CT Advanced Examinations II - STEP Week 4 Workbook

CT Advanced [TYPE OF WORKBOOK HERE] | [SYSTEM NAME HERE] Examinations II STEP Week 4 Classroom Workbook Education & Workforce Solutions SIEMENS Your potential is calling. Healthineers CT Advanced Examinations II | SOMATOM 7 Welcome A Message from Nanci Wozniak Welcome to your training experience with Education & Workforce Solutions. I want to personally thank you for choosing Siemens Healthineers. We are honored to have you as our partner and hope you will enjoy this course. Our teams strive to ensure your priorities and needs are met. We sincerely appreciate your hard work around what really matters - the human side of health care. You are our heroes. Thank you for being part of the Siemens Healthineers family and we look forward to our partnership with you. Nani llig Nanci Wozniak Vice President, Education & Workforce Solutions CX SV USA – Customer Service Organization Siemens Healthineers Clinical Training and Continuing Education Contact Information Customer Care Center - Clinical Application Support: Call 1-800-888-7436 PEPconnect https://pep.siemens-info.com/en-us 2 CT Advanced Examinations II | SOMATOM 7 Contents Welcome.......................................................................................................2 Contents .......................................................................................................3 Course Description ........................................................................................4 Day 1............................................................................................................6 Cardiac Anatomy & Vasculature Review.......................................................7 CT Cardiac Patient Prep ........................................................................45 Cardiac CTA.........................................................................................69 Guided Demo ....................................................................................114 Day 2........................................................................................................118 CT Cardiac Acquisition Principles ............................................................119 CT Cardiac Contrast Injection .............................................................175 CT Cardiac Image Reconstruction .......................................................189 Cardiac ECG Editing ...........................................................................209 CT Cardiac Imaging Artifacts and Pitfalls .............................................219 Guided Demo ....................................................................................239 Day 3........................................................................................................243 Dual Energy...........................................................................................244 Principles of DE Physics ......................................................................245 Dual Energy Approaches ....................................................................259 Guided Demo ....................................................................................304 Day 4........................................................................................................315 syngo.via Dual Energy Workflow ............................................................316 Guided demo ....................................................................................317 3 CT Advanced Examinations II | SOMATOM 7 Course Description Course Overview: The CT Siemens Technologist Education Program Week four is designed to give CT technologists an in depth look at Siemens advanced system capabilities and examination procedures. Advanced CT Examinations to include CT anatomy, acquisition, image quality, and post-processing techniques including syngo.via® for CTA Cardiac and Dual Energy applications. Upon completion of this course, you will be able to: • Identify key anatomy on CTA cardiac and Dual Energy exams • Navigate protocol building and protocol selection appropriate to each clinical application • Explain and demonstrate importance of patient preparation, positioning, and clinical history in obtaining optimal images • Understand CT physics as they relate to acquiring each advanced examination • Employ Siemens proprietary dose reduction technologies • Explain post processing strategies as they relate to the advanced exam acquired 4 CT Advanced Examinations II | SOMATOM 7 SIEMENS Healthineers STEP Siemens Technologist Education Program SOMARIS 7 All Scanners Week 4: Advanced Examinations II HOOD05162003200791 Effective: 06/25/2021 Unrestricted © Siemens Healthineers, 2022 Notes 5 CT Advanced Examinations II | SOMATOM 7 Day 1 SIEMENS Healthineers Day 1 Advanced Examinations II .... Unrestricted © Siemens Healthineers, 2022 Notes 6 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy & Vasculature Review Agenda – DAY 1 SIEMENS Healthineers ... • Welcome / Introductions • Cardiac Anatomy and Vasculature Review • CT Cardiac Patient Prep • Patient History; Patient Positioning; Scan Range; ECG Lead Placement; Breathing Instructions Day 1 • Cardiac CTA • Clinical Indications; Conducting System; ECG Advanced Examinations II Basics; CT Physics; Protocol Selection; Dose Considerations; Medication • Guided Demo • Hands – On Lab 3 Unrestricted © Siemens Healthineers, 2022 Unrestricted © Siemens Healthineers, 2022 Notes 7 CT Advanced Examinations II | SOMATOM 7 SIEMENS Healthineers ... SOMARIS 7 Cardiac Anatomy and Vasculature Review 4 Unrestricted © Siemens Healthineers, 2022 Notes 8 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... Did you Know? Interesting Facts about the Heart 1. Size of your fist and weighs between 7 to 15 ounces (200 to 425 grams) 2. Located between your lungs in the middle of your chest, behind and slightly to the left of your sternum 3. A double‐layered membrane called the pericardium surrounds your heart like a sac 4. Pumps about 5 to 6 liters or 1.5 gallons of blood/minute 5. Beats 60 – 80 times per minute 6. The heart can beat as fast as 200 beats per minute when exercising 7. Each day the average heart beats 100,000 times, pumping about 2,000 gallons (7,571 liters) of blood 8. In one year, the heart beats 3 million times 9. In an average lifetime (70 years), the heart beats more than 2.5 billion times 5 Unrestricted © Siemens Healthineers, 2022 Notes 9 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... Cardiac Muscle Layers The human heart has three layers in its wall. Pericardial Fibrous They are, from inside outwards: cavity pericardium Myocardium • Endocardium – an endothelial lining • Myocardium – composed of cardiac muscle Endocardium • Pericardium – fibro‐serous covering of the heart broken into three layers: • Visceral Pericardium (Epicardium) • Parietal Pericardium • Fibrous Pericardium Parietal pericardium Visceral pericardium (epicardium) www.stylepinner.com 6 https://socratic.org/questions/which‐is‐the‐cardiac‐muscle‐layer‐of‐the‐heart Unrestricted © Siemens Healthineers, 2022 Notes 10 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... Heart Chambers The heart consists of 4 chambers – 2 atria (upper chambers) and 2 ventricles (lower chambers). RV • Upper chambers (atria) – receive incoming blood LV • Right atrium (RA) RA • Left atrium (LA) LA • Lower chambers (ventricles) – pump blood out of the heart • Right ventricle (RV) Left ventricle (LV) R • https://radiologyassistant.nl/img/containers/main/cardiac‐anatomy/a5097978b7ce42_4‐ chamber.jpg/177a2df8154388c7909f8739941ade1a.jpg https://www.mayoclinic.org/diseases‐conditions/heart‐disease/symptoms‐causes/syc‐ 7 20353118 Unrestricted © Siemens Healthineers, 2022 Notes 11 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... Heart Valves • Valve anatomy is complex • There are two types of heart valves: Atrioventricular (AV) valves and Semilunar (SL) valves • The mitral and tricuspid atrioventricular (AV) valves separate the atria from the ventricles, while the aortic and pulmonary semilunar (SL) valves separate the ventricles from the great arteries. • AV valves have leaflets and SL valves have cusps. • The AV valves are characterized by large asymmetric leaflets hinged to ring shaped annuli on the secured end and tethered to the ventricles by an elaborate apparatus made up of the chordae tendineae and papillary muscles on the mobile end. • The AV valves are slightly thicker than the SL valves, and the left‐sided valves are slightly thicker than the right‐sided valves. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4209403/#:~:text=The%20mitral%20a 8 nd%20tricuspid%20atrioventricular,and%20SL%20valves%20have%20cusps. Unrestricted © Siemens Healthineers, 2022 Notes 12 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... Heart Valves • Heart valves act as gates allowing blood to pass between chambers or from chamber to associated blood vessels. • Valves prevent the backward flow of blood. They act as one‐way inlets of blood on one side of a ventricle and one‐way outlets of PULMONARY MITRAL VALVE blood on the other side of a ventricle. VALVE atrium There are 4 Heart Valves atrium 1. Tricuspid ventricle 2. Pulmonary 3. Mitral (Bicuspid) ventricle 4. Aortic TRICUSPID AORTIC VALVE VALVE 9 Unrestricted © Siemens Healthineers, 2022 Notes 13 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... Heart Valves Tricuspid valve (right atrioventricular valve) – Anterior • is located between the right atrium and Pulmonary valve the right ventricle. (right semilunar valve) • Pulmonary valve (right semilunar valve) – is located between the right ventricle and the Aortic valve (left semilunar valve) pulmonary artery. • Mitral (Bicuspid) valve (left atrioventricular valve) – is located between the left atrium and the left ventricle. • Aortic valve (left semilunar valve) – is located between the left ventricle and the aorta. Mitral valve (left atrioventricular valve) Tricuspid valve (right atrioventricular valve) Posterior https://biology‐forums.com/index.php?action=gallery;sa=view;id=8519 https://www.hopkinsmedicine.org/health/conditions‐and‐diseases/heart‐valve‐ 10 diseases Unrestricted © Siemens Healthineers, 2022 Notes 14 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... Blood Flow Right Heart • Right Atrium receives deoxygenated blood from the Superior Vena Cava (SVC) and the Aorta Inferior Vena Cava (IVC). It contracts sending blood into the right ventricle through the Pulmony Left atrium tricuspid valve. artery • Right Ventricle contracts sending blood into Puvalvery Vaitral pulmonary artery atrium Left Heart Tricuspid ventricle • Newly oxygenated blood enters the left atrium through pulmonary veins. It contracts Right ventricle pushing blood through the Mitral (Bicuspid) valve into the left ventricle. @2017 MAYO • Left Ventricle contracts pushing blood into the aorta. 12 Unrestricted © Siemens Healthineers, 2022 Notes 15 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... Blood Flow Oxygen‐poor blood from the The pulmonary veins carry upper parts of the body returns oxygen‐rich blood from the to the heart through the superior Superior lungs back to the left atrium of vena cava Vena Cava the heart Aorta Oxygen‐poor blood from the Pulmonary The left atrium collects the lower parts of the body returns Artery to the heart through the inferior Pulmonary oxygen‐rich blood and forces it Vein through the mitral (bicuspid) vena cava Left valve into the left ventricle Atrium Mitral Valve The right atrium collects the oxygen‐poor blood and forces it Right The left ventricle receives Atrium oxygen‐rich blood and forces it through the tricuspid valve into Aortic Valve through the aortic valve to the the right ventricle Tricuspid Pulmonary aorta Valve Valve Left Ventricle The right ventricle receives Right The aorta carries the oxygen‐ oxygen‐poor blood and forces it Ventricle rich blood from the heart to through the pulmonary valve to the rest of the body. The aorta the pulmonary arteries to lungs is the largest artery. Interior Vena Cava 13 Unrestricted © Siemens Healthineers, 2022 Notes 16 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers .. Coronary Vessels • Coronary arteries supply blood to the heart muscle. • Like all other tissues in the body, the heart muscle needs oxygen‐rich blood to function. • Also, oxygen‐depleted blood must be carried away by cardiac veins • The coronary vessels wrap around the outside of the heart. • Small arterial branches dive into the heart muscle to bring it food https://www.hopkinsmedicine.org/health/conditions‐and‐diseases/anatomy‐and‐ 14 function‐of‐the‐coronary‐arteries Unrestricted © Siemens Healthineers, 2022 Notes 17 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... Coronary Vessels Coronary Arteries – Anterior View Coronary Arteries – Posteroinferior View Sinuatrial (SA) Left coronary artery nodal branch (ghosted) (ghosted) Ascending aorta Pulmonary trunk Circumflex branch of left coronary Left coronary artery (ghosted) artery Sinuatrial (SA) Site of nodal branch SA node- Posterior left ventricular Right pulmonary Circumflex branch of branch veins Right left coronary artery Right coronary coronary Anterior interventricular artery (ghosted) artery branch (left anterior Site of AV node descending) of left coronary artery Atrioventricular (AV) nodal branch Diagonal branch (ghosted) Left marginal branch of circumflex branch Crux of heart Apex Right marginal branch Posterior interventricular branch of right coronary artery (posterior descending) of right coronary artery 15 http://e‐medicaltextbook.blogspot.com/2008/08/coronary‐circulation.html Unrestricted © Siemens Healthineers, 2022 Notes 18 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... Coronary Vessels Cardiac Veins – Anterior View Cardiac Veins – Posteroinferior View Coronary sinus (ghosted) Oblique vein of left atrium Great (ghosted) cardiac vein Great cardiac Oblique vein vein of left atrium Anterior Coronary cardiac Sinus veins Small cardiac vein Small cardiac vein Middle cardiac vein Middle cardiac vein (ahosted) Posterior vein of left ventricle 16 http://e‐medicaltextbook.blogspot.com/2008/08/coronary‐circulation.html Unrestricted © Siemens Healthineers, 2022 Notes 19 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... Coronary Vessels The 2 main coronary arteries are the left main and right coronary arteries. Left coronary 1. Left main coronary artery (LMCA) – supplies artery blood to the left side of the heart muscle (left atrium and left ventricle). The left main Circumflex coronary divides into branches: artery • Left anterior descending artery (LAD) – Left (obtuse) branches off the left coronary artery and Right marginal coronary artery supplies blood to the front of the left artery side of the heart. Left anterior descending Right artery • Circumflex artery (CX) – branches off the left coronary artery and encircles the (acute) heart muscle. This artery supplies blood marginal Diagonal artery arteries to the outer side and back of the heart. https://www.hopkinsmedicine.org/health/conditions‐and‐diseases/anatomy‐and‐ 17 function‐of‐the‐coronary‐arteries Unrestricted © Siemens Healthineers, 2022 Notes 20 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... Coronary Vessels 2. Right coronary artery (RCA) – supplies blood to the right ventricle, the right atrium, and the SA (sinoatrial) and AV (atrioventricular) Left coronary nodes, which regulate the heart rhythm. The artery right coronary artery divides into smaller Circumflex branches, including: artery • Right posterior descending artery Left (obtuse) Acute marginal artery Right marginal • coronary artery • Together with the left anterior descending artery Left anterior artery, the right coronary artery helps supply descending blood to the middle or septum of the heart. Right artery (acute) • Smaller branches of the coronary arteries marginal Diagonal include obtuse marginal (OM), septal artery arteries perforator (SP), and diagonals https://www.hopkinsmedicine.org/health/conditions‐and‐diseases/anatomy‐and‐ 18 function‐of‐the‐coronary‐arteries Unrestricted © Siemens Healthineers, 2022 Notes 21 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... Coronary Vessels Myocardium Blood Supply 1) Four Chamber 2) Two Chamber 3 Long Axis 4 Base 5 Mid 6 Apex RCA IIIII RCA or CX LAD AN LAD or CX CX RCA or LAD 19 Unrestricted © Siemens Healthineers, 2022 Notes 22 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... Coronary Vessels Standard views of Coronary Arteries Left Coronary Superior vena Artery hof aorta art coronary branch of LAO 60 LAO 90 RAO 30 RAO 30 / Cran 20 Warteroman Right Coronary Artery Inferior Branch of vena cava R . coronary artery RAO 30 / LAO 45 / LAO 90 RAO 30 / Caud 20 Caud 15 Cran 15 20 Unrestricted © Siemens Healthineers, 2022 Notes 23 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... CT Cross‐Sectional Anatomy 1. Aortic Root 2. Left Main Coronary Artery (LMCA) 1 2 21 CT angiography by Dr Tarun K Mittal Unrestricted © Siemens Healthineers, 2022 Notes 24 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers' ... CT Cross‐Sectional Anatomy 1. Right Ventricular Outflow Tract (RVOT) 2. Main Pulmonary Artery 3. Left Pulmonary Artery 1 4. Right Pulmonary Artery 5. Right Superior Pulmonary Vein 6 6. Superior Vena Cava (SVC) 2 5 4 3 22 CT angiography by Dr Tarun K Mittal Unrestricted © Siemens Healthineers, 2022 Notes 25 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... CT Cross‐Sectional Anatomy 1. Right Coronary Artery (RCA) 2. Right Ventricular Outflow Tract (RVOT) 3. Aortic Root 1 2 4. Left Coronary Artery (LCA) 5. Left Pulmonary Vein 6. Left Atrium 7. Right Pulmonary Vein 3 7 4 5 6 23 CT angiography by Dr Tarun K Mittal Unrestricted © Siemens Healthineers, 2022 Notes 26 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers CT Cross‐Sectional Anatomy 1. Right Coronary Artery (RCA) 2. Right Ventricle 2 1 O 3 3. Left Anterior Descending Artery (LAD) 4. Left Ventricle 5. Circumflex Artery (CX) 8 4 6. Left Atrium 7. Ascending Aorta 7 5 8. Right Atrium 6 24 Unrestricted © Siemens Healthineers, 2022 Notes 27 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... CT Cross‐Sectional Anatomy 1. Right Coronary Artery (RCA) 1 2. Left Anterior Descending Artery (LAD) 3. Left Main Coronary Artery (LMCA) 2 3 25 Unrestricted © Siemens Healthineers, 2022 Notes 28 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... CT Cross‐Sectional Anatomy 1. Ascending Aorta 2. Right Ventricle 2 3. Left Anterior Descending Artery (LAD) 4. Left Atrium 9 5. Left Superior Pulmonary Vein 3 6. Thoracic Aorta 7. Right Superior Pulmonary Vein 4 8. Superior Vena Cava (SVC) 5 9. Right Atrium 6 26 Unrestricted © Siemens Healthineers, 2022 Notes 29 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... CT Cross‐Sectional Anatomy 1. Right Coronary Artery (RCA) 1 2 2. Left Anterior Descending Artery (LAD) 3. Circumflex Artery (CX) 3 27 Unrestricted © Siemens Healthineers, 2022 Notes 30 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... CT Cross‐Sectional Anatomy 1. Right Coronary Artery (RCA) 1 2. Left Anterior Descending Artery (LAD) 3. Circumflex Artery (CX) 2 4. Left Main Coronary Artery (LMCA) 3 4 28 Unrestricted © Siemens Healthineers, 2022 Notes 31 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... CT Cross‐Sectional Anatomy 1. Right Ventricular Outflow Tract (RVOT) 1 2. Anterior Wall of Left Ventricle 3. Aortic Root 4. Left Atrium 2 5. Right Atrium 5 3 4 29 CT angiography by Dr Tarun K Mittal Unrestricted © Siemens Healthineers, 2022 Notes 32 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... CT Cross‐Sectional Anatomy 1. Anterior Atrioventricular Groove 2. Interventricular Groove 1 2 3. Left Ventricular Outflow Tract (LVOT) 4. Posterior Atrioventricular Groove 6 5. Crista Terminalis 6. Right Atrium 5 3 4 30 CT angiography by Dr Tarun K Mittal Unrestricted © Siemens Healthineers, 2022 Notes 33 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers' ... CT Cross‐Sectional Anatomy 1. Right Ventricle 1 2. Left Ventricle 3. Papillary Muscles 2 4. Mitral Valve Leaflets 6 5. Left Atrium 3 6. Right Atrium 4 5 31 CT angiography by Dr Tarun K Mittal Unrestricted © Siemens Healthineers, 2022 Notes 34 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... CT Cross‐Sectional Anatomy 1. Right Atrium 2. Inferior Vena Cava (IVC) 3. Coronary Sinus 1 2 3 32 CT angiography by Dr Tarun K Mittal Unrestricted © Siemens Healthineers, 2022 Notes 35 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... CT Cross‐Sectional Anatomy 1. Inferior Vena Cava (IVC) 2. Descending Thoracic Aorta 1 2 33 CT angiography by Dr Tarun K Mittal Unrestricted © Siemens Healthineers, 2022 Notes 36 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... CT Cross‐Sectional Anatomy RCA LAD CX 34 Unrestricted © Siemens Healthineers, 2022 Notes 37 CT Advanced Examinations II | SOMATOM 7 Cardiac Anatomy and Vasculature Review SIEMENS Healthineers ... Cardiac Planes Three major cardiac planes are A. vertical long axis (two chamber view) B. horizontal long axis (four chamber view) C. short axis (SAX) RV B. Horizontal long axis LA RA LV LV RV LV LA A. Vertical long C. Short Axis axis A B C 35 Image courtesy of: https://thoracickey.com/cardiac‐computed‐tomography/ Unrestricted © Siemens Healthineers, 2022 Notes 38 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Fill in the blanks: The human heart has three layers in its wall. They are ______________, ______________, and ? . ________________ 1. 2. 3. 36 Unrestricted © Siemens Healthineers, 2022 Notes 39 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: Which of the following statements regarding the chambers of the heart is NOT true? ? a) There are two upper chambers called atria b) There are two lower chambers called ventricles c) The right atrium receives oxygenated blood from the Superior Vena Cava (SVC) and the Inferior Vena Cava (IVC). d) The left ventricle contracts pushing blood into the aorta 37 Unrestricted © Siemens Healthineers, 2022 Notes 40 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: Which number represents the Circumflex 1 2 Artery? a) 1 b) 2 c) 3 3 38 Unrestricted © Siemens Healthineers, 2022 Notes 41 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: Which vessel is number 2 referring to? a) Circumflex Artery b) Right Coronary Artery c) Left Main Coronary Artery d) Ramus Artery 2 39 Unrestricted © Siemens Healthineers, 2022 Notes 42 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers' ... Please Answer: Which anatomy is represented by number 4? a) Aortic valve cusps b) Mitral valve leaflets c) Tricuspid valve leaflets d) Pulmonary valve cusps 4 40 Unrestricted © Siemens Healthineers, 2022 Notes 43 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: Name the three coronary arteries being pointed to by 1, 2, and 3 in the image. 1 1. 2 2. 3. BONUS: what is the pathology visualized in the coronary vessels? 3 41 Unrestricted © Siemens Healthineers, 2022 Notes 44 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Patient Prep SIEMENS Healthineers ... SOMARIS 7 CT Cardiac Patient Prep 42 Unrestricted © Siemens Healthineers, 2022 Notes 45 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Patient Prep SIEMENS Healthineers ... Overview • Scanning hearts is a complex CTA exam that requires total patient cooperation for the exam to be successful. • For many patients, this might be their first experience getting a CT exam. Most patients are nervous and apprehensive about getting an exam of this nature. Because of these emotions, their heart rate can elevate and become erratic. • It is the technologist’s responsibility to make sure that the patient is comfortable, relaxed and understands every aspect of the exam. • When a patient fully understands all the exam steps, his or her heart rate is more likely to remain steady and does not elevate. 43 Unrestricted © Siemens Healthineers, 2022 Notes 46 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Patient Prep SIEMENS Healthineers ... Patient History • Obtain a thorough clinical history for determining the coronary risk profile. • Obtain patient consent for the exam and any medications given. • Ask the patient if they have had a CT scan before. • Ask the patient if they have ever had an exam where an iodinated contrast media was used. • If yes, then ask if they did OK with it or if they have had any adverse reaction to the contrast media. • Ask the patient if they have had any heart surgeries. • If the patient has had a bypass graft, LIMA/RIMA graft, or a stent placement you will need to include this in the scan range. • 18‐gauge or larger intravenous needle in the antecubital vein. • Right antecubital access is preferred to prevent streak artifacts that arise from contrast accumulation in the left Subclavian vein. • Injection site tested and flushed with saline. 44 Unrestricted © Siemens Healthineers, 2022 Notes 47 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Patient Prep SIEMENS Healthineers ... Patient Position • Positioning of patient in scanner iso‐center is essential for reliable estimation of lateral attenuation. • Patient lying on back (supine). Feet first is common practice. X-ray tube Patient Detector × × 45 Unrestricted © Siemens Healthineers, 2022 Notes 48 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Patient Prep SIEMENS Healthineers ... Patient Position • Make sure the patient is comfortable. • Build up area under arms so the patient’s arms are relaxed. • Place the knee cushion under the patient’s knees so their back is not stressed. • Remember that the patient might be on the table for an extended period. Any stress can cause the heart rate to elevate. • Heart centered in the scan FOV. Patient can be placed slightly to the right on the table to iso‐center the heart. × 46 Unrestricted © Siemens Healthineers, 2022 Notes 49 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Patient Prep SIEMENS Healthineers ... Scan Range • Scan direction is defaulted to cranial‐caudal Carina to the apex RIMA/LIMA of heart • A scan range of 12–15 cm from the carina to the apex of graft the heart • If a calcium scoring exam is done prior to the coronary CTA exam, the scan range for the calcium score can be a little longer • The apex of the heart can be misleading through the diaphragm, ensure scan range is sufficient • Targeted Field of View – 150 to 220 mm • For bypass grafts, the scan range will be longer • If the patient has a RIMA/LIMA graft, start scan above the shoulders 47 Unrestricted © Siemens Healthineers, 2022 Notes 50 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Patient Prep SIEMENS Healthineers ... ECG Placement ECG Being prepared for CT Cardiac Scanning HOOD05162002599541 48 Unrestricted © Siemens Healthineers, 2022 Notes 51 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Patient Prep SIEMENS Healthineers ... ECG Placement • ECG leads during a gated Cardiac CTA allows for 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. Ensure the patient is lying down on the table with his or her arms above the head before placing ECG leads on the patient (for male patients, shave the area if needed) 2. Clean area where the leads will be placed 3. Plug leads into the ECG socket (depends on the table model) 4. Attach the leads to the pad before placing on the patient. Make sure the wires are not tangled and the hub is out of the scan FOV 5. Observe ECG trace to ensure a good signal. If the signal is not adequate, adjust leads 49 Unrestricted © Siemens Healthineers, 2022 Notes 52 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Patient Prep SIEMENS Healthineers .. ECG Placement • ECG electrodes are often used hospital wide and are typically intended for long‐term use; therefore, it may take up to fifteen minutes for the electrodes to provide maximum conductivity. ECG -+rode ECG Electrode • Although alcohol wipes are frequently used to remove ECG Elec oils and lotion from skin prior to placing ECG ectrode electrodes, alcohol can dry the skin and even increase CG Elect E resistance between the electrode and skin. Rctrode CG Electrode ECG _ de › • For best results, use the preparation guidelines provided by the electrode manufacturer. • This may involve using a prep strip that is included on the electrode itself or in the electrode packaging. 50 Unrestricted © Siemens Healthineers, 2022 Notes 53 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Patient Prep SIEMENS Healthineers ... ECG Placement Color coding according to AHA Black electrode: Left mid‐clavicular line, directly • below clavicle Red electrode: Left mid‐clavicular line, at 6th or 7th • intercostal space. White electrode: Right mid‐clavicular line, directly • below clavicle. Green electrode: Right mid‐clavicular line, at 6th or 7th • intercostal space. Note: Ideally, all pads should be placed above the level of the ribs if possible. If you must remove a pad, then replace it with a new one 51 Unrestricted © Siemens Healthineers, 2022 Notes 54 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Patient Prep SIEMENS Healthineers .. ECG Placement The system supports two types of quality feedback with respect to ECG ID123456 1. Quality of bonding (impedance of ECG pads vs patient skin) 0.24 5 20 mA 140 kV 2. Strength of signal 90 2! II Note: The system takes 4‐5 seconds to measure the impedance of all 4 electrodes. 90 - II 0.0 100.0 52 Unrestricted © Siemens Healthineers, 2022 Notes 55 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Patient Prep SIEMENS Healthineers ... ECG Placement Display of the human torso ECG signal intensity bar. At • The scanner measures the impedance for every electrode. icon indicates an issue. least 3 bars should be • A low impedance is needed for good signal quality. displayed • The impedance measurement can be repeated by pressing the channel button for more than two 140 kV 6 66 mA 0.00 s seconds. • If the gantry displays an electrode in yellow or red, III remove the electrodes, re‐prepare skin and try again. 80 • You may change the electrode to a new one if you still see the yellow or red display. bpm • Choose the ECG channel with the strongest signal. For most patients that is channel II with at least “three bars” strength. 300 -2000.0 0.00 53 Unrestricted © Siemens Healthineers, 2022 Notes 56 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Patient Prep SIEMENS Healthineers ... ECG Placement Signal Strength 90 - II • The Signal Strength of the ECG signal is displayed by means of six (0‐5) different bars if signal quality is poor, check that the IN electrode is property attached, Bad impedance (red) Some electrodes seem to have lost contact. Please check electrodes and reattach if necessary. • Caused by lack of contact to skin e.g., due to hair or oil. Please check the electrode and electrode connector impedance was last measured at: 0%:21:17 and/or change the position of the electrode until red Time elapsed since last measurement: indication is gone Medium impedance (yellow) • Electrode may have good contact to the skin, but the impedance is poor. Please check the electrode and electrode connector or change the position of the electrode until yellow indication is gone 54 Unrestricted © Siemens Healthineers, 2022 Notes 57 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Patient Prep SIEMENS Healthineers ... ECG Placement Good / Bad Trace Heart Rate (bpm) Min: 60 Max: 60 Avg: 60 You can cycle through the three (3) ECG channels to 60 60 60 60 60 60 60 • change the QRS complex by pressing the ECG channel selection button at the patient measurement module (PMM). Heart Rate (bpm) Min: 56 Max: 68 Avg: 6' 63_ 61 60 56 58 58 61 55 Unrestricted © Siemens Healthineers, 2022 Notes 58 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Patient Prep SIEMENS Healthineers ... ECG Placement • Grounding cable is recommended if you can’t get a good ECG signal without it. • Connect the grounding cable on the same arm as the contrast media injector 56 Unrestricted © Siemens Healthineers, 2022 Notes 59 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Patient Prep SIEMENS Healthineers ... ECG Placement Patient Measurement Module (PMM) Current physiological measurement Previous physiological measurement module module • located at the end of the table (different for every table). • You can start to measure the impedance manually by pressing the channel selector on PMM for 2 seconds. 57 Unrestricted © Siemens Healthineers, 2022 Notes 60 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Patient Prep SIEMENS Healthineers ... Breathing Instructions • The patient breath‐hold is one of the most important aspects of scanning Coronary CTA exams • Practice the breath‐hold repeatedly with the patient prior to scanning Two (2) types of breath‐hold instructions 1. Hyperventilation – “Take in a breath” (pause) “Blow it out” (pause) “Take in another breath and hold it” (10‐12 seconds long) • Observe the heart rate. You should see a drop in the heart rate when the patient hold his or her breath • You cannot use this breathing instruction when you use Bolus Tracking, as the breath hold would be too long 2. Normal Breath Hold – “Take in a breath and hold it” (4‐5 seconds long) • Suitable breathing instruction with all scan modes and contrast timing method 58 Unrestricted © Siemens Healthineers, 2022 Notes 61 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Patient Prep SIEMENS Healthineers ... Breathing Instructions Motion artifacts caused by breathing during the scan can mean the difference between an optimal scan and a non‐ diagnostic scan 59 Unrestricted © Siemens Healthineers, 2022 Notes 62 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... True or False: Knowing if the patient had a prior LIMA or RIMA graft will not change how you scan the patient? ? a) True b) False 60 Unrestricted © Siemens Healthineers, 2022 Notes 63 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: Which of the following statements regarding ECG lead placement are true? ? a) Ensure the patient is lying down on the table with his or her arms above the head before placing ECG leads on the patient b) Always clean the area where the leads will be placed with alcohol c) Attach the leads to the pad before placing on the patient. d) Make sure the wires are not tangled and the hub is out of the scan FOV 61 Unrestricted © Siemens Healthineers, 2022 Notes 64 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: Match the ECG lead color with the proper placement on the patient. a) Black electrode = _____ b) Red electrode = _____ c) White electrode = _____ 1 2 d) Green electrode = _____ 3 4 62 Unrestricted © Siemens Healthineers, 2022 Notes 65 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: If the human torso on the gantry display shows an electrode in red, what does that indicate? ? a) Moderate Impedance b) Good Impedance c) Bad Impedance d) Caution 63 Unrestricted © Siemens Healthineers, 2022 Notes 66 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: What is this piece of equipment? a) Contrast warmer b) ECG wrap c) ECG grounding strap d) Charger 64 Unrestricted © Siemens Healthineers, 2022 Notes 67 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... True or False: Breathing motion can be the difference between a successful or unsuccessful Cardiac CTA exam. Always practice the breathing instructions with the ? patient. a) True b) False 65 Unrestricted © Siemens Healthineers, 2022 Notes 68 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA SIEMENS Healthineers ... SOMARIS 7 Cardiac CTA 66 Unrestricted © Siemens Healthineers, 2022 Notes 69 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Clinical Indications SIEMENS Healthineers ... • Coronary CTA has numerous clinical applications. Its most prominent role is in the assessment of patients with possible coronary artery stenoses, but a relatively low likelihood of disease, with the aim to rule out coronary stenoses and avoid the need for an invasive coronary angiogram. • This includes patients with various clinical scenarios, such as atypical symptoms, unclear electrocardiographic changes or stress test results, patients with new onset of heart failure, and patients before noncoronary cardiac surgery. Assessment of coronary anomalies is another strong indication, but much less frequent. Stephan Achenbach, MD, FACC, FESC https://appliedradiology.com/articles/top‐ten‐clinical‐indications‐for‐coronary‐ct‐ 67 angiography Unrestricted © Siemens Healthineers, 2022 Notes 70 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Clinical Indications SIEMENS Healthineers ... Clinical Indications for performing Cardiac CTA include, but are not limited to: • Ruling out luminal stenosis • Coronary anomalies • Assessing coronary artery stents • Determining the presence and extent of coronary atherosclerotic plaque Stephan Achenbach, MD, FACC, FESC https://appliedradiology.com/articles/top‐ten‐clinical‐indications‐for‐coronary‐ct‐ 68 angiography Unrestricted © Siemens Healthineers, 2022 Notes 71 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Clinical Indications SIEMENS Healthineers ... Luminal Stenosis Coronary Anomalies Stephan Achenbach, MD, FACC, FESC https://appliedradiology.com/articles/top‐ten‐clinical‐indications‐for‐coronary‐ct‐ 69 angiography Unrestricted © Siemens Healthineers, 2022 Notes 72 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Clinical Indications SIEMENS Healthineers ... Assessing coronary stents Atherosclerotic plaque Stephan Achenbach, MD, FACC, FESC https://appliedradiology.com/articles/top‐ten‐clinical‐indications‐for‐coronary‐ct‐ 70 angiography Unrestricted © Siemens Healthineers, 2022 Notes 73 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Conducting System / ECG Basics SIEMENS Healthineers' ... Why use ECG? Quality ECG information is critical for the successful reconstruction of diagnostic Cardiac CTA images. HeartRate [27 /1117 /163 5 Orginal ECG Phase Delay -400 ms • The use of ECG leads during a prospectively or 69 retrospectively gated Cardiac CTA allows for the real‐time acquisition of a patient’s cardiac rhythm during the 10 11 12 13 14 examination. • Poorly mounted electrodes leads to the artifacts as shown here. 71 Unrestricted © Siemens Healthineers, 2022 Notes 74 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Conducting System SIEMENS Healthineers ... Electrical System of the Heart • In the simplest terms, the heart is a pump made up of muscle tissue. Like all muscle, the heart needs a source of energy and oxygen to function. Sinoatrial • The heart's pumping action is regulated by an electrical (SA) node conduction system that coordinates the contraction of the various chambers of the heart. Atrioventricular The electrical conducting system includes: (AV) node Left bundle • branch • Sinoatrial (SA) Node Heart • Atrioventricular (AV) Node • Bundle of His (right and left bundle branches) Right bundle branch Purkinje • Purkinje fibers fibers https://www.hopkinsmedicine.org/health/conditions‐and‐diseases/anatomy‐and‐ 72 function‐of‐the‐hearts‐electrical‐system Unrestricted © Siemens Healthineers, 2022 Notes 75 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Conducting System SIEMENS Healthineers ... Sinoatrial (SA) node • The conduction system starts with the pacemaker of the heart – a small bundle of cells known as the SA node AV node AV bundle (bundle of His) sinoatrial (SA) node. • The SA node is located in the wall of the right atrium Purkinje's fibers. inferior to the superior vena cava. • The SA node is responsible for setting the pace of the heart as a whole and directly signals the atria to contract. • The signal from the SA node is picked up by another mass of conductive tissue known as the atrioventricular (AV) node (0.03 sec) Left/right bundle branches https://www.hopkinsmedicine.org/health/conditions‐and‐diseases/anatomy‐and‐ 73 function‐of‐the‐hearts‐electrical‐system Unrestricted © Siemens Healthineers, 2022 Notes 76 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Conducting System SIEMENS Healthineers ... Atrioventricular (AV) node • The atrioventricular (AV) node is in the right atrium in the inferior portion of the interatrial septum SA node AV node AV bundle (bundle of His) • The AV node picks up the signal sent by the SA node and transmits it through the Bundle of His (0.12 sec) Purkinje's fibers. Left/right bundle branches https://www.hopkinsmedicine.org/health/conditions‐and‐diseases/anatomy‐and‐ 74 function‐of‐the‐hearts‐electrical‐system Unrestricted © Siemens Healthineers, 2022 Notes 77 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Conducting System SIEMENS Healthineers ... Bundle of His and Purkinje fibers • The Bundle of His is a strand of conductive tissue that runs through the interatrial septum and into the SA node AV node AV bundle interventricular septum. (bundle of His) • The Bundle of His splits into left and right branches in the interventricular septum and continues running Purkinje's fibers. through the septum until they reach the apex of the heart (0,01 sec) • Branching off from the left and right bundle branches are many Purkinje fibers that carry the signal to the walls of the ventricles, stimulating the cardiac muscle cells to contract in a coordinated manner to efficiently pump blood out of the heart. Left/right bondlle branches https://www.hopkinsmedicine.org/health/conditions‐and‐diseases/anatomy‐and‐ 75 function‐of‐the‐hearts‐electrical‐system Unrestricted © Siemens Healthineers, 2022 Notes 78 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Conducting System SIEMENS Healthineers .. Normal Heart Rhythm Each normal heartbeat should follow the same sequence of electrical events: • The P wave represents depolarization of the atria in response to signaling from the sinoatrial node (i.e., atrial contraction) ST segment • The QRS complex represents depolarization of the PR interval ventricles (i.e., ventricular contraction), triggered by signals from the AV node • The T wave represents repolarization of the ventricles (i.e., ventricular relaxation) and the completion of a standard heartbeat P wave T wave • Between these periods of electrical activity are intervals allowing for blood flow (PR QRS complex interval and ST segment) https://ib.bioninja.com.au/standard‐level/topic‐6‐human‐physiology/62‐the‐blood‐ 76 system/electrocardiography.html Unrestricted © Siemens Healthineers, 2022 Notes 79 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – ECG Basics SIEMENS Healthineers ... Electrocardiogram • The heart contracts when pumping blood and rests R (1) when receiving blood. This process can be illustrated by an Electrocardiograph (ECG). • You want to scan in the area of the least amount of motion. P p • Chambers undergo alternating periods of relaxation and contraction: ₹ S DIASTOLE – relaxation – usually right before the P (4) (3) (2) • wave (1) R-wave • SYSTOLE – contraction – usually just after the T (2) Ventricular relaxation (3) Ventricular contraction wave (4) Atrial contraction • For high heart rates, it can sometimes be better to scan in SYSTOLE, when the heart is contracted. 77 Unrestricted © Siemens Healthineers, 2022 Notes 80 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – ECG Basics SIEMENS Healthineers ... Electrocardiogram Data generated via electrocardiography can be Normal Sinus Rhythm Arrhythmia used to identify a variety of heart conditions, including: • Arrhythmias (irregular heart beats) Complexes normal, evenly spaced. Rate 60-100 bpm All complexes normal, rhythm irregular • Bradycardia (depressed resting heart rate = < 40 Bradycardia Tachycardia bpm) • Tachycardia (elevated resting heart rate = Complexes normal, evenly spaced. Rate < 60 bpm Complexes normal, evenly spaced. Rate > 100 bpm >120 bpm) Atrial Fibrillation Ventricular Fibrillation • Fibrillations (unsynchronized contractions of ummmm either atria or ventricles leading to dangerously spasmodic heart activity) Baseline irregular. Ventricular response irregular Rapid, wide irregular ventricular complexes https://ib.bioninja.com.au/standard‐level/topic‐6‐human‐physiology/62‐the‐blood‐ 78 system/electrocardiography.html Unrestricted © Siemens Healthineers, 2022 Notes 81 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – ECG Basics SIEMENS Healthineers ... Electrocardiogram Heart Rate (bpm) Min: 60 Max 60 Avg: 60 Normal sinus 60 60 60 60 60 60 60 Pacemaker rhythm Abnormal 15 . 02 . 63 . 108 . 81 . 38 . 96 - 100 - 111 . 77 - 70 Atrial sinus rhythm Fibrillation adjust leads – Premature 30 (Loss Of P wave Premature Atrial Ventricular Contraction Contraction 79 Unrestricted © Siemens Healthineers, 2022 Notes 82 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – ECG Basics SIEMENS Healthineers' ... When to scan the heart? Notice the difference in size of the left ventricle in the systolic view from the Systolic Diastolic size of the left ventricle in the diastolic view. R Systolic T EP Q 0 80 Unrestricted © Siemens Healthineers, 2022 Notes 83 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: The heart has its own electrical conducting system that starts in the right atrium in a small bundle of cells known as the ___________ and is also known as the ? pacemaker for the heart. a) Atrioventricular (AV) node b) Bundle of His c) Sinoatrial (SA) node d) Purkinje Fibers 81 Unrestricted © Siemens Healthineers, 2022 Notes 84 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers .. Please Answer: The dark blue bar represents which phase of the cardiac cycle? a) Systolic R R b) Relaxation c) Contraction d) Diastolic T EP EP Q s 82 Unrestricted © Siemens Healthineers, 2022 Notes 85 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – CT Physics SIEMENS Healthineers ... Cardiac Acquisition Requirements Fast Gantry Rotation • High Temporal Resolution – helps to minimize motion artifacts Thin Collimation • High Spatial Resolution – helps to depict small coronary anatomy (1 – 4 mm in diameter) Multi‐Slice CT • Fast Continuous Coverage – enabling acquisition of the whole heart in one short breath‐hold ECG Gating • Synchronization to heartbeat – acquisition and reconstruction in a consistent cardiac phase 83 Unrestricted © Siemens Healthineers, 2022 Notes 86 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – CT Physics SIEMENS Healthineers ... Temporal Resolution • Temporal resolution is the time that it takes to acquire an image. • A good example of temporal resolution is the shutter speed on a camera. The faster it takes a picture the less motion is seen. • Shutter speed determines image quality of objects in motion. • Reducing or eliminating motion is especially useful when trying to image the beating heart. So, the faster the rotation time the faster the exposure will be. David Hofbman 200 84 Unrestricted © Siemens Healthineers, 2022 Notes 87 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – CT Physics SIEMENS Healthineers ... Temporal Resolution • The temporal resolution controls the reconstruction System Rotation Time Temporal angle and corresponds to the number of projections (s)/(ms) Resolution considered for the reconstruction of a cardiac image. Definition AS 0.33s / 330ms 165ms • A higher resolution (the value itself becomes lower) Definition AS+ 0.30s / 300ms 150ms leads to reduced motion artifacts but may result in decreased image quality. Definition 0.28s / 280ms 140ms Edge/Edge + • The temporal resolution is fixed for Cardiac spiral ranges. Therefore, you cannot edit the Temporal Dual Source 1st 0.33s / 330ms 83ms Generation Resolution parameter. Definition 0.28s / 280ms 75ms • Cardiac acquisition varies between single source and Flash/Drive dual source CT scanners. Force 0.25s / 250ms 66ms 85 Unrestricted © Siemens Healthineers, 2022 Notes 88 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – CT Physics Temporal Resolution • For most CT examinations performed on today’s Multi‐detector CT systems, each image or slice that is reconstructed is a result of data collected during a 360‐degree rotation. • To reconstruct a complete Cardiac CT image, however, only 180‐degrees of data are required. • In cardiac CTA it is desirable to scan quickly in order to limit the amount of motion and therefore, to improve the temporal resolution. • Cardiac CT imaging is performed using data from only half a 360‐degree gantry rotation. 86 Unrestricted © Siemens Healthineers, 2022 Notes 89 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – CT Physics SIEMENS Healthineers ... Temporal Resolution Single Source CT – e.g., Definition AS+ • Rotation Time = 0.30s / 300ms • Temporal Resolution = 300ms / 2 = 150ms 87 Unrestricted © Siemens Healthineers, 2022 Notes 90 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – CT Physics SIEMENS Healthineers ... Temporal Resolution SOMATOM Definition – 1st generation SOMATOM Definition Flash, Drive & SOMATOM Force Rotation 90⁰ Rotation direction direction 95⁰ 26 cm 33 cm Detector B Detector B Detector A Detector A 88 Unrestricted © Siemens Healthineers, 2022 Notes 91 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – CT Physics SIEMENS Healthineers ... Temporal Resolution Dual Source CT – 1st generation (90⁰) • Rotation Time = 0.30s / 300ms • Temporal Resolution = 330ms / 4 = 83ms 89 Unrestricted © Siemens Healthineers, 2022 Notes 92 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – CT Physics SIEMENS Healthineers ... Temporal Resolution Dual Source Definition Flash/Drive & Force (95⁰) • Rotation Times = 0.28s (280ms) / 0.25s (250ms) • Temporal Resolution = 280ms / 3.75 = 75ms 250ms / 3.75 = 66ms 90 Unrestricted © Siemens Healthineers, 2022 Notes 93 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – CT Physics SIEMENS Healthineers ... Temporal Resolution SOMATOM Definition – 1st gen. SOMATOM Definition Flash, Drive SOMATOM Force • 2 x 32 slices • 2 x 64 slices • 2 x 96 slices • Rotation Time 0.33s • Rotation time 0.28s • Rotation Time 0.25s Tube A/B angle 90°> Tube A/B angle 95°> Tube A/B angle 95°> • • • • Detector B FoV 26cm • Detector B FoV 33cm • Detector B FoV 35cm • Temp. Res: 330ms / 4 = 83ms • Temp. Res: 280ms / 3.75 = 75ms • Temp. Res: 250ms / 3.75 = 66ms (280ms x 95°/360°=75ms) (250ms x 95°/360°=66ms) • • 91 Unrestricted © Siemens Healthineers, 2022 Notes 94 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – CT Physics SIEMENS Healthineers ... Temporal Resolution CT with Multi‐segment Recon (BiSegment) • This method compensates for varying heart rates by using the reconstruction method most appropriate for the length of the cardiac phase from which images are to be reconstructed. • The 180‐degrees of data can be divided unequally over two segments in cases where an irregular heart rate causes the diastolic phase to be too short for even 90 degrees of the data to be used without motion. • In these cases, 60 degrees of data will be used from one cycle, for example, while 120 degrees of data will be used from an adjacent cycle to give a total of 180‐ degrees. Siemens calls this process of automatic adjustment of the reconstruction method Adaptive Cardio Volume (ACV). 92 Unrestricted © Siemens Healthineers, 2022 Notes 95 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – CT Physics SIEMENS Healthineers ... Temporal Resolution CT with Multi‐Segment (BiSegment) Recon • Software attempts to increase temporal resolution • Two segment recon varies between Example: 160ms TR gives 83ms BiSegment TR ‐or‐ 150ms TR gives 75ms BiSegment TR. Source: Stephan Achenbach, M.D., University of Erlangen, Germany / Publication: Half‐Scan vs. Multi‐Segment Reconstruction for CT Coronary Angiography / December 93 2006 Unrestricted © Siemens Healthineers, 2022 Notes 96 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – CT Physics SIEMENS Healthineers ... Spatial Resolution High Spatial Resolution is the ability to see small objects in detail. 0.3 mm 0.7 mm 1.0 mm: 1.4 mm Courtesy of Medical University, of South Carolina, Charleston, USA 94 Unrestricted © Siemens Healthineers, 2022 Notes 97 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: How many degrees of data is required for Cardiac CT scanning? ? a) 360⁰ b) 90⁰ c) 180⁰ d) 280⁰ 95 Unrestricted © Siemens Healthineers, 2022 Notes 98 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: Which of the following CT scanner rotation times will provide the best Temporal Resolution? ? a) 0.33 sec b) 0.25 sec c) 0.28 sec d) 0.30 sec 96 Unrestricted © Siemens Healthineers, 2022 Notes 99 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Protocol Selection SIEMENS Healthineers ... Scan Modes The following Cardiac CT modes are provided: • ECG‐triggered sequence – prospective Recommended scan mode • ECG‐gated spiral – retrospective Initial situation Regular sinus rhythm . ECG-triggered sequence • BiSegment spiral – retrospective Moderate heart rate . Limited to increased variance Several ectopic beats . High to very high heart rate ECG-gated spiral . Very irregular heart rate, which needs a high flexibility in reconstruction up to editing the ECG . Very high heart rate BiSegment spiral 97 Unrestricted © Siemens Healthineers, 2022 Notes 100 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Protocol Selection SIEMENS Healthineers ... Definition AS64 / AS+128 / Edge / SOMATOM Edge Plus Depending on the scanner and software version, default protocols may include: Dual Energy Protocol . Replace Append Calcium Score ardia • CaScore Topogram · Cut • CaScoreSeq scula · Keep Coronary CTA RT Auto reference lines None • FAST_Cardio ecia • CoroCTA_AdaptSeq_Edge_IR • CoroCTA_AdaptSeq ivat • CoronaryCTA_IR API Language German • CoronaryCTARoutine • CoroCTA_BiSeg • CoroCTA_HeartFlow • TAVI 98 Unrestricted © Siemens Healthineers, 2022 Notes 101 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Protocol Selection SIEMENS Healthineers ... Definition AS64 Prospective Triggered Adaptive Cardio Seq. Retrospective Spiral Prospective Triggered ECG Gating Heart Rate <60 bpm and stable <60 bpm and stable <65 bpm Contrast amount* Scan time x injection Scan time x injection Scan time x injection (not <65 ml) rate + 10 ml rate + 10 ml rate + 10 ml Injection rate 5‐6 ml/s (faster is 5‐6 ml/s (faster is 5‐6 ml/s (faster is better) better) better) Rotation Time 0.33 sec 0.33 sec 0.33 sec CARE kV ON ON ON Quality ref. mAs Use default Use default Use default CARE Dose4D ON ON ON Patient dose Lowest Depends on ECG Depends on ECG pulsing range pulsing range *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 99 exams. Unrestricted © Siemens Healthineers, 2022 Notes 102 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Protocol Selection SIEMENS Healthineers ... Definition AS+128 / Edge / SOMATOM Edge Plus Prospective Triggered Adaptive Cardio Seq. Retrospective Spiral Prospective Triggered ECG Gating Heart Rate <70 bpm and stable <70 bpm and stable <75 bpm Contrast amount* Scan time x injection Scan time x injection Scan time x injection (not <65 ml) rate + 10 ml rate + 10 ml rate + 10 ml Injection rate 5‐6 ml/s (faster is 5‐6 ml/s (faster is 5‐6 ml/s (faster is better) better) better) Rotation Time 0.30 sec 0.30 sec 0.30 sec CARE kV ON ON ON Quality ref. mAs Use default Use default Use default CARE Dose4D ON ON ON Patient dose Lowest Depends on ECG Depends on ECG pulsing range pulsing range *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 100 exams. Unrestricted © Siemens Healthineers, 2022 Notes 103 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Protocol Selection SIEMENS Healthineers ... Definition Flash / Drive / SOMATOM Force Depending on the scanner and software version, default protocols may include: Dual Energy Protocol . Replace Append Calcium Score ardia • Flash_CaScore / TurboFlash_CaScore Topogram · Cut • DS_CaScore scula · Keep • DS_CaScoreSeq RT Auto reference lines None Coronary CTA ecia • FAST_Flash_Cardio / FAST_TurboFlash_Cardiac • DS_CoroCTA_AdaptSeq ivat • DS_CoronaryCTA API Language German • DS_CoroCTA_BiSeg • DS_CoroCTA_HeartFlow • Flash_TAVI_IR / TurboFlash_TAVI 101 Unrestricted © Siemens Healthineers, 2022 Notes 104 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Protocol Selection SIEMENS Healthineers ... Definition Flash / Drive Flash Mode Adaptive Cardio Seq. Retrospective Spiral Prospective Triggered ECG Gating Heart Rate <60 bpm and stable <75 bpm and stable Any heart rate Contrast amount* Physicians' discretion Scan time x injection Scan time x injection (not <65 ml) rate + 10 ml rate + 10 ml Injection rate 5‐6 ml/s (faster is 5‐6 ml/s (faster is 5‐6 ml/s (faster is better) better) better) Rotation Time 0.28 sec 0.28 sec 0.28 sec CARE kV ON ON ON Quality ref. mAs Use default Use default Use default CARE Dose4D ON ON ON Patient dose Lowest Depends on ECG Depends on ECG pulsing range pulsing range *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 102 exams. Unrestricted © Siemens Healthineers, 2022 Notes 105 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Protocol Selection SIEMENS Healthineers ... SOMATOM Force Turbo Flash Mode Adaptive Cardio Seq. Retrospective Spiral Prospective Triggered ECG Gating Heart Rate <78 bpm and stable Any heart rate (stable) Any heart rate Contrast amount* Physicians' discretion Scan time x injection Scan time x injection (not <65 ml) rate + 10 ml rate + 10 ml Injection rate 5‐6 ml/s (faster is 5‐6 ml/s (faster is 5‐6 ml/s (faster is better) better) better) Rotation Time 0.25 sec 0.25 sec 0.25 sec CARE kV ON ON ON Quality ref. mAs Use default Use default Use default CARE Dose4D ON ON ON Patient dose Less than 1 mSv Depends on ECG Depends on ECG (100kV) pulsing range pulsing range *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 103 exams. Unrestricted © Siemens Healthineers, 2022 Notes 106 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Dose Considerations SIEMENS Healthineers ... ECG Pulsing • OFF: With ECG Pulsing OFF the scan radiation is at MAX Dose throughout the scan range. OFF: • Auto: System takes over with automatic adaption of the pulsing window to the heart rate, tube output is reduced to 25% of the nominal value. Auto: • Manual: User enters the start and end phase for the max dose window prior to scanning, tube output is reduced to 25% of the nominal value throughout the rest of the scan. Manual: • MinDose Auto: System takes over with automatic adaption of the pulsing window to the heart rates, tube output is reduced to 4% of the nominal value. MinDose Auto: • MinDose Manual: User enters the start and end phase for the max dose window prior to scanning, tube output is reduced to 4% of the nominal value throughout the rest of the scan. MinDose Manual: 104 Unrestricted © Siemens Healthineers, 2022 Notes 107 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Medication SIEMENS Healthineers ... Beta Blockers* • Beta Blockers**,*** are used to reduce the heart rate and/or steady an arrhythmic sinus rhythm. • Oral Beta Blocker (Metoprolol) 50‐100 mg @ 30‐90 minutes prior to exam. • Intravenous Beta Blocker (Metoprolol) up to 4x5 mg @ 5‐minute intervals once the patient is on the table Beta blocker Medication 100 mg 20 * The amounts and regiment of any Beta blockers and Nitrates given are the sole responsibility of the radiologist/cardiologist or the treating physician. The amounts and regiments above are examples and are not necessarily the recommendations of Siemens. **Mollet NR, Cademartiri F, Nieman K, Sais F, Lemos PA, McFadden EP, et al. Multislice spiral computed tomography coronary angiography in patients with stable angina pectoris. Journal of the American College of Cardiology. 2004 Mar,43(12):2265‐70 105 ***Pannu HK, Alvarez W, Fishman EK, ß‐Blockers for Cardiac CT: A Primer for the Radiologist. American Journal of Roentgenology. 2006 Jun; 186(6 Suppl 2):S341‐5 Unrestricted © Siemens Healthineers, 2022 Notes 108 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA – Medication SIEMENS Healthineers ... Nitrates* • Nitrates are used to dilate (enlarge) the coronary arteries. N - • Can be given either in tablet form or spray. O • Nitrates typically cause reflex tachycardia. N+-0 O. -O O • The use of beta blockers cancels the tachycardia. O O • Nitrates: 1 x 0.4 mg with a wait time of 3–5 minutes before the scan Nitroglycerin 0.4mg Sublingual Tablets - 25 Tablet Bottle * Achenbach S, Ulzheimer S, Baum U, Kachelrieß M, Ropers D, Giesler T, et al. Noninvasive Corornary Angiography by Retrospectively ECG‐Gated Multislice Spiral CT. 106 Circulation. 2000 Dec; 102 (23): 2823‐8. Unrestricted © Siemens Healthineers, 2022 Notes 109 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: Match the scan mode to the scan mode type ? a) ECG‐gated spiral = _____________ b) ECG‐triggered sequence = _______________ c) BiSegment Spiral = ______________ Options: Prospective or Retrospective 107 Unrestricted © Siemens Healthineers, 2022 Notes 110 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... True or False: It is appropriate to use an ECG‐triggered sequence (prospective) scan mode for a patient with a very high heart rate. ? a) True b) False 108 Unrestricted © Siemens Healthineers, 2022 Notes 111 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: Which ECG Pulsing mode is where the system takes over with automatic adaption of the pulsing window to the heart rates and tube output is reduced to ? 4% of the nominal value. a) Auto b) MinDose Manual c) Manual d) MinDose Auto 109 Unrestricted © Siemens Healthineers, 2022 Notes 112 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: Which statements are true regarding the use of medications with Cardiac CTA scanning? ? a) Beta Blockers are used to reduce the heart rate and/or steady an arrhythmic sinus rhythm. b) Nitrates are used to dilate the coronary arteries c) Nitrates typically cause reflex tachycardia d) Beta Blockers cancel out the tachycardia caused by nitrates 110 Unrestricted © Siemens Healthineers, 2022 Notes 113 CT Advanced Examinations II | SOMATOM 7 Guided Demo Didactic Guided Demo SIEMENS Healthineers ... Protocol Selection and Configuration • Access the simulator • Options > Configuration • HeartView > Demo mode on > Apply > OK • Register a test patient • Review HeartView Configuration • Patient Model Dialogue • Review all Cardiac protocols listed • Review trigger card of both prospective and retrospective scans 111 Unrestricted © Siemens Healthineers, 2022 Notes 114 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA SIEMENS Healthineers ... Hands – On Lab A 1. Go to Options > Configuration > double click HeartView > check Demo mode “on” > apply > OK 2. Register a test patient 3. Review Cardiac protocols. How many Calcium Score protocols are there? __________ How many Coronary CTA protocols are there? _________ Is there a TAVI protocol? _________ Is there a HeartFlow protocol? _________ 4. Select a prospective (sequential) protocol and load it. What is the default cardiac phase? ____________ Is there ECG Pulsing available? _______ What is the rotation time? __________ What is the temporal resolution? _______ 5. Select a retrospective (spiral) protocol. Where is ECG Pulsing located? ____________________ Change between the different pulsing choices. Do you see a difference in the ECG? ______________________ 6. What are the different options available for ECG pulsing? _______________________________________ 112 Unrestricted © Siemens Healthineers, 2022 Notes 115 CT Advanced Examinations II | SOMATOM 7 Thank you SIEMENS Healthineers ... for your enthusiasm! Siemens Healthineers Instructor Training and Development Center (TDC) • Name: Cary, NC USA • Phone Number: siemens‐healthineers.com • Email: xxxx@siemens‐Healthineers.com ....... Author | Department 113 Unrestricted © Siemens Healthineers, 2022 Notes 116 CT Advanced Examinations II | SOMATOM 7 SIEMENS Healthineers STEP Siemens Technologist Education Program SOMARIS 7 All Scanners Week 4: Advanced Examinations II HOOD05162003200791 Effective: 06/25/2021 Unrestricted © Siemens Healthineers, 2022 Notes 117 CT Advanced Examinations II | SOMATOM 7 Day 2 SIEMENS Healthineers Day 2 Advanced Examinations II .... Unrestricted © Siemens Healthineers, 2022 Notes 118 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles Agenda – DAY 2 SIEMENS Healthineers ... • Welcome / Introductions • CT Cardiac Acquisition Principles • Prospective, Adaptive Cardio Sequence, and Retrospective CTA scanning; Flash/Turbo Flash scan; Calcium Scoring; TAVR • CT Cardiac Contrast Injection • CT Cardiac Image Reconstruction • ECG Editing • CT Cardiac Image Artifacts and Pitfalls • Guided Demo – syngo.via CT Cardiac • Hands – On Lab 3 Unrestricted © Siemens Healthineers, 2022 Notes 119 CT Advanced Examinations II | SOMATOM 7 SIEMENS Healthineers ... SOMARIS 7 CT Cardiac Acquisition Principles 4 Unrestricted © Siemens Healthineers, 2022 Notes 120 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... Three Acquisition Modes 1. Prospective ECG Triggering (Step and Shoot) • Sequence • Adaptive Cardio Sequence 2. Retrospective ECG Gating • Classical Helical Cardiac Spiral 3. Flash or Turbo Flash Mode • High Pitch Dual Source Cardiac Spiral 5 Unrestricted © Siemens Healthineers, 2022 Notes 121 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... • Prospective ECG Triggering • All SOMARIS 7 scanners: AS 64, AS+128, Edge, Edge Plus, Flash, Drive, Force • Adaptive Cardiac Sequence Prospective Triggering (ACS) – all SOMARIS 7 scanners • Arrhythmia Compensation • Flex Padding • ECG Pulsing with Cardio Best Phase • Scan range adaptation • Retrospective Spiral ECG Gating – all SOMARIS 7 scanners • Flash Spiral – SOMATOM Definition Flash and SOMATOM Drive only • Flash Turbo Spiral – SOMATOM Force only 6 Unrestricted © Siemens Healthineers, 2022 Notes 122 CT Advanced Examinations II | SOMATOM 7 SIEMENS Healthineers ... SOMARIS 7 Prospective EGC Triggered 7 Unrestricted © Siemens Healthineers, 2022 Notes 123 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... Prospective ECG Triggering • Prospective ECG triggering combined with step‐and‐ shoot acquisition of axial slices acquires the Move Stop Move Stop Move Stop appropriate amount of scan data needed for image reconstruction during the previously selected heart phase. • The ECG signal of the patient is monitored during examination, and axial scans are started with a predefined time offset relative to the R‐waves. • In the ECG‐triggered sequence mode, the patient table moves the patient to the first z‐position. The scan is triggered depending on the ECG. Then the patient is Heart Rate (bpm) Min: 78 Max 84 Avg: 80 Var. 3.3 78 80 83 78 80 78 84 moved to the next z‐position. The procedure is repeated until the range to be scanned is completed. • Reconstruction is done prospectively based on timestamps from the recorded ECG.. 8 Unrestricted © Siemens Healthineers, 2022 Notes 124 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... Prospective ECG Triggering How does the “classic” Cardio Sequence work? (all default Calcium Scoring Sequence examinations) • Scan start is determined prospectively based on last three heart cycles. • Good results for patients with stable heart rate. • Ectopic heart beats lead to scanning in the wrong phase; therefore, the image quality decreases! Scan! Scan! 1000 ms 980 ms 990 ms 1000 ms. 970 ms 9 Unrestricted © Siemens Healthineers, 2022 Notes 125 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... Prospective ECG Triggering • Adaptive Cardio Seq. (ACS) – OFF Heart Rate (bpm) Min: 60 Max: 60 Avg: 60 60 60 60 60 60 60 • Sequential scanning • Single predefined cardiac phase (default is 70%) DEMO MODE • Scan start is determined prospectively based on last Adaptive Cardio Seq. BestPhase manual three heart cycles Scan 70 Phase Start 70 Pulsing off Unit % • Estimated arrival of next R peak Range 70 to 70 Unit % Recon quick 75 ms • Good results for patients with stable low heart rates Routine Scan Recor Auto Tasking Trigger • Sudden change in heart rate may lead to acquisition in the wrong phase and this could affect the rest of the scan 10 Unrestricted © Siemens Healthineers, 2022 Notes 126 CT Advanced Examinations II | SOMATOM 7 SIEMENS Healthineers ... SOMARIS 7 Retrospective Spiral ECG Gating 11 Unrestricted © Siemens Healthineers, 2022 Notes 127 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... Retrospective Spiral ECG Gating • Spiral scan and the patient’s ECG is recorded simultaneously and continuously throughout the entire 60 60 heart cycle Range • Better for patients with high heart rates, arrhythmias, or irregular heart rates. Heart Rate (bpm) Min: 60 Max: 60 Avg: 60 • ECG Pulsing with Cardio Best Phase is available with the 60 60 60 60 60 Retrospective Spiral ECG Gating • User can also employ Cardio Best Phase to optimally detect the Best Diastolic or Best Systolic phases for image reconstruction Pulsing manual BestPhase BestDiast Range 65 to 75 Phase Start 70 • Acquired scan data permits multiphase reconstruction Unit % Unit % for cardiac function analysis Est. HR auto Original ECG Recon mono 75 ms Can edit the ECG in this mode for challenging patients Routine Scan Recon Auto Tasking Trigger • 12 Unrestricted © Siemens Healthineers, 2022 Notes 128 CT Advanced Examinations II | SOMATOM 7 SIEMENS Healthineers ... SOMARIS 7 Adaptive Cardio Sequence (ACS) Prospective Triggering 13 Unrestricted © Siemens Healthineers, 2022 Notes 129 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... Adaptive Cardio Sequence (ACS) Arrhythmia Compensation • Enhanced robustness of the scan mode by omitting or repeating scans on demand FlexPadding • More flexibility to find the optimal reconstruction phase with an extended scan range ECG Pulsing with Cardio Best Phase • Lowers the dose (down to 25%) just like in a spiral mode for dose reduction • BestPhase The algorithm searches for the BestPhase within the scan range. Scan Range Adaption • Depending to the scan range the real Acquisition will adapt 14 Unrestricted © Siemens Healthineers, 2022 Notes 130 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... Adaptive Cardio Sequence (ACS) The Adaptive Cardiac Sequence is a special scan mode, that monitors the ECG of the patient while the scan is being performed. It can detect irregular heartbeats and repeat scans at a certain table position, if necessary. It also allows more than one phase of the heart cycle to be scanned. • Scan start is determined prospectively based on last three heart cycles • Scan is omitted when extra systole is detected before scan • Scan is repeated if extra systole occurs during or shortly after scan 1000 ms. 980 ms 990 ms Scan! Scan! Repetition! 15 Unrestricted © Siemens Healthineers, 2022 Notes 131 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... Adaptive Cardio Sequence (ACS) Arrhythmia Compensation • If an ectopic beat occurs just before the scan initiation, the acquisition will not occur, and the table will remain at that slice position. The scan is triggered again at the same slice location by the arrival of the next heartbeat. The table feed and acquisition will then resume as normal until the next ectopic occurrence. • If the ectopic beat occurs during the scan, the table will remain at that slice position. The scan will be triggered again at the same slice location by the next heartbeat. As the default, the images are reconstructed using data from the secondary trigger • When ectopic beats occur, the scan is only repeated once per table position. The table will resume immediately after the repeated scan in order to avoid acquiring the data in the late enhancement phase. 16 Unrestricted © Siemens Healthineers, 2022 Notes 132 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers .. Adaptive Cardio Sequence (ACS) Coronary CTA with Arrhythmic HR Heart Rate (bpm) Min: 52 Max 122 Avg: 83 .122 . 00 52 115 52 55 • Heart rate variability is very high, e.g., more than 10 bpm • Standard settings can result in high dose values Adaptive Cardio Seq. BestPhase BestDiast Scan 70 = to 70 Phase Start 70 • End Diastolic reconstruction very likely to be Pulsing auto Unit % non diagnostic Range 70 = Unit % Recon quick 66 ms • Acquisition and reconstruction parameters should be adapted 17 Unrestricted © Siemens Healthineers, 2022 Notes 133 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... Adaptive Cardio Sequence (ACS) Scanning modes Quick scan at 260⁰ ° and reconstruct at 180⁰ • • TR = rotation time/2 • adjustable phase of ±83 ms or ±8% of the RR cycle • no phase shifting (like VA11 or earlier), minimum dose Flex scan earliest at 170ms and reconstruct at 180⁰ • • TR = rotation time/2 • adjustable phase of 0% to 100% depending on scan range dose is e.g., 460⁰/260⁰ = 1.77 more than Quick scan • 18 Unrestricted © Siemens Healthineers, 2022 Notes 134 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... Adaptive Cardio Sequence (ACS) Flex Padding Organ characteristic: Cardio CTDIvol (32cm): mGy • When Flex Padding and ECG Pulsing are DLP: mGy*cm activated, the scanner automatically adapts both the length of the acquisition window Scan time 0.17 s and the max dose range, based on the Rotation time Flex 0.28 s .] variation in the heart rates. Delay 2 5 3 Est. Exam time 6.96 5 • Higher heart rate variances result in longer acquisition and longer max dose ranges, which in turn provide more flexibility for Routine Scan Recon optimal image reconstruction. • There will be an increase in radiation dose with higher regular heart rates. 19 Unrestricted © Siemens Healthineers, 2022 Notes 135 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... Adaptive Cardio Sequence (ACS) Flex Padding uses a fixed acquisition window (earliest start at ~170ms) • Adjustable acquisition window (Scan X to Y) • Automatic adaptation of the acquisition window depending on the variance of the heart rate • ECG pulsing ‐ examine functional studies Adaptive Cardio Seq. Scan 40 to Pulsing manual Range 90 Unit % 20 Unrestricted © Siemens Healthineers, 2022 Notes 136 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... Adaptive Cardio Sequence (ACS) ECG pulsing for Adaptive Cardio Sequence (ACS) • Free selection of acquisition window • Free phase shifting after scanning Adaptive Cardio Seq. • Not limited to a fixed acquisition Scan 40 to Pulsing manual 06 • Selectable pulsing window like in a spiral mode 14 Range 60to 80M Can be used with % or ms. Good for a lot of heart rates. Unit % • 21 Unrestricted © Siemens Healthineers, 2022 Notes 137 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... Adaptive Cardio Sequence (ACS) ECG pulsing for Adaptive Cardio Sequence (ACS) • Free phase shifting after the scan for reconstruction. • ACS can be used for single and multiphase reconstructions, dependent on the amount of cardiac data available. BestPhase manual Phase Start 65 65% Unit % Recon quick 150 mg 22 Unrestricted © Siemens Healthineers, 2022 Notes 138 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... Adaptive Cardio Sequence (ACS) ECG Pulsing with Cardio Best Phase 60 (Range) • Is available with the Adaptive Cardio Sequence (ACS) Max Dose mode. Using this mode, the user can define the time points for the acquisition (Scan) as well as the max (Scan ) dose plateau (Range) used for ECG Pulsing. 25% of Dose Heart Rate (bpm) Min: 60 Max: 60 Avg: 60 The user can also employ Cardio Best Phase to 60 60 60 60 60 60 • optimally detect the Best Diastolic or Best Systolic phases for image reconstruction. • The tube output is reduced to 25% of the nominal Adaptive Cardio Seq. BestPhase BestDiast value outside the max dose plateau. The acquired scan Scan 20 H to 80 Phase Start 70 data permits multiphase reconstruction for cardiac Pulsing manual Unit 1% function analysis Range 65to 75 Unit % Recon quick 75 ms Routine Scan Recon |Auto Tasking Trigger 23 Unrestricted © Siemens Healthineers, 2022 Notes 139 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: Which acquisition mode gives you the lowest dose? a) Retrospective ? b) Auto c) Manual d) Prospective 24 Unrestricted © Siemens Healthineers, 2022 Notes 140 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Multiple Choice: When would you use a retrospective protocol? a) High heart rate ? b) Arrythmia c) When ventricular function is needed d) Lowest dose possible 25 Unrestricted © Siemens Healthineers, 2022 Notes 141 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: Which scan mode has arrhythmia compensation? a) Retrospective ? b) Prospective c) Manual d) Adaptive Cardiac Sequence 26 Unrestricted © Siemens Healthineers, 2022 Notes 142 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: Which scan mode has the lower dose? a) Prospective ? b) Retrospective 27 Unrestricted © Siemens Healthineers, 2022 Notes 143 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Fill in the Blank: When flex padding and ECG pulsing are activated, the scanner will automatically adapt both the ___________ of the acquisition window and the ____________ dose range? ? 28 Unrestricted © Siemens Healthineers, 2022 Notes 144 CT Advanced Examinations II | SOMATOM 7 SIEMENS Healthineers ... SOMARIS 7 High Pitch Dual Source Cardiac Flash/Turbo Flash 29 Unrestricted © Siemens Healthineers, 2022 Notes 145 CT Advanced Examinations II | SOMATOM 7 Dual Source Video SIEMENS Healthineers ... Dual Source CT Ready beyond tomorrow in cardiac imaging 30 Unrestricted © Siemens Healthineers, 2022 Notes 146 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... High Pitch Dual Source Cardiac Flash or Turbo Flash Mode bart Rate (bpm) Mir 60 Max 60 Avg 60 HR / Variance • A special ECG triggered spiral technique is employed. In The ECG signal is used prospectively to acquire images of the whole heart within one cardiac cycle. • It uses the motionless phase of the myocardium to avoid motion artifacts. ECG for Flash scanning compatibility Recon | Auto Tasking Trigger • There are no options in changing the scan phases: the default is a starting phase of 60%! • This scan mode is available on all Dual Source scanners Table Speed Values 2 • SOMATOM Drive: 458 mm/s (1) Single source CT (2) Dual source CT • SOMATOM Force: 737 mm/s (3) Tube A (4) Tube B 31 Unrestricted © Siemens Healthineers, 2022 Notes 147 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... High Pitch Dual Source Cardiac The Flash mode/Turbo Flash mode is an ECG‐Triggered, Heart Rate (bpm) Min: 55 Max: 73 Avg: 63 • high pitch (3.4/3.2) spiral scan that acquires the whole 60 60 58 58 56 56 55 heart in one R to R interval (one heartbeat) and provides a low dose scan (<1 mSv with 100 kV). -4 1 2 • Prediction based on 3 cycles • The heart rate needs to be less than 60 bpm and stable. • It is recommended that the patient weight be less than 185 lbs. Table Speed Values • SOMATOM Drive: 458 mm/s • SOMATOM Force: 737 mm/s 32 Unrestricted © Siemens Healthineers, 2022 Notes 148 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... High Pitch Dual Source Cardiac How can we achieve such a FLASH speed? 09.09.07-11:56:32-DST-1.3.1. e SOMATOM Definition Flash *06-Sep-2009, M, 12D CT 2010A.1 20090901 0 POO 18-Sep-2009 H-SP • It cannot be achieved instantly, of course! 11:34:19.72 1 IMA 1 Distance: 31.03 cm TOP • The table must accelerate gradually, and for that we SP -301.0 1-1 SP 1: -711.0 SP 2: -872.0 LEN: need to move the table around 30cm before the actual 161.0 GT FoV: 0.0 scan start range CE: R 10cm ........................ KV 120 mA 35 TI 5.2 GT 0.0 SL 0.6 33 Unrestricted © Siemens Healthineers, 2022 Notes 149 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... High Pitch Dual Source Cardiac FlashCheck TurboFlash Protocols • The FlashCheck is done during the Flash Training TurboFlash_CaSc (Fl_CaSc) FAST_TurboFlash_Cardiac (Fl_CorCTA) • If you include an API in the exam, the breathing • Default start phase is 60% command will also be in the Flash Check. • Pitch is 3.2 • Maximum heart rate is 65 (to 70 MAX)* NOTE: Perform the FlashCheck with API and the table • Rotation Time 0.25s movement together to calm the patient TurboFlash CaScore DS CaScore DS CaScoreSeq FAST TurboFlash Cardiac DS_CoronaryCTA_AdaptSeq DS_CoroCTA_AdaptSeq_Edge DS_CoronaryCTA DS CoronaryCTABiSeg DS CoronaryCTA05s 34 Unrestricted © Siemens Healthineers, 2022 Notes 150 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers .. High Pitch Dual Source Cardiac Flash Training Examination Se 247D . ... . . . . . . . ..... • Due to the high table speed, “Flash Training” is LEN 1 258.4 recommended. Foy CE 0/0 R • A popup‐window will appear 10cm • You can skip the Flash Training KV 120 mA 35 178 GT 0.0 :1024 0/0 T120On UOPO 1ja M 350 Flash_Thorax (Adult) VA50, Training abcde Total mAs: 278 Topogram Recon job 1 2 3 4 56 78 Series description FI_Thorax 5.0 Br36 3 Due to the high table speed FI_Thorax Auto recon - the travel distances before and after the scan may be significantly longer, Auto filming Il every 1 image Auto viewing potentially up to 400 mm each. the stopping distance required for this examination is larger than 25 mm. No. of filmed images0 Auto postprocessing None Therefore, to help maintain patient safety. it is recommended to perform a test run. Auto reference lines Auto transfer None Requested procedure Thorax Flash_Thorax (Adu -] Caution: Skipping of the test run is done at the users own risk None Body part examined Chest Start Skip Cancel Help Load Routine Scan Recon Auto Tasking 35 Unrestricted © Siemens Healthineers, 2022 Notes 151 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... High Pitch Dual Source Cardiac Bariatric Table • All Turbo Flash Modes have a Pitch higher than 1.5 307kg • With a bariatric table (max table load 307kg) the Turbo Flash Mode is only available up to a patient weight of max 220kg. • The patient's weight must be entered in the Patient registration. • A popup will appear if not already entered during registration 36 Unrestricted © Siemens Healthineers, 2022 Notes 152 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... High Pitch Dual Source Cardiac 3 questions for 3 scan modes Cardiac patient • Is the cardiac rhythm stable? Unstable Stable rhythm • Do you need cardiac function in addition to cardiac rhythm anatomy? Function Coronaries needed only • Is the heart rate below 70 bpm? Retrospective Prospective spiral sequential LOW HR (<70bpm) High HR (270bpm) Wide pulsing window Adjust pulsing provides anatomy and window to provide Prospective High-pitch Prospective function with ECG anatomy and sequential spiral sequential editing capability function with ECG Everyone editing capability Pulsing window Lowest radiation DSCT temporal Advanced Users provides anatomy and contrast dose resolution enables and function for possible anatomy for any HR any HR with a low dose exam 37 Unrestricted © Siemens Healthineers, 2022 Notes 153 CT Advanced Examinations II | SOMATOM 7 SIEMENS Healthineers ... SOMARIS 7 FAST Phase 38 Unrestricted © Siemens Healthineers, 2022 Notes 154 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... You must know in which cardiac phase to scan and reconstruct Systole Unstable High Pitch Spiral ms ? Low HR Arrhythmic Mid HR Low Pitch Spiral ? Diastole Regular High HR % Step and Shoot 39 Unrestricted © Siemens Healthineers, 2022 Notes 155 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... FAST Phase • An intuitive and fully integrated solution in the cardiac workflow designed to help quickly set up complex and often time‐consuming cardiac procedures reliably and repeatedly. • Automatic ECG analysis of heart rate and rhythm (variability) in real‐time • Chooses the most appropriate phase of the heart cycle to scan and reconstruct • Comprehensive cardio CT made easy in combination with FAST Planning and Rapid Results • In a nutshell: The complexity of cardiac scanning can be considerably high if compared to other scan types due to challenges arising from varying heart rates and heart rate variability. • With FAST Phase fully integrated in the Cardiac workflow, the most appropriate scan parameters and reconstruction parameters are suggested based on an automatic analysis of the patient's heartbeat prior to scanning. • This allows standardized, easily reproducible cardiac scans. 40 Unrestricted © Siemens Healthineers, 2022 Notes 156 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... FAST Phase Standardizes Cardiac Acquisitions – Simplified Automatically choosing when to scan and reconstruct. Measurement of heart rate (HR) and rhythm (HR variability). HR HR Scan Mode Phase Delay Variability 68 68 Low HR Regular Systole ms Mid HR Unstable % R‐R Arrhythmic Step and Diastole High HR High Pitch Low Pitch Spiral Spiral Shoot 60 ‐ 75% 93 93 93 93 93 93 93 93 93 Low HR Regular ms Systole Mid HR Unstable % R‐R High Pitch Low Pitch Step and Diastole High HR Arrhythmic Spiral Spiral Shoot 0 ‐ 35% 83 78 80 78 83 80 78 78 Low HR Regular Systole ms Mid HR Unstable % R‐R High Pitch Low Pitch Step and Diastole High HR Arrhythmic Spiral Spiral Shoot 0 – 200 ms 41 Note: Available on the SOMARIS 7 systems Unrestricted © Siemens Healthineers, 2022 Notes 157 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... FAST Phase For FAST Phase, the heartbeat is characterized by: HeartView X • Heart rate General Preview Series Multiphase Auto Trigger • Slow, moderate, high Thresholds Scan perform with contrast Heart Rate Start Ph. End Ph. Unit Best Phase Unit • Heart rate variability Low-Regular 70 70 % BestDiast % Low-Unstable 75 Regular, unstable, arrhythmic 65- % BestDiast % • Low-Arrhythmic 60 80 % BestDiast % For each of the 9 resulting heart rate categories a set of Moderate-Regular 60 80 % BestDiast % • Moderate-Unstable 60 80 % BestDiast % optimized scan and reconstruction parameters is Moderate-Arrhythmic 200 350- ms BestSyst ms predefined. High-Regular 30- 40 % BestSyst % High-Unstable 200 350 ms BestSyst ms • These parameters are stored in a special look up table High-Arrhythmic 200 350 ms BestSyst ms for both contrast and non‐contrast examinations. OK Apply Default Settings Cancel Help 42 Unrestricted © Siemens Healthineers, 2022 Notes 158 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... FAST Phase To adjust the default parameters, the look up table can During the cardiac scan, click on the icon in the Trigger be accessed by Options > Configuration > HeartView > card Auto Trigger tab 3. Somaris/7 - Configuration Panel Heart Rate (bpm) Min: 60 Max: 60 Avg: 60 Var. 0.0 h / h / h / h / h / h / h / h ! 60 60 60 60 60 Browser Pateralour Transfer Conversion Auto Delete CT-Log Expert-i Image Text Scan Protocol E-Logbook Examination Editor Assistant Configuration Tracking HeartView Respiratory HeartView Intervention General Preview Series Multiphase Auto Trigger Scan auto BestPhase auto Thresholds Scan perform with contrast Range 70 to 70 Phase Start 70 Filming Filming Report D Layout Editor Configuration Heart Rate Start Ph. End Ph. Unit Unit Pulsing 70 to 70- Unit % Low-Regular 70 pestolast % Low-Unstable 65 Unit % % VPCT Neu Low-Arrhythmic 60 leartVier Recon quick 66 ms Moderate-Regular 60- % DS_CoroCTA_Adapts Moderate-Unstable 60- % ast - 19% Moderate-Arrhythmic 200 6:51 ms ms Routine Topogram Scan Recon Auto Tasking Trigge High-Regular 30- BestSyst . DS_CorAdSeq High-Unstable 200 -* ms BestSyst High-Arrhythmic 200- ms BestSyst ms OK Apply Default Settings Cancel Help 00 43 Unrestricted © Siemens Healthineers, 2022 Notes 159 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... FAST Phase There are two separate look up tables available for scans: HeartView X 1. With contrast – this is used for exams with contrast General Preview Series Multiphase Auto Trigger media such as coronary CTA. Thresholds Scan perform with contrast 2. Without contrast – this is used for exam without Heart Rate Start Ph. End Ph. Unit Best Phase Unit contrast media such as calcium scoring. Low-Regular 70 : % BestDiast % To switch between the two look up tables select the Low-Unstable 65* 75 % BestDiast % • Low-Arrhythmic 60 80* % desired option from the dropdown list located in the % BestDiast Moderate-Regular 60 80-: % BestDiast % upper right corner (orange box). Moderate-Unstable 60 80 % BestDiast % It is then possible to adjust the values by entering Moderate-Arrhythmic 200 350- ms BestSyst ms • values to the fields accordingly. High-Regular 30-: 40- % BestSyst % High-Unstable 200 350- ms BestSyst ms If necessary, it is possible to restore factory settings by High-Arrhythmic 200 350- ms BestSyst ms • use of the “Default Settings“ button located at the bottom of the window (red box). OK Apply Default Settings Cance Help 44 Unrestricted © Siemens Healthineers, 2022 Notes 160 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers .. FAST Phase • If necessary, thresholds for heart rate and heart rate >. HeartView x variability can be adjusted. General Preview Series Multiphase Auto Trigger Threshold configuration can be accessed via the Thresholds Auto Trigger Thresholds x • Thresholds button on the Auto trigger card (orange Hei Heart Rate box). Low-1 Low-L LOW Moderate High In the Auto Trigger Thresholds window, the lower and Low-Arr 67 bpm -+ 85bpm • upper thresholds can be entered in the corresponding Moderate-I Moderate-L fields. Moderate-Arr Heart Rate Variability High-1 High-L Regular Unstable Arrhythmic High-Arr 4bpm 12 bpm OK App OK Cancel 45 Unrestricted © Siemens Healthineers, 2022 Notes 161 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... FAST Phase To use FAST Phase, select “Scan” in the Trigger Card DS_CoroCTA_AdaptSeq (Adult) Test 17.07.24-13:15:51-STC Total mAs: Topogram Heart Rate (bpm) Min: 80 Max 60 Avg: 60 Ver: 0.0 . DS_CorAdSeq RT 1 h 1 h 1 h th Ih Iht. • Sequence Mode • Set “Scan” to auto • Applies look up table to Trigger & Pulsing setting Scan auto BostPhase auto auto • Spiral Mode Phase Start Pulsing o to Unit BestSyst BestDiast Unit % manual • Set “Pulsing” to auto oad Reco Recon quick 86 ms Applies look up table to Pulsing setting Routine Scan Recon|Auto Tasking Trigger • • BestPhase PLEASE NOTE: Using FAST Phase (auto) disables manual • Set “BestPhase” to auto input options. FAST Phase can be applied independently to • Applies lookup table to the reconstruction acquisition and reconstruction (best phase) or to both. 46 Unrestricted © Siemens Healthineers, 2022 Notes 162 CT Advanced Examinations II | SOMATOM 7 SIEMENS Healthineers ... SOMARIS 7 Calcium Score 47 Unrestricted © Siemens Healthineers, 2022 Notes 163 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... Calcium Score Motivation • Calcium Scoring based Agatston score is the established standard for risk assessment despite its aged definition. • These scan requirements for Calcium Score yield a rigid protocol with little room for optimization (120 kV /130 kV, 3 mm Qr36) • Lower kV will give a higher Calcium Score due to higher contrast. Florian Oslansky | SHS CS EDU APT AN1 2 48 Unrestricted © Siemens Healthineers, 2022 Notes 164 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... Calcium Score kV Independent Calcium Scoring (Agatston) 80 kV 100 kV 120 kV • VB20 introduces a special kernel allowing voltage‐ independent Agatston Scoring: Sa36 140 KV • This kernel uses a special look‐based correction in the raw data space to adjust for different attenuation of Original [HU] calcium at different kV levels. Thus, allowing for better tailoring of tube voltage to patient size. PLEASE NOTE: Due to special calculation during the reconstruction process, a Sa36 corrected image of 120 kV scan will not have an identical image impression when compared to a reconstructed image of the same 120 kV Artificial 120 [HU] scan using a Qr36 kernel. 49 Unrestricted © Siemens Healthineers, 2022 Notes 165 CT Advanced Examinations II | SOMATOM 7 Tin Filtration* SIEMENS Healthineers ... • Dedicated spiral and sequence protocols are available for calcium scoring with Tin filtration • The tin filtered spectra are available in dedicated scan protocols for non‐ contrast studies. • These protocols are marked with the suffix Sn. • CARE kV selects Sn100 kV Sn • The Sn100 kV spectra has an equivalent Agatston Score (120 kV) result • Due to the mean X‐ray intensity maintained Note: • The CaScore protocol should only be used with Sn100 as the kV setting. • Automated kV selection methods are turned of. 50 *select scanners Unrestricted © Siemens Healthineers, 2022 Notes 166 CT Advanced Examinations II | SOMATOM 7 SIEMENS Healthineers ... SOMARIS 7 TAVR – Transcather Aortic Valve Replacement 51 Unrestricted © Siemens Healthineers, 2022 Notes 167 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... TAVR 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 52 Unrestricted © Siemens Healthineers, 2022 Notes 168 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... TAVR • 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. General Hints • Test bolus method can be optimal • Use fast scanning mode (i.e., Flash/Turbo Flash) • Immediate delay in case you outrun the bolus • Dilute contrast, low kV if possible • Start conservatively; work contrast doses down 53 Unrestricted © Siemens Healthineers, 2022 Notes 169 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Acquisition Principles SIEMENS Healthineers ... TAVR ECG gated CT Angiography of the heart and aorta is becoming a routine requirement in the planning of TAVR procedures: A • Access route (minimal luminal diameter, tortuosity, calcification) ..... • Valve sizing ERC • Coronary ostial height .... • Optimal fluoroscopic angles ... • Incidental findings ........ NC LC 54 Unrestricted © Siemens Healthineers, 2022 Notes 170 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Multiple Choice: Which SOMATOM scanners are capable of the high pitch cardiac scanning known as Flash or Turbo Flash? ? a) Definition AS+128 b) Definition Flash c) Drive d) Edge Plus e) Force 55 Unrestricted © Siemens Healthineers, 2022 Notes 171 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: An intuitive and fully integrated solution in the cardiac workflow designed to help quickly set up complex and often time‐consuming cardiac procedures reliably and repeatedly ? is known as? a) FAST Planning b) FAST Decision Making c) FAST Phase d) FAST Scan 56 Unrestricted © Siemens Healthineers, 2022 Notes 172 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: The any kV kernel used in Calcium Scoring for Agatston equivalent scoring is? ? a) Qr36 b) Br28 c) Ca26 d) Sa36 57 Unrestricted © Siemens Healthineers, 2022 Notes 173 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: TAVR is an ideal alternative to open heart surgery for high‐risk patients who are not optimal surgical candidates? ? a) True b) False 58 Unrestricted © Siemens Healthineers, 2022 Notes 174 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Contrast Injection SIEMENS Healthineers ... SOMARIS 7 CT Cardiac Contrast Injection 59 Unrestricted © Siemens Healthineers, 2022 Notes 175 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Contrast Injection SIEMENS Healthineers ... Contrast Bolus Timing Goal • Optimal arterial enhancement of the coronary arteries with minimal venous contamination in the right heart Contrast Options • CARE Bolus (Bolus Tracking) • Test Bolus with Dynamic Evaluation RCA LAD CX 60 Unrestricted © Siemens Healthineers, 2022 Notes 176 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Contrast Injection SIEMENS Healthineers ... CARE Bolus (Bolus Tracking) • The pre‐monitoring scan should be at the level of the ascending aorta, about 1‐2 cm above the Left Main Ostia. • The ROI must be set well within the ascending aorta, avoiding any calcified portion of the wall. • The scan will automatically trigger when the prescribed HU has been reached. • A breath hold time between 4–5 seconds for the CTA exam should be used. • Triggering – 100 to150 HU depending on the scanner: • AS+128 = 120HU • Edge/Edge Plus = 120HU • Flash/Drive = 120HU 912 00 • Force = 120HU‐150HU Topogram PreMonitoring • Monitoring scan delay – 10 seconds I.V. Bolus 13 of 30 Monitoring 6 of 30 OR_ CorCTA RT E (HUI 200 - 160 - 120 - 80 40 5 10 15 20 25 Routine Scan Recon 61 Unrestricted © Siemens Healthineers, 2022 Notes 177 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Contrast Injection SIEMENS Healthineers ... Test Bolus • Test Bolus utilizes a small amount of contrast to determine peak enhancement (CTA scan delay time). • The Test Bolus scan should be at the level of the ascending aorta, about 1–2 cm above the Left Main Ostia. O • The scan is like the monitoring phase in Bolus Tracking without the pre‐monitoring series and the scan does not auto trigger. • The user terminates the scan after peak enhancement. • Since you do not have a pre‐monitoring scan, the Test Bolus scan has to be well placed. • Use the images from the calcium score scan as a reference or if you didn’t scan a calcium score, you can perform a Control Scan for accuracy. 62 Unrestricted © Siemens Healthineers, 2022 Notes 178 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Contrast Injection SIEMENS Healthineers ... Test Bolus • 10 second scan delay for Test Bolus • 15 – 20 ml of contrast • 30 – 40 ml saline chaser • 5 – 6 ml/s (Use the same injection rate as the CTA exam) • API Test Bolus – Hyperventilation or a normal breath‐hold. NOTE: This can be a long breath‐hold, so prepare the patient. • Start the scan and the injector at the same time. • After a 10‐second delay, the scanner starts taking images one after the other. Continue to watch the ascending aorta while it starts to fill with contrast. Once the contrast has peaked (brightest ascending aorta image), wait until one or two more images are scanned past peak enhancement, and then terminate the scan by pushing the “Suspend” button. 63 Unrestricted © Siemens Healthineers, 2022 Notes 179 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Contrast Injection SIEMENS Healthineers ... Test Bolus – Dynamic Evaluation • Open the DynEva (Dynamic Evaluation) option under Examination Viewing applications at the top of the screen. • Go to the Browser and load the DynEva images into the Dynamic Evaluation card. Rep Tissue Classification Steps Upper Limit [HU] 3071 Lower Limit [HU] m48 40 1. Insert the scan delay (10 seconds) in the “Delay from -1024- SL 100100 200 340 Start of Injection (s)” field Delay from start 0.0 f injection [s] 2. Select the ROI icon. 3. Draw the ROI in the ascending aorta. It does not DynEva matter which section or slice you draw the ROI. 4. Record the (Time to Peak number). This number is the time of peak enhancement. End Evaluation RO Time To Sample [HU] Peak [s] at 25.0 s 11.Jan-2005 516.7 25.0 516.7 64 Unrestricted © Siemens Healthineers, 2022 Notes 180 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Contrast Injection SIEMENS Healthineers .. Scan Delay • Add 3 – 5 seconds to the Time to Peak number. This is Delay 28 s the scan delay time for the Coronary CTA exam. Slice 0.6 mm Acq. 128 × 0.6 mm • Type this number in the Delay area of the Routine folder in the Examination card. No. of images 135 • The added 3–5 seconds is to avoid additional contrast in the right atrium. Comments For example: if Time to Peak is 25s, insert 28 – 30s Range: Begin End Table: Position -1846.0 2 -1996.0. -1795 ROI Peak HUT Time To Sample [HU) Peak [S t 25.0 s Routine Scan Recon 516.7 25.0 516.7 65 Unrestricted © Siemens Healthineers, 2022 Notes 181 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Contrast Injection SIEMENS Healthineers ... Contrast Volume • Contrast Volume suggestions • 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. 66 Unrestricted © Siemens Healthineers, 2022 Notes 182 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Contrast Injection SIEMENS Healthineers ... Contrast Volume Suggestions* • AS64, AS+128, Edge, Edge Plus, Flash, Drive and Force • Contrast volume = (Scan time x Flow rate) + 10 ml of contrast • Saline chaser = 40 ml • Flow rate = 5–6 ml/s • Flash Mode (Flash) and Turbo Flash Mode (Force) • Contrast volume = (Scan time x Flow rate) + 5 ml of contrast (or less, up to physician discretion) • Saline Chaser = 40 ml • Flow rate = 5‐6 ml/s 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. 67 Unrestricted © Siemens Healthineers, 2022 Notes 183 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Contrast Injection SIEMENS Healthineers ... Dual Flow Injectors with Mixing Capabilities Purpose • To 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 • Flow rate: 5–6 ml/s • Total Contrast: 71 ml • Total Saline: 64 ml • 1st phase: Contrast 65 ml 2nd phase: 20/80 mix= 6 ml contrast + 24 ml saline for total of 30 ml • 3rd phase: Saline Chaser 40 ml • 68 Unrestricted © Siemens Healthineers, 2022 Notes 184 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Contrast Injection SIEMENS Healthineers ... Flash / Turbo Flash scan Injection Protocol examples* • Test Bolus is recommended • 10ml / Flow 6ml/sec for TB • 60ml / Flow 6ml/sec Contrast • 60ml / Flow 6ml/sec Saline • Scan delay: TB Peak + 5s • Bolus Tracking is also possible • Trigger @ 150HU • ! 3‐5 sec ! API • 70‐80ml / Flow 6ml/sec Contrast • 60ml / Flow 6ml/sec Saline 69 * All values are from the field and not a SIEMENS recommendation Unrestricted © Siemens Healthineers, 2022 Notes 185 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Multiple Choice: What are the available contrast timing types typically used in cardiac imaging? ? a) Empirical Delay b) Test Bolus c) CARE Bolus d) Hand Injection 70 Unrestricted © Siemens Healthineers, 2022 Notes 186 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: If Test Bolus is used, which application is needed to determine the delay? ? a) Dynamic Contrast b) Dynamic Bolus Tracking c) Dynamic Evaluation d) Dynamic Injection 71 Unrestricted © Siemens Healthineers, 2022 Notes 187 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... True or False: An advantage of Dual Flow injectors is they give you the ability to regulate the amount of contrast that is seen in the right side of the heart. ? a) True b) False 72 Unrestricted © Siemens Healthineers, 2022 Notes 188 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers ... SOMARIS 7 CT Cardiac Image Reconstruction 73 Unrestricted © Siemens Healthineers, 2022 Notes 189 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers ... • For the assessment of the coronary arteries, a single image series in the most optimal cardiac phase (typically in diastole) is used. • For ejection fraction, two image series in the end‐diastole and end‐systole are required. • Additionally, multiphase reconstructions at 5% or 10% R‐R increment throughout the whole cardiac cycle are needed for left ventricular wall motion and stroke volume analysis. Cardio best phase Three ways to reconstruct phases: • Relative % • Absolute positive milliseconds • Absolute negative milliseconds Preview series 74 Unrestricted © Siemens Healthineers, 2022 Notes 190 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers ... Cardio Best Phase • The Cardio Best Phase 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. • Under the Best Phase drop down you will see three options: 1. Best Diastolic Heart Rate (bpm) Min: 60 Max 60 Avg: 60 2. Best Systolic 60 60 60 60 60 60 60 3. Manual • The Manual selection is for defining a new phase or to determine the Best Diastolic or Best Systolic manually. Pulsing auto BestPhase BestDiast To determine the best diastolic or best Range 70to Phase Start manual • BestSyst systolic phase manually you will need to Unit % Unit BestDiast create a data set using the Preview Series. Est. HR auto Original ECG Recon mono 75 ms Routine Scan Recon Auto Tasking Trigger 75 Unrestricted © Siemens Healthineers, 2022 Notes 191 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers ... Three Ways for Phase Reconstruction The temporal resolution of the image data (within a cardiac cycle) can be defined as a relative percentage of the R to R interval or absolute time (milliseconds) as an offset to the R‐waves. Percentages (%) Positive milliseconds Negative milliseconds 70 % " 700ms " -300ms ' 76 Unrestricted © Siemens Healthineers, 2022 Notes 192 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers ... Relative Percentages (%) • The percentage method is more forgiving in many circumstances because the assumption is, that even if the heart rate changes a little; the diastolic phase will still begin at about same point relative to the entire 0 100% 100% cycle. 100% is always 100%. • Percentages measure from the left R peak to the right R 70% 70% peak. Left Right 77 Unrestricted © Siemens Healthineers, 2022 Notes 193 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers .. Absolute Positive Milliseconds • When using the positive absolute method, the increments are expressed in positive milliseconds. 0 • This means that if a patient has a heart rate of 60 beats per minute, the distance between any R‐to‐R peak 0 1000ms 1000ms would be one second, or 1000 milliseconds. 700ms • Of course, as the heart rate changes, which it surely 700ms will do, the time either gets longer or shorter. Left Right • So, to reconstruct an image during the diastolic phase for any given cardiac cycle, we will need to tell the computer to create images during the diastolic phase, it will be expressed as X number of milliseconds from the left R‐ peak. 78 Unrestricted © Siemens Healthineers, 2022 Notes 194 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers .. Absolute Negative Milliseconds • When using the absolute negative method, the increments are expressed in negative milliseconds. -1000ms • This means that if a patient has a heart rate of 60 beats per minute, the distance between any R‐to‐R peak -1000ms 0 0 would be one second, or 1000 negative milliseconds. 300ms • Of course, as the heart rate changes, which it surely -300ms will do, the time either gets longer or shorter. Left Right • So, to reconstruct an image during the diastolic phase for any given cardiac cycle, we will need to tell the computer to create images during the diastolic phase, it will be expressed as X number of milliseconds from the right R‐ peak. 79 Unrestricted © Siemens Healthineers, 2022 Notes 195 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers' ... Sinus Rhythm A perfect sinus rhythm would have the same distance When you look at the sinus rhythm after the scan, you from one R peak to the other R peak throughout the scan. would like to see the Best Diastolic phase (dark blue line) There are no perfect sinus rhythms due to varying heart the same distance from the right R peak on all the R to R rates and cardiac arrhythmias. But, if the patient is intervals. prepped correctly and does not have any cardiac arrhythmias, you can get close. Left Right 80 Unrestricted © Siemens Healthineers, 2022 Notes 196 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers ... Example • Sometimes you might scan a patient that has an abnormality, and you have an R to R interval that is 75% 75% longer than the rest. Reconstructing using percentage (%) produces an artifact in the data set. • Percentage (%) and positive milliseconds measure from the left R peak to the right R peak. • Negative milliseconds measure from the right R peak to the left R peak. • In this case, reconstructing using negative milliseconds could help to improve the exam 300ms 300ms 81 Unrestricted © Siemens Healthineers, 2022 Notes 197 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers ... Why % and not positive (+) ms or negative (‐) ms? • Using percentage is familiar and it is easy to express. BestPhase BestDiast • That does not mean that you cannot go back and use positive or negative milliseconds to try and get better Phase Start results if using percentage did not give you the best Unit % phase. Unit % % ms 82 Unrestricted © Siemens Healthineers, 2022 Notes 198 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers ... Preview Series Preview Series • For Cardiac CT spirals, a preview series can be used to find out the optimum phase start for additional reconstruction. • A preview series consists of several images at one slice position, each with a different delay. Offset mode, interval, and number of images are set up in the HeartView Configuration dialog box. • Images with different delays are reconstructed, stored in a separate series, and displayed in the tomographic segment. • Can be selected on the Trigger Subtask card. 83 Unrestricted © Siemens Healthineers, 2022 Notes 199 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers ... Preview Series • The Preview Series is a pre‐selection function that can be used to identify the most suitable cardiac phase for image reconstruction. • The Preview Series is configured by placing the cursor over the Preview Series icon and right clicking the BestPhase manual mouse. Phase Start • Select manual for Best Phase. Unit % • In the Phase Start area, type in 0 for percentages (%), Preview Series 0 for positive milliseconds or ‐1000 for negative Original ECG M milliseconds. Recon mono 82 ms • If you use milliseconds, change the Unit to ms for milliseconds. uto Tasking Trigger 84 Unrestricted © Siemens Healthineers, 2022 Notes 200 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers ... Preview Series) • Scroll through the data set created by the first recon job and select an image around mid RCA. • This series at the mid‐ventricular level is where the RCA is visible in cross‐section in the right AV groove. RCA • Left click the Preview Series Icon. While the heartbeats, the motion created at the level of the mid RCA is the most visible. • The theory is that if you can find an image in the Preview Series with minimal or no motion, then at this phase the RCA and the other coronary arteries will be suitable for reconstruction. 85 Unrestricted © Siemens Healthineers, 2022 Notes 201 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers ... Preview Series • Scroll trough the Preview Series images. • You are looking at the RCA that has minimal or no motion. • When you find the RCA with minimal or no motion, then this is the phase that you will reconstruct for Best Phase. • The phase information is located at the bottom of the images. • Type this phase into the Phase Start area. • If you cannot find a suitable phase, you might have to try using positive or negative milliseconds with Preview Series. 86 Unrestricted © Siemens Healthineers, 2022 Notes 202 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers ... Multiphase • With Multiphase, it is possible to reconstruct up to 24 different heart phases within one recon job. • Set the reconstruction parameters as desired on the Recon parameter card. • Click the Multiphase icon on the Trigger parameter card. • Click the Recon button to start reconstruction. • The images are reconstructed and stored in one series. 10% 20% 30% 40% 50% 60% 70% 80% 90% Note: Start delay, end delay, and the increment between start and end delay are set up on the Multiphase tab card of the HeartView Configuration dialog box. 87 Unrestricted © Siemens Healthineers, 2022 Notes 203 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers ... Multiphase reconstruction • Select the desired phases first Heart Rate (bpm) Min: 78 Max: 84 Avg: 78 Var: 3.3 78 83 80 78 78 84 4 . 78 78 80 83 • Select phases in the range 0% to 100% or ‐2000 ms to 2000 ms in the list on the Trigger parameter card. -2 -1 0 5 or – – Pulsing auto BestPhase manual • Select a range of phases by clicking and dragging the Range 70 to 70 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 % mouse in the blue bar. Unit % Est. HR auto Original ECG Note: If you have not selected a phase, it changes to Recon mono 66 ms • yellow. Routine Scan Recon Auto Tasking Trigger 88 Unrestricted © Siemens Healthineers, 2022 Notes 204 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers ... Multiphase reconstruction • With multiphase, it is possible to reconstruct up to 24 Heart Rate (bpm) Min: 78 Max: 84 Avg: 78 Var. 3.3 different heart phases within one recon job. 78 83 80 78 78 84 78 78 80 83 • The images are reconstructed and stored in one series 5 • You can change the parameters for Multiphase -1 0 reconstruction according to your needs Pulsing auto BestPhase manual Range 70 | to 70 - 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 % • Can be selected on the Trigger Subtask card. 70 75 80 85 90 95 % Original ECG Increment 10 % Recon mono 66 ms Routin Increment 5 % Increment 1 % Auto Tasking Trigger Increment 100 ms Increment 50 ms Increment 10 ms Clear Selection 89 Unrestricted © Siemens Healthineers, 2022 Notes 205 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers ... TrueStack • Motion artifacts are smoothed out and it can be difficult to define if plaque is present in the coronary artery or due to motion. • TrueStack displays the “True Stacks” without a overlay of 10%. • This method works for sequential and spiral scanmodes. • Can be selected on the Trigger Subtask card. Recon quick 75 ms Standard TrueStack quick 75 ms to Taski quick 75 ms TrueStack 90 Unrestricted © Siemens Healthineers, 2022 Notes 206 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers ... TrueStack Standard Overlapping vs. TrueStack • “True Stack” recon has sharp edge detection at site of transitioning heart beats • (no blended overlap/smoothing) • Misalignment is easily recognized on True Stack recons • Misalignments may be missed or subtle with standard recons that blend ~ 1cm of z‐plane data from two separate cardiac cycles (smoothing effect) • Standard recon coupled with misalignment can create a pseudo‐stenosis BestPhase auto • Reading coronary CTA with True Stack recon is encouraged Phase Start Unit % Recon quick 66 ms M quick 66 ms Auto Taski quick 66 ms TrueStack ger 91 Unrestricted © Siemens Healthineers, 2022 Notes 207 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Reconstruction SIEMENS Healthineers ... TrueStack Misalignment Artifact on Plaque True Stack Recon Standard Recon LAD Stenosis? Axial Sequential Scan • Inadequate Breath Hold • Misalignment • Severe LAD Stenosis? • Cath needed to clarify? • True Stack Recon with clear • Standard recon with obscured misalignment visualized misalignment • LAD stenosis is uncertain, but artifact • Created appearance of a potentially is recognized significant LAD stenosis 92 Images Courtesy of Marcus Scherer, Sanger Heart and Vascular Institute Unrestricted © Siemens Healthineers, 2022 Notes 208 CT Advanced Examinations II | SOMATOM 7 Cardiac ECG Editing SIEMENS Healthineers ... SOMARIS 7 Cardiac ECG Editing 93 Unrestricted © Siemens Healthineers, 2022 Notes 209 CT Advanced Examinations II | SOMATOM 7 Cardiac ECG Editing SIEMENS Healthineers ... • ECG trace editing is used to modify the ECG signal • After spiral scan data has been acquired trace editing is possible • Several modification tools are available by right clicking on the ECG Trace • In patients with a single or a few extra‐systolic beats overall image quality may be improved by editing the ECG prior to reconstruction. • Disabling the corresponding R‐peaks prevents image reconstruction in the extra systolic heart periods. Hint: • The use of absolute values (ms or ‐ms) is recommended for editing. • Please keep in mind that absolute gating (in ms) must be chosen if R‐peaks (syncs) are disabled. 94 Unrestricted © Siemens Healthineers, 2022 Notes 210 CT Advanced Examinations II | SOMATOM 7 Cardiac ECG Editing SIEMENS Healthineers .. You can disable, delete, and enable sync 71 To disable a sync, right‐click on either the sync bar itself 73 69 • Delete Sync or the R‐peak dot preceding the sync that is to be Disable Sync disabled, and select Disable Sync from the menu box Adapt curve scaling • To delete, right‐click on the R‐peak dot preceding the sync that is to be deleted and select Delete Sync from 3 the menu box. 4 5 • To enable a disabled sync, right‐click on the disabled 71 65 sync or on the R‐peak dot preceding the sync that is to Delete Sync be enabled and select Enable Sync from the menu box. Enable Sync The enabled sync will return to its original position as Adapt curve scaling indicated by the striped bar. 3 4 5 95 Unrestricted © Siemens Healthineers, 2022 Notes 211 CT Advanced Examinations II | SOMATOM 7 Cardiac ECG Editing SIEMENS Healthineers ... You can also move a Sync • When a positive millisecond (ms) value is used: Left‐click on the R‐peak dot preceding the sync bar then move the two‐headed arrow sideways until the desired position is reached. Note that the blue sync bar will not move the R‐peak dot until the LMB is released. • When a negative millisecond (‐ms) value is used: Left‐click on the R‐peak dot after the sync bar then move the two‐headed arrow sideways until the desired position is reached. 68 69 69 73 71 69 0 2 3 4 96 Unrestricted © Siemens Healthineers, 2022 Notes 212 CT Advanced Examinations II | SOMATOM 7 Cardiac ECG Editing SIEMENS Healthineers ... • Cardiac CT misalignment is the inappropriate registration of x, y, or z plane data at sites of transitioning heart beats on axial sequential or helical scans. • Occurs with recons that stitch the heart together using multiple heart beats to provide whole heart coverage. 97 Images Courtesy of Marcus Scherer, Sanger Heart and Vascular Institute Unrestricted © Siemens Healthineers, 2022 Notes 213 CT Advanced Examinations II | SOMATOM 7 Cardiac ECG Editing SIEMENS Healthineers ... Case #1 Baseline Reconstruction Prominent T waves are HeartRate(bpm) Min: 51 Max: 166 Avg: 71 Phase BestDiast 77 % Recon mono 82 ms Original ECG Pulsing: 30 % to 70 % misinterpreted by the system as R 58 71 52 78 52 - 150 . 78 . 150 . 80 peaks and extra recon syncs are in the ECG trace 3 5 6 8 t 98 Note: Case from 2 cm scanner Unrestricted © Siemens Healthineers, 2022 Notes 214 CT Advanced Examinations II | SOMATOM 7 Cardiac ECG Editing SIEMENS Healthineers ... Case #1 Edited Reconstruction Disabling of additional recon syncs HeartRate(bpm) Min: 51 Max: 166 Avg: 71 Phase manual -406: ms Recon mono 82 ms Original ECG Pulsing: 30 % to 70 % 71 52 78 52 - 150 . Delete Sync 18 - 150 - 80 Disable Sync 8 99 Note: Case from 2 cm scanner Unrestricted © Siemens Healthineers, 2022 Notes 215 CT Advanced Examinations II | SOMATOM 7 Cardiac ECG Editing SIEMENS Healthineers ... Case #2 Baseline Reconstruction HeartRate(bpm) Min: 28 Max: 95 Avg: 54 Phase Start -450- ms r ACV Original ECG DECG Pulsing Synthetic Sync 54 95 39 56 28 58 13 14 15 16 17 18 19 20 Multiple PVC’s during exam PVC #1 PVC #2 100 Note: Case from 2 cm scanner Unrestricted © Siemens Healthineers, 2022 Notes 216 CT Advanced Examinations II | SOMATOM 7 Cardiac ECG Editing SIEMENS Healthineers ... Case #2 Initial Edit Reconstruction HeartRate(bpm) Min: 28 Max: 95 Avg: 54 Phase Start -450 ms M ACV Original ECG D ECG Pulsing E Synthetic Sync 55 54 95 39 56 28 12 13 15 16 17 18 Multiple PVC’s during exam PVC #1 PVC #2 101 Note: Case from 2 cm scanner Unrestricted © Siemens Healthineers, 2022 Notes 217 CT Advanced Examinations II | SOMATOM 7 Cardiac ECG Editing SIEMENS Healthineers ... Case #2 Final Edit Reconstruction HeartRate(bpm) Min: 29 Max: 113 Avg: 62 Phase Start -450 ms ACV Original ECG DECG Pulsing Synthetic Sync 54 95 62 · 107 56 38 - 113 . 13 14 16 17 19 79 Inserting additional recon syncs 102 Note: Case from 2 cm scanner Unrestricted © Siemens Healthineers, 2022 Notes 218 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Imaging Artifacts and Pitfalls SIEMENS Healthineers ... SOMARIS 7 CT Cardiac Image Artifacts and Pitfalls 103 Unrestricted © Siemens Healthineers, 2022 Notes 219 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... What are step Artifacts • 12–20 mm steps in z‐direction characterize step artifacts, depending on the system and the detector configuration. • Steps can be restricted to the heart or may be visible in the ambient structures, too. • Although step artifacts may be caused by several different reasons, their appearance is very similar. Some causes • non diastolic recon • problems with ECG signal • arrhythmia • wrong recon phase 104 Unrestricted © Siemens Healthineers, 2022 Notes 220 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... Step Artifact caused by patient motion • Patient movement such as breathing, swallowing or other patient movement • Visible in MPR as well as MIP images • Not restricted to the heart 105 Unrestricted © Siemens Healthineers, 2022 Notes 221 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... How to improve step artifacts caused by patient motion • Care for complete patient instructions about breathing, swallowing and patient movement before and (preferably via the API) during scanning. SIEMENS althineers • Inform the patient to lie still • Inform possible sensation of warmth due to contrast Sick injection • Explain the duration of exam and breaths hold time • Emphasize that good breath‐hold is crucial to exam • Practice breathing instructions • Make sure breathing instructions are given correctly before the actual scan 106 Unrestricted © Siemens Healthineers, 2022 Notes 222 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... Step artifact caused through bad gating phase • Caused by non‐diastolic reconstruction due to irregular heart motion unstable high heart rate • extra systoles or • Arrhythmia • Due to problems with the ECG signal or due to an incorrect gating phase Location • Restricted to limited areas of the cardiac anatomy, e.g., due to an extra beats OR • Involves the entire heart, e.g., because of insufficient ECG signal, arrhythmia or wrong phase start for reconstruction 107 Unrestricted © Siemens Healthineers, 2022 Notes 223 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... Example (A) • Blocks in z‐direction that are shifted against each other • Steps are restricted to the heart • Reconstruction phase set to ‐440 ms A Improvement (B) • Reconstruction phase start has been adapted to ‐500 ms by generating a preview series and selecting the phase start setting resulting in the best images (without blurring) Hint: • Mid‐segment of the right coronary artery is the most critical B segment as it is the fastest moving coronary artery • Try to find a optimal heart phase for reconstruction at the level of the mid segment of the right coronary artery by using the preview series 108 Unrestricted © Siemens Healthineers, 2022 Notes 224 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... Steps Caused by Single Ectopic Beat HeartRate(bpm) Min: 46 Max 198 Avg: 76 Phase Sta FI ACV Original ECG ECG Pulsing 90 46 50 73 68 13 14 disable Sync delete Sync Original ECG shifted to R-peak Routine Scan Recon Auto Tasking Trigger HeartRate(bpm) Min: 50 Max 152 Avg: 65 Phase Start 65 % E ACV Original ECC DECO Pulsing F Synthetic Sync BO 50 51 53 68 65 who Original ECG 10 71 Edited ECG Original: The image Edited: RCA clearly shows a blurred Edited ECG Routine Scan Recon Auto Tasking | Trigger displayed origin of the RCA The image quality can be improved by editing the ECG to remove the extra beat 109 Unrestricted © Siemens Healthineers, 2022 Notes 225 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... Ectopic Beats in Combination with ECG Pulsing Ectopic Beats in Combination with ECG Pulsing CorCTA 0.75 B257 60% Avg. RR: 1073 ms 1s IMA: 2 of 3 High Noise due to reconstruction in a low dose interval 1-37 Improvement • Edit the ECG to remove the extra beat and move all reconstruction windows to high dose phases 74-107 108- 137 • 169-200 Using ECG pulsing for patients with a high probability for ectopic WWW Ectopic B @topic BearIL beats and ECG irregularities is not recommended. • The probability for the occurrence of ectopic beats is especially 201-232 233-264 265-296 297-308 high right after the start of breath‐hold. • Therefore, practice breath‐hold instructions with the patient before the scan and closely observe the ECG for the occurrence of irregularities. 110 Unrestricted © Siemens Healthineers, 2022 Notes 226 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... Steps Caused by Unstable High Heart Rate Example Min Max import In case of complex ventricular arrhythmia, coronary CTA is 177 116 100 Original ECG Phase Delay. Avg -400 ms not recommended. 97 - 101 - 103 . 104 - 104 - 102 . 100 . 98 . 98 93 84 Improvement 10 • In cases of severe arrhythmia or very fast changes of the patient’s heart rate during the scan procedure, improvement steps may be very limited. • Physicians may recommend application of beta blockers. 111 Unrestricted © Siemens Healthineers, 2022 Notes 227 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... Steps Caused by Badly Mounted Electrodes Example Improvement • Blocks in z‐direction • Try different phase start for reconstruction • Restricted to the heart • Edit the ECG, might help, but time consuming 121 11111 1763 F Original ECG Phase Dela HeartRate: so no 150 original ECG Phase Delay Import HeartRate: -400 ms -400 ms 60 60 10 11 72 13 14 To avoid this type of artifact from the beginning, properly attach the electrodes and have a stable ECG signal! A 112 Unrestricted © Siemens Healthineers, 2022 Notes 228 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... Slab Artifacts • Slab artifacts are 12–20 mm high (depending on system type and detector configuration) 1.16 • Similar to step artifacts, but they are not shifted against each other • Slabs result from the different brightness of 0 neighbored slabs due to varying contrast medium concentration (enhancement) during scanning • Slight slabs are completely normal and usually do not hinder diagnosis • This image describes artifacts that are caused by a too high dose of contrast medium, which also may lead to streak artifacts. A 113 Unrestricted © Siemens Healthineers, 2022 Notes 229 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... How To Avoid Excessive Contrast Enhancement Example • The image below shows several bands of different intensity (i.e., slabs) in the area of high density. • This indicates that the contrast medium dose has been too high. • A possible reason for this may be due to a short delay time used in the scan protocol. Improvement By Better Contrast Protocols • Optimized contrast medium parameters have been used in the example to the left. • There are two different methods for contrast timing: • CARE Bolus • Test Bolus protocol. 114 Unrestricted © Siemens Healthineers, 2022 Notes 230 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... How To Avoid Streak Artifacts Due To High Contrast Enhancement In The Right Atrium Example • The image below shows ranges of high‐density emitting streaks of high contrast. • The artifact is caused by high concentration of contrast medium in the right atrium, or the reconstruction has been performed with thin slices (0.6 mm). • The image is blurred because the technique may have been too low for a larger patient. Improvement • The examination can be improved by using an optimized contrast medium protocol with a properly determined delay time. • The image is scanned with optimized CM scan parameters (saline flush, double‐headed injector, and proper technique). 115 Unrestricted © Siemens Healthineers, 2022 Notes 231 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... Streak Artifacts • Streak artifacts are thinner than steps and slabs, not parallel, and usually have a starting point. • They result from reflected radiation or from extreme contrast density differences in neighboring regions. • Metal artifacts or high contrast medium concentration, for example, can cause streak artifacts in the right atrium (RA). • Thin horizontal and parallel streaks may also result from the reconstruction of thin slices, e.g., 0.6 mm. • The reconstruction of 0.75 mm slices is recommended for routine evaluation (refer to exception heavy calcifications and stents). 116 Unrestricted © Siemens Healthineers, 2022 Notes 232 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... How To Avoid Streak Artifacts By Metal Implants Examples • The image below shows an artificial valve that causes bright streaks • Clips and other metal implants may also cause such artifacts • This image shows a stent in the aorta • The origin of the streaks are the stent struts Improvements • Improvement is difficult • Higher doses, thicker slices and smoother kernels can help reducing metal artifacts Utilize iMAR * -90 • * Optional license 117 Unrestricted © Siemens Healthineers, 2022 Notes 233 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... How to Avoid Streak Artifacts by ECG leads The image shows artifacts from ECG leads. Make sure they are out of the scan field. 118 Unrestricted © Siemens Healthineers, 2022 Notes 234 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... Improvement Dedicated recon with iMAR could improve metal Recon job 2 3 5 6 8 Series description CorCTA 3.0 B30f BestDiast artifacts. Slice 3.0 mm J Advanced reconstruction options ADMIRE Kemel B30f medium smo| iMAR Artifact correction None FAST I Window Cardiac INone Neuro coils Dental fillings Spine implants Shoulder implants Extended FoV FOV 200 mm 2 ge order Pacemaker Center X 0 mm Thoracic coils Hip implants Overview Center Y 0 mm No Extremity implants Mirroring None Comments Extended CT scale 256 Matrix Routine Scan Recon Auto Tasking Trigger 119 Unrestricted © Siemens Healthineers, 2022 Notes 235 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... Blurring Artifacts • Diffuse parts or whole image is blurred • Blurring artifact also called blooming or partial volume artifacts • Reasons: • Incorrect phase start • Insufficient mAs • Slice width is too thick • Calcification and stents • Cause steps in 3‐D post processing • (sagittal and coronal view) Complication • Delayed or impossible diagnosis • Less common in high end CT scanners 120 Unrestricted © Siemens Healthineers, 2022 Notes 236 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... How To Avoid Blurring Artifacts Example Improvement • Stent appears blurred • Reconstruct image with 0.75 mm , 0.6 mm • Lumen not assessable in diagnostic IQ • Use B46 kernel • MPR reconstructed in 1mm SL • Display in MPR • Artifact caused by either low spatial resolution or poor signal‐to‐noise‐ratio 121 Unrestricted © Siemens Healthineers, 2022 Notes 237 CT Advanced Examinations II | SOMATOM 7 CT Cardiac Image Artifacts and Pitfalls SIEMENS Healthineers ... How To Avoid Blurring Artifacts Due To Wrong Gating Example Improve • The image is blurred and shows the anatomic • The image quality is improved by structures of the heart with poor quality. reconstruction with a phase start of 60%. • It has been reconstructed with a phase start of • Utilize preview series to determine the best 85 %. phase start. 122 Unrestricted © Siemens Healthineers, 2022 Notes 238 CT Advanced Examinations II | SOMATOM 7 Guided Demo Didactic Guided Demo SIEMENS Healthineers ... Protocol Selection and Configuration • Access the simulator • Options > Configuration • HeartView > Demo mode on > Apply > OK • Register a test patient • Review prospective Calcium Score protocol • Review retrospective Coronary CTA protocol • Review Adaptive Cardio Sequence protocol • Set the scan to 20‐80, and the range to 65‐70. Observe the different dose regions illustrated on the ECG • Review FLASH and TURBO FLASH scanning • Review ms/% recons • Review ECG Editing 123 Unrestricted © Siemens Healthineers, 2022 Notes 239 CT Advanced Examinations II | SOMATOM 7 Cardiac CTA SIEMENS Healthineers ... Hands – On Lab A 1. Go to Options > Configuration > double click HeartView > check Demo mode “on” > apply > OK 2. Register a test patient 3. Select an Adaptive Cardio Sequence (ACS) protocols. Is this a prospective or retrospective scan mode? _______ 4. Set the scan range to 40 – 80. Observe how the ECG dose region changes. Set a recon range of 70% and a recon range of 75%. Can you do this? ______________ 5. Choose and scan any prospective cardiac scan. Are you able to edit the ECG trace? Perform a recon with ms and a recon with %. 6. Choose and scan any non‐FLASH or TURBO FLASH retrospective cardiac scan. Are you able edit the ECG trace? Perform a multiphase recon and a TrueStack recon. 7. Choose and scan a FLASH or TURBO FLASH cardiac scan. Are you able to edit the ECG trace? 124 Unrestricted © Siemens Healthineers, 2022 Notes 240 CT Advanced Examinations II | SOMATOM 7 Thank you SIEMENS Healthineers ... for your enthusiasm! Siemens Healthineers Instructor Training and Development Center (TDC) • Name: Cary, NC USA • Phone Number: siemens‐healthineers.com • Email: xxxx@siemens‐Healthineers.com ....... 125 Unrestricted © Siemens Healthineers, 2022 Notes 241 CT Advanced Examinations II | SOMATOM 7 SIEMENS Healthineers STEP Siemens Technologist Education Program SOMARIS 7 All Scanners Week 4: Advanced Examinations II HOOD05162003200791 Effective: 06/25/2021 Unrestricted © Siemens Healthineers, 2022 Notes 242 CT Advanced Examinations II | SOMATOM 7 Day 3 SIEMENS Healthineers Day 3 kV 1 kV 2 Advanced Examinations II .... Unrestricted © Siemens Healthineers, 2022 Notes 243 CT Advanced Examinations II | SOMATOM 7 Dual Energy Agenda – DAY 3 SIEMENS Healthineers ... • Welcome / Introductions • Dual Energy • Principles of Dual Energy CT Physics • Dual Energy Approaches • Single Source • Dual Source • Guided Demo – syngo.via Dual Energy workflow • DE Basic Viewer – Optimum Contrast / Monoenergetic • Bone Removal Head / Body • Monoenergetic Plus • Hands – On Lab 3 Unrestricted © Siemens Healthineers, 2022 Notes 244 CT Advanced Examinations II | SOMATOM 7 Principles of DE Physics SIEMENS Healthineers ... SOMARIS 7 Dual Energy – Principles of DE Physics 4 Unrestricted © Siemens Healthineers, 2022 Notes 245 CT Advanced Examinations II | SOMATOM 7 Principles of Dual Energy CT Physics SIEMENS Healthineers ... What is Dual Energy? • With Dual Energy (DE), it is possible to obtain additional information about the chemical composition of body materials to get both morphological and functional information. • Dual Energy CT (DECT) is based on the fact that there are two major mechanisms responsible for attenuation of X‐rays in the CT relevant diagnostic energy range: the Photoelectric effect and Compton scattering. • During a Dual Energy scan, CT datasets are acquired with different kV. This allows visualization of differences in the energy dependence of the attenuation coefficients of different materials. • Only materials with substantially different attenuation behavior (effective atomic number Zeff) can be discriminated using DECT. • Quality and accuracy of DE‐based material discrimination depends on the separation between the high and low kV spectra. Be er spectral separa on is desired. tt ti 140kV 5 Unrestricted © Siemens Healthineers, 2022 Notes 246 CT Advanced Examinations II | SOMATOM 7 Principles of Dual Energy CT Physics SIEMENS Healthineers ... What is Dual Energy? • Dual Energy spectral imaging offers more clinical information than traditional single energy CT. • It can enable crisp images with sharp contrast and improved visualization and quantification, thus helping physicians to efficiently make a precise diagnosis. The Analogy: Moving from Black & White to Color TV Traditional Single Energy Acquisition Dual Energy Spectral Acquisition 6 Unrestricted © Siemens Healthineers, 2022 Notes 247 CT Advanced Examinations II | SOMATOM 7 Principles of Dual Energy CT Physics SIEMENS Healthineers .. Iodine Ratio • Scanning the same volume of the patient with 2 Iodine different spectra will measure differences in x‐ray 80kV 296 HU attenuation at different photon energies e.g., 80kV and 140kV. • Comparing Iodine and Bone (Calcium) the density Calcium change of Iodine between 80kV and 140kV is a lot 670 HU compared to bone which does not change that much. • This material behavior/ratio of can be calculated Iodine • Ratio = HU (low kV) / HU (high kV) 140kV 144 HU • Calcium = 670 HU (80 kV) / 450 HU(140 kV) = 1.49 • Iodine = 296 HU (80 kV) / 144 HU(140 kV) = 2.06 Calcium 450 HU 7 Unrestricted © Siemens Healthineers, 2022 Notes 248 CT Advanced Examinations II | SOMATOM 7 Principles of Dual Energy CT Physics SIEMENS Healthineers ... Iodine Ratio • A larger iodine ratio means a better spectral Iodine Ratio separation. 4,5 • This ratio describes how well a material can be 4 separated from soft tissue or water‐like materials that 3,5 have a ratio of 1 3 • The ratio of material depends on the used kV 2,5 combination 2 Iodine Ratio 1,5 1 DS 80/140 100/Sn140 80/Sn140 100/Sn150 90/Sn150 80/Sn150 70/Sn150* typical 80/140 8 Unrestricted © Siemens Healthineers, 2022 Notes 249 CT Advanced Examinations II | SOMATOM 7 Principles of Dual Energy CT Physics SIEMENS Healthineers ... • Higher CT HU value at 80kV = iodine, bone, metal • Higher CT HU value at 140kV = fat, plastic, uric acid • Almost same CT HU value = water, soft tissue, blood 80kV 100kV 120kV 140kV Iodine Fat Calcium Plastic 140kV 9 Unrestricted © Siemens Healthineers, 2022 Notes 250 CT Advanced Examinations II | SOMATOM 7 Principles of Dual Energy CT Physics SIEMENS Healthineers ... • Because x‐ray absorption is energy‐ dependent, changing the tube‘s kilo voltage (kV) results in a material‐specific change of Slope = CT value low kV attenuation. CT value high kV • Material Slope identifies and separates different materials. lodine Bone 80KV CT-value 80 KV 140kV IDENTITY O HU Blood Water Fat CT-value 000 HU 140 kV Air 0 HU 10 Unrestricted © Siemens Healthineers, 2022 Notes 251 CT Advanced Examinations II | SOMATOM 7 Principles of Dual Energy CT Physics SIEMENS Healthineers ... Spectral Separation • Image quality is crucial for reliable DECT imaging since dual energy data processing is sensitive to small changes of the Hounsfield units. • Relevant criteria comprise the spectral separation and temporal coherence of the low and high energy data, as well as, the temporal and spatial resolution of the CT images, but of course also the dose efficiency or the workflow aspects play an important role in enabling efficient DECT imaging in daily routine. • The spectral separation manifests itself in the overlap of the detected low and high energy X‐ ray spectrum, with a better spectral separation meaning less overlap. 11 Unrestricted © Siemens Healthineers, 2022 Notes 252 CT Advanced Examinations II | SOMATOM 7 Principles of Dual Energy CT Physics SIEMENS Healthineers ... Spectral Separation with Tin Filter DE without Tin Filter DE with Tin Filter • Significant spectral overlap • Minimized spectral overlap • Limits energy separation • Increased energy separation with Tin Filter • Limits dose efficiency • Complete dose neutrality Number of quanta Number of quanta SOMATOM. Force .. 80 kV 80 kV 140 kV Sn150 kV overlap overlap SOMATOM Drive SOMATOM Definition Flash 80 KV Sn140 kV Conventional Photon energy Dual Source Dual Energy CT DE with Tin Filter Photon energy 12 Unrestricted © Siemens Healthineers, 2022 Notes 253 CT Advanced Examinations II | SOMATOM 7 Principles of Dual Energy CT Physics SIEMENS Healthineers ... Spectral Separation with Tin Filter This single energy gray-scale image An inferior spectral separation (i.e ., With excellent spectral separation the does not allow you to differentiate conventional DE or Twin Beam) allows differentiation is clear (i.e ., with Dual the two materials present here. differentiation but not well separated Source technology with Tin Filter) .... there is still noise in the green/ orange material space. DE 13 Unrestricted © Siemens Healthineers, 2022 Notes 254 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... True or False: Only materials with substantially different attenuation behavior (effective atomic number Zeff) can be discriminated using Dual Energy CT ? a) True b) False 14 Unrestricted © Siemens Healthineers, 2022 Notes 255 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: The Hounsfield Units of which material more than doubles between 140kV and 80kV? ? a) Bone / Calcium b) Blood c) Iodine d) Soft Tissue 15 Unrestricted © Siemens Healthineers, 2022 Notes 256 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... True or False: The spectral separation manifests itself in the overlap of the detected low and high energy X‐ray spectrum. Better spectral separation means there is more ? overlap between the low and high kV? a) True b) False 16 Unrestricted © Siemens Healthineers, 2022 Notes 257 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... True or False: Adding a Tin filter to the high kV in Dual Energy scanning helps reduce the dose and softens the beam but there is no improvement to image quality? ? a) True b) False 17 Unrestricted © Siemens Healthineers, 2022 Notes 258 CT Advanced Examinations II | SOMATOM 7 Dual Energy Approaches SIEMENS Healthineers ... SOMARIS 7 Dual Energy Approaches 18 Unrestricted © Siemens Healthineers, 2022 Notes 259 CT Advanced Examinations II | SOMATOM 7 Single Source Dual Energy SIEMENS Healthineers ... DualSpiral Dual Energy – since VA44 TwinBeam Dual Energy – since VA48 1 st scan 80 KV 2nd scan 140 kV 19 Unrestricted © Siemens Healthineers, 2022 Notes 260 CT Advanced Examinations II | SOMATOM 7 Single Source – DualSpiral Dual Energy SIEMENS Healthineers ... DualSpiral Dual Energy • Available on these following scanners • SOMATOM Definition AS • SOMATOM Definition AS+ SOMATOM SOMATOM Definition Definition AS AS+ • SOMATOM Definition Edge • SOMATOM Edge Plus SOMATOM SOMATOM Edge Plus Definition Edge 20 Unrestricted © Siemens Healthineers, 2022 Notes 261 CT Advanced Examinations II | SOMATOM 7 Single Source – DualSpiral Dual Energy SIEMENS Healthineers ... Protocols Depending on the scanner and software version, default protocols may include: Dua DE Head BrainHem post intervention TBDE Thorax Analysis IR TBDE_Thorax_Analysis_XCARE Car TBDE_Thorax_Analysis TBDE_Thorax_LungNodules • DualSpiral Dual Energy protocols all start with “DE” and DE Abdomen Monoenergetic are found in the dedicated Dual Energy Folder DE_Abdomen_LiverVNC_late Vas TBDE Abdomen VNC DE_Abdomen_KidneyStones TBDE_Abdomen_KidneyStones F DE_Body_BoneMarrow DE_Spine_Metal TBDE_Spine_Metal_Vol Spe TBDE_Hand_Gout DE Foot Gout TBDE Foot_Gout DE_Knee_BoneMarrow P TBDE_HeadAngio_BoneRem TBDE Head BrainHem TBDE_CarotidAngio_BoneRem TBDE BodyAngio_BoneRem IR TBDE_BodyAngio_BoneRem TBDE_Body_OptiCon TBDE ExtrAngio_BoneRem 21 Unrestricted © Siemens Healthineers, 2022 Notes 262 CT Advanced Examinations II | SOMATOM 7 Single Source – DualSpiral Dual Energy SIEMENS Healthineers ... • During a Single Source DualSpiral Dual Energy scan, two CT datasets are acquired at different kV and mA levels DE_Abdomen_KidneyStones (Adult) using two successive spiral scans in the same direction. Topogram • The two spirals are automatically coupled making scan set‐up and scan parameter selection as easy as any - DE_Abd80kV RT 1 standard single energy spiral. - DE_Abd140kV In a fully automated procedure, the two data sets are 2 • non‐rigidly registered to compensate for potential patient motion between the two spirals and match the patient’s anatomy 22 Unrestricted © Siemens Healthineers, 2022 Notes 263 CT Advanced Examinations II | SOMATOM 7 Single Source – DualSpiral Dual Energy SIEMENS Healthineers ... Dose in successive scanning 1st spiral 2nd spiral @ low kV @ high kV • Each spiral is carried out at approximately half the dose of a conventional 120 kV scan. Scan parameters can be flexibly adapted to the size of the patient and the planned examination. All dose reduction techniques such as automatic exposure control (CARE Dose4DTM) and iterative reconstruction (SAFIRE*/ADMIRE*) are available for the Single Source DualSpiral Dual Energy scan mode. Low kV scan high kV scan Versatility • The first spiral typically uses 80 kV at a pitch of 0.6. The second spiral uses 140 kV at a fast pitch of 1.2 guaranteeing a good balance at sufficient power reserves and fast data acquisition. • Certain DualSpiral protocols, e.g., Bone Marrow and Gout, use a pitch of 0.7 for both low kV and high kV. 23 *Option Unrestricted © Siemens Healthineers, 2022 Notes 264 CT Advanced Examinations II | SOMATOM 7 Single Source – DualSpiral Dual Energy SIEMENS Healthineers ... Acquisition • No specific patient preparation is required for a Single Source DualSpiral Dual Energy exam • kV settings are fixed at 80kV and 140kV • Adding a recon job is only possible in the low kV/first scan. The parameters will be automatically defined for the high kV/second scan. • All scan and recon parameters for the high kV/second scan are dimmed Mother with editable scan 30 kV parameters Recon • Use of Iodine not recommended DE_Abd80kV RT • Spiral Mode only DE_Abd140KV RT] loFol • Use manual breathing commands Avoid major patient motion during and between scan ranges Daughter with dimmed scan • parameters 140 kV Recon • No Pause can be added before or in between the two series • Software will not process images if delay between scans is greater than 3 minutes 24 *Option Unrestricted © Siemens Healthineers, 2022 Notes 265 CT Advanced Examinations II | SOMATOM 7 Single Source – DualSpiral Dual Energy SIEMENS Healthineers ... Reconstructions Low kV series (editable parameters) Recon job 1 3 3 4 5 6 7 8 Series description #PP DE_Knee80kV 0.75 Qr40 Slice 0.75 mm Recon job type . Axial . 3D ADMIRE Kernel Qr40 Window Bone Begin position -1742.0 mm End position -1592.0 mm High kV series (dimmed parameters) 43878 HD FoV FoV 250 mm mage order Craniocaudal Recon job Series description #PP DE_Knee140kV 0.75 Qr40 Center X 0 mm Increment 0.5 mm Slice 0.75 mm] Recon job type o Axial . 3D Overview Center Y 0 mm No. of images 301 2 ADMIRE Mirroring None Comments Kernel Qr40 Extended CT scale Matrix size 512 Window Bone Begin position -1742.0 mm End position -1592.0 mm HD FoV FOV 250 mm Image order Craniocaudal Center > 0 mm Increment 0.5 mm Overview Center Y 0 mm = No. of images 301 Mirroring None Comments Extended CT scale Matrix size 512 25 *Option Unrestricted © Siemens Healthineers, 2022 Notes 266 CT Advanced Examinations II | SOMATOM 7 Dual Energy SIEMENS Healthineers ... FAST DE Results • Fast DE Results allows automated post‐processing of Series description DE_Abd80kV 5.0 Br38 reconstructed dual energy images. Auto recon Auto viewing • For a single dual energy recon job, it is now possible to select up to three different dual energy application Auto postprocessing None classes for “on‐scanner” post processing via the Auto FAST DE Results Tasking tab. • Automatically generates Dual Energy datasets at the AWP and sends pictures directly to PACS for a FAST DE Results 1 ... straightforward Dual Energy scan mode Application class Output type Output series description None None • Check the tick box next to FAST DE Results and click the None None box with the ellipses to configure the FAST DE Results. None None Output: Original settings Slice |1:5 mm ] Increment 1.0 mm • This opens the menu to select the Application Class, Auto transfer None select Output type, and set Output series description. 26 Unrestricted © Siemens Healthineers, 2022 Notes 267 CT Advanced Examinations II | SOMATOM 7 Dual Energy SIEMENS Healthineers ... FAST DE Results • By checking the “Original's settings” box the slice FAST DE Results thickness and increment set in the recon tab will be Application class Output type Output series description used for reconstruction None None None None None None • If unchecked, slice thicknesses can be manually entered in the corresponding box Output: Original settings Slice 1.5 mm Increment |1.0 mm Auto transfer None • The thin‐slice low/high energy reconstruction of the default scan protocol should be used • Please note that it is not possible to reconstruct FAST DE slices that are thinner than the original input slices. This will yield in an error message. • If thicker slices are created, please make sure the series is adequately labeled by entering the necessary information in the output series description field. 27 Unrestricted © Siemens Healthineers, 2022 Notes 268 CT Advanced Examinations II | SOMATOM 7 Single Source – DualSpiral Dual Energy SIEMENS Healthineers ... FAST DE Results These are the Application class options available with SOMARIS 7 DualSpiral Dual Energy • Monoenergetic Plus • Mixed Recon job 3 3 5 6 8 Series description #PP DE_Abd80kV 1.5 Qr40 • Rho/Z Auto recon Auto filming every 1image Auto viewing No. of filmed images 0 Auto postprocessing None FAST DE Results ... Application class Output type Output series description None None None Monoenergetic Plus None Mixed None Rho/Z orginal settings Slice 1.5 mm Increment 1.0 mm andino Auto transfer None 28 Unrestricted © Siemens Healthineers, 2022 Notes 269 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: Which of the following scanners can perform Dual Spiral Dual Energy? ? a) SOMATOM Definition AS+ b) SOMATOM Edge Plus c) SOMATOM Force d) SOMATOM Definition Flash 29 Unrestricted © Siemens Healthineers, 2022 Notes 270 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... True or False: In DualSpiral Dual Energy the two spirals (low kV and high kV) are automatically coupled ? a) True b) False 30 Unrestricted © Siemens Healthineers, 2022 Notes 271 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: Which of the following statements regarding DualSpiral Dual Energy is not accurate? ? a) The low kV series is editable b) The high kV series is dimmed and cannot be edited c) IV contrast is recommended d) The kV settings are fixed 31 Unrestricted © Siemens Healthineers, 2022 Notes 272 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... True or False: Fast DE Results allows automated post‐ processing of reconstructed dual energy images? ? a) True b) False 32 Unrestricted © Siemens Healthineers, 2022 Notes 273 CT Advanced Examinations II | SOMATOM 7 Single Source – TwinBeam Dual Energy SIEMENS Healthineers ... TwinBeam Dual Energy (TBDE) • Available on these following scanners • SOMATOM Definition AS+ • SOMATOM Definition Edge • SOMATOM Edge Plus SOMATOM Definition AS+ 6 .. SOMATOM Definition Edge SOMATOM Edge Plus 33 Unrestricted © Siemens Healthineers, 2022 Notes 274 CT Advanced Examinations II | SOMATOM 7 Single Source – TwinBeam Dual Energy SIEMENS Healthineers ... Protocols Depending on the scanner and software version, default protocols may include: Dua DE Head BrainHem post intervention TBDE Thorax Analysis IR TBDE_Thorax_Analysis_XCARE Car TBDE_Thorax_Analysis TBDE_Thorax_LungNodules • TwinBeam Dual Energy protocols all start with “TBDE” DE Abdomen Monoenergetic and are found in the dedicated Dual Energy folder DE_Abdomen_LiverVNC_late Vas TBDE Abdomen VNC DE_Abdomen_KidneyStones TBDE_Abdomen_KidneyStones F DE_Body_BoneMarrow DE_Spine_Metal TBDE_Spine_Metal_Vol Spe TBDE_Hand_Gout DE Foot Gout TBDE Foot_Gout DE_Knee_BoneMarrow P TBDE_HeadAngio_BoneRem TBDE Head BrainHem TBDE_CarotidAngio_BoneRem TBDE BodyAngio_BoneRem IR TBDE_BodyAngio_BoneRem TBDE_Body_OptiCon TBDE ExtrAngio_BoneRem 34 Unrestricted © Siemens Healthineers, 2022 Notes 275 CT Advanced Examinations II | SOMATOM 7 Single Source – TwinBeam Dual Energy SIEMENS Healthineers ... • Requires a Single Source CT scanner with an X‐ray filter that is divided into a tin part (Sn) and a gold part (Au). • The gold part yields the low energy spectrum, and the tin part yields the high energy spectrum. • Both energy spectra is scanned simultaneously in order to reduce the impact of patient motion. • Enables scans with contrast media 35 Unrestricted © Siemens Healthineers, 2022 Notes 276 CT Advanced Examinations II | SOMATOM 7 Single Source – TwinBeam Dual Energy SIEMENS Healthineers ... • Enables high contrast dynamic applications • Fully dose modulated scan (CARE Dose4DTM) Iterative reconstruction (SAFIRE*/ADMIRE*) are High Energy • Spectra (Sn) available • iMAR* (iterative metal artifact reduction) applicable • The high energy (Sn) is always on the front side of the gantry. • The low energy (Au) is always on the back side of the gantry. Au Low Energy AI Sn Spectra (Au) 36 *Option Unrestricted © Siemens Healthineers, 2022 Notes 277 CT Advanced Examinations II | SOMATOM 7 Single Source – TwinBeam Dual Energy SIEMENS Healthineers ... • TwinBeam Dual Energy compared with single energy CT results in similar noise, in addition to, dual energy capabilities at lower radiation dose. • Because of beam hardening, TwinBeam Dual Energy can lead to decreased CNR values of iodinated structures. Sn Au • All additional radiation dose reduction technologies applicable, such as SAFIRE* and ADMIRE* Euler, A., Parakh, A., Falkowski, A. L., Manneck, S., Dashti, D., Krauss, B., .. Schindera, S. T. (2016). Initial results of a single‐source dual‐ 37 energy computed tomography technique using a split‐filter. Investigative Radiology, 51(8), 491‐498. doi:10.1097/rli.0000000000000257 *Option Unrestricted © Siemens Healthineers, 2022 Notes 278 CT Advanced Examinations II | SOMATOM 7 Single Source – TwinBeam Dual Energy SIEMENS Healthineers ... Acquisition Spiral Mode only TBDE_Abdomen_VNC (Adult) • AuSn120 kV is only option on SOMARIS 7 single source Topogram • systems TB_Abdomen RT • Pitch factor is limited TBDE 2 Total mAs: • Full field‐of‐view (FoV) of 50cm CARE Dose4D MI CARE KV Off ] Slice 5.0 mm - Acq. 64 x 0.6 mm Performed with Adaptive Dose Shield to avoid Pitch 0.3 2| • Eff. mAs KV AUSn120 | Direction Craniocaudal unnecessary radiation. Organ characteristic: Abdomen CTDIvol (32cm): mGy DLP: mGy*cm • Image acquisition is possible for all rotation times (up to Scan time 6.95 s 0.28 seconds) Scan start Start button Rotation time 0.33 s Delay Language German • Due to the scan technique, there is no dose penalty for API None TwinBeam Dual Energy. All default scan protocols, single energy and TwinBeam Dual Energy, have the same dose Routine| Scan Recon Auto Tasking 38 Unrestricted © Siemens Healthineers, 2022 Notes 279 CT Advanced Examinations II | SOMATOM 7 Single Source – TwinBeam Dual Energy SIEMENS Healthineers ... Reconstruction TwinBeam Reconstruction Modes Slice weighting for L and H recons L (low energy) + H (high energy) • For Spiral scans only • L+H reconstruction creates one low and one high Au fuiltered / Sn filtered dataset intended for post‐processing in syngo.via C (Composed) • Single energy diagnostic image • No DE information • All data from detector are used (full dose) Series C • For 3D: coronal and sagittal reformats L+H HID FOV FoV 300 mm 2| 39 Unrestricted © Siemens Healthineers, 2022 Notes 280 CT Advanced Examinations II | SOMATOM 7 Single Source – TwinBeam Dual Energy SIEMENS Healthineers ... FAST DE Results “L+H” must be selected in the Series dropdown list of the Series description TB_Thorax 5.0 Bf37 Recon tab to be able to use FAST DE Results in the Auto Auto recon Tasking tab. Auto viewing Auto postprocessing None Recon job 3 3 4 5 6 7 8 Se FAST DE Results ... Slice 1.5 mm - Auto Tasking DE series C ADMIRE Kernel Qr40 FAST Window Abdomen Series description TB_Thorax 5.0 B157 Series L+H Auto recon HD FOV FoV 300 mm + Auto viewing Center X 0 mm Auto postprocessing None Overview Center Y 0 mm FAST DE Results .... ] Mirroring None Auto Tasking DE series L+H Extended CT scale Matrix size 512 Routine Scan Recon 40 Unrestricted © Siemens Healthineers, 2022 Notes 281 CT Advanced Examinations II | SOMATOM 7 Single Source – TwinBeam Dual Energy SIEMENS Healthineers ... FAST DE Results These are the Application class options available with SOMARIS 7 TwinBeam Dual Energy • Monoenergetic Plus • Mixed Recon job 1 3 3 4 5 6 7 8 Series description #PP TB_Abdomen 1.5 Qr40 • Virtual Unenhanced Auto recon Optimum Contrast Auto filming every 1image Auto viewing • No, of filmed images O Auto postprocessing None FAST DE Results 1 ... • Liver VNC Application class Output type Output series description • Rho/Z None None None Monoenergetic Plus None Mixed None Virtual Unenhanced Optimum Contrast 1.0 mm Liver VNC lgs Slice 1:5 mm Increment Rho/Z Auto transfer None 41 Unrestricted © Siemens Healthineers, 2022 Notes 282 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: Which of the following scanners are capable of scanning with TwinBeam Dual Energy? ? a) SOMATOM Definition AS+ b) SOMATOM Definition Drive c) SOMATOM Definition Edge d) SOMATOM Edge Plus e) SOMATOM Force 42 Unrestricted © Siemens Healthineers, 2022 Notes 283 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... True or False: A benefit of scanning with TwinBeam Dual Energy vs DualSpiral Dual Energy is the ability to scan with contrast? ? a) True b) False 43 Unrestricted © Siemens Healthineers, 2022 Notes 284 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: The TwinBeam filter is comprised of which two materials? ? a) Tungsten b) Gold c) Platinum d) Tin 44 Unrestricted © Siemens Healthineers, 2022 Notes 285 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... True or False: SOMARIS 7 TwinBeam Dual Energy offers the following kV combination options: AuSn120kV and AuSn140kV? ? a) True b) False 45 Unrestricted © Siemens Healthineers, 2022 Notes 286 CT Advanced Examinations II | SOMATOM 7 Dual Source Dual Energy SIEMENS Healthineers ... O Dual Energy powered by Dual Source CT O 46 Unrestricted © Siemens Healthineers, 2022 Notes 287 CT Advanced Examinations II | SOMATOM 7 Dual Source Dual Energy SIEMENS Healthineers ... Dual Source Dual Energy • Available on these following scanners A‐System B‐System Low kV High kV incl SPS* • SOMATOM Definition Flash • SOMATOM Drive Sn • SOMATOM Force 47 *SPS= Selective Photon Shield Unrestricted © Siemens Healthineers, 2022 Notes 288 CT Advanced Examinations II | SOMATOM 7 Dual Source Dual Energy SIEMENS Healthineers ... Protocols Dua DE_Thorax_Analysis_XCARE DE_Thorax_Analysis ca DE_Thorax_LungPBV DE Abdomen VNC DE_Abdomen_KidneyStones DE AbdomenSeq DE_Body_BoneMarrow DE_Spine_Metal_Vol DE_Hand_Gout DE_Foot_Gout DE_Knee_BoneMarrow Sp. DE_HeadAngio_BoneRem DE_Head_BrainHem DE_CarotidAngio_BoneRem DE_CarotidAngioFast_BoneRem DE_BodyAngio_BoneRem DE_BodyAngioFast_BoneRem DE_ExtrAngio_BoneRem DE CoronaryCTA_HeartPBV DE CoronaryCTA AdaptSeg 48 Unrestricted © Siemens Healthineers, 2022 Notes 289 CT Advanced Examinations II | SOMATOM 7 Dual Source Dual Energy SIEMENS Healthineers ... kV Options • The Dual Source (DS) Dual Energy scan is performed with two different X‐ray sources at two different kV levels at the same time. For example: • Tube A: 80/90/100kV • Tube B: Sn140kV (Flash/Drive) • Tube B: Sn150kV (Force) • This acquisition results in two datasets (A and B) acquired in a single scan. • With DS Dual Energy CT post‐processing applications (e.g., bone removal, kidney stone, etc.), we combine both data sets (A + B) to process and visualize the pathological structures of the body. • Better spectral resolution is achieved by using an additional tin filter (Sn) for the high energy spectrum. 49 Unrestricted © Siemens Healthineers, 2022 Notes 290 CT Advanced Examinations II | SOMATOM 7 Dual Source Dual Energy SIEMENS Healthineers ... Field of View The optimal field of view for DS Dual Energy imaging is limited by the smaller scan field of tube B. Dual Energy Rotation direction A 95⁰ information is only available within this smaller scan field known as the DE usable FoV. SOMATOM Definition Flash / SOMATOM Drive 78cm • FoV Tube A = 78cm • Diagnostic FoV Tube A = 50cm 50cm • FoV Tube B = 33cm DE FoV • DE usable FoV = 33cm 33cm B 35.4cm Detector B SOMATOM Force • FoV Tube A = 78cm • Diagnostic FoV Tube A = 50cm FoV Tube B = 35.4cm Detector A • • DE usable FoV = 35.4cm 50 Unrestricted © Siemens Healthineers, 2022 Notes 291 CT Advanced Examinations II | SOMATOM 7 Dual Source Dual Energy SIEMENS Healthineers ... Field of View • Always position isocenter • Off‐centering (left or right) to include the region of interest may be necessary (i.e., for kidney or liver) :SP -751:0 • Contrast timing is mostly the same as for non‐Dual Energy examinations DE Usable FoV • After the AP & Lateral topograms are scanned, two blue boxes indicate the DE usable FoV of 33cm or 35.4cm • Outside the DE usable FoV only one kV data is displayed; therefore, the reconstruction of single energy data with a FoV > 33cm or > 35.4cm is possible 51 Unrestricted © Siemens Healthineers, 2022 Notes 292 CT Advanced Examinations II | SOMATOM 7 Dual Source Dual Energy SIEMENS Healthineers ... Reconstructions All default Dual Energy reconstruction jobs could produce Slice 1.5 mm ] different combination of reconstructions. ADMIRE Strength Kernel Qr40 • A+B+M Window Abdomen • A: Data from Tube A ….… A_100kV* • B: Data from Tube B ….... B_Sn140kV* Series A+B DE Comp. 0.5 2- • M: Mixed data set .…... M_0.5* A+B+M • A+B A+B FAST DE FoV 332 mm 2 • A: Data from Tube A ….… A_100kV* Center X 4 mm 3 • B: Data from Tube B ….... B_Sn140kV* Overview Center Y 0 mm • FAST DE Mirroring None • F: Mixed data set ……… F_0.5* (DE Composition) e.g., Definition Drive (VB10) – DE_Abdomen_VNC The default “DE Composition” calculates a 120kV equivalent image in perspective of CNR 52 *Part of the series description Unrestricted © Siemens Healthineers, 2022 Notes 293 CT Advanced Examinations II | SOMATOM 7 Dual Source Dual Energy SIEMENS Healthineers ... Reconstruction – DE Composition • “DE Composition” indicates the mixing ratio of the low and high kV dataset • The weight is always the % of the LOW kV dataset HU value. • M: Mixed data set .…... M_0.6 (=> 60% low kV + 40% high kV) HUmix w HUlow  (1 ) w HUhigh   • Example: Mixed = 0.6  HUmix = 0.6 x HUlow + (1 – 0.6) x HUhigh • Color LUT, windowing and level can be adjusted separately 53 Unrestricted © Siemens Healthineers, 2022 Notes 294 CT Advanced Examinations II | SOMATOM 7 Dual Source Dual Energy SIEMENS Healthineers ... Reconstructions • FAST DE for improved workflow with Dual Source DE – Slice 0.75 mm Recon job type . Axial . 3D advantages with respect to M‐images: SAFIRE Recon axis axial Kernel D30f medium smooth Type MPR • Faster reconstruction – eliminates unnecessary Window Spine datasets in data base (A+B series) Series FAST DE DE Comp. 0.5 Slice 0.75 mm Recon job type o Axial 3D SAFIRE Recon region: Narrow Wide . • 3D reconstruction with workstream 4D – A+B+M Series Kernel D30f medium smooth None Window Spine can only be reconstructed in axial orientation Begin position -795.0 mm Series A+B+M DE Comp. 0.5 End position -955.0 mm lice 0.75 mm ] DE Composition SAFIRE • Less image noise for a DE composition close to 0 or 1 Kernel D30f medium smooth A Window Spine Integrated DE MAR* – The DE composition will have in 1 .0.5 Series FAST DE DE Comp. 40.0 • 0.5 . 00 this case negative values (e.g., F _ ‐ 0.3) FoV 120 mm Image order Craniocaudal • Extended CT scale is possible Center X 0 mm Increment 0.75 mm Overview Center Y 0 mm No. of images 214 2 Mirroring None Comments Extended CT scale 54 *Metal Artefact Reduction Unrestricted © Siemens Healthineers, 2022 Notes 295 CT Advanced Examinations II | SOMATOM 7 Dual Source Dual Energy SIEMENS Healthineers ... Composition Slider • Symbols indicate the recommended composition DE Composition: non factors, for example, for non‐contrast vs. vascular metal contrast examinations. artefact contrast reduction B A K • Whether the high kV data comes from source "A" or X from source "B" depends on your scanner type. -1.0 -0.5 +0.0 +0.5 +1.0 • However, the letter of the high kV source is always displayed above the 0 on the scale because the composition factor is the weight of the low kV image. Recon job . 6 3 3 3 6 7 8 Series description_DE_Abdomen 5.0 B30f Slice 5.0 Prothesis imaging (Strong setting) SAFIRE Kemel B30f medium smooth B A window A domen Seri FAST DE M DE Comp. 0.2 +0.5 +1.0 Prothesis imaging Fov 300 mm (Standard setting) Jdal 55 Unrestricted © Siemens Healthineers, 2022 Notes 296 CT Advanced Examinations II | SOMATOM 7 Dual Source Dual Energy SIEMENS Healthineers ... Reconstruction – Mixed images The default “DE Composition” calculates a 120kV equivalent image in perspective of CNR DE Composition: B A -1.0 -0.5 +0.0 405 80kV Sn150kV FAST DE (F_0.5) +C kV 100/Sn150 (F 0.5) eff.mAs 184/93 ref.mAs 190/95 TI 0.5 GT 0.0 SL 2.0/128x0.6/p0_6 373 6/0 Br40.d2n.A35C0.A5j.F 120kV equivalent 56 Unrestricted © Siemens Healthineers, 2022 Notes 297 CT Advanced Examinations II | SOMATOM 7 Dual Source Dual Energy SIEMENS Healthineers ... FAST DE Results These are the Application class options available with SOMARIS 7 Dual Source Dual Energy • Monoenergetic Plus • Mixed Recon job 1 2 3 4 5 6 7 8 Series description #PP DE_Thorax 1.5 Qr40 2 • Virtual Unenhanced Auto recon Auto filming every image Auto viewing • Optimum Contrast No. of filmed images O Auto postprocessing None FAST DE Results [ ... • Lung PBV Application class Output type Output series description • Liver VNC None None None Monoenergetic Plus None • Rho/Z Mixed None Virtual Unenhanced Optimum Contrast Slice 1.5 mm Increment Lung PBV 1.0 Liver VNC Auto transfer None Rho/Z 57 Unrestricted © Siemens Healthineers, 2022 Notes 298 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: Which of the following scanners are Dual Source Dual Energy scanners? ? a) SOMATOM Edge Plus b) SOMATOM Force c) SOMATOM Definition Flash d) SOMATOM Drive 58 Unrestricted © Siemens Healthineers, 2022 Notes 299 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... True or False: The Dual Source (DS) Dual Energy scan is performed with two different X‐ray sources at two different kV levels at the same time. ? a) True b) False 59 Unrestricted © Siemens Healthineers, 2022 Notes 300 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... Please Answer: What is the FAST DE “F” reconstruction? a) A combination of the A and B tube reconstruction for ? DE post‐processing b) A combined image series form the low and high kV for normal image reconstruction c) There is no “F” reconstruction 60 Unrestricted © Siemens Healthineers, 2022 Notes 301 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... True or False: SAFIRE/ADMIRE can be used when reconstructing a Dual Energy reconstruction? ? a) True b) False 61 Unrestricted © Siemens Healthineers, 2022 Notes 302 CT Advanced Examinations II | SOMATOM 7 Knowledge Check SIEMENS Healthineers ... True or False: DE Composition indicates the mixing ratio of the low and high kV dataset? ? a) True b) False 62 Unrestricted © Siemens Healthineers, 2022 Notes 303 CT Advanced Examinations II | SOMATOM 7 Guided Demo SIEMENS Healthineers ... syngo.via Dual Energy Workflow Guided Demo 63 Unrestricted © Siemens Healthineers, 2022 Notes 304 CT Advanced Examinations II | SOMATOM 7 Dual Energy – DE Basic Viewer SIEMENS Healthineers ... Optimum Contrast Optimum Contrast 140 keV 80 keV • Optimum Contrast is an intelligent method that changes the blending ratio of low and high energy data on a pixel‐ by‐pixel basis, depending on the corresponding Hounsfield units (CT numbers). • For higher CT numbers, which occur in regions of high iodine concentration, larger proportions of the image are taken from low tube energy data. As a result, areas of contrast enhancement are accentuated. eff mas 220 ref MAN 42- SL 1 504119405 320 14/0 Optimum Contrast Standard Mixed 64 Unrestricted © Siemens Healthineers, 2022 Notes 305 CT Advanced Examinations II | SOMATOM 7 Dual Energy – DE Basic Viewer SIEMENS Healthineers' ... Monoenergetic Monoenergetic • With Monoenergetic imaging, metal artifacts can be reduced in both Single Source and Dual Source Dual Energy data. • Select the energy level at which implants, clamps, or screws will have the smallest impact on image quality and get unsurpassed scan results. Conventional CT Dual Energy CT 65 Unrestricted © Siemens Healthineers, 2022 Notes 306 CT Advanced Examinations II | SOMATOM 7 Dual Energy – Bone Removal Head / Body SIEMENS Healthineers' ... syngo.CT DE Direct Angio • syngo.CT DE Direct Angio accurately highlights vessel structures on CT angiography (CTA) data sets and suppresses bone structures to provide you with a bone free view of the vessel system, e.g., to subtract bone in CTAs. • Overcoming limitations of conventional bone removal software, the DE approach reliably isolates even complex vasculature, such as at the base of the skull, where CTAs are difficult to interpret. 66 Unrestricted © Siemens Healthineers, 2022 Notes 307 CT Advanced Examinations II | SOMATOM 7 Dual Energy – Monoenergetic Plus SIEMENS Healthineers ... syngo.CT DE Monoenergetic Plus • syngo.CT DE Monoenergetic Plus allows users to display monoenergetic images in a range of 40–190 keV. By displaying multiple monoenergetic regions of interest and the associated absorption curves, Monoenergetic Plus lets users easily compare and quantify lesions and tissues. • The ability to export statistical information for further evaluation is very beneficial for various research and diagnostic tasks. In addition, high enhancement is observed even for low iodine concentrations at low energy levels. • Monoenergetic imaging has become a reliable routine tool for image quality enhancement and metal artifact reduction. 67 Unrestricted © Siemens Healthineers, 2022 Notes 308 CT Advanced Examinations II | SOMATOM 7 Didactic Guided Demo SIEMENS Healthineers ... syngo.via Dual Energy workflow Mixed 45 keV monoenergetic • DE Basic Viewer • Optimum Contrast • Basic Monoenergetic • Bone Removal for Head and Body • Open a DE CTA of the head and body • Demonstrate DE Bone removal editing • Monoenergetic Plus • Load a study with metal to evaluate metal artifact reduction • Load a contrasted DE study to demonstrate Mono ROI features • Export ROI statistics and show 68 Unrestricted © Siemens Healthineers, 2022 Notes 309 CT Advanced Examinations II | SOMATOM 7 Dual Energy SIEMENS Healthineers ... Hands – On Lab A 1. Log onto syngo.via SmartSimulator. Find patients on Patient Browser given to you by the instructor and assign them to the Dual Energy Workflow. Once ready, proceed. 2. Open a DE study with contrast into Basic DE Viewer. Use the slider in the in‐segment mini‐toolbar. What happens to the image if you slide Left? ___________________________ Right? ___________________________________ 3. Change to a “Side‐by‐Side” layout. What is displayed in the segments? _________________________________ 4. Change back to the “General Viewing” layout. 5. Select Optimum Contrast from the drop‐down menu. How does the image change? ________________________ 6. What is featured in the Optimum Contrast in‐segment mini‐toolbar? ______________________________________ 7. Move the “C” slider in the mini‐toolbar to “ ‐100”. How does the image change? _____________________________ 8. Select a patient with metal and open in Dual Energy. Select Monoenergetic from the Basic Viewer. 9. Activate the Monoenergetic ROI and create an ROI in the image. Where did you activate the ROI? ______________ 10. What range is recommended for Metal Artifact Reduction (PI)? ______________________________ 69 Unrestricted © Siemens Healthineers, 2022 Notes 310 CT Advanced Examinations II | SOMATOM 7 Dual Energy SIEMENS Healthineers ... Hands – On Lab B 1. Go back to the patient with contrast. Select the Bone Removal step. 2. What tools are available in the Bone Removal workflow step? ___________________________________________ 3. Activate Fine Tuning and adjust the image with the mini‐toolbar. How does the image change? _______________ _____________________________________________________________________ 4. Toggle Show/Hide plaques on/off. How does the image change? _________________________________________ 5. Toggle “Show Mixed”. How does the image change? _________________________________________________ 6. Use the Bone Removal mini‐toolbar to edit the bone removal. Add/remove bone / vessels from the image. 7. Deactivate bone removal and create a VRT Radial Range. 70 Unrestricted © Siemens Healthineers, 2022 Notes 311 CT Advanced Examinations II | SOMATOM 7 Dual Energy SIEMENS Healthineers ... Hands – On Lab C 1. Select the Application class Monoenergetic Plus . Use the slider in the in‐segment mini‐toolbar. What happens to the image if you slide Left? _______________________ Right? ____________________________ 2. Activate the Monoenergetic ROI and make 3 ROIs in the dataset. What is displayed on the graph? ______________ ________________________________________________________________________ 3. Right mouse click on the graph. What options are displayed? ________________________________________ Toggle them on/off to see what happens. 4. What do the error bars represent on the graph curves? ________________________________________________ 5. Can the ROI statistics be exported? _____________________________________________ 71 Unrestricted © Siemens Healthineers, 2022 Notes 312 CT Advanced Examinations II | SOMATOM 7 Thank you SIEMENS Healthineers ... for your enthusiasm! Siemens Healthineers Instructor Training and Development Center (TDC) • Name: Cary, NC USA • Phone Number: siemens‐healthineers.com • Email: xxxx@siemens‐Healthineers.com ....... Author | Department 72 Unrestricted © Siemens Healthineers, 2022 Notes 313 CT Advanced Examinations II | SOMATOM 7 SIEMENS Healthineers STEP Siemens Technologist Education Program SOMARIS 7 All Scanners Week 4: Advanced Examinations II HOOD05162003200791 Effective: 06/25/2021 Unrestricted © Siemens Healthineers, 2022 Notes 314 CT Advanced Examinations II | SOMATOM 7 Day 4 SIEMENS Healthineers Day 4 Advanced Examinations II .... Unrestricted © Siemens Healthineers, 2022 Notes 315 CT Advanced Examinations II | SOMATOM 7 syngo.via Dual Energy Workflow Agenda – DAY 4 SIEMENS Healthineers ... • Welcome / Introductions • Guided Demo – syngo.via Dual Energy workflow • Kidney Stone • Virtual Unenhanced / Liver VNC • Gout • Bone Marrow • Lung Analysis – Lung Vessels and Lung PBV • Hands – On Lab • End of Class Assessment 3 Unrestricted © Siemens Healthineers, 2022 Notes 316 CT Advanced Examinations II | SOMATOM 7 Guided demo SIEMENS Healthineers ... SOMARIS 7 Guided Demo 4 Unrestricted © Siemens Healthineers, 2022 Notes 317 CT Advanced Examinations II | SOMATOM 7 Dual Energy – Kidney Stone SIEMENS Healthineers ... syngo.CT DE Calculi Characterization • syngo.CT DE Calculi Characterization allows identification and characterization of different kinds of kidney stones. • The basis for this approach is the utilization of DECT data in order to calculate a visual color‐coded material decomposition into uric acid and other stone types. • syngo.CT DE Calculi Characterization also includes the Kidney Stone Navigator for handy review and evaluation of all potential stones that have been identified. 5 Unrestricted © Siemens Healthineers, 2020 Notes 318 CT Advanced Examinations II | SOMATOM 7 Dual Energy – Virtual Unenhanced / Liver VNC SIEMENS Healthineers ... syngo.CT DE Virtual Unenhanced • With DE, it is possible to perform a contrast scan right away and to view a virtual non‐contrast image without the need for a non‐contrast scan. Another advantage of DECT is the ability to quantify the iodine uptake [mg/mL] in tissue and lesions. • syngo.CT DE Virtual Unenhanced has been extended by optimized visualization of other organs apart from the liver. Virtual non‐contrast (VNC) imaging has been successfully applied for kidney, pancreas, lung, aorta and lymph nodes. • For the evaluation of liver lesions, syngo.CT DE Virtual Unenhanced includes the well‐established application Liver VNC with an algorithm optimized for liver tissue. 6 Unrestricted © Siemens Healthineers, 2020 Notes 319 CT Advanced Examinations II | SOMATOM 7 Dual Energy – Gout SIEMENS Healthineers ... syngo.CT DE Gout • syngo.CT DE Gout facilitates the visualization of deposited uric acid crystals in peripheral extremities by automatically color‐coding these crystals to visualize those deposits. • Conventional methods of diagnosing gout, for example the aspiration of the joint fluid, are limited in feasibility, especially in acute cases where the joint is inflamed and painful. In these cases, an aspiration may not be performable. • syngo.CT DE Gout overcomes these limitations by being non‐invasive, more specific, and fast. 7 Unrestricted © Siemens Healthineers, 2020 Notes 320 CT Advanced Examinations II | SOMATOM 7 Dual Energy – Bone Marrow SIEMENS Healthineers ... syngo.CT DE Bone Marrow • Bone Marrow can be affected by various pathologies, such as bone bruises after trauma and diffuse tumor infiltrations. Up to now, the major modality for imaging these pathologies has been MRI. With the benefits of Dual Energy, CT imaging can now also aid in the diagnosis. • The DE application syngo.CT DE Bone Marrow allows for the segmentation and visualization (color‐coding) of the bone marrow based on a material decomposition into bone marrow and calcium. • This application can be used both for Dual Source and Single Source data sets (DualSpiral Dual Energy). 8 Unrestricted © Siemens Healthineers, 2020 Notes 321 CT Advanced Examinations II | SOMATOM 7 Dual Energy – Lung Analysis SIEMENS Healthineers ... syngo.CT DE Lung Analysis • syngo.CT DE Lung Analysis allows the color‐coding of vessels that are affected, e.g., by pulmonary emboli and therefore show a significantly lower iodine concentration than non‐affected vessels. • It also enables fast evaluation of the related lung perfusion defects without the use of an additional non‐ contrast scan. • syngo.CT DE Lung Analysis directly visualizes the local iodine concentration in the lung parenchyma, which is a measure of the local blood volume, thus enabling a display of the area of possibly affected tissue. • syngo.CT DE Lung Analysis is a combination of syngo Dual Energy Lung Vessels and syngo Dual Energy Lung PBV. 9 Unrestricted © Siemens Healthineers, 2020 Notes 322 CT Advanced Examinations II | SOMATOM 7 Didactic Guided Demo SIEMENS Healthineers ... syngo.via Dual Energy workflow • Kidney Stone • Navigate to kidney stones and mark them • Use automatic navigator and manual marker • Virtual Unenhanced / Liver VNC • Slide between CT and Overlay • Create DE ROI and view result options • Open Fat Map – Liver VNC only and create a DE ROI • Gout • Identify cumulative volume of gout crystals • Bone Marrow • Slide between CT and Overlay • Lung Analysis – Lung Vessels/Lung PBV • Evaluate for clots and perfusion of lung parenchyma 10 Unrestricted © Siemens Healthineers, 2022 Notes 323 CT Advanced Examinations II | SOMATOM 7 Dual Energy SIEMENS Healthineers ... Hands – On Lab A 1. Log onto syngo.via SmartSimulator. Find patients on Patient Browser given to you by the instructor and assign them to the Dual Energy Workflow. Once ready, proceed. 2. Open the Kidney Stone patient. Use the slider in the in‐segment mini‐toolbar. What happens to the image if you slide Left? ___________________________ Right? _______________________________ 3. Use the kidney stone navigator to move through the stones. Mark a stone using the in‐segment mini‐toolbar. Can you navigate forward and backward with this navigator? ______________________________ 4. Now, activate the manual kidney stone marker. Where did you go to activate the manual marker? ______________ 5. What might be an advantage of using the manual kidney stone marker vs the navigator ? _____________________ _____________________________________________________________________________________________ 6. Find a blue stone and a red stone and mark both. What result details are given once you mark a stone? ________________________________________________________________________________________ 7. What type of stone is a blue stone? __________________________ A red stone? ________________________ 8. View the markers on the graph. What is the Volume of the stones? _____________________________ 11 Unrestricted © Siemens Healthineers, 2022 Notes 324 CT Advanced Examinations II | SOMATOM 7 Dual Energy SIEMENS Healthineers ... Hands – On Lab B 1. Open the VNC/Liver VNC patient. Select Virtual Unenhanced step. Use the slider in the in‐segment mini‐toolbar. What happens to the image if you slide Left? _______________________ Right? ____________________________ 2. Activate the DE ROI tool. Where did you find this tool? Make a DE ROI in a Kidney. What results are displayed? How can you see more results than what was displayed by default? ___________________________________________ 3. Activate a Normalization ROI and place in the Aorta. Where did you find this ROI? _____________________ What happened to the image/results after placing the normalizing ROI in the aorta? ______________________________ 4. Switch to Liver VNC step and perform a DE ROI in the liver. Are the displayed results the same as from VNC? If not, what is different? ______________________________________________________________________________ 5. Activate Fat Map. How do the images change after activating it? ________________________________________ 6. Create 2 DE ROIs in the liver with Fat Map active. Are any of the Fat Fraction results <0 or >100? How can you have a fat fraction that is less than 0 or greater than 100? _________________________________________________ 7. Why do we have two workflows (almost identical) for VNC and Liver VNC? What is different between them? ____ ____________________________________________________________________________________________ 12 Unrestricted © Siemens Healthineers, 2022 Notes 325 CT Advanced Examinations II | SOMATOM 7 Dual Energy SIEMENS Healthineers ... Hands – On Lab C 1. Open the Gout patient. Use the slider in the in‐segment mini‐toolbar. What happens to the image if you slide Left? Right? ____________________________ _______________________ 2. What does the green color represent in the fused image / VRT? ________________________________ 3. What is the Volume of Gout for this patient? ____________________________________________ 4. Activate the Punch tool from the upper left corner menu and cut out some of the green in the VRT segment. Does the volume change after punching it out? __________________________________________________________ 5. Open the Bone Marrow patient. Use the slider in the in‐segment mini‐toolbar. What happens to the image if you slide Left? _______________________ Right? ____________________________ 6. Does this patient have an injury? _______________________ Take a snapshot with and without color overlay of the injury. Where do these snapshots go? _________________________________ 7. What color represents the area of the injury? ___________________________________ What body material does this color represent? ____________________________________ 13 Unrestricted © Siemens Healthineers, 2022 Notes 326 CT Advanced Examinations II | SOMATOM 7 Please complete your assessment and print SIEMENS Healthineers ... your certificate after the completion of your course. 1. Log into https://pep.siemens‐info.com/activity 2. Under the My Events section, select the card for the course you just completed. 3. Select Launch to start the final assessment. 4. Upon successful completion, close the assessment window to return to the event page. 5. Select View Certificate option to complete the survey and print or save your certificate. 14 Unrestricted © Siemens Healthineers, 2022 Notes 327 CT Advanced Examinations II | SOMATOM 7 Dual Energy SIEMENS Healthineers ... Hands – On Lab D 1. Open the Lung Analysis patient. From the workflow step, choose Vessels from the dropdown menu. How does the image appearance change / look? _________________________________________________________ 2. What does the blue color represent? _______________ The red color? ______________________________ 3. Does this patient have a blood clot in the lung vessels? How could you confirm this using the in‐segment slider? ___________________________________________ 4. From the workflow step, choose Lung PBV from the dropdown menu. How does the image appearance change / look? _________________________________________________________ 5. If this patient had a clot, how does the lung parenchyma appear in that area on Lung PBV view? ____________ ___________________________________________ 6. Activate the different lung segmentation options. How many are there? _______________________________ 7. While in Lung PBV, activate the Normalization ROI and place it in the Pulmonary Trunk. How does the image appearance change? __________________________________________ 15 Unrestricted © Siemens Healthineers, 2022 Notes 328 CT Advanced Examinations II | SOMATOM 7 Thank you SIEMENS Healthineers ... for your enthusiasm! Siemens Healthineers Instructor Training and Development Center (TDC) • Name: Cary, NC USA • Phone Number: siemens‐healthineers.com • Email: xxxx@siemens‐Healthineers.com ....... Author | Department 16 Unrestricted © Siemens Healthineers, 2022 Notes 329 CT Advanced Examinations II | SOMATOM 7 On account of certain regional limitations of sales rights and service availability, we cannot guarantee that all products included in this brochure are available through the Siemens sales organization worldwide. Availability and packaging may vary by country and is subject to change without prior notice. Some/All of the features and products described herein may not be available in the United States. The information in this document contains general technical descriptions of specifications and options as Local Contact Information well as standard and optional Siemens Medical Solutions USA, features which do not always Inc. have to be present in individual 40 Liberty Blvd. cases. 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