SOMATOM

Instructions for Use – Additional

user information in accordance with
NEMA XR 28-2018

siemens-healthineers.com
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 Legend

CAUTION
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not avoided, could result in minor or moderate injury or material damage.
CAUTION consists of the following elements:
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 Table of contents

1 Introduction 6
1.1 Compatible systems 6
1.2 Applicability 7

2 Computed tomography perfusion 8

2.1 Purpose of CT perfusion studies 8
2.2 Components of a CT brain perfusion study 10
2.3 Body perfusion considerations 10
2.4 Perfusion acquisition types 11
2.5 Scan modes for acquisition of perfusion data 12
2.5.1 SOMATOM Force 12
2.5.2 SOMATOM Drive / SOMATOM Definition Flash 14
2.5.3 SOMATOM Edge Plus / SOMATOM Definition Edge /
SOMATOM Definition AS (128-slice) / Biograph mCT /
Biograph Vision 15
2.5.4 SOMATOM Edge Plus / SOMATOM Definition Edge /
SOMATOM Definition AS (128-slice) — Sliding Gantry
configuration 17
2.5.5 SOMATOM Confidence / SOMATOM Definition AS
(20/40/64-slice) / Biograph mCT / Biograph Vision 18
2.6 Scan parameter effects on dose 19
2.6.1 kV effects on dose 19
2.6.2 mA effects on dose 20
2.6.3 Considerations for peak skin dose 20
2.6.4 Required imaging attributes for perfusion imaging 21
2.6.5 Contrast injection considerations 21
2.6.6 Other considerations and references 22
2.6.7 Recommended reading 23

3 Automatic Exposure Control (AEC) 24

3.1 General information 24
3.2 How AEC works 25
3.2.1 Adaptation to anatomy 25
3.2.2 When to use AEC 26
3.2.3 When NOT to use AEC 26
3.2.4 AEC – effect of AEC control setting 27
3.2.5 AEC – considerations of patient size, shape,
composition, and age 27
3.2.6 AEC – dynamic scanning 28
3.2.7 AEC – how to tell if the dose has changed 28
3.3 Summary 29

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 Table of contents

4 Scan parameter description acc. to AAPM 30

5 Important further reading 32

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 1 Introduction

1 Introduction
These instructions for use are in accordance with NEMA XR 28-2018.

This document provides information about NEMA XR 28-2018, Appendix A, B

and C.

Manufacturer-specific edits or modifications related to the specific product

implementation are complementing this information, where required.

• Any reference to the “manufacturer” shall be construed as referring to

Siemens Healthcare GmbH.

• References to the “user” are addressing you.

For detailed information on the content provided in this document, see

( Page 32 Important further reading).

1.1 Compatible systems

NEMA XR 28-2018, Appendix A, B and C and related manufacturer-specific edits
or modifications apply to the following systems:

• SOMATOM Definition AS

• SOMATOM Definition Edge

• SOMATOM Confidence

• SOMATOM Edge Plus

• SOMATOM Definition Flash

• SOMATOM Drive

• SOMATOM Force

• Biograph mCT

• Biograph Vision

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 1 Introduction

1.2 Applicability
This document is valid only in conjunction with the Instructions for Use of the
corresponding SOMATOM CT system.

WARNING

Not observing the Instructions for Use and the safety information of the
medical device and the equipment!

Injury to the patient or personnel, and damage to the equipment.

◆ Always observe the Instructions for Use of the particular units used.
This includes the labels applied on the equipment as well as the
Instructions for Use documents.
◆ Always use this Instructions for Use document in conjunction with all
Instructions for Use documents provided.
◆ Follow the safety instructions and safety signs.
◆ For references purposes, store the Instructions for Use near
your workplace.

WARNING

Operation of the system, applications, or functionality by non-

trained users!

Injury to the patient or personnel, or damage to the equipment.

◆ Only trained and qualified users, certified in accordance with country-

specific regulations, are authorized to operate the system. For
example, physicians, radiologists, or technologists.

For appropriate training, contact your Representative at

Siemens Healthineers.

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 2 Computed tomography perfusion

2 Computed tomography
perfusion
The following information is in accordance with NEMA XR 28-2018,
Appendix A.

2.1 Purpose of CT perfusion studies

Computed tomography (CT) perfusion studies are used to assess the delivery
and perfusion of blood to an organ and/or its tissues.

Such studies may be valuable for evaluating blood supply to neoplastic and
non-neoplastic tissue (including normal and ischemic tissue). In particular, CT
perfusion imaging allows the evaluation of cerebral ischemia or of the extent
of angiogenesis associated with a tumor.

CT perfusion should be performed only for a valid medical reason and with the
minimum radiation dose necessary to achieve an adequate exam.

The use of perfusion scans in children should be particularly reviewed for

clinical impact and justified. Particular attention should be paid to displayed
CTDIvol when modifying protocols.

CT perfusion imaging relies on the linear relationship between CT attenuation,

expressed in Hounsfield Units (HU) and represented in a particular pixel of
an image, versus the amount of iodinated contrast material perfusing the
corresponding region of tissue attenuating the x-rays.

Dynamic CT scanning enables the calculation of perfusion parameter maps,

e.g., anatomic images where the pixel value represents mean transit
time, blood flow, blood volume, or permeability, depending upon the post-
processing algorithm used.

Scan technique parameters (e.g., kV, mAs) for CT perfusion studies should be
set at values lower than those used for routine diagnostic scanning of the same
anatomical area.

Perfusion imaging involves visualization of temporal changes in iodine

enhancement, rather than resolution of small or subtle anatomical detail.

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 2 Computed tomography perfusion

The post-scan software processing of the data is relatively insensitive to

increased noise levels; hence, perfusion scans do not require the use of the
same radiation levels.

In general, lower kV improves visualization of iodine contrast and consequently

allows use of lower radiation doses.

Lower kV settings are therefore recommended to be used as long as sufficient

image quality for perfusion post-processing can be obtained. Body perfusion
imaging of obese patients, for example, may be an application that requires use
of higher kV values.
Users should carefully review the manufacturer’s reference perfusion
protocols, which reflect the recommended kV, mA, and scan time for a typical
perfusion acquisition.

Additional guidance may be obtained from professional societies, regulatory

agencies, educational textbooks, or peer-reviewed literature. The American
Association of Physicists in Medicine provides a set of reasonable scan protocols
for CT brain perfusion imaging that is freely available to users via its public
webpage. See ( Page 23 Recommended reading).

Because CT perfusion requires specialized post-processing software, a CT

perfusion acquisition should not be performed unless this software is readily
available to the institution.

All users should be trained in both CT perfusion acquisitions

and post-processing and should follow professional society perfusion
practice guidelines.

Before any changes are made to the manufacturer’s reference protocols,

both a radiologist and medical physicist familiar with CT perfusion should
be consulted. Changes in protocol and the reason for the changes should be
communicated to the radiologic technologist. Any changes to the protocols
should be evaluated with respect to the image quality (less than diagnostic
level), temporal sampling, and radiation dose of the manufacturer’s original
reference perfusion protocols.

It is essential that all users understand that CT perfusion images will be much
noisier than images of the same body region acquired for most other diagnostic
purposes and that this level of image quality is sufficient for the calculation of
perfusion parameters.

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 2 Computed tomography perfusion

2.2 Components of a CT brain perfusion study

Assessment of tissue perfusion for stroke includes a diagnostic quality non-
contrast brain exam, an optional CT angiogram of the circle of Willis that may
include the carotid arteries, and a CT perfusion exam. It may also include a post-
contrast CT scan of the brain for assessment of residual lesion enhancement.

In the assessment of tumors, a non-contrast scan for localization of the area of

interest is often done prior to the CT perfusion exam.

In all cases, the CT perfusion exam should have technique factors that are lower
than those used for the other components of the study (e.g. the non-contrast,
post-contrast and angiogram scans). Specific acquisition times for perfusion
exam depend on the post-processing algorithm used, but in all cases the
exam must be performed over a relatively long period of time (typically 40-50
seconds and potentially up to 3 minutes; consult model-specific user manual
and radiologist) in order to measure the time-dependent physiologic process of
blood flow through the brain.

Since the scan location is fixed, the same anatomy is irradiated repeatedly
during this scan time. Scan times are also affected by the concentration,
volume, and rate of delivery of the contrast agent.

The lenses of the eyes are more radiosensitive than the skin. Scanning through
the orbits should be avoided, if possible, by the use of patient positioning
and/or gantry tilting. Consult the medical physicist to ascertain appropriate
deterministic thresholds across the body.

2.3 Body perfusion considerations

Perfusion scanning of the torso, typically referred to as body perfusion CT is not
currently performed as frequently as head perfusion scans.

It is essential to refer to manufacturers’ reference protocols (if provided) and

to involve a radiologist and medical physicist familiar with the principles and
techniques for body CT perfusion imaging, as well as communicate with the
radiologic technologist. Because of the higher attenuation of the torso, body
perfusion scans may require a higher kV than head perfusion scanning.

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 2 Computed tomography perfusion

Again, the image quality obtained should be noisier than most conventional
body CT scans as the post-processing algorithm is able to extract the needed
time attenuation information from the noisy data set. Respiratory motion
is an important consideration in body perfusion CT and methods to limit
diaphragmatic motion during the scan, or realign anatomic regions after
the scan using registration algorithms should be used to minimize errors
introduced from the movement of the tissue of interest during the course of the
perfusion scan.

In the rare event that a body perfusion scan would be performed in a pediatric
patient, sedation in small children may be required.

2.4 Perfusion acquisition types

NeuroPCT scans are performed in a continuous exposure mode, in which the
table does not move and the x-rays are turned on over the entire scan period.
This provides the highest degree of temporal sampling for the brain.

BodyPCT is the equivalent perfusion acquisition mode for lesions for the body,
when the highest temporal sampling is required.

NeuroPCTSeq and BodyPCTSeq are acquisition modes where the table does
not move, and a pause may be inserted. This method can be used to reduce
the dose as long as the temporal sampling rate remains adequate for the post
processing software to be used.

NeuroVPCT and BodyVPCT protocols use the Adaptive 4D Spiral, designed for
perfusion scanning and for extending the coverage of tissue which is obtained
beyond detector width. In both cases the temporal sampling rate is reduced
in comparison with continuous exposure modes where the table remains
stationary, and a pause may be inserted.

You must ensure that the sampling frequency remains adequate for the
post-processing software.

In Adaptive 4D Spiral mode, the scanner emits x-rays continuously while the
table continuously moves back and forth across the prescribed scan range. As
a result, the amount of anatomy that is imaged is increased.

The temporal sampling rate varies based on the acquisition mode selected and
can affect the total dose for the scan.

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 2 Computed tomography perfusion

2.5 Scan modes for acquisition of perfusion data

The temporal sampling rate varies based on the acquisition mode selected and
can affect the total dose for the scan.

The following tables summarize the various scan modes that can be used for
acquisition of perfusion data on the respective system.

Communication of the summary tables should be conveyed by the facility to

the radiologist, qualified medical physicist and radiologic technologist.

The temporal sampling rate should at least be about 1.5 s in order

to adequately measure the first passage of contrast material through
the region.
When using Siemens perfusion software for post-processing, there is no
need to exceed a total scan time of 45 s.

For further information, see ( Page 32 Important further reading).

2.5.1 SOMATOM Force

Scan mode Cover‐ Temporal sam‐ Acquisi‐ Clinical considerations

age [mm] pling rate tion/Dose con‐
siderations

NeuroPCT 57.6 0.5 – 1.0 s Highest temporal sam‐ Can be used for acute
pling for 48 s stroke imaging.
Preferably scan at the level of
the basal ganglia in order to
include those vascular territo‐
ries frequently associated with
acute stroke.

Neuro‐ 57.6 Default 1.5 s Intermittent scanning Can be used for acute
PCTSeq for 48 s stroke imaging.
Cycle time can be var‐ Preferably scan at the level of
ied within the scan. the basal ganglia in order to
include those vascular territo‐
ries frequently associated with
acute stroke.

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 2 Computed tomography perfusion

Scan mode Cover‐ Temporal sam‐ Acquisi‐ Clinical considerations

age [mm] pling rate tion/Dose con‐
siderations

NeuroVPCT 114 – 224 1.5 s Largest coverage Whole brain dynamic imaging
in acute stroke for volumetric
analysis of core infarct, penum‐
bra, and status of collaterals.

BodyPCT 57.6 0.5 – 1.0 s Highest temporal sam‐ Good breath-hold is manda‐
pling for 48 s tory.
The volumetric scanning
BodyVPCT allows covering
whole organs or tumors, which
increases reproducibility in fol‐
low-up scenarios.

Body‐ 57.6 Default 1.5 s Intermittent scanning Good breath-hold is manda‐

PCTSeq for 48 s tory.
Cycle time can be var‐ The volumetric scanning
ied within the scan. BodyVPCT allows covering
whole organs or tumors, which
increases reproducibility in fol‐
low-up scenarios.

BodyVPCT 114 – 224 1.5 s Largest coverage Good breath-hold is manda‐

tory.
The volumetric scanning
BodyVPCT allows covering
whole organs or tumors, which
increases reproducibility in fol‐
low-up scenarios.

HeartVPCT 105 Heart rate depend‐ Good breath-hold is manda‐

ent, typically tory.
2-3 heartbeats
This scan mode allows the eval‐
uation of hemodynamically
significant coronary artery dis‐
ease.

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 2 Computed tomography perfusion

2.5.2 SOMATOM Drive / SOMATOM Definition Flash

Scan mode Cover‐ Temporal sam‐ Acquisi‐ Clinical considerations

age [mm] pling rate tion/Dose con‐
siderations

NeuroPCT 38.4 0.5 – 1.0 s Highest temporal sam‐ Can be used for acute
pling for 40 s stroke imaging.
Preferably scan at the level of
the basal ganglia in order to
include those vascular territo‐
ries frequently associated with
acute stroke.

Neuro‐ 38.4 Default 1.5 s Intermittent scanning Can be used for acute
PCTSeq for 40 s stroke imaging.
Cycle time can be var‐ Preferably scan at the level of
ied within the scan. the basal ganglia in order to
include those vascular territo‐
ries frequently associated with
acute stroke.

NeuroVPCT 100 Default 1.5 s Largest coverage Whole brain dynamic imaging
in acute stroke for volumetric
analysis of core infarct, penum‐
bra, and status of collaterals.

BodyPCT 38.4 0.5 – 1.0 s Highest temporal sam‐ Good breath-hold is manda‐
pling for 40 s tory.
The volumetric scanning
BodyVPCT allows covering
whole organs or tumors, which
increases reproducibility in fol‐
low-up scenarios.

Body‐ 38.4 Default 1.5 s Intermittent scanning Good breath-hold is manda‐

PCTSeq for 40 s tory.
Cycle time can be var‐ The volumetric scanning
ied within the scan. BodyVPCT allows covering
whole organs or tumors, which
increases reproducibility in fol‐
low-up scenarios.

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 2 Computed tomography perfusion

Scan mode Cover‐ Temporal sam‐ Acquisi‐ Clinical considerations

age [mm] pling rate tion/Dose con‐
siderations

BodyVPCT 100 – 150 Default 1.5 s Largest coverage Good breath-hold is manda‐
tory.
The volumetric scanning
BodyVPCT allows covering
whole organs or tumors, which
increases reproducibility in fol‐
low-up scenarios.

HeartVPCT 73 Heart rate depend‐ Good breath-hold is manda‐

ent, typically tory.
2-3 heartbeats
This scan mode allows the eval‐
uation of hemodynamically
significant coronary artery dis‐
ease.

2.5.3 SOMATOM Edge Plus / SOMATOM Definition Edge /

SOMATOM Definition AS (128-slice) / Biograph mCT /
Biograph Vision

Scan mode Cover‐ Temporal sam‐ Acquisi‐ Clinical considerations

age [mm] pling rate tion/Dose con‐
siderations

NeuroPCT 38.4 0.5 – 1.0 s Highest temporal sam‐ Can be used for acute
pling for 40 s stroke imaging.
Preferably scan at the level of
the basal ganglia in order to
include those vascular territo‐
ries frequently associated with
acute stroke.

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 2 Computed tomography perfusion

Scan mode Cover‐ Temporal sam‐ Acquisi‐ Clinical considerations

age [mm] pling rate tion/Dose con‐
siderations

Neuro‐ 38.4 Default 1.5 s Intermittent scanning Can be used for acute
PCTSeq for 40 s stroke imaging.
Cycle time can be var‐ Preferably scan at the level of
ied within the scan. the basal ganglia in order to
include those vascular territo‐
ries frequently associated with
acute stroke.

NeuroVPCT 86 Default 1.5 s Largest coverage Whole brain dynamic imaging

in acute stroke for volumetric
96*
analysis of core infarct, penum‐
100** bra, and status of collaterals.

BodyPCT 38.4 0.5 – 1.0 s Highest temporal sam‐ Good breath-hold is manda‐
pling for 40 s tory.
The volumetric scanning
BodyVPCT allows covering
whole organs or tumors, which
increases reproducibility in fol‐
low-up scenarios.

Body‐ 38.4 Default 1.5 s Intermittent scanning Good breath-hold is manda‐

PCTSeq for 40 s tory.
Cycle time can be var‐ The volumetric scanning
ied within the scan. BodyVPCT allows covering
whole organs or tumors, which
increases reproducibility in fol‐
low-up scenarios.

BodyVPCT 86 – 139 Default 1.5 s Largest coverage Good breath-hold is manda‐

tory.
96 – 144*
The volumetric scanning
100 –
BodyVPCT allows covering
150**
whole organs or tumors, which
increases reproducibility in fol‐
low-up scenarios.
* optionally 0.30 s — ** optionally 0.28 s

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 2 Computed tomography perfusion

2.5.4 SOMATOM Edge Plus / SOMATOM Definition Edge /

SOMATOM Definition AS (128-slice) — Sliding Gantry
configuration

Scan mode Cover‐ Temporal sam‐ Acquisi‐ Clinical considerations

age [mm] pling rate tion/Dose con‐
siderations

NeuroPCT 38.4 0.5 – 1.0 s Highest temporal sam‐ Can be used for acute
pling for 40 s stroke imaging.
Preferably scan at the level of
the basal ganglia in order to
include those vascular territo‐
ries frequently associated with
acute stroke.

Neuro‐ 38.4 Default 1.5 s Intermittent scanning Can be used for acute
PCTSeq for 40 s stroke imaging.
Cycle time can be var‐ Preferably scan at the level of
ied within the scan. the basal ganglia in order to
include those vascular territo‐
ries frequently associated with
acute stroke.

NeuroVPCT 87 Default 1.5 s Largest coverage Whole brain dynamic imaging

in acute stroke for volumetric
96*
analysis of core infarct, penum‐
100** bra, and status of collaterals.

BodyPCT 38.4 1s Highest temporal sam‐ Good breath-hold is manda‐

pling for 40 s tory.
The volumetric scanning
BodyVPCT allows covering
whole organs or tumors, which
increases reproducibility in fol‐
low-up scenarios.

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 2 Computed tomography perfusion

Scan mode Cover‐ Temporal sam‐ Acquisi‐ Clinical considerations

age [mm] pling rate tion/Dose con‐
siderations

Body‐ 38.4 Default 1.5 s Intermittent scanning Good breath-hold is manda‐

PCTSeq for 40 s tory.
Cycle time can be var‐ The volumetric scanning
ied within the scan. BodyVPCT allows covering
whole organs or tumors, which
increases reproducibility in fol‐
low-up scenarios.

BodyVPCT 87 – 151 1.5 s Largest coverage Good breath-hold is manda‐

tory.
96 – 160*
The volumetric scanning
100 –
BodyVPCT allows covering
167**
whole organs or tumors, which
increases reproducibility in fol‐
low-up scenarios.
* optionally 0.30 s ** optionally 0.28 s

2.5.5 SOMATOM Confidence / SOMATOM Definition AS

(20/40/64-slice) / Biograph mCT / Biograph Vision

Scan mode Cover‐ Temporal sam‐ Acquisi‐ Clinical considerations

age [mm] pling rate tion/Dose con‐
siderations

NeuroPCT 19.2 0.5 – 1.0 s Highest temporal sam‐ Can be used for acute
pling for 40 s stroke imaging.
Preferably scan at the level of
the basal ganglia in order to
include those vascular territo‐
ries frequently associated with
acute stroke.

NeuroVPCT 84 1.5 s Largest coverage Whole brain dynamic imaging

in acute stroke for volumetric
(not Sliding 90*
analysis of core infarct, penum‐
Gantry)
bra, and status of collaterals.

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 2 Computed tomography perfusion

Scan mode Cover‐ Temporal sam‐ Acquisi‐ Clinical considerations

age [mm] pling rate tion/Dose con‐
siderations

BodyPCT 19.2 0.5 – 1.0 s Highest temporal sam‐ Good breath-hold is manda‐
pling for 40 s tory.
The volumetric scanning
BodyVPCT allows covering
whole organs or tumors, which
increases reproducibility in fol‐
low-up scenarios.

Body‐ 19.2 Default 1.5 s Intermittent scanning Good breath-hold is manda‐

PCTSeq for 40 s tory.
Cycle time can be var‐ The volumetric scanning
ied; two cycle times BodyVPCT allows covering
can be selected. whole organs or tumors, which
increases reproducibility in fol‐
low-up scenarios.

BodyVPCT 84 1.5 s Largest coverage Good breath-hold is manda‐

tory.
(not Sliding 90*
Gantry) The volumetric scanning
BodyVPCT allows covering
whole organs or tumors, which
increases reproducibility in fol‐
low-up scenarios.
* optionally 0.30 s

2.6 Scan parameter effects on dose

2.6.1 kV effects on dose

The effect on dose from changing kV is non-linear. Holding all other parameters
constant, changing from 80 kV to 120 kV will result in approximately a two- to
four-fold increase in dose.

Consult the applicable section of the user documentation manual for more
details on the effect of kV changes on CTDI.

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 2 Computed tomography perfusion

2.6.2 mA effects on dose

Changing the mA or mAs has a linear effect on dose. Holding all other
parameters constant, doubling the mA or mAs will double the dose.

Note that the effects of kV and mA or mAs on dose are multiplicative. For
example, a three-fold increase in dose that occurs from increasing kV combined
with a two-fold increase in dose from doubling the mA will result in a six-fold
increase in overall dose.

2.6.3 Considerations for peak skin dose

The highest radiation dose accruing acutely at a single site on a patient’s skin,
referred to as the peak skin dose, is an important parameter in assessing risk of
erythema (skin reddening) and epilation (hair loss). The necessity for repeated
scanning of the same location over extended times results in skin doses that
can be higher than those associated with routine CT applications.

Factors that influence these doses include kV, mA, scan time,
perfusion acquisition type, and table movement, if any, during the
perfusion acquisitions.

As with patient dose, lower kV settings are recommended and should be used
as appropriate to achieve diagnostic image quality for perfusion evaluation
with respect to image noise based on body size, region scanned, and
scanner type.

In all cases, users should carefully refer to the Siemens reference perfusion
protocols within the scan protocol document under online instructions
for use to determine appropriate kV, mA, and scan times for typical
perfusion acquisitions.

Additional guidance may be found at professional society and/or regulatory

websites (see ( Page 23 Recommended reading)).

For an overview of all relevant dose and imaging performance data for
your system, see “Dosimetry and imaging performance report” in the System
Owner Manual.

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 2 Computed tomography perfusion

2.6.4 Required imaging attributes for perfusion imaging

The purpose of a CT perfusion series is to assess tissue perfusion and delivery of
blood to the organ and/or tissues of the organ; the acquisition parameters are
different from those needed for routine low contrast CT imaging applications.

The acceptable noise level in CT perfusion is typically higher than that for
acquisitions routinely used in diagnostic imaging.

Automatic exposure control should not be used unless the manufacturer’s

reference perfusion protocol employs it. Protocols should be adjusted
accordingly for patient age and size, injection rate, injection volume, and
exam type (stroke versus tumor evaluation and head versus body).
CT perfusion scans need to acquire data over a sufficiently long duration to
accommodate the transit time associated with the physiological process of the
contrast bolus moving through the vascular system.

The acquisition duration for a stroke study must cover the time from prior to
the arrival of the contrast material bolus through the approach of the venous
signal to baseline. This duration is directly dependent on the volume of contrast
material injected, the rate of injection, and the patient’s cardiac output. If
contrast material volumes or injection rates change from exam to exam, the
scan duration will need to be adjusted accordingly.
The user should consult the perfusion post-processing software manual for
more detailed imaging and CT perfusion information.

2.6.5 Contrast injection considerations

As the iodine concentration of contrast material decreases, contrast
material volume or flow rate may need to be adjusted to deliver the
required enhancement.

Operators should pay close attention to the shape of the bolus, follow the
bolus with saline and utilize an injector capable of delivering the required
injection rates.

The contrast injection rate should be determined by referring to the applicable

section of this user manual, contrast agent labeling, professional guidelines,
and in consultation with a physician.

Special consideration should be given for children due to their smaller size.

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 2 Computed tomography perfusion

2.6.6 Other considerations and references

Due to the necessity of obtaining data over an extended time period in order
to calculate relevant perfusion parameters, repeated scanning of the same
location is required.

As a result, CT perfusion acquisitions produce peak skin doses higher than

those associated with routine diagnostic CT imaging. Deterministic effects
(e.g., tissue reactions such as skin reddening, hair loss) are dose-threshold
phenomena that can appear with peak skin doses > 2 Gy.

As with all CT scanning, the CTDIvol value displayed on the operator console
should always be confirmed prior to the scan.
For CT perfusion without table motion, the value of CTDIvol tends to
overestimate the actual peak skin dose by approximately a factor of two (See
reference to Bauhs, below.). User manuals may contain an informative section
that describes means for conversion of the displayed CTDIvol or dose profile to
an estimated phantom peripheral dose, which may serve as an estimate for
peak skin dose.

A typical CT perfusion study should not result in a console-displayed CTDIvol of

more than 1000 mGy.

Care should be taken and consideration given prior to rescanning a patient

within a short time with a perfusion acquisition over the same anatomy due to
concerns about reaching a cumulative peak skin dose value greater than the
deterministic threshold for skin injury.

Sites should have a QA program for oversight and review of any protocol
changes. As with other scan types, the CTDIvol for a CT perfusion acquisition is
recorded in both the DICOM screen capture and the DICOM CT dose structured
report and should be used for QA follow up for all scanning.

Additional information on CT perfusion may be obtained in the user manuals

for the CT perfusion post-processing software, from the ACR practice guide
for CT perfusion, from the AAPM website that contains reference perfusion
protocols as well as other perfusion related information (please visit FDA
website for documents related to radiation dose quality assurance).

All the reference protocols provided within the software of this system,
including those for CT perfusion, are included in the applications protocol
document supplied with the system. This document provides a concise
description of each scanning series with the protocol, reference technique
factors, and dose information for each.

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 2 Computed tomography perfusion

While the preceding information is specific to perfusion imaging, it is also

relevant for other applications where repeated scans of one section of anatomy
are required (e.g., interventional, kinematic imaging, etc.).

2.6.7 Recommended reading

J. A. Bauhs, T. J. Vrieze, A. N. Primak, M. R. Bruesewitz, and C. H. McCollough,
2008, "CT Dosimetry: Comparison of Measurement Techniques and Devices,"
Radiographics Vol. 28, pp. 245-253.

ACR-ASNR-SPR Practice Guideline for the Performance of Computed

Tomography (CT) Perfusion in Neuroradiologic Imaging at American College of
Radiology website
AAPM CT Scan Protocols website

FDA website on "Radiation Dose Quality Assurance: Questions and Answers"

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 3 Automatic Exposure Control (AEC)

3 Automatic Exposure Control

(AEC)
The following information is in accordance with NEMA XR 28-2018,
Appendix B.

3.1 General information

Patients come in all shapes and sizes. For the purpose of achieving a desirable
image quality with a scan technique that reflects the patient’s size and shape,
there are several approaches employing automatic and manual mA setting
modes of CT operation.

These approaches are designed to adjust the x-ray output of the system
according to the x-ray attenuation presented by a patient’s anatomy. For
example, the patient’s weight or body mass index (BMI) may be used as a guide
to set a fixed mAs for the acquisition. Alternatively, some measure of patient
thickness or girth, such as anterior-posterior (AP) thickness, lateral width, or
patient circumference can be used as a basis to choose an appropriate fixed
mAs value, i.e., a value that yields an image adequate for diagnosis with a
patient dose as low as reasonably achievable.

However, these methods have at least two inherent limitations.

First, as they produce a fixed mAs value, they do not adjust for differences
in body-region thickness and associated variation in x-ray attenuation along
the patient length and/or around the patient circumference. Second, the use
of weight, thickness or circumference is an incomplete surrogate for x-ray
attenuation, which is one of the most relevant physical parameters affecting
image quality and which depends on the elemental composition and density
of human tissue as well as on its shape and thickness.

Automatic Exposure Control (AEC), on the other hand, is designed to adjust the
scanner radiation output to meet a desired, pre-set level of image quality/noise
criterion by empirically assessing the patient’s attenuation and automatically
modulating the mA accordingly. AEC can provide a desired level of image
quality/noise at a lower patient dose than would be possible with a fixed
scanner radiation output.

In general, CT systems may accomplish AEC in two ways:

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 3 Automatic Exposure Control (AEC)

1. Modulating the mA dynamically during scanning in the X-Y and/or Z

dimensions to adapt to variations in the patient’s attenuation.

2. Adjusting the mAs to a fixed value based on measurement and calculation

of the patient’s overall attenuation: the mAs is constant during scanning, but
its value has been quantitatively determined so as to yield an average pre-set
level of image noise.

Most AEC systems operate as described in no. 1, above.

Discussion of AEC hereafter applies to these types of systems, unless

otherwise indicated.

3.2 How AEC works

On the basis of a patient’s attenuation, AEC sets mA values as the x-ray
tube rotates around the patient. The technology uses knowledge about the
scanner’s imaging chain and the measured attenuation of the patient to
appropriately adjust mA values in order to achieve the desired, constant image
noise/quality criterion.

Larger patients typically require scanning at a higher mAs than the mAs used
for smaller patients.

Similarly, thicker projections (e.g., laterally through the shoulders vs. AP

through the shoulders) typically require more mAs to achieve the same
resultant image noise/quality criterion.

Finally, anatomy with greater attenuation (e.g., abdomen or pelvis compared

to the lungs) requires more mAs to achieve the same image noise/
quality criterion.

3.2.1 Adaptation to anatomy

As patient attenuation changes throughout the course of the scan, either
rotationally around the patient or along the length of the patient, AEC is
designed to adjust dynamically the mA for each body part and projection. If
the attenuation does not change, AEC sets the mA at a constant value that
is appropriate for the overall patient thickness, and that achieves the desired
image noise/quality criterion.

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 3 Automatic Exposure Control (AEC)

3.2.2 When to use AEC

AEC technology has the greatest impact when the portion of the patient
being scanned has non-uniform size, shape, or density. In these cases, AEC
adjusts scanner radiation output to the changing anatomy and modulates the
mA in the Z-direction (along the patient) and/or in the XY-direction (around
the patient).

Even though AEC is used, before scanning the operator must still select scan
parameters, including AEC parameters, which provide a desired image noise/
quality criterion.

Scan parameters, including AEC parameters, must be chosen to carefully

balance patient radiation dose and image performance.
Even when the patient’s anatomy has consistent size, shape, and density
throughout the planned scan range, AEC technology chooses the appropriate
exposure settings to achieve the image noise/quality criterion requested by
the user.

When bismuth or other shields are considered for use in the planned scanned
range, consult the system user manual for specific information. Additional
information about the proper use of bismuth shields can be found in the “AAPM
Position Statement on the Use of Bismuth Shielding for the Purpose of Dose
Reduction in CT scanning”, available at aapm.org.

3.2.3 When NOT to use AEC

AEC might not be available for all scanning modes or on all scanners.

When AEC is available, if users do not understand the relationship between AEC
parameters, image noise, and dose, AEC should not be used.

Also, if the patient cannot be centered in the scanner, AEC is not recommended
because the attenuation calculations used for AEC are designed with the
assumption that the patient is centered in the gantry.

Finally, if there is any question, radiologic technologists should always consult

their medical physicists and radiologists to ensure that proper exposure
techniques are used.

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 3 Automatic Exposure Control (AEC)

AEC does not guarantee reduction of radiation doses in all patients

Use of AEC does not always result in dose reduction, especially when compared
to a fixed mA/mAs protocol. For example, when providing the desired image
noise/quality criterion setting for a large patient, AEC might appropriately
increase the scanner radiation output as compared to that for an average-
sized patient.

For most examinations of average-sized or small patients, and for the same
image noise/quality criterion settings, AEC use will result in the same or lower
CTDIvol as that of a fixed mA/mAs protocol. (However, a larger patient would
appropriately require more fixed mA than for a smaller patient.)

Radiologic technologists must be fully aware that proper patient centering is

critical for accurate AEC function.

Improper patient centering can result in an exposure that is either too high
or too low to achieve the desired image noise/quality criterion.

Note that proper patient centering can be more challenging for smaller
pediatric patients, and so special care should be taken.

3.2.4 AEC – effect of AEC control setting

For a given patient, changing the image noise/quality criterion setting in AEC
will affect the patient dose: asking for lower image noise/higher image quality
criterion will result in more dose to the patient (e.g. increasing the ‘Quality ref.
mAs’ value).

In contrast, asking for higher image noise/lower image quality criterion (e.g.
decreasing the ‘Quality ref. mAs’ value) will result in less dose to the patient.

3.2.5 AEC – considerations of patient size, shape,

composition, and age
For a given AEC image noise/quality criterion setting, larger patients and more
attenuating body regions may result in a higher scanner radiation output.

Smaller patients and less attenuating body regions may result in a lower
scanner radiation output.

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 3 Automatic Exposure Control (AEC)

While AEC can be an effective dose-reduction tool for pediatric patients, special
care should be taken with this patient group.

3.2.6 AEC – dynamic scanning

When a scanning protocol contains multiple x-ray tube rotations at the same
table location, such as perfusion or interventional CT, the effect on patient
dose of incorrect selection of protocol settings will be multiplied by the number
of rotations.

For such protocols, operators must take extra care when setting manual mAs
or AEC parameters to achieve the desired level of image noise/quality criterion.
For example, in perfusion scanning, the image noise can often be much
higher (yielding a lower dose) than for routine diagnostic scanning of the
same region because the primary application of perfusion-scan data is for
quantitative analysis and characterization of perfusion parameters rather than
for diagnostic visualization.

The manufacturer’s reference protocol provides an indication as to whether use

of AEC is or is not recommended with these scan modes.

3.2.7 AEC – how to tell if the dose has changed

For every patient, and any time AEC settings are changed, in order to confirm
a correct level of scanner radiation output for that patient’s size and exam
protocol, users should examine the predicted CTDIvol and DLP displayed prior to
performing the scan, as a step in operator confirmation of system settings.

When a large patient is scanned at a particular setting of image noise/quality

criterion, the CTDIvol and DLP will be higher than for a smaller patient at the
same AEC settings.

Predicted CTDIvol and DLP values are displayed on the scanner’s dose display on
the user interface prior to confirmation of settings for scanning.

After scanning, the values are updated to reflect the average of the actual
mAs values used in the scan and are displayed on the user interface as well as
recorded in the DICOM radiation dose structured report.

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 3 Automatic Exposure Control (AEC)

3.3 Summary
AEC is a versatile and powerful tool designed to tailor the scanner’s radiation
output to each patient based on the patient’s size, age, shape and attenuation
and the user’s requested level of image noise/quality criterion.

AEC technology uses measured patient attenuation values to adjust the

mA dynamically in order to achieve the requested level of image noise/
quality criterion.

However, AEC settings must be chosen with the same care used to choose
all other parameters that affect radiation dose to the patient. Before the scan
parameters are confirmed, careful attention must be paid to CTDIvol and DLP
displayed on the user interface; scanner radiation output associated with the
prescribed protocol must be checked and confirmed prior to scanning.

Used properly, AEC is a key technology to help ensure that the appropriate
radiation dose is used for every patient.

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 4 Scan parameter description acc. to AAPM

4 Scan parameter description

acc. to AAPM
The following information is in accordance with NEMA XR 28-2018,
Appendix C.

Corresponding generic naming of Siemens scan parameters are included in the

scan protocol list of the AAPM CT Lexicon, version 2, 2022-03-08.
In the table below, only names are listed for which an applicable AAPM
(American Association of Physicists in Medicine) description exists.

Siemens name AAPM description

Topogram CT localizer radiograph (i.e. the scanned projec‐

tion radiograph, often acquired by the CT system
to allow the user to prescribe the start and end
locations of the scan range)

Sequence Axial scan mode: Data acquisition while the

patient table remains stationary; the table posi‐
tion may be incremented between x-ray expo‐
sures to collect data over a longer z axis range

Spiral Helical or Spiral scan mode: Data acquisition

while the patient table is continuously moving
along the z axis

Dynamic (continuous) Dynamic scan mode - single detector width:

or Serio (intermittent); Data acquisition at multiple time points over the
same anatomic location(s) while the patient table
scan mode name: Dyn‐
remains stationary; x-ray exposure can be contin‐
Multi or DynSerio
uous or intermittent

Adaptive 4D Spiral; Dynamic scan mode - multiple detector widths:

Data acquisition at multiple time points over the
scan mode name:
same anatomic location(s) while the patient table
DynMulti4D or Dyn‐
cycles back and forth between designated start
Serio4D (ECG trig‐
and end locations in order to get an image of a
gered)
region wider than the detector

Model dependent: Interventional CT - Intermittent x-ray expo‐

Biopsy or Intervention sures
(i-Sequence/i-Spiral)

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 4 Scan parameter description acc. to AAPM

Siemens name AAPM description

Model dependent: Interventional CT - Continuous x-ray exposures

CARE Vision or Inter‐
vention (i-Fluoro)

Test Bolus Test Bolus: Scan mode used to measure the

contrast transit time using a small injection of
contrast media

CARE Dose Angular tube current modulation

CARE Dose 4D Angular and longitudinal tube current modula‐

tion

kV Tube potential: The electric potential applied

across an x-ray tube to accelerate electrons
towards a target material, expressed in units of
kilovolts (kV)

Quality reference mAs Image quality reference parameter for AEC

Reference kV

Detector Configuration Detector configuration

or Aqu (Acquisition) on
Exam Card

Slice (mm) Nominal width of reconstructed image along the

z axis

Table Feed (mm/rot)* Table feed per 360 degree rotation of the x-ray
tube (helical scan mode)

Pitch Pitch: Unitless parameter used to describe the

table travel during helical CT; equal to table travel
(mm) per gantry rotation ÷ total nominal beam
width (mm)

Position increment Distance between two consecutive recon‐

structed images

Kernel Reconstruction property that determines sharp‐

ness or smoothness of image in the axial plane

* Cannot be directly modified on the user interface. Value is calculated/

determined by other settings.

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 5 Important further reading

5 Important further reading

You can find further detailed information in the reading material below:

• For an overview of all relevant dose and imaging performance data for your
system, see “Dosimetry and imaging performance report” in the System
Owner Manual.

• For information on Automatic Exposure Control (AEC), see “CARE Dose4D” in

the Instructions for Use.

• Using the Scan Protocol Assistant on your system, you can have all scan
protocols listed in an overview window. You can also export this scan
protocol list.

See “Listing scan protocols” in the Online Help at the workplace.

For an overview of all available scan protocols including their relevant

parameters on your system, you can search the Online Help at the workplace
after selecting Help > Help.

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Caution: Federal law restricts this device to sale by or on is not our intention to exclude anyone. We continue to
the order of a physician, dentist, or veterinarian (21 CFR update our documentation with this in mind.
801.109(b)(1)).
The original language of this document is English.
Gender inclusivity: At Siemens Healthineers, we want to
address all genders equally in our Instructions for Use. It

Siemens Healthineers Manufacturer

Headquarters Siemens Healthcare GmbH
Siemens Healthcare GmbH Henkestr. 127
Henkestr. 127 91052 Erlangen
91052 Erlangen Germany
Germany
Phone: +49 9131 84-0
siemens-healthineers.com

Published by Siemens Healthcare GmbH / Print No. C2-SW.640.06.02.24 / © Siemens Healthcare GmbH, 2019 - 2023
Date of first issue: 2019-05 / Revision date: 2023-03