Somatom Session 28

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Cover Story
Iterative Reconstruction
Goes Mainstream
Page 6
FAST CARE Hits

the Bulls Eye
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Issue Number 28 / June 2011

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Science
syngo.via with the

SOMATOM DenitionFlash: A Technical
Revolution
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Clinical
Results
New 70 kV Protocol
Ensures Low Radiation
Dose in Pediatric
Patients with Congenital
Heart Disease
Page 54
Science
CARE kV How to Optimize Individualized Dose
Page 62
28
31.05.11 10:46
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27.05.11 09:07
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Content
28
Growing Demand for

Postmortem Imaging
58
Reliable Detection and Diagnoses of Gout

Using Dual Energy Acquisition Technique
Clinical Results
60
DECT: Virtual Non-Calcium Technique

Detects Posttraumatic Bone Bruise
Life
Cardio-Vascular
38 Thoracic Triple Rule-Out in Low
Dose Acquisition Technique Using
Prospective ECG-Triggering
40 SOMATOM Definition AS+ Scanning:
Coronary Artery Anomaly
42 Retrograde Filling of Occluded
Proximal Coeliac Trunk Confirmed
by CTA
Acute Care
52 Dual Energy CT: Virtual Non-Contrast Imaging of a Complicated
Renal Cyst
54 New 70 kV Protocol Ensures Low
Radiation Dose in Pediatric Patients
with Congenital Heart Disease
56 Diagnosing Pulmonary Embolism
Using High Pitch Protocols
Oncology
44 CT Examination Reveals Extremely
Small Stone in the Kidney with
SAFIRE
46 4-Phase Liver Examination with
SOMATOM Emotion 16 Unveiled
Liver Haemangioma
48 SOMATOM Emotion 16 Chest
Imaging: Ground Glass Opacity in
the Upper Right Lung
Orthopedics
58 Reliable Detection and Diagnoses of
Gout Using Dual Energy Acquisition
Technique
60 Dual Energy CT: Virtual Non-Calcium
Technique Detects Posttraumatic
Bone Bruise of the Knee
Neurology
50 SOMATOM Emotion 16: Intracranial
Head CTA Dolichoectasia of the
Basilar Artery
62 CARE kV How to Optimize

Individualized Dose
65 Choosing the kV is Now an Easy
Equation a First In-practice Report
on CARE kV
66 Dose Neutral Dual Energy Scanning
with Dual Source CT
68 Free Trial Licenses for syngo.via

are now available
69 Experience Lounge: Hands-on
Workshops at ECR 2011
69 Clinical Workshop on Cardiac CT
at Munich University
70 New Series of Live Clinical Webinars
70 FAST CARE for All Patients of syngo
Evolve Customers
71 Investment Protection for
SOMATOM CT Scanners
72 Frequently Asked Questions:
How can Dose be Reduced with
syngo.via
73 Upcoming Events & Congresses
73 Clinical Workshops 2011
74 Siemens Healthcare Publications
75 Imprint
Science
Session28_Inhalt.indb Abs2:5
27.05.11 09:35
Coverstory
Iterative Reconstruction
Goes Mainstream
Iterative Reconstruction (IR) offers radiologists the choice: lower
the radiation dose or get better image quality. IR is now becoming part
of radiological routine.
By Eric Johnson
Flat as an ironing board, flanked by

fields of waving wheat and canola,
the 10,000-person town of Winkler
could be Central Castings selection for
Anytown USA, even though it sits a
15 minutes drive north of the border in
Canadian Manitoba. Typical, average,
middle-of-the-road, with a whiff of Lake
Wobegone the fictional setting made
world-famous by (almost) local author
Garrison Keillor.
Just west of town in a former farming

field, Winklers Boundary Trails Health
Centre fits the mould. It is a general
hospital, treating the range of ailments
that afflict a regional population of some
65,000. Were not a specialized institution as such, comments radiologist Bob
McGregor, MD, here we treat all kinds
of patients, all kinds of diseases and all
regions of the body. Ordinary as that
seems on the outside, McGregor has
It moves us well along

the path of ALARA, but
it ensures that we still
can do our primary job,
which is to capture an
excellent diagnostic
image.
Bob McGregor, MD, Winklers Boundary Trails
Health Centre, Manitoba, Canada
since last September been using a technology that clearly is extraordinary:

iterative reconstruction. IR used to
be the exclusive preserve of molecular
imaging and nuclear medicine, but
thanks to ongoing increases in computing power, now it is routinely available
for CT imaging. IR is up and running in
day-to-day practice, not just here in middle America, but also in middle Europe
and middle South America as well. Joining McGregor in mainstreaming IR are
two other radiologists: Hatem Alkadhi,
MD of Switzerlands University Hospital
Zurich, and Dany Jasinowodolinski,
MD of Brazils Hospital do Corao in
So Paulo.
Down with Dosage

Between the three resides some 45
years of radiological experience, much
of it logged on what is still the industry
workhorse and standard for image
creation: filtered back projection (FBP).
And good as FBP is at generating quality
images which of course is the radiologists primary mission all three of them
recognize the rising pressure of ALARA.
As low as reasonably achievable has
Session28_Inhalt.indb 6
27.05.11 09:35
Coverstory
1 The dataset of a patient with urinary stones is acquired with SAFIRE and a very low radiation dose of 1.6 mSv. Obviously the image does not
appear noisy in spite of the low dose usage. Courtesy of University Hospital Zurich, Zurich, Switzerland
27.05.11 09:35
Coverstory
People fear
radiation, partly
because its so
mysterious,
something they
cannot feel or see.
Hatem Alkadhi, MD, MPH,
University Hospital Zurich, Switzerland
become their byword, especially in

the wake of the notorious 200809
overdosing of brain-scan patients in
the US.
People fear radiation, observes Alkadhi, partly because its so mysterious,
something they cannot feel or see.
He personally believes that the publics
angst has been hyped, not least by
sensational media reports and pseudoscientific claims. Still, he takes a bettersafe-than-sorry view toward low-dosage. In the case of, say, a 50-year-old
male who has lower abdominal pain
and needs a one-off scan, the exposure

is really not a significant health risk,
he notes. On the other hand we have
many patients for instance, those with
a lymphoma or urinary stones who
are younger and who need repeated
scans over relatively long periods.
Especially for these we should, as a
priority, keep doses as low as we can.
Since coming online last November,
this is precisely what University Hospital
Zurich has been doing with its new
Sinogram Affirmed Iterative Reconstruction, better known as SAFIRE.*,**
Alkadhi says that doses for chest scans

have tumbled nearly ten-fold from
57 to 0.60.8 mSv; for abdominal
images the exposure has been dropped
from 810 to about 1.6 mSv. With its
IRIS** system (Iterative Reconstruction
in Image Space), Canadian Boundary
Trails has also dropped exposure
mightily: McGregor reports declines of
45 percent in abdominal-pelvic scans
and 55 percent in chest imaging.
Also using IRIS, Hospital do Corao
is achieving radiation reduction of
50 percent that, according to Jasino-
* The information about this product is being provided for planning purposes. The product is pending 510(k) review, and is not yet commercially available in the U.S.
** In clinical practice, the use of SAFIRE or IRIS may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A
consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task.
27.05.11 09:35
Coverstory
wodolinski, are accompanied by 35 percent less noise.
Business as Usual
Dosage drop has come at no sacrifice to
image quality. McGregor has cataloged
same-patient images taken first with
FBP and then with IRIS, and concluded
that images are equivalent. The doctors
do find that IR changes the texture
of the body views, rendering them differently than conventional FBP. But
after a short adjustment period, one
gets used to this change, Alkadhi notes,
IRIS is a big
step forward
for us.
Dany Jasinowodolinski, MD,
Hospital do Coracao, Sao Paolo,
Brazil
27.05.11 09:35
Coverstory
Data recycling: the nous behind IR

Iterative reconstruction (IR) is the latest
in a long line of innovations to reduce
radiation dose. Reconstruction refers to
the task of building an image out of
a scans projection raw data. Iterative
refers to the method. Calculations are
repeated over and over, to zero in on
the best possible image, minus artifacts
and noise.
The fundamentals of IR have long been
known and applied in other fields, but

until recently, to use it with CT imaging
in conventional clinical medicine was
simply too time-consuming: the computer took too long to reconstruct the
images. In 2009, that changed. Newlylaunched IRIS (Iterative Reconstruction in
Image Space) was powerful enough to
plough through the iterations within
acceptable cost and time limits. SAFRIE
SAFIRE*
Image data
recon
Exact image
correction
Image Data Space
Image Data Space
IRIS
(Sinogram Affirmed Iterative Reconstruction),* released shortly afterwards, is

even more powerful. Whereas IRIS first
reconstructs a master image and then
iterates on that, SAFIRE also iterates back
through the raw data itself (see graphic),
allowing even greater reductions**
in radiation-exposure and eliminating
conventional CT artifacts.
Exact image
correction
Image data
recon
Compare
Dose reduction** or image quality improvement

Well-established image impression
Fast reconstruction in image space
Raw Data Space
Raw Data Space
Master
recon
Raw data
recon
Full raw data

projection
Compare
More powerful dose reduction than image-based methods

Superior image quality
Ready for clinical routine use with fast image reconstruction
performance of up to 20 images per second
* The information about this product is being provided for planning purposes. The product is pending 510(k) review, and is not yet commercially available in the U.S.
** In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation
with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task.
27.05.11 09:36
Coverstory
adding that quality is retained with IR,

just in a slightly different way.
Although the three doctors are using IR
to slash dose, it can also be used to
improve image quality. In cases where
imaging is typically difficult say,
bariatric patients IR can raise results,
notes Alkadhi. Depending on the specific circumstances, quality can still be
hiked with a dose decline.
Either way, IR is quickly integrated into
radiological routine. After a short settling-in period, McGregors day-to-day
work with IRIS is much the same as it
was with its FBP predecessor. So, too, is

Alkadhis with SAFIRE. Generating
images for an abdominal dataset might
take an extra 30 seconds or so, he
notes. Jasinowodolinskis IRIS takes
about one minute longer to create
images than the previous FBP system.
All the doctors expect that ever-rising
computation power will in due course
eliminate that extra processing time
altogether.
IR is definitely a worthwhile investment,
they conclude. IRIS is a big step forward
for us, offers Jasinowodolinski.
It moves us well along the path of

ALARA, says McGregor, but it ensures
that we still can do our primary job,
which is to capture an excellent diagnostic image. Ordinary aims, extraordinary
dose-reduction that will be IR.
Eric Johnson writes about technology, business
and the environment from Zurich. Formerly
he headed what is now a Thompson-Reuters
bureau and corresponded for McGraw-Hill
World News.
Leading hospitals in their countries

Boundary Trails Health
Centre
Acute services to the community are
provided by the 94-bed Boundary
Trails Health Centre, Canada. This
facility, which also acts as a regional
Hospital do Corao
The HCor Hospital do Corao is
located in the Paraiso neighborhood
in the city of So Paulo, Brazil. It
diversified its scope of services and
offers treatment in 37 medical specialties today, such as orthopedics,
UniversittsSpital Zrich
The University Hospital Zurich is
located in the center of Zurich,
opposite the University of Zurich and
the Federal Technical High School
(ETHZ). Comprised of 40 departments and institutes, both specialised and comprehensive, University
Hospital Zurich incorporates all
medical disciplines. University
health centre providing primary, secondary, and community health care

to the residents of South Central
Manitoba, is located between Winkler and Morden and serves a population of about 65,000 in the area. It
is an integral part of the services

offered by Regional Health Authority
Central Manitoba Inc. Currently,
there are approximately 450
employees working at the Boundary
Trails Health Centre.
traumatology, oncology, neurology,

urology, gastroenterology, surgery in
diverse specialties, image diagnosis,
sports medicine, and nutriology,
among others. In order to accomplish
its social mission as philanthropic
hospital, the HCor offers the most
advanced technology in cardiologic

procedures to needy children. The
HCor has the most advanced technology within the health care area in Latin
America, with a highlight for the Diagnosis Center which performs more
than 1,2 million exams annually.
Hospital Zurich is serving approximately 200,000 patients a year. With

850 beds and more than 270,000
hospital days, University Hospital
Zurich is one of the largest hospitals
in Switzerland. The Institute of Diagnostic and Interventional Radiology
offers the full spectrum of general
diagnostic and interventional radiology and features sub-specialization
expertise. It combines excellence in

research and outstanding education
with the highest quality health care.
The number of inpatient and outpatient radiology procedures totals over
100,000 annually, which are carried
out at the request of medical specialists and general physicians. The hospitals expert radiologists work with
skilled technologists and nurses.
11
27.05.11 09:36
News
1 FAST Spine delivers an automatic segmentation of the spinal canal and automatic labeling of the vertebrae.
Courtesy of University Hopspital of Zurich, Switzerland
FAST CARE Hits the Bulls Eye

FAST CARE ushers in a new era in computed tomography. After the market
launch at the RSNA 2010, the new technology platform has been up and
running in clinical institutions for several months. Experiences in Zurich,
London and Tacoma prove that FAST simplies and accelerates workows,
and reduces radiation dose even further thanks, in particular, to the new
CARE kV technology.
By Ingrid Horn, PhD
The latest generation SOMATOM Definition AS the high-end, single-source CT

scanner from Siemens has been delivered with the innovative technology
platform FAST CARE since March 2011.
CARE (Combined Applications to
Reduce Exposure) unite all technologies
currently used by Siemens to reduce radiation doses in a unique manner. Although
enormous progress in terms of radiation
protection and dose reduction has been

made in the last 15 years, reducing
radiation doses in computed tomography even further remains an issue for
Hatem Alkadhi, MD. It is assumed that
all additional radiation is unhealthy
for patients. As a result, we aim to continue avoiding unnecessary radiation,
exploiting the technical potential to
reduce doses for patients to its fullest,
explains the Zurich-based radiologist.

He researches at the Institute for Diagnostic Radiology based at the University
Hospital Zurich, Switzerland, a selected
test center for CARE.
Over a six month period, Alkadhi and his
team have performed an in-depth analysis of CARE kV technology in clinical context. CARE kV is a breakthrough addition
to CARE Dose4DTM, a tool which already
27.05.11 09:36
2A
2B
2 These two images show the abdomen scan in 2009 (Fig. 2A) with 140 kV and as follow-up examination in 2011 (Fig. 2B) with CARE kV and
only 100 kV. Both images have the same image quality although using lower kV in 2011.
allows maximum image quality with

minimum dose for each patient, thanks
to real-time dose modulation. So whats
the advantage of CARE kV? The answer
is clear: in addition to the current
modulation familiar from CARE Dose4D,
CARE kV also optimizes CT examinations
and the administered dose via the automatic selection of suitable voltage in
line with pertinent diagnostic issues and
the patients physique. The radiologist
explains the situation as follows: We
used to be confronted frequently with
the problem of whether we should
reduce the tube voltage or not, and to
what extent. And, if so, whether the
reduced image quality jeopardizes a reliable diagnosis. We often used parameters such as body weight or body mass
index to assist us in the decision-making
process. However, the question of which
body weight should necessitate a reduction in tube voltage and radiation dose,
and the extent of the said reduction
proved divisive. By contrast, CARE kV
plans the examination for us in advance
with an optimized radiation dose, usually decreasing this so that the patient
ultimately receives less radiation.
Meanwhile, the radiologists in Zurich
have found scientific evidence for the
reduction in radiation dose via CARE kV.
They carried out a study of vascular
patients who require repeated CT scans
within the context of follow-up treatment. Material pre-dating the launch of
CARE kV is available concerning these
patients. This permits an effective
comparison of radiation dose and image
quality with and without the use of

CARE kV. They are also currently collecting relevant data for the CT examination
of the neck region with regard to bone
and soft tissue. Alkadhi summarizes:
The additional dose reduction is huge
in the case of all patient groups examined. He indicates a dose reduction
of between 20 and 30 percent for all
evaluated patients. If circumstances
are favorable, reductions of up to 50
percent in scans of the neck region are
even possible in isolated cases.
Olivia Egan in London, England, is also
a fan of the CARE package. She holds
the post of CT Superintendent Radiographer at the Chelsea and Westminster
Hospital and views the issue from a different perspective, commenting: CARE
gives my technical team a high degree
of security as regards dose reduction.
Olivia Egan views the easy compatibility
of CARE kV with FAST as an additional
benefit. FAST (Fully Assisting Scanner
Technologies) stand for all programs
designed to simplify scanning workflows. She goes on to outline a further
benefit of FAST Adjust, namely that it
allows less experienced technicians on
the roster to achieve the highest quality
images with the lowest radiation dose
possible. FAST Adjust ensures that scan
parameters such as scan time, pitch or
tube current can be set correctly with
just a single click. In just a few weeks,
these simple operations have become
routine for the technologists in London.
Employees at MultiCares Tacoma General Hospital trauma service in Tacoma,

Washington, USA, highly appreciate how
FAST (Fully Assisting Scanner Technologies) takes care of the finer details at the
CT and accelerates workflows in the process. MultiCare Imaging Manager, Joe
Larson is full of praise for the FAST Spine
technology: FAST Spine gives us an
enormous time advantage in the case of
suspected spinal column injuries. The
program marks the vertebrae within a
predetermined scan area of the spine
automatically and calculates the position of vertebrae and disks for an anatomically correct image reconstruction.
Up until now, this process was performed manually by a technologist vertebra by vertebra, which easily took a
half-hour or more. Larson explains,
FAST Spine accelerates the entire process automatically and naturally. The
images are produced immediately, so
that the surgeon can evaluate them in
real time. This allows the trauma surgeon to decide more quickly whether to
operate. FAST Spine also reduces the
time normally placed on CT technologists, because quick action is essential in
trauma cases. Both physicians and CT
technologists at Tacoma General Hospital point to FAST CARE as essential to
improving their working environment.
Ingrid Horn, PhD, studied biology and biochemistry. She is an expert in science communications and an experienced medical writer.
www.siemens.com/fastcare
13
27.05.11 09:36
News
New SIERRA Expert Sub-Committee Focusing on

Pediatric Dose Reduction Established
Within SIERRA, Siemens expert panel on dose reduction, a new group,
concentrating on dose savings in pediatric radiology, has been formed.
By Stefan Ulzheimer, PhD, and Heidrun Endt, Computed Tomography, Siemens Healthcare, Forchheim Germany
The latest dose reduction features

like a 70 kV mode will especially
benet our youngest patients.
But it is also important that the
equipment is used in an optimal
fashion ().
Elliot Fishman, MD, Johns Hopkins University Hospital, Baltimore, U.S.
The Siemens Radiation Reduction Alliance

(SIERRA) was founded in June 2010. Sixteen radiologists, physicists and cardiologists, renowned for their scientific
research on dose in medical imaging,
joined the expert panel to set up tasks to
determine how dose can be further
reduced.
When imaging children, dose becomes
even more important as children are
more sensitive to radiation. Researchers
in this special field of radiology have
joined together in a SIERRA sub-committee. This sub-committee will not only
concentrate on new technologies but
equally important on education for
pediatric imaging. Siemens scanners provide a lot of innovative technologies to
reduce dose, so education should focus
on these technologies, their functionality
and optimal application in daily clinical
practice. Marilyn Siegel, MD, Mallinck-
rodt Institute of Radiology, St. Louis, U.S.,

will head this new group within SIERRA.
Siegel joined the SIERRA panel in June
2010 as did Elliot Fishman, MD, Johns
Hopkins University Hospital, Baltimore,
U.S . Additionally both will now support
the efforts concerning pediatric radiology. CARE kV and CARE Child, the most
recent technologies that come with Siemens SOMATOM Scanners, were developed and tested in close collaboration
together with Siegel.
For Siemens, dose reduction, while delivering excellent image quality in radiology
and during interventional procedures,
has always been a top priority. Innovative
CARE (Combined Applications to Reduce
Exposure) features are an integral part of
all Siemens systems. Using lower tube
voltages in CT can dramatically reduce
dose, especially in small patients and
children1. However, this potential has not
been widely exploited because a lot of

related conditions have to be observed.
As defining the ideal tube voltage for
each patient was not an easy step to
make, this parameter was seldom
adapted to the current patient and examination in clinical practice. Now CARE kV
automatically selects the optimal tube
voltage based on the individual patient
and application. Furthermore, with CARE
Child, Siemens provides the industrys
first-ever scans with voltage as low as
70 kV. Combining both, CARE kV and
CARE Child, leads to a dramatic reduction
of dose, especially in pediatric patients.
Fishman states: The latest dose reduction features like a 70 kV mode will especially benefit our youngest patients. But
it is also important that the equipment is
used in an optimal fashion. Therefore, Im
happy to work with Siemens and my
peers on optimizing protocols and on
27.05.11 09:36
News
education programs to make sure that

new technology is not only developed
but also adopted as fast and as broadly
as possible.
One of the first steps of the newly established sub-committee will be a publication that summarizes the possibilities of
dose reduction for pediatric patients.
Other activities in terms of best practice
sharing are planned, in order to transfer
the expert advice to as many radiologists
as possible who perform CT examinations
in children.
[1] Siegel MJ et al. Radiation dose and image quality in
pediatric CT: effect of technical factors and phantom
size and shape. Radiology. 2004, Nov; 233(2):51522.
The members of the SIERRA sub-group focusing on pediatric

imaging are Marilyn Siegel, MD, Elliot Fishman, MD, and
Joseph Foss, MD, (Arnold Palmer Hospital for Children & Women,
Orlando, U.S.). Additionally, Cynthia Rigsby, MD, (Childrens
Memorial Hospital, Chicago, U.S.) and Robert Gilkeson, MD,
(University Hospital Case Medical Center, Cleveland, U.S.) have
joined the sub-committee. They will all help to optimize the use
of leading edge technology in daily clinical practice, sharing
their knowledge in this special field of radiology. The formation
and follow-up of this expert panel with its sub-committee indicates
once more, Siemens ongoing efforts to reduce dose to the lowest
extent possible.
www.siemens.com/low-dose-CT
Expert Advice on Dose Reduction

Always at Your Fingertips
By Heidrun Endt, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Siemens SOMATOM scanners come with

innovative technologies for dose reduction, making low dose CT examinations
possible for every patient. Now a new
series of flyers is available which
includes advice on how to reduce dose
even further: experts from Siemens CT
Research & Development department
share their knowledge about using these
technologies in the most efficient way.
How to reduce dose in Pediatric CT
imaging is one of the first flyers out of
this series. As children are more sensitive to radiation than adults, it is of
utmost importance to pay attention
when imaging pediatric patients. This
flyer includes tips and tricks* to guide
the user from patient preparation to
protocol selection and application of
features such as CARE Dose4D.
Two more flyers are available: How to
reduce dose in Cardio CT, suitable for
the SOMATOM Definition AS Family

and another one for the SOMATOM
Definition Flash, both with syngo CT
2011. Which is the most appropriate
scan mode for the patient and which
reconstruction parameters should be
chosen? These flyers provide all the
information necessary in daily clinical
practice.
As the series continues, more flyers will
be available on the latest technologies,
for example CARE kV.
n
To have expert advice on dose reduction
always at the fingertips, flyers can be
ordered via the Customer Information
Portal, Siemens Internet.
*Appropriate for syngo CT 2010 or earlier.
www.siemens.com/CT-infoportal
Training & Education;
Order your training material
How to reduce dose in Pediatric CT

imaging and Cardio CT: three flyers out
of a new series are available providing
expert advice on dose reduction.
Somatom28_News_Sierra_Dose.indd 15
15
31.05.11 11:07
News
Faster Abdominal Aortic Stent Planning with

syngo.via and the CT Cardio-Vascular Engine
By Philip Stenner, PhD, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Abdominal aortic aneurysms (AAA) pose

a serious threat to patients as a rupture
will cause abdominal bleeding which is
a life-threatening condition. Ruptured
aneurysms are responsible for roughly
9,000 annual deaths in the US.1 With an
occurrence of 4%-7% in adults of 65
years and older, AAAs are a common
disease worldwide.2 Up until the late
80s, the conventional treatment was an
open repair of the aorta. The treatment
of AAAs was revolutionized in 1991 by
the first endovascular aortic repair
(EVAR).3 With this technique, a stent is
inserted through a catheter to the place
of the aneurysm and expanded to stabilize the surrounding vessel. Today, compared to an open repair, the risks for the
patient are dramatically reduced, leading to 30-day mortality rates of only

1.2%.4
Crucial for the success of an EVAR procedure is correct pre-procedural planning
to assess the anatomy and optimal stent
size for each patient. With its high spatial resolution, Computed Tomography
(CT) is the method of choice. With
SOMATOM Scanners on the scanner side
and syngo.via on the post-processing
side, Siemens Healthcare provides
an excellent solution for the planning
of EVAR procedures. The software
syngo.CT Vascular Analysis* provides
an efficient and reliable assessment of
the abdominal aortic anatomy.
Due to comprehensive automated pre-
processing, like automated bone and

table removal, an immediate vascularonly view is provided. The Autotracer**
automatically segments and labels the
vessels even before the case is opened.
The aorta is displayed in a curved planar
reformation and the centerline is automatically created providing the basis for
important length measurements.
Since 95% of aortic aneurysms are infrarenal, i.e. below the ostia of the renal
arteries, syngo.CT Vascular Analysis
provides a dedicated stent planning
template for these cases (Fig. 1). The
template guides the user through measuring the length and diameters of the
aneurysm, the aorta, and the left and
right illiac arteries. The distance of the
aneurysm to the renal arteries and to
the illiac bifurcation are also included.
Along with the registration of all measurements in the Findings Navigator, all
diameter measurements are automatically saved in the stent planning template which is easily accessed in the
report editor. The automation greatly
facilitates the workflow and allows for a
reliable assessment of abdominal aortic
stent parameters thus providing a sound
basis for EVAR procedures.
1 Macari M, et al. Radiology 2006,

Vol. 241, No. 3, 908914.
2 Katzen BT, et al. Circulation 2005;
112: 16631675.
3 Parodi JC, et al. Ann Vasc Surg. 1991;
5: 491499.
4 Prinssen M, et al. N Engl J Med 2004;
351:16071618.
*syngo.CT Vascular Analysis is available either
as a stand-alone software package or as one of
several software and hardware features in the CT
Cardio-Vascular and Acute Care Engines.
1 The success of endovascular aortic repair strongly depends on correct pre-procedural
planning. syngo.via and the CT Cardio-Vascular Engine provide a powerful means for
efficient and reliable assessment of the abdominal aortic anatomy and all parameters
necessary for stent planning.
**Available in the Acute Care Engine Pro and CT

Cardio-Vascular Engine Pro
www.siemens.com/ct-cardiology
27.05.11 09:36
1 Assessment of tumor change over time is essential for efficient oncological follow up. Being able to decide about response, stable or progressive disease determines the decision for therapy continuation or change in the oncological regimen. Radiologists can benefit vastly from having
the right diagnostic software like syngo.via and the CT Oncology Engine at their disposal.
syngo.via Powers CT Oncology Engine for

Oncological Assessment
By Jochen Dormeier, MD, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Oncological diagnosis and assessment of

effectiveness of cancer therapeutics
make use of standards like RECIST 1
(response evaluation criteria in solid
tumors) and standards set by the WHO
(World Health Organization).2 Therefore,
easy access to the right measurement
tools as well as dedicated reporting capabilities are essential to report on response
or progression comparing the most current with the baseline examination.
Either in parallel to conventional reporting from PACS or by reporting directly
using the CT Oncology Engine, syngo.via
facilitates this assessment by bundling a
variety of dedicated functionalities for
oncological reading.
Even before the case is opened,
syngo.via works in the background to
pre-fetch relevant patient image data
from previous examinations. In addition,
for lung cases, computer aided detection,
and for virtual colonoscopy cases, polypenhanced viewing algorithms prepare
the cases as second reader tools its
results being immediately available.

For comparison with previous examinations, the current and baseline images
are loaded into the reading physicians
preferred layout. The datasets are automatically registered so that the same
anatomical areas are displayed in both
datasets while scrolling through the
scans. If measurements have already
been performed with syngo.via for the
baseline, these measurements are available in the findings navigator for easy
call-up and comparison with the specific
lesion in the current scan. As soon as the
lesion in the baseline and the current
examination are measured and linked,
the report provides relevant information
about RECIST and volumetric changes of
the tumor size.
In contrast to conventional 2-dimensional
PACS based reading, syngo.vias approach
of working with data volumes and utilizing automated segmentation algorithms
provides access to reproducible results for
volumetric assessment of tumor burden.
Especially for volumetric approaches,

scientific publications have shown
significant deviations in disease assessment compared to RECIST and WHO
and requests for large studies have been
formulated.3 Here the CT Oncology
Engine immediately provides the right
tools at the fingertips.
1 Eisenhauer EA et al. New response evaluation
criteria in solid tumors: revised RECIST
guideline (version 1.1). J. Eur J Cancer. 2009
Jan; 45(2): 228-47
2 World Health Organization, WHO Handbook for
Reporting Results of Cancer Treatment, Offset
Publication No. 48, Geneva, 1979
3 Prasad SR, et. al. CT tumor measurement for
therapeutic response assessment: comparison
of uni-dimensional, bi-dimensional, and
volumetric techniques-initial observations.
Radiology 2002; 225(2): 416419
www.siemens.com/ct-oncology
17
27.05.11 09:36
News
SOMATOM Emotion The Most Popular CT

in the World* Now with IRIS**
By Rami Kusama, Computed Tomography, Siemens Healthcare, Forchheim, Germany
The success story of over 7,000

SOMATOM Emotion installations
continues. To meet present and future
demands for higher quality and costefficient healthcare, Siemens has introduced IRIS Iterative Reconstruction in
Image Space at this years ECR 2011
on the SOMATOM Emotion 16 as well
as the SOMATOM Emotion Excel
Edition. With the introduction of IRIS on
the worlds biggest installed base, this
compact scanner is set to offer not
only improved image quality or lower
dose** for better patient care, but will
also help users to stay at the forefront

in an increasingly competitive and
rapidly changing healthcare market.
There is no doubt that medical imaging
saves lives and thus its utilization has
increased immensely over the years.
With its increased utilization, radiation
dose and radiation dose reduction have
become one of the most discussed
topics in and outside of the imaging
community.
As an innovation leader in dose reduction, Siemens has long applied CARE
(Combined Applications to Reduce
Standard FBP
Raw data
recon
Limited dose reduction

Ultra-fast recon without iterations
IRIS
Image data
recon
Image
correction
Significant dose reduction

Image quality improvement
Fast recon in image space
Dose savings may vary according to body region. Data on file.
Dose reduction with CT has been limited by the currently used filtered back projection reconstruction algorithm as displayed on the left. Using IRIS results in increased image quality or dose savings
for a wide range of clinical applications.
Exposure), a comprehensive approach

to all areas of diagnostic and interventional imaging. Today, the Siemens
CARE standard brings together a wide
variety of advanced technologies and
applications to meet the needs of
patients and physicians for appropriate
radiation dose with the best possible
outcomes for diagnoses and interventions.
In addition, depending on the system
configuration, IRIS can also be added
retrospectively for already installed
SOMATOM Sensations as well as
SOMATOM Emotion 16-slice configurations.
Bringing IRIS on the Emotion, our
widest installed base, means offering
low dose to the widest possible patient
population, says Peter Seitz, Vice
President Marketing CT.
The SOMATOM Emotion produces clinically excellent results, while reducing
ongoing costs, and protecting business
through superb system reliability.
Siemens also continues to offer a
consistent software platform, syngo,
throughout all product lines to make
training faster, more efficient, and less
expensive to facilities worldwide. If you
are a radiologist, technologist, or financial administrator, you will also enjoy
the knowledge that you own the worlds
most popular CT scanner*, now with IRIS.
* Based on the number of systems worldwide.

** Expected availability summer 2011.
In clinical practice, the use of Iterative Reconstruction IRIS may reduce CT patient dose depending on
the clinical task, patient size, anatomical location,
and clinical practice. A consultation with a radiologist and a physicist should be made to determine
the appropriate dose to obtain diagnostic image
quality for the particular clinical task.
www.siemens.com/
SOMATOMEmotion
27.05.11 09:36
News
The new
SOMATOM Spirit
is equipped
with a gantryfront display.
The New SOMATOM Spirit Modern. Easy. Reliable.

By Florian Belohlavek, Computed Tomography, Siemens Healthcare, Forchheim, Germany
The new SOMATOM Spirit sets standards

in the segment of entry-level CT.
Siemens sub-second, multi-slice CT
scanner stands out due to simplicity and
excellent reliability without loss of
quality. Making state-of-the-art CT
affordable is one of the key goals in the
Siemens CT vision. With the SOMATOM
Spirit a modern, easy-to-use and reliable multi-slice CT, Siemens provides an
adequate answer for day-to-day examinations in clinical practice, says Peter Seitz,
Vice President Marketing, Business Unit
CT, Siemens Healthcare. A combination
of well-proven components and modern
features like a gantry-front display, fast
computer hardware and an adjustable
patient table are setting new standards in
the entry-level segment.
Modern
The SOMATOM Spirit is a synonym for
efficient system design. This philosophy
is easily recognized in the slim and
highly efficient gantry that has become
the benchmark in the CT industry.
And, starting with the 2011 models, the
SOMATOM Spirit comes equipped with a
gantry-front display showing parameters
such as tube current, tube voltage, scan

time, table position and gantry tilt, all
particularly useful, for example, for
interventional and other procedures.
Equipped with the industry leading
detector material UFC,TM the SOMATOM
Spirit offers a segment-leading, highcontrast resolution of 15.5 lp/cm at 0%
modulation transfer function (MTF).
The SOMATOM Spirit offers a comprehensive spectrum of CT applications to
perform all the 2D and 3D functions that
are required in daily routine. Additionally, a wide selection of optional features
is available to equip the scanner for special needs, for example Neuro Perfusion,
Dental CT or automated bone removal.
Easy
Siemens has designed a tailor-made,
ease-of-use, syngo user interface for the
SOMATOM Spirit. A follow-me approach
is used that quickly takes the user step
by step through all the procedures
required for a successful scan. The user is
logically guided through procedures for
patient registration, protocol selection
and patient positioning in preparation for
the scan. Standardized procedures and
protocols make it easy for all staff members to achieve standardized results. Also
important for rapid and reliable workflow
is the state-of-the-art computer hardware
with an excellent recon speed of five
images per second. In addition, the new
patient table facilitates easy patient positioning and contributes to efficient and
profitable workflow.
Reliable
Siemens believes that the only time that
can be afforded is UPTIME, so engineering
and production efforts emphasize this
goal. Results from the almost 2,000 systems installed around the globe indicate
that the SOMATOM Spirit has a 99.6%*
UPTIME rate and regularly achieves 10,000
scans and more without a single glitch.
Addressing all needs of an affordable
multi-slice CT used in daily routine, the
SOMATOM Spirit is modern, easy and reliable. A system that can be trusted.
* Results may vary. Data on file.
www.siemens.com/
SOMATOMSpirit
19
27.05.11 09:36
News
Successful RSNA 2010 for

Siemens Research Partners
Researchers from the Medical University of South
Carolina (MUSC) were especially successful and
received three awards from the conference committee.
Thomas Henzler, MD, Prof. Joseph Schoepf,

MD, (Director of Cardiovascular Imaging and
CT Research and Development, MUSC) and
Markus Weininger, MD, presenting the certificates for their successful, prize-winning
research.
By Heidrun Endt and Stefan Ulzheimer, PhD, Computed Tomography, Siemens Healthcare, Forchheim Germany
MUSC was awarded trainee research
prizes in three different categories:
chest radiology, emergency imaging and
cardiac. The research for these three
outstanding contributions was done on
Siemens SOMATOM scanners.
Triple-rule-out examinations obtained in
patients with acute chest pain were
further analyzed. Matthias Renker, BSC,
presented a study where an evaluation
with an automated detection algorithm
for lung nodules was added to the clinical reading as some of these lesions are
overseen during emergency imaging.
Thomas Henzler, MD, is working at the

University hospital of Mannheim and
currently visiting MUSC as a research
fellow. He presented that CT examinations in cases of acute pulmonary embolism can additionally be used to assess
signs of right ventricular strain. Thus the
expensive measurement of a specific
biomarker for right ventricular dysfunction might no longer be necessary.
Cardiac CT with the SOMATOM
Definition Flash enables an overall
assessment in patients with coronary
artery disease: morphology of the ves-
sels, cardiac function and perfusion.

Markus Weininger, MD, concluded that
one examination may provide all the
information that is necessary for the
diagnosis of coronary artery disease.
Thus SOMATOM scanners are used for
scientific research very successfully providing innovative technology and software features that improve patient care.
www.rsna.org
SOMATOM Denition Flash the Gold Standard in CT

By Peter Aulbach, Computed Tomography, Siemens Healthcare, Forchheim, Germany
A system or device is called the gold
standard, if it is the best and most successful for the required task. The ECRI
is an US non-profit organization that
researches quality, cost effectiveness
and patient safety of medical equipment.
They serve more than 5,000 members
including hospitals, public and private
payers and government agencies. In the
case of CT, they assessed all relevant
competing technologies in the market
and compared their capabilities for the
most common tasks in CT.
Their conclusion was that only the
SOMATOM Definition Flash provides fast,

low-dose scanning that minimizes the
effects of patient movement, making it
especially valuable in trauma, pediatric
and cardiac cases. Special advantages are
amongst many others:
A Cardiac Flash mode requiring very
low dose
Excellent, reliable image quality at all
heart rates
Tripe rule-out examination for chest
pain, in less than one second
The Flash scan mode is a viable alternative, particularly for patients unable
to hold their breath or those at low
cardiac risk
The combination of fast imaging for
uncooperative children (Flash mode)
and dose reduction makes the system a
very useful tool for pediatric imaging
The Adaptive 4D Spiral that enables
good brain and excellent body perfusion

imaging with widest coverage of any
evaluated systems of up to 48 cm
The effective dose for a Dual Energy
scan that is the same as for a conventional single energy scan
Excellent image quality and dose
management
Noise reduction, with iterative reconstruction techniques for dose reduction
Whole-body studies that are completed
in under five seconds
Studying the ECRI1 results one could
conclude that the SOMATOM Definition
Flash is the best and most successful
technology for CT routine and advanced
tasks thus rightly defining the gold
standard in CT imaging.
www.ecri.org
ECRI Institute Report, HEALTH DEVICES, MARCH 2011
27.05.11 09:36
News
International CT Image Contest 2011

Siemens Repeats a Previous Success
Excellent image quality is essential for accurate clinical diagnostics.
Additionally, another important ambition should be the lowest possible
radiation exposure for the patient.
By Michaela Spaeth-Dierl, medical editor, Spirit Link Medical, Erlangen, Germany
Siemens Healthcare wants to support its

customers in making efficient use of
hardware and software to reduce dose on
CTs and in sharing their experiences with
colleagues and other interested audiences. Therefore, the first International
CT Image Contest was inaugurated in
2010 with great success. Almost 300
users of Siemens CT scanners from about
30 countries submitted their best clinical
images taken with the lowest possible
radiation dose. There was even a fan
community on Facebook with more than
1600 members, who discussed the
images submitted. In addition, internet
users were able to publically vote for their
favorite picture. The internet page
devoted to the contest received 17,000
hits within 6 months. Following up on

this amazing interest, Siemens Healthcare
has now announced the International CT
Image Contest 2011. The contest was
officially launched at the European Congress of Radiology (ECR) 2011 in Vienna
on March 3rd. Siemens customers who
work with a Siemens SOMATOM CT scanner of any performance class will have
the opportunity to compete for the title
of the best image in seven categories.
The submissions will be evaluated by an
international top-class jury made up of
acknowledged experts in the following
categories: Cardiology, Angiography,
Dual Energy, Pediatrics, Trauma,
Neurology and areas of clinical routine
including Thorax, Abdomen and Pelvis.
Images can be submitted until

September 18th, 2011.
The contest will close with an awardwinning ceremony at the RSNA in
Chicago at the end of November. In
addition, monthly winners will be
picked by the expert jury. Each monthly
category winner will receive a certificate
as low-dose CT expert.
Terms and conditions of entry for the
International CT Image Contest 2011
can be obtained here:
www.siemens.com/image-contest
You can be a fan of the International CT Image Contest 2011 at
www.facebook.com/imagecontest
Following up on
the amazing
interest in the
first International
CT Image Contest
in 2010, Siemens
Healthcare has
now announced
the International
CT Image Contest
2011.
21
27.05.11 09:36
News
Data Analysis Aids Dose Reduction with the

New CARE Analytics
By Tiago Campos, Computed Tomography, Siemens Healthcare, Forchheim, Germany
The measurement and calculation of

radiation dose is an important topic for
efficient dose management, not only in
computed tomography (CT) but also for
all areas where X-ray exposure is utilized. Siemens provides tools such as
DICOM Dose Structured Reports (DICOM
SR) and CARE Analytics.*
The DICOM SR contains comprehensive
data for each irradiation event, the
accumulated dose (CTDI and DLP) in CT,
and information about the context of

the exposure. The data is provided in
DICOM standard format that can be sent
to any system which receives, stores
and/or processes dose information, such
as conventional PACS or workstations.
In order to evaluate and analyze the
information contained in the DICOM SR
files, Siemens provides a new, free tool:
CARE Analytics.
CARE Analytics allows dose received by
patients during an examination with

computed tomography systems, X-ray
and fluoroscopy devices as well as
angiography systems, to be analyzed
and evaluated. Hence, it can help
radiologists and other clinicians, for
example, to optimize their scan protocols, and to work with reduced dose.
This software tool can be installed on
any office computer connected to the
hospital network and is able to retrieve
and query SRs from DICOM nodes
directly or import them from a USB
device. Dose reporting data can then be
exported and analyzed with standard
tools, such as Microsoft Excel.
With the use of CARE Analytics, medical
staff is able to compare dose given
during different examinations in order
to further optimize the scan protocols.
In addition, it is possible to ascertain
the dose a patient has received on different systems over a series of examinations. Dose reporting between multiple
hospitals is also possible. The increased
transparency lets clinicians improve
their working practices and be more
sparing with the dose given than in
the past. Contact your local Siemens
representative in order to obtain CARE
Analytics.
* further details in: SOMATOM Sessions 27, page

6871
www.siemens.com/ihe
At Siemens, one of the core responsibilities is to provide medical institutions with solutions that enable them to further lower radiation dose. CARE Analytics is yet another tool
to help achieve that goal.
27.05.11 09:36
News
The coupling of scanner and injector in

combination with predened contrast
protocols promotes fast
and effective workow.
The handling, combined with the Medrad
injector, is simple and
dependable.
SYNC.
START
Prof. Christoph Becker, MD, and Barbara

Wieser, Department of Radiology, LudwigMaximilians-University, Campus- Grosshadern,
Munich, Germany
CARE Contrast III

By Florian Belohlavek and Ute Feuerlein, Computed Tomography, Siemens Healthcare, Forchheim, Germany
One of the biggest challenges in computed tomography is a high quality contrast scan. In the year 2005, Siemens
Healthcare took an important step by
introducing a solution for bolus injection
coupling. By synchronizing the scan and
contrast media injection, the bolus injector workflow could be simplified and
adapted to the needs of the clinical environment. Even if only one technician is
present, the reading physician is able to
perform high quality contrast scans on
the one hand and handle the simultaneous bolus injection on the other. This
unique CARE solution is based on the
international standard for the communication between CT and injector the
CANopen application profile for medical
diagnostic add-on modules.
In 2009, another important milestone
was passed with the introduction of the
second version of CARE Contrast. CARE
Contrast II facilitates contrast enhanced
clinical workflow by synchronizing CT

scan and contrast media injection using
a single button control from either the
scanner or the injector. In addition, the
injection parameters are automatically
transferred to the patient protocol,
the e-logbook and to the Modality Performed Procedure Step (MPPS) thus
completing the data for the examination. With this, no separate documentation is needed, resulting in significant
workflow improvements: e.g. the injector information is available from the picture archiving and communication system (PACS) when reading the images or
accessible from the hospital information
system (HIS) / radiology information
system (RIS).
A new and higher level of injector coupled scanning has now been reached
with the latest Siemens innovation CARE
Contrast III. It is based upon the highly
integrated CANopen, class-4 standard
for bi-directional communications that

can reach a new level of improved contrast workflow. In addition to all features
of the earlier versions, CARE Contrast III
is equipped with the latest innovations:
For the first time, contrast protocols can
be defined and managed on the scanner
console and transferred to the injector.
By operating contrast management on
the scanner console, a combination of
scan and contrast protocols in integrated examination protocols is possible. Protocols on the scanner can be
adjusted to cover the frequently used
cases in the clinical environment and
can be transferred to other scanners
with the same setup. CARE Contrast III is
available for the SOMATOM Definition
AS and Definition Flash family with the
latest scanner software version.
23
27.05.11 09:37
News
Synergies in CT
For Better Patient Care
By Stefan Ulzheimer, PhD, Computed Tomography,
Medical progress very often relies on

teamwork. Both Bayer Healthcare and
Siemens Healthcare continuously strive
to improve CT quality at the lowest possible radiation levels. This happens by
combining technological and pharmaceutical expertise. Both companies are promoting the exchange of knowledge
among the most experienced CT users
worldwide and through researching and
working together.
This is done by sharing relevant research
results, joint scan protocol development,
attendance at expert panels, by organizing joint symposia and by publishing podcasts with medically interesting cases.
Furthermore courses at the Imaging

Science Institute in Berlin (part of the
Charit, the biggest University Hospital
in Europe) are offered where radiologists
receive hands-on training as well as
STAR (Specialized Training in Advances in
Radiology) Workshops, an international
educational forum for practizing radiologists. So far, STAR meetings have been
held in 36 countries with more than
26,000 radiologists attending.
A recent highlight of these joint activities
was the lunch symposium at ECR 2011.
Here experts like Michael Lell, MD,
Marilyn Siegel, MD, Joseph U. Schoepf,
MD, and Andreas Mahnken, MD, shared
Almost 800 participants attended the BayerSiemens Lunch Symposium at ECR 2011.
their extensive research on iterative

reconstruction, pediatric dose optimization, and contrast media administration
with almost 800 medical specialists
attending. Even the exhibition at
the Bayer Communication Center in
Leverkusen was a winner with over
5,000 visitors from the general public.
www.star-program.com
SOMATOM Sessions
Only One Click Away
By Sandra Kolb, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Siemens Computed Tomography magazine,

SOMATOM Sessions, is now available as online
version: www.siemens.com/somatom-sessions.
Reading magazines attentively is time

consuming and difficult for a radiologist
in an active, successful practice.
Would it not be great to read about the
exciting possibilities with Siemens CT
on an iPad? Scrolling through the latest
news on the Blackberry at the airport?
Or discussing an exceptional case study
with a colleague directly at the office
PC? Now we have the answer: the
online version of SOMATOM Sessions.
The online magazine is now only one
mouse click away for reading or reference 24/7.
All articles and case studies can be
browsed by specialty and a smart overview of all the hot topics like low dose
in computed tomography and training
possibilities is offered. And readers can

now leave a comment, so its feasible to
interact with the editorial team or other
readers. It is also possible to subscribe
and get the latest news via email and
if desired forward interesting articles
to a friend by email or through social
networks.
The printed Sessions will continue to
be published twice a year. The printed
copies can be ordered on the online
sessions homepage.
Visit us now and enjoy.
www.siemens.com/
somatom-sessions
27.05.11 09:37
News
Five Areas of Ecological Improvements in CT

By Johann Russinger, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Siemens has a long history of ecological

improvements. Recently Siemens targeted
primarily five areas: ecological manufacturing, radiation minimization, life-cycle
extension, refurbishing and recycling.
Development of used energy for a thoracic scan

120%
100%
Ecological Manufacturing
Dose
Siemens concern for environmental safety

begins long before the first scan in the
planning phase together with R&D and
during prototype development. One
example is taken, lead is no longer used as
counter-weights and has been eliminated
in many other areas in newer models. All
materials are selected keeping ecological
aspects in mind. In short, potential ecological burdens are eliminated for the
entire life-cycle of the system.
100%
80%
60%
70%
-45%
40%
39%
20%
0%
SOMATOM Sensation 16
SOMATOM Denition
2003
2006
SOMATOM Denition Flash

2009
Dose reduction for a typical Cardio scan
Radiation Minimization
120%
Siemens SOMATOM Definition Flash was

designed primarily to make CT exams
much healthier for patients using less
radiation dosage than previous systems
e.g. less than 1 mSv for cardiac examinations. In this context, the SOMATOM
Definition Flash requires 45% less energy
for a standard thorax scan and 85% less
energy for a cardiac Flash scan compared
to previous models.
100%
100%
Dose
80%
-50%
60%
40%
50%
-70%
20%
15%
0%
SOMATOM Sensation 16
SOMATOM Denition
2003
2006
Life-cycle Extension
The third area of ecological responsibility
involves life-cycle extension in other
words, extending the useful life of the
scanner before it needs to be replaced
with a newer model. Along with a wide
selection of software updates, Siemens
offers Evolve, a long-term and financially
attractive update program designed to
keep existing systems up-to-date and
therefore extending their useful lives.
-30%
shipped back to the factory where they

are refurbished and re-sold with a new
equipment warranty.
Recycling
Last but not least, recycling systems at

the end of their life-cycle are very important. A possibility for responsible conduct
comes when a system simply must be
recycled. And here our story has come
Refurbishing
full circle. All possible measures were
When a customer becomes ready for a
taken into account in the beginning
new system for his radiology department, when the system was designed to make
Siemens offers a trade-in program for their recycling easy years later:
All substances contained in the product
existing scanner. Complete CT systems
and its packaging are documented.
and their components are dismantled and
SOMATOM Denition Flash

2009
Plastic parts are labeled for recycling.

Disassembly instructions for highquality recycling are available.
Product take-back is carried out
according to strict EU directives.
More than 97% of the used materials
can be recycled.
The environmental product declaration is available for download via
internet.
www.siemens.com/healthcarenews
25
27.05.11 09:37
News
The SOMATOM Denition Flash

Helps to Deal with Everyday Clinical
Challenges
With the SOMATOM Denition Flash, highest clinical requirements can
be met. Six recently published scientic papers show the capabilities of
the system in pediatric imaging and when using iterative reconstruction.
By Heidrun Endt, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Imaging pediatric patients

In the field of pediatric radiology, special
conditions and clinical needs have to
be considered. Three scientific papers
report on CT examinations obtained with
children, proving the capabilities now
brought into routine clinical practice with
the system.
A group of researchers from France
examined 30 children up to six years old,
suffering from congenital heart disease
(CHD). Different anatomic structures
such as the heart, the coronary arteries
and thoracic vessels had to be assessed
while dose should be kept down. This

is especially important in this patient
population as follow-up examinations
after therapy and further observation
might be necessary in the coming years.
Applying a prospectively ECG-triggered
scan mode, known as step-and-shoot
mode, the physicians achieved impressively low-dose values with a mean
radiation dose of 0.26 mSv. Image quality was rated 4.7 on a scale from 1 to 5.
All examinations provided diagnostic
image quality. According to the authors,
the study [...] demonstrates that tech-
1 A two-month-old
child underwent surgery to correct transposition of the great
arteries. Due to the
short scan time of
0.3 seconds there
was no need for
sedation or breathhold in this CT examination. The image
shows a narrowing of
the tracheal lumen
(arrow).
Courtesy of FriedrichAlexander University
Erlangen-Nuremberg,
Germany
nological improvements in CT allow the

acquisition of high-quality images with
very low radiation doses in pediatric
patients with CHD.1
CT examinations of 32 children also
suffering from CHD, were analyzed
in terms of image quality, radiation dose
and diagnostic accuracy by a group
of researchers in Minnesota. The images
were obtained applying different pitch
values from 2.25 up to 3.4. In addition
the results were compared to CT scans
acquired with a conventional multislice-CT scanner. Those examinations
obtained with a pitch of 3.4 with the
SOMATOM Definition Flash could be carried out with the lowest possible radiation dose. In addition, the young patients
were breathing normally during the
examinations. The diagnostic quality of
the CT examinations acquired under different clinical conditions was not influenced by the scan speed and free breathing. So the authors conclude that the
high pitch scan mode [...] may be the
preferred mode of imaging for specific
pediatric patient subsets for definition
of combined cardiac and extracardiac
anatomy.2
At the University of Erlangen, 30 children
diagnosed with CHD or cardiovascular
malformation, underwent CT examination with the SOMATOM Definition Flash.
The physicians performed these scans in
high-pitch mode. This scan mode
enabled them to obtain the diagnostic
images with a mean scan time of 0.49
27.05.11 09:37
2A
2B
News
2 Two CT examinations of the thorax obtained at different time points from a patient diagnosed with lung cancer to monitor chemotherapy.
With IRIS, a significant reduction of radiation dose from 2.8 mSv* to 1.4 mSv* could be achieved while maintaining excellent image quality.
CT examination of the thorax without IRIS, CTDIvol = 5.11 mGy, DLP = 199 mGy cm, eff.dose = 2.8 mSv* (Fig. 2A). CT examination of the thorax
with IRIS, CTDIvol = 2.54 mGy, DLP = 98 mGy cm, eff. dose 1.4 mSv* (Fig. 2B). Courtesy of Hospital Calmette, Lille, France
seconds. Despite patient motion, due to

the speed of the scan there was neither
need to sedate the young patients nor for
controlled ventilation. On the one hand,
this improves the workflow, as personnel
specialized in sedation and anesthesia in
children are not necessary. On the other
hand, even more importantly, the
patients are not exposed to additional
risks because of these anesthetic procedures. The conclusion by the authors:
High-pitch chest CT is a robust method
to provide highest image quality making
sedation or controlled ventilation [...]
unnecessary, whereas maintaining low
radiation dose values.3
IRIS as a powerful tool to

reduce dose
SOMATOM scanners offer a wide spectrum of technologies developed to
reduce radiation exposure to the lowest
possible dose. IRIS, Siemens Iterative
Reconstruction in Image Space, has
meanwhile been repeatedly scientifically
validated.
A study published by Bittencourt et al.
reports about 55 coronary CT Angiography examinations that were reconstructed twice, applying filtered back
projection as the conventional reconstruction method and in a second step
applying IRIS: image noise decreased and
higher signal to noise ratios could be
achieved with iterative reconstruction.
This was true for all three scan modes

which were chosen due to different
clinical conditions.4 Thus, dose can be
reduced for coronary CT Angiography
examinations without compromising
image quality.
Researchers from France carried out a
study that was divided in two parts. In
the first part they assessed 32 chest CT
examinations obtained with the established scan protocol settings of their
institution. They reconstructed the imaging datasets twice, once with filtered
back projection and once with IRIS.
Objective and subjective image noise
could be clearly reduced and the image
quality scores increased when images
were reconstructed with IRIS. Based on a
detailed analysis of lesion conspicuity,
the authors state that IRIS enables [...]
significant reduction of image noise
without loss of diagnostic information
[...].5
For the second part of their study the
researchers evaluated chest CT examinations of 80 patients. These patients
underwent a first CT examination in a
conventional mode, without IRIS. As all
of them needed a follow-up scan, a
second CT examination was performed.
The follow-up scans were obtained
with reduced dose and with the use of
IRIS. This led to a mean effective dose of
1.5 mSv* compared to 2.3 mSv* for the
conventional mode. The authors con-
clude that IRIS enables dose reduction

without loss of diagnostic information
and that even higher dose reductions
than 35% may be feasible.6
Scientically validated
These publications provide an unbiased
proof: Highest clinical requirements are
met with the SOMATOM Definition
Flash, opening new possibilities for CT
in daily clinical practice.
1
Paul JF et al. Radiation dose for thoracic and coronary step-and-shoot CT using a 128-slice dual-source
machine in infants and small children with congenital
heart disease. Pediatr Radiol. 2011 Feb; 41(2):244-9.
Han BK et al. Accuracy and safety of high pitch computed tomography imaging in young children with
complex congenital heart disease. Am J Cardiol. 2011
May 15;107(10):1541-6.
Lell MM et al. High-pitch spiral computed tomography:

effect on image quality and radiation dose in pediatric
chest computed tomography. Invest Radiol. 2011 Feb;
46(2):116-23.
Bittencourt MS et al. Iterative reconstruction in image

space (IRIS) in cardiac computed tomography: initial
experience. Int J Cardiovasc Imaging. 2010 Dec 1.
[Epub ahead of print]
Pontana F et al. Chest computed tomography using

iterative reconstruction vs filtered back projection
(Part 1): Evaluation of image noise reduction in 32
patients. Eur Radiol. 2011 Mar;21(3):627-35.
Pontana F et al. Chest computed tomography using

iterative reconstruction vs filtered back projection
(Part 2): image quality of low-dose CT examinations in
80 patients. Eur Radiol. 2011 Mar;21(3):636-43.
*calculated using published conversion factors: 0.014

mSv/mGy cm (McCollough C et al. Strategies for
Reducing Radiation Dose in CT. Radiol Clin North Am.
2009 January; 47(1): 2740.)
27
27.05.11 09:37
Business
Growing Demand
for Postmortem Imaging
Postmortem examination by means of computed tomography and
other imaging techniques is still a novelty in many countries.
But at the forensic institute of the University of Zurich, Switzerland,
scanning the bodies is daily routine.
By Irne Dietschi
The mans body, after being exhumed

from the cemetery in the early morning
hours, was brought to the Institute
of Legal Medicine at the University of
Zurich around 9 a.m. The coffin was
admitted through the wide entering
gates on a trolley, pushed through the

hall, where mortuary fridges are arrayed
along the wall, and brought straight
to the adjoining imaging section of the
institute. There, the body underwent
a complete CT scan. It took no more than
ten minutes to push it through the wide

opening of the SOMATOM Definition
Flash, thereby virtually cutting the body
into thousands of razor-thin slices. All
this while the mans body remained in
the coffin (Fig. 1).
1 The wide bore of 78 cm allows scanning of larger objects such as coffins too.
27.05.11 09:37
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Business
The Dose Report New Feature of Utilization

Management
Typically, dose data are available to operators during every examination,
but these data are sometimes not documented afterwards for later reference
or analysis. With Siemens service offering, Utilization Management, dose
information can be accessed for SOMATOM Denition systems.*
By Benjamin Gutheil and Janine Krebs, Customer Service, Siemens Healthcare, Erlangen, Germany
Siemens Utilization Management (UM)

includes dose reports as a new feature.
UM is a proactive service offered from
Siemens UPTIME Services that provides
system-specific usage data. Access to
these detailed data enables users to
leverage their systems full potential.
They receive extensive equipment utilization analyses and anonymous benchmark information about comparable
systems at other facilities operating in
similar environments, as well as dose
information on a regular basis.
With the new dose report, operators
obtain an overview of the total number
and the percentage split of scan ranges

per selected protocol, as well as the
available dose information for the
selected month. They can see if any
specific values have been exceeded.
What are the key benefits?
Visibility of dose usage data on a
monthly or multi-monthly period
Increased awareness of radiation
exposure among clinicians
Easy way to track system and dose
utilization details at the point of care
Increased patient safety
How does the user obtain access to

these data?
With regards to Computed Tomography,
dose reports are made available through
the LifeNet UPTIME Services Portal.
This is Siemens secure web portal providing users with the information
needed to manage the productivity
of their Siemens diagnostic equipment.
In the dose report, users obtain
an overview of all selected protocols,
indicating if any specific values have
been exceeded and what radiation dose
has been administered.
* from software version VA20
1 All important figures are collected in the dose report. The user gets additional information about system utilization.
31
27.05.11 09:37
Business
Francisco Tardguila, MD, Head of the Department of Radiology with his team next to the SOMATOM Definition Flash which allows the acquisition of
MinDose data for full functional evaluation with syngo.via, even at minimum dose.
syngo.via with the SOMATOM

Denition Flash: A Technical Revolution
Povisa hospital was Spains rst private clinic to introduce syngo.via with the
SOMATOM Denition Flash CT scanner in 2009. Since then, work has become
faster and more accurate, and patient gures have increased.
By Manuel Meyer
Povisa Hospital, Vigo. Main entrance.
As soon as talk turns to the new

SOMATOM Definition Flash and
syngo.via, Carlos Delgado, MD, cardiac
radiologist at the Povisa private hospital
in Northern Spain, goes into raptures. In
September 2009, the hospital, located
in Vigo, Galicia, substituted its 64-slice
CT scanner for the new SOMATOM
Definition Flash and installed the imaging
software syngo.via. Says Carlos Delgado:
Since then, weve been working faster
and more accurately and have also
reduced radiation doses considerably.
The radiologist is particularly impressed

by syngo.via: The software is a technical revolution. While patient diagnosis
used to take between 20 and 30 minutes, he can now perform the same task
in less than five minutes with syngo.via.
This is chiefly due to the softwares automated preparation of cases, which
allows him to concentrate more closely
on diagnosis. Carlos Delgado explains
that syngo.via segments and labels the
coronary vessels, removes ribs from
images and displays the corresponding
Somatom28_Business_syngo.via.indd 32
31.05.11 11:21
Business
Besides improved workows,

syngo.via generally
boosts diagnostic safety.
Carlos Delgado, MD, cardiac radiologist,
Povisa private hospital, Vigo, Spain
cardiac CT automatically, performing

preparatory tasks which once had to be
done by the radiologists. I can now display clinical images on the screen within
seconds and with a single mouse click.
The time saved is particularly significant
in emergencies. Accident victims diagnoses reach the emergency room just 15
minutes after scanning.
Greater Diagnostic Safety

However, the time reduction is not the
most important benefit. Besides
improved workflows, syngo.via generally
boosts diagnostic safety. This also
proves significant in emergencies, as
attending physicians or radiologists are
not always familiar with cardiac CT imaging. Although Delgado believes there are
too many ways to process a CT image in
general, he finds syngo.via easy to learn
and very intuitive. Above all, the online
system means users are no longer tied to
a single workplace, but can access the CT
images anywhere in the hospital and
even from home via the internet.
This constitutes a qualitative leap
which, according to the radiologist,
should nonetheless be regarded in
conjunction with the new SOMATOM
Definition Flash CT scanner and its
unique Dual Source technology. With
its split-second scanning function, the
Flash mode allows him to scan the entire
heart in just a quarter of a heartbeat.
Reduced Radiation Dose

The new Siemens CT scanners offer
patients an extra advantage in terms of
pediatric radiology. The increased scan
speed as well as dedicated algorithms
drastically reduce the radiation dose,

comments the radiologist. Carlos Delgado emphasizes that CT scans which
continue to transmit radiation doses of
15 millisieverts with some conventional
64-slice CT scanners generate just 0.9
millisieverts with the new Definition
Flash scanner.
And with the new syngo.CT Cardiac
Function, it is now possible to use
MinDose data for a full functional
assessment.
The syngo.CT Cardiac Function software
defines landmarks in images taken during a diastole and adapts these anatomic
regions for images taken during other
phases of the cardiac cycle. These intelligent algorithms can perform highly
reliable cardiac anatomy segmentation
even with noisy low-dose data. So in
effect, not a single image is wasted.
Thorax radiologist Concha Martnez, MD,
adds: The new Dual Energy imaging,
which permits improved characterization of injuries and pathological tissue
changes, facilitates a more precise
diagnosis.
However, realizing the devices full
potential took time. Povisa hospital
was the first clinic in Spain to introduce
syngo.via with the new CT scanner in
2009.
We were testing the beta version of
syngo.via, and no one had any experience with it at the time. That means that
we could experience the very first version of the system and consult Siemens
CT in improving the prototype with additional features and tools. And whenever
we had an issue or question, Siemens
service was outstanding. And it still is.
Above: Carlos Delgado, MD, radiologist (left)

and Concepcin Martnez, MD (right), radiologist
and Head of TAC Section, at the main entrance
of Povisa Hospital. Below Francisco Tardguila,
MD, Head of Radiology Department, next to his
syngo.via reading workplace.
33
27.05.11 09:37
Business
Left: SOMATOM Definition Flash examination of the abdomen. Above: Automatic pre-processing with syngo.via enables quick and easy evaluation of
the entire colon. Below: With syngo.via a CT series is compared with an MR dataset whereby the lesion is quantified with a volume measurement tool.
Of course, now working on a released

product we do not have many issues.
But if I have a problem nowadays, its
solved by Siemens the same day,
enthuses Carlos Delgado.
Siemens offers a 24/7 hotline support if
wished. Technical questions as well as
application questions will be answered.
Thereby the dedicated application specialist can support online via desktop
sharing, after the customer gives access
to the syngo.via server.
In general, however, the Povisa radiologists verdict is thoroughly positive:
Since the acquisition of the new CT
scanner with syngo.via, weve not only
had to work more due to the increase in
information, but, above all, because we
treat more patients, he jokes.
More Patients Thanks to the

Latest Technology
The physicians are so impressed with
the new technology that theyre sending
us more and more patients. We used
to perform a couple of scans daily in
cardiac CT, and now we do up to five,
confirms Francisco Tardaguila, MD, Head
Radiologist. The low radiation doses
mean that an increasing number of pediatricans throughout Galicia are sending
patients, affirms the former president of
the Spanish Radiology Association.
As a Spanish reference clinic in the field
of radiology, being equipped with the
latest radiology technology was a matter
of prestige, says Francisco Tardaguila.
The decision not only increased the productivity and medical opportunities
within his radiology department, but
also proved economically advantageous,
as the new CT scanner attracts wealthy
private patients from across Spain.
This is an important economic growth
factor for a private hospital, which is,
with 600 beds, considerably smaller

than Vigos two state hospitals. However, if Povisa was one of Spains major
league clinics specializing in radiology
before the introduction of the new
Siemens CT scanner, it certainly became
the FC Barcelona of Spanish radiology
afterwards, says the Head Radiologist,
playfully comparing his departments
new image and abilities with the famous
Spanish soccer club.
Freelance journalist Manuel Meyer lives and

works in Madrid. He regularly reports on scientific and medical issues for various media.
27.05.11 09:37
Business
Surviving in the Battle for Referrals

Marketing is becoming a more and more important topic for medical
institutions. No matter whether it is compensating for the new competition
down the street or simply the need to get enough patients to cover the
running costs, promoting ones services can be a decisive factor. For this,
Siemens has launched a new customer marketing toolkit.
By Jan Freund
Computed Tomography, Siemens Healthcare, Forchheim, Germany
In recent years, medical practice has signicantly changed. New applications

have been introduced that allow a safer
and more sustainable diagnosis and
treatment. But the changes did not affect
only the medical side. More and more
institutions are confronted with economic challenges resulting from reimbursement cuts, competition and,
in the end, the requirement to perform
medical services protably. So what formerly was mainly the eld of business
driven enterprises has now become an
important aspect in the decision making
and operation of many medical institutions.
The battle for referrals has intensied as
many limiting conditions have changed
as well. The progress in medical technology has made high-end imaging including CT affordable to a larger number of
institutions. This is, in general, a favorable development as, in the end, it is of
benet for the patients. But along with
this improvement came many new regulations, limited resources or cost
increases and, nally, the competitor
right across the street. Consequently,
hospitals, clinical practices and imaging
centers have to make sure that they are
perceived as the rst choice for referrers
and patients for their services. In business, this is known as marketing.
Many institutions have already recognized this as an important part of their
business and have started to market
themselves. One example is Franklin

Woods Community Hospital, an institution of Mountain States Health Alliance
(MSHA), USA. The vast majority of Emergency Department examinations here are
walk-in patients. So obviously, waiting
time is a big factor. Therefore, MSHA has
put much focus on this and is now
actively marketing it by posting Emergency Department waiting times for their
institutions online.
Because the importance of marketing is
growing for customers, Siemens has put
together a very comprehensive set of
tools to actively support their marketing
activities. This toolkit, which helps to
promote CT practice by providing the
tools necessary, consists of examples for
all typical marketing channels like print,
online and social media as well as scripts
for radio and TV advertisement. Now,
customers can simply download the
clearly structured templates. To set up an
advertisement in a magazine for example, the respective image and text sections of the template just need to be
exchanged by the customer and the ad is
ready to use.
Siemens offers this service free of charge
to its customers. To get an overview of
the customer marketing toolkit, just visit:
www.msha.com/
www.siemens.com/CT-toolkit
As one kind of marketing, the MSHA is showing online waiting times for their patients.
35
27.05.11 09:37
Business
What Prompts Customers to buy Multiple

SOMATOM Denition Flash Scanners
If someone trades his common CT scanner for a high-end device in times of
a global economic crisis, one is surprised. But if, instead, they buy not only
one but ve high-end scanners, there must be a good reason.
By Michaela Spaeth-Dierl, medical editor, Spirit Link Medical, Erlangen, Germany
The SOMATOM Definition Flash is

considered by many to be the Porsche
among CT scanners. But high quality
combined with speed comes at a price.
Still, many customers have recently
taken advantage of so-called Multi-Unit
Deals. This means that some SOMATOM
Definition Flash customers bought not
only one SOMATOM Definition Flash
scanner, but up to six or even nine at
a time.
What prompted them to do that, despite
the tense economic situation, the high
investment and the fact that typical charges for CT examinations are decreasing?
SOMATOM Sessions talked to Gilbert
Raff, MD of the Royal Oak Hospital in
Michigan, Elliot Fishman, MD of the
Johns Hopkins Hospital in Baltimore,
Maryland, and Vinay Malhotra, MD
from Tacoma, Washington, who were
all involved in the purchasing decision
for more than one SOMATOM Definition
Flash.
SOMATOM Sessions: What was your

intention in buying multiple SOMATOM
Definition Flash scanners? And in what
way would you say it was a worthwhile
investment?
FISHMAN: Weve been working with our
first SOMATOM Definition Flash scanners for roughly two years, now.
We have a new hospital opening in
2012 and we needed five new scanners.
We decided on SOMATOM Definition
Flash, looking at what the best scanner
was for our patients from a dose-saving
perspective and with regard to technology. From that perspective, it was
the best we were able to do for our
money. Its an outstanding product
across all modalities, whether its cardiac CT or oncological imaging for lowdose pancreas or liver exams. We are
very, very happy with the product.
RAFF: We have three hospitals and we
wanted to offer equivalent coronary
and cardiothoracic care to all our
patients at all three hospitals, whether

they are young and therefore require
lowest possible doses, or suffer from
high and irregular heart rates.
MALHOTRA: The reason why we chose
the Flash systems is their versatility. In
the past, systems have been geared
either to work for cardiology, cardiovascular or general radiology. And it
increases the costs if you put multiple
systems in the hospital and you have to
decide each time where to send your
patient depending on what information
you need. Now, for the first time, were
able to get it all from one scanner without putting too much money into multiple systems and not putting too many
systems in one place. Now you can perform cardiac and trauma CT as well as
oncological, neurological or acute care
exams or examine children all with
one CT system. And you can do it with a
high degree of safety, with lowest radiation doses, and still get great results.
Now, for the rst time, were able to get it all

from one scanner without putting too much
money into multiple systems and not putting
too many systems in one place.
Gilbert Raff, MD, Royal Oak Hospital, Michigan, USA
27.05.11 09:37
Business
the entire hospital system. Using the

Flash we are now talking about a radiation dose which is less than 25% of it was
four years ago, even without using any
iterative reconstruction dose-saving technologies such as IRIS* or SAFIRE**. This
dose-saving aspect is very important for
our patients. To me, anything that can
improve images while decreasing dose
is where we need to be moving in the
future and the Flash is already there.
SOMATOM Sessions: Why did you
invest in syngo.via in addition to the
SOMATOM Definition Flash?
Here was a system

that was able to do
everything effectively and properly
with low radiation
doses.
Vinay Malhotra, MD, Tacoma,
Washington, USA
SOMATOM Sessions: And are there any

further advantages?
RAFF: Yes, absolutely. There is the high
throughput and the automated functions.
Its a very fast scanner, and it quickly
delivers results from all the modalities
you talked about. And that means reducing the waiting time and eliminating
coordination efforts since all patients can
be examined with the Definition Flash.
Another important issue is patient safety:
For example, if you wanted to do a scan
of a baby or small child in the past, an
anesthetist was required hours before,
during and even after the scan. With the
SOMATOM Definition Flash, a full pediatric scan can be done in less than one second, independent of breathing movement. This system makes sedation and
forced breathing obsolete. We made this
investment so that we would be able to
deliver a superior result uniformly across
MALHOTRA: Because with syngo.via there

is no IT- or connectivity issue. Were based
in different locations, but were connected centrally. That means we can do
everything on one platform, nobodys
reading on different platforms and getting into disagreements over what this
looks like or what that looks like. With
one system that connects easily, I can
focus on one particular problem instead
of having to focus on many problems at a
time. And it helps all physicians because
you only have to train them once, not
over and over again. Thats why we
picked syngo.via to complement the
Flash, for the ease of use, its uniformity
across the system and the cost and time
savings. Years ago everyone was focusing
on new systems with only the following
in mind: cardiology and number of slices.
What they didnt realize: Here was a system that was able to do everything effectively and properly with low radiation
doses. So I think this is something that
people are taking a while to catch on to
since other vendors are still propagating
the old paradigms.
SOMATOM Sessions: Thank you very
much. To sum up: With the SOMATOM
Definition Flash you get fast scanning at
lowest dose without the need for breathhold or sedation in case of pediatric
patients, and even for patients with high
and irregular heart rates. A detailed consideration shows that buying multiple
SOMATOM Definition Flash scanners is a
reasonable and worthwhile investment
that pays off in the end. With the purchase and use of multiple scanners, the
advantages of the single unit multiply.

And working with a uniform, efficient
system simplifies workflows and so saves
time and money.
* In clinical practice, the use of Iterative Reconstruction IRIS may reduce CT patient dose depending on
the clinical task, patient size, anatomical location,
and clinical practice. A consultation with a radiologist and a physicist should be made to determine
the appropriate dose to obtain diagnostic image
quality for the particular clinical task.
** The information about this product is being provided for planning purposes. The product is pending
510(k) review and not available in the U.S..
In clinical practice, the use of SAFIRE may reduce
CT patient dose depending on the clinical task,
patient size, anatomical location, and clinical
practice. A consultation with a radiologist and a
physicist should be made to determine the appropriate dose to obtain diagnostic image quality for
the particular clinical task.
Its an outstanding
product across all
modalities,
whether its cardiac CT or oncological imaging for
low-dose pancreas
or liver exams.
Elliot Fishman, MD, Johns Hopkins
Hospital, Baltimore, Maryland, USA
www.siemens.com/SOMATOMDefinition-Flash
37
27.05.11 09:37
Clinical Results Cardio-Vascular
Case 1
Thoracic Triple Rule-Out
in Low Dose Acquisition Technique
Using Prospective ECG-Triggering
By Johannes Rixe, MD,* Andreas Rolf, MD,* Andreas Blaha**
*Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
** Siemens AG, Healthcare Sector, Business Unit CT, Forchheim, Germany
HISTORY
DIAGNOSIS
A 28-year-old female patient weighting

55 kg at a height of 175 cm (Body MassIndex 18) presented with chest pain
and shortness of breath under exertion.
Additionally, she complained about
backache that had initially occurred a
few hours before admission.
She had an elevated blood pressure
of 160/100 mmHg. D-Dimer testing
showed very slightly elevated values
(1.1 times upper-normal value), Troponin T was negativ. The ECG documented
no relevant ST-T elevations. Because of
the multiple but typical symptoms and
the equivocal laboratory and ECG findings, we referred the patient for ECGtriggered CT to rule out pulmonary
embolism (PE), aortic dissection and coronary artery disease (CAD).
1A
The investigation was performed using

a SOMATOM Definition CT scanner. In
order to obtain optimal image quality at
a preferably low radiation dose, nitroglycerine was given sublingually immediately prior to the examination.
At a heart rate of 61 bpm, a prospectively ECG-triggered scan was performed
from the aortic arch to the diaphragm
at a tube voltage of 80 kV and a tube
2A
1B
1A VRT discovered a regular

course of LAD and no stenosis.
1B MIP of LAD
showed no calcification or stenosis.
2B
2A VRT of RCA depicted a regular

course and no stenosis.
2B MIP displayed RCA

without calcifications or
stenosis.
27.05.11 09:37
Cardio-Vascular Clinical Results
current of 215 mAs. With an estimated

radiation dose of only 0.94 mSv (using
published conversion factor of 0.014)
outstanding image quality could be
achieved. With the CT Angiography a
coronary artery disease could be ruled
out and additionally a pulmonary embolism could be excluded as well as an aortic dissection. Due to these results from
the CT scan, no further medical treatment
was declared to be necessary and the
patient was discharged from hospital a
few hours later.
3 The right pulmonary artery did not

show any signs of pulmonary embolism.
4 Even the left pulmonary artery did not

show any signs of PE and no aortic arch
dissection was visible.
COMMENTS
Using an individually adapted scan protocol with prospective ECG-triggering,
the SOMATOM Definition CT scanner
allows accurate assessment of coronary
arteries and intra-thoracic vessels with
excellent image quality at a very reasonable radiation dose.
Therefore a SOMATOM Definition Dual
Source CT scanner can reliably rule out
CAD, pulmonary embolism and aortic dissection at very low radiation exposure.
5 Axial MIP of pulmonary arteries did not

discover any thrombus.
6 Curved MIP of aortic arch and descending aorta showed no aortic dissection.
EXAMINATION PROTOCOL
Scanner
SOMATOM Definition
Scan mode
Triple Rule Out
Slice collimation
64 x 0.6 mm
Scan area
Thorax
Slice width
0.75 mm
Scan length
186 mm
Spatial Resolution
0.33 mm
Scan direction
Cranio-caudal
Reconstruction increment
0.4 mm
B26f
Scan time
14 s
Reconstruction kernel
Tube voltage
80 kV
Contrast
Tube current
356 mAs/Rot
Volume
CTDIvol
3.58 mGy
Flow rate
140 ml
7 ml/s
DLP
67 mGy cm
Start delay
20 s
Eff. dose
0.94 mSv
Postprocessing
syngo Circulation
Rotation time
0.33 s
39
27.05.11 09:38
Case 2
SOMATOM Denition AS+ Scanning:
Coronary Artery Anomaly
By Peter Wilson, MD,* Robert Dittrich **
*Department of Radiology, Northside Medical Imaging, Coffs Harbour, Australia
**Siemens Healthcare Australia and New Zealand
HISTORY
COMMENTS
A 72-year-old male patient was initially

referred to the hospital due to chest
pain. Anomalous left main coronary
artery origin was found on coronary
angiography. The coronary anatomy was
clarified in more detail with a retrospectively gated coronary CT Angiography.
DIAGNOSIS
An anomalous left main coronary artery
origin from the right sinus of Valsalva in
conjunction with the origin of the right
coronary artery was found with CT
Angiography. The left main coronary
artery subsequently had an unusual
course anterior to the pulmonary trunk.

Patent stenting in the left coronary
artery was detected to pass the ostium
of a second diagonal branch. A branch
stent had been placed proximal of the
second diagonal artery. Both stents were
discovered to be patent. Small plaque
formations were found in the coronary
arteries elsewhere without significant
stenosis. No infarction was visible. The
left ventricular function (ejection fraction, EF) was detected to be normal (EF:
55 %) and the calcium score moderate.
Totally applied radiation dose including
Calcium Scoring was 4.17 mSv (using
the published conversion factor of 0.014
mSv/mGy cm).
Coronary artery anomalies are difficult

to characterize on catheter angiography.
CT coronary angiography is ideal to
demonstrate the course of anomalous
arteries and the anatomy of their origins. This helps in deciding whether the
anomaly places the patient at higher
cardiac risk or if it is a benign variant. An
assessment of coronary stents is now
feasible by this method. In this case the
anomaly seemed benign. These complex
stents were shown to be patent.
Scanner
SOMATOM Definition AS+
Scan mode
Coronary CTA
Effective dose
2.28 mSv
Scan area
Heart
Slice collimation
128 x 0.6 mm
Scan length
137 mm
Slice width
0.6 mm
Scan direction
Cranio-caudal
Spatial Resolution
0.33 mm
Scan time
7.87 s
0.3 mm
Tube voltage
100 kV
126 / 146
Tube current
57 mAs
Contrast
Rotation time
0.3 s
Volume
Dose modulation
CARE Dose4D
Flow rate
5 ml/s
CTDIvol
10.04 mGy
Start delay
Bolus tracking
DLP
163 mGy cm
Postprocessing
syngo 3D
70 ml
27.05.11 09:38
1 VRT overview showed the course of the left coronary artery (LAD).
2 VRT overview showed the distal right coronary artery (RCA).
3 Curved multiple planar reformation of the LAD and diagonal

branch showed two stents after bifurcation.
4 Patent in-stent lumen of the LAD stent was visualized by curved

MPR.
5 MIP overview highlighted the common ostium of left and right

coronary artery.
6 Curved MPR discovered the region from the posterior descending

artery (PDA arrow) to the distal left circumflex coronary artery (LCX
arrowhead).
41
27.05.11 09:38
Case 3
Retrograde Filling of Occluded Proximal
Coeliac Trunk Conrmed by CTA
By Kim Smith, MD
Radiology SA Central Districts Hospital, Elisabeth Vale, Australia
HISTORY
A 64-year-old male presented with
chronic (> 5 years) abdominal pain,
especially after meals. Contrast enhanced
CT, plain films, barium meal and ultrasound had, over that period of time,
not determined a cause for his pain.
Mesenteric angina was suspected and
a CT mesenteric angiogram performed.
DIAGNOSIS
A particular feature of this mans pain
was that it was primarily post-prandial.
Mesenteric angina was suggested after
most other possibilities had been
excluded. It was an unlikely cause and is
responsible for as little as 5% of intestinal ischemia.1 It is more commonly
found in the elderly and often of acute
onset. Other than pain, there were very
few indicators to help the clinician.
There was no sign of small bowel
obstruction and few episodes of vomiting. The following is quoted from the
report written by the radiologist who
supervised the examination:
There is a significant abnormality of the
foregut blood supply. There is a small
stump origin of the coeliac with a 2 cm
length of occlusion of the coeliac axis.
The coeliac axis fills retrograde (inferior
pancreaticoduodenal to gastroduodenal
as well as gastroepiploic to left gastric
arcade). The very horizontal nature of the
proximal occluded coeliac axis suggests
that the occlusion is thought to be due to
long-standing diaphragmatic crus compression. As a result, the superior mesenteric artery (SMA) is hypertrophied and is
of generous caliber measuring 7 mm in
diameter for the first 5 cm of its length
with large caliber collaterals involving the
duodenum and pancreas.
COMMENTS
CT Angiography proved to be the definitive examination for this case. For some
years this man had debilitating pain
which had been virtually impossible to
diagnose. The following images clearly
show the coeliac artery obstruction and
abnormal re-filling which allowed the
gut to function despite an otherwise
life-threatening vascular abnormality.
Despite its long standing nature, the
chances of an acute event are quite high
and chronic mesenteric vessel disease
has a mortality rate of 40%.1 In addition
to this catastrophic possibility, mesenteric ischemia can cause weight loss, a
fear of eating (sitophobia) due to the
severity of post prandial pain, gastric
ulcers and ischemic gastritis.2, 3
CTA has a good resolution of distal,
small caliber vessels. In addition to this
benefit, CTA is readily accessible to
general practitioners. The low probability of a positive examination result
means this condition is most likely going
to be investigated by a local clinician
exhausting possibilities.
Once diagnosed the primary treatment

is surgical intervention. Whether it is by
open or endoluminal method, the blood
supply to the affected region of gut
needs to be restored. Grafting manmade material or vessels harvested from
the patients leg are well established
means of bypassing the obstruction.
Great strides have been made in re-canalizing stenosed vessels without open
surgery. However, in the case under discussion, it was the opinion of the reporting radiologist that the complete
obstruction of the coeliac artery at its
origin would require open surgery.
1 Jayaprakash Sreenarasimhaiah Chronic mesenteric ischemia. Best Practice & Research Clinical
Gastroenterology. April 2005 (Vol. 19, Issue 2,
Pages 283295)
2 Musil F, Kouhout P, Elis P, Krajina A, Podhola M.
Chronic mesenteric ischemia. Vnitr Lek. 2000 Jul;
46(7):41822. [Article in Czech]
3 Barry D. Toombs, MD and James M. Jing, MD.
Current Concepts in the Evaluation of Vascular
Disease: Magnetic Resonance & Computed Tomographic Angiography. Tex Heart Inst J. 2000;
27(2): 170192.
27.05.11 09:38
Cardio-Vascular Clinical Results
1 20 mm sagittal slab MIP shows normal

a SMA but the coeliac artery immediately
superior does not fill from the aorta.
2 3 mm axial MIP reveals the coeliac artery root

and filled artery but no connection between the two
(arrowhead).
4 Full thickness MIP shows the same

region as Fig. 3 but more clearly identifying calcific plaques which may influence
treatment (arrowhead).
3 VRT image demonstrates the unenhanced

area of obstruction and abnormal re-filling
and hypertrophic SMA (arrow ahead).
5 Fused VRT and MPR shows regular enhancement

of the right kidney.
6 MIP technique highlights the vascular

status of the SMA.
Scanner
SOMATOM Definition AS 64
Scan area
Abdomen and Pelvis
Slice collimation
64 x 0.6 mm
Scan length
370 mm
Slice width
0.75 mm
Scan direction
Cranio-caudal
Spatial Resolution
0.6 mm
Scan time
6s
0.5 mm
B20f
Tube voltage
120 kV
Tube current
160 eff. mAs
Contrast
Dose modulation
CARE Dose4D
Volume
CTDIvol
10.16 mGy
Flow rate
100 ml
5 ml/s
DLP
399 mGy cm
Start delay
12 s
Rotation time
0.5 s
Postprocessing
syngo InSpace4D
Pitch
1.5
43
27.05.11 09:38
Clinical Results Oncology
Case 4
CT Examination Reveals Extremely
Small Stone in the Kidney with SAFIRE
By Hatem Alkadhi, MD, MPH*, Andreas Blaha**
*University Hospital Zurich, Zurich, Switzerland
**Computed Tomography, Siemens Healthcare, Forchheim, Germany
HISTORY
DIAGNOSIS
A 39-year-old, male patient showed up

in the emergency room with severe,
persisting abdominal pain while continuously seeking a more comfortable position
to lay down. Immediate observations
indicated most likely an acute renal
colic. The patient did not report a family
history of kidney stones. He was immediately hydrated intravenously and
transferred to the radiology department.
Standard imaging methods for this

group of patients is a conventional
abdominal X-ray image, followed by
a non-contrast CT examination. Utilizing
SAFIRE* (Sinogram Affirmed Iterative
Reconstruction) together with an especially adapted, low dose acquisition protocol developed by Siemens, 1.6 mSv
was sufficient to get good image quality
and diagnostic accuracy.
No kidney cysts, no pyelectasis could
be detected but, using the series reconstructed with SAFIRE*, a small stone
could be seen in the right kidney.
Scanner
SOMATOM Definition AS 64
Scan area
Abdomen
Eff. dose
1.6 mSv
Scan length
435 mm
Rotation time
0.5 s
Scan direction
Cranio-caudal
Pitch
0.6
Scan time
18 s
Slice collimation
64 x 0.6 mm
Tube voltage
120 kV
Slice width
2 mm
Tube current
30 eff. mAs
Spatial Resolution
0.33 mm
Dose modulation
CARE Dose4D
1.4 mm
CTDIvol
2.41 mGy
B30 / I30
DLP
108 mGy cm
Postprocessing
syngo.via
*The information about this product is being provided for planning purposes. The product is pending 510(k) review
and not available in the U.S.. In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the
clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist
should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task.
27.05.11 09:38
Oncology Clinical Results
COMMENTS
SAFIRE* allowed to reliably identify a
small stone in the right kidney. The
diameter of the calculi was measured to
be 0.3 x 0.2 mm. Due to its small size
the likelihood that the stone will pass
without further treatment is very high.

Although the dataset is acquired with a
very low radiation dose of 1.6 mSv, it
does not appear noisy.
1 syngo.via with SAFIRE image reconstruction shows the small stone and also offers size measurement.
45
27.05.11 09:38
Case 5
4-Phase Liver Examination
with SOMATOM
Emotion 16 Unveiled
Liver Haemangioma
By Gao, Yong, MD*, Li, Chen Wei**, Andreas Blaha***
*Department of Radiology, Shanghai Jiangong Hospital, Shanghai, China
**Computed Tomography, Siemens Healthcare, SLC, China
***Computed Tomography, Siemens Healthcare, Forchheim, Germany
HISTORY
The patient presented in the hospital
complaining of occasional abdominal
pain. Ultrasound showed signs of a
lesion measuring approximately 3 cm
in size in segment VIII of the liver.
Therefore we transferred the patient
with suspected haemangioma to the
SOMATOM Emotion 16 CT scanner for
further clarification.
Haemangiomas are the most common
liver lesions, accounting for nearly 5-7 %
of all benign tumors.1 They are congenital, vascular malformations. Due
to the increasing age of the patient,
there was the suspicion, that the tumor
size may have increased with the growth
of the liver.
1 Iris-diaphragm phenomena is visible in axial image (arrow; arrowhead in sagittal image reconstruction.)
Somatom28_Case5_Hemangioma.indd 46
31.05.11 11:27
Oncology Clinical Results
DIAGNOSIS
COMMENTS
We performed a 4-phase liver examination, non-contrast, arterial, portal

venous and the equilibrium phase
(approximately 5 minutes after initial
contrast injection) to evaluate the
potential enhancement of the lesion.
A lesion measuring 3.4 cm in diameter
and 12 ml in volume could be confirmed. The non-contrast series showed a
hypodense structure, the late contrast
enhancement in the late phase showed
isodense values (56HU), a haemangioma was diagnosed.
The initial peripheral nodular contrast
enhancements continuously become
isodense, also known as iris-diaphragm
phenomena (Fig 1).
A 4-phase CT examination is a feasible

method to diagnose haemangioma.
With focus on low radiation dose applied
to the patient, customized SOMATOM
Emotion acquisition protocols achieve
low radiation values.
To keep track of possible changes in
growth, the patient was kept on a
follow-up, latest in one year period.
1
Ishak KG, Rabin L.Benign tumors of the liver.

Med Clin North Am 1975 ; 59 : 995-101
Scanner
SOMATOM Emotion 16
Scan area
Abdomen
Scan length
181 mm
Scan direction
Cranio-caudal
Scan time
6s
Tube voltage
110 kV
Tube current
137 eff. mAs
CTDIvol
7.65 mGy
DLP
138.5 mGy cm
Rotation time
0.6 s
Pitch
1.0
Slice collimation
16 x 1.2 mm
Slice width
1.5 mm
Reconstruction
kernel
B41s
Postprocessing
syngo.via
47
27.05.11 09:38
Case 6
SOMATOM Emotion 16 Chest Imaging:
Ground Glass Opacity
in the Upper Right Lung
By Tadashi Kobayashi MD,* Tomoaki Shinkai RT,** and Katharina Otani, PhD***
*Department of Surgery , Kobayashi Hospital, Tokyo, Japan; **Department of Radiology, Kobayashi Hospital, Tokyo, Japan;
***Research & Collaboration Development Marketing Department, Marketing Division, Healthcare Sector, Siemens Japan K.K.,
Tokyo, Japan
HISTORY
A 78-year-old male was referred to the
hospital for a detailed chest examination
after an anomaly was seen in the chest
radiography that he underwent for
screening. A CT of the thorax was
ordered to further check the patients
lungs.
the peripheral right middle lobe, but

their size was too small to make a confident diagnosis. Neither lymph node
enlargement nor pleural effusion could
be detected. Lung cancer was suspected. The patient was referred to a
hospital specialized in cancer treatment.
DIAGNOSIS
COMMENTS
The CT images clearly revealed a ground

glass opacity (GGO) of increased attenuation in the upper lobe of the right lung.
GGO is defined as hazy, increased attenuation of the lung, but with preservation
of bronchial and vascular margins, i.e.
caused by partial filling of air.1 The GGO
had an irregular shape and measured
about 12x12 mm. The bronchi and
arteries could clearly be seen, as well as
a slightly pulled-in area of the visceral
pleura. Small nodules were also seen in
The patient experienced no discomfort

during the CT scan. Images were ready
and of excellent quality soon after the
scan. GGO was clearly seen and a diagnosis could be forwarded to the referring hospital. The diagnosis of primary
lung cancer was confirmed at the
referred hospital and the patient underwent surgery.
1
Scanner
SOMATOM
Emotion 16
Scan area
Thorax
Scan length
333 mm
Scan direction
Cranio-caudal
Scan time
10 s
Tube voltage
130 kV
Tube current
110 eff mAs
CTDIvol
12.23 mGy
DLP
449 mGy cm
Rotation time
0.6 s
Slice collimation
16 x 1.2 mm
Slice width
1.5 mm
Reconstruction
kernel
B80
Postprocessing
syngo InSpace4D
JH Austin, Glossary of terms for CT of the lung:

recommendations of the Nomenclature Committee
of the Fleischner Society, Radiology August 2996
200:327331
27.05.11 09:38
1 Coronal view in VRT of the lungs.
2 Ground glass opacity in VRT.
3 Coronal MIP of the lungs.
4 Ground glass opacity in axial MIP.
5 Ground glass opacity in the right upper lung lobe.
6 Axial view of ground glass opacity shows pulled-in

area of visceral pleura.
49
27.05.11 09:38
Clinical Results Neurology
Case 7
SOMATOM Emotion 16: Intracranial Head
CTA Dolichoectasia of the Basilar Artery
By Dieter Fedders, MD,* Piotr Sokolowski, MD,** Wolfgang Khler**
*Department of Radiology Hubertusburg, Wermsdorf, St. Georg group of companies, Leipzig, Germany
**Department of Neurology Hubertusburg, Wermsdorf, St. Georg group of companies, Leipzig, Germany
HISTORY
DIAGNOSIS
This 57-year-old male patient has been

complaining of dizziness and diplopia
for approximately one year. He was
referred for Ear Neck Throat (ENT) consultation, which did not reveal any pathological clinical findings. On subsequent
MRI of the head in 2009, a megadolichoshaped basilar artery (i.e. a dolichoectasia of the basilar artery) was diagnosed.
Over the past several months, the
patient has complained of an increase in
dizziness, at times with falls and ataxia
on standing and walking. At present he
also complains of a numb sensation and
decreased strength of the left arm and
foot, which have been present since
October 2010. He had trigeminal neuralgia approximately 2 years ago.
He was admitted to the hospital because
of an increase in his known symptoms
of dizziness and a left-sided hemi-symptoms since October 2010. A review of
his medical history confirmed that he
has a megadolicho-shaped basilar artery
(i.e. dolichoectasia of the basilar artery)
and an intra-cranial aneurysm.
The presence of a posterior cerebral

artery aneurysm on the left side at the
junction of P1- to the P2-line could be
confirmed. As suspected in the previous
examination, there was no evidence of a
posterior communicating artery branch.
The origin of the right posterior cerebral
artery is located to the right of the aneurismal sac.
The left vertebral artery aneurysm with
dolichoectasia of the basilar artery dilates
approximately 1.1 cm in diameter.
Arising from the head of the basilar
artery, a nose shaped aneurysm sac
measuring largest diameter of 1.3 cm
could be outlined. Other parts of the
aneurysm measured 0.9 cm in diameter.
An internal carotid artery ectasia on the
right at the origin of the middle cerebral
artery could be confirmed as well.
COMMENTS
The CT Angiography clearly confirmed
the segments of the vessel with perfused lumen. An interventional followup procedure could then be considered.
With the acquisition of thin slices with
the SOMATOM Emotion 16, the former
diagnosis of left posterior communicating artery aneurysm could be reliably
excluded. It showed the origin of the
right posterior cerebral artery out of a

saccular aneurysm of the left posterior
cerebral artery. The anatomical conditions could be reliably determined.
Scanner
SOMATOM
Emotion 16
Scan area
Carotid Head CTA
Scan length
159 mm
Scan direction
Caudo-cranial
Scan time
13 s
Tube voltage
110 kV
Tube current
70 eff. mAs
CTDIvol
12.52 mGy
DLP
218.14 mGy cm
Rotation time
0.6 s
Slice collimation
16 x 0.6 mm
Slice width
0.75 mm
Reconstruction
increment
0.5 mm
Reconstruction
kernel
H31s
Contrast
Volume
95 ml
Flow rate
4 ml/s
Start delay
Bolus tracking
(Aorta ascendens)
Postprocessing
syngo 3D
27.05.11 09:38
2 T2w coronar MRI shows an aneurysm sac and lumen of the basilar artery.
Note mesencephal compression and oedema in the right peduncle of the brain as
well as in the right subthalamic region. Mild hydrocephalus.
1 VRT view shows the aneurysm of the left vertebral

artery, the basilar artery aneurysm and the aneurysm
of the left posterior cerebral artery (PCA) with the
branching of the right PCA from the aneurysm sac.
3, 4 In the VRT
Neurology
Clinical Results
superior view, a posterior communicating artery (PcoA) is
not detectable
(source images decisive for diagnosis)
(Fig. 3). The same
can be revealed in
the posterior view
(Fig. 4).
5, 6 In the MIP
view, branching of
the P1 segment
of the left PCA from
the basilar artery
aneurysm to the
aneurysm sac can be
shown as well as
further branching of
both PCA from the
aneurysm. Ectasia of
the right internal
carotid artery can be
revealed above the
cavernous segment.
51
27.05.11 09:38
Clinical Results Acute Care
Case 8
Dual Energy CT: Virtual Non-Contrast
Imaging of a Complicated Renal Cyst
By Shuichi Kawada MD,* Yutaka Imai MD PhD,* Sayoko Miyanishi**
*Department of Radiology, Tokai University, Kanagawa, Japan
**Siemens Japan K.K., Imaging & Therapy Systems Division, Tokyo, Japan
HISTORY
DIAGNOSIS
A 40-year-old female came to the emergency department with lower abdominal

pain. Her anamnesis included systemic
lupus erythematosus with chronic renal
impairment caused by lupus nephritis.
She had been on hemodialysis for about
10 years after going through peritoneal
dialysis. A Dual Energy CT scan for detailed
examination was ordered. From the
Dual Energy CT data, an iodine map and
a virtual non-enhanced (VNC) image
was generated for comparison with a
true non-enhanced CT that was taken
one month ago.
The CT images revealed kidney atrophy

on both sides and multiple cystic lesions.
Inside the left upper kidney, a uniform
region with slightly higher density than
the surrounding tissue was seen. A complicated cyst was suspected, but it could
not be determined on the contrast
enhanced CT images whether the region
showed higher density due to contrast
medium uptake. The iodine map and the
fused iodine and VNC images showed
that the high density region did not contain contrast medium. From the comparison of VNC and true non-enhanced CT
Scanner
SOMATOM Definition Flash
Scan mode
Dual Energy VNC
Scan area
Abdomen Pelvis
Scan length
435 mm
Scan direction
Cranio-caudal
Scan time
19 s
Tube Voltage
100 kV / 140 kV
Tube current
140 mAs / 119 mAs
Dose modulation
CARE Dose4D
CTDIvol
11.57 mGy
DLP
523 mGy cm
Rotation time
0.5 s
Slice collimation
32 x 0.6 mm
Slice width
1.5 mm
Reconstruction Increment
1.5 mm
D30f
images, it could be confirmed that the

lesion was a complicated cyst of homogeneously high attenuation corresponding to a category II cystic lesion according
to Bosniak Criteria. No treatment was
required. The patient remained in the
hospital for observation and could be
released three days later.
COMMENTS
Complicated cysts of category II according to Bosniak Criteria show homogeneously high attenuation without iodine
uptake. They are therefore difficult to
distinguish from iodine enhancing
lesions on contrast enhanced CT. Dual
Energy CT was found very useful for this
case since with one single CT scan two
data sets are available after Dual Energy
CT post-processing with the LiverVNC
application: virtual non-contrast images
and iodine maps. In addition, the Selective Photon Shield introduced with the
SOMATOM Definition Flash proved useful for the further separation of the two
tubes X-ray spectra during acquisition. It
leads to an improved material decomposition. Furthermore, the patient did not
receive additional dose from the Dual
Energy CT scan compared to a conventional Single Energy CT scan.
Contrast
Volume
100 ml (300 mg/ml)
Flow Rate
1.5 ml/s
Start delay
120 s
27.05.11 09:38
Acute Care Clinical Results
1 Fused 100 kV and 140 kV images give

a mixed image that corresponds to a 120 kV
single energy image. A high density region
can be seen in the left kidney (arrow).
2 With fused iodine and VNC images of

a 50/50 ratio, it can be shown that the high
density region inside the left kidney does
not contain iodine (arrow).
4 A true non-contrast image was

taken one month before.
6 The fused iodine and VRT image also

show nicely that there is no contrast medium
in the high density region.
5 Even the virtual non-enhanced image

showed that the high density region did
not contain contrast medium.
7 Coronal fused iodine and VNC images

of a 50/50 ratio visualized the dense region
well (arrow).
3 The pure iodine image shows a region of

higher density (arrow) but no iodine uptake.
8 The same can be shown in the coronal

iodine image (arrow).
9 The same can be shown in the coronal

VNC image (arrow).
53
27.05.11 09:38
Case 9
New 70 kV Protocol Ensures Low
Radiation Dose in Pediatric Patients
with Congenital Heart Disease
By Michael Lell, MD, PD,* Oliver Rompel, MD,* Andreas Blaha**
*Radiology Department, University of Erlangen-Nuremberg, Erlangen, Germany
**Computed Tomography, Siemens Healthcare, Forchheim, Germany
HISTORY
A 10-month-old male baby underwent
surgery for multiple ventricular septal
defects (VSD) as well as a secundumtype atrial septal defect (ASD). Partially
anomalous pulmonary venous return,
insufficiency of the tricuspid valve and a
patent ductus arteriosus were corrected

in prior surgical procedures, as was
banding of the pulmonary artery. The
post-operative phase, after closure of
the VSDs and ASD, was complicated
with infection and secretion from the
sternotomy wound appeared. Before

re-thoracotomy, a low-dose chest CT
was performed as planning base for
the following surgery.
1 VRT gave an overview of the 70 kV chest acquisition.
2 Fused VRT and MPR image showed the location of the ductus
arteriosus botalli clip (arrow).
27.05.11 09:38
DIAGNOSIS
The scan on a SOMATOM Definition AS+
revealed the proper location of the
ductus-arteriosus clip. A sickle shaped
retrosternal fluid collection could be
demonstrated as well as interstitial
edema and dystelectasis. The right
ventricle was enlarged and the right
ventricular wall significantly thickened.
COMMENTS
With the fast acquisition time of 1.21
seconds covering 129 mm, precise diagnosis could be established in mild sedation. Children with congenital heart disease usually require multiple imaging
studies in the follow-up. Therefore, it is
critical to keep the cumulating radiation
dose as low as possible. A dedicated
low-dose pediatric acquisition protocol,
with auto selection and adjustment of
kV and mAs is very useful in this patient
group to ensure consistently high image
quality at reasonably low dose.
3
Scanner
SOMATOM Definition AS+
Scan area
Thorax
Scan length
129 mm
Scan direction
Caudo-cranial
Scan time
1.21 s
Tube voltage
70 kV
Tube current
130 eff. mAs
Dose modulation
CARE Dose4D
CTDIvol
0.24 mGy
DLP
4 mGy cm
Rotation time
0.5 s
Pitch
1.4
Slice collimation
32 x 1.2 mm
Slice width
1.5 mm
Spatial Resolution
0.33 mm
B30f / I30
Contrast
Volume
5 ml
Flow rate
Injection per hand
Start delay
after injection completed
Postprocessing
InSpace4D
5 Sagittal view of the pediatric chest.
4 In this axial slice, a retrosternal fluid depot is well visible.
55
27.05.11 09:38
Case 10
Diagnosing Pulmonary Embolisms
Using High Pitch Protocols
By Ermidio Rezzonico, Filippo Del Grande, MD, Ospedale Civico, Lugano, Switzerland
HISTORY
DIAGNOSIS
COMMENTS
A young woman, aged 22 years, presented in the Emergency Department

with right-sided, para-vertebral pain.
The patient complained of progressively
worsening pain for the past six weeks.
At this stage, the pain was also respiration dependent. The patient did not
show any further symptoms. The thoracic X-ray demonstrated an effusion in
the right lung and the left costo-phrenic
angle was collecting fluid. The Polymerase Chain Reaction Test (PCR) and
D-dimer were elevated. The patient was
then transferred to the radiology department for a thoracic CT Angiography to
rule out the presence of a pulmonary
embolism.
The examination was performed according to our CT protocol for the evaluation
of a pulmonary embolism, which
includes a CT Flash Thorax acquisition.
The examination showed a left-sided
pulmonary embolism located at the level
of the bifurcation medial of the lingula
and the basal lateral segment of the left
inferior lobe. There was a minimal
increase in parenchyma density in shape
of a triangle corresponding to the basal
medial lobe of the left inferior lobe. A
further small pleuritic effusion was visible on the right, extending from the
wing of the great fissure.
Two fundamental advantages are provided when using the CT Flash Thorax
protocol to rule out pulmonary embolism. 1) Due to the extremely rapid
acquisition time, there is no need for
breath-hold. 2) A low radiation dose is
required of particular interest for
younger patients.
The pulmonary artery tree was shown
in high quality, the exact contrast
enhancement timing was ensured by
using Bolus Tracking.
While using high pitch examination protocols, the system ensures very high
image quality even in a less cooperative
patient group.
In this case, low radiation dose (estimated effective radiation dose 1.9 mSv)
and continuous breathing during acquisition resulted in very good image quality.
Scanner
SOMATOM Definition Flash
Scan area
Flash Thorax
Slice collimation
0.6 mm
Scan length
307 mm
Slice width
3 mm
Scan direction
Cranio-caudal
Spatial Resolution
0.33 mm
Scan time
1s
3 mm
B31
Tube voltage
100 kV
Tube current
112 eff. mAs
Contrast
Dose modulation
CARE Dose4D
Volume
CTDIvol
4.3 mGy
Flow rate
100 ml
4.5 ml/s
Rotation time
0.28 s
Start delay
Bolus tracking
Pitch
2.0
Postprocessing
syngo 3D
27.05.11 09:38
2 The sagittal reconstructions demonstrate a filling defect of the

left pulmonary artery.
1 The coronal reconstructions demonstrate a filling defect of the

left pulmonary artery.
3 The axial image also allows visualization of the pleural effusion.
4 The evaluation of the pulmonary parenchyma demonstrates the

pleural effusion on the right lung.
27.05.11 09:38
Clinical Results Orthopedics
Case 11
Reliable Detection and Diagnoses of Gout
Using Dual Energy Acquisition Technique
By Andreas Artmann, MD, Markus Ratzenbck, MD, Irene Noszian, MD, Klemens Trieb, MD
Radiologie im GHZ and Klinikum Wels-Grieskirchen, Wels, Austria
HISTORY
Usually, rheumatologic diseases are of
many kinds, numerous and varied, making a quick diagnosis sometimes difficult.
Siemens Computed Tomography, using
Dual Energy acquisition techniques,
allows the visualization of uric acid
deposits. These urate crystal deposits are
most often located in peripheral joints
or near the surrounding soft tissues. The
question, which had to be clearified in
this investigation was whether the urate
crystal deposits must have a minimum
size to trigger clinical symptoms.
76 peripheral joints were examined and
evaluated using Dual Energy CT techniques. The size of the uric crystal
deposits were correlated to the presence
of pain at the exact location of these
deposits. Additionally, the correlation
between serum uric acid blood levels
and the final diagnosis, including the

results of all available examinations, was
established.
DIAGNOSIS
Urate crystal deposits > 2 mm correlated
to 100 % with pain at the exact given
location. All patients with urate crystal
deposits > 2 mm had increased uric acid
blood levels, either actually or reported.
These patients were then finally diagnosed with gout, taking all performed
examinations into consideration.
Urate crystal deposits 2 mm did not
correlate in any instance with pain
exactly at the deposit site. The uric acid
blood levels in these patients at the
time of the examination were partly
elevated (43 %) partly normal (57 %).
In patients with no detectable urate

crystal deposits, the uric acid blood levels were normal. The existing symptoms
were explained through differential
diagnosis (some of which were found
during the Dual Energy CT examination).
COMMENTS
Dual Energy CT allows the quantitative
imaging of urate crystal deposits. A
minimum size of the urate crystal deposits > 2 mm seems to be the pre-requisite
for inducing clinical symptoms. Taking
into consideration the size of the urate
crystal deposits, the diagnosis of clinically
manifested gout can be reliably made.
Patients, of course, prefer the non-invasive acquisition protocol in comparison
to invasive punctures.
Scanner
1. Scan area
SOMATOM Definition
DE Hand, Elbow, Foot, Ankle
2. Scan area
DE Knee
Scan length
Adjusted to anatomy
Scan length
Adjusted to anatomy
Scan direction
Cranio-caudal
Scan direction
Cranio-caudal
Scan time
Depending on Scan Length
Scan time
Depending on Scan Length
Tube voltage
A 140 kV / B 80 kV
Tube voltage
A 140 kV / B 80 kV
Tube current
A 55 eff mAs / B 233 eff mAs
Tube current
A 70 eff mAs / B 298 eff mAs
Dose modulation
CARE Dose4D
Dose modulation
CARE Dose4D
Slice collimation
32 x 0.6 mm
Slice collimation
32 x 0.6 mm
Slice width
0.75 mm
Slice width
0.75 mm
0.5 mm
0.5
CTDIvol
8.5 mGy
CTDIvol
9.4 mGy
DLP
203 mGy cm
DLP
175 mGy cm
Rotation time
0.5 s
Rotation time
1s
D30f
D30s smooth
Postprocessing
syngo DE Gout
Postprocessing
syngo DE Gout
27.05.11 09:38
1 Advanced stage of gout with numerous tophi, urate

deposits are visualized in green colour.
2 The localization of the urate deposits > 2 mm correlated to

100% with pain.
3 DECT allows specific and quantitative visualization of

urate deposits.
4 Patient with wrist pain: with the help of DECT the diagnosis
gout could be made.
5 Urate deposits > 2 mm, typical for clinical manifest gout.
6 Tophus with osteodestruction.
59
27.05.11 09:38
Clinical Results Orthopedics
Case 12
Dual Energy CT: Virtual Non-Calcium
Technique Detects Posttraumatic Bone
Bruise of the Knee
By Gregor Pache, MD, Stefan Bulla, MD, Philipp Blanke, MD and Prof. Mathias Langer, MD
Department of Radiology, University of Freiburg, Germany
1A
1B
1C
1D
1 Axial image taken with Dual Energy CT bone window shows intact osseous structures at this height of the tibial plateau (Fig. 1A). Gray-scale
virtual non-calcium (VNCa) image reveals bilateral bone marrow edema (Fig. 1B, arrows). Corresponding T2-weighted MR image of posttraumatic
bone bruises in the posteromedial and posterolateral tibia plateau (Fig. 1C, arrows). Colour-coded virtual non-calcium image makes the bone
bruises more obvious (Fig. 1D, arrows).
27.05.11 09:38
Orthopedics Clinical Results
2 Coronal image taken with Dual Energy CT bone window discovers a small fracture in the posteromedial tibia plateau (arrow).
HISTORY
A 49-year-old male patient, with sustained, high-energy knee trauma due to
a skiing accident, was referred to the
radiology department. As the radiography result was equivocal, a CT scan of
the knee was performed to rule out a
fracture.
DIAGNOSIS
CT revealed a small circumscribed fracture in the posteromedial tibia plateau
(Fig.2). Additionally a Dual Energy CT
(DECT) virtual non-calcium image (VNCa)
(Fig.1B) was calculated (r value = 1.43)
discovering bone marrow edema in the
3 Sagittal T2-weighted MR image rereveals a complete tear of the

anterior cruciate ligament (arrow).
posteromedial and posterolateral tibia

plateau. Although the edema appeared
subtle on the gray-scale VNCa, the
color-coded VNCa image made the bone
bruises obvious (Fig.1D). In light of
these findings, subsequently performed
corresponding T2-weighted MR image
confirmed both bone bruises (Fig.1C).
Sagittal T2-weighted image revealed a
complete anterior cruciate ligament tear
(Fig.3).
COMMENTS
The DECT virtual non-calcium technique
subtracts calcium from cancellous bone,
making post-traumatic bone bruises of
the knee potentially detectable with CT.
It is well known that the bone bruise

pattern can predict associated softtissue injuries. Typically, as seen in this
case, bone bruises of the posterolateral
tibial plateau are associated with anterior cruciate ligament tears. Although
DECT will not replace MRI in the evaluation of knee trauma, DECT might be
helpful to guide further diagnostic
work-up. DECT might also constitute
an option for those patients who have
contra-indications to MR imaging or for
whom MR imaging is not available.
Most importantly, as compared with the
CTDIvol of 8.71 mGy required for a single
energy CT scan, it was possible to obtain
this extra information without additional
radiation dose.
Scanner
SOMATOM Definition
Scan area
Knee
Rotation time
1s
Scan length
139 mm
Pitch
0.7
Scan direction
Cranio-caudal
Slice collimation
20 x 0.6 mm
Scan time
34 s
Slice width
2 mm
Tube voltage (A/B)
140/80 kV
Spatial Resolution
0.33 mm
Tube current (A/B)
43/183 mAs
1.0
Dose modulation
none
D30
CTDIvol
8.69 mGy
Contrast
none
DLP
131 mGy cm
Postprocessing
Dual Energy
61
27.05.11 09:38
Science
CARE kV
How to Optimize Individualized Dose
An important aspect in patient care is reducing dose. Tube current and tube
voltage play a central role in this regard.
By Stefan Ulzheimer, PhD, Heidrun Endt, and Christianne Leidecker, PhD
Computed Tomography, Siemens Healthcare, Forchheim, Germany
Modulating the tube current with CARE

Dose4D is a well-known method for
Siemens customers to reduce patient
radiation exposure. To further explore
dose reduction potential by adjusting the
tube voltage, Siemens SOMATOM scanners feature an additional innovative
technology, CARE kV. Combining CARE
Dose4D and CARE kV enables an optimized, automatic adjustment of tube current and tube voltage individualized for
each patient and the clinical indication.
Tube current modulation with

CARE Dose4D
Siemens SOMATOM scanners provide a
wide spectrum of technologies to
reduce radiation exposure to the
patient. One of these technologies is
CARE Dose4D, the automated, real-time
tube current modulation. Dose savings
of up to 68% are possible when adjusting the tube current to the patients size
and shape.1,2
Based on an user specified image qual-
ity, the system determines the mean

tube current based on the topogram and
subsequently modulates the tube current in real time during the examination.
To specify image quality, the user sets a
reference value, the so-called Quality
Reference mAs. This has to be done
only once for each protocol. The values
should be based on those for a standard
patient of 75 kg.
CARE Dose4D enables constant image
quality over the entire scan range. As
1A
1B
1C
Contrast (lodine)
HU
Small Patient
Medium Patient
Large Patient
Contrast
300
200
Noise (at equal dose)
HU
Contrast-to-Noise Ration (CNR)

(at equal dose)
Small Patient
Medium Patient
Large Patient
Noise
Small Patient
Medium Patient
Large Patient
CNR
40
40
30
30
20
20
10
10
100
kV
80
100
120
140
kV
0
80
100
120
140
kV
0
80
100
120
140
1 Iodine contrast (1A), noise (1B) and, most importantly, the contrast-to-noise ratio (CNR) (1C) in CT depend strongly on the tube voltage but
also the patient size when the dose is kept constant. The lower the tube voltage the higher the iodine contrast in the image because the average
energy of the spectrum gets closer to the k-edge of iodine (33.2 keV) (1A). In small patients, lowering the tube voltage at constant dose has
almost no effect on image noise. Larger objects absorb a significant amount of low energy photons and therefore the noise can rise dramatically
(1B). The CNR as a measure for the resulting image quality behaves accordingly. For small patients the CNR increases when going to lower kV, for
bigger patients it has a maximum and drops again when lowering the tube voltage (1C). CARE kV takes all these effects into account and suggests
the optimum kV for each patient also taking into account the power limits of the CT scanner for the different kV settings.
27.05.11 09:38
Science
the patients diameter varies between

different parts of the body, the tube
current is automatically adjusted during
the examination. This is true not only
for different body regions, but also for
different angles during rotation.
Table 1: Tube voltage adjustment with CARE kV
Tube voltage adjustment

with CARE kV
Adjusting the tube current is a wellestablished method to reduce radiation
exposure. While the dose reduction
potential when optimizing the tube
voltage is known and has been previously shown,3, 4 it is in fact, rarely realized in daily clinical practice. The relationship between tube current, tube
voltage and image quality (contrast,
noise and contrast-to-noise ratio (CNR))
in CT is an intricate procedure (Fig. 1)
and thus, adjusting the tube voltage to
each individual patient and exam is
challenging and mostly too time consuming. To overcome these challenges,
Siemens has developed a new tool,
CARE kV, which automatically recommends the optimal tube voltage for the
individual patient and clinical indication. Simultaneously, CARE Dose4D will
adjust the tube current.
As with CARE Dose4D, the goal is to
maintain a specified image quality while
minimizing dose. While image quality
may be characterized by many parameters, two important ones are contrast
and noise. Image quality is considered
constant when the contrast-to-noise
ratio (CNR) is kept constant. Herein lies
the potential of tube voltage adjustment: lowering kV typically leads to an
increase in contrast and thus potentially
allows more noise and therefore less
dose while image quality (CNR) is kept
constant.
Because the extent of this increase is
different for various materials such as,
for example, iodine (high increase) and
soft tissue (small increase), the optimal
tube voltage will depend on the clinical
indication. Typically, studies which will
benefit most from tube voltage adjustment are vascular exams such as CT
angiograms, CT enterographies, and CT
urograms. Abdominal and pelvis exams
will benefit as well. In non-contrast
kV
mAs
Pitch
CTDI
80
462
1.00
100
297
1.00
-20%
120
210
1.00
11.00
140
147
1.00
+5%
In this example exam, 120 kV at 210 mAs with a pitch of 1.0 was the routine protocol, and
the user selected a Liver contrast setting along the slider bar. The information gathered
from the topogram, along with the user-provided contrast information, allowed the optimal
kV to be selected for this patient and exam. CARE kV chose 100 kV. Despite the increase in
mAs the reduced kV allowed for a 20% dose reduction at constant image quality. The first
selection (80 kV) could be achieved under different parameters, such as lower pitch, but at
the current settings it exceeded the tube limits.
2 The CARE kV user interface: The quality reference mAs and reference kV of the specific exam
are used to determine and maintain image quality for each exam in conjunction with the CARE kV
slider, which is used to indicate the type of exam being performed, allowing the tool to optimize
dose for each specific exam. The optimal kV and mAs settings are now shown on the left panel
and will be implemented in the scan. The semi mode allows the user to force a specific kV while
the tube current is still adjusted according to the defined quality reference mAs value.
exams, there is no additional benefit

from contrast improvement at lower kV.
However, CARE kV will still recommend
the optimal scan settings to the individual patient, for example by suggesting
low kV-settings for pediatric patients.
There is one important caveat, though:
simply lowering the tube voltage without adjusting tube current can result in
too high an image noise and therefore a
reduced image quality despite increased
contrast. Thus, it is essential to adjust
tube current when changing the kV-setting and this task is automatically
accomplished with CARE kV (Table 1).
Taking into account patient size and the
clinical indication, CARE kV automatically recommends the optimal tube
voltage and tube current. In doing so, it
also considers system limits when determining the individual patient and exam
settings. Thus, low kV-settings will be
typically observed for small patients,
where the range of tube current is suffi-
cient because of the overall smaller

X-ray attenuation. For larger patients,
the optimal setting may be reached at
higher tube voltage.
The combination of CARE kV and CARE
Dose4D enables an individualized
patient care by optimizing scan parameters for each individual patient and
clinical question.
How to use CARE kV

Similar to CARE Dose4D, when using
CARE kV, the first step is to specify a reference. This reference value should be
set for a standard patient of 75 kg and
should be exam specific. If the user
already works on a Siemens system, the
previously used combination of mAsand kV-settings can be kept and set as
quality reference mAs and reference kV.
Alternatively, the Siemens standard scan
protocols available on the scanner can
be used as a recommended starting
point.
63
27.05.11 09:38
3A
120 kV, CTDIvol=15.0 mGy
3B
100 kV, CTDIvol=9.8 mGy
3 Follow-up case with CARE kV. The baseline scan (3A) was done with the standard protocol with 120 kV. For the follow-up scan CARE kV
suggested the optimal tube voltage of 100 kV for the individual patient and the specific application (3B). In combination with CARE Dose4D,
Siemens automatic online tube current modulation, this led to a 35% dose reduction (CTDIvol of 15 mGy vs. 9.8 mGy). Courtesy of University
Hospital of Munich, Grohadern, Germany
Dose Reduction
80%
60%
40%
20%
0
20
25
30
35
40
Patient diameter/cm
4 The smaller the patient the higher the
dose saving potential with CARE kV. This
graph shows how much dose can be saved
in contrast enhanced scans compared to a
standard 120 kV scan. The dose saving
potential is up to 60%.
Most importantly, the position of the

dose optimization slider has to be set
according to the clinical indication (Fig.
2). The symbols on the CARE kV settings
dialogue will help to define the exam
type; a slider on the far right side indicates a vascular exam, moving the slider
to the left will optimize settings for less
iodine content until, at the far left, the
settings are optimized for a non-contrast
scan. For each protocol one defines,

these settings should be adjusted once.
CARE kV will then adjust for the individual patient characteristics. Additionally,
for each exam, a minimum and maximum kV-setting can be specified to be
used, if necessary.
For routine scanning, three different
operation modes of CARE kV are available. When CARE kV is set to On, the
system will recommend optimized kVand mAs-settings. When CARE kV is set to
Semi, a user specified kV setting will be
used and mAs-values will be adjusted
based on the specified reference values.
This is particularly helpful for multi-phase
or follow-up exams where a constant kVsetting enables comparisons between the
different scans and/or exams of the same
patient. Last but not least, when CARE kV
is set to Off, the scan is performed with
the reference kV-setting defined in the
respective scan protocol.
As an additional feature, Siemens now
offers five kV-settings, ranging from
70 kV, 80 kV, 100 kV, and 120 kV to
140 kV. All available settings are considered when determining the optimal
setting for the individual patient and
clinical question.
Especially for pediatric examinations with
CARE Child, Siemens now makes it possible to scan with a tube voltage as low as
70 kV. This will particularly benefit children with their smaller body size in terms
of reduced radiation. Depending on
patient size CARE kV can save up to 60%
of patient dose compared to a 120 kV
scan at comparable image quality (Fig. 4).
Big step towards individual

patient care in CT
With CARE kV, Siemens SOMATOM scanners are the first in the medical imaging
industry to provide a tool for an automated adjustment of tube voltage. Additionally, they are the first to provide the
possibility to scan with 70 kV. These
innovative features bring patient care a
big step further towards an individualized level of care.
References
1 Greess H et al. Rofo. 2004 Jun;176(6):862-9.
2 Greess H et al. Eur Radiol. 2004 Jun;14(6):995-9.
3 Siegel MJ et al. Radiology. 2004 Nov;233(2):
515-22.
4 McCollough CH et al. Radiol Clin North Am. 2009
Jan;47(1):27-40.
5 Katharine Grant, PhD et al. White Paper, Siemens
Healthcare, 2011.
www.siemens.com/low-dose
27.05.11 09:38
Science
Choosing the kV is Now an Easy Equation

a First In-practice Report on CARE kV
By Jan Freund, Computed Tomography, Siemens Healthcare, Forchheim, Germany
It sounds so easy: Introduce a functionality that automatically suggests the

appropriate voltage setting for each scan.
But reality is often unfortunately
not so easy and it took until RSNA 2010,
before Siemens could introduce the
industrys first automated kV setting
functionality. Now, a few months after
its introduction, CARE kV proves its capabilities and potential in clinical practice.
CARE kV the rst automated

voltage setting
The right tube voltage value, measured
in kV, is one of the essential parameters
in CT scanning. Together with the tube
current, measured in mAs, it directly
affects the image quality and the associated dose. While the tube current can
be seen as the amount of photons created by the X-ray tube, the chosen tube
voltage value defines their energy. With
CARE kV, Siemens introduced the first
automated, exam-specific voltage setting. It is one of the many highlights of
the FAST CARE technology platform and,
with regards to dose reduction, perhaps
the most important.
Taking a closer look into what changing

the tube voltage means for CT and consequently how CARE kV works, it also
becomes clear why it is not as trivial as
it sounds. When changing the kV value,
many other parameters have to be readjusted as well. For example, in vascular studies using contrast media, lower
kV values are favorable. Due to its
higher attenuation, iodine then becomes
much brighther, resulting in increased
contrast of the vessels. But switching to
a lower kV value requires that the mAs
value also have to be changed in order
to maintain the same contrast-to-noise
ratio (CNR). Unfortunately, this correlation is not linear and thus requires complicated calculations (see also page 63).
Typically, in clinical practice, neither
knowledge nor time for this is at hand.
As a result, tube voltages are typically
not adjusted and remained mostly at
120 kV (Fig.1), the established standard.
Dose saving with CARE kV

But this will now change with CARE kV.
User defined reference values describe
the expected image quality in terms of
CNR. CARE kV then takes the patients

habitus from the topogram and the chosen examination type into consideration,
proposes the appropriate kV and sets all
other parameters accordingly to get the
defined CNR. And this pays off: Siemens
monitored CARE kV during the first
months after its introduction and evaluated the results. After having scanned
more than 12,000 patients, there was
a clear shift towards 100 kV and 80 kV
scans (see Figure 1B). With this, dose
could be saved in more than two thirds
of these patients, compared to the initial
protocols. And the dose reduction itself
was significant. For example, abdomen
scans could be reduced to below 10 mGy
using 100 kV, down from 14.1 mGy
with the former standard protocol set
at 120 kV. And this dose reduction of
around 30% came with no compromise
in image quality, as CNR could be maintained.
So, in the end, it has become as easy as it
sounds. With CARE kV, CT users can make
use of the full potential of their system
while patients benefit from significantly
reduced dose.
Lower dose in 67% of patients with CARE kV

1A
1B
Without CARE kV
100
kV usage [%]
100
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
1 The evaluation of applied

kV shows a clear shift toward
lower kV values using CARE kV.
Source: Internal data evaluation based on anonymous
assessment on SRS connected
scanners.
With CARE kV
kV usage [%]
0
70
80
100
120
140
Tube voltage [kV]
70
80
100
120
140
Tube voltage [kV]
65
27.05.11 09:38
Science
Dose Neutral Dual Energy Scanning

with Dual Source CT
By Peter Aulbach, Computed Tomography, Siemens Healthcare, Forchheim, Germany
CARE Dose4D
UFC
Iterative
Reconstruction
in Image Space
(IRIS)
X-Ray
Image data
recon
UFC
Image
correction
Light
Dose Shield
Raw data
recon
Dose Shield
Image data
recon
Image
correction
DSCT
Selective
Photon Shield
X-Ray low
en
Selective Photon Shield
en
At
ua
kV
tio
80
nA
Adaptive
Dose Shield
ua
tio
nB
140
kV
At
X-Ray on
SinogramAfrmed Iterative
Reconstruction
(SAFIRE)*
*The information about this
product is being provided for
planning purposes. The
product is pending 510(k)
review, and is not yet
commercially available in the
U.S
X-CARE
With Siemens unique Dual Source technology, all renowned dose-saving techniques can be applied, including
Ultra Fast Ceramic (UFC), CARE Dose4D, Adaptive Dose Shield, X-CARE, IRIS and SAFIRE.* Together with the
Selective Photon Shield, this makes Dual Energy as dose-efficient as conventional 120 kV scans. So all the diagnostic and image quality improving advantages of Dual Energy imaging are available with the same dose as a
Single Energy scan without a dose penalty.
27.05.11 09:38
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www.DSCT.com
Life
Free Trial Licenses for syngo.via are Now Available

By Marion Meusel, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Siemens Healthcares CT online portal,
Discover. Try. Get a Quote. for clinical
applications now offers the possibility to
learn more about CT specific applications
for syngo.via. Key feature descriptions
give you a first impression, and trial
license orders can be placed immediately.
syngo.CT Colonography is one of the
new features available on syngo.via.
CT-based colonography has become a
routine clinical tool for oncological assessment of the colon. Especially in the case
of failed or incomplete conventional
colonoscopy, as well as occlusive cancer
that prevents assessment of the proximal part of the colon, risk of bleeding,
or wall perforation, virtual colonoscopy
is the appropriate clinical method.
syngo.CT Colonography offers a dedicated non-invasive evaluation of the
entire colon based on low-dose, highresolution spiral CT scans. The application
combines the advantages of 2D and 3D
reading strategies for time efficient
analysis of the colon and provides fully
automated path finding and fast real-time
fly-through navigation with a high-quality
virtual endoscopic viewing technique.
syngo.CT Vascular Analysis allows the
1A
1B
1 Fig. 1A: CT-based colonography combines the advantages of 2D and 3D reading strategies
for time-effective analysis of the colon and provides high-quality virtual endoscopic viewing.
Fig. 1B: The vascular-only view allows the immediate evaluation and quantification of angiography images of the general vessels.
evaluation and quantification of angiography images of the general vessels with

a vascular-specific set of display functions. Due to automatic pre-processing
steps, an immediate view of the
extracted vessels is provided as soon as
the case is opened. The automatic sideby-side layout, e.g. to display both
carotid arteries, helps to better assess
and evaluate complex lesions. In the
case of abdominal aortic aneurysms
(AAA) syngo.CT Vascular Analysis provides
a dedicated stent planning template. The
automatic pre-processing features
ensure that the case is immediately
ready for review when opened, thus saving many manual workflow steps to bring
more efficiency into emergency situations.
One of the causes of acute chest pain can
be aortic dissection. As part of triple ruleout protocols syngo.CT Vascular Analysis
allows the immediate assessment of the
aorta and the vascular walls. The aortic
arch is easily evaluated in a curved planar
reformation. The software thus facilitates
life-saving decisions when every second
counts.
syngo.CT Vascular Analysis further facilitates pre-procedural planning, e.g. for
transcatheter aortic valve implantation.
The automatic side-by-side layout allows
for a quick assessment of the peripheral
arteries to check for an optimal access
path. The cross sections enable a reliable calculation of the vessel diameters.
The manual plane functionality yields a
visualization of the aortic arch and the
curvature is calculated with dedicated
evaluation tools.
To find out more about these features
and many more syngo.via applications,
free trial licenses can be ordered online.
www.siemens.com/DiscoverCT
27.05.11 09:38
Experience Lounge:
Hands-on Workshops at ECR 2011
By Susanne von Vietinghoff, Computed Tomography,
Siemens Hands-on Workshops at the
Experience Lounge are becoming an
established learning forum as they have
now been held for the 7th time at ECR.
More than 250 participants had the
opportunity to read cases from CT, MR as
well as nuclear medicine under the guidance of experienced experts. As part of
the Breast Care Day at ECR 2011, there
were sessions on Thursday dedicated to
MR breast reading and reporting held by
Prof. Werner A. Kaiser, MD, from the Institute of Diagnostic and Interventional Radiology I, Friedrich-Schiller-University Hospital Jena, Germany. CT Oncology courses
were held by PD Anno Graser, MD, Assistant Professor at the Department of Clinical Radiology at the University Hospital in
Hands-on Workshop at this year European

Radiology Congress (ECR) in Vienna
Munich-Campus Grosshadern. At the

beginning of each 1.5-hour session the
speaker gave a introduction of the topic
and an update on state-of-the-art scanning techniques. During his session on
cardiology, Prof. Dieter Ropers, MD, from
the Medical Institute for Cardiology and
Angiography at the University Hospital
Erlangen, Germany pointed out the different possibilities on how to perform a
cardiac examination from basic sequence
scanning to the most advanced Flash
Spiral data acquisition.
After the short introduction, it was
time for the participants to experience
Siemens imaging software for themselves. One workstation and monitor
were available for each team of two par-
ticipants to follow and interact with the

instructors. PD Rolf Janka, MD, from the
Department of Radiology at the University Hospital of Erlangen, Germany, took
the participants along a flight through
the colon explaining the multiple advantages of syngo.via. Participants during
the CT Dual Energy session held by Ralf
Bauer, MD, from the Institute for Diagnostic and Interventional Radiology
Johann Wolfgang Goethe-University at
Frankfurt/ Main, Germany, highly appreciated that post-processing of Dual
Energy data is so fast and easy to use.
The next possibility to join one of our
Workshops is the annual meeting of the
European Society of Cardiology (ESC)
from 2731 August 2011 in Paris.
Clinical Workshop on Cardiac CT at Munich University

By Susanne von Vietinghoff, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Cardiac CT is a rapidly evolving field that
provides a clinically valid method for
non-invasive assessment of coronary
artery disease and structural cardiac
pathology. In 2011, Siemens Healthcare
will offer two workshops for radiologists
who would like to deepen their clinical
University Hospital in Munich
knowledge and practical skills on cardiac

CT. The workshops will be offered in
cooperation with Christoph Becker, MD,
Professor of Radiology and Section Chief
of CT and PET/CT at the University Hospital in Munich - Campus Grosshadern,
Germany.
The three-day training will cover scientific
lectures, clinical presentations, live examinations as well as hands-on sessions with
advanced syngo evaluation software. All
aspects of cardiac CT imaging (calcium
scoring, CTA, functional imaging, viability
imaging and valve imaging) will be
addressed in comprehensive lectures that
support the hands-on training sessions.
Opportunities for advanced training and

observation of live CT cases on the
SOMATOM Definition Flash will be part
of the course. Up to 50 clinical CTA cases
will be reviewed during the course with
cross correlations (invasive angiography
and IVUS).
Date Details: July, 2022, 2011
November, 911, 2011
More details about the course and how
to book can be found via the following
link:
www.siemens.com/life-courses
69
27.05.11 09:38
Life
NEW Series of Live Clinical Webinars

By Susanne von Vietinghoff, Computed Tomography, Siemens Healthcare,
Forchheim, Germany
A seminar can be joined via webinar

without leaving the office.
Radiologists are busy people. Scanning,

processing and diagnosing 30 or more
patients each workday leaves little time
and opportunity to look for information
to remain up-to-date in their profession.
Therefore, bringing education and training to the medical imaging specialists
has always been given high priority at
Siemens.
Siemens newest efforts are live, crossmodality, clinical webinars. Each month
there will be presented and discussed

what is new and exiting in one of the
different modalities.
A live webinar is more than just information, medical imaging specialists
can learn from some of the worlds
renowned clinicians and also have the
opportunity to interact live with them.
The first of these webinars on December
16th 2010, conducted by Prof. Stephan
Achenbach, MD, from the University
Hospital of Erlangen/Germany, was
dedicated to Low Dose in Cardiac CT
Imaging.
During his presentation, he explained
the motivation as well as need to
increase dose only very cautiously, especially when it comes to coronary CTA.
Potential strategies on how to lower
dose were outlined in a clear way,
ranging from basic technologies like
ECG-based, tube-current modulation
(pulsing) for spiral acquisitions to more
advanced, techniques like the Flash

Spiral scan mode.
After this first very positive experience,
the following webinars are planned for
the near future:
MR: Emergencies in Neuro Imaging
Interventional Imaging: Hybrid Surgery
Multi-modality Reading in Oncology
IQ-SPECT: Maximize Speed and Minimize Dose
The next clinical webinar for CT will be
on Thursday 09th of June at 15:30 CET.
The topic will be CT Stroke Management and the webinar will be held by
Prof. Bernd Tomandl, MD.
To register for any of the above or to
view recorded past webinars, please use
the following link:
www.siemens.com/clinicalwebinars
FAST CARE for All

Patients of syngo
Evolve Customers
By Katharina Linseisen, Computed Tomography,
syngo Evolve, Siemens non-obsolescence

program consists of software and hardware upgrades. Together with the new
FAST CARE Platform, it provides innovative enhancements and access to new
features for SOMATOM Definition AS
scanners. To give medical professionals
FAST Adjust: Direct adjustment of all parameters can be done with a single click.
27.05.11 09:38
Life
Investment Protection for SOMATOM CT Scanners

By Katharina Linseisen, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Up-to-date, powerful software and hardware are key factors for maximizing the
performance and diagnostic quality of
CT systems. syngo Evolve, Siemens nonobsolescence program, contains wellplanned upgrades of the existing software and hardware. It helps to keep pace
with rapidly developing technology. With
syngo Evolve, SOMATOM scanners that
have been installed for 3 to 5 years, get
new, state-of-the-art hardware and the

latest software providing improved
performance and access to the latest
innovations. Thus, syngo Evolve ensures
increased investment protection for CT
scanners. And, because it
is an option which can be included in the
Siemens service contract, it allows economical and accurate budget planning.
With the upgrade, customers benefit
System capabilities
from feature enhancements for the

existing software solutions, allowing
higher productivity and improved competitiveness. Additionally, new clinical
applications that can be purchased
after the upgrade, promote new business
opportunities.
With syngo Evolve, SOMATOM scanners
are prepared for the innovations which
are yet to come.
www.siemens.com/ct-evolve
Technological development
With syngo Evolve, customers get access to
innovative clinical and diagnostic applications to expand the capabilities of their
system.
Access to new applications with syngo Evolve
A well-planned software and hardware

upgrade with syngo Evolve will bring the
system to the next level of performance.
System performance upgrade with syngo Evolve
System performance without syngo Evolve

Time
syngo Evolve helps to keep pace with rapidly developing technology.
more time for their patients, the new

FAST CARE technology accelerates workflow and lowers radiation exposure to
previously unseen levels. Thus, it levers
untapped potential in patient-centric
productivity.
Definition AS scanners with a syngo
Evolve contract will automatically get
the new FAST CARE platform.
It includes the following innovative
enhancements that allow delivering
FAST CARE to all patients:
CARE kV: first automated, exam-specific tube voltage setting to optimize
contrast-to-noise-ratio and reduce
dose by up to 60%
CARE Child: dedicated pediatric CT

imaging, including industrys first 70
kV scan modes and dedicated protocols to significantly lower radiation*
CARE Dose Configurator: more precise
and simplified dose modulation,
allowing more accurate parameter
adjustments to the patients anatomy
CARE Profile: visualization of the dose
distribution along the topogram prior
to the scan
CARE Dashboard: visualization of
activated dose reduction features to
analyze and manage the dose to be
applied in the scan
FAST Adjust: intuitive scan parameter
adjustment at the push of a button
Without syngo Evolve, a system remains at

the same performance level over its entire
life cycle.
In addition to the syngo Evolve upgrade,

FAST CARE offers a range of optional
features to utilize the scanner even
more efficiently, e.g. FAST Planning
allows a safer, faster and more standardized workflow at the scanner via immediate, organ-based settings of scan and
recon ranges.
* license must be ordered separately, requires new
STRATON X-ray tube
International:
www.siemens.com/DiscoverCT
USA only:
www.usa.siemens.com/
webShop/CT
71
27.05.11 09:39
Life
Frequently Asked Questions:

How can Dose be Reduced with syngo.via?
By Ivo Driesser, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Since the introduction of cardiac scanning many different features have been
introduced to minimize radiation dose.
ECG-pulsing is one of them. For a full
cardiac evaluation, including functional
assessment, it was previously necessary
to scan with normal pulsing.
This has changed with improved algorithms in syngo.via.
They detect the shape of the ventricles
even when the scan is performed with

MinDose. MinDose pulsing reduces the
dose in the systolic phase even more.
Only 4% of the normal dose is used in
the systolic phase.
On the trigger subtask MinDose auto
or MinDose manual can be selected
(Fig. 1).
Where can I find my results?
After opening the study in syngo.via, the
results are displayed correctly in the CT

Cardiac Function Workflow step. The
noise of the images does not influence
the calculations (Fig. 2).
The calculation of ejection fraction, cardiac output and more are now possible
with low dose.
Conclusion: syngo.via makes virtually
full cardiac function assessment possible
with low dose.
1 Pulsing:
MinDose
auto (marked
in red).
2 Adequate
results with
lowest possible
dose are
directly accessible without any
clicks.
72 SOMATOM
Titel Magazine
Sessions
February
June2008
2011 www.siemens.com/healthcare-magazine
27.05.11 09:39
Life
Upcoming Events & Congresses
Title
Dates
Short Description
Location
Contact
DRK
Jun 1 4, 2011
92. Deutscher Rntgenkongress
Hamburg, Germany www.roentgenkongress.de
DEGRO
Jun 2 5, 2011
17. Jahreskongress der Deutschen Wiesbaden,

Gesellschaft fr Radioonkologie Germany
http://congress.cpb.de
/2/Startseite.
degro-2011.0.html
ISCT
Jun 13 16, 2011
International Symposium on
Multidetector Row CT
San Francisco, USA
www.isct.org
SCCT
Jul 14 16, 2011
6. Annual Scientific Meeting of

the Society of Cardiovascular
Computed Tomography
Denver, USA
www.scct.org
ESC
Aug 27 31, 2011
European Society of Cardiology

Congress 2011
Paris, France
www.escardio.org/
congresses/esc-2011
RSNA
Nov 27 Dec 2, 2011
97. Annual Meeting of Radiological Society of North America
Chicago, USA
www.rsna.org
Clinical Workshops 2011

As a cooperation partner of many renowned hospitals, Siemens Healthcare offers continuing CT training programs.
A wide range of clinical workshops keeps participants at the forefront of clinical CT imaging.
Workshop Title
Dates
Location
Course
Language
Course Director
Coronary CTA
Interpretation Workshop
Jun 30 Jul 1, 2011

Dec 15 16, 2011
Erlangen,
Germany
English
Prof. Dieter Ropers, MD
Clinical Workshop
on Cardiac CT
Jul 20 22, 2011

Nov 09 11, 2011
Munich,
Germany
English
Prof. Christoph Becker, MD
Hands-on Tutorials at ESC 2011
Aug 27 30, 2011
Paris, France
English
Siemens Healthcare
Clinical Training Course on

Cardiac CT
Sept 10 11, 2011
Kuching,
Malaysia
English
Prof. Sim Kui Hian, MD

Ong Tiong Kiam, MD
ESGAR CT Colonography Workshop
Sept 14 16, 2011
Dublin, Ireland
English
Prof. Helen Fenlon, MD

Martina Morrin, MD
Clinical Workshop on Dual Energy
Sept 30 Oct 1, 2011
Forchheim,
Germany
English
PD Thorsten Johnson, MD
In addition, you can always nd the latest CT courses offered by Siemens Healthcare at www.siemens.com/SOMATOMEducate
SOMATOM Sessions November 2010 www.siemens.com/healthcare-magazine 73
27.05.11 09:39
Subscription
Siemens Healthcare Publications

Our publications offer the latest information and background for every healthcare
eld. From the hospital director to the radiological assistant here, you can quickly nd
information relevant to your needs.
Medical Solutions
Innovation and trends
in healthcare. The
magazine, published
three times a year, is
designed especially
for members of the
hospital management,
administration personnel, and heads of
medical departments.
AXIOM Innovations
Everything from the worlds
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