3. Editorial
André Hartung,
Vice President
Marketing and Sales
Business Unit CT,
Siemens Healthcare
Dear Reader,
Imagine an emergency room only a With syngo.via, Siemens’ new work- sure. CT is steadily moving into the first
few short years ago: in the middle of place software, all time consuming line of emergency and stroke imaging
the night, a 55-year-old, unconscious pre- and post-processing steps are mainly because of the wide diagnostic
patient is wheeled in. All neurologic eliminated and all diagnostic infor- spectrum, speed and diagnostic pre-
observations indicate stroke. But mation – including information from cision. Providing all the advantages in
how severe? Is it an occlusion or a other modalities such as MR, MI and CT imaging aligned with measures to
hemorrhage and where is it located? PET – are available in almost real time. minimize the radiation exposure has
All crucial questions that demand fast Best possible image quality is pro- always been one of Siemens key goals.
answers! The physician on duty could vided with sophisticated “signal boost” Therefore we have recently introduced
request a head CT examination that technologies or image-optimizing new technical developments like IRIS to
could possibly involve two scans at 15 techniques resulting in definitive reduce radiation exposure to the lowest
to 30 mSv radiation dose. The physician grey and white tissue differentiation level in the CT industry. In functional
would then begin with extensive post- in neuro imaging. Excellent image imaging, e.g. for CT brain perfusion, the
processing – possibly using a PACS quality and fast processes are bene- dose can be reduced by up to 50 % with
Workstation before the CT results could ficial for both physicians and patients 4D Noise Reduction, without compro-
provide life the necessary clinical infor- as they are preconditions for highest mising image quality. And our Adaptive
mation required. Not a very pleasant diagnostic accuracy and, at the same Dose Shield completely eliminates pre-
alternative for the physicians or the time, low dose safety for the patient. and post-spiral radiation that cannot be
patient. utilized for image reconstruction. These
In all patient groups, including difficult are only a few examples from dozens of
Now imagine the same situation in a obese and pediatric patients, as well as additional large and small improvements
modern emergency room equipped with emergency room situations, safety is developed by our dedicated employees
Siemens cutting-edge technology such strongly linked to ALARA (As Low As to make the radiologist’s life easier and
as SOMATOM Definition Flash scanner – Reasonably Achievable) radiation ex- the patient’s healthcare better. You will
that scans faster than all other CT posure. In the past, especially in acute find many of these reported in this, and
scanners on the market – with latest clinical cases, lowering the radiation in future editions of SOMATOM Sessions.
neuro imaging software and syngo.via exposure when utilizing CT for diagnosis
software that “post-process on-the-fly” was not the primary focus. In stroke Good reading,
Within minutes, the physician would cases, “minutes equaled mind” and for Sincerely
have access to the head scan results with accident victims, minutes could mean
all post-processing completed at lowest life or death. Today, thanks to Siemens’
possible dose, including non-enhanced significant leadership in bringing low
CT for exclusion of hemorrhage, com- dose CT into clinical routine, image André Hartung
plete vascular status plus functional quality is not necessarily tied to a slower
information. diagnosis path and higher dose expo-
* syngo.via can be used as a standalone device or together with a variety of syngo.via based software options,
which are medical devices in their own rights..
SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 3
4. Content
6 22
Content The Best of Both Worlds International CT Image Contest
at Lowest Dose
Cover Story Cover Story
6 Exciting advances in computed 6 The Best of Both Worlds in Neuro
tomography (CT) examination Imaging
methods, including low dose
protocols, technical innovations
such as whole brain CT Perfusion, News
Dual Energy or Neuro Best Contrast
applications and groundbreaking 16 Affordable Performance in 16- and
radiological research have drama- 64-slice CT
tically changed the diagnostic 18 Best Balance Between Image Quality
approach for reading physicians and Reduced Dose
by enabling new indications and 19 IRIS Now Extended to SOMATOM
improved timing in the examination Definition AS 20 and SOMATOM
of patients with acute neurological Definition AS 40
deseases. SOMATOM Sessions 20 syngo CT 2010B Now Available:
discussed with five experienced New Software Version for the
physicians how CT can routinely be SOMATOM Definition AS Launched
used as the key diagnostic modality 21 Worldwide Dose Counter
in neuro imaging before the start 22 International CT Image Contest –
of appropriate treatment. Highest Image Quality at
Lowest Dose
4 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
5. Content
48 60
– Highest Image Quality Vasospasm After Subarachnoid Hemorrhage: Study Finds Atherosclerosis in 3,500
Volume Perfusion CT Neuro Year old Egyptian Mummies
Business Science
26 New Feature: Neuro Image Quality Oncology 58 CT in Pediatrics: Easier and Safer
Surpasses all Expectations 42 3D Guided RF Ablation and CT With the Flash
Perfusion – a New Combination for 60 Study Finds Atherosclerosis in
Monitoring of Treatment Response 3,500 Year old Egyptian Mummies
Clinical Results 44 SOMATOM Definition Flash: 61 Independent Validation of Perfusion
Routine Re-staging of Oesophageal Evaluation Software
Cardio-Vascular Carcinoma Utilizing IRIS Technology 62 Reduced Procedure Time and
28 Adenosine Myocardial Stress Radiation Dose in Interventional
Imaging Using SOMATOM Neurology CT Workflow
Definition Flash 46 SOMATOM Definition AS+: CT 64 Scientific Validation of the
30 SOMATOM Definition Flash: Perfusion With Extended Coverage SOMATOM Definition Flash
Visualization of the Adamkiewicz for Acute Ischemic Stroke
Artery by IV-CTA in Dual Power Mode 48 Vasospasm After Subarachnoid
32 Dynamic Myocardial Stress Perfusion Hemorrhage: Volume Perfusion CT Life
34 Pre-operative Exclusion of Coronary Neuro
Artery Stenosis With Less Than 66 Behind the Scenes: CT Scan Protocols
1 mSv Dose Acute Care 68 First syngo.via Hands-on Workshops
36 Utilizing Ultra Low Dose of 0.05 mSv 52 Dual Energy Scanning: Diagnosis at ECR 2010
for Premature Baby With Congenital of Ruptured Cocaine Capsule 68 Upcoming Events & Congresses
Heart Disease 54 Progressive Kidney Hematoma 69 Training Website for Knowledge
38 SOMATOM Definition Flash: Pediatric Post-interventional Biopsy Improvement
Patient Without Sedation and 56 SOMATOM Definition Dual Source 69 Free Trial Licenses for Neuro Imaging
Breath-Holding High Pitch vs. Routine Pitch Scanning 70 Frequently Asked Questions
40 SOMATOM Definition Flash: Dual in a Pediatric Lung Low Dose 70 Dual Energy CT: Learning From the
Energy Coronary CT Angiography for Examination Experts
Evaluation of Chest Pain After RCA 71 Clinical Workshops 2010
Revascularization 72 Siemens Healthcare – Customer
Magazines
73 Imprint
SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 5
7. Coverstory
The Best of Both Worlds in
Neuro Imaging
Exceptional Image Quality Meets Lowest Dose
in Neuroradiology
At Duke University Medical Center in Durham, North Carolina, USA and
elsewhere, Siemens equipment is helping radiologists combine exceptional
image quality in neuro imaging with innovative dose-reducing features
to maximize diagnostic confidence.
By Sameh Fahmy
Exciting advances in computed tomo- Perfusion imaging with Siemens’ unique
graphy (CT) examination methods, in- Adaptive 4D Spiral and the use of CT
cluding low dose protocols, technical Angiography from the aortic arch to the
innovations such as whole brain CT cranium are further expanding possibili-
Perfusion, Neuro BestContrast or Dual ties, increasing the diagnostic confidence
Energy applications and groundbreaking of neurologists and potentially enabling
radiological research have dramatically more appropriate treatment decisions.
changed the diagnostic approach for “By providing really good image quality,
reading physicians by enabling new indi- we are able to improve the efficiency of
cations and improved timing in the ex- care,” says David S. Enterline, MD, Asso-
amination of patients with acute neuro- ciate Professor of Radiology and Division
logical deseases. CT is routinely used as Chief of Neuroradiology at Duke Uni-
the key diagnostic modality in neuro versity Medical Center in Durham, North
imaging before the start of appropriate Carolina, USA. “And through dose sav-
treatment to detect or exclude intracra- ings, we can minimize the risk to pa-
nial hemorrhage, either traumatic or tients.” “Neuro BestContrast
non-traumatic, or to detect other causes allows radiologists
of acute onset of neurological disease, Neuro BestContrast
such as stroke, intracerebral tumors, or Although newer techniques are revolu- to better visualize
hematoma. Rapid evaluation is critical tionizing stroke assessment, the gold
the gray/white mat-
after trauma and with symptoms such standard for the initial diagnosis of
as weakness, headache, and dizziness, stroke and intracranial hemorrhage is ter interface to see
which is why CT is the modality of still non-contrast imaging of the brain.
choice in these scenarios. Siemens has always placed emphasis on
subtle edema and
Exceptional image quality is key to opti- providing the highest image quality on signs of stroke, and
mize diagnosis, and lower dose imaging all of their scanners for this challenging
helps to minimize the risk to the patient. application. Now, Siemens has taken
to better delineate
It is often said that the price of improved image quality to the next level. Last the cortical margin.”
image quality with CT is increased radia- year, Duke became the first hospital in
tion dose, but Siemens has shown that the United States to install Siemens’ David S. Enterline, MD, Division Chief
Neuroradiology, Duke University Medical
high quality, low dose imaging is possi- Neuro BestContrast, an application that
Center in Durham, North Carolina, USA
ble in even the most challenging neuro- dramatically increases gray/white matter
radiology applications. Whole brain CT differentiation in non-contrast head CT
SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 7
8. Coverstory
1A 1B 1C
1 Comparing conventional head CT imaging (Fig. 1A) with the new IRIS technology (Fig. 1B) shows decreased image noise. Combining IRIS
with Neuro BestContrast technology provides very high image quality with decreased noise by utilizing reduced radiation dose (Fig. 1C).
exams using the SOMATOM Definition experience of radiologists in Europe. In At the University Hospital in Göttingen,
line of scanners. Enterline says that Neuro a blinded study whose results were pre- Germany, Peter Schramm, MD, Deputy
BestContrast allows radiologists to sented at the 2009 scientific assembly Head of the Department of Neuro-
better visualize subtle edemas as well and annual meeting of the Radiological radiology, was able to compare images
as subtle signs of stroke, and to better Society of North America, neuroradiolo- acquired before and after the implemen-
delineate the cortical margin, adding, gists preferred Neuro BestContrast data tation of Neuro BestContrast in a patient
“My colleagues and I uniformly feel that sets in 97 % of cases.1 Other readers, with head trauma whose hospitalization
with better image quality, our comfort who viewed the Neuro BestContrast coincided with the hospital’s transition
level and our ability to make diagnoses data set side-by-side with the traditional to the new software. “We were able to
are significantly increased.” images, also rated image quality better perform an exact comparison intra-
The improved image quality experienced in more than 90 % of the cases and individually, and in that case it was really
by Enterline and his colleagues at Duke lesion conspicuity higher in more than impressive to see the improvement that
is also evidenced by clinical data and the 50 % of the cases. came along with Neuro BestContrast,”
“I think Neuro BestContrast and
IRIS work perfectly with each
other and have additive value
in reducing dose.”
Christoph Becker, MD, Professor of Radiology and Section Chief of CT and PET/CT
at Munich University Hospital, Munich, Germany
8 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
9. Coverstory
Schramm says. “The delineation of the 2
edema and the margins of the edema Iterative Reconstruction in Image Space (IRIS)
were definitely better visualized using
Neuro BestContrast, and the same ap-
plies to the changes that occur in acute
stroke.”
Neuro BestContrast improves non-con-
trast head images by taking advantage
Fast Image Data Space
of the fact that clinically important infor-
mation from CT scans is contained in me-
dium and low frequencies, while high fre-
quencies are dominated by image noise.
The software processes high-frequency Image data Image
data differently than the low-to-medium recon correction
frequency data, resulting in improved
tissue contrast without the amplification
of image noise.
Compare
Enterline says the use of Neuro BestCon-
trast has the potential to reduce radiation
dose as well. His preliminary data has
documented a 15 to 20 % improvement Master
in gray/white matter differentiation that
Slow Raw Data Space
recon
can allow for image acquisition at a lower
dose than is currently used. “Our institu-
tion has traditionally fought for lower
dose,” he says, “and I think this will now
allow us to further reduce our dose.”
IRIS
Neuro BestContrast can be combined
with another new Siemens technology
known as Iterative Reconstruction in Strong artifact and dose reduction
Image Space (IRIS) to reduce dose and Well-established image impression
improve image quality even further. Fast reconstruction in image space
“I think they work perfectly with each
other and have additive value,” says
2 IRIS takes all of the data, which contains fine details as well as significant amounts
Christoph Becker, MD, Professor of Radi-
of noise, combines it in a master image and cleans it up in the fast-processing image space
ology and Section Chief of Computed rather than in the slow-processing raw data area. The result is that that high spatial resolu-
Tomography and PET/CT at Ludwig-Maxi- tion is preserved and noise is reduced – without disrupting workflow.
milians-University in Munich, Germany.
Iterative reconstruction uses a correction
loop to improve image quality in several
steps, or iterations. The idea was first bines it in a master image and cleans it of dense structures such as bone and
introduced in the 1970s, but the com- up in the fast-processing image space calcium, making it easier to visualize
puting power and time required for the rather than in the slow-processing raw or rule out subarachnoid hemorrhage.
reconstruction made it impractical for data area. The result is that high spatial Preliminary data from Becker show that
use in clinical settings. An alternative resolution is preserved and noise is re- IRIS reduces dose by 25 % in head CT
known as statistical image reconstruction duced – without disrupting workflow. exams yet achieves the same level of
reduced the time associated with itera- Becker says the combination of Neuro noise as filtered back projection, the tra-
tive reconstruction but produced a tex- BestContrast and IRIS, which is available ditional method for image reconstruc-
ture that radiologists found unaccept- on the SOMATOM Definition line of tion. Becker notes that clinicians can
able. With IRIS, Siemens took a different scanners, allows him and his colleagues also choose to use the same dose as fil-
approach. The algorithm takes all of the to better differentiate the basal ganglia tered back projection yet deliver signifi-
data, which contains fine details as well and to see subtle signs of stroke. He cantly better image quality using IRIS.
as significant amounts of noise, com- adds that IRIS also reduces the blooming In the United States, Ridgeview Medical
SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 9
10. Coverstory
Center in Waconia, Minnesota, USA in- CT while the patient is still in the scanner,
stalled IRIS on its SOMATOM Definition allows improved detection of acute
AS 40-slice CT and its Definition AS+ stroke, which has been substantiated in
128-slice scanner early in 2010. Chief several studies,” says Ke Lin, MD, Assis-
of Radiology, David Gross, MD, directly tant Professor of Radiology at New York
compared images produced using IRIS University Langone Medical Center in
with traditional filtered back projection New York City, USA. In a study of 100
images and then enthusiastically adopt- patients presenting to the emergency
ed IRIS. “After two or three days, we department within three hours of stroke
decided that there’s no sense in even onset, Lin and his colleagues found that
comparing anymore,” Gross says. “With CT Perfusion provided significantly im-
the improvement in radiation dose, the proved sensitivity and accuracy in acute
image quality is not changed, so we stroke detection over non-contrast CT.
just switched right over to it.” Specifically, the researchers found that
Neuro BestContrast and IRIS build upon “With the improve- CT Perfusion revealed 64.6% of acute
other Siemens innovations in neuro infarctions compared to 26.2 % for non-
imaging that maximize diagnostic confi-
ment in radiation contrast CT. CT Perfusion also had an ac-
dence. The “Posterior Fossa Optimization” dose using IRIS, curacy of 76 % compared to an accuracy
algorithm, which was introduced in 2001 of 52 % for non-contrast CT.2
and is implemented in all SOMATOM
the image quality Lin and his colleagues obtained CT Per-
Sensation and Definition scanners, is not changed, so fusion data from a z-direction coverage
significantly reduces streaks and dark of 24 mm centered at the mid-basal
bands, known as Hounsfield Bars, to we just switched ganglia which maximizes the visualiza-
allow for better resolution with less right over to it.” tion of the middle cerebral artery terri-
artifact. Siemens’ z-Sharp Technology tory. Still, the researchers noted that
provides routine isotropic resolution of David Gross, MD, Chief of Radiology they missed ten infarcts that were out-
0.33 mm, one of the industry’s highest, Ridgeview Medical Center, Waconia, side of this volume of coverage. The ad-
enabling the visualization of small Minnesota, USA vent of whole brain CT Perfusion using
anatomical details such as fine vascular Siemens’ unique Adaptive 4D Spiral, how-
structures. For ultra-high-resolution bone ever, further increases the value of CT
imaging for inner ear structures, Siemens’ Perfusion by expanding the scan range.
z-UHR Technology provides 0.24 isotro- The revolutionary scan mode, which is
pic resolution. hemorrhage and ischemic stroke mimics, available on the SOMATOM Definition
the use of perfusion CT imaging is in- line of scanners, overcomes the limita-
Perfusion CT and CTA creasingly being adopted. “Dynamic CT tions of a static detector design by ap-
While non-contrast head CT exams are Perfusion imaging, which can be acquired plying a continuously repeated bi-direc-
still important for excluding intracranial immediately after the non-contrast head tional table movement that smoothly
“Dynamic CT Perfusion imaging, which can
be acquired immediately after the non-
contrast head CT while the patient is still in
the scanner, allows improved detection of
acute stroke, which has been substantiated
in several studies.”2, 4
Ke Lin, MD, Assistant Professor of Radiology, Department of Radiology, New York University
Langone Medical Center, New York, USA
10 SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine
11. Coverstory
3
3 Perfusion CT
imaging is in-
creasingly be-
ing adopted in
daily routine.
This function
overcomes the
limitations of a
static detector
design, which
provides full
brain coverage,
and the poten-
tial for improve-
ment in diag-
nostic accuracy
for acute stroke.
moves the patient in and out of the a smooth, fast, and user-friendly work- graphy adds approximately 10 minutes
gantry over the desired scan range. Lin flow. A number of steps are automated, to the acute stroke workflow. “That’s not
has recently switched to a SOMATOM including motion correction, bone seg- a lot of time considering that the addi-
Definition AS+ Scanner with all the mentation, arterial input function deter- tional information provided by the CT
advantages of full brain coverage. “With mination, and vascular pixel elimination. Perfusion and the CT Angiography may
the increased coverage, we now expect The software allows for simultaneous have very important implications for the
further improvement in acute stroke visualization of functional parametric patient’s treatment and management,”
detection accuracy, as well as the full maps of cerebral blood flow, cerebral Lin says.
delineation of the ischemic penumbra blood volume, time to peak, mean tran-
and the infarct core,” Lin says. sit time and other clinically important Reducing Dose in CT Perfusion
The stroke imaging workflow at NYU information. With the click of a button, Lin recognizes that, while the use of CT
Langone Medical Center also includes clinicians can toggle between axial, Perfusion is moving from academic
a CT Angiography immediately following sagittal and coronal reformations. medical centers to community hospitals,
the CT Perfusion exam to evaluate clot Lin and his colleagues acquire the CT some barriers to its widespread adoption
location, clot burden, and collateral re- Perfusion data for the whole brain in remain. Chief among them is a concern
cruitment. Lin adds that the information just 45 seconds. Next, CT Angiography about the radiation dose associated with
is also used for planning interventional data from the aortic arch through the the acquisition of CT Perfusion and CT
procedures such as mechanical throm- whole brain, a scan range of typically Angiography data. The use of Siemens
bectomy. more than 30 cm, is acquired in a couple 4D Noise Reduction, however, can re-
Lin says the fast image acquisition of of seconds to deliver valuable infor- duce the radiation noise of dynamic CT
the SOMATOM Definition AS+ 128-slice mation about the feeding vessels that Perfusion. The reconstruction technique
scanner, combined with the rapid post- are not covered by the initial perfusion treats the static anatomical information
processing of the Siemens syngo Volume scan. Post-processing takes an additional differently from the dynamically chang-
Perfusion CT Neuro software, allows three to five minutes. In total, when ing perfusion information that results
reading physicians to arrive quickly at an time for interpretation is accounted for, from the in and outflow of the contrast
appropriate treatment decision through the use of CT Perfusion and CT Angio- agent. By sampling multiple passes over
SOMATOM Sessions · May 2010 · www.siemens.com/healthcare-magazine 11
