somatom sessions 17

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SOMATOM

Sessions

No 17/December 2005RSNA-Edition

Nov. 27th

Dec. 2nd, 2005

www.siemens.com/medical

COVER STORYDual Source CT Imaging A New Era in ComputedTomographyPage 4

NEWSCT Clinical Engines Speedand Confidence

Page 19

BUINESSSOMATOM Emotion Excel-lent Price-Performance RatioPage 25

Revenue InvestmentPays OffPage 27

CLINICAL OUTCOMESOncology Respiratory Gating

Page 34

Acute Care Diagnosis andSurgical Planning in TraumaticParaplegiaPage 42

SCIENCEIncreased Speed and Resolu-tion Make a Difference inCoronary Artery ImagingPage 46

CUSTOMER CAREEDUCATE Free CME-Credited CD-SetPage 49


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The number of slices acquired per rotation has doubled every 18 months in the last years,

with Siemens being an innovation leader in both technical concepts and clinical applications.

At RSNA 2003, Siemens set another landmark as the first company to introduce 64-slice CT.

Only two years later, our SOMATOM Sensation 64 is installed in over 500 institutions

world-wide the largest installed base in this segment.

At Siemens, we continue to challenge the future view on CT technology and clinical applica-

tions. We understand that supplying our users with innovative hardware is not enough. Intro-

ducing our new CT Clinical Engines, we provide perfect clinical CT solutions in neurology, diag-

nostic oncology, cardiovascular and acute care available across Siemens' CT product line and

based on Siemens' unique syngo platform.

The time has come to explore totally new CT concepts and to move beyond the simple adding

of more detector slices. At RSNA 2005, Siemens moves CT into a new era with the introduction

of the world's first Dual Source CT, the SOMATOM Definition a breath-taking innovation that

started with a simple scribble and was designed in cooperation with the world's leading clinical

experts. Experience completely new dimensions of CT. Redefine the clinical role of CT in car-

diac imaging and acute care. Explore new clinical frontiers with dual energy scanning. Join us

to reach new levels of excellence in CT.

Now, enjoy reading this 17th issue of the SOMATOM Session magazine. It is the introduction

to another great CT year in a year in which Siemens will once again set the trend.

Sincerely,

Dear Reader,

Bernd Ohnesorge, PhD, Vice President CT Marketing and Sales

2 SOMATOM Sessions17

EDITORS LETTER

DeutscherZukunftspreis/

AnsgarPudenz

Bernd Ohnesorge, PhD,

Vice President

CT Marketing and Sales


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SOMATOM Sessions 17 3

CONTENT

COVER STORY4 Dual Source CT Imaging A New Era in Computed Tomography

12 Dual Source CT Imaging The Idea behind the Technology

NEWS19 Speed and Confidence

21 Leader in Customer Care

21 NEW Advanced Vessel Analysis

22 Proven Leadership

22 Trendsetting Injector Coupling Device

23 Enhanced Workflow

BUSINESS24 Virus Protection Shields Medical Systems

24 The Easy Way from Sequential to Multislice CT

25 Excellent Price-Performance Ratio

26 Reimbursement in the US

27 Investment Pays Off

CLINICAL OUTCOMES28 Cardiovascular: CT Angiography of Chest, Abdomen, Pelvis and Upper Extremities

with CARE Dose4D and z-Sharp

30 Cardiovascular: Peripheral Runoff

32 Oncology: Computer Assisted Reading - More Speed. Enhanced Confidence

34 Oncology: Respiratory Gated CT-Imaging in Radiation Therapy of Lung Cancer

36 Oncology: Restaging Bronchial Carcinoma after Radiotherapy Treatment

38 Oncology: Making a Difference with PET and CT in Complex Cases

40 Neurology: Bone Subtraction CTA for Vascular Mapping in Head and Neck Imaging

42 Acute Care: 40-Slice CT for Diagnosis and Surgical Planning in Traumatic Paraplegia

SCIENCE44 Head and Neck Imaging

46 Increased Speed and Resolution Make a Difference in Coronary Artery Imaging

CUSTOMER CARE48 Customer Event

48 Cardiac CT Live Case Workshop

48 First High-end Users Meeting

49 Free CME-Credited CD-Set

49 Service: Frequently Asked Questions

50 Service: CT News on the Web

50 Service: Upcoming Events and Courses

51 Imprint


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4 SOMATOM Sessions 17

Dual Source CT Imaging

A New Era inComputed Tomography

Four prominent medical specialists from radiology, cardiologyand medical physics sat down together recently to discussa revolutionary innovation in CT technology: dual source CT imaging.Here is how the experts assessed the new technology.

By Catherine Carrington

COVER STORY

Buzz. Its what fills the air when people take note of an

exciting new trend, a technological revolution that

promises to change the future, an innovation so creativeit defines out of the box thinking.

Buzz. Its what energized the room when four computed

tomography (CT) experts gathered in Cleveland, Ohio, to

envision the future of imaging, and how it will change

with the introduction of a revolutionary new technology:

dual source CT.

The first system worldwide to contain this new technology

is Siemens SOMATOM Definition. Overcoming the

convention of thinking in terms of numbers of slices, it is

equipped with two X-ray source/detector systems that

rotate in synchrony, simultaneously capturing image data

in half the time required with conventional technology.Two X-ray sources, two detectors, a multitude of clinical

possibilities.

At the table were neuroradiologist Michael Modic, M.D.,

chairman of radiology at the Cleveland Clinic Foundation;

radiologist Richard White, M.D., head of the section of

cardiovascular imaging at the Cleveland Clinic Foundation;

cardiologist Gilbert Raff, M.D., director of CT and MRI

research at William Beaumont Hospital, Royal Oak,

Michigan; and medical physicist Cynthia McCollough,

Ph.D., director of the CT Clinical Innovation Center at Mayo

Clinic, Rochester, Minnesota.

Coronary CTAexamination with83 ms temporal

resolution ofa patient withvarying heart

rate of 85-93 bpmduring the scan.

MIP LAD DiastoleCourtesy: University Hospital Erlangen

MIP LAD Diastole


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MICHAEL MODIC, M.D.,chairman of radiology at the

Cleveland Clinic Foundation

RICHARD WHITE, M.D.,radiologist, head of the

section of cardiovascular

imaging at the Cleveland

Clinic Foundation

GILBERT RAFF, M.D.,cardiologist, director of CT

and MRI research at William

Beaumont Hospital, Royal

Oak, Michigan

CYNTHIA MCCOLLOUGH,Ph.D., medical physicist,

director of the CT Clinical

Innovation Center, Mayo

Clinic, Rochester, Minnesota

COVER STORY


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COVER STORY

SOMATOM Sessions: 64-slice CT scanner have been a

remarkable innovation, but we are wondering what

challenges still remain. Are there ways in which CT can

become even better?

DR. RAFF: Cardiac CT has extremely high accuracy in finding

a lesion and in excluding significant stenosis. However, it

is very important to both, the patients management andinterventional planning, to discover exactly how severe the

lesion is whether it is a 25 percent stenosis or a 75 percent

stenosis. Any move in that direction is key.

The second issue is patient preparation. I have an entire

holding area staffed with nurses and equipped with

monitors, all dependent on having to give patients beta

blockers to slow the heart rate. We could save a lot of time,

work and cost if we didnt need to give patients these beta

blockers.

DR. WHITE: The leap from 16- to 64-slice technology really

made it possible for us to do coronary CT angiography. But

were still dependent upon picking the right patients. With

future CT technology improvements, we need to be able to

do an examination on any patient.

DR. MODIC: CT is the ideal modality for imaging acute

stroke. The first decision for us is blood no blood, and

CT is very good at answering that question. But we alsoneed to evaluate the intracranial vessels, including fast and

accurate separation of vessels and bone. Moreover, calcified

plaque in the carotid arteries has been a limiting factor in

applying CT to the evaluation of stroke. We need a tool that

is better able to differentiate tissues.

DR. MCCOLLOUGH: Radiation dose has become of

increasing concern. With present multislice CT technology,

as temporal resolution improves, the radiation dose goes

up. Its a concern that hangs over the technology and makes

everyone worry.

Four CT experts from the US gathered in Cleveland to envision the future of imaging, and how it will change with the

introduction of dual source CT.


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Dual source CT meets all of these challenges. Consider cardiac

imaging: Each of the two source/detector systems must travel

only 90 degrees to acquire image data, resulting in a doubling

of temporal resolution. It provides a temporal resolution of 83

ms a factor of two better than the 165-ms temporal

resolution of the best single source CT scanners. Together with

a spatial resolution of less than 0.4 mm, it enables SOMATOM

Definition to visualize the smallest anatomical structures with

exceptional quality without the compromises associated with

beta blockers and ECG-gated, multisegment reconstruction.

SOMATOM SESSIONS: How will dual source CT solve some of

the challenges you continue to face in cardiac imaging?

DR. RAFF: Even in patients that we consider ideal today, there

is always cardiac motion and subtle amounts of blurring at thelevel of the stenosis. The only way were going to push coronary

CTA to achieve the quality we need to make key clinical

decisions is with higher temporal resolution.

DR. WHITE: Any opportunity to capture that coronary artery

as its flying by is a major gain. With 83-ms temporal resolution,

independent of the heart rate, youre also getting away from

the need for segmented reconstruction approaches.

SOMATOM SESSIONS: Lets talk about multisegment

reconstruction. Its said to improve temporal resolution and

overcome problems associated with a high heart rate. Are the

images of consistently high quality?

DR. WHITE: Mult isegmental

reconstruction is not a panacea, and

quite often its detrimental rather than

beneficial. Youre averaging data from

multiple cardiac cycles, and thats not

the most desirable approach.

Multisegment reconstruction should

not be relied upon as the answer to

temporal resolution.

DR. MCCOLLOUGH: If you average

two cardiac cycles and the heart

doesnt come back to exactly the samespot on a submillimeter level, youve

just blurred out that 1- or 2-mm artery

youre trying to see.

SOMATOM SESSIONS: High temporal

resolution eliminates the need to give

beta blockers. We have discussed the

operational benefits, but is there also

a clinical benefit?


DR. RAFF: A considerable number of patients cant take beta

blockers. For example, patients with asthma are not

candidates for cardiac CT today. And some patients are beta

blocker resistant. If dual source CT means that fewer patients

are rejected beforehand, and more of the patients we do

image have diagnostic results, thats quite important in the

scheme of things.

DR. WHITE: Theres another aspect to consider. Lets say,

based on the CT study, youre concerned about athero-

sclerosis and want to determine its functional importance.

Having beta blockers on board may preclude immediately

doing a functional assessment with stress testing. Thats a

problem that dual source CT can solve.

Cardiac Imaging

Gilbert Raff, MD, director of CT and MRI research,

William Beaumont Hospital, Royal Oak, Michigan

Better coronary imaging at thislevel is going to revolutionize

the treatment of coronarydisease, and coronary disease is

the most commmon serioushealth problem in

the developed world.

COVER STORY


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SOMATOM Definition delivers the lowest possible radiation

exposure in cardiac CT imaging today, despite using two

X-ray sources instead of one. How? Dual source CT images

the heart twice as fast; therefore, Adaptive ECG-pulsingTM

delivers the dose necessary for cardiac imaging in less than

half the time as the most dose-efficient single source CT

scanner. In addition, dual source CT easily acquires images

even at the highest

heart rates, thus allowing for scanning at higher table speed.

Higher table speed results in lower radiation exposure

compared to single-source CT.

SOMATOM SESSIONS: Is dose exposure a big issue in

cardiac CT?

DR. RAFF: Yes, its a concern. When the dose gets to behigher than for a coronary angiogram, theres a

psychological barrier, and everyone from patients to

government regulators become reluctant.

DR. MCCOLLOUGH: Radiation dose becomes a very hot-

button topic because people dont understand it. If someone

comes to the emergency room and its clearly important to

evaluate them with CT, then the dose risk is negligible in

comparison to the medical necessity of the exam. But in

those patients that come for rule-out examinations,

minimizing radiation exposure is very important. Reducing

the dose in cardiac CT by a factor of two will be an important

prerequisite for further establishing the technique in clinical

practice.

DR. RAFF: Im concerned about the patient who has CT after

equivocal results on a stress test. Theyve had a nuclear

procedure with radiation, a CT scan with radiation, and they

may go on to cardiac catheterization, with more radiation.

Anything we can do along that pathway to minimize

radiation exposure is critically important.

SOMATOM SESSIONS: Does radiation dose resonate with

your patients? Could you draw patients to your center by

emphasizing that dual source CT offers excellent image

quality at half the dose?DR. MODIC: Absolutely.

DR. WHITE: Why not put it out there as a mandate? We

should tell patients: This is one of our core values, to reduce

dose without sacrificing image quality. Lowering dose is the

right thing to do for multiple reasons.

Acute CareA combination of the highest temporal resolution and the

highest power available in the industry enables dual source

CT to easily image critical and challenging acute care

patients. This includes not only patients who are short of

breath or have a high heart rate, but also obese patients.

SOMATOM Definition has a wide, 78-cm gantry bore, a

200-cm scan range, and a combined 160-kW of power from

two independent X-ray sources. Together, these ensure

excellent image quality and enable scanning at high speed

for pure arterial-phase imaging, even in the heaviest of

patients.

SOMATOM SESSIONS: How important is it to be able toimage obese patients with adequate power and at an

optimal table speed?

DR. MODIC: Any time you can match dose with body mass,

youre better off. With dual source CT, youve got enough

power to take care of the patient.

DR. RAFF: In obese patients, the deterioration of image

quality can be so substantial with conventional CT scanners

that many of these patients have undiagnosable lesions.

Based on our experience with heavier patients, we dont

examine cardiac patients with a body mass index over

38 kg/m2.

DR. MCCOLLOUGH: We have successfully done abdominal


COVER STORY

Michael Modic, M.D., chairman of radiology,

Cleveland Clinic Foundation

If you have a strong,premier cardiac program,youll have to have a dual

source CT. A health systemlike ours should

probably have several.

Radiation Dose


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resolution of 165 ms, there is still going to be motion blur.

So I think dual source CT could be a huge benefit for

imaging of pediatric patients without sedation, or for

imaging an injured patient who is in pain and cant hold

still, or a patient who is agitated for some other reason.

Dual Source CT Allows Dual Energy ImagingDual energy imaging possible only with dual source CT

leverages differences in attenuation that depend on the

types of tissues being scanned, as well as on the energy

level. Scanning an object with 80 kV results in a different

attenuation than scanning an object at 140 kV. This raises

the possibility of direct subtraction of either vessels or bone

during scanning, as well as characterization of other tissues.

By using two X-ray sources simultaneously at different

energies, SOMATOM Definition can acquire two data sets with different information from a single scan. This may

offer the possibility of going beyond mere visualization of

anatomy to differentiation and characterization of tissues.

SOMATOM SESSIONS: What clinical opportunities does

dual energy scanning offer?

DR. MCCOLLOUGH: One of the most important challenges

in cardiovascular CTA is calcium. If a patient has a lot of

calcium in the coronaries, you cant see through that bright

spot to make a good diagnosis. Thats one of the things

were hoping dual energy will help us deal with.


studies on a patient weighing more than 500 pounds, using

a 64-slice scanner. But we have to make compromises. We

have to lower the table speed and, therefore, we cant

optimize the exam from a contrast perspective, as we would

with a regular patient. So if dual source CT allows us to scan

obese patients using the dose and the table speed we prefer,

there will be fewer trade-offs. And, in cardiac CT of obese

patients, lowering the table speed is not sufficient. You

simply need more X-rays for those patients.

SOMATOM SESSIONS: Should physicians be concerned

about the extra radiation dose to the obese patient?

DR. MCCOLLOUGH: The target organs that you worry about

for cancer are buried inside all that tissue, which absorbs a

lot of the radiation. It turns out that the effective dose,

which is an indicator of cancer risk from ionizing radiation,

only goes up by 10 to 20 percent, even though the scanneris cranking out double or quadruple the usual dose.

SOMATOM SESSIONS: Are there other types of acute care

patients for whom dual source CT could make an important

difference?

DR. MCCOLLOUGH: Weve done imaging of non-sedated

kids for a decade and a half because weve had an electron-

beam CT in our practice. Weve recently replaced that

scanner with a 64-slice scanner, and weve been doing well

with kids, but we still have to spend a long time in the exam

room calming them down if theyre agitated. At a temporal

COVER STORY


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COVER STORY

DR. MODIC: The whole issue of calcium isnt just in the

heart. It could be in the lungs. It could be in peripheral

angiography, even in the hands and feet. Well be able to do

bone subtraction, not in postprocessing, but based on the

dual energy source.

SOMATOM SESSIONS: Dr. Modic, youre a neuroradiologist.

Would it be helpful to you to be able to discriminate bone

and vascular tissue when imaging the brain?

DR. MODIC: Absolutely, especially given the emergence of

CT and CTA in the evaluation of patients with subarachnoidhemorrhage and acute stroke. The high cervical carotids

and the skull base those are difficult areas. Were very

eager to see the quality of the images we can achieve using

dual energy. Its likely to have a profound effect on the use

of CT in neuroradiology.

DR. WHITE: Dual energy is the big unknown for dual source

CT thats going to take it into an entirely different dimension.

We dont know what the prospects are for smarter contrast

agents, for example. We might adjust energies according to

the agent. There are probably opportunities we havent even

begun to anticipate.

Financial JustificationSOMATOM SESSIONS: From an operational or economic

standpoint, how would each of you justify investing in a

dual source CT scanner?

DR. MODIC: If you have a strong, premier cardiac program,

youll have to have a dual source CT. A health system like

ours should probably have several. If you have the patient

demand, the throughput that you can achieve through these

devices more than justifies the cost.

DR. MCCOLLOUGH: I can see dual source CT in the

emergency room, taking care of acute care and traumatizedpatients. Also in a big pediatric hospital. These are the places

where sub-100 milliseconds should be a clear win, and

where it may be worth paying the price differential.

DR. RAFF: For a cardiac program like ours, dual source CT is

an obvious choice. Its very important for us to be the best.

In addition, our emergency room sees six thousand patients

a year with chest pain, and their average length of stay is

over 24 hours. Were finishing up a series of studiesRichard White, M.D.,

head of the section of cardiovascular

imaging, Cleveland Clinic Foundation

Any opportunity to capturethat coronary artery

as its flying by is a major gain.With 83-ms temporal resolution,independent of the heart rate,youre also getting away from theneed for segmentedreconstruction approaches.


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showing a dramatic decrease in length of stay when CT is

used to evaluate chest pain patients. If we could eliminate

beta blockers, we could probably reduce the length of stay

by another two hours. Those are the kind of compelling

numbers that hospital administrators with busy emergency

rooms are going to look at. Also, if a hospital is competing

with other institutions, it will be a distinguishing feature.

Patients will like the convenience.

Evolution or Revolution?SOMATOM SESSIONS: Many of the advances in CT over the

last several years have been evolutionary. The increasing

number of slices with each new scanner is the most obvious

example. Is dual source CT another evolutionary change, or

is it revolutionary?

DR. MCCOLLOUGH: This scanner jumps off the curve,because its not about the slices, its about rotation time.

We went from a half-second to 0.42 seconds to 0.37 seconds

to 0.33 seconds, and the gains were 0.08 and 0.05 and 0.04

seconds. Now we jump off a curve thats reaching its upper

limit and virtually cut rotation time in half, thats a big deal.

DR. WHITE: I think its both. You can count on it being

evolutionary on day one as we learn how to use it. But then,

the prospects for this technology to set a whole new

direction are amazing, and it will sustain that for quite some

time.

DR. RAFF: We have to consider the potential impact on

cardiology, and, through it, on medicine in general and the

healthcare system. Better coronary imaging at this level is

going to revolutionize the treatment of coronary disease,

and coronary disease is the most common serious health

problem in the developed world.

Author: Catherine Carrington is a medical editor in Vallejo,

California.

Cynthia McCollough, Ph.D.,

director of the CT Clinical

Innovation Center, Mayo Clinic,

Rochester, Minnesota

Dual source CT could be ahuge benefit for imaging of

pediatric patients withoutsedation, or for imaging an

injured patient who is in pain andcant hold still, or a patient

who is agitated

for some other reason.


COVER STORY


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COVER STORY


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Dual Source

CT Imaging The Idea behindthe Technology

With the introduction of the DualSource CT technology at this years RSNA,

Siemens once again demonstrates its

leadership in technology and clinical

applications, moving beyond the simple

adding of more detector rows a race

that had dominated CT technology for

the past couple of years.

SOMATOM Definition is the worlds first CT scanner to

incorporate this new technology with which Siemens is

once again pushing technical and clinical boundaries to a

higher level by adding a second X-ray source and detector

to the CT system. The results are unprecedented image

quality and detail at lowest patient exposure while ensuring

substantially increased diagnostic speed and confidence.

Patient table

Gantry

Detector 1

X-ray unit 2

X-ray unit 1

Rotation ofX-ray unitand detector

Detector 2

COVER STORY


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COVER STORY

SOMATOM Definitions heart rate independent resolution

is 83 milliseconds, permitting scans of virtually every heart

and any heart rate from acute chest pain evaluation to

coronary visualization to functional analysis of the heart.

Together with the high spatial resolution of below 0.4 mm, it

makes the visualization of the smallest anatomical structures

possible with exceptional quality.

In combination with a 78-cm large gantry bore and field of

view, 200-cm scan range, and its high generator power, the

system allows most accurate scans or acute patients,

independent of size or condition. And all this at the lowest

possible dose. Additionally, SOMATOM Definition offers the

widest range of clinical applications, allowing fast and most

confident diagnoses to comprehensive reporting in only amatter of minutes. Intuitive and computer-assisted reading

tools also assist physicians in early detection, fast evaluation,

and precise follow up of malignant diseases, sometimes even

enabling them to review results before the patient is off the

table. Whats more, SOMATOM Definitions capabilities promote

pioneering new clinical opportunities at the highest level.

How Does it Work?The use of two X-ray sources and two detectors at the same

time result in double the temporal resolution, double speed and

twice the power, while even further lowering radiation dose.

Cardiac ImagingOptimal cardiac imaging can be best achieved in the diastolic

phase of the heartbeat. The faster the heart rate, the shorter

this phase becomes. With a single source CT scanner, the

X-ray source/detector system has to obtain data projections of

180 degrees to take an image within the diastolic phase. With

Dual Source CT, each of the two source/detector combinationsneeds to travel only 90 degrees to acquire an exceptional

cardiac image. Based on 0.33 s rotation time, this concept

provides an unprecedented temporal resolution of 83 ms,

independent of the heart rate.

Advantages at a Glance


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100 bpm Dual Source CT

60 bpm single source CT 60 bpm Dual Source CT

100 bpm single source CT

At a low and stableheart rate, the time asingle source CT

scanner needs forimaging is sufficient.Nevertheless, the

substantially highertemporal resolution ofDual Source CT

eliminates residualmotion.

At higher or varyingheart rates, the diastolicphase is too short

for a single source CTscanner, resulting inpoor image quality.

Dual Source CT, on theother hand, deliverssharp and detailed

cardiac images in ashort diastolic phaseand even in the systolic

phase.

COVER STORY


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COVER STORY

Heartbeat-controlled

dose modulation

Heartbeat-controlled

dose modulation





Dose Reduction

Dual Source CT images

the heart twice as fastas single source CT

scanners, reducing theECG-pulsing window bymore than half.

To overcome insufficient

temporal resolution athigh heart rates, singlesource CT scanners use

multisegment recon-struction with high doseand limited reliability.

Dual Source CT, on theother hand, maintainsthe lowest dose, inde-

pendent of the heart rate.

At the same time, SOMATOM Definition offers the lowest

possible radiation exposure in cardiac CT. Thanks to Dual

Source CT, the CT gantry needs to travel only 90 degrees to

acquire an exceptional cardiac image with unprecedented

temporal resolution of 83 ms, independent of the heart

rate. Monitoring the ECG in real-time, Siemens Adaptive

ECG-pulsing instantly reacts to any changes of the heartrate. Now that cardiac acquisition is twice as fast, the time

of high exposure during the heart beat, controlled by dose

modulation, can be cut by more than half compared to

single source CT scanners.

Instead of using multisegment reconstruction at higher

heart rates, Dual Source CTs highest temporal resolution

allows to acquire cardiac images from single heartbeats, at

any heart rate. Using automated table speed adaptation,

SOMATOM Definition increases the pitch with higher heart

rates, resulting in a faster table speed and a corresponding

reduction of radiation exposure. In other words, the higher

the heart rate, the less time is required for imaging the

heart, and consequently lower dose is needed.

Obese PatientsScanning obese patients with single source CT usually results in

a trade-off between speed and image quality. Dual Source CTovercomes this limitation of restricted power reserves with a

second X-ray source. In other words, it accumulates the power

of the two independent sources, resulting in unprecedented

160 kW, providing sufficient X-ray power reserves for high quality

imaging of patients whether tall or small, thin or large at

maximum volume coverage speed and fastest rotation time.

And, because scan speeds can be increased, the higher power

is used to improve quality, while dose maintains the same as in

single source CT. And the large bore of SOMATOM Definition

makes patient positioning much easier.


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Scan speed

Quality

Power

Dose


Scan speed

Quality

Power

Dose

SINGLE SOURCE CT WITH LIMITED KW.

Insufficient power for high-speed scanningof obese patients.

DUAL SOURCE CT WITH 160 KW*.

Dual Source CT accumulates the power of two

seperate sources resulting in unprecedented 160 kW*.

* Depends on system configuration.

When imaging obese patients at a high table speednecessary for pure arterial scanning, even astate-of-the-art, single source CT scanner may not have

sufficient power.

Dual Source CT, on the other hand, delivers sharp anddetailed images at any scan speed, because it

accumulates the power of two independent sources.

COVER STORY


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Energy 1:

Iodine

296 HU

Bone 670 HU

80 kV

Iodine

144 HU

Energy 2:

Bone 450 HU

140 kV

As X-ray absorption is energy-dependent, changingthe tube's kilo voltage results in a material-specific

change of attenuation.


COVER STORY

It has always been an aim to collect as much information

as possible for differentiation of tissues. Dual Source CT

assists in opening the door beyond visualization, moving

into a new world of characterization. Permitting the use of

two sources simultaneously at different energies, SOMATOM

Definition makes it possible to acquire two data sets

simultaneously from a single scan, running the tubes at two

different kV levels. The result are two data sets with diverse

information, which can allow the user to differentiate,characterize, isolate, and distinguish the imaged tissue and

material obtaining specific details about the scanned

object beyond morphology.

Spectacular research topics lie ahead, waiting to be explored,

as dual energy helps pave the way for a broad spectrum of

potential clinical uses. Possible application fields are: direct

subtraction of either vessels or bone during scanning,

classification of tumors in oncology, characterization of

plaques in vessels and the differentiation of body fluids in

emergency diagnostics.

Tissue Differentiation

Using a single source CT scanner,

diagnosing the circled area becomesdifficult, as insufficient informationdoes not allow a differentiation

between different tissue types.

Dual Source CT, on the other hand,

enables physicians to easilydifferentiate tissue types. The lesion

could be identified as a lipid

degeneration, color-coded in darkred.Object

140 kVAttenuation A

80 kVAttenuation B


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In order to enhance clinical workflow in

the computed tomography (CT) environ-

ment, Siemens CT Division is introduc-

ing a new generation of CT Clinical En-

gines. Supplying our customers with

hardware dedicated to their needs is not

enough, says Bernd Montag, PhD, Pres-

ident of the CT Division. We also want

to provide them with applications and

workflow tools that are specifically de-

signed to enhance image quality and

workflow efficiency in their particular

clinical departments. The CT Clinical En-

gines marry the world's most innovative

CT technology with syngo, Siemens

unique clinical applications solution.

Perfect synergy, designed to reliably se-

cure outstanding clinical outcomes

the new CT Clinical Engines bring togeth-er state-of-the-art CT scanner features

such as the industrys fastest rotation

speed, lowest possible dose scanning

modes and direct 3D data reconstruction

with exactly the right syngo solutions.

With our new CT Clinical Engines, we

take clinical application to the center of

our strategy, says Bernd Ohnesorge,

PhD, Vice President of CT Marketing and

Sales. The CT Clinical Engines will pro-

vide our framework to introduce further

innovations in the rapidly developingclinical fields of neurology, diagnostic

oncology, cardiovascular and acute care

that will drive the future of CT. They are

designed to enhance speed and diag-

nostic confidence by delivering excep-

tional image quality, fast access to im-

age data, and flexible access to intuitive

syngo clinical applications throughout

the radiology environment.

NEWS

The Complete Solution forCardiovascular CT

The CT Cardiac Engine offers the com-

plete solution for cardiovascular CT im-

aging. From scan to diagnosis, it covers

everything to achieve a streamlined car-

diovascular workflow. State-of-the-art

ECG-synchronized acquisition, image

reconstruction techniques and intuitive

ECG-editing to exclude extra beats be-

fore image reconstruction, ensure opti-

mal image quality. The lowest possible

dose for patients is provided with intelli-

gent adaptive ECG-pulsing. An innova-

By Louise McKenna, PhD, MBA, Global Product and Marketing Manager CT-Workplaces, and Stefan Wnsch, PhD, Global

Product and Marketing Manager Clinical Solutions, Siemens AG, Medical Solutions, CT Division, Forchheim, Germany

C T C L I N I C A L E N G I N E S

Speed and Confidence


tive, dedicated cardiovascular imaging

user interface simplifies daily workflow

and ensures highest throughput. The CT

Cardiac Engine facilitates cardiovascular

diagnosis from vascular analysis with

accurate stenosis measurement to stent

planning, from cardiac morphology to

functional analysis, concluding in a

comprehensive report.

Full Confidencein Neuro CTThe CT Neuro Engine delivers the tech-

nology required to perform artifact-free

imaging with the high spatial and tem-

syngo Circulation as a

key component of the CT

Cardiac Engine offersphysicians the industrys

most comprehensive

software for cardiac CT,

setting a new benchmark

for improving clinical

outcomes through inno-

vative software solutions.

syngo Neuro DSA CT as

part of the CT NeuroEngine offers tools for

fast and easy assessment

of head and neck

images, including direct

bone subtraction CTA.


20/54


21/54


22/54

Bernd Ohnesorge, PhD, Vice

President CT Marketing & Sales

of Siemens Medical Solutions,

receives the Frost & Sullivan

Award from Stephen Mohan, Vice

President Sales, Healthcare

Practice North America, Frost &

Sullivan, at the 6th international

conference on Cardiac CT in

Boston, MA, USA.

NEWS


S O MATO M S e n sa t io n

Proven LeadershipWith well over 500 installations, the

SOMATOM Sensation 64 is the worlds

most widely installed 64-slice computed

tomography (CT) system. Its outstanding

capabilities are not only recognized by

physicians, but also by market analysts

and engineering experts.

Frost & Sullivan has awarded Siemens

Medical Solutions the 2005 Enabling

Technology of the Year award in recogni-

tion of being the first company to success-

fully introduce a 64-slice CT system.

Since the introduction of the SOMATOM

Sensation 64, healthcare professionals

consider it an industry standard in high-

quality imaging. On the basis of its tech-

nological capability, Siemens has set a

benchmark in the development and

adoption of high-end technologies in the

imaging industry, said Stephen Mohan,

Vice President Sales, Healthcare Practice

North America, Frost & Sullivan.

In recognition of its exceptional image

quality, speed, and ease-of-use, the

SOMATOM Sensation 64 was also hon-

ored with the gold award in the 2005

Medical Design of Excellence Awards

(MDEA). Judges in the eighth annual

MDEA competition recognized the sys-

tems excellent engineering such as

its revolutionary z-SharpTM Technology

identifying it as a paradigm shift in CT

scanning technology. Sponsored by Can-

non Communications, publishers of "Eu-

ropean Medical Device Manufacturer"

(EMDM) magazine, the MDEA program

honors design and engineering achieve-

ments within the medical industry.

www.frost.com;

www.devicelink.com/expo/awards02/

k

C A R E Co n tr a st C T

Trendsetting Injector Coupling DeviceSiemens Computed Tomography (CT)

customers can now profit from a unique

synergy of trendsetting scanner tech-

nology, the seamlessly integrated syngo

CARE Contrast CT, and contrast media

injector devices, resulting in the most

efficient contrast management on the

market. Siemens CARE solutions havebeen expanded with the new option

CARE Contrast CT, extending the func-

tionality of all Siemens SOMATOM CT

scanners and optimizing contrast en-

hanced CT examinations.

CARE Contrast CT connects the CT scan-

ner and the injector, therefore allowing

starting or stopping the scan from one

single entry point. This is a trendsetting

answer to the increasing demands of

fast contrast enhanced CT scanning. It

speeds up clinical workflow and allows

efficient and confident monitoring of

patients during contrast media injection

and scan start, even if only one techni-

cian is present.

CARE Contrast CT is the first scanner

interface using a new standard (namedCiA425) for injector coupling devices in

medicine. The interface is designed to

cover future communication tasks be-

tween scanner and injector and will

open up new fields of contrast-based ap-

plications. It is currently supported by

leading injector companies MEDRAD

and MEDTRON. Following this trend,

additional releases of injectors from oth-er companies are expected soon.

CARE Contrast

CT greatly

speeds up

workflow in

contrast-

enhanced

CT scans.


23/54


NEWS

s y n g o 2 0 0 6 A

Enhanced Workflowsyngo 2006A, Siemens newest work-

flow software, will be delivered on new

syngo MultiModality workplaces1 by the

end of January 2006. Continuing the

Think Clinical theme, it gives users ac-

cess to new features and functionalities

designed to enhance workflow and di-

agnostic confidence.

Key Clinical AreasThree key clinical areas have been the

focus: cardiovascular CT, neuro CT and

CT imaging in oncology and early detec-

tion, thus providing key building blocks

for the four new CT Clinical Engines just

introduced at RSNA namely CT Cardiac

Engine, CT Neuro Engine, CT Acute Care

Engine and CT Oncology Engine (see

page 19).

syngo Circulation, designed for one-

stop, fast, robust morphological and

functional cardiac evaluation, makes its

debut in syngo 2006A. In combination

with enhancements to syngo InSpace

4D, such as bone removal and advanced

vessel segmentation and analysis func-

tionalities, users have access to superior

tools for comprehensive cardiac assess-

ment, fast evaluation of chest pain,

complex vascular exams, and fractures.

In neuro CT, visualization of complex

cerebro-vascular structures has been

hindered by the dense bone at the base

of the skull. Siemens new syngo Neuro

DSA CT facilitates subtraction of bone

from contrasted vessels allowing excep-

tional visualization of these vessels. New

features in syngo Neuro Perfusion CT in-

clude automatic tissue-at-risk assess-

ment, offering enhanced speed and

confidence in tumor perfusion and

stroke workflow.

With syngo 2006A, Siemens adds an-

other computer assisted reading tool to

its portfolio. syngo Colonography with

PEV (Polyp Enhanced Viewing) is a sec-

ond reader tool for the automated de-

tection of colon lesions. Together with

syngo LungCARE CT with NEV (Nodule

Enhanced Viewing), Siemens offers its

users an exceptional level of confidence

for early detection and follow-up exams

of the colon and lung.

Another new addition to the oncology

portfolio, syngo Body Perfusion CT, en-

ables the user to obtain an accurate pic-

ture of a tumors dynamic profile, help-

ing to optimize treatment decisions. On

top of the new clinical functionalities,

syngo 2006A provides the user with sig-

nificant improvements of workflow per-

formance. DICOM transfer of up to 21

images per second can be achieved, as

well as loading capacity of up to 3,200

images.

syngo Colonography with PEV (Polyp Enhanced Viewing)

is among the new computer assisted reading tools for

early detection available with syngo 2006A.

The syngo Body Perfusion CT option allows for the

quantitative evaluation of dynamic CT data of organs and

tumors, following the injection of a compact bolus.

1

Formerly: LEONARDO


24/54

BUSINESS


S I E M E N S R E M O T E S E R V I C E

Virus Protection Shields

Medical SystemsRegular computers can easily be pro-

tected against viruses. But regular virus

protection software cannot be indis-

criminately used on medical equip-

ment. Without the corresponding vali-

dation and testing, a systems safety and

efficacy may be significantly impacted.

Siemens Virus Protection solves the

problem. The solution is designed to

handle virus-related security matters on

syngo-based systems. It is the first

on the market to address this issue for

medical systems, significantly support-

ing customers in keeping their medical

systems healthy.

Siemens Virus Protection is based on

a virus scanner by Trend Micro, Inc., a

global leader in antivirus and content

security software and services. It in-

cludes regular updates with the latest

engines and patterns, using a VPN

(Virtual Private Network) broadband

Siemens Remote Service connection. The

Virus Protection program has been de-

veloped, validated and thoroughly test-

ed in both Germany and the United

States and is now available for Siemens

computed tomography systems.* Virus

protection for medical systems has be-

come a necessity due to the common

usage of various data media and inter-

net connections. As long as our cus-

tomers did not optimize their workflow

through network connectivity, there

was no need for such services, says

Wolfgang Heimsch, PhD, head of

Siemens Medical Solutions Customer

Service Division. Now healthcare pro-

viders are increasingly using networked

systems, so the market needs a suitable

virus protection solution.

* depending on software configuration

S O MATO M S pi r i t

The Easy Way From Sequential

to Multislice CTTo support customers in advancing their

computed tomography (CT) perform-

ance, Siemens Life Customer Care Solu-

tion offers Elevate, a program dedicat-

ed to updating outdated systems with

new ones for example SOMATOM AR

sequential scanners from the 1990s

with the spiral, dual-slice CT SOMATOM

Spirit, a cost-effective system for clinical

routine. When comparing the two sys-tems, the SOMATOM Spirit offers many

advantages: Its spiral scan mode and

multislice technology broadens the clin-

ical spectrum. Concurrently, together

with its fast scan time, spiral scanning

speeds up data acquisition and thus re-

duces motion artifacts. With the syngo-

based, easy-to-operate user interface

and an image reconstruction time of

only one second, the SOMATOM Spirit

accelerates the whole diagnostic

process. Thanks to the SOMATOM Spir-

its multislice technology, users can re-

construct different slice thicknesses

based on one single scan for example,

thin slice, high-contrast images and

wider slices with soft tissue display at

low contrast resolution. The SOMATOM

Spirit offers better resolution in high-

contrast structures, and a better low-contrast detectability in soft tissue.

Siemens unique UltraFastCeramic

(UFCTM) detector material and dose

reduction software lower patient dose

while achieving better image quality.

All in all, a lot of reasons why SOMATOM

AR owners should consider converting

their system.

www.siemens.com/

SOMATOMElevate

k

Siemens Virus Protection handles

virus-related security matters on syngo

based systems.

Elevate Siemens managed

system upgrade program brings

clinical performance to a higher

level: from the sequential single-

slice SOMATOM AR to the new

spiral, multislice SOMATOM Spirit.


25/54

SOMATOM Sessions17 25

BUSINESS

Interview

S O MATO M Emo t io n

Excellent Price-Performance RatioSiemens Medical Solutions recently

installed the first SOMATOM Emotion

16-slice computed tomography (CT)

system at the following locations: in

Germany, at the Israelitische Kranken-

haus, Hamburg and Klinikum Nurem-

berg Nord; in Belgium, at Clinique du

Sud-Luxembourg/St. Joseph, Arlon;

and in the US, at the Ohio State Uni-

versity, Columbus. SOMATOM Ses-

sions spoke with Johann-C. Steffens,

MD, Head of Radiology of the Israeliti-

sche Krankenhaus.

What are your first experiences with

the 16-slice SOMATOM Emotion?

The amazing fact for me was that the

new 16-slice SOMATOM Emotion

worked as a reliable scanner from the

very first day, replacing our 6-slice CTscanner. Installation took only two

days. The syngo user interface of the

16-slice SOMATOM Emotion is so sim-

ilar to the SOMATOM Emotion with six

slices that there were no changes in

how to operate the system, and no

need for additional training. We now

use the scanner for our daily routine

as well as for advanced applications

like CT Colonography.

Which clinical advantages and image

quality, compared to a 6-slice CT,does the 16-slice configuration of

the SOMATOM Emotion provide?

We appreciate the low image noise

and high resolution that the system

allows us to achieve. Because of the

faster rotation time and the higher

number of slices, we can perform sub-

millimeter lung examinations in one

single breath-hold, so that motion arti-

facts are reduced. In addition, run-offs

can be performed in better resolution

and with a longer range, giving us the

opportunity to see smaller details. We

achieve very good image quality inabdominal imaging and imaging of

bony structures. In addition, the im-

age quality of head scans is outstand-

ing.

With the 16-slice configuration of

the SOMATOM Emotion, the resolu-

tion and the number of slices in-

creased. How about patient dose?

Patient dose does not increase. Be-

cause of the efficient system design,

the effective patient dose is generally

very low. For most examinations theeffective patient dose is less than with

our former 6-slice system.

To which users would you recom-

mend the new configuration of the

SOMATOM Emotion?

I think this scanner provides radiolo-

gists the opportunity to perform rou-

tine and advanced applications. There-

fore it enables them to get more

patients from their referrals and also

increase the number of referrals. In

addition, the low investment and life-

cycle costs permit radiologists with

limited budgets to purchase a scannerwith excellent performance. Especial-

ly radiological departments in small

and mid-size hospitals and imaging

centers can profit from the excellent

price-performance ratio of the SO-

MATOM Emotions 16-slice configura-

tion.

www.israelitisches-krankenhaus.dek

Johann-C. Steffens,

MD: The SOMATOM

Emotion 16 enables

us to achieve low

image noise and high

resolution.

The Israelitische Krankenhaus in

Hamburg is a 205-bed hospital con-

sisting of the Medical Clinic and the

Surgery Clinic, plus an interdiscipli-nary intensive care unit and the De-

partment of Anesthesiology. The Radi-

ological Practice of Dr. Steffens, a

Cardiological Practice, a Neurological

Practice and the cancer research cen-

ter, Indivumed, are located on the

same premises and closely cooperate

with the hospital.


26/54


27/54

NEWS SECTION


BUSINESS

R E V E N U E

Investment Pays OffModern equipment is one of the key

factors in providing more efficient and

higher quality healthcare today. Both clin-

ical community and patients benefit from

an improved clinical workflow and ad-

vances in medical diagnosis. In computed

tomography (CT), scan modes, scan and

image reconstruction times, resolution,

applications and user interfaces, as well as

dose reduction methods, have all devel-

oped quickly over the past few years.

Keeping a hospital up-to-date is a finan-

cially significant task. However, two re-

cent analyses show that it pays off.

A Giant LeapHospital Moinhos de Vento, Porto Alegre,

Brazil, took one giant leap forward when

it replaced two single-slice scanners with

one SOMATOM Sensation Cardiac 16 in

2004. When comparing the database of a

six-month period prior to the installation

to a six-month period after the installa-tion, they realized that the average time

for scheduling an examination was re-

duced from 26 to 11 minutes; that the

number of examination increased by

52 percent; that the average contrast vol-

ume was reduced by 25 percent; and that

the number of examinations with patient

sedation was reduced from 4 percent to

3.2 percent. Using modern, multislice

equipment dramatically streamlines the

workflow and increases patient care and

comfort, concludes J.A. Marconato, MD

at the hospital. He points out, however,

that this improvement is only possible if

the entire staff works together as a team

from scheduling the examinations to di-

agnosing the images: Today, the limita-

tions are no longer set by the equipment.

Step by StepOf course, one expects such savings from

a major upgrade step even if one new

scanner replaces two old ones. But it also

pays off to be among the early adopters

of new CT technology. The Chairman of

the Radiology Department at a huge US

hospital compared core data from several

systems, starting with the SOMATOM Plus

4, the SOMATOM Volume Zoom and the

SOMATOM Sensation 16, up to the SO-MATOM Sensation 64. One basic result:

Acquisition and reconstruction times de-

creased dramatically over the years, en-

abling higher patient throughput. The

clinic has increased its patient volume

from less than 20 patients per day with

the SOMATOM Plus 4 to well over 60

while enabling on demand examina-

tions instead of the long waiting lists com-

mon with the older systems. In spite of

higher staffing required to run the

SOMATOM Sensation 64, the expenses,

as a percentage of the revenue, trend

down. This is due to higher patient vol-

ume, and also to a different staffing skill

mix. Today, more aides are hired for tasks

that do not require the expertise of a tech-

nologist to ensure the same patient tran-

sit time and patient care. With this combi-

nation of measures, the clinic has been

able to continuously reduce expenses;

from more than 60 US$ per exam to 45,

despite rising market prices for the scan-

ners. As a result, expenses as a percent-

age of net revenue have decreased from

over 16 to only 9 percent. In summary, in-

creased coverage, speed, resolution, ap-

plications, indications and availability not

only increase patient care: When it comes

down to finances, these improvementsalso decrease spending. A detailed pres-

entation, now available on CD, was held

by the clinic's radiology chairman at the

7th SOMATOM CT User Conference

2005 (see page 49).

Results may vary. Data on File.

Abdominal CT Scan Total Exam Time

35

3025

20

15

10

5

0

Time(Minu

tes)

Plus4 Volume Zoom

Acquisition

Patient TransitRecon

Sens at ion 16 Sen sa ti on 64

An abdominal scan with the SOMATOM Plus 4

took more than 30 minutes total examination

time with the SOMATOM Sensation 64, every-

thing was done in five minutes.

Expense Trends

By continuously upgrading their CT equipment,

the US c linic has been able to increase patient

throughput while reducing costs.

18

1614

12

10

8

6

4

2

0

Perc

ent

Plus4 Volume Zoom Sensation 16 Sensation 64

Payroll & Benefits

Medical Supply & OtherDirect EquipExpenseTotal Expense


28/54


Case 1:CT Angiography of Chest, Abdomen, Pelvis andUpper Extremities with CARE Dose4D and z-SharpBy Dominik Fleischmann, MD, Jeffrey C. Hellinger, MD, and Geoffrey D. Rubin, MD, Department of Radiology,

Cardiovascular Imaging Section, Stanford University Medical Center, Stanford, CA, USA

HISTORY

A 34-year-old woman with right arm numbness was referred

for CTA of the upper extremities as well as the chest,

abdomen and pelvis. The patient's past medical history was

significant for a right brachial artery aneurysm presumably

caused by vasculitis which had been treated with a

reversed vein graft and secondary interventions over the

past 10 years. The patient also had a history of bilateral iliac

artery aneurysms.

The imaging goal in this particular case was to identify or

exclude a vascular cause for the patient's recent right arm

symptoms. Because of the patient's history and the known

iliac artery aneurysms, the large arteries of the body were

also imaged. We chose a single CTA acquisition with the

patients arms placed next to her body and a single contrast

medium injection into a left antecubital vein.

Care Dose4D Automated Dose Modulation

[ 1 ] Consistently excellent image quality throughout the entire scanning range in vascular territories

within the body and in the upper extremities off-center at an average of 180 effective mAs

0

50

100

150

200

250

300

350

400

450

500

550

600

650

700

750

800longitudinaldistanceinmm

Effective mAs (Houndsfield Units)

0 50 100 150 200 250 300

Eff. mAsRef mAs: 250, kVp 120

A

verage180mAs

73

245

93

160

106

252

158Image Noise(HU)

Dose Modulation(eff. mAs)

Oncology NeuroCardiovascular Acute CareCLINICAL OUTCOMES


29/54

Scanner SOMATOM Sensation

64-slice configuration

Scan area From lower neck to finger-tips;arms by side of body

Scan length 77.5 mm

Scan time 29 s

Scan direction cranio-caudal

kV 120 kV

Effective mAs 180 at 250 Ref mAs

Rotation time 0.5 s

Slice collimation 0.6 mm

Slice width 1 mm

Pitch 0.7

Reconstruction increment 0.7 mm

CTDI 13.41 mGy

Kernel B25f

Contrast Omnipaque 350 mg iodine/ml

Volume 25 cc at 5 cc/s, 100 cc at 4 cc/s,

followed by 40 cc saline flush

Start delay 5 s

NEWS SECTIONCLINICAL OUTCOMES


EXAMINATION PROTOCOL

[ 2 ] A left vertebral artery origin

directly off the aortic arch is present.

Otherwise, the supraaortic vessels arewithin normal limits.

[ 3 ] Right common iliac artery

aneurysm and small left internal ili-

ac artery aneurysm. A high-gradestenosis of the celiac artery, due to

median arcuate ligament impinge-

ment is noted.

[ 4 ] Multiple mild focal dilata-

tions within the right brachial

artery, a reversed vein graft.The graft is patent with mild

stenosis distally. Several surgical

clips are also noted.

DIAGNOSIS

Incidentally noted is a left vertebral artery origin directly off

the aortic arch. Otherwise, the supraaortic vessels are within

normal limits. The right subclavian and axilary arteries are

patent. Multiple focal areas of mild dilatation (11 to 14 mm indiameter) are seen within the right brachial artery reversed

vein graft. The graft is patent with mild stenosis distally. The

radial, ulnar, and interossea arteries are patent.

A high-grade stenosis of the celiac artery origin, due to

median arcuate ligament impingement, is noted. The thora-

co-abdominal aorta and its visceral branches are otherwise

unremarkable. A 15 mm right common iliac artery aneurysm

and a small, 11 mm left internal iliac artery aneurysm are

seen in the pelvis.

COMMENTS

The patient was positioned in supine position with her arms

placed at the sides of her body, to enable coverage of the

entire chest-abdomen-pelvis and upper extremities vessel ter-

ritories within a single CTA acquisition, and with a single injec-

tion of contrast medium. Although such positioning may

cause streak artifacts in the shoulder region and excessive

noise within the upper extremities, the use of automated tube

current modulation (CARE Dose4DTM) and high spatial resolu-

tion using z-Sharp Technology resulted in virtually artifact-free

visualization of all clinically relevant vessels at unprecedented

image quality.


30/54


Case 2:Peripheral RunoffBy Jean-Bernard DHarcour, MD, Cliniques du Sud-Luxembourg,

site St. Joseph, Arlon, Belgium

HISTORY

A 55-year-old patient with previous history of left femoral

bypass was presented for mild claudication of the right leg.

A CTA runoff with the SOMATOM Emotion was performed.

DIAGNOSISCTA shows severe aorto iliac athromatosis and complete

occlusion of the left iliac axis. Left aorto femoral bypass is

patent. On the left side, a short occlusion of the distal super-

ficial femoral artery (SFA) is disclosed. On the right side,

there is no significant stenosis of the iliac axis but a long

occlusion of the SFA is shown. On both sides, peripheral

arteries are patent.

[ 1 ] VRT showing occlusion of the left iliac artery

and patency of aorto femoral bypass. Bone removal

was performed with syngo InSpace4D.

COMMENTS

This case demonstrates the ability of the SOMATOM Emotion

with 16-slice configuration to achieve complete arterial map-

ping, thus enabling the physician to plan vascular therapy.

syngo InSpace4D with bone removal allows a quick overview

of the entire vascular tree and permits a reliable analysis of

heavily calcified segments. Complete evaluation should not

take more than 15 minutes.

[ 2 ] VRT of the complete examination



31/54


32/54


Case 3:Optimizing Clinical Workflow in CT ColonographyUsing syngo Colonography PEVBy Anno Graser, MD, and Christoph R. Becker, MD, Department of Clinical Radiology,

University Hospital Munich-Grosshadern, Munich, Germany

[ 2 ] Adenomatous polyp in the trans-

verse colon close to the hepatic flexure

[ 3 ] CAD identified several

additional small lesions.

At our center, the demand for colorectal cancer screening is

growing and the number of CT colonography (CTC) exami-

nations is increasing rapidly. We are constantly looking for

tools that help us to improve speed and enhance confidence

and offer our patients the highest possible level of care. A

study performed at our institution to be presented at this

years Radiologic Society of North America (RSNA) annual

meeting (Session SSG 10-07, Tuesday, November 29) shows

that PEV reaches 94% sensitivity in the detection of polyps inthe important 5-9 mm size range. In addition, the study

shows that PEV can be integrated into clinical routine due to

its short running time of 4 minutes per dataset. With PEV

running in the background, syngo Colonography PEVs per-

formance remains unrivalled, delivering excellent perform-

ance in everyday clinical routine increasing reader confi-

dence and shortening evaluation time.

The case presented here shows how PEV improves human

[ 1 ] Anastomosis of the descending

colon and the remaining sigmoid

Computer Assisted Reading More Speed.Enhanced ConfidenceThe use of computer assisted reading tools such as syngo

Colonography with PEV (Polyp Enhanced Viewing) and

syngo LungCARE CT with NEV (Nodule Enhanced Viewing)

can significantly enhance clinical workflow, adding speed

and diagnostic confidence. Two expert centers look at just

how much value second-reader products can add to their

clinical workflow.

reader performance and level of confidence in the detection

of polyps. The 62-year-old male patient had undergone par-

tial sigmoidectomy for resection of a stage T2 cancer in

2002. The patient underwent CTC, following incomplete

colonoscopy.

There is end-to-side anastomosis of the descending colon

and the remaining sigmoid [Fig. 1] and a 15-mm adenoma-

tous polyp in the transverse colon close to the hepatic flex-

ure [Fig. 2]. The PEV algorithm identified several additionalsmall polyps: one difficult to see hiding between two folds

[Fig. 3], another had been obscured by a puddle of fluid on

the supine scan and can only be seen on prone images where

there is slightly increased image noise seen as the character-

istic cobble stone pattern of the colonic mucosa which nev-

ertheless does not prevent detection of the lesion [Fig. 3]. In

summary, PEV shows an excellent performance in the detec-

tion of colonic lesions.



33/54


CLINICAL OUTCOMES

Case 4:Improved Workflow for Detectionof Pulmonary NodulesBy Marco Das, MD, Andreas Horst Mahnken, MD, Georg Mhlenbruch, MD, Joachim Ernst Wildberger, MD,

Department of Diagnostic Radiology, Rolf. W Gnther, MD, Director, Department of Diagnostic Radiology, and

Thomas Kraus, MD, Department of Occupational Health, RWTH Aachen University, Aachen, Germany

[ 2 ] The NEV software

detected the nodule and

marked it as a potential

lesion with a red circle. The

mark has to be evaluated

by the radiologist to confirmthis finding as a true posi-

tive finding.

[ 3 ] The software allows a quantitative evaluation of

the nodule and gives information about diameters, volume,

and CT density values. It also allows a comprehensive view

of the anatomical location between the vessels in this 3D-

rendered scene of the finding (Volume Of Interest, VOI).

After identifying the nodule as a true positive finding, all

these parameters are stored in the final report.

Multidetector-row computed tomography (MDCT) is the

method of choice for detection of pulmonary nodules.

Increased spatial resolution with modern CT scanners facili-

tates the detection of nodules as small as one or two mil-

limeters. Overlooked pulmonary nodules, regardless of size,

may have potentially severe consequences for the patient.

Reasons for missing nodules may be perception errors or

misinterpretation. Double reading during clinical routine has

been suggested to reduce false negative diagnosis. In times

of increased workload and limited human capacity, this

goal is not always practicable. Moreover, quantification of

nodules is problematic due to inter- and intraobserver vari-

ability. Thus, computer algorithms have been developed to

aid the radiologist for the detection and quantification of pul-

monary nodules.

ENHANCED CONFIDENCE

syngo LungCare CT with NEV facilitates the detection work-

flow and provides easy objective quantification and reporting

of pulmonary nodules. Fig. 1 shows a routine low-dose chest

MDCT examination of a 66-year-old male patient (120 kV, 10

mAs eff., 16 x 0.75 mm collimation, rotation time 0.5 sec,

table feed/rotation 18 mm, 1 mm slice thickness, 0.5 mm

reconstruction). With initial standard reading using Maxi-

mum-Intensity-Projection (MIP technique; 5 mm thick sec-

tion), a pulmonary nodule was not detected, probably

because of its central location closely surrounded by largevessels. During initial standard reading, the NEV algorithm

runs in the background and marks potential lesion candidates

for reviewing after the initial read. The nodule was detected

and marked by the software automatically [Fig. 2] and was

confirmed by the reading radiologist. With one additional

mouse-click, quantification of the nodule was performed

[Fig. 3]. After final reporting, the patient underwent CT-guid-

ed, fine-needle aspiration biopsy and small-cell lung cancer

was finally diagnosed during cytopathological work-up.

[ 1 ] 66 year old male patient

who received a low-dose

MDCT chest examination for

the detection of pulmonary

nodules. Initial reading missed

the nodule located centrallybetween several surrounding

vessels in the left lower lobe.


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Case 5:Respiratory Gated CT-Imagingin Radiation Therapy of Lung CancerBy J. Dinkel, MD, A. Jensen, MD, U. Mende, MD, PhD, Department of Radiation Oncology, and J. Debus MD, PhD,

Director, Department of Radiation Oncology, University of Heidelberg, Germany

this patient, the breathing frequency was over 12 cycles/min.

CT data was collected in spiral mode, with simultaneous

acquisition of 24 parallel sections using a 1.2 mm collimation

and appropriate spiral pitch of 0.1. The respiratory signal

from the patient was synchronized and simultaneously

recorded during free-breathing CT data acquisition, using a

chest-belt with a pressure sensor. Virtually correlated 4D

phase volumes (with the time as the fourth dimension) were

reconstructed after the scan to form a model of anatomic

movement. 7 different reconstructions were performed cor-

responding to different phases of the breathing cycle.

In these CT scans, a 4 x 3.7 x 3.8 cm lobular mass was clearly

visible in the medial aspect of the left upper lobe extending

to the left hilus. Various nodular calcified lymph nodes as

well as an enlarged aorticopulmonary lymph node could beseen in the mediastinal region. Additionally, the CT scan

showed an extrathoracic metastasis in the left adrenal

gland. In our scans, the tumor mobility was about 2.1 mm in

[ 1 ] Nodular calcified lymph node as well as an

enlarged aorticopulmonary lymph node can be seen

in the mediastinal region.

[ 2 ] Metastasis in the left adrenal gland

HISTORY

A 62-year-old female patient under chemotherapy treatment

for a non-small-cell lung cancer and cerebral metastases

was examined using the SOMATOM Sensation Open with a

4D respiratory gated data acquisition protocol in order to

determine the full range of motion of critical internal struc-

tures and the lung cancer during respiration. This method

was used to achieve a more targeted radiation treatment.

DIAGNOSIS

Respiratory gating supplies information about tumor motion

during the patient's breathing cycle. The introduction of the

latest generation multislice CT systems with short acquisi-

tion times permits the evaluation of thoracic structures with

a temporal resolution of 250 ms. Short acquisition times inthis set-up are achieved by simultaneous acquisition of 24 or

40 transverse sections, half-second scanner rotation, and

advanced respiratory-gated reconstruction algorithms. In


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CLINICAL OUTCOMES


Scanner SOMATOM Sensation Open

Scan area ThoraxScan length 300 mm

Scan time 51.85 s

Breathing frequency > 12 cycles/min.

kV 120 kV

Effective mAs 400 mAs

Rotation time 0.5 s


Slice width 1.5 mm

Pitch 0.1

Reconstruction increment 1 mm

CTDI 35.63 mGy

Kernel B10f

Postprocessing syngo Inspace4D

3A 3B

the x-axis (L-R), 6.2 mm in the y-axis (A-P) and 5.2 mm in the

z-axis. The mass, however, did not show a deformation dur-

ing the breathing cycle. Visualization of structure motion is

possible with dedicated software syngo Inspace4D.

COMMENTS

New approaches in radiation therapy with the use of more

and more conformal dose application in combination with

higher doses per fraction for irradiation treatment need

accurate delineation of tumor and critical structures espe-

cially in areas where artifacts distorting the geometric shape

and location of the organs cannot be tolerated. Motion arti-

facts usually occur at boundaries of anatomical structures

(both target volumes and organs at risk), resulting in the

image degradation and the inability to correctly delineateanatomical structures. This leads to erroneous position,

shape and volume information for target volumes and other

regions affected by motion.

The respiratory gated data acquisition in CT allows the plan-

ning physician to visualize and study the organ and tumor

motion in 3D coordinates and time, contributing to a better

understanding of the target area and potential sparing of

healthy tissue by minimization of treatment volume and

reduction of side effects. Respiratory gating is a promising

new tool to increase the quality of RT planning and patient

treatment.

[ 3A, 3B ] Two reconstructions corresponding to different phases of the breathing cycle demonstrate the

range of motion of critical internal structures and the lung cancer during respiration.


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CLINICAL OUTCOMES

[ 4 ] Tumoral encasement ofthe inferior pulmonic vein

[ 5 ] Post obstructive lung changeson the right side

[ 6 ] MPR views of the paramediastinal fibrotic changes

[ 3 ] Tumoral mass caudal inthe right hilum



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38 SOMATOM Sessions17

Case 7:Making a Difference with PET andCT in Complex Cases

Biograph High-Resolution Examination

The powerful functional imaging in Positron Emission Tomo-

graphy (PET) became even more powerful with the addition of

anatomical data from CT. The diagnostic limitations of stand-

alone PET and CT procedures are eliminated with combined

PET/CT imaging technology, which has become the gold

standard for tumor diagnosis and staging. Siemens Biograph

PET/CT hybrid-imaging scanners provide seamlessly matched

functional and anatomical images from a single non-invasive

procedure, enabling accurate tumor diagnosis, whole-body

staging, target definition and treatment planning. The Bio-

graph provides complete clinical information regarding the

exact location, size and metabolic activity of disease.

HISTORY

This 63-year-old female patient with severe scoliosis and his-

tory of surgically removed gallbladder cancer in 2004 was

seen for follow-up in March 2005. In this routine follow-up,

the patient was diagnosed with Non Small Cell Lung Cancer

(NSCLC), and a hybrid PET/CT was ordered for staging.

DIAGNOSIS

In addition to several pulmonary lesions and the NSCLC, the

PET/CT study, obtained on the Biograph 16 HI-REZ, identified

multiple bone lesions within the spine [Fig. 1, Fig. 2], two

intra-abdominal lesions [Fig. 3], as well as additional 6 mm

lesions in the thorax wall [Fig. 4, Fig. 5]. The metastatic and

some other bone lesions were almost undetectable in the CT

images.

COMMENTSPET has a major role in early detection, staging and treatment

planning of lung cancer and related metastases. FDG PET

influences patient management decisions, effecting treat-

ment outcomes and quality of life. Adding co-registered,

detailed anatomical data acquired with a diagnostic CT scan

increases the diagnostic accuracy and provides the reading

and referring physician with the possibility to assess func-

tional and structural changes in one exam.

Using hybrid PET/CT scanning was critical in diagnosing the

additional, unexpected bone metastases and lesions in the

thoracic wall. Some of these bone lesions would have beendifficult to detect using a stand-alone CT. However due to the

patients extreme case of scoliosis, an exact correlation of

stand-alone PET data to the corresponding vertebras was only

possible by using co-registered functional (PET) and anatomi-

cal (CT) information provided by the PET/CT hybrid imaging

scan. The HI-REZ PET imaging technology of the Biograph 16,

with its unmatched additional resolution, also played a signifi-

cant role in accurately identifying the smaller lesions in the

thorax wall, allowing greater diagnostic confidence to the

interpreting physician.[ 1 ] CT Spine image of patient with severe case of scoliosis



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CLINICAL OUTCOMES

Contrast

Volume 90 cc

Dual phase CT acquisition of the thorax and(arterial and portal venous) upper abdomen

[ 3 ] Fused PET/CT image identifies

two intra-abdominal lesions.

[ 4 ] CT image of the thorax wall [ 5 ] PET/CT image identifies 6 mm

lesions in the thorax wall.

[ 2 ] PET/CT image showing multiple

bone lesions within the spine


Scanner Biograph 16

FDG 11mCi

Uptake time 62 min

Beds 7

Time per bed 3 min

HI-REZ yes

Scan area Whole body

Scan direction Cranial-caudal

Effective mAs 30 mAs

Rotation time 0.5 s


Slice width 5.0 mm

Table feed/rotation 24 mm

Pitch 1

Reconstruction increment 5.0 mm

Case courtesy of Martina Eschmann, MD, Tuebingen University, Tuebingen, Germany


40/54


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CLINICAL OUTCOMES

[ 1A ] Osteolysis of the mandible with

cortical destruction [ 1B and 1C ]; Fistula

of the bone in bone [ 1B ] and soft tissue

window [ 1C ]; Inflammation of the soft

tissue along the fistula with skin retraction

[ 2 ] BSCT-Angiogram: frontal view [ 2A ]

and left carotid artery from a lateral

[ 2B ] and medial [ 2C ] view

1A

1B

1C

2A

2B

2C


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Case 9:40-Slice CT for Diagnosis and SurgicalPlanning in Traumatic ParaplegiaBy Steffen Gnther, MD, and Markus F. Berger, MD, Institute of Diagnostic Radiology,

Swiss Paraplegic Center, Nottwil, Switzerland

HISTORY

A 22-year-old man was brought to our hospital by emergency

transport helicopter (REGA) with incomplete paraplegia sub

L2 (ASIA D) following a motorcycle accident. Prior to admis-

sion, the patient had been completely healthy. A vertebral

fracture was suspected and CT scanning of the lumbar spine

for diagnosis and surgical planning was performed. Following

initial posterior instrumentation, a follow-up examination

was performed to document the operative result and to

assess the need for additional anterior stabilisation.

DIAGNOSIS

CT scanning revealed a traumatic burst type vertebral body

fracture of L2 with loss of spinal stability. Bony compromise of

the spinal canal was present. An additional MR scan showedtraumatic injury to the conus medullaris, as the patient unfor-

tunately also had a tethered cord.

Follow-up CT after initial treatment by posterior USS-titanium

stabilisation from L1 to L3 demonstrated an exellent opera-

[ 2 ] Axial image showing postoperative

follow up after burst type fracture of vertebral

body L2. Note the minimal metal artefacts.

[ 1 ] VRT lateral view of the lumbar spine

showing fracture of vertebral body L2

with extension into the posterior column

tive result. Due to the intended straightening of the fracture

zone, there was a relatively large bony defect in the body of

L2 and the need for additional anterior intervertebral fusion

L1/L2 in a second intervention. After both successful opera-

tions the patient showed partial recovery of neural function.

COMMENTS

By using 1.0 s rotation and z-Sharp Technology's flying focal

spot, the SOMATOM Sensation scanner with 40 slices allows

us to achieve both extended coverage and the highest reso-

lution in one examination. Vertebral fractures can be

assessed from whole body datasets in multiple planes and

unprecedented detail. Due to the marked reduction of metal

artefacts, imaging of the postoperative spine has dramatical-ly improved. We can now see what was completely invisible

before. The volume rendered images created with the syngo

InSpace4D application on the CT workstation are simply stun-

ning.



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CLINICAL OUTCOMES

[ 3 ] VRT images showing postoperative results after posterior-lateral stabilisation;

different views with colour emphasis on the metal implants. Note the virtual absence

of streak artefacts and the excellent delineation of implanted bone chips.


Scanner SOMATOM Sensation 40-slice configurationPre-surgery Post-surgery

Scan area Lumbar spine Lumbar spine

Scan length 250 mm 194 mm

Scan time 46 s 18 s

Scan direction Caudal-cranial Caudal-cranial

kV 120 kV 120 kV

Effective mAs 482 mAs 261 mAs Postprocessing InSpace4D InSpace4D

Rotation time 1.0 s 1.0 s

Slice collimation 0.6 mm 0.6 mm

Slice width 0.75 mm 0.75 mm

Pitch 0.45 0.9

Kernel B25s B25s


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SCIENCE


Patients with carcinoma of the oral cavity that infiltrate bone

require resection of the involved part of the mandible. This

resection may be performed in a continuity-preserving or, in

more advanced cases, continuity-interrupting resection. To

cover larger defects in order to provide fixation of prosthetic

dentures and restore the ability to masticate, microvascular

grafts are required. Fibula- and radius-grafts are commonly

used. Before reconstructive surgery, detailed information of

the host region is essential for the surgeon [1]. Tumor recur-

rence has to be ruled out, the viability of surrounding bone

has to be assured, and the vascular situation in the host

region has to be assessed. Besides course and diameter of

the external carotid artery (ECA) and its branches, it is

mandatory to be aware of angiopathies. Nutritive-toxic and

age dependent vessel alterations can be encountered fre-

quently in this patient population. Prior resection or preoper-

ative radiation therapy seriously affects the vascularbed in thereceiver region. A decision for or against microvascular

reconstruction has to be made based on the results of the

angiography. Selective catheter angiography (digital sub-

traction angiography, DSA) is still the gold standard in the

diagnosis of the head and neck vasculature. Major drawbacks

of DSA for preoperative vascular mapping are the relatively

high costs and risks of neurological complications. Recently,

multislice spiral computed tomography angiography (CTA)

has emerged as an alternative technique to DSA in a large

Multislice CT AngiographyHead and Neck Imaging

By Michael Lell, MD, Institute of Radiology, University Erlangen-Nuremberg; Bernd F. Tomandl, MD, Department of

Neuroradiology, Klinikum Bremen; Axel Barth, Product Manager Applications, Siemens AG, Medical Solutions, CT Division,

Forchheim; Emeka Nkenke, MD, Department of Maxillofacial Surgery, University Erlangen-Nuremberg; all Germany

variety of indications [39]. In the following paragraphs, the

protocols and results for CTA used at the authors institution

will be reviewed.

Imaging ProtocolPrior to entering the CT suite, an 18-gauge intravenous

catheter is placed in the right antecubital vein, and all mobile

dentures are removed. The patient is placed in supine posi-

tion with the head bedded in a headrest. A biphasic CT scan

is performed with a 16-slice or 64-slice spiral CT scanner

(SOMATOM Sensation 16 or 64). The arterial phase study is

used to create 3D angiographic images, the delayed phase

study for tumor staging. CARE Bolus can be applied to deter-

mine the individual start delay (TimeDelay) for the arterial

phase. Alternatively, the test-bolus method (10 ml contrast

media, 30 ml NaCl 0.9%) can be used: the test-bolus

sequence is then loaded in the Dynamic Evaluation appli-cation, and contrast enhancement curves of the arterial and

venous system can be analyzed in detail. Time-to-peak plus

2s is used as the delay be

somatom sessions 17

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