somatom sessions 19

SOMATOMSessions

No 19/November 2006RSNA-EditionNov. 26th–Dec. 1st, 2006

€ 10.00www.siemens.com/medical

COVER STORYsyngo WebSpace: Leading the Workflow Revolution inVolume CT Page 4

Two: The New Arithmetic of CTPage 8

NEWSClinically Proven: The Benefit of syngo Lung CAD –Now PMA Approved 2

BUSINESSLife in the Global Village:A Dialogue With Prof. Michael Knopp, MDPage 15

CLINICAL OUTCOMESOncology – Improved Followup For Pulmonary Nodules Page 22

Acute Care – NEW: Compre-hensive 3D Stroke ImagingPage 26

SCIENCESee the Whole Disease:Neuro Perfused Blood Volume ImagingPage 32

EDUCATION & EVENTSThe World’s First SOMATOM Definition WorkshopPage 35

Highlights

2 SOMATOM Sessions 19

EDITOR’S LETTER

Dear Reader,

André Hartung, Vice President Marketing and Sales

Cover Page: Real-time, spiral dual energy volume rendering technique (VRT) of a head and neck CTA shows

the precise cerebral vasculature status. Kindly provided by the University of Munich, Grosshadern, Germany.

André Hartung,

Vice President Marketing

and Sales

In recent years, developments in the computed tomography (CT) field have accelerated with

breath-taking speed and have radically improved medical imaging. Siemens was able to make a

decisive contribution to this fascinating, quantum leap in CT development. Our success is based

upon a simple principle: cooperation with the best clinical experts. We are proud to say that we

have for years maintained professional contacts to experts from around the world. From the very

earliest stages of research, product development and design, Siemens relies upon the advice and

recommendations of external medical experts to determine our focus – and this focus has been on

the needs and demands of the end users. In this way, our products have been able to make a sig-

nificant difference for our customers.

Our newest innovations underscore the clinical advantages of our products: The Dual Source CT

SOMATOM® Definition completely eliminates the need for beta-blockers to reduce heartbeat

frequency during CT heart examinations. Image quality and speed remain outstanding under these

conditions, including emergency room and obese patients. The first clinical installations utilizing

our Dual Source CTs with two x-ray sources and two detectors permitting imaging at two different

energy levels simultaneously are already in use. And the previously difficult challenge of quickly

and efficiently managing large volumes of high-resolution images and making these images

available wherever you are has been elegantly solved with syngo® WebSpace software. Efficient 3D

CT post-processing from remote computer around the world is now a reality. (For more informa-

tion, see our Cover Stories). The intelligent interaction and high-performance post-processing of

diagnostic information has become increasingly more important in daily clinical routine.

The medical profession has hardly begun to utilize the full potential of computed tomography and,

as usual, Siemens is taking the lead. In teamwork with our internal and external experts, all things

are possible. And making the difference for you, our customers, is our passion!

Enjoy reading

SOMATOM Sessions 19 3

CONTENT

COVER STORY4 syngo WebSpace: Leading the Workflow Revolution in Volume CT

8 Two: The New Arithmetic of CT

NEWS12 Clinically Proven: The Benefit of syngo Lung CAD – Now PMA Approved

14 The Results Are Ready When You Are

14 Improving Financial and Operational Outcomes With Utilization Management

BUSINESS15 Life in the Global Village: A Dialogue With Prof. Michael Knopp, MD

19 Quality, Valuability and Flexibility

CLINICAL OUTCOMES20 Cardiovascular: Improved Workflow and Speed Combining

SOMATOM Definition & AXIOM Artis dFC

22 Oncology: Improved Follow up For Pulmonary Nodules With syngo LungCARE and syngo Lung CAD

24 Neurology: Child – 11 Months: Visualization of a Choroid Plexus Papilloma

26 Acute Care: NEW – Comprehensive 3D Stroke Imaging With syngo Neuro PBV

SCIENCE28 CARE Dose4D: New Technique for Radiation Dose Reduction

32 See the Whole Disease: Neuro Perfused Blood Volume Imaging

EDUCATION & EVENTS35 The World’s First SOMATOM Definition Workshop

36 Continuous Updates in SOMATOM LifeNet

37 New Course Selector

37 Frequently Asked Questions

38 Efficient Tools to Explore New Clinical Opportunities

38 Upcoming Events and Courses

39 Imprint

COVER STORY

syngo WebSpace: Leading the WorkflowRevolution in Volume CTUntil now, the potential of volume CT imaging for diagnosis and treatment has been limited due to workstation accessibility issues. But syngo WebSpace, a new server / thin client technology, is rapidly meeting this challenge and making access to 3D data available from everywhere*. SOMATOM Sessions’ Tim Friend talked with Prof. Elliot Fishman about the workflow implications of this new technology.

Elliot Fishman, MD, Professor of Radiology and Oncology, Johns Hopkins Medical Institutions, Baltimore, Maryland.


COVER STORY


By Tim Friend

The most extraordinary feature of syngo WebSpace is how

ordinary it appears.

As I look on, Elliot Fishman, MD, Professor of Radiology and

Oncology at the Johns Hopkins Medical Institutions in Balti-

more, chooses a desktop computer at random in an empty

cubicle across the hall from his office. He accesses Internet

Explorer and, with a brief flash of keystrokes, downloads a

syngo WebSpace client onto the computer’s hard drive. After

about a minute, a new icon appears on the desktop screen.

The program is loaded and ready to run.

Fishman clicks on the icon, which accesses the Internet and

connects to a server. Up pops a menu of patients who have

undergone CT scanning in the radiology department. One

more mouse click, and the screen displays a 3D state-of-

the-art CT image of a heart. The way someone might rev the

engine to display the power of a new Ferrari, he spins the

heart and manipulates the dramatically detailed image to

display the speed at which syngo WebSpace is able to operate

over a typical broadband internet connection.

A naive bystander would not realize what has just occurred.

But physicians accustomed to using a PACS workstation for

two-dimensional images and having to wait in line to log

onto a separate workstation for access to three-dimensional

images would immediately stop in their tracks and know they

were witnessing something remarkable and brand new.

Harnessing the Power of theInternet for CTUntil now, the state of the art for Siemens Medical Solutions

has been syngo InSpace4DTM software for volume visualiza-

tion of images made with Siemens scanners using the Multi

Modality Workplace (MMWP). syngo InSpace, which became

available in 2003, aided the paradigm shift from axial images

to volume images, Fishman says. With true volume imaging,

physicians began to realize the value of diagnostic and treat-

ment information contained in such massive data sets. syngo

InSpace4D can remain state of the art for Siemens Medical

Solutions, but access is limited to dedicated workstations.

What Fishman has just demonstrated with syngo WebSpace

is the beginning of a revolution that will make the clinical use

of 3D and 4D medical diagnostic CT imaging as common and

routine as logging onto the internet.

“WebSpace is sort of like InSpace on steroids,” says Fishman.

“Everything we could do on that workstation – on the MMWP

– at a fixed location, we can now do anywhere, anytime.

What that means in practical terms is that syngo WebSpace is

making 3D data practical for the common man.”

syngo WebSpace resolves one of the most important chal-

lenges to the broader clinical use of volume images today:

limited access to workstations. This has been the primary

bottleneck of workflow in the radiology departments of most

major medical centers. The bottleneck arose as demand for

volume imaging dramatically increased in recent years.

“In the past, when no one really thought of 3D or post-pro-

cessing as a critical part of CT, it wasn’t so much of an issue,”

explains Fishman. “No one was clamoring for the information,

so there was no urgency to use the workstation. As someone

“Everything we could do on that

workstation at a fixed location, we can

now do anywhere*, anytime.

What that means in practical terms

is that syngo WebSpace is making 3D

data practical for the common man.”Elliot Fishman, MD, Professor of Radiology and Oncology,

Johns Hopkins Medical Institutions, Baltimore, Maryland

Elliot Fishman concentrating on the syngo WebSpace screen.


COVER STORY

who has taught 3D courses for ten years with Siemens, one

of the things we discovered was that, back in the beginning,

people would say, ‘This 3D stuff is okay, but I’m probably not

going to do it.’ Then, after a few years, people started saying

‘Well, it’s interesting. I’ll have to keep my eye on it.’ Finally,

three to four years ago, with 16-slice CT, the real change

began, and people were saying, ‘This 3D stuff is something I

probably should do.’ I noticed a big difference last year at the

64-slice level courses. Suddenly I was hearing, ‘I agree with

you, we have to do it. The problem is, we can’t do it, because

there are twenty people in my group and we only have one

workstation. It’s not part of our workflow. We can’t get to the

system. The system is down the hall from the scanner. Yes we

agree with you that this is a valuable tool, but how do we do

workflow?’ That’s really what syngo WebSpace does answer.”

Movie Magic for Medical ApplicationsBack in Fishman’s office, which is crowded with files of

thousands of ‘antique’ hard-copy images, he outlines the

evolution of CT in recent history. He was instrumental in

developing 3D medical imaging in the early 1980s working

with animation legends Lucas Films and Pixar to adopt movie-

magic computer graphics technology for medical applications.

As the software was being developed for medical imaging,

he began collaborating with Siemens.

“At Hopkins, we’ve been Siemens users for more than twen-

ty years. We’ve been involved in CT and using Siemens scan-

ners since 1982. We’ve seen the technology change from the

DR3 scanner through single-slice spirals, through 4-slice spi-

rals, through 16 to 64 slices, to literally the new Dual Source

CT, SOMATOM Definition, which is being installed at Hopkins

and expected to be operational within two weeks,” Fishman

says. “From the beginning, one of the things we have viewed

differently from many of our colleagues elsewhere is that CT

is more than slices. CT is volumes of data, and the best way

to get information from the CT scan was to use the volume

rather than the slices. We’ve always been involved with

development and working with Siemens on workstations for

visualization. So whether it was with 3D Virtuoso or currently

with the MMWP and syngo InSpace4D, our concept was

always that CT is volume visualization. CT has gone from a

study of an abdomen – let’s say that was 30 slices – to 100

slices

to 300 and now to thousands of slices. Because of those

capabilities, our abilities have changed over time. Yes, we have

always looked at the pancreas and the liver and lungs with CT,

but now we can do it better than ever – more accurately

with higher sensitivity and higher specificity. Because of all

these important changes, we have been able to develop

new applications, from CT angiography to virtual bron-

“syngo WebSpace takes

a process that is really good

and really critical, which

is 3D post-processing, and

makes it available every-

where* so that it pushes

the process throughout

the enterprise.”Elliot Fishman, MD, Professor of

Radiology and Oncology, Johns Hopkins

Medical Institutions, Baltimore, Marylandsyngo WebSpace allows fast examination of clinical images – wherever you are.


COVER STORY

choscopy to virtual colonoscopy. The common theme that

everything has had is that you needed to look at information

as a volume.” The development of powerful workstations

able to handle the amount of data generated by 16- and

64-slice CT scanners made physicians realize the potential

for diagnosing and treating diseases in their patients. They

started wanting more. But the new popularity also created

the workflow bottleneck. Over the past six months, Fishman,

together with other experts and Siemens Medical Solutions,

has collaborated to overcome this latest challenge. syngo

WebSpace is the result of that collaboration.

Anytime, Anywhere* Access Speeds WorkflowA syngo WebSpace server receives information from scanners

in a radiology department instantly. With high-speed Internet

connections, anyone can log onto the syngo WebSpace

system and use their PC or laptop** just like a MMWP. After

spinning the 3D heart in his syngo WebSpace demonstration

via the Internet, Fishman notes that he perceives virtually no

difference in speed compared with the MMWP.

Initially, Siemens has created syngo WebSpace systems that

can accommodate five, ten or twenty simultaneous users.

But Fishman expects demand to increase rapidly. He says in

the past, busy physicians wouldn’t bother coming to the radi-

ology department to look at the volume images. It was simply

a question of time – trips to other floors or buildings on a

large hospital campus were impractical. But now, physicians

can log onto the internet, download the syngo WebSpace

program one time, and use the system whenever it is con-

venient. Surgeons may even use the system while operating.

Radiologists can have access to all of their volume data at

their homes with a broadband internet connection. The new

applications are limitless. Fishman says syngo WebSpace will

reshape medical education as well. Currently, students, resi-

dents and fellows can view volume images during conferences

rather than look at static two-dimensional pictures. He also

sees syngo WebSpace as attractive to referring physicians.

Hospitals can offer access to such remarkable CT data to

physicians in their own offices. They can view studies of their

patients via syngo WebSpace within minutes of the images

being taken at a radiology unit. Physicians also may find the

service helpful during office visits to discuss diagnosis and

treatment plans with their patients.

Clearly, all roads with syngo WebSpace lead to everyday

practical use of the most advanced CT imaging information.

“syngo WebSpace takes a process that is really good and really

critical, which is 3D post-processing, and just makes it available

everywhere so that it pushes the process throughout the

enterprise,” says Fishman. “The result is better patient care,

more efficient care, and better management of patients,

because it puts much more information into the hands of the

clinician – quickly and easily.”

Author: Tim Friend, a USA Today reporter for 17 years, is now a freelance science and medical writer based in Alexandria, VA. He is the author of Animal Talk: Breaking the Codes of Animal Language,and has just finished a second book on the discovery of a new life form on earth.

“The result is better patient care,

more efficient care, and better

management of patients, because

it puts much more information

into the hands of the clinician –

quickly and easily.”Elliot Fishman, MD, Professor of Radiology and Oncology,

Johns Hopkins Medical Institutions, Baltimore, MarylandJohns Hopkins Medical Institutions, Baltimore, Maryland.

*internet connection required

**PC or laptop must meet minimum specifications

www.siemens.com/syngo-WebSpacek


COVER STORY

Two sources, two detectors and the ability to operate two X-ray tubes at different energy levels: These features of Dual Source Computed Tomographyhave opened the way to a broad range of new applications.

Two: The New Arithmetic of CT

Andreas H. Mahnken, MD, MBA, Senior Physician at the Clinic

for Diagnostic Radiology at the Aachen University Hospital,

Germany, knows what he wants. Integrated into the daily

routine of a major hospital, the radiologist is familiar with the

questions posed to him on a daily basis. How severe is the

stenosis? After therapy, is the tumor still vital? Are the liga-

ments still intact after the knee fracture? What fluids can be

By Hildegard Kaulen, PhD

Andreas Mahnken considers utilizing xenonas a contrast medium in ventilation studies.

detected: blood, abscess, ascites? Previously, many of these

questions could not be answered completely using computed

tomography. But Mahnken particularly values this modality.

CT is fast, robust, and requires almost no waiting time.

By increasing the number of detector rows, previous CT

developments dramatically increased the speed of acquisi-

tions. However, he says, these days, acquisition speed is no

longer an issue. A further increase of slices would not help gain

the additional information required to improve diagnoses.

Since the introduction of the SOMATOM Definition, Mahnken

is not only convinced that the world’s first Dual Source CT

improves patient care by making non-invasive, cardiac CT

diagnosis routinely accessible for all patients, but also that

the new technology opens the door beyond simple visuali-

zation of Hounsfield values. Dual Source CT is not only an

excellent diagnostic device for daily routine exams, it is also

an interesting tool to discover completely new clinical appli-

cations. Mahnken has been working with the SOMATOM

Definition since May 2006.

In “normal” mode, for example both X-ray tubes run at the

same energy level, acquisition time is cut in half. The result: a

heart-rate independent temporal resolution of 83 ms that

eliminates the need for ß-blockers and reduces radiation

exposure in cardiac CT.

“Dual energy provides

information that extends beyond

the actual imaging.”Andreas Mahnken, MD, MBA,

Senior Physician, Clinic for Diagnostic Radiology,

Aachen University Hospital, Aachen, Germany


COVER STORY

In dual energy mode, on the other hand, each tube uses a

different X-ray energy. “We are currently exploring the full

benefits of spiral dual energy,“ says Mahnken. “When scan-

ning an anatomical structure at 80 kV, one obtains a different

attenuation than that obtained at 140 kV. This provides infor-

mation that extends beyond the actual imaging. syngo Dual

Energy should provide us with a new look at clinical questions.

For the first time, we are able to reliably separate cartilage

from tendons in a CT image. This is truly amazing. Dual energy

broadens the application spectrum we know from computed

tomography. The new technology also helps in the visualiza-

tion of the hot problems of CT, the differentiation between

hard plaques and contrast agents. We can now display the

true vessel lumen without interfering plaques. A convincing

example of how important dual energy will be in everybody’s

daily Radiology work.“

The Principle of Dual Energy

SOMATOM Definition permits the use of twosources simultaneously at different kilovoltage(kV) levels. This offers the possibility to acquiretwo data sets simultaneously from a single spiral scan, running the tubes at two energy levels. The X-ray tube’s kV determines the average energy level of the X-ray beam. Changing the kV setting results in an alteration of photonenergy and a corresponding attenuation modifi-cation of the materials scanned. In other words,X-ray absorption is energy-dependent, for example, scanning an object with 80 kV resultsin a different attenuation than with 140 kV. Most important, this attenuation depends on the type of tissue scanned.syngo Dual Energy uses two X-ray sources running at different energy levels and acquiringtwo data sets of diverse information, whichallows to differentiate, characterize, isolate, anddistinguish the imaged tissue and material toobtain specific details about the scanned objectbeyond morphology.

80 kVAttenuation B

140 kVAttenuation A

Contrast Scans

Mahnken, who completed two years of training in health-

care management, knows how to calculate costs and sees

another advantage of syngo Dual Energy in the area of non-

contrast scans. By using the X-ray tubes at two energy levels,

the contrast medium can be masked. Previously, two scans

were required to achieve this. “We now perform only a single,

contrast enhanced, spiral dual energy scan,” says Mahnken.

“This provides two advantages: On the one hand, we can

subtract the contrast medium out of the images, avoiding

the non-enhanced examination and saving the correspon-

ding radiation exposure. The resulting dual energy image

helps, on the other hand, to reliably characterize liver and

kidney lesions. Now, we can, for example, quickly differenti-

ate between contrast enhanced and hypo-lipid areas, and

immediately identify possible tumors. In addition, through

distribution of the iodine, we also obtain information on

perfusion, which in turn provides a visualization of the vitality


COVER STORY

Christoph Becker, MD, Section Chief CT at the Institutefor Diagnostic Radiology at Grosshadern UniversityHospital in Munich, Germany:

“SOMATOM Definition’s breathtaking image qualityenables us to access completely new clinical applications,setting new benchmarks in CT. In particular, the use of syngo Dual Energy paves the way for a broad spectrum ofpotential clinical uses, one of the most significant technol-ogy shifts since the introduction of Multislice CT. A verypromising application field is syngo Dual Energy DirectAngio, the accurate subtraction of bone in CTAs even in

complicated anatomical regions. Overcoming limitationsof conventional bone removal software, the dual energyapproach reliably isolates even complex vasculature, forexample, at the base of the skull where CTAs are difficult tointerpret. To quickly and without manual post processingsteps, see a narrowing in the carotid artery without theskull blocking the view helps us to increase our diagnosticefficiency. Another dual energy application we often per-form is the evaluation of lung perfusion defects. A spiraldual energy scan allows direct visualization of the localiodine concentration in the lung parenchyma, clearly dis-playing the area of possibly affected tissue.”

Additional Voices: Christoph Becker, MD

[ 2 ] The corresponding dual energy maximum intensity projection (MIP) enables immediate rule-out of aneurysms or sub-arachnoidal-bleedings.

[ 1 ] Real-time, spiral dual energy volume rendering technique (VRT)of a head and neck CTAshows the precise cerebral vasculature status.

COVER STORY


“For the first time, we are able to reliably

separate cartilage from tendons in a CT image.

This is truly amazing.”Andreas Mahnken, MD, MBA, Senior Physician, Clinic for Diagnostic Radiology,

Aachen University Hospital, Aachen, Germany

of the tissue. For example, if we use heat in treating a primary

liver cell carcinoma, we want to subsequently see whether

we were successful. If the tumor remains free of contrast

medium, it means that blood flow to the tumor has stopped

and it is no longer being supplied.“ He points to a liver scan

displayed on his monitor. “This is a tumor where contrast

medium no longer deposits. We were successful with the

ablation.” Mahnken always attaches great importance to

contrast medium. “We currently use iodine almost exclusively.

We haven’t even started to consider ‘intelligent’ dual energy

contrast medium. A new contrast medium that we could

consider, would be xenon, an inert gas. We could use xenon to

measure pulmonary ventilation. We have some experience

using this gas in anesthesiology, and know it is not harmful

to patients. Why shouldn’t it be used as a contrast medium

for dual energy? Iodine for pulmonary perfusion, xenon for

ventilation – that would produce a complete pulmonary

diagnostic evaluation.”

Further PerspectivesMahnken also sees potential for syngo Dual Energy in

characterizing body fluids. “We are just at the very beginning

in this area. It will require additional research to be able to

differentiate between blood, pus, urine, or ascites with cer-

tainty,” he explains, while keeping an eye on the workflows

in the department. “To date, body fluids have only been

characterized via MRI or biopsy. A spiral dual energy scan

could provide comparable results. MRI and CT would come a

step closer, without arguing over competing application

areas. It is another interesting perspective of SOMATOM

Definition’s syngo Dual Energy capabilities.”

Author: Hildegard Kaulen, PhD, is a molecular biologist. After positions at Rockefeller University in New York and Harvard MedicalSchool in Boston, she has worked since the mid-90s as a freelancescience journalist for well-known newspapers and scientific journals.

Additional Voices:David P. Nadich, MD

David P. Naidich, MD, Professor of Radiology andMedicine, NYU Medical Center and School of Medicine, New York, USA:

“The introduction of the SOMATOM Definition has been

particularly exciting for our department. The utilization

of syngo Dual Energy allows the possibility of evaluat-

ing the distinct material components of the body in a

way that was previously not possible. As an example, we

recently performed a spiral dual energy examination on

a patient with a metallic stent graft within a thoracic

aortic aneurysm. Heterogeneous high attenuation areas

within this aneurysm had caused previous evaluations

for an endoleak to be particularly difficult. However, on

the current scan the generation of virtual contrast and

noncontrast maps from the dual energy data allowed

us to confidently diagnose an enhancing endoleak

tract within pre-existing high attenuation thrombus.

What’s more, we are looking into the characterization

of solitary pulmonary nodules. With these lesions of

just a few millimeters, it is currently difficult to tell

whether they are malignant or benign. It should be

easier to clarify this question by subtracting the energy

levels, which is now possible for the first time. Calcium

is also important. We want to use syngo Dual Energy to

look at these deposits and the area behind them.

Perhaps one day, people will examine calcium deposits

in the breast with spiral dual energy scan. Who knows?

I think that many new applications will come to us

by chance. Essentially, every fundamental CT develop-

ment has proven itself. I expect nothing less from Dual

Source CT’s syngo Dual Energy.”


NEWS

C O M P U T E R A I D E D D ET E C T I O N ( C A D )

Clinically Proven: The Benefit of syngoLung CAD – Now PMA Approved Siemens once again confirms its trend-

setting role in the dynamically-evolving

market of CT Computer-Aided Detection

(CAD) products by integrating new

CAD features into its applications syngo

LungCARE CT and syngo Colonography

CT. The seamless integration of CAD into

the reading workflow is intended to

speed up and enhance diagnostic confi-

dence when interpreting large datasets

with hundreds of images. This clearly

illustrates Siemens’ focus on compre-

hensive healthcare solutions.

Siemens’ first automated detection

product for thoracic CT exams, syngo

LungCARE NEV (Nodule Enhanced View-

ing), was introduced in December 2003

and now boasts more than 500 installa-

tions worldwide. Now, Siemens' latest

FDA approved computer-aided detection

product, syngo Lung CAD, is available.1

Increased Detection Accuracysyngo Lung CAD is based on proprietary

image processing and pattern recogni-

tion algorithms that have been trained

on a large database of thoracic CT stud-

ies. The software is designed to assist ra-

diologists in the detection of solid pul-

monary nodules during review of multi-

detector computed tomography (MDCT)

examinations of the chest. syngo Lung

CAD alerts the radiologist to regions of

interest (ROI) that may have been over-

looked in the initial read.

Clinically proven, syngo Lung CAD has

been validated in the largest multi-cen-

ter, multi-reader study performed

to date on the use of CAD in thoracic

CT examinations. The objective was to

demonstrate the added clinical value of

CAD in helping to detect more lung nod-

ules. Each of the nearly 200 cases was

reviewed by 17 radiologists using data

from four leading medical centers in the

U.S. The use of syngo Lung CAD as a sec-

ond reader helped all participating radi-

ologists to increase their detection accu-

racy for clinically significant lung

nodules. “The results represent important

confirmatory evidence for the clinical use

of CAD in detecting otherwise over-

looked lung nodules in MDCT studies of

the thorax,” said David Naidich, MD,

Professor of Radiology and Medicine at

New York University Medical Center, and

principal investigator of the study.

Detection and Trackingof Lung Nodulessyngo Lung CAD detects a range of nod-

ule sizes, starting at 3 mm in dia-

meter. The added value for the radiologist

using syngo Lung CAD in the second

read has been shown to be at different

nodule sizes, including nodules greater

than or equal to 3 mm as well as nodules

greater than or equal to 5 mm. The auto-

matically detected nodules cover the

full range of locations and contours and

the CAD software works equally well in

the presence or absence of intravenous

contrast.

While syngo Lung CAD provides essential

support for the detection of lung nod-

ules, the syngo LungCARE CT applica-

tion facilitates interpretation as well as[ 1 ] Display of growth rate of nodules in a follow up setting.


NEWS

tracking of nodules in follow-up exams. In

particular, the auto correlation and auto

segmentation tools enable monitoring of

nodules, such as, tracking nodule volume

and density changes. “With this user-

friendly CAD approach, syngo Lung CAD

can be integrated into day-to-day work-

flow and allows not only for the identifi-

cation and evaluation of lesions of inter-

est, it also bridges diagnostic decisions

[ 2 ] Automated detection of potential nodules with syngo Lung CAD (red = CAD findings).

with treatment planning,” says Marco

Das, MD, RWTH Aachen University.

1 Requires a syngo MultiModality Workplace

(formerly LEONARDO), with Siemens’ latest soft-

ware release, min. syngo 2006A.

“The results represent important confirmatory evidence

for the clinical use of CAD in detecting otherwise overlooked

lung nodules in MDCT studies of the thorax.”David Naidich, MD

New York University Medical Center

customer’s system

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Utilization Management – Advanced ReportNumber of Patient Exams per Day


NEWS

S I E M E N S R E M OT E S E R V I C E

Improving Financial and Operational Outcomes With Utilization Management

AU TO - P R O C E S S I N G

The Results Are Ready When You Are

CT customers can not only measure

various parameters of their system utiliza-

tion, but also compare their utilization

performance with other CT users.

Improved patient and investment plan-

ning are only two of the challenges con-

fronting customers today. Now Siemens

offers anonymous benchmark informa-

tion that is electronically available in the

form of the Utilization Management

Advanced Report. With this report cus-

tomers can benchmark their CT per-

formance with the best of their peers.

With Siemens Utilization Management

CT customers already have access to

detailed utilization data that indicate

potential for better staff planning and

system scheduling, as well as continu-

ously monitoring examination times. Via

electronic reports Siemens Utilization

Management provides detailed informa-

tion about system efficiency and utiliza-

tion. The reports are accessible via a per-

sonalized internet portal and contain, for

example, the number of patient exami-

nations and the average examination

time.

Auto-processing of CT data is Siemens‘

latest in a stream of innovative solutions

for improved workflow in CT. With its

pre-processing technology for Oncology,

Cardiac and Acute Care imaging, Siemens

is helping radiologists to get the images

they need to make diagnostic decisions

faster and more efficient than ever be-

fore.

In the area of Oncology, data acquired

on a Siemens SOMATOM CT scanner for

both lung and colon exams is automati-

cally processed off-line as it arrives at

the syngo MultiModality Workplace.

When the radiologist accesses the exam

data using syngo Lung CAD1 or syngo

Colonography PEV 2, potential lesions

are already marked and ready for review,

saving valuable time and enhancing

diagnostic confidence.

syngo Circulation features* new auto-

processing tools3 for cardiac and acute

care exams. Siemens’ new Cardio Best-

Phase tool automatically selects and re-

constructs the best cardiac phase for im-

age review. With the new PE Detection

application, pulmonary emboli are

marked for review and are available

when the dataset is opened. These are

tools that have the potential to save

valuable time when making time-critical

diagnostic decisions.

www.siemens.com/utilizationmanagementThis is a service of Life – our customer care solution

k

1 syngo Lung CAD is an option for syngo

LungCARE and must be purchased separately.2 syngo Colonography PEV is an option for syngo

Colonography and must be purchased separately.3 PE Detection is an option for syngo Circulation

and must be purchased separately.

*510(k) pending

Please note: PE Detection application is

work in progress and is not commercially

available in the U.S., requires syngo 2007 C.


BUSINESS

Interview

LI F E I N T H E G LO B A L V I LL AG E – P E R F O R M A N C E , S P E E D, E F F I C I E N C Y

A Dialogue With Michael Knopp, MD,Chairman and Professor of Radiology

Michael Knopp, MD, is a citizen of the world. According to

his birth certificate, he is German. But he spent his younger

days in the United States, earned his university and medical

degrees in Germany, and returned to the U.S. seven years

ago. Today, Knopp is Chairman and Professor of Radiology

at the University Medical Center of The Ohio State University

in Columbus. There he heads up a department with 300

employees and an annual budget of 180 million dollars.

SOMATOM Sessions spoke with Knopp about living between

two cultures, the differences in health insurance on each side

of the Atlantic, and why he twice purchased the SOMATOM

Emotion 16-slice configuration.

Professor Knopp, we are meeting you today in Jena,Germany. What are you here for?I am attending the Fourth International Congress on MR-

Mammography and will be introducing the results of our

research on tissue differentiation with contrast media.

What keeps you going?For one thing, the desire to achieve an even faster and

more precise diagnosis that leads to the right therapy. My

main concern is the patient. But I am also driven by basic

research. For example, the question of whether imaging is

a way to learn something about the molecular character-

istics of a pathological structure, and whether we can use

this information for a personalized treatment. I want to

push the envelope.

Why are you, although born and educated in Germany,pursuing these questions at Ohio State University?To answer this question, I must give you a little background.

I lived in Columbus for a while back in the 1970s. My father,

also a doctor, did his specialist training in radiology at The

Ohio State University, and my uncle was a Professor of

Psychiatry there, so I have roots in that city. After I had

worked at the German Cancer Research Center for ten years,

I received the offer to chair the Department of Radiology

at the University of Greifswald. While I appreciated that

opportunity, the other opportunities on the horizon to join

the National Cancer Institute in Washington, D.C. and sub-

sequently to join The Ohio State University were more

tempting and challenging.

What kind of conditions did you find there?When I started in Columbus four-and-a-half years ago, many

things did not reflect the latest standards. Workflow,

image quality, and patient comfort did not live up to my

expectations of a modern radiology department. I there-

fore felt an urgent need to make several changes, but in the

beginning, the only budget equipment available was what

had been approved for my predecessor. Since then, my

team and I have brought in more than 35 million dollars of

grant revenue and started the Wright Center of Innovation

Michael Knopp, MD, PhD, Chairman and Professor of Radiology, Ohio State University Medical Center,Ohio, USA.


BUSINESS

What do you see as the most significant differences between what you were doing in Germany and what youare now doing in the United States?The demands on each side of the Atlantic are the same, and

while we practice more subspecialty Radiology in the US and

have a different training approach, there are not so many

differences. We must find better, faster, and more efficient

ways to diagnose and treat an ever-growing older population.

What’s different are the general conditions. In the U.S., there

is the old familiar problem of getting expenses refunded.

Many patients have no health insurance, or only a portion of

the cost will be paid. So we have to deal with the situation

that our charges may not be paid at all, or may not be paid

in full. Therefore we may end up carrying a considerable

portion of the cost ourselves. Subsequently, we are forced

to find very cost-effective ways of imaging and to manage

within our payer mix. Those who can pay their bills in full

compensate for those who cannot. Luckily, we have a very

reasonable payer and social structure in Ohio. Most patients

are reasonably insured. Nevertheless, cost efficiency will be

increasingly an important subject. It is, by the way, basically

the same situation in Germany now with the fee for a case

based system. Financial resources are in short supply all

over. That is why the SOMATOM Emotion 16 was also a

good choice from a cost point of view – with service, for

example.

What differences are evident from the patient’s point of view?That’s also an interesting perspective. In both countries the

healthcare system plays an important role. In Germany,

however, people have until now thought very little about

where the money is coming from to pay for healthcare,

there is a strong feeling of entitlement. Contributions to a

health insurance plan are mandatory and linked to the salary

and employment. In the U.S., there is no mandatory health

insurance or coverage below age 65. U.S. citizens therefore

“We are forced to find very

cost-effective ways of working”

“The modest space require-

ments, the high diagnostic image

quality, and the fast image

management convinced.”

And then, soon afterward, you bought a second SOMATOMEmotion 16?Yes. A year later, when the single slice CT on the main

campus also had to be replaced, it was clear that the only

logical choice was a SOMATOM Emotion 16-slice configura-

tion. The modest space requirements, the high diagnostic

image quality, and the fast image management with the

PACS system – in other words, the entire workflow process

and the technical features – convinced us.

in Imaging, an academia-industry collaboration. Originally, I

was also very limited by the existing space. The best option I

had for replacing our old single-slice CT was to find a system

that had a small footprint – so it would fit into the room

where the old system had been housed – and that didn’t

need an external cooling device outside the gantry. I recog-

nized then that facility renovation can easily eat up a third of

the cost of the new equipment, and we naturally wanted to

save ourselves this expense. It did not take long for us to

make a decision to buy the SOMATOM Emotion 16-slice con-

figuration. Our system was the very first one on American

soil. We had it installed even before it was introduced at the

European Congress of Radiology in March 2005. Today we

manage all of our routine work with it. That way, we can

keep our high-end scanners free for special jobs like, for

example, complicated cardiovascular procedures.


BUSINESS

“The number of CT images

has risen every year by 18 percent.

We have to be able to keep up

with the demand.”

have to think a lot more about who pays for health care and

what they can afford. This is one reason why Americans

attach great importance to it. So we have a kind of paradoxical

situation that there are very high expectations for the quality

of medical services, while a significant part of the population

cannot pay for it. For our routine CT-imaging it means that

we need a system that delivers top image quality while

being cost effective. Fast imaging allows not only excellent

throughput but also reduces motion artifacts. We have to

work very efficiently, which we can definitely do with the

SOMATOM Emotion.

Could you please describe the workflow at your institu-tion from scanning to diagnosis?Optimized image and work flow management is not just a

question of saving time but also has to do with the increas-

ing specialization. Today we do all the imaging with the

SOMATOM Emotion 16 according to a standardized proto-

col. After the scan the images are sent automatically into the

PACS system, where everyone has access to them and that

includes both source data and the 3D reconstructions. Thus,

we have created a highly efficient and effective workflow

that goes beyond the individual departmental borders and

specializations. Only in this way are we able to keep up with

the increasing demands. Radiologists specialize more fre-

quently in modalities in Germany, while in the U.S. there’s

a very strong preference to specialize in anatomic areas such

as the chest, abdomen, musculo-skeletal, interventional

or neuro. Regardless of which approach is taken, everyone

involved needs fast access to the images. Another difference

in workflow within a teaching institution is that in the U.S.,

patient studies are frequently first discussed with the resi-

dents and then a diagnosis is made. In Germany, it is fre-

quently an opposite workflow. It’s amazing how different

approaches, environments and training at the end do create

the same needs and outcome.

What do you mean by “increasing demands”?The number of CT images has been rising for years. In the

last calendar year, our rate of increase was 18 percent. That

has to do with the fact that we are taking much better

images today, and you can see much more detail on them

than ever before. For this reason, we decided we needed the

16 slice scanner and not the 4-slice scanner for our routine

work. The 16-slice offers improved diagnostic confidence,

which we would not want to withhold from our patients. In

Columbus, another factor plays a role: our overall popula-

tion is growing at a rate of three percent every year, that is

certainly also different to Germany where it is shrinking

because of the low birthrate.


BUSINESS

What do you use the two SOMATOM Emotion 16 scannersin your department for?As I have already mentioned, we have one on both our

east campus and our main campus. Both of them are inte-

grated into the full daily spectrum of routine clinical in- and

outpatient care. We manage all of our daily business with

them. We can also easily use both of them for emergencies

if necessary. For complicated cardiac questions, we fall

back on our 64-slice scanner. For routine imaging, however,

we usually don’t need to use it. Not many patients have to

be examined with the high-end scanners. Our motto is:

use the best image quality possible for necessary examina-

tions but don’t do additional imaging unless there is a very

good reason. We always have to keep in mind that not

every exam request is indicated and is going to be paid for.

How does your family cope with life between two cultures?I never hid the fact that I could imagine myself working and

living in the U.S. My wife, while also German was open

minded and up for it, too. In addition, we have four children,

and they also feel right at home in both cultures. It’s worth

noting, however, that the world has become smaller and

smaller in recent years. That was quite different in the

seventies. Back then, phoning long distance was an expen-

sive undertaking and was limited to important calls. These

days, we communicate with the whole world over the

internet, listen to our favorite music and hometown news

on the Web radio, can watch German television shows via

podcasts, and read the online version of our any local

paper. The world has become a global village, and it’s exciting

to be working and living in it.

“We manage all of our daily business with the two

SOMATOM Emotion 16 scanners. We can also easily use

both of them for emergencies if necessary.”

The interview with Prof. Michael Knopp, MD, was conducted

by medical journalist Hildegard Kaulen, PhD, in Jena, Germany.

SOMATOM Emotion

SOMATOM Emotion 16-slice configuration – a synthesis ofadvanced clinical performance and low life-cycle costs.

Brain-CT: collimation 12 x 0.6 mm, rotationtime 1.5 sec, 130 kV, 270/280 effective mAs.

BUSINESS


Pr o v e n E x c e l l e n c e b y R e fu r b is h e d S y s t e m s

Quality, Valuability and Flexibility

The “Proven Excellence” process, in com-

bination with an understanding of what

today’s customers need, has made

Siemens Medical’s Refurbished Systems

(RS) what it is today: a customer-oriented

solution provider for medical pre-owned

systems.

Siemens offers customers the Proven

Excellence program which makes the

company’s refurbished business unique

in a highly competitive market. World-

wide there are already 585 RS-systems

installed.

The program is the centerpiece of a

strategy that emphasizes both the “like

new” quality as well as the favorable

price-performance ratio of its products.

From Siemens, customers can expect

professional service response, including

warranties typically equivalent to those

of new systems like flexible service

agreements, spare parts availability for

at least five years, and stringent quality

assurance standards.

Five Step Quality CheckAll pre-owned systems entering the

Proven Excellence process undergo a

five-step quality check. The first step is

called “Selection” and includes a thor-

ough assessment of age and condition

of the specific system. During the second

step, “De-installation,” professional ser-

vice providers and Siemens engineers

perform an onsite inspection. Approved

systems are de-installed and transferred

to Forchheim, Germany. The third step,

“Refurbishing,” is the most comprehen-

sive in the Proven Excellence program. It

includes the cleaning, disinfecting, and

repainting of each system to make it

look like new. Furthermore, worn parts

are replaced with original spare parts. All

components and sub-systems are then

thoroughly checked for proper function-

ing. Software updates to the latest ver-

sion are performed. Afterwards, the

system is checked with original test

equipment and procedures. This means

that the system must pass exactly the

same tests that brand-new systems

have to pass. After successful comple-

tion of testing, the Proven Excellence

quality seal is applied.

In the fourth step, the “Re-Installation,”

the systems are installed and started-

up by Siemens technicians. Repeated

performance tests follow and, upon

completition, the customer receives the

Proven Excellence quality certificate.

“Warranty and services,” the last step in

the process, is fulfilled by local Siemens

customer service engineers.

Additionally, Siemens Refurbished Sys-

tems can, with its world-wide locations

(including the U.S.), offer an interesting

choice of value-added solutions that

include service contracts with compre-

hensive spare parts coverage, flexible

financing and qualified support services

worldwide.

Siemens points to its stringent Proven-

Excellence process as the company’s

assurance of quality and reliability to its

Refurbished Systems’ customers globally.

After the System is cleaned, repainted, and brought up to the latest technical standards, it is thoroughly tested. A Siemens engineer runs exactlythe same tests on the refurbished CT that a new system would have to pass before being delivered to the customer.

www.siemens.com/proven-excellence

k


Oncology NeurologyCardiovascular Acute CareCLINICAL OUTCOMES

Case 1 Stenting of a Severe, Noncalcified Stenosis: Combining SOMATOM Definition & AXIOM Artis dFC to Improve Workflow and SpeedBy Stephan Achenbach, MD, Associate Professor, and Josef Ludwig, PhD, Associate Professor, Department

of Internal Medicine II, University of Erlangen-Nuremberg, Germany

HISTORY

A 32 year-old Asian male suffering from chest pain was

admitted to the emergency room in the early morning. The

age of the patient was unusual for a cardiovascular event

and the fact that he apparently had an important university

exam the same day made the case even more dubious. The

patient was in good condition and the physical examination

did not reveal anything out of the ordinary. As for cardio-

vascular risk factors, he had mild hypercholesterolemia and

nicotine abuse. His ECG showed discrete signs of ST-Elevation

in II and III. Initial enzyme levels were normal. In order to

secure a diagnosis, he was transferred to the SOMATOM

Definition CT scanner to perform a non-invasive coronary CT

angiography.

DIAGNOSIS AND COMMENTS

His heart rate showed 81 beats per minute and scan para-

meters were automatically adapted to the heart rate resulting

in a six second scan. Betablockade was unnecessary due to

the high temporal resolution of the scanner. The evaluation

was performed using standard 3D evaluation software and

syngo Circulation as a dedicated cardiac CT evaluation tool.

High-resolution images revealed that RCA and LAD were

without pathology. However, a severe, non-calcified stenosis

was diagnosed in the mid segment of the left circumflex –

a rather unusual finding for a 32 year-old man.

The patient was transferred to the angio suite for immediate

treatment. Using the advantages of a universal syngo Work-

place, the CT data could be directly accessed and evaluated

[ 1 ] Showed with syngo Circulation: Detail of asevere, non-calcified stenosis which was diagnosed inthe mid segment of the left circumflex (arrow).

[ 2 ] Overview of vessel lumen, 2D and 3D data with syngo Circulation. 3D reconstruction illustrates that the left circumflex coronary artery lesion is immediately distal to the origin of the obtuse marginal branch (arrow).

CLINICAL OUTCOMES


[ 3 ] Overview of vessel lumen, 2D and 3D data with IC3D.

[ 4 ] Detail of the stenosis, diagnosed in the midsegment of the left circumflex.

Scanner SOMATOM DefinitionScan area Cardiac Scan

Scan length 125 mm

Scan time 6 s

Scan direction cranio caudal

Heart rate 81 bpm

kV 120 kV

Effective mAs 330 mAs/rot.

Rotation time 0.33 s

Slice collimation 0.6 mm

Slice width 0.75 mm

Pitch 0.36

Reconstruction increment 0.6 mm

CTDI 26.6 mGy

Kernel B26f

EXAMINATION PROTOCOL

Contrast

Volume 55 ml

Flow rate 5 ml / s

Start delay 21 s

by the interventional cardiologist as well. The AXIOM Artis

dFC-system with the integrated 3D Quantification tool syngo

IC3D, allows accurate 3D planning for a more precise interven-

tional treatment.

COMMENTS

With the AXIOM Sensis hemodynamic recording system con-

necting to the hospital s information system server, required

demographics were downloaded automatically. syngo online

IC3D measurement provided accurate values for vessel

dimensions as well as the geographic location of the stenosis

relative to the ostium of the obtuse marginal branch without

foreshortening effects. A 13 mm drug eluting stent was

deployed. In conclusion the combined use of both the Dual

Source CT and the AXIOM Artis dFC achieved positive results.



Case 2: Improved Follow up For Pulmonary Nodules Withsyngo LungCARE and syngo Lung CADBy Marco Das, MD, Georg Mühlenbruch, MD, Andreas H. Mahnken, MD, Rolf W. Günther, MD, Joachim Ernst Wildberger, MD,

all from the Department of Diagnostic Radiology, RWTH Aachen University, Aachen, Germany

The detection of pulmonary nodules is one of the most

common exams in chest multidetector-row CT (MDCT).

Small pulmonary nodules can easily be overlooked and lead

to false negative results, which could have severe conse-

quences for the patient. Improved visualization using maxi-

mum intensity projection (MIP) and computer-aided detection

(CAD) are beneficial for significant improvement of radiologist’s

detection rate for small pulmonary nodules. However, the

diagnostic challenge of how to characterize nodules remains.

Criteria like shape, density or enhancement are often used, but

size and size change are the most effective way for charac-

terization. New guidelines from the Fleischner Society1 address

this problem, for the first time providing radiologists with

practical follow up suggestions for small pulmonary nodules.

This guideline is based on recent lung cancer screening trials,

and suggests follow-up for pulmonary nodules depending

on nodule size and patient risk classification. Thus, objective

and reliable nodule detection and follow-up measurements

have become more and more important as manual measure-

ments yield high intra- and interreader variability.

[ 1 ] A small pulmonary nodule(diameter 2.1 mm)in the apical seg-ment of the upperlobe on the left lungwas found by theCAD software andmarked after verifi-cation by the Radio-logist. Using theautomated followup function [Fig. 1A], the correspondingcounterpart in thefollow up examina-tion is automaticallymarked [Fig. 1B].

1B

1A

Delete Marker Set AnnotationSet Annotation

Link To Get CounterpartGet Counterpart

Scanner SOMATOM Sensation 64-slice configuration

Scan area Lung

Scan length 250-320 mm

Scan time 10 s

Scan direction cranio-caudal

kV 120 kV

Effective mAs 10 (<80 kg); 20 (>80 kg) mAs

Rotation time 0.5 s

Slice collimation 64 X 0.6 mm

Slice width 1.0 mm

Table feed / rotation 18 mm


Kernel B50f

CLINICAL OUTCOMES


[ 2 ] syngo Lung CAD soft-ware was used for the detection of additionalpulmonary nodules on the follow up examination.Findings of the software(circled in red) indicatingthe need for verification by the radiologist. Finally reported nodulesare marked in green.

1 MacMahon H, Austin JH, Gamsu G, Herold CJ, Jett JR, Naidich DP, Patz

EF Jr, Swensen SJ; Fleischner Society. Guidelines for management of small

pulmonary nodules detected on CT scans: a statement from the Fleischner

Society. Radiology 2005; 237: 395–400.

HISTORY

This case presents a 64 year old female with colorectal cancer,

who underwent chest MDCT for detection of pulmonary

metastasis.

DIAGNOSIS

The initial read was negative for pulmonary nodules, but the

use of syngo Lung CAD indicated the presence of two very

small nodules (both with a nodule diameter about 2 mm).

Short term follow-up was performed to detect potential

growth of these two nodules, and assess the degree of

metastatic disease.

COMMENTS

Using the automatic follow-up mode in syngo LungCARE,

previously marked nodules were automatically aligned with

the corresponding nodule (counterpart) in the follow-up

examination. Volumetry results were directly compared and

growth rate estimated. Additionally CAD was run on the

follow up examination, enhancing diagnostic confidence.

In our experience, syngo Lung CAD is a clinically valuable

tool, helping physicians to be sure that all potential lesions

are identified. The automatic follow-up feature of syngo

LungCARE CT helps to eliminate errors in assessing the growth

progression, or regression, of lesions, thereby enhancing our

diagnostic confidence for chest exams.


2A

2B



Case 3: Child – 11 Months: Visualization of a ChoroidPlexus PapillomaBy Andrzej Kosciesza, MD, Piotr Nuzynski, MD, Department of

Radiology, Bogdanowicz Hospital, Warsaw, Poland

HISTORY

A normally developing infant aged eleven months suffered a

minor trauma. Ultrasonographic examination disclosed

triventricular hydrocephalus and abnormal hyperechogenic

mass in midline partially involving the lateral ventricles and

the third ventricle.

DIAGNOSIS

On CT examination an abnormal mass of highly increased

density was seen, involving the lateral ventricles and the

third ventricle, associated with supratentorial hydrocephalus.

On histological examination choroid plexus papilloma was

found.

COMMENTS

This case demonstrates the usefulness of CT in the assessment

of the character and precise location of well vascularized

congenital tumours in children. Short acquisition time and

secondary reconstructions of outstanding quality using a

SOMATOM Emotion 16-slice configuration enable correct

diagnosis and precise planning of surgical treatment.

[ 1 ] Supratentorial hydrocephalus: abnormal massesinvolving the lateral ventricles – [Fig. 1A] VRT sagittal,[Fig. 1B] MIP axial and [Fig. 1C] VRT coronal.

1A

1B

1C


CLINICAL OUTCOMES

Contrast

Volume 12 ml

Flow rate manual

Start delay manual

Scanner SOMATOM Emotion 16-slice configuration

Scan area Head

Scan length 126 mm

Scan time 22 s

kV 130 kV

Effective mAs 240 mAs

Rotation time 1.5 s

Slice collimation 16 x 1.2 mm


Slice width 1.5 mm

Pitch 0.55


Kernel H40s medium

SOMATOM Emotion 16-slice configuration with a wide-open gantry in the children scan room, all painted in a very colorful way so that the small patients are not afraid of examinations.



Case 4: NEW: Comprehensive 3D Stroke ImagingWith syngo Neuro PBVBy Jie Lu1, MD, Miao Zhang1, MD, Jiuhong Chen2, Prof. Kuncheng Li, MD1,1Xuanwu Hospital, Capital Medical University Beijing, China 2SIEMENS Ltd., China

HISTORY

A 59 year old male was delivered to our stroke unit in the

Xuanwu hospital three hours after onset of right-sided

extremity weakness and a right-sided hemiparesis. On

examination in the emergency room, he was found to have

profound right extremity paresis, an expressive aphasia and

facial palsy on the left side. A complete stroke evaluation

was scheduled. In order to meet the demand of fast hemo-

dynamic imaging of the entire brain, CT Perfusion and whole

brain perfused blood volume calculation using syngo Neuro

PBV (Perfused Blood Volume)* were performed. This new

approach allows for routine calculation of three-dimension-

al, color-coded whole brain images overcoming the

limited scan coverage of Perfusion CT.

DIAGNOSIS AND COMMENTS

After exclusion of hemorrhage with a non-contrast CT scan,

color maps of CT Perfusion demonstrated delayed Time to Peak

(TTP) and reduced cerebral Blood Flow (CBF) and Cerebral

Blood Volume (CBV) in the area of the arteria cerebri media.

Using syngo Neuro Perfusion CT, oligemic tissue that is near

the threshold for tissue at risk and regions of the core infarct

were indicated [Fig. 1].

To overcome the limited scan coverage of Perfusion CT, the

three-dimensional extend of the stroke area can now be

defined using the new software syngo neuro PBV [Fig. 2]

thus increasing the safety of treatment decision. Due to the

perfusion parameters, an occlusion of the main cerebral

artery was suspected which has been confirmed by a CT

angiography in the concurrent stroke workflow [Fig. 3].

Based on the differential diagnoses obtained with CT Perfusion

and 3D evaluation of perfused blood flow using syngo Neuro

PBV and the right therapeutic window – 50 mg RTPA, antico-

agulants and platelet anti-aggregates were administered. This

led to a relief of the symptoms by the next day, for example

partial words could be understood. The patient was released

from the hospital in a stable condition one week later.

*available 04/2007 with syngo 2007C

[ 1 ] CT Perfusion demonstrates a clear infarct of the left hemisphere with delayed TTP [marked areas, Fig. 1A] reduced cerebral blood volume [Fig. 1B] and reduced cerebral blood flow [Fig. 1C]. The “tissue at risk” assessment clearly indicated the core infarct [red areas, Fig. 1D] and with a large area of “tissue at risk” [yellow areas, Fig. 1D]which might be rescued after intervention.

1A 1B 1C 1D

Now FDA Cleared


CLINICAL OUTCOMES


Scanner SOMATOM Sensation SOMATOM Sensation64-slice configuration 64-slice configurationNon-enhanced CT CT angiography

Scan area Head Head

Scan length 133 mm 474 mm

Scan time 9.81 s 5.96 s

Tube voltage 120 kVp 120 kVp

Effective mAs 480 mAs 150 mAs

Rotation time 1.0 s 0.5 s

Slice collimation 64 x 0.6 mm 64 x 0.6 mm

Slice width 1.0 mm 1.0 mm

Reconstruction 0.8 mm 0.8 mmincrement

Kernel H20 S H20 S

[ 2 ] The three dimen-sional extent of thestroke area can be displayed using a colorcoded map of the per-fused blood volume ofthe whole brain(arrows).

[ 3 ] CTA revealed a stenoses in the left internalcarotid artery (arrow).


The need to reduce radiation dose and optimize image quality

have spurred vendors to develop novel techniques1. In this

respect, automatic exposure control techniques represent

the most important and efficient method for reducing radiation

dose while maintaining desired image quality2. The present

article discusses fundamental basis, clinical applications

and advantages of automatic exposure control techniques,

with particular emphasis on Siemens’ syngo CARE Dose4D

technique.

What are the Limitations of Manually Selected Fixed Tube Current?Manual selection of a fixed tube current remains the most

commonly used way of performing CT scanning1. With this

technique, the technologist prescribes a tube current value

for CT scanning and the entire scanning is done at the speci-

fied fixed tube current. The scanner does not change the

tube current based on patient size and/or attenuation.

Although radiation dose reduction can be achieved with

such fixed tube current technique, there are some limita-

tions of this technique that can be addressed with use of

automatic exposure control technique. For example, surveys

suggest that many centers do not change the tube current

based on patient size1. As a consequence, patients might be

overdosed or image quality might not meet the clinical

needs. Rapid development in CT technology and newer clini-

cal applications makes it difficult to adapt scanning protocols

with fixed tube current for different size patients and clinical

indications.

Moreover, unlike automatic exposure control techniques, the

fixed tube current technique cannot modulate tube current in

response to rapidly changing patient size or attenuation

within a slice position or from one slice position to the next.

What is Automatic Exposure Control? Automatic exposure control techniques used in CT are

analogous to photo timing in digital radiography. The latter

technique terminates the exposure once a pre-specified

radiographic density is obtained, which implies that exposure

is terminated earlier (lower radiation dose) for smaller

patients and longer exposure time (higher dose) is allowed

for larger patients2. In this way, photo timing technique

allows optimization of radiation exposure while maintaining

desired or specified image quality. Likewise, automatic expo-

sure techniques used in CT scanning adapt tube current in

the x-y plane (angular) or along the scanning direction in

z-axis or both (combined modulation) based on size and

attenu-ation of the body region (attenuation profile) being

scanned to obtain specified image quality or noise with

lowest possible radiation dose. The image noise, an important

determinant of image quality, is determined by x-ray beam

attenuation as it traverses through the patient.

Angular ModulationDuring CT scanning, the x-ray tube continuously emits x-rays

from 360 degrees (projection angles) around the patient

over the entire scan length. Since image noise is dominated

by those projections, which have the highest attenuation,

tube current – and with it also dose – can be reduced for

those projections which have a low attenuation without

increasing overall image noise. Therefore, in asymmetric or

non-circular body parts, such as the shoulders, there is less

x-ray beam attenuation in the anteroposterior direction

compared to the lateral direction. Thus, within each slice

position, less photons or lower tube current would be neces-

sary in anteroposterior direction than in the lateral direction.

Tube current modulation minimizes unnecessary x-rays in

EDUCATIONSCIENCE

CARE Dose4DNew Technique for Radiation Dose ReductionDiscussion of fundamental basis, clinical applications and advantages of automatic exposure control techniques, with particular emphasis on the CARE Dose4DTM technique

By Mannudeep K. Kalra, MD and Thomas J. Brady, MD, Division of Cardiac Imaging,

Department of Radiology, Massachusetts General Hospital, Boston, USA


the anteroposterior projection without any substantial effect

on image quality.

The technical implementation of angular modulation differs

from vendor to vendor. Some only offer sinusoidal modulation,

others are limited in the modulation range (min. to max ratio).

Siemens‘ CARE Dose4D modulates the tube at all rotation

times without compromising the modulation range, compa-

rable to an organ specific dose reduction.3

z-Axis AdaptationWith z-axis adaptation, the tube current changes from one

slice position to the other without optimization in the x-y axis.

The technique automatically selects higher tube current for

larger patients and anatomical regions with higher attenua-

tion and lower tube current for smaller patients and anato-

mical regions with low attenuation in order to maintain

desired image quality at optimum radiation dose2. Lastly,

combined modulation technique (CARE Dose4D), discussed

in the following section, combines benefits of angular and

z-axis modulation techniques.

How does CARE Dose4D technique work?From a single topogram, the CARE Dose4D technique

measures attenuation profile in the z-axis in the direction of

projection and also in the perpendicular direction with a

sophisticated algorithm4. Tube current values are calculated

and adapted to the patient size and attenuation changes

based on these attenuation profiles. Tube current adjustment

SCIENCE

Effect of Modulation Strengths on Radiation Dose for Slim and Obese Patients

0 50 100 150 200 300 400250 350

100

200

80

60

40

20

120

140

160

180

slim patient

slim region

obese patient

obese region

X-ray attenuation

(compared to reference attenuation)

constant dose

constantimage noise

obese patient/region:

strong increase

average increase

weak increase

slim patient/region:

weak decrease

average decrease

strong decrease

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[ 1 ] The sophisticated algorithm provides desired image quality for all patients, slim to obese. Individual preferences on tube current increase and decrease can be realized by choosing strong, moderate or weak.


SCIENCE

individual preference of the user. For a given protocol, this

value reflects the effective mAs used in a certain body region

for a “reference patient” defined as a “typical adult,” weighing

70 kg to 80 kg (for adult protocols) or as a “typical child”

having the age of 6 years (for pediatric protocols).

The technique adapts the tube current to the individual

patient size based on the quality reference mAs value. It

determines whether the patient is “slim” or “obese” from the

topogram and adapts the tube current based on the pre-

selected adaptation strengths (weak, average or strong). As

illustrated in Fig. 1 the system uses an advanced algorithm to

adapt tube current so that the user gets the desired image

quality. This means that for example for slim patients tube

current is reduced less than constant image noise would

require. For obese patients to get the desired image quality

tube current is increased less than constant image noise

would require.

The adaptation strengths are prospectively set for these

patient types and determine the extent of change in effective

mAs. Thus, image quality and radiation dose can be controlled

by selecting an appropriate modulation strength and/or quality

reference mAs value.

depends on a user defined so-called “image quality reference

mAs” (z-axis modulation). Based on these tube current

levels, real-time tube current modulation during each tube

rotation according to patient’s angular attenuation profile

(angular modulation) is then performed.

The challenging part of automatic exposure techniques is how

to adapt the tube current to the different sizes of patients

and how to compensate for changes along the patient’s

length. The first and simplest approach would be a modulation

which keeps the noise constant from patient to patient and

over the whole scan. However, this approach has two limita-

tions: Firstly, this is not possible from a technical perspective

since the range of attenuation changes from patient to

patient and also during a single scan (for example shoulder

to neck) is much larger than any tube can provide. Secondly,

studies have shown that, from a clinical perspektive, needs

are different. In smaller patients, lower noise levels are des-

ired, whereas in obese patients more noise is often accepta-

ble due to higher contrast . This indicates different require-

ments for automatic exposure techniques.

With CARE Dose4D, tube current is modulated so that both

limitations are overcome. The user selects a “quality reference

mAs” according to the diagnostic requirements and the

[ 2 ] CT image acquired with CARE Dose4D techniques reveal excellent image quality with substantial dose reduction.[Fig. 2A] Chest-CT with 20% mean dose reduction and [Fig. 2B] abdomen-liver with 38% mean dose reduction5.

2A 2B


SCIENCE

Where Can CARE Dose4D Technique be Applied?CARE Dose4D technique can be used for CT scanning of

neck, chest, abdomen, and pelvis [Fig. 2]. The technique is

commercially available on Siemens MSCT scanners with 1 to

64 detector configurations. It is also available on the Dual

Source CT, the SOMATOM Definition. CARE Dose4D can be

used in scans for all patients, including pediatric and obese

patients. It also can be used for patients with metal prostheses

without causing unnecessary increase in the radiation dose7.

This is due to the fact that a special detection algorithm is

implemented into CARE Dose4D8 [Fig. 3].

What is the Evidence Supporting CARE Dose4D?Several large studies have evaluated CARE Dose4D techni-

que its effect on image quality and radiation dose in clinical

routine4-6.

For instance Dr. Rizzo and colleagues4 have reported that,

“compared with constant tube current technique, there was

a 19% (15.4/19.0) reduction in radiation dose for angular

modulation, a 42% (11.0/19.0) reduction with ‘weak decrease

(slim) – strong increase (obese)’ type of combined modulation

and a 44% (10.6/19.0) reduction with ‘average decrease

(slim) – average increase (obese)’ type of combined modula-

tion.”

Mulkens et al5 have also found that, “mean dose reduction

for combined angular and z-axis modulation technique and

for the angular modulation technique alone was as follows:

thorax, 20% and 14%, respectively; abdomen-liver, 38% and

18%, respectively; abdomen-pelvis, 32% and 26%, respecti-

vely; lumbar spine, 37% and 10%, respectively; and cervical

spine, 68% and 16%, respectively.”

For CT colonography, Graser et al6 have reported 33% (prone)

to 35% (supine) dose reduction with CARE Dose4D compared

to CARE Dose technique.

References1 Kalra MK et al. Radiology. 2004; 230: 619–28.

2 Kalra MK et al. Radiology. 2004; 233: 649–57.

3 Greess H et al. Eur Radiol 2002; 12: 1571–76.

4 Rizzo S et al. AJR Am J Roentgenol. 2006; 186: 673–9.

5 Mulkens TH et al. Radiology. 2005; 237: 213–23.

6 Graser A et al. Am J Roentgenol. 2006; 187: 695–701.

7 Rizzo S et al. Am J Roentgenol 2005; 184: 491–496.

8 Tejas Dalal et al. Radiology 2005; 236: 671–675.

1332 mA

20 mA

Reduced doselevel based ontopogram

Scan withconstant mA

Real-timeangular dosemodulation

X-raydose

Slice position

CT-Scan With CARE Dose4D

[ 3 ] Instead of just taking into account the patient’s external dimensions and apparent size,CARE Dose4D analyzes the cross-secional anatomyin real-time and adjust the emitted X-ray dose accordingly – providing excellent image quality withminimized exposure.

SCIENCE


See the Whole DiseaseNeuro Perfused Blood Volume ImagingBy Stephan P. Kloska1, MD, Tobias Fischer1, MD, and Roman Fischbach1, MD, Hendrik Ditt2, MSc, 1Department of Clinical Radiology, Chairman: W. Heindel, MD, University of Muenster, Germany 2Siemens AG, Medical Solutions, CT Division, Forchheim, Germany

IntroductionComputed tomography is still the most widely used imaging

modality in the evaluation of acute stroke as magnetic reso-

nance imaging (MRI) is hampered by its relatively limited

availability. CT angiography and perfusion CT (PCT) improve

the diagnostic yield of non-enhanced CT (NECT) by direct

visualization of cerebral vessels and assessment of cerebral

hemodynamics. PCT is used to calculate color-coded maps

of the hemodynamic parameters cerebral blood flow (CBF),

cerebral blood volume (CBV) and time to peak enhancement

(TTP) and thus allows detailed evaluation of perfusion distur-

bances including delineation of brain tissue with irreversible

damage and tissue at risk1. In contrast to diffusion weighted

MRI or MRI perfusion measurement, PCT evaluation is

restricted to a subvolume of the brain due to the limited

width of the CT detector. Therefore, an ischemic area may

only be covered in part and infarctions outside of the selected

PCT level may be missed.

In order to meet the demand of fast hemodynamic imaging

of the entire brain, neuro perfused blood volume software

(Siemens Medical Solutions, Forchheim, Germany) presents a

practical approach that allows for routine calculation of three-

dimensional color-coded whole brain perfused blood volume

images thereby overcoming the limited scan coverage of PCT.

Imaging ProtocolCT imaging in patients with suspected acute stroke at our

institution consists of NECT followed by PCT and CTA2. The

scan delay for the CTA is derived from the time to peak

enhancement in the sagittal sinus in PCT to allow for com-

bined arterial and venous vessel evaluation. NECT and CTA

cover the entire brain and both scans are acquired with iden-

tical detector collimation, section thickness and reconstruc-

tion increment. For the CTA, intravenous injection of

100 mL of a non-ionic high concentration contrast agent

(350 – 400 mg iodine/mL) followed by a saline flush of

50 mL with a flow rate of 4 mL/s is performed.

Images of the whole brain NECT and CTA data sets are loaded

into the syngo Neuro Perfused Blood Volume CT (PBV)* soft-

ware for the calculation of the PBV. The software generates

PBV data sets by fully automatic registration and normalized

subtraction of the NECT data from the CTA data [Fig. 1].

The result of the subtraction operation reflects the overall

brain parenchymal enhancement. After filtering, PBV images

are displayed using a color code similar to perfusion CT maps.

In normal perfused brain parenchyma, the white matter

usually is coded in blue to dark green color corresponding to

the physiologically lower blood perfusion, whereas the basal

ganglia and cortex have higher normal perfusion values and

are displayed in yellow or green [Fig. 2].

[ 1 ] Calculation of Neuro Perfused Blood Volume(PBV) Imaging (NECT = non-enhanced computed tomo-graphy; CTA = computed tomography angiography).


SCIENCE

[ 2 ] Visualization of Neuro PerfusedBlood Volume Imagingin a patient withoutperfusion abnormality.The color-coded 3D-dataset displays regu-lar levels of blood volume in the whiteand grey matter

Examination Protocol

Contrast 350–400 mg iodine/mL

Volume 100 ml (volume of contrast agent)

50 ml (volume of saline)

Flow rate 4 ml / s

Postprocessing PBV ß-version syngo Neuro PBV* PBV ß-version syngo Neuro PBV*

Non-enhanced CT CT angiography

Scanner SOMATOM Sensation SOMATOM Sensation SOMATOM Sensation SOMATOM Sensation16-slice configuration 64-slice configuration 16-slice configuration 64-slice configuration

Scan area Head Head Head Head

kV 120 kV 120 kV 120 kV 120 kV

Effective mAs 360 mAs 480 mAs 130 mAs 175 mAs

Rotation time 1 s 1 s 1 s 0.5 s

Slice collimation 16 x 0.75 mm 64 x 0.6 mm 16 x 0.75 mm 64 x 0.6 mm

Slice width 1 mm 1 mm 1 mm 1 mm

Reconstruction increment 0.8 mm 0.8 mm 0.8 mm 0.8 mm

Kernel H20 S H20 S H20 S H20 S

Tube voltage 120 kVp 120 kVp 120 kVp 120 kVp

Field of view 230 mm 230 mm 230 mm 230 mm

SCIENCE


References1 Murphy BD et al. Stroke. 2006; 37: 1771–1777.

2 Kloska SP et al. Radiology 2004; 233(1): 79–86.

3 Hunter GJ et al., AJNR 1998; 19(1): 29–37.

4 Hunter GJ et al. Radiology 2003; 227(3): 725–730.

5 Schellinger PD et al. Stroke 2003; 34(2): 575–583.

to detect perfusion abnormalities. As PBV CT visualizes the

irreversibly damaged brain tissue3, 4 perfusion CT will remain

an important part of our CT protocol for prospectively assess-

ing tissue at risk (mismatch imaging) especially in patients

where intravenous or local arterial fibrinolysis is discussed5.

syngo Neuro PBV is a valuable tool to visualize site and

extent of ischemic brain damage and to better select the

level of the brain subvolume to be assessed in more detail by

perfusion CT.

Neuro Perfused Blood Volume ImagingThe 3D-PBV datasets are viewed on a MMWP workstation

in multiplanar mode (MMWP®, Siemens Medical Solutions,

Forchheim, Germany). The volume of the 3D-PBV covers

the whole brain. Areas of reduced perfusion have a blue to

purple color coding [Fig. 3].

Discussion and PerspectiveNeuro perfused blood volume imaging is a new feature that

can be seamlessly integrated into a routine CT stroke imaging

protocol, as it does not require any additional scans beside

the usual NECT and CT angiography performed in patients

with suspected acute ischemic stroke. Since the entire brain

is covered, syngo Neuro PBV overcomes the limited volume

coverage of PCT and thus serves as a sensitive imaging tool

[ 3 ] 81 year-old man with acute left-sided hemiplegia andaphasia since 3 hours.Non-enhanced CT(NECT) revealed signsof infarction in the leftmiddle cerebral artery(MCA) territory [Fig. 3A]. CT angiography (CTA)excludes occlusion ofthe proximal middlecerebral artery (MCA)on the left [Fig. 3B].The three-dimensionalperfused blood volume(PBV) calculation [Fig.3C] demonstrated thevolume of perfusionabnormality in closecorrelation to themagnetic resonanceimaging follow-upwith diffusion-weigh-ted imaging (DWI)sequence [Fig. 3D].

3A

3C

3D

3B

* available 04/2007, for SOMATOM and

Defintion only, requires syngo 2007C

EDUCATION & EVENTS


E D U C AT I O N

The World’s FirstSOMATOM DefinitionWorkshop

In October 2006 the Department of Radiology and the

Department of Cardiology at the University Hospital Munich

Grosshadern, Germany, hosted the world’s first Workshop for

the SOMATOM Definition Dual Source CT (DSCT) scanner.

The three-day course program covered scientific lectures,

clinical presentations, live examinations on the SOMATOM

Definition, and primarily hands-on sessions at the work-

stations. All aspects of cardiac CT imaging like calcium

scoring, CTA, functional-, viability- and valve imaging were

addressed in comprehensive lectures that supported the

hands-on training sessions. The workshop was held by both

radiologists and cardiologists.

A technically fully equipped course room and syngo Multi-

Modality Workplaces were available. Siemens Medical

Solutions provided one workstation per two participants to

use throughout the entire training period. Maximum training

success was achieved in small groups with not more than ten

participants who could benefit from an interactive exchange

of experience away from their daily routine work. The Partici-

pants observed live CT cases on the SOMATOM Sensation in

its 64-slice configuration and the world’s first DSCT scanner,

the SOMATOM Definition.

The training was aimed at preparing participants to satisfy all

levels of certification according the ACC-AHA Guidelines. The

University of Munich Cardiac Imaging Group at Grosshadern

Clinic has one of the world’s largest coronary CTA databases

with cross correlations to invasive angiography and intravas-

cular ultrasound. Up to 50 clinical CTA cases were reviewed

during the course. By providing cross correlations (invasive

angiography and IVUS) in all cases, learning success was

enhanced.

The course attracted many more applicants than were able to

join and the feedback has been outstanding: ”Well organized,

richly illustrated live cases and practical tips and tricks usable

Since October 1999 both University

Hospitals in Munich, Grosshadern and

Innenstadt, belong to the Ludwig-

Maximilian-University of Munich. Now,

with its 2,428 beds and 9,000 staff

members, the University of Munich

Hospital is – aside from the University

Hospital in Berlin (Charité) – the largest

facility of this kind in Germany. The Uni-

versity Hospital can look back to almost

200 years of history closely tied to the

development of the medical faculty.

The Hospital Grosshadern in Munich

Location of the workshop: University Hospital, Munich, Grosshadern, Germany.

This faculty is part of the University of

Ingolstadt, which opened its doors for

instruction in 1472. Ingolstadt re-

mained the seat of the University until

1800. More Information about the hos-

pital: www.klinikum.uni-muenchen.de


EDUCATION & EVENTS

S I E M E N S R E M OT E S E R V I C E

Continuous Updates in SOMATOM LifeNet

More information and updates with SOMATOM LifeNet.

Service, Support, and Information: SOMATOM LifeNet, the

information and service portal available directly at the

CT scanner consoles, not only comes in new colors – it con-

tinuously offers more services and information. For instance,

Siemens informs a customer via a news ticker about new

and upcoming software applications. If the customer is inter-

ested in new applications, information and corresponding

(free of charge) 90 day trial licenses can be downloaded via

LifeNet.

SOMATOM LifeNet also offers application guides and

e-Training for software applications that can be downloaded

directly to the scanner. This way, getting started with the

application is uncomplicated and easy.

Designed to support customers in their daily work, SOMATOM

LifeNet offers fast and easy access to information, as well as

to a broad range of services using the Siemens Remote

Service (SRS) connection as a direct line to Siemens.

www.siemens.com/somatomeducateThis is a service of Life – our customer care solution

k

Participants of the SOMATOM Definition workshopat interactive hands-on sessions.

in my own clinical practice made this course absolutely worth

the trip,” was the enthusiastic comment from Dimitri De

Vuyst, MD, AZ Sint-Maarten, Department of Radiology,

Mechelen, Belgium.

Dilek Öncel, MD, Sifa Hospital, Department of Radiology,

Izmir, Turkey declared, “This course was very well-organized

not only to improve application skills, but also widening our

clinical perspective.”

The course has been contucted under direction of PD

Christoph Becker, MD, head of CT from the Department of

Radiology and collegues and PD Andreas Knez, MD, Head of

cardiac CT from the Department of Cardiology and col-

legues.

Because the workshop has been so successful, the hospital

has decided to offer additional courses in 2007. The dates will

be displayed in the CT Course Selector on the Siemens CT

webpage. To register online the following link can be used:

www.siemens.com/ct-LifeNet This is a service of Life – our customer care solution

k


EDUCATION & EVENTS

C T- O N LI N E : C O U R S E S C H E D U LE

New Course Selector

Continuous education is becoming more and more impor-

tant. But searching the web for specific medical courses is

time consuming and does not always produce the desired

results. Siemens Medical Solutions has designed a new tool –

the Course Selector – to give the customer an easier access to

the medical education he or she is looking for. Whether

searching globally or locally, whether searching for personal

training or e-learning, whether cardiology or radiology is the

focus. Just define dedicated criteria to find the right Siemens

offering. More information and registration on the web:

www.siemens.com/somatomeducateThis is a service of Life – our customer care solution

k

Convolution Kernel for Stents and CalcificationsFor a better visualization of stents and calcifications, you

can use the convolution kernel B46. This is available on all

SOMATOM Sensation and SOMATOM Definition scanners

with the HeartView CT option. B46 is an edge preserving

noise reduction kernel that has been optimized to display

small vessels and reduce the blooming effect for higher

density structures.

Why Do We Have Step Artifacts in Cardiac Images?In these images [Fig. 1 and 2] one can clearly see breathing

artifacts. To recognize these artifacts, reconstruct a large

FoV, so that the whole chest is displayed. The spine is shown

without artifact, but the sternum and the heart show steps.

This is caused by breathing, where the patient’s chest moves

in an anterior direction. To avoid these artifacts, practice the

breathing instructions with the patient prior to the scan.

Via LifeNet, the information and service portal available

directly at the CT-scanner consoles (see p. 36), find further

FAQs and learn how to easily use Siemens computed tomog-

raphy scanners and applications in daily clinical practice.

This is a service of Life – our customer care solution

S E R V I C E

Frequently Asked Questions

[ 1 ] Step artifacts in the lungs and in the liver (red arrow) are only visible in anterior part.

[ 2 ] No step artifacts are visible in the spine (white arrow).


EDUCATION & EVENTS

C T O N LI N E

Efficient Tools to Explore New Clinical Opportunities

Enabling customers to take full advantage of their CTs

post processing capabilities is the goal of Siemens Medical

Solutions. That is why Siemens provides their customers with

a new e-Learning program which will be available on CD.

This e-Learning is based on the latest software version syngo

2007 and comprises clinical post processing applications for

Computed Tomography.

The applications are available for newly purchased systems.

In the future, they will be also accessible for installed CT

systems for customers having a syngo Evolve contract.*

Evolve helps to stay up to date by regularly updating soft-

and hardware. This syngo interactive e-Learning tool enables

the user to familiarize himself with new applications or to get

prepared for a 90 day trial. The syngo e-Learning CD is available

for order at the local Siemens Life Representative or at:

[email protected].

In addition, you can always find the latest CT courses offered by Siemens Medical Solutions at www.siemens.com/SOMATOMEducate.

Upcoming Events & Courses

Title Location Short Description Date Contact

Arab Health Dubai, UAE Exhibition and Congress Jan. 29–Feb.1, 2007 www.arabhealthonline.com

ESGAR CTC Nice, France Hands-on Workshop Jan. 25–27, 2007 www.esgar.orgWorkshop on CT Colonography

23nd Annual Computed Orlando, USA JHU CME Course Feb.15–18, 2007 www.ctisus.comBody Tomography 2007

ECR Vienna, Austria Exhibition and March 9–13, 2007 www.ecr.orgScientific Congress

ACC New Orleans, USA Annual Scientific March 24–27, 2007 www.acc.orgSession and Exposition

Deutsche Gesellschaft Mannheim, 73. Jahrestagung April 12–14, 2007 www.dgk.orgfür Kardiologie Germany

ITEM Yokohama, Japan Trade fair April 13–15, 2007 www.j-rc.org

Advanced Topics Baltimore, USA CT Angiography, 3D: April 20–22, 2007 www.hopkinscme.org/in CT Scanning: Current State of the Art,

focus: Cardiac CT

Deutscher Röntgen- Berlin, Germany Exhibition and Congress May 16–19, 2007 www.drg.dekongress

Stanford Symposium San Francisco, USA 9th Annual International June 13–16, 2007 radiologycme.stanford.eduSymposium on Multidetector-Row CT

This is a service of Life – our customer care solutionk

* Availability of single applications depending on system prerequisites.

Screenshot of syngo 2007 e-Learning: Brought to the customer by Life – Customer Care from Siemens Medical Solutions.

CUSTOMER CARE

SOMATOM SESSIONS – IMPRINT

PublisherSiemens AG

Medical Solutions

Computed Tomography Division

Siemensstraße 1

D-91301 Forchheim

Responsible for Contents:André Hartung

EditorsMonika Demuth, PhD

([email protected])

Stefan Wünsch, PhD

([email protected])

Editorial BoardNina Bastian

Thomas Flohr, PhD

Louise McKenna, PhD

Julia Kern-Stoll

Axel Lorz

Matthew Manuel

Jens Scharnagl

Bernhard Schmidt, PhD

Heiko Tuttas

Authors of this IssueS. Achenbach, MD, Department of Internal Medi-

cine II, University of Erlangen-Nürnberg, Germany

C. Becker, MD, Institute for Diagnostic Radiology at

Großhadern University Hospital in Munich, Germany

T. Brady, MD, Division of Cardiac Imaging, Depart-

ment of Radiology, Massachusetts General Hospital

in Boston, MA, USA

M. Das, MD, Department of Diagnostic Radiology,

RWTH University Aachen, Germany

R. Fischbach, MD, Department of Clinical Radiology,

University Münster, Germany

T. Fischer, MD, Department of Clinical Radiology,


R. Günther, MD, Department of Diagnostic

Radiology, RWTH University Aachen, Germany

M. Kalra, MD, Division of Cardiac Imaging, Depart-

ment of Radiology, Massachusetts General Hospital

in Boston, MA, USA

S. Kloska, MD, Department of Clinical Radiology,


A. Kosciesza, Department of Radiology,

Dr. Jan Bogdanowicz Independent Group of Public

Health Service, Warsaw, Poland

K. Li, MD, Prof. Xuanwu Hospital, Capital Medical

University, Beijing, China

J. Lu, MD, Xuanwu Hospital, Capital Medical Uni-

versity, Beijing, China

J. Ludwig, PhD, Department of Internal Medicine

II, University of Erlangen-Nuremberg, Germany

A. Mahnken, MD, Clinic for Diagnostic Radiology,

University Hospital in Aachen, Germany

G. Mühlenbruch, MD, Department of Diagnostic


D. Naidich, MD, Department of Radiology and

Medicine, New York University Medical Center and

School of Medicine, New York, USA

P. Nuzynski, Department of Radiology,

Dr. Jan Bogdanowicz Independent Group of Public

Health Service, Warsaw, Poland

© 2006 by Siemens AG, Berlin and Munich, All rights reserved

J. Vlahos, MD, Department of Radiology and

Medicine, New York University Medical Center and

School of Medicine, New York, USA

J. Wildberger, MD, Department of Diagnostic


M. Zhang, MD, Xuanwu Hospital, Capital Medical

University, Beijing, China

Hildegard Kaulen, PhD, freelance author,

Tim Friend, freelance author,

Tony DeLisa, freelance author

Jessica Amberg; Karin Barthel; Nina Bastian;

Dagmar Birk; Andreas Blaha; Jiuhong Chen; Hen-

drik Ditt; Christoph Hachmöller, MD; Larissa Hein-

rich; Lars Hofmann, MD; Julia Kern-Stoll; Johann-

Gerhard Kreft; Per-Anselm Mahr; Louise McKenna,

PhD, MBA; Hansjürgen Lüder; Doris Pischitz; Ingo

Schmücking, MD; Gitta Schulz; Stefan Wünsch,

PhD; Zimmermann Alexander; all Siemens

Medical Solutions

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SOMATOM Sessions with a total circulation of 35,000 copies is sent free of

charge to Siemens Computed Tomography customers, qualified physicians

and radiology departments throughout the world. It includes reports in the

English language on Computed Tomography: diagnostic and therapeutic

methods and their application as well as results and experience gained with

corresponding systems and solutions. It introduces from case to case new

principles and procedures and discusses their clinical potential.

The statements and views of the authors in the individual contributions do

not necessarily reflect the opinion of the publisher.

The information presented in these articles and case reports is for illustra-

tion only and is not intended to be relied upon by the reader for instruction

as to the practice of medicine. Any health care practitioner reading this

information is reminded that they must use their own learning, training and

expertise in dealing with their individual patients. This material does not

substitute for that duty and is not intended by Siemens Medical Solutions to

be used for any purpose in that regard. The drugs and doses mentioned

herein are consistent with the approval labeling for uses and/or indications

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nosis and treatment of patients, including drugs and doses prescribed in

connection with such use. The Operating Instructions must always be strictly

followed when operating the CT System. The sources for the technical data

are the corresponding data sheets. Results may vary.

Partial reproduction in printed form of individual contributions is permitted,

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We welcome your questions and comments about the editorial content

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CUSTOMER CARE

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SOMATOMSessions

No 19/November 2006RSNA-EditionNov. 26th–Dec. 1st, 2006

€ 10.00www.siemens.com/medical

COVER STORYsyngo WebSpace: Leading the Workflow Revolution inVolume CT Page 4

Two: The New Arithmetic of CTPage 8

NEWSClinically Proven: The Benefit of syngo Lung CAD –Now PMA Approved Page 12

BUSINESSLife in the Global Village:A Dialogue With Prof. Michael Knopp, MDPage 15

CLINICAL OUTCOMESOncology – Improved Followup For Pulmonary Nodules Page 22

Acute Care – NEW: Compre-hensive 3D Stroke ImagingPage 26

SCIENCESee the Whole Disease:Neuro Perfused Blood Volume ImagingPage 32

EDUCATION & EVENTSThe World’s First SOMATOM Definition WorkshopPage 35

Highlights

SOM

ATO

MSe

ssio

ns

On account of certain regional limitations of sales

rights and service availability, we cannot guarantee

that all products included in this brochure are available

through the Siemens sales organization worldwide.

Availability and packaging may vary by country and is

subject to change without prior notice. Some/All of

the features and products described herein may not

be available in the United States.

The information in this document contains general

technical descriptions of specifications and options

as well as standard and optional features which do

not always have to be present in individual cases.

Siemens reserves the right to modify the design,

packaging, specifications and options described herein

without prior notice. Please contact your local Siemens

sales representative for the most current information.

Note: Any technical data contained in this document

may vary within defined tolerances. Original images

always lose a certain amount of detail when repro-

duced.

Please find fitting accessories:

www.siemens.com/medical-accessories

Siemens AG, Medical SolutionsHenkestr. 127, D-91052 ErlangenGermanyTelephone: +49 9131 84-0www.siemens.com/medical

© 2006 Siemens SOMATOM Sessions

Order No. A91CT-00303-41M1-7600

Printed in Germany

CC CT 00303 ZS 1106/35.

SOMATOM SessionsIssue No.19/November 2006

Siemens AG, Medical SolutionsComputed TomographySiemensstr. 1, D-91301 ForchheimGermanyTelephone: +49 9191 18-0

somatom sessions 19

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