Siemens Computed Tomography Somatom Sessions 34 01959749

SOMATOM Sessions
Answers for life in Computed Tomography
December 2014
Issue 34
TwinBeam Brings Single Source

Dual Energy to Clinical Routine
Page 06
News
Business
Clinical Results
Science
Dose Inspection
a Reason to be Proud
Page 18
Flexible Flash for

a Forward-Thinking
Hospital
Page 40
Diagnosis of a Complex
Pediatric CHD using
ECG-Triggered Adaptive
Sequential Cardiac CT
Page 66
SOMATOM Force from

Translational Research to
Clinical Routine
Page 72
Editorial
The functions of the new

SOMATOM Definition Edge
will take high-end procedures
to clinical routine in many
hospitals.
Professor Michael Lell, MD,
Senior Radiologist at University Hospital
Erlangen-Nuremberg in Germany
Cover page:
A control study of a liver metastasis after microwave ablation treatment
a normal CT image with contrast (left), a monoenergetic image at 50keV
(middle), and a fused VNC/iodine image (right) show a hypodense lesion in
the liver and in the right kidney. The image contrast is greatly increased by
monoenergetic imaging. And both lesions show no significant enhancement
in the fused VNC/iodine image, therefore, residual tumor tissue can be
confidently excluded and a kidney cyst can be diagnosed.
Courtesy of University Hospital Erlangen-Nuremberg, Erlangen, Germany
2 SOMATOM Sessions | December 2014 | www.siemens.com/SOMATOM-Sessions
Editorial
Dear Reader,
It is my great pleasure and privilege to
present our 34th SOMATOM Sessions
magazine.
As this is my first editorial for this prestigious magazine, I think a short introduction is warranted. I have been with
Siemens for 31 years now and with
Healthcare for the past 15 years. From
2003 until 2012, I was head of the
Healthcare for India and the neighboring countries. Since October 2012,
Ihave been based at CR headquarters
leading global sales. As of August 2014,
I have additionally been in charge of
global marketing.
To me, SOMATOM Sessions is really a
magazine by our users and for our users.
This is your platform to share your
experiences and knowledge with fellow
clinicians worldwide. Of course, we
also seize the opportunity to present our
exciting new technological developments. It is extremely encouraging to
see the enthusiastic participation from
many different parts of the world
Europe/Americas/Asia from research
institutes to stand-alone imaging centers from users of SOMATOM Force
to SOMATOM Scope.
In our cover story, we are delighted to
bring you details of our latest innovation TwinBeam Dual Energy1 our
pathbreaking Dual Energy solution for
SOMATOM Definition Edge and
SOMATOM Definition AS+. About 10
years back, we introduced the Dual
Energy solution to our Dual Source CT
scanners and, since then, have been
constantly setting higher standards and
developing new clinical applications
using the Dual Energy concept. With
TwinBeam Dual Energy, we are now

enabling many of these leading
applications on our single source CT
scanners, too. With our unique Dual
Energy solutions also available for
single source CT systems, we are confident that Dual Energy scans will
soon become clinical routine around
the world.
Our recently introduced SOMATOM
Force with over 35 installations and
over 50,000 scans already performed
across the globe continues to create enormous excitement. We are
extremely proud to feature a range
ofcontributions reporting on initial
experiences with our most powerful
CT scanner.
In their article Leading the Way
(page 14), radiologists Dr. Francesca
Pugliese and Dr. Gudrun Feuchtner
highlight how they put Dual Source
technology to its best use when it
comes to functional imaging of the
heart.
Doctors Gulin Bu and Ying Miao from
China share an interesting case (Case
10) in which they successfully imaged
an 18-month-old child, with a heart
rate ranging from 117125 bpm
using our SOMATOM Definition AS+
at 80 kV.
We also report how Dr. Laurent
Collignon of CHR La Citadelle in Lige,
Belgium, was surprised to receive
acall from the local radiation dose
monitoring agency AV Controlatom.
He was thrilled to hear from them
that their records show his hospital
as among those with the lowest radiation dose in the country. This is made
possible with their newly installed

SOMATOM Perspective scanners. You
can read more about this on pages 18
to 21.
On page 30, you will find an interesting article by Dr. Jos Venncio from
Lisbon, Portugal, explaining how
impressed he is with the installation
of our latest 16-slice CT scanner,
SOMATOM Scope.
These are just a few of the interesting insights and valuable reports on
real clinical improvements that you
can find in this edition.
As I mentioned earlier, this is a magazine for you and by you. We want to
encourage you to share your unique
experiences with us so that we can
help to spread them with the clinical
community worldwide. Naturally,
weare also very keen to receive feedback on which information is most
useful for you and any suggestions
for further improvements.
With warm regards,
Raghavan Dhandapany,
Vice President CT Marketing
and Sales
1
TwinBeam Dual Energy is currently pending

510(k) clearance and is not yet comercially
available in the United States.
SOMATOM Sessions | December 2014 | www.siemens.com/SOMATOM-Sessions 3
Contents
December 2014
Contents
06
Cover Story
TwinBeam Brings Single Source Dual Energy to Clinical Routine
News
Clinical Results
12 TwinBeam Dual Energy:

New Benchmark in SingleSource Dual Energy
14 Leading the Way in Stress Myocardial CT Perfusion
Imaging
18 Dose Inspection a Reason to be Proud
22 teamplay Connecting the Imaging World
24 Intraoperative CT Better Views for Neurosurgeons
28 Stellar Detector: A Slovakian Success Story in
Coronary Artery Surgery
30 SOMATOM Scope: Cost-Saving Quality
32 Metal Artifact Reduction in a Trauma Setting
34 Cardiac CT: As Simple as That
38 SOMATOM Force: Initial Research Results Testify
toClinical Strength
Cardiovascular
48 Discovery of a Type II Endoleak after EVAR in
a Patient with Renal Insufficiency using Dynamic
4D CT Angiography
50 Low Dose Coronary CT Angiography using ECG-Gated
Retrospective Spiral CT
52 Diagnosing a Bilateral Iliac Artery Stenosis using
Runoff CT Angiography
54 Comprehensive Cardiac CT Study for
Simultaneous Evaluation of the Coronary Arteries
and the Myocardium
Business
40 Flexible Flash for a Forward-Thinking Hospital
44 SAFIRE by the Numbers
46 Balancing Clinical and Business Demands
Oncology
56 CT Volume Perfusion Imaging in a Case of Suspected
Pancreatic Cancer
Acute Care
58 Whole-Body CTA with Reduced Radiation Dose and
only 20 mL of Contrast Media
60 Identification of Posterior Cruciate Ligament Avulsion
using Dual Energy CT
62 Retained Endoscopy Capsule: Metal Artifact Reduction
with Monoenergetic Imaging
Contents
18
40
66
72
Customer Excellence
64 Dual Energy CT Assessment of Amiodarone
InducedLiver Damage
Pediatrics
66 Diagnosis of a Complex Pediatric CHD using
ECG-Triggered Adaptive Sequential Cardiac CT
68 Persistent Bilateral Patent Ductus Arteriosus and
Confluent Pulmonary Arteries a Rare Congenital
Cardiac Malformation
70 Evaluation of Williams-Beuren Syndrome in a Twomonth-old Child using a Single Rotation Scan Mode
84 CT Physics Workshop Focus on Radiation Dose

Optimization
84 Siemens Educational Platform Study Flexibly:
When and Where it Suits You Best
85 Clinical Workshops 2015
86 Upcoming Events & Congresses 2014/2015
87 Tips & Tricks: Editing Bone Removal Results in
Dual Energy
88 Subscriptions
89 Imprint
Science
72 SOMATOM Force from Translational Research
to Clinical Routine
77 FAST Spine and FAST Planning
78 Leading Concept in High-End CT Imaging
80 Dual Energy: Spectral CT More Precisely Defined
Professor Michael Lell, MD, senior radiologist at University Hospital Erlangen-Nuremberg in Germany is convinced that establishing the new
SOMATOM Definition Edge functionalities will transform routine procedures in his maximum-care hospital. TwinBeam Dual Energy brings to his
everyday clinical practice those clinical applications that have been well established in Dual Source systems. Iterative metal artifact reduction (iMAR)
enables great outcomes for patients with metallic implants undergoing cancer treatment. And ADMIRE offers further potential to reduce X-ray dose.
TwinBeam
Brings Single Source Dual

Energy to Clinical Routine
Siemens presented the new SOMATOM Definition Edge with TwinBeam Dual
Energy technology at the 2014 RSNA. With TwinBeam Dual Energy technology,
SOMATOM Definition Edge acquires both X-ray spectrums simultaneously.
Further functions include an algorithm for reducing metal artifacts within one
single scan and ADMIRE, the latest generation of iterative reconstruction for
dose reduction.
Text: Hildegard Kaulen, PhD, Photos: Alex Pusch
Cover Story
University Hospital Erlangen-Nuremberg

is a maximum-care facility that covers
the entire spectrum of clinical disciplines. It also receives referrals of complicated cases from the surrounding
area. Professor Michael Lell, MD, is a
senior radiologist and has been working in Erlangen for 17 years. He explains
the challenges maximum-care facilities
are faced with on a daily basis. Questions such as: Isa lesion benign or
malignant? Can the lesion be treated
with image-guided therapy? How is a
tumor responding to treatment? Can
we predict the outcome of treatment
at an early stage? What is the impact
of occlusion following pulmonary
embolism? Since contrast-enhanced
CT scans provide the most information,
additional non-contrast CT scans are
largely avoided to reduce radiation
exposure. For some indications, the
addition of non-contrast scans is
required for diagnosis or advanced
post-processing. If both scans are performed in succession, we need to
accept that the data will not be registered 100%, says Lell. With two consecutive image stacks, the volumes
will never be perfectly correlated
because the respiratory depth is not
identical or the patient may have been
moved to a slightly different position.
The new SOMATOM Definition Edge CT
helps to avoid exactly these types of
issues. It enables a contrast-enhanced
image and a virtual non-contrast image
to be obtained from Dual Energy data
recorded at the same time. The challenge of precise registration can be
consigned to history since only one
scan is required to calculate the data.
Siemens has developed a new technical
solution for this purpose: TwinBeam
Dual Energy1. In the new SOMATOM
Definition Edge, a new tube design
splits the X-ray beam emitted from the
X-ray source into two different energy
spectra before it reaches the patient.
The simultaneous acquisition of the
Dual Energy volumes removes the need
for complex and time-consuming registration procedures of the non-contrast-enhanced scan and the contrast
enhanced scan, says Lell, explaining
the new technology. The radiologist
evaluated these functions in the sur
gical department, right next to the
resuscitation room.
1A
1B
A control study of a liver metastasis after microwave ablation

treatment A monoenergetic image at 50keV (Fig. 1A) and a fused
VNC/iodine image (Fig. 1B) show a hypodense lesion in the liver
and in the right kidney. The image contrast is greatly increased by
monoenergetic imaging. And both lesions show no significant
enhancement in the fused VNC/iodine image, therefore, residual
tumor tissue can be confidently excluded and a kidney cyst can be
diagnosed.
Courtesy of University Erlangen-Nuremberg, Erlangen, Germany
Cover Story
TwinBeam Dual Energy is now bringing advanced clinical Dual Energy

applications to single source CT scanners and into everyday clinical practice, says Lell. This device is therefore an extremely interesting prospect
for many institutions looking to expand
their diagnostic portfolio. The functions in the new SOMATOM Definition
Edge can also be used with the
SOMATOM Definition AS+ and are
therefore available to a broad section

of the installed base as an upgrade
opportunity.
Virtual non-contrast images

of all organs
The radiologist, who began his medical career in surgery, appreciates the
ever-increasing importance of his
discipline. Today, radiologists can get
more and more clinical information
2A
from the images. Every morning,

atthe interdisciplinary tumor board,
wepresent the cases, Lell explains.
Itis no longer enough to simply say
whether or not a lesion is likely to be
malignant. We have to provide more
information. Iodine uptake is con
sidered as a surrogate parameter of
tumor perfusion and viability. This
information can be derived from the
TwinBeam Dual Energy data, which
also indicates whether a particular
therapy is effective before shrinkage
occurs. New biological cancer therapies
are very expensive and cost-effectiveness is of high importance. Patients
need to be triaged into those who will
profit from such a therapy and those
who will not. TwinBeam Dual Energy
will enhance the decision criteria in
addition to traditional morphological
information.
The software in the new SOMATOM
Definition Edge calculates the virtual
non-contrast image for all organs, even
the lungs. Since pulmonary vessels are
obstructed in a pulmonary embolism
(PE), less contrast medium will be delivered to the affected lobe or segment.
Iodine maps can be derived from the
DE data to provide information about
the residual perfusion of the lungs.
The images can also be reconstructed
directly at the CT scanner. We need
the images right away, says Lell, commenting on the workflow requirements in his day-to-day clinical work.
In the emergency department, for
example, every second counts.
2B
A follow up study after a cardiac pump implantation two VRT

images show that the severe artifacts caused by the implanted
pump (Fig. 2A) are significantly reduced by iMAR reconstruction
technique, and the surrounding anatomical structures can be
clearly visualized (Fig. 2B).
The innovative functions of the new

SOMATOM Definition Edge also include
FAST 3D Align. This algorithm sym
metrically aligns the acquired volume
during the reconstruction process if
the images are not straight. Seriously
injured or comatose patients often
cannot be positioned in the optimal
manner, says Lell. The trauma and
pain often distort their posture. With
FAST 3D Align, the physician receives
a symmetrical image of the findings
for all areas of the body where the
anatomy is the same on both sides.
Cover Story
Images with metal artifacts

can conceal pathologies.
These artifacts cause particular difficulties when examining the mouth or pelvis.
iMAR now tackles this challenge.
Professor Michael Lell, MD,
Senior Radiologist, University Hospital
Erlangen-Nuremberg, Germany
Algorithm to reduce
metal artifacts
Metal artifacts also play a considerable
role in Lells everyday work. Cardiac
patients have stents, pacemakers or
implantable defibrillators. Many patients
have amalgam fillings or metal crowns,
an artificial hip, knee, or shoulder

joint, a metal disc replacement or
vertebral body cages. And there are a
lot of patients who are given screws
and plates after fractures. There are
a whole range of CT images that cannot be interpreted due to metal artifacts, says Lell. Images with metal
artifacts can conceal pathologies,

he continues. Metal artifacts can
even suggest pathology where none
exists. In computed tomography,
metal objects lead to a non-linear
change in the X-ray spectrum and
inconsistent projection data.
Artifacts due
to amalgam fillings
In the case of a squamous cell car
cinoma in the mouth or throat, CT
isoften requested to determine the
infiltration depth of the tumor and
the nodal status, says Lell. However,
at least two thirds of our patients
have fillings or metal crowns in their
mouth, which can conceal smaller
lesions in the oral cavity on CT images,
even though the tumors are clinically
evident. His close collaboration with
the Departments of Head and Neck
Surgery and Oral and Maxillofacial
Surgery means that he is regularly
confronted with this problem. German
S3 guidelines therefore favour MRI
rather than CT for cancers in the oral
Process of iterative metal artifact reduction in iMAR1
31520136XX_39L_SI_IMAR_Grafik.indd
1
The
new SOMATOM Definition
Edge corrects metal artifacts using the iMAR algorithm, which employs iterative artifact correction. The metal image data
is not simply suppressed; instead, the missing image information is supplemented from other parts of the sinogram. With an additional beam-hardening
correction and the adaptive sinogram mixing Siemens has developed an algorithm that exceeds standard metal artifact reduction.
01.10.14 15:07
References
E. Meyer, R. Raupach, M. Lell, B. Schmidt, and M. Kachelrie. Frequency split metal artifact reduction (FSMAR) in CT.
Med. Phys. 39(4):1904-1916, April 2012
E. Meyer, R. Raupach, M. Lell, B. Schmidt, and M. Kachelrie. Normalized metal artifact reduction (NMAR) in computed tomography.
Med. Phys. 37(10):5482-5493, October 2010
Cover Story
cavity and oropharynx. Lell explains

why there is still an indication for
using CT: Many patients with head
and neck tumors find it difficult to
breathe and swallow and cannot lie
still long enough for a perfect MRI.
An increasing number of patients also
have pacemakers, still considered to
be a contraindication for MRI. We
need a good way of correcting metal
artifacts so that we can utilize the
benefits of CT, says Lell. He disagrees
with reducing metal artifacts by
increasing the tube voltage or current.
This may mean that more photons
reach the detector, but it also increases
the dose.
The new SOMATOM Definition Edge
corrects metal artifacts using the iMAR
algorithm, which employs iterative
error corrections. The metal image
data are not simply discarded; instead,
the missing image information is
replaced with other parts of the sinogram. The algorithm is also suitable
for challenging situations such as
patients with pacemakers. In addition
to the normal correction of metal artifacts, Siemens has integrated another
algorithm that performs corrections
for beam-hardening artifacts and
enables additional diagnostic information to be obtained using adaptive
sinogram mixing. This produces diagnostic images with a significant
reduction in metal artifacts.
3A
Metal Implants Inserted in Germany

per Year1
Update: January, 2014
Coronary stents:
300,000
Hip prostheses:
220,000
Knee prostheses:
170,000
Pacemakers:107,000
Implantable Cardioverter Defibrillators:
45,000
Shoulder prostheses:
8,000
Artificial discs:
7,000
Finger joint prostheses:
5,000
Ventricular assist devices:
2,600
Vertebral body cages:
2,500
Ankle joint prostheses:
1,500
Source: BVMed Bundesverband M

edizintechnologie e.V.
1
The numbers are estimated values.
Artifacts due to osteo

synthesis and hip implants
Professor Lell appreciates the combination of DE and iMAR at his CT unit
dedicated to trauma patients. Osteosynthesis devices absorb the X-rays,
meaning that fewer or no photons
reach the detector for certain projections. This makes it difficult to assess
the interface between bone and metal,
Lell explains. But this is precisely the
area of interest. Orthopedic surgeons
want to know whether the screws and
plates are placed optimally and whether
the fractures are healing adequately.
3B
Two axial images show that the image quality is greatly enhanced with ADMIRE reconstruction (Fig. 3B) although only 21 mGy dose
was applied to this three-year-old boy.
Courtesy of Luzerner Kantonsspital, Luzern, Switzerland
University Hospital Erlangen-Nuremberg is a maximum-care facility that covers the entire spectrum of clinical disciplines.
It also receives referrals of complex cases from the surrounding area.
This is of special importance in patients

with re-intervention after a nonunion
fracture.
Hip joint prostheses interfere with
thediagnosis of rectal and urogenital
disease, says Lell. Particularly if both
hip joints have been replaced, iMAR
isthe most effective way to correct
theimages and avoid non-diagnostic
images. He estimates that one in
twenty patients who have a CT scan of
the abdomen and pelvis at University
Hospital Erlangen-Nuremberg have an
artificial hip. This may be completely
different in other hospitals, he says.
We are a maximum-care hospital in
auniversity city with a predominantly
young population. Clinics that focus on
orthopedics may certainly see many
more patients with artificial hips.
Reduce dose even more with

ADMIRE
Reducing dose is and remains an
important issue in CT. We have already
improved this greatly in routine CT;
the most prominent dose reduction has
been achieved in cardiac CT, says Lell.
For slim patients with low heart rates,
we have now been able to perform an
entire coronary angiography with less
than 1 mSv for quite a while. We need
to focus on the dose for chest and
abdomen CTs in a similar way, he continues. Ninety percent of our examinations focus on the thorax and abdomen. This is the area where we need
further improvements.
The new SOMATOM Definition Edge

and the SOMATOM Definition AS+ in
combination with a Stellar detector
upgrade also offer ADMIRE. ADMIRE
decouples spatial resolution and
image noise, delivering good resolution with less noise and a lower dose.
This latest generation of iterative
reconstruction has further potential
for dose reduction. ADMIRE is the
logical next step after SAFIRE and
uses explicit reconstruction models
for CT systems equipped with Stellar
detectors. Initially introduced in the
SOMATOM Force, this innovative
procedure is now available for other
systems with fully integrated Stellar
detectors.
Even the new TwinBeam Dual Energy
in the new SOMATOM Definition Edge
does not compromise on dose. The
beam emitted from an X-ray source is
broken down into two energy spectra
by the innovative STRATON tube
assembly system. This means that all
dose reduction programs can be
used.
Fewer metal artifacts, Dual Source
applications with the new TwinBeam
Dual Energy CT scan mode, and
further potential to reduce radiation
dose enabled by ADMIRE Lell is
convinced that the functions of the
new SOMATOM Definition Edge will
take high-end procedures to clinical
routine in many hospitals. p
Hildegard Kaulen, PhD, is a molecular

biologist. After stints at the Rockefeller University in New York and the Harvard Medical
School in Boston, she became a freelance
science journalist in the mid-1990s. She
contributes to numerous reputable daily
newspapers and scientific journals.
1
TwinBeam Dual Energy and iMAR are currently

pending 510(k) clearance and is not yet comercially available in the United States.
iMAR is designed to yield images with a reduced

level of metal artifacts compared to conventional
reconstruction if the underlying CT data is
distorted by metal being present in the scanned
object. The exact amount of metal artifact reduction and the corresponding improvement in
image quality achievable depends on a number
of factors, including composition and size of the
metal part within the object, the patient size,
anatomical location and clinical practice. It is
recommended, to perform iMAR reconstruction
in addition to conventional reconstruction.
In clinical practice, the use of SAFIRE and ADMIRE
may reduce CT patient dose depending on the
clinical task, patient size, anatomical location, and
clinical practice. A consultation with a radiologist
and a physicist should be made to determine
theappropriate dose to obtain diagnostic image
quality for the particular clinical task.
The statements by Siemens customers described
herein are based on results that were achieved in
the customers unique setting. Since there is no
typical hospital and many variables exist (e.g.,
hospital size, case mix, level of IT adoption) there
can be no guarantee that other customers will
achieve the same results.
Further Information
www.siemens.com/
SOMATOM-Definition-Edge
News
TwinBeam Dual Energy:

New Benchmark in
Single Source Dual Energy
TwinBeam Dual Energy is an innovative technology unique to Siemens.
It offers greater versatility than other computed tomography systems due
to full Dual Energy capabilities with simultaneous acquisition of high
and low energy datasets delivering excellent images at the right dose.
By Susanne Hlzer and Johannes Georg Korporaal, PhD
Computed Tomography, Siemens Healthcare, Forchheim, Germany
Extending the Dual Energy

portfolio
Dual Source Dual Energy (DSDE)
imaging introduced by Siemens in
2005 isthe established benchmark in
Dual Energy Computed Tomography.
From the very beginning, the aim
was to introduce clinically relevant
Dual Energy CT applications rather
than merely a research tool.
To bring the benefits of Dual Energy
to more users, Siemens introduced
single source Dual Energy with the
Dual Spiral approach available on systems from 16 to 128 slices.
The Dual Energy Portfolio has now

been extended even further with
theintroduction of TwinBeam Dual
Energy1 technology on the SOMATOM
Definition Edge scanners. This innovative Dual Energy approach allows
simultaneous acquisition of high
andlow energy datasets using single
source systems, enabling all applications utilizing iodine contrast.
Siemens Dual Energy CT is routinely
applicable to virtually all patients
without compromising on image
quality or radiation dose.
TwinBeam Dual Energy:

How it works
TwinBeam Dual Energy is a new technology that provides a unique way to
perform Dual Energy scans. To create
two X-ray spectra simultaneously from
a single tube, the beam is pre-filtered
using two different materials: gold (Au)
and tin (Sn). As a result, the 120 kV
X-ray beam is split into a high- (Sn)
and low-energy (Au) X-ray spectrum
before it reaches the patient (Fig.1).
Due to the additional filtration, this
acquisition technique requires sufficient tube power reserves, which are
1
1
The schematic
visualization of
aTwinBeam scan
shows the simultaneous acquisition
of datasets.
readily available on Siemens CT scanners with the STRATON tube.
2A
2B
Image acquisition is possible for all

rotation times (up to 0.28 seconds) and
for the full field-of-view of 50 cm.
Furthermore, different from other
single source Dual Energy acquisition
techniques, the full number of projections is available for both spectra
resulting in uncompromised image
quality. In terms of detection, the
simultaneously acquired low- and
high-energy data can be reconstructed
separately to provide a high- and lowenergy image series. These datasets
can be examined independently. Alternatively, a composed reconstruction is
available (disregarding spectral differences) to give a single energy image
dataset with uncompromised image
quality.
Clinical benefits
of TwinBeam Dual Energy
TwinBeam Dual Energy enables simultaneous acquisition of high- and lowenergy datasets. Therefore it is possible
to use True Dual Energy applications
on single source CT systems with no
compromise on dose. The full range
ofdose reduction techniques such as
ADMIRE2 and CARE Dose4D can be
implemented consistently for compliance with the ALARA principle.
Among the major clinical benefits are,
for example, evaluations of pulmonary
embolism using syngo.CT DE Lung
Analysis. This application provides
immediate diagnostic information such
as location of the affected vessel and
details of the perfusion defect in the
parenchyma, at a glance. TwinBeam
Dual Energy together with syngo.CT
DE Direct Angio delivers a bone-free
view of the vascular system, making
iteasier to assess cardio-vascular
diseases.
Initial clinical results have proven the
concept of TwinBeam Dual Energy with
positive outcomes. Iodine maps in
thelungs, liver, and kidneys show the
iodine distribution throughout the
entire volume and produce artifact-free
virtual non-contrast (VNC) images.
Dual Energy bone removal also works
very well, for both the thorax-abdomen
scans as well as for the head. This indi-
A whole body CT angiography acquired with TwinBeam Dual Energy shows

an infra-renal abdominal aortic aneurysm (AAA). VRT images can be easily
created after automatic bone removal (Fig. 2B).
cates that the new TwinBeam Dual

Energy acquisition technique can
deliver high-quality images for confident diagnosis.
Conclusion
TwinBeam Dual Energy meets the
technical requirements for the use in
clinical routine entirely without any
compromises. The Dual Energy CT
application portfolio on syngo.via
isnow available for cases acquired
using single source Dual Energy. p
TwinBeam Dual Energy is currently pending

510(k) clearance and is not yet commercially
available in the United States.
2
In clinical practice, the use of ADMIRE may reduce
CT patient dose depending on the clinical task,
patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate
dose to obtain diagnostic image quality for the
particular clinical task.
News
Gudrun Feuchtner, MD, Innsbruck Medical University, Austria (left) and Francesca Pugliese, MD, PhD, William Harvey Research Institute, Queen Mary
University, London, UK (right) are both radiologists and carry out research to establish the usefulness of stress myocardial CT perfusion imaging.
Leading the Way

in Stress Myocardial
CT Perfusion Imaging
Radiologists Francesca Pugliese, MD, PhD, and Gudrun Feuchtner, MD, are each
investigating different methods of combining coronary CT angiography with
stress myocardial CT perfusion imaging using the SOMATOM Definition Flash
CT scanner to provide additional functional information to guide patient care.
Text: Linda Brookes, Photos: Jrn Tomter, Harald Voglhuber
News
Alongside the daily work of coronary

CT angiography (cCTA) scanning in the
Cardiac Unit of the Department of Radiology at Innsbruck Medical University,
Austria, and at the Centre for Advanced
Cardiovascular Imaging, part of the
William Harvey Research Institute, Queen
Mary University of London, currently
based in the London Chest Hospital,
research is being carried out to establish the clinical usefulness of stress
myocardial CT perfusion imaging. Both
units are using a SOMATOM Definition
Flash CT scanner.
cCTA is an important non-invasive
method for the anatomical detection of
coronary artery disease, but additional
information about the hemodynamic
significance of coronary stenoses is
often needed, particularly in the case
of intermediate lesions (30 to 70 percent reduction of lumen diameter).
Traditionally, this information has been
obtained by combining cCTA with other
imaging techniques such as perfusion
imaging with PET or SPECT, or magnetic
resonance imaging. The benefits of
extending cCTA to include complementary functional information using stress
myocardial CT perfusion imaging, and
so avoiding the need for separate scans
or hybrid imaging, is very attractive for
both cardiologists and patients. It eases
both the workflow and the diagnostic
burden.
Earlier technical issues with CT per

fusion imaging have been resolved
through improvements in CT scanners
with increased temporal and spatial
resolution and increased coverage.
As a result, and with recent studies
confirming its safety and feasibility,
CT perfusion imaging is moving closer
toward being introduced into routine
clinical practice to provide more information about the significance of
coronary lesions and guide treatment
selection. The two academic hospitals
in Austria and the UK are taking the
lead in performing the proof of concept and validation studies needed
for this to take place.
In London, a team led by Francesca
Pugliese, MD, PhD, Senior Clinical
Lecturer (Assistant Professor) and
Consultant in Cardiovascular Imaging,
carries out around 2,500 dedicated
coronary and cardiac CT scans annually. These are predominantly done
in patients with suspected coronary
artery disease, but also other conditions such as prior to intervention or
valve replacement, or for the evalu
ation of cardiomyopathies. The
SOMATOM Definition Flash scanner
was installed at this center in 2009.
The center provides care for a large
population, including serving as
referral center for patients from
In Innsbruck, Gudrun M. Feuchtner,

MD, PD, Assoc. Professor for Radiology
and Vice-Chair of Department of
Radiology, and her colleagues do more
than 1,000 cardiac CT scans peryear
for the cardiology, cardiac surgery,
and emergency departments of the
hospital. We started cardiac imaging
very early, in 2002, with a16-slice
CT, she says. It has been along tradition in our hospital to always be at
the forefront in cardiovascular imaging. She adds, We saw a rise in the
number of patients after installation
of the SOMATOM Definition Flash CT
scanner in 2009. The 2 128-slice
Dual Source CT clearly improved image
quality and enabled us to image
patients at a higher heart rate, so this
resulted in an increased number of
scans per year.
Both Pugliese and Feuchtner aim
tospend about half their time with
patients and half on research, although
each admits that the patients often
take up more time.
4
1
A 56-year-old female
presented with unstable
angina chest pain to
the emergency department ten hours after
onset. ECG and cardiac
enzymes were normal.
CCTA discovered normal
RCA, CX and LAD,
but suggested septal
branch occlusion.
2A
specialized clinics, outpatient and

inpatient services, and from other
centers and hospitals. This service
will continue and expand further
when the center moves to a new
state-of-the-art cardiovascular center
at St. Bartholomews Hospital later
this year.
2B
With worsening symptoms,

she underwent an invasive
angiography confirming
aseptal branch high-grade
stenosis. Treament was
conservative using medication. Her symptoms
improved and she was
discharged after 3 days.
Courtesy of Department
of Radiology and Cardiology
at Innsbruck Medical
University, Innsbruck, Austria
3
2
Static CT perfusion
displayed a matching
large subendocardial
anteroseptal perfusion
defect (Figs. 2A and 2B)
and the corresponding
wall motion abnormality
(Hypokinesis, Fig. 3).
News
Static versus dynamic CT

perfusion imaging
At Innsbruck, Gudrun Feuchtner and
her colleagues do static CT perfusion
imaging, in which a single data
sample of contrast enhancement is
acquired during first-pass enhancement of cCTA. An advantage of static
CT perfusion, Feuchtner points out,
is the low radiation dose. She and her

colleagues from University Hospital
Zurich developed a low-dose protocol
in which radiation exposure over the
entire stress-rest cCTA protocol was
only 2.5 mSv, compared with about
10 mSv reported with older technologies such as SPECT.[1] For these procedures, the SOMATOM Definition Flash
is being used with syngo.CT Cardiac
5
5
A 55-year-old female
presented to the rapid
access chest pain clinic,
showing atypical chest
discomfort (retrosternal,
triggered by stress but
with inconsistent relationship with exercise). She
had hypertension and
hyperlipidemia as cardiovascular risk factors. CCTA
showed eccentric, mild
plaque in the LM (arrow)
and moderate plaque
more distally in the LAD
(dashed arrow). RCAand
CX were normal.
6A
6B
6C
CT dynamic perfusion raised suspicion of a perfusion defect in the septum

area, but the dynamic parametric map showed no significant reduction of
MBF (> 80 mL/100 mL*min), indicating no significant perfusion defects.
7
7
This was confirmed by invasive
angiography with fractional
flowreserve in the LAD of 0.82,
indicating no lesion-specific
ischaemia. RCA and LCxwere
confirmed to be normal.
Courtesy of Centre for Advanced
Cardiovascular Imaging, Queen Mary
University of London, London,
GreatBritain
Function Enhancement, as part of the

Cardiovascular Engine on syngo.via1,
which Feuchtner points out is very
flexible and can be operated from any
connected workstation. The latter is
especially useful in a large hospital,
where the radiology department is
spread around the hospital and where
the PACS workstations are also used
for training residents and students.
The syngo.via and the CT Cardiovascular Engine allow us to read coronary
CTA and other cardiac workflows from
any workstation connected with the
syngo.via server, which saves a lot of
time, she says. The automated preprocessing segmentation of the coronary arteries with syngo.via saves time
for the technicians. Feuchtner is running a pilot project using syngo.via
Webviewer2, which is directly connected
to the syngo.via server and allows
images to be read on iPads, making
them fully mobile around the hospital.
Cardiac surgeons use it for bedside
image presentations to patients before
surgery and it is especially popular
with pediatric cardiac surgeons,
Feuchtner notes.
In London, Francesca Pugliese and her
team are concentrating on dynamic
CT perfusion imaging. Unlike static perfusion, which captures a single set of
images at a single time point within the
early arterial phase, multiple images
are acquired at sequential times of contrast enhancement after injection of
a contrast bolus to create time-attenuation curves (TACs). Image analysis is
carried out using dedicated software3
for the assessment of quantitative
myocardial perfusion by Siemens. This
allows extraction of the quantitative
information from the scan by applying
a two-compartment mathematical
model to the TACs. It is indispensable
to create parametric maps of perfusion
parameters from a dynamic acquisition,
including for instance myocardial blood
flow (MBF) and myocardial blood volume (MBV), Pugliese says. She rates
this dynamic approach as closer to the
other well-established perfusion techniques such as PET imaging and magnetic resonance imaging.
Pugliese agrees that the static approach
may have some advantages in terms of
lower radiation exposure, and because
News
Both researchers use dedicated software solutions by Siemens to analyze

and visualize the results of myocardial CT perfusion imaging.
it is less demanding as it involves only

one acquisition. However, she states
that one major drawback is that it relies
on the presence of at least one normally perfused part of the heart against
which attenuation in the ischemic area
can be compared. In addition to this,
the diagnostic value of the static perfusion depends on the timing if the
correct time point is not met, then the
results may be misleading. By contrast,
dynamic perfusion has the advantage
of providing quantitative information
on the myocardial perfusion over a time
period. Pugliese sees some limitations,
however: With dynamic perfusion we
have to try to minimize the radiation
dose in the field of view that we set.
We also have to ensure that the patients
are fully cooperative and able to hold
their breath for 30 seconds rather than
the five to seven seconds required for
static perfusion, which can be difficult
while feeling chest pressure after the
adenosine infusion.
It is quite possible that the static technique may be appropriate in patients
evaluated for the first time for chest
pain, that is, patients who do not have
a massive abnormal coronary circulation, but it remains to be shown whether
this isequally robust in patients with
very advanced disease where there are
collateral circulations, or patients postrevascularization, Pugliese suggests.
With the dynamic technique, we can
quantify a parameter indicative of MBF,
which has the potential to be a more
objective and comprehensive physiological assessment as we have recently
shown.[2]
Despite this, neither Francesca

Pugliese nor Gudrun Feuchtner see
a strong argument in favor of either
static or dynamic perfusion imaging
over the other. Studies in different
populations have shown similar results
for the performance of both techniques and no direct head-to-head
comparison study has demonstrated
superiority of either technique.
The future of CT myocardial

perfusion imaging
Pugliese and Feuchtner agree that
there is still a need for more multicenter trials to validate the technique
and implement it widely in clinical
practice. But although dynamic CT
myocardial perfusion imaging is still
at a relatively early stage of validation, there is already great interest in
using it in clinical practice, according
to Pugliese. There is a general feeling that it is feasible, the equipment
is here and it works, and our results
are absolutely encouraging. But we
will need more multi-centric data,
she cautions. Clinicians with experience in acquisition and evaluation
may consider using it instead of other
perfusion imaging techniques in particular circumstances, for reasons
related to availability, to local expertise or in specific clinical situations,
she suggests. However, as it is a new
technique Pugliese believes that
widespread implementation may
require a few years.
Dynamic CT perfusion imaging will
need improvement and radiation dose
reduction techniques, like better cov-
erage of the myocardium and iterative reconstruction, Feuchtner notes.

This could be delivered by the most
recent Dual Source CT, SOMATOM
Force, which as well as the new
detector has a new Vectron tube that
maintains contrast enhancement
while reducing radiation dose. That
would make the full dynamic scan
more feasible for practice, Gudrun
Feuchtner believes. And Francesca
Pugliese agrees: Clearly, the newer
technology provides images with less
noise and it is equipped with lower
kV capability, so everything is optimized for better images with lower
radiation, she says. p
Linda Brookes is a freelance medical writer
and editor who divides her time between
London and New York, working for a variety
of clients in the healthcare and pharma
ceutical fields.
References
[1] Feuchtner G et al., Adenosine stress
high-pitch 128-slice dual-source
myocardial computed tomography
perfusion for imaging of reversible
myocardial ischemia: comparison with
magnetic resonance imaging., Circ
Cardiovasc Imaging. (2011)
Sep;4(5):540-9.
[2] Rossi, A, Pugliese F et al., Diagnostic
performance of hyperaemic myocardial
blood flow index obtained by dynamic
computed tomography: does it predict
functionally significant coronary lesions?,
European Heart Journal Cardiovascular
Imaging (2014) 15, 8594
typical hospital and many variables exist (e.g.
achieve the same result.
syngo.via can be used as a standalone device or
together with a variety of syngo.via-based software options, which are medical devices in their
own right. syngo.via and the syngo.via based software options are not commercially available in all
countries. Due to regulatory reasons its future availability cannot be guaranteed. Please contact your
local Siemens organization for further details.
2
The application syngo.via WebViewer is not for
diagnostic viewing/reading on mobile devices in
the U.S. Please refer to your sales representative
as to whether the product is available for your
country. Diagnostic reading of images with a web
browser requires a medical grade monitor.For
iPhone and iPad country specific laws may apply.
Please refer to these laws before using for diagnostic reading/viewing.For Japan: Applications on
iPhone / iPad / iPod are not a medical device in
Japan. Use at your own risk. They are not intended
to be used for diagnosis.
3
syngo Volume Perfusion CT Body Myocardium
News
Laurent Collignon, MD, Head of the Medical Imaging Centre at CHR La Citadelle and his team perform 40 pediatric CT scans per month.
For these especially vulnerable and all other patients, they are focussing on lowering patient exposure.
Dose Inspection
a Reason to be Proud
CHR La Citadelle in Lige, Belgium, is among the hospitals with the lowest radiation
doses in the country. For more than fifteen years, the imaging department of CHR
La Citadelle has been focused on lowering patient exposure. It regularly receives
questions from well-informed parents anxious about the level of radiation that will be
used during the medical treatment of their child. CHR La Citadelle has two SOMATOM
Perspective CT scanners from Siemens one for the emergency department and one
in the general radiology department.
Text: Erika Claessens, Photos: Bert Janssen
News
Bringing down radiation doses has

always been our focus, especially when
it comes to children, explains Laurent
Collignon, MD, and Head of the Medical
Imaging Centre at CHR La Citadelle in
Lige, Belgium. No wonder I was surprised, but also proud and truly satisfied that our hospital is among those
with the lowest radiation doses in the
country.
rooms in Belgium. One child in eight

visiting our department is affected by
an injury or shows symptoms where
medical imaging is advised by our clinicians. We do 40 pediatric CT scans
per month and I regularly get questions
from well-informed parents anxious
about the level of radiation dose that
will be used during the medical imaging of their child.
radiation doses, close to or sometimes even below the standard 25 percentile. Inorder to exclude any errors
in reporting, a second check has been
made and confirmed the 25 percentile, which became standard for La
Citadelle.
Monitoring patient
radiation dose
In most cases, Collignon states, they

can relieve their anxiety by taking CT
images. As such, they are not taking
less images, but they use technology
that enables low radiation dose levels.
We consider ourselves lucky that
contemporary technological innovations in medical imaging have rapidly
enhanced over the years, too.
Grardy has been working for years

in the health sector in Belgium and
had already noticed herself that CHR
La Citadelle was making huge efforts
in lowering patient radiation doses.
Of course, Iam happy to see that
AV Controlatom is a certified independent, non-profit organization licensed

by the Belgian Federal Agency for
Nuclear Control (FANC). It performs
annual dosimetric data controls in medical imaging for a number of Belgian
hospitals. FANC is responsible for monitoring the patient radiation dose and
medical image quality in the Belgian
health sector.
Following several radiology roundtable discussions in 2008, FANC recommended regulating patient dosimetry.
The first official guidelines for the
registration of the dosimetric data within
medical imaging departments in the
healthcare sector were produced in
2011. The determination of radiation
dose is an important issue for all stakeholders, and is critical in protecting
patients from high radiation doses.
Initially, the controls were performed
every three years but now they take
place annually.
Raising awareness
Laurent Collignon points out: For more
than fifteen years, the Imaging Department of CHR La Citadelle has been
focused on lowering patient radiation
doses. Even my predecessor, radiologist
Leon Rausin, MD, always emphasized
the importance of lowering radiation
dose as much as possible. At the time,
people were becoming increasingly
concerned about the radiation from
medical imaging equipment, and governments and environmental organizations felt the need to start prevention
campaigns to raise awareness among
citizens.
Nevertheless, he will never refuse to
use computed tomography, he explains,
because it can be a life-saving tool. I
work in one of the busiest emergency
Working together towards

lower radiation dose
Annual check of radiation

dose values
Nathalie Grardy is a certified medical
physics expert in radiology and works
for AV Controlatom. She calculates
the local average and median values
recorded in periodic studies of radiation dose, provided annually by the
hospitals. These results are compared
with the reference values determined
by FANC and sent back to the head
ofthe department at the hospital
together with advice on how to optimize its systems to lower the radiation dose for patients without compromising image quality. She explains
how radiation dose is defined: In
Belgium, the minimum defined percentile for radiation dose is at percentile 25, the maximum percentile 75.
The 25 percentile is considered best
practice for the healthcare sector as
defined in the guidelines from the
European Comission1. The maximum
percentile 75 is defined as the limit
of good practice, which means that
it ispreferable for a hospital not to
pass the percentile 75 during a routine control with a standard patient.
When the obtained percentile of a
scanner is above 75, I need to examine
the conditions in which the results
were achieved, Grardy states. It
also means that I will check if the
working methods and the equipment
used can be improved in one way or
another. However, in the case of the
CHR La Citadelle, in several instances
we came across exceptionally low
I was surprised, but

also proud and truly
satisfied that our
hospital is among
those with the lowest
radiation doses in
the country.
Laurent Collignon, MD,
Head of the Medical Imaging Centre
at CHR La Citadelle in Lige, Belgium
News
AV Controlatom
Founded in 1965, AV Controlatom
(AVC) is a certified independent,
non-profit organization licensed
by the Belgian Federal Agency
for Nuclear Control (FANC). Its
main objective is to assure the
radiation protection of workers
in nuclear environments, the
public, and the environment
against medical, industrial, and
natural sources of ionizing radi-
1A
ation. This protection is assured

by performing preliminary studies of the equipment, periodic
inspections, training employees,
and performing inspections during the removal of radioactive
waste.
The activities of AVC are divided
into: Health physics, medical
physics, dosimetry, administra-
tion, and quality of safety techniques.

The radiation experts working
for AVC have a university or
equivalent education. Their
knowledge is kept up-to-date
by attending courses at Belgian
or foreign universities, conferences, and meetings of specific
associations.
1B
Number of Patients
6.90
60
12.96
50
40
30
20
10
0
0
10
12
14
16
18
20
22
Dose values in CTDIvol (mGy)

1
1A Abdominal CT: In Belgium the recommended dose levels for adults
abdominal CT are between 6.90 and 12.96 CTDIvol (mGy). The graph
above shows the dose distribution for 2,644 patients scanned on the
two installed SOMATOM Perspective CT systems at CHR La Citadelle in
Lige, Belgium. The majority of the scans were performed far below
6.90 CTDIvol (mGy).
2A
2A
Number of Patients
27.25
1B Example of an abdominal CT scan

from CHR La Citadelle in Lige, Belgium.
The image quality is excellent at a
dose level, far below the given Belgium
reference values. The dose level for this
obese adult patient was 6.59 CTDIvol (mGy).
52.80
2B
50
40
30
20
10
0
8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Dose values in CTDIvol (mGy)
1
2A Pediatric head scans: In Belgium the recommended dose levels
for pediatric head scans are between 27.25 and 52.80 CTDIvol (mGy).
The graph above shows the dose distribution for 498 children scanned
on the two installed SOMATOM Perspective CT systems at CHR La
Citadelle in Lige, Belgium. All scans were performed far below the
max. recommended dose level of 52.80 CTDIvol (mGy).
1
ccording to the Belgian Federal Agency for Nuclear Control (FANC) recommended
A
dose levels, released on Oct 10 th, 2012.
2B Example of pediatric head scan from CHR La

Citadelle in Lige, Belgium. The image quality
is excellent at a dose level, far below the given
Belgium reference values. The dose level for
this patient was 18.37 CTDIvol (mGy).
In the case of the CHR La Citadelle, in several

instances we came across exceptionally
low radiation doses, close to or sometimes
even below the standard 25 percentile.
Nathalie Grardy, certified medical physics expert in radiology at AV Controlatom, Belgium
some hospitals achieve a low radiation

dose with their SOMATOM Perspective
CT scanner. This is due to the narrow
collaboration between the company
offering computed tomography, the
medical team, and the local technologists. Its always possible to get low
radiation dose percentiles if all these
actors work together and all go for the
same goal.
Since the installation of a SOMATOM
Perspective at CHR La Citadelle, the
reduction in dose levels has been significant. New technologies such as
iterative reconstruction with SAFIRE2

or drastic optimization of protocols
with Siemens CT experts, and also the
implementation of SILT techniques
(small increments long term) have
made this possible.
The SOMATOM Perspective scanner
at CHR La Citadelle runs 24 hours a
day, seven days a week, Collignon
says. Our annual reports are the result
of analyzed data taken on a huge scale
and from a large number of patients
so we know that the low percentiles
are not an exception and, more impor-
Ta doluptae nimposapit hillam et estisciam re conecte non nobit

lignate latium, earum consere, il modipsa necuptias ut.
CHR La Citadelle
CHR La Citadelle is one of the largest public hospitals
in the French-speaking part of Belgium, with 1,036
beds, of which 128 are reserved for children. Offering
a hospital for all, and health for everyone, CHR
La Citadelle employs over 400 physicians, treating all
kinds of health conditions in adults and children,
using cutting-edge technology. The childrens department of CHR La Citadelle is widely recognized as a
university reference center.
tantly, they are authenticated by the

federal agency. Of course, there will
come atime when it will become difficult toreduce the dose levels any
further. While some radiation dose is
necessary, if we can bring it down
and also help our patients, then we
feel satisfied. And its not just to promote new technologies. Its because
lowering radiation dose has been our
hospitals number one aim for more
than fifteen years. p
For more than 25 years, journalist and
editorErika Claessens has contributed to
numerous print and online publications
inboth Belgium and the Netherlands.
Herprincipal topics are entrepreneurial
innovation and sustainability. She works
inAntwerp, Belgium.
1E
uropean Guidelines on Quality Criteria for
Computed Tomography.
2 In clinical practice, the use of SAFIRE may reduce
patient size, anatomical location, and clinical
practice. A consultation with a radiologist and a
physicist should be made to determine the appropriate dose to obtain diagnostic image quality
forthe particular clinical task. The following test
method was used to determine a 54 to 60% dose
reduction when using the SAFIRE reconstruction
software. Noise, CT numbers, homogenity, low
contast resolution, and high contrast resolution
were assessed in a Gammex 438 phantom. Low
dose data reconstructed with SAFIRE showed the
same image quality compared to full dose data
based on this test. Data on file.
Further Information
www.siemens.com/
SOMATOM-Perspective
News
teamplay
Connecting the Imaging World
teamplay is a network of healthcare professionals and patients with the
common goal of advancing medicine and human health in a team effort. By
connecting medical institutions and their imaging devices, teamplay aspires
to create an extensive virtual imaging team with global reach. It provides
its members with tools to deal effectively with big data and the challenges
of increasing cost pressures.
By Ivo Driesser*, Florian Reinhold**
**Computed Tomography, Siemens Healthcare, Forchheim, Germany
**syngo, Siemens Healthcare, Erlangen, Germany
Based online in a cloud, teamplay can

support users in making prompt and
well-informed decisions by giving them
an instant and intelligible overview
of performance data. It can monitor
parameters such as imaging throughput or dose levels from the whole
fleet down to each individual device
a simplified report of use showing
where workflows may need adjusting.
teamplay links all users and their data
to show comparable benchmarks and
to facilitate the effortless exchange of
images and reports with other healthcare providers.
teamplay Usage1
teamplay Usage improves imaging
efficiency by providing a clear overview of usage data and a comparison
with readily available benchmark
information. From a daily summary
ofthe fleet, to a detailed analysis of
utilization trends, Usage enables
easyaccess to an institutions performance parameters. By continually
comparing institutional performance
with that of partners and with global
benchmarks, it offers the key to further improvement potential.
With teamplay Usage the exact usage of all the medical equipment even across multiple
sites of one institution can be monitored, and the answers to many questions can be found
with just a few clicks.
In everyday clinical routine, questions may arise such as: We may

need to carry out up to 10% additional
CT scans for lung cancer imaging.
Is my department prepared? The
Usage function can monitor exactly

how all the medical equipment is
being used and can deliver answers to
questions such as these in just a few
clicks.
News
teamplay Dose1, 2
teamplay Dose provides easy access
to current and historical dose data to
support quality assurance processes
inmonitoring imaging radiation dose.
teamplay Dose will display data for continuous dose performance evaluation
regardless of the modality or vendor.
This allows efficient dose data analysis,
benchmarking against other institutions,
and providing comparisons with current
industry standards to increase dose
efficiency. The solution gives an overview of protocols used according to
type and target region. teamplay Dose
makes dose events visible to allow for
timely analysis and implementation
ofmeasures inresponse to abnormal
events. Display of dose events is based
on specific institutional reference levels
as well as on nationally defined targets.
teamplay Dose also provides an intuitive and easy way to map institution
protocols onto standard protocols.
teamplay Dose provides easy access to current and historical dose data to support
quality assurance processes in monitoring imaging radiation dose.
Transparency in dose values allows

for a clear overview and monitoring of
easy adaptations to scan protocols. This
helps to answer questions such as
What is the impact of using CARE kV?.
It also gives a useful picture of commonly occurring data, for instance
CTDIvol and DLP.
1 This product is not a medical device and currently

under development, is not for sale in the U.S.,
China and other countries. Its future availability
cannot be guaranteed.
2 teamplay Dose Management is not intended for the
monitoring of individual patient doses.
Further Information
www.siemens.com/teamplay
The teamplay homebase screen shows all important data at a glance.
Professor Jrg-Christian
Tonn, MD, Professor
Stefan Zausinger, MD,
and Associate Professor
Christian Schichor, MD
(from left to right) are
convinced that using
intraoperative CTis in
the interests not only
of the patients but also
of surgical specialists
other than neurosurgeons and the administrators in their hospital
in Munich, Grosshadern.
Intraoperative CT
Better Views for Neurosurgeons
The Neurosurgical Department at the University Hospital Grosshadern
inMunich, Germany, was one of the first to introduce intraoperative CT
imaging in neurosurgery. Now the hospital is beefing up its capacities.
SOMATOM Sessions talked to three pioneers of this technology in brain
surgery, spinal surgery, and neurovascular surgery. They argue that intra
operative CT can increase patient safety, results in a smoother neuro
navigation workflow, and has a reasonable cost-benefit ratio.
Text: Philipp Grtzel von Grtz, Photos: Alberto Venzago
Neurosurgery without imaging is like
a cake without sugar almost unthinkable. When Professor Jrg-Christian
Tonn, MD, Director of Department of
Neurosurgery at the University Hospital Grosshadern, is resecting a brain
tumor, he needs to know exactly
where the malignancy is located. This
means we have to perform imaging
up-front. And we also need to check
the result of our resection.
His colleagues, the spinal surgeon

Professor Stefan Zausinger, MD, and
the neurovascular surgeon Associate
Professor Christian Schichor, MD, are
also imaging-driven guys, as Tonn
puts it. When Zausinger places screws
into the vertebral bodies of a patient
with instabilities of the spine, he relies
on neuronavigation which is heavily dependent on up-to-date imaging
material. And Schichor needs imag-
ing not only to visualize the aneurysm,

but also to verify whether his clipping
procedure was a success.
Obviously, a multitude of imaging
modalities can provide neurosurgeons
with anatomical and functional information: ultrasound and fluoroscopy,
angiography, and magnetic resonance
imaging (MRI), and computed tomography (CT). Each of these modalities
News
can be used pre-operatively and intraoperatively. At Grosshadern, the neurosurgeons became interested in using
the SOMATOM Definition AS in a sliding gantry configuration as an intraoperative CT system some years ago.
And for a few good reasons: Compared
with MRI, CT is cheaper and requires
less maintenance; it does not need
shielding and thus major construction
activities; there is almost no interference with surgical workflows; and conventional surgical instruments can be
used.
By using intraoperative CT
it becomes easier to preserve delicate structures,
and at the same time we
can be more certain that
we have removed the
tumor as completely as
possible.
Professor Jrg-Christian Tonn, MD,
Department of Neurosurgery,
University Hospital Grosshadern, Munich
Tumor surgery:
Where exactly is the brain?
The specific benefits of intraoperative
CT are best illustrated with typical
patient scenarios. Professor Tonn uses
a neuronavigation system to resect
brain tumors with the goal of preventing further brain damage. But a neuronavigation system is only as reliable as
the images that it can draw upon: We
usually have preoperative MRI images.
However, during surgery, many things
change. When we resect tumors of the
brain tissue, the brain might shift to one
side or the other. And in meningioma
patients, the surgical field changes due
to the drilling that needs to be done to
remove this tumor, which can involve
the adjacent bony region. Using intraoperative CT allows the dataset for the
neuronavigation system to be updated
whenever necessary. The result is that
intraoperative CT imaging with the
SOMATOM Definition AS becomes easier to preserve delicate structures, and
at thesame time we can be more cer1A
tain that we have removed the tumor

as completely as possible, says Tonn.
Spinal fusion: More

accurate screw placement,
fewer complications
Spinal fusion surgery is another area
where intraoperative CT comes into
its own. In spinal fusion, adjacent vertebral bodies are fused mechanically
with the help of screws and rods in
order to reduce spinal instabilities.
According to Professor Zausinger,
these spinal instabilities mostly affect
patients with degenerative diseases
of the spine: But we also see patients
with traumatic spinal injuries and
with spinal instabilities as a result of
malignant tumors.
In times of shifting demographics,
spinal fusion surgery looks set to
become more common. In the U.S.,

there were more than 465,000 fusion
surgeries in 2011, according to the
analysts at GlobalData. The challenge
with spinal fusion is that the screws
need to be placed as accurately as
possible for two reasons, as Zausinger
points out: Malpositioning of the
implants can cause damage to the
nerve roots or to the spinal cord, or
to some vessels adjacent to the
spinal cord. And it can also lead to
an insufficient stabilization procedure with persistent and often painful instability.
In order to minimize the risks that
are associated with malpositioning,
Zausinger routinely uses intraoperative CT for spinal fusion surgery. The
first examination is performed right
before the screws are to be placed. The
1B
1
Intraoperative CT-imaging after
navigated screw placement in L4:
All screws are placed correctly and
completely within the pedicles
and vertebral bodies without
damage to surrounding structures.
Please note the dorsally positioned
radiotranslucent retractor, which
can be left in place during the
scanning procedure without
causing artifacts to the images
(Fig. 1A). Postoperative X-ray
image of the lumbar spine confirms correct position of transpedicularly placed screws in
vertebral L4 and L5 (Fig. 1B).
News
In order to minimize
risks resulting from
malpositioning of
implants, I routinely
use intraoperative
CT for spinal fusion
surgery.
Professor Stefan Zausinger, MD,
University Hospital Grosshadern,
Munich
dataset is fed directly into the neuronavigation system, so that navigation

is as accurate as possible. Once all the
screws are in place, a second intra
operative CT is performed in order to
check their positions.
Zausinger says there are two major
advantages to this setup: First, the
images that are necessary for the
navigation-aided stabilization procedure are generated in the final surgical
position of the patient. This results
inmore accurate images and thus
improved navigation. The second
advantage is that we can check the
position of the implants immediately.
We can see during surgery whether
the screws or the rods are compressing any structure, and we also see
hematomas right away. Should a
problem be identified, it can be corrected immediately. This is not only
efficient, it can also spare the patient
from apotential re-operation.
Clipping of aneurysms:
What about perfusion?
In aneurysm surgery, there is no navigation. Nevertheless, intraoperative
CT can make abig difference. Professor
Schichor started using intraoperative
CT in patients in need of aneurysm
clipping surgery four years ago. Three
to four such surgeries are performed
in Grosshadern per week, and many
of them take advantage of intraoperative CT. Patients with complicated
vessel lesion, for example large aneurysms, or aneurysms that are partially
thrombosed, benefit most from intraoperative CT, says Schichor. When
using intraoperative CT, he looks specifically at CT angiography and CT
perfusion scans: In CT angiography,
we see whether the vessel patency is
preserved. And with CT perfusion
scans, we can have a look at the distant perfusion in order to evaluate
The benefits of intraoperative CT in

spinal fusion come without additional
radiation exposure: A CT examination
before surgery has to be carried out
anyway. And after surgery, it is necessary to perform a control CT as well.
The only difference is that, in our
setup, the two CTs are taken intraoperatively, says Zausinger. In fact, with
intraoperative CT there are even workflow benefits: Thanks to a deep integration with the neuronavigation
system, the coregistration procedure
with the CT images takes place automatically. All that has to be done is
toplace a reference star at a spinous
process.
whether the clipping has some detrimental effect on other brain regions.
Dynamic CT imaging allows them
obtain functional information, beyond
tissue morphology. With CT perfusion
imaging it is possible to obtain information about blood flow, blood volume,
and various other perfusion metrics as
permeability, time to drain, time to
peak and mean transit time. With 4D-CT
angiography one can see movies of
blood flow from arterial to venous phase
to assess the hemodynamic status of
the tissue.
Schichor says that no other imaging
modality is capable of providing this
kind of information intraoperatively:
With MRI and ultrasound, you are
always dealing with the problem of
visual artifacts produced by the clips.
And conventional angiography tells us
nothing about distant brain perfusion.
Looking back, Schichor recalls several
patients in whom the surgeon who
performed the clipping was convinced
that he had occluded the aneurysm.
Only intraoperative CT revealed that
this was not the case. We also had
one patient in whom a large aneurysm
was pressing the clip downwards toward
the vessel. Only in the perfusion CT
did we see an elative perfusion deficit
in distant regions of the brain. We corrected the clipping, and perfusion was
back to normal.
Intraoperative CT:
Advantages in terms of
safety, usability, and costs
It is these kinds of patient that best
illustrate the benefits of intraoperative
Patients with complicated vessel lesions,

for example large
aneurysms, or aneurysms that are partially
thrombosed, benefit
most from intraoperative CT.
Associate Professor
Christian Schichor, MD,
University Hospital Grosshadern, Munich
CT in neurosurgery. Tonn, Schichor,

Zausinger, and their colleagues have
gathered data from several prospective
patient series in order to better analyze
these benefits scientifically. In one of
these studies, the experts compared
intraoperative CT-assisted neuronavigation with conventional neuronavigation based on preoperative imaging
inpatients with spinal fusion surgery.
Zausinger: We found that repositioning was necessary in about seven percent of screws. This percentage is very
similar to the percentage of patients
who had to be reoperated in the era
before intraoperative CT was available.
Since the introduction of intraoperative
CT, there has not been a single patient
who had to be reoperated due to repositioning of the screws. Screw position
can now be proved by intraoperative
CT images during the procedure and
can be corrected immediately if
necessary.
Another patient series was about meningioma patients. Surgeons at the University used intraoperative CT to visualize
tumor tissue for resection that might
otherwise have been missed without
having images from intraoperative
CTavailable for assessing the tumor
resection success during surgery.
Reducing postoperative complications
is also a concern for surgeons; therefore, having access to reliable images
during surgery is important. Tonn
explains that by reducing complications, the likelihood of a re-admission
decreases, which means that the hospital saves money. Intraoperative CT
therefore can actually support cost
efficiency for a hospital, he concludes.
One gantry and

two sliding doors
It is no surprise, then, that Tonn was
able to convince the hospital administration at University Hospital Grosshadern to buy a second intraoperative
CT to be installed in the hospitals new
surgery building, which opened its
doors in summer 2014.
The new Operationszentrum (OPZ)
directly adjacent to the hospitals main
building is an eye-catcher, architecturally. But above all it is designed as an
answer to the demands of the increasingly interdisciplinary nature of surgery.
Intraoperative CT: The Siemens Solution

The intraoperative CT scanner
from Siemens was designed with
the needs of the surgeon always
in mind. Rather than moving the
table with the patient into the
CT gantry, the intraoperative CTs
large gantry slides on rails over
the patient on a standard surgical table. The advantage of this
solution is that the surgeon has
imaging on demand and easy
access to the site of surgery by
moving the CT gantry out of the
way when not in use and sliding
it back into the initial position.
The gantry can slide over the
patient automatically later on
always in the correct position,
without endangering the patient.
Water-cooling instead of air-cooling the CT gantry is an important feature that helps meet
cleanliness requirements. Floormounted sliding gantries are
likely to have less impact on
laminar air flow in the operating
theater compared with ceilingmounted rail systems. Unique on
the market is that the Siemens

sliding gantry comes with a dual
room configuration: One CT
scanner can be used to serve two
adjacent operating rooms, which
can optimize the cost-benefit
ratio. It is even possible to have
a parking garage in between
the two operating theaters such
that both rooms can be kept
clean. Compared with most
mobile CT vendors that largely
focus on visualizing bone in nonobese patients, the soft tissue
contrast offered on Siemens intraoperative CT systems allows
visualization of tumors and nerve
structures in greater detail. So is
the ability to perform CT angiograms, CT perfusion imaging,
metal artifact reduction, Dual
Energy capabilities, and iterative
reconstruction methods to reduce
dose. As such, Siemens intra
operative CT is the modality of
choice for those surgeons who
need to see more than just bone
in patients ranging from pediatric to obese.
The building, which required an investment of 196 million euros, features

32 brand-new operating theaters that
are equipped with state-of-the-art
medical technology.
that adoption of intraoperative CT

will increase, and this is certainly in
the interests not only of the patients
but also of our hospital administrators. p
The OPZs intraoperative CT is a modern SOMATOM Definition AS+ with

128 slices. It is a dual-room solution
that is mounted on rails in-between
two operating theaters, separated by
two sliding doors, so that the CT can
be used by surgeons in both rooms.
Philipp Grtzel von Grtz is a medical

doctor turned freelance writer and book
author based in Berlin, Germany. His focus
ison biomedicine, medical technology,
health IT, and health policy.
Tonn expects the second intraoperative CT to increase interest in the

technology considerably: It will be
easier for other surgical specialties to
use intraoperative CT, since the technology will be available in two rooms.
The previous system is already being
used occasionally by trauma surgeons
to screw pelvic or other complex
fractures. ENT surgeons are also very
interested, and in the new building
we will share a floor. I am convinced

herein are based on results that were achieved
inthe customers unique setting. Since there is no
Further Information
www.siemens.com/
sliding-gantry
News
Stellar Detector:
A Slovakian Success Story
in Coronary Artery Surgery
To improve cardiac diagnosis and follow-up after stent placement,
Jessenius diagnostic center upgraded the SOMATOM Definition Flash with
two new Stellar detectors. Following the upgrade, Jessenius is now better
able to monitor the functioning of stents and to plan treatment and coronary
artery surgeries in an optimized way.
Text: Marcela Fuknov, Photos: Thomas Steuer
During the examination, thepatient benefits from the increased image c ontrast and faster acquisition.
In 2012, the Jessenius Diagnostic

Center in Nitra, Slovakia, decided to
upgrade its existing Dual Source
computed tomography (CT) system
SOMATOM Definition Flash with a
new technology, the Stellar detector
from Siemens. This also made them
the first site in Europe to install such
an upgrade. The main reason for the
upgrade was to improve the quality
of cardiac imaging, especially the

management of stent placement.
Thanks to the upgraded CT system,
they can now diagnose coronary
artery, heart, and aortic disease, as
well as pulmonary embolism significantly better, and can quickly differentiate them from other causes of
acute chest pain.
Economical upgrade
Martin Halaj, MD, a certified radiologist and head of the board at Jessenius
center, recognizes the Stellar detector
as a cutting-edge technology: It
improved the quality of examinations,
precision, diagnostics, and significantly
reduced the radiation dose for patients
when used in combination with SAFIRE.
News
We also appreciate the high imaging

contrast and faster examination. We
have acquired a higher level of assessment technology without the need to
purchase a new CT scanner.
Stent monitoring
The SOMATOM Definition Flash now
with the Stellar detector featuring innovative Edge technology allows clinicians
to streamline the monitoring of patients
with a stent. We can monitor the correct deployment of the stent, and are
able to verify the patency of the stent
much more precisely than before. We
look at sharper images with less blooming of calcifications and metal stent
struts now. The high image quality provides more diagnostic confidence making it easier to determine restenosis or
thrombosis, says Halaj.
More precise imaging

In addition to the impressive benefits
of Dual Source CT, such as minimizing
image blurring with a native temporal
resolution of 75 ms, the SOMATOM
Definition Flash with the Stellar detector
now also brings further advantages.
The Stellar detector minimizes crosstalk between neighboring detector rows
which reduces the so-called slice blurring significantly. This results in more
precise image profiles, which in turn
allows improving spatial resolution
from 0.33 mm to 0.30 mm.
Lower noise, improved detail

Due to the innovative integration of
electronic components, noise is minimized increasing the signal-to-noise
ratio with the Stellar detector. This
makes it possible to use contrast
medium more effectively, achieving
a high quality of imaging in various
types of examinations. Siemens had
already set a trend when low-kV
imaging was introduced with 70 kV
scan modes and CARE Child at the
SOMATOM Definition Flash. Low kV
imaging elicits an improved iodine
contrast enhancement, which in turn
enables the SOMATOM Definition
Flash to provide a more effective use
of the contrast medium.
With the Stellar detector, even more
investigations can now be carried out
at low kV levels; for instance, abdomen
scanning which previously was performed at 120 kV and can now be done
at 100 or even 80 kV. Furthermore,
the full electronic integration of the
Stellar detector allows an extension
of the so-called dynamic range. This
feature known as HiDynamics
increases the sensitivity of the detector, especially in low kV images. As the
radiologists at Jessenius Diagnostic
Center confirm, with the Stellar detector upgrade, low-contrast object can
now be displayed with improved image
contrast. At Jessenius, SOMATOM
Definition Flash with Stellar detectors
allows the technologists to make
more effective use of the administered contrast medium.
With high-quality CT angiography,

physicians at Jessenius are also able
to identify high-risk patients for
treatment, says Halaj. Angiography
examinations of a patients blood vessels are really precise now. I remember
a low-risk patient with a main stem
stenosis. This was a young man with
atypical symptoms. The high-quality
CT angiography literally saved his life.
The example from Slovakia shows
clearly how SOMATOM Definition Flash
overturns a number of well-established beliefs about how a CT is run
and redefines what can be achieved
in clinical practice: With the Stellar
detector upgrade and SAFIRE, not
only can dose and contrast media
application can be optimized, diagnostic confidence can also benefit. p
Marcela Fuknov studied journalism at
Comenius University in Bratislava, got her
diploma in 1999 and since 2002 has worked
as contributing editor in Slovakias second
best-selling weekly magazine ZIVOT. She is
specialized in real-life and medical stories,
is contributing editor of the weekly health
section, writing stories about patients, dealing
with new scientific medical information and
cooperating with various patient organizations. In 2012 she was a finalist of the
EU Health Prize for Journalists in Brussels.

1
Improved diagnostic
confidence
We look at sharper images

with less blooming of
calcifications and metal
stentstruts now.
Martin Halaj, MD, radiologist and head
of the board at Jessenius center
Jessenius has also implemented

Siemens Sinogram Affirmed Iterative
Reconstruction (SAFIRE) for additional
dose reduction of potentially up to
60%,1 depending on the patient and
application. Using SAFIRE now allows
the site to process practically all
images with the benefits of iterative
reconstruction. However, image quality
is essential as well as dose reduction.
Clear visualization of the delicate
structures and deposits in coronary
arteries, the contours of blood vessels,
and reliable identification of calcifi
cation and restenosis allow them to
establish new standards.
In clinical practice, the use of SAFIRE may reduce

particular clinical task. The following test method
was used to determine a 54 to 60% dose reduction
when using the SAFIRE reconstruction software.
Noise, CT numbers, homogeneity, low-contrast
resolution and high contrast resolution were
assessed in a Gammex 438 phantom. Low dose
data reconstructed with SAFIRE showed the same
image quality compared to full dose data based
on this test. Data on file.
Further Information
www.siemens.com/
SOMATOM-Definition-Flash
News
SOMATOM Scope:
Cost-Saving Quality
As a global pioneer in a time of tight budgets, the Portuguese Institute of
Oncology, Lisbon, Francisco Gentil (IPOLFG) was the first clinic worldwide
to install the new SOMATOM Scope, delivering high-quality clinical outcomes
in an economical way.
Text: Manuel Meyer, Photos: Pedro Guimares
While the costs of cancer diagnostics

and treatment continue to rise in Portugal as elsewhere, state healthcare
budgets have shrunk considerably in
the wake of the continuing financial
crisis. In view of this funding shortfall,
the Portuguese Institute of Oncology
in Lisbon (IPOLFG) like many other
public hospitals is faced with a decisive question: How to save expenditures without compromising on high
quality standards inthe treatment of
patients?
A world premiere
One of the ways in which we
answered this question was the acquisition of the SOMATOM Scope CT
scanner, says Jos Venncio, MD.

As head of the radiological department at the IPOLFG, he was involved
to a considerable extent in the decision to install the new Siemens CT
scanner in February this year the
first in any hospital worldwide. And
after just a few months, he is certain:
It was the right decision. Immediately
striking were the various features of
the eCockpit. By increasing usage efficiency in all phases of use, from rest
periods to operation, they noticeably
reduce CT running costs, says the
55-year-old head radiologist.
Due to the devices reduced energy
consumption, a further advantage is
the SOMATOM Scopes low heat waste,
as it requires less air conditioning.
Efficient usage
Venncio is experiencing the extremely
high reliability and low maintenance
costs of the SOMATOM Scope. The scanner features innovative eMode technology that analyzes scanning parameters
in real time and instantly finetunes the
scan with the right balance between
dose, image quality, and efficiency.
This means the system is not operated
at peak, reducing wear and tear to all
movable parts. He also cites the benefits of the eStart function, which gently
preheats the X-ray tube after extended
periods of non-use to avoid the stress
of cold starts. The result is high reliability both from the scanner and the
tube.
In IPOLFG, almost one third of all patients undergo CT imaging for diagnostic and therapeutic monitoring.
News
The user-friendly software has clearly

enhanced clinical workflow and reduced
waiting periods between scans.
Jos Venncio, MD, Head Radiologist at the IPOLFG
However, as the radiologist points out,

the new CT scanner has many more
advantages. When he was tasked with
heading the radiological department
four years ago, the assignment was not
only to bring down the cost of radiology,
but also to make it more efficient in
light of personnel shortfalls arising from
layoffs and hiring freezes imposed at
the IPOLFG as part of government austerity measures.
that intelligently combines both

clinical excellence and cost efficiency.
Equipped with powerful technology
but still affordable in a time of tight
budgets, managing the number of
scans required annually is not a problem according to Venncio, who
describes the devices price-performance ratio as optimal.
Reduced waiting periods
In the procurement of a CT scanner,

the head radiologist was particularly
intent on ensuring that high quality
standards in diagnosis and imaging
should be guaranteed, including
3D image processing and advanced
applications such as provided by
syngo.via. Here, too, the SOMATOM
Scope has proven its worth across the
board, Jos Venncio says.
Today, we must work more using

fewer staff and resources, comments
Jos Venncio, who has been at the
IPOLFG for 28 years. The scanner supports us in that mission. The userfriendly software and technologies such
as FAST Planning and FAST Spine have
clearly enhanced clinical workflow and
reduced waiting periods between scans.
Almost 35,000 scans a year

The mid-sized hospital with 257 beds
and around 1,800 members of staff is
the largest of three state-run oncology
institutes in Portugal. The IPOLFG in
Lisbon is responsible for 5.5 million
people or half of the population, covering not only Greater Lisbon, but also
the entire south of Portugal as well as
the island regions of Madeira and the
Azores.
The radiology department plays a key
role as almost all patients attending an
oncology clinic require X-rays for diagnosis and monitoring of treatment.
29 radiologists carried out a total of
113,768 X-ray examinations of which
35,000 were CT scans (performed on
two scanners).
Powerful and affordable

Despite this relatively high workload,
the clinic management and the head
radiologist made a conscious decision
with the SOMATOM Scope, a scanner
1A
1B
High quality
Excellent image quality, even for

large volume coverage: This patient
was imaged using CARE Dose4D and
IRIS and dose was reduced to 6.5 mGy
(while the European Comission1
recommends a maximum of 35 mGy)
Reduced X-ray dose

Thanks to this scanner and its dosesaving technologies, weve also managed to reduce the X-ray dose for all
scans, Venncio explains. This, he
says, is especially important for cancer
patients, who must undergo several
X-rays, as well as for the many younger
and more vulnerable patients. The
IPOLFG is the only hospital in its entire
jurisdiction that provides pediatric
oncology services. In some cases
follow-up studies - weve been able
to reduce the dosage by up to 40 percent while maintaining high levels of
quality and diagnostic confidence,
the head radiologist notes. p
Manuel Meyer writes for the German
rztezeitung in Spain and Portugal.
Further Information
www.siemens.com/
SOMATOM-Scope
The Portuguese Institute of Oncology, Lisbon,

Francisco Gentil (IPOLFG), Portugal.

1
European Guidelines on Quality Criteria for

Computed Tomography.
News
Metal Artifact Reduction

in a Trauma Setting
The Berufsgenossenschaftliche Unfallklinik was one of the first
customers to install a SOMATOM Definition Edge in combination with
Dual Energy to reduce metal artifacts.
By Jrgen Merz, PhD
The Berufsgenossenschaftliche
Unfallklinik (BGU), located close to
the University Hospital Tbingen is a
major trauma center in south-west
Germany.
In mid-2012, the hospital decided to
replace their older system with the
SOMATOM Definition Edge. BGU was
one of the first customers to install
a SOMATOM Definition Edge in combination with Dual Energy to reduce
metal artifacts. The Siemens high-end
single source CT is equipped with the
renowned Stellar detector technology
and several further dose reduction
features. It is now easier for clinicians
at BGU to evaluate tissue and bone
structures near to metal implants
(screws, nails, plates) than with previous CT generations. Metal implants
can, therefore, be removed earlier
from patients.
Trauma center requirements
Challenge metal artifacts
As a trauma center, BGUs portfolio

mostly includes healthcare services for
all kind of accidents and ranges from
fractures to spinal surgery and polytraumata. Many patients receive metal
implants for a few weeks in order to
stabilize difficult fractures or degenerated bone tissue. In addition, a large
number of patients need to undergo
CT scans more than once for example, to follow-up after surgery. Chief
radiologist at BGU, Oliver Luz, MD, is
an experienced user of the SOMATOM
Definition Edge and its monoenergetic
Dual Energy application. It is essential
for the hospital that a newly installed
CT delivers images of high diagnostic
validity with lowest dose possible, on
the one hand; and, on the other hand,
offers additional value for their specialist portfolio asaregional trauma
center.
Streak artifacts often caused by metal

implants make it hard to differentiate
the tissue around the metal object that
is stabilizing a critical, complex fracture or fixing a weakness in the spine.
Just to be safe, we previously left
the implants in the body rather longer
instead of removing them too early,
Luz says. Dual Energy monoenergetic
imaging enables radiologists to view
the images at different keV levels and
according to their particular needs
to reduce metal artifacts.
Excellent image quality

fast and at a low dose:
Technical specifications
Besides the fast pitch of 1.7 that enables
up to 23 cm/s acquisition in trauma
scanning, SOMATOM Definition Edge
comes with the S
tellar detector tech-
Our experience imaging patients on the

SOMATOM Definition Edge helps us to avoid
unnecessary surgery and also makes it possible to
remove plates and other implants earlier than
before. That saves a lot of money and inconvenience
for us and for our patients.
Oliver Luz, MD, Radiologist,
University Hospital and BGU, Tbingen, Germany
News
1
1
A male patients lower
extremity was scanned
with only 0.18/0.20 mSv.
Femur shaft intra
medullary nailing could
clearly be displayed by
reducing metal artifacts
providing higher diagnostic confidence.
Courtesy of BGU,
Tbingen, Germany
2
2
The monoenergetic
CTscan showed distal
radius fracture with
synostosis in the lower
extremity.
Courtesy of BGU,
Tbingen, Germany
nology providing high signal-to-noise

ratio. The combination of Edge technology, 0.5 mm slices, and SAFIRE offers
excellent image quality at a reduced
dose of up to 60%.1 The SOMATOM
Definition Edge allows us to scan at
anextremely low dose with excellent
image quality, says Luz.
Luz. The patient can start rehab earlier

and has a quicker recovery from the
injury. The hospital also benefits from
the scanner: The new technology
attracts additional patients and helps
to prevent unnecessary surgical procedures caused bymisleading interpretation of diagnostic images. p
Safe suggestions
for early implant removal
SOMATOM Definition Edge and Dual
Energy allow us to better evaluate bone
tissue in the presence of metal artifacts. On average, we tend to suggest
removal of metal implants earlier than
with our previous system, concludes
1 In clinical practice, the use of SAFIRE may reduce

for the particular clinical task. The following test
software. Noise, CT numbers, homogeneity, lowcontrast resolution and high contrast resolution
dose data reconstructed withSAFIRE showed the
based on this test.
Further Information
www.siemens.com/
SOMATOM-Definition-Edge
For the Portuguese private hospital SAMS in Lisbon, where Paulo Pedro, MD is head of the cardiology
department, the SOMATOM Perspective is particularly suitable for cardiological CT.
Cardiac CT:
As Simple as That
Cardiovascular diseases are among the most frequent causes of death worldwide. Innovative diagnostic approaches are becoming increasingly important.
At the Portuguese private hospital SAMS in Lisbon, the cardiology department
has been using the SOMATOM Perspective for two years.
Text: Manuel Meyer, Photos: Miguel Ribeiro Fernandes
News
Stress, smoking, lack of exercise,

unhealthy nutrition, high blood pressure the factors contributing to
cardiovascular diseases are many and
manifold. According to the World
Health Organization (WHO), coronary
and cardiovascular diseases are among
the leading overall causes of death
the industrialized countries and the
upward trend is continuing especially
in developing countries.
In response, many practices and hospitals are permanently aiming to improve
their examination methods and diagnostic capabilities. One of them is the
Portuguese private hospital SAMS in
Lisbon, which purchased a SOMATOM
Perspective two years ago.
Reduced radiation dosage
workflow and allows the doctor to

concentrate more on the diagnosis,
he says. This not only saves valuable
time, which is essential in the case
of heart attacks, for instance, but
generally also offers more diagnostic
confidence, says Pedro.
The scanner not only allows certain
and speedy identification of valvular
defects, stenosis, and diseased coronary vessels and heart muscles. It has
also proven its value in combination
with syngo.via Element CT in the
exclusion of coronary heart diseases
and in the examination of patients
after bypass operations, the head
cardiologist confirms.
Cardiac CT really
is not difficult.
All it takes is practice,
good knowledge of
cardiological anatomy,
and an appreciation
of computer work.
Paulo Pedro, MD,
SAMS, Lisbon, Portugal
Due to its excellent image quality and

the technical abilities to greatly reduce
the radiation dosage with the iterative
reconstruction method SAFIRE1, for us
the CT scanner is particularly suitable
for cardiological CT examinations,
explains Paulo Pedro, MD, head of the
cardiology department at the SAMS
hospital.
Also, the 128-slice CT scanner offers
exceptionally short scanning times, he
says, which is particularly important in
cardiac CT due to the constant heartbeat. Pedro is enthusiastic about the
SOMATOM Perspective: Especially
with ambiguous disease patterns, the
CT scanner delivers the better and
alsothe more affordable examination
method, and it also helps us avoid
exposing patients to risky, yet sometimes unnecessary interventions.
Especially user-friendly
He hopes to eliminate the reservations
of some colleagues who still regard
cardiac CT as too complicated and intricate: Cardiac CT really is not difficult.
All it takes is practice, good knowledge
of cardiological anatomy, and an
appreciation of computer work. The
53-year-old cardiologist thinks that
the SOMATOM Perspective makes
handling and diagnostics especially
user-friendly thanks to the reading
workplace syngo.via Element CT.
The automatic case preparation with
syngo.via Element CT accelerates the
A male patient underwent a coronary CT angiography to exclude restenosis intrastent

and control bypass. Courtesy of SAMS, Lisbon, Portugal
News
Of sequences and spirals

Paulo Pedro favors the approach of
spiral scans in combination with the
SAFIRE technology, which reduces
the radiation dosage through iterative
reconstruction: In this modality, I
achieve the ideal balance between
radiation dosage and image quality,
since a dosage of between 2 and 4 mSv
at 110 kV gives me a multiphase image
display that reconstructs the beating
heart in various phases, which is often
necessary in order to be able to distinguish lesions from motion artifacts.
At high heart rates, he applies multiphase spiral CTs, while at lower heart
rates, he also uses sequential CTs.
Time for preparation

Although the CT scanner is used by
all specialist departments, cardiac
exclusively is performed every Monday
morning. This allows me to concentrate better and without time pressure on every patient and also to collaborate more intensively with the
radiologist, says Pedro. This approach,
he says, is particularly successful with
cardiac CT.
You need sufficient time and calmness to prepare the patient for the
examination. Because if the patient is
nervous or stressed with a very high
or irregular heart rate, it is difficult to
secure significant CT images, Pedro
confirms.
Step-by-step tutorial for

successful cardiac CT:
Step 1: Patient anamnesis
Ensure all of the patients files
and reports are available (e.g.,
ECGs, ultrasound, reports of
initial examinations).
Prepare the patient for the
CT scan, check patient history
including currently or previously prescribed medication.
Take into consideration pos
sible patient-related problems
(obesity, claustrophobia, medication given, current ailments
etc.).
Check beta blocker to be
administered.
Step 2: Patient
preparation
A few days before the examination, you should call the patient
to confirm whether he or she
is taking the medication as
instructed.
On the day of the CT scan:
Check heart rate. If necessary,
give beta blockers to reduce
heart rate.
Give glyceroltrinitrate for

dilation of the coronary vessels.
Prepare the flow rate and
volume of contrast media.
Step 3: Patient positioning

& instructions
Shave and clean the skin for an
oil-free surface.
Position the patient head-first
on the CT scanner. Prepare
catheter for vascular injection
of contrast media, into the
right arm if possible.
Mention the intensive warm
sensation that may be caused
by contrast agent.
Position patients arms above
head.
Check correct positioning of
chest.
Verify that the patient is lying
comfortably.
Use knee support to improve
patient comfort.
Apply ECG electrodes.
Place leads only after the patient
is positioned with arms up.
Use fresh supply of ECG leads.
Therefore, preparation is crucial for

successful cardiac CT, says the Portuguese cardiologist, who has successfully introduced a six-step system
for his CT examinations. Pedro also
presents his approach in a step-bystep tutorial video. Computed tomography will prevail in cardiology and
play an increasingly important role.
Nobody should shut themselves off
from it, says Paulo Pedro. p
Manuel Meyer is a writer for the German
rztezeitung in Portugal and Spain.

together with a variety of syngo.via-based software
options, which are medical devices in their own right.
syngo.via and the syngo.via based software options
are not commercially available in all countries. Due
to regulatory reasons its future availability cannot
be guaranteed. Please contact your local Siemens
organization for further details.
According to Paulo Pedro, MD preparation is crucial for successful cardiac CT.
News
The SOMATOM Perspective makes handling and diagnostics especially user-friendly

thanks to the reading workplace syngo.via Element CT.
Use ultrasound gel to improve

signal conduction.
Arrange the ECG cable along
patients side.
Secure the cable splitter away
from scan field.
Check ECG on the gantry display.
Good ECG (upper part of the image)
has clear R-peaks; sub-optimal ECG
(lower part) has noise.
Rehearse breathing commands with
the patient and instruct the patient
not to move during CT scan.
Center the patient in the scan field.
Step 4: Calcium Scoring

First scan without contrast agent
to establish level of calcification in
the vessel.
Perform ECG check and use the
automated result as a guide for your
subsequent scan mode decision
(green: go, yellow: second-best
choice with certain risks, red: not
possible).
Conduct a monitoring scan/
topogram.
Determine scan range: Position the
scan range over the heart from the
carina to the apex.
Set up Phase Start: In the Phase
Start area, specify the image acquisition phase.
Perform Calcium Scoring as a

sequence scan.
BestPhase: Automatically detects
the optimal systolic and diastolic
phase for motionless coronary
visualization.
Ensure that BestDiast is selected
in the BestPhase area and click
Recon. Images are reconstructed
in the optimal stage of the diastolic
phase (B35s kernel), 3.0 mm slice
and 1.5 mm increment. 3.0 mm
are necessary for Agatston Score.
Go to heart isolation and Coronary Tree Visualization to yield

an immediate view of vascular
structures.
Take a look at the automatic
vessel centerline extraction and
anatomic labeling.
Navigate through multiphase
images.
After finishing your coronary
analysis and evaluation, click the
case navigator workflow task
CTcardiac function to proceed
with the evaluation.
After pre-processing, you can
already see the results overview:
Check the beating heart to make
the quantification details such as
polar maps of wall motion, wall
thickening, and wall thickness
available.
Step 6: Final report

With a single click create a report
with syngo.via Element CT.
Further Information
www.siemens.com/
SOMATOM-Perspective
Watch the
step-by-step
tutorial via
this QR code.
Step 5: Coronary CTA

Place the ROI in the center of the
ascending aorta, away from any
calcified portion of the aortic wall.
Use bolus tracking and therefore
specify the trigger threshold:
Ensure that auto trigger is selected.
The recommended threshold is
100 HU.
The subsequent CTA scan will
be triggered once this threshold
is reached in the reference ROI.
Perform coronary CTA spiral scan.
To reconstruct CTA images, work
again with BestPhase function.
syngo.via Element CT with its
clinical applications guides you
through a fast and reliable diagnosis including pre-processed
steps:

forthe particular clinical task. The following test
software. Noise, CT numbers, homogenity, low
contast resolution, and high contrast resolution

News
SOMATOM Force: Initial Research

Results Testify to Clinical Strength
Over 35 SOMATOM Force are now installed and used in clinical routine
at various leading facilities around the world. Scientific publications
arealready reporting results that demonstrate how this new Dual Source
scanner has the potentialto change CT imaging forever.
By Stefan Ulzheimer, PhD
SOMATOM Force was introduced

atlast years annual meeting of the
Radiological Society of North America
(RSNA). Its radical new technical
design includes, for example, the new
Vectron X-ray tube that can deliver
up to 1,300 mA at low kV, has the
smallest focal spot in the industry,
and comes with completely new and
optimized spectra and pre-filtration
options (tin filters). Another example
is the wider StellarInfinity detector again
with the largest number of physical
detector elements in each of the 96
detector rows (920) and a 3D antiscatter collimator that, in combination with even faster rotation speeds
(0.25 s), leads to scan speeds of up
to 737 mm/s with highest spatial resolution. Initial research results reveal
how these advances are being transformed into clinical benefits.
Lung and other highcontrast, high-resolution

imaging applications
SOMATOM Force is equipped with a
new tin filter positioned at the exit of
the X-ray tube emission window that
hardens and optimizes the X-ray spectrum for high-contrast applications
where no iodine contrast is involved
such as lung imaging, virtual colonoscopy, and bone imaging for inner
ear and paranasal sinuses.
The entirely new model-data-based
iterative reconstruction technique
ADMIRE1 (Advanced Modeled Iterative
Reconstruction) was introduced first
on SOMATOM Force. In combination,
this leads to scan modes with extra
ordinarily low patient dose values,
which is especially important as
scans are performed on potentially
1
1
Ultra-low-dose
chest examination with an
effective dose
of 0.06 mSv.[1]
Courtesy of
University
Hospital Zurich,
Switzerland
completely healthy patients to help

detect diseases earlier.
Gordic et al. were able to show that
chest CT for the detection of pulmonary nodules can be performed on a
SOMATOM Force [...] producing high
image quality, sensitivity, and effective
radiation dose of 0.06 mSv [...] using
these new and unique scan modes in
combination with ADMIRE.[1] This
means that a comprehensive CT scan
can now be carried out at dose levels
of a conventional chest X-ray.
The same optimized scan modes with
tin pre-filtration in combination with
ADMIRE were evaluated in connection
with the large COPD gene multi-center
trial.[2] The authors conclude that the
SOMATOM Force using ADMIRE [...]
can acquire accurate quantitative CT
images with acceptable image noise at
very low-dose levels (0.15 mGy). This
opens up new diagnostic and research
opportunities in CT phenotyping of the
lung for developing new treatments
and increased understanding of pulmonary disease.[3]
A group of researchers from University
Medical Centre Mannheim, Germany,
concentrated on the advantages of
SOMATOM Force for temporal bone
imaging. Due to the improved spatial
resolution in conventional scan mode
and the industrys smallest focal spot
size along with the completely redesigned detector system, they found that
ADMIRE can deliver even better image
quality at lower dose compared with
dedicated ultra-high resolution scan
modes used on previous systems.[4]
News
2
2
Body perfusion
ofacomplete liver
with an effective
dose of 14.7 mSv.
Courtesy of
University Medical
Centre Mannheim,
Germany
CT angiography (CTA) and

cardiac Imaging
CARE kV has been optimized on
SOMATOM Force and is now able to
adjust the tube voltage at an even
greater range of kV settings and to use
low kV imaging for a broader spectrum
of patients. CTAs in particular benefit
from the possibility of optimizing the kV
setting in 10 kV steps over a wide range
of tube voltages (70 kV to 150 kV). 70
and 80 kV can be used in adult patients
leading to a significant dose reduction
compared with traditional 120 kV protocols.[5]
Low kV imaging can be used to reduce
radiation dose or contrast medium2
dose or even both. An initial patient
study investigating this effect in coronary CTA (cCTA) shows that in nonbariatric patients, SOMATOM Forces
high-pitch coronary CT angiography
at70 kV [...] results in robust image
quality for studying the coronary arteries, at significantly reduced radiation
dose (0.44 mSv) andcontrast medium
volume (45 mL) [].[6]
The even higher scan speed of 737 mm/s
and a native temporal resolution of
66ms make SOMATOM Force the ideal
cardiac scanner. Due to the extremely
high scan speed, breath-hold becomes
optional in almost all applications. The
introduction of the Turbo Flash Spiral
renders the fast and dose efficient scan
mode even more robust. A patient study
performed at the Medical University
ofSouth Carolina showed that cCTA
with the Flash Turbo spiral of the
SOMATOM Force [...] can be performed at HR up to 75 bpm while

maintaining diagnostic image quality,
being associated with an average
radiation dose of 0.6 mSv.[7] A similar study from Switzerland came to
comparable conclusions.[8]
Body perfusion
CT Perfusion (CTP) information might
be the best marker for an early and
reliable prediction of whether a particular cancer treatment is effective.
For example, it has been shown that
CTP is the best predictor of outcome
after chemoembolization of liver
metastases.[9, 10] However, in the
past, CT perfusion in the body trunk
has been limited by relatively high
radiation dose levels. Now, SOMATOM
Force can overcome this barrier. At
low kV levels previously not possible
due to the lack of X-ray power at low
kV, reasonable radiation doses comparable with conventional multi-phasic
liver examinations can be achieved
for comprehensive CTP studies of the
abdomen. p
In clinical practice, the use of ADMIRE may reduce

Early clinical experience based on imaging of the

left ventricle and aortic root (TAVI studies) demonstrate that a reduction of contrast media administration may be possible using SOMATOM Forces
Turbo Flash Mode and its low kV/High mA capabilities.

References
[1] Gordic S, et al. Ultralow-dose chest
computed tomography for pulmonary
nodule detection: first performance
evaluation of single energy scanning
with spectral shaping, Invest Radiol.
2014 Jul;49(7):465-73. doi: 10.1097/
RLI.0000000000000037.
[2] Manichaikul A, et al. Genome-wide
study of percent emphysema on
computed tomography in the general
population. The Multi-Ethnic Study of
Atherosclerosis Lung/SNP Health Association Resource Study. Am J Respir Crit
Care Med. 2014 Feb 15;189(4):408-18.
doi: 10.1164/rccm.201306-1061OC.
[3] Newell JD Jr, et al. Very Low-Dose
(0.15mGy) Chest CT Protocols Using
the COPDGene 2 Test Object and a
Third-Generation Dual-Source CT
Scanner With Corresponding ThirdGeneration Iterative Reconstruction
Software., Invest Radiol. 2014 Sep 5.
[4] Meyer M, et al. Initial results of a new
generation dual source CT system using
only an in-plane comb filter for ultra-high
resolution temporal bone imaging. Eur
Radiol. 2014 Sep 8. [Epub ahead of print]
[5] Meinel FG, et al. Image quality and
radiation dose of low tube voltage 3rd
generation dual-source coronary CT
angiography in obese patients: a
phantom study. Eur Radiol. 2014 Jul;
24(7):1643-50. doi: 10.1007/s00330014-3194-x. Epub 2014 May 10.
[6] Meyer M, et al. Closing in on the K Edge:
Coronary CT Angiography at 100, 80,
and 70 kV-Initial Comparison of a
Second- versus a Third-Generation DualSource CT System. Radiology. 2014 May
31:140244. [Epub ahead of print]
[7] Morsbach F, et al. Performance of turbo
high-pitch dual-source CT for coronary
CT angiography: first ex vivo and patient
experience. Eur Radiol. 2014
Aug;24(8):1889-95. doi: 10.1007/
s00330-014-3209-7. Epub 2014 May 17.
[8] Gordic S, et al. High-pitch coronary CT
angiography with third generation
dual-source CT: limits of heart rate. Int J
Cardiovasc Imaging. 2014 Aug;30(6):
1173-9. doi: 10.1007/s10554-0140445-5. Epub 2014 May 11.
[9] Morsbach F, et al. Perfusion CT best
predicts outcome after radioembolization
of liver metastases: a comparison of
radionuclide and CT imaging techniques.
Eur Radiol. 2014 Jul;24(7): 1455-65. doi:
10.1007/s00330-014-3180-3. Epub
2014 May 12.
[10] Reiner CS, et al. Early treatment
response evaluation after yttrium-90
radioembolization of liver malignancy
with CT perfusion. J Vasc Interv Radiol.
2014 May;25(5):747-59. doi: 10.1016/j.
jvir. 2014.01.025. Epub 2014 Mar 13.
Business
Flexible Flash
for a Forward-Thinking Hospital
In the Regional Hospital of Bolzano, Italy, trauma victims from skiing, hiking and other
accidents often present. Others are suffering from a stroke, cardiac disease, or cancer.
Thus sophisticated diagnostic imaging capabilities are required for adequate patient care.
SOMATOM Sensation 16 and SOMATOM Definition Flash together with syngo.via and
dedicated clinical software applications help to manage this great diversity of clinical tasks
in Bolzano.
Text: Claudia Flisi, Photos: Toni Anzenberger
Patrizia Pernter, MD,

is r adiologist at the
Regional Hospital of
Bolzano in Italy. She
andher team are among
thefirst in Italy to use
SOMATOM Definition
Flash with syngo.via.
Business
A flash of uncertainty
tzi is not the reason that the hospital
invested in the SOMATOM Definition
Flash and syngo.via1, however. The
SOMATOM Sensation 16 arrived in
2004 and proved its worth as an allaround CT scanner, reliable and easy
to use. So it was decided to purchase
the Dual Source CT SOMATOM
Definition Flash in 2011, in part to
replace an older CT. syngo.via was
acquired at the same time, and the
idea was to use the scanner and software primarily in cardiology, as in
Bolzano hospital about 2,400 coronary
angiography exams a year are done.
Aortic dissection, type Stanford A VRT and MIP images clearly demonstrate
an aortic dissection involving the ascending aorta and the aortic arch.
The intimal tear extends into the brachiocephalic artery.
Courtesy of Regional Hospital of Bolzano, Italy
When Patrizia Pernter, MD, was studying medicine at the University of

Innsbruck in Austria in the late 1980s,
she wanted to pursue a specialization
in pediatrics. She had no idea that she
would wind up as a radiologist.
Radiology became an option when
Pernter returned to her hometown of
Bolzano, Italy, in 1991. Training at the
Regional Hospital of Bolzano included
a stint in radiology, which she found
fascinating. Since more openings
existed for young physicians in that
area than in pediatrics, she accepted
aposition in radiology at the hospital.
tzi the Iceman also emerged in 1991,
literally, when two tourists stumbled
across a human corpse half frozen in
the ground in the tztal Alps, about
60 kilometers from Bolzano. This discovery turned out to be one of the oldest mummies in the world, and a rare
wet mummy because humidity can
still be found in his cells, making him a
prime candidate for medical research.
Iceman was scanned with the

SOMATOM Sensation 16. This enabled
researchers todo a complete body
analysis of the mummy in excellent
resolution for the first time, revealing
details not previously discernible.
One major finding is that tzi anatomically resembles modern man rather
than a primitive ancestor.
We were among the first hospitals

in Italy to try the Dual Source CT
SOMATOM Definition Flash with
syngo.via, recalls Pernter. Being
among early users always comes
with a bit of uncertainty. Nevertheless, we wanted the best equipment
available, and so we decided to try
it out.
Today, every single one of the hospitals vascular exams is done with this
system. We could already read vessels without Dual Energy, but now
with syngo.via we can remove extraneous details to clarify our results,
Pernter elaborates.
Ironically, the system has wound up
being used for less than one-third of
the hospitals cardiac cases because it
is so much in demand by other departments, notes Giampietro Bonatti, MD,
Bolzanos Head of Radiology. syngo.via
With syngo.via
Patrizia Pernter
works inter
actively with
a greater volume
of super-thin
slice images.
She and her
colleagues see
more in greater
detail and finish
diagnosis faster
than before.
The fortunes of Patrizia Pernter and

tzi intersected in 2005 when the
Business
is used in oncology, neurology, and

especially trauma the latter significant in Bolzano because of its mountain setting. The area is a magnet
for skiers in the winter, hikers in the
summer, and motorcyclists anytime.
When timing is everything

In the ER, timing is everything and our
speed has improved with syngo.via,
Pernter points out. She gives the example of a recent trauma victim, a man in
his fifties who had been hit by a truck
and arrived in the ER unconscious.
Medical technicians had alerted the
staff to probable trauma to his thorax,
but the extent of his injuries was
unknown. The patient was stabilised
and a CT was done with the SOMATOM
Definition Flash. As doctors, we want
to see what is going on in toto and
there is no better way to see what has
happened with the vascular system,
she observes.
The CT revealed a life-threatening
lesion to the victims aorta and a
hematoma in his superior abdomen.
Also, almost all his ribs were broken
and there was non-critical pelvic
damage. We needed to know the
dynamic of these injuries and the system provided it, Pernter continues.
In addition, syngo.via provided measurements to determine the size of
the prosthesis needed for the aortic
repair. Because the aorta is curved,
At the Regional Hospital of Bolzano syngo.via on SOMATOM Definition Flash is used in

oncology, neurology, and especially trauma the latter significant in that region because
of its mountain setting.
accurate calculation is not easy, and,

in the past, surgeons have resorted
to their own ways of measuring.
syngo.via makes these calculations
precisely and consistently, and helped
save the patients life.
Enhanced confidence after

stroke intervention
Stroke victims are like trauma patients
in that speed is of the essence. Pernter
and Giampietro Bonatti, an interven-
The Iceman Scan

At first glance, tzi the Iceman
would appear to be an ideal
patient for scanning slender,
quiet, and cooperative. But
his age and physical state
present certain disadvantages
to radiologists. Because the
mummy is maintained at a
temperature of six degrees
Centigrade and a relative
humidity of 98 percent in his
chamber at the South Tyrol
Museum of Archeology
in effect sheathed in ice he
must be defrosted before

scanning. To hold this disruption to a minimum and to
ensure that his skin does not
dry out, scientists have only
scanned him three times since
2001), for brief sessions, and
only during winter months.
As his left arm extends awkwardly across the front of
his chest, two passages are
needed for a full body scan.
Fortunately, the Iceman is not
the type to complain.
tional neuroradiologist, cite one

feature of syngo.via in combination
with Dual Energy that has excited
them: They can determine immediately whether a patient is suffering
from post-procedural bleedings. This
happens when a stroke victim comes
in with an acute ischemic stroke. The
patient is sent for an angio CT; if the
blockage isin an area where intervention is possible, the thrombus will be
aspirated. Then a CTA is performed.
Afterwards, the doctors want to know
if the patient has bled during this procedure, because follow-up treatment
depends on the answer.
But analysis can be tricky, as Pernter
explains: Contrast is used in the angiography so it can be difficult to distinguish between bleeding and contrast
medium. What you see on the grayscale images could be blood or contrast medium, you dont know. With
syngo.CT DE Brain Hemorrhage, we
can remove the dye from the images
and thus differentiate between bleeding and contrast medium. This is a
concrete, immediate benefit and we
are very pleased with it. We can tell
the neurologist whether the procedure
was successful and then a therapy of
anti-coagulants can be started right
away. We take advantage of this feature with about 50 stroke patients a
year.
Business
Imaging in oncology
In the oncology department, speed is
not necessarily as important as it is for
trauma and stroke. However, detailed
resolution and low radiation dosage are
crucial. For example, hepatic tumors
require multiphasic imaging, a sequence
of CT scans without contrast, 30 seconds, 80 seconds, and five minutes
after an injection of contrast medium.
You can see the development very well
on our workstation, reports Patrizia
Pernter.
Now we work interactively with a

greater volume of super-thin slice
images, one millimetre thick or less.
Obviously we see more and in greater
detail, notes Pernter, adding, If I had
to generate my reports in another
way, it would take longer.
Information overload?
The problem, if any, according to the
doctor, is that one may get lost in the
information because there is so much
and it is so interesting. Occasionally,
With the system using Dual Energy, it

may be possible to skip the first phase
without contrast entirely, do a scan,
then generate the non-contrast phase
virtually. This approach is currently
being tested at a hospital in Turin,
Italy, and is being followed closely by
Bolzano. The advantage would be a
further reduction of the patients exposure to radiation. The one possible
drawback is that accuracy is compromised if the patient is too large, but
very few cancer patients who would
be undergoing this test are obese, the
doctor observes.
From oncology to cardiology, stroke to
trauma, syngo.via has proved its worth
throughout the hospital. Because it
arrived together with the SOMATOM
Definition Flash, Pernter is hard-pressed
to attribute every improvement to
oneversus the other. The SOMATOM
Definition Flash is fast, and so is
syngo.via. For example, with the Flash
we can do a whole body scan from top
to bottom in a single sweep. We couldnt
do that before. With all the tubes sticking out of the patient, measuring blood
pressure, and so on, then repositioning
for another scan, you could lose 15
minutes between one scan and another.
Now we dont have that problem.
The system handles at least 40 patients
a day over 12 hours, not markedly different from the volume before 2011.
What has changed most in terms of
workflow for the radiology department
is the speed and accuracy of reporting.
Before 2011, the CT scan would be
performed, the technician would put
together a packet of 200 to 500 images,
then the physician would examine
these images and make a report.
This customization helps radiologists

tailor their exams to the focus of
theclinician, the pathology, and the
organ or area under scrutiny.
Doctors love it, claims Pernter, and
so do radiology students. When our
students come here for training,
you cant peel them away from the
syngo.via workplaces, she says.
Since the hospital will be extended
further there may be more of these
workplaces in the near future. p
The SOMATOM Definition

Flash together with
syngo.via has wound up
being used for less than
one-third of the hospitals
cardiac cases because it
is so much in demand by
other departments.
Giampietro Bonatti, MD, Head of
Radiology, Regional Hospital of Bolzano
Patrizia Pernter and her colleagues use

the data they generate for discussion
purposes. They discuss a case and
decide in a multidisciplinary environment how to proceed in the treatment
of the patient.
More of an issue is the temptation to
elaborate the data. You say, Oh, if I
look at this in a slightly different way
because you can. It happens often,
and does take up time that you might
not otherwise spend. But, on the
other hand, we dont have to change
from one workstation to another to
view the results of different elaborations, because syngo.via is multi-disciplinary and fully integrated, she
reports.
Another advantage is that every
operator who works with syngo.via
can personalize it to his or her
requirements. Images can be manipulated to a degree not possible
before. Distortions can be corrected
and precise measurements taken.
Based in Italy, Claudia Flisi writes about the

intersections of science and technology for
the International New York Times and many
other publications.
1

together with a variety of syngo.via-based software options, which are medical devices in their
own right. syngo.via and the syngo.via based
software options are not commercially available
in all countries. Due to regulatory reasons its
future availability cannot be guaranteed. Please
contact your local Siemens organization for
further details.
Further Information
www.siemens.com/
syngovia-for-ct
Business
SAFIRE by the Numbers

Located in southern Paris, the Bictre Hospital is a public institution, part of
the expansive Paris-Sud University Hospital complex. The hospital purchased
aSiemens SOMATOM Definition AS scanner in March 2010 and upgraded
toinclude iterative reconstruction with SAFIRE (Sinogram Affirmed Iterative
Reconstruction) software in September 2013. As a large public institution,
Bictre Hospital literally has its scanner on duty round-the-clock. It performs
about 22,000 examinations a year on some 15,000 different individuals.
Text: Bill Hinchberger, Photos: Antoine Doyen
Since proof is typically lacking of

SAFIREs ability to produce good quality images with lower doses of radiation, Bictre laboratory technician
Alfredo Cantarinha and Laurence
Rocher, MD, compiled detailed comparative data on examinations of the
same patients before and after the
upgrade. Their main conclusion: On
average SAFIRE1 allows for a 30 percent dosage reduction without any
significant deterioration in image
quality in their specific set-up. The
dose reduction is particularly important for sensitive cases, such as pregnant women, and patients with conditions that require them to have
repeated examinations to measure
the progress of their ailments and

treatments.
How do you describe SAFIRE to
people who are not familiar with it?
Cantarinha: SAFIRE stands for Sinogram Affirmed Iterative Reconstruction.
That seems complicated, but I have
come up with a simple explanation.
When you take an image, you get a
signal and you get noise. SAFIRE recognizes the noise and eliminates it,
so we get a better quality impression.
Why did the Bictre Hospital
purchase SAFIRE?
Rocher: This is a public institution,
so the decision was taken by the purchasing department at AGEPS (the
General Agency for Health Equipment

and Products). I knew how much it
would cost, and I knew that the amount
was significant, so I asked myself
whether it was worth it. I collected a
lot of data prior to the upgrade so that
I could compare them with the results
afterwards.
I have no role in deciding how to spend
money, but we are pleased that the
decision-makers at AGEPS acted in the
interest of the patients.
What did you find when you compared the before-and-after data?
Cantarinha: For example, I examined
the figures for dose length product
inmGy cm and body mass index for
Alfredo Cantarinha, X-ray technologist,

Bictre Hospital, Paris, France
After all, we
should never
forget that we
are here for
the patients.
Laurence Rocher, MD,
Bictre Hospital, Paris, France
Business
1A
1B
1
Fig.1A was created before
SAFIRE was implemented
with a dose of CTDIvol of
17 mGy. Fig.1B shows an
equal image impression
with SAFIRE and a dose of
only 9 mGy.
2A
2B
2
Dose reduction in
combination with
SAFIRE keeps the image
impression constant.
Fig.2A shows an axial
image withthe original
dose and Fig.2B shows
SAFIRE in combination
with a dose reduction.
cancer patients before and after the

upgrade.
Putting the numbers on a graph, for
instance for examinations of the thorax
and abdomen, I found an average reduction in dosage of 30 percent thanks to
SAFIRE.
What in detail are the benefits
ofSAFIRE?
Cantarinha: In a nutshell, it reduces
noise. SAFIRE recognizes and removes
the noise to improve the image quality.
Beyond that, theres the automatic
adjustment of the tube voltage by
CARE kV to a lower voltage depending
on the kind of examination you are
doing. If it is ascan using contrast media
and the patients size allows for it,
CARE kV will automatically adjust to a
lower kV. There are two advantages:
Reduced kilovolts, which greatly
reduces the dose to the patient, and
better contrast.
Are there any special cases?
Cantarinha: SAFIRE provides an undeniable benefit for impressions and settings with multiple phases. In the case
of kidney cancer, there was a 41 percent
decrease in the radiation dosage. Thats
just phenomenal. This is important

for these patients because they have
to be rescanned every six months
during their chemotherapy treatments.
How important is the radiographer
to the process when using SAFIRE?
Cantarinha: It might seem pretentious
to say so, but even the most beautiful
machines, like sophisticated jet airplanes, need pilots to command them.
Thats our job as radiographers to
keep a steady hand on the machine.
Is it difficult to adapt to SAFIRE
after using other systems?
Rocher: Someone asked me that same
question at a professional conference.
We had a scanner from another company before installing the SOMATOM
Definition AS in March 2010. Understandably, you need some time to get
acquainted with a new machine, but
after six months everything was better. Four years down the line, nobody
talks about the old system anymore.
It has been eight months since we
installed SAFIRE. The radiologists
cantell you that the use of SAFIRE
has become routine, that they have
completely adapted. p
A former correspondent in South America

for The Financial Times and Business Week,
Bill Hinchberger is a Paris-based freelance
writer. He has contributed to publications
like The Lancet and Science, and reported
for the Medical Education Network Canada.
1

for the particular clinical task. The following test
software. Noise, CT numbers, homogeneity, lowcontrast resolution and high contrast resolution

Further Information
www.siemens.com/care-right
Business
Balancing Clinical
and Business Demands
Pressure on healthcare providers is growing as a result of the global
economic crisis and also due to demands for increased standards of clinical
care. With SOMATOM Perspective, Siemens has developed a computed
tomography system that balances the need for high-quality diagnostic images
with the challenge of efficiency.
By Florian Hein
Many countries are dealing with the

consequences of a worldwide downturn, which has led to shrinking purchasing power and reduced national
budgets. Healthcare service providers
are greatly affected by this vicious
circle given that healthcare expenditure is one of the largest costs for
these countries. Still, clinical demands
worldwide are increasing rapidly
high-end clinical care, which a decade

ago was available only in selected
regions and for some patients, has
now become the standard level of
care. This situation demands well-
considered investments and the efficient use of medical devices to secure
success in clinical practice today.
In response to this challenge, Siemens
has developed a CT scanner that com-
bines high-end diagnostic quality

witha lower total cost of ownership
SOMATOM Perspective. Key components
of the CT system had to be adjusted
todiscover new ways of achieving
greater efficiency.
CT scanner hardware
The hardware components of a CT
system include an X-ray tube with a
high-voltage generator, a detector, and
a gantry upon which all moving parts
are mounted. These components are
highly interdependent; in designing
a well-balanced system the aim is to
produce a scanner that is powerful
enough to meet high clinical demands,
but still as economical as possible.
One key parameter is the distance
between tube and detector, which is
reflected in the focus-isocenter distance as well as in the focus-detector
distance. This setting determines the
space required for all further CT components and the level of generator
power needed.
With an efficient scanner design and innovative iterative reconstruction

approaches that improve temporal resolution by 20%, excellent cardiac imaging
is possible in this case even with a heart rate of 67 bpm.
Courtesy of PUMC Hospital, Bejing, China
SOMATOM Perspective has an optimized focus-isocenter distance of just

535 millimeters, compared with other
currently available scanners of similar
clinical performance that typically have
a larger focus-isocenter distance of
upto 600 mm (Fig.2).[1] Due to the
inverse square law, a smaller focusdetector distance means that the available X-rays are used more efficiently.
This means that by decreasing the
Business
A short isocenter distance means more efficient

use of the available X-rays. It also allows for a compact
system design.
focus-isocenter distance from 600 mm

to 535 mm, (600 mm/535mm) 1
equals 25% more photons are available
at the same generator power or a
respectively smaller generator is sufficient to obtain the same image quality.
A smaller generator decreases the
footprint and involves lower energy
consumption and heat dissipation,
reducing the total cost of ownership.
Image reconstruction
Together with the hardware of a CT
system, image reconstruction algorithms
are essential to calculate an image. Fast,
efficient, and artifact-free image reconstruction saves time and costs while
improving the diagnosis. Additional
algorithms are built into SOMATOM
Perspectives image reconstruction chain
in order to reduce artifacts, improve
spatial and temporal resolution for cardiac imaging, and to reduce image
noise. These factors result in overall
dose reduction to the patient as well as
reduced stress on the system.
One of the most challenging tasks for
a CT system is cardiac imaging. The temporal resolution has to be high enough
to freeze the motion of the heart. With
reconstruction methods such as iTRIM
for SOMATOM Perspective, the temporal
resolution of a cardiac image can be
improved (Fig.1). iTRIM can provide a
temporal resolution of 195 ms based
on the rotation time of 0.48 seconds
available in cardiac modes. Based on
traditional half-scan reconstruction
eStart prevents a critical temperature rise in the tube

following a period of non-use, since the tube is the most
delicate part of a CT system.
methods that simply use 180 of the

data to reconstruct a cardiac image,
this temporal resolution corresponds
to an equivalent rotation time of
0.39 seconds1 for a 360 rotation.[2]
eCockpit
With the goal of improving the efficiency of scanner usage to meet the
business benchmarks for operation,
Siemens looked to the huge base of
over 19,000 installed scanners worldwide for clues: How do some cus
tomers achieve higher uptime, fewer
component replacements, and a
longer system lifetime? How can we
help other customers to benefit from
similar results? The answer is eCockpit,
comprising eStart, eMode, and
eSleep. These functions support the
most economic CT scanner use and
areduction in overhead costs. In its
design, the entire working day of a
CT system was taken into consideration from start-up to scanning to
stand-by to achieve great efficiencies in scanner operation.
eStart extends the tube lifetime by
pre-warming the tube after extended
periods of non-use; this may be every
morning for high throughput facilities,
or prior to each scan in smaller hos
pitals. In an X-ray tube, typically only
0.2% of the electrical energy used is
converted into X-rays. The rest is converted into heat on the X-ray tubes
anode. Even though the anode is made
of tungsten, a material with a very
high melting point (3,422C) to allow

for the highest possible generated
X-ray flux, sudden heating puts enormous stress on the structure of the
anode. eStart reduces the deterioration associated with cold starts, which
extends the tubes lifespan. In urgent
cases, trauma for example, it is also
possible to start the scan without
eStart and save time where it counts.
Siemens has published a recent white
paper that offers a detailed look at all
relevant components and interdependencies of a CT system, and explains
why SOMATOM Perspective has the
right technological parameters to
achieve an optimal balance between
clinical and business needs. p

References
[1] Data on file, Siemens Healthcare 7/2014
[2] Sebastian Vogt, PhD, Harald Schndube,
PhD, Thomas Allmendinger, PhD, Johan
Sunnegrdh, PhD, Karl Stierstorfer, PhD,
Herbert Bruder, PhD, and Thomas Flohr,
PhD, iTRIM A Novel CT Image Reconstruction Algorithm to Enhance Temporal
Resolution, White Paper,
Siemens Healthcare 11/2011
1 With iTRIM in cardiac mode, temporal
resolution is equivalent to a rotation time of
0.39 s with classic FBP reconstruction.
Further Information
www.siemens.com/
SOMATOM-Perspective
Clinical Results Cardiovascular
Case 1
Discovery of a Type II Endoleak after

EVAR in a Patient with Renal Insufficiency
using Dynamic 4D CT Angiography
By Holger Haubenreisser, MD
Institute of Clinical Radiology and Nuclear Medicine, University Medical Centre Mannheim,
Medical Faculty Mannheim, Heidelberg University, Germany
History
A 72-year-old male patient with
poor kidney function (GFR 40 mL/min)
was admitted to the hospital with
a suspected endoleak after an endovascular aneurysm repair (EVAR) of
the abdominal aorta. A dynamic 4D CT
angiography (CTA) was requested to
confirm the endoleak and to specify
its type.
Diagnosis
CT images showed an abdominal
aortic aneurysm (AAA) and a stent
within it, placed during EVAR. Proof
of an endoleak (Figs. 1 and 2) was

seen in the delayed phase, as was
the aneurysmal feeder artery (Fig.3).
A type II endoleak was confirmed.
Comments
Due to the patients poor kidney function, the examination was completed
with only 12cc of contrast, at a 60%
dilution (total injected volume 20cc),
followed by a 30cc saline chaser, both
with a 5cc/s injection rate. This was
achieved by conducting the scan at
70 kV, to close the gap to the k-edge
and enhance the contrast, as well as
by using a dynamic 4D scan protocol

for a shorter scan range than a standard abdominal CTA. The multiple
acquisition time points of the dynamic
scan make overtaking or missing the
bolus highly unlikely. The images were
viewed on a 4D viewer. It was seen
clearly that the contrast flow into the
aneurysm (the endoleak) was delayed
in comparison with that into the aorta.
This is an indirect sign of a type II
rather than a type I endoleak. Further
evaluation of the same dataset revealed
a small feeder artery, thus confirming
the diagnosis. p
Examination Protocol
Scanner
SOMATOM Force
Scan area
Abdomen
Slice collimation
48 1.2 mm
Scan length
222 mm
Slice width
1.5 mm
Scan direction
Adaptive 4D spiral
Reconstruction increment
1 mm
Scan time
36 s
Reconstruction kernel
Bv36
Tube voltage
70 kV
0.5 mm
Tube current
200 mAs
Contrast
400 mg/mL
CTDIvol
43.46 mGy
Volume
12 mL (20 mL diluted to 60%)

+ 30 mL saline
DLP
905 mGy cm
Flow rate
5 mL/s
Effective dose
13.6 mSv
Start delay
8s
Rotation time
0.25 s
Cardiovascular Clinical Results
1A
1B
2A
2B
12
3A
Axial (Fig.1) and sagittal (Fig.2) views of VRT (A) and MPR (B) images show the endoleak (arrows).
3B
VRT image demonstrates the feeder artery (arrows) to the aneurysm and thus confirms a type II endoleak.
Case 2
Low Dose Coronary CT Angiography

using ECG-Gated Retrospective Spiral CT
By Paulo G. Pedro, MD, Rui Cruz Ferreira, MD, Raquel Gouveia, MD, Rui Conduto, MD, Berta Carla, MD,
Elisabete dAscenso, FT, Miguel Pereira, RT
Department of Cardiology and Imagiology, SAMS Hospital, Lisbon, Portugal
History
Diagnosis
A 75-year-old male patient, with

high blood pressure and elevated
cholesterol levels, was admitted due
to a recent onset of atypical chest
discomfort. The physical examination
was unremarkable. Biometric para
meters, such as weight (58 kg), height
(169 cm), heart rate (53 bpm), blood
pressure (130/80 mmHg), as well as
ECG and echocardiogram were normal
at admission. A maximal treadmill
stress test (Bruce Protocol) disclosed
moderate exercise tolerance (730)
with no angina but minor ST-T changes
on the left precordial leads. A coronary
CT angiography (cCTA) was requested
for further evaluation.
cCTA images depicted a 14 mm-long

mixed plaque in the mid-left anterior
descending artery (LAD) causing a
7090% stenosis in the distal section.
No significant plaques were seen in
the left-main (LM), the circumflex (Cx)
or the right coronary artery (RCA).
The left ventricular ejection fraction
was 65% with no wall motion abnormalities.
Calcium scoring (with a total score
of 59.5) revealed a mild calcification
status with calcified plaques mainly
distributed in the LAD and the Cx.
A cardiac catheterization was
performed, confirming the LAD
stenosis. A zotarolimus-eluting stent
(2.7514 mm) was successfully
deployed after a pre-dilatation using
a plain balloon. An excellent angiographic result was achieved and the

patient was then asymptomatic.
Comments
cCTA resulted in a decisive diagnosis
for this patient considering the original
symptoms of atypical chest pain and
an equivocal stress test. The disclosed
nature of the plaques and severity of
the stenosis further helped in planning
a percutaneous interventional procedure.
The application of all supplied advanced
techniques, such as ECG pulsing, iterative reconstruction (SAFIRE1), iTrim
and lower kV setting (110 kV), resulted
in excellent image quality and a very
low effective dose of only 1.44 mSv. p
Scanner
SOMATOM Perspective
Scan area
Heart
Rotation time
0.48 s
Scan mode
ECG-gated retrospective
spiral scan
Pitch
0.27
Scan length
99.5 mm
Slice collimation
64 x 0.6 mm
Scan direction
Cranio-caudal, feet first
Slice width
0.75 mm
Scan time
4.6 s
0.5 mm
Tube voltage
110 kV
I30s
Tube current
87 mAs
Heart rate
5153 bpm
Temporal resolution
195 ms with iTrim
Contrast
370 mg/mL
CTDIvol
6.47 mGy
Volume
75 mL + 60 mL saline
DLP
103 mGy cm
Flow rate
6 mL/s
Effective dose
1.44 mSv
Start delay
Test bolus
1 In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice.
A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical
task. The following test method was used to determine a 54 to 60% dose reduction when using the SAFIRE reconstruction software. Noise, CT numbers,
homogeneity, low-contrast resolution and high contrast resolution were assessed in a Gammex 438 phantom. Low dose data reconstructed with SAFIRE showed
the same image quality compared to full dose data based on this test. Data on file.
1A
1B
2A
2B
3A
3B
13
Curved MPR (Fig.1), VRT (Fig.2) and MIP

(Fig.3) images show a severe LAD stenosis
(arrows) caused by mixed plaques.
Patient protocol records the dose resulting

from each scan series.
Case 3
Diagnosing a Bilateral Iliac Artery Stenosis

using Runoff CT Angiography
By Aarthi Govindarajan, MD, Prasanna Vignesh, MD, Arun Kumar, MD, Raj Kumar, MD
Aarthi Diagnostics, Vadapalani, Chennai, Tamilnadu, India
1A
1B
1
VRT (Fig. 1A), MIP
(Fig. 1B) and MPR
(Fig. 1C) images
show moderate
stenoses from soft
plaques in the
proximal segment
of both common
iliac arteries, and a
mild stenosis from
concentric soft
plaque at the bifurcation of the distal
abdominal aorta.
1C
History
Diagnosis
Comments
A 42-year-old male patient, a known

smoker and alcoholic with a history
of claudication and pain in both lower
limbs, was referred to our hospital.
Physical examination revealed that the
patient was normotensive. His family
history was unremarkable. Peripheral
CT angiography was requested to rule
out peripheral arterial diseases.
The MPR, MIP, and volume-rendered

CT images demonstrated moderate
stenoses from soft plaques in the
proximal segment of both common
iliac arteries. A mild stenosis from
concentric soft plaque was also seen
at the bifurcation of the distal abdo
minal aorta.
Peripheral CT angiography is valuable

in imaging workup and helps in establishing a quick diagnosis. SOMATOM
Scope allows a longer scan range
within a shorter scan time and a slice
width as thin as 1.5 mm. Its high scan
speed along with the high pitch setting enables a clear visualization of
the vascular structures with a homogeneous contrast within the entire
runoff range. p
No significant plaques or stenoses

were seen in the peripheral lower
limb arteries.
2A
2B
VRT images demonstrate moderate stenoses in the proximal segment of both common iliac arteries from two different views.
Scanner
SOMATOM Scope
Scan area
Runoff
Rotation time
0.8 s
Scan length
1158 mm
Pitch
1.5
Scan direction
Cranio-caudal
Slice collimation
16 1.2 mm
Scan time
32 s
Slice width
1.5 mm
Tube voltage
110 kV
1 mm
Tube current
60 mAs
I31s
Dose modulation
CARE Dose4D
Contrast
CTDIvol
3.89 mGy
Volume
90 mL
DLP
470 mGy cm
Flow rate
4 mL / s
Effective dose
2.6 mSv
Start delay
Bolus tracking
Case 4
Comprehensive Cardiac CT Study for

Simultaneous Evaluation of the Coronary
Arteries and the Myocardium
By Kakuya Kitagawa, MD, PhD, Tatsuro Ito, MD, Hajime Sakuma, MD, PhD, Naoki Nagasawa, PhD, Akio Yamazaki*,
Shiro Nakamori, MD, Hiroshi Nakajima, MD, PhD**
**Department of Radiology, Mie University School of Medicine, Mie, Japan
**Department of Cardiology, Mie University School of Medicine, Mie, Japan
Comments
History
A 67-year-old male patient, with a
history of peripheral arteriosclerosis
obliterans and inferior wall myocardium infarction, had been treated with
an interventional stenting placed in
the left circumflex artery (LCx) #1314.
A comprehensive cardiac CT study,
including coronary CT angiography
(cCTA), stress myocardial dynamic
perfusion, and delayed enhancement,
was ordered to simultaneously evaluate both the coronary artery and the
myocardium.
Diagnosis
Coronary CTA images showed a left
coronary artery (LCA) dominant system (Figs.1A and 1B). Mixed plaques
could be seen in the proximal left
anterior descending artery (LAD).
1A
These plaques caused a moderate

stenosis in segment #6 (Fig.2A) and a
mild stenosis in segment #7 (Fig.2B).
No significant in-stent stenosis was
seen in the LCx #1314, with the
exception of a mild stenosis distal to
the stent (Fig.2C).
Adenosine-induced stress myocardial
dynamic perfusion CT images showed
no significant ischemic area. Reduced
myocardial blood flow could be seen
in the basal septal inferior wall area,
which corresponds with the old infarction (Fig.3).
Delayed enhancement CT images
showed sub-endocardial infarction
from the basal septum inferior wall to
the apical inferior wall. This became
partially transmural at the apex (Fig.4).
Myocardium viability was retained.
1B
Coronary CTA images show a LCA dominant system (Fig. 1A MIP, Fig. 1B VRT).
In this case, a comprehensive study with

excellent results was achieved with
a total effective dose of only 5.9 mSv.
In myocardial perfusion evaluation,
not only a high temporal resolution
but also accurate myocardial CT values
extremely important. Half-reconstruction methods offer a high temporal reso
lution but, at the same time, result in
myocardial CT value fluctuation related
to X-ray source position, impacting the
evaluation of myocardial perfusion.
SOMATOM Definition Flash offers
a Heart Perfusion mode (Systolic ECGtriggered Sequential Shuttle mode)
which is equipped with an advanced
algorithm that offers both 75 ms high
temporal resolution and stabilized
myocardial CT values with 360 full
reconstruction at the same time. This
works very well in the evaluation of
myocardial perfusion together with
a perfusion analysis application that
enables a fast calculation of the myocardial blood flow with a color map.
Furthermore, we also apply this Heart
Perfusion mode for delayed enhancement CT which also requires accurate
myocardial CT values.[1]
Scanning four time-points and averaging them using the motion correction
algorithm of the perfusion application,
this excellent scan mode can offer clear
delayed enhancement images with
reduced artifact and noise. This study
exemplifies the feasibility of one-stopshop cardiac CT examination including
assessment of coronary artery stenosis,
ischemia, and myocardial viability with
reasonably low radiation dose. p
References
[1] Kurobe Y, Kitagawa K, J Cardiovasc Comput
Tomogr. 2014 Jul-Aug;8(4):289-98.
2A
2B
2C
Coronary CTA images show mixed plaques (arrows)

in the proximal LAD causing a moderate stenosis in
segment #6 (Fig. 2A) and a mild stenosis in segment
#7 (Fig. 2B). No significant in-stent stenosis was seen
at LCx #1314 with the exception of a mild stenosis
(Fig. 2C, arrow) distal to the stent.
Stress myocardial dynamic perfusion

CT images show no significant ischemic
area, but reduced myocardial blood
flow in the basal septal inferior wall area
(arrows) which corresponds with the
old infarction.
Delayed enhancement CT
images show sub-endocardial
infarction from the basal septum
inferior wall to the apical inferior
wall. This became partially
transmural at the apex.
Table1: Scheme of a comprehensive cardiac CT study

Topogram
CaScore
Enter
room
Vasodilator
NTG
i.v. blocker
(if needed)
Exit
room
40 min.
Stress
Myocardial
Dynamic
Perfusion
Delayed
Enhancement CT
Coronary
CTA
Scanner
SOMATOM Definition Flash
Scan mode
Stress Myocardial Perfusion
Coronary CTA (Sequence)
Delayed Enhancement CT
Scan area
Left Ventricle
Heart
Left Ventricle
Scan length
67 mm
102.8 mm
69 mm
Scan direction
Shuttle
Cranio-caudal
Shuttle
Scan time
32 s
5s
9s
Tube voltage
80 kV
80 kV
80 kV
Tube current
127 mAs/rot.
197 mAs/rot.
370 mAs/rot.
Dose modulation
CARE Dose4D
CARE Dose4D
CTDIvol
28.9 mGy
8 mGy
17.9 mGy
DLP
208 mGy cm
82 mGy cm
128 mGy cm
Effective dose
2.9 mSv
1.2 mSv
1.8 mSv
Volume
40 mL
41 mL
Flow rate
5 mL/s
3.4 mL/s
Start delay
4s
17 s
Scan timing
Adenosine infusion start

2min
scan
Adenosine infusion release

3min
Nitro
5min
scan
Coronary CTA
5min
scan
Contrast
Clinical Results Oncology
Case 5
CT Volume Perfusion Imaging

in a Case of Suspected Pancreatic Cancer
By Sonja Sudarski, MD, Mathias Meyer, MD, Holger Haubenreisser, MD, Stefan O. Schnberg, MD,
Thomas Henzler, MD
History
A 62-year-old male patient presented
to the hospital, complaining of persistent upper abdominal pain which
was exacerbated after intake of fatty
foods. He claimed to have lost 15 kg
and to have completely quit consuming alcohol in the past two months.
Fatty defecation had not been observed,
however, a tendency toward obstipation had developed which could be
occasionally relieved by inducing
vomiting.
stricted by the lesion. Extensive paragastric collaterals were formed.
The patient had a history of acute

pancreatitis, gastrointestinal ulcer
bleeding within the duodenum,
chronic type B gastritis, and pandiverticulosis.
The patient underwent surgical

exploration and resection. The histopathology revealed local advanced
pancreatic adenocarcinoma.
Endosonography results indicated a

suspected chronic pancreatitis. Eso
phagogastroduodenoscopy revealed
erosive gastritis, a gastric voiding
disorder as well as an axial hiatus
herniation.
Comments
A biphasic CT examination of the

chest and abdomen, as well as perfusion imaging of the pancreas, were
requested for further evaluation.
Diagnosis
CT images revealed a hypodense
lesion, measuring 6.4 3.2 cm, in
the corpus of the pancreas. The
lesion was compressing the portal
vein, had infiltrated the splenic vein
and reached the coeliac trunk, the
common hepatic artery and the
gastroduodenal artery. It also surrounded the left gastric artery, and
the splenic artery which was con-
No suspicious lymph nodes or metastases were seen within the chest and
abdomen. Compared with the supposedly healthy and normally perfused
tissue of the pancreatic head, the
lesion was hypoperfused.
MRI confirmed the CT findings,
showing a contrast-enhanced lesion
with moderate diffusion restriction.
Organ perfusion CT studies provide

anatomical as well as functional information, which is useful for tissue
characterization and evaluation of
response to therapy.[1] Pancreatic
perfusion studies were first performed
in the 1990s.[2] However the lack
of full organ coverage was the most
obvious limitation of this technique,
as were the radiation dose concerns
that made multiphasic scanning the
standard procedure for decades.
With the evolution of larger detectors
and dose saving strategies, wholeorgan CT perfusion studies are increasingly performed in patients to gain
additional functional information.[3]
In this case, it was possible to stay
within the diagnostic reference dose
values for the complete chest, abdo
minal and volume perfusion CT scans.
The CT Body Perfusion application of

the syngo.via VA30 allows automatic
motion correction and noise reduction,
as well as the creation of perfusion
maps such as blood flow, blood volume,
and flow extraction product (permeability). Before finding its way into clinical routine, large studies are needed in
order to investigate the robustness of
the perfusion parameters and to define
possible cut-offs that help to properly
interpret the quantitative measurements. p
References
[1] Cao N, Cao M, Chin-Sinex H, Mendonca M,
Ko SC, Stantz KM. Monitoring the Effects
of Anti-angiogenesis on the Radiation
Sensitivity of Pancreatic Cancer Xenografts
Using Dynamic Contrast-Enhanced
Computed Tomography. Int J Radiat Oncol
Biol Phys. 2014 Feb 1;88(2):4128. doi:
10.1016/j.ijrobp.2013.11.002.
[2] Miles KA, Hayball MP, Dixon AK. Measurement of human pancreatic perfusion
using dynamic computed tomography
with perfusion imaging. Br J Radiol. 1995
May;68(809):4715.
[3] Xie Q, Wu J, Tang Y, Dou Y, Hao S, Xu F,
Feng X, Liang Z. Whole-organ CT perfusion
of the pancreas: impact of iterative reconstruction on image quality, perfusion
parameters and radiation dose in 256-slice
CT-preliminary findings.
PLoS One. 2013 Nov 26;8(11):e80468.
doi: 10.1371/journal.pone.0080468.
1A
1B
1
Curved MPR (Fig.1A) and VRT
(Fig.1B) images show that the lesion
was compressing the portal vein, had
infiltrated the splenic vein and reached
the coeliac trunk, the common hepatic
artery, and the gastroduodenal artery.
It also surrounded the left gastric
artery and the splenic artery which
was constricted through the lesion.
The extensive paragastric collaterals
that were formed can also be seen.
2A
2B
2
In comparison with the normal pancreatic
tissue, the adenocarcinoma revealed hypodensity in the temporal MIP (Fig. 2A), less
blood flow (Fig. 2B), less blood volume
(Fig. 2C) and a decreased flow extraction
product (Fig. 2D).
2C
2D
3
3
Relative time-density curves
(ROI#3 in yellow =
normal pancreatic tissue;
ROI#4 in green =
adenocarcinoma).
Scanner
SOMATOM Force
Scan area
Upper Abdomen
Scan mode
VPCT
Scan length
174 mm
Scan direction
Adaptive 4D spiral
Scan time
43 s
Tube voltage
70 kV
Tube current
200 mAs
Dose modulation
CTDIvol
46.66 mGy
DLP
914.9 mGy cm
Rotation time
0.33 s
Slice collimation
48 1,2 mm
Slice width
1.5 mm
Reconstruction
increment
1.0 mm
Reconstruction
kernel
Br36
Contrast
400 mg / mL
Volume
50 mL + 50 mL
Saline
Flow rate
5 mL / s
Start delay
5s
Clinical Results Acute Care
Case 6
Whole-Body CTA with Reduced Radiation

Dose and only 20 mL of Contrast Media
By Mathias Meyer, MD, Holger Haubenreisser, MD, Sonja Sudarski, MD,
Stefan O. Schnberg, MD, Thomas Henzler, MD
History
Diagnosis
A 70-year-old female patient was

referred to our emergency department
complaining about a new onset of
back pain and malignant hypertension.
The initially performed CTA, on a
16-slice single source CT with 100 mL
contrast media, revealed a Stanford B
dissection. The patient was again
referred to our department for re-evaluation, 12 hours later, with progressive back pain, a new onset of chest
pain and increasing blood creatinine
levels.
A re-evaluation CTA confirmed a

Stanford B aortic dissection, beginning behind the junction of the left
subclavian artery and stretching to
just below the diaphragm, with a new
partially thrombotic occlusion of the
false lumen. The aortic dissection was
progressive, compared to the initial
CTA 12 hours earlier.
1A
Comments
Aortic CTA is a valuable, fast and
non-invasive imaging tool with high
availability and diagnostic accuracy.[1]
Recent technological developments

allow not only for substantial dose
reduction but also for improvements
in image acquisition. With the recent
introduction of SOMATOM Force, these
advantages further influence patient
acquisition parameters positively.
These technical advantages include
the Vectron tube with increased peak
tube current and Advanced Modeled
Iterative Reconstruction (ADMIRE1),
allowing for routine adult CTA imaging
at low tube voltages of down to 80 kV
while maintaining diagnostic image
quality. Low tube voltage imaging
1B
1
Sagittal MIP (Fig.1A)
and VRT (Fig.1B)
images show the
partially occluded
Stanford B dissection
beginning after the
junction of the left
subclavian artery.
Acute Care Clinical Results
results in higher vascular attenuation

but also higher image noise. This
effect leads to low tube voltage protocols with a reduced amount of contrast
media in this whole body CTA using
20 mL compared with 100 mL used in
the previous CTA scan while preserving diagnostic image quality throughout the application of ADMIRE1. Aortic
CTA, using a Dual Source CT high-pitch
mode acquisition protocol with 80 kV
tube voltage, shortens the acquisition
time (in this case 0.91 s) on the one
hand and reduces radiation exposure
to the effective dose of 2.3 mSv compared with the previous CTA scan on
the other hand. p

References
[1] Nienaber, C.A., et al., Noninvasive
imaging approaches to evaluate the
patient with known or suspected aortic
disease. Circ Cardiovasc Imaging, 2009.
2(6): p. 499-506.
1 In clinical practice, the use of ADMIRE may reduce

3D reconstruction of the vascular structures of the same patient with

excellent vascular contrast.
Scanner
SOMATOM Force
Scan area
Chest Pelvis
Pitch
3.2
Scan length
673.6 mm
Slice collimation
192 0.6 mm
Scan direction
Cranio-caudal
Slice width
1 mm
Scan time
0.91 s
0.8 mm
Tube voltage
80 kV
Bv36 (ADMIRE 5)
Tube current
140 mAs
Contrast
400 mg / mL
Dose modulation
CARE Dose4D
Volume
20 mL contrast mixed with 20 mL saline
CTDIvol
2.09 mGy
Flow rate
3.9 mL / s
DLP
154.6 mGy cm
Start delay
Bolus tracking in the descending aorta

+ additional delay of 4 s
Rotation time
0.25 s
Case 7
Identification of Posterior Cruciate

Ligament Avulsion using Dual Energy CT
By Patrick McLaughlin, MD, Paul Mallinson, MD, Hugue Ouellette, MD, Savvas Nicolaou, MD
Department of Radiology, Vancouver General Hospital and University of British Columbia Vancouver, British Columbia, Canada
History
Diagnosis
A 41-year-old male patient was transported by emergency services to a

level one trauma center, after a high
speed, head on, motor vehicle collision. The patient was a passenger and,
despite being restrained at the time
of collision, suffered significant dashboard contact. Clinical examination
revealed increased anterior translation
of the left knee.
The CT examination discovered an

acute avulsion fracture at the posterior
cruciate ligament insertion.
Comments
Mixed CT images (Fig. 2), reconstructed
using a 0.5 blend of Sn 140 kV and
80 kV data and a high spatial frequency
deconvolution kernel (B75), provided
excellent depiction of fine bony detail
and allowed best depiction of the
fracture line as it extended into the
weight bearing surface of the posterior

tibial plateau (not shown). Virtual noncalcium reconstructed Dual Energy (DE)
CT images (Q34, strength 3) confirmed
the presence of extensive bone marrow
edema in the proximal left tibia which
correlated well with the fat suppressed
T2 weighted MRI (Fig. 3). DE CT images,
reconstructed using the collagen application, showed that the posterior cruciate ligament was buckled but intact
(Fig. 4). There also was a moderate acute
lipohemarthrosis. p
Scanner
Scan area
Left knee
Pitch
0.7
Scan length
168 mm
Slice collimation
40 x 0.6 mm
Scan direction
Cranio-caudal
Slice width
0.75 mm
Scan time
10 s
0.7 mm
Tube voltage
80 kV / Sn140 kV
B75, Q34f (SAFIRE 3)
Tube current
16382mAs
Contrast
Dose modulation
CARE Dose4D
Volume
CTDIvol
7.59 mGy
Flow rate
DLP
141 mGy cm
Start delay
Rotation time
0.5 s
Plain radiograph, lateral projection, of the left

knee showed a small fracture fragment arising
from the posterior aspect of the proximal left
tibia and a moderate sized effusion collecting
in the suprapatellar bursa.
Sagittal CT image demonstrated a small

avulsion fracture at the expected insertion
site of the posterior cruciate ligament.
3A
3B
3C
3D
3E
3F
4A
Axial and coronal virtual non-calcium reconstructed DE CT images (Figs. 3A, 3B, 3D, 3E) displayed extensive bone marrow
edema in the proximal left tibia which correlated almost identically with high T2 signal areas on the fat suppressed T2 weighted
MRI images (Figs. 3C and 3F).
4B
Sagittal DE CT image, reconstructed using the collagen application (Fig. 4A),

confirmed that the posterior cruciate ligament was intact but had an irregular buckled
contour. This finding correlates well with the sagittal proton density image from the
subsequently performed MRI (Fig. 4B).
VRT DE CT image
showed the three
dimensional view
of the extensive bone
marrow edema in
the proximal left tibia.
Case 8
Retained Endoscopy Capsule: Metal Artifact

Reduction with Monoenergetic Imaging
By Pui Wai Cheng FRCR, Gregory E. Antonio, MD, Hiu-Ming Tung FRCS
St Teresas Hospital, Kowloon, Hong Kong
History
A 32-year-old female patient, with
known Crohns disease, underwent a
terminal ileum resection eight years
ago at another hospital. Three years
later a capsule endoscopy was performed, which was complicated by
capsule retention. The patient had
been complaining of an on-and-off
abdominal pain before being referred
to our hospital. A Dual Energy (DE)
CT scan was performed for further
evaluation.
Diagnosis
obscuring the surrounding tissues

(Fig.2). We used the syngo DE mono
energetic application at various energy
levels to see the effects on metal
artifact reduction. At 127 keV (Fig.3)
we found that the metal artifacts
were significantly reduced and the
surrounding tissues were diagnosable. At 190 keV (Fig.4) the metal
artifacts were almost completely

removed, yet the soft tissue contrast
was somewhat suppressed. The inside
structure of the capsule (Figs.5A and
5B) could be seen at a bone window
setting. Without artifact reduction
using DE CT monoenergetic imaging,
the evaluation of the tissues surrounding the capsule would have been significantly compromised. p
The contrast-enhanced CT images

revealed an endoscopy capsule, with
metallic components, lodged in a distended ileal pouch of the distal ileum,
above the narrowed ileocolic anastomosis at the medial wall of ascending
colon. A curved reformatted CT image
(Fig.1) showed a long and inflamed
distal ileal segment with significant
mural thickening and luminal narrowing, just proximal to the ileo-colic anastomosis. Marked contrast enhancement of the thickened mucosa of the
distal ileum was observed along with
associated fibrofatty proliferation of
the mesentery. This is characteristic
of Crohns disease. The endoscopy
capsule was then surgically removed
along with part of the inflamed distal
ileum. The patient recovered uneventfully.
Scanner
SOMATOM
Definition Flash
SOMATOM
Definition Flash
Scan area
Lower Abdomen
Abdomen / Pelvis
Scan mode
Dual Energy
Spiral
Scan length
97.6 mm
442.4 mm
Scan time
3.6 s
9.4 s
Scan direction
Cranio-caudal
Cranio-caudal
kV
100 kV / Sn 140 kV
100 kV
Effective mAs
136 mAs
206 mAs
CTDIvol
11.28 mGy
8.51 mGy
DLP
131 mGy cm
390 mGy cm
Effective dose
1.97 mSv
5.85 mSv
Dose modulation
CARE Dose4D
CARE Dose4D
Rotation time
0.5 s
0.5 s
Slice collimation
32 0.6 mm
128 0.6 mm
Slice width
1 mm
1 mm
0.8 mm
0.8 mm
Comments
D30f (SAFIRE)
I30f (SAFIRE)
Volume
90 mL
Flow Rate
2.5 mL / s
Start delay
90 s
On the mixed images (equivalent to

the single energy images acquired at
120 kV) of a DE CT scan, the endoscopy capsule was seen as a bright
object with beam-hardening artifacts
Contrast
6
1
Curved reformatted CT image
showed a long, inflamed distal
ileal segment (arrowheads)
proximal to the narrowed
ileo-colic anastomosis (long
arrow) with the endoscopy
capsule trapped in the blind
ileal pouch (dashed arrow).
2A
Photograph of the
endoscopic capsule.
2B
2
Short (Fig. 2A) and long axis (Fig. 2B) views of the
endoscopic capsule displayed in soft tissue window in
themixed images (equivalent to single energy images
acquired at 120 kV). The metal artifacts obscuring the
surrounding tissues are clearly demonstrated.
3A
3B
3
endoscopic capsule displayed in soft tissue window
in the monoenergetic images at 127 keV. The metal
artifacts are significantly reduced and the surrounding
tissues are diagnosable.
4A
4B
4
endoscopic capsule displayed in soft tissue window
in the monoenergetic images at 190 keV. The metal
artifacts are almost completely removed, yet the soft
tissue contrast was somewhat suppressed.
5A
5B
5
endoscopic capsule displayed in bone window in
monoenergetic images at 190 keV. The inside structure
of the capsule can be recognized.
Case 9
Dual Energy CT Assessment of Amiodarone

Induced Liver Damage
By Hirochika Suzuki, MD, Ayano Imafuji, MD, Maho Kato, MD, and Hiroko Omiya, MD
Department of Radiology, Tsushima Municipal Hospital, Aichi, Japan
History
1
1
The mixed 120 kV
image shows
higher CT attenuations in the liver
and in the spleen.
A 61-year-old female patient, suffering

from ventricular fibrillation, had been
under long-term control with a daily
dose of amiodarone. She had an
implanted cardiovascular defibrillator
and no history of blood transfusions.
Dual Energy (DE) CT was performed
toassess the status of amiodaroneinduced liver damage.
Diagnosis
2
2
Fused iodine
imaging reveals
high iodine
depositions in
the liver.
3
3
Virtual noncontrast CT
shows normal
liver density.
In the mixed 120 kV image (Fig.1),

organs such as the liver, the spleen and
the pancreas showed highly increased
CT attenuations. Although the scan was
performed without contrast media,
CT values in the liver reached 117 HU.
Similar increased densities were also
measured in the spleen (98 HU) and
in the pancreas (67 HU). In the fused
iodine image (Fig.2), an increased
iodine concentration in both the liver
and spleen was demonstrated, compared to that in the kidneys and in the
muscles. In the virtual non-contrast
(VNC) image (Fig. 3), the liver density
was normal (67 HU). The measured
iodine concentration in the liver was
2.4 mg/mL (Fig.4). Measurement values of CT attenuations and iodine concentrations are summarized in table 1.
Comments
Amiodarone is an iodine-containing
antiarrhythmic drug available worldwide. Long-term amiodarone administration causes hepatotoxicity due to
iodine accumulation in the liver.[1,2]
The lungs, myocardium, thyroid, spleen
and pancreas are the main target organs
for iodine deposition.[1,2,3] In cases
in which amiodarone is considered life
sustaining, a liver biopsy can reveal

the necessity of continuing the medication or not. A Dual Energy CT scan
without contrast media can reveal an
increased iodine concentration in the
liver and other organs, therefore

providing information to analyze the
extent of liver damage. In this case,
CARE Dose4D was applied and the
achieved effective mAs with 100/Sn
140 kV were 104/87, instead of the

reference mAs of 230/178. This
resulted in a DLP of 176 mGy cm and
an effective dose of only 2.64 mSv. p
4
4
Iodine concentration in the
liver reaches 2.4 mg/mL.
Table 1: CT attenuations and iodine concentrations

Liver
Spleen
Pancreas
Aorta
Blended 120 kVp Image
HU
117
98
67
40
Virtual Noncontrast CT
HU
67
55
40
38
Iodine Concentration
mg/dL
2.4
1.8
0.1
Scanner
Scan area
Abdomen
DLP
176 mGy cm
Scan length
200 mm
Effective dose
2.64 mSv
Scan direction
Cranio-caudal
Rotation time
0.5 s
Scan time
10 s
Pitch
0.6
Tube voltage
100 kV / Sn 140 kV
Slice collimation
32 0.6 mm
Tube current
104 / 87 mAs
Slice width
0.6 mm
Dose modulation
CARE Dose4D
0.5 mm
CTDIvol
8.37 mGy
D30f

References
[1] Goldman IS, et al. Increased hepatic density and phospholipidosis
due to amiodarone. AJR 1985; 144: 541-546
[2] Harris L et al. Side effects of long-term amiodarone therapy.
Circulation 1983; 67: 45-51
[3] Kuhlman JE, et al. Amiodarone pulmonary toxicity: CT findings
in symptomatic patients. Radiology. 1990; 177: 121-125
The outcomes achieved by Siemens customers described herein are based on

results that were achieved in the customers unique setting. Since there is no
typical hospital and many variables exist (e.g., hospital size, case mix, level of
IT adoption) there can be no guarantee that other customers will achieve the
same results.
Clinical Results Pediatrics
Case 10
Diagnosis of a Complex Pediatric CHD using

ECG-Triggered Adaptive Sequential Cardiac CT
By Guilin Bu, MD and Ying Miao, MD
Department of Radiology, Guangxi Nanxi Shan Hospital, Guangxi, P.R. China
History
A heart murmur was detected in an
18-month-old girl six months ago. An
echocardiography revealed an atrial
septal defect (ASD), a ventricular septal defect (VSD), an overriding aorta,
a persistent left superior vena cava
(PLSVC), an anomalous pulmonary
venous connection (APVC), and pulmonary hypertension. A cardiac CT
examination was requested to specify
the diagnosis and type of APVC as
well as to demonstrate the complex
anatomical structures of the heart.
tion (PAPVC) was specified by showing the right superior pulmonary veins
(RSPV) connected with the RA. Additionally, a main pulmonary window,
a right aortic arch which caused a
tracheal stenosis, an anomalous origin of the coronary arteries, and a
pig bronchus (i.e. the right superior
bronchus is originated directly from
the supracarinal trachea) were seen.
CT images confirmed the echocardiography findings of an ASD, a VSD, an

overriding aorta, and a PLSVC draining
into the coronary sinus (CS) and then
into the right atrium (RA). A partial
anomalous pulmonary venous connec-
PAPVC is the condition when one or

more, but not all four, pulmonary veins
are connected to the right atrium or
systemic veins. Corrective surgery has
positively changed the outlook for
this group of patients and is the only
definitive way of management. Surgical approach and techniques differ
as per types of anomalous venous
connections and also associated cardiac

anomalies. Missing these anomalous
veins before surgery is hazardous. In
this case, cardiac CT examinations not
only specified the diagnosis of a PAPVC,
confirming the other associated cardiac
anomalies shown by echocardiography,
but also allowed visualization of the
findings such as a main pulmonary
window, a right aortic arch which caused
a tracheal stenosis, an anomalous origin of the coronary arteries, and a pig
bronchus which had been missed by
echocardiography. Taking into consideration the higher heart rate (117125
bpm) and lower dose necessary for
the child, an ECG-triggered adaptive
sequential cardiac scan was performed
in the systolic phase, which resulted
in excellent image quality with only
0.91 mSv effective dose and 15 mL
contrast media. p
1A
1B
1C
1D
1E
Diagnosis
Comments
MPR (Figs.1A1C) and VRT

(Figs. 1D and 1E) images show
an ASD (Fig.1A, dashed arrow),
a VSD (Fig. 1B, dashed arrow),
an overriding aorta (Fig.1B),
a PLSVC draining into the CS
(Figs.1C and 1D, arrowhead),
and a PAPVC with the RSPV
draining into the RA (Figs. 1A,
1D and 1E, arrow).
Pediatrics Clinical Results
2A
2B
2
VRT (Fig.2A) and MPR (Fig.2B)
images show a main pulmonary window
(asterisks) and a right aortic arch
(Fig.2B, arrow).
3
MPR images show an anomalous origin
of the coronary arteries (dashed arrows),
and a right aortic arch (Fig.3A, arrow).
4
VRT images show a pig bronchus
(dashed arrow) and a tracheal stenosis
caused by a right aortic arch (Fig.4B).
3A
4A
3B
4B
Scanner
SOMATOM
Definition AS+
Scan area
Thorax
Scan mode
ECG triggered
adaptive sequential
scan
Scan length
171.5 mm
Scan direction
Cranio-caudal
Scan time
6s
Tube voltage
80 kV
Tube current
70 mAs
CTDIvol
0.83 mGy
DLP
14 mGy cm
Effective dose
0.91 mSv
Rotation time
0.3 s
Slice collimation
128 0.6 mm
Slice width
0.75 mm
Reconstruction
increment
0.5 mm
Reconstruction
kernel
B26f
Temporal
resolution
150 ms
Heart rate
117125 bpm
Contrast
350 mg/mL
Volume
15 mL
Flow rate
1.3 mL/s
Start delay
21 s
Case 11
Persistent Bilateral Patent Ductus Arteriosus

and Confluent Pulmonary Arteries
A Rare Congenital Cardiac Malformation
By Valria M. Moreira, MD, Mariana M. Lamaci, MD, Hlder Andrade Gomes, MD, Bernardo N. Alves de Abreu, MD,
Fbio V. Fernandes, MD, Juliana H.S.M. Bello, MD, Carlos Eduardo E. dos Prazeres, MD, Matheus de S. Freitas, MD,
Paulo Czar F. Dias Filho, MD, Adriano Camargo de C. Carneiro, MD, Tiago A. Magalhes, MD, Carlos E. Rochitte, MD,
Caroline Bastida de Paula, BD*
Department of Cardiovascular Imaging, Hospital do Corao, So Paulo, Brazil
*Siemens Healthcare Brazil
Diagnosis
History
A newborn baby, weighing 3 kg, with
syndromic facies was referred to the
hospital due to a prenatal diagnosis
of a complete atrioventricular septal
defect and a pulmonary atresia discovered during a fetal echocardiography. A physical examination revealed
a continuous heart murmur at the
1A
left and right upper sternal border

and a systolic murmur at the left
lower sternal border. A blood oxygen
saturation test in room air resulted in
a saturation level of 93%. Since the
anatomy and the source of the pulmonary blood flow were unclear, a
cardiac CT examination was requested
for pre-operative assessment.
1B
2A
2B
12
Anterior (Fig.1) and posterior (Fig.2) views of VRT images show a confluent
pulmonary artery (Fig.1, asterisks), a pulmonary atresia (Fig.1, short arrows),
a left PDA (Fig.1, long arrows), and a right PDA (Fig.2, arrows).
CT images demonstrated a pulmonary

atresia and a complete atrioventricular
septal defect, hereby confirming the
findings of the echocardiography. Additionally, a bilateral patent ductus arteriosus (PDA) with a confluent pulmonary artery, a right-sided descending
aorta, and balanced ventricles in the
presence of situs solitus were also seen.
Comments
A persistent bilateral PDA is an uncommon abnormality which occurs during
the development of the aortic arch and
the pulmonary arteries. It is most commonly seen accompanied by pulmonary
atresia and non-confluent branch pulmonary arteries and is strongly associated with heterotaxy syndrome. It is
important to thoroughly evaluate the
pulmonary arterial supply for signs of
a pulmonary atresia prior to surgery. In
this case, a rarely seen congenital cardiac
malformation is presented a bilateral
PDA with a confluent pulmonary artery.
As a non-invasive imaging modality, CT
is increasingly used in the diagnosis and
management of structural heart disease.
It provides complementary diagnostic
information to echocardiography and,
in some cases, makes an invasive angiography unnecessary. Technological
advances allow not only dose reduction
but also improved image acquisition.
The Dual Source CT Flash mode with
its high pitch spiral scanning not only
shortens the acquisition time, but also
reduces the radiation exposure. p
3A
3B
4A
4B
3C
Cranial views of VRT (Figs.3A

and 3B) and MPR (Fig.3C)
images show the confluent
pulmonary artery (asterisks),
pulmonary atresia (Figs. 3B
and 3C, short arrows), a left
PDA (Figs. 3A and 3B, long
arrows), a right PDA (Figs. 3A
and 3B, arrowheads) and a
right-sided descending aorta
(Fig. 3C, dashed arrow).
MPR images demonstrate

the atrial septal defect
(Fig. 4A, asterisk) and the
ventricular septal defect
(Fig.4B, asterisk).
Scanner
Scan area
Heart
Rotation time
0.28 s
Scan length
99.3 mm
Pitch
3.0
Scan direction
Cranio-caudal
Slice collimation
128 0.6 mm
Scan time
0.25 s
Slice width
0.6 mm
Tube voltage
80 kV
0.3 mm
Tube current
28 mAs
B30f
Dose modulation
CARE Dose4D
Contrast
CTDIvol
0.46 mGy
Volume
6 mL
DLP
7 mGy cm
Flow rate
1 mL/s
Effective dose
0.63 mSv
Start delay
Bolus tracking
Case 12
Evaluation of Williams-Beuren
Syndrome in a Two-month-old Child
using a Single Rotation Scan Mode
By Hans-Christoph Becker, MD
Department of Clinical Radiology, University Hospital Grosshadern, Munich, Germany
History
A two-month-old boy, with known
Williams-Beuren syndrome, was presented to the hospital for surgical
repair. Prior to surgery, a CT scan was
ordered to evaluate the cardiovascular
structures. The main focus was to
define the origin of the coronary
arteries relative to the aortic stenosis.
Diagnosis
CT images clearly showed a significant stenosis of the ascending aorta
directly above the aortic root. Both
coronary arteries originated slightly
below the stenosis. A dysplastic right
pulmonary artery and a very small
fistula were also seen between the

descending aorta and the right upper
pulmonary vein.
Comments
CT scans are routinely used for cardiovascular evaluations. In this case, the
CT aided in the planning of the surgical correction of the aortic stenosis,
also demonstrating that resection and
re-insertion of the coronary arteries
would not be necessary. Furthermore,
it also showed a dysplastic right pulmonary artery and a very small DAPVF
(descending aorta-pulmonary vein
fistula), which would have not been
echocardiographically detected.
One of the challenges of performing

a CT scan on a baby, with a heart rate
of 153 bpm, was to complete scanning
as quickly as possible. Therefore, a single rotation scan mode was applied to
acquire the whole heart in just 0.15 s.
This resulted in an excellent image
quality without motion artifact even
though the baby was free breathing
during the scanning. Taking into consideration the exposure dose for the
baby, 70 kV was selected to achieve a
DLP of only 12 mGy cm. This scan mode
is routinely applied in our department
on small size babies. p
Scanner
SOMATOM Force
Scan area
Heart
Rotation time
0.25 s
Scan mode
Single rotation scan
Slice collimation
192 0.6 mm
Scan length
46.8 mm
Slice width
0.6 mm
Scan direction
Cranio-caudal
Bv40 ADMIRE
Scan time
0.15 s
Temporal resolution
66 ms
Tube voltage
70 kV
Heart rate
153 bpm
Tube current
376 mAs
Contrast
400 mg/mL
Dose modulation
CARE Dose4D
Volume
5 mL + 20 mL saline
CTDIvol
2.09 mGy
Flow rate
0.5 mL /s
DLP
12 mGy cm
Start delay
2 s after the contrast arrival

at the ascending aorta
Effective dose
1.12 mSv
1A
1B
1
A VRT (Fig. 1A)
and three MIP
(Figs. 1B,1C and1D)
images show a
significant stenosis
(arrows) of the
ascending aorta
directly above the
aortic root. Both
coronary arteries
originate slightly
below the stenosis.
1C
1D
2A
2B
2
VRT (Fig. 2A) and
MIP (Fig. 2B) images
show adysplastic
right pulmonary
artery.
3A
3B
3
VRT images show
a DAPVF from two
different views.
Science
SOMATOM Force
from Translational Research
to Clinical Routine
With the recently introduced SOMATOM Force, high-precision imaging at
ultra-low dose is possible with minimized motion artifacts, the potential to
reduce sedation, and even with significantly reduced burden for the kidneys.
CT-imaging therefore has the potential to go beyond diagnostics and become
part of therapy evaluation strategies, as experts from Germany and Switzerland report.
Text: Wiebke Kathmann, PhD, Photos: Anna Schroll
Soon after the introduction of

Siemens new scanner SOMATOM
Force, expectations were high regarding new applications for CT imaging
as it is almost twice as fast, more precise, and even more patient-friendly
than previous scanners. The new
Dual Source CT scanner enables radiologists to perform even more personalized diagnostics in the young
and the old, the small and the large,

and regarding almost any clinical
question. Optimal parameter settings
for each patient are possible, as radiologists from the University Medical
Centre Mannheim of Heidelberg University, Germany, University Hospital
Zurich, Switzerland, and University
Hospital Munich-Grosshadern, Germany, report. They were among the
SOMATOM Force is almost twice as fast, more precise, and even more patient-friendly
than any of its predecessors.
first to explore the new technology in

the clinical and translational research
setting.
Clinical frontiers being tested with the
SOMATOM Force are 4D-CT angiography
in oncology response patient populations and elderly patients undergoing
cardiovascular examinations. For them
radiation and contrast medium dose
are of utmost importance. Also of
interest are low kV perfusion imaging
for tissue differentiation, and therapy
evaluation in oncology patients. Last
but not least, the SOMATOM Force is
well suited to help customers improve
the health of people in their communities by enabling earlier diagnoses of
diseases such as lung cancer or colon
cancer using ultra low radiation dose
techniques with spectral filtration of
unnecessary photons.
Personalized low-kV
diagnostics
Experts at the Mannheim University
Medical Centre at Heidelberg University
are convinced that almost all contraindications for CT have been eliminated
with SOMATOM Force. Mannheim was
the first site at which the SOMATOM
Force was installed worldwide. The
installation, a part of the M2OLIE
research campus initiative funded by
the German Federal Ministry of Education and Research, allows the researchers from Mannheim to continuously
1A
1B
Discovery of a type II endoleak after EVAR in a patient with renal insufficiency using dynamic 4D CT Angiography with only
12 cc contrast medium VRT images demonstrate the endoleak (Fig.1A) and the feeder artery (Fig.1B) to the aneurysm
(read the full case study on page 48). Courtesy of University Medical Centre Mannheim at Heidelberg University, Germany
improve and develop novel personalized

and functional CT techniques together
with Siemens in a public-private partnership. As Professor Stefan Schnberg,
MD, Chairman of the Institute of Clinical Radiology and Nuclear Medicine at
the University Medical Centre of the
Heidelberg University explains, The
new scanner can solve the problems
presented by every radiological situation
for virtually every patient in ageneral
population with avery complex age
and disease structure. This is due to
the once again improved technical features allowing for extra-low kVimaging not only in infants and slim adults
but even obese patients. Due tothe
powerful new Vectron tubes the tube
voltage could be lowered while maintaining a very high photon flux rate at
a very small focal point. This puts the
SOMATOM Force two steps ahead in
contrast-to noise, allowing not only for
a reduction in radiation dose but also
contrast medium1 amount.
With the two new StellarInfinity detectors
delivering a 50% increase in detector
coverage, an unmatched rotation speed
of 0.25 s, and its ultra-high pitch scanning the SOMATOM Force facilitates
anunseen temporal resolution of down
to 66 ms and an acquisition speed of
up to 737 mm/s. These capabilities are
especially important in cardio-thoracic
imaging. Additionally, the field of view
of the high pitch spiral (now called
Turbo Flash Mode) could be extended
up to 50 centimeters. This opens up
the opportunity to depict even some of
the smallest vessels such as coronary
arteries or calcified lesions in perfect

resolution, as Associate Professor
Thomas Henzler, MD, Head of CardioThoracic Imaging at the Institute of
Clinical Radiology and Nuclear Medicine of the University Medical Centre
Mannheim at Heidelberg University,
states. There is no longer a need to
worry about dose or motion artifacts,
as the extended field of view enables
radiologists to scan practically all
patients in the extremely fast Turbo
Flash spiral mode.
Expanding frontiers for

low-kV imaging
Low-kV imaging with resulting radiation dose reduction is of particular
importance in performing CT scans in
pediatric and elderly patients. In the
young low-kV imaging creates the
possibility to further optimize radiation dose using SOMATOM Force as a
major advantage in itself, especially
when combined with high-speed data
acquisition, allowing the scan to be
performed when children are free
breathing. As Henzler points out, the
new scanner enables the radiologist
to scan a broader range of pediatric
indications now that dose and sedation are no longer an issue.
In the elderly, the focus is less on
radiation dose per se but on the
resulting savings in contrast medium,
as these patients often suffer from
reduced kidney function. Therefore,
any reduction in the amount of contrast media1 isof great value when
performing a CT scan. These patients

may require CT scanning more frequently in order to continually manage their medical conditions, for
example, they may receive a CT study
in order to evaluate a suspected
leakage from an aortic stent or when
planning a transcatheter aortic valve
implantation (TAVI) procedure. TAVI
is an intervention performed increasingly often in the elderly, as highgrade aortic valve stenosis iscommon
in this age group and the intervention
can be performed with a minimally
invasive endovascular approach. Open
heart surgery can be avoided. As in
any minimally invasive intervention,
the original status and functional
outcome need to be assessed using
quantitative data from precise functional imaging. With the SOMATOM
Force, contrast media1 may potentially be reduced, which means that
SOMATOM Force can be considered
as kidney friendly. Kidney friendly
CT imaging is therefore possible in
these patients with already reduced
kidney function. This is not only a
gain for patients but for the healthcare system as well, as these patients
might otherwise have to undergo
prolonged pre- and after-care, especially if they are diabetics.
Another future application of
SOMATOM Force could be the earlier
evaluation of coronary artery disease. Now CT radiation dose levels
are somewhat similar to the dose
apassenger receives on a couple of
transatlantic flights, we have started
Science
needed in functional cardiac CT with

SOMATOM Force, Alkadhi feels he
can now encourage colleagues to no
longer settle for a less precise imaging
method. With scans that can use as
little as 30 milliliters of contrast media
per scan, the novel high-end CT can
provide reliable quantitative data to
base a sound decision on.
Since radiation dose can be so low, another future application of the SOMATOM Force might
well be early detection of coronary artery disease with submillisievert CT angiography.
This visualizes calcified as well as small non-calcified plaques and could play a larger role in
the near future, according to Professor Stefan Schnberg, MD (left) and Associate Professor
Thomas Henzler, MD (right).
to scan patients with an intermediate

cardiovascular risk profile directly
with a submillisievert CT angiography
instead of a non-contrast enhanced
calcium score in order to directly
visualize all kinds of plaques, reports
Henzler.
Free breathing scans

New cardiac applications are also one
of the fields of interest of Professor
Hatem Alkadhi, MD, Section Head of
Computed Tomography at University
Hospital Zurich. So far an elevated
heart rate puts limits on ultra-low dose
cardiac CT imaging. With SOMATOM
Force, this is no longer thecase. The
very robust, ultra-fast Turbo Flash
spiral mode allows for consistent lowdose cardiac scans at below 1 mSv
with excellent image quality. In addition, the 66 ms temporal resolution
means that there are no disruptive
motion artifacts even inpatients with
a heart rate of up to 75 beats per
minute, as Alkadhi found in two studies. The Turbo Flash spiral mode is now
the main mode he performs heart
CTscans with, a valuable option for
older patients with elevated heart
rates.
SOMATOM Force. Thanks to the outstanding temporal resolution of the

Turbo Flash spiral mode breathing
commands are no longer necessary.
Images with minimized motion impairment are possible without patients
having to hold their breath. As a result,
patient handling in CT-scanning is
much simpler, reports Alkadhi.
Taken together with the potential for
reduced amount of contrast media1
Alkadhi also stresses the advantage

of patient-friendly CT imaging in children. Due to the engineering achievements leading to ultra-fast CT scans
with ultra-low dose, high resolution,
and minimized motion, SOMATOM
Force allows more infants and children
with congenital heart disease to be
evaluated with CT imaging. Inthis context, he points out the value ofthe
versatility in kV settings. We can now
custom-size it in steps of10 kV from
70 to 150 kV, which is agreat advantage for the individual patient.
Early detection of lung

disease
Alkadhis other focus in working with
the SOMATOM Force is in the early
detection of lung cancer. The technical
triad of high-speed data acquisition,
high resolution, and broadened field
of view, allowing for free breathing
scans, opens up new possibilities in
lung imaging.
For Professor Hatem Alkadhi, MD, the technical triad of high-speed data acquisition,
high resolution, and broadened field of view, allowing for free breathing scans, opens up
a new field of application: early detection of lung disease.
In the elderly as well as the young,

free breathing during the scan is
another major advantage of the
Science
2A
2B
Ultra-low-dose thoracic scanning with a DLP of 2 mGy cm only MPR (Fig.2A) and VRT (Fig.2B) images reveal bilateral
bronchiectasis and mosaic perfusion suggesting cystic fibrosis. Courtesy of University Hospital Zurich, Zurich, Switzerland
In his first clinical study, Alkadhi and

coworkers examined several ultra-lowdose protocols (0.06 mSv) for a single
source thorax CT. We wanted to prove
the hypothesis that using the tin filters
and a tube voltage of 100 kV gives us
the best image quality and the lowest
noise, while still being able to visualize. The two new tin filters add to the
precision as they create almost monochromatic energy spectra, which
improves the contrast-to-noise ratio
even further. For lung scans, this adds
up to a better discrimination of soft
tissue and air.
Alkadhis data derived from a lung
phantom are impressive and were presented at the 2014 meeting of the
(RSNA). We are now down to the dose
level of an ordinary X-ray without any
compromise in image quality while
obtaining more information to base
our treatment decision on. Therefore,
CT scans using SOMATOM Force might
become a tool that is more frequently
used for the earlier detection of lung
cancer, predicts Alkadhi.
Therapy evaluation in
cancer patients
Early detection of cancer as well as
cost-effective use of new specific but
costly medications such as monoclonal
antibodies are indispensable objectives of todays healthcare systems.
Dynamic perfusion imaging could contribute to this goal as initial results in
patients with renal cell or gastrointestinal stromal tumors (GIST) imply.
At the Clinical Radiology Department
of University Hospital Grosshadern,
Munich, Germany, the focus has long
been on functional and perfusion
imaging using high-end CTs. As Professor Anno Graser, MD, former Head
of the CT unit for Oncological Radiology, envisioned, the SOMATOM Force
opens up the possibility of dynamic
perfusion imaging of cancerous lesions
and helps physician better determine
which patients might respond to
antiangiogenic therapies. Right now,
we are in the early stages of our
research. But we have already been
able to prove that quantification of
the therapy response with the
SOMATOM Force. More importantly,
determining blood flow allows us

to differentiate between pseudoprogression in the sense of lesion
enlargement and true progression.
Furthermore, this CT imaging makes
it possible to evaluate patients at a
much earlier point in time. We can
now evaluate treatment response
within seven days instead of ten
weeks after therapy was initiated.
Having access to more information
about a patients response to chemotherapy allows the medical oncology
team to make more informed decisions about the treatment strategy.
Low-kV perfusion imaging

ofthe body stem
The last word on whether Dual Energy
CT (DECT) protocols or dynamic perfusion imaging excel in regard to
clinical informative value has not
been spoken. With the possibility of
dynamic perfusion imaging at low kV
and dose exposure, some traditional
CT-protocols might turn dynamic in
the future though, as they might offer
more attractive information. For now,
Professor Hans-Christoph Becker, MD,
3A
3A
Evaluation of Williams-Beuren Syndrome in a two-month-old child using single rotation scan mode with 70 kV and 5 cc contrast
medium, without sedation MIP images show a significant stenosis of the ascending aorta directly above the aortic root, and both
coronary arteries originate slightly below the stenosis (read the full case study on page 70).
Courtesy of University Hospital Grosshadern, Munich, Germany
former Head of General Radiology

at University Hospital Grosshadern,
considers DECT as the imaging
modality of choice mainly in tissue
discrimination, as in kidney stones,
and in the detection of lung emboli
or infiltrations.
For him, the novelty with the
SOMATOM Force is true perfusion
imaging. The powerful two new
tubes are the enablers of these
dynamic CT scans of the body stem
at a reasonable dose, Becker states.
Becker is also impressed with the
option of whole heart dynamic stress
myocardial CT perfusion imaging.
Mainly owing to the broader detectors (approx. 6 cm each), perfusion
imaging of the whole organ is now
possible with minimized motion or
cone beam artifacts. This is of clinical relevance for instance in patients

with asuspected infarction of the
posterior wall, an area that is hard to
evaluate even with methods other
than CT, Becker explains.
Standard X-ray imaging

tasks possibly moving to CT
Within only a few months, almost all
non-contrast CT imaging protocols
have become the domain of
SOMATOM Force at University Hospital in Grosshadern, be it of the paranasal sinus, the lung or the abdomen.
These ultra-low-dose protocols at
< 100 kV with tin filters have outcompeted other protocols, because
they are very reliable and fast to perform and evaluate, says Becker. As
they run with a radiation dose of far
lower than 1 mSv, which isthe range

of conventional imaging, the question
arises of whether X-ray imaging still
has a place in these applications.
As various institutions have proven,
SOMATOM Force is bound to take CT
beyond CT. It allows dedicated research
to introduce new applications or widen
existing ones to potentially improve
tomorrows routine CT imaging for better therapeutic outcomes. p
Wiebke Kathmann, PhD, is a frequent
contributor to medical magazines. She holds
aMaster in Biology and a PhD in Theoretical
Medicine and was employed as an editor
for many years before becoming a freelancer
in 1999. She is based in Munich, Germany.
1 Early clinical experience based on imaging of

the left ventricle and aortic root (TAVI studies)
demonstrate that a reduction of contrast media
administration may be possible using SOMATOM
Forces Turbo Flash Mode and its low kV/High mA
capabilities.
herein are based on results that were achieved
in the customers unique setting. Since there is no
Further Information
www.siemens.com/
SOMATOM-Force
Professor Hans-Christoph Becker, MD (right) and Professor Anno Graser, MD (left)
consider DECT as the imaging modality of choice mainly in tissue discrimination.
Science
FAST Spine and FAST Planning

By Susanne von Vietinghoff
Trauma patients are particularly vulnerable and need to be examined quickly

and diagnosed reliably. But in real life,
preparation and post-processing of scans
can be time consuming and prone to
errors. This could result in non-comparable results as well as avoidable delays
and expense. The requirement to expedite medical processes while enhancing quality and reducing costs is growing steadily. These conditions have been
a driving force for Siemens in developing its Fully Assisting Scanner Technologies (FAST.) These aim to streamline the CT scan procedure as well as
the overall radiology workflow, (Fig.1)
resulting in higher quality and productivity: In short, creating increased efficiency. Therefore, in addition to the
medical perspective, the (health) economic view is especially interesting.
An investigation conducted in Germany,
explored the efficiency enhancements
generated by Siemens FAST in the CT
process.1 Measurements were taken in
20 cases without FAST Planning (Fig. 2)
and FAST Spine (Fig. 3) and then, in a
second phase, using both FAST features.
The results showed that both process quality and outcome quality are
Scan
preparation
Scan
Reconstruction/
post processing
FAST Planning
Storing
Diagnosis
FAST Spine
FAST Planning and FAST Spine tackle the critical steps of scan preparation
and reconstruction.
enhanced using FAST. With FAST

Planning, the number of adjustments
to set up the scan and recon ranges
using FAST Spine cut processing time
for spinal examinations. The process
also became less dependent on the
individual operator or on anatomical
anomalies of the patient, thus delivering more consistent image quality.
The CT imaging process and the associated time-consuming and complex
procedures are clearly simplified and
automated with FAST Planning and
FAST Spine. Enabling reproducible
results and streamlined examinations,
FAST technologies improve efficiency

and optimize the overall clinical outcome. Therefore, the positive impact
of these technologies on the radiological workflow is demonstrated
both from a medical and economic
perspective. p
1 Data on file.
Further Information
www.siemens.com/FASTCARE
3
2
FAST Planning
means an immediate,
organ-based setting
of scan and recon
ranges with a single
click.
3
FAST Spine automatically labels the
vertebrae and discs
and prepares the
reconstruction in the
correct anatomical
orientation.
Science
Leading Concept
in High-End CT Imaging
For almost a decade now, Siemens Dual Source concept has spearheaded computed
tomography imaging and proven its value in exceptional products. During this time,
Dual Source CT (DSCT) has continually set new standards in CT imaging. In 2013, the
latest pinnacle was reached with the introduction of SOMATOM Force.
By Jan Freund
Over the past four decades, experts

from a range of scientific fields
physicists, clinicians, IT experts, engineers have been working on ideas
to take CT imaging forward, aiming
at better, more reliable diagnostic
results that will ultimately help physi-
cians to determine the optimal treatment path for the patient.
Concepts in high-end
CT imaging
In developing their computed tomography systems, the various vendors
have taken a variety of approaches.
Among these, three distinct concepts
can be identified in the arena of highend CT imaging:
Dual layer detector design:
Two different layers of detector
material absorb either low and high
energy photons of the X-ray beam
to evaluate two different energy
spectra
Wide detector coverage enabled by
a large detector array beyond the
established 64-row design, with up
to 16 cm coverage
Dual Source CT with two tube
detector pairs integrated at an
approximate 90-degree angle
Dual layer detectors
Scan with Dual Source CT

615mm acquired using Flash
mode (pitch 3.2) in 0.8 s. VRT
images show an infrarenal EVAR
with no signs for an endoleak.
The dose applied to the patient
(185 kg) was 3.3 mSv only.
Courtesy of Universitaets-Spital,
Zurich, Switzerland
Dual layer detectors were only introduced as a clinical product in 2013 so

practical experience is limited, even
though prototypes and concepts reach
back to 2005. However, initial results
indicate that Dual Source CT is a better
method of acquiring Dual Energy
information.[1]
The general idea is that the X-ray
beam is absorbed by a two-layered
detector after it has penetrated the
patient, delivering two different
energy spectra from the respective
layers, thus enabling Dual Energy
imaging (see also page 81). But a natural drawback of this design is that in
every other non-Dual Energy examination, users have to live with the
systems drawbacks (e.g. higher electronic noise, fixed kV settings, etc.),
making it aspecialized niche scanner.
Wide detector coverage in

single source CT
The other two concepts, wide detector
coverage and Dual Source CT have
been used much more extensively in
clinical routine. The extent of clinical
and scientific results that have been
published on these two concepts therefore allows a reliable comparison. The
initial motivation for wide detector
coverage beyond the established 64-row
detector design was to cover larger
anatomies (e.g. whole organs or vascular structures) using a fast scan mode
at high spatial resolution. Another field
was dynamic studies such as perfusion
or long-range angiographies.
Although the available wide detector
designs enable coverage of organs, such
as the heart, the concept itself had
several drawbacks: In 2012, a paper
concluded that for a 140 mm system, 24.5% of imaging volume exhibits more severe cone beam artifacts
than a 64-slice system, which also
poses a patient dose concern. In addition, this system may suffer from a
36% peak power (flux) loss, which is
equivalent to about 20% image noise
increase. Therefore, a wide coverage
CT system using a single X-ray source
is likely to face some severe challenges
in IQ and clinical accuracy.[2]
2
Science
Dynamic 4D study conducted with SOMATOM Force 796 mm acquired using dynamic 4D spiral mode at 70 kV with 1 mSv.
MIP images show nicely the dynamic flow of the vascular details in the lower extremities. In comparison to an one-time
Runoff CTA, a dynamic 4D scan provides more diagnostic information in multiple acquisition phases.
Courtesy of University Medical Centre Mannheim at Heidelberg University, Germany
It is important to note that the wide

detector further is limited by its temporal resolution (resulting in motion
artifacts) and also by its capabilities
regarding spiral acquisition modes for
volumes larger than 16 cm. Based on
advanced and comprehensive cardiac
studies, such as studies on electron
beam CT scanners,[3] a temporal resolution far below 100 ms is favored
when patients with high and irregular
heart rates are to be scanned. Since no
conventional single source CT scanner
can deliver the required rotation speed,
reconstruction approaches were introduced to somewhat reduce motion
artifacts and compensate for the lacking temporal resolution. But although
these methods have been available
for several years now, their true impact
in regular clinical routine still remains
to be seen and has thus far only been
shown for lower and stable heart
rates.[4] In dynamic studies, for example in myocardial perfusion assessments,
temporal resolution below 100 ms is
also required.
Dual Source CT
In contrast to this, Dual Source CT has
shown that it can compensate these
limitations and actually achieve the
intended goal of fast large volume
coverage. With hundreds of clinical
publications based on the Dual Source
concept, this approach has clearly
established itself as the pinnacle in
high-end CT. Taking the cardiac arena

in particular, several studies have
demonstrated that Dual Source CT
avoids of the issue of heart rate control[5], makes it possible to image
children even when they are not
sedated[6], and facilitates significant
dose reduction to far below one mSv,
not only in selected cases but also
forlarge patient populations.[7]
When it comes to Dual Energy imaging, only Dual Source truly scans at
two independent individual kV settings
or energy levels, making it the gold
standard in this arena. And now, the
unique capabilities of SOMATOM
Force allow clinical researchers to take
CT imaging into new clinical fields
where CT previously could not be
applied, for instance scanning patients
with renal insufficiencies or conducting long-range dynamic studies for
treatment planning (Fig.1) or vascular surgeries (Fig.2).
Consequently, Dual Source CT has
not only established itself firmly as
the leading technological approach
with more than 1,500 Dual Source
installations since the initial intro
duction of Dual Source scanning
withSOMATOM Definition. It also
continues to set the clinical gold standard in CT imaging with SOMATOM
Definition Flash and pushes innovation in high-end CT with SOMATOM
Force. p
References
[1] Gabbai M, et al. Material characterization
with CT: comparison of commercial
investigative technologies in phantoms.
Acta Radiol. 2014 Sep 2
[2] Li B, et al. Simulation and analysis of
image quality impacts from single source,
ultra-wide coverage CT scanner. J Xray
Sci Technol. 2012;20(4):395-404.
[3] Achenbach S, et al. Value of electronbeam computed tomography for the
noninvasive detection of high-grade
coronary-artery stenoses and occlusions.
[4] Lee H et al.. Impact of a vendor-specific
motion-correction algorithm on image
quality, interpretability, and diagnostic
performance of daily routine coronary
CT angiography: influence of heart rate
on the effect of motion-correction.
Int J Cardiovasc Imaging. 2014 Jul 20
[5] Alkadhi et al. Accuracy of dual-source CT
coronary angiography: First experience
in a high pre-test probability population
without heart rate control. Eur Radiol.
2006 Dec;16(12):2739-47.
[6] Lell MM et al. High-pitch spiral computed
tomography: effect on image quality and
radiation dose in pediatric chest computed
tomography. Invest Radiol. 2011
Feb;46(2):116-23.
[7] Sidhu MS et al. Advanced adaptive
axial-sequential prospectively electrocardiogram-triggered dual-source coronary
computed tomographic angiography
inapatient with arterial fibrillation.
J Comput Assist Tomogr. 2011 Nov-Dec;
35(6):747-8.
Further Information
www.DSCT.com
Science
Dual Energy: Spectral CT

More Precisely Defined
Over the past six years, a new alphabet soup of technologies and marketing
buzzwords has been created in computed tomography: spectral CT,
dual layer detectors, kV-switching, Dual Energy CT, single source Dual Energy,
Dual Source Dual Energy. Lets try to enlighten this situation.
By Stefan Ulzheimer, PhD, and Susanne Hlzer
Computed tomography (CT) has

become a very fast and robust technology for the diagnosis of many
diseases; modern diagnostic imaging
without CT is now unimaginable.
However, the information it provides
is limited in the sense that it only
measures X-ray attenuation values in
a patient.
One possibility to acquire additional
information using X-rays is to measure
the patient at two different energies
since the attenuation of all materials
is energy dependent. This energy
dependence is different for different
materials. In the X-ray energy ranges
for diagnostic imaging, only two independent physical effects contribute to
X-ray absorption: the Compton effect
and the photoelectric effect. Measuring at more than two different energy
spectra does not provide additional
information. Conventional single
energy CT already uses a spectrum
of photons because that is what X-ray
tubes produce. Therefore, calling
this technique spectral CT would be
misleading at best.
The physical principle underlying
Dual Energy acquisition is always the
same; however, the technical means
of acquiring the data can vary. Of
course, all the major CT vendors also
come up with different marketing
names for their solutions, spectral CT
being one of them.
The early years: Siemens

introduces fast kV-switching
Back in 1986, Siemens introduced a
CT scanner that was able to acquire
Dual Energy data using rapid switching of the tube voltage between
CT projections.[1] It could be used
clinically to improve accuracy in bone
mineral density measurements.[2]

This was achieved by using an improved
beam-hardening correction or, in
general, creating material density
maps in CT.[3] This method of acquiring Dual Energy data is today typically
called fast kV-switching (Fig.1).
However, fast kV-switching technology
comes with many limitations and com-
With fast kV-switching, Dual Energy data can be acquired by rapidly switching
the tube voltage between CT projections.
Science
Idealized dual layer detector technology: In reality a certain amount of highand low-energy photons are registered in both layers which significantly reduces
spectral seperation.
promises. Due to the permanent rapid

switching, a lower number of projections are available to create each image,
which leads to reduced image quality
and diagnostic accuracy.[4] In addition,
only the tube voltage but not the tube
current can be modulated between
individual projections. This leads either
to massive over-exposure in the highkV projections or a severe under-exposure in the low-kV projections.[4, 5]
Moreover, the separation of the highenergy spectrum and the low-energy
spectrum is poor because no optimized
filters can be used for each of the spectra; smearing therefore occurs between
the high-energy and the low-energy
spectrum due to the rapid switching.
But good spectral separation is a pre
requisite for an accurate evaluation of
Dual Energy data. And, established dose
reduction technologies, even the most
basic ones such as tube current modulation do not work with this implementation. Siemens decision not to pursue
this technology in the mid 1980s has
proven correct since the implementations of fast kV-switching available today
still struggle with the same problems.
[46] There are a number of alter

native Dual Energy acquisition techniques, which we discuss now in
turn.
Dual layer detectors

A further Dual Energy acquisition
method based on a single source CT
system is the use of a dual layer detector. The top detector layer primarily
absorbs (and measures) the low-energy
photons, while the bottom layer
absorbs the remaining high-energy
photons (Fig. 2).
With this approach, the spectral separation of high and low keV is also poor.
The reason for this is the behavior of
the detector, which is physically not
able to distinguish precisely between
high and low energy photons. Both
high and low energy p
hotons are
absorbed in both layers. The construction of this detector requires two photodiodes, which significantly increases
electronic noise. This leads to inferior
image quality for dual and single
energy images. Again, the increased
electronic noise and the poor spectral
Slow kV-switching: Both kV and

mA are switched between half
rotations of the gantry, either in
sequence or in spiral modes.
separation force the use of higher

dose levels to compensate for the
lower image quality.
Slow kV-switching
A third possibility to acquire Dual
Energy data is slow kV-switching.
Here, both kV and mA are switched
between half rotations of the gantry,
either in sequence or in spiral modes.
The image quality in this approach is
comparable to the fast kV-switching
technology. Again, the limitation is
the number of projections for each
kV setting (Fig.3).
The time needed to switch from 80 kV
to 140 kV and adjust the mA is typically in the order of 100 ms. During
this time, the patient is exposed to
radiation that does not provide useful
information. Thus, this method does
not follow the ALARA (as low as reasonably achievable) principle. Broad
clinical applicability of the slow kVswitching method is hindered because
of the decreased image quality and
thecomparably longer scan times. In
acute and pediatric cases especially,
Science
itis essential to scan quickly, making

slow kV-switching not suitable for
clinical routine.
Successive scanning
To enable Dual Energy also on single
source scanners, Siemens introduced
Dual Spiral Dual Energy (Fig.4).
This approach is available on nearly
all Siemens scanners, starting from
SOMATOM Perspective and SOMATOM
Definition AS systems, up to
SOMATOM Definition Edge.
During a single source Dual Energy
scan, two CT datasets are acquired at
different kV and mA levels using two
successive spiral scans. The two spirals are automatically coupled. Scan
set-up and scan parameter selection
are as easy as for any standard single
energy spiral. With this scan approach,
both datasets acquire the full number
of projections for the low and high
kV setting. In a fully automated procedure, the two datasets are nonrigidly registered to compensate for
potential patient motion between the
two spirals. They match the patients
anatomy exactly. The large number
of projections and low noise values
provide very good image quality for

each of the energies.
Each spiral is carried out at approximately half the dose of a conventional
120 kV scan. Of course, scan para
meters can be flexibly adapted to the
size of the patient and the planned
examination. All dose reduction techniques, including automatic exposure
control (CARE Dose4D) and iterative
reconstruction (SAFIRE1), are available for the single source Dual Energy
scan mode.
The first spiral typically uses 80 kV at
a pitch of 0.6. The second spiral uses
140 kV or 130 kV at a fast pitch of 1.2,
providing a good balance at sufficient
power reserves and with fast data
acquisition. The excellent image quality in conjunction with the easy-toperform scan and the dose-optimized
scan protocols make Siemens single
source Dual Energy approach reliable
and flexible.
The latest quantum leap

insingle source Dual Energy
CT: TwinBeam Dual Energy2
As described in detail on page 12 of
this issue, the latest quantum leap in
data acquisition with a single source
scanner is the introduction by Siemens

of a new tube assembly with a dedicated
filtration that can overcome all the
problems with previously described
techniques. It allows for simultaneous
Dual Energy data acquisition in combination with fast rotation speeds, full
availability of projections for each of
the energies, and optimized spectral
separation.
Still the gold standard in Dual

Energy CT: Dual Source CT
However, Dual Source Dual Energy
(DSDE) imaging introduced by Siemens
in 2005 is still the established gold
standard in Dual Energy computed
tomography (see also page 78). Dual
Energy scan modes on Siemens Dual
Source CT scanners offer the same
flexible selection of scan protocol
parameters as single energy modes.
They acquire Dual Energy data simultaneously and make use of all relevant
dose reduction technologies, such as
automated tube current modulation
(CARE Dose4D). With the introduction
of the Selective Photon Shield and different spectral shaping on both tubes,
it is possible to optimize spectral separation and to perform Dual Energy scans
1st scan
low kV
2nd scan
high kV
Single source Dual Energy scan mode: Two CT datasets are acquired at different kV and mA levels using two successive
spiral scans. The two spirals are automatically coupled.
Science
using the same dose compared with a

120 kV single energy scan.[9, 10]
From the outset, Siemens aimed to

introduce clinically relevant Dual Energy
applications rather than simply providing a tool for research. These applications include the characterization of
kidney stones or the calculation of virtual non-enhanced images and iodine
uptake maps, for example to quantify
iodine uptake in lesions, to reveal perfusion defects in the myocardium, or to
assess hemorrhages in the cerebrum
(Fig. 5).
Through the continuous development
of DSDE starting with the original
SOMATOM Definition, to SOMATOM
Definition Flash and now SOMATOM
Force, users can benefit from a decade
of experience delivering Dual Energy
applications to clinical practice.
The Dual Energy application syngo.CT DE Brain Hemorrhage enables clinicians

to assess cerebral hemorrhages.
Evaluation of
Dual Energy data
Only well-measured data can lead to
accurate results. Any of the previously
described acquisition methods can
be used to produce colorful images or
diagrams. But in conclusion, spectral
CT in this context can rather be considered a misleading marketing term.
Dual Energy CT defines the technology
more precisely. And in consequence,
when it comes to Dual Energy imaging,
clinically useful evaluation methods
are what is really important. Siemens
offers a wide portfolio of applications.
[79] With more than 130 scientific
publications, over 1,500 installed Dual
Source CT scanners, and more than
75,000 Dual Energy examinations per
year, Siemens Dual Source Dual Energy
can be considered the leader in clinical
Dual Energy CT. p
particular clinical task. The following test method
was used to determine a 54 to 60% dose reduction
when using the SAFIRE reconstruction software.
Noise, CT numbers, homogenity, low contast resolution, and high contrast resolution were assessed
in a Gammex 438 phantom. Low dose data reconstructed with SAFIRE showed the same image
quality compared to full dose data based on this
test. Data on file.
2
TwinBeam Dual Energy is currently pending 510(k)
clearance and is not yet comercially available in the
United States.
1

References
[1] Kalender WA, Perman WH, Vetter JR,
Klotz E. Evaluation of a prototype
dual-energy computed tomographic
apparatus. I. Phantom studies.
Med Phys. 1986 May-Jun;13(3):334-9.
[2] Kalender WA, Klotz E, Suess C.
Vertebral bone mineral analysis:
anintegrated approach with CT.
Radiology. 1987 Aug;164(2):419-23.
[3] Kalender WA, Klotz E, Kostaridou L.
Analgorithm for noise suppression
indual energy CT material density
images. IEEE Trans Med Imaging.
1988;7(3): 218-24.
[4] Geyer LL, Scherr M, Krner M, Wirth S,
Deak P, Reiser MF, Linsenmaier U.
Imaging of acute pulmonary embolism
using a dual energy CT system with
rapid kVp switching: Initial results
[5]
Lv P, Lin XZ, Li J, Li W, Chen K. Differentiation of small hepatic hemangioma
from small hepatocellular carcinoma:
recently introduced spectral CT method.
Radiology. 2011 Jun;259(3): 720-9.
[6] Zhang D, Li X, Liu B. Objective characterization of GE discovery CT750 HD
scanner: gemstone spectral imaging
mode. Med Phys. 2011 Mar;38(3):
1178-88.
[7] Delesalle MA, Pontana F, Duhamel A,
Faivre JB, Flohr T, Tacelli N, Remy J,
Remy-Jardin M. Spectral optimization
of chest CT angiography with reduced
iodine load: experience in 80 patients
evaluated with dual-source, dual-energy
CT. Radiology. 2013 Apr;267(1): 256-66.
[8] Lell MM, Kramer M, Klotz E,

Villablanca P, Ruehm SG. Carotid
computed tomography angiography
with automated bone suppression:
acomparative study between dual
energy and bone subtraction
techniques. Invest Radiol. 2009
Jun;44(6):322-8.
[9] Graser A, Becker CR, Staehler M,
Clevert DA, Macari M, Arndt N,
Nikolaou K, Sommer W, Stief C, Reiser
MF, Johnson TR. Singlephase dualenergy CT allows for characterization
of renal masses asbenign or malignant.
Invest Radiol. 2010Jul; 45(7):
399-405.
[10] Schenzle JC, Sommer WH, Neumaier
K, Michalski G, Lechel U, Nikolaou K,
Becker CR, Reiser MF, Johnson TR.
Dual energy CT of the chest: how
about the dose? Invest Radiol. 2010
Jun;45(6):347-53.
Further Information
www.siemens.com/dualenergy
Customer Excellence
CT Physics Workshop
Focus on Radiation Dose Optimization
By Katrin Seidel, Computed Tomography, Siemens Healthcare, Forchheim, Germany
Everyone is using terms such as
ALARA, Right Dose or low-kV scanning. When focusing on dose, it
becomes increasingly important for
physicists to exploit the full dose-saving potential of their CT scanners.
Siemens is therefore offering the
chance to learn more about dose saving possibilities of SOMATOM CT systems. The next course is scheduled
for March 2425, 2015, in Forchheim,
Germany.
Successful course held

for physicists
A two-day workshop, designed
especially for physicists, was held on
September 2324, 2014, at Siemens
CT headquarters in Forchheim, Germany, with a focus on dose management and new medical imaging
technologies.
Siemens physics specialists guided

participants through tailored lectures
followed by interactive discussions
covering topics such as CARE Dose4D,
CARE kV, Turbo Flash scanning, and
iterative reconstruction techniques.
A tour through the CT factory and
detector center was also included to
show first-hand how our CTs are
manufactured.
Rounding off this unique course,
Holger Haubenreisser, MD, a radiologist from the University of Mannheim
in Germany shared his practical knowledge of institutional dose monitoring
in daily routine.
The 12 available places were quickly
filled by participants from all over
the world who appreciated the direct
contact with high-level R&D physicists and the opportunity to discuss
issues in person. p
Holger Haubenreisser, MD, from the University

Mannheim, Germany, focuses on dose monitoring
in clinical routine.
If you are interested in participating

in March, please visit the following
website for registration details:
Further Information
www.siemens.com/
SOMATOMEducate
Siemens Educational Platform Study

Flexibly: When and Where it Suits You Best
By Katrin Seidel, Computed Tomography, Siemens Healthcare, Forchheim, Germany
The clinical platform includes publications, a series of How to flyers with
useful expert advice, training programs
such as fellowships, workshops, and
hands-on tutorials, as well as recommended CT literature to extend and
consolidate knowledge.
Live webinars
On the Siemens educational platform users
can follow latest news in medical imaging.
Siemens Healthcares educational platform is an established and comprehensive clinical information page with a
wide range of programs offering valuable ways to improve clinical skills and
to use Siemens CT systems to their full
potential.
In addition to the e-learning programs,

Siemens offers regular live clinical
webinars with opportunities for live
interaction, held by experienced clinicians. The latest webinar was conducted by Thomas Henzler, MD, from
the University of Mannheim in Germany. Thomas Henzler, one of the
first SOMATOM Force users, shared
his extensive knowledge of the bene-
fits of low-kV scanning in daily routine

and in challenging clinical settings
while maintaining the balance between
low dose and best image quality. This
free webinar was originally presented
live. p
You can view the recording and get
information about further scheduled
webinars and more via the following
link:
Further Information
www.siemens.com/
SOMATOMEducate
Customer Excellence
Clinical Workshops 2015

As a cooperation partner of many renowned hospitals, Siemens Healthcare offers continuing CT training programs.
In a wide range of workshops, clinical experts share latest experiences and options in clinical CT imaging.
Workshop Title/
Special Interest
Date
Location
SCCT Hawaii
The Winter Meeting
January
1821, 2015
Hawaii,
USA
Body Perfusion Workshop
January
2223, 2015
Hands-on at the ECR
Course
Language
Organizer Course Director
Link
English
Society of Cardiovascular
Computed Tomography
www.scct.org/hawaii/2015/
Forchheim,
Germany
English
Siemens Healthcare
www.siemens.com/
SOMATOMEducate
March
48, 2015
Vienna,
Austria
English
Siemens Healthcare
www.siemens.com/ECR
Optimized TAVI
Procedural Planning:
CT and Angiography
March
10, 2015
Erlangen,
Germany
English
Siemens Healthcare
Prof. Stephan Achenbach, MD
Markus Kasel, MD
Martin Arnold, MD
www.siemens.com/
SOMATOMEducate
Workshop for Physicists
March
2425, 2015
Forchheim,
Germany
English
Siemens Healthcare
www.siemens.com/
SOMATOMEducate
Hands-on at the ESGAR

Workshop/Colonography
April
1517, 2015
Bruges,
Belgium
English
ESGAR
Philippe Lefere, MD,
Stefaan Gryspeerdt, MD
www.esgar.org
Workshop on Dual Energy
May
78, 2015
Forchheim,
Germany
English
Siemens Healthcare
Assist. Prof. Ralf Bauer, MD
www.siemens.com/
SOMATOMEducate
Advanced Cardiovascular CT
May
1215, 2015
London,
UK
English
Siemens Healthcare
Organizers:
Ed Nicol, MD,
Simon Padley, MD,
Sujal Desai, MD
www.imperial.ac.uk

Congress/Colonography
June
0912, 2015
Paris,
France
English
ESGAR
Prof. Yves Menu
www.esgar.org
Oncology Imaging
Course 2015
June
2527, 2015
Dubrovnik,
Croatia
English
OIC
Prof. Maximilian F. Reiser, MD
Prof. Christian Herold, MD
Prof. Hedvig Hricak, MD
www.oncoic.org
Hands-on at the ESC
August 29
September 2,
2015
London,
UK
English
Siemens Healthcare
www.siemens.com/ESC

Workshop/Colonography
September
1618, 2015
Florence,
Italy
English
ESGAR
Assist. Prof. Emanuele Neri
www.esgar.org
Workshop for Physicists
October
2728, 2015
Forchheim,
Germany
English
Siemens Healthcare
www.siemens.com/
SOMATOMEducate
Coronary CTA
Interpretation Workshop
November
1213, 2015
Erlangen,
Germany
English
Siemens Healthcare
Prof. Stephan Achenbach, MD
www.siemens.com/
SOMATOMEducate
In addition, you can always find the latest CT courses offered by Siemens Healthcare
at www.siemens.com/SOMATOMEducate
Customer Excellence
Upcoming Events & Congresses 2014/2015

Short Description
Date
Location
Title
Contact
November 30
December 05,
2014
Chicago, USA
RSNA
www.rsna.org
Arab Health
January
2629, 2015
Dubai, UAE
Arab Health
www.arabhealthonline.com
European Society of Radiology
March
0408, 2015
Vienna, Austria
ECR
www.myesr.org
Cardiac Magnetic Resonance Imaging

& Computed Tomography
April
1618, 2015
Cannes, France
Cardiac MRI & CT
http://cardiacmri-ct.medconvent.at/
European Conference
on Interventional Oncology
April
2225, 2015
Nice, France
ECIO
www.ecio.org
European Society for Radiotherapy

& Oncology
April
2428, 2015
Barcelona, Spain
ESTRO
www.estro.org
European Stroke Conference
May
1215, 2015
Vienna, Austria
esc
www.eurostroke.eu
Particle Therapy Co-Operative Group
May
1823, 2015
San Diego, USA
PTCOG
www.ptcog.ch
Annual Meeting of the Association for

European Paediatric and Congenital
Cardiology
May
2023, 2015
Prague, Czech
Republic
AEPC
www.aepc.org
American Society of Clinical Oncology
May 29
Jun 02, 2015
Chicago, USA
ASCO
www.am.asco.org
European Society of Paediatric Radiology
June
0206, 2015
Graz, Austria
ESPR
www.espr.org
European Society of Thoracic Imaging
June
0406, 2015
Barcelona, Spain
ESTI
www.myesti.org
International Society for Computed

Tomography
June
0710, 2015
San Francisco,
USA
ISCT
www.isct.org
European Society of Gastrointestinal

and Abdominal Radiology
June
0912, 2015
Paris, France
ESGAR
www.esgar.org
The American Association of Physicists

in Medicine
July
1216, 2015
Anaheim, USA
AAPM
www.aapm.org
Society of Cardiovascular
Computed Tomography
July
1619, 2015
Las Vegas, USA
SCCT
www.scct.org
European Society of Cardiology
August 29
Sep. 02, 2015
London, UK
ESC
www.escardio.org
European Society for Medical Oncology
September
2630, 2014
Madrid, Spain
ESMO
www.esmo.org
American Society for Radiation Oncology
October
1821, 2015
San Antonio,
USA
ASTRO
www.astro.org
November 29
Dec. 04, 2015
Chicago, USA
RSNA
www.rsna.org
Customer Excellence
Tips & Tricks:

Editing Bone Removal Results in Dual Energy
By Patricia Jacob, Computed Tomography, Siemens Healthcare, Forchheim, Germany
For some patients, bone removal
images may contain minor defects
such as the following:
False vessel interruptions
False vessel terminations
False detection of calcium in
organs showing low enhancement
or rapid motion
Remaining bone fragments or
metal markers
For each of these four cases, there is

a specific manual interaction allowing
you to remove the defect efficiently
in syngo.via VA20 Dual Energy.
You can edit the bone removal results

only if the bone highlighting view is
switched off and the fine tuning or the
bone opacity modes are deactivated.
An icon at the mouse pointer indicates

which interaction you can perform in
a particular situation.
The segmentation threshold allows

you to restrict bone removal editing to
regions with a high average CT value.
You can remove bone fragments or
avoid vessel tracking errors caused by
vessels with high contrast agent
enhancement. p
The following interactions are possible

Connecting vessel segments
Extending vessels
Restoring vessel defects
Removing calcium fragments
Editing bone removal results:

Four different actions are possible, the mouse pointer indicates the availability of this interaction:
Connecting vessel segments:
Drag the mouse while holding the mouse button, and release it on an adjacent vessel segment.
Extending vessels:
Click a vessel that terminates unexpectedly and drag it to a point where the vessel should end.
Restoring vessel defects:
Click an isolated, non-recognized vessel defect.
Removing calcium fragments:
Click an isolated calcium fragment. The volume is not displayed as bone any longer.
1
1
Editing the bone
removal results is
only possible if the
bone highlighting
view is switched off
and the fine tuning
or bone opacity
modes are deactivated. To connect
vessel segments:
drag the mouse
while holding
the mouse button,
and release it on
an adjacent vessel
segment.
Subscriptions
Siemens Healthcare Publications

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

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

magazines, please visit www.siemens.com/
healthcare-magazine
Imprint
2014 by Siemens AG, Berlin and Munich,

All Rights Reserved
Publisher: Siemens AG, Healthcare
Henkestrae 127, 91052 Erlangen, Germany
Henzler, Thomas, MD, Institute of Clinical Radiology

and Nuclear Medicine, University Medical Centre
Mannheim, Medical Faculty Mannheim, Heidelberg
University, Germany
Chief Editors: Monika Demuth, PhD;

Stefan Ulzheimer, PhD
Imafuji, Ayano, MD, Department of Radiology,

Tsushima Municipal Hospital, Aichi, Japan
Clinical Editor: Xiaoyan Chen, MD
Ito, Tatsuro, MD, Department of Radiology,

Mie University School of Medicine, Mie, Japan
Project Management: Miriam Kern; Sandra Kolb

Responsible for Contents: Raghavan Dhandapany
Editorial Board: Xiaoyan Chen, MD; Monika Demuth,
PhD; Raghavan Dhandapany; Andreas Fischer; Jan
Freund; Julia Hlscher; Axel Lorz; Stefan Ulzheimer, PhD
Authors of this issue:
Alves de Abreu, Bernardo N., MD, Department of Cardiovascular Imaging, Hospital do Corao, So Paulo, Brazil
Andrade Gomes, Hlder, MD, Department of Cardiovascular Imaging, Hospital do Corao, So Paulo, Brazil
Antonio, Gregory E., MD, St Teresas Hospital,
Kowloon, Hong Kong
Becker, Hans-Christoph, MD, Department of Clinical
Radiology, University Hospital Grohadern, Munich,
Germany
Bello, Juliana H.S.M.,MD, Department of Cardiovascular Imaging, Hospital do Corao, So Paulo, Brazil
Bu, Guilin, MD, Department of Radiology, Guangxi
Nanxi Shan Hospital, Guangxi, P.R. China
Camargo de C., Carneiro Adriano MD Department
ofCardiovascular Imaging, Hospital do Corao,
So Paulo, Brazil
Kato, Maho, MD, Department of Radiology,

Kitagawa, Kakuya, MD, PhD, Department of Radiology, Mie University School of Medicine, Mie, Japan
Suzuki, Hirochika, MD, Department of Radiology,

Kumar, Arun, MD, Aarthi Diagnostics, Vadapalani,

Chennai, Tamilnadu, India
Tung, Hiu-Ming, FRCS, St Teresas Hospital,

Kowloon, Hong Kong
Kumar ,Raj, MD, Aarthi Diagnostics, Vadapalani,

Chennai, Tamilnadu, India
Vignesh, Prasanna, MD, Aarthi Diagnostics,

Vadapalani, Chennai, Tamilnadu, India
Lamaci, Mariana M., MD, Department of Cardiovascular Imaging, Hospital do Corao, So Paulo,
Brazil
Yamazaki, Akio, Department of Radiology,

Magalhes, Tiago A., MD, Department of Cardio

vascular Imaging, Hospital do Corao, So Paulo,
Brazil
Mallinson, Paul, MD, Department of Radiology,
Vancouver General Hospital and University of British
Columbia Vancouver, British Columbia, Canada
McLaughlin, Patrick, MD, Department of Radiology,
Carla, Berta, MD, Department of Cardiology and

Imagiology, SAMS Hospital, Lisbon, Portugal
Cheng, Pui Wai, FRCR, St Teresas Hospital, Kowloon,
Hong Kong
Miao, Ying, MD, Department of Radiology, Guangxi

Nanxi Shan Hospital, Guangxi, P.R. China
Conduto, Rui, MD, Department of Cardiology and

Moreira, Valria M., MD, Department of Cardio

vascular Imaging, Hospital do Corao, So Paulo,
Brazil
dAscenso, Elisabete, FT, Department of Cardiology

and Imagiology, SAMS Hospital, Lisbon, Portugal
de S. Freitas, Matheus, MD, Department of Cardiovascular Imaging, Hospital do Corao, So Paulo, Brazil
Dias Filho, Paulo Czar F., MD, Department of Cardiovascular Imaging, Hospital do Corao, So Paulo, Brazil
dos Prazeres, Carlos Eduardo E., MD, Department
ofCardiovascular Imaging, Hospital do Corao,
So Paulo, Brazil
Fernandes, Fbio V., MD, Department of Cardiovascular Imaging, Hospital do Corao, So Paulo, Brazil
Schnberg, Stefan O., MD, Institute of Clinical

Radiology and Nuclear Medicine, University Medical
Centre Mannheim, Medical Faculty Mannheim,
Heidelberg University, Germany
Sudarski, Sonja, MD, Institute of Clinical Radiology
University, Germany
Meyer, Mathias, MD, Institute of Clinical Radiology

University, Germany
Cruz Ferreira, Rui, MD, Department of Cardiology

andImagiology, SAMS Hospital, Lisbon, Portugal
Sakuma, Hajime, MD, PhD, Department of Radiology,

Nagasawa, Naoki, PhD, Department of Radiology,

Nakajima, Hiroshi, MD, PhD, Department of Cardiology, Mie University School of Medicine, Mie, Japan
Nakamori, Shiro, MD, Department of Cardiology,
Nicolaou, Savvas, MD, Department of Radiology,
Omiya, Hiroko, MD, Department of Radiology,
Journalists: Linda Brookes; Erika Claessens; Claudia

Flisi; Marcela Fuknov; Philipp Grtzel von Grtz;
Bill Hinchberger; Wiebke Kathmann, PhD; Hildegard
Kaulen, PhD; Manuel Meyer
Authors Siemens: Caroline Bastida de Paula;
Ivo Driesser; Jan Freund; Florian Hein; Susanne
Hlzer; Patricia Jacob; Johannes Georg Korporaal,
PhD; Jrgen Merz, PhD; Florian Reinhold; Katrin
Seidel; Stefan Ulzheimer, PhD; Susanne von
Vietinghoff
Photo Credits: Toni Anzenberger; Antoine Doyen;
Miguel Ribeiro Fernandes; Pedro Guimares; Bert
Janssen; Alex Pusch; Anna Schroll; Thomas Steuer;
Jrn Tomter; Alberto Venzago; Harald Voglhuber
Production and PrePress: Norbert Moser,
Kerstin Putzer, Siemens AG, Healthcare
Reinhold Weigert, Typographie und mehr ...
Schornbaumstrae 7, 91052 Erlangen
Proofreading and Translation:
Sheila Regan, uni-works.org
Design and Editorial Consulting:
Independent Medien-Design, Munich, Germany
In cooperation with Primafila AG, Zurich,
Switzerland
Managing Editor: Mathias Frisch
Photo Editor: Andrea Klee
Layout: Antje Blees, Mathias Frisch,
Pia Hofmann
All at: Widenmayerstrae 16,
80538 Munich, Germany
Gouveia, Raquel, MD, Department of Cardiology and

Ouellette, Hugue, MD, Department of Radiology,

Govindarajan, Aarthi, MD, Aarthi Diagnostics,

Vadapalani, Chennai, Tamilnadu, India
Pedro ,Paulo G., MD, Department of Cardiology

Haubenreisser, Holger, MD, Institute of Clinical Radiology and Nuclear Medicine, University Medical Centre
University, Germany
Pereira, Miguel, RT, Department of Cardiology

The entire editorial staff here at Siemens

Healthcare extends their appreciation to all the
experts, radiologists, scholars, physicians and
technicians, who donated their time and energy
without p
ayment in order to share their expertise
with the readers of SOMATOM Sessions.
Rochitte, Carlos E., MD, Department of Cardiovascular Imaging, Hospital do Corao, So Paulo, Brazil
SOMATOM Sessions on the Internet:

Note in accordance with 33 Para.1 of the German Federal Data Protection Law:
Despatch is made using an address file which is maintained with the aid of an automated
data processing system.
SOMATOM Sessions with a total circulation of 32,000 copies is sent free of charge to
Siemens Computed Tomography customers, qualified physicians and radiology departments throughout the world. It includes reports in the English language on Computed
Tomography: diagnostic and therapeutic methods and their application as well as results
and experience gained with corresponding systems and solutions. It introduces from
caseto case new principles and procedures and discusses their clinical potential.
The statements and views of the authors in the individual contributions do not necessarily
reflect the opinion of the publisher.
The information presented in these articles and case reports is for illustration only and
isnot intended to be relied upon by the reader for instruction as to the practice of medicine. Any health care practitioner reading this information is reminded that they must use
their own learning, training and expertise in dealing with their individual patients. This
material does not substitute for that duty and is not intended by Siemens Medical Solutions
to be used for any purpose in that regard. The drugs and doses mentioned herein are
consistent with the approval labeling for uses and/or indications of the drug. The treating physician bears the sole responsibility for the diagnosis and treatment of patients,
including drugs and doses prescribed in connection with such use. The Operating Instructions must always be strictly followed when operating the CT System. The sources for
the technical data are the corresponding data sheets. Results may vary.
Partial reproduction in printed form of individual contributions is permitted, provided
the customary bibliographical data such as authors name and title of the contribution
aswell as year, issue number and pages of SOMATOM Sessions are named, but the
editors request that two copies be sent to them. The written consent of the authors and
publisher is required for the complete reprinting of an article.
We welcome your questions and comments about the editorial content of SOMATOM
Sessions. Manuscripts as well as suggestions, proposals and information are always
welcome; they are carefully examined and submitted to the editorial board for attention.
SOMATOM Sessions is not responsible for loss, damage, or any other injury to unsolicited
manuscripts or other materials. We reserve the right to edit for clarity, accuracy, and
space. Include your name, address, and phone number and send to the editors,
address above.
On account of certain regional limitations ofsales 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 described herein may
not be available in the United States.
The information in this document contains general technical descriptions of specifications
and options as well as standard and optional features which do not always have to be present
in individual cases.
Siemens reserves the right to modify the design, packaging, specifications and options
described herein without prior notice. Please contact your local Siemens sales representative
for the most current information.
Note: Any technical data contained in this document may vary within defined tolerances.
Original images always lose a certain amount of detail when reproduced.
The statements by Siemens customers described herein are based on results that were
achieved in the customers unique setting. Since there is no typical hospital and many
variables exist (e.g., hospital size, case mix, level of IT adoption) there can be no guarantee
that other customers will achieve the same results.
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Local Contact Information
Siemens AG
Medical Solutions
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& Radiation Oncology
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Phone: +1-888-826-9702
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Phone: +49 9131 84-0
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Healthcare Headquarters
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Healthcare
Henkestrae 127
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Phone: +49 9131 84-0
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SOMATOM Sessions

Answers for life in Computed Tomography

TwinBeam Brings Single Source

Flexible Flash for

SOMATOM Force from

The functions of the new

2 SOMATOM Sessions | December 2014 | www.siemens.com/SOMATOM-Sessions

TwinBeam Dual Energy, we are now

possible with their newly installed

TwinBeam Dual Energy is currently pending

SOMATOM Sessions | December 2014 | www.siemens.com/SOMATOM-Sessions 3

TwinBeam Brings Single Source Dual Energy to Clinical Routine

12 TwinBeam Dual Energy:

4 SOMATOM Sessions | December 2014 | www.siemens.com/SOMATOM-Sessions

84 CT Physics Workshop Focus on Radiation Dose

SOMATOM Sessions | December 2014 | www.siemens.com/SOMATOM-Sessions 5

Brings Single Source Dual

6 SOMATOM Sessions | December 2014 | www.siemens.com/SOMATOM-Sessions

University Hospital Erlangen-Nuremberg

A control study of a liver metastasis after microwave ablation

SOMATOM Sessions | December 2014 | www.siemens.com/SOMATOM-Sessions 7

TwinBeam Dual Energy is now bringing advanced clinical Dual Energy

therefore available to a broad section

Virtual non-contrast images

from the images. Every morning,

A follow up study after a cardiac pump implantation two VRT

8 SOMATOM Sessions | December 2014 | www.siemens.com/SOMATOM-Sessions

The innovative functions of the new

Images with metal artifacts

an artificial hip, knee, or shoulder

artifacts can conceal pathologies,

Process of iterative metal artifact reduction in iMAR1

cavity and oropharynx. Lell explains

Metal Implants Inserted in Germany

Finger joint prostheses:

Ventricular assist devices:

Vertebral body cages:

Ankle joint prostheses:

Source: BVMed Bundesverband M

Artifacts due to osteo

10 SOMATOM Sessions | December 2014 | www.siemens.com/SOMATOM-Sessions

This is of special importance in patients

Reduce dose even more with

The new SOMATOM Definition Edge

Hildegard Kaulen, PhD, is a molecular

TwinBeam Dual Energy and iMAR are currently

iMAR is designed to yield images with a reduced

SOMATOM Sessions | December 2014 | www.siemens.com/SOMATOM-Sessions 11

TwinBeam Dual Energy:

Extending the Dual Energy

The Dual Energy Portfolio has now

TwinBeam Dual Energy:

12 SOMATOM Sessions | December 2014 | www.siemens.com/SOMATOM-Sessions

readily available on Siemens CT scanners with the STRATON tube.

Image acquisition is possible for all

A whole body CT angiography acquired with TwinBeam Dual Energy shows

cates that the new TwinBeam Dual

TwinBeam Dual Energy is currently pending

SOMATOM Sessions | December 2014 | www.siemens.com/SOMATOM-Sessions 13

Leading the Way

Alongside the daily work of coronary

Earlier technical issues with CT per

In Innsbruck, Gudrun M. Feuchtner,

specialized clinics, outpatient and

Finger joint prostheses:

Ventricular assist devices:

Vertebral body cages:

Ankle joint prostheses:

1 This product is not a medical device and currently