Somatom sessions 31

SOMATOM Sessions
Answers for life in Computed Tomography
Issue Number 31 / November 2012
RSNA Edition
Cover Story
New Clinical Insights –
Faster Diagnosis
Page 06
News
FAST Dual Energy
Boosts Comprehensive
Imaging and Treatment
in Oncology
Page 16
Business
We Are Family
Page 22
Clinical
Results
Diagnosis of Coronary-
Vertebral Subclavian
Steal Syndrome using
iTRIM Technique
Page 34
Science
CARE kV Allows
a Reduction of
Radiation Dose
Page 52

Editorial
“Due to its broad benefits to the
healthcare system, image guided
therapy is now a major trend in
medicine.
Together with our network of
outstanding clinical and industrial
partners, we will continue to
lead the way in this exciting field.”
Walter Märzendorfer, Chief Executive Officer, Business Unit Computed Tomography and Radiation Oncology,
Siemens Healthcare, Forchheim, Germany
Cover page: Courtesy of Clinique Pasteur, Toulouse, France
2 SOMATOM Sessions · November 2012 · www.siemens.com/healthcare-magazine

Editorial
SOMATOM Sessions · November 2012 · www.siemens.com/healthcare-magazine 3
Dear Reader,
Over the last few years, dose reduction
in CT has become a highly considerably
issue. The result is that considerably lower
dose levels on average are applied to
our patients. For some body regions, the
improvements are spectacular. Who would
have thought 10 years ago, in the early
days of cardiac CT, that a coronary CT
Angiography would be possible for an
adult patient using an effective dose of
less than 1 mSv?
At some point we have to ask ourselves
whether the battle for the lowest dose
makes sense beyond the second digit.
Clearly, a 50 or 60% dose reduction is
great when you start at 5 or 10 mSv.
Yet, below 1 mSv it could be argued that
the best possible image quality might be
more relevant than another 0.1 mSv in
dose reduction. And equally important:
even with the latest technologies many
examinations still require a couple of mSv
in adult patients, e.g. around 3 to 4 mSv
for a typical abdomen. So below 1 mSv
might not be the right dose for every
patient, too.
We will therefore shift the focus of our
efforts in dose reduction – from low dose
to right dose. We will advise on absolute
dose values whenever possible. We will
continue to develop highly innovative
dose reduction technologies, such as
CARE kV or SAFIRE.1 We will continue to
work together with experts, for example
in our Siemens Radiation Reduction Alli-ance
(SIERRA), to optimize protocols and
improve training. However, we will not
exclusively promote dose levels of below
1 mSv. Because we believe our patients
deserve the right dose for the best possi-ble
diagnosis.
We will also release the latest version
of syngo.via,2 introducing a wider range
of applications and features designed
to make reading easier than ever. One
example is Bone Reading,2 where images
now show the entire spine and rib cage
unfolded. In TAVI planning, the all-new
syngo.CT Cardiac Function – Valve Pilot2
supports the assessment of the annulus
plane.
Finally, we will work to further improve
access to state-of-the-art imaging with
the SOMATOM® Perspective 64-slice con-figuration.
Featuring the latest technolo-gies
already introduced to the 128-slice
configuration, this scanner includes
a footprint of only 18 m2. Its versatility
covers single-click reconstruction and
labeling of the entire spine through
to advanced intervention.3 Our tailored
solution for advanced visualization in
this segment come with a dedicated
set of applications to join the world of
syngo.via.
I do hope you enjoy reading more about
these topics and catching up on a broad
range of clinical and business news in
this latest edition of SOMATOM Sessions.
With best regards,
Peter Seitz,
Vice President Marketing,
Computed Tomography,
Siemens Healthcare,
Forchheim, Germany
Peter Seitz
1 In clinical practice, the use of SAFIRE may reduce CT
patient dose depending on the clinical task, patient size,
anatomical location, and clinical practice. A consultation
with a radiologist and a physicist should be made to
determine the appropriate dose to obtain diagnostic
image quality for the particular clinical task.
2 Under FDA review. Not available for sale in the U.S.
3 These features are not commercially available in the
U.S. Due to regulatory reasons their future availability
cannot be guaranteed. Please contact your local Siemens
organization for further details.

Content
Cover Story
Cover Story
06 New Clinical Insights –
Faster Diagnosis
News
12 Precision and Flexibility on Rails
16 FAST Dual Energy Boosts Compre-hensive
Imaging and Treatment in
Oncology
18 A New Course for CT Scanning
Suggested by the Latest Research
20 CARE Right. Committed to the Right
Dose in CT
06 syngo.via now fulfills
many established computed
tomography functions.
Whether working on oncological,
neurological or cardiac cases,
radiologists can save time
and may potentially improve the
quality of their findings.
18
A New Course for
CT Scanning Suggested
by the Latest Research
06
Faster Diagnosis
Business
22 We Are Family
26 IRIS and Emotion in Daily Practice
Clinical Results
Cardiovascular
28 Low Dose CT Scanning with
70 kV in Congenital Heart Disease of
a 3-month-old Infant
30 Low Dose CT Diagnosis of Pediatric
Aortic Coarctation using CARE kV,
SAFIRE and Flash Mode
32 Unroofed Coronary Sinus
Syndrome – Diagnosis with Dual
Source CT using Flash Mode
34 Diagnosis of Coronary-Vertebral
Subclavian Steal Syndrome using
iTRIM Technique
Content

Science
44 Research Clusters Enable Transfer
of Basic Research to Clinical Routine
– Part II. Concentrated Expertise
Against Coronary Heart Disease
48 Image Quality in Computed
Tomography – Part I. Low Contrast
Detectability
52 CARE kV Allows a Reduction of
Radiation Dose
Customer
Excellence
54 Clinical Fellowships: Localized
Learning from the Experts
54 ESC Hands-on Tutorials (HoT’s)
Oncology
36 Minimally Invasive Treatment
of Hepatocellular Carcinoma using
a Siemens Miyabi System
Acute Care
38 Aortic Dissection Follow-Up using
Fast Mode with SOMATOM Definition
Edge
Orthopedics
40 Metal Artifact Reduction by
Energetic Extrapolation in Single
Source Dual Energy CT1
42 Metal Artifact Reduction using Dual
Energy CT Monoenergetic Imaging
55 New Dual Energy Technology for
SOMATOM Definition
55 Flash Imaging – A Book Full of Flash
Expertise
56 Frequently Asked Question
56 Clinical Workshops 2012/2013
57 Upcoming Events & Congresses
2012/2013
58 Subscriptions
59 Imprint
20
CARE Right. Committed to
the Right Dose in CT
52
CARE kV Allows a Reduction of
Radiation Dose
Content
1 Under FDA review. Not available for sale in the U.S.

Cover Story
Faster Diagnosis
syngo.via now fulfills many established computed tomography (CT)
functions. Whether working on oncological, neurological or cardiac cases,
radiologists can save time and may potentially improve the quality of
their findings.
By Oliver Klaffke
Late on Friday afternoon, and the ground-floor
radiology department of the
Maussins-Nollet clinic in Paris is alive with
activity. Radiologist Catherine Radier,
MD, is still on duty in her tiny ground-floor
office. Dedicated to her work, she prefers
to deal with her patients face-to-face
rather than stare endlessly at screens:
“Radiology is all about people,” she states.
For Radier, any technological advance
that allows her to spend more time with
her patients is a welcome development.
This is precisely why she uses a syngo.via
system from Siemens.
“Personally I have benefited greatly
from the advances that syngo.via and
the CT Oncology Engine have brought to
radiology,” Radier says. Both the Siemens
SOMATOM® Definition AS and the CT
Oncology Engine are in use at her clinic.
Thanks to the data pre-processing and
retrieval capabilities of these systems,
images are instantly available and records
are always at hand. In addition, computer-aided
detection of lesions has opened
up a new diagnostic dimension for the
radiologist.
“Personally, I have benefited
greatly from the advances that
syngo.via and the CT Oncology
Engine have brought to radiology.”
Catherine Radier, MD, Radiologist, Maussins-Nollet clinic, Paris, France

Recently, Ms. Radier had the chance to
test one of Siemens latest additions:
syngo.CT Bone Reading.1 This is an appli-cation
designed to support the visual
identification of bone metastases or
fractures.1 Detecting them in ribs and
vertebrae can be a tedious task for radi-ologists:
“One can become easily con-fused,
wading through stacks of two-dimensional
images,” Radier explains.
A palette of oncology functions
The new application for bone assessment
“opens” the entire chest cavity virtually;
providing unfolded rib and spine views,
so that three dimensions become two,
and the whole region is displayed as a
single layer. Furthermore, ribs and verte-brae
are numbered automatically to aid
future reference.
Once findings are noted, they are auto-matically
remembered by syngo.via’s
Findings Navigator and can be easily
retrieved. As a core tool, this facility is an
aid to radiologists’ day-to-day work and
is particularly useful when they need to
share findings with other physicians,
“I can easily walk them through a case,
going from finding to finding,” Radier
explains.
Another valuable functionality has been
added to syngo.CT Segmentation, which
has been designed to segment lesions in
the lung, liver, and the lymphatic systems.
Advanced Hounsfield Unit Statistics1
are collated to lesions for assessment of
hypodense areas of tumors, which might
be an indicator of necrosis. These are
then color-coded to provide an overview.
In addition, volume and percentage
compared to complete tumor volume is
calculated and displayed. Determining
changes in tumor size as well as changes
in tumor density is essential both in
assessing the progress of the disease,
and in evaluating its treatment.
The CT Oncology Engine also provides
a clear overview of tumor loads and
dimensions clearly over time. Thanks to
its pre-retrieval function, syngo.PET&CT
Cross-Timepoint Evaluation automatically
makes existing data available. By show-ing
this in a so called trending table or
graph, measurements from up to eight
examinations can be compared: “Build-ing
such a table takes less than a second,”
Radier notes.
Fast access to lifesaving
diagnostic information about
stroke patients
Meanwhile in northern Germany,
an emergency helicopter is landing at
Goettingen University Hospital with
a patient suffering an acute stroke.
Over 1,000 stroke patients are treated
here every year: “Our aim is to restore
the blood supply to affected tissue as
soon as possible,” says neuroradiologist
PD Peter Schramm, MD. This is essential
if neurological damage is to be kept to
a minimum, as up to two million brain
cells can be lost every minute following
a stroke: time is brain.”
“Three key diagnostic questions are
need to be answered in acute stroke:
How large are the areas of core infarct
and tissue that could potentially be saved
(penumbra) with further treatment in
1 Rib and spine assessment are redefined with syngo.CT Bone Reading.
Courtesy of Medical University of Vienna, Department of Radiology, Vienna, Austria
1
Cover Story
1 The option is pending 510(k) clearance, and is not yet
commercially available in the United States.

the brain tissue? Is the stroke caused by
bleeding or a clot? And what is the size
and location of the clot?” All three ques-tions
can be addressed with CT.
As the stroke patient is rushed from the
helicopter to the radiology unit Schramm
turns to his SOMATOM Definition AS+
CT scanner with the CT Neuro Engine.
The new perfusion imaging application
syngo.CT Neuro Perfusion1 is now avail-able
on the thin client-server platform
syngo.via. “Treatment without precise
knowledge of core infarct size and pen-umbra
may do more harm than benefit,”
says Schramm. “Therefore, diagnostic
imaging tools are required to see the size
of the core infarct and penumbra. These
need to be able to cover the whole brain,
safely, accurately and fast.”
“The syngo.CT Neuro Perfusion includes
a Tissue at Risk model that is based on
the mismatch between blood volume and
blood flow,” Schramm says. However,
users can also select a custom mismatch,
based on user-defined perfusion metrics.
Schramm is investigating the Siemens’
unique metric, Time To Drain (TTD), to
look for signs of early ischemia. Important,
but often overlooked are differences
in the hemodynamics of gray vs. white
matter: therefore the penumbra analysis
can be restricted not only to the affected
scrolling through axial CT Angiography
(CTA) source images. However, estimating
the size of the clot is somewhat cumber-some
and often not possible, since the
images are taken at a single point in time.
This is where syngo.CT Dynamic Angio
comes into play. Dynamic CTA appears to
be a solution to this limitation. Movies
of blood flow, from arterial to venous
phases can be created and temporal
Maximum Intensity Projections (tMIP)
especially seem to better characterize
the clot size due to retrograde collateral
filling.
“With my SOMATOM Definition AS+ and
the CT Neuro Engine, I am able to identify
core and penumbra, exclude bleeding
and determine the size and location
of the clot,“ says Schramm. “Routinely,
“We need
a reliable
stroke diagnosis
within
10 minutes.”
PD Peter Schramm, MD,
Neuroradiologist,
University Hospital Goettingen, Germany
“Dual Energy
opens new
dimensions in
diagnosis.”
Prof. Michael Lell, MD,
Radiologist, University Hospital
Erlangen-Nuremberg, Germany
hemisphere. On top of that it can per
selection be limited to the brain gray
matter. For whole brain perfusion imag-ing,
the Adaptive 4D Spiral technology
moves the table of the CT smoothly back
and forth, providing coverage beyond
the width of the detector.
The acute therapy varies according to
what caused the stroke: thrombolytics
need to be administered when a clot is
responsible; however, they are contra-indicated
when bleeding is the cause. A
native head scan will answer the ques-tion
“is it bleeding or is it a clot” quickly.
Excellent image quality is required here
as the subtle nuances indicative of the
early signs of ischemic stroke can be
difficult to see. “I routinely use Neuro
BestContrast,” says Schramm.
If the result discovers a clot as the rea-son
for the stroke, treatment can include
the administration of thrombolytic drugs
to dissolve the clot on the one hand and,
increasingly, interventional techniques
for clot retrieval. “With modern neuro-interventional
techniques, such as cath-eters
and clot retrieval devices, there’s
practically no proximal intracranial artery
we can’t open up,” says Schramm. To do
this, it is vital to see exactly where the
vessel is obliterated. Generally, one can
determine the location of the clot by
Cover Story

patients are ready for stroke intervention
in less than 10 minutes. This gives me
confidence in better selecting patients
that may benefit from interventional
stroke treatment,“ concludes Schramm.
Overcome limitations of con-ventional
methods
“As radiologists we live in exciting times,”
says Prof. Michael Lell, MD, radiologist at
Erlangen-Nuremberg University Hospital
in southern Germany. He has also had
the chance to explore some of the new
syngo.via applications resulting from
the Dual Energy functionality – which,
he believes, “opens up new dimensions
in diagnosis.”
One of these applications is syngo.CT
DE Gout,2 an application that detects the
build-up of uric acid crystals: the cause
of gout. “We expect an improvement in
treatment, as this application will help
us differentiate between the apparently
similar symptoms of gout and other forms
of arthritis,” Lell observes. To date, CT
imaging has not been standard proce-dure
in the diagnosis of gout. In tradi-tional
clinical practice, the presence
of increased levels of uric acid and salt
crystals in joints has been seen as an indi-cation
of gout. However, it is not always
so simple. In an acute phase, the levels
of uric acid might actually be quite low,
giving a false negative reading. Punctur-ing
the joints is not always feasible and
not always diagnostic. Furthermore, in
some gout patients, the crystals only form
in the fibres – not the joints. To further
complicate matters, the blood levels of
uric acid associated with some other
arthritic diseases can be as high as those
with gout.
2 Infarct (red) and penumbra (yellow) with the tissue at risk model.
Courtesy of University Hospital Goettingen, Germany
3 syngo.CT DE Gout color-codes uric acid crystals to easily diagnose gout.
Courtesy of Nan Xi Shan Hospital, Guilin, China
2
3
Cover Story
2 syngo.CT DE Gout is not commercially available in
the U.S. Due to regulatory reasons its future availability
cannot be guaranteed.

Every year rheumatologists refer between
50 and 100 patients to Lell and his col-leagues
for CT examinations: “It is essen-tial
to have a reliable way of judging
whether the salts are present or not,” he
says. This is exactly what syngo.CT DE
Gout does, through its ability to clearly
show any salt crystals on the CT images.
Bringing clarity to gout
diagnosis and treatment
“Clear visuals also make communication
easier with the patients,” Lell notes.
Normally, two-dimensional CT images
can leave patients more confused than
enlightened; whereas three-dimensional
images of a joint – with the salts high-lighted
in color – make the situation
much clearer.
A further advantage of CT scans comes
from their ability to assist the physician
in assessing the success of gout therapy:
“Tracking the presence of uric acid salts
with CT over time is a good way of
telling whether any improvements have
taken place,” says Lell. syngo’s pre-retrieval
feature assists with this. Even
before a scan has started, any previous
images will have been identified and
readied for comparison with the most
recent findings. “One can then spot easily
whether the disease has advanced or
not,” Lell adds.
In some cases, using Dual Energy can be
especially helpful: “Think of uric acid and
of calcium pyrophosphate as indicators
of different diseases,” says Lell. “With Dual
Energy, one can tell them apart. They
are marked in different colors; in no
time, the radiologist can tell exactly what
disease the patient is suffering from.”
Boosting myocardial perfusion
analysis
At Innsbruck University Hospital in
Austria, matters of the heart are at the
core of the daily work of radiologist
Gudrun Feuchtner, MD. She performs
up to eight coronary CT Angiographies
a day: “Time is a precious commodity,”
she says. syngo.via is helping her to get
more from her images in less time.
Evaluating myocardial perfusion is one of
Feuchtner’s regular jobs. She has already
been using CT for this task; however, now
she has had the chance to test the new
features of syngo.CT Cardiac Function.
The Enhancement extension shows the
perfusion of the heart on an AHA-con-form,
17-segment polar map – it there-fore
provides a swift overview of vital
details.
Looking at perfusion to get an idea of
the state of the myocardium has many
advantages over simply identifying ste-noses:
“With the improved enhancement
functionality, I can overcome the short-falls
of purely anatomical imaging as it
helps me to assess the hemodynamic
relevance of a stenosis,” Feuchtner says.
With syngo.CT Cardiac Function, she can
track physiological changes within the
myocardium, “It is far easier to identify
a perfusion defect on a 17-segment
map,” she adds.
The Hybrid View offers a particularly
elegant way of presenting results, by
providing a three-dimensional display of
the heart. Besides the coronary arteries,
it shows an overlay of left ventricular
function and perfusion – whether intact
or dysfunctional: “The Hybrid View
allows a clear judgment of the diseased
vessels,” says Feuchtner.
In the course of her examinations in
Innsbruck Feuchtner gets yet more valu-able
information by using syngo.CT
Cardiac Function. Besides evaluating first
pass enhancement, she also applies the
technique of late enhancement imaging
to CT. By waiting 6–8 minutes after con-trast
agent administration, a second scan
4 The Hybrid View helps to correlate the perfusion defect with the supplying
coronary artery. Courtesy of Clinique Pasteur, Toulouse, France
4
Cover Story

“It is far easier to identify
a perfusion defect
on a 17-segment map.”
Gudrun Feuchtner, MD, Radiologist,
University Hospital Innsbruck, Austria
1 Rapid Results Technology is not commercially available
in the U.S. Due to regulatory reasons its future availability
The statements by Siemens’ customers described herein
are based on results that were achieved in the customer’s
unique setting. Since there is no “typical” hospital and
many variables exist (e.g., hospital size, case mix, level
of IT adoption) there can be no guarantee that other
customers will achieve the same results.
allows the radiologist to differentiate
viable from scarred tissue.[1] Informa-tion
about the still-functioning regions
of the heart muscle is vital for planning
pacemaker surgery. It makes no sense
to place electrodes in regions that are
no longer working properly. Normally,
MRI is used for late enhancement assess-ment,
but in certain circumstances it is
contra-indicated, e.g. if the patient has
a cardiac pacemaker.[2] In these cases,
computed tomography may be the
method of choice: “syngo.CT Cardiac
Function-Enhancement is therefore
particularly useful in planning revascu-larisation
procedures,” Feuchtner states.
“Its images are proving a great help for
the cardiac surgeon.”
Saving time in cardiology
Displaying perfusion within the myo-cardium
in this way makes interpretation
much easier. Until now, this task
demanded considerable amounts of an
individual’s time, concentration and
endurance. Thanks to the Automatic Pre-processing
in syngo.via, all the neces-sary
data is now made readily available.
“With syngo.via we observe a reduction
of read-out time and time-to-diagnosis,”
says Feuchtner. By introducing Rapid
Results Technology1 Siemens takes image
evaluation a step further and combines
efficient reading with increased stan-dardization.
The generation of images
now is not only automated, but also
reproducible. The design of individual
protocols helps to drive the evaluation
of coronary and general vessels and may
help to establish a constant quality of
care.
When it comes to Transcatheter Aortic
Valve Implantation (TAVI) planning,
syngo.CT Cardiac Function – Valve Pilot2
supports the quantitative assessment of
the annulus plane. The annulus plane is
displayed and the minimum, maximum,
and effective diameters of the aortic
annulus are provided as the case is
opened.
Cover Story
Further Information
www.siemens.com/syngo.via
Oliver Klaffke is a science and business writer,
who lives in Switzerland and France. Publications
for which he has written previously include the
New Scientist and Nature, among others.
References
[1] Hamilton-Craig C, et al. JACC Cardiovasc Imaging.
2011 Feb; 4(2):207-8.
[2] Schroeder S, et al. Eur Heart J. 2008
Feb; 29(4):531-56.

News
Precision and
Flexibility on Rails
Austria and Japan not only share a passion for classical music. The field
of X-ray diagnostics reveals more common ground: clinics in both countries
are trailblazers as far as the use of SOMATOM® Definition AS systems with
sliding gantry
configurations is concerned.
By Regina Sailer, PhD
Be it pain management, tumor therapy,
or trauma classification, the SOMATOM
Definition AS with Sliding Gantry masters
a diverse range of clinical applications, as
events in Japan and Austria convincingly
disclose. The nascent system has now
been put through its paces in both coun-tries,
and has been in operation at the
Wels Clinic in Grieskirchen, Upper Austria,
since February 2012. Experiences of the
system in Osaka, where the world’s first
SOMATOM Definition AS with Sliding
Gantry was installed at the Toyonaka
Municipal Hospital in November 2011,
date back even further.
Multiple applications for
diagnosis
and therapy
The high-end system has created a host
of new opportunities for diagnosis and
intervention in both countries. The con-ventually-
run hospital in Wels demon-strates
exactly how clinic resources can
be used more effectively as a result. With
approximately 1,200 beds, the hospital
serves Upper Austria’s entire central
region. The system is deployed primarily
in the clinic’s trauma division, concur-rently
coping with an additional daily
workload of 35 to 50 routine CTs.
Senior physician Thomas Muhr, MD, radi-ologist
and the clinic’s acting medical
director, explains: “A major focus of our
clinical activities is CT controlled pain
management of the spine.” With over
6,000 cases of intervertebral disk infil-tration
annually, Wels leads the national
field as far as treatment for this condi-tion
is concerned.
“ The resultant precision
which can be attained is
absolutely phenomenal,
and the images are
excellent.”
Thomas Muhr, MD, Radiologist and medical director,
Wels Clinic in Grieskirchen, Austria

Wels hospital is equipped with a sliding gantry solution designed for use in two rooms, namely in both the trauma room and a second room
in which routine CT scans are carried out. Both of these rooms are equipped with a stationary, height-adjustable table. The gantry itself can be moved
to any desired position via the rail system.
Cardiac examinations are also increasing
in frequency at the Wels Clinic, which has
a very active cardiac surgery department,
gradually becoming part of the hospital’s
daily routine. “Here, the CT scanner is
currently used chiefly for exclusion diag-nostics
and clarification during bypass
operations,” Muhr explains. “The resul-tant
precision which can be attained is
absolutely phenomenal, and the images
are excellent,” adds the radiologist.
Smaller interventions, including facet
joint blocks in the lumbar region, lung
punctures, and biopsies are also part of
the clinic’s routine.
Its proximity to the trauma division
results in the system’s additional use in
the diagnosis of whiplash injuries, joint
injuries, fractures or shoulder injuries,
and frequently for CT brain scans. It is
also implemented in the examination of
oncology patients during comparative
tumor evaluations, for instance. CT-con-trolled
radiofrequency therapy is also
offered. Although the latter counts as
one of the Wels Clinic’s specialist fields,
the corresponding case numbers are
low, in strong contrast to the situation
at Osaka’s 650-bed municipal hospital,
where tumor therapy is at the very heart
of the SOMATOM Definition AS system’s
activities.
Focus on oncological therapy
in Osaka
At the Toyonaka Municipal Hospital,
the rail-guided SOMATOM Definition AS
flexes its muscles primarily in the field
of precision oncological therapy. Taku
Yasumoto, MD, uses the technology to
perform between 50 and 60 interventions
on a monthly basis. Barring emergency
procedures, standard examinations
include lung biopsies and treatment of
hepatocellular carcinomas, which have a
high incidence rate in Japan, using radio-frequency
ablation (RFA). Yasumoto favors
a combined technique of transcatheter
arterial chemoembolization (TACE),
followed by RFA. Here, the SOMATOM
Definition AS with Sliding Gantry is
teamed with an AXIOM Artis angiography
system from Siemens. Both procedures
are performed in a single location on
a treatment couch. This saves space, an
important factor in Japan. Patients and
clinic personnel alike benefit as a result,
as TACE plus RFA can now be carried out
conveniently without location transfers.
During these interventions, imaging
quality is particularly crucial. Yasumoto
emphasizes that, above all, minimally
invasive therapy must be highly selective,

News
and that optimal real-time imaging is
absolutely essential in consequence.
According to Yasumoto, this is where the
scanner comes into its own, offering clear
benefits during treatment, as both the
needle tips, Lipiodol® and microbubbles
can be visualized perfectly with the CT.
In addition, the 3D-visualization also helps
less experienced personnel with the
precise localization of organs and tissue,
while, on the other hand, experienced
radiologists benefit greatly from the six-image
display.
A customized system
The system in Osaka has been adapted
in line with Yasumoto’s specifications
in order to function with even greater
precision. The screens are now stacked
vertically on top of one another on a
small trolley and positioned above the
board with the joystick. The trolley fits
perfectly between CT construction and
retracted C-arm, allowing the physician
to view the screen and operate the joy-stick
with his left hand without having
to let go of the needle shaft with his
right hand.
Yasumoto has developed two additional
special devices to assist him during exam-inations,
which he has integrated effec-tively
within the existing system. Besides
the glove, he uses a personal invention
in the shape of a type of cage which
surrounds the needle while he holds it.
He has also replaced the conventional
protective CT shields with a personally
designed “Kamakura” (Japanese for
“igloo”). This contraption is draped directly
over the gantry. The upper section con-sists
of leaded crystal, while the lower
section forms a lead cover, two milli-meters
thick, which protects Yasumoto’s
arms and chest while still permitting
him to reach through into the gantry’s
interior.
One CT for two rooms
Osaka Toyonaka Municipal Hospital
witnessed the first ever global use of the
SOMATOM Definition AS with Sliding
Gantry. Although the Wels Clinic was the
fifth to be equipped with the system,
it is revolutionary in another respect. It
was the world’s first hospital to be fitted
with a sliding gantry solution designed
for use in two rooms, namely in both the
trauma room and a second room in which
routine CT scans are carried out. Both of
these rooms are equipped with a station-ary,
height-adjustable table. The gantry
itself can be moved to any desired posi-tion
via the rail system serving both rooms
with a single click from the control room.
This allows the team at Wels to use the
CT scanner in both rooms as required,
either routinely for “daily business” or for
emergency patients in the trauma room.
When severely injured individuals are
admitted, an event which occurs approx-imately
every three days, the lead-lined
partition between the adjacent rooms is
simply opened, allowing the SOMATOM
Definition AS to slide into the emergency
area via the rail system, where the patient
waits on a special treatment couch
equipped with a carbon plate.
Both the CT and the diagnostic process
can be completed easily and conveniently
on this special couch. “A considerable
benefit,” explains Thomas Muhr, “as, after
conveying the patient from the ambu-lance
to the carbon plate, no more trans-fers
are required until the time comes to
1 Computed tomography during arterial portography
(CTAP) was performed to confirm a hepatocellular
carcinoma diagnosis and to aid the physician in deciding
on the access path to this challenging tumor location
(see also case 5, page 36).
Courtesy of Toyonaka Municipal Hospital, Osaka, Japan
2 Polytrauma cases are routine in Wels, Austria.
Courtesy of Wels Clinic, Grieskirchen, Austria
1 2

News
The trolley allows Taku Yasumoto, MD, to view the screen and operate the joystick with his left
hand without
having to let go of the needle shaft with his right hand.
Regina Sailer, PhD, is a communications
scientist. She writes for German print and online
media as a freelance journalist. Her specialist
topics include the fields of medicine, health,
new therapies, and research. She lives and works
in Salzburg, Austria.
The products/features (here mentioned) are not com-mercially
available in all countries. Due to regulatory
reasons their future availability cannot be guaranteed.
Please contact your local Siemens organization for
further details.
move the individual to a hospital bed.”
Up to nine transfers used to be required
to complete the diagnostic process. Prob-lems
involving obese patients, for whom
the old examination table had to be sta-bilized
with an extra support, are now
also a thing of the past. The new system
receives top marks from the team at Wels
for both its larger bore and improved
hygiene. Muhr comments: “The techni-cally
optimized water-cooling system
means that we benefit from less patho-gen
contamination during interventions
and polytrauma. And the reduced heat
loss heralds further improvements in
energy efficiency.”
Speedy post-processing with
syngo.via
The trauma patients at Wels not only
benefit from increased efficacy as far as
transport and diagnosis are concerned.
In addition, the visualization software
syngo.via, which is fully integrated at
Wels, facilitates significantly faster CT
post-processing in the field of trauma
care. Thomas Muhr reports: “syngo.via
is a great support, as we can use it to
reconstruct images and create 3D-recon-structions
in a matter of seconds.” This
is particularly advantageous for trauma
patients: “We used to require around
an hour from the patient’s arrival to the
completion of the final image. The new
CT has allowed us to reduce this to 35
minutes,” adds the Wels-based radiolo-gist.
Not only emergency admissions have
been experiencing faster diagnostic
procedures since the new equipment’s
arrival – oncological patients have also
benefited. “We are now in a position to
measure tumors and calculate their vol-umes
immediately with a simple click.
This has simplified things considerably,”
explains Muhr, who also underlines the
system’s user-friendliness and the advan-tageous
impact of automatic preparation
on cases.
A giant step forward for
patients and colleagues
All these new options represent a giant
step forward for both patients and col-leagues,
reports Thomas Muhr, summa-rizing
experiences to date as follows: “It
is impossible to rate the acceleration of
our work triggered by this new technol-ogy
highly enough, particularly in the
field of trauma care.” According to Muhr,
this progress also goes hand in hand
with pleasingly high stability. Downtime
is the exception to the rule, despite the
system’s novelty. And what happens if
the system should malfunction? “In this
case, Siemens reacts immediately. The
support provided is excellent,” says Muhr.
Colleagues at Wels particularly appreci-ate
this dedicated service, adds the physi-cian,
and are always happy to participate
in new projects involving Siemens.
The new SOMATOM Definition AS has
also established itself as an extremely
valuable tool in Japan during its first year
in service. According to Yasumoto, the
outstanding image quality has success-fully
enhanced minimally invasive ther-apy,
particularly when combined with
ultra-precise table motion.
www.siemens.com/sliding-gantry

News
FAST Dual Energy Boosts Comprehensive
Imaging and Treatment in Oncology
SOMATOM® Definition – Siemens’ first generation Dual Source CT – boosted
by FAST Dual Energy now offers valuable functional parameters helping to
answer critical oncological questions fast and without increasing radiation
dose or contrast media consumption. Specialists at the Institute of Clinical
Radiology and Nuclear Medicine at the University Medical Center Mannheim,
Germany, appreciate the user-friendly system in their daily imaging and
therapy routines.
By Ruth Wissler, MD
The Institute of Radiology and Nuclear
Medicine at the University Medical Center
Mannheim, Germany, performs between
100 and 120 CT readings per day. An
increasing number of outpatients are sup-plied
with telemedical services and tele-radiology,
respectively. Six hospitals rely
on the comprehensive radiology service
during the night, and a smaller satellite
hospital uses the entire IT infrastructure
for telemedical purposes. Since the insti-tute’s
SOMATOM Definition was equipped
with FAST Dual Energy about six months
ago, its utilization has reached approxi-mately
50% of the Dual Source CT read-ings,
with an upward trend.
Besides cardiovascular, neurological
and trauma readings, the Mannheim
Radiology Department provides the entire
spectrum of oncological imaging and
interventional oncological therapies, e.g.
Transcatheter Arterial Chemoemboliza-tion
(TACE), Selective Internal Radiation
Therapy (SIRT), and Radiofrequency
Ablation (RFA). The embedded “Centre
of Rare Tumors” focuses on special
“ Meanwhile I don’t ask
myself when to use Dual
Source CT with FAST
Dual Energy, but rather
when not to use it.”
Thomas Henzler, MD,
Head of computed tomography at the Institute
of Clinical Radiology and Nuclear Medicine at
the University Medical Center Mannheim, Germany
tumor entities such as sarcoma and
Gastrointestinal Stromal Tumors (GIST).
Oncological challenges in
radiology
“We are faced with growing requirements
from referring oncologists, and we have
to supply them with functional parame-ters,”
says Thomas Henzler, MD, Head of
computed tomography at the Institute of
Clinical Radiology and Nuclear Medicine
at the University Medical Center Mann-heim,
Germany. Increasingly individual-ized
diagnostics, personalized interven-tion
planning, and therapy monitoring
call for sophisticated imaging technolo-gies.
Combining Dual Energy CT and MRI
with PET-CT provides better functional
information.
For example, the progress in targeted
therapies requires a new quality of ther-apy
monitoring. “Functional imaging
shows us, that there is imaging beyond
Response Evaluation Criteria in Solid
Tumors (RECIST),” says Thomas Henzler.
“We see that patients receiving targeted
therapies live longer, even without reduc-tion
of tumor size. So this may partially
indicate an improper classification of
malignancies if we just use morphological
criteria.”
The aim is not only to state the presence
and the changes in size of tumors during

1 57-year-old patient with large peritoneal GIST metastasis. Low keV monoenergetic iodine maps allowed significantly better assessment
of metastatic contrast enhancement, which is an important marker for therapy response evaluation under targeted therapy with Imatinib.
Courtesy of University Medical Center Mannheim, Germany
recon
part 2
high kV
data
recon
part 1
3D
recon
FAST Dual
Energy image
low kV
data
recon
part 1
therapy, but also to assess the tumor
vascularization or status before and after
chemoembolization.
Dual Energy CT provides better
functional information
Currently, a large variety of functional
imaging solutions are available. But Dual
Energy CT according to Henzler, is prob-ably
the most commonly available and
cost-efficient imaging method. Dual
Energy CT will increasingly gain signifi-cance
because medical imaging has to
take into account the advantage for the
patient as well as the incremental effi-ciency
cost ratio. One very important
aspect of using SOMATOM Definition with
Dual Energy CT is to get functional infor-mation
quickly without increasing the
radiation dose or the amount of contrast
agent. In therapy monitoring, for exam-ple,
the low kV monoenergetic selective
iodine contrast enhancement allows sig-nificantly
better assessment of metastases
(see Fig. 1).
With an optimal composition of low and
high kV data the contrast-to-noise ratio
can be improved. This optimal composi-tion
is provided with the Dual Energy
composition slider included in FAST Dual
Energy; consequently the amount of
contrast agent used may potentially be
optimized. During the last few years the
discussion has focussed on reducing the
radiation dose, but not reducing the con-trast
agent. “As we found out in a study,
dose neutrality can only be confirmed
for Dual Source Dual Energy CT,” empha-sizes
Henzler.
Clinical advantages: FAST Dual
Energy reconstruction
Considerable timesaving is one promi-nent
clinical feature. Henzler: “I would
assume that for 3D reconstruction, data
transmission and storage we can save
three to five minutes per case.” During
a normal working day this adds up to a
considerable acceleration of workflow.
This is an important aspect for the tech-nicians,
too, because there is no addi-tional
workload.
The use of FAST Dual Energy right from
the start allows generation of additional
information such as functional data, if
needed, without having to store three
times the amount of data, because unused
datasets are eliminated and the Picture
Archiving and Communication System
(PACS) is not ‘jam-packed’. The specialists’
experience with SOMATOM Definition
boosted by FAST Dual Energy at the Insti-tute
of Clinical Radiology and Nuclear
Medicine at the University Medical Center
in Mannheim, represents state of the
art practice in acceleration of workflow,
lean data sets and excellent acceptance
by technicians.
1
2 FAST Dual Energy can use statistical
information from both images simultane-ously
and provides a combined filter for
improved mixed images at low and high
Dual Energy composition value.
2
Ruth Wissler, MD, studied veterinary and
human medicine. She is an expert in science
communications and medical writing.

News
A New Course for CT Scanning
Suggested by the Latest Research
Two recently published scientific studies show how CT scanning might
change established guidelines in the case of acute coronary syndrome
and in preventive medicine. Siemens SOMATOM® CT scanners are well
equipped to set a new course.
By Heidrun Endt, MD
Computed Tomography, Siemens Healthcare, Forchheim, Germany
Since the 1970s, when CT became com-mercially
available for the first time, it has
become a key imaging tool to approach
a range of clinical questions. Two large
clinical trials have recently been published
showing how CT scanning might have an
even greater impact and change estab-lished
guidelines in the future.
Patient management in
the case of acute coronary
syndrome
The New England Journal of Medicine,
one of the most renowned medical
journals, published a multi-center study
on the use of coronary CT Angiography
(cCTA) examinations in the emergency
department. The authors included in their
study 1,370 patients who had presented
with suspected acute coronary syndrome.
All of these patients had a low to inter-mediate
risk of acute coronary syndrome.
The patients were then assigned to two
groups; one receiving traditional care
management as it is performed and estab-lished
at the study location, the other
receiving cCTA as the initial imaging test.
A follow-up was conducted within 30 days
of the event. The researchers concluded
that cCTA in these patients “[…] appears
to allow the safe, expedited discharge
from the emergency department of many
patients who would otherwise be admit-ted”[
1] and that this approach is there-fore
“[…] more efficient than traditional
care.”[1] Efficient workflow is important,
especially in the emergency department.
There would clearly not be enough time
to adjust the CT scan protocol manually
for each patient. Two studies[2, 3] pub-lished
recently evaluated the potential
for the use of CARE kV, the automated
tube voltage adjustment from Siemens,
for cCTA examinations. In both studies,
one part of the examinations was carried
out with a manually-adjusted tube volt-age
based on the BMI of the patient; for
the second group of patients CARE kV
was used to determine the optimal tube
voltage. With CARE kV, the selection of
tube voltage resulted in a changed set-ting
in 17 out of 38 patients in the first
study and the mean CTDIvol decreased
from 12.4 mGy to 8.7 mGy.[2] In the
second study, Park et al. conclude that
they were able “[…] to reduce radiation
exposure while maintaining diagnostic
1 CARE kV proposed the
use of 80 kV as optimal tube
voltage setting for this CT
examination of the heart.
A 0.7 mSv effective dose
was applied for the coronary
CT Angiography (Figs. 1A–B).
Within their study[2] the
authors from Massachusetts
General Hospital evaluated
the use of CARE kV for this
application.
Courtesy of Massachusetts
General Hospital, Boston,
USA
1A 1B

the protocol for each patient manually;
for scanning persons at high-risk of lung
cancer in the context of preventive med-icine,
where it is especially important to
keep the radiation dose low.
2 A 55-year old patient
suffering from scleroderma
had to undergo a CT exami-nation
of the thorax. A lesion
in the left upper lobe (arrow,
Fig. 2A) was diagnosed as
well as lung fibrosis (arrows,
Fig. 2B). Due to the use of
SAFIRE, the examination could
be carried out with an effec-tive
dose of 0.35 mSv on the
SOMATOM Definition AS 64.
The examination was included
in the scientific study written
by Baumueller et al.[6]
Courtesy of University
Hospital Zurich, Switzerland
with X-CARE; here the tube current is
lowered for certain angles of the rotation
of the X-ray beam. Ketelsen et al. evalu-ated
thoracic CT examinations in 30
patients.[7] These patients were given
an initial CT scan without X-CARE and
had to undergo a second scan as follow-up.
For this second examination, X-CARE
was used to lower the radiation dose to
the female breast and the thyroid gland.
Based on their measurements, the authors
recommend that X-CARE “[…] should
be used in thoracic CT examinations in
male and female patients with a possible
decrease in organ equivalent doses of
sensitive organs by about 30%.”[7]
The impact of these large
clinical trials
Cardiovascular diseases are on the rise
and lung cancer is the most common
cause of cancer-related deaths. Conse-quently,
image quality […]”.[3] Further dose
reduction can be achieved with iterative
reconstruction. An international group of
researchers evaluated the use of SAFIRE
in an obese patient population for cCTA.
Compared with their standard protocol
with 120 kV, the low dose protocol with
100 kV and SAFIRE “[…] can reduce the
radiation requirements by 50% while
maintaining diagnostic image quality in
the obese patient population.”[4]
Low-dose CT for persons at
high-risk of lung cancer
The New England Journal of Medicine
published a large clinical trial with more
than 53,000 persons at high-risk of lung
cancer.[5] The persons were assigned
to one of two groups. Each participant
underwent three annual examinations for
several years; either with conventional
X-ray examination (group 1) or a low-dose
CT scan (group 2). Afterwards, there was
a follow-up phase that showed that mor-tality
from lung cancer was reduced in
the low-dose CT scan group.
Scanning these persons in a preventive
context requires special attention to
radiation dose. Baumueller et al. assessed
the use of SAFIRE for low dose examina-tions
of the lung. The authors conclude
that the “radiation dose of non-enhanced
lung CT can be lowered to a submilli-sievert
level, while image quality still
remains diagnostic when data are recon-structed
with SAFIRE.”[6] Special organ-sensitive
dose protection can be achieved
2A 2B
research into how to manage
these diseases in an optimal fashion is
of great importance. Studies such as the
two large clinical trials presented above
[1, 5] help lead the way to optimized
management. Of course, until results
find their way into practical guidelines,
more studies are needed to further sup-port
their findings and subjects need to
be looked at from different angles. The
technologies implemented in Siemens
SOMATOM CT scanners would be of great
benefit in both cases: For scanning in the
case of suspected acute coronary syn-drome,
when there is no time to adjust
References
[1] Litt HI, et al. N Engl J Med.
2012 Apr 12;366(15):1393-403.
[2] Ghoshhajra BB, et al. Cardiac Computed
Tomography Angiography With Automatic Tube
Potential Selection: Effects on Radiation Dose
and Image Quality. J Thorac Imaging.
2012 Jul 27. [Epub ahead of print]
[3] Park YJ, et al. J Cardiovasc Comput Tomogr.
2012 May;6(3):184-90.
[4] Wang R, et al. Eur J Radiol.
2012 Nov;81(11):3141-5.
[5] National Lung Screening Trial Research Team.
N Engl J Med. 2011 Aug 4;365(5):395-409.
[6] Baumueller S, et al. Low-dose CT of the lung:
potential value of iterative reconstructions.
Eur Radiol. 2012 Jun 15. [Epub ahead of print]
[7] Ketelsen D, et al. Invest Radiol.
2012 Feb;47(2):148-52.
News
In clinical practice, the use of SAFIRE may reduce CT
patient dose depending on the clinical task, patient
size, anatomical location, and clinical practice. A
consultation with a radiologist and a physicist should
be made to determine the appropriate dose to obtain
diagnostic image quality for the particular clinical
task. The following test method was used to determine
a 54 to 60% dose reduction when using the SAFIRE
reconstruction software. Noise, CT numbers, homo-geneity,
low-contrast resolution and high contrast
resolution were assessed in a Gammex 438 phantom.
Low-dose data reconstructed with SAFIRE showed the
same image quality compared to full-dose data based
on this test. Data on file.

News
CARE Right. Committed to
the Right Dose in CT
In CT, achieving reliable clinical results with the greatest patient safety does
not mean reducing radiation at all costs. Experts recommend absolute values.
By Ivo Driesser, Computed Tomography, Siemens Healthcare, Forchheim, Germany
The guiding principle in applying radiation
is “As Low As Reasonably Achievable”, or
ALARA. In computed tomography this
means applying not just the lowest, but
also the right dose for sound diagnostic
imaging. Siemens has, therefore, made a
commitment to delivering the right dose
in CT with CARE Right. CARE Right sum-marizes
Siemens’ efforts in the areas of
dose reduction technology, finding the
right dose levels for individual exams and
managing patient dose throughout the
institution.
Right dose technology
In order to get to the right dose and to
reduce it to as low as reasonably achiev-able
for the clinical task, the clinical staff
need to have the right dose technology.
From the beginning of the CT era, devel-oping
highly innovative dose reduction
technologies was one of Siemens’ main
goals. Back in the 1990s, Siemens intro-duced
CARE – the Combined Applications
to Reduce Exposure. In CT scans, three
aspects are crucial: individual size and
stature of the patient, examination type,
Reference values Switzerland1 Germany2 European Union3 USA4
Head Routine CTDIvol [mGy] 65 65 60 75
Thorax Routine CTDIvol [mGy] 15 12 30
Abdomen Routine CTDIvol [mGy] 15 20 35 25
Default Siemens
Protocol
Standard values* Standard SAFIRE***
values*/**
Head Routine CTDIvol [mGy] 59.8 41.4 455
Thorax Routine CTDIvol [mGy] 7.4 4.4 1.56
Abdomen Routine CTDIvol [mGy] 14.2 10.1 6.57
1 Bundesamt für Gesundheit (Merkblatt R-06-06, Diagnostische Referenzwerte in der Computertomographie, 01.04.2010)
2 Bundesamt für Strahlenschutz (Bekanntmachung der aktualisierten diagnostischen Referenzwerte für diagnotische und interventionelle Röntgenuntersuchungen. Vom 22. Juni 2010)
3 European Guidelines on Quality Criteria for Computed Tomography (http://www.drs.dk/guidelines/ct/quality/htmlindex.htm)
4 American College of Radiology (CT Accreditation Program Requirements, Clinical Image Quality Guide, 13.04.2012)
5 Becker HC, et al. Radiation exposure and image quality of normal computed tomography brain images acquired with automated and organ-based tube current modulation multiband filtering and
iterative reconstruction. Invest Radiol. 2012 Mar;47(3):202-7.
6 Baumueller S, et al. Low-dose CT of the lung: potential value of iterative reconstructions. Eur Radiol. 2012 Jun 15. [Epub ahead of print] CTDIvol for the protocol using 100 kV.
7 May MS, et al. Dose reduction in abdominal computed tomography: intraindividual comparison of image quality of full-dose standard and half-dose iterative reconstructions with dual-source computed
tomography. Invest Radiol. 2011 Jul;46(7):465-70. CTDIvol for abdominal CT calculated according to the conclusion.
Tab. 1: Absolute values which can be obtained with default protocols on the SOMATOM Definition Flash in comparison with reference values
from different regions.
and, finally, applied radiation dose. They
are all the key drivers for the resulting
image quality.
Individual patient and exami-nation
types
First, the patient’s habitus both in-plane
and along the longitudinal axis influences
the dose that needs to be applied.
Siemens’ CARE Dose4D is unique in adjust-ing
modulation in real time during the
scan based on only one topogram so that
the right dose is always applied accord-
Study values**
*** Values are based on the default protocols of the SOMATOM Definition Flash with syngo CT 2012B and an average sized patient of 1.75 m and 75 kg
*** Iterative Reconstruction is used
*** In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with
a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task. The following test method
was used to determine a 54 to 60% dose reduction when using the SAFIRE reconstruction software. Noise, CT numbers, homogenity, low-contast resolution and high contrast
resolution were assessed in a Gammex 438 phantom. Low dose data reconstructed with SAFIRE showed the same image quality compared to full dose data based on this test.
Data on file.

ing to the strongly varying attenuation
in x-, y- and z-direction during one scan.
Second, also the tube voltage should be
adapted to the individual patient and
examination type. In a CTA, for example,
lower kV is beneficial as the contrast
media enhanced vessels can be depicted
with a better contrast-to-noise-ratio (CNR).
However in non-contrast scans or in
obese patients higher kV may be better
to provide enough power to obtain good
and diagnostic image quality. Siemens’
CARE kV is still the only solution on the
market that automatically determines the
appropriate kV and scan parameters to
deliver the right dose for the particular
scan and the required image quality.
Third, iterative reconstruction approaches
proved to be beneficial in reconstructing
images of the same diagnostic quality
acquired with a lower dose compared
to the established filtered backprojection
technique. With outstanding clinical
results, SAFIRE – Sinogram Affirmed
Iterative Reconstruction – enables a dose
reduction potential of up to 60%.***
Siemens has also introduced new image
reconstruction systems that allow itera-tive
reconstructions of up to 20 images
per second, fast enough for clinical
routine. As a result, many Siemens sites
across the globe use SAFIRE consistently
for every examination, even in time
crucial environments like acute care.
Absolute dose values –
essential for the right dose
But next to having access to the right tech-nology,
it is essential to know the right
dose levels to perform an examination
according to ALARA. There is an ongoing
debate about the balance between
image quality and amount of radiation.
On this issue, Siemens, together with key
opinion leaders, founded SIERRA – the
Siemens Radiation Reduction Alliance.
Feedback from this and other panels of
experts provides input for a dedicated
development team. That produces the
various Siemens protocols needed to
comply with the full range of patient
types, disease types, examination pro-cedures,
and with the expectations of
reading physicians with regard to image
quality. The result is a sophisticated
library of scan protocols focused on apply-ing
the right dose for each examination.
In order for users to know, whether they
apply the right dose levels, absolute dose
values are a pre-requisite. Therefore
Siemens provides them along with its pro-tocols
and they are confirmed in external
peer-reviewed publications (see references
5-7 in Tab.1). Users can apply these val-ues
as a reference to compare their cur-rent
dose level with regional recommen-dations
and with the dose delivered by
Siemens CT scanners (see Tab. 1).
Documenting dose – a basis
for management, compliance
and improvement
Finally, organizations need to manage
dose across their institutions. Regional
regulations sometimes require that radi-ation
given to patients is documented.
Other CT administrators like to have an
overview as a basis for dose optimization.
Both cases require structured access to
dose data. With DoseMAP – Siemens’ new
Dose Management Program – data can
be accessed from various sources, such
as scanners, PACS or RIS and aggregated
to the type of report required. With
EduCARE, Siemens also offers specialized
trainings focussing on applications to
reduce dose. CME-accredited tutorials
and webinars can be booked by users for
specific topics. Furthermore, Siemens has
introduced a new cross-modality consul-tancy
program, called Optimize CARE.
Siemens professionals work with the
customer on site to analyze the current
situation, define and implement improve-ment
measures to reasonably reduce
radiation and then monitor the progress
with the customer to finally hit the right
dose.
Commitment to the right dose
Siemens’ efforts in optimizing dose
have also been recognized by others. An
impartial organization, KLAS, stated in
its report “CT 2011: Focused on Dose”
that Siemens was the “leader to catch“,
honoring Siemens’ commitment to deliv-ering
the right dose.
News
1 Siemens CT updated free-of-charge the SOMATOM Definition AS family for their
customers to SAFIRE, the latest evolution in iterative reconstruction. With SAFIRE, it
was possible to achieve excellent image quality with a low dose value (CTDIvol:10 mGy).
1

Business
We Are Family
Only 12 months after the debut of the SOMATOM® Perspective 128-slice
configuration, its sibling is on its way – this time in 64-slice configuration.
The SOMATOM Perspective family brings plenty of new features along with
its great economics.
By Eric Johnson
The SOMATOM Perspective scanners are
ideal for larger private practices and mid-size
hospitals, offering them a first step
towards the upper-end of computed
tomography (CT).
“One-size-fits-all has never been the
Siemens approach to CT or to medical
equipment in general, because we know
that requirements vary from clinic to clinic
and practice to practice,” comments
Florian Belohlavek, Siemens Global Prod-uct
Marketing Manager for the SOMATOM
Perspective, CT. “So, to meet these needs,
we now offer the SOMATOM Perspective
family.” The machines share quite a num-ber
of unique functionalities, but differ
in their scan coverage capabilities and
thus clinical applications. Such is their
similarity that customers can buy this
64-slice machine as a starter system from
the high-end segment, and in time,
upgrade directly to a 128-slice model. The
main difference between the two is a
matter of clinical performance. The 128-
slice has a powerful cardiac and vascular
package; the 64-slice addresses custom-ers
that only face cardiac questions once
in a while and focus on having a strong
workhorse for everyday clinical tasks.
The new SOMATOM Perspective was
unveiled in November, at the 2012 Radio-logical
Society of North America (RSNA)
conference, and featured a host of
upgraded components. However, one
element definitely remains unchanged:
the positioning as the most economical
CT in its class.
Born this way. So, what’s new?
The first new addition to the FAST CARE
platform is a feature already available in
SOMATOM Definition scanners: FAST
Spine.1 This speedier system for recons of
the spine is an option for the SOMATOM
Perspective family. By preparing ana-tomically
aligned reconstruction ranges,
as well as the labeling of all acquired
vertebrae and discs, FAST Spine1 may
potentially reduce time needed for pre-paring
spine recons, which is important
in time-crucial cases in acute care.Then
there is the introduction of tilted spiral
scanning2 for analyses of the head and
spine. While the previous SOMATOM
Perspective offered tilted sequential scan-ning,
this now can be done in spiral mode.
Also new is i-Control,3 an in-room
remote control for interventions. It
transfers all scanner controls into the
scan room, e.g. for the patient table
movement, or remote command for the
gantry and scanner functions.
Dose protection has been boosted, too.
A new password system enables scan pro-tocols
to be changed only by authorised
people at a practice or clinic, not just by
anybody with access to the machine. In
addition, the integrated gantry display
Only one year after the debut of the 128-slice SOMATOM Perspective,
another is on its way – this time in 64-slice configuration.

1 This case of liver tumor was examined with SOMATOM Perspective. The VRT image highlights multiple liver lesions and fine details
of the mesenteric arteries. Courtesy of Diagnosezentrum Favoriten, Vienna, Austria
1
has been upgraded. More information is
reported, in a larger format, making it
easier to both read and use.4
Practice made perfect
As would be expected in a high-end
system, the SOMATOM Perspective family
offers some of the latest innovations in
CT. Dose reduction is achieved in three
ways. The first of these is through the
application of CARE Dose4D, which adapts
the X-ray tube current throughout the
duration of scan, helping to create images
of consistent quality for all organs, patient
shapes, and sizes – in real time. This over-comes
the most common challenges of
CT imaging: a) the applied dose in ante-rior,
posterior, and lateral positions needs
to be different; b) each slice requires
different dose values’, and c) patients
are quite heterogeneous (young/elderly,

Business
2 (IVR) helps to visualize even very small
2 A case of lymphoma – VRT image shows multiple enlarged lymph nodes in the mediastinum
and great anatomical details in the lungs. Courtesy of Clinique Sainte Marie, Paris, France
small/large), so the applied dose must
be adapted to the individual patient;
d) patients can move after the initial
topogram was acquired, thus a real-time
adjustment is needed during the scan.
Secondly, iterative reconstruction (IR)
further aids dose reduction. Until recently,
using IR with CT imaging in conventional
clinical medicine was simply too time-consuming:
reconstructing images with
iterative algorithms required too much
computational power. With Sinogram
Affirmed Iterative Reconstruction
(SAFIRE), Siemens has introduced raw-data-
based iterative reconstruction that
can achieve a dose reduction of up to
60%5 across a wide range of applica-tions.
It also delivers excellent image
quality. Due to its reconstruction speed
of up to 15 images/second, SOMATOM
Perspective brings SAFIRE into the daily
routine.
The final element of dose reduction
comes from Ultra Fast Ceramic (UFC)
detectors, which have already become
a key feature in CTs predating the
SOMATOM Perspective. UFCs enable the
capture of smaller X-ray doses, yet they
still respond with high luminance. This
means that they outperform conventional
detectors, which require more radiation
to generate an image of equal quality.
Besides this comprehensive dose port-folio,
the new scanner also features new
functionalities like iTRIM and IVR, improv-ing
its diagnostic capabilities. The first,
Iterative Temporal Resolution Improve-ment
Method (iTRIM) improves temporal
resolution, which is essential in cardiac
imaging. This novel algorithm analyzes
the image for fast moving sections and
applies an iterative image reconstruction
when required. This supports diagnosis
in demanding situations, for example
when imaging hearts with rapid move-ments.
Interleaved Volume Reconstruction
diagnostic details using a sophisticated
reconstruction algorithm.
Taking care of business
Money, time, space – the SOMATOM
Perspective family saves all, which brings
down both capital and operating costs.
The speed of installation represents a
major plus for the SOMATOM Perspective
family. Since the scanner and control
room have the smallest footprint of any
comparable CT system – just 18.5 square
meters (199 square feet) – a SOMATOM
Perspective will easily fit into the space
of an existing CT, with room to spare. It’s
also lightweight: tipping the scales at
1,719 kg (3,790 lbs), whereas conven-tional
CTs can weigh anything from just
over two, to nearly three metric tonnes
(4,409-6,613 lbs). Existing CT power
sources – rated at 75-150 kVA – can be
used because the SOMATOM Perspective
requires only 70 kVA. This allows instal-lation
in an existing scan room, without
the need for extending, floor reinforce-ment
or rewiring. All this means that
instead of the 3-4 days downtime usu-ally
needed to fit a conventional CT, the
SOMATOM Perspective can be up and
running within 48 hours.
In operation, these CTs run at lower
temperatures and use less energy. Cool-ing
requirements and total electricity
consumption are around half those of a
conventional scanner. Then comes the
masterstroke: eMode. Built into the user
interface, eMode allows operation of the
scanner in a patient-friendly and finan-cially
efficient way – with a single click. An
analysis of the scan is made in real time,
and the system is instantly fine-tuned
according to the requirements of the user.
This reduces wear and tear on the sys-tem.
Coupled with this it comes a new
‘service plus’ approach from Siemens:
for customers who run the SOMATOM
Perspective in eMode for more than 80
percent of its operating time, their insti-tution
will be rewarded with dedicated
eMode service benefits.6
Taking care of people
Of course, money isn’t everything. The
SOMATOM Perspective is also simple to

Both the 64-slice and the 128-slice configuration offer the Illumination Moodlight.
Eric Johnson writes about technology,
business and the environment from Zurich.
Previously he headed what is now a Thompson-
Reuters bureau and corresponded for McGraw-
Hill World News.
www.siemens.com/
SOMATOM-Perspective
4 The features (here mentioned) are not com-mercially
available in the U.S. Due to regulatory
reasons their future availability cannot be
guaranteed. Please contact your local Siemens
organization for further details.
5 In clinical practice, the use of SAFIRE may reduce
CT patient dose depending on the clinical task,
patient size, anatomical location, and clinical
practice. A consultation with a radiologist and
a physicist should be made to determine the
appropriate dose to obtain diagnostic image
quality for the particular clinical task. The follow-ing
test method was used to determine a 54
to 60% dose reduction when using the SAFIRE
reconstruction software. Noise, CT numbers,
homogeneity, low-contrast resolution and high
contrast resolution were assessed in a Gammex
438 phantom. Low-dose data reconstructed with
SAFIRE showed the same image quality compared
to full-dose data based on this test. Data on file.
6 Individual service benefit availability is subject
to country-specific offerings.
use. Operators will appreciate ‘ease-your-
workday’ accessories such as FAST
Planning, FAST Cardio Wizard, the newly
introduced FAST Spine,1 Workstream4D,
the storage box and a standard recon-struction
speed of up to 20 images per
second. The gantry also offers Siemens’
unique Illumination MoodlightTM, which
helps to banish the sterile, clinical look-and-
feel of most examination rooms. As
they are so fast and accurate, the scan-ners
may allow patients to undergo fewer
scans altogether, and during those scans
to spend less time holding their breath,
rolling or stretching. That is a bonus for
patients.
So in addition to clinical advancements
and significantly reduced overall costs,
patients may also benefit from the patient
friendly features. This is what makes up
the cumulative strength of this family:
It enhances patient care and business.
1 FAST Spine is not commercially available in the
U.S. Due to regulatory reasons its future avail-ability
2 Tilted spiral scanning is not commercially avail-able
in the U.S. Due to regulatory reasons its
future availability cannot be guaranteed.
3 i-Control is not commercially available in the
U.S. Due to regulatory reasons its future avail-ability

Business
IRIS and Emotion in Daily Practice
Technical modernization proves particularly challenging for small
radiology practices. It is essential to strike the right balance between
technical progress, patient expectations, personal aspirations, and
costs. Radiologist Christoph Voigt, who runs his own practice based
in the Protestant Hospital in Hattingen, Germany, is well on track
with the Siemens package, consisting of SOMATOM® Emotion and IRIS.
By Ingrid Horn, PhD
“Back then, when the issue of a new CT
system cropped up, we decided on an
ideal combination,” says Christoph Voigt.
A SOMATOM Emotion 16 scanner, an
unpretentious yet high-quality computed
tomography scanner from Siemens, has
graced his practice since March 2012.
The most popular model in the compact
class is equipped with the high-perfor-mance
Ultra Fast Ceramic (UFC) detector
technology. As a result, the SOMATOM
Emotion generates premium-quality
images while helping to minimize radia-tion
exposure for patients. However,
Christoph Voigt, who had prior experi-ence
of Siemens’ CT technology, decided
to go a step further in the knowledge
that appropriate image reconstruction
methods can produce an additional
reduction in patient dose. The Hattingen-based
radiologist chanced upon IRIS
while researching this topic. “Iterative
Reconstruction in Image Space” success-fully
reduces image noise to such an
extent that the radiation dose used to
generate the images can be decreased
significantly without impairing image
quality. In the meantime, many CT
models produced by Siemens can be
upgraded with iterative reconstruction.
Christoph Voigt explains his decision as
follows: “We wanted to purchase a reli-able,
modern and economically efficient
device with genuinely good prospects.”
Raised competitive profile
IRIS is en vogue. The radiologist and his
partners are aware that following current
trends is key to remaining competitive.
The team at the Protestant Hospital in Hattingen, Germany, is proud to work with SOMATOM Emotion in combination with IRIS.
Main tasks include colonographies, tumor and nervous system imaging.

Business
1 Thorax CT of a patient suffering from a bronchial carcinoma.
Courtesy of RSN Hattingen, Germany
Hattingen lies on the periphery of the
Wuppertal conurbation in the German
federal state of North Rhine-Westphalia.
The practice owners decided to invest in
IRIS to raise their competitive profile and
set themselves apart from other radiol-ogy
institutions. Above all, it is a way to
counteract patient migration to radiol-ogy
centers. As a result, they spread the
good news of their practice’s technical
upgrade via local newspaper. And atten-tion
was certainly paid by patients. As
Christoph Voigt discovered during ensu-ing
discussions, the dose reduction facil-itated
by IRIS was the most important
aspect in their eyes. Meanwhile, he has
realized exactly how much the SOMATOM
Emotion and IRIS combination achieves.
When compared to his previous images
and external images of patients, he puts
the average dose savings at 50%.1
Dose reduction as top priority
Patients at the joint practice are referred
by both local practitioners and the hos-pital.
Approximately 25 patients with a
wide range of clinical diagnoses receive
CT scans daily. Christoph Voigt explains:
“We do everything the device permits
with the exception of cardiac CTs.” Appli-cations
in focus include colonographies
and tumor and nervous system imaging.
Voigt places great emphasis on an opti-mized
balance of image quality and radi-ation
dose. In some cases, such as muscle-skeletal
system imaging, he retains the
conventional dose in order to benefit
from increased image quality with IRIS. In
general, however, dose reduction is the
top priority. Voigt says: “This method is
particularly beneficial for young people
with testicular carcinomas or lymphomas,
as the total radiation load in the face of
the frequent checkups decreases.” The
thorax CT of a patient suffering from a
bronchial carcinoma convincingly dem-onstrates
the way in which outstanding
images can be achieved with a reduced
radiation dose and via the use of IRIS.
Although the radiation load is just as high
as in the case of the two-plane X-ray, the
CT provides more information than the
classic radiograph, which may aid the
physician in making decisions regarding
possible surgical interventions. As a result,
www.healthcare.siemens.com/
computed-tomography/
clinical-applications/iris
1
paranasal sinuses are only scanned with
the CT scanner and IRIS technology in
Hattingen.
Christoph Voigt believes that his practice
now provides standard examinations at
university level thanks to the new device
configuration. He is equally impressed
by the fact that, after just a brief famil-iarization
phase, the use of IRIS and the
interpretation of the resultant images
have quickly become routine. IRIS is
always an asset in the eyes of Christoph
Voigt, whether a small radiology prac-tice
is debating a new acquisition or an
upgrade.
Ingrid Horn, PhD, studied biology and
biochemistry. She is an expert in science com-munications
and an experienced medical writer
with an emphasis on biomedical topics in fields
including medical engineering, neuroscience,
oncology, and pediatrics.
1 In clinical practice, the use of IRIS may reduce
CT patient dose depending on the clinical task,
patient size, anatomical location, and clinical
practice. A consultation with a radiologist and
a physicist should be made to determine the
appropriate dose to obtain diagnostic image
quality for the particular clinical task. The follow-ing
test method was used to determine a up to
60% dose reduction when using the IRIS recon-struction
software. Noise, CT numbers, homo-geneity,
low-contrast resolution and high
contrast resolution were assessed in a Gammex
438 phantom. Low-dose data reconstructed
with SAFIRE showed the same image quality
compared to full-dose data based on this test.
Data on file.
The statements by Siemens’ customers described
herein are based on results that were achieved
in the customer’s unique setting. Since there
is no “typical“ hospital and many variables exist
(e.g., hospital size, case mix, level of IT adoption)
there can be no guarantee that other customers
will achieve the same results.

Clinical Results Cardiovascular
Case 1
Low Dose CT Scanning with
70 kV in Congenital Heart Disease
of a 3-month-old Infant
By Martin Wong,* Wai Leng Chin**
** Paediatric Cardiology Unit, Pusat Jantung Hospital Umum Sarawak, Malaysia
** Siemens Healthcare, Regional RHQ, Singapore
HISTORY
A 3-month-old male infant was admitted
with central cyanosis and a heart murmur.
An echocardiography revealed complex
cyanotic heart disease (situs inversus,
dextrocardia, tricuspid atresia, univentric-ular
heart and pulmonary atresia). The
pulmonary artery anatomy could not be
clearly delineated in echocardiography.
DIAGNOSIS
A CT Angiography (CTA) revealed a
confluent central pulmonary artery, uni-focally
supplied by a ductus arteriosus
(Figs. 1–3, arrows). The ductus arteriosus
originated from the descending aorta
and ran a tortuous S-shape course before
inserting into the right pulmonary artery.
There was a long segment narrowing
of the proximal right pulmonary artery
(Fig. 3, dashed arrow) between the pul-
monary artery confluence and the ductal
insertion site. Otherwise, both distal
pulmonary arteries were of average size.
The univentricular heart (Fig. 4, asterix)
and dextrocardia were also seen in the
CTA.
The infant successfully underwent
a left modified Blalock-Taussig shunt
as the first step in the single ventricle
repair pathway.
1 2

Cardiovascular Clinical Results
examination protocol
Scanner SOMATOM
Definition Flash
Scan area Thorax
Scan length 147 mm
Scan direction Cranio-caudal
Scan time 0.35 s
Tube voltage 70 kV
Tube current 132 eff. mAs
Dose
CARE Dose4D
modulation
CTDIvol 1.29 mGy
DLP 19 mGy cm
Rotation
0.28 s
time
Pitch 2.0
Slice collimation 0.6 mm
Slice width 0.6 mm
Spatial
Resolution
0.33 mm
Reconstruction
increment
0.4 mm
Reconstruction
kernel
B26
Contrast
Volume 8 mL
Flow rate 1.0 mL/s
Start delay CARE Bolus
COMMENTS
70 kV CTA clearly demonstrated the
complex pulmonary artery anatomy
and enabled a prompt diagnosis and
pre-operative planning. Invasive cardiac
catheterization became unnecessary.
The combined effect of the low kilo-voltage
setting of 70 kV and the auto-
4 Thin MIP 10 mm
shows univentricular
heart (asterix), and
dextrocardia.
4
*
matic tube current dose modulation
for low radiation dose is feasible in
small-size pediatric patients, without
impairing image quality.
3
1–3 VRT (Fig. 1),
thin MIP 7 mm
(Fig. 2) and 5 mm
(Fig. 3) images show
a confluent central
pulmonary artery,
unifocally supplied by
a ductus arteriosus
(Figs. 1–3, arrows).
The ductus arteriosus
originated from the
descending aorta
and ran a tortuous
S-shape course before
inserting into the
right pulmonary
artery. A long seg-ment
narrowing of
the right pulmonary
artery (Fig. 3, dashed
arrow) could also be
visualized between
the pulmonary artery
confluence and the
ductal insertion site.

Case 2
Low Dose CT Diagnosis of
Pediatric Aortic Coarctation using
CARE kV, SAFIRE and Flash Mode
By Pei Nie, MD,* Ximing Wang, MD,* Zhaoping Cheng, MD,* Yanhua Duan, MD,* Xiaopeng Ji, MD,*
Jiuhong Chen, MD, PhD**
** Shandong provincial key laboratory of diagnosis and treatment of cardio-cerebral vascular diseases,
Shandong Medical Imaging Research Institute, Shandong University, Jinan, Shandong, P. R. China
** CT Research Collaboration, Siemens Ltd. China, Beijing, P. R. China
HISTORY
A 4-year-old boy was presented with a
history of hypertension. A physical exam-ination
revealed upper extremity hyper-tension
and diminished femoral pulses.
A systolic ejection murmur, at the left
upper sternal border, radiated to the
interscapular area. A cardiovascular CT
examination was requested to evaluate
the aortic anatomy prior to surgery.
DIAGNOSIS
A thoracic CT Angiography (CTA) scan with
ECG triggering confirmed the coarctation
of the aorta (Figs. 3, 5-8). The coarctation
was distal to the left subclavian artery and
measured 15 mm in diameter proximal
to the obstruction, 5 mm at the smallest
diameter, 16 mm distal to the obstruction
and 10 mm in length. Additionally, a small
patent ductus arteriosus (Figs. 4, 7-8)
was found, connecting the main pulmo-nary
artery and the upper descending
aorta. The cardiac structures, as well as
the origins and the courses of the coro-nary
arteries, showed no abnormalities.
COMMENTS
Flash Mode enables an ECG-triggered
spiral scan starting at 10% of the R-R inter-val
with a high pitch of 3.4. The heart rate
1 Flash Mode enables data acquisition within one cardiac cycle.
2 The parameters of CT scanning and contrast injection were recorded in the patient protocol.
1
2

3 4
6
varied between 78 to 100 bpm (Fig. 1),
however, the image acquisition of the
entire thorax was completed within one
cardiac cycle in only 0.46 s. Therefore
neither sedation nor breathhold was
necessary.
A combination of various techniques
was applied to lower the radiation dose
to 0.35 mSv – CARE Dose4D (automatic
tube current modulation), CARE kV (auto-matic
tube voltage optimization) and
SAFIRE (raw data-based iterative recon-struction).
The amount of contrast medium used
could also be reduced to 18 mL (1.2 mL
per kg body weight) – thanks to the
Flash scanning speed and the intensive
enhancement achieved at 70 kV.
Scanner
SOMATOM
Definition Flash
Scan area Thorax
Scan length 144 mm
Scan direction Caudo-cranial
Scan time 0.32 s
Tube voltage 70 kV with CARE kV
Dose modulation CARE Dose4D
CTDIvol 0.37 mGy
DLP 8 mGy cm
Effective dose 0.35 mSv
Rotation time 0.28 s
Pitch 3.4
Slice collimation 128 x 0.6 mm
Slice width 0.75 mm
Spatial Resolution 0.33 mm
Reconstruction
0.5 mm
increment
Reconstruction
kernel
I26f, SAFIRE
Heart rate 78 – 100 bpm
Contrast
350 mg/mL,
Ultravist, Iopromide
Volume
18 mL (contrast)
+ 15 mL (saline)
Flow rate 1.5 mL/s
Start delay 25 s
3–8 Maximum Intensity Projection (MIP) images (Figs. 3–4) and volume-rendered images
(Figs. 5–8) demonstrated the coarctation of the aorta (arrows) and the patent ductus arteriosus
(dashed arrows) between the main pulmonary artery and the upper descending aorta.
5
7
8
Cardiovascular Clinical Results
In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task,
patient size, anatomical location, and clinical practice. A consultation with a radiologist and
a physicist should be made to determine the appropriate dose to obtain diagnostic image quality
for the particular clinical task. The following test method was used to determine a 54 to 60% dose
reduction when using the SAFIRE reconstruction software. Noise, CT numbers, homogeneity, low-contrast
resolution and high contrast resolution were assessed in a Gammex 438 phantom. Low
dose data reconstructed with SAFIRE showed the same image quality compared to full dose data
based on this test. Data on file.

Case 3
Unroofed Coronary Sinus Syndrome –
Diagnosis with Dual Source CT using
Flash Mode
By Hongliang Zhao, MD,* Minwen Zhen, MD,* Yi Huan, MD,* Fu Fu Chen, MD,** Hong Tao Liu, MD**
** Department of Radiology, Xijing Hospital, the Fourth Military Medical University, Xian, P.R. China
** Healthcare Sector, Siemens Ltd. China, Shanghai, P. R. China
HISTORY
A 70-year-old female patient with a known
history of hypertension presented herself
to the hospital complaining of stuffiness
in the chest for the past two months.
A Dual Source Coronary CT Angiography
(CTA) was performed to rule out coronary
heart disease.
DIAGNOSIS
The CTA images clearly showed an atrial
septal defect (ASD, Figs. 1– 3) with left-to-
right shunting. The coronary sinus (CS)
opened into the left atrium (Figs. 1– 4),
and the great and middle cardiac veins
were enlarged before they joined the
coronary sinus. An anomalous vascular
structure, running in the right atrio-ventricular
groove, along with the right
coronary artery connected the right
atrium and the coronary sinus (Figs. 1–5).
Mixed plaques were present in the
proximal left anterior descending (LAD)
artery with less than 50 % luminal steno-sis
(Fig. 6). The other coronary vessels
appeared to be normal.
COMMENTS
Unroofed coronary sinus syndrome
(URCS), also called coronary sinus septal
defect, is a rare congenital cardiac anom-aly.
The roof of the CS is either partially
or completely absent resulting in a com-munication
between the CS and the left
atrium (LA). Trans-thoracic echocardio-graphy
is the most widely used imaging
modality for suspected unroofed CS, but
is limited in its ability to visualize the
posterior cardiac structures such as the CS.
Dual Source CT, with its excellent spatial
and temporal resolution, allows for the
visualization and the evaluation of the
Scanner SOMATOM Definition Flash
Scan area Heart Pitch 3.4
Scan length 195 mm Slice collimation 128 x 0.6 mm
Scan direction Cranio-caudal Slice width 0.75 mm
Scan time 0.42 s Temporal Resolution 75 ms
Tube voltage 100 kV Reconstruction increment 0.4 mm
Tube current 266 eff. mAs Reconstruction kernel B26f
Dose modulation CARE Dose4D Heart rate 58 bpm
CTDIvol 2.6 mGy Contrast
DLP 67 mGy cm Volume 60 mL
Rotation time 0.28 s Flow rate 4 mL/s
Effective dose 0.94 mSv Start delay 19 s
posterior structures of the heart. With
its widespread use for coronary artery
assessment, Dual Source CT is emerging
as a potentially useful non-invasive imag-ing
modality for the evaluation of the
coronary venous system. A variety of new
techniques can be combined to reduce
the radiation dose and to achieve better
image quality. In this case, CARE Dose4D,
tube voltage of 100 kV and Flash Mode
using a pitch of 3.4 were jointly used to
lower the patient radiation dose to only
0.94 mSv.

1 2
3 4
5 6
1–6 The ASD and jet of dense contrast (left-to-right shunt) entering the right atrium (arrowhead), as well as the site of the unroofing
(dashed arrows) are shown in Figs. 1–3. An anomalous vascular structure running within the right atrio-ventricular groove along with the
right coronary artery connecting the right atrium and the coronary sinus (arrows) are presented in Figs. 1–5. A mixed plaques in the
proximal LAD with less than 50% luminal stenosis (double arrows) is visualized in Fig. 6.

Case 4
Diagnosis of Coronary-Vertebral
Subclavian Steal Syndrome using
iTRIM Technique
By PG Pedro, MD,* P Oliveira, RT,* P Coelho, RT,* L Pereira, RT,* D Jesus, RT,* H Pereira, RT,* J Ramalho, RT,*
J Costa, RT,* A Chaves, RT**
** Department of Radiology and Cardiology, SAMS Hospital, Lisbon, Portugal
** Siemens Healthcare, Portugal
HISTORY
A 59-year-old female patient with multiple
cardiovascular risk factors (type II diabe-tes,
hypertension, hypercholesterolemia,
smoker) had suffered an anterior myo-cardial
infarction (AMI) 5 years ago and
later developed a CCS class II angina
pectoris. Catheterization disclosed an
occluded mid-segment in the left anterior
descending artery (LAD) and an 80%
lesion in the circumflex artery (Cx).
A coronary artery bypass graft (CABG)
was then performed with a left internal
mammary anastomosis (LIMA) to LAD
and a radial free graft, from LIMA to an
obtuse marginal (OM) branch. The patient
remained asymptomatic until recently,
in spite of the severe risk factors. Three
months later, moderate angina reap-peared
as well as episodes of dizziness,
mainly during upper limb exercise. One
month later, a new AMI in the lateral
wall occurred. An urgent femoral cathe-terization
revealed thrombotic occlusion
of the Cx artery. The LAD artery had an
1 Heart and great vessels isolated volume rendering reconstructions (VRT) show occluded left subclavian artery and retrograde filling of the
axillary
artery, through the patent LIMA and left vertebral artery. The radial artery bypass graft is occluded and a coronary Cx stent is patent.
old occlusion and the LIMA graft could
not be catheterized. The right coronary
artery (RCA) was normal. Primary angio-plasty
of the culprit Cx was performed
and a bare metal coronary stent was
successfully deployed. Rest chest pain
was resolved, but mild effort angina
and dyspnea resumed one week later.
A physical examination disclosed absent
pulses in the left arm. A cardiac CT
Angiography (CTA) was then performed.
1A 1B 1C

atherosclerotic disease. It is unclear
whether the surgical procedure itself
accelerates the growth of the lesions in
the subclavian artery. This is mainly due
to the enhanced local flow and conse-quent
endothelial shear stress. In the
patient described, pre-operative upper
limb arterial pressures were symmetrical
and poor risk factors might also have
contributed to the subclavian disease
progression.
In this well-documented case, a large
acquisition window, ranging from the
middle neck region to the diaphragm,
was used to ensure good anatomical
coverage; primarily that of the proximal
supra-aortic vessels to prepare for a future
surgical decision. Since the left carotid
artery is disease free, a left carotid-axillary
shunt is being proposed.
Siemens SOMATOM Perspective with
iTRIM technique allowed for fast cardiac
CTA acquisition with a higher temporal
resolution. Together with the fast volume
rendering technique (VRT) on syngo.via,
superb anatomic details could be yielded
to avoid further invasive studies.
2A 2B 2C
2 Curved multiplanar reformations
(cMPR) of the LIMA / LAD (Fig. 2A),
RCA (Fig. 2B) and Cx (Fig. 2C).
3 Four chamber (Fig. 3A) and short axis
(Fig. 3B) views depict left ventricular wall
thinning. Polar map of the left ventricular
wall motion (Fig. 3C).
DIAGNOSIS
A total occlusion of the left subclavian
artery was demonstrated, 1.8 cm from its
origin, proximal to the LIMA and ipsilateral
vertebral artery. Both of these supply a
scant axillary artery flow (Fig. 1). In spite
of this fact, the LIMA was well enhanced,
with a good anastomosis to the mid LAD
(Figs. 1 A, C and Fig. 2). The radial (LIMA
to OM) anastomosis was totally occluded,
only a metal clip path could be seen
(Fig. 1C). The Cx stent was patent, with
no signs of restenosis and the RCA was
normal (Figs. 1 and 2). The right brachio-cephalic
and left carotid arteries were
also normal (Fig. 1). The left ventricular
ejection fraction was 53%, with lateral
wall and apical akinesis (Fig. 3). The left
atrium was enlarged (Figs. 1B and 3A).
A complementary triplex Doppler scan
disclosed reversal of the left vertebral
artery flow. A diagnosis of coronary-vertebral
subclavian steal syndrome was
confirmed.
COMMENTS
Coronary and/or vertebral subclavian steal
syndrome is a well-known late complica-tion
of CABG, occurring in patients with
pre-existent mild to moderate subclavian
3A
3B
3C
Scanner SOMATOM Perspective
Scan area Middle neck to diaphragm Slice width 0.75 mm
Scan length 250 mm Temporal Resolution 195 ms
Scan direction Cranio-caudal , Feet first Reconstruction increment 0.5 mm
Scan time 12 s Reconstruction kernel B26s and B46s
Tube voltage 130 kV Heart rate 60 bpm
Tube current 289 mAs Contrast Iopromide 370
Dose modulation CARE Dose4D Volume 100 mL contrast
CTDI + 60 mL saline vol 32.09 mGy
DLP 974 mGy cm Flow rate 6 mL/s
Effective dose 13.6 mSv Start delay 5 s (Bolus
tracking,
triggered
at 70 HU)
Rotation time 0.48 s
Pitch 0.27

Clinical Results Oncology
Case 5
Minimally Invasive Treatment
of Hepatocellular Carcinoma using
a Siemens Miyabi System
By Taku Yasumoto, MD, PhD,* Katharina Otani, PhD**
** Toyonaka Municipal Hospital, Department of Radiology, Osaka, Japan
** Siemens Japan K.K., Healthcare H IM, Research & Collaborations Department, Tokyo, Japan
HISTORY
A 71-year-old male patient, with known
hepatitis C, came to the hospital for
an annual follow-up. A 4-phase liver CT
examination revealed a hepatocellular
carcinoma (HCC) with a diameter of
3 cm. The patient was scheduled for
transarterial chemoembolization (TACE)
to be followed by radiofrequency abla-tion
(RFA).
DIAGNOSIS AND
TREATMENT
All procedures were performed on a
Miyabi system that consists of a CT sliding
gantry (SOMATOM Definition AS) and
an angiography system (Artis zee ceiling-mounted
system). An arterial portography
(CTAP, Fig. 3C) was performed to con-firm
the HCC diagnosis before treatment
began. The contrast media was injected
through a catheter that was advanced
into the superior mesenteric artery (SMA).
The feeding arteries of the tumor came
off both the left (LHA, Fig. 1A) and the
right hepatic arteries (RHA, Fig. 2A). A
super-selective angiogram as well as an
embolization was performed at the level
of segment 4 in both arteries (Figs. 1B
and 2B). The follow-up confirming angio-gram
was performed through the com-mon
hepatic artery (CHA, Figs. 1C and
2C). The whole procedure was success-fully
completed within 120 minutes.
A non-contrast CT was performed to con-firm
the retention of the Lipiodol® in the
entire tumor (Fig. 4). The RFA procedure
was carried out one week later (Fig. 5),
successfully completed within 75 minutes.
The patient recovered without complica-tions.
COMMENTS
The Miyabi system is an integrated sys-tem
with an angiography unit and a CT
sliding gantry unit. Both units share a
common patient table, facilitating quick
transportation of the patient from one
unit to the other without risking dislodg-ment
of the catheter. Whereas the angi-ography
offers higher spatial resolution
necessary for detailed imaging of the
blood vessels, the CT offers better low
contrast resolution which is necessary for
imaging the extension of the tumor and
to confirm the retention of the Lipiodol
in the entire tumor after TACE. The CTAP
can obtain much better portal venous
enhancement using less contrast media
(total volume of 50 mL of 150 mg/mL of
iodine at 2.5 mL/s, patient dependent,
with a start delay of 25 s, injected through
a dual injector as a mixture of contrast
medium and saline solution) in compari-son
to a standard contrast CT scan (100
mL of 370 mg/mL of iodine at 4 mL/s).
The other challenge presented in this case
was caused by the special location of the
tumor – directly below the diaphragm and
above the gallbladder. A critical decision
had to be made regarding the access path
of the RFA procedure, necessary to avoid
potential complications occurring to
the lung or to the gallbladder. The views
displayed on the CT monitor and the
three dimensional imaging were helpful
to ensure a minimally invasive proce-dure.
Scanner SOMATOM Definition
AS Sliding Gantry
Scan area Abdomen
Scan mode CTAP
Scan length 206 mm
Scan time 4.5 s
Scan direction Cranio-caudal
Tube voltage 120 kV
CTDIvol 10.46 mGy
DLP 240 mGy cm
Effective dose 3.6 mSv
Rotation time 0.5 s
Reconstructed
1 mm
slice thickness
Increment 1 mm
Kernel I30f, SAFIRE
Contrast 150 mg/mL iodine
Volume 50 mL
Flow Rate 2.5 mL/s
Start delay 25 s

1A 1B 1C
1 A CHA angiogram (Fig. 1A) shows the feeding artery from the LHA. Super-selective angiogram and embolization were performed at the
level of segment 4 (Fig. 1B), and confirmed by a CHA angiogram (Fig. 1C, arrow).
2A 2B 2C
2 A RHA angiogram (Fig. 2A) showed another feeding artery from the RHA. Super-selective angiogram and embolization were performed
at the level of segment 4 (Fig. 2B). The embolization of both feeding arteries at the level of segment 4 (LHA, Fig. 2C, arrow and RHA, Fig. 2C,
dashed arrow) was confirmed by a CHA angiogram.
3A 3B 3C
3 CT images of non-contrast (Fig. 3A), arterial phase (Fig. 3B) and CTAP (Fig. 3C) showed the extension of the tumor.
The CTAP image showed soft tissue contrast much better.
4 Non-contrast CT image
confirmed the retention of the
Lipiodol in the entire tumor.
5 CT images discovered
the critical access path for
the RFA procedure.
4 5

Clinical Results Acute Care
Case 6
Aortic Dissection Follow-Up using Fast
Mode with SOMATOM Definition Edge
By Prof. Hans-Christoph R. Becker, MD
Department of Clinical Radiology, Grosshadern Clinic, Ludwig-Maximilians-University (LMU) Munich, Germany
1 2
3

Somatom sessions 31

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