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Cover Story
Be FAST, take CARE
Page 6
Iterative Reconstruction
Reloaded
Page 14
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SOMATOM Sessions
News
Business
syngo.via: Ready for
Prime Time in Clinical
Practice
Page 34
RSNA-Edition
Clinical
Results
SOMATOM Denition
Flash: Rule-Out of Coronary Artery Disease,
Aortic Dissection and
Cerebrovascular Diseases
in a Single Scan
Page 60
Science
Dose Parameters
and Advanced Dose
Management on
SOMATOM Scanners
Page 68
27
Editorial
Imprint
Chief Editors:
Monika Demuth, PhD
(monika.demuth@siemens.com)
Stefan Ulzheimer, PhD
(stefan.ulzheimer@siemens.com)
Clinical Editor:
Andreas Blaha
(andreas.blaha@siemens.com)
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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.
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Street
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Photo Credits:
Thorsten Rother, Jez Coulson/InsightVisual, Johannes Krmer, Philip Singer/
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Photos, Stephan Sam
State
Country
Editorial
Andr Hartung,
Vice President
Marketing and Sales
Business Unit CT,
Siemens Healthcare
Dear Reader,
Recent improvements in healthcare have
created a serious backlog of patients at
many medical facilities, creating a contradictory situation: the medical care is
better but it has become more difficult
to be treated as medical facilities stagger
under an ever-increasing workload.
Adding to the contradictory matrix is a
medically well-informed public concerned with radiation exposure. An efficient, faster throughput of patients while
maintaining quality care has become
the critical issue in modern health care.
The creative and innovative products
developed by Siemens to deal with this
situation are truly amazing. The revolutionary, single-source SOMATOM
Definition AS (and AS+) scanner that
reduces many scans to a one click operation at extremely low dose. The
second noteworthy is the unique
SOMATOM Definition Flash scanner that
scans an entire thorax in less than one
second with sub-mSv dose and can
freeze even the fastest beating heart,
producing diagnostic quality cardiology
images in minutes.
We then introduced the syngo.via*,
multi-modality imaging software. With
syngo.via*, the reading physician can
observe and analyze CT, MR, PET,
Radiography, Fluroscopy and Angiography simultaneously on a single
monitor eliminating many trips from
the regular reading workplace to various
workstations. Another great advantage
of syngo.via* is the pre-processing
Andr Hartung
** 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.
** 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.
Content
Contents
Cover Story
20
A Pediatric Breakthrough
Cover Story
6 Be FAST, Take CARE
News
Business
30 1,000th SOMATOM Definition AS
Installed A Success Story
32 Time is Brain A Comprehensive
Stroke Program at the University
of Utah Considerably Improves
Patients Outcome
34 syngo.via: Ready for Prime Time in
Clinical Practice
36 SOMATOM Spirit: A Choice That
Paid Off
Content
32
60
Time is Brain
Clinical Results
Cardio-Vascular
38 SOMATOM Definition Flash Ruling
out Coronary Artery Disease with
0.69 mSv
40 SOMATOM Definition Flash:
Low-Dose Abdomen Pediatric Scan:
Follow-Up Study of Fibromuscular
Dysplasia
42 CT Dynamic Myocardial Stress
Perfusion Imaging Correlation
with SPECT
Oncology
44 SOMATOM Definition Flash: Motionfree Thoracic Infant Scan: Follow-Up
Study After Chemotherapy
46 SOMATOM Definition Flash:
Dual Energy Carotid Angiography
for Rapid Visualization of
Paraganglioma
48 Total Occlusion of the Left Superior
Pulmonary Vein by a Metastasis
Detected with Dual Energy CT
50 SOMATOM Spirit: Follow-Up Examination of Cerebral Meningioma
Neurology
52 SOMATOM Definition Flash: Improving Image Quality of Brain Scans
With IRIS, X-CARE and Neuro
BestContrast
Science
54 Volume Perfusion CT Neuro as a Reliable Tool for Analysis of Ischemic
Stroke Within Posterior Circulation
Acute Care
56 Dual Source, Dual Energy CT:
Improvement of Lung Perfusion
Within 5 Hours in a Patient With
Acute Pulmonary Embolism
58 Differentiation of Pulmonary Emboli
and Their Effect on Lung Perfusion
Determined With a Low-Dose Dual
Energy Scan
60 SOMATOM Definition Flash: Rule-Out
of Coronary Artery Disease, Aortic
Dissection and Cerebrovascular
Diseases in a Single Scan
62 SOMATOM Definition Flash: RIPIT to
the Rescue Fast CT Examination
for Trauma Patients
Pulmonology
64 Xenon Ventilation CT Scan Demonstrates an Increase in Regional
Ventilation After Bullectomy in a
COPD Patient
Life
74 Clinical Fellowship: Learning From
the Experts in the Field
76 STAR: Specialized Training in
Advances in Radiology
76 Evolve Update Facilitates Dose
Savings
77 Frequently Asked Questions
77 Siemens Healthcare is Proud to
Present a New Series of Live Clinical
Webinars
78 News at Educate Homepage:
Recommended CT Literature
78 Clinical Workshops 2011
79 Upcoming Events & Congresses
80 Corporate Magazines
81 Imprint
Orthopedics
66 SOMATOM Definition: Dual Energy
Locates Progressive Wrist Arthritis
Coverstory
The new generation of the FAST CARE software will be availabe for all SOMATOM Definition scanners spring 2011.
Coverstory
A program that
guides users intuitively through
the entire CT scan
makes the task
simpler, safer,
more reproducible and more
efcient.
Michael Lell, MD, PD, Departement
of Radiology, University of
Erlangen-Nuremberg, Erlangen,
Germany
Coverstory
such situations have to be resolved manually, which costs time. With FAST CARE,
the FAST Adjust function suggests the
ideal solution. But the focus is also on
faster diagnostics. This is where the
strengths of syngo.via,* Siemens new,
leading-edge imaging software, come
into effect. The software automatically
loads the images into the appropriate
application and segments them in such
a way that they can be adjudged without further ado. The physician can arrive
at a final diagnosis with just a few clicks
of the mouse as the images have already
been pre-processed for him. The application is determined by the disease-specific
criteria of the case at hand and no longer
needs to be independently selected.
Since syngo.via handles all preparatory
steps, the physician can focus completely on his actual task, namely diagnostics. This, too, saves time and
enhances diagnostic reliability.
*** 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.
*** SAFIRE: 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.
*** Data on le.
3 FAST Planning uses the defined anatomical landmarks to set the correct ranges. When
applied manually without FAST CARE, only based on the coronal view the lower part of the
lung could be easily be missed (indicated by the reference line).
4 Direct setting of the scan range in with FAST Planning assures covering the entire
organ without overscanning
Coverstory
5 FAST Cardio
Wizard: It is an
intuitive guidance software,
integrated
in the Cardio
workflow.
6 Anatomically
correct spine
reconstructions
are typically
very time consuming procedures, as every
spinal cord and
disc needs to
have an own
recon layer
depending on
its individual
position. With
FAST Spine,
these manual
steps can be
simplified to
ideally just a
single click.
Assistant Professor Dr. med. Michael Lell studied at the University of Regensburg and Technische
Universitt Mnchen. He is specialized in diagnostic radiology. Currently, he is Senior Physician at
the Institute of Radiology, Erlangen University Clinic, Erlangen, Germany, where he has been working
since 1997. He was a visiting researcher at the David Geffen School of Medicine at the University
of California, Los Angeles, and is a member of various national and international professional bodies.
He is also a peer reviewer of several medical journals.
Coverstory
We Need Better
Default Protocols.
Dr. Aaron Sodickson, MD, PhD, Assistant Director of
Emergency Radiology, Brigham and Womens Hospital,
Harvard Medical School, Boston, spoke to journalist
Dr. Hildegard Kaulen for SOMATOM Sessions:
Dr. Sodickson, in the past three years,
concerns have been raised about
cumulative exposure by repetitive CT
imaging. How serious is the problem?
SODICKSON: There is persistent controversy over the risk models that exist for
radiation exposure of the magnitude
used in CT. We attempted to quantify the
levels of risk using the most common
Linear-No-Threshold risk model used in
the 7th Biological Effects of Ionizing
Radiation (BEIR-VII) report. We studied
32,000 patients undergoing CT at our
institution, using the BEIR-VII model to
estimate cumulative cancer risks from
CT exposures. We found that 7% of our
cohort had undergone enough previous
CT radiation exposure to increase their
cancer risk by at least 1% or more above
baseline. As a result, we believe that
patients undergoing recurrent imaging
over time warrant heightened radiation
protection efforts.
Many CT users dont take full advantage of the available dose reduction
tools and work with protocols that are
not fully optimized. Is active assistance, such as that provided by FAST
CARE, the key to a more universal
adoption?
SODICKSON: Active assistance is one of
many excellent solutions. Any automation that makes scanning easier and
helps to create reproducible results
across the wide range of patient sizes
and technologist skill levels is extremely
valuable. But we also need better default
protocols that are dose-optimized and
robust in order to ensure adequate diagnostic image quality for every patient.
We need close collaboration between CT
manufacturers, radiologists, technologists, and medical physicists. By combining our different areas of expertise,
we can best reach consensus about
what works and what doesnt, and what
represents adequate image quality for
the particular diagnostic task at hand.
What are the essentials for a radiation
risk assessment program?
SODICKSON: We should routinely review
the imaging history of our patients. We
are working to implement a decision
support system that alerts ordering physicians in real time of the magnitude of
a patients radiation risk. Our goal is to
bring appropriate perspective to the risk/
benefit decision by providing the best
risk estimates possible. We hope this will
enhance an active and critical review of
the imaging order and an assessment of
how the scan fits into the longitudinal
medical history of the patient.
Will risk assessment interfere with
the workflow and lengthen the decision making and scanning process?
SODICKSON: That depends on how it is
implemented. We need solutions that
create an efficient workflow without
frustrating delays. Otherwise they might
not be accepted in clinical routine.
An exciting feature for dose reduction
is lowering kV. You had the chance to
test CARE kV, which is a part of FAST
11
News
evaluating it for two years. All cardiovascular CT and MRI exams, neurovascular
CT, and body CT studies requiring additional processing (e.g. CT urography and
colonography) are automatically routed
to the syngo.via server, and six radiolo-
News
Somatom_News_CC.indd 13
13
10.11.10 11:36
News
Iterative Reconstruction
Reloaded
For the rst time, SAFIRE* introduces the usage of raw-data information
within iterative reconstruction for everyday use in clinical practice.
By Jan Freund, Business Unit CT, Siemens Forchheim, Germany
For quite some time, iterative reconstruction has been heavily discussed in
the CT community as a highly promising
method to achieve significant dose
reduction without compromising image
quality. Essentially, iterative reconstruction introduces a correction loop in
the image generation process that
cleans up artifacts and noise in low-dose
images. The proposed approach is, that
after the initial reconstruction using the
weighted filtered back projection
(WFBP), the measured data of the
acquired image (in the so-called image
space) is compared to the data (raw-
1A
1A Plain FBP
data). But until now, the implementation of this method for clinical practice
was limited as the necessary re-transformation of data from the image to the
raw-data space was very time-consuming
and the computational power required
to make it feasible for everyday use was
not available. Therefore, vendors found
several different approaches to handle
this limitation in their first individual
solutions.
1B
1C
1D
1C IRIS
1D SAFIRE
News
** 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.
** Results may vary. Data on file.
15
1B
1A
Topic
1C
News
Topic
1 80-year old patient with severe aortic valve stenosis prior to transcatheter aortic valve implantation (TAVI). Pre-procedural Flash Spiral
angiography was performed using high-pitch spiral data acquisition prospectively triggered at 60% of the R-R interval (128 x 0.6 mm slices,
100 kV, 320 mAs, SOMATOM Definition Flash). For thoraco-abdominal
angiography including the coronary arteries (Arrowhead) only 40 ml of
contrast agent was used (flow rate 4 ml /s). Estimated effective radiation
dose was 4.3 mSv. at a scan time of 1.7 seconds.
Images show assessment of aortic annulus diameters in syngo.via (Fig.
1A dotted line) as well as distances between the aortic annulus and the
coronary ostia. In addition, peripheral arteries have been evaluated for
significant stenosis (Fig. 1B). The red arrow indicates an occluded iliac
artery, making transfemoral access impossible here. The same data also
shows pronounced calcification along the whole thoracic aorta (Fig. 1C).
160
140 ml*
Amount of Contrast Agent [mL]
140
120
100 ml#
100
80
60
40 ml
40
20
0
Single-Source CT
for Abdominal
Aorta
Single-Source CT
for Triple Rule Out
Dual Source CT
SOMATOM
Definition Flash
2 Up to 60%
less contrast
media by use of
high-pitch spiral
DSCT angiography of the
complete aorta
compared to
other CT technologies.
Courtesy of
University
of ErlangenNuremberg,
Erlangen,
Germany
*Loewe C, Eur Radiol 2010; #Wu W, AJR 2009; Flash Thorax Protocol
17
The Panel will meet twice a year to discuss new ideas and investigate whether
measures already agreed upon are having a positive impact. The next meeting
takes place at RSNA 2010.
www.siemens.com/low-dose-CT
News
19
News
Siemens has been in the forefront of dose-reduction. Marilyn J. Siegel, MD, Pediatric Radiologist, Washington University School of Medicine and
St. Louis Childrens Hospital, Missouri, USA
News
1 6 weeks old pediatic case after congenital heart surgery (utilizing 3 mSv)
21
Topic
News
Highly cost-effective
According to Dr. Pavel Ryska, responsible
for the SOMATOM Emotion 6, the decision to purchase Siemens scanners was
based both upon positive experiences
with the previous range and on the high
service level offered. Ryska values the
Emotion 6 range as it facilitates a high
examination density in line with mandatory medical standards for a large number of applications, making procedures
extremely cost-effective. Moreover, the
device is easy to install and has no
specific spatial demands. In Ryskas
view, a further benefit is the systems
reliability, which results in high economic efficiency.
The head of department particularly
appreciates the syngo user interface,
which not only facilitates fast orientation, but also functions in a manner
similar to other radiological devices
from the same manufacturer (such as
magnetic resonance), with the result
that staff from other departments
quickly become familiar with its
operation (so-called multi-modality
workplaces).
In the light of the fact that Czech
hospitals conclude fixed fee contracts
with health insurance providers, the
Indispensable workhorse
Ryska believes that, as a university
hospital, his establishment should be at
the forefront of technical progress.
However, he knows only too well that,
the Czech healthcare system has limited
resources. With its excellent speed- and
examination quality ratio, the highly
efficient SOMATOM Emotion 6 blends
into this medical landscape with consummate ease. In fact, it could be
termed the indispensable workhorse,
while the Definition AS+ is called on to
perform more challenging tasks.
A particular benefit of the CT devices at
the hospital in Hradec Krlov highlighted by Ryska is the variable and
therefore reduced patient radiation
exposure, achieved by state-of-the-art
technology (ultra-fast ceramic detectors
and CARE Dose4D technology). Exposure
is reduced by between 30 and 40 percent on average in comparison with
earlier models. Physicians are
Patient contact:
the highly efficient SOMATOM
Emotion 6 allows patient needs at a
public hospital funded by health
insurance firms to be met to the
required quality standards without
significant waiting periods.
23
News
News
The assessment of cardiac function also works with noisy MinDose images.
(30% dose savings in comparison with normal ECG Pulsing with 20% plateau)*
CT Cardio-Vascular Engine
offers automated workows
Siemens looked at the concerns of
SOMATOM CT users and has also
addressed clinical challenges such as
time management, cost pressure and
work sharing. Based on syngo.via,**
Siemens has released a completely renewed CT Cardio-Vascular Engine that
almost entirely automates clinical workflows. Radiologists can immediately
start diagnosing thanks to automated
performing pre-processing, the clear
arrangement of physiological parameters. In cardiac function evaluation,
these pre-settings and supportive
evaluation tools enable the user to skip
25
News
Advanced
Imaging for
Four-Legged
Patients
Installing the SOMATOM
Spirit has brought a new
level of patient care to Croft
Veterinary Hospital in Cramlington, Northumberland,
UK, while also increasing
referrals.
In 2008 Croft Vets has opened the doors to its state-of-the-art flagship
veterinary hospital.
In the same way that tertiary care hospitals provide the most advanced medical
care for humans, Croft Veterinary Hospital
in Cramlington, Northumberland, UK,
provides companion animals with
specialized care using state-of-the-art
equipment. Co-founder Malcolm Ness,
BVetMed, says that he and his colleagues wanted to build a referral center
where patient care would not be compromised by technological limitations.
This is why they chose to install Siemens
SOMATOM Spirit multi-slice CT scanner
when they moved to a new and larger
facility in 2008. We just wanted to do
things better and to continue to improve,
largely for the good of the patients,
but also for our own academic and intellectual satisfaction, Mr. Ness says.
While the use of CT in veterinary practices is still relatively rare, Mr. Ness
explains that the Spirit technology has
allowed him and his colleagues to work
more efficiently while improving patient
outcomes. Metastases from mammary
cancers in dogs that were once visual-
By Sameh Fahmy
News
* 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.
The jury of the largest corporate publishing contest in Europe honored the best
publications out of over 600 entries. We
hope you are just as satisfied with our
media as the jury. Dont hesitate to tell us
your opinion at editor.medicalsolutions.
healthcare@siemens.com.
If you would like to subscribe to any of
our periodicals, please visit our websites.
www.siemens.com/healthcaremagazine
www.siemens.com/healthcareeNews
27
News
Dual Energy CT
Dual Energy CT (DECT) allows for the
acquisition of a virtual non-enhanced
image and an iodine image with a single
scan, whereas the conventional method
1A
1B
1C
1D
1 Dual Energy CT
provides all the information needed for the
characterization of
renal masses in a singlephase scan. Diagnosis of
angiomyolipoma in the
left kidney:
1A: information of both
tubes;
1B: virtual non-contrast
image;
1C: iodine image;
1D: overlay of B and C
News
Myocardial Perfusion
Myocardial perfusion imaging is one indication to which the spectrum of Computed
Tomography is extended due to the innovative technology of the SOMATOM Definition
Flash. Mahnken et al. from Aachen report on
initial experience in quantitative whole heart
stress perfusion CT imaging7 in an animal
model. They assume that this technique is
able to show the hemodynamic effect of high
grade coronary stenosis7 and that it exceeds
the present key limitation of cardiac computed tomography.7 First clinical experience
is shown in a study by Bastarrika et al.:
Outlook
Further publications are expected to
come, showing how these new techniques are applied in clinical practice.
The editors of these two special issues
are convinced and conclude: , For sure,
innovative research on imaging technology () will contribute to advances in
clinical medicine and patient care.9
Siemens Computed Tomography will
proceed and will stay committed to its
innovation leadership.
1 Haberland U. et al. Performance assessment of
dynamic spiral scan modes with variable pitch
for quantitative perfusion computed tomography. Invest Radiol. 2010 Jul;45(7):378-86.
2 Morhard D. et al. Advantages of extended brain
perfusion computed tomography: 9.6 cm coverage
with time resolved computed tomography-angiography in comparison to standard stroke-computed
tomography. Invest Radiol. 2010 Jul;45(7):363-9.
3 Helck A. et al. Determination of glomerular filtration rate using dynamic CT-angiography: simultaneous acquisition of morphological and functional
information. Invest Radiol. 2010 Jul;45(7):387-92.
4 Goetti R. et al. Quantitative computed tomography liver perfusion imaging using dynamic spiral
scanning with variable pitch: feasibility and initial results in patients with cancer metastases.
Invest Radiol. 2010 Jul;45(7):419-26.
5 Graser A. et al. Single-phase dual-energy CT allows
for characterization of renal masses as benign or
malignant. Invest Radiol. 2010 Jul;45(7):399-405.
6 Thomas C. et al. Differentiation of urinary calculi
with dual energy CT: effect of spectral shaping
by high energy tin filtration. Invest Radiol. 2010
Jul;45(7):393-8.)
7 Mahnken AH. et al. Quantitative whole heart
stress perfusion CT imaging as noninvasive
assessment of hemodynamics in coronary artery
stenosis: preliminary animal experience. Invest
Radiol. 2010 Jun;45(6):298-305.
8 Bastarrika G. et al. Adenosine-stress dynamic
myocardial CT perfusion imaging: initial clinical
experience. Invest Radiol. 2010 Jun;45(6):306-13.
9 Fink C. et al. Advances in CT technology. Invest
Radiol. 2010 Jun;45(6):289.
http://journals.lww.com/
investigativeradiology
http://radiology.rsna.org/
content/256/2.toc
29
Business
The updated appearence of the new SOMATOM Definition AS, now with a clear resemblence that it inherited together with multiple features from
the SOMATOM Definition Flash.
Business
Right after its introduction, the manufacturing lines of the SOMATOM Definition AS
were filled and have remained filled since then.
31
Business
consisting of a neuro-interventionalist
Steve Stevens a neuro-surgeon and a
stroke neurologist committed to saving
precious time, developed a stroke program that provides fast and appropriate
treatment of the stroke patient. Part of
this program is the foundation of a
stroke center with a Brain Attack Team
available 24/7. This multi-disciplinary
team now consists of emergency physicians, neurologists, neurosurgeons,
radiologists, and specially trained nurses
and medical staff. This team is notified
as soon as a stroke is suspected, often
even before the patient reaches the
hospital.
Topic
The University of Utah stroke unit is equipped with latest CT scanner technology using
a SOMATOM Definition AS+ and the Adaptive 4D spiral technology in order to provide
whole brain perfusion in stroke patients. Having a brain attack protocol in place,
In-house stroke neurologists, residents, or fellows from the department of Neurology
quickly assess the patient and immediately proceed with a CT study to determine
the nature of the stroke: ischemic or hemorrhagic.
33
Business
No manual intervention
A patient comes to CIMOP for a vascular
scan. Once the image acquisition has
been done, it is transferred to the PACS
where Dr. Martin-Bouyer could do a
simple reconstruction in manual mode.
But with syngo.via*, he can use the case
preparation function instead. A vascular
application is selected and the images
Business
syngo.via,* which can connect to a standard PC, can be integrated into all
imaging machines and all PACS.
35
Business
1A
1B
Topic
1C
1D
1 A, B: Nitamar Abdala, MD, is convinced that SOMATOM Spirit fulfills the expectations of small
hospitals and furthermore offers a wide range of capabilities. C: Perfusion: Hypoperfused area
right frontal in this axial slice. D: Dental: Mandibula and molars in volume rendered technique
37
Case 1
SOMATOM Denition Flash:
Ruling out Coronary Artery Disease
with 0.69 mSv
By Ralf W. Bauer, MD, J. Matthias Kerl, MD and Thomas J. Vogl, MD
Goethe University Clinic, Department of Diagnostic and Interventional Radiology, Frankfurt, Germany
HISTORY
A 68-year-old patient with atypical
chest pain and known, year-long arterial
hypertension presented at the radiology
department in order to rule out coronary
artery disease. Ultrasound showed concentric left ventricular (LV) hypertrophy
and aortic valve stenosis, grade 1. The
resting heart rate was 50 bpm and no
beta-blockers were injected.
DIAGNOSIS
Coronary CT angiography using the prospectively ECG-gated Flash Spiral was
performed utilizing only 0.69 mSv radia-
tion dose. Mild concentric LV hypertrophy and minor calcifications of the aortic
valve were found. There was no sign of
macroangiopathic arteriosclerotic changes
in the main coronary arteries and their
major branches. Coronary artery disease
could be ruled out in this patient.
COMMENTS
In only 0.29 seconds scan time without
the use of beta-blockers, Coronary CT
angiography using 100 kV tube voltage
and the Flash Spiral acquisition mode
allowed ruling out coronary artery dis-
1 Volume rendered
display of the major
coronary arteries
was underlined with
multi-planar reconstruction (MPR).
2 Caudo-cranial
view of the distal
part of the right coronary artery (RCA)
and patent ductus
arteriosus (PDA).
3 Curved planar
reformatted (CPR)
display of the RCA.
4 90 degree
angulated view of
the RCA (compared
with Fig.3).
5 Curved planar
reformatted (CPR)
display of the left
anterior descending artery LAD.
6 CPR display of
the entire course
of the LAD.
EXAMINATION PROTOCOL
Scanner
Scan mode
Flash Spiral
Rotation time
0.28 s
Scan area
Heart
Pitch
3.4
Scan length
135 mm
Slice collimation
128 x 0.6 mm
Scan direction
Cranio-caudal
Slice width
0.75 mm
Scan time
0.29 s
Reconstruction increment
0.4 mm
Heart rate
50 bpm
Reconstruction kernel
B26f
Tube voltage
100 kV / 100 kV
Contrast
Tube current
370 mAs/rot.
Volume
70 ml
Dose modulation
CARE Dose4D
Flow rate
5 ml/s
CTDIvol
2.59 mGy
Start delay
Test bolus
DLP
49 mGy cm
Postprocessing
syngo InSpace4D
Effective Dose
0.69 mSv
39
Case 2
SOMATOM Denition Flash:
Low-Dose Abdomen Pediatric Scan: Follow-Up
Study of Fibromuscular Dysplasia
By Pia Sfstrm, MD, Nils Dahlstrm, MD and Petter Quick
Department of Radiology and Center for Medical Image Science and Visualization (CMIV),
Linkping University Hospital, Linkping, Sweden
HISTORY
DIAGNOSIS
COMMENTS
EXAMINATION PROTOCOL
Scanner
Scan mode
Flash Spiral
Rotation time
0.28 s
Scan area
Abdomen
Pitch
Scan length
240 mm
Slice collimation
128 x 0.6 mm
Scan direction
Cranio-caudal
Slice width
0.75 mm
Scan time
0.6 s
Reconstruction increment
0.6 mm
Tube voltage
80 kV
Reconstruction kernel
B31f
Tube current
88 mAs
Contrast
Dose modulation
CARE Dose4D
Volume
CTDIvol
1.4 mGy
Flow rate
2 ml/s
DLP
44 mGy cm
Start delay
Eff. Dose
0.88 mSv
Postprocessing
syngo 3D Basic
41
Case 3
CT Dynamic Myocardial Stress Perfusion
Imaging Correlation with SPECT
Kheng-Thye Ho, FACC,* Kia-Chong Chua, MSC,*
Ernst Klotz,** and Christoph Panknin,**
*Department of Cardiology, Tan Tock Seng Hospital, Singapore, Republic of Singapore
**Business Unit CT, Siemens Healthcare, Forchheim, Germany
1A
1B
2A
2B
HISTORY
A 61-year-old male with cardiac risk factors of hypertension and hyerlipidemia
presented with symptoms of atypical
chest pain. Resting ECG was unremarkable. Dipyridamole-stress nuclear myocardial perfusion imaging (NMPI) had demonstrated a very large, reversible defect
involving the apex, anterior wall and septum. The total defect size was quantified
as 34% of the left ventricle. Left ventricular ejection fraction was estimated as
65% in the post-stress images by gating.
Post-stress dilatation was noted in the
scan, which is an adverse prognostic sign
in the presence of coronary artery disease. Invasive coronary angiography
demonstrated total occlusion of the proximal LAD, with collaterals arising from
3A
3B
3C
Topic
3D
3E
DIAGNOSIS
COMMENTS
Another relevant finding was the reduction of MBF in the defect area at stress
even below its MBF at rest. This is evidence of a horizontal myocardial steal
occurring during vasodilator stress. These
findings are compatible with the angiographic findings of severe, complete
occlusion of the proximal LAD, and the
presence of collaterals from the left circumflex coronary artery (LCx) and right
coronary artery (RCA). In the normal resting situation, collaterals form LCx and RCA
supply the myocardium in the occluded
LAD territory. During vasodilator stress,
EXAMINATION PROTOCOL
Scanner
Scan length
73 mm
Slice collimation
128 x 0.6 mm
Scan time
30 s
Reconstruction increment
2 mm
B25
Heart rate
Reconstruction kernel
Tube voltage
100 kV
Contrast
Tube current
300 mAs/rot
Volume
60 ml
Flow rate
6 ml/s
CTDIvol
Start delay
Rotation time
285 ms
Postprocessing
43
Case 4
SOMATOM Denition Flash
Motion-free Thoracic Infant Scan: Follow-Up
Study After Chemotherapy
By Susann Skoog, MD, Nils Dahlstrm MD, and Petter Quick
Department of Radiology and Center for Medical Image Science and Visualization (CMIV),
Linkping University Hospital, Linkping, Sweden
HISTORY
DIAGNOSIS
COMMENTS
Continuous follow-up CT examinations
are necessary to monitor the treatment
effect and determine the complete
EXAMINATION PROTOCOL
Scanner
Scan mode
Eff. Dose
0.54 mSv
Scan area
Thorax CTA
Pitch
Scan length
172 mm
Slice collimation
128 x 0.6 mm
Scan direction
Cranio-caudal
Slice width
0.75 mm
Scan time
0.42 s
Reconstruction increment
0.6 mm
Tube voltage
120 kV
Reconstruction kernel
B31f
Tube current
20 mAs
Contrast
Dose modulation
CARE Dose4D
Volume
30 ml Ultravist 370 mg / ml
CTDIvol
1.23 mGy
Flow rate
1 ml/s
Rotation time
0.28 s
Start delay
30 s
DLP
30 mGy cm
Postprocessing
syngo InSpace4D
*Effective Dose was calculated using the published conversion factor for a pediatric (5 year old) chest of 0.036 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.
45
Case 5
SOMATOM Denition Flash: Dual Energy
Carotid Angiography for Rapid Visualization
of Paraganglioma
By Joo Carlos Costa, MD;* J. Oliveira, MD;* J. Dinis, MD;* R. Duarte, MD;* O. Borlido, RT;* M. Gonalves, RT;*
D. Martins, RT;* S. Silva, RT;* D. Teixeira, RT,* A. Chaves,** and Andreas Blaha**
* Radiology Department, Hospital Particular de Viana do Castelo, Viana do Castelo, Portugal
** Business Unit CT, Siemens Healthcare, Forchheim, Germany
HISTORY
DIAGNOSIS
A Dual Energy CT angiography examination confirmed a solid mass with the size
of 2.5 cm in diameter, located in the right
carotid bulb which could lead to carotid
paraganglioma. The arterial enhancement of the carotid arteries did not show
any signs of stenoses or occlusions.
There is no vascular abnormity present in
the Circle of Willis. Due to exact contrast
timing, venous contamination could be
avoided.
COMMENTS
The SOMATOM Definition Flash allows
the acquisition of Dual Energy examination at a low-dose level of 0.84 mSv.
Using syngo DE Direct Angio, the
EXAMINATION PROTOCOL
Scanner
Scan mode
Dual Energy
Slice width
1 mm
Scan area
Carotid CTA
Reconstruction increment
0.5 mm
Scan length
185 mm
Spatial Resolution
0.33 mm
Scan direction
Cranio-caudal
Reconstruction kernel
D26f
Scan time
5s
DLP
68 mGy cm
Tube voltage
140 kV / 100 kV
Effective Dose
0.84 mSv
Tube current
Contrast
Dose modulation
CARE Dose4D
Volume
CTDIvol
3.29 mGy
Flow rate
5 ml/s
Rotation time
0.28 s
Start delay
6s
Slice collimation
64 x 0.6 mm
PostProcessing
70 ml contrast
4 Coronal MPR of
the paraganglioma
(arrow).
5 Coronal angio
view compares both
carotids.
6 Lateral angio
view focusing on
paraganglioma in
carotid bulb
(arrow).
47
Case 6
Total Occlusion of the Left Superior
Pulmonary Vein by a Metastasis Detected
with Dual Energy CT
By Luca Flors, MD, Carlos Leiva-Salinas, MD, Klaus D. Hagspiel, MD
Department of Radiology, University of Virginia, VA, USA
DIAGNOSIS
HISTORY
A 58-year-old male patient with history of
metastatic melanoma (pulmonary, pleural mediastinal and brain metastases),
recurrent malignant pleural effusion that
required multiple episodes of thoracocentesis and recent right thoracoscopic talc
The Dual Energy CT images showed multiple bulky mediastinal, bilateral hilar
and right pleural metastases. The left
mediastinal lesions produced encasement and occlusion of the left superior
pulmonary vein. The Dual Energy
perfused blood volume (PBV) images
revealed a severe perfusion defect in the
left upper lobe, caused by the complete
tumoral occlusion of the left upper pulmonary vein. Smaller caliber of vessels
were noted in the low-attenuating portion of the under-perfused lung.
COMMENTS
1 CTPA coronal sub-volume, Maximum Intensity Projection (MIP) shows right and left hilar,
mediastinal as well as right pleural metastases. The left hilar mass encases and occludes the
left superior pulmonary vein (arrow). The left upper pulmonary artery remains permeable
(arrowhead).
2A
2B
2 Axial (Fig. 2A) and coronal (Fig. 2B) images in lung window setting show relative hypodensity of the left upper lobe, a large left pulmonary effusion and a right hilar mass with near complete occlusion of the superior vena cava. Smooth septal thickening is also seen in the right
upper lobe, most likely due to interstitial edema. Chest drainage tubes are seen in the right arrow pleural space as well as a small amount of
pleural air related to the recent pleurodesis.
3A
3B
3C
3 Coronal (Fig. 3A and 3B) and axial (Fig. 3C) Dual Energy Lung PBV images demonstrate near complete loss of perfusion of the left upper
lobe caused by metastasis occluding the left superior pulmonary vein. Alteration of the perfusion is also noted within the right upper lobe
due to septal thickening.
EXAMINATION PROTOCOL
Scanner
SOMATOM Definition
Scan mode
Scan area
Thorax
Slice collimation
0.6 mm
Scan length
308 mm
Slice width
1.5 mm
Scan direction
Cranio-caudal
Reconstruction increment
1 mm
Scan time
10 s
Reconstruction kernel
B30f
140 kV / 80 kV
Contrast
Volume
Dose modulation
CARE Dose4D
Flow rate
4 ml/s
CTDIvol
16.90 mGy
Start delay
17 s
Rotation time
0.5 s
Postprocessing
49
Case 7
SOMATOM Spirit: Follow-Up Examination
of Cerebral Meningioma
By Wolfgang Gerlach, MD,* Andreas Blaha**
*Private Practice, Heidenheim, Germany,
**Business Unit CT, Siemens Healthcare, Forchheim, Germany
HISTORY
This 74-year-old female patient underwent a regular follow up procedure
of the known meningioma located
in the ventral part of the clivus. To
exclude progress of the meningioma
a CT-Angiography was ordered.
DIAGNOSIS
The cerebral CT-Angiography (CTA) was
performed with 80 ml of contrast media
to achieve a good delineation of the
meningioma. A homogeneous opacification of the lesion needed to be achieved
(Mean density could be measured with
110 Hounsfield units, HU). The meningioma is situated at the clivus, almost
extending to the foramen magnum. The
size was measured with 2.9 x 2.5 cm.
The sagittal view of the CTA shows the
extension towards the spinal cord, but no
derogation of the spinal cord could be
seen. No abnormity of the cerebral vascular system could be detected.
COMMENTS
The patient requires continuous monitoring to detect early signs of progression
of the lesion. Therefore a low dose protocol was selected 0.5 mSv*. No progression could be observed, so the next
monitoring examination is recommended
in 12 months.
To achieve the pure arterial contrast
*Effective Dose was calculated using the published conversion factor for an adult head of
0.0021mSv (mGy cm)-1 [1].
[1] McCollough CH et al. Strategies for Reducing Radation Does in CT, Radiol. Clin. N. Am. 47:
(2009) 27-40.
EXAMINATION PROTOCOL
Scanner
SOMATOM Spirit
Scan mode
Spiral
Pitch
1.5
Scan area
Head
Slice collimation
1.5 mm
Scan length
66 mm
Slice width
2 mm
Scan direction
Caudo-cranial
Reconstruction increment
1 mm
H31s
Scan time
22 s
Reconstruction kernel
Tube voltage
130 kV
Contrast
Tube current
Volume
80 ml
CTDIvol
33 mGy
Flow rate
2 ml/s
Rotation time
1.5 s
Start delay
CARE Bolus
DLP
239 mGy cm
Postprocessing
syngo InSpace4D
Eff. Dose
0.5 mSv
51
Case 8
SOMATOM Denition Flash:
Improving Image Quality of Brain Scans With
IRIS, X-CARE and Neuro BestContrast
By Dominik Augart, Barbara Wieser and Christoph Becker, MD
Department of Radiology, Ludwig-Maximilians-University, Munich, Germany
HISTORY
COMMENTS
EXAMINATION PROTOCOL
DIAGNOSIS
The first scan revealed a chronic subdural hematoma with old as well as
fresh blood. There was no indication of
intra-cerebral, subarachnoid or intraventricular bleeding. Additionally, there
was no indication of an ischemic event.
A significantly better judgment of the
spread and differentiation between old
and new blood as well as the chronic
subdural hematoma was first possible
with the second examination one week
later. This clearly showed additional
hypodense structure indicating fresh
bleeding that could not be detected in
the previous examination.
Scanner
Scan area
Head
Head
Scan length
150 mm
150 mm
Scan direction
Cranio-caudal
Cranio-caudal
Scan time
9s
30 s
Tube voltage
120 kV
120 kV
Tube current
320 mAs
306 mAs
Rotation time
1.0 s
1.0 s
Dose modulation
CARE Dose4D
CTDIvol
42.21 mGy
49.80 mGy
DLP
661 mGy cm
761,88 mGy cm
Effective Dose
1.4 mSv
1.6 mSv
Slice collimation
128 x 0.6 mm
40 x 0.6 mm
Slice width
5 mm
5 mm
Reconstruction
kernel
J37s
H37
SOMATOM Sensation 64
1B
1A
Flash
S64
1 Significantly improved image quality to delineate the bleeding (arrow). Chronic dural hematoma (Fig. 1B arrow).
2A
2B
Flash
S64
2 Fresh bleeding could be outlined by the hypodense structure (arrow) that couldnt be clearly seen in the initial examination (Fig. 2B arrow).
53
Case 9
Volume Perfusion CT Neuro as a Reliable Tool
for Analysis of Ischemic Stroke Within Posterior
Circulation
By Philipp Glitz, MD
Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
HISTORY
DIAGNOSIS
1 Delayed Time to peak (TTP) and prolonged mean transit time (MTT) show a delay of blood
flow in the whole left PCA-territory including the thalamus and the left cerebral peduncle
whereas cerebral blood volume (CBV) and cerebral blood flow (CBF) were unchanged.
3 Fusion of CTA and TTP delay indicate the occlusion (arrow) and
the corresponding perfusion delay in the PCA-territory (arrowhead).
COMMENTS
This case illustrates, that VPCT allows a
reliable analysis concerning ischemic
stroke changes also within the posterior
circulation territory including thalamus
and midbrain. Moreover, the VPCT can
be used as a quick, feasible tool for the
assessment of the tissue at risk and
thereby the patient management could
be influenced.
EXAMINATION PROTOCOL
Scanner
Scan mode
Adaptive 4D Spiral
Slice collimation
0.6 mm
Scan area
Head
Slice width
3 mm
Scan length
96 mm
Reconstruction increment
1 mm
Scan direction
Reconstruction kernel
H20f
Scan time
46 s
Contrast
Tube voltage
80 kV
Volume
30 ml
Tube current
200 mAs
Flow rate
5 ml/s
CTDIvol
Rotation time
218 mGy
0.3 s
Postprocessing
55
Case 10
Dual Source, Dual Energy CT:
Improvement of Lung Perfusion Within 5 Hours
in a Patient With Acute Pulmonary Embolism
By Tetsuro Nakazawa, MD; Masahiro Higashi, MD, PhD; Hiroaki Naito, MD, PhD
Department of Radiology, National Cardiovascular Center, Osaka, Japan
HISTORY
DIAGNOSIS
Heparin therapy was started. Thrombolytic therapy was planned, and then
an Inferior Vena Cava (IVC) filter was
placed. The patient felt instant relief
from dyspnea and therefore a follow-up
Dual Energy CT scan was performed at
16:30. The mixed CT images revealed
that the thrombus was unchanged compared to five hours earlier. Yet, the Dual
Energy lung PBV images showed that
the patients lung perfusion had
improved.
1A
1B
2A
11:30
1C
11:30
1D
11:30
2C
11:30
1 CT at 11:30 shows thrombus located in both pulmonary arteries (Fig. 1A and 1B).The Lung
PBV Dual Energy data revealed a significant reduction of pulmonary perfusion (Fig. 1C and 1D).
16:30
16:30
2 After initiating heparin therapy no
reduction of thrombus could be observed
(Fig. 2A and 2B),
COMMENTS
In the past, scintigraphy was used for PE
diagnosis. In recent years however MDCT
has replaced scintigraphy for PE diagnosis. The diagnosis can be done by confirming clots in vessels with CT. In the
case of this patient, PE could be diagnosed on single Energy CT, but the rea-
son for the improvement of clinical symptoms could not be confirmed. Only with
PBV images acquired by Dual Energy CT
could we presume that pulmonary perfusion improvement was the cause for the
relief of the symptoms. Perhaps this was
the result of an increased blood flow
around the thrombus, which was too small
to be seen from the state of the thrombus
itself. Only functional images (meaning
perfusion images) could reveal it. We were
able to see this small change with only one
Dual Energy CT scan. Dual Energy Lung
PBV was extremely helpful in this case.
EXAMINATION PROTOCOL
Scanner
SOMATOM Definition
Scan mode
Pitch
0.8
Scan area
Thorax
Slice collimation
0.6 mm
Scan length
290 mm
Slice width
1 mm
Scan direction
Cranio-caudal
Reconstruction increment
1 mm
Scan time
6.9 s
Reconstruction kernel
D30f
80 kV / 140 kV
Contrast
45 mAs / 225mAs
Volume
60 ml
Dose modulation
CARE Dose4D
Flow rate
2 ml/s
Rotation time
0.33 s
Postprocessing
3A
2B
16:30
1 week later
3C
2D
16:30
3B
2 weeks later
1 week later
3D
2 weeks later
3 CT Dual Energy Lung PBV one week later showed almost complete perfusion recovery
(Fig. 3A and 3B). 2 weeks later perfusion and ventilation scintigraphy unveiled only a small
remaining defect (Fig. 3C and 3D).
57
Case 11
Differentiation of Pulmonary Emboli and
Their Effect on Lung Perfusion Determined
With a Low-Dose Dual Energy Scan
By Luca Flors, MD, Carlos Leiva-Salinas, MD, Klaus D. Hagspiel, MD
Department of Radiology, University of Virginia, VA, USA
HISTORY
A 48-year-old male patient, status post
right lung transplant with history of coal
workers pneumoconiosis, emphysema
and left upper lobe lobectomy, presented with acute onset of shortness of
breath. He was referred to our department for CT angiography in order to rule
out pulmonary thromboembolism.
DIAGNOSIS
COMMENTS
EXAMINATION PROTOCOL
Scanner
SOMATOM Definition
Scan mode
DE Lung
Pitch
0.8
Scan area
Thorax
Slice collimation
0.6 mm
Scan length
328.5 mm
Slice width
1.5 mm
Scan direction
Cranio-caudal
Reconstruction increment
1 mm
Scan time
11 s
Reconstruction kernel
B30f
140 kV / 80 kV
Contrast
Volume
Dose modulation
CARE Dose4D
Flow rate
4 ml/s
CTDIvol
Rotation time
3.79 mGy
0.5 s
Start delay
Postprocessing
17 s
syngo DE LungPBV
1A
1B
2A
2B
2C
2D
3A
3B
59
Case 12
SOMATOM Denition Flash: Rule-Out of
Coronary Artery Disease, Aortic Dissection and
Cerebrovascular Diseases in a Single Scan
Junichiro Nakagawa, MD,* Osamu Tasaki, MD, PhD,* Tomoko Fujihara**and Katharina Otani, PhD**
*Trauma and Acute Critical Care Center, Osaka University Hospital, Osaka, Japan
**Marketing Division, Healthcare Sector, Siemens Japan K.K., Tokyo, Japan
3A
HISTORY
3B
DIAGNOSIS
COMMENTS
Dual Source CT Flash Spiral was used
for long range CT-Angiography (Fig. 5).
It gave us necessary information to rule
out critical acute coronary syndrome,
thoracic aortic dissection and cerebrovascular lesions. The Flash Spiral mode is
EXAMINATION PROTOCOL
Scanner
Scan mode
Flash Thorax
Scan area
Head to Thorax
Scan length
570.5 mm
Scan direction
Caudo-cranial
Scan time
2.07 s
Tube voltage
120 kV / 120kV
Tube current
Dose modulation
CARE Dose4D
CTDIvol
9.06 mGy
DLP
574 mGy cm
Rotation time
0.28 s
Pitch
2.3
Slice collimation
0.6 mm
Slice width
0.75 mm
Reconstruction increment
0.6 mm
Reconstruction kernel
B35f
Contrast
Volume
95 ml
Flow rate
4.0 ml/s
Start delay
28 s Bolus Tracking
61
Case 13
SOMATOM Denition Flash: RIPIT
to the Rescue Fast CT Examination
for Trauma Patients
Savvas Nicolaou, MD
Vancouver General Hospital, Department of Emergency Trauma Radiology, Vancouver, Canada
HISTORY
A 70-year-old female was involved in
a high-speed motor vehicle collision.
An auto launch was triggered immediately and the patient was transferred
by helicopter to Vancouver General
Hospital (VGH).
Immediate imaging was required to
quickly ascertain the patients condition.
A RIPIT FLASH was performed (Rapid
Imaging Protocol In Trauma).*
DIAGNOSIS
The brain demonstrated subarachnoid
hemorrhage and small hemorrhagic
COMMENTS
Given the age and frailty of the patient,
an immediate assessment of the patients
condition was required and this was
provided in a matter of seconds with the
FLASH RIPIT protocol.
EXAMINATION PROTOCOL
Scanner
Scan area
Head to Pelvis
Pitch
1.8
Scan length
911 mm
Slice collimation
128 x 0.6 mm
Scan direction
Cranio - caudal
Slice width
3 mm
Scan time
3.8 s
Spatial Resolution
0.33 mm
Tube voltage
140 kV
Reconstruction increment
1.5 mm
Tube current
149 mAs
Reconstruction kernel
B36f
Dose modulation
CARE Dose4D
Contrast
370 mg/ml
CTDIvol
16.53 mGy
Volume
150 ml
DLP
1596 mGy cm
Flow rate
5.0 ml/s
Rotation time
0.28 s
Start delay
6s
*The RIPID protocol has been introduced in SOMATOM Sessions # 25 by Savvas, Nicolaou in November 2009
**Acute Respiratory Distress Syndrome
1, 2 Volume
Rendered (VRT)
view showing
vascular status
of this trauma
patient.
3, 4 Fast pitch
of 1.8 allows
long range
scanning from
head to pelvis.
The sagittal
view (Fig. 4)
shows artifact
free aortic
angiogram.
Case 14
Xenon Ventilation CT Scan
Demonstrates an Increase in Regional
Ventilation After Bullectomy
in a COPD Patient
By Calvin Yeung W.H., MD and Gladys G. Lo, MD
Department of Diagnostic and Interventional Radiology, Hong Kong Sanatorium and Hospital
HISTORY
DIAGNOSIS
EXAMINATION PROTOCOL
COMMENTS
With an Xenon CT examination of the
thorax, it is possible to demonstrate,
in addition to the morphologic assessment, the functional state of the lung.
In this case it showed less ventilation in
the left lower lobe which the bronchoscopist and surgeon used to plan the
site for lung volume reduction surgery.
Bronchoscopic lung volume reduction
surgery was attempted, but failed due
to significant collateral flow, detected
during the placement of endobronchial
valve (one-way valve placed in bronchius).
A video-assisted thoracoscopic bullectomy was performed. The bulla in the
left lower lobe was surgically resected
with no complications and the patient
recovered well. After surgery there was
a significant subjective improvement
in dyspnoea that was confirmed by pulmonary function testing. The Forced
Expiratory Volume in 1 second (FEV1)
increased from 0.62 l to 0.87 l (25% to
38% of predicted value); FEV1/ Forced
Scanner
SOMATOM
Definition Flash
Scan mode
Scan area
Thorax
Scan length
310 mm
Scan direction
Cranio - caudal
Scan time
9s
Tube voltage
80kV/140kV
Tube current
80 eff. mAs/
48 eff.mAs
Dose modulation
CARE Dose4D
CTDIvol
3.82 mGy
Eff. Dose
1.7 mSv
Rotation time
0.26 s
Slice collimation
64 x 0.6 mm
Slice width
1 mm
Spatial Resolution
0.33 mm
Reconstruction
increment
0.8 mm
Reconstruction
Kernel
D30
Contrast
Xenon gas
inhalation
Start delay
90 s
Postprocessing
syngo DE Xenon
65
Case 15
SOMATOM Denition:
Dual Energy Locates Progressive Wrist Arthritis
By Philipp Weisser, MD, Ralf W. Bauer, MD, J. Matthias Kerl, MD and Thomas J. Vogl, MD
Department of Diagnostic and Interventional Radiology, Goethe University Clinic, Frankfurt, Germany
HISTORY
1A
DIAGNOSIS
1B
COMMENTS
1 Massive, destructive erosions in the
EXAMINATION PROTOCOL
Scanner
SOMATOM
Definition
Scan mode
DE Extremity
Scan area
Scan length
282 mm
Scan direction
Cranio - caudal
Scan time
21 s
140 kV / 80 kV
Dose modulation
CARE Dose4D
CTDIvol
12.97 mGy
eff. Dose
0.32 mSv
Rotation time
1s
Slice collimation
64 x 0.6 mm
Slice width
2 mm
Spatial Resolution
0.33 mm
Reconstruction
increment
1 mm
Contrast
Volume
90 ml
Flow rate
4 ml/s
Start delay
360 s
Postprocessing
syngo DE Gout
2A
2B
2 Distinctive demarcation of synovitis in the right wrist, pronounced Dual Energy characteristics and impressive visualization of the synovitis (arrow).
3A
3B
3 3D Fusion rendering, showing the destructions and synovitis of the right wrist (arrow).
4A
4B
4 Difference of density in synovitis after application of iodine contrast agent at 80 and 140 kV. We measured around 140 HU in 80 kV,
and around 90 HU in 140 kV (arrow).
67
Science
1 Calculating effective
dose for adults. From the
Patient Protocol of this
abdominal scan, the DLP is
obtained:
Science
Calculating effective dose from scanner dose information for a pediatric body exam.
2
2 Calculating effective dose for children. Using the same values as in the first example, the DLP is: DLP = 274 mGycm. First you have to
determine if the DLP refers to a 32 cm or 16 cm CTDI phantom. In this case, the DLP is reported in the 32 cm body CT dose phantom. This value
has to be converted to the head CT dose phantom if pediatric conversion factors published in [table 1] shall be used to compute the effective
dose: DLP = 2.0 * 274 mGycm = 548 mGycm. Note: Typical values are between 2.0 and 2.4 for Siemens scanners. Values can be found in the
System Owner Manual. Since the method of using conversion factors to determine the effective dose is a very rough method usually using a correction factor of 2.0 is sufficiently accurate for all scanners. For a 5-year old child, a factor of 0.02 mSv/(mGycm) for abdominal exams is used
[table 1] to estimate E. E = 548 mGycm 0.02 mSv/(mGycm). = 11 mSv. If the DLP was already measured in the 16 cm head phantom like it is
the case on new scanners the conversion factors from table 1 can be used directly without applying an additional factor of 2.0 to 2.4.
Table 1
Region of body
1 year old
5 year old
10 year old
Adult
0.013
0.0085
0.0057
0.0042
0.0031
Head
0.011
0.0067
0.0040
0.0032
0.0021
Neck
0.017
0.012
0.011
0.0079
0.0059
Chest
0.039
0.026
0.018
0.013
0.014
0.049
0.030
0.020
0.015
0.015
Trunk
0.044
0.028
0.019
0.014
0.015
Towards assessing
patient dose
When asking the question of what is
the radiation dose, one really is inter-
sents a risk-related quantity for the control of radiation exposure and optimization of protection. It cannot be measured
directly, but rather is calculated using
defined dosimetric models. Hence, it
applies to a reference person and does not
provide risk information for the individual.
69
Science
be viewed on the
scanner console,
sent to PACS or to
an independent
server used to monitor dose data.
Special considerations
for children
Conversion factors are also available for
children of various ages [table 1].
Special attention has to be paid to the fact
that the conversion factors published
apply to values reported in the head CT
dose phantom.
In the past scanners, CTDI values were
reported in the head CT dose phantom
for head exams and the body CT dose
phantom for body exams, irrespective of
the patient age. This was in line with the
original IEC standards, which did not
provide instructions for pediatric exams.
Thus, for calculations regarding pediatric
body exams, an additional calculation
step has to be performed, as illustrated
in Figure 2.
The example shown illustrates that the
same exposure leads to an effective dose
that is almost three times higher for a
five year old than an adult. While being
purely theoretical, the example shows
that, it is of utmost importance to pay
special attention when imaging pediatric
patients, in particular to use dedicated
pediatric protocols in combination with
Science
CARE Dose4D.
To standardize dose reporting for pediatric patients, future editions of IEC standards will require dose reporting in the
head CT dose phantom for pediatric
exams, irrespective of the body region
imaged. Starting with software version
syngo CT 2011A, Siemens will implement
this new requirement. As a consequence,
the conversion factors [table 1] can be
directly applied also in pediatric protocols. To ease the transition, the CT dose
phantom size was added to the user
interface and it is also reported in the
Dose SR.
A new standard:
Dose Structured Reports
As the first CT manufacturer Siemens
now provides the new Dose SR almost
across its complete CT product portfolio.
reporting data can be exported and analyzed with standard tools, such as Microsoft Excel.
With the prompt implementation of
Dose SR and the new tool CARE Analytics
Siemens provides the customer with all
the information needed for a transparent dose management.
References
1 IEC 61223-2-6 Evaluation and routine testing in
medical imaging departments Part 2-6: Constancy tests Imaging performance of computed
tomography X-ray equipment
2 Jessen KA, Panzer W, Shrimpton PC, et al. EUR
16262: European Guidelines on Quality Criteria
for Computed Tomography. Paper presented at:
Office for Official Publications of the European
Communities; Luxembourg. 2000.
3 Shrimpton PC, Hillier MC, Lewis MA, Dunn M.
National survey of doses from CT in the UK:
2003. Br J Radiol Dec;2006 79(948):968980.
[PubMed: 17213302]
71
Science
have brought about a marked improvement for Cardio CT, according to Dr. Jrg
Hausleiter, specialist in non-invasive,
cardiac CT diagnostics at the German
Heart Centre Munich. He explains: The
data at our center shows that three or
four years ago, we had an average effective radiation exposure of 10 mSv; now,
we are at under 2 mSv.
Science
1
73
Life
Dr. Ralf Bauer (left) and Dr. Matthias Kerl (right) are in charge of the CT fellowship program at Johann Wolfgang Goethe University in Frankfurt/ Germany.
75
Life
1B
International:
www.siemens.com/DiscoverCT
USA only:
www.usa.siemens.com/
webShop/CT
Life
1
Frequently
Asked
Questions
By Ivo Driesser, Business Unit CT,
Siemens Healthcare, Forchheim,
Germany
Dialog, the X-CARE zone adapts automatically. That means that the X-CARE
zone is always placed on the anterior part
of the body. In the comment line there is
also the entry X-CARE.
What about obese patients?
X-CARE checks the patient size for every
individual patient and creates the best
dose distribution so that the best possible
image quality is guaranteed.
How to get X-CARE?
Your Siemens contact representative will
be happy to help you arrange for free
trial licenses.
In the first session, Prof. Stephan Achenbach, MD from Erlangen University will
present a current status report on low
dose imaging in the field of cardiac CT.
Prof. Achenbach will present many clinical cases with excellent image quality
acquired with a minimum of radiation
dose. Each webinar session is recorded
and available online for later review.
More clinical webinars are planned so
dont wait and please register now for
further information.
www.siemens.com/webinars
77
Life
like to recommend these books to physicians and technologists who want to get
a more detailed insight into the technology of CT, cardio-vascular or oncologic
CT applications.
With this comprehensive overview,
which will grow over time and be constantly updated, you will always have
the latest CT-related book publications
to further improve clinical know-how
right at your finger tips.
On the Educate Homepage, the authors
names can be found as well as book
titles and order numbers with a forwarding link for convenient online ordering.
www.siemens.com/
SOMATOMeducate
Workshop Title
Date
Location
Course Language
Course Director
April 6 8, 2011
July 20 22, 2011
October 4 6, 2011
Munich,
Germany
English
Erlangen,
Germany
English
Kuching,
Malaysia
English
Forchheim,
Germany
English
PD Thorsten Johnson, MD
May 6 7, 2011
September 16 17, 2011
Life
Dublin, Ireland
Gothenburg,
Sweden
March 3 7, 2011
Siemens Healthcare
Paris, France
Siemens Healthcare
English
English
In addition, you can register and nd the latest CT courses offered by Siemens Healthcare at www.siemens.com/SOMATOMEducate
Dates
Short Description
Location
Contact
RSNA
November 28
December 3, 2010
Chicago, USA
www.rsna.org
Arab Health
Dubai, UAE
www.arabhealthonline.
com
International
Stroke Conference
http://strokeconference.
americanheart.org/portal/
strokeconference/sc/
ECR
March 3 7, 2011
European Society of
Radiology
Wien, Austria
www.myesr.org
AHA
www.americanheart.org
ACC
April 3 5, 2011
American College of
Cardiology
www.acc.org
ITEM
www.jira-net.or.jp
AOCR
www.aocr.org
DGK
Mannheim, Germany
www.dgk.org
DRK
June 1 4, 2011
ASNR
June 4 9, 2011
Seattle, USA
www.asnr.org
ISCT
International Symposium on
Multidetector Row CT
www.isct.org
SCCT
Society of Cardiovascular
Computed Tomography
Denver, USA
www.scct.org
79
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