SOMATOM Sessions - Siemens Healthcare

SOMATOM Sessions 

The Difference in Computed Tomography 

Issue Number 26/May 2010 

International Edition 

Cover Story 

The Best of Both Worlds 

in Neuro Imaging 

Page 6 

News 

Best Balance Between 

Image Quality 

and Reduced Dose 

Page 18 

Business 

More for Less in Monaco 

Page 28 

Clinical 

Results 

SOMATOM Defi nition AS+: 

CT Perfusion With 

Extended Coverage for 

Acute Ischemic Stroke 

Page 50 

Science 

CT in Pediatrics: Easier 

and Safer With the Flash 

Page 62

Editorial 

“Our new neurological 

software combined with 

the SOMATOM Defi nition 

line of scanners repre- 

sents a quantum leap 

in speed, low dose and 

diagnostic accuracy.” 

Sami Atiya, PhD, Chief Executive Officer, 

Business Unit Computed Tomography, Siemens Healthcare, Forchheim, Germany 

Cover Page: With Volume Perfusion CT Neuro fused with carotid CT Angiography the perfusion status of the brain tissue 

can be observed. Courtesy of University Hospital Göttingen, Germany. 

2 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine

Dear Reader, 

Imagine an emergency room only a 

few short years ago: in the middle of 

the night, a 55-year-old, unconscious 

patient is wheeled in. All neurologic 

observations indicate stroke. But 

how severe? Is it an occlusion or a 

hemorrhage and where is it located? 

All crucial questions that demand fast 

answers! The physician on duty could 

request a head CT examination that 

could possibly involve two scans at 15 

to 30 mSv radiation dose. The physician 

would then begin with extensive postprocessing 

– possibly using a PACS 

Workstation before the CT results could 

provide life the necessary clinical information 

required. Not a very pleasant 

alternative for the physicians or the 

patient. 

Now imagine the same situation in a 

modern emergency room equipped with 

Siemens cutting-edge technology such 

as SOMATOM Definition Flash scanner – 

that scans faster than all other CT 

scanners on the market – with latest 

neuro imaging software and syngo.via 

software that “post-process on-the-fly” 

Within minutes, the physician would 

have access to the head scan results with 

all post-processing completed at lowest 

possible dose, including non-enhanced 

CT for exclusion of hemorrhage, complete 

vascular status plus functional 

information. 

André Hartung, 

Vice President 

Marketing and Sales 

Business Unit CT, 

Siemens Healthcare 

With syngo.via, Siemens’ new workplace 

software, all time consuming 

pre- and post-processing steps are 

eliminated and all diagnostic information 

– including information from 

other modalities such as MR, MI and 

PET – are available in almost real time. 

Best possible image quality is provided 

with sophisticated “signal boost” 

technologies or image-optimizing 

techniques resulting in definitive 

grey and white tissue differentiation 

in neuro imaging. Excellent image 

quality and fast processes are beneficial 

for both physicians and patients 

as they are preconditions for highest 

diagnostic accuracy and, at the same 

time, low dose safety for the patient. 

In all patient groups, including difficult 

obese and pediatric patients, as well as 

emergency room situations, safety is 

strongly linked to ALARA (As Low As 

Reasonably Achievable) radiation exposure. 

In the past, especially in acute 

clinical cases, lowering the radiation 

exposure when utilizing CT for diagnosis 

was not the primary focus. In stroke 

cases, “minutes equaled mind” and for 

accident victims, minutes could mean 

life or death. Today, thanks to Siemens’ 

significant leadership in bringing low 

dose CT into clinical routine, image 

quality is not necessarily tied to a slower 

diagnosis path and higher dose expo- 

* 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 rights.. 

André Hartung 

Editorial 

sure. CT is steadily moving into the first 

line of emergency and stroke imaging 

mainly because of the wide diagnostic 

spectrum, speed and diagnostic precision. 

Providing all the advantages in 

CT imaging aligned with measures to 

minimize the radiation exposure has 

always been one of Siemens key goals. 

Therefore we have recently introduced 

new technical developments like IRIS to 

reduce radiation exposure to the lowest 

level in the CT industry. In functional 

imaging, e.g. for CT brain perfusion, the 

dose can be reduced by up to 50 % with 

4D Noise Reduction, without compromising 

image quality. And our Adaptive 

Dose Shield completely eliminates pre- 

and post-spiral radiation that cannot be 

utilized for image reconstruction. These 

are only a few examples from dozens of 

additional large and small improvements 

developed by our dedicated employees 

to make the radiologist’s life easier and 

the patient’s healthcare better. You will 

find many of these reported in this, and 

in future editions of SOMATOM Sessions. 

Good reading, 

Sincerely 

SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 3

Content 

Content 

Cover Story 

6 

The Best of Both Worlds 

6 Exciting advances in computed 

tomography (CT) examination 

methods, including low dose 

protocols, technical innovations 

such as whole brain CT Perfusion, 

Dual Energy or Neuro Best Contrast 

applications and groundbreaking 

radiological research have dramatically 

changed the diagnostic 

approach for reading physicians 

by enabling new indications and 

improved timing in the examination 

of patients with acute neurological 

deseases. SOMATOM Sessions 

discussed with five experienced 

physicians how CT can routinely be 

used as the key diagnostic modality 

in neuro imaging before the start 

of appropriate treatment. 

4 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 

Cover Story 

6 The Best of Both Worlds in Neuro 

Imaging 

News 

24 

International CT Image Contest 

at Lowest Dose 

16 Affordable Performance in 16- and 

64-slice CT 

18 Best Balance Between Image Quality 


19 IRIS Now Extended to SOMATOM 

Definition AS 20 and SOMATOM 

Definition AS 40 

20 syngo CT 2010B Now Available: 

New Software Version for the 

SOMATOM Definition AS Launched 

20 Worldwide Dose Counter 

21 syngo.via Workstation Face-off 

Sessions 

22 syngo.via CT Speedometer 

24 International CT Image Contest – 

Highest Image Quality at 

Lowest Dose

– Highest Image Quality 

Business 

28 More for Less in Monaco 

30 New Feature: Neuro Image Quality 

Surpasses all Expectations 

Clinical Results 

Cardio-Vascular 

32 Adenosine Myocardial Stress 

Imaging Using SOMATOM 

Definition Flash 

34 SOMATOM Definition Flash: 

Visualization of the Adamkiewicz 

Artery by IV-CTA in Dual Power Mode 

36 Dynamic Myocardial Stress Perfusion 

38 Pre-operative Exclusion of Coronary 

Artery Stenosis With Less Than 

1 mSv Dose 

40 Utilizing Ultra Low Dose of 0.05 mSv 

for Premature Baby With Congenital 

Heart Disease 

42 SOMATOM Definition Flash: Pediatric 

Patient Without Sedation and 

Breath-Holding 

44 SOMATOM Definition Flash: Dual 

Energy Coronary CT Angiography for 

Evaluation of Chest Pain After RCA 

Revascularization 

52 

Vasospasm After Subarachnoid Hemorrhage: 

Volume Perfusion CT Neuro 

Oncology 

46 3D Guided RF Ablation and CT 

Perfusion – a New Combination for 

Monitoring of Treatment Response 

48 SOMATOM Definition Flash: 

Routine Re-staging of Oesophageal 

Carcinoma Utilizing IRIS Technology 

Neurology 

50 SOMATOM Definition AS+: CT Perfusion 

With Extended Coverage for 

Acute Ischemic Stroke 

52 Vasospasm After Subarachnoid 

Hemorrhage: Volume Perfusion CT 

Neuro 

Acute Care 

56 Dual Energy Scanning: Diagnosis 

of Ruptured Cocaine Capsule 

58 Progressive Kidney Hematoma 

Post-interventional Biopsy 

60 SOMATOM Definition Dual Source 

High Pitch vs. Routine Pitch Scanning 

in a Pediatric Lung Low Dose 

Examination 

Science 

Content 

64 

Study Finds Atherosclerosis in 3,500 

Year old Egyptian Mummies 

62 CT in Pediatrics: Easier and Safer 

With the Flash 

64 Study Finds Atherosclerosis in 

3,500 Year old Egyptian Mummies 

65 Independent Validation of Perfusion 

Evaluation Software 

66 Reduced Procedure Time and Radiation 

Dose in Interventional CT Workflow 

68 Scientific Validation of the SOMATOM 


Life 

70 Behind the Scenes: CT Scan Protocols 

72 First syngo.via Hands-on Workshops 

at ECR 2010 

72 Upcoming Events & Congresses 

73 Training Website for Knowledge 

Improvement 

73 Free Trial Licenses for Neuro Imaging 

74 Frequently Asked Questions 

74 Dual Energy CT: Learning From the 

Experts 

75 Clinical Workshops 2010 

76 Siemens Healthcare – Customer 

Magazines 

77 Imprint 


Coverstory 


The Best of Both Worlds in 

Neuro Imaging 

Exceptional Image Quality Meets Lowest Dose 

in Neuroradiology 

Exciting advances in computed tomography 

(CT) examination methods, including 

low dose protocols, technical 

innovations such as whole brain CT 

Perfusion, Neuro BestContrast or Dual 

Energy applications and groundbreaking 

radiological research have dramatically 

changed the diagnostic approach for 

reading physicians by enabling new indications 

and improved timing in the examination 

of patients with acute neurological 

deseases. CT is routinely used as 

the key diagnostic modality in neuro 

imaging before the start of appropriate 

treatment to detect or exclude intracranial 

hemorrhage, either traumatic or 

non-traumatic, or to detect other causes 

of acute onset of neurological disease, 

such as stroke, intracerebral tumors, or 

hematoma. Rapid evaluation is critical 

after trauma and with symptoms such 

as weakness, headache, and dizziness, 

which is why CT is the modality of 

choice in these scenarios. 

Exceptional image quality is key to optimize 

diagnosis, and lower dose imaging 

helps to minimize the risk to the patient. 

It is often said that the price of improved 

image quality with CT is increased radiation 

dose, but Siemens has shown that 

high quality, low dose imaging is possible 

in even the most challenging neuroradiology 

applications. Whole brain CT 

Coverstory 

At Duke University Medical Center in Durham, North Carolina, USA and 

elsewhere, Siemens equipment is helping radiologists combine exceptional 

image quality in neuro imaging with innovative dose-reducing features 

to maximize diagnostic confi dence. 

By Sameh Fahmy 

Perfusion imaging with Siemens’ unique 

Adaptive 4D Spiral and the use of CT 

Angiography from the aortic arch to the 

cranium are further expanding possibilities, 

increasing the diagnostic confidence 

of neurologists and potentially enabling 

more appropriate treatment decisions. 

“By providing really good image quality, 

we are able to improve the efficiency of 

care,” says David S. Enterline, MD, Associate 

Professor of Radiology and Division 

Chief of Neuroradiology at Duke University 

Medical Center in Durham, North 

Carolina, USA. “And through dose savings, 

we can minimize the risk to patients.” 

Neuro BestContrast 

Although newer techniques are revolutionizing 

stroke assessment, the gold 

standard for the initial diagnosis of 

stroke and intracranial hemorrhage is 

still non-contrast imaging of the brain. 

Siemens has always placed emphasis on 

providing the highest image quality on 

all of their scanners for this challenging 

application. Now, Siemens has taken 

image quality to the next level. Last 

year, Duke became the first hospital in 

the United States to install Siemens’ 

Neuro BestContrast, an application that 

dramatically increases gray/white matter 

differentiation in non-contrast head CT 

“Neuro BestContrast 

allows radiologists 

to better visualize 

the gray/white matter 

interface to see 

subtle edema and 

signs of stroke, and 

to better delineate 

the cortical margin.” 

David S. Enterline, MD, Division Chief 

Neuroradiology, Duke University Medical 

Center in Durham, North Carolina, USA 


Coverstory 

1A 1B 1C 

1 Comparing conventional head CT imaging (Fig. 1A) with the new IRIS technology (Fig. 1B) shows decreased image noise. Combining IRIS 

with Neuro BestContrast technology provides very high image quality with decreased noise by utilizing reduced radiation dose (Fig. 1C). 

exams using the SOMATOM Definition 

line of scanners. Enterline says that Neuro 

BestContrast allows radiologists to 

better visualize subtle edemas as well 

as subtle signs of stroke, and to better 

delineate the cortical margin, adding, 

“My colleagues and I uniformly feel that 

with better image quality, our comfort 

level and our ability to make diagnoses 

are significantly increased.” 

The improved image quality experienced 

by Enterline and his colleagues at Duke 

is also evidenced by clinical data and the 

experience of radiologists in Europe. In 

a blinded study whose results were presented 

at the 2009 scientific assembly 

and annual meeting of the Radiological 

Society of North America, neuroradiologists 

preferred Neuro BestContrast data 

sets in 97 % of cases. 1 Other readers, 

who viewed the Neuro BestContrast 

data set side-by-side with the traditional 

images, also rated image quality better 

in more than 90 % of the cases and 

lesion conspicuity higher in more than 

50 % of the cases. 


At the University Hospital in Göttingen, 

Germany, Peter Schramm, MD, Deputy 

Head of the Department of Neuroradiology, 

was able to compare images 

acquired before and after the implementation 

of Neuro BestContrast in a patient 

with head trauma whose hospitalization 

coincided with the hospital’s transition 

to the new software. “We were able to 

perform an exact comparison intraindividually, 

and in that case it was really 

impressive to see the improvement that 

came along with Neuro BestContrast,” 

“I think Neuro BestContrast and 

IRIS work perfectly with each 

other and have additive value 

in reducing dose.” 

Christoph Becker, MD, Professor of Radiology and Section Chief of CT and PET/CT 

at Munich University Hospital, Munich, Germany

Schramm says. “The delineation of the 

edema and the margins of the edema 

were definitely better visualized using 

Neuro BestContrast, and the same applies 

to the changes that occur in acute 

stroke.” 

Neuro BestContrast improves non-contrast 

head images by taking advantage 

of the fact that clinically important information 

from CT scans is contained in medium 

and low frequencies, while high frequencies 

are dominated by image noise. 

The software processes high-frequency 

data differently than the low-to-medium 

frequency data, resulting in improved 

tissue contrast without the amplification 

of image noise. 

Enterline says the use of Neuro BestContrast 

has the potential to reduce radiation 

dose as well. His preliminary data has 

documented a 15 to 20 % improvement 

in gray/white matter differentiation that 

can allow for image acquisition at a lower 

dose than is currently used. “Our institution 

has traditionally fought for lower 

dose,” he says, “and I think this will now 

allow us to further reduce our dose.” 

IRIS 

Neuro BestContrast can be combined 

with another new Siemens technology 

known as Iterative Reconstruction in 

Image Space (IRIS) to reduce dose and 

improve image quality even further. 

“I think they work perfectly with each 

other and have additive value,” says 

Christoph Becker, MD, Professor of Radiology 

and Section Chief of Computed 

Tomography and PET/CT at Ludwig-Maximilians-University 

in Munich, Germany. 

Iterative reconstruction uses a correction 

loop to improve image quality in several 

steps, or iterations. The idea was first 

introduced in the 1970s, but the computing 

power and time required for the 

reconstruction made it impractical for 

use in clinical settings. An alternative 

known as statistical image reconstruction 

reduced the time associated with iterative 

reconstruction but produced a texture 

that radiologists found unacceptable. 

With IRIS, Siemens took a different 

approach. The algorithm takes all of the 

data, which contains fine details as well 

as significant amounts of noise, com- 

2 

Iterative Reconstruction in Image Space (IRIS) 

Fast Image Data Space 

Slow Raw Data Space 

Compare 

Strong artifact and dose reduction 

Well-established image impression 

Fast reconstruction in image space 

bines it in a master image and cleans it 

up in the fast-processing image space 

rather than in the slow-processing raw 

data area. The result is that high spatial 

resolution is preserved and noise is reduced 

– without disrupting workflow. 

Becker says the combination of Neuro 

BestContrast and IRIS, which is available 

on the SOMATOM Definition line of 

scanners, allows him and his colleagues 

to better differentiate the basal ganglia 

and to see subtle signs of stroke. He 

adds that IRIS also reduces the blooming 

Image data 

recon 

Master 

recon 

Image 

correction 

Coverstory 

2 IRIS takes all of the data, which contains fine details as well as significant amounts 

of noise, combines it in a master image and cleans it up in the fast-processing image space 

rather than in the slow-processing raw data area. The result is that that high spatial resolution 

is preserved and noise is reduced – without disrupting workflow. 

of dense structures such as bone and 

calcium, making it easier to visualize 

or rule out subarachnoid hemorrhage. 

Preliminary data from Becker show that 

IRIS reduces dose by 25 % in head CT 

exams yet achieves the same level of 

noise as filtered back projection, the traditional 

method for image reconstruction. 

Becker notes that clinicians can 

also choose to use the same dose as filtered 

back projection yet deliver significantly 

better image quality using IRIS. 

In the United States, Ridgeview Medical 


Coverstory 

Center in Waconia, Minnesota, USA installed 

IRIS on its SOMATOM Definition 

AS 40-slice CT and its Definition AS+ 

128-slice scanner early in 2010. Chief 

of Radiology, David Gross, MD, directly 

compared images produced using IRIS 

with traditional filtered back projection 

images and then enthusiastically adopted 

IRIS. “After two or three days, we 

decided that there’s no sense in even 

comparing anymore,” Gross says. “With 

the improvement in radiation dose, the 

image quality is not changed, so we 

just switched right over to it.” 

Neuro BestContrast and IRIS build upon 

other Siemens innovations in neuro 

imaging that maximize diagnostic confidence. 

The “Posterior Fossa Optimization” 

algorithm, which was introduced in 2001 

and is implemented in all SOMATOM 

Sensation and Definition scanners, 

significantly reduces streaks and dark 

bands, known as Hounsfield Bars, to 

allow for better resolution with less 

artifact. Siemens’ z-Sharp Technology 

provides routine isotropic resolution of 

0.33 mm, one of the industry’s highest, 

enabling the visualization of small 

anatomical details such as fine vascular 

structures. For ultra-high-resolution bone 

imaging for inner ear structures, Siemens’ 

z-UHR Technology provides 0.24 isotropic 

resolution. 

Perfusion CT and CTA 

While non-contrast head CT exams are 

still important for excluding intracranial 

“With the improvement 

in radiation 

dose using IRIS, 

the image quality 

is not changed, so 

we just switched 

right over to it.” 

David Gross, MD, Chief of Radiology 

Ridgeview Medical Center, Waconia, 

Minnesota, USA 

hemorrhage and ischemic stroke mimics, 

the use of perfusion CT imaging is increasingly 

being adopted. “Dynamic CT 

Perfusion imaging, which can be acquired 

immediately after the non-contrast head 


CT while the patient is still in the scanner, 

allows improved detection of acute 

stroke, which has been substantiated in 

several studies,” says Ke Lin, MD, Assistant 

Professor of Radiology at New York 

University Langone Medical Center in 

New York City, USA. In a study of 100 

patients presenting to the emergency 

department within three hours of stroke 

onset, Lin and his colleagues found that 

CT Perfusion provided significantly improved 

sensitivity and accuracy in acute 

stroke detection over non-contrast CT. 

Specifically, the researchers found that 

CT Perfusion revealed 64.6% of acute 

infarctions compared to 26.2 % for noncontrast 

CT. CT Perfusion also had an accuracy 

of 76 % compared to an accuracy 

of 52 % for non-contrast CT. 2 

Lin and his colleagues obtained CT Perfusion 

data from a z-direction coverage 

of 24 mm centered at the mid-basal 

ganglia which maximizes the visualization 

of the middle cerebral artery territory. 

Still, the researchers noted that 

they missed ten infarcts that were outside 

of this volume of coverage. The advent 

of whole brain CT Perfusion using 

Siemens’ unique Adaptive 4D Spiral, however, 

further increases the value of CT 

Perfusion by expanding the scan range. 

The revolutionary scan mode, which is 

available on the SOMATOM Definition 

line of scanners, overcomes the limitations 

of a static detector design by applying 

a continuously repeated bi-directional 

table movement that smoothly 

“Dynamic CT Perfusion imaging, which can 

be acquired immediately after the noncontrast 

head CT while the patient is still in 

the scanner, allows improved detection of 

acute stroke, which has been substantiated 

2, 4 

in several studies.” 

Ke Lin, MD, Assistant Professor of Radiology, Department of Radiology, New York University 

Langone Medical Center, New York, USA

3 

moves the patient in and out of the 

gantry over the desired scan range. Lin 

has recently switched to a SOMATOM 

Definition AS+ Scanner with all the 

advantages of full brain coverage. “With 

the increased coverage, we now expect 

further improvement in acute stroke 

detection accuracy, as well as the full 

delineation of the ischemic penumbra 

and the infarct core,” Lin says. 

The stroke imaging workflow at NYU 

Langone Medical Center also includes 

a CT Angiography immediately following 

the CT Perfusion exam to evaluate clot 

location, clot burden, and collateral recruitment. 

Lin adds that the information 

is also used for planning interventional 

procedures such as mechanical thrombectomy. 

Lin says the fast image acquisition of 

the SOMATOM Definition AS+ 128-slice 

scanner, combined with the rapid postprocessing 

of the Siemens syngo Volume 

Perfusion CT Neuro software, allows 

reading physicians to arrive quickly at an 

appropriate treatment decision through 

a smooth, fast, and user-friendly workflow. 

A number of steps are automated, 

including motion correction, bone segmentation, 

arterial input function determination, 

and vascular pixel elimination. 

The software allows for simultaneous 

visualization of functional parametric 

maps of cerebral blood flow, cerebral 

blood volume, time to peak, mean transit 

time and other clinically important 

information. With the click of a button, 

clinicians can toggle between axial, 

sagittal and coronal reformations. 

Lin and his colleagues acquire the CT 

Perfusion data for the whole brain in 

just 45 seconds. Next, CT Angiography 

data from the aortic arch through the 

whole brain, a scan range of typically 

more than 30 cm, is acquired in a couple 

of seconds to deliver valuable information 

about the feeding vessels that 

are not covered by the initial perfusion 

scan. Post-processing takes an additional 

three to five minutes. In total, when 

time for interpretation is accounted for, 

the use of CT Perfusion and CT Angio- 

Coverstory 

3 Perfusion CT 

imaging is increasinglybeing 

adopted in 

daily routine. 

This function 

overcomes the 

limitations of a 

static detector 

design, which 

provides full 

brain coverage, 

and the potential 

for improvement 

in diagnostic 

accuracy 

for acute stroke. 

graphy adds approximately 10 minutes 

to the acute stroke workflow. “That’s not 

a lot of time considering that the additional 

information provided by the CT 

Perfusion and the CT Angiography may 

have very important implications for the 

patient’s treatment and management,” 

Lin says. 

Reducing Dose in CT Perfusion 

Lin recognizes that, while the use of CT 

Perfusion is moving from academic 

medical centers to community hospitals, 

some barriers to its widespread adoption 

remain. Chief among them is a concern 

about the radiation dose associated with 

the acquisition of CT Perfusion and CT 

Angiography data. The use of Siemens 

4D Noise Reduction, however, can reduce 

the radiation noise of dynamic CT 

Perfusion. The reconstruction technique 

treats the static anatomical information 

differently from the dynamically changing 

perfusion information that results 

from the in and outflow of the contrast 

agent. By sampling multiple passes over 


4 

5 

Coverstory 


4 With Volume 

Perfusion CT (VPCT) 

fused with carotid 

CTA the perfusion 

status of the brain 

tissue can be revealed. 

This patient 

presented after 

onset of stroke and 

underwent lysis 

therapy. The followup 

examination 

showed a complete 

revascularization 

of the previously 

hypoperfused area. 

Courtesy of University 

Hospital Göttingen, 

Germany. 

5 With Dual Energy 

(DE) Bone Removal 

vascular structures 

can quickly be separated 

from the bones 

even in difficult areas 

such as the base of 

the skull. This clearly 

proves the clinical 

benefit of DE for 

clinical routine. 

Courtesy of University 

Hospital Munich, 

Campus Großhadern, 

Germany. 

the same volume it allows for the reduction 

of image noise. So the initial scan 

can be performed with a lower tube 

current, thus saving dose. The result 

is that radiation dose is reduced by 

up to 50 % while retaining equivalent 

diagnostic information. 

Although such dose-saving features can 

benefit patients, Lin cautions that the 

issue of dose must be kept in context 

during an acute stroke. “The acute critical 

ischemic event that could kill the 

patient takes priority over the slight increase 

in radiation dose that is imparted 

to the patient in order to arrive at a 

more accurate diagnosis, a clearer 

understanding of the patient’s pathophysiology, 

and a broader understanding 

of the acute event,” he emphasizes. 

Lin points out that only 2 % of acute 

stroke patients receive intravenous 

tissue plasminogen activator (tPA), the 

only U.S. Food and Drug Administration 

approved drug for acute stroke. He says 

this low rate is largely because of the 

restrictive three-hour time window in 

which the drug is approved for use. 

An additional factor is that an unknown 

time of onset, which occurs in up to 

25 % of acute stroke patients, disqualifies 

patients from receiving the drug. 

In Europe, the University of Göttingen, 

Germany has established stroke units 

where patients are examined in an elongated 

time window of 4.5 hours after the 

onset of stroke, based on results from the 

Third European Cooperative Acute Stroke 

Study 3 (ECASS III), so that more patients 

can benefit from tPA treatment. 

Rather than making treatment decisions 

based on the clock, the use of perfusion 

CT and CT Angiography can help deliver 

truly personalized medicine for acute 

stroke patients. The adage “time is brain” 

still applies, Lin says, but technology can 

enable a new paradigm that says that 

“physiology is brain.” 

“The rallying cry of ‘physiology is brain’ 

is really a summation of the proposal 

to use a patient’s own pathophysiology, 

his own cerebral hemodynamics, to determine 

whether he still has significant 

amounts of salvageable tissue at risk 

and therefore should be a candidate for 

acute stroke therapy within the confines

of the safety profile of the various treatments,” 

Lin says. 

A Range of Neuro Imaging 

Options 

Of course, the use of CT in neuroradiology 

is not limited to patients with acute 

stroke. syngo Volume Perfusion CT 

Neuro software provides a rapid and 

automated evaluation of brain tumors 

that enhances the ability to grade 

tumors, plan biopsies, and monitor 

therapy. The use of MRI to image brain 

tumors is well established, but Schramm 

notes that the use of CT Perfusion can 

be advantageous in some cases. Intracerebral 

lymphomas, for instance, can 

be difficult to differentiate using MRI but 

can be easily identified using perfusion 

CT. “My prognosis is that CT will gain 

even more ground in the coming years, 

and this is due to the fact that it is 

broadly available, less expensive than 

MRI, and, in many cases, offers better 

spatial resolution,” he says. 

Another tool that significantly improves 

workflow and diagnostic confidence in 

the assessment of vascular structures of 

the head and neck is syngo.via* CT 

Neuro DSA (Digital Subtraction Angiography), 

which automates the removal 

of bone from images, even in difficult 

areas such as the base of the skull. The 

very robust technique uses a non-contrast, 

low-dose scan that is acquired before 

the actual CT Angiography and is 

then used to automatically remove all 

the bone structures in the scanned region. 

On Dual Source CT scanners such 

Coverstory 

“We were able to perform an exact comparison 

intra-individually, and in that 

case it was really impressive to see the 

improvement that came along with 

Neuro BestContrast.” 

Peter Schramm, MD, Deputy Head of the Department of Neuroradiology, 

University of Göttingen, Germany 

as the SOMATOM Definition and 

Definition Flash “syngo Dual Energy 

Direct Angio” offers a similar technique 

which permits direct removal of bone 

using only one scan. It uses the fact 

that two X-ray sources running simulta- 

“Siemens is committed 

to reducing 

radiation dose to 

the lowest possible 

level. Innovations 

such as IRIS are 

evidence of this 

commitment as is 

X-CARE” 

Sami Atiya, PhD, Chief Executive 

Officer, Business Unit Computed 

Tomography, Siemens Healthcare, 

Forchheim, Germany. 

neously at different energies can acquire 

two data sets with different attenuation 

levels. 

“DSA is susceptible to any motion that 

occurs between the exams,” Becker 

points out, “whereas with Dual Energy 

there are never any motion artifacts 

when we extract the bone from the 

dataset.” The scan speed of up to 

45,8 cm per second and the temporal 

resolution of 75 milliseconds that is 

possible with the SOMATOM Definition 

Flash can be particularly helpful in 

scanning the carotid arteries, Becker 

says, since they quickly fill with contrast 

media. He says the high-pitch Flash 

mode makes it easy to accurately time 

the scan so that pure arterial phase can 

be achieved without venous overlay that 

can impair visualization. Additionally, 

the information from dynamic CTAs 

using the Adaptive 4D Spiral technology 

offers new insights in cerebral hemodynamics 

to evaluate endoleaks, Takayasu 

disease, or complex hemodynamics of 

dural arteriovenous fistula. Becker adds 

that Siemens’ latest imaging software, 

syngo.via*, speeds workflow by allowing 

him and his colleagues to access and 

share data from anywhere** within the 

network. 

As Low as Reasonably 

Achievable 

“In developing advances that aim to improve 

the diagnostic confidence of physicians 

and patient outcomes, Siemens 

is committed to reducing radiation dose 

to the lowest possible level following the 

* 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 rights. 

** 

Prerequisites include: internet connection to clinical network, DICOM compliance, meeting of minimum hardware requirements, and adherence to local data security regulations.

7 

Coverstory 

6A 6B 

6 X-CARE is especially important in CT for protecting dose sensitive tissue, e.g. the lenses of the eyes (Fig. 6A). To further reduce the 

radiation dose for the lenses, additional safety devices like an eye protector (Fig. 6B) can be used. 

Dose Shield 

2007 

Dose Shield 

Adaptive Dose Shield 

Up to 25 % dose reduction 

Selective 

Photon 

Shield 

2008 

80 kV 

Attenuation B 

Selective 

Photon 

Shield 

No dose penalty 

140 kV 

Attenuation A 

2008 

4D Noise 

Reduction 


7 Siemens has been a pioneer in creating a host of innovative technical features that significantly reduce radiation exposure in CT scans. 

Using these features may result in variant values of dose reduction. 


‘as low as reasonably achievable’ 

(ALARA) principle. Innovations such as 

IRIS are evidence of this commitment, 

as is Siemens X-CARE”, says Sami Atiya, 

PhD, Chief Executive Officer, Business 

Unit Computed Tomography, Siemens 

Healthcare in Forchheim, Germany. The 

application protects sensitive organs by 

lowering the tube current during the 

portion of the rotation in which the area 

of concern would otherwise be near the 

X-ray source. Enterline, at Duke University 

Medical Center in Durham, USA, points 

out that X-CARE is especially important 

for protecting the lenses of the eyes, 

which are particularly radiosensitive. He 

says the technology has allowed him and 

his colleagues to reduce dose to the lens 

up to 30 % in preliminary data without 

a reduction in image quality. They 

routinely use X-CARE in their practice. 

Another technology that minimizes dose 

to patients is the Siemens Adaptive 

Dose Shield, available on the SOMATOM 

2008 

Neuro BestContrast 

Up t o 30 % dose reduction 

Definition AS and Definition Flash scanners. 

With traditional spiral CT exams, 

patients are exposed to unnecessary 

radiation at the beginning and the end 

of the exam. The Adaptive Dose Shield 

automatically moves collimators into 

place to block this unnecessary exposure, 

thereby reducing dose by up to 25 %. 

Becker notes that the proportion of overbeaming 

is especially significant over 

small scan ranges, so pediatric patients 

and those requiring head CT exams 

stand to gain the most. 

Becker and his colleagues further reduce 

radiation dose with Siemens CARE 

Dose4D, which provides real-time modulation 

of dose, based on patient size 

and the anatomy being imaged. “I totally 

insist on using it,” Becker says. “We 

don’t switch this option on and off – 

we use it for every CT scan.” 

Concerns about radiation dose have 

moved from the medical journals and 

conference halls into the mainstream 

2008 

X-CARE X-ray low 

X-ray on 

Up t o 40 % dose 

reduction 

2009 

Image data 

recon 

Coverstory 

news media. Enterline and others say 

that, as a result, patients increasingly 

ask about the potential consequences 

of their exposure to medical imaging. 

Discussing the risks and benefits associated 

with CT imaging with patients 

helps reassure them, Enterline says, and 

so does having technology that minimizes 

dose. “It’s our responsibility to do what 

we can to minimize dose and to make 

sure that the studies are appropriate,” 

he adds. “It’s the right thing to do for 

patients.” 

Sameh Fahmy is an award-winning freelance 

medical and technology journalist based in 

Athens, Georgia, USA 

1 Diehn F, et al. – RSNA 2009 presentation SSE23- 

03: A Preliminary Study of Novel Post-processing 

Tool: Multi-Band Filtration of Noncontrast Head 

CTs. 

2 Lin K, et. al. – Cerebrovascular Diseases 2009; 

28:72-79 

3 Hacke W, et al. – NEJM 2008;359 (13) 1317-1329 

4 Thomandl B, et al. – RadioGraphics, 23:565-592 

Image 

correction 

Iterative 

Reconstruction in 

Image Space (IRIS) 



News 

Affordable Performance 

in 16- and 64-slice CT 

At the European Congress of Radiology in March 2010, Siemens 

introduced new 16- and 64-slice systems to the market: The SOMATOM 

Emotion Excel Edition and the SOMATOM Defi nition AS Excel Edition. 

By Jan Freund, Steven Bell and Rami Kusama, Business Unit CT, Siemens Healthcare, Forchheim, Germany 

The new Excel Editions from Siemens 

are especially cost-effective versions 

of the SOMATOM Emotion 16-slice and 

SOMATOM Definition AS 64-slice scanners. 

The Excel Edition is the result of 

Siemens’ commitment to developments 

that bring new technology to more 

people through reducing the costs of 

these innovations. These new additions 

to the Emotion and Definition AS families 

offer customers access to 16-slice 

and 64-slice Siemens technology in 

scanners that include many of the advantages 

that existing Emotion and 

Definition AS customers know, at a 

significantly more advantageous price. 

On the one side, the SOMATOM Emotion 

Excel Edition is especially designed to 

make it easier for small and medium-sized 

hospitals and practices to enter the 

world of 16-slice computed tomography. 

It continues the success story of the 

Emotion platform that remains the most 

popular CT in the world. 

The success of the SOMATOM Emotion 

platform to date has been due to superb 

image quality, a simplified and efficient 

workflow, and the ability to save money 

over the life of the CT system. To date, 

there are around 7000 systems installed 

worldwide. The 16-slice SOMATOM 

Emotion Excel Edition builds on the prior 

success of this imaging platform to bring 

these advantages to more customers 

and patients. It offers the smallest focalspot 

size and a high number of effective 


The new Excel Editions from Siemens are especially affordable versions of the SOMATOM Emotion 

16-slice and SOMATOM Definition AS 64-slice scanners.

detector channels for increased image 

clarity and resolution. It continues 

Siemens’ focus on dose reduction with 

the exclusive CARE Dose4D algorithm 

offering dose reduction of up to 68 % in 

routine scanning. Customers will also 

continue to benefit from the easy-to-use 

syngo user interface that Siemens 

customers across all imaging modalities 

are familiar with. 

On the other side, the SOMATOM 

Definition AS Excel Edition introduces 

a high-end, yet affordable 64-slice workhorse 

for both everyday clinical routine 

and advanced imaging. It will broaden 

the portfolio of the SOMATOM Definition 

AS family and continue its legacy as the 

world´s first adaptive scanner. Its unique- 

ness is the unprecedented adaptability 

to any patient and any clinical question, 

making it an expert in virtually any 

clinical field. With the introduction of 

the SOMATOM Definition AS Excel 

Edition, Siemens continues to lead the 

world of innovation by making two ends 

meet: bring outstanding imaging technology 

and advanced clinical applications 

to budget-minded customers. 

The SOMATOM Definition AS Excel 

Edition addresses the growing market for 

entry-level 64-slice scanners. Especially 

this segment is currently facing a very 

strong trend towards commoditization, 

demanding a reliable, cost-efficient 

64-slice system to realize high throughput 

in everyday clinical routine. For this, 

www.siemens.com/ 

somatom-emotion 


somatom-definition-as 

News 

the scanner offers the highest degree of 

flexibility with its 78 cm gantry and a 

table load capacity of up to 300 kg thus 

avoiding delays and patient exclusions. 

Combined with the industry’s highest 

sub-mm resolution and coverage speed 

in its segement, a rotation speed of 0.33 

seconds and unique applications like 3Dguided 

CT interventions, the SOMATOM 

Definition AS Excel Edition delivers 

state-of-the-art CT imaging and can 

cope with literally every need in clinical 

routine. At the same time, it sets standards 

in patient safety by providing a 

unique composition of dose protection 

features like CARE Dose4D, the innovative 

Adaptive Dose Shield, which avoids 

unnecessary overradition in every spiral 

scan, or IRIS – the Iterative Reconstruction 

in Image Space which allows a dose 

reduction of up to 60 %. With its onsite 

upgradeability to the standard AS 

64-slice and AS+ 128-slice configurations 

and with the smallest footprint in its 

segment, the new Edition is the ideal 

system for customers that are both 

performance and budget-minded. 

Finally, together with syngo.via* – 

Siemens’ new imaging software – the 

SOMATOM Definition AS Excel Edition 

grants access to a whole new world of 

workflow improvement. 

By moving from post-processing of image 

data to having it pre-processed and 

ready to review, it sets new standards in 

ease-of-use and thus clinical efficiency. 

The SOMATOM Emotion Excel Edition 

was released on the first of April 2010 

and the SOMATOM Definition AS Excel 

Edition on the first of May. For more 

information about the new Excel Editions, 

the local Siemens representative can be 

contacted. 



News 

Best Balance Between 

Image Quality 


Iterative Reconstruction in Image 

Space (IRIS) provides individual choices 

and benefi ts for all patients. 

By Annette Tuffs, MD 

It is a difficult choice for physicians 

to decide what benefits the patient most, 

the highest resolution with best image 

quality and diagnostic confidence – 

or the lowest radiation level to reduce 

the long-term risks for their patients. 

Modern CT technology like IRIS cannot 

entirely overcome this dilemma, of 

course, but it provides flexible solutions 

that allow choices for the individual 

patient according to age, condition, 

suspected pathology and the specific CT 

investigation being performed, thereby 

permitting the reading physician to 

carefully weigh the benefits of highest 

possible resolution against the advantages 

of minimized radiation exposure. 

IRIS – A Success Story 

The peak of these impressive developments 

is IRIS, which stands for Iterative 

Reconstruction in Image Space. It had 

its debut at the 2009 RSNA meeting in 

Chicago and has proven to be another 

Siemens success story in substantially 

reducing radiation dose. It is based upon 

“iterative reconstruction,” a method first 

developed in the 1970s to reduce noise 

in CT images. 

Iterative reconstruction includes a “correction 

loop,” in which images are repeatedly 

calculated by assumptions. The 

image becomes softer in homogenous 

tissue regions while, at the same time, 

high-contrast tissue boundaries are maintained. 

Image resolution and image noise 

are no longer closely inter-dependant. 

However, this process required a lot of 

time and enormous computing capacity 

and therefore – before IRIS – was not 

feasible for use in clinical routine. Now, 

Siemens engineers and scientists have 

optimized the process and developed 

IRIS, where time and computing capacity 

are no longer an issue. 

“We are enthusiastic about this innovative 

method in CT scanning, that´s why 

we use it in our greatly improved daily 

routine,” says Professor Joseph Schoepf, 

MD, whose Department of Radiology at 

the Medical University of South Carolina, 

Charleston, USA, was one of the first 

to gain clinical experience with IRIS. 

His department has been using IRIS on 

a routine basis since autumn 2009 for 

about 15 patients per day. 

All Patients Benefi t 

Several university hospitals, in Germany 

and abroad, have already been able to 

gather extensive clinical experience with 

IRIS. One of them is the University 

Hospital, Erlangen in Germany, where 

Michael Lell, MD, Senior Physician at the 

Radiology Institute, has been involved in 

studies concerning the potential of IRIS 

in reducing radiation dosage. In one of his 

studies, that he will submit for publication 

in the next months, more than 70 

patients have been evaluated with and 

without IRIS. The radiologists in Erlangen 

were looking specifically at the abdomen. 

“As a preliminary result, we can say 

that we were able to achieve a 50 % 

dosage reduction while maintaining 

high standards of image quality,” Lell 


1 

1 Since autumn 2009 in the University Hospitals 

Munich and Erlangen-Nuremberg all CT scan 

protocols have been changed to use IRIS in clinical 

routine. 

recounts. Which patients will benefit 

most from the use of IRIS? “All patients 

should have the benefit,” says Lell, “and 

therefore we changed all our protocols 

to include IRIS.” However, there are specific 

patient groups that should benefit 

even more, for instance children, since 

they demand the smallest possible dose 

because of long-term, higher potential 

radiation risks and, at the same time, 

have smaller body structures, which are 

more difficult to visualize in CT scanning 

procedures. 

Lell specifically mentions the group of 

children and juvenile patients with mucoviscidosis, 

an unstable condition that can 

require frequent CT scans. He is optimistic 

that, with the ongoing fine-tuning of IRIS, 

further dose reductions will be possible 

and he is confident that the magic threshold 

of up to 70 % reductions can be 

reached. 

Special Object: 

Cardiovascular Stent 

Another group of patients that especially 

benefit from IRIS is the increasing number 

of obese patients of both genders 

and all ages. Even when the smaller of 

these morbidly obese patients are able to 

squeeze through the CT gantries, the 

resulting images are often substandard, 

sometimes strikingly so. 

“The diagnostic results can be greatly 

improved with IRIS in obese patients,” 

says Schoepf. His hospital mainly cares 

for patients with either digestive disease 

or cardiovascular disease. His special

interest is testing IRIS in patients with 

heart stents that are supposed to keep 

the coronary arteries open. 

“Coronary stents are the Achilles’ heels 

of radiological heart diagnostics,” says 

Schoepf. With IRIS, it is easier to detect 

whether there is a true obliteration of 

the stent or the so-called, “beam hardening,” 

that only simulates closure of the 

stent. Preliminary results of a study at 

the Medical University of South Carolina 

have already shown that IRIS will help 

to make this important distinction, that 

has a major impact on therapeutic decisions 

and results. 

Searching for Small Liver 

Metastases 

Another important area with far-reaching 

therapeutic consequences is the imaging 

IRIS Now Extended to SOMATOM Defi nition AS 20 

and SOMATOM Defi nition AS 40 

By Rami Kusama, Business Unit CT, Siemens Healthcare, Forchheim, Germany 

Because at Siemens dose reduction has 

continued to be given top priority, assuring 

both patients and medical personnel 

the best in medical care with the least 

possible risk, the availiability of IRIS with 

the SOMATOM Definition, SOMATOM 

Definition Flash, and SOMATOM 

Definition AS+ and AS 64, will be extended 

to the SOMATOM Definition AS 

40, as well as AS 20. Now all scanners 

from the SOMATOM Definition family* 

will benefit from excellent diagnostic 

image quality with levels of dose lower 

than ever before. With IRIS, Siemens’ 

smart approach to iterative reconstruction, 

up to 60% additional dose reduction 

can be achieved in a wide range of daily 

routine CT applications. 

Dose reduction with CT has been limited 

by the currently used filtered back projection 

reconstruction algorithm. When 

using this conventional reconstruction of 

acquired raw data, a trade-off between 

spatial resolution and image noise has to 

be considered. Higher spatial resolution 

of the liver, especially when searching 

for small metastases of malignant tumors 

elsewhere in the body. “With IRIS, we 

have a much better chance of finding 

these lesions,” says Schoepf. 

Konstantin Nikolaou, MD, Prof. of 

Radiology, Associate Chair of the Department 

of Radiology, Munich University 

Hospital, Germany, also agrees that all 

patients can profit from the use of IRIS, 

some of them more than others. Since 

last autumn, he and his colleagues have 

changed all the protocols to use IRIS. By 

April 2010, more than 3.000 patients of 

all ages and conditions profited from 

improved IRIS image quality or dose 

reduction. Overall dose reductions in all 

body regions of about 30 % were 

achieved, and current scientific studies 

at the University of Munich are designed 

increases the ability to see the smallest 

detail; however, it is directly correlated 

with increased image noise. 

In an iterative reconstruction, a correction 

loop is introduced into the image 

generation process. To avoid long reconstruction 

times, IRIS first applies a raw 

data reconstruction only once. During this 

initial raw data reconstruction, a socalled 

and newly developed master 

volume is generated that contains the full 

amount of raw data information, but at 

the expense of significant image noise. 

During the following iterative corrections, 

the image noise is removed without 

degrading image sharpness. The 

new technique results in increased image 

quality or dose savings of up to 60 % 

for a wide range of clinical applications. 

90 day, free trial licenses for IRIS are 

now also available. The local sales 

representative can be contacted for 

details. 

*requires syngo CT 2010A or syngo CT 2010B 

to prove this effect. “IRIS has improved 

our daily routine because of higher image 

quality or lower dose.” The Munich 

radiologists are currently running studies 

where the diagnostic results from IRIS 

images are compared with conventional 

images, and their recent finding have 

shown that an experienced radiologist 

can easily adjust to the new kind of 

image impressions. “A trained eye can 

benefit from the IRIS specific images – 

the improved spatial image resolution in 

high contrast areas, with less noise in 

the low contrast areas.” 

Annette Tuffs, MD, is a medical journalist 

based in Heidelberg, Germany. The former 

medical editor of the daily Die Welt has 

been contributing to the Lancet and the 

British Medical Journal since 1990. 

News 

Iterative Reconstuction in Image Space (IRIS) 

Fast Image Data Space 

Slow Raw Data Space 

Compare 

Image data 

recon 

Master 

recon 

Image 

correction 

� Up to 60 % dose reduction 

� Image quality improvement 

� Fast recon in image space 

� Well-established image impression 

� 90 day, free trial license 


News 

syngo CT 2010B Now Available: 

New Software Version for the 

SOMATOM Defi nition AS Launched 

By Jan Freund, Business Unit CT, Siemens Healthcare, Forchheim, Germany 

The new syngo software version, CT 

2010B, for SOMATOM Definition AS 

scanners, was released in April 2010. 

It makes IRIS (Iterative Reconstruction 

in Image Space) available to SOMATOM 

Definition AS customers. With IRIS, a 

dose reduction of up to 60% is possible 

without compromising image quality. 

In addition, native head-image quality 

can be significantly improved with 

Neuro BestContrast without an increase 

in dose. By separating low and high fre- 

Worldwide Dose Counter 

By Peter Seitz, Business Unit CT, Siemens Healthcare, Forchheim, Germany 

With the SOMATOM Definition Flash, 

coronary CTAs become routinely available 

at dose levels below 1 mSv. Now everybody 

can check dose values for themselves, 

in daily routine, worldwide, and in 

almost real-time. Being able to image the 

coronary arteries with a radiation dose of 

below 1 mSv is impressive in itself, but it 

becomes even more impressive when this 

happens everyday, all around the globe 

and not just in a few specialized cases. 

That’s why Siemens decided to make average 

doses of Flash Spiral Cardio scans – 

our all-new high-pitch mode for scan 

speeds up to 458 mm/s – publicly available. 

With this ultrafast scanning, the 

SOMATOM Definition Flash acquires the 

entire heart in only around 270 ms, reducing 

radiation exposure to the minimum, 

all the while maintaining the excellent 

image quality that previously was 

only possible at much higher dose levels. 

At www.siemens.com/low-dose anyone 

can observe the current average dose on 

the installed base. This value is updated 

every 30 minutes by statistical data 


quency data, it specificly optimizes the 

tissue contrast without amplifying the 

image noise, resulting in an improvement 

of signal to noise ratio of up to 

30 %. In dynamic studies, such as CT 

Perfusion images, noise can be significantly 

reduced. As a result, radiation 

dose can be lowered without compromising 

image quality. The Adaptive 

Signal Boost optimizes lower signals, 

e.g. when low dose or obese protocols 

are used. Neuro BestContrast, 4D Noise 

Reduction and the Adaptive Signal Boost 

will be available free of charge. CARE 

Contrast II synchronizes CT scan and 

contrast media injection. With its open 

interface technology, it is ready for 

future applications. The syngo CT 2010B 

will be delivered with all new systems 

beginning in May 2010 and as a field 

roll-out to the complete installed base 

of the SOMATOM Definition AS. 

View on the Siemens Healthcare 

dose counter homepage. 

analysis that is sent from SOMATOM 

Definition Flash installations worldwide. 

In addition latest news and further information 

are available on Siemens Low 

Dose CT. 

www.siemens.com/low-dose

syngo.via 

Workstation 

Face-off Sessions 

By Karin Barthel, Business Unit CT, 

Siemens Healthcare, Forchheim, Germany 

At RSNA 2009, Siemens Healthcare 

introduced their new imaging software, 

syngo.via,* a client-server based software 

solution which allows to display 

most used applications across various imaging 

modalities – dedicated not only to 

general radiology but tailored to specific 

clinical fields such as oncology, neurology, 

vascular imaging and cardiology as well. 

Since then, syngo.via has participated at 

2 major face-offs. At a face-off, several 

industry vendors enter the arena to demonstrate 

cases live on their respective 

workplaces, permitting the audience to 

make an immediate, direct comparison of 

the software versions and results. 

First, syngo.via met the challenge at the 

6th International MDCT Symposium 2010 

in Garmisch-Partenkirchen, Germany, 

where about 1.600 CT experts were registered. 

Thomas Mang, MD, from the University 

Hospital in Vienna demonstrated 

the cases for Siemens. The first was a 

vascular case where an aneurysm needed 

to be evaluated. With syngo.via, Mang 

could fulfill all tasks ahead of time in outstanding 

clinical quality. Only 2 minutes 

were required since many steps, like table 

removal, bone removal, naming of vessels, 

curved MPRs and orthogonal views, were 

automatically calculated by syngo.CT 

Vascular Analysis.** The second case was 

an oncology case in which multiple liver 

lesions had to be measured. The automatic 

synchronization of datasets, the 

propagation of previous results and the 

unique Findings Navigator helped to 

speed up the workflow tremendously. 

The contouring algorithm worked perfectly 

and measured reliably, even for the 

very complex liver lesions that, in comparison 

to the surrounding tissue, showed 

very similar density. 

The second competition was the workstation 

face-off at the ECR in March 2010 

in Vienna, Austria. There, 3 cases where 

demonstrated by Marco Das, MD, from 

the University Hospital in Maastricht, The 

Netherlands. The first case was a vascular 

case whereby a high-grade stenosis in 

the common carotid artery needed to be 

quantified and an occlusion in the MCA 

segment had to be displayed. The case 

was completed with syngo.via with only 

a few steps. Due to all the automated 

tools, Das only had to click into the areas 

of interest and could show the results. 

The second case was a brain perfusion in 

which the MTT, CBF and CBV parameters 

had to be measured. Here it was only 

necessary to open the syngo Volume 

Perfusion CT Neuro application to accept 

the results and to place a ROI into the infarction. 

Everything else was automatically 

calculated by the system. All in all, 

this took only 45 seconds. 

The third case was a PET/CT case in which 

the assessment of response to treatment 

between 3 time-points had to be done 

with an volumetric assessment according 

to RECIST, WHO and volume, including 

percentual change between examinations 

as well as an metabolic SUV assessment 

based on PET data. With the Findings 

Navigator it was very simple to jump 

from finding to finding. And the comparison 

of findings was easy to use since all 

images such as CT, PET, Fused and MIP 

images were displayed next to each 

other. Due to the dedicated lung, liver 

and lymph algorithms, all kinds of lesions, 

no matter if large or small were 

contoured and measured precisely. These 

results showed that syngo.via currently 

will be an industry standard for state-ofthe-art 

imaging solution. 

News 

With syngo.via, a vascular case, demonstrated during the face-off in Vienna, 

was completed with only a few steps due to automated tools. 

Thomas Mang, MD, 

AKH, Vienna, Austria 

“Due to the automated 

features within syngo.via, 

manual preparation of 

cases is no longer necessary. 

Now, a radiologist can 

start working where he 

wants to start, with reading 

the case.” 

Marco Das, MD, 

Maastricht University 

Medical Center, 

The Netherlands 

“I saw the syngo.via face-off 

in Garmisch and was very 

impressed. So, when I was 

asked to demonstrate it in 

Vienna, I agreed immediately. 

Although the software was 

new for me, it was easy to 

learn and I was proud to 

demonstrate it at the ECR.” 


** 

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

1A 

News 

syngo.via CT Speedometer 

In November 2009, Siemens Healthcare introduced syngo.via, a new 

client-server based imaging solution concept to improve quality 

of patient care, to cut costs for healthcare and to help hospitals and 

practices optimize their workfl ows. 

By Karin Barthel, Business Unit CT, Siemens Healthcare, Forchheim, Germany 

syngo.via* is a new imaging software 

that supports the physician’s diagnostic 

work with indication-specific workflows, 

layouts, and tools. Unlike typical radiological 

workplace setups – often equipped 

with multiple, isolated workstations – 

syngo.via is a server-based imaging software 

that can be seamlessly integrated 

in PACS or RIS-based working scenarios, 

accessible from any** PC within a clinical 

network. 

To give an overview of the many opportunities 

for saving time in CT, an easy 

to use tool has now been created: the 

syngo.via CT Speedometer. The CT Speedometer 

shows exactly how utilizing 

syngo.via can save time during the whole 

workflow, from patient registration over 

reading the cases up to distributing the 

report. Many time-consuming steps 

which previously had to be done manually 

can now be avoided. 

The following illustrates just a few of the 

time-saving features that are quickly located 

and explained with the CT Speedometer: 

Image Prefetching – 

Up-to-date imaging History 

As soon as the patient is registered or 

data arrives, syngo.via automatically 

initiates a query in all connected archives 

(e.g. PACS) for previous exams or reports. 

Any reasonable previous examinations 

of a patient from CT, MR, AX or other 

moda-lities are prefetched. Thus, a complete 

imaging history is available before 

the physician starts reading the case. 

Summary: Manual, time-consuming 

querying and loading data is history 

with syngo.via. 

Preprocessing – Reading can be 

Started Faster Than Ever Before 

For example, as soon as a vascular case 

arrives at the server, syngo.via automatically 

starts to preprocess the data set. In 

this case, the table removal, bone removal 

and the labeling of main vessels will be 

automatically done by syngo.CT Vascular 

Analysis.*** Curved MPR reformations 

and orthogonal views of the main vessels 

will also be created automatically 

(Fig. 1A). 

Summary: There is no need to prepare 

the data set before being able to read 

the case. 

One Click Stenosis – 

Measurement Straight Away 

In cardiac evaluations, three reference 

points are automatically placed before, 

in and after a stenosis by syngo.CT 

Coronary Analysis.*** The entire vessel 

lumen can be controlled with a dedicated 

profile curve displayed next to the vessel. 

By accepting the measurement, the 

results – including the images – are 

documented in the Findings Navigator 

(Fig. 1B). 

Summary: There is no need to go 

through the entire case manually. 

Multimodality Oncology – 

Holistic Oncology Imaging 

Because syngo.via provides multimodality 

imaging, it can provide additional and 


** Prerequisites includes: internet connection to clinical network, DICOM compliance, meeting of minimum hardware requirements, and adherence to local data security regulations. 

*** The syngo.CT Vascular Analysis and syngo.CT Coronary Analysis options are pending 510(k) review and are not yet commercially available in the U.S. 

1B

The speedometer shows exactly how much 

time can be saved with syngo.via. 

www.siemens.com/ct-speedometer 

potentially decisive diagnostic information 

in oncology cases. Any image data, in 

addition to CT, from PET, MRI or ultrasound 

available for the patient, can easily 

be integrated into the oncology reading 

layout with drag and drop (Fig. 1C). 

Summary: There is no need to switch 

between different data-sets or interfaces. 

Lesion Picking – One Click 

Synchronization 

In Neuro Cases, syngo.via offers a oneclick 

aneurysm evaluation. By simply 

clicking on the finding, e.g., in the VRT 

view, the same finding will be centered 

in the axial, coronal and sagittal views, 

and the other way round (Fig. 1D). 

Summary: No manual update of corresponding 

windows is necessary. 

Findings Navigator – 

Reproducible Results 

While reading the patient, findings 

and measurements can be created, for 

example, the grade of stenoses or 

1C 1D 

lengths of aneurysms. These are automatically 

saved in the Findings Navigator. 

Whenever a user opens a case, the last 

findings are still there. By clicking on a 

finding, the image will again be displayed 

as it was before the last save. 

Summary: No difficult reproduction of 

old measurements is necessary. 

News 

“With syngo.via, I can cut the time for my cardiovascular 

diagnosis from 25 minutes to only 4 minutes.” 

Stéphane Rusek, PhD, Centre Cardio-Thoracique de Monaco, Monaco 

“In an acute care case, e.g. a whole body scan 

with multiple fi ndings – syngo.via can save up to 

23 minutes to diagnosis.” 

Marco Das, MD, University Hospital, Maastricht, The Netherlands 

“Due to the automatic pre-processing of syngo.via a 

substracted case of CT Neuro DSA can be seen immediately 

instead of waiting up to 5–12 min post-processing 

time with a traditional CT Neuro DSA software.” 

Jacques Kirsch, MD, Department of Radiology, Hospital Notre-Dame, Tournai, Belgium 

“When reading an oncology follow-up examination such 

as a PET/CT which demonstrates multiple foci of cancer, 

comparison with prior appearance is essential to 

report response of therapy, syngo.via can reduce this 

total interpretation time by 65 %.” 

James Busch, MD, Specialty Networks, USA 

Reporting – Complete 

Summary Automatically 

Finally, when the reading physician is ready 

to close a case, a summary including all 

image findings and measurements will be 

created and saved to the PACS system. 

Work can be finished with a few easy clicks. 

There is no need to fax or mail results. 

1 Time saving opportunities with 

syngo.via: 

In preprocessing alone, up to 7 min 

can be saved (1A). In cardiac evaluation, 

one-click stenosis measurement 

(1B) saves an additional 4 min. This 

also applies to multimodality oncology 

reading (1C), and with CT Neuro 

DSA aneurysm evaluation (1D), up 

to 1 min can be saved (results may 

vary; data on file). 

More time saving features can be 

found in the CT Speedometer. 

www.siemens.com/ct-speedometer 


News 

International CT Image 

Contest – Highest Image 

Quality at Lowest Dose 

By Rami Kusama, Business Unit CT, Siemens Healthcare, Forchheim, Germany 

Excellent image quality is an essential 

requirement in computed tomography 

(CT). At the same time, the patient’s 

radiation exposure should be kept as low 

as possible. Siemens wants to motivate 

its users to utilize all dose reduction 

features available on their CT scanners 

to the full extent and share their experi- 

1 Winner in Cardiac 

Moderate Atherosclerosis 

(SOMATOM Definition Flash / 

0.97 mSv dose), Yuko Utanohara, 

MD and co-authors: 

Nobuo Iguchi, MD, PhD; Kenji 

Horie; Tatsunori Niwa; Sakakibara 

Heart Institute, Japan 

History: 

A 68-year-old female, non-smoker, 

with a 3-year history of hyperlipidemia, 

shortness of breath and chest 

tightness on exertion was referred 

for detailed examination to our department 

after heart murmur was 

detected for the first time. 

Diagnosis: 

The coronary arteries showed 

moderate atherosclerosis on CT. 

Jury statement: 

“This case study is not only aesthetically 

pleasing, but in addition, it 

demonstrates that supreme diagnostic 

accuracy can be achieved at 

very low doses, with unambiguous 

visualization of the coronary artery 

lumen up to the very distal segments 

of the coronary artery tree.” 

ences with other users. For this reason, 

Siemens initiated the International CT 

Image Contest from October 1, 2009 to 

February 1, 2010 asking physicians from 

around the world to send in their work 

to compete for the best image quality at 

the lowest possible radiation dose. 

Around 300 low dose cases from more 


1 

than 30 countries were submitted and 

were evaluated by a jury of internationally 

renowned professors. 

The Jury 

Professor Stephan Achenbach 

University of Erlangen, Germany 

Professor Dominik Fleischmann

Stanford University Medical Center, USA 

Professor Elliot K. Fishman 

Johns Hopkins University Hospital, USA 

Professor Yutaka Imai 

Tokai University School of Medicine, 

Japan 

Professor Zengyu Jin 

Peking Medical Union College, China 

Professor Borut Marincek 

University Hospital Zurich, Switzerland 

Professor Maximilian Reiser 

Ludwig-Maximilians-University Munich, 

Germany 

Professor Uwe Joseph Schoepf 

Medical University of South Carolina, 

USA 

Participation 

Images could be submitted online on 

a contest website by users of the 

SOMATOM Definition, SOMATOM Definition 

AS, as well as SOMATOM Definition 

2 

Flash, in the categories of: cardiac, 

neuro, abdomen and pelvis, vascular, 

thorax, as well as Dual Energy. Every 

internet viewer could select their 

“favorite image” in a public voting. 

Winner Announcement 

The winner announcement took place 

at the ECR 2010 in Vienna during the 

Bayer Schering Pharma and Siemens 

Healthcare joint Satellite Symposium. 

Winning images (Figs. 1–6) were exhibited 

at the Grand CT Image Gallery. 

For those who could not attend the 

ECR, the winners were announced at 

the same time on the contest website 

and via press release. 

www.siemens.com/Image-Contest 

The free contest poster can be 

ordered at: 

www.siemens.com/ct-poster 

 

Winner in public voting: Interrupted Aortic 

Arch (SOMATOM Definition/ 0.45 mSv dose), 

Pannee Visrutaratna, MD, Maharaj Nokorn 

Chiangmai Hospital, Thailand 

History: A five-month old girl has suffered from 

tachypnea, poor feeding, and poor weight gain 

since she was one month old. 

Diagnosis: Interrupted Aortic Arch. The arch 

interruption occurs distal to the origin of the 

left subclavian artery. The descending thoracic 

aorta is supplied by a large patent ductus 

arteriosus. 

2 Winner in Neuro 

Perfusion after Occluded Stent 

(SOMATOM Definition AS / 7.55 mSv 

dose), Robert McGregor, MD; Boundary 

Trails Health Centre; Canada 

History: 

Carotid CTA and perfusion imaging 

was obtained in a 55-year-old female 

post SILK stent for right internal carotid 

aneurysm. 

Diagnosis: 

CTA revealed occlusion of the stented 

right internal carotid artery. Perfusion 

imaging demonstrated decreased 

CBF, increased MTT, but maintained 

CBV, indicating a large perfusion 

defect without significant infarction. 


“The case nicely presents the potential 

of comprehensive stroke assessment 

by CT Perfusion. CT Perfusion may 

suffer from image noise with unsharp 

margins of the infarcted territory. 

In this example, the margins of the 

infarct are clearly displayed allowing 

determination of the extent of the 

infarction precisely.” 


News 

3 Winner in Abdomen and Pelvis 

Cancer of Pancreas (SOMATOM Definition 

/ 6.34 mSv dose), Prof. Dan Han, MD 

and Yu-Hui Chen, MD; Hospital of Kunming 

Medical College; P.R. China 

History: 

A 59-year-old male had experienced upper 

abdominal pain for four years. A mass 

in the head and neck of pancreas was 

identified in both Ultrasound and MRI. 

Diagnosis: 

The advanced cancer of pancreas resulted 

in a significant narrowing in the portal 

vein and the collateral circulation was 

established. 


“This CTA shows the encasement of the 

portal vein / SMV confl uence making the 

patient unresectable. The case with the 

highest image quality is the one that provides 

the most information content for 

the radiologist and the referring physician. 

This case fulfi lls these criteria completely 

at a very low radiation dose.” 

4 Winner in Vascular 

Child Aortic Transposition (SOMATOM 

Definition Flash / 0.25 mSv dose), Gregory 

Nicaise, MD and co-author: Philippe Everarts, 

MD, Centre Hospitalier de Jolimont, 

Belgium 

History: 

A 2-year-old child with chronic dyspnea and 

pulmonary infection was presented for a CT 

examination. 

Diagnosis: 

Aortic transposition, left bronchial stenosis, 

atelectasy, pulmonary clarity and air trapping 

were detected. 


“This case demonstrates excellent image 

quality achieved at ultra-low dose permitting 

a comprehensive and accurate diagnosis 

in a complex congenital heart defect.” 


3 

4

5 

6 

News 

5 Winner in Thorax 

Flash ECG Thorax (SOMATOM Definition 

Flash / 0.82 mSv dose), Petter Quick; CMIV 

Linköping University; Sweden 

History: 

A 47-year-old woman was presented to the 

CT-department with unspecific chest pain. 

Diagnosis: 

The CT examination showed no pathology and 

could successfully rule out coronary disease, 

pulmonary embolism as well as lung tumor. 


“This case represented everything that 

chest CT can be – a high quality, volume 

data set that can provide information 

for vascular imaging as well as the lung 

parenchyma. High quality imaging requires 

the right scanner, the right protocols 

and the right execution of these 

protocols. This image tells that story 

very nicely.” 

6 Winner in Dual Energy 

Carotid and Circle of Willis 

(SOMATOM Definition Flash / 1.12 mSv dose), 

João Carlos Costa, MD, Diagnóstico por 

Imagem, Lda, Portugal 

History: 

A healthy 75-year-old female was presented 

to the CT-department with a family history 

of carotid artery stenosis. 

Diagnosis: 

Small atherosclerotic plaques in the emergence 

of braquiocephalic trunk and left carotid artery 

were identified. 


“This case illustrates the power of Dual 

Energy CT for tissue differentiation. In 

a single image and at tremendously low 

doses, all tissue layers in the human body 

can be simultaneously and intuitively 

displayed and provide the anatomic context 

of the target structure, the carotid 

circulation.” 


Business 

Stéphane Rusek, PhD, is convinced that syngo.via radically transforms the use of CT even for his colleagues, turning it into an all’round 

tool for all doctors: (from left to right) Filippo Civaia, MD, Philippe Rossi, MD, Stéphane Rusek, PhD, Laura Iacuzio, MD. 

More for Less in Monaco 

At Monaco’s Centre Cardio-Thoracique, Siemens’ latest groundbreaking 

image-processing software, syngo.via, is boosting the productivity of the 

cardio-vascular team. 

By Oliver Klaffke 

Only a few meters up from the harbor, 

yet still within sight of the multi-milliondollar 

fleet resting in the sun, is located 

Monaco’s Centre Cardio-Thoracique 

where Stéphane Rusek, PhD, head of the 

hospital’s IT department, is trying to 

extract as much diagnostic information 

as he can for as little cost and time as 

possible. 

Rusek’s goal is to boost the productivity 

of radiologists and cardiologists by using 

computed tomography (CT) images to 

diagnose cardiac cases. And syngo.via,* 

Siemens’ groundbreaking imaging 

software, he’s convinced, is the answer. 

syngo.via has the capacity to help 

medical professionals use CT images 

more easily and efficiently, thus freeing 

up more time for actual diagnosis. 

Stéphane Rusek is personally responsible 

for implementing Siemens’ latest breakthrough 

in image processing at the 

Monaco clinic. “A new era in image processing 

and CT diagnosis has dawned,” 

he says. “What the iPhone did for mobile 

computing, syngo.via is doing for CT. It 

offers a user-friendly interface that gets 

the most out of the technology without 

users even being aware of the sophisticated 

software responsible, let alone 

having to learn to manipulate it.” 

syngo.via has been specifically designed 

to free medical professionals from the 

burden of having to process the vast 

amount of images made available by 

today’s CT examinations. Ten years ago, 


such examinations delivered around 

50 images; nowadays they generate 

thousands – far too many for anyone 

to handle promptly and effectively. 

Rusek is convinced that syngo.via radically 

transforms the use of CT, turning 

it into an useful tool for all doctors. 

“We are on the brink of a boom in cardiovascular 

CT that will see it become 

standard and routinely used in every 

hospital,” he says. And the time seems 

ripe. Health authorities around the 

world appear increasingly willing to 

fund cardiac CT. They have been funded 

in the USA since early 2010, and, in 

Europe, German health authorities are 

now looking into authorizing payment 

for cardiac related examinations. The

certain result will be to make such 

exams more widely available. 

“The enormous benefit of the cardiovascular 

applications in syngo.via 

is that they save time,” says Rusek. 

“Cardiologists no longer need to carry 

out tasks that can be done faster and 

better by software.” Preparing scans 

for diagnosis can be extremely timeconsuming, 

especially in cardiac cases. 

For example, manually deleting the 

bony rib cage from images and highlighting 

the arteries takes a lot of effort. 

In Monaco, before syngo.via, cardiologists 

often needed up to half an hour 

just to prepare the images for diagnosis. 

Fortunately, time consuming and 

numerous mouse clicks to diagnosis may 

soon be no more than a distant memory. 

Today, cases can be automatically prepared 

and presented using syngo.via. 

“My guess is that five out of the six 

clicks that you once had to make with 

the mouse are no longer necessary,” 

smiles Rusek. As soon as his medical 

colleagues click to open a case in their 

inbox, syngo.via lets them get straight 

down to diagnosis. It will already have 

prepared the cases automatically and 

identified a process to meet the specific 

diagnostic needs. Images are immediately 

displayed in disease-related 

layouts along with the appropriate tools 

1 

for deeper investigation. The medical 

professionals are then carefully guided 

through a series of steps that they 

predefined in the software for their 

institution. 

“The syngo.via Cardio-Vascular application 

package** now cuts the time 

for cardio-vascular diagnosis from 

25 to only 4 minutes – a factor of six.” 

Information Available – Quality 

and Effi ciency 

“Here in Monaco, we have benefited 

greatly from these disease-related workflows,” 

says Rusek. For each diagnosis, 

syngo.via presents a to-do list to help 

professionals get all the necessary information 

reliably and in shortest time. 

Simply following these procedures is a 

great way to maintain the high standards 

that are increasingly the norm 

in medicine. In Monaco, the cardiology 

team has completely redefined its 

standards and processes, thanks to 

syngo.via. “Now everybody working here 

uses the same processes,” says Rusek. 

“This greatly reduces the risk of errors 

and omissions during diagnosis. 

And since all relevant related data are 

stored along with the case and are retrievable 

at the click of a mouse, writing 

reports has become much easier. “It’s 

Business 

the perfect way to organize patient 

documentation, so that the physician in 

charge can work efficiently on the case,” 

says Rusek. 

In the past, cardiologists at Centre 

Cardio-Thoracique often had to switch 

between workstations to retrieve older 

data stored on different computers. 

No longer. “In our radiology department, 

that’s a thing of the past,” says Rusek. 

Using syngo.via, cases can be easily 

accessed from any computer linked to 

the hospital’s network. Gone is the need 

to wait until a workstation becomes 

available. At the PCs on their office 

desks, medical professionals can immediately 

and conveniently view any case 

they want. Even specialists working at a 

distance can log in utilizing a broadband 

internet connection and get the information 

they need quickly and efficiently. 

Siemens Healthcare is dedicated to 

making these benefits available everywhere, 

not just for Stéphane Rusek and 

his colleagues on the beautiful shores 

of the Mediterranean Sea. 

Oliver Klaffke is a science and business 

writer based in Switzerland. He has been 

on assignment for New Scientist and 

Nature in the past. 

1 syngo.via CT Cardio-Vascular applications** for full cardiac assessment in less than 4 min: the automated case preparation, that saves up to 

12 typical steps together with advanced visualization tools, like the Image Sharpening Filter for calcified lesions or stents, saves up to 21 min for 

a full cardiac assessment (results may vary; data on file). 


** 

The syngo.CT Vascular Analysis and syngo.CT Coronary Analysis options are pending 510(k) review and are not yet commercially available in the U.S.

Business 

New Feature: Neuro 

Image Quality Surpasses 

all Expectations 

A better and quicker workfl ow that leads to more time for patient care and 

diagnosis – this is the bottom line for Peter Schramm, MD, of the University 

of Göttingen, Germany, after testing the new features of syngo CT 2010B. 

But specifi cally for him, as neuroradiologist, the new dimension in neuro 

image quality is also a main improvement and a very impressive one. 

By Wiebke Kathmann, PhD 

The new software version, syngo CT 

2010B, offers several new features including 

Neuro BestContrast, 4D Noise 

Reduction, Iterative Reconstruction in 

Image Space (IRIS), CARE Contrast II and 

Adaptive Signal Boost. Together they 

truly improve the diagnostic precision 

and workflow as could be clearly demonstrated 

during the Market Entrance 

Phase (MEP) by Peter Schramm, MD, 

Deputy Head of the Neuroradiology 

Department at the University of 

Göttingen. He was among the first 

physicians worldwide to test the new 

features in the clinical environment on a 

SOMATOM Definition AS+ scanner. As a 

neuroradiologist, he was especially impressed 

by Neuro BestContrast because 

it achieves a very substantial improvement 

in image contrast, thereby significantly 

improving the distinction between 

gray and white matter in the 

brain – a very important feature in the 

diagnosis of acute stroke patients where 

tissue changes on the scale of 5 to 10 

HU can decide between life and death. 

Neuro BestContrast absolutely fulfilled 

Schramm’s expectations. „Simply by 

looking at the images in our digital 

Picture Archiving and Communication 

System (PACS), we could recognize the 

point in time at which the new software 

had been installed. A lot of our patients 

get a follow-up CT scan, so we could 

also compare scans from before and 

after the software was implemented. 

When Siemens told us that they were 

aiming at improving the differentiation 

of brain tissue, we were wondering how 

A better and quicker 

workflow that 

leads to more time 

for patient care and 

diagnosis – this is 

the bottom line for 

Peter Schramm, 

MD, of the University 

of Göttingen.

“At some point in the 

future, neuroradiologists 

may no longer 

need to perform 

the complete stroke 

CT protocol.” 

Peter Schramm, MD, 


they would be able to achieve an improvement 

in contrast without losing 

spatial resolution. But they did – by 

processing low and high frequencies 

separately.“ 

One-Stop-Shopping 

For clinicians performing perfusion imaging, 

4D Noise Reduction is the most 

interesting feature. Static and dynamic 

components are treated separately as 

a means to reduce noise, thus improving 

the image quality and clinical outcome. 

Schramm could confirm this in acute 

stroke patients, who are frequently quite 

agitated. 

The main advantage, however, that 

Schramm sees with 4D Noise Reduction 

is a reduction in radiation dose while 

still being able to get all the diagnostic 

information from one 4D volume perfusion 

scan. “At some point in the future, 

neuroradiologists may no longer need 

to perform the complete stroke CT 

protocol consisting of a non-contrast CT, 

a whole brain perfusion CT including 4D 

spiral scans and a CT Angiography of the 

brain vessels. Due to the precision with 

4D Noise Reduction, there could be ‘onestop-shopping’, 

the non-contrast CT 

could be skipped by using the first of the 

multi-spiral CT images before the contrast 

medium arrives and the angio-information 

could be taken from one arte- 

rial sequence. For the patient that would 

mean one instead of three CT scans, 

consequently a shorter examination 

time and, in the end, less radiation.“ 

Less Radiation 

With the Iterative Reconstruction in 

Image Space (IRIS), Siemens recently 

introduced a new approach to additionally 

reduce dose by up to 60 % and, at 

the same time, improve image quality for 

a wide range of clinical applications. After 

an initial raw-data reconstruction, a 

newly developed master image is generated 

followed by several iterative corrections 

that remove image noise without 

degrading image sharpness. With this 

approach, IRIS achieves a similar image 

quality as with true iterative reconstructions 

but avoids the long reconstruction 

times, as multiple translations from and 

to the raw data are not needed. For 

Schramm, the main promise IRIS holds 

with this new method is a reduction of 

radiation dose. So far, he and his team 

have worked with the regular dose. After 

testing IRIS, they will now commence 

with a controlled, stepwise dose reduction 

during the next few weeks. In 10 % 

steps with about 500 neuroradiological 

cases each, they hope to prove that IRIS 

allows a reduction of radiation dose while 

keeping the image quality at the same 

level. “Most likely, IRIS will allow for a 

reduction by 20 % in neuroradiology. In 

spinal CT, I expect a reduction by 25 to 

30 % without any loss of image quality,” 

says Schramm. “In very obese patients 

and abdominal CT applications, I can 

realize a dose reduction of up to 60 %.“ 

Saving Time 

Regarding the use of CARE Contrast II – 

the new coupling interface for scanner 

and bolus injector – Schramm experienced 

two advantages: first, the improved 

workflow for the technician due 

to the synchronization of injector and 

scanner and therefore improved patient 

care; second, and more important, the 

time saved due to the automatic and 

digital transfer of the whole dataset on 

contrast media, flow rate etc. to the 

patient protocol. ”This archiving of the 

complete data set – be it for legal, re- 

Business 

search, or clinical purposes – saves time,“ 

explains Schramm.”This makes it a very 

interesting feature for both research 

and in clinical routine.“ 

Benefi t for the Obese Patient 

As for the Adaptive Signal Boost, 

Schramm is convinced that it will improve 

diagnostic precision and reliability, 

for example in CT imaging of the spine. 

“This application is on the rise due to 

improvements in CT technology and the 

growing number of bariatric patients 

who simply do not fit into the MRT and 

where it is crucial to provide the required 

image quality for clinical evaluation.” 

Here the Adaptive Signal Boost 

improves the diagnostic accuracy in soft 

tissue imaging, especially of paravertebral 

and intra-spinal structures. “In routine 

examinations, these features do not 

“Most likely, IRIS will 

allow for a reduction 

of radiation dose 

by 20-30 % in neuroradiology.” 

Peter Schramm, MD, 


necessitate changes in the workflow for 

the technician,” says Schramm, “They 

hardly notice the changes, whereas the 

clinical results are very impressive for 

the radiologist at the end of the line.” 

Wiebke Kathmann, PhD, is a frequent contributor 

to medical magazines in the German-speaking 

world. She holds a Master 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. 


Clinical Results Cardio-Vascular 

Case 1 

Adenosine Myocardial Stress Imaging 

Using SOMATOM Defi nition Flash 

By Gudrun Feuchtner, 1, 4 Robert Goetti, 1 André Plass, 2 Monika Wieser, 2 Christophe Wyss, 3 

Fernando Vega-Higuera, 5 Hans Scheffel, 1 Michael Fischer, 1 Hatem Alkadhi, 1 Sebastian Leschka 1 

1 Institute of Diagnostic Radiology, University Hospital Zurich, Switzerland 

2 Clinic of Cardiovascular Surgery, University Hospital Zurich, Switzerland 

3 Cardiology Division, University Hospital, Zurich, Switzerland 

4 Department of Radiology II, Innsbruck Medical University, Austria 

5 Business Unit CT, Siemens Healthcare, Forchheim, Germany. 

HISTORY 

A 51-year-old male with atypical chest 

pain and intermediate coronary risk profile 

(cigarette smoking and hypercholesterolemia) 

underwent two coronary 

128-slice Dual Source CT Angiographies: 

the first under adenosine myocardial 

stress-imaging, the second at rest. 

DIAGNOSIS 

High-pitch CT Angiography showed 

severely calcified left coronary artery 

(Fig. 1C) with significant stenosis, and 

bare-metal stent in the RCA. 

Adenosine CT stress imaging showed 

a reversible myocardial perfusion 

EXAMINATION PROTOCOL 

Scanner SOMATOM Definition Flash 

defect indicating ischemia anteroseptal 

at midventricular level (Figs. 1A–1B) 

corresponding to left artery descending 

(LAD) stenosis. No defect was found inferior 

of right coronary artery (RCA) vascular 

territory. Invasive angiography 

confirmed a significant 90 % stenosis at 

mid LAD and a patent RCA bare-metal 

stent. Total radiation dose was 2.2 mSv 

for adenosine stress and rest CT scans 

using high-pitch Flash Spiral mode at 

3.4 pitch factor. The delay between both 

scans was 5 minutes. Scan time was 

0.44 seconds for each study, tube settings 

were 100 kV and 320 mAs, gantry 

rotation time was 0.28 s. 


COMMENTS 

Adenosine stress-imaging of reversible 

myocardial ischemia is feasable with 

128-slice Dual Source CT with comprehensive 

evaluation of coronary arteries. 

Assessment of PBV reversible ischemia 

with CT is helpful to improve accuracy of 

coronary CT Angiography, especially in 

cases of severe coronary calcification or 

limited in-stent lumen visibility. 

Scan mode Flash Spiral Pitch 3.4 

Scan area Heart Slice collimation 128 x 0.6 mm 

Scan length 135 mm Slice width 0.75 mm 

Scan direction Cranio-caudal Reconstruction increment 0.4 mm 

Scan time 0.44 s Reconstruction kernel B 26f 

Tube voltage 100 kV / 100 kV Volume 80 ml 

Tube current 320 mAs/rot. Flow rate 5 ml/s 

Dose modulation CARE Dose4D Start delay 10 s 

CTDIvol 3.09 mGy Postprocessing syngo CT Cardiac – 

Effective Dose 2.2 mSv (in total) Function prototype* 

Rotation time 0.28 s 

*The product is not commercially available in the US.

1A 

2A 

3A 

4A 

First CTA under adenosine stress Second CTA at rest 

4B 

1B 

2B 

3B 

4C 

1C 

Cardio-Vascular Clinical Results 

1 By injecting adenosine 

under stress, a perfusion defect 

anteroseptal was shown (arrow, 

Fig. 1A), which was reversible 

after 5 minutes Rest Scan 

(arrow, Fig. 1B). 

A significant mid LAD stenosis 

was detected by CT, and 

quantified as 90 % by invasive 

angiography. Distal after stenosis 

a severely calcified artery 

was found (arrow, Fig. 1C). 

2 Short axis at midventricular 

level showed anteroseptal 

myocardial perfusion 

defect during adenosine 

stress (Fig. 2A, arrow), 

which was reversible at 

rest (Fig. 2B, arrow). 

3 Color maps of the myocardium 

showed black/dark 

areas (Fig. 3A, arrow) indicating 

ischemic myocardium during 

stress. There was no defect 

at the inferior myocardial 

region supplied by RCA 

corresponding to patent 

RCA stent (Fig. 3B, arrow). 

4 Automated quantification 

of hypo-attenuating 

perfusion defect anteroseptal 

midventricular during 

stress (Fig. 4A, arrow) represented 

with the prototype 

of the syngo CT Cardiac 

Function software,* including 

3D segmentation (Fig. 4B). 

No perfusion defect inferior 

of RCA vascular territory could 

be detected (Fig. 4C, arrow). 

* The product is not commercially 

available in the US.


Case 2 

SOMATOM Defi nition Flash: 

Visualization of the Adamkiewicz Artery 

by IV-CTA in Dual Power Mode 

By Yoshiyuki Mizutani, MD* and Tomoko Fujihara** 

*Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan 

**Application Department CT Team, Customer Service Division, Siemens-Asahi Medical Technologies, Tokyo, Japan 

HISTORY 

A 75-year-old female was referred to 

the radiology department of Sakakibara 

Heart Institute to examine where her 

Adamkiewicz artery originated before 

treatment of her thoracic descending 

aortic aneurysm (TAA). The patient was 

scanned with Dual Source CT in dual 

power mode. 

At the referring hospital, the patient 

1 

1 TAA was clearly seen on the Dual Source CT images (VRT). 

had been diagnosed with TAA (descending 

aorta of 5.6 cm diameter) by computed 

tomography and echography as 

well as right coronary artery (RCA) stenosis 

by conventional angiography. She 

was referred to Sakakibara Heart Institute 

for surgical vessel replacement and 

coronary artery bypass grafting with 

saphenous vein graft to RCA. 


2 

DIAGNOSIS 

TAA was clearly seen on the Dual Source 

CT images. An artery originating from a 

lumbar artery was detected, bifurcating 

from the aorta at the upper level of the 

4th lumbar vertebra, entering into the 

spinal canal from the intervertebral foramen 

between the 4th and 5th lumbar 

vertebrae and running along the spinal 

cord on the ventral side up to the lower 

2 TAA was clearly seen on the Dual Source CT images (thin MIP).

3A 

3B 

3 Adamkiewicz artery entering into the spinal canal (Fig. 3A) 

from the intervertebral foramen between the 4th and 5th lumbar 

vertebrae and running along the spinal cord on the ventral side up 

to the lower level of the 12th thoracic vertebra where it changed 

direction forming a hairpin shaped structure (Fig. 3B). 

level of the 12th thoracic vertebra where 

it changed direction forming a hairpin 

shaped structure. It connected into the 

anterior spinal artery. According to these 

characteristics this artery was identified 

as the Adamkiewicz artery. 

The true lumen of the aorta was highly 

enhanced, reaching a CT value of 746 

HU at the level between the 4th and 5th 

lumbar vertebrae whereas the Adamkiewicz 

artery reached a maximum CT 

value of only 140 HU. 

COMMENTS 

The course of the Adamkiewicz artery 

needs to be determined before surgery 

for TAA repair to ensure that it is not 

damaged during surgery and to reduce 

the risk of postoperative paraplegia. 

However, visualizing the Adamkiewicz 

artery with intravenous (IV) CTA is a 

challenging task as injection and scan 

protocols need to be tailored to the location 

and size of this artery. Since the 

Adamkiewicz artery is a tiny vessel, a 

fair amount of contrast media needs to 

be injected at reasonably high rates to 

ensure that this tiny vessel is enhanced. 

In addition, since the Adamkiewicz 

artery runs partially inside the spinal 

canal, enough dose needs to be applied 

to achieve a high signal to noise ratio 

(SNR) in an area surrounded by bones. 

Dual Source CT in the dual power mode 

combines the power of two X-ray tubes 

and two generators and can therefore 

provide twice as much X-ray output as 

a single source CT at the same pitch. As 

a result, areas that need additional dose 

can be scanned at high scan speed and 

appropriate tube current for a high SNR. 

The high scan speed was essential for 

visualizing the Adamkiewicz artery, 

since it required several seconds after 

enhancement of the aorta until the 

small arteries were enhanced, then 

quickly scan over the required long scan 

range while the small arteries were still 

enhanced. 

4 


4 Adamkiewicz artery connected into the anterior spinal artery. 


Scanner SOMATOM 


Scan area Thorax-abdomen 

Scan length 280 mm 

Scan direction Cranio-caudal 

Scan time 8.41 s 

Tube voltage 100 kV / 100 kV 

Tube current 600 eff. mAs 

Dose modulation CARE Dose4D 


Slice collimation 128 x 0.6 mm 

Reconstruction 

increment 

0.3 mm 


kernel 

B36 

Volume 100 ml 

Flow rate 5.0 ml/s 

Postprocessing syngo InSpace 



Case 3 

Dynamic Myocardial Stress Perfusion 

By Florian Schwarz, MD, Fabian Bamberg, MD, MPH, Christoph R. Becker, MD, 

Alexander Becker, MD, Konstantin Nikolaou, MD 

Department of Clinical Radiology, University of Munich, Campus Großhadern, Munich, Germany 

1 

1 Maximum intensity display of the right coronary artery, demonstrating 

heavy calcified plaque in the proximal segment and calcified 

and non-calcified plaque in the intermediate segment, causing 

a mild to moderate stenosis (arrow). 

HISTORY 

A 71-year-old male was referred for evaluation 

of stable chest pain syndrome 

and enrolled in a prospective cohort study 

to evaluate the diagnostic accuracy and 

clinical feasibility of dynamic myocardial 

stress perfusion imaging by cardiac CT. 

Coronary CT Angiography (CTA) and 

CT-based assessment of myocardial perfusion 

under adenosine stress was performed 

prior to cardiac catheterization. 

DIAGNOSIS 

Coronary CTA revealed heavy calcified 

plaque and a mild to moderate lesion of 

the right coronary artery (RCA, Figs. 1 

and 2). Dynamic adenosine stress perfusion 

imaging revealed homogeneous 

perfusion of the myocardium without 

defined perfusion defect (Figs. 4 and 5). 


2 

2 Curved multiplanar reformation of the left anterior descending 

coronary artery with minor calcified and non-calcified plaque in the 

proximal segment of the vessel (arrow). 

COMMENTS 

Non-invasive myocardial perfusion imaging 

by CT may represent an attractive 

option to determine the hemodynamic 

relevance of obstructive coronary lesions, 

or lesions with limited evaluability due 

to heavy calcification. However, further 

validation using appropriate gold standards 

is warranted. 

After undergoing the CT Perfusion scan, 

the patient received conventional medical 

therapy.

3A 

80 

60 

40 

CT [HU] 

20 

0 

time [s] 

0 5 10 15 20 25 30 

4 


3 Principle: dynamic volumetric myocardial stress perfusion to quantify Myocardial Blood Flow (MBF). Comparison of different time 

attenuation curve (TCA) pattern with a slower and lower peak (86 ml / 100 ml / min) in an ischemic segment (Fig. 3A) and normal blood flow 

(MBF 159 ml / 100 ml / min) in an healthy segment (Fig. 3B). 

4 Systolic reconstruction display of long axis, color-coded myocardial 

stress perfusion image of the left ventricle indicating homogeneous 

perfusion (green) and the absence of a circumscribed 

perfusion defect. 


Scanner SOMATOM Definition 

5 Short axis color-coded perfusion map of the left ventricle 

demonstrating homogeneous perfusion (green) under 

adenosine stress. 

Scan mode Dynamic Stress Perfusion Mode Dose modulation no 

Scan area Left ventricular myocardium CTDIvol 94.15 mGy 

Scan length 72 mm Rotation time 0.28 s 

Scan direction Cranio-caudal Slice collimation 32 x 1.2 mm 

Scan time 31 s Slice width 3 mm 

Heart rate 72 bpm Reconstruction increment 2 mm 

Tube voltage 100 kV Reconstruction kernel B23f 

Tube current 350 mAs/rot. Post processing syngo VPCT 

3B 

100 

80 

60 

40 

CT [HU] 

20 

0 

time [s] 

0 5 10 15 20 25 30 

5 

Body Myocardium 



Case 4 

Pre-operative Exclusion of Coronary 

Artery Stenosis With Less Than 1 mSv Dose 

By Sebastian Leschka, MD* and Andreas Blaha** 

* Institute of Diagnostic Radiology, University Hospital Zurich, Zurich, Switzerland 

** 

Business Unit CT, Siemens Healthcare, Forchheim, Germany 

HISTORY 

A 71-year-old male patient with a history 

of cerebral infarction caused by a highgrade 

stenosis of the left internal carotid 

artery and lysis therapy was now referred 

to the radiology department to 

rule out coronary artery disease. 

In addition to the coronary CT Angiography 

(CTA) examination a non-enhanced 

calcium-scoring scan (CaSc) 

was performed. 

The CTA was acquired with a fast pitch 

spiral technique (Flash Spiral Cardio) 

while a mean heart rate of 56 bpm was 

present. 

DIAGNOSIS 

Threshold = 130 HU (102.7 mg/cm 3 CaHA) 

In total, ten calcified lesions could be 

detected in the CaSc. Diffuse distribution 

of calcified deposits was observed in 

the right coronary artery (RCA), the left 

artery descending (LAD) and the left circumflex 

coronary artery (CX). The total 

Agatston score was 130. 

CTA unveiled a normal coronary artery 

anatomy, right dominant coronary supply 

type with regular sized lumen of the 

coronary arteries. RCA and LAD showed 

no hemodynamic relevant lesions. CX 

coronary artery unveiled a stenosis 

smaller than 50% in its proximal segment. 

A deep myocardial bridging of the 

LAD could also be depicted. 


COMMENTS 

In combination with the CaSc (0.35 mSv) 

and the CTA (0.8 mSv), an effective 

dose* of 1.1 mSv was applied to the 

patient to detect coronary artery disease. 

The entire acquisition time of the CTA 

was 280 ms; calcium scoring was 

acquired in 120 ms. 

The Flash Spiral cardio method quickly 

and reliably combines low radiation 

dose values with the accurate display of 

the coronary arteries in all segments. 

Artery Numbers of Calcium Score (2) Volume [mm 3 ] (3) Equiv. Mass 

Lesions (1) [mg CaHA] (4) 

LM 0 0.0 0.00 0.0 

LAD 2 27.5 29.3 4.89 

CX 3 48.3 50.5 8.57 

RCA 5 53.6 66.2 10.81 

Total 10 129.5 146.0 24.27 

(1) Lesion is volume based, (2) Equivalent Agatston score, (3) Isotropic interpolated volume, (4) Calibration Factor: 0.790 

*Effective Dose was calculated using the published conversion factor for an adult chest of 0.014 mSv (mGy cm) -1 [1]. 

[1] McCollough CH et al. Strategies for Reducing Radiation Dose in CT, Radiol. Clin. N. Am. 47: (2009) 27-40.


1 

Scanner SOMATOM Definition 


Scan mode Flash Spiral CorCTA Rotation time 0.28 s 

Scan area Thorax Pitch 3.4 

Scan length 130 mm Spatial Resolution 0.33 mm 


Scan time 0.28 s Slice width 0.75 mm 

Heart rate 56 bpm Reconstruction increment 0.7 

Tube voltage 100 kV / 100 kV Reconstruction kernel B26f 

Tube current 320 mAs/rot. Volume 60 ml 

Dose modulation CARE Dose4D Flow rate 6 ml/s 

CTDIvol 3.10 mGy Start delay Test Bolus 

DLP 57 mGy cm Postprocessing syngo Circulation 

Effective Dose 0.8 mSv syngo InSpace 

1 VRT of the Coronary arteries shows deep 

myocardial bridging of LAD (arrow). 

4 

4 MIP of the coronary artery tree with 

removed blood pool of the left ventricle 

reveals calcifications (arrow). 

2 

2 MIP of the LAD shows myocardial bridging 

(arrow). 

5 6 

5 A stenosis is present in the proximal 

segment of CX artery (arrow). 

3 

3 MIP of the first diagonal branch (D1) of the 

LAD, discovers plunge into myocardium. 

6 Cross-sectional view displays the 

stenotic area of CX artery. 


1 


Case 5 

Utilizing Ultra Low Dose 

of 0.05 mSv for Premature Baby 

With Congenital Heart Disease 

By Jean-Francois Paul, MD 1 and Andreas Blaha 2 

1 Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France 

2 Business Unit CT, Siemens Healthcare, Forchheim, Germany 

1 CT imaging with VRT technique shows ventricular septal defect (arrows) 

and persistent foramen ovale (PFO, arrowheads). 

HISTORY 

A premature baby was referred to the 

radiology department with diagnosis of 

congenital heart disease. An atrial and 

left ventricular septum defect could be 

detected with echocardiography but 

with a doubt about the exact origin and 

*Effective Dose was calculated using the published conversion factor for a pediatric (newborn) chest of 0.039 mSv (mGy cm) -1 [1]. 

To take into account that Siemens calculates the CTDI in a 32 cm CTDI phantom an additional correction factor of 2 had to be applied. 

[1] McCollough CH et al. Strategies for Reducing Radiation Dose in CT, Radiol. Clin. N. Am. 47: (2009) 27-40. 


course of right pulmonary artery (RPA). 

Therefore a low dose CT examination 

was requested, utilizing low kilovoltage 

(kV) and low milliampere seconds (mAs) 

to achieve ultra low dose radiation 

values. 

DIAGNOSIS 

A mild stenosis present at the ostium 

of the right pulmonary artery could be 

observed. Although the RPA showed an 

irregularity it had a normal anatomical 

course. The ventricular septum defect as 

well as the still open atrial septum could 

be clearly revealed by using oblique planar 

reformations. The right coronary artery 

was well depicted despite a heart 

rate of 157 bpm. 

COMMENTS 

The data acquisition was performed 

with a SOMATOM Definition Flash using 

the ECG-triggered sequential mode 

(Flash Cardio Sequence) which resulted 

in an ultra low dose value. Calculated 

with the dose length product (DLP) of 

0.7, an estimated dose of 0.05 mSv could 

be achieved.* 

Using the Definition Flash low dose acquisition 

technique it was possible to detect 

this congenital heart disease (CHD) 

in a very early stage of the patients life.

2 3 

4 



5 


2 Ventricular 

septal defect in 

MIP technique 

(caudo-cranial 

view, arrow); PFO 

(arrowhead). 

3 Caudo-cranial 

view MIP shows 

mild stenosis and 

irregularity of 

the RPA (arrow). 

4 Cranio-caudal 

view in VRT-technique. 

5 Fused VRT and 

MIP highlighting 

RPA (arrow). 

Scan mode Flash Cardio Sequence Effective Dose 0.05 mSv 

Scan area Thorax Rotation time 0.28 s 

Scan length 33 mm Feed/Rotation one rotation 


Scan time 0.18 s Slice width 0.75 mm 

Tube voltage 80 kV / 80 kV Reconstruction increment 0.4 mm 

Tube current 22 mAs / rot. Reconstruction kernel B26f 

CTDIvol 0.18 mGy Postprocessing CT Cardiac Engine 

DLP 0.7 mGy cm 



Case 6 


Pediatric Patient Without Sedation 

and Breath-Holding 

By Kaori Takada, MD* and Tomoko Fujihara** 

* Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan 

** 

Application Department CT Team, Customer Service Division, Siemens-Asahi Medical Technologies, Tokyo, Japan 

HISTORY 

A 4-year-old boy with Tetralogy of Fallot 

(TOF, Fig.1), pulmonary atresia (PA) 

and major aorto-pulmonary collateral 

arteries (MAPCAs) was referred to the 

radiology department of Sakakibara 

Heart Institute for a follow-up examination 

using a SOMATOM Definition Flash, 

Dual Source CT in Flash Spiral mode 

following treatment of his pulmonary 

artery stenosis. 

The patient was diagnosed shortly after 

birth with TOF, PA, MAPCA. When he 

was 10 months old, a stent was inserted 

in the largest MAPCA and a central shunt 

was placed when he was 16 months old. 

When he was 2 years old, he underwent 

right and left modified Blalock-Taussig 

1 

1 Ventricular septal defect that is one 

characteristic of TOF. 

shunt surgeries (therefore the subclavian 

artery is connected with the pulmonary 

artery) within 9 months. Then, at 

the age of 3, an artificial vessel was constructed 

from the right ventricle (RV) 

to the pulmonary artery by palliative 

Rastelli procedure. 

The patient now underwent a percutanous 

transluminal angioplasty (PTA) 

of pulmonary artery. A low dose, Dual 

Source CT scan in the Flash Spiral mode 

was ordered to confirm his postoperative 

condition, in particular concerning 

the pulmonary circulation. The patient’s 

weight was 15.6 kg (34.39 lb). 

He was not sedated and no breath-hold 

was needed during the scan. His mean 

heart rate was 95 bpm. 

DIAGNOSIS 

The Dual Source CT images showed that 

the RV-pulmonary artery conduit was 

patent and that the anastomosis site 

had no stenosis. Neither the right nor 

the left pulmonary arteries (about 

4 mm diameter) presented any significant 

stenosis (Fig. 2). 

A stent was confirmed in the biggest 

MAPCA, which bifurcated from the 

descending aorta at the level of the left 

atrium. It went to the right superior and 

inferior lung lobes, and connected one 

artery originating from right central pulmonary 

artery. Although the stent itself 

was patent, a stenotic part was seen distal 

of the stent (Fig. 3). The Dual Source 


CT images revealed a tortuous artery 

originating from a right subclavian artery 

that supplied the right and left inferior 

lung lobes. The left lung was perfused 

mainly by the left central pulmonary 

artery. The right middle lung lobe 

was perfused by the large right inferior 

diaphragmatic artery (its distal end was 

connected to an artery originating from 

the central pulmonary artery). 

Incidentally, the right coronary artery 

(RCA) was found to originate from the 

aorta at the upper level of left coronary 

artery, the left coronary cusp (Fig. 4), 

which could neither be seen in the previously 

performed catheter angiography 

nor in a 16-MSCT examination. 

Based on these findings a catheter PTA 

of the pulmonary artery stenosis at the 

distal part of the stent was planned. 

COMMENTS 

Dual Source CT Angiography has 

emerged as an essential diagnostic tool 

for the assessment of complex congenital 

heart disease. Nevertheless, dose has 

remained a concern, in particular when 

referring pediatric patients for cardiac 

CT. With the Flash Spiral mode of the 

second generation Dual Source CT, 

pediatric patients can be scanned at 

ultra low dose, as in this case at 1.63 

mGy (effective dose 0.644 mSv). Apart 

from dose concerns, additional challenges 

have been associated with imaging 

pediatric congenital heart disease

patients: the patients have high heart 

rates, the cardiac vessels are tiny, sedation 

often presents a risk and most patients 

cannot hold their breath. This 

Dual Source CT Flash scan of 211 mm 

2A 3A 

2B 3B 

4A 

4B 

2 Both, right and left pulmonary arteries (about 4 mm diameter) 

had now significant stenosis. 

4 RCA originated from left coronary cusp (arrows). 

length was taken in only 0.51 seconds 

without sedation or breath-hold. Vessels 

were clearly visualized without artifacts. 

Even coronary anomaly could be seen 

despite the patient’s high heart rate of 


3 Stent was embedded in largest MAPCA that showed 

a stenosis (arrow) distal of stent (arrowhead). 



Scan mode Flash Spiral 

Scan area Thorax / Chest 




Tube voltage 80 kV 

Tube current 104 eff. mAs 

CTDIvol 

1.63 mGy 

Effective Dose 0.644 mSv 


Pitch 3.4 


Slice width 0.6 mm 

Reconstruction increment 0.3 mm 

Spatial resolution 0.33 mm 

Reconstruction Kernel B26f, B46f (stent) 

Contrast 

95 bpm. Pulmonary artery in-stent stenosis 

could also be evaluated. The Dual 

Source CT Flash images were extremely 

helpful for further treatment planning. 

Flow Rate 2.5 ml/s 

Start delay 17 s 

Volume 30 ml 



Case 7 


Dual Energy Coronary CT Angiography 

for Evaluation of Chest Pain After RCA 

Revascularization 

By Ralf W. Bauer, MD, J. Matthias Kerl, MD, Thomas J. Vogl, MD 

Department of Diagnostic and Interventional Radiology, Clinic of the Goethe University, Frankfurt, Germany 

HISTORY 

A 54-year-old female patient underwent 

coronary stent percutaneous transluminal 

coronary angioplasty (PTCA) of 

the right coronary artery (RCA) four 

months ago for acute ST-elevation 

myocardial infarction of the inferioseptal 

wall. Now, the patient suffered from 

reduced physical power and labile blood 

1 

1 Prior to recanalization: Cardiac catheterization 

showed a prominent RV branch and 

in-stent occlusion of the mid and distal RCA 

(arrow). 

pressure and had an event of syncope 

three weeks ago. Invasive coronary angiography 

was performed to assess stent 

patency. In-stent occlusion of the mid 

and distal RCA with moderate collateralization 

from the left anterior descending 

(LAD) and left circumflex artery (LCX) 

and a patent right ventricular (RV) 


2 

2 Curved multiplanar reformates showed 

instent thrombosis with occlusion beginning 

in the proximal RCA. In the RV branch, which 

was clearly visible on pre-interventional cath 

images, no contrast material filling could be 

delineated (arrows). 

branch were found (Fig. 1). Recanalization 

was performed with placement of 2 

drug-eluting stents in the distal and mid 

RCA. During intervention, a small contrast 

material extravasation was seen 

near the ostium in the proximal RCA. 

A small intima dissection was suspected 

and another stent was placed to close 

3 

3 Dual Energy iodine mapping showed a 

large area with decreased perfusion in 

the arterial phase in the inferoseptal wall 

extending from the base to the apex of the 

heart (arrow).

4 

the leakage. Three hours after intervention, 

the patient developed chest tightness 

and retrosternal pain. ECG showed 

signs of the known old infarction 

inferiorseptally (Q waves in II, III and 

aVF) but no signs of acute ischemia. 

She was sent to CT to rule out aortic 

dissection. 

DIAGNOSIS 

Cardiac CT was performed in Dual Energy 

mode with retrospective ECG-gating. 

There was no sign of contrast material 

extravasation or aortic dissection. Dual 

Energy CT Angiography revealed in-stent 

thrombosis with occlusion of the RCA 

13 mm after its origin (Fig. 2). While 

on cardiac cath the RV branch was still 

open, DECT showed an occlusion of the 

vessel due to the thrombus in the proximal 

RCA, explaining the patient’s symptoms. 

Dual Energy myocardial iodine 

mapping showed a large hypoperfused 

4 Late enhancement was present in the inferoseptal 

wall corresponding to the perfusion 

defect in arterial phase. 

5 

area inferoseptal extending from the 

base down to the apex (Fig. 3). Low 

dose step-and-shoot late enhancement 

images 7 minutes after contrast injection 

showed corresponding delayed 

contrast material washout (Fig. 4). On 

regular anatomical multiplanar reformates, 

a moderate thinning of the left 

ventricular myocardium was present 

in that area (Fig. 5). 

COMMENTS 

In this case, Dual Energy coronary 

CT Angiography was used to image a 

complication of interventional recanalization, 

i.e. acute in-stent thrombosis, 

while the initial clinical diagnosis of 

acute aortic dissection could reliably 

be ruled out. 

A further complication was the occlusion 

of the RV branch (which was patent 

prior to intervention) due to the large 

thrombus formation beginning very 

5 Regular anatomical multiplanar reformates 

showed moderate thinning of the interoseptal 

wall consistent with chronic ischemia (arrow). 


proximally in the RCA. The new hybrid 

reconstruction algorithm for coronary 

CTA images preserves the high temporal 

resolution of 75 ms of the Dual Source 

system and allows for motion-free imaging 

of the vascular structures. According 

to the clinical history of the patient, 

assessment of the myocardium with 

Dual Energy first-pass perfusion and 

late enhancement imaging showed signs 

of chronic infarction in the inferoseptal 

wall of the left ventricle. Increased tube 

power as well as improved separation of 

the spectra by using a tin filter (140 kV 

+ Sn filter) allowed for artifact-free imaging 

of myocardial perfusion. Complete 

diagnostic work-up of the coronary 

arteries and the myocardium was 

achieved with a total dose length product 

of only 294 mGy cm (227 mGy cm CTA + 

67 mGy cm late enhancement). 



Scan mode Dual Energy 

Scan area Heart 




Tube voltage A/B 100 kV/140 kV+Sn filter 

Tube current A/B 165 mAs/140 mAs 

CTDIvol 

13.29 mGy 


Pitch 0.17 


Slice width 


0.75 mm 

increment 


0.4 mm 

kernel D26f 

Volume 70 ml contrast media 

Flow rate 5 ml/s 

Start delay Test bolus 

Post processing syngo Dual Energy 


Clinical Results Oncology 

Case 8 

3D Guided RF Ablation and 

CT Perfusion – a New Combination for 

Monitoring of Treatment Response 

By Hatem Alkadhi, MD* , ** and Jan Freund*** 

* Institute of Diagnostic Radiology, University Hospital Zurich, Zurich, Switzerland; 

** Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA 

*** 


Today, there is a significant trend for 

more routine biopsies, as well as an increasing 

volume of more complex interventional 

procedures such as radio frequency 

(RF) ablations and minimally 

invasive surgical procedures. In addition, 

the need for large perfusion ranges is increasing 

with the demand for complete 

and comprehensive assessments of the 

whole disease in the entire organ. The 

current challenge in CT interventions is 

to overcome the limitations of conventional 

2D CT guidance where, especially 

in difficult cases, the safe navigation 

of the needle is a challenge. 

A more accurate overview of the needle 

position and surrounding organs has 

often been lacking during difficult pro- 

1 

1 Contrast-enhanced abdominal CT shows 

an exophytic mass in the left kidney (arrow). 

cedures, especially when using oblique 

needle positions in both fluoroscopic 

and non-fluoroscopic procedures. 

Strongly motivated by the increased volume 

of these interventions, radiologists 

have been looking for a solution that 

adds precision while reducing procedure 

time, freeing up the CT suite for more 

patients and procedures and, in addition, 

bringing new revenue opportunities. 

At University Hospital Zurich, radiologists 

are working on an impressive and promising 

solution utilizing Siemens’ realtime 

3D image guidance for minimally 

invasive procedures and CT Perfusion 

in combination with the innovative 

Adaptive 4D Spiral technology. The following 

case demonstrates a 3D guided 

2 The image shows the RFA procedure of 

the left kidney tumor. 


2 

RF ablation of a renal cell carcinoma 

with a combined monitoring of treatment 

response by Adaptive 4D Spiral 

volume perfusion CT. 

PATIENT HISTORY 

An 80-year-old female patient presented 

to the emergency department with macrohematuria. 

A CT of the abdomen 

revealed a mass in the left kidney that 

was suspicious of a renal cell carcinoma 

(Fig. 1). Because severe co-morbidities 

prevented open surgery, the patient was 

scheduled to undergo radio frequency 

ablation (RFA). Considering the large size 

of the tumor, embolization of the mass 

was performed prior to RFA (Fig. 3). 

3 

3 Selective catheter angiography of the left 

renal artery demonstrating the hyper-vascularized 

tumor of the lower pole (left). Angiography 

after embolization shows subtotal 

devascularization of the tumor (right).

4 

4 Blood volume map shows a largely devascularized tumor after 

embolization treatment, however, also a strongly perfused area 

in the medial, lower part of the tumor (red, yellow). 

DIAGNOSIS 

Due to the large size of the tumor, conventional 

CT Perfusion studies are normally 

unable to capture the entire tumor 

and therefore deliver only partial perfusion 

information. To circumvent this 

limitation, the patient was sent for a 

volume perfusion scan to the SOMATOM 

Definition AS offering the Adaptive 4D 

Spiral scan modes. This allows CT Perfusion 

coverage of up to 7 cm. The Adaptive 

4D Spiral scan was performed one 

day after embolization. It showed the 

tumor to be largely devascularized. 

However, a small proportion in the medial 

lower part of the tumor still showed 

blood flow (Fig. 4). 

Two days later, a CT-guided RFA was performed 

using the Adaptive 3D Intervention 

Suite with its needle path planning 

and on-line tracking mode. Particularly 

the perfused tumor part as demonstrated 

by perfusion CT was targeted (Fig. 2). 

In order to safely reach the dedicated 

areas, a 3D visualization of axial, coronal 

and sagittal slices during the intervention 

was used. In combination with a 2-click 

path planning, a fast and precise needle 

navigation was ensured. Radiation exposure 

could be kept very low by applying 

an interventional sequence scan mode 

for needle navigation. 

A CT Perfusion study performed the 

day after RFA shows complete devascularization 

of the tumor (Fig. 5) indicating 

a successful treatment of the patient. 

With the ability to perform perfusion 

studies over the entire region of interest, 

it is now possible to assess the extent of 

the disease and visualize the function of 

potential metastases. The combination 

of CT Perfusion studies and CT guided 

RFAs allows the reading physician to 

more precisely assess the treatment 

success after RFA in a timely manner. This 

makes it possible to monitor devascularization 

of the kidney tumors only one 

day after RFA. 

COMMENTS 

5 

The increased precision of the 3D visualization 

especially helps to more precisely 

position RF needles to ensure the correct 

placement in the perfused tumor area. 

Oncology Clinical Results 

5 Blood volume map shows complete devascularization of the kidney 

tumor (purple, blue) after RF treatment. 

It gives a more accurate overview of the 

needle position and surrounding organs 

during difficult procedures, such as 

oblique needle positions of RFAs. This 

ensures a higher success rate of RF treatments. 

In addition, the automated needle 

guidance and tracking tool significantly 

helps to speed up the insertion and 

needle placement with a reduced patient 

exposure. 

The 3D minimal invasive suite in particular 

now offers the freedom to direct 

the entire procedure with just the touch 

of a button – without ever leaving the 

patient’s side. No ongoing, extensive 

communication with the technician for 

additional distance measurements, 

windowing and image adjustments is 

necessary. Since the user is now able 

to easily switch between fluoroscopic, 

sequential and spiral examinations 

without time-consuming scan protocol 

manipulation, the physician saves 

additional time reducing the overall 

interventional procedure time. This 

frees up the valuable CT suite more 

quickly for waiting patients and procedures. 


Clinical Results Oncology 

Case 9 


Routine Re-staging of Oesophageal 

Carcinoma Utilizing IRIS Technology 

By Michael Lell, MD*and Andreas Blaha** 

*Department of Radiology and the Imaging Science Institute (ISI), University of Erlangen-Nuremberg, Erlangen, Germany 

**Business Unit CT, Siemens Healthcare, Forchheim, Germany 

HISTORY 

The 55-year-old male patient presented 

with a history of oesophageal cancer. 

He previously underwent combined radiochemotherapy. 

CT was requested for 

re-staging to discuss further therapy 

options for the patient. 

DIAGNOSIS 

A contrast enhanced CT revealed bilateral 

well-perfused lung, also the port catheter 

was well positioned in the vena cava 

superior. Following treatment, there was 

still prominent thickening of the wall 

of the distal oesophagus und enlarged 



lymph nodes in the mediastinum. In 

addition, a small pericardial effusion, 

most probably a side effect of radiotherapy, 

was visualized. There was no 

evidence of liver or lung metastases and 

there were no enlarged lymph nodes at 

the level of the celiac trunk. An isolated 

solitary cyst (Bosniak I) was located in 

the upper left kidney. 

COMMENTS 

Several measures to reduce dose were 

employed with this patient. Online tube 

current modulation (CARE Dose4D) and 

Scan mode Thorax DLP 260 mGy cm 

Scan area Thorax-Abdomen Effective Dose 3.9 mSv 

Scan length 656 mm Rotation time 0.33 s 


Scan time 21 ms Slice width 0.75 mm 

Tube voltage 120 kV Reconstruction increment 0.4 mm 

Tube current Ref.mAs 100 eff. mAs Reconstruction kernel I41 

Dose modulation CARE Dose4D Postprocessing syngo CT 3D 


iterative reconstruction in image space 

technology (IRIS) were utilized, which 

lead to a significant reduction in dose 

and noise as compared to conventional 

CT, improving image quality. This examination 

reliably demonstrated the 

possibility of acquiring excellent image 

quality at reduced dose levels (3.9 mSv / 

DLP: 260 mGy cm).

1 

3 

1 VRT and fused MPR show the extension of oesophageal 

wall thickening. 

3 Axial slice highlights wall thickening of the oesophagus 

(arrowhead), and pericardial effusion (arrows). 

2 

4 

Oncology Clinical Results 

2 Coronal cut demonstrates the solitary cyst (left kidney, arrow), and 

distal oesophageal wall thickening (arrowhead, IRIS reconstruction). 

4 Low and homogenous noise in the entire dataset using IRIS 

(coronal slice) reveals oesophageal thickening (arrows). 


Clinical Results Neurology 

Case 10 

SOMATOM Defi nition AS+: 

CT Perfusion With Extended Coverage 

for Acute Ischemic Stroke 

By Ke Lin, MD 

Department of Radiology, New York University Langone Medical Center, New York, USA 

HISTORY 

A 53-year-old male with history of hypertension 

presented with sudden onset 

of expressive aphasia and weakness. 

The patient had experienced two similar 

but transient episodes in the previous 

1 

12 months. He arrived to the emergency 

department of NYU Langone Medical 

Center within 1 hour of symptom onset 

and was immediately evaluated for 

acute ischemic stroke by non-contrast 


head CT (NCCT), dynamic CT Perfusion 

(CTP) of the brain, and CT Angiography 

(CTA) of the cervical and intracranial 

arterial vasculature. 

1 Dynamic CT 

Perfusion (CTP) 

cerebral blood flow 

(CBF) map shows 

markedly decreased 

CBF to the left 

frontal operculum. 

CTP cerebral blood 

volume (CBV) map 

shows matched 

decreased CBV 

in this region 

indicating irreversible 

infarct core. 

A penumbra-core 

map generated by 

using thresholds of 

CBV ≤ 1.2 ml / 100 ml 

for core (red) 

and CBF ≤ 35 ml / 

100 ml / min 

and CBV >1.2 ml / 

100 ml for penumbra 

(yellow) shows 

little salvageable 

tissue at this level.

2 

DIAGNOSIS 

While NCCT showed only subtle blurring 

of the normal gray/white matter interface 

at the left frontal operculum, CTP 

with extended coverage revealed the full 

extent of the acute ischemia in the anterior 

left middle cerebral artery (MCA) 

territory. There was severe compromise 

of cerebral blood flow (CBF) to the mid 

and inferior left frontal lobe. At the level 

of the operculum (Broca’s area), there 

was a matched defect in low CBF and 

low cerebral blood volume (CBV) indicative 

of irreversible infarct core (Fig. 1). 

However, there was appreciable CBF/CBV 

mismatch on the other acquired slices, 


Scanner SOMATOM Definition AS+ 

indicative of salvageable tissue at risk 

(Fig. 2). CTA showed embolic occlusion 

of the frontal opercular division of the 

left MCA secondary to plaque rupture 

at the left carotid bulb. The patient was 

then rapidly treated with intravenous 

thrombolytic therapy with mild improvement 

of symptoms. 

COMMENTS 

The SOMATOM Definition AS+ scanner 

with 128-slice configuration and Adaptive 

4D Spiral technology allows larger CTP 

coverage with a single bolus of contrast. 

2 The penumbra-core 

maps from selected slices 

above and below the 

level shown in Fig. 1: 

the extents of both the 

salvageable ischemic 

penumbra (yellow) and 

the irreversible infarct 

core (red) are fully depicted. 

Neurology Clinical Results 

In this case, the setting with 96 mm of 

z-direction coverage (and 1.5 seconds 

temporal resolution) covered nearly the 

entire supratentorial brain. syngo VPCT 

Neuro extracts first-pass data from the 

45 seconds dynamic acquisition enabling 

a rapid exam. The extents of both 

the salvageable ischemic penumbra and 

the irreversible infarct core were fully 

depicted. Rescue of ischemic penumbra 

is the main rationale for aggressive 

stroke intervention, and its identification 

through perfusion imaging may form the 

basis of patient selection for therapy in 

the near future. 

Scan mode Adaptive 4D Spiral Rotation time 0.3 s 

Scan area Head Slice collimation 64 x 0.6 mm 

Scan length 96 mm Slice width 10 mm 

Scan direction Caudo-cranial and cranio-caudal Reconstruction increment 5 mm 

Scan time 45 s Reconstruction kernel H20f 

Tube voltage 80 kV Contrast Volume 50 ml iodine 

Tube current 200 eff. mAs Flow rate 5 ml/s 

Dose modulation CARE Dose4D off Start delay 4 s 

CTDIvol 218.8 mGy Postprocessing syngo VPCT Neuro 



Case 11 

Vasospasm After Subarachnoid 

Hemorrhage: 

Volume Perfusion CT Neuro 

By Bruno A. Policeni, MD 

Radiology Faculty, Neuroradiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA 

1 

HISTORY 

L R 

1 3D CT Angiography shows a right mid cerebral artery (MCA) bi-lobed aneurysm 

(arrow). No other aneurysms were found. 

A 36-year-old female with a history of 

migraine developed a sudden onset of 

the worst headache of her life, lost control 

of the entire right side of her body 

and fell to the floor. However she had 

no trauma to her head and did not lose 

consciousness. She was admitted to the 

emergency department where a head CT 

(Fig. 2) showed right sylvian fissure and 

inter-hemispheric fissure hyperdensity 

consistent with subarachnoid hemor- 

rhage. The temporal horns were mildly 

dilated due to early obstructing hydrocephalus 

and a small amount of intraventricular 

blood was present in the left 

occipital horn. A CT Angiography was 

performed and showed a 7 mm x 4 mm 

bi-lobed berry aneurysm with a narrow 

neck arising from the M1 segment of the 

right mid cerebral artery (MCA, Fig.1). 

The patient was transferred to the 

angiography suite for conventional 


angiography, confirming the right MCA 

aneurysm (Fig. 3). She underwent immediate 

aneurysm coil embolization. On 

day four after the intervention, her neurologic 

exam attested deterioration and 

she showed a left facial palsy, indicating 

suspected vasospasm. The patient was 

referred to the radiology department for 

comprehensive stroke imaging, including 

CT Angiography and Volume Perfusion 

CT (VPCT) of the brain to rule out 

vasospasm. 

DIAGNOSIS 

Using the Adaptive 4D Spiral technology 

a 9.6 cm volume perfusion scan covering 

the entire brain was performed and 

the resulting perfusion parameter maps 

were qualitatively and quantitatively 

evaluated in 3D. They demonstrated an 

impaired brain perfusion in the right 

MCA and ACA vascular territory distribution 

with prolonged Mean Transit Time 

(MTT), reduced Cerebral Blood Flow 

(CBF) in the same area and slightly 

increased Cerebral Blood Volume (CBV, 

Fig. 4). CT Angiography images were obtained 

from the dynamic VPCT data and 

showed areas of narrowing in the right 

MCA and anterior cerebral artery (ACA, 

Fig. 6). The following angiography confirmed 

the vasospasm findings consis-

2 3 

4 


2 Head CT without contrast 

demonstrates right sylvian 

fissure and interhemispheric 

fissure hyperdensity consistent 

with subarachnoid hemorrhage 

(arrows). The temporal 

horns are mildly dilated 

due to early obstructing 

hydrocephalus (arrowhead). 

3 Conventional angiography 

demonstrates the right MCA 

aneurysm in the right internal 

carotid artery injection (arrow). 

4 VPCT axial multi-parameter view showing a Maximum Intensity Projection (MIP), Cerebral Blood Flow (CBF), Cerebral Blood Volume (CBV), Time To Peak, 

Time To Drain (TTD) and Mean Transit Time (MTT), MTT and TTD (time to drain, a Siemens origin parameter) being the most useful parameters in this case. 



5 

5 3D view of the Time To Drain (TTD) parameter map of the entire brain. Time to drain is a Siemens unique deconvolution based parameter describing 

the time of the earliest washout of contrast medium in seconds. It is a very sensitve parameter to detect perfusion asymetries like MTT. 

tent with segmental narrowing in the 

right MCA/ACA and delayed capillary 

transit time (Fig. 7A). The patient was 

immediately treated with 8 mg intraarterial 

nicardipine for a period of 10 

minutes and balloon angioplasty was 

performed in the right MCA. Immediate 

follow-up confirmed a successful treatment 

(Fig. 7B) and there was also an improvement 

in the neurologic exam, 

specifically in the left facial palsy. The 

patient was discharged on day 17, neurologically 

stable with resolution of the 

facial droop, well-controlled pain and 

ambulating without assistance. She was 

scheduled for a follow-up exam in the 

clinic 6 weeks later. 

COMMENTS 

syngo VPCT Neuro offers dynamic perfusion 

analysis of the entire brain. That, 

as in this case, enables the detection of 

vasospasms – even those located in 

upper brain regions or in the posterior 

fossa, not covered by traditional Perfu- 


sion CT through the base of skull. Thus 

syngo VPCT Neuro in combination with 

the Adaptive 4D Spiral technology is enhancing 

the diagnostic application. The 

ability to obtain a CT Angiography with 

the same data acquisition is crucial for 

the correlation to the vascular territory 

showing prolonged MTT. Temporal parameter 

maps like MTT in 2D and 3D 

delivered by syngo VPCT Neuro may act 

as a sensible tool to detect perfusion 

asymmetries in the two hemispheres as 

an indicator for vasospasm.

6 

7A 7B 

6 Coronal CTA MIP reconstruction from 

the dynamic series demonstrates areas 

of severe vasospasm (arrows) in the right 

ICA and MCA compared to the normal left 

MCA (arrowhead). 


7 Conventional angiography confirmed severe vasospasm (arrows): segmental narrowing in the right MCA/ACA and a delayed capillary transit 

time (Fig. 7A). Follow up demonstrates resolution of the vasospasm after nicardipine injection and balloon angioplasty (Fig. 7B, arrows). 


Scanner SOMATOM Definition AS+ 

Scan mode Adaptive 4D Spiral (spiral shuttle mode) Rotation time 0.3 s 

Scan area Head Slice collimation 128 x 0.6 mm 

Scan length 96 mm Slice width 5 mm for perfusion, 1 mm for CTA 

Scan direction Cranio-caudal and caudo-cranial Reconstruction kernel H20f 

Scan time 45 s; 30 scans total Volume 40 cc Isovue-370 and 50 cc normal saline 

Tube voltage 80 kV Flow rate 8 ml/s 

Tube current 200 mAs Start delay No delay 

CTDIvol 218 mGy Post processing syngo Volume Perfusion CT Neuro 


Clinical Results Acute Care 

Case 12 

Dual Energy Scanning: 

Diagnosis of Ruptured Cocaine Capsule 

By Ralf W. Bauer, MD, J. Matthias Kerl, MD, Thomas J. Vogl, MD, Philipp Weisser, MD 

Department of Diagnostic and Interventional Radiology, Clinic of the Goethe University, Frankfurt, Germany 

HISTORY 

A 32-year-old male passenger on a flight 

from South America landed at Rhein- 

Main International Airport in Frankfurt. 

He showed a conspicuous and slightly 

delirious behavior. The customs and 

border police were alert and questioned 

him whether he was carrying or had 

consumed drugs. At first, he denied, but 

as his medical condition dramatically 

worsened, he admitted that he had 

swallowed 24 self-packed capsules with 

columbian cocaine. The patient developed 

heavy attacks of abdominal cramps 

and became more and more apathetic. 

He was transferred to the hospital to localize 

the capsules, to confirm the number, 

and to check, if one of the capsules 

had opened and cocaine had come into 

the bowel lumen – or if the capsules 

had caused an ileus. 


DIAGNOSIS 


A contrast-enhanced, Dual Energy CT 

(DECT) scan of the abdomen was performed. 

24 capsules with an average 

size of 2.5 x 3.5 cm and hyperdense 

content were found, confirming the 

patient’s story. Average CT values of the 

hyperdense content were 203 HU at 

80 kV and 140 HU at 140 kV. The capsules 

were spread all through the small 

bowel and colon. However, there was 

one capsule in the rectum, that was significantly 

larger than the others and its 

content showed lower attenuation values 

of 139 HU at 80 kV and 77 HU at 

140 kV. DECT further revealed a thin hyperdense 

layer-like structure that peeled 

off from that capsule, therefore the suspicion 

arose that the capsule actually 

had ruptured. Rectoscopy was performed 

immediately and the torn cap- 


sule was secured. The patient recovered 

on the intensive care unit without further 

major medical treatment and could 

be relieved from the rest of his freight 

with the use of laxatives. 

COMMENTS 

With the use of DECT, a reliable diagnosis 

of the ruptured cocaine capsule could 

be performed and immediate medical 

help provided. To our knowledge this 

is the first report on the Dual Energy 

behaviour of columbian cocaine. This 

might be of future relevance for in vivo 

differentiation of cocaine or heroin of 

different origin in uncommunicative 

body packers. However, further research 

in this field is needed to confirm our 

results. 

Scan mode Dual Energy Rotation time 0.5 s 

Scan area Abdomen Pitch 0.55 

Scan length 464 mm Slice collimation 14 x 1.2 mm 

Scan direction Cranio-caudal Slice width 1.5 mm 

Scan time 24 s Reconstruction increment 1.0 mm 

Tube voltage A/B 140 kV / 80 kV Reconstruction kernel D30f 

Tube current A/B 49 eff. mAs / 212 eff. mAs Contrast Volume 90 ml 


CTDIvol 9.14 mGy Postprocessing syngo Dual Energy

1 

3 

5 

1 Cocaine capsules distributed throughout the whole intestine. 

3 Color-coding of cocaine capsules facilitates detection and 

counting. 

5 ROI measurements demonstrate typical Dual Energy values of 

columbian cocaine. 

2 

4 

6 

2 Virtual colonoscopy view. 

Neuroradiology Clinical Results 

4 Ruptured cocaine capsule. Arrows point at the loose outer layer. 

6 The coronal reformate shows large amounts of fluid in the 

colon lumen. However, no ileus was present. 



Case 13 

Progressive Kidney Hematoma 

Post-interventional Biopsy 

By Sebastian Leschka, MD * and Andreas Blaha ** 

*Institute of Diagnostic Radiology, University Hospital Zurich, Zurich, Switzerland 


HISTORY 

To determine further therapy, the 21year-old 

patient, status after hepatitis B, 

was referred to the radiology department. 

Here a biopsy of the renal parenchyma 

was performed upon which a 

haemorrhage occurred, accompanied by 

the formation of a hematoma. A 3-phase 

kidney CT was performed. Due to the 

nephritic syndrome only 60 ml of contrast 

media with a flow rate of 4 ml/s 

followed by a 60 ml NaCl bolus (4 ml/s) 

was injected for the kidney CTA. 

1 

DIAGNOSIS 

In the native phase, an accumulation of 

liquid at the lower left renal pole was 

seen. The arterial phase showed an 

extravasation of contrast media out of 

the left kidney. An inhomogeneous 

hematoma measuring 15 x 7.5 x 5 cm 

was detected around the left kidney. 

Both kidneys were perfused symmetrically, 

unique renal arteries were seen 

bilaterally. In the venous phase a normal 

renal calyx developed on both sides. 

COMMENTS 

Despite the low quantity of applied contrast 

media, a contrast media enhancement 

in the left kidney could be identified 

due to a quick acquisition time of 

0.7 seconds. The SOMATOM Definition 

Flash allowed a precise and rapid 

diagnosis with a reduced given patient 

radiation dose of 3.3 mSv. 

1 Fused VRT/MPR 

highlight kidney 

hematoma.


2A 


Acute Care Clinical Results 

Scan mode 3-phase kidney Rotation time 0.28 s 

Scan area Abdomen Pitch 2.1 

Scan length 218 mm Slice collimation 128 x 0.6 mm 

Scan direction Cranio-caudal Slice width 2 mm 

Scan time 0.7 s Reconstruction increment 1 mm 

Tube voltage 120 kV / 120 kV Reconstruction kernel B30f 

Tube current 100 eff. mAs Contrast Volume 60 ml Iodine 


CTDIvol 7.71 mGy Postprocessing syngo CT 3D 

syngo InSpace 

2 Axial non-enhancement multiplanar reformation (MPR, Fig. 2A); axial early enhancement MPR shows haemorrhages in the 

kidney hematoma (arrow, Fig. 2B). Axial late state MPR shows persistent bleeding (arrow, Fig. 2C). 

3A 

2B 

3B 

3 Sagittal non-enhancement MPR (Fig. 3A); sagittal early enhancement MPR shows hemorrhages in the kidney hematoma 

(arrow, Fig. 3B); sagittal late state MPR shows persistent bleeding (arrow, Fig. 3C). 

2C 

3C 



Case 14 

SOMATOM Defi nition Dual Source 

High Pitch vs. Routine Pitch Scanning in 

a Pediatric Lung Low Dose Examination 

By Harald Seifarth, MD,* Walter Heindel, MD,* Andreas Blaha ** 

*Department of Clinical Radiology, University Hospital, Münster, Germany 


HISTORY 

A 5-year-old male patient with a history 

of neutropenia after stem-cell transplantation 

was referred to the radiology 

department. The patient presented with 

persistent fever despite ongoing treatment 

with antibiotics. A CT examination 

was scheduled to exclude the presence of 

pulmonary mycosis. The CT examination 

was performed with a high pitch protocol 

(pitch = 3.0), resulting in a scan time 

of only 0.9 seconds. 

DIAGNOSIS 

The present CT examination showed no 

signs of any fungal pulmonary infection 

or other inflammatory changes. Minor 

bilateral, subpleural dystelectases could 

be observed. 

In the previous examination (pitch 1.4, 

scan time 4.5 seconds, scan length 

189 mm, 50 ref mAs), artifacts due to 

respiratory motion during the acquisition 

hampered the evaluability of the 

exam. The study showed small pulmonary 

infiltrates. 


1 2 

1 High pitch scan – axial slice of high pitch 

acquisition, no motion artifacts (arrow) 

due to breathing. 

3 

3 High pitch scan – entire lung in low 

dose technique (10 eff. mAs), no motion 

artifacts are visible. 

2 Regular scan – axial slice 

of high resolution regular scan. 

4 

4 Regulars scan – artifacts due 

to respiratory motion (arrows).

Acute Care Clinical Results 

5 6 COMMENTS 

Because of motion, the previous CT 

scan made diagnosis more difficult 

(Figs. 2, 4, 6). The fast acquisition 

speed made it possible to reliably 

rule out the presence of pulmonary 

infiltrations and mycosis. Although 

only 10 mAs were utilized, a high 

diagnostic image quality was preserved. 

Using the new high pitch 

scanning technique a significant reduction 

of radiation dose is feasible. 

7 

5 High pitch scan – sharp delineation 

of pulmonary segments. 

6 Regular scan – sagittal image shows 

motion artifact of the diaphragm due to 

breathing during the acquisition. 

7 Volume rendered image of the thorax, showing regular bronchial tree. 

*Effective Dose was calculated using the published conversion factor for an 5-year-old pediatric chest of 0.082 mSv (mGy cm) -1 [1]. 

To take into account that Siemens calculates the CTDI in a 32 cm CTDI phantom an additional correction factor of 2 had to be applied. 

[1] McCollough CH et al. Strategies for Reducing Radiation Dose in CT, Radiol. Clin. N. Am. 47: (2009) 27-40. 


Scanner SOMATOM 

Definition 

Scan mode Thorax HiPitch 

Scan area Thorax 



Scan time < 1s 

Tube voltage A/B 120 kV / 120 kV 

Tube current A/B 10 eff. mAs 

Dose modulation CARE Dose4D 

CTDIvol 

0.56 mGy 

DLP 9 mGy cm 

Effective Dose 0.37 mSv* 


Pitch 3.0 


Slice width 


1.0 mm 

increment 


0.5 mm 

kernel B60f 

Postprocessing syngo CT 3D 

syngo InSpace 


Science 

CT in Pediatrics: Easier 

and Safer With the Flash 

The SOMATOM Defi nition Flash allows even squirming infants and small 

children to be scanned with maximum image quality at lightning speed, 

without movement artifacts, anesthesia, or ventilation. This makes 

computed tomography increasingly interesting for pediatric diagnostics, 

solely in the event of clear indications. 

By Hildegard Kaulen, PhD 

Being able to “freeze” movements in 

order to scan small children without sedation 

is every radiologist’s dream. Anesthesia 

transforms what would be a comparatively 

fast scan into a time-consuming, 

possibly risky affair. Therefore, Michael 

Lell, MD, Assistant Professor at the University 

Hospital in Erlangen, is extremely 

satisfied with the various pediatric 

options offered by the new SOMATOM 

Definition Flash. As small patients are 

moved through the tube at a speed of 

almost half a meter per second, they no 

longer have to hold their breath or lie 

still for protracted periods. Sedation is 

no longer necessary either, and, as a 

result, the entire imaging process is reduced 

to a few minutes. Lell has been 

working with the Flash for 16 months. 

During this period, he has successfully 

scanned 50 infants and toddlers, and 

the same number of children and adolescents, 

without sedation or anesthesia. 

His experience with the Flash in 

the field of pediatric diagnostics is outstanding. 

Says Lell: “The image quality 

1A 1B 

1 Thorax CT scan for lung investigation of a 15-month-old child with cystic fibrosis with a 10-slice CT (Fig. 1A) 

and for follow-up 12 months later with the SOMATOM Definition Flash (Fig. 1B) showing artifact-free lung tissue. 


attained without sedation impresses us 

time and again. This is particularly striking 

during a direct comparison between 

the Flash and another CT. We examined 

a 15-month-old child with Down’s syndrome 

and cystic fibrosis using a 10-row 

CT. The images contained movement 

artifacts despite sedation. We examined 

the child once more at 27 months, this 

time using the Flash. The results? Razorsharp 

images without sedation (Fig.1). 

One child even attempted to sit up during 

the scan. Everyone was convinced

that the images would be blurred, but 

this wasn’t the case.” 

Young patients are usually examined 

using ultrasound or MRI devices. Children 

undergoing an MRI must be sedated. 

Lell comments: “Anesthesia and ventilation 

necessitate considerable time and 

effort. We are dependent on assistance 

from other specialist disciplines. The anesthetic 

must be induced, controlled and 

reversed by an anesthetist, and the children 

have to be monitored for several 

hours afterward. Whereas scanning time 

is relatively short, outpatient care is necessary 

for hours.” Medical treatment, 

care and logistics result in substantial 

costs, and the associated risks can also 

be considerable. Anesthesia is an invasive 

procedure. Complications may arise 

at any time. Says Lell: “Ventilation also 

leads to anesthesia-related pulmonary 

atelectasis, a condition which causes 

parts of the lungs to collapse, impeding 

gas exchange. It is difficult to assess these 

areas accurately during imaging. This issue 

becomes irrelevant if anesthesia and 

Indications for 

Pediatric CT Scans: 

�� Polytrauma 

�� Congenital heart disease 

�� Serious lung diseases such 

as cystic fibrosis or atypical 

pneumonias 

� Tumor staging 

Benefits of Flash CT 

in Pediatrics: 

� Images free of movement artifacts, 

even in the case of 

squirming children 

� No sedation or deep general 

anesthesia 

� Imaging possible without assistance 

from other disciplines 

such as anesthesia or nursing 

� No outpatient care or aftercare 

� No complications as a result 

of anesthesia 

ventilation are not used. If it’s a choice 

between performing CT with anesthesia 

or not, then the answer in the case of 

the Flash is a definite no.” 

Setting New Standards 

The SOMATOM Definition Flash is able 

to freeze movements due to its unique 

speed. Scanning speeds of up to 45.8 cm 

per second with a temporal resolution 

of 75 ms ensure that complete chest 

scans of young patients can be recorded 

in 0.4 to 0.5 seconds. No other device 

is as fast. The Flash also sets new standards 

when it comes to radiation exposure. 

The Adaptive Dose Shield reduces 

radiation exposure in every single spiral 

scan. But the most impressive dose reduction 

is possible in the field of cardiology 

where ultrafast Flash Spiral cuts 

down radiation compared to conventional 

ECG-gated examinations by up to 90 %. 

Lell believes that the Flash will make CT 

scans an increasingly attractive option 

for younger patients. The radiologist 

considers indications to be the decisive 

factor. In pediatrics, a CT would only be 

considered in the event of medical indications 

with few or no alternatives, such 

as polytrauma or tumor staging. In the 

case of multiple injuries, it is more important 

to clarify the extent of the trauma 

suffered than to contemplate a statistical 

increase in cancer risk in the distant 

future. Says Lell: “Some indications necessitate 

a CT examination, even if we are 

aware of the effective dose. We don’t 

know exactly how this dose may affect 

the cancer risk in any case as no longterm 

data is available based on medical 

imaging exposure levels.” Lell already 

insists on reduced dose protocols. He 

and his team have developed protocols 

like these for all pediatric indications. In 

Erlangen, children are always scanned 

with a tube voltage of 80 or 100 kV. 

Special anatomy adapted cushions are 

used to fix the small patients during the 

examination. Contrast agents are used 

very sparingly. Lell also ensures that the 

examination area is kept to a minimum, 

and strives to achieve the attention to 

detail necessary for diagnosis. 

Science 

Assistant Professor Michael Lell, 

MD, completed his medical studies 

at the universities of Regensburg and 

Munich with subsequent qualification 

as a consultant in radiology and 

habilitation. Employed by the University 

Hospital in Erlangen since 1999. 

Promoted to Chief Physician in 2009. 

One-year residency at the David 

Steffen School of Medicine at UCLA. 

Member of national and international 

professional associations; reviewer 

for various journals. 

Hildegard Kaulen, PhD, is a molecular biologist. 

After stints at the Rockefeller University in 

New York and the Harvard Medical School in 

Boston, she moved to the field of freelance 

science journalism in the mid-1990s and contributes 

to numerous reputable daily newspapers 

and scientific journals. 


Science 

Through the use of a SOMATOM Emotion 6 from Siemens Healthcare, an international research team discovered 

atherosclerosis in 3500 year old Egyptian mummies. 

Study Finds Atherosclerosis in 

3,500 Year old Egyptian Mummies 

By Steven Bell, Business Unit CT, Siemens Healthcare, Forchheim, Germany 

A team of cardiologists led by Drs. 

Gregory S. Thomas of the University of 

California, Irvine and Adel H. Allam of 

Al Azhar University, Cairo, found that 

atherosclerosis is not only a disease 

of modern man, but was present in 

humans as far back as 1,530 BC. 

The team of cardiologists working 

closely with a team of Egyptologists 

undertook the most comprehensive CT 

study of vascular disease in Egyptian 

mummies to date by scanning 22 mummies 

over a four-day period in the Cairo 

Museum of Antiquities. The study was 

co-sponsored by Siemens Healthcare and 

aimed to investigate whether atherosclerosis, 

the precursor of heart disease, is an 

affliction of modern man or whether this 

disease existed thousands of years ago. 

The imaging for this project was undertaken 

on a SOMATOM Emotion 6-slice 

configuration that was donated to the 

Museum as part of an earlier study in 

conjunction with National Geographic 

to image the famous mummified remains 

of King Tutankhamun. 

The researchers were able to locate and 

identify vascular tissue in 16 out of the 

22 mummies imaged in this study. Of 

these 16, 9 had visible signs of arterial 

calcification, considered to be pathognomonic 

of atherosclerosis, from which the 

researchers were able to conclude that 

atherosclerosis is not a disease exclusive 

to modern humans. Findings of calcification 

were made in men and women who 

lived between 1570 BC and 364 AD. The 

social status of most patients included in 


the study was shown to be of an elevated 

nature, which may have contributed 

to the process of disease due to lifestyle 

issues. The main aim of this project was 

to identify the presence or absence of 

atherosclerosis in an ancient patient 

population, however, the study also 

offered prominent Egyptologists the 

opportunity to view the mummified 

remains of these patients in a way that 

was not damaging to these ancient 

artifacts, the protection of which is 

central to the thinking of all members 

of this research study. 

The results of this project were published 

in the November 18, 2009 edition 

of the JAMA and also presented at the 

November AHA Meeting in Orlando, 

Florida, USA.

Independent Validation of 

Perfusion Evaluation Software 

By Katharina Otani, PhD and Toshihide Itoh 

Research Collaboration Development, Siemens Asahi Medical Technologies, Tokyo, Japan 

A study by an independent Japanese 

research group reported that Siemens CT 

Perfusion software syngo VPCT Neuro, 

using the maximum slope model to derive 

cerebral blood flow (CBF), delivered 

among the most accurate results in the 

assessment of stroke infarct size compared 

to other commercial software. 1 

Kohsuke Kudo, MD, PhD, from Iwate 

Medical University and his colleagues 

from five other universities in Japan used 

data of 10 stroke patients acquired with a 

four-detector-row scanner and applied 

different algorithms to generate CT Perfusion 

maps, in particular CBF, cerebral 

blood volume (CBV) and mean transit 

time (MTT) or time to peak (TTP) maps: 

A – singular-value decomposition (SVD, 

CT Perfusion 3, GE Healthcare) 

B – inverse filter IF (Version 2.0, Hitachi 

Medical Systems) 

C – singular-value decomposition (SVD, 

Version 1.201, Philips Healthcare) 

D – maximum slope (MS, VA70A, 

Siemens Healthcare) 

E – box modular transfer function (bMTF, 

Ph 7, Toshiba Medical Systems). 

Kudo compared the perfusion maps with 

the results from free software (Perfusion 

Mismatch Analyzer, PMA) distributed 

by the Acute Stroke Imaging Standardization 

Group (ASIST) Japan that applies 

two well-documented deconvolution 

algorithms: standard singular-value decomposition 

(sSVD) and block-circulant 

singular-value decomposition (bSVD). 

sSVD and bSVD algorithms differ with respect 

to their sensitivity to contrast tracer 

delay effects. bSVD is considered the 

“gold standard” since it is relatively insensitive 

to tracer delay. 

Kudo found that commercial software 

could be classified in two groups: those 

giving similar results to the CBF maps 

obtained with sSVD (A, C, E) and those 

giving similar results to the CBF maps 

obtained with bSVD (B, D). Abnormal 

MTT/TTP areas appeared larger than 

those in bSVD for maps of all commercial 

software (A, C, D, E) except for one vendor’s 

software (B). An editorial in the 

same journal issue commented: 2 “The 

results of the study by Kudo et al. 1 also 

support the use of the maximum slope 

method for CT perfusion post-processing. 

Indeed, a recent MR imaging study 3 of 

“True multi-center 

trials on stroke 

assessment by CT 

Perfusion and optimization 

of patient 

management will 

only be possible 

once every vendor’s 

software delivers 

the same 

perfusion maps.” 

Kohsuke Kudo, MD, PhD, Iwate Medical 

University 

Science 

acute stroke patients reported higher positive 

predictive values for infarction by 

using maximum slope-derived parameters 

(first moment, TTP), versus both delaysensitive 

and delay-insensitive deconvolution-derived 

parameters. These results 

highlight the delay-insensitive nature of 

perfusion maps derived from maximumslope 

algorithms. At present, however, 

there remains insufficient evidence to suggest 

whether maximum-slope methods 

outperform delay-insensitive deconvolution 

algorithms.” Kudo started working on 

standardization of perfusion software 

after he programmed his own software 

and discovered that his results differed not 

only from the results of one commercial 

software but that the results from all software 

packages also differed from each 

other. With Makoto Sasaki, MD, he set up 

ASIST Japan supported by a grant from the 

Japanese governement. ASIST Japan has 

introduced a color look-up table for perfusion 

maps. Kudo emphasizes that “true 

multicenter trials on stroke assessment by 

CT Perfusion and optimization of patient 

management will only be possible once 

every vendor’s software delivers the same 

perfusion maps”. 

In his study, Kudo used earlier perfusion 

software versions such as Siemens “Neuro 

PCT”. In the meantime however, Siemens 

has developed “syngo VPCT Neuro”, a volume 

perfusion software that gives the option 

to also apply a new tracer delay insensitive 

deconvolution algorithm in addition 

to the as well delay insensitive maximum 

slope model used in this study. Kudo is 

currently working on further multi-vendor 

comparison studies. 

1 Kudo K, et al . Radiology. 2010 Jan; 254(1):200-9 

2 Konstas A A, et al. Radiology, 2010; 254(1):22-25 

3 Christensen S, et al. Stroke 2009, 40 : 2055 – 2061 

http://asist.umin.jp/index-e.htm 

SOMATOM Sessions · Mai 2010 · www.siemens.com/healthcare-magazine 65

Science 

Reduced Procedure Time 

and Radiation Dose in Inter- 

ventional CT Workflow 

By Prof. A.H. Mahnken, MD and F. Schoth, MD 

RWTH Aachen University Hospital, Aachen, Germany 

Percutaneous lung biopsy is one of the 

most common CT-guided procedures. 

This technique can be performed using 

sequential CT-scanning or CT-fluoroscopy. 

Because CT-fluoroscopy may result in 

significant radiation exposure to the 

patient as well as the interventionalist, 

repeated sequential CT-scanning is common 

practice due to the minimal radiation 

exposure to the operating physician. 

However, this approach requires several 

breath holds, with the target lesion mov- 

ing during in- and expiration. For many 

patients, it is virtually impossible to repeatedly 

come back to the same breath 

hold position. Therefore, small lesions 

in particular, will often move out of 

plane. This problem is particularly pronounced 

in the basal sections of the 

lung and is a major issue when dealing 

with small lesions of 1 cm or less. 

Combining CT-guided procedures with 

the Interactive Breath-Hold Control 

device (IBC) has been shown to increase 

1A 1B 

45 15 

30 


the radiologists’ accuracy and confidence 

with needle biopsy of the lung. A simple 

light display allows the patients to monitor 

their breathing level and consistently 

return to their reference breath-hold 

position during their biopsies. The IBC 

was developed to assist with CT interventional 

procedures, but may also be 

very useful for PET CT, radiation therapy, 

ultrasound, fusion imaging, and other 

procedures and modalities where respiratory 

motion is an issue. At the depart- 

1 The IBC system brings down the total procedure time. In this example, the time from placing the reference grid to harvesting three samples 

from a small lung nodule was less than 50 seconds. 

60

2 

2 Combining CT-guided procedures with the Interactive Breath-Hold Control device (IBC) has been shown to increase the radiologists’ accuracy 

and confidence with needle biopsy of the lung. 

ment of Diagnostic Radiology, RWTH 

Aachen University Hospital in Germany, 

a study was conducted to evaluate the 

IBC system in CT-guided lung biopsy. 

Schoth and colleagues assessed the effect 

of an IBC system on procedure time and 

technical success in trans-thoracic CTguided 

lung biopsies. In 36 patients with 

a pulmonary nodule, CT-guided biopsy 

was done using a SOMATOM Definition 

scanner, the Adaptive 3D Intervention 

Suite from Siemens and the breath-hold 

device. In a two-arm study with and 

without the device, the biopsy was visually 

successful in all patients. The diameter 

of the target lesion was comparable 

in both groups (IBC: 30 +/– 19 mm; control: 

28 +/– 15 mm). But the number of 

imaging steps was significantly smaller 

(p < 0.05) and the intervention time was 

significantly shorter (p < 0.05) in the IBC 

group (IBC: 9 +/– 5 steps, 17 +/– 10 min; 

control: 13 +/– 5 steps, 26 +/– 12 min). 

Application of the IBC unit reduced the 

intervention time and radiation expo- 

sure in CT-guided biopsy of pulmonary 

nodules while reducing the procedure 

steps. 

In combination with optimized planning 

using the new Adaptive 3D Intervention 

software from Siemens for 3D CT-guided 

interventions, biopsy of smaller nodules 

becomes much easier, resulting in a 

higher technical success rate. With the 

early detection and histological proof of 

lung cancer, treatment is more effective. 

Prognosis significantly improves when 

lung cancer is detected and treated before 

metastases occur. Therefore, a high 

success rate of diagnostic punctures 

during the diagnostic workup greatly 

supports therapy. Moreover, IBC is a relevant 

support to therapeutic procedures 

such as radiofrequency ablation or stereotactic 

radiation therapy of small lung 

tumors. 

Regarding dose reduction, the IBC integrates 

and supplements perfectly into 

the huge expertise that Siemens has 

accumulated to reduce radiation dose in 

* The device will be distributed by Medspira (USA) (www.medspira.com) and Siemens AG. 

Science 

CT-guided examinations with such applications 

as CARE Dose4D and HandCARE, 

protecting patients and physicians from 

radiation exposure during CT interventions. 

Schoth F, Plumhans C, Kraemer N, Mahnken A, 

Friebe M, Günther RW, Krombach G. – Evaluation 

of an Interactive Breath-Hold Control System 

in CT-Guided Lung Biopsy. Rofo. 2010 Feb 8. 

3 

3 Interactive Breath-Hold Control System was 

developed by Mayo Clinic Rochester, USA to assist 

CT-guided interventional procedures.* 


Science 

Scientifi c Validation of the 

SOMATOM Defi nition Flash 

One of the cornerstones of Siemens CT activities has always been the 

scientifi c validation of Siemens’ products and solutions. Independent peerreview 

of publications in scientifi c journals provides an unbiased and 

objective assessment of the capabilities of the systems. 

By Stefan Ulzheimer, PhD, and Peter Seitz 


Since the introduction of the Siemens 

SOMATOM Definition Flash at RSNA 

2008, and its commercial availability in 

July 2009, the CT scanner has been covered 

in 15 presentations at the annual 

meeting of the Radiological Society 

of North America in 2009 and ten peerreviewed 

publications in renowned 

journals. 

These presentations and publications 

prominently feature the notable advantages 

of the SOMATOM Definition Flash 

that enhance efficiency and significantly 

improve patient care. 

Split-second Thorax – Lell et al. from 

the University Hospital of Erlangen demonstrated 

the SOMATOM Definition 

Flash’s capabilities with its high-pitch 

scan mode in thorax examinations. 1 

Twenty-four consecutive patients who 

presented with chest pain received a 

high-pitch thorax scan (Pitch 3.2) to 

exclude coronary artery disease, pulmonary 

embolism and aortic dissection. 

The average dose was 1.6 mSv for patients 

who were scanned with a 100 kV 

protocol and 3.2 mSv for patients who 

were scanned with a 120 kV protocol. 

The authors conclude that the “[…] highpitch 

scan mode allows motion artifact 

free and accurate visualization of the 

thoracic vessels and diagnostic image 

quality of the coronary arteries in patients 

with low and stable heart rates at 

a very low radiation exposure.” 

The dose saving potential of the highpitch 

scan mode of SOMATOM Definition 

Flash was also evaluated by Sommer et 

al. in a study using an anthropomorphic 

phantom and the data of 31 patients. 2 

The average scan time for the complete 

thorax was 0.7 seconds, the average 

dose 4.1 mSv, only one fifth of the dose 

of a conventional gated chest scan. 

Sub-mSv Heart – The robust visualization 

of the coronary arteries with excellent 

image quality at ultra low doses of 

below 1 mSv was the focus of three publications 

by researchers from Zurich, 

Switzerland 3 and Erlangen, Germany. 4,5 

The latest study from Erlangen used the 

Flash Spiral scan mode in 50 consecutive 

patients with body weight up to 100 kg 

and heart rates up to 60 beats per minute 

with an average effective dose of 

0.78 to 0.99 mSv and excellent image 

quality. 5 The average dose was 0.87 

mSv. In a similar study from Zurich, 

Leschka et al. found an average dose of 

0.9 mSv in 35 consecutive patients. 3 In 

both studies 99% of all coronary segments 

could be evaluated 3,5 and the image 

quality was rated excellent in 94 % 

of the segments or as, “at least good,” in 

5 % of the segments. 5 

Assessment of Myocardial Perfusion – 

The SOMATOM Definition Flash offers 

completely new possibilities to assess 

perfusion deficits in the myocardium 


due to its unmatched temporal resolution 

and high volume coverage even at 

high heart rates in stressed patients. 

Bastarrika et al. showed that “[…] this 

technique can demonstrate subendocardial 

infarction not seen on SPECT but 

confirmed by MRI and can detect ischemia 

in good correlation with stressperfusion 

MRI and SPECT.” 6 Fig. 1 shows 

a short axis view of the myocardium 

comparing stress perfusion measured 

with the SOMATOM Definition Flash 

(Fig. 1A) and SPECT (Fig. 1B). 

Single Dose Dual Energy – The latest 

innovation in the area of Dual Energy CT 

(DECT), the Selective Photon Shield, is 

based on an additional tin filter (TF) 

for the high energy spectrum on the 

SOMATOM Definition Flash. The Selective 

Photon Shield allows for the acquisition 

of Dual Energy data without any 

dose penalty compared to standard single 

energy scans and significantly improves 

the separation of the energy spectra. 

A group of scientists from Zurich confirmed 

this for the syngo application, 

“Calculi Characterization,” using it for the 

differentiation of uric acid (UA) and non- 

UA stones and concluded: “DECT with TF 

and 80-140 kV tube voltage settings 

significantly improves the discrimination 

between UA-containing and non-UA 

containing urinary stones as compared 

with DECT without using the TF […].” 7 

Lell et al. from the University of Erlangen

1A 

1 New frontiers in cardiac diagnosis with CT: stress-perfusion images of the heart using the unmatched temporal resolution of the 

SOMATOM Definition Flash compared to SPECT. A stress perfusion scan on the SOMATOM Definition Flash nicely depicts a perfusion 

defect in the myocardium (Fig. 1A). The perfusion defect could be confirmed using SPECT (arrows, Fig. 1B). Courtesy of Joseph Schoepf, 

MD, Medical University of South Carolina, USA. 

evaluated the application of DECT to 

create bone-free data sets to assess the 

supraaortic arteries. 8 Automatic bone 

removal allows for a faster and more reliable 

diagnosis of vessels close to boney 

structures. The authors conclude that 

“[…] excellent bone suppression could 

be achieved” using the improved scan 

modes and evaluation methods on the 

SOMATOM Definition Flash. 

By combining multi-phase protocols to 

one Dual Energy exam, the dose-saving 

potential of DECT was evaluated by 

Sommer et al. in patients after endovascular 

aneurism repair using virtual noncontrast 

images. They achieved a dose 

reduction of 44 % compared to a biphase 

protocol. In 70 examinations, all 

24 endoleaks were detected and correctly 

classified. 9 

More to Come – In addition to the 

above mentioned publications, many 

others are in the pipeline, promising to 

validate the technical advancements of 

the SOMATOM Definition Flash and, 

even more importantly, how this translates 

into clinical and workflow advan- 

tages. For example, a special issue of 

“Investigative Radiology” on “Advances 

in CT technology,” specifically focusing 

on Dual Source, Dual Energy CT and 

multi-slice CT with 128 or more slices, 

is scheduled for this summer. 

1 Lell M, Hinkmann F, Anders K, Deak P, Kalender 

WA, Uder M, Achenbach S. High-pitch electrocardiogram-triggered 

computed tomography of 

the chest: initial results, Invest Radiol. 2009 

Nov;44(11):728-33. 

2 Sommer WH, Schenzle JC, Becker CR, Nikolaou 

K, Graser A, Michalski G, Neumaier K, Reiser MF, 

Johnson TR. Saving Dose in Triple-Rule-Out Computed 

Tomography Examination Using a High- 

Pitch Dual Spiral Technique. Invest Radiol. 2010 

Feb;45(2):64-71. 

3 Leschka S, Stolzmann P, Desbiolles L, Baumueller 

S, Goetti R, Schertler T, Scheffel H, Plass A, Falk V, 

Feuchtner G, Marincek B, Alkadhi H. Diagnostic 

accuracy of high-pitch dual-source CT for the 

assessment of coronary stenoses: first experience. 

Eur Radiol. 2009 Dec;19(12):2896-903. 

4 Lell M, Marwan M, Schepis T, Pflederer T, Anders 

K, Flohr T, Allmendinger T, Kalender W, Ertel D, 

Thierfelder C, Kuettner A, Ropers D, Daniel WG, 

Achenbach S. Prospectively ECG-triggered highpitch 

spiral acquisition for coronary CT Angiography 

using dual source CT: technique and initial 

experience. Eur Radiol. 2009 Nov;19(11):2576-83. 

5 Achenbach S, Marwan M, Ropers D, Schepis T, 

Pflederer T, Anders K, Kuettner A, Daniel WG, 

1B 

Science 

Uder M, Lell MM. Coronary computed tomography 

angiography with a consistent dose below 

1 mSv using prospectively electrocardiogramtriggered 

high-pitch spiral acquisition. Eur Heart 

J. 2010 Feb;31(3):340-6. 

6 Bastarrika G, Ramos-Duran L, Schoepf UJ, Rosenblum 

MA, Abro JA, Brothers RL, Zubieta JL, Chiaramida 

SA, Kang DK Adenosine-stress dynamic 

myocardial volume perfusion imaging with second 

generation dual-source computed tomography: 

Concepts and first experiences. JCCT 2010 

DOI: 10.1016/j.jcct.2010.01.015. 

7 Stolzmann P, Leschka S, Scheffel H, Rentsch K, 

Baumüller S, Desbiolles L, Schmidt B, Marincek 

B, Alkadhi H. Characterization of Urinary Stones 

With Dual-Energy CT: Improved Differentiation 

Using a Tin Filter. Invest Radiol. 2010 Jan; 

45(1):1-6. 

8 Lell M, Hinkmann F, Nkenke E, Schmidt B, 

Seidensticker P, Kalender WA, Uder M, Achenbach 

S. Dual energy CTA of the supraaortic arteries: 

Technical improvements with a novel dual 

source CT system. Eur J Radiol. 2009 Oct 8 

[Epub ahead of print]. 

9 Sommer WH, Graser A, Becker CR, Clevert DA, 

Reiser MF, Nikolaou K, Johnson TR. Image quality 

of virtual noncontrast images derived from dualenergy 

CT Angiography after endovascular 

aneurysm repair. J Vasc Interv Radiol. 2010 Mar; 

21(3):315-21. 

10 Johnson TR, Schenzle JC, Sommer WH, Michalski 

G, Neumaier K, Lechel U, Nikolaou K, Becker H-C, 

Reiser MF. Dual energy CT: How about the dose? 

Invest Radiol. 2010 (in press). 


Life 

Behind the Scenes: 

CT Scan Protocols 

Standard scan protocols are by far more sophisticated than CT users might 

realize. Christiane Koch is the scan protocol designer for Siemens Healthcare, 

Computed Tomography and knows what is important in this fi eld. 

By Heike Theessen 


How would you describe your job 

as a scan protocol designer? 

Koch: My task is to create scan protocols 

for all scanners and all software versions. 

Together with colleagues from 

departments of physics, product definition, 

marketing, development and the 

application specialists, I design and set 

up Siemens default scan protocols. 

In doing so, dose and other guidelines 

of various radiological societies from 

different countries need to be observed. 

Scan protocols have to be comparable 

through different software versions and 

scanner models. For example a protocol 

called “AbdomenRoutine” on a 

SOMATOM Emotion is similar to the 

protocol on a SOMATOM Definition. 

I consolidate the data for the scan protocols 

in a comprehensive data base. 

These files become translated to a database 

called, “ModeLibrary”, and afterwards 

as usable scan protocol to the 

user interface. 

I am in close collaboration with customers 

and application specialists worldwide, 

both during the development 

phase and after systems are installed. 

How do you validate scan protocols 

before a new scanner is released? 

Koch: Functionality and performance are 

tested with phantoms in our laboratory 

during the development phase. For intuitive 

tests, we do invite Radiographers in 

order to simulate a real live scenario. 

This is all done before new scanners are 

delivered to any customer. Then, during 

the so-called “Market Entrance Phase”, 

our collaboration partners begin scanning 

patients and the scan protocols are 

clinically tested. The results are reviewed 

and validated by radiologists and physicists. 

Before the new CT system is finally 

released, scan protocols are adapted 

according to the results of all prior tests. 


Christiane Koch is the scan protocol designer for Siemens CT. 

What is important to know when 

users want to change parameters in 

a default scan protocol? 

Koch: Around 50% of all scan protocol 

parameters run in the background. 

These parameters are, for example, dose 

modulation types and additional reconstruction 

algorithms. It would be ideal if 

our customers would use the default protocols. 

In this manner, following the

Data for the scan protocols are being consolidated in a comprehensive 

data base. 

ALARA principle, the best possible image 

quality at the lowest possible dose can 

be achieved. But, of course, all users need 

to adapt certain parameters to fit their 

individual needs such as breathing 

instructions for the patient or transfer 

rules indicating where images should 

be sent. 

If the operator wants to change any 

parameters within a scan protocol, it is 

important to select the correct base protocol. 

For example an “AbdomenRoutine” 

protocol should not be changed to 

fit a neck examination and vice versa. 

Also, if an institute has scanners from 

different vendors or different scanner 

models, tube current values can not be 

compared when it comes to dose. Only 

the CTDIvol value represents a comparable 

figure. The CTDIvol is a measured 

value of the dose absorbed during a 

CT examination. 

Dedicated children protocols are provided 

on all Siemens CT scanners. What 

is so special about these protocols? 

Koch: Children scan protocols are developed 

in cooperation with pediatric 

radiologists in order to ensure even 

lower dose values as compared to adult 

protocols. By using children protocols, 

the user does not have to adjust dose 

values to the age or weight of the child. 

In these protocols, CARE Dose4D automatically 

adapts the tube current to the 

individual patient’s anatomical charac- 

teristics. However, children older than 

6 years or heavier than 55 kg can be 

examined with regular adult protocols. 

Fast scan times are very helpful when 

scanning children since they probably 

will not, or cannot, hold still for the 

duration of the scan. An increased pitch 

value or faster rotation time also support 

fast acquisitions. Repeated scanning 

can be avoided. 

Where can users find more information 

about CT scan protocols? 

Koch: The Workflow Assistant is included 

within the CT Life Card. It is available for 

the SOMATOM Definition family starting 

with software version syngo CT 2007B 

(VA11). Application Guides do exist for 

older scanner models. These media 

include valuable facts about scan protocols, 

physical fundamentals, dose measures 

and practical tips and tricks. 

Life 

“The best possible image 

quality at the lowest dose 

can be achieved by using 

the default scan protocols.” 

Christiane Koch, Business Unit CT, Siemens Healthcare, 

Forchheim, Germany. 

Tips from the expert: 

� Do not use a protocol from a certain 

body region and change it to 

a protocol to fit another body 

region. 

� When comparing dose values of 

different scanner models and 

different vendors, it is important 

to compare CTDIvol values, not 

tube current values. Tube current 

values are related primarily to 

filter settings and the scanner 

geometry. 

� Customized scan protocols can be 

exported through the Scan Protocol 

Assistant to Excel to be used on 

a PC for further documentation, 

e.g. documentation of dose values. 

� All or certain scan protocols can 

be copied from one scanner to 

another scanner via the Scan Protocol 

Assistant. Pre-conditions are 

the same scanner model and identical 

software version. 

www.siemens.com/life-courses 


Life 

First syngo.via Hands-on 

Workshops at ECR 2010 

By Heike Theessen, Business Unit CT, Siemens Healthcare, Forchheim, Germany 

For the 6th consecutive year, Siemens 

Healthcare offered hands-on workshops 

in the experience lounge at ECR 2010. 

Participants could benefit from very 

comprehensive sessions for CT, MR as 

well as PET and SPECT CT. 

Unlike previous years however, the new 

imaging software syngo.via* was used 

for the sessions CT Cardiology, CT Oncology 

and CT Colonography. During the 90 

minute sessions, Tobias Pflederer, MD, 

from Erlangen University and Thomas 

Mang, MD, from Vienna University, demonstrated 

how they can use syngo.via 

for their daily reporting. 

At the beginning of each session, a theoretical 

introduction into the topic was 

given by the speakers. Pflederer pointed 

out the various dose reduction possibilities 

for Cardiac CT while Mang gave an 

overview of patient preparation and 

reading techniques for CT Colonography. 

After a brief demonstration of syngo.via 

by Siemens application specialists, the 

Upcoming Events & Congresses 


T. Mang, MD, hold the session on CT Colonography using syngo.via 

participants could experience Siemens 

new imaging software for themselves. 

The instructing physicians guided them 

step-by-step through the applications, 

explaining the benefits of syngo.via. 

Customers particularly liked the automated 

case preparation, where all coronary 

arteries are automatically labelled 

and functional evaluations for left and 

right ventricle are already done. 

Next workshops with syngo.via are 

planned for ESC 2010 in Stockholm. 


Title Location Short Description Date Contact 

ASNR Boston, USA 48th Annual Meeting May 15-20, 2010 www.asnr.org 

ISCT San Francisco, 12th International May 18–21, 2010 www.isct.org 

USA Symposium on 

Multidetector-Row CT 

WCC Bejing, China World Congress of June 16–19, 2010 www.worldheart.org 

Cardiology Scientific 

Sessions 2010 

SCCT Las Vegas, USA 5th Annual July 14–15, 2010 www.scct.org 

Scientific Meeting 

ESC Stockholm, Cardiology August 28 – www.escardio.org 

Sweden Congress September 01, 2010 

ESNR Bologna, Italy Neuroradiology October 04–09, 2010 www.esnr.org 

Congress 

RSNA Chicago, USA Annual Meeting of November 28– www.rsna.org 

Radiological Society December 03, 2010 

of North America

Training Website for Knowledge Improvement 

By Jakub Mochon, Computed Tomography Division, Siemens Medical Solutions, Malvern, Pennsylvania, USA 

Recent years have brought significant 

progress to the area of ischemic stroke 

therapy. Equally important developments 

have taken place on the diagnostic 

side. With availability of Adaptive4D 

Spiral on all SOMATOM Definition scanners, 

coverage for perfusion imaging 

has been extended beyond the limitation 

of the detector size. Physicians can 

now adjust the coverage to the specific 

needs of the patient and the indications 

of the neurological exam. New syngo 

Volume Perfusion CT Neuro software 

offers improved guided workflow and 

enables rapid sharing of perfusion data 

and maps utilizing syngo Expert-i. In order 

to improve the knowledge on Siemens 

offerings in this area, Siemens USA 

Siemens’ newest application for neurological 

imaging, syngo Volume Perfusion 

CT Neuro, can now be tried for 90 days 

at no cost. 

syngo Volume Perfusion CT Neuro facilitates 

quantitative 3D volume evaluation 

for differential diagnosis of brain tumors 

and ischemic stroke. In combination 

with Adaptive 4D Spiral technology, extended 

brain coverage is feasible.* It is 

the most complete 3D stroke evaluation 

software on the market and the only application 

with both maximum slope and 

deconvolution models integrated, supporting 

diagnostic results even in critical 

situations. With the 3D Auto Stroke functionality, 

therapeutic decisions can be 

made without complex user interac- 

has launched a dedicated website: 

https://www.med.usa.siemens.com/ 

stroke. Particularly beneficial is the three 

part Webcast presented by Ke Lin, MD, 

from New York University: https://www. 

med.usa.siemens.com/stroke/webcast/ 

Part 1: Appropriateness of perfusion in 

stroke diagnosis: Where and when to 

use it. 

Part 2: Workflow, Acquisition and Post 

Processing. 

Part 3: How to read and interpret studies. 

Siemens is also working closely with Applied 

Radiology: http://www.appliedradiology.com/ 

on an educational stroke 

forum that will further discuss the diverse 

needs of the stroke teams at the clinics 

and particularly emphasize the beneficial 

Free Trial Licenses for Neuro Imaging 

By Marion Meusel, Business Unit CT, Siemens Healthcare, Forchheim, Germany 

tions. All relevant perfusion parameters 

(CBF, CBV, TTP, MTT) are shown in one 

view. The integrated “3D Tissue at Risk 

Evaluation” gives confidence in the differentiation 

between cerebral tissue at 

risk and core infarct. All these features 

make syngo Volume Perfusion CT Neuro 

night shift and 24/7 service ready. 

role and utility of CT imaging in 

stroke care. 

Life 

In order to improve the knowledge on Siemens 

offerings, Siemens USA has launched a dedicated 

website https://www.med.usa.siemens.com/stroke 

Similar free-trial licenses are available 

for many more clinical applications. 

International: 

www.siemens.com/DiscoverCT 

USA only: www.usa.siemens.com/ 

webShop/CT 

syngo Volume 

Perfusion CT Neuro – 

All dynamic information 

in one view. 

*Available for the 

SOMATOM Definition 

family only.

Frequently Asked Questions 

By Ivo Driesser, Business Unit CT, Siemens Healthcare, Forchheim, Germany 

In the Scan Protocol Assistant (SPA), 

the user has access to all scan protocols. 

These protocols can be adapted, changed 

or deleted. Everything is clearly listed 

as in the patient model dialog. The 

layout is comparable to the examination 

Siemens Healthcare will offer a workshop 

on Dual Energy CT in cooperation 

with Thorsten Johnson, MD, Associate 

Professor of Radiology and Head of Computed 

Tomography at Munich University 

Hospital, Campus Großhadern, Germany. 

The course will take place in Forchheim, 

Germany from September 10th to September 

11th 2010. 

The field of Dual Energy CT scanning 

is expanding incredibly fast. Twelve different 

FDA cleared Dual Energy applications 

have already been introduced since 

the launch of Dual Source CT in 2005, 

creating both clinical and educational 

demand. Siemens Healthcare will provide 

a comprehensive overview to those who 

are just starting to integrate Dual Energy 

CT into their daily routine with emphasis 

on understanding the principles and fully 

card, which makes it easy to find the 

entries which should be changed. 

How can SPA help in daily routine? 

1. The entry “CTDIvol”, for example, can 

be added for all scan protocols as follows: 

First the SPA has to be opened, via 

Dual Energy CT: Learning From the Experts 

By Heike Theessen, Business Unit CT, Siemens Healthcare, Forchheim, Germany 

utilizing the potential of Dual Energy CT. 

The two-day training session will include 

presentations on both the physical principles 

and the clinical benefits of Dual 

Energy CT. A hands-on session at a 

SOMATOM Definition scanner, as well as 

on a workstation for extended case review 

is also part of the workshop. “Some 

of the things covered in the workshop 

During a workshop 

Thorsten Johnson, MD 

will present both the 

physical principles 

and clinical benefits 

of Dual Energy CT. 


Example of 

the Trigger 

card of 

SOMATOM 

Definition 

scanner. 

“Options”, “Configuration” and “Scan 

Protocol Assistant”. 

Step 1: Select “Change Protocols.” 

Step 2: Select all protocols. 

Step 3: Go to “scan” where you see all 

the scan parameters. Click on the configuration 

icon (marked in red on the image). 

Select the “CTDIvol” box and place in 

the menu bar via the arrow (marked in 

green). Click on the configuration icon 

again. If desired the“CTDIvol” entry can be 

selected in the menu bar and moved to 

the preferred location. 

2. For 3D reconstructions it is preferable 

to have a non-square matrix. Select in 

Step 2 all the affected protocols by using 

the filter “3D recon jobs”. In in Step 3 

you can change the matrix size. Select 

the column “Matrix size” and in the l ower 

part, make your changes. All selected 

protocols will now be changed. 

In this way, protocols are easily and quickly 

adapted to the users preferences. 

have been used reliably in daily routine 

for years. Some others are only a couple 

of months old. Upon completion of the 

workshop, participants will be at the forefront 

of Dual Energy technology,” says 

course director Johnson. 

www.siemens.com/life-courses

Clinical Workshops 2010 

As a cooperation partner of many renowned hospitals, 

Siemens Healthcare offers continuing CT training programs. 

A wide range of clinical workshops keeps participants at 

the forefront of clinical CT imaging. 

Workshop Title Dates Location Course Course 

language director 

Clinical Workshop on July, 28–30 2010 Erlangen, English Prof. Stephan Achenbach, MD 

Cardiac CT / Erlangen Germany 

Clinical Workshop on July, 07–09 2010 Munich, English PD Konstantin Nikolaou, MD 

Cardiac CT / Munich December, Germany Prof. Christoph Becker, MD 

15 –17 2010 Alexander Becker, MD 

Clinical CTA Interpretation November, Erlangen, English Prof. Stephan Achenbach, MD 

Course / Erlangen 18–19 2010 Germany 

Hands-on Workshop September, St. Gallen, German PD Hatem Alkadhi, MD 

Cardiac CT 23–25 2010 Switzerland PD Sebastian Leschka, MD 

Clinical Training Course June, 26–27 2010 Kuching, English Prof. Sim Kui Hian, MD 

on Cardiac CT October, 30–31 2010 Malaysia Ong Tiong Kiam, MD 

Virtual CT-Colonography June, 11–12 2010 Berlin, German Prof. Bernd Lünstedt, MD 

November, 05–06 2010 Germany 

Dual Energy Workshop September, Forchheim, English PD Thorsten Johnson, MD 

10 –11 2010 Germany 

ESGAR CT-Colonography September, Lisbon (Cascais), English 

Workshops 23–24 2010 Portugal Prof. Filippe Caseiro-Alves, MD 

April Dublin, Prof. Helen Fenlon, MD 

13–15, 2011 Ireland Martina Morrin, MD 

September Gothenburg, Prof. Mikael Hellström, MD 

14 –16, 2011 Sweden 

Cardiac-CT Workshop/ Autumn 2010 Dubai, UAE English PD Christoph Becker, MD 

Dubai Alexander Becker, MD 

Hands-on Workshops August, Stockholm, English n.a. 

during ESC 2010 28–31 2010 Sweden 

Experience Lounge November, 28 – Chicago, English n.a. 

at RSNA 2010 December, 2 2010 USA 

In addition, you can always fi nd the latest CT courses offered by Siemens Healthcare at www.siemens.com/SOMATOMEducate 

Life 


Life 

Siemens Healthcare – Customer Magazines 

Our customer magazine family offers the latest information and background for every 

healthcare fi eld. From the hospital director to the radiological assistant – here, you can 

quickly fi nd information relevant to your needs. 

Medical Solutions 

The Magazine for Healthcare Leadership 

May 2010 

Medicine in 2050 

How today’s babies will grow into the future of healthcare 

Inhalt_May_10_eng.indd 1 23.04.10 09:10 

AXIOM Innovations 

Everything from the worlds 

of interventional radiology, 

cardiology, fluoroscopy, 

and radiography. This semiannual 

magazine is primarily 

designed for physicians, 

physicists, researchers, and 

medical technical personnel. 


Innovation and trends 

in healthcare. The 

magazine, published 

three times a year, is 

designed especially 

for members of the 

hospital management, 

administration personnel, 

and heads of 

medical departments. 

MAGNETOM Flash 

Everything from the world 

of magnetic resonance 

imaging. The magazine 

presents case reports, 

technology, product news, 

and how-to’s. It is primarily 

designed for physicians, 

physicists, and medical 

technical personnel. 



of computed tomography. 

With its innovations, clinical 

applications, and visions, 

this semiannual magazine 

is primarily designed for 

physicians, physicists, 

researchers, and medical 

technical personnel. 

For current and prior issues and to order the magazines, please visit www.siemens.com/healthcare-magazine 


News 

Our latest topics 

such as product 

news, reference 

stories, reports, 

and general 

interest topics are 

always available at 


healthcare-news 

Perspectives 


of clinical diagnostics. This 

semi-annual publication provides 

clinical labs with diagnostic 

trends, technical innovations, 

and case studies. 

It is primarily designed for 

laboratorians, clinicians and 

medical technical personnel.

SOMATOM Sessions – IMPRINT 

© 2010 by Siemens AG, Berlin and Munich 

All Rights Reserved 

Publisher: 

Siemens AG 

Healthcare Sector 

Business Unit Computed Tomography 

Siemensstraße 1, 91301 Forchheim, Germany 

Chief Editors: 

Monika Demuth, PhD 

(monika.demuth@ 

siemens.com) 

Stefan Wünsch, PhD 

(stefan.wuensch@ 

siemens.com) 

Responsible for Contents: André Hartung 

Editorial Board: 

Andreas Blaha 

Helge Bohn 

Andreas Fischer 

Thomas Flohr, PhD 

Julia Hoelscher 

Klaudija Ivkovic 

Axel Lorz 

Peter Seitz 

Stefan Ulzheimer, PhD 

Alexander Zimmermann 

Authors of this Issue 

H. Alkadhi, MD, Institute of Diagnostic Radiology, 

University Hospital Zurich, Zurich, Switzerland 

F. Bamberg, MD, Department of Clinical Radiology, 

University of Munich, Campus Großhadern, 

Munich, Germany 

R. W. Bauer, MD, Department of Diagnostic and 

Interventional Radiology, Clinic of the Goethe 

University, Frankfurt, Germany 

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 35,000 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 case to 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 is not 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. 

A. Becker, MD, Department of Clinical Radiology, 



C. R. Becker, MD, Department of Clinical Radiology, 



G. Feuchtner, MD, Institute of Diagnostic Radiology, 


M. Fischer, MD, Institute of Diagnostic Radiology, 


R. Goetti, MD, Institute of Diagnostic Radiology, 


W. Heindel, MD, Department of Clinical Radiology, 

University Hospital, Münster, Germany 

J. M. Kerl, MD, Department of Diagnostic and 

Interventional Radiology, Clinic of the Goethe 


M. Lell, MD, Department of Radiology and 

the Imaging Science Institute (ISI), University 

of Erlangen-Nuremberg, Erlangen, Germany 

S. Leschka, MD, Institute of Diagnostic Radiology, 


K. Lin, MD, Department of Radiology, New York 

University Langone Medical Center, New York, 

NY, USA 

A. H. Mahnken, MD, RWTH Aachen University 

Hospital, Aachen, Germany 

Y. Mizutani, MD, Department of Radiology, 

Sakakibara Heart Institute, Tokyo, Japan 

K. Nikolaou, MD, Department of Clinical Radiology, 



J.-F. Paul, MD, Centre Chirurgical Marie 

Lannelongue, Le Plessis-Robinson, France 

A. Plass, MD, Clinic of Cardiovascular Surgery, 


B. Policeni, MD, Radiology Faculty, Neuroradiology, 

University of Iowa Hospitals and Clinics, Iowa 

City, Iowa, USA 

H. Scheffel, MD, Institute of Diagnostic Radiology, 


SOMATOM Sessions is also available on the internet: www.siemens.com/SOMATOMWorld 

F. Schoth, MD, RWTH Aachen University Hospital, 

Aachen, Germany 

F. Schwarz, MD, Department of Clinical Radiology, 



H. Seifarth, MD, Department of Clinical Radiology, 

University Hospital, Münster, Germany 

K. Takada, MD, Department of Radiology, 

Sakakibara Heart Institute, Tokyo, Japan 

T. J. Vogl, MD, Department of Diagnostic and 

Interventional Radiology, Clinic of the Goethe University, 

Frankfurt, Germany 

P. Weisser, MD, Department of Diagnostic and Interventional 

Radiology, Clinic of the Goethe 


M. Wieser, MD, Clinic of Cardiovascular Surgery, 


C. Wyss, MD, Cardiology Division, University 

Hospital Zurich, Zurich, Switzerland 

Sameh Fahmy, freelance medical and technology 

journalist Tony DeLisa, freelance author 

Wiebke Kathmann, PhD, freelance scientific journalist 

Hildegard Kaulen, PhD, freelance scientific journalist 

Oliver Klaffke, freelance scientific journalist 

Annette Tuffs, MD, medical journalist 

Peter Aulbach; Karin Barthel; Andreas Blaha; 

Steven Bell; Ivo Driesser; Kerstin Fellenzer; Tomoko 

Fujihara; Jan Freund; Tanja Gassert; Toshihide 

Itoh; Christiane Koch, Rami Kusama; Marion 

Meusel; Jakub Mochon; Katharina Otani, PhD; 

Kerstin Putzer; Heike Theessen; Peter Seitz; Stefan 

Ulzheimer PhD; Fernando Vega-Higuera; 

Stefan Wünsch, PhD; all Siemens Healthcare 

Photo Credits: Greg Morris, Yohanne Lamoulére/ 

Agentur Focus, Harald Krieg, Thorsten Rother 

Production: Norbert Moser, Siemens AG, 


Design and Editorial Consulting: 

Independent Medien-Design, Munich, Germany 

In cooperation with Primafila AG, Zurich, 

Switzerland; 

Managing Editor: Christa Löberbauer; 

Photo Editor: Susanne Nips; Layout: Claudia 

Diem, Mathias Frisch; All at: Widenmayerstraße 

16, 80538 Munich, Germany 

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 author’s name and title of the 

contribution as well 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. 

Imprint 

SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 77 

unsubscribe from info service 

“Neuro BestContrast 

allows radiologists to 

better visualize subtle 

edemas as well as 

subtle signs of stroke, 

and to better delineate 

the cortical margin.” 

David S. Enterline, MD, 

Duke University Medical Center in Durham, North Carolina, USA 

Country 

State 

Yes, I consent to the above information being used 

for future contact regarding product updates and other 

important news from Siemens. 

City 

Postal Code 

E-mail 

Street 

the monthly healthcare e-newsletter 

Please print clearly! 

Name 

Stay up to date with the latest information 

Register for: 

Title 

AXIOM Innovations 

Function 


Department 

MAGNETOM Flash 


Institution 

Please enter your business address 

Please include me in your mailing list for the 

following Siemens Healthcare customer magazine(s): 

Subscription

SUBSCRIBE NOW! 

– and get your free copy of future 

SOMATOM Sessions! Interesting information 

from the world of computed tomography – gratis 

to your desk. Send us this postcard, or subscribe 

online at www.siemens.com/ct-news 

SOMATOM 

Sessions 

Rapid evaluation is 

critical after trauma and 

with symptoms such as 

weakness, headache, 

and dizziness, which is 

why CT is the modality 

of choice in these 

scenarios. Exceptional 

image quality is key to 

optimize diagnosis, and 

lower dose imaging 

minimizes risk to the 

patient. 


Halthcare Sector 

H CC 11 

Henkestraße 127 

91052 Erlangen 

Germany 

Global Siemens Headquarters 


Wittelsbacherplatz 2 

80333 Muenchen 

Germany 

www.siemens.com/healthcare-magazine 

On account of certain regional limitations of 

sales rights and service availability, we cannot 

guarantee that all products included in this 

brochure are available through the Siemens 

sales organization worldwide. Availability and 

packaging may vary by country and is subject 

to change without prior notice. Some/All of 

the features and products 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. 

Not for distribution in the US. 

Global Siemens 

Healthcare Headquarters 


Healthcare Sector 


91052 Erlangen 

Germany 

Phone: +49 9131 84 - 0 

www.siemens.com/healthcare 

Order No. A91CT-41011-14M1-7600 | Printed in Germany | CC CT 41011 ZS 0510/27. | © 05.2010, Siemens AG 

Global Business Unit 



Computed Tomography 

Siemensstraße 1 

91301 Forchheim 

Germany 

Phone: +49 9191 18 - 0 


Local Contact Information 

Asia/Pacific: 

Siemens Medical Solutions 

Asia Pacific Headquarters 

The Siemens Center 

60 MacPherson Road 

Singapore 348615 

Phone: +65 9622 - 2026 


Canada: 

Siemens Canada Limited 


2185 Derry Road West 

Mississauga ON L5N 7A6 

Canada 

Phone: +1 905 819 - 5800 


Europe/Africa/Middle East: 




D-91052 Erlangen 

Germany 

Phone: +49 9131 84 - 0 


Latin America: 

Siemens S.A. 


Avenida de Pte. Julio A. Roca No 516, Piso 7 

C1067ABN Buenos Aires Argentina 

Phone: +54 11 4340 - 8400 


USA: 

Siemens Medical Solutions U.S.A., Inc. 

51 Valley Stream Parkway 

Malvern, PA 19355-1406 

USA 

Phone: +1-888-826 - 9702 



ISCT-Edition May 2010 26

SOMATOM Sessions - Siemens Healthcare

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?