COLLEGE OF ENGINEERING GUINDY, ANNA UNIVERSITY, CHENNAI-25

Digital Subtraction Angiography

Prepared by: S. Dinesh Reg. No. 2011224001 ME / Medical Electronics II semester 5/2/2012

Digital subtraction angiography refers to techniques which subtract two images that are obtained before and after contrast media is administered to the patient for the purpose of studying blood vessels

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CONTENTS
1. 2. 3. 4. 5. 6. 7. 8. Introduction Block diagram Digital image processor Image memory and integration Image subtraction Contrast medium Indications & contradictions References

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INTRODUCTION
Digital subtraction angiography refers to techniques which subtract two images that are obtained before and after contrast media is administered to the patient for the purpose of studying blood vessels (angiography). Digital subtraction angiography (DSA) is a new, and rapidly developing, technology in the field of diagnostic radiology. DSA is one of several computer-assisted radiologic tools for diagnosing conditions associated with the internal structure of blood vessels. The technique usually involves injecting contrast medium into the veins and measuring over time the changing concentration of contrast medium passing through the vascular structures of interest. Through the use of a computer, the images before the contrast injection are subtracted from those after injection to give a numerical representation of the arterial structure under study. This relatively noninvasive technique can be performed on an outpatient basis with very low risk of morbidity compared to conventional and (invasive) techniques such as arteriography. DSA has been shown to have important clinical uses in diagnostic studies of the carotid, renal, intracranial, and peripheral arteries, the aorta and in pulmonary studies. There are reasonable expectations that this procedure will develop to the point where it will have wide applicability in the diagnosis of coronary artery disease in the next several years. DSA systems work in the manner depicted in figure as follows: a contrast medium is injected intravenously; X-ray detection of the contrast medium produces 1 to 30 exposures per second (before and after the injection of contrast medium); and arterial images are converted from analog to digital form and transmitted to a computerstorage complex. The digitalized image information makes it possible to subtract the pre-contrast images from those obtained after contrast injection so as to visualize arterial structures without direct arterial puncture and injection. The data can be recalled for viewing on a video screen, and successive images created through subtraction techniques which allow the contrast of the arterial structures to be visualized for the detection of abnormalities. The purpose of the subtraction process used in DSA is to eliminate (or factor out) the bone and soft tissue images that would otherwise be superimposed on the artery under study . The serial images show

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changes in the contrast appearance over time (temporal subtraction) and at varying Xray intensities (energy subtraction). Most DSA examinations require 25 to 45 minutes to perform , if there are no technical complications (e.g., difficulties with catheterization), and can be performed on an outpatient basis. This is a considerable advantage in safety and cost over most standard arteriographic examinations, which require at least overnight observation of the patient in the hospital to detect postprocedure arterial obstruction or hemorrhage. However, a small number of the latter have been safely performed on an ambulatory basis in recent years.

FIG: Digital Subtraction Angiography According to this picture, you could find the status of blood vessel whether it is in normal or abnormal situation. For example, you could easily find the positions where it becomes narrow, where it has a tumor, where the blood is obstructed, where it is deformity or malformation and so on.

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FIG: DSA SETUP

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FIG: CT STROKE DSA IMAGE

BLOCK DIAGRAM:

The heart of this system is a digital image processing system which acquires images from a video camera and provides timing signals to both the x-ray generator and the

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image acquisition system to control the flow of data from the x-ray source into the image processor. 1. The image acquisition process begins when the timing signals, delivered to the x-ray generator under computer control, initiates the production of x-rays which are transmitted through the patient and received by the image intensifier. 2. An aperture, placed between the image intensifier and the video camera, controls the amount of light delivered to the camera. This manages the signal-to-noise ratio of the acquired image 3. A video camera receives the light image from the image intensifier and converts it to a electronic video signal which is delivered to the image processor in analog form. 4. The image processor digitizes the image, stores it in memory, and makes it available in digital form for subtracttion with another image set acquired at a different time or at a different energy. 5. A common algorithm using digital radiographic systems is temporal subtraction . In this technique, dynam-ic images of the patient are acquired at a rate of 1 exposure per second or more. A contrast agent is injected into the patient either intravenously or intra-arterially. 6. A second set of dynamic images is acquired after the contrast agent flows into the area being imaged. The unopacified images (no contrast) are subtracted from the opacified images with the subtraction process isolating the signal (which is present only in the opacification image), removing the static anatomical structures that are common to both the opacified and unopacified images. The elimination of background structures makes the arteries visible in the subtraction image even when they are not visible or barely visible before subtraction.

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DIGITAL IMAGE PROCESSOR:

FIG: DIGITAL IMAGE PROCESSING SYSTEM

The block diagram for a typical digital image processor is shown in Figure above. The digital Processor has basic functions illustrated in this diagram including (1) Acquiring and digitizing the video images, (2) Storing the digital images in memory, (3) Performing arithmetic operations (subtraction, addition and constant multiplication) on the image data, (4) Displaying the digital images on video monitors, and (5) Storing the image data on magnetic media or an optical disk. The image processor also contains a microprocessor or system controller that controls the basic operations of the image processor, the x-ray generator, and other components, coordinating and controlling the operation of the digital imaging system. 1. We will assume that an analog video image has been acquired by the x-ray system, image intensifier, and video camera.

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2. The analog signal is delivered to the image processor that provides some preprocessing to adjust the amplitude and level of the video signal to satisfy the input specifications of the analog-to-digital converter. Many images are acquired in a 512 x 512-pixel matrix although some systems use a 1024 x 1024 matrix. The image matrix controls the sampling rate of the analog to digital converter. 3. Following digitization, the image data are logarithmically transformed, meaning that the pixel values are replaced by their logarithm. The logarithmic transformation is required to remove stationary anatomical structure during image subtraction.

IMAGE MEMORY AND INTEGRATION After logarithmic transformation and digitization of the incoming video signal, the image is stored in one memory of the image processor. Each pixel in the digital image is represented by a digital number having a minimum of 10 bits corresponding to the digit-ization range of the image-processors analog-todigital converter. Often more than one image is added ("integrated") to reduce noise and improve the SNR of the image. This averaging is provided by a feedback loop in which the incoming image is added to the contents of the previ-ously stored image on a pixelby-pixel basis. IMAGE SUBTRACTION In digital subtraction angiography, two images are acquired. The first is the "mask" image, which is obtained before contrast media is injected into the patient. The second is the "opacification" image, which follows injection of the contrast media and is obtained when the contrast bolus reaches the artery to be imaged. The mask and opacification images can be modeled mathematically by assuming that the patient has a thickness xt and a linear attenuation coefficient of t. Before contrast media is injected into the patient, the photon fluence delivered to the image intensifier is:

Im = I0 e(t.xt)

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CONTRAST MEDIUM:
Contrast medium are selected based on their: 1. OSMOLALITY 2. VISCOSITY 3. IONICITY Viscosity: Resistance of a liquid to shear forces Osmolality: Osmolality is a count of the number of particles in a fluid sample. The unit for counting is the mole which is equal to 6.02 x 1023 particles (Avogadro's Number). Ionicity: The ionic character of a solid is defined by ionocity..

Because of their chemical properties, contrast media are usually thicker (viscosity) and have greater osmolality (more molecules per kilogram of water) than blood, plasma, or cerebrospinal fluid. Viscosity and osmolality play a part in the development of contrast reactions. Ionicity is the characteristic of a molecule to break up into a positively charged cation and a negatively charged anion, resulting in more molecules per kilogram of water and thus increasing osmolality. Nonionic agents do not have this property and hence are less osmolar. Iodinated contrast media are among the most commonly used injectable in radiology today. Modern iodinated contrast agents can be used almost anywhere in the body. Most often they are used intravenously but can be administered intra-arterially and intra-abdominally.

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They are usually safe, and adverse effects are generally mild and self-limiting. Nonetheless, severe or life-threatening reactions can occur.

Commonly Used Iodinated Contrast Medium:

Ionic Diatrizoate (Hypaque 50; GE Healthcare) Metrizoate Isopaque (Conray 370; Nycomed A/S) Ioxaglate (Hexabrix; Mallinckrodt, Inc.) Nonionic Iopamidol (Isovist-370; Bracco Diagnostics Inc.) Iohexol (Omnipaque 350; GE Healthcare)

Monomer

1,550 (high)

Monomer

370

2,100 (high)

Dimer

320

580 (low)

Monomer

370

796 (low)

Monomer

350

884 (low)

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Iodixanol (Visipaque 320; GE Healthcare)

Dimer

320

290 (iso)

INDICATIONS:
-Unstable angina or chest pain -Heart attack -Before a bypass surgery -Abnormal treadmill test results -Disease of heart valve -To monitor rejection of heart failure

CONTRAINDICATIONS:
-Allergy to contrast medium -Hypertension(uncontrolled blood pressure) -Problems with blood coagulation -Severe anemia -Fever -Uncontrolled rhythm(arrhythmias)

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REFERENCES:
1. Wikipedia 2. https://www.beaumonthospitals.com/diagnostic-procedurescerebral-angiography 3. Physics of medical x-ray imaging 4. American College of Radiology. Manual on Contrast Media 5. http://www.atlantabrainandspine.com/subject.php?pn=cerebralangiogram-064 6. Photos Courtesy: Google search engine