Beruflich Dokumente
Kultur Dokumente
Issue 33
SOMATOM Force:
Bringing Personalized
Medicine to CT
Page 06
News
Business
Clinical Results
Science
syngo.via Frontier
Gateway to an Open
Research Environment
Page 31
Radiation Hygiene
Transparent and Easy
Page 72
Editorial
Cover page:
Dynamic CTA 64 cm acquired with spiral 4D mode at 80 kV, 110 mAs,
with 45 mL contrast. The vascular structures of the complete trunk
are clearly demonstrated, and the suspected leaking from the aortic stent
could be confidently ruled out.
Courtesy of University Medical Center Mannheim, Germany
Editorial
Dear Reader,
In todays fast changing global healthcare environment, Siemens aspiration
is to contribute in two major directions.
Together with our excellent network
of academic partners, we continue to
extend the frontiers of available diagnostic and treatment capabilities. At
the same time and equally important
we innovate to make our technology
accessible to more patients around the
world.
The cover article in this RSNA 2013
edition of SOMATOM Sessions introduces the latest frontier-shifting CT
scanner from the Siemens innovation
powerhouse. The new Dual Source CT
SOMATOM Force* builds on the outstanding clinical success of Siemens
unique Dual Source technology pushing current capabilities and opening
up new possibilities. SOMATOM Force
features enhanced temporal, spatial
and contrast resolution and introduces Turbo Flash scanning with up
to 730 mm per second z-coverage for
free-breathing CT imaging. Its outstanding tube power already available at 70 kV makes low kV imaging
accessible to virtually all patients and
Walter Maerzendorfer,
CEO of the Computed Tomography
& Radiation Oncology Business Unit,
Imaging and Therapy Systems Division,
Siemens Healthcare,
Forchheim, Germany
** T
his product is 510(k) pending. Not available
for sale in the U.S.
** The products/features (here mentioned) are
not commercially available in all countries. Due
to regulatory reasons their future availability
cannot be guaranteed. Please contact your
local Siemens organization for further details.
06 Cover Story
SOMATOM Force:
Bringing Personalized
Medicine to CT
December 2013
Contents
News
Clinical Results
Cardiovascular
48 Myocardial Ischemia Assessment using
Adenosine-Stress Dynamic Myocardial CT Perfusion
50 Coronary CTA with Reduced Contrast and Radiation
Dose of 0.19 mSv
52 Bicuspid Aortic Valve with Anomalous Coronary
Artery Fistula A Rare Incidental Coincidence
Business
Neurology
54 Dynamic Volume Perfusion CT in a Case of
Childhood Moyamoya Disease before and after
Surgical Revascularization
56 Differentiating an Intracranial Hemorrhage
from Iodine in Acute Stroke after Intra-arterial
Recanalization
Acute Care
58 Diagnosis of Splenic Rupture in an 11-year-old Girl
using a Sliding Gantry CT
Contents
14
18
32
72
Customer Excellence
Pulmonology
60 Automated Quantification of Pulmonary Perfused
Blood Volume in Acute Pulmonary Embolism using
Dual Energy CTPA
Urology
62 Diagnosing Small Renal Calculi using Low Dose
Dual Energy CT at 0.8 mSv
64 Differentiating Stent from Stone: A New Approach
using Dual Energy CT
Pediatrics
66 Diagnosing Tracheal Stenosis in a 10-week-old Baby
without Sedation
76
77
78
79
Science
68 Image Quality in Computed Tomography
72 Radiation Hygiene Transparent and Easy
74 Radiation Protection Scientifically Proven for
Routine Practice
Cover Story
SOMATOM Force:
Bringing Personalized
Medicine to CT
A quantum leap in CT engineering: Siemens new scanner, the SOMATOM
Force, takes over the lead in the Dual Source CT portfolio. As such it will enable
radiologists not only to perform even more individualized diagnostics, but also
to contribute to personalized medicine and new therapy concepts. Interdisciplinary imaging experts at the University Medical Center Mannheim, Germany,
share their experience of the first SOMATOM Force installed worldwide.
By Irne Dietschi
1A
1B
High resolution stent imaging coronary CTA images acquired with Turbo Flash mode in only 0.18 s, at 70 kV and pitch 3.2,
with 0.43 mSv. The patients heart rate varied between 58 to 70 bmp during the examination. The VRT image (Fig. 1A) shows
nicely two long stents in both LAD and Cx. The curved MPR image (Fig. 1B) shows the details in the LAD stent.
Cover Story
The Institute of Clinical Radiology at the University Medical Center in Mannheim, Germany, is the very first place worldwide to install the new
SOMATOM Force (Associate Professor Thomas Henzler, MD, left, Professor Stefan Schnberg, MD, right, patient, middle).
Cover Story
The immediate proximity between hospital, patients, and research is regarded as a huge advantage
by dean Professor Uwe Bicker, MD, PhD: University Medical Center Mannheim was successful in the
national competition for the so called research campus, funded by the German Ministery of Education and Research, which in Mannheim involves a public private partnership with Siemens. Bicker is
very proud of the reputation and the amount of expertise that has been accumulated at the campus
lately, especially in imaging. He is reassured by research student Sonja Sudarski who considers
Mannheim to be invaluable for young researchers with a vision, especially as the medical faculty
is equipped with the latest technology.
With the SOMATOM Force we have eliminated almost all contraindications for CT.
The scanner allows precise and individualized imaging of all patients and thus
changes our thinking of CT completely.
Associate Professor Thomas Henzler, MD,
University Medical Center Mannheim, Germany
Cover Story
Cover Story
Cover Story
5A
5C
5
Whole liver perfusion
22 cm acquired at
80 kV, 100 mAs,
with 17.58 mSv only,
for an obese patient
(118 kg) with liver
tumor.
5B
5D
Cover Story
6
6
Dynamic Runoff
61 cm acquired with
spiral 4D mode at
70 kV, 130 mAs, with
1.39 mSv and 45 mL
contrast. MIP images
show nicely the
dynamic flow of the
vascular details,
and additionally, the
tendons as well.
Cover Story
At the University Medical Center in Mannheim, the medical faculty has defined three fundamental
topics it wants to pursue with the SOMATOM Force in various clinical studies: treatment response,
nephroproctection and motion artifact reduction. From left to right: Professor Stefan Schnberg, MD,
director of Radiology and Nuclear Medicine, Professor Lothar Schad, PhD, director of computerassisted clinical medicine, Florian Lietzmann, MD, team leader of CT physics research at the institute
of computer-assisted clinical medicine, Thomas Henzler, MD, head of cardio-thoracic imaging.
Further Information
www.siemens.com/
SOMATOM-Force
News
Getting Further in CT
with New Imaging Possibilities
Siemens continues to improve its advanced visualization platform syngo.via for
CT: Combined with continuous scanner innovations, Siemens syngo.via VA30*
offers a range of additional options for diagnosis and pre-procedural planning.
By Arjen Bogaards, PhD, Jochen Dormeier, MD, Susanne Hlzer, Dominik Panwinkler, Philip Stenner, PhD
Computed Tomography, Siemens Healthcare, Forchheim, Germany
Every year, clinical routine is becoming more and more demanding. Physicians and clinical staff need to make
best use of diagnostic technology tools
available at their particular medical
institution. It is essential to their job to
understand diseases more comprehensively and make the right treatment
decisions faster. This requires technology providers to continuously innovate
medical imaging equipment. Siemens
syngo.via software is designed to furthermore accelerate workflow across
all modalities, managing both day-today and more challenging cases successfully. For this reason, the software
must be based on concepts that are
efficient, flexible, and intelligent. Automated pre-fetching of prior examinations and pre-processing saves valuable
time, allowing physicians, technicians
and IT professionals to focus on their
core patient-centric tasks. Modular
licensing models offer flexibility so
that the system can grow in line with
needs and budget. Workflows are
Comprehensive myocardial
perfusion analysis
Coronary CTA is a well-established
method of ruling out coronary artery
stenosis. Often, an intermediate stenosis is found whose hemodynamic
relevance may be unclear. In such cases,
a myocardial stress perfusion examination can help to decide whether a
patient should undergo PCI2 or not.
As a one-stop shop, CT is becoming
increasingly important in the assessment of myocardial perfusion. Different approaches are currently available,
but Siemens is the only manufacturer
to offer the full spectrum of myocardial
perfusion analysis: Whether simple
first-pass enhancement, Dual Energy
perfusion scanning, or quantitative
dynamic myocardial perfusion. With
syngo.via VA30 and the new perfusion evaluation feature in syngo.CT
Cardiac Function-Enhancement, it is
now possible to evaluate comprehensively all types of myocardial perfusion.
Rather than simply looking at a firstpass enhancement scan, the quantifi-
Advanced oncological
analysis
Assessment of tumor perfusion in
follow-up examinations allows identification of tumor viability before
changes in tumor sizes are visible.
Identifying these changes at an early
stage of oncological treatment adds
supplementary clinical information
especially when following up on
state-of-the-art treatment with antiangiogenic drugs. The body perfusion functionality is now available in
syngo.via and provides quantification
of blood flow, blood volume, and permeability, combined with automated
motion correction for improved anatomical alignment. In addition to its
Adobe Acrobat Professional required; 2PCI: Percutaneous coronary intervention; 3CT DE Heart PBV and/or syngo VPCT Body-Myocardium required
News
the chances of a good outcome. However, the time it takes from the stroke
patient arriving in the emergency
department to receiving thrombolytic
drugs (door-to-needle times) remains
a major challenge in many hospitals.
An important element in this cascade
of events is the imaging software that
is connected to the CT scanner. It is
decisive to increase speed and confidence of the diagnosis and consequently for the implementation and
monitoring of effective treatment.
Generally, a non-contrast CT scan
and single phase CT Angiography will
be administered to exclude bleeding
and confirm the presence of an occlusion in order to determine eligibility
for thrombolytic drug administration.
syngo.CT Neuro Perfusion can help
to visualize the size of the core infarct
and penumbra; the latter represents
tissues that may be salvaged through
further reperfusion therapy.
Excitingly, 4D CT Angiography is
used increasingly and several novel
applications are beginning to emerge.
syngo.CT Dynamic Angio can create
News
7B
7a
movies that visualize the flow of contrast from arterial to venous phase and
depict tMIPs. This can help the clinician better assess the collateral status
and define the occlusion length in
stroke.[3] As such, 4D CT Angiography
has potential in helping to select the
patient optimally suited for interventional clot retrieval. All indications at
the present suggest that CT imaging
will remain the cornerstone of stroke
care.
References
[1] Automatic detection of lytic and blastic
thoracolumbar spine metastases on
computed tomography. Hammon M.
et al; Eur Radiol. 2013 July; 23(7):
18621870.
[2] Meretoja A et al. Reducing in-hospital
delay to 20 minutes in stroke thrombolysis. Neurology. 2012, 79:306-13.
[3] Frlich AM et al. 4D CT Angiography
More Closely Defines Intracranial
Thrombus Burden Than Single-Phase CT
Angiography. AJNR Am J Neuroradiol.
Published online before print April 25,
2013.
** T
he products/features (here mentioned) are
not commercially available in all countries. Due
to regulatory reasons their future availability
cannot be guaranteed. Please contact your local
Siemens organization for further details.
** This product is 510(k) pending. Not available
for sale in the U.S.
Further Information
www.siemens.com/
ct-clinical-engines
News
syngo.CT Cardiac Function Valve Pilot: physicians are able to work with zero-delay for quantitative
assessment of the aortic annulus.
News
CT adds tremendously
to the TAVI procedure by
making it safer.
Professor Stephan Achenbach, MD,
Department of Cardiology, University of Erlangen-Nrnberg
Assessing critical
structures easily
Worldwide, an estimated 40,000
patients have received TAVI.[2] The
landmark, multicenter trial PARTNER
(Placement of AoRTic TraNscathetER
Valve) demonstrated that the TAVI
procedure reduced all-cause mortality by nearly 50% in patients who
were ineligible for the open procedure.[1] Furthermore, key secondary
end points, such as patient condition,
had significantly improved by the
time of the one-year follow up. In the
group of patients who were defined
as having a high surgical risk, TAVI
was found to be non-inferior to surgical aortic valve implantation. Mortality rates after one year were 24.2%
for TAVI, compared with 26.8% for the
surgical procedure.[3]
News
The fundamental
advantage of the software
is that it finds the aortic
annulus automatically.
Professor U. Joseph Schoepf, MD,
Department of Radiology,
Medical University of South Carolina, Charleston, U.S.
Schoepf says that helping to determine a suitable access route for the
relatively large catheters required by
the procedure is another area where
the software excels. It offers singleclick localization and quantification of
the smallest iliac diameter, as well as
visualization and subtraction of aortic
calcifications. Furthermore, it automatically calculates the area and diameter of vessels: Even the most experienced observers derive substantial
value from features like these because
they improve quantitative accuracy
and workflow, Schoepf says.
News
Improving outcomes,
reducing costs
Patients who undergo TAVI have substantially shorter hospital stays than
those undergoing surgical valve replacement.[3] Also, patients treated medically have higher rates of rehospitalization than those undergoing TAVI.[1]
By improving patient outcomes, the
accuracy and safety offered by syngo.via
has the potential to decrease costs
further. Achenbach notes that TAVI procedures require a large clinical team;
therefore, even saving 10 to 15 minutes during the procedure by determining the optimal viewing angle in
advance can make a big difference.
As physicians experience with the procedure grows, Schoepf and Achenbach
believe that there will be fewer complications and better outcomes. Currently,
2A
2B
With the SOMATOM Definition Flash very little amounts of contrast are required
toacquire the entire anatomy relevant for TAVI planning (only 40 mL in this case)
Courtesy of University of Erlangen-Nrnberg, Erlangen, Germany
References
[1] Leon MB, et al. Transcatheter aorticvalve implantation for aortic stenosis in
patients who cannot undergo surgery.
NEngl J Med. 2010;363:1597-607.
[2] Holmes DR, et al. 2012 ACCF/AATS/SCAI/
STS expert consensus document on
transcatheter aortic valve replacement.
JThorac Cardiovasc Surg. 2012 Sep;
144(3):e29-84.
[3] Smith CR et. al., Transcatheter versus
Surgical Aortic-Valve Replacement in
High-Risk Patients N Engl J Med 2011;
364:2187-2198).
[4] Schoepf JU et. al., Automated annulus
assessment accuracy in comparison to
standard software and manual assessment. RSNA 2012
[5] Tamburino C et. al., Incidence and
predictors of early and late mortality
after transcatheter aortic valve implantation in 663 patients with severe aortic
stenosis. Circulation, 123 (2011),
pp.299-308
[6] Jilaihawi H, et al. Cross-sectional
computed tomographic assessment
improves accuracy of aortic annular
sizing for transcatheter aortic valve
replacement and reduces the incidence
of paravalvular aortic regurgitation.
JAm Coll Cardiol. 2012;59:1275-1286
[7] Wuest W, et al. Dual source multidetector CT-angiography before Transcatheter Aortic Valve Implantation (TAVI)
using ahigh-pitch spiral acquisition
mode. EurRadiol. 2012 Jan;22(1):51-8.
Further Information
www.siemens.com/CT-TAVI
Svenja Hennigs, MD, is Head of the hospitals Department of Radiology and Nuclear Medicine at the Knappschaftskrankenhaus in Bottrop, Germany.
News
The abdominal aorta is the main supplier of blood to the abdomen and the
lower extremities. Technically, it is a
flexible tube with an average diameter
of around two centimeters. Most people will never be aware of what is the
largest artery in the human body. It is
an organ that normally works silently
for decades. But there are exceptions:
Approximately one in thirty adults will
develop an aneurysm in the abdominal
aorta defined as an increase in
vessel diameter to more than three
centimeters.
Cutting-edge technology
slashes radiation dose
Hennigs recalls that the hospital had
been working with a 64-slice CT system for many years. At some time,
News
Quicker examinations,
higher image quality
Having worked with the SOMATOM
Definition Edge for four months,
Hennigs and her colleagues have discovered various additional benefits
and regular care with 346 beds in nine clinical departments. More than 50,000 patients are treated per
year, a large number of which are outpatients. The
department of radiology keeps nine radiologists and
15 radiology assistants busy. Apart from the SOMATOM
Definition Edge, they have a Siemens MRI, three
angiography systems, a mammography unit, and two
workplaces plus nuclear medicine and ultrasound.
News
1A
1B
Image comparison for follow-up scan of same patient between previous 64-slice system (Fig. 1A) and new
SOMATOM Definition Edge (Fig. 1B) with SAFIRE at half the dose with comparable diagnostic image quality.
Courtesy of Knappschaftskrankenhaus Bottrop, Germany
Previous 64-slice system (Fig. 1A)
kV-Setting
DLP
318 mGy cm
158 mGy cm
CTDI
7.32 mGy
3.66 mGy
A quantum leap
When looking at the modern CT systems available on the market last year,
Hennigs also considered other vendors
instead of SOMATOM Definition Edge
News
CARE kV
Adjusting the tube voltage for every
CT scan can help deliver the right
dose to every patient; and varying kV
values for different applications can
help achieve optimal image quality.
This potential was known but the
adjustments were too complicated to
do manually, as the tube current then
needs to be adapted accordingly.
CARE kV automatically selects the
tube voltage and CARE Dose4D adapts
the tube current.
Adaptive 4D Spiral
1
News
2A
Outlook
2B
2C
2D
2E
2F
References
[1] Eller A, et al. Invest Radiol. 2012
Oct;47(10):559-65.
[2] Park YJ, et al. J Cardiovasc Comput
Tomogr. 2012 May-Jun;6(3):184-90.
[3] Siegel MJ, et al. Invest Radiol. 2013
Aug;48(8):584-9.
[4] Siegel MJ, et al. Radiology. 2013
Aug;268(2):538-47.
[5] Goetti R, et al. Invest Radiol. 2012
Jan;47(1):18-24.
[6] Reiner CS, et al. Invest Radiol. 2012
Jan;47(1):33-40.
[7] Klotz E, et al. Performance evaluation
of a new CT detector with minimal
electronic noise for low dose abdominal
perfusion imaging. Insights Imaging
(2013) 4 (Suppl 1):200
[8] Tacelli N, et al. Eur Radiol. 2013
Aug;23(8):2127-36.
The initial positive assessment of the SOMATOM Perspective has continued at Sainte-Marie Medical Imaging Center in Osny, near Paris, France.
News
without SAFIRE. In most cases, reducing the power and therefore the
radiation does not affect the quality
of the image.
Surgery and treatment for overweight
persons are among the fields in which
the Sainte-Marie Medical Imaging
Center excels. This year again, the
clinic was placed among the top ten
clinics in the Ile-de-France region
according to the 2013 Ranking of
Hospitals and Clinics published by le
Figaro Magazine. We work in liaison
with the obesity treatment center
at the Sainte-Marie Medical Imaging
Center, Fuchs explains. Radiography
and echography are the first investigations requested prior to bariatric
surgery. When talking about CT-scans,
Fuchs explains, we mostly deploy
the SOMATOM Perspective to detect
pathologies or, more often, multipathologies related to overweight.
Improved temporal
resolution for heart scans
In cardiology, temporal resolution is
the most important factor. To achieve
the lowest possible value, the spiral
must rotate as fast as possible. On
the SOMATOM Perspective, especially
with the help of iTRIM software,
satisfactory results can be achieved.
News
With optimizing protocols to the right dose, a perfect balance between image quality
and radiation exposure can be achieved.
An efficient, economic
scanner
Overall it is evident that the SOMATOM
Perspective is the preferred choice for
radiology centers. A large number of
SOMATOM Perspective scanners have
been sold in France and a lot of them
are now in use in the Paris region. Ever
since the SOMATOM Perspective was
installed at the Sainte-Marie Imaging
Center, it has attracted visits from
numerous specialists from countries
such as Belgium, Switzerland, the USA,
Korea, Japan, and Australia. Although
economic constraints exercise evergreater pressure on budgets, reducing
the quality of care is not an acceptable option at all. Everyone is aware
of the good price position and low
operating costs for the SOMATOM
Perspective. It can be installed easily
and quickly in just one day. It is
very lightweight and so does not
Further Information
www.siemens.com/
SOMATOM-Perspective
News
syngo.via Frontier
Gateway to an Open Research Environment
By Philip Stenner, PhD
Computed Tomography, Siemens Healthcare, Forchheim, Germany
New developments
With the launch of syngo.via Frontier,
Siemens is opening up access to
a range of cardiovascular and Dual
Energy CT research prototypes. In the
future, new prototypes may also be
made available in other fields and
from other external partners, giving
the user the chance of a head start
on current research questions. For
customers with strong programmer
know-how, an optional package is
available that allows design and
implementation of new prototypes.
That will help to leverage personal
research endeavors.
Further Information
www.siemens.com/
syngo.via-frontier
IodineLine
* This product is 510(k) pending. Not available for sale in the U.S.
BoneLine
TissueLine
** A
ccessible with syngo.via Frontier. Not for clinical use.
News
Continuous Commitment
to the Right Dose
By Ivo Driesser and Jan Freund
Computed Tomography, Siemens Healthcare, Forchheim, Germany
Expert jury
Leading radiologists from around the world formed the jury:
Professor Harold Litt, MD, University of Pennsylvania,
Philadelphia (USA),
Professor Willi A. Kalender, MD, PhD, University of
Erlangen-Nuremberg Germany),
Professor Marilyn J. Siegel, MD, Mallinckrodt Institute
of Radiology, St. Louis (USA),
News
*Winners had not been decided at the time of the editorial deadline.
Facebook community
This year, the Facebook fan page has been particularly
successful inviting everyone to interesting discussions about
the most impressive cases submitted. Over the five-month
duration of the contest from June to October 2013
a fan community of over 17,200 users liked, viewed, and
commented on the images. Image Contest fans could also
vote for their favorite picture in a public vote. The Siemens
Internet page devoted to the contest received over 84,700
Further Information
www.siemens.com/care-right
www.siemens.com/image-contest
* I n clinical practice, the use of SAFIRE may reduce CT patient dose depending
on the clinical task, patient size, anatomical location, and clinical practice. A
consultation with a radiologist and a physicist should be made to determine
the appropriate dose to obtain diagnostic image quality for the particular
clinical task. The following test method was used to determine a 54 to 60%
dose reduction when using the SAFIRE reconstruction software. Noise, CT
numbers, homogeneity, low-contrast resolution and high contrast resolution
were assessed in a Gammex 438 phantom. Low dose data reconstructed
with SAFIRE showed the same image quality compared to full dose data based
on this test.
Data on file.
News
Dose-optimized DE
All of these DE applications are performed in a dose-optimized DE scan
mode. In order to avoid doubling the
dose, both scans are performed at
approximately half the dose of a conventional 120 kV scan. Furthermore,
Siemens Single Source DE scan mode
utilizes all dose reduction functionalities: e.g. CARE Dose4D for real-time
tube current modulation, or SAFIRE**
for the reduction of tube current
through iterative reconstruction.
News
Single Source DE scan: syngo.CT DE Brain Hemorrhage* shows iodine concentration in the brain,
to rule-out intra-cranial bleeding. Courtesy of CHU Carmeau, Nmes, France
3
3
Single Source DE scan:
syngo.CT DE Virtual
Unenhanced* shows
enhanced lesion in the
liver.
Courtesy of LMU
Grosshadern,
Munich, Germany
Further Information
www.siemens.com/
dual-energy
News
News
A sound investment
The SOMATOM Perspective family is
not closing doors to growth. The
investment can be tailored according
to the clinical need and business
situation of healthcare institutions.
They have the possibility to start with
a SOMATOM Perspective 16-slice
configuration and upgrade to 32, 64,
and 128 slices whenever economically sensible or clinically necessary.
This is why the SOMATOM Perspective
family not only solves economic challenges; it also opens up new opportunities for healthcare institutions to
meet higher clinical demands.
** T
his product is 510(k) pending.
Not available for sale in the U.S.
** In clinical practice, the use of SAFIRE may
reduce CT patient dose depending on the
clinical task, patient size, anatomical location, and clinical practice. A consultation
with a radiologist and a physicist should
be made to determine the appropriate
dose to obtain diagnostic image quality
for the particular clinical task. The following test method was used to determine a
54 to 60% dose reduction when using the
SAFIRE reconstruction software. Noise,
CT numbers, homogeneity, low-contrast
resolution and high contrast resolution
were assessed in a Gammex 438 phantom. Low dose data reconstructed with
SAFIRE showed the same image quality
compared to full dose data based on this
test. Data on file.
Further Information
www.siemens.com/
SOMATOM-Perspective
News
News
syngo.via facilitates
cardiovascular reading
When it comes to reading cCTA and
perfusion images, Pichler is extremely
satisfied with syngo.via and the CT
Cardio-Vascular Engine. The display
of coronary arteries in Curved Planar
Reformation (CPR) is not only performed extremely quickly, but also very
robustly. He also finds it is especially
helpful in certain situations; when
evaluating lesion lengths, for instance.
On my previous system, the CPR generation was tedious and manual which
is why I never used it. With the automation on syngo.via, the evaluation of
CPRs has now become a routine task.
The Enhancement functionality on
syngo.via allows him to visualize
ischemic areas at the push of a button.
Further Information
www.siemens.com/
ct-cardiology
Business
Transferring knowledge
The re-allocation of the CT was a
crucial step, says Meretoja. It didnt
immediately lead to a reduction in
door-to-needle time, but it helped us
identify other bottlenecks that we
could eliminate once the CT was available. We learned, for example, that
it was wise to bypass the emergency
department cubicle. We transport
stroke patients directly into the CT
room, carry out a very brief neurological examination and perform the
CT examination, immediately afterwards. All in all, these refinements
of the admission processes save us
an awful lot of time. In bare figures,
Helsinki University Hospital managed
to reduce door-to-needle time within
ten years from 108 minutes to as
little as 20 min.[1] This is more than
one hour quicker than in most other
parts of the world, including the rest
of Europe and the U.S. And stroke care
improvements are absolutely costeffective at Helsinkis. In 2007, we
paid 11.3 million for 2,000 stroke
patients treated in our hospital plus
3.2 million for 6,000 admissions to
the neurological ER, stresses Kaste.
Successful stroke treatment including stroke unit care and thrombolysis
saved us 14.4 million in the costs of
chronic institutional care. This means
that the neurological ER is actually
cost neutral.
So is it possible to transfer knowledge about optimum processes in
acute stroke care to other countries?
Meretoja has proven that it is. He spent
18 months in Australia as a fellow
at University of Melbourne. There, he
tested the applicability of the Helsinki
protocol in a totally different healthcare setting including the re-allocation of a CT into the emergency
department. Within a year, the Helsinki result was duplicated. Measures
of process improvement similar to
those we implemented in Helsinki
drove door-to-needle time down from
45 to 25 minutes.[2] As such, the
Helsinki Model represents an enormous opportunity to improve stroke
care globally.
Business
Dynamic CT Angiography
In other words, CT is indispensable to
acute stroke care at least in hospitals
where the shortest possible door-to-
One-stop management
ofacute stroke
Given that there is so much progress
in CT imaging, and traditional medical
therapies for stroke patients are
increasingly being supplemented by
References
[1] Meretoja A, Strbian D, Mustanoja S,
Tatlisumak T, Lindsberg PJ, Kaste M.
Reducing in-hospital delay to
20minutes in stroke thrombolysis.
Neurology. (2012) 79:306-13.
[2] Meretoja A, Weir L, Ugalde M, Yassi N,
Yan B, Hand P, Truesdale M, Davis SM,
Campbell BC. Helsinki model cut stroke
thrombolysis delays to 25 minutes in
Melbourne in only 4 months. Neurology.
2013 Aug 14. [Epub ahead of print]
[3] Frlich AM, Schrader D, Klotz E,
Schramm R, Wasser K, Knauth M,
Schramm P. 4D CT Angiography More
Closely Defines Intracranial Thrombus
Burden Than Single-Phase CT Angiography. AJNR Am J Neuroradiol. 2013 Apr
25. [Epub ahead of print]
[4] Meretoja A, Churilov L, Campbell BC,
AvivRI, Yassi N, Barras C, Mitchell P, Yan B,
Nandurkar H, Bladin C, Wijeratne T,
Spratt NJ, Jannes J, Sturm J, Rupasinghe
J, Zavala J, Lee A, Kleinig T, Markus R,
Delcourt C, Mahant N, Parsons MW, Levi
C, Anderson CS, Donnan GA, Davis SM.
The Spot sign and Tranexamic acid On
Preventing ICH growth - AUStralasia
Trial (STOP-AUST): Protocol of a phase II
randomized, placebo-controlled, doubleblind, multicenter trial. Int J Stroke.
2013 Aug 26. [Epub ahead of print]
The statements by Siemens customers described
herein are based on results that were achieved
in the customers unique setting. Since there is no
typical hospital and many variables exist (e.g.,
hospital size, case mix, level of IT adoption) there
can be no guarantee that other customers will
achieve the same results.
Further Information
www.siemens.com/
ct-clinical-engines
One motivation for Attila Sekillioglu, MD, (left) and Rainer Ulmer, MD, (right) from ZDR in Ludwigshafen purchasing a SOMATOM Perspective
was the cutting-edge technology, offering the perfect combination of straightforward operation, low space requirements, broad technical possibilities
at a reasonable price.
All-in-one
The Center for Radiological Diagnostics (ZRD) in Ludwigshafen, Germany,
has been able to significantly expand the range of examinations it offers.
The SOMATOM Perspective 64 not only allows radiologists there to perform
cardiac imaging for the first time and to reduce examination times, it also
offers the possibility of upgrading to a 128-slice CT scanner in the future.
By Philipp Braune
Business
Diagnosing using the syngo.via software enables the ZRD to benefit from numerous
automated processes and a high degree of efficiency.
Business
Business
2.85 m
SOMATOM Perspective
SOMATOM Perspective
While options were still being considered, the Siemens
SOMATOM Perspective 64-slice configuration came onto
the market at just the right time to meet the needs of
Senoo Hospital. Director Senoo explained, Above all, the
device itself is compact and it offers a 64-slice CT scanner
with superior cost performance. It was precisely the factor
of compact size versus powerful performance and efficient
running costs that finally sealed the decision.
4.50 m
Scanning Room
Operations Room
The installation diagram shows the limited space for a new CT system at
Senoo Hospital. However after the SOMATOM Perspective 64-slice configuration was installed, the staff were very surprised at its compact size.
Case 1
History
Diagnosis
1A
Comments
CTA can detect calcified plaques of
the coronary arteries; however, the
severity of the stenosis might not be
interpretable if the coronary artery is
extensively calcified. Adenosine-Stress
Dynamic Myocardial CT Perfusion permits evaluation of the hemodynamic
significance caused by the stenosis,
and assists in the decision-making process for optimal patient treatment.
1B
1
VRT (Fig.1A)
and curved
MPR (Fig.1B)
images demonstrate the
extensively
calcified LAD.
2A
2B
2
Curved MPR images show multiple
calcified plaques in the Cx (Fig. 2A) and
RCA (Fig. 2B).
3
Perfusion images reveal myocardial
perfusion defects (in blue) in the LAD
territory.
4
Angiographic images confirmed the mid
LAD stenosis (Fig. 4A). The patient was
treated with PTCA and stenting of the mid
LAD with an excellent angiographic result
(Fig. 4B).
Cx
RCA
Examination Protocol
3
4A
4B
Scanner
SOMATOM
Definition Flash
Scan area
Heart
Scan mode
VPCT
Scan length
70 mm
Scan direction
Cranio-caudal
Scan time
31 s
Tube voltage
100 kV
Tube current
Dose modulation
CARE Dose4D
CTDIvol
78.2 mGy
DLP
562 mGy cm
Effective dose
7.9 mSv
Rotation time
0.28 s
Slice collimation
32 x 1.2 mm
Slice width
3 mm
Reconstruction
increment
2 mm
Reconstruction
kernel
B23f
Contrast
Volume
50 mL contrast +
40 mL saline
Flow rate
6 mL/s
Start delay
Determined by test
bolus
Case 2
History
Comments
Diagnosis
The CT images demonstrated a mild
stenosis, from soft plaque, in the
proximal left anterior descending
artery (LAD), and a myocardial bridge
in the middle LAD with no evidence
of stenosis. The circumflex (Cx) was
small in caliber but showed no evidence of stenosis. The right coronary
artery (RCA) appeared normal.
Examination Protocol
Scanner
Scan area
Heart
Slice collimation
128 0.6 mm
Scan length
115 mm
Slice width
0.75 mm
Scan direction
Cranio-caudal
Temporal resolution
75 ms
Scan time
0.39 s
Reconstruction increment
0.5 mm
Tube voltage
70 kV
Reconstruction kernel
I26f
5769 bpm
Tube current
270 eff.mAs
CTDIvol
0.78 mGy
Contrast
DLP
13.7 mGy cm
Volume
45 mL
Effective dose
0.19 mSv
Flow rate
3.5 mL/s
Rotation time
0.28 s
Start delay
Pitch
3.4
1A
1B
1C
Curved MPR (Fig. 1A), MIP (Fig. 1B), and VRT (Fig. 1C) images demonstrate the LAD with mild stenosis (arrows) from soft
plaque, and a myocardial bridge (arrowheads) in the middle LAD with no evidence of stenosis. The Cx (dashed arrow) and the
RCA (double arrows) appear to be normal, although the Cx is small in caliber.
Case 3
Examination Protocol
History
A 43-year-old male patient, clinically
diagnosed with aortic stenosis, was
referred for pre-operative evaluation.
He complained of restlessness, chest
pain, breathlessness, and heart palpitations.
Diagnosis
The CT images revealed calcified
bicuspid aortic valves with severe
aortic stenosis and left ventricular
hypertrophy (Figs. 1 and 2) associated
with ischemic changes in the myocardium. There was additional evidence
that the right conus artery arose from
the right aortic sinus and communicated with the main pulmonary artery
anteriorly (Fig. 3). These findings
suggested an anomalous coronary
artery fistula. The remainder of the
coronary arterial system and cardiac
anatomy was normal. The patient successfully underwent an aortic valve
replacement with a mechanical prosthesis and suturing of the coronary
artery fistula.
Comments
Coronary-pulmonary artery fistulas
are uncommon cardiac anomalies,
usually congenital, with an estimated
incidence of 0.002% in the general
population.[1] Most coronary-pulmonary artery fistulas are clinically and
References
[1] Burch GH, Sahn DJ. Congenital coronary
artery anomalies: the pediatric perspective. Coron Artery Dis 2001;12:60516.
[2] A. Tomasian,M. Lell, J Currier,J Rahman,
M.S.Krishnam, Coronary artery to
pulmonary artery fistulae with multiple
aneurysms... The British Journal of
Radiology, 81(2008), e218e220.
[3] A.R Zeina, J Blinder, U Rosenschein E
Barmeir. Coronary-pulmonary artery
fistula diagnosed by multidetector
computed tomography: Postgrad Med J.
2006 July; 82(969): e15.
[4] Tzemos N, Therrien J, Yip J et al.
(September 2008). Outcomes in adults
with bicuspid aortic valves. JAMA 300
(11): 1317132
Scanner
SOMATOM
Definition Edge
Scan mode
Scan area
Heart
Scan length
172.5 mm
Scan direction
Cranio-caudal
Scan time
7.5 s
Tube voltage
100 kV
Tube current
79 eff. mAs
Rotation time
0.28 s
Pitch
0.17
Slice collimation
128 x 0.6 mm
Slice width
0.6 mm
Reconstruction
increment
0.3 mm
Temporal
Resolution
75 ms
Reconstruction
kernel
I26f, SAFIRE
CTDIvol
14.69 mGy
DLP
286 mGy cm
Effective Dose
4 mSv
Contrast
Volume
70 mL
Flow Rate
5.5 mL/s
Start delay
6s
3a
3b
3c
Case 4
Examination Protocol
History
An 11-year-old boy was admitted to
the hospital complaining of progressive weakness of the right arm for the
past 6 days and unclear enunciation,
accompanied by nausea and vomiting
for the past 2 days. An MR examination raised questions as to a cerebral
infarction of the left parietal and
frontal lobe, which was confirmed by
a CT 11 days later (Fig.1). DSA images
(Fig.2) indicated the possibility of
the Moyamoya disease. CTA and Volume Perfusion CT (VPCT) examinations were ordered for pre-operative
planning.
Diagnosis
Comments
Moyamoya disease is characterized
by a progressive steno-occlusive
vasculopathy of the terminal portion
of the internal carotid artery and its
main branches. It is associated with
the development of dilated, fragile
collateral vessels at the base of the
brain, which are termed Moyamoya
vessels. These collateral vessels have
the appearance of a puff of smoke.
Most patients suffer from recurrent
ischemic attacks. Dynamic VPCT can
be used to evaluate the details of
cerebral hemodynamic changes in
Scanner
SOMATOM
Definition Flash
Scan area
Head
Scan length
100 mm
Scan direction
Adaptive 4D Spiral
Scan time
36 s
Tube voltage
70 kV
100
Dose modulation
n. a.
CTDIvol
56.42 mGy
DLP
665 mGy cm
Effective dose
1.4 mSv
Rotation time
0.28 s
Pitch
0.55
Slice collimation
32 x 1.2 mm
Slice width
3 mm
Reconstruction
increment
2 mm
Reconstruction
kernel
H20f
Contrast
Volume
32 mL + saline
Flow rate
4.0 mL/s
Start delay
5s
Left
Right
Diff.
CBF
47.7
51.7
-8%
CBV
3.39
2.70
+26%
MTT
5.19
3.38
+54%
11
Left
Right
Diff.
CBF
54.5
53.4
+2%
CBV
3.32
2.80
+16%
MTT
4.19
3.25
+29%
Table 2: Post-operative
Partially restored reserve
capacity indicated by
normalized CBF and
diminished increase of
CBV and MTT.
3a
3b
Pre
5a
Post
5B
Pre
Post
3D TTD (Fig. 5A) and TTS (Fig. 5B) maps showed the full extent of the
hemodynamic disturbance before surgery and the significant postoperative
improvement.
Case 5
Differentiating an Intracranial
Hemorrhage from Iodine in Acute Stroke
after Intra-arterial Recanalization
By Alida A Postma, MD, Paul AM Hofman, MD, Joachim E Wildberger, MD
Dept. of Radiology, Maastricht University Medical Center, Maastricht, the Netherlands
History
A 57-year-old male patient was presented to an external hospital with
a left-sided grade 1 paralysis. This
resulted from a large infarction in the
right middle cerebral artery (MCA)
territory. Treatment with intravenous
rtPA was started but then suspended
due to the suspicion of a small hemorrhage in the non-contrast CT. The
patient was referred to a tertiary center
for intra-arterial recanalization (IAR).
Diagnosis
The non-contrast CT images demonstrated a small focus of subarachnoid
hemorrhage in a right parietal sulcus
(Fig. 1A). A faint loss of gray-white
matter differentiation and effacing
of the sulci in the MCA territory was
seen (Fig. 1B). CTA images showed
an occlusion of the right proximal
1A
2A
1B
2B
the breakdown in the blood brain barrier in a patient who had received contrast during IAR? DE scan was helpful
for differential diagnosis. The hyperdensity in the right MCA territory at
the level of basal ganglia was shown in
the iodine overlay maps (IOM) and the
iodine images, but was not seen in
the virtual non-contrast (VNC) images
(Fig. 4). Therefore, a contrast extravasation was confirmed and a hemorrhage was excluded. Consistent with
the pre-IAR scan, the small focus of
hyperdensity in the subarachnoid
space of a right parietal sulcus (Fig. 5)
appeared again in the mixed and VNC
images with only a minor density
increase, but was not seen in the IOM
and the iodine images, suggesting a
remaining hemorrhage.
Follow-up CTs, at day 1 and day 5,
showed no signs of hemorrhage in the
MCA territory (Fig. 6), which confirmed
the interpretation of contrast extravasation due to the breakdown of the
blood brain barrier. At discharge, the
patient had partially recovered but
there remained a grade 4 paresis of
the right arm and leg as well as a discrete facial asymmetry.
Comments
CBF
CBV
MIP
TTD
MTT
TTP
Mixed
VNC
IOM
lodine
Mixed
IOM
VNC
lodine
6A
6B
Examination Protocol
Scanner
SOMATOM
Definition Flash
Scan area
Head
Scan mode
Scan length
155 mm
Scan direction
Cranio-caudal
Scan time
9s
Tube voltage
80 kV / Sn 140 kV
Tube current
Dose modulation
CARE Dose4D
CTDIvol
36.43 mGy
DLP
615 mGy cm
Effctive dose
1.29 mSv
Rotation time
0.5 s
Slice collimation
128 x 0.6 mm
Slice width
1 mm
Reconstruction
increment
1 mm
Reconstruction
kernel
D26f
Case 6
History
Diagnosis
Comments
View of our trauma room with a sliding gantry solution. In the back, the sliding gantry is in its
normal position in the standard CT examination room. The CT suite and the trauma room are
separated by a sliding X-ray-proof (background) door. If CT is required for a trauma patient, the
door opens and the gantry slides over. The patient is scanned without the need for any further
relocation.
References
[1] Huber-Wagner S, Lefering R, Qvick L-M,
et al. Effect of whole-body CT during
trauma resuscitation on survival:
a retrospective, multicentre study.
Lancet. 2009;373:145561
3
1
Excellent image
quality in the upper
abdomen with
very good iodine
enhancement at
100 kV and no
artifacts compromising the
diagnosis of splenic
rupture. Pancreas,
kidneys, and liver
appear normal.
2
2
Coronal 3 mm MPR
shows the ruptured
spleen and lots
of free abdominal
fluid while liver
and kidneys appear
normal. There is
no detectable difference in image
quality to a
stationary gantry
with moving table.
3
Excellent image
quality to confirm
no spine injury.
Examination Protocol
Scanner
Scan area
Chest/Abdomen
Rotation time
0.5 s
Scan length
63 cm
Pitch
1.2
Scan direction
Cranio-caudal
Slice collimation
64 x 0.6 mm
Scan time
12 s
Slice width
1.0 / 5.0 mm
Tube voltage
100 kV
Reconstruction increment
0.5 / 5.0 mm
Tube current
261 mAs
Reconstruction kernel
Dose modulation
CARE Dose4D
Contrast
CTDIvol
5.75 mGy
Volume
75 mL
DLP
329 mGy cm
Flow rate
2 mL/s
Effective dose
4.6 mSv
Start delay
70 s
Case 7
History
A 75-year-old male patient presented
to the emergency department complaining of a sudden onset of severe
dyspnea and chest pain. The patient
had a history of prostate cancer.
A physical examination revealed
that the patient was normotensive
(118/60 mmHg), tachycardic (93 bpm)
and his oxygen saturation was 94%
at room air. Troponin I serum levels
(0.46 ng/mL) as well as D-dimers
plasma levels (21.5 mg/L) were elevated. The patient was referred to
the radiology department for a Dual
Energy CT pulmonary angiography
(CTPA) to rule out pulmonary
embolism.
Diagnosis
The CTPA demonstrated filling defects
in both the left and right main pulmonary arteries as well as bilaterally
in the lobar, segmental and sub-segmental pulmonary arteries (Fig. 1).
This confirmed the diagnosis of
severe acute pulmonary embolism.
Multiple wedge-shaped parenchymal
perfusion defects were visualized in
both lungs on the iodine distribution
maps derived from the Dual Energy
Comments
The Lung PBV application of the
syngo.CT DE Lung Analysis software
allows for an automated quantification of pulmonary perfused blood
volume as a surrogate for pulmonary
perfusion. PBV values are calculated
by relating the pulmonary parenchymal iodine content to the enhancement of a reference input vessel. In
addition to a global analysis, PBV values are also generated for each lung
as well as for the upper, middle and
lower zones of each lung separately,
thereby demonstrating the regional
distribution of pulmonary perfusion
abnormalities. Age-specific norm values for pulmonary PBV have recently
been published.[1] PBV quantification
can be used to assess the severity of
an acute pulmonary embolism [24]
and the regional distribution of pulmonary perfusion abnormalities in
emphysema.[5]
References
[1] Meinel FG, Graef A, Sommer WH,
Thierfelder KM, Reiser MF, Johnson TR.
Influence of vascular enhancement, age
and gender on pulmonary perfused blood
volume quantified by dual-energy-CTPA.
Eur J Radiol. May 24 2013.
[2] Nagayama H, Sueyoshi E, Hayashida T,
Ashizawa K, Sakamoto I, Uetani M. Quantification of lung perfusion blood volume
(lung PBV) by dual-energy CT in pulmonary
embolism before and after treatment:
preliminary results. Clin Imaging.
May-Jun 2013;37(3):493-497.
[3] Meinel FG, Graef A, Bamberg F, et al.
Effectiveness of Automated Quantification
of Pulmonary Perfused Blood Volume
Using Dual-Energy CTPA for the Severity
Assessment of Acute Pulmonary Embolism.
Invest Radiol. Mar 20 2013.
[4] Sueyoshi E, Tsutsui S, Hayashida T,
Ashizawa K, Sakamoto I, Uetani M. Quantification of lung perfusion blood volume
(lung PBV) by dual-energy CT in patients
with and without pulmonary embolism:
preliminary results. Eur J Radiol. Dec
2011; 80(3):e505-509.
[5] Meinel FG, Graef A, Thieme SF, et al.
Assessing pulmonary perfusion in
emphysema: automated quantification of
perfused blood volume in dual-energy CTPA.
Invest Radiol. Feb 2013;48(2):79-85.
1A
1B
1
The CTPA images demonstrate filling
defects in both the left and right main
pulmonary arteries as well as bilaterally in
the lobar, segmental and sub-segmental
pulmonary arteries.
2A
2B
2
Multiple wedge-shaped parenchymal
perfusion defects are visualized in both
lungs on the iodine distribution maps
derived from the Dual Energy CTPA.
The global pulmonary perfused blood
volume (PBV) is 27%.
3a
3b
3
Normal PBV in a patient without
pulmonary embolism demonstrates
homogenous pulmonary perfusion.
The global pulmonary perfused blood
volume (PBV) is 101%.
Examination Protocol
Scanner
Scan area
Thorax / Chest
Rotation time
0.28 s
Scan length
313 mm
Pitch
0.55
Scan direction
Caudo-cranial
Slice collimation
64 x 0.6 mm
Scan time
8.5 s
Slice width
1.5 mm
Tube voltage
100 kV / Sn 140 kV
Reconstruction increment
1 mm
Tube current
Reconstruction kernel
Q30f
Dose modulation
CARE Dose4D
Contrast
370 mg/mL
CTDIvol
11.9 mGy
Volume
DLP
391 mGy cm
Flow rate
4 mL/s
Effective dose
5.47 mSv
Start delay
Case 8
History
A 27-year-old female patient presented herself to the hospital with
acute flank pain. She complained of
recurrent back pain for the past two
years and was recently treated with
antibiotics for a urinary infection
which improved without complica-
Diagnosis
tions. Her family history was unremarkable. An ultrasound examination
was primarily performed for the kidneys and bladder. There were no signs
of either hydronephrosis or calculi
in the urinary system. A Dual Energy
(DE) CT was then ordered for further
clarification.
Examination Protocol
Comments
Scanner
Scan area
Abdomen / Pelvis
Scan length
422 mm
Scan direction
Cranio-caudal
Scan time
5s
Tube voltage
80 kV / Sn 140 kV
Tube current
35 / 14 eff. mAs
Dose modulation
CARE Dose4D
CTDIvol
1.21 mGy
DLP
54 mGy cm
Effective dose
0.81 mSv
Rotation time
0.28 s
Pitch
0.6
Slice collimation
128 0.6 mm
Slice width
1 mm
Reconstruction increment
0.7 mm
Reconstruction kernel
D30f
1A
1B
2A
Oblique MPR images show two tiny renal calculi on the left. One is about 3 mm in diameter (arrows),
and the other one is even smaller (dashed arrows).
2B
DE images reveal two renal calculi on the left. The bigger one (arrows) exhibits densities of up to 515 HU,
and both were classified as non-uric acid.
Case 9
History
A 36-year-old male patient, with two
indwelling ureteric stents (Double
J stents) placed in both ureters, was
admitted to the hospital. Prior to the
removal of the stents, a CT examination was ordered to evaluate if the
prior stones had been all cleared and
if any new stones had formed.
Diagnosis
A few kidney stones in each kidney
were detected. Two of the stones
were clinically significant. Both were
calcium-based stones measuring
5 mm in diameter. One of these
stones was in the lower pole of the
left kidney and the other in the upper
pole of the right kidney, located
within the curve of the ureteric stent
(Fig.1). On conventional CT images,
the renal calculus is isodense with the
ureteric stent and nearly impossible
to differentiate if they are touching.
The Dual Energy scan allowed to this
stone to be resolved from the adjacent ureteric stent (Figs. 24).
References
[1] Moe OW. Kidney stones: pathophysiology
and medical management.
Lancet;367:333-44.
[2] Manglaviti G, Tresoldi S, Guerrer CS, et al.
In vivo evaluation of the chemical composition of urinary stones using dual-energy
CT. AJR American Journal of
Roentgenology;197:W76-83.
[3] Stolzmann P, Kozomara M, Chuck N, et al.
In vivo identification of uric acid stones
with dual-energy CT: diagnostic performance evaluation in patients. Abdominal
Imaging;35:629-35
Examination Protocol
Scanner
SOMATOM
Definition Flash
Scan area
Abdomen/Pelvis
Scan length
439.5 mm
Scan direction
Cranio-caudal
Scan time
13.5 s
Tube voltage
Tube current
Dose modulation
CARE Dose4D
CTDIvol
8.25 mGy
Comments
DLP
394 mGy cm
Effective dose
5.9 mSv
Rotation time
0.5 s
Pitch
0.85
Slice collimation
32 x 0.6 mm
Slice width
0.75 mm
Reconstruction increment
0.5 mm
Reconstruction kernel
Q30f
1A
1B
3A
Coronal MPR images show one stone in the lower pole of the
left kidney (arrow), and the other one in the upper pole of the
right kidney which is difficult to distinguish from the stent.
3B
4A
4B
Case 10
History
Diagnosis
Comments
Due to the critical situation of the
baby, sedation was not an option.
Therefore, the scanning was performed with free-breathing using
Examination Protocol
Scanner
Scan area
Thorax
Rotation time
0.28 s
Scan length
104 mm
Pitch
Scan direction
Cranio-caudal
Slice collimation
128 x 0.6 mm
Scan time
0.26 s
Slice width
0.6 mm
Tube voltage
80 kV
Reconstruction increment
0.3 mm
Tube current
40 mAs
Reconstruction kernel
B31f
Dose modulation
CARE Dose4D
Contrast
CTDIvol
0.84 mGy
Volume
7 mL
DLP
11 mGy cm
Flow Rate
1 mL/s
Effective dose
0.99 mSv
Start delay
Bolus tracking
1A
1B
The posterior view of the VRT images demonstrates the tracheal stenosis (arrows) and the innominate artery
running across the front of the trachea.
Science
Image Quality in
Computed Tomography
Part III: Artifacts
By Stefan Ulzheimer, PhD and Rainer Raupach, PhD
Computed Tomography, Siemens Healthcare, Forchheim, Germany
1A
Beam-hardening artifacts
The most prominent beam-hardening
artifact is known as the Hounsfield
bar, a dark band between the petrous
bones in the base of the skull obliterating the mid portion of the brain stem
(Fig.1A). During a CT scan, the tube
emits a polychromatic X-ray spectrum
that contains photons of differing
energies.
Attenuation of X-rays depends on the
energy, but this attenuation decreases
with higher photon energy. Therefore,
the spectral consistency of X-rays
changes as they pass through an object:
1b
Beam-hardening artifacts: Hounsfield bar, the dark band between the petrous bones in the base of the skull obliterating the mid
portion of the brain stem (Fig. 1A). Fig. 1B shows the same slice as Fig. 1A: Improvement with beam-hardening correction.
Science
2A
2B
2
Artifacts in a thorax
scan from breathing
and movement of the
heart (Fig. 2A).
Improvement with
a motion artifact
correction algorithm
(Fig. 2B).
imaging that consider the two components, soft tissue and bone.[2]
3A
3B
Science
Motion artifacts
CT images are reconstructed in a particular segment of projections. Movement of an object or patient during
this time leads to inconsistent data.
Artifacts typically occur as streaks,
blurred or double contours (Fig. 2A).
Protocols for critical examinations may
include special motion correction
algorithms to suppress such artifacts
(Fig. 2B).
Generally, a fast gantry rotation speed
is recommended to minimize motion
artifacts. The SOMATOM Definition
Flash and Edge offer rotation times
down to 0.28 seconds per 360 degrees,
fast enough to freeze physiological
processes. Dedicated cardiac reconstruction algorithms can be used to
display sub-millimeter structures near
to the heart, for example coronary
arteries. These use information from
an ECG taken in parallel to determine
optimized temporal windows and
require only 180 degrees of data to
reconstruct a CT image with improved
temporal resolution. Temporal resolution can be further improved with Dual
Source technology on the SOMATOM
Definition Flash. Even uncooperative
patients and children can be scanned
without the appearance of motion
artifacts using Dual Source. Siemens
latest generation of Dual Source CT
4A
4B
Cone artifacts
Cone artifacts arise due to an approximation of the measured slices of
MSCT systems to truly parallel planes.
If the detector width in the z-direction
increases, then deviations from this
simplified description will also increase
resulting in characteristic artifacts.
Given that the misfit extends away from
the center of rotation, cone artifacts
are strongest typically at the periphery,
for example near the ribs. Siemens
MSCT scanners provide effective cone
correction or cone beam reconstruction, when required, depending on the
number of detector rows.
Nevertheless, excessive increase in
detector coverage as seen with several
recent product introductions in the
industry, comes along with a significant increase of these cone and also
scatter artifacts. At such an extend, the
disadvantages outweigh the clinical
benefits of covering large volumes,
4C
Artifacts caused by metal implants (Fig. 4A). Dual Energy based metal artifact reduction (MAR) in 140 keV monoenergetic
images (Fig. 4B). VRT of the metal prosthesis with MAR (Fig. 4C).
Science
5A
5B
Patient exceeding the field of measurement without correction (Fig. 5A). Same slice as in Fig. 5A reconstructed with
HD FoV reconstruction (Fig. 5B).
Metal artifacts
Metal artifacts are a combination of
almost all of the effects described
above. The particular effect that may
occur depends on the alloy, shape, size,
and position. Generally, the transition
from tissue to metal is very abrupt
compared with the size of the detector
channels. So partial volume effects or
sampling errors contribute to metalinduced artifacts, which appear as thin
streaks emanating from the edges.
As the size of the metallic object
increases, so does the attenuation of
the X-rays. Beam hardening becomes
relevant. Moreover, the absolute signal
measured in certain detector elements
behind the implant becomes so low that
the reading is no longer reliable due
to the high level of noise. Both effects
may completely destroy the image content for rays passing through a large
amount of metal. Using a higher voltage
reduces beam hardening as well as a
lack of detector signal due to smaller
attenuation at higher photon energies.
Selecting higher mAs, on the other
hand, does not improve the situation
significantly but will increase radiation
References
[1] Kalender WA: Computed Tomography,
Publicis MCD: 22ff (2000)
[2] Herman GT, Trivedi SS. A Comparative
Study of Two Postreconstruction Beam
Hardening Correction Methods, IEEE
Transactions on Medical Imaging.
1983 Sep; Vol MI-2; No 3: 128-135
[3] Flohr T, Stierstorfer K, Raupach R,
Ulzheimer S, Bruder H. Performance
evaluation of a 64-slice CT system
with z-flying focal spot. Rofo. 2004
Dec;176(12):1803-10.
Science
Radiation Hygiene
Transparent and Easy
Medical physicists carry a significant responsibility for their patients.
Facilitating and establishing a safety culture in a medical environment
is therefore one of their main priorities. The Albert Schweitzer Hospital
in Dordrecht, the Netherlands, uses Siemens CARE Analytics on a daily
basis to keep a check on safety and radiation doses for the radiology and
cardiology department equipment.
By Erika Claessens
trol, and equipment producing ionizing radiation, and thus affect most of
our scanners and technical equipment.
Our hospital must keep to these regulations to optimize radiation doses,
meaning lowering the dose as much as
possible, and also to perform quality
control on patient doses.
Science
Increased transparency
CARE Analytics was very easy to install
on our computers. Our hospital scanning equipment contains comprehensive data for each irradiation event, the
accumulated dose in CT, and information about the context of the exposure.
Until now, this data was only archived
in dose structured reports and not processed any further. The data is now
sent to the software tool on our desktop, where it is stored and processed.
With CARE Analytics, we can evaluate
and analyze the information in a stan-
CARE Analytics offers many possibilities and opportunities to Jeroen Bosman and his team
for efficient dose management.
Exploring trends
Further Information
www.siemens.com/care-right
Science
1
1
Radiation dose
reduction in daily
practice showed
no adverse impact
on image quality.
Radiation dose
reduced by 15%
and then 30% in
reference mAs
(compared with
previous practice)
was applied in
allthoracic and
abdomino-pelvic
protocols.
Science
French
recommendations
Nmes
2012
Nmes
2013
Nmes
2012 vs. 2013
French recommendations
vs. Nmes 2013
Chest
15 mGy
4.2mGy
2.5mGy
40.5%
83.3%
Abdominal
17mGy
7.5mGy
5.1mGy
32.0%
70.0%
Lumbar Spine
45mGy
16.2 mGy
8.8mGy
45.7%
80.4%
Head
65mGy
48.8mGy
36.3mGy
25.6%
44.2%
2A
2B
2
In an optimized protocol for
urinary stones, irradiation was
decreased by more than
70percent (Fig. 2B) compared
with previous protocols
(Fig. 2A). Urinary calculi can be
detected without any change
in accuracy.
Customer Excellence
Define structures
When using the Bone & Vessel Isolation mode for the first time, the bone
removal edit mode is automatically
1
1
Bone Opacity
from the upper left
corner of the VRT
segment allows to
view the marked
and unmarked
structures.
Optimized view
Based on the structures that are
marked as bones in the bone mask,
bone structures can be highlighted in
MPR and VRT images. The highlighting
functions can be used to optimize
the bone removal masks. In the editing
mini toolbar, click the Hide marked
structures icon or Show marked
structures icon.
In the VRT segment, an adjustable
semi-transparent view of the bones can
be displayed. This view is based on the
structures that are marked or unmarked
as bone in the bone removal mask.
From the upper left corner of the VRT
segment, choose Bone Opacity. In
the bone opacity mini toolbar at the
bottom of the segment, the marked/
unmarked slider can be dragged to
the left or to the right to change the
opacity level of the structures.
In the VRT segment all identified bone structures are hidden. Clicking on a structure (displayed in transparent blue) allows to add
(blue plus sign) or remove (red minus sign) it from the removal mask. In the editing mini toolbar, marked structures can be shown
or hidden.
Customer Excellence
Date
Location
January
1112, 2014
Hawaii,
USA
Clinical Workshop
on Dual Energy
February
1415, 2014
Course
Language
Course Director/Organizer
Link
English
Siemens Healthcare
Prof. Stephan
Achenbach, MD
Suhny Abbara, MD
www.scct.org/training/cta/
Forchheim,
Germany
English
Siemens Healthcare
Prof. Thorsten Johnson,
MD
www.siemens.com/
SOMATOMEducate
March
18 19, 2014
Forchheim,
Germany
English
Siemens Healthcare
www.siemens.com/
SOMATOMEducate
Coronary CTA
Interpretation Workshop
March
2728, 2014
Erlangen,
Germany
English
Siemens Healthcare
Prof. Stephan
Achenbach, MD
www.siemens.com/
SOMATOMEducate
April
2426, 2014
Oslo,
Norway
English
ESGAR
Anders Drolsum, MD
www.esgar.org
Advanced Cardiovascular CT
April 29
May 2, 2014
London,
UK
English
www.imperial.ac.uk
June
1821, 2014
Salzburg,
Austria
English
ESGAR
Prof. Gerhard Mostbeck,
MD
www.esgar.org
Oncology Imaging
Course 2014/Oncology
June
2628, 2014
Dubrovnik,
Croatia
English
OIC
Prof. Maximilian Reiser,
MD
www.oncoic.org
September
23 24, 2014
Forchheim,
Germany
English
Siemens Healthcare
www.siemens.com/
SOMATOMEducate
October
810, 2014
Leeds,
UK
English
ESGAR
Damian Tolan, MD
www.esgar.org
Coronary CTA
Interpretation Workshop
November
6 7, 2014
Erlangen,
Germany
English
Siemens Healthcare
Prof. Stephan
Achenbach, MD
www.siemens.com/
SOMATOMEducate
In addition, you can always find the latest CT courses offered by Siemens Healthcare
at www.siemens.com/SOMATOMEducate
Customer Excellence
Date
Location
Title
Contact
December
0106, 2013
Chicago, USA
RSNA
www.rsna.org
Internationales Symposium
Mehrschicht CT
January
2225, 2014
GarmischPartenkirchen,
Germany
Mehrschicht
CT
www.ct2014.org
Arab Health
January
2730, 2014
Dubai, UAE
Arab Health
www.arabhealthonline.com
March
0610, 2014
Vienna, Austria
ECR
www.myesr.org
April
0408, 2014
Vienna, Austria
ESTRO
www.estro.org
April
1113, 2014
Cannes, France
Cardiac MRI
& CT
http://cannes2014.medconvent.at
April
2326, 2014
Berlin, Germany
ECIO
www.ecio.org
May
0609, 2014
Nice, France
esc
www.eurostroke.eu
May 30
June 03, 2014
Chicago, USA
ASCO
www.am.asco.org
June
0206, 2014
Amsterdam,
The Netherlands
ESPR
www.espr.org
June
0912, 2014
ISCT
www.isct.org
June
1214, 2014
Amsterdam,
The Netherlands
ESTI
www.myesti.org
June
1821, 2014
Salzburg, Austria
ESGAR
www.esgar.org
July
1013, 2014
SCCT
www.scct.org
August 30
September 02,
2014
Barcelona, Spain
ESC
www.escardio.org
September
1417, 2014
ASTRO
www.astro.org
September
2630, 2014
Madrid, Spain
ESMO
www.esmo.org
November 30
December 05,
2014
Chicago, USA
RSNA
www.rsna.org
Customer Excellence
Further Information
www.siemens.com/
SOMATOMEducate
Customer Excellence
Country-specific programs
An important feature of STAR is cooperation with national radiology societies.
They are involved in defining topics
appropriate to the needs of the respective countries be it the healthcare
system, access to radiology equipment
or training on a specific subject. Representatives of the societies also play
an active role as program chairs. Attendance at STAR meetings varies greatly
with countries sending between
Enthusiastic feedback
The most convincing evidence of the
STAR programs success is the enthusiasm of its participants. Feedback is given
after each event to assess its educational value, the quality of the speakers,
and the interest of the participants in
attending future STAR meetings. Visiting
radiologists appreciate the high quality
of the conference, and the practical
knowledge that you can never find in
the literature, and the chance to learn
from the best of the best international
faculty. STAR meetings are in constant
demand and are often repeated in countries where previous programs have
been held.
To learn more about STAR please visit
the following website.
Further Information
10000
www.star-program.com
5000
-12
-02
-03
-04
-05
-06
-07
-08
-09
-10
-11
-93
-94
-95
-96
-97
-98
-99
-00
Customer Excellence
There is a
SOMATOM
Sessions for
everyone
see which
one suits
you best.
Further Information
www.siemens.com/
SOMATOM-Sessions
From January
2225, 2014,
the 8th International
Symposium for
Multislice CT
will take place
in GarmischPartenkirchen,
Germany.
Further Information
http://www.ct2014.org
Subscription
Medical Solutions
Innovations and trends in
healthcare. The magazine
is designed especially for
members of hospital management, administration
personnel, and heads of
medical departments.
AXIOM Innovations
Everything from the world
of interventional radiology,
cardiology, and surgery.
MAGNETOM Flash
Everything from the world
of magnetic resonance
imaging.
Heartbeat
Everything from the world
of sustainable cardiovascular care.
Imaging Life
Everything from the world
of molecular imaging
innovations.
Imprint
Dikraniant, T., MD, Internal Medicine DepartmentCardiology, Europa Clinics, Brussels, Belgium
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SOMATOM Sessions with a total circulation of 25,000 copies is sent free of charge
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Computed Tomography: diagnostic and therapeutic methods and their application
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It introduces from case to case new principles and procedures and discusses their
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The statements and views of the authors in the individual contributions do not
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The information presented in these articles and case reports is for illustration only
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