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Answers for life in Computed Tomography
Issue Number 30 / August 2012

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Cover Story
Performance is Becoming
More Accessible
Page 6
SOMATOM Denition
Edge: Low Dose,
Quality Images
Page 16
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SOMATOM Sessions
News
Business
US Edition
Global Siemens Headquarters
Low Dose, High

Resolution for
Pediatric Cardiology
Page 34
Clinical
Results
Diagnosis of an
Intracranial
Dual-Aneurysm
using the new
SOMATOM Perspective
Page 54
Science
Beating Cancer
Treating Individuals
Page 69
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A. Nchanduca, RT, Clinica Girassol, Luanda, Angola
Borek Foldyna, MD, University of Leipzig,
Heart Center, Leipzig, Germany
Christian Fink, MD, University of Mannheim, Germany
Christian Lcke, MD, University of Leipzig,
Christoph Schlke, MD, University of Muenster,
Muenster, Germany
Claudia Andres, MD, University of Leipzig,
Constana Palma Borges, MD, Clinica Girassol,
Luanda, Angola
Erdie Q. Dizon, Radiographer, Tan Tock Seng Hospital,
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Fahim H. Jafary, MD, FACC, FSCAI, Tan Tock Seng
Hospital, Singapore
Fumiaki Ishida MD, Toho University Omori Medical
Center, Tokyo, Japan
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Inner Mongolia, P. R. China
Gang-feng Hu, MD, Wuxi Peoples Hospital Afliated
to Nanjing Medical University, Wuxi, P.R. China
Go Sano MD, Toho University Omori Medical Center,
Tokyo, Japan
Hailiang Jia, MD, Baotou Central Hospital,
Harald Seifarth, MD, University of Muenster,
Muenster, Germany
Heather Gill-Frerking, Reiss-Engelhorn Museums,
Mannheim, Germany
Christian Rayr freelance journalist, Paris, France;

Irne Dietschi science and medical writer, Switzerland;
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Germany; Robert L. Bard medical writer, Michigan, USA
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Savvas Nicolaou, MD, Vancouver General Hospital,
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Susumu Sakamoto MD, PhD, Toho University Omori
Thomas Henzler, MD, University of Mannheim,
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Vasco Silva, MD, Clinica Girassol, Luanda, Angola.
Wilfried Rosendahl, PhD, Reiss-Engelhorn Museums,
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Xiang-ming Fang, MD, Wuxi Peoples Hospital Afliated
Xiao-yun Hu, MD, Wuxi Peoples Hospital Afliated to
Nanjing Medical University, Wuxi, P.R. China
Yingning Wang, MD, Peking Union Medical College,
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Hui-jun Lu, MD, Wuxi Peoples Hospital Afliated
Jagajothi Devadoss, Senior Radiographer,
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Jian Cao, MD, Peking Union Medical College,
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Joana Costa, MD, Institut Jules Bordet
Joo Carlos Costa, MD, Hospital Particular de Viana
do Castelo, Viana do Castelo, Portugal
Johann Steffens, MD, Israelitisches Krankenhaus,
Hamburg, Germany
Johannes Wessling, MD, University of Muenster,
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Jyoji Nakagawara, MD, Nakamura Memorial Hospital,
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Kai Sun, MD, Baotou Central Hospital, Inner Mongolia,
P. R. China
Kazutoshi Isobe MD, PhD, Toho University Omori
Keishi Sugino MD, PhD, Toho University Omori Medical
Keita Sato MD, Toho University Omori Medical Center,
Tokyo, Japan
Kianoush Ansari Gilani, MD, University Hospital
Radiology, Cleveland, Ohio, USA
Leslie Ciancibello, RT, University Hospital Radiology,
Cleveland, Ohio, USA
Lijun Ma, MD, Baotou Central Hospital,
Ludger Feyen, MD, University Hospital Mnster,
Germany
Lukas Lehmkuhl, MD, University of Leipzig,
M. Reis, RT, Hospital Particular de Viana do Castelo,
Viana do Castelo, Portugal
M. Sozinho, RT, Clinica Girassol, Luanda, Angola
Marisa Gonalves, RT, Hospital Particular de Viana
Masahiro Kobayashi MD, Toho University Omori
Matthias Gutberlet, MD, University of Leipzig,
Heart, Center, Leipzig, Germany
Nao Hirota MD, Toho University Omori Medical Center,
Tokyo, Japan
Naoshi Kikuchi MD, Toho University Omori Medical
Nobuyuki Shiraga MD, PhD, Toho University Omori
P. Miguel, RT, Clinica Girassol, Luanda, Angola
Ping-yan Qian, MD, Wuxi Peoples Hospital Afliated
Prof. Robert C. Gilkeson, MD, University Hospital
C. Rosa, RT, Clinica Girassol, Luanda, Angola
Ruijuan Han, MD, Baotou Central Hospital,
S.Bastos, RT, Clinica Girassol, Luanda, Angola
Editorial
Peter Seitz,
Vice President Marketing,
Computed Tomography,
Siemens Healthcare,
Forchheim, Germany
Dear Reader,
Over the past few months, several breakthroughs in CT have been implemented
in clinical practice. These innovations
address an increasing demand for efficiency in diagnostic imaging, as well as
the possibility to individualize imaging
for each patient.
When investing in high-end technology,
such as 128-slice CT scanners, the balance between performance and cost has
become the key criterion in many buying
decisions. The Sainte-Marie Hospital near
Paris is an example of where high expectations in imaging quality have to be
matched with the need to manage high
patient numbers. In this issue, read how
the SOMATOM Perspective was rapidly
implemented at this hospital providing
the perfect balance for both requirements.
At the German Heart Center in Leipzig,
syngo.via has helped to reduce the time
required for vessel segmentation tenfold,
a considerable difference especially
when handling complicated cases. Its
automatic pre-processing also speeds
up TAVI planning significantly.
In addition to performance and cost

effectiveness, high-end quality remains
essential in daily CT clinical use. In
Switzerland, at the Inselspital in Bern
full use is made of the Stellar Detector
which provides the high resolution at the
lowest possible dose required in clinical
imaging of children awaiting cochlea
implants. The hospital has an international
reputation in this field and was among
the first to implement the Stellar Detector
and SOMATOM Definition Edge.
High resolution is also key for the German
Heart Center in Munich, where the Stellar
Detector is used in their Flash Dual Source
scanner. When assessing the relevance
of a stenosis in a small coronary artery,
the remaining diameter that needs to be
depicted can be as small as 1 millimeter
or even less. A remarkable new achievement.
CT has come a long way in meeting many
challenges in resolution, quality and dose.
Today, Siemens is celebrating the 1000th
delivery of a Dual Source scanner worldwide. This confirms DSCT as the leading
CT technology around the globe. Read in
this issue about how Dual Source CT is
used at the Minneapolis Heart Institute
to individualize imaging for each patient.
And about how smart algorithms, such

as CARE kV, help to individualize parameters, e.g. the amount of radiation
applied to each patient.
Because thats what Siemens focuses
its entire innovative energy on: helping
to manage financial performance whilst
offering individualization at the most
demanding levels. For this reason,
Siemens developed the smallest 128-slice
scanner and is continuously improving
the capabilities of unmatched Dual Source
technology.
Discover for yourself in this latest issue
of SOMATOM Sessions how these innovations can impact clinical practice.
Any feedback in the form of comments,
criticisms or suggestions will be gladly
received.
Yours,
Peter Seitz
Content
Content
Cover Story
22
34
Siemens International
CT Image Contest 2011
Low Dose, High Resolution

for Pediatric Cardiology
Cover Story
06 Performance is Becoming
More Accessible
News
6 Sainte-Marie Clinic in Osny,

France was one of the first places,
to have the recently introduced
SOMATOM Perspective CT scanner
installed at the beginning of 2012.
SOMATOM Sessions visited the
medical imaging team there to talk
about their first experiences in
diagnostic, economic and ecological
respects and how performance is
becoming more accessible.
12 Stellar Detector: Lower Radiation

Dose, Increased Precision
16 SOMATOM Definition Edge:
Low Dose, Quality Images
20 Iterative Reconstruction
Lower Dose in Clinical Routine
22 Siemens International CT Image
Contest 2011
26 syngo.via Brings Improved Automation and Additional Functionality to
Clinical Routine
28 App now Available for
29 KLAS Report 2011 Honors Siemens
Commitment to Low-Dose CT
30 Pushing Boundaries in CT Latest
Research in Functional Imaging
Business
32 Straton X-ray Tube: HighPerformance under Challenging
Conditions
34 Low Dose, High Resolution for
38 eMode on SOMATOM Perspective
a Chance to Optimize Total Cost
of Ownership in Clinical Routine
Clinical Results
Cardio-Vascular
40 Adaptive 4D Spiral CT Angiography
for the Diagnosis of a Capillary
Hemangioma
42 Diagnosis of Coronary-Ventricular
Fistula with Giant Coronary Aneurysm
using Flash Mode
44 Diagnosis of Truncus Arteriosus
using Flash CT Scanning
46 Follow-up on CABG using iTRIM
Method for Coronary CTA
Content
62
Diagnosis of Sub-acute Pulmonary
Emboli using Flash mode, SAFIRE and
100 kV
72
Education and Awareness Brings
Condence to Decision-making in
Medical Imaging
74
Siemens Hands-on Workshops
at the ECR and ESC
Customer
Excellence
48 Diagnosis and Follow-up of
RCA Aneurysm using Flash Scanning
at 0.3 mSv
62 Diagnosis of Sub-acute Pulmonary

Emboli using Flash Mode, SAFIRE
and 100 kV
Oncology
50 Xenon Ventilation Imaging using
Dual Energy CT in Combined
Pulmonary Fibrosis and Emphysema
52 Non-Hodgkin Lymphoma with
Rare Metastases in the Pancreas
Pulmonology
64 Dynamic Volumetric Expiratory
Imaging for Diagnosis of Tracheobronchomalacia using Flash CT
Scanning
Neurology
54 Diagnosis of an Intracranial
Dual-Aneurysm using the new
SOMATOM Perspective
56 Whole Brain Perfusion CT Reveals
Acute Misery Perfusion
Acute Care
58 CT Perfusion Identifies Delayed
Cerebral Ischemia after Subarachnoid
Hemorrhage
60 Time Resolved CT Angiography in
Patients after EVAR
Science
74 Siemens Hands-on Workshops

at the ECR and ESC
75 Clinical Webinar: Highly Topical
Information Presented by Specialists
75 Coronary CTA Interpretation
Workshop Level II
76 Frequently Asked Question
77 Clinical Workshops 2012
77 Upcoming Events & Congresses
2012
78 Subscription
79 Imprint
66 Lung Ventilation Imaging with

Xenon Dual Energy CT
68 Discovering the Mysteries of Our
Ancestors With Dual Energy CT
69 Research Clusters Enable Transfer of
Basic Research to Clinical Routine
72 Education and Awareness Brings
Confidence to Decision-making in
Medical Imaging
1 In the Sainte-Marie Clinic in Osny, France, about 800 patients have been already examined with the new SOMATOM Perspective.
Almost all pathologies have been successfully investigated. This follow-up study of a spine fracture is an example of osteoarticular
imaging. Courtesy of Sainte-Marie Clinic, Osny, France
Cover Story
More Accessible
At the beginning of 2012, the Sainte-Marie Clinic in Osny, France, was one
of the rst places in the world to have the SOMATOM Perspective CT scanner
installed. The event was welcomed by the whole medical imaging team,
which received the new piece of Siemens equipment and which has already
noticed its diagnostic, economic, and ecological performance.
By Christian Rayr
Between Paris and Pontoise, roads and

motorways pass through a string of industrial suburbs, then towns and villages,
which are generally green and welcoming,
without interrupting the urban network.
It is in Osny, in the uplands of Pontoise,
that you can begin to imagine that you
are in the countryside. On the one hand
we are in Paris, we are an extension of
the capital. On the other hand, beyond us,
the countryside really begins, explains
Franck Lamesa, General Charge Nurse
for Medical Imaging at the Sainte-Marie
Clinic.
The medical imaging centre was founded
by a group of radiologists in the 1960s
to meet the health requirements of a continuously growing population. It was
initially located in the town of Pontoise
itself and the centre grew over time, with
doctors and radiologists all practicing in
very different specialties, says Alexandre
Fuchs, MD, co-director of the SainteMarie medical imaging center. As a result
of development, the centre had to grow
and relocate. The medical imaging centre
is now located primarily in Osny. It is
associated with the Sainte-Marie Clinic
(see box next page) and is responsible
for a large part of the care offered to a
town of 500,000 residents, of which the
socio-economic status is very mixed.
Fuchs remembers, in 1999 we became
the first establishment in France to have
the first multi-slice Siemens CT scanner
(4 slices), which was revolutionary at

the time. This was within the framework
of a partnership with Siemens, one of
the world leaders in imaging. From this
time, the partnership has only become
stronger and several devices have
arrived to complete the equipment. The
SOMATOM Definition AS, with 128 slices,
was installed in 2010, again one of the
first in France. Two MRIs arrived as well
as syngo.via, the new multi-modality
imaging software. At the end of January
2012, as one of the first worldwide, the
all-new SOMATOM Perspective scanner
was installed, having been introduced
officially at the Radiological Society of
North America (RSNA) congress in Chicago at the end of November 2011.
800 Patients already examined

Fuchs says, after six weeks of using the
CT scanner, we are only just beginning to
see all its possibilities, but it has already
met all of our expectations. We have
examined about 800 patients and have
been able to study almost all pathologies
without any problem: oncology, pediatrics, cardiac, vascular, osteoarticular,
cerebral etc. We are very satisfied with
the results.
It is 11.20 am on this Monday morning
in Osny. Already eighteen patients have
been through the SOMATOM Perspective
tunnel this morning. One every ten minutes, explains Guillaume Hamel, the
Alexandre Fuchs, MD is co-director of the

Sainte-Marie Clinic near Paris
operator who works with the two scanners, SOMATOM Definition AS and
SOMATOM Perspective. Perspective is a
little bit slower than SOMATOM Definition
AS. With the SOMATOM Perspective, we
can do a thorax examination in 3 seconds
(1.5 seconds with SOMATOM Definition
AS), pelvic abdominal examination in
8 seconds, and lumbar rachis in 10 seconds. The device is extremely easy to use.
And the reconstruction module means
Cover Story
Entrance of the Sainte-Marie Clinic, Osny, France
Sainte-Marie in Osny: A Health Center

with Advanced Medical Imaging
Since it was founded, the Sainte-Marie Clinic has relocated
and expanded several times. Today it is made up of several
buildings covering an area of around 14,000 square meters.
It specializes in surgery and oncology and is fitted with the
highest quality technical equipment. It has an accident
and emergency department, which is open 24 hours a

day, seven days a week. For run of the mill consultations,
the Sainte-Marie Clinic has also opened a versatile medical
service that brings together several specialist surgeries.
Composed of two buildings facing each other the medical imaging centre and the institute of radiology the
Sainte-Marie Clinic is involved in the care of in-patients
but also receives a large number of external patients.
Franck Lamesa explains: We are open ten hours per day
and see approximately 300 patients a day. About three
percent of these are emergency patients, five to ten percent are patients in the hospital and the others are patients
with outpatient appointments. All kinds of examinations
are carried out: standard or very low dosage radiology,
echography, mammogram, and osteodensitometry,
amongst others. They also include interventional procedures, macro and micro biopsies, infiltrations, and infusions.
Working in partnership with Siemens, the Sainte-Marie
Clinic has devices from each of the previous generations:
a digital Siemens mammogram, two Siemens MRIs
(1.5T Aera and 1.5T Essenza), two Siemens CT scanners
(SOMATOM Definition AS and SOMATOM Perspective)
and syngo.via as mutli-modality imaging software. The
SOMATOM Perspective, the newest one, was installed in
Osny as one of the first worldwide.
that the images can be smoothed very

quickly.
High-quality images, radiation

cut by half
High-quality images are obtained very
quickly, confirms Fuchs. The syngo
interface and the syngo.via imaging software allows the images to be transferred
quickly to the internal network, with
complete fluidity. The images are very
easy to read. Depending on the programmed examination and the pathology
being looked for, the images can be seen
instantly and in accordance with the
adapted slice. Both operators and doctors
think that the workflow is remarkably
easy. The fact that an examination can
be carried out so quickly is an important
asset. Fuchs says that this is because we
do a lot of pediatric work here and children
have a natural tendency to move during
The use of the eMode software allows the team in Osny to work at more or less
80 percent of the systems maximum intensity, which extends a longer life cycle.
Cover Story
The atmosphere in the examination room can be softened thanks to the Illumination Moodlight.
This lighting system can be adjusted in terms of color and intensity.
examinations. We also do a lot of oncology work, with patients who have had to
undergo numerous repetitive examinations. Thanks to this new CT scanner and
Sinogram Affirmed Iterative Reconstruction SAFIRE* in short , which we also
use with SOMATOM Definition AS, we
have observed that the radiation doses
are markedly reduced. After four to six
weeks of use, the team believes that the
reduction of the doses is around 50 percent, which they think is very significant.
A quick, less stressful

examination
The arrival of the SOMATOM Perspective
also has another benefit for patients:
* 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.
Ease of use, speed

of acquisition, image
quality, decrease
in radiation doses
SOMATOM
Perspective has a
larger number of
advanced options.
Alexandre Fuchs, MD,
Sainte-Marie Clinic, Osny, France
Cover Story
it means that waiting times are considerably reduced. On average we do

40 examinations a day with SOMATOM
Perspective, explains Franck Lamesa.
Today we could do up to 50. And if there
was not a shortage of radiologists, maybe even 80. But already, instead of waiting three weeks or a month, our patients
can get an appointment within 48 hours.
Even the atmosphere in the examination
room is softened thanks to the Illumination Moodlight. This lighting system can
be adjusted in terms of color and intensity, which is very useful when working
with children everyday. Their attention
can be drawn to an external stimulus and
can make a possibly stressful examination
less of a big deal. Some claustrophobic
patients also seem to be more at ease
with Moodlight. SOMATOM Perspective
appears to be suitable for any indication
and any patient from the calmest to
the most anxious. For those who have a
tendency to move either voluntarily or
involuntarily.
Economic installation and

functioning
Alexandre Fuchs and Franck Lamesa both
think that the device has benefits other
With the SOMATOM Perspective, Alexandre Fuchs, MD can obtain high-quality images very quickly.
After that the images can be reviewed immediately at the syngo.via workplace.
than the medical ones, for example

organizational and economic benefits.
SOMATOM Perspective is a smaller scanner that has been designed particularly
carefully in respect of actual demands
for medical equipments and is amazingly
compact in comparison to traditional
devices. Franck Lamesa and Guillaume
Hamel were both amazed by its generator: a small box measuring 70 by 30
At the end of January 2012, as one of the first worldwide, the all-new SOMATOM Perspective
scanner was installed in Sainte-Marie imaging center.
centimeters that can be run from a tiny

storage cupboard at the side of the
examination room and does not require
a refrigerated place. In total, a room
measuring less than 20 square meters is
big enough for the scanner. In addition
to this, it is easy to install. As it is ultra
light, the SOMATOM Perspective does
not need a reinforced floor. It has its own
air-cooling system and therefore does not
require air conditioning: it can operate
in a room where the temperature fluctuates between 18 and 30 degrees Celsius.
Finally, it can be installed in just one day,
whereas conventional scanners require a
minimum of three to four days for installation, on average.
The SOMATOM Perspective is also cost
effective, which is important in times
where healthcare institutions are subject to pressure from multiple sources
to provide that their care is profitable.
Another advantage of the new CT scanner is a kind of automatic saving. The
use of the eMode allows us to economize
scanner operation, working at more or
less 80 percent of its maximum power,
which prolongs the life cycle, explains
Fuchs. An automated parameter setting
uses less power and enables more profitable material management.
We have started on an active evaluation process of the eMode, says Franck
Lamesa. We do at least 95 percent of
examinations using this software feature.
Cover Story
Value for MRI

By Eric Johnson
More for less this is technologys history lesson. Take
mobile phones: not only have they shrunk from paving
brick to billfold size, they have gained massive functionality
while declining in real price. Ditto the trend for automobiles, personal computers, refrigerators, and just about
any gadget you can name.
That includes medical-imaging devices. Siemens is taking
seriously both the economic pressures on global healthcare systems and its attendant responsibility to innovate
and invest in premium products that also are cost-efficient.
So here come a new array of accessible innovations:
the SOMATOM Perspective CT, the ACUSON S1000
ultrasound system, and a new MAGNETOM system.
Until its worldwide commercial launch in early 2012,
3 Tesla MRI was beyond reach of most non-research
hospitals and clinics. Of course 3T delivers higher signalto-noise, more detail and the ability to shorten scan time,
but until now, budgets of small and medium-sized hospitals and practices typically stretched only as far as 1.5T.
With an upcoming MAGNETOM 3T system, those budgets
recalculate, and not just due to outstanding image quality
and lower capital outlay. The new 3T MRI system offers
premium imaging at a reduced total cost of ownership
compared to other MRI scanners in this product range. This
will be the best in class standard bore 3T.
A crucial factor for those savings, and the systems clinical
success is the excellent usability, making 3T MRI less
complex. In the past, 3Ts often required full-time medical
physicists to keep them working properly. These highlyskilled technicians sort the settings and planar positioning,
and they screen scans for artifacts, quantum effects, and
other negatives. Clinics, by contrast, generally lack the
Every year a usage analysis is carried out

with Siemens: if the eMode is used for
at least 80 percent of scans, the imaging
centers can benefit from various advantages e.g. training days, specific applications, re-evaluation of the maintenance
contract, and so on. This leads to another
financial gain. One should not forget
that these savings also have an ecological effect, adds Franck Lamesa.
A scanner for all radiology

centers
Franck Lamesa: Ease of use, speed of
acquisition, image quality, decrease in
work-volume to justify hiring such an employee. But they

can employ two virtual staff members: Siemens Tim
(total imaging matrix) and Dot (day optimizing throughput) systems. These allow an easy and fast patient setup
and organize the work for the MRI operator, allowing
an easy, intuitive operation of MAGNETOM 3T systems
with excellent, reproducible results.
According to the customer, a typical cardiac exam on a
1.5T scanner with conventional software takes an hour.
With 3T and Tim and Dot, this time can be significantly
reduced.
Eric Johnson writes about business, the environment, medicine

and technology from Zurich, Switzerland. He studied chemistry, and
prior to working independently, headed what is now a ThompsonReuters bureau and corresponded for McGraw-Hill World News.
radiation doses SOMATOM Perspective,

which is a high-end device, has a larger
number of advanced options. This scanner even makes non-routine procedures
in the majority of radiology sites possible:
interventional procedures, infusions,
emergencies Its a flagship machine
that responds to the current requirements
of all radiology centers.
Christian Rayr is a freelance journalist based

in Paris, France. He writes for various medical
publications and covers medical topics for the
general media.
www.siemens.com/
SOMATOM-Perspective
11
News
Stellar Detector: Lower Radiation Dose,

Increased Precision
The new CT detector technology from Siemens wins over users
immediately, as an interview conducted by SOMATOM Sessions with
doctors at the German Heart Center in Munich, Germany reveals.
By Martina Lenzen-Schulte, MD
As a rule, innovations can only be

achieved if one ventures away from predefined paths of thinking. This is often
easier said than done, but it is nonetheless
true. The first big step in the development of CT solid-state detectors was the
introduction of a highly efficient detector
material. Now, Siemens has also taken
a new approach in a different area the
improvement of the detector electronics.
And behold, the fine tuning of this new
element has paid off. At the German Heart
Center Munich, Stefan Martinoff, MD,
Director of the Radiology Institute, and
Jrg Hausleiter, MD, Head of the Cardio-
1A
logical Intensive Care Unit have already

been amongst the first to work with the
new technology.
SOMATOM Sessions: You are now
already utilizing the full performance
of the new Stellar Detector in the
SOMATOM Definition Flash CT. What
has been your experience?
MARTINOFF: Here we are dealing with
an apparently better image quality compared to previous detector generations.
On the one hand, this is due to reduced
electronic noise, because naturally, every-
1B
thing that generates noise is a disruptive

factor. One immediately notices in the
images how well they have been able to
reduce the noise with the new detector.
The members of our staff also confirm
this. Moreover, the resolution is noticeably higher, as we have already been able
to determine.
HAUSLEITER: We particularly like the fact
that these advantages are not offset by
disadvantages. On the heart, which is
constantly moving, it is not only a matter
of morphologically analyzing the coronary vessels and their alterations. We
1C
1 Example of a bypass follow-up study done with the Stellar Detector. Courtesy of German Heart Center Munich, Munich, Germany
News
would also like to exclude any distortion

that is due to movement. With the new
Stellar Detector, we can continue to use
the SOMATOM Definition Flashs tried
and tested highest heart rate independent temporal resolution a compelling
argument with the beating heart.
SOMATOM Sessions: What in your
view are the diagnostic advantages
resulting from this?
HAUSLEITER: It is our job to inform
coronary patients about their prognoses
as precisely as possible. We know that a
stenosis of the coronary vessels is hemodynamically relevant if more than a 70
percent restriction exists, which means
that the cardiac muscles blood circulation
is impaired. In order to be capable of
determining this with a vascular diameter
of approximately three millimeters, we
would have to be capable of determining
whether a residual lumen of at least
one millimeter is still open. Even for an
angiography, this is a challenge. The new
detector that breaks the barrier of below
three millimeters could provide a true
advantage in cases like that.
Stefan Martinoff, MD, and Jrg Hausleiter, MD, are talking about the new Stellar Detector
technology in their SOMATOM Definition Flash and how it creates a win-win situation for them
and their patients.
As radiologists, we especially
appreciate the increase in precision
we see with the new detector.
MARTINOFF: In addition, we would like

to be better able to evaluate the quality
of a plaque and to describe its position
in relation to the vascular wall more precisely, which means: How calcified is it,
and is it possibly only in the coronary
arterys wall? Here, the limited spatial
resolution, which leads to so-called
blooming, has always presented us with
interfering artifacts, which we sometimes
cannot classify correctly. If the interference is prevented, it could contribute to
an enormous clinical precision. Based
on the Stellar Detectors initial images, it
looks as if this could be achieved. At the
moment we are in the process of quantifying it with larger samples.
to keep open. It is not only an advantage

that one can possibly evaluate lumina of
less than three millimeters. It is also helpful if as we can already see a verification of the very small branching becomes
discernible, which indicates the reduced
perfusion of an entire area.
HAUSLEITER: Actually, the improved

spatial resolution and the prevention of
artifacts are important in many vessels,
not least of which are the carotid arteries.
Additionally, there is the evaluation of
stents, which have an even smaller lumen
than the vessels that they are designed
MARTINOFF: As radiologists, we especially appreciate the increase in precision

in cases in which we would like to provide the surgeon or cardiologist with
the most precise details possible about
anatomic conditions before an operation
or an intervention for example, before
Stefan Martinoff, MD,

Institute for Radiology and Nuclear Medicine, German Heart Center, Munich, Germany
a valve intervention by means of TAVI

(Transcatheter Aortic Valve Implantation).
Or if we want to rule out an aortic disease
in a young patient, for example in the
case of Marfan syndrome. Such examples
also show that there are many interdisciplinary issues for which radiologists
and cardiologists feel jointly responsible
for the good of the patients.
SOMATOM Sessions: Less blooming
and fewer artifacts are one side
of the improvement, and the reduced
electronic noise through the use of
TrueSignal technology is the other.
13
News
evaluations by means of imaging, for

example if stitch leakages are suspected.
In these cases, it can be vital to receive
information about the childs condition
quickly and without complications. Using
the new Stellar Detector with the 70 kV
scan mode, we recently managed to evaluate a special case after very complex
surgery with unprecedented precision.
The German Heart Center in Munich is now utilizing the full performance
of the new Stellar Detector in their SOMATOM Definition Flash CT.
The entrance of the German Heart Center in Munich, Germany
HAUSLEITER: In the future, this will give

us a significant advantage, especially
with overweight patients. These patients
often have in addition to lipometabolic
disorders, high blood pressure and diabetes a so-called metabolic syndrome,
which makes them even higher risk
candidates for coronary cardiac disease.
The fatty tissue strongly reduces radiation, which allows the electronic noise
to dominate and makes it a disruptive
problem with these patients. This complicates the diagnostics, so we are especially glad of the improved image quality
in such cases.
MARTINOFF: This is also true for other
indications with these patients, for
example if one has to evaluate the organs
parenchyma in adiposity cases, which
used to be difficult because of high electronic noise. One has to consider that
this will affect an increasing clientele in
future. While patients with over 150
kilograms of body weight used to be the
exception, they are now coming for an
assessment increasingly often. For the
first time with this new system, we are
seeing very good images, even with very
adipose patients with a body mass index
of over 35.
What advantages does this have with

respect to the dose?
scan of the heart, or just 100 instead of

120 kilovolts for carotid arteries.
SOMATOM Sessions: Do all these

advantages have an effect on workflow?
HAUSLEITER: We already see that we can

get by with a lower X-ray dose on a broad
front and the image quality has improved
at the same time. Up to now, one could
practically only reduce the noise by
increasing the dose. Or one had to accept
the noise, if one aimed for the lowest
possible exposure. Now only 80 instead
of 100 kilovolts are required for a CT
MARTINOFF: This is extremely beneficial

in pediatric cardiology, since the Flash
has the potential to reduce motion
artifacts, reduce controlled breathing or
reduce the need for sedation in young
children and babies. Here at the Heart
Center, many children with heart conditions are surgically treated. We are regularly required to perform post-surgical
MARTINOFF: Doctors save time in immediately seeing top images after scanning,
also during post-processing. In addition,
readers can diagnose much more reliably
when everything is so well-depicted
the radiologist is visibly more relaxed. If,
as a diagnostician, you are seeing even
the branches of branches, you have a very
good feeling.
News
We already see that we can get by

with a lower X-ray dose on a broad front,
and the image quality has improved
at the same time.
Jrg Hausleiter, MD,
Cardiological Intensive Care Unit, German Heart Center, Munich, Germany
HAUSLEITER: This also applies to digital

post-processing, and when we want
answers to particular questions. We can
access much more precise basic data with
the new device. For the first time, we
can now access a dataset with a layer
thickness of only 0.5 millimeters instead
of 0.6 millimeters, which allows a significantly higher spatial resolution of
0.3 millimeters.
MARTINOFF: The breaking of this barrier
has been anticipated for a long time. The
physics departments always said that
this could only be done with a trade-off
of a higher dose, but as we have seen
now, it does work. In the future, medical
facilities that have to answer special
questions will not be able to avoid the
use of such high-end precision imagery.
I can definitely recommend the use of
the Stellar Detector to everyone.
HAUSLEITER: After all, the new technology creates an absolute win-win situation
for every patient and his or her attending physician, because all the patients
may have the potential to benefit from
the dose reduction and the increase in
imaging precision.
Martina Lenzen-Schulte, MD, is a physician,
medical journalist, author and moderator. She
writes for medical journals and the consumer
media.
Jrg Hausleiter, MD:

He is a cardiologist and medical
specialist for internal medicine.
Hausleiter is head of the
Cardiological Intensive Care Unit
at the German Heart Center
in Munich. His scientific focus
includes non-invasive coronary
diagnostics and interventional
valve and stent therapies.
Stefan Martinoff, MD:

For more than a decade,
radiologist Martinoff has directed
the Institute for Radiology and
Nuclear Medicine at the German
Heart Center in Munich and is
currently also its Deputy Medical
Director. He played a leading role
in installing the first completely
digital X-ray department in the
German State of Bavaria.
The statements by Siemens customers described herein

are based on results that were achieved in the customers
unique setting. Since there is no typical hospital and
many variables exist (e.g., hospital size, case mix, level
of IT adoption) there can be no guarantee that other
customers will achieve the same results.
15
News
SOMATOM Definition Edge:

Low Dose, Quality Images
The Inselspital Bern in Switzerland was the rst hospital to introduce the
SOMATOM Denition Edge CT in clinical application. The teams judgment
after a short period of practice: cutting-edge!
By Irne Dietschi
The new SOMATOM Definition Edge, the first single source CT to use the newly developed Stellar Detector
is the latest acquisition by the Inselspital in Bern.
News
The 86-year-old lady had all the symptoms of a wake-up stroke when she
was admitted to the Institute of Neuroradiology at Bern University hospital,
the so-called Inselspital, one morning
at the end of March 2012. Suffering
from hemiplegia on her left, she was in
a bad clinical condition. Thats why
we decided not to have her examined by
MRI, which we usually recommend for
strokes, but to do the diagnostics by CT
instead, explains PD Christoph Ozdoba,
MD, senior neuroradiologist at the Inselspital. Given the seriousness of the case,
Ozdoba and his team were able to test in
full the capacity of the institutes latest
acquisition: the new SOMATOM Definition
Edge, the first single source CT to use
the newly developed Stellar Detector by
Siemens.
While the patient lay on the table, anaesthetized, Ozdoba and head technologist
Nadja Feusi ran through almost all the
features provided by the new tomograph,
including the possibility to visualize the
perfusion of the entire brain a crucial
parameter in stroke diagnostics. When
the first images appeared on the screen,
displaying the infarct of this patient in its
entire dimension, we were immediately
convinced that our CT diagnosis would be
accurate, says Ozdoba. Chief physician
Prof. Gerhard Schroth is pleased beyond
expectations: The images yielded by this
CT are cutting-edge, he says. The speed
of the machine is quite astonishing,
adds Nadja Feusi, who is becoming more
familiar with the Definition Edge every
day she operates it.
Decisive argument:
dose reduction
Bern University hospital is the very first
clinic worldwide where the single source
CT SOMATOM Definition Edge has been
introduced into clinical application. Apart
from the machine at the Institute of
Neuroradiology, a second scanner will be
provided for the new emergency room,
due at the beginning of July. When we
evaluated the system in October 2011
we were soon convinced that we wanted
to have it, although we didnt foresee
at that time that we would be the first
ones to actually operate it, says Ozdoba.
12 In neuroradiology excellent images and sharp resolution, combined

with an advanced post-processing software are key. The SOMATOM Definition Edge
comprises all of that, like in this stroke investigation of a patient who presented
in Bern University hospital.
17
News
Head technologist Nadja Feusi already ran through almost all the features provided by the new
computed tomograph and is becoming more familiar with it every day she operates it.
The SOMATOM Definition Edge includes

the possibility to visualize the perfusion of
the entire brain a crucial parameter in
stroke diagnostics.
The installation of the scanner, supported

by a Siemens engineer during the first
few days after delivery, went surprisingly
smoothly. In fact, we were so amazed
at its stability that we decided to run it
routinely after only four days.
The decisive argument in losing no time
was dose reduction. I admit I was quite
critical about this point at the beginning,
suspecting that this was pure marketing,
but now, we reckon to save no less than
30 to 40 percent of the radiation formerly
used, says Christoph Ozdoba. The quality of the images is at least the same, the
resolution better than with our predecessor. This major improvement is due
to the revolutionary Stellar Detector,
the first fully-integrated detector with
TrueSignal Technology which allows for
0.3 millimeter spatial resolution.
Thus, even fine lesions and previously
hidden vessels are visible. Moreover, the
Definition Edge is very fast, the gantry
defining the neuro-protocols: stroke examinations, the post-operative controlling

and pre-operative planning of neurosurgical interventions (hemorrhages, tumors),
the planning of stereotactic interventions
such as deep brain stimulation, the planning and controlling of spinal surgery,
the visualization of aneurysms, stenoses
in the carotis etc. Stroke examinations
are of special relevance here because
the Inselspital is one of the major stroke
centers in Switzerland, treating up to
1,000 patients per year. And even though
MRI is regarded as the standard examination by many, CT could become more
significant in this field owing to the
extensive qualities of the new scanner.
rotating at 0.28 seconds rotation speed

and thus scanning up to 23 centimeters
per second becomes possible. Clinically,
this means scanning the whole heart
in half a second, a 50 centimeter thorax
in roughly two seconds or performing
a two-meter scan of the entire body in
nearly eight-and-a-half seconds.
Advanced post-processing
software
What is even more important than speed
in neuroradiology are excellent images
and sharp resolution, combined with an
advanced post-processing software such
as an advanced vascular program all
of which the Definition Edge comprises.
The system must cover the whole scope
of neurological CT diagnostics where
microstructures are just as important as
whole brain visualizations, says Ozdoba.
In the first phase after the installation
he and his team have mainly been busy
Promising for the pediatric

eld
An important partner of the institute
is the Ear, Nose and Throat clinic. The
Inselspital Bern has an international
News
We were so amazed at its stability that

we decided to run it routinely after
only four days. The decisive argument
in losing no time was dose reduction.
PD Christoph Ozdoba, MD,
senior neuroradiologist, Inselspital Bern, Switzerland
reputation for cochlea implantations,

and the institute of neuroradiology does
all the preparative examinations of the
hearing system, especially of the petrosal
bone. The SOMATOM Definition Edge is
fantastic for visualizing those miniature
structures in high resolution, says
Christoph Ozdoba. Considering that most
of the patients destined for a cochlea
implant are children, whose developing
brain should be exposed to as little radiation as possible, another advantage of
the scanner becomes apparent: with its
minimal doses the SOMATOM Definition
Edge meets childrens needs especially
well. It is therefore hardly surprising
Ozdoba regards the application of the
scanner as very promising for a large
pediatric field.
No doubt it will take several months to
tap the maximum of the machine and
to define all the protocols conceivable in
clinical use. However, one thing seems
to be certain: in Bern the SOMATOM
Definition Edge has already been worth
the investment after only one week.
Irne Dietschi is an award-winning Swiss
science and medical writer.

PD Christoph Ozdoba, MD, was immediately convinced that CT diagnosis

will be accurate with the SOMATOM Definition Edge.
19
News
Iterative Reconstruction
Lower Dose in Clinical Routine
Siemens Iterative Reconstruction solutions prove their dose
reduction value in facilities worldwide. Now the dose reduction
potential is enhanced with SAFIRE.
By Jan Freund
Computed Tomography, Siemens Healthcare, Forchheim, Germany
Iterative reconstruction (IR) has been a

topic of interest in computed tomography
for decades. Initially, the main limitation
was the available computing power. Transferring the data from a reconstructed
image back into the raw data space by
modeling the scan parameters for the next
reconstruction loop was time-consuming.
Long calculation times prohibited the use
of iterative imaging in clinical routine,
as this could take up to several hours for
large datasets.
IRIS makes IR interesting in

clinical life
With the introduction of IRIS Iterative
Reconstruction in Image Space at RSNA
2009, Siemens launched iterative reconstruction for the SOMATOM Definition
family. It is mathematically proven that
noise reduction can be completely separated from artifact reduction.* By avoiding
computing intensive forward projections
back to the raw data, Siemens found
an intelligent approach to leverage dose
reduction with iterative reconstruction.
Thereby image noise was reduced considerably with iterative loops in image
space. The reduction in image noise can
be converted into patient dose reduction.
Noisy images acquired with lower dose
could be cleaned up using IRIS, restoring
* Data on file.
the initial image quality at a reduced

dose of up to 60%. [2, 3] Performing the
iteration loops in image space compensated for the lack of computing power and
made iterative reconstruction feasible
in CT.
Further improved image

quality with SAFIRE
In 2010, Siemens introduced SAFIRE
the Sinogram Affirmed Iterative Reconstruction and new image reconstruction
systems (IRS) hardware explicitly designed
to support iterative reconstruction algorithms. SAFIRE not utilizes forward projections into raw data for the image improvement process. Now, CT images can be
converted back into the raw data space
which validates the reconstructed dataset using the raw dataset. The iteration
loops in the raw data space correct geometrical imperfections and further reduce
image artifacts.
SAFIRE has the potential to reduce dose
by up to 60% and to improve image quality with regards to artifacts, contrast, and
sharpness further enhancing the image
quality already realized with IRIS. [3, 4]
To provide IRIS customers with their full
range of IR advantages, Siemens delivered
SAFIRE free of charge to existing IRIS
users.
Certainly the new single source CT
systems SOMATOM Definition Edge and
the 128-slice SOMATOM Perspective

both introduced at RSNA 2011 were
equipped with SAFIRE. Furthermore
Siemens released IRIS for the SOMATOM
Emotion and SOMATOM Sensation 64
installed bases.
On top of that new image reconstruction
hardware accelerated the introduction
of iterative reconstruction into clinical
routine. Dedicated hardware solutions
delivered a reconstruction speed of up
to 20 images per second on SOMATOM
Definition scanners, boosting performance to a level comparable to conventional CT systems without IR capabilities.
With this, SAFIRE can be utilized in acute
care and other time-sensitive clinical
applications.
Siemens IR is independently
validated
SAFIRE dose reductions potential was
also recognized by the scientific community. Many publications on IRIS and
SAFIRE have shown the dose reduction
potential for various body regions and
their clinical suitability. [14]
The distribution of SAFIRE increased to
approximately 1,000 installations worldwide as of mid-2012, covering more
than a third of the installed SOMATOM
Definition AS and SOMATOM Definition
Flash systems. The unique combination
of proven dose reduction with a perfor-
mance suitable for everyday use was key

to introducing iterative reconstruction
in clinical routine. Many institutions
all over the world now perform all their
examinations using SAFIRE and achieve
consistently low dose values for all
patients.
These affirmative developments encourage Siemens to pursue a goal: all CT
examinations with the latest Siemens
scanners could soon be performed below
the average natural background radiation
of 2.4 mSv. The introduction of IRIS and
SAFIRE was a major step in this direction:
More than 70% of all Siemens standard
protocols with iterative reconstruction
for the SOMATOM Definition Flash are
now below the average annual natural
background radiation of 2.4 mSv (based
on syngo CT 2011A and draft of syngo
CT 2012B). And the CT community is
already looking forward to Siemens next
cutting-edge innovations such as the
Stellar Detector.
1 MIP image of a 47-year-old patient after therapy of an aortic dissection

type B with an intra-aortic prosthesis from a SAFIRE validation study. [5]
Images were scanned with 50% dose reduction compared to the institutions
established standard protocol and reconstructed with SAFIRE strength 3.
The dose-length product of the scan was 368 mGy cm, the estimated effective
dose is 5.3 mSv.
Courtesy of University Hospital Zurich, Switzerland
References
[1] Bulla S et al. Eur J Radiol. 2011 Jun 8.
[Epub ahead of print]
[2] Hu XH et al. Clin Radiol. 2011 Nov;66(11):1023-9.
[3] Moscariello A et al. Eur Radiol. 2011
Oct;21(10):2130-8.
[4] Winklehner A et al. Eur Radiol. 2011
Dec;21(12):2521-6.
In clinical practice, the use of SAFIRE and 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 following test method was used to determine a 60% dose
reduction when using the IRIS reconstruction software
and a 54% to 60% dose reduction when using SAFIRE
reconstruction software: Noise, CT numbers, homogeneity, low-contrast resolution and high contrast resolution were assessed in a Gammex 438 phantom. Low dose
data reconstructed with SAFIRE and IRIS showed the
same image quality compared to full dose data based
on this test. Data on file.
2 VRT image of the same patient which also clearly illustrates the correct placement of the prosthesis. Courtesy of University Hospital Zurich, Switzerland
21
News
Siemens International
CT Image Contest 2011
At the start of last years congress of the Radiological Society of
North America (RSNA), Siemens Healthcare announced the winners
of the International CT Image Contest 2011. More than 160 institutes
and hospitals from 43 countries from all continents had submitted
over 600 clinical cases, acquired using Siemens CT scanners with low
radiation dose.
Monika Demuth, PhD, and Tiago Campos, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Spurred on by the success of the first

competition for computed tomography
(CT) images in 2010, Siemens announced
the International CT Image Contest
2011. Customers using a CT scanner from
the SOMATOM Definition family or a
SOMATOM Emotion, SOMATOM Sensation
or SOMATOM Spirit had the opportunity
to present an international jury of recognized experts with clinical images in seven
medical categories: Cardiac, Routine,
Vascular, Dual Energy, Trauma, Neuro,
Pediatrics.
For the first contest in 2010, the jury
received around 300 clinical images from
over 30 countries. More than twice as
many clinical images were submitted the
second time around a clear indication
that dose reduction is a key issue for CT
users on all continents around the world.
Peter Seitz, Vice President Marketing CT,
Siemens Healthcare awarded the prizes
to the winners at the RSNA 2011. The
seven winners, selected by an interna-
tional jury of experts, hail from China,

England, France, Ireland, Macau, Singapore, USA and the public vote winner
from Taiwan. As well as exhibiting a high
quality standard, the images are impressive examples of how valuable diagnostic
information can be obtained even at low
dose.
The members of the jury were Professor
Stephan Achenbach, MD, from the
Giessen-Marburg University (Germany),
Professor Dominik Fleischmann, MD, from
the Stanford University Medical Center
(U.S.A.), Professor Elliot K. Fishman, MD,
from the Johns Hopkins Hospital in Baltimore (U.S.A.), Professor Yutaka Imai,
MD, from the Tokai University School of
Medicine (Japan), Professor Zengyu Jin,
MD, from the Peking Union Medical College (China), Professor Borut Marincek
from the University Hospitals Case Medical Center in Cleveland (U.S.A.), Professor
Maximilian Reiser, MD, from the LudwigMaximilians-University in Munich
(Germany), and Professor Uwe Joseph

Schoepf, MD, from the Medical University of South Carolina (U.S.A.).
For the duration of the contest, between
March and September 2011, a fan community comprising more than 4,000
members discussed the submitted images
on Facebook. In addition, Image Contest
fans could vote for their favorite picture
in a public vote. The internet page devoted
to the contest received over 50,000 hits
within just eight months. The aim was
to raise public awareness of the responsibility that manufacturers and radiologists
have in relation to diagnostic radiation.
More information on the International
CT Image Contest including all clinical
details and respective protocols are available at:
www.siemens.com/image-contest
News
1
1
Winner of Category Cardiac:
Submitter: Carolyn Young, RT,

Great Ormond Street Hospital for Children
NHS Trust, UK
Patients History: A 3-day-old baby, with
a Tetralogy of Fallot and absent pulmonary
valve variant, was referred to CT imaging
for evaluation of the degree of pulmonary
artery enlargement and of bronchial compression for surgical planning.
Diagnosis: A perimembranous VSD
(Ventricular Septum Defect), RV (Right Ventricle)
hypertrophy and overinflated left lung were
shown using CT imaging. The main pulmonary
artery measured 1.9 cm in diameter and its
proximal branches were grossly dilated. Both
right and left main bronchi were completely
collapsed resulting from their location behind
the dilated pulmonary arteries.
Scanner: SOMATOM Definition
Dose: 0.7 mSv
2
2
Winner of Category Routine:
Submitter: Yang Guo-Qing, MD,

Center Peoples Hospital of Suining, P. R. China
Patients History: A 63-year-old female patient
had been suffering from asymptomatic recurrent
melena for the past year. Fecal occult blood test
was positive. However, endoscopic examinations
of the stomach and colon revealed no positive
findings.
Diagnosis: A non-contrast CT showed a soft
tissue lesion with calcification in the distal
segment of the ileum. The lesion was enhanced
and supplied by feeding vessels in the contrast
scan followed. The patient underwent surgery
and the pathology results confirmed a stromal
tumor.
Scanner: SOMATOM Sensation 16
Dose: 1.3 mSv
23
News
3
3
Winner of Category Vascular:
Submitter: Liz DArcy, RT, Wexford General Hospital, Ireland

Patients History: A 43-year-old male patient, non-smoker,
complaining about chest and back pains as well as numbness
and weakness of the legs, was referred for CT evaluation of
the complete aorta to rule out a dissection or other vascular
pathology.
Diagnosis: CT Angiography demonstrated coarctation of
the aorta with extensive collateral supply arising from the
superior segment.
Scanner: SOMATOM Definition AS
Dose: 2.4 mSv
4
4
Winner of Category Dual Energy:
Submitter: Teh Hui Seong, MD, and Trishna Sumer Shikhare, MD,
Khoo Teck Puat Hospital, Singapore
Patients History: A 69-year-old male patient presented with
a pulsating abdominal mass and an acute onset of lower abdominal
pain. CT Angiography was performed and an abdominal aortic
aneurysm was detected for which the patient underwent Endovascular
Aortic Aneurysm Repair (EVAR) and aorto- iliac stent implantation.
Diagnosis: Post EVAR CT Dual Energy (DE) imaging showed neither
evidence of a contrast leak or haemorrhage, nor haemoperitoneum
or retroperitoneal collection.
Scanner: SOMATOM Definition Flash
Dose: 5.9 mSv
5
5
Winner of Category Trauma:
Submitter: Wen Chao Bai, MD, Macau University Hospital, Macau

Patients History: A 55-year-old male patient suffered a left lower
tibial fracture in a traffic accident 9 years ago. Internal immobilization followed and was then removed 2 years later. Recently, the
patient complained of pain in his left ankle combined with limping.
CT imaging was required for evaluation.
Diagnosis: An immobilization screw remaining in the left distal
tibial extremity was clearly demonstrated. Changes due to traumatic
arthritis were additionally visualized.
Dose: 0.1 mSv
News
6
6
Winner of Category Neuro:
Submitter: Robert Kufchak, RT,

Buffalo Womens and Children Hospital, USA
Patients History: A 10-year-old boy was presented to the hospital
with a projectile penetrating the forehead.
Diagnosis: A non-contrast CT examination showed that the tip of
the projectile ended intracranially, just above the anterior left ethmoid
after breaching the anterior left frontal sinus and the left cribriform
plate. A small pneumocephalus was seen underlying the frontal bone.
There was no evidence of either extra-axial or intraparenchymal
hemorrhage, nor direct injury to the orbit or globe.
Dose: 0.1 mSv
7
7
Winner of Category Pediatrics:
Submitter: Jean Francois Paul, MD,

Centre Chirurgical Marie Lannelongue, France
Patients History: A 13-month-old baby in respiratory distress
was referred for a CT check-up after an ultrasound examination
evoking an aortic aneurysm.
Diagnosis: CT Angiography revealed a voluminous thoracic
aortic aneurysm.
Dose: 1.0 mSv
8
8
Winner of Category Public Vote:
Submitter: Tsai Yi-Shan, MD,

Chou Chen-Miao, National Cheng Kung University Hospital, Taiwan
Patients History: CHD
Diagnosis: Intra-cardiac TAPVR with small ASD.
Left upper pulmonary vein drainage into the ASD region shows
flow into LA and RA.
Dose: 0.8 mSv
25
News
syngo.via Brings Improved

Automation and Additional
Functionality to Clinical Routine
The Heart Center Leipzig, Germany, stands to benet from improvements
that further boost the reading of cardiovascular cases and allow for functional
assessment of pulmonary arteries based on Dual Source CT (DSCT) Dual
Energy data. The clinic is one of the rst sites to evaluate syngo.via VA11 in
clinical routine.
By Philip Stenner, PhD
The Heart Center Leipzig in Germany,

is equipped with a SOMATOM Definition Flash scanner and a five-user set-up
of syngo.via. We have been testing
syngo.via VA11 for four months now.
As the automation helps us greatly in
clinical routine almost all colleagues
in my team use the CT Cardio-Vascular
Engine on a regular basis, says Lukas
Lehmkuhl, MD, senior radiologist in

cardiac CT. Around 1,200 cardiac CT scans
are performed each year at the Heart
Center Leipzig.
Automation of recurring steps

in cardiovascular evaluations
Lehmkuhl uses syngo.via for routine
purposes, but sees its main advantages
in dealing with cases that previously

required intensive segmentation, i.e. all
cardiovascular studies and functional
exams. syngo.via takes a lot of work off
our hands as recurring steps are automated, such as calculating curved planar
reformations or labeling vessels. In comparison with other software, syngo.via
has reduced the amount of time for ves-
syngo.CT Dynamic Angio

makes it possible to
classify different types
of endoleaks in followup examinations of
endovascular aneurysm
repair procedures.
Lukas Lehmkuhl, MD, Heart Center Leipzig, Germany
News
syngo.CT Dynamic Angio helps Lukas Lehmkuhl, MD with the evaluation of AAA stent patency based on 4D image data.
sel segmentation tenfold at the Heart

Center Leipzig. syngo.via VA11 worked
especially well for one complicated case:
A patient with mitral valve endocarditis
underwent a cCTA. Since he was scheduled for urgent surgery there was not
enough time for a cardiac catheter. However, the advanced features in syngo.CT
Coronary Analysis helped to detect a significant coronary stenosis which could
then be adequately treated during the
operation with a bypass graft.
As Automated Preprocessing is also part
of syngo.CT Vascular Analysis, Lehmkuhl
also profits from tremendous time-savings
for all studies including the aorta, such
as pre-procedural planning scans for transcatheter aortic valve implantations (TAVI).
Boosting assessment of 4D
EVAR1 follow-ups
Lehmkuhl further appreciates new
diagnostic possibilities with syngo.CT
Dynamic Angio. Since this application
provides 4D analysis of time-resolved CT

studies, it helps with follow-up studies
of stent grafts and allows the detection
of endovascular leakages. syngo.CT
Dynamic Angio makes it possible to
classify different types of endoleaks in
follow-up examinations of endovascular
aneurysm repair studies, says Lehmkuhl.
As the handling of several time points
is now straight forward, the sensitivity
has significantly increased allowing for
confident evaluations.
Morphological and functional

analysis with Dual Energy CT
Lehmkuhl regards the new Dual Energy
(DE) application syngo.CT DE Lung
Analysis as a potential game changer
when it comes to evaluating pulmonary
emboli. The challenge here is to assess
the impact of thrombi in peripheral vessels in addition to a purely morphological
detection. With syngo.CT DE Lung
Analysis we have the means to close the
gap between CTA of pulmonary arteries

and scintigraphy, says Lehmkuhl. It is
now possible to detect thrombi in the peripheral vessels due to a reduced iodine
enhancement. And at the same time it is
possible to judge whether a more central
occlusion is actually hemodynamically
relevant. According to Lehmkuhl, the rate
of false negatives can be significantly
lowered for the CTA of pulmonary arteries.
EVAR: Endovascular aortic repair.

www.siemens.com/
ct-clinical-engines
27
News
App now Available for

By Sandra Kolb
In keeping with today's age of digital

information, the SOMATOM Sessions
magazine has been available online
since June 2011.
Siemens CT has now launched an app
that makes the content of the latest articles available for reading on the iPhone
or iPad. SOMATOM Sessions readers can
download this app free-of-charge from
the App Store (an Android app is due for
release in August 2012). The SOMATOM
Sessions app optimizes content to be read
easily on either device and also enables
offline browsing of articles. Just as on the
website, the articles are conveniently

sorted by category within the app and
readers can opt to receive alerts via push
notifications when new content is published. An exclusive feature not available
on the website allows users to bookmark
articles for later reading.
In the established online version of
SOMATOM Sessions, readers benefit from
the easy to read blog style, articles sorted
according to subject, and links to interesting topics on training. Each article
now contains links to related articles and
further online resources. As a feature-
packed alternative to the print edition, the

new online format also includes engaging
videos which are linked directly to related
content for easy navigation with a single
click. SOMATOM Sessions online has a
host of social features: readers can communicate with authors via the contact
form or comment on articles directly.
To check out the new SOMATOM Sessions
app for iPhone and iPad, go to:
www.siemens.com/
SOMATOM-Sessions
SOMATOM Sessions online, now available for mobile devices

News
KLAS Report 2011 Honors Siemens

Commitment to Low-dose CT
By Christiane Torres* and Peter Aulbach**
** Computed Tomography, Siemens Healthcare, Malvern, USA
** Computed Tomography, Siemens Healthcare, Forchheim, Germany
Siemens was recognized as the industry

low-dose leader in the most recent KLAS
CT 2011: Focused on Dose report. In the
same report, the SOMATOM Definition
Flash took first place in the high-end CT
space and the SOMATOM Definition AS+
(128-slice) earned first kudos from customers. KLAS is an independent organization based in Utah, USA that publishes
reports measuring vendor performance
in the healthcare sector. During the survey, healthcare providers were asked to
evaluate the systems in use at their institution according to a standard set of
questions and interviews.
Siemens A real partner in

dose reduction
KLAS found that Siemens was chosen
as the low-dose leader by their own
customers almost 100% of the time. In
addition, about 14% to 23% of non
Siemens users in the study also describe
Siemens as the low-dose leader, and
these percentages are significantly
higher than those of any other vendor.
According to the KLAS report, the overwhelming theme was an appreciation
for Siemens dedicated resources to
develop new technology that helps providers reduce dose and can be summarized in one simple sentence: The overall, industry perception is that Siemens
is the low-dose leader to catch.
Siemens also received highest ranking
for physician education offerings, an
important factor in achieving consistently
low dose exams for patients. Furthermore, providers felt that Siemens is leading in terms of the ability to adapt existing customer protocols to incorporate
and utilize new dose-saving technologies.
The KLAS study applauded: Overall, pro-
viders felt that Siemens is really a partner

in helping them reduce dose.
Siemens Innovations at work

The SOMATOM Definition Flash took first
place in the high-end CT space ratings. It
remains the undisputed winner with the
highest recommendation rate (Fig. 1) in
the KLAS survey, along with the highest
rankings for product reliability/uptime,
ease of use, functionality, and quality of
training.
Dual Source CT capabilities such as the
Flash Spiral scanning for cardiac scans
routinely below 1 mSv or dose neutral
Dual Energy CT are still unique in the
market.
Preliminary results show good satisfaction
ratings for the SOMATOM Definition AS+
with 100% satisfaction ratings when it
comes to functionality that makes this
a true price-performance system. The
1
SOMATOM Definition AS+ features a rotation time as fast as 0.30 s, stroke imaging of the entire brain, plus the recently
added sequential Dual Energy scanning.
Plus it also ships with state-of-the-art
dose-saving features such as CARE kV,
IRIS (Iterative Reconstruction in Image
Space) and SAFIRE (Sinogram Affirmed
Iterative Reconstruction), the Adaptive
Dose Shield and X-CARE.
The SAFIRE algorithm is currently rolled
out free-of-charge to the international
installed base of SOMATOM Definition
customers who already use IRIS, showing
Siemens commitment to making low
dose CT as widely available as possible
for optimum patient care.
Information about the product was taken from less

than fifteen provider organizations. Readers should
only consider the measurement as an early indicator
of performance from a small sample of clients.
78%
Evangelist
67%
67%
67%
65%
Naysayer
64%
55%
45%
18%
10%
0%
9%
11%
8%
21%
7%
0%
Siemens
SOMATOM
Definition
Flash
Vendor A
64-slice CT
Vendor B
64-slice CT
Vendor B
Siemens
320-slice CT SOMATOM
Definition
AS 64
Vendor C
Vendor A
256-slice CT 64-slice
HD CT
Vendor C
64-slice CT
1 This chart compiled by KLAS researchers compares Evangelists and Naysayers for a range
of CT scanners in active use: The blue bars in the chart represent the percentage of users who
would recommend and actively speak in favor of the product. The orange bar represents the
number of users who would actively speak against the CT system.
KLAS CT 2011: Focused On Dose report, 11/2011, www.KLASresearch.com, 2011 KLAS Enterprises, LLC.
All rights reserved.
29
News
Pushing Boundaries in CT
Latest Research in Functional Imaging
Ground-breaking research published in a special edition of Investigative
Radiology reveals insights into new functional imaging methods.
By Heidrun Endt, MD
Functional CT imaging is currently attracting considerable interest in scientific

research. Investigative Radiology published a special issue [e.g. 1-5] dedicated
to this emerging field with a focus on
oncology and cardiovascular medicine.
Eight of the thirteen clinical studies
included in this edition used Siemens
SOMATOM CT scanners.
Perfusion CT imaging as a
quantitative imaging method
When evaluating new therapy methods
in oncology, a change of thinking is
required. New drugs or treatments may
trigger other reactions in the tumor tissue
that cannot be measured at an early
stage with current criteria (e.g. tumor
size). Perfusion CT needs to be assessed
comprehensively to prove its worth as
a reliable biomarker.
A group of researchers from Zurich,
Switzerland, analyzed perfusion patterns
of primary malignant liver tumors and
hepatic metastases in 30 patients with
computed tomography (CT) and ultrasound examinations. [1] A SOMATOM
Definition Flash was used for the CT part
of the study. With the Adaptive 4D Spiral
a scan range of 14.8 cm was covered
enabling perfusion imaging of the whole
organ. By using this technology repeatly,
bi-directional table movements are performed. As many patients may not be
able to hold their breath for the duration
required, motion correction is crucial for
gathering reliable data. The study found

that quantitative analysis of tumor perfusion was feasible in all patients [] [1]
after motion correction. The perfusion
evaluation with syngo Volume Perfusion
CT Body included arterial liver perfusion,
portal-venous perfusion and total perfusion.
Another study published in this special
issue details research into CT perfusion
imaging of the kidneys. [2] The perfusion patterns of renal cell carcinomas
were evaluated in 21 patients with the
SOMATOM Definition Flash and the
Adaptive 4D Spiral. After motion correction all examinations could be assessed
and a reliable evaluation of the renal
perfusion was possible. Considerable
tumor heterogeneity was found in both
qualitative and quantitative analyses
reinforcing the use of volumetric techniques for both perfusion imaging and perfusion analysis. [2] Such tumor heterogeneity may become the salient point in
the assessment of therapy response for
new drugs.
Dual Energy CT for evaluation

of body perfusion
Iodine-related attenuation (IRA) can be
depicted with Dual Energy CT (DECT). As
the amount of contrast medium respectively iodine enhancing a tumor, or more
general a tissue depends on the status
of vascularization IRA can be used for
evaluation of perfusion. [3] Researchers
from the University Medical Center

Mannheim, University of Heidelberg,
Germany, evaluated hepatic metastases
in 24 patients with gastrointestinal
stromal tumors (GIST) with a SOMATOM
Definition. 23 patients received tyrosine
kinase inhibitors as therapy and 11 underwent several DECT studies for follow-up.
The CT data were also evaluated according to the Choi criteria, where the density
of the tumor is assessed. The authors
concluded: DECT is a promising imaging
method for the assessment of treatment
response in GIST, as IRA might be a more
robust response parameter than the Choi
criteria. [3]
Cardiovascular imaging with

Dual Energy CT
Researchers from the University Medical
Center Mannheim, University of Heidelberg, Germany, and Medical University of
South Carolina, USA, collaborated for a
study to optimize the contrast material
injection protocol for DECT in patients
with suspected pulmonary embolism.
[4] The study included the CT examinations of 100 patients with a SOMATOM
Definition. Four different contrast injection protocols were evaluated. The iodine
delivery rate (IDR) and the iodine concentration were set to different values
whereas the total iodine delivery was kept
constant. The protocol with the highest
concentration of iodine and the highest
IDR (400 mg I/mL; 1.6 g I/s) [] maxi-
mizes the attenuation in the structures

of interest []. [4] DECT in case of pulmonary embolism delivers [...] a traditional CTPA [CT pulmonary angiography]
and visualization of blood perfusion in
a single acquisition and may therefore
provide incremental value to pulmonary
angiography alone. [4]
1A
1B
1C
1D
The need for proof and

evaluation
In the foreword, the editors of this special
issue of Investigative Radiology emphasize the need for studies evaluating functional CT imaging: Clinical radiology is
increasingly confronted with clinicians
demands for quantitative information to
better characterize and stratify disease,
or to evaluate treatment response. [5]
New imaging methods need to be
assessed in terms of feasibility and quantitative parameters gained in clinical
tests used up to now. These results and
future quantitative studies will make an
important contribution toward fulfilling
this request so that functional CT imaging is ready for wider use in the future.
References
[1] Goetti R et al. Quantitative perfusion analysis
of malignant liver tumors: dynamic computed
tomography and contrast-enhanced ultrasound.
Invest Radiol. 2012 Jan;47(1):18-24.
[2] Reiner CS et al. CT perfusion of renal cell
carcinoma: impact of volume coverage on
quantitative analysis. Invest Radiol. 2012
Jan;47(1):33-40.
[3] Apfaltrer P et al. Contrast-enhanced dualenergy CT of gastrointestinal stromal tumors: is
iodine-related attenuation a potential indicator
of tumor response? Invest Radiol. 2012
Jan;47(1):65-70.
[4] Nance JW et al. Optimization of contrast
material delivery for dual-energy computed
tomography pulmonary angiography in
patients with suspected pulmonary embolism.
Invest Radiol. 2012 Jan;47(1):78-84.
[5] Fink C et al., Functional Computed Tomography
Imaging. Invest Radiol. 2012 Jan;47(1):1
http://journals.lww.com/
investigativeradiology/
toc/2012/01000
1 A 47-year-old male patient suffering from colon cancer with hepatic

metastases was included in a scientific study. [1] The CT perfusion examination
was performed to evaluate therapy response to chemotherapy (Avastin, FOLFOX).
Fig. 1A: maximum intensity projection, Fig. 1B: arterial liver perfusion, Fig. 1C:
portal-venous perfusion, Fig. 1D: time-intensity curve. The measurements show
a central-necrotic metastasis with enhanced perfusion at its margins.
Courtesy of University Hospital Zurich, Switzerland
2A
2B
2C
2D
2 A 57-year-old male patient with a gastro-intestinal stromal tumor (GIST)

and hepatic metastases underwent Dual Energy CT. Fig. 2A: virtual 120 kV image,
Fig. 2B: virtual noncontrast image, Fig. 2C: iodine map, Fig. 2D: fused iodine
map. The examination was part of a study [3] that was set up to evaluate iodinerelated attenuation as an indicator of tumor response in GIST.
Courtesy of University Medical Center Mannheim, Germany
31
Business
STRATON X-ray Tube

High performance under Challenging Conditions
By Christine Dehm, PhD,* and Holger Reinsberger**
**Clinical Products, Siemens Healthcare, Erlangen, Germany
**Customer Services, Siemens Healthcare, Erlangen, Germany
Siemens developed the STRATON X-ray

tube for high-performance CT scanning
in extreme operating conditions.
Benets of the STRATON design

The STRATON tube differs significantly
from a standard tube. Unlike conventional
tubes, the anode in the STRATON tube
is cooled directly, creating a powerful
tube which is much smaller than conventional designs (Fig. 2). This means that
two X-ray tubes can be installed in dual
source platforms for scans at high temporal resolution, which is essential especially for cardiac imaging. As the anode
is cooled directly, long runoff scans or
perfusion studies are not interrupted by
cooling processes.
Technology and operating

conditions
X-ray tubes are subject to high voltages
of up to 140 kV and high currents. The
materials used in the tube design must
be able to withstand a high vacuum,
extreme temperatures and permanent
temperature changes. New technology
had to be developed for the STRATON
tube design, including the deflection coils
which shape the electron beam. The new
design can shape different focal spot sizes
with just one emitter.
In each X-ray tube 1% of electrical energy
applied results in an X-ray beam. The
rest of the electrical energy is converted
into heat. When the electron beam hits
the anode, the energy density reaches
values up to half the energy density on
the surface of the sun. A power of 100 kW
is directly applied to the focal spot by the
generator (Fig. 1). While the power is
Emitter
Rotation
Cathode
Oil for cooling
Deflection coils
Anode
Motor
Electron beam
X-rays
Focal spot
1 Schematics of the STRATON tube with anode directly attached to the tube envelope.
applied, the temperature in the focal spot

reaches 2,500 C, and the temperature
on the focal track hits 2,000 C. The back
of the anode has due to the direct
cooling a temperature of only 200 C,
resulting in a temperature gradient of
more than 1,800 C/cm. Emitter temperatures reach up to about 2,500 C, and
must also be kept very stable at high
temperatures.
The STRATON tube components must
also endure other extreme conditions
like significant centrifugal forces. The

tube rotation frequency is 160 Hz. With
the additional scanner rotations, the
STRATON tube has to grapple with 40
times the gravity (40 g), which is about
10 times higher than the centrifugal
force a passenger is exposed to in a roller
coaster.
Even though these extreme conditions
put the tube under enormous stress,
continuous technical improvements have
made the Straton tube one of the most
Business
reliable and long-lasting tubes in the

industry.
2A
2B
Wear and tear affecting an

X-ray tube
All X-ray tubes are consumables and the
wear caused during operation will sooner
or later lead to failure. One example of
deterioration is emitter erosion. Over
time, the cathode material becomes thinner until it melts. Physical stress caused
by the temperature changes can cause
micro leaks. The constant bombardment
of the anode with electrons leads to a
rough surface which eventually results
in insufficient dose.
The need to increase tube life

In an ideal world, a technical system
should survive for its designed service
life and fail after this period as illustrated
in Fig. 3 (blue line). As the variables affecting wear are hard to predict, the service
life of an X-ray tube cannot be ensured
and a tube failure may occur at any time.
By examining a large number of tubes,
the failure rate and the average time
until a tube will fail can be measured.
The failure distribution over time can be
expressed in a linear relationship Fig. 3
(red line). Siemens constantly monitors
the quality, investigates the reasons for
tube failure and continuously improves
clinical capabilities and the quality of its
X-ray tubes. With tube optimization, physical conditions will still affect the service
life of the tube, however the tube failure
will decrease as illustrated in Fig. 3 (green
line). The area between the red line and
the green line represents the average
increased tube life.
10 cm
2 The compact design of the STRATON tube (Fig. 2A) allows two acquisition systems
within one scanner for dual source and dual energy scanning. A conventional tube is shown
for comparison (Fig. 2B).
Distribution of failure
100%
ideal
90%
x-ray tube
80%
x-ray tube with

quality improvement
70%
60%
50%
40%
30%
20%
10%
Siemens service solution

Siemens offers a unique service for
remotely determining the remaining life
span of a tube. Thanks to the Guardian
program including TubeGuard, a replacement tube is ordered before a failure
occurs. To cover the financial risk, Siemens
provides a warranty for its tubes and offers
a service contract during the life cycle.
0%
time
3 Distribution of failure versus time for an ideal case with only one cause of failure
(blue line). In case of multiple failure causes which can occur at different times
(like wear caused in an X-ray tube) a linear relationship results (red line). With continuous
tube optimization the failure rate over time can be decreased (green line).
www.siemens.com/TubeGuard
33
Business
Low Dose, High Resolution for

The Dual Source computed tomography (CT) scanner from Siemens,
the SOMATOM Denition Flash, is winning the hearts of both pediatric
cardiology patients and their doctors at a Minnesota childrens hospital.
The reason: lower radiation doses, higher temporal resolution, and
unmatched patient comfort.
By Robert L. Bard
The SOMATOM Definition Flash from

Siemens is changing the clinical care
of pediatric cardiology patients at the
Minneapolis Heart Institute and Childrens
Hospital and Clinics of Minnesota for
the better. Pediatric cardiologist Kelly Han,
MD, who serves as Director of Congenital
Cardiac Imaging at the hospital, says the
capabilities of the SOMATOM Definition
Flash are unique because its isovolumetric
resolution is outstanding, meaning it is
the same resolution regardless of the
plane. In comparison to magnetic reso-
nance imaging (MRI), Han explains, the

plane you are focused on with MRI is very
good, but the other planes are not as
clear. Thanks to the SOMATOM Definition
Flashs Dual Source approach, the temporal resolution of 75 msec freezes cardiac
motion during the acquisition time frame.
That robustly prevents motion artifacts.
The temporal resolution is an extremely
important concern in pediatric cardiology
because of babies high heart rates,
babies inability to perform breath holding on command, and the radiation expo-
sures from imaging. Imaging risks are

lower today, according to Han, because
by using the dose-efficient Flash Spiral
scan mode in combination with SAFIRE,
the radiation dose is just a fraction of
previous generation scanners. Additionally, she mentioned, todays CT scan
may eliminate the need for diagnostic
heart and thus further decrease radiation exposure.
John Lesser, MD, Director of Cardiovascular Computed Tomography and Magnetic
Resonance Imaging at the Minneapolis
1 3-day-old baby with an interrupted

aortic arch. Courtesy of Minneapolis Heart
Institute and Childrens Hospital and Clinics
of Minnesota, Minneapolis, USA
2 An anomalous RCA from ascending aorta from a 17-year-old child weighing 200 lb.
Courtesy of Minneapolis Heart Institute and Childrens Hospital and Clinics of Minnesota,
Minneapolis, USA
Business
Heart Institute, talks about the changing

clinical practice resulting from the Dual
Source CT SOMATOM Definition Flashs
high temporal resolution and decreased
radiation. Because the radiation dose
is so low, we can do multiple scans for
different purposes now if necessary, he
says. For instance, we can look at the
anatomy and function by doing two different scans with a minimal increase in
radiation, allowing us to answer multiple
questions in one small time frame and
limit the radiation exposure.
Individualizing patient care

and imaging modality selection
Imaging has become individualized at
the Minneapolis Heart Institute. As Han
says, It takes a lot of physician interaction, and every single scan has to be
tailored to the question that needs to be
answered for that patient; it is not something that can be rigidly protocolized.
The individualized approach limits
radiation exposure by imaging only the
necessary structures rather than using
standardized protocols that image more
anatomy than is clinically relevant. The
recently introduced FAST CARE platform
helps individualize the protocols. For
example, the CARE kV function automatically selects the optimum kV step
to save the maximum amount of dose
without compromising image quality.
One of the greatest benefits of the
The experts David Dassenko, MD, Kelly Han, MD, and John Lesser, MD, (from left to right)
were discussing about lower radiation doses, higher temporal resolution and patient comfort
for their cardiology patients during the interview with SOMATOM Sessions.
SOMATOM Definition Flash is that sedation may not be indicated in all cases
because of the Flashs extraordinary high
speed. It can allow for some patient
movement and may not require a breathholding sequence due to its scan speed
of up to 458 mm/s. There is also a definite increase in patient friendliness and
patient comfort with the Flash technology. When sedation is not used, parents
can take their child home right after
the scan is finished. This is a significant
benefit, because recovery time is eliminated.

The choice of imaging modality is also
highly individualized. Advanced modalities are required in neonatal patients
who have complex anatomy, and CT
is a desirable option because it will not
damage these patients small blood
vessels. Patients with congenital heart
disease are living longer and longer,
says Han, and they need to have healthy
blood vessels in case a heart catheteri-
If you are going to translate

into a major shift from traditional
diagnostic heart catheterization
to CT scans you could potentially
see a signicant staff savings to
the institution.
David Dassenko, MD, Director of the Cardiovascular Care Center,
cardiac intensivist and anesthesiologist at Childrens Hospitals and
Clinics of Minnesota
35
Business
The Flash CT is
a much better
answer to those
questions than
the older generation scanners
used to be.
Kelly Han, MD, Director of Congenital
Cardiac Imaging, Childrens Hospitals
and Clinics of Minnesota
zation is vital later in life. Lesser simplifies the diagnostic decision tree to two
simple questions: Number one: What
do I need? And number two: What is
the least risk? According to Han, The
SOMATOM Definition Flash CT is a much
better answer to those questions than
the older generation scanners used to
be.
Efciency and cost savings

David Dassenko, MD, Director of the
Cardiovascular Care Center, who is a
cardiac intensivist and an anesthesiologist at Childrens Hospitals and Clinics
of Minnesota, says that the speed of the
testing process and the reduced need
for sedation are two more reasons why
Flash CT imaging is the desirable imaging
choice. Dassenko notes that anesthesia
charges by the hour, and the use of
CT is a much faster diagnostic test. For
example, a diagnostic heart catheterization takes approximately one to two
hours to complete, he explains, and
the staff time typically includes an anesthesiologist and a resident physician or
a nurse anesthetist and the cost that
that implies. Typically, an hours worth
of operating room time plus our time is
in the thousands of dollars, so if we can
minimize the time down to a few minutes,
the obvious cost savings are there.
Scanning is exceptionally more efficient

without the need for a breath hold.
Says Dassenko, In the past, a pediatric
CT almost always required intubating
the baby and putting the baby to sleep
so that an anesthesiologist could hold
the babys breath. With the Dual Source
Technology of the SOMATOM Definition
Flash, the paradigm has been dramatically changed. Changes in sedation
have caused the CT scanner turnaround
to be faster. Lesser points out that an
MRI in a patient who requires a breath
hold and thus sedation and intubation
takes up 23 slots (scheduling units for
the scanner), but a CT takes up only one
slot. MRI may also be contraindicated
in patients who have metal implants,
especially in congenital heart patients
who commonly have coils, stents, pacemakers or internal cardiac defibrillators.
Furthermore, both MRI and heart catheterization typically require contrast, and
Flash CT does not.
Since CT commonly eliminates or
decreases anesthesia, the recovery times
are also eliminated or decreased. In
patients where sedation is indicated, such
as those with anxiety, the doses are
lower and the recovery times are shorter
than they used to be, reports Dassenko.
Many of our patients have congenital
heart disease and are therefore considered
to be relative high risk for complications

associated with anesthesia, so eliminating
or minimizing sedatives decreases the
risk of adverse events, he says.
The decreased role and costs of anesthesia
in pediatric cardiology with the use of
SOMATOM Definition Flash represent a
major shift in clinical care and have freed
up the anesthesia team for other needs
throughout the medical center. Dassenko
concludes, If you are going to translate
into a major shift from traditional diagnostic heart catheterization to CT scans
that are much, much less time involved,
you could potentially see a significant
staff savings to the institution. Lesser
adds that eliminating catheterizations
dramatically decreases expenses, because
CT may be able to provide the desired
information for the same diagnostic
indications and does not have the costly
complications associated with diagnostic
heart catheterization.
New imaging paradigm

requires teamwork
Han, Lesser, and Dassenko all agree that
the new imaging paradigm is changing
the process of diagnosing patients, and
The Minneapolis Heart Institute and

Childrens Hospital and Clinics of Minnesota.
Kelly Han, MD, explains to the patient what will happen during the imaging procedure.
they emphasize that teamwork is vital

to the success of the paradigm. Lesser,
commenting on the Minneapolis Heart
Institutes experience, says There is something very unique to our team approach:
it is an adult cardiology unit that has a
pediatric cardiologist associated with it
(Han), and I dont know of any other place
that has such an adult-child interaction.
This arrangement is beneficial because
the pediatric specialists have expertise
related to unusual cases, and the CT
technicians are likely to have special skills
in order to manipulate the images of the
small babies while imaging at the lowest
possible radiation dose. Lesser adds that
adult cardiology brings forth the benefit
of technicians tremendous experience,
because of the high volume of patients.
Han concurs, adding, In order to do
CT well, it is a team approach: You have
to have techs who are well-trained and
an anesthesiologist who understands
the risks of sedation and knows exactly
what the ordering physician is trying to
accomplish with the scan.
The Dual Source CT SOMATOM Definition
Flash has improved communication and
teamwork between physicians. Lesser
notes that teamwork was not well established with the use of the older generation scanners. Han is currently using
Flash CT clinically to diagnose children
with complex anatomy who are less
than eight years of age, because of its
favorable risk profile.
Robert L. Bard is a freelance medical writer

certified by the American Medical Writers
Association who also conducts clinical research
at the University of Michigans Division of
Cardiovascular Medicine.
www.siemens.com/
SOMATOM-Definition-Flash
Because the
radiation dose is
so low, we can do
multiple scans for
different purposes
now if necessary.
John Lesser, MD,
Director of Cardiovascular Computed
Tomography and Magnetic Resonance
Imaging at the Minneapolis Heart Institute
37
Business
eMode on SOMATOM Perspective

a Chance to Optimize Total Cost of
Ownership in Clinical Routine
By Silvia Meyer
Customer Services, Siemens Healthcare, Erlangen, Germany
In a tough financial climate and faced by

increasing competitive challenges, healthcare institutions have to maintain a high
level of diagnostic excellence and treatment quality. On the other hand, there are
more budget restrictions than ever before
and reimbursement rates are decreasing
globally.
Siemens is offering a new service benefit
program called eMode for SOMATOM
Perspective that delivers answers to these
challenges. A SOMATOM Perspective
service contract can be ordered optional
to the scanner purchase. If a medical
institution then is running their SOMATOM
Perspective with eMode in 80% of their
scans, several additional service components like the following examples can be
made use of.1
over my shoulder. Once the customer

has shared their desktop and handed over
mouse control, the Application Specialist
can provide instant support in any application queries. This means that the customer can work productively and benefits
from CT expertise. Data protection is
assigned the highest priority: Siemens
Remote Services are based on a certified
IT infrastructure and secure VPN connections.

Ms. Bak was impressed with the initial
ease of use of syngo Remote Assist and
became a clear promoter of the tool:
Remote support from an experienced
Siemens application specialist is extremely
helpful in the daily routine, e. g. for
changing protocol settings or when pre-
syngo Remote Assist2, 3 for

excellent application support
in CT imaging
Whenever customers need support in
clinical applications, they can call their
local Siemens Uptime Service Center for
immediate support from an Application
Specialist. With the customers permission,
the system is connected with Siemens
Remote Service via an encrypted broadband connection to provide secure data
transfer. Ms. Bak, executive technician
from the radiology department in Mutlangen, Germany, had already the chance
to experience the ease of use of syngo
Remote Assist. I trust Remote Assist
Services completely. The Siemens application expert sees what Im doing and
I can see what Siemens is doing. Its
almost like having the expert watching
The Application Specialist can provide instant support for any application.
Business
eMode and a respective service benefit program allows operating the SOMATOM Perspective in a patient friendly and financially efficient way.
paring a special CT examination especially for things that need to be done less
often this saves me lots of time. Having
now worked on a Siemens system for the
first time, Im extremely happy as a new
user that the Siemens expert can connect
to the system remotely and immediately
help me with all my questions. I feel
more secure.
Service contract adjustment2

actively optimizes total cost
of ownership
Another lever to improve operational
cost of the SOMATOM Perspective for
the medical institution is the Service
contract adjustment benefit option.
When using the scanner with eMode
in 80% of scans, customers can earn
a discount on their annual service contract price. As an example, Siemens
Uptime Services in Germany is offering
a business model where the monetary
benefit shows an even higher positive
impact on the total cost of operation,
the longer the scanner lifecycle of the

customer is.
With the choice of different eMode
service benefits we can not only save
time through efficient workflows when
choosing syngo Remote Assist, we can
even save real money by having an optimized cost-benefit-ratio by choosing service contract adjustments, says Johann
Steffens, MD, who has chosen this benefit for his private clinic in Hamburg for
the first operating year.
More information on how customers can
benefit from the SOMATOM Perspective
and eMode service benefits, as well as
country-specific information on eMode
service benefit programs is available from
local Siemens Uptime Services representatives.
eMode is designed to get the most out of

Further details can be collected from the local service

organization
2
eMode service benefits are subject to country-specific
availability
3
syngo Remote Assist is based on Siemens Remote
Services (SRS) which is an efficient and comprehensive
infrastructure for medical equipment-related remote
services. Siemens provides SRS-based services via
a reliable bidirectional infrastructure based on a
powerful and secure Virtual Private Network (VPN).
syngo Remote Services are ISO 27001 certified.
1
39
Clinical Results Cardio-Vascular
Case 1
Adaptive 4D Spiral CT Angiography for
the Diagnosis of a Capillary Hemangioma
By Xiang-ming Fang, MD,* Xiao-yun Hu, MD,* Hong-wei Chen, MD,* Ping-yan Qian, MD,*
Gang-feng Hu, MD,* Hui-jun Lu, MD,* Chenwei Li, MD**
**Department of Radiology, Wuxi Peoples Hospital Affiliated to Nanjing Medical University, Wuxi, P. R. China
**Healthcare Sector, Siemens Ltd. China, Shanghai, P. R. China
HISTORY
A 29-year-old female patient presented
herself to the hospital with a tumor
on the ulnar side of her left ring finger.
The tumor had appeared a month earlier,
small and asymptomatic. It however
progressed in size and caused discomfort and occasional bleeding. Physical

examination revealed a firm, non-pulsatile subcutaneous tumor near the distal
interphalangeal joint. The capillary
return and the movement of the finger

were normal. The skin covering the
tumor appeared normal and there was
no sensory loss.
1 The VRT image shows that the tumor (arrow) is well defined
and clearly separated from the phalanx.
2 The VRT image shows one of two draining veins (arrow).
Cardio-Vascular Clinical Results
DIAGNOSIS
COMMENTS
Non-contrast CT images showed a soft

tissue tumor, measuring 1.8 x 1.7 cm,
on the ulnar side of the distal left ring
finger. The tumor was well defined
and clearly separated from the phalanx
(Fig. 1). CT Angiography (CTA) images
acquired with the Adaptive 4D Spiral
demonstrated significant and homogeneous enhancement of the tumor
with its feeding artery, along with two
draining veins (Fig. 23). These results
suggested a vascular tumor or a vesseloriginated tumor. The patient underwent surgery and the pathology report
confirmed a capillary hemangioma.
Vascular abnormalities of the hand are

infrequent and capillary hemangiomas
of digital arteries are particularly rare. It
is difficult to differentiate a hemangioma
from a soft tissue lesion, such as an
abscess, cyst, or neuroma, when the
tumor is non-pulsatile, and the typical
symptoms of arterial insufficiency (pain,
pallor, no pulse, and paresthesia) are not
present. Normal radiographs are usually
not helpful unless erosive bone changes
are suspected. Although angiography
and nuclear scanning have proved to be
helpful, they are considered invasive
with possible complications. Contrarily,
a CTA examination is noninvasive and

easily available. In this case, the advanced
4D Spiral CTA with dynamic scanning
technique was used to demonstrate the
feeding artery and draining veins, thus
providing valuable information not only
for the diagnosis but also for surgery.
EXAMINATION PROTOCOL
Scanner
SOMATOM
Definition Flash
Scan area
Hand
Scan length
150 mm
Scan Mode
Adaptive 4D Spiral
Scan direction
Caudo-cranial
and cranio-caudal
Scan time
24 s
Tube voltage
100 kV
Tube current
120 mAs
CTDIvol
100 mGy
DLP
1520 mGy cm
Effective Dose
1.2 mSv
Rotation time
0.285 s
Slice collimation
32 x 1.2 mm
Slice width
1.5 mm
Reconstruction
increment
1.0 mm
Reconstruction kernel
B20f
Contrast
Volume
50 ml
Flow rate
3.5 ml/s
Start delay
Bolus tracking
3 The VRT image demonstrates the feeding artery (arrowhead) and

two draining veins (arrows).
41
Case 2
Diagnosis of Coronary-Ventricular
Fistula with Giant Coronary Aneurysm
using Flash Mode
By Kai Sun, MD,* Ruijuan Han, MD,* Lijun Ma, MD,* Ligang Li, MD,** Gang Wang, MD,* Hailiang Jia, MD*
** Department of Radiology, Baotou Central Hospital, Inner Mongolia, P. R. China
** Healthcare Sector, Siemens Ltd. China, Shanghai, P. R. China
HISTORY
DIAGNOSIS
COMMENTS
A 44-year-old female patient presented

herself to the hospital with paroxysmal
chest distress after exertion for the past
10 days. The duration of the distress
varied between 10 minutes and several
hours. There was no history of hypertension or diabetes. An electrocardiogramm showed a sinus rhythm without
significant ST-T changes. A coronary
CTA was requested for further evaluation.
A coronary CT Angiography (cCTA)

using Flash mode with a high pitch and
an ECG-triggered spiral scanning revealed
an extremely rare combination of coronary anomalies. These included a giant
coronary aneurysm originating off a fistula connecting the left coronary artery
and the right ventricle, an anomalous
single coronary artery arising from the
left sinus of Valsalva, and the absence of
the right coronary artery (RCA) as well
as of the left circumflex coronary artery
(LCx).
The combination of such coronary

anomalies is extremely rare. cCTA imaging provided a comprehensive overview
of the anomalies, thus offering information necessary to aid the physician in diagnosis. Dual Source CT with Flash mode
and ECG-triggering, using single spiral
scanning and a very high pitch, not only
shortens the acquisition time but also
reduces the radiation exposure to the
patient. In this case, the entire heart was
scanned in just 0.23 s with a dose of
only 0.8 mSv.
Scanner
SOMATOM Definition Flash
Scan area
Heart
Rotation time
0.28 s
Scan length
13 cm
Pitch
3.4
Scan direction
Cranio-caudal
Slice collimation
128 x 0.6 mm
Scan time
0.23 s
Slice width
0.75 mm
Tube voltage
100 kV
Reconstruction increment
0.4 mm
Tube current
375 ref. mAs
B26f
Dose modulation
CARE Dose4D
Contrast
CTDIvol
3.59 mGy
Volume
60 mL
DLP
59 mGy cm
Flow rate
5 mL/s
Effective Dose
0.8 mSv
Start delay
8s
16 Images show a giant coronary aneurysm (Figs. 35, solid arrows) originating off a fistula
(Figs. 1, 2, 5, dashed arrows) connecting the left coronary artery and the right ventricle, and an
anomalous single coronary artery arising from the left sinus of Valsalva (Figs. 12, arrowheads).
The right coronary artery (RCA) and the left circumflex coronary artery (LCx) are absent.
43
Case 3
Diagnosis of Truncus Arteriosus
By Vasco Silva, MD,* Joo Carlos Costa, MD,** Constana Palma Borges, MD,* Joana Costa, MD,*** Marisa Gonalves, RT,**
M. Reis, RT,** P. Miguel, RT,* M. Sozinho, RT,* A. Nchanduca, RT,* C. Rosa, RT,* S.Bastos, RT,* Ana Chaves ****
**** Radiology Department, Clinica Girassol, Luanda, Angola
**** Radiology Department, Hospital Particular de Viana do Castelo, Portugal
**** Radiology Department Institut Jules Bordet, Brussels
**** CT Application Specialist, Siemens Healthcare, Portugal
HISTORY
A 4-year-old girl, weighing 7.5 kg with
a provisional diagnosis of congenital
heart disease, was transferred by the
National Board of Health from Angola to
the Girassol private practice in Luanda.
Despite the previous administration of
beta-blockers, her heart rate remained
at 93 bpm when CT was performed to
evaluate the complex structure of the
heart.
DIAGNOSIS
The cardiac CT Angiography confirmed
the diagnosis of a truncus arteriosus
with ventricular septal defect (Collett and
Edwards type I; Van Praagh type 1A). A
common arterial trunk arised from both
ventricles, which communicated via a
large perimembranous ventricular septal
defect (VSD) (Fig. 1). The arterial trunk
divided into the aorta and the main
pulmonary artery. The main pulmonary
artery subsequently divided into the left
and right branched pulmonary arteries.
(Figs. 2 and 3). Both coronary arteries
arised from the common arterial trunk
proximal to the main pulmonary arteries
(Fig. 4). The anatomical abnormalities
were confirmed and repaired in subsequent surgery.
truncoconal septation. It occurs in 1%

to 2% of infants with congenital heart
defects. CT provides excellent characterization of the anatomy and levels of
anatomic detail which are especially
useful for surgical planning. Flash CT
features a high temporal resolution
which allows diagnosis at a high heart
rate, reduced exposure dose and minimizes the necessary amount of contrast
media (in this case, 93 bpm, 0.8 mSv
and 10 mL). This is particularly important
for pediatric cardiac CT examinations
of congenital heart disease where the
patients normally have a higher heart rate
and incompatibility with beta-blockers.
Scanner
Scan mode
ECG triggered sequential scan
Scan area
Heart
Scan length
98 mm
Scan direction
Cranio-caudal
Scan time
4s
Tube voltage
100 kV
Tube current
99 eff. mAs
Rotation time
0.28 s
Slice collimation
128 x 0.6 mm
Slice width
0.75 mm
0.4 mm
Temporal Resolution
75 ms
B30f
CTDIvol
4.11 mGy
DLP
57 mGy cm
Effective Dose
2.26 mSv
Contrast
COMMENTS
Truncus arteriosus is a congenital heart
disease resulting from the failure of
Volume
10 mL contrast media
Flow Rate
2 mL/s
Start delay
6s
1 MPR image shows a common arterial trunk arising from both ventricles, which communicate via a large perimembranous ventricular
septal defect (arrow).
23 MIP (Fig. 2) and VRT (Fig. 3) images demonstrate the arterial trunk which divides into the aorta and main pulmonary artery,
and the main pulmonary artery subsequently divides into the left and right branch pulmonary arteries.
4 MIP image reveals both coronary arteries arising from the common arterial trunk proximal to the main pulmonary arteries.
45
Case 4
Follow-Up on CABG using
iTRIM Method for Coronary CTA
By Yingning Wang, MD, Jian Cao, MD, Zhou Li, MD
Department of Radiology, Peking Union Medical College, Beijing, P.R. China
HISTORY
A 55-year-old male patient, who had

undergone a Coronary Artery Bypass
Graft (CABG) 8 years ago, was referred
to the CT department for a follow-up
evaluation.
DIAGNOSIS
1 VRT image demonstrates an overview of both LIMA and SVG grafts which are patent.
LIMA graft remains intact at its origin (arrow) off the subclavian artery and is grafted to
the LAD artery (dashed arrow). A left SVG was laid over the pulmonary artery and originated proximally off the anterior wall of the ascending aorta. A mild stenosis in mid-RCA
(arrowhead) can also be visualized.
The CT images demonstrated two

bypasses Left Internal Mammary Artery
Left Anterior Descending Artery
(LIMA-LAD) and Aorta-Saphenous Vein
Diagonal 1 (AO-SV-D1). The LIMA graft
was left intact at its origin off the
subclavian artery and was grafted to
the LAD artery, distal to the occlusion
(Figs. 1, 2 and 4). A left Saphenous Vein
Graft (SVG) was laid over the pulmonary
artery, and originated proximally off the
anterior wall of the ascending aorta. It
was anastomosed to the first diagonal
branch of the LAD, distal to the stenosed
site (Figs. 1 and 4). Both grafts remained
patent, with no evidence of stenosis.
The following findings were seen for
the original coronary arteries: A mild
stenosis, from soft plaque, in the midRight Coronary Artery (mid-RCA, Fig. 3),
a severe stenosis, from soft plaque,
in the Left Main Artery (LMA, Fig. 5),
occlusion, from both soft and calcified
plaque, in the proximal LAD (Fig. 5), and
a severe stenosis, from soft plaque, in
the proximal D1 (Fig. 5). The Circumflex
(CX) was small in caliber but showed
no evidence of stenosis (Fig. 6).
2 Curved
MPR image
presents the
entire course
of the LIMA
graft and its
patent anastomosis to the
LAD.
3 Curved MPR
shows RCA with
mild stenosis
from soft plaque
(arrowheads).
COMMENTS
In CABG follow-up studies, especially
those with saphenous vein grafts, catheter angiography is often difficult. Cardiac
CT can obtain both 2D and 3D images,
to depict in detail the course and status
of the grafts. Generally, to avoid motion
artifacts, a high temporal resolution
is required. This involves sophisticated
hardware to speed up the rotation time.
Alternatively, image reconstruction algorithms, such as the iterative Temporal
Resolution Improvement Method (iTRIM)
can be used to improve the temporal
resolution. iTRIM enhances temporal
resolution by 20% [1], allowing temporal
resolution to be improved to 192 ms
potentially aiding the physician in making
a reliable diagnosis.
4 VRT image shows the full extent

of LIMA graft from its proximal origin
(arrow) off the subclavian artery to
its distal anastomosis with the LAD
(dashed arrow). The SVG connected
to D1 (double arrows) is patent.
5 Curved MPR
shows severe stenosis,
from non-calcified
plaque in LM, occlusion from both soft
and calcified plaque
in proximal LAD and
severe stenosis from
non-calcified plaque
in proximal D1.
6 Curved MPR
shows CX is small
in caliber with
no evidence of
stenosis.
Scanner
SOMATOM Perspective
Scan area
Heart
Scan length
250 mm
Scan direction
Cranio-caudal
Scan time
12 s
Tube voltage
130 kV
Tube current
255 eff. mAs
CTDIvol
28.35 mGy
DLP
877.82 mGy cm
Effective dose
12.3 mSv
Rotation time
0.48 s
Pitch
0.27
Slice collimation
64 x 0.6 mm
Slice width
0.75 mm
Temporal Resolution
192 ms
0.5 mm
B31s
Patient heart rate
35 53 bpm
Contrast
References
[1] Schndube H et al. Evaluation of a novel CT
image reconstruction algorithm with enhanced
temporal resolution, Proc. SPIE 7961,
79611N (2011).
Volume
80 mL (370 mgL/mL contrast media)

+50 mL saline
Flow rate
5 mL/s
Start delay
23 s
47
Case 5
Diagnosis and Follow-up of
RCA Aneurysm using Flash Scanning
at 0.3 mSv
By Fahim H. Jafary, MD, FACC, FSCAI, Senior Consultant Cardiologist,* Jagajothi Devadoss,
Senior Radiographer,* Erdie Q. Dizon, Radiographer,* Wynne Chia, Senior Application Specialist, CT**
** Department of Cardiovascular Medicine, Tan Tock Seng Hospital, Singapore
** Siemens Healthcare, Regional Headquarters, Asia, Australia
HISTORY
DIAGNOSIS
An 18-year-old male patient, with known

Kawasakis disease, had a prior diagnosis
of a right coronary artery (RCA) aneurysm by invasive angiography in 2007.
The aneurysm was reported measuring
7.38 mm. He presented himself to the
hospital for an assessment and to establish a baseline CTA (Computed Tomography Angiography) to follow the progression of the aneurysm.
A coronary CTA scan was performed
using a high pitch Flash Spiral mode, and
six months later a follow-up examination
was conducted.
50 mg of oral Atenolol was administered
to the patient an hour prior to the study.
Nitroglycerine spray was also administered prior to scanning. The patients heart
rate was 6366 beats per minute at the
time of both studies, and the patient
tolerated the procedures with no complications.
The effective radiation dose was
0.34 mSv and 0.32 mSv, respectively in
both studies.
This is a limited study to determine the

progression of a previously identified
proximal RCA aneurysm. Prior CT images
showed a large aneurysm in the proximal
RCA that arose 2 mm beyond the ostium
measuring 8.3 mm in diameter (Figs.
12), with a mild layering of thrombus
at the inferior margin (Fig. 3). All findings were unchanged in the image review
on the follow-up CT exam (Fig. 4).
COMMENTS
A coronary aneurysm is rare, especially
in young patients. Follow-up CT scans
are necessary to monitor the progress of
the aneurysm. Therefore, it is important
to minimize the exposure dose to the
patient. Flash scanning uses an ECGtriggered spiral scan to acquire the entire
heart in one heart cycle. This provides
a very short scan time (0.3 s) and a very
low, consistent dose (0.3 mSv), as seen
in these two follow-up CT examinations
of the patient.
Scanner
SOMATOM Definition
Flash
Scan area
Heart
Scan length
138 mm
Scan direction
Cranio-caudal
Scan time
0.3 s
Tube voltage
80 kV
Tube current
272 eff. mAs
CTDIvol
1.26 mGy
DLP
24 mGy cm
Effective dose
0.3 mSv
Rotation time
0.28 s
Pitch
3.4
Slice collimation
128 x 0.6 mm
Slice width
0.6 mm
Temporal
Resolution
75 ms
Reconstruction
increment
0.3 mm
Reconstruction
kernel
B26f
Contrast
Volume
60 mL
Flow rate
6 mL/s
Start delay
Test Bolus Peak

Trigger + 15 secs
1 VRT images show a large aneurysm in the

proximal RCA (baseline, arrow).
2 VRT images show a large aneurysm in the

proximal RCA (baseline, arrow).
3 MPR image reveals a mild layering of thrombus

at the inferior margin (arrow).
4 RCA aneurysm was unchanged in the

follow-up examination.
49
Clinical Results Oncology
Case 6
Xenon Ventilation Imaging using
Dual Energy CT in Combined Pulmonary
Fibrosis and Emphysema
Keishi Sugino, MD, PhD,* Masahiro Kobayashi, MD,** Fumiaki Ishida, MD,* Naoshi Kikuchi, MD,* Nao Hirota, MD,*
Keita Sato, MD,* Go Sano, MD,* Kazutoshi Isobe, MD, PhD,* Susumu Sakamoto, MD, PhD,* Yujiro Takai, MD, PhD,*
Nobuyuki Shiraga, MD, PhD,** and Sakae Homma, MD, PhD*
**Department of Respiratory Medicine, Toho University Omori Medical Center, Tokyo, Japan
**Department of Radiology, Toho University Omori Medical Center, Tokyo, Japan
HISTORY
A 76-year-old man was admitted to our
hospital complaining of progressive dyspnea during exertion. He had a 50-year
smoking history averaging 20 cigarettes
per day. He had no known exposure to
1A
asbestos. The chest auscultation revealed

bilateral fine crackles in the lung bases.
Laboratory data upon admission showed
high levels of KL-6 (1283 U/mL) and SP-D
(168 ng/mL). The results of an arterial
blood gas analysis were as follows:

pH, 7.44; PaCO2, 34.8 Torr; and PaO2,
88.1 Torr on room air. The pulmonary
function test revealed mixed-ventilatory
impairment (FVC, 2.22 L, 69.6% of
1B
1 Chest CT revealed paraseptal and centrilobular emphysematous lesions significantly in both upper lobes and reticular lesions
with honeycombing formations bilaterally in the sub-pleural lower lobes.
Oncology Clinical Results
predicted, FEV1 1.46 L, 65.2% of predicted,

FEV1%, 65.8%,) with decreased diffusing
capacity (DLco, 7.79 mL/min/mm Hg,
51.2% of predicted, DLco/VA, 2.11 L/s,
49.9% of predicted) and increased residual volume (RV, 2.23 L, 123.2% of predicted). A chest X-ray showed reticular
shadows bilaterally in the lower lung
fields. A chest CT revealed paraseptal
and centrilobular emphysematous lesions,
significantly in both upper lobes, and
reticular lesions with honeycombing
formations bilaterally in the sub-pleural
lower lobes (Fig. 1).
DIAGNOSIS
Based upon the results of the increased
serum inflammatory markers (KL-6 and
SP-D), the mixed-ventilatory impairment
with decreased diffusing capacity and
the chest CT results, the patient was diag-
nosed with pulmonary emphysema associated with idiopathic pulmonary fibrosis

(IPF), the so-called combined pulmonary
fibrosis and emphysema (CPFE).
Scanner
SOMATOM
Definition Flash
Scan area
Chest
COMMENTS
Scan length
345.0 mm
Scan time and delay
10.09 s
3D Xenon-CT imaging showed large focal

xenon ventilation defects in the upper
lobes, and in contrast, slightly decreased
xenon ventilation with several defects
and volume loss with diffuse hypoventilation in the fibrotic lesions in the lower
lobes. These results clearly demonstrated
that the areas of ventilatory failure were
to be found not only in the upper lobes,
but also in the middle and lower lobes
(Fig. 2, 3). The xenon-enhanced areas
accumulated to 64.2% in the whole lungs
(Fig. 2). Xenon-CT Imaging may be useful for differentiating lesions in cases of
CPFE.
Scan direction
Cranio-caudal
kV
80 kV / 140 kV
Effective mAs
230 / 95 mAs
Rotation time
0.28 s
Slice collimation
64 x 0.6 mm
Reconstructed
slice thickness
2 mm
Increment
1.5 mm
Kernel
D30f
2, 3 3D Xenon-CT imaging and coronal MPR showed large focal xenon ventilation defects in the upper lobes, and in contrast, slightly
decreased xenon ventilation with several defects and volume loss with diffuse hypoventilation in the fibrotic lesions in the lower lobes.
51
Clinical Results Oncology
Case 7
Non-Hodgkin Lymphoma with Rare
Metastases in the Pancreas
By Harald Seifarth, MD, Christoph Schlke, MD, Johannes Wessling, MD
Department of Clinical Radiology, University of Muenster, Germany
HISTORY
COMMENTS
A 24-year-old female patient was presented to the emergency department

with superior vena cava (SVC) syndrome.
The thoracic CT scan showed a hypodense
mass surrounding and compressing the
SVC. The biopsy revealed a highly aggressive B-cell non-Hodgkin lymphoma (NHL).
An abdominal CT was then performed
for lymphoma staging.
B-cell NHL is the most common lymphoma

histotype. The affliction of the retroperitoneal lymph nodes and the kidneys is
commonly seen during staging. However
an involvement of the pancreas is rare
and reported in only 2% of patients with
NHL. CT imaging, especially with multi-
DIAGNOSIS
The thoracic CT scan revealed a large,

hypodense mediastinal mass, extending
from the sternal notch to below the bifurcation of the trachea. The left anonymous
vein was occluded and stenoses of the
right anonymous vein, the SVC (Figs.1
and 3), the right superior pulmonary vein
and both pulmonary arteries (Fig. 2) were
seen. The mass encased the supra aortic
vessels, the aortic arch, the trachea and
the esophagus. The trachea (Fig. 1) was
stent-expanded.
The abdominal CT scan revealed multiple
extranodal involvements of both kidneys (stage IV, Figs. 5 and 6). Additionally, several hypodense lesions could be
detected in the pancreas (Fig. 4), resulting in pancreatic duct distension in the
corpus and tail. There was no apparent
affliction of the retroperitoneal lymph
nodes.
planar reformations, can clearly demonstrate the multiple lesions and structures
involved. In this case, the metastases in
the parenchyma of the pancreas and the
slight ectasia of the distal duct could be
clearly visualized.
Scanner
Scan area
Thorax
Abdomen
Scan length
286 mm
420 mm
Scan direction
Caudo-cranial
Cranio-caudal
Scan time
4s
9s
Tube voltage
120 kV
120 kV
Tube current
86 mAs
104 mAs
Dose modulation
CARE Dose4D
CARE Dose4D
CTDIvol
5.8 mGy
8.5 mGy
DLP
177 mGy cm
307 mGy cm
Effective dose
2.48 mSv
4.6 mSv
Rotation time
0.28 s
0.5 s
Pitch
0.6
0.6
Slice collimation
128 x 0.6 mm
128 x 0.6 mm
Slice width
1.0 mm
1.5 mm
0.5 mm
0.7 mm
B30
B20
Volume
90 mL
100 mL
Flow rate
2.5 mL/s
3 mL/s
Start delay
45 s
85 s
Contrast
1 An axial image showed a mediastinal mass encasing the aorta,

the trachea and the SVC. The SVC was nearly occluded (arrow) and
the trachea is stented.
2 An oblique MPR image showed the stenoses of both pulmonary

arteries (arrows).
3 An oblique MIP image demonstrated the stenosis of the

SVC (arrow) and the azygos vein (dashed arrow).
4 An oblique MPR image showed the lymphoma manifestation

in the pancreas (arrow).
5 An axial image presented the lymphoma manifestation in the

pancreas (arrow) and in the right kidney (dashed arrow).
6 An oblique MPR image demonstrated multiple hypodense lesions

in the left kidney (arrows), consistent with the NHL-manifestation.
53
Clinical Results Neurology
Case 8
Diagnosis of an Intracranial
Dual-Aneurysm using the new
SOMATOM Perspective
By Johann Steffens, MD
Department of Radiology, Israelitisches Krankenhaus, Hamburg, Germany
HISTORY
An 84-year-old female patient with
a known small left internal carotid
aneurysm was admitted to the hospital
due to a sudden onset of ptosis and a
lack of right eye abduction.
A smaller aneurysm, measuring 1 cm

in diameter, was also seen at the left
internal carotid artery siphon. There was
no evidence of intracranial bleeding.
COMMENTS
DIAGNOSIS
CT images showed a large aneurysm,
measuring 2.9 cm in diameter, at the
right internal carotid artery (ICA) siphon,
compressing the right orbital apex.
CT Angiography (CTA) may be accurate

and reliable for the detection and characterization of intracranial aneurysms.
In this case, CTA demonstrated that the
newly developed large aneurysm of the
right carotid artery siphon compressing

the orbital apex was responsible for the
symptoms. The complete head and neck
region was acquired in just 4 seconds
using the new 128-slice SOMATOM
Perspective. The CT data set could be
clearly visualized and demonstrated
in any desired plane in VRT (Volume
Rendered Technique) or curved MPR
(Multiple Planar Reformation) images.
Scanner
SOMATOM Perspective
Scan area
Head and neck
Rotation time
0.6 s
Scan length
316 mm
Slice collimation
64 x 0.6 mm
Scan direction
Caudo-cranial
Slice width
0.75 mm
Scan time
4s
0.4 mm
Tube voltage
110 kV
I 30
Tube current
68 eff. mAs
Contrast
CTDIvol
5.08 mGy
Volume
50 mL
DLP
224.45 mGy cm
Flow rate
3 mL/s
Effective dose
1.5 mSv
Start delay
12 s
Neurology Clinical Results
2 Curved MPR image reveals a small aneurysm

at the left ICA siphon (arrow).
1 Curved MPR image shows a large aneurysm

at the right ICA siphon.
3 VRT image reveals a small aneurysm at the left ICA siphon (arrow).
4 Oblique MPR image presents the right orbital apex compressed

by the aneurysm.
55
Clinical Results Neurology
Case 9
Whole Brain Perfusion CT Reveals
Acute Misery Perfusion
By Jyoji Nakagawara, MD
Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan
16
CBF, MTT and CBV images acquired before (Figs. 13) and after (Figs. 46) treatment.
8A
7 IMP-SPECT1 confirms perfusion CT findings.
8B
8 Stenosis could be visualized in both right (Fig. 8A)

and left (Fig. 8B) internal carotid arteries.
HISTORY
An 84-year-old patient was referred to
the hospital with transient left-sided
hemiparesis. A cervical echo-arteriogram
revealed a stenosis of the right cervical
carotid artery. The hemi-paresis gradually progressed after admission. MRI was
contra-indicated, since the patient had
a pacemaker. Instead a whole brain
perfusion CT and an IMP-SPECT1 were
ordered.
DIAGNOSIS
The cervical CT Angiography showed
severe stenosis of the right internal
carotid artery (ICA, Fig. 8A). The whole
brain perfusion CT demonstrated a critical perfusion state of the right cerebral
hemisphere a decrease of Cerebral
Blood Flow (CBF, Fig. 1), an increase of
Cerebral Blood Volume (CBV, Fig. 3) and
a prolongation of Mean Transit Time
(MTT, Fig. 2), which definitely suggested
an acute misery perfusion state. The
patient was diagnosed with a progressing
stroke due to severe stenosis of the right
ICA. The IMP-SPECT also showed reduced
blood flow to the same area (Fig. 7). An
emergency carotid artery stenting (CAS)
was performed. After the CAS treatment,
the left-sided hemiparesis immediately
improved and then disappeared. An
emergency treatment of the left internal
carotid artery stenosis was considered

unnecessary at the time. The follow-up
whole brain perfusion CT, on day one after
CAS treatment, demonstrated marked
improvement of the cerebral perfusion of
the right cerebral hemisphere (Figs. 46).
The patient was discharged one month
later, and scheduled for out-patient follow-ups.
COMMENTS
Patients suffering from an ischemic
penumbra with abrupt occlusion of the
cerebral arteries in embolic stroke and
acute misery perfusion with hemodynamic cerebral ischemia could be candidates for acute revascularization procedures. Up to now, image modality was
not sufficient to confirm the diagnosis of
an acute misery perfusion with hemodynamic cerebral ischemia in routine clinical
practice. In patients with progressing
strokes, whole brain perfusion CT allows
the identification of a critical perfusion
state such as an acute misery perfusion
of the affected cerebral hemisphere.
Emergency CAS treatment has not yet
been established in the Japanese stroke
management guidelines. However, whole
brain perfusion CT could reveal a critical
perfusion state, such as an acute misery
perfusion, and could therefore be useful
for the indication of emergency therapeutic intervention within a narrow time

window.
1
IMP-SPECT: single photon emission computed

tomography (SPECT) using N-isopropyl-(iodine-123)
p-iodoamphetamine (123I-IMP). Some of the biomarkers
referenced herein are not currently recognized by the
U.S. FDA as being safe and effective, and Siemens does
not make any claims regarding its use. Please contact
your local Siemens organization for further details.
Scanner
SOMATOM Definition AS+
Scan area
Whole brain
Scan length
96 mm
Scan time
45 s
Scan direction
Caudo-cranial and
cranio-caudal
Tube voltage
80 kV
Tube current
180 eff. mAs
Rotation time
0.3 s
Slice collimation 64 x 0.6 mm

Reconstructed
slice thickness
5 mm
Increment
5 mm
Kernel
H22f
CTDIvol
198.7 mGy
Effective dose
4.8 mSv
Contrast
Volume
30 mL iodine
+ 20 mL saline
Flow Rate
6 mL/s
Start delay
5s
57
Clinical Results Acute Care
Case 10
CT Perfusion Identies Delayed Cerebral
Ischemia after Subarachnoid Hemorrhage
By Andre Kemmling, MD, Ludger Feyen, MD
Department of Clinical Radiology, University Hospital, Muenster, Germany
HISTORY
A 61-year-old female patient was admitted to the hospital suffering from a thunderclap headache, followed by a rapid
deterioration of her consciousness level
and then coma. Non-enhanced CT (Fig. 1)
and CT Angiography (CTA), upon admission, showed an acute subarachnoid
hemorrhage (SAH) due to an anterior
communicating aneurysm (Hunt-Hess
grade 3, Fisher grade 3). The aneurysm
was promptly secured by surgical clipping;
however, the intubated patient remained
in a deep coma after the initial event.
Therefore, a neurological evaluation of
her consciousness level and the detection
of new focal deficits were not possible.
DIAGNOSIS
An initial CT Perfusion (CTP, Fig. 3A)
scan was performed on day 4 for the
evaluation of delayed cerebral ischemia
(DCI) and vasospasm. There was severe
reduction in tissue perfusion in the
anterior watershed white matter of the
right hemisphere (mean transit time
1
1 Non-enhanced CT on admission
showed subarachnoid hemorrhage.
It is necessary to monitor patients with

SAH to promptly identify treatable and
reversible causes of neurological deterioration. DCI is defined as the delayed
development of a focal neurological
deficit and/or cerebral infarction due to
SAH.[1] Clinical monitoring for DCI consists of repeated neurological assessments, however, not all ischemic events
are detectable during a clinical examination.
DSA is considered the gold standard for

the detection of arterial vasospasm. [2].
CTA has a high specificity and a high
negative predictive value, and is therefore
an increasingly useful screening tool to
limit the use of DSA. Unlike CT perfusion,
it does not allow quantitative assessment
of brain perfusion required for metabolic
demands of the tissue. Also, not all
patients with angiographic vasospasm
manifest clinical symptoms. [3] A combination of CT protocols (non-enhanced
+ CTA + CTP) has the highest predictive
value for DCI monitoring. The combination of delayed MTT (> 7 s) and visible
vasospasms on CTA is highly accurate in
selecting patients that need an endovascular intervention for vasospasm. [4, 5]
Furthermore, CBF asymmetry between
hemispheres is an independent predictor
of DCI. [6] Early deficits in CT perfusion
identify patients with subsequent DCI and
their detection constitute image-guided
management of SAH patients. [7, 8]
Dynamic CT perfusion imaging allows sensitive evaluation of DCI and vasospasms
2A
2B
[MTT] > 7 s, cerebral blood flow [CBF]

< 47 mL/100 mL/min). Digital subtraction angiography (DSA, Fig. 2A) showed
severe proximal vasospasms. Endovascular therapy was initiated with an intraarterial nimodipine infusion (Fig. 2B).
A follow-up CTP scan (Fig. 3B) revealed
a normalized perfusion of the former
ischemic right hemisphere (MTT < 4 s,
CBF > 65 mL/100 mL/min). The patient
subsequently recovered while retaining
minor deficits.
COMMENTS
2 DSA image showed severe proximal vasospasm before treatment (Fig. 2A).
Follow-up DSA demonstrated normalized perfusion after treatment (Fig. 2B).
3A
Topic
in the whole brain of patients with SAH.

It is increasingly feasible due to drastically lowered radiation doses, achievable
with the latest available CTP protocols
and modern CT scanners. The thin slice
(1.5 mm) 4-dimensional dataset (96 mm
brain coverage) in this case allowed sharp
multiplanar reformatting within the
syngo VPCT Neuro application. A newer
syngo.via application (CT Dynamic Angio)
can process the same VPCT dataset to
screen-time resolved maximum intensity
projections and to assess arrival time of
enhanced collaterals (Fig. 4).
Multimodal CT imaging and particularly
CT perfusion have become valuable tools
for detecting and monitoring vasospasms
and delayed cerebral ischemia. CT perfusion may become pivotal for imageguided decision making for interventional
therapy.
3 Initial CTP
images showed
severe DCI in the
right hemisphere
(Fig. 3A).
A follow-up CTP
scan revealed
a normalized
perfusion of the
former ischemic
right hemisphere
(Fig. 3B).
3B
Scanner
Scan mode
Adaptive 4D Spiral
Scan area
Head
Scan length
96 mm
Scan direction
Cranio-caudal / caudo-cranial
Scan time
45 s
Tube voltage
80 kV
Tube current
200 mAs
Rotation time
0.285 s
Slice collimation
32x 1.2mm
Slice width
10 mm
4 CT Dynamic
Reconstruction
kernel
H20f
CTDIvol
256.38 mGy
DLP
3036 mGy/cm
Effective Dose
6.4 mGy cm
Contrast
Ultravist 370
Volume
30 mL contrast agent + 50 mL NaCl
Flow
6 mL/s
References
[1] Vergouwen MDI, Hemorrhage PitIM-DCCotCCMoS.
Neurocritical Care 2011;15:308-311.
[2] http://www.ajnr.org/content/27/1/26.full
[3] Greenberg ED, et al. American Journal of Neuroradiology
2010;31:1853-1860.
[4] Wintermark M et al. Cerebrovascular diseases
(Basel, Switzerland) 2008;26:163-170.
[5] Wintermark M,et al. AJNR American Journal of Neuroradiology
2006;27:26-34.
[6] Washington CW, Zipfel GJ, Hemorrhage PitIM-DCCotCCMoS.
Neurocritical Care 2011;15:312-317.
[7] Sanelli PC et al.Neuroradiology 2011;53:425-434.
[8] van der Schaaf et al. Stroke 2006;37:409-413.
Angio collateral
assessment:
time resolved
collateral filling
in early arterial
phase (right vs.
left hemisphere).
Case 11
Time Resolved CT Angiography
in Patients after EVAR
By Claudia Andres, MD, Borek Foldyna, MD, Christian Lcke, MD, Matthias Gutberlet, MD, Lukas Lehmkuhl, MD
Department of Diagnostic and Interventional Radiology, University of Leipzig, Heart Center, Leipzig, Germany
HISTORY
DIAGNOSIS
The patient presented himself for a

follow-up examination after an endovascular implantation of an aorto-biiliacal
Y-stentgraft due to an extant infrarenal
aortic aneurysm in June 2004. The previous examination showed an increase
in the size of the aneurysm sac (to max.
57 mm) and an endoleak type IB. The
endoleak was then shut out with an
atrium stentgraft of the left common

iliac artery. In the current contrast media
duplex ultrasound, there was no hint of
an endoleak or a perforation. For further
assessment, a dynamic CT Angiography
of the abdominal aorta was performed.
The dynamic CT Angiography of the

abdominal aorta demonstrated an unobtrusive stent prosthesis. Compared
to the examination before stent implantation, the aneurysm sac showed a constant width with its maximal diameter
being 57 mm. In the ventral part of the
aneurysm sac, a type IIA endoleak was
clearly defined, fed from the inferior
mesenteric artery.
1A
1B
1C
2A
2B
2C
12 Axial (Fig. 1) and VRT (Fig. 2) images showing the different points in time after reaching the bolus tracking threshold.
(Fig. 1A/2A) 12 s p.t.: significantly enhanced stentgraft, no endoleak visible.
(Fig. 1B/2B) 17 s p.t.: well-enhanced stentgraft, and a type IIA endoleak in the ventral aneurysm sac could be visualized.
(Fig. 1C/2C) 32 s p.t.: no longer enhanced stentgraft, however a well-enhanced endoleak.
Acute Care Clinical Results
3A
3B
3C
3D
3 Relative time density curves in the aorta (curve 1, yellow), the endoleak (curve 3, orange)
and the aneurysm sac (curve 2, green) together with the respective cross-sections where the
ROIs were placed: aorta (Fig. 3B), endoleak (Fig. 3C), aneurysm sac (Fig. 3D).
COMMENTS
Contrary to the contrast media ultrasound
examination, the dynamic CT Angiography
helped determine the existence of an
endoleak and helped the physician to
determine an explanation for the missing
reduction in size of the aneurysm sac.
Dynamic CTA may aid the physician
in detecting the flow patterns of the
different endoleaks by using multiple
acquisitions at different time points and
thereby increases both the sensitivity
and the specificity for the detection of
endoleaks. The gathered information
concerning the dynamic of endoleaks
considerably eases classification.[1]
References
[1] Lehmkuhl et al., Dynamic computed tomography angiography (dCTA) after abdominal aortic
endovascular aneurysm repair (EVAR): Differences in contrast agent dynamics in the aorta
and endoleaks Preliminary results J Vasc Interv
Radiol. 2012 Apr 9. [Epub ahead of print]
Scanner
Scan area
Abdomen
Scan length
283 mm
Scan direction
Cranio-caudal / caudo-cranial
Scan time
54 s
Total scan phase s/steps
10
Temporal resolution
5s
Tube voltage
80 kV
Tube current
120 mAs
CTDIvol
28.47 mGy
DLP
629 mGy cm
Effective dose
9.4 mSv
Rotation time
0.285 s
Slice collimation
128 x 0.6 mm
Slice width
1.5 mm
B30f
Contrast
Volume Contrast
80 mL
Flow rate
4 mL/s
Volume Saline
40 mL
61
Case 12
Diagnosis of Sub-acute Pulmonary Emboli
using Flash Mode, SAFIRE and 100 kV
By Savvas Nicolaou, MD,* Jennifer Powell**, Karl Krzymyk***
*** Vancouver General Hospital, Department of Emergency Trauma Radiology, Vancouver, Canada
*** CS Applications, Siemens Healthcare, Canada
*** CT Collaborations USA, Siemens Healthcare, USA
HISTORY
DIAGNOSIS
A 44-year-old male patient presented

himself to the hospital due to worsening
shortness of breath on exertion for the
past 6 months. A CT scan with contrast
was requested to rule out pulmonary
emboli (PE).
The post-contrast CT scan revealed good

opacification of the pulmonary arteries.
The images showed extensive right-sided
pulmonary emboli involving the posterior
segment of the right upper lobe
(arrow, Fig. 1A) and all segments of the
1A
1B
2A
1C
1D
2C
right lower lobe (arrowheads, Figs. 12).

Further thrombus could be visualized in
the posterior segment of the left upper
lobe (dashed arrow, Fig. 2B). These areas
of thrombus are incompletely occlusive
and are slightly eccentric, which may
2B
12 Images showed extensive bilateral pulmonary emboli involving the posterior segment of the right upper lobe (arrow, Fig. 1A),
all segments of the right lower lobe (arrowheads, Figs. 12) and the posterior segment of the left upper lobe (dashed arrow, Fig. 2B).
Acute Care Clinical Results
represent sub-acute pulmonary emboli.

There was no evidence of right heart
strain nor of any mediastinal adenopathy
or pericardial effusion.
COMMENTS
PE can be life threatening, and PE
patients generally have difficulties holding their breath during a CT scan. Using
Flash mode, the image acquisition of the
entire thorax can be completed in less
than one second (in this case 0.6 seconds). Therefore, motion artifacts can
be avoided even without breath-hold.
Since regular follow-up CT scans are
necessary for PE patients, radiation dose
reduction is essential. In this case, the
patients effective dose was reduced to
1.46 mSv by combining the Flash mode,
SAFIRE (Sinogram Affirmed Iterative
Reconstruction) and 100 kV.
3 Volume-rendered images demonstrated good opacification of the pulmonary arteries which

clearly revealed the thrombus in the posterior segments of the right lower lobe (arrows).
Scanner
Scan area
Thorax
Pitch
3.2
Scan length
287 mm
Slice collimation
128 x 0.6 mm
Scan direction
Cranio-caudal
Slice width
0.75 mm
Scan time
0.67 s
0.5 mm
Tube voltage
100 kV
I26f
Tube current
289 eff. mAs
Contrast
Dose modulation
CARE Dose4D
Volume
CTDIvol
3.01 mGy
70 mL (Optiray 350)
+ 30 mL saline
DLP
104 mGy cm
Flow rate
4.5 mL/s
Effective dose
1.46 mSv
Start delay
18 s
Rotation time
0.28 s
63
Clinical Results Pulmonology
Case 13
Dynamic Volumetric Expiratory Imaging
for Diagnosis of Tracheobronchomalacia
By Kianoush Ansari Gilani, MD, Leslie Ciancibello, RT, and Prof. Robert C. Gilkeson, MD
University Hospital Radiology, Cleveland, Ohio, USA
HISTORY
An 82-year-old female patient with a
long history of asthma was presented to
the radiology department complaining
of a persistent cough, which did not
respond to inhalers and standard asthma
therapy. A High Resolution CT (HRCT)
was requested to evaluate bronchiectasis
and interstitial lung disease.
A standard non-contrast volumetric CT
was performed, followed by a dynamic
volumetric expiratory imaging to evaluate
a suspected tracheomalacia.
DIAGNOSIS
The dynamic volumetric expiratory
imaging demonstrated significant
dynamic airway collapse (Figs. 13)

throughout the visualized airways, thus
establishing the diagnosis of tracheobronchomalacia.
COMMENTS
Expiratory collapse of the central airways,
termed tracheomalacia, is an important
and often unrecognized cause of chronic
cough. Traditional airway imaging assessment includes a series of selected axial
images taken in end-expiration to evaluate parenchymal air trapping and tracheobronchial airway collapse. End-expiratory
imaging is limited in the evaluation of
airway collapse as it fails to capture the
important dynamic nature of an airway

collapse. The markedly improved temporal resolution of the Flash CT technology
enables volumetric evaluation of the chest
and central airways in imaging times of
less than 1 second. When synchronized
with the beginning of the patients active
expiratory phase, Flash CT scanning
enables low dose (0.66 mSv) volumetric
imaging of the airways in the times used
for a FEV-1(Forced Expiratory in 1 second),
a standard metric for pulmonary function
testing.
In this case, the ultra fast acquisition and
low dose imaging capabilities of the
Flash CT technology enabled the dynamic
physiologic evaluation of the airways.
Scanner
Scanner
Scan area
Thorax (standard)
Scan area
Thorax (expiratory)
Scan length
24.2 mm
Scan length
14 mm, thoracic inlet to carina
Scan direction
Cranio-caudal
Scan direction
Cranio-caudal
Scan time
3s
Scan time
0.9 s
Tube voltage
120 kV
Tube voltage
120 kV
Tube current
273 eff. mAs
Tube current
40 Eff. mAs
Dose modulation
CARE Dose4D
Dose modulation
CARE Dose4D
CTDIvol
17.96 mGy
CTDIvol
2.2 mGy
DLP
532 mGy cm
DLP
47 mGy cm
Rotation time
0.5 s
Rotation time
0.28 s
Pitch
1.2
Pitch
Slice collimation
128 x 0.6 mm
Slice collimation
128 x 0.6 mm
Slice width
2 mm
Slice width
2 mm
Spatial Resolution
0.33 mm
Spatial Resolution
0.33 mm
1 mm
1 mm
B31f
B31f
Pulmonology Clinical Results
1A
1B
2A
2B
3A
3B
13 Comparison of
images acquired in
inspiratory phase (A)
and expiratory phase (B)
demonstrates the normal
airways (A) and the
tracheomalacia (B) in
axial images (Fig. 1),
fly-through images
(Fig. 2) and VRT images
(Fig. 3).
65
Science
Lung Ventilation Imaging

with Xenon Dual Energy CT
Due to the high prevalence of lung disease worldwide, specialists are always
looking for new simple and patient-friendly methods for lung imaging.
By Katharina Otani, PhD, R&C Department, HIM, Siemens Japan KK, Tokyo, Japan
Chronic obstructive pulmonary disease

(COPD) is a serious, incurable disease.
Yet, treatment can slow its course. Prof.
Norinari Honda, Chairman of the Department of Radiology, Saitama Medical Center, Saitama Medical University proposed
that Xenon Dual Energy CT (DECT) ventilation imaging of the whole lung in the
single-breath technique may be faster
than the multiple-breath technique and
a useful diagnostic tool for early detection
of COPD and other lung diseases.
Imaging methods using

xenon gas
In Japan, repeated inhalation of stable
xenon-oxygen mixtures with up to 35%
xenon for xenon-enhanced CT brain imaging is approved by Japanese pharmaceutical law and covered by national health
insurance for cerebral blood flow measurement. Radioactive isotopes of xenon
have been used in molecular imaging
as a radiotracer for the evaluation of pulmonary ventilation such as in dynamic
pulmonary Single Photon Emission Computed Tomography (SPECT) imaging. For
this, the patient usually inhales a xenonoxygen mixture in a closed circuit for
several minutes (wash-in) to reach equilibrium and finally exhales the xenon
mixture through a one-way valve inhaling
ambient air for several minutes (washout). A gamma camera continuously
acquires data during wash-in, equilibrium
and wash-out phases. Maps of ventilation
rate can be obtained based on the Kety
model, as long as the lung function is
not too severely impaired. In Dual Energy
Prof. Norinari Honda, Chairman of the Department of Radiology, Saitama Medical Center,
Saitama Medical University reported that Xenon Dual Energy CT ventilation of the whole
lung in single-breath technique may depict ventilation.
CT multiple-breath technique, stable nonradioactive xenon is used as a contrast

medium. By scanning a single slice of the
lung, wash-in and wash-out of xenon is
monitored similarly to SPECT imaging. The
whole lung is only scanned once during
breathhold after equilibrium is reached.
Several studies have demonstrated that
this technique may be useful for evaluating COPD and asthma.
Single-breath technique for

Xenon Dual Energy CT
Saitama Medical University, Saitama Medical Center, Kawagoe, Saitama prefecture
in Japan installed a SOMATOM Definition

Flash CT scanner in March 2010. Prof.
Norinari Honda, who specializes in chest
radiology and nuclear medicine, thought
that a single-breath technique may be
applicable to Xenon DECT for obtaining
pulmonary ventilation images. This technique would have the advantage of shortening the examination time and reducing the patients exposure to xenon gas,
reducing side effects and increasing
xenon concentration to improve image
quality above the multiple-breath technique. Prof. Honda designed two phantom experiments to evaluate the tech-
Science
1A
1B
1C
1D
1E
1F
1G
1H
1 Xenon Dual Energy CT ventilation images acquired in single-breath technique after inhalation of 41% (Figs. 1 A, B), 60% (Figs. 1 CE), 80%
(Figs. 1 FH) xenon mixed with 59, 40, 20% oxygen respectively. A maximum enhancement was measured for the highest xenon concentration.
nique and confirmed feasibility in four

volunteer scans. [1] In the first phantom
experiment, a bag filled with xenonoxygen mixtures of various concentrations was scanned to confirm the linear
dependence of xenon concentration
and Hounsfield (HU) values. In a second
phantom experiment Prof. Hondas group
demonstrated that one time simultaneous inspiration of a xenon-oxygen mixture with 35% xenon injected into tubes
with different apertures appears on CT
images as inhomogeneous xenon distribution, similar to how xenon may distribute in the lung.
Beyond 35% Xenon

concentrations
Since the air that we breathe contains
only 20% oxygen, Prof. Honda presumed
that mixtures of up to 80% xenon and
20% oxygen may be feasible for Xenon
DECT. At the 4th Japanese Society of
Pulmonary Functional Imaging meeting,
[2] Prof. Honda et al presented the case
report of a healthy volunteer who underwent Xenon DECT scans in single-breath
technique after inhalation of five xenonoxygen mixtures containing 35, 41, 61

and 80% xenon. Prof. Honda measured
a maximum enhancement of 49.2 HU
(standard deviation SD 9.31) for the highest xenon concentration compared to
36.2 HU (SD 6.84), and 40.2 HU (SD 9.23)
after 41 and 60% xenon inhalation respectively as shown in Fig. 1. No side effects
were reported except for a transient mild
dizziness, but a rigorous clinical study
would be needed to confirm the safety
before xenon mixtures of more than
35% could be used in clinical routine.
prize went to Keishi Sugimoto, MD et al,

Toho University Omori Medical Center,
Tokyo, for his report on Xenon DECT
for differential diagnosis of combined
pulmonary fibrosis and emphysema.
[4] More studies are expected to be
reported soon.
Clinical applications
References
[1] Honda N et al. Radiology 2012; 262: 262-268
[2] The 4th Japanese Society of Pulmonary Functional Imaging meeting, 10-12 February 2012,
Otsu, Shiga, Japan, http://jspfi4.umin.ne.jp/
(Japanese)
[3] Yanagita H, et al. Prediction of postoperative
pulmonary function by single-breath dual
energy xenon CT: a preliminary report. Insight
into imaging (ECR2012 Book of abstracts)
2012:3 Suppl 1;B-0030
[4] The 4th Japanese Society of Pulmonary Functional Imaging meeting, 10-12 February 2012,
Otsu, Shiga, Japan, http://jspfi4.umin.ne.jp/
(Japanese)
Xenon DECT in single-breath technique

gathered much attention at the 4th Japanese Society of Pulmonary Functional
Imaging meeting. [2] Ms. Hisami Yanagita
working with Prof. Honda presented
preliminary results of a clinical study on
whether lung function after lobectomy
of lung cancer patients scheduled for
surgery could be estimated on Xenon
DECT images before surgery [3] and
received a poster prize. Another poster
www.saitama-med.ac.jp/
kawagoe/ (Japanese)
67
Science
Discovering the Mysteries

of Our Ancestors With Dual Energy CT
Thomas Henzler, MD,* Heather Gill-Frerking,** Wilfried Rosendahl, PhD,** and Christian Fink, MD*
** Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim,
Medical Faculty Mannheim, Heidelberg University, Germany
** Reiss-Engelhorn Museums, Mannheim, Germany
Why was a nail driven into a persons skull
2000 years ago? How can we learn about
the diseases suffered by South American
women in the past millennia? By scanning
mummies with Dual Energy Computed
Tomography (CT), a group of researchers
in Mannheim has been able to unlock
some of the mysteries of how our ancestors lived.
Scientists were only first able to unwrap
the secrets of mummified bodies without
destroying them in the nineteenth century. In 1895, Wilhelm Conrad Rntgen
discovered a new kind of ray [1] which
we now refer to as the X-ray; and X-ray
images of mummies were published a
year later. [2]
Since then, different medical imaging
techniques have been used to gather vast
quantities of data on mummies and the
embalming process. Researchers from
Mannheim, Germany used the SOMATOM
Definition with Dual Energy CT technique
to divulge the past of the mummies
examined in the German Mummy Project.
To date, this group of researchers has
scanned 20 mummies and skulls from
regions around the world.
Dual Energy CT performs the scan at two
different energy levels which helped the
scientists to differentiate between the
materials of the body, bandages and burial
objects and create an impression of how
our ancestors looked many years ago.
Beyond material differentiation, Dual
Energy CT can reduce metal artifacts.
Fig. 1 shows a Roman skull penetrated
by a long nail, which was presented as a
Celtic trophy. More than 2000 years later,
the skull was found filled with pebbles in
a fountain of a Celtic farm near Koblenz
in Germany. Researchers used monoenergetic images at energy levels from
1A
1B
20 kV
1C
1E
40 kV
1D
160 kV
180 kV
1 This trophy a skull penetrated by a long nail was scanned with Dual Energy CT.
Among the monoenergetic images generated (Figs. 1AD) the image at 180 kV (Fig. 1D)
delivered a precise image of the object despite the metallic implant (Fig. 1E).
2A
2B
2 These Dual Energy CT images show calcifications (arrows) in the femoral vessels of
a mummy found in South Africa (Figs. 2AB). With Dual Energy plaque identification software these calcifications could be characterized as typical of arteriosclerosis (Fig 2B).
40 kV to 180 kV to analyze the skull.

Although information on the culture and
habits of our ancestors is intriguing for
anthropologists, medical researchers can
also learn more about pathologies from
a specific period. Dual Energy CT images

showed calcifications typical of arteriosclerosis in the femoral vessels of an
approximately 1000-year-old female
mummy found in South America (Fig. 2).
Science
At the time, risk factors such as lack of

exercise or high-fat diet correlated with
arteriosclerosis today were not present,
which can help us to understand modern
diseases in pathophysiological research.
Dual Energy CT is also used in clinical
routine today to differentiate soft-tissue
masses or calculate virtual non-contrast
CT images based on scans using contrast
medium. As can be seen in the example
of arteriosclerosis, the research by the
German Mummy Project not only helps

us to understand our ancestors past but
also establishes correlations between
historic and modern diseases.
www.umm.uni-heidelberg.de/
inst/ikr/pdf/2011_12_
Anthropologie.pdf (German)
www.g-o.de/dossier-detail-570-4.
html (German)
[1] Rntgen W. Ueber eine neue Art von Strahlen.

Sitzungsberichte der Wuerzburger Physik.medic. Gesellschaft, Wuerzburg, 1895.
[2] Knig C., 14 Photographien von RntgenStrahlen aufgenommen im Physikalischen
Verein zu Frankfurt a. M., Frankfurt, 1896.
www.rem-mannheim.de
Research Clusters Enable Transfer

of Basic Research to Clinical Routine
Part I. Beating Cancer Treating Individuals
By Monika Demuth, PhD, Computed Tomography, Siemens Healthcare, Forchheim, Germany
People and diseases have something in

common: no two individuals are identical.
As our knowledge of specic diseases,
such as tumors, improves it is becoming
increasingly apparent that often generalized oncological treatment regimes
do not serve the individual patient well
enough. Diseases and their prescribed
treatments can trigger discrete effects
in different patients. This is because the
effects of a particular cancer therapy
depend on a host of factors, including
the tumors individual biological characteristics (biomarkers), the stage of the
disease, patient age and physical condition, and many others. These factors
inform the development of modern, individualized cancer therapies. The goal is
to achieve the optimal balance for each
patient; in other words, a compromise
including a highly effective treatment for
the individual with the lowest possible
level of side effects. An ambitious goal
for modern medical research.
Combining Professional
Expertise
The German Federal Government offers
structural funding for leading-edge tech-
nology in the country, in so-called clusters, to facilitate the optimal networking

of professional expertise. The intention is
to produce additional scientific benefits
and accelerate market launches of innovative products, processes, and services.
The Government has already organized
several competitions to encourage
leading-edge clusters to develop novel
approaches to a long-term, regional or
national cluster strategy. Prof. Konstantin
Nikolaou, MD and Clemens Cyran, MD,
radiologists at the University Clinic affiliated to the Ludwig Maximilian University
(LMU) of Munich, are involved in a project run by the Munich Biotech LeadingEdge Cluster, known as m4. The m4
project is one of several high-end clusters
in Bavaria and is funded by the Federal
Ministry of Education and Research and
by the Bavarian State Ministry for Trade,
Transport and Technology. The key focus
of the Munich cluster is the dedicated
development of medical treatments for
personalized oncological medicine. The
cluster itself is a collaboration between
biotechnology and pharmaceutical companies, research institutes and institutions
affiliated to Munichs two leading univer-
University Clinic Munich, Campus Grohadern

plays a main role within the m4 project.
sities, LMU and TUM (Technical University

of Munich) and their University Clinics,
the Munich Helmholtz Center and the
citys Max Planck Institute. The m4 project is coordinated by BioM Biotech Cluster
Development GmbH.
In 2009, the m4 initiative won one such
leading-edge cluster competition enabling its various research groups to start
work on over 30 projects centered around
the theme of Personalized Medicine in
Oncology. One of the medical projects
run by m4 Non-invasive Monitoring
of Molecular Therapies in Oncology:
69
Science
Bench to Bedside Establishment of Biomarkers in Therapy Response is supervised by the aforementioned physicians
at the Institute for Clinical Radiology, part
of the University Hospital in Grohadern
Munich (Director: Prof. Reiser, MD).
Siemens always advocates the importance
of such fundamental research. As a result,
the company has made significant contributions to this influential, prestigious
project and supports the concerted efforts
through the provision of technical expertise and considerable financial assistance.
In the past, the efficacy of traditional,

cytotoxic tumor therapies, such as chemotherapy and radiotherapy, was usually
monitored exclusively on the basis of
changes in tumor size and morphology.
Precisely defined algorithms are applied
in order to describe tumor response based
on its size change during therapy. However, molecular cancer therapies, which
effectively inhibit tumor growth and
restrict blood circulation to the tumor as
opposed to destroying it cytotoxically,
are now becoming increasingly popular.

Conventional tumor monitoring, which
measures possible size alterations, is no
longer sufficient in many cases when
so-called anti-angiogenic pharmaceutical
therapies are prescribed. Since these
therapies are not primarily cytotoxic,
instead reducing the microcirculation and
metabolism of tumor tissue, the success
of a treatment can be determined chiefly
via an analysis of these two effects. As
a result, when assessing therapeutic
success, it is advisable to use functional
and molecular imaging procedures in
addition to established morphological
imaging. This allows the rating of factors
such as oxygen supply, perfusion and
diffusion in the tumor tissue for an earlystage evaluation of therapy response
(ideally a few days after start of the treatment in question). Responders can,
therefore, be differentiated from nonresponders effectively. Functional imaging
procedures appear better suited to the
presentation of the therapeutic success
of molecular treatments and the development of various imaging biomarkers
1A
1B
The Project
Day 7
Therapy
Day 0
1D
Control
1C
1 MR perfusion maps (plasma flow, mL/100mL/min). Experimental, subcutaneous prostate

carcinomas in rats with sorafenib therapy prior to treatment (day 0) and after seven days of
therapy. A significantly reduced plasma flow in the prostate carcinoma allograft with sorafenib
therapy was observed between days 0 and 7.
(prognostic imaging biomarkers, predictive imaging biomarkers, and therapy

response imaging biomarkers) than their
established, purely morphological counterparts.
Animal experiments performed to date
by researchers at the University Hospital
in Grohadern as part of the m4 project
emphasize the potential of functional
imaging procedures with dynamic, contrast-enhanced magnetic resonance
imaging (MRI), computed tomography
(CT) and contrast-enhanced ultrasound
for tumor imaging. Still, further studies
are needed to apply the technology to
actual clinical practice. With this in mind,
the project is currently focusing on the
standardization of perfusion imaging,
the systematic, reproducible analysis of
kinetic data, and the highly accurate
definition of the region of interest in
which tissue microcirculation is measured.
One project, for example, assesses the
validation of recorded non-invasive
MRI and CT imaging biomarkers against
immunohistochemical assessment.
The aim is to investigate the individual
biological significance of perfusion
parameters compared with the actual
mechanisms at cellular level. Ultimately,
the results of the animal experiments will
be applied in a clinical setting. Here, the
consideration of personalized molecular
therapies already approved for human
use and the reduction of costs and risks
in applying this new treatment form are
essential. Should the pharmaceutical
prove ineffective, the use of correct imaging procedures and techniques could
result in a swifter termination of treatment than is normally the case with current conventional morphological followups. This could reduce adverse side
effects for patients. Ideally, in the future
it will be possible to evaluate the success
or failure of molecular tumor therapies
at an early stage so as to be able to
adjust and complement the various treatment concepts quickly and individually.
Unsurprisingly, high-function, dynamic,
contrast-enhanced screenings of this
nature require state-of-the-art equipment.
Researchers working on the leading-edge
cluster project use Siemens MAGNETOM
Verio 3 Tesla MRI scanners and the high-
Science
2A
2B
2C
2D
2E
2F
2 CT perfusion maps of a patient with pleural metastases of a renal cell carcinoma (red arrow,
top row: before treatment, bottom row: after treatment). The perfusion screening with CT provides proof of therapy response showing a significant decline in the perfusion of this metastasis
after just two weeks of treatment (bottom row) with a tyrosine-kinase inhibitor (TKI).
end ultrasound system, Siemens ACUSON

S3000, which are used for both animal
experiments and patient screenings. CT
screenings use the Siemens SOMATOM
Definition Flash scanner.
Project Objectives
In the first three-year project phase, Prof.
Konstantin Nikolaou, MD, Clemens Cyran,
MD, and their scientific team will conduct
pre-clinical trials on tumor models in
rats. In one model, for example, a colon
carcinoma implanted subcutaneously is
treated with regorafenib, an angiogenesis
inhibitor. The tumor is examined via CT
perfusion before and after treatment
and the results correlated with an immunohistochemical tumor analysis. This
initial project phase aims to optimize
both CT methods and the standardized
quantification of tumor perfusion as a
non-invasive imaging biomarker of therapy response.
The second project phase runs parallel
to the first. Methods established in the
experimental model will be made more
rapidly available in the clinic, e.g. for
patients with colon carcinomas under-
going anti-angiogenic therapies. Prof.

Christoph Becker, MD, and associate Prof.
Anno Graser, MD, senior consultants
in the CT department at the University
Hospital in Grohadern, provide a crucial
interface in the transfer of research
findings to clinical practice. The second
phase of the project will focus on certain
clinical aspects, for instance workflows
relating to new research methods and
large data volumes. Investigations will
seek to determine the sections of the
patients body that require scanning and
the required parameters in the affected
physical area to achieve the optimal balance between radiation dose, contrast
agent dose and screening validity. It is
also essential to identify this area again
in the follow-up examination by taking
the underlying scan parameters from the
previous scan and configuring the scan
settings precisely (protocol retention).
Furthermore, it is important to determine
how the extremely high data volumes
incurred during dynamic, time-resolved
screenings can be processed and optimally saved (improving data handling).
It is crucial to ascertain how radiation
dose, which accumulates during CT perfusion screenings, particularly in the

event of multiple scans, can be reduced
using the SOMATOM Definition Flash. In
addition to these core aspects, perfusion
imaging with Dual Energy CT is a further
project theme that may offer a possible
approach to reducing radiation dose,
particularly in sequential screenings.
The research findings will also cover postprocessing, e.g. in connection with
motion correction in respiratory movements. Moreover, the cost efficiencies
of modern tumor therapy monitoring
are to be determined and the benefits
offered by Siemens technologies identified, such as the Adaptive 4D Spiral or
the shuttle mode for multi-phase imaging of an entire organ.
The initial pre-clinical and clinical research
findings described show that personalized
and individualized treatment concepts
are set to shape the medical world, and
oncology in particular, decisively in the
coming years. Non-invasive radiological
and nuclear medical imaging, an important diagnostic tool for clinical disciplines,
will play an increasingly significant role
in primary diagnostics and therapy monitoring. Great challenges remain for all
medical and industrial participants as
they seek to establish functional and
molecular tumor imaging as an effective
complement to tumor morphology in
meaningful clinical algorithms.
71
Science
Education and Awareness Brings

Condence to Decision-making in
Medical Imaging
Survey sponsored by SIERRA, the Siemens Radiation Reduction Alliance,
exposes Americans concerns, inuences, and levels of basic awareness
about medical imaging tests.
By Stefan Ulzheimer, PhD, Computed Tomography, Siemens Healthcare, Forchheim, Germany
The Siemens Radiation Reduction Alliance
(SIERRA), an expert panel established
to advance the cause of dose reduction
in medical imaging, sponsored a recent
survey that evaluates the decisionmaking process of potential patients in
response to situations where a medical
scan is recommended by a physician.
Scrutiny is increasing over medical imaging scans and the use of radiation. The
study reveals that awareness and familiarity with medical imaging tests leads
to clearer decisions for American adults
about their healthcare.
In the survey of more than 1000 American adults, several questions were asked
about the use of medical imaging tests,

followed by five real-life scenarios of
varying severity where each respondent
was asked to decide whether to go ahead
with a specific medical imaging test for
themselves or a loved one. The results
show a direct correlation between the
familiarity with a medical imaging test
Science
This survey sponsored by SIERRA provides perspective on

the patient concerns that doctors deal with at the practice
level every day when it comes to medical imaging.
Marilyn Siegel, MD, Mallinckrodt Institute of Radiology, St. Louis, USA
and the likelihood that they will go ahead

with that test at the recommendation of
a physician.
Familiarity with a medical

technology correlates
with consumers attitude
The technologies most familiar to consumers defined as those who have
either heard of or have had the test correspond to the percentage of consumers
who would go ahead with the test in the
survey scenarios. Of the technologies
highlighted in the survey, consumers are
most aware of X-rays (96%) and would
go ahead with a physicians recommendation for an X-ray in the survey scenario
(88%). Consumers were least familiar
with nuclear heart scan technology, with
just over one-third (39%) of surveyed
consumers having received or heard of
the test, and only 28% of respondents
indicating they would follow a physicians
recommendation for a nuclear heart scan.
Lack of knowledge on specic

technologies
The study found that 90% of American
adults could correctly identify the primary
use of medical imaging tests, citing use
as a diagnostic tool to find out whats
wrong, to see internally what cant be
seen otherwise, and as a non-invasive
procedure instead of exploratory surgery
as the top reasons.
Further, roughly two in five respondents
(41%) identify radiation exposure as a
risk associated with medical imaging tests.
Yet, when asked which medical imaging
tests use radiation, the survey shows that

many American adults are unfamiliar
with what technologies utilize radiation
to produce images, and which do not.
Twenty-three percent of respondents cite
ultrasound technology and 60% cite MRI
when asked which of the following technologies use ionizing radiation to produce
images?.
Despite the perceived risk of radiation
exposure, when respondents reviewed all
the options in the five survey scenarios,
including the physicians recommendation, almost 80% of the time consumers
went with the physicians advice, which
entailed proceeding with a medical imaging scan for themselves or a loved one.
These results reinforce how the benefits
of medical imaging far outweigh radiation
concerns for a majority of Americans.
Information and options are

key for patients
The results illustrate that for many
consumers who opt not to have the test
in a potentially critical medical scenario,
the information and available options are
the deciding factors when making an

informed decision about their care.
The survey shows that information and
understanding are critical for patients
when assessing the benefits and perceived
risks of these tests. As a longtime pioneer
in radiation dose reduction, Siemens
Healthcare is committed to working with
clinical staff to provide the resources they
need to help patients make informed
decisions about their care. As a consequence of the survey results, Siemens
also launched a new internet portal for
patient education on medical imaging
(www.medicalradiation.com).
SIERRA intends to publish the survey
results in a peer-reviewed journal to draw
the attention of the medical community
to the importance of not only the education of professionals but also patient
education.
More details about the survey results
can be found under:
www.siemens.com/
US-Dose-Survey
Marilyn Siegel, MD, from the Mallinckrodt Institute of Radiology in St. Louis is a SIERRA panel physician.
Customer Excellence
Siemens Hands-on Workshops

at the ECR and ESC
By Susanne v. Vietinghoff, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Siemens hands-on workshops offer
detailed instruction on the latest techniques in computed tomography. Each
course is conducted in a classroom setting
and covers topics from image acquisition
to processing and interpretation.
During the Siemens hands-on workshops
at the European Congress of Radiology
(ECR) and the European Society of Cardiology (ESC) attendees learnt to get the
most from Siemens advanced visualization tools with case-based demonstrations
by clinical experts. These workshops are
free of charge for registered attendees
and are fully CME accredited.
Workshops during ECR:
During the CT workshops the presenters
focused on optimizing reading criteria as
well as image quality and postprocessing.
CT workshops:
CT Oncology presented by
Anno Graser, MD
CT Colonography presented by
Thomas Mang, MD
CT Dual Energy presented by
Ralf Bauer, MD
CT Neurology presented by
Peter Schramm, MD
CT Cardiology presented by
Matthias Kerl, MD
The program also included workshops
for MR Mammography, advanced reading
in PET/CT and 3D Breast Tomosynthesis.
With ten workplaces available on the
course, participants benefited from an
individual learning environment.
Workshops during ESC:
For the upcoming ESC 2012 in Munich,
Siemens is hosting workshops on computed tomography, magnetic resonance,
molecular imaging, ultrasound, angiography and laboratory diagnostics.
Due to the high demand last year, the

number of sessions has been increased
and two workshop rooms are available
for parallel sessions. Attendees can
register onsite for the workshops at the
ESC.
The six CT sessions on technical principles, clinical indications and analysis
of cardiac CT datasets will be held by
Matthias Kerl, MD from the University
Hospital in Frankfurt. During these
90-minute sessions he will talk in detail
about triaging patients with suspected
coronary artery disease (CAD). The goal
of the non-invasive CT examination is
to differentiate between patients with
and without significant stenosis.
Matthias Kerl will also demonstrate why
coronary CT Angiography (CTA) is often
perceived as the most promising technique for non-invasive CT and how far
coronary CTA has become part of clinical
routine. This hands-on session includes
the latest dose-saving techniques, main
indications, and tips and tricks. Multiple
cases will also be presented and discussed
during an introduction to the syngo.via
advanced visualization software.
A statement from one of last years
participants underlines the success of
the Siemens hands-on workshops:
The tips and short-cuts shown during
the workshop are very helpful. It is fascinating to see the possibilities offered
by on-screen image processing, says
Marjolein Kamphuis-Menses, MD,
ERASMUS University Medical Center,
Rotterdam. Further information at:
www.siemens.com/
SOMATOMEducate
ECR 2012 Hands-on workshop:

CT Dual Energy presented by Ralf Bauer, MD
ESC 2011 Hands-on tutorial:

CT Cardiology presented by Tobias Pflederer, MD
Customer Excellence
Clinical Webinar: Highly Topical

Information Presented by Specialists
Siemens clinical webinars feature the
latest information in healthcare imaging
and new medical imaging technologies.
Each of the webinars is held by clinical
experts and can be watched anytime from
anywhere.
The following topics which are
currently available:
Low Dose Cardiac CT by Prof. Stephan
Achenbach, MD, PhD. Stephan
Achenbach presents his experiences of
cardiac CT scanning and explains how
excellent imaging is achievable at
lowest possible dose values.
CT Stroke Management by Prof. Bernd
Tomandl, MD. Bernd Tomandl shows
the combination of non-enhanced CT,
CT Perfusion and CT Angiography
scanning for patients with acute

ischemic strokes.
The most current webinar is:
High-resolution CT (HRCT) scans for
patients referred for interstitial lung
diseases with Martine Remy-Jardin,
MD, PhD. During the presentation,
Martine Remy-Jardin discusses the
clinical disease pattern of interstitial
lung diseases including potential diagnostic methods while demonstrating
the value of HRCT scanning for such
patients. Further information at:
Siemens webinars are held by clinical experts.
www.siemens.com/
SOMATOMEducate
Coronary CTA Interpretation

Workshop Level II
Periodically, Siemens offers workshops
for clinical personnel to share experiences
on how to get the most out of their technology. One offer is a cardiac interpretation workshop held at the University of
Erlangen-Nuremberg, Germany where
participants collect hands-on experiences
in the interpretation of coronary CT
Angiography datasets. Over the two days,
attendees use syngo.via to evaluate 50
original coronary CT Angiography scans
which help them to get towards Level II
certification. The cases range from easy,
introductory cases to more advanced
cases with difficult diagnoses and typical
pitfalls. Invasive coronary angiography
correlation is available for the CT Angiography cases. The faculty will be available to provide help and guidance during
the whole course.
This course is most suited for cardiologists and radiologists who have basic
knowledge of cardiac computed tomography, who want to improve their interpretation skills and gather experience
in recognizing typical and more complex
findings.
Patrizia Pernter, MD from Bolzano/Italy:
I enjoyed the Cardio Workshop in
Erlangen completely because it fulfilled
my expectations. The practical exercises
are exactly what is needed to learn the
everyday tools. Prof. Ropers answered

all the questions during the course and
solved all issues that were raised in a
helpful manner. I have learned a lot that
is very important for my daily practice.
The next course date is scheduled for
September 2728, 2012.
www.siemens.com/
SOMATOMEducate
75
Customer Excellence
Frequently Asked Question

By Ivo Driesser, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Why are two different Quality Reference Tube Current Values Displayed?
Since 2011, CARE kV has been available
on Siemens high-end scanners.* CARE kV
can set the tube voltage (kV) automatically for individual examinations which
optimizes contrast-to-noise ratio and
reduces dose by up to 60%. CARE kV sets
the correct kV values based on patient
size and examination type.
When changing the kV value manually,
the tube current (mAs) needs to be re-cal-
culated to ensure the best image quality.

CARE kV adapts the kV value and calculates a new quality reference mAs value
for the new kV value.
The original and the new values can
always be verified easily. In the scan
protocol, the original value is marked in
green on the scan subtask card. In the
left lower corner of the tomosegment,
the new calculated tube current value
(ref. mAs) is highlighted in green (Fig. 1).
The reason for this is simple: When a
follow-up scan is performed on a scanner

that is not equipped with CARE kV, the
radiographer can manually set the new
kV and quality ref. mAs values. That
means the best dose for the patient and
optimum image quality can be set, even
on a scanner which is not equipped with
CARE kV.
* SOMATOM Definition AS, SOMATOM Definition Flash
1 The original tube current value is marked in green on the scan subtask card (arrowhead).
In the left lower corner of the image, the new calculated tube current value (ref.mAs) is highlighted in green (arrow).
Customer Excellence
Clinical Workshops 2012

As a cooperation partner of many renowned hospitals, Siemens Healthcare offers continuing CT training programs.
A wide range of clinical workshops keeps participants at the forefront of clinical CT imaging.
Workshop Title / Special Interest
Date
Location
Course Director
Link
Hands-on at the ESGAR

Congress / Colonography
June 12 15
Edinburgh, UK
ESGAR S. Halligan, MD
www.esgar.org
Oncology Imaging Course

2012 / Oncology
June 28 30
Dubrovnik, HR
OIC Prof. M. Reiser, MD
www.oncoic.org
Clinical Workshop on
Cardiac CT / Cardiac
July 4 6
Munich, GER
Siemens Healthcare
Prof. C. Becker, MD
www.siemens.com/
SOMATOMEducate
Cardiac CT Level II Training / Cardiac
July 17 20
London, UK
British Institute of Radiology
www.bir.org.uk
Hands-on Tutorial at ESC 2012 /

Cardiac
Aug 25 29
Munich, GER
Siemens Healthcare
www.siemens.com/ESC
Cardiac CT Level II Training / Cardiac
Sept 11 14
London, UK
British Institute of Radiology
www.bir.org.uk
CT Neuro Perfusion Workshop
Sept 14 15
Gttingen, GER
P. Schramm, MD
www.kelcon.de/_d-upl/
Programm_Hands_on_
Workshop_Goettingen.pdf
Hands-on at the ESGAR Workshop /

Colonography
Sept 19 21
Valencia, S
ESGAR L. Marti-Bonmati
www.esgar.org
CTA Interpretation Course / Cardiac
Sept 27 28
Erlangen, GER
Siemens Healthcare
Prof. D. Ropers, MD
www.siemens.com/
SOMATOMEducate
Oct 17 19
Munich, GER
Siemens Healthcare
Prof. C. Becker, MD
www.siemens.com/
SOMATOMEducate
DE / Dual Energy
Nov 2 3
Forchheim,
GER
Siemens Healthcare
Prof. T. Johnson, MD
www.siemens.com/
SOMATOMEducate
Dec 12 14
Munich, GER
Siemens Healthcare
Prof. C. Becker, MD
www.siemens.com/
SOMATOMEducate
In addition, you can always find the latest CT courses offered by Siemens Healthcare at www.siemens.com/SOMATOMEducate
Upcoming Events & Congresses 2012

Title
Dates
Short Description
Location
Contact
ESTI
June 22 24
European Society of Thoracic Imaging London, GB
www.esti2012.org/
SCCT
July 19 22
Society of Cardiovascular
Computed Tomography
Baltimore,
Maryland
www.scct.org/
ESC
Aug 29 Sept 2
European Society of Cardiology
Munich, Germany
www.escardio.org
AOCR
Aug 30 Sept 2
Asian Oceanian Congress

of Radiology
Sydney, Australia
www.aocr.org/
ASTRO
Oct 28 31
Annual Meeting of the American

Society of Radiation Oncology
Boston, U.S.
www.astro.org/
Medica
Nov 14 17
World Forum for Medicine
Dusseldorf, Germany
www.medica-tradefair.com/
RSNA
Nov 25 30
Annual Meeting of Radiological

Society of North America
Chicago, U.S.
www.rsna.org/
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A. Nchanduca, RT, Clinica Girassol, Luanda, Angola
Borek Foldyna, MD, University of Leipzig,
Christian Fink, MD, University of Mannheim, Germany
Christian Lcke, MD, University of Leipzig,
Christoph Schlke, MD, University of Muenster,
Muenster, Germany
Claudia Andres, MD, University of Leipzig,
Constana Palma Borges, MD, Clinica Girassol,
Luanda, Angola
Erdie Q. Dizon, Radiographer, Tan Tock Seng Hospital,
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Fahim H. Jafary, MD, FACC, FSCAI, Tan Tock Seng
Hospital, Singapore
Fumiaki Ishida MD, Toho University Omori Medical
Gang Wang, MD, Baotou Central Hospital,
Gang-feng Hu, MD, Wuxi Peoples Hospital Afliated
Go Sano MD, Toho University Omori Medical Center,
Tokyo, Japan
Hailiang Jia, MD, Baotou Central Hospital,
Harald Seifarth, MD, University of Muenster,
Muenster, Germany
Heather Gill-Frerking, Reiss-Engelhorn Museums,
Mannheim, Germany
Christian Rayr freelance journalist, Paris, France;

Irne Dietschi science and medical writer, Switzerland;
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Sakae Homma MD, PhD, Toho University Omori

Savvas Nicolaou, MD, Vancouver General Hospital,
Vancouver, Canada
Susumu Sakamoto MD, PhD, Toho University Omori
Thomas Henzler, MD, University of Mannheim,
Germany
Vasco Silva, MD, Clinica Girassol, Luanda, Angola.
Wilfried Rosendahl, PhD, Reiss-Engelhorn Museums,
Mannheim, Germany
Xiang-ming Fang, MD, Wuxi Peoples Hospital Afliated
Xiao-yun Hu, MD, Wuxi Peoples Hospital Afliated to
Nanjing Medical University, Wuxi, P.R. China
Yingning Wang, MD, Peking Union Medical College,
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Hong-wei Chen, MD, Wuxi Peoples Hospital Afliated

Hui-jun Lu, MD, Wuxi Peoples Hospital Afliated
Jagajothi Devadoss, Senior Radiographer,
Tan Tock Seng Hospital, Singapore
Jian Cao, MD, Peking Union Medical College,
Beijing, P.R. China
Joana Costa, MD, Institut Jules Bordet
Joo Carlos Costa, MD, Hospital Particular de Viana
Johann Steffens, MD, Israelitisches Krankenhaus,
Hamburg, Germany
Johannes Wessling, MD, University of Muenster,
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Jyoji Nakagawara, MD, Nakamura Memorial Hospital,
Sapporo, Japan
Kai Sun, MD, Baotou Central Hospital, Inner Mongolia,
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Kazutoshi Isobe MD, PhD, Toho University Omori
Keishi Sugino MD, PhD, Toho University Omori Medical
Keita Sato MD, Toho University Omori Medical Center,
Tokyo, Japan
Kianoush Ansari Gilani, MD, University Hospital
Leslie Ciancibello, RT, University Hospital Radiology,
Cleveland, Ohio, USA
Lijun Ma, MD, Baotou Central Hospital,
Ludger Feyen, MD, University Hospital Mnster,
Germany
Lukas Lehmkuhl, MD, University of Leipzig,
M. Reis, RT, Hospital Particular de Viana do Castelo,
Viana do Castelo, Portugal
M. Sozinho, RT, Clinica Girassol, Luanda, Angola
Marisa Gonalves, RT, Hospital Particular de Viana
Masahiro Kobayashi MD, Toho University Omori
Matthias Gutberlet, MD, University of Leipzig,
Heart, Center, Leipzig, Germany
Nao Hirota MD, Toho University Omori Medical Center,
Tokyo, Japan
Naoshi Kikuchi MD, Toho University Omori Medical
Nobuyuki Shiraga MD, PhD, Toho University Omori
P. Miguel, RT, Clinica Girassol, Luanda, Angola
Ping-yan Qian, MD, Wuxi Peoples Hospital Afliated
Prof. Robert C. Gilkeson, MD, University Hospital
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Answers for life in Computed Tomography
Issue Number 30 / August 2012

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Resolution for
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Science
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Issue Number 30 / August 2012

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Based on this strategy we are able to

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In addition to performance and cost

And about how smart algorithms, such

SOMATOM Sessions August 2012 www.siemens.com/healthcare-magazine

Low Dose, High Resolution

6 Sainte-Marie Clinic in Osny,

12 Stellar Detector: Lower Radiation

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62 Diagnosis of Sub-acute Pulmonary

74 Siemens Hands-on Workshops

66 Lung Ventilation Imaging with

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Between Paris and Pontoise, roads and

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800 Patients already examined

Alexandre Fuchs, MD is co-director of the

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Entrance of the Sainte-Marie Clinic, Osny, France

Sainte-Marie in Osny: A Health Center

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