Professional Documents
Culture Documents
Siemens AG
Wittelsbacherplatz 2
80333 Muenchen
Germany
Siemens AG
Healthcare Sector
Henkestrae 127
91052 Erlangen
Germany
Phone: +49 9131 84 - 0
www.siemens.com/healthcare
26
www.siemens.com/healthcare-magazine
SOMATOM
Sessions
91052 Erlangen
Germany
Siemens AG
Halthcare Sector
H CC 11
Henkestrae 127
Siemens AG
Medical Solutions
Computed Tomography
Siemensstrae 1
91301 Forchheim
Germany
Phone: +49 9191 18 - 0
www.siemens.com/healthcare
Asia/Pacific:
Siemens Medical Solutions
Asia Pacific Headquarters
The Siemens Center
60 MacPherson Road
Singapore 348615
Phone: +65 9622 - 2026
www.siemens.com/healthcare
May 2010
Rapid evaluation is
critical after trauma and
with symptoms such as
weakness, headache,
and dizziness, which is
why CT is the modality
of choice in these
scenarios. Exceptional
image quality is key to
optimize diagnosis, and
lower dose imaging
minimizes risk to the
patient.
Global Siemens
Healthcare Headquarters
Latin America:
Siemens S.A.
Medical Solutions
Avenida de Pte. Julio A. Roca No 516, Piso 7
C1067ABN Buenos Aires Argentina
Phone: +54 11 4340 - 8400
www.siemens.com/healthcare
USA:
Siemens Medical Solutions U.S.A., Inc.
51 Valley Stream Parkway
Malvern, PA 19355-1406
USA
Phone: +1-888-826 - 9702
www.siemens.com/healthcare
Cover Story
The Best of Both Worlds
in Neuro Imaging
Page 6
Canada:
Siemens Canada Limited
Medical Solutions
2185 Derry Road West
Mississauga ON L5N 7A6
Canada
Phone: +1 905 819 - 5800
www.siemens.com/healthcare
Europe/Africa/Middle East:
Siemens AG
Medical Solutions
Henkestrae 127
D-91052 Erlangen
Germany
Phone: +49 9131 84 - 0
www.siemens.com/healthcare
SOMATOM Sessions
News
Business
ISCT-Edition
Clinical
Results
SOMATOM Denition AS+:
CT Perfusion With
Extended Coverage for
Acute Ischemic Stroke
Page 46
Science
CT in Pediatrics: Easier
and Safer With the Flash
Page 58
Editorial
Imprint
Chief Editors:
Institution
Department
Function
Title
Name
P. Weisser, MD, Department of Diagnostic and Interventional Radiology, Clinic of the Goethe
University, Frankfurt, Germany
Street
Postal Code
City
State
Editorial Board:
Andreas Blaha
Helge Bohn
Andreas Fischer
Thomas Flohr, PhD
Julia Hoelscher
Klaudija Ivkovic
Axel Lorz
Peter Seitz
Stefan Ulzheimer, PhD
Alexander Zimmermann
Country
Neuro BestContrast
allows radiologists to
better visualize subtle
edemas as well as
subtle signs of stroke,
and to better delineate
the cortical margin.
Medical Solutions
MAGNETOM Flash
SOMATOM Sessions
AXIOM Innovations
73
The drugs and doses mentioned herein are consistent with the approval labeling
for uses and/or indications of the drug. The treating physician bears the sole
responsibility for the diagnosis and treatment of patients, including drugs and
doses prescribed in connection with such use. The Operating Instructions must
always be strictly followed when operating the CT System. The sources for the
technical data are the corresponding data sheets. Results may vary.
Partial reproduction in printed form of individual contributions is permitted, provided the customary bibliographical data such as authors name and title of the
contribution as well as year, issue number and pages of SOMATOM Sessions are
named, but the editors request that two copies be sent to them. The written consent
of the authors and publisher is required for the complete reprinting of an article.
We welcome your questions and comments about the editorial content of
SOMATOM Sessions. Manuscripts as well as suggestions, proposals and information are always welcome; they are carefully examined and submitted to the editorial board for attention. SOMATOM Sessions is not responsible for loss, damage,
or any other injury to unsolicited manuscripts or other materials. We reserve the
right to edit for clarity, accuracy, and space. Include your name, address, and
phone number and send to the editors, address above.
Cover Page: With Volume Perfusion CT Neuro fused with carotid CT Angiography the perfusion status of the brain tissue
can be observed. Courtesy of University Hospital Gttingen, Germany.
Note in accordance with 33 Para.1 of the German Federal Data Protection Law:
Despatch is made using an address file which is maintained with the aid of an
automated data processing system.
SOMATOM Sessions with a total circulation of 35,000 copies is sent free of charge
to Siemens Computed Tomography customers, qualified physicians and radiology
departments throughout the world. It includes reports in the English language
on Computed Tomography: diagnostic and therapeutic methods and their application as well as results and experience gained with corresponding systems and
solutions. It introduces from case to case new principles and procedures and discusses their clinical potential.
The statements and views of the authors in the individual contributions do not
necessarily reflect the opinion of the publisher.
The information presented in these articles and case reports is for illustration only
and is not intended to be relied upon by the reader for instruction as to the practice of medicine. Any health care practitioner reading this information is reminded that they must use their own learning, training and expertise in dealing with
their individual patients. This material does not substitute for that duty and is not
intended by Siemens Medical Solutions to be used for any purpose in that regard.
Subscription
Editorial
Andr Hartung,
Vice President
Marketing and Sales
Business Unit CT,
Siemens Healthcare
Dear Reader,
Imagine an emergency room only a
few short years ago: in the middle of
the night, a 55-year-old, unconscious
patient is wheeled in. All neurologic
observations indicate stroke. But
how severe? Is it an occlusion or a
hemorrhage and where is it located?
All crucial questions that demand fast
answers! The physician on duty could
request a head CT examination that
could possibly involve two scans at 15
to 30 mSv radiation dose. The physician
would then begin with extensive postprocessing possibly using a PACS
Workstation before the CT results could
provide life the necessary clinical information required. Not a very pleasant
alternative for the physicians or the
patient.
Now imagine the same situation in a
modern emergency room equipped with
Siemens cutting-edge technology such
as SOMATOM Definition Flash scanner
that scans faster than all other CT
scanners on the market with latest
neuro imaging software and syngo.via
software that post-process on-the-fly
Within minutes, the physician would
have access to the head scan results with
all post-processing completed at lowest
possible dose, including non-enhanced
CT for exclusion of hemorrhage, complete vascular status plus functional
information.
Andr Hartung
* syngo.via can be used as a standalone device or together with a variety of syngo.via based software options,
which are medical devices in their own rights..
Content
Content
22
Cover Story
Cover Story
6 Exciting advances in computed
tomography (CT) examination
methods, including low dose
protocols, technical innovations
such as whole brain CT Perfusion,
Dual Energy or Neuro Best Contrast
applications and groundbreaking
radiological research have dramatically changed the diagnostic
approach for reading physicians
by enabling new indications and
improved timing in the examination
of patients with acute neurological
deseases. SOMATOM Sessions
discussed with five experienced
physicians how CT can routinely be
used as the key diagnostic modality
in neuro imaging before the start
of appropriate treatment.
News
16 Affordable Performance in 16- and
64-slice CT
18 Best Balance Between Image Quality
and Reduced Dose
19 IRIS Now Extended to SOMATOM
Definition AS 20 and SOMATOM
Definition AS 40
20 syngo CT 2010B Now Available:
New Software Version for the
SOMATOM Definition AS Launched
21 Worldwide Dose Counter
22 International CT Image Contest
Highest Image Quality at
Lowest Dose
Content
48
60
Business
26 New Feature: Neuro Image Quality
Surpasses all Expectations
Clinical Results
Cardio-Vascular
28 Adenosine Myocardial Stress
Imaging Using SOMATOM
Definition Flash
30 SOMATOM Definition Flash:
Visualization of the Adamkiewicz
Artery by IV-CTA in Dual Power Mode
32 Dynamic Myocardial Stress Perfusion
34 Pre-operative Exclusion of Coronary
Artery Stenosis With Less Than
1 mSv Dose
36 Utilizing Ultra Low Dose of 0.05 mSv
for Premature Baby With Congenital
Heart Disease
38 SOMATOM Definition Flash: Pediatric
Patient Without Sedation and
Breath-Holding
40 SOMATOM Definition Flash: Dual
Energy Coronary CT Angiography for
Evaluation of Chest Pain After RCA
Revascularization
Science
Oncology
42 3D Guided RF Ablation and CT
Perfusion a New Combination for
Monitoring of Treatment Response
44 SOMATOM Definition Flash:
Routine Re-staging of Oesophageal
Carcinoma Utilizing IRIS Technology
Neurology
46 SOMATOM Definition AS+: CT
Perfusion With Extended Coverage
for Acute Ischemic Stroke
48 Vasospasm After Subarachnoid
Hemorrhage: Volume Perfusion CT
Neuro
Acute Care
52 Dual Energy Scanning: Diagnosis
of Ruptured Cocaine Capsule
54 Progressive Kidney Hematoma
Post-interventional Biopsy
56 SOMATOM Definition Dual Source
High Pitch vs. Routine Pitch Scanning
in a Pediatric Lung Low Dose
Examination
Life
66 Behind the Scenes: CT Scan Protocols
68 First syngo.via Hands-on Workshops
at ECR 2010
68 Upcoming Events & Congresses
69 Training Website for Knowledge
Improvement
69 Free Trial Licenses for Neuro Imaging
70 Frequently Asked Questions
70 Dual Energy CT: Learning From the
Experts
71 Clinical Workshops 2010
72 Siemens Healthcare Customer
Magazines
73 Imprint
Coverstory
Coverstory
Neuro BestContrast
Although newer techniques are revolutionizing stroke assessment, the gold
standard for the initial diagnosis of
stroke and intracranial hemorrhage is
still non-contrast imaging of the brain.
Siemens has always placed emphasis on
providing the highest image quality on
all of their scanners for this challenging
application. Now, Siemens has taken
image quality to the next level. Last
year, Duke became the first hospital in
the United States to install Siemens
Neuro BestContrast, an application that
dramatically increases gray/white matter
differentiation in non-contrast head CT
Neuro BestContrast
allows radiologists
to better visualize
the gray/white matter interface to see
subtle edema and
signs of stroke, and
to better delineate
the cortical margin.
David S. Enterline, MD, Division Chief
Neuroradiology, Duke University Medical
Center in Durham, North Carolina, USA
Coverstory
1A
1B
1C
1 Comparing conventional head CT imaging (Fig. 1A) with the new IRIS technology (Fig. 1B) shows decreased image noise. Combining IRIS
with Neuro BestContrast technology provides very high image quality with decreased noise by utilizing reduced radiation dose (Fig. 1C).
Coverstory
IRIS
Neuro BestContrast can be combined
with another new Siemens technology
known as Iterative Reconstruction in
Image Space (IRIS) to reduce dose and
improve image quality even further.
I think they work perfectly with each
other and have additive value, says
Christoph Becker, MD, Professor of Radiology and Section Chief of Computed
Tomography and PET/CT at Ludwig-Maximilians-University in Munich, Germany.
Iterative reconstruction uses a correction
loop to improve image quality in several
steps, or iterations. The idea was first
introduced in the 1970s, but the computing power and time required for the
reconstruction made it impractical for
use in clinical settings. An alternative
known as statistical image reconstruction
reduced the time associated with iterative reconstruction but produced a texture that radiologists found unacceptable. With IRIS, Siemens took a different
approach. The algorithm takes all of the
data, which contains fine details as well
as significant amounts of noise, com-
Image data
recon
Image
correction
Compare
Master
recon
Coverstory
Coverstory
3
3 Perfusion CT
imaging is increasingly being adopted in
daily routine.
This function
overcomes the
limitations of a
static detector
design, which
provides full
brain coverage,
and the potential for improvement in diagnostic accuracy
for acute stroke.
11
Coverstory
With Volume
Perfusion CT (VPCT)
fused with carotid
CTA the perfusion
status of the brain
tissue can be revealed. This patient
presented after
onset of stroke and
underwent lysis
therapy. The followup examination
showed a complete
revascularization
of the previously
hypoperfused area.
Courtesy of University Hospital Gttingen, Germany.
4
the same volume it allows for the reduction of image noise. So the initial scan
can be performed with a lower tube
current, thus saving dose. The result
is that radiation dose is reduced by
up to 50 % while retaining equivalent
diagnostic information.
Although such dose-saving features can
benefit patients, Lin cautions that the
issue of dose must be kept in context
during an acute stroke. The acute critical ischemic event that could kill the
patient takes priority over the slight increase in radiation dose that is imparted
to the patient in order to arrive at a
more accurate diagnosis, a clearer
understanding of the patients pathophysiology, and a broader understanding of the acute event, he emphasizes.
Lin points out that only 2 % of acute
stroke patients receive intravenous
tissue plasminogen activator (tPA), the
only U.S. Food and Drug Administration
approved drug for acute stroke. He says
this low rate is largely because of the
restrictive three-hour time window in
which the drug is approved for use.
An additional factor is that an unknown
time of onset, which occurs in up to
25 % of acute stroke patients, disqualifies
patients from receiving the drug.
In Europe, the University of Gttingen,
Germany has established stroke units
where patients are examined in an elongated time window of 4.5 hours after the
onset of stroke, based on results from the
Third European Cooperative Acute Stroke
Study3 (ECASS III), so that more patients
can benefit from tPA treatment.
Rather than making treatment decisions
based on the clock, the use of perfusion
CT and CT Angiography can help deliver
truly personalized medicine for acute
stroke patients. The adage time is brain
still applies, Lin says, but technology can
enable a new paradigm that says that
physiology is brain.
The rallying cry of physiology is brain
is really a summation of the proposal
to use a patients own pathophysiology,
his own cerebral hemodynamics, to determine whether he still has significant
amounts of salvageable tissue at risk
and therefore should be a candidate for
acute stroke therapy within the confines
Coverstory
As Low as Reasonably
Achievable
In developing advances that aim to improve the diagnostic confidence of physicians and patient outcomes, Siemens
is committed to reducing radiation dose
to the lowest possible level following the
* syngo.via can be used as a standalone device or together with a variety of syngo.via based software options, which are medical devices in their own rights.
** Prerequisites include: internet connection to clinical network, DICOM compliance, meeting of minimum hardware requirements, and adherence to local data security regulations.
Somatom_26_Inhalt_USA.indd Abs2:13
10.05.10 09:39
Coverstory
6A
6B
6 X-CARE is especially important in CT for protecting dose sensitive tissue, e.g. the lenses of the eyes (Fig. 6A). To further reduce the
radiation dose for the lenses, additional safety devices like an eye protector (Fig. 6B) can be used.
Dose Shield
Selective
Photon
Shield
80 kV
Dose Shield
Attenuation B
140 kV
Attenuation A
2007
2008
2008
Selective
Photon
Shield
4D Noise
Reduction
No dose penalty
Up to
Up to
25 % dose reduction
50 % dose reduction
7 Siemens has been a pioneer in creating a host of innovative technical features that significantly reduce radiation exposure in CT scans.
Using these features may result in variant values of dose reduction.
Coverstory
X-ray low
Image data
recon
Image
correction
X-ray on
2008
2008
2009
Neuro BestContrast
X-C ARE
Iterative
Reconstruction in
Image Space (IRIS)
Up to
30 % dose reduction
Up to
40 % dose
Up to
60 % dose reduction
reduction
15
News
Affordable Performance
in 16- and 64-slice CT
At the European Congress of Radiology in March 2010, Siemens
introduced new 16- and 64-slice systems to the market: The SOMATOM
Emotion Excel Edition and the SOMATOM Denition AS Excel Edition.
By Jan Freund, Steven Bell and Rami Kusama, Business Unit CT, Siemens Healthcare, Forchheim, Germany
The new Excel Editions from Siemens are especially affordable versions of the SOMATOM Emotion
16-slice and SOMATOM Definition AS 64-slice scanners.
News
www.siemens.com/
somatom-emotion
www.siemens.com/
somatom-definition-as
* syngo.via can be used as a standalone device or together with a variety of syngo.via based software options, which are medical devices in their own rights.
17
News
Special Object:
Cardiovascular Stent
Another group of patients that especially
benefit from IRIS is the increasing number of obese patients of both genders
and all ages. Even when the smaller of
these morbidly obese patients are able to
squeeze through the CT gantries, the
resulting images are often substandard,
sometimes strikingly so.
The diagnostic results can be greatly
improved with IRIS in obese patients,
says Schoepf. His hospital mainly cares
for patients with either digestive disease
or cardiovascular disease. His special
News
Image data
recon
Image
correction
Compare
Master
recon
Up to 60 % dose reduction
Image quality improvement
Q Fast recon in image space
Q Well-established image impression
Q 90 day, free trial license
Q
Q
19
News
Somatom_26_Inhalt_USA.indd Abs2:20
10.05.10 09:39
News
Spiral Cardio scans our all-new highpitch mode for scan speeds up to 458
mm/s publicly available. With this ultrafast scanning, the SOMATOM Definition
Flash acquires the entire heart in only
around 270 ms, reducing radiation exposure to the minimum, all the while maintaining the excellent image quality that
previously was only possible at much
higher dose levels.
At www.siemens.com/low-dose anyone
can observe the current average dose on
the installed base. This value is updated
www.siemens.com/low-dose
21
News
International CT Image
Contest Highest Image
Quality at Lowest Dose
By Rami Kusama, Business Unit CT, Siemens Healthcare, Forchheim, Germany
Winner in Cardiac
Moderate Atherosclerosis
(SOMATOM Definition Flash /
0.97 mSv dose), Yuko Utanohara,
MD and co-authors:
Nobuo Iguchi, MD, PhD; Kenji
Horie; Tatsunori Niwa; Sakakibara
Heart Institute, Japan
History:
A 68-year-old female, non-smoker,
with a 3-year history of hyperlipidemia, shortness of breath and chest
tightness on exertion was referred
for detailed examination to our department after heart murmur was
detected for the first time.
Diagnosis:
The coronary arteries showed
moderate atherosclerosis on CT.
1
Jury statement:
This case study is not only aesthetically pleasing, but in addition, it
demonstrates that supreme diagnostic accuracy can be achieved at
very low doses, with unambiguous
visualization of the coronary artery
lumen up to the very distal segments of the coronary artery tree.
The Jury
Professor Stephan Achenbach
University of Erlangen, Germany
Professor Dominik Fleischmann
Participation
Images could be submitted online on
a contest website by users of the
SOMATOM Definition, SOMATOM Definition AS, as well as SOMATOM Definition
Winner Announcement
The winner announcement took place
at the ECR 2010 in Vienna during the
Bayer Schering Pharma and Siemens
Healthcare joint Satellite Symposium.
Winning images (Figs. 16) were exhibited at the Grand CT Image Gallery.
For those who could not attend the
ECR, the winners were announced at
the same time on the contest website
and via press release.
www.siemens.com/Image-Contest
The free contest poster can be
ordered at:
www.siemens.com/ct-poster
2
2 Winner in Neuro
Perfusion after Occluded Stent
(SOMATOM Definition AS / 7.55 mSv
dose), Robert McGregor, MD; Boundary Trails Health Centre; Canada
History:
Carotid CTA and perfusion imaging
was obtained in a 55-year-old female
post SILK stent for right internal carotid aneurysm.
Diagnosis:
CTA revealed occlusion of the stented
right internal carotid artery. Perfusion
imaging demonstrated decreased
CBF, increased MTT, but maintained
CBV, indicating a large perfusion
defect without significant infarction.
<<bitte
berall
Dosis-Tacho>>
<<bitte
berall
mitmit
Dosis-Tacho>>
Jury statement:
The case nicely presents the potential
of comprehensive stroke assessment
by CT Perfusion. CT Perfusion may
suffer from image noise with unsharp
margins of the infarcted territory.
In this example, the margins of the
infarct are clearly displayed allowing
determination of the extent of the
infarction precisely.
23
News
Jury statement:
This CTA shows the encasement of the
portal vein / SMV conuence making the
patient unresectable. The case with the
highest image quality is the one that provides the most information content for
the radiologist and the referring physician.
This case fullls these criteria completely
at a very low radiation dose.
Winner in Vascular
Child Aortic Transposition (SOMATOM
Definition Flash / 0.25 mSv dose), Gregory
Nicaise, MD and co-author: Philippe Everarts, MD, Centre Hospitalier de Jolimont,
Belgium
History:
A 2-year-old child with chronic dyspnea and
pulmonary infection was presented for a CT
examination.
Diagnosis:
Aortic transposition, left bronchial stenosis,
atelectasy, pulmonary clarity and air trapping were detected.
4
Jury statement:
This case demonstrates excellent image
quality achieved at ultra-low dose permitting a comprehensive and accurate diagnosis in a complex congenital heart defect.
News
5
5 Winner in Thorax
Flash ECG Thorax (SOMATOM Definition
Flash / 0.82 mSv dose), Petter Quick; CMIV
Linkping University; Sweden
History:
A 47-year-old woman was presented to the
CT-department with unspecific chest pain.
Diagnosis:
The CT examination showed no pathology and
could successfully rule out coronary disease,
pulmonary embolism as well as lung tumor.
Jury statement:
This case represented everything that
chest CT can be a high quality, volume
data set that can provide information
for vascular imaging as well as the lung
parenchyma. High quality imaging requires the right scanner, the right protocols and the right execution of these
protocols. This image tells that story
very nicely.
6
6 Winner in Dual Energy
Carotid and Circle of Willis
(SOMATOM Definition Flash / 1.12 mSv dose),
Joo Carlos Costa, MD, Diagnstico por
Imagem, Lda, Portugal
History:
A healthy 75-year-old female was presented
to the CT-department with a family history
of carotid artery stenosis.
Diagnosis:
Small atherosclerotic plaques in the emergence
of braquiocephalic trunk and left carotid artery
were identified.
Jury statement:
This case illustrates the power of Dual
Energy CT for tissue differentiation. In
a single image and at tremendously low
doses, all tissue layers in the human body
can be simultaneously and intuitively
displayed and provide the anatomic context of the target structure, the carotid
circulation.
25
Business
Business
One-Stop-Shopping
For clinicians performing perfusion imaging, 4D Noise Reduction is the most
interesting feature. Static and dynamic
components are treated separately as
a means to reduce noise, thus improving
the image quality and clinical outcome.
Schramm could confirm this in acute
stroke patients, who are frequently quite
agitated.
The main advantage, however, that
Schramm sees with 4D Noise Reduction
is a reduction in radiation dose while
still being able to get all the diagnostic
information from one 4D volume perfusion scan. At some point in the future,
neuroradiologists may no longer need
to perform the complete stroke CT
protocol consisting of a non-contrast CT,
a whole brain perfusion CT including 4D
spiral scans and a CT Angiography of the
brain vessels. Due to the precision with
4D Noise Reduction, there could be onestop-shopping, the non-contrast CT
could be skipped by using the first of the
multi-spiral CT images before the contrast medium arrives and the angio-information could be taken from one arte-
Less Radiation
Saving Time
Regarding the use of CARE Contrast II
the new coupling interface for scanner
and bolus injector Schramm experienced two advantages: first, the improved workflow for the technician due
to the synchronization of injector and
scanner and therefore improved patient
care; second, and more important, the
time saved due to the automatic and
digital transfer of the whole dataset on
contrast media, flow rate etc. to the
patient protocol. This archiving of the
complete data set be it for legal, re-
27
Case 1
Adenosine Myocardial Stress Imaging
Using SOMATOM Denition Flash
By Gudrun Feuchtner,1, 4 Robert Goetti,1 Andr Plass,2 Monika Wieser,2 Christophe Wyss,3
Fernando Vega-Higuera,5 Hans Scheffel,1 Michael Fischer,1 Hatem Alkadhi,1 Sebastian Leschka1
Institute of Diagnostic Radiology, University Hospital Zurich, Switzerland
Clinic of Cardiovascular Surgery, University Hospital Zurich, Switzerland
3
Cardiology Division, University Hospital, Zurich, Switzerland
4
Department of Radiology II, Innsbruck Medical University, Austria
5
Business Unit CT, Siemens Healthcare, Forchheim, Germany.
1
HISTORY
COMMENTS
DIAGNOSIS
High-pitch CT Angiography showed
severely calcified left coronary artery
(Fig. 1C) with significant stenosis, and
bare-metal stent in the RCA.
Adenosine CT stress imaging showed
a reversible myocardial perfusion
EXAMINATION PROTOCOL
Scanner
Scan mode
Flash Spiral
Pitch
3.4
Scan area
Heart
Slice collimation
128 x 0.6 mm
Scan length
135 mm
Slice width
0.75 mm
Scan direction
Cranio-caudal
Reconstruction increment
0.4 mm
Scan time
0.44 s
Reconstruction kernel
B 26f
Tube voltage
100 kV / 100 kV
Volume
80 ml
Tube current
320 mAs/rot.
Flow rate
5 ml/s
Dose modulation
CARE Dose4D
Start delay
10 s
Postprocessing
syngo CT Cardiac
CTDIvol
3.09 mGy
Effective Dose
Rotation time
0.28 s
Function prototype*
1B
1C
1 By injecting adenosine
under stress, a perfusion defect
anteroseptal was shown (arrow,
Fig. 1A), which was reversible
after 5 minutes Rest Scan
(arrow, Fig. 1B).
A significant mid LAD stenosis
was detected by CT, and
quantified as 90 % by invasive
angiography. Distal after stenosis a severely calcified artery
was found (arrow, Fig. 1C).
2A
2B
3A
3B
4A
4C
4B
Case 2
SOMATOM Denition Flash:
Visualization of the Adamkiewicz Artery
by IV-CTA in Dual Power Mode
By Yoshiyuki Mizutani, MD* and Tomoko Fujihara**
*Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan
**Application Department CT Team, Customer Service Division, Siemens-Asahi Medical Technologies, Tokyo, Japan
HISTORY
A 75-year-old female was referred to
the radiology department of Sakakibara
Heart Institute to examine where her
Adamkiewicz artery originated before
treatment of her thoracic descending
aortic aneurysm (TAA). The patient was
scanned with Dual Source CT in dual
power mode.
At the referring hospital, the patient
DIAGNOSIS
had been diagnosed with TAA (descending aorta of 5.6 cm diameter) by computed tomography and echography as
well as right coronary artery (RCA) stenosis by conventional angiography. She
was referred to Sakakibara Heart Institute for surgical vessel replacement and
coronary artery bypass grafting with
saphenous vein graft to RCA.
2 TAA was clearly seen on the Dual Source CT images (thin MIP).
3A
3B
COMMENTS
The course of the Adamkiewicz artery
needs to be determined before surgery
for TAA repair to ensure that it is not
damaged during surgery and to reduce
the risk of postoperative paraplegia.
However, visualizing the Adamkiewicz
artery with intravenous (IV) CTA is a
challenging task as injection and scan
protocols need to be tailored to the location and size of this artery. Since the
EXAMINATION PROTOCOL
Scanner
SOMATOM
Definition Flash
Scan area
Thorax-abdomen
Scan length
280 mm
Scan direction
Cranio-caudal
Scan time
8.41 s
Tube voltage
100 kV / 100 kV
Tube current
Dose modulation
CARE Dose4D
Rotation time
0.5 s
Slice collimation
128 x 0.6 mm
Reconstruction
increment
0.3 mm
Reconstruction
kernel
B36
Volume
100 ml
Flow rate
5.0 ml/s
Postprocessing
syngo InSpace
31
Case 3
Dynamic Myocardial Stress Perfusion
By Florian Schwarz, MD, Fabian Bamberg, MD, MPH, Christoph R. Becker, MD,
Alexander Becker, MD, Konstantin Nikolaou, MD
Department of Clinical Radiology, University of Munich, Campus Grohadern, Munich, Germany
1 Maximum intensity display of the right coronary artery, demonstrating heavy calcified plaque in the proximal segment and calcified
and non-calcified plaque in the intermediate segment, causing
a mild to moderate stenosis (arrow).
HISTORY
DIAGNOSIS
COMMENTS
A 71-year-old male was referred for evaluation of stable chest pain syndrome
and enrolled in a prospective cohort study
to evaluate the diagnostic accuracy and
clinical feasibility of dynamic myocardial
stress perfusion imaging by cardiac CT.
Coronary CT Angiography (CTA) and
CT-based assessment of myocardial perfusion under adenosine stress was performed prior to cardiac catheterization.
3A
3B
CT [HU]
80
60
40
20
time [s]
0
0
10
15
20
25
CT [HU]
100
80
60
40
20
0
time [s]
0
30
10
15
20
25
30
3 Principle: dynamic volumetric myocardial stress perfusion to quantify Myocardial Blood Flow (MBF). Comparison of different time
attenuation curve (TCA) pattern with a slower and lower peak (86 ml / 100 ml / min) in an ischemic segment (Fig. 3A) and normal blood flow
(MBF 159 ml / 100 ml / min) in an healthy segment (Fig. 3B).
4 Systolic reconstruction display of long axis, color-coded myocardial stress perfusion image of the left ventricle indicating homogeneous perfusion (green) and the absence of a circumscribed
perfusion defect.
EXAMINATION PROTOCOL
Scanner
SOMATOM Definition
Scan mode
Dose modulation
Scan area
CTDIvol
no
94.15 mGy
Scan length
72 mm
Rotation time
0.28 s
Scan direction
Cranio-caudal
Slice collimation
32 x 1.2 mm
Scan time
31 s
Slice width
3 mm
Heart rate
72 bpm
Reconstruction increment
2 mm
Tube voltage
100 kV
Reconstruction kernel
B23f
Tube current
350 mAs/rot.
Post processing
syngo VPCT
Body Myocardium
33
Case 4
Pre-operative Exclusion of Coronary
Artery Stenosis With Less Than 1 mSv Dose
By Sebastian Leschka, MD* and Andreas Blaha**
* Institute of Diagnostic Radiology, University Hospital Zurich, Zurich, Switzerland
** Business Unit CT, Siemens Healthcare, Forchheim, Germany
HISTORY
DIAGNOSIS
COMMENTS
Numbers of
Lesions (1)
Equiv. Mass
[mg CaHA] (4)
LM
0.0
0.00
0.0
LAD
27.5
29.3
4.89
CX
48.3
50.5
8.57
RCA
53.6
66.2
10.81
Total
10
129.5
146.0
24.27
(1) Lesion is volume based, (2) Equivalent Agatston score, (3) Isotropic interpolated volume, (4) Calibration Factor: 0.790
*Effective Dose was calculated using the published conversion factor for an adult chest of 0.014 mSv (mGy cm)-1 [1].
[1] McCollough CH et al. Strategies for Reducing Radiation Dose in CT, Radiol. Clin. N. Am. 47: (2009) 27-40.
EXAMINATION PROTOCOL
Scanner
SOMATOM Definition
Scan mode
Rotation time
0.28 s
Scan area
Thorax
Pitch
3.4
Scan length
130 mm
Spatial Resolution
0.33 mm
Scan direction
Cranio-caudal
Slice collimation
128 x 0.6 mm
Scan time
0.28 s
Slice width
0.75 mm
Heart rate
56 bpm
Reconstruction increment
0.7
Tube voltage
100 kV / 100 kV
Reconstruction kernel
B26f
Tube current
320 mAs/rot.
Volume
60 ml
Dose modulation
CARE Dose4D
Flow rate
6 ml/s
CTDIvol
3.10 mGy
Start delay
Test Bolus
DLP
57 mGy cm
Postprocessing
syngo Circulation
Effective Dose
0.8 mSv
syngo InSpace
35
Case 5
Utilizing Ultra Low Dose
of 0.05 mSv for Premature Baby
With Congenital Heart Disease
By Jean-Francois Paul, MD1 and Andreas Blaha2
Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France
Business Unit CT, Siemens Healthcare, Forchheim, Germany
1
2
DIAGNOSIS
A mild stenosis present at the ostium
of the right pulmonary artery could be
observed. Although the RPA showed an
irregularity it had a normal anatomical
course. The ventricular septum defect as
well as the still open atrial septum could
be clearly revealed by using oblique planar reformations. The right coronary artery was well depicted despite a heart
rate of 157 bpm.
COMMENTS
HISTORY
A premature baby was referred to the
radiology department with diagnosis of
congenital heart disease. An atrial and
*Effective Dose was calculated using the published conversion factor for a pediatric (newborn) chest of 0.039 mSv (mGy cm)-1 [1].
To take into account that Siemens calculates the CTDI in a 32 cm CTDI phantom an additional correction factor of 2 had to be applied.
[1] McCollough CH et al. Strategies for Reducing Radiation Dose in CT, Radiol. Clin. N. Am. 47: (2009) 27-40.
2 Ventricular
septal defect in
MIP technique
(caudo-cranial
view, arrow); PFO
(arrowhead).
3 Caudo-cranial
view MIP shows
mild stenosis and
irregularity of
the RPA (arrow).
4 Cranio-caudal
view in VRT-technique.
EXAMINATION PROTOCOL
Scanner
Scan mode
Effective Dose
0.05 mSv
Scan area
Thorax
Rotation time
0.28 s
Scan length
33 mm
Feed/Rotation
one rotation
Scan direction
Cranio-caudal
Slice collimation
128 x 0.6 mm
Scan time
0.18 s
Slice width
0.75 mm
Tube voltage
80 kV / 80 kV
Reconstruction increment
0.4 mm
Tube current
22 mAs / rot.
Reconstruction kernel
B26f
CTDIvol
0.18 mGy
Postprocessing
CT Cardiac Engine
DLP
0.7 mGy cm
37
Case 6
SOMATOM Denition Flash:
Pediatric Patient Without Sedation
and Breath-Holding
By Kaori Takada, MD* and Tomoko Fujihara**
*Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan
**Application Department CT Team, Customer Service Division, Siemens-Asahi Medical Technologies, Tokyo, Japan
HISTORY
A 4-year-old boy with Tetralogy of Fallot
(TOF, Fig.1), pulmonary atresia (PA)
and major aorto-pulmonary collateral
arteries (MAPCAs) was referred to the
radiology department of Sakakibara
Heart Institute for a follow-up examination using a SOMATOM Definition Flash,
Dual Source CT in Flash Spiral mode
following treatment of his pulmonary
artery stenosis.
The patient was diagnosed shortly after
birth with TOF, PA, MAPCA. When he
was 10 months old, a stent was inserted
in the largest MAPCA and a central shunt
was placed when he was 16 months old.
When he was 2 years old, he underwent
right and left modified Blalock-Taussig
shunt surgeries (therefore the subclavian artery is connected with the pulmonary artery) within 9 months. Then, at
the age of 3, an artificial vessel was constructed from the right ventricle (RV)
to the pulmonary artery by palliative
Rastelli procedure.
The patient now underwent a percutanous transluminal angioplasty (PTA)
of pulmonary artery. A low dose, Dual
Source CT scan in the Flash Spiral mode
was ordered to confirm his postoperative condition, in particular concerning
the pulmonary circulation. The patients
weight was 15.6 kg (34.39 lb).
He was not sedated and no breath-hold
was needed during the scan. His mean
heart rate was 95 bpm.
DIAGNOSIS
COMMENTS
Dual Source CT Angiography has
emerged as an essential diagnostic tool
for the assessment of complex congenital heart disease. Nevertheless, dose has
remained a concern, in particular when
referring pediatric patients for cardiac
CT. With the Flash Spiral mode of the
second generation Dual Source CT,
pediatric patients can be scanned at
ultra low dose, as in this case at 1.63
mGy (effective dose 0.644 mSv). Apart
from dose concerns, additional challenges have been associated with imaging pediatric congenital heart disease
2A
3A
2B
3B
95 bpm. Pulmonary artery in-stent stenosis could also be evaluated. The Dual
Source CT Flash images were extremely
helpful for further treatment planning.
EXAMINATION PROTOCOL
4A
4B
Scanner
Scan mode
Flash Spiral
Scan area
Thorax / Chest
Scan length
211 mm
Scan direction
Cranio-caudal
Scan time
0.52 s
Tube voltage
80 kV
Tube current
CTDIvol
1.63 mGy
Effective Dose
0.644 mSv
Rotation time
0.28 s
Pitch
3.4
Slice collimation
128 x 0.6 mm
Slice width
0.6 mm
Reconstruction increment
0.3 mm
Spatial resolution
0.33 mm
Reconstruction Kernel
Contrast
Flow Rate
2.5 ml/s
Start delay
17 s
Volume
30 ml
39
Case 7
SOMATOM Denition Flash:
Dual Energy Coronary CT Angiography
for Evaluation of Chest Pain After RCA
Revascularization
By Ralf W. Bauer, MD, J. Matthias Kerl, MD, Thomas J. Vogl, MD
Department of Diagnostic and Interventional Radiology, Clinic of the Goethe University, Frankfurt, Germany
HISTORY
A 54-year-old female patient underwent
coronary stent percutaneous transluminal coronary angioplasty (PTCA) of
the right coronary artery (RCA) four
months ago for acute ST-elevation
myocardial infarction of the inferioseptal
wall. Now, the patient suffered from
reduced physical power and labile blood
branch were found (Fig. 1). Recanalization was performed with placement of 2
drug-eluting stents in the distal and mid
RCA. During intervention, a small contrast material extravasation was seen
near the ostium in the proximal RCA.
A small intima dissection was suspected
and another stent was placed to close
the leakage. Three hours after intervention, the patient developed chest tightness and retrosternal pain. ECG showed
signs of the known old infarction
inferiorseptally (Q waves in II, III and
aVF) but no signs of acute ischemia.
She was sent to CT to rule out aortic
dissection.
DIAGNOSIS
Cardiac CT was performed in Dual Energy
mode with retrospective ECG-gating.
There was no sign of contrast material
extravasation or aortic dissection. Dual
Energy CT Angiography revealed in-stent
thrombosis with occlusion of the RCA
13 mm after its origin (Fig. 2). While
on cardiac cath the RV branch was still
open, DECT showed an occlusion of the
vessel due to the thrombus in the proximal RCA, explaining the patients symptoms. Dual Energy myocardial iodine
mapping showed a large hypoperfused
COMMENTS
In this case, Dual Energy coronary
CT Angiography was used to image a
complication of interventional recanalization, i.e. acute in-stent thrombosis,
while the initial clinical diagnosis of
acute aortic dissection could reliably
be ruled out.
A further complication was the occlusion of the RV branch (which was patent
prior to intervention) due to the large
thrombus formation beginning very
EXAMINATION PROTOCOL
Scanner
Scan mode
Dual Energy
Scan area
Heart
Scan length
170 mm
Scan direction
Cranio-caudal
Scan time
4.8 s
13.29 mGy
Rotation time
0.28 s
Pitch
0.17
4 Late enhancement was present in the inferoseptal wall corresponding to the perfusion
defect in arterial phase.
Slice width
0.75 mm
Reconstruction
increment
0.4 mm
Reconstruction
kernel
D26f
Volume
70 ml contrast media
Flow rate
5 ml/s
Start delay
Test bolus
Post processing
41
Case 8
3D Guided RF Ablation and
CT Perfusion a New Combination for
Monitoring of Treatment Response
By Hatem Alkadhi, MD*,** and Jan Freund***
* Institute of Diagnostic Radiology, University Hospital Zurich, Zurich, Switzerland;
** Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
*** Business Unit CT, Siemens Healthcare, Forchheim, Germany
PATIENT HISTORY
An 80-year-old female patient presented
to the emergency department with macrohematuria. A CT of the abdomen
revealed a mass in the left kidney that
was suspicious of a renal cell carcinoma
(Fig. 1). Because severe co-morbidities
prevented open surgery, the patient was
scheduled to undergo radio frequency
ablation (RFA). Considering the large size
of the tumor, embolization of the mass
was performed prior to RFA (Fig. 3).
DIAGNOSIS
Due to the large size of the tumor, conventional CT Perfusion studies are normally unable to capture the entire tumor
and therefore deliver only partial perfusion information. To circumvent this
limitation, the patient was sent for a
volume perfusion scan to the SOMATOM
Definition AS offering the Adaptive 4D
Spiral scan modes. This allows CT Perfusion coverage of up to 7 cm. The Adaptive 4D Spiral scan was performed one
day after embolization. It showed the
tumor to be largely devascularized.
However, a small proportion in the medial lower part of the tumor still showed
blood flow (Fig. 4).
Two days later, a CT-guided RFA was performed using the Adaptive 3D Intervention Suite with its needle path planning
and on-line tracking mode. Particularly
the perfused tumor part as demonstrated by perfusion CT was targeted (Fig. 2).
In order to safely reach the dedicated
areas, a 3D visualization of axial, coronal
and sagittal slices during the intervention
was used. In combination with a 2-click
COMMENTS
The increased precision of the 3D visualization especially helps to more precisely
position RF needles to ensure the correct
placement in the perfused tumor area.
43
Case 9
SOMATOM Denition Flash:
Routine Re-staging of Oesophageal
Carcinoma Utilizing IRIS Technology
By Michael Lell, MD*and Andreas Blaha**
*Department of Radiology and the Imaging Science Institute (ISI), University of Erlangen-Nuremberg, Erlangen, Germany
**Business Unit CT, Siemens Healthcare, Forchheim, Germany
HISTORY
The 55-year-old male patient presented
with a history of oesophageal cancer.
He previously underwent combined radiochemotherapy. CT was requested for
re-staging to discuss further therapy
options for the patient.
DIAGNOSIS
A contrast enhanced CT revealed bilateral
well-perfused lung, also the port catheter
was well positioned in the vena cava
superior. Following treatment, there was
still prominent thickening of the wall
of the distal oesophagus und enlarged
COMMENTS
Several measures to reduce dose were
employed with this patient. Online tube
current modulation (CARE Dose4D) and
EXAMINATION PROTOCOL
Scanner
Scan mode
Thorax
DLP
260 mGy cm
Scan area
Thorax-Abdomen
Effective Dose
3.9 mSv
0.33 s
Scan length
656 mm
Rotation time
Scan direction
Cranio-caudal
Slice collimation
128 x 0.6 mm
Scan time
21 ms
Slice width
0.75 mm
Tube voltage
120 kV
Reconstruction increment
0.4 mm
Tube current
Reconstruction kernel
I41
Dose modulation
CARE Dose4D
Postprocessing
syngo CT 3D
2 Coronal cut demonstrates the solitary cyst (left kidney, arrow), and
distal oesophageal wall thickening (arrowhead, IRIS reconstruction).
45
Case 10
SOMATOM Denition AS+:
CT Perfusion With Extended Coverage
for Acute Ischemic Stroke
By Ke Lin, MD
Department of Radiology, New York University Langone Medical Center, New York, USA
HISTORY
A 53-year-old male with history of hypertension presented with sudden onset
of expressive aphasia and weakness.
The patient had experienced two similar
but transient episodes in the previous
1 Dynamic CT
Perfusion (CTP)
cerebral blood flow
(CBF) map shows
markedly decreased
CBF to the left
frontal operculum.
CTP cerebral blood
volume (CBV) map
shows matched
decreased CBV
in this region
indicating irreversible infarct core.
A penumbra-core
map generated by
using thresholds of
CBV 1.2 ml / 100 ml
for core (red)
and CBF 35 ml /
100 ml / min
and CBV >1.2 ml /
100 ml for penumbra (yellow) shows
little salvageable
tissue at this level.
2 The penumbra-core
maps from selected slices
above and below the
level shown in Fig. 1:
the extents of both the
salvageable ischemic
penumbra (yellow) and
the irreversible infarct
core (red) are fully depicted.
DIAGNOSIS
While NCCT showed only subtle blurring
of the normal gray/white matter interface at the left frontal operculum, CTP
with extended coverage revealed the full
extent of the acute ischemia in the anterior left middle cerebral artery (MCA)
territory. There was severe compromise
of cerebral blood flow (CBF) to the mid
and inferior left frontal lobe. At the level
of the operculum (Brocas area), there
was a matched defect in low CBF and
low cerebral blood volume (CBV) indicative of irreversible infarct core (Fig. 1).
However, there was appreciable CBF/CBV
mismatch on the other acquired slices,
COMMENTS
The SOMATOM Definition AS+ scanner
with 128-slice configuration and Adaptive
4D Spiral technology allows larger CTP
coverage with a single bolus of contrast.
EXAMINATION PROTOCOL
Scanner
Scan mode
Adaptive 4D Spiral
Rotation time
0.3 s
Scan area
Head
Slice collimation
64 x 0.6 mm
Scan length
96 mm
Slice width
10 mm
Scan direction
Reconstruction increment
5 mm
Scan time
45 s
Reconstruction kernel
H20f
Tube voltage
80 kV
Contrast Volume
50 ml iodine
Tube current
Flow rate
5 ml/s
Dose modulation
Start delay
4s
CTDIvol
218.8 mGy
Postprocessing
47
Case 11
Vasospasm After Subarachnoid
Hemorrhage:
Volume Perfusion CT Neuro
By Bruno A. Policeni, MD
Radiology Faculty, Neuroradiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
HISTORY
A 36-year-old female with a history of
migraine developed a sudden onset of
the worst headache of her life, lost control of the entire right side of her body
and fell to the floor. However she had
no trauma to her head and did not lose
consciousness. She was admitted to the
emergency department where a head CT
(Fig. 2) showed right sylvian fissure and
inter-hemispheric fissure hyperdensity
consistent with subarachnoid hemor-
DIAGNOSIS
Using the Adaptive 4D Spiral technology
a 9.6 cm volume perfusion scan covering the entire brain was performed and
the resulting perfusion parameter maps
were qualitatively and quantitatively
evaluated in 3D. They demonstrated an
impaired brain perfusion in the right
MCA and ACA vascular territory distribution with prolonged Mean Transit Time
(MTT), reduced Cerebral Blood Flow
(CBF) in the same area and slightly
increased Cerebral Blood Volume (CBV,
Fig. 4). CT Angiography images were obtained from the dynamic VPCT data and
showed areas of narrowing in the right
MCA and anterior cerebral artery (ACA,
Fig. 6). The following angiography confirmed the vasospasm findings consis-
4 VPCT axial multi-parameter view showing a Maximum Intensity Projection (MIP), Cerebral Blood Flow (CBF), Cerebral Blood Volume (CBV), Time To Peak,
Time To Drain (TTD) and Mean Transit Time (MTT), MTT and TTD (time to drain, a Siemens origin parameter) being the most useful parameters in this case.
49
5 3D view of the Time To Drain (TTD) parameter map of the entire brain. Time to drain is a Siemens unique deconvolution based parameter describing the time of the earliest washout of contrast medium in seconds. It is a very sensitve parameter to detect perfusion asymetries like MTT.
COMMENTS
syngo VPCT Neuro offers dynamic perfusion analysis of the entire brain. That,
as in this case, enables the detection of
vasospasms even those located in
upper brain regions or in the posterior
fossa, not covered by traditional Perfu-
7A
7B
7 Conventional angiography confirmed severe vasospasm (arrows): segmental narrowing in the right MCA/ACA and a delayed capillary transit
time (Fig. 7A). Follow up demonstrates resolution of the vasospasm after nicardipine injection and balloon angioplasty (Fig. 7B, arrows).
EXAMINATION PROTOCOL
Scanner
Scan mode
Rotation time
0.3 s
Scan area
Head
Slice collimation
128 x 0.6 mm
Scan length
96 mm
Slice width
Scan direction
Reconstruction kernel
H20f
Scan time
45 s; 30 scans total
Volume
Tube voltage
80 kV
Flow rate
8 ml/s
Tube current
200 mAs
Start delay
No delay
CTDIvol
218 mGy
Post processing
51
Case 12
Dual Energy Scanning:
Diagnosis of Ruptured Cocaine Capsule
By Ralf W. Bauer, MD, J. Matthias Kerl, MD, Thomas J. Vogl, MD, Philipp Weisser, MD
Department of Diagnostic and Interventional Radiology, Clinic of the Goethe University, Frankfurt, Germany
HISTORY
DIAGNOSIS
COMMENTS
With the use of DECT, a reliable diagnosis
of the ruptured cocaine capsule could
be performed and immediate medical
help provided. To our knowledge this
is the first report on the Dual Energy
behaviour of columbian cocaine. This
might be of future relevance for in vivo
differentiation of cocaine or heroin of
different origin in uncommunicative
body packers. However, further research
in this field is needed to confirm our
results.
EXAMINATION PROTOCOL
Scanner
Scan mode
Dual Energy
Rotation time
0.5 s
Scan area
Abdomen
Pitch
0.55
Scan length
464 mm
Slice collimation
14 x 1.2 mm
Scan direction
Cranio-caudal
Slice width
1.5 mm
Scan time
24 s
Reconstruction increment
1.0 mm
140 kV / 80 kV
Reconstruction kernel
D30f
Contrast Volume
90 ml
Dose modulation
CARE Dose4D
Flow rate
3 ml/s
CTDIvol
9.14 mGy
Postprocessing
53
Case 13
Progressive Kidney Hematoma
Post-interventional Biopsy
By Sebastian Leschka, MD * and Andreas Blaha **
*Institute of Diagnostic Radiology, University Hospital Zurich, Zurich, Switzerland
**Business Unit CT, Siemens Healthcare, Forchheim, Germany
HISTORY
DIAGNOSIS
COMMENTS
Despite the low quantity of applied contrast media, a contrast media enhancement in the left kidney could be identified due to a quick acquisition time of
0.7 seconds. The SOMATOM Definition
Flash allowed a precise and rapid
diagnosis with a reduced given patient
radiation dose of 3.3 mSv.
1 Fused VRT/MPR
highlight kidney
hematoma.
EXAMINATION PROTOCOL
Scanner
Scan mode
3-phase kidney
Rotation time
0.28 s
Scan area
Abdomen
Pitch
2.1
Scan length
218 mm
Slice collimation
128 x 0.6 mm
Scan direction
Cranio-caudal
Slice width
2 mm
Scan time
0.7 s
Reconstruction increment
1 mm
Tube voltage
120 kV / 120 kV
Reconstruction kernel
B30f
Tube current
Contrast Volume
60 ml Iodine
Dose modulation
CTDIvol
CARE Dose4D
7.71 mGy
Flow rate
4 ml/s
Postprocessing
syngo CT 3D
syngo InSpace
2A
2B
2C
2 Axial non-enhancement multiplanar reformation (MPR, Fig. 2A); axial early enhancement MPR shows haemorrhages in the
kidney hematoma (arrow, Fig. 2B). Axial late state MPR shows persistent bleeding (arrow, Fig. 2C).
3A
3B
3C
3 Sagittal non-enhancement MPR (Fig. 3A); sagittal early enhancement MPR shows hemorrhages in the kidney hematoma
(arrow, Fig. 3B); sagittal late state MPR shows persistent bleeding (arrow, Fig. 3C).
55
Case 14
SOMATOM Denition Dual Source
High Pitch vs. Routine Pitch Scanning in
a Pediatric Lung Low Dose Examination
By Harald Seifarth, MD,* Walter Heindel, MD,* Andreas Blaha **
*Department of Clinical Radiology, University Hospital, Mnster, Germany
**Business Unit CT, Siemens Healthcare, Forchheim, Germany
HISTORY
A 5-year-old male patient with a history
of neutropenia after stem-cell transplantation was referred to the radiology
department. The patient presented with
persistent fever despite ongoing treatment with antibiotics. A CT examination
was scheduled to exclude the presence of
pulmonary mycosis. The CT examination
was performed with a high pitch protocol (pitch = 3.0), resulting in a scan time
of only 0.9 seconds.
DIAGNOSIS
The present CT examination showed no
signs of any fungal pulmonary infection
or other inflammatory changes. Minor
bilateral, subpleural dystelectases could
be observed.
In the previous examination (pitch 1.4,
scan time 4.5 seconds, scan length
189 mm, 50 ref mAs), artifacts due to
respiratory motion during the acquisition hampered the evaluability of the
exam. The study showed small pulmonary infiltrates.
COMMENTS
EXAMINATION PROTOCOL
Scanner
SOMATOM
Definition
Scan mode
Thorax HiPitch
Scan area
Thorax
Scan length
159 mm
Scan direction
Cranio-caudal
Scan time
< 1s
120 kV / 120 kV
10 eff. mAs
Dose modulation
CARE Dose4D
CTDIvol
0.56 mGy
DLP
9 mGy cm
Effective Dose
0.37 mSv*
Rotation time
0.33 s
Pitch
3.0
Slice collimation
64 x 0.6 mm
Slice width
1.0 mm
Reconstruction
increment
0.5 mm
Reconstruction
kernel
B60f
Postprocessing
syngo CT 3D
syngo InSpace
*Effective Dose was calculated using the published conversion factor for an 5-year-old pediatric chest of 0.082 mSv (mGy cm)-1 [1].
To take into account that Siemens calculates the CTDI in a 32 cm CTDI phantom an additional correction factor of 2 had to be applied.
[1] McCollough CH et al. Strategies for Reducing Radiation Dose in CT, Radiol. Clin. N. Am. 47: (2009) 27-40.
57
Science
CT in Pediatrics: Easier
and Safer With the Flash
The SOMATOM Denition Flash allows even squirming infants and small
children to be scanned with maximum image quality at lightning speed,
without movement artifacts, anesthesia, or ventilation. This makes
computed tomography increasingly interesting for pediatric diagnostics,
solely in the event of clear indications.
By Hildegard Kaulen, PhD
1B
1 Thorax CT scan for lung investigation of a 15-month-old child with cystic fibrosis with a 10-slice CT (Fig. 1A)
and for follow-up 12 months later with the SOMATOM Definition Flash (Fig. 1B) showing artifact-free lung tissue.
Science
Indications for
Pediatric CT Scans:
Q Polytrauma
Q Congenital heart disease
Q Serious lung diseases such
as cystic fibrosis or atypical
pneumonias
Q Tumor staging
Benefits of Flash CT
in Pediatrics:
Q Images free of movement artifacts, even in the case of
squirming children
Q No sedation or deep general
anesthesia
Q Imaging possible without assistance from other disciplines
such as anesthesia or nursing
Q No outpatient care or aftercare
Q No complications as a result
of anesthesia
Hildegard Kaulen, PhD, is a molecular biologist. After stints at the Rockefeller University in
New York and the Harvard Medical School in
Boston, she moved to the field of freelance
science journalism in the mid-1990s and contributes to numerous reputable daily newspapers
and scientific journals.
59
Science
Through the use of a SOMATOM Emotion 6 from Siemens Healthcare, an international research team discovered
atherosclerosis in 3500 year old Egyptian mummies.
The imaging for this project was undertaken on a SOMATOM Emotion 6-slice
configuration that was donated to the
Museum as part of an earlier study in
conjunction with National Geographic
to image the famous mummified remains
of King Tutankhamun.
The researchers were able to locate and
identify vascular tissue in 16 out of the
22 mummies imaged in this study. Of
these 16, 9 had visible signs of arterial
calcification, considered to be pathognomonic of atherosclerosis, from which the
researchers were able to conclude that
atherosclerosis is not a disease exclusive
to modern humans. Findings of calcification were made in men and women who
lived between 1570 BC and 364 AD. The
social status of most patients included in
Science
Independent Validation of
Perfusion Evaluation Software
By Katharina Otani, PhD and Toshihide Itoh
Research Collaboration Development, Siemens Asahi Medical Technologies, Tokyo, Japan
A study by an independent Japanese
research group reported that Siemens CT
Perfusion software syngo VPCT Neuro,
using the maximum slope model to derive cerebral blood flow (CBF), delivered
among the most accurate results in the
assessment of stroke infarct size compared to other commercial software.1
Kohsuke Kudo, MD, PhD, from Iwate
Medical University and his colleagues
from five other universities in Japan used
data of 10 stroke patients acquired with a
four-detector-row scanner and applied
different algorithms to generate CT Perfusion maps, in particular CBF, cerebral
blood volume (CBV) and mean transit
time (MTT) or time to peak (TTP) maps:
A singular-value decomposition (SVD,
CT Perfusion 3, GE Healthcare)
B inverse filter IF (Version 2.0, Hitachi
Medical Systems)
C singular-value decomposition (SVD,
Version 1.201, Philips Healthcare)
D maximum slope (MS, VA70A,
Siemens Healthcare)
E box modular transfer function (bMTF,
Ph 7, Toshiba Medical Systems).
Kudo compared the perfusion maps with
the results from free software (Perfusion
Mismatch Analyzer, PMA) distributed
by the Acute Stroke Imaging Standardization Group (ASIST) Japan that applies
two well-documented deconvolution
algorithms: standard singular-value decomposition (sSVD) and block-circulant
singular-value decomposition (bSVD).
sSVD and bSVD algorithms differ with respect to their sensitivity to contrast tracer
delay effects. bSVD is considered the
gold standard since it is relatively insensitive to tracer delay.
Kudo found that commercial software
could be classified in two groups: those
giving similar results to the CBF maps
obtained with sSVD (A, C, E) and those
giving similar results to the CBF maps
True multi-center
trials on stroke
assessment by CT
Perfusion and optimization of patient
management will
only be possible
once every vendors software delivers the same
perfusion maps.
Kohsuke Kudo, MD, PhD, Iwate Medical
University
acute stroke patients reported higher positive predictive values for infarction by
using maximum slope-derived parameters
(first moment, TTP), versus both delaysensitive and delay-insensitive deconvolution-derived parameters. These results
highlight the delay-insensitive nature of
perfusion maps derived from maximumslope algorithms. At present, however,
there remains insufficient evidence to suggest whether maximum-slope methods
outperform delay-insensitive deconvolution algorithms. Kudo started working on
standardization of perfusion software
after he programmed his own software
and discovered that his results differed not
only from the results of one commercial
software but that the results from all software packages also differed from each
other. With Makoto Sasaki, MD, he set up
ASIST Japan supported by a grant from the
Japanese governement. ASIST Japan has
introduced a color look-up table for perfusion maps. Kudo emphasizes that true
multicenter trials on stroke assessment by
CT Perfusion and optimization of patient
management will only be possible once
every vendors software delivers the same
perfusion maps.
In his study, Kudo used earlier perfusion
software versions such as Siemens Neuro
PCT. In the meantime however, Siemens
has developed syngo VPCT Neuro, a volume perfusion software that gives the option to also apply a new tracer delay insensitive deconvolution algorithm in addition
to the as well delay insensitive maximum
slope model used in this study. Kudo is
currently working on further multi-vendor
comparison studies.
1 Kudo K, et al . Radiology. 2010 Jan; 254(1):200-9
2 Konstas A A, et al. Radiology, 2010; 254(1):22-25
3 Christensen S, et al. Stroke 2009, 40 : 2055 2061
http://asist.umin.jp/index-e.htm
61
Science
1A
1B
60
45
15
30
1 The IBC system brings down the total procedure time. In this example, the time from placing the reference grid to harvesting three samples
from a small lung nodule was less than 50 seconds.
Science
2 Combining CT-guided procedures with the Interactive Breath-Hold Control device (IBC) has been shown to increase the radiologists accuracy
and confidence with needle biopsy of the lung.
* The device will be distributed by Medspira (USA) (www.medspira.com) and Siemens AG.
63
Science
The dose saving potential of the highpitch scan mode of SOMATOM Definition
Flash was also evaluated by Sommer et
al. in a study using an anthropomorphic
phantom and the data of 31 patients.2
The average scan time for the complete
thorax was 0.7 seconds, the average
dose 4.1 mSv, only one fifth of the dose
of a conventional gated chest scan.
Sub-mSv Heart The robust visualization of the coronary arteries with excellent image quality at ultra low doses of
below 1 mSv was the focus of three publications by researchers from Zurich,
Switzerland3 and Erlangen, Germany.4,5
The latest study from Erlangen used the
Flash Spiral scan mode in 50 consecutive
patients with body weight up to 100 kg
and heart rates up to 60 beats per minute with an average effective dose of
0.78 to 0.99 mSv and excellent image
quality.5 The average dose was 0.87
mSv. In a similar study from Zurich,
Leschka et al. found an average dose of
0.9 mSv in 35 consecutive patients.3 In
both studies 99% of all coronary segments could be evaluated3,5 and the image quality was rated excellent in 94 %
of the segments or as, at least good, in
5 % of the segments.5
Assessment of Myocardial Perfusion
The SOMATOM Definition Flash offers
completely new possibilities to assess
perfusion deficits in the myocardium
due to its unmatched temporal resolution and high volume coverage even at
high heart rates in stressed patients.
Bastarrika et al. showed that [] this
technique can demonstrate subendocardial infarction not seen on SPECT but
confirmed by MRI and can detect ischemia in good correlation with stressperfusion MRI and SPECT. 6 Fig. 1 shows
a short axis view of the myocardium
comparing stress perfusion measured
with the SOMATOM Definition Flash
(Fig. 1A) and SPECT (Fig. 1B).
Single Dose Dual Energy The latest
innovation in the area of Dual Energy CT
(DECT), the Selective Photon Shield, is
based on an additional tin filter (TF)
for the high energy spectrum on the
SOMATOM Definition Flash. The Selective Photon Shield allows for the acquisition of Dual Energy data without any
dose penalty compared to standard single
energy scans and significantly improves
the separation of the energy spectra.
A group of scientists from Zurich confirmed this for the syngo application,
Calculi Characterization, using it for the
differentiation of uric acid (UA) and nonUA stones and concluded: DECT with TF
and 80-140 kV tube voltage settings
significantly improves the discrimination
between UA-containing and non-UA
containing urinary stones as compared
with DECT without using the TF [].7
Lell et al. from the University of Erlangen
Science
1A
1B
1 New frontiers in cardiac diagnosis with CT: stress-perfusion images of the heart using the unmatched temporal resolution of the
SOMATOM Definition Flash compared to SPECT. A stress perfusion scan on the SOMATOM Definition Flash nicely depicts a perfusion
defect in the myocardium (Fig. 1A). The perfusion defect could be confirmed using SPECT (arrows, Fig. 1B). Courtesy of Joseph Schoepf,
MD, Medical University of South Carolina, USA.
Uder M, Lell MM. Coronary computed tomography angiography with a consistent dose below
1 mSv using prospectively electrocardiogramtriggered high-pitch spiral acquisition. Eur Heart
J. 2010 Feb;31(3):340-6.
Bastarrika G, Ramos-Duran L, Schoepf UJ, Rosenblum MA, Abro JA, Brothers RL, Zubieta JL, Chiaramida SA, Kang DK Adenosine-stress dynamic
myocardial volume perfusion imaging with second generation dual-source computed tomography: Concepts and first experiences. JCCT 2010
DOI: 10.1016/j.jcct.2010.01.015.
Stolzmann P, Leschka S, Scheffel H, Rentsch K,
Baumller S, Desbiolles L, Schmidt B, Marincek
B, Alkadhi H. Characterization of Urinary Stones
With Dual-Energy CT: Improved Differentiation
Using a Tin Filter. Invest Radiol. 2010 Jan;
45(1):1-6.
Lell M, Hinkmann F, Nkenke E, Schmidt B,
Seidensticker P, Kalender WA, Uder M, Achenbach
S. Dual energy CTA of the supraaortic arteries:
Technical improvements with a novel dual
source CT system. Eur J Radiol. 2009 Oct 8
[Epub ahead of print].
Sommer WH, Graser A, Becker CR, Clevert DA,
Reiser MF, Nikolaou K, Johnson TR. Image quality
of virtual noncontrast images derived from dualenergy CT Angiography after endovascular
aneurysm repair. J Vasc Interv Radiol. 2010 Mar;
21(3):315-21.
10 Johnson TR, Schenzle JC, Sommer WH, Michalski
G, Neumaier K, Lechel U, Nikolaou K, Becker H-C,
Reiser MF. Dual energy CT: How about the dose?
Invest Radiol. 2010 (in press).
65
Life
Life
www.siemens.com/life-courses
67
Life
Mang, MD, from Vienna University, demonstrated how they can use syngo.via
for their daily reporting.
At the beginning of each session, a theoretical introduction into the topic was
given by the speakers. Pflederer pointed
out the various dose reduction possibilities for Cardiac CT while Mang gave an
overview of patient preparation and
reading techniques for CT Colonography.
After a brief demonstration of syngo.via
by Siemens application specialists, the
* syngo.via can be used as a standalone device or together with a variety of syngo.via based software options, which are medical devices in their own rights.
Location
Short Description
Date
Contact
ASNR
Boston, USA
www.asnr.org
ISCT
San Francisco,
USA
12th International
Symposium on
Multidetector-Row CT
www.isct.org
WCC
Bejing, China
World Congress of
Cardiology Scientific
Sessions 2010
www.worldheart.org
SCCT
5th Annual
Scientific Meeting
www.scct.org
ESC
Stockholm,
Sweden
Cardiology
Congress
August 28
September 01, 2010
www.escardio.org
ESNR
Bologna, Italy
Neuroradiology
Congress
www.esnr.org
RSNA
Chicago, USA
Annual Meeting of
Radiological Society
of North America
November 28
December 03, 2010
www.rsna.org
Life
Example of
the Trigger
card of
SOMATOM
Definition
scanner.
Life
Dates
Location
language
Course
director
Course
Clinical Workshop on
Cardiac CT / Erlangen
Erlangen,
Germany
English
Clinical Workshop on
Cardiac CT / Munich
Munich,
Germany
English
PD Konstantin Nikolaou, MD
Prof. Christoph Becker, MD
Alexander Becker, MD
November,
1819 2010
Erlangen,
Germany
English
Hands-on Workshop
Cardiac CT
September,
2325 2010
St. Gallen,
Switzerland
German
PD Hatem Alkadhi, MD
PD Sebastian Leschka, MD
Kuching,
Malaysia
English
Virtual CT-Colonography
German
September,
10 11 2010
Forchheim,
Germany
English
PD Thorsten Johnson, MD
ESGAR CT-Colonography
Workshops
September,
2324 2010
April
1315, 2011
September
14 16, 2011
Lisbon (Cascais),
Portugal
Dublin,
Ireland
Gothenburg,
Sweden
English
Cardiac-CT Workshop/
Dubai
Autumn 2010
Dubai, UAE
English
PD Christoph Becker, MD
Alexander Becker, MD
Hands-on Workshops
during ESC 2010
August,
28 31 2010
Stockholm,
Sweden
English
n.a.
Experience Lounge
at RSNA 2010
November, 28
December, 2 2010
Chicago,
USA
English
n.a.
In addition, you can always nd the latest CT courses offered by Siemens Healthcare at www.siemens.com/SOMATOMEducate
71
Life
Medical Solutions
The Magazine for Healthcare Leadership
May 2010
Medicine in 2050
Medical Solutions
Innovation and trends
in healthcare. The
magazine, published
three times a year, is
designed especially
for members of the
hospital management,
administration personnel, and heads of
medical departments.
News
Our latest topics
such as product
news, reference
stories, reports,
and general
interest topics are
always available at
www.siemens.com/
healthcare-news
Inhalt_May_10_eng.indd 1
23.04.10 09:10
AXIOM Innovations
Everything from the worlds
of interventional radiology,
cardiology, fluoroscopy,
and radiography. This semiannual magazine is primarily designed for physicians,
physicists, researchers, and
medical technical personnel.
MAGNETOM Flash
Everything from the world
of magnetic resonance
imaging. The magazine
presents case reports,
technology, product news,
and how-tos. It is primarily
designed for physicians,
physicists, and medical
technical personnel.
SOMATOM Sessions
Everything from the world
of computed tomography.
With its innovations, clinical
applications, and visions,
this semiannual magazine
is primarily designed for
physicians, physicists,
researchers, and medical
technical personnel.
Perspectives
Everything from the world
of clinical diagnostics. This
semi-annual publication provides clinical labs with diagnostic trends, technical innovations, and case studies.
It is primarily designed for
laboratorians, clinicians and
medical technical personnel.
For current and prior issues and to order the magazines, please visit www.siemens.com/healthcare-magazine
Editorial
Imprint
Chief Editors:
Institution
Department
Function
Title
Name
P. Weisser, MD, Department of Diagnostic and Interventional Radiology, Clinic of the Goethe
University, Frankfurt, Germany
Street
Postal Code
City
State
Editorial Board:
Andreas Blaha
Helge Bohn
Andreas Fischer
Thomas Flohr, PhD
Julia Hoelscher
Klaudija Ivkovic
Axel Lorz
Peter Seitz
Stefan Ulzheimer, PhD
Alexander Zimmermann
Country
Neuro BestContrast
allows radiologists to
better visualize subtle
edemas as well as
subtle signs of stroke,
and to better delineate
the cortical margin.
Medical Solutions
MAGNETOM Flash
SOMATOM Sessions
AXIOM Innovations
73
The drugs and doses mentioned herein are consistent with the approval labeling
for uses and/or indications of the drug. The treating physician bears the sole
responsibility for the diagnosis and treatment of patients, including drugs and
doses prescribed in connection with such use. The Operating Instructions must
always be strictly followed when operating the CT System. The sources for the
technical data are the corresponding data sheets. Results may vary.
Partial reproduction in printed form of individual contributions is permitted, provided the customary bibliographical data such as authors name and title of the
contribution as well as year, issue number and pages of SOMATOM Sessions are
named, but the editors request that two copies be sent to them. The written consent
of the authors and publisher is required for the complete reprinting of an article.
We welcome your questions and comments about the editorial content of
SOMATOM Sessions. Manuscripts as well as suggestions, proposals and information are always welcome; they are carefully examined and submitted to the editorial board for attention. SOMATOM Sessions is not responsible for loss, damage,
or any other injury to unsolicited manuscripts or other materials. We reserve the
right to edit for clarity, accuracy, and space. Include your name, address, and
phone number and send to the editors, address above.
Cover Page: With Volume Perfusion CT Neuro fused with carotid CT Angiography the perfusion status of the brain tissue
can be observed. Courtesy of University Hospital Gttingen, Germany.
Note in accordance with 33 Para.1 of the German Federal Data Protection Law:
Despatch is made using an address file which is maintained with the aid of an
automated data processing system.
SOMATOM Sessions with a total circulation of 35,000 copies is sent free of charge
to Siemens Computed Tomography customers, qualified physicians and radiology
departments throughout the world. It includes reports in the English language
on Computed Tomography: diagnostic and therapeutic methods and their application as well as results and experience gained with corresponding systems and
solutions. It introduces from case to case new principles and procedures and discusses their clinical potential.
The statements and views of the authors in the individual contributions do not
necessarily reflect the opinion of the publisher.
The information presented in these articles and case reports is for illustration only
and is not intended to be relied upon by the reader for instruction as to the practice of medicine. Any health care practitioner reading this information is reminded that they must use their own learning, training and expertise in dealing with
their individual patients. This material does not substitute for that duty and is not
intended by Siemens Medical Solutions to be used for any purpose in that regard.
Subscription
SOMATOM Sessions
Siemens AG
Wittelsbacherplatz 2
80333 Muenchen
Germany
Siemens AG
Healthcare Sector
Henkestrae 127
91052 Erlangen
Germany
Phone: +49 9131 84 - 0
www.siemens.com/healthcare
26
www.siemens.com/healthcare-magazine
SOMATOM
Sessions
91052 Erlangen
Germany
Siemens AG
Halthcare Sector
H CC 11
Henkestrae 127
Siemens AG
Medical Solutions
Computed Tomography
Siemensstrae 1
91301 Forchheim
Germany
Phone: +49 9191 18 - 0
www.siemens.com/healthcare
Asia/Pacific:
Siemens Medical Solutions
Asia Pacific Headquarters
The Siemens Center
60 MacPherson Road
Singapore 348615
Phone: +65 9622 - 2026
www.siemens.com/healthcare
May 2010
Rapid evaluation is
critical after trauma and
with symptoms such as
weakness, headache,
and dizziness, which is
why CT is the modality
of choice in these
scenarios. Exceptional
image quality is key to
optimize diagnosis, and
lower dose imaging
minimizes risk to the
patient.
Global Siemens
Healthcare Headquarters
Latin America:
Siemens S.A.
Medical Solutions
Avenida de Pte. Julio A. Roca No 516, Piso 7
C1067ABN Buenos Aires Argentina
Phone: +54 11 4340 - 8400
www.siemens.com/healthcare
USA:
Siemens Medical Solutions U.S.A., Inc.
51 Valley Stream Parkway
Malvern, PA 19355-1406
USA
Phone: +1-888-826 - 9702
www.siemens.com/healthcare
Cover Story
The Best of Both Worlds
in Neuro Imaging
Page 6
Canada:
Siemens Canada Limited
Medical Solutions
2185 Derry Road West
Mississauga ON L5N 7A6
Canada
Phone: +1 905 819 - 5800
www.siemens.com/healthcare
Europe/Africa/Middle East:
Siemens AG
Medical Solutions
Henkestrae 127
D-91052 Erlangen
Germany
Phone: +49 9131 84 - 0
www.siemens.com/healthcare
SOMATOM Sessions
News
Business
ISCT-Edition
Clinical
Results
SOMATOM Denition AS+:
CT Perfusion With
Extended Coverage for
Acute Ischemic Stroke
Page 46
Science
CT in Pediatrics: Easier
and Safer With the Flash
Page 58