CT Advanced Scanning Techniques Classroom & Turnover Workbook SOMATOM Emotion Scope Perspective

Stellesi ECCO CT Advanced Scanning Techniques Classroom & Turnover Workbook SOMATOM Emotion, Scope & Perspective SIEMENS Healthineers www.usa.siemens.com/education I. Contact Information Summary Welcome to Siemens Healthineers Virtual Education (Offerings & Registration) • Siemens Healthineers is dedicated to helping you get the Workshops & Fellowships • most out of your investment throughout the entire product life cycle and beyond. Our goal is to enable you to take technology further, profitability higher, and patient Visit www.usa.siemens.com/clinicaleducation for more care to the next level. Find the information, resources, and information regarding the current Siemens tools you need to get the most out of your recent Clinical Training and Continuing Education portfolio. investment and stay up-to-date. Visit www.usa.siemens.com/Welcome2Healthcare. Discover. Try. Buy. on webShop Clinical Training and Continuing Education Do you want to “Discover. Try. Buy.” options, accessories, and clinical education to make the most of your Customer Care Center - Clinical Application Support: imaging equipment? Discover images, case studies, and video demonstrations with the latest clinical Call 1-800-888-7436 applications. Try advanced applications utilizing Troubleshooting assistance free software trials. Buy applications, coils, clinical • education, and accessories, conveniently at any time. Immediate assistance for software • Visit www.usa.siemens.com/webShop today! applications and workflow issues Please provide the Functional Location Number when Siemens Training Centers • calling for assistance. Siemens Clinical Education Training Center – TDC2 Clinical Education Offerings: 110 Mac Alyson Court Cary, NC 27511 Call 1-888-221-8010 (follow the prompts) Classroom Training (Offerings, Registration • & Scheduling) Educational Symposia • On-site Training • Printed Self-studies • 2 II. Contents I. Contact Information Summary...........................................................................................................................2 II. Contents ..................................................................................................................................................................3 III Course Description ................................................................................................................................................5 1. What is syngo ® 6 ...................................................................................................................................................... 1.1 Objectives ....................................................................................................................................................... 6 1.2 syngo User Interface 6 .................................................................................................................................... 1.3 Patient Browser ...........................................................................................................................................10 1.4 Viewing Task Card .......................................................................................................................................15 1.5 Filming Task Card....................................................................................................................................... 23 2. System Hardware................................................................................................................................................ 25 2.1 Objectives ..................................................................................................................................................... 25 2.2 Gantry ........................................................................................................................................................... 26 2.3 Patient Table ............................................................................................................................................... 30 2.4 Acquisition Workplace/Console..............................................................................................................31 2.5 Positioning Accessories ............................................................................................................................ 36 3. Scan Acquisition and Reconstruction ............................................................................................................37 3.1 Objectives ..................................................................................................................................................... 36 3.2 Scan Protocol Selection/Patient Model Dialog..................................................................................37 3.3 Review/Modify Topogram Parameters ................................................................................................. 38 3.4 Dual Topogram........................................................................................................................................... 38 3.5 Review/Modify Scan Parameters........................................................................................................... 40 3.6 Review/Modify Reconstruction Parameters ........................................................................................41 3.7 Review/Modify Auto Tasking Parameters .............................................................................................41 3.8 Save Protocol Changes ............................................................................................................................ 42 3.9 Topogram and Range Manipulation..................................................................................................... 43 3.10 Image reconstruction.............................................................................................................................. 44 4. Dose Considerations ...........................................................................................................................................51 4.1 Objectives ......................................................................................................................................................51 4.2 Dose Basics in CT........................................................................................................................................51 4.3 CARE Dose4D ............................................................................................................................................. 54 4.4 eCockpit.........................................................................................................................................................61 4.5 FAST CARE ................................................................................................................................................... 65 5. CTA Anatomy ........................................................................................................................................................73 3 5.1 Objectives ......................................................................................................................................................73 5.2 Cerebral Vasculature - Circle of Willis ..................................................................................................73 5.3 Neck Vasculature - Carotids and Vertebrals .......................................................................................74 5.4 Thoracic Vasculature.................................................................................................................................77 5.5 Abdominal Vasculature ........................................................................................................................... 82 5.6 Pelvis and Lower Extremity Vascular ................................................................................................... 86 6. Contrast Enhancement ..................................................................................................................................... 92 6.1 Objectives..................................................................................................................................................... 92 6.2 Purpose of Appropriate Contrast Timing ............................................................................................ 92 6.3 Key Factors that Contribute to Quality Contrast Opacification ................................................... 93 6.4 Types of Injection Delays ......................................................................................................................... 96 7. Advanced Examinations - Acquisition & Post Processing Techniques................................................. 100 7.1 Objectives.................................................................................................................................................... 100 7.2 CTA Carotids/Circle of Willis................................................................................................................. 100 7.3 CTA Abdomen/Pelvis/AAA..................................................................................................................... 105 7.4 CTA Thorax/Pulmonary Arteries...........................................................................................................110 7.5 Coronary CTA..............................................................................................................................................115 7.6 Scan Acquisition........................................................................................................................................119 7.7 iTRIM* (*Optional on the SOMATOM Perspective, included with HeartView) ......................... 123 7.8 ECG Check* (*Optional on the SOMATOM Perspective, included with HeartView)................ 124 7.9 TAVR – Transcatheter Aortic Valve Replacement ............................................................................ 124 7.10 VPCT/Volume Neuro Perfusion CT..................................................................................................... 128 7.11 Dual Energy CT........................................................................................................................................ 133 7.12 Dual Energy Applications..................................................................................................................... 138 4 III Course Description Course Objectives:: Upon completion of this course, you will be able to: Navigate the syngo® user interface • Select and customize patient scan protocols • Navigate the Exam Card and modify scan parameters as necessary • Reconstruct images using WorkStream4D • Identify and apply available dose optimization techniques such as CARE Dose4D, CARE • kV, and SAFIRE/ADMIRE Utilize various methods of contrast timing, such as CARE Bolus and Test Bolus • Post-process images using various 3D editing tools • Identify workflow steps involved in scanning advanced examinations, such as CTAs, PEs, • Neuro Perfusion, Dual Energy, and TAVR procedures. 5 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 1. What is syngo ® 1.1 Objectives Notes This section will review the software that runs your CT scanner, including: Layout of the User Interface • Patient Browser • Viewing • Filming • After completing this section, you will be able to: Identify the major features of the syngo user interface • Access and navigate the Patient Browser to find and manage patient data • NOTE: The pictures of the components shown here are only examples. The appearance of your components depends on the system configuration syngo is a standardized software platform found on most of Siemens medical imaging systems. It is user friendly, efficient, and offers a similar look and feel across multiple modalities. This helps improve clinical workflows and optimizes all of the various processes involved in the course of imaging patients. Because syngo runs on a Windows operating system platform, many of the features, tools, shortcuts and options will be familiar. 1.2 syngo User Interface The syngo user interface has several notable features: • Task Cards for easy access to various functions from a single screen. A Main Menu Bar across the top of the Task Card that contains textual shortcuts • for all of the functions on that page. • Tool Cards and Subtask Cards that contain icon shortcuts to commonly used features A Status Bar along the bottom that provides information on background • functions, any system or software errors, and information on available system storage. Easily accessible and content-sensitive Help Files. • 6 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 1.2.1 Task Cards Notes Task cards provide access to the most basic functionalities of the syngo software. They offer an efficient means of displaying multiple applications or windows at the same time, without cluttering the user interface. Some task cards are present on all systems, even across modalities, like: Examination • Viewing • Filming • 3D • Patient Applications Edit Insert View Setup Image Options System Help Examination Viewing otal mAs: Table: Position Height K oad lecor Reco -400.0 100.0 K Routine Checkup not completed: system should not be used for patient exa .. () Eo ) 23-Oct-2012 18:51:3 A few things to remember about syngo task cards are: Operations and functions on one task card are independent of those on another • task card. It is very easy to switch between task cards to perform a variety of tasks, without • having to “close” any application When a new application is opened, it usually presents as an additional task • cards. 7 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 1.2.2 Main Menu Bar Notes Along the top of every window you will find the Main Menu bar. The Main Menu bar provides shortcut access to all of the options, features and tools specific to that Task Card. All of the Menu Bar shortcuts are dropdowns, offering even more options than what are displayed by default. While many options, features and tools can also be accessed by icons or keyboard shortcuts, the Main Menu bar provides easy, text-based access to virtually everything you need within syngo. Patient Applications Edit Insert View Setup Image Options System Help Examination Viewing Total mAs: Table: Position Height -400.0 100.0 K oad Routine heckup not completed, system should not be used for patient exa .. () Foi)>< 23-Oct-2012 18:51:3 1.2.3 Tool Cards/Subtask Cards Tool Cards house numerous icon shortcuts to most of the features in syngo. They typically duplicate what is also available in the Main Menu drop downs. The Tool Cards are further divided into Subtask Cards which help to organize the shortcuts under common functionalities, like measurement tools and data management. abert applications Transfer Edit View Image Took Scroll Evaluation Ocbons System Help Examination| COWABUNGA Ma 3 PHASE LIVER Viewing Filming oftm4a 119 300-40 300-40 CT 2006AD 1 85 Tools [Image ] View Eval WW 120 ret mAs 200 300 -40 8 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 1.2.4 Status Bar Notes The Status Bar appears at the bottom of the main window as is visible at all times. Here, the system will display real-time status information for functions you have initiated in the background, like network transfers, filming or burning data to disk. Icons on the bottom right are also visible and display the current status of other important processes, like available hard drive and disk space, connection to accessory devices like the i-Control or CARE Contrast injectors, and Expert-i. The USB icon enables safe removal of connected USB devices, like thumb drives or external hard drives. The Status Bar will also always display the current system date and time. Examination | Viewing COW ABUNGA Ma PHASE LIVER Filming Offm4: 119 tel A4+ 200 300 -40 [image | View ES ? Eval 3/1 8/2009 07.44. 9 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 1.2.5 Help Files Notes The Help shortcut in the Main Menu Bar launches the software help files - the Knowledge Gateway. The Help portal offers a comprehensive, organized, searchable database of topics covering all aspects of they syngo software and your scanner. The Help Files can also be reached using the F1 key on the keyboard. This is important to note as F1 launches “context-sensitive” help, meaning you are immediately directed to the text specific to what you were working on at the time. Patient Applications Edit Insert View Setup Image Options System Help Help. About Somaris SIEMENS 32 Settings ? Help AJAJA| Light / Dark al Saved searche Favorite topics Search Library * Save to favorites Add to collection Print Search within page Resizing the Patient Browser Window Enter your search here ... a You can enlarge or reduce the size of the Patient Browser window on your Contents screen. Resizing and maximizing is done so that the status area of the top-most Browsing through Patients' Data - syngo classic task card is always visible. Even after maximizing, the Patient Browser window will not occupy the full screen. + Patient Browser To see as much data as possible, you can adjust the size of the contents Customizing the Patient Br ... and navigation area within the window as well. If you enlarge the contents > Customizing the Patien ... area, the navigation area decreases and vice versa. > Resizing the Patient B ... How to Adjust the Size of the Window > Displaying and Hiding ... > Displaying and Arrangi ... If you want to adjust the window size, move the mouse cursor to a > Switching between Tre ... border until it appears as ! or ... > Enabling the Image Sta ... U Drag the window border to a new position. + Accessing Patient Data Click the El symbol in the upper right comer if you want to + Inspecting EPR and Report ... maximize the window + Maintaining the Database Table: Position Height 0.0 105.0 Routine 1.3 Patient Browser Within syngo, patient data is stored and managed in the Patient Browser. Here is where you have access to all of the patient and examination data stored in the local database or on external devices. The Patient Browser is used to: Locate known patients – currently in the database or in connected external media Schedule future patients – future patients can be pre-registered for easy access upon their arrival Post-process images – images can be loaded from the Patient Browser into other • dedicated software for qualification and quantification Correct or rearrange data – patient information or exam details can often be • edited if initially entered incorrectly 10 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Archive or network studies – patient data can be sent to connected hard disks or Notes • transferred via the network to remote storage nodes Film/print exams – images can be sent to the Filming Task Card for formatting • and printing 0 Patient Browser Patient Applications Transfer Edit View Filter Evaluation Sort Options Help ? Send × SIM Local Database /DE_Bodyangio, ZOE CTA abdominellen . [502] Dose Report Scheduler /DE_Carotid, SCHI CTA Herz [501] Patient Protocol DVD-ROM /DE_Implant CTA thorakalen Aor /DE_VNC_Kidney, RAK CT Abdomen /DE_VNC_Kidney. WUE /SD_AS+_Abdomen_Lebe /SD_AS+_C_L-Spine_Bor /SD_AS+_disc_lombar, Tc /SimPatient2, LSpine /SimPatient3, CAP Patient Name Patie ... ~ Date of Birth Sex |Comm ... Studies |Series | Mark Status Patient Latest Exam ... DB Date and /DE_Bodyangio, ZOE 00214508 07-Oct-1961 M A 27 03-May-2010 13:52:09 24-May-2012 14:2 /DE_Carotid, SCHI 00216197 03-Nov-1955 M 23 14-Apr-2009 10:18:11 24-May-2012 14:3 /DE_Implant Anonymou - O 13 25-Jan-2011 09:52:54 /DE_VNC_Kidney, RAK 24-May-2012 14:5 00216198 13-Nov-1966 M 8 14-Apr-2009 17:41:10 24-May-2012 14:5 /DE_VNC_Kidney. WUE 00104762 25-Mar-1949 F 13-May-2009 11:22:26 24-May-2012 15:0 /SD_AS+_Abdomen_Leber: 00214518 27-Nov-1925 M 7 06-Feb-2008 15:58:23 24-May-2012 15:0 /SD_AS+_C_L-Spine_Bone 10073253 28-Dec-1975 F 8 28-Nov-2010 09:47:41 24-May-2012 14:2 /SD_AS+_disc_lombar, Tour 90900 12-Jun-1959 F 14 09-Feb-2011 10:14:27 24-May-2012 14:2 /SimPatient2, LSpine 1234 02-Jun-1942 M 3 05-Oct-2007 15:20:59 24-May-2012 15:2 /SimPatient3, CAP Anonymou - 20-Nov-2008 12:06:24 24-May-2012 15:3 /SimPatient4, Head Anonymou - 18-Nov-2008 11:53:44 24-May-2012 15:3 OO Current Filter Off If you have an optional CT Workplace, the Patient Browser is shared between the two consoles through a shared database, and patient data is accessible on both. Acquisition CT Workplace Database Workplace 1.3.1 Accessing the Patient Browser The Patient Browser can be accessed from the Main Menu bar under the Patient > Browser drop-down, or conveniently from the numeric keypad shortcuts on the keyboard. Patient Applications Edit Insert View Setup Image Options System Help E-Logbook F12 1 ..... ...... ....... ...... Register. Num 0 Emergency Browser .. Num Examination Job Status Close Patient Filming Layout .. Film Task Status Film Preview .. Expose Film Task Ctrl+F 11 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 1.3.2 Main Menu Notes Just like in the default Monitor Layout, the Patient Browser has a Main Menu Bar. These dropdown menus provide text shortcuts to most every feature and function you will need within the Browser. After you have selected desired data in the Patient Browser, you can use the text dropdowns in the Main Menu Bar to send that data to other applications (such as Filming, Patient Registration, 3D, etc.) Patient Applications Transfer Edit View Filter Evaluation Sort Options Help Import Ctrl+1 × Send to PACS_Primary Num + to Send to PACS_Secondary Send to Export to ... [13] ABD WITH [14] ABD WITH Local Database Finalize Medium and Eject from DVD-Writer domen UROGRA [15] ABD WITH Local Job Status ... Ctrl+L e/s/ Scheduler Network Job Status ... Ctrl+N [501] Patient Protocol Worklist DVD-Writer Import from Off-line .. [601] Raw Data Export to Off-line ... Record Off-line Files 13.02.04-12:46:38-STD-SI 13.02.04-12:44:58-STD-SI PHYSICS2013, annualLAL ACR Phantom Scans, La 1 1 1 1e/s / 12 01 20 18:00:17 STD Patient name EMERY, MADELINE Patient ID 281112 Study description Abdomen UROGRAM (Adult) dy daten Mar-1937 99.4 1014 102.4 103.4 105.4 106.4 107 4 109.4 110.4 112.4 113.4 1144 115.4 Current Filter: C 1.3.3 Tool Bar Below the Main Menu Bar on the Patient Browser is the Tool Bar. This is another area where you can find convenient shortcuts to various features and functionalities, but here they are represented by graphic icons. This area is very configurable, so you can show or hide whatever shortcuts you’d like. After you have selected desired data in the Patient Browser, you can use the icons in the Main Menu Bar to send that data to other applications (such as Filming, Patient Registration, 3D, etc.) Patient Applications Transfer Edit View Filter _Evaluation Sort Options Help ? EE × 12 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 1.3.4 Navigation Area Notes The Navigation Area displays all of the patient examination data that is currently on the hard drive of the CT system or in databases/storage media connected to the scanner. Local Database. /DE_Bodyangio, ZOE CTA abdominellen [502] Dose Report Scheduler /DE_Carotid, SCHI CTA Herz [501] Patient Protocol DVD-ROM /DE_Implant_ CTA thorakalen Aor /DE_VNC_Kidney, RAK CT Abdomen /DE_VNC_Kidney, WUE /SD AS+ Abdomen Lebe /SD_AS+_C_L-Spine_Bor /SD_AS+_disc_lombar, Tc /SimPatient2, LSpine /SimPatient3. CAP The Local Database is where you will find all of the patient examinations that are currently on the hard drive of the scanner. From here, you can view, film, export, transfer, merge, edit, post-process and delete patient scan data. The Scheduler serves to connect your scanner to your facilities HIS/RIS. When configured, patient information will be pre-populated here and can be called up quickly when it is time to scan the patient. Lastly, any external disk drives connected to your scanner will be displayed. Here you can view and import patient studies that have been saved to a CD or DVD. Local Database . Scheduler DVD-RW DVD-ROM 13 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 1.3.4 Navigation Area Notes In the Navigation Area, patient data is displayed in a hierarchy, starting with the selected database to the patient folder level to the examination level to the individual scan series. patient folder patient examinations examination series CT. Brain Stroke P CT ain Tumor Pe Local Database . CT_Colonography_ _ Colonography [6] Colo_prone 0 75 B20f R/11111 1 DVD-ROM CT_NeuroDSA_CO [4] Colo_sup [6] Colo_prone DVD-RW E16_NeuroDSA_C€ S64_NeuroDSA_C S64 NeuroPerfusio SD_AS+_VPCT_Br Data here can be sorted or filtered in a variety of ways to display only the data of interest: Filtering allows for the display of only a sub-set of the database to be displayed • for instance, only abdomen studies or only head studies. A pink cone (coffee – filter) icon on the left side of the Browser indicates that a filter is active. Patient Applications Transfer Edit View Filter Evaluation Sort Option Off Ctrl+F Not Archived Not Printed Not Sent Not Marked Marked Not Exported Local Database_ 1 Head 2 Neck Scheduler 3 Shoulder 4 Thorax DVD-RW ASIT 5 Abdomen AS 6 Spine DVD-ROM Z Pelvis 8 Specials 9 Upper Extremities AS A Lower Extremities B Cardiac rss C Vascular D PET E Private E SPECT G RT H Raw Sorting helps organize the patient data and helps to find studies more quickly. • Data may be sorted chronological or alphabetical, by slice location or image number, depending on the browser level selected. Select the level for sorting (Local Database, Patient, etc.) and open the Sort function in the Browser Main menu 14 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 1.3.5 Content Area Notes The Content Area offers a preview look of any images selected above. These can be sorted/displayed by Slice Location or by Image Number, in either ascending or descending order. The Content Area can be also be displayed in Image Stamps or Image Text by toggling the View > Image Stamps. Patient name $64_Orbital_Fracture tion Head FacialBone Date of birth 09-Sep-198 Study date 30-Jun-2005 1 2 3 4 21.2 6 7 8 9 22.6 20.5 19.8 191 18.4 17.7 17.0 15 12.8 16 12.1 HA 18 10.7 19 10.0 29 30 1.6 32 0.2 -0.5 35 2.6 Patient name S64_Orbital_Fracture Study description Head_FacialBones Date of birth 09-Sep-1984 Study date 30-Jun-2005 Imag ... Image Type |Slice Width |Slice Po .. KV MAS Gantry Tilt Kernel |FoV Image Comm ... |Mark Status |Work Status KV mAS SPI 1.0 22.6 120.0 115 U.UU [H60s] 240 R///// 1.0 21.9 120.0 115 0.00 SPI 1.0 [H60s] 240 R///// 21.2 120.0 115 [H60s] 240 R///// 1.0 20.5 120.0 115 0.00 [H60s] R///// 1.0 240 19.8 120.0 115 0.00 1.0 [H60s] 240 R///// SPI 19.1 120.0 115 0.00 [H60s] 240 R///// 1.0 18.4 120.0 115 0.00 [H60s] 240 R///// SPI 1.0 17.7 120.0 115 0.00 [H60s] 240 R///// 1.0 17.0 120.0 115 0.00 [H60s] 240 R///// 1.0 16.3 120.0 115 0.00 [H60s] 240 R///// 1.0 15.6 120.0 115 0.00 [H60s] 240 R///// 1.0 14.9 120.0 115 0.00 [H60s] 240 R///// 1.0 14.2 120.0 115 0.00 [H60s] 240 R//// / 1.4 Viewing Task Card The Viewing Task Card is where examination images can be viewed, optimized and evaluated. Here you can choose different layouts, manipulate and scroll through data, and perform measurements for evaluation. Up to three patient “folders” can be loaded in at a time. 2008AD 1.03 H-SP-CR COW ABUNGA Ma 3 PHASE LIVER BV 120 elf /As 119 ret MÃE 200 300 -40 T 200640.1 00 H-SP.CR Patient Eval 15 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 1.4.1 Loading Images Notes Entire patient examinations, single series, or individual images can be loaded into the Viewing Task Card from the Patient Browser. Launch the Browser and select the desired data. If the Viewing Task Card is already open, simply double-click the data to load, or use the icon on the Tool Bar or the drop down in the Main Menu Bar to load to viewing. The folders on the right are placeholders for loading up to three different patients at the same time. Patient Applications Transfer Edit View Image Tools Scroll Evaluation Options System Help Register ... Num 0 Examination Emergency ... Load to Viewing Load Report Load Last Report Reconstruction Update Reference Lines Mode Reference Lines Viewing Export CT Patient Browser Import CT Patient Applications Transfer Edit View Filter Evaluation Sort Options Help ? Filming La Film Task Load to Viewing Ca Film Previe Expose Fil [11] Delays 5x5 Copy to Fi [10] With Contrast 5x5 Show MPF Local Database Abdomen ABDWW [9] Non Contrast 5x5 Complete 3 PHASE LIVER Scheduler [1] Topogram 0.6 T20s Print Previ Print Previ DVD-ROM Abd Angio Print List DUIWIL Print DVD-RW AORTA (AAA) View CAP Search CAROTID CTA 1 Close Bros CAROTID CTA 2 Carotid w/ Stenosis CHEST (ECG GATED) itient Eval 23 .57.0 24 25 26 27 28 29 30 31 32 33 .62.0 -67.0 -720 -77.0 -82.0 -87.0 -92.0 -97.0 -102.0 -107.0 Querying database ... Current Filter. Off PNP Device Mounted - Drive(l:): Total Space(1910 MB) XOu 03-Oct- 2013 10-5 1.4.2 Layout of the Viewing Card The Viewing Task Card consists of three primary areas - the Main Menu Bar, the Image Area, and the Control Area. Just like in the default Monitor Layout and the Patient Browser, the Viewing Task Card has a Main Menu Bar as well. These drop-down menus provide text shortcuts to most every feature and function you will need within the Viewing Card and corresponds to the tools available in other icons on the screen. Patient Applications Transfer Edit View Image Tools Scroll Evaluation Options System EBp Examination Viewing Filming PHASE ABD TOOLS Image View 16 CT Advanced Scanning Techniques | Classroom & Turnover Workbook The Image Area of the Viewing Task Card is where the patient data is displayed, Notes • evaluated and optimized. The layout can be configured to meet a variety of evaluation needs. Patient Applications Transfer Edit View Ime Is Scroll Evaluation Options System Help Examination Viewing HASE ABD Filming 03-Oct-2013 11:03 The Control Area of the Viewing Task Card is on the right side of the screen, and • includes the patient folders and Tool Cards. The folders on the right are placeholders for loading up to three different patients at the same time. The open folder indicates the patient that is currently visible on the screen. Patient Applications Transfer Edit @ Tools Scroll Evaluation Options System Examination Viewing Filming 3 PHASE ABD Tools Image View Patient 03-Oct-2013 11:03 17 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 1.4.3 Image Manipulation in Viewing Notes There are many different ways to manipulate the images in the Viewing Task Card. Note that most of these functions are not exclusive to just the Viewing card but work throughout the syngo software. In the Viewing Task Card it is possible to manipulate a single image or multiple images simultaneously and only depends on what is selected - or active - at the time. An “active” image segment is one that has a blue border around it. To select a single image, click on it with the mouse. The image will be marked • with a blue dashed border, indicating it is active. To select several different images, click on them with the mouse while holding • down the CTRL key. This is typically referred to as multi-select. 12-12-20 16 :28- 12- SID- Specials 12.12.20-16:28:13-STD-Specials Po ... KV 100 |12.12.20-16:28:13-STD-1.3.12 .... eff mAs 96 ref.mAa 261 OTOO SL 5.0.32x1.20] 366-2/0 18 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Panning and Zooming functions are enabled by default in the Viewing Task Card. Notes To pan an image, simply click and drag in the center of a segment to move the • image to the desired location. To zoom an image, click and drag near the edge of a segment. Moving the mouse • up enlarges the image; moving the mouse down reduces the image. 12.12 20-16:28-13 STD Specials Po . 12.12 20-16:28:13-STD-1 3.12 .... im Homotol SOMATOM Definition 51 25 Pan SOMATOM Definition2123 H SP CR kV 100 Jeff.mAs 95 ref.mAs 261 .TI 0.5 GT 0.0 SL 5.0/32x1.2/00.6 :366 -2/0 B30f S3C0 A1eva Zoom Pan/Zoom Pan/Zoom Reset 30f $300 A12 You can Scroll through images in the Viewing Task Card depending on the current layout: If the images are stacked, the dog-ear in the upper right corner allows you to page • through data forwards or backwards, one image at a time. The vertical scroll bar allows you to do the same, or you can click a scroll bar end • point to jump directly to the first or last image in the set. There are also options on the numeric keypad to scroll forwards or backwards • through images, exam series or entire studies. Dog Ear Image () and (+) SOMATOM Definition Flash - First Page Center +/ Image (-) Page (-) + Scrolling Series +/- Page (+) Scrolling Image +/ + KV 100 eff mAs 95 fref mAs 261 Image (+) GT 0.0 SL 5.0/32x1.2/p0.8 366 -2/0 B30f S300 A1 eva Last Page 19 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Images in the Viewing Task Card can be Windowed to change the contrast and Notes brightness using the middle mouse button or scroll wheel, depending on your hardware. Drag the mouse left or right to adjust the contrast, or the window width. • Drag the mouse up or down to adjust the brightness, or the window center. • The actual window values are displayed within the image. To restore the original window values, you can select Image > Home from the Main Menu Bar AS+RenaICTA Definition AS: AS+RenalCTA H Definition AS. 21-Jul-2010 09:06:48.77 9 IMA 0 MPR IAL A SL 1.0 298 | SL 1.0 1400 AS+RenaICTA Definition AS CT 2008G AS+RenBICTA 6ª Jul-2010 9 in 49.77 A LA 1.4.4 Tool Cards The Viewing Tool Cards house a wide assortment of image display and evaluation icons, like measurement Tools Image View tools and data management functions, all easily accessible and neatly grouped under tabbed headers. The properties of many of the tools can be configured by XYZ right-clicking on a button to view and modify the properties. Patient Eva 20 CT Advanced Scanning Techniques | Classroom & Turnover Workbook The Tools Tab contains all of the features and functions related to measuring and Notes annotating your patient images. Tools Image View The first column of buttons contains the region of interest tools. Use these to draw circular, rectangular or freehand ROIs on patient images. XYZ ROI Circle • ROI Rectangle • Freehand ROI • The second column of buttons enables various measurement functions. The ruler icon is a straight-line distance measurement - just click and drag to measure any length. The center icon is the pixel lens tool, which measures a 5x5 pixel size wherever you click. And the Freehand Distance allows you to evaluate the length of an irregular shape - just click and drop points around an object, and double click when done. Distance • Pixel Lens • Freehand Distance • In the third column of buttons you’ll find the Angle measurement tool, the annotation icon and the crosshair. The angle measurement allows you to draw two lines and have the angulation between them displayed. You can add text onto your images with the annotation icon - just click where you would like the content to go and begin typing. The crosshair icon allows you to drop references axes on your image to help with setting measurement points. Angle • Annotation Text • Crosshair • The Image Tab contains tools for manipulating the size, position or appearance of your patient images. Tools Image View The first button will quickly magnify a selected image • by 2. The second and third icons enable and reset the pan • and zoom functions. R R RT B 20 The icons on the second row allow you to flip your • images left to right or top to bottom, or rotate an image in 90 degree increments. N - O NOTE: that the “flip” functions do NOT change the patient positioning indicators - the markers move with the image and do not re-label an incorrectly positioned patient. The bottom row icons quickly access stored windowing presets, such as lung or soft tissue. 21 CT Advanced Scanning Techniques | Classroom & Turnover Workbook The View Tab contains tools that allow you to change the screen layout. Notes The first two buttons enable image stripe - meaning • images are displayed one right after the other in Tools Image View adjacent segments - or image stack, where you can scroll through your images within the same segment. The interactive movie icon allows you to flip through • a series of loaded images so they are displayed as a movie. You can do this manually with the mouse, or automatically by setting various properties like speed and direction. The next few icons offer various screen layouts, from 1 on 1 up to 64 on 1, to meet • virtually any type of viewing need. The last icon allows you to load two different series, studies or even patients for • side by side comparison. The Patient Tab contains additional shortcuts to common syngo functions. Their availability and location may differ on your system. Patient Eval On the Acquisition Workplace, the first row of icons • on the Patient Tab provides quick access to =B registering a patient, closing an open patient folder or opening the Scheduler. The second row offers a filming preview shortcut and • the ability to push selected data to the Filming Task Card. The last row offers a shortcut to the Patient Browser • and a button to push selected data to the 3D Task Card. The last set of tools on the Evaluation Tab offer the ability to perform some advanced manipulations to gray Patient | Evaluation scale images when the raw data for these images is no longer available. X RJ The first button - Average - allows for the creation • of a new series from two or more images that have been averaged together. The second button - Filter - enables you to apply a • variety of image-data filters [like Low Contrast Enhancement or Advanced Smoothing Algorithm] when you no longer have the raw data to simply reconstruct in a different kernel. The last button - Subtraction - allows for one dataset to be subtracted from • another - like contrast and non-contrast - if other dedicated software for this function is not available. 22 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 1.5 Filming Task Card Notes The Filming Task Card serves as a virtual film sheet where images can be organized and formatted prior to sending to a film or paper printing device. Patient Applications Edt Film Image Options System Help Examina ... Viewing Filming 1 of 4 CT64707 E Last Sheet 1 image(s) 1 Copies 3D Expose every 11 Simulati ... expout |Images |Camera 29-Apr-2014 13:59:37 Several sets of tools enable customization of the film job prior to printing. Number of Copies • 1 Copies Expose Film Job (Send to Print) • Auto Expose • Film Job Status • Delete auto • EA Window Presets 1 & 2 • Zoom/Pan • Reset Zoom/Pan • 23 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 1.5.1 Filming Tool Cards Notes The Layout Tab offers several ways to format the film sheet, from 1:1 to 30:1. Layout Images |Camera The Images Tab offers tools to customize the amount of text shown on each image, to show or hide image graphics, and to size the image to the segment. Layout Images Camera N The Camera Tab allows for the selection of the desired camera/printer (if more than one is available) and the desired film size. Layout | Images |Camera Camera PRINTER Status: Not Ready Film Size Inch 14x17 24 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 2. System Hardware 2.1 Objectives Notes This section will review the primary hardware components of your CT scanner, including: Gantry • Table • Acquisition Workplace [Monitors, Computers, Input Devices] • Phantoms and Accessories • After completing this section, you will be able to: Identify the primary gantry components of the CT System • Identify the table features and weight limits • Identify the control room hardware and input devices used to control and interact • with the system NOTE: The pictures of the components shown here are only examples. The appearance of your components depends on the system configuration. 25 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 2.2 Gantry Notes The interior of the gantry consists of the rotating x-ray detector system. This includes the x-ray tube and collimator and the UFC (Ultra Fast Ceramic) or Stellar detector system. The gantry also contains the generator, the motor drive, the data acquisition system and the unit control. The gantry contains laser light markers for vertical and horizontal positioning as well as the microphone and loudspeaker for the intercom system. (4) SIEMENS (3) (1) (1) SOMATON (2) 1. Gantry operator panels 2. Laser light markers 3. Display 4. Loudspeaker and microphone on the back of the gantry 26 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 2.2.1 Gantry Operator Panels Notes To the left and right on the front of the gantry, there are gantry operator panels with keys and displays for gantry and patient table control. Load STOP Scan Stop Patient Scan Start Horizontal Zeroing Laser Light Fast Out Fast In Gantry Tilt Presets A/B Unload Patient Table Adjust Keys 2.2.2 Gantry Display The gantry display is located at the front of the gantry. With this display you can observe your system operation. (1) (2) (3) 30 kV 180 m/ 5.83 s (2) (3) CU ky 350 mA 100 s 160 -1886.5 +30.0º +00.0 : 125 John Doe AccNr 905523692786 › -1886.5 1. Tube voltage (kV) 2. Tube current (mA) 3. Scan time (topograms or sequences) / Rotation time (spirals) 27 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 2.2.3 Gantry Tilt Notes The gantry can be tilted forward (+) or backward (–) up to 30° depending on the system configuration and current scan parameters. + 2.2.4 Gantry Connectors On the front of the gantry at the bottom is a removable cover under which can be found connection ports for various optional accessories. These include features such as a scanning footswitch, respiratory gating system, CARE Contrast system, and the interventional iControl. Please consult your Siemens representative regarding your purchased optional equipment.. DMATOM (3) (4) ( 2 ) Josie ( 1 ) (3) SOMATOM Scope SOMATOM Perspective 1. Scanning footswitch (optional) 1. i-Control (optional) 2. Push button for plug release 2. Scanning footswitch (optional) 3. Respiratory gating (optional) 3. Push button for plug release 4. Hole for cables, including bolus injec- 4. Respiratory gating (optional) tor cable (optional) 5. Hole for cables, including bolus injec- tor cable (optional) 28 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes -I. X 322 SOMATOM Definition AS NOTE: On some Perspective scanners the foot switch connection is located below the foot pedals that control table movement. To connect footswitch: lift cover; plug in footswitch, lower cover with cable resting in notches shown below. 2.2.5 Gantry Lighting – SOMATOM Perspective (optional) On the right side of the gantry is the LED light panel that provides a more comfortable scanning environment. Its color changes according to your configuration. 29 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 2.3 Patient Table Notes The patient table facilitates movement into and out of the gantry for CT examinations. Table weight limits and scan ranges vary based on hardware and purchased options. Please consult your Siemens representatives regarding your specific configuration. SIEMENS SOMATOM (2) (1) (3) 1. Patient table with movable table top 2. Handle on the table top with locking device 3. Label: The patient table corresponds to type B applied part. It is protected against electrical shock by limiting admissible leakage currents in accordance with IEC 60601-1 30 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes 2.4 Acquisition Workplace/Console The Acquisition Workplace/Console includes all of the components used to interact with the scanner and the patient. (6) (2) (3) (1) (4) (7) .... 1. Monitor 2. Control box 3. Keyboard 4. Mouse 5. Image control system (ICS) 6. Image reconstruction system (IRS) 7. Uninterruptible power supply (UPS) NOTE: On the Scope system, the PSB (Power Switch Box) replaces the UPS, which is an option. 31 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 2.4.1 Computers Notes The CT scanner is controlled by two main computers, the image control system and the image reconstruction system. Depending on the delivery date, the design of these computers may vary. (1) (2) 1. Image Reconstruction System (IRS) 2. Image Control System (ICS) The image control system (ICS) is the computer on which you make all your entries. With it, you control the CT scanner, evaluate your studies and store them. The image reconstruction system (IRS) communicates with the scan system. It uses the measured data of the detector system to calculate the images for each slice. It then passes on the data to the image control system. 2.4.2 Monitor On the monitor, you can see and control the examination procedure and view the images. An additional monitor for use in an examination room or doctor’s room is available. 32 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 2.4.3 Mouse Notes The mouse is used to navigate through the syngo software. The left mouse button is used to click on and select objects. The right mouse button is used to call up context menus that serve as shortcuts to common commands. The scroll wheel is used to scroll through images or adjust window/level settings. FUITTSU 2.4.4 Keyboard The keyboard is an important input device that is used to type characters, numbers, and commands into the syngo software. NOTE: Only use a keyboard approved by Siemens. (1) FUJITSU (2) (3) (4) 1. Function keys 2. Typewriter keyboard 3. Cursor keys 4. Symbol keypad 33 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 2.4.5 Numeric Keypad Notes The Siemens keyboard replaces the standard numerical keys with quick-access shortcut keys for commonly used functions. Numerals can be entered using the numerical keys on the top row of the keyboard. O 1 + + - + - + B + H3 + D 34 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 2.4.6 Control Box Notes During the exam, the operator remotely controls the table and gantry - as well as the radiation - with the control box at the main scanning console. Buttons on the control box allow the operator to raise or lower the table, or move it out completely to a parked position. For gantries that tilt, the control box allows the user to angle the gantry in a positive or negative direction up to 30 degrees. The control box also enables the user to start, stop, or pause the radiation in the scan room. The patient communication system is also built into the control box, and the operator can listen to the patient and deliver necessary scanning instructions without being in the scan room. SIEMENS (7) (8) (6) (9) (5) STOP (10) (4) (1) (3) (2) NOTE: It is important to observe any motion of the table and gantry at all times in order to ensure patient safety. 1. Move key: Use this key to move the patient table or tilt the gantry to the next mea- suring position. 2. Unload patient key: Use this key to unload a patient. 3. Start key: Use this key to trigger a scan. 4. Radiation warning lamp: This display lamp lights up during radiation 5. Suspend key: Use this key to hold the scan procedure. This is the preferred method for interrupting a scan before completion. You should not use the STOP key for this purpose. 6. Hear patient key: Press this key if you want to hear what the patient is saying. The light diode indicates that the listening connection is active. Press the key again to release the listening connection. 7. Loudspeaker 8. Call patient key: Hold this key down while you are speaking into the microphone. 9. STOP key: Use this key to stop scanning altogether in an emergency. 10. Microphone 35 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 2.5 Positioning Accessories Notes Siemens also offers a wide variety of optional accessories for scanning, including a table top foot extension, standard head holder, tiltable head holder, head and arm support cushion, foot pedal and positioning sponges. NOTE: Please consult with your Siemens representative for a list of the accessories suitable for your workflow and system. AA A 3.1 Objectives After completing this section, you will be able to: Select an appropriate scan protocol • Modify scanning parameters as needed • Perform a CT examination • Reconstruct examination images using WorkStream4D • Utilize iterative reconstruction methods to improve image quality/reduce dose • 36 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 3. Scan Acquisition and Reconstruction 3.2 Scan Protocol Selection/Patient Model Dialog Notes The Patient Model Dialog is the interface where scan-specific information – like patient position and breathing instruction language – is selected prior to a scan. It is also where the desired system scan protocol(s) is/are chosen for the current patient examination. Patient Model Dialog (1) Adult I Ene Protocol . Replace Child Append () (4) ardia .(6) Topogram . Cut scu (8) .Keep (2 ) (5)- RT Auto reference lines None (9) ecia (3) rivat API Language German (10) OK Cancel 1. Adult/Child – the system stores two distinct sets of protocols: one set for adults, and one set for children. These can be customized to meet desired scanning needs. 2. Patient Position – select the appropriate icon to define the patient position on the table. The system will then label all images appropriately with right, left, anterior, posterior, etc. 3. Change Patient Position – this icon is typically used during an exam when the patient positioning is changed for further scanning (e.g. between supine and prone high-resolution chest exams). 4. Cardiac Wizard – if available, the Cardiac Wizard provides a customizable step- by-step tutorial for performing a Cardiac CTA examination. 5. Patient Protocols – here, patient protocols are stored under their respective body regions. Hover the mouse over a body region to see and select the desired protocol. 6. Patient Protocols – if available, additional patient protocols are stored under spe- cialty headers such as Dual Energy and Radiation Therapy. 7. Replace/Append Protocol – when combining protocols into a single examination, this option allows for a second protocol to replace what has already been selected or to be added to what has already been selected. 8. Cut/Keep Topogram - when combining protocols into a single examination, this option allows for the Topogram of the second protocol to be removed or kept. 9. Auto Reference Lines – enables choices for populating scan reference lines on the Topogram. 10. API Language – enables the selection of the Automated Patient Instruction (breathing instruction) language. Ensure that the desired scan information has been selected, and click OK. 37 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 3.3 Review/Modify Topogram Parameters Notes Prior to any scan, a topogram must be acquired. The topogram serves many purposes it is used to check for accurate, isocenter patient positioning; it is used to identify – objects that could cause artifacts; it is used to plan the scan; and it is used by CARE Dose4D to define appropriate dose modulation for the patient. Three parameters should be reviewed prior to acquiring the topogram: 1. Topogram length (128, 256, 512, 768, 1024, 1536, 2048) 2. Tube position (Top, Bottom, or Lateral) 3. Scan direction (Craniocaudal, Caudocranial) mA 36 kV 120 Scan time 5.3 s Slice 0.6 mm (1) Topogram length -512mm (2) Tube position Top Bottom Latera Comments Table: Position Height 0.0 M 150.0 Craniocaudal (3) Routine Scan Auto Tasking 3.4 Dual Topogram The Dual Topogram feature helps to synchronize the scan range when two topograms are used. When acquiring a topogram range, the table continues to move after the radiation ends because the table must decelerate before it comes to a stop. Previously, if a second topogram was added (e.g. when adding a lateral 1st Topo Scan begin topogram to an AP topogram), the table would Scan en start from the last table feed in position and scan in the opposite direction. Because feed out of the deceleration range of Scan range the first topogram, the Scan range second topogram range does not correlate. This results in Table Slow down Scan en unequal topogram coverages and unnecessary Table stop Scan begin 2nd Topo radiation dose to the 1st Scan end # 2nd Scan begin patient. 1st Scan begin # 2nd Scan end 38 CT Advanced Scanning Techniques | Classroom & Turnover Workbook With the Dual Topogram feature, the table start position for the second topogram Notes will be adjusted automatically, resulting in two topograms with the same z-axis coverage. 1st Topo Scan begin Scan end feed in feed out Scan range Scan range Table Scan end Scan begin Slow down Table Move Table stop 2nd Topo 1st Scan end = 2nd Scan begin 1st Scan begin = 2nd Scan end Dual Topogram is included by default in all Cardiac scan protocols and in the SpineSeq scan protocol. It can be added manually to any other scan protocols. To add a second topogram using the Dual Topogram feature: In the chronicle, select the first/existing topogram either before or after scanning • it. From the right mouse button menu, select Repeat. A second topogram is added. Topogram Control Scan Add Scan Chest wo RT 3D 3D Pause Memo Contrast Bolus Tracking Cut Copy Paste Repeat On the Routine subtask card, enable Attach to previous Topogram. The • Topogram length will be copied, the tube position will be changed to the 90 degree orthogonal position, and the Scan Direction will be reversed automatically. Topogram mA Topogram KV 130- Chest wo Scan time 5.7 s Slice 0.6 mm Topogram length 485 mm Attach to previous Topograr Tube position Top Bottom Lateral Comments Table:Position Height direction 26.0 - 119.0 Caudocranial 39 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 3.5 Review/Modify Scan Parameters Notes Check the default scan parameters on the Routine and Scan cards and adjust if necessary. The Routine subtask card displays the following parameter information: 1. Radiation parameters 2. Time settings 3. Slice thickness/collimation 4. Number of image 5. Comment lines 6. Examination range, current table position (horizontal and vertical), and scan direction 7. Incremental table controls (up/down; in/out) Eff. mAS CARE Dose4D (1) kV 120 CTDIvol (32cm): mGy DLP mGy*cm Scan time (2) 5.15 s Delay 2 5=| (3) Slice 5.0 mm Acq. 128 x 0.6 mm (4) No. of Images = 41 (5) Comments Range: Begin End Table: Position -50.03 . Height KI (7) (6) -250.0 0.0 150.0 Craniocaudal Routine Scan Recon Auto Tasking The Scan subtask card contains additional information including Automatic Patient Instructions (API) and CARE Dose 4D controls. Rotation time, scan time and the pitch factor may be adjusted here. 1. CARE Dose parameter 2. Time parameters 3. Slice/collimation and pitch 4. Radiation start point and API. (1) CARE Dose4D M CARE KV ( 3) Slice 5.0 mm - Acq. 128 x 0.6 mm Pitch 0.6 Eff. mAS kV 120 Direction Craniocaudal Organ characteristic: Abdomen CTDIvol (32cm): mGy DLP: mGy*cm (2) Scan time 5.15 s (4) Scan start Start button Rotation time 0.5 s Delay 2 s Language German API None Routine Scan Recon Auto Tasking 40 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 3.6 Review/Modify Reconstruction Parameters Notes The Reconstruction subtask card contains all of the parameters necessary to customize a scan series as desired. (1) Recon job 2 3 4 5 6 7 8 Series description Abdomen 5.0 B30f (2) Slice 5.0 mm (8) Recon job type . Axial 3D (3) SAFIRE (9) Recon region Narrow Wide (4) Kernel B30f medium smooth Abdomen - Diaphragm to Ischium (5)FAST Window Abdomen Begin position 50.0 mm End position -350.0 mm == (6) HD Fov FoV 300 mm (10) Image order Craniocaudal Center X 0 mm Increment 5.0 mm Overview Center Y 0 mm il (11) No. of images 61 Mirroring None Comments (7) Extended CT scale (12) Routine Scan Recon Auto Tasking 1. Selected reconstruction job and series 7. Extended CT Scale description 8. Recon job type 2. Reconstructed slice thickness 9. Recon region coverage 3. SAFIRE/ADMIRE (Iterative reconstruction) 10. Image order 4. Kernel/algorithm 11. Reconstruction increment and num- ber of images 5. FAST Window and Organ-specific window 12. Recon specific image comments 6. Extended/HD FoV and Positional details To add and customize additional reconstruction jobs, click on the next free radio button to add a new job. If no recon jobs are available (if all of the radio buttons have been used), delete a recon job that has already been reconstructed to free a space. NOTE: This does NOT delete the reconstructed images from the Patient Browser – only the completed job in the chronicle. Recon job & # 2 4 3 8 7 8 3.7 Review/Modify Auto Tasking Parameters The Auto Tasking subtask card allows reconstructed data to be automatically transferred to various locations, including the Filming card, the 3D card, remote network nodes, etc. Auto Tasking parameters are defined individually for each recon job. 41 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 3.8 Save Protocol Changes Notes User-modified scan protocols can be saved for future use. Confirm that all parameters on the Routine, Scan, Recon, and Auto Tasking • subtask cards are as desired. Save the protocol by clicking Edit > Save Scan Protocol • Rename the protocol to something relevant and click Save • Save Scan Protocol ? X Save in: MIAbdomen to AbdMultiPhase.MIAdult ................................................................................................................................. AbdomenRoutine.MIAdult AbdomenSeq.MIAdult AbdomenVol.MIAdult Colonography.MIAdult File name : ABDOMEN_W_WO_Customized Save Save as type: | MIAdult Files Cancel NOTE: Saving the protocol without changing the name will override the original protocol used. Siemens recommends renaming customized protocols – perhaps using UPPERCASE letters for easier identification - leaving the Siemens defaults unchanged. NOTE: Protocol names can only include letters, numbers and underscores. Spaces, dashes, or other special characters are not allowed. Protocol names can be up to 44 characters long. NOTE: Siemens recommends saving customized protocols in their original folders. NOTE: User must have sufficient privileges or authority to make changes to saved scan protocols. In the Patient Model Dialog, user-customized scan protocols are indicated by a dot in front of the name. 42 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 3.9 Topogram and Range Manipulation Notes There are many standard and optional software features that help facilitate workflow and the process of scan planning and preparation. 3.9.1 Auto FoV Auto Field of View (FoV) automatically resizes the displayed field of view (graphical scan range box) to best accommodate the size of the current patient. Auto FoV saves time in setting up patient studies and promotes scan consistency. Only recon ranges that have Auto FoV turned on will be affected. These protocols have Auto FoV enabled by default: Head • Shoulder • Abdomen • Pelvis • Extremity • Body Angio • Trauma • Once a topogram is scanned, the FoV is adapted automatically to the body contours. If you move the range along the Z-axis, the XY contours update in real time. ETEST. PATIENT Hospital: :TEST, PATIENT Hospital::TEST, PATIENT Definition AS 01234567 Definition AS:[01234567 CT 2010B :*12-Sep-1962, M, 50Y CT 2010B *12-Sep-1962, M, 50 1-2 H-SP 12-Sep-2012 1-2 H-SP::12-Sep-2012 1-1 :18:10:06.84 18:10:06.84 1 IMA 1 IMA TOP 1 SP -1.0 388 If needed, the FoV can be adapted manually. Auto FoV is then temporarily switched off for that scan/reconstruction. 43 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 3.9.2 FAST Planning Notes FAST Planning automatically identifies anatomic landmarks on the acquired topogram and adapts the scan range and FoV to incorporate desired anatomy for the current patient based on selectable presets. It also automatically adapts head scans to isocenter. Recon region: Narrow . Wide Upper Abdomen - Diaphragm to lliac crest . None E-Neck Vascular +- Thorax -Cardiac El-Upper Abdomen Diaphragm to lliac crest - Diaphragm to llium Liver FAST Planning benefits: Easy, built-in workflow • Faster scan planning customized to each patient • More consistent, standardized planning of scan ranges • Improved head image quality with adaptation to isocenter • 3.10 Image reconstruction 3.10.1 3D Image Reconstruction - WorkStream4D WorkStream 4D allows for the reconstruction of sagittal, coronal and/or oblique MPRs and thin MIPs directly in the Recon card without the need for thin, overlapped data sets or dedicated post-processing in the 3D card. STEP 1 – Enable 3D Reconstructions On the Examination Recon card, select 3D as the Recon job type. Recon job 1 8 8 4 5 8 7 8 Series description Abdomen 5.0 SPO ax Slice 5.0 mm Recon job type axial G 3D IRIS Recon axis axial Kernel B30f medium smooth Window Abdomen Type SP oblique Image order Head to feet Position increment 5.0 mm FOV 342 mm x 342 mm No. of images 41 = Comments Routine Scan Recon Auto Tasking The screen layout will change to display coronal, axial and sagittal planning images. 44 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes STEP 2 – Adapt the FoV, Range, and Direction The pink box represents the desired FoV. The orange boxes represent the recon range and direction. TEST. PATIENT Hospital TEST. PATIENT Hospita TEST. PATIENT 01234567 01234567 *12-Sep-1962, M. 50Y "12-Sep-1962, M. 50Y 12.Sep- 1982. M. 50Y 12-Sep-2012 12-Sep-2012 18:15:14.39 18:15:14.39 MPR 2 MPR 2 MPR 2 A Adjust these boxes to include the anatomy desired in the reconstruction. • Rotate boxes as necessary to plan oblique ranges. • ODD Resolution 512 square Planning base Abdomen 5.0 B30f TEST , PAT 512 square 512 non-square :34567 Total mAs: 1033 256 non-square(reduced image resolution) TEST. PATIENT Hospital TEST. PATIENT TEST. PATIENT Hospital 01234567 01234567 "12-Sep-1962, M, 50Y "12-Sep-1962, M, 50Y 12. Sep-1982. M. 50Y 12-Sep-2012 12-Sep-2012 18:15:14.39 18:15:14.39 MPR 2 MPR 2 MPR 2 E SL 3.0 If desired, a non-square reconstruction matrix can be defined to further limit the anatomy included in the reconstruction, e.g. for spines. 45 CT Advanced Scanning Techniques | Classroom & Turnover Workbook STEP 3 – Review and Modify Parameters Notes In the Recon subtask card, check the reconstruction parameters and modify if necessary (e.g. desired slice thickness and increment, image order, kernel, and the Type of image to be reconstructed (MPR or MIP Thin)). Recon job 1 8 8 4 8 8 7 8 Series description Abdomen 5.0 SPO sag Slice 5.0 mm Recon job type @ axial O 3D IRIS Recon axis sagittal Kernel B30f medium smooth Window Abdomen Type SP oblique Image order Left to right Position increment 5.0 mm FOV 126 mm x 326 mm No. of images 26 Comments Routine Scan Recon Auto Tasking STEP 4 – Reconstruct the Series To reconstruct the series: Click the Recon button • Load Hold Recon Recon 3.10.2 Iterative Reconstruction – IRIS, SAFIRE, ADMIRE IRIS (Iterative Reconstruction in Image Space), SAFIRE (Sinogram Affirmed Iterative Reconstruction), and ADMIRE (Advanced Modeled Iterative Reconstruction) are reconstruction technologies that allow scans to be acquired at lower doses and reconstructed with image quality that is comparable to full-dose scans. NOTE: Please consult with your Siemens representative for details on which Iterative Reconstruction solution is available for your system. 46 CT Advanced Scanning Techniques | Classroom & Turnover Workbook How to Enable and Use IRIS Notes STEP 1 – Enable IRIS for a Reconstruction Job On the Recon subtask card, select the IRIS checkbox to activate the IRIS mode. The Recon job number is marked in blue indicating IRIS is active for that • reconstruction job. The Kernel selection list on the Recon subtask card changes to the Algorithm • selection list. The algorithms are marked by the characters “I” (for body, counterpart of • B-kernels), “J” (for Head, counterpart of H-kernels), or “V” (for UHR, counterpart of U-kernels), for example, I30f, I30s, J30f, J30s, V80u, V90u. Recon job 2 3 4 5 6 78 Series description AbdRoutine 5.0 141s Slice 5.0 mm Recon job type o axial 3D IRIS M Recon begin -1228.0 mm Algorithm 141s medium + Recon end -1428.0 mm Window Abdomen Image order Craniocaudal Recon increment 5.0 mm Extended Foy D FoV 300 mm No. of images Center X 0 mm Overview Center Y 0 mm Comments feASAsd STEP 2 – Select the Desired Algorithm From the Algorithm selection list, select the desired algorithm depending on the body region you want to examine. STEP 3 – Begin the Reconstruction Start the reconstruction by clicking the Recon button. NOTE: IRIS cannot work with Extended FoV or Extended CT scale simultaneously. NOTE: Do not load IRIS images into syngo Osteo CT or syngo Calcium Scoring CT. 47 CT Advanced Scanning Techniques | Classroom & Turnover Workbook How to Enable and Use SAFIRE or ADMIRE Notes STEP 1 – Enable SAFIRE or ADMIRE for a Reconstruction Job On the Recon subtask card, select the SAFIRE or ADMIRE checkbox to activate the respective iterative reconstruction mode. The Recon job number is marked in blue indicating SAFIRE/ADMIRE is active for • that reconstruction job. The Kernel selection list on the Recon subtask card changes to the Algorithm • selection list. Recon job 1 2 3 4 5 6 7 8 Series description Abdomen 5.0 130f 5 Slice 5.0 mm Recon job type o Axial . 3D SAFIRE Strength 5 Recon region: Narrow . Wide o Algorithm 130f medium smooth None FAST M Window Abdomen Begin position -933.7 mm al End position -1284.5 mm= HD FOV FOV 322 mm: Image order Craniocaudal Center X 1 mm Increment 5.0 mm 2: Overview Center Y 0 mm : No. of images 71 Mirroring None Comments Extended CT scale Routine Scan Recon Auto Tasking STEP 2 – Select the Desired Algorithm From the Algorithm selection list, select the desired algorithm depending on the body region you want to examine. SAFIRE M ] Strength 5 Algorithm 130f medium smooth FAST M Window .SoftTissue El-Standard 130f medium smooth! 140f medium HD F - 144f medium -Vascular @-LowContrast Overview E.Lung/Bone E.Cardio Mirroring E.DE Extended CT s| B. All 48 CT Advanced Scanning Techniques | Classroom & Turnover Workbook STEP 3 – Select the Desired Strength Notes In the Strength selection box, select a Strength from 1 to 5. The Strength describes the intensity with which the iterative reconstruction algorithms are applied. The higher the Strength, the lower the image noise in the reconstructed image but the more modified the image may appear. STEP 4 – Perform a Preview You can perform a Preview reconstruction to evaluate images done with different Algorithms and Strength values. This can only be done when a scan has already been performed. On the Recon parameter card, click the Open SAFIRE/ADMIRE Preview icon to • open the toolbar SAFIRE M Strength 5 Algorithm 130f me Open SAFIRE Preview! FAST M Window Abdomen Use the dog ear to scroll through the axial images and select a level to preview • PATIENT. TEST Hospital 01234567 SOMATOM Definition Flash 31-Oct-1981, 0, 31Y CT 20128 31-Oct-2012 H-SP-CR 20:20:35.63 101 IMA 69 RTD 2 SP - 1277 kV 80 eff.mAs 165 ref.mAs 490 TI0.6 GTOO SL 5.0/128x0,6/pQ 322 - 1/0 940f SORO A3eva On the toolbar, select a Strength number(s) to define the Strength value for the • selected algorithm. Selected strength numbers will have a black background. You can choose as few as one and as many as five Algorithm 130f medium smooth Strength 1 2 3 4 5 V 49 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Click the Start SAFIRE/ADMIRE Preview icon to start the preview reconstruction Notes • Preview image(s) will appear in the three boxes at the top of the screen. Use • the horizontal scroll bar if necessary to view them all. The Strength value will be displayed in the comment section beneath each image. Preview image(s) will be stored together in a new series in the Patient Browser PATIENT. TEST Hospital PATIENT, TEST Hospital PATIENT. TEST 01234567 SOMATOM Definition Flash 01234567 SOMATOM Definition Flash 01234567 SOMATOM Definition Flash 131-Oct-1981, 0. 31Y CT 20128 :31-Oct-1981, 0. 31Y CT 2012B *31-Oct- 1981. 0. 31Y H-SP.CR CHSPER 31-Oct-2012 H-SP.CR 31-Oct-2012 31-Oct-2012 20:20:31.05 20:20:31.05 20:20:31.05 201 IMA 2 201 IMA 3 SP- 1105.4 SPI 2 SPI2 SP -1105.4 SP -1105.4 eff.mAs 165 ref.mAs 490 TI0.5 GTOO SL 5.0/128x0.6/p0,6 322 - 1/0 130f1 S3CO A3eva Select the desired preview image. It will highlight with a magenta border. Click • Accept to confirm, and the selected values will automatically populate to the Recon parameter card Start the reconstruction of the actual data series using the blue Check Mark • button. Hint: You can perform a preview reconstruction as often as necessary. NOTE: The image impression of images which are reconstructed with SAFIRE or ADMIRE can differ from the images which are reconstructed with a conventional (filtered back projection) method. Compare the SAFIRE or ADMIRE images with the conventional images side-by-side using comparable kernels. 50 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 4. Dose Considerations 4.1 Objectives Notes After completing this section, you will be able to: List the relevant dose terms in CT • Differentiate Absorbed Dose from Effective Dose • Discuss key techniques to reduce dose in CT • Use CARE Dose4D effectively to reduce dose • 4.2 Dose Basics in CT The use of diagnostic CT imaging has risen steadily since its commercial introduction, but only in the last decade have we begun to focus critical attention on the amount of radiation that patients receive. There are many measurements of dose and various terms describing dose that we come across on a daily basis when scanning patients in CT, including: Radiation exposure • mAs • Surface dose • mGy • mSv • Patient dose • Organ dose • CTDI (CTDI100 / CTDIFDA / CTDIw/ CTDIvol) • DLP • Effective dose • 4.2.1 Absorbed Dose – CTDI and DLP The absorbed dose or energy dose characterizes the amount of energy deposited in matter after being exposed to a certain amount of radiation. It can also be thought of as the amount of radiation produced by the scanner. This rather simple definition is a physical quantity and does not reflect the biological effects of radiation, since it does not take into account the damage it might cause in different tissues. The absorbed energy dose is measured in CTDI phantom plastic phantoms which have similar diameters and attenuation as the human body. Two sizes are used for measuring, a 16 centimeter phantom for the head and a 32 centimeter 16cm - head phantom for the body. Each phantom has holes for the dose chambers, four at one centimeter below the surface and one in the center. The chambers are then used to measure the x-ray 32cm - body energy being absorbed in Joule per kilogram. 51 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes • Reported as CTDI – Computed Tomography Dose Index Defined as the amount of radiation required to deposit 1 Joule (J) of energy in 1 • kilogram of any kind of matter 1 Joule per kilogram = 1 Gray = 1000 mGy • Describes dose from a single axial scan • Characterizes the amount of energy deposited in a single axial slice of tissue • Useful to optimize scan parameters and compare scanners • CTDIw (where w means weighted) is derived from averages of the four peripheral and one central probe measurements and is expressed CTDIw = (⅓CTDI100,c+ ⅔CTDI100,p.) CTDIvol (where vol means volume) is derived from the sum of 1/3 of the CTDI100 Phantom Center and 2/3 of the CTDI100 Phantom Surface. It is the average dose absorbed in the scanned volume of the phantom, equal to that of a same size patient (32cm) CTDI100 is an International standard in which the dose is measured in a 100mm long ionization chamber, or 50mm on either side of the irradiated slice. CTDI100 and CTDIvol are two currently used measurements applied universally to measure dose. In order to calculate the total absorbed dose for a complete CT examination, the range that is being examined must also be taken into account. The Dose Length Product or DLP is the product of CTDI volume and the examination range: • DLP - Dose Length Product - represents an estimate of the total dose of the examination and takes into account the actual scan length of the examination. DLP = CTDIvol x length • Recorded and displayed in the Patient Protocol after the exam has been • performed. CTDIvol vs. DLP 120010 € 60cm 30cm CTDIvol = 13.2 mGy CTDIvol = 13.2 mGy DLP = 792 mGy/cm DLP = 396 mGy/cm 52 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 4.2.2 Effective Dose - mSv Notes The CTDIvol gives a good estimate of the average dose applied in the scanned volume, as long as the patient size is similar to the size of the respective dose phantoms. In order to more accurately assess the radiation risk to the patient, the concept of the “Effective Dose” was introduced by the ICRP (International Commission on Radiation Protection). The Eff. Dose is expressed as a weighted sum of the dose applied not only to the organs in the scanned range, but also to the rest of the body. The organs are weighted according to their radiation sensitivity. Effective Dose cannot be measured directly but only estimated • Measured in whole body phantoms or calculated by sophisticated software • Considers direct and scatter radiation for all organs in scan volume, tells • radiation risk for whole human body Depends on the absorbed energy dose, gender, age, type of exposed organs, and • the volume or range being covered Measured in Sievert (Sv) or millisievert (mSv) • Table 3. Normalized effective dose per dose-length product (DLP) for adults (standard physique) and pediatric patients of various ages over various body regions. Conversion factor for adult head and neck and pediatric patients assume use of the head CT dose phantom (16 cm). All other conversion factors assume use of the 32-cm diameter CT body phantom 78,79 Region of Body k (mSvmGy 1cm 1) 0 year old 1 year old 5 year old 10 year old Adult Head and neck 0.013 0.0085 0.0057 0.0042 0.0031 Head 0.011 0.0067 0.0040 0.0032 0.0021 Neck 0.017 0.012 0.011 0.0079 0.0059 Chest 0.039 0.026 0.018 0.013 0.014 Abdomen ~& pelvis 0.049 0.030 0.020 0.015 Trunk 0.044 0.028 0.019 0.014 0.015 American Association of Physicists in Medicine [AAPM]. (2008). The measurement, reporting, and management of radiation dose in CT, Report of AAMP task group 23 of the Diagnostic Imaging Council CT Committee (96). Retrieved from https://www.aapm.org/pubs/reports/RPT_96.pdf We can estimate the dose to the patient in mSv using the total DLP of one’s scan and multiplying it by a respective tissue weighting factor. The weighting factors are used because the damage that radiation causes in different types of organic tissue is not identical, for example, the breast is very sensitive to radiation, whereas the liver is much less sensitive. NOTE: Because effective dose is an estimate, it is not explicitly displayed on the scanner but rather must be calculated using generally accepted weighting factors. 53 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 4.3 CARE Dose4D Notes 4.3.1 CARE Dose4D Fundamentals CARE Dose4D is Siemens’ technology for automated exposure control. It optimizes dose and helps deliver the desired diagnostic image quality across a broad spectrum of patient sizes, ages, exam types and clinical indications. Automated Exposure Control • Optimized Dose • Consistent image quality across all patients • Features: mAs automatically adapted to patient size • Real-time dose adaptation in multiple planes • Benefits: Ease of use in protocol selection • Optimal diagnostic image quality in every slice • Lowest possible dose levels • 54 CT Advanced Scanning Techniques | Classroom & Turnover Workbook CARE Dose4D uses three methods of adaptation simultaneously: Notes Dose adaptation based on current patient size - Topogram • Angular modulation in the X/Y axes • Z-axis modulation • CARE Dose4D modulates the dose that is necessary based on a user-defined Quality reference mAs. The Quality reference mAs defines the desired image quality - or the noise value - for a protocol if that protocol was used to scan an average sized patient. CARE Dose4D will compare the desired image quality - as defined by the Quality reference mAs - and determine if the dose should be increased or decreased for that patient - based on their individual size - in order to maintain the image quality expected. 55 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Quality reference mAs: Notes Defines the desired image quality - or noise value - for a protocol for an averaged • sized patient Average sized patient = 70 - 80kg • Foro Example Examination Vie ving 1994, 0, 100Y The Quality reference mAs value defines the overall image quality (noise) of the current protocol and may be adapted within each protocol to the user's individual preference of desired image quality Filming This is the average eff. AbdomenRoutine (Adult) CD4D-Example 100 Total mAs: 186 mAs that will be applied opogram by CARE Dose4D for the Quality ref. mAs 160 Abdomen current scan range. Eff. mAs 65 This will be updated to CARE Dose4D P Pitch KV 120 Direction [Craniocaudal ] the real applied eff. mAs after the scan and can CTDIvol 4.51 mGy differ slightly. Scan time 10.98 s2 Scan st Rotation time 0.5$ - Delay API None Enables or Disables Load CARE Dose4D Routine Scan Recon Auto Tasking Automatic checkup procedure completed successfuly. DB-Sep- 2004 14.4 Topogram: Used to calculate dose and plan scan ranges • Patient centering is critical • Isocenter • Incorrect positioning can lead to under- or over-irradiation • Patient Too High in Gantry: Patient image magnified • Patient size over-estimated • May result in more dose/over irradiation • May affect image quality • Patient Too Low in Gantry: Patient image minified • Patient size under-estimated • May result in less dose/under irradiation • May affect image quality • 56 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes 4.3.2 CARE Dose4D Configuration Though CARE Dose 4D automatically adapts for differences in patient size, it is possible to customize specific CARE Dose4D behaviors using the CARE Dose4D Configuration Tool. This tool allows the user to customize the dose curves that are applied to different body regions for several different patient sizes. Customizing CARE Dose4D dose curves: Body regions • Different sized patients • Examination Configuration Patient Dose Workflow Topogram Processing Contrast Display Options CARE Dose4D configuration: mAs adaptation to patient size Dose notification CARE Profile v Organ characteristics Child Adult slim Adult obese Brain Average Average Average Exposed range Neck Average Average Average Shoulder Average Average Average Dose Report Thorax Average Average Average Activate Dose Report Auto transfer Abdomen Average Average ÃAverage Pelvis Average Very weak Average Additional transfer None Spine Average Weak Osteo Average Average Average Strong Average Dose Alert Head/Vascular Head Average Very strong Average Average Average Adult Child Vascular Body Average Runoff Average Average Average CTDIvol 1000:| mGy 1000 mG Cardio Average Average Average DLP mGy cm mGy"cm Respiratory Average Average Average QK Apply Default Settings Cancel Help CARE Dose4D dose curves may be customized for patients of a specific body habitus Child • Adult Slim • Adult Obese • Examination Configuration Patient Dose Workflow Topogram Processing Contrast Display Options CARE Dose4D configura jant cina Dose notification CARE Profile Organ characteristics Child Adult slim Adult obese Brain Average Average Average Exposed range Neck Average Average Average Shoulder Average Average Average Dose Report Thorax Average Average Average Abdomen Average Average Average Activate Dose Report Auto transfer Pelvis Average Average Average Additional transfer None Spine Average Average Average Osteo Average Average Average Average Dose Alert Head/Vascular Head Average Average Vascular Body Average Average Average Adult Child Runoff Average Average Average CTDIvol 1000 mG Cardio Average Abrerage Average mGy'cm Respiratory Average Average Average DLP mGy"cm OK Apply Default Settings Cancel Help 57 CT Advanced Scanning Techniques | Classroom & Turnover Workbook CARE Dose4D dose curves may be customized for specific body parts Notes Examination Configuration Patient Dose Workflow Topogram Processing Contrast Display Options CARE Dose4D configuration: mAs adaptation to patient size Dose notification CARE Profile Organ characteristics Child Adult slim Adult obese Exposed range Brain Average Average Average Neck Average Average Average Shoulder Average Average Average Dose Report Thorax Average Average Average Activate Dose Report Auto transfer v Abdomen Average Average Average Pelvis Average Average Average Additional transfer None Spine Average Average Average Osteo Average Average Average Dose Alert Head/Vascular Head Average Average Average Adult Child Vascular Body Average Average Average Average CTDIvol 1000 mGy M Runoff Average 1000 mGy Average Cardio Average Average Average DLP mGy*cm mGy*cm mGy* Respiratory Average Average Average OK Apply Default Settings Cancel Help CARE Dose4D dose curves are based on a 70-80 kilogram reference patient Using stronger curves for patients larger than 70-80 kg increases dose • Using stronger curves for patients smaller than 70-80kg decreases dose • Attenuation for reference patient OBESE Constant Very strong Relative image noise Strong tube current Average 150%- Weak Very weak 100% "Quality ref. mAs" 50% SLIM >Relative attenuation 1 Slim patient Obese patient 58 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 4.3.3 Pediatric Considerations Notes What do we consider a pediatric patient? For head - patients < 6 years old • For body - patients < 55kg • For head examinations, Siemens recommends using a child head protocol on patients 6 years old and less. Older than 6, the head shape and size is roughly the same as that of an adult, and an adult head protocol should be used. For body examinations there is far more variability in shape, size, and attenuation. Siemens recommends using dedicated pediatric protocols for children weighing less than 55 kilograms. Although these protocols use the same Quality reference mAs values as for adults, pediatric protocols use special bow tie filters and other parameters to more aggressively reduce the dose for smaller patients. Above 55 kilograms, it is recommended that all patients be scanned using a default adult protocol. But because we DO have dedicated pediatric curves, we can further decide how we want to modulate dose if these patients are more or less the size of an adult - do we want to have the same image quality as we would an adult, or do we insist on reducing IQ and dose because the patient is still “pediatric”? Desire same IQ/Dose Incremental change in as Adult? CARE Dose4D curve towards "strong" - What if the size of a Child is more or less similar to the size of a reference Adult (75kg) Desire reduced IQ/Dose because patient is Ped? Incremental reduction of Quality reference mAs Pediatric image quality will be relative to Adult image quality when the same Quality reference mAs is used. CARE Dose4D will still modulate higher or lower to accommodate patients larger or smaller than the reference. The CARE Dose4D curves for pediatric protocols can be moved incrementally towards “strong” so that CARE Dose4D will modulate more aggressively for smaller patients - resulting in consistent image quality and lowest possible dose. 59 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Maintain Consistent IQ for Pediatric and Adult Patients: Notes CARE Dose4D modulates normally • Curves can be moved towards “strong” = more aggressive modulation = lower • dose for smaller patients Maintain image quality / dose CARE Dose4D curve modulating 'strong" reference patient Towards strong Average tube current (mAs) 20 kg 40 kg 60 kg 80 kg 100 kg patient thickness In many instances, however, radiologists insist on reading pediatric images with more noise - as long as they are still diagnostic - for the sake of reducing dose to this patient population. Lowering the Quality reference mAs for these protocols will establish a new reference - one of lower dose and higher noise - for all patients scanned with this protocol Reduced Dose for All Pediatric Patients: Lower Quality reference mAs • Reduces Dose • Reduces Image Quality • Noisier, diagnostic images • Reduce dose for all pediatric patients scanned with protocol Lowering Quality ref mAs reduces dose for all patients scanned with Reference Patient protocol tube current (mAs) 20 kg 40 kg 60 kg 80 kg 100 kg patient thickness 60 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 4.4 eCockpit Notes eCockpit is a bundle of features that help enable more economic CT scanner usage to reduce overhead costs. For this, the entire working day of a CT system was taken into consideration, from start-up to scanning to scan breaks, to facilitate the most economic scanner usage. eSleep eStart e eMode eCockpit includes eStart, eMode, and eSleep. 4.4.1 eStart eStart extends the tube lifetime by pre-warming the tube before a scan. If your SOMATOM CT scanner has not been used for over an hour, the x-ray tubes will have cooled down. Before performing a scan it is recommended to perform a tube warm up. When an eStart is recommended, a corresponding icon and message are • displayed in the status bar. eStart is recommended, please click eStart or select Setup>eStart Click the Setup menu and then click eStart. • Ensure that all objects are removed from the scan field and then click OK. • View Setup Image Options API / Comment .. Calibration ... Check-up Quality .. Continue e Start e Start For best X-ray tube lifetime please run eStart procedure. Please leave the scan room. X-rays will be produced during the eStart procedure. Click Cancel to skip procedure. Click OK to continue OK Cancel 61 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 4.4.2 eMode Notes eMode, or efficiency mode, ensures that the scanner is operating in e the most patient friendly and financially efficient way. Once the user has prepared a scan protocol and entered all required information, eMode analyzes the parameters in real-time and instantly fine-tunes the scan. Therefore, the system is operated in the most economical way, reducing wear and tear of all moveable parts while maximizing image quality. Consistent use of eMode relieves the system of unnecessary wear and increases the scanner’s life cycle. The goal of eMode is to keep each scan below 20kW. When a green e appears in the lower left corner of the examination card after scan parameters are set, the scanner is operating in eMode. The load and adjust buttons will be covered in more detail in section two of the workbook covering scanning and acquisition. ℮ Load eMode checks the kW value used for each scan series and adjusts parameters to • maintain efficiency when necessary. The parameter changes are configurable in Scan Protocol Assistant. Some scans cannot work in eMode such as cardiac and other ECG gated studies • Most scans are eMode ready or need slight modifications in scan time to bring the • scan series in to its most efficient setting. Example 1: Scan protocol shows no conflict and average power is below 20kW • eMode indicator is green, and no action is required to perform the scan. • 200 mm Patient: 175 cm 75 kg Scan time: 6.24 s e Load Recor Pitch factor: 0.60 62 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Example 2: Notes Scan protocol shows no conflict but average power is above 20kW • eMode indicator is yellow • • Load – scan parameters are not optimized and scan will be non-eMode Adjust – scan parameters are automatically optimized and scan will be • eMode 200 mm Patient 175 cm Scan time: e 6.24 s Adjust Load Recor Pitch factor: 0.60 200 mm Patient: 175 cm Scan time: 6.71 s ℮ Adjust Load Read Reco Pitch factor: 0.55 4.4.3 eSleep eSleep saves energy by stopping gantry rotation during scanner downtime. The system rapidly returns to scan ready mode when needed, allowing users to resume their normal routines in no time. 63 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 4.4.4 eRatio Notes The eRatio value is the combined calculation of the eMode and eStart usage. The diagram at the right corner of the status bar shows you the actual usage of both function in percentage. The function will extend the lifetime of the tube. Siemens recommends a usage of above 80%. 0.0 º Tilt Table:Position Height -1118.0 125.0 Routine eRatio eStart is recommended, please select Setup/eStart HO Lle Start 25-Jun-2014 15:0 The eRatio is calculated as follows: eRatio = 50% eMode usage + 50% eStart usage (# executed eStarts / # proposed • eStarts) 64 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 4.5 FAST CARE Notes Siemens’ FAST CARE technology is a package of software features designed to help improve workflow and lower radiation exposure to patients. FAST – Fully Assisting Scanner Technologies. Features that optimize processes and improve efficiency by making time-consuming and complex procedure steps faster and more intuitive. CARE – Combined Applications to Reduce Exposure. Solutions that deliver excellent image quality while lowering radiation exposure. The portfolio of FAST CARE features is comprehensive. We will highlight only a few here. 4.5.1 CARE kV CARE kV is a technology that allows optimization of kV to minimize patient dose and maintain image quality. It provides automatic kVp adaptation to the patient’s size and the examination type and can automatically suggest kV and eff. mAs to optimize the contrast to noise ratio. Benefits: Optimized exposure • Optimized image quality • Optimized signal to noise ratio • No calculations needed to get the right mAs value • Lowering the kV value for a CT examination can lower the radiation dose to the patient and improve image contrast. 120k 100KV CTDIvol = 17.3mGY CTDIvol = 7.71mGY 65 CT Advanced Scanning Techniques | Classroom & Turnover Workbook When using CARE kV, resultant image quality is based on the following: Notes Reference kV • Quality Reference mAs (CARE Dose4D) • Position of Dose Optimization Slider • Quality ref. mAs 210 | Ref. V 120 Dose saving optimized for: XH There are three modes for CARE kV: Off, On, and Semi CARE kV - Off Select Off in the dropdown menu to disable CARE kV • The system will use the default kV and Quality ref. mAs values in the protocol • Eff. mAs will not automatically be adjusted if you manually change the kV • CARE Dose4D CARE KV Off Slice 5.0 mm - Acq. 128x0.6 mm Pitch 0.6 2 Eff. mAS 210 KV 120 -J Direction Craniocaudal Organ characteristic: Abdomen CTDIvol (32cm): 14.19 mGy DLP: 305.0 mGy*cm Scan time 5.15 Scan start Start button Rotation time 0.5 s Delay 2 s Language German API None Routine Scan Recon Auto Tasking 66 CT Advanced Scanning Techniques | Classroom & Turnover Workbook CARE kV - On Notes Select On in the dropdown menu to enable CARE kV • Set the dose optimization slider at the desired position • Non contrast scans • Soft Tissue with contrast scans • Vascular scans • kV will be defined based on the patient size (as determined by the Topogram), the • reference kV, and the examination type (as indicated by the slider) CARE Dose4D CARE KV On Quality ref. mAs 210 | Ref. V 120 Eff. mAs kV 120 Dose saving optimized for: Organ characteristic: Abdomen XH CTDIvol (32cm): mGy DLP: mGy*cm 1 2 3 4 5 6 9 10 11 12 00 - Scan time 5.15 s Scan start Start button Rotation time 0.5 s Delay 2 s H Language German API None Routine Scan Recon Auto Tasking CARE kV – Semi Select Semi in the dropdown menu to enable CARE kV in Semi mode • Set the dose optimization slider at the desired position • Select the desired kV value from the drop down menu • The kV will remain fixed; however the eff. mAs will adapt based on the patient • size (as determined by the Topogram) and the examination type (as indicated by the slider) This is particularity useful in cases where the kV value must remain consistent • from study to study (e.g. Oncology follow up) CARE Dose4D CARE KV Semi Quality ref. mAs 210 |Ref. kV 120 Eff. mAs 210 KV 120 Dose saving optimized for: Organ characteristic: Abdomen 70 80 X CTDIvol (32cm): 14.19 mGy ILP: 100 120 1 1 1 1 140 Scan time 5.15 2 Scan start Start button Rotation time 0.5 s Delay 2s= Language German API None Routine Scan Recon | Auto Taskina 67 CT Advanced Scanning Techniques | Classroom & Turnover Workbook CARE kV – Grouping Notes An additional feature when using CARE kV is Grouping. This is useful when scanning multiple scan ranges – e.g. multi-phase liver – where the same kV value is desired for all ranges. Right-click on each of the desired series in the Chronicle and select Add to CARE • kV group A link icon on the chronicle series indicates it is part of a Grouping • Remove from CARE kV group works the opposite way • Topogram Dose saving optimized for. Non Contrast RT 1 2 3 4 5 6 7 8 9 10 11 12 18 Pause Dose saving optimized for. Arterial Phase Control Scan X Pause Memo Venous Phase 12 Bolus Tracking TestBolus Dose saving optimized for. 81 Copy X Paste Repeat 8 10 11 12 Add to CARE KV group Remove from CARE KV group The proposed kV will be the same for all series in the group and will be calculated • as a collective average of the parameters set for each series based on the patient size (as determined by the Topogram), the set reference kVs, and the examination types (as indicated by the slider) 90 80 70 60 50 40 Dose 30 20 Topogram Dose saving optimized for. 10 L X 10 7 12 ¥ 90 80 kV 100 k 120 kV 140 kV Non Contrast RT 2 3 5 80 6 Dose saving optimized for. 70 60 Pause X 150 40 DDose 30 Arterial Phase RT 9 10 11 12 20 10 Venous Phase RT Dose saving optimized for 80 kV 100 K 120 KV 140 KV 90 80 70 9 10 11 12 . 60 50 40 Dose 30 20 10 0 80 70 60 50 E of all Scans: 40 ODose 30 20 10 O 80 KV 100 k 120 KV 140 KV 68 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Configuring CARE kV Limits Notes It is possible to set minimum and maximum kV values for desired protocols in the Scan Protocol Assistant. For example: If you don’t want to scan with 140kV for vascular exams, set the max to 120kV • If you don’t want to scan with 80kV for head exams, set the min to 100kV • Scan Protocol Assistant 3 5 Change parameters Protocol Topogram Scan Recon Auto tasking Trigger Intervention Contrast Including topogram Range Scan name time HandCARE |Bolus trigger level | X-CARE Upper limit max. sc. | Lower limit | Ret CTDINOI Ref DLP max. kv min. kv Ref. KV Abdomen / AbdomenRoutine (Adult) Topogram: 35mA, 512mm, AP, Craniocaudal Abdomen 5.15 off 25 On 120 Select all Sequence scans Spiral scans Multiscans Interventional scans Adaptive 4D spiral scans i-Sequence i-Spiral i-Fluoro CARE Dose type CARE 4D Fast Adjust Dose modulation v Upper limit max. scan time CARE KV On lower limit max.mAs 25 Quality ref. mAs 210 Dose Notification Ref CTDIvol mAs 210 Ref. KV 120 Ref DLP KV 120 Auto kV Dose saving optimized for. min.kV 80 max.kV140 Dose Parameter 4.5.2 CARE Profile CARE Profile provides the user with a graphical representation of how the dose will be distributed along the Z-axis for a particular acquisition. It allows for visualization of areas where the maximum mAs may be exceeded or areas of conflict where system limitations will be reached. This allows the user to make parameter adjustments as necessary to optimize both dose and image quality. Different colors and patterns of the CARE Profile curve help identify areas that may need the attention of the user. 69 CT Advanced Scanning Techniques | Classroom & Turnover Workbook CARE Profile - Green Notes If the CARE Profile curve is displayed in all green, the effective mAs needed for the scan can be applied by the scanner with no interaction to adjusting. The load button is available to proceed to scan. TEST, PATIENT Hospital: TE MAS 01234567 SOMATOM Definition Flash: 01 23-Oct-1950, O, 62Y CT 2012B 2 23-Oct-2012 . H-SP 23 19:57:01.64 20 1 IMA 1 12-2 21 TOP SP SP -751.0 SP 1: -7610 SP 2: -1057.0 SP LEN: 306.0 GT: 0.0 FOV: 500 CE: R R 10cm: ........ KV 120 KV eff mA 25 ret TI 5.3 TI GT 010 GT SL 512 0/0 ..... T2Of UOPO 1eva 350 35 50: nE CARE Profile - Yellow If the CARE Profile curve is displayed in all yellow, the effective mAs needed for the scan exceeds the system limits. The scan is invalid and action is required to continue. The load button is NOT available to proceed to scan. 10.08.25-11:35:39-DST-Specials ... H Hospital MAS 217 10.08.25-11:35:39-DST-1.3.1 ... SOMATOM Definition Flash: *18-Nov-1858, 0, 151Y CT 2011A.0.11_P03 25-Aug-2010 H-SP 14:33:34.77 :1 IMA 1 TOP 1 SP 1: -774.5 SP -666.5 SP122 -1113.5 LEN1 339.0 GT 0.0 FOV 500 0/0 R KV 120 mA 35 1 5.3 GT 0.0 A ............ 512 0/0 T20f UOPO 1eva 358 70 CT Advanced Scanning Techniques | Classroom & Turnover Workbook CARE Profile – Yellow Peak Notes If the CARE Profile curve is green with a localized yellow peak, the necessary effective mAs cannot be reached in the area of yellow. This can often be the case in the scanning of the shoulder region of obese patients. The user can choose to adapt the scan parameters to resolve the issue, or can choose to proceed with the scan. If the range is scanned without making adjustments to the parameters, the yellow peak will be “cut off”, meaning the system will only deliver the maximum mAs value indicated by the dotted yellow vertical line. In most instances, increasing the scan time or the pitch even slightly will typically resolve the conflict. 205 TEST, PATIENT H Hospital: 01234567 SOMATOM Definition Flash *23-Oct-1950, 0, 62Y CT 2012B. 23-Oct-2012 . H-SP 19:57:01.64 1 IMA 1 TOP SP -751.0 7510 1057.0 306.0 R 10cm: 12of UOPO Lem CARE Profile – Green Striped Peak If the CARE Profile curve is green with a localized green striped peak, this area exceeds the system limits but the reduction in image quality will be negligible. The load button is available to proceed to scan. ........................................... 285 TEST, PATIENT Hospital: MAS 01234567 SOMATOM Definition Flash 23-Oct-1950, O, 62Y CT 2012B 23-Oct-2012 H-SP 19:57:01.64 1 IMA 1 TOP SP -751.0 SP 1: -7610 SP 2: -1057.0 LEN: 306.0 FON 0.0 500 0/0 10 cm MAY TI 5.3 22Of JOF 71 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 4.5.3 CARE Dashboard Notes 4. CARE Dashboard displays all of the available dose reduction features in one place and allows you to check which dose reduction features are currently in use. CARE Dashboard can be enabled using the icon on the Examination card, seen below. Here, all of the available dose reduction features on the system – like CARE Dose4D, X-CARE, etc. – will be displayed, and a green dot will highlight which features are enabled for the prescribed scan series. It is not possible to enable or disable a feature here. CARE Dashboard serves only as a quick overview of what features are being used to reduce dose for the scan. Patient Applications Edit Insert View Setup Image Options System Help Examination CARE Dashboard X Adaptive Dose CARE Dose(4D) CARE KV Dose Notification SAFIRE X-CARE MinDose Adaptive Cardiac ECG Pulsing Shield Sequence Thorax Viewing Abdomen Pelvis HeadAngio Filming CorAdSeq Learn more Close ThoraxRoutine (Adult) 10.10.22-09:15:57-DST-Specials PolyTraum 10.10.22-09:15:57-DST-' Total mAS: 3D Topogram MA 35 Thorax KV 120 Memo Scan time 5.3 s Simulation Pause Slice 0.6 mm Abdomen RT Topogram length 512 mm Pelvis RT Tube position . Top Bottom Lateral Pause Comments RH HeadAngio RT able: Position Height -726.5 ] 100.0 Craniocaudal ] 72 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 5. CTA Anatomy 5.1 Objectives Notes After completing this section, you will be able to: Identify vascular anatomy of the head and neck • Identify vascular anatomy of the thorax • Identify vascular anatomy of the abdomen and pelvis • Identify vascular anatomy of the lower extremities • 5.2 Cerebral Vasculature - Circle of Willis Circle of Willis Anterior Anterior Cerebral Lt. Middle Cerebral Communicating Arteries Artery Artery Carotid Arteries Posterior Rt. Middle Cerebral Communicating Artery Arteries Posterior Cerebral Basilar Artery Arteries Rt. & Vertebra Arteries Anterior Middle communicating Anterior artery cerebral cerebral artery artery Ophthalmic artery Internal carotid artery artery Posterior communicating artery Posterior cerebral artery Pontine Superior cerebellar artenes artery Basilar artery Anterior inferior cerebellar artery Vertebral artery Anterior Posterior spinal inferior artery cerebellar artery 73 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes 5.3 Neck Vasculature - Carotids and Vertebrals 74 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes 1. Right and Left Internal Carotid Arteries 2. Basilar Artery 75 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes 1. Right and Left Internal Carotid Arteries 2. Right and Left External Carotid Arteries 3. Right and Left Vertebral Arteries 2 1. Right and Left Common Carotid Arteries 2. Right and Left Vertebral Arteries 76 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 5.4 Thoracic Vasculature Notes A 77 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes 1b 3a 1a 3 4 1. Brachiocephalic Artery (innominate artery) a. Right Subclavian Artery b. Right Vertebral Artery c. Right Common Carotid Artery 2. Left Common Carotid Artery 3. Left Subclavian Artery a. Left Vertebral Artery 4. Ascending Aorta 5. Descending Aorta 1. Right Subclavian Artery 2. Common Carotid Arteries 3. Jugular Vein 4. Left Subclavian Artery 78 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes 1. Brachiocephalic Artery 2. Left Common Carotid 3. Left Brachiocephalic Vein 4. Left Subclavian Artery 1. Superior Vena Cava 2. Aortic Arch 3. Left and Right Internal Mammary Arteries 79 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes 3 4 5 1. Ascending Aorta 2. Right Pulmonary Artery 3. Pulmonary Trunk 4. Left Pulmonary Artery 5. Descending Aorta 6. Pulmonary Arteries/Veins Spin: 1. Ascending Aorta 2. Pulmonary Trunk 3. Descending Aorta 4. Right and Left Pulmonary Arteries 5. SVC 80 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes 2 1. Right Pulmonary Vein 2. Ascending Aorta 3. Left Atrium 4. Left Pulmonary Vein 5. Descending Aorta 6. Pulmonary Arteries 1. Descending Aorta 2. Azygos Vein 3. Esophagus 4. Hemiazygos Vein 81 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 5.5 Abdominal Vasculature Notes 28 F 82 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes 1. Celiac Axis a. Hepatic Artery b. Splenic Artery c. Gastric Artery 2. Superior Mesenteric Artery 3. Right and Left Renal Arteries 4. Inferior Mesenteric Artery 5. Right and Left Common Iliacs 1. Aorta 2. Left Gastric Artery 83 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes IF 1. Aorta 2. Hepatic Artery 3. Celiac 4. Splenic Artery H F 1. Right Renal Artery 2. Aorta 3. Superior Mesenteric Artery 4. Left Renal Artery 84 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes ANIC IF 1. Aorta 2. Superior Mesenteric artery 3. Inferior Mesenteric Artery 4. Lumbar Artery ANIC. 1. Aorta 2. Inferior Mesenteric Artery 85 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes Pping -90 1. Right Common Iliac Artery 2. Inferior Mesenteric Artery 3. Left Common Iliac Artery 5.6 Pelvis and Lower Extremity Vascular 86 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes 1. Right and Left External Iliac Arteries 2. Right and Left Internal Iliac Arteries/Hypogastric Arteries 1. Right and Left External Iliac Arteries 2. Right and Left Internal Iliac Arteries 87 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes O 1. Right and Left Femoral Arteries 2. Right and Left Femoral Profunda (deep) Arteries O 1. Right and Left Superficial Femoral Arteries 88 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes O O 1. Right and Left Popliteal Arteries 1. Right and Left Popliteal Arteries 89 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes 1. Right and Left Popliteal Arteries w 1. Anterior Tibial Artery 2. Posterior Tibial Artery 3. Fibular (Peroneal) Artery 90 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes O 3 1. Anterior Tibial Artery 2. Posterior Tibial Artery 3. Fibular (Peroneal) Artery 2 3 1. Anterior Tibial Artery 2. Posterior Tibial Artery 3. Fibular (Peroneal) Artery 91 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 6. Contrast Enhancement 6.1 Objectives Notes After completing this section, you will be able to: List key factors associated with successful contrast injections • Distinguish between the use of empirical delays, Test Bolus, and Automatic Bolus • Tracking/CARE Bolus List the steps involved in utilizing automatic bolus tracking • 6.2 Purpose of Appropriate Contrast Timing When scanning patients using intravenous contrast media, it is important that the scan acquisition be obtained during the optimal window of peak contrast enhancement for the following reasons: Optimize a uniform opacification • Reduce contrast medium dosage • Mitigate contrast-associated artifacts • HU Early Late Optimal Window Time 92 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 6.3 Key Factors that Contribute to Quality Contrast Opacification Notes There are many factors that can influence optimal contrast opacification during a CT scan. Patient factors include: Anatomy of interest, clinical reason for scan, body size, cardiac output, IV access, • renal function, age, gender Injection factors include: Rate • Volume • Iodine Concentration • Duration • Flush • Scan factors include: Timing delay, scan duration • Since most patient factors cannot be changed, we will highlight here some of the injection and scan parameters that we can control in the effort to optimize CT contrast enhancement 6.3.1 Injection Rate The contrast injection rate is simply the speed at which contrast medium is injected. It is measured in mL/sec. As the injection rate increases: Enhancement increases • Duration decreases • As the injection rate decreases: Enhancement decreases • Duration increases. • 350 T - 5 mL/sec 3007 3 mL/sec 250- I mL/sec 200 150 - 1007 50 - Contrast Enhancement (HU) 0 25 50 75 100 125 150 175 200 Time (sec) 93 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 6.3.2 Injection Volume Notes The contrast injection volume is the amount of contrast medium injected. It is measured in mL. The speed of modern CT scanners generally allows for a reduction in contrast volume used. As scans become faster: Injection durations should decrease – no injecting longer than scan • Injection rates should increase to optimize enhancement • However, the amount of contrast volume reduction we are able to appreciate does have limits: Cannot increase injection rate indefinitely – no 20mL/sec injections • Contrast level must be sustained throughout scan • Need adequate contrast volume for patient size, total circulation, physiology • 6.3.3 Iodine Concentration The contrast concentration is the amount of iodine present in the contrast medium being used. It is measured in mg Iodine/mL. Depending on type and vendor, IV concentrations include 140, 150, 200, 240, 250, 270, 300, 320, 350 or 370 mg/mL. Increased concentration: Means more iodine delivered without increasing rate • Can allow for reduced contrast volume • Effect on enhancement: Depends on anatomy being visualized (e.g. more pronounced in aorta than in • liver) Effect on enhancement may be nominal when comparing similar concentrations • 94 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 6.3.4 Injection Duration Notes The duration is the total length of injection time. It is typically measured in seconds. The injection duration directly affects the timing of peak enhancement As injection duration increases, peak enhancement is delayed • 350- 300- 1-sec injection 250-| 3-sec injection 5-sec injection 200- 8-sec injection 12-sec injection 150- .......... 20-see injection 100- 0000000 30-sec injection 50- Aortic Enhancement (HU) 0- 0 5 10 15 20 25 30 35 40 Time after the start of injection (sec) 6.3.5 Scan Timing For most CT scans acquired with IV contrast, it is typically desired that one acquisition be obtained during peak enhancement. This can prove challenging with today’s faster scanners and shorter scan times. Longer scans may require slower injection rates or more contrast volume. • Shorter scan may use faster rates and less contrast, but too little contrast may • give suboptimal results 6.3.6 Saline Flush A “saline flush” is the process of injecting normal saline (sodium chloride/NaCl) immediately following the contrast bolus. There are several advantages to this practice: Propagates contrast bolus • Compacts contrast bolus • Optimizes contrast volume – none wasted in tubing • Clears IV line • Patient hydration • NOTE: Administration of a saline flush typically requires the use of a dual-headed contrast injector. 95 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 6.3.7 Considerations for Contrast Injections Notes Transit Time vs. Time to Peak: Transit Time – First arrival of contrast to the area of interest • Time to Peak – Start of maximum enhancement • Typical peak enhancement ranges: Aorta: ~20 – 30s for arterial • Hypervascular structures: ~25 – 40s • Portal-venous: ~60 – 80s • Pulmonary: ~10 - 25s • Time to Peak enhancement will depend on injection rate and duration. 6.4 Types of Injection Delays 6.4.1 Empirical Delays An Empirical Delay is a user-specified time delay based on averages and experience. Empirical Delays are based on established, average transit times [first appearance of contrast] of the circulatory system. They are still used, especially for portal-venous phase abdominal exams. Examples: Aorta: ~20 seconds; range 10-28 seconds • PV system: ~50 seconds; range 45-90 seconds • Pulmonary artery: ~8 seconds; range 16-41 seconds • Variations in delays from patient to patient may average as much as 10 to 15 • seconds Advantages: Easy to use • Will render good results for a large percentage of the population • Disadvantages: Based on averages • Will not work for every patient • May require additional scans or a repeat examination if poor results are seen • 96 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 6.4.2 Test Bolus Notes Test Bolus typically involves the use of a small pre-scan test injection to explicitly measure contrast time to peak. Test Bolus can be added to the scan by right mouse clicking in the Chronicle and selecting Test Bolus Typical workflow: Small, compact bolus (~20 ml @ 4-6 ml/s) • Contrast monitored in ascending or descending aorta • Low dose sequence scans (~ every 2 seconds) • Add a scan delay to time to peak for arterial scans (~10 seconds) • No additional scan delay for pulmonary • O After peak enhancement has been reached, the acquired images can be loaded into Dynamic Evaluation – a time density program – to determine the delay time. CORONARY S84 Examination Viewing "01-Ser-1930.M. 74Y CORONARY 564 IT-H6v-2004 16:58:18 94 MA 2 AVE Rep 0 Tissue Classification Upper Limit [HU] Filming 3071 Lower Limit [HU] -1024 Delay from start 10.0 MYUMEDICAL CENTER CORONARY 984 of injection [s] Ref: KAPLAN, SALL 0000 SentAtion 64 01-Sep-1930 CT 2005A 18-Nov-2004 16.SP.CR 14: 28:09 25 DynEva End Evaluation 258 JEAN RICA mode 18 - Nov- 2004 14 97 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes Advantages: Accurate determination of time-to-peak enhancement • Specific contrast volumes can be determined based on total scan time and • injection rate No additional table movement or Automated Patient Instructions (API) delays • Used widely in cardiac CT angiography • Disadvantages: Requires an additional injection • Requires additional radiation for monitoring phase • Evaluation process requires loading images into another program • Overall examination time may be increased • 6.4.3 Automatic Bolus Tracking – CARE Bolus CARE Bolus is an automatic bolus tracking software that is incorporated into the scan protocol and provides real-time injection monitoring. It triggers the scan automatically based on a user-defined HU threshold (anticipation of peak enhancement). Tracks the arrival of the contrast bolus in real time • Tailors the start of the spiral scan to the individual patient • Achieves optimal enhancement without the guess work • CARE bolus can be added to the scan by right mouse clicking in the Chronicle and selecting CARE Bolus. Pre-monitoring Start Injection Monitoring Spiral scan reference scan scans HIIHII 98 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Example workflow: Notes Injection Protocol: 50-150 ml @ 4-6 ml/s depending on area of interest • Monitoring scans: Region of Interest (ROI) in Ascending Aorta • Shallow breathing • Scan delay: 10 seconds for arterial; minimal for PE • Cycle time: 1 to 2 seconds • Threshold 100-150 HU • Patent Apcicasons Edt Ireen ylow Seup 2D Toch Qctone System Help OTOO 51200 The LAPA Topogram HeartRate(bpm) Min: 62 Max: 62 Avg: 62 PreMonitoring ng 62 62 62 62 62 I.V. Bolus 13 of 30 - Monitoring of 30 RT R. L CorCTA RT E [HUI 200 160 120 80 40 O Spiral 5 10 15 20 25 30 Routine Scan Recon Advantages: Easy way to determine the arrival of contrast • “Adjusts” for variation in patient physiology • Helps obtain consistent results on most patients • Disadvantages: Requires additional radiation for monitoring • Threshold is arbitrary and based on averages • Delays after trigger will vary depending on table position and CT scanner • Hyperventilation API may increase delay after trigger • “Panic” scanning • Triggering errors due to calcifications or “movement” of ROI • 99 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7. Advanced Examinations - Acquisition & Post Processing Techniques 7.1 Objectives Notes After completing this section, you will be able to: Select appropriate protocols for advanced CT examinations • Define appropriate contrast injection parameters to optimize contrast • enhancement Determine the most appropriate means of post-processing of an examination • based on desired outcomes and available software features/options 7.2 CTA Carotids/Circle of Willis CT Angiography of the head and/or neck is often indicated in the evaluation of: Aneurysm • Dissection • Stroke • Occlusive Disease • Arterial/Venous Malformations • Trauma • 100 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.2.1 Protocol Selection Notes Dedicated protocols for CT Angiography of the head and neck can be found in the Vascular section of the Patient Model Dialog. Patient Model Dialog · Adult 1 Energy Protocol . Replace . Child · Append ardi Topogram . Cut ascul . Keep RT Auto reference lines None Jecia riva API Language German OK Cancel Depending on the scanner and software version, default protocols may include: Circle of Willis HeadAngio_XCARE_SAFIRE • HeadAngio_SAFIRE • HeadAngio_XCARE • HeadAngioRoutine • HeadAngioVol • NeuroDSACT • Carotids CarotidAngio_SAFIRE • CarotidAngioRoutine • CarotidAngioVol • CarotidDSACT • 101 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.2.2 General Hints Notes Topogram: Lateral at 256mm or • PA at 512mm (PA topogram allows for better visualization of aortic arch for ease • of ROI placement for bolus tracking) Patient breathing instruction (API) to include Do Not Breathe, Do Not Swallow • Empirical delays or bolus tracking can be used to optimize contrast bolus • When imaging both unenhanced and enhanced studies for use in DSA, make sure • there is minimal movement during and between scans for optimal post processing and accurate bone removal. For reconstruction images for 3D at least 50% overlap will give best outcome. • 7.2.3 Injection Protocol Iodine Concentration: 300-370 mg Iodine/ml • Volume: 50-90 ml • Saline: 30-50 ml (recommended) • Flow Rate: 4-5 ml/sec • Start delay of 15-20 seconds or bolus tracking in the aortic arch using 60-100 HU • trigger to optimize bolus (depending on scanner) NOTE: Iodine volumes may vary based on concentration, patient size, and user preference 7.2.4 Post Processing Goals and Examples Thin MIPs sagittal and coronal through area of interest • Oblique MIPs as necessary, esp. carotid bifurcation • Curved MIPs for non-linear vessels • Neuro DSA for bone removal • Radial ranges – spins, tumbles • VRT images if needed • Vessel measurements • 102 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Thin MIPs sagittal and coronal through area of interest Notes Oblique MIPs as necessary, esp. carotid bifurcation RA Curved MIPs for non-linear vessels 103 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Neuro DSA for bone removal Notes CT NeuroDSA_COW ST-NEURODSA_COW HP # 2465 8/19/2004 8/19/2004 11:26:43.00 11:26:43.00 MPR VRT CLI sim bone mask sim bene mask Radial ranges – spins, tumbles Ary le bes weet mor VRT images if needed 104 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Vessel measurements Notes 7.3 CTA Abdomen/Pelvis/AAA CT Angiography of abdomen and/or pelvis is often indicated in the evaluation of: Aneurysm • Dissection • Occlusive Disease • Ischemic Processes • Pre- and Post-Op Stent Placement • Pre- and Post-Op Organ Transplant or Resection • Evaluation of Thrombus • Evaluation of Arterial Venous Malformations • Tumors, cysts, or pseudo cysts • Trauma • 105 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.3.1 Protocol Selection Notes Dedicated protocols for CT Angiography of the abdomen and pelvis can be found in the Vascular and Abdomen sections of the Patient Model Dialog. Patient Model Dialog . Adult al Energy Protocol · Replace Child .Append ardia Topogram · Cut ascul . Keep RT Auto reference lines None beci rival API Language German OK Cancel Depending on the scanner and software version, default protocols may include: Vascular BodyAngio_SAFIRE • BodyAngioRoutine • BodyAngioVol • AngioRunOff_SAFIRE • AngioRunOff • WholeBodyAngio_SAFIRE • WholeBodyAngio • Abdomen AbdMultiPhase • 106 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.3.2 General Hints Notes Patient supine, arms overhead – head first or feet first • Breathing instructions (API) on inspiration • Oral contrast medium of water may be used as to not obscure blood vessels • When imaging post-operative stent, an unenhanced and a delay scan are • recommended to evaluate endovascular leak When reconstructing images for 3D, a 50% overlap and smoother kernel (e.g. B20) • are recommended for optimal post processing More than one series may be scanned by right click > repeat for multiple phases • Empirical delays and/or bolus tracking may be used for optimal contrast bolus • for arterial phase When using empirical delays 20-25 second recommended for arterial phase and • 50-75 second delay recommended for venous phase If scanning pancreas then may consider 40-50 sec delay and thinner • reconstruction Unenhanced and delayed scans may be needed for kidney evaluation, and liver • evaluation for tumor, cyst, or vascular malformation 7.3.3 Injection Protocol Iodine Concentration: 300-370 mg Iodine/ml • Volume: 100-150 ml • Saline: 40-60 ml (if utilized) • Flow Rate: 3-5 ml/sec • Start delay of 20-30 seconds or Bolus tracking in the aorta using 100-250 HU • trigger to optimize bolus (depending on scanner) NOTE: Iodine volumes may vary based on concentration, patient size, and user preference 7.3.4 Post Processing Goals and Examples Thin MIPs sagittal and coronal through area of interest • Oblique MIPs as necessary to demonstrate AS+RenalCTA H • 000 *14-Feb-1960, 7 5 anatomy/pathology 21-Jul-2010 09:06:49.77 9 IMA 0 VRT Curved MIPs for non-linear vessels • Bone removal to display vessels • Radial ranges – spins, tumbles • VRT images if needed • Vessel measurements • LA 107 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Thin MIPs sagittal and coronal through area of interest Notes Oblique MIPs as necessary to demonstrate anatomy/pathology AL Curved MIPs for non-linear vessels 108 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Bone removal to display vessels Notes L LA Radial ranges – spins, tumbles sets Defout Radal SUO 99 Angle between images 19.5 deg Number of images 19 A Start Close Help VRT images if needed ET 2008G SIMA O Manip, VRT LA 109 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Vessel measurements Notes 7.4 CTA Thorax/Pulmonary Arteries CT Angiography of the thorax is often indicated in the evaluation of: Pulmonary Embolism • Vascular Abnormalities • Congenital Abnormalities • Aneurysm • Dissection • Pre- and Post-op for placement of stents and grafts • Occlusive Disease • Trauma • 110 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.4.1 Protocol Selection Notes Dedicated protocols for CT Angiography of the thorax and pulmonary arteries can be found in the Vascular section of the Patient Model Dialog. Patient Model Dialog · Adult Dual Energy Protocol . Replace . Child Append ardia Topogram . Cut Vascul . Keep RT Auto reference lines None beci API Language German OK Cancel Depending on the scanner and software version, default protocols may include: Vascular ThorAngio_XCARE_SAFIRE • ThorAngio_SAFIRE • ThorAngio_XCARE • ThorAngioRoutine • ThorAngioVol • Embolism_SAFIRE • Embolism • 7.4.2 General Hints Patient supine, arms overhead – head first or feet first • Breathing instructions (API) should be “Do Not Breathe” or “Stop Breathing” to • help prevent Valsalva (can influence contrast opacification in pulmonary arteries for PE exams) Study can be ECG gated, depending on scanner and software options (for PE, • congenital abnormalities and for visualization of Cardiac Vessels) Images can be acquired in caudocranial direction to limit motion artifact and • contrast artifact in IVC If planning for Pulmonary Embolism study, ROI should be placed in pulmonary • trunk for best results If planning for Thoracic aorta study, ROI can be placed in ascending aorta (be • aware that streaking from the IVC may interfere with ROI placement and cause premature trigger and scan start.) Unenhanced studies and/or delays may be needed in the case of post op stent • placement to check for graft leakage 111 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Image reconstruction kernels of B30 for soft tissue may be used, B70 or B80 for Notes • lung and B26 or B30 for thin reconstructions ( kernels may have prefix of I if using SAFIRE) For optimal 3D image post processing, thin reconstructions with at least 50% • overlap are recommended. 7.4.3 Injection Protocol Iodine Concentration: 300-370 mg Iodine/ml • Volume: 60-130 ml • Saline: 40-60 ml (recommended) • Flow Rate: 4-5 ml/sec • Start delay of 15-30 seconds or bolus tracking in the aorta or pulmonary trunk • using 100-150 HU trigger to optimize bolus (depending on scanner and protocol) NOTE: Iodine volumes may vary based on concentration, patient size, and user preference 7.4.4 Post Processing Goals and Examples Thin MIPs sagittal and coronal through area of interest • Oblique MIPs as necessary, esp. aorta “Candy Cane” view and pulmonary arteries • Curved MIPs for non-linear vessels • Bone removal to display vessels • Radial ranges – spins, tumbles • VRT images if needed • Vessel measurements • Thin MIPs sagittal and coronal through area of interest L A 112 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Oblique MIPs as necessary, esp. aorta “Candy Cane” view and pulmonary arteries Notes A Curved MIPs for non-linear vessels LAF> Bone removal to display vessels 113 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Radial ranges – spins, tumbles Notes A 0.75mm_100KV_126- SP H1066.4 10cm Manip VRT Angle beused in O between images 10 CAUD 90 F VRT images if needed Vessel measurements 114 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.5 Coronary CTA Notes Unlike most other CT examinations, imaging of the heart is unique due to the fact that the organ of interest is in constant motion. Like conventional photography, imaging a moving object often results in blurry images. In CT angiography of the heart, the acquisition and reconstructions are correlated to the patient’s heart rate at the time of the scan in an effort to generate images in periods of least motion. Therefore, it is generally desired to scan patients who have a stable, low heart rate to help ensure success. CTA of the heart is often indicated in the evaluation of: Congenital heart disease • Coronary abnormalities • Pre- and Post-operative evaluation • Coronary CTA Requirements High temporal resolution (minimize motion • artifacts) High spatial resolution (depiction of small and • complex cardiac anatomy) Fast coverage (scan entire heart within single • breath hold) Synchronization of acquisition and reconstruction to the patient’s heart beat • 7.5.1 Protocol Selection Dedicated protocols for Coronary CTA can be found in the Cardiac section of the Patient Model Dialog. Patient Model Dialog · Adult Dual Energy Protocol . Replace . Child Append ardia Topogram . Cut ascul . Keep RT Auto reference lines None pecia rivat API Language German OK Cancel Depending on the scanner and software version, default protocols may include: CaScore • CoronaryCTARoutine • CoronaryCTA_IR • 115 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.5.2 General Hints Notes Patient supine, arms overhead – head first or feet first • Have the patient wear comfortable, loose-fitting clothing, or dress the patient in a • gown if possible. Take care to remove any metal from the scan range. Make sure the patient is comfortable. Use a knee sponge if available to relieve • back strain and relax the abdomen, and offer a blanket for warmth. Utilize beta blockers and/or vasodilators as instructed by a physician • Make certain ECG leads are connected appropriately and a good signal is • obtained Breathing instructions (API) on inspiration • Test Bolus or Bolus Tracking may be used for optimal contrast bolus Explain the • purpose of the examination and let the patient ask questions. Inform the patient of the warm sensation that often follows IV contrast • administration. Reinforce that body and breathing motion have a negative impact on the quality • of the examination. Practice the breathing instructions prior to the exam 7.5.3 Placement of ECG Leads/Electrodes The use of ECG leads during a gated Cardiac CTA allows for the real-time acquisition of a patient’s cardiac rhythm during the examination. Quality ECG information is critical for the successful reconstruction of diagnostic Cardiac CTA images. 1. Position and immobilize the patient on the table with arms above the head before placing ECG leads 2. Shave the area as needed to ensure optimal skin contact 3. Clean the area as directed by the lead manufacturer to remove skin oils 4. Attach the leads to the pads before placing on the patient. Wet gel electrodes are recommended. 5. Plug leads into the correct ECG socket (configuration dependent on table model) 116 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 6. Attach the leads to the patient in the following manner: Notes White Electrode on the right mid-clavicular line, directly below the clavicle • Black Electrode on the left mid-clavicular line, directly below the clavicle • Red Electrode on the left mid-clavicular line, 6th or 7th intercostal space • 7. Make sure the leads are not tangled and are positioned as best as possible outside of the scan field of view 8. Observe the ECG trace to ensure good signal/low impedance. If the signal is not adequate, adjust the leads, or cycle through the ECG channels by pressing the ECG channel selection button. Choose the channel with the strongest signal. NOTE: If you must remove a pad, replace it with a new one. NOTE: While it is possible to obtain an ECG signal with alternative electrode placement, it is strongly recommended that these guidelines be followed for proper functionality of the CT system during Cardiac CTA examinations. Good Trace: Heart Rate (bpm) Min: 60 Max: 60 Avg: 60 60 60 60 60 60 60 Signal Noise: Heart Rate (bpm) Min: 56 Max: 68 Avg: 61 63 61 60 56 58 58 117 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.5.4 Injection Protocol Notes Due to the relatively short scan duration, only a small volume of contrast is required for the CTA study. However, more contrast volume is needed when a longer scan range is required, for example, in bypass graft studies. A saline chaser is highly recommended to flush out the intravenous line and to provide a more uniform enhancement. For optimal enhancement the iodine concentration should be between 350–370 mg iodine/ml. The minimum contrast volume should not be less than 65 ml. Always try to use the highest injection flow rate. This keeps the bolus tight and better contrast enhancement is achieved. Recommended formula for determining contrast volume for Coronary CTA: Contrast volume = (scan time x flow rate) + 10ml of contrast • Saline chaser = 40ml • Flow rate = 5 – 6ml/sec • NOTE: Iodine volumes may vary based on concentration, patient size, and user preference NOTE: Larger patients require more contrast, up to 100ml. NOTE: These values are based on best practice scenarios. Your facility may have their contrast injection and bolus timing protocols for use when scanning coronary CTA exams. Your Education Specialist will discuss with you what injection protocols work best for your facility and scanning practices. Dual flow injectors with mixing capabilities: Dual flow injectors with mixing capabilities allow to you mix contrast and saline as a second phase to the injection process. This gives you the ability to regulate the amount of contrast that is seen in the right side of the heart. An example of this formula: Total Contrast 71 ml = Total Saline 64 ml = Contrast 65 ml = 20/80 mix 6 ml contrast/24 ml saline = 30 ml = Saline Chaser 40 ml = Flow rate 5–6 ml/s = 118 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Dual flow injectors without mixing capabilities: Notes If you have a dual flow injector that does not have mixing capabilities, you can add a second injection phase at a reduced flow rate to regulate the amount of contrast in the right side of the heart. An example of this formula: Total contrast 75 ml = Total saline 40 ml = Contrast 60 ml@5 ml/s = Low flow rate 15 [email protected] ml/s = Saline chaser 40 ml@5 ml/s = 7.5.5 Synthetic Sync With synthetic trigger/sync, in the case of ECG signal loss during a scan, the system calculates the sync pulses by averaging over the last few measured heart beats. A simulated ECG is then used to continue the scan. The synthetic trigger/sync option is activated by default for a cardiac scan. It is recommended that you keep this option always activated for a scan using contrast medium. If this option is deactivated, a scan will be aborted in the case of ECG signal loss during the scan. 1. Choose Options > Configuration. 2. Click the HeartView icon. 3. On the General tab, select the ECG Synthetic Trigger/Sync check box. ECG Synthetic Trigger / Sync 7.6 Scan Acquisition Cardiac examinations are available in two modes: ECG-gated (retrospective) spiral • ECG-trigger (prospective) sequence • 7.6.1 ECG-gated (Retrospective) Spiral Retrospective ECG gating uses the spiral mode for imaging. Continuous exposure to radiation is applied or the entire cardiac cycle over several consecutive heart beats. The ECG is recorded simultaneously with the spiral data acquisition to allow for retrospective selection of the cardiac phase for images reconstruction. NOTE: The ECG-gated spiral mode is recommended for patients with arrhythmia or a higher heart rate. 119 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.6.2 Setting Up ECG Pulsing Notes 1. On the Trigger sub-task card, select the ECG Pulsing check box. 2. In the ECG Pulsing area, select % (relative time) or ms (abso- lute time) as the unit in the third list. % 3. In the first and second boxes, specify the starting point and the ending point of the pulsing window. % ms M ECG Pulsing 702 % 7.6.3 ECG-gated (Retrospective) Spiral Prerequisites The patient is positioned properly. • ECG electrodes are placed properly and stable ECG signals are available. • A proper cardiac scan protocol has been chosen. • Bolus timing has been planned. • A topogram is available, on which the heart range is defined for the CorCTA scan. • ECG pulsing has been set up. • 7.6.4 ECG-gated (Retrospective) Spiral Information A coronary CTA scan is carried out in a similar way as a typical contrast-enhanced examination. For a CTA scan, bolus timing is important. The scan should be initiated when the vessel of interest has an optimal contrast enhancement. After a cardiac scan is done in the spiral mode, the ECG that is used for the cardiac scan is updated on the Trigger sub-task card. Continuous pink lines appear to indicate the uninterrupted radiation exposure over a few heart beats. 62 62 62 2 3 4 120 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.6.5 Setting up BestPhase* (*Optional on the SOMATOM Perspective, included with Notes HeartView) NOTE: BestPhase is not available on all systems/software versions. For an inexperienced user, determining the optimal cardiac phase or phases may be challenging. Moreover, it is time-consuming to perform multiple reconstruction jobs that may not yield the desired results. The BestPhase function is a tool that can adapt to the individual patient’s heart motion and automatically identifies the optimal diastolic and systolic phases for cardiac reconstruction. It helps the inexperienced user by predicting the optimal phases for image reconstruction and speeds up the workflow by reducing the number of unsuccessful recon jobs. 1. Click the Trigger sub-task card. 2. Select one of the following in the BestPhase list: BestSyst manual BestSyst BestDiast BestSyst: lets the system decide the optimal systolic phase. • BestDiast: lets the system decide the optimal diastolic phase. • 7.6.6 Selecting a Cardiac Recon Phase 1. Make sure that Manual is selected in the BestPhase list of the Trigger sub-task card. BestPhase manual 65 % 2. Select % (relative time) or ms (absolute time) as the unit in the third list. % % ms 3. Specify the phase value in the second box. NOTE: A negative value (unit: %) defines starting points before R-peaks. 7.6.7 ECG-Triggered (Prospective) Sequence Prospective ECG triggering uses the sequence mode for imaging. The appropriate cardiac phase is used to trigger a scan. To time the trigger, the mean RR interval of the three preceding heart beats is used to predict the arrival of the next heart cycle. A reliable prediction is only possible if the heart rhythm is regular. NOTE: Use this dose-saving sequence mode for patients with a lower and stable heart rate. 121 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.6.8 Setting up Phase Start Notes 1. In the Phase Start area of the Trigger sub-task card, select % (relative time) or ms (absolute time) as the unit in the second list. % % ms 2. Specify the phase starting time in the first box. Phase Start 65 % NOTE: A negative value (unit: %) defines starting points before Rpeaks. NOTE: For a scan with an irregular heart rate, try % instead of ms. 7.6.9 ECG-Triggered (Prospective) Sequence Prerequisites The patient is positioned properly. • ECG electrodes are placed properly and stable ECG signals are available. • A proper cardiac scan protocol has been chosen. • Bolus timing has been planned. • A topogram is available, on which the heart range is defined for the CorCTA scan. • Phase start has been set up. • 7.6.10 ECG-Triggered (Prospective) Sequence Information A coronary CTA scan is carried out in a similar way as a typical contrast-enhanced examination. For a CTA scan, bolus timing is important. The scan should be initiated when the vessel of interest has an optimal contrast enhancement. After a cardiac scan is done in the sequence mode, the ECG that is used for the cardiac scan is updated on the Trigger sub-task card. Dashed pink lines appear to indicate the periodical radiation exposure over a few heart beats. 62 62 62 2 3 4 NOTE: The scan duration in the sequence mode depends on the heart rate. The more irregular the heart rate, the longer the cardiac scan will last. 122 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.6.11 ECG-Triggered (Prospective) Sequence Recon Notes In the sequence mode, scan data is only acquired in a pre-defined cardiac phase. This is done by specifying the Phase start before a scan. Therefore, after the scan, you cannot reconstruct the images in a different cardiac phase. Functional analysis of the heart is not possible. However, you can work with general recon parameters, for example, setting up the slice width and recon increment for coronary evaluation. 7.7 iTRIM* (*Optional on the SOMATOM Perspective, included with HeartView) NOTE: iTRIM is not available on all systems/software versions. iTRIM (Iterative Temporal Resolution Improvement Method) is designed to improve temporal resolution of cardiac CT images. iTRIM with motion weighting allows cardiac examinations on the Perspective with a temporal resolution of 195ms. 180º WFBP iTRIM iTRIM is based on the observation that the presence of motion artifacts does not significantly change the histogram of a CT image. This information is used to reconstruct an image from less than half a turn of data. First, a conventional cardiac partial scan weighted filtered back projection (WFBP) reconstruction is performed, resulting in a temporal resolution equivalent to 180 degrees of CT data. Then, an iterative reconstruction algorithm using only a subset of the full 180 degrees cardiac data set is started. The iterative loop has two steps: First, the image is updated with the projection data subset using the SART (Simultaneous Algebraic Reconstruction Technique) iterative reconstruction framework. After each SART iteration, the HU value of each pixel is adjusted according to the respective histogram of the lower temporal resolution image. Then, a motion detection technique is used after the iteration. The iTRIM image from the final iteration of the reconstruction is combined with the conventional 180 degrees WFBP image. In regions that exhibit motion, more iTRIM image is used for the final image, whereas in static regions, more the WFBP image is used. After the reconstruction of cardiac images, the time resolution for each scan will be displayed in the comment entry on the axial images. NOTE: iTRIM is not applied on RTD images so only check the image quality and time resolution after real series have been reconstructed. 123 CT Advanced Scanning Techniques | Classroom & Turnover Workbook NOTE: If you choose to use full rotation sequence cardiac scan, iTRIM is also not Notes available. 7.8 ECG Check* (*Optional on the SOMATOM Perspective, included with HeartView) ECG Check analyzes the patient’s heart rate and offers a recommendation on TestBolus 3 - -- which scan should be performed. It helps the user to select the most Contrast appropriate acquisition method – ECG- Delete unsuitable scans triggered prospective sequence or ECG- gated retrospective spiral – based on CorSeq RT the patient’s heart rate. It helps to ensure the lowest possible dose with Pause the best possible image quality for each patient. CorCTA 5 Based on 10 consecutive heart beats, Pause ECG check advises the user which acquisition method(s) are CorCTABi RT 6 recommended or are not suitable based on the current patient’s heart rate, heart rhythm, presence of extra Load Hold ECG systoles, and customer preference/ Recon Check configuration. 7.9 TAVR – Transcatheter Aortic Valve Replacement TAVR – Transcatheter Aortic Valve Replacement - is a minimally-invasive procedure in which a severely stenotic aortic valve is replaced by deploying a new, artificial valve in its place, typically by way of a trans-femoral catheter. It is an ideal alternative to open heart surgery for high-risk patients who are not optimal surgical candidates. Critical aortic stenosis in 2-5% of adults > 75 years old • 32% are not surgical candidates • Dismal prognosis: 50% death @ 2 years after first symptoms • ECG gated CT Angiography of the heart and aorta is becoming a routine requirement in the planning of TAVR procedures: Access route (minimal luminal diameter, tortuosity, calcification) • Valve sizing • Coronary ostial height • Optimal fluoroscopic angles • Incidental findings • 124 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes 7.9.1 Protocol Selection Dedicated protocols for CT Angiography of the heart and aorta can be found in the Cardiac section of the Patient Model Dialog. Imaging should extend from the aortic arch (and potentially the subclavian artery) through the groin. ECG gating is required for the aortic root; however, ECG gating is not typically necessary for the abdominal aorta and peripheral vessels. Patient Model Dialog . Adult Dual Energy Protocol . Replace Child Append ardie Topogram . Cut scul . Keep RT Auto reference lines None pecia PET API Language English OK Cancel 7.9.2 General Hints Test bolus method can be optimal • Use fast scanning mode (i.e. Flash) • Immediate delay in case you outrun the bolus • Dilute contrast, low kV if possible • Start conservatively; work contrast doses down • 7.9.3 Post Processing Goals and Examples Aortofemoral Diameters Measure the inner luminal diameter • Reference recommended minimum vessel lumen diameter, in mm, for device • considered 2D 1 Distance: 0.79 cm 2D 1: Min/Max; 137 /232 2D 2 Distance: 0.88 cm 2D 2 Min/Max: 114 /188 2D 2 ....... LCIA 125 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes Aortofemoral Morphology Tortuosity • Kinking • Stenosis/occlusion • Calcification • Aortic Annulus A CRC . . . . . . .... . . NC LC Diameter 20.6 mm, 2 Mean Diameter 23.6 mm Area 4.34 cm2 Derived Diameter 23.5 mm Circumference 7.68 cm Derived Diameter 24.4 mm ............ ..... ...... 126 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Notes Annular Calcification Coronary Ostial Height Fluoroscopic Angle ....... RAOLAO 10. .. CRANICAUD. 23. Incidental Findings 127 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.10 VPCT/Volume Neuro Perfusion CT Notes VPCT – Volume Neuro Perfusion CT - is a non-invasive procedure in which cerebral blood flow and circulation are evaluated in cases of suspected stroke. A stroke is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. Cerebral Infarction, Cerebrovascular Accident (CVA), Brain Attack Stroke was 4th leading cause of death in U.S. in 2010 Leading cause of severe, long-term disability • Approximately 795,000 people suffer a stroke each year in the U.S. • More than 140,000 die each year in the U.S. • Someone in the U.S. has a stroke approximately every 45 seconds • Area of brain affected by stroke Carotid artery Blood clot Ischemic Stroke: Caused by blockage of a blood vessel • Blood clot within a vessel – thrombosis • Blood clot that has migrated and now occludes a vessel in the brain or neck • embolism. Ischemic Stroke - Ischemic stroke is a Constriction or narrowing of an artery in the life-threatening event • in which part of the head or neck - stenosis brain does not receive enough oxygen, Accounts for approximately 80% of all strokes usually due to a blood clot lodged • in a cerebral artery. Can potentially be treated with thrombolytic • medication Blood clot Therapy • Early medical intervention with tPA (Tissue • Plasminogen Activator = e.g. Activase®) dissolves blood clots; however, this Carotid artery treatment must be selective and is not for disease everyone! Additionally, the drug must be given within a time window of 3-6 hours to be • 128 effective CT Advanced Scanning Techniques | Classroom & Turnover Workbook Hemorrhagic Stroke: Notes Caused by bleeding of a blood vessel into the surrounding brain tissue • Accounts for approximately 20% of all strokes • Hemorrhagic stroke Can reliably be seen with standard CT • CT is the primary imaging modality • Therapy • Blood clotting medication • Non-contrasted CT scan only • Bleeding occurs inside or around brain tissue NOTE: Therapies for ischemic and hemorrhagic strokes are mutually exclusive. CT as the primary imaging modality in stroke diagnosis should answer 3 questions: Is there an hemorrhagic, ischemic or some other underlying, non-ischemic • disease? What is the extent of currently infarcted brain (core) and is there associated brain • tissue at risk of irreversible ischemic damage (or “tissue at risk”) Are any vessels occluded and, if so, where? • 7.10.1 Protocol Selection CT can provide comprehensive diagnostic stroke information in less than 15 minutes: Non-enhanced CT Head CT Perfusion CT Angiography Non-contrasted/non-enhanced Head CT Primary imaging modality: • Proven excellence in demonstrating or ruling out hemorrhagic stroke • Absence of major early CT signs is the accepted standard criterion for systemic • thrombolysis CT is readily available and provides immediate results • 129 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Perfusion CT: Notes Shows hemodynamic status • Type and extent of ischemic process • Quality of collateral flow • CT Angiography: Provides information about vascular pathology • Shows/confirms occlusion type and location • Improves planning of potential interventions • Dedicated protocols for CT Neuro Perfusion can be found in the Specials section of the Patient Model Dialog. Patient Model Dialog · Adult Dua Ener ergy Protocol · Replace Child Append ardia Topogram . Cut ascul Keep RT Auto reference lines None pecia PET API Language English OK Cance Depending on the scanner, software version and available purchased options, default protocols may include: NeuroPCT • NeuroPCTSingle • NeuroVPCT_Stroke • NeuroVPCT_Tumor • 130 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.10.2 Injection Protocol Notes For CT Neuro Perfusion, time is the critical factor when injecting contrast media. In order to evaluate cerebral blood flow, contrast must circulate similarly to the blood that is being evaluated and must roughly equal the cerebral circulation time of approximately 5 seconds. As such, Siemens recommends 40mL contrast injected at 8cc/sec, for an injection duration of 5sec. This will provide a compact, highly- enhanced bolus of an appropriate volume, rate, and duration. 20 Normal Perfusion 10 1 7 13 19 25 31 14g or 16g antecubital IV • Concentration: 370 mg Iodine/ml • Volume: 40 ml • Flow Rate: 8 ml/sec • Flow Duration: 5 sec • Start delay: None - begin contrast and scan simultaneously • Single fused or multislice images through basal ganglia (approximately 1 – 2cm • above sella) OR Volume/4D Perfusion acquisition • Scan Duration: ~40 sec • 131 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.10.3 Post Processing Goals and Examples Notes Dynamic scan data is loaded into Neuro Perfusion (PCT) or Volume Neuro Perfusion (VPCT Neuro) for evaluation. This may involve simple analysis using Regions of Interest (ROI) over different areas of the brain to compare time-attenuation curve information: 20 ₸ Normal Perfusion 10 - + C 1 7 13 19 25 31 Early Phase 20 Ischemia 10 7 13 19 25 31 Late Phase Advanced parameters such as cerebral blood flow, cerebral blood volume, time to peak, mean transit time, and tissue at risk can provide additional information regarding the scope and severity of the infarction. CBF CBV TTP MTT Cerebral Blood Flow Cerebral Blood Volume Time to Peak Mean Transit Time (ml/100ml/min) (ml/100ml) (s) (s) Flow rate of volume Volume of flowing blood Time of local peak Time required for blood of blood through Scaled 1000:1, so a value Enhancement to pass through cerebral vasculature of 30 = 3% blood volume Scaled in 0.1s, so a value tissue of 182 = 18.2 seconds 132 CT Advanced Scanning Techniques | Classroom & Turnover Workbook The neuro perfusion acquisition is generally followed with a carotid/COW CTA for Notes further evaluation of contributory vascular pathology 7.11 Dual Energy CT A Dual Energy CT scan is one that is acquired using two different kV values, typically: 80/100kV • 130kV/140kV • Rotation direction 33 cm Detector B Detector A Using dedicated Dual Energy applications, the low- and high-energy data can be combined and processed to aid in the evaluation of a wide variety of anatomic structures and pathologic functions, such as: Kidney Stones • Bone Removal • Liver Virtual Non-Contrast • Vascular applications • 133 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Cardiovascular applications Notes • Gout • Brain Hemorrhage • Perfusion (Neuro, Body) • Lung Vessels • Oncology • 7.11.1 Physics of Dual Energy The basic principle of x-ray technology is that anatomic structures attenuate x-rays differently based on the composition/density of the anatomy. For example, bone attenuates x-rays significantly more than does lung tissue. This is apparent in that bone displays white and lung tissue is much darker on x-ray. There is a general appreciation of what most anatomic structures look like when exposed with the characteristic 120kV used for CT exams. The fundamental tenet of Dual Energy is that anatomic structures – like bone - will attenuate x-rays differently when exposed to other x-ray energy values, meaning bone itself will look different at 80kV than at 140kV than at the familiar 120kV. This is apparent in the different Hounsfield Unit values that are appreciated at different kV settings. In this image, bone and iodine have been scanned at both 80kV and at 140kV. The different HU values at each kV can be appreciated. Bone 550 HU lodine Bone 400 HU 350 HUY lodine CA150 HU 80KV 140kV+SPS (selective photon shield) Scanning with two different energies allows us to compare the variations in HU values and extrapolate additional anatomic and physiologic information beyond the standard computed tomography scan. 134 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Keep in mind that x-rays are not monoenergetic, meaning that a 140 kV x-ray is not Notes purely 140 kV, but rather the average energy of a polyenergetic beam. Therefore, filtration is used on the 140 kV tube to filter out the lower energy levels, “hardening” the x-ray spectrum and resulting in a better differentiation of the kV values between the low and high energies. S1: 80 KV S2: 140 KV S1: 80 KV S2: 140 KV + SPS 15* 10€ 80 KV 15* 10€ 80 KV -140 kV 140 kV 140 kV + SPS 10- 10 5- 5 number of quanta number of quanta 50 100 150 50 100 150 photon energy (keV) photon energy (keV) Today, there are several different means of acquiring Dual Energy data sets: Single Source DE scanners utilizing two consecutive spiral acquisitions – one using • low energy and one using high energy – for the different kV data sets. Single Source CT scanners utilizing special filtration to divide the x-ray beam into • two different energies. This allows for the low and high energy data to be acquired simultaneously. Dual Source Dual Energy scanners, which utilize two x-ray tubes and two • corresponding detector arrays. This allows for the low and high energy data (A and B) to be acquired simultaneously. NOTE: Not all systems are capable or equipped to perform Dual Energy scans, and those that are may not be able to perform all of the types of examinations listed here. Please consult with your Siemens representative regarding your individual system capabilities. NOTE: For the purpose of this workbook and the scanners referenced, this section will focus on Single Source Dual Spiral Dual Energy. 135 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.11.2 Dual Spiral Dual Energy Notes Dual Spiral Dual Energy supports a dual- energy exam on a single x-ray tube CT system. A Dual Spiral Dual Energy exam consists of two consecutive spiral scans of different voltages. The same range is scanned twice with different tube voltages: the first spiral scan uses 80kV; the second spiral scan uses Two separate acquisitions 130kV. The scan data sets (80kV and 130kV) Two separate energies can be evaluated by using the syngo Dual Spiral Dual Energy application to visualize information about anatomical and pathological structures. NOTE: Dual Spiral Dual Energy protocols, whose name starts with “DE”, are available from the various body regions (for example, from the Abdomen region) in Patient Model Dialog, and are protected by a license. NOTE: The syngo Dual Spiral Dual Energy application is available from the syngo.via software. 7.11.3 Dual Spiral Dual Energy Exam Range A Dual Spiral Dual Energy exam range is a special kind of auto-range, as by the paper clip linking the consecutive low-energy and the high-energy series. DE_Abd80kV DE_Abd130kV RT 2 The two spiral scans in a Dual Spiral Dual Energy exam are bound together and cannot be split. Exam parameters of the second spiral are inherited from exam parameters of the first spiral, and cannot be changed. Therefore, edit the exam parameters of the first spiral (for example, scan range Begin & End), if necessary. NOTE: The first spiral scan uses 80kV and the second spiral scan uses 130kV. 136 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.11.4 Protocol Selection Notes Dedicated protocols for Dual Energy examinations can be found in the Dual Energy section of the Patient Model Dialog. Patient Model Dialog . Adult 1 En Protocol . Replace Child Append ardia Topogram . Cu scu . Keep RT Auto reference lines None ecia rivat API Language German OK Cancel 7.11.5 General Hints Isocenter is critical for best possible image quality and dose modulation • For DE exams both AP and lateral Topograms are recommended • Using lateral topogram as reference, table height for DE can be adjusted with the • Feed Up/Down buttons on the Examination card. The region of interest can be centered using the laser marker lights and the • centering can be adjusted after checking the AP and lateral topograms × Caudocranial F 137 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.12 Dual Energy Applications Notes Dual Energy broadens the clinical relevance of CT acquisition beyond anatomy visualization only – it enables the characterization, quantification, and differentiation of materials and provides additional information about the structures being imaged. With dedicated protocols, Dual Energy is easily incorporated into the daily scanning routine. The following are some available Dual Energy clinical applications specific to Single Source Dual Spiral DE technology. NOTE: syngo Dual Spiral Dual Energy application are available from the syngo.via software. 7.12.1 syngo Dual Energy Calculi Characterization The main determinants in the management of patients with urinary stone disease are the location, size, and chemical composition of the stone. The syngo Dual Energy Calculi Characterization application visualizes chemical differences in kidney stones. The basis for this approach is a material decomposition into uric acid and other stone types. Conventional CT can detect only calculi but does not offer information on stone types. Dual Energy makes it possible to differentiate uric acid stones from other stone types, and in so doing, help identify those patients who can benefit from medical treatment alone and avoid unnecessary interventional procedures and costs. 1400 80 KV [HUI 1300 1200 1.13 1100 - 1000 900 800 OHyorgulapatte 700 - 600 Ogathe 500 - 400 . OUic ACID 300 - 200 100 130 KV THUI 100 200 300 400 500 600 700 800 900 1000 138 CT Advanced Scanning Techniques | Classroom & Turnover Workbook Using Dual Energy Calculi Characterization, uric acid stones are depicted in red, Notes which non-uric acid stones are depicted in blue. Kidney Stones X 80 kV [HU] ,40 900 O Hydroxylapatite - - 20 Oxalat 800 Non uric acid stone 700- 600 500 eine ......... .:40 400 300 .- Uric Acid 200 Uric acid stone 100 Urine 140-kV [HU]- 0 90 180 270 360 460 540 630 80 kV [HU] 140 kV [HU] Urine 33 26 Ratio 1.15 Minimum 200 Maximum 3071 Range 7 F Calculate Siemens Default Help 7.12.2 syngo Dual Energy Monoenergetic Plus The Monoenergetic Plus Application Class allows for the display of images equivalent to those acquired with a monoenergetic x-ray beam of selectable energy (40 – 90 keV). By changing the energy (keV), the contrast 15 104 between different structures and materials 140kVp spectra may be enhanced. 10 70keV Monoenergetic 40 45 190 5 O 50 100 150 photon energy (keV) As the slider is adjusted, the recalculated images are displayed. 139 CT Advanced Scanning Techniques | Classroom & Turnover Workbook 7.12.3 syngo Dual Energy Gout Notes Gout is a type of arthritis often characterized by the deposition of uric acid crystals in the joints. It typically presents in recurring episodes of pain, swelling, and inflammation over the affected area. Gout can be difficult to distinguish from other forms of arthritis and usually requires the microscopic evaluation of joint fluid. Dual Energy imaging can help classify the uric acid, offering a more definitive and non- invasive diagnosis of the disease. The Gout Application Class helps to differentiate between urate, bone, bone marrow, and contrast agent. Potential urate is displayed in green and iodine in purple, by default. RPH V(<0): 20.42 cm3 140 141 On account of certain regional limitations of sales rights and service availability, we cannot guarantee that all products included in this brochure are available through the Siemens sales organization worldwide. Availability and packaging may vary by country and is subject to change without prior notice. Some/All of the features and Local Contact Information products described herein may not be Siemens Medical Solutions USA, Inc. available in the United States. 40 Liberty Blvd. Malvern, PA 19355-9998 The information in this document USA contains general technical descriptions Telephone: +1-888-826-9702 of specifications and options as well as siemens.com/healthcare standard and optional features which do not always have to be present in Legal Manufacturers individual cases. Computed Tomography & Radiation Oncology Siemensstr. 1 Siemens reserves the right to modify the DE-91301 Forchheim design, packaging, specifications and Germany options described herein without prior Telephone: +49 9191 18-0 notice. Please contact your local siemens.com/healthcare Siemens sales representative for the most current information. Siemens Shanghai Medical Equipment Ltd. Note: Any technical data contained in 278 Zhou Zhu Road this document may vary within defined Shanghai 201318 tolerances. Original images always lose P.R. China a certain amount of detail when reproduced. Siemens Healthcare Headquarters Siemens Healthcare GmbH Healthcare Sector Henkestr. 127 91052 Erlangen Germany Phone: +49 9131 84-0 siemens.com Published by Siemens Healthcare GmbH · Order No. HOOD05162003017489 · Printed in USA · 0000.x · ©Siemens Healthcare GmbH, 2017 142