Somatom Sessions 32

SOMATOM Sessions
Answers for life in Computed Tomography
Issue Number 32 / June 2013
Cover Story
True Dual Energy
Succeeds
Page 06
News
Saving Dose,
Reducing Patient Burden
Page 12
Business
Maximum Single
Source Performance
for High-end
Cardiac Imaging
Page 20
Clinical
Results
Free-breathing
Coronary CTA with
Double Flash Spiral
Protocol
Page 32
Science
Finding the Right Dose
with the Right Tools
Page 40
Editorial
We see our role as supporting

institutions in achieving the
right dose that delivers high
diagnostic image quality while
exposing the patient to only
as much dose as required.
Peter Seitz, Vice President Marketing,
Computed Tomography, Siemens Healthcare, Forchheim, Germany
Cover page: Courtesy of Erasmus Medical Center, Rotterdam, the Netherlands
2 SOMATOM Sessions June 2013 www.siemens.com/SOMATOM-Sessions
Editorial
Peter Seitz,
Vice President Marketing,
Computed Tomography,
Siemens Healthcare,
Forchheim, Germany
Dear Reader,
In this issue youll read about the inroads
that Dual Energy imaging has made and
continues to make in CT routine today.
At centers such as Grosshadern Hospital
at the University of Munich, more than
50 percent of all abdominal scans are now
performed using Dual Energy. And while
back in the early days in 2005 Dual Energy
was limited to Dual Source scanners,
Single Source applications as found on
the SOMATOM Definition Edge are
becoming standard. And in radiation
therapy planning, Dual Energy can help
to reduce metal artifacts.
Moreover, its use in combination with
the latest Dual Source technology delivers
highly valuable additional information
even for delicate patients; for example
when imaging infants with congenital
heart or lung disease. Recently, researchers from Japan have also shown the
positive impact on oncology treatment
decisions in complicated structures of
the neck.
Some months ago, I introduced our shift

in focus from the lowest dose to the right
dose in CT. In this issue, youll find more
examples of institutions that use the
entire current portfolio of dose reduction
techniques to achieve average dose values that are constantly and significantly
below the reference values of national
authorities. Of course, a permanent reduction in average dose values is what really
counts as impressive as a single low
dose case can be.
CARE kV does this by making it very
easy to use the lowest possible kV setting,
especially in small patients with low
attenuation, and in contrast examinations
where lower kV settings provide better
iodine display. SAFIRE does this by making powerful noise and therefore dose
reduction available with reconstruction
times of merely a few seconds. When you
combine both with the hardware-based
noise reduction of the Stellar Detector,
youll be surprised how far your average
dose values can drop.
So that we can share even more examples, were launching the third round of
our CT image contest in June focusing
on the right dose in CT. The Right Dose
Image Contest 2013 will once again be
supported by a jury of globally renowned
experts, this time consisting of members
of SIERRA (Siemens Radiation Reduction
Alliance). Across several categories, they
will choose the institutions that best
demonstrate how they achieve images
at the right dose for an ideal balance
between diagnostic quality and low radiation. For the first time, a new category
will be given for consistency in dose
reduction. And youll have the opportunity to present your finest cases to the
world on your own profile page.
Enjoy these and many more topics in
this issue and dont forget to check out
our SOMATOM Sessions App.
Best regards,
Peter Seitz
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.
SOMATOM Sessions June 2013 www.siemens.com/SOMATOM-Sessions
Content
xx
12
Content
Cover Story
xxxx
Siemens
Saving
Dose, International
CT
Image Contest
2011
Reducing
Patient Burden
Cover Story
06 True Dual Energy Succeeds
06 Radiologists and technicians

across the globe are breaking new
ground in CT imaging with Dual
Energy (DE). SOMATOM Sessions
talked to four leading experts
about their clinical experiences
in routine and research areas, the
possibilities for sharper contrast,
significant metal artifact reduction, and new prospects on the
horizon.
News
12 Saving Dose, Reducing Patient Burden

14
FAST Spine A Story of Best Practice
in Spine Reconstruction
16 Rib and Spine Assessment in Acute
Care with syngo.CT Bone Reading
16 Right Dose Image Contest 2013
17 Expanding the Clinical Portfolio with
the Siemens Intervention Solution
18 Unique Technology for Improved
Routine and New Research Opportunities
16
Right Dose Image

Contest 2013
Business
20 Maximum Single Source Performance
for High-end Cardiac Imaging
Clinical Results

Cardiovascular
22 Coronary CTA with 80 kV: Improving
Image Quality with Reduced Radiation
and Contrast Medium Dose
24 70 kV CT Pulmonary Angiography
in an Adult Patient with a Dose
of < 1 mSv and PA Attenuation of
> 1,000 HU
26 Dual Source CT: Assessment of
Hypoplastic Arch Associated with
Ductus Arteriosus
28 Cardiac CT in a 5-Month-Old Baby
with VACTERL Syndrome after Cardiac
Surgery
Content
24
70 kV CT Pulmonary
Angiography
32
Free-breathing Coronary CTA

with Double Flash Spiral Protocol
40
Finding the Right Dose

with the Right Tools
Science
30 Evaluation of Femoral Artery Pseudoaneurysms with Arteriovenous Fistula
using CTA Runoff Scanning
32 Free-breathing Coronary CTA with
Double Flash Spiral Protocol
Oncology
34 Squamous Cell Carcinoma of the
Head and Neck: Volume Perfusion CT
36 Diagnosis of Rectal Tumor using
SOMATOM Perspective
Neurology
38 Dose Reduction in Head CT
Examination using SAFIRE
40 Finding the Right Dose with the

Right Tools
43 New Opportunities in Cancer
Detection with Hepatic AEF
44 Image Quality in Computed
Tomography
50 Tips & Tricks: How to Accelerate

Reconstruction of Dual Energy Data
51 Clinical Workshops 2013
51 Upcoming Events & Congresses 2013
Customer
Excellence
53 Imprint
52 Subscriptions
48 syngo Evolve Update for SOMATOM

Definition Family Members
49 Workshop on Dual Energy at CT
Headquarters in Germany
49 CT Physics Made Easy with New
Webinar
Cover Story
True Dual Energy Succeeds

Radiologists and technicians across the globe are breaking new ground
in CT imaging with Dual Energy. SOMATOM Sessions talked to four
leading experts about their clinical experiences in routine and research
areas, the possibilities for better contrast, significant metal artifact
reduction, and new prospects on the horizon.
By Wiebke Kathmann, PhD
Exciting technical innovations in computed tomography imaging continue.

Dual Energy (DE) scanning in particular
has been expanding rapidly since it
became available for the first time on
a commercial multislice CT scanner.
Back in 2005 DE was introduced to the
market on the Dual Source CT scanner
SOMATOM Definition.
More and more radiologists rely on
True Dual Energy CT from Siemens due
to remarkable features such as:
1. Improved diagnostic options
2. No extra dose with Dual Source Dual
Energy scans
3. Applicable to almost all clinical
challenges and most patients
We are working on
the Single Source
scan mode because
I am convinced
that Single Source
DE allows a specific and quantitative assessment
of iodine uptake.
Thorsten Johnson, MD,
University Hospital Munich,
Campus Grohadern, Germany
Beyond morphology
True DE supplies additional information
compared to a conventional CT scan for
Dual Source DE and dose optimized for
Single Source DE. In conjunction with
high spatial and temporal resolution, DE
applications are used to great effect both
in routine clinical practice and research.
DE is most widely applied to characterize
material, e.g. in kidney stones or gout.
Dual Source DE is also well established
in heart imaging that is prone to motion
artifacts due to breathing and movement
of the beating heart. In the meantime,
True Dual Energy is also available on the

Siemens Single Source CT scanner fleet
ranging from any configuration of the
SOMATOM Definition AS to the SOMATOM
Definition Edge. And progress continues:
other applications are now also making
their way from research into clinical
practice. Four experts describe how they
integrate DECT in their daily routine and

outline their research interests.
Munich, Germany: Research

into Single Source DE
At University Hospital Munich, Campus
Grohadern, Germany, there always has
been a strong focus on DECT imaging.
Cover Story
Today, about 50 percent of all abdominal

CT examinations are routinely performed
with DE. As one of the clinical innovators
of Dual Source CT applications, Thorsten
Johnson, MD, explains that their experience has mostly been with Dual Source
DE. He has been involved since the early
days and co-developed many algorithms
along the way. At present, his research
focuses on Single Source DE on the
SOMATOM Definition Edge. If the differentiation of cancerous lesions and blood
filled cysts was possible this application
would have broad clinical relevance and
would be of great interest to a range of
users, for instance oncological centers.
The different behavior of iodine uptake
may help distinguishing between cysts,
which do not enhance, and iodine uptaking lesions. Johnsons team is working
on the Single Source DE scan mode as
he is convinced that Single Source DE scan
mode on the SOMATOM Definition Edge
might also be very specific for iodine as
on the Dual Source scanners. Usually, if
you want to quantify the iodine uptake
of a lesion, you perform scans with and
without contrast medium. With the Single
Source DE scan mode on the SOMATOM
Definition Edge you can perform two
scans directly consecutively at half dose
with the benefit of the additional DE.
Johnsons team has had promising initial
With Dual Source DE,

potential problems
can be discovered earlier and with greater
precision, helping
improve a patients
quality of life.
Mohamed Ouhlous, MD, PhD,
Erasmus Medical Center,
Rotterdam, the Netherlands
results in recent cases with excellent

image quality at a low dose level (Fig. 1).
Rotterdam, the Netherlands:

DECT in infants no sedation
with no dose penalty
Only recently, experts from the cardiovascular imaging group at the radiology
department at the Erasmus Medical
1
1 DECT of a liver
with a hypodense
mass. The case
was acquired with
SOMATOM
Definition Edge.
Courtesy of
University Hospital
Munich, Campus
Grohadern,
Germany
Center in Rotterdam, the Netherlands,

started using Dual Source DE in pediatric
scans. Their goal: To enable well-founded
treatment decisions based on anatomical
and functional information without the
need for sedation or anesthesia, or indeed
without increasing radiation dose. As
senior radiologist Mohamed Ouhlous, MD,
PhD, explains, the purely anatomical
information supplied by conventional CT
is not sufficient for children with congenital heart and lung disease. We also
need quantitative information, for example on ventilation and perfusion, for the
pediatric cardiologist and pulmonologist.
Therefore, we started to explore other
imaging modalities. We were convinced
that DECT could give us the additional
information required once we discovered
that DECT can create images of perfusion defects in adults with lung emboli.
These are generally hard to see, because
of the many collaterals. My reasoning
was: If you can quantify the blood flow
in the lung, why not use it in children
with congenital heart and lung disease?
Step by step the team developed a protocol on the SOMATOM Definition Flash.
First, they replaced the regular CT scans
with Flash scans and noticed that they
could reduce the need for sedation for
Cover Story
their young patients. Even on crying

infants, they could perform the scan
between breaths without artifacts. The
result: Pediatricians requested CT scans
more often. After some initial experience with these young patients using
the Flash protocol, the team moved on
to the issue of lung perfusion, i.e. visualizing iodine distribution of the lung.
Since December 2012, the Erasmus team
has scanned twelve children and infants,
the youngest being one-day old, with
Dual Source DECT. The image quality
has surpassed everyones expectations.
The clinicians in particular were excited.
Dual Source DECT scans provide them
with extra information on abnormalities
that the clinician might not see in the
ultrasound examination. Nowadays, they
want the CT before they start with an
angio so they have a certain roadmap,
says Ouhlous. Compared with angiography, DECT not only has advantages in
iodine and radiation dose, it is also noninvasive using intravenous rather than
intra-arterial contrast application. And it
may potentially help reduce the risks with
2
2 Scan of a
7-month-old child
with congenital
heart defect using
1.4 mSv effective
dose. The patient
was scanned
with SOMATOM
Definition Flash
(Dual Source DE)
and evaluated
with syngo.CT
DE Lung Analysis
(syngo.via VA20).
Courtesy of
Erasmus Medical
Center, Rotterdam,
the Netherlands
sedation or anesthesia that some other

techniques entail. Ouhlous concludes
that good information can be gained by
Dual Source DE techniques. Therefore,
3A
Dual Source DE is used regularly for this

specific group of patients and is now
an accepted imaging tool for congenital
heart and lung diseases that might
3B
3 Negative cartilage invasion of the thyroid cartilage imaged with DECT in a 65-year-old man with hypopharyngeal cancer
(weighted average (WA) image, Fig. 3A; iodine overlay (IO) image, Fig. 3B).
Courtesy of National Cancer Center Hospital East, Chiba, Japan
Cover Story
affect the children later in life. Potential

problems can be discovered earlier and
with greater precision.
Chiba, Japan: Dual Source DE

may avoid overtreatment
Another pioneer of DECT in oncological
radiology, Hirofumi Kuno, MD, is staff
radiologist at the National Cancer Center
Hospital East in Chiba, Japan. As a specialist in head and neck oncological radiology especially laryngeal and hypopharyngeal squamous cell carcinoma
he sees many patients with these somewhat rare cancers. Hoping to avoid overtreatment of his patients, he was looking
for a CT application that could reliably
discriminate between laryngeal cartilage
and iodine-enhanced tumor tissue. In conventional CT images, both have roughly
the same CT values making them hard
to distinguish. Clinically, however, it is
essential to clarify whether there is thyroid cartilage invasion when deciding on
treatment options.
This is where DECT comes into play. Kuno
saw the potential of DE in distinguishing
iodine-enhanced tumor and cartilage
in CT imaging using syngo.CT DE. Im
not interested in the technology per se,
but in the benefits for the patient, Kuno
states. The benefit of DE is clearly the
positive impact of the high quality images
on the treatment decision. It allows
precise diagnosis of the cancer in spite
of the complicated structures in the neck
and the diversity of appearance, which
often leads to false positive results. Here,
it can make the difference between
organ-conserving therapies (chemo radiation) and more aggressive treatments
(laryngectomy), which potentially have
a major impact on a patients quality of
life due to a possible post-surgery loss
of voice.
As soon as the SOMATOM Definition Flash
was installed at the hospital in March
2010, Kuno began his work. In close collaboration with Siemens, he developed
a scan protocol and investigated whether
it led to improved diagnostic performance.
Little difference was noted in reconstruction time and image evaluation compared with conventional CT scans. The
program prepares the weighted average
From our perspective,

any institution with a
SOMATOM Definition
Flash can start using
Dual Source DE protocol for head and
neck tumors from
one day to the next.
Hirofumi Kuno, MD,
National Cancer Center Hospital East,
Chiba, Japan
(WA) and iodine overlay images (IO).

The WA image allows the evaluation of
the cartilage (invasion, erosion, lysis or
lysis plus extralaryngeal invasion). The
second contrast i.e. the enhancement
pattern on IO images enables the distinction of uptake due to the blood vessels of the cancer tissue as opposed to
blood vessel free cartilage.
By 2012, we had scanned around 300
patients with laryngeal or pharyngeal
cancer. T4 stage is invasion throughout
the cartilage which, according to guidelines, calls for laryngectomy. We are convinced that in this patient population
the tumor could be downstaged to T3
using CT scans with higher resolution.
That should result in a decision to pursue
function-preserving treatment, says
Kuno. He found that using Dual Source
DECT improved specificity and sensitivity
in detecting the extent of cartilage invasion. The results of his study were published in the journal Radiology in October
2012.[1] Kunos conclusion: Combined
analysis of WA and IO images obtained
with DECT improves the diagnostic performance and interobserver reproducibility of evaluations of laryngeal cartilage
invasion by small cell carcinoma. This is
of the utmost importance for the treat-
ment strategy, especially when attempting a function-preserving therapy.

Meanwhile, Kuno examines most of his
head and neck cancer patients using Dual
Source DE. The technology has made its
way from research to clinical routine in
just two years and is now an established
protocol. This was possible as DE scans
always include the normal 120 kV image
so that nothing is lost no extra dose is
applied. The only difference is the need
for more disk space to archive the images.
For the technician, DE scans do not
affect the workflow, explains Kuno. Also,
the time required for the scan and the
iodine dose is the same for the patient.
He truly believes that T4 staging of
laryngeal and pharyngeal cancers may
become much easier for non-specialized
institutions. From our perspective, any
institution with a SOMATOM Definition
Flash can start using Dual Source DE
protocol for head and neck tumors from
one day to the next.
Hamburg, Germany: Exceptional image quality with DE

a must for radiation planning
At Radiologische Allianz an association of practices focusing on radiology,
nuclear medicine and radiation therapy
Cover Story
with nine locations in Hamburg experts

are now using DECT scanning. Their
interest is in metal artifact reduction,
a major issue in radiation therapy. DE
helps in planning radiation therapy for
patients with head and neck cancers,
cancers of the pelvis, or prostate cancer.
In these patients metal artifacts are a
challenge as preceeding treatments using
metal such as seed implantation of 25
to 80 small metal radiation emitting pins,
in patients with prostate cancer, endoprosthesis of the hip or implants in the
mouth cavity affect CT images. All these
metal implants create white stripes and
make it hard to draw the precise outline,
for example of the lymph drainage pathways in the mouth, explains Matthias
Kretschmer, medical physicist. The radiation therapist can no longer define the
target volume, and the medical physicist
can no longer predict the precise radiation dose needed. Single Source DE
produces more accurate images for the
radiation oncologist and helps the physicist to calculate his dose estimate using
more reliable data. Just as with real
estate, what counts in CT images is location, location, location. We can only hit
If a topogram
depicts metal
implants, we
replace the
conventional CT
with a Single
Source DE scan.
Matthias Kretschmer, MSc,
Radiologische Allianz,
Hamburg, Germany
the tumor precisely if the location of the

patient under the linear accelerator is
exactly the same as in the previous planning CT, stresses Kretschmer.
When the Hamburg team started out,
they were still using conventional CT
Single Source DE: The Scan Principle
1st scan
140 kV
2nd scan
80 kV
The Single Source DE scan mode consists of two successive automated spiral
scans at different tube voltage (kV) and tube current (mA) levels. Each scan
is performed at approximately half the dose which confidently comply with
the ALARA principle.
scans; they compared the results with

those from a Single Source DE scan with
a SOMATOM Definition AS 20 Open. This
was necessary as the Hounsfield Units
(HU) change as a result of the monoenergetic application. New correlation
True Dual Energy

DEfinitely excellent images:

Crisp image quality
Information beyond morphology
highlight, characterize, quantify,
and differentiate material
DEfinitely the right dose:

No dose penalty with full number
of projections
All dose saving features applicable
such as SAFIRE and CARE Dose4D
Dedicated protocols and evaluation
software applications for various
clinical questions
Low radiation and contrast media
dose applicable for virtually
all patients from pediatric to older
patients
Cover Story
4A
4B
4 Metal artifact reduction with Single Source DE Monoenergetic: Conventional CT (Fig. 4A); Monoenergetic image at 120 keV (Fig. 4B)
The patient was scanned with SOMATOM Definition AS20 (Single Source DE) and evaluated with syngo.CT Dual Energy (integral part of
syngo.via VA20 advanced user). Courtesy of Radiologische Allianz, Hamburg, Germany
tables for each monoenergetic mode used

in artifact reduction had to be calculated
on the phantom and stored in the planning software. In Hamburg, the team has
the benefit of having Julia Sudmann, PhD,
a medical doctor and radiation therapist
in training on the CT. She can immediately assess the location from the topogram and predict whether hampering
metal artifacts are to be expected. In this
case, conventional CT scans are no longer performed. Instead, the application is
immediately switched to a Single Source
DE scan. After only a few runs, treatment
planning improved in 60 percent of cases
where Single Source DE application was
used, Sudmann recalls.
A decision on whether to use Single
Source DE is made according to the
individual case with the location of the
tumor in relation to the implant being
the strongest determinant. Based on the
scans performed so far, Sudmann finds
Single Source DE has clear advantages

for tumors in the mouth base. For these
patients we will be using Single Source
DE as standard from now on. She sees
a sensible application in patients with
prostate cancer and with permanent
seed implants who have a biochemical
relapse that means an increase in the
PSA value and who need repeated
external radiation. Overall, we will most
likely use it in about five percent of our
patients with head and neck or pelvic
cancers who have endoprostheses or
implants.
To be successful in clinical practice, DE
needs to deliver excellent image quality,
no dose penalty, and broad applicability
to virtually all patients. The experiences
of these four CT experts described in the
interviews show that True Dual Energy
does just this. It is not only well established in the field of research but even
more important in daily clinical routine.
Medical writer Wiebke Kathmann, PhD, is

a frequent contributor to medical magazines
for physicians of German-speaking media. She
holds an MSc in biology and a PhD in theoretical
medicine and has worked as an editor for
many years before becoming freelance in 1999.
She is based in Munich and Karlsruhe, Germany.
Reference
[1] Kuno H et al. Evaluation of cartilage invasion
by laryngeal and hypopharyngeal squamous
cell carcinoma with dual-energy CT. Radiology.
2012 Nov;265(2):488-96.
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/dual-energy
11
News
Saving Dose, Reducing Patient Burden

A plucky physician from St. Louis and technological advances by Siemens are
working together to cut dose levels in pediatric patients to unprecedented levels.
By Ron French
Its difficult for Marilyn Siegel, MD, to

keep a smile off her face these days. For
years, the pediatric radiologist at Washington University School of Medicine and
St. Louis Childrens Hospital has been
leading a campaign of words and research
to lower dose exposure in children. Her
story is one of success, and it is one
shared by the complete line of Siemens
computed tomography equipment.
Spreading the low-dose gospel

In the United States alone, more than
70 million CT scans are performed each
year double the number of a decade
ago. But even with todays technology,
the radiation dose of those scans has a
deleterious cumulative effect on patients
particularly the pediatric patients Siegel
works with each day in St. Louis, Missouri,
USA: Effective dose in children is three
to five times higher than in adults at comparable exposure levels, she said. The
low dose advocate travels around the
globe speaking to physicians about the
importance and methodology of dose
reduction: Even for one-time exams, you
want the dose low. But its particularly
important for patients who come back
for multiple examinations; theyre going
to start accumulating dose. Lung transplant patients are an example.
The goal is to reduce dose, while maintaining or improving image quality. Today,
technology is catching up with Siegels
vision.
The next step in exquisite

images
The Siemens SOMATOM Definition AS,
64-slice configuration, has been the
hospitals workhorse for four years. It is a
Single Source scanner, featuring leading
technologies, like real-time dose modula-
At Washington University School of Medicine and St. Louis Childrens Hospital Marilyn Siegel, MD,
has been leading a campaign of words and research to lower dose exposure in children.
tion CARE Dose4D or the Adaptive Dose

Shield to avoid spiral over-radiation, both
crucial for pediatric scanning. Recent
upgrades to the machine have taken dose
reduction to new lows. In 2011, Siemens
upgraded the SOMATOM Definition AS,
64-slice configuration to include CARE kV,
which automatically adjusts voltage to
match body size and scan type. CARE kV
supplements CARE Dose4D to a complete
automated exposure control for an optimal balance between diagnostic image
quality and lowest possible dose.
Siegel was the first in the United States
to use CARE kV on children. The results
were amazing, she said. The mean dose
reduction was 30%. In smaller patients,
it could be up to 50%.
If you looked at all our patients from
2 kg to 120 kg we were getting 6 mGy;
under 50 kg, we were down to about
5 mGy, Siegel said. I was remarkably
impressed. The contrast was maintained,

and the dose went down 30%. We were
under 1 mSv, with exquisite images. I was
amazed the first time I saw it. According to the pediatric radiologist, CARE kV
was a step forward: The biggest impact
has been on contrast-enhanced and
angiographic imaging. But across the
board, in any procedure, it has had an
impact, she pointed out.
Siegel recalls the case of a 3-year-old girl
with heart disease who had undergone
multiple operations: We wanted to see
anatomy, she explained. We did a CT
with no sedation at 70 kV, with a dose
of less than 1 mSv and got outstanding
images.
Quicker iterative reconstruction (IR) with reduced noise

The success story continued in 2012 with
the installation of Siemens Sinogram
News
Affirmed Iterative Reconstruction (SAFIRE).

SAFIRE removes artifacts and noise from
scanned images. Because radiologists
are trained to read images with some
noise, the technology means that milliamperage can be lowered to the point
that an acceptable level of noise is in
the image, reducing dose in children by
as much as 60%.
SAFIRE also provides a vastly improved
IR performance thanks to enhanced
image reconstruction computing power
and smartly engineered signal processing. In other models, IR can take up to
45 minutes to reconstruct a patients
data set; with SAFIRE, reconstruction
takes only seconds to a few minutes. In
pediatric CT, Siegel was the first to use
CARE kV in combination with SAFIRE.
The results stunned the physician: the
overall mean radiation dose of scans
fell from 8.3 mGy to 4.5 mGy roughly
equivalent to annual background radiation. Milligray values in CT Angiography
scans dropped from 6.2 to 2.8; Chest
abdomen pelvis scans plummeted from
10.5 to 4.8. The real issue out there is
dose, but you also have to have great
image quality, Siegel pointed out. The
goal is to get to less than 1 mSv with
pediatrics at good diagnostic image quality. This technology is helping us get
there.
The Gold Standard

While Siegel has already shown herself
able to perform excellent image quality
at a very low dose with the 64-slice configuration of the SOMATOM Definition AS,
she wanted to go for Siemens high-end
scanner, the SOMATOM Definition Flash.
The Flash is the gold standard of computed tomography, with all of the features of the AS 64-slice configuration but
with two tubes and detectors and thus
much faster acquisition speed. Traditionally, most of our CT imaging has had
a pitch of 1.2 to 1.5, Siegel said. We
couldnt go past 1.5 because soon you
werent radiating enough of the patient
to get an image. With the Flash, we can
scan much faster. When we use it for
congenital heart disease, we use a pitch
of 3.4. We can scan in less than a second
and reduce the radiation dose again. We
The goal is to get

to less than 1 mSv
with pediatrics
at good diagnostic
image quality. This
technology is helping us get there.
Marilyn Siegel, MD, pediatric radiologist at
Washington University School of Medicine and
St. Louis Childrens Hospital, Missouri, USA.
can use pitches of 3.0 or 2.8 for all our

exams, with an incredible effect on dose.
The major advantage for everyone is
reduction in sedation and reduction in
breathing artifacts, Siegel said. If you
have healthy kids coming in for their first
chest and abdomen exam, you dont need
to give sedation if they can stay still for
a second or two. It has improved the
quality of the exam and reduces burden
on patients.
Using the high-pitch scan modes of the
Flash and with its built-in CARE kV, along
with the 20% reduction in milliamperage
reconstructed with SAFIRE, Siegel was
able to realize even greater dose savings:
The overall mean of all scans was reduced
to 2.7 mGy, she said.
The SOMATOM Definition Flash also facilitates the new Stellar Detector, which
limit electronic noise. The Stellar Detector
delivers a spatial resolution down to
0.30 millimeters without increasing dose.
This provides improved images of vessels,
for example.
Getting closer
In the fall of 2013, Siegel will head for
Germany to work with Siemens engineers
on the next step in pediatric imaging:
making Dual Energy scans dose-neutral.
If I can show that the dose stays low,
then it becomes an exciting tool, Siegel
said. Pretty pictures alone dont do it. It
will help in areas that we so far havent
evaluated, like vessel perfusion in the
lung and heart together, and assessment

of tumor response by tracking iodine.
The bottom line is: Its going to allow
functional imaging that we havent done
before with CT.
Siegel and Siemens arent finished yet.
She proudly displays a chart showing
the incredible dose savings that are possible when the SOMATOM Definition AS
64-slice configuration is combined with
CARE kV and SAFIRE. Above the chart
are the words: We are getting closer.
Its exciting, Siegel said, smiling. You
can affect lives.
Ron French is a freelance business and medical
writer based in Detroit, Michigan, USA. He also
writes for the Detroit News.

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.
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.
13
News
FAST Spine A Story of Best Practice

in Spine Reconstruction
SOMATOM Definition AS boosted by FAST Spine provides a remarkably accelerated workflow in spine reconstruction. In the department of radiology at
the Centre Hospitalier Universitaire de Tivoli (CHU Tivoli), an affiliation of the
Universit Libre de Bruxelles, Belgium, the specialists are impressed by the
ease of use, the speed and the quality of the automated spine reconstruction.
By Ruth Wissler, MD
The radiology department at CHU Tivoli

performs about 92,000 CT examinations
per year. The radiological staff consists of
15 radiologists and about 22 technicians.
Almost a quarter of the examinations are
orthopedic and spinal CTs.
The hospital is focused on neurosurgical
interventions. About 30% of the patients
are referred for spinal examination by general practitioners or surgeons from other
clinics. Since their SOMATOM Definition
AS+ was equipped with FAST Spine from
the end of March 2012, it has been used
there in almost all clinical cases of back
pain, sciatica and herniated discs.
Since we installed FAST Spine on our
SOMATOM Definition AS+ system, all of
my clinical staff have been very enthusiastic about the user-friendly software.
The technicians are more independent,
and we, the doctors, can concentrate on
the interpretation of the clinical images,
mentioned Pietro Scillia, MD, head of the
Department of Radiology at the Centre
Hospitalier Universitaire de Tivoli in Belgium.
Benefits of FAST Spine support

clinical imaging routines
Considerable time-saving is one prominent clinical feature. FAST Spine allows
faster setup and preparation of spine
reconstructions, including automatic
labeling. Immediately after the data acqui-
1 FAST Spine delivers an automatic segmentation of the spinal canal and automatic
labeling of the vertebrae.
Courtesy of University Hospital of Zurich, Switzerland
News
With FAST Spine

we were able
to increase the
number of exams
by about 20%
per day.
Pietro Scillia, MD,
Head of the Department of Radiology
at the Centre Hospitalier Universitaire
de Tivoli, Belgium
sition, FAST Spine automatically starts

detecting the spinal vertebrae, and labels
them according to their anatomical position. FAST Spine then uses this information for typical reconstruction modes for
the spinal vertebrae or discs. Time-critical
spine examinations also benefit from the
high reproducibility of the reconstructions. With FAST Spine we were able to
increase the number of exams by about
20% per day, says Pietro Scillia. It is
very convenient to use and we employ it
in almost all orthopedic cases. Even with
difficult spine patterns, the automated
detection works.
FAST Spine helps to reduce

reimbursement challenges
The department of radiology plays an
important economic role for CHU Tivoli,
with just 6% of the hospitals doctors

contributing almost 15% of the overall
profits. In this situation, the department
is particularly dependent on an effective
CT system, as the relatively low reimbursement also has to pay for the device
purchase. That is an enormous challenge
for us, says Scillia. We are basically
dependent on a well working system with
an effective workflow, because we want
to perform very good exams and not just
a lot of exams.
The specialists experiences at CHU Tivoli
with SOMATOM Definition AS+ boosted
by FAST Spine tell a story of best practice
in radiology by accelerating workflow and
increasing number of exams per day.
Due to its significant clinical benefits,
Siemens has also extended the availability of FAST Spine to the SOMATOM
Perspective Family and will introduce

it for the SOMATOM Emotion* Family in
the last quarter of 2013.
Ruth Wissler, MD, studied veterinary and
human medicine. She is an expert in science
communications and medical writing.

* Under development. Not available for sale in the U.S.
15
News
Rib and Spine Assessment in Acute Care

with syngo.CT Bone Reading
By Philip Stenner, PhD, Computed Tomography, Siemens Healthcare, Forchheim, Germany
1 syngo.CT Bone Reading displays the

entire rib cage rolled on a 2D planar
reformat. Courtesy of University Hospital
Salzburg, Austria
Trauma cases with suspected multiple

injuries to the thorax and spine call for a
complete and reliable evaluation of the
ribs and vertebral bodies. Diagnosis of
possible fractures needs to be available
very quickly. Simply scrolling through axial
slices while trying to focus on the point
of interest can be very time-consuming
due to the oblique orientation of the ribs.
syngo.CT Bone Reading revolutionizes
rib and spine assessment: The application
identifies and labels the ribs, and displays
curved 2D images of the entire rib cage
on a multi-planar reformat. In addition,
the vertebral bodies are labeled and the
spine is presented in an unfolded view
for a straightforward overview of the
anatomy. Thanks to the Automatic
Pre-Processing, the case is ready to be
reviewed immediately on opening.

The planar display of the rib cage facilitates the direct detection of lesions,
e.g. fractures of vertebral bodies or ribs.
When the user clicks on a fracture, the
system centers the axial, sagittal, and
coronal views on the area of interest to
allow a detailed assessment.
The system also provides cross sections
of the spine orthogonal to the unfolded
view and updates the position along the
spine while scrolling in real time.
In conclusion, syngo.CT Bone Reading
can effectively increase speed in bone
assessment.
www.siemens.com/ct-acute-care
Right Dose Image Contest 2013

By Ivo Driesser, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Following the success of the image contests held over the past few years, Siemens
Healthcare has decided once more to
invite radiologists and radiographers from
across the world to take part in the latest
round of this international competition.
Again a jury of experts, this time consisting of members of SIERRA (the Siemens
Radiation Reduction Alliance), will choose
in eight different categories the institutions who best demonstrate how they
achieve images with the right dose for an
ideal balance between diagnostic quality
and low radiation.
From June 2013, any clinical institution
or hospital with a CT scanner from the
SOMATOM Family can once again submit their best images to be shown on
the contest website.
A new element this year is the fact that

sustainable dose management at the
participating institution will also play a
role in the evaluation of the images.
Indeed, there will even be an additional
category for the entrant with the best
dose reduction strategy.
The many hundreds of submissions
weve had in the past few years clearly
demonstrate that our customers enjoy
presenting their work to a global audience and having it discussed by a specialist community, explains Peter Seitz,
Vice President of CT Marketing.
www.facebook.com/imagecontest
www.siemens.com/imagecontest
1 Coarctation of aorta. Winning image

2011, category Vascular, by Liz DArcy,
Wexford General Hospital, Ireland.
News
Expanding the Clinical Portfolio

with the Siemens Intervention Solution
By Jrgen Merz, PhD, Computed Tomography, Siemens Healthcare, Forchheim, Germany
The number of therapeutic interventions

using CT has increased considerably over
the last few years. More complex procedures can be performed faster, with better outcomes, fewer complications, at a
lower cost and with less discomfort for
the patient.
Increasing markets for

minimally invasive therapy
As the number of indications for minimally invasive therapy increases, more
and more CT scanners are used for this
purpose; sometimes even exclusively.
Today, for example, interventions are
performed on one third of SOMATOM
Definition AS scanners.* The clinical
spectrum ranges from CT-guided biopsies, through pain treatment (particularly in the spinal region) and drainage
of inflammatory processes, to ablation
of tumors in the lungs, abdomen and
pelvic area.
Standard intervention features

on the SOMATOM Definition
Family
Siemens recognized this trend at an early
stage, invested significantly in this area
and today offers an intervention solution
for its CT systems that is highly valued
by clinicians. Among the SOMATOM
Definition Family (AS, Edge, Flash) basic
2D interventional features are already
part of the standard configuration as
well as HandCare, a radiation reduction
feature for the operator.
Advanced intervention solution for dedicated individual

and clinical needs
As interventional procedures become
more and more complex, doctors develop
more sophisticated and highly individualized workflows. Consequently, Siemens
advanced solutions allow the adaption
1 Radio Frequency Ablation Therapy in a patient with lung cancer with

SOMATOM Definition AS+. Courtesy of Department of Radiology, University
of Munich, Grosshadern, Munich, Germany
and optimization of the workflow to the

individual need and the clinical setting.
Intervention Pro allows the operator
to switch between spiral, sequential and
fluoroscopy protocols on the fly, while
the in-built Layout Editor enables the
screen layout to be specifically adapted
to clinical questions or personal preferences (e.g. 3D layout for spinal interventions or the additional display of MR
images). The Adaptive 3D Intervention
package provides the option of planning
and conducting the intervention completely in 3D. Immediately after the scan,
the operator is provided with coronal,
axial and sagittal views in his specific
layout. Needle path planning in both 2D
and 3D and a needle detection algorithm
provide high-quality results. i-Needle
sharp solves the challenge of metal

artifacts from the needle. i-Fluoro (CT
fluoroscopy) allows the person performing the intervention to track the intervention instrument in real time during the
procedure. An optional foot switch and
an additional control unit (i-Control; wireless, if desired) enable the surgeon to
work directly on the patient completely
independently. The package is rounded
off by a variety of measurement and
analysis tools. These options can also be
purchased together as a package the
Adaptive 3D Interventional Suite providing the operator with a fully equipped
interventional CT system.
* Data on file
17
News
Unique Technology for Improved

Routine and New Research Opportunities
Two exclusive Siemens technologies, Dual Source Dual Energy CT
and the Stellar Detector, take routine applications to a new level and
open up opportunities for innovative research.
By Heidrun Endt, MD, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Dual Source Dual Energy CT

In 2012, the American Journal of
Roentgenology (AJR) published a special
supplement on Dual Energy CT (DECT).
Several review articles outlined the current
status of scientific research and different
approaches to DECT. An important statement in the supplement declared that:
Of the various methods that have been
proposed for acquiring DECT data, image
acquisition based on DSCT [Dual Source
CT] is the most intensely evaluated
approach in the c urrent literature.[1]
Has this also been transferred to use into
daily routine?
Researchers from Universit Lille Nord

de France state that this technique can
be used for chest CT Angiography examinations for routine diagnostic evaluation.[2] Examinations were carried out
on 80 patients using Dual Source Dual
Energy on a SOMATOM Definition
Flash with a reduced amount of iodine
(170 mg/mL). In addition to images at
80 kV and 140 kV, further monoenergetic
images (50/60/70/80/90/100 keV) were
reconstructed using syngo Dual Energy.
Monoenergetic images at 60 keV were
the best choice for the assessment of central vessels, images at 100 keV for the
systemic veins. These images at 100 keV

also presented with reduced perivenous
artifacts, known from conventional CT
examinations. Researchers compared all
these with single energy CT images,
acquired with a standard dose of contrast
medium. According to the study DECT
examinations offered adequate image
quality for the systemic veins with the
advantage of considerable reduction in
the amount of iodine contrast used.[2]
In addition the evaluation of the central
vessels was not degraded, which is the
limitation of single energy CT with reduced
contrast media administration.[2]
80 kV
140 kV
120 kV
60 keV
70 keV
100 keV
1 Fig. 1 shows images

from a DE Angiography
examination of the thorax
that was included in a
study:[1] Original polychromatic images at 80 kV,
140 kV, mixed image
at 120 kV (upper image
series), and 3 of 6 monochromatic reconstructions
at levels of 60 keV, 70 keV
and 100 keV (lower image
series). The central vessels
could best be assessed at
lower keV levels (60 keV);
the reconstruction at
100 keV provided best conditions for the systemic
veins. Courtesy of Hospital
Calmette, Lille, France
News
One review article in the AJR supplement described DECT for head and neck
imaging.[3] According to the review
there are several established applications
for different body regions, for instance
the chest and abdomen. The experience
for the use for the head and neck region
is limited so far, but early results are
promising, and further research is encouraged.[3] A study by researchers in Japan
also suggests further potential of DECT
(see also Cover Story).[4] Here, DECT
was used to evaluate the invasion of the
laryngeal cartilage in 72 patients with
laryngeal and hypopharyngeal squamous
cell carcinoma (SCC). The cases were
read either with weighted-average images
alone which are comparable to conventional CT images or in combination
with iodine-overlay images. The combined reading enabled a full exploitation
of the possibilities of DECT. A concluding
statement by the authors illustrated that
DECT improves diagnostic confidence and
interobserver reproducibility.[4]
The Stellar Detector

The Stellar Detector, introduced in
2011, offers clinical benefits for a range
of applications, including coronary CT
Angiography. Researchers at University
Hospital Zurich, Switzerland, assessed
these benefits using a SOMATOM
Definition Flash.[5] In their study they
began with an evaluation of a particular
coronary phantom simulating different
stenosis and plaque densities. These
2A
scans were performed twice: once with

the Stellar Detector and once with a
conventional detector. Subsequently,
these findings were confirmed clinically
in the second part of the study. Coronary CT Angiography was carried out on
30 patients using a SOMATOM Definition
Flash equipped with the Stellar Detector.
Conventional detector technology can
reconstruct images with a slice thickness
of 0.6 mm, whereas the Stellar Detector
in combination with SAFIRE enables a
slice thickness of 0.5 mm. By comparing
the two different reconstructions, the
authors conclude that with the new
technology image noise is significantly
reduced and stenosis quantification could
be done more accurately.[5]
At the German Heart Center, Munich,
Germany, coronary CT Angiography
examinations acquired before (group B)
and after (group A) the installation of
the Stellar Detector were compared.[6]
Each group had 20 patients and the
examinations were performed using the
same protocol (100 kV, 370 mAs). The
groups were matched in terms of age,
sex and BMI to allow comparison. Images
acquired with the Stellar Detector and
reconstructed with SAFIRE in group A had
an impressive noise reduction of 30%.[6]
Outlook
In their chest CT Angiography study,
researchers from France recommend
the routine use of DECT for this application.[2] As well as evaluating clinical
images, they also made full use of the

potential for contrast media reduction.[2]
Yet, many clinical questions are still
waiting to be answered in more detail
with DECT as shown by the study from
Japan.[4]
This is also the case for the Stellar Detector. There are proven benefits of using
the Stellar Detector in coronary CT Angiography examinations that are routinely
performed all over the world.[5, 6]
However, further research is needed on
the impact of the Stellar Detector, for
example in stent imaging, an application
that shows promising initial results in
scientific studies.
While these exclusive technologies
Dual Source DECT and the Stellar Detector open up new research opportunities, they continue to benefit everyday
clinical routine.
References
[1] Henzler T, et al. AJR Am J Roentgenol.
2012 Nov;199(5 Suppl):S16-25.
[2] Delesalle MA, et al. Radiology.
2013 Apr;267(1):256-66.
[3] Vogl TJ, et al. AJR Am J Roentgenol.
2012 Nov;199(5 Suppl):S34-9.
[4] Kuno H, et al. Radiology.
2012 Nov;265(2):488-96.
[5] Morsbach F, et al. Invest Radiol.
2013 Jan;48(1):32-40.
[6] Deseive S, et al. Scientific presentation at ECR
2013: Impact of a new detector technology
(Stellar, Siemens Healthcare) on image noise in
coronary CTA, B-0372.
2B
2 A 63-year old male
patient underwent coronary
CT Angiography examination.
This examination was included
in a study.[3] Fig. 2A was
conventionally reconstructed
with 0.6 mm slice thickness.
For Fig. 2B, 0.5 mm slice
thickness was used in combination with SAFIRE strength 3.
The latter enabled a more
precise evaluation of the
stenosis and therefore a
more precise quantification.
Courtesy of University
Hospital Zurich, Switzerland
19
Business
Maximum Single Source Performance

for High-end Cardiac Imaging
For the Clinique Bizet, when it came to choosing a new CT scanner size
mattered. This Parisian clinic sits amid some of Europes most valuable real
estate. With space at a premium and a team unwilling to compromize on
performance, the clinic found that the Siemens SOMATOM Definition Edge
offered the ideal solution.
By Bill Hinchberger
Tuesday at the Clinique Bizet: With nearclockwork efficiency, one after another,
patients are ushered into a small room
just 23-square meters for CT scans. Even
a patient with his complete equipment,
a bed from the intensive care unit and
five people working to organize the scan
can fit easily into the room together with
the system. Although the clinic is located
in Paris exclusive right-bank 16th arrondissement, its patients represent a crosssection of Frances 21st century multicultural population. Most of them are
here for thorax and abdominal scans,
although in the afternoon, a cardiologist
will swing by to supervise one of his

twice-weekly, three-hour cardiac sessions.
The challenge of staying ahead

The World Health Organization places
France at the top of its national healthcare rankings. But, as anyone who even
glances at the headlines can tell, the
country is struggling with the same
economic and budgetary pressures that
plague the rest of Europe. Health remained
a priority in the 2013 national budget,
but the 2.7% increase in spending for
the sector just barely outdistanced the
2012 inflation rate. The challenge both
for national leaders and hospital administrators is the same: Find ways to
maintain or even improve quality, while
simultaneously keeping a lid on costs.
The 180-bed Clinique Bizet is one of
two branches of a hospital known as
the Centre dImagerie de lOuest Parisien
(West Parisian Imaging Center, or CIMOP).
Although it is private, patients are referred
from the public system, and fees are
subject to the same controls that prevail
elsewhere. With facilities squeezed into
a sliver of prime Parisian real estate, the
Clinique Bizet must also make the most
of sometimes cramped quarters.
The team around Yves Martin-Bouyer, MD (left picture) and Philippe Durand at the Clinique Bizet in Paris found an ideal solution
for their tight spatial conditions but high demands of CT imaging: the SOMATOM Definition Edge.
Business
All of these factors came into play when

Chief Radiologist Yves Martin-Bouyer,
MD, needed to purchase a new scanner
last year.
CIMOP has a second, 140-bed branch
called Val dOr in the western Parisian
suburb of Saint Cloud. The hospital has
been working with Siemens equipment
since 2000. It even mentions the relationship on its website. But that legacy
provided no guarantees. Martin-Bouyer
analyzed the pros and cons of machines
made by all the major manufacturers.
One was rejected outright because its
equipment was simply too big for the
space it was supposed to occupy.
Versatility and quality results

Martin-Bouyer says that the Siemens
SOMATOM Definition Edge got the nod
for three main reasons: ease of installation, advanced technology, and top-notch
software. In particular, the chief radiologist liked the Siemens machines Stellar
Detector, its high rotation speed (0.28 seconds), and fast pitch (up to 1.7), which
is important for run-offs. It is extremely
versatile, says the physician. It can be
used for oncology, vascular radiography,
and examinations of the legs. You are
able to get an image very quickly, and it
is of superior quality. You have the feeling that the images are more reliable.
Cost was also a consideration. I should
also mention the financial factor, MartinBouyer adds. The prices were roughly the
same. There was just a slight difference.
More than the purchase price, there was
no need for reconstruction of the scanning room, so that it was possible to
change the scanner only. In total a costsensitive high-end scanner that doesnt
need too much space.
Consistently high quality images translate
into fewer headaches for Clinique Bizets
staff of four radiologists and 20 technicians, who together perform around
6,000 CT scans a year. There are no
discussions, he says. The results are
very good.
Philippe Durand, MD head of the interventional cardiac department at Saint
Joseph Hospital in Paris who oversees
twice weekly sessions at the Clinique
Bizet, seconds Martin-Bouyers verdict.
There is not a single image that I cannot

interpret, he points out. Before, there
was at least one a day.
1A
Benefits to clinicians and

patients alike
Thanks to the Siemens SOMATOM
Definition Edge, patients benefit from
what Martin-Bouyer estimates to be an
average of 30 to 40% reduction in radiation doses at his clinic, compared to
the previous model. In coronary studies
doses have even dropped from 950 DLP
(dose length product) to 250.
Examinations can also be performed more
quickly. The patient is on the machine
for about 10 to 15 minutes, estimates
Martin-Bouyer. It is very quick. The
chief radiologist reports that this does
not generally translate into fitting more
examinations into a workday. He says
that the time devoted to the procedure
itself is dwarfed by that required for preparing the patient for the test, as well
as for the subsequent analysis. However,
Durand reports boosting the number of
examinations he can oversee during his
three-hour slots at the Clinique Bizet, from
between seven and eight to ten.
Getting to the heart of cardiac

problems
The scanner has proven especially effective for cardiac examinations around
550 cases per year at the Clinique Bizet.
The quality is the best you can imagine,
says Martin-Bouyer.
There is better resolution on the interior
of a stent. You freeze the movement
of the stent and the movement of the
artery, Durand adds. You get great
images, even with people who have rapid
arrhythmias. He says that the speed of
the machine also helps patients who have
trouble holding their breath for prolonged
periods, which is often the case for people with heart conditions.
CIMOP has enjoyed ISO 9001 certification on its quality management systems
for nearly a decade. Now it is in the process of trying to attain a similar stamp of
approval for its information security
management system: namely ISO 27001.
This approval has become more likely,
thanks to the SOMATOM Definition Edge,
1B
1 Cardiac follow-up: SOMATOM Definition

Edge delivers better image quality (Fig. 1A)
almost 10 seconds faster and with a reduction
in dose by over 12 mSv than previous 64-slice
system (Fig. 1B).
SOMATOM
Definition Edge 64 slice
Scantime
4.0 s
13.53 s
kV-Setting 100 kV,

86 mAs
Scan
length
147 mm
120 kV,
733 mAs
DLP
217 mGy cm
1137 mGy cm
Dose
3.04 mSv
15.91 mSv
138 mm
with its superior compatibility. The

machine can talk to other systems, he
notes. Its data can be easily converted
to work with other systems.
A former correspondent in South America for

The Financial Times and Business Week, Bill
Hinchberger is a Paris-based freelance writer.
He has contributed to publications like
The Lancet and Science, and reported for the
Medical Education Network Canada.
21
Clinical Results Cardiovascular
Case 1
Coronary CTA with 80 kV: Improving
Image Quality with Reduced Radiation
and Contrast Medium Dose
By Takehito Shizuka, MD*, Haruka Iwase, MD*, Hiroaki Kobayashi, MD*, Yae Matsuo, MD*, Saburou Yanagisawa, MD*,
Nobuaki Fukuda, MD*, Akihiro Saitou, MD*, Shitoshi Hiroi, MD*, Toyoshi Sasaki, MD*, Chikashi Negishi, MD**,
Youichi Satou, MD**
** Department of Cardiology, National Hospital Organization Takasaki General Medical Center, Japan
** Diagnostic Imaging Center National Hospital Organization Takasaki General Medical Center, Japan
HISTORY
1A
1B
An 84-year-old female patient, with a

history of hypertension and dyslipidemia,
was hospitalized due to heart failure.
Cardiac enzyme tests were normal. After
an improvement of her heart failure, the
first coronary CTA was performed. This
revealed an aneurysm and a chronic total
occlusion (CTO) of the left anterior descending artery (LAD) and a 75% stenosis
of the right coronary artery (RCA) which
was then treated with a stent. A second
coronary CTA was performed to evaluate
the characteristics of the CTO after the
intervention.
1C
1D
DIAGNOSIS
An aneurysm located directly in front of
the diagonal and the septal branches, as
well as the CTO (Figs. 1A and 1B), could
be clearly visualized in the LAD. Neither
calcified plaques nor thrombosis were
seen in the aneurysm (Figs. 1C and 1D).
A stent shown in the proximal RCA was
patent (Fig. 3A). The distal branches of
the RCA were well developed supposedly
to compensate the limited blood supply
of the occluded LAD. A few small calcified
plaques were present in the proximal
circumflex artery (Cx, Fig. 3B).
1 VRT images with different presets (Figs.1A and 1B) showed the CTO (arrows) and the
aneurysm (dashed arrows) in the LAD. Neither calcified plaques nor thrombosis were seen
in the aneurysm (Fig. 1C MPR and Fig. 1D MIP).
2A
2B
2 An angiographic
image (Fig. 2A) and
a VRT image (Fig. 2B)
demonstrated
both left and right
arteries.
3A
3B
3 A patent stent
in the RCA (Fig. 3A)
and few small
calcified plaques
could be revealed
with curved MPRs
(Fig. 3B).
COMMENTS
To achieve the optimal CT image quality
with the lowest possible dose, various
CT techniques have been established. In
the newly developed Stellar Detector,
the photodiode and the analog-to-digital
converters (ADCs) were combined in
single application-specific integrated circuit (ASICs). This therefore reduces the
path of the analog signal and decreases
the electronic noise which in turn directly
enhances the image quality. In this case,
SAFIRE as a raw data-based iterative reconstruction technique, Flash Cardio Spiral
provided by Dual Source CT, CARE kV, and
CARE Dose4D were all additionally applied
to minimize the dose to 0.38 mSv while
maintaining the image quality. The 80 kV
setting selected by CARE kV remarkably
enhanced the contrast although only
42 mL (including test bolus injection)
contrast medium were used.
examination protocol
Scanner
SOMATOM Definition Flash
Scan area
Heart
Pitch
3.4
Heart rate
56 bpm
Slice collimation
128 x 0.6 mm
Scan length
111 mm
Slice width
0.75 mm
Scan direction
Cranio-caudal
Spatial resolution
0.3 mm
Scan time
0.2 s
Reconstruction
increment
0.4 mm
Tube voltage
80 kV with CARE kV
Kernel
I36f
Effective mAs
316 mAs
SAFIRE
SAFIRE
Dose modulation
CARE Dose4D
Contrast
CTDIvol
1.46 mGy
Volume
42 mL
(including test bolus)
DLP
27.1 mGy cm
Flow rate
3.5 mL/s
Effective dose
0.38 mSv
Start delay
Test Bolus Tracking
Rotation time
0.28 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.
23
Case 2
70 kV CT Pulmonary Angiography in
an Adult Patient with a Dose of <1 mSv
and PA Attenuation of >1,000 HU
By Ralf W. Bauer, MD, Firas Al-Butmeh, MD, Boris Schulz, MD, Thomas J. Vogl, MD, J. Matthias Kerl, MD
Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, Germany
HISTORY
A 31-year-old female patient underwent a CT pulmonary angiography (CTPA)
for a clinically suspected pulmonary
embolism (PE). CTPA was conducted on
a SOMATOM Definition AS (64-slice configuration) with a novel 70 kV protocol.
DIAGNOSIS
The patient conforms to a normal body
habitus (173cm, 65kg, BMI 21.7kg/m).
The 70 kV protocol, combined with
SAFIRE, resulted in a very low dose exposure of only 0.77 mSv (DLP 55 mGy cm x
0.014 mSv/mGy cm) for an entire chest
scan. Due to the low-energy X-ray spectrum emitted at 70 kV, the intravascular
attenuation in the pulmonary arteries

exceeded 1,000 HU in the central and
850 HU in the segmental branches,
although only 60 mL of iodinated contrast
material were administered (350 mg
Iodine/mL). This resulted in an overall
excellent image quality which allowed
the reliable exclusion of a PE.
COMMENTS
Due to unspecific symptoms, many
patients are referred for CTPA to exclude
a PE with negative results. Low true
positive rates are still a common problem,
although scores, e.g. the Wells score,
are adapted increasingly to estimate the
pre-test likelihood of a PE. Therefore, it

is essential to reduce radiation exposure
in this patient group to a minimum.
The novel 70 kV option, combined with
model-based iterative reconstruction
(SAFIRE), helps to achieve unprecedented
low dose values with high image quality,
not only in children, but also in adults
with normal body habitus. The lowenergy X-ray spectrum results in extremely
high vascular attenuation with common
high-iodine content contrast material.
This bears potential for the use of lowiodine contrast media and an overall
reduced iodine load. This could be beneficial for high-risk patients regarding
contrast-induced nephropathy.
Scanner
SOMATOM Definition AS (64-slice configuration)
Scan area
Chest
Rotation time
0.5 s
Scan length
277.5 mm
Pitch
1.2
Scan direction
Cranio-caudal
Slice collimation
64 x 0.6 mm
Scan time
6.02 s
Slice width
1.0 mm
Tube voltage
70 kV
Reconstruction increment
0.5 mm
Tube current
141 eff. mAs
Reconstruction kernel
I26f SAFIRE 3
Dose modulation
CARE Dose4D
Contrast
CTDIvol
1.85 mGy
Volume
60 mL
DLP
55 mGy cm
Flow rate
4 mL/s
Effective dose
0.77 mSv
Start delay
5s
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
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.
Cardiovascular Clinical Results
16 Excellent image
quality in a normal
sized female patient
(Fig.1). The extreme
vascular attenuation
requires a wider window (w 1700, c 250)
to reduce the signal
from iodine in the
pulmonary arteries
(Fig. 2); attenuation
of more than 1000 HU
in the pulmonary
trunk (Fig. 3). Attenuation of almost 900
HU in the segmental
pulmonary arteries
was achieved with only
60 mL of iodinated
contrast material with
an iodine concentration of 350 mg/mL
(Fig. 4). MIP (Fig. 5);
VRT (Fig. 6) images
showed the brightly
enhanced pulmonary
arteries including the
peripherals.
25
Case 3
Dual Source CT: Assessment
of Hypoplastic Arch Associated
with Ductus Arteriosus
By Torel Ogur, MD, Patrick T. Norton, MD, Klaus D. Hagspiel, MD
Department of Radiology and Medical Imaging, University of Virginia, USA
1A
1B
1 Two images at the level of the aortic arch demonstrate the decrease in image noise and increase in signal to noise ratio when using SAFIRE
(Fig. 1A) versus filtered back projection (Fig. 1B).
HISTORY
DIAGNOSIS
A 13-day-old male baby, with numerous

congenital abnormalities including left
lateral displacement of the left nipple and
umbilicus, digital abnormalities that were
attributable to amniotic bands, displaced
anus and spinal dysraphism was referred
for CT Angiography (CTA) of the chest
for detailed evaluation of an aortic arch
anomaly.
The volume rendered images, using the

SAFIRE reconstructed images, showed
a hypoplastic arch with a patent ductus
arteriosus (Figs. 2). The ascending aorta
measured 7 mm in diameter and the
aortic arch demonstrated diffuse narrowing down to between 2.4 and 2.6 mm.
This was most pronounced in the preductal segment. The left vertebral artery
originated directly from the aortic arch.

The ductus arteriosus was patent and
measured 4.5 mm. The descending
thoracic aorta measured 5.3 mm distal
to the patent ductus arteriosus.
COMMENTS
2A
The scan was performed employing the X-CARE

scan mode, CARE Dose4D and CARE kV on a
SOMATOM Definition Flash scanner. Reference
mAs was set at 125, reference kV at 120 kV, and
the CARE kV slider set to 7. CARE kV automatically
selected 80 kV and an average effective mAs of 32.
Radiation dose could further be reduced by using
SAFIRE level 3 iterative reconstructions, resulting
in an extremely low age adapted effective dose of
0.37 mSv for this fully diagnostic CTA scan of the
chest.
Pediatric patients with congenital abnormalities
often require multiple imaging exams over their
lifetime. This makes it critical to keep cumulative
radiation dose as low as possible while maintaining
diagnostic accuracy. In addition to being fully diagnostic, the rapid acquisition time of only 1.2 seconds
obviated the need for breath-holding and sedation.
A comparison of two images (Figs. 1A and 1B) at
the level of the aortic arch reconstructed with both
filtered back projection and iterative reconstruction,
demonstrated the decrease in image noise and
increase in signal to noise ratio achieved with SAFIRE.
2B
2 Two volume rendered images using the SAFIRE reconstructed
images show a hypoplastic arch (Figs. 2, arrow) with patent ductus arteriosus
(Fig, 2B, dashed arrow).
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.
Scanner
SOMATOM
Definition Flash
Scan area
Thorax
Scan length
75 mm
Scan direction
Cranio-caudal
Scan time
1.2 s
Tube voltage
80 kV
Tube current
32 eff. mAs
Dose modulation
CARE Dose4D
CTDIvol
0.51 mGy
DLP
4.2 mGy cm
Effective dose
0.37 mSv
Rotation time
0.28 s
Pitch
0.6
Slice collimation
128 x 0.6 mm
Slice width
0.6 mm
Reconstruction
increment
0.4 mm
Reconstruction
kernel
I30f (SAFIRE)
Contrast
Volume
4 mL
Flow rate
Hand injection iv in
left saphenous vein at
approx. 0.5 mL/s
Start delay
2s
27
Case 4
Cardiac CT in a 5-Month-Old Baby with
VACTERL Syndrome after Cardiac Surgery
By Torel Ogur, MD, Patrick T. Norton, MD, Klaus D. Hagspiel, MD
Department of Radiology and Medical Imaging, University of Virginia, USA
1A
1C
1B
1D
HISTORY
A 5-month-old baby boy with a history
of double outlet right ventricle (DORV)
with atrial septal defect (ASD), ventricular
septal defect (VSD), patent foramen ovale
(PFO) and VACTERL syndrome (unilateral
renal agenesis, syndactyly, congenital
hemivertebrae) was referred for cardiac
CT. He underwent surgical repair with
an ASD and VSD patch and PFO ligation
at ten weeks of age. He was readmitted
due to atrial tachycardia and worsening
pulmonary hypertension. Cardiac catheterization revealed systemic pulmonary
artery (PA) pressures and near atretic left
pulmonary veins. The cardiac surgeon
requested the CT for a detailed evaluation
of the pulmonary veins prior to possible
surgical repair.
DIAGNOSIS
1 Axial Minimum Intensity Projection (MIP) images demonstrate the severely stenotic
ostium of the right superior (Fig. 1A, arrow) and the normal right inferior pulmonary vein
(Fig. 1B, arrow). The left superior vein has a high grade ostial stenosis (Fig. 1C, arrow)
and the left inferior pulmonary vein is occluded (Fig. 1D, arrow).
The study was performed using the Flash

mode and 80 kV. SAFIRE was used to
allow further reduction of the radiation
dose. The scan demonstrated four separate pulmonary veins, all of which drained
into the left atrium. The right inferior
pulmonary vein was normal, whereas the
right superior vein had a severe ostial
stenosis (Figs. 1A and 1B). The left superior pulmonary vein also had a severe
ostial stenosis and the left inferior pulmonary vein was occluded at the ostium
(Figs.1C and 1D). There was no evidence
of an ASD or VSD, and the PFO was successfully ligated. There was also a left
aortic arch with aberrant right subclavian
artery (Fig. 2). The left main coronary
artery originated abnormally from the
2 A VRT image shows the aberrant right subclavian artery (arrow).
left aspect of the non-coronary sinus

(Fig. 4). The right upper lobe bronchus
originated directly from the right aspect
of the trachea, a so-called pig bronchus
(Fig. 3).
3 A VRT image shows the right upper lobe bronchus (arrow)

originating from the trachea, a so-called pig bronchus.
Scanner
SOMATOM
Definition Flash
Scan mode
Flash mode
Scan area
Heart
COMMENTS
Scan length
87 mm
Scan direction
Cranio-caudal
Children with congenital heart disease

often require repeated cardiac imaging
studies for follow-up. Even though echocardiography is the most important diagnostic modality, CT can be necessary
in selected cases. Therefore, it is of the
utmost importance to keep the radiation
dose as low as possible. The use of the
Flash cardiac mode combined with a
low kV setting, allowed the study to be
performed with very low dose. Newer
reconstruction techniques, other than
the classical filtered back projection algorithm, allow further reduction of dose
while maintaining or even improving the
image quality. Iterative reconstruction
(SAFIRE) was used in this case, demonstrating the pulmonary venous and overall cardiac and aortocoronary anatomy
in high quality with an estimated ageadapted effective radiation dose of only
1.88 mSv.
Scan time
0.2 s
Tube voltage
80 kV
Tube current
82 eff. mAs
Dose modulation
CARE Dose4D
CTDIvol
1.32 mGy
DLP
21 mGy cm
Effective dose
1.88 mSv
Rotation time
0.28 s
Pitch
3.0
Slice collimation
128 x 0.6 mm
Slice width
0.6 mm
Reconstruction
increment
0.6 mm
Reconstruction
kernel
I26 / 41f (SAFIRE)
Contrast
350 mg/ccm
diluted with saline
Volume
7 mL diluted
to 10 mL
Flow rate
1 mL/s
Start delay
Bolus tracking
4 An axial subvolume MIP image

demonstrates the origin of the left main
coronary artery (arrow) from the
left aspect of the non-coronary sinus.

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, lowcontrast 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.
29
Case 5
Evaluation of Femoral Artery
Pseudoaneurysms with Arteriovenous
Fistula using CTA Runoff Scanning
By Hong Liang Zhao, MD
Department of Radiology, Xijing Hospital, Xian, P.R. China
HISTORY
DIAGNOSIS
COMMENTS
A 16-year-old male patient, with a known

history of trauma, developed a tender
pulsatile mass in his left thigh. A CT
Angiography (CTA) runoff was ordered
to evaluate detailed vascular structures.
Two saccular pseudoaneurysms were

found in the left upper-mid thigh (Fig. 1).
Both aneurysms breached into the left
superficial femoral artery (Fig. 2). Tumorlike venous structures developed locally,
due to a fistula connecting the aneurysms
and the femoral vein (Fig. 2). Most of the
veins drained into the great saphenous
vein, resulting in an ectatic state of the
vein. The left femoral artery was significantly dilated. There were neither signs
of mural thrombosis nor of wall thickening of the aneurysm. The vascular structures in the right leg appeared to be
normal.
Pseudoaneurysms are common vascular

abnormalities caused by the disruption of
the vessel wall. A pseudoaneurysm with
an arteriovenous fistula is rare. Prompt
diagnosis and treatment are necessary to
avoid the morbidity and mortality associated with hemorrhage and rupture.
Low dose CTA is valuable in the imaging
workup and may help enable a quick
diagnosis.
Scanner
Scan area
CTA Runoff
Pitch
0.9
Scan length
1,102 mm
Slice collimation
128 x 0.6 mm
Scan direction
Cranio-caudal
Slice width
1 mm
Scan time
16 s
Spatial Resolution
0.33 mm
Tube voltage
80 kV
0.7 mm
Tube current
190 eff. mAs
B26f
Dose modulation
CARE Dose4D
Contrast
CTDIvol
3.72 mGy
Volume
70 mL
DLP
419 mGy cm
Flow rate
3.5 mL/s
Effective Dose
1.82 mSv
Start delay
21 s
Rotation time
0.5 s
2
2 Thin slab
VRT image shows
the breach of the
aneurysm (arrow)
and the fistula to
the femoral vein
(dashed arrow).
3A
1 An overview of the CTA runoff.
3B
3 The vascular structures can be shown with VRT images using different
presets.
31
Case 6
Free-breathing Coronary CTA
with Double Flash Spiral Protocol
By Man Ching So, MD*, Chi Ming Wong, MD*, Wai Leng Chin**
** Sir Run Run Shaw Heart & Diagnostic Center, St. Teresas Hospital, Kowloon, Hong Kong SAR, China
** Siemens Healthcare, Singapore
1A
1B
1C
1D
1 Double Flash Spiral scan with a single contrast injection in the same patient scanned with free-breathing.
VRT (Fig. 1A) and curved MPR (Fig. 1C) images of 1st Flash Spiral scan which was free from breathing artifact and
2nd Flash Spiral scan (Figs. 1B and 1D) with one slight breathing artifact (arrows) in the distal LAD.
HISTORY
An 80-year-old female patient, with

known hypertension, obesity, supra-ventricular ectopic, and supra-ventricular
tachycardia, presented herself due to
recent onset of chest discomfort. Coronary CTA was performed to exclude the
presence of ischemic heart disease. Upon
arrival, the patient had a heart rate of
61 beats per minute and could not hold
her breath. Therefore the examination
was conducted using the double Flash
Spiral (prospectively ECG-triggered
high-pitch mode) protocol under freebreathing. Two Flash Spiral scans were
consecutively performed with a single
bolus of intravenous contrast medium.
DIAGNOSIS
The patients calcium score was 1,788
and all 3 arteries showed pathological
changes. A severe stenosis was demonstrated in the mid left anterior descending artery (LAD) as well as a moderate
stenosis in the proximal left circumflex
(LCX) artery. There were mild stenoses in
the left main, the proximal left LAD, the
first diagonal artery, the right coronary
artery and the first obtuse marginal artery.
The posterior descending, postero-lateral
and distal left anterior descending arteries
were normal. Conventional angiography
confirmed severe stenoses in the mid
2 The stenosis correlated with conventional angiogram.
COMMENTS
LAD and proximal LCX. Pericutaneous
coronary intervention with implantation
of a drug eluting stent in the mid LAD
and LCX, after rotational atherectomy
under intravascular ultrasound guidance,
was successful.
This case demonstrated that coronary

CTA performed in patients who are
unable to hold their breath with the
double Flash Spiral protocol allows the
diagnosis of coronary artery stenoses
and can potentially simplify the planning
of a coronary interventional procedure.
Scanner
Scan area
Mid-pulmonary arteries
to diaphragm
Pitch
3.4
Scan length
116 mm
Slice collimation
128 x 0.6 mm
Scan direction
Cranio-caudal
Slice width
0.75 mm
Scan time
0.39 s
Spatial Resolution
0.33 mm
Tube voltage
100 kV
0.4 mm
Tube current
370 mAs
B26f & B46f
Dose modulation
No
Contrast
400 mg/mL
CTDIvol
3.58 + 3.59 mGy
Volume
60 mL
DLP
117.86 mGy cm
Flow rate
5 mL/s
Effective dose
1.65 mSv
Start delay
Test bolus + 2 sec
Rotation time
0.28 sec
33
Clinical Results Oncology
Case 7
Squamous Cell Carcinoma of the
Head and Neck: Volume Perfusion CT
By Timothy J. Amrhein, MD, Zoran Rumboldt, MD, PhD
Department of Radiology and Radiological Sciences, Medical University of South Carolina, Charleston, SC, USA
HISTORY
1A
1B
A 54-year-old male with a three-month

history of a tender right neck mass
associated with right-sided headaches,
epistaxis, otalgia, diplopia, and paresthesias of the right face and tongue,
was referred to the otolaryngology for
further evaluation. The patient reported
fevers, night sweats and weight loss.
A fine needle aspirate of the dominant
right neck mass yielded a preliminary
diagnosis of squamous cell carcinoma.
The patient was then referred to the
radiology for diagnostic imaging.
1C
1D
DIAGNOSIS
An initial pre-treatment contrast
enhanced neck-CT (CENCT) demonstrated
an avidly enhancing heterogeneous
4.2 x 2.6 x 5.7 cm mass, arising from the
right nasopharynx with lateral extension
into the right masticator space and superior extension into the right foramen
ovale and cavernous sinus (Figs. 1A and
1B). Additionally, there was an enlarged
avidly enhancing right level IIB lymph
node with central hypoattenuation suggestive of necrosis (Figs. 1C and 1D). The
patient then underwent Volume Perfusion
CT (VPCT) of the neck to further characterize the underlying pathology. This VPCT
demonstrated elevated capillary permeability (CP), blood volume (BV), and blood
flow (BF) within the primary mass relative to normal adjacent tissues (Fig. 2A).
Similar characteristics were identified
within the viable periphery of the centrally necrotic right level 2B lymph node
(Fig. 2B). Of note, this lymph node was
located approximately 5 cm inferior and
1 Initial pretreatment CENCT. Axial image demonstrated avidly enhancing heterogeneous

mass arising from the right nasopharynx with lateral extension into the right masticator space
(Fig. 1A). Coronal image demonstrated superior extension of the primary mass into the foramen
ovale and cavernous sinus (Fig. 1B). Axial image demonstrated a markedly enlarged and peripherally enhancing right level IIB lymph node concerning metastatic involvement (Fig. 1C).
Coronal image redemonstrated the enlarged concerning right level IIB lymph node (Fig. 1D).
4.5 cm posterolateral to the primary

mass and would not typically have been
included with standard neck perfusion CT
protocols. Mean BF and CP values within
the primary mass were 144.6 (mL/100g/
min) and 38.7 (mL/100g/min), respec-
tively. These elevated values predicted a

good treatment response to chemotherapy and radiation therapy. Similar values
were present in the nodal metastasis
(111.8 mL/100g/min and 29.7 mL/100g/
min respectively).
2A
The patient underwent standard

chemotherapy and radiation therapy
and returned for a follow up CENCT
four months after the initial scan. This
demonstrated a near complete to complete response with macroscopic resolution of the primary neoplasm and nodal
disease (Fig. 3). There was no evidence
of residual or recurrent disease over the
following 3 months.
COMMENTS
VPCT offers dynamic perfusion analysis
of the entire neck allowing for characterization of both the primary neoplasm and
areas of nodal involvement. Standard neck
perfusion CT is unable to cover the entire
neck volume precluding the concomitant
acquisition of perfusion information in
areas of nodal metastatic disease. Changes
in functional parameters acquired with
VPCT may allow for prediction of treatment response before and during therapy.
2B
Scanner
SOMATOM
Definition AS+
Scan mode
Volume Perfusion
Protocol using
Adaptive 4D Spiral
Scan area
Neck
Scan length
130 mm
Scan direction
Cranio-caudal
Scan time
49 s
Tube voltage
80 kV
Tube current
150 eff. mAs
Dose modulation
CARE Dose4D
CTDIvol
128 mGy
DLP
1875 mGy cm
Rotation time
0.3 s
Slice collimation
128 x 0.6 mm
Slice width
3 mm
Reconstruction
increment
2 mm
Reconstruction
kernel
B20f
2 Neck VPCT: CP, BV, BF and reduced MTT within the primary mass were elevated (Fig. 2A).
Similar perfusion characteristics within a right level IIB lymph node concerning metastatic
involvement could be detected (Fig. 2B).
3A
3B
Contrast
Volume
40 mL contrast
+ 50 saline
Flow rate
4 mL/s
Start delay
No delay
3 Post treatment CENCT. Primary right nasopharyngeal mass (Fig. 3A)

and right level IIB lymph node were resolved (Fig. 3B).
35
Clinical Results Oncology
Case 8
Diagnosis of Rectal Tumor
using SOMATOM Perspective
By Zheng, Tiesheng, MD, Sun, Hongtu, MD, Wu, Yuzhang, MD
Department of Radiology, Panshi City Hospital, Jilin, P. R. China
HISTORY
A 62-year-old female patient, with a
known diagnosis of rectal tumor,
presented herself for further evaluation
before treatment.
DIAGNOSIS
CT images showed a cauliflower-like,
broad-based soft tissue mass located on
the left-posterior wall of the rectum
(Figs. 1 to 3). It measured 25 x 22 mm
and was causing luminal narrowing. There
were no signs of wall thickening nor
of infiltration of the peri-rectal fat. The
enhancement of the mass was mild and
homogeneous. A regular shaped, hypodense lesion (Fig. 4) was revealed in the
1A
left hepatic lobe, measuring 13 x 10 mm

in size and with 15 HU CT value. After
intravenous contrast injection, no
enhancement was present suggesting a
cyst. Neither enlarged lymph nodes nor
ascites were found. All other abdominal
and pelvic organs appeared to be normal.
A rectalscopic examination resulted in
a benign rectal tumor. The patient was
scheduled for a rectoscopical tumor resection.
COMMENTS
Although rectoscopy is accurate in the
detection of rectal tumors, it does
not allow the evaluation of extra-rectal
1B
diseases. CT is valuable in the preoperative assessment and staging in assumed

cases of cancer. Rapid advances in CT
technology have improved the accuracy
and usefulness of computer imaging.
In our department, we experience the
great advancement from 6-slice to
128-slice in the daily routine examinations. It allows a longer scan range
within a shorter scan time and with a
slice width as thin as 0.6 mm. The fast
scanning speed also reduces motion
artifacts. Furthermore, the newly developed syngo.via workstation allows
efficient reading and decreases the postprocessing workload.
1C
1 Coronal (Fig. 1A) and sagittal (Fig. 1C) MPR and VRT (Fig, 1B) images show the rectal tumor that caused luminal narrowing (arrows).
The peri-rectal fat tissues are not infiltrated (dashed arrows).
3A
3B
3 Axial images of arterial (Fig. 3A) and venous

(Fig. 3B) phases present mild and homogenous
enhancement of the tumor (arrows).
4A
4B
2 syngo.via helps to speed up reading and facilitates creation of findings.
Scanner
SOMATOM Perspective
Scan area
Abdomen / pelvis
Rotation time
0.6 s
Scan mode
Arterial / venous phase
Pitch
0.6
Scan length
518 mm
Slice collimation
64 x 0.6 mm
Scan direction
Cranio-caudal
Slice width
1 / 7 mm
Scan time
13 s
Reconstruction
increment
0.7 / 7 mm
Tube voltage
110 / 130 kV
B30s
Tube current
86 / 74 mAs
Contrast
Iopromide 370
Dose modulation CARE Dose4D
Volume
80 mL
CTDIvol
6.36 / 8.15 mGy
Flow rate
3 mL/s
DLP
374.27 / 491.44 mGy cm
Start delay
Bolus tracking
Effective dose
5.6 / 7.4 mSv
4 Axial images of arterial (Fig. 4A)

and venous (Fig. 4B) phases reveal the
non-enhanced hepatic lesion (arrows).
37
Clinical Results Neurology
Case 9
Dose Reduction in Head CT Examination
using SAFIRE
By Fabio Onuki Castro, MD, Juliana Mancini Ruthes, MD, Carlos Martinelli, MD, Caroline Bastida de Paula*,
Vinicius Zim Henrique*
Department of Radiology, Hospital do Corao, So Paulo Brazil
*Siemens Healthcare, Brazil
HISTORY
COMMENTS
A 90-year-old male patient had suffered

from an extensive ischemic stroke in
the irrigation territory of the middle-right
cerebral artery. This had caused significant
compression on noble brain structures.
He underwent a decompressive craniectomy. A CT examination was ordered for
follow-up.
A comparative analysis was performed

on the images, reconstructed with and
without SAFIRE. Not only would SAFIRE
allow the dose to be reduced, the image
quality was also significantly improved.
Even though, in this special case, a fast
scan (pitch 1.4) was performed to prevent
artifacts that might had been caused by
DIAGNOSIS
CT images showed large areas of brain

loss (encephalomalacia/gliosis) involving
the right temporal region. This was
characterized by hypodense cortical/
subcortical areas as seen in CT and was
associated with the accentuation of the
brain grooves and fissures. A similar area
involving the frontal cortical gyri, adjacent to the upper left area of surgical
decompression (craniotomy), could also
be seen.
the uncontrollable motion of the patient.

The improvements were demonstrated
by the higher definition around the edges
and by the improved signal-to-noise ratio
in the images.
The efficiency of the SAFIRE technology
may contribute to diagnostic accuracy.
Scanner
Scan area
Head
Scan length
162 mm
Scan direction
Caudo-cranial
Scan time
3s
Tube voltage
100 kV
Tube current
380 mAs
Dose modulation
CARE Dose4D
CTDIvol
36.62 mGy
DLP
744 mGy cm
Effective dose
1.56 mSv
Rotation time
1s
Pitch
1.4
Slice collimation
128 x 0.6 mm
Slice width
1 mm
Reconstruction
increment
0.7 mm
H30s w/o SAFIRE

J30s with SAFIRE
In clinical practice, the use of IRIS may reduce CT

patient dose depending on the clinical task, patient
size, anatomical location, and clinical practice. A
consultation with a radiologist and a physicist should
be made to determine the appropriate dose to obtain
Neurology Clinical Results
1A
1B
14 The figures show four
different slices (Figs. 1 to 4)
with and without SAFIRE
(A without; B with SAFIRE).
The B images show a great
noise reduction and a better
differentiation between healthy
and damaged brain tissue.
There is also a considerable
sharpening on the edges,
especially in the craniotomy
area. (For all images, window
settings = 90/45, slice width
= 3 mm).
Courtesy of Hospital do
Corao, So Paulo, Brazil.
2A
2B
3A
3B
4A
4B
39
Science
Finding the Right Dose with the Right Tools

Belgian radiologist Tom Mulkens, MD, PhD, from the Heilig Hartziekenhuis
in Lier is a CT specialist with particular interest in radiation dose. His longtime engagement shows that reducing the dose in CT exams is not only
a question of good practice, but also of the right tools and continuous
efforts to preserve diagnostic image quality.
By Irne Dietschi
Tom Mulkens, MD, PhD (left picture) and his team, Heilig Hartziekenhuis in Lier, Belgium has a special interest for years: Reduction of radiation dose.
Some participants at the European

congress of radiology (ECR) 2013 were
surprised when Tom Mulkens, a tall and
silver-haired radiologist from Belgium,
commented on the presentations of a
French and Spanish colleagues. The CT
images projected on the over-sized screen
of the conference room in Vienna were
as clear-cut as any clinician could wish
for an accurate diagnosis. Yet, it wasnt
the image quality the Belgian specialist
dared question, but the accompanying
dose values. Both presentations showed
mean DLP values of 800 and 900 mGy cm
for standard head CT, for example. Tom
Mulkens criticized those values as outdated. At his own hospital in Belgium,
standard head CT is performed at an
average DLP of 340 mGy cm, an average
CTDI of 20 mGy and a mean effective
dose of 0.85 mSv. The scanners used are
SOMATOM Emotion 16 and SOMATOM
Definition AS+ by Siemens.
Tom Mulkens, radiologist at the Heilig

Hartziekenhuis in Lier, is a well-known
CT specialist in his country. Dose reduction in CT has been my very special interest for 15 years; it has almost become
a hobby, the 50-year-old doctor says. In
Belgium he has visited nearly every radiology department to generate awareness
of this important issue. His know-how in
dose modulation and the scan protocols
of his department, where around 14,000
to 15,000 CT scans are performed every
year, are in high demand among his colleagues. Good images and dose reduction
dont necessarily compete, he says. CT
technology has advanced so much in the
last ten to fifteen years that radiation can
be reduced substantially without impairing the quality of the image.
Tom Mulkens has been adamant about
this topic ever since in 2001 articles started
to come out trying to connect CT scans
with possible future cancers. Although
these numbers were rough estimates

based on a purely theoretical extrapolation
of the linear non-threshold model to low
dose values, the news of these publications shocked the radiology community,
says Tom Mulkens. For him personally
the papers had an even greater effect:
He started his research on dose optimization in CT exams.
In a 2005 study, he and his team examined the effect of an automatic exposure
control mechanism in CT, thereby reducing radiation doses between 20 and 68%.
[1] A study on children suffering from
sinusitis, published around the same time,
was equally successful. [2] Mulkens et al.
were able to lower the effective dose to
a level comparable to that used for standard radiography, with resulting CT scans
that were still of diagnostic image quality. Active dose management shows that
between 2006 and 2012 his department
accomplished a cut in the mean radiation
Science
Table 1: Evolution of local dose values as dose length product (DLP) in mGy cm
reference dose values
actual dose values
EU3
France4
Belgium5
year
1999
2004
2007
percentile
75 %
75 %
CT HEAD
1050
CT THORAX
Belgium5
HH LIER
HH LIER
HH LIER
HH LIER
2007
2006
2009
2011
2012
75 %
25 %
mean
value
mean
value
mean
value
mean
value
1050
1020
740
1000
850
600
327
780
500
400
240
220
240
225
115
CT ABDOMEN
780
650
830
415
400
410
350
212
CT L - SPINE
n.a.
n.a.
870
475
375
525
500
325
CT SINUS
n.a.
n.a.
150
70
60
65
60
33
Evolution of local dose values (DLP, mGy cm) in CT in adults, Heilig Hartziekehuis Hospital, Lier in comparison with recommended national
and European diagnostic reference level (DRL) values, 2006-2012.
dose between 50 and 68% for adults

(Table 1) and children, depending on
the CT examination, e.g. from a DLP of
1,000 to 327 mGy cm for head scans.
In 2012 two new Siemens CT scanners
were installed in the Heilig Hartziekenhuis, both with Right Dose Technology,
including iterative reconstruction possibilities: IRIS for the SOMATOM Emotion 16
and SAFIRE for the SOMATOM Definition
AS+. This new function made the biggest
difference so far. Thanks to SAFIRE we
were able to cut the doses roughly by
half. Even in difficult conditions, Tom
Mulkens and his team now manage good
values. He mentions the case of a very
obese patient who was referred to radiology with diverticulitis, requiring a scan
of the abdomen. In a standard protocol,
with a patient being very obese, the
Contrast-to-Noise ratio (CNR) would have
been much lower, but we were able to
increase it by use of iterative reconstruction and by choosing a low tube voltage
with the help of CARE kV, the doctor
says (Fig.1).
The improvements become most apparent
in pediatric CT, an area where the need
for dose reduction is most obvious because
children, depending on their age, are five

to eight times more sensitive to radiation
than adults. Tom Mulkens shows that his
data for pediatric CT in 2012 were now
way below the reference values prescribed
by the Belgian authorities Federal agency
for nuclear control (FANC) in 2010. The
CT of the head, for example, in Mulkens
department is now performed with a CTDI
of 11 mGy (children below 12 months)
to 20 mGy (adults), whereas the official

Belgian numbers for this examination
range from a CTDI of 35 to 50 mGy.
Mulkens recounts two recent clinical
examples to illustrate the differences:
A newborn baby who had a traumatic
delivery after very long labor with vacuum
extraction of the head in a nearby university hospital received a CT scan of the head
(Fig. 2) the same day. The images showed
1A
1B
1 CT abdomen in a very obese 65-year-old-man (BMI > 35) with acute colon sigmoid
diverticulitis (arrows) at 100 kV. CARE kV and 185 mAs was used, which gives a CTDIvol of
7.3 mGy and DLP of 348 mGy cm of the whole exam. That corresponds to a calculated
effective dose of 5.2 mSv.
41
2A
2D
2B
Scan
2C
kV
mAs /ref.
CTDIvol
mGy
DLP
mGy cm
TI
s
cSL
mm
2.7
0.6
147
1.0
0.6
Patient Position H-SP

Topogram
80
35 mA
Non contrast
head scan
100
101 / 250
3A
8.83
2 Newborn male baby

with traumatic head delivery
with vacuum extraction at
nearby university hospital.
CT of the head the same day
shows small hemorrhagic
brain lesions (arrow) and
overlapping of the skull bones
(Fig. 2A).
Control CT of the head at
the Heilig Hartziekehuis
showed complete recovery
with no residual brain
lesions or injury four months
later (Fig. 2C). Scan parameters showed dose reduction of 50% after use of
SAFIRE, compared with
initial CT scan at birth. 2D
CTDIvol value is based on
a 16 cm phantom.
3B
3 Male newborn with
respiratory distress after
very fast delivery. Standard
radiography, which was
repeated several times in
the first few days, showed
disturbing image of bilateral air collections, indicating bilateral pneumothorax
(Fig. 3A, arrows). CT exam
(Fig. 3B) of the thorax on
day 5 with comparable dose
(effective dose of 0.14 mSv)
to thorax radiography confirmed the diagnosis of
bilateral pneumothorax.
some small hemorrhagic brain lesions

(arrow) and overlapping skull bones.
The CT dose parameters were CTDIvol of
20.12 mGy, DLP of 322 mGy cm and a
calculated effective dose of 3.2 mSv. A
control CT scan at our own hospital four
months later showed complete recovery
of the hemorrhagic brain lesions and bone
lesions, Mulkens says. In this case the
dose level was now 50% lower, with an
effective dose of 1.6 mSv and comparable
diagnostic image quality (Fig. 2).
Another case was that of a newborn
admitted to his department with respiratory distress after a very fast delivery.
The X-rays the radiologists made of
the thorax did not show clearly enough
whether the baby was suffering from
pneumothorax or pneumomediastinumair formation between the heart, lungs
and the chest wall. I suggested to do
a CT, which confirmed the presence of
a bilateral pneumothorax, Mulkens

recounts (Fig.3). The CT was performed
at a dose level not higher than in a standard radiographic exam. The baby was
fine and recovered from the pneumothorax without a specific therapy.
X-ray dose in CT will remain a key issue
for the radiology team in Lier. Growing
experience and increasing medical technology will be important companions for
them to maintain their pioneer position
in dose reduction.
References
[1] Mulkens TH et al., Radiology.
2005 Oct;237(1):213-23.
[2] Mulkens TH et al., AJR Am J Roentgenol.
2005 May;184(5):1611-8.
[3] European Guidelines on Quality Criteria for
Computed Tomography, EUR 16262 (http://
www.drs.dk/guidelines/ct/quality/htmlindex.htm)
[4] Societe Francaise de Radiologie (SFR)
(http://www.sfrnet.org/)
[5] Royal Belgium Radiological Society (http://rbrs.org/)
Irne Dietschi is an award-winning Swiss

science and medical writer. She writes for the
public media, such as the Neue Zrcher Zeitung
and has published several books.

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.
Science
New Opportunities in Cancer Detection

with Hepatic AEF
The new application syngo.CT Onco Function Hepatic AEF extends
diagnostic options in oncology. First studies show promising results in the
detection of Hepatocellular carcinoma or liver metastases compared
with current methods.[1, 2] Complementary information is obtained from
a conventional 3 phase liver scan. The new application is now available
on syngo.via application MM Oncology.
By Jochen Dormeier, MD, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Hepatocellular carcinoma (HCC) or
metastases might be characterized by a
relatively elevated arterial component
supply compared with healthy liver tissue.
To assist physicians in differentiating
healthy from tumorous tissue, the new
oncology software syngo.CT Onco
Function-Hepatic AEF uses the arterial
enhancement fraction (AEF) of the liver.
Various scientific studies[1, 2, 3] have
used the additional mapping and quantifiability using the new feature to describe
an enhanced diagnostic benefit that can
be applied to a variety of clinical problems.
These include:
Primary diagnosis in cases of suspected
HCC or liver metastases
Follow-up during or after oncological
therapy
Early detection of tumor recurrence,
e.g. following RF-ablation
AEF indicates the ratio of arterial perfusion to total perfusion in the liver. The
new software automatically registers the
unenhanced (native), arterial and portal
venous scans of an abdominal multiphase
CT and subsequently computes the AEF
dataset. The results are presented as a
color-coded AEF map which indirectly
reflects the ratio of hepatic arterial perfusion to that of total perfusion. Together
with the regular phases of the abdominal
CT scan, the AEF dataset is then displayed
in a specially adapted layout. The synchronized navigation through all phases
and the AEF mapping enable radiologists
1 Color-coded arterial enhancement fraction (AEF) images are

calculated from unenhanced (upper left), arterial (upper right) and portalvenous (lower left) abdominal phases. A HCC lesion is clearly shown
in segment 8 (arrows).
Courtesy of Seoul National University Hospital, Seoul, Republic of Korea
to compare suspicious findings immediately in all segments. In addition to the

visual comparison, the exact AEF values
can be measured in freely definable
regions of interest. In this way, pathological areas can be identified efficiently
and further diagnosed using, for example,
CT-guided biopsies. A retrospective study
was able to show an increase of 17 percent in the detection rate for HCC.[1]
References
[1] Kim KW, Lee JM, Klotz E, Park HS, Lee DH,
Kim JY, Kim SJ, Kim SH, Lee JY, Han JK, Choi BI.
Quantitative CT color mapping of the arterial

enhancement fraction of the liver to detect
hepatocellular carcinoma. Radiology 2009;
250:425-434
[2] Joo I, Lee JM, Kim KW, Klotz E, Han JK, Choi BI.
Liver metastases on quantitative color mapping
of the arterial enhancement fraction from
multiphasic CT scans: Evaluation of the hemodynamic features and correlation with the
chemotherapy response. Eur J Radiol 2011;
80:278-283
[3] Mahnken AH, Klotz E, Schreiber S, Bruners P,
Isfort P, Gnther RW, Wildberger JE. Volumetric
arterial enhancement fraction predicts tumor
recurrence after hepatic radiofrequency ablation
of liver metastases: initial results.
Am J Roentgenol. 2011; 196:573-9
43
Science
Image Quality in Computed Tomography

Part II: High-Contrast Spatial Resolution
By Stefan Ulzheimer, PhD, Computed Tomography, Siemens Healthcare, Forchheim, Germany
After discussing low contrast detectability

in part I (SOMATOM Sessions No. 31) the
focus here is on another key parameter
of imaging systems: spatial resolution.
Spatial resolution in high-end computed
tomograpy (CT) can thereby be compared
very well with that in a simple digital
camera.
Given that CT is a three-dimensional (3D)
imaging method, the spatial resolution
also needs to be assessed in 3D. Traditionally, this has been done separately in the
x/y-direction the plane in which the
X-ray tube and the detector are located

and in the z-direction along the patients
longitudinal axis. These are also referred
to as in-plane (x/y-direction) and crossplane (z-direction) resolution.
In-plane resolution
In-plane resolution can be assessed
using intuitive or more objective scientific
methods.
Let us begin with an intuitive approach,
namely how a physical grid of varying
dimensions is depicted by the imaging
15 lp/cm
14 lp/cm
16 lp/cm
17 lp/cm
13 lp/cm
18 lp/cm
19 lp/cm
12 lp/cm
20 lp/cm
11 lp/cm
21 lp/cm
10 lp/cm
9 lp/cm
1 lp/cm
Bead Point Source

8 lp/cm
2 lp/cm
7 lp/cm
6 lp/cm
3 lp/cm
5 lp/cm
4 lp/cm
1 High-contrast resolution module of the CATPHAN phantom with 121 lp/cm grids
and a point source.
system. In this approach, a phantom

e.g. CATPHAN phantom equipped with
a CTP 528 high-contrast resolution insert
is imaged by the CT scanner. This insert
contains grids of various sizes consisting
of high-contrast bars of a set width
separated by equal-sized gaps (Fig. 1).
Measured from the image, the spatial
resolution is then specified in line pairs
per centimeter (lp/cm), i.e. the maximum
number of bars and gaps per centimeter
that can just be visually resolved. For
example, a grid with bars 0.5 mm in thickness and 0.5 mm gaps contains 10 of
these line pairs (bar/gap) per centimeter.
If this grid can just be visualized, the
maximum visual resolution of the system
is 10 lp/cm.
When the size of the gaps and bars is
reduced, the contrast between the bars
decreases until they can no longer be
distinguished (Fig. 2A).
While this intuitive method is widely
accepted, there is a more scientific
approach to describe high-contrast resolution: the modulation transfer function
(MTF). The MTF can be described as how
the contrast between our bars reduces
with increasing frequency of the bar patterns by plotting the contrast against the
frequency of the bar patterns (Fig. 2B).
Mathematically, the MTF can also be
defined as the Fourier transform of the
point-spread-function (PSF) of a system.
The PSF shows how a point is depicted
by a system. Clearly, the ideal system
does not exist that can depict a point as
a point. Each imaging system will depict
it as a somewhat blurred spot or even a
completely distorted structure. The MTF
approach can also be used as a measurement method. A wire that is thin enough
but still with sufficiently high contrast
to be considered a point is scanned. A
Fourier transform of the obtained PSF
Science
can be calculated from the frequency f as

d = 1/(2 f).
In the example above, a frequency of
5.9 lp/cm with 10% contrast in the image
means that a structure with a minimum
size of roughly d = 1/(2 * 5.9 cm-1) =
0.085 cm = 0.85 mm can be safely
resolved in the image.
Sometimes other points are specified,
e.g. the so-called cut-off frequency where
the MTF drops to 0. However, these data
points have no clinical relevance. The
specification of a resolvable object in mm,
therefore, should always be obtained
using a visual method or refer to 510%
of the MTF, where the structure can
really be seen in the image.
2A
5 lp/cm
6
800
CT number [HU]
600
400
Cross-plane resolution
200
0
0
0.25
0.5
x [cm]
0.75
1.0
2A Image reconstructed with the B50 kernel: Here, the contrast between the bars in each grid
reduces until the bars can no longer be distinguished. This can be evaluated quantitatively by
plotting the CT numbers along a line across the bars. The bars are blurred so their rectangular
shape is depicted as a blurred edge. Here, the contrast is roughly 80% for the 5 lp/cm grid
(red line) and approximately only 15% remains for the 8 lp/cm grid.
again gives the MTF. In CT, the MTF

depends on many factors that cannot be
changed but also on some that can be
changed by the user.
Interpreting manufacturer
specifications
In practice, only a small number of parameters are given in the manufacturers
data sheets and so it is important to interpret these correctly. Often only a few
MTF data points in dedicated high-resolution scan modes are specified. A more
relevant high-contrast specification might
look like this:
5.9 lp/cm@10% MTF (in typical body
mode)
This means that structures with frequencies of 5.9 lp/cm are depicted with a contrast of 10% in the images in typical body
mode. In practice, the contrast differences still seen in the images will also
depend on the noise level in the images.
In typical clinical situations CT contrast
differences below 510% can no longer
be detected by an observer.[1] Therefore,
clinically relevant specifications should
state the frequency at 510% MTF and
the exact scan and reconstruction parameters should be given.
Intuitively, spatial resolution is related
to the smallest object size that can be
resolved. The method described to measure lp/cm can, however, be directly translated to any object size since one line
pair consists of two structures of equal
size. The frequency f of the bar patterns
can be calculated from the width d of the
bar patterns, as f = 1/(2 d). Re-arranging
this equation, the minimum object size d
In general, the same principles discussed above also apply in the z-direction,
especially as isotropic datasets are now
possible following the introduction of
multislice scanners.
Traditionally, the resolution in the
z-direction was much lower than in the
x/y-plane and therefore the appearance
of individually acquired slices was much
more obvious than today.
Consequently, in the z-direction slice
thickness is still the most commonly
used parameter to characterize spatial
resolution.
Again, there are various ways to measure
either spatial resolution in the z-direction
or the slice thickness. A straightforward
method is to take the same grids as used
to assess in-plane resolution, only tilted
by 90. A method recommended by the
International Electrotechnical Commission
(IEC) uses wire or strip ramps oriented
parallel to the x- or y-axis but tilted against
the x/y-plane.[4] Using basic trigonometry, the slice width can be determined
from the length of the wire or strip that
is depicted in one image. A correction
may be necessary to account both for the
thickness of the wire or strip itself and
for the in-plane reconstruction properties
(e.g. the kernel) that influence the visible
length of the wire or strip in the image.
The best method to determine the slice
thickness is to measure the actual PSF in
the z-direction again. In CT this is usually
referred to as Slice Sensitivity Profile (SSP).
45
Science
2B
5 lp/cm
6
100%
7
75%
B50
Contrast [HU]
8
50%
25%
0
0
12
line pairs per cm

2B Plotting the contrast against the resolution, produces the MTF for the B50 kernel
and this scan mode. The MTF completely characterizes the high-contrast resolution of this
dedicated scan mode in combination with this kernel.
Typically, a thin gold disc is moved along

the z-direction and the relative contrast
of the disc is plotted against its z-position
(Fig. 3). Intuitively, the profile of a slice
has a rectangular shape like a slice of
bread. In CT, however, the SSP may differ
from that ideal shape depending on the
scan mode. In sequential scanning the
shape is trapezoidal due to the geometry
of a CT scanner; in spiral CT the profile is
bell-shaped. If one moves the thin gold
disc slowly into the slice, it does not
suddenly appear in full contrast but the
contrast slowly increases until it reaches
a maximum in the middle of the slice.
The slice thickness is now defined as
the full-width-at-half-maximum (FWHM)
of the SSP.[4] The FWHM is the width of
the slice profile when the contrast
reduces by 50%.
If the SSP shape differs greatly from the

rectangular shape, the resolution can be
improved by reconstructing overlapping
slices. Typically, 2-3 overlapping slices
per nominal slice width yields the best
compromise between resolution and
additional data volume generated.[1]
This method can produce, for example,
a visual resolution of 0.3 mm from
slices that are nominally 0.5 mm thick.
Siemens Technologies to
Optimize Spatial Resolution
Spatial resolution depends highly on the
sampling of the data acquired. Siemens
CT scanners use various oversampling
techniques. Oversampling avoids aliasing,
improves resolution and reduces noise.
For in-plane imaging, a flying focal spot
of the X-ray tube is used, i.e. two focal
spot positions for the same projection

angle shifted by half the detector width.
This doubles the number of data points
within the plane without a dose increase
as only half the dose is applied for each
projection. The detector channels are
also shifted by one quarter detector width
within one rotation so that opposite projections yield slightly different data points.
This again doubles the number of projections for image reconstruction. Siemens
uses the z-Sharp feature unique to the
Siemens STRATON tube, which uses a
flying focal spot in the X-ray tube in the
z-direction, too.[2] This provides the
highest resolution entirely independent
of the spiral pitch and at all scan speeds.
The majority of systems from other
vendors are still bound to discrete pitch
values that offer EITHER high scan speed
OR high image quality.
A small and stable focal spot of the
X-ray tube is also an important factor in
achieving optimal spatial resolution
both in-plane and in the z-direction. The
Siemens STRATON tube offers a focal spot
of 0.7 x 0.7 mm for ultra high-resolution
applications such as inner-ear scanning
and a flying focal spot of 0.9 x 1.1 mm
for standard applications.
Compared to systems with conventional
detectors, the Siemens Stellar Detector
enables reconstruction of slices with an
actual effective slice width of 0.5 mm
and has been shown to improve stenosis
grading significantly due to improved
spatial resolution with reduced image
noise.[3] Other vendors may specify the
same slice thickness by tweaking the
tolerances recommended by the IEC.
The IEC recommends a deviation of up
to 0.5 mm from the specified slice width
for thicknesses below 1 mm.[4] This
could mislead users into believing that a
slice of 0.8 mm, for example, is actually
0.5 mm thin by specifying 0.5 mm in
the user interface (Fig. 3). It is, however,
important to note that detector width
alone does not determine spatial resolution. Even if the detector elements have
a width of 0.5 mm, the same is not necessarily true for the reconstructed slice
widths as many factors play a role in
achieving maximum spatial resolution.
Another way to increase spatial resolu-
Science
tion, albeit at the price of higher dose is

the use of dedicated grids. On all highend scanners in the Siemens Definition
class Ultra High Resolution (UHR), grids
are available both in-plane and in the
z-direction. These can be moved in front
of the detector to reduce the aperture
of the detector elements by 50% in both
planes. This option is mainly used in
inner-ear or bone imaging.
Siemens proprietary scintillator material
Ultra Fast Ceramics (UFC) offers high
X-ray absorption, short decay times, and
extremely low afterglow, key parameters
for high spatial resolution. The decisive
properties of scintillator materials that
are important for spatial resolution are
decay time and afterglow. Both characterize the light output of the scintillator
after the X-rays are switched off. UFC has
decay characteristics that are optimized
with respect to all other system parameters, especially the length of one projection. It offers a consistent decay time
of 2.5 microseconds, and an afterglow
below 104 after 1 millisecond and 105

after 10 milliseconds. Today, other vendors still use afterglow correction mechanisms [5] since long decay time and high
afterglow can ruin spatial resolution due
to blurring between the projections. Yet,
increasing scintillator speed beyond certain limits no longer makes sense if it is
significantly faster than the duration of
one projection.
Other important factors for a well-balanced system with optimized spatial
resolution are the number of projections
per rotation, an optimized scanner geometry that takes all other parameters
into account. Of course, a wide range
of optimized reconstruction kernels
that can address all clinical challenges is
essential as well.
Returning to the digital camera mentioned at the start, we now know that
the number of megapixels is not enough
to characterize its performance. Much
more important is a well-balanced system
with quality, harmonized components
and versatile image processing. The same

applies to a CT scanner at more than
10,000 times the price of a simple digital
camera.
References
[1] Willi A. Kalender. Computed Tomography:
Fundamentals, System Technology, Image Quality, Applications, Publicis Publishing (2011)
[2] Flohr TG, Stierstorfer K, Ulzheimer S, Bruder H,
Primak AN, McCollough CH. Image reconstruction and image quality evaluation for a 64-slice
CT scanner with z-flying focal spot. Med Phys.
2005 Aug;32(8):2536-47.
[3] Morsbach F et al. Stenosis quantification in
coronary CT angiography: impact of an integrated
circuit detector with iterative reconstruction.
Invest Radiol. 2013 Jan;48(1):32-40.
[4] IEC 61223-3-5, Ed.1 (2004-08) Evaluation and
routine testing in medical imaging departments
Part 35: Acceptance tests Imaging performance of computed tomography X-ray equipment
[5] Hsieh J, Gurmen OE, King KF. Investigation of
a solid-state detector for advanced computed
tomography. IEEE Trans Med Imaging. 2000
Sep;19(9):930-40.
100%
Contrast
Ideal Slice Profile
0.5 mm Sequential Scan
0.5 mm Spiral Scan Siemens
0.5 mm Spiral Scan Vendor B
50%
FWHM
0%
-0.50
-0.25
0.25
0.50
z-position in mm
3 Slice Sensitivity Profiles for sequential scans and spiral scans for a 0.5 mm slice compared with the ideal rectangular
slice profile. IEC tolerances allow much wider slices than the real FWHM of 0.5 mm found on Siemens systems with the
Stellar Detector.
47
Customer Excellence
syngo Evolve Update for

SOMATOM Definition Family Members
By Jutta Reindler, Computed Tomography, Siemens Healthcare, Forchheim, Germany
The syngo Evolve non-obsolescence
program from Siemens makes innovations
possible even in installed CT scanners.
More than 1,000 systems in operation
worldwide are currently being updated
with the rollout of the new syngo CT
2012B software.
Customers with SOMATOM Definition
Flash and AS systems installed in 2009
and 2010 and all SOMATOM Definition
customers can benefit from the new
syngo CT 2012B software. It includes the
following features to enhance routine
workflow:
Password protected scan protocols:
Protection is now available to avoid
unauthorized modifications. This
functionality requires a password in
order to use the Scan Protocol Assistant
and save changed scan protocols.
Customized anonymization attributes: Patient data can be anonymized.
For this, the content has to be taken
offline. The software then allows different attributes, such as format or name,
to be configured.
Improvements to syngo Expert-i*:
Expert-i enables interaction with the
syngo CT Workplace from virtually anywhere in the hospital. With the syngo
Evolve update, Expert-i now supports
dual monitor use as well as dual screen
display (switch using hot key).
Improvements to the Patient
Browser search by Latest examination date: The new software allows
a search for the latest examination date
for a particular patient. Thus, the data
from previous examinations required
for a follow-up can be found efficiently.
This can ease the daily workflow.
Password protection is now available to avoid unauthorized modifications.

The
FAST CARE Technology is now

available: The FAST CARE Technology*
is now also available to SOMATOM
Definition Evolve customers accelerating workflow and lowering radiation
exposure to unseen levels. For more
information on the features included
please see: www.siemens.com/fast-care
Special features
Some features are offered especially to
individual members of the SOMATOM
Definition Family. One such feature is
syngo Dual Energy** as part of Evolve for
SOMATOM Definition Flash. This includes
FAST Dual Energy enabling easy and intuitive immediate 3D-reconstruction of
acquired Dual Energy data. WorkStream4D
reconstructs axial, sagittal, coronal, or
double-oblique images directly from

standard Dual Energy scanning protocols.
There is no need to generate the individual image series first. The elimination of
time-consuming and error-prone manual
reconstruction steps makes the workflow
much faster.
In addition, using FAST Dual Energy for
reconstruction significantly reduces the
data volume and saves considerable filming and archiving resources.
After installation, e-learning CDs and
dedicated application training help the
customers to make the full use of the
new scanner capabilities.
** FAST Planning features to be purchased separately
** Requires Dual Energy Scanning with selective
Photon Shield
Customer Excellence
Workshop on Dual Energy at

CT Headquarters in Germany
By Axel Lorz, Computed Tomography, Siemens Healthcare,
Forchheim, Germany
As part of Siemens Healthcare longestablished tradition of offering training,

a workshop on Dual Energy CT was held
in February 2013. Speaker was Thorsten
Johnson, MD, Associate Professor of Radiology and Head of Computed Tomography
at Munich University Hospital, Germany.
Dual Energy scanning has increasing clinical relevance and so radiologists were
quick to fill the 12 available places. Participants came from all parts of the world
to attend the course at the headquarters
of Siemens CT in Forchheim, Germany.
The two-day training session included
presentations on both the clinical benefits and physical principles of Dual and
Single Source Dual Energy CT.
A hands-on session at a SOMATOM

Definition Flash scanner and at workstations for extended case review was
included in the workshop. Course director and specialist Thorsten Johnson
covered all the twelve FDA cleared clinical Dual Energy applications with an
emphasis on the optimization of scan
parameters. As an early pioneer of Dual
Energy CT and in view of his extensive
daily practice at Munich University
Hospital, Johnson made the workshop
a particularly exciting experience. After
the workshop, participants left fully
equipped with the latest information on
work at the forefront of CT Dual Energy
technology.
Thorsten Johnson, MD, Associate Professor

of Radiology hosted an exciting Dual Energy CT
workshop at the Siemens CT headquarters in
Forchheim.
For further information

and booking options:
www.siemens.com/
SOMATOMEducate
CT Physics Made Easy with New Webinar

By Axel Lorz, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Walter Huda,
PhD, from
the Medical
University of
South Carolina,
focuses on
dose and image
quality in his
new webinar.
Siemens Healthcare has added a new

webinar focusing on CT physics to their
educational program. In this session,
Walter Huda, PhD, Medical University of
South Carolina, Charleston, USA provides
an introduction to physics for CT and
practical tips on mastering the trade-off
between dose and image quality. A well-
known scientist and professor of radiology

internationally, Walter Huda is actively
involved in the clinical application of medical imaging. In his everyday work, one
of his main concerns is to maximize diagnostic information while keeping patient
dose as low as reasonably achievable
(ALARA).
In six half-hour sessions, Huda guides
the listener through:
CT dose
Image quality
CARE Dose4D
CARE kV
Clinical techniques
Clinical practice
From the basics of CT physics to advanced
dose-saving techniques, Walter Huda
explains ways to reduce the amount of

radiation while still achieving the best
possible image quality. In addition to
a strong theoretical background, Huda
offers many practical tips. Participants
learn, for example, the influence of tube
voltage on dose and contrast-to-noise
ratio and hear a discussion about the
impact on bariatric or pediatric patient
scans. After completing the six modules,
the participant will have a thorough
understanding of how to best use all the
SOMATOM dose-saving features.
www.siemens.com/
clinicalwebinars
49
Customer Excellence
Tips & Tricks: How to Accelerate

Reconstruction of Dual Energy Data
By Patricia Jacob, Computed Tomography, Siemens Healthcare, Forchheim, Germany
FAST Dual Energy (DE) as part of the
syngo CT 2012B software recently has
been introduced to the Siemens Dual
Source scanners.
3D reconstruction fast and

smooth
FAST DE can accelerate workflow by enabling easy and intuitive direct 3D reconstructions of acquired DE data (Fig. 1).
FAST DE has been included into
WorkStream 4D. Thus often time-consuming manual reconstruction steps
have been eliminated. In the Recon
card, different reconstruction series are
available: A+B+M / A+B / FAST DE (F).
With FAST DE (F) the generation of 3D
reconstructed para-axial, sagittal and
coronal images will now be possible by
directly using the CT data. These 3D
series indicated by an F in the series
name can then be easily incorporated
into routine CT protocols.
1 For a swifter run, select FAST DE in the Recon card and then choose 3D
as the recon type.
Saving storage space

Calculating a FAST DE series is not only
much quicker than an A+B+M series.
Also, storing just one rather than three
sets of data reduces overall data volume.
A separate autotransfer functionality
for each series is also available.
Reducing metal artifacts

Both the mixed image series and FAST DE
image series are a combination of the
acquired low and high kV datasets (Fig. 2).
The mixing ratio can be adjusted by setting the composition factor to define the
linear weight of the low kV images. The
intensity of the high kV images is derived
from the composition factor. A FAST DE
series can be reconstructed with a negative composition factor making it possible to reduce metal artifacts.
2 To adjust the composition factor, use the composition slider for the mixed
and/or FAST DE image series. Symbols indicate the recommended composition
factors, for example for non-contrast and vascular examinations.
Customer Excellence
Clinical Workshops 2013

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
Course Director
Link
Hands-on at the
ESGAR Congress/Colonography
June, 47
Barcelona,
Spain
ESGAR
Prof. Carmen Ayuso, MD
www.esgar.org
Oncology Imaging Course

2013/Oncology
June, 2729
Dubrovnik,
Croatia
OIC
Prof. Maximilian Reiser, MD
www.oncoic.org
Clinical Workshop on
Cardiac CT/Cardiac
July, 1719
Munich,
Germany
Siemens Healthcare
Prof. Christoph Becker, MD
www.siemens.com/
SOMATOMEducate
Workshop for Physicists
Oct, 2223
Forchheim,
Germany
Siemens Healthcare
www.siemens.com/
SOMATOMEducate
CTA Interpretation Course/Cardiac
Nov, 78
Erlangen,
Germany
Siemens Healthcare
Prof. Stefan 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
The term partner does not imply a legal partnership or joint venture relationship.
Upcoming Events & Congresses 2013

Short Description
Date
Location
Title
Contact
World Congress of Thoracic Imaging
June, 811
Seoul, Korea
WCTI
www.wcti2013.org
International Society for

Computed Tomography
June, 1720
Washington DC, USA
ISCT
www.mdctcourse.com
European Conference on
Interventional Oncology
June, 1922
Budapest, Hungary
ECIO
www.ecio.org
Society of Cardiovascular
Computed Tomography
July, 1114
Montreal, Canada
SCCT
www.scct.org
European Society of Cardiology
Aug, 31Sept, 4
Amsterdam,
The Netherlands
ESC
www.escardio.org
American Society for

Radiation Oncology
Sept, 2225
Atlanta, USA
ASTRO
www.astro.org
Radiological Society of
North America
Dec, 16
Chicago, USA
RSNA
www.rsna.org
51
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Register for the
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Imprint
SOMATOM Sessions IMPRINT

2013 by Siemens AG,
Berlin and Munich
All Rights Reserved
Kobayashi, Hiroaki, MD, National Hospital Organization Takasaki General Medical Center, Japan
Publisher:
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Medical Solutions
Computed Tomography & Radiation Oncology
Siemensstrae 1, 91301 Forchheim, Germany
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Stefan Ulzheimer, PhD
Clinical Editor:
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Project Management:
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Responsible for Contents:
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Editorial Board:
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Authors of this issue:
Al-Butmeh, Firas, MD, Goethe University
Frankfurt, Germany
Amrhein, Timothy J., MD, Medical University
of South Carolina, Charleston, USA
Bauer, Ralf W., MD, Goethe University
Frankfurt, Germany
Ching So, Man, MD, St. Teresas Hospital,
Kowloon, Hong Kong SAR, China
Fukuda, Nobuaki, MD, National Hospital Organization Takasaki General Medical Center, Japan
Hagspiel, Klaus D., MD, University of Virginia,
USA
Hiroi, Shitoshi, MD, National Hospital Organization Takasaki General Medical Center, Japan
Iwase, Haruka, MD, National Hospital Organization Takasaki General Medical Center, Japan
Kerl, J. Matthias, MD, Goethe University

Frankfurt, Germany
Martinelli, Carlos, MD, Hospital do Corao,

So Paulo Brazil
Matsuo, Yae, MD, National Hospital Organization Takasaki General Medical Center, Japan
Ming Wong, Chi, MD, St. Teresas Hospital,
Kowloon, Hong Kong SAR, China
Negishi, Chikashi, MD, National Hospital Organization Takasaki General Medical Center, Japan
Norton, Patrick T., MD, University of Virginia,
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Ogur, Torel, MD, University of Virginia, USA
Onuki, Castro, MD, Hospital do Corao,
So Paulo Brazil
Rumboldt, Zoran, MD PhD, Medical University
of South Carolina, Charleston, SC, USA
Saitou, Akihiro, MD, National Hospital Organization Takasaki General Medical Center, Japan
Sasaki, Toyoshi, MD, National Hospital Organization Takasaki General Medical Center, Japan
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Schulz, Boris, MD, Goethe University Frankfurt,
Germany
Shizuka, Takehito, MD, National Hospital Organization Takasaki General Medical Center, Japan
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Sessions.
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SOMATOM Sessions

Answers for life in Computed Tomography

Issue Number 32 / June 2013

We see our role as supporting

Cover page: Courtesy of Erasmus Medical Center, Rotterdam, the Netherlands

2 SOMATOM Sessions June 2013 www.siemens.com/SOMATOM-Sessions

Some months ago, I introduced our shift

In clinical practice, the use of SAFIRE may reduce CT

SOMATOM Sessions June 2013 www.siemens.com/SOMATOM-Sessions

06 True Dual Energy Succeeds

06 Radiologists and technicians

12 Saving Dose, Reducing Patient Burden

4 SOMATOM Sessions June 2013 www.siemens.com/SOMATOM-Sessions

Right Dose Image

Free-breathing Coronary CTA

Finding the Right Dose

40 Finding the Right Dose with the

50 Tips & Tricks: How to Accelerate

48 syngo Evolve Update for SOMATOM

SOMATOM Sessions June 2013 www.siemens.com/SOMATOM-Sessions

True Dual Energy Succeeds

Exciting technical innovations in computed tomography imaging continue.

True Dual Energy is also available on the

6 SOMATOM Sessions June 2013 www.siemens.com/SOMATOM-Sessions

integrate DECT in their daily routine and

Munich, Germany: Research

Today, about 50 percent of all abdominal

With Dual Source DE,

results in recent cases with excellent

Rotterdam, the Netherlands:

Center in Rotterdam, the Netherlands,

SOMATOM Sessions June 2013 www.siemens.com/SOMATOM-Sessions

their young patients. Even on crying

sedation or anesthesia that some other

Dual Source DE is used regularly for this

8 SOMATOM Sessions June 2013 www.siemens.com/SOMATOM-Sessions

affect the children later in life. Potential

Chiba, Japan: Dual Source DE

From our perspective,

(WA) and iodine overlay images (IO).

ment strategy, especially when attempting a function-preserving therapy.

Hamburg, Germany: Exceptional image quality with DE

SOMATOM Sessions June 2013 www.siemens.com/SOMATOM-Sessions

with nine locations in Hamburg experts

the tumor precisely if the location of the

Single Source DE: The Scan Principle

10 SOMATOM Sessions June 2013 www.siemens.com/SOMATOM-Sessions

scans; they compared the results with

True Dual Energy

DEfinitely excellent images:

DEfinitely the right dose:

tables for each monoenergetic mode used

Single Source DE has clear advantages

Medical writer Wiebke Kathmann, PhD, is

The statements by Siemens customers described

SOMATOM Sessions June 2013 www.siemens.com/SOMATOM-Sessions

Saving Dose, Reducing Patient Burden

Its difficult for Marilyn Siegel, MD, to

Spreading the low-dose gospel

The next step in exquisite

tion CARE Dose4D or the Adaptive Dose

12 SOMATOM Sessions June 2013 www.siemens.com/SOMATOM-Sessions

impressed. The contrast was maintained,

Quicker iterative reconstruction (IR) with reduced noise

The goal is to get

With FAST Spine