Toshiba's VISIONS Magazine - issue 26

SEMAR in
Neuroradiology
Rivierenland
Hospital
Lung SURESubtraction
in Everyday Practice
Revolutionize
Tumor Treatment
VISIONSMagazine for Medical & Health Professionals I February 2016
24 I COMPUTED TOMOGRAPHY
10 I MODALITY FUSION
33 I CUSTOMER FOCUS 55 I COMPUTED TOMOGRAPHY
26

VISIONS magazine is a publication of Toshiba Medical Systems Europe (Toshiba) and is offered free of charge to medical and
health professionals. The magazine is published twice a year. Registration to access full, previously published, digital editions
can be done via the web site: www.toshiba-medical.eu/visions. Toshiba stores and uses personal data of the registration to
send out the magazine and inform about new developments in the clinical market. Readers can customize preferences or
opt-out, after registration, in the online VISIONS profile. News items and articles are announced firstly, as pre-publication, via the
dedicated VISIONS LinkedIn Group: https://www.linkedin.com/groups/3698045. In this group you can also actively participate
in discussions about the content and future direction of the magazine. Alternatively you can e-mail us at: VISIONS@tmse.nl.
Follow us also on SlideShare: http://www.slideshare.net/toshibamedical.
Publisher
TOSHIBA Medical Systems Europe B.V.
Zilverstraat 1
NL-2718 RP Zoetermeer
Tel.: +31 79 368 92 22
Fax: +31 79 368 94 44
Web: www.toshiba-medical.eu
Email: info@tmse.nl
Editor-in-chief
Jack Hoogendoorn (jack.hoogendoorn@toshiba-medical.eu)
Modality coordinators and reviewers
CT: Roy Irwan, Chloe Steveson
UL: Jeroen Uijttenhout
Design & Layout
Boerma Reclame (www.boermareclame.com)
Commissioned photography
Cojan van Toor (www.cojanvantoor.nl)
Printmanagement
Het Staat Gedrukt (www.hetstaatgedrukt.nl)
Text contributions
“Customer Focus: Rivierenland Hospital, Tiel”
by The Creative Practice (www.thecreativepractice.com)
Subscription Service
www.toshiba-medical.eu/visions
VISIONS magazine is covering Toshiba’s European region and as such reflects products, technologies and services for this
particular area. The mentioned products may not be available in other geographic regions. Please consult your Toshiba
representative sales office in case of any questions.
© 2016 by TOSHIBA Medical Systems Europe
All rights reserved
ISSN 1617-2876
26
Partnering advanced diagnostic imaging
with minimally invasive intervention is
possibly the most promising future for
radiology and surgery in oncology.
Read more on page 10.
Digital illustration of Cancer cell in colour background”, ID 45675334 © Krishnacreations | Dreamstime.com
www.toshiba-medical.eu ULTRASOUND CT MRI X-RAY SERVICES
Our lives and social environment are subject to constant change and create
ever-increasing needs and high demand for better medical solutions. We at
Toshiba aim to maximize the quality, safety, and efficiency of medical care,
supporting clinical practice with reliable quality products and innovative,
cutting-edge technologies.
The high image resolution and superior operability of our medical systems
creates new clinical value. While our advanced applications, supported by
highly reliable technologies, open the door to the next stage of medical care.
We will continue to provide a wide variety of leading-edge solutions for the
benefit of all people around the world, and seek to further development in the
field of healthcare following our basic commitments: “Improving the quality of
life”, “Lifelong commitment to innovation”, and “Achieving lifetime partnerships”.
Toshiba: Made for Life!
MADE FOR LIFE.

VISIONS26 | 3
We live in an era that is characterized by rapid change. Change in itself is not new, but perpetual, as
Heraclitus (535-475 BC) already observed: Everything changes and nothing remains still ...You cannot step twice
into the same stream1
However, the pace of change these days is undeniably different. Computing power has doubled every two
years2, while products are becoming smaller and smarter. Our vision and interests are no longer limited to
our immediate region, but extend over the entire planet by leveraging communication tools, such as satellite
communications, the Internet and social media. While “one small step for man” on the moon has long been
relegated to history, the next “giant leap for mankind” focuses on human settlement on Mars, and self-propelled
vehicles are almost a reality.
Such acceleration is also seen in high-tech industries, in which the technologies used in today’s products, renew,
improve and merge continuously at a rapid pace. In the medical imaging industry, advanced technologies
enable faster, safer and more extensive completion of daily routines and complex work flows. Here, modality
fusion can provide an ever better opportunity for more accurate diagnoses. Toshiba’s ‘intellectual brains’work
‘twenty-four-seven’ on futuristic solutions to progress developments and ensure that what was not visible or
available yesterday, appears as a reality on our horizon today.
Obviously, organizational management is also subject to change in these dynamic conditions. Partnerships,
mergers and acquisitions are realistic options, whereas continuity and other guarantees for the future are
unmistakable key focus areas.
What exact changes the future holds for us are unknown. What I do know is that our unprecedented
commitment, personal attention, customer-centered mentality, specialized skills and knowledge will remain.
These specific qualities are deeply anchored in our corporate culture and employees, and are characteristic and
distinctive of Toshiba as your Dedicated Imaging Specialists.
Kind regards,
Dear reader,
EDITORIAL
Jack Hoogendoorn
Sr. Manager Marketing Communications
Toshiba Medical Systems Europe BV
1 Quoted by Plato in Cratylus, 402a
2 Moore’s Law

©2016 TOSHIBA MEDICAL SYSTEMS4 | VISIONS26
10 Revolutionize Tumor Treatment
18 New frontiers in forensic radiology
22 Bismuth Shields: Are they necessary in 2016?
24 SEMAR in neuroradiology
28 Seeing the unseen
33 Rivierenland Hospital, Tiel
43 Providing New Diagnostic Possibilities in Tanzania
10
28
33
Fused advanced diagnostic
imaging combined with minimally
invasive intervention.
3D SMI enables visualization of the
entire vascular structure in an area of
interest.
The Radiology Department
at Rivierenland Hospital, Tiel,
The Netherlands
CONTENTS
COMPUTED TOMOGRAPHY
CUSTOMER FOCUS
ULTRASOUND
COMPUTED TOMOGRAPHY
ULTRASOUND
COMPUTED TOMOGRAPHY
MODALITY FUSION
CAD, CTA, Adaptive Motion Correction (AMC), Forensics
Tumor treatment, cancer, tumor ablation
Bismuth shields, image quality
Single energy, Metal artefact reduction
SMI, Doppler
Corporate Social Responsibility, Tanzania
VISIONS
SPECIAL
1 cm

VISIONS26 | 5
46
58
51
51
The Aquilion Lightning sets the standard in
the 16-slice class of CT systems with excellent
specifications and modern clinical applications.
Dual Energy technology provides
differentiation of tissues of similar
density and atomic number.
Noninvasive quantification of left ventricular
(LV) contractility is a topical challenge in
modern echocardiography.
Noninvasive quantification of left
ventricular (LV) contractility is a topical
challenge in modern echocardiography.
COMPUTED TOMOGRAPHY
46 Aquilion Lightning: world’s first
16-row low-dose routine scanner
51 Normal values of left ventricle strain using
3D Wall Motion Tracking technology
55 Lung SURESubstraction in Everyday Practice
58 Practical uses of Dual Energy CT
62 Determination of the cerebral perfusion
territories using CT Perfusion imaging
03 Editorial
06 News
09 Message from the President
ULTRASOUND
Left ventricle, strain ratio, 3D wall motion tracking
Routine Radiology, dose reduction, AIDR 3D Enhanced,
78 cm gantry opening
COMPUTED TOMOGRAPHY
COMPUTED TOMOGRAPHY
COMPUTED TOMOGRAPHY
Dual energy
CT Perfusion, perfusion territories, CAD
CTPA, Lungs, Subtraction

NEWS
Olea Medical to join Toshiba Medical
Systems Corporation Group
New edition of the Vantage Titan 3T
FIRST enhances images quality
and lowers dose
Wearvue: a small, light, next genera-
tion wearable work support tool
The acquisition enables Toshiba to accelerate the growth of its
MRI business and offer new clinical added value to healthcare
providers by leveraging Olea’s cutting-edge software technology
for advanced post-processing and image analysis as well as its
broad relationships with the world’s key research institutions and
customers.
Toshiba will also be able to provide multi-modality solutions
by integrating Olea’s post-processing software with “Vitrea”, a
widely known enterprise and scanner-connected workstation
by Vital Images Inc., another subsidiary of Toshiba, to improve
collaboration among experts, consolidate and standardize
workflows and enhance diagnostic confidence.
More information: http://www.olea-medical.com/en
Toshiba has launched the Toshiba 3-tesla MRI system Vantage
Titan™ 3T / iS Edition (iS: intelligent Solution). In order to fully satisfy
the clinical demands, the system incorporates the new gradient
coil system employed in Saturn Gradient, which enables higher
image quality with open-bore MRI systems. It also provides a suite
of advanced applications, achieving robust, efficient, and highly
accurate examinations in the safe and reliable environments.
More information: http://tinyurl.com/o957wvtClinically viable model-based iterative reconstruction is now
a reality with the launch of Toshiba’s FIRST; Forward projected
model-based Iterative Reconstruction SoluTion. FIRST improves
image quality with significant noise reduction while reducing
radiation dose and drastically cuts the time needed for model-
based CT image reconstruction, helping providers make critical
diagnoses and treatment decisions more effectively.
AvailablefortheAquilionONE™FamilyofCTsystems,FIRSTimproves
high-contrast spatial resolution and helps to make exams safer for
patients by providing reduction in dose, meaning customers don’t
need to choose between safety and high quality images.
More information: http://tinyurl.com/hwceylk
“Wearvue”is a next generation wearable device for the B2B market
that will help to achieve a hands-free working environments in
facilities such as factories and logistics centres as well as during
activities like infrastructure maintenance.
Wearvue is worn like a pair of glasses and, at only 50 grams, is
designed to be light and comfortable enough for long periods of
use. The design also achieves a natural appearance that does not
distract nor disturb people during conversations. In use, aToshiba-
developed original optical system projects data, text and colour
images, to the right-hand lens of Wearvue, with a 1:1 aspect ratio.
The optical system secures a wide viewing area and a depth of
field that makes the data easy to see without obscuring the wider
view. Wearvue also includes a personal adjuster for changing the
angle of image projection, ensuring that it can be worn by an
estimated 98% of Japanese adults.

VISIONS26 | 7
NEWS
AMSTERDAM
AMSTERDAM
AMSTERDAM
A
NTTDoCoMoYoyogiBuilding,Tokyo A
Landmarktower,Yokohama B
Asakusatemple,Tokyo C
Tokyotower,Tokyo D
ToshibaHeadquarter,Tokyo E
Odaiba'sstatueofliberty,Tokyo F
FujiSankeiBuilding,Tokyo G
Cosmoclock21,Yokohama H
Ginza'swako,Tokyo I
Tokyoskytree,Tokyo J
ToshibaMedicalSystemsHeadquarter,Tokyo K
ShinjukuCenterBuilding,Tokyo L
B
C
D
E F
G
H
I
J
K
1
2
3
4
5
6
Koningshavenbrug,Rotterdam
OudeKerk,Amsterdam
Vredespaleis,DenHaag
BasiliekvandeH.Nicolaas,Amsterdam
DeMunt,Amsterdam
Hoftoren,DenHaag
Binnenhof,DenHaag
1
2
3
4
5
6
7
7
8
9 10 11 13
Euromast,Rotterdam
HetPaleisopdeDam,Amsterdam
Erasmusbrug,Rotterdam
NEMO,Amsterdam
Domtoren,Utrecht
HotelNewYork,Rotterdam
ToshibaMedicalSystems,Zoetermeer
8
9
10
11
12
13
14
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12
►
Next page is part of the VISIONS Photo Page Series reflecting an eye for
the beauty of our planet, the environment and the direct surroundings
where Toshiba’s systems are installed by Toshiba and its customers. Not
the actual imaging products but photos of sceneries, cities, countries or
other cultural aspects are highlighted on this photo page.
The Photo Page is based upon an idea of Prof. Edwin van Beek.
Every reader of VISIONS can participate and get their picture published.
The submitted content should include: high resolution (300dpi) image,
photo of the hospital and a brief text, name of photographer and Toshiba
system(s) installed. The complete result is shown on the opposite page.
Send your pictures and texts to: jack.hoogendoorn@toshiba-medical.eu,
Subject: Photo Page
Meet us in Tokyo or Amsterdam
It is with great pride thatToshiba announces the new
high tech training facility; theTokyo room.The design
of the Tokyo room is based upon Toshiba’s new view
on learning development.The many technological
features and unique lay-out adds a new dimension
to the training courses, making them even more
valuable than so far. The room is easy recognizable
by a stylish and detailed silhouette of the city’s
skyline. The next room where the skyline-concept
will be applied is the Amsterdam room. Actually a
large area where the usage of state-of-the-art X-ray
systems are taught and demonstrated.
Both skylines include some recognizable and
well known highlights. How good is your ‘skyline-
knowledge’? Do the test!

Ego Vivo/Self-portrait 25 was shown at Lowlands; an
annual three day music and performing arts festival,
held in the Netherlands in August since 1993. Although
the main focus is on music - rock, pop, dance, hip hop
and alternative - Lowlands also offers cinema, (street)
theatre, cabaret, art, science, stand-up comedy, ballet
and literature. Lowlands is attended by around 50,000
visitors, spread over 250 acts and more than ten stages
every year.
Text Source: Wikipedia – Photography: Annick Vroom
Ego Vivo/Self-portrait 25, 2013 Bronze
and Concrete by artist Caspar Berger,
is part of the ongoing Skeleton project,
started in 2012
Caspar Berger: “In the Skeleton project
I want to make tangible what lies beneath
the skin. I have had my entire body
scanned using the Toshiba Aquilion Prime
80-slice CT-scanner to produce, with a 3D
printer, the most accurate possible copy
of my skeleton. I can then make silicone
moulds allowing me to cast copies of my
skeleton in bronze, silver and plaster.”
Text Source: Caspar Berger (www.casparberger.nl)
Photography: Bas Uterwijk (www.basuterwijk.com)

VISIONS26 | 9
PRESIDENT’S
MESSAGE
“We are, and
always will be,
committed to
you and your
business”
You may have heard recently that Toshiba Corporation
is restructuring and seeking a majority shareholder(s) for
Toshiba Medical Systems Corporation, headquartered in
Japan. I would like to use this opportunity to reaffirm our
commitment to you and the continuation of our services
and support you have come to rely upon.
Toshiba is undertaking this step to strengthen the
financial resources dedicated towards realising our
company’s medical growth strategies. It is a decision
based on careful and thorough consideration. We have
been contributing to the medical industry by providing
innovative and advanced products, solutions and services
to our customers world-wide for over 100 years. However,
today’s industry is growing and changing rapidly.
Despite the fact that Toshiba Corporation has invested
significantly over the years in healthcare, in order us to
reach our full future potential, continued investment is
required, particularly in the areas such as research and
development and mergers and acquisitions.
Inviting outside investments in the business by majority
shareholder(s) will allow us to make timely strategic
investments that would lead to higher growth. We see
Toshiba Corporation’s recent decision as a positive one
for our future to continue setting high value on customer
satisfaction and providing advanced products and
solutions including service and maintenance support in
ways that demonstrate our commitment.
We are expecting to continue our current activities
and direction focused on strong growth in de medical
imaging market. The sales, marketing, installation,
training, maintenance and service of our products
will continue. Over the mid/long-term we are looking
forward to expanding our business by strengthening
RD, introducing leading-edge technology and adding
new business segments to our portfolio.
I assure you that our commitment and dedication to you
and your business will stay unchanged. I would like to
thank you for your patience and understanding during
this time of transition.
Toshio Takiguchi
President and Chief Executive Officer
Toshiba Medical Systems Corporation

To put it briefly, fusion technique in radiology means
simultaneously using images taken with different modalities
(ultrasound, CT, MRI, PET-CT) and at different times for the
same patient. The images can be matched, and/or in some
cases fused. Our team at Danderyd Hospital uses two types
of fusion techniques to get closer to a desirable and optimal
result. One is fusion of ultrasound with CT or MRI, and
the other is fusion of CT with CT, in 2D and 3D. Toshiba’s
ultrasound system (Aplio 500) and Aquilion ONE CT scanner
are used at Danderyd Hospital both for diagnostic and
intervention purposes.
We work intensely with the development of tumor
diagnostics before and after ablation treatment, and with
developing more precise placement of needles/electrodes
for thermal (MW, RF) and non thermal (IRE) ablation
treatment. We are also working on improving the work
flow surrounding ablation treatments. The results are very
positive and we presented our experiences at a symposium
during a scientific conference held atThe Swedish Society of
Medicine in Stockholm.”
What is the most promising future possibility for radiology and surgery in oncology?
The answer is clear: Partnering advanced diagnostic imaging with minimally invasive
intervention. That is, if you ask radiologist Anastasios Michos, Deputy Department
Head and Method Development Specialist for ablation therapy within the Radiology
Department of Danderyd Hospital, Stockholm, Sweden.
Anastasios Michos 1)
TECHNOLOGY MODALITY FUSION
1) Deputy Department
Head and Method
Development Specialist
for ablation therapy
within the Radiology
Department of
Danderyd Hospital,
Stockholm, Sweden.
”The two fields are directly connected. If advanced
diagnostic imaging and the effort to achieve minimally
invasive intervention are developed in harmony with the
needs of modern healthcare, a real revolution in tumor
treatment will be possible.” Another important parameter
is the cooperation between healthcare representatives,
such as hospital administration, physicians and nurses, and
the medical industry. These parties could - and should -
collaborate, with the joint goal of helping cancer patients
and opening up new paths in cancer diagnostics and
treatment.
At Danderyd Hospital we started a project a few years ago
specifically on the theme “advanced diagnostic imaging
and minimally invasive intervention”, where the main goal
is to develop the techniques for tumor ablation.
Our team, the so called ablation team, consists of
radiologists, surgeons and anesthesiologists as well as
industry representatives, mainly from Toshiba, Vital Images
and Angiodynamics.
Tumor treatment, cancer, tumor ablation
Revolutionize Tumor Treatment
Combining Advanced Diagnostic Imaging
and Minimal Invasive Intervention

Following are some cases where ultrasound fusion was used
to perform diagnostic and/or interventional examinations.
GNEU150013
Kidney Tumor Diagnostics and Kidney Tumor
Ablation Guided by Ultrasound-CT Fusion
Small exophytic kidney tumor. The tumor is localized
with the help of ultrasound-CT fusion technique and
thereafter ultrasound contrast. Image 1 shows the
abnormality loaded with ultrasound contrast medium.
Image 2 shows a corrected match between CT and
ultrasound images. Image 3: The radiofrequency needle
is placed with support from the virtual needle guide
navigation and the tumor is ablated. Image 4: Vitrea
software (ViTAL Images) is used real-time during the
procedure for Fusion and 3D reconstruction of CT
with the needle in place. With the software the tumor
(yellow), kidney (blue) and needle are visible, isolated
Image 3
Image 1
Mr. Anastasios Michos demonstrating fusion technology on
a phantom model
The screen of the Aplio 500 shows the needle position in
both the Ultrasound and CT image
Image 2
Smart Fusion: Correlating different imaging
modalities in real-time, Smart Fusion allows
you to locate difficult lesions faster, to navigate
complex anatomy securely, and to improve your
confidence while carrying out invasive procedures.
For a comprehensive pre- and post-interventional
evaluation Smart Fusion allows you to work in any
ultrasound imaging mode including color Doppler
and contrast-enhanced ultrasound.
Smart Fusion reads 3D DICOM data sets from all major
imaging modalities and shows the corresponding
images contained in real-time adjacent to the live
ultrasound display.
VISIONS26 | 11

Image 6
Image 4
Image 5
Biopsy Guided by Ultrasound-CT Fusion
Lung Biopsy
With the help of ultrasound-CT fusion a small peripheral change of the lung tissue is localized. After contrast-
enhanced ultrasound to identify any necrotic areas a safe lung biopsy can be performed.
from the CT image. Furthermore all images are fused
and a 3D reconstruction is created showing clearly
that the needle is in the desired position relative to the
tumor. Image 5 shows a CT image of the tumor before
treatment and image 6 shows a CT image of the tumor
three months after treatment (an ablation cavity has
appeared that covers the entire tumor).

Small suspected liver change in a patient with colon cancer.
The change is visible on CT but not on ultrasound. With
the help of ultrasound-CT fusion followed by contrast
ultrasound the change can be localized anatomically (see
green circle, image 1). The change is isoechogenic in the
arterial phase (image 2) and has wash-out in the portal
phase (image 3); therefore a metastasis is strongly suspected.
Small tumorous change in kidney (see green circle on
MRI image) to be ablated. The change is not visible on
ultrasound. With the help of ultrasound-MRI fusion the
change can be localized anatomically (image 1). Through
contrast-enhanced ultrasound it can be visualized (green
circle, image 3). The radiofrequency needle can then be
placed and ablation can be performed.
Tumor Diagnostics With the Help of
Ultrasound-CT/MRI Fusion
Liver Tumor Diagnostics Kidney Tumor Diagnostics
Image 2
Image 3Image 3
Image 2
Image 1 Image 1
GNEU150013 VISIONS26 | 13

Irreversible Electroporation (IRE treatment - Nanoknife)
of Liver Tumor
Atumor,justunderthreecentimeterswide,closetothecranial
part of the gallbladder and in direct contact with the portal
vein (see image 1). To avoid risking damage to blood vessels
and/or gallbladder, the decision is made to use IRE ablation
technique. Seven IRE needles (six around the tumor and one
centrally) are positioned with the help of Toshiba’s Aplio 500
ultrasound system; the distance between the needles should
be somewhere between one and two centimeters. After
needle placement the position is verified using the Aquilion
ONE CT scanner (AIDR 3D)without contrast (see image 2).
Fusion and 3D reconstruction of CT with contrast before
needle placement and CT without contrast with the needles
in place (see images 3-6). Since CT verification after needle
placement (image 2) is done without contrast it cannot give
Image 2
Image 4 Image 6
Image 1 Image 3
Image 5
sufficient information regarding needle position in relation
to the tumor and blood vessels. To solve this problem Vitrea
software (Vital Images) is used live during the procedure.
With the help of this software:
- tumor and liver are isolated from image 1
- needles are isolated from image 2
- all images are fused and a 3D reconstruction is created.
These 3D fused images show that the needles are in a good
position relative to the tumor and blood vessels, albeit
somewhat deep. All needles are backed up a bit and the
treatment is performed.The treatment consists of 90 electric
pulses of 3000 volts between each needle pair, and takes
around half an hour in total.

GNEU150013
Image 1 shows an ultrasound image of the tumor without
contrast before treatment and image 2 shows it after
treatment. Image 3 shows an ultrasound image of the
tumor with contrast after treatment.
Image 1 shows a CT image of the tumor before treatment
(here it can be seen that the tumor is on the portal vein and
is partially compressing it). Image 2 shows a CT image of the
tumor two weeks after IRE treatment (in the tumor location
Image 1
Image 2 Image 3
Image 3Image 2Image 1
an ablation cavity has appeared that covers the entire
tumor; the portal vein is open). Image 3 shows a CT image of
the tumor three months after treatment (the ablation cavity
has shrunk; the portal vein is open).
VISIONS26 | 15

Small liver metastasis which is poorly visualized
with ultrasound. The metastasis can be localized
anatomically with the help of ultrasound-MRI fusion
(see yellow circle). The microwave needle must be
placed carefully since the abnormality is situated deep
in the tissue and there are a few blood vessels along
the way that must be avoided. The virtual needle guide
navigation technique is used to obtain better control
during placement (the green line and the little blue
dot show location of the needle and the needle point
respectively, the purple oval shows the estimated result
of the ablation).
Liver metastasis which is poorly visualized with ultrasound.
The metastasis can be localized anatomically with the help
of ultrasound-MRI fusion (see yellow circle). The microwave
needle must be placed carefully since the abnormality is
situated deep in the tissue (close to the cardia, see pink
circle) and there are a few blood vessels along the way
that must be avoided. The virtual needle guide navigation
technique is used to obtain better control during placement
(the green line and the little blue dot show location of the
needle and needle point respectively). The purple oval
shows the estimated result of the ablation. Image 2 shows
ongoing ablation after correct needle placement.
Liver Tumor Ablation Guided by Ultrasound-CT/MRI Fusion
and Virtual Needle Guide Navigator
Case 1
Case 2
Image 1
Image 2

Get even smarter! Register now for this unique 2-day workshop on Neurological
Imaging with Dynamic Volume CT. The workshop aims to provide a working knowledge
of current 320-row dynamic volume MDCT (Aquilion ONETM
ViSION Edition) for
neurological imaging, covering evaluation of both brain perfusion and dynamic CTA,
as well as cerebrovascular anatomy and pathology. An experienced faculty will guide
you from scan procedures to the implementation of comprehensive image protocols
for diagnosis and management of neurological conditions. In addition, the highly
interactive program allows hands-on interpretation and discussion of clinical case
studies.Afterwards, participants will know how to apply dynamic volume CT for optimal
brain imaging.
09:00 - 09:10 Opening and introduction
09:10 - 09:50 Imaging of ischemic stroke: what is important
and why?
Marianne van Walderveen
09:50 - 10:15 Basic principles of perfusion
Uulke van der Heide
10:15 - 10:45 Coffee
10:45 - 11:15 Brain perfusion scan procedures and analyses
Joost Roelofs
11:15 - 12:00 Comprehensive ischemic stroke protocol: tips and
tricks for the clinical practice
Marianne van Walderveen
12:00 - 12:30 CT technology and radiation dose
Raoul Joemai
12:30 - 14:00 Lunch
14:00 - 14:15 Workstation introduction
Joost Roelofs
14:15 - 17:00 Hands-on workstation with clinical cases,
read with the experts
19:00 - 22:00 Dinner
09:00 - 09:45 Imaging of fistulous intracranial lesions,
what is important and why
Patrick Brouwer
09:45 - 10:05 4D CTA acquisition protocol, how and why?
Joost Roelofs
10:05 - 10:30 4D CTA, technical possibilities, pitfalls and artifacts
Peter Willems
10:30 - 11:00 Coffee
11:00 - 11:20 4D CTA in AVMs
Peter Willems
11:20 - 11:40 4D CTA in dAVF
Peter Willems
11:40 - 12:00 4D CTA in miscellaneous clinical conditions
and future applications
Patrick Brouwer
12:00 - 13:30 Lunch
13:30 - 15:45 Hands-on workstation with clinical cases,
read with the experts
15:45 - 16:00 Course Diploma and Adjourn
First Day Brain Perfusion/Dynamic CTA Second Day 4D CTA
We look forward to welcoming you to Leiden!
Please register at:
http://bit.ly/1ZlWNXj
Neurological Imaging
with Dynamic Volume CT
12 - 13 May 2016

The increased knowledge and improved technology in
Radiology facilitated the use of diagnostic imaging in
forensic settings.
In 1896, thanks to the brilliant idea of a coroner, in court a
radiographic film was used to document the anatomical
location of a bullet wound following a gunshot. Later, in
the wake of this unusual application of diagnostic imag-
ing, the use of radiology in the field of forensics gained
enthusiastic endorsements. In 1984 in Italy, Di Maio
published a handbook on the correct use of diagnostic
imaging in the study of deaths by firearms, in order to
assist and to guide traditional autopsy. A traditional
autopsy provides extensive information for the patholo-
gist, however a radiological ‘pre-autopsy’ may be able to
guide and direct the traditional autopsy. In 1983 the first
post-mortem computed tomography (PMCT) was made.
A PMCT satisfies three fundamental objectives of a post-
mortem examination: the identification of the corpse,
finding any foreign bodies and assessment of the cause
of death1.
In clinical practice the physician determines the diagno-
sis and choice of treatment strategy based on both the
radiological report and a physical medical examination
since Radiology can never completely replace the physi-
cal examination. The same applies to forensics, where a
non-invasive “pre-autopsy” guides coroner in the search
of the main elements that could cause death, but does
not replace the actual physical examination, the autopsy
TECHNOLOGY
CAD, CTA, Adaptive Motion Correction (AMC), Forensics
New frontiers in forensic radiology
Since ancient times people have tried to find answers to the question that always
accompanies man’s life: the way of death. Until recently traditional autopsy was the
only method to identify the cause of death. However, the sense of respect for the
corpse and the fear of desecration represented serious obstacles to the spread of
this practice.
COMPUTED TOMOGRAPHY
1) Department of Radiology,
University of Foggia, Viale
Luigi Pinto 1, 71100 Foggia,
Italy.
2) Department of Forensic
Pathology, University of
Foggia, Colonnello d’Avanzo
Hospital, Viale degli Aviatori
1, 71100 Foggia, Italy.
3) Department of Radiology,
Scientific Institute Hospital
“Casa Sollievo della
Sofferenza”, Viale Cappuccini
1, 71013 San Giovanni
Rotondo, Foggia, Italy.
Gianpaolo Grilli 1) Giulio Zizzo 1), Annagrazia Cecere 1), Cristoforo Pomara 2), Giuseppe Guglielmi 1,3)
Dr. Gianpaolo Grilli
Dr. Giulio Zizzo
Dr. Giuseppe Guglielmi
in this case. This innovative technique was commonly
called “Virtopsy” because it combines two fundamental
aspects in the study of the corpse. In fact, “virtus” reflects
the need to make a useful and efficient investigation and
“autopsy” refers to describe something that you see with
your own eyes. The combination of the two words sug-
gests the radiologist will substitute the subjectivity associ-
ated with the activity of“seeing with their own eyes”with
the execution of an exam that documents impartially the
anatomical lesions responsible of the death.
Compared with conventional autopsy, Virtopsy with
CT has many advantages. First, the traditional autopsy
is interpreted in many cultures (Judaism Islam) as an
attempt to desecrate the corpse and, for this reason, it is
rejected. Additionally, a PMCT is non-invasive, so doesn’t
interfere with the corpse allowing a traditional autopsy to
be performed afterwards with only minimal disruption.
The possibility to give a high dose of radiation permits
a large amount of information to be acquired for further
detailed analysis at a later date after the corpse has been
buried. In contrast, the traditional autopsy doesn’t allow
further study into the cause of death at a later time
because the collection of biological materials can only
occur during the autopsy. PMCT also allows evaluation of
the presence of bodily gas and foreign bodies which are
not possible with a traditional autopsy.
Despite all these indisputable advantages, Virtopsy
doesn’t allow a “color” assessment of anatomic lesions:
such a drawback could be solved with the application of
3D volume rendering (3D VR) techniques. Furthermore, it
doesn’t allow the differentiation of soft tissues, which is
better assessed with magnetic resonance imaging (MRI),
and evaluation of vascular lesions, that would require the
administration of a contrast agent. In view of these con-
siderations, PMCT has most use in cases of identification
of the corpse, multiple trauma, drowning, burns, gunshot
injuries, hanging and documentation of previous injuries.
Deaths from cardiac causes deserve special treatment,
because the main cause of natural death is heart failure.

Figure 1a: Post mortem CT (PMCT) shows soft tissue swelling of right neck
Figure 1b-c: PMCT-angiography (PMCTA) showing the leakage of contrast agent into the trachea
(2b) and the peri-pharyngeal spaces (2c) in multi planar reformats (MPR)
VISIONS26 | 19CTEU1500105
For this reason, it’s very important to differentiate the
cardiac lesions responsible for death from concomitant
injuries which are not sufficient in themselves to cause
death.
The further development of PMCT techniques led to
the introduction of contrast agents to assess vascular
lesions and post mortem CT angiography (PMCTA)2.
The use of contrast agents, permits the complete filling
of the vascular system and helps to identify vascular
lesions and other sources of bleeding causing death.
The standard protocol consists in a non contrast acqui-
sition followed by three acquisitions with contrast. An
imaging finding is considered real when it is present in
at least two of the three post-contrast phases; other-
wise it is interpreted as an artifact. The contrast agent,
consisting of paraffin oil and 6% of Angiofil® (Fumedica
AG, Muri, Switzerland), it is usually injected into the
femoral vessels through the heart-lung machine,
Virtangio® perfusion device (Fumedica AG). The com-
parison between the traditional autopsy and PMCTA
showed a substantially overlap in terms of sensitivity
in the evaluation of the cause of death. In particular,
PMCTA is superior in identifying vascular and skeletal
lesions3. In contrast, the traditional autopsy allows a
better assessment of the morphology of diseases of the
organs. Although PMCTA is an emerging and attractive
technique, the University of Foggia was the only Italian
center to use PMCTA for post-mortem investigation.
Toshiba’s Aquilion™ 64 scanner provided the possibil-
ity to study the body during both the pre- and post-
contrast phases and it confirmed that PMCTA is not
a replacement, but a valuable addition to traditional
autopsy. The use of post-mortem diagnostic imaging,
in fact, may be of great interest in cases of sudden
death in apparently healthy people (Fig. 1 a-c).
1: Fatal hemoptysis and hematemesis in a 38 year old man

Figure 2a: Post mortem CT demonstrates bony and metal-
lic fragments in right temporal lobe. The bullet (cause of
streak artifacts) is embedded on the opposite side.
Figure 2b: VR (Volume rendering) reconstruction in PMCT-
angiography (PMCTA) allows visualization of the Circle of
Willis, abruptly interrupted at the level of the right middle
cerebral artery, along bullet trajectory.
PMCT is very useful in identifying foreign bodies, such as
bullets in murder/suicide cases with firearms. PMCT (Fig.
2a), in fact, allows easy identification of ferromagnetic
objects in the human body; in addition post-contrast
imaging allows identification of vascular lesions respon-
sible for death (Fig. 2b). Another similar example is the
additional information provided in the case of stab inju-
ries (Fig. 3 a-d).
The growing interest of the scientific community towards
this emerging diagnostic post-mortem technique has led
to the establishment of an international research group,
Technical Working Group Post-mortem Angiography
Methods (TWGPAM). The main objective of this research
group is, first of all, to establish a standardized protocol of
performing PMCTA and to encourage proper transmis-
sion of scientific information, through the organization of
annual international workshops.
CONCLUSION
Based on our clinical experience and scientific research
the two types of autopsy, non invasive “Virtopsy” and
traditional invasive, are not overlapping and/or inter-
changeable because both provide important and com-
plementary information. PMCTA should not therefore be
considered an additional examination, but as an essential
element for the complete assessment of the corpse. Also,
it must be emphasized that such investigations should
not be interpreted as an invasion of the coroner’s exper-
tise, but in view of the integration of knowledge of the
coroner and the radiologist.
2: Gunshot suicide of a 54 year old man

References
1 Pomara C, FineschiV, Scalzo G, Guglielmi G.Virtopsy versus digital autopsy:
virtual autopsy. Radiol Med. 2009; 114(8):1367-1382.
2 Grabherr S, Grimm J, Dominguez A, Vanhaebost J, Mangin P. Advances in
post-mortem CT-angiography. Br J Radiol. 2014; 87(1036):20130488.
3 PomaraC,BelloS,GrilliG,GuglielmiG,TurillazziE.Multi-phasepostmortem
CT angiography (MPMCTA): a new axillary approach suitable in fatal
thromboembolism. Radiol Med. 2015; 120(7):670-673.
VISIONS26 | 21
Figure 3a: Post mortem CT (MDCT) shows pleuro-pericar-
dial effusion.
Figure 3c-d: Oblique coronal MPR and VR reconstructions show the leakage of contrast agent through anterior to posterior
wall of the left ventricle, indicating the bullet pathway.
Figure 3b: Arterial phases PMCT-angiography (PMCTA)
demonstrates leakage of contrast agent through the
anterior wall of the left ventricle.
3: Firearm homicide of a 62 year old man
CTEU1500105

At the Turku University Hospital and Imaging Centre of
SouthWest Finland, bismuth shields have been in use for a
number of years. Based on the AAPM Position Statement,
the hospital physicists decided to advise against the
use of bismuth shields for the hospital’s new scanners:
Aquilion ONE™, Aquilion™ PRIME and Aquilion™ LB.
The LB scanner is situated in the radiation therapy depart-
ment and used for treatment simulation and planning
purposes, which makes potential HU shifts unacceptable.
The radiographers were initially reluctant to change their
procedures for the Aquilion ONE and PRIME without clear
evidence that not using the shields would not increase
radiation dose to the patient. To provide clear evidence
we performed some phantom tests.
We aimed to assess the image quality: artefacts, change
in HU values and change in noise in the vicinity of the
shield and further from the shield, in CT scans of the neck
with and without a thyroid bismuth shield.
METHODS
A Rondo anthropomorphic phantom from head to
shoulders was used for the experiments and thermolu-
minescence dosimeters were used to estimate the skin
dose. The testing setup is shown in fig. 1. Fig. 2 shows
the scan range and the exposure modulation from
SUREExposure with PRIME.
Initially, the tests were carried out using Aquilion PRIME
with a clinical head and neck protocol (0.5mm x 80,
120kV, SUREExposure (SD=12.5), 0.5s rotation speed. Scans
were performed with and without the thyroid bismuth
1) Turku Heart Centre,
Turku University
Hospital, Finland
2) The Medical Imaging
Centre of Southwest
Finland, Turku
University Hospital,
Finland
3) Department of
Medical physics, Turku
University Hospital,
Finland
TECHNOLOGY
Bismuth shields, image quality
Jukka Järvinen, Lic. Phil. 1,2,3)
Bismuth Shields: Are they
necessary in 2016?
Jukka Järvinen, Lic. Phil.
CT bismuth shielding is an outgoing tradition in many radiology departments after
the AAPM’s February 2012 Position Statement was published in which they gave three
convincing reasons against their use. The first and foremost reason was that their use
could alter tube current modulation (AEC) resulting in “unpredictable and potentially
unwanted levels of dose and image quality”. It further described, how placing the
shield on the patient before performing the scanogram, causes the AEC to significantly
increase the current in the region of the shield. Likewise, placing the shield after the
scanogram, results in deterioration of image quality as the AEC does not attempt to
compensate for it.The Position Statement cites image artefacts, HU shift and backwards
scattering of radiation as further reasoning against their use.
COMPUTED TOMOGRAPHY
Figure 1: Phantom setup
Figure 2: Scanning area and modulation
shield in place. Images were reconstructed every 3mm
without overlap and AIDR3D Standard was applied to all
reconstructions.

More thorough testing was carried out using the Aquilion
ONE with a routine helical head protocol (0.5mm x 32,
120kV, SUREExposure (SD=2.3), 0.75s rotation speed.
This protocol is a relatively high dose protocol when
compared to the protocol used in the Aquilion PRIME
experiments. We first imaged the phantom without any
shielding and measured the dose from both scanograms
and the helical scan. Then the measurements were
repeated when the thyroid shield was positioned before
the scanograms and again when positioning the shield
after the scanograms. Images were reconstructed every
5mm without overlap and AIDR3D Standard was applied
to all reconstructions.
Regions of interest were placed at fixed distances (25,
50, 75 100mm) from the skin surface on every slice
to measure HU shift and noise levels. Presence of streak
artefacts was determined visually with the workstation as
shown in Fig. 3. The closer the shield was positioned, the
more striking the artifacts became.
RESULTS
In the Aquilion ONE tests, image quality changes were
deemed severe with streaking artefacts, HU shift and
changes in noise levels. Fig. 3 shows how the image
quality changes were evaluated on the CT scanner. The
artifacts were limited to the areas close to the skin surface
and were more severe where the shield was also closer to
the skin surface. Local skin dose saving was again approxi-
mately 30% and positioning the shield after the scano-
gram resulted in 24% less dose compared to positioning
it before the scanogram. Results for the image quality tests
with Aquilion ONE are shown in fig. 4 to 7. The HU shifts
and changes in the noise levels were not limited to the
areas close to the surface, but continue up to 5 cm deeper.
It is important to notice the baseline HU and noise levels
without shielding, which reveal how severe the changes
were in relative terms with changes up to 90 % in noise
levels. The image quality degradation continued in the
areas closer to the jaw where the shielding was very lim-
ited. Beyond the edges of the shield, there was no notice-
able degradation except very close to the surface.
The image quality results from the Aquilion PRIME tests
supported the results with ONE. With PRIME, we meas-
ured local skin dose savings up to 35%, which is similar to
what has been published previously.
CONCLUSION
In conclusion, we do not encourage our radiographers
to utilize bismuth shielding with modern scanners as low
dose protocols are able to achieve similar dose savings
with more uniform image quality. Bismuth shielding
cannot be used for any studies in which quantitative
measurements are to be performed. As such, given the
radiologist’s consent to the acknowledged lower local
Figure 3: Image quality evaluation
Figure 4 Figure 5
Figure 6: Noise levels without a bismuth
shield in a head scan with Aquilion ONE.
Slice 316 marks the top.
Figure 7: Noise levels with a bismuth
shield in a head scan with Aquilion ONE.
Slice 316 marks the top and shield is
positioned from slice 400 to slice 486.
image quality, the Toshiba Aquilion scanners are capable
of producing image quality those experienced with the
shields might expect. However, similar results can be
achieved with low dose protocols utilizing AIDR 3D and
higher noise levels. Developing low dose protocols in a
university hospital is a challenging project, but we are
progressing with it, here in Turku, and can well recom-
mend doing so.
336 356 376 396 416 436 456 476 496
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336 356 376 396 416 436 456 476

1) Army head doctor, head
doctor and department
manager of the. Viii –
radiology department,
Armed Forces Central
Hospital Koblenz
TECHNOLOGY COMPUTED TOMOGRAPHY
Single energy, Metal artefact reduction
SEMAR in neuroradiology
The postoperative monitoring of a brain aneurysm following intervention with a coil
or clip using CT is very difficult to assess due to, amongst others, increased metallic
streak artefact. SEMAR technology can significantly reduce metallic streak artefacts and
improve diagnosis on CT images.
Dr. S. Waldeck 1), Dr. D. Veit
One of the challenges in radiology today is metal
artefacts, such as those caused by neuroradiological or
neurosurgical interventions by clips or coils.
In MR angiography metals may lead to the complete
obliteration of the surrounding area. CT images display
considerable artefacts caused by beam hardening
effects and signal loss when imaging metal objects. The
artefacts not only make visualization of the metal object
difficult but also the adjacent structures. Especially in
neuroradiology, where density differences of a few
Hounsfield units are crucial in order, for example, to
recognize the onset of ischemia, this is an important
limitation. As the use of stents and coils has increased in
recent years, the incidence of metal artefacts causing non-
diagnostic CT scans has increased. Post-interventional
monitoring studies of the most critically ill patients who
have experienced subarachnoid haemorrhage (SAH)
especially for the early recognition of vasospastically
determined ischemia highlight these typical issues and
challenges of imaging.
Therefore, in recent years, Toshiba has intensified its
commitment to reducing the effects of metal artefacts
and to making diagnosis faster and more accurate. In
2005 Toshiba developed Boost 3D technology. The streak
artefacts that occur in the adjacent structures where
there are large differences in density, e.g. with metal
implants, are reduced1. With the introduction of iterative
dose reduction, Adaptive Iterative Dose Reduction in 3D
(AIDR3D)thestreakartefactswerereducedfurther.AIDR3D
operates in both the raw data and the image data spaces2
and has already led to an improvement in image quality.
THIRD GENERATION OF METAL ARTEFACT
REDUCTION: SEMAR
Single Energy Metal Artefact Reduction (SEMAR) is an
innovative new algorithm specifically developed for metal
artefact reduction that works in the raw data and results in
significantly better image quality.
The SEMAR algorithm is complex and contains several
iterative processes. Essentially, the algorithm reconstructs
the original raw data using filtered back-projection. The
metallic components are then identified within the
image and extracted. This extracted data is then forward-
projected to ultimately obtain corrected raw data without
the metallic components. Several iterative and corrective
processes are incorporated to ensure the accuracy of this
corrected raw dataset and to ensure high-quality results.
After this step, the corrected raw data is reconstructed
with AIDR 3D to obtain an image dataset without the
metallic components and the artifacts associated with
them. The previously extracted metallic components are
then added to create the SEMAR images.The final SEMAR
image contains significantly fewer metal artefacts and has
Figure 1a: CCT without SEMAR Figure 1b : CCT with SEMAR

much improved image quality. Thus, the diagnosis of the
metal object as well as the surrounding tissue is made
possible for the first time3.
Volumetric SEMAR is available on the Toshiba Aquilion
ONE CT scanner withVersion 6 software. In neuroradiology
the 16cm coverage of the Aquilion ONE CT has particular
advantages, allowing the whole brain can be scanned in a
single rotation. The patient no longer needs to be moved
during a scan of the whole brain4. This allows isophasic
imaging of the entire head and also dynamic imaging for
the visualization of blood flow and perfusion.
The particular advantages of SEMAR metal artefact
reduction in neuroradiology are presented below using
some clinical examples.
SEMAR – AFTER SUBARACHNOID-HAEMORRHAGE
WITH COILING OF A HAEMORRHAGING ANEURYSM
In the neuroradiological treatment of aneurysms special
coils are used which are made of platinum with silk.
within conventional CT images the coils create severe
Army head doctor Dr Stephan Waldeck (top left) and his team
Figure 1c : angiography before aneurysm coiling Figure 1d : 3D-Vrt after aneurysm coiling
metal artefacts, which make it impossible to assess the
structures adjacent to the aneurysm (Fig. 1a).The adjacent
structures can be visualized with SEMAR, even though
some artefacts remain (Fig. 1b).
In the post-intervention monitoring of most intensive care
patients the clinician wants answers to complex issues
including vasospasm, haemorrhage, ischemia, vessel
rupture in one examination if possible. These sometimes
complex questions can be answered by whole-brain
perfusion in the shortest possible time and with high
levels of detail.
The new SEMAR technology also improves image quality
of the structures surrounding the coiled aneurysm (Figure
1 d). In particular, it was not previously possible to see the
fine detail of the vessels with conventional CT images only
by means of invasive catheter angiography (Fig. 1c).
Thus,thecombinationofwholebrainperfusionandSEMAR
means enormous diagnostic and clinical improvements
providing added value in everyday clinical practice.

SEMAR – APOPLEXY WITH COCHLEA IMPLANT ON
BOTH SIDES
As part of stroke diagnosis, the first, most important
task of the radiologist is to quickly and reliably exclude
bleeding. This is achieved most reliably by native CT.
Additional imformation as to the localization of the vessel
occlusion, the thrombus length or the penumbra/core
mismatch can then be answered by CT angiography
and CT perfusion. The aim of the diagnosis is to give the
patient appropriate treatment, within the therapeutic
time window, as soon as possible.
In the case described below a 54- year-old patient was
admitted with a left-side hemiparesis, but with an unclear
time window (wake-up stroke). To make matters worse,
the patient has cochlear implants (CI) on both sides, so
that there is pronounced metallic streak artefacts making
diagnosis more difficult (Fig. 2a). An alternative MRI
examination was not possible.
In the subsequent CT angiogram, the streak artefacts make
it difficult to accurately localise the vessel occlusion (CTA
Fig. 2b).
A whole brain perfusion scan was then performed
(Fig. 2c) which clearly shows an occlusion of the right
middle cerebral artery in the M2 segment as a cause of
left-sided hemiparesis. Following SEMAR reconstruction
of the CTA and brain perfusion the streak artefacts are
significantly reduced, though not removed entirely,
allowing accurate diagnostic results (comparison image
2b and Fig. 2c).
In addition, the whole brain perfusion images with SEMAR
allow accurate perfusion calculations to be performed
clearly showing the delayed TTP in this case (Fig. 2d).
In summary, metal artefact reduction using SEMAR in stroke
diagnosis in patients with non-removable metal implants
such as cochlear implants provides improved image quality
and more accurate diagnosis.Thus, even under challenging
conditions, haemorrhage, vessel breaches or abnormal
perfusion can generally be diagnosed with certainty.
Figure 2a: CCT native without SEMAR
Figure 2b: CTA helical
Figure 2c: CTA with SEMAR

VISIONS26 | 27
Figure 2d: CT-perfusion with raised ttp right with media obstruction right
Bibliography
1. paul et al: the reduction of image noise and streak artefact in the thoracic
inlet during low dose and ultra-low dose thoracic Ct, phys. med. biol. 55
(2010) 1363-1380
2. matsuki et al: impact of adaptive iterative dose reduction (aiDr) 3D on
low-doseabdominalCt:comparisonwithroutine-doseCtusingfiltered
back projection, acta radiologica 2013; 54: 869-875
3. augusto et al: total hip prosthesis Ct with single-energy projection-
basedmetallicartefactreduction:impactonthevisualizationofspecific
periprosthetic soft tissue structures, skeletal radiol (2014) 43:1237-1246
4. page et al: Comparison of 4 cm z-axis and 16 cm z-axis multidetector Ct
perfusion, eur radiol Doi 10.1007/s00330-009-1688-8
CTEU150106

1) Department of Endoscopy
and Ultrasound,
Kawasaki Medical School,
Okayama, Japan
TECHNOLOGY
SMI, Doppler
Dr. Jiro Hata, M.D., Ph. D 1)
Seeing the Unseen
Dr. Jiro Hata
Superb Micro-Vascular Imaging (SMI) is a novel ultrasound Doppler technique available
only on the Aplio™ Platinum Series. Compared with conventional Doppler methods,
SMI has the advantages of high frame rates, high sensitivity (in particular in vessels with
low velocities), high spatial resolution and low motion artefacts. SMI has clinical value
in the evaluation of neoplastic diseases, inflammatory diseases and other disorders.
SMI is extremely useful in the evaluation of the density and the shape of tumor vessels,
assessment of activity in inflammatory diseases, diagnosis of ischemia or necrosis
and monitoring chemotherapy response. The advantage of SMI over other imaging
modalities is that even in a patient breathing freely, SMI can visualize the minute blood
flow which shows the physiological change due to the respiratory cycle.
ULTRASOUND
With the latest update on SMI, 3D SMI images can be
constructed from 2D images obtained with SMI. 3D SMI
images provide high resolution, three dimensional map-
pings of vascular structures and vessel branching, which
enable more effective and accurate diagnosis, surgical
planning and treatment evaluation.
NEOPLASMS
SMI has demonstrated significant clinical value for evalu-
ating the density and shape of tumor vessels.
Clinical advances and future directions of SMI
Submucosal Tumor (SMT)-like Gall Bladder Cancer
The grayscale images from a 71 year old woman (Fig. 3a)
showed the presence of cholesterol polyps in the gall
bladder. A solid component resembling biliary sludge
was also found (Fig. 3b). Even with a higher frequency
transducer, one cannot confirm whether this was a
malignant tumor as the surface was smooth. The con-
trast enhanced ultrasound with time arrival parametric
imaging (Fig. 3c) revealed rich perfusion inside the solid
component, suggesting the presence of cancer. Also, SMI
Figure 1: 3D SMI image of normal kidney
This looks like a 3D image created by CT angio-graphy,
but it is impossible to delineate each of these small vessels
separately on a CT. The scale on the right side indicates the
high spatial resolution of SMI.
Figure 2: 3D SMI image of normal liver
This shows the fine vascular structure of a normal liver. This
resembles a real specimen taken from the real liver, but it
is impossible to make molds of these tiny vessels because
they are so fragile. 3D SMI enables a delineation of vascular
structure at a specimen level.
1.5 cm 1 cm

VISIONS26 | 29ULEU160047
showed abundant tumor vessels (Fig. 3d).The patient was
diagnosed with gall bladder cancer, which was proven
by pathological examination (Fig. 3e). This was a unique
cancer presentation because it looked like a submucosal
tumor (SMT) but SMI was useful for making the correct
diagnosis.
Gall Bladder Cancer
The following case is another example of gall bladder
cancer.The suspicious area at the bottom of the gall blad-
der was observed in grayscale (Fig. 4a), but the diagnosis
could not be confirmed by the grayscale image alone.
However, the 3D SMI image showed the entire vascularFigure 3: Submucosal tumor (SMT)-like gall bladder cancer
Figure 4: Gall bladder cancer
3a. Grayscale
3d. cSMI
4a. Grayscale
3e. Surgical dissection
4b. 3D SMI
3b. Grayscale with magnification
3c. Contrast enhanced ultrasound
with time arrival parametric imaging

structure inside this tiny tumor (Fig. 4b). Therefore, SMI is
extremely sensitive for delineating tumor vessels and it
can increase diagnostic confidence.
Pancreas Head Cancer
SMI is not only able to detect tumors with increased
vascularity but can detect hypovascular tumors as well,
as demonstrated by this case of pancreatic cancer. On
grayscale (Fig. 5a), the localization or even the presence
of a tumor could not be confirmed. However, with cSMI,
a hypovascular area in the pancreas was visible, strongly
suggesting the presence of pancreatic cancer, which is
commonly found to be hypovascular (Fig. 5b). After fine
needle aspiration, the diagnosis was confirmed by surgi-
cal dissection (Fig. 5c). The distribution of cancer upon
gross examination resembled the shape visualized non-
invasively by SMI.
SMI enables the delineation of normal vascular structures
and hypovascular areas inside the pancreas. In compari-
son, conventional color Doppler is inferior in visualizing
the presence of the hypovascular areas in the pancreas.
Ovarian Cancer
A 33 year-old female presented with complaints of
abdominal fullness. On grayscale, a large cystic tumor
5a. Grayscale
6a. Grayscale
7a. Longitudinal view of the right testis
in grayscale
5b. cSMI
6b. cSMI
7b. cSMI, longitudinal
5c. Surgical dissection
6c. 3D SMI
7c. cSMI, transverse
Figure 5: Pancreas head cancer
Figure 6. Ovarian cancer
Figure 7. Acute epididymitis

VISIONS26 | 31ULEU160047
Figure 8. Traumatic renal injury
Figure 9. Cavernous transformation of the portal vein
8a. Grayscale
9a. Grayscale
8c. CEUS
9c. CEUS
8b. cSMI
9b. cSMI
8d. 3D SMI
9d. 3D SMI

was observed in the abdominal cavity (Fig. 6a). There
were a few solid components inside the cystic area but
it could not be confirmed whether this was a tumor or
sediments caused by infection or hemorrhage. cSMI
clearly showed the rich vascular structure inside this
solid component (Fig. 6b) and 3D SMI enabled a clear
understanding of the entire vascular structure of this
tumor (Fig. 6c). The diagnosis was ovarian cancer, which
was later confirmed by pathological examination of the
resected specimen.
INFLAMMATION
SMI is particularly useful for evaluating disease activity,
including inflammation, because of its high sensitivity to
low velocity blood flow.
Acute Epididymitis
A 12 year-old boy presented with complaints of scrotal
pain. On grayscale, the diagnosis of acute epididymi-
tis was expected because there was swelling of the
epididymis at the patient’s right testis (Fig. 7a). This
suspicion was confirmed by using SMI, which dem-
onstrated hyperemia of the epididymis, representing
severe inflammation (Fig. 7b, 7c). In patients with acute
scrotal pain, the differentiation between testicular tor-
sion and acute epididymitis is very important because
the clinical courses of treatment are different. The diag-
nosis of acute epididymitis can be easily confirmed by
using SMI based on its strong ability to delineate tiny
blood vessels.
OTHER
SMI is effective in the diagnosis of ischemia or necrosis.
Traumatic Renal Injury
A 22 year-old man complained of left flank pain after
badly hitting his left flank. On grayscale (Fig. 8a), there
were some suspicious areas adjacent to his left kidney
but the injury site could not be confirmed. By using cSMI,
an avascular defect was detected (Fig. 8b) and confirmed
by CEUS (Fig. 8c). 3D SMI clearly showed the entire area of
vascular defect (Fig. 8d), which enabled a quick and accu-
rate diagnosis. Appropriate treatment was successfully
performed before the condition of the patient worsened.
Cavernous Transformation of the Portal Vein
On the grayscale images from a 17 year-old boy a por-
tal vein deformity was observed but the abnormality
was not clearly delineated by using conventional color
Doppler due to overpainting (Fig. 9a). cSMI revealed the
portal vein was composed of several small vessels instead
of one portal vein (Fig. 9b). By using monochrome SMI
(mSMI) with a higher frequency transducer (Fig. 9c), tiny
vessels composing the portal vein were delineated. In
addition, 3D SMI (Fig. 9d) clearly showed the cavernous
transformation of the portal vein.
CONCLUSION
There are several options for using ultrasound to evalu-
ate vascular structures. With conventional color Doppler,
large diameter vessels and high velocity blood flow can
be visualized, including display of the flow direction.
SMI can detect low velocity, minute vessels, resulting in
a more accurate and confident diagnosis. With 3D SMI,
the entire vascular structure in an area of interest can be
visualized, potentially allowing more effective surgical
planning and treatment evaluation.
Bring your brochures to life.
Download the Toshiba MedicalAR app for your smartphone
or tablet. Scan any page containing the medicalAR icon and
see it come to life as a movie on your device.
SMI
Toshiba’s innovative SMI technology expands the range of visible blood flow and provides
visualization of low velocity microvascular flow unseen before with ultrasound. SMI’s level
of vascular visualization, combined with high frame rates, advances diagnostic confidence
when evaluating lesions, cysts and tumors, improving patient outcomes and experience.

VISIONSSPECIAL
Customer Focus:
Rivierenland Hospital, Tiel
Making a Difference in a Regional Hospital
Interview with Ed Drooggelman, Head of Diagnostic Imaging, Peter Schelling, Head
of Coordination and John Jansen, Team Leader Medical Instrumentation Service
Interview with Dr. Susanne Tonino - van Boldrik and Dr. Jim Geselschap,
Interventional Radiologists Dr. Maarten Asselman, Cardiologist and key users
of the new diagnostic equipment.
Photo by Sprangers Bouwbedrijf BV
Enhancing Clinical Practice Daily

©2016 TOSHIBA MEDICAL SYSTEMS34 | VISIONSSPECIAL
With 373 beds at its main unit in Tiel, the Rivierenland
Hospital aims to provide high quality, regional healthcare
services across 19 specialisms. When the Hospital came
to replace its CT and X-Ray equipment and expand its
cathlab facilities, specialists and management chose
unanimously for Toshiba.
The Hospital’s previous systems were installed in 2000.
With an anticipated lifetime of around 10-11 years, the
equipment had already outperformed all expectations.
However, Radiology staff at the Hospital considered them
outdated and experienced restrictions in advancing their
Cardiology capabilities, in particular. In 2013, the process
of selection and replacement of these systems began.
A Working Group was established to gather information
from all staff in relevant Departments, and the needs
and preferences of Radiologists, Cardiologists and Key
Users of the eventual new systems, as well as the Medical
Instrumentation Service, were included.
THOROUGH EVALUATION
The specific requirements of all staff, who would work
with the equipment, were evaluated by Ed Drooggelman,
Head of Diagnostic Imaging at the Hospital, who also car-
ried out a detailed assessment of the short- and longer
term implications and the costs. The resultant equip-
ment purchase proposal was approved by Rivierenland’s
Investment Committee and, in turn, it’s Executive Board.
Making a Difference
in a Regional Hospital
The Rivierenland Hospital is a regional hospital located in Tiel, the Netherlands. It plays
an important role in healthcare in the Betuwe area in the province of Gelderland. As
part of a major overhaul of its Radiology Department, the Hospital recently purchased
new Toshiba Aquilion™ Prime CT, Infinix™-i and Ultimax™-i X-Ray systems. Alongside
this, they rebuilt the Radiology rooms, leveraging the specialist expertise of Toshiba.
VISIONS talked to Ed Drooggelman, Head of Diagnostic Imaging, Peter Schelling,
Head of Coordination, and John Jansen,Team Leader Medical Instrumentation Service,
to find out how the project went.
“Combining the specific requests of our Radiologists and
Cardiologists and based on our very positive, past experi-
ence with Toshiba, we made a clear choice for Aquilion
Prime CT, Infinix-i and Ultimax-i X-Ray systems,” said Ed.
“Alongside the specific features of Toshiba’s high quality
products that support improved safety, faster diagnosis
and enhanced clinical capabilities, the excellent service
record was a particularly important factor in our decision.”
With the new systems chosen, the Hospital decided to
also overhaul its Radiology suite to house the new equip-
ment. This required the creation of entirely new rooms.
“Based on our positive
experience we made a
clear choice for Toshiba.” Ed Drooggelman, Head of Diagnostic Imaging

VISIONSSPECIAL | 35
Once again, Radiologists, Cardiologists and Key Users of
the eventual new systems were consulted on every detail
of the new facilities during design.
“Toshiba Technical Service provided a great deal of input
for the design blueprint,” remarked Ed. “The design fea-
tures spacious, wider rooms for easier maneuvering of
equipment and patients’ beds and optimum mobility. A
color coding system for storage facilities was integrated
to provide clear categorization of the storage of accesso-
ries, enhance efficiency and improve the ambiance of the
rooms. The lighting was also specially-designed to create
a light and pleasant working environment.”
Planning for installation of the systems was led by Peter
Schelling, Rivierenland’s Head of Coordination.
“Weekly planning meetings were held. Our objective was
to realize the plans with minimal impact on resident staff
and patients, such as noise and debris. With Toshiba’s
extensive experience in realistic planning, construction
and installation, we were able to develop an intricately
detailed plan and complete all stages of construction
and installation of the new equipment according to the
schedule,”he said.“One very important consideration was
the replacement of these systems without a single day of
downtime. In a small hospital like Rivierenland, additional
systems for use during construction phases or downtime
are simply not available. When it was necessary, Toshiba
even provided an Infinix-i, ensuring temporary cover, and
they were very flexible, often utilizing time out of our
usual work hours to complete the build.”
360 DEGREES OF SAFETY
The redesign of Rivierenland Hospital’s facilities is a
prime example of Toshiba’s holistic commitment to ‘360
Degrees of Safety’ – a campaign that provides compre-
hensive (360 degree) attention to features that ensure
safety for customers and patients in all aspects of system
installation, operation and work flow.
Toshiba’s ‘360 Degrees of Safety’ campaign includes
product features, such as reduced dose and advanced
dose management; safer patient experience through
larger bores, table movement/range, multi-axis posi-
tioned; features that reduce operator error and create a
safer environment for operator through ergonomic user
design and multi-axis positioned. And also services, such
as education and support that contribute to patient, staff
and overall site safety.
ESSENTIAL SERVICE
John Jansen is Rivierenland Hospital’s Team Leader
Medical Instrumentation Service. Keeping essential
equipment fully functional is critical at the Hospital, just
as it is in other regional facilities. John is responsible for
management of 2,000 (650 different types of) devices at
the Hospital, and issues inevitably occur daily. An average
of around 200 devices must be replaced each year due to
expiration of their normal lifetimes. In addition, all medi-
cal devices require regular maintenance at a rate of about
200 devices per year.
“Toshiba provides full
service during working
hours, and often beyond.”
Peter Schelling, Head of Coordination
XREU150022

“Toshiba’s Engineers have been coming here for years and
know their way around,” said John. “They performed the
installation of the new systems independently, almost
entirely as agreed, and required minimal guidance or
cooperation required from our side. They have, of course,
provided explanation of the overall functioning of the sys-
tems, so that we can react on first-line failures. And we will
shortly also receive a full, technical training on all the new
systemsdelivered,sothatwecanmonitoranyfaultsbetter.”
Collaboration with Toshiba’s Engineers and mutual trust
are very important to facilitate John’s role. Clear commu-
nication and definitive arrangements and appointments
determine who does what and when.
“Toshiba provides full service during working hours, and
often beyond,”remarked John.“Direct telephone contact
with a technician is always possible, and we are never
diverted through a switchboard contact, who doesn’t
know anything about the equipment or who to connect
you to. If a Toshiba Engineer is required on site, they can
usually visit the same day, and if parts are required, they
can be delivered within two hours. Toshiba’s Engineers
and our Key Users are highly trained, so everyone is com-
petent in handling any problems with the systems.”
MINIMIZING DOWNTIME
With limited resources, it is essential for Rivierenland
Hospital to avoid downtime of any devices.
“A large part of the failures we can correct ourselves,
or after a brief telephone conversation with a Toshiba
Engineer,” added John. “Even if a part is needed, we can
already start disassembly, so that assembly can begin
immediately, as soon a Toshiba Engineer arrives with the
part. This saves a lot of downtime, often the device can
be in use again after less than an hour, and frequently, it
is not necessary for a Toshiba Engineer to visit us on site.
This benefits everyone.”
BEST FOR PATIENTS AND STAFF
“Our partnership with Toshiba, its high quality systems,
innovative technology, commitment and flexible service
help us to provide the best to our patients and our staff,”
concluded Ed. “We can now expand our contribution to
healthcare in the region.”
Esther van Beverloo, Margret Gubbels and Helen van Rooijen Radiographers, John Jansen, Medical Instrumentation Service,
Dr.Jim Geselschap, interventional radiologist
“Our partnership with Toshiba
help us to provide the best to
our patients and our staff.”

VISIONSSPECIAL | 37XREU150022
Enhancing Clinical Practice Daily
The Rivierenland Hospital has a total of around 1,500 staff and volunteers. Its Radiology
Department comprises 50 staff, including five resident Radiologists supported by a large
team of Radiodiagnostic Technicians. The Cardiology Department also has five resident
Cardiologists supported by technical experts. VISIONS met with Susanne Tonino - van
Boldrik (M.D.), Radiologist, Maarten Asselman (M.D.), Cardiologist, and some of the tech-
nicians (the key users of the diagnostic equipment) to find out how the new Toshiba
Aquilion™ Prime CT, Infinix™-i and Ultimax™-i X-Ray systems benefit their work.
Investing in equipment in the hospitals is generally always
a well-considered process, but making the right choices
in functionality, after service and value is accentuated
even. Shared use of key systems between specialisms
is essential at Rivierenland Hospital, just as it is in many
other regional facilities. The Radiology- and Cardiology
Teams at Rivierenland Hospital were the key consultants,
not only in the decision to purchase the three Toshiba
systems, but also in developing the new rooms to oper-
ate the equipment in. Flexibility and close cooperation
within and between Rivierenland’s specialists, their teams
and Toshiba, has ensured that their individual- and joint
needs have been realized to benefit the widest range of
daily clinical practice.
NEW POSSIBILITIES IN RADIOLOGY
Susanne Tonino - van Boldrik, is one of the five
Radiologists at the Hospital. She has worked at
Rivierenland for seven years and is one of the two
Radiologists on the team, who carry out interventional
vascular procedures, alongside all other radiology func-
tions. Familiar with the quality of Toshiba products and
service, the Radiology Department opted unanimously
for the Toshiba systems. Installing the new Aquilion
Prime, Infinix-i and Ultimax-i has not only upgraded the
clinical capabilities of the Radiology Department, but
motivated the entire team in their daily work.
“It has been an ‘eye-opener’ for us to have a system, like
the Aquilion Prime,” she remarked. “As a small unit, we
have some limitations in the procedures we can carry out.
There are a lot of things we can do here, but rarer cases
have to be referred. With the new CT system, we can
expand our contribution to care. The images that it gives
us bring new opportunities to implement additional
procedures, such as Cardiac-CT and CT-colonography,
which will be introduced here in the near future.”
The major dose reductions achievable with each sys-
tem compared to the Hospital’s previous ones have
Dr.Susanne Tonino, interventional radiologist
“The Aquilion Prime has
been an ‘eye-opener’ for us.”
broadened the scope of examinations. Susanne refers to
examinations for patients with pulmonary embolism, as
an example, and how the reduced dose and flowing angio
from pelvis to toes that is possible with the Infinix-i has
enabled the Department to do more with less contrast.
And while achieving vast improvements in workflow are
not a key priority for the Department, Susanne particu-
larly appreciates the added efficiencies that the systems
bring to her daily work, such as the significant improve-
ment in the speed of obtaining images from the Toshiba
Aquilion Prime on the back station.

ENHANCED MOTIVATION
According to Susanne, one of the biggest gains has been
the motivational effect that the new systems have had on
all who work with them.
“Everyone on our team is very excited about what they
can learn with the new systems. It has brought new
energy and enthusiasm into their work. Of course, new
opportunities can also bring new problems, but the team
thoroughly enjoys challenges, and solving these issues
together is very inspiring for all of us as a unit. In addi-
tion, it stimulates the generation of new ideas. With the
enhanced modalities provided by the systems, and the
benefits of the new examination rooms, it has been a
tremendous boost for us all.”
IMPROVED CAPABILITIES IN CARDIOLOGY
Alongside bringing the option for new possibilities for the
future, the new Aquilion Prime, Infinix-i and Ultimax-i sys-
tems installed have already enabled many improvements
in existing clinical practice in Cardiology. Cardiologist,
Maarten Asselman, joined Rivierenland’s Cardiology
Team three years ago and immediately became involved
in development of Rivierenland’s new Cathlab.
“We are very satisfied with the new systems. They are a
great improvement in comparison with our old systems
and we are already seeing many benefits,” he said. “As
well as better image quality, the advanced digital soft-
ware provides many new opportunities to enhance our
cardiological diagnostics. While we do not carry out coro-
nary interventions here at Rivierenland, procedures, such
as pacemaker implantation, for example, have become
easier, faster and less invasive for patients using the
enhanced imaging provided by the new systems.”
“With a dose reduction of 75% already achieved com-
pared to the Hospital’s previous systems, patient and key
user safety has been drastically improved.”
“The faster gantry movement of the systems and Flat
Panel Detector (FPD) size of 30cm x 30cm in particular
support better cardiological diagnostics,”added Maarten.
“And with increasing prevalence of obesity within the
general population and the incidence of cardiological
conditions associated with this, the ease of maneuver-
ability of larger patients that the systems allow us is a
great advantage.”
“We are already seeing
many benefits to
enhance our cardio-
logical diagnostics.”
Dr. Maarten Asselman, Cardiologist
Dr. Jim Geselschap, Interventional Radiologist

Robert van Drie, Radiographer
RELIABLE SERVICE
One of the most important aspects in the choice for
Maarten was the high quality, fast and reliable service that
Toshiba offers.
TheToshiba systems were also chosen with a view to intro-
ducing Cardiac-CT procedures at the Hospital. With the
Aquilion Prime now operational for a few months, struc-
tural plans to train technicians in Cardiac CT techniques
have been formulated and training will begin later this year.
ENTHUSIASTIC USERS
Radiodiagnostic Technicians, Marga Blommestein, Mariët
van der Klis and Robert van Drie are key users of the new
systems. As well as enhanced diagnostic capabilities, many
practical advantages of the systems are of course particu-
larly beneficial to those who operate the machines daily.
“Ihaveworkedherefor26yearsandhaveseenRiverenland
grow from a very small regional hospital with many limi-
tations to incorporating a strong Radiology Department
with a great many opportunities,” remarked Marga. “The
recent redevelopment, including the introduction of
Toshiba systems has been a milestone in our develop-
ment that has greatly enhanced our capabilities.”
A.G. van Veldhoven, Nurse, M. Stellaard, Radiographer, J.M.C. Willemsen, Radiographer, M.M. Blommestein, Radiographer,
Dr. S. Tonino, interventional radiologist, M.W.H. Gubbels, Radiographer

“Toshiba systems has
been a milestone in
our development.” Marga Blommenstein, Radiographer
Eugenie Koelemeijer (L), Radiographer, J.M.C.Willemsen (R), Radiographer
“Having relocated to this area, I joined Rivierenland 15
years ago from the much larger Nieuwegein Hospital,”
said Mariët. “It has been fantastic to see the develop-
ment of the CT functionality here and now to have the
opportunity to work with the Aquilion Prime. The system
is much better than our previous model. I can scan faster,
the gantry is bigger, it makes less noise, and the func-
tionalities are better. We have an excellent visibility of
patients’ and can maneuver them more easily. The table
goes lower. With the Aquilion’s intuitive tools, our work-
flow can be improved.”
“The Ultimax-i is a faster, very fine system that is far more
user- friendly than our previous one,” remarked Robert
van Drie, who has worked at Rivierenland for 10 years.
“Our training in using the system was thorough, but
paced, so that we could learn at our own tempo, which
brought us extra confidence in using the system.”

Sjoerd Iken, Clinical Applications Specialist X-Ray, Toshiba
Medical Netherlands.
Per February 2016: International Senior Product Manager
(CardioVascular) X-Ray, Toshiba Medical Systems Europe.
EFFECTIVE TRAINING
Training in use of the new systems was given to the key
users by John van Gulik, Toshiba’s Application Specialist
CT, and Sjoerd Iken,Toshiba’s X-Ray Application Specialist
X-Ray. Key users were trained individually using a train-
the-trainer approach - those who attended the training
continually exchange and share the knowledge that
they acquired amongst their colleagues.
TAILOR MADE FACILITIES
In addition, the new examination rooms are designed with
needs of all staff and patients in mind.
“We were consulted on every detail of the new facilities,”
added Robert. “The preparation- and changing rooms
are wider; all rooms have a good width for maneuver-
ing patients’beds that gives far better mobility. And the
color coding optimizes efficiency and also adds to the
pleasantness of working in the room. All in all, it is a
super, well-illuminated room with plenty of space to
move in. Together with the new systems from Toshiba,
it has made our work a great deal more efficient and
enjoyable.”
Through its close and continued collaboration with
Toshiba Medical Systems, the Rivierenland Hospital in
Tiel is better equipped to deliver specialized diagnostics
and patient care.

The people hospital
“The best care for our patients:
Attention, lovely atmosphere,
and excellent service”
The foundation ‘Vrienden van ziekenhuis Rivierenland’ raises money
for projects that make the hospital stay more enjoyable for all patients.
These projects cannot be financed by the regular hospital budgets.
Several projects have already been realized: comfortable waiting
rooms for family of terminally ill patients, new fitness gear for better
revalidation, a beautifull furnished meditation room for prayer or
reflection, and new pleasant big wall posters for the Radiology
departement.
This year we focus on making chemo therapy treatment more
comfortable for cancer patients. Help us, to help them by making a
donation. Together, we make sure that all people feel at home in
hospital Rivierenland.
Additional information:
www.zrt.nl or www.vriendenvanzrt.nl.

VISIONS26 | 43
Iringa, one of Tanzania’s 30 administrative regions, has
a population of over 1.5 million people, which grows
by 1.6% per year. The region, which covers almost
60,000km2, includes the Ruaha National Park, which has
an abundance of wildlife and attracts approximately
7,500 visitors per year. Iringa Regional Hospital is one of
25 regional hospitals in the country. It is a referral center
for six district hospitals in the region and more than
100 other medical facilities. The Hospital has 445 beds.
Admissions commonly include children suffering from
malnutrition, pregnant women with pregnancy related
complications, or complications with childbirth and
infectious diseases.
GROWING CHALLENGES
Dr. Nyakiroto, the Director of Iringa Hospital, described
the immense and growing challenges that it faces.
“The disease burden in our region is very high. It
includes high prevalence of malnutrition and HIV and its
complications. The region also experiences 30% of the
national cases of malaria, with more than 95% of these the
most dangerous form caused by Plasmodium falciparum.
CSR ULTRASOUND
Corporate Social Responsibility, Tanzania
In addition, we see increasing incidence of diabetes and
hypertension. And, because of the vast improvement of
infrastructure in our region in recent years, the incidence
of car accidents has strongly increased. Our hospital lacks
facilities for this. While it has Medical-, Pediatric-, Surgical-,
Orthopedic-, Traumatology-, Obstetric-, Gynecology-,
Ophthalmology-, Dental-, Radiology- and Laboratory
Departments, we have no special Casualty Ward or
Intensive Care,” he said. “We experience immense, daily
challenges in obtaining qualified staff, basic supplies
and equipment and in keeping the latter up-and-
running. And with limited budget, the purchase of new
equipment is mostly impossible.”
REQUEST FOR HELP
A request for ultrasound equipment from the Hospital
was relayed via Cees Stavenuiter, a general practitioner
Providing New Diagnostic
Possibilities in Tanzania
Like many others in developing countries, Iringa Regional Hospital inTanzania faces many
challenges in providing quality health services to the community. Alongside limited and
inconsistent supplies of medicines, laboratory reagents and other hospital supplies, some
essential equipment, such as certain diagnostic systems are lacking.The result is that even
the hospital’s most basic diagnostic capabilities are compromised on a daily basis.Toshiba
recently donated an Aplio XG ultrasound system to the hospital and organized training
in its use and maintenance to staff, supporting their efforts to provide better healthcare.
Entrance Iringa Regional Refferal Hospital, Tanzania
Way to hospital departments
ULEU150046

from Denmark, who visited the facility in 2013 as part of
a regional Corporate Social Responsibility (CSR) program.
Through this, Richard Stavenuiter, Toshiba’s Product
Manager Ultrasound Systems became aware of the
desperate need for support and took action.
“When I first visited Iringa Regional Hospital in 2013,
I was struck by the lack of equipment, and the fact that
much of the Hospital’s existing equipment was broken
and unusable, because they did not have the resources,
personnel, and know-how to repair it,”remarked Cees. ”In all
departments, the healthcare professionals simply did not
have access to the resources that more advanced hospitals,
in developed countries, have by default. Watching these
dedicatedprofessionalsdeliverthebestpossiblehealthcare
under the difficult conditions and observing the ethical
dilemmas that they faced under these circumstances
emphasized the urgency of the question of how we could
help in the best way?”
Particularly indicative of the lack of budget were the
challenges faced by the Radiology Department. The
needs were very basic. The Hospital was entirely lacking
an operational ultrasound system. The existing ultrasound
and X-Ray machines were so old that they were no
longer functional. Mr. Festo, Head of Radiology at the
Hospital experienced even more basic problems, such as
lack of X-Ray films, which was exacerbated by regional
administration. Managing the Radiology facility has
required extreme prioritization and optimizing the use of
equipment and supplies to cope with such issues.
VERSATILE SOLUTION
After thorough consultation with the Hospital and TecMed -
Toshiba’s partner in South-Africa, who is also responsible for
the Tanzania area, Toshiba decided to donate a used Aplio
XG to the Radiology Department, as part of its own Global
CSR Program1.
“We agreed that an Aplio XG ultrasound system with
five transducers would offer optimal service under the
circumstances for a wide variety and many different clinical
applications, including diagnostic imaging for Abdominal,
Vascular, Breast, Cardiac, Obstetric and Gynecology
indications,” said Richard.
Shipment of the system was arranged through a reliable
Danish charity organization, with experience in shipping
donation goods toTanzania.This was vital to ensure that the
equipment arrived safely at the right destination.
“Importantly, we also realized that the Hospital required
support in learning to use and maintain their ‘new’ system,”
added Richard. “So, we organized trainings for specialists in
how to use the Aplio XG correctly and taught the technicians
how to carry out some basic, first-line service. Toshiba
Medical Systems Europe will also provide second-line
support for some years ahead.
Pediatric department
Doctor Trainees - Radiographers Service maintenance training of hospital engineer

VISIONS26 | 45
References
1. http://www.toshiba.co.jp/csr/en/report/download.htm
NEW DIAGNOSTIC POSSIBILITIES
All those involved at the Hospital were deeply grateful to
Toshiba for donation of the Aplio XG ultrasound system,
which opens a world of new diagnostic possibilities for them.
“Health professionals at the Hospital were forced to almost
treat patients‘in the dark’, as working without key diagnostic
equipment meant they often did not definitively know the
cause of patients’ illnesses,” said Richard. Now, the diag-
nostic results can provide a better direction in treatment.
”In addition, the ultrasound system will also eliminate the
need to refer patients to hospitals in Dar Es Salaam - a day’s
travel by car or public transport. A trip that deters many
patients from obtaining the diagnosis that can help them.”
Examinations and treatment for certain groups of patients
and certain conditions require direct payment from patients
in Tanzania. With the Aplio XG ultrasound system, the
Hospital has the opportunity to generate returns that can
be invested in other services. In addition, experts from other
hospitals will come to improve their ultrasound skills with
the Aplio XG, with the specialists at Iringa Regional Hospital
simultaneously benefitting from their expertise.
Toshiba’s professional approach and the support provided in
training with the system, as well as its commitment to follow
up care and service was also highly appreciated. In the past,
other companies have donated equipment to the Hospital,
but with no after care, it has ultimately become unusable.
“Our new Toshiba Aplio XG ultrasound system will be the
heart of the hospital for many years ahead,” said Dr. Francis
Nyabysani, Medical Officer at the Hospital. “Implementing
a support strategy that provides maximal and longer term
benefits to the Iringa Regional Hospital has required a close
collaboration with the Hospital staff,”concluded Richard.“We
hope that the support will provide many years of enhanced
diagnostic capacity for the health professionals there and
enable them to help many more patients, despite the
challenging conditions that they face.”
Hands-on training on the Toshiba Aplio XG ultrasound system
ULEU150046

Aquilion Lightning: world’s first
16-row low-dose routine scanner
16-row CT scanners are a real asset: They are the workhorse CT scanner in the
department and also offer a very good price/quality ratio. Toshiba Medical is setting
the standard in the 16-slice class of CT systems with excellent specifications and
modern clinical applications that are normally only available in high-end CT scanners.
PRODUCT COMPUTED TOMOGRAPHY
Routine Radiology, dose reduction, AIDR 3D Enhanced, 78 cm gantry opening
Aquilion Lightning™: world’s first 16-row
low-dose routine scanner
New applications and clinical added value

THE WORLD’S FIRST AQUILION LIGHTNING LOW-
DOSE CT SCANNER WAS INSTALLED AT THE RIO,
OBERHAUSEN.
Toshiba’s Aquilion Lightning 16-slice CT scanner utilizes
technology developed for high-end CT systems in con-
junction with 0.5mm detector elements, the thinnest in
the industry, and excellent low-contrast resolution. The
Aquilion Lightning also has a suite of clinical applications
to improve workflow for faster, more accurate diagnosis.
78 CM GANTRY OPENING – SCANNING WITHOUT
COMPROMISING
Clinically important features such as the 78 cm gantry
aperture is unique in 16-slice CT scanners. Patients feel
less claustrophobia, and obese patients feel more com-
fortable. Interventions are made easier with increased
space for instruments.
SPECIAL FEATURE: SEMAR METAL ARTEFACT
REDUCTION
Metal artefacts caused by, for example, by dental fillings,
implants or coils have hampered CT imaging in the past
or even made diagnosis impossible. Artifacts caused by
metal can lead to the complete obliteration of the sur-
rounding tissues. Toshiba has developed Single Energy
Metal Artefact Reduction – SEMAR for high-end CT
scanners and this is now also available with the Aquilion
Lightning. SEMAR can be used to reduce the artifacts
caused by metal objects and improve the visualization
For the first time in a 16-row-CT scanner: Images on
the left show significant artifacts from the metallic
hip implant obscuring the adjacent tissue. The SEMAR
images on the right show almost complete removal of
the artifacts providing clear visualization of the metal
implant and surrounding tissue.
“Effective cooperation over a long period.” This picture was presented by Andreas Henneke,
Head of CT Product Division to Dr Behr who has been a Toshiba CT customer for 23 years.
RIO, Oberhausen is in four locations in Oberhausen and has 14
consultants. The new Aquilion Lightning was installed at the
location in Osterfeld, the radiology practice is on the premises
of Marien Hospital enabling the examination of in-patients
and outpatients. The range of services includes the complete
radiological diagnosis using the latest procedures and systems.
of both the metal object and surrounding tissues. SEMAR
can be applied to all body regions improving diagnosis
for orthopaedics, neurological and general radiology
applications allowing confident diagnosis.

NEW PUREVISION DETECTOR: UP TO 40% LOWER DOSE
Radiologists today are pushing CT scanners to perform
more advanced procedures in less time while ensuring
superior patient care and increased patient safety. With
the introduction of PUREViSION technology,Toshiba’s new
CT detector meets these expectations right now.
Breakthrough innovations in manufacturing processes
and data acquisition system (DAS) design have resulted
in a detector with a 40% increase in light output and
minimal electronic noise, making PUREViSION one of
the most efficient detectors commercially available and
still the only detector featuring true 0.5 mm resolution
for high-quality imaging. For routine diagnostic and
therapeutic CT procedures PUREViSION off ers improved
patient safety through a lower radiation dose. And since
patient safety should never be an option, Toshiba’s com-
mitment is to deliver PUREViSION technology across the
entire Aquilion™ CT product range.
Non Contrast Head CT, dose: CTDi: 32 mGy, 51% below the reference value of 65 mGy of the Federal Office for Radiation
Protection for brain and skull CT scans.
Official handover of the Aquilion Lightning CT scanner: (from the left) Andreas Henneke, Head of CT Product Division
at Toshiba Medical Systems Germany; Dr Christoph Behr, RIO oberhausen; Henk Zomer, Senior Manager, Business Unit
CT, Toshiba Medical Systems Europe; Jürgen Faust, Managing Director, Toshiba Medical Systems Germany; Mikel Lips,
Product Manager, Business Unit CT, Toshiba Medical Systems Europe.
Dr Christoph Behr
“We examine many outpatients who are often difficult
to position. The 78 cm gantry opening makes it much
easier to position the patient.”

VISIONS26 | 49
4TH GENERATION OF ITERATIVE DOSE REDUCTION
The new Adaptive Iterative Dose Reduction by Toshiba,
AIDR 3D Enhanced – omnipresent in the new Aquilion
Lightning – is the fourth generation of iterative dose
reduction from Toshiba and once more significantly
improves the image quality and high-contrast resolution.
AIDR 3D works in both the raw and image space and
routinely leads to a dose reduction of up to 75% – in all
patients. The fast reconstruction speed allows AIDR 3D to
be applied to all scans, including trauma CT, where time
is of the essence.
AIDR 3D ENHANCED FULLY AUTOMATIC WITH EACH
PATIENT WITH AIDR 3D
AIDR 3D Enhanced is fully integrated into the automatic
tube current modulation software SUREExposure™ 3D, tak-
ing the guesswork out of optimizing patient dose. With
SUREkV, the lowest kV will be selected based on patient size
and SUREExposure settings for low kVp imaging.
Chest CT with IV contrast, dose: CTDi: 2.7 mGy, 77% below
the reference value of 12 mGy of the Federal Office for
Radiation Protection for chest CT scans.
Sinusitis, dose: CTDi: 1.9 mGy, 79 % below the reference value of 9 mGy of the Federal
Office for Radiation Protection for facial skull/sinusitis CT scans.
Lumbar spine-CT DLP: 371 mGy*cm; 75% below the reference value of the Federal Office for
Radiation Protection (the reference value for a segment is 250 mGy*cm and therefore, 1,500
mGy*cm for the overall examination of the lumbar spine).
CT angiography of the carotid arteries using SURESubtraction,
just 50 ml contrast agent was administered.
CTEU150107
Dr Christoph Behr
“We have been working with Toshiba
CT scanners for 23 years. The Aquilion
Lightning is the sixth Toshiba CT scan-
ner. About 30–40 patients referred
either as in-patients via the institute or
as outpatients are examined each day
with the new CT scanner.”

SUREKV SETS KV AUTOMATICALLY – A LOWER DOSE
AND MORE CONTRAST
For effective dose reduction, it is, also important to opti-
mize the tube voltage (kV) as much as possible. With
SUREKV, the lowest kV will be selected based on patient
size and SUREExposure settings for low kVp imaging.
This reduces the X-ray dose and at the same time,
increases the enhancement of IV contrast in CT
Angiography enabling less IV contrast to be administered
improving patient safety even more.
Dr Christoph Behr
“Our referring colleagues, both within the
hospital and outside were impressed by
our quality and the achieved dose reduc-
tion. Our angiographiess were received
with enthusiasm.”
Angiography of the thoracic aorta, 70 ml contrast agent. Pelvis-leg angiography with fully-automatic bone
removal using SURESubtraction to clearly show the new
collateral vessels in a patient with peripheral arterial
occlusive disease.
Note: dose values references as valid in Germany

Toshiba's VISIONS Magazine - issue 26

Toshiba's VISIONS Magazine - issue 26

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Toshiba's VISIONS Magazine - issue 26