Académique Documents
Professionnel Documents
Culture Documents
Cover Story
Dual Source CT Reshapes
Clinical Imaging
Page 4
News
syngo CT Oncology
Page 14
Clinical
Outcomes
Acute Care: New Insight
Into Kidney Stone Detection and Treatment With
Spiral Dual Energy
Page 44
Science
Half-Scan vs. Multi-Segment Reconstruction for
CT Coronary Angiography
Page 54
Education &
Events
New: Cardiac CT Poster
Page 60
Editors Letter
Andr Hartung,
Vice President Marketing
and Sales.
Dear Reader,
To provide the worlds population with
the best possible, economically solid,
medical care is the challenge faced by all
healthcare systems today. This places the
responsibility squarely upon medical doctors, clinics and other healthcare institutions to cost-efficiently provide faster and
more reliable diagnoses and treatments.
Given the pressure to constantly reduce
costs, it is no longer practical to expect
the investment in high-end imaging
equipment to be amortized from imaging
patients alone: the entire clinical process,
whether in hospitals or practices, must
be accelerated while improving healthcare quality. In everyday practice, this
means reducing the time required from
suspicion to diagnosis, reducing the
number of examinations and shortening
the length of hospital stays all improvements that can be ideally supplemented
by computed tomography (CT). CT offers
an incredibly broad spectrum of examinations, is widely available, usually
around the clock with minimum personnel requirements. New clinical applications and ease-of-use promise a bright
future for CT in improved patient care
while further reducing costs.
The recent introduction of Dual Source
CT with the SOMATOM Definition represents a break-through in the entire medical imaging industry. Beta-blockers are no
longer necessary for heart CT scans and
Andr Hartung
Cover Page: Volume rendered image of a dual energy examination of the hands of an adult patient with acute gout. With the dual energy information, deposits of uric
acid can be detected within the tophi. Areas of active inammation additionally show an increased contrast enhancement. By Drs. T. Johnson, S. Weckbach, H. Kellner,
M. Reiser and C. Becker, University of Munich Grosshadern, Munich/Germany. Cf. Molecular Imaging of Gout (Arthritis & Rheumatism; in press)
Content
Cover Story
4
News
10 Maximum CT Capabilities in Minimum Space
14 Fully Automated Tumor Tracking With syngo CT Oncology
16 syngo Circulation Siemens Scientifically Validated
Cardiac CT Software
Business
17 Flexibility for the Future Now
22 Big Progress for a Small Clinic
25 Cardiac CT Takes Off
4
Dual Energy For Clinical Routine
Clinical Outcomes
Cardiovascular:
30 Heterotopic Heart Transplant With Arrhythmic
Heart Rate of 45 125 bpm
32 Reliable In-Stent Lumen Visualization With
Dual Source CT Coronary Angiography
34 Abdominal CTA With Direct Dual Energy Bone Subtraction
Oncology:
36 New: syngo CT Oncology
38 Improved Evaluation and Follow-up of Routine
Diagnostic Oncology Exams With syngo CT Oncology
Neurology:
40 Utilizing the SOMATOM Emotion 16 for a Neuro DSA CTA
Evaluation of a Suspected PICA Aneurysm
25
Cardiac CT Takes Off
Acute Care:
42 Dual Source CT Triple Rule Out Without -Blocker
44 New Insight Into Kidney Stone Detection and Characterization
With Spiral Dual Energy
Science
46 Detecting Coronary Atherosclerosis by DSCT Images With
Color Maps
48 Coronary CT Angiography With DSCT Implications for
Contrast Media Delivery
52 Nefertitis Bust An Inside View
54 Half-Scan vs. Multi-Segment Reconstruction for CT Coronary
Angiography
32
DSCT Coronary Angiography
Cover Story
Cover Story
Cover Story
3
3 Pulmonary embolism (arrow).
Cover Story
4 Volume rendered image of a dual energy examination of the hands of an adult patient with
acute gout. With the dual energy information, deposits of uric acid can be detected within the
tophi. Areas of active inflammation additionally show an increased contrast enhancement.
artifact, an inadequate signal-to-noise ratio as a result of obesity, and other technical factors. Because the Definition produces fewer nondiagnostic scans, fewer
patients require nuclear stress testing or
cardiac catheterization to determine the
physiologic significance of a questionable
finding.
And although using two x-ray sources
might suggest an increase in radiation
dose, Dual Source CT can substantially reduce patient exposure for cardiac applications. As the Definition images the heart
twice as fast, an adaptive ECG-controlled
pulsing can apply the dose necessary in
less than half the time. In addition, DSCT
adapts the table speed according to the
heart rate of the patient, thus automatically reducing cardiac dose at higher
heart rates. Besides, the resulting improvement in diagnostic confidence is likely to
reduce radiation exposure over the long
term. According to Litt, about 20 % of patients who come to the ED with chest
pain return to the hospital within a
month with the same symptoms. Because
emergency physicians have confidence
in the reliability of cardiac CT, they are
less likely to repeat the scan than they
might be with nuclear imaging.
By doing CT, which gives a lot of confidence in a negative study, youre avoiding
the need for further studies down the
road and perhaps decreasing the overall
radiation that that patient will be exposed
to in a lifetime, Litt says.
Cover Story
5A
5B
5B
Cover Story
6A
6B
6 Long distance peripheral
run-off examination
with dual energy technique. The ability to
show (Fig. 6A) or hide
(Fig. 6B) calcified plaque
(arrow) allows asessment of the remaining
lumen.
gout. Dual energy imaging is now providing new information on the source of
soft tissue swelling and the extent of
joint destruction in advanced gout.
Many other dual energy applications are
nearing clinical use. Plaque imaging is
perhaps the most intensely anticipated.
Increasingly sophisticated plaque removal tools can be used to mask calcification
and minimize blooming artifact, making
it much easier to evaluate the severity of
arterial stenosis. Perhaps even more intriguing is the possibility for dual energy
techniques to detect inflammation,
thereby distinguishing stable from unstable plaques.
Im pretty amazed at the progress in
dual energy techniques in just the last
year, Becker says. I believe dual energy
will become a substantial part of routine
scanning for a number of different applications we cant even conceive of yet.
Im pretty amazed at the progress in dual energy techniques in just the last year. I believe
dual energy will become a substantial part of
routine scanning for a number of different
applications we cant even conceive of yet.
Christoph Becker, MD, Associate Professor of Radiology and Section Chief of body CT and PET CT,
Department of Clinical Radiology, University Hospital of Munich, Munich-Grosshadern, Germany
News
News
Maximum CT Capabilities
in Minimum Space
In a discussion with SOMATOM Sessions, Professor Gerhard Mostbeck, MD,
Department of Radiology, Otto Wagner Hospital and Medical Center, Vienna,
Austria, describes how daily workow has improved with their new SOMATOM
Emotion 16-slice conguration.
Interview by Robert Harsieber, PhD
11
News
recognize the number and origin of nodules in the lungs. Radiologists are not
perfect we make mistakes but now
we have new computer aided detection
(CAD) software that automatically recognizes and marks suspicious structures for
us.
In what other ways has the SOMATOM
Emotion 16-slice configuration been
useful?
The Emotion provides high image quality
as well as software for special applications. For example, neuro-radiology plays
a key role in our work here. We support a
stroke unit that encounters, on average,
one stroke per day. So of course, it is important to be able to image the vessels of
the brain.
There is also a new solution with which
we can subtract the skull bones, and
then, from what is left on the scan,
News
Another novelty of the SOMATOM Emotion 16-slice configuration is that we can select
automatic multiplanar reconstructions coronal and sagittal, says Prof. Mostbeck.
13
News
Vahid Yaghmai, MD, Associate Professor of Radiology at Northwestern University-Feinberg School of Medicine, Illinois.
News
One click 3D-segementation and size evaluation of liver lesions with syngo CT Oncology.
Simplied Follow-Ups
To obtain automated measurements
from the syngo CT Oncology*, a radiologist clicks on the lesion on the display, and
immediately receives a readout of x, y,
and z dimensions, RECIST and WHO measurements, and lesion volume. If the
scan is a follow-up, the system displays
previous data on the same lesion, and
calculates any dimensional change during
the interim.
A simplified follow-up is one of the biggest
benefits of this new syngo software; there
is no need to find the same tumor on
previous images, and then determine
which slice shows the greatest single
dimension for RECIST or WHO measurements those repetitive functions are now
all embedded in the software. When you
follow patients based on these measurements, you want consistent and reliable
data, and this software gives reliable and
consistent information. It virtually eliminates human error and the variations in
In the longer term, automated tumor measurement can take radiology firmly into
the third dimension. While each component of a CT scan is a two-dimensional
slice of the patients anatomy, tumors
themselves are three-dimensional objects,
and the new-found ability to measure
volume will allow comparisons to see
whether volume, RECIST or WHO is most
appropriate for evaluating treatment.
Already, data regarding the volume of lung
cancer nodules suggests that volume
should be the way to follow treatment,
Yaghmai says. However, nobody knows
what volume means in terms of patient
management for tumors of the liver or
lymph nodes. Even before the precise role
of volume measurements is determined,
accuracy and repeatability have value in
improving patient care, says Yaghmai. We
do not want the human factor to be a component of these measurements. Its better
for patient to have realistic information.
Whether or not volume becomes a standard modality for evaluating treatment,
Yaghmai says, software like this will be
eventually standard for any follow-up of
oncology patients. Previously, the technology was not available, and now it is.
*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.
15
News
Web Selection as the worlds first Webenabled CT, providing Zero Delay Workflow Solution with instant accessibility
of 3D volume data to users at any location, 24 hours a day. Getting onboard
with SOMATOM Sensation Web Selection
marks the second time in two years that
ARMC has become first in the world to
obtain brand-new CT technology and
IT workflow solutions from Siemens. In
2005, ARMC was first to receive the
SOMATOM Sensation 40. Now the 238-
17
Business
first customer to use it. Alamance performs CT for all medical indications, but
it has had its eye on cardiac CT angiography. With the SOMATOM Sensation 40
scanner obtained in 2005, the hospital
began expanding into cardiovascular
imaging, primarily for peripheral arteries
and carotids. Now the hospital is planning
for cardiac CT angiography, expanding it
patient base as the place to be for diagnosing coronary artery disease.
SOMATOM Sensation Web Selection
addresses exactly these needs, with its
advanced imaging capabilities. It offers
industrys highest rotation speed of
0.33 s which is essential to freeze the cardiac motion. At the same time the highest isotropic resolution of 0.33 mm enabled by Siemens unique z-Sharp
technology gives the user the ability to
see smallest detail such as the entire coronary artery tree or even coronary instent lumen.
The combination of both, speed and
resolution is key in cardiac imaging. Not
only to freeze motion and make smallest
details clearly visual for the physicians but
especially to image calcified plaques with
as little blooming artifacts as possible.
Combined with the latest evaluation software, the SOMATOM Sensation is a powerful tool in Cardiac CT.
Whats more. DeAngelo says the
SOMATOM Sensation Web Selections
Multimodality workplace is set up with
sophisticated post-processing software
for a wide variety of functions.
We have a new Multimodality Workplace
with advanced post-processing capabili-
Order
Patient Preparation
Process
Distribute
Scan Data
MultiModality Workplaces +
CT Clinical Engines +
syngo Expert-i
Office PC
Acquisition
Workplace
CT
Workplace
WebSpace
Server
Home
PC/Laptop
Shared Database
PACS
Archive
PACS Reading
Workstations
ing images from a PACS archive for postprocessing at the Multimodality workplace
can now be used in more productive
ways. Radiologists and surgeons no longer have to wait in line for the Multimodality workplace to view the highest
quality CT images, nor must they waste
time and effort switching between the
workstation and a personal computer
when viewing images in 3D. And that
midnight drive from the radiologists home
to the hospital simply to spend ten minutes reading an image? Thats history, too.
We will see significant costs savings in
the long term, but the benefits are immediate. Physicians are able now to access
images over the Internet, which is saving
everyone time and money, Hudson says.
19
Business
Business
Investing in Flexibility
in the Future
We were already a filmless radiology
department and fairly state of the art. But
with SOMATOM Sensation Web Selection
we see multiple advantages for us,
DeAngelo says. There is a huge workflow
benefit for everyone, including our radiologists and referring physicians particularly orthopedic and vascular surgeons.
ARMCs continued trust and investment
into the SOMATOM Sensation product line
shows the success of the technological
and clinical capabilities of the system.
Alamances decision to optimize its busy
CT program with the SOMATOM Sensation
Web Selection will accelerate the way they
can deliver patient care. The ability to scan
and post-process patients faster will have
a positive impact on patient throughput,
especially at peak times or with unexpect-
ed ER admissions, says Jan Chudzik, Product Marketing Manager for the SOMATOM
Sensation. The thin client-based accessibility of 3D images to the physicians anywhere and anytime will help to shorten
the overall process of patient diagnosis by
cutting out the typical delays of a workstation/PACS-bounded workflow.
For any institution purchasing expensive
imaging equipment, flexibility for the
future is an important consideration, adds
Hudson. The rapid pace of technological
evolution can cause million-dollar imaging
systems to become outdated in just three
to five years. Purchasing the Sensation 40
with knowledge that it could be upgraded
to a 64-slice system gave Alamance the
flexibility it needed. Siemens e-Tune is
packaged with Web Selection to offer protection against technological obsolescence. e-Tune guarantees that Alamance
receives software and even hardware updates for the next several years.
DeAngelo is confident that the hospital
made the right choice, saying, This will
carry us quite some time into the future.
The Web Selection with e-Tune extends
our original investment in 2005 in the
Sensation 40 to a total of five years.
21
Business
Business
The diagnosed ureteral tumor stands out (arrow) as do the contrasting white areas in the kidney and the ureter. Only this
morning we discovered a ureter tumor that we would not have recognized with our old equipment, Engelhard says.
23
Business
Custom-Made Advantages
The choice of a Siemens CT also turned
out to be a great advantage when it came
to installation, says Engelhard. In this instance, Martha-Maria had some very exacting, demanding requirements. Planning was to begin only in late summer
2006, yet installation and full functionality had to be completed by December 31
because on the next day, January 1st,
2007, Germanys value-added tax would
Frank A. Miltner is a Munich-based media consultant and a scientific and medical journalist. He
is a former editor of the German magazine Focus
and editor-in-chief for Lifescience.de and Netdoktor.de as well as the author of several books.
non-invasive heart diagnostics, not only for our patients and for
our small hospital, but also for the whole region. Among nonuniversity clinics, at present we have no competition.
What has changed for the patients?
We can, for example, rule out coronary diseases, conduct
artery hardening analyses, recognize soft plaques, and diagnose
patients with small and middle pre-test probability or middle
PROCAM risk to the extent that preventive measures can then be
introduced. With this CT, we not only work more accurately,
but also spare many patients the discomfort of a heart-catheter
examination.
What has changed for your cardiology department?
Our reputation has grown noticeably, patient numbers have increased, and we now have a cooperative program with established cardiologists. Word spread about our cardio CT, and patients have begun to ask about it. This CT not only improves the
quality and thus the reputation of our Department of Cardiology,
it also provides for significant hospital revenues. It has been
only three months since we introduced the new equipment,
and we are fully on budget with our financial plans. The investment was worthwhile for us in all respects.
Business
25
Extraordinary Exposure
for Jet Pilots
Thanks to its high sensivity and specificity, DSCT has become increasingly recognized
in international aviation medicine when diagnosing CAD in asymptomatic pilots at the
German Heart Center, Munich, Germany.
In terms of accelerated
temporal resolution,
SOMATOM Definition sets
groundbreaking standards.
Stefan Martinoff, MD,
Director, Institute for Radiology and Nuclear Medicine,
German Heart Center, Munich, Germany
Business
Cardiac Health:
Strict Guidelines for Pilots
In aeromedicine, bicycle ergometrics is
recognized as the essential stress test
for the health and fitness of pilots. With
respect to CAD, however, ergometrics do
not enable diagnosis until a stage that
shows changes in the electrocardiogram
(ECG) due to ischemia. Yet before the coronary blood flow becomes insufficient,
the stenosis diameter has to reach 50 %.
This means that ergometrics are of significant value for assessing patients at risk.
However, during routine screening of
young, asymptomatic patients with a low
coronary risk score like Framingham and
PROCAM Score, as is the case of most pilots, this method has a coronary heart
Effective Cooperation
in Cardiac CT
For this reason, the German Air Force
Institute of Aviation Medicine looked for
a suitable cooperation partner in diagnostic cardiology and high-resolution cardiac CT, and found that partner in the
German Heart Center in Munich (DHM).
The DHM is one of the leading cardiac
centers in Europe, and was one of the
first facilities to use MSCT technology on
the heart. The center has been equipped
with state-of-the-art CT scanners from
Siemens since 2002. The first MSCT system that the center used was SOMATOM
27
Business
greater certainty.
From a cardiological perspective, Hausleiter particularly stresses the advantages
of CTA as a noninvasive method to identify
plaque-accumulation in the coronary
arteries. Due to the high spatial and temporal resolution of CTA imaging, we can
show calcified as well as noncalcified
plaque. During plaque rupture, blood clots
occur which can consequently cause a
heart attack. Therefore, Hausleiter assumes that these deposits especially the
noncalcified will, in the future, be increasingly considered for the diagnosis of
arteriosclerosis in asymptomatic patients
with low to intermediate risk to suffer
from CAD like the pilots.
Reliable Diagnosis
in Asymptomatic Pilots
Since 2003, Wonhas and his colleagues
have been using MSCT in aeromedical
assessments with the support of DHM. As
in the past, they routinely perform ergometrics at the Institute of Aviation Medicine once annually as a screening method.
Now, however, if changes are noted in
the ECGs and ergometrics when compared
to those from the previous year for example, a new, higher-grade arrhythmia or
new ST segment changes the physicians authorize additional, noninvasive
examinations. This means that a transthoracal echocardiogram (TTE) is performed
Business
1A
1B
1C
1D
ber that Wonhas sent to us to be examined in 2003 and 2004 had a relatively
high hit rate. The subsequent procedure
confirmed that the approach we are using makes sense.
International Recognition in
Aeromedicine
Based on the results presented by Wonhas
and colleagues, the German Armed Forces
have since recognized CTA with MSCT as
the diagnostic procedure for their flying
service, and use it as routine. The Federal
Office for Civil Aeronautics, the highest
monitoring agency for aviation in Germany, has also accepted this method because of its high negative predictive value.
Internationally, NATO (North Atlantic
1E
Armed Forces or civilian airline will continue to benefit from his expertise. As a result, our method makes a lot of sense.
29
Case 1
Heterotopic Heart Transplant With
Arrhythmic Heart Rate of 45 125 bpm1,2
and Post-Surgical Control with Cardiac CT
By Shu-Hsun Chu, MD, Cardiovascular Center, Far Eastern Memorial Hospital, Taipei, Taiwan
HISTORY
A 52-year-old man suffered for two years
from dyspnea on exertion and chest
tightness. Because progressive symptoms
failed to respond to medical treatment,
the patient was admitted for heart transplantation evaluation. In April 2001, a
in the ambulance. When the donor arrived at the hospital, his blood pressure
was 60/30 mm Hg, and heart rate 36 bpm.
An immediate sternotomy revealed that
the heart was already arrested, distended
and cyanotic. The donor was soon put on
1
1 VRT display shows
the heterotopic
transplanted heart
on the patients
right side and the
native heart on
the left.
3 Maximum Intensity
Projection (MIP) image
shows the artifacts
free coronary arteries
of the native heart
(arrow heads) and the
right coronary artery
of the transplanted
heart (arrow).
EXAMINATION PROTOCOL
Scanner
SOMATOM Definition
Scan area
Scan length
205 mm
Scan time
16.3 s
Scan direction
Cranio-caudal
Heart rate
kV
120 kV
Effective mAs
400 mAs/rot
Rotation time
0.33 s
Temporal resolution
HR independent 83 msec
Slice collimation
0.6 mm
Spatial resolution
0.33 mm
Slice width
0.75 mm
Pitch
0.22
Reconstruction increment
0.4 mm
Kernel
B26
References
1 Cp. Chiu KM, Lin TY, Chu SH. Successful Heterotopic Heart Transplantation after Cardiopulmonary Bypass
Rescue of Arrested Donor Heart. Transplantation Proceedings 2006; 38: 15141515.
2 Cp. Chiu KM, Lin TY, Li SJ, Chan CY, Chu SH. Hybrid Pulmonary Artery Conduit Angioplasty for Heterotopic
Heart Transplantation. Transplantation Proceedings 2006; 38: 15381540.
31
Case 2
Reliable In-Stent Lumen Visualization
With Dual Source CT Coronary Angiography
By Annick C. Weustink, MD, and Nico R. Mollet, MD, PhD,
Departments of Radiology and Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
HISTORY
A 58-year-old man with a history of hypertension and hypercholesterolemia was
admitted to the hospital with symptoms
of suspected stable angina pectoris.
The patient was referred to conventional
coronary angiography after a positive
exercise-ECG test. Conventional angiography showed significant stenoses at the
level of the proximal right coronary artery
(RCA) and the proximal left anterior descending coronary artery (LAD). Percutaneous intervention was undertaken and
one bare-metal stent in the RCA and two
overlapping bare-metal stents in the LAD
were successfully implanted. The patient
was referred to follow-up CT coronary
angiography after 18 months.
DIAGNOSIS
The patient was scanned on a Dual
Source CT (DSCT) scanner. Nitroglycerine
was administered prior to the CT scan;
however, the patient did not receive prescan beta-blockers. The patient had a
heart rate of 76 beats/minute during the
CT scan. DSCT coronary angiography was
able to reliably rule out the presence of
in-stent restenosis in both the RCA and
LAD stents.
COMMENTS
The SOMATOM Definition CT scanner
uses two X-ray sources and two detectors
at the same time. This is one of the important features for cardiac CT scanning. It
allows scanning of the heart with a heart-
EXAMINATION PROTOCOL
Scanner
SOMATOM Definition
Scan area
Heart
Scan length
103 mm
Scan time
7,3 sec
Scan direction
Caudo-cranial
Heart rate
76 bpm
kV
120 kV
mAs / Rot
400 mAs/rot
Rotation time
0.33 sec
Temporal resolution
HR independent 83 msec
Slice collimation
0.6 mm
Spatial resolution
0.33 mm
Pitch
0.32
0.75 mm
Increment
0.4 mm
CTDIvol
45,31 mGy
Kernel
B46f
90 ml
Flow rate
5,5 ml/s
Bolus tracking
On
1 Volume Rendered CT image showing the stents in the proximal-to-mid LAD and the mid part of the RCA.
2
2 3 Curved multiplanar CT images showing excellent visualization of the in-stent lumen of both the RCA
(Fig. 2) and LAD (Fig. 3) stents, thereby reliably ruling out the presence of in-stent restenosis.
33
Case 3
SOMATOM Definition Abdominal CTA
With Direct Dual Energy Bone Subtraction
By Alec J. Megibow MD, MPH, FACR and Johnny Vlahos, MD, Department of Radiology, NYU Medical Center, New York, USA
HISTORY
DIAGNOSIS
COMMENTS
A 75-year-old man was referred for presurgical MDCT evaluation of a known abdominal aortic aneurysm that had been
detected on screening abdominal ultrasound. A contrast enhanced CTA scan of
the abdomen was performed on the
SOMATOM Definition.
The acquisition parameters allowed precise localization of the origin of the aneurysm with respect to the renal arteries
and allowed for necessary measurements
of the neck of the aneurysm, the distance
from the renal arteries to the aortic bifurcation and to each common iliac bifurcation to be calculated, and the adequacy of
the run-off to the lower extremities to be
assessed. Finally, a small accessory
renal artery supplying the upper pole of
the right kidney was detected. Based on
this single study, the patient was considered a candidate for endovascular repair.
1
1 Precise visualization of the abdominal
aneurysm and their relations to
skeletal landmarks is possible with
the SOMATOM Denition.
EXAMINATION PROTOCOL
Additionally, critical small vessels such as
an accessory right upper pole renal artery
can be easily preserved. Using dual energy acquisitions, abdominal CTA segmentations can be performed, eliminating
manual post processing steps and thereby significantly reducing reporting time.
The degree of bone segmentation is at
the discretion of the radiologist; in this
example, the dual display allows the vascular map to be superimposed over the
skeletal structures. This aids the surgeon
in establishing landmarks that can aid in
the fluoroscopic based endovascular repair. The success of the bone removal is
illustrated in the MIP image (Fig. 2).
Scanner
SOMATOM Definition
Scan area
Abdominal CT Angiography
Scan length
410 mm
Scan time
12 sec
Scan direction
Caudo-cranial
kV
140 kV and 80 kV
Effective mAs
Rotation time
0.5 sec
Slice collimation
0.6 mm
Spatial resolution
0.33 mm
Slice width
2 mm
2 mm
Increment
1.5 mm
CTDIvol
10.7 mGy
Kernel
D20f
100 ml
Flow rate
4 ml/s
Bolus tracking
On
35
1
1 Follow-up of a
lung lesion. Growth
parameters are
generated at the
touch of a button.
A comprehensive results
table includes growth
parameter for all lesions
including doubling time
and tumor burden.
Courtesy of Marco Das, MD,
RWTH Aachen, Germany.
37
Case 4
Improved Evaluation and Follow-up
of Routine Diagnostic Oncology Exams
With syngo CT Oncology*
By Axel Kttner, MD, and Alexander Aplas, MD, Institute of Diagnostic Radiology, University of Erlangen-Nuremberg,
Erlangen, Germany
38
HISTORY
A 70-year-old man underwent a routine
follow-up CT exam at three months while
undergoing chemotherapy for malignant
melanoma. The software facilitates 3D
lesion segmentation and delivers standard lesion parameters: RECIST, WHO and
volume (Fig. 1). The automated lesion
EXAMINATION PROTOCOL
Scanner
matching marked previously reported lesions in the follow-up exam and the percental change in lesion parameters were
automatically calculated and sent to the
DICOM SR (Fig. 2). Doubling time and
tumor burden are also automatically calculated and as a useful eye catcher, tumor burden is highlighted in red, demonstrating significant growth of marked
Scan area
Thorax-Abdomen
Pitch
1.2
Scan length
686 mm
Reconstruction increment
0.8 mm
B4If
Scan time
15 s
Kernel
Scan direction
cranio-caudal
Contrast
kV
120 kV
Volume
100 ml
Effective mAs
150 mAs
Flow rate
3 ml / s
Rotation time
0.5 s
Postprocessing
Slice collimation
0.6 mm
syngo CT Oncology
Spatial resolution
0.33 mm
Slice width
1 mm
2
2 Automated lesion
matching identied the
previously identied
lesions in the follow-up
exam. The percental
change in basic tumor
parameters were automatically calcu-lated and
presented in the report.
39
Case 5
Utilizing the SOMATOM Emotion 16-slice
configuration for a Neuro DSA CTA Evaluation
of a Suspected PICA Aneurysm
By Adam J. Davis, MD, Hartsdale Imaging, Hartsdale, New York, USA
HISTORY
EXAMINATION PROTOCOL
Scanner
Scan area
Head
Slice collimation
0.6 mm
Scan length
138 mm
Slice width
0.75 mm
Scan time
10 s
Pitch
0.9
Scan direction
Caudo Cranial
Reconstruction increment
0.5mm
kV
120 kV
Kernel
H20 / H70
Effective mAs
176 mAs
Postprocessing
Rotation time
0.6 s
2 A more magnified MRA image utilizing clip planes isolates the left PICA. The best view orientation gives a
hint as to the true nature of the finding, although
the vessel course and origin are not clearly defined
on the MRA, and the outpouching cannot be entirely
eliminated in any view. The study remains non-diagnostic.
41
Case 6
Dual Source CT Triple Rule Out
Without Beta-Blocker
By Christoph R. Becker, MD, Section Chief, Computed Tomography
Department of Clinical Radiology, University Hospital of Munich-Grosshadern, Munich, Germany
HISTORY
A 60-year-old male patient, suffering
from a severe chest pain, arrived in the
Department of Radiology of the University Hospital in Munich, Grohadern. In
order to rule out the major causes of
chest pain (such as myocardial infarction,
pulmonary embolism, and aortic dissection) in a one stop diagnosis, the patient
was transferred directly to the CT department. A gated scan of chest was performed on the SOMATOM Definition,
without the use of beta-blockers.
the major causes of chest pain in a onestop diagnosis without the compromise
of beta-blockers. Now we can accurately
triage chest-pain patients within 10 minutes after presenting to our department.
With the SOMATOM Definition, a special
Chest Pain protocol can be used, applying reduced dose to the patient through
the combination of two scan ranges,
EXAMINATION PROTOCOL
DIAGNOSIS
The gated chest pain protocol of the
SOMATOM Definition enabled the immediate visualization of the entire thorax
as well as the coronary arteries without
motion artifacts. As shown in the images
below, a Stanford type B aortic dissection
was identified. The patient was referred
to Vascular Surgery Department for stent
placement.
COMMENTS
Chest pain is one of the most common
and complex symptoms for which patients
seek medical care. With standard diagnostic evaluation, patients with chest pain
undergo multiple serial tests and long
observation periods. This ties up staff as
well as space for up to a whole day. Dual
Source CT enables us to quickly rule out
Scanner
SOMATOM Definition
Scan area
Chest
Scan length
285 mm
Scan time
16 sec
Scan direction
Cranio-caudal
Heart rate
6570 bpm
kV
120 kV
mAs/Rot
320 mAs/Rot
Rotation time
0.33 sec
Temporal resolution
HR independent 83 msec
Slice collimation
0.6 mm
Spatial resolution
0.33 mm
Slice width
0.6 mm
Pitch
0.30
Reconstruction increment
0.75
Effective dose
9,2 mSv
Kernel
B26
Volume
80 ml
Flow rate
4,5 ml/s
Start delay
CareBolus+5s
43
Case 7
SOMATOM Definition: New Insight Into
Kidney Stone Detection and Characterization
With Spiral Dual Energy
By Anno Graser, MD, Thorsten Johnson, MD, and Christoph R. Becker, MD,
Department of Clinical Radiology, University Hospital of Munich-Grosshadern, Munich, Germany
HISTORY
DIAGNOSIS
A 34-year-old male (Fig. 1A) and a 55year-old male with latent gout (Fig. 1B)
separately visited our Acute Care unit
with flank pain. They had been presented after multiple occurrence of nephrolithiasis and urolithiasis. Both patients
were referred to our Dual Source CT
for evaluation of abdominal stones.
Contrast enhanced CTA scans of the
abdomen were performed on the
SOMATOM Definition using spiral dual
energy.
The dual energy acquisition allowed precise localization of the kidney stones.
In addition Patient B showed dilatation
of the right ureter proximal to the calculus. Moreover, dual energy analysis
permitted a characterization of the
scanned tissue or material. The red colorcoding of the urethral stone shown in
Patient A (Fig. 2A) indicates an uric acid
stone. In contrast, the vertebrae can be
identified as blue-colored structure. After
Dual Energy CT, we could transfer the pa-
1A
tient for drug therapy treatment. Subsequently, the stone passed spontaneously
and was analysed. The analysis confirmed
that the concrement consisted of 100%
uric acid.
The blue color-code shown in Patient B
(Fig. 2B) characterizes a calcium oxalate
stone. Based on this dual energy study,
the stone was removed in an interventional procedure. The lab analysis of the
removed stone confirmed the calcium
oxalate composition.
1B
1 Using conventional MDCT imaging, urethral stones (arrows) can clearly be visualized in both patients
(Fig. 1A and 1B). However, they cannot be characterized based on a conventional CT single source image.
44
EXAMINATION PROTOCOL
Scanner
SOMATOM Definition
SOMATOM Definition
Patient
Patient A
Patient B
Scan area
Abdominal Scan
Abdominal Scan
Scan length
377 mm
215 mm
25 sec
Scan time
44 sec
Scan direction
Craniocaudal
Craniocaudal
kV
140 kV and 80 kV
140 kV and 80 kV
Effective mAs
Rotation time
0.5 sec
0.5 sec
Slice collimation
0.6 mm
0.6 mm
Spatial resolution
0.33 mm
0.33 mm
Slice width
0.75 mm
0.75 mm
2.0 mm
2.0 mm
Increment
1.5 mm
1.5 mm
CTDIvol
18.07 mGy
15.4 mGy
Kernel
D30
D30
CareDose4D
on
on
COMMENTS
The majority of kidney stones can be
grouped as either calcium oxalate stones
(80%) or uric acid material (9%). Conventional CT imaging helps to locate and visualize kidney stones. However, a fast and
secure characterization is not possible.
Dual energy scanning overcomes this limi-
2A
2B
2B
ize, isolate, and distinguish the imaged tissue and material as shown in Fig. 2A and
2B. In our case, dual energy scanning offers new insights into the characterization
of urolitis. A corresponding treatment decision can be reached immediately, avoiding
unnecessary hospitalization.
45
Science
Dual Source CT
Detecting Coronary Atherosclerosis
by Dual Source Computed Tomography Images
With Color Maps
By Sei Komatsu1,2, Dieter Ropers1, Axel Kttner3, Ulrike Ropers1, Martin Wechsel1, Tobias Pflederer1, Alexander Kuhlmann1,
Katharina Anders3, Werner Bautz3, Werner G. Daniel1, Atsushi Hirayama2, Kazuhisa Kodama2, Stephan Achenbach1
Department of Internal Medicine 2, University of Erlangen-Nuremberg, Erlangen, Germany
Cardiovascular Division, Osaka Police Hospital, Osaka, Japan
3
Institute of Diagnostic Radiology, University of Erlangen-Nuremberg, Erlangen, Germany
Color-coded Coronary
Analysis
Recently, Dual Source computed tomography (DSCT) has become available. Due
to its high temporal resolution, coronary
arteries can now be visualized with reduced motion artifacts. Spatial resolution
of DSCT reaches 0.33 mm allowing more
precise visualization of the coronary
arteries. However, the grade of stenosis
does not predict an acute coronary syndrome 1 due to positive remodeling (compensatory enlargement of lumen area 2).
1A
1C
1A
1A Cross-sectional image of
vessel without plaque (Left).
Plaque Map (Right). Concentric graduation from red to
yellow spreads outside the
vessel.
50
0
200
350*
100
White
68
136
273
341
409
*Maximum CT number of
Contrast Media
1B
205
500
350
300
250
200
150
70
(HU)
500
350
300
250
200
150
50
25
0
-25
-50
70
50
25
~ 0a
~ -25
~ -50
3A
4A
4B
5A
5B
b
c
d
LP
lipid pool
3B
4C
5C
5D
FP
LP
branch
CP
LP+FP
4 An example of non-calcified
plaque. Fig. 4A: Curved MPR.
Fig. 4B: Color-coded curved MPR.
Fig. 4C: Color-coded cross-sectional image at Q1 (Fig. 4B dot).
100200
200500
050
50100
100200
200500
100200
200350
Interpretation of Coronary
Plaque with Color Analysis
A typical vessel without plaque is demonstrated in Fig. 3A. Areas of orange, light
green and green are demonstrated as
concentric circles (Fig. 3B). A typical
example of lipid-rich plaque is shown in
Fig. 4. The curved MPR of left anterior
descending coronary artery shows a noncalcified plaque with positive remodelling
in the proximal segment of the coronary
artery (Fig. 4A). Fig. 4B and 4C, respectively, demonstrate color maps of the
curved MPR and cross-sectional image at
the level of the atherosclerotic lesion.
Green, which ranges from 0 to 50 HU,
and light-green, which ranges from 50 to
100 HU, are dominant. This suggests that
the plaque consists of predominantly
lipid-rich components.
We also show another example of various
plaque types. The left anterior descending artery of an asymptomatic patient
was analyzed (Fig. 5). Cross-sectional images at the points b, c and d in Fig. 5A
are shown as Fig. 5B, Fig. 5C, and Fig. 5D,
respectively. In Fig. 5B, lipid-rich plaque
as light green is present at 36 oclock
position of the vessel. In the vessel, area
less than 0 HU (transparent) is found at
56 oclock, suggesting a lipid-pool.
Fig. 5C demonstrates calcified plaque in
white. Fig. 5D shows mixed plaque in light
green and green, suggesting a mixture
of fibrous and lipid-rich plaque.
References
1 Ambrose JA et al. J Am Coll Cardiol 1988: 12(1):
5662.
2 Glagov S et al. N Engl J Med. 1987: 316(22):
13715.
3 Schroeder S et al. J Am Coll Cardiol. 2001: 37(5):
14305.
4 Achenbach S et al. Circulation. 2004: 109(1): 147.
5 Komatsu S et al. Circ J 2005: 69(1): 727.
6 Komatsu S et al. Int J Cardiol 2007: 117(3): 423-9.
7 Komatsu S et al. Vascular Disease Prevention 2006:
3(4): 319325.
8 Komatsu S et al. Int J Cardiol 2007: 117(3):423-9.
9 syngo Circulation: The Next generation.
SOMATOM Session 18. 89, 2006.
47
Science
Implications for
Contrast Media Delivery
Multi-detector row computed tomography
(MDCT) has substantially improved over
the past years with faster gantry rotation,
more powerful X-ray tubes, dedicated interpolation algorithms and last but not
least the introduction of Dual Source
CT (DSCT) with the SOMATOM Definition
(Siemens Medical Solutions, Forchheim,
Germany) in 2006.
As one of the consequences of this technical evolution, CT angiography (CTA)
of the coronaries has become an established technique for minimally invasive
EXAMINATION PROTOCOL
Scanner
SOMATOM Definition
Collimation
2 x 64 [2 x 32] x 0.6 mm
Pitch
kVp
120
mAsrot
400*
Rotation time
330 ms
Slice thicknesseff
0.75 mm
Increment
0.4 mm
Kernel
Amount
Saline chaser
Bolus timing
Scan parameters, reconstruction parameters and contrast injection parameters for a suggested cardiac scan protocol
with the SOMATOM Definition (Siemens).
* In addition, a dose modulation concept is recommended (e.g. Care Dose 4D; ECG-pulsing).
** x = (Scan duration + 10%); Clinical example: Contrast material will be injected with 2g iodine/s , followed by a 6s injection at 1.5g iodine/s, if the scan lasts 10s.
The latter can be calculated from the overall injection duration; e.g. overall scan duration +10% = 11s, minus 5s for the first (fixed) injection phase. Therefore,
using iopromide 300, 33 mL will be injected with 6.6 mL/s followed by 30 mL iopromide 300 with 5 mL/s.
Science
1A
1B
1 Male patient with intermittent atypical chest pain and an increased cardio-vascular risk profile. He has a history of smoking (30 pack years)
and moderate hyperlipidaemia. Contrast-enhanced DSCT of the coronary arteries was performed to rule out coronary artery disease.
Fig. 1A: 3D-VRT (Volume Rendering Technique) shows the left coronary artery without pathological findings.
Fig. 1B: Curved multiplanar reformat (MPR) of the right coronary artery shows an eccentric, non-calcified plaque without relevant lumen
narrowing (arrows).
49
Science
2A
2B
Science
Scan Timing
In any case, using empiric scan delays
cannot be recommended with modern
MDCT or DSCT. With 16- (or more) slice
MDCT, the start delay of a CTA has to be
chosen individually. In the clinical setting,
two modes are currently available for optimal enhancement after intravenous contrast delivery1,4: Automated bolus tracking
provides a sufficiently robust, easy to use
method. A pre-monitoring scan is performed at the upper level of the heart using a low-dose scanning technique (120
kVp; 20 mAs (effective)). A region-of-interest is placed in the ascending aorta and
attenuation values (in Hounsfield units;
HU) are continuously measured during
the contrast injection. When the trigger
threshold level (e.g. 140 HU) is reached,
an automated start of the spiral scan is
initialized.
Alternatively, a test-bolus methodology
can be applied. A small additional volume
of contrast material (usually 15 ml 20
ml) is injected at the same flow rates as
used for the contrast enhanced scan protocol. By repeat acquisition of serial scans
(monitoring scans every 2 s from approximately 10 s 40 s; usually at the level of
the heart), individual flow dynamics can
be assessed more precisely: From the enhancement over time within the target
vessel lumen, the time-to-peak enhancement can be calculated. The latter is chosen as start delay. The test-bolus data also
allows estimation of the bolus geo-metry
with a given amount of contrast material
at a selected flow rate. Moreover, this
technique allows determination of cardiac
output from the contrast enhancement
curve and therefore constitutes a more in-
Saline Chaser
The use of double-power injectors has
been advocated for automated saline
flushing at the injection site, especially for
CTA examinations. Otherwise, approximately 20 ml 30 ml of contrast material
will be retained in the dead space between the brachial vein and the superior
vena cava. In consequence, performing
saline flush improves arterial enhancement and reduces the amount of contrast
needed for a diagnostic examination. This
has a positive impact on patient safety
and costs.6
In summary, optimal contrast bolus
shaping with special emphasis on bolus
design and timing is a key issue in modern
DSCT imaging of the coronary arteries. The
IDR is the most important factor for
achieving this goal and can be optimized
by adapting the flow rate of the injector to
the iodine concentration of the chosen
contrast medium. Typical IDRs lie between
1.5 g l/s and 2.0 g I/s. The test-bolus
methodology and automated bolus
tracking are widely used as an adjunct to
the regular CTA scan and help to increase
the robustness of this examination
method.
1 Cademartiri F., van der Lugt A, Luccichenti G,
Pavone P, Krestin GP. Parameters affecting bolus
geometry in CTA: A review. J Comput Assist Tomogr
2002; 26: 598 607.
2 Bae KT. Peak contrast enhancement in CT and MR
angiography: When does it occur and why? Pharmacokinetic study in a porcine model. Radiology 2003;
227: 809 816
3 Fleischmann D. High-concentration contrast media
in MDCT angiography: Principles and rationale.
Eur Radiol 2003; 13 Suppl 3: N39 N43
4 Bae KT. Test-bolus versus bolus-tracking techniques
for CT angiographic timing. Radiology 2005; 236:
369 370.
5 Mahnken AH, Klotz E, Hennemuth A, Jung B, Koos
R, Wildberger JE, Gnther RW. Measurement of cardiac output from a test-bolus injection in multislice
computed tomography.
Eur Radiol 2003; 13: 2498 2504.
6 Schoellnast H, Tillich M, Deutschmann HA,
Deutschmann MJ, Fritz GA, Stessel U, Schaffler GJ,
Uggowitzer MM. Abdominal multidetector row computed tomography. Reduction of cost and contrast
material dose using saline flush. J Comp Assist
Tomogr 2003; 27: 847 853.
51
Science
Science
husband, in their function as priests, represented the important God, Aton. During
their rule, the royal couple often allowed
various portrayals of themselves with
their children.
Results and interpretations about the CTscan of Nefertitis bust will soon appear in
appropriate scientific publications.
Reference:
2 This image shows the plaster layer over the shoulder area of the
limestone sculpture of the queen.
53
Science
CT Coronary Angiography
Half-Scan vs. Multi-Segment
Reconstruction for Computed Tomography
Coronary Angiography
Considerations on the effects on image quality
By Stephan Achenbach, MD, Department of Internal Medicine 2, University of Erlangen-Nuremberg, Erlangen, Germany
Coronary artery visualization by multidetector row (or better, multi-slice) computed tomography (coronary CT angiography, coronary CTA) is rapidly entering
mainstream cardiology. High accuracies
have been reported for the detection
of coronary artery stenoses by 16- and
64-slice CT and especially a high negative
predictive value makes coronary CTA a
useful tool in the assessment of certain
patient populations with chest pain 1. In
a joint statement by several professional
societies, led by the American College of
Cardiology, the use of CT coronary angiography has been labeled an appropriate indication to rule out or establish the
presence of coronary artery stenoses in
several clinical situations 2.
Cardiac Motion
Rapid motion of the heart and coronary
arteries and ensuing impairment of image quality are the major problems that
may exist in CT coronary angiography. Insufficient image quality can lead to falsepositive or false-negative findings, with
the consequence of unnecessary further
testing in the first case and of missed
diagnoses in the latter. In order to avoid
artifacts caused by motion, two aspects
are important.
Firstly, with widely used single source
computed tomography systems it is
important to use data for image reconstruction that was acquired during a
cardiac phase of relatively little motion
of the coronary arteries.
Secondly, it is essential to limit data used
for image reconstruction to as short a
Multi-Segment Reconstruction
(Multi-Phase Reconstruction)
1. Variability of the
Cardiac Cycle
segment of the coronary cycle as possible. In order to reconstruct one cross-sectional image, data acquired from 180
of parallel data projections are necessary.
Most computed tomography systems contain one x-ray tube, so that one-half rotation of the gantry is necessary to acquire
data from 180.
Half-Scan Reconstruction
Science
1A
1B
1C
1D
1 Fig. 1A to Fig. 1C: Angiography image of a right coronary artery (RCA) and colored outline in three subsequent heartbeats, projected on top of each other (Fig. 1D), clearly showing that variations of the position of coronary arteries in each subsequent
1E
1F
1G
1H
55
Science
age of several, non-identical cardiac cycles. With higher true temporal resolution
of CT scanners using half-scan (or singlesegment) reconstruction, heart rate variations are not a limitation and motionfree imaging becomes possible (Fig 2).
2C
3C
Science
4A
4B
4C
4D
4E
4F
5. Examples
Multi-segment reconstruction may theoretically lead to shorter data windows used
for image reconstruction (compensated for
by using data from several consecutive cardiac cycles), but it does not in all cases
lead to elimination of motion artifact or
improved image quality. In fact, Magnetic
Resonance coronary angiography uses extensive averaging of heart beats in their
data acquisition and reconstruction process, but even though the theoretical resolution of magnetic resonance coronary artery imaging is below 0.5 mm, images
never reach the crispness and sharpness
seen in cardiac CT. This is the consequence
of blurring which is caused by the averaging of usually eight to 16 cardiac cycles.
4 Exclusion of an ectopic beat to avoid artifact in 64-slice CT. In the ECG trace, gray bars
indicate the times during which data is used for image reconstruction (Fig. 4A). Because
of the ectopic beat, one of these data windows is in systole (arrow). This leads to artifacts which can be seen in the CT images at the level of the mid to distal right coronary
artery (arrows, Figs. 4A and 4C). After exclusion of the data acquired during the ectopic
beat from image reconstruction in Fig. 4D (marked in blue), the right coronary artery is
sharply delineated (arrows, Figs. 4E and 4F).
57
Science
5A
5A
57-year-old female.
Heart rate 68/min.
Half-scan reconstruction yields good image quality of the
right coronary artery.
Multi-segment reconstruction at the same
cardiac phase (40 %
of cardiac cycle)
shows obvious motion artifact of the
right coronary artery
(right, arrow).
5B
73-year-old male.
Heart rate 72/min.
Half-scan reconstruction (left) yields
good image quality
of the right coronary
artery. Multi-segment reconstruction
at the same cardiac
phase (70 % of cardiac cycle) shows obvious motion artifact of
the right coronary artery (right, arrow).
5B
Summary
Even though multi-segment reconstruction, as compared to half-scan reconstruction, offers nominally shorter data
windows during each cardiac cycle used
for image reconstruction, the fact that
data from several cardiac cycles need to
References
1 Budoff MJ, Achenbach S, Blumenthal RS, et al.;
Circulation 2006; 114(16): 176191.
2 Hendel RC, Patel MR, Kramer CM, et al.;
J. Am. Coll. Cardiol. 2006; 48(7): 1475 97.
The E-logbook input fields are individually configurable to include what really
matters in the department. Parameters
that are already available within the
system (e.g. patient name, Patient ID,
dose values) will be transferred to the
E-Logbook automatically after completing
the examination. Other parameters can
then be typed in manually if desired. All
recorded examination data are saved to
a local database. Searching for a certain
59
www.siemens.com/
ct-cardiac-poster
www.siemens.com/
somatomeducate
Exclusively during this clinical workshop: The participants could evaluate more than 50 datasets.
61
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