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No 18/June 2006

Stanford-Edition
June 14th
June 17th, 2006

www.siemens.com/medical

Highlights
COVER STORY
Saving Time, Money and Lives
Page 4
NEWS
3D-Reading
Wherever You Are
Page 10
BUSINESS
Utilization Report Now Also
Available for CT Systems
Page 15
CLINICAL OUTCOMES
Cardiovascular Dual Source
CT after Left Main Coronary
Artery Stenting
Page 17
CLINICAL OUTCOMES
Neurology Complete
Occlusion of Left Carotid
Artery and Stenosis at
Right Carotid Artery
Page 29
SCIENCE
Radiation Dose with Dual
Source CT
Page 38
CUSTOMER CARE
Evolve Update Facilitates
Enhanced CT Fluoroscopy
Page 45

SOMATOM
Sessions
Picture

Deutscher Zukunftspreis/Ansgar Pudenz

EDITORS LETTER

Bernd Ohnesorge, PhD,


Vice President
CT Marketing and Sales

Dear Reader,
At RSNA 2005, Siemens moved CT into a new era. With the introduction of the worlds first Dual Source
CT, the SOMATOM Definition, the CT slice race is coming to an end. Now, only six months after its introduction, the first ten systems are up and running in the worlds leading clinical institutions ten out of
approximately 150 scanners that will be installed in the year 2006. In this issue, these Dual Source CT
users will share their excitement about their first clinical experiences with the new scanner, and our
technology experts will explain the miracle of dose reduction with two tubes running at the same time.
However, we at Siemens understand that supplying our users with innovative CT scanner technology is
not enough. Therefore, we have dedicated a significant part of this issue to explaining how you can
benefit from our CT Clinical Engines to continuously enhance your diagnostic performance in the key
clinical fields of cardiovascular CT, neuro CT, acute care CT and CT in diagnostic oncology. In the meantime, nearly 50 percent of our high-end CT customers decide to equip their system with one or more
CT Clinical Engine, customized to their clinical needs.
But we want to take CT workplace innovation even further. Have you ever thought about turning your
office PC or laptop computer into a high-performance CT workstation? Now you can. With syngo
WebSpace* Siemens is the first CT manufacturer to introduce a client-server solution for 3D reading
wherever you are. While you are reading this, the first clinical installations of syngo WebSpace* are
being implemented and customized for very different clinical environments from private imaging
centers to large hospital enterprises.
In this 18th SOMATOM Sessions customer magazine issue, you will discover that CT has gone beyond
innovative tube and detector technology. This issue's cover story from the chest pain unit of the Medical
University of South Carolina represents a great example that CT manufacturers have to think differently
today. New developments have to pay attention to all steps from the patient entering the CT room to
the clinical report. Now, we invite you to enjoy reading about todays synthesis of innovations in CT
scanners and workplaces that enhance your clinical workflow.
Sincerely,

Bernd Ohnesorge, PhD, Vice President CT Marketing and Sales


* Pending 510(k): The information about this product is being provided for planning purposes only.
This product is pending 510(k) review, and is not yet commercially available in the U.S.
Cover Page: syngo Neuro DSA delineates the complete vascular tree from aortic arch to the Circle of Willis
obtained with a SOMATOM Definition. Kindly provided by the University of Munich, Grohadern, Germany.

SOMATOM Sessions 18

CONTENT

COVER STORY
4

Saving Time, Money and Lives

NEWS
8

syngo Circulation The Next Generation

10

3D-Reading Wherever You Are

12

Siemens and BrainLAB Develop New Solutions for Neurosurgery

13

New Features with syngo CT 2006C

13

And the Winner is

14

Individualized Head Image Reconstructions Always Thinking (a)Head.

BUSINESS
15

An Expert Opinion from Anywhere in Just a Few Seconds

15

Utilization Report Now Also Available for CT Systems

CLINICAL OUTCOMES
16

Cardiovascular: Faster Diagnosis and Full Confidence in Cardiac CT

17

Cardiovascular: Dual Source CT after Left Main Coronary Artery Stenting

21

Cardiovascular: CT Angiography of the Chest

23

Oncology: Faster Diagnosis and Full Confidence in Oncology CT

24

Oncology: Silikoasbestosis of the Lung with Secondary Bronchial Carcinoma

26

Oncology: Improving Patient Outcomes with PET/CT

28

Neurology: Faster Diagnosis and Full Confidence in Neuro CT

29

Neurology: Complete Occlusion of Left Carotid Artery and Stenosis


at Right Carotid Artery

31

Neurology: CTA of the Neck Stenosis of Left Carotid Artery Evaluated


with CT Digital Subtraction Angiography

33

Neurology: Cerebral Perfusion in a Patient with Dengue Hemorrhagic Fever

35

Acute Care: Faster Diagnosis and Full Confidence in Acute Care CT

36

Acute Care: Trauma Diagnosis in Seconds: 64-Slice Spiral Computed Tomography


Serving Full and Frank Image Acquisition

SCIENCE
38

Radiation Dose with Dual Source CT

41

The Sarawak Experience A Report After 18 Months in Clinical Practice

CUSTOMER CARE
45

Evolve Update Facilitates Enhanced CT Fluoroscopy

45

Service: Frequently Asked Questions

46

Service: CT Education on the Web

46

Service: Upcoming Events and Courses

47

Imprint

SOMATOM Sessions 18

COVER STORY

Looking into computed tomography as a diagnostic tool to quickly assess the cause of acute chest pain:
Christian Thilo, MD, Eric Powers, MD, and U. Joseph Schoepf, MD (from left).

Saving Time, Money


and Lives
Diagnosing chest pain symptoms can be a costly, time-consuming process,
often involving invasive tests and hospital admission. But new CT technology
promises welcome relief for both patients and hospital staff.
By Sameh Fahmy

The scenario is a common one at the Medical University of


South Carolina (MUSC) and at hospitals around the globe: A
patient presents to the emergency department with acute
chest pain, but ECG and blood test results are inconclusive.
The current protocol for ruling out coronary syndromes as a
cause for the pain is time consuming, expensive and often
involves an invasive angiogram. MUSCs U. Joseph Schoepf,

SOMATOM Sessions 18

MD, associate professor of radiology and medicine, and his


colleagues are exploring an alternative that may provide
physicians and patients with a clear, definitive diagnosis that
saves time and money.
In 2004, the hospital was among the first in the United
States to install the Siemens SOMATOM Sensation 64-slice
computed tomography (CT) system. Schoepf, who is also

COVER STORY

Any type of post-processing


is much more diagnostic with
a 64-slice scanner.
U. Joseph Schoepf, MD, Associate Professor
of Radiology and Medicine, Medical University
of South Carolina, Charleston, SC

Director of CT Research and Development at MUSC, says the


benefits of the technology were immediately and intuitively
evident. Because of the better temporal and spatial resolution, any type of post-processing, any type of 3D, looks much
better and is much more diagnostic with a 64-slice CT scanner, he says.
Using the technology to diagnose acute chest pain was both
a result of the strength of the 64-slice CT scanner and the
limitations of ECGs and blood tests as stand-alone diagnostic
tools. Cardiac enzyme tests do not reach diagnostic levels of
sensitivity until at least six hours after the onset of pain. This
necessitates a period of observation, often combined with
treadmill testing to help diagnose unstable angina. The
observation period for acute chest pain patients can take
several hours and may necessitate hospital admission, but
does not necessarily produce a clear diagnosis.
The testing that we do and that we continue to do includes
tests which have limited sensitivity and specificity and limited
diagnostic value, says Eric Powers, MD, professor of medicine and Director of the Acute Coronary Syndrome Center at
MUSC. So even after the testing wed do, wed frequently be
left with a question instead of a definite answer.
Angiography is commonly used to rule out coronary artery
disease as the cause for chest pain, but the technique is costly,
invasive and carries risks such as bleeding and infection. The
fact of the matter is, there are lots and lots of patients wed
prefer not to take to cardiac catheterization for whom wed
rather settle the issue about the presence or absence of
coronary artery disease using a noninvasive test, Powers says.

ers undergo conventional work-up that includes catheterization. Schoepf explains that in these patients, the addition
of a CT scan is likely to be detrimental, as it may delay the
onset of therapy.
Those patients who present with acute chest pain but have
non-diagnostic ECG results and initially negative cardiac
markers and Schoepf says these are the vast majority of
patients are given a chance to enroll in the trial in which
the 64-slice CT scan is used as a diagnostic tool.
CT has been shown to effectively rule out coronary artery
disease as a source of chest pain and has the further benefit
of ruling out non-cardiac causes such as acute pulmonary
embolism or aortic dissection.
From a cardiologists point of view, the enthusiasm comes
from the excellent images that are taken, Powers says. "The
excellent detail of the coronary vessels that allows us to
make the assessment.
In addition to the SOMATOM Sensation in its vascular center,
MUSC has installed a second 64-slice system adjacent to its
emergency room to facilitate a smooth workflow. If a CT
scan is deemed necessary, hospital staff simply moves
patients through a single set of double doors to be scanned.
Although the CT trial is still enrolling patients, preliminary
results are promising. In patients where ECG and blood test
results were inconclusive, those who underwent CT imaging

Promising Initial CT Trials


To put the SOMATOM Sensation 64-slice system to the test,
Schoepf and his colleagues began a clinical trial that aims to
enroll 100 patients. Those patients who present to the emergency department with chest pain and have a high likelihood
of coronary artery disease positive ECG and cardiac mark-

A SOMATOM Sensation 64-slice computed tomography scanner


is installed directly adjacent to the emergency room at MUSC.

SOMATOM Sessions 18

COVER STORY

and were found not to have a coronary syndrome or other


acute pathology were discharged in an average of eight
hours. Those who did not undergo the CT scan were discharged in an average of 17.6 hours.
The data suggest a marked cost savings as well. The average
cost of emergency department treatment for patients who
underwent the CT scan was 2,413 dollar compared to 3,438
dollar for those who did not undergo the scan a saving of
over 1,000 dollar per patient.
But numbers dont tell the whole story. Schoepf recalls a 22
year old patient who presented to the emergency department with acute chest pain. The patient had a family history
of heart disease and his ECG results showed clear signs of
ischemia in the myocardium. But the patients relatively
young age made Schoepf doubtful that coronary artery disease was the cause and that an invasive test was warranted.
The CT scan revealed a congenital coronary abnormality in
which the patient had an aberrant artery between the root
of the aorta and the pulmonary artery. Every contraction of
the patients heart would squeeze the aberrant artery, producing ECG results that looked like those of a heart attack.

Schoepf says diagnosing the patients anomaly using an


angiogram would have been difficult, and that the CT scan
was able to produce a better diagnosis with less risk to the
patient. That was obviously very much of an eye opener,
Schoepf says of the case. I think that convinced pretty much
everybody involved about the particular value of the CT.
In the case of another patient, a 66 year old man who presented to the emergency department with acute chest pain,
the CT scan determined significant atherosclerotic changes
60 percent stenosis as well as an important incidental
finding: it revealed an early-stage squamous cell carcinoma
of the lung. Such extra-cardiac findings are not too rare,"
says Christian Thilo, MD, research physician in the Departments of Radiology and Cardiology at MUSC. We find pleural
effusions, pneumonia and sometimes tumor nodules in
the lungs.
Another real benefit thats difficult to qualify is how the
reduced wait time for patients can ease anxiety. When you
tell patients within a very short period of time that you have
an answer and they are normal, what does that do? Powers
asks. That lifts a huge weight off their shoulders.

The SOMATOM Sensation 64-slice computed tomography scanner ensures immediate access and fast diagnosis for
patients with unclear causes of chest pain.

SOMATOM Sessions 18

COVER STORY

A non-invasive test
which is diagnostically
accurate to assess the
presence of coronary
artery disease is a crucial step in the development of cardiology.
Eric Powers, MD, Professor of Medicine,
Director of the Acute Coronary
Syndrome Center, Medical University
of South Carolina, Charleston, SC

An (sub) acute LAD occlusion


(arrow) diagnosed in a patient presenting with atypical chest pain and
inconclusive ECG and lab testing.

A tumor in the left atrium has been


identified with the SOMATOM Sensation 64
(arrow).

Further Benefits with Dual Source CT


MUSC has purchased and will soon install a Siemens
SOMATOM Definition, the worlds first Dual Source CT. By using
two X-ray source and detector systems that rotate in synchrony, the SOMATOM Definition acquires image data in half
the time of conventional technology. The Dual Source scanner has a temporal resolution of 83 milliseconds and a spatial
resolution below 0.4 millimeter, which Schoepf says will further facilitate the emergency diagnosis of acute chest pain.
Even with a 64-slice scan, beta blockers are commonly used
to slow a patients heart rate so that physicians can get the
sharpest image possible. Some patients, such as those with
asthma, are not candidates for beta blockers, while others
are beta blocker resistant.
Schoepf anticipates that the better temporal resolution of
Dual Source CT will make giving patients beta blockers
unnecessary, saving time in the emergency department and
making the technology available to a wider group of patients.
He adds that the decreased scan times and other technical
advances mean that the patients radiation dose is cut substantially, and that patients breath-hold times are reduced,
which is of vital importance in critically ill patients.
Schoepf says the rate at which CT technology is progressing
exceeds the ability of academic medicine to assess its benefits, but the trial currently underway demonstrates a commitment to evidence-based medicine and a patient-centered
atmosphere.

If you have to cut through a lot of red tape in order to make


the interdepartmental logistics work, that is not a very good
background for a speedy assessment of patients with acute
chest pain, Schoepf says. In this scenario, there needs to be
very good interaction between the departments of emergency medicine, cardiology and radiology to make this test
as efficient as possible. Fortunately, at this institution, I believe
we are in that particular situation.
And while the researchers await final results from their
study, they already grasp the potential of the technology and
its implications for cardiology.
An accurate, non-invasive technique to evaluate coronary
artery disease has really been one of the holy grails of cardiology forever, really, Powers says. This technology holds
the prospect that it really could be what weve been waiting
for throughout history. That sounds kind of grandiose, but the
fact of the matter is, a noninvasive test which is diagnostically accurate to assess the presence of coronary artery disease
is a crucial step in the development of cardiology.

Author: Medical writer Sameh Fahmy holds a masters degree in


science and technology journalism from Texas A&M University and
is based in Athens, GA.

SOMATOM Sessions 18

NEWS

s y n g o C I R C U L AT I O N

The Next Generation


The entrance of CT into the world of
cardiovascular imaging has considerably changed the research and clinical
environment over the past few years.
The advent of 64-slice CT-scanners has
brought the ability to perform reliable
and routine cardiovascular imaging to a
wide range of customers. Whereas it
was a mere research topic three to five
years ago, the majority of sites now routinely perform non-invasive CT imaging
to rule out cardiovascular disease.
Siemens CT division not only contributed to this development by inventing one of the most sophisticated scanner technologies, but also by
engineering excellent software: syngo
Circulation is the main pillar of the CT

Cardiac Engine. Developed in 2005 and


commercially available since the beginning of this year, it combines morphological analysis of the coronary artery
tree with an easy and fast functional assessment of the left ventricle. Only six
months after rolling out the first version, the next generation of syngo Circulation is on the horizon. This new version will greatly enhance existing
functionality, and by adding a number
of new features, take syngo Circulation
to the top of cardiovascular evaluation
software.
While loading up to 3600 images in the
background, the diastolic phase is automatically loaded first, so the user can
start performing an initial evaluation.

Additionally, an automatic segmentation of the whole heart is performed in


the background, so the user can easily
switch between a full thorax view and a
heart-only view.
The quantitative coronary analysis has
become faster and easier. A workflow
status indicates which coronaries have
been evaluated and which have not.
The addition of vessel segments became possible by simply clicking into the
VRT image. The stenosis measurement
now includes an editable vessel contour
line to facilitate an accurate stenosis
measurement [Fig. 1]. The location of
the stenosis can now be defined by
clicking onto the respective location in
an AHA 15-segment model.

[ 1 ] The quantitative coronary analysis (QCA) of the NEW


syngo Circulation.
The VRT can be easily
faded out under the
coronary arteries
overlay (lower right).
An adaptable contour line makes the
stenosis measurement even more
accurate (upper left).
The further simplified
reporting dialogue
allows quick reporting (lower left).

SOMATOM Sessions 18

NEWS

[ 2 ] The new Plaque Analysis (PA) allows the volumetric analysis of coronary
plaque. The histogram and color coding facilitate an easy visualization of the
findings.

[ 3 ] The improved left ventricular analysis (LVA) enables a comprehensive


evaluation of myocardial function. A Bulls Eye blot with coronary artery overlay
simply visualizes any wall motion abnormality.

One of the highlights of the new syngo


Circulation software is a dedicated plaque
analysis tool1. The automatic color coding
of different HU values for three components (calcified, intermediate, low) allows
a rapid visualization of coronary plaques.
The composition and volume of all components can be defined and a histogram
simplifies the visualization of the distribution of the different components. The color-coded overlay is visible in the cross-sectional (IVUS-) views and the curved MPRs
[Fig. 2].
The functional analysis also features new
possibilities. The valvular plane of the left
ventricle is automatically defined. By setting a clickpoint indicating the anterior
septum endo- and epicard are outlined
and can be easily corrected using a threedimensional contouring tool. It takes less
than two minutes to edit contours for systole and diastole. Functional parameters
are automatically displayed including the
Cardiac Index. A Bulls Eye blot indicates
thickness and thickening and wall motion
abnormalities. A simple click into the AHA
17-segment Bulls Eye blot and short and
long axis views are automatically oriented
to the respective location. The movie
function allows the cine display of the myocardium to accurately assess wall motion [Fig. 3].
At the end of the evaluation all findings,
including images, will end in a comprehensive report which can be either stored
as DICOM Structured Report or printed as
HTML or PDF file.
The new syngo Circulation lets me save
even more time in my daily work, however facilitating a thorough analysis of the
coronaries and the myocardium. In particular, the new plaque tool and the comprehensive functional analysis greatly complement the streamlined quantitative
coronary artery (QCA) evaluation, says
Andreas Knez, MD, Associate Professor
Cardiology, University Hospital of MunichGrosshadern.
1

Licensing fees may apply.


SOMATOM Sessions 18

NEWS

N EW syngo We bSpace *

3D-Reading Wherever You Are

3D-Reading Wherever You Are. Axel Kttner, MD, University of Erlangen.

syngo WebSpace is Siemens Medical


Solutions CT Divisions new client server
solution. A real pace setter, it offers instant access to CT data plus state-of-theart 2D, 3D and 4D post-processing tools
enterprise-wide and beyond.
syngo WebSpace is designed to offer
the ultimate speed and flexibility across
the entire clinical workflow. Real-time
streaming of reconstructed CT data to the
powerful server allows users instant
access to CT data via PACs or any PC client
throughout the institution, in their home
office or while traveling, by simply connecting to the network. Large thin-slice
data in sets up to 5000 slices per session
are immediately available for 2D, 3D and
4D interactive reading using a client server version of the highly popular syngo
InSpace 4D clinical application, which is
also capable of supporting advanced
tools such as bone removal and advanced
vessel analysis. Whats more, with all
10

SOMATOM Sessions 18

rendering taking place on the server,


users benefit from unprecedented processing speed.

Up to 20 Concurrent Users
I am really excited about this new product, says Axel Kuettner, MD, University of
Erlangen in Germany. Within a matter of
seconds I can connect my laptop to the
server and interact with a routine abdominal or even multiphase cardiac dataset
using full 3D and 4D capabilities. And that
is something that is really going to speed
up our clinical workflow!
For us as cardiologists, the ability of the
new thin client server solution to provide
immediate availability of original CT data
in the cath lab, in the office, or in the
cardiac care unit plays a pivotal role, says
Stephan Achenbach, MD, University of
Erlangen. In addition, therapeutic decisions in Cardiology often have to be made
very quickly. Therefore the possibility to

Screenshot syngo WebSpace (Login,


evaluation with syngo InSpace 4D).
obtain immediate expert knowledge by
day and night will again substantial
importance.
syngo WebSpace facilitates from 5 up to
20 concurrent users, depending on the
server configuration, from any number of
clients throughout the hospital network
and via secure access from the home
office or while traveling. Larger enterprises can access multiple servers to further expand the possible number of concurrent sessions. This offers clinical facilities of various size a very cost effective
solution for fast image distribution and
high availability routine clinical postprocessing, because once connected to
the central server, any PACS workplace or
PC can be turned into a CT processing
workplace.
For a large institution such as Hopkins,
this client-server solution means that we
can offer all our staff access to CT data,
24/7. Now our physicians can have access

NEWS

Modality

Data transfer

syngo WebSpace
Thin slice short term storage

syngo WebSpace is also ideally suited for


short term storage of thin-slice CT data.
Traditionally, large volume thin-slice data
has been stored for a matter of days on
the CT scanner, and only thick-slice data
has been archived. The short term storage provided by this server solution will
give users instant access to thin slice data.
It avoids the need of sending all thin-slice
data sets directly to the PACS and frees up
the CT Scanner data base at the same
time.
syngo WebSpace represents what CT imaging is demanding in a state-of-the-art
workplace solution today, says Dr. Bernd
Ohnesorge, Vice President CT Division at
Siemens Medical Solutions, respectively.
It provides high speed access to CT data
combined with routine and advanced
reading tools, and can be fully integrated
into an existing PACS and IT environment.
The simple client-server architecture is
highly cost effective not only because of
its multi-user capability, but also because
it makes use of existing computer resources. This should lead to higher productivity and faster diagnosis.
Siemens Medical Solutions is showcasing
syngo WebSpace for the first time at Stanfords 8th Annual Symposium on Multislice
CT, San Francisco, USA, 1417th June
2006.

CT-Scanner with syngo Modality Workplaces

Server

Ideal Short Term Storage


Solution

Workflow with syngo WebSpace

PACS Archive

Data
transfer

Server access

Workplaces

where and when they need it and not just


at the workstations in our 3D lab or at the
scanner. The client server solution expands our capabilities to deliver outstanding patient care and improve workflow,
explains Prof. Elliot Fishman of Johns Hopkins Medical Centers in Baltimore, USA.
Plus its syngo, which means we dont
have to invest time and resources in retraining staff.

Office
Computer

Home
Laptop

PACS Reading
Station

* Pending 510(k): The information about this product is being provided for planning purposes only.
This product is pending 510(k) review, and is not yet commercially available in the U.S.

SOMATOM Sessions 18

11

NEWS

Klaus Peter, MD, medical director of the University Hospital Munich (left) and Jrg-Christian Tonn, MD, (right)
inaugurate the surgery room with the SOMATOM Sensation Open sliding gantry.

S O M AT O M S e n s a t i o n O p e n

Siemens and BrainLAB Develop


New Solutions for Neurosurgery
Thanks to an integration of computed tomography (CT) images from the
SOMATOM Sensation Open and navigation from BrainLAB, Inc., the University
Hospital Munich-Grosshadern, Germany,
can operate more precisely and therefore
more patient-friendly. The neurosurgery
clinic inaugurated its new surgery room
with a so-called sliding gantry of the
SOMATOM Sensation Open. Because of
the bigger gantry bore of the SOMATOM
Sensation Open with 82 cm, patient positioning is more flexible, and also scanning
with a head clamp, which is regularly used

12

SOMATOM Sessions 18

in neurosurgery, becomes easier. Also,


the patient does not have to be moved
for imaging, because the CT gantry slides
over him. Therefore, SOMATOM Sensation Open is an ideal imaging solution for
use during surgery. A real novelty is the
cooperation with BrainLAB. It allowed an
integrated solution of CT imaging from
Siemens and the navigation system of
BrainLAB. Through the joint work we
learned a lot about how to improve the
clinical workflow, says Frank EngelMurke, MD, responsible product manager at Siemens CT division.

The integrated solution works as follows: the position of the patient and the
surgical instruments are tracked in real
time and a dedicated software integrates this information with the pre- and
intraoperative acquired CT images.
Operations are less invasive and more
accurate," summarizes Jrg-Christian
Tonn, MD, director of the neurosurgery
department at Munich-Grosshadern.

k www.klinikum.uni-muenchen.de

NEWS

S O M AT O M S p i r i t

New Features with


syngo CT 2006C
Since the end of January 2006 all SOMATOM Spirit scanners
are being delivered ex-factory with the latest software: syngo
CT 2006C. This upgrade introduces several new workflow features to further simplify system operation and to broaden the
clinical application spectrum of the SOMATOM Spirit.
CARE Dose has been upgraded to CARE Dose4D, enabling the
most sophisticated real time dose modulation with dose reduction up to 66 percent, without compromising diagnostic
image quality. The new Scan Protocol Assistant offers an easy
five-step interface to adjust protocols. Further optional features are the new E-logbook, an efficient tool which helps to
manage patient information and includes a browser linked to
the patient image database. Additionally, syngo Neuro Perfusion CT and syngo Body Perfusion CT are now supported.

syngo 2006C further enhances the clinical capabilities


of the SOMATOM Spirit.

k www.siemens.com/computed-tomography

S O M AT O M S p i r i t

And the Winner is


When it comes to design awards,
Siemens computed tomography (CT)
systems seem to have a regular sub-

scription. This year, the SOMATOM


Spirit won an iF gold award 2006 at
the product design contest of the

International Forum Design GmbH in


Hannover, Germany. The jury bestowed
the price during the iF award ceremony
at the IT-fair CeBIT. The SOMATOM Spirit
convinced the jury by its attractive design, innovation and functionality. Each
year the International Forum Design
bestows the well-known iF product
design award. Fifty products won an iF
gold award in 2006, the iPod nano from
Apple and the new Passat from Volkswagen, too. About 1000 participants
from 37 countries had applied with 1952
products and concepts. The SOMATOM
Spirit was also shortlisted for the 2006
Design Award of the Federal Republic of
Germany.

k www.ifdesign.de,
www.designpreis.de

Bernd Ohnesorge (left), PhD, Vice President CT Marketing and Sales, Karin Ladenburger, Product Manager CT Segments, and Klaus Thormann, Design Manager of
designafairs, received the "iF gold award 2006" for the SOMATOM Spirit.
SOMATOM Sessions 18

13

NEWS

HEAD IMAGING

Individualized Head Image


Reconstructions Always Thinking (a)Head
Siemens has now integrated new convolution kernels settings and scan modes
which allow the user to individualize the
image impression in Neuro imaging.*
CT is usually considered the initial modality in routine and advanced head imaging. Management of patients with stroke,
bleeding, acute trauma as well as visualization of sinuses and complex intracranial structures like inner ear requires best
image quality for the reader.
Whether physicians prefer head images
with a smooth layout or extreme sharp
grey-white differentiation in their clinical
routine, Siemens now allows further individualization of head images e.g. at the
level of the basal ganglia or the cortex.
Now various settings for image recon-

struction can be selected out of an


extended kernel list, leading to excellent
and customized image impression for
confident diagnosis in the head.
The new convolution kernels have comparable sharpness as conventional
Siemens kernels, but offer a different texture within the images, like en-hanced
edge visualization. They can be applied as
alternative reconstruction algorithms for
all head protocols. This allows now vendor independent visualization of images.
Additional steps for head image acquisition and reconstruction (optimized scan
protocols, iterative beam hardening
correction) have been integrated. This
yields to improved grey-white matter
differentiation, particularly within the

parenchyma close to the bone/ brain


interface. Where ever a high signal to
noise ratio is clinically needed a 2x1s scan
mode can be used. Depending on the
clinical need scan modes can be freely
selected to always ensure excellent
image quality.
We thank Dr. Graeb Senior, Neuro Radiologist at the Vancouver General Hospital,
Dr. Hudon Neuro Radiologist Foothills
Medical Center, Calgary, and Dr. Emery
Neuro Radiologist University of Alberta,
Edmonton, for their valuable inputs and
collaboration in achieving these results.
* Available with SOMATOM Definition and with
software version syngo 2006A for all SOMATOM
Sensation 40/64 and Open, for Sensation 10/16
available Q1/2007.

Enhanced filter setting allows for highest image quality in the head with individualized Kernels.
A: Excellent grey-white differenciation. B: Excellent visualization of details with z-sharp.
Courtesy Vancouver General Hospital, Canada

14

SOMATOM Sessions 18

BUSINESS

s y n g o E X P E R T- I *

An Expert Opinion from Anywhere


in Just a Few Seconds
Which radiologist or technologist does
not know the moments, where she or
he would like to have a second opinion
on how to reconstruct a CT scan? A possible scenario: the outpatient center
located on the other side of the road,
the CT attending or consulting physician
is paged, but is presently in the main
building and it takes him a while to get
to the scanner. All work has to be
stopped until clarification is reached.
Now Siemens can offer a much more
convenient solution for these problematic situations syngo Expert-i.** It
takes one phone call and a PC anywhere inside the hospital network to
receive an expert opinion. The person
requesting help simply starts syngo
Expert-i and receives a connection pass-

word. Consulting physicians can simply


log on with this password as a remote
user via web based access from any networked PC. Full screen access to the
syngo CT Workplace*** is possible
(including total mouse control). Especially demanding CT applications like
cardiac CT will benefit from this solution. Requesting a second opinion on
how to edit the ECG or on how to reconstruct the data is in your hands with a
simple mouse click. With an adequately
fast connection and VPN access to the
hospital network, this solution will even
work from home for expert on call
expertise. No matter what the need is,
the optional syngo Expert-i connects
the expert with the physician and technologist with the scanner.

* Pending 510(k): The information about this


product is being provided for planning purposes.
The product is pending 510(k) review, and is not
yet commercially available in the U.S.
**Option to be purchased separately.
***On SOMATOM Definition systems only, on other
systems from early 2007 on.

syngo Expert-i saves time: From any


networked PC consulting physicians can
simply log on with a password as
a remote user via web based access.

S I E M E N S R E M OTE S E RVI C E

Utilization Reports Now Also


Available for CT Systems
Together with Christoph Becker, MD, of
the University Hospital Munich-Grosshadern, Germany, Siemens has developed system utilization reports for computed tomography (CT) systems. They
will support CT users with detailed data
that indicate potential for better staff
planning and system scheduling, as well
as continuously monitoring examination
times. These reports are accessible via a
personalized internet portal and are currently available on a monthly basis.
Siemens Utilization Management helps
in a sensible way to reveal irregularities
in the CT workflow and to react accord-

ingly. In addition to the more efficient


usage of the system, patient waiting
time can be reduced. For the staff, Utilization Management means a well-balanced working routine throughout the
entire day, says Becker.
Initially, utilization reports were only
available to magnetic resonance systems
users. After positive experiences, users
requested to expand this service to other
Siemens imaging systems. Today, imaging systems are both established diagnostic tools and high-value investments
that must be deployed as cost-effectively
as possible. This is a challenge that many

universities as well as small practices face


every day. Radiology departments must
also achieve a positive performance bottom line. That is why Siemens is now
working on extending the CT Utilization
Management portfolio. Following the
basic Utilization Management reports,
Siemens is already planning consulting
services, such as detailed benchmark
analyses of systems operating in similar
environments. There are also recommendations for process improvements
to ensure optimum system utilization.
k www.siemens.com/
utilizationmanagement

SOMATOM Sessions 18

15

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neurology

Acute Care

Cardiovascular
Faster Diagnosis and Full Confidence in Cardiac CT
By Lars K. Hofmann, MD, Global Product and Marketing Manager Cardiovascular CT,
Siemens AG, Medical Solutions, CT Division, Forchheim, Germany

A CT Cardiac Engine offers a complete solution for cardiac CT


imaging. From scan to diagnosis, it offers a unique combination of innovative scanner technology and syngo clinical
application solutions to optimize the CT system for cardiac
and vascular applications.
The CT Cardiac Engine delivers the technology for fastest
possible rotation speed, state-of-the-art ECG-synchronized
acquisition, image reconstruction techniques and intuitive
ECG-editing, always providing optimal image quality. With
ECG-pulsing the patient receives the lowest dose possible.

For Cardiac Evaluation


The completely guided cardiac evaluation with syngo Circulation and syngo Calcium Scoring enables the physician to
make a diagnosis in under 10 minutes. Accurate stenosis
measurements are supported by automatically updated crosssectional views of the vessel (IVUS View) and display of
curved reformats. To further optimize lesion characterization, a plaque measurement tool facilitates the volumetric
definition of different plaque components.
The fully automated cardiac function evaluation allows a
robust measurement of ejection fraction (EF), stroke volume
and cardiac index. Additional analysis of myocardial thickness and wall motion can easily be performed and displayed
via Bulls eye plot or cine function.
From cardiac morphology to coronary artery stenosis measurement, this functional analysis results in a comprehensive
report that turns data into diagnostic outcomes.

For Vascular Evaluation

From scan to diagnosis, the CT Cardiac Engine offers


a unique combination of innovative scanner technology
and syngo clinical applications.

16

SOMATOM Sessions 18

syngo InSpace4D Advanced Vessel Analysis stands for exceptional speed and image quality for quantitative vascular diagnosis and planning of interventions. With the Advanced
Vessel Analysis 1-click segmentation, the physician can automatically extract any vessel from its surrounding tissue making accurate stenosis quantification an easy task.
k www.siemens.com/computed-tomography

CLINICAL OUTCOMES

Case 1:
Dual Source CT after Left Main Coronary Artery
Stenting in a Patient with Arrhythmias
By Stephan Achenbach, MD1 ; Ulrike Ropers, MD1 ; Dieter Ropers, MD1; Katharina Anders, MD2; Axel Kttner, MD2;
Willi Kalender, PhD3; Werner Bautz, MD2 Werner G. Daniel, MD1
1

Department of Internal Medicine 2 (Cardiology), University of Erlangen-Nuremberg, Erlangen, Germany

Institute for Diagnostic Radiology, University of Erlangen-Nuremberg, Erlangen, Germany

Institue for Medical Physics, University of Erlangen-Nuremberg, Erlangen, Germany

HISTORY
A 63 year old male patient with known chronic occlusion of
the left anterior descending coronary artery and previous
bypass surgery (internal mammary artery graft to left anterior descending coronary artery 15 years previously) experienced an acute coronary syndrome (non-ST elevation myocardial infarction). A high grade stenosis of the left main
coronary artery was found. Percutaneous coronary intervention (PCI) and stent placement (Taxus 5.0/12 mm) of the
left main coronary artery was performed to restore blood
flow to the left circumflex coronary artery and an intermedi-

ate branch [Fig. 1]. The left internal mammary artery bypass
graft and right coronary artery were found patent at the time
of angiography and left main intervention.
Several days after stent placement, the patient experienced
non-typical chest pain at rest and a Dual Source CT scan was
performed to investigate stent patency. During the DSCT
scan, the patient developed arrhythmias (supraventricular
ectopic beats). Image reconstruction was performed in systole
(300 ms after R-wave), and half-scan reconstruction (heart
rate independent 83 ms temporal resolution) was used.

1A

1B

[ 1A ] Angiography of the right coronary artery (arrow).

[ 1B ] Angiography of the intact internal mammary


artery graft (large arrow) to the left anterior descending
coronary artery (small arrows).

SOMATOM Sessions 18

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CLINICAL OUTCOMES

Cardiovascular

1C

Oncology

Neurology

Acute Care

1D

[ 1C ] High-grade stenosis of left main coronary


artery (arrow).

[ 1D ] After PCI and stent placement into the left main


coronary artery, there is no residual stenosis in the left
main coronary artery (large arrow). Diffuse disease of
the left circumflex coronary artery remains (small
arrows; arrowhead = intermediate branch).

[ 2 ] ECG trace during DSCT data acquisition. Heart rate is highly irregular due to supraventricular ectopic beats,
rapidly changing between 48 and 90 bpm.

DIAGNOSIS

COMMENTS

In the systolic reconstructions, the heart, coronary arteries,


and the bypass graft were visualized free of motion artifacts
[Fig. 3-5], in spite of the presence of arrhythmias throughout
data acquisition. The left main coronary artery stent was
depicted in axial and frontal multiplanar reconstructions and
could clearly be demonstrated to be free of acute thrombotic
occlusion or restenosis [Fig. 3]. In addition, reconstructions of
the arterial bypass graft and of the right coronary artery
showed both vessels free of significant stenosis. Diffuse disease had remained in the left circumflex coronary artery after
the percutaneous intervention, and these stenoses were also
demonstrated by DSCT, without change to the angiographic
finding [Fig. 4 and 5]. Thus, a repeat invasive coronary
angiogram was not necessary.

In spite of arrhythmias during scanning, Dual Source CT was


able to rule out the presence of in-stent narrowing or occlusion of the newly implanted left main coronary artery stent.
In addition, patency of the internal mammary artery bypass
graft and absence of new stenosis in the right coronary
artery could be demonstrated.

18

SOMATOM Sessions 18

CLINICAL OUTCOMES

3A

3B

[ 3 ] Reconstruction of the left main coronary artery stent in a frontal [ 3A ] and axial
plane [ 3B ] and in a curved multiplanar
reconstruction that shows the stent and the
left circumflex coronary artery [ 3C ]; (large
arrow: patent stent, small arrows: diffuse
disease in left circumflex coronary artery,
compare to Fig. [ 1D ]).

3C

4A

4B

[ 4 ] Curved multiplanar reconstruction of the right coronary artery [ 4A ] (arrow, no significant


stenosis) and of the left main and left anterior descending coronary artery [ 4B ] (known to be
occluded; arrows = LAD, arrowhead = distal segment of IMA bypass graft and anastmosis to LAD).

SOMATOM Sessions 18

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CLINICAL OUTCOMES

Cardiovascular

5A

Oncology

Neurology

Acute Care

5B

[ 5A, 5B ] 3-dimensional reconstruction of the heart and coronary arteries. The patent internal mammary
artery graft to the left anterior descending coronary artery can clearly be appreciated.

EXAMINATION PROTOCOL
Scanner

SOMATOM Definition Dual Source CT

Pitch

0.22

Scan area

Aortic arch to diaphragm

Reconstruction increment

0.3 mm

Scan length

137 mm

Kernel

B26f

Scan direction

cranio-caudal

Heart rate

highly irregular between


48 and 90 bpm

Contrast

370 mg iodine/ml
(Ultravist, Schering AG)

kV

120 kV

Volume

65 ml

Effective mAs

380 mAs/rot.

Flow rate

5 ml / s

Temporal Resolution

83 ms

Start delay

23 s

Rotation time

330 ms

Slice collimation

2 x 64 x 0.6 mm

Slice width

0.6 mm

20

SOMATOM Sessions 18

CLINICAL OUTCOMES

Case 2:
CT Angiography of the Chest Triple Rule Out
By Lanett Varnell, MD, and Gordon D. Graham, MD, Imaging Center,
Chattanooga Heart Institute, Chattanooga, TN, USA

HISTORY
A 66 year old woman suffering shortness of breath was
examined. A performed echocardiography showed abnormal findings.
An ECG-synchronized multi-slice CT of the chest was performed to rule out pulmonary embolism or coronary artery
disease. Using a collimation setting of 0.6 mm resulted in a
spatial resolution 0.33 mm in order to get a detailed analysis
of coronary vessels.

DIAGNOSIS AND COMMENTS


No evidence of infiltrate or mass could be detected in the lung
window. The mediastinal windows did not show lymphadenopathy by size criteria. Also, the cardiothoracic ratio
remained within normal limits.
A pulmonary diagram demonstrates a pulmonary artery of 1.8
cm in diameter. No pulmonary arterial filling-defect through
third order branching could be detected. The thoracic
angiogram shows an artifact-free aortic root measuring

[ 1 ] Normal origin and course of right coronary


artery seen.

3.14 cm without evidence of aneurysm or dissection inside the


FOV. Wall thickness and motion were normal, the ejection
fraction 65 percent. The coronary arteries were displayed free
of motion artifacts. The left main artery (LM) with a length of
about 10 mm showed almost circumferential calcifications. The
left anterior descending coronary artery (LAD) showed a
non-calcified plaque in the proximal one third with possible,
clinically significant obstruction. The left circumflex coronary
artery (LCX) also suggested diffuse non-calcified plaque with
calcifications distally. A potentially significant obstruction was
noted in the mid segment of the vessel. Also the right coronary
artery (RCA) showed diffuse calcifications with soft plaque,
resulting in a diffuse mildly obstructive disease.
A structurally normal heart with intact left ventricular function
can be concluded. Diffuse atherosclerotic disease was noted
including significant calcified and non-calcified plaquing.
A triple vessel disease with clinically significant obstruction is
suggested. Patient subsequently underwent cardiac catherization followed by coronary artery bypass graft (CABG).

[ 2 ] Diffuse plaque noted in the left coronary artery.

SOMATOM Sessions 18

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CLINICAL OUTCOMES

Cardiovascular

Oncology

Neurology

Acute Care

[ 3 ] Diffuse plaquing, both soft and calcific.

[ 4 ] Normal origin of Left Main.

[ 5 ] Soft plaque probably with clinically significant


obstruction.

[ 6 ] Calcified plaque noted three vessel disease noted.

EXAMINATION PROTOCOL
SOMATOM Sensation 40-slice
configuration

Slice collimation

0.6 mm

Slice width

0.75 mm

Scan area

From arch to artery

Pitch

0.24

Scan length

131.5 mm

Reconstruction increment

0.4 mm

Scan time

18 s

Kernel

B25f

Scan direction

cranio-caudal

kV

120 kV

Contrast

370 mg iodine/ml (Ultravist, Berlex)

Effective mAs

795 mAs

Volume

120 ml

Rotation time

0.37 s

Flow rate

4 ml / s

Scanner

22

SOMATOM Sessions 18

Cardiovascular

Oncology

Neurology

Acute Care

CLINICAL OUTCOMES

Oncology
Faster Diagnosis and Full Confidence in Oncology CT
By Ken Field, Global Product and Marketing Manager Oncology CT, Siemens AG,
Medical Solutions, CT Division, Forchheim, Germany

The CT Oncology Engine provides a complete solution for CT


imaging in oncology. For early disease detection, diagnosis,
intervention, reporting, and follow-up, the CT Oncology
Engine provides a unique combination of innovative scanner
solutions and syngo clinical applications, designed to achieve
a streamlined diagnostic oncology workflow.

For Lung and Colon Evaluation


syngo LungCARE CT with Nodule Enhanced Viewing (NEV)
and syngo CT Colonography with Polyp Enhanced Viewing
(PEV) provide state-of-the-art workflow for early detection,
visualization, reporting, and follow-up for the lung and colon
regions. Second-reader tools are integrated into the workflow
to ensure a comprehensive evaluation of CT study data.

For Tumor Evaluation


syngo Body Perfusion enables the functional analysis of body
tumors for tissue differentiation and staging. Intuitive tumor
perfusion enables fast, easy visualization of a tumors vascularization profile and aids in differentiating tumors.

For Gaining better Insight


syngo Image Fusion allows the user to fuse two DICOM image
datasets acquired on different imaging modalities to form
a new image dataset that contains enhanced information.
With syngo Image Fusion, a physician can combine functional information obtained with SPECT or PET with anatomical
information obtained from CT.

For Interventional Procedures


CARE Vision CT optimizes interventional procedures by providing real-time visualization and scan protocols that significantly reduce radiation exposure to patients and staff.

The CT Oncology Engine provides a unique


combination of innovative scanner solutions
and syngo clinical applications.

k www.siemens.com/computed-tomography

SOMATOM Sessions 18

23

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neurology

Acute Care

Case 3:
Silikoasbestosis of the lung with secondary
bronchial carcinoma
By Manfred Oldendorf, MD, Medical Director,
Department of Radiology, Hospital Nuremberg North, Nuremberg, Germany

HISTORY

A 67 year old male patient shows fine particulate and


asbestos pollution of the lung for more than 30 years because
of professional reasons. He has suffered from accretive difficulty in breathing with restrictive disorder of the ventilation
and pulmonary hypertension for 5 years.

DIAGNOSIS
The CT scan showed a Silikoasbestosis of the lung with secondary bronchial carcinoma of the lung (plate epithelium
carcinoma, histological firmed). Disseminated, military nodules with calcification were detected, as well as an interstitial
lung deformation with emphysema bubbles, which were
caused by retraction. The images clearly show a solid tumor
on the right upper lobe without necrolysis and a calcified
medistinal lymphatic gland.

[ 1 ] VRT: miliary calcification of the lung, eggshell like


lymph node calcification mediastinal and hilar.

2A

2B

[ 2 ] Disseminated, miliary nodules with calcification,


interstitial lung deformation with emphysema bubbles caused by retraction. [ 2A ] Lung window setting.
[ 2B ] Mediastinum window setting.

24

SOMATOM Sessions 18

CLINICAL OUTCOMES

[ 3 ] Solid tumor on the right upper lobe without


necrolysis (hist.plate ephitelium carcinoma (arrow)) and
Calcified mediastinal lymphatic gland (arrow head).

[ 4 ] VRT: fibrotic deformed lung structure (white).

EXAMINATION PROTOCOL
SOMATOM Emotion
16-slice configuration

Pitch

0.8

Reconstruction increment

1.2; 6.0 mm

Scan area

Thorax

CTDIvol

14.5

Scan length

320 mm

Kernel

Scan time

13.0 s

Scan direction

Caudo-cranial

kV

130 kV

Contrast

Effective ref. mAs

68 158 mAs (Care Dose4D)

Volume

120 ml

Rotation time

0.6 s

Flow rate

2.0 ml / s

Slice collimation

16 x 1.2 mm

Start delay

60 s

Slice width

1.5; 6.0 mm

Postprocessing

MPR, MIP, VRT

Scanner

SOMATOM Sessions 18

25

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neurology

Acute Care

Case 4:
Improving Patient Outcomes with PET/CT
By John Myers, Diagnostic Services Director, Kansas City Cancer Center, Overland Park, Kansas, USA

The diagnostic capabilities of PET/CT technology in oncology


are substantially broadened when compared to those of
individual CT or PET studies and can have a significant effect
on patient outcomes. The Biograph hybrid imaging system
provides the powerful combination of functional and anatomical information in a single diagnostic procedure, enabling

accurate tumor diagnosis, whole-body staging, target definition, and treatment planning. As hybrid PET/CT imaging
becomes the standard diagnostic tool in oncology cases,
patients are benefiting from earlier detection of disease and
metastases, as well as more accurate assessments during
and after treatments.

Metastatic Bladder Cancer


HISTORY

DIAGNOSIS

A 64 year old male with a long history of cigarette smoking,


hypertension and hydronephrosis was referred for PET/CT to
follow-up on an initial diagnosis of invasive urothelial carcinoma after a negative CT scan was performed.

The PET/CT study, performed on a Siemens Biograph 16 with


HI-REZ, detected a hypermetabolic lymph node of 1.2 cm,
located next to the iliac vein, iliac artery and ureter [Fig.
24]. The metastatic lesion was not detectable in the standalone CT, due to its size and close relationship to the above
mentioned anatomy [Fig. 1].
[ 1 ] CT scan of the pelvis
shows the close proximity of
the normal pelvic anatomy
and abnormal lymph node.

Lymph node

Iliac artery

Ureter
Iliac vein

26

SOMATOM Sessions 18

CLINICAL OUTCOMES

[ 2 ] Fused PET/CT image shows the hypermetabolic


lymph node situated in the pelvis (red spot).

[ 3 ] PET, CT and fused PET/CT axial slices through the


pelvis, revealing the hypermetabolic lymph node.

COMMENTS
PET/CT plays a major role in the detection, staging and treatment of oncology cases. In this particular case, the importance of using hybrid PET/CT technology was critical, as the
management, and ultimately the outcome of this patients
case would have been significantly different if he only underwent a PET scan, or only had the CT scan during the diagnostic
evaluation. While the lymph node was not diagnosed at all in
the standalone CT, a dedicated PET scan could have potentially misinterpreted the abnormal activity as FDG in the ureter.
Only the co-registered, detailed anatomical and functional
data illustrated the true diagnosis and changed the treatment plan and overall outcome for this patient.
The HI-REZ PET imaging technology of the Siemens Biograph
16, in conjunction with the spectacular detail in the anatomical imaging of the CT, makes it possible to see detailed
anatomy and functional processes in a single exam and can
make a difference in diagnoses and outcomes in complex
oncological cases.

[ 4 ] PET, CT and fused PET/CT sagittal, coronal and


axial slices demonstrate exact localization and relationship of the lesion with the surrounding anatomy.

EXAMINATION PROTOCOL
Scanner

Biograph 16

CT Protocol

Slice width

5 mm

Pitch factor

0.75

Scan area

Whole Body

Reconstruction increment

3 mm

kV

120 kV

PET Protocol

Effective mAs

140 mAs

Dosage

15.0 mCi FDG

Rotation time

0.5 s

Bed Times

3min/bed position

Slice collimation

16 X 1.5 mm

Recon Method

Iterative

SOMATOM Sessions 18

27

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neurology

Acute Care

Neuro
Faster Diagnosis and Full Confidence in Neuro CT
By Stefan Wnsch, PhD, Global Product and Marketing Manager Neurology CT,
Siemens AG, Medical Solutions, CT Division, Forchheim, Germany

A CT Neuro Engine offers a complete solution for neuro CT


imaging. From scan to diagnosis, the CT Neuro Engine provides a unique combination of innovative scanner solutions
and syngo clinical applications, designed to achieve a
streamlined neuro workflow. The CT Neuro Engine delivers
the technology required to perform artefact-free imaging
with the high spatial and temporal resolution needed for fast
and accurate visualization of complex neurological disorders, the head, neck, spine, and the evaluation of acute
ischemic stroke. Using Interactive 3D Volume reading, in
combination with dedicated scanner solutions, allows optimal visualization and treatment planning of complex C spine
fractures. A diagnosis will be fast and confident, turning data
into a diagnostic outcome within minutes.

For Stroke Evaluation


The fully automated syngo Neuro Perfusion CT ensures the
fastest differential diagnosis of ischemic stroke and tissue at
risk evaluation in less than 10 minutes at a flow rate of 5-8
ml/s. It allows the simultaneous calculation of diagnostic
images in less than 1 min.

For Vascular Evaluation


syngo Neuro DSA CT is the first CT-based digital subtraction
angiography for non invasive assessment of intracranial vessels
and CTA data of the neck. It is ideally suited for the delineation
of aneurysms and other vascular diseases. syngo Neuro DSA CT
enables fully automated subtraction of vessels from bones,
thus enhancing the visualization of even the smallest cerebral
vessels and helping to improve diagnostic confidence.

For Brain Tumor Evaluation

The CT Neuro Engine provides a unique combination of innovative scanner solutions and syngo
clinical applications.

Fully automated syngo Neuro Perfusion CT facilitates quantitative evaluations of brain tumors. The fast quantitative evaluation enhances the ability to grade tumors, plan biopsies
and monitor therapy.
k www.siemens.com/computed-tomography

28

SOMATOM Sessions 18

CLINICAL OUTCOMES

Case 5:
Complete Occlusion of Left Carotid Artery
and Stenosis at Right Carotid Artery
By Amit Mehta, MD, Chief Radiologist, and Susan Hall, CT Technologist,
St. Catharines General Site Niagara Health System, Ontario, Canada

HISTORY

DIAGNOSIS AND COMMENTS

A 68 year old female admitted to our facility for a pre operative assessment for carotid endarterectomy. The patient has
experienced episodes of vision loss in the right eye over the
past 2 or 3 months, but had no speech difficulties and no
motor or sensory deficits have been detected. The patient
had a history of a carotid Doppler examination in 2003 at
which time she had severe stenosis of both internal carotid
arteries (ICA). A Doppler ultrasound in 2006 showed an
occluded left ICA and 80 90 percent stenosis of the right
ICA. She also has a history of hypertension and smokes. The
CNS exam was grossly intact. A CTA of the carotids was performed for pre-operative assessment.

The CTA data confirmed a complete occlusion of the left


common carotid and internal carotid arteries. The left external carotid artery is partially reconstituted via a muscular collateral artery. Additionally, a severe stenosis at the bifurcation of the right internal and external carotid artery by a
mixed calcified and soft plaque was detected. With the high
resolution of SOMATOM Sensation 64 and syngo Neuro DSA
the CTA of the whole carotid artery could be displayed and
evaluated easily using the automated bone subtraction
functionality.

[ 1 ] VRT of the carotid arteries.

SOMATOM Sessions 18

29

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neurology

Acute Care

[ 2 ] CT digital subtraction angiogram: frontal view.

[ 3 ] MIP image obtained with the automated subtraction

VRT display after automatic substraction of bone


using syngo (kursiv) Neuro DSA CT.

algorithm of syngo Neuro DSA showing occlusion of the


left common carotid and internal carotid arteries with severe
stenosis of the right internal carotid artery. A muscular collateral fills the left external carotid artery.

EXAMINATION PROTOCOL
Scanner

SOMATOM Sensation 64-slice


configuration

Pitch

0.95

Reconstruction increment

0.4 mm

Scan area

Carotids and Circle of Willis

CTDI

15.33 mGy

Scan length

266 mm

Kernel

B20f

Scan time

5.36 s

Scan direction

Caudo-Cranial

Contrast

350 mg iodine/ml (Optiray)

kV

120 kV

Volume

70 ml

Effective mAs

200 mAs (150 mAs for native scan)

Flow rate

4 ml / s

Rotation time

0.33 s

Start delay

2 sec

Slice collimation

0.6 mm

Bolus Tracking

trigger 100hu at aortic arch

Slice width

0.6 mm

Postprocessing

syngo Neuro DSA, CT

30

SOMATOM Sessions 18

CLINICAL OUTCOMES

Case 6:
CT-DSA of a Common Carotid Artery
in a Young Woman
By Harald Grzer, MD, Diagnosezentrum Margareten, Vienna, Austria

HISTORY
A 46 years old woman with a history of hypertension presented an acute onset of vertigo, fatigue, severe headache and somnolence in our institution. CCT showed neither recent signs of supra- or infratentorial ischaemia, nor bleeding nor intracranial mass.
Colour coded Doppler ultrasound was not completely conclusive due to a high carotid bifurcation and a moderate elongation of
the internal carotid artery on both sides, as well as tachyarrythmia. A 60-90 percent stenosis of the left ICA was suspected, therefore the patient was scheduled for carotid CTA.

DIAGNOSIS AND COMMENTS


Using the functionality of digital subtraction CT-angiography, automatically subtracting a noncontrast from a contrast enhanced study, the complete vascular tree could be
demonstrated and the suspected 90 percent stenosis of the

left internal carotid artery at its origin could be verified. The


right carotid artery was not affected. The patient is now on
aspirin therapy and endarterectomy is scheduled.

[ 1 ] VRT of left carotid artery.

SOMATOM Sessions 18

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CLINICAL OUTCOMES

Cardiovascular

Oncology

Neurology

Acute Care

[ 2 ] The CTA demonstrates stenosis of the


left internal carotid
artery (arrow).
The right carotid artery
is not affected.

[ 3 ] The CTA demon-

strates a 90% stenosis


of the left internal
carotid artery ostium
with slight calcifications (arrow), the
left external carotid
was not affected.

EXAMINATION PROTOCOL
SOMATOM Emotion 16-slice
configuration

Slice width

0.75 mm

Pitch

0.8

Scan area

Carotids and Circle of Willis

Kernel

B20s

Scan length

168 mm

Scan time

13.6 s

Contrast

370 mg iodine/ml

Scan direction

Caudo Cranial

Volume

70 ml

kV

130 kV

Flow rate

4 ml / s

Effective mAs

90 mAs

Start delay

2s

Rotation time

0.6 s

Slice collimation

16 x 0.6 mm

Postprocessing

Neuro CT-DSA, MPR, VRT

Scanner

32

SOMATOM Sessions 18

CLINICAL OUTCOMES

Case 7:
Cerebral Perfusion in a Patient
with Dengue Hemorrhagic Fever
By Nitamar Abdala, MD, Radiology Professor, and Carolina Salazar, MD, Radiology Resident UMDI Unidade Mogiana
de Diagstico por Imagem, So Paulo, Brazil

HISTORY
A 53 year old male patient with acute high intensity
headache episodes and syncope (nausea) one month ago,
left hemiplegics, and no more associated symptoms, was
referred to the hospital. The patient had a history of hypertension with drug control and Dengue Hemorrhagic five
years ago.
Patients that suffer from Dengue Hemorrhagic can eventually
have low blood flow with hypo cerebral perfusion which can
cause cerebral infarction like watershed, which means,
stroke in the frontier areas. Most of these lesions occur
between the anterior and median cerebral arteries, as well
as in the basal ganglia. Since this patient had an old stroke

possibly caused by an ischemic event related to Dengue


Hemorrhagic five years ago and moreover the patient still
lives in the endemic area, it was suspected that the current
symptoms could be related to the cerebral hypo perfusion.

DIAGNOSIS AND COMMENTS


CT data acquired with the first SOMATOM Spirit in Brazil
shows a lesion detected at right basal ganglia interpreted as
encephalic scar from previous event. The current CT Perfusion study shows signals that can be related to hypo perfusion of left basal ganglia.

[ 1 ] Overview of CT

perfusion data. Upper


left MiP image, Upper
right Blood Flow,
Lower left Blood Volume, Lower right Time
To Peak data.

SOMATOM Sessions 18

33

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neurology

Acute Care

Dengue / Dengue Hemorrhagic Fever


Dengue and dengue hemorrhagic fever (DHF) are
acute febrile diseases, found in the tropics, with a geographical spread similar to malaria. Caused by Flavivirus, the disease is transmitted to humans by the
mosquito Aedes aegypti. The disease is manifested by a
sudden onset of fever, with severe headache, joint
and muscular pains (myalgias and arthralgias, severe
pain gives it the name break-bone fever), leukopenia
and rashes. The dengue rash is characteristically bright
red and covers most of the body. DHF also shows
higher fever, hemorrhagic phenomena, thrombocytopenia, and hemoconcentration. In around 5 percent of
cases there is dengue shock syndrome (DDS) and hemorrhage, leading to death. There is no commercially
ready vaccine.

[ 2 ] MIP image shows an old lesion at right basal


ganglia interpreted as encephalic scar from an old
stroke (3). And suggested hypoperfused area in
the left basal ganglia (3).

3A

3B

[ 3 ] Perfusion data of Blood Flow [ 3A ] and Blood Volume [ 3B ] from CT Perfusion study shows hypo perfused are

a of left basal ganglia ( 3) and the old lesion in the right basal ganglia (3).

EXAMINATION PROTOCOL
Scanner

SOMATOM Spirit

Slice width

10 mm

Scan area

Basal ganglia

Table feed / rotation

0 mm

Scan length

10 mm

Kernel

H31s

Scan time

40 s

Contrast

300 mg iodine/ml (Henetix)

kV

80 kV

Volume

40 ml

Effective mAs

220 mAs

Flow rate

5 ml / s

Rotation time

1.5 s

Start delay

5s

Slice collimation

5.0 mm

Postprocessing

syngo Neuro Perfusion CT

34

SOMATOM Sessions 18

Cardiovascular

Oncology

Neurology

Acute Care

CLINICAL OUTCOMES

Acute Care
Faster Diagnosis and Full Confidence
in Acute Care CT
By Lars K. Hofmann, MD, Global Product and Marketing Manager Cardiovascular CT,
Siemens AG, Medical Solutions, CT Division, Forchheim, Germany

A CT Acute Care Engine provides a complete solution for CT


imaging in an emergency situation. The requirements for CT
imaging are challenging and diverse, from acute chest pain
patients to complex poly-trauma to stroke assessment
every second counts.
The CT Acute Care Engine delivers a complete solution needed to make fast and confident decisions. By combining stateof-the-art functionality for cardiac, vascular and neuro CT
imaging, and adding innovative workflow features to highresolution acquisition, the CT Acute Care Engine provides a
complete clinical portfolio for imaging emergency patients
from head to toe.

Cardiovascular Evaluation
The CT Acute Care Engine provides the tools physicians need
to diagnose todays vascular emergency from aortic dissection or pulmonary embolism to coronary artery disease and
acute vascular obstructions.
syngo Circulations fast-track non-invasive cardiac evaluation
enables fully automated segmentation of the coronary arteries, fast and accurate stenosis quantification and reliable
wall motion and cardiac function analysis. syngo InSpace4D
Advanced Vessel Analysis stands for exceptional speed and
image quality for real-time diagnosis and interventional
planning.

Polytrauma Evaluation
syngo InSpace4D also enables exceptional visualization of
complex vasculature and fractures from head to toe. It
allows fast high quality imaging of full body scans with automated bone segmentation including transparency mode
allowing the rapid visualization of complex fractures.

Stroke and Neurovascular Evaluation


syngo Neuro DSA CT and syngo Neuro Perfusion CT lead to a
quantitative evaluation for differential diagnosis of stroke
and exclusion of subarachnoidal bleeding (SAB) in an emergency situation. syngo Neuro Perfusion CT with its guided
workflow and automatic quantification of cerebral blood
flow (CBF), cerebral blood volume (CBV), time to peak (TTP),
allows the assessment of tissue-at-risk and the evaluation of
perfused blood volume in less than 10 min from scan to diagnosis. The fully automated workflow of syngo Neuro DSA CT
facilitates direct subtraction of native and contrast-enhanced
scans for optimal visualization and evaluation of complex
cranial vascular structures and supports interventional planning e. g. coiling or clipping of aneurysms in SAB patients.
k www.siemens.com/computed-tomography

The CT Acute Care Engine delivers the complete solution needed to make fast and confident decisions.

SOMATOM Sessions 18

35

CLINICAL OUTCOMES

Cardiovascular

Oncology

Neurology

Acute Care

Case 8:
Trauma Diagnosis briefly: 64-Slice
Spiral Computed Tomography
By Florian T. Schmid, MD, Bjrn Stinn, MD, Jrg-Thomas Kluckert, MD, Thomas Chlibec, MD, and Simon Wildermuth, MD, PhD,
Institute of Radiology, Kantonsspital St. Gallen, Switzerland

HISTORY
A 52 year old male fell off a 7 m high roof during maintenance work. After the arrival of the med-evac helicopter, the
emergency physician diagnosed an initial Glasgow-ComaScore (GCS) of 3, hypotonia and tachycardia. The left pupil
was fixed under direct light. An asymmetric mydriasis existed
in both eyes. A periorbital hematoma developed quickly on
the left side and there was visible blood flow out of the nose
and left ear. The patient was hemodynamically stabilized by
transfusion, intubated on site and afterwards airlifted to our
clinic. At the emergency room the patient received a rightsided pleural drain (Buelau) and a CT examination of the head
and body was performed as per standard trauma protocol.

DIAGNOSIS
The initial native CCT-scan showed frontobasal contusions on
both sides and in the right basal ganglias. A mixed subarachnoid and subdural bleeding in the left hemisphere lead to a

[ 1 ] Frontobasal contusions on both sides and mixed

subarachnoid and subdural bleeding in the left hemisphere (arrows).

36

SOMATOM Sessions 18

consecutive shift of the centerline and to an initial, tentorial


herniation. The aqueduct was free. The thin-slice reconstruction showed singular, pontine and cerebellar shear-lesions.
The frontal base was ambilaterally fractured and emanated
into the right temporal bone and pneumencaphalon.
A hematotympanon on the left was probably caused by a
longitudinal fracture of the petrous bone which sphenoidally
emanated.
The viscerogenic cranium endured a tripoidal fracture on the
right and an ipsilateral blow-out fracture of the orbital base
without herniation of orbital soft tissue. The diagnosis was a
consecutive hematosinus.
A ventral right pneumothorax without relevant collapse of
lung tissue could be found after insertion of the Buelaudrainage. The bilateral postobasal lung contusions were corresponding with the costal fractures of ribs three and four on
the right. According to the trauma mechanism, a liver laceration of segment five and six could also be found, with a large

[ 2 ] The viscerogenic cranium endured a tripoidal fracture on the right and an ipsilateral blow-out fracture of
the orbital base.

SCIENCE

[ 3 ] A liver laceration was found with a hematoma

and active portal-venous hemorrhage.

hematoma and active, portal-venous hemorrhage. Little perihepatic and interenteric liquid with an attenuation of 40 HU
correlate with a caudal liver capsule lesion. Mesenteric, hepatic
and gastric edema matched the patients initial shock state.
Despite a small, v-shaped perfusion defect of the left kidney,
there were no further abdominal pathologies. An arterial injury
as a cause of the perfusion defect could be reliably excluded.
The spine did not show any injuries only degenerations.
A little Pipkin 3 impact fracture of the right femur was detected.
Together with a non-dislocated fracture of the frontal pelvic
ring, including the advocated anterior acetabulum, it marked
the power vectors. A fracture of the right dorsal pelvic ring
caused instability while striding the right iliosacral joint.

COMMENTS
Already in 1976, Cowley influenced the concept of golden
hour1 and illustrated that trauma management always
means time management. The mortality of traumatized
patients increases significantly after the first hour, and
includes not only first aid and quick transport. The time
before therapy is essential. A fast and comprehensive diagnosis became the solution for a successful triage and therapy.2
Todays multislice CT with slice configurations of 40 and more
slices, short rotation times and high-performance tubes
allow a diagnosis with detailed information about the neurosurgical, traumatological, thoracic- and abdominal surgical
state of the patient.
In this case, the initial prognostic detection of shear lesions in
brainstem and cerebellum already indicated a possible lethal
outcome. Nevertheless, the perceptibility of such minimal
changes of the modern spiral CT of the brain indicates a
huge progress in technology. The findings were not only
quantitative, in terms of short examination times of large
volumes, but also qualitative with continuously better spatial
resolutions down to 0.33 mm in isotropic voxels.
A modern dose modulation method like Care Dose 4D considerably reduces the necessary dose exposure.

[ 4 ] Fractures of the right femur (3) and of the frontal


pelvic ring (3) were detected.

EXAMINATION PROTOCOL
Scanner

SOMATOM Sensation 64-slice


configuration

Head Scan Protocol


Scan area

Head

Scan length

242.5 mm

Scan time

17.41 s

Scan direction

caudocranial

kV

120 kV

Effective mAs

380 mAs

Rotation time

1s

Slice collimation

0.6 mm

Slice width

1 mm

Pitch

0.8

Reconstruction increment

0.7 mm

CTDI

59.43 mGy

Kernel

H21s / H70h

Body Scan Protocol


Scan area

Body

Scan length

641 mm

Scan time

21.51 s

Scan direction

craniocaudal

kV

120 kV

Ref mAs

200 mAs (Care Dose 4D)

Rotation time

0.37 s

Slice collimation

0.6 mm

Slice width

1.5 mm

Pitch

0.6

Reconstruction increment

0.7 mm

CTDI

10.84 mGy

Kernel

B10f / B30f / B60f

Contrast

350 mg iodine/ml (Iomeron)

Volume

150 ml (polyphasisch)

Flow rate

3.5 ml / s

Start delay

Care Bolus Tracking

Postprocessing

InSpace 4D

1 Cowley RA (1976) The resuscitation and stabilization of major multiple


trauma patients in a trauma center environment. Clin Med 83: 14.
2 A.Beck, F.Gebhard, Th. Fleiter, E. Pfenninger, L.Kinzl: [Time optimized
modern shock room management using digital techniques]; Unfallchirurg. 2002
Mar; 105(3): 2926.

SOMATOM Sessions 18

37

SCIENCE

EDUCATION

[ 1 ] VRT renderings of a 59 year old male patient with suspicion of RCA stenosis. The mean heart rate of the patient during
the scan was 85 bpm. Left: diastolic reconstruction at 65 % of the cardiac cycle. Right: end-systolic reconstruction at 28 % of the
cardiac cycle. In both cases, the coronary arteries are clearly depicted with little or no motion artifacts.

SOMATOM Definition
Radiation Dose with Dual Source CT
Reducing radiation dose is a major concern in cardiac CT. With dedicated
dose reduction mechanisms, however, radiation dose in Dual Source CT can
be efficiently reduced to a level well below that of single source CT.
By Thomas Flohr, PhD, Head of Physics and Application Development, Herbert Bruder, PhD, Karl Stierstorfer, PhD,
Physics and Application Development, Siemens AG, Medical Solutions, CT Division Forchheim, Germany,
and Cynthia McCollough, PhD, Director of the CT Clinical Innovation Center, Mayo Clinic, Rochester, Minnesota, USA

Temporal resolution better than 100 ms in combination with


sub-mm spatial resolution and examination times below 10 s
to cover the entire heart volume are considered pre-requisites for a successful implementation of cardiac CT into routine clinical algorithms. SOMATOM Definition is a Dual Source
CT (DSCT) scanner with a 0.33 s gantry rotation time and
2 x 32 x 0.6 mm collimation in combination with z-SharpTM
Technology for the simultaneous acquisition of 2 x 64 overlapping 0.6 mm slices. With these technical specs, it can fulfill these requirements: temporal resolution is as good as 83
milliseconds independent of the heart rate for coronary CTA
and functional evaluation. 0.33 mm through-plane resolution can be routinely achieved for the evaluation of stents
and severely calcified coronary arteries. The scan time for a 120
mm scan volume ranges between 5 and 9 s, depending on the
patients heart rate. First clinical experience has already demonstrated a considerably increased robustness of the method
for the imaging of patients with high heart rates [Fig. 1].
In addition to their benefits for cardiac examinations, DSCT
scanners also show promising properties for general radiology
applications. First, both X-ray tubes can be operated simultaneously in a standard spiral or sequential acquisition mode,
in this way providing up to 160 kW X-ray peak power. These

38

SOMATOM Sessions 18

power reserves are not only beneficial for the examination of


morbidly obese patients, whose numbers are dramatically
growing in western societies, but also to maintain adequate
X-ray photon flux for standard protocols when very high
volume coverage speed is necessary. Among them are acute
care situations, where the scanner has to be operated with
fast gantry rotation (0.33 s) and at high pitch (p = 1.5). Additionally, both X-ray sources can be operated at different kVsettings and/or different pre-filtrations, in this way allowing
dual energy acquisitions.
A major concern in cardiac CT is high radiation dose to the
patient, which is mainly caused by the highly overlapping
data acquisition due to the low spiral pitch required for
gapless volume coverage in each phase of the cardiac cycle.
In cardiac DSCT, both X-ray sources have to be simultaneously operated at the power level needed for single source CT, since each of them contributes only a quarter rotation to an
image slice. Without further optimization, DSCT would increase radiation dose to the patient by almost a factor of two.
With dedicated dose reduction mechanisms, however, radiation dose can be efficiently reduced to a level well below that
of single source cardiac CT. The three major steps to radiation
dose reduction are:

SCIENCE

use of a new optimized ECG-pulsing with shorter exposure


windows that can be reliably applied even in the presence
of arrhythmia
use of single-segment reconstruction at all heart rates that
enables efficient adaptation of the spiral pitch to the heart
rate
use of an optimized cardiac beam-shaping filter that avoids
unnecessary exposure outside the central heart region

Efficient ECG-Controlled Tube


Current Modulation
In cardiac CT, ECG-controlled modulation of the X-ray tube
current is applied to restrict the time interval of maximum
exposure to those cardiac phases where diagnostic image
quality is required [Fig. 2]. The plateau of high dose must
extend over the data range needed for image reconstruction, as well as additional ranges for retrospective optimization of the cardiac phase used for image reconstruction. In
single source CT, image reconstruction requires a high dose
plateau of at least half the gantry rotation time at iso-center,
and the data range needed for phase optimization has to be
larger than in DSCT due to the lower temporal resolution. In
DSCT, image reconstruction requires a high dose plateau of
only a quarter of the gantry rotation time at iso-center.
Consequently, the time interval with full dose can be much
shorter, which results in reduced radiation exposure compared with single source CT. The potential for dose reduction
depends on the heart cycle length and, hence, on the
patients heart rate.
For ECG-controlled modulation of the tube current, a prospective method is needed to estimate the time of the Rpeak for the next cardiac cycle. Using conventional approaches, the mean value of some preceding heart cycles is used
to estimate the next RR-interval. This method fails if the
patients heart beat is arrhythmic. For DSCT, a much more

robust algorithm for prospective estimation of the cardiac


cycle length by refined analysis of the patients ECG has been
developed and implemented. This algorithm takes nonrhythmic heart beats, such as extra-systoles, into account
and can be applied also in case of arrhythmia.

Adaptation of Spiral Pitch to the


Patients Heart Rate
In single source CT, improved temporal resolution is obtained
at the expense of limited spiral pitch and correspondingly
increased radiation dose to the patient. For a so-called singlesegment reconstruction, the table has to travel so slowly
that each z-position of the heart is seen by a detector slice
during each phase of the cardiac cycle. Consequently, the
patients heart rate determines the spiral pitch: if the heart
rate goes up, the spiral pitch can be increased, too. If multisegment reconstructions are applied at higher heart rates to
improve temporal resolution, the spiral pitch has to be reduced again: for a 2-segment reconstruction, each z-position of
the heart has to by seen be a detector slice during two consecutive heart beats; for a 3-segment reconstruction during
three consecutive heart beats; and so on. In general, manufacturers of single source CT scanners recommend an adaptive approach for ECG-gated cardiac scanning: the pitch of
the ECG-gated spiral scan is kept constant at a relatively low
value of 0.2 0.25, and more segments are used for image
reconstruction at higher heart rates to improve temporal
resolution. Up to a certain threshold heart rate, a single-segment reconstruction is performed, if the heart rate increases
this threshold, two or even more segments are used. Even if
a certain adaptation of the pitch is available, as proposed by
some manufacturers, the range of variation is very small, e. g.
between 0.2 and 0.25.
Using a DSCT-system, a temporal resolution of a quarter of the
gantry rotation time is achieved independent of the patients

ECG-controlled Tube Current Modulation


[ 2 ] ILLUSTRATION OF ECG-controlled tube current modulation
for the evaluated DSCT system. For coronary CT angiography, the
image reconstruction window should be located within the window
of maximum tube current. The temporal width of the image reconstruction window is 83 ms for the DSCT; it is 165 ms for a single
source CT at 0.33 s gantry rotation time. For the DSCT, the temporal
width of the window of maximum tube current can be selected by
the user. It can be much shorter than for a single source CT system,
thereby reducing radiation dose to the patient.

Recon
Recon
100%

Current

690 x 490

single source CT
20%

Dual Source CT
Time

SOMATOM Sessions 18

39

SCIENCE

Comparison of Relative Radiation Dose


DSCT
Nonoptimized
200%
+ Cardiac
bowtie

+ Pitch adaptation

150%
single
source CT
100%

50%

< 55

55 - 70 70 - 90 > 90 bpm

100%

single source CT
+ ECG-pulsing

50%

Dual Source CT
< 55

55 - 70

70 - 90

> 90 bpm

[ 3 ] RELATIVE RADIATION DOSE for ECG-gated scanning with


single source CT and DSCT, assuming equivalent image noise. For
both systems, no ECG-controlled dose modulation is used. The single source CT system is operated at a pitch of 0.2, a typical value
for ECG-gated coronary CTA. The non-optimized DSCT system (also
operating at a pitch of 0.2) increases radiation dose by almost a
factor of 2.
With an optimized cardiac bowtie-filter, the dose increase is reduced
to a factor of 1.53. With additional pitch adaptation, the radiation
dose for the DSCT system is only 80 percent of the radiation exposure with single source CT at clinical relevant heart rates of 70 90
bpm, when ECG controlled dose modulation is not used.
[ 4 ] RELATIVE RADIATION DOSE for ECG-gated scanning with
single source CT and DSCT, with ECG-controlled dose modulation,
using the same scaling as in Figure 3. For single source CT, the window of full dose is 400 ms, for DSCT it is 210 ms. The relative dose
with single source CT increases with increasing heart rate, due to the
decreasing dose reduction effect of ECG-controlled dose modulation
and the constant spiral pitch. The relative dose with DSCT decreases
with increasing heart rate. At clinical relevant heart rates between
70 and 90 bmp, the radiation exposure with DSCT is only about 50%
of the radiation exposure with the single source CT system , when
ECG controlled dose modulation is applied.

heart rate. Single-segment reconstruction using data from


one cardiac cycle for image reconstruction can be applied at
all heart rates. Since multi-segment reconstruction will not
be required, the spiral pitch can be efficiently adapted to the
patients heart rate and significantly increased at elevated
heart rates, compared with single source CT systems that
have to use multi-segment reconstruction at higher heart
rates. Pitch values ranging from 0.25 at lower heart rates up
to 0.5 at high heart rates are possible, resulting in coverage
of the entire heart volume within 5 9 s with 2 x 32 x 0.6 mm
collimation. The increased pitch at higher heart rates does
not only reduce the examination time, but reduces the radiation dose to the patient. At constant tube output (constant
mA) and fixed gantry rotation time, higher pitch is directly
equivalent to reduced patient dose: an ECG-gated examination that is performed at a pitch of 0.4 instead of 0.2 results
in only 0.2/0.4 = 0.5 times the radiation dose. Using the evaluated DSCT scanner, the patients heart rate is monitored
before the examination, the lowest heart rate observed during
the monitoring phase is taken and an additional safety margin of 10 bpm is subtracted to automatically adjust the pitch.

Optimized Cardiac Beam-Shaping Filter


Because patient thickness decreases at the periphery, the X-

40

SOMATOM Sessions 18

ray beam can be attenuated by shaped filters to reduce radiation intensity in the scan-plane (in the fan-angle direction)
with increasing distance from the iso-center. In cardiac CT,
the region of interest, the heart, is centered within the thorax,
and radiation can, in principle, be restricted to a cardiac field
of view (FOV) of about 25 cm in diameter. Thus, the radiation
dose outside the cardiac FOV can be reduced by an optimized beam-shaping filter and by the smaller scan field of view
of the second X-ray tube-detector system.
The effects of the three dose saving steps are summarized in
Fig. 3 and 4. In Fig. 3, the relative radiation dose for ECGgated cardiac CTA with DSCT is compared with the dose for a
corresponding single source CT-system, both without ECGpulsing. Dose reduction for DSCT comes from the cardiac
bowtie-filter and the adaptation of the pitch to the patients
heart rate. In Fig. 4, the effect of ECG-gated dose modulation
is additionally taken into account for both systems. Applying
the three dose saving steps, dose reduction up to a factor of
two compared with single source CT can be demonstrated
Further Reading
Flohr, T., et. al.: First performance evaluation of a dual-source CT (DSCT)
system, Eur Radiol. 2006 Feb; 16(2): 25668.
Achenbach, S., et al.: Contrast-enhanced coronary artery visualization
by dual-source computed tomography Initial experience. Eur J Radiol.
2006 Mar; 57(3): 3315.

SCIENCE

Cardiac CT
The Sarawak Experience A Report
After 18 Months in Clinical Practice
By Sim Kui Hian, MD, Head of Cardiology, Sarawak General Hospital, Kuching, Malaysia,
and Tobias Seyfarth, MD, CT Marketing Manager Asia Pacific, Siemens Medical Solutions, Singapore

The Sarawak General Hospital (SGH) is the largest hospital in


East Malaysia, situated on the island of Borneo. It is a tertiary
referral centre for the population of Sarawak, which in terms
of land area is the largest state in Malaysia. It has all the major
surgical and medical disciplines and it also functions as a
teaching hospital for the medical faculty of the state university.
The Department of Cardiology, headed by Professor S. K.
Hian, was set up as a separate entity from Internal Medicine
in 2000. Within five years, it has established itself as one of
the top cardiac units in this part of the world. The department has state-of-the-art facilities such as a fully integrated
cardiac information archiving system, cardiac MR and cardiac
CT. It provides a comprehensive range of diagnostic and
therapeutic cardiovascular interventions which include 3-D
echocardiography, cardiac catheterization, IVUS and catheterbased coronary, cardiac and other vascular interventions.
Whereas the hospitals main purpose is to serve the public
health of the state, it is also active in cardiovascular research.
Between 2003 and 2005, more than 60,000 volunteers have
been registered in a state-wide cardiovascular disease risk
database to asses the ten-year risk for the development of
CHD (Myocardial Infarction and Coronary Death) [presented
at the ASEAN Congress of Cardiology, September 2004,
Bangkok, Thailand].
Furthermore, the department participates in several international multi-center clinical trials, including the recently concluded OASIS-5, OASIS-6 and TIMI-EXTRACT therapeutic trials of patients with acute coronary syndrome, as well as new
drug-eluting stent registries such as e-Cypher, Taxus Olympia,
E-Five (Endeavour) and e-Healing (Genius).

Getting Started with Cardiac CT


With a fund from the state-owned Sarawak Heart Foundation,
the SGH purchased a SOMATOM Sensation 64 Cardiac CT
scanner in December 2004, which was installed January 2005
in the radiology department of the hospital. Since then the
scanner has been jointly used by the Departments of Radiology
and Cardiology. At present, every patient with a medical indication can undergo a cardiac CT scan free of charge.

The utilization of CT for the assessment and evaluation of


coronary vessels in South East Asia, in general, has been rather
low prior to 2004. Since the emergence of 64-slice CTs in
2004, coronary CTA has become more feasible on a routine
level for many hospitals, even though very few of them had
previous experience in coronary CTA. To overcome this limitation, two cardiologists from SGH attended a clinical workshop in late 2004 in Erlangen, Germany, and two others were
sent to Rotterdam, The Netherlands, to receive formal training in cardiac CT. This proved to be an invaluable experience
and served as the basis for the centers entrance into the cardiac CT business. To date, the hospital has performed approximately 1,300 cardiac CT scans, around 370 of which have
been correlated with an invasive cathlab procedure. In 2005,
one additional cardiologist spent four weeks as a fellow at
the Department of Cardiology at the Erlangen University.
Being the first 64-slice CT in a public hospital in South East

Symptomatic Patients

100

STEMI

NSTEMI/
CAD

Known
CAD

+ ETT/
EAP

Equivocal
ETT/
Atypical CP

High-risk
Asymptomatic

92,9

78,9

86,7

43,8

33,3

22,2

80
77,8
56,7

60
46,2

40

20

21,1
13,3

7,1
I 3+VD

I 2VD

I 1VD

I NS CAD

[ 1 ] Percentage of coronary artery disease on CTA

& CCA under different clinical presentations (n=261).

SOMATOM Sessions 18

41

SCIENCE

10 Year CVD Risk Assessment*


N = 70

Normal scan

Abnormal scan

Framingham Low Risk (<10 %)

43 (61.4%)

35 (81.4%)

8 (18.6%)

PROCAM Low Risk (<10 %)

59 (84.3%)

46 (78.0 %)

13 (22.0%)

Framingham Medium-High Risk

27 (38.6%)

18 (66.7%)

9 (33.3%)

PROCAM Medium-High Risk

11 (15.7%)

7 (63.6%)

4 (36.4%)

*Source: Ang CK, et al. J Geriatr Cardiol 2006; 3(1): 1721).

Asia, with a high number of patients scanned in a short time,


inspired the Department of Cardiology to investigate the
possibility of utilizing this large amount of patient data for
research purposes.
After thorough analyses of the collected patient data and
previously published articles from other sites, SGHs first publication in a major journal discussed the feasibility and accuracy of 64-slice CT from a center with limited experience1. In
a further study involving 301 patients, an increase in sensitivity, specificity, negative and positive predictive value could
be shown over each quarter of the first year (2005), with a
sharp increase in the first six months (which is considered the
initial learning time), while reaching a stable plateau after
nine months. This report from a hospital with no previous
experience in cardiac CT might be more applicable to a
large number of first-time CT users than the figures published mainly in international journals by those centers with
a long history of cardiac CT. A major finding was that a minimum time frame of six months should be assigned as a starting phase in a center with high volume caseload until the
interpretation skills of the physicians reached an acceptable
confidence level in daily routine. The chance of receiving a
transfer of knowledge by clinical workshops and fellowships
at renowned hospitals proved to be very important, while
facilities to confirm the CT diagnoses by a subsequent invasive cathlab procedure during the learning curve is beneficial
(where indicated or in a research environment).
In addition to the pure correlation of cardiac CT data to invasive cathlab images, the Department of Cardiology has also
been focusing on redefining cardiovascular risks for certain
patient subgroups.

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SOMATOM Sessions 18

Clinical Studies
The prelude to this was the identification of significant coronary disease among clinical subsets of 261 patients with cardiac symptoms2. One-third of the patients with atypical chest
pain and over 20 % of asymptomatic patients were found to
have significant coronary disease on CTA, which correlates
closely (over 95 %) with conventional angiography.
Subsequently, 70 patients at the clinic with atypical cardiac
chest pain (ACCP) were selected over a one month period
and offered a coronary CT scan. CTA confidently excluded
significant coronary disease as the cause of the chest pain for
76 % of the patients3. When the 10-year CVD risk was calculated using PROCAM and Framingham algorithms, the general finding was that despite getting a low risk profile in
PROCAM and Framingham, around 20 % (22 %; 18.6 % respectively) of the patients with ACCP had an abnormal CT scan (as
defined by a lumen stenosis of 50 % or more or significant
coronary calcification (CaSC >400)) [see table]. On the other
hand, around 65 % of patients with a mid to high risk by
PROCAM and Framingham (63.6 %; 66.7 % respectively) had
normal CT scans (defined as absence of any lesion 50 %
and CaSC of <400). This would suggest that patients might
benefit from non invasive risk stratification with the utilization of CT in addition to the current algorithms. CTA of the
coronaries can help to identify low risk patients who might
benefit from a more aggressive treatment. With coronary CTA
readily available in many centers around the world, it has the
potential to become the non-invasive investigation tool of
choice for evaluation of atypical chest pain and also helps to
enhance the risk stratification of CVD.

SCIENCE

More interesting results have been found in the coronary


CTAs of the asymptomatic patient group. In this subgroup of
66 patients (all of them with a Diabetes mel. Type II), around
20 % of the patients showed a stenosis of 5075 %, and in
around 30 % of the patients a stenosis greater than 75 % in at
least one major coronary vessel was present.
What is the clinical value of these findings? It will allow physicians to redefine and estimate the relative importance of established and putative risk factors of cardiovascular disease. And
because the low sensitivity and specificity of existing algorithms is understood, CTA will help to alert physicians about
patients whose overall cardiovascular risk (by present modes of
calculation) was low but who nevertheless harbor underlying
coronary disease, thus requiring further intensive therapy.
To further broaden the scientific scope of the center, the
Department of Cardiology at SGH has established ties with the
Radiology Department of Aachen University (RWTH Aachen)
for a co-operation on various clinical questions involving cardiac CT. With this, an enlarged patient cohort might be studied,

Symptomatic Patients
35

No. of patients

30

50 75%
21,2%

25
20
>75%
15
10

28,8%

5
0
Sig. Stenosis Present

Sig. Stenosis Absent

[ 2 ] Prevalence of coronary disease in


66 asymptomatic type II diabetes patients.

Clinical Images: Patient with Coronary Stenosis


47 year old man, Coronary risk
factors Asymptomatic. Exercise
treadmill test in 2004 was negative.
CTA revealed a moderate stenosis
(4050%) in the proximal LCx and
a significant stenosis (6070%) in
the mid segment of the left circumflex artery. Patient declined any
further invasive investigation, was
started on aspirin and aggressive
lipid lowering therapy.

Prox and mid LCx stenosis.

Cross section of prox LCx lesion.

45 year old male, diabetic patient with concurrent hypertension and


obesity. CT angiography was done to screen for coronary artery disease,
in view of his multiple risk factors.
CTA revealed a significant stenosis in the proximal LAD. The patient
underwent conventional coronary angiography which confirmed the
lesion in the LAD. The patient opted for medical therapy.

Prox and mid LAD stenosis.

SOMATOM Sessions 18

43

SCIENCE

thus overcoming the largest limitation encountered in single


site research.
An exciting collaboration is the study of right ventricular function. At SGH, a report has been published on the accuracy of
left ventricular function by cardiac CT while using the dedicated syngo Circulation software when compared to cardiac
MRI4. The department has also embarked on a novel method
to evaluate plaque vulnerability5.
To share the knowledge gained in cardiac CT, the hospital
opened its doors to the clinical public, inviting them to their
first clinical training program (four times annually) in February 2006 under the umbrella of the world-wide Siemens
Medical Solutions Life Educate program. This might represent a cheaper, more convenient alternative to the overseas
training centers in Europe and North America for Asian
physicians. Additionally, the center now facilitates its own
DICOM database with more than 150 interesting cardiac CT
cases with the respective cathlab correlation for interactive
teaching. A sufficient number of state-of-the-art workstations are available, all of which feature the latest in cardiac
CT evaluation software, syngo Circulation.
In summary, after 18 months it can be said that the center
has established itself as a strong provider of routine coronary
CTAs to the public with a high diagnostic confidence (around
811 scans per day). Furthermore, it has been able to successfully submit several scientific contributions in the field of
cardiac CT highlighting the clinical use of the newly emerged
imaging option6, 7. The opportunity to collaborate with
renowned medical institutions is surely a great one. Hopefully, such clinical achievements can be maintained and continued on a different level. With the start of clinical training programs, SGH will share its knowledge regionally and help to
bring medical personnel new to cardiac CT quickly to a high
level of confidence and experience.

From left to right: Dr. Ang CK;


With the necessary operaDr. Chan WL; Dr. Chin SP
tional requirements in place,
in addition to a highly motivated medical staff, this success story will be surely seen
around the world. Cardiac CT is a valuable clinical tool that
everybody can benefit from.
The research results represented in this article are the combined effort of the research team in SGH including: Ong
Tiong Kiam, MD, Chin Sze Piaw, MD, Ang Choon Kiat, MD,
Annuar Rapaee, MD, Chan Wei Ling, MD, Liew Chee Khoon,
MD, Liew Houng Bang, MD, Alan Fong, MD, Martin Wong,
MD, and Prof. Sim Kui Hian, MD.
k www.cardiacsgh.health.gov.my
References
1 Ong TK et al. Feasibility and Accuracy of 64-Row MDCT Coronary Imaging
From A Centre With Early Experience: A Review And Comparison With Established Centers. Med J Malaysia 2005; 60(5): 625632.
2 Chin SP et al. 64 Slice MDCT accurately detects a high prevalence of
coronary artery disease among high-risk symptomatic and asymptomatic
patients. Oral abstract TCT 2005 (Washington, USA) Am J Cardiology Suppl
2005: (96): H2122.
3 Ang CK et al. High-resolution computed tomography in patients with
atypical cardiac chest pain: a study investigating patients at 10-year cardiovascular risks defined by the Framingham and PROCAM scores; J Geriatr
Cardiol 2006; 3(1): 1721.
4 Liew CK et al. Assessment of left ventricular ejection fraction: comparison
of two dimensional echocardiography, cardiac magnetic resonance imaging
and 64-row multi-detector computed tomography; J Geriatr Cardiol 2006;
3(1): 28.
5 Chin SP et al. Vessel Density Ratio: A Novel Approach to Identifying Culprit
Lesions in Acute Coronary Syndrome by MDCT; ACC 2006 (Atlanta, USA).
6 Ong TK et al. Accuracy Of 64 Multi Row Detector Computed Tomography
In Detecting Coronary Artery Disease in 134 Symptomatic Patients: Influence
of Calcification; American Heart Journal (In Press).
7 Chan WL at al. Feasibility And Accuracy Of Coronary Imaging In Elderly
Patients Using The Multi Detector Row Computed Tomography; J Geriatr
Cardiol 2006; 3(1): 914.

From left to right: Annuar R, MD;


Prof A. Mahnken, MD (University
of Aachen); radiographer; Prof. HK
Sim, MD; TK Ong, MD; Fong A, MD;
radiographer; T. Seyfarth, MD,
(Siemens Medical Solutions).

44

SOMATOM Sessions 18

CUSTOMER CARE

L I F E : N E W C L I N I C A L A P P L I C AT I O N S F O R I N S TA L L E D S Y S T E M S

Evolve Update Facilitates


Enhanced CT Fluoroscopy
syngo Evolve is Siemens non-obsolescence program that always ensures the
latest software and hardware updates
for medical equipment. The latest Evolve
update, syngo CT 2006G, is now available for all SOMATOM Sensation 10, 16
and 16 Cardiac CT systems covered by
a syngo Evolve contract. It provides
significant workflow improvements and
access to new optional clinical applications such as syngo InSpace 4DTM with
bone removal1, 2, CARE Contrast CT2 for
optimized contrast agent application,
syngo Body Perfusion2, and CARE Vision
CT2, which now features a new screen

layout for enhanced needle navigation.


Computed tomography (CT) fluoroscopy
allows precise needle guidance for interventional procedures such as drainage, biopsy and pain therapy. CARE Vision CT is Siemens solution for minimally
invasive interventional procedures and
offers maximum dose reduction. The
speed of the intervention, in comparison
with other modalities, makes it often the
method of choice, says Jaques Kirsch,
MD, Head of Radiology Department,
Clinique Notre-Dame in Tournai, Belgium.
The in-room monitor and X-ray control
facilitate easy and fast operation, and

CARE Vision CT, among other features,


permits the additional display of the slices
adjoined with the area of operation.
Courtesy Clinic Notre Dame, Belgium
the HandCARETM feature reduces X-ray
for the patient and the operators hand.
CT fluoroscopy case studies of vertebroplasty and percutaneous sympathectomy
can be found under the link below.
1

Bone removal requires VolPro graphics card.

Option to be purchased separately.

k www.siemens.com/CT-Fluoroscopy

SERVICE

Frequently Asked Questions


Via the SOMATOM World User Lounges, Siemens applications specialists answer your questions on how to easily
use Siemens Computed Tomography scanners and applications in daily clinical practice. Additionally, SOMATOM Sessions
offers a regular column with frequently asked questions for
offline reference.
How do I change the default window/level settings for
specific protocols?
Select options/configuration/viewer/evaluation general and
the protocol in question, and set the window and levels for
windows 1 & 2 to your organ-specific preferences.
What is the reason for the CD-device not mounted error?
The last CD was ejected manually from the CD drive. Restart
the system to re-establish communication between the
scanner and drive. To prevent this error, always use the soft
key in the transfer drop-down to eject a CD.

Can I get the entire patient-relevant scan data combined


in one report?
Yes. The patient protocol is available after the examination is
closed. This protocol is listed in the patient browser and can
be loaded to the viewing card to read the values, e.g. dose
length product or total mAs applied to the patient. You can
enable the patient protocol in options/configuration/examination. If the checkbox is selected, the protocol will automatically be added to the patient study after the examination is finished.
How can I get full image quality of syngo InSpace images
displayed in the viewing card?
When saving images with the save as-button in syngo
InSpace, check the entry in the image size field. 1024x1024
should be selected in the save to database-window. After
loading the saved images to the syngo viewing card, the best
image quality is available.
k www.siemens.com/SOMATOMWorld
SOMATOM Sessions 18

45

CUSTOMER CARE

C T ONLINE

CT Education on the Web


k www.star-program.com
STAR is an international educational forum sponsored by
Siemens Medical Solutions and Schering AG, aimed at presenting cutting-edge developments in radiology. The program
is held as a regular forum on a regional basis involving eminent and independent experts from all fields of radiology.
The meetings typically last two days and consist of 45minute faculty lectures followed by 90 to 120-minute workshops or panel discussions. The communication of radiological advances at a high level contributes to an intensive
exchange of experience between the lecturers and the physicians of the host country. Abstracts of the lectures are available on the STAR internet site. Over the 12 years of its existence, STAR has conducted 89 symposia in 26 countries all
over the world with more than 11,000 radiologists attending.
Often, more than 80 percent of a country's practising radiol-

ogists were present. Schering and Siemens are perfect partners in this educational enterprise: Much of the meetings
success is due to the close links both companies maintain
with radiologists around the world.

Upcoming Events & Courses


Title

Location

Short Description
st

Date

Contact

Society of
Cardiovascular CT

Washington DC, USA

1 Annual Scientific Meeting


in cooperation with the 7th
International Conference
on Cardiac CT

July 1316, 2006

www.scct.org

Advanced Topics
in Multidetector
CT Scanning

Cruise to the
Mediterranean

CME Course

July 29Aug. 5, 2006

www.ctisus.com

ESC

Barcelona, Spain

World Congress
of Cardiology 2006

Sept. 26, 2006

www.escardio.org

ESTRO

Leipzig, Germany

European Society for


Therapeutic Radiology and
Oncology Estro

Oct. 812, 2006

www.estroweb.org

JFR

Paris, France

Socit Franaise de
Radiologie Congrs

Oct. 2125, 2006

www.sfrnet.org

TCT

Washington, USA

Transcatheter Cardiovascular
Therapeutics Symposium

Oct. 2227, 2006

www.tct2006.com

ASTRO

Philadelphia, PA, USA

American Society for


Therapeutic Radiology and
Oncology Annual Meeting

Nov. 59, 2006

www.astro.org

AHA

Chicago, USA

American Heart Association


Scientific Sessions

Nov.1215, 2006

www.scientificsessions.org

Medica

Dsseldorf, Germany

MEDICA 2006

Nov.1518, 2006

www.medica.de

RSNA

Chicago, USA

Radiological Society
of North America

Nov. 26Dec.1, 2006

www.rsna.org

In addition, you can always find the latest CT courses offered by Siemens Medical Solutions at www.siemens.com/SOMATOMEducate.

46

SOMATOM Sessions 18

CUSTOMER CARE

SOMATOM SESSIONS IMPRINT


2006 by Siemens AG, Berlin and Munich, All rights reserved
Publisher
Siemens AG
Medical Solutions
Computed Tomography Division
Siemensstrae 1
D-91301 Forchheim
Responsible for Contents:
Bernd Ohnesorge, PhD
Chief Editors
Monika Demuth, PhD
(monika.demuth@siemens.com)
Doris Pischitz, M.A.
(doris.pischitz@siemens.com)
Stefan Wuensch, PhD
(stefan.wuensch@siemens.com)
Editorial Board
Nina Bastian
Joachim Buck, PhD
Chad DeGraaff
Thomas Flohr, PhD
Andr Hartung
Julia Kern-Stoll
Axel Lorz
Matthew Manuel
Louise McKenna, PhD
Jens Scharnagl
Authors of this Issue
N. Abdala, MD, Department of Radiology, UMDI,
Sao Paulo, Brazil

T. Chlibec, MD, Institute of Radiology, Kantonsspital St. Gallen, Switzerland

C. Salazar, MD, UMDI Unidade Mogiana de


Diagstico por Imagem; So Paulo, Brazil

C. McCollough, PhD, CT Clinical Innovation Center,


Mayo Clinic, Rochester, Minnesota, USA

F. T. Schmid, MD, Institute of Radiology, Kantonsspital St. Gallen, Switzerland

W. G. Daniel, MD, Department of Internal Medicine


II, University of Erlangen-Nuremberg, Germany

U. J. Schoepf, MD, Department of Radiology and


medicine, Medical University of South Carolina,
Charleston, USA

H. Grzer, MD, Department of Radiology Hartmannspital Vienna, Austria

K. H. Sim, MD, Department of Cardiology,


Sarawak General Hospital, Kuching, Malaysia

G. D. Graham, MD, Imaging Center, Chattanooga


Heart Institute, Chattanooga, TN, USA

B. Stinn, MD, Institute of Radiology, Kantonsspital


St. Gallen, Switzerland

S. Hall, Niagara Health Region, St. Catharines


General Site Ontario, Canada

L. Varnell, MD, Imaging Center, Chattanooga


Heart Institute, Chattanooga, TN, USA

W. Kalender, PhD, Institue for Medical Physics,


University of Erlangen-Nuremberg, Germany

S. Wildermuth, MD, PhD, Institute of Radiology,


Kantonsspital St. Gallen, Switzerland

J.-T. Kluckert, MD, Institute of Radiology, Kantonsspital St. Gallen, Switzerland

Sameh Fahmy, freelance author

A. Kttner, MD, Institute for Diagnostic Radiology,


University of Erlangen-Nuremberg, Germany
A. Mehta, MD, Niagara Health Region,
St. Catharines General Site Ontario, Canada
J. Myers, Kansas City Cancer Center,
Overland Park, Kansas, USA
M. Oldendorf, MD, Medical Director Department of
Radiology, Klinikum Nuremberg North, Germany

Jessica Amberg; Nina Bastian; Andreas Blaha; Herbert Bruder, PhD; Jan Chudzik; Ana P. Pieroni De
Menezes; Ken Field; Thomas Flohr, PhD; Lars Hofmann, MD; Julia Kern-Stoll; Louise McKenna, PhD,
MBA; Doris Pischitz; Rainer Raupach, PhD; Gitta
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S. Achenbach, MD, Department of Internal Medicine II, University of Erlangen-Nuremberg, Germany

E. Powers, MD, Department of Radiology and


medicine, Medical University of South Carolina,
Charleston, USA

K. Anders, MD, Institute for Diagnostic Radiology,


University of Erlangen-Nuremberg, Germany

D. Ropers, MD, Department of Internal Medicine


II, University of Erlangen-Nuremberg, Germany

Printers
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Printed in Germany

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and radiology departments throughout the world. It includes reports in the
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The statements and views of the authors in the individual contributions do
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The information presented in these articles and case reports is for illustration only and is not intended to be relied upon by the reader for instruction
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No 18/June 2006
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June 14th
June 17th, 2006

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Highlights

SOMATOM
Sessions
Picture

COVER STORY
Saving Time, Money and Lives
Page 4
NEWS
3D-Reading
Wherever You Are
Page 10
BUSINESS
Utilization Report Now Also
Available for CT Systems
Page 15
CLINICAL OUTCOMES
Cardiovascular Dual Source
CT after Left Main Coronary
Artery Stenting
Page 17
CLINICAL OUTCOMES
Neurology Complete
Occlusion of Left Carotid
Artery and Stenosis at
Right Carotid Artery
Page 29
SCIENCE
Radiation Dose with Dual
Source CT
Page 38
CUSTOMER CARE
Evolve Update Facilitates
Enhanced CT Fluoroscopy
Page 45

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SOMATOM Sessions
Issue No.18/June 2006

On account of certain regional limitations of sales


rights and service availability, we cannot guarantee
that all products included in this brochure are
available through the Siemens sales organization
worldwide. Availability and packaging may vary
by country and is subject to change without prior
notice. Some/All of the features and products
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2006 Siemens SOMATOM Sessions


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