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SOMATOMSessions

No.15/December 2004

www.siemens.com/medical

RSNA-Edition

Nov. 28thDec. 3rd, 2004

Highlights

COVER STORY

Siemens ComputedTomography is MultislicePage 4

SOMATOM Spirit: Join theWorld of Multislice CTPage 9

NEWSPolyp Enhanced ViewingReceives 510(k) ClearancePage 14

CLINICAL OUTCOMESCase Studies with theSOMATOM Sensation 64Page 19 and 22

syngo Colonography CTwith PEV Detection ofSigmoid Carcinoma withTwo Synchronous PolypsPage 27

SCIENCEBone SubtractionCT-Angiography for Imagingof Intracranial ArteriesPage 31

The Secrets of ImageReconstructionPage 39

CUSTOMER CARELife Evolve andExpand: Every thingsMuch FasterPage 43


2/50

Picture

SOMATOM

Sessions

No.15/December 2004


RSNA-Edition

Nov. 28thDec. 3rd, 2004

Highlights

COVER STORYSiemens ComputedTomography is MultislicePage 4

SOMATOM Spirit: Join theWorld of Multislice CT

Page 9

NEWSPolyp Enhanced ViewingReceives 510(k) ClearancePage 14

CLINICAL OUTCOMESCase Studies with theSOMATOM Sensation 64Page 19 and 22

syngo Colonography CT

with PEV Detection ofSigmoid Carcinoma withTwo Synchronous PolypsPage 27

SCIENCEBone SubtractionCT-Angiography for Imagingof Intracranial ArteriesPage 31

The Secrets of ImageReconstruction

Page 39

CUSTOMER CARELife Evolve andExpand: EverythingsMuch FasterPage 43


3/50

2004 has been a very special year for the Siemens Computed Tomography (CT) family. Exactly

30 years ago, in 1974, our CT Division was born with the introduction of our first system, called

SIRETOM. Together with our clinical partners, we proudly look back on 30 years at the fore-

front of technical innovation to improve patient care. The latest result of this collaboration is

the SOMATOM Sensation 64, which after an extensive clinical test period has been avail-

able to the general market since August and delivers breath-taking clinical outcomes in Radio-

logy and Cardiology. By the end of 2004, it will be installed in nearly 150 hospitals all over

the world.

Since its introduction in 1998, multislice CT has doubled performance almost every year.

Driven by these extremely rapid innovation cycles, multislice CT and the related advancedapplications will soon become standard in all clinical segments. Siemens CT takes the lead in

this trend with exciting innovations that you will read about in our cover story: The SOMATOM

Spirit, our brand new multislice CT product with its pioneering design, provides excellent

clinical performance and attractive life-cycle cost to make multislice CT affordable for every

clinical practice. At the same time, further innovations based on the proven SOMATOM Sensa-

tion and SOMATOM Emotion platforms provide access to latest clinical applications, such as

Cardiac CT, Perfusion CT and early diagnosis of lung and colon cancer, to a broad user community.

Enjoy reading about the history, the present and the future of Siemens CT.

Yours sincerely,

Bernd Ohnesorge, PhD,

Vice President CT Marketing and Sales

Dear Reader,

Bernd Ohnesorge, PhD, Vice President CT Marketing and Sales

2 SOMATOM Sessions 15

EDITORS LETTER


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SOMATOM Sessions 15 3

CONTENT

COVER STORY4 Siemens Computed Tomography is Multislice

9 Join the World of Multislice CT

12 30 Years of Innovation Leadership

NEWS14 A CT System for Mummies

14 Polyp Enhanced Viewing Receives 510(k) Clearance

15 Mayo Clinic Rochester and Siemens Launch Joint CT Clinical Innovation Center

15 Advanced Bone Removal

BUSINESS16 Reimbursement in the U.S.

17 Good News for the Bottom-line

17 A New Dimension in System Support

18 LEONARDO Intelligent Investment

CLINICAL OUTCOMES19 SOMATOM Sensation 64: Patency of Left Main Coronary Stent

22 SOMATOM Sensation 64: Aneurysm of the Anterior Communicating Artery

24 SOMATOM Sensation Open: Arch of Riolan and Pancreatic Cancer

27 SOMATOM Sensation 16: syngo Colonography CT with PEV Detection of SigmoidCarcinoma with Two Synchronous Polyps

29 SOMATOM Emotion 6: Adenocarcinoma of the Sphenoid Sinus

SCIENCE31 Bone Subtraction CT-Angiography for Imaging of Intracranial Arteries

34 CT Urography in Clinical Routine

37 Increased Reader Effectiveness for Small Pulmonary Nodules

39 The Secrets of Image Reconstruction

42 Volume CT with Flat-panel Detectors

CUSTOMER CARE43 Everythings Much Faster44 Hands-on CT-Colonography

44 Free Trial Clinical Software

45 Training on CD

45 Service: Frequently Asked Questions

46 Service: CT Online

46 Service: Upcoming Events

47 Imprint


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COVER STORY

No other area of medical imaging has witnessed a perform-

ance explosion comparable to the one which has occurred in

computed tomography (CT). Just a few years ago, almost all

CT systems had only a single-slice detector. Scan times of 30

seconds were state-of-the-art for a head CT scan. Cardiac CT

was possible, however, limited to the display of calcifications

in the coronary vessels. The detail resolution was in the one

millimeter range, and more than one millimeter in the

z-direction.


The explosion in performance capability noted above was

sparked at the 1998 convention of the Radiological Society of

North America (RSNA) in Chicago, where all major CT manu-

facturers presented systems with four detector slices. Scan

times suddenly decreased to just a fraction of what they had

been; improved volume coverage and reduced gantry rota-

tion time enabled new applications such as CT examinations

of the heart and coronary vessels. As multislice CT is coming

of age, Siemens Medical Solutions now offers multislice sys-

With this year s RSNA, Siemens Medical Solutions offers multislice computedtomography systems for all markets, clinical needs and budgets.

Siemens Computed

Tomography is Multislice

Multislice CT for the

first time enabled

cardiac imaging with

thin slices.

Courtesy Deutsches

Herzzentrum Munich


6/50

tion Cardiac 64 with their rotation speed of 0.33 seconds. At

the same time, Siemens' development team has improved

dose efficiency and minimized radiation exposure. And it

was not just the technology that leaped forward: CT hasgrown from a purely diagnostic method for already sympto-

matic diseases to a patient-friendly and reliable tool for the

early visualization of, for example, lung and colorectal can-

cer, or coronary heart disease.

Completing the High-End PortfolioThis development culminates in the SOMATOM Sensation 64

and SOMATOM Sensation Cardiac 64 and firmly establishes a

new benchmark for diagnostic excellence. Their Siemens

proprietary z-Sharp Technology enables the industrys best

isotropic resolution of below 0.4 millimeter voxel size in clin-

ical routine. The STRATON X-ray tube utilizes an electron

beam that is accurately and rapidly deflected, creating two

alternating and overlapping X-ray projections reaching each

detector element. This doubles the scan information without

a corresponding increase in dose, resulting in substantially

enhanced spatial resolution and image quality. Additionally,

the unique STRATON X-ray tubes direct cooling eliminates

the need for heat storage capacity and enables the industrys

COVER STORY


tems for all markets, medical purposes and budgets from

the new economical dual-slice scanner SOMATOM Spirit to

the latest flagship model SOMATOM Sensation 64.

Clinical AdvantagesCompared to single-slice systems, multislice CT scanners re-

present a technological milestone with respect to increased

volume coverage, shorter examination times, improved axial

image resolution through thinner detector slices, and better

utilization of the X-ray tube output. Examination protocols

can thus be optimized for maximal volume coverage, short-

est scan times, highest spatial resolution or fastest temporal

resolution. Clinically, this leads to a variety of improved and

new applications.

For instance, with a rotation time of 0.5 seconds and simul-

taneous scanning of four slices, the SOMATOM Volume

Zoom Siemens' first multislice CT scanner already

attained an 800 percent increase in performance compared

to a conventional one-second, single-slice spiral scanner.

These performance improvements created the groundwork

to optimize the most clinically important examination

parameters.

For example, the time requirement for a standard examina-

tion protocol was reduced by a factor of eight compared to a

single-slice CT system. This is an advantage in pediatrics, or

when examining uncooperative or trauma patients, or

patients who have difficulty holding their breath. Alterna-tively, the examination volume could be increased up to 800

percent within a given examination time, beneficial for

example, for peripheral runoffs. One example for substan-

tially increased volume coverage per time unit is peripheral

angiography of the legs.

However, the improvement of the in-plane resolution through

reduction of the collimated slice thickness proved to be the

most important advantage. This made it possible to perform

routine examinations of the thorax and the abdomen with

slice thicknesses of only 1.25 millimeters, instead of the five

to eight millimeters which had been common for single-slice

CT scanners. Resolution already came close to the ideal situ-ation of isotropic voxels. As a result, it became possible to

obtain high-quality data for three-dimensional image post-

processing to produce multi-planar reformattings (MPRs)

and both maximum intensity projections (MIPs) and minimum

intensity projections (MinIPs) in arbitrary planes. Thus, prac-

tically all diagnostic needs can be satisfied with just one scan.

Within the past six years, multislice CT technology made

another giant leap from the SOMATOM Volume Zoom with

four slices and 0.5 seconds gantry rotation time to the 64

slices of the SOMATOM Sensation 64 and SOMATOM Sensa-

The SOMATOM

Volume Zoom in

1998 was Siemensfirst multislice

CT system.

The SOMATOM

Sensation 40completes the

high-end

CT portfolio.


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COVER STORY

Interview

The University Hospital of Munich-Grosshadern was among the first toutilize the SOMATOM Sensation 64 in daily clinical routine. SOMATOMSessions talked to Christoph R. Becker, MD, Department of ClinicalRadiology, about the implications of the new system for cardiology.

A Diagnostic Cardiac Scan can now be

Created even at Higher Heart Rates.

What are your first experi-

ences with the SOMATOM

Sensation 64?

The amazing fact for me was

that the SOMATOM Sensation 64

worked as a reliable scanner

from the first day on. It has

replaced one of our two 16-slice

CT scanners. Installation took

only one weekend. The syngo

user interface of the SOMATOM

Sensation 64 is so similar to theone of the Sensation 16 that our

technician at first did not realize

she was sitting in front of a brand new machine. After

optimizing the scan protocols, we now use the scanner

for our daily routine as well as research projects and

investigate about 40 patients in a daily eight-hour shift.

The fastest scanner in the world how does the

increased temporal resolution and volume coverage

of 0.33 seconds per rotation effect cardiac imaging?

The stability of imaging the heart and in particular the

coronary arteries with the SOMATOM Sensation 64 is

improved by the shorter scan time that now takes only 9seconds. This means that less contrast media is necessary

for a CTA investigation as well as fewer heart beats are

acquired during the scan. The temporal resolution has

now reached the point that a diagnostic cardiac scan can

be created at any heart rate. Even in bradycardic arrhyth-

mic situations, a fully diagnostic scan can be achieved.

What fields in cardiac imaging are improved by the

superior spatial resolution of below 0.4 millimeter

voxel size?

Triple Ruleout: With theSOMATOM Sensation 64,physicians can simulta-

neously assess the pul-monary arteries, the

aorta and the coronaryarteries all in one, in abreath-hold as short as

15 seconds.

Courtesy University Hospital

Munich-Grosshadern

Christoph R. Becker,

MD, Department of

Clinical Radiology,

University Hospital

Munich-Grosshadern,Germany

Our initial impression is that the blooming artifact of

stents and calcifications is significantly reduced by the

higher spatial resolution, thus allowing us to assess the

lumen of stents and to rule out in-stent stenoses.

Patients with chronic coronary artery disease tend to

have a significant amount of coronary calcifications. Here

the first time we may be able to assess the patency of

coronary arteries with extensive calcifications in their wall.

What new clinical applications are appearing in car-

diac CT imaging with the SOMATOM Sensation 64?

With the SOMATOM Sensation 16, cardiac CT was already

established for ruling out coronary artery disease inambiguous clinical cases and in the suspicion of coronary

anomalies. With the SOMATOM Sensation 64, CT may fur-

ther establish its role in the fast diagnosis of acute coro-

nary syndrome and acute chest pain. With the new ECG

gated chest CTA protocol, it fulfills the requirements of an

easy to use, simple, robust and readily available tool to

simultaneously assess the pulmonary arteries, the aorta

and the coronary arteries within 15 seconds!

We are currently studying the ability of the SOMATOM

Sensation 64 to assess the patency of stents and to fol-

low the course of patients after coronary intervention.


8/50

fastest CT rotation time of 0.33 seconds. SOMATOM Sensa-

tion 64s unmatched clinical performance finally eliminates

the necessity to compromise between image resolution and

scan speed.With the introduction of the new SOMATOM Sensation 40,

Siemens continues the tradition of the SOMATOM Sensation

product line to continually integrate cutting-edge imaging

applications into daily clinical practice. Like the SOMATOM

Sensation 64, it also benefits from the revolutionary z-Sharp

Technology and the unique STRATON X-ray tube, enabling

acquisition of 40 slices with unprecedented image quality

and below 0.4 millimeter isotropic detail. Together with its

gantry rotation speed of 0.37 seconds, the SOMATOM Sensa-

tion 40 opens the world of unprecedented diagnostic detail

to hospitals, imaging centers and private practices. As with

all other SOMATOM Sensation scanners, Siemens Speed4D

Technology also supports workflow and dose manage-

ment on the SOMATOM Sensation 40.

Both SOMATOM Sensation 40 and SOMATOM Sensation 64

that even further expands the scope of applications pro-vide breathtaking image sharpness and clarity. With their

faster rotation and increased scan speeds, the SOMATOM

Sensation 64 and SOMATOM Sensation Cardiac 64 push the

boundaries of temporal resolution to a new level, enabling

cardiac examinations with previously unachievable image

quality. The SOMATOM Sensation upgrade philosophy allows

that every SOMATOM Sensation scanner can easily develop

with the clinical necessities of users. In fact, the SOMATOM

Sensation 40 can easily be upgraded to a 64-slice system if

desired.

The SOMATOM Sensation 16, with the industrys largest

installed base of 16-slice CT scanners, represents a time-


COVER STORY

The large

gantry bore of

the SOMATOM

Sensation

Open is ideal

for RTP, where

patient

positioning is

crucial.

The SOMATOM

Sensation Open

allows easy

patient

positioning

which is crucial,

for example,

in emergency

situations.

With the SOMATOM Sensation Open, Siemens introduces alarge bore CT system that delivers a new level of diagnostic

support for radiation therapy planning, as well as CT-based

trauma examinations, interventional procedures and imag-

ing of bariatric patients with excellent performance in rou-

tine and advanced CT examinations. It's spacious 82 cen-

timeter gantry bore allows increased accessability and easy

positioning for all patients. Its 82 centimeter field of view

ensures visualization of the entire anatomy, improving both,

therapy planning and diagnostic examinations. The 20-slice

system provides excellent coverage and resolution with 1.2

millimeter collimation. Rotation speeds of one and 0.5 sec-

onds are available.The first installations of the SOMATOM Sensation Open were

successfully completed in early summer 2004. Customers

are very pleased with its performance and its enhanced

specifications. The SOMATOM Sensation Open gives us the

flexibility of a large bore CT while having a solution for virtu-

ally all advanced CT examinations at the same time, says

Professor Jrgen Debus, MD, PhD, Director of Radiation

Oncology, University of Heidelberg, Germany, where one of

the first systems was installed.

S O M A TO M S e n s a t i o n O p e n

Flexibility andHigh Performance


9/50


COVER STORY

The SOMATOM Emotion 6 ideally combines a comprehensiveportfolio of clinical applications with easy siting require-

ments and low life-cycle costs. It demonstrates that

advanced clinical applications for example syngo Lung-

Care CT and syngo Colonography CT and a cost conscious

budget do not have to be mutually exclusive.

Rapid 3D-based visualization of pulmonary nodules with

syngo LungCARE CT, semi-automated vessel quantification

with syngo Vessel View, and advanced diagnostic perspec-

tives like syngo Colonography CT are just some of the fea-

tures that can be added to the customer's clinical routine.

Patients appreciate the slim system design with its 70 cen-

timeter gantry opening and also the numerous dose reduc-

S O M AT O M E m o t io n 6

A Strong System Ready for the Future

tion features for example CARE Dose4D available for allSOMATOM Emotion scanners. Reliably performing these

routine and advanced applications today, the SOMATOM

Emotion 6 can easily be expanded with further system

enhancements and upgrades, keeping pace with new devel-

opments in the CT world. With the great success of the

SOMATOM Emotion scanners and their evolution through-

out their five-year history, Siemens remains committed to

this important member of its SOMATOM product family.

Development of the SOMATOM Emotion product line contin-

ues, even beyond six slices, ensuring that it will continue to

evolve and meet the future clinical requirements of multi-

slice CT.

tested, reliable CT system that efficiently combines high-end

performance with investment protection. The fact that the

SOMATOM Sensation 16 itself was introduced just three

years ago, illustrates the momentum innovations havegained since CT became multislice, explains Bernd Montag,

PhD, President of Siemens Computed Tomography Division.

And the fact that it was again Siemens that introduced the

first 64-slice system underlines our mission as innovation

leaders.

The Best of Both WorldsSmaller hospitals and practices with a lot of routine CT exam-

inations are adequately served with the scanners of the

SOMATOM Emotion series. With 3,000 systems installed,

they are among the most popular CT systems in the world.

And with good reasons: They combine the best of both

worlds. Their cost-benefit ratio and their comprehensive

portfolio of clinical applications make them the ideal choice

for busy hospitals and radiology practices that need a reli-

able CT scanner for routine and advanced examinations.

The SOMATOM Emotion was first introduced in 1999 as a sin-

gle-slice, spiral CT scanner. Since then, Siemens has continu-ally improved its performance. A dual-slice version was

added in 2000 providing faster scanning capabilities, better

anatomical coverage, and the possibility to routinely scan

with thin slices. In 2003, Siemens added the SOMATOM

Emotion 6.

The latest member of the SOMATOM Family is the dual-slice

SOMATOM Spirit. It is the right choice for small hospitals or

practices that want to start improving their patient care by

adding CT examinations to their diagnostic portfolio (see

also pages 911). With its extensive portfolio of forward-

looking, patient and user friendly CT scanners, the Siemens

SOMATOM family offers the right multislice CT system for

any size hospital or practice, any diagnostic need and any

reasonable budget.

More than 3,000

SOMATOM Emotion

scanners have been

installed during the

past five years.The

SOMATOM Emotion 6 is

the right CT system for

routine and advanced

clinical applications.Courtesy of H.-Hart Zieken-

huis, Lier, Belgium.


10/50


COVER STORY

Multislice CT has become a standard in clinical routine

today. We feel that every patient and physician should

profit from the advantages a multislice CT system offers,

says Bernd Ohnesorge, PhD, Vice President Marketing and

Sales, Siemens Medical Solutions, Computed Tomography

Division. With its extremely attractive price, the SOMATOM

Spirit is the multislice computed tomography (CT) scanner

for both small and large facilities. It is not only the ideal

system to replace outdated scanners or to add an additional

CT to an overworked facility, it is also the multislice scanner

of choice for an affordable, easy entry into the fascinating

world of CT. With its specifications, the SOMATOM Spirit is

the perfect multislice CT for day-to-day examinations. It is

also ideally suited for small, outlying clinics utilizing teleradi-

S O MATO M S pi r i t

Join the World of Multislice CTThe newest member of Siemens Computed Tomography family is thetrend-setting, sub-second, dual-slice SOMATOM Spirit, a cost-effective systemfor day-to-day clinical routine.

The SOMATOM Spirit is Siemens new dual-slice system for the ambitious entry into the fascinating world of multislice CT.


11/50


COVER STORY

A comprehensive set of applications is available for the SOMATOM Spirit.


12/50


COVER STORY

The new look and feel of the SOMATOM Spirit inspires.

ology, as well as medical fields other than radiology, such as

ENT and urology practices, dental surgeons and general prac-

titioners. By adding CT to their medical services, almost any

practice or facility can improve the quality of patient care andincrease patient volume.

Cost-EffectivenessThe SOMATOM Spirit acquires two slices per rotation but

has the price tag of a single-slice scanner, thus making multi-

slice CT universally affordable. With the introduction of the

SOMATOM Spirit, a new era of affordable, efficient multislice

CT begins.

It is not just the purchase price that makes the SOMATOM

Spirit economical: Low space requirements only 17 square

meter (183 square feet) and fast installation time, efficient

preventive maintenance, high reliability and uptime ensures

a good return on investment. The break-even point can be

reached in a short period of time with only a few patients per

day. However, depending on the type of examinations, up to

50* patients can be examined in an eight-hour workday,

making it one of the most cost effective, multislice CTs on the

market today.

High PerformanceWith the SOMATOM Spirits detector collimation of one mil-

limeter and its gantry rotation time of one second, physi-

cians do not have to compromise when it comes to clinicalperformance. For even better results, 0.8 seconds gantry

rotation time is available as an option. X-ray efficiency is

assured by the optimized system geometry of the

SOMATOM Spirit, the highly efficient UFC (UltraFast

Ceramic) detector material, and Siemens dose reduction

software, CARE Dose and CARE Bolus. All these features lead

to excellent image quality and, at the same time, significant-

ly reduce dose.

Clinical ApplicationsAdditionally, the SOMATOM Spirit offers a comprehensive

spectrum of routine CT applications. The standard applica-tion portfolio includes real-time multi-planar reformatting

(MPR), syngo 3D SSD (shaded surface display), Volume Mea-

surements, and CT-Angiography. The optional syngo VRT

(volume rendering technique) software facilitates 3D display.

To support examination and diagnosis of lumen, syngo Fly

Through is available as an option. Further specialized,

optional applications like syngo Dental CT and syngo Osteo

CT are also on hand. These features make the SOMATOM

Spirit a good investment also for dental surgeons, orthopedic

physicians and general practitioners.

The CT specific elements of syngo, Siemens intuitive multi-

modality user interface, were simplified especially for the

SOMATOM Spirit to further increase user comfort. syngo can

be learned and applied without extensive training. The user

is guided through examinations, and workflow is automated

wherever possible. The intuitive handling and the automa-

tion gives the user confidence from the very beginning.

Trend-setting DesignWith a gantry aperture of 70 centimeters (27.6 inches) and

a patient table load of up to 200 kg (450 lbs), the patient

spectrum of the SOMATOM Spirit is virtually unlimited. The

flared, wide gantry opening and the short bore allow for

easy patient positioning and access, making the SOMATOM

Spirit a comfortable CT for both patient and medical staff.

The appealing, esthetic design also helps to alleviate patient

inhibitions.

The SOMATOM Spirit is Siemens latest CT and incorporates

over 30 years of CT know-how and expertise of the worlds

leader in multislice CT. It combines new innovations withsuccessful and proven functions, technologies, and compo-

nents of other SOMATOM products.

Who would have thought, just a year ago, that a sub-second,

multislice CT would be affordable as an entry-level system?

asks Ohnesorge. With the SOMATOM Spirit, we offer our

customers just that to enhance their clinical portfolio for

providing better patient care.

The SOMATOM Spirit will be available worldwide in Spring

2005.

* Results may vary. Data on file.


13/50


COVER STORY

Computed tomography has come a long way from the SIRE-

TOM and its first computed tomograms of the brain to the

three-dimensional display of the interior anatomy with a res-

olution of below 0.4 millimeters offered by todays

SOMATOM Sensation 64. Today, a virtual flight through the

human colon can be performed just as easily as a selective

examination of the coronary arteries. Innovative develop-

ments from Siemens constantly made significant contribu-

tions toward enhanced diagnostic possibilities, patient-

friendliness and cost-effectiveness. A recently introduced

patient and user friendly design study of a future CT system

shows that Siemens will continue to pursue these goals in

the future.

Ever since Wilhelm Conrad Rntgen discovered X-rays back

in 1895, radiologists and researchers have attempted to

image anatomical structures in three dimensions as well. The

innovating work performed by British engineer Godfrey

Hounsfield and US physicist A.M. Cormack led to a combina-

tion of computer and X-ray technology which culminated in

the birth of the CT in 1972. Hounsfields success as the gen-

erally recognized father of CT was all the more remarkable

due to the fact that the British company for which he

worked, EMI, had previously produced only recods and elec-

tronic components. In that very same year, Siemens estab-

lished its own CT development within its Basic Research

Department at Erlangen, Germany. Just two years later, thecompany introduced the first CT scanner, the SIRETOM. It

enabled physicians to distinguish soft tissue in the brain,

thus detecting tumors, hematomas and strokes by their size

and position. In addition, it also made possible differentia-

tion between brain ventricles and tissue.

At the end of 1977, the worlds first whole body CT scanner,

the SOMATOM 1, set yet another milestone. During the

course of CT development, the scanned slices of the body

constantly became thinner, thus enabling increasingly

detailed display of the human anatomy. In 1985, surfaces, for

example of bones, could be displayed three-dimensionally

for the first time. In 1987, the slip ring technology of theSOMATOM Plus Classic enabled, for the first time, continuous

rotation of the gantry about the patient. Based on this

progress, Siemens began to develop spiral CT during the

same year. With this technique, the table bearing the patient

moves slowly through the rotating gantry.

1989 the first spiral scanner hit the market. Its continuous

measurement permitted volume scanning of 24 centimeters

in only 24 seconds, making it possible, for example, to scan

the patients lungs during a single breath-hold. In 1991 a

mouse-controlled Windows interface also made the CT sys-

The SIRETOM was the first CT system from

a manufacturer of medical equipment.

C T H I S T O RY

30 Years of InnovationLeadershipThirty years ago, in May 1974, Siemens became the first medical equipmentmanufacturer to put a computed tomograph (CT) on the market: the SIRETOM.


14/50


COVER STORY

tems easier and more convenient to operate. During the fol-

lowing year, the CT production department moved from

Erlangen to a new factory located about 20 kilometers to the

north in Forchheim. The development and marketing

departments followed. Also in 1992, CT initially entered

angiography, the display of blood vessels. Due to faster rota-

tion and processing speeds, vessels filled with contrast medi-

um could now be scanned before the contrast medium wasdistributed in the patients body. 1998 marked the beginning

of multislice CT with the SOMATOM Volume Zoom. For the

first time, multiple in this case four slices of the patients

body could be scanned during a single rotation of the gantry.

Together with its fast rotation time of 0.5 seconds, this sys-

tem also enabled non-invasive display of coronary vessels.

Calcifications and stenoses can thus be visualized and treated

in their early stages.

New Diagnostic PossibilitiesThe latest system, the SOMATOM Sensation Cardiac 64,

scans 64 slices of the patients body per gantry rotation. Itattains a gantry rotation speed of 0.33 seconds and, at

below 0.4 millimeters, the highest resolution in the CT indus-

try. This extends the systems diagnostic possibilities consid-

erably, especially in cardiology, where the moving heart and

all of its blood vessels can be displayed in high resolution, or

a virtual flight through the coronary arteries can be generat-

ed.

In addition to the actual CT systems, Siemens also develops

their central elements, such as the X-ray tube and the detec-

tor. Equipped with the UltraFastCeramic (UFC) detectors, in

use since 1996, CTs from Siemens attain a high image quality

with a substantially reduced radiation dose. Thanks to its

directly cooled anode and compact design, the new STRA-

TON X-ray tube made gantry rotation times of 0.33 seconds

attainable for the first time. Its innovative electron beam

deflection system generates two alternating focal spots to

create two alternating X-ray beams for two separate detec-

tor measurements, and is also a patented Siemens develop-

ment.The constant further development of CT has recently

enabled additional clinical applications: In the fall of 2003,

Siemens became the first CT supplier ever to receive clear-

ance for a computer-aided technique for identifying nodules,

that is, possible tumors, in the lung. CT is also used for the

diagnosis of colon cancer: A virtual flight through the human

colon can visualize even the smallest polyps. If these are

removed in time, an outbreak of colon cancer can very prob-

ably be prevented.

Today, 30 years after the beginning of CT, physicians and

researchers have a highly developed tool at their disposal

which helps them diagnose anatomic processes quickly andin a manner which minimizes patient discomfort. The diag-

nostic information obtained has constantly improved, while

the radiation dose required has decreased significantly.

Siemens sales figures also show just how important CT has

become for routine medical work: While only two SIRETOM

CT systems were sold in 1974, almost 2,000 systems are now

produced each year at Siemens two plants in Forchheim,

Germany, and Shanghai, China. The basic technical princi-

ples underlying increasingly innovative imaging techniques

for the diagnosis and therapy of illnesses have advanced in

leaps and bounds.

With the SIRETOM, it took seven minutes to image oneslice of the patients brain.

Today's images of the SOMATOM Sensation 64 areacquired within seconds and offer much better resolution.

Courtesy University Hospital Munich-Grosshadern


15/50

Polyp Enhanced Viewing (PEV) is the lat-

est addition to Siemens growing port-

folio of cutting-edge, computer assisted

detection tools such as syngo LungCARE

CT with NEV. An optional add-on to the

popular syngo Colonography CT appli-

cation, PEV is designed as a second read-

er that allows the radiologist to make a

computer assisted second-pass over

the patient data. Focused on optimizing

workflow efficiency, PEV can be activat-ed as the radiologist begins the primary

read. The PEV results are ready for re-

The Egyptian Supreme Council of Antiq-

uities plans an interesting research proj-

ect on mummies. Its purpose is conser-

vation of the mummies and, at the same

time, to study health and disease in an-

cient Egypt. The National Geographic So-

ciety (NGS) and Siemens Medical Solu-

tions are supporting the project.

Together, they have donated a SO-

MATOM Emotion 6, mounted in a trailer.

It is planned, during a three- to five-year

period, to scan many mummies that are

still to be found in Egypt.

Egyptian mummies span a period of

3,000 years, starting 5,000 years ago.

Today, they serve as a window into the

NEWS

s y n g o C O L O N O G R A P H Y C T

Polyp Enhanced Viewing Receives 510(k) Clearanceviewing as the radiologist confirms the

end of the primary read. The PEV tool

then highlights potential lesions that

were not marked by the radiologist, in

addition to all potential lesions marked

by the radiologist during the first read,

and also indicates potential lesions

marked by the radiologist that were not

visualized by the PEV tool.

As CT-Colonography (CTC) gains in-

creasing acceptance as an alternative toconventional colonoscopy and demand

rises, particularly for early detection

radiologists have a lot to gain from

workflow enhancing tools such as PEV:

Reading CTC is a demanding, meticu-

lous process, requiring focused and ex-

tremely attentive concentration. Reader

fatigue is a real problem. Given the fact

R E S E A R C H

A CT System

for Mummiespast. It will be possible to not only inves-

tigate diseases of antiquity but also to

provide important information for con-

servation of the mummies and to clarify

many questions in Egyptology.

CT technology enables us to virtually

unwrap the mummies without damag-

ing them, states Zahi Hawass, PhD, Sec-

retary General of the Supreme Council of

Antiquities and Explorer in Residence of

the NGS. The system is installed in a

trailer so we can do house calls and

need not transport our patients. The re-

search project will be headed by Dr.

Hawass. F. DeWolfe Miller, PhD, Profes-

sor of Epidemiology at the University of

syngo Colonography CT with PEV automatically

highlights potential lesions that were overlookedduring the radiologists first read.

The CT-Trailer for the Mummy Project is equipped with a SOMATOM Emotion 6.

that there are not enough radiologists

to interpret the growing number of CT

scans performed in the United States,

any assistance in interpreting CTC will

be embraced enthusiastically by radiol-

ogists, says Mark Baker, MD, Cleveland

Clinic, USA.

Further workflow enhancements to

syngo Colonography CT will include

automated polyp measurement and vi-

sualization of unseen areas. Thesetools will really speed up my diagnostic

workflow, says Johannes Wessling, MD,

University Clinic, Muenster, Germany. It

is time consuming to measure polyps

manually, and we need to know polyp

size before recommending treatment.

Reliable automated tools will make CTC

diagnosis quicker.

Hawaii, USA, and a team of Egyptian sci-

entists will operate the CT system.

For this scientific project, the SOMATOM

Emotion 6 offers several advantages: It

combines high capabilities with minimal

siting requirements. Because of it s wide

gantry, the mummies can be positioned

without difficulty.

The National Geographic Channel will

air a TV special on the project globally

and in the United States in early 2005.

SOMATOM Sessions will also keep read-

ers posted on the progress of this unusu-

al project.

Further Information: www.ngs.org


16/50

Advanced Bone Removal* is a new feature of syngo InSpace4D designed to

improve diagnostic outcomes and optimize pre-operative planning for surgical pro-

cedures. The fully automated workflow facilitates fast segmentation and removal

of bony structures. It provides enhanced visualization of vascular structures,

stenoses, aneurysms and stents, plus complex fractures.

s y n g o I n S p a c e 4 D

Advanced Bone Removal

The Mayo Clinic in Rochester, MN, was

the first institution in the United States

to use the new SOMATOM Sensation 64

in clinical practice. The system was in-

stalled in July 2004 as the core equip-

ment of the new Mayo/Siemens CT Clin-

ical Innovation Center, where clinicians

and researchers seek to advance com-

puted tomography (CT) imaging and

post-processing techniques for use in

patient care. That we are the first U.S.

site to install this system continues our

long history of innovation in CT. We

expect the Siemens 64-slice system to

allow us to take CT imaging into new

levels of performance and clinical utility,

said Cynthia McCollough, PhD, associate

professor of radiologic physics, Mayo

Clinic College of Medicine. A five year

agreement for the joint operation of the

Innovation Center was signed duringthe official opening ceremony on Sep-

tember 22, 2004, as part of a Compre-

hensive Research Agreement between

the Mayo Clinic Foundation and Siemens

Medical Solutions. Under the direction

of McCollough and J. G. Fletcher, MD, the

center will allow medical and technical

researchers from the Mayo Clinic Col-

lege of Medicine, as well as researchers

from Siemens CT division, to work to-

gether to advance the clinical applica-

tions, quantitative capabilities, and pa-

tient care advantages of state-of-the-art

CT imaging. Key areas of research will in-

clude the investigation of optimized

clinical protocols with minimized radia-

tion exposure, the development of new

clinical applications in cardiac, vascular

and neuro CT examinations, and ad-vances in imaging options for morbidly

obese patients. The introduction of the

Mayo/Siemens CT Clinical Innovation

Center at the Mayo Clinic in Rochester is

a major milestone in the long standing

and growing partnership between the

Mayo Clinic Foundation and its medical

facilities in Scottsdale, Jacksonville and

Rochester, and Siemens Medical Solu-

A L E A P A H E A D I N C T

Mayo Clinic Rochester and Siemens Launch

Joint CT Clinical Innovation Center

tions. This center will allow us to apply

the latest research results immediately

in day to day patient care, and thus pro-

vides both partners a unique opportunity

to lead innovation in clinical CT, said

Bernd Ohnesorge, PhD, Vice President

of CT Marketing and Sales, Siemens

Medical Solutions. Along with the instal-

lation of the first SOMATOM Sensation

64 scanner, Mayo Clinic Rochester andSiemens CT have closed an agreement

for the installation over the course of

the next nine months of four additional

SOMATOM Sensation 64-slice CT scan-

ners for body, neuro, trauma and cardiac

CT imaging, as well as one SOMATOM

Sensation Open for use in interventional

CT and imaging of morbidly obese pa-

tients.

J. G. Fletcher, MD, and

Cynthia McCollough, PhD,

of the Mayo Clinic College

of Medicine, cutting the

ribbon for the new

SOMATOM Sensation 64

with Bernd Ohnesorge,

PhD, and Thomas Flohr,

PhD, of Siemens Medical

Solutions.


NEWS

*Advanced Bone Removal is pending 510(k) review and is not yet commercially available in the U.S. Advanced Bone Removal provides

a fast one-click workflow.


17/50


BUSINESS

C T B U S I N E S S

Reimbursement in the U.S.Physicians performing CTA and CTCcan obtain Medicare coverage but mighthave to campaign for it.

Imaging Technology advances all the

time. With each new application, it is

important to understand how physi-

cians can utilize these applications and,

of course, understand how they can

procure reimbursement for them at their

practices. Over this past year, two Com-

puted Tomography applications have

been hot issues in the realm of reim-

bursement: Coronary CT-Angiography

(coronary CTA) and CT-Colonography

(CTC). Private insurers might already

reimburse these procedures or some

physicians might practice in an area

where Medicare covers them.

Multislice CTAAny physicians with Medicare patients

and practice in South Carolina, New

York, or New Jersey may now be able to

obtain reimbursement for coronary

CTA. The procedure can be billed in

these areas using the reimbursement

code for CTA, Chest, without contrast

material(s), followed by contrast mate-

rial(s) and further sections, including

post-processing. The reimbursement

amounts are covered in table 1. Cover-age and the specific amount depends

on what region the practice is located

(please refer to your carrier for more

detailed requirements). The coverage

guidelines for these decisions are broad

and make specific note to the use of

multislice CT (16+ slices). "In view of the

burgeoning interest in cardiac CT imag-

ing, this reimbursement is a big step in

the process of growing coverage for

these exciting and patient-friendly CT

applications," says Michael Poon, MD,

chief of cardiology at Cabrini Medical

Center, New York City.

Another application making waves in the

imaging community is CTC. This yearhas

seen its preliminary addition to the

reimbursement catalogue, and, at thetime of printing, Medicare of New

York/New Jersey is considering cover-

age for this procedure. Physicians must

check with their carrier before billing. A

great breakthrough in this area is a Wis-

consin physician who, over the summer,

was able to petition his HMO to reim-

burse him for the procedure for his

screening of average-risk asympto-

matic patients.

This direct appeal from practices to their

carriers is growing and finding success.An imaging center in Los Angeles was

able to appeal to their carrier for reim-

bursement of Coronary CTA. Devoting a

little time to compiling clinical evidence

and an appropriate argument could reap

benefits for practices, resulting in reim-bursement for procedures otherwise

not currently paid by their carrier. Taking

on a project such as this not only gener-

ates increased revenue for their single

practice but benefits patients and imag-

ing as a whole.

Siemens understands that reimburse-

ment of procedures is a critical compo-

nent of physicians workflow, and there-

fore will continue to provide information

and strategies to assist as the climate of

reimbursement changes so that theycan continue to provide such advanced

services to their patients.

Michael Poon, MD and chief of

cardiology at Cabrini Medical Center

in New York City, welcomes growing

coverage for coronary CTA.

CT Coronary Angiography

New York/New Jersey $586.38 $763.95

South Carolina $517.94

CTA Reimbursement

[ Table 1 ]


18/50

Intelligent management of dose and

contrast media is a vital component for

good patient and staff care it can also

make a real impact on the bottom-line.

Automated real-time dose modulation

allows radiologists to offer patient-

friendly exams without compromising

diagnostic image quality supporting a

more efficient workflow and higher pa-

tient throughput. Additionally, it can en-

hance tube life: all important factors for

improving efficiency and keeping costs

down. Siemens offers two key workflow

solutions for dose management: CARE

Dose4D and CARE Vision.

CARE Dose4D provides a fully automat-

ed dose modulation workflow designed

to deliver the lowest possible dose with

the best possible image quality. The auto-

C A R E S O L U T I O N S

Good News for the Bottom-line

mated protocol facilitates a fast work-

flow, because it is not necessary to adapt

protocols manually for each new patient.

CARE Dose4D is an essential tool offer-

ing benefits for all modern radiology

environments. For cardiac studies,

Siemens offers ECG-pulsing, which

modulates the dose so that the optimal

dose is applied during expected diastole

and only 20 percent are applied during all

other phases.

CARE Vision is an ideal complement to

CARE Dose4D and is designed to opti-

mize workflow for minimally invasive

procedures. With options such as Hand

CARE, dose to the radiologist during

exams is also minimized.

Appropriate management of contrast

delivery is also very desirable, not only

Siemens computed tomography (CT)

scanners are renowned for their per-

formance and reliability. To increase

system uptime even further, Siemens

offers a new service, SIEMENS REMOTE

SERVICE (SRS). SRS combines high-tech

medical engineering with modern infor-

mation technology. Services which for-

for patient well-being, but also for cost

and efficiency. Siemens CARE Bolus is

specifically designed to reduce contrast

media volume without compromising

diagnostic outcome. In terms of work-

flow, CARE Bolus negates the need for a

test bolus, facilitates contrast phase

shaping, and the fully automated trig-

gering protocol maximizes efficiency

even for emergency exams. It is the

ideal contrast management solution for

all radiology practices.

S I E M E N S R E M O T E S E R V I C E

A New Dimension in System Support

merly required on-site visits are now

available via data transfer.

For example, in the unlikely event of

a system breakdown, Siemens can re-

motely log onto it and evaluate the er-

ror. In most cases, Siemens can even

solve the problem by remotely chang-

ing software parameters to get systems

up and running again without delay. In

other cases, Siemens specialists may re-

motely support the on-site, customer

service engineer with valuable informa-

tion.

The company even monitors system pa-

rameters in order to react on deviations,

such as cooling parameter variations,

before they lead to performance trou-

bles or downtime. Additionally, Siemensprovides, via SRS, a virus scanner with

continuous updates to support cus-

tomers in keeping their system and IT-

network clean.

SRS also enables Siemens to support

customers with helpful information

directly to the scanner, 90-day free trial

licenses, and other services that in-

crease workflow and performance.

Real-time dose modulation

with CARE Dose4D.


BUSINESS

With SRS, serviceswhich formerly

required on-site

visits are now

available via data

transfer.

500 mA

30 mA


19/50


BUSINESS

LEONARDO is Siemens multi-modality,

post-processing workplace, built on a

state-of-the-art software platform with

a graphics interface that delivers superior

image quality, and a very comprehen-

sive portfolio of post-processing appli-

cations. LEONARDO is designed to meet

the clinical needs of radiologists as well

as other clinical specialists.

As a syngo workplace, LEONARDO pro-

vides physicians with all the benefits of a

common user interface for virtually all

clinical applications a clear advantage

for ease of use and workflow efficiency

in terms of saving time in clinical routine.

The syngo user interface also makes it

easy to get the hang of using new appli-cations, because the user is not con-

stantly confronted with a new look and

feel. LEONARDO allows users to concen-

trate on using their time efficiently for

making the right diagnosis as quickly

and as accurately as possible.

The installation of our new SOMATOM

Sensation 64 CT scanner, together with

the latest software version including

numerous new post-processing tools,

could have been quite disruptive to our

routine clinical workflow, explains

Katharina Anders, MD, University Hospi-

tal, Erlangen, Germany. But, the familiar

syngo interface and the intuitive work-

flow of new post-processing options

ensured the fast, smooth integration of

our new system into daily routine.

For computed tomography (CT) users,

LEONARDO offers the full range of CT

post-processing applications such as

syngo InSpace4D, syngo Vessel View,

syngo Colonography and syngo Lung-

CARE CT with NEV. In contrast to the

dedicated CT post-processing work-

place, Wizard, LEONARDO is a stand-

alone workplace, which is easily inte-

grated into the radiology or hospitalnetwork, facilitating easy transfer of re-

constructed data sets. LEONARDO al-

lows the radiologist to get on with read-

ing, diagnosis and reporting without

interruption. Furthermore, in busy radi-

ology departments there is little room

for post-processing at the Wizard, be-

cause the most efficient workflows uti-

lize the Wizard for reconstruction and

preliminary reads, while the next

patient exam is already underway.

When we are scanning patients there isabsolutely no time for reviewing cases

or doing significant post-processing on

the Wizard workplaces located at each

of our three SOMATOM Sensation CT

scanners. We perform a lot of cardiac

and CTA exams, for example, which

involve significant post-processing so

LEONARDO is a vital part of our work-

flow. We send the reconstructed data

sets directly to LEONARDO, where cases

can be processed and reviewed without

disturbing workflow and throughput at

the scanner. LEONARDO really helps us

to achieve a more efficient clinical work-

flow, says Axel Kuettner, MD, University

Hospital, Tuebingen, Germany.

For radiologists who work in a multi-

modality environment, LEONARDO

offers one of the most comprehensive

portfolio of post-processing applica-

tions on one software platform in the

market today. LEONARDO integrates

applications for CT, magnetic resonance

imaging, nuclear medicine, fluoroscopy,

angiography and radiation therapy

planning. As such, LEONARDO can be

uniquely configured to suit the specificclinical needs of users in cardiology or

oncology, for example. Whats more,

LEONARDO supports a number of differ-

ent DICOM formats and is therefore

compatible with data acquired on imag-

ing modalities from different vendors.

This means that LEONARDO is a secure

investment for any radiology depart-

ment, because the range of applications

can be extended to meet developing

clinical needs without having to pur-

chase a new workplace. A LEONARDOworkstation is an intelligent investment

designed for today, tomorrow and

beyond.

Further Information:


W O R K P L A C E S

LEONARDO Intelligent InvestmentBy Louise McKenna, PhD, Global Product Marketing Manager LEONARDO

and Workplaces, Siemens AG, Medical Solutions, CT Division

As a syngo work-

place, LEONARDO

provides physicians

with all the benefits

of a common user

interface for virtual-

ly all clinical appli-

cations.

LEONARDO integrates applications for CT, magnetic

resonance imaging, nuclear medicine, fluoroscopy,

angiography and radiation therapy planning.


20/50

HISTORY

A 51-year-old male with stable angina pectoris underwent

percutaneous intervention of the left main and left anterior

descending coronary artery. Two drug eluting (paclitaxel-

coated) stents were positioned during an elective proce-

dure. A conventional coronary angiogram was scheduled

after six months to monitor potential development of intima

hyperplasia or in-stent restenosis within the left main coro-

nary stent. The patient did not develop recurrent anginal

complaints during follow-up. A multislice computed tomog-

raphy (MSCT) coronary angiogram was performed using the

Siemens SOMATOM Sensation 64 scanner the same day of

Case 1:Patency of Left Main Coronary Stentby Nico R. Mollet, MD, and Filippo Cademartiri, MD, Department of Radiology and Cardiology,

Erasmus Medical Center, Rotterdam, The Netherlands

[ 1 ] Cranio-anterior view; Ao: Aorta; CX: circumflex coro-

nary artery; D1: first diagonal branch; LAD: left anterior

descending coronary artery; LM: left main coronary

artery; MO: first marginal branch; RCA: right coronary

artery; RV: right ventricle.

[ 2 ] Posterior view (after removing the cardiac atriae)

the conventional angiogram. The patient was already on

long-termbeta-blockade and the pre-scan heart rate was 58

beats/minute. Therefore, no pre-medication before the scan

was administered. The entire heart was scanned within a sin-

gle breath hold of 11.6 seconds.

DIAGNOSIS

The MSCT coronary angiogram allows direct visualization of

the coronary lumen inside the stent, thereby reliably exclud-

ing the presence of in-stent restenosis. The operators

1 2

SOMATOMSensation

SOMATOMEmotion

CLINICAL OUTCOMES



21/50


SOMATOMSensation

SOMATOMEmotion

CLINICAL OUTCOMES

[ 3 and 4 ] Curved planar reconstructions of the left main (LM) and left anterior descending

(LAD) coronary artery. The stents located at the LM and proximal LAD are clearly visible due to

their high-density material. No significant lesions were found in the non-stented part of the

vessel [3A and 3B]. The use of higher reconstructions kernels allows more reliable visualization

of the coronary lumen within the stent and in-stent restenosis could be ruled out on

the MSCT scan [4A and 4B].

3A

4A 4B

3B


22/50

intended to cover the entire left main and proximal left ante-

rior descending coronary artery with overlapping stents.

However, the MSCT coronary angiogram demonstrated a

gap between the stents, which can be of risk to developfuture in-stent restenosis. No significantly obstructive

stenoses were shown on the MSCT scan. These findings

were confirmed on the conventional angiogram [Fig. 6], and

the patient did not undergo further percutaneous treat-

ment.

COMMENTS

The latest 64-slice CT scanner is able to scan the entire heart

in less than 12 seconds over a scan range of 140 millimeter

and is equipped with a higher spatial and temporal resolu-

tion when compared to previous scanner generations. The

improved spatial resolution (below 0.4 mm in every dimen-

sion) is of importance in the visualization of the coronary

lumen within stents. The use of higher reconstruction ker-

nels (e.g. B46f) reduces the blooming effect related to the

high-density material of the stents and can be a helpful tool

to evaluate the in-stent coronary lumen [Fig. 4A and 4B].

EXAMINATION PROTOCOL

Scanner SOMATOM Sensation 64

Scan area from carina to diaphragm

Scan length 140 mm

Scan time 11.6 s

Scan direction caudo-cranial

Heart rate 58 bpm

KV 120 kV

Effective mAs 900 mAs

Rotation time 0.33 s

Slice collimation 0.6 mm

Pitch 0.2

Reconstructed slice width 0.75 mm

Reconstruction increment 0.5 mm

Kernel B46f

CLINICAL OUTCOMES

CONCLUSION

This case shows the potential of MSCT coronary angiography

to rule out significant in-stent restenosis in stents. Non-inva-

sive follow-up of patients after stenting of the coronary

arteries is a future indication of this technique.

[ 6 ] Conventional angiography image confirming

the absence of significant intima hyperplasia.

[ 5 ] The maximum intensity projected (MIP) CT image

clearly shows a gap between the stents. Cross-sectional

images of different parts of the stented segment show:

[a] patent proximal stent, [b] calcified plaque at the outer

border of the stent struts, [c] absence of stent struts

within the gap, and [d] patent distal stent.

a b c d



23/50



Scan area Circle of Willis

Scan length 145 mm

Scan time 3 s


KV 100 kV


Rotation time 0.5 s


Slice width 0.6 mm

Tabe feed / rotation 19.2 mmPitch 1


Kernel B30f

Contrast OMNIPAQUE 300

Volume 80 ml

Flow rate 4 ml / s

Start delay bolus tracking

Postprocessing MIPs, VRT

SOMATOMSensation

SOMATOMEmotion

CLINICAL OUTCOMES


Case 2:Aneurysm of the Anterior Communicating ArteryBy Edward Paul Lindell, MD, Department of Radiology, Mayo Clinic Rochester, USA

HISTORY

A 73 year old man with a prior history of ruptured anterior

communicating artery aneurysm treated at another institu-

tion with surgical clipping in 1990, presented to our institu-

tion for the first time with subacute gait difficulties. As part of

his evaluation, a cerebral CT angiogram was performed. Vol-

umetric display and slab multiplanar reconstructions were

reviewed.

DIAGNOSIS AND COMMENTS

The aneurysm clip was clearly defined with a remarkable lack

of artifact. A small 3 mm aneurysm remnant was seen adja-

cent to the clip. No abnormalities to account for his symp-

toms were found. Nevertheless, the SOMATOM Sensation

[ 1 ] Sagittal MPR image demonstrating the clip

with minimal artifacts posterior superiorly, and the

aneuryism remnant visible posterior inferior.

64 allows for dramatically reduced artifact from metal rela-

tive to previous scanners. We were able to confidently distin-

guish a minute, but critically important, vascular structure

immediately adjacent to an aneurysm clip with only minimal

identifiable artifact. In combination withthe 0.4mm isotropic

resolution, this case clearly demonstrates the excellent

image quality achieved with the Siemens 64-slice scanner

and its z-Sharp Technology.


24/50

CLINICAL OUTCOMES


[ 2A and 2B ] Axial images demonstrating the clip with minimal artifacts to the clip (white arrow)

and a 3 mm aneuryism remnant. [B] Larger image of the aneurysm remnant (yellow arrow).

[ 3A and 3B ] VRT showing nicely the 3 mm aneurysm remnant and the dramatic lack of metallic hardware artifacts

(arrows).

BA

A B


25/50

SOMATOMSensation

SOMATOMEmotion

CLINICAL OUTCOMES


Case 3:Arch of Riolan and Pancreatic CancerBy J. Dinkel, MD, U. Mende, MD, PhD, Department of Radiation Oncology, and J. Debus, MD, PhD, Director,

Department of Radiation Oncology, University of Heidelberg, Germany

HISTORY

A 66 year old female with stage III pancreatic cancer under

radiochemotherapy treatment with known complete occlu-

sion of the celiac trunk and the superior mesenteric artery. She

does not have clinically significant ischemic bowel disease.

DIAGNOSIS

We performed a standard dual-phase CT Angiography (CTA,

arterial and venous phase), with the SOMATOM Sensation

Open, with its 82 cm bore and extended field of view of 82

cm, which revealed a hypoattenuating tumor located in the

pancreatic body and tail. The pancreatic mass is best seen on

the portal venous phase image [Fig. 1].

An important characteristic for the determination of poten-

tial resectability is perivascular tumor invasion, particularly in

relation to the celiac and mesenteric arteries, the splenic and

superior mesenteric veins, and the portal vein confluence.The pancreatic tumor invades the common hepatic and

splenic arteries. Moreover, MPR, curved MPR, 3D VRTs, and

MIPs show a complete obliteration of the celiac trunk and

the superior mesenteric artery (SMA). Axial and coronal

images from the late arterial/portal-venous inflow phase

demonstrate encasement at the portal vein confluence and

absence of contrast enhancement of the splenic vein. The

collateral circulation is achieved via hypertrophic gastroepi-

ploic vein [Fig. 2A]. The patient had developed sufficient col-

lateral circulation and did not experience any ischemic symp-

toms.

As the celiac axis and SMA are occluded, the collateral circu-

lation is achieved via the arch of Riolan [Fig. 3A, 4B]. This

arterial arcade provides an anastomosis between the territo-

ries of the superior and inferior mesenteric arteries. It con-

nects the left colic branch of the inferior mesenteric artery

with the middle branch of the superior mesenteric artery,

which is also called the meandering mesenteric artery. Itmay become very hypertrophic and tortuous as in the case

[ 1A and 1B ] Axial image [A]: hypoattenuating tumor located in the pancreatic body and tail of the pancreas.

[B] The pancreatic mass is best seen on the portal venous phase images (arrows). Encasement at the portal vein

confluence and absence of contrast enhancement of the splenic vein.

A B


26/50


CLINICAL OUTCOMES


Scanner SOMATOM Sensation Open

Scan area from diaphragm to

aortic bifurcation

Scan length 207 mm

Scan time 4.4 s

Scan direction cranio-caudal

KV 120 kV

Effective mAs 71 mAs (ref. mAs 160)

Rotation time 0.5 s


Slice width 1.5 mm

Pitch 1.2


Kernel B20f

Contrast non ionic contrast media(300 mg iodine per ml)

Volume 100 ml

Flow rate 4 ml/sec + 40 ml saline chaser

Start delay bolus tracking

Postprocessing MPR, VRT, syngo Inspace

presented here. We found no internal collateralisation

between the three branches of the celiac trunk [Fig. 2B, 3B,

4B].

The common hepatic artery is also completely obliterated.

Therefore, the proper hepatic artery is filled via retrograde

flow from the pancreaticoduodenal arcade and the gastro-

duodenal artery. There are usually two arcades (80%), one

on both the anterior and posterior side of the pancreas

(anterior, posterior). In the case presented here the posteri-

or arcade is hypertrophic [Fig. 4A, 4B]. The longitudinal path-

ways via the dorsal pancreatic artery play an important role

in collateral circulation. In this case, it appears as a direct

anastomotic channel between the celiac branches and the

SMA (22%) and provides flow to the celiac trunk and the left

gastric artery [Fig. 4B]. The splenic artery is encased and has

no communication with the celiac trunk. The collateral circu-

lation is achieved via the left gastroepiploic artery [Fig. 4B].

The major causes of celiac axis and SMA stenosis are athero-

sclerosis, acute and chronic dissection, and compression of the

celiac axis by the median arcuate ligament. The stenosis of the

celiac trunk and SMA seems to be old and due to atheroscle-

rosis. However, we can asume that obturations of the common

hepatic and splenic arteries are due to the pancreatic cancerresulting in new, complex collateral circulation pathways.

[ 2A ] The splenic vein is encased and has no communica-

tion with the portal vein. The communication is achieved

via the gastroepiploic vein to the superior mesenteric vein.

[ 2B ] Total obliteration of the celiac trunk and the superi-

or mesenteric artery (SMA). No internal collateralisaton

between the three branches of the celiac trunk.


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SOMATOMSensation

SOMATOMEmotion

CLINICAL OUTCOMES


COMMENTS

The use of multislice CT (MSCT) with CTA is ideally suited for

the evaluation of patients with pancreatic cancer. The

SOMATOM Sensation Open enables us to examine distinctarterial and venous phases, in one breathhold. Its 20-slice

detector, 0.5 s rotation time, and large bore make it an ideal

system for both, primary diagnosis in oncology, and CT-

based RTP. The coupling of fast scanning capabilities of MSCT

with thin slices and close interscan spacing provides accurate

pancreatic tumor staging and more sensitive detection of

vascular encasement. Indeed, major collateral pathways (i.e.Arch of Riolan) in patients with arterial axis stenosis can be

identified effectively, and this imaging modality provides

essential information for planning surgical or interventional

procedures.

[ 3A ] Arch of Riolan (MIP). It connects the left colic

branch of the inferior mesenteric artery with the middle

branch of the superior mesenteric artery.

[ 3B ] Slab section VRT. Inferior mesenteric artery;

Superior mesenteric artery; Common hepatic

artery; Celiac trunk; Splenic artery

[ 4A ] Slab section VRT.

Anterior and posterior pancreaticoduodenal arcades.

The posterior arcade is hypertrophic.

[ 4B ] Collateral circulation pathways (3D VRT).

Arch of Riolan; left gastroepiploic artery;

longitudinal pathways via the dorsal pancreatic

artery; pancreaticoduodenal arcade

anterior pancreaticoduodenal arcade

posterior pancreaticoduodenal arcade


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CLINICAL OUTCOMES

syngo Colonography CT with PEV

Case 4:Detection of Sigmoid Carcinoma withTwo Synchronous PolypsBy Dragan Salovic, MD, Radiology Department, Jacques Kirsch, MD, Head of Radiology Department, ASBL Clinique Notre-

Dame de Tournai, Belgium; Louise McKenna, PhD, Stefan Wuensch, PhD, Siemens Medical Solutions, Forchheim, Germany

syngo Colonography CT is designed to support the physicianin the visualization, evaluation and follow-up of colonic

lesions. Polyp Enhanced Viewing (PEV) is one of the key new

features being integrated into the popular syngo Colonogra-

phy CT software. PEV is designed as a second reader tool for

automated visualization of polyps and other lesions of thecolon. It recently obtained 510(k) clearance by the FDA. PEV,

together with tools such as automated size measurement

and synchronized prone/supine reading, is designed to help

improve workflow and enhance diagnostic confidence.

HISTORY

A 57 year old, male patient presented with pain and discom-

fort in the left lower abdominal quadrant and a positive

occult blood test. He was referred for evaluation through

virtual colonoscopy.


The endoluminal view in the bottom right quadrant displays

the mass in the sigmoid colon [Fig. 1] that was confirmed by

conventional colonoscopy with polypectomy. Histo-patholo-

gy confirmed a low grade adenocarcinoma (T2 M0 N0). In

addition, CT Colonography showed two sessile polyps of 6millimeter and 4 millimeter proximal to the lesion [Fig. 2, 3].

In order to show the capability of syngo Colonography CT

with PEV as a second reader tool, the dataset was evaluated

with the new automated software tool. PEV visualized the

previously identified polyp (adenocarcinoma). PEV con-

firmed two small polyps of 4 millimeter and 6 millimeter size,

which had been identified during the first read. This case

nicely demonstrates the benefit the automated software

PEV provides, enhancing physician's confidence in identifica-

tion of potential bowel lesions.



Scan area whole abdomen

Scan length 44.7 mm

Scan time 9.3 s

Scan direction cranio-caudal

KV 120 kV


Rotation time 0.5 s


Slice width 2 mm

Tabe feed / rotation 24 mm

Pitch 1

Reconstruction increment 1 mm

Kernel B20f

Postprocessing syngo Colonography CT with PEV

NowFDACleared


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SOMATOMSensation

SOMATOMEmotion

CLINICAL OUTCOMES


[ 2A and 2B ] Marker

4b indicates a sessile

polyp measuring

approximately 4 mm

visualized in both the

2D [A] and 3D [B]

views identified by

the reader (yellow

marker) and by PEV

(red marker).

[ 3A and 3B ] Marker

9b indicates a sessile

polyp measuringapproximately 6 mm

visualized in both the

2D [A] and 3D [B]

views, identified by

the first reader and

the second reader

tool PEV.

[ 1 ] User interface of syngo

Colonography CT with PEV: coronal

image (MPR, top left), axial image

(top right), 3D overview segmentand display of virtual flight and

markers, detected by the reader

(yellow marker) and PEV (red marker,

lower left), endoluminal view indi-

cates a non-stenotic filling effect in

the left colon (lower right).

A

A

B

B

4b

c7bc7b

9b

c8bc8b


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Case 5:Adenocarcinoma of the Sphenoid SinusBy M. Oldendorf, MD, R. Loose, PD, MD, PhD, Institute for Diagnostic and Interventional Radiology,

Klinikum Nord, Nuremberg, Germany

HISTORY

A 59 year old female with a 15-year history of recurrent

sinusitis was referred to our clinic due to pain in the nose

and behind the left eye. In the past, the patient underwent

a sinusitis surgery procedure to enlarge the left septum of

the maxillary sinus. No regular follow up exams were per-

formed between the operational procedure and her last

visit. Suspecting an obstructive lesion with possible bone

destructions in the nasopharynx, a high resolution CT scan

was performed.


With the advantage of the scanner's 0.5 mm collimation high-

resolutionoption and using a slice with of 0.63 mm, the bone

destructions in the left medial and anterior septum of the

maxillary sinus with participations of adjacent ethmoid cells

could be identified, indicating the presence of a tumor.

An opacification in the right maxillar sinus, with air fluid lev-

el but without bone destruction, was also observed.

Histologic analysis of the tumoral lesion confirmed T3 graded

adenocarcinoma.


Scanner SOMATOM Emotion 6

Scan area from C1 to suborbital bridge

Scan length 80 mm

Scan time 25 s


KV 130 kV


Rotation time 0.5 s


Slice width 0.63 mm

Tabe feed / rotation 3.0 mm

Pitch 1

Reconstruction increment 0.5 mmKernel H21f

Postprocessing MPR, VRT

SOMATOMSensation

SOMATOMEmotion

CLINICAL OUTCOMES

SOMATOM Emotion 6 with High Resolution Mode

The SOMATOM Emotion 6 multislice CT Scanner, in contrastto the way many other scanners operate, uses six slices for all

scan modes including those with sub-millimeter collimation.

Utilizing six slices per rotation, scan times and breath hold

times are shortened and motion artifacts are reduced or

even eliminated. Furthermore, faster scans decrease tubeloading and therefore can extend tube life. Thus, the

SOMATOM Emotion 6 is an excellent system for scanning

fine structures like the inner ear, sinuses, and joints.


31/50

[ 1A ] MPR of the sinus indicating the presence of

obstructive mass in the right sinus as well as in the

left sinus (arrows).

[ 1B ] Bone destructions in the left anterior and poste-

rior septum also indicating the presence of a tumor

(arrows).

[ 2 ] CT scan shows a soft-tissue mass involving the

frontal sinus with intracranial invasion through the pos-

terior wall. Anterior ethmoid air cells were also involved.

[ 3 ] VRT facial bone demonstrating the bone destruc-

tions of the left anterior septum of the maxillary sinus

(arrow), whereas the right septum is not affected.

SOMATOMSensation

SOMATOMEmotion

CLINICAL OUTCOMES



32/50


SCIENCE

Initial Clinical ExperienceBone Subtraction CT-Angiography* for Imagingof Intracranial ArteriesBy B. F. Tomandl, MD, Division of Neuroradiology, Department of Neurosurgery; M. S. Dassel, MD, M. Lell, MD,

Department of Diagnostic Radiology, University of Erlangen-Nuremberg, Germany; E. Klotz, H. Ditt, Physics and

Application Development, Siemens AG, Medical Solutions, CT Division

Since the introduction of spiral CT, the investigation of

intracranial arteries by means of CT Angiography (CTA) has

gained increasing importance. This is especially true for the

detection of intracranial aneurysms in patients with sub-

arachnoid haemorrhage (SAH). CTA with modern multislice

scanners (MSCT) and state-of-the-art post-processing is

coming close to replacing digital subtraction angiography

(DSA) as the gold standard. While supraclinoid aneurysms

are detected easily, it is still difficult and sometimes impossi-

ble to see aneurysms at the level of the skull base. In 1994

Grzer et al. published a paper about "subtraction"-CTA

where a set of non-enhanced images was subtracted from

contrast enhanced spiral CT. Their approach used subtraction

on an image by image basis requiring perfect immobilization

of the patient for the whole acquisition time of both scans.

As even discrete movements of the patients lead to insuffi-

cient subtraction results, this method was not very success-

ful. Bone removal is still a major challenge, even with state of

the art post-processing workstations.

Improving on the old idea of subtraction CTA, we tested a

new three-dimensional approach. Using the data from an

additional low-dose CT scan, our method selectively elimi-

nates bony structures from the CTA data set using 3D regis-

tration techniques. Thus, after the bone removal process, all

information about vascular and soft tissue structures are

maintained for further processing. The algorithm works fully

automatically. To date, we have used a prototype implemen-

tation of the software on 27 patients with intracranial

aneurysms. 25 cases were performed using a four-slice

MSCT scanner (SOMATOM Volume Zoom), and two cases

were performed with a 64-slice MSCT (SOMATOM Sensation

64). Bone subtraction was successful in all cases resulting in

[ 1A and B ] [A] shows the head with bones. In the resulting source images [B], only the bony structures are removed,

while arteries and brain parenchyma are still visible after the subtraction process as shown on this coronal MPR-image.

A B

* The information about this product is being provided for planning

purposes. The product is pending 510(k) review, and is not yet

commercially available in the U.S.


33/50


SCIENCE

Our initial experience shows that the method is easy to use

and thus applicable in clinical routine work. It is particularly

useful for aneurysms involving the skull base. Bone subtrac-

tion CTA clearly facilitates 3D visualization at the worksta-tion, representing a step in the direction of a standardized

representation of CTA data.

Case StudyTherapy Planning of Oculomotoric Palsy

A 54 year old female patient with a three months history of

oculomotoric palsy was reported to have normal findings on

MRI including MRA. Bone Subtraction CTA (BSCTA) was per-

formed, and we detected an aneurysm of the right internal

carotid artery (ICA), at the origin of the posterior communi-

cating artery, thus explaining irritation of the oculomotoric

nerve. BSCTA helped to optimally depict the aneurysm and

to adjust the optimal working projection for planning the

coiling procedure that was performed three days later.

This case clearly demonstrates how BSCTA helps to delineate

aneurysms in the area of the skull base [Fig. 2]. There is still

some overlap of the ICA from the cavernous sinus, since the

examination was performed with the four-slice scanner.

[ 2A ] On the

non-subtracted

CTA images theaneurysm of

the right ICA is

visible, but the

course of the

ICA is not seen

within the

skull-base.

[ 2B ] On the

BSCTA images the

aneurysm (arrow)and its relation to

the ICA is clearly

visible. Note some

overlap from the

cavernous sinus

(arrowheads).

[ 2C ] BSCTAallows the physi-

cian to depict the

optimal working

projection for the

coiling procedure.

Arrow: aneurysm;

Arrowheads: Cav-

ernous sinus part-

ly hiding the ICA.

[ 2D ] DSA:Using the infor-

mation of BSCTA

this projection

was used as the

working projec-

tion for coiling

the aneurysm

(arrow).

diagnostic images including the carotid arteries within the

skull base. Artifacts occurred only when the patients moved

during one of the two scans. With the four-slice scanner, filling

of the cavernous sinus always occurred, leading to more orless overlap with the intracavernous part of the internal

carotid arteries. The two cases performed with the 64-slice

scanner using a test bolus for determination of bolus timing

with a scan time below five seconds did not show this overlap.

The information about this product is being provided for planning

purposes. The product is pending 510(k) review, and is not yet

commercially available in the U.S.


34/50


SCIENCE

EXAMINATION PROTOCOLS

Case 1* Case 2*Scanner SOMATOM SOMATOM

Volume Zoom Sensation 64

Scan area first vertebral first vertebral

body to the vertex body to the vertex

Scan length 150 mm 150 mm

Scan time 28 s 4.5 s

Scan direction caudocranial caudocranial

kV 120 kV 120 kV

Effective mAs 180 mAs 200 mAs

Rotation time 0.5 s 0.5 s

Slice collimation 1.0 mm 0.6 mm

Slice width 1.25 mm 0.75 mm

Tabe feed / rotation 2.7 mm 11 mm

Reconstruction 0.5 mm 0.4 mm

increment

Kernel H30f H30f

Contrast 300 mg 300 mgiodine / ml iodine / ml

Volume 100 ml + 40 ml NaCl 70 ml + 40 ml NaCl

Flow rate 4 ml/s 4 ml/s

Start delay CARE Bolus test bolus

Case StudyFollow up of a Mycotic Aneurysmof the Right Main Carotid Artery

A 57 year old female patient was examined with MRI due to

chronic headaches. There was no acute, severe headache so

that subarachnoid haemorrhage had probably not occurred

in this patient. An aneurysm of the M2-segment of the MCA

was suspected on the axial T2w-images. MRA was not per-

formed. We performed CTA for an optimal delineation of the

aneurysm, which is probably of mycotic origin.

Using a 64-slice scanner with reduced contrast media and

optimal bolus-timing determined from a test-bolus provided

a pure arterial phase of both ICAs. There is no longer any

overlap of the ICA from the cavernous sinus.

* low dose protocol: same parameters as above using a low dose

protocol (50 mAS).

The information about this product is being provided for planning

purposes. The product is pending 510(k) review, and is not yetcommercially available in the U.S.

[ 3A and B ]

Using the unsub-

tracted images

intensive post

processing with

clip-planes

(arrowheads)

and manual

manipulation isnecessary to get

a free view on

this aneurysm of

the right MCA,

which is probably

a mycotic

aneurysm

(arrow).

[ 3C ] BSCTA

allows a free view

at the intracranialarteries without

the use of clip-

planes. In this case

the 64-slice scan-

ner was used with

optimal bolus tim-

ing, thus the cav-

ernous sinus does

not disturb the

view at the ICAs.

A

B


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In many instances, CT urography has replaced standard

intravenous urography in the diagnostic algorithm for pain-

less hematuria. Problems with this technique when per-

formed using a four-slice MDCT scanner, compared with

standard intravenous urography, include diminished spatial

resolution, increased radiation dose, and incomplete opacifi-

cation of the ureters, particularly the distal segments. Using

16-slice MDCT and higher, with a slice collimation of 0.75 mil-

limeter, both five millimeter axial and reformatted images

can be made. Spatial resolution is much improved. Both the

use of compression bands and continuous intravenous

administration of saline during CT urography have bee

Documents

Somatom Sessions 15