastolic left
ventricular pressure (LVEDP 18 mmHG).
After initiating treatment with an angiotensin converting enzyme inhibitor, a
calcium channel blocker and an
angiotensin-1 inhibitor, the complaints
gradually resolved.

1B

1 Curved multiplanar CT images showing excellent visualization of the course of the left coronary artery (Fig. 1A)

and the ostium of the right coronary artery (Fig. 1B).

20 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Cardiovascular Clinical Outcomes

2A

2B

2 Cath Lab view (inverted MIP) allows rule-out of stenotic atherosclerotic lesion.

3A

3B

3 Due to Spiral Dual Energy VRT the course of the LCA can be excellently visualized (Fig. 3A). Ostium hidden in the

intramyocardial structure is identied (Fig. 3B).

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition

Scan area

Cardiac Scan

Rotation time

0.33 s

Scan time

8s

Slice collimation

64 x 0.6 mm

Scan direction

cranio-caudal

Slice width

0.75 mm

Heart rate

60 bpm

Pitch

0.2 automatically adapted by the

Tube voltage

100 kV

Temporal resolution

HR Independent 83 ms

Reconstruction increment

0.5 mm

Spatial resolution

0.33 mm

Kernel

B26f

Tube current

287 mAs/rot.

scanner depending on the heart rate

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

21

Clinical Outcomes Cardiovascular

Case 2
SOMATOM Definition:
Ultra low Dose Cardiac CTA-Sequence
By Joerg Hausleiter, MD, Franziska Herrmann, MD, Stefan Martinoff, MD, German Heart Center, Munich, Germany

HISTORY
A 66-year-old male patient was presented
to rule-out severe calcification and significant stenosis. The patient had a history

of high cholesterol as well as a family history of cardiovascular disease. Since the


patient was free of symptoms and showed

a stable heart rate, a cardiac sequence


mode was selected to achieve the lowest
possible radiation exposure.

1
1 Rule-out of

signicant
stenosis in all
major vessels at
lowest dose of
1,5 mSv.

22 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Cardiovascular Clinical Outcomes

2 LMCA*, LAD** without hemodynamically signicant

3 RCA*** without hemodynamically signicant stenosis.

stenosis, minor soft plaque in proximal LAD.

DIAGNOSIS
Calcium scoring excluded significant calcifications, with the resulting score
below the age-related 10th percentile.
CT Angiography revealed multiple, very
minor, soft plaques without any hemodynamic relevance (Fig. 13), but did not
reveal any high-grade stenosis.

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition

Scan area

Heart

Scan length

133 mm

Scan time

14 s

Heart rate

50 bpm

Tube voltage

120 kV

Tube current

210 mAs/rot.

COMMENTS

Temporal resolution

83 ms heart rate independent

Spatial resolution

0.33 mm

The SOMATOM Definition allows for a true


temporal resolution of 83 ms and thus
increases robustness for cardiac scanning.
Here, a coronary CT angio-graphy was
performed with cardiac sequence technique, a so-called step-and-shoot mode.
For this, a prospectively triggered acquisition mode is used, resulting in lowest
possible radiation exposure. In this
patient (BMI 26.6, 110 kg) the CTA was
performed with an effective dose of 1.5
mSv calculated with conversion factor
of 0,017.

Rotation time

0.33 s

Slice collimation

0.6 mm

*Left Main Coronary Artery


**Left Anterior Descending Artery
***Right Coronary Artery

Slice width

1.2 mm

Reconstruction increment

0.75 mm

CTDIvol

11.96 mGy

Kernel

B20

Contrast
Volume

110 ml

Flow rate

4.5 ml/s

Start delay

7s

Postprocessing

syngo InSpace

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

23

Clinical Outcomes Cardiovascular

Case 3
Detection of an Excentric Plaque Causing
a Relevant Stenosis of Proximal Right Coronary
Artery Using Dual Source Computed Tomography
By Johannes Rixe, MD, Andreas Rolf, MD, Guido Conradi, MD, and Thorsten Dill, MD, FESC,
Kerckhoff Heart Center, Department of Cardiology/Cardiovascular Imaging, Bad Nauheim, Germany

HISTORY
A 62-year-old female patient was admitted to hospital with recurrent episodes of
tachycardia. On ECG paroxysmal atrial
fibrillation was documented. Since she
was highly symptomatic with shortness
of breath and chest pain during tachycardia, radiofrequency ablation of atrial
fibrillation was successfully performed.
As there was one episode of tachycardia
with ST-segment depression associated
with chest pain, but coronary artery
disease had been ruled out invasively
two years prior, she was referred for CT
coronary angiography.

1
1 Volume rendering

technique image
(VRT) of the right
coronary artery
(RCA) demonstrating
a relevant stenosis
of the proximal vessel segment.

DIAGNOSIS
The patient was scanned on a Dual
Source CT (DSCT) scanner. Since she was
on continuous beta-blocker medication
no beta-blocker was given, but nitroglycerine was administered sublingually.
During CT scan, mean heart rate was
56 bpm. DSCT coronary angiography
accurately demonstrated an extensive
excentric mixed coronary plaque causing
a subtotal stenosis of the lumen of the
proximal right coronary artery.
Thus, invasive angiography was performed
and the patient received a 3.5 mm bare
metal stent. She was discharged from
hospital, symptom-free, two days later.

24 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

2 Maximum intensity

projection (MIP)
of the proximal segment of RCA, demonstrating a mixed
coronary plaque
with signs of atherosclerotic vessel
remodeling.

Cardiovascular Clinical Outcomes

3
3 The VRT image of

the entire heart


with pulmonary vessels shows the highgrade stenosis of
proximal RCA

COMMENTS
4
4 The VRT image of

left anterior descending artery


(LAD) and left circumflex artery (CX)
demonstrates that
both LAD and CX are
inconspicuous in
their entire course.

Due to its excellent temporal and spatial


resolution, the SOMATOM Definition CT
scanner allows accurate and artifact-free
visualization of coronary arteries as well
as coronary plaques. As a heart-rate controlling pre-medication is dispensable, a
non-invasive coronary angiography can
be reliably performed, even under conditions of daily routine, where an invasive
approach is not imperatively indicated.
This example shows accurate detection
of coronary plaque burden and presence
of a high-grade stenosis of right coronary
artery as a rather unexpected finding. It
underlines the potential of DSCT for fast
and non-invasive coronary angiography
in selected patients.

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition

Scan area

Heart

Slice width

0.75 mm

Scan length

124 mm

Pitch

0.22 automatically adapted by the

Scan time

11.57 s

Scan direction

Cranio-caudal

Reconstruction increment

Heart rate

57 bpm

CTDIvol

53.72 mGy

Tube voltage

120 kV

Kernel

B26f

Temporal resolution

83 ms heart rate indpendent

Contrast

Iopamidole 370

Spatial resolution

0.33 mm

Volume

65 ml

Tube current

400 mAs/rot.

Flow rate

5 ml/s

Rotation time

0.33 s

Start delay

Test bolus transit time + 2 s

Slice collimation

0.6 mm

Postprocessing

MPR, cMPR, MIP, VRT, syngo Circulation

scanner, depending on the heart rate


0.4 mm

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

25

Clinical Outcomes Cardiovascular

Case 4
Acute Myocardial Infarction and Complication of
Non-Calcified Plaque in Left Anterior Descending
Coronary Artery
A. De La Vega, MD*, P. Urdiales, MD**, J. Pereyra, MD**, A. Schroeder, MD*,**
*Department of Radiology, Institute of Imaging, Neuqun, Argentina
**Department of Cardiology, Cardiovascular Institute of South, Cipolletti, Argentina

HISTORY

1 Basal short axis

view in late enhance T1 TFL 2D


segmented with
non-selective inversion pulse MRI
demonstrating
acute transmural
infarction of the
anterior wall visualized like rim of
hyper-enhancement. The central
area of hypo signal
is corresponding to
the region of nonreflow or micro vascular obstruction.

2 Atherosclerotic

non-calcified
plaque in proximal
segment of left
anterior descending coronary artery with significant stenosis
(arrow).

26 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

A 63-years-old female patient with atypical chest pain and suspicions of acute
aortic syndrome arrived at our institution.
The echocardiogram demonstrated abnormal findings in right Valsalva sinus
like intimal tear which was confirmed by
transesophageal echocardiogram. Contrast enhanced MR angiography of the
thoracic aortic artery was performed
without signs of dissection, haematoma,
or intimal tears and was complemented
with cardiac exploration. Hypokinesis of
anterobasal wall was visualized in cine
MR acquisition and acute transmural infarction with no reflow area of the anterior wall was found in late enhancement.
A cardiac CT scan was performed to investigate possible lesion of the left anterior descending coronary artery.

DIAGNOSIS
The root aortic artery and Valsalva sinus
were visualized and clearly determined to
be free of dissection, intramural haematoma, or intimal tears. In addition, threedimensional reconstruction of the heart
coronary arteries was made using the
multi-modality workstation. syngo
InSpace4D and syngo Circulation were
used for anatomic coronary arteries
evaluation as well as morphologic and
functional left ventricular analysis.
The left anterior descending artery showed
atherosclerotic, non-calcified plaque in
the proximal segment with significant
stenosis. The left main coronary artery
and left circumflex coronary artery
showed both vessels free of significant

Cardiovascular Clinical Outcomes

3 Correlation with coronary angiography.

4 Coronary dissection in proximal segment of left anterior descend-

ing artery, with persistence of contrast media in false lumen.

stenosis and atherosclerotic plaque disease. The right coronary artery was visualized with an atherosclerotic plaque in
proximal segment without significant stenosis. The percutaneous coronary angiography of the left anterior descending
coronary artery shows significant stenosis complicated with intimal dissection
and abnormal blood flow type TIMI II. An
Angioplasty and stent placement (Evolution 3.5 x 18 mm) in the lesion site was
performed to restore blood flow to the left
anterior descending coronary artery.

COMMENTS
In this patient with non-typical chest pain,
the MR angiography was able to eliminate
acute aortic syndrome and, at the same
time, anterobasal transmural infarction
with no-reflow area could be demonstrated.
Using the previously installed SOMATOM
Sensation 64 Multislice CT, we were able
to identify the etiologic cause of anterior
infarction and characterization of responsible atherosclerotic plaque, leading to
endovascular therapeutic resolution.

EXAMINATION PROTOCOL
Scanner

SOMATOM Sensation 64-slice configuration

Scan area

heart

Slice width

0.6 mm

Scan length

118.4 mm

Pitch

0.2
0.3 mm

Scan time

14.7 s

Reconstruction increment

Scan direction

cranio-caudal

CTDIvol

59 mGy

Heart rate

65 bpm

Kernel

B40f

Tube voltage

120 kV

Contrast

350 mg/iodine/ml

Temporal resolution

up to 83 ms

Volume

70 ml
4.5 ml/s

Spatial resolution

0.33 mm

Flow rate

Tube current

850 eff. mAs

Start delay

21 s

Rotation time

0.33 s

Postprocessing

syngo Circulation

Slice collimation

0.6 mm

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

27

Clinical Outcomes Oncology

Case 5
The SOMATOM Definition AS With the
CT Oncology Engine Outstanding Clinical
Outcomes From Diagnosis to
Treatment for Everyday Oncology
By Cathrin Boehner, MD, Department of Diagnostic Radiology, University of Erlangen-Nuremberg, Erlangen, Germany
Louise McKenna, PhD, MBA, Jan Chudzik and Andreas Blaha, CT Division, Siemens Medical Solutions, Forchheim, Germany

28 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Oncology Clinical Outcomes

Siemens newest CT scanner, SOMATOM


Definition AS, is the ideal routine radiology CT scanner. From diagnostic imaging
to biopsy and CT guided, minimally invasive therapies, this is a scanner that has
been designed to be the ultimate allrounder.
In this section, we take a focused look at
how the SOMATOM Definition AS with its
wealth of unique new technologies and
features, can be combined with the CT
Oncology Engine to create a solution that
gives clinicians the opportunity to reach
new levels of diagnostic confidence and
the opportunity to achieve even better
clinical outcomes in routine oncology
imaging.
In routine oncology, CT plays an increasingly important role in diagnostics and
staging. In recent years there has also
been a steady rise in the use of CT for
biopsy and for image guided, minimally
invasive therapies such as radiofrequency
ablation (RFA). The new SOMATOM Definition AS has been designed with these
growing trends in mind. With its Adaptive
3D Intervention and ultra-efficient, new
interventional workflow, the SOMATOM
Definition AS takes interventional CT to
a new level of speed and accuracy.
For all procedures, whether non-fluoroscopic (step and shoot) or fluoroscopic,
the traditional 2D workflow has been significantly enhanced. Beginning with a
new intuitive and fully customizable user
interface, clinicians can tailor everything
from the scan protocols, through image
reconstruction to real-time viewing with
a screen setup that can even include
previous studies for reference. Clinicians
also benefit from i-Auto Needle Detection,
which helps in path planning or determining the position of the needle if it has
gone outside the scan range when using
step and shoot modes. When extra clarity
is needed, the i-PrecisionView allows
one-touch adjustment of mAs settings
for the next scan, returning automatically
to the dose managed protocol on the
next scan. Additionally i-NeedleSharp
facilitates additional clarity when using
artefact-prone materials such as metal
needles.
The SOMATOM Definition AS also features
a completely new concept for in-room
control. The i-Control delivers the ultimate

i-Control ultimate level of in-room control for minimally invasive procedures.

in remote in-room control for the entire


interventional procedure. In combination
with a foot switch for activating the scan,
clinicians are able, to carry out the entire
procedure without the need for additional
personnel. The i-Control facilitates full control of the syngo Acquisition Workplace via
a remote mouse joystick; it also features
full table control offering one-click positioning to last scan or table position. In
addition, images can be windowed according to customizable presets.
But the most trendsetting innovation
for interventional CT is the possibility to
perform interventions using 3D guidance.
Adaptive 3D Intervention allows clinicians to acquire a spiral scan (i-Spiral)
of up to 40 cm, with a single click, at any
point during the interventional procedure.
Images are reconstructed in real time
and can be directly used to assess needle
position in 3D viewing of coronal and

sagittal as well as axial images, which is


especially important in more complex
procedures, such as oblique entry in the
thorax. The spiral acquisition also facilitates visualization as a VRT, a view that
offers an excellent real life representation of the needle position in relation to
sensitive organs or vascular structures,
for example.
The exceptional flexibility offered by
the SOMATOM Definition AS opens the
door to a range of workflow improvements with the potential to improve
patient care and clinical outcomes. From
drainages, to alcohol or cement flow
monitoring for pain therapy, the ability to
get fast and reliable 3D images in combination with features such as i-Auto Needle Detection, offers clinicians a new level
of speed for daily routine plus exceptional
precision and confidence for more complex procedures.

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

29

Clinical Outcomes Oncology

1A

1B

1C

1D

1E

1 Target lesion 1 (Fig. 1A, 1B) and lesion 2 (Fig.1C upper images)

demonstrated rapid growth. Significant growth was recorded at


three monthly intervals. 1C: At the final pre-therapy scan these
lesions had grown 276% and 59% respectively (in 3D volume).
1D + 1E: A third lesion was identified in follow-up scan that was
not identified in the initial follow-up scan.

In the following case Cathrin Boehner,


MD, from the University of ErlangenNurembergs Department of Diagnostic
shares with us her first experiences of
the SOMATOM Definition AS with
Adaptive 3D Intervention.

vals. Target lesions demonstrated an


overall growth. Due to the size and position of the lesions, the oncology team decided that radio-frequency ablation (RFA)
was the most appropriate therapy option
at this stage.

HISTORY

IMAGES AND COMMENTS

A 67-year-old, female patient underwent


routine CT for follow-up of colon cancer.
The initial staging thorax CT in 2006
revealed several metastatic lung lesions
that were monitored at 3-monthly inter-

syngo CT Oncology was used for followup of target lesions and sequential evaluation revealed significant growth (Fig. 1).
This SW facilitates automated lesion
matching, which is particularly useful in

30 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

the lung where lesions may be displaced


due to differences in lung volume dependent upon breath hold. Computer calculation of growth parameters eliminates
inter-reader differences in lesion size
evaluation and the calculation of volume
allows us to gain a better overview of the
growth of the lesions as a whole in comparison to the 2D measurement alone.
For RFA procedure the new SOMATOM
Definition AS uniquely offers the ability
to perform real time 3D interventions.
The ability to instantly visualize the
needle position in coronal and sagittal

Oncology Clinical Outcomes

planes as an integrated part of the interventional scanning workflow is very


desirable for these more complex procedures, where careful positioning in
relation to sensitive anatomies is vital to
ensure the best possible clinical outcome.
This is very often the case for lungs
where oblique entry may cause issues for
needle visualization when using 2D only
(Fig. 2).
The reduction of needle artifacts proved
invaluable for the ablation of the smaller
lesion. At 6 mm, it could easily have been
obliterated in the images due to the rela-

tively large size of the needle combined


with artifacts. Applying i-NeedleSharp
allowed a greater degree of accuracy for
targeting the small lesion with the first
shot.
Since we prefer to use a step-n-shoot
approach, the one-click table positioning
and rapid image refresh rate, even when
incorporating an interventional spiral
(i-Spiral), are good for workflow optimization. An additional plus is that we can
also use CARE Dose4D and HandCARE for
interventional procedures. This means
that we not only save dose by being more

accurate, but also through active dose


management, which is a huge plus in
terms of patient care.
Overall, our first experiences with the
SOMATOM Definition AS have been very
positive. We believe that the innovative
interventional workflow will allow us
to be faster in our routine cases and
enhance clinical outcomes in terms of
speed, accuracy and, of course, risk minimization for complex interventional
procedures.

2 Auto needle detection facilitates accurate path-planning in sagittal, axial and coronal images (top). Original scan images

are seen in the second row. Users can select further images such as topogram and colored VRT images for easy reference
during the procedure. Images are updated in real time and the layout can be changed at the click of a button.

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

31

Clinical Outcomes Oncology

Case 6
Hide and Seek CT Colonoscopy
Solves the Riddle
By Rolf Janka, MD, Department of Diagnostic Radiology,
University of Erlangen-Nuremberg, Erlangen, Germany

HISTORY

DIAGNOSIS

A 79-year-old, male patient was referred


for CT colonoscopy (CTC) following optical colonoscopy. Unusually, the request
was not due to an incomplete optical
colonoscopy. The patient was referred
because the gastroenterologist had identified a large polyp for resection but was
unable to identify its exact location and
secure it for resection during the optical
procedure.

The patient was scanned using our standard, low-dose protocol on a SOMATOM
Sensation 64 in both the prone and supine positions. The CT images immediately
revealed the reason behind the difficulties
experienced by the gastroenterologist.
The patient exhibited the anatomical
anomaly, situs inversus, a partial malrotation of the colon where the internal organs are reversed inside the abdominal

cavity and the small bowel is located lateral to the descending colon. If this condition has not been previously identified
in a patient, it is impossible for the gastroenterologist to recognize during an optical procedure.
Using CTC, we were able to demonstrate
the exact size and location of the polyp
(Fig. 1) to the gastroenterological surgeon. The global view together with the

1
1 The 1.66 cm polyp (2b)

was identied in the


ascending colon,
approximately 203 cm
from the rectum.

32 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Oncology Clinical Outcomes

2
2 An additional 0.5 cm

polyp in the sigmoid


colon was identied in
the CTC exam.

3D virtual endoscopy, with automatic size


measurement, proved convincing tools
for communication with our surgical colleagues. Additionally, we were able to
identify another smaller lesion in the sigmoid colon which had not been identified
in the optical exam (Fig. 2).

COMMENTS
This case clearly demonstrates the clinical
benefit of x-ray vision for difficult anatomical cases. CTC gave us a clear picture
of the entire anatomy and, using syngo
Colonography CT, we were able to confidently guide the surgeons to a successful
clinical outcome.

EXAMINATION PROTOCOL
Scanner

SOMATOM Sensation 64-slice configuration

Scan area

Abdomen

Scan length

500 mm

Scan time

9s

Scan direction

cranio-caudal

Tube voltage

120 kV

Tube current

30 eff. mAs and 15 eff. mAs

Rotation time

0.5 s

Slice collimation

0.6 mm

Slice width

1.0 mm

Pitch

1.4

Reconstruction increment

0.7 mm

Kernel

B20/ B10

Postprocessing

syngo Colonography CT

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

33

Clinical Outcomes Oncology

Case 7
Follow-up of Pediatric Patient With
Lymphoma Enhanced Diagnostic Confidence
With syngo CT Oncology
By Tanja Radkow, MD, and Axel Kuettner, MD, Department of Diagnostic Radiology,
University of Erlangen-Nuremberg, Erlangen, Germany.

HISTORY

DIAGNOSIS

A 7-year-old patient was referred to the


University Pediatric Clinic after presenting
with unexplained chronic fatigue. The
patient was diagnosed with a stage IVb
Hodgkin lymphoma and underwent
chemo and radiation therapy. Following
treatment, residual lymph nodes in the
para-cecal and para-aortal regions
remained.

At the initial 15-month follow-up scan,


evaluation of target cecal lymph nodes
indicated a slight increase in the size of
target lesions. A diagnostic laparoscopy
and lymph node biopsy was performed.
The histopathology was negative.
At the next 4-month follow-up exam,
correlation and evaluation of target lymph
nodes reading only the axial images
proved challenging due to the removal of
some lymph nodes (Fig. 1), and moreover, due to the mobile-nature lymph
nodes in the abdominal region. Addition-

1 Target lesion 4 had been resected at biopsy (arrow).

34 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

ally, the previous CT images were acquired during expiration, while current
images were acquired during inspiration,
leading to a considerable displacement of
target lymph nodes. This is not an unusual situation, particularly when scanning
young children or other low compliance
patients.
Using syngo CT Oncology, we were able
to register the two exams and automatically propagate all target lesions to the
follow-up exam. Due to the precise registration it was relatively easy to confirm

Oncology Clinical Outcomes

matching target lesions, even in clusters.


Calculation of the percentage change in
size of the lesions was automatically
calculated by the software. Overall, assessment of target lesions revealed a
-23 percent (RECIST) change in total
tumor burden (Fig. 2) demonstrating that
there was no progression, which correlated with the negative histopathology
results.

COMMENTS
Having access to software that supports
routine diagnostic oncology workflow with
automated tools that facilitate precise
alignment, plus calculation of tumor size
and growth, provides increased diagnostic confidence that is particularly appreciated in sensitive pediatric cases like this.

EXAMINATION PROTOCOL
Scanner

SOMATOM Sensation 64-slice configuration

Scan area

Thorax Abdomen

Scan length

500 mm

Scan time

11 s

Scan direction

cranio-caudal

Tube voltage

120 kV

Tube current

80 eff. mAs

Rotation time

0.5 s

Slice collimation

0.6 mm

Slice width

1.0 mm

Pitch

1.2

Reconstruction increment

0.8

Kernel

B41f/B70f

Postprocessing

syngo CT Oncology

2 Overall, the total tumor burden has remained constant indicating that there has been no disease progression in

the 19 months since treatment, comparing initial examination (left) with last follow-up.

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

35

Clinical Outcomes Oncology

Case 8
Quantitative Measurement of Emphysema
Using the Automated Lung Parenchyma Analysis
Software of syngo InSpace4D
By Florian F. Behrendt, MD*, Rolf W. Gnther, MD*, Marco Das, MD*, Thomas Kraus, MD**
*Department of Diagnostic Radiology, University Hospital, RWTH-Aachen University, Germany
**Department of Occupational Health, University Hospital, RWTH-Aachen University, Germany

HISTORY
A 59-year-old asbestos-exposed, male
patient who underwent MDCT as part of a
lung cancer screening trial was evaluated1.

DIAGNOSIS
The patient showed severe centrilobular
emphysema with architectural destruction.
Further analysis was performed using
syngo InSpace4D with a new automated
lung parenchyma analysis software. After
initial 3D segmentation of the lung, the
program automatically detects the lung
contours and the airways. Then attenuation areas below -950 HU are segmented
as emphysema. This threshold has been
pathologically validated in several studies2,
3, 4
. Total lung volume (TLV) and emphysema volume (EV) were calculated. Furthermore, areas of emphysema were segmented into four clusters with different volumes
(cluster 1: 2 8 l; cluster 2: 865 l; cluster 3: 65 187 l; cluster 4: > 187 l).
Software analysis showed a TLV of 8010 ml
and an EV of 26.2 percent. Analysis of em-

physema clusters resulted in emphysema


volumes of 0.8 percent, 1.1 percent, 0.4
percent, 23.2 percent for clusters 14,
respectively.

COMMENTS
The automated lung parenchyma analysis
software which is integrated in syngo
InSpace4D allows quick and reliable threedimensional evaluation of emphysema,
including TLV and EV. Furthermore pattern
diagnosis and distribution of emphysema
can be calculated. Regional differences can
be observed and the exact localisation of
the emphysema can be described which
yields potential benefit before volume reduction surgery of the lung and therapy
response control. In a further step, an
analysis of different emphysema cluster,
which result in a so called bulla index (BI)
was performed. This type of analysis is a
new feature compared to previous quantification software (e.g. syngo Pulmo CT)5, 6.
This advanced evaluation of the emphy-

1
1 The software allows

a quantitative threedimensional analysis of


the pulmonary emphysema and gives information about total
lung volume and emphysema volume. The
low attenuation volume (LAV in %) represents the emphysema
index.

sema could be important especially for


the monitoring of clinical trials of therapy
if a shift between the different clusters is
detected. A shift, for example, from large
clusters to small clusters is a sign of a
possible therapy success.
The new automated lung parenchyma
analysis software provided a detailed
3D analysis of the pattern of pulmonary
emphysema.

EXAMINATION PROTOCOL
Scanner

SOMATOM

Scan area

chest

Slice collimation

0.75 mm

Scan length

372 mm

Slice width

1 mm

Scan time

16 s

Sensation

Pitch

Scan direction

cranio-caudal

Reconstruction increment

0.7 mm

Kernel

B40

Tube voltage

120 kV

Tube current

63 eff. mAs

Rotation time

0.5 s

Contrast

none

Postprocessing

syngo InSpace4D
Automated Lung
Parenchyma
Analysis Software

36 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Oncology Clinical Outcomes

2A

2B

2C

2D

2 The color coded clustering shows the distribution of the emphysema in

the lung. The absolute volume of size 4 clusters (red colored) is 23.2 percent
of the whole lung volume, which indicates a severe emphysema.

References
1 Das M, Muhlenbruch G, Mahnken AH, et al. Asbestos Surveillance Program Aachen (ASPA): Initial
results from baseline screening for lung cancer in
asbestos-exposed high-risk individuals using low-dose
multidetector-row CT. Eur Radiol 2007;17:1193-9.
2 Gevenois PA, de Maertelaer V, De Vuyst P, et al.:
Comparison of computed density and macroscopic
morphometry in pulmonary emphysema. Am J
Respir Crit Care Med 1995;152:653-7.
3 Gevenois PA, De Vuyst P, de Maertelaer V, et al.:

Comparison of computed density and microscopic


morphometry in pulmonary emphysema.
Am J Respir Crit Care Med 1996;154:187-92.
4 Bankier AA, De Maertelaer V, Keyzer C, et al.: Pulmonary emphysema: subjective visual grading versus
objective quantification with macroscopic morphometry and thin-section CT densitometry. Radiology
1999;211:851-8.
5 Zaporozhan J, Ley S, Eberhardt R, et al.: Paired inspiratory/expiratory volumetric thin-slice CT scan for

emphysema analysis: comparison of different quantitative evaluations and pulmonary function test.
Chest 2005;128:3212-20.
6 Zaporozhan J, Ley S, Weinheimer O, et al.: Multidetector CT of the chest: influence of dose onto
quantitative evaluation of severe emphysema:
a simulation study. J Comput Assist Tomogr
2006;30:460-8.

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

37

Clinical Outcomes Neurology

Case 9
Dual Energy for Ruling out Sinus Thrombosis
or Cerebral Abscess From Acute Parenchymal
Hemorrhage at Right Parietal Lobe
By Dominik Morhard, MD, Thorsten R. Johnson, MD, Prof. Maximilian F. Reiser, MD, and Christoph Becker, MD, PD,
Department of Clinical Radiology, University Hospital of Munich-Grohadern, Munich, Germany

HISTORY

COMMENTS

A 67-year-old male patient with known


multiple myeloma, stadium 3, under anticoagulatory therapy after aortic valve
reconstruction, presented at the emergency room with a right sided visual field
defect. Initial non-enhanced CT (NECT)
showed an acute parenchymal hemorrhage at the left parietal lobe (Fig. 1).
To rule out sinus-thrombosis or cerebral
abscesses, a Spiral Dual Energy CT (DECT)
scan was performed after intravenous iodine contrast agent application. Material
differentiation using the so called LiverVNC algorithm and slightly modified default parameters (Fig. 2) resulted in
a virtual non-enhanced / native (VN) and
color-coded semi-quantitative iodine concentration (C) images1. Fused MPR images of VN and C images showed a solitary,
pathological contrast enhancement in
the centre of the hemorrhage (Fig. 3)
that was masked by the surrounding hyper dense blood in the standard CT images without selective material differentiation. MRI, performed six hours later,
showed a good correlation of the T1weighted gadolinium-enhanced images
to the DECT (Fig. 4).

The Liver VNC algorithm, which was


used for material differentiation in this
case was optimized for parenchymal organs of the abdomen such as liver and
kidneys. Specific modifications and filters
on the algorithm for brain analysis and
examinations with a radiation dose comparable to standard cranial CT scans
(Note: CTDI of this examination: 29.0)
may result in improved image quality.
Possible future applications for DECT of
the head could be routinely contrastenhanced scanning with reconstruction
of virtual non-enhanced images without

a previous NECT to rule out hemorrhage


resulting in a radiation dose reduced
by half.
References
1 Johnson TR, Krauss B, Sedlmair M, Grasruck M,
Bruder H, Morhard D, Fink C, Weckbach S, Lenhard
M, Schmidt B, Flohr T, Reiser MF, Becker CR. Material
differentiation by dual energy CT: initial experience.
Eur Radiol. 2007 Jun;17(6):15107. Epub 2006 Dec 7.
2 Wavre A, Baur AS, Betz M, Mhlematter D, Jotterand
M, Zaman K, Ketterer N. Case study of intracerebral
plasmacytoma as an initial presentation of multiple
myeloma. Neuro Oncol. 2007Jul; 9(3):3702. Epub
2007 May 23.

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition

Scan area

Head

Scan length

180 mm

Scan time

23 s

Scan direction

cranio-caudal

Tube voltage A/B

140 kV / 80 kV

Tube curren A/B

84 eff. mAs / 357 eff. mAs

Rotation time

0.33 s

Slice collimation

0.6 mm

DIAGNOSIS

Slice width

1 mm

Pitch

0.8

A solitary spot of contrast enhancement


in the centre of an acute parenchymal
hemorrhage and ruled out sinus thrombosis guides the diagnosis to malignant
tumor. Although intracerebral plasmacytoma is very rare, this is the most
probable diagnosis2. Unfortunately the
patient died on the second day after
symptom onset. As there was no bioptical
probe taken, a final histological diagnosis
is missing.

Reconstruction increment

0.75 mm

CTDIvol

29 mGy

Kernel

D31

Contrast
Volume

95 ml

Flow rate

2.4 ml/s

Start delay

180 s

Postprocessing

Liver-VNC-algorithm on a syngo MMWP running the dual energy


application, cross-sectional thick-MPR-Reformations (5 mm)

VNC = Virtual Non-Contrast, MPR = Multiplanar Reformation

38 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Neurology Clinical Outcomes

1 NECT showing an acute parenchymal hemorrhage

2 Settings for material differentiation by Spiral Dual Energy using

in the left parietal lobe.

the Liver VNC algorithm.

3 Fused MPR images of virtual non-enhanced and iodine

images shows a solitary, pathological contrast enhancement in the centre of the hemorrhage (arrow).

4 MRI, performed six hours after the DECT, shows a good correlation

of the T1-weighted gadolinium-enhanced images to the DECT (arrow).

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

39

Clinical Outcomes Neurology

Case 10
Multisection CT for Complete Evaluation of
Patients With Subarachnoid Hemorrhage (SAH)
By Bernd F. Tomandl, MD, Department of Neuroradiology, Klinikum Bremen, Bremen, Germany

HISTORY

COMMENTS

A 48-year-old man was delivered to our


hospital with suspected subarachnoid
hemorrhage Grade II (Hunt and Hess).
Non-enhanced CT confirmed the diagnosis
of SAH and CT-angiography was performed immediately. We found a small
(3 mm) aneurysm of the distal internal
carotid artery that was treated with coils
later the same day. Six days later, the
patient developed right-sided hemiplegia
and aphasia. Vasospasm was suspected
and confirmed with ultrasound. CT-angiography and CT-perfusion were performed, showing severe vasospasm of
the cerebral arteries of the left hemisphere
with markedly reduced values of CBF and
CBV already evident. Therefore, the patient was immediately treated with intraarterial administration of Nimodipine
which led to improvement of both vasospasm and clinical symptoms.

In Patients with subarchnoid hemorrhage


(SAH), the fast detection of the source
of bleeding is mandatory for therapy
planning. CT-angiography is a well established tool and has meanwhile replaced
DSA for the initial search for aneurysms
in many institutions, as it allows not only
for detection of the aneurysms but also
for therapy planning for both clipping
and coiling. Beneath the three dimensional imaging, exact measurement of an
aneurysm is achieved allowing for determination of the size of the first coil if
interventional therapy is possible. But
even if the initial therapy of an aneurysm
was successful in a patient with SAH,

many patients will still develop vasospasm, possibly leading to infarction


or even death. Multisection CT allows
detection of severe vasospasm with the
use of CTA which is most helpful when
combined with CT-perfusion. Vasospasm
can be treated with administration of
vasoactive subtances or with balloondilatation.
Thus multisection CT with its abilities to
precisely demonstrate the intracerebral
arteries in combination with CT-perfusion
allows a complete evaluation of patients
with subarachnoid hemorrhage: aneurysm detection, therapy planning and
evaluation of vasospasm.

EXAMINATION PROTOCOL
Scanner

SOMATOM Sensation

Scan area

first cervical body to vertex

Scan length

15 cm

Scan time

20 s

Scan direction

Caudo-cranial

Tube voltage

120 kV

Tube current

160 eff. mAs

Rotation time

0.5 s

Slice collimation

4 x 1 mm

Slice width

1.25 mm

Pitch

0.875

Reconstruction increment

0.5 mm

CTDIvol

27.8 mGy

Kernel

B30

FoV

120 mm2

Contrast
Volume

80 ml

Flow rate

4 ml/s

Start delay

Bolus tracking

Postprocessing

Thin section MIP (15mm), Volume Rendering

40 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Neurology Clinical Outcomes

1A

1B

1C

1 Small Aneurysm (arrow) of the distal internal carotid artery at the origin of the anterior choroids artery

demonstrated on thin section (15 mm) MIP and volume rendered CTA in comparison to DSA.

2A

2B

2 CTA and DSA on the day of

admission (left) in comparison


to the ndings of CTA and
DSA six days later, showing
severe vasospasm of the arteries of the left hemisphere.

3A

3B

3 Maps of CBF and CBV show

an area of severely decreased


perfusion in the anterior part
of the MCA territory thus
explaining the clinical condition
of the patient with hemiplegia
of the right side and aphasia.

CBF = Cerebral Blood Flow, CBV = Cerebral Blood Volume


MCA = Middle Cerebral Artery, DSA = Digital Subjection Angiography
SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

41

Clinical Outcomes Acute Care

Case 11
Dual Source CT Perfusion Defect Visualization
With Spiral Dual Energy Scanning
Benot Ghaye, MD and Jean-Franois Monville, MD,
Department of Medical Imaging, University Hospital of Lige, Lige, Belgium

HISTORY

DIAGNOSIS

A 76-year-old male presented to the


emergency department with sudden onset
of dyspnoea. Pulmonary embolism was
suspected and the patient was referred
to our department for CT pulmonary
angiography. A Dual Source CT scan of
the thorax was performed on the
SOMATOM Definition using Spiral Dual
Energy evaluation.

The dual energy scan revealed massive


pulmonary embolism and consequent
peripheral perfusion defects. The patient
was transferred to ICU and treated with
anticoagulation and supportive therapy.

COMMENTS
In the dual energy mode, two x-ray sources
are operated simultaneously at different

kV levels of 80 kV and 140 kV. The


resulting two spiral data sets acquired in
a single scan provide diverse information
that allows differentiating, characterizing, isolating and distinguishing the
imaged tissue and material.
In the thorax, dual energy mode allows
investigating lung perfusion after iodinated contrast medium injection. In
patients with pulmonary embolism, the

1
1 Excellent visualization of

perfusion defects made


possible by spiral dual energy
scanning.

42 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Acute Care Clinical Outcomes

dual energy mode provides new areas


of research, as both morphologic and
functional information of the effect of
intravascular clots on lung perfusion are
obtained using a single modality.
Note
The information presented in this case study is for
illustration only and is not intended to be relied upon
by the reader for instruction as to the practice of
medicine. Any health care practitioner reading this
information is reminded that they must use their
own learning, training and expertise in dealing with
their individual patients. This material does not
substitute for that duty and is not intended by
Siemens Medical Systems to be used for any purpose
in that regard.
The drugs and doses mentioned herein are consistent
with the approval labeling for uses and/or indications
of the drug. The treating physician bears the sole
responsibility for the diagnosis and treatment of
patients, including drugs and doses prescribed in
connection with such use. The Operating Instructions
must always be strictly followed when operating
the CT System. The source for the technical data
is the corresponding data sheets. Results may vary.

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition

Scan area

Thorax

Scan length

342mm

Scan time

8s

Scan direction

Caudo-cranial

Tube voltage A/B

140 kV / 80 kV

Tube current A/B

51 eff. mAs / 213 eff. mAs

Rotation time

0.5 s

Slice collimation

0.6 mm

Reconstructed slice thickness

1.5 mm

Spatial Resolution

0.33 mm

Increment

0.5 mm

CTDIvol

6.96 mGy

Kernel

D30f

Contrast
Contrast Amount

100 ml Enhance / 50ml NaCl

Contrast Flow rate

5 ml/s

Start delay

CARE Bolus

Postprocessing

syngo DE lung PBV

2
2 A massive pulmonary embolism and

consequent peripheral perfusion


defects were detected.

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

43

Clinical Outcomes Acute Care

Case 12
Trauma Scan: Active Areas of Contrast
Extravasation Detect Active Hemorrhage
By Savvas Nicolaou, MD, Department of Radiology, Vancouver General Hospital, Vancouver, Canada

HISTORY

DIAGNOSIS

A male patient who had been involved


in a motor vehicle collision was presented
to the emergency department. After being
stabilized, the patient was immediately
transferred to the SOMATOM Definition
scanner for a complete trauma scan of
chest, abdomen and pelvis.

An initial arterial phase of the study was


done to assess the thoracic aorta. On the
most inferior images through the upper
abdomen a splenic laceration with perisplenic hematoma and numerous small
areas of increased attenuation are present
within the spleen indicating small pseu-

1 The initial phase of the study reveals inactive (arrow-head) and active (red arrow)

bleedings as well as complete laceration (arrow).

44 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

doaneurysms and areas of increased


attenuation surrounding the spleen within the perisplenic hematoma. On the
venous portion of the study, the lacerated
spleen and small pseudoaneurysms were
again identified through the perisplenic
hematoma. However, outside the con-

Acute Care Clinical Outcomes

3 The active hemorrhage was identied because the CT scan made active bleeding (white arrows)

and complete laceration (red arrow) clearly distinguishable.

fines of the spleen, areas of greater attenuation were also more clearly recognized.
The regions of increased attenuation
being pathognomonic for areas of active
contrast extravasation clearly indicating
areas of active hemorrhage.
Consequently, the patient was transferred
to the radiological suite, where the pseudoaneurysms and the active areas of hemorrhage were successfully embolized.

COMMENTS
This case is an excellent example of the
clinical utility of the SOMATOM Definition
for trauma scanning. It was the fast and
accurate diagnosis that made it possible to
intervene just as fast and accurately and
successfully treat the hemorrhage.

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition

Scan area

Abdomen

Scan length

400 mm

Scan time

10 s

Scan direction

cranio-caudal

Tube voltage

120 kV

Tube current

250 eff. mAs

Rotation time

0.5 s

Slice collimation

0.6 mm

Slice width

0.6 mm

Pitch

1.2

Reconstruction increment

0.5 mm

CTDIvol

11.5 mGy

Kernel

B20

Contrast
Volume

80ml Enhance /50ml NaCL

Flow rate

4 ml/s

Start delay

CARE Bolus

Postprocessing

syngo InSpace4D

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

45

Science

Adaptive 4D Spiral a Flexible Solution


for Dynamic Scanning
By Thomas Flohr, PhD, Ernst Klotz,
CT Division, Siemens Medical Solutions, Forchheim, Germany

1A

1B

0s

1E

1,2 s

1F

4,8 s

6,0 s

1 Inow and outow of contrast media into the cerebral vasculature of a pig (courtesy of

Aachen University, Germany). One run of the dynamic spiral was acquired every 1.2 s.

46 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Science

The first ten years after the broad introduction of multi-detector row CT (MDCT)
into clinical practice were characterized
by a race for more slices. 4-slice, 8-slice,
16-slice, 32-slice and 64-slice CT-systems
were introduced in rapid succession. With
the latest generation of 64-slice CT-scanners, the whole body can be examined
with isotropic sub-millimetre resolution

1C

in very short scan times, and a further


increase in the number of simultaneously
acquired slices to speed up the system
even more will not necessarily translate
into increased clinical benefit. Hence, the
race for more slices has gradually come
to an end. Instead, new developments are
ongoing to solve remaining limitations
of conventional MDCT-scanners. Dual

Source CT, as an example, can dramatically improve the temporal resolution of cardiac examinations. Dual energy acquisitions have the potential to expand the
scope of CT beyond the mere depiction of
the patients anatomy towards functional
imaging. Yet another challenge is the visualization of dynamic processes in extended anatomical ranges, e.g. to charac-

1D

2,4 s

1G

3,6 s

1H

7,2 s

8,4 s

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

47

Science

terize the inflow and outflow of contrast


agent in the arterial and venous system in
dynamic CT angiographies or to determine
the enhancement characteristics of the
contrast agent in volume perfusion studies. One way to solve this problem is the
introduction of area detectors large
enough to cover entire organs, such as the
heart, the kidneys or the brain, in one axial
scan (requiring 120 mm volume coverage
or more). While CT-systems with area detectors can acquire dynamic volume data
by repeatedly scanning the same anatomical range without table movement, they
have to cope with a number of serious
drawbacks: the wide cone angle of area
detectors cannot be adequately handled by
current non-exact image reconstruction
approaches, with the consequence of cone
beam artifacts in the images. Scattered radiation increases significantly and degrades the stability of Hounsfield numbers
and the signal-to-noise ratio of the images.
The anode angle of the x-ray tube has to
be increased to uniformly illuminate an
area detector in the z-direction. As a conse-

quence, the length of the focal spot on the


anode plate has to be decreased, and the
maximum output of the x-ray tube will be
seriously compromised. Furthermore, area
detector technology is a specialized solution for repeated axial scanning of limited
anatomical ranges, it does not provide any
benefit for the vast majority of routine examinations that are based on conventional
spiral acquisition protocols.
In a sense, area detector technology is
a brute-force approach to the problem of
dynamic volume scanning which can
also be solved by innovative acquisition
schemes using MDCT-technology with limited detector z-coverage. We propose an
adaptive dynamic spiral mode that
allows for time-resolved scanning of areas
larger than the detector width by continuous periodic table movement (Fig.2).
Using an average pitch of 0.5 for volume
perfusion acquisitions at full gantry rotation speed (rotation time 0.30 s), a scan
range of 10 cm (e. g. the entire brain) can
be covered in 1.5 s with a 4 cm detector.
Images in the central scan region are

detector

detector

width

width

scan area

table movement
2 Acquisition principle of the adaptive 4D spiral: time-resolved scanning of areas larger than

the detector width by continuous periodic table movement.

48 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

acquired every 1.5 s, the maximum time


interval between two images at the
boundaries of the scan range is less than
3.0 s. The temporal sampling rate is sufficient for a reliable perfusion evaluation
resulting in a volumetric display of hemodynamic parameters in stroke patients.
Using Patlak analysis, extended head and
body tumors can also be examined. With
an average pitch of 1 for multiphase
studies and 4D CTA acquisitions at full gantry rotation speed (rotation time 0.30 s), a
scan range of 27 cm can be covered in
only 2.5 s with a 4 cm detector, for ex-ample. Due to smooth, optimized table
acceleration and deceleration schemes,
patient comfort is guaranteed. Fig. 1
shows the dynamics of the inflow and outflow of contrast media into the cerebral
vasculature in an animal study performed
at the University of Aachen, Germany. The
new Siemens approach of adaptive CT
scanning has the potential to exceed the
limitations of conventional scanning,
thus offering new insights in functional
CT imaging.

Science

Dual Source CT:


Detecting Urinary Stones by Spiral Dual
Energy Computed Tomography With
Virtual Non-Enhanced Images
Most often, non-enhanced CT scans are performed for the purpose of stone
detection when a contrast-enhanced scan is subsequently planned. But performing several phases may not be routinely justied, especially for younger
patients. In this study, we have assessed the potential of virtual non-enhanced
images using dual source, dual energy data for the detection of urinary stones.
By Paul Stolzmann, MD, Hans Scheffel, MD, Thomas Frauenfelder, MD, Thomas Schertler, MD, Lotus Desbiolles, MD,
Sebastian Leschka, MD, Borut Marincek, MD, Hatem Alkadhi, MD,
Institute of Diagnostic Radiology, University Hospital, Zurich, Switzerland

The Dual Source CT scanner is composed


of two x-ray tubes and two detector units
arranged on the rotating gantry with
an angular offset of 901. When running
both tubes at the same voltage, a high
temporal resolution is achieved that is
used primarily for the evaluation of coronary arteries1. When operating the x-ray
tubes at different tube voltages, two
different x-ray spectra are simultaneously
obtained that improve the characterization and differentiation of various tissues2.

CT for the Detection


of Urinary Stones
Non-enhanced CT of the urinary tract
is recognized as the most accurate technique for the detection of urinary stones3.
Advantages of CT are the high sensitivity
and specificity of the diagnosis and the
simultaneous recognition of other associated pathologies. Most often, non-enhanced CT scans are performed for
the purpose of stone detection when a
contrast-enhanced scan is subsequently
planned. But, performing several phases

may not be routinely justified especially


for younger patients. Thus, techniques
should be developed that enable the
detection of urinary stones using only
one contrast-enhanced scan that would
reduce the total radiation exposure to
the patient. For this purpose virtual nonenhanced images may be generated by
the use of spiral Dual Energy CT. This
technique could prove useful when only
contrast-enhanced imaging has been
performed and further information of
non-enhanced images would be necessary for the validation of the diagnosis
in retrospect. Dual energy allows for the
decomposition of voxel data through
attenuation values at different kV levels.
A material decomposition algorithm
divides each voxel into soft tissue and
iodine. Separate image series are gained
that bear either the iodine content or the
residual image, giving rise to virtual nonenhanced images. In this study, we have
assessed the potential of virtual nonenhanced images using dual source, dual
energy data for the detection of urinary
stones.

Dual Energy Scanning


and Set-Up
A three-phase CT scan protocol consisting
of a standard non-enhanced scan, a
nephrographic and an excretory phase of
contrast enhancement were performed
with 40 patients with suspected urinary
stone disease. Automated real-time,
anatomy-based dose modulation (CARE
Dose4D) was used with all patients. The
nephrographic phase was acquired in the
dual source, spiral dual energy mode with
tube voltages set at 80 kV and 140 kV and
quality reference-tube current time products set at 400 effective mAs and 95
effective mAs, respectively. Virtual nonenhanced CT images were reconstructed
using a software analysis tool recommended by Siemens. Thereby, as mentioned
above, voxel data is decomposed by a
three-material decomposition algorithm
that divides each voxel into soft tissue, fat
(together representing one of the two
main components), and iodine (second
main component). Information about
these two main components of the voxel
was then transcribed into separate stacks

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

49

Science

1A

1B

1C

1D

1 Comparison of standard non-enhanced CT and dual energy virtual non-enhanced CT reconstruction. A 43-year-old female patient with

a history of chronic urinary stone disease. Fig. 1A + B: Standard non-enhanced CT reconstructions at the level of the kidneys show
a staghorn calculus in the right renal pelvis (Fig. 1A: transverse image; Fig. 1B: volume rendered image). Fig. 1C + D: Virtual nonenhanced CT reconstructions from contrast-enhanced. Dual Energy CT similarly demonstrate the right pelvic urinary stone (Fig. 1C:
transverse image; Fig. 1D: volume rendered image).

50 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Science

of DICOM image files and a series of


virtual non-enhanced images were
displayed for read-out. Agreement between non-enhanced CT and virtual
non-enhanced CT images regarding the
diagnosis of urinary stone disease was observed (Figs. 1 and 2). Three false-negative and no false-positive ratings occurred
using virtual non-enhanced CT images,
and false-negative ratings occurred in
obese patients only. Sensitivity and specificity for virtual non-enhanced CT for the
diagnosis of urinary stone disease were
83 percent and 100 percent. Positive
predictive and negative predictive values
were 100 percent and 88 percent, respectively. Importantly, sensitivity decreased in
abdominally obese patients. Nevertheless,
the SOMATOM Definition delivered
highly reproducible results.

Dual Energy Imaging Enables


new CT Applications
The Spiral Dual Energy analysis technique
is related to the varying response of tissues to x-rays of different energies. The
potential of dual energy imaging was actually investigated 20 years ago. However, at that time, the introduction into daily clinical routine was precluded by
severe technical limitations4. With singlesource CT scanners, dual energy data had
to be separately acquired in two subsequent helical scans. If minimal changes in
patient position occur, voxel decomposition will be valueless because both datasets no longer represent the same voxel.
This is no longer true with the recently

introduced SOMATOM Definition CT scanner utilizing two x-ray tubes for the acquisition of dual energy data simultaneously2.
The other major problem of initial Dual
Energy CT was the weak power reserve of
the x-ray tube when it was operated with
low voltage: images did not reach an adequate noise level when compared to images that were acquired with high tube
voltages4. Both recent developments in
tube and detector technology and the
above mentioned advantage of dual energy data acquisition is the key to the
clinical application of Dual Source, Dual
Energy CT, i.e. virtual non-enhanced images can be reconstructed from the
nephrographic phase CT data set when
scanned in the dual energy mode. This
technique allows for the diagnosis of urinary stone disease with good sensitivity
and an excellent specificity. Iodine subtraction to generate a virtual non-enhanced CT image is one possible application of Dual Energy CT using the above
described software algorithm from contrast-enhanced CT data. Three false-negative ratings occurred only in obese patients. It is most likely that this finding
represents the general problem of CT imaging in obese patients that goes along
with a higher image noise, and thereby is
responsible for a deterioration of diagnostic accuracy. It appears that standard
non-enhanced CT should be considered in
abdominally obese patients rather than
virtual non-enhanced CT through dual
energy acquisition. Taken together, virtual non-enhanced CT images reconstructed
from contrast-enhanced Dual Energy CT

2A

allows for the accurate detection of urinary stones with a good sensitivity and
excellent specificity, keeping in mind that
sensitivity is reduced in obese patients.

Future of Dual Energy in


Imaging of the Urinary Tract
Body dual energy application not only
preserves the possibility of calculating
non-enhanced images from contrastenhanced phases as shown in our study:
ex-vivo studies have demonstrated that
the decomposition of urinary stones was
possible with the use of two different
tube voltages5,6. Thus, Dual Source, Dual
Energy CT has the potential to differentiate urinary stone compositions. This
could be of high clinical relevance for
proper medical management, keeping in
mind that urinary alkalinisation is the
therapy of choice in patients with uric acid
stones, and shock waves can be avoided
that potentially may harm the renal parenchyma.
References
1 Flohr TG, McCollough CH, Bruder H, Petersilka M,
Gruber K, Suss C et al.: Eur Radiol. 16: 256-68, 2006.
2 Johnson TR, Krauss B, Sedlmair M, Grasruck M,
Bruder H, Morhard D et al.: Eur Radiol. 17: 1510-7,
2007.
3 Dalrymple NC, Verga M, Anderson KR, Bove P, Covey
AM, Rosenfield AT et al.: J Urol. 159: 735-40, 1998.
4 Kelcz F, Joseph PM and Hilal SK: Med Phys. 6:
418-25, 1979.
5 Deveci S, Coskun M, Tekin MI, Peskircioglu L, Tarhan
NC and Ozkardes H: Urology. 64: 237-40, 2004.
6 Mostafavi MR, Ernst RD and Saltzman B: J Urol.
159: 673-5, 1998.

2B

2 A 70-year-old female patient presenting with acute pyelonephritis and left sided ureteral obstruction. CT was performed after nephros-

tomy and pigtail insertion on the left side. Fig. 2A: Standard non-enhanced CT image at the level of the kidneys shows bilateral urinary
stones (arrows). Fig. 2B: Virtual non-enhanced CT image similarly demonstrates the urinary stones on both sides.

Results will be published in Investigative Radiology, Dec. 2007

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

51

Science

Cold-Water Corals as Climate Archives


in the Ocean Depths
Computed Tomography of
Sediment Cores Provides Outstanding
Insights for Geologists
International deep-sea research over the last decade has led to the stunning
discovery of lush coral gardens in the cold, dark waters of the deep. Much like
tropical, shallow-water corals, their calcareous skeletons bear detailed chemical
records of past climate. Computed tomography scans of sediment cores containing corals provide geologists with an outstanding mode of visualization.
By Matthias Lpez Correa, MSc Geology, PhD-student; Anna Bednorz, MSc-student of Geology;
Andr Freiwald, Prof. PhD, Institute of Paleontology, University of Erlangen-Nuremberg, Erlangen, Germany.
Monika Demuth, PhD, CT Division, Siemens Medical Solutions, Forchheim, Germany.

1 Submersible image of dense colonies of the cold-water coral Lophelia pertusa a 350m waterdepth.

52 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Science

In our imagination, we usually associate


corals with warm, sunlit, tropical waters,
with lush and colorful gardens at snorkeling depths, home to an exceptional number of fish and other ocean species. But
oceanographic research vessels, equipped
with manned submersibles and cameraarmed robots, have brought up new insights from the deep-sea bottom at several
hundred to a thousand meter depth far
beyond the reach of scuba diving unveiling rich, cold-water coral ecosystems.
These live very differently than tropical,
shallow-water corals by feeding on zooplankton rather than depending on sunlight and warm temperatures. They occur
in all the worlds oceans, typically at 500
to 1000 m depth in complete darkness
and at temperatures of 8 to 10 C and below.
One of the latest ship expeditions with
the R/V Poseidon on the Norwegian Shelf
documented the worlds northernmost
corals in the Stjernsund Fjord at 70
northern latitude, far beyond the Arctic
Circle. The dives of the submersible JAGO
showed a wide-spread distribution of the
white, cold-water coral Lophelia pertusa,
whose skeletons form rigid frameworks
that, over time, grew into mounds and
reef-like structures on the sea bottom.
These mounds formed by corals and sediment, extend over many kilometers and
reach several tens of meters in height.
The calcareous frameworks were precipitated by the small coral polyps forming
the living zone on top of each branch.
The coral branches provide a home to
many other species of living organisms,
forming biological hotspots in the
depths, comparable to coral reefs in shallow waters. In particular, they provide
shelter and breeding grounds for many
commercially important fish species. At
the same time these vulnerable moundhabitats, which took thousands of years
to grow, are at risk of destruction by the
vigorous trawling techniques of industrial
fishery. An important task of the ongoing
research by geologists and biologists is
also the mapping of the coral distribution
and the promotion of potential marine
protected areas put into effect through
national and international environmental
laws.

Corals The Oceans Diary


Cold-water corals provide natural, deepsea archives. Their skeletons store information on the temperature and salt content of seawater as well as its nutrient
concentrations and many other important characteristics needed to reconstruct
past ocean currents and their link with
past climate changes. Similar to the annual rings of a tree, the minute growth
bands in coral skeletons are a geochemists
pages in this diary of the ocean. The
ocean depths, long thought to be a static
realm, is highly variable and reacts quickly to climatic changes for example, during shifts from ice-ages to warm periods.
The Norwegian fjords, like the Stjernsund
trough, were carved out during the last
ice age by huge glaciers that reached
their maximum extent about 20,000 years
ago. The rapid retreat of these ice streams
and the resulting sea-level rise at the
beginning of the present warm period,
about 11,000 years ago, lead to the Atlantic waters flooding the Norwegian shelf

and fjords, creating the conditions for


the build-up of the coral ecosystems on
the ocean bottom. This climatic shift is
documented by a sediment change, from
boulders and gravels laid down by glaciers
to coral-bearing mud and sands of the
present warm period. Marine sediment
stacks of cold-water corals are routinely
sampled by marine geologists with coring
devices. Radiocarbon dating of the first
corals above the glacial gravels tell us
when marine conditions favorable for
corals were first established.

Computed Tomography
Changes in coral preservation, their
three-dimensional arrangement and the
sedimentary structures help unravel the
mound history related to past oceanographic and climatic changes. Their positions can tell, for example, if the coral
colonies are still in their original life positions or were tumbled-over and transported by currents. Previously, an understanding of the third dimension had to be

2A
2 Oceanographic

research vessel R/V


Poseidon cruising the
north-Norwegian
Stjernsund Fjord,
home to the worlds
most northern corals
(Fig 2B). Manned
submersible JAGO
aboard the vessel,
being prepared for
a dive in the 400 m
deep fjord (Fig. 2A).

2B

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

53

Science

3 Deep-sea sediments and coral mounds grown over thousands of years can be analyzed with gravity cores. One-meter segment of

a sediment core showing glacial moraine deposits with rock fragments in the lower half of the last ice-age, overlaid by cold-water
coral deposits of the present warm-period. Conventional 2D core cut with corals visible as small white cross-sections (left), x-ray slice
showing the pronounced boundary of dense glacial sediments appearing light, and mud with corals above (middle), 3D-rendering
of rock-fragments and corals and their position in the sediment.
4 A SOMATOM Sensation high-resolution, 3D-visualization of corals in the sediment core,

allowing core analyses of unprecedented detail and precision.

gathered from single, two-dimensional


core cuts and required much knowledge
and experience. Scanning of these sediment cores with computed tomography
(CT), in particular, the SOMATOM Sensation and Definition, is a major step forward in the interpretation of these coral
mounds. The strong density contrasts of
the corals and glacial rock fragments
against the sandy and muddy background
sediment allow an ideal three-dimensional visualization with minute detail. The
high-resolution images provided by the
SOMATOM Sensation CT scanner also

show the degree of coral fragmentation


from current erosion, a characteristic
often overseen in two-dimensional core
cuts. The non-invasive analysis of core
cuts also permits the localization and
selection of samples for radiometric
dating and often, a first determination of
the coral species prior to core opening.
Computed tomography opens up a thirddimension in sediment core analysis and
is certain to become a standard tool for
geological sciences applicable to cores
containing heterogeneous materials.

54 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

References
1 Freiwald, A., Foss, J.H., Grehan, A., Koslow,
T. & Roberts, J.M. (2004): Cold-water Coral Reefs.
UNEP-WCMC, Cambridge, UK, 84 pp.
2 Roberts, J.M., Wheeler, A.J., Freiwald, A. (2006):
Reefs of the deep: the biology and geology of coldwater coral ecosystems. Science 312: 543547.
This research was supported by HERMES-project,
EC contract no. GOCE-CT-2005-511234

www.cool-corals.de
www.eu-hermes.net

Life

Life Behind the Scenes


Behind the scenes, several thousand employees work in the Customer
Care Team at Siemens Medical Solutions. Enjoy the interviews of two
employees both performing essential functions in Customer Care:
education and remote system monitoring.
By Rami Kusama, CT Division, Siemens Medical Solutions, Forchheim, Germany

Interview: Mr. Karl Krzymyk: Customer


Care, Headquarter Application Specialist,
Forchheim, Germany
You work within the Customer Care
division the so-called Life team at
Siemens Medical Solutions. What
exactly does the Life team do?
Life is more complex than you might
expect. Our goal is to take care of our
customers. We keep them informed, train
them and we keep their systems up and
running and regularly provide updates
and upgrades. Thats basically our task,
and we have several methods to accomplish this. For example, some colleagues
train customers on scanner functionalities; other colleagues organize clinical
trainings, such as fellowships or CME
credited courses. There are many other
functions, and I myself, work as a headquarter Application Specialist within this
team.

What is your main function as a Headquarter Application Specialist?


My main task is to train fellow Siemens
Application Specialists from around the
world on the latest software versions, and
to support them with news and updates.
Most of the training takes place in Forchheim, Germany, where I have been working
for the past three years. I also train customers on site to keep them up-to-date on the
latest developments in applications and
technologies.

whether they are from Norway; South Africa or New Zealand. We cover everything
from basic training for beginners to training on specific software versions to expert
training on new features like syngo Dual
Energy or Cardiac imaging. We also support
them with e-learning and live web casts to
ensure quickest knowledge distribution.
The goal, of course, is to make sure that all
Applications Specialists worldwide are
thoroughly qualified to train our customers
on the usage of their systems.

How much time do you invest in training


your fellow Application Specialists?
For almost 200 colleagues worldwide, we
provide around 30 training sessions a year,
each lasting about 25 days. Overall, half
of my time is spent on training Application
Specialists. We really provide a wide range
of training here at headquarters to make
sure that all specialists are on the highest
possible knowledge level, regardless of

Where are the Application Specialists


located?
Our team locations are where our customers are located. All major countries have
their own Application Specialists. For
example, in the USA, we have around 50
specialists responsible for customer education. Almost all countries have their own
specialists.

We keep our customers informed,


train them and we keep their systems
up and running and provide regular
updates and upgrades.
Karl Krzymyk mainly provides training to fellow application specialists,
who are actually Siemens face-to-face representatives to our customers.

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

55

Life

Guardian systems are


monitored pro-actively
around the clock via
Siemens Remote Service.
Coping with problems before they interfere with
workflow: Preston Elliott (left) and a colleague monitoring
a customers system

What are the most important challenges that you encounter in your job?
Well, first, keeping our own knowledge
level up-to-date. In the fast development
cycle we are in, this can sometimes be
challenging. Second, Id say time difference is always an issue, but with e-mail,
most questions can be answered easily.
And third, adapting to different cultures
to make sure that all attendees get the
most out of our training efforts. What really helps is the companionship you can
feel within Siemens its universal.
What was your most interesting
business trip?
This, I can answer right away. I was in
Kutaisi, Georgia in the middle of winter,
and I received my luggage on the last day
of my 5 day visit. It was quite an experience, buying european clothes in Kutaisi!
As a member of the Customer Care
team, how do customers influence
your job?
Most customers dont realize how many
of their ideas and suggestions influence
our organization they are the number
one motivation for our product development. Once these ideas are implemented,
I visit customers to train them on the
latest applications. So, it is really a never
ending cycle.
What do you like most about your job?
Definitely, to work and help people from
all over the world, to influence and guide
future developments, and to travel to
places I would never have the chance to
see otherwise.

Interview: Mr. Preston Elliott, Customer


Care, Technical Support Engineer,
North Carolina, USA
Within the Life Team, what is the role
of the Technical Support Group?
Our goal here is to keep our customers
systems up and running. If a scanner is
not available due to a technical defect,
it causes tremendous workflow interruption, which is what we try to avoid with
our Guardian program. It detects technical problems during system operation
without interfering with the workflow.
Guardian systems are monitored pro-actively around the clock via Siemens Remote Service through the Regional Support Center.
What is your main function here at
the Regional Support Center?
I have been involved with the Guardian
program since its beginning in 2004. Our
job is to make sure that our customers
systems are running smoothly, and to
notify them if there are technical problems acute or potential. We monitor
SOMATOM systems in real time using
advanced monitoring tools.
On our screen, we monitor events from
our customers systems where the
critical level is flagged. For example,
events with a red flag mark an urgent
event. In that case, we call our customers
immediately to clarify the problem.
Our job is very much comparable to an
ICU, (Intensive Care Unit) where the
patients heart beat and blood pressure
are constantly monitored. Instead of
monitoring the patient, we monitor our

56 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

customers system to ensure that everything is running smoothly.


Do you also receive calls from
customers?
Well, of course they can call us, but with
Guardian this generally does not happen.
This is a good sign, since it means the
Guardian system is functioning efficiently.
Our task is to be pro-active and to warn
customers of potential problems before
they actually happen. We call them and
often, we are able to address the issue via
phone or online through our Siemens
Remote Service connection. Or, if the
problem cannot be solved remotely, we
schedule onsite service at their convenience, when there are no patient examinations scheduled.
Doesnt it get boring sitting in front
of your screen all day?
No, actually not at all. When we are not
responding to events, we have the opportunity to further develop our monitoring
capabilities through historical review
and team discussions with the many other technical support engineers. That way,
everyone in our organization benefits.
We also train colleagues and participate
in training ourselves.
What do you like about your job?
Its a good feeling to know that we can
support our customers so that they can
take care of their patients and not worry
about the performance and availability
of systems.

Life

Free 90 Day Trial Licenses* for Clinical Applications


By Rami Kusama, CT Division, Siemens Medical Solutions, Forchheim, Germany

syngo CT Oncology
syngo CT Oncology is the very first software designed to enhance diagnostic
outcomes across your entire routine oncology imaging workflow, which covers
60 percent of your daily routine:
Fully automated lesion measurement,
segmentation and follow-up.
Auto-pilot for lung and liver lesions,
plus lymph nodes.
Diagnostic certainty in 3 minutes.**
Experience a new level of speed and
accuracy, improving results for referring
physicians and the level of patient care:
This software gives reliable and consistent information. It virtually eliminates
human error and the variations in measurement that can occur when doing it manually. Eventually, software like this will be
standard for any follow-up of oncology

patients. Previously, the technology was


not available, and now it is.***
Experience the new level of oncology
imaging workflow now with our 90 day
free trial.* Ask for your additional
benefits if you are already an Oncology
Engine customer. Please contact your
local Siemens representative for more
information.

* Minimum system requirements need to be


fulfilled for these options to be available. Ask
your Siemens representative to check your
system configuration.
** Results may vary. Data on file.
*** Vahid Yaghmai MD, Associate Professor of
Radiology, Northwestern University Feinberg
School of Medicine, Chicago, USA

syngo CT Oncology permits automated, one-click


3D segmentation of liver and lung lesions plus
other solid lesions and lymph nodes. It eliminates
the guess-work and allows automated measurement of tumor size: RECIST, WHO, 3D volume, and
total tumor burden.

syngo Neuro Perfusion


Blood Volume CT

Complete diagnosis of ischemic strokes is


feasible with syngo Neuro PBV CT and syngo
Neuro Perfusion CT offering 3D visualization
of perfused blood volume (PBV) in the whole
brain, as an indicator for stroke.

Schramm, P., et al.: Comparison of CT and CT Angiography Source Images With Diffusion-Weighted Imaging in
Patients With Acute Stroke Within 6 Hours After Onset.
Stroke. 2002;33:2426-2432
Lev, MH, et al.: Utility of Perfusion-Weighted CT Imaging

syngo Neuro Perfusion Weighted Maps


(PWM) and syngo Neuro Perfused Blood
Volume (PBV) CT are two new applications for the 3D visualization of stroke.
syngo Neuro PWM, available only on
MMWP* for all SOMATOM Emotion scanners, is a powerful tool to visualize color
coded CTA source images by suppressing
vessels and bones. Stroke infarcted areas
can be correlated via CTA source images
as has been suggested by Lev et al., 2001
and Schramm P. et al., 2002. syngo Neuro PBV CT ** available on MMWP and CT
Workplace, in contrast, is a normalized
subtraction of plain CT data from CTA
source images, providing local contrast
media enhancement. This data allows for
a quantitative measurement of perfused

blood volume, visualizing infarcted areas


in three dimensions (Hunter et al., 2003
and Kloska et al., 2007). This application
is available for SOMATOM Definition
and SOMATOM Sensation on MMWP and
CT only. Additionally, the syngo Neuro
PWM license is always integrated into
the syngo Neuro PBV CT option free of
charge.

in Acute Middle Cerebral Artery Stroke Treated With


Intra-Arterial Thrombolysis. Stroke, 2001;32:2021-2028
Hunter, GJ et al.: Whole-Brain CT Perfusion
Measurement of Perfused Cerebral Blood VolumeAcute
Ischemic Stroke: Probability Curve for Regional Infarction.

Radiology 2003; 227:725730


Kloska, S. et al.: Color-coded perfused blood volume
imaging using multidetector CT: initial results of wholebrain perfusion analysis in acute cerebral ischemia Eur
Radiol. 2007 Feb 23; [Epub ahead oaf print]

*requires syngo 2007C on a MMWP workplace,


released 04/2007.
**requires syngo CT 2007 for CT Workplace
and syngo 2007C for the MMWP workplace.

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

57

Life

In Step With the Future


As part of LIFE, Siemens Medical Solutions
comprehensive Customer Care program,
syngo Evolve, directly focuses on improving technology. As a performance driver,
syngo Evolve helps keep a system in step
with rapidly developing technological
advances so that performance, speed
and diagnostic quality remains at a consistently high level. The spectrum of services
includes upgrades of important applications as well as system software, user interfaces and hardware.
The latest enhancement for SOMATOM
Sensation CT scanners comes with the new
software version syngo CT 2007S. Evolve
customers automatically receive syngo CT
2007S accompanied by comprehensive

information and a training package.* This


state-of-the-art software is designed to
keep the diagnostic and interventional
capabilities of a CT scanner up to the most
modern technological standards, even
though the customer might have purchased his/her equipment some years ago.
Thats syngo Evolve.
One of the enhancements is an improved
WorkStream4D application featuring
non-square matrices. The ability to select
the matrix format for long and extended
body regions allows e.g. much better
run-off reconstructions and whole spine
visualization.
New purchasable options such as
syngo Neuro DSA CT, syngo LungCAD or

syngo Neuro DSA CT Improved visualization of


the cerebral vasculature. One of the new options
available with syngo CT 2007S.

syngo Colonography CT PEV can make


clinicians life easier and open new clinical
fields. Customers can take advantage of
this 90 day free trial licenses.
* Affected customers will be contacted by
customer service.

Free DVD of the


SOMATOM World Summit 2007 in Berlin
Siemens Medical Solutions Computed Tomography (CT) Division
has successfully captured the entire proceedings of their 8th
international SOMATOM World Summit 2007 (formerly known
as International SOMATOM CT User Conference), held in Berlin
from May 4th to May 5th 2007 in cooperation with Bayer Schering
Pharma AG.
Berlin has been a city of knowledge and culture since the days
of Friedrich the Great in the 18th century. No other region in
Europe has as high a concentration of scientific, academic and
research facilities as Berlin. The city invests around 1.8 billion
annually in these areas and was thus the ideal venue for us
to share the remarkable new clinical developments in CT since

the last International SOMATOM CT User Conference in 2005.


The conference was held in Germanys oldest, preserved commercial power plant, the famous E-werk, which dates back to
1881. More than 300 participants from 30 countries enjoyed
the special atmosphere and two very intense days of lectures
and interactive break-out sessions.
The complete e-learning package of this conference on DVD will
be ready to order free of charge beginning 2008.You will benefit
from 34 outstanding presentations given by an international luminary faculty of research groups from across the globe, sharing their exciting experiences on the clinical impact of Dual
Source CT. You will learn more about advances in clinical applications for Dual Energy, cardiovascular and acute-care CT as
well as 3D data management and much, much more. Customers benefit from Siemens clinical e-learning opportunities as
part of our customer care program Life, and participate in the
latest clinical results in the various fields of CT imaging.

www.siemens.com/
somatomeducate
Free of charge: The complete e-learning package
of this conference is available on DVD.

58 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Life

Clinical Workshops 2008


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

Workshop Title

Dates

Location

Course language Course director

Clinical Workshop on Cardiac CT

27.29.02.08

Erlangen/Germany

English

Prof. Dr. Stephan Achenbach

Clinical Workshop on Cardiac CT

15.16.02.08
16.17.05.08
12.13.09.08

Paris/France

English

Dr. Jean Francois Paul

Clinical Workshop on Cardiac CT

21.23.04.08
23.25.06.08

Munich/Germany

English

PD Dr. Christoph Becker


Dr. Alexander Leber

31.01. 01.02.08
17.18.04.08
12.13.06.08

Erlangen/Germany

English

Prof. Dr. Stephan Achenbach

03.05.03.08
03.05.11.08

Mnster/Germany

English

PD Dr. Kai Uwe Jrgens

Clinical Training course on Cardiac CT 23.24.02.08


24.25.05.08
23.24.08.08
29.30.11.08

Kuching/Malaysia

English

Prof. Sim Kui Hian


Dr. Ong Tiong Kiam

Clinical Workshop on Cardiac CT

04.05.04.08

Monte Carlo/Monaco

English

Dr. Filippo Civaia


Dr. Philippe Rossi

CT-Colonography Workshop

14.15.03.08

Bruessels/Belgium

English

Dr. Stefaan Gryspeerdt


Dr. Philippe Lefere

Hands-on Workshop Cardiac-CT

03.04.07.08

Zrich/Switzerland

German

Dr. Hatem Alkadhi

Clinical Workshop on State-of-the-Art 05.08.05.08


Applications
22.25.09.08

Mnster/Germany

English

PD Dr. Kai Uwe Jrgens

Refresher Course
for Multislice CT Scanner

22.24.01.08
04.06.03.08
20.22.05.08

Siemens
Training Center
Erlangen/Germany

English/
German

Virtual CT-Colonography Workshop

15.16.02.08
29.30.04.08
19.20.09.08

Berlin/Germany

German

Prof. Bernd Lnstedt

Dual Energy Workshop

25.26.01.08
11.12.04.08
11.12.07.08

Forchheim/Germany

English

Dr. Thorsten Johnson

Clinical Workshop on Cardiac CT

23.25.01.08

Linkping/Sweden

English

Dr. A. Persson

Clinical Workshop on Cardiac CT

09.10.03.08

Linkping/Sweden

Swedish

Dr. A. Persson

Clinical Webspace 3D-Workshop

21.22.01.08

Linkping/Sweden

English

Dr. A. Persson

Clinical CT Colonography Workshop

10.12.12.08

Linkping/Sweden

Swedish

Dr. A. Persson

Clinical CTA Interpretation Course


on Cardiac CT
Clinical Workshop on Cardiac CT

Course dates are subject to change. For latest information please refer to the course selector at www.siemens.com/life-courses

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

59

Life

Key Element of Leading-Edge


Cardiac Health Care Virtual CTA Course
In January 1920, 2008, the next coronary CTA course will take place in Denver,
Colorado, conducted by Radiology Imaging Associates (RIA), a Denver based private practice group. The course, Coronary CTA: Revolutionizing Cardiac Care,
will be held by Simeon Abramson, MD,
course director and thoracic radiologist
for RIA. Outstanding best organization,
materials, and comprehensive course I
have ever attended. Should be a model for
other imaging courses, so declares L.J., a
radiologist from Ypsilanti, Michigan.
The two-day course delivers hands-on
exposure to interpreting 100 CTA cases
(52 of them at an actual workstation). In
addition to the live course, RIA provides
an online training module that can be utilized both with the course or separately
for those who want to learn on their own
time and at their own pace. The 50-case,
online virtual-training module features
numerous images from the SOMATOM

Sensation 64-slice CT scanner. Most of


the modules case study images come
from the Sensation 64, says Abramson,
It provides great images. Abramson has
found the SOMATOM Sensation 64 to be
particularly useful in patients with irregular sinus rhythm: The ECG editing capabilities of the Sensation enable us to get a
diagnostic scan in irregular heart rhythm
patients, many of which are sent to us
because they cant be scanned anywhere
else, says the course director.
Our referral base expanded significantly
upon obtaining the Sensation 64, particularly from new sources, he said. The
SOMATOM Sensation 64-slice CT Scanner,
though, may be just one factor for the increased referral activity. RIAs Cardiac CT
course is receiving rave reviews from radiologists and cardiologists around the
country and is one of only four courses
endorsed by the Society of Cardiovascular
Computed Tomography.

Simeon Abramson, MD,


course director
and thoracic radiologist
for Radiology Imaging
Associates (RIA).

www.cardiactraining.com

SOMATOM Sessions
Now Online
It is our great pleasure to introduce the new SOMATOM Sessions
Online. From now on, the latest customer magazin can be read not
only printed but also online. Adapted to our customers specific requirements, the online edition offers such exciting extra features as
the integrated image viewer for modifying zoom, contrast and brightness of clinical images. Additionally, movies can be found, a search
function is available as well as the ability to download specific content.
www.siemens.com/
somatom-sessions

SOMATOM Session Online makes it possible


to explore all the content of the printed
version in even greater detail.

60 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Life

SOMATOM Life:
Clinical Poster
Gallery
Educate welcomes a new building block
in the wide range of continuous learning
programs the Clinical Poster Gallery.
After the successful introduction of the
CT Cardiac Anatomy poster, we are happy to announce two more additions to the
Gallery: CT Neuro Anatomy* and CT
Colonography Spectrum of Diseases*.
Together with Stephan Kloska, MD, from
Muenster University, Muenster, Germany,
Siemens Medical Solutions designed a
poster focusing on anatomy and CT-specific landmarks relevant for CT angiographies of neck and head vessels. Information about a recommended stroke
workflow is also included. The radiology
department of Muenster performs around
5500 neuro examinations per year, providing the faculty with extensive experience in neuroradiology.

Thomas Mang, MD, and co-workers from


the Medical University of Vienna, Austria,
have performed around 800 CTC exams
on their SOMATOM Sensation 16 and 64
scanners over the past four years. Based
on their experience with virtual colonoscopy, they have created a poster demonstrating the spectrum of CTC findings
in colon diseases. All diseases are briefly
described and extensively illustrated in
3D and 2D CT images, guiding and assisting users in the reporting of findings in
CTC examinations. Order your poster free
of charge via the link below.
* available beginning 2008

www.siemens.com/ct-poster

Thanks to the cooperation with clinical experts,


there now exists a growing Clinical Poster Gallery.
Available are: CT Cardiac Anatomy, Neuro Anatomy* and Colonography Spectrum of Diseases*.

Frequently Asked Questions


Can I save dose by combining the
non-contrast head routine scan and the
non-contrast scan of the Neuro DSA
CT protocol?
No, there are only marginal dose savings
in the effective organ dose if you combine
the non-contrast scans. Instead, the image
quality would decrease for the non-contrast
head routine scan.
This is because the Neuro DSA CT default
protocol is using low dose settings for the
non-contrast scan. The resulting image
quality is sufficient for bone removal in the
syngo Neuro DSA application but may be
insufficient for identification of pathologies
in the brain.

Dose examples for the


SOMATOM Sensation 64:
a) With a head routine scan AND the
Neuro DSA CT scan: 2.7 mSv for male
and 2.9 mSv for female, based on default parameter settings.
b) With a combined non-contrast scan for
Neuro DSA CT: 2.7 mSv for male and
2.9 mSv for female, with the following
parameter changes in the Head Neuro
scan: kV of 100, mAs of 550, rotation
time of 0.5 s, pitch of 0.45. In addition
you have to do a second reconstruction
with the kernel H22 that should be
used for processing in syngo Neuro
DSA.

syngo Neuro DSA result image of a large


aneurysma of a 28-year-old female (CT-system:
SOMATOM Sensation 64-slice configuration).
Courtesy of Mayo Clinic, Rochester, Minnesota, USA

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

61

Life

Staying Up-to-date With the


New CT Customer Information Portal
Siemens Medical customers will find
just the information they need to get the
most out of their SOMATOM CT scanners
in the new CT Customer Information Portal that has been designed exclusively for
users of SOMATOM CT systems.
Whether it is information about educational offerings, such as CME credited
e-learning, clinical courses, fellowships
or free educational posters or how to

expand the capabilities of their scanners


with functionality that was not available
at the time of purchase. Customers will
also have access to the latest clinical cases. And to help improve their daily clinical
routine and workflow, they will be able
to access the Tips & Tricks section and FAQ.
The new CT Customer Information Portal
is one of three channels Siemens Medical
Solutions offers to regularly inform their

SOMATOM users. Customers can also


subscribe to a monthly e-newsletter service and sign up for the bi-annual magazine, SOMATOM Sessions.
www.siemens.com/ct-infoportal

Upcoming Events & Courses


Title

Location

Short Description

Date

Contact

Moscow Healthcare

Moscow, Russia

International exhibition

Dec. 0509, 2007

www.zdravo-expo.ru/en

5 International
Symposium of
Multislice CT

GarmischPartenkirchen,
Germany

Scientific talks
and lectures

Jan. 1619, 2008

www.ct2008.org

Arab Health

Dubai, UAE

Exhibition and scientific


congress

Jan. 28 - 31, 2008

www.arabhealthonline.com

24th Annual Computed


Body Tomography 2008:
The Cutting Edge

Orlando, USA

CME Course

Feb. 1417, 2008

www.hopkinscme.net

ECR

Vienna, Austria

Exhibition and
scientific congress

March 711, 2008

www.ecr.org

Deutsche
Gesellschaft fr
Kardiologie

Mannheim,
Germany

74th annual meeting

March 2729, 2008

www.dgk.org

ACC

Chicago, USA

Exhibition and scientific


congress

March 29
April 1, 2008

www.acc08.acc.org

ITEM

Yokohama, Japan

Trade fair

April 46, 2008

www.j-rc.org

ECIO

Florence, Italy

1st European Conference


on Interventional Oncology

April 1012, 2008

www.ecio2008.org

ESGAR CTC
Workshop

Vigo, Spain

Hands-on workshop
on CT-colonography

April 1214, 2008

www.esgar.org

Deutscher
Rntgenkongress

Berlin, Germany

Exhibition and
scientific congress

April 30
May 3, 2008

www.drg.de

10th Annual International


Symposium on
Multidetector-Row CT

Las Vegas, USA

Stanford CME
course and exhibition

May 1316, 2008

radiologycme.
stanford.edu

th

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

62 SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

Imprint

SOMATOM Sessions Imprint


2007 by Siemens AG, Berlin and Munich, All rights reserved
Publisher
Siemens AG
Medical Solutions
Computed Tomography Division
Siemensstrae 1
D-91301 Forchheim
Responsible for Contents
Andr Hartung
Chief Editors
Monika Demuth, PhD
(monika.demuth@siemens.com)
Stefan Wnsch, PhD
(stefan.wuensch@siemens.com)
Editorial Board
Andreas Blaha; Thomas Flohr, PhD; Murat Guengoer;
Louise McKenna, PhD; Julia Kern-Stoll; Axel Lorz; Jens
Scharnagl; Bernhard Schmidt, PhD; Lisa Suckert; Heiko
Tuttas; Alexander Zimmermann;
Authors of this Issue
H. Alkadhi, MD, Institute of Diagnostic Radiology,
University Hospital, Zurich, Switzerland
C. Becker, MD, Department of Clinical Radiology,
University Hospital of Munich-Grohadern, Munich,
Germany
A. Bednorz, Institute of Paleontology, University of
Erlangen-Nuremberg, Erlangen, Germany
F. Behrendt, MD, Department of Diagnostic Radiology,
University Hospital, RTWH-Aachen University, Germany
C. Boehner, MD, Department of Diagnostic Radiology,
University of Erlangen-Nuremberg, Erlangen, Germany
G. Conradi, MD, Kerckhoff Heart Center, Department
of Cardiology/Cardiovascular Imaging, Bad Nauheim,
Germany
M. Das, MD, Department of Diagnostic Radiology,
University Hospital, RTWH-Aachen University, Germany
L. Desbiolles, MD, Institute of Diagnostic Radiology,
University Hospital, Zurich, Switzerland
T. Dill, MD, FESC, Kerckhoff Heart Center, Department
of Cardiology/Cardiovascular Imaging, Bad Nauheim,
Germany
T. Frauenfelder, MD, Institute of Diagnostic Radiology,
University Hospital, Zurich, Switzerland
A. Freiwald, PhD, Institute of Paleontology, University
of Erlangen-Nuremberg, Erlangen, Germany
B. Ghaye, MD, Department of Medical Imaging, University
Hospital of Lige, Lige, Belgium

R. Gnther, MD, Department of Diagnostic Radiology,


University Hospital, RTWH-Aachen University, Germany
J. Hausleiter, MD, German Heart Center, Munich,
Germany
F. Herrmann, MD, German Heart Center, Munich,
Germany
R. Janka, MD, Department of Diagnostic Radiology,
University of Erlangen-Nuremberg, Erlangen, Germany

A. Rolf, MD, Kerckhoff Heart Center, Department of


Cardiology/Cardiovascular Imaging, Bad Nauheim,
Germany
H. Scheffel, MD, Institute of Diagnostic Radiology,
University Hospital, Zurich, Switzerland
T. Schertler, MD, Institute of Diagnostic Radiology,
University Hospital, Zurich, Switzerland

T. Johnson, MD, Department of Clinical Radiology,


University Hospital of Munich-Grohadern, Munich,
Germany

A. Schroeder, MD, Department of Radiology, Institute


of Imaging, Neuqun, Argentina; Department of
Cardiology, Cardiovascular Institute of South, Cipolletti,
Argentina

T. Kraus, MD, Department of Occupational Health,


University Hospital, RTWH-Aachen University, Germany

P. Stolzmann, MD, Institute of Diagnostic Radiology,


University Hospital, Zurich, Switzerland

A. Kuettner, MD, Department of Diagnostic Radiology,


University of Erlangen-Nuremberg, Erlangen, Germany

B. Tomandl, MD, Department of Neuroradiology,


Klinikum Bremen, Bremen, Germany

W. A. Leber, MD, Department of Clinical Radiology,


University Hospital of Munich-Grohadern, Munich,
Germany

P. Urdiales, MD, Department of Cardiology, Cardiovascular Institute of South, Cipolletti, Argentina

S. Leschka, MD, Institute of Diagnostic Radiology,


University Hospital, Zurich, Switzerland
M. Lpez Correa, Institute of Paleontology, University
of Erlangen-Nuremberg, Erlangen, Germany
B. Marincek, MD, Institute of Diagnostic Radiology,
University Hospital, Zurich, Switzerland
S. Martinoff, MD, German Heart Center, Munich,
Germany
J.-F.- Monville, MD, Department of Medical Imaging,
University Hospital of Lige, Lige, Belgium
D. Morhard, MD, Department of Clinical Radiology,
University Hospital of Munich-Grohadern, Munich,
Germany
S. Nicolaou, MD, Department of Radiology, Vancouver
General Hospital, Vancouver, Canada
K. Nikolaou, MD, Department of Clinical Radiology,
University Hospital of Munich-Grohadern, Munich,
Germany
J. Pereyra, MD, Department of Cardiology, Cardiovascular Institute of South, Cipolletti, Argentina
T. Radkow, MD, Department of Diagnostic Radiology,
University of Erlangen-Nuremberg, Erlangen, Germany

A. De La Vega, MD, Department of Radiology, Institute


of Imaging, Neuqun, Argentina
Catherine Carrington, freelance author
Tony DeLisa, freelance author
Karin Barthel; Nina Bastian; Dagmar Birk; Andreas Blaha;
Jan Chudzik; Monika Demuth, PhD; Thomas Flohr, PhD;
Tanja Gassert; Murat Guengoer; Christoph Hachmller,
MD; Julia Kern-Stoll; Ernst Klotz, Rami Kusama; Per-Anselm Mahr; Louise McKenna, PhD, MBA; Marion Meusel;
Rainer Raupach, PhD; Gitta Schulz; Katja Stcker; Heike
Theessen; Peter Seitz; Stefan Wnsch, PhD; Alexander
Zimmermann; all Siemens Medical Solutions
Production
Norbert Moser, Siemens Medical Solutions
Layout
independent Medien-Design
Widenmayerstrasse 16
D-80538 Munich
PrePress
MEDia_asset_pool,
Waldstr. 18, 91054 Erlangen

M. Reiser, MD, Department of Clinical Radiology,


University Hospital of Munich-Grohadern, Munich, Germany

Printers
Farbendruck Hofmann
Gewerbestrae 5
D-90579 Langenzenn
Printed in Germany

J. Rixe, MD, Kerckhoff Heart Center, Department of


Cardiology/Cardiovascular Imaging, Bad Nauheim,
Germany

SOMATOM Sessions is also available on the internet:


www.siemens.com/SOMATOMWorld

Note in accordance with 33 Para.1 of the German Federal Data Protection Law: Despatch
is made using an address file which is maintained with the aid of an automated data processing
system.
SOMATOM Sessions with a total circulation of 35,000 copies is sent free of charge to Siemens
Computed Tomography customers, qualified physicians and radiology departments throughout
the world. It includes reports in the English language on Computed Tomography: diagnostic and
therapeutic methods and their application as well as results and experience gained with corresponding systems and solutions. It introduces from case to case new principles and procedures
and discusses their clinical potential.
The statements and views of the authors in the individual contributions do not necessarily reflect
the opinion of the publisher.
The information presented in these articles and case reports is for illustration only and is not intended to be relied upon by the reader for instruction as to the practice of medicine. Any health
care practitioner reading this information is reminded that they must use their own learning,
training and expertise in dealing with their individual patients. This material does not substitute
for that duty and is not intended by Siemens Medical Solutions to be used for any purpose in that

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

SOMATOM Sessions November 2007 www.siemens.com/medical-magazine

63

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SOMATOM Sessions
The Difference in Computed Tomography
Issue no. 21 / November 2007
RSNA-Edition
November 25th 30 th, 2007

Cover Story
Growth of Denition
Family Signals New
Era in CT
Page 6

News
syngo 2008A Automating Routine Workow
Page 14

Clinical
Outcomes
The SOMATOM
Denition AS With the
CT Oncology Engine
Page 28

Science
Adaptive 4D Spiral
a Flexible Solution for
Dynamic Scanning
Page 46

Life
Life Behind the Scenes
Page 55

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On account of certain regional limitations of


sales rights and service availability, we cannot
guarantee that all products included in this
brochure are available through the Siemens
sales organization worldwide. Availability and
packaging may vary by country and is subject
to change without prior notice. Some/All of the
features and products described herein may
not be available in the United States.
The information in this document contains
general technical descriptions of specifications
and options as well as standard and optional
features which do not always have to be present
in individual cases.
Siemens reserves the right to modify the design,
packaging, specifications and options described
herein without prior notice.
Please contact your local Siemens sales
representative for the most current information.
Note: Any technical data contained in this
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Head Office
Takanawa Park Tower
3-20-14, Higashi-Gotanda
Shinagawa-ku
Tokyo 141-8644
Japan
Telephone: +81 3 54 23-85-10
Siemens Ltd. China
No. 7, Wangjing Zhonghuan Nanlo
Chaoyang District
Beijing 100 102
China
Telephone: +86 10 64 76 88 88
Siemens Medical Solutions
Asia Pacific Headquarters
The Siemens Center
60 MacPherson Road
Singapore 348615
Telephone: +65 6490 8182