Resident Physics Lectures: Digital Subtraction Angiography (DSA)

Resident Physics Lectures
Digital Subtraction Angiography

(DSA)
Prof. J.K Tonui, PhD
School of Medicine,
Department of Radiology & Imaging
Learning Objectives
 At the end of this lecture, the student is expected to:
 Discuss digital subtraction angiography (DSA) imaging.
 Describe how images are produced of contrast filled vessels in
isolation from other tissues.

 Describe briefly the DSA subtraction algorithm
2 RIB 810, 811 & RIB 812 Imaging Physics 8/18/2019

Introduction
 Digital subtraction angiography (DSA)
 Is a radiographic technique used in diagnosis of vascular diseases,
and
 Hence, is used to obtained images of arteries in various parts of
the body (e.g. in the heart and brain), and

 This procedure is performed both with and without contrast agent
administered to the artery in order to distinguish vessels clearly

from distracting surrounding bone and soft tissues.
What is Angiography?
 Angiography
 Is usually shortened as “Agio”, which
 Is a Greek word meaning “ blood vessel”, hence
 Angiography is mainly an x-ray technique used specifically for
imaging and diagnosis of blood vessels, but

o Was initially used to diagnose pathology of the vessel such as plague
formation, and
o May be used also for minimal guided invasive surgery of vascular system,
mainly cardiac artery.

Complementary Techniques
 Complementary techniques to x-ray angiography
 Include MR, CT and/or US diagnostic vascular imaging
techniques, which
 Are non-invasive unlike x-ray angiography which requires
insertion of a catheter into the vessel to inject a contrast

material, and
 Common terminologies used are arteriography for arteries
studies, and venography for veins studies.

Digital Subtraction Angiography (DSA)
 X-ray angiography
 Is a special type of digital fluoroscopy, where
o Two digital images are obtained, before and after contrast agent is
administered to the pt. (i.e. pre- and post contrast), and

o The two images are subtracted to get images of the vessels alone,
and
o The image removed is referred as a “mask or unopacified image”.

The DSA
 In x-ray DSA
 The first image is obtained before the contrast agent is
administered to vessel of the pt, to produce a pre-contrast or

mask image, which shows the distracting background, and
 The second image is obtained when the contrast agent, usually
iodine is introduced, and

 The two “movie” like images are digitized and subtracted by the
computer of the imaging system.

The DSA
 Subtraction process
 Eliminates or cancels out the images
that are present in both frames usually

the bone and soft tissues, and
 Leaves out an outlined of the opacified
vessel, i.e. an image of the contrast

material-filled vessel only, and
 Fig. shows typical x-ray Angio suite.

The DSA
 Clinical DSA
 Is a powerful technique for visualizing the blood vessels in human
body, because
 In normal x-ray projection images, blood vessels are hardly visible due
to very low contrast between vessels and surrounding tissues, but

 In DSA, contrast agent injected (iodinated solution) enhances the
contrast or visibility of the vessel.

The DSA
 Note that,
 Even with contrast agent injection, there is no contrast between
vessel and surrounding tissues if no further processing is done, and

 May even leads to misdiagnosis because the vessels may appear
like bones, and

 It is for this reason that real-time subtraction of pre- and post-
contrast images is performed.

The DSA
 Note that
 Subtraction processes increase image noise, but
 The perception of low-contrast vessels is increased due to
removal of distracting background tissues.
 DSA
 Has proven useful in identification of vascular abnormalities such as:
o Occlusions, stenosis, ulcerated plagues and aneurysms.

The DSA
 In general, DSA is acquisition of digital
fluoroscopic images
 First, before the contrast agent is administered Mask
Image
into the blood in the vessel, and
 Secondly, after the contrast agent is
administered, and subtracti

on Image
 Then, performing real-time subtraction of pre-
and post contrast images as shown in Fig.

Contrast Agent
 The blood vessels
 Are not normally seen in an x-ray image because of its low tissue
contrast, and
 In angio, a contrast agent solution of high-Z element (iodine usually) is
injected into blood vessel to increase image contrast, and

 Due to high-Z and density, iodine absorbs photons more than
blood and tissue, which

 In turn creates detailed images of the blood vessels in real time.

Contrast Agent
 Initial contrast media
 Used for intravascular injection were called high-osmolar
contrast media (HOCM), and

 HOCM has osmolarity (a measure of particle concentration in a
solution) of about seven to eight times higher than plasma, but

 The high value of osmolarity caused adverse effects on the
patients such as pain, endothelial damage, thrombosis and increased

pressure in the pulmonary circulation.

Contrast Agent
 Due to the adverse effects of HOCM
 Low-osmolar contrast media (LOCM) were first used in
1970’s and these helped reduce these side effects, and

 One of the major risks of modern iodine contrast media is
allergic reactions to iodine.

The DSA Imaging
 The heart of a DSA system
 Is a digital image processing system, which
o Provides timing signals to both x-ray generator and the image
acquisition system or camera, and

o Controls the flow of data from the x-ray source into the image
processor, and
o Fig. in next slide shows block diagram of a typical DSA system.

Diagram of DSA System

The DSA System
 The mask or non-contrast image
 Is taken before contrast medium has reached target area, and
 Only normal anatomy is shown and stored on a computer memory, and
 Usually two frames are acquired – one to stabilise exposure factors,
and second is the mask.
 The contrast image
 Is s taken when the vessels are filled with contrast medium, and
 It shows filled vessels superimposed on normal anatomy and is also
stored on the computer memory.

The DSA System
 Fig. below
 Shows two images being subtracted (post-contrast – pre-constrat), pixel by
pixel, and
 The resulting subtraction image is stored as a third image, which
 Shows the filled vessels only.

The DSA System
 Recording
 Can continue to provide a series of subtracted images, as shown
in Fig below and may be viewed in real-time.

The DSA System
 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,
and
 Serial images show changes in the contrast appearance over time
(temporal subtraction) and at varying X-ray intensities (energy

subtraction) as shown in figures in previous slide.

The DSA System
 Most DSA examinations
 Require 25 to 45 minutes to perform provided there are no technical
complications, e.g. difficulties with catheterization, and

 Can be performed on an outpatient basis (low cost).
 Temporal subtraction
 Are time dependent (i.e. serial images are taken at different times) and
o Pre-contrast images are called “mask images”,
o Post-contrast images are called “live images”.

The DSA System
 In temporal subtraction
 The mask image is subtracted from live image, which
 Gives subtracted Image as shown in Fig. below.

The DSA Images
Mask image
(original)
Live image (original + Mask-Live
contrast media)

The DSA Images
Mask image Live image Live-Mask

The DSA Images
MASK LIVE MASK - LIVE LIVE - MASK

Image Acquisition Process
 A computer is used to control image acquisition, where
 A timing signal is sent to an x-ray generator to initiate x-rays
production, which
 Are in turn incident to the patient, and
 Exiting x-rays are directed thro’ an II tube similar to that used
in fluoroscopy, which
 Convert x-rays to light and magnify to high intensity.

 An aperture (collimator)
 Is placed between II and a video camera, in order
 To controls the amount of light delivered to the camera.
 The video camera
 Receives the light image from the II and
 Converts it to an electronic video signal, which
 Is then delivered to the image processor in analog form.

 The image processor
 Digitizes and stores the image in its memory, and
 Makes it available in digital form for subtraction with another
image set acquired at a different time or at a different energy, and

 The subtraction is done by a computer algorithm which removes
a “mask” image or images that are present in the two images

obtained.

Subtraction Algorithm
 Computer algorithm
 Use temporal (time) subtraction,
where
 Two images obtained at different
times are subtracted, one with and

the other without contrast agent, as
shown in this Fig.

Subtraction Algorithm
 Dynamic (moving) images of the patient
 Are acquired at a rate of 1 exposure per second or more:
o 1st without contrast or unopacified, and
o 2nd with contrast or opacified (with contrast agent).
 Subtraction
o The two images obtained before and after contrast agent has been
administered are subtracted to remove the mask (image before

contrast agent is administered).

Algorithm
 Subtraction
 Of unopacified image (no contrast) is made from the opacified image (with
contrast), and
 Is done in order to isolate signal present only in opacification image, i.e.
 It removes static anatomical structures (mask) that are common to both
opacified and unopacified images, which

 Eliminates background structures or mask, hence
 Making arteries visible in the subtracted image, which
 Were not visible or barely visible before subtraction.

Image Subtraction
 Two images are acquired:
 First - "mask" image
o which is obtained before contrast media is injected into the patient, and
 Second - "opacification" image,
o Which is obtained when contrast media is administered and allowed to
settle at the artery being imaged.
 And both images can be modeled mathematically by assuming
that pt. has thickness, xt and linear attenuation coefficient of μt.

Image Subtraction
 Before contrast media is injected into the patient,
 The photon flux delivered to II is given by:
  t xt
I m  I oe
 After injected of contrast agent to opacify the artery, then
 II receives a photon flux given by:
  t xt   I x I 
I I  I oe
 where xI is thickness (where xI << xt) and μI is linear
attenuation coefficient of contrast medium (Iodine).

Image Subtraction
 Since video signal is directly proportional to x-ray photon
flux, then
 Video signal of the mask is given as
  t xt
I m  I o e
 Video signal with opacification is given by
   t xt   I x I 
I I  I o e
 Where α is the conversion factor which relates the amplitude of
the video signal to the photon flux.

Image Subtraction
 The two equations in previous slide can be subtracted in
two ways:
1. Linear subtraction
o subtraction of images without logarithmic transformation
2. Logarithmic subtraction
o subtraction of the images after logarithmic transformation (n)

Linear Subtraction
 In this subtraction,
 Opacification image is subtracted from the mask image directly and
is given as
 t xt   t xt   I xI 
Slin  I m  I I  I o e  I o e
 I o e  t xt
1  e   I xI

 where Slin is the subtraction image.

Linear Subtraction
 From previous slide,
 If we assume a small iodination signal such that μIxI<< 1, then the
equation in previous slide becomes
 
Slin    I xI I o e  x t t
 Hence, in linear subtraction,
 Thickness of contrast agent, xI is modulated by patient thickness, xt and
 The resulting image retains unwanted patient anatomy still superimposed on
the desired opacified arterial image, hence rarely used.

Logarithmic Subtraction
 Unlike linear subtraction,
 The logarithmic subtraction does not retain stationary anatomical
structure that may obscure the small signal, because

 The mask and opacification image data are first expressed in
logarithm form as:
InI m  In  InI o  t xt
InI I  In  InI o  t xt   I xI

Logarithmic Subtraction
 The logarithmic equations are then subtracted as:
Slog  InI m - InI
 In  InI o  t xt  In  InI o  t xt   I xI
 Which gives:
S log   I xI
 Thus, this equation shows that the resulting equation is a
function of the contrast agent (iodine) only, and
 Pt.’s thickness or anatomy on which opacification is superposed
do not affect subtraction image and this method is used in DSA.

Image Display and Archival Memory
 After processing,
 The digital images are displayed on a computer screen for
examination by the radiologist, or

 Printed on special films for examination and achieving or
 The digital images are stored or archived in computer storage
systems such as hard-disk , CD, etc.

Resident Physics Lectures: Digital Subtraction Angiography (DSA)

Uploaded by

Copyright:

Available Formats

Resident Physics Lectures: Digital Subtraction Angiography (DSA)

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Resident Physics Lectures: Digital Subtraction Angiography (DSA)

Uploaded by

Copyright:

Available Formats

Resident Physics Lectures

Digital Subtraction Angiography

 Discuss digital subtraction angiography (DSA) imaging.

 Describe how images are produced of contrast filled vessels in

isolation from other tissues.

2 RIB 810, 811 & RIB 812 Imaging Physics 8/18/2019

 Is a radiographic technique used in diagnosis of vascular diseases,

the body (e.g. in the heart and brain), and

administered to the artery in order to distinguish vessels clearly

 Is usually shortened as “Agio”, which

 Is a Greek word meaning “ blood vessel”, hence

 Angiography is mainly an x-ray technique used specifically for

imaging and diagnosis of blood vessels, but

mainly cardiac artery.

4 RIB 810, 811 & RIB 812 Imaging Physics 8/18/2019

 Include MR, CT and/or US diagnostic vascular imaging

insertion of a catheter into the vessel to inject a contrast

studies, and venography for veins studies.

 Is a special type of digital fluoroscopy, where

administered to the pt. (i.e. pre- and post contrast), and

6 RIB 810, 811 & RIB 812 Imaging Physics 8/18/2019

 The first image is obtained before the contrast agent is

administered to vessel of the pt, to produce a pre-contrast or

iodine is introduced, and

computer of the imaging system.

 Eliminates or cancels out the images

that are present in both frames usually

vessel, i.e. an image of the contrast

8 RIB 810, 811 & RIB 812 Imaging Physics 8/18/2019

 Is a powerful technique for visualizing the blood vessels in human

to very low contrast between vessels and surrounding tissues, but

contrast or visibility of the vessel.

9 RIB 810, 811 & RIB 812 Imaging Physics 8/18/2019

 Even with contrast agent injection, there is no contrast between

vessel and surrounding tissues if no further processing is done, and

like bones, and

contrast images is performed.

10 RIB 810, 811 & RIB 812 Imaging Physics 8/18/2019

 Subtraction processes increase image noise, but

 The perception of low-contrast vessels is increased due to

removal of distracting background tissues.

 Has proven useful in identification of vascular abnormalities such as:

o Occlusions, stenosis, ulcerated plagues and aneurysms.

11 RIB 810, 811 & RIB 812 Imaging Physics 8/18/2019

 Secondly, after the contrast agent is

administered, and subtracti

and post contrast images as shown in Fig.

12 RIB 810, 811 & RIB 812 Imaging Physics 8/18/2019

injected into blood vessel to increase image contrast, and

blood and tissue, which

13 RIB 810, 811 & RIB 812 Imaging Physics 8/18/2019

 Used for intravascular injection were called high-osmolar

contrast media (HOCM), and

solution) of about seven to eight times higher than plasma, but

patients such as pain, endothelial damage, thrombosis and increased

14 RIB 810, 811 & RIB 812 Imaging Physics 8/18/2019

 Low-osmolar contrast media (LOCM) were first used in

1970’s and these helped reduce these side effects, and