SOMATOM

Issue no.12

SESSIONS

Contents

CASE REPORTS FROM

MULTISLICE CT –
SOMATOM Sensation 16
SOMATOM SESSIONS 12
From the Editor
This is the twelfth issue of Siemens SOMATOM® Sessions.
In this issue, we would like to share with you the ex-
citements of CT volume imaging with the SOMATOM
Sensation 16. We present you with clinical case reports
from our clinical partners.
To order copies of the past issue or submit your registration
for receiving future issues, please visit our Web site at:
http://www.siemensmedical.com/somatomsessions
As always, we appreciate your suggestions and comments.
Xiaoyan Chen, M.D., MBA
Editor of SOMATOM Sessions
2
The information in this document contains general descriptions of the tech-
nical options available, which do not always have to be present in individual
cases. The required features should therefore be specified in each individual
case at the time of closing the contract.
The information presented in the case report is for illustration only and is not
intended to be relied upon by the reader for instruction as to the practice of
medicine. Any health care practitioner reading this information is reminded
that they must use their own learning,training and expertise in dealing with
their individual patients. This material does not substitute for that duty and is
not intended by Siemens Medical Solutions Inc., to be used for any purpose
in that regard.
The drugs and doses mentioned herein were specified to the best of our
knowledge. We assume no responsibility whatsover for the correctness of
this information.Variations may prove necessary for individual patients.
The treating physician bears the sole responsibility for all of the parameters
selected.
Contents

CASE 1: CASE 7:
CT Angiography for Intracranial Aneurysm Liver Metasteses Page 22
– Diagnosis of Anterior Communicating
Artery Aneurysm Page 4 CASE 8:
Mobile Distal Ureteral Stone Page 24
CASE 2:
Incidental Diagnosis of Early Stage Lung CASE 9:
Cancer with Suspected PE Page 6 Multiple Pathology Page 26

CASE 3: High Resolution Multislice CT

Selective Celiomesenteric Stenosis Visual- in Critical Ill Patients Page 28
isation by Contrast Enhanced 16-slice CT Page 10
CASE 10:
CASE 4: Adult Respirators Distress Syndrome (ARDS) Page 28
Incidental Diagnosis of an Aberrant
Right Subclavian Artery in a Case of Isolated CASE 11:
Peripheral Pulmonary Embolism Page 14 AIDS-related Non-Hodgkin’s Lymphoma Page 30

CASE 5: CASE 12:

Acute Rupture of an Abdominal Aortic Three-phase Renal CT – Diagnosis of Renal
Aneurysm after Aortic Stent Fracture Page 17 Pelvic Transitional Cell Carcinoma Page 32

CASE 6:
Direct Aortic Origin of Left Gastric Artery
Diagnosed Incidentally During Pre-operative
Evaluation for Hepatic Arterial Infusion
Pump Placement. Page 20
SOMATOM SESSIONS 12

Case 1: CT Angiography for Intracranial

Aneurysm – Diagnosis of Anterior Communicating
Artery Aneurysm

HISTORY DIAGNOSIS AND COMMENTS

The patient is a 44-year-old female with past medical CT angiography show a lobulated aneurysm arising off
history of a stroke and hypertension, with outside MR of the left A-1 / A2 junction. This measures 13 mm in trans-
showing suspicion of aneurysm. She has complaints of left verse diameter. The neck of the aneurysm is broad based
hemibody numbness, which is constant since the past and extends towards the anterior communicating artery
stroke. to the right. However, the bulk of the aneurysm and
dome project laterally to the left. There is a hypoplastic
left A-1 segment. The right A-1 segment is widely patent.
EXAMINATION PROTOCOLS Both carotid siphons widely patent and unremarkable in
appearance.
Scanner SOMATOM Sensation 16 Two critical surgical factors are defined by the CT angio-
Scan region Head gram: 1) the neck is broad based, making coil embolization
Length 10 cm less favorable, and 2) that while the bulk of the aneurysm
Slice collimation 16 x 0.75 mm projects to the left, the neck is most accessible from the
Scan direction Cranio-caudal right. The right approach is also more favorable since the
Rotation time 0.5 s nondominant hemisphere would undergo surgical mani-
kV 120
pulation.
Eff. mAs 200
The patient subsequently underwent a right frontotem-
Kernel H20 smooth
Scan time 7.5 s
poral craniotomy and microsurgical clipping of anterior
Slice width 1 mm communicating artery aneurysm.
Reconstruction Increment 0.5 mm

Contrast non ionic contrast media

(300 mg iodine per ml)
Volume 100 ml
Flow rate 4 ml / s
Delay Bolus tracking with CARE Bolus

Postprocessing Thin MIP and VRT on the Wizard

4
[ 1 ] Oblique volume rendering with high opacification [ 2 ] Lateral VRT with high opacificaton shows relation-
shows aneurysm with broad neck at the A1/A2 junction, ship of skull base to the aneurysm.
and hypoplastic left A1 segment.

[ 3 ] Base view VRT shows aneurysm projecting to the left. [ 4 ] Axial CT base data image through aneurysm.

5
SOMATOM SESSIONS 12

Case 2: Incidental Diagnosis of Early Stage

Lung Cancer with Suspected PE
HISTORY EXAMINATION PROTOCOLS
A 62-year-old male patient with a history of heavy smoking Scanner SOMATOM Sensation 16
for many years (more than 30 pack-years) now suffers from Scan Area Lung
coughing and shortness of breath. His blood test Scan length 30 cm
results show slightly elevated d-dimer. He was referred Scan time 10 s
to the radiology department with suspected pulmonary Scan direction caudocranial
embolism. KV 120
Effective mAs 100
Rotation time 0.5 s
Slice collimation 16 x 0.75 mm
DIAGNOSIS AND COMMENTS Slice width 1st: 0.75 mm
2nd: 3 mm
Even though there was no filling defect found within the 3rd: 0.75 mm
Table feed / rotation 15 mm
pulmonary vessels, the CT was able to delineate even the
Reconstruction increment 1st: 0.6 mm
very peripheral pulmonary arteries [Fig. 1]. The images 2nd: 3 mm
reconstructed with high resolution kernel did not show any 3rd: 20 mm
sign of chronic PE such as mosaic pattern perfusion Kernel 1st: B 20 f
2nd: B 20 f
[Fig. 2]. The diameter of the right ventricle and the main 3rd: B 70 f
pulmonary arteries were within a normal range, and there
was no signs of increased right heart load. Pulmonary
Contrast non ionic contrast media
embolism as a reason for the symptoms could be ruled out. (300 mg iodine per ml)
However, a solitary pulmonary nodule in the right lower Volume 120 ml
lobe was shown without signs of benignancy [Fig. 3]. Flow rate 5 ml / s
Having the raw data of the CT scan still available on the Start delay Test Bolus
(20 ml contrast + 50 ml
scanner, an additional retrospective reconstruction was Nacl chasing, ROI positioned at
done with the following parameters: Kernel: B50f, slice the main pulmonary artery)
width: 0.75 mm, increment 0.6 mm. These images were +4s

loaded into LungCARE program to perform an accurate vol-

ume measurement [Fig. 4]. Postprocessing MPRs and MIPs on the Wizard,
VRT and Volume measurement
The patient was asked to come back for a follow-up scan in with LungCARE
3 months. The follow-up exam revealed a typical growth
pattern of lung cancer. The patient was refered to the tho-
racic surgery department, and the nodule was fully re-
sected. The pathology diagnosis proved the lesion to
be a stage 1 lung cancer. The patient is doing well after
the surgery.

The reason for the coughing, shortness of breath and the

elevated d-dimer was never discovered. The symptoms
vanished a few hours after the first CT scan.

6
[ 1 ] MIP images show no filling defect within the
pulmonary vessels while being able to delineate even
the very peripheral pulmonary arteries.

7
SOMATOM SESSIONS 12

[ 2 ] Image reconstructed with high resolution kernel

shows no signs of chronic PE such as mosaic pattern
perfusion.
[ 3 ] A solitary pulmonary nodule found in the right
lower lobe shows no signs of benignancy (first scan).

[ 5 ] Follow up CT exam in 3 months – Volumetric

measurement performed with LungCARE program shows
the growth of the nodule (260.68 mm3 as compared
to 163.23 mm3 from the first scan).
[ 4 ] Follow up CT exam in 3 months – axial image
presents the slightly changed nodule which is connected
to the vessel.

8
 CASE 2: Incidental Diagnosis of Early Stage
Lung Cancer with Suspected PE

[ 6 ] Screenshot of LungCARE program shows the projected position of the marker

and the volumetric measurement (163.23 mm3) of the solidary nodule (first scan).

9
SOMATOM SESSIONS 12

Case 3: Selective Celiomesenteric Stenosis

Visualisation by Contrast Enhanced 16-slice CT
HISTORY EXAMINATION PROTOCOLS
A 72-year-old caucasian female smoker was admitted for Scanner SOMATOM Sensation 16
recurrent episodes of postprandial painful abdominal KV 120
cramps and colic. Prior to admission she had weight loss mAs 140
by unknown cause. Her medical history included hyper- Slice collimation 16 x 0.75 mm
tension, rheumatic arthritis, carotid stenosis and stroke; Slice width 2.0 mm
previous surgeries included cholecystectomy, carotid Field of View 38.0 cm
Reconstruction increment 1.0 mm
endarterectomy and inguinal hernia repair. She was taking
Rotation time 0.5 s
Sulfasalazine and Methotrexate for her history of active
Feed per rotation 15 mm
rheumatic arthritis, hypertension was controlled with Total acquisition time 14.4 s
Quinapril and Bisoprolol, and high cholesterol levels were Reconstruction algorithm B 30 f
controlled with Simvastatine. Her family history was indica- Total number of images 409
tive for vascular diseases.
At physical examination, paraumbilical and abdominal Contrast Omnipaque® 300 mg/l
aorta murmurs on auscultation were noticed, all peripheral Injection volume 120 ml
pulses were easily palpable and bilaterally equal. No abnor- Injection rate 3.5 ml/s
mality was detected by sonography of the upper abdomen. Start delay 24 s
The patient was referred to the radiology department with
high clinical suspicion of chronic intestinal ischemia. Postprocessing MPR, MIP and VRT
A contrast-enhanced Multislice Computed Tomography
(MSCT) scan was performed, that provided high quality
images on which vascular mesenteric lesions could be
assessed. Splanchnic vessels were also visualised by digital DIAGNOSIS AND COMMENTS
substraction angiography (DSA). Stenotic lesions of the ori-
gin and lower part of the superior mesenteric artery (SMA) The celiac and superior mesenteric arteries are the main-
were visible on both the angiogram and the MSCT scan stay of vascular supply to the abdominal viscera. They sup-
[Fig. 1, 3B, 4B, 5]. Extensive calcifications in lower parts of ply the hepatobiliary system, pancreas, spleen, omentum,
SMA were only visualised by MSCT [Fig. 4B, 5]. A normal and most of the bowel, except the esophagus, the distal
celiac trunk was visulized with DSA probably due to the colon and rectum beyond the transverse colon. Insufficient
positioning of the catheter just prior to the intestinal blood flow can cause postprandial abdominal
origin of the stenosis [Fig. 2]. With MSCT calcifications were pain and weight loss1. The angiographic criteria of chronic
visible in the celiac trunk; the presence of calcified mesenteric ischemia consist of the presence of significant
lesions complicated the evaluation of stenosis [Fig. 3A]. stenosis or obliteration of 2 of the 3 main gastrointestinal
arteries2.
For the diagnostic evaluation of a patient referred with clin-
ical suspicion of chronic intestinal ischemia several imaging
techniques are available3 4. DSA is still considered to be the
gold standard in diagnosing splanchnic vessel disease.
However, using modern MSCT scanners the abdominal
aorta, the origins of the splanchnic arteries, their central
parts, and first branches can be visualised with diagnostic
quality. Advantages of MSCT angiography include minimal
invasiveness, short examination time and the opportunity

10
 A B

[ 1 ] DSA frontal (A) and lateral (B) visualisations demonstrate two stenotic lesions in the SMA.

A B

[ 2 ] DSA frontal (A) and lateral (B) visualisations show normal aspect of the celiac trunk.

11
SOMATOM SESSIONS 12
A B
[ 3A ] Axial MPR image shows calcification of the
celiac trunk (arrow).
to rule out other causes of abdominal pain. In patients with
chronic disorders or suspected alteration of mesenteric
blood flow the diagnostic value of a non-invasive diagnos-
tic test as MSCT is comparable to DSA5. Suspicion of mesen-
teric ischemia based upon careful evaluation of patient
history and clinical situation should be an early indication
for CT. Only in critically ill patients DSA is the preferred
method because total procedure time (acquisition, image
processing and evaluation) is shorter and immediate inter-
vention is possible. In conclusion, visualisation and evalua-
tion of the splanchnic vessels by MSCT angiography in
patients with suspicion of chronic intestinal ischemia is
promising.
12
[ 3B ] Axial MPR image shows the soft plaques and the
calcification which cause the stenosis of the SMA.
REFERENCES
1 Rogers DM, Thompson JE, Garret WV et al: Mesenteric vascular
problems: a 26-year experience. Ann Surg 1982; 195: 554-565
2 Clark RA, Gallant TE: Acute mesenteric ischemia: angiographic
spectrum. Am J Roentgenol 1984; 142(3): 555-62
3 Pérez C, Llauger J, Puig J, Palmer J: Computed tomographic findings
in bowel ischemia. Gastrointest Radiol 1989; 14: 241-245
4 Franquet T, Bescos JM, Reparaz B: Non-invasive methods in the
diagnosis of isolated superior mesenteric vein thrombosis:
US and CT. Gastrointest Radiol 1989; 14: 321-325
5 Klein HM, Lensing R, Klosterhalfen B, Tons C, Gunther RW: Diagnostic
imaging of mesenteric infarction. Radiology 1995; 197(1): 79-82
 CASE 3: Selective Celiomesenteric Stenosis
Visualisation by Contrast Enhanced 16-slice CT

A B

[ 4A ] Curved line denotes the curvature of the plane in [ 4B ] Curved MPR image demonstrates the extented
figure 4B. part of the SMA with extensive calcification.

[ 5 ] VRT images
demonstrate clearly
the severe calcifica-
tions and the stenosis
of the SMA.

13
SOMATOM SESSIONS 12

Case 4: Incidental Diagnosis of an Aberrant

Right Subclavian Artery in a Case of Isolated Peripheral
Pulmonary Embolism

HISTORY DIAGNOSIS AND COMMENTS

A 72-year-old man presented with acute right sided pleu- The CT scan confirmed the diagnosis of acute pulmonary
ritic chest pain. His past medical history revealed a 90% embolism and revealed a filling defect in the periphery of
proximal stenosis in the left anterior descending coronary the medial segment of the right lung base. There was
artery treated by PTCA in 1996. The physical examination another irregular filling defect in a medial subsegment of
was unremarkable. The screening laboratory tests includ- the right middle lobe. Another small filling defect was seen
ing hemogram, coagulation status and chemistry had in a lingular branch. Filling defects were isolated to subseg-
normal results. The electrocardiogram showed a former mental and smaller pulmonary arteries. No central filling
known sinus bradycardia (53 bpm). The echocardiogram defects were present. The lungs were clear with the excep-
demonstrated a left ventricular hypertrophy with pre- tion of a 2 mm nodular density in the periphery of the
served overall function and without any regional wall anterior segment of the right upper lobe. No other nodular
motion abnormalities. The ejection fraction was 60%. The densities were identified. A mildly prominent lymph node
right ventricle was normal in size and function. The was noted in the mediastinum in the subcarinal region
posteroanterior and the lateral chest radiograph demon- measuring 9 mm in the short axis.
strated a prominence of the right hilum and a mild
cardiomegaly. There was no pleural effusion or pneumo- Incidentally, the scan also revealed an aberrant right sub-
thorax. The lungs were clear. In order to exclude pul- clavian artery (ARSCA), also known as arteria lusoria (after
monary embolism (PE) as the source of his symptoms a lusus naturae, freak of nature)1. This is a rare anomaly
CT scan of the chest on a 16-slice CT scanner was per- of the aortic arch. Based on autopsy findings, the ARSCA
formed using a standard pulmonary embolism protocol. has a prevalence of 0.7% in the general population2.
The ARSCA arises as the last branch of the aortic arch and
traverses the mediastinum from left to right, scalloping the
EXAMINATION PROTOCOLS oesophagus posteriorly. Abnormal involution or absence of
the fourth right aortic arch during the embryonal stage,
Scanner SOMATOM Sensation 16 which normally forms the proximal part of the right sub-
Scan Area Entire Thorax clavian artery is the cause for the aberrant course of this
Scan length 25 cm artery3. Since the persisting right aortic arch forms the root
Scan time 7s of the aberrant artery, the ARSCA often has a broad base
Scan direction caudocranial (Kommerell’s diverticulum)4. The aberrant right subclavian
kV 120 artery is usually asymptomatic and, as in this case, only
Effective mAs 200
strikes the clinician as an anatomic curiosity; however,
Rotation time 0.5 s
sometimes dysphagia, dyspnea, coughing, stridor, recur-
Slice collimation 16 x 0.75 mm
Slice width 0.75 mm
rent pneumonia, thoracic pain, or Horner syndrome may
Table feed / rotation 18 mm develop. When symptoms are intractable, surgical correc-
tion should be considered5–8. Importantly, the rare but
Contrast Ultravist™ (300 mg iodine per ml)
potentially lethal association of the ARSCA with congenital
Volume 125 ml heart defects or aneurysms must be considered.
Flow rate 3.0 ml / s
Start delay CARE Bolus

Postprocessing Coronal and sagittal MPRs,

MIPs and VRTs

14
[ 1 ] Subsegmental pulmonary embolism in the right [ 2 ] Subsegmental pulmonary embolism in the right
middle lobe. lower lobe.

[ 3 ] Axial CT section at the level of the origin of [ 4 ] Multiplanar reconstruction of the proximal part of
the ARSC. the aberrant right subclavian artery traversing the midline
from left to right.

15
SOMATOM SESSIONS 12
[ 5 ] Multiplanar reconstruction of the ARSCA, scalloping
the oesophagus from posterior.
[ 6 ] Volume rendered visualization of the aortic arch and
its major branches. The ARSCA has its origin distal to the
left carotid artery and the left subclavian artery and
crosses the midline posterior to the oesophagus.
16
In this case, using 16-slice CT with submillimeter resolution,
a diagnosis of subsegmental pulmonary embolism as the
source of the patient’s signs and symptoms could be estab-
lished within 7 seconds. Residual uncertainty concerning
the accuracy of CT for diagnosing central and peripheral
pulmonary embolism should be finally overcome with the
advent of this technology9. As strikingly demonstrated in
this case, CT also allows reliably establishing important
alternative and additional diagnoses in patients with sus-
pected PE, which may range from incidental congenital
variants, such as here, to life threatening conditions (e.g.
aortic dissection)10.
REFERENCES
1 Bayford, D. (1794) An account of singular case of obstructed deglutition.
Memoires Med Soc of London 2: 275-86
2 Molz, G., Burri, B. (1978) Aberrant subclavian artery (arteria lusoria):
Sex differences in the prevalence of various forms of the malformations.
Evaluation of1378 observations. Virch Arch A Pathol Anat Histol 380: 303-15
3 Janssen, M., M. G. Baggen, et al. (2000) Dysphagia lusoria:
clinical aspects, manometric findings, diagnosis, and therapy.
Am J Gastroenterol 95(6): 1411-6
4 Kommerell, B. (1936) Verlagerung des Ösophagus durch eine abnorm
verlaufende Arteria subclavia dextra (Arteria lusoria). Fortschr Geb
Roentgenstr Nuklearmed 54: 590-5
5 McNally, P. R. and K. M. Rak (1992) Dysphagia lusoria caused by
persistent right aortic arch with aberrant left subclavian artery and
diverticulum of Kommerell. Dig Dis Sci 37(1): 144-9
6 Stork, T., R. Gareis, et al. (2001) Aberrant right subclavian artery
(arteria lusoria) as a rare cause of dysphagia and dyspnea in a 79-year
old women with right mediastinal and retrotracheal mass, and coexisting
coronary artery disease. Vasa 30(3): 225-8
7 Jebara, V. A., E. Arnaud-Crozat, et al. (1989). Aberrant right subclavian
artery aneurysm: report of a case and review of the literature. Ann Vasc
Surg 3(1): 68-73
8 Turkenburg, J. L., M. I. Versteegh, et al. (1994). Case report: aneurysm
of an aberrant right subclavian artery diagnosed with MR imaging. Clin
Radiol 49(11): 837-9.
9 Schoepf UJ, N. Holzknecht, et al. (2002). Subsegmental pulmonary
emboli: improved detection with thin-collimation multidetector-row spiral
CT. Radiology (222): 483-90.
10 Schoepf, U. J., M. A. Kessler, et al. (2001). Multislice CT imaging of
pulmonary embolism. Eur Radiol (11): 2278-86.
Case 5: Acute Rupture of an Abdominal Aortic
Aneurysm after Aortic Stent Fracture
HISTORY EXAMINATION PROTOCOLS
A 74-year-old male patient with known aortic disease Scanner SOMATOM Sensation 16
was referred to computed tomography because of the Scan Area From diaphragm to knee
suspicion of a penetrating aortic aneurysm with acute Scan length 70.9 cm
haemorrhage. The patient presented at the emergency Scan time 31 s
department with symptoms of abdominal pain with an Scan direction Craniocaudal
acute onset 24 hours ago. Laboratory findings showed a KV 120
Effective mAs 200
haemoglobin level of 10.5mg / dl. Abdominal ultrasound
Rotation time 0.5 s
performed by the surgeons revealed a huge abdominal
Slice collimation 16 x 0.75 mm
aneurysm. The patient underwent aneurysm stenting Slice width 0.75 mm
some months ago. In addition graft surgery with a iliac-iliac Table feed / rotation 12 mm
cross-over bypass had been performed. At arrival at the Pitch* Volume pitch 16, Pitch factor 1
radiology department the patient was still in a stable con- Reconstruction increment 0.7 mm
dition. Kernel B 30 f

Contrast non ionic contrast media

(300 mg iodine per ml)
DIAGNOSIS AND COMMENTS Volume 120 ml
Flow rate 5 ml/s
The 16-slice CT angiography data set showed aneurysmatic
Start delay Test bolus (20 ml; 5 ml / s + NaCl):
dilation of the aorta at the level of the diaphragm. Within time to peak (22 s) + 8 s = 30 s
the infrarenal abdominal aorta a stentgraft could be identi-
fied extending into the left common iliac artery. In addition Postprocessing STS MIP coronal and sagittal,
occlusion of the proximal right common iliac artery is VRT on InSpace (Leonardo)
shown with a cross-over bypass graft to the right iliac
artery arising from the left external iliac artery [Fig. 1, 2, 3].
Surrounding the aortic stent an aneurysmal sac with a * Volume pitch = table feed per rotation / single slice collimation;
maximal diameter of 5.5 cm and wall calcifications can be Pitch factor = table feed per rotation / collimation

identified. The opacified lumen within the stent showed a

diameter of approximately 1.8 cm. Arising at the posterior
aspect of the stent in between the first and second stent
strut extravasating contrast material can be found ex-
tending into the aneurysmal sac. In addition a rupture of
the aneurysmal sac is shown leading to a massive intra-
abdominal and retroperitoneal haemorrhage [Fig. 4, 5].
The final diagnosis based on MSCT angiography is rupture
of an abdominal aneurysm after abdominal aortic stent
fracture.
The patient underwent immediate emergency surgery
but died after insertion of a ballon blocker due to haemor-
rhagic shock.

17
SOMATOM SESSIONS 12

[ 1 ] Volume rendering (InSpace) shows aorto-iliac stent [ 2 ] Volume rendering (InSpace) shows equidistant lower
graft (arrows) and left-to-right iliac cross over bypass stent struts but extended distance between the first two
(arrow heads) due to right common iliac struts (arrow heads). The contrast extravasation can also
occlusion. be depicted (arrows).

[ 3 ] Screen shot of InSpace

18
 CASE 5: Acute Rupture of an Abdominal Aortic
Aneurysm after Aortic Stent Fracture

A B

[ 4 ] Coronal (A) and axial (B) thin MIP views show the aneurysmal sac within the infrarenal aorta
surrounding the stentgraft. The wall can be easily identified by calcifications (arrows).
At the right lateral aspect of the sac rupture (A, asteriks) with contrast extravasation into a large
hematoma is shown (arrow heads).

A B

[ 5 ] Coronal (A) and axial (B) MPR shows the extension of the hematoma in the pararenal
and perirenal space (arrows). Hematoma is supplied by acute extravasation of blood and contrast
(arrow heads) due to acute rupture of the abdominal aneurysm.

19
SOMATOM SESSIONS 12

Case 6: Direct Aortic Origin of Left Gastric Artery

Diagnosed Incidentally During Pre-operative Evaluation
for Hepatic Arterial Infusion Pump Placement.

HISTORY DIAGNOSIS AND COMMENTS:

A 70-year-old female presented for pre-operative abdomi- Mild atherosclerosis was present in the abdominal aorta.
nal arterial anatomy evaluation for placement of a hepatic Multiple low attenuation lesions were present in the liver,
arterial chemotherapy infusion pump. Her past medical his- which were consistent with colon cancer metastases. CT
tory was significant for colorectal cancer metastatic to the angiography of the mesenteric arteries revealed an inci-
liver, status-post colon resection. CT angiography was per- dental finding of the left gastric artery originating directly
formed using a 16-slice multislice CT. from the aorta [Fig. 1]. The common hepatic and splenic
arteries arose from the aorta as a common trunk (hepa-
tolienal trunk) [Fig. 2, 3]. The left gastric artery had a dia-
EXAMINATION PROTOCOLS meter of 2 mm. The length and course of the arteries were
normal. This variation occurs rarely, with angiographic
Scanner SOMATOM Sensation 16 and autopsy studies reporting a prevalence ranging from
Scan Area T11 – S1 0.5 – 6%1 – 5. The embryological theory for this variation is
Scan length 29.7 cm that the normal longitudinal anastomosis between the
Scan time 10 s four roots of the omphalomesenteric artery fails to fully
Scan direction Caudocranial complete 56. The first root does not unite with the other
KV 120 roots, and therefore develops separately into a left gastric
Effective mAs 157
artery arising directly from the aorta.
Rotation time 0.5 s
Knowledge of the origin of the left gastric artery is impor-
Slice collimation 16 x 0.75 mm
Slice width 0.75 mm
tant for certain operations, particularly when dissection
Table feed / rotation 15 mm of the perivascular lymph nodes is required. Left peripheral
Reconstruction increment 0.4 mm and hilar types of cholangiocarcinoma, as well as gastric
Kernel B 30 f cancers, have a higher incidence of metastasis to lymph
nodes along the left gastric artery than for other ar-
Contrast Ultravist™ (300 mg iodine per ml) teries7 – 10. Furthermore, in patients with gastric bleeding,
Volume 125 ml the left gastric artery supplies the bleeding site in approxi-
Flow rate 4 ml/s mately 85% of cases11.
Start delay 30 s In this case, 16-slice multislice computed tomography
(MSCT) allowed for thin slice acquisition (0.75 mm),
Postprocessing Coronal and sagittal MIP and VRT increased z-axis coverage, and a shorter scanning time.
These improvements allowed for superior spatial resolu-
tion resulting in clearer depictions of fine vascular details.
Three-dimensional reconstruction of the mesenteric arter-
ies was considered helpful by the surgeon during pre-
operative evaluation for hepatic arterial infusion pump
placement. Nowadays, even the smallest branches of the
abdominal vessels may be visualized in a rapid, non-inva-
sive fashion using 16-slice MSCT angiography.

20
[ 1 ] Maximum-intensity-projection showing left gastric
artery originating directly from the aorta.
[ 3 ] Volume rendered anterior-posterior visualization
of the abdominal aorta, showing hepatolienal trunk and
direct aortic origin of the left gastric artery (arrow).
[ 2 ] Volume rendered anterior-posterior visualization of
the abdominal aorta and its major branches.
REFERENCES:
1 Yildirim, M., H. Ozan, et al. (1998) Left gastric artery originating directly
from the aorta. Surg Radiol Anat. 20(4): 303-05.
2 Kiss F. (1926) Über einige Varietaten der Arteria hepatica und Arteria
cystica. Z Anat Entw Gesch 81: 601-619.
3 Naidich J.B., T.P. Naidich, et al. (1978) The origin of the left gastric artery.
Radiology 126: 623-626.
4 Eaton P.B. (1917) The coeliac axis. Anat Rec 13: 369.
5 Vandamme J.P. and J. Bonte. (1985) The branches of the celiac trunk.
Acta Anat 122(2): 110-14.
6 Tandler J (1904) Über die Varietäten der Arteria coeliaca und deren
Entwickelung. Anat Hft. 25: 472-500.
7 Kosaka T., N. Ueshige, et al. (1999) Lymphatic routes of the stomach
demonstrated by gastric carcinomas with solitary lymph node metastasis.
Surg Today. 29(8): 695-700.
8 Tsuji T., T. Hiraoka, et al. (2001) Lymphatic spreading pattern of intra-
hepatic cholangiocarcinoma. Surgery. 129(4): 401-7.
9 Tsagareishvili A. (1959) Variants of the origin of the left gastric artery
and their practical significance in stomach resection. Vestn Khir Grekova.
83: 104-07.
10 Sawai K., T. Azuma, et al (1984) Angiographic analysis of vascular
anatomy in gastric cancer. Nippon Geka Gakkai Zasshi 85: 143-52.
11 Kelemouridis V., C.A. Athanasoulis, et al. (1983) Gastric bleeding sites:
an angiographic study. Radiology. 149(3): 643-8.
21
SOMATOM SESSIONS 12

Case 7: Liver Metasteses

HISTORY EXAMINATION PROTOCOLS

A 33 year old female presented with Cushings disease. An Scanner SOMATOM Sensation 16
ultrasound was performed. This showed liver nodules, Scan Area From dome of diaphragm
there was also a suspicion of an adrenal mass. CT was to s. pubis
requested for Adrenal malignancy or Malignancy Scan length 42.3 cm
with ectopic ACTH secretion. Scan time 10.24 s
Scan direction Craniocaudal
kV 120
Effective mAs 140, modulated to 114 with
DIAGNOSIS AND COMMENTS: CARE Dose
Rotation time 0.5 s
Contrast enhanced CT of the chest, abdomen and pelvis Slice collimation 16 x 1.5 mm
were performed. Slice width 2 mm
Table feed / rotation 24 mm
Below the diaphragm, there were numerous deposits in all
Pitch Volume pitch 16, Pitch factor 1
segments of the liver. A lesion in the head of pancreas
Reconstruction increment 1.5 mm
obstructed the pancreatic duct, which is very dilated with Kernel B 20 f Smooth
atrophy of the rest of the pancreas. No para-aortic or
pelvic lympadenopathy was seen. Spleen and Kidneys
Contrast Iopamidol (300 mg iodine per ml)
were normal. Adrenals were both enlarged, consistent
Volume 100 ml
with hypertrophy. Flow rate 3 ml/s
Following the CT exam the patient was admitted for a Start delay 70 s
Liver biopsy. Histology showed metastatic neuroendocrine
tumour. The patient was referred to Clinical Oncology. Postprocessing VRT with InSpace

22
[ 1 ] Coronal VRT image using InSpace at the level of the [ 2 ] Coronal VRT image using InSpace. It demonstrates
porta hepatis. It demonstrates enlarged liver with metas- the enlarged liver with metastases. The enlarged liver
tases. The enlarged liver displaces right kidney and ele- displaces right kidney. Both adrenals are enlarged due to
vates the right hemi-diaphragm. ectopic ACTH.

23
SOMATOM SESSIONS 12

Case 8: Mobile Distal Ureteral Stone

HISTORY A B

A 64-year-old female patient with hematuria and recurrent

lower abdominal pain underwent abdominal X-ray imag-
ing, ultrasonography and CT.

EXAMINATION PROTOCOLS
Scanner SOMATOM Sensation 16
Scan length 38 cm
Scan time 15,8 S
Scan direction craniocaudal
[ 1 ] conventional radiographic image of the region of the
kV 120
distal left ureter and the bladder demonstrates no sign of
Effective mAs 180
the stone (A). By choosing special setting, VRT image (B)
Rotation time 0,5 s
from the non contrast enhanced CT data set permits clear
Slice collimation 16 x 0,75 mm
depiction of the stone (arrow), even when overlaying with
Slice width 1 mm
bone structures (os pubis).
Table feed / rotation 12 mm
Pitch Volume pitch 16, Pitch factor 1
Reconstruction increment 0,7 A
Kernel B 30 f

Contrast non ionic contrast media

(370 mg iodine per ml)
Volume 100 ml
Flow rate 2 ml/s
Start delay 80 s (venous phase)

Postprocessing VRT with InSpace

DIAGNOSIS AND COMMENTS B

A mobile distal ureteral stone could be detected in CT. An

unknown descensus of the bladder, as pitfall, lead to the
missing of the stone in conventional R-ray imaging and in
abdominal US. Transrectal ultrasound also revealed the
floating stone. In no modality hydronephrosis was visible.
The chronic dilatation of the distal ureter permits a mobility
of the stone of up to 8 cm proximal during CT examination.
Ureteroscopy was performed, whereas the stone could
be caught with a Dormia-basket, desintegrated by laser
lithotripsy and extracted successfully. The patient resolved
quickly. [ 2 ] The stone was detected in transrectal ultrasound
(arrow, B) not in abdominal ultrasound (A).

24
 A B

[ 3A ] The high resolution CT data set can easily be [ 3B ] Rotated lateral VRT image projection with the stone
displayed in VRT in a “Martius like” projection allowing an displayed through the left foramen obturatum.
anatomically non distorted view from cranial oblique in
the pelvis for better ureter stone detection.

A B

[ 4A ] This VRT setting better permits visualization of the [ 4B ] For clear exclusion of hydronephrosis the
stone in the distal left ureter. demarcation of the renal calyces and renal pelvis is
superor in this VRT setting.

[ 4A + 4B ] After bolus i.v.contrast administration and an 8 minutes delay, the kidneys, ureter
and bladder can be visualized in VRT images. Compared to the non contrast data set, the stone is
displayed more proximal and clearly in the dilateded distal left ureter.

25
SOMATOM SESSIONS 12

Case 9: Multiple Pathology

HISTORY EXAMINATION PROTOCOLS

A 42 year old man, currently undergoing treatment for Scanner SOMATOM Sensation 16
Neuroendocrine tumuor, was referred for CT of the chest Scan Area From Apices to Mid L4
and abdomen. Scan length 39.6 cm
Chemotherapy had been completed. Unfortunately he had Scan time 8.0 s
been unable to attend for a post 6 cycle treatment CT. Bio- Scan direction Craniocaudal
chemistry results indicated 5 Hydroxindole acetic acid (5 kV 120
Effective mAs 140 effective, Modulated to 99
HIAA) as rising. A recent chest X-ray demonstrated new
Rotation time 0.5 s
lung changes and it was considered that these may repre-
Slice collimation 16 x 1.5 mm
sent progressive hilar changes. In view of the new chest Slice width 2 mm
mass, CT was requested to determine whether second line Table feed / rotation 28.5
chemotherapy should be employed. Pitch Volume pitch 19, Pitch factor 1.2
Reconstruction increment 1.5 mm
Kernel B 20 F smooth

DIAGNOSIS AND COMMENTS

Contrast Iopamidol (300 mg iodine per ml)
An enhanced examination was performed with acquisition Volume 100 ml
during arterial phase, to demonstrate hypervascular Flow rate 4 ml / s
Hepatic lesions. Start delay 25 s

The CT examination demonstrated evidence of previous

left upper lobe surgery, Multiple small peripheral pul- Postprocessing VRT and MIP with InSpace

monary metastases were shown. Below the diaphragm,

multiple liver metastases were demonstrated, though
these were stable with reference to previous CT examina-
tion. Multiple sclerotic bone metastase were noted
throughout the vertebral column. A single left renal nodule
was shown. The patient was referred back to the care of
oncology for follow up.
Neuroendocrine tumours have a relatively good prognosis
REFERENCE
Hauser H, Wolf G, Uranus S et al. Neuroendocrine tumours in various organ
systems in a ten year period. Eur J Surg Oncol 1995: 21: 142–146.
Meeran K. Carciniod andother neuroendocrine tumours. Summer school
2000. 10–14 July 2000 UK.

compared with other tumours and may survive for many

years. Use of Chemotheraputic agents has largely been dis-
appointing, though some agents have had some effect.

26
[ 1 ] VRT image using InSpace demonstrates single left [ 2 ] Coronal VRT image using InSpace shows arterial
renal deposit and multiple sclerotic spinal deposits. phase, superior mesenteric and hepatic artery, also
Also evidence of the previous upper lobe surgery is shown neovascularity, with multiple tortuous vessels supplying
with healed ribs. the Hepatic deposits.

[ 3 ] Coronal VRT image using InSpace demonstrates

multiple peripheral metastases. Of particular interest is
the small nodule sitting on apex of left hemi-diagphram.
Such a lesion would be difficult if not impossible to detect
on an axial slices, thus demonstrating the value of volume
data acquisition and of course volume post processing
technique (InSpace).

27
SOMATOM SESSIONS 12

High Resolution CT in Critical Ill Patients

Multislice spiral CT drastically reduces examination
time compared to singleslice CT Scanners [Fig. 1]. Short
examination times are of utmost importance in exam-
ining critical ill patients, patients who are short of
breath, on mechanical ventilation or uncooperative.
The new generation of multislice CT scanners offer
simultaneous acquisition of 16 sub-millimeter slices.
This represents a breakthrough on the way towards
true isotropic resolution in clinical routine. Images
in arbitrarily chosen planes in an image quality as
the original axial slices now can be achieved not only
in cooperative patients in a relatively well physical
status but also in patients from intensive care units.

Case 10: Adult Respirators Distress Syndrome (ARDS)

HISTORY EXAMINATION PROTOCOLS

A 70-year-old patient was admitted to hospital with cough Scanner SOMATOM Sensation 16
and fever. He had prior resection of the right upper lobe Region Thorax
because of lung cancer. Despite the use of intensive anti- Scan length 360 mm
biotic therapy the patient’s condition rapidly deteriorated Slice collimation 16 x 0.75 mm
and intubation and mechanical ventilation became neces- Table feet / rotation 18 mm
sary. He developed signs of ARDS over the following days. Pitch Volume pitch 24, Pitch factor 1.5
Scan direction craniocaudal
Fig. 2 shows the portable radiograph, CT was performed
Rotation time 0.5 s
the same day [Fig. 3].
KV 140
Eff. mAs 100 (with CARE Dose)
Scan time 10 s
DIAGNOSIS AND COMMENTS: Reconstructed slice width 0.75 mm
Reconstruction increment 0.5 mm
CT revealed hilar and mediastinal lymphadenopathy and a kernel B 40 / B 70
solid mass in the right upper lung suggestive for tumor
recurrence. Bilateral airspace opacities, pleural and peri- Contrast non ionic contrast media
cardial effusion as well as interstitial thickening and a (300 mg iodine per ml)
Total volume 80 ml
pneumothorax on the left side became evident.
Injection rate 3 ml/s
Start delay 50 s
Despite being on mechanical ventilation, high resolution
imaging of the lung is possible. This facilitates the inter-
Postprocessing VRT and MIP with Inspace
pretation of acute lung disease. CT is clearly superior in
detecting inflammatory processes and complications like
pneumothorax.

28
 Scantime 10 s; Pitch 1,5
0
5
1 x 1 mm;
RT 0,75 s

100

5
4 x 1 mm;
RT 0,5 s
200

300

16 x 0,75 mm;
5 RT 0,5 s

400 [mm]

[ 1 ] Comparison of volume coverage with different CT types. [ 2 ] Portable radiograph shows

bilateral airspace opacities.

[ 3 ] MPR and VRT images show bilateral airspace consolidation and interstitial thickening
predominantly in the dorsal parts of the lung. Images reconstructed with high resolution kernel
demonstrate subpleural lines and interlobular septal thickening on the right side, pneumothorax
and honeycombing on the left.

29
SOMATOM SESSIONS 12

Case 11: AIDS-related Non-Hodgkin’s Lymphoma

HISTORY EXAMINATION PROTOCOLS

A 32-year-old patient with acquired immunodeficiency syn- Scanner SOMATOM Sensation 16
drome presented with fever, lethargy, a decreased level of Region Thorax-Abdomen
consciousness and shortness of breath. Chest radiograph Scan length 600 mm
demonstrated a huge effusion in the right hemithorax. Slice collimation 16 x 0.75 mm
Subsequently a CT scan of the thorax and abdomen was Table feet / rotation 18 mm
performed [Fig. 4]. Pitch Volume pitch 24, Pitch factor 1.5
Scan direction craniocaudal
Rotation time 0.5 s
KV 120
DIAGNOSIS AND COMMENTS: Eff. mAs 140 ( with CARE Dose)
Scan time 17 s
The CT scan showed enlarged axillary lymph nodes as well
as bihilar, mediastinal and retroperitoneal lymphaden- Reconstruction
opathy. Thickening of the pleura with contrast enhance- Reconstructed slice width 0.75 mm
ment and large pleural effusion is suggestive for pleura Reconstruction increment 0.5 mm
empyema. Atelectasis and air space opacification is kernel B 40 / B 70c
demonstrated on the right side, nodules in an otherwise
clear left lung. Inhomogeneity of the liver and spleen is due Contrast material non ionic contrast media
to early contrast phase. Percutaneous drainage of the right (300 mg iodine per ml)
pleural space revealed tuberculous empyema, analysis of Total volume 120 ml
the CSF was also suggestive for TB meningitis. Non- Injection rate 3 ml/s
Start delay 30 s
Hodgkin’s lymphoma was diagnosed from lymph node
biopsy.
Within a scantime of 17 seconds the thorax and abdomen
(length of range: 600 mm) was examined with sub-mil-
limeter slice collimation allowing for isotropic resolution.
MPR in coronal orientation provide an excellent overview
in just a couple of images. The short examination time is
crucial to achieve motion-free images in critical ill patients.
If isotropic resolution is not required the examination time
can be further reduced if a 16 x 1.5 mm collimation is used.

30
 A C

[ 4 ] MPR image reconstructed with high resolution kernel (A, B) demonstrate right sided pleural
effusion and the atelectasis and bilateral pulmonary nodules.
MPR of thorax-abdomen scan (C) shows right sided empyema and lymph node conglomerates.

31
SOMATOM SESSIONS 12

Case 12: Three-phase Renal CT – Diagnosis

of Renal Pelvic Transitional Cell Carcinoma
HISTORY A

68 year old male presenting with hematuria.

EXAMINATION PROTOCOLS
Scanner SOMATOM Sensation 16
Scan region Abdomen and Pelvis
Length 30–40 cm
Slice collimation 16 x 0.75 mm
Scan Craniocaudal
Rotation time 0.5 s
kV 120
Eff. mAs 130
Kernel B20 smooth
Scan time 12.5–17 s
Slice width 3 mm
Increment 2.5 mm

Post-Processing
Reconstruction Image Set
Slice width 1 mm
Increment 0.8 mm

Postprocessing Leonardo Workstation

Thin MIP Coronal obliques oriented
parallel to the kidneys
VRT Inspace

All scans phases were scanned with 0.75 mm collimation,
pitch 16, at 120 kVp, 130 effective mAs, and 0.5 s scan time.
A non-contrast scan is done to localize the kidneys, assess
for calcifications and allow for determination of enhance-
ment following IV contrast. A test injection with 20 ml of
contrast is used to determine the delay time for a vascular
phase exam. Contrast is injected at 4 ml / s and images
obtained over the upper abdomen every 2 seconds begin-
ning at 20 seconds for 40 seconds. Time to peak enhance-
ment of the upper abdominal aorta is calculated. The
vascular phase scan is performed using this delay time
plus 5 seconds for error and to allow venous filling. This
scan includes the upper abdominal aorta through the iliac
arteries. Then, a parenchymal phase scan was performed
of the entire abdomen and pelvis; the delay time from the
start of the contrast injection to the beginning of the
parenchymal phase scan was approximately 120 s.
All scan phases were reconstructed at standard field of
view, B20 kernel, with a diagnostic set of images with 5 mm
slice thickness and 2.5 mm reconstruction interval. These
images were for diagnostic review on the MagicView 1000.
A second set of 1 mm slice thick images with an 0.8 mm
reconstruction interval were also created, for use in 2- and
3-dimensional reconstructions. The reconstructions were
done on the Wizard or Leonardo workstations. Oral con-
trast was not administered as it can interfere with the 2-
and 3-D renderings.

32
B C

[ 1 ] (A) Unenhanced, (B) vascular phase, and (C)

Nephrographic phase axial CT images show a 2.1 x 1.5 cm
enhancing mass (arrow) within the right renal pelvis,
surrounded anteriorly by excreted contrast.

A B

[ 2 ] (A) Oblique coronal and (B) sagittal multiplanar

reformations show the location of this mass within the
renal pelvis.

33
SOMATOM SESSIONS 12
[ 3 ] Volume rendering (using InSpace) from the nephro-
graphic phase scan also gives a 3-dimensional appear-
ance to the tumor showing it in relationship to the proxi-
mal right ureter.
A B
34
DIAGNOSIS AND COMMENTS:
A 2.1 x1.5 cm enhancing mass is seen in the right renal
pelvis. The mass demonstrates no calcification on the un-
enhanced images, and enhancement from 44 Hounsfield
units pre-contrast to 83 Hounsfield units on the nephro-
graphic phase following contrast [Fig. 1]. No renal
parenchymal mass, lympha-denopathy, or vascular inva-
sion is identified. Coronal oblique and sagittal images,
and volume rendering [Fig. 2, 3] demonstrate the tumor
posterior within the renal pelvis but invading and nar-
rowing the pelvis rather than a polypoid mass as suspected
by the axial images. Therefore this tumor was not amen-
able to percutaneous or endoscopic resection, and the
standard surgical treatment of nephroureterectomy was
offered. The vascular phase can be also used to render the
renal vessels for surgical planning [Fig. 4].
Diagnosis: Transitional cell carcinoma of the right renal
pelvis.
Treatment: This patient subsequently underwent success-
ful laparoscopic nephroureterectomy.
[ 4 ] Volume rendering (using InSpace) from the vascular
phase scan shows two right renal arteries (A) including
plus an early branch from the main renal artery and
a single right renal vein (B). The location and relative
position to each other are important for surgical planning
purposes.
IMPRESSUM

Published by International Distribution

CT Marketing Xiaoyan Chen, M.D., MBA Stefan Schaller, Ph.D.

Siemens AG CT Concepts CT Concepts
Medical Solutions
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eMail xiao_yan.chen@siemens.com

Anil Gupta
CT Marketing

Siemens AG, Medical Solutions

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91301 Forchheim, Germany
Phone +49-9191-18-8121
Fax +49-9191-18-9998
eMail anil.gupta@siemens.com

THIS ISSUE’S AUTHORS

Case 1 Case 4 Case 8

Jeffrey S. Ross, M.D. Patrick Ingelfinger, Marco Das, Gudrun Feuchtner, Ferdinand Frauscher, Alexan-
Section of Neuroradiology Ann McGinnis, U. Joseph Schoepf der v. Smekal
Division of Radiology Department of Radiology Brigham Department of Radiodiagnostics, Radiology II,
Cleveland Clinic Foundation and Women’s Hospital University Hospital
Desk L-10 Harvard Medical School Anichstrasse 35
9500 Euclid Ave. 75 Francis Street A 6020 Innsbruck
Cleveland, OH 44195 Boston, MA 02115 Austria
USA USA
Case 10 / Case 11
Case 2 Case 5 Dr. Michael Lell
Peter Herzog, MD Bernd J. Wintersperger, MD Institut für Diagnostische Radiologie,
Department ofDiagnostic Radiology Department of Diagnostic Radiology Universität Erlangen
Klinikum Großhadern Klinikum Großhadern Maximiliansplatz 1,
Marchionistrasse 15 Marchionistrasse 15 91054 Erlangen,
81377 Munich, 81377 Munich, Germany
Germany Germany
Case 12
Case 3 Case 6 Brian R Herts, M.D.
D.B. Rouw, P.M.A. van Ooijen, W.G.J. Tukker, Vito Cantisani, Babak N. Kalantari, Koenraad Section of Abdominal Imaging
J. Dorgelo, R. Vliegenthart, M. Oudkerk J. Mortele, Jean M. Allen, U. Joseph Schoepf, Division of Radiology
Dept. of Radiology, Stuart G. Silverman, Elisa Pagliara, Pablo R. Ros Cleveland Clinic Foundation
Groningen University Hospital, Department of Radiology, Desk Hb-6
Groningen, Brigham & Women’s Hospital, 9500 Euclid Ave.
The Netherlands Harvard Medical School, Cleveland, OH 44195
Boston, Massachusetts, USA USA

Case 7 / Case 9
Prof. Adrian Dixon
Department of Radiology
Addenbrookes Hospital
Hills rd, Cambridge.
CB2 2QQ.
UK
35
SOMATOM SESSIONS 12

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