CT Somatom Sessions 33 01220034

SOMATOM Sessions
Answers for life in Computed Tomography
December 2013 | International Edition
Issue 33
SOMATOM Force:
Bringing Personalized
Medicine to CT
Page 06
News
Business
Clinical Results
Science
syngo.via Frontier
Gateway to an Open
Research Environment
Page 31
Ready for the

Next Revolution
in Stroke Care?
Page 40
Coronary CTA with

Reduced Contrast
and Radiation Dose
of 0.19 mSv
Page 50
Radiation Hygiene
Transparent and Easy
Page 72
Editorial
In a general population with

a very complex age and disease
structure, the SOMATOM Force
can solve the problems presented
by every radiological situation
for virtually every patient.
Professor Stefan Schnberg, MD,
University Medical Center Mannheim, Germany
Cover page:
Dynamic CTA 64 cm acquired with spiral 4D mode at 80 kV, 110 mAs,
with 45 mL contrast. The vascular structures of the complete trunk
are clearly demonstrated, and the suspected leaking from the aortic stent
could be confidently ruled out.
Courtesy of University Medical Center Mannheim, Germany
2 SOMATOM Sessions | December 2013 | www.siemens.com/SOMATOM-Sessions
Editorial
Dear Reader,
In todays fast changing global healthcare environment, Siemens aspiration
is to contribute in two major directions.
Together with our excellent network
of academic partners, we continue to
extend the frontiers of available diagnostic and treatment capabilities. At
the same time and equally important
we innovate to make our technology
accessible to more patients around the
world.
The cover article in this RSNA 2013
edition of SOMATOM Sessions introduces the latest frontier-shifting CT
scanner from the Siemens innovation
powerhouse. The new Dual Source CT
SOMATOM Force* builds on the outstanding clinical success of Siemens
unique Dual Source technology pushing current capabilities and opening
up new possibilities. SOMATOM Force
features enhanced temporal, spatial
and contrast resolution and introduces Turbo Flash scanning with up
to 730 mm per second z-coverage for
free-breathing CT imaging. Its outstanding tube power already available at 70 kV makes low kV imaging
accessible to virtually all patients and
allows for unmatched iodine contrast

enhancement. All this, together with
a new level of spectral separation for
high precision Dual Energy applications, opens the door to CT examinations tailored to specific patient need.
SOMATOM Force has the true potential to deliver the right diagnostic precision at previously impossible low
radiation and contrast dose levels.
In the cover article, you will sense
the excitement about the initial experience of SOMATOM Force at the
University Medical Centre Mannheim,
Germany.
The established SOMATOM Perspective,
on the other hand, is an excellent
example of how to leverage a leading
technology position to develop a highperformance, affordable routine system with excellent economics. Originally introduced as a 128- and 64-slice
system, the SOMATOM Perspective
family has now expanded into the
32- and 16-slice arena*. In the related
article, you can see how affordability
and full upgradeability within the
product family together with high-tech
features such as SAFIRE, iTRIM, and
Single Source Dual Energy make these
scanners a great choice even for
challenging economic environments.
As a complement to our CT system

portfolio, we are launching the
syngo.via software VA30** with
expanded functionality for existing
applications as well as new applications, such as syngo.CT Liver Analysis*.
Finally, I would like to thank heartily
all the participants in the International
Right Dose Image Contest for so
many truly wonderful contributions.
Enjoy reading about these and a
range of other interesting topics in
this issue of SOMATOM Sessions.
Walter Maerzendorfer,
CEO of the Computed Tomography
& Radiation Oncology Business Unit,
Imaging and Therapy Systems Division,
Siemens Healthcare,
Forchheim, Germany
** T
his product is 510(k) pending. Not available
for sale in the U.S.
** The products/features (here mentioned) are
not commercially available in all countries. Due
to regulatory reasons their future availability
cannot be guaranteed. Please contact your
local Siemens organization for further details.
SOMATOM Sessions | December 2013 | www.siemens.com/SOMATOM-Sessions 3
06 Cover Story
SOMATOM Force:
Medicine to CT
December 2013
Contents
News
Clinical Results
14 Getting Further in CT with New Imaging Possibilities

18 Improving Accuracy and Workflow Speed in
Transcatheter Aortic Valve Implantation
22 Fighting Aortic Aneurysms with Modern CT
Technology
26 Scientifically Validated: New Applications for CARE kV
and Adaptive 4D Spiral
28 Back Among the Pioneers
31 syngo.via Frontier Gateway to an Open Research
Environment
32 Continuous Commitment to the Right Dose
34 Charting New Paths with True Dual Energy
36 Open Up New Opportunities with New Configurations
38 Getting to Grips with Stress Myocardial Perfusion
Imaging
Cardiovascular
48 Myocardial Ischemia Assessment using
Adenosine-Stress Dynamic Myocardial CT Perfusion
50 Coronary CTA with Reduced Contrast and Radiation
Dose of 0.19 mSv
52 Bicuspid Aortic Valve with Anomalous Coronary
Artery Fistula A Rare Incidental Coincidence
Business
Neurology
54 Dynamic Volume Perfusion CT in a Case of
Childhood Moyamoya Disease before and after
Surgical Revascularization
56 Differentiating an Intracranial Hemorrhage
from Iodine in Acute Stroke after Intra-arterial
Recanalization
Acute Care
58 Diagnosis of Splenic Rupture in an 11-year-old Girl
using a Sliding Gantry CT
40 Ready for the Next Revolution in Stroke Care?

44 All-in-one
47 When Space is at a Premium Compact High Quality
Scanning
Contents
14
18
32
72
Customer Excellence
Pulmonology
60 Automated Quantification of Pulmonary Perfused
Blood Volume in Acute Pulmonary Embolism using
Dual Energy CTPA
Urology
62 Diagnosing Small Renal Calculi using Low Dose
Dual Energy CT at 0.8 mSv
64 Differentiating Stent from Stone: A New Approach
using Dual Energy CT
Pediatrics
66 Diagnosing Tracheal Stenosis in a 10-week-old Baby
without Sedation
76
77
78
79
Tips & Tricks: Easy Bone and Vessel Isolation

Clinical Workshops 2014
Upcoming Events & Congresses 2013/2014
Free DVD of the 11th SOMATOM World Summit
in Orlando
80 Twenty Years of STAR A Successful Educational
Program for Radiologists
81 From Print to App: SOMATOM Sessions for Everyone
81 2014 Multislice CT Symposium in Garmisch
82 Subscriptions
83 Imprint
Science
68 Image Quality in Computed Tomography
72 Radiation Hygiene Transparent and Easy
74 Radiation Protection Scientifically Proven for
Routine Practice
Cover Story
SOMATOM Force:
Medicine to CT
A quantum leap in CT engineering: Siemens new scanner, the SOMATOM
Force, takes over the lead in the Dual Source CT portfolio. As such it will enable
radiologists not only to perform even more individualized diagnostics, but also
to contribute to personalized medicine and new therapy concepts. Interdisciplinary imaging experts at the University Medical Center Mannheim, Germany,
share their experience of the first SOMATOM Force installed worldwide.
By Irne Dietschi
Curtain up on Siemens latest accomplishment in outstanding engineering:

The new SOMATOM Force CT scanner
the lead Dual Source scanner now
in the market, re-writes the way CT
will be used in the future for diagno-
1A
sis and treatment decisions. The

premiere takes place at the German
University Medical Center Mannheim, where the Institute of Clinical
Radiology is proud to be the very
first research institution worldwide to
install the new CT system. The interdisciplinary Mannheim specialists

were excited to start working and
doing translational research with their
new scanner, not only because the
SOMATOM Force is almost twice as
1B
High resolution stent imaging coronary CTA images acquired with Turbo Flash mode in only 0.18 s, at 70 kV and pitch 3.2,
with 0.43 mSv. The patients heart rate varied between 58 to 70 bmp during the examination. The VRT image (Fig. 1A) shows
nicely two long stents in both LAD and Cx. The curved MPR image (Fig. 1B) shows the details in the LAD stent.
Cover Story
The Institute of Clinical Radiology at the University Medical Center in Mannheim, Germany, is the very first place worldwide to install the new
SOMATOM Force (Associate Professor Thomas Henzler, MD, left, Professor Stefan Schnberg, MD, right, patient, middle).
fast, more precise, and even more

patient friendly than any of its predecessors, but also because they believe
that it is possibly a vehicle for a new
medical paradigm. From now on,
imaging is no longer limited to classical diagnostics, says Professor Stefan
Schnberg, MD, director of the hospital, and he explains: As radiologists,
we now have the possibility to create
value-based medicine by targeting
the clinical endpoint of medical procedures: the recovery of the patient.
CT is the imaging technique that in
comparison with MRI or PET, delivers
the most robust data in the long run,
adds Professor Lothar Schad, PhD,
director of computer-assisted clinical
medicine at the faculty. The consistency of quantitative data that we are
able to produce using the high-end CT
device cannot be equalled using any
other imaging system, he says. Schad
thinks that CT will become more and
more accepted as an imaging biomarker, which will set the benchmark

for other imaging techniques.
The Medical Faculty Mannheim, part
of Heidelberg University, has been
focusing on medical technology for
over a decade, according to the facultys dean Professor Uwe Bicker, MD,
PhD. The renowned University Medical
Center is located near the center
of the city, on a campus designed
for translational clinical research.
The immediate proximity between
the hospital, patients, and research
is regarded as a huge advantage by
the dean: Mannheim was successful
in the national competition for the
so-called research campus, funded
by the German Ministry of Education
and Research, which in Mannheim
involves a public private partnership
with Siemens.
In this context, dean Uwe Bicker also
points out some of the limits of tech-
nological progress: Technology by

itself is useless unless its application
is affordable for healthcare providers,
he says. In his opinion, this equation
is one of the most challenging for the
future.
So, how does the SOMATOM Force
contribute to solving this challenge?
It does so in the first place with a
number of engineering milestones,
which are believed to change behavior patterns in CT imaging. Schnberg
is enthusiastic: In a general population with a very complex age and
disease structure, this new scanner
can solve the problems presented by
every radiological situation for virtually every patient, he says. Associate
Professor Thomas Henzler, MD, head
of cardio-thoracic imaging at the Institute of Clinical Radiology, is equally
excited. He is convinced that With
the SOMATOM Force we have eliminated almost all contraindications for
Cover Story
dose are concerned. Only this highend CT system is capable of offering

the variety of parameters for such an
individualized approach.
Individualized diagnostics is related
to precision medicine. In the future,
imaging will contribute substantially
to the response evaluation of certain
therapies, for example for cancer
patients. Large nations are revising
their healthcare policies radically in
this respect: Henceforth, it will increasingly depend on the response rate
the endpoints, as Schnberg puts it
whether medical treatment will be
reimbursed or not. In such an environment, novel high-end systems such as
the SOMATOM Force are fundamental
for precise and sound decision-making
by provision of quantitative data.
The immediate proximity between hospital, patients, and research is regarded as a huge advantage
by dean Professor Uwe Bicker, MD, PhD: University Medical Center Mannheim was successful in the
national competition for the so called research campus, funded by the German Ministery of Education and Research, which in Mannheim involves a public private partnership with Siemens. Bicker is
very proud of the reputation and the amount of expertise that has been accumulated at the campus
lately, especially in imaging. He is reassured by research student Sonja Sudarski who considers
Mannheim to be invaluable for young researchers with a vision, especially as the medical faculty
is equipped with the latest technology.
CT. The scanner allows precise and

individualized imaging of all patients
and thus changes our thinking of CT
completely. In his and Schnbergs
view the new system is especially
promising in individualized diagnostics: Every patient should have his or
her best possible diagnostic procedure, meaning that the CT scan of

an 85-year-old woman, weighing 60
kilograms, has in terms of parameter
settings little in common with that
of a 40-year-old morbidly obese man
with a BMI of 40 as far as required
The SOMATOM Force is expected to

lead to positive changes in a number
of areas. First of all, it is two steps
ahead in contrast-to-noise.
Low-kV imaging for

all patients
The engineers have put huge effort
into lowering the tube voltage, while
maintaining very high photon flux at
a very small focal spot. Low kV exams
are no longer only possible for small
children and slim adults, but will be
possible for practically all adults and
even obese patients from now on.
This, as a matter of routine, results
in a reduction in radiation dose, and
more: With the SOMATOM Force,
the contrast-to-noise ratio has been
With the SOMATOM Force we have eliminated almost all contraindications for CT.
The scanner allows precise and individualized imaging of all patients and thus
changes our thinking of CT completely.
Associate Professor Thomas Henzler, MD,
Cover Story
Low dose for challenging patient 63 cm acquired with

Turbo Flash mode in only 1.2 s, at 80 kV and pitch 2.4,
with 1.9 mSv. The image quality is excellent although the
patients left arm had to be kept in the scan field of view.
improved to such an extent that a scan

can be done with much lower contrast medium amounts than previously.
Whereas the average CT scanner
requires between 90 and 110 milliliters
for a certain application, the SOMATOM
Force will produce the same image
quality with just a fraction of the contrast medium dose. For a thoracic CT,
for example, volumes as low as 25 to
35 milliliters are expected.
Dual Energy lung PBV 32 cm acquired in only 4 s,

with 55 mL contrast, at 90/Sn 150 kV. An wedge shaped
perfusion defect area is depicted in the left upper lobe,
although no pulmonary emboli is present. The image
quality is excellent due to greater spectrum separation.
This aspect is especially important

with regard to kidney protection, as
Henzler explains: In radiology, weve
been discussing CT doses for years,
even though weve known that nephropathy induced by iodinated contrast
is the greater problem with some
people undergoing computed tomography. Up to 20 percent of patients,
especially if they are older and suffering from chronic diseases such as
diabetes, might have to undergo prolonged pre- and after-care because

the contrast agent may harm their
kidneys. With the new scanner, this
time and cost intensive procedures
might no longer be necessary. In
short: SOMATOM Force is a versatile
scanner. We are expecting to be able
to examine all patients adequately,
even those suffering from renal
insufficiency, says Henzler.
As radiologists, we now have the

possibility to create value-based
medicine by targeting the clinical
endpoint of medical procedures:
the recovery of the patient.
Professor Stefan Schnberg, MD,
Cover Story
Lowest dose for early

detection of lung and colon
diseases
For lung and colon scans, the contrastto-noise ratio is also expected to rise
significantly. Why? The SOMATOM
Force has further developed the pop-
ular Flash Spiral mode into the new

Turbo Flash mode: Besides being
almost twice as fast, it now uses two
selective photon shields instead of
one. The two tin filters optimize the
X-ray spectrum to boost contrast
between soft tissue and air in patient
scans. The resulting increase in the
contrast-to-noise ratio can be reinvested in lowering the dose, allowing

a reduction of approximately 30 percent compared with other high-end
CTs.
What this means for clinical practice
is explained by Schnberg: Computed
tomography could very well become
an important tool for the early detection of lung cancer. The radiation dose
for the risk evaluation of bronchial carcinoma has dropped to an extent that
dose is no longer an issue compared
with the added value which you create
with this exam.
Moreover, the Turbo Flash mode
might not only reveal lung lesions, but
could also be used for the exclusion
or early detection of two other major
diseases: coronary heart disease and
susceptibility to stroke. As for the
detection of colon diseases, studies
have produced excellent evidence in
support of colon CT. The results have
shown that colon CT is almost equal
to classical coloscopy, indicating that it
could at least be applied in cases where
classical coloscopy is not possible,
Schnberg says.
The SOMATOM Force is not only
characterized by low doses, new contrasts, and reduced need for contrast
medium, but also by speed. Compared
with its predecessors, it moves breathtakingly fast.
Free breathing for all patients
Dynamic CTA 64 cm acquired with spiral 4D mode at 80 kV, 110 mAs,

with 45 mL contrast. The vascular structures of the complete trunk are clearly
demonstrated, and the suspected leaking from the aortic stent could be
confidently ruled out.
One problem frequently found in conventional scans is motion artifacts,

often resulting in insufficient image
quality. Studies show that in cases of
pneumonia, for example, a significant
number of scans carried out with a
standard system are unsatisfactory due
to blurring. This leads to readmissions
that could otherwise have been prevented. If doctors ask their colleagues
in the radiology department to redo a
scan, in one of three cases the reason
is impaired image quality. The new
SOMATOM Force and its novel Turbo
Flash mode can help to minimize this
problem: Compared with the former
Flash Spiral scan mode, Turbo Flash
is almost twice as fast, scanning at
737 mm/s. This means that the Turbo
Flash mode literally freezes respiration, or other motion induced by the
Cover Story
5A
5C
5
Whole liver perfusion
22 cm acquired at
80 kV, 100 mAs,
with 17.58 mSv only,
for an obese patient
(118 kg) with liver
tumor.
5B
diaphragm or the bowel. So, free

breathing no longer impedes image
quality.
This is a relief, for instance, for older
or maybe overweight patients who have
trouble holding their breath. It is also
relevant for trauma patients who are in
considerable pain and/or unconscious,
and in pediatric CT where doctors can
now perform a CT exam without the
need for sedation or controlled breathing in children. Finally, speed is a crucial
factor in cardiac CT. So far we have
been able to perform a cardiac CT far
below 1 mSv in patients whose heart
rate was below 65, says Henzler.
With the new system we will move to
a situation in which we can examine
higher heart rates and still remain
below 1 mSv, acquiring robust results
we havent seen before. Henzler
5D
believes that those facts will also

generate clinical value: Cardiac CT
will be more consistently integrated
in the workflow of the emergency
room as an algorithm for patients with
intermediate cardiac risk.
Larger field of view

With the SOMATOM Force, Siemens
engineers have extended the field
of view of the Flash Spiral mode to
up to 50 centimeters. They accomplished this major improvement by
introducing the new powerful
VECTRON tube which evolved from
technology initially introduced with
the renowned STRATON tube, and
with the StellarInfinity detector. Based
on the innovative Stellar technology,
the new detector now additionally
enhances resolution by 25%, and moreover extends the former z-coverage
by 50%. The combination of two

VECTRON tubes and two StellarInfinity
detectors in a Dual Source CT enable
the realizing of the unique Turbo
Flash mode. Henzler is intrigued by
this masterpiece of engineering and
innovation. The geometry of the
detector has been changed in an
ingenious way that we havent seen
so far in computed tomography, he
says. We will be able to show even
the smallest vessels such as the coronary arteries or calcified lesions in
perfect resolution, without having
to worry about the dose or motion
artifacts. Moreover, the extended
field of view will enable radiologists
to scan practically all patients in
Turbo Flash scan mode, including
obese adults as well as patients with
kidney disease. With the SOMATOM
Force it is expected that the Turbo
Cover Story
6
6
Dynamic Runoff
61 cm acquired with
spiral 4D mode at
70 kV, 130 mAs, with
1.39 mSv and 45 mL
contrast. MIP images
show nicely the
dynamic flow of the
vascular details,
and additionally, the
tendons as well.
Flash mode will become standard,

establishing ultra-high pitch scanning
as the true successor of conventional
spiral modes.
Finally, the SOMATOM Force is likely
to become the diagnostic CT tool of
choice for personalized medicine: It
offers precision CT at its best and is
therefore two steps ahead in functional analysis and decision making.
Dynamic perfusion at half

the dose
Although MRI will probably remain
the benchmark for functional imaging,
CT is gaining ground very fast. CT
has unmatched advantages if you
need imaging in large quantities and
within time limits, Schnberg says.
The SOMATOM Force offers dynamic

perfusion which usually requires
high radiation doses at up to half
the dose compared with conventional
state-of-the-art CTs, e.g. for the perfusion of the liver. The engineering
solution lies in the new StellarInfinity
detector (with TrueSignal technology
plus its 50 percent wider coverage)
and the redesign of the Adaptive
Dose Shield, already known from the
SOMATOM Definition Flash scanner.
Matching the scan speed of the
SOMATOM Force, the collimator blades
can be opened and closed at twice
the speed.
Clinical application is possible for
various organs, such as pancreas,
abdomen, kidneys or the liver.
Dynamic perfusion of the liver, for
example, which at present requires

doses between 60 and 70 mSv, is
expected to be possible at the dose of
a conventional 4-phase liver protocol.
Why does this make sense? Think of
Bevacizumab, says Henzler: On the
one hand, Bevacizumab is an impressive drug which suppresses angiogenesis in various cancers, including
colorectal, lung or kidney. However, it
is a costly drug. If you want to know
whether patients are responding to
the treatment, one way is to monitor
these patients with repetitive perfusion CT. Short-term monitoring can
reveal which patients respond to antiangiogenesis treatment, and which
patients do not. Long-term CT monitoring with functional parameters may
help to detect recurrence.
Cover Story
cardiac catheter examination. With

this we have achieved three goals,
Schnberg explains: First, we have
supported our colleagues in cardiology in their daily work by making sure
that catheter exams are conducted
with higher therapeutic yield; second,
we are more cost-effective; third,
weve enriched the interventional
scope of cardiology by referring to our
colleagues those patients who actually need an intervention. Analysis
of this new workflow modality has
shown that it is actually cost effective. In the view of dean Uwe Bicker,
this is the key factor for any technological innovation: If it is cost effective, it will prove itself on the market.
At the University Medical Center in Mannheim, the medical faculty has defined three fundamental
topics it wants to pursue with the SOMATOM Force in various clinical studies: treatment response,
nephroproctection and motion artifact reduction. From left to right: Professor Stefan Schnberg, MD,
director of Radiology and Nuclear Medicine, Professor Lothar Schad, PhD, director of computerassisted clinical medicine, Florian Lietzmann, MD, team leader of CT physics research at the institute
of computer-assisted clinical medicine, Thomas Henzler, MD, head of cardio-thoracic imaging.
In other tumors such as gastrointestinal

stromal tumors, the most promising
way to assess treatment response is Dual
Energy. In various studies conducted
in Mannheim, iodine-related attenuation has proven to be a very robust
response parameter, as Thomas Henzler
explains. Whereas the Dual Energy
scanners of the first generation had
certain limits in coverage, the new
scanner increases energy separation
by 30 percent. We expect that the
SOMATOM Force will produce a clearcut improvement because of the
spectral upgrade, says Henzler. In his
view, Dual Energy is clearly gaining
ground: Many vascular questions can
be answered spectrally in post processing, because the two energies have
been separated so effectively.
In Mannheim, the medical faculty

has defined three major topics that it
wants to pursue with the SOMATOM
Force in various clinical studies:
treatment response, nephroprotection, and motion artifact reduction.
Researchers believe that the new
standing of computed tomography
could affect the workflow of a clinic
substantially: CT could evolve into an
all-in-one triage for new diagnostics
and therapy models. One field in
which this progress is already beginning to emerge is cardiology and
the treatment of acute coronary syndrome: At the University Medical
Center Mannheim, if a patient at risk
shows no relevant stenosis of the
coronary arteries in cardiac CT, he or
she is automatically excluded from
CT for cardiovascular issues is a role

model for interdisciplinary workflow
and decision making. But the other
important domain that he and his
radiology group are aiming for is
oncology. Schnberg believes that
cancer is the future market for the
high-end CT system SOMATOM Force.
My vision is that in five years from
now, oncologists around the world
will prescribe innovative molecular
substances based on functional imaging. If you have to attend to millions
of people globally, you need an
efficient imaging system in order to
apply those substances cost-effectively. And this will most likely be CT.
Irne Dietschi is an award-winning Swiss

science and medical writer. She writes for
the public media, such as the Neue Zricher
Zeitung and has published several books.
The product is pending 510(k) clearance, and is

not yet commercially available in the United States.
The statements by Siemens customers described
herein are based on results that were achieved
in the customers unique setting. Since there is no
typical hospital and many variables exist (e.g.,
hospital size, case mix, level of IT adoption) there
can be no guarantee that other customers will
achieve the same results.
Further Information
www.siemens.com/
SOMATOM-Force
News
Getting Further in CT
with New Imaging Possibilities
Siemens continues to improve its advanced visualization platform syngo.via for
CT: Combined with continuous scanner innovations, Siemens syngo.via VA30*
offers a range of additional options for diagnosis and pre-procedural planning.
By Arjen Bogaards, PhD, Jochen Dormeier, MD, Susanne Hlzer, Dominik Panwinkler, Philip Stenner, PhD
Computed Tomography, Siemens Healthcare, Forchheim, Germany
Every year, clinical routine is becoming more and more demanding. Physicians and clinical staff need to make
best use of diagnostic technology tools
available at their particular medical
institution. It is essential to their job to
understand diseases more comprehensively and make the right treatment
decisions faster. This requires technology providers to continuously innovate
medical imaging equipment. Siemens
syngo.via software is designed to furthermore accelerate workflow across
all modalities, managing both day-today and more challenging cases successfully. For this reason, the software
must be based on concepts that are
efficient, flexible, and intelligent. Automated pre-fetching of prior examinations and pre-processing saves valuable
time, allowing physicians, technicians
and IT professionals to focus on their
core patient-centric tasks. Modular
licensing models offer flexibility so
that the system can grow in line with
needs and budget. Workflows are
rendered more flexible, too, as physicians can view images on mobile

devices. Sharing findings with colleagues is also easier for fast and
reliable clinical decisions. syngo.via
software guides users through the
entire workflow, identifying human
anatomy, and enabling radiologists to
deliver reliable and meaningful quantitative results. Therefore, syngo.via
VA30 is designed to meet as many
clinical challenges as possible.
Automatic completion of manufacturerspecific AAA graft order forms

with syngo.CT Rapid Stent Planning**.
Comprehensive evaluation of myocardial perfusion with

syngo.CT Cardiac Function Enhancement.
syngo.CT Liver Analysis**: In-depth analysis of liver vascularization combined

with surgery planning.
Automated AAA stent

planning
match the specific requirements of

other vendors.1
Pre-procedural planning for the treatment of an abdominal or thoracic

aortic aneurysm requires a precise
assessment of several anatomical parameters. Numerous vendors offer stent
grafts, each of which requires its own
set of measurements. Anatomical
assessment and completion of the graft
order forms can be tedious and timeconsuming. The new syngo.CT Rapid
Stent Planning** introduces automatic
completion of manufacturer-specific
stent order forms. That holds out the
prospect of skipping all the cumbersome steps and streamlining abdominal aortic stent planning. It represents
an ideal extension to the Rapid Results
Technology: Dedicated protocols guide
the user through all length and diameter measurements, which are then
automatically stored in the corresponding order form. For delivery purposes,
syngo.CT Rapid Stent Planning** provides three order forms as PDFs: Gore
Excluder, Zenith Flex, and Medtronic
Endurant. Furthermore, new order
form templates can be generated to
Comprehensive myocardial
perfusion analysis
Coronary CTA is a well-established
method of ruling out coronary artery
stenosis. Often, an intermediate stenosis is found whose hemodynamic
relevance may be unclear. In such cases,
a myocardial stress perfusion examination can help to decide whether a
patient should undergo PCI2 or not.
As a one-stop shop, CT is becoming
increasingly important in the assessment of myocardial perfusion. Different approaches are currently available,
but Siemens is the only manufacturer
to offer the full spectrum of myocardial
perfusion analysis: Whether simple
first-pass enhancement, Dual Energy
perfusion scanning, or quantitative
dynamic myocardial perfusion. With
syngo.via VA30 and the new perfusion evaluation feature in syngo.CT
Cardiac Function-Enhancement, it is
now possible to evaluate comprehensively all types of myocardial perfusion.
Rather than simply looking at a firstpass enhancement scan, the quantifi-
syngo.CT Bone Reading enriched

bySpine CAD.
cation of iodine concentration in the

myocardium and inspection of quantitative blood flow and volume data
provide additional clinical benefits.3
The visualization in AHA-compliant
17-segment polar maps and the direct
overlay in MPR segments help to
pinpoint the perfusion defect. With
syngo.via VA30, the evaluation of
myocardial perfusion becomes faster,
easier, and more reliable.
Advanced oncological
analysis
Assessment of tumor perfusion in
follow-up examinations allows identification of tumor viability before
changes in tumor sizes are visible.
Identifying these changes at an early
stage of oncological treatment adds
supplementary clinical information
especially when following up on
state-of-the-art treatment with antiangiogenic drugs. The body perfusion functionality is now available in
syngo.via and provides quantification
of blood flow, blood volume, and permeability, combined with automated
motion correction for improved anatomical alignment. In addition to its
Adobe Acrobat Professional required; 2PCI: Percutaneous coronary intervention; 3CT DE Heart PBV and/or syngo VPCT Body-Myocardium required
News
View of the neurovasculature from

arch to vertex with syngo.CT Neuro DSA.
use in oncology, a further clinical

application is to assess perfusion in
cases of organ transplantation.
The new syngo.CT Liver Analysis**
delivers in-depth clinical insights based
on comprehensive analysis of CT datasets and tools for surgery planning.
For the surgeon it is crucial to know
the precise size and location of tumors
before the operation. It is also essential to assess the amount of liver tissue
that is to be resected and the exact
anatomical vascular supply to the
affected liver segments. By dissecting
the liver virtually using the software,
the physician is able to compare the
amount of resected and residual
liver tissue one of the key factors in
the surgery outcome. syngo.CT Liver
Analysis** supports these pre-operative planning steps by combining
tailored functions and tools with intuitive workflow guidance.
Extended bone reading

support
Building on the success of syngo.CT
Bone Reading, the application has
been enhanced with CAD* (Computer
Assessment of diffuse tumor infiltrations with

syngo.CT DE Bone Marrow**.
Aided Detection) functions to identify

suspicious spine lesions. Intended for
use as a second reader tool after the
initial read has been completed, this
supplementary tool draws the radiologists attention to regions of interest
(ROI) that may have been initially
overlooked. In addition to the revolutionary new visualization in bone reading which adapts complex anatomies
to reading needs this new feature
has demonstrated potential in detecting lytic and blastic metastasis as
reported in a scientific publication
from the Department of Radiology,
University Hospital Erlangen.[1]
With these new additions, syngo.via
VA30 offers a comprehensive portfolio
enabling holistic oncological reading.
CT imaging the cornerstone

of stroke care
Across the globe, 1 in 6 people will
suffer a stroke at some point in their
life. It is one of the worlds most threatening diseases. Almost two million
brain cells could be lost every minute
if a stroke patient is left untreated.
Fast treatment is essential to improve
the chances of a good outcome. However, the time it takes from the stroke
patient arriving in the emergency
department to receiving thrombolytic
drugs (door-to-needle times) remains
a major challenge in many hospitals.
An important element in this cascade
of events is the imaging software that
is connected to the CT scanner. It is
decisive to increase speed and confidence of the diagnosis and consequently for the implementation and
monitoring of effective treatment.
Generally, a non-contrast CT scan
and single phase CT Angiography will
be administered to exclude bleeding
and confirm the presence of an occlusion in order to determine eligibility
for thrombolytic drug administration.
syngo.CT Neuro Perfusion can help
to visualize the size of the core infarct
and penumbra; the latter represents
tissues that may be salvaged through
further reperfusion therapy.
Excitingly, 4D CT Angiography is
used increasingly and several novel
applications are beginning to emerge.
syngo.CT Dynamic Angio can create
News
7B
7a
Evaluation of multiple monoenergetic ROIs with syngo.CT DE Monoenergetic Plus**.
movies that visualize the flow of contrast from arterial to venous phase and
depict tMIPs. This can help the clinician better assess the collateral status
and define the occlusion length in
stroke.[3] As such, 4D CT Angiography
has potential in helping to select the
patient optimally suited for interventional clot retrieval. All indications at
the present suggest that CT imaging
will remain the cornerstone of stroke
care.
New boost for Dual Energy

CT with syngo.via VA30
True Dual Energy offers extended
diagnostic possibilities taking CT imaging beyond morphology by enabling
exploration of functional and quantitative aspects. And progress still continues.
A highlight of the syngo.via VA30
is the new Dual Energy application
syngo.CT DE Bone Marrow**. The bone
marrow can be affected by various
pathologies, such as bone bruises after
trauma as well as by diffuse tumor
infiltrations. Until today, the major
modality for imaging these pathologies has been MRI. With the benefit of
True Dual Energy, CT imaging can now
also aid in the diagnosis. syngo.CT DE
Bone Marrow** allows for the segmentation and the visualization (colorcoding) of the bone marrow based on
a material decomposition into bone
marrow and calcium. This application
can be used for both Dual Source and
Single Source Dual Energy datasets.
Furthermore the syngo.CT DE Virtual

Unenhanced* application has been
complemented in order to address a
wider clinical spectrum. While the
well-established Liver VNC algorithm
enables quantification of the iodine
uptake in the liver tissue, the new Virtual Unenhanced algorithm has been
improved for optimized visualization
of those organs that in contrast to
the liver do not contain variable
amounts of fat, such as the lung, kidney, and pancreas. The iodine uptake
may give additional indications about
the malignancy of a lesion. Moreover,
the effectiveness of a therapy can be
validated by evaluating the development of the iodine uptake in the treated
lesion before and after treatment.
Monoenergetic imaging has become
a reliable application to improve
image quality as well as for effectively
reducing metal artifacts. syngo.via
VA30 together with syngo.CT DE Monoenergetic Plus** offers a new, powerful algorithm allowing for a better
quantitative assessment of different
tissues and lesions by displaying
multiple monoenergetic ROIs and the
associated absorption curves. A further
benefit for research and diagnostic
tasks is the ability to export the statistical information to the file system for
more in-depth evaluation.
syngo.via VA30 offers a broader
range of tools to meet todays growing clinical requirements with the
support of high quality CT imaging.
Further steps will follow opening

up to users the opportunity to fully
exploit their diagnostic technology.

References
[1] Automatic detection of lytic and blastic
thoracolumbar spine metastases on
computed tomography. Hammon M.
et al; Eur Radiol. 2013 July; 23(7):
18621870.
[2] Meretoja A et al. Reducing in-hospital
delay to 20 minutes in stroke thrombolysis. Neurology. 2012, 79:306-13.
[3] Frlich AM et al. 4D CT Angiography
More Closely Defines Intracranial
Thrombus Burden Than Single-Phase CT
Angiography. AJNR Am J Neuroradiol.
Published online before print April 25,
2013.
** T
he products/features (here mentioned) are
not commercially available in all countries. Due
to regulatory reasons their future availability
cannot be guaranteed. Please contact your local
Siemens organization for further details.
** This product is 510(k) pending. Not available
for sale in the U.S.
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 right.
Not for diagnostic use.
Further Information
www.siemens.com/
ct-clinical-engines
News
Improving Accuracy and Workflow

Speed in Transcatheter Aortic Valve
Implantation
Computed tomography provides valuable information for the
planning of transcatheter aortic valve implantation, and the
syngo.CT Cardiac Function Valve Pilot application of syngo.via speeds
up workflow while increasing accuracy and safety for patients.
By Sameh Fahmy, MS
Transcatheter aortic valve implantation (TAVI, also known as transcatheter

aortic valve replacement (TAVR) in
the U.S.) has been shown to significantly prolong the lives of those severe
aortic valvular stenosis patients, who
because of comorbidities are not
candidates for surgical valve replace-
ment.[1] However, careful planning

of this advanced procedure which is
necessary for optimal patient outcome
can present a number of challenges
for physicians.
Exact measurements of the anatomy
of the heart are necessary so that
the appropriate sized prosthesis is
selected. Choosing a prosthesis that

is too small can lead to a paravalvular
leak, for example, while fitting one that
is too large could cause a catastrophic
rupture of the aortic root. In addition,
the catheters used in the procedure
are relatively large, so physicians must
be able to reliably assess calcifications,
syngo.CT Cardiac Function Valve Pilot: physicians are able to work with zero-delay for quantitative
assessment of the aortic annulus.
News
CT adds tremendously
to the TAVI procedure by
making it safer.
Professor Stephan Achenbach, MD,
Department of Cardiology, University of Erlangen-Nrnberg
stenoses, and the diameter of the

peripheral arteries, in order to select
asuitable access route and avoid
potentially fatal complications.
Despite these challenges, physicians
such as Professor U. Joseph Schoepf,
MD and Professor Stephan Achenbach,
MD are able to plan the TAVI procedure
efficiently, accurately, and with confidence. Joseph Schpf is Professor of
Radiology and Medicine and Director of
CT Research and Development at the
Medical University of South Carolina in
the United States. Stephan Achenbach
is Chairman of the Department of Cardiology at the University of ErlangenNrnberg in Germany. They both were
among the first to test the application
syngo.CT Cardiac Function Valve
Pilot.
The software provides a dedicated
workflow for CT TAVI planning; automatically measuring the dimensions
of the aortic annulus providing singleclick localization and quantification of
the smallest iliac diameter, and automatically calculating the corresponding
C-arm angulation for a given projection.
It enhances our workflow efficiency,

which is an aspect that is becoming
increasingly significant especially
in centers with extremely high volumes, Schoepf says. What is more
important for me is that it enhances
accuracy and safety for patients.
Assessing critical
structures easily
Worldwide, an estimated 40,000
patients have received TAVI.[2] The
landmark, multicenter trial PARTNER
(Placement of AoRTic TraNscathetER
Valve) demonstrated that the TAVI
procedure reduced all-cause mortality by nearly 50% in patients who
were ineligible for the open procedure.[1] Furthermore, key secondary
end points, such as patient condition,
had significantly improved by the
time of the one-year follow up. In the
group of patients who were defined
as having a high surgical risk, TAVI
was found to be non-inferior to surgical aortic valve implantation. Mortality rates after one year were 24.2%
for TAVI, compared with 26.8% for the
surgical procedure.[3]
While the clinical trials that led to the

introduction of the TAVI procedure
used echocardiography and conventional angiography for pre-procedural
planning, Achenbach stresses that CT
provides the information that improves
the safety and accuracy of the procedure. The question of whether there
are arteries of the body, especially in
the legs, available to use for an access
route can, by far, be best answered
by CT, Achenbach says. And we now
have data that clearly show that CT is
the best tool for choosing the correct
size of prosthesis.
The manual detection and measurement of the annulus the structure
demarcated by the hinges of the
aortic valve leaflets is a particularly
cumbersome and time-consuming
process, but one at which the software excels. As the case is opened, it
displays the annular plane and calculates critical measures, such as the
area, and long and short axes of the
annulus. The ostium views help to
determine the distance between the
coronary ostia and the annulus plane.
A process that could otherwise take
News
The fundamental
advantage of the software
is that it finds the aortic
annulus automatically.
Professor U. Joseph Schoepf, MD,
Department of Radiology,
Medical University of South Carolina, Charleston, U.S.
up to approximately 20 minutes now

happens almost instantaneously, and
with an unparalleled level of reproducibility.
In a study presented at the 2012
annual meeting of the Radiological
Society of North America, Schoepf
and his colleagues found that the
software was in excellent agreement
with human observers.[4] He adds
that even in cases where manual
adjustments are necessary, the use
ofthe software still saves time by
giving radiologists a good starting
point from which they can work.
These sorts of measurements are
crucial going into the procedure, but
theyre also where substantial human
error can occur with pretty dire
consequences, Schoepf says. The
beauty of having a computer algorithm to do it is that if you give it the
same task twice, it comes up with

thesame measure.
Choosing the appropriate prosthesis
is a balancing act for physicians.
Patients who develop a paravalvular
leak have a higher likelihood of death
following TAVI;[5] however, a recent
study demonstrated that using CT
substantially reduces the incidence
of paravalvular aortic regurgitation,
when compared to transesophageal
echocardiography based sizing with
rates of 7.5% and 21.9%, respectively.[6]
A similar balancing act occurs in
measuring the ostia. A measurement
that is too short will result in the
unnecessary exclusion of a patient,
while one that is too large has the
potential to result in the implantation
of a prosthesis that occludes a coronary artery.
Schoepf says that helping to determine a suitable access route for the
relatively large catheters required by
the procedure is another area where
the software excels. It offers singleclick localization and quantification of
the smallest iliac diameter, as well as
visualization and subtraction of aortic
calcifications. Furthermore, it automatically calculates the area and diameter of vessels: Even the most experienced observers derive substantial
value from features like these because
they improve quantitative accuracy
and workflow, Schoepf says.
Minimizing contrast dose to

improve safety
According to Achenbach, one feature
of syngo.via that is of particular benefit to patients is the automatic calculation of the corresponding C-arm angulation for a given CT projection. This
News
feature improves workflow, while also

increasing the accuracy of the procedure as physicians in the cath lab use
the best-possible viewing angle.
Achenbach notes that a large percentage of patients undergoing TAVI have
renal insufficiency, which makes keeping contrast dose usage to a minimum
an important consideration for patient
safety. There are several methods to
find the optimum viewing angle in the
cath lab, but they all require contrast
dose, Achenbach says. If you know
which angle to use to look at the aortic
valve, you dont have to do extra imaging in the cath lab to find this out.
Achenbach and Schoepf both use a
SOMATOM Definition Flash Dual Source
CT scanner for TAVI planning to further minimize contrast dose. Planning
the procedure requires a relatively
large scan range, from the shoulder to
the hip, but the speed with which the
scanner acquires data allows them to
keep contrast dose to a minimum. In a
study of 42 patients, Achenbach and
his colleagues were able to assess aortic
root anatomy and vascular access in
less than 2 seconds, using 40 mL of
iodinated contrast agent.[7] That we
can do everything so quickly and with
so little contrast is of great benefit to
patients undergoing the TAVI procedure, Achenbach says, and youre not
sacrificing any image quality.
Improving outcomes,
reducing costs
Patients who undergo TAVI have substantially shorter hospital stays than
those undergoing surgical valve replacement.[3] Also, patients treated medically have higher rates of rehospitalization than those undergoing TAVI.[1]
By improving patient outcomes, the
accuracy and safety offered by syngo.via
has the potential to decrease costs
further. Achenbach notes that TAVI procedures require a large clinical team;
therefore, even saving 10 to 15 minutes during the procedure by determining the optimal viewing angle in
advance can make a big difference.
As physicians experience with the procedure grows, Schoepf and Achenbach
believe that there will be fewer complications and better outcomes. Currently,
2A
2B
With the SOMATOM Definition Flash very little amounts of contrast are required
toacquire the entire anatomy relevant for TAVI planning (only 40 mL in this case)
Courtesy of University of Erlangen-Nrnberg, Erlangen, Germany
two major manufacturers produce

the prostheses, but the physicians
expect increased competition from
other manufacturers to drive down
costs further.
TAVI is currently indicated for patients
who are inoperable because of comorbid conditions, as well as those who
are considered a high surgical risk.
However, the minimally invasive nature
of the procedure makes it appealing
to younger and healthier patients:
As the results of the procedure get
better and better, theres less incentive to do conventional surgery,
even maybe in healthier patients,
Achenbach says. So the question of
who receives this procedure and who
undergoes conventional surgery will
constantly need to be recalibrated.
Sameh Fahmy, MS, is an award-winning

freelance medical and technology reporter
based in Athens, Georgia, USA.
inthe customers unique setting. Since there is no

References
[1] Leon MB, et al. Transcatheter aorticvalve implantation for aortic stenosis in
patients who cannot undergo surgery.
NEngl J Med. 2010;363:1597-607.
[2] Holmes DR, et al. 2012 ACCF/AATS/SCAI/
STS expert consensus document on
transcatheter aortic valve replacement.
JThorac Cardiovasc Surg. 2012 Sep;
144(3):e29-84.
[3] Smith CR et. al., Transcatheter versus
Surgical Aortic-Valve Replacement in
High-Risk Patients N Engl J Med 2011;
364:2187-2198).
[4] Schoepf JU et. al., Automated annulus
assessment accuracy in comparison to
standard software and manual assessment. RSNA 2012
[5] Tamburino C et. al., Incidence and
predictors of early and late mortality
after transcatheter aortic valve implantation in 663 patients with severe aortic
stenosis. Circulation, 123 (2011),
pp.299-308
[6] Jilaihawi H, et al. Cross-sectional
computed tomographic assessment
improves accuracy of aortic annular
sizing for transcatheter aortic valve
replacement and reduces the incidence
of paravalvular aortic regurgitation.
JAm Coll Cardiol. 2012;59:1275-1286
[7] Wuest W, et al. Dual source multidetector CT-angiography before Transcatheter Aortic Valve Implantation (TAVI)
using ahigh-pitch spiral acquisition
mode. EurRadiol. 2012 Jan;22(1):51-8.
Further Information
www.siemens.com/CT-TAVI
Svenja Hennigs, MD, is Head of the hospitals Department of Radiology and Nuclear Medicine at the Knappschaftskrankenhaus in Bottrop, Germany.
Fighting Aortic Aneurysms

with Modern CT Technology
A hospital that formerly served coal workers and their families
has reinvented itself as a modern center of medical care. A distinct
focus lies on the catheter-based treatment of life-threatening
aortic aneurysms, a method that requires regular CT follow-up.
The SOMATOM Definition Edge has helped the hospital
Knappschaftskrankenhaus in Bottrop in Germany to speed up
these examinations and to reduce radiation exposure considerably.
By Philipp Grtzel von Grtz, MD
News
The abdominal aorta is the main supplier of blood to the abdomen and the
lower extremities. Technically, it is a
flexible tube with an average diameter
of around two centimeters. Most people will never be aware of what is the
largest artery in the human body. It is
an organ that normally works silently
for decades. But there are exceptions:
Approximately one in thirty adults will
develop an aneurysm in the abdominal
aorta defined as an increase in
vessel diameter to more than three
centimeters.
Stent treatment as a new

standard of care
Aortic aneurysms with a diameter of
more than four to five centimeters are
considered critical from a medical point
of view. The larger the diameter, the
higher the risk of a rupture. And a rupture of this high-volume, high-pressure
artery can easily result in death: Nine
out of ten patients with this condition
will die. The perfidious thing about
these ruptures is that they happen without warning, which is why abdominal
aortic aneurysms are sometimes called
the silent killers.
Ruptures of aortic aneurysms, in other
words, need to be avoided at all costs,
and they can be. Aortic aneurysms are
a treatable condition. For decades,
open surgery was the method of choice.
Today, most aortic aneurysms are
treated by catheter-based implantation
of aortic stents a quicker and far
less invasive method of permanently
stabilizing the artery. The Knappschaftskrankenhaus in Bottrop is one of several hospitals that have specialized in
this new method. Our vascular surgeons perform more than 150 of these
procedures per year. This means that
our hospital is among the leading institutions in Germany in this field, says
Svenja Hennigs, MD, Head of the hospitals Department of Radiology and
Nuclear Medicine.
CT as a tool for planning

and follow-up
There is a good reason why Svenja
Hennigs, as a radiologist, is such an
advocate of aortic stenting: Without
modern radiology, and particularly
modern CT examinations, stent treatments of aortic aneurysms would
Without modern radiology, and particularly modern CT examinations, stent treatments

of aortic aneurysms are unthinkable even in Knappschaftskrankenhaus in Bottrop.
be unthinkable. Every single patient

needs numerous CT examinations
before and after the stent implantation. The radiologist is the indispensable partner of the vascular surgeon
who is confronted with an aneurysm
patient.
First of all, the CT is a planning tool:
We need a good reconstruction of
the aorta and the origins of the renal
and mesenteric arteries before the
intervention to choose the ideal prosthesis, explains Hennigs. This is why
we use thin slices of one millimeter
to get the necessary raw data and to
be able to provide a proper 3D model
for our surgeons.
After the stent implantation, the CT
examination becomes the single most
important tool for following up the
patients. The vascular surgeons at the
Knappschaftskrankenhaus examine
the patients on the day after the
implantation. There are further followup examinations after three, six and
twelve months. Later on, the frequency
of examinations depends on the individual situation. Most patients come
at least once a year. This means
that we have far more CT examinations of aortic aneurysm patients per
year than we have surgeries. At the
moment, the department of radiology
performs 15 such examinations per
week. And this number will probably
increase further in the years to come.
Watching out for endoleaks

The most important reason for
regular CT follow-up examinations is
the search for endoleaks. These are
defined as persistent blood flow within
the aneurysm sac. There are five different types of endoleak with different
characteristics and different degrees
of clinical relevance. As a rule, an endoleak increases the risk of an expansion of the aneurysm and, ultimately,
the risk of rupture. This is why endoleaks need to be detected and closely
monitored. In some cases, a second
intervention may be necessary.
The problem with repeated CT examinations is that they add up to fairly
high radiation dosages over the years.
Together with tumor patients, aortic
aneurysm patients are probably the
patients with the highest radiation
exposure, says Hennigs. But there is
good news for the aneurysm patients
at the Knappschaftskrankenhaus.
Thanks to the new SOMATOM
Definition Edge CT system that was
installed in Bottrop in March 2013,
the average radiation dose per examination has been reduced considerably.
Cutting-edge technology
slashes radiation dose
Hennigs recalls that the hospital had
been working with a 64-slice CT system for many years. At some time,
News
a CT. And it is particularly good for

tumor patients or certain patients with
neurological conditions who need to
be examined again and again, explains
Hennigs. Another impressive example
that she cites is patients who need
preventive CT examinations for lung
tumors. Such examinations are being
carried out on asbestos workers. But
they are also increasingly recommended
for heavy smokers. In past days, a
conventional lung CT would require a
radiation dose of 8 to 10 millisievert
(mSv). Modern low-dose CTs bring that
down to 3 to 4 mSv. With the SOMATOM
Definition Edge, we are able to do a lowdose CT of the lung at 1 to 1.5 mSv. And
believe it or not, we had one patient
who needed as little as 0.8 mSv.
The Knappschaftskrankenhaus in Bottrop is among the leading institutions in Germany
in treating aortic aneurysms by catheter-based implantation of aortic stents.
we started thinking about upgrading

to a new one. When I heard about the
SOMATOM Definition Edge in 2012,
I was immediately interested. We
learned that the new Stellar detector
and the iterative reconstruction algorithm SAFIRE can lead to a reduction
in radiation dose of up to 60 percent*
under optimal conditions. This really
thrilled us, because it was exactly
what we were looking for.
Siemens Stellar detector is the first
fully-integrated detector. It reduces
electronic noise, which helps to reduce
radiation dose and to improve spatial
resolution by generating ultra-thin
slices.
When the new CT was installed in
Bottrop, the radiologists there were
quickly convinced of the systems

benefits.
In a lean patient with an aortic aneurysm, we often need less than half
the radiation dose than we did with
the previous 64-slice system. As
expected, adipose patients are somewhat more challenging. But even in
these situations, the dose is down by
20 to 30 percent in many patients.
Together with Siemens, Hennigs is
currently evaluating the average dose
reduction that was achieved with the
SOMATOM Definition Edge in a series
of 50 aortic aneurysm patients.
Assistants allowed to think

The reduction in radiation dose is not
only good for aortic aneurysm patients:
Its good for every patient who needs
In combination with the new Stellar

detector, the iterative image reconstruction technology SAFIRE is the key
to achieving the outstanding low radiation doses. SAFIRE features a set of
pre-specified programs. It also allows
for a certain degree of manual control,
as Svenja Hennigs explains: We turn
SAFIRE on for practically every patient.
The radiological assistant then decides
individually whether he or she can risk
going down a little further or not. The
SOMATOM Definition Edge is, in fact,
the first CT system for many years that
allows the radiological assistant to
think in new directions.
Quicker examinations,
higher image quality
Having worked with the SOMATOM
Definition Edge for four months,
Hennigs and her colleagues have discovered various additional benefits
Coal in the genes

The Knappschaftskrankenhaus Bottrop opened in
1931 as a hospital for miners who worked in the
numerous coal mines of the Ruhr Basin in Germany
at that time, the powerhouse of Central Europe.
There is still a small sculpture in the entrance hall
that reminds visitors and patients of these roots:
St. Barbara, patron saint of miners. Today, the Knappschaftskrankenhaus is a modern hospital for acute
and regular care with 346 beds in nine clinical departments. More than 50,000 patients are treated per
year, a large number of which are outpatients. The
department of radiology keeps nine radiologists and
15 radiology assistants busy. Apart from the SOMATOM
Definition Edge, they have a Siemens MRI, three
angiography systems, a mammography unit, and two
workplaces plus nuclear medicine and ultrasound.
News
1A
1B
Image comparison for follow-up scan of same patient between previous 64-slice system (Fig. 1A) and new
SOMATOM Definition Edge (Fig. 1B) with SAFIRE at half the dose with comparable diagnostic image quality.
Courtesy of Knappschaftskrankenhaus Bottrop, Germany
Previous 64-slice system (Fig. 1A)
SOMATOM Definition Edge (Fig. 1B)
kV-Setting
120 kV, 95 mAs
100 kV, 92 mAs
DLP
318 mGy cm
158 mGy cm
CTDI
7.32 mGy
3.66 mGy
to the new system. First of all, speed.

We are now able to perform a thoracic
CT within 3 seconds, and an abdomen
takes around 12 seconds. Its extremely
quick. The limiting factor is not the
examination, but getting the patient in
and out again.
Hennigs is also very impressed by
the image quality that the SOMATOM
Definition Edge provides: I would put
it this way: The images are more brilliant. This becomes particularly obvious
with CT examinations of bone fractures.
When I compare high-resolution images
of fracture lines from the same patient
recorded with the previous 64-slice CT
against the new one, the overall impression is totally different. It is far better
now, much clearer and more detailed.
A quantum leap
When looking at the modern CT systems available on the market last year,
Hennigs also considered other vendors
instead of SOMATOM Definition Edge
system. But I thought that the more

compact system in combination with
high end detector technology fitted
our needs better. The fact that the
SOMATOM Definition Edge also features Dual Energy (DE) technology
made the decision even easier: Our
urologists and nephrologists, in particular, asked us to provide DE technology for visualizing urinary tract
stones and uric acid crystals. So we
decided to also acquire the DE applications that come with the SOMATOM
Definition Edge, and we are now
using it regularly. It provides excellent
DECT images.
All in all, neither the radiologists nor
radiological assistants in Bottrop miss
the previous 64-slice system: The
SOMATOM Definition Edge really is
a quantum leap forward. We are still
discovering new possibilities with it.
And once you have learned to work
with all its features, the results are
fantastic.
Philipp Grtzel von Grtz is a medical

doctor turned freelance writer and book
author based in Berlin, Germany. His focus
is on biomedicine, medical technology,
health IT, and health policy.
* In clinical practice, the use of SAFIRE may reduce

CT patient dose depending on the clinical task,
patient size, anatomical location, and clinical
practice. A consultation with a radiologist and a
physicist should be made to determine the appropriate dose to obtain diagnostic image quality
for the particular clinical task. The following test
method was used to determine a 54 to 60%
dose reduction when using the SAFIRE reconstruction software. Noise, CT numbers, homogeneity,
low contrast resolution and high contrast resolution were assessed in a Gammex 438 phantom.
Low dose data reconstructed with SAFIRE showed
the same image quality compared to full dose
data based on this test. Data on file.
News
New Applications for CARE kV

and Adaptive 4D Spiral
By Heidrun Endt, MD
Recently published scientific studies

present evidence of the additional
benefits of CARE kV and the Adaptive
4D Spiral which until now had only
been described in terms of potential.
CARE kV
Adjusting the tube voltage for every
CT scan can help deliver the right
dose to every patient; and varying kV
values for different applications can
help achieve optimal image quality.
This potential was known but the
adjustments were too complicated to
do manually, as the tube current then
needs to be adapted accordingly.
CARE kV automatically selects the
tube voltage and CARE Dose4D adapts
the tube current.
Many scientific studies have shown

the benefits of CARE kV for different
types of examination.[1,2] Yet, studies focusing on pediatric CT imaging
with CARE kV had been lacking until
researchers from Mallinckrodt Institute
of Radiology, St. Louis, US, published
their latest results. In their study
they first evaluated the potential of
CARE kV for CT Angiography examinations using three different-sized
pediatric phantoms.[3]
voltage of 100 kV. In a phantom study,

CT perfusion examinations with
SOMATOM Definition Flash either
with conventional detector technology
or the Stellar detector were compared at 80 kV and 100 kV. In view of
the minimized electronic noise, the
authors conclude: The Stellar detector
allows the routine use of 80 kV for
abdominal perfusion imaging. For
identical CNR this reduces the dose by
35% compared to 100 kV.[7]
In the second step, these findings

were used in a study with 87 pediatric
patients.[4] The tube voltage set as
reference was 120 kV. With CARE kV,
the tube voltage was lowered to
100 kV, 80 kV, or even 70 kV in 82
of these 87 patients (i.e. 94% of the
cases). Image quality was assessed
subjectively; 15 of these cases were
also compared with a previous CT scan
at 120 kV. Contrast-to-noise ratio
(CNR) was evaluated in these cases.
The authors outline the implications
for patient care: Use of automated
kilovoltage selection technology
appears to be an effective strategy
for optimizing tube voltage selection
and reducing radiation dose while
maintaining image quality in contrastenhanced pediatric CT and should
be introduced into routine clinical
practice.[4]
New cancer treatment options

including anti-angiogenic drugs that
influence blood supply to a tumor
have been introduced and are still
under intense evaluation.
Adaptive 4D Spiral
1
This examination of a baby was

included in a study.[4] The VRT shows
well enhanced mediastinal vessels and
a persistent left superior vena cava
(arrow). The effective dose for this scan
was 0.36 mSv.
Courtesy of Mallinckrodt Institute of
Radiology, Saint Louis, USA
CT Perfusion imaging with Adaptive

4D Spiral delivers qualitative and
quantitative information about perfusion patterns. In recent years, scientific studies have been published that
focus on different organs and tumor
entities.[5,6] Usually, the examinations had to be performed with a tube
Researchers from University of Lille,

France have used Adaptive 4D Spiral
technology to assess treatment outcomes in the case of non-small-cell
lung cancer (NSCLC).[8] In group 1,
17 patients received conventional
chemotherapy, 23 patients in group 2
were also given an anti-angiogenic
drug (Bevacizumab). The perfusion
information was derived before treatment begin and then at three later
points in time. Perfusion was quantified using two new parameters: total
tumor vascular volume (TVV, in mL),
which is based on blood volume; and
total tumor extravascular flow (TEF,
in mL/min), which is based on the
volume transfer constant ktrans also
known as flow extraction product. In
addition, RECIST (Response Evaluation
Criteria in Solid Tumors) data was collected to assess tumor size. Given the
changes in perfusion parameters and
in RECIST, the authors summarized
a key finding: Specific therapeutic
effects of anti-angiogenic drugs can be
detected before tumour shrinkage.[8]
News
2A
Outlook
2B
2C
2D
2E
2F
Since the introduction of CARE kV

and Adaptive 4D Spiral, several studies
have been published indicating broad
potential application. This portfolio
has now been extended. In the case
of CARE kV, initial studies have shown
the benefits when scanning young
patients. Further research is expected
on low kV imaging in pediatric CT, in
particular. For Adaptive 4D Spiral, the
perfusion evaluation of tumors was
scientifically validated for different
clinical questions.[5,6] New developments in other areas, such as with
the Stellar detector, may lead to new
options for existing technologies.[7]
The possibility of perfusion imaging
at 80 kV will be of great interest to
the scientific community. The study
from France shows that with Adaptive 4D Spiral technology a prediction
of a treatment response to anti-angiogenic drugs is possible for cases of
NSCLC. In their conclusion, the authors
indicate the potential: If these promising preliminary results can be confirmed by larger studies, perfusion CT
could represent a very useful noninvasive tool for thoracic oncologists
to manage anti-angiogenic treatments in clinical practice with the
objective of avoiding pointless therapies and their potential adverse
events as well as cost savings.[8]
The examination of this 62-year-old patient suffering from an adenocarcinoma

of the lung in the left lower lobe was included in the study.[8]
Images on the left-hand side show the situation before treatment, images
on the right-hand side were obtained after one cycle of therapy (including
anti-angiogenic drugs).
Conventional images (mediastinal window) are shown in Fig. 2A and 2B. Perfusion
information can be derived from Fig. 2C and 2D (TVV) and 2E and 2F (TEV).
The perfusion maps show a decrease in vascularity (TVV from 4.4 mL to 1.6 mL;
TEF from 4.3 mL to 2.2 mL) whereas no change in tumor size could yet be seen
in the mediastinal images.
Courtesy of University Hospital of Lille, France

References
[1] Eller A, et al. Invest Radiol. 2012
Oct;47(10):559-65.
[2] Park YJ, et al. J Cardiovasc Comput
Tomogr. 2012 May-Jun;6(3):184-90.
[3] Siegel MJ, et al. Invest Radiol. 2013
Aug;48(8):584-9.
[4] Siegel MJ, et al. Radiology. 2013
Aug;268(2):538-47.
[5] Goetti R, et al. Invest Radiol. 2012
Jan;47(1):18-24.
[6] Reiner CS, et al. Invest Radiol. 2012
Jan;47(1):33-40.
[7] Klotz E, et al. Performance evaluation
of a new CT detector with minimal
electronic noise for low dose abdominal
perfusion imaging. Insights Imaging
(2013) 4 (Suppl 1):200
[8] Tacelli N, et al. Eur Radiol. 2013
Aug;23(8):2127-36.
The initial positive assessment of the SOMATOM Perspective has continued at Sainte-Marie Medical Imaging Center in Osny, near Paris, France.
Back Among the Pioneers

One of the first ever installations of a SOMATOM Perspective CT scanner
was at Sainte-Marie Medical Imaging Center in Osny, near Paris, France in
January 2012. One and a half years later, SOMATOM Sessions returned to the
center to discover whether the initial enthusiasm and hopes were justified.
The positive assessment made at that time was entirely confirmed.
And particularly attractive in this era of austerity at an affordable price.
By Christian Rayr
News
eMode reduces material

wear, extends the machines
lifetime, and eliminates
downtime. Weve had
no breakdowns or annoying
problems to report.
Alexandre Fuchs, MD,
Sainte-Marie Medical Imaging Center, Osny, France
Alexandre Fuchs, MD is a doctor, specialising in diagnostic and co-director

of Imagerie Medicale Sainte Marie.
His initial, positive assessment of the
SOMATOM Perspective has not changed.
The center is guided by the principle of
achieving the utmost excellence and,
therefore always seeks the best diagnostic equipment for its patients. And
this means that Fuchs is in a position
to make comparisons. The SOMATOM
Perspective delivers perfect diagnostic
efficiency he notes. So far, almost
10,000 patients have benefited from
its use. Franck Lamesa, general supervisor of the Sainte-Marie Medical
Imaging Center, adds: The number of
scans conducted currently stands at
12,400. With the SOMATOM Perspective,
we have performed approximately
5,500 abdominopelvic scans, as well
as 2,300 thoracic scans, 1,200 lumbar
scans, 800 brain scans, and 800 sinus
scans.
Good results have been achieved in all
pathological areas: cancer, pediatrics,
rheumatology, cardiology, and neurology, to name just a few. Work in oncology is ongoing here, Fuchs points out,
because we collaborate closely with
the Sainte-Marie Medical Imaging
Center and its cancer treatment center
next door. For us, the work involves
standard scans. Image acquisition is
perfect, and all the preparatory and

analytical work is carried out with the
help of syngo.via. We are one of the
major users of this software, especially its applications for oncology.
Post-treatment image data are validated by the radiologist and are then
stored automatically so that treatment process can be tracked.
Significantly lower radiation

doses
Levels of radiation dose pose an acute
problem both in oncology and pediatrics. There must be no question of
radiation overdoses when examining
a childs abdomen, thorax, or head.
Extreme caution is also essential with
cancer pathology where multiple
images are required for diagnosis,
during treatment, and at the regular
check-ups that follow. Thanks to
iterative reconstruction with SAFIRE
(Sinogram Affirmed Iterative Reconstruction), significantly lower radiation doses are possible. In overall
terms, we are satisfied with SAFIRE
for pediatrics as well as oncology,
Fuchs comments. Based on experience,
the technicians and radiologists at
the Sainte-Marie Imaging Center stated
that SAFIRE enables an average dose
reduction of 30 to 40 percent, or
even 50 percent compared to scans
without SAFIRE. In most cases, reducing the power and therefore the
radiation does not affect the quality
of the image.
Surgery and treatment for overweight
persons are among the fields in which
the Sainte-Marie Medical Imaging
Center excels. This year again, the
clinic was placed among the top ten
clinics in the Ile-de-France region
according to the 2013 Ranking of
Hospitals and Clinics published by le
Figaro Magazine. We work in liaison
with the obesity treatment center
at the Sainte-Marie Medical Imaging
Center, Fuchs explains. Radiography
and echography are the first investigations requested prior to bariatric
surgery. When talking about CT-scans,
Fuchs explains, we mostly deploy
the SOMATOM Perspective to detect
pathologies or, more often, multipathologies related to overweight.
Improved temporal
resolution for heart scans
In cardiology, temporal resolution is
the most important factor. To achieve
the lowest possible value, the spiral
must rotate as fast as possible. On
the SOMATOM Perspective, especially
with the help of iTRIM software,
satisfactory results can be achieved.
News
With optimizing protocols to the right dose, a perfect balance between image quality
and radiation exposure can be achieved.
Likewise for imaging of the inner ear

and the petrous portion of the temporal bone, centralized collection and
analysis of the raw data have made
it possible to optimize the protocols.
That delivers more than satisfactory
results in terms of slice thickness and
perfect balance between image quality and radiation dose.
An efficient, economic
scanner
Overall it is evident that the SOMATOM
Perspective is the preferred choice for
radiology centers. A large number of
SOMATOM Perspective scanners have
been sold in France and a lot of them
are now in use in the Paris region. Ever
since the SOMATOM Perspective was
installed at the Sainte-Marie Imaging
Center, it has attracted visits from
numerous specialists from countries
such as Belgium, Switzerland, the USA,
Korea, Japan, and Australia. Although
economic constraints exercise evergreater pressure on budgets, reducing
the quality of care is not an acceptable option at all. Everyone is aware
of the good price position and low
operating costs for the SOMATOM
Perspective. It can be installed easily
and quickly in just one day. It is
very lightweight and so does not
Technicians praise the simple operation of the

SOMATOM Perspective.
require floor reinforcements, nor does

it take up much space. Thanks to its
air-cooling system, it does not require
water-cooling, and use of the eMode
software makes this scanner even
more reliable and durable.
eMode for a perfect scan

eMode is a software that automatically sets the scan parameters to
encourage economical use of the system, but without ever compromising
image quality or dose. This feature
reduces material wear, extends the
machines lifetime, and eliminates
downtime. Weve had no breakdowns
or annoying problems to report,
Fuchs notes.
Technicians praise the simple operation of the SOMATOM Perspective.
They use eMode on almost every scan,
with an average usage of at least
99 percent. Only cases of massive
obesity leads to non-eMode scans.
They also appreciate the machines
rapid image acquisition with eMode.
If the slightest problem arises in the
scan settings for example, should
a patient go beyond the standard
protocols a warning lamp lights up.
To adjust the scan parameters, the
technician simply has to press the
Fast Adjust button to automatically
adjust the scan parameters and to scan

on eMode again. With this machine,
a technician could easily carry out
12 scans per hour, Fuchs comments.
We perform six per hour: One patient
every ten minutes, including emergencies, which is a fairly good rate. Whats
more, we investigate some pathologies that take longer such as cancers
or vascular problems. As a matter of
fact, its no longer the machine that
sets the limit nowadays, its actually
the radiologist. We need to be able to
duplicate ourselves!
Christian Rayr is a freelance journalist based
in Paris, France. He writes for various medical
publications and covers medical topics for the
general media.
Further Information
www.siemens.com/
SOMATOM-Perspective
News
syngo.via Frontier
Gateway to an Open Research Environment
By Philip Stenner, PhD
At the RSNA 2013, Siemens introduced

syngo.via Frontier*, a novel concept in
the field of medical imaging. It opens
up access to research prototypes, provides the means for individual prototype
development, and allows participation
in a global network of fellow researchers. Engaging in state-of-the-art research
will therefore be possible for a larger
group of interested CT users.
Research in medical imaging is as
important and rewarding as it is exciting whether evaluating new scan
protocols for clinical practice, monitoring treatment success, or testing and
analyzing new advanced imaging
software. Before entering the market,
underlying algorithms within these
applications have already been thoroughly tested by Siemens together
with collaborating customers. Active
participation in an initial evaluation of
a prototype has been reserved to institutions with a collaboration agreement
with Siemens until now.
Opening access to research

syngo.via Frontier is a novel research
tool offered to literally every clinical
institution. Any interested syngo.via
user can buy and install it. Prototypes
currently under development can then
easily be downloaded from the dedi-
cated prototype store. The research

prototypes are not medical devices
and are therefore not intended for
use in clinical routine. They are not
tied to the regular product development cycle. Thus new prototypes are
available for research much sooner
than released applications.
The idea behind opening access to
research software with syngo.via
Frontier is as follows: Traditional standalone research software is often
installed on a computer away from the
everyday reading location. This is a
clear downside, because this lack of
integration into the routine reading
workflow results in tedious data and
result transfers. The new syngo.via
Frontier, however, provides a direct
connection between the clinical
syngo.via server and the dedicated
syngo.via Frontier server. The research
prototypes may thus be accessed from
any syngo.via client in the institution
and are directly integrated in the usual
syngo.via user interface. This tight
integration enables the researcher
to send and retrieve data and result
images easily for inclusion in an
ongoing on site research study, for
instance.
online community to share experiences with fellow researchers and

Siemens experts. The global exchange
of research ideas may help to transform individual research endeavors
with limited resources into effective
collaborative efforts and may even
facilitate the set-up and management
of international multicenter studies.
New developments
With the launch of syngo.via Frontier,
Siemens is opening up access to
a range of cardiovascular and Dual
Energy CT research prototypes. In the
future, new prototypes may also be
made available in other fields and
from other external partners, giving
the user the chance of a head start
on current research questions. For
customers with strong programmer
know-how, an optional package is
available that allows design and
implementation of new prototypes.
That will help to leverage personal
research endeavors.
With syngo.via Frontier, the user also

obtains access to an international
Further Information
www.siemens.com/
syngo.via-frontier
Low kV (100) Value [HU]
High kV (Sn 140) Value [HU]
IodineLine
The prototype Siemens DE Rho/Z maps helps to

differentiate tissue based on electron density and
effective atomic number.**
* This product is 510(k) pending. Not available for sale in the U.S.
BoneLine
TissueLine
The prototype Siemens DE Scatter Plots

visualizes energy dependencies for detailed
analysis of material homogeneity.**
** A
ccessible with syngo.via Frontier. Not for clinical use.
News
Continuous Commitment
to the Right Dose
By Ivo Driesser and Jan Freund
At the 99th Radiological Society of North America (RSNA)

2013 in Chicago, Siemens underlined its commitment to
delivering the right balance between image quality and
radiation dose or in short: the CARE Right philosophy.
Showcasing innovations as well as impressive clinical results
from the Right Dose Image Contest, Siemens highlighted
clearly its role as trendsetter in delivering sustainable solutions to minimize radiation exposure.
ADMIRE Next generation iterative

reconstruction
Along with the SOMATOM Force, Siemens also introduced
its latest milestone in right dose technology: Advanced
Modeled Iterative Reconstruction ADMIRE. In 2010,
Siemens introduced its raw-data based iterative reconstruction SAFIRE (Sinogram Affirmed Iterative Reconstruction). With proven dose reduction potential of up to 60%*
together with performance values that make it truly
suitable for clinical routine, SAFIRE is now used daily at
hundreds of sites often for every examination.
Building on these proven outcomes, ADMIRE now additionally leverages Siemens superior scanner technologies
such as the flying focal spot in the STRATON and VECTRON
ADMIRE now additionally leverages Siemens

superior scanner
technologies like the
flying focal spot in the
STRATON and VECTRON
tube or the fullyintegrated detector
design from the
Stellar and StellarInfinity
detectors.
tube or the fully integrated detector design from the

Stellar and StellarInfinity detectors. By implementing new
advanced models of these crucial scanner geometry components into the iterations cycles, ADMIRE can support
new levels of image quality.
Without compromising on the dose reduction capabilities,
ADMIRE now enables improved sharpness or low-contrast
detectability, minimized artifacts even applied to thicker
slices of 3 or 5 mm. This, combined with a new generation of image-processing computers, will allow ADMIRE
to transfer its potential into clinical practice. Introduced
together with the SOMATOM Force at the RSNA 2013,
ADMIRE will be made available for all systems with Stellar
detectors later in 2014.
International Right Dose Image Contest 2013

Once again, the International CT Image Contest has
attracted excellent submissions from users of SOMATOM
CT scanners from across the globe. Siemens Healthcare
announced the winners of the competition in eight clinical
categories. Over 320 cases were submitted from more
than 135 institutes and hospitals in countries from all
continents. Any users of a CT scanner from the SOMATOM
family had the chance to present their best clinical images
to an international jury of recognized experts. The winning
images were shown during the congress of the 99th RSNA
2013 in Chicago.
New award for sustainable dose

management
In addition to the existing eight clinical categories
(Cardiac, Dual Energy, Neuro, Oncology, Pediatrics, Routine,
Trauma, and Vascular) a further award was included in
this years competition for the institution with the best
dose reduction strategy.
Expert jury
Leading radiologists from around the world formed the jury:
Professor Harold Litt, MD, University of Pennsylvania,
Philadelphia (USA),
Professor Willi A. Kalender, MD, PhD, University of
Erlangen-Nuremberg Germany),
Professor Marilyn J. Siegel, MD, Mallinckrodt Institute
of Radiology, St. Louis (USA),
News
Pick of the Month June*

Submitter: Ronald Booij, Erasmus Medical Center Rotterdam,
the Netherlands
Patient History: A seven-month-old child with severe aortic
coarctation was referred for CT imaging. The patient indicated
absence of groin pulsations and hypertension in upper body
part. Examination by ultrasound suggested presence of double
aortic arch.
Diagnosis: The investigation results showed indication of
a normal relationship between the atria, ventricles, and large
vessels. A severe aortic coarctation distal of the left subclavian
artery and strong collaterals through the intercostal artery to
the aorta descendens could be depicted. There was no evidence
of double aortic arch.
Dose management: We scanned the young patient with
the CARE kV option. We use almost all of our adult and child
protocols with this option to keep our image quality preferences
constant. In this case, the system used 70 kV and 16 eff. mAs.
With the help of SAFIRE, CARE kV (the dose optimization
slider on position 11) and a strong dose modulation curve for
CARE Dose4D the optimal image quality with the lowest dose
was achieved.
Comments: Due to the high pitch technology, even this
free-breathing patient had no motion artifact. No anesthetics
were used.
Scanner: SOMATOM Definition Flash
Effective dose: 0.28 mSv
*Winners had not been decided at the time of the editorial deadline.
Associate Professor Peter Schramm, MD, University

Medicine Goettingen (Germany),
Professor Elliot K. Fishman, MD, Johns Hopkins University,
Baltimore (USA),
Professor Hyun Woo Goo, MD, University of Ulsan
(South Korea),
Professor Hatem Alkadhi, MD, University Hospital Zurich,
(Switzerland),
Aaron Sodickson, MD, PhD, Harvard Medical School,
Boston (USA),
Kheng-Thye Ho, MD, PhD, Khoo Teck Puat Hospital
(Singapore)
and Professor Uwe Joseph Schoepf, MD, Medical
University of South Carolina (USA).
Facebook community
This year, the Facebook fan page has been particularly
successful inviting everyone to interesting discussions about
the most impressive cases submitted. Over the five-month
duration of the contest from June to October 2013
a fan community of over 17,200 users liked, viewed, and
commented on the images. Image Contest fans could also
vote for their favorite picture in a public vote. The Siemens
Internet page devoted to the contest received over 84,700
hits. This level of interest suggests that the aim of the

contest was achieved to raise awareness of sustainable
dose management and the importance of balancing low
dose with diagnostic quality imaging.
More information on the Image Contest including all
clinical details and respective protocols is available at:
Further Information
www.siemens.com/care-right
www.siemens.com/image-contest
* I n clinical practice, the use of SAFIRE may reduce CT patient dose depending
on the clinical task, patient size, anatomical location, and clinical practice. A
consultation with a radiologist and a physicist should be made to determine
the appropriate dose to obtain diagnostic image quality for the particular
clinical task. The following test method was used to determine a 54 to 60%
dose reduction when using the SAFIRE reconstruction software. Noise, CT
numbers, homogeneity, low-contrast resolution and high contrast resolution
were assessed in a Gammex 438 phantom. Low dose data reconstructed
with SAFIRE showed the same image quality compared to full dose data based
on this test.
Data on file.
News
Charting New Paths with True Dual Energy

Siemens True Dual Energy provides many applications available for daily
clinical use. True Dual Energy not only enables faster and more reliable
diagnoses, but also further extends the application spectrum of CT and
turns complex examinations into easy routine.
By Susanne Hlzer and Jrgen Merz, PhD
Thanks to pioneering application

development, CT examination methods such as Dual Energy (DE) scanning have expanded into many new
clinical fields.
Single Source DE to characterize tissue or calculi

The introduction of Single Source DE
imaging for the SOMATOM Definition
Edge and SOMATOM Definition AS
made it possible to add tissue characterization to morphology. The routineready Single Source DE scan mode
is available on every SOMATOM
Definition AS even on the 20-slice
configuration and has just recently
also been introduced for the
SOMATOM Perspective family. With
Single Source DE, a range of applications has emerged such as syngo.CT
DE Calculi Characterization.* By visualizing uric acid crystals in joints, a
diagnosis of gout can be confirmed
with certainty. Monoenergetic imaging for routine-ready metal artifact
reduction can overcome many difficulties in CT imaging. More confident
diagnostic evaluation prior to surgical
procedures such as the removal
of metal plates or screws is also
possible.
Single Source DE scan:

Monoenergetic shows a metal
artifact-reduced image for
undisturbed view of the implants
and the surrounding tissue.
Courtesy of LMU Grosshadern,
Munich, Germany
Introducing new applications

For SOMATOM Definition AS+ and
SOMATOM Definition Edge scanners,
two more application classes are
being introduced: syngo.CT DE Virtual
Unenhanced* is designed to perform
a material decomposition into iodine
contrast agent, fat, and liver tissue.
It also creates a virtual non-contrast
image. Additionally, syngo.CT DE Brain
Hemorrhage* is designed to identify
bleedings and lesions by displaying the
contrast agent concentration in the
brain.
Dose-optimized DE
All of these DE applications are performed in a dose-optimized DE scan
mode. In order to avoid doubling the
dose, both scans are performed at
approximately half the dose of a conventional 120 kV scan. Furthermore,
Siemens Single Source DE scan mode
utilizes all dose reduction functionalities: e.g. CARE Dose4D for real-time
tube current modulation, or SAFIRE**
for the reduction of tube current
through iterative reconstruction.
Full flexibility for system

configuration and future
upgrades
The new Single Source DE functionality
is not only limited to new installations.
Systems already installed can also
benefit: SOMATOM Definition AS+ and
SOMATOM Definition Edge scanners
can easily be upgraded with the new
Single Source DE applications.
News
Single Source DE scan: syngo.CT DE Brain Hemorrhage* shows iodine concentration in the brain,
to rule-out intra-cranial bleeding. Courtesy of CHU Carmeau, Nmes, France
3
3
Single Source DE scan:
syngo.CT DE Virtual
Unenhanced* shows
enhanced lesion in the
liver.
Courtesy of LMU
Grosshadern,
Munich, Germany
* This product is 510(k) pending.

Not available for sale in the U.S.
** In clinical practice, the use of SAFIRE

may reduce CT patient dose depending
on the clinical task, patient size, anatomical location, and clinical practice.
A consultation with a radiologist and a
physicist should be made to determine
the appropriate dose to obtain diagnostic
image quality for the particular clinical
task.
Further Information
www.siemens.com/
dual-energy
News
Open Up New Opportunities

with New Configurations
Service providers in healthcare are facing growing economic challenges.
Atthe same time, the demand for seamless healthcare has intensified.
To address both these aspects, new SOMATOM Perspective 16- and 32-slice
configurations have been introduced to the SOMATOM Perspective family.
By Florian Hein
The majority of countries in Europe

have to deal with the consequences
of the crisis in the global economy
leading to shrinking purchasing power
and reduced national budgets. Healthcare service providers are greatly
affected by this vicious circle, as healthcare expenditure is one of the largest
costs for these countries. In the U.S.,
too, where affordable healthcare
is a major goal for the next few years,
healthcare institutions have to do
more with less, because of tremendous budget cuts. On the other hand,
clinical demands worldwide are
increasing rapidly high-end clinical
care, which a decade ago was available only in selected regions and for
some patients, has now become the
standard level of care. This is why a
well thought-out investment and the
efficient use of medical devices are
key today to success in clinical practice worldwide.
To meet these requirements, Siemens

offers the SOMATOM Perspective
the most economical CT of its class.
With a new 16- and 32-slice configuration*, the SOMATOM Perspective is
entering into a new market segment.
The two new configurations combine
first-class clinical care and an optimized total-cost-of-ownership position for healthcare institutions. The
features and technologies of the
SOMATOM Perspective family are
designed to accomplish these two
objectives, especially in the 16- and
32-slice market segments.
A broad clinical portfolio is now

available with the new SOMATOM
Perspective family from routine
scanning in oncology and
neurology to complex cardiac
imaging.
Courtesy of Radiology Department
of Israelitisches Krankenhaus,
Hamburg, Germany and
SAMS Hospital, Lisboa, Portugal
News
Economical scanner usage

eMode enhanced with the eStart and
eSleep functionalities provides a comprehensive package known as eCockpit
that not only saves electricity costs,
but also enhances scanner lifetime. The
renowned eMode was introduced two
years ago to reduce wear and tear on
the CT system. Nowadays, more than
90% of scans performed on SOMATOM
Perspectives are eMode scans. Usage
of 80% or above is already showing
a downtime reduction of more than
20%. Furthermore, customers with a
Siemens service contract may choose
one of the valuable benefits. Service
price reduction of up to 10% or application training free of charge are just
some of the advantages individually
designed by the Siemens service organizations in specific countries.
Johann Christian Steffens, MD, from
the Radiology Clinic of Israelitisches
Krankenhaus in Hamburg, Germany, was
one of the first SOMATOM Perspective
users. We use eMode as our standard
mode for 98.8% of all scans. Weve been
running the SOMATOM Perspective for
two years now and we are still using
the first tube, Steffens explains.
Highest clinical standards

with a 16-slice CT
With Single Source Dual Energy,
Siemens does not limit the highest clinical standards to the upper multislice
CT world. For the first time, this technology is available for 16- and 32-slice
CT scanners delivering significant
additional value in CT image reading.
The application syngo Dual Energy
Monoenergetic, for example, helps to
significantly reduce metal artifacts
a challenge every healthcare institution
faces with CT scans when it comes to
imaging a hip implant or a complicated
fracture (read more on page 34).
The right dose

For best patient care, the raw-data
based iterative reconstruction method
SAFIRE improves diagnoses while
reducing overall dose values by up to
60%**. With 15 reconstructed images
per second, SAFIRE is routine ready:
This has been proven by existing
SOMATOM Perspective users. Every
second thorax scan, for example, is
To address growing economic challenges and deliver seamless healthcare,

the SOMATOM Perspective family has been extended. 16- and 32-slice configurations
have been added to the SOMATOM Perspective 64 and 128.
a SAFIRE scan and some sites even

use it for every single scan. In order to
make this well-established technology accessible for literally all patients,
SAFIRE is now also available for the
16- and 32-slice segment.
A sound investment
The SOMATOM Perspective family is
not closing doors to growth. The
investment can be tailored according
to the clinical need and business
situation of healthcare institutions.
They have the possibility to start with
a SOMATOM Perspective 16-slice
configuration and upgrade to 32, 64,
and 128 slices whenever economically sensible or clinically necessary.
This is why the SOMATOM Perspective
family not only solves economic challenges; it also opens up new opportunities for healthcare institutions to
meet higher clinical demands.
** T
his product is 510(k) pending.
Not available for sale in the U.S.
** In clinical practice, the use of SAFIRE may
reduce CT patient dose depending on the
clinical task, patient size, anatomical location, and clinical practice. A consultation
with a radiologist and a physicist should
be made to determine the appropriate
dose to obtain diagnostic image quality
for the particular clinical task. The following test method was used to determine a
54 to 60% dose reduction when using the
SAFIRE reconstruction software. Noise,
CT numbers, homogeneity, low-contrast
resolution and high contrast resolution
were assessed in a Gammex 438 phantom. Low dose data reconstructed with
SAFIRE showed the same image quality
compared to full dose data based on this
test. Data on file.
Further Information
www.siemens.com/
SOMATOM-Perspective
News
Getting to Grips with Stress Myocardial

Perfusion Imaging
Cardiologist Philipp Pichler, MD, is currently investigating CT stress myocardial
perfusion imaging. He has already discovered the benefits of Dual Source
technology in the SOMATOM Definition and the advanced cardiac visualization
capabilities of the CT Cardio-Vascular Engine.
By Philip Stenner, PhD
In the heart of Vienna, Austria, Philipp

Pichler, MD, coordinates an interdisciplinary team of cardiologists and
radiologists investigating how stress
myocardial CT perfusion imaging can
help to classify the hemodynamic
relevance of coronary stenosis. The
team consists of physicians from three
different Viennese institutions: The
cardiology departments of the General
Hospital (Allgemeines Krankenhaus
Wien, AKH) and Hanusch Hospital,
and the radiology department of the

Confraternitt (Wolfgang Dock, MD
and Helmuth Mendel, MD). Himself a
cardiologist, Pichler enjoys the benefits of working with radiologists to
achieve a more immediate and complete diagnosis of cardiac and of noncardiac findings.
Pichler works at AKH and Hanusch
Hospital, the latter is where he and
his colleagues recruit patients for
their study on first-pass myocardial

stress perfusion imaging. Consenting
patients that meet the inclusion criteria (e.g. increased pre-test likelihood
of coronary artery disease) are referred
to the radiological department at
the Confraternitt. Here, a SOMATOM
Definition and the CT Cardio-Vascular
Engine on syngo.via provide all that is
required to perform a comprehensive
first-pass myocardial perfusion examination. In a first step, patients undergo
With the new 17-segment

polar maps you can quickly
and easily assess the size
of the affected area. This
is definitely a benefit not
only for inexperienced users.
Philipp Pichler, MD, Vienna General Hospital, Vienna, Austria
News
a low-dose coronary CTA (cCTA) to

assess their coronary status. In case of
unclear stenoses, a first-pass enhancement stress exam is carried out that
is later validated using single photon
emission computed tomography (SPECT)
still being the gold standard. In the
case of hemodynamically relevant stenosis, the patients are referred again
to Hanusch Clinic to undergo percutaneous coronary intervention. Unless
the patients weight indicates otherwise, Pichler runs a 100 kV scan to keep
the radiation dose low for the perfusion examination.
Minimizing motion artifacts

with DSCT
As part of their study, Pichler and colleagues also focus on interesting side
aspects relevant to CT myocardial perfusion imaging, such as the impact of
Single Source CT (SSCT) vs. Dual Source
CT (DSCT) on temporal resolution and
image quality. A research protocol
allows him to reconstruct only the data
from one tube, mimicking a SSCT scan.
For the 50 patients included so far,
Pichler has discovered that the image
quality is significantly better with DSCT.
He sees the benefit as twofold: Betablockage is not applied in the stress
perfusion scan as it may cause false
negative findings. Moreover, the application of adenosine increases the heart
rate. Both factors require the highest
native temporal resolution possible,
according to Pichler.
syngo.via facilitates
cardiovascular reading
When it comes to reading cCTA and
perfusion images, Pichler is extremely
satisfied with syngo.via and the CT
Cardio-Vascular Engine. The display
of coronary arteries in Curved Planar
Reformation (CPR) is not only performed extremely quickly, but also very
robustly. He also finds it is especially
helpful in certain situations; when
evaluating lesion lengths, for instance.
On my previous system, the CPR generation was tedious and manual which
is why I never used it. With the automation on syngo.via, the evaluation of
CPRs has now become a routine task.
The Enhancement functionality on
syngo.via allows him to visualize
ischemic areas at the push of a button.
Evaluating myocardial perfusion with syngo.CT Cardiac Function.
Together with the 17-segment polar

maps, he now enjoys a quicker and
more accurate assessment of ischemic
areas. We now use it routinely it
has become more than a simple addon. In one case, the polar map was
especially useful: A patient had suffered from an old infarct that had
caused irreversible damage. Some time
later, the patient had further complications and developed another perfusion defect. After differentiating the
results obtained from the rest/stress
scans, this new problem appeared to
be reversible and was easily distinguished as such. With the new 17-segment polar maps, you can quickly and
easily assess the size of the affected
area. This is definitely a benefit not
only for inexperienced users, says
Pichler. He also enjoys having a complete solution for myocardial perfusion imaging: From a CT scanner that
allows him to freeze cardiac motion
with high native temporal resolution,
to state-of-the-art reading: With the
current syngo.via, you now have an
advanced visualization platform that
matches the outstanding quality of
your scanners.

The private clinic Confraternitt in Vienna,

Austria.
Further Information
www.siemens.com/
ct-cardiology
For Associate Professor

Atte Meretoja, MD, (left) and
Professor Markku Kaste, MD, (right)
at Helsinki University Hospital
improving stroke care is key.
Ready for the Next

Revolution in Stroke Care?
Modern stroke care would be inconceivable without rapid brain imaging. In
Helsinki, reallocating a CT to the emergency department enables thrombolytic
therapy to be administered to stroke patients in only 20 min.[1] This pioneering approach to stroke care can be transferred to other countries.[2] New CT
technologies, such as dynamic CT Angiography, are likely to help neurologists
even further in choosing the best therapy.
By Philipp Grtzel von Grtz, MD
Business
The first CT revolution at Helsinki University Hospital took place in 2004.

At that time, we told our radiologists
to move the best CT available from the
department of radiology to the emergency department, recalls Professor
Markku Kaste, who was Head of the
Department of Neurology at Helsinki
University for several years. They
were not amused at first, but we managed to convince them in the end.
Streamlining the chain

ofrecovery
The goal was to improve stroke care
by streamlining the chain of recovery
in cases of acute stroke. In patients
with acute stroke, time is brain, says
Kaste. The quicker a patient receives
intravenous thrombolytic therapy, the
higher the likelihood that he or she
will survive without permanent disability. Since time is so critical, neurologists
have created a parameter that helps to
quantify how long it takes until a stroke
patient receives thrombolytic therapy
in a hospital. The door-to-needle time
is the time that passes from the moment
the paramedics carry the patient
through the entrance to the hospital
until the life-saving thrombolysis is
finally administered. Door-to-needle
time is of the utmost importance in
patients with ischemic stroke, says
Kaste. We have shown that saving 15
minutes in door-to-needle time means,
on average, one month more of high
quality of life for the stroke patient.
Relocating the CT a SOMATOM
Definition AS+ with CT Neuro Engine
to the emergency room was one critical measure that Helsinki University
undertook to reduce door-to-needle
time. Another very important aspect
was hospital pre-notification, says
stroke specialist Atte Meretoja, MD, a
young colleague of Kastes. Helsinkis
emergency medical service now
informs the hospital routinely whenever a stroke patient is about to be
admitted. This allows the CT room to
be prepared. And the time before
admission is also used to contact relatives, to retrieve the patients medical
history, and to pre-order certain laboratory tests.
Transferring knowledge
The re-allocation of the CT was a
crucial step, says Meretoja. It didnt
immediately lead to a reduction in
door-to-needle time, but it helped us
identify other bottlenecks that we
could eliminate once the CT was available. We learned, for example, that
it was wise to bypass the emergency
department cubicle. We transport
stroke patients directly into the CT
room, carry out a very brief neurological examination and perform the
CT examination, immediately afterwards. All in all, these refinements
of the admission processes save us
an awful lot of time. In bare figures,
Helsinki University Hospital managed
to reduce door-to-needle time within
ten years from 108 minutes to as
little as 20 min.[1] This is more than
one hour quicker than in most other
parts of the world, including the rest
of Europe and the U.S. And stroke care
improvements are absolutely costeffective at Helsinkis. In 2007, we
paid 11.3 million for 2,000 stroke
patients treated in our hospital plus
3.2 million for 6,000 admissions to
the neurological ER, stresses Kaste.
Successful stroke treatment including stroke unit care and thrombolysis
saved us 14.4 million in the costs of
chronic institutional care. This means
that the neurological ER is actually
cost neutral.
So is it possible to transfer knowledge about optimum processes in
acute stroke care to other countries?
Meretoja has proven that it is. He spent
18 months in Australia as a fellow
at University of Melbourne. There, he
tested the applicability of the Helsinki
protocol in a totally different healthcare setting including the re-allocation of a CT into the emergency
department. Within a year, the Helsinki result was duplicated. Measures
of process improvement similar to
those we implemented in Helsinki
drove door-to-needle time down from
45 to 25 minutes.[2] As such, the
Helsinki Model represents an enormous opportunity to improve stroke
care globally.
Helsinkis emergency medical service now

informs the hospital routinely whenever a
stroke patient is about to be admitted. This
reduces door-to-needle time.
Associate Professor Atte Meretoja, MD,

has proven that transferring knowledge about
optimum processes in acute stroke care to
other countries is possible.
Business
CT saves critical time

Without imaging, neither Helsinki University Hospital nor Royal Melbourne
Hospital would have ever achieved
this standard, according to Kaste:
CT Imaging for us is really the cornerstone of stroke care. It is where
everything starts. A plain CT is standard for every stroke patient who
comes in. It can exclude hemorrhages
quickly and cheaply. The MRI is used
for selected patients only, pregnant
women, for example, or patients with
basilar artery thrombosis. The latter
have an extended time window for
thrombolysis, and the neurologists
need to know about the condition of
the brain stem before starting treatment.
Younger patients are also candidates
for an MRI. They are more likely to
suffer from conditions that can be
better visualized in the MRI, such
as vasculitis, dissections, or cerebral
venous sinus thrombosis. But even
in these patients we usually begin
with a plain CT, says Meretoja. The
reality at the moment is that the MRI
leads to a considerable delay, and we
dont want that. In acute stroke care,
CT is what saves us time and saves
the patients brain.
Dynamic CT Angiography
In other words, CT is indispensable to
acute stroke care at least in hospitals
where the shortest possible door-to-
needle time is taken seriously. But

CT also needs to evolve so that it continues to fulfill the requirements of
stroke care in the future. Stroke care
is changing. In recent years, intraarterial clot retrieval devices have
become increasingly popular. They
are used to extract blood clots and
thus open blocked arteries mechanically with or without stent implantation. Meretoja: There are numerous
clinical studies at the moment that
try to figure out which stroke patients
benefit from these methods and which
dont. The global stroke community
hasnt nailed the selection criteria
for these interventions yet, but I am
pretty sure that we will get there over
the next couple of years.
There is little doubt that CT imaging
will play a role here. At the moment,
the neurologists at Helsinki University
supplement the plain CT examination
with a CT Angiography and a CT perfusion scan in patients who might
benefit from intra-arterial therapies.
Patients with clear signs of a blocked
major vessel are sometimes referred
directly to the angiography suite.
Around 50 to 100 stroke patients per
year from a total of 2,000 receive
intra-arterial therapy in Helsinki at
the moment.
New technologies such as dynamic
4D CT Angiography called syngo.CT
Dynamic Angio could help pinpoint
suitable patients more accurately.
New technologies such as

dynamic CT Angiography
could help pinpoint suitable
patients more accurately.
Associate Professor Atte Meretoja, MD,
Helsinki University Hospital, Finland
They can be used to measure the length

of a thrombus, for example, and they
give some indications about its consistency. Dynamic CT Angiography can
also visualize collaterals and thus help
the neurologist to evaluate how much
brain tissue might be rescued by opening the vessel in the region of a blocked
artery.[3] None of this is a standard of
care these days. But there are a lot of
studies going on with different imaging criteria. It will be very exciting to
look at all these results, says Meretoja.
Progress in imaging triggers

research
Imaging is also becoming a cornerstone for the second type of patient
with acute stroke, those with intracerebral hemorrhage. In these patients,
we are still in a situation similar to
ischemic stroke 15 years ago, Meretoja
explains. There is really no proven
therapy, except for stroke unit treatment and, toa certain degree, blood
pressure lowering.
But there are some exciting new developments in imaging at the moment,
and again it is CT technology that is
leading the way. What we have learned
in recent years is that hemorrhagic
stroke, like ischemic stroke, is a dynamic
phenomenon. We now know that
intracerebral hemorrhages expand in
the early hours after a hemorrhagic
stroke in at least 30 percent of patients.
With the help of modern CT technology,
In acute stroke care,

CT is what saves us time and
saves the patients brain.
Professor Markku Kaste, MD,
Helsinki U
niversity Hospital, Finland
neurologists and neuroradiologists are

able to identify this subset of patients
with ongoing bleedings.
We use CT Angiography with contrast
medium. There are many emerging
parameters: We can visualize bleedings
outside the vessel and measure the
amount and the speed of contrast
medium pouring out. We can count the
bleeding spots, determine the size of
these spots, and much more. What is
still lacking is an established treatment.
But studies are ongoing, and it was the
advances in CT imaging that really triggered this direction in stroke therapy
research.[4]
One-stop management
ofacute stroke
Given that there is so much progress
in CT imaging, and traditional medical
therapies for stroke patients are
increasingly being supplemented by
interventional therapies, will acute

stroke care in the future move in the
same direction as therapy in acute
myocardial infarction? Will there be
the neurological equivalent of a cath
lab? A room that combines CT imaging and an angiography suite that
would allow patients to be treated
right away without any further transport not only with intravenous
thrombolysis but also, if necessary,
with interventional therapies?
The jury is still out. While we still
dont know exactly how many patients
benefit from interventional therapies,
all this talk of neurological cath labs
is somewhat speculative, says
Meretoja. If it turns out that the target
group for interventional recanalization therapy is only five percent of
all patients with ischemic stroke, it
might not make sense to bring every
patient to the angio-suite right away.
If the proportion is 15 percent, it
might well make sense.
For the moment, CT imaging to triage
patients remains the method of choice
to provide for quickest possible stroke
care. Nearly a decade after Helsinki
University moved its CT to the emergency department, the fruits of this
revolution by relocation are still being
reaped. So, it might not have been
the final revolution in stroke care.
History is ongoing.
With syngo.CT Dynamic Angio collateral status

in stroke can clearly be visualized and occlusion
length e
fficiently measured. Courtesy of University
Hospital Gttingen, Germany
Philipp Grtzel von Grtz, is a medical

doctor turned freelance writer and book
author based in Berlin, Germany. His focus
is on biomedicine, medical technology,
health IT, and health policy.

References
[1] Meretoja A, Strbian D, Mustanoja S,
Tatlisumak T, Lindsberg PJ, Kaste M.
Reducing in-hospital delay to
20minutes in stroke thrombolysis.
Neurology. (2012) 79:306-13.
[2] Meretoja A, Weir L, Ugalde M, Yassi N,
Yan B, Hand P, Truesdale M, Davis SM,
Campbell BC. Helsinki model cut stroke
thrombolysis delays to 25 minutes in
Melbourne in only 4 months. Neurology.
2013 Aug 14. [Epub ahead of print]
[3] Frlich AM, Schrader D, Klotz E,
Schramm R, Wasser K, Knauth M,
Schramm P. 4D CT Angiography More
Closely Defines Intracranial Thrombus
Burden Than Single-Phase CT Angiography. AJNR Am J Neuroradiol. 2013 Apr
25. [Epub ahead of print]
[4] Meretoja A, Churilov L, Campbell BC,
AvivRI, Yassi N, Barras C, Mitchell P, Yan B,
Nandurkar H, Bladin C, Wijeratne T,
Spratt NJ, Jannes J, Sturm J, Rupasinghe
J, Zavala J, Lee A, Kleinig T, Markus R,
Delcourt C, Mahant N, Parsons MW, Levi
C, Anderson CS, Donnan GA, Davis SM.
The Spot sign and Tranexamic acid On
Preventing ICH growth - AUStralasia
Trial (STOP-AUST): Protocol of a phase II
randomized, placebo-controlled, doubleblind, multicenter trial. Int J Stroke.
2013 Aug 26. [Epub ahead of print]
Further Information
www.siemens.com/
ct-clinical-engines
One motivation for Attila Sekillioglu, MD, (left) and Rainer Ulmer, MD, (right) from ZDR in Ludwigshafen purchasing a SOMATOM Perspective
was the cutting-edge technology, offering the perfect combination of straightforward operation, low space requirements, broad technical possibilities
at a reasonable price.
All-in-one
The Center for Radiological Diagnostics (ZRD) in Ludwigshafen, Germany,
has been able to significantly expand the range of examinations it offers.
The SOMATOM Perspective 64 not only allows radiologists there to perform
cardiac imaging for the first time and to reduce examination times, it also
offers the possibility of upgrading to a 128-slice CT scanner in the future.
By Philipp Braune
With practices in Mannheim and Ludwigshafen, the

Center for Radiological Diagnostics (ZRD) provides care for
patients across the entire Rhine-Neckar region (2.3 million
inhabitants) and boasts a broad examination spectrum
in the fields of radiography, CT, MRI, and nuclear medicine.
When the practice on the west side of the Rhine started
looking for a replacement for its existing 6-slice scanner,
Siemens Healthcare developed a payment plan that allowed
it to operate a new 64-slice CT for the same monthly price.

The ZRD has been using the first SOMATOM Perspective 64
in Germany since January 2013.
Rainer Ulmer, MD, and Attila Sekillioglu, MD, from the ZRD,
together with chief radiographer Kornelia Grf, describe
their experiences of transitioning to the new computed
tomography scanner, the financial implications, as well
as the wider range of diagnostic possibilities.
Business
Why did you decide to replace your 6-slice CT with a

SOMATOM Perspective 64?
Rainer Ulmer, MD: One initial motivation was the cuttingedge technology used in the new system. And since we
were due to renew our old scanner after six years anyway,
we also wanted to expand our range of examinations in
the field of cardiology.
Attila Sekillioglu, MD: Up to now, devices for cardiac
imaging have been in a completely different price category.
But the SOMATOM Perspective really is an all-in-one system: It offers the perfect combination of straightforward
operation, low space requirements, broad technical possibilities and at a reasonable price. For us, this was the
smart way to conquer a new market.
How was the process of switching over from one
system to the other?
Ulmer: We really had a very short changeover time and
not much had to be moved around in the actual room.
Once we disconnected the old system, the new system
was in place within two weeks. If we hadnt also had to
carry out some renovations that were due, we could have
easily managed the changeover within a week.
Kornelia Grf: The patients are always very nervous when

they enter the room, but they tend to notice the lighting
even if they dont realize that its a new device. They often
comment on the blue or red light, which helps to relax
thesituation.
Ulmer: Operation is now much easier thanks to the larger
key panel, which is especially helpful when youre wearing
gloves. The LCD monitor above the gantry is also great for
reading the patient name and vital information.
What are the most important improvements that the
SOMATOM Perspective 64 has brought to your practice?
Ulmer: The speed of the system helps us in all areas. In
abdomen and thorax examinations, patients simply have
to breathe in for a few seconds. It is also crucial that we
are able to reduce radiation down to a minimum during
interventions in periradicular therapies for example so
that we can only see the bones and needles. The system
does this automatically in some cases.
And this results in a clear reduction in dose?
What were your first impressions?
Ulmer: Yes, by at least a third. This is also important to

the patients, since they dont understand many of the
other technical details they often ask about the radiation dose.
Sekillioglu: I thought it looked nice and compact. We

managed to install a new high-end system in the old
room without having to change it; the mood lighting
really improves the space. It has a completely different
atmosphere, not cold and clinical but really quite appealing. The patients and the team are very happy with it.
Grf: We hear questions about radiation all the time. The

dose value is a hot topic for patients. This is why we use
the SAFIRE algorithm to reduce the dose as far as possible,
alongside other techniques. I think a low radiation dose
makes a significant difference to the patients, and this is
something that makes a practice stand out.
The speed of the

SOMATOM Perspective
helps us in all areas.
Rainer Ulmer, MD,
Center for Radiological Diagnostics (ZRD)
in Ludwigshafen, Germany
Diagnosing using the syngo.via software enables the ZRD to benefit from numerous
automated processes and a high degree of efficiency.
Business
Sekillioglu: In the past, we had to decide in advance

whether to perform a standard examination of the thorax,
or whether to focus on the arteries or veins.
With the previous system, we had a specific examination
procedure for detecting a pulmonary embolism, which
differed from the standard examination for the thorax. We
now carry out the examination using a procedure that
can answer all of our questions even those asked retrospectively. We no longer have to make trade-offs between
examination time, image resolution, the amount of contrast medium, and the radiation dose. This is a key advantage for us.
To what extent has the examination time been
reduced by the new system?
The Center for Radiological Diagnostics (ZRD) provides care for patients
across the entire Rhine-Neckar region with its 2.3 million inhabitants.
Grf: By around fifty percent. In fact, the only limiting

factor is the setting-up time, as before. The examinations
themselves are really surprisingly quick.
What is your impression of the syngo.via software?
Could you give a concrete example to explain how

the SOMATOM Perspective has expanded your range of
examinations?
Sekillioglu: Due to the new system, we now have intensive cooperation with colleagues in cardiology who perform transcatheter aortic valve implantations. With these
TAVIs, the valve is inserted through the groin in a minimally invasive procedure. The planning of the operation
therefore requires a detailed image of the heart, on one
hand, and also a complete scan of the overall area up to the
groin so that we can determine whether the arteries in the
groin and the aorta are big enough for the valve to pass
through. Our task is then to provide high-quality images
and measurements of the heart and the branches of the
coronary arteries all the way through to the groin. With
the new system, we are optimally equipped to do this.
Were there particular cases where the advantages of
the new system became immediately clear?
Ulmer: In one case, we discovered a pulmonary embolism.
The patient would otherwise have died. He was complaining of pain in his right leg and the internist who referred
him suspected that the problem was in the patients spine.
We performed a complete examination using the new system and the monitor showed straightaway that he had a
fulminant pulmonary embolism on both sides, which had
been caused by a thrombosis in his leg. I called an ambulance immediately.
Ulmer: Since we were already familiar with the interface

from using syngo, the transition was easy. However, we
soon noticed that the software has actually become even
more user-friendly. There are more automated processes
that support our work; you can just tell that syngo.via has
really been designed for practitioners.
Would you recommend purchasing
a SOMATOM Perspective to colleagues?
Sekillioglu: Yes, absolutely. When considering a new
CT system for your practice, you have to take so many
elements into account: Do you need to carry out modifications, make structural changes, or replace the air conditioning system? Can you afford to procure a high-end
system? None of these were an issue with the SOMATOM
Perspective. The device fit into the previous space and was
installed very quickly. It is now part of the practice and I
notice how much I enjoy the examinations simply because
I can do so much more.
Ulmer: It is also an investment in the future. With the
SOMATOM Perspective, we have managed to expand into
the field of cardiology without having to make large
advance payments. The revenue from public healthcare
has decreased by over fifty percent in the past decade in
Germany, and it is difficult to anticipate what will happen
in the future. It would have been too great a risk to invest
into a high-end system specifically for cardiology. The
SOMATOM Perspective provided an economically viable
yet future-oriented option. With the 64-slice configuration,
we can deliver high-quality images for cardiology. If
demand increases, we can upgrade to the 128-slice version
for a reasonable price.
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.
Business
When Space is at a Premium

Compact High Quality Scanning
By Tomoko Fujihara, Computed Tomography, Siemens Healthcare, Tokyo, Japan
Masaaki Senoo, MD, director of Senoo Hospital in Hiroshima

understands the problems of limited space: The scanning
room at his hospital is only 12.8 square meters. When
considering purchasing a new, more powerful CT, the
SOMATOM Perspective 64-slice configuration appeared
to be the ideal option: A CT that can be installed easily
even in compact spaces while still offering efficiency,
low dose, and high image quality. Senoo Hospital was the
first in Japan to install the scanner. Masaaki Senoo, MD,
and chief radiological technologist Toshihiko Oguma
reported on their experience of installation and initial use.
CT for cardiac scanning

Senoo Hospital located in Hiroshima, Japan, is run according to the principle of patient-centered medicine with
respect for each individual. This chimes well with Siemens
concept of patient-centered device development and so
when the time came to decide on a new CT scanner, hospital director Masaaki Senoo looked immediately to the
SOMATOM range. Having heard positive feedback from
nearby hospitals and from his colleagues on Siemens devices,
the decision came down to a 16-slice or 64-slice CT scanner.
One opinion was that the 16-slice was adequate in terms
of cost performance and installation space, but the 64-slice
would be much better suited for heart CT scans.
For Masaaki Senoo, MD, director of Senoo Hospital in Hiroshima (right)

and chief radiological technologist Toshihiko Oguma (left) it was precisely
the factor of compact size versus powerful performance and efficient running costs that confirmed the decision in favor of a SOMATOM Perspective
64-slice configuration.
2.85 m
SOMATOM Perspective
SOMATOM Perspective
While options were still being considered, the Siemens
SOMATOM Perspective 64-slice configuration came onto
the market at just the right time to meet the needs of
Senoo Hospital. Director Senoo explained, Above all, the
device itself is compact and it offers a 64-slice CT scanner
with superior cost performance. It was precisely the factor
of compact size versus powerful performance and efficient
running costs that finally sealed the decision.
4.50 m
Installation in small space

In the past, maintaining a 64-slice CT scanner in a limited
space was unthinkable. Due to a new space-saving design,
the SOMATOM Perspective could be installed at Senoo
Hospital without any need for room modifications or power
source installation work. Once it was up and running in
the scanning room, staff were surprised again at the truly
compact size. It even feels smaller than the single slice CT
device we were using before, said Senoo.
Initial experience and advantages

In addition to the advantage of its small size, staff soon
noticed the quietness of the SOMATOM Perspective. Workflow has also become noticeably more efficient with a reduction in the time required for the examination. Patients, too,
Scanning Room
Operations Room
The installation diagram shows the limited space for a new CT system at
Senoo Hospital. However after the SOMATOM Perspective 64-slice configuration was installed, the staff were very surprised at its compact size.
appreciate not having to wait long for their CT examination.

Both Director Senoo, MD, and his chief radiological technologist, Oguma, agree that it was a choice well made:
If they had to decide again which high-power CT best fit
their needs, they would choose the SOMATOM Perspective
without a shadow of a doubt.
Clinical Results Cardiovascular
Case 1
Myocardial Ischemia Assessment using

Adenosine-Stress Dynamic Myocardial
CT Perfusion
By Dikraniant T., MD; Ghijselings L., MD; Vargas Lobos M., MT; Genard L., MT; Derauw O., MT; Deconinck D., MT
1
2
Internal Medicine Department-Cardiology, Europa Clinics, Brussels, Belgium

Medical Imaging Department, Europa Clinics, Brussels, Belgium
History
Diagnosis
A 66-year-old male patient, complaining of evolutive exertional dyspnea

for the past few months, presented
himself for a cardiac check-up. He
was once a heavy smoker but has not
smoked for the past 7 years. He had
moderate dyslipidemia, controlled
by statin. The classical examinations,
carried out at the consultation, were
normal with exception of the bicyclestress test, which showed objective
dyspnea at the peak exercise of 110
watts without ECG abnormalities.
Since the stress test was non-conclusive, CTA was proposed to complete
the examinations.
CTA images showed multiple calcified

plaques in all three coronary arteries,
most extensively in the proximal and
mid segments of the LAD (Figs.1
and 2). It was therefore impossible to
determine conclusively the severity
of the stenosis. After the administration of adenosine, the ECG showed
no significant abnormality at all.
Stress perfusion images (Fig. 3)
showed a significant reduction in the
myocardial blood flow in the LAD
territory, compared with the CFX or
RCA territories. The findings depicted
a significant ischemia in this region.
In the cath lab, the mid LAD stenosis
was confirmed and the patient was
1A
treated with percutaneous transluminal

coronary angioplasty and stenting of
the mid LAD with an excellent angiographic result (Fig. 4).
Comments
CTA can detect calcified plaques of
the coronary arteries; however, the
severity of the stenosis might not be
interpretable if the coronary artery is
extensively calcified. Adenosine-Stress
Dynamic Myocardial CT Perfusion permits evaluation of the hemodynamic
significance caused by the stenosis,
and assists in the decision-making process for optimal patient treatment.
1B
1
VRT (Fig.1A)
and curved
MPR (Fig.1B)
images demonstrate the
extensively
calcified LAD.
Cardiovascular Clinical Results
2A
2B
2
Curved MPR images show multiple
calcified plaques in the Cx (Fig. 2A) and
RCA (Fig. 2B).
3
Perfusion images reveal myocardial
perfusion defects (in blue) in the LAD
territory.
4
Angiographic images confirmed the mid
LAD stenosis (Fig. 4A). The patient was
treated with PTCA and stenting of the mid
LAD with an excellent angiographic result
(Fig. 4B).
Cx
RCA
Examination Protocol
3
4A
4B
Scanner
SOMATOM
Definition Flash
Scan area
Heart
Scan mode
VPCT
Scan length
70 mm
Scan direction
Cranio-caudal
Scan time
31 s
Tube voltage
100 kV
Tube current
125 eff. mAs
Dose modulation
CARE Dose4D
CTDIvol
78.2 mGy
DLP
562 mGy cm
Effective dose
7.9 mSv
Rotation time
0.28 s
Slice collimation
32 x 1.2 mm
Slice width
3 mm
Reconstruction
increment
2 mm
Reconstruction
kernel
B23f
Contrast
Volume
50 mL contrast +
40 mL saline
Flow rate
6 mL/s
Start delay
Determined by test
bolus
Case 2
Coronary CTA with Reduced Contrast

and Radiation Dose of 0.19 mSv
By Yining Wang, MD, Jian Cao, MD
Department of Radiology, Peking Union Medical College, Beijing, P.R. China
History
Comments
A 61-year-old female patient was

referred to the hospital complaining
of chest pain and shortness of breath.
A coronary CT Angiography (cCTA)
was requested to rule out coronary
artery disease.
cCTA is a valuable non-invasive imaging examination with high diagnostic

accuracy. Technological advances
allow not only dose reduction but also
improvement in the image acquisition. The SOMATOM Definition Flash
scanner has several technical advantages, including the Stellar detector
and Sinogram Affirmed Iterative
Reconstruction (SAFIRE) the first
raw data-based iterative reconstruction application. Both make it possible
to use lower tube voltage in cCTA
examinations with excellent image
quality.
Diagnosis
The CT images demonstrated a mild
stenosis, from soft plaque, in the
proximal left anterior descending
artery (LAD), and a myocardial bridge
in the middle LAD with no evidence
of stenosis. The circumflex (Cx) was
small in caliber but showed no evidence of stenosis. The right coronary
artery (RCA) appeared normal.
The use of a lower tube voltage (70 kV)

scanning protocol leads to a significant
increase in mean attenuation and mean
contrast enhancement of the coronary
arteries as well as significantly higher
image noise. The contrast enhancement
allows minimizing the amount of contrast media and the image noise can be
solved perfectly with the application of
SAFIRE technique. Dual Source CT Flash
mode with very high pitch spiral scanning, can not only shorten acquisition
time, but also reduce the radiation
exposure and the necessary amount of
contrast medium (in this case, 0.39 s,
0.19 mSv and 45 mL).
Scanner
SOMATOM Definition Flash
Scan area
Heart
Slice collimation
128 0.6 mm
Scan length
115 mm
Slice width
0.75 mm
Scan direction
Cranio-caudal
Temporal resolution
75 ms
Scan time
0.39 s
Reconstruction increment
0.5 mm
Tube voltage
70 kV
Reconstruction kernel
I26f
5769 bpm
Tube current
270 eff.mAs
Patient heart rate
CTDIvol
0.78 mGy
Contrast
DLP
13.7 mGy cm
Volume
45 mL
Effective dose
0.19 mSv
Flow rate
3.5 mL/s
Rotation time
0.28 s
Start delay
Test Bolus Peak Trigger + 21 s
Pitch
3.4
1A
1B
1C
Curved MPR (Fig. 1A), MIP (Fig. 1B), and VRT (Fig. 1C) images demonstrate the LAD with mild stenosis (arrows) from soft
plaque, and a myocardial bridge (arrowheads) in the middle LAD with no evidence of stenosis. The Cx (dashed arrow) and the
RCA (double arrows) appear to be normal, although the Cx is small in caliber.
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.
Case 3
Bicuspid Aortic Valve with Anomalous

Coronary Artery Fistula A Rare Incidental
Coincidence
By Kamal K. Sen MD, Professor & Head, Sudhakar P. DMRD, Senior Resident, Kannan G. MBBS, Junior Resident
Department of Radiology & Imaging, PSG Institute of Medical Sciences & Research, Coimbatore 64004, Tamil Nadu, India
History
A 43-year-old male patient, clinically
diagnosed with aortic stenosis, was
referred for pre-operative evaluation.
He complained of restlessness, chest
pain, breathlessness, and heart palpitations.
Diagnosis
The CT images revealed calcified
bicuspid aortic valves with severe
aortic stenosis and left ventricular
hypertrophy (Figs. 1 and 2) associated
with ischemic changes in the myocardium. There was additional evidence
that the right conus artery arose from
the right aortic sinus and communicated with the main pulmonary artery
anteriorly (Fig. 3). These findings
suggested an anomalous coronary
artery fistula. The remainder of the
coronary arterial system and cardiac
anatomy was normal. The patient successfully underwent an aortic valve
replacement with a mechanical prosthesis and suturing of the coronary
artery fistula.
Comments
Coronary-pulmonary artery fistulas
are uncommon cardiac anomalies,
usually congenital, with an estimated
incidence of 0.002% in the general
population.[1] Most coronary-pulmonary artery fistulas are clinically and
hemodynamically insignificant and

are usually found incidentally.[2, 3]
Congenital abnormalities of the coronary arteries are an uncommon but
important cause of chest pain. Rare
hemodynamic abnormalities may lead
to sudden cardiac death. An Electrocardiographic-(ECG) gated multi
detector CT is superior to conventional
angiography in delineating the ostial
origin and the path of an anomalous
coronary artery. Familiarity with the
CT appearances of various coronary
artery anomalies and an understanding of the clinical significance of these
anomalies are essential for a correct
diagnosis and planning patient treatment. Bicuspid aortic valves are the
most common cardiac valvular anomaly, occurring in 12% of the general
population. This is twice as common
in males as in females.[4]

References
[1] Burch GH, Sahn DJ. Congenital coronary
artery anomalies: the pediatric perspective. Coron Artery Dis 2001;12:60516.
[2] A. Tomasian,M. Lell, J Currier,J Rahman,
M.S.Krishnam, Coronary artery to
pulmonary artery fistulae with multiple
aneurysms... The British Journal of
Radiology, 81(2008), e218e220.
[3] A.R Zeina, J Blinder, U Rosenschein E
Barmeir. Coronary-pulmonary artery
fistula diagnosed by multidetector
computed tomography: Postgrad Med J.
2006 July; 82(969): e15.
[4] Tzemos N, Therrien J, Yip J et al.
(September 2008). Outcomes in adults
with bicuspid aortic valves. JAMA 300
(11): 1317132
Scanner
SOMATOM
Definition Edge
Scan mode
ECG-gated spiral scan
Scan area
Heart
Scan length
172.5 mm
Scan direction
Cranio-caudal
Scan time
7.5 s
Tube voltage
100 kV
Tube current
79 eff. mAs
Rotation time
0.28 s
Pitch
0.17
Slice collimation
128 x 0.6 mm
Slice width
0.6 mm
Reconstruction
increment
0.3 mm
Temporal
Resolution
75 ms
Reconstruction
kernel
I26f, SAFIRE
CTDIvol
14.69 mGy
DLP
286 mGy cm
Effective Dose
4 mSv
Contrast
Volume
70 mL
Flow Rate
5.5 mL/s
Start delay
6s
3a
A non-enhanced CT axial image shows calcification

in the bicuspid aortic valve.
3b
3c
Post-contrast cCTA image demonstrates the aortic stenosis,

the left ventricular hypertrophy and a section of the conus
artery fistula course (arrow).
VRT images reveal the origin (dashed arrows) and the

course (arrows) of the coronary artery fistula.
Clinical Results Neurology
Case 4
Dynamic Volume Perfusion CT in a Case

of Childhood Moyamoya Disease before and
after Surgical Revascularization
By Zhenlin Li, Chief Technologist, Prof. Bin Song, MD, Jin Zhao, Technologist, Kai Zhang, Technologist,
Bing Wu, MD, Xi Zhao*, MD
Department of Radiology, Huaxi University hospital, Chengdu, Sichuan, P.R. China
*Siemens Healthcare China
History
An 11-year-old boy was admitted to
the hospital complaining of progressive weakness of the right arm for the
past 6 days and unclear enunciation,
accompanied by nausea and vomiting
for the past 2 days. An MR examination raised questions as to a cerebral
infarction of the left parietal and
frontal lobe, which was confirmed by
a CT 11 days later (Fig.1). DSA images
(Fig.2) indicated the possibility of
the Moyamoya disease. CTA and Volume Perfusion CT (VPCT) examinations were ordered for pre-operative
planning.
shown in Table 1. Time to Drain (TTD)

and Time to Start (TTS) were also significantly increased (Fig. 5A).
Diagnosis
The patient recovered completely

from his speech impediment. His right
arm, however, remained weaker than
the left, but muscle strength improved
from III (at admission) to V (at discharge).
Prior to the operation, CTA images

(Fig. 3) showed that the ACA A1 segment was occluded on the left, and
had severe stenoses on the right.
The MCA M1 segments were highly
stenosed on both sides. The bilateral
vertebral arteries, the posterior cerebral arteries (PCA), and the basilar
artery were unusually enlarged. The
left posterior communicating artery
(PCOM) was noticeably dilated in comparison with the one on the right.
VPCT images showed an exhausted
reserve capacity in the left MCA
territory indicated by the increase of
cerebral blood volume (CBV), the
reduction of cerebral blood flow (CBF)
and the strong increase of mean transit time (MTT) (above the frequently
used penumbra threshold of 145%
for relative MTT used in stroke) as
A direct bypass procedure by anastomosis of the left superficial temporal

artery (STA) to the middle cerebral
artery (MCA) was performed (Fig. 4).
After successful surgery, VPCT images
showed a partially restored reserve
capacity in the left MCA territory indicated by normalized CBF and diminished increase of CBV and MTT as
shown in Table 2. The increase of TTD
and TTS also diminished in magnitude
and spatial extent (Fig. 5B).
Comments
Moyamoya disease is characterized
by a progressive steno-occlusive
vasculopathy of the terminal portion
of the internal carotid artery and its
main branches. It is associated with
the development of dilated, fragile
collateral vessels at the base of the
brain, which are termed Moyamoya
vessels. These collateral vessels have
the appearance of a puff of smoke.
Most patients suffer from recurrent
ischemic attacks. Dynamic VPCT can
be used to evaluate the details of
cerebral hemodynamic changes in
Scanner
SOMATOM
Definition Flash
Scan area
Head
Scan length
100 mm
Scan direction
Adaptive 4D Spiral
Scan time
36 s
Tube voltage
70 kV
mAs per image
100
Dose modulation
n. a.
CTDIvol
56.42 mGy
DLP
665 mGy cm
Effective dose
1.4 mSv
Rotation time
0.28 s
Pitch
0.55
Slice collimation
32 x 1.2 mm
Slice width
3 mm
Reconstruction
increment
2 mm
Reconstruction
kernel
H20f
Contrast
Volume
32 mL + saline
Flow rate
4.0 mL/s
Start delay
5s
patients with Moyamoya disease

before and after surgery. Cerebral CTA
is useful for assessing the abnormalities of the intracranial arteries and the
patency of bypass grafts.
Neurology Clinical Results
Left
Right
Diff.
CBF
47.7
51.7
-8%
CBV
3.39
2.70
+26%
MTT
5.19
3.38
+54%
Table 1: Pre-operative Exhausted

reserve capacity indicated by increase
of the CBV, the reduction of CBF
and the strong increase of MTT
(54% increase is above the frequently
used penumbra threshold of 145%
for relative MTT used in stroke).
11
Left
Right
Diff.
CBF
54.5
53.4
+2%
CBV
3.32
2.80
+16%
MTT
4.19
3.25
+29%
Table 2: Post-operative
Partially restored reserve
capacity indicated by
normalized CBF and
diminished increase of
CBV and MTT.
3a
3b
MR images acquired at admission

showed infarction of the left
parietal and frontal lobe. CT images
acquired 11 days later confirmed
the infarction although with very
subtle signs (arrows).
Pre
5a
The post-operative overlaid CTA

images showed the course of the
STA (arrow) MCA bypass (arrowheads).
Pre-operative DSA images demonstrated that the ACA A1 segment

was stenosed on the right
(R, arrow), and occluded on the
left (L, arrow). The MCA M1
segments were highly stenosed
on both sides (arrowheads). The
dilated PCOM and the collateral
vessels from PCA to ACA were also
seen on the left (L, dashed arrow).
Post
5B
Pre-operative CTA images demonstrated the vascular changes of

ACA A1 and MCA M1 as described
in Fig. 2. In addition, it also
showed that the bilateral vertebral
arteries (arrows), PCA (arrowheads), basilar artery (curved
arrow) and the left PCOM (dashed
arrow) were unusually dilated.
Pre
Post
3D TTD (Fig. 5A) and TTS (Fig. 5B) maps showed the full extent of the
hemodynamic disturbance before surgery and the significant postoperative
improvement.
Clinical Results Neurology
Case 5
Differentiating an Intracranial
Hemorrhage from Iodine in Acute Stroke
after Intra-arterial Recanalization
By Alida A Postma, MD, Paul AM Hofman, MD, Joachim E Wildberger, MD
Dept. of Radiology, Maastricht University Medical Center, Maastricht, the Netherlands
History
A 57-year-old male patient was presented to an external hospital with
a left-sided grade 1 paralysis. This
resulted from a large infarction in the
right middle cerebral artery (MCA)
territory. Treatment with intravenous
rtPA was started but then suspended
due to the suspicion of a small hemorrhage in the non-contrast CT. The
patient was referred to a tertiary center
for intra-arterial recanalization (IAR).
Diagnosis
The non-contrast CT images demonstrated a small focus of subarachnoid
hemorrhage in a right parietal sulcus
(Fig. 1A). A faint loss of gray-white
matter differentiation and effacing
of the sulci in the MCA territory was
seen (Fig. 1B). CTA images showed
an occlusion of the right proximal
MCA (Fig. 2A). Perfusion CT (Fig. 3)

revealed a mismatch of reduced cerebral blood flow (CBF) and cerebral
blood volume (CBV) which indicated
the existence of a penumbra. Time to
drain (TTD), mean transit time (MTT)
and time to peak (TTP) were increased
indicating a delayed blood supply.
Following a successful intra-arterial
thrombectomy, a large mixed hyperdense area in the cortical and subcortical zones in the MCA territory, at the
level of the basal ganglia, was shown
in the mixed images (comparable to
conventional CT images) of a Dual
Energy (DE) CT scan (Fig. 4). This posed
a critical question is it a hemorrhage
as a reperfusion complication in a
patient with pre-IAR intracranial hemorrhage? Or is it an iodine extravasation in the brain parenchyma due to
1A
2A
1B
2B
Non-contrast CT axial images

demonstrated a small focus of
subarachnoid hemorrhage in a right
parietal sulcus (Fig. 1A, arrows), and
a faint loss of gray-white matter differentiation with effacing of the sulci in the
right (MCA) territory (Fig. 1B).
1
the breakdown in the blood brain barrier in a patient who had received contrast during IAR? DE scan was helpful
for differential diagnosis. The hyperdensity in the right MCA territory at
the level of basal ganglia was shown in
the iodine overlay maps (IOM) and the
iodine images, but was not seen in
the virtual non-contrast (VNC) images
(Fig. 4). Therefore, a contrast extravasation was confirmed and a hemorrhage was excluded. Consistent with
the pre-IAR scan, the small focus of
hyperdensity in the subarachnoid
space of a right parietal sulcus (Fig. 5)
appeared again in the mixed and VNC
images with only a minor density
increase, but was not seen in the IOM
and the iodine images, suggesting a
remaining hemorrhage.
Follow-up CTs, at day 1 and day 5,
showed no signs of hemorrhage in the
MCA territory (Fig. 6), which confirmed
the interpretation of contrast extravasation due to the breakdown of the
blood brain barrier. At discharge, the
patient had partially recovered but
there remained a grade 4 paresis of
the right arm and leg as well as a discrete facial asymmetry.
Comments
VRT images show an occluded right

proximal MCA (Fig. 2A, arrow),
and a successful recanalization
(Fig. 2B).
In patients undergoing IAR, hemorrhages are feared complications and

therefore a post-procedural CT is standard practice. However, iodine had
been administered in this patient group
during the intervention. Therefore, the
differentiation of intracranial hemorrhage from a contrast extravasation is
difficult with conventional CT within
the first 24 hours after IAR due to the
similarity of the Hounsfield densities of
hemorrhages and iodine.
Neurology Clinical Results
On the other hand, iodine and hemorrhages have a different attenuation

at lower kV levels. This is used in
3-material decomposition after scanning at two different energy levels
(80 kV/Sn 140 kV). Using the Brain
hemorrhage application, the differentiation between iodine and hemor3
CBF
CBV
MIP
TTD
MTT
TTP
Volume-perfused CT images show a mismatch between the

reduced CBF and CBV representing an existing penumbra (MIP,
in yellow) in the right MCA territory. TTD, MTT and TTP are
elevated, demonstrating a delayed blood supply.
Mixed
VNC
rhages becomes possible. In this

patient, hyperdense areas were present after recanalization and a large
hemorrhage was feared. However,
IOM convincingly showed the density
to be iodine, while VNC showed
no signs of hemorrhage in this area.
Therefore, an antiplatelet therapy
IOM
lodine
DECT images show the hyperdensity in the

subarachnoid space (arrows) in the mixed
and the VNC images, but not in the IOM
and the iodine image, suggestive of hemorrhage, consistent with the pre-IAR scan.
could be continued. DECT is helpful

in determining the nature of a hyperdense area, by discriminating between
hemorrhages or iodine. This aids in
the clinical decision-making and
allows for early adjustment of the
patients therapy treatment.
Mixed
IOM
VNC
lodine
DECT images show the hyperdensity in the right

MCA territory at the level of basal ganglia in the
mixed, IOM, and iodine images, but not in the VNC
image, suggestive of contrast enhancement due
to breakdown of the blood brain barrier.
6A
6B
6 Follow-up noncontrast CT, at day 1,

shows an infarction in
the right MCA territory
(Fig. 6B), despite successful recanalization. No
hemorrhage was present.
Scanner
SOMATOM
Definition Flash
Scan area
Head
Scan mode
Dual Energy (post IAR)
Scan length
155 mm
Scan direction
Cranio-caudal
Scan time
9s
Tube voltage
80 kV / Sn 140 kV
Tube current
392 / 196 mAs
Dose modulation
CARE Dose4D
CTDIvol
36.43 mGy
DLP
615 mGy cm
Effctive dose
1.29 mSv
Rotation time
0.5 s
Slice collimation
128 x 0.6 mm
Slice width
1 mm
Reconstruction
increment
1 mm
Reconstruction
kernel
D26f
Clinical Results Acute Care
Case 6
Diagnosis of Splenic Rupture in an

11-year-old Girl using a Sliding Gantry CT
By Claudia Frellesen, MD, J. Matthias Kerl, MD, Thomas J. Vogl, MD, Ralf W. Bauer, MD
Department of Diagnostic and Interventional Radiology, Goethe University, Frankfurt, Germany
History
Diagnosis
Comments
An 11-year-old girl had fallen off a

horse and had been hit by the horses
hoof. The paramedics found her
complaining of abdominal pain and
with a tense abdominal wall. She was
transferred to the hospitals trauma
room. Here an interdisciplinary team
of pediatricians, anesthesiologists,
trauma and abdominal surgeons as
well as radiologists examined the
young patient according to standardized algorithms, based on the ATLS
(advanced trauma life support) guidelines. An early abdominal ultrasound
revealed free abdominal fluid especially in the Kollers and Morrisons
pouch. This led to the decision to conduct a thoraco-abdominal contrastenhanced trauma CT.
The examination was performed on

a SOMATOM Definition AS 64 sliding
gantry system, equipped with
CARE kV. The images were acquired
at 100 kV, as suggested by the scanner, resulting in a total DLP of only
329 mGy cm (4.6 mSv). Image quality
was excellent in all anatomical areas,
with a high level of enhancement in
all parenchymal organs and vessels.
Hereby, the diagnosis of a splenic
rupture with free abdominal fluid was
reliably made. Injuries of other parenchymal organs, vessels, the lungs and
the spine were as well confidently
excluded. The patient was immediately transferred to the operating
room.
Blunt abdominal trauma can lead to

life-threatening injuries. Integrating
whole body CT early in the management of polytrauma patients results in
improved survival and facilitates early
triage for adequate therapy.[1] In the
previous trauma room solution, with a
stationary conventional 16-slice scanner, the patient needed to be relocated
from the trauma room to the CT suite
and back. This caused delay in diagnosis and treatment and bore the risk of
dislocating tubes and lines and aggravating spine injuries. The current two
room sliding gantry solution elegantly
overcomes these drawbacks. The
trauma patient remains stationary on
the examination table and the gantry
slides over if required. Another benefit
of this solution is that the down time
of the standard CT suite and subsequent
delays for regularly scheduled in- and
outpatients can be reduced to a minimum and daily throughput increases.
Together with the state-of-the-art dose
reduction strategies, such as CARE kV
and SAFIRE, image quality improves
while dose exposure is effectively
reduced. The precision of the system
is equivalent to a conventional CT with
stationary gantry and moving table,
facilitating submillimeter high-resolution imaging e.g. of the temporal bone
as well as the coronary arteries with a
temporal resolution of 150 ms.
View of our trauma room with a sliding gantry solution. In the back, the sliding gantry is in its
normal position in the standard CT examination room. The CT suite and the trauma room are
separated by a sliding X-ray-proof (background) door. If CT is required for a trauma patient, the
door opens and the gantry slides over. The patient is scanned without the need for any further
relocation.

References
[1] Huber-Wagner S, Lefering R, Qvick L-M,
et al. Effect of whole-body CT during
trauma resuscitation on survival:
a retrospective, multicentre study.
Lancet. 2009;373:145561
Acute Care Clinical Results
3
1
Excellent image
quality in the upper
abdomen with
very good iodine
enhancement at
100 kV and no
artifacts compromising the
diagnosis of splenic
rupture. Pancreas,
kidneys, and liver
appear normal.
2
2
Coronal 3 mm MPR
shows the ruptured
spleen and lots
of free abdominal
fluid while liver
and kidneys appear
normal. There is
no detectable difference in image
quality to a
stationary gantry
with moving table.
3
Excellent image
quality to confirm
no spine injury.
Scanner
SOMATOM Definition AS 64 Sliding Gantry System
Scan area
Chest/Abdomen
Rotation time
0.5 s
Scan length
63 cm
Pitch
1.2
Scan direction
Cranio-caudal
Slice collimation
64 x 0.6 mm
Scan time
12 s
Slice width
1.0 / 5.0 mm
Tube voltage
100 kV
0.5 / 5.0 mm
Tube current
261 mAs
B30f, B60f, B75f
Dose modulation
CARE Dose4D
Contrast
CTDIvol
5.75 mGy
Volume
75 mL
DLP
329 mGy cm
Flow rate
2 mL/s
Effective dose
4.6 mSv
Start delay
70 s
Clinical Results Pulmonology
Case 7
Automated Quantification of Pulmonary

Perfused Blood Volume in Acute Pulmonary
Embolism using Dual Energy CTPA
By Felix G. Meinel, MD, Anita Graef, MD and Thorsten R. C. Johnson, MD
Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Germany
History
A 75-year-old male patient presented
to the emergency department complaining of a sudden onset of severe
dyspnea and chest pain. The patient
had a history of prostate cancer.
A physical examination revealed
that the patient was normotensive
(118/60 mmHg), tachycardic (93 bpm)
and his oxygen saturation was 94%
at room air. Troponin I serum levels
(0.46 ng/mL) as well as D-dimers
plasma levels (21.5 mg/L) were elevated. The patient was referred to
the radiology department for a Dual
Energy CT pulmonary angiography
(CTPA) to rule out pulmonary
embolism.
Diagnosis
The CTPA demonstrated filling defects
in both the left and right main pulmonary arteries as well as bilaterally
in the lobar, segmental and sub-segmental pulmonary arteries (Fig. 1).
This confirmed the diagnosis of
severe acute pulmonary embolism.
Multiple wedge-shaped parenchymal
perfusion defects were visualized in
both lungs on the iodine distribution
maps derived from the Dual Energy
CTPA (Fig. 2). The global pulmonary

perfused blood volume (PBV) was
27%. For comparison, figure 3 demonstrates homogenous pulmonary
perfusion and normal PBV in a patient
without pulmonary embolism.
Comments
The Lung PBV application of the
syngo.CT DE Lung Analysis software
allows for an automated quantification of pulmonary perfused blood
volume as a surrogate for pulmonary
perfusion. PBV values are calculated
by relating the pulmonary parenchymal iodine content to the enhancement of a reference input vessel. In
addition to a global analysis, PBV values are also generated for each lung
as well as for the upper, middle and
lower zones of each lung separately,
thereby demonstrating the regional
distribution of pulmonary perfusion
abnormalities. Age-specific norm values for pulmonary PBV have recently
been published.[1] PBV quantification
can be used to assess the severity of
an acute pulmonary embolism [24]
and the regional distribution of pulmonary perfusion abnormalities in
emphysema.[5]

References
[1] Meinel FG, Graef A, Sommer WH,
Thierfelder KM, Reiser MF, Johnson TR.
Influence of vascular enhancement, age
and gender on pulmonary perfused blood
volume quantified by dual-energy-CTPA.
Eur J Radiol. May 24 2013.
[2] Nagayama H, Sueyoshi E, Hayashida T,
Ashizawa K, Sakamoto I, Uetani M. Quantification of lung perfusion blood volume
(lung PBV) by dual-energy CT in pulmonary
embolism before and after treatment:
preliminary results. Clin Imaging.
May-Jun 2013;37(3):493-497.
[3] Meinel FG, Graef A, Bamberg F, et al.
Effectiveness of Automated Quantification
of Pulmonary Perfused Blood Volume
Using Dual-Energy CTPA for the Severity
Assessment of Acute Pulmonary Embolism.
Invest Radiol. Mar 20 2013.
[4] Sueyoshi E, Tsutsui S, Hayashida T,
Ashizawa K, Sakamoto I, Uetani M. Quantification of lung perfusion blood volume
(lung PBV) by dual-energy CT in patients
with and without pulmonary embolism:
preliminary results. Eur J Radiol. Dec
2011; 80(3):e505-509.
[5] Meinel FG, Graef A, Thieme SF, et al.
Assessing pulmonary perfusion in
emphysema: automated quantification of
perfused blood volume in dual-energy CTPA.
Invest Radiol. Feb 2013;48(2):79-85.
Pulmonology Clinical Results
1A
1B
1
The CTPA images demonstrate filling
defects in both the left and right main
pulmonary arteries as well as bilaterally in
the lobar, segmental and sub-segmental
pulmonary arteries.
2A
2B
2
Multiple wedge-shaped parenchymal
perfusion defects are visualized in both
lungs on the iodine distribution maps
derived from the Dual Energy CTPA.
The global pulmonary perfused blood
volume (PBV) is 27%.
3a
3b
3
Normal PBV in a patient without
pulmonary embolism demonstrates
homogenous pulmonary perfusion.
The global pulmonary perfused blood
volume (PBV) is 101%.
Scanner
Scan area
Thorax / Chest
Rotation time
0.28 s
Scan length
313 mm
Pitch
0.55
Scan direction
Caudo-cranial
Slice collimation
64 x 0.6 mm
Scan time
8.5 s
Slice width
1.5 mm
Tube voltage
100 kV / Sn 140 kV
1 mm
Tube current
145 eff. mAs / 120 eff. mAs
Q30f
Dose modulation
CARE Dose4D
Contrast
370 mg/mL
CTDIvol
11.9 mGy
Volume
70 mL contrast + 100 mL saline
DLP
391 mGy cm
Flow rate
4 mL/s
Effective dose
5.47 mSv
Start delay
Bolus triggering in the pulmonary trunk with a threshold of

100 HU and an additional delay
of 7s
Clinical Results Urology
Case 8
Diagnosing Small Renal Calculi using

Low Dose Dual Energy CT at 0.8 mSv
By Hilton Muniz Leao Filho, MD, Caroline Bastida de Paula, BM, Vinicius Zim Henrique, PM
Department of Radiology of Hospital do Corao, Brazil
History
A 27-year-old female patient presented herself to the hospital with
acute flank pain. She complained of
recurrent back pain for the past two
years and was recently treated with
antibiotics for a urinary infection
which improved without complica-
Diagnosis
tions. Her family history was unremarkable. An ultrasound examination
was primarily performed for the kidneys and bladder. There were no signs
of either hydronephrosis or calculi
in the urinary system. A Dual Energy
(DE) CT was then ordered for further
clarification.
The entire abdominal region was

scanned and two small renal calculi,
measuring up to 3 mm, were depicted
on the left side. The calculi were
characterized as non-uric acid exhibiting densities of up to 515 HU. Neither
hydronephrosis nor ureteral calculi
were shown. The evaluation of the
rest of the region was unremarkable.
Comments
Scanner
Scan area
Abdomen / Pelvis
Scan length
422 mm
Scan direction
Cranio-caudal
Scan time
5s
Tube voltage
80 kV / Sn 140 kV
Tube current
35 / 14 eff. mAs
Dose modulation
CARE Dose4D
CTDIvol
1.21 mGy
DLP
54 mGy cm
Effective dose
0.81 mSv
Rotation time
0.28 s
Pitch
0.6
Slice collimation
128 0.6 mm
Slice width
1 mm
0.7 mm
D30f
Excellent detection and characterization of urinary calculi are achievable

using a very low dose protocol. The
homogeneous blue color in the bones
indicates that the algorithm works
very well even using such a low dose.
However, it should also be noted that
the patients body weight and habitus
are important factors to consider when
choosing the right dose. This patient
was young and had a BMI of 19 kg/m2.
Such small calculi could be wrongly
colored or even remain undetectable if
a similar low dose were applied to a
heavier patient, mainly due to increased
image noise.
Urology Clinical Results
1A
1B
2A
Oblique MPR images show two tiny renal calculi on the left. One is about 3 mm in diameter (arrows),
and the other one is even smaller (dashed arrows).
2B
DE images reveal two renal calculi on the left. The bigger one (arrows) exhibits densities of up to 515 HU,
and both were classified as non-uric acid.
Clinical Results Urology
Case 9
Differentiating Stent from Stone:

A New Approach using Dual Energy CT
By Boris Waldman BSc, LLB, Eddy Rizk BRadSci, Joseph Sanki MBBS
Superscan Radiology, New South Wales, Australia
History
A 36-year-old male patient, with two
indwelling ureteric stents (Double
J stents) placed in both ureters, was
admitted to the hospital. Prior to the
removal of the stents, a CT examination was ordered to evaluate if the
prior stones had been all cleared and
if any new stones had formed.
Diagnosis
A few kidney stones in each kidney
were detected. Two of the stones
were clinically significant. Both were
calcium-based stones measuring
5 mm in diameter. One of these
stones was in the lower pole of the
left kidney and the other in the upper
pole of the right kidney, located
within the curve of the ureteric stent
(Fig.1). On conventional CT images,
the renal calculus is isodense with the
ureteric stent and nearly impossible
to differentiate if they are touching.
The Dual Energy scan allowed to this
stone to be resolved from the adjacent ureteric stent (Figs. 24).
contain no molecules with a greater

atomic number than oxygen. This
explains why, like uric acid, stents are
distinguishable from non-uric acid
stones.[2, 3] If a different type of stent
is used, the differentiation from urinary calculi will depend on whether
its molecular composition is significantly different to that of common
calculi.

References
[1] Moe OW. Kidney stones: pathophysiology
and medical management.
Lancet;367:333-44.
[2] Manglaviti G, Tresoldi S, Guerrer CS, et al.
In vivo evaluation of the chemical composition of urinary stones using dual-energy
CT. AJR American Journal of
Roentgenology;197:W76-83.
[3] Stolzmann P, Kozomara M, Chuck N, et al.
In vivo identification of uric acid stones
with dual-energy CT: diagnostic performance evaluation in patients. Abdominal
Imaging;35:629-35
Scanner
SOMATOM
Definition Flash
Scan area
Abdomen/Pelvis
Scan length
439.5 mm
Scan direction
Cranio-caudal
Scan time
13.5 s
Tube voltage
100 kV/Sn 140 kV
Tube current
268/204 eff. mAs
Dose modulation
CARE Dose4D
CTDIvol
8.25 mGy
Comments
DLP
394 mGy cm
The proposed method shows great

promise for distinguishing non-uric
acid stones from ureteric stents. The
method is expected to be valid for at
least 90% of nephrolithiasis cases
based on the current type of urinary
stents.[1] Current Double J stents
are generally made of polyurethane.
Thus, like uric acid (C5H4N4O3), they
Effective dose
5.9 mSv
Rotation time
0.5 s
Pitch
0.85
Slice collimation
32 x 0.6 mm
Slice width
0.75 mm
0.5 mm
Q30f
1A
1B
3A
Coronal MPR images show one stone in the lower pole of the
left kidney (arrow), and the other one in the upper pole of the
right kidney which is difficult to distinguish from the stent.
3B
VRT image generated from the DE scan shows the

stone (in blue) located within the curve of the right
ureteric stent.
Axial images show that the stone located within

the curve of the right ureteric stent is much easier
tosee on the DE image (Fig. 4B, in blue).
4A
4B
Coronal MPR images demonstrate that the stone located

within the curve of the right ureteric stent is much easier
tosee on the DE image (Fig. 3B, in blue).
Clinical Results Pediatrics
Case 10
Diagnosing Tracheal Stenosis

in a 10-week-old Baby without Sedation
By Prof. Oliver Mohrs, MD, Barbara Brecher, MD, Andrej Jrg,* Christoph Lauff*
Radiologie Darmstadt at Alice-Hospital, Darmstadt, Germany
*Siemens Germany, Business Management CT
History
Diagnosis
A 10-week-old baby girl with congenital tracheomalacia was admitted

to the hospital due to acute obstructive bronchitis. She was suffocating
and unconscious with notable lip
cyanosis. After emergency treatment,
a bronchoscopy was performed revealing a long segmental tracheomalacia.
During the examination, the trachea
completely collapsed. A thoracic CT
was ordered for pre-operative planning.
The CT images demonstrated a

tracheal stenosis between the innominate artery and the oesophagus
(Figs. 1 and 2). Both lungs showed
no abnormalities and the course of
the thoracic aorta and its branches
were normal (Fig. 3). An aortopexy
was considered for further treatment.
Comments
Due to the critical situation of the
baby, sedation was not an option.
Therefore, the scanning was performed with free-breathing using
the Flash mode. The required scan

time was only 0.26 s and the image
quality was fully diagnostic. In order
to lower the patient dose, 80 kV
was selected for the scanning which
resulted in a higher contrast to noise
ratio and a dose of only 0.99 mSv.
The Flash mode provides very short
scan time and therefore enables CT
examination for babies without sedation. Combined with lower kV settings,
sufficient diagnostic information is
obtained even with a very low dose.
Scanner
Scan area
Thorax
Rotation time
0.28 s
Scan length
104 mm
Pitch
Scan direction
Cranio-caudal
Slice collimation
128 x 0.6 mm
Scan time
0.26 s
Slice width
0.6 mm
Tube voltage
80 kV
0.3 mm
Tube current
40 mAs
B31f
Dose modulation
CARE Dose4D
Contrast
CTDIvol
0.84 mGy
Volume
7 mL
DLP
11 mGy cm
Flow Rate
1 mL/s
Effective dose
0.99 mSv
Start delay
Bolus tracking
Pediatrics Clinical Results
1A
1B
The posterior view of the VRT images demonstrates the tracheal stenosis (arrows) and the innominate artery
running across the front of the trachea.
An axial image shows the tracheal stenosis (arrow)

between the innominate artery and the oesophagus.
A VRT image reveals the normal course of the thoracic

aorta and its branches.
Science
Image Quality in
Computed Tomography
Part III: Artifacts
By Stefan Ulzheimer, PhD and Rainer Raupach, PhD
In parts I and II of this series, the

key image parameters in Computed
Tomography (CT) were discussed for
low and high contrast resolution.
In this third part, the most common
artifacts in CT images, their origin,
and possible ways to correct them
are in focus.
The term artifact originally derived
from the Latin phrase arte factum
which translates as (something) made
with skill. In radiology, artifact refers
to unwanted structures in the image
that are artificially created, are not
normally present, and therefore do
1A
not represent the real anatomy or

pathology of the patient.
Artifacts in CT are usually based on
imperfections in the data or a misinterpretation of the measured projection data due to various physical
phenomena. As CT images are still
generally derived by means of filtered
back-projection,[1] artifacts not only
occur at the originating location as
common in conventional radiography,
but may also affect the entire image.
For example, a thin metallic wire
causes streak artifacts emanating
from its origin, butalso disturbs a
larger part of the surrounding area.
Beam-hardening artifacts
The most prominent beam-hardening
artifact is known as the Hounsfield
bar, a dark band between the petrous
bones in the base of the skull obliterating the mid portion of the brain stem
(Fig.1A). During a CT scan, the tube
emits a polychromatic X-ray spectrum
that contains photons of differing
energies.
Attenuation of X-rays depends on the
energy, but this attenuation decreases
with higher photon energy. Therefore,
the spectral consistency of X-rays
changes as they pass through an object:
1b
Beam-hardening artifacts: Hounsfield bar, the dark band between the petrous bones in the base of the skull obliterating the mid
portion of the brain stem (Fig. 1A). Fig. 1B shows the same slice as Fig. 1A: Improvement with beam-hardening correction.
Science
2A
2B
2
Artifacts in a thorax
scan from breathing
and movement of the
heart (Fig. 2A).
Improvement with
a motion artifact
correction algorithm
(Fig. 2B).
Radiation behind the object contains

a higher proportion of high-energy
photons than the primary beam, but
fewer low-energy photons. The signals
measured at the detector, however,
represent an averaged attenuation over
all energies resulting in averaged data.
As a result, reconstructed images show
dark areas or streaks, for instance
between dense bones.
The strength of this beam-hardening
effect depends significantly on the
atomic composite, the size of the object,
and the voltage used. Heavy atoms
such as calcium in bones cause a more
distinct effect than soft tissue. A lower
voltage with a lower peak energy in the
X-ray photons intensifies the artifacts.
It follows then that dense bones, very
concentrated iodine contrast media,
or implanted metals may cause significant beam-hardening artifacts.
Correction of this effect for soft tissue
is routinely performed during data
processing to provide a homogeneous
soft tissue level over the entire object.
However, simultaneous beam-hardening correction for a combination of soft
tissue, bone, etc. requires more sophisticated algorithms, such as iterative
reconstruction approaches.
Siemens CT systems provide dedicated
reconstruction algorithms enabling
almost complete removal of artifacts in
brain scans. On top of that dedicated
algorithms are also available for cardiac
imaging that consider the two components, soft tissue and bone.[2]
3A
Partial volume artifacts

Partial volume artifacts occur when
the edge of a high contrast structure,
for example bone or metal, partly
overshadows a particular channel
when projecting onto the detector.
In this case, the signal measured is
the cumulated intensity of the rays
passing exclusively through the
object and the environmental tissue.
This applies to in-plane projections
as well as to the z-direction. The data
acquired is then incorrect, because
the signal attenuation is measured,
but CT images are reconstructed by
means of a filtered back-projection
of attenuation integrals.[1] Here,
artifacts are typically streak-shaped
and may look very similar to beamhardening artifacts.
As detector channels in multislice
computed tomography (MSCT) are
small in width, sampling artifacts
occur only at the edges of objects with
very high attenuation coefficients,
such as metallic objects or small dense
calcifications. Thinner collimation
reduces the level of partial volume
artifacts, because contours are sampled more precisely. All Siemens MSCT
systems have scan modes with submillimeter collimation that should be
used where high contrast structures
are present.
3B
Spiral or windmill artifacts

without z-Sharp (Fig. 3A).
No windmill artifacts with
z-Sharp (Fig. 3B).
Science
Motion artifacts
CT images are reconstructed in a particular segment of projections. Movement of an object or patient during
this time leads to inconsistent data.
Artifacts typically occur as streaks,
blurred or double contours (Fig. 2A).
Protocols for critical examinations may
include special motion correction
algorithms to suppress such artifacts
(Fig. 2B).
Generally, a fast gantry rotation speed
is recommended to minimize motion
artifacts. The SOMATOM Definition
Flash and Edge offer rotation times
down to 0.28 seconds per 360 degrees,
fast enough to freeze physiological
processes. Dedicated cardiac reconstruction algorithms can be used to
display sub-millimeter structures near
to the heart, for example coronary
arteries. These use information from
an ECG taken in parallel to determine
optimized temporal windows and
require only 180 degrees of data to
reconstruct a CT image with improved
temporal resolution. Temporal resolution can be further improved with Dual
Source technology on the SOMATOM
Definition Flash. Even uncooperative
patients and children can be scanned
without the appearance of motion
artifacts using Dual Source. Siemens
latest generation of Dual Source CT
4A
the SOMATOM Force increases the

rotation speed even to 0.25 seconds
per rotation, allowing a large number
of patients to be scanned without
breathhold.
Spiral artifacts (windmill

artifacts)
CT scanners acquire raw data from
finite detector channels. All spiral
reconstruction algorithms require an
interpolation in the z-direction of this
data to axially aligned projections.
This induces errors in cases of high
contrast objects, such as bones or
metals, compared with the idealized
situation of an arbitrarily fine grid of
sampled data points. Resulting artifacts appear as windmill-like structures
near to their sources (Fig. 3A) and
seem to rotate around the center when
scrolling through the stack of axial
images.
Spiral artifacts can be reduced effectively by improving the sampling
pattern in the z-direction. Siemens
proprietary z-Sharp technology with
double z-sampling [3] is an advanced
approach that can completely overcome this well-known issue with MSCT
systems (Fig. 3B). Other vendors need
to offer fixed low pitch protocols to
improve sampling; however, Siemens
z-Sharp allows the pitch to be adjusted
over a wide range to continuously
4B
adapt scanning speed to the clinical

task. This technology is therefore
superior to other approaches to reducing spiral artifacts through scan and
reconstruction parameters. z-Sharp is
provided for all Siemens CT systems
using the renowned STRATON tube, as
well with the latest tube generation,
the VECTRON tube introduced with
SOMATOM Force.
Cone artifacts
Cone artifacts arise due to an approximation of the measured slices of
MSCT systems to truly parallel planes.
If the detector width in the z-direction
increases, then deviations from this
simplified description will also increase
resulting in characteristic artifacts.
Given that the misfit extends away from
the center of rotation, cone artifacts
are strongest typically at the periphery,
for example near the ribs. Siemens
MSCT scanners provide effective cone
correction or cone beam reconstruction, when required, depending on the
number of detector rows.
Nevertheless, excessive increase in
detector coverage as seen with several
recent product introductions in the
industry, comes along with a significant increase of these cone and also
scatter artifacts. At such an extend, the
disadvantages outweigh the clinical
benefits of covering large volumes,
4C
Artifacts caused by metal implants (Fig. 4A). Dual Energy based metal artifact reduction (MAR) in 140 keV monoenergetic
images (Fig. 4B). VRT of the metal prosthesis with MAR (Fig. 4C).
Science
5A
5B
Patient exceeding the field of measurement without correction (Fig. 5A). Same slice as in Fig. 5A reconstructed with
HD FoV reconstruction (Fig. 5B).
especially as the volume coverage can

be achieved more effectively with fast
acquisition speeds.
Metal artifacts
Metal artifacts are a combination of
almost all of the effects described
above. The particular effect that may
occur depends on the alloy, shape, size,
and position. Generally, the transition
from tissue to metal is very abrupt
compared with the size of the detector
channels. So partial volume effects or
sampling errors contribute to metalinduced artifacts, which appear as thin
streaks emanating from the edges.
As the size of the metallic object
increases, so does the attenuation of
the X-rays. Beam hardening becomes
relevant. Moreover, the absolute signal
measured in certain detector elements
behind the implant becomes so low that
the reading is no longer reliable due
to the high level of noise. Both effects
may completely destroy the image content for rays passing through a large
amount of metal. Using a higher voltage
reduces beam hardening as well as a
lack of detector signal due to smaller
attenuation at higher photon energies.
Selecting higher mAs, on the other
hand, does not improve the situation
significantly but will increase radiation
dose. Intelligent automatic exposure

controls such as Siemens CARE Dose4D
exclude metallic objects when calculating optimal mAs settings, because
no benefit is observed with regard
to image quality compared with the
higher dose. Dual Energy scanning
which is available on the SOMATOM
Force, SOMATOM Definition Flash,
the SOMATOM Definition Edge, all
SOMATOM Definition AS systems, and
now also for SOMATOM Perspective
scanner family can also be used to
reduce metal artifacts efficiently by
calculating monoenergetic images
another form of advanced beamhardening correction (Fig. 4A/B). Furthermore, all Siemens CT scanners
apply advanced filters to the raw data
to reduce disturbing noise structures.
Objects outside the field of

measurement
The relation between CT raw data
and reconstructed images causes artifacts if objects are inside the gantry,
but exceed the field of measurement.
Patients larger than the maximal scanning field or arms lateral to the body
likewise produce artificial hyperdense
edges (Fig. 5A) if not accounted for in
the reconstruction. The latest Siemens
scanners automatically apply advanced
extrapolation-type algorithms (HD FoV)

in order to reduce those artifacts considerably (Fig. 5B). Moreover, they
offer special reconstruction techniques
to display objects located outside the
field of measurement with high accuracy. This is especially important in
radiation therapy planning where treatment plans are based on the correct
measurement of CT numbers and
parts of the patient are frequently
located outside the field of measurement due to fixation devices. There
are diverse origins of artifacts in CT
imaging. Solutions need to be equally
diverse to intelligently deliver diagnostic results.

References
[1] Kalender WA: Computed Tomography,
Publicis MCD: 22ff (2000)
[2] Herman GT, Trivedi SS. A Comparative
Study of Two Postreconstruction Beam
Hardening Correction Methods, IEEE
Transactions on Medical Imaging.
1983 Sep; Vol MI-2; No 3: 128-135
[3] Flohr T, Stierstorfer K, Raupach R,
Ulzheimer S, Bruder H. Performance
evaluation of a 64-slice CT system
with z-flying focal spot. Rofo. 2004
Dec;176(12):1803-10.
Science
Radiation Hygiene
Transparent and Easy
Medical physicists carry a significant responsibility for their patients.
Facilitating and establishing a safety culture in a medical environment
is therefore one of their main priorities. The Albert Schweitzer Hospital
in Dordrecht, the Netherlands, uses Siemens CARE Analytics on a daily
basis to keep a check on safety and radiation doses for the radiology and
cardiology department equipment.
By Erika Claessens
When refining innovative tools for

dose management it is critical to
achieve the highest technical performance to meet the needs of both
patients and medical staff. Furthermore influenced by European Commission research on the subject
most European countries have now
started to regulate the dissemination
of good ALARA (As Low As Reasonably Achievable) practice in medical
imaging. So Siemens scored a bulls
eye when it launched CARE Analytics.
Being a free of charge application
embedded in the comprehensive Dose

Management Program DoseMAP, it
perfectly ties into the overall Combined Applications to Reduce Exposure
(CARE) philosophy of Siemens.
I am responsible for radiation hygiene
at the Albert Schweitzer Hospital,
explains Jeroen Bosman, medical
physicist. The specific technical regulations brought out by our government cover the safe use of ionizing
radiation in all hospitals. They are part
of a larger family of radiation protection laws surrounding the use, con-
trol, and equipment producing ionizing radiation, and thus affect most of
our scanners and technical equipment.
Our hospital must keep to these regulations to optimize radiation doses,
meaning lowering the dose as much as
possible, and also to perform quality
control on patient doses.
Simple and efficient

The measurement and calculation of
radiation dose is important for efficient
dose management, not only in CT but
also for all areas where X-ray exposure
Thanks to the free

CARE Analytics tool,
we are now able to
simplify the rather
complex handling
of data measurement and analysis.
Jeroen Bosman, Albert Schweitzer Ziekenhuis,
Dordrecht, the Netherlands
Science
is used. Thanks to the free CARE Analytics tool provided by Siemens, my

staff and I are now able to simplify the
rather complex handling of data measurement and analysis, says Bosman.
Our hospital handles approximately
twenty thousand CT scans a year. Before
2012, we had to derive the exact information from a massive database by
asking our staff to manually fill in huge
amounts of numbers on paper
questionnaires.
Those days are over, Bosman points
out, smiling. Work is now simplified
to a huge extent. Moreover, the information is optimized, filtered by individually chosen parameters and all
the numbers are brought together in
simplified colored graphics. Seeing
the affect of adjusting a scan protocol
doesnt take a long time anymore.
Increased transparency
CARE Analytics was very easy to install
on our computers. Our hospital scanning equipment contains comprehensive data for each irradiation event, the
accumulated dose in CT, and information about the context of the exposure.
Until now, this data was only archived
in dose structured reports and not processed any further. The data is now
sent to the software tool on our desktop, where it is stored and processed.
With CARE Analytics, we can evaluate
and analyze the information in a stan-
CARE Analytics offers many possibilities and opportunities to Jeroen Bosman and his team
for efficient dose management.
dard file format, such as Microsoft

Excel for example. This helps us when
it comes to optimizing scan protocols
and working to reduce dosages. I can
also easily provide data information
on received patient doses for different
systems over a series of examinations
to the government inspection officer
or other third parties. In the future,
dose reporting between multiple hospitals could also be made possible. The
increased transparency lets us improve
our working practices and be more
sparing with the doses given than in
the past.
Exploring trends
The Albert Schweitzer Hospital in Dordrecht, the

Netherlands, uses Siemens CARE Analytics software on a daily basis to keep a check on safety and
radiation doses for their radiology and cardiology
department equipment.
In terms of gaining time, installing

CARE Analytics was an eye-opener. But
my interest is more in using the data
gathered to detect unusual situations
and trends. Before, it was impossible
to clearly disentangle such deviant
information. With this software tool,
I can zoom in and have a closer look
at the information. I can explore it
widely and do significant research
to work out exactly what happened.
This can lead to a protocol adaptation
or a new way of working with the CT
equipment. Or it could reveal a technical problem we were formerly not
aware of. I can adjust scan protocols,
choosing from about ten different
parameters for scan protocols, with
a primary goal of lowering the dose
without compromising image quality.

This would never have been possible
before when processing the data and
adjusting the scanning protocols by
hand, he says. My work has become
more interesting now, as the software tool offers so many possibilities
and opportunities to analyze the
numbers.
Protecting patients and medical staff
from unnecessary radiation is a major
concern. Today, thanks to advanced
technologies and applications, outcomes for diagnosis and intervention
can be optimized at the same time as
reducing radiation.
Erika Claessens has contributed as a
journalist and editor to numerous print and
online publications in both Belgium and the
Netherlands. Her principal topics are entrepreneurial innovation and technology. She
works from Antwerp, Belgium.

Further Information
www.siemens.com/care-right
Science
Radiation Protection Scientifically

Proven for Routine Practice
The Centre Hospitalier Universitaire Carmeau (CHU Carmeau) is a large
and busy hospital in the south of France. Maintaining workflow efficiency
while keeping investigations and diagnosis safe is a major challenge in the
current circumstances. Results from a series of studies conducted on-site have
been successfully integrated into daily practice. This has enabled smoother
workflows and a clear decrease in radiation dose.
By Jean-Paul Beregi, MD, PhD, and Joel Greffier
Department of Radiology at Centre Hospitalier Universitaire Carmeau, France
The CHU Carmeau is part of the

university of Nmes in the south of
France. It facilitates 1,200 beds and
the hospital provides healthcare to
450,000 inhabitants. Emergency care
is available 24 hours a day, 7 days
a week. With an average of 63,000
emergency admissions per year, scans
are required day and night for all
indications bones, brain, abdomen
or cardiovascular regardless of
how acute the case. In 2011, a new
SOMATOM Definition AS+ CT scanner
for use mainly in emergency cases
and for in-patients replaced the previous device. A second CT scanner
(acquired in 2009) was upgraded to
the same level as the first one. In 2012,
over 28,000 CT scans and traditional

X-rays were performed by 22 technologists and 13 radiologists.
As part of a drive to improve workflow
efficiency and clinical practice, Joel
Greffier, medical physicist, and JeanPaul Beregi, MD, head of radiology at
CHU Carmeau conducted a series
of studies. Important parameters for
improvement were patient management, image availability and quality,
radiation dose, and reproducibility.
The main objective was to investigate
new dose reduction technologies in
routine CT scanning.
Before Siemens Sinogram Affirmed
Iterative Reconstruction (SAFIRE) was
1
1
Radiation dose
reduction in daily
practice showed
no adverse impact
on image quality.
Radiation dose
reduced by 15%
and then 30% in
reference mAs
(compared with
previous practice)
was applied in
allthoracic and
abdomino-pelvic
protocols.
introduced into clinical practice, the

impact on image quality and radiation
dose reduction was studied using a
quality image phantom (Catphan 500).
Several acquisitions were performed
at different kV settings (from 80 to
140 kV), different mAs (from 50 to
350 mAs) and at two pitches (0.8 and
1.2). After each CT scan acquisition,
the CTDIvol was recorded and the raw
data was reconstructed with filtered
back projection and SAFIRE at a
strength of 5 for three reconstruction
thicknesses and two different filters
(B30/I30 and B70/I70). In total, 2,016
parameter combinations were evaluated. syngo.via was used to measure
the signal and noise for a standardized ROI with five different inserts
(air, low density polyethylene, water,
acrylic, teflon) and an in-plane spatial
resolution (MTF 10%).
Calculations of signal-to-noise ratio
(SNR) and contrast-to-noise ratio (CNR)
showed significantly decreased noise
with increasing levels of SAFIRE,
without any change in the signal and
modular transfer function (MTF). It
could be concluded that increasing
SAFIRE levels improve the image quality indices with identical radiation
doses (qualitative advantage). Therefore, if parameters are optimized
during acquisition to reduce patient
dose, SAFIRE can compensate for the
increase in noise and deliver the same
high quality image as before (quantitative advantage).
Science
Table 1: Radiation Dose used in Nmes

vs. Recommendations by French authorities
CTDIvol (mGy)
Exam
French
recommendations
Nmes
2012
Nmes
2013
Nmes
2012 vs. 2013
French recommendations
vs. Nmes 2013
Chest
15 mGy
4.2mGy
2.5mGy
40.5%
83.3%
Abdominal
17mGy
7.5mGy
5.1mGy
32.0%
70.0%
Lumbar Spine
45mGy
16.2 mGy
8.8mGy
45.7%
80.4%
Head
65mGy
48.8mGy
36.3mGy
25.6%
44.2%
2A
2B
2
In an optimized protocol for
urinary stones, irradiation was
decreased by more than
70percent (Fig. 2B) compared
with previous protocols
(Fig. 2A). Urinary calculi can be
detected without any change
in accuracy.
The same methodology was then

applied to an anthropomorphic phantom (Rando) and results were compared to those obtained with the
Catphan 500. In practice, all CT scans
were executed with CARE Dose4D
activated and with CARE kV activated
or semi-activated (depending on localization and exam type) to reduce radiation dose. Furthermore, a systematic
reduction in mAs was applied by the
percentage reductions in the reference.
The kV was kept constant to avoid signal variation and so as not to change
the pitch since there was no effect on
radiation dose. Both kVp and pitch
were adapted to the location and type
of exam. With a decrease in the reference mAs, a parallel reduction in the
effective mAs during acquisition was
observed. This reduction in effective
mAs was linear to radiation dose
reduction.
This decrease in mAs was introduced
into daily practice gradually over two
months to allow all radiologists to
adapt and also to be entirely sure that
there was no impact on image quality
for routine diagnosis. A 15% and
then 30% reduction in reference mAs
(compared with previous practice)

was applied in all thoracic and
abdomino-pelvic protocols. Iterative
reconstructions with two levels of
SAFIRE (strength 3 and strength 4)
were offered to radiologists (strength
2 was the initial choice before dose
reduction). During this period, we
observed that routine workflow
remained unchanged. Radiologists
were surprised by the change in the
image, but there were no cases of misinterpretation or difficulties in evaluating nodules or infiltrations. Radiologists were given some training to
help them to understand the benefits
of the dose reduction technologies
and to convince them of the choice
(Fig.1).
In routine practice, radiation dose
reduction has now been introduced
for all scan protocols and SAFIRE
(mainly level 3 or 4 according to the
protocol) is used. The choice was to
have the lowest dose for all patients,
especially for pregnant women where
radiologists do not need a specific
protocol (Tab.1). For the moment,
there is no weight-adapted kVp protocol to standardize acquisitions or for
patients whose weight is not known.

There is, however, some space for
improvement. The team is now working to optimize the protocol to fit the
specific needs of the physician requesting the exam. For example, they have
a new protocol for urinary stones
where irradiation can be decreased
(<70%). Abdominal structures present
more noise, but it is possible to see
urinary calculi without any change in
accuracy (Fig.2).
Our results show that medical personnel and patients at the CHU Carmeau
radiology department benefit from
using SAFIRE in clinical routine
which we were able to confirm through
studies. Offering the clinical staff the
chance to become familiar with the
functionalities of SAFIRE increased
acceptance and convinced them firmly
of the advantages of using SAFIRE in
daily practice.
Customer Excellence
Tips & Tricks: Easy Bone and Vessel Isolation

By Patricia Jacob, Computed Tomography, Siemens Healthcare, Forchheim, Germany
In syngo.via VA20 syngo.CT Vascular
Analysis and MM Reading, the bone
removal function can be used to
create an individual isolation of high
intensity structures, such as bones
and contrast-enhanced vessels. This
function allows, for example, to
remove only the joint socket for a
view of a fractured joint.
Define structures
When using the Bone & Vessel Isolation mode for the first time, the bone
removal edit mode is automatically
started. In the edit mode, the functions provided to define an individual

removal mask can be used. It makes
manual marking of individual bone
and vessel structures possible in order
to apply a user-specific bone mask for
each dataset. Unlike the other bone
removal options, this mode starts
with an unmarked volume and allows
the user to define structures. After
finishing the removal mask, the editing mode has to be deactivated. The
editing results are retained in the
removal mask. By clicking the Bone
1
1
Bone Opacity
from the upper left
corner of the VRT
segment allows to
view the marked
and unmarked
structures.
& Vessel Isoltion icon, the removal

mask can be displayed or hidden. To
further modify the removal mask, the
bone removal mask has to be started
again.
Optimized view
Based on the structures that are
marked as bones in the bone mask,
bone structures can be highlighted in
MPR and VRT images. The highlighting
functions can be used to optimize
the bone removal masks. In the editing
mini toolbar, click the Hide marked
structures icon or Show marked
structures icon.
In the VRT segment, an adjustable
semi-transparent view of the bones can
be displayed. This view is based on the
structures that are marked or unmarked
as bone in the bone removal mask.
From the upper left corner of the VRT
segment, choose Bone Opacity. In
the bone opacity mini toolbar at the
bottom of the segment, the marked/
unmarked slider can be dragged to
the left or to the right to change the
opacity level of the structures.
In the VRT segment all identified bone structures are hidden. Clicking on a structure (displayed in transparent blue) allows to add
(blue plus sign) or remove (red minus sign) it from the removal mask. In the editing mini toolbar, marked structures can be shown
or hidden.
Customer Excellence
Clinical Workshops 2014

As a cooperation partner of many renowned hospitals, Siemens Healthcare offers continuing CT training programs.
In a wide range of workshops clinical experts share latest experiences and options in clinical CT imaging.
Workshop Title/
Special Interest
Date
Location
SCCT CTA Academy 2014
January
1112, 2014
Hawaii,
USA
Clinical Workshop
on Dual Energy
February
1415, 2014
Workshop for Physicists
Course
Language
Course Director/Organizer
Link
English
Siemens Healthcare
Prof. Stephan
Achenbach, MD
Suhny Abbara, MD
www.scct.org/training/cta/
Forchheim,
Germany
English
Siemens Healthcare
Prof. Thorsten Johnson,
MD
www.siemens.com/
SOMATOMEducate
March
18 19, 2014
Forchheim,
Germany
English
Siemens Healthcare
www.siemens.com/
SOMATOMEducate
Coronary CTA
Interpretation Workshop
March
2728, 2014
Erlangen,
Germany
English
Siemens Healthcare
Prof. Stephan
Achenbach, MD
www.siemens.com/
SOMATOMEducate
Hands-on at the ESGAR

Workshop/Colonography
April
2426, 2014
Oslo,
Norway
English
ESGAR
Anders Drolsum, MD
www.esgar.org
Advanced Cardiovascular CT
April 29
May 2, 2014
London,
UK
English
Imperial College London:

Ed Nicol, MD;
Simon Padley, MD and
Sujal Desai, MD
www.imperial.ac.uk

Congress/Colonography
June
1821, 2014
Salzburg,
Austria
English
ESGAR
Prof. Gerhard Mostbeck,
MD
www.esgar.org
Oncology Imaging
Course 2014/Oncology
June
2628, 2014
Dubrovnik,
Croatia
English
OIC
Prof. Maximilian Reiser,
MD
www.oncoic.org
Workshop for Physicists
September
23 24, 2014
Forchheim,
Germany
English
Siemens Healthcare
www.siemens.com/
SOMATOMEducate

Workshop/Colonography
October
810, 2014
Leeds,
UK
English
ESGAR
Damian Tolan, MD
www.esgar.org
Coronary CTA
Interpretation Workshop
November
6 7, 2014
Erlangen,
Germany
English
Siemens Healthcare
Prof. Stephan
Achenbach, MD
www.siemens.com/
SOMATOMEducate
In addition, you can always find the latest CT courses offered by Siemens Healthcare
at www.siemens.com/SOMATOMEducate
Customer Excellence
Upcoming Events & Congresses 2013/2014

Short Description
Date
Location
Title
Contact
Radiological Society of North America
December
0106, 2013
Chicago, USA
RSNA
www.rsna.org
Internationales Symposium
Mehrschicht CT
January
2225, 2014
GarmischPartenkirchen,
Germany
Mehrschicht
CT
www.ct2014.org
Arab Health
January
2730, 2014
Dubai, UAE
Arab Health
www.arabhealthonline.com
European Society of Radiology
March
0610, 2014
Vienna, Austria
ECR
www.myesr.org
European Society for Radiotherapy &

Oncology
April
0408, 2014
Vienna, Austria
ESTRO
www.estro.org
Cardiac Magnetic Resonance Imaging &

Computed Tomography
April
1113, 2014
Cannes, France
Cardiac MRI
& CT
http://cannes2014.medconvent.at
European Conference on Interventional

Oncology
April
2326, 2014
Berlin, Germany
ECIO
www.ecio.org
European Stroke Conference
May
0609, 2014
Nice, France
esc
www.eurostroke.eu
American Society of Clinical Oncology
May 30
June 03, 2014
Chicago, USA
ASCO
www.am.asco.org
European Society of Pediatric Radiology
June
0206, 2014
Amsterdam,
The Netherlands
ESPR
www.espr.org
International Society for Computed

Tomography
June
0912, 2014
San Francisco, USA
ISCT
www.isct.org
European Society of Thoracic Imaging
June
1214, 2014
Amsterdam,
The Netherlands
ESTI
www.myesti.org
European Society of Gastrointestinal

and Abdominal Radiology
June
1821, 2014
Salzburg, Austria
ESGAR
www.esgar.org
Society of Cardiovascular Computed

Tomography
July
1013, 2014
San Diego, USA
SCCT
www.scct.org
European Society of Cardiology
August 30
September 02,
2014
Barcelona, Spain
ESC
www.escardio.org
American Society for Radiation Oncology
September
1417, 2014
San Francisco, USA
ASTRO
www.astro.org
European Society for Medical Oncology
September
2630, 2014
Madrid, Spain
ESMO
www.esmo.org
Radiological Society of North America
November 30
December 05,
2014
Chicago, USA
RSNA
www.rsna.org
Customer Excellence
Free DVD of the 11th SOMATOM World

Summit in Orlando
By Katrin Seidel, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Connecting Knowledge
in Orlando, Florida:
Listening to the latest
innovation in CT
A bi-annual conference for CT practitioners, the 11th SOMATOM World Summit

took place for the first time in the United
States in Orlando, Florida. Under the
inspiring theme Connecting Knowledge, this years conference offered
another unique opportunity to connect
medical staff from around the world to
share their experience and understanding of the latest developments in CT.
State-of-the art technology was the
focus of the conference with a special
emphasis on dose management and
patient care in optimizing the clinical
workflow in daily routine. An impressive range of experts gave lectures
covering the following clinical themes:
Right Dose CT imaging
Acute care
New horizons in Dual Energy
Synergies in CT for better patient care
Vascular
Cardiology
Neurology
Pediatrics
Oncology
Therapy
Established products such as Dual

Energy, SAFIRE, and FAST CARE
(including CARE kV, CARE Child) and
the new Stellar detector technology
were analyzed from a clinical perspective. Each subject was illustrated
with practical examples from routine
hospital settings or during clinical
trials. One example was the use of
the Stellar detector in combination
with CARE Dose4D to reduce radiation dose while providing excellent
image quality.
The most up-to-date information about
technical innovation in CT is shared
in clinical conferences, workshops,
and supporting material. Siemens
Healthcare offers an established and
comprehensive clinical platform with
a wide range of educational programs.
They include informative and interesting publications, a series of How
to flyers with useful expert advice,
webinars, training programs (fellowships, workshops, and hands-on
tutorials) to extend and consolidate
knowledge.
Siemens educational platform offers

additional valuable information on
ways to improve clinical skills and
usage of Siemens CT systems to their
full potential. The new DVD of the
SOMATOM World Summit featuring
recordings of the presentations is now
ready for delivery. This e-learning
method is an excellent way to learn
about state-of-the-art CT at ones own
pace and at a time and place convenient. True to the motto Connecting
Knowledge, a free copy can be
ordered through the following link:
Further Information
www.siemens.com/
SOMATOMEducate
Customer Excellence
Twenty Years of STAR A Successful

Educational Program for Radiologists
By Axel Lorz, Computed Tomography, Siemens Healthcare, Forchheim, Germany
STAR is an acronym for Specialized
Training in Advances in Radiology. It is
an international educational program
for practicing radiologists. In 2013,
twenty years of success in driving and
sharing knowledge with STAR were
celebrated. STAR events include a regular forum to share opinions on and
experiences of the latest developments
in radiology together with an eminent
faculty of independent experts. The
two-day format has proved popular
over the years and includes 13 lectures
(45 min.) complemented by five onehour workshops for detailed case discussions. Pathological conditions in
all body organs and all modalities are
covered. An excellent advisory board
of 21 leading radiologists from all over
the world supports the STAR program
with valued expertise. STAR is jointly
sponsored by Siemens and Bayer
Healthcare and is run as a non-commercial educational initiative.
Country-specific programs
An important feature of STAR is cooperation with national radiology societies.
They are involved in defining topics
appropriate to the needs of the respective countries be it the healthcare
system, access to radiology equipment
or training on a specific subject. Representatives of the societies also play
an active role as program chairs. Attendance at STAR meetings varies greatly
with countries sending between
STAR event in New Delhi, India, 2012
100500 participants. Programs are

held at locations around the world to
facilitate participation and allow for a
customized approach according to local
needs and reflecting national characteristics. To date, 169 STAR events
have been held in 36 countries across
the globe, attended by almost 27,000
radiologists, and supported by around
200 faculty members. The next STAR
events are scheduled for January 2014
in Vietnam and Thailand.
The total numbers of

countries, sites, and
participants show the
continuous expansion
of the STAR program
over 20 years.
Accumulated number of participants

30000
25000
20000
15000
Enthusiastic feedback
The most convincing evidence of the
STAR programs success is the enthusiasm of its participants. Feedback is given
after each event to assess its educational value, the quality of the speakers,
and the interest of the participants in
attending future STAR meetings. Visiting
radiologists appreciate the high quality
of the conference, and the practical
knowledge that you can never find in
the literature, and the chance to learn
from the best of the best international
faculty. STAR meetings are in constant
demand and are often repeated in countries where previous programs have
been held.
To learn more about STAR please visit
the following website.
Further Information
10000
www.star-program.com
5000
-12
-02
-03
-04
-05
-06
-07
-08
-09
-10
-11
-93
-94
-95
-96
-97
-98
-99
-00
Customer Excellence
From Print to App:

SOMATOM Sessions for Everyone
By Sandra Kolb, Computed Tomography, Siemens Healthcare, Forchheim, Germany
SOMATOM Sessions has grown steadily.
For more than 12 years, the printed
magazine has delivered the latest news
from the world of computed tomography.
Peoples reading habits, however, are
changing radically and the customer
magazine adapts, too.
In June 2011, the online equivalent
of SOMATOM Sessions was launched.
This online version offers all articles
available in print as well as exclusive
content at www.siemens.com/
SOMATOM-Sessions. Readers can comment on and forward articles, find articles relating to a topic and interesting
links to further information. Additionally topics can be sorted and organized
by clinical interest. The online platform
makes the very latest content such
as reports from trade fairs available
to readers quickly.
In 2012, by multiple requests the
SOMATOM Sessions app was developed
for Apple and Android to add even
There is a
SOMATOM
Sessions for
everyone
see which
one suits
you best.
more value. Both website and app

offer new multi-media content and
opportunities for interaction.
In the app, users can configure their
start page according to their interests,
bookmark content to read later offline,
rate articles and share content easily.
Download the app from iTunes or the
Google Play Store for free keyword:
CT Sessions.
With a broad base of readers, the

Siemens customer magazine for
computed tomography now has a
range of formats to suit everyone.
Further Information
www.siemens.com/
SOMATOM-Sessions
2014 Multislice CT Symposium in Garmisch

By Monika Demuth, PhD, Computed Tomography, Siemens Healthcare, Forchheim, Germany
From January 2225, 2014, the 8th
International Symposium for Multislice
CT will take place in Garmisch-Partenkirchen, Germany. In keeping with
the concept of Life Long Learning
From January
2225, 2014,
the 8th International
Symposium for
Multislice CT
will take place
in GarmischPartenkirchen,
Germany.
emphasis will be placed on practical,

hands-on training. Another focus will
be the latest scientific developments
and technical innovations in the field
of computed tomography (CT), that
in all probability will strongly affect
quality of future clinical practice. Symposium events will demonstrate ways
in which to combine clinical research
and practical application in CT more
effectively. Leading experts will guide
participants through a high-level program including clinical lectures and
refresher courses. Specific case studies and results from cardiology, acute
diagnostics, neurology, ENT, oncology
and other fields will be presented and
discussed in the round. A new interactive file-reading session will take
place for the first time. In this session,
leading experts in various medical

fields will provide live analysis of cases
with opportunities for the audience
to take part and work out solutions
together.
The symposium is accredited by
the Bavarian Landesrztekammer
so participants will have the option
of registering for CME credits. The
conference language is German.
Further Information
http://www.ct2014.org
Subscription
Siemens Healthcare Publications

Our publications offer the latest information and background for every
healthcare field. From the hospital director to the radiological assistant
here, you can quickly find information relevant to your needs.
Medical Solutions
Innovations and trends in
healthcare. The magazine
is designed especially for
members of hospital management, administration
personnel, and heads of
medical departments.
AXIOM Innovations
Everything from the world
of interventional radiology,
cardiology, and surgery.
MAGNETOM Flash
of magnetic resonance
imaging.
Heartbeat
of sustainable cardiovascular care.
Imaging Life
of molecular imaging
innovations.
SOMATOM Sessions Online

The online version includes additional video features
and greater depth to the articles in the printed
SOMATOM Sessions magazine. Read online at:
www.siemens.com/SOMATOM-Sessions
For current and past issues and to order the

magazines, please visit www.siemens.com/
healthcare-magazine
Imprint
2013 by Siemens AG, Berlin and Munich,

All Rights Reserved
Publisher:
Siemens AG, Healthcare Sector
Henkestrasse 127, 91052 Erlangen, Germany
Chief Editors:
Monika Demuth, PhD; Stefan Ulzheimer, PhD
Clinical Editor: Xiaoyan Chen, MD
Project Management: Miriam Kern; Sandra Kolb
Responsible for Contents: Peter Seitz
Editorial Board:
Xiaoyan Chen, MD; Monika Demuth, PhD;
Andreas Fischer; Jan Freund; Julia Hlscher;
Axel Lorz; Peter Seitz; Stefan Ulzheimer PhD
Authors of this issue:
Bastida de Paula, Caroline, Department of
Radiology of Hospital do Corao, Brazil
Johnson, Thorsten R. C., MD, Institute

for Clinical Radiology, Ludwig-Maximilians
University Hospital Munich, Germany
Kannan, G., Department of Radiology & Imaging,
PSG Institute of Medical Sciences & Research,
Tamil Nadu, India
Kerl, J. Matthias, MD, Department of Diagnostic
and Interventional Radiology, Goethe University,
Frankfurt, Germany
Li, Zhenlin, Department of Radiology, Huaxi
University Hospital, Chengdu, Sichuan, P.R. China
Meinel, Felix G., MD, Institute for Clinical
Radiology, Ludwig-Maximilians-University
Hospital Munich, Germany
Postma, Alida A., MD, Dept. of Radiology,
Maastricht University Medical Center, Maastricht,
the Netherlands
Prof. Mohrs, Oliver, MD, Radiologie Darmstadt
at Alice-Hospital, Darmstadt, Germany
Bauer, Ralf W., MD, Department of Diagnostic

Frankfurt, Germany
Prof. Song, Bin, MD, Department of Radiology,

Huaxi University Hospital, Chengdu, Sichuan,
P.R. China
Beregi, Jean-Paul, MD, PhD, Department of

Radiology at CHU Carmeau, France
Rizk, Eddy, Superscan Radiology, New South

Wales, Australia
Brecher, Barbara, MD, Radiologie Darmstadt

at Alice-Hospital, Darmstadt, Germany
Sanki, Joseph, Superscan Radiology, New South

Wales, Australia
Cao, Jian, MD, Department of Radiology,

Peking Union Medical College, Beijing, P.R. China
Sen, Kamal K., MD, Department of Radiology &

Imaging, PSG Institute of Medical Sciences &
Research, Tamil Nadu, India
Deconinck, D., MT, Medical Imaging Department,

Europa Clinics, Brussels, Belgium
Derauw, O., MT, Medical Imaging Department,
Sudhakar, P., Department of Radiology &

Imaging, PSG Institute of Medical Sciences &
Research, Tamil Nadu, India
Dikraniant, T., MD, Internal Medicine DepartmentCardiology, Europa Clinics, Brussels, Belgium
Vargas Lobos, M., MT, Medical Imaging

Department, Europa Clinics, Brussels, Belgium
Frellesen, Claudia, MD, Department of Diagnostic

Frankfurt, Germany
Vogl, Thomas J., MD, Department of Diagnostic

Frankfurt, Germany
Genard, L., MT, Medical Imaging Department,

Waldman, Boris, BSc, Superscan Radiology,

New South Wales, Australia
Ghijselings, L., MD, Medical Imaging Department,

Wang, Yining, MD, Department of Radiology,

Peking Union Medical College, Beijing, P.R. China
Graef, Anita, MD, Institute for Clinical Radiology,

Ludwig-Maximilians-University Hospital Munich,
Germany
Wildberger, Joachim E., MD, Dept. of Radiology,

the Netherlands
Greffier, Joel, Department of Radiology at CHU

Carmeau, France
Wu, Bing, MD, Department of Radiology, Huaxi

Hilton Muniz, Leao Filho, MD, Department of

Zhang, Kai, Department of Radiology, Huaxi

Hofman, Paul AM, MD, Dept. of Radiology,

the Netherlands
Zhao, Jin, Department of Radiology,

Huaxi University Hospital, Chengdu, Sichuan,
P.R. China
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 25,000 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.
Zim Henrique, Vinicius, PM, Department of

Irne Dietschi, science and medical writer,
Switzerland; Erika Claessens, journalist and
editor, Belgium; Philipp Grtzel von Grtz, MD,
freelance writer and book author, Germany;
Sameh Fahmy, MS, freelance medical and
technology reporter, USA; Christian Rayr,
freelance journalist, France; Philipp Braune,
Kommpagnons, Germany
Peter Aulbach; Arjen Bogaards, PhD;
Monika Demuth, PhD; Jochen Dormeier, MD;
Ivo Driesser; Heidrun Endt, MD; Jan Freund;
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PhD; Stefan Ulzheimer, PhD; Xi Zhao, MD
Photo Credits:
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Wolfram Schroll/fotogloria;
Franck Ferville/Agence Vu,
MattiImmonen; Miquel Gonzalez/laif,
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Siemens AG, Healthcare Sector
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In cooperation with Primafila AG, Zurich,
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Photo Editor: Julia Berg
Layout: Claudia Diem, Mathias Frisch,
Pia Hofmann, Heidi Kral, Irina Pascenko
All at: Widenmayerstrae 16,
80538 Munich, Germany
The entire editorial staff here at Siemens
Healthcare extends their appreciation to all
the experts, radiologists, scholars, physicians
and technicians, who donated their time and
energy without payment in order to share
their expertise with the readers of SOMATOM
Sessions.
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SOMATOM Sessions

Answers for life in Computed Tomography

December 2013 | International Edition 

Ready for the

Coronary CTA with

In a general population with

2 SOMATOM Sessions | December 2013 | www.siemens.com/SOMATOM-Sessions

allows for unmatched iodine contrast

As a complement to our CT system

SOMATOM Sessions | December 2013 | www.siemens.com/SOMATOM-Sessions 3

14 Getting Further in CT with New Imaging Possibilities

40 Ready for the Next Revolution in Stroke Care?

Tips & Tricks: Easy Bone and Vessel Isolation

SOMATOM Sessions | December 2013 | www.siemens.com/SOMATOM-Sessions 5

Curtain up on Siemens latest accomplishment in outstanding engineering:

sis and treatment decisions. The

install the new CT system. The interdisciplinary Mannheim specialists

6 SOMATOM Sessions | December 2013 | www.siemens.com/SOMATOM-Sessions

fast, more precise, and even more

more accepted as an imaging biomarker, which will set the benchmark

nological progress: Technology by

SOMATOM Sessions | December 2013 | www.siemens.com/SOMATOM-Sessions 7

dose are concerned. Only this highend CT system is capable of offering

CT. The scanner allows precise and

her best possible diagnostic procedure, meaning that the CT scan of

The SOMATOM Force is expected to

Low-kV imaging for

8 SOMATOM Sessions | December 2013 | www.siemens.com/SOMATOM-Sessions

Low dose for challenging patient 63 cm acquired with

improved to such an extent that a scan

Dual Energy lung PBV 32 cm acquired in only 4 s,

This aspect is especially important

diabetes, might have to undergo prolonged pre- and after-care because

As radiologists, we now have the

SOMATOM Sessions | December 2013 | www.siemens.com/SOMATOM-Sessions 9

Lowest dose for early

ular Flash Spiral mode into the new

contrast-to-noise ratio can be reinvested in lowering the dose, allowing

Free breathing for all patients

Dynamic CTA 64 cm acquired with spiral 4D mode at 80 kV, 110 mAs,

10 SOMATOM Sessions | December 2013 | www.siemens.com/SOMATOM-Sessions

One problem frequently found in conventional scans is motion artifacts,

diaphragm or the bowel. So, free

believes that those facts will also

Larger field of view

by 50%. The combination of two

SOMATOM Sessions | December 2013 | www.siemens.com/SOMATOM-Sessions 11

Flash mode will become standard,

Dynamic perfusion at half

The SOMATOM Force offers dynamic

12 SOMATOM Sessions | December 2013 | www.siemens.com/SOMATOM-Sessions

example, which at present requires

cardiac catheter examination. With

In other tumors such as gastrointestinal

In Mannheim, the medical faculty

CT for cardiovascular issues is a role

Irne Dietschi is an award-winning Swiss

The product is pending 510(k) clearance, and is

SOMATOM Sessions | December 2013 | www.siemens.com/SOMATOM-Sessions 13

rendered more flexible, too, as physicians can view images on mobile

Automatic completion of manufacturerspecific AAA graft order forms

Comprehensive evaluation of myocardial perfusion with

14 SOMATOM Sessions | December 2013 | www.siemens.com/SOMATOM-Sessions

December 2013 | International Edition