Applicationguide Sensation10 Clinicalappl 1syngo 2006a 07-00209692

Clinical
Applications 1
Application Guide
syngo Dental CT
syngo Osteo CT
syngo Pulmo CT
syngo LungCARE CT
syngo Volume Evaluation
syngo Dynamic Evaluation
syngo Neuro Perfusion CT
syngo Body Perfusion CT
Software Version syngo CT 2006G

Dear SOMATOM user,
We would like to present you our application guide for
clinical applications. To improve future versions of this
application guide we would highly appreciate your
questions, suggestions, and comments. The informa-
tion presented in this application guide is for illustra-
tion 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, train-
ing, and expertise in dealing with their individual
patients. This material does not substitute for that duty
and is not intended by Siemens Medical Solutions Inc.,
to be used for any purpose in that regard.
The drugs and doses mentioned are consistent with
the approval labeling for uses and/or indications of the
drug. The treating physician bears the sole responsibil-
ity for the diagnosis and treatment of patients, includ-
ing drugs and doses prescribed in connection with
such use. The Operating Instructions must always be
strictly followed when operating the MR/CT System.
The source for the technical data is the corresponding
data sheets.
The pertaining operating instructions must always be
strictly followed when operating a SOMATOM scanner.
The statutory source for the technical data are the cor-
responding data sheets. We express our sincere grati-
tude to the many customers who contributed valuable
input.
Special thanks to Sabine Meissner, Daniel Rinck, Oliver
Hauenstein, Ernst Klotz, Heinz Fichte, Axel Barth,
Heike Theessen, Christiane Bredenhöller and Kristin
Pacheco for their valuable assistance. Special thanks to
the former editor of this application guide, Bettina Hin-
richsen, for her great efforts and contribution.
Please contact us:
USC-Hotline: Tel. no. +49-1803-112244
email: ct-application.hotline@med.siemens.de
Editor: Ute Feuerlein
Overview
User Documentation 10
Application Information 12
syngo Dental CT 18
syngo Osteo CT 36
syngo Pulmo CT 54
syngo LungCARE CT 78
syngo Volume Evaluation 100
syngo Dynamic Evaluation 116
syngo Neuro Perfusion CT 132
syngo Body Perfusion CT 156
3
Contents
Matrix 8
User Documentation 10
Application Information 12
• Image Converter 12
- Split-up multi-phase series 14
• Report Template Configuration 15
• File Browser 16
- Key features 16
syngo Dental CT 18
• Key Features 18
• Prerequisites 20
• Scan Protocols 22
• Scanning Information 25
• Workflow 26
- Loading the images 26
- Inspecting the input images 27
- Preparing the reconstruction of Dental
images 27
- Reconstructions 31
- Mandibular canal 31
- Documenting the Results 32
• Additional Important Information 33
syngo Osteo CT 36
• Key Features 36
• Workflow 42
• Configuration 47
- Siemens Reference Data: 53
4
Contents
syngo Pulmo CT 54
• Key Features 54
• Workflow 58
- Loading the images 58
- Starting the Pulmo CT Evaluation 60
- Pulmo CT Evaluation Results 61
- Automatic Saving of Images 62
- Filming Pulmo CT Results 62
• Pulmo CT Evaluation in Advanced Mode 63
- Manual Segmentation 63
- Automatic Segmentation 64
- HU-Subranges and Percentiles 64
- Advanced Results Display 65
- Comparison with Reference Data 66
- Enabling the Export of Pulmo CT Results 68
- Configuring the Calculation 68
- Configuring the Display of Histograms 69
- Configuring the HU-Subranges 70
- Configuring the Segmentation 71
syngo LungCARE CT 78
• Key Features 78
• Workflow 83
- Layout 83
- Visualization and Evaluation 85
- Marker Display 86
- Selection of a Report Series 87
- NEV Calculation 87
- Identification and Marking of Lesion 87
- Segmentation of the Nodule and Volume
Calculation 89
- Follow-up Mode 90
- Documentation and Report 92
- Ending an Evaluation 94
5
Contents

- Synchronization of both studies in the
FollowUp Mode 97
- Report templates 98
- Graphical lung model 98
syngo Volume Evaluation 100

• Key Features 100
• Workflow 103
- Loading the Images 103
- Preparing Volume Calculation 104
- Planning a Volume 104
- Evaluation Results 110
- Documentation of Results 111
syngo Dynamic Evaluation 116

• Workflow 119
- Loading the Images 119
- Inspecting the Input Images 120
- Generation of Parameter Images 121
- Creating a Baseline Image 123
- Evaluation of Region of Interests 124
- Enhancement Curve 125
- Documentation of Results 126
syngo Neuro Perfusion CT 132

- Contrast Medium Injection 139
6
Contents
- General Hints 140

• Workflow Concept 142
- Calculated Images Standard Neuro PCT 144
- Calculated Images Tumor Neuro PCT 146
- CBF/CBV 149
- Optimization 150
- Arterial Shift (only for
Tumor calculation) 152
syngo Body Perfusion CT 156

- Sensation 16 160
- Sensation Cardiac 162
- Sensation 10 164
- Emotion 16 166
• Patient Preparation 169
- Contrast Medium Injection 170
• Workflow 171
- Definition 172
- Calculation 179
- Arterial Input Function 181
- BodyPerfusion Result Images 184
- Workflow Concept 187
7
Matrix
syngo syngo syngo

Dental CT Osteo CT Pulmo
CT
SOMATOM Sensation 16 ● ● ●
SOMATOM Sensation Cardiac ● ● ●
SOMATOM Sensation 10 ● ● ●
SOMATOM Emotion 16 ● ● ●
❍ Standard
● Option
depending on the system configuration.
Please contact the local Siemens representative for
further information.
8
syngo syngo syngo syngo syngo
Lung- Volume Dynamic Neuro Perfu- Body Perfu-
CARE Evaluation Evaluation sion CT sion CT
● ❍ ❍ ● ●
● ❍ ❍ ● ●
● ❍ ❍ ● ●
● ❍ ❍ ● ●
9
User Documentation
For further information about the basic operation,

please refer to the corresponding syngo CT Operator
Manual:
syngo CT Operator Manual Volume 1:
Security Package
Basics
SOMATOM LifeNet
syngo Patient Browser
syngo Data Set Conversion
Camtasia
SaveLog

Preparations
Examination
HeartView CT
Respiratory Gating
CARE Bolus CT
CARE Vision CT
syngo Viewing
syngo Filming

syngo 3D
syngo InSpace4D
10
User Documentation

syngo Dental CT
syngo Osteo CT
syngo Volume

syngo Argus
syngo Calcium Scoring
syngo Vessel View

syngo Colonography
syngo LungCARE CT
syngo Pulmo CT
11
Application Information
Image Converter
The CT Application Common DICOM Adapter pro-
vides conversion between different DICOM data sets as
they may be provided by other CT vendors.
– You will find the converter in the Application menu
of the Patient Browser.
12
In the pop-up window you can select for which appli-

cation you want to convert the images.
13
Split-up multi-phase series

1.Select Split-up series according to trigger delay
from the section Split-up HeartView 4D series, if
you intend to split-up the series of multi-phase heart
reconstruction according to the different heart
phases included.
Or
2.Select Split-up series according to slice position to
split-up the series according to the different slice
positions it contains.
After conversion you can load these data sets in the
application of your choice.
14
Report Template
Configuration
Under Options/Configuration you will find the Report
Template Configuration.
With the Report Configuration you can edit the basic
information, e.g. hospital information for your report
templates of the applications:
– CalciumScoring
– Colon
– LungCARE
Additionally you can insert your logo and select which
reference data you want to use.
15
File Browser
The File Browser provides you with a secure possibility
for accessing and managing data in a private folder,
which is a well defined part of the file system. This user
partition is strictly separated from the file system con-
taining.
The user partition is shared read only and may be used
for transferring data from the scanner to other com-
puters, e.g., transferring DICOM images (export to
offline), transferring AVIs, or accessing files (PDF files)
which were downloaded via SOMATOM LifeNet.
Key features
• Copy images and files to the CD Burn folder
• Access to all created reports and movies (AVI files)
• Access to the Offline folder
• Access to downloaded files
Open the File Browser via main menu entry
Options > File Browser.
The File Browser provides special folders for our appli-
cations. Therein, the created reports and movies are
saved.
With an external PC connected, you can access your
offline data on the external PC for post-processing.
Transfer files to floppy:
– Select the desired files and send them via the right
mouse button menu on a floppy disk.
16
Burn on CD:
– Do not burn files on CD-R parallel to other transfer
jobs.
– Make sure that the amount of data to be burned
does not exceed the CD-R storage capacity.
– Select the desired files and drag & drop them into the
folder Burn on CD (or send them via the right mouse
button menu to the folder Burn on CD).
– Open the LocalJobStatus in the Patient Browser
and clear all entries.
– Select Record to Offline in the Transfer menu of the
Patient Browser.
– CD burning starts.
– Hint: CD burning of offline files is only possible in
Single session.
Review reports and movies:
– Select the desired files and double-click on them.
– The corresponding program, e.g. Movie Media Player
will be opened and you can review what you have
saved.
– Now you can send these files to floppy or burn it on
CD.
Hint
Files with the following extensions cannot be started/
opened from the FileBrowser
“.bat“, “.cmd“, “.com“, “.exe“, “.reg“, “.dot“, “.htm“,
“.html“, “.pl“, “.vbs“, “.js“, “.wsf“, “.wsh“, “.xml“
17
syngo Dental CT
Key Features
syngo Dental CT program is a dedicated post-process-
ing and image evaluation software for the teeth and
the jaw, which creates panoramic and paraxial views
of the upper and lower jaw.
Typical applications are pre-surgical planning for
implants, information about the structure of the jaw
bones and localization of the mandibular canal.
To do this, the Dental card provides you with the fol-
lowing methods:
• Evaluation on a separate syngo task card on the user
interface
• Reformatting of a curvilinear range of panoramic
views along the jaw bone
• Reformatting of paraxial views perpendicular to the
panoramic views or parallel to the table top
• Display and definition based on Maximum Intensity
Projection (MIP) and Multi Planar Reformatted (MPR)
images
• Definition of panoramic and paraxial parameters
such as Number of Views, Distance (mm) and Thick-
ness (mm)
• Individual paraxial lines can be interactively moved
and deleted
• Multiple paraxial range definitions on one reference
image by using a cluster & copy function
• Interactive definition of the Mandibular Canal on
paraxial and panoramic view
18
syngo Dental CT
• Distance, ROI and angle measurement tools are

available on the Dental CT task card
• Presentation of results in the form of multiple image
display with reference markings
• Result images can be copied to a film sheet – in ana-
tomical size with maximum use of the film sheet
• For easy reprinting, the results of the latest Dental CT
Film are stored in the Patient Browser
• All images can be stored on the hard disk
Panoramic view
Paraxial view
19
syngo Dental CT
Prerequisites
• Only original images can be loaded into Dental.
• Use only axial images.
• High Resolution volume data set of the lower and/or
upper jaw.
• The data set should be acquired using thin slice spiral
technique with overlapping increment.
• All scans must have the same zoom factor, same
reconstruction center, same slice orientation and an
image matrix of 512*512 pixel.
• The maximum range length is limited to 160 mm.
• At least 4 images are required.
20
syngo Dental CT
21
syngo Dental CT
Scan Protocols
You will find the Dental scan protocols under the body
region Head.
For SOMATOM Sensation 16/Sensation Cardiac:
A typical scan range of 5 cm will be covered in
7.18 sec.
For SOMATOM Sensation 10:
10.59 sec.
For SOMATOM Emotion 16:
8.51 sec.
Sensation 16 Dental
kV 120
Effective mAs/ 80
Quality ref. mAs
Rotation Time 0.75 sec.
Acquisition 16 x 0.75 mm
Slice collimation 0.75 mm
Slice width 0.75 mm
Feed/Rotation 6.6 mm
Pitch Factor 0.55
Increment 0.5 mm
Kernel H60s
CTDIVol 16.9 mGy
Effective dose Male: 0.41 mSv
Female: 0.43 mSv
22
syngo Dental CT
Sensation Cardiac Dental

kV 120
Effective mAs/ 80
Quality ref. mAs
Slice width 0.75 mm
Pitch Factor 0.55
Increment 0.5 mm
Kernel H60s
CTDIVol 16.9 mGy
Female: 0.43 mSv
Sensation 10 Dental
kV 120
Effective mAs/ 80
Quality ref. mAs
Slice width 0.75 mm
Pitch Factor 0.55
Increment 0.5 mm
Kernel H60s
CTDIVol 16.88 mGy
Female: 0.36 mSv
23
syngo Dental CT
Emotion 16 Dental
kV 130
Effective mAs/ 45
Quality ref. mAs
Slice width 0.75 mm
Pitch Factor 0.8
Increment 0.5 mm
Kernel H70s
CTDIVol 12.42 mGy
Female: 0.27 mSv
24
syngo Dental CT
Scanning Information
• It is mandatory to position the patient head in the
center of the scan field – use the lateral laser light
marker for positioning.
• Gantry tilt is not necessary since you have the ability
to tilt the reference line to generate an axial refor-
matted image at the desired plane.
However, in order to minimize the scan length for the
same anatomical region, it is recommended to posi-
tion the patient’s head at the appropriate scan plane
whenever possible:
– For the upper and lower jaw:
occlusal plane in parallel to the scan plane.
– For either jaw:
jaw bone in parallel to the scan plane.
• It is recommended to end the exam first, and then
start the Dental evaluation.
25
syngo Dental CT
Workflow
Loading the images

After loading the images into syngo Dental, and
defining the panoramic line, the following layout is dis-
played:
The upper left segment shows a lateral MIP image of

the jaw for overview purposes, with a red reference
line indicating the image plane displayed in the upper
right segment.
The upper right segment contains all axial MPR refer-
ence images in an image stack.
26
syngo Dental CT
Inspecting the input images

In order to optimize the image display, before starting
the syngo Dental CT reconstruction, you may want to
zoom and pan the images.
Before defining a panoramic line, you should choose a
suitable image position in the image stack so that the
upper or lower jaw is optimally displayed. Therefore
you can move and tilt the red reference line in the
upper left segment.
Preparing the reconstruction of Dental

images
1.Defining a Panoramic Line
You can plan the reconstructions by drawing a pan-
oramic reference line in the right upper segment:
• Click along the teeth or along the jaw bone to set the
base points. To finish the reference line, double click
onto the last base point.
The MPR from segment 2 is duplicated in segment 3
and 4.
• Segment 2 displays the drawn panoramic reference
line and the starting and end point of later recon-
structions are indicated with B (Begin) and E (End).
• Segment 3 shows green paraxial slice lines.
• Segment 4 shows up to seven yellow panoramic
lines.
27
syngo Dental CT
2.Editing the Panoramic Line

If you are not satisfied with the panoramic reference
line, you can
• modify the reference line by:
– reshaping or
– moving it
• delete the reference line completely and draw a new
one.
3.Panoramic View Parameters

You can define the panoramic view parameters in the
Panorama task card.
• Number of views: Defines how many panoramic
views will be reconstructed.
Range is: 1,3,5,7, while the reference line is always
the center line.
• Distance in mm: Defines the distance between the
panoramic views.
Range is: 1.0-5.0 mm.
• Thickness in mm: Defines the slice thickness of the
panoramic views. Minimum thickness is the slice
thickness of the input images, maximum thickness is
20 mm.
28
syngo Dental CT
4.Marking the lingual side

You will notice a small cross in the center of the right
upper segment. This is the reference point for the ori-
entation marks (buccal + lingual) of the later recon-
structed paraxial slices. The cross should be placed on
the tongue area.
5.Editing paraxial slices

If you are not satisfied with the program suggestions
for the paraxial slice lines displayed in the lower left
segment, you can
• move the paraxial line
• add a line
• delete one line
• delete all of them completely
6.Paraxial Slice Parameters
You can define the reconstruction parameters for your
paraxial slices in the Paraxial task card.
• Length in mm: Defines the length of the recon-
structed paraxial slices.
Range is: 16.0 - 50 mm.
• Distance in mm: Defines the distance between the
paraxial slices.
Range is: 1.0-6.0 mm.
Note that this will remove the distance modifications
made interactively.
29
syngo Dental CT
• Thickness in mm: defines the slice thickness of the

paraxial slices.
Range is: 0.39 - 20 mm.
Minimum slice thickness is the slice thickness of the
input images.
• Select the Orthogonal checkbox if you want the
paraxial slices to be reconstructed orthogonal to the
reference image
• deselect the Orthogonal checkbox, if you want the
paraxial slices to be calculated parallel to the table
top.
• The Begin and End lines are never used for the recon-
struction of the paraxial lines. They are only used to
define the reconstruction range and define the
reconstruction direction.
7.Clustering Paraxial slices
You can also cluster paraxial slices for a single tooth.
First you have to shorten the range of the paraxial slice
lines in segment 3 in a way that it covers only one
tooth, now start the cluster function. You can easily
copy the cluster to other teeth.
30
syngo Dental CT
Reconstructions
1. Starting the Reconstruction
To start the calculation of the panorama views and
paraxial slices click the Start Evaluation button in the
control area.
2.Reconstruction Results
• Segment 3 shows all paraxial slices, including the
reference image, in an image stack. The B mark indi-
cates the buccal side, the L mark indicates the lingual
side of the reconstructions.
• Segment 4 shows the panoramic views, including
the reference image, in an image stack.
• The lines in the panoramic views represent each
paraxial position and do not indicate a measure-
ment.
Mandibular canal
For implant planning it is important that you can out-
line the mandibular canal within the panorama views
and paraxial slices.
To outline the mandibular canal, you have two options.
You can either draw a line over the canal in a pan-
oramic view and the program will immediately display
blue markers in the paraxial slices for the mandibular
canal position, or you can also mark the mandibular
canal on the paraxial views, by placing markers either
on all views, or only on the first and last view, showing
the mandibular canal.
31
syngo Dental CT
Documenting the Results

1.Filming the Results
The Dental CT reconstructions can be easily filmed and
exposed in an anatomical scale on a predefined Dental
filming layout. Select the images you want to film,
copy them to the Filming card and expose the film job.
2.Saving the Results

When you save your images, 4 new series will be cre-
ated. Make sure you film all of the reconstructions
before saving them.
32
syngo Dental CT
Additional Important
Information
• The Dental scan protocol delivers high resolution
images for Dental CT evaluation, however, you can
also reconstruct images with a softer kernel, e.g.
H20s, for 3D/SSD post-processing.
The reconstruction of a Dental image is saved as a CT

image. Thus, evaluation of secondary reconstructions
is possible.
Caudal view
AP-cranial view
33
syngo Dental CT
• Image orientation:
– In the paraxial view, a B indicates buccal and a L
lingual. The lingual marker + must always be posi-
tioned at the tongue. If not, simply drag & drop it
back.
– In the panoramic view, a B stands for “Begin” and
an E for “End”.
– The image orientation refers to the first paraxial in
a paraxial reconstruction. This is documented by
an additional note in the image text.
• Filming: for the maximum use of the film, film
directly from the Dental card instead of Patient
Browser. For easy reprinting, the results of the most
recent Dental CT Film are stored in the Patient
Browser in the folder Film.
• It is recommended to change the image windowing
on the virtual film sheet.
• A semi-automatic detection tool can be used to mark
and outline the mandibular canal on both paraxial
and panoramic images for easy viewing and filming.
• Multiple paraxial ranges can be defined on one ref-
erence image by cluster & copy function.
I. e., you can group a number of paraxial lines and
copy the lines to another location, e.g. over individ-
ual sockets at different locations.
34
syngo Dental CT
• ROI definition for statistical evaluations and deletion

of graphics is possible.
Paraxial lines using

”Cluster”.
• In the control area, you can configure if you want to

display the paraxial lines orthogonal to the reference
line.
35
syngo Osteo CT
This is an application package for the quantitative

assessment of vertebral bone mineral density for the
diagnosis and follow-up of osteopenia and osteoporo-
sis.
Key Features
This program enables the quantitative determination
of bone mineral density (BMD) of the spine in mg/ml of
calcium hydroxyapatite (CaHA) to assist the physician
with diagnosis, staging, and follow-up of osteopenia
and osteoporosis with CT. The patient is scanned
together with the water- and bone-equivalent calibra-
tion phantom.
36
syngo Osteo CT
Scan Protocols
Scan Protocols
You will find the Osteo scan protocols under body
region Spine:
Sensation 16 Osteo
kV 80
mAs/ 250
Quality ref. mAs
Rotation time 1.0 sec.
Slice width 10.0 mm
Feed/Scan 0.0 mm
Kernel S80s
CTDIVol 5.3 mGy
Female: 0.81 mSv
Sensation Cardiac Osteo

kV 80
mAs/ 250
Quality ref. mAs
Slice width 10.0 mm
Feed/Scan 0.0 mm
Kernel S80s
CTDIVol 5.3 mGy
Female: 0.81 mSv
37
syngo Osteo CT
Sensation 10 Osteo
kV 80
mAs/ 250
Quality ref. mAs
Slice width 10.0 mm
Feed/Scan 0.0 mm
Kernel S80s
CTDIVol 5.0 mGy
Female: 0.78 mSv
Emotion 16 Osteo
kV 80
mAs/ 220
Quality ref. mAs
Slice width 10.0 mm
Feed/Scan 0.0 mm
Kernel S80s
CTDIVol 6.16 mGy
Female: 0.77 mSv
38
syngo Osteo CT
The special kernels are mostly used for physical mea-
surements with phantoms, e.g. for adjustment proce-
dures (S80s), for constancy and acceptance tests
(S80s, U90), or for specification purposes (U90). For
special patient protocols, S80s and U90 are chosen,
e.g. for Osteo (S80s) and for high resolution bone
studies (U90).
Patient positioning:
• Set the table height at 125. The gantry tilt will be
available from –22° to +22°.
• Patients should be positioned straight on the table.
Support the knees to compensate for lordosis.
• The calibration phantom should be positioned
directly below the target region.
Put the Gel-pad between the calibration phantom
and the patient to eliminate air pockets.
39
syngo Osteo CT
Scanning:
• With CARE Dose 4D the mA values are adapted for
each Osteo range, according to the patient diameter.
Therefore special obese protocols for the Osteo eval-
uation are no longer necessary.
• Typically, one scan each is performed at L1, L2 and
L3 levels. Use image comments L1, L2, L3, L4, L5, or
T12 prior to scanning of the respective vertebrae.
These comments will be used for Osteo evaluation
results (no blanks or other deviations are allowed,
e.g. use “L4“ instead of “L 4“, or “T12“ instead of
“TH12“).
• Before ending the examination, you can drag & drop
the recon jobs from the chronicle to the topogram
segment to get the Topographics, i. e. the cut lines
for each vertebra on the topogram.
• Position the cut line of scanning through the middle
of the vertebra, i. e. bi-sector between the angle of
the upper and lower end plate.
• The phantom must be included in the FoV of the
images for evaluation.
• It is recommended to end the exam first, and then
start the Osteo CT evaluation.
• Do not use the calibration phantom from other CT
scanners, as your system is calibrated to a particular
phantom.
40
syngo Osteo CT
Comparison of evaluation data:

• Due to an optimized algorithm for Osteo calculation,
especially the results for obese patients are more
precise (modified beam hardening in image recon-
struction is not used any more). This may have an
effect if current Osteo evaluation data of the same
patient is compared with data evaluated with soft-
ware version VA50 or older.
• Small deviations with the same scanning conditions
have to be taken into account.
Topographic
Phantom inside
the FoV
41
syngo Osteo CT
Workflow
After loading the images into the Osteo application,
press Start Evaluation.
Check the correct positioning of the ROIs in the Cali-
bration phantom. You can change the position by mov-
ing the two circles.
Water Bone
equivalent equivalent
42
syngo Osteo CT
Correcting contour lines

You can perform correction of the contours by moving
the base points. The following order is recommended:
1.Center of the spinal canal (C)
2.Uppermost point of the cortical spinal body (A)
3.Intermediate point (L)
4.Intermediate point (R)
5.Uppermost point of the spinal canal (T)
– Click on a base point with the mouse.
– Move it keeping the left mouse key pressed.
If you are satisfied with the contours press Accept
Contours otherwise skip the image. If the contours for
all images are accepted, the results are automatically
displayed. The skipped images are not taken into
account.
The third segment contains two summary images:
As results the bone mineral density (mg CaHA/ml) and
the standard deviation are displayed. The results are
listed in a table:
• the evaluated vertebra
(if the comment is correctly inserted, e.g. L1)
• the scan number of the image
• the trabecular bone mineral density for each verte-
bra and the pixel standard deviation (in brackets)
• the cortical bone mineral density for each vertebra
and the pixel standard deviation (in brackets)
• additionally the average and standard deviation over
all evaluated vertebrae are listed
43
syngo Osteo CT
The other summary image displays a graph which

shows the comparison of all evaluated vertebrae with
the selected Reference Data.
T-score
This is the deviation of average BMD of the patient
from that of a young healthy control. It represents
bone loss with reference to the peak bone mass.
Z-score
This is the deviation of average BMD of the patient
from that of a healthy person of the same age. It is an
indicator of biological variability.
44
syngo Osteo CT
The second and the fourth segment belong together.

The second segment shows the tomogram images
with the contours superimposed. The fourth segment
shows the calculated results of the corresponding
tomogram image. Both segments are bordered by the
same color. If you scroll through one of these seg-
ments, the other segment is updated to the same ver-
tebra.
45
syngo Osteo CT
After End Evaluation the evaluation results are auto-

matically saved in three series:
– Summary
contains both images of the third segment
– Contours
contains the tomogram images with the contours
superimposed (second segment)
– Tables
contains the result tables for each vertebra (fourth
segment)
46
syngo Osteo CT
Configuration
In the Osteo configuration you can define the follow-
ing parameters:
You can
• use the Siemens standard reference database or cre-
ate and import your own
• change between 1 and 2 standard deviations (dis-
play of the summary graph)
• use the Siemens Reference phantom or enter values
for bone and water manually
• change the age of the young controls, used for the
calculation of the T-Score
• enable the export of results:
47
syngo Osteo CT
How can you save the results on your PC?

– Select Option/Configuration from the main menu
and click icon CT Osteo.
– Activate the checkbox Enable Export of Results.
– Exit the configuration dialog.
– Call up the Osteo card and you will see
the new icon Export results on the lower,
right part of the screen.
– Click on this icon to copy the evaluation
results to floppy disk (note: with every mouse click
on the icon, the previous result file will be
appended).
– The data file can be transferred to your PC for fur-
ther evaluation, e.g. with MS Excel.
48
syngo Osteo CT
Example for one patient with three Osteo tomo-

grams:
PATIENT; John Smith; 007; 64; Male
IMAGE; L2; 234; 2; 27-JAN-1998; 11:12:17; 61.7;
48.9; 55.3; 20.8; 20.1; 21.5; 205.8; 192.0; 198.7;
50.6; 47.5; 49.5
IMAGE; L3; 236; 3; 27-JAN-1998; 11:12:18; 60.4;
54.5; 49.3; 22.3; 21.1; 21.8; 210.5; 191.9; 180.7;
50.4; 47.5; 52.3
IMAGE; L4; 238; 4; 27-JAN-1998; 11:12:18; 59.3;
43.1; 55.0; 20.6; 29.0; 23.3; 201.8; 178.1; 192.3;
43.6; 45.9; 44.2
REFDATA; 64; Male; 20; -4.35; -3.12; 75.4; 125.3; 26.5
Data Structure of the result file:
PATIENT; <Patient name>; <Patient ID>;
<Age of patient>; <Sex of patient>
IMAGE; <Vertebra name>; <Image number>;
<Scan number>; <Scan date>; <Scan time>; <TML>;
<TMR>; <TMT>; <TSL>; <TSR>; <TST>; <CML>; <CMR>;
<CMT>; <CSL>; <CSR>; <CST>
49
syngo Osteo CT
REFDATA; <Age of patient>; <Sex of patient>;

<Age of young normal>; <T-Score>; <Z-Score>;
<BMD reference data, age matched>;
<BMD reference data, young control>;
<Standard deviation reference data>
Abbreviations:
TML Trabecular Mean Left
TMR Trabecular Mean Right
TMT Trabecular Mean Total
TSL Trabecular Standard Deviation Left
TSR Trabecular Standard Deviation Right
TST Trabecular Standard Deviation Total
CML Cortical Mean Left
CMR Cortical Mean Right
CMT Cortical Mean Total
CSL Cortical Standard Deviation Left
CSR Cortical Standard Deviation Right
CST Cortical Standard Deviation Total
50
syngo Osteo CT
Information
• Fractured vertebrae are not suitable for Osteo CT
evaluation since the more compact nature of these
vertebrae result in bone mineral density value that is
much higher than one would expect.
• When entering a missing Patient Data, the Osteo CT
- Patient Data dialog box pops up when you start
evaluating images of a patient whose age or gender
is missing. Both values are required for Osteo CT
evaluation.
Caution: The age and sex of the patient are taken into
account in Osteo CT evaluation. Make sure the patient
sex and age are correct.
• When you examine a patient who is older than 80

years, the patient examination data can not be com-
pared with the reference data base.
• It is recommended to film directly from the Osteo
card. Select images or series with Edit/Select all, and
click film icon. You can also configure your film lay-
out, e.g. 3 x 3 as shown in Option/ Configuration/
FilmingLayout.
51
syngo Osteo CT
Note: it is not recommended to use filming setting of

4 x 5 segments since the image text elements of the
result image are overlapped and hard to read.
Siemens Reference Data:

The Siemens reference data was acquired at three
European centers, including 135 male and 139 female
subjects, 20 to 80 years of age.
52
syngo Osteo CT
53
syngo Pulmo CT
Key Features
Pulmo CT is an application package which is used for
quantitative evaluation of the lung density and struc-
ture.
Pulmo CT can be used for various applications such as
early detection, quantification and follow-up of
emphysema, asbestosis and silicosis. Other applica-
tions are pre-surgical assessment prior to lung volume
reduction surgery or investigation of new therapeutic
approaches.
To do this the Pulmo card provides you with the follow-
ing methods:
interface
• Automatic contour tracing to isolate the lung paren-
chyma from adjacent tissues
• Automatic segmentation (anterior, posterior, cen-
tral, peripheral)
• Display of attenuation values in histograms
• Calculation of the lung area by pixels included in pre-
determined HU ranges
• Color-coded display of HU ranges and percentiles for
direct viewing and identification of different densi-
ties in the lung image
• Volume calculation of automatically or interactively
defined contours
54
syngo Pulmo CT
• Table with statistical values for left, right and total

lung values (Mean Density, Standard Deviation,
Area, Full Width Half Maximum, Volume)
• Comparison with reference group (Siemens refer-
ence population based on 50% vital capacity or user-
defined reference group)
The Pulmo task card can be set up for two different
modes:
• The Standard Mode, with automatical/semi-auto-
matical outlining of the lung contours. It generates
the most common used result values.
• In Advanced Mode, it is possible to evaluate the
lung parenchyma by:
– Manual segmentation
– Automatic segmentation
– Defining HU-subranges and percentiles
– Volume calculation
– Comparison with individual reference data
55
syngo Pulmo CT
Prerequisites
• The syngo Pulmo CT program accepts only tomo-
gram images.
• The images have to belong to one study.
• No specific scan protocols are necessary for this
option. The scan protocols for routine thorax imag-
ing can be used. The scan parameters used are
dependent on the indications and objectives of the
study design. For example, spiral mode for lung vol-
ume evaluation or HR sequence mode for interstitial
lung diseases.
• Only original or JPEG-lossless compressed images
can be used. You cannot load lossy compressed
images.
56
syngo Pulmo CT
• You should only compare scans which were per-

formed at the same respiratory status.
The lung density of a patient varies depending on
the respiratory status, i.e. if the scan is performed
during full inspiration, full expiration or at a level in
between (defined as a percentage of the vital capac-
ity).
Full Inspiration Full Expiration
Density = @ Density = >2x@
Lung density at full inspiration/expiration
57
syngo Pulmo CT
Workflow
Loading the images

Before evaluation, the images are displayed as an
image stack (in a 1:1 layout) with a dog-ear for scroll-
ing.
After evaluating the last loaded tomogram, the Pulmo
task card automatically switches to a 2:2 layout for
standard results display (tables and summary):
• Segment 1 displays the tomogram images with the
background subtracted and the histogram curves
superimposed.
• Segment 2 contains the statistical results for the cor-
responding tomograms on the left side.
• Segment 3 summarizes the average evaluation
results for all tomograms. Usually, this is the Sum-
mary Statistics; optionally the Average Subranges
and the Average Percentiles are available.
58
syngo Pulmo CT
• Segment 4 shows the comparisons with reference

data, if available.
59
syngo Pulmo CT
Starting the Pulmo CT Evaluation

• After loading images, you can scroll through and
window them for better display.
• Click the Start Evaluation button.
The Pulmo CT evaluation starts by automatically
finding the contour for both lungs. The automatic
contour detection starts for the 1st image. The areas
within the contours will be evaluated.
• If the software cannot find any characteristic lung
contour, corresponding messages will appear or the
contour may be drawn in a strange position.
• Check the contours.
Usually, the contours will be shaped and positioned
correctly, but in the event they are not, you have the
ability to modify the contour by using the drawing
tools. You can post-process the contour with the fol-
lowing tools:
– Include/exclude lung regions or separate the con-
tour area
– Set a new starting point for a contour
– Start the contour drawing all over again (discard-
ing all changes)
– Exclude bronchi or trachea
– Draw the left or right lung contour by freehand
• With the Accept Contours button, you accept the
contours and finish the evaluation of this image.
For unacceptable images, you can skip the evalua-
tion.
In Standard Mode, the Pulmo CT evaluation will pro-
ceed to the next image.
60
syngo Pulmo CT
Pulmo CT Evaluation Results

After contours have been found for the last tomogram
(and segmentation in advanced mode), the Pulmo
task card automatically switches to a 2:2 layout. The
software calculates the results and displays them.
• Segment 1 shows the resultant histograms for each
tomogram with the frequency of HU values:
– white line for both sides
– blue line for the right lung
– green line for the left lung
The corresponding CT image is shown in the back-
ground.
• Segment 2 shows an image stack of tables with the
HU value statistics for each tomogram. It displays the
following results:
– Mean HU value
– Standard deviation for HU values
– Area for left and right lung and total area (cm²)
– FWHM (Full width at half maximum): Relates to
the most frequent value and characterizes the his-
togram shape
• Segment 3 summarizes the average evaluation
results for all tomograms (same categories as in seg-
ment 2). You can choose between:
– Summary Statistics
– Average Subranges (optional)
– Average Percentiles (optional)
• Segment 4 is only used when configured for
advanced result display. It optionally shows two dif-
ferent comparisons with reference data.
61
syngo Pulmo CT
Automatic Saving of Images

Images with histograms, result tables, and the evalua-
tion summary are saved in the Local Database as new
series for the patient. The series are consecutively
numbered. They are labeled: Histogram, Tables, Sum-
mary Tables, Segmentation, etc.
• Images, result tables and the summary are saved as
soon as the task card switches to the result display
(2:2 layout).
• If you click the End Evaluation button in advance,
only the contour images and the result tables that
have been calculated so far are stored.
Filming Pulmo CT Results

When the results are presented, the icons for filming
and exposing are activated. All Pulmo CT evaluation
results can easily be copied to the Filming task card,
where they can be exposed.
62
syngo Pulmo CT
Pulmo CT Evaluation in
Advanced Mode
The advanced mode offers a variety of more extended
evaluation methods than available with the standard
evaluation. The lung tomograms can be evaluated in
more details.
The advanced mode is switched on in the Pulmo Con-
figuration dialog box. There, you can combine auto-
matic and half-automatic segmentation methods and
optimize several evaluation options according to your
needs.
Note that the advanced mode remains activated until
you switch it off again.
Manual Segmentation
After activating the manual segmentation, several
icons and buttons are added to the Pulmo task card.
The "guided" workflow differs from the standard
mode: After accepting the contour for an image, you
continue with the manual segmentation for this
image.
To manually segment the lung you have to:
• Draw the segmentation lines
• Select the segmentations for evaluation
• Use the Accept Segmentation button to finish
63
syngo Pulmo CT
Automatic Segmentation
The automatic segmentation divides the lungs into
sub-areas for evaluation of:
• whole lung
• central lung
• peripheral lung
HU-Subranges and Percentiles

You can set up the evaluation of desired HU ranges and
HU frequency classes by configuring the subranges
and percentiles.
1.HU-Subranges Graph
By defining lower and upper HU-limits, the percentage
of lung area within the defined HU range is calculated.
Example: input: -1000 and -930; output: 25%
2.Percentiles Graph
By defining the percentage, the HU limits for given per-
centage ranges are calculated.
Example: input: 25%; output: -1000 HU and -930 HU
64
syngo Pulmo CT
Advanced Results Display

In advanced mode, the Pulmo task card will display the
following results.
When volume calculation has been activated:
• The result tables for each scan will include a value for
volume and height of the lung (segment 2).
• The summary gives you values for the complete
scanned volume as well as for the vertical expansion
(segment 3).
When segmentation has been activated:
• Segmentation results (from automatic and manual
segmentation) and range results will be displayed
(segments 3 and 4).
When subranges or percentiles have been configured:
• Segment 3 shows an image with the pixels within
the different subranges or percentiles displayed in
color.
• Segment 4 displays additional tables with results for
HU ranges and HU frequency classes.
When reference data is available:
• Data can be compared with reference data
(segment 4).
65
syngo Pulmo CT
Comparison with Reference Data

The reference data used for comparison depends on
the Pulmo CT configuration. It can be either the Sie-
mens reference data or your own reference data.
If configured, two reference data comparisons are dis-
played in segment 4 after evaluation:
• Mean value comparison
• Histogram comparison
1.Mean Values
The diagram is the graphical representation of the
mean HU values for the current patient compared to
reference group (patients aged between 20 and 80).
Additionally, the T-score and Z-score are displayed.
• The middle line inside the diagram shows the mean
HU values of the reference group related to age.
• The upper and the lower lines indicate the double
standard deviation (+/- 2SD).
• The mean HU value for the current patient is shown
as a horizontal line. The value itself is shown as
image text.
• The individual values for each tomogram are indi-
cated by small circles.
66
syngo Pulmo CT
2.Histogram Comparison
The histogram compares the relative HU frequency for
the current patient to the appropriate male or female
reference group.
• The white line shows the relative HU frequency (den-
sity of lung) for the current patient.
• The yellow line indicates the value for the reference
group.
• Upper and lower blue line indicates the double stan-
dard deviation (+/- 2SD).
3.Z-Score and T-Score

Both scores are used to allow comparison to the refer-
ence group.
• The Z-score describes the deviation of the mean lung
density of the current patient from the mean lung
density of the reference group, normalized by the
standard deviation of the reference group.
Mean HU (of patient) - Mean HU (of age-matched reference group)

SD (of reference group)
• The T-score describes the deviation of the of mean

lung density of the current patient from the mean
lung density of the young reference group, normal-
ized by the standard deviation of the reference
group. Note that the age of the young reference
group is configurable.
Mean HU (of patient) - Mean HU (of young reference group)

SD (of reference group)
67
syngo Pulmo CT
Configuration
The Pulmo Configuration dialog box is used to switch
the advanced mode on and to configure the special
evaluation options to your needs.
Enabling the Export of Pulmo CT

Results
All Pulmo CT results can be exported. The export con-
figuration is divided into:
• Export of standard results (for example, mean val-
ues, and standard deviations) to floppy disk
• Export of histograms to the file system (as floppy
disks do not have sufficient space for several histo-
grams)
Configuring the Calculation

On the Calculation tab of the Pulmo Configuration,
you can:
• adapt the basic calculation parameters for Pulmo CT
evaluation
• Choose which part of the lung you want to evaluate:
left, right or both
• If desired, restrict the HU value range in the Evalua-
tion Limits area:
– Enter a value for Maximum (HU): default is 3071
– Enter a value for Minimum (HU): default is -1024
68
syngo Pulmo CT
• modify parameters for automatic contour detection

– Enter a value for the Contour Threshold (HU):
default is -200
– Enter a value for the Number of Erosions: default
is 2
• enable automatic saving of 3D preparations
• switch on the calculation of the lung volume
• switch on Manual Segmentation
Configuring the Display of Histograms

You can configure the display of the histograms.
• Set the HU range which is displayed in the histo-
grams (-1024 ... 3071 HU):
– Enter a value for the Histogram Maximum (HU).
– Enter a value for the Histogram Minimum (HU).
• Choose a Histogram Shape:
– Abs. Freq.: Absolute frequency of HU values
– Peak Freq.: Only peaks of HU values. Same as
above but y-axis is scaled, so that maximum fre-
quency is 100.
– Rel. Freq.: Relative frequency of HU values in per-
cent.
Tip: We recommend the Rel. Freq. option, because
with the other shapes you cannot compare histograms
of different patients.
69
syngo Pulmo CT
Configuring the HU-Subranges

With the Pulmo CT evaluation, it is possible to evaluate
particular HU-subranges in more detail.
• On the Subranges tab, you can determine HU
ranges and calculate relative frequencies.
• On the Percentiles tab, you can set classes of fre-
quencies and calculate which HU value intervals are
related.
1.HU-Subranges
• Enter the Lower Limit (HU) to mark the lower limit
of the evaluated range.
• Enter the Upper Limit (HU) to set the upper limit.
• Enter a value into the Increment (HU) field to subdi-
vide the range into steps.
2.Percentiles
• Enter the Lower Limit (%) to mark the lower bound-
ary of the percentage range.
• Enter the Upper Limit (%) to set the upper bound-
ary.
• Enter a value into the Increment (%) field to subdi-
vide the percentage range.
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syngo Pulmo CT
Configuring the Segmentation

You can configure the automatic segmentation or acti-
vate the manual segmentation of lungs.
1.Automatic Segmentation
• Choose which areas should be evaluated
– Whole: the whole lung
– Central: central area of both sides of the lung
– Peripheral: only the lateral areas
– Central&Peripheral: first the central area and
then the peripheral areas
• Choose how the segments will be created
– with same anatomic height
– with approximately same area
• Enter an appropriate value in the Number of Seg-
ments field
• Enter an appropriate value in the Distance field (for
peripheral and central areas only)
• Enter an appropriate value in the ROI width field (for
peripheral areas only)
• Check the AP Grad field to calculate the Anterior-
Posterior gradient (change of mean HU within the
segments).
71
syngo Pulmo CT
Information
• Siemens Reference Data for lung-healthy individuals
was acquired at 50% vital capacity. For a meaningful
comparison of the current patient with the Siemens
reference data, the patient must also be scanned at
50% vital capacity.
• User-Specific Reference Data
It is possible to integrate your own reference data,
e.g. data acquired at full inspiration, for the evalua-
tion.
Please contact the local Siemens representative for
further information.
• T-score and Z-score results will only be displayed if a
reference data comparison is selected.
• Exporting Pulmo CT Results; Availability depends on
configuration
You can export the current Pulmo evaluation results.
They will be saved as a semicolon separated ASCII
file. You can import this file into any spreadsheet
program for further investigation.
The export is available for standard results and for
histograms.
– Standard results (such as mean values and stan-
dard deviations) are exported to floppy disk
– Histograms are exported to the file system (they
are too large for floppy disks)
(Note: with every mouse click on the icon, the pre-
vious result file on the floppy will be appended).
– The data file can be transferred to your PC for fur-
ther evaluation, e.g. with MS Excel.
72
syngo Pulmo CT
• Entering a missing Patient Data

The Pulmo CT - Patient Data dialog box pops up
when you start evaluating images of a patient whose
age or gender is missing. Both values are required for
Pulmo CT evaluation.
Caution: The age and sex of the patient are taken into
account in Pulmo CT evaluation. Make sure the patient
sex and age are correct.
• Zooming or panning of images is not possible for
Pulmo CT evaluation
• You cannot use the Separate, Include, Exclude tool
nor the Exclude Trachea/Bronchi tool for freehand
contours. Instead, use the freehand draw tools
• Do not modify the patient (Browser menu Edit > Cor-
rect), if results are already calculated. This may
result in inconsistent patient or image information.
73
syngo Pulmo CT
Example of result file:

START; 20-FEB-1998 12:01:17
PATIENT; John Smith; 007; 64; Male
IMAGE; 234; 21; 27-JAN-1998 11:12:17;-200;1
RESULTS; LEFT; 234; -1024; 3071; -905; 43.4; 22.5;
112; 34.5; 0.1
RESULTS; RIGHT; 234; -1024; 3071; -899; 33.4; 19.5;
85; 30.1; 0.1
RESULTS; TOTAL; 234; -1024; 3071; -903; 38.1; 21.0;
93; 64.6; 0.1
SUBRANGE; LEFT; 234; 1; -1000; -400; 200; 75.0; 15.9;
3.3
SUBRANGE; RIGHT; 234; 1; -1000; -400; 200; 80.9;
15.1; 2.2
SUBRANGE; TOTAL; 234; 1; -1000; -400; 200; 78.0;
15.5; 2.8
SUBRANGE; LEFT; 234; 2; -1024; 1000; 0; 100.0
SUBRANGE; RIGHT; 234; 2; -1024; 1000; 0; 100.0
SUBRANGE; TOTAL; 234; 2; -1024; 1000; 0; 100.0
PERCENTILE; LEFT; 234; 1; 0; 100; 25; -1012; -954; -
953; -885; -884; -800; -799; -112
PERCENTILE; RIGHT; 234; 1; 0; 100; 25; -1023; -934; -
933; -888; -887; -785; -784; -211
PERCENTILE; TOTAL; 234; 1; 0; 100; 25; -1023; -944; -
943; -886; -885; -793; -793; -112
……
74
syngo Pulmo CT
Data structure of the result file:

START; <Date and Time of the evaluation start>
PATIENT; <Patient name>; <Patient ID>;
<Age of patient>;
<Sex of patient>
IMAGE; <Image number>; <Scan number>;
<Scan date and time>; <Threshold Contour>;
<Number of Shrinkings>
RESULTS; <LEFT/RIGHT/TOTAL>; <Image number>;
<Lower eval. limit>; <Upper eval. limit>; <Mean>;
<Standard Deviation>; <Area>; <FWHM>;
<Accumulated Volume>; <Accumulated Height>
SUBRANGE; <LEFT/RIGHT/TOTAL>; <Image number>;
<Subrange Number>; <Lower Limit>; <Upper Limit>;
<Increment>; <Percent Area first subrange>; .....;
<Percent Area last subrange>
PERCENTILE; <LEFT/RIGHT/TOTAL>;
<Image number>; <Percentile range number>;
<Lower Limit>; <Upper Limit>; <Increment>;
<Lower HU value first percentile>;
<Upper HU value first percentile>; .....;
<Lower HU value last percentile>;
<Upper HU value last percentile>
AUTOSEGMENT; <LEFT/RIGHT >;
<Image number>; <Segmentation number>;
<W=Whole/C=Central/P=Peripheral>;
<A=Area/H=Heights>; <Number of segments>;
<Distance>; <ROI width>;
<AP gradient: 0=no / 1=yes>;
<Mean value first segment>; ....;
<Mean value last segment>;
<Standard deviation first segment>; ....;
<Standard deviation last segment>;
<Area first segment>; ....; <Area last segment>;
<AP-Gradient>
75
syngo Pulmo CT
MANSEGMENT; <LEFT/RIGHT>;
<Image number>; <Segmentation number, always 1>;
<Number of segments>;
<Mean value first segment>; ....;
<Mean value last segment>;
<Standard deviation first segment>; ....;
<Standard deviation last segment>;
<Area first segment>; ....; <Area last segment>
TOTALRESULTS; <LEFT/RIGHT/TOTAL>;
<Upper eval. limit>; <Lower eval. limit>; <Mean>;
<Standard Deviation>; <Area>; <FWHM>;
<Accumulated Volume>; <Accumulated Height>
TOTALSUBRANGE; <PATIENT/REFERENCE/RATIO>;
<Subrange Number>; <Lower Limit>; <Upper Limit>;
<Increment>;
<Percent Area first subrange (or Ratio for RATIO)>; .....;
<Percent Area last subrange (or Ratio for RATIO)>
TOTALPERCENTILE;
<PATIENT/REFERENCE/DIFFERENCE>;
<Percentile range number>;
<Lower Limit>; <Upper Limit>; <Increment>;
<Lower HU value first percentile
(or difference for DIFFERENCE)>;
<Upper HU value first percentile
(or difference for DIFFERENCE)>; .....;
<Lower HU value last percentile
(or difference for DIFFERENCE)>;
<Upper HU value last percentile
(or difference for DIFFERENCE)>
REFDATA; <Age of patient>; <Sex of patient>;
<Age of young normal>; <T-Score>;
<Z-Score>; <Reference data, age matched>;
<Reference data, young control>;
<Standard deviation reference data>
END; <Date and Time of the evaluation end>
76
syngo Pulmo CT
77
syngo LungCARE CT
A dedicated software for visualization and evaluation

of pulmonary nodules using low-dose lung scanning
and for subsequent follow-up studies.
Key Features
• Selection of different reports.
• 3D Visualization with Thin Slabs using MPR, MIP and
VRT displays.
• Computer-guided localization of pre-marked lesion
(Nodule Enhanced Viewing, NEV).
• Close-up inspection of suspected lesion with the
Rotating MPR mode.
• Automatic evaluation of pulmonary nodules with
perspective VRT or MPR display.
• Automatic volume and diameter measurements of
pulmonary nodules.
• Easy and flexible reporting of the evaluated nodules.
• Follow-up mode with synchronization of two data
sets.
• Automatically linked nodules, display of the corre-
sponding history graph.
• Saving of different reports.
78
syngo LungCARE CT
Prerequisites
• High Resolution volume data set which was acquired
within a single breathhold.
• The data set must be contiguous.
• Isotropic data volume. Maximal acceptance up to
10 mm slice thickness, but the thinner the slices the
better the results.
• Only original images can be used. No post-processed
or compressed images.
• For a better synchronization in Follow-up mode, the
data sets should cover nearly the same volume.
We recommend using the same scan parameters for
the Follow-up study.
79
syngo LungCARE CT
Scan Protocols
You will find the LungCARE scan protocols under body
region Thorax.
CARE Dose 4D is off as default because for LungCARE
protocols the lowest mAs values are used.
9.33 sec.
14.33 sec.
13.70 sec.
Sensation 16 LungCARE
kV 120
Effective mAs/ 20
Quality ref. mAs
Slice width 1.0 mm
Pitch Factor 1.5
Increment 0.7 mm
Kernel B50f
CTDIVol 1.6 mGy
Female: 1.0 mSv
80
syngo LungCARE CT
Sensation Cardiac LungCARE

kV 120
Effective mAs/ 20
Quality ref. mAs
Slice width 1.0 mm
Pitch Factor 1.5
Increment 0.7 mm
Kernel B50f
CTDIVol 1.6 mGy
Female: 1.0 mSv
Sensation 10 LungCARE
kV 120
Effective mAs/ 20
Quality ref. mAs
Slice width 1.0 mm
Pitch Factor 1.5
Increment 0.7 mm
Kernel B50f
CTDIVol 1.64 mGy
Female: 1.03 mSv
81
syngo LungCARE CT
Emotion 16 LungCARE
kV 110
Effective mAs/ 15
Quality ref. mAs
Slice width 1.0 mm
Pitch Factor 1.5
Increment 0.7 mm
Kernel B50s
CTDIVol 1.28 mGy
Female: 0.86 mSv
82
syngo LungCARE CT
Workflow
Layout
After loading a series into syngo LungCARE a 4-seg-
ment layout is displayed.
– upper left segment: Slab Segment
– upper right segment: Slice Reference Segment
– lower left segment: Slab Reference Segment
– lower right segment: VOI Segment
83
syngo LungCARE CT
Slab Segment
The upper left segment displays a thick 3D slab of the
data volume.
• Allows navigation in a slab with adjustable thickness
interactively and in Real-time through the volume.
• Different visualization techniques are available:
MPR Thick, MIP Thin, VRT Thick.
• Ability to change the orientation of the slab and do a
blow up into a full screen layout.
Slice Reference Segment
The upper right segment displays the original axial
slices of the data volume.
• Allows navigation through the axial slices of the data
volume.
• Display of the best corresponding Slice Reference
image according to the slab segment.
Slab Reference Segment
The lower left segment displays a coronal MPR of the
loaded data volume.
• In the Slab Reference Segment the location and the
thickness of the slab from the Slab Segment is dis-
played with two bounding lines. They are arranged
symmetrically to a middle line. The view direction of
the Slab for the slab segment is identified with
arrows.
• It is possible to navigate through the MPR in the Slab
Reference Segment.
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syngo LungCARE CT
• You can navigate rapidly through the volume by

either
– dragging the slab to any position
– using the marker as a navigator aid.
Visualization and Evaluation

Two workflows are possible:
1.First identify and mark all the suspected lesions in
the entire data set during the first pass navigation.
Then as a second step, the individual close-up evalu-
ation of the pre-marked lesions.
2.Immediately evaluate each suspicious lesion as soon
as it was visualized during the first navigation.
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Marker Display
Each marker is given a unique ID and is defined more
closely with a color. The marker changes from red to
yellow and then to green according to the workflow.
After evaluation the marker and the corresponding
nodule have the same color. The nodule is then addi-
tionally defined more closely with the status display in
the image text.
Status Color Status Color Shape

Nodule enhanced viewing red circular
marked red rectangular
evaluated yellow rectangular
reported green rectangular
The marker and the nodule also change from green

back to yellow and red when undoing the correspond-
ing workflow steps.
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Selection of a Report Series

– Load the series into syngo LungCARE
– Window Select Report appears
– Select an existing report or create a new one
– After confirmation the Nodule Enhanced View-
ing (NEV) Calculation starts automatically
NEV Calculation
– After the NEV calculation is finished and you want
to display the result, in the slab segment, view the
entire data set through at least once.
– Press the [NEV] button in the Control Area.
– In the slab segment all detected nodules are
marked with a red circular ROI.
– The NEV marked nodules can be used for further-
evaluation.
Identification and Marking of Lesion

• Scroll through the data set with Thin-slab MPR, MIP
or VRT in the Slab Segment.
• If NEV calculation had been performed before, scroll
through the data set in the Slab segment and evalu-
ate the NEV marked nodules.
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• Click on a suspicious lesion, activate the rotating

MPR with the SmartSelect menu. Magnified MPR
projections rotate along the center which is created
by the current mouse position. It is now possible to
distinguish between solitary structures (e.g. pulmo-
nary nodule) and elongated structures (e.g. vessel).
• Mark each suspicious lesions by activating the
SmartSelect menu.
• The marker is shown in the Slab Segment and in the
Slab Reference Segment.
• The best corresponding slice is shown in the Slice
Reference Segment.
• As you scroll through the data set, markers are dis-
played in the Slab Segment accordingly.
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Segmentation of the Nodule and Vol-

ume Calculation
• Click on the lung nodule, activate VOI via the Smart-
Select menu.
• A localized, magnified (perspective rendering) VRT
with the lung nodule is displayed in the lower right
segment (VOI Segment).
• It is possible to interactively rotate and zoom the Vol-
ume of Interest in VRT.
• The VRT display can be changed to MPR, with the
ability to scroll through the volume and to change
the orientation to axial, coronal or sagittal.
• With the SmartSelect menu, activate the function
Evaluate Nodule.
• A segmentation of the nodule is started, the seg-
mented nodule is highlighted in yellow.
• The software automatically calculates the volume,
the diameter in all three axes, and the max/min
diameters of the nodule.
• It is also possible to call up a HU histogram to identify
any calcifications within the nodule.
If you are not satisfied with the results of the automatic
segmentation and evaluation, you can manually alter
the results for more exact representation of the lesion/
nodule.
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Follow-up Mode
For comparison it is possible to load two data sets into
LungCARE. The Layout of the taskcard changes to:
– upper left segment:
Slab segment of the prestudy
– lower left segment:
Slab Reference segment of the prestudy
– upper right segment:
Slab segment of the follow-up study
– lower right segment:
Slab Reference segment of follow-up study.
The most recent acquisition is displayed on the right
side of the image area. VOI mode is done synchro-
nously for both studies. The Slab segments change to
the corresponding VOI segments. You can continue
with the evaluation in the VOI segment of the follow-
up study as you used in single mode.
The Follow-up mode provides:
– Alignment of the slab positions
– Synchronization of viewing parameters, e.g. win-
dowing, zoom/pan
– Get Counterpart:
The same anatomical structure of an evaluated nod-
ule of the pre-study will be found in the follow-up
study.
– Linking of counterpart markers:
Linking of two segmented markers transfer the infor-
mation given in the pre-study automatically to the
corresponding nodule of the follow-up study
– Calculation of the growth:
In the report the growth of the nodules will be calcu-
lated and clearly illustrated as a history graph.
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Display of the Slab segment in FollowUp mode.
Display of the VOI segment in FollowUp mode.
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Documentation and Report

During the evaluation, specific details such as location,
morphology and characteristics of each nodule can be
entered into the Nodule details dialog.
The entries for the nodule descriptor list boxes can be
configured.
Thumbnails of the four segments are automatically
displayed in the lower end of the dialog. Up to two of
these images can be selected.
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The Report Wizard provides you with a brief table of

the evaluated nodules.
You can also enter any additional observed abnormali-
ties and his/her conclusion.
• The Report template is configurable.
• It is possible to print the report or to export the
report in several formats e.g. PDF-, HTML- or RTF-
Format.
• All information that was manually or automatically
entered is saved in the database.
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Ending an Evaluation
After ending the LungCARE Evaluation the Save
report dialog appears. For identification of the created
report you can enter a comment.
Display of the history graph in FollowUp mode.
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Information
1.You have problems with the automatic volume cal-
culation, i.e. the system does not calculate the vol-
ume after selecting Evaluate Nodule in the VOI seg-
ment.
Try this:
• Change the view of the VOI segment to MPR.
• Check the position of the set marker. If the marker is
not set properly over the nodule, delete the marker
via the smart select menu.
• Place your cursor exactly in the center of the lesion,
activate the smart select menu and set the marker
directly in the VOI segment, then proceed with the
calculation.
2.You cannot find the correct entries in the smart

select menus?
Try this:
• There are two different kinds of smart select menus
available in the slab and in the VOI segment depend-
ing on your mouse cursor position.
– One menu belongs to the segment, e.g. Delete
VOI
– One menu belongs to the lesion, e.g. Evaluate
Nodule
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• Place the mouse cursor either in the segment or in

the centre of the marker to get the right access.
3.You cannot access the Nodule Details window

because the icon is greyed out.
• This happens when you have selected the other
screen segments. To activate the Nodule Details
again right mouse click in the VOI segment.
• If you have already opened the Nodule Details for a
lesion and entered some information, you can only
modify the details again via the Report Wizard.
• NEV markers are red circles, set markers are red
squares, evaluated markers are yellow squares and
reported markers are green squares. So we have a
traffic light principle, and this helps to make sure no
lesions are missed for evaluation or report.
4.Rotating MPR is not available in the smart select

menu?
• Rotating MPR is not available for NEV markers
• First delete the NEV marker via the smart select
menu, then you can proceed with the identification
and evaluation of the lesion.
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Synchronization of both studies in the

FollowUp Mode
When you switch on synchronization by selecting one
side of the schematic display of the lung, the positions
of both Slab Segments are aligned. Synchronization is
switched on as default after loading the second study
into the FollowUp mode.
Synchronization of the two data sets means that all
modifications of viewing parameters in one data set
are automatically reproduced in the other. This pro-
vides a very easy way of optimizing display of the two
data sets.
Depending on the patient data, you can select which
lung to base data synchronization on.
If you want to view both studies without Synchroniza-
tion, you can switch it off by deselecting the schematic
display of the lung so that no side is highlighted.
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Report templates
Newly created report templates must at least contain
one table.
• Press the according button on the left side of the
screen to add a table.
Please note, that the responsibility accepted by us is
restricted to the delivered report templates.
Graphical lung model

Numbering and location of the lung segments in the
graphical lung model of the nodule details dialog in
LungCARE can be found in literature. (see: Schiebler,
Schmidt, Zilles; Anatomie, 8. Auflage, 1999 Springer
Verlag)
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99
Volume is an evaluation function which allows most

accurate calculation of a volume out of a stack of two-
dimensional images.
This can be done by Volume-of-Interest (VOI) defini-
tion and by limiting the minimum and maximum den-
sity (HU) values for calculation. Different views of the
image data provide fast navigation and easy volume
definition.
Potential applications are volume measurements of a
tumor or organs such as liver, lung and kidney.
Key Features
To do this, the Volume Evaluation card provides you
with the following features:
interface.
• Calculation of 5 different Volumes is possible in par-
allel.
• For easy navigation, the image data is displayed in 3
different views: coronal, sagittal and axial.
• Use of syngo functions such as Navigation lines and
dog ears can be used for fast paging through each
view.
• Transversal thick slice Multi Planar Reformat (MPR),
Maximum Intensity Projection (MIP) or Minimum
Intensity Projection (MinIP) segments are available
for better recognition of the Volume of Interest.
• Zoom & Pan is available for each image segment
which is especially helpful for Volume definition of
smaller structures.
100
• Interactive outlining of freehand and elliptical

Regions-of-Interest is available, with the ability to
define evaluation (HU) limits inside the VOI.
• Automatic interpolation between two pending ROIs
is performed, i. e. you only have to define the ROI in
selected images within the stack.
• Automatic detection of a volume using threshold
based 3D region growing, for quick calculation of
high contrast structures such as bone, lung or con-
trast filled organs.
• Combination of interactive and automatic approach
possible.
• Dedicated linking methods available for fusion or
separation of ROIs, in order to define complex vol-
umes.
• Display of color-coded VOIs for easy differentiation
of multiple volumes.
• Configuration of result parameters.
101
Prerequisites
The images must fulfill the following conditions:
• Only images of one patient must be loaded for eval-
uation with Volume
• Use only axial images
• The scans must have been acquired with the same
table height and the same gantry tilt
• Only image data sets with the same slice orientation
must be used; (the selection should not include a
topogram image)
• The loaded images must have the same zoom factor
and the same reconstruction center
• At least four images must be loaded before volume
evaluation can be performed
• The time range between the first and the last image
must not exceed one hour
• The data capacity of the volume must not exceed
1024 images with matrix dimensions of
512 x 512 pixels
102
Workflow
Loading the Images

After loading the images into syngo Volume Evalua-
tion the following layout is displayed:
1 2
3 4
• Segment 1: Display of sagittal images.

The images are sorted from left to right, according to
the patient’s anatomy.
• Segment 2: Display of coronal images.
The images are sorted from front to back, according
to the patient’s anatomy.
• Segment 3: Display of transversal images.
The images are sorted from head to feet, according
to the patient’s anatomy.
• Segment 4: Display of either the evaluation results or
thick slice images (MaxIP, MinIP or MPR images) that
correspond to the transversal images in segment 3.
103
Preparing Volume Calculation

Before you start the volume definition, first optimize
the display of the images. To make interactive volume
definition easier, you can
• delete images that you do not require for volume cal-
culation from the original data set
• change the display of the images in the MIP/results
segment using the display mode (MaxIP, MinIP or
MPR) and the slice thickness
• scroll through the image stack
• window, zoom and pan images
• show/hide image text display
• set evaluation limits: Using the evaluation limits you
can perform volume calculation within a defined HU
value range
Planning a Volume
Volume Evaluation offers different tools and methods
to plan a volume.
• You can use the Automatic Volume Detection fea-
ture, where the system automatically defines a vol-
ume around a seed point. Volume CT searches for
directly connected voxels within a defined HU range
and assigns them to the volume.
• You can use the Interactive Volume Definition,
where you draw either elliptical or freehand regions
of interest (ROIs) on the images. The ROI contours
define the outer border of the volume.
104
Planning a Volume with Automatic Volume Detec-

tion
The automatic method is best used to evaluate a struc-
ture which has a different contrast (HU) than the sur-
rounding tissue, such as the lung. You plan the volume
with just a few clicks.
Automatic Volume Detection uses the 3D region grow-
ing method. You enter thresholds that are to be con-
sidered for region growing and set seed points.
Volume Evaluation searches for directly connected
voxels within the threshold limits, and assigns them to
the VOI.
The system then generates a volume considering all
voxels that are found with region growing and which
CT value lies within the Evaluation Limits.
• Check and adapt the thresholds, if necessary.
• Set a seed point.
• To enlarge the volume, set additional seed points.
• To include only a specific range of HU values into the
volume, change the Evaluation Limits. By default,
the Evaluation Limits are identical to the Threshold.
• To start the evaluation, click the Start Evaluation
button. The evaluation results are displayed in seg-
ment 4. The volume is colored on all images in all
views.
• You can define a new volume.
You can correct the Evaluation Limits and restart the
evaluation. If the result is not satisfactory, you can
delete the volume.
105
Restricting Automatic Volume Detection

You can restrict Automatic Volume Detection to a
defined smaller volume.
• Draw an ROI around the image area of interest on at
least the first and the last image that you want to be
included in the volume. The ROIs define the bound-
ing box for the automatic approach.
• Check the Thresholds and set the seed point inside
the object to be detected.
• Region growing only includes voxels that fulfill the
following conditions:
• Their HU value lies within the thresholds.
• They are connected to the seed point.
• They lie inside the bounding box.
Planning a Volume with the Interactive Volume
Definition
For structures that are not so well defined, it is recom-
mended to use the Interactive Volume Definition
method. You can precisely adapt the ROIs to complex
body structures.
You can draw either elliptical or freehand ROIs on the
transversal images or on the thick slice images (for fast
navigation).
The contours of the ROIs define the outer border of the
evaluated volume. You do not need to define the ROIs
on every slice. The system automatically interpolates
ROIs on the images which lie between the images with
defined ROIs.
106
• Check the images and search for the desired object

structure.
• You can start at any image in segments 3 or 4.
We recommend displaying an image that shows the
center of the desired structure.
• Draw an ROI around the area that is to be considered
to be part of the object structure.
• Do the same on another image, for example, the first
or last image that shows the structure.
The system automatically inserts ROIs on the inter-
mediate images. These ROIs are drawn with a dotted
line to indicate that they are assumed for the evalu-
ation of the volume, but that they are not confirmed
by you. The contour of a user-defined ROI is a solid
line. All ROIs have the same color and number.
• Scroll through the images and modify, if necessary,
the interpolated ROIs to the true structure of the
desired volume. You can edit an interpolated ROI or
replace it with a new ROI.
• To extend the volume, insert an ROI before/after the
first/last image on which an ROI is already defined.
• To include only a specific range of HU values into the
volume, change the Evaluation Limits.
By default, the Evaluation Limits take all HU values of
the last evaluation.
• To start the evaluation, click the Start Evaluation
button. The evaluation results are displayed in seg-
ment 4. The volume is colored on all images in all
views.
• You can define a new volume.
You can correct the Evaluation Limits and restart the
evaluation. If the result is not satisfactory, you can
delete the volume.
107
Overlap and Mark&Link Method

You can define complex volumes using the automatic
(overlap) and manual (mark&link) method.
• Overlapping method
Draw ROIs that overlap each other vertically for at least
a few pixels, so that it is automatically combined to
one volume. Interpolated ROIs (dotted line) are shown
in the intermediate images.
Two or more small ROIs that are drawn within one
image and a big ROI in a different image that overlaps
both small ROI's, are automatically combined into one
volume. This works in both directions:
top-down and bottom-up.
108
With the Overlap method, you can also create a vol-

ume from two ROIs that do not overlap in the first step.
It is then necessary to draw an ROI in an image which
lies between the two other ROIs, so that the new ROI
overlaps with the two previous ROIs. This way, you can
easily define a VOI around tortuous body structures.
• Mark & link method

If two ROIs do not have a common projection point,
you can link them manually for interpolation.
You can link non-overlapping ROIs to one volume. First
you mark one ROI, and then you link a second ROI to it.
The system connects the ROIs and inserts interpolated
ROIs on the intermediate images.
109
Evaluation Results
When you click the Start Evaluation button, the sys-
tem calculates the planned volume within the evalua-
tion limits.
The evaluation results are displayed in segment 4.
Only the statistic parameters that are set in the config-
uration dialog box are calculated. Volume pixels and
evaluation results are the same color.
The evaluation results and the thick slice images are
both displayed in segment 4. To switch the display,
click the MIP/Result icon.
The evaluation results include general patient informa-
tion, date and time of the evaluation and for each vol-
ume the configured statistic parameters.
• Volume [cm3/mm3] Size of the volume.
• Height [cm/mm] Maximum height of the volume in
cm – corresponding to the patient’s anatomical feet-
to-head orientation.
• Width [cm/mm] Maximum width of the volume in
cm – corresponding to the patient’s anatomical left-
to-right orientation.
• Depth [cm/mm] Maximum depth of the volume in
cm – corresponding to the patient’s anatomical ante-
rior to posterior orientation.
• Mean [HU] Mean CT value of the volume in HU.
• SD Standard deviation from the Mean value [HU].
110
• L Threshold [HU] Lower threshold considered for

automatic volume detection.
• U Threshold [HU] Upper threshold considered for
automatic volume detection.
• L Eval Limit [HU] Lower evaluation limit considered
for volume calculation.
• U Eval Limit [HU] Upper evaluation limit considered
for volume calculation.
Documentation of Results
If all volumes are evaluated, you can save and film the
results.
Save – stores to your local database:
• The transversal images with the color-coded VOI
• The reformatted images (sagittal, coronal, MPR/MIP)
• The displayed result sheet
Two new series are created.
• The VolumeResult series, which consists of the 4
images and the result sheet that are currently dis-
played.
• The VolumeAxial series, which is a copy of the
loaded transversal images and also includes the
color-coded ROIs.
111
Configuration
In the Volume Configuration dialog box, you define

which evaluation results are given by Volume Evalua-
tion.
– Unit of Volume Parameters
mm3 Volume is given in mm3.
cm3 Volume is given in cm3.
112
– Volume Statistic Parameters

Volume Volume is calculated in the defined unit:
mm3 or cm3.
Max. height [cm] Maximum height of the recon-
structed volume.
Max. width [cm] Maximum width of the recon-
structed volume.
Max. depth [cm] Maximum depth of the recon-
structed volume.
Mean value [HU] Mean CT value of the volume in
HU.
Standard deviation [HU] Pixel standard deviation.
Thresholds [HU] Range of CT values that have been
considered for automatic volume detection in HU.
Evaluation limits [HU] Range of CT values that have
been considered for volume calculation in HU.
– Coronal/Sagittal Slice Thickness

In the Coronal/Sagittal slice thickness area you can
preset the slice thickness for sagittal and coronal
images.
Select same as input images if you want to have the
slice thickness of the input images applied.
113
Information
• Loading Images
After all images are loaded, your system checks
whether the sorted images have an equally spaced
ascending or descending timestamp. If that is not the
case, a warning box is displayed but loading is contin-
ued.
If the distance between slices and the slice thickness of
the loaded images are not identical, a warning box is
also displayed.
• ROI and Volume Definition
– If you insert/modify an ROI, the system automati-
cally plans the ROIs on the preceding/following
images (interpolated ROIs) up to that image with
the previous/next user-defined ROI.
– User-defined ROIs have a solid contour line,
whereas interpolated ROIs have a dotted contour
line.
– When you modify an interpolated ROI (dotted
line), it becomes a user-confirmed ROI and is dis-
played with a solid line.
– The system never modifies the shape of a user-
defined ROI. If you insert or modify an ROI, the
shape of previous/following interpolated ROIs may
change.
– If a new ROI touches or overlaps another user-
defined ROI (solid line), the ROIs are merged dur-
ing volume calculation.
– If a new ROI touches or overlaps an interpolated
ROI (dotted line), the new ROI replaces the system
defined ROI.
114
• Restrictions for Linking and Unlinking

There are some restrictions for linking and unlinking:
– Linking can be done on user-defined ROIs as well
as on interpolated ROIs. If you link an interpolated
ROI (dotted line), it becomes a user-confirmed ROI
(solid line).
– You cannot unlink interpolated ROIs. The unlink-
ing only works with user-confirmed ROIs.
– If you modify the volume (for example, move a
ROI) before linking an ROI to the already selected
ROI, the marking is reset.
• Evaluation
– Bounding voxels, where no voxel lies within the
entered range of HU values, region growing stops.
Check the depth of the volume in the coronal and
sagittal view. To complete region growing inside the
entire volume, set multiple seed points if necessary.
– You can edit the thresholds even after the volume
has been evaluated.
– You can modify or delete the last evaluated volume.
115
Dynamic evaluation is a function which allows you to

analyze the absolute or relative enhancement of
Hounsfield values within a Region of Interest.
The enhancement value is computed from a stack of
CT images which are obtained at different points in
time after contrast agent injection. For dynamic evalu-
ation, usually images from the same cross-section of
the body are taken, such as a Multi-scan through an
unclear process in the liver.
Key Features
The time to the maximum enhancement (Time-to-
Peak) and the way a certain tissue or structure absorbs
the contrast medium can be very helpful in differential
diagnosis of a given process.
To do this the Dynamic Evaluation card provides you
with the following methods:
interface.
• Selection dialog for slice positions to be evaluated in
Multi-slice studies.
• Volume data sets can be evaluated also, e.g. for mea-
surement of contrast enhancement in a vessel dur-
ing spiral acquisition and further optimization of
contrast injection procedure for follow-up studies.
• Dynamic evaluation of 5 different regions (circular
and irregular) and a pixel lens are possible in parallel.
• ROI definition and pixel lens are automatically cop-
ied to all pending images of the stack and show an
immediate display of the time-density curves, i. e. a
calculation can be done with only one interaction.
116
• Use of syngo functions like dog ears or cine mode for

fast paging through the image stack.
• Easy selection, modification and deletion handling
for the ROIs.
• Constant display of the time-density curves with a
scalable sampling line, and of the tabular results
which display for each separate ROI
– the mean Hounsfield value
– the time to the peak enhancement (in seconds)
– the density value (HU) of a given time position,
chosen by shifting the sampling line to that point.
• Separate image stack segment for further output
images such as
– Average image
– Maximum Intensity Projection image
– Peak Enhancement image
– Time-to-Peak image.
• Configuration dialog to enable customized results.
117
Prerequisites
In dynamic evaluation, images that were scanned as
part of an examination with contrast agent at a con-
stant table position are evaluated.
• The selection consists only of CT tomogram images.
• The images belong to the same study.
• The images were acquired within 1 hour.
• Images of at least 4 different time positions must be
loaded to Dynamic Evaluation.
• The relevant DICOM attributes are the same on all
images.
118
Workflow
Loading the Images

After loading the images into syngo Dynamic Evalua-
tion following layout is displayed:
119
• Tomo segment
The loaded input images are displayed in the upper
left-hand segment. The images are sorted by the
acquired time.
• Parameter image segment
Parameter images are displayed in the upper right-
hand segment
– MIP image
– Average image
– Peak Enhancement image/Time to Peak image
• Baseline image segment
The baseline image is displayed in the lower left
hand segment (base for enhancement calculation).
By default, the first image of the loaded images is
used as the baseline image.
• Result segment
black after loading
Inspecting the Input Images

Before you begin the evaluation, optimize the display
of loaded images in the tomo segment in such a way
that the regions to be evaluated are clearly visible:
– Scroll through the image stack
– Window, Zoom and pan images
– Remove the images that are not suitable for
dynamic evaluation (e.g., when the patient has
moved during scanning).
120
Generation of Parameter Images

As soon as you load the original image material, your
system performs an evaluation of the entire image
area. The results (parameter images) are displayed in
the parameter image segment.
Each time you make a change to the original data set
(by removing images, and/or defining a new baseline
image) your system recalculates the parameter images
on the basis of the existing images.
– The average image is an averaged addition of all pix-
els at each pixel location across the images of the
tomo segment.
– MIP image: Parameter image where each pixel is the
maximum value of all images at that pixel location.
The image data is checked pixel by pixel. The pixels
with the maximum intensity are displayed in an
image.
– Time to Peak image: Parameter image where each
pixel indicates the period of time (in tenths of a sec-
ond) from the time when the first image was
acquired (Delay = 0) or the time when the contrast
was injected (Delay > 0) to the time when the high-
est CT value is reached at that pixel location. The
longer the time period until the peak CT value is
reached, the brighter the pixels.
121
With a Time to Peak image, for example, you can easily

detect structures in which the contrast did not spread
as fast as in comparable structures.
Hint: The time to peak (in seconds) at the cursor posi-
tion in the Time to Peak image is the CT value displayed
in the lower right corner divided by 10.
– Peak Enhancement image: Parameter image where
each pixel indicates the enhancement at that pixel
location.
CT value of a pixel = maximum value found at that
pixel location (pixel value of the MIP image) – CT
value of the baseline image at that pixel location.
With a Peak Enhancement image, for example, you

can easily detect structures that were not completely
filled with contrast.
Hint: You can activate or deactivate the calculation

of the Time to Peak image and the Peak Enhance-
ment image in the configuration.
122
Creating a Baseline Image

A baseline image is used as a basis for all enhancement
calculations.
The enhancement is calculated relative to the baseline
image. Therefore, the baseline image must show the
state before enhancement starts.
By default, the first image of the loaded images is used
as the baseline image.
You can even define the last image before the
enhancement starts as the baseline image. If you do
so, the mean gray values of the selected image and all
the images that have been acquired before the
selected image are displayed in the baseline image.
The result is a smoother image that can be used to
define the ROIs.
If you want to use a different baseline image, proceed
as follows:
• Scroll to the required image in the tomo segment.
• Click on the button Generate baseline image with
the mouse.
123
Evaluation of Region of Interests

You select the image regions to be evaluated by mark-
ing them with ROIs or applying the pixel lens (a circular
ROI with a fixed but configurable diameter). An abso-
lute/relative CT-value calculation is performed for this
selected image.
• You can draw either elliptical ROIs or freehand ROIs.
• You can modify a ROI in any image, precisely adapt-
ing it to the shape you feel is relevant.
• The number of ROIs that you can define is limited to
five – you can only draw one pixel lens.
• The ROIs that you have drawn are transferred to the
other views.
• To aid examination, they are numbered in sequence
and color-coded.
Display of the PixelLense curve
124
Enhancement Curve
As soon as you have defined an ROI, an enhancement
curve (time-density curve) is calculated and displayed
in the fourth segment. To facilitate identification, this
curve has the same color and numbering as the associ-
ated ROI. The maximum CT-value of the ROI first drawn
is indicated by a dashed sampling line.
In the table, for each ROI, the following parameters are
given:
• Peak [HU]: Highest CT value detected in the ROI.
• Time to Peak [s]: Period of time in seconds from the
time when the first image was acquired (Delay = 0)
or the time when the contrast was injected
(Delay > 0) to the time when the highest CT value is
reached in an ROI.
• Sample [HU]: CT value at the point of time (in sec)
where the vertical line is positioned on the enhance-
ment curve.
Absolute/Relative Enhancement curve
The enhancement curves are displayed as absolute or
relative curves.
• The Absolute Enhancement curve displays the origi-
nal CT-value derived at every point in time during
the examination.
• The Relative Enhancement curve displays the varia-
tion of CT-values with reference to the CT-values in
the baseline image at every point in time.
125
Documentation of Results
During the evaluation you have drawn individual ROIs
and have generated enhancement curves and result
tables. You can save and print out this information or
store it on a floppy for further processing.
To document the evaluation, two new series are stored
to your local database.
• The DynEva Curves series consists of 3 images and
the result sheet that is currently displayed:
– One original or (fused) Multi-slice image currently
displayed
– The image displayed in segment 2, for example,
the MIP image
– The baseline image
– The displayed result sheet
• The DynEva Parameter series consists of the param-
eter images in segment 2:
– The Time to Peak image (if configured)
– The Peak Enhancement image (if configured)
– The Average image
– The MIP image
126
Configuration
You can make the following settings in DynEva Config-
uration:
– Calculate Time to Peak Image

A Time to Peak Image is generated and displayed in
the upper right-hand segment. You can use the
image for ROI definition.
– Calculate Peak Enhancement Image
A Peak Enhancement Image is generated and dis-
played in the upper right-hand segment. You can use
the image for ROI definition.
– Enable export of results
Enables the export feature: Results can be stored on
floppy disk.
– Enable printing of results
Enables the print feature: Results can be printed.
– Diameter of Pixel Lens
Diameter of the circular ROI (pixel lens) in pixels.
127
Information
• Slice Position with Multi-Row Scanners
When you use a multi-row scanner several slice posi-
tions are scanned per acquisition. When you load the
images, the window Slice Selection is displayed in
which you can define the slice position to be analyzed.
You can evaluate either the scanned examination data
or an averaged slice position.
• Help to Interpret the Enhancement
Parameter images that help to interpret the enhance-
ment are displayed in segment 2, for example, the MIP
image and the Peak Enhancement image.
• Defining the Tissue Range
With Tissue Classification you can exclude all tissue
regions outside the CT-value range entered. This
allows you to emphasize the organ to be examined and
remove disturbing factors.
HU limitation does not affect evaluation of the ROIs
and only appears at the Time to Peak and the Peak
Enhancement image.
The excluded tissue densities are masked by a color in
the baseline image. The excluded areas are displayed
black in the Time to Peak and Peak Enhancement
images.
128
• Filtering
To reduce noise in the Time to Peak and Peak Enhance-
ment image you can apply a smoothing filter.
Filtering does not affect the evaluation of ROIs.
• Moving the Sampling Line
If you want to evaluate the enhancement values for a
different point in time, move the sampling line in the
horizontal direction.
You can display the tomographic image for the time
marked by the sampling line as the top image in the
tomo segment. To do that, double-click on the sam-
pling line.
• Delay of Injection
You usually start the CT scans with contrast medium
after a delay following contrast medium injection. You
can have this off-set taken into account in calculation
of the Time to Peak image and enhancement curves.
The results then refer to the time of contrast medium
administration (zero on the time scale).
➭ Enter the delay from the start of injection of the con-
trast to the start of the scan and confirm with the
Enter key.
129
• Relative Enhancement Curve

Time Axis (X)
The point of time for an image is computed relative to
the point of time at which the first input image was
acquired:
Point of Time = Acquisition Time – Acquisition Time of
the First Image + Delay
Enhancement Axis (Y)
The mean CT value of each ROI is plotted on the
enhancement axis of the enhancement curve.
The value is relative to the CT values of the baseline
image. The mean CT value of an ROI inside the baseline
image is assumed to be 0.
• Absolute Enhancement Curve
Time Axis (X)
The point of time for an image is computed relative to
the point of time at which the first input image was
acquired:
Point of Time = Acquisition Time – Acquisition Time of
the First Image + Delay
Enhancement Axis (Y)
The absolute mean CT value of each ROI is plotted on
the enhancement axis of the enhancement curve.
130
131
The Neuro Perfusion application offers you the ability

to perform two different evaluations:
– Standard Neuro Perfusion
– Tumor Neuro Perfusion (of the brain)
This is an application software package for the quanti-
tative evaluation of dynamic CT data of the brain fol-
lowing injection of a highly concentrated iodine con-
trast bolus. The main application is in the differential
diagnosis and management of acute ischemic stroke
and brain tumor.
Key Features
• The software optimally supports the stringent time
and workflow requirements in an emergency setting
where time is brain.
• Parameters generated for Standard Neuro Perfusion
include among others cerebral blood flow (CBF),
cerebral blood volume (CBV), the time to local perfu-
sion onset (Time-to-Start) and the time to local per-
fusion peak (Time-to-Peak).
• For Tumor Neuro Perfusion, permeability and blood
volume images are calculated.
132
133
Scan Protocols
You will find the Neuro Perfusion scan protocol under
body region Specials.
NeuroPCTSingle: For Multislice systems a protocol
variant based on acquiring just one 10 mm slice can be
selected in the Patient Model dialog.
A typical scan range of 12 cm will be covered in 22 sec.
For the dynamic multiscan a time of 40 sec. is pre-
defined.
A typical scan range of 12 cm will be covered in 24 sec.
For the dynamic multiscan a time of 40 sec. is pre-
defined.
30.75 sec. For the dynamic multiscan a time of 40 sec.
is predefined.
Sensation 16 BaseSeq Cerebrum

Seq
kV 120 120
mAs/Quality 320 360
ref. mAs
Rotation Time 1.0 sec. 1.0 sec
Acquisition 12 x 0.75 mm 12 x 1.5 mm
Slice 0.75 mm 1.5 mm
collimation
Slice width 4.5 mm 9.0 mm
Feed/Scan 9.0 mm 18.0 mm
Kernel H31s H31s
CTDIVol 71.7 mGy 69.1 mGy
Effective dose Male: Male:
1.1 mSv 2.52 mSv
Female: Female:
1.22 mSv 2.63 mSv
134
Sensation 16 DynMulti
kV 80
Effective mAs/Quality 209
ref. mAs
Slice width 12.0 mm
Increment 1.0 sec.
Kernel H30s
CTDIVol 15.9 mGy
Sensation BaseSeq Cerebrum

Cardiac Seq
kV 120 120
mAs/Quality 320 360
ref. mAs
collimation
Kernel H31s H31s
1.1 mSv 2.52 mSv
Female: Female:
1.22 mSv 2.63 mSv
135
Sensation Cardiac DynMulti

kV 80
ref. mAs
Slice width 12.0 mm
Increment 1.0 sec.
Kernel H30s
CTDIVol 15.9 mGy
Sensation 10 BaseSeq Cerebrum

Seq
kV 120 120
mAs/Quality 320 360
ref. mAs
collimation
Kernel H31s H31s
1.62 mSv 3.91 mSv
Female: Female:
1.9 mSv 3.88 mSv
136
Sensation 10 DynMulti
kV 80
ref. mAs
Slice width 12.0 mm
Increment 1.0 sec.
Kernel H30s
CTDIVol 14.8 mGy
Emotion 16 BaseSeq Cerebrum

Seq
kV 130 130
mAs/Quality ref. 250 270
mAs
Slice collimation 5.0 mm 8.0 mm
Kernel H31s H31s
1.03 mSv 2.04 mSv
Female: Female:
1.11 mSv 2.25 mSv
137
Emotion 16 DynMulti
kV 80
ref. mAs
Slice width 9.6 mm
Increment 1.0 sec.
Kernel H31s
CTDIVol 15.84 mGy
138
Contrast Medium Injection

Such a standard protocol may be slightly modified for
specific reasons; e.g. the start delay can be increased
by a few seconds for patients with very low cardiac
output.
IV injection protocol
Contrast medium Non-ionic
Concentration 300 – 370 ml
Injection rate 8 ml/sec.
Total volume 40 ml
– A short bolus is preferable.

– If a flow rate of 8 ml/s is considered not recommend-
able for a specific patient, the protocol can be
reduced to 40 ml at 5ml/s. Image quality will be
reduced but the technique will still be fully diagnos-
tic.
– Image quality can be considerably improved by using
a saline chaser bolus with the same flow rate. This is
particulary important if lower flow rates than the
optimal one are to be used.
139
• Additional measures to facilitate the injection, like

using a large gauge cannula (18 is usually sufficient)
and warming the contrast media to body tempera-
ture to reduce its viscosity, should be considered.
Note: As with any contrast medium application, ver-
ify that the particular models and brands that you
use in the chain injector/contrast medium/cannula
are approved by their respective manufacturers for
the use with the parameters you select.
General Hints
• Motion during acquisition must be avoided. There-
fore, if at all possible you should try to explain the
course of the examination to the patient and use
additional head fixation in any case.
• The standard examination slice for the analysis of
ischemia (Standard Perfusion) is best positioned
such that it cuts through the basal ganglia at the
level of the inner capsule. This selection includes
those vascular territories of the brain that are fre-
quently affected by perfusion impairment associ-
ated with acute stroke in the carotid territory.
• The slice should be selected flatter than in normal
head CT scan. The angulation should be adjusted
perpendicular to the occipital segment of the supe-
rior sagittal sinus well above the confluence of
sinuses.
140
• The eye lens should never be positioned in the scan

plane.
• For Dynamic Multiscans, the increment is the time
between the reconstructed images, e.g if the incre-
ment is 1.0 sec., then every second one image will
be reconstructed.
• The smallest possible increment is 0.05 sec. and can
be changed in steps of 0.05 sec..
Example of a stan-
dard slice through
the basal ganglia
in a lateral topo-
gram.
141
Workflow Concept
The icons described below are located in the control
area of the Neuro PCT task card and are arranged in
accordance with the work flow. The tool palettes con-
tain additional icons for results display and evaluation.
Standard Calculation: Starts the stan-

dard Neuro Perfusion evaluation.
Tumor Calculation: Starts the tumor eval-

uation.
Interactive Movie On: Scrolls quickly

through the dynamic CT image set (in all
segments – just like a video sequence).
The scrolling is controlled by your mouse
movement.
Remove Image: Removes the displayed

images from the current dynamic CT
image set.
Segmentation: Defines the area of the CT

image for which perfusion is to be calcu-
lated. This is the area of brain tissue within
the inner skull contour as detected by the
system and subjected to a tissue classifica-
tion.
Bridging: Allows you to bridge any gaps in

the skull bone if the system cannot auto-
matically detect a continuous inner skull
contour.
142
Reference Vessel: Automatically a refer-

ence vessel which will serve as a normal-
ization reference for the perfusion calcu-
lation is defined.
For a typical slice through the basal gan-
glia, such a vessel is the superior sagittal
sinus.
Max. Enh. [HU]: Shows the maximum
enhancement after calculating the time
density curve.
Define Vessels: Defines areas of brain tis-

sue as vessels by comparing their
enhancement values with the maximum
contrast enhancement found in the refer-
ence vessel. Allows you to set the percent-
age of the maximum enhancement that
will be used as a vessel definition thresh-
old.
Calculate: Performs the perfusion calcula-

tion on the previously segmented brain
tissue.
Optimization: Enables/disables optimiza-

tion for the perfusion calculation.
Save Set: Stores all calculated parameter

images to the local database.
Save: Stores selected parameter images

(with or without graphics) to the local
database.
143
Calculated Images Standard Neuro

PCT
Standard Set
• MIP
Temporal Maximum Intensity Projection (over the
full time span)
• Flow
Cerebral blood flow image (ml/100ml/min.)
144
• Blood Volume
Blood volume image (relative volume ratio of blood).
The image is scaled in ml/1000 ml, thus a value of 30
in the image means 3% blood volume.
• Time to Peak
Time of local peak enhancement. The image is
scaled in 0.1 s, therefore a value of 182 in the image
means 18.2 seconds. If optimization is turned on,
the zero time point is set to the lower limit for the
time to start.
145
Calculated Images Tumor Neuro PCT

Standard Set
• MIP
Temporal Maximum Intensity Projection (over the
full time span)
• Permeability
The active portion of malignant brain tumors may
exhibit increased permeability, due to a disorder or
disruption of the BBB (blood-brain-barrier). Pixel
based Patlak Permeability is calculated as the slope
of the linear regression line of the Patlak values for
each pixel over time.
The images are scaled 0.5ml/100ml/min.
146
• Patlak Blood volume

Tumors often display increased blood volume in the
active portion of brain tumors, reflecting tumor neo-
angionesis. Pixel based Patlak Blood Volume is calcu-
lated as the intercept of the linear regression line of
the Patlak values for each pixel over time.
The images are scaled ml/1000 ml.
• Patlak Basics
Tumors often display increased numbers of abnor-
mal blood vessels, reflecting tumor neo-angionesis.
In general, the active portion of malignant brain
tumors exhibit increased perfusion and permeabil-
ity, due to a disorder or disruption of the BBB (blood-
brain-barrier).
Pixel based Permeability and Blood Volume Images
are calculated with a modified two compartment
(plasma, interstitium) Patlak approach based on first
pass data. Both images are calculated from CT
enhancement values that start after the peak of the
arterial time attenuation curve only. A normalized
arterial input function is automatically generated.
147
Formula
Explanation for formula on the left side

At each point "t" of examination time, the contrast
media concentration in tissue "c(t)" = Transfer constant
"K" * Sum of blood contrast media concentrations till
"t" ("Integral" / b(t)) +Fractional vascular volume "FVV"
* Contrast media concentration in blood "b(t)".
148
CBF/CBV
Normalization (Standard)
If this checkbox is selected, CBF and CBV images are
normalized to the non-ischaemic hemisphere and are
displayed with optimized color tables, after confirming
the Normalization dialog.
Normalization (Tumor)
Same as CBF/CBV Normalization (Standard) (Item only
available if CBF and CBV images selected in the Tumor
calculation tab of Neuro PCT Configuration.)
Normalization improves the display of CBF and CBV

images. The Cerebral Blood Flow and Volume images
are displayed with optimized color tables.
Normalization is indicated by <N> at the bottom of the
images. After confirming the Arterial Input Function/
Optimization dialog the Normalization Dialog opens
(if CBF/CBV Normalization is selected in the Proper-
ties dialog).
149
In the Normalization dialog three buttons are dis-

played:
• right hemisphere in the image non ischemic
• no difference between the hemispheres
• left hemisphere in the image non ischemic.
The preselected button corresponds to the automatic
proposal of the software. If this is not correct, you can
overwrite this preselection.
Optimization
The system analyzes the entire set of dynamic CT
images in order to identify the earliest onset of con-
trast enhancement and the minimum rise time.
The areas with the earliest start and shortest rise times
are mapped to the MIP image and displayed in red
(default color).
150
Lower limits:
Start (s) = Time of the earliest enhancement
onset in seconds
Rise (s) = Time to peak (s) – Time to Start (s)
Upper Limits:
Start (s) = Time of the latest enhancement
onset in seconds
Peak (s) = Time of the highest level of Contrast
enhancement
151
Arterial Shift (only for Tumor calcula-

tion)
The shift displays the global arterial shift in seconds.
The automatic Shift checkbox is selected by default if
shift values are positive. Deselect the checkbox if you
want to set the value for the shift manually. After per-
forming the optimization, both curves (tissue and arte-
rial) are adapted according to the shift.
152
Information
1.Why are Short Injection Times for the analysis of
ischemia (Standard Perfusion) Necessary?
The brain has a very short transit time (approx. 3 to 5
seconds) and a relatively small fractional blood volume
(approx. 2 to 5%). This requires a compact bolus for
optimal time resolution and a certain minimum
amount of contrast for optimal signal to noise ratio.
Bolus definition can be significantly improved and the
amount of contrast necessary reduced by using a
saline chaser bolus with the same flow rate directly fol-
lowing the CM injection.
2.What do Normal, Contrast-Enhanced and Neuro

PCT Images Show?
In order to interpret Neuro Perfusion CT images cor-
rectly, it is essential to understand that they are “func-
tional“ or “parameter“ images that display a different
type of information than standard CT images: Normal
CT images basically show only morphological proper-
ties of tissues by displaying their x-ray attenuation rel-
ative to that of water as CT-values in HU-units.
Standard contrast-enhanced CT extends this limitation
either to make a compartment visible that normally
has low contrast (e.g. vascular structures in CTA) or to
qualitatively display major perfusion differences of tis-
sues (e.g. tumors or multiphase liver studies).
153
Neuro Perfusion CT tries to utilize all the information

hidden in the temporal changes of contrast enhance-
ment by fitting a mathematical model to the local time
attenuation curves. For each voxel this process yields a
variety of numbers which describe different aspects of
tissue perfusion. As the human eye is so much faster
and better suited to interpret images than large
amounts of numbers, it makes sense to display these
quantities in the form of images.
3.What do Pixel Values Mean in the Neuro PCT
Images?
It is very important to realize that pixel values now
have a different meaning, which depends on the type
of image currently displayed. So if you point the cursor
into a parameter image, keep in mind that you do not
read a CT-value but a functional unit. A time-to-peak
image, for example, displays numbers proportional to
the time until the bolus peak is reached; so higher
numbers mean later bolus arrival.
A CBF image, on the other hand, displays numbers pro-
portional to blood flow; so smaller numbers indicate
lower flow.
4.Filming Color Images
If a color hardcopy device is connected to the system,
color images can be printed via the Filming task card.
It is recommended to send the color images from the
Viewing task card after having saved them on the
Neuro PCT task card.
154
5.How can you Fine-Tune the Color Mapping?

– For “flow images” (CBF and CBV) – the color palette
for the flow image is designed as such, that after
optimal adjustment with the arrow buttons the fol-
lowing approximate correspondence will result for a
normal brain:
red _ vessels
green/yellow _ gray matter
blue _ white matter
black _ no calculation (CSF space)
This will be automatically adjusted if normalization is
turned on.
After adjustment (use non-ischemic hemisphere as
guideline) ischemic areas will therefore be displayed
either in violet (very low flow) or as a mismatch with
the nonischemic side (gray matter is blue instead of
green).
– For “Time images” (Time to Start and Time to Peak) –
the color palette for the time images maps increas-
ing time values on a spectral scale: Violet _ blue _
green _ yellow _ red
Display should be adjusted with the arrow buttons
such that the areas with latest arrival times are just
slightly red. As with the flow image black means no
calculation (CSF space, or areas with extremely low
flow – no time assessment possible).
155
The syngo Body Perfusion CT (BodyPCT) option allows

the quantitative evaluation of dynamic CT data of
organs and tumors following the injection of a com-
pact bolus of iodinated contrast material. It is an eval-
uation toolkit particularly useful to study the hemody-
namics of tumors, either for characterization or
monitoring.
By providing images of blood flow, blood volume and
permeability, syngo Body Perfusion CT allows an
assessment of perfusion disturbances and of perfusion
changes during therapy. It might be helpful as a
research tool while evaluating new forms of treat-
ment.
Key Features
• Predefined scan protocols for fast dynamic multi-
slice data acquisition after i.v. injection of a compact
bolus of iodine contrast
• Predefined evaluation settings for different organs
• Input of a target region of interest and multi-slice
segmentation of parenchyma
• Automatic motion correction either within each slice
or over the width of the detector
156
• Fast simultaneous multi-slice calculation of perfu-

sion parameter images, e.g.:
– Temporal MIP image
– Blood flow image
– Blood volume image
– Permeability image depicting extra-vascular leak-
age
• For the analysis of liver perfusion
– ROI input and analysis of aortic, portal venous and
splenic enhancement
– Calculation of arterial and portal venous hepatic
flow and determination of the hepatic perfusion
index (proportion of hepatic arterial perfusion to
total liver perfusion)
• Optimized color display of these images including
image type dependent multi-slice windowing
157
• Composite images allowing a merged display a full

slice anatomical MIP or Average image with the color
parameter display in the target ROI
• ROI measurements with calculation of mean value
and standard deviation for detailed analysis of perfu-
sion changes
158
159
Scan Protocols
As body perfusion CT is still mainly a research tool, the
default protocols listed might have to be adapted to
meet your specific needs.
BodyPCTSingleSeq: For Multislice systems, a protocol
variant based on acquiring just one 10 mm slice can be
selected in the Patient Model dialog.
Sensation 16
BodyPCT
A multiscan with a scan time of 30 sec. is predefined.
DynMulti
kV 120
mAs 100
Rotation Time 1.0 sec
Slice width 6.0 mm
Feed/Rotation 0.0
Increment 1.0 sec.
Kernel B30s
CTDIVol 7.0 mGy
160
BodyPCTSeq
A dynamic serio scan with a scan time of 30 sec. for the
first range and 1 sec. cycle time is predefined. The sec-
ond range is with a scan time of 55 sec. and 5 sec.
cycle time predefined.
DynSerio
kV 120
mAs 100
Slice width 6.0 mm
Feed/Scan 0.0 mm
Kernel B30f
CTDIVol 7.0 mGy
DynSerio
kV 120
mAs 100
Slice width 6.0 mm
Feed/Scan 0.0 mm
Kernel B30f
CTDIVol 7.0 mGy
161
Sensation Cardiac
BodyPCT
DynMulti
kV 120
mAs 100
Slice width 6.0 mm
Feed/Rotation 0.0
Increment 1.0 sec.
Kernel B30s
CTDIVol 7.0 mGy
BodyPCTSeq
DynSerio
kV 120
mAs 100
Slice width 6.0 mm
Feed/Scan 0.0 mm
Kernel B30f
CTDIVol 7.0 mGy
162
DynSerio
kV 120
mAs 100
Slice width 6.0 mm
Feed/Scan 0.0 mm
Kernel B30f
CTDIVol 7.0 mGy
163
Sensation 10
BodyPCT
DynMulti
kV 120
mAs 100
Slice width 12.0 mm
Feed/Rotation 0.0
Increment 1.0 sec.
Kernel B30s
CTDIVol 6.8 mGy
BodyPCTSeq
DynSerio
kV 120
mAs 100
Slice width 12.0 mm
Feed/Scan 0.0 mm
Kernel B30f
CTDIVol 6.8 mGy
164
DynSerio
kV 120
mAs 100
Slice width 12.0 mm
Feed/Scan 0.0 mm
Kernel B30f
CTDIVol 6.8 mGy
165
Emotion 16
BodyPCT
A multiscan a scan time of 30 sec. is predefined.
DynMulti
kV 110
mAs 120
Slice width 4.8 mm
Feed/Rotation 0.0
Increment 1.0 sec.
Kernel B31s
CTDIVol 9.24 mGy
BodyPCTSeq
A dynamic serio scan with a scan time of 26.7 sec. for
the first range and 0.6 sec. cycle time is predefined.
The second range is with a scan time of 55.6 sec. and
5 sec. cycle time predefined.
DynSerio
kV 110
mAs 120
Slice width 4.8 mm
Feed/Scan 0.0 mm
Kernel B31s
CTDIVol 9.24 mGy
166
DynSerio
kV 110
mAs 120
Slice width 4.8 mm
Feed/Scan 0.0 mm
Kernel B31s
CTDIVol 9.24 mGy
167
A comprehensive study consists of three sections:
Preparation, examination and post-processing.
Important for good evaluation results are adequate
patient preparation positioning, and guidance.
There are two scan mode choices.
• Dynamic Multiscan
Multiple continuous rotations at the same table posi-
tion are performed for data acquisition. Normally, it
is applied for fast and short dynamic contrast stud-
ies. The increment represents the time between
reconstructed images, e.g. if the increment is
1.0 sec., then every second one image will be recon-
structed.
• Dynamic Serioscan
Dynamic serial scanning is also performed without
table feed. It consists of one rotation scans with
short interscan delays, as it provides more flexibility
in adjusting the temporal resolution.
• The smallest possible increment is 0.05 sec. and can
be changed in steps of 0.05 sec.
• We recommend to use Multiscans for short scan
times, e.g. flor flow analysis and dynamic scans for
longer scan times
168
Patient Preparation
With the syngo Body Perfusion CT application, differ-
ent organs and body regions can be evaluated. All
body regions share a common problem: motion due to
breathing and swallowing. Acquiring the dynamic data
usually requires at least 40 seconds which is hard to do
in one breathold, therefore good patient preparation
positioning and guidance is essential to achieve good
input images for the BodyPerfusion evaluation.
• To minimize artifacts oral and rectal contrast agents
should not be administered prior to a BodyPerfusion
scan.
• It helps to carefully explain the course of the exami-
nation to the patient and to observe the following
hints.
– Position the patient as comfortably as possible.
e.g. place a cushion under the patient knees.
– Additional patient fixation might be helpful e.g. a
fixation strap.
– Give precise patient respiratory instruction: if pos-
sible rehearse the breathing instructions with the
patient before the examination. We recommend
performing the scan in expiration.
169
Contrast Medium Injection

Such a protocol may be slightly modified for specific
reasons; e.g. the start delay can be increased by a few
seconds for patients with very low cardiac output
Dual phase injection protocols for tumor evaluation
are currently under investigation.
IV injection protocol
Contrast medium Non-ionic
Concentration 300 – 370 ml
Injection rate (flow) 5 ml/sec.
Total volume 40-50 ml
170
Workflow
Artifact-free images are essential to achieve good
results within the BodyPerfusion evaluation.
• Scroll through the images and check if they are arti-
fact-free.
– No partial volume or motion artifacts
– If only a few slices are affected, images should be
excluded from the evaluation if possible.
• To obtain optimal calculation results, it is essential to
calculate images with organ specific parameters.
Therefore select the adequate organ from the list
box.
• The workflow of processing a volume is given in the
Body PCT workflow panel that includes two catego-
ries:
– Definition
– Calculation
171
Definition
Tissue ROI
• The organ or tumor to be analyzed is interactively
delineated by drawing a rectangular target region of
interest. This allows automatic motion correction
and an optimized determination of the fitting
parameters for the main area of interest. Default
wise perfusion parameters are only calculated for
this target region.
• It is nevertheless possible to also calculate perfusion
parameters outside this area, then, however, with-
out correcting for motion. E.g. if you want to evalu-
ate the kidneys during a pancreas evaluation you can
set "Whole Image" in the BodyPerfusion Configura-
tion.
• We recommend creating a tissue ROI, as this opti-
mizes automatic parameter selection for the target
region of interest. If no tisuue ROI is defined the
whole image is used.
172
• The dimension of the ROI shall be as large as to span

the entire object of interest but at the same time as
small as possible.
173
Arterial ROI
The arterial ROI must lie well inside the vessel of inter-
est (e.g. aorta) at each point of time of the scanned
images, otherwise partial volume effects might influ-
ence arterial enhancement and the arterial TDC.
• Select the partial volume free vessel such as aorta,
femoral artery, renal artery or carotid artery.
• Place the ROI inside this vessel.
• The image where you place the Arterial ROI is the ref-
erence image for further interactions.
• Note: For Liver evaluations make sure that the portal
vein is also delineated well within this slice.
• Confirm the TDC dialog
174
• While scrolling through the image stack, you can

adjust the position of the ROI on any image and for
each acquisition time separately. The ROIs in the fol-
lowing images are adjusted accordingly. (It is not
possible to modify the dimension of an ROI. You
have to draw a new ROI instead.)
175
Liver perfusion
Applying the maximum slope model separately to the
arterial and portal venous phase of the hepatic tissue
enhancement curve allows calculating the arterial and
portal venous component of hepatic blood flow. ROIs
are placed over the aorta, the portal vein and the
spleen.
176
Portal vein ROI

The ROI must lie well inside the portal vein at each
point of time of the scanned images, otherwise the
partial volume effect will influence the true enhance-
ment and the TDC.
177
Spleen Tissue ROI

The ROI must lie well inside the spleen and major
splenic vessels should be excluded at each point of
time of the scanned images, otherwise the spleen TDC
might not be correct, which has influence on the nor-
malization of the portal-venous liver flow.
• The ROI should be drawn well inside the boundaries
of the spleen and must exclude major vessels.
178
Calculation
Segmentaton
Segmentation is based on the definition of a HU
(Hounsfield unit) range within the first original axial
image, i.e. the image without contrast media. Pixels
that lie outside of the HU range are excluded from the
result image calculation and will later on be seen as
background values. Segmentation is necessary to
exclude pixels (air, bone, vessels) that should not go
into the result calculation.
Define Vessels
Vessels should be excluded from the result image cal-
culation as only tissue is of interest for the perfusion
calculations described here. A relative threshold in per-
cent of the arterial max. enhancement is used for this
purpose. All major vessels should be excluded, i.e.
marked with red color, but the pixels of the object of
interest itself and other areas should not be marked
with red color. Often a compromise between these
two conditions is necessary, so that the relative thresh-
old is as high as possible but does not exclude object
pixels you are interested in.
• This step eliminates the vessels from the calculation
• The relative threshold value should be set to a value
until the major vessels are shown in red color.
179
• Keep attenuation such that the vascularization of the

tumor is not included.
Calculation
• After pressing the calculation button the Arterial
Input Function dialog appears.
180
Arterial Input Function
The window shows the arterial input function and the

mean tissue time attenuation curve with different
scales.
Shift [s]
Mean arterial shift calculated from comparison of arte-
rial and mean tissue TDC
automatic Shift
Switch between global (the same fixed shift in seconds
applied for each pixel TDC) and local arterial shift (an
individual arterial shift in seconds applied for each
pixel TDC)
181
Patlak Start [s]

Time when Patlak calculation will start
Patlak start time and arterial shift only affect Patlak
result images (Permeability, Patlak Blood Volume,
RSquare, Residuals) and do not influence other result
images.
The curves shown in above dialog have different
scales, the scale on the left is for the arterial curve,
shown in red, the scale on the right for the mean tissue
curve shown in blue.
The Patlak start time shown numerically in seconds
and as yellow vertical line should lie at the earliest
point in time when the contrast media is already well
mixed up within the tissue, i.e. normally shortly before
the peak of the mean tissue curve.
182
Lower Limits
• Start [s]
Minimum start time of local enhancement calcu-
lated from the arterial curve. This value should cor-
relate with the arterial curve from above dialog,
where the earliest onset of enhancement is around
5 seconds.
• Rise [s]
Shortest rise time of local enhancement calculated
from the arterial curve. This value should correlate
with the arterial curve from above dialog, where the
time from onset to peak of arterial enhancement is
around 7 seconds.
Upper Limits
• Start [s]
Sets an upper bound for the latest start time of local
enhancement.
• Peak [s]
Sets an upper bound for the time to peak enhance-
ment.
The above optimization parameters influence the
result images from the "Max. Slope Model", like "Blood
Flow" but do not affect the Liver result images (ALP,
PVP, HPI) and Patlak result images (Permeability, Patlak
Blood Volume, RSquare, Residuals). If only Liver or Pat-
lak result images are of interest, these parameters can
be ignored.
183
BodyPerfusion Result Images

• Flow
Perfusion Image ("Flow"). The image is scaled in
"ml / 100 ml / min". Calculation is done for all seg-
mented pixels and all vessels that were marked red
after pushing the "Define Vessels" button will be sup-
pressed.
Patlak
• Permeability
Vessel permeability is an index of pathophysiological
significance. It indicates the amount of extravascular
liquid. The images are scaled in 0.5ml/100ml/min.
184
• Patlak Blood Volume

Tumors often display increased blood volume in the
active portion, reflecting tumor neo-angiogenesis.
Pixel based Patlak Blood Volume is calculated as the
intercept of the linear regression line of the Patlak
values for each pixel over time. The image is scaled
"1:1000", i.e. scale is 0.1%.
Liver perfusion
• ALP
Image of arterial liver perfusion scaled in "ml / 100
ml / min".
185
• PVP
Image of portal venous liver perfusion scaled in
"ml / 100 ml / min".
• HPI
Image of hepatic perfusion index. The Hepatic Per-
fusion Index expresses the proportion of hepatic
arterial perfusion to total liver perfusion in percent
HPI = ArterialPerfusion x 100%

ArterialPerfusion + PortalPerfusion
186
Workflow Concept
The icons described below are located in the control
area of the Body PCT task card and are arranged in
accordance with the work flow. The tool palettes con-
tain additional icons for results display and evaluation.
Reset: Reloads the initially loaded set of

images and resets all previously per-
formed actions.
Remove Image: Removes the displayed

images from the current evaluation.
Tissue ROI: Allows to draw a rectangular

ROI around the tissue to be evaluated.
Adjust Tissue ROI: Allows to change the

position of the ROI manually.
2D motion correction: Starts the auto-

matic 2D motion correction on the basis of
HU values you can configure.
3D motion correction: Starts the auto-

matic 3D motion correction on the basis of
HU values you can configure.
Accept 3D motion correction: Confirms

the automatic 3D motion correction.
187
Arterial ROI: Allows to draw an elliptical

ROI within the reference artery.
Adjust Arterial ROI: Allows to change the

position of the elliptical ROI manually.
The next three buttons are only shown for

Liver perfusion:
Portal Venous ROI: Allows to draw an

elliptical ROI within the portal vein.
Adjust Portal Venous ROI: Allows to

change the position of the elliptical portal
vein ROI manually.
Spleen ROI: Allows to draw a freehand

ROI following the boundaries of the
spleen.
Segmentation: Starts segmentation

depending on the HU values you can con-
figure.
Min/Max HU: Adjust upper and/or lower
limits of the HU range in the Min/Max HU
edit fields, if required.
Max. Enh. [HU]: Shows the maximum
enhancement after calculating the time
density curve.
188
Define Vessel: Starts definition of blood

vessels depending on the HU values you
can configure.
Rel. Thresh. [%]: Allows you to set the per-

centage of the maximum enhancement
that will be used as a vessel definition
threshold.
Calculate: Starts Body PCT calculation.
Filter Repetitions: Sets the number of fil-

tering cycles. The more repetitions, the
smoother are the images.
Save Set: Stores all result images as gray

scale images without graphics to the local
data base.
Color On/Off: Allows to toggle between

color and gray scale presentation of the
images.
Color Window Minus: Allows to fine-

adjust the coloring of the result images.
Color Window Plus: Allows to fine-adjust

the coloring of the result images.
Composite Image: Allows to toggle

between a view that combines MIP
images with color result images and the
standard view.
189
Elliptical ROI1: Allows to draw an ellipti-

cal ROI into any result image.
Freehand ROI1: Allows to draw a free-

hand ROI into any result image.
TDC ROI: Calculates and displays the TDC

for an area in the result image and addi-
tionally shows the corresponding Patlak
Plot.
TDC Lens: Calculates and displays the TDC

for a small circle of fixed size in the image
and additionally shows the corresponding
Patlak Plot.
Save: Stores selected parameter images

(with or without graphics) to the Local
Database.
Copy to Film Sheet: Copies the selected

images/results to the Virtual Film Sheet of
the Filming task card.
Expose Film Task: Sends the film sheets

from the Filming task card to the camera
for exposure.
190
Information
Motion correction
The target region of interest can be dynamically
tracked to compensate for motion using automatic
registration techniques. The user initially selects a ref-
erence image (slice position and time point) and draws
the target region of interest within this slice. For every
other point in time the target region is then shifted in
such a manner, that certain characteristics within the
region differ minimally from the reference target.
Correction can either be restricted to shifting within
each of the acquired slices separatly (2D correction) or
by also moving between the slices positions (3D cor-
rection). In the 3D mode, only one set of parameter
images based on the optimal 3D registration path is
calculated, while in the 2D mode one set of parameter
is calculated for each slice.
The result of the correction process can be checked by
the user by visually inspecting the position of the
shifted target region while scrolling through the stack
of images. If the user is not satisfied with the result he
can manually correct the position slice by slice.
Depending on the number of slices or the number of
fused images, the optimal path and the best fitting tis-
sue ROI of each image within the optimal path are
detected.
191
• For an optimal path, the best-position-images are

selected automatically and strung together to a new
series.
• 3D motion correction is limited to 1 cm displacement
in x and y direction from the position of the refer-
ence ROI and only for neighboring slices in z direc-
tion.
• You can change the path by clicking into any other
segment: The ROI will be shown at the same position
but within the new slice.
• After accepting 3D motion correction a new evalua-
tion is only possible when you reload the images by
clicking on the Reset icon.
192
Composite Images
Composite images can be generated by merging a dis-
play of a full slice anatomical MIP or Average image
with the color parameter information in the selected
target ROI. Click on the Composite Image icon on the
View subtask card to toggle between a view that com-
bines MIP images with color result images and the
standard view (MIP or Average image, depending on
configuration).
193
194
Fusion
Fusion of images is recommended if the original
images were reconstructed with thin slice width, e.g.
smaller than 5mm. Thicker slices will lead to less noisy
result images, as the statistical analysis is improved
and important structural information will more clearly
be shown within the Functional CT color or grayscale
result images.
After fusing of images, slices with fused images will be
generated depending on the selected fuse mode (e.g.,
applying the mode fuse 2 slices on four input slices cre-
ates three new slices).
Filtering
Filtering should normally be performed in order to
improve the image quality (noise reduction). The num-
ber of filter repetitions adjusts the strengths of
smoothing. At least two to four filter repetitions should
usually be performed.
195
Siemens AG
Wittelsbacherplatz 2
D-80333 Muenchen
Germany
Headquarters
Siemens AG
Medical Solutions
Henkestr. 127
D-91052 Erlangen
Germany
Telephone: +49 9131 84-0
www.siemens.com/medical
Contact Address
Siemens AG
Medical Solutions
Computed Tomography
Siemensstr. 1 © 2000-2005, Siemens AG
D-91301 Forchheim Order No.
C2-023.630.21.01.02
Germany Printed in Germany
Telephone: +49 9191 18-0 09/2005

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Clinical

Software Version syngo CT 2006G

syngo Volume Evaluation 100

syngo Dynamic Evaluation 116

syngo Neuro Perfusion CT 132

syngo Body Perfusion CT 156

• Additional Important Information 95

syngo Volume Evaluation 100

syngo Dynamic Evaluation 116

syngo Neuro Perfusion CT 132

- General Hints 140

syngo Body Perfusion CT 156

syngo syngo syngo

For further information about the basic operation,

syngo CT Operator Manual Volume 2:

syngo CT Operator Manual Volume 3:

syngo CT Operator Manual Volume 4:

syngo CT Operator Manual Volume 5:

syngo CT Operator Manual Volume 6:

In the pop-up window you can select for which appli-

Split-up multi-phase series

• Distance, ROI and angle measurement tools are

Sensation Cardiac Dental

Loading the images

The upper left segment shows a lateral MIP image of

Inspecting the input images

Preparing the reconstruction of Dental

2.Editing the Panoramic Line

3.Panoramic View Parameters

4.Marking the lingual side

5.Editing paraxial slices

• Thickness in mm: defines the slice thickness of the

Documenting the Results

2.Saving the Results

The reconstruction of a Dental image is saved as a CT

• ROI definition for statistical evaluations and deletion

Paraxial lines using

• In the control area, you can configure if you want to

This is an application package for the quantitative

Sensation Cardiac Osteo

Comparison of evaluation data:

Correcting contour lines

The other summary image displays a graph which

The second and the fourth segment belong together.

After End Evaluation the evaluation results are auto-

How can you save the results on your PC?

Example for one patient with three Osteo tomo-

REFDATA; <Age of patient>; <Sex of patient>;

• When you examine a patient who is older than 80

Note: it is not recommended to use filming setting of

Siemens Reference Data:

• Table with statistical values for left, right and total

• You should only compare scans which were per-

Full Inspiration Full Expiration

Density = @ Density = >2x@

Lung density at full inspiration/expiration

Loading the images

• Segment 4 shows the comparisons with reference

Starting the Pulmo CT Evaluation

Pulmo CT Evaluation Results

Automatic Saving of Images

Filming Pulmo CT Results

HU-Subranges and Percentiles

Advanced Results Display