s

S O M ATO M S E S S I O N S

Case Reports
from
multislice CT –
SOMATOM
Volume Zoom

S P E C I A L I S S U E I I
From the Editor

This is the second special issue of Siemens SOMATOM®

Sessions with case reports from the early users of
our new multislice CT: SOMATOM Volume Zoom. This
special issue focuses on presenting the clinical results on
the improvement of the spatial resolution of the diagnostic
images especially by using the UHR (Ultra High Resolu-
tion) technique and 0.5 mm slice collimation. On the other
hand, it also shows you the improvement of the routine
applications on CTA and soft tissue studies.

As always we would appreciate your suggestions and

comments.

Special thanks to Dr. Roman Fishbach for his valuable

assistance.

Xiaoyan Chen, M.D.

Editor of SOMATOM Sessions

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2
Contents

Letter from the Editor Page 2

Petrous Bone (Case 1)
Ulrich Baum, MD
Institute of Diagnostic Radiology, University of Erlangen-Nuremberg Page 4
Petrous Bone (Case 2)
Ulrich Baum, MD
Institute of Diagnostic Radiology, University of Erlangen-Nuremberg Page 6
Sinuses
Ulrich Baum, MD
Institute of Diagnostic Radiology, University of Erlangen-Nuremberg Page 8
Lung Fibrosis
Micheal Lell, MD
Institute of Diagnostic Radiology, University of Erlangen-Nuremberg Page 10
Thoracic Spine
Ulrich Baum, MD
Institute of Diagnostic Radiology, University of Erlangen-Nuremberg Page 12
Thoracic Cord Herniation Through Ventral Dural Defect
Daniel A. Finelli, M.D.
Section of Neuroradiology,The Cleveland Clinic Foundation Page 14
Wrist
Micheal Lell, MD
Institute of Diagnostic Radiology, University of Erlangen-Nuremberg Page 16
Bilateral Renal Angiomyolipoma
Cheng Hong, MD, Roland Bruening, MD
Klinikum Grosshadern, University of Munich Page 18
Supraglottic and Glottic Larynx Cancer
Cheng Hong, MD, Roland Bruening, MD
Klinikum Grosshadern, University of Munich Page 20
Squamous Cell Carcinoma of the Oropharynx
Micheal Lell, MD
Institute of Diagnostic Radiology, University of Erlangen-Nuremberg Page 22

3
Petrous Bone

History: Results:
64-year-old female patient with a hearing deficit on Computed tomography confirms the suspicion of a
the right side for the last 6 months. The computed tomo- cholesteatoma on the right side. There is a small formation
graphy exam was performed in clinical suspicion of a at the top of the middle ear and the external auditory
cholesteatoma on the right side. canal. The malleoincudal articulation is fixed by the tumor.
This is more impressive in the coronal plane than in the
axial plane. In axial plane there is only the suspicion of
Technical data: fixation of the auditory ossicles over a short distance; in
the coronal plane you can clearly see that the malleolus
Scan
is fixed by the tumor over a long distance. The anatomy of
Region Petrous bone
the inner ear and the mastoid cells are normal.
Scan length 40 mm
Slice collimation 2 x 0.5 mm
Table feed/rotation 1 mm
Pitch 1
Comments:
In another case (case 2) we reported about a new special
Scan direction caudocranial
scan mode called UHR (Ultra High Resolution) implemented
Rotation time 0.75 s
in the SOMATOM Volume Zoom. Ultra High Resolution
kV 140
improves the spatial resolution in the scan plane but not in
mAs 200
the longitudinal axis. A further improvement implemented
Kernel U80
in the SOMATOM Volume Zoom is the reduced slice colli-
Scan time 62 s
mation of 0.5 mm. 0.5 mm slices allow an improved spatial
resolution along the longitudinal axis. A slice thickness of
Image reconstruction
0.5 mm means nearly isotropic imaging of petrous bone
Reconstructed slice width 0.5 mm
with a voxel size of 0.2 x 0.2 x 0.5 mm 3 and improves the
Reconstruction increment 0.3 mm
visibility of details in the multiplanar reconstructions.

Postprocessing
Multiplanar reformations +

4
a b

Fig. 1: Axial plane. A differentiation of tumor parts in the external auditory

Sharp delineation of the malleoincudal articulation, canal and the middle ear is not possible.
the inner ear, the canal for facial nerve and the mastoid. Osteodestruction cannot be excluded. Fixation of the
Soft tissue formation at the top of the middle ear. auditory ossicles is suspected.

a b
Fig. 2: Multiplanar reformations.
Isotropic imaging allow high resolution MPR without to the auditory ossicles and the extent in the middle
step artifacts. The MPR show the contact of the tumor ear and the external auditory canal.

5
Petrous Bone

History: Results:
54-year-old male patient with hearing deficiency The anatomy of the inner, middle ear and the mastoid cells
(more pronounced on the left side than on the right). are normal. CT can rule out a capsular otosclerosis.

Comparison of high and ultra high resolution images

Technical data: demonstrates a much better delineation of the ossicular
chain in the middle ear, the ossicular joints and the bone
Scan
structure of the mastoid.
Region Petrous bone*
Scan length 46 mm
Slice collimation
Table feed/rotation
4 x 1 mm
2.7 mm
Comments:
UHR stands for Ultra High Resolution. This is a special
Pitch 2.7
scan mode implemented in the SOMATOM Volume Zoom
Scan direction caudocranial
– the new multislice spiral CT scanner from Siemens. In
Rotation time 0.75 s
addition to the normal detector collimator, a special proce-
kV 140
dure has been developed for fine collimation. This allows to
mAs 140
achieve the ultra high resolution of bony structures within
Kernel U80/H70
a 25 cm scan FOV. Besides, the shorter scan time (0.75 s)
Scan time 14.7 s
also reduces the motion artifacts and improves the visibility
of detail (better delineation of the ossicular chain, the semi-
Image reconstruction
circular canals and the cochlea).
Reconstructed slice width 1 mm
Reconstruction increment 0.5 mm

Postprocessing
Multiplanar reformations +

* The same region was scanned twice with the same

parameter in UHR (Ultra High Resolution) mode and
normal HiRes mode.

6
a b a b
Fig. 1: Superior semicircular canal. Normal anatomy. Fig. 2: Internal auditory canal and lateral semicircular.
Fig. 1a without, Fig. 1b with UHR. Normal anatomy. Fig. 2a without, Fig. 2b with UHR.

a b a b
Fig. 3: Malleoincudal articulation. Normal anatomy. Fig. 4: Cochlea and malleoincudal articulation.
Fig. 3a without, Fig. 3b with UHR. Normal anatomy. Fig. 4a without, Fig. 4b with UHR.

Fig. 5: MPR (Coronal).

Fig. 5a without, Fig. 5b with UHR.

7
Sinuses

History:
A 12-year-old male patient has a history of surgery on
bilateral cholesteatoma. CT was performed to rule
out a recurrent cholesteatoma. Furthermore a chronic
sinusitis was suspected.
Results:
After prosthetic stapedectomy, a recurrent cholesteatoma
is found on the left side, while normal postoperative findings
after tympanoplasty on the right. Multiplanar reformations
of the paranasal sinuses allow ruling out thickening of the
mucosa or polyps in the sinuses.

Technical data:
Comments:
Scan
The conventional rule of the petrous bone study with single
Region frontal sinus to alveolar
slice CT was oriented parallel to the orbito-meatal line,
body of maxilla
and the sinus study was performed in the coronal plane in
Scan length 108 mm
order to visualize the fine bony structures in the axial plane
Slice collimation 4 x 1 mm (UHR mode*)
(floor of the orbit, cribrose plate). This was because the
Table feed/rotation 2.7 mm
image quality of the secondary multiplanar reformations was
Pitch 2.7
not optimal, i. e. the stepping artifacts were not avoidable
Scan direction craniocaudal
completely. Therefore, the gantry tilt has to be applied, the
Rotation time 0.75 s
scan has to be performed twice (axial and coronal) and
kV 140
the patient has to undergo a difficult positioning for coronal
mAs 165
scan.
Kernel U80
Scan time 20 s
The UHR mode with the SOMATOM Volume Zoom allows
imaging of the petrous bone with Ultra High Resolution
Image reconstruction
in the axial plane as well as optimal coronal reformations
Reconstructed slice width 1 mm
of the middle ear and the paranasal sinuses. The image
Reconstruction increment 0.5 mm
quality of the multiplanar reformations is comparable to the
direct coronal scan without noticeable stepping artifacts.
Postprocessing
Assessment of bony structures parallel to the axial plane
Multiplanar reformations +
becomes possible. Therefore, a second examination in the
* Ultra High Resolution mode axial and coronal plane is no longer necessary for studies
involving the midface and the petrous bone (axial slice
orientation) as well as the base of the skull, the floor of the
orbit or the hard palate (coronal slice orientation).

8
Fig. 1: Axial image. Fig. 2: Coronal MPR.
Ethmoidal sinuses. Normal anatomy. Maxillary and ethmoidal sinuses. Assessment of the
base of skull and the orbital floor without stepping or
metal artifacts.

Fig. 3: Coronal MPR (left side). Fig. 4: Coronal MPR (right side).
Metallic stapes prothesis after postsurgical defect Tympanoplasty Typ V.
of the auditory ossicles. Cholesteatoma around the Correct attachment of the tympanoplasty.
prothesis.

9
Lung Fibrosis

History: Image reconstruction

69-year-old female patient suffering from progressive Reconstructed slice width 1.25 mm/5 mm

dyspnea since six months. Decreased physical performance Reconstruction increment 1 mm/2.5 mm

for months, Raynaud’s phenomenon for over 20 years,

pronounced dryness of mouth and eyes. Slow recovery Postprocessing

after a febrile infection. The patient complains of left sided Multiplanar reformations +

discomfort associated with breathing, which is most

pronounced with deep inspiration. The conventional chest
X-ray shows an increased interstitial pattern in the left
lower lobe and a left sided pleural effusion. Unremarkable
bronchoscopy, increased lymphocyte count with increased
CD4/CD8 ratio in the bronchoalveolar lavage. Pulmonary
function test revealed a slightly decreased diffusion capacity.

Technical data: Results:

Enlarged mediastinal and left hilar lymph nodes. Streaky
Scan
peribronchial thickening in the left lower lobe, left sided
Region apex of the lung to adrenal glands
pleural effusion. The high resolution images show bilateral
Scan length 272 mm
micro nodules and ground glass opacities.
Slice collimation 4 x 1 mm
Diagnosis: Pulmonary involvement in systemic sclerosis
Table feed/rotation 6 mm
with secondary Sjögren’s syndrome. Pulmonary fibrosis
Pitch 6
after left lower lobe pneumonia.
Scan direction caudocranial
Rotation time 0.5 s
kV 140
mAs 165 Comments:
Kernel B50/B30 The so called “Combi-Scan“, the acquisition of a high
Scan time 23.35 s resolution volume data set with reconstruction of images
of different slice thickness yields conventional and high-
Contrast Injection
resolution CT images from one scan. This results in
Volume 120 ml (non-ionic contrast medium)
decreased radiation exposure, a gap free HR-CT data set,
Concentration 300 mg iodine/ml
and thus optimal conditions for 2D and 3D image post-
Flow rate 2.5 ml/s
processing.
Start delay 50 s

10
Fig. 1a: Coronal MPR, slice width 1.25 mm. Fig. 1b: Coronal MPR, slice width 5 mm.
Fibrotic changes in left lower lobe. Degradation of image quality due to reduced
Clear delineation of bronchi and interlobes. z-resolution.

a b

Fig. 2a: Enlarged lymph nodes in the upper

mediastinum.
Fig. 2b: Axial image (high resolution) showing
inhomogenous distribution of ground glass opacities
and fibrotic changes in left lower lobe.

Fig. 3: Sagittal MPR

Peribronchial thickening and ground glass opacities
indicating active process.

11
Thoracic Spine

History: Results:
52-year-old female patient with known bone metastases CT shows a diffuse mixed osteolytic and osteosclerotic
from breast carcinoma. The MR study of the thoracic spine metastatic involvement of the entire thoracic spine,
indicates loss of height of several vertebras in the middle predominately affected are the 2nd, 4th, 7th, 11th and 12th
section. For planning of possible surgery or radiation therapy vertebras. Metastases are found not only in the vertebral
a CT study of the spine was required. bodies but also in the pedicles and spinous processes.
Sagittal MPRs show a slight ventral compression of the
anterior part of the 7th vertebra, but normal height of the
Technical data: posterior part. Sagittal MPR further exclude significant loss
of vertebral body height of the other vertebras.
Scan
Region first thoracic vertebra to
first lumbar vertebra
Scan length 273 mm
Comments:
Multislice spiral CT makes it possible to scan a large
Slice collimation 4 x 1 mm
section of the spine (e. g. the entire thoracic segment) with
Table feed/rotation 4 mm
high, almost isotropic resolution. This provides optimal
Pitch 4
secondary image reformations (e. g. MPR, SSD).
Scan direction craniocaudal
Indications for large section with high resolution imaging
Rotation time 0.75 s
of the spine are found in trauma cases and for therapy
kV 140
planning (surgery, radiation therapy) in bone metastases
mAs 210
as well.
Kernel B60
Scan time 59 s

Image reconstruction
Reconstructed slice width 1 mm/3 mm
Reconstruction increment 1 mm/3 mm

Postprocessing
Multiplanar reformations +

12
a
b spinal canal.
Fig. 1: Sagittal MPR.
The sagittal MPRs show diffuse osteolytic metastases
of the thoracic spine and additionally osteosclerotic
metastases of the 2nd, 4th, 7th, 11th and 12th vertebral body.
Slight compression of the anterior part, but exclusion
of loss of height of the posterior part of the 7th vertebra
(b). Normal width of the spinal cord.
Fig. 2: Axial image.
Osteosclerotic metastases of the body of the vertebral
body and the right posterior pedicle. No stenosis of the
Fig. 3: Axial image.
Osteosclerotic metastases of the right part of the
vertebral body, both posterior pedicle and the left rib.
Normal width of the spinal canal.
13
Thoracic Cord Herniation Through Ventral Dural Defect
History:
The patient is a 67-year-old woman who had experienced
progressive left sided pain, numbness, and burning sen-
sation, extending from her mid chest level to the left leg and
foot over the past nine months. She also had right sided
leg weakness, especially in the knee and hip regions. These
symptoms were making it very difficult for the patient to
walk, and she had sustained several falls, though without
serious injury. The patient had been evaluated by several
neurology and spine surgery consultants at another insti-
tution, who felt her constellation of symptoms, referred to
as a Brown-Sequard Syndrome, suggested a right sided
spinal cord lesion at the T8-9 level. The patient had an
extensive workup including spinal tap, electromyographic
(EMG) studies, MRI scans of thoracic and lumbar spine,
and thoracolumbar myelogram with CT myelography,
without reaching a definitive diagnosis, but her physicians
felt they had excluded a compressive, neoplastic, or other
surgical lesion.
The patient was referred to CCF for another opinion, and
on neurologic examination was felt to again have symptoms
suggesting a Brown-Sequard Syndrome, however likely
at a higher level, approximately T4. Review of the outside
MRI studies demonstrated a local anterior and rightward
deviation in the position of the spinal cord at T4, with a
deformed local contour of the cord, and an associated thin
collection of fluid in the anterior epidural space; findings
which had not been appreciated previously. The outside
thoracolumbar myelogram and CT was found to have been
targeted at the T8 level, and did not include adequate
evaluation of the upper thoracic levels. The MR findings were
quite suspicious for the rare clinical condition of a ventral
spinal cord herniation through a dural defect.
14
Technical data:
For optimal further evaluation, confirmation, and pre sur-
gical planning, the decision was made to perform another
thoracic myelographic study, targeted at the T4 level, with
post myelographic, high resolution spiral CT study on
the Siemens SOMATOM Volume Zoom scanner. The high
speed, high resolution attributes of the multislice array
allowed a 1 mm spiral dataset to be obtained in a single
breathhold. This yielded an extremely detailed, artifact-free
set of images and multiplanar reconstructions for neuro-
radiologic analysis and surgical planning, far superior to the
patient’s prior CT or MRI studies.
Results:
The study clearly demonstrated the ventral, right-sided
dural defect at T4-5, with contrast laden CSF both in the
thecal sac, and in the anterior, epidural CSF collection, thus
clearly outlining the dural margins. The thoracic spinal cord
was shown to be herniated into and partially through the
dural defect. The cord was deformed locally, with the CT
myelographic study clearly demonstrating a “pinching“
of the cord at the margins of the dural tear. The study also
showed that the T4-5 disk space was abnormal, with
evidence of a remote right sided disk herniation, which had
healed. This was likely the cause of the dural tear.
The patient was taken to surgery, where T4-5 laminectomy
was performed. The dorsal thecal sac dura was incised,
exposing the spinal cord, which was carefully freed from
the herniation. A 2 cm long tear in the anterior dura was
found and repaired, and the dorsal dural incision was closed.
The patient had an uneventful post operative course,
and had an improvement in her neurologic deficits on the
first postoperative day. She is now three weeks post-op,
has undergone physical therapy, and has experienced near
complete resolution of her symptoms.
Summary
In this case, the combination of clinical, surgical, and neuro- Zoom, allowed the diagnosis of a rare spinal cord
radiological expertise of CCF physicians, coupled with the abnormality, the treatment of which kept a patient from
imaging capabilities of the Siemens SOMATOM Volume becoming wheelchair bound.

a b

Fig. 1a: Axial post-myelographic CT image at the Fig. 1b: Axial CT image at T4-5, shows the ventral,
level of T6 demonstrates the anterior extradural fluid right-sided dural defect, with herniation of the thoracic
collection containing myelographic contrast-laden spinal cord through the defect, causing pinching and
cerebrospinal fluid, clearly outlining the ventral dura. local deformity of the cord.

c d

Fig. 1c, and Fig. 1d: parasagittal multiplanar recon- dural defect, centered at the disk space. Note the
struction of the axial CT data shows the local deviation deformity of the upper end plate of T5, and the mild
and deformity of the spinal cord at T4-5, where it is ventral impression due to remote disk protrusion,
herniated through the 2 cm cranio-caudal dimension which was suspected to be the cause of the dural tear.

15
Wrist

History: Results:
A 36-year-old patient who fell playing squash. Moderate Fracture in the middle third of the scaphoid bone without
swelling and pain of the wrist, typical triggerpoint at fragment dislocation.
Tabatièr. Suspected fissure of the scaphoid on conventional
X-ray. After temporary immobilization, a CT scan was per- CT scan was performed with patient lying prone, immo-
formed to confirm diagnosis. bilized arm over head, longitudinal axis of scaphoid in
scan plane. Despite plaster, good image quality could be
achieved. With the high resolution achieved by using
Technical data: the Ultra High Resolution mode (UHR), subtle assessment
of the trabecular bone is possible. Thin slices with small
reconstruction increment is the basis for optimal 2D and
Scan
3D imaging. MPRs in sagittal and coronal plane allow easy
Region distal radioulnar articula-
recognition of anatomy and exact assessment of joints.
tion to metacarpal bones
Interactive volume rendering, especially with stereoscopic
Scan length 44 mm
view, creates a spectacular view of the anatomy and the
Slice collimation 4 x 1 mm (UHR* mode)
fragments, helping both patients and surgeons to visualize
Table feed/rotation 3 mm
the pathology in 3-dimension.
Pitch 3
Scan direction craniocaudal
Rotation time 0.75 s
kV 120
mAs 90
Kernel U80
Scan time 12.2 s

Image reconstruction
Reconstructed slice width 1 mm
Reconstruction increment 0.3 mm

Postprocessing
Multiplanar reformations +
VRT +

* Ultra High Resolution

1
Fig. 1: Axial images show fracture in the middle third
of the scaphoid.

16
2 3
Fig. 2 and 3: Multiplanar reformations in planes demonstrate fracture, allowing exact assessment of
parallel to the radial bone and in the radio-ulnar plane, the joints and fragments.

4 5
Fig. 4 and 5: Volume rendering can create opaque and
transparent image of the scaphoid and the relation of
the fragments.

17
Bilateral Renal Angiomyolipoma

History: Image reconstruction

A 34-year-old male presented with a one-year history of Reconstructed slice width 1.25 mm

abdominal pain. He described this pain as being cramping Reconstruction increment 0.8 mm

at times, easing off when walking around. He felt that his

abdomen had become swollen and heavy over the previous Postprocessing

2 months. In the clinical examination, a huge soft mass Multiplanar reformations +

was found in the abdomen. Ultrasound examination showed

large masses in both kidneys. An abdominal CT was per-
formed.

Technical data: Results and comments:

Abdominal spiral scanning with a multislice spiral CT scanner Angiomyolipomas are seen on CT as circumscribed renal
(SOMATOM Volume Zoom, Siemens Medical Engineering, masses. The presence of intratumoral fat is almost diag-
Forchheim, Germany), and multiplanar reformations (MPR). nostic of angiomyolipomas. Problems in diagnosis occur
when angiomyolipomas are composed predominantly of
Scan
muscle or vascular tissue and contain only minimal amounts
Region Abdomen (Venous phase)
of fat. Such small amounts of fat can be easily overlooked
Scan length 300 mm
unless searched for carefully in the CT study. The recent
Slice collimation 4 x 1 mm
multislice CT technology offers the potential to cover much
Table feed/rotation 6 mm
larger anatomic areas without sacrificing image resolution
Pitch 6
or quality and to clearly identify the fat-containing areas
Scan direction craniocaudal
when compared to the single slice CT technology. This is
Rotation time 0.5 s
evident in this case (Fig. 1).
kV 120
mAs 130
The thin slice (4*1 mm) acquisition and reconstruction
Kernel B20
(1.25 mm) with an increment of 0.8 mm (36 % overlap) pro-
Scan time 25.9 s
vide the possibility to achieve a high quality coronal MPR
image (Fig. 2). This allowed us to evaluate the abdominal
Contrast Injection
mass and determine the relationship between the mass
Volume 120 ml (non-ionic contrast medium)
and its surrounding structures so that we could provide
Concentration 300 mg iodine/ml
clearer diagnostic information for the surgery planning.
Flow rate 3.5 ml/s
Start delay 70 s

18
Fig. 1: Patient with bilateral renal angiomyolipoma.
Coronal reformatted image shows huge multiple
bilateral renal masses. The kidneys are all displaced.
The lesions contain low-density areas consistent
with fat.
Fig. 2: Coronal reformatted image generated from
the axial data set. There is extensive involvement of
perinephric space by the bilateral angiomyolipomas.
19
Supraglottic and Glottic Larynx Cancer

History: Results and comments:

A 58-year-old male with history of smoking with swallow- This case illustrates the advantages of multislice spiral CT.
ing disorder of three months. It affords the ability to simultaneously evaluate the soft
tissue mass and the surrounding structures (Fig. 1). The
increasing pitch and subsecond scan time allowed cover-
Technical data: age of the entire cervical region in one spiral. This shorter
Spiral scanning with a multislice spiral CT scanner examination time reduces the number of motion artifacts
(SOMATOM Volume Zoom, Siemens, Forchheim, Germany), and represents an advantage for patients who are not able
and multiplanar reformations (MPR). to cooperate. The kernels used ensure a high quality soft
tissue detail.
Scan
Region Hyoid to subglottic space
In this case, one could argue that multiplanar reformatted
Scan length 160 mm
images are actually more critical than the axial images
Slice collimation 4 x 1 mm
themselves. Coronal and sagittal reformatted image of axial
Table feed/rotation 4 mm
sections can be useful to evaluate the extent of different
Pitch 4
lesions (Fig. 2). In special cases concerning the laryngeal
Scan direction craniocaudal
skeleton, high resolution CT with a slice width of 1 mm is
Rotation time 0.5 s
possible.
kV 120
mAs 110
Kernel B30
Scan time 21.56 s

Contrast Injection
Volume 80 ml (non-ionic
contrast medium)
Concentration 300 mg iodine/ml
Flow rate 3 ml/s
Start delay 40 s

Image reconstruction
Reconstructed slice width 1.25 mm
Reconstruction increment 1.0 mm

Postprocessing
Multiplanar reformations +

20
Fig. 1: Patient with right-sided supraglottic and glottic
carcinoma. Axial image demonstrates clearly soft
tissue detail, the infiltration of the pre-epiglottic fat and
the adjacent structures.
Fig. 2: The sagittal reformatted image displays the
extent of the tumor. Step artifacts are negligible due to
the thin collimation used to acquire the original axial
images. The extensive tumor spread cranially is well
documented.
21
Squamous Cell Carcinoma of the Oropharynx

History: Results:
57-year-old male patient with progressive swallowing The depth of the tumor infiltration is best visualised with
disorder. History of nicotine and alcohol abuse. a combination of axial and reformated coronal and sagittal
Clinical examination raises suspicion of a tonsillar carcinoma images. MPR images minimize partial volume effects
with infiltration of the tongue and enlarged right sided and allow better tumor delineation. Critical areas like the
cervical lymph nodes. parapharyngeal, paralaryngeal, preepiglottic and preverte-
bral space can be visualised in their full extension.
Infiltration of the base of the skull with bone destruction
Technical data: can be diagnosed without additional coronal scanning.
Criteria for lymph node malignancy, known from ultra-
Scan
sound, like the L/T quotient (ratio of maximal longitudinal
Region base of skull to aortic arch
to maximal axial diameter) are more practicable. This leads
Scan length 260 mm
to more accurate staging, and pathology can be better
Slice collimation 4 x 1 mm
demonstrated to the clinical partner, allowing easier imagi-
Table feed/rotation 6 mm
nation of the situs than with axial images.
Pitch 6
Scan direction craniocaudal
Rotation time 0.5 s
kV 120
mAs 165
Kernel B30
Scan time 22.4 s

Contrast Injection
Volume 150 ml (non-ionic
contrast medium)
Concentration 300 mg iodine/ml
Flow rate 2.5 ml/s
Start delay 80 s

Image reconstruction
Reconstructed slice width 4 mm/1.25 mm
Reconstruction increment 2 mm/1 mm

Postprocessing
Multiplanar reformations
Fig. 1: Tumor infiltrating right floor of the mouth, base
+ of the tongue and tonsillar space. Typical rim enhance-
ment of ipsilateral lymph node metastasis.
Calcified plaque dorsally in the left carotid bifurcation
leading to an asymptomatic internal carotid artery
stenosis.

22
Fig. 2: Central hypodensity indicating tumor necrosis.
Tumor spreads close to the mandible, but there is no
bony destruction. Parapharyngeal space is obliterated
by tumor. Small lymph nodes along the great vessels
on both sides with no signs of malignancy.
Fig. 4: Sagittal image demonstrates size of tumor in
relation to intrinsic muscles of the tongue, the floor of
the mouth and the valleculae epiglotticae as well as
the hard and soft palate. Good delineation of the spatium
retropharyngeum, the hypodense space between the
prevertebral fascia and the pharynx.
Fig. 3: Coronal image clearly demonstrates
craniocaudal tumor spread and relation to adjacent
structures like the submandibular glands.
Fig. 5: Sagittal images allow accurate assessment
of lymph nodes. Lymph node metastases ventral
of internal jugular vain, lymph nodes without signs
of malignancy dorsal.
23
This Issue’s Authors
Ulrich Baum, MD
Institute of Diagnostic Radiology
University of Erlangen-Nuremberg
Maximiliansplatz 1, D-91054 Erlangen
Germany
Impressum
Published by
CT Marketing
Siemens AG
Medical Engineering
Siemensstrasse 1
91301 Forchheim, Germany
Correspondence
and U.S. Distribution
Barbara Cammisa
Siemens Medical Systems, Inc.
186 Wood Avenue South
Iselin, NJ, 08830, USA
Phone +01 412 351 0803
Fax +01 732 321 3291
eMail barbara.cammisa@
exchange.sms.siemens.com
Micheal Lell, MD Daniel A. Finelli, MD
Institute of Diagnostic Radiology Section of Neuroradiology
University of Erlangen-Nuremberg The Cleveland Clinic Foundation
Maximiliansplatz 1, D-91054 Erlangen 9500 Euclid Avenue, Cleveland,
Germany Ohio 44195
USA
Cheng Hong, MD, Roland Bruening, MD
Department of Diagnostic Radiology
Klinikum of the
Ludwig-Maximilians-University
Marchioninistr. 15, D-81377 Munich
Germany
International Distribution
Xiaoyan Chen, M.D. George Savatsky, B.A., M.A.
CT Product Creation CT Marketing
Siemens AG, Medical Engineering Siemens AG, Medical Engineering
Siemensstrasse 1 Siemensstrasse 1
91301 Forchheim, Germany 91301 Forchheim, Germany
Phone +49-9191-18-9652 Phone +49-9191-18-8142
Fax +49-9191-18-9998 Fax +49-9191-18-9998
eMail xiao-yan.chen@med.siemens.de eMail george.savatsky@med.siemens.de
Lisa Reid, B.S., R.T. (R)
CT Application Manager
Siemens AG, Medical Engineering
Siemensstrasse 1
91301 Forchheim, Germany
Phone +49-9191-18-8405
Fax +49-9191-18-9998 Order No. A91100-M2100-F236-01-7600
Printed in Germany
eMail lisa.reid@med.siemens.de BKW 62236 WS 010035.