IEEE SENSORS JOURNAL, VOL. 14, NO.

3, MARCH 2014 747

A Measurement System to Realize 3-D Carotid

Occlusion Measurement from 2-D
Conventional Ultrasonography
Domenico Capriglione, Member, IEEE, Luigi Ferrigno, Member, IEEE, Gianfranco Miele, Member, IEEE,
Vincenzo Paciello, Member, IEEE, Alfredo Paolillo, Member, IEEE, and Paolo Sommella, Member, IEEE

Abstract— A novel measurement system for the 3-D recon- for the early assessment of pathology, as well as for the
struction of occlusions of the carotid artery is presented. The monitoring of the progression of a degenerative phenomenon.
proposed system can be added onto a conventional diagnostic In clinical practice, the Ultra-Sound (US) techniques (also
ultrasonographic system, so that it can be considered as an
upgrade for preexisting equipments. It retrieves information from including B-mode, Color Doppler, Color Power Angio) rep-
a set of ordinary 2-D ultrasound images and spatial sensors in resent the most used diagnostic tools for assessing CVDs
order to build a 3-D representation of the vessel and of a possible (with respect to other modalities such as Magnetic Resonance
occlusion and to extract measurements of important medical Imaging and Computed Tomography Angiography), thanks to
parameters from them. The geometrical modeling of carotid is the following key advantages: i) real-time quick examination;
dealt with. This paper is also concerned with a metrological
characterization of the measurement procedure, including the ii) low costs; iii) repeatability and reliability; and iv) absence
development of a model for the estimation of the uncertainty of radiations and non-invasiveness.
according to international standards. Experimental results are Obviously, a major problem of the clinical examina-
also reported and discussed. tion based on US imaging is the need for quantitative
Index Terms— Biomedical measurements, measurement uncer- measurements. In order to overcome the drawbacks of
tainty, thickness measurement, volume measurement, biomedical image segmentation and IMT measurement manually per-
image processing, ultrasonic imaging. formed by operators, investigation efforts are being addressed
to the development and characterization of fully auto-
I. I NTRODUCTION
matic (user independent) systems able to detect the carotid

T HE artherosclerosis is a kind of cerebrovascular and

cardiovascular disease (CVD) whose consequences (cere-
bral infarction, embolus, ictus, ischaemia) seriously cause
layers and boundaries. In [4] an interesting method is
presented, focused on the segmentation of US carotid
images based on active snakes and on its classification as
human morbidity and mortality. According to World Health either healthy or diseased with a support vector machine
Organization, CVDs represent the third leading cause of death (SVM) classifier. The proposed classifier operates on single
in the world [1]. More in details, the atherosclerotic process images, thus the results are not representative of the vol-
refers to the degeneration of the arterial wall and the deposition umetric arrangement of the carotid interfaces, but depend
of lipids and other bloodborne material within the arterial wall on the specific selection of that image. An interesting
of almost all vascular tissues. review about main segmentation algorithms is reported
Several studies evidenced the relationships between the in [5], where dynamic programming, deformable snakes,
carotid artery wall status and CVDs [2]; specifically, an Hough Transforms and classification approaches are com-
increased Intima – Media Thickness (IMT) is correlated to an pared.
augmented risk of brain infarction or cardiac attack. Moreover, On the other hand, IMT it is not sensitive to the changes in
the presence of a carotid plaque has been correlated to degen- plaque burden, which turned out to be a stronger predictor
erative pathologies like vascular dementia and Alzheimer’s of cardiovascular events [6]. Consequently, in most recent
disease [3]. Hence, the inspection of the carotid wall is crucial years an increased interest moved towards area and volumetric
Manuscript received September 20, 2013; accepted October 19, 2013. Date measurements of carotid plaque burden such as total plaque
of publication October 24, 2013; date of current version January 10, 2014. area (TPA), total plaque volume (TPV) [7], vessel wall volume
The associate editor coordinating the review of this paper and approving it (VWV) [8], and vessel wall thickness maps (VWT maps) [9].
for publication was Prof. Aime Lay-Ekuakille.
D. Capriglione, L. Ferrigno, and G. Miele are with the Depart- The hypothesis is that the area and volumetric measurements
ment of Electrical and Information Engineering, University of Cassino are more reflective of the plaque burden so that they may
and Southern Lazio, Cassino 03043, Italy (e-mail: capriglione@unicas.it; provide complementary information to IMT.
ferrigno@unicas.it; g.miele@unicas.it).
V. Paciello, A. Paolillo, and P. Sommella are with the Department of Hence, two different approaches have been extensively
Industrial Engineering, University of Salerno, Fisciano 84084, Italy (e-mail: investigated: i ) revisiting conventional method based on
vpaciello@unisa.it; apaolillo@unisa.it; psommella@unisa.it). 2-D B-mode imaging [10], [11] and ii) exploring the 3-D
Color versions of one or more of the figures in this paper are available
online at http://ieeexplore.ieee.org. ultrasound potential to provide comprehensive quantification
Digital Object Identifier 10.1109/JSEN.2013.2287298 of plaque [12]–[14]. The majority of these studies developed
1530-437X © 2013 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission.
See http://www.ieee.org/publications_standards/publications/rights/index.html for more information.
748 IEEE SENSORS JOURNAL, VOL. 14, NO. 3, MARCH 2014

algorithms for 3-D reconstruction of a geometric model of

the lumen and wall of coronary arteries from US images
able to achieve a good geometric accuracy, if compared with
results based on manual segmentation performed by an expert
physician. Following the trends in surgery and radiology, also
for the US image-based reconstruction, an increasing interest
is addressed to the experimental estimation of measurement
error in comparison with objective references [15]. More in
detail, a phantom presenting 3D features of plaques could
be realized using stereolitography [16] and employing new Fig. 1. Functional blocks of a 3-D measurement system based on 2-D images
tissue mimicking materials suitable for ultrasound studies and add-on devices (the units for 3-D measurements are in red).
[17]. However, yet in few examples [18]–[19] the volume
measurements provided by 3-D model have been compared
with pulsatile phantoms of the carotid bifurcation; moreover which the image scanning plane can be changed elec-
the experimental set-up typically includes a limited series of tronically and without particular work by the operator.
operating conditions. Thus, the quantitative assessment of the The major disadvantage of such systems is the cost.
plaque and lumen has to be further explored to provide an Comparing these solutions, the former offers better cheapness
accurate clinical tool. and flexibility, while the latter is generally characterized by a
Starting from previous studies about longitudinally-oriented better easiness of use. A common limitation for both classes
2D images for automatic IMT measurement [20], the authors of instruments is that the area and volume measurements
aim to introduce an accurate and low-cost real-time system provided by these instruments do not include any information
for 3-D reconstruction of the carotid plaque. The principal about their uncertainty. In this paper, the problem of the eval-
contribution of the presented work is an extensive metrological uation of the uncertainty of the 3-D reconstruction based on
characterization of the 3-D image system based on a rigorous US imaging has been dealt with, in terms of the identification
analytical approach according to international guideline. The of the main uncertainty sources and of its propagation.
direct extension of the provided experimental set-up may
also represent an effective methodology to assess the quan- III. T HE P ROPOSED M EASUREMENT S YSTEM
titative estimations provided by a wide class of ultrasound Due to the very wide diffusion of 2-D systems, the first kind
3-D-reconstruction systems. of instruments has been considered for the prototype design
The paper is organized as follows: the collocation of the and implementation. Focusing the attention on such a type of
work in the context of 3-D US carotid imaging is moti- instruments [21]–[22], they can be schematized as reported in
vated in Section II. The ultrasound 3-D reconstruction system Fig. 1.
is described in Section III in terms of both the hardware The first block is composed by the hardware for cap-
components and algorithms for image processing. Then, the turing the 2-D images (probe) and for locating the probe.
preliminary characterization and tuning of the systems are The acquired 2-D images are processed in order to extract the
described in Section IV as well as the analytical approach information required for the 3-D reconstruction. Finally the
adopted for the estimation of the measurement uncertainty. 3-D image is processed to achieve the wanted measurements.
Section V reports the experimental results achieved by apply- An important aspect to be considered in the system design
ing the suggested methodology during the clinical activity. and realization is that the carotid volume varies with the
Finally, some conclusions are drawn in section VI. heart activity thus giving a very low repeatability in the
measurements. To overcome such a problem, the 2-D image
II. M OTIVATION OF THE W ORK acquisitions have to be synchronized with the heart activity
obtaining the same experimental conditions for each image.
Different 3-D ultrasound instruments are present on the
In Fig. 2, the schematic of the proposed prototype is shown.
market, but most of them either are able to make only
In the following, the hardware, the system operation and the
qualitative measurements or are highly expensive. They can be
main software sections are described in detail.
classified into two main classes: i) based on “add-on” devices,
and ii) based on sensor arrays.
1) Systems based on “add-on” devices exploit typical A. The Hardware
2-D ultrasound probes, together with additional hard- As described above, the goal of the proposal is the real-
ware which is needed to locate each image of the set of ization of a low cost 3D ultrasound measurement system able
acquired images in the 3-D space. The volume of interest to operate with common 2D ultrasounds by the adoption of a
is analyzed by suitably spacing the different image suitable add-on measurement system. Required features are the
planes. In order to avoid unacceptable errors in the capability of operating with most of the existing 2D ultrasound
3-D reconstruction, the position and the orientation of systems without the need for any hardware or software change
the probe should be evaluated with an adequate accuracy. in the 2D ultrasound instrument. To this aim, some hardware
2) Systems based on sensor array employ special probes, components are required. They concern with systems for the
containing arrays of ultrasound sources/receivers for acquisition of the 2D images from the existing ultrasound,
CAPRIGLIONE et al.: MEASUREMENT SYSTEM TO REALIZE 3-D CAROTID OCCLUSION MEASUREMENT 749

position tracking, and the Firewire interface for the acquisition

of the 2-D images coming from the frame grabber.
d) The add-on package is composed of three main hardware
blocks: d.1) the probe angle measurement sub-system, d.2) the
probe position tracking system, d.3) the synchronization unit.
d.1) The angle of incidence, namely the angle between the
start analysis plane and the current scanning plane, is
measured by a specific sub-system based on a tri-axial
MEMS accelerometer, LIS352AX by STMicroelectron-
ics. The LIS352AX has an acceleration range of ±2g,
a sensitivity of 363 mV/g and total non-linearity of
±0.5% of the full scale. In detail, the angle of incidence
is measured as the angle by which the gravitational
acceleration vector rotates during the scanning as seen in
a coordinate reference system fixed onto the probe. Due
to the slow dynamics involved, a simple low-pass RC-
filter with a cut-off frequency of 25 Hz has been adopted
to limit the signal bandwidth. To improve the system
stability the device has been powered by a suitable
voltage regulator.
d.2) The probe position tracking is made by using a
gyroscopic-based device, the Micro-ISU BP3010 by Bul-
mer Electronics & Control. It includes gyroscopes and
accelerometers as well as internal circuits for power sup-
ply regulation, three microprocessors (for data compen-
Fig. 2. Simplified block diagram of the proposed prototype.
sation and communication management) and a RS-232
communication module for interfacing with the external
PC. Through this communication port the device sends,
with a maximum update rate of 64 Hz, the incremental
systems for the correct localization of the 2D probe in the velocity on each axis with a resolution of 1 mm/s over
3D space and suitable processing units. Fig. 2 schematically a 16 bits length word.
highlights these components: (a) the traditional 2D ultrasound d.3) It is well known that the cardiac activity might cause
system, (b) the frame grabber, (c) the processing unit, and artifacts in the ultrasound images of the carotid artery.
(d) the add-on package. Images of the same carotid, acquired with the same
a) A traditional 2-D ultrasound system by Philips has been orientation of the ultrasound probe, might differ since
adopted for the production of the 2D ultrasound images. It is the carotid expansion due to the cardiac systolic events.
the ATL 5000T M , with 7-12 MHz changeable pulse ultrasound Thus, most of the ultrasound systems adopt an ECG
frequency. It allows to employ both B-mode and Color Power synchronization. In the proposed solution the synchro-
Angio (CPA) images which highlight also slow blood fluxes to nization unit is based on ECG signals provided by
be evidenced whichever the ultrasound orientation with respect an ad-hoc realized device. Aim of this device is only
to the flux direction. In particular, 10 MHz frequency was the detection of the systolic event of the heart activity
chosen, since it allows up to 39 mm analysis depth with a and not a complete analysis of the cardiac trace. For
good resolution. Consequently, a very wide variety of carotid these reasons, a simplified version that employs only
arteries can be analyzed (generally the carotid is modeled like two electrodes (typical of ECG systems) enveloping
a tube with a medium circular section of about 1 cm of radius the patient’s wrists is adopted. The differential voltage
and with the center placed under the skin at 12-20 mm depth). detected by the electrodes is suitably amplified by a
b) A PAL/NTSC compatible frame grabber device two-stage module, which is constituted by a differential
DFG1394-1e by Total Turn Key Solutions was used. It grabs instrumentation amplifier followed by an operational
the current display of the screen of the ultrasound machine and amplifier in non-inverting configuration. To prevent the
sends it to the PC-based processing unit through the Firewire ECG artifacts due to the 50 Hz noise of the power
bus. It allows the connection of the add-on system with the supply, and due to the low frequency wandering, a band-
most widespread ultrasound machines available on the market. pass filter with cutoff frequencies of 0.3 Hz and 33 Hz
c) The processing unit is based on a PC equipped with has been arranged after the amplifier module.
a PCMCIA Data Acquisition Board NI 6062E, and with
RS-232 and FirewireTM interfaces. The DAQ board is
employed for data acquisition from the sensors at a sampling B. General Operation of the System
frequency of 500 samples/s. The RS 232 data interface bus The intended simplicity of the realized system allows the
is used for the communication with the sub-system for the diagnostician to carry out a clinical exam in exactly the same
750 IEEE SENSORS JOURNAL, VOL. 14, NO. 3, MARCH 2014

Fig. 4. Carotid artery transversal (a) and longitudinal (b) views.

As for the 3-D reconstruction, different solutions could be

adopted such as to use transversal images (Fig. 4a), longitu-
dinal images (Fig. 4b) or mixed solutions. Many experimental
tests were carried out and they proved that the optimal choice
in terms of image quality and 3-D reconstruction is achieved
using longitudinal images; moreover the best longitudinal
images are obtained by placing the probe in a back-lateral
position [23], [24].
Finally, the software provides the 3-D reconstruction of the
plaque and of the artery, as well as the percentage of occlu-
sion and plaque volume together with related measurement
Fig. 3. The add-on package. uncertainties.

manner of a common 2D ultrasound exam. In particular, once C. The Trigger Detection for Data Storing Module
mounted the add-on package on the 2D ultrasound probe This is a very important software module that allows a
(Fig. 3) the diagnostician moves and tilts the probe until he reliable measurement process. It has a double aim. On one
finds a satisfying view of the segment of the carotid artery. hand, it has to guarantee the selection of 2D images syn-
Then, he pushes a button while holding the probe. This is a chronized with respect to the systolic cardiac event. On other
procedure similar to that adopted by a diagnostician to grab hand, it must allow the synchronization of the measurement
and print a photo of the ultrasound exam. information coming from the angle and movement sensors
This event is captured by the Trigger Detection For Data with the acquired 2D ultrasound image.
Storing module (described in the following subsection), which This module receives as inputs the signals acquired by the
is synchronized by the ECG signal. This module acquires DAQ board (i.e. the ECG, the accelerometer, and the push
the probe angles and positions and selects the appropriate button) and those coming from the data communication busses,
image from the frame grabber. In this way, although the frame namely the images coming from the FirewireTM bus and the
gabber continuously acquires 2-D images, only the images movement data coming from the RS 232 bus.
acquired after a programmable delay triggered by the diastolic It has been developed in the LabViewTM environment and
movement of the heart are stored on an external hard disk and operates as follows. When the diagnostician selects an image,
successively employed for 3-D reconstruction. and pushes the acquisition button, the Trigger Detection For
This step is repeated for each angle of incidence chosen Data Storing module selects the first 2D ultrasound image
by the diagnostician. Typically, a range of ±5° with a step that occurs after a suitable delay after the trigger event
of one degree for the angle of incidence allows to achieve an generated by the ECG signal. In the same time the software
acceptable 3-D reconstruction [23], [24]. collects measurement data coming from the add-on package
Once the data acquisition is completed, the diagnostician by means of a mobile acquisition window that has a length
has to select a box (Region of Interest, ROI) on any image. of 100 ms. This solution averages the angular and translation
This box is the area of the image that will be processed in order measurements, allowing the outlier filtering and the reduction
to extract the 2-D outline of the relevant interfaces between of noise.
different tissues in the image. A useful feature of the proposed As far as the software implementation is concerned, it can
prototype is that if the edge detection fails on a single image, be schematized as the parallel execution of three synchronized
the diagnostician can choose between two solutions: whether loops. The first collects data coming from the DAQ board, the
to discard this image or to launch an edge correction routine. second from the movement probe and the third from the frame
CAPRIGLIONE et al.: MEASUREMENT SYSTEM TO REALIZE 3-D CAROTID OCCLUSION MEASUREMENT 751

Fig. 5. Examples of outputs of the segmentation procedure. Fig. 6. A position example of the contour lines.

grabber. The first loop executes a point by point acquisition on the knowledge of its pixel coordinates (px, py) and on the
and collects data into three vectors, one for each acquired orientation and position values (θx , θ y , d x , d y ) of the probe:
quantity, managed as a sliding window of 100 ms length.      
x cos (θx ) − cos θy · sin (θx ) dx + px · tan (θx )·sin (θx )
A software routine detects when the ECG signal reaches the = − sin (θx ) cos θ y · cos
desired level and slope and generates an interrupt for the
y  (θx ) px ·sin (θx )
z 0 sin θ y dy
acquisition of the last 100 ms of data about the trigger event.  
px
In the same way, the second loop polls the RS232 bus at a · py (1)
baud rate of 38400 bps and collects data from the movement 1
probe. This adopted Micro-ISU BP3010 sensor acquires data Where px is the distance along the x-axis of the center of the
at a frequency of 64 Hz, which implies about 6 samples in the selected image from the origin of the x axis.
considered 100 ms window. Finally, the third loop manages By processing each point of the three interfaces of each
frames coming from the frame grabber and selects the first image, the 3-D reconstruction of the carotid can be displayed
image that occurs after the trigger event. and saved. This process is illustrated in Fig. 6. In particular
Fig. 6a) shows the interfaces related to a single 2-D image,
D. Software: 2-D Edge Detection while in Fig. 6b) the positioning of the interface pixels of 2-D
As for the 3-D image reconstruction phase, it is realized by images corresponding to all angles of incidence is reported.
segmenting each 2-D image, in the current plane, to extract
the object contours, which in turn are used to obtain the object F. Software: Percentage Occlusion Measurement
surface [21], [25]. Compared with other approaches available In order to evaluate the percentage of carotid occlusion, O% ,
in literature, the main advantage of such a solution is related the artery volume, VL , and the plaque volume, VP , have to be
to the amount of data to be stored and managed because only measured:
the interesting points are processed. Consequently it allows a VP
O% = · 100. (2)
fast and efficient 3-D rendering to be achieved. VL
Each 2-D image is processed in order to extract the three To this aim the reconstructed 3-D carotid (see Fig. 7a) is
interfaces: intima-lumen in near wall, intima-lumen in far sliced in the x direction, with a x-step, x, equal to one
wall, lumen-plaque. The segmentation is completely automatic pixel, obtaining for each cross section in the z − y plane the
[20]. The technician is asked only to select the ROI for the polygons representing the lumen and the plaque, respectively
image analysis, aiming at simplifying the elaboration software (Fig. 7b and Fig. 7c). The lumen polygon is defined by the
and at reducing the elaboration time. The contour detection interpolated interface between intima-lumen interfaces (in the
algorithm is based on the recursive application of suitable near and far wall), while the plaque polygon is delimited
cost functions. Namely, three cost functions are used, one for by the interpolated lumen-plaque and far wall lumen-intima
each interface. They are composed of some terms taking into interfaces. The volumes are obtained summing the single slice
account the characteristics of the investigated contours, such volumes, said ALj and APj the area of each polygon of the
as, for example, gray level above and below the contour or the lumen and plaque, respectively (Fig. 7d):
contour regularity. These terms are weighted by coefficients
empirically evaluated during a training phase performed on 
NL 
NP
VL = ALj · x, VP = APj · x. (3)
different carotid CPA images. In Fig. 5 the outputs of the
j =1 j =1
segmentation procedure for two CPA images are shown.
Each area is computed by dividing it into adjacent triangles
with consecutive points of the section contour:
E. Software: 3-D Volume Reconstruction  
Mkj 
The three interfaces intima-lumen in near wall, lumen- 1  
intima, and intima-media in far wall are extracted from the Akj = ·  (yi · zi+1 − yi+1 · zi ) , (4)
2  
i=1
2-D image processing [23], [24]. Then, the 3-D reconstruction
algorithm locates each point of each interface in the 3-D space considering all the Mkj points describing the polygon (see
with respect to a given reference system (O, x, y, z), based Fig. 7d).
752 IEEE SENSORS JOURNAL, VOL. 14, NO. 3, MARCH 2014

Fig. 8. Measured biases for the sensor x-axis.

As an example, in Fig. 8 the mean errors between the

imposed angle of incidence and the measured one are reported
for the x-axis of the sensor. As a result, the selected device
exhibits a mean error over the range of interest (−10°, +10°)
that can be modeled with a uniform pdf within the range
[−0.6°, +0.6°]. Similar results have been obtained for y-axis
and z-axis.

B. Sub-System for the Measurement of the Probe Position

The subsystem for the measurement of the probe position
has been characterized by a comparison with a 4 axes Adept
Fig. 7. Main steps for the percentage occlusion measurement: a) recon-
structed 3-D carotid, b) 3-D interfaces of plaque volume, c) 3-D interfaces Cobra 600TM robot, acting as a reference instrument. Such
lumen volume, d) area evaluation, e) single slice volume. a system achieves a repeatability on the XY plane equal
to 0.017 mm, whereas the repeatability for the Z-plane is
0.003 mm. The robot arm can be programmed into given
The plaque volume measurements can be useful for the positions by sending commands written with a specific syntax
correct medical diagnosis, but, after processing the images through a RS-232 serial port. To this purpose, a LabView
and applying these relationships the measurements are still software, which controls the robot arm and has a graphical
expressed in pixels. If one knows the pixel-to-millimeter user interface, has been implemented.
conversion factor, k, which depends on the specific probe and A preliminary test has been carried out to assess the
machine used, then: performance of the probe position measurement sub-system
3 in absence of any motion or vibration. In this way, the
Vmm
p = k3 Vp . (5) intrinsic noise related to the accelerometer responses can be
highlighted. Results have been obtained considering 9000 con-
IV. P RELIMINARY C HARACTERIZATION AND T UNING secutive measurements over an interval equal to 15 minutes.
OF THE M EASUREMENT S YSTEM The obtained results have shown an intrinsic repeatability,
estimated as the experimental standard deviation referred to
A deep experimental characterization has been carried out
the estimated mean value of 0.012% for all the directions.
to assess the prototype performance and to correct possible
Furthermore some tests with different probe speeds have
systematic effects.
been carried out over a path 15 mm-long for each one of the
considered directions. The following speeds have been con-
A. Sub-System for the Measurement of the Angle of incidence sidered: 20 mm/s, and 10 mm/s. Each path has been covered
in the direct and reverse direction (D and R, respectively) and
The subsystem for the measurement of the angle of inci-
for each path 100 consecutive measurements have been made.
dence has been characterized by a comparison with a com-
Two figures of merit have been considered:
puter controlled pan-tilt unit, namely the PTU-46 by Directed
Perception. This unit has an angular resolution equal to 0.013° i) % defined as the mean percentage bias between the
and an overall accuracy of 0.039°. imposed and estimated distance;
The experiment has been conducted on the biaxial ii) σ % defined as the percentage experimental standard
accelerometer fixing the measurement subsystem for the angle deviation of % with respect to the imposed distance.
of incidence onto the pan-tilt unit, and varying for each axis Obtained results are reported in Table I. Some considera-
the pan-tilt angle in the +/−30° range with a resolution step tions can be made:
of 0.5°. For each step, 200 consecutive measurements have - the performances of x-axis and y-axis are generally better
been executed. than those obtained with the z-axis;
CAPRIGLIONE et al.: MEASUREMENT SYSTEM TO REALIZE 3-D CAROTID OCCLUSION MEASUREMENT 753

TABLE I
R ESULTS FOR T EST ON THE S UB -S YSTEM FOR THE M EASUREMENT
OF THE P ROBE P OSITION

Fig. 9. Examples of simulated arteries with plaques: a) two cases of plaques

with different volumes; b) cases with different skin-artery distances, where
the directions of incidence are reported.

TABLE III
T HE E RRORS IN P LAQUE V OLUME M EASUREMENTS

TABLE II
A PPLIED C ORRECTION G AINS IN THE E STIMATION
OF THE P ROBE M OVEMENTS

The prototype software processes the obtained artificial

2-D images in order to reconstruct the plaque and to evaluate
3
the volume measurements (V pmm ). Then, the error (e%) of
the measurement system on the carotid plaque volume is
3
calculated as e% = 100 · (V pmm − V p,R E F )/V p,R E F . The
obtained results are summarized in Table III. A systematic
effect is highlighted: the measurement error is negative for
each test (the system underestimates the volume). Besides, the
- for the x and y axes the overall accuracy is bounded results show that e% increases with the distance d.
within the 10% with a good repeatability while the z-axis Thus, the corrected volume of the plaque is evaluated as:
shows a worse performance, particularly for the reverse 3
movements. V Pc = c · V Pmm = c · k 3 · V P (6)
Taking into account the obtained results, suitable mean cor-
where c is the correction factor. The error value e% depends on
rection gains have been applied to the estimated x, y, and z
both carotid position and plaque dimension; consequently, the
distances both for the direct movement and for the reverse
correction factor c should assume different values according
side. The adopted movement correction gains are reported in
with these parameters. Nevertheless, for both plaque and
Table II.
stenosis volume calculation, the error variation is always
contained in a 1% range, and can be judged negligible with
C. Sub-System for the 3-D Volume Reconstruction respect to all uncertainty sources. For this reason, a c mean
The characterization steps have been carried out in an value is used (c =1.032), calculated from the average of
emulation environment. To this aim the software prototype was the percentage errors e%. The uncertainty of the correction
tested on a number of artificial images reproducing the human factor c was computed from the standard deviation of e% (as
carotid, obtained in a 3D CAD environment (Autocad 2000™). reported in the following sub-section).
The artery is modeled like a cylinder and the plaque, repre-
sented as a section of a spherical shape, is positioned inside
it. Several plaques of different nominal volumes (V p,R E F ) D. Uncertainty Estimation
were simulated and different distances (d) of the carotid with The measurement uncertainty is evaluated by a-priori analy-
respect to the skin were considered (see Fig. 9). sis, applying the uncertainty propagation law, suggested by the
The 2-D acquisition process is emulated slicing the sim- ISO-GUM [26], on the relationships implemented in the soft-
ulated artery: for each angle of incidence, a corresponding ware and taking into account the metrological characterization
plane is built; the volume sections projected onto the selected made in the previous sub-section.
planes give the 2-D images. Five planes rotating in the interval In particular, considering the two volume measurements
[−5°, +5°] around a pivot axis were considered. uncorrelated, the occlusion measurement uncertainty is
754 IEEE SENSORS JOURNAL, VOL. 14, NO. 3, MARCH 2014

evaluated as: TABLE IV

 2  U NCERTAINTY C OMPONENTS
∂O% ∂O% 2 2
u2O% = u2Vp + uVL
∂Vp ∂VL
  2
2
1 VP
= uVp + − 2
2
u2VL . (7)
VL VL
The uncertainties on the volume estimations depend on both
the image processing and the position measurement as detailed an uncertainty contribution due to the angle measurement (for
in the following. In particular using eq. (3), it is obtained: each axis) can be estimated as:
  ∂V 2 
u2V = u2Aj = x2 u2Aj 0.6◦
j ∂Aj j
(8) uθ = √ = 0.35◦ (15)
3
In order to evaluate the uncertainty of each jth cross section In the uncertainty evaluation of the plaque volume (see eq. (5))
area, the ISO-GUM law is applied to eq.(4), assuming uncor- also the uncertainty of the k factor and of the correction factor
related the 3-D coordinates of the plaque contour pixels: has to be considered:
Mj    c 2  c 2  c 2
 ∂Aj 2
∂Aj ∂Aj 
∂Aj 2  ∂ VP ∂ VP ∂ VP
u2Aj = u2yi + · u2zi +2
u yi , zi u 2V c = u 2C + u 2k + u 2VP
∂yi ∂zi
∂yi ∂zi P ∂c ∂k ∂ VP
i=1
(9) = k 6 · V P2 · u 2C + 9 · k 4 · c2 · V P2 · u 2k + k 6 · c2 · u 2VP . (16)
where u(yi , zi ) is the correlation between the z and y 3D
coordinates of each contour point and: In eq. (16) u k depends on the ultrasound probe specifications;
∂Aj ∂Aj typically a good approximation [21] for many probes is
= zi+1 − zi−1 ; = yi+1 − yi−1. (10)
∂yi ∂zi mm
u k = 0.2 · 10−3 . (17)
The uncertainty and the correlation of the coordinates pixel
y and z of a generic contour point P(x, y, z) can be calculated The term u c is estimated as standard deviation of the cor-
considering eq. (1), and considering negligible the uncertainty rection factors reported in Table III. In particular, a value of
on px (namely the abscissa of the image). Therefore, we u c = 0.005 has been found.
obtain: Summarizing, Table IV reports the uncertainty components
  
2 ∂y 2 2 ∂y 2 2 ∂y 2 2 to be considered in the overall uncertainty estimation.
uy = · uθ x + · uθy + · u py
∂θx ∂θ y ∂ py
  
∂z 2 2 ∂z 2 2 ∂z 2 2 V. E XPERIMENTAL R ESULTS
u2z = · uθy + · udy + · u py (11)
∂θ y ∂d y ∂ py
In this Section, experimental results of tests carried out on
∂y ∂z 2 two patients in different hospitals are shown. The first test is
u(y, z) = · u (12)
∂θ y ∂θ y θ y related to a patient under the age of thirty years and without
evident diseases in the carotid artery. The second test is carried
The uncertainty component on the edge position, along the
out on a patient with carotid atherosclerosis.
py direction, u py mainly depends on the image noise, on the
The first test was conducted in a hospital clinic, namely
edge detection algorithm and so on [18], and it does not
“Villa dei Fiori” in Acerra, Italy. The probe used for this
depend on the add-on system. It was experimentally evaluated
type of testing is the vascular and cardiac probe L12-5 38.
as:
5 pi xels It emits ultrasounds in a frequency interval ranging from
u py = √ = 2.9 pi xels (13) 5 to 12 MHz, and is connected to the ultrasound Philips ATL
3
HDI 5000. The second test was carried out in the hospital
The uncertainty component due to d y was evaluated by con- “Santa Maria Incoronata dell’Olmo” in Cava de’ Tirreni, Italy,
sidering the experimental variability of the correction factors using the probe for HST (Hemispheric Sound Technology)
described in the sub-section B. In particular, five different vascular analysis connected to the ultrasound Aloka Prosound
speeds (5 mm/s, 7 mm/s, 10 mm/s, 12 mm/s, 15 mm/s) 5000SV. In detail, in the first test the probe has a resolution
have been considered. The resulting standard deviation of the of 0.066 mm/pixel, while in the second test a resolution of
correction factors was equal to 0.5 mm, then: 0.1 mm/pixel is experienced. The use of different probes shows
ud y = 0.5mm (14) the suitability of the proposed measurement system to different
ultrasound equipment.
Finally, the uncertainty on the angle of incidence depends The two considered tests differ also in the plaque volume: in
on the error of the package used in evaluating the angles. the first test a patient with a very small (practically negligible)
Considering a maximum absolute error equal to 0.6° (in plaque has been considered, whereas, in the second test an
the range of interest), and assuming a uniform distribution, appreciable plaque volume has been involved.
CAPRIGLIONE et al.: MEASUREMENT SYSTEM TO REALIZE 3-D CAROTID OCCLUSION MEASUREMENT 755

TABLE V TABLE VI
P ROBE P OSITIONS AND A NGLES P ROBE P OSITIONS AND A NGLES

Fig. 10. The 2-D edge detection on the #1 acquired B-mode image.

Fig. 12. The 2-D edge detection on images #1 and #2.

The obtained results as for the volume measurement and the

stenosis percentage together with their uncertainty are reported
in the following.
V Pc = 200 mm3 O% = 6.6 %
u v = 40 mm3 u O% = 1.5 %
Looking at the obtained results, it is possible to highlight that
the relative uncertainty is about 20% for both measurements.

B. Results of the Second Test

Ten B-mode images were considered. Also in this case, no
movement on both the z-axis angle and on the z direction was
performed. The values measured as for the x and y angles and
directions are reported in Table VI, while Fig. 12 sketches the
2-D edge detections for the image #1 and #2.
Once again, the overall uncertainty is evaluated by consider-
Fig. 11. The reconstructed 3-D carotid model. ing the components reported in Table IV and eqs. (7) and (16).
The obtained results as for the volume measurements and
the stenosis percentage together with their uncertainty are
A. Results of the First Test reported in the following.
Five B-mode images were considered. The values measured V Pc = 340 mm3 O% = 16%
as for the x and y angles and directions are reported in the u v = 46 mm3 u O% = 2 %
Table V. In addition, no movement on both the z-axis angle
and on the z direction was considered. In this case, the plaque volume is greater than the one of the
In the post processing stage, the selection of the ROI is previous test, thus the relative measurement uncertainty related
carried out and the 2-D edge detection is performed. As an to the stenosis percentage is smaller (about 12%).
example, Fig. 10 depicts the output of this stage for the
image #1. Fig. 11 sketches the reconstructed 3-D carotid model VI. C ONCLUSION
achieved by processing the five images with eq. (1). A low-cost measurement system for the three-dimensional
As for the uncertainty estimation, taking into account the analysis of occlusions within the carotid artery has been intro-
components reported in Table IV and eqs. (7) and (16), we duced. The proposed system can be added onto a conventional
obtain the overall uncertainty for both the stenosis percentage diagnostic ultrasonographic system in the shape of an add-on
and the plaque volume (u O% and u v , respectively). package, in order to upgrade preexisting equipment. The paper
756 IEEE SENSORS JOURNAL, VOL. 14, NO. 3, MARCH 2014

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Domenico Capriglione (M’04) was born in Cava de’ Tirreni, Italy, in 1975.
three-dimensional ultrasound vessel wall volume: An imaging phenotype
He received the M.S. degree (cum laude) in electronic engineering from
of carotid atherosclerosis,” Ultrasound Med. Biol., vol. 33, no. 6,
the University of Salerno, Salerno, Italy, in 2000. Since 2001, he has been
pp. 905–914, 2007.
an Assistant Professor of electrical and electronic measurements with the
[9] B. Chiu, M. Egger, J. D. Spence, G. Parraga, and A. Fenster, “Quan- Department of Electrical and Information Engineering, University of Cassino
tification of carotid vessel wall and plaque thickness change using 3D and Southern Lazio, Cassino, Italy. His current research interests include
ultrasound images,” Med. Phys., vol. 35, pp. 3691–3710, Jul. 2008. measurement systems based on face recognition, DSP-based measurement
[10] H. G. Beebe, S. X. Salles-Cunha, R. P. Scissons, S. M. Dosick, systems, instrument fault detection and diagnosis, measurement of electro-
R. C. Whalen, S. S. Gale, et al., “Carotid arterial ultrasound scan magnetic compatibility, and measurements on RF and telecommunication
imaging: A direct approach to stenosis measurement,” J. Vascular systems. He is co-author of more than 100 scientific articles, most of which
Surgery, vol. 29, no. 5, pp. 838–844, 1999. were published in relevant international journals. He is a member of the
[11] A. H. Rotstein, R. N. Gibson, and P. M. King, “Direct B-mode NASCET Italian Association for Electrical and Electronic Measurements (GMEE),
style stenosis measurement and Doppler ultrasound as parameters for the National Inter-University Consortium for Telecommunications (CNIT),
assessment of internal carotid artery stenosis,” Australasian Radiol., the Italian Federation of Electrical, Electronic, Automation, Information and
vol. 46, no. 1, pp. 52–56, Mar. 2002. Telecommunication (AEIT).
CAPRIGLIONE et al.: MEASUREMENT SYSTEM TO REALIZE 3-D CAROTID OCCLUSION MEASUREMENT 757

Luigi Ferrigno (M’04) received the M.S. degree Vincenzo Paciello (M’08) was born in Salerno,
in electronic engineering from the University of Italy, in 1977. He received the M.S. degree in
Salerno, Salerno, Italy, and the Ph.D. degree in electronic engineering and the Ph.D. degree in infor-
electrical engineering from the University of Napoli, mation engineering from the University of Salerno,
Napoli, Italy. He is currently an Associate Professor Fisciano, Italy, in 2002 and 2006, respectively. Since
of Electrical and Electronic Measurements and the 2008, he is an Assistant Professor of electrical
Chief of the Metrological Laboratory LAT105 with and electronic measurements with the University of
the Department of Electrical and Information Engi- Salerno. He has been with the new Department of
neering at the University of Cassino and Southern Industrial Engineering of the same university since
Lazio, Italy. His current research interests include January 2011. His current research interests include
the realization and characterization of wireless sen- mechanical and electronic measurements, wireless
sor networks, the realization of the measurement system for nondestructive sensor networks, instrument interfaces, and digital signal processing for
testing, the characterization of electric system and components in non- advanced instrumentation.
sinusoidal conditions, and characterization of wired and RF digital transmis-
sion apparatuses.
Alfredo Paolillo (M’08) was born in Belvedere
Marittimo, Italy, in 1972. He received the M.S.
degree in electronic engineering and the Ph.D.
Gianfranco Miele (S’06–M’08) was born in degree in information engineering from the Univer-
Cassino, Italy, on May 26, 1979. He received the sity of Salerno, Salerno, Italy, in 2000 and 2004,
M.S. degree (cum laude) in telecommunication engi- respectively. He is an Assistant Professor of elec-
neering and the Ph.D. degree in electrical and infor- tronic measurements with the Faculty of Engineer-
mation engineering from the University of Cassino, ing, University of Salerno, Italy. He has been with
in 2004 and 2008, respectively. Since 2011, he the Department of Industrial Engineering of the
has been an Adjunct Researcher of electrical and University of Salerno since January 2011. His main
electronic measurements with the Dipartimento di interests are in measurement systems based on vision
Ingegneria Elettrica e dell’Informazione (DIEI), for- and on numerical signal analysis.
merly the Dipartimento di Automazione, Elettro-
magnetismo, Ingegneria dell’Informazione e Matem-
atica Industriale, University of Cassino and Southern Lazio, Cassino, Italy. In Paolo Sommella (M’11) received the M.S. degree in
2008, he was awarded the Carlo Offelli Prize for the best Ph.D. disserta- electronic engineering and the Ph.D. degree in infor-
tion in electronic measurement subject titled “Design and implementation mation engineering from the University of Salerno,
of an apparatus for reliable and repeatable power measurement in DVB- Fisciano, Italy, in 2004 and 2008, respectively. He
T systems.” His current research interests include electrical and electronic has been a Research Fellow with the University of
measurements, and, in particular, design and implementation of innovative Salerno since 2010. His current research interests
methods for performance assessment of RF telecommunication systems and are instrument fault detection and diagnosis, mea-
communication networks, image-based measurement systems, measurement of surement in software engineering, and biomedical
electromagnetic compatibility, and DSP-based measurement systems. He is a image processing.
member of the Italian Association for Electrical and Electronic Measurements
(GMEE) and of the IEEE “Instrumentation and Measurement Society.”