Stefan Ulzheimer

Mayo Clinic - Rochester, Rochester, Minnesota, United States

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Publications (27)104.07 Total impact

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    ABSTRACT: To evaluate the image quality and diagnostic accuracy of very low-dose computed tomography (CT) angiography (CTA) for the evaluation of coronary artery stenosis.
    European Heart Journal – Cardiovascular Imaging 06/2014; · 2.39 Impact Factor
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    ABSTRACT: Computed tomography (CT) accounts for more than half of the total radiation exposure from medical procedures, which makes dose reduction in CT an effective means of reducing radiation exposure. We analysed the dose reduction that can be achieved with a new CT scanner [Somatom Edge (E)] that incorporates new developments in hardware (detector) and software (iterative reconstruction). We compared weighted volume CT dose index (CTDIvol) and dose length product (DLP) values of 25 consecutive patients studied with non-enhanced standard brain CT with the new scanner and with two previous models each, a 64-slice 64-row multi-detector CT (MDCT) scanner with 64 rows (S64) and a 16-slice 16-row MDCT scanner with 16 rows (S16). We analysed signal-to-noise and contrast-to-noise ratios in images from the three scanners and performed a quality rating by three neuroradiologists to analyse whether dose reduction techniques still yield sufficient diagnostic quality. CTDIVol of scanner E was 41.5 and 36.4 % less than the values of scanners S16 and S64, respectively; the DLP values were 40 and 38.3 % less. All differences were statistically significant (p < 0.0001). Signal-to-noise and contrast-to-noise ratios were best in S64; these differences also reached statistical significance. Image analysis, however, showed "non-inferiority" of scanner E regarding image quality. The first experience with the new scanner shows that new dose reduction techniques allow for up to 40 % dose reduction while still maintaining image quality at a diagnostically usable level.
    Clinical neuroradiology. 01/2014;
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    ABSTRACT: To compare the computed tomography (CT) dose and image quality with the filtered back projection against the iterative reconstruction and CT with a minimal electronic noise detector. A lung phantom (Chest Phantom N1 by Kyoto Kagaku) was scanned with 3 different CT scanners: the Somatom Sensation, the Definition Flash and the Definition Edge (all from Siemens, Erlangen, Germany). The scan parameters were identical to the Siemens presetting for THORAX ROUTINE (scan length 35 cm and FOV 33 cm). Nine different exposition levels were examined (reference mAs/peek voltage): 100/120, 100/100, 100/80, 50/120, 50/100, 50/80, 25/120, 25/100 and 25 mAs/80 kVp. Images from the SOMATOM Sensation were reconstructed using classic filtered back projection. Iterative reconstruction (SAFIRE, level 3) was performed for the two other scanners. A Stellar detector was used with the Somatom Definition Edge. The CT doses were represented by the dose length products (DLPs) (mGycm) provided by the scanners. Signal, contrast, noise and subjective image quality were recorded by two different radiologists with 10 and 3 years of experience in chest CT radiology. To determine the average dose reduction between two scanners, the integral of the dose difference was calculated from the lowest to the highest noise level. When using iterative reconstruction (IR) instead of filtered back projection (FBP), the average dose reduction was 30%, 52% and 80% for bone, soft tissue and air, respectively, for the same image quality (P < 0.0001). The recently introduced Stellar detector (Sd) lowered the radiation dose by an additional 27%, 54% and 70% for bone, soft tissue and air, respectively (P < 0.0001). The benefit of dose reduction was larger at lower dose levels. With the same radiation dose, an average of 34% (22%-37%) and 25% (13%-46%) more contrast to noise was achieved by changing from FBP to IR and from IR to Sd, respectively. For the same contrast to noise level, an average of 59% (46%-71%) and 51% (38%-68%) dose reduction was produced for IR and Sd, respectively. For the same subjective image quality, the dose could be reduced by 25% (2%-42%) and 44% (33%-54%) using IR and Sd, respectively. This study showed an average dose reduction between 27% and 70% for the new Stellar detector, which is equivalent to using IR instead of FBP.
    World journal of radiology. 11/2013; 5(11):421-429.
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    ABSTRACT: OBJECTIVES: To evaluate the image quality and diagnostic accuracy of very low-dose, dual-source computed tomography (DSCT) angiography for the evaluation of coronary stents. BACKGROUND: Iterative reconstruction (IR) leads to substantial reduction of image noise and hence permits the use of very low-dose data acquisition protocols in coronary computed tomography angiography. METHODS: Fifty symptomatic patients with 87 coronary stents (mean ± SD diameter 3.0 ± 0.4 mm) underwent coronary DSCT angiography (heart rate, 60 ± 6 beats/min; prospectively electrocardiography-triggered axial acquisition; 80 kV, 165 mA, 2 × 128 × 0.6-mm collimation; 60 ml of contrast at 6 ml/s) before invasive coronary angiography. DSCT images were reconstructed using both standard filtered back projection and a raw data-based IR algorithm (SAFIRE, Siemens Healthcare, Forchheim, Germany). Subjective image quality (4-point scale from 0 [nondiagnostic] to 3 [excellent image quality]), image noise, contrast-to-noise ratio as well as the presence of in-stent stenosis >50% were independently determined by 2 observers. RESULTS: The median dose-length product was 23.0 (22.0; 23.0) mGy·cm (median estimated effective dose of 0.32 [0.31; 0.32] mSv). IR led to significantly improved image quality compared with filtered back projection (image quality score, 1.8 ± 0.6 vs. 1.5 ± 0.5, p < 0.05; image noise, 70 Hounsfield units [62; 80 Hounsfield units] vs. 96 Hounsfield units [82; 113 Hounsfield units], p < 0.001; contrast-to-noise ratio, 11.0 [9.6; 12.4] vs. 8.0 [6.2; 9.3], p < 0.001). To detect significant coronary stenosis in filtered back projection reconstructions, the sensitivity, specificity, positive predictive value, and negative predictive value were 97% (32/33), 53% (9/17), 80% (32/40), and 90% (9/10) per patient, respectively; 89% (43/48), 79% (120/152), 57% (42/74), and 96% (121/126) per vessel, respectively; and 85% (12/14), 69% (51/73), 32% (11/34), and 96% (51/53) per stent, respectively. In reconstructions obtained by IR, the corresponding values were 100% (33/33), 65% (11/17), 85% (33/39), and 100% (11/11) per patient, respectively; 96% (46/48), 84% (129/152), 66% (47/71), and 98% (127/129) per vessel, respectively; and 100% (14/14), 75% (55/73), 44% (14/32), and 100% (55/55) per stent, respectively. These differences were not significant. CONCLUSIONS: In selected patients, prospectively electrocardiography-triggered image acquisition with 80-kV tube voltage and low current in combination with IR permits the evaluation of patients with implanted coronary artery stents with reasonable diagnostic accuracy at very low radiation exposure.
    JACC. Cardiovascular imaging 03/2013; · 14.29 Impact Factor
  • Stefan Ulzheimer, Heidrun Endt, Thomas Flohr
    Health physics 03/2011; 100(3):325-8. · 0.92 Impact Factor
  • Stefan Ulzheimer, Thomas Flohr
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    ABSTRACT: Since its introduction in the early 1970s, computed tomography (CT) has undergone tremendous improvements in terms of technology, performance and clinical applications. Based on the historic evolution of CT and basic CT physics, this chapter describes the status quo of the technology and tries to anticipate future developments. Besides the description of key components of CT systems, a special focus is placed on breakthrough developments, such as multi-slice CT and dedicated scan modes for cardiac imaging.
    12/2008: pages 3-23;
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    ABSTRACT: This work assesses the temporal resolution of dual-source computed tomography (CT) in a visually intuitive manner. Exploiting the principles of ring artifact creation, a phantom containing a highly attenuating delta function signal (a wire) was rotated at the same speed as the gantry, creating a partial ring artifact where the angular extent of the artifact provides a direct indication of the temporal resolution. A demonstration of the effect of the evaluated 165 and 83 ms nominal temporal resolutions on motion artifacts in cardiac CT is provided using patient data.
    Medical Physics 03/2008; 35(2):764-8. · 2.91 Impact Factor
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    ABSTRACT: To develop a consensus standard for quantification of coronary artery calcium (CAC). A standard for CAC quantification was developed by a multi-institutional, multimanufacturer international consortium of cardiac radiologists, medical physicists, and industry representatives. This report specifically describes the standardization of scan acquisition and reconstruction parameters, the use of patient size-specific tube current values to achieve a prescribed image noise, and the use of the calcium mass score to eliminate scanner- and patient size-based variations. An anthropomorphic phantom containing calibration inserts and additional phantom rings were used to simulate small, medium-size, and large patients. The three phantoms were scanned by using the recommended protocols for various computed tomography (CT) systems to determine the calibration factors that relate measured CT numbers to calcium hydroxyapatite density and to determine the tube current values that yield comparable noise values. Calculation of the calcium mass score was standardized, and the variance in Agatston, volume, and mass scores was compared among CT systems. Use of the recommended scanning parameters resulted in similar noise for small, medium-size, and large phantoms with all multi-detector row CT scanners. Volume scores had greater interscanner variance than did Agatston and calcium mass scores. Use of a fixed calcium hydroxyapatite density threshold (100 mg/cm(3)), as compared with use of a fixed CT number threshold (130 HU), reduced interscanner variability in Agatston and calcium mass scores. With use of a density segmentation threshold, the calcium mass score had the smallest variance as a function of patient size. Standardized quantification of CAC yielded comparable image noise, spatial resolution, and mass scores among different patient sizes and different CT systems and facilitated reduced radiation dose for small and medium-size patients.
    Radiology 06/2007; 243(2):527-38. · 6.34 Impact Factor
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    ABSTRACT: We present a theoretical overview and a performance evaluation of a novel z-sampling technique for multidetector row CT (MDCT), relying on a periodic motion of the focal spot in the longitudinal direction (z-flying focal spot) to double the number of simultaneously acquired slices. The z-flying focal spot technique has been implemented in a recently introduced MDCT scanner. Using 32 x 0.6 mm collimation, this scanner acquires 64 overlapping 0.6 mm slices per rotation in its spiral (helical) mode of operation, with the goal of improved longitudinal resolution and reduction of spiral artifacts. The longitudinal sampling distance at isocenter is 0.3 mm. We discuss in detail the impact of the z-flying focal spot technique on image reconstruction. We present measurements of spiral slice sensitivity profiles (SSPs) and of longitudinal resolution, both in the isocenter and off-center. We evaluate the pitch dependence of the image noise measured in a centered 20 cm water phantom. To investigate spiral image quality we present images of an anthropomorphic thorax phantom and patient scans. The full width at half maximum (FWHM) of the spiral SSPs shows only minor variations as a function of the pitch, measured values differ by less than 0.15 mm from the nominal values 0.6, 0.75, 1, 1.5, and 2 mm. The measured FWHM of the smallest slice ranges between 0.66 and 0.68 mm at isocenter, except for pitch 0.55 (0.72 mm). In a centered z-resolution phantom, bar patterns up to 15 lp/cm can be visualized independent of the pitch, corresponding to 0.33 mm longitudinal resolution. 100 mm off-center, bar patterns up to 14 lp/cm are visible, corresponding to an object size of 0.36 mm that can be resolved in the z direction. Image noise for constant effective mAs is almost independent of the pitch. Measured values show a variation of less than 7% as a function of the pitch, which demonstrates correct utilization of the applied radiation dose at any pitch. The product of image noise and square root of the slice width (FWHM of the respective SSP) is the same constant for all slices except 0.6 mm. For the thinnest slice, relative image noise is increased by 17%. Spiral windmill-type artifacts are effectively suppressed with the z-flying focal spot technique, which has the potential to maintain a low artifact level up to pitch 1.5, in this way increasing the maximum volume coverage speed that can be clinically used.
    Medical Physics 09/2005; 32(8):2536-47. · 2.91 Impact Factor
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    ABSTRACT: The meanwhile established generation of 16-slice CT systems enables routine sub-millimeter imaging at short breath-hold times. Clinical progress in the development of multidetector row CT (MDCT) technology beyond 16 slices can more likely be expected from further improvement in spatial and temporal resolution rather than from a mere increase in the speed of volume coverage. We present an evaluation of a recently introduced 64-slice CT system (SOMATOM Sensation 64, Siemens AG, Forchheim, Germany), which uses a periodic motion of the focal spot in longitudinal direction (z-flying focal spot) to double the number of simultaneously acquired slices. This technique acquires 64 overlapping 0.6 mm slices per rotation. The sampling scheme corresponds to that of a 64 x 0.3 mm detector, with the goal of improved longitudinal resolution and reduced spiral artifacts. After an introduction to the detector design, we discuss the basics of z-flying focal spot technology (z-Sharp). We present phantom and specimen scans for performance evaluation. The measured full width at half maximum (FWHM) of the thinnest spiral slice is 0.65 mm. All spiral slice widths are almost independent of the pitch, with deviations of less than 0.1 mm from the nominal value. Using a high-resolution bar pattern phantom (CATPHAN, Phantom Laboratories, Salem, NY), the longitudinal resolution can be demonstrated to be up to 15 lp/cm at the isocenter independent of the pitch, corresponding to a bar diameter of 0.33 mm. Longitudinal resolution is only slightly degraded for off-center locations. At a distance of 100 mm from the isocenter, 14 lp/cm can be resolved in the z-direction, corresponding to a bar diameter of 0.36 mm. Spiral "windmill" artifacts presenting as hyper- and hypodense structures around osseous edges are effectively reduced by the z-flying focal spot technique. Cardiac scanning benefits from the short gantry rotation time of 0.33 s, providing up to 83 ms temporal resolution with 2-segment ECG-gated reconstruction.
    RöFo - Fortschritte auf dem Gebiet der R 01/2005; 176(12):1803-10. · 2.76 Impact Factor
  • Stefan Ulzheimer, Kaiss Shanneik, Willi A. Kalender
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    ABSTRACT: Calcium in the form of hydroxyapatite (HA) is regarded as a known marker for the presence of atherosclerotic lesions of the coronary arteries. Several studies have demonstrated that the risk for coronary events is associated and strongly correlated with the amount of coronary calcium (1,2). The absence of coronary calcium does almost certainly imply the absence of coronary artery disease (CAD) (3), which, according to a World Health Report by the World Health Organization (WHO), is the leading cause of mortality in the world, amounting to 13.7%.
    12/2004: pages 129-141;
  • Stefan Ulzheimer, Willi A Kalender
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    ABSTRACT: Electron beam tomography (EBT) has been used for cardiac diagnosis and the quantitative assessment of coronary calcium since the late 1980s. The introduction of mechanical multi-slice spiral CT (MSCT) scanners with shorter rotation times opened new possibilities of cardiac imaging with conventional CT scanners. The purpose of this work was to qualitatively and quantitatively evaluate the performance for EBT and MSCT for the task of coronary artery calcium imaging as a function of acquisition protocol, heart rate, spiral reconstruction algorithm (where applicable) and calcium scoring method. A cardiac CT semi-anthropomorphic phantom was designed and manufactured for the investigation of all relevant image quality parameters in cardiac CT. This phantom includes various test objects, some of which can be moved within the anthropomorphic phantom in a manner that mimics realistic heart motion. These tools were used to qualitatively and quantitatively demonstrate the accuracy of coronary calcium imaging using typical protocols for an electron beam (Evolution C-150XP, Imatron, South San Francisco, Calif.) and a 0.5-s four-slice spiral CT scanner (Sensation 4, Siemens, Erlangen, Germany). A special focus was put on the method of quantifying coronary calcium, and three scoring systems were evaluated (Agatston, volume, and mass scoring). Good reproducibility in coronary calcium scoring is always the result of a combination of high temporal and spatial resolution; consequently, thin-slice protocols in combination with retrospective gating on MSCT scanners yielded the best results. The Agatston score was found to be the least reproducible scoring method. The hydroxyapatite mass, being better reproducible and comparable on different scanners and being a physical quantitative measure, appears to be the method of choice for future clinical studies. The hydroxyapatite mass is highly correlated to the Agatston score. The introduced phantoms can be used to quantitatively assess the performance characteristics of, for example, different scanners, reconstruction algorithms, and quantification methods in cardiac CT. This is especially important for quantitative tasks, such as the determination of the amount of calcium in the coronary arteries, to achieve high and constant quality in this field.
    European Radiology 04/2003; 13(3):484-97. · 4.34 Impact Factor
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    ABSTRACT: We analyzed the accuracy of multi-detector row spiral computed tomography (MDCT) using a 16-slice CT scanner with improved spatial and temporal resolution, as well as routine premedication with beta-blockers for detection of coronary stenoses. Seventy-seven patients with suspected coronary disease were studied by MDCT (12x0.75-mm cross-sections, 420 ms rotation, 100 mL contrast agent IV at 5 mL/s). Patients with a heart rate above 60/min received 50 mg atenolol before the scan. In axial MDCT images and multiplanar reconstructions, all coronary arteries and side branches with a diameter of 1.5 mm or more were assessed for the presence of stenoses exceeding 50% diameter reduction. In comparison to invasive coronary angiography, MDCT correctly classified 35 of 41 patients (85%) as having at least 1 coronary stenosis and correctly detected 57 of 78 coronary lesions (73%). After excluding 38 of 308 coronary arteries (left main, left anterior descending, left circumflex, and right coronary artery in 77 patients) classified as unevaluable by MDCT (12%), 57 of 62 lesions were detected, and absence of stenosis was correctly identified in 194 of 208 arteries (sensitivity: 92%; specificity: 93%; accuracy: 93%; positive and negative predictive values: 79% and 97%). MDCT coronary angiography with improved spatial resolution and premedication with oral beta-blockade permits detection of coronary artery stenoses with high accuracy and a low rate of unevaluable arteries.
    Circulation 03/2003; 107(5):664-6. · 15.20 Impact Factor
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    ABSTRACT: To compare the image quality of electron beam tomography (EBT) and multislice spiral CT (MSCT) for coronary artery visualization. Two groups of 30 patients without coronary stenoses were studied by MSCT (4 x 1 mm collimation) or EBT (3 mm slice thickness). Contrast-to-noise ratio (CNR), overall length of the visualized arteries and vessel length free of motion artifacts were measured. Length of visualized arteries was equal in MSCT and EBT. In EBT, longer segments were depicted free of motion artifacts (MSCT: 73%, EBT: 92% of visualized length, P< 0.001) and CNR was significantly higher than in MSCT (15.4 vs. 9.0; P< 0.001). In both modalities, vessel diameters correlated closely to quantitative coronary angiography. EBT and MSCT permit reliable coronary artery visualization and measurement of vessel diameters. For the used scan protocol, MSCT images had a lower CNR and were more frequently affected by motion.
    Investigative Radiology 02/2003; 38(2):119-28. · 5.46 Impact Factor
  • Journal of The American College of Cardiology - J AMER COLL CARDIOL. 01/2003; 41(6):468-468.
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    ABSTRACT: Although multidetector CT (MDCT) with retrospectively ECG-gated image reconstruction has been shown to permit noninvasive visualization of the coronary arteries, the 125-250 msec required for image acquisition frequently causes motion artifacts. We investigated the influence of a patient's heart rate on the presence of motion artifacts and on accuracy of stenosis detection on contrast-enhanced MDCT. In 100 patients, MDCT was performed, and ECG-gated cross-sectional images were retrospectively reconstructed. From the 10 data sets obtained for each patient (reconstructed at 0-90% of the cardiac cycle in increments of 10%), we chose the best data set for every coronary artery. The images of the arteries were evaluated for occurrence of artifacts and the presence of high-grade stenosis (diameter reduction exceeding 70%) or occlusions. MDCT results were compared with coronary angiographic findings. Of the 400 coronary arteries, 115 (29%) could not be evaluated because of motion artifacts (n = 84) or other reasons (n = 31). Overall, 51 (49%) of 104 stenoses were revealed on MDCT. For detecting stenosis in those arteries that we could evaluate, MDCT had a sensitivity of 91% (51 of 56 stenoses detected) and a specificity of 89%. As the heart rate increased, the number of arteries that could be evaluated decreased, and overall sensitivity for stenosis detection decreased from 62% (heart rate < or = 70 beats per minute) to 33% (heart rate > 70 beats per minute). MDCT can reveal coronary stenoses, but the usefulness of MDCT as an aid in accurately evaluating stenoses decreases as a patient's heart rate increases.
    American Journal of Roentgenology 11/2002; 179(4):911-6. · 2.90 Impact Factor
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    ABSTRACT: Multi-slice spiral CT (MSCT) permits the detection of coronary stenoses. We investigated the influence of the patient's heart rate (HR) during the scan on stenosis detection and the presence of motion artifacts. In 100 patients MSCT was performed and retrospectively ECG-gated cross-sectional images were reconstructed. 115 of 400 coronary arteries (29%) were unevaluable due to motion artifacts (84/115) or other reasons (31/115). In evaluable arteries, sensitivity was 91% (51/56 high grade stenoses detected), specificity was 89%. With increasing HR, the number of unevaluable arteries increased and overall sensitivity for stenosis detection decreased from 62% (HR < or = 70 bpm) to 33% (HR > 70 bpm). MSCT permits detection of coronary stenoses, but evaluability and accuracy decrease with increasing HR.
    Biomedizinische Technik 02/2002; 47 Suppl 1 Pt 2:782-5. · 1.16 Impact Factor
  • Biomedizinische Technik - BIOMED TECH. 01/2002; 47:782-785.
  • The American Journal of Cardiology 11/2001; 88(7):792-5. · 3.21 Impact Factor
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    ABSTRACT: Multislice spiral computed tomography (MSCT) with retrospectively ECG-gated image reconstruction permits coronary artery visualization. We investigated the method's ability to identify high-grade coronary artery stenoses and occlusions. A total of 64 consecutive patients were studied by MSCT (4x1 mm cross-sections, 500-ms rotation, table feed 1.5 mm/rotation, intravenous contrast agent, retrospectively ECG-gated image reconstruction). All coronary arteries and side branches with a luminal diameter >/=2.0 mm were assessed concerning evaluability and the presence of high-grade stenoses (>70% diameter stenosis) or occlusions. Results were compared with quantitative coronary angiography. Of 256 coronary arteries (left main, left anterior descending, left circumflex and right coronary artery, including their respective side branches), 174 could be evaluated (68%). In 19 patients (30%), all arteries were evaluable. Artifacts caused by coronary motion were the most frequent reason for unevaluable arteries. Overall, 32 of 58 high-grade stenoses and occlusions were detected by MSCT (58%). In evaluable arteries, 32 of 35 lesions were detected, and the absence of stenosis was correctly identified in 117 of 139 arteries (sensitivity, 91%; specificity, 84%). If analysis was extended to all stenoses with >50% diameter reduction, sensitivity was 85% (40 of 47) and specificity was 76% (96 of 127). MSCT with retrospective ECG gating permits the detection of coronary artery stenoses with high accuracy if image quality is sufficient, but its clinical use may presently be limited due to degraded image quality in a substantial number of cases, mainly due to rapid coronary motion.
    Circulation 05/2001; 103(21):2535-8. · 15.20 Impact Factor

Publication Stats

2k Citations
104.07 Total Impact Points


  • 2008
    • Mayo Clinic - Rochester
      • Department of Radiology
      Rochester, Minnesota, United States
  • 2007
    • Mayo Foundation for Medical Education and Research
      • Department of Radiology
      Scottsdale, AZ, United States
  • 2000–2003
    • Friedrich-Alexander Universität Erlangen-Nürnberg
      • Institute of Physics
      Erlangen, Bavaria, Germany