Comparison of vessel contrast measured with a scanning-beam digital x-ray system and an image intensifier/television system.

Vessel contrast was measured in the fluoroscopic images produced by a scanning-beam digital x-ray (SBDX) system and an image intensifier/television (II/TV) based system. The SBDX system electronically scans a series of pencil x-ray beams across the patient, each of which is directed at a distant small-area detector array. The reduction in detected scatter achieved with this geometry was expected to provide an increase in image contrast. Vessel contrast was evaluated from images of a phantom containing iodinated tubes. The vessels were inserted into an acrylic stack to provide a patient-mimicking scattering medium. Vessel diameter ranged from 0.3 to 3.1 mm. Images were acquired at 100 kVp with the SBDX and II/TV systems and averaged to reduce x-ray noise. The II/TV system was operated in the 6-in. image intensifier mode with an anti-scatter grid. The increase in contrast in the SBDX images, expressed as a ratio of the measured SBDX and II/TV contrasts, ranged from 1.63 to 1.79 for individual vessels. This agreed well with a prediction of the contrast improvement ratio for this experiment, based on measurements of the scatter fraction, object-plane line spread functions, and consideration of the source spectrum and detector absorption properties. The predicted contrast improvement ratio for SBDX relative to II/TV images was 1.62 to 1.77.

The AAPM/RSNA physics tutorial for residents: fluoroscopy: optical coupling and the video system.

In fluoroscopic/fluorographic systems, an image intensifier is optically coupled to recording cameras. The optical distributor is responsible for transmitting a focused image from the output phosphor of the image intensifier to the focal planes of the cameras. Each camera has an aperture, which is used to control the level of light reaching its focal plane. The aperture setting determines the patient x-ray exposure level and the image noise level. Increasing the x-ray exposure reduces image noise; reducing the x-ray exposure increases image noise. Fluoroscopic/fluorographic systems always include a video camera. The functions of the video system are to provide for multiple observers and to facilitate image recording. The camera head contains an image sensor, which converts the light image from the image intensifier into a voltage signal. The device used to generate the video signal is a pickup tube or a charge-coupled device sensor. The method used is raster scanning, of which there are two types: progressive and interlaced. The vertical resolution of the system is primarily determined by the number of scan lines; the horizontal resolution is primarily determined by the bandwidth. Frame rate reduction can be a powerful tool for exposure reduction.

Improved densitometric measurement of left ventricular ejection fraction using dual-energy digital subtraction angiography.

The effects of misregistration artifacts and background corrections on the densitometric measurement of left ventricular ejection fraction (EF) from digital subtraction angiography (DSA) images were studied in 20 patients. Densitometric ejection fraction measurements were performed on both conventional time subtraction images and on dual-energy subtraction images. Dual-energy subtraction is not sensitive to the motion induced artifacts which often mar time subtraction images. While the time subtraction images had varying degrees of misregistration artifacts, none of the dual-energy studies contained significant misregistration artifacts. Densitometrically determined ejection fractions measured with and without correction for background signals were compared. Poor agreement between time subtraction ejection fractions determined with and without background correction (EFNO-BKG = 0.88 EFBKG - 6.0%, SEE = 8.1%, r = 0.83) demonstrated the sensitivity of time subtraction EFs to the performance of a background correction procedure. Conversely, densitometric measurement of ejection fraction using dual-energy subtraction was significantly less sensitive to the performance of a background correction (EFNO-BKG = 0.99 EFBKG - 5.3%, SEE = 4.3%, r = 0.96). Since background correction requires accurate definition of ventricular borders, but motion artifacts often preclude accurate border definition, it is concluded that dual-energy subtraction is a significantly more robust method for measuring left ventricular ejection fraction using densitometry. It is further concluded that identification of the systolic endocardial border is not required when performing densitometric EF measurements on dual-energy images. Drawing of the end-diastolic border alone is sufficient to produce an accurate ejection fraction measurement.

Optimization of beam parameters for dual-energy digital subtraction angiography.

Dual-energy digital subtraction angiography (DSA) is immune to the misregistration artifacts which plague conventional temporal subtraction DSA. However, since the signal-to-noise ratio (SNR) of dual-energy DSA is lower than temporal subtraction it is important to optimize the dual-energy technique with respect to the SNR. This study investigates the optimization of x-ray exposure parameters for the low- and high-energy x-ray beams, drawing upon our experience with dual-energy DSA studies in 20 cardiac patients. It is shown that the SNR is optimized, with respect to patient exposure, when the image intensifier (II) exposure for the high-energy beam is approximately 5 times higher than the low-energy beam. The unequal distribution of exposure between the low- and high-energy beams is achieved by selecting different video apertures for the two beams, and is therefore referred to as the "dual-aperture" technique. The dual-aperture technique achieves the same SNR as the single-aperture technique (which uses equal II exposures for the two beams) with 45% less patient exposure. In addition, the dual-aperture technique enhances the ability to maintain an optimum low-energy kVp, which increases the dual-energy signal amplitude. The optimum high-beam filter thickness for use with the dual-aperture approach is determined. The optimum filter thickness, which is dependent upon the desired tube loading, is found to range from 1.3 to 2.0 mm Cu for tube loads ranging from 188 to 688 J/beam pair.

Densitometric assessment of regional left ventricular systolic function during graded ischemia in the dog by use of dual-energy digital subtraction ventriculography.

Densitometric analysis of images obtained by digital subtraction angiography (DSA) allows for more reproducible and less operator-dependent quantitation of ventricular function. Conventional DSA uses temporal subtraction but is limited by misregistration artifacts. Dual-energy digital subtraction angiography (DE-DSA) is immune to such misregistration artifacts. The ability of DE-DSA to quantitate changes in regional ventricular volume resulting from ischemia was tested. Densitometric analysis of both phase-matched and ejection fraction DE-DSA images was used to quantitate regional left ventricular systolic function during four levels of ischemia ranging from mild to severe in open-chest dogs (n = 10). DE-DSA left ventriculograms were obtained by means of central venous injections of iodinated contrast medium. Ischemia was graded according to percentage of systolic wall thickening as measured by sonomicrometry. Phase-matched end-systolic images were obtained at each of four levels of ischemia by subtracting an end-systolic control image from each end-systolic ischemic image. Ejection fraction images were obtained at the control level and at each level of ischemia by subtracting an end-systolic image from an end-diastolic image of the same cardiac cycle. The resulting wall motion difference signals represent the changes in regional ventricular volumes and were quantitated by densitometry. Densitometry was able to detect the effect of all levels of ischemia on regional function, even the mildest. Densitometric analysis of both phase-matched and ejection fraction DE-DSA images provides a sensitive technique for detecting and quantitating the changes in regional left ventricular systolic volume that occur with ischemia.

Measurement of absolute blood iodine concentration during digital subtraction ventriculography.

A system to measure the absolute iodine concentration (mg iodine/milliliter blood) in the left ventricle (LV) during digital subtraction ventriculography has been developed. The technique uses a catheter to draw blood from the LV through a detection cell. This occurs as the iodine bolus passes through the heart. The cell determines iodine concentration by measuring x-ray attenuation as the iodinated blood passes between a low-power x-ray tube and a diode detector. In vitro and in vivo testing of the system was conducted. The system response was linear (r = 0.99) with respect to iodine concentration. This response was independent of hematocrit. Dispersion of contrast medium in the catheter caused distortion of the shape of the time-concentration curve. The impulse response of the system was measured and found to be independent of hematocrit. A correction algorithm based on Wiener filter deconvolution was developed. In vitro testing using simulated time-concentration curves demonstrated that the rms error in the iodine measurement after dispersion correction did not exceed 4% over the region of the time-concentration curve extending from the peak to the point on the tail where the signal fell to 50% of its peak value. Cardiac output was measured from the time-concentration curve via the indicator-dilution method in an animal model. This cardiac output measurement (COI) agreed closely with cardiac output measured simultaneously with an aortic flow probe (CO(P)), namely, COI = 1.02 CO(P)-0.03 L/min, r = 0.95, SEE = 10%, p < 0.001.(ABSTRACT TRUNCATED AT 250 WORDS)

Limitations of the lead oxide vidicon for dual-energy digital subtraction angiography.

Dual-energy digital subtraction angiography (DSA) can be performed, with some modifications, using existing systems designed for conventional DSA work. However, the video camera generally found in such installations, the lead oxide vidicon, places significant limitations on the image quality of dual-energy DSA. If the video camera is operated in a 60 Hz, 266 line progressive scanning mode to maintain a nominal 30 subtraction images/s frame rate, the maximum available X-ray pulse width is limited to 5 ms. The resulting required increase in low-energy kVp reduces the dual-energy signal-to-noise ratio by approximately 40% for cardiac dual-energy DSA imaging. In addition, the performance of the video camera with respect to read-out lag is much more important for dual-energy DSA than conventional single-energy imaging. Measurements show that lag reduces the iodine contrast in dual-energy DSA by up to 20% when a 30 Hz vertical scan mode is used, and by up to 27% when a 60 Hz vertical scan mode is employed. Replacement of the lead oxide vidicon with a CCD camera removes these limitations.

Left ventricular dual-energy digital subtraction angiography: a motion immune digital subtraction technique.

Digital subtraction angiography (DSA) allows quantitative analysis of ventricular function via densitometric and parametric imaging techniques. However, DSA is limited by the artifacts in temporal subtraction images that result from patient and cardiac motion. Dual-energy subtraction imaging is insensitive to motion. This study evaluated the initial application of dual-energy subtraction in cardiac patients. The image quality of dual-energy subtraction left ventriculograms obtained from a pulmonary artery injection of contrast was assessed in 13 patients, ranging in weight from 54 to 100 kg. The dual-energy images were compared with left ventricular images obtained using standard left ventricular injection cine angiography. End-systolic and end-diastolic ventricular volumes calculated from the cine (C) and dual-energy (DE) images using the Area-Length method were compared. The resulting regression line was DE = 0.98 C+ 7.0 ml, and the r value was 0.987. Dual-energy subtraction provided good left ventricular visualization, free from misregistration artifacts, even during patient motion.

A correlated noise reduction algorithm for dual-energy digital subtraction angiography.

It has long been recognized that the problems of motion artifacts in conventional time subtraction digital subtraction angiography (DSA) may be overcome using energy subtraction techniques. Of the variety of energy subtraction techniques investigated, non-k-edge dual-energy subtraction offers the best signal-to-noise ratio (SNR). However, this technique achieves only 55% of the temporal DSA SNR. Noise reduction techniques that average the noisier high-energy image produce various degrees of noise improvement while minimally affecting iodine contrast and resolution. A more significant improvement in dual-energy DSA iodine SNR, however, results when the correlated noise that exists in material specific images is appropriately cancelled. The correlated noise reduction (CNR) algorithm presented here follows directly from the dual-energy computed tomography work of Kalender who made explicit use of noise correlations in material specific images to reduce noise. The results are identical to those achieved using a linear version of the two-stage filtering process described by Macovski in which the selective image is filtered to reduce high-frequency noise and added to a weighted, high SNR, nonselective image which has been processed with a high-frequency bandpass filter. The dual-energy DSA CNR algorithm presented here combines selective tissue and iodine images to produce a significant increase in the iodine SNR while fully preserving iodine spatial resolution. Theoretical calculations predict a factor of 2-4 improvement in SNR compared to conventional dual-energy images. The improvement factor achieved is dependent upon the x-ray beam spectra and the size of blurring kernel used in the algorithm.(ABSTRACT TRUNCATED AT 250 WORDS)

Digital subtraction bronchography with stable xenon.

An experimental animal study using digital subtraction fluoroscopy to image the bronchial tree with stable xenon shows that major bronchi can be imaged. A fast frame rate is necessary to minimize the effects of subject motion. Optimum contrast between air in lung and xenon in bronchi is obtained when the first two-thirds of a vital capacity breathhold consists of air or oxygen and the last one-third consists of 100% xenon.

Videodensitometric quantitation of mean blood flow.

Standard angiography demonstrates the anatomy of arterial occlusive disease but does not define its physiological significance. However, measurement of flow in a compromised vessel at rest and following peripheral dilatation provides important physiological information. Using digital subtraction angiography, femoral arterial flows determined by the cross-correlation transit time technique were compared to measurements by electromagnetic flowmeter. Thirty-five femoral arterial flow measurements were obtained in nine dogs instrumented with an electromagnetic flow probe and balloon occluder. Renografin 76 (7 cc) was power-injected at 14 cc/sec into the distal abdominal aorta. Angiographic flow measurements correlated well with electromagnetic flowmeter measurements (r = 0.94, standard deviation of the difference (SDD) = 15 ml/min). Intravenous studies provided somewhat poorer correlation due to difficulties in defining dimensions (r = 0.72, SDD = 36). Paired contrast injections (2 injections in succession) in 11 studies increased flow from an average of 80 to 250 ml/min (a 210 +/- 100% increase), providing an estimate of a vessel's capacity to provide increased flow during peripheral dilatation. Thus, reliable angiographic flow determinations may be obtained by arterial and intravenous contrast injections, adding physiological information to anatomical definition.

Work in progress: hybrid temporal-energy subtraction in digital fluoroscopy.

Initial clinical results using a digital fluoroscopic implementation of the combined time-energy ("hybrid") subtraction technique are described, with emphasis on carotid and renal imaging. Where patient motion artifacts are due to soft-tissue motion alone, hybrid subtraction can remove them. Due to the need for a finite separation time between high- and low-energy pairs, however, the present implementation of the hybrid technique is not completely immune to soft-tissue motion. The intrinsic signal-to-noise ratio of hybrid imaging is less than that of conventional temporal subtraction. However, since the low-energy temporal subtraction images are included in the hybrid data set, the diagnostic quality of the examination is not compromised.

Work in progress: a correction for tissue iodine accumulation in videodensitometric measurements of left ventricular ejection fraction.

Left ventricular ejection fractions were determined following eight intravenous injections in three dogs using area/length and digital videodensitometric techniques. Ejection fractions were measured by both techniques for all beats during left ventricular opacification. Even after noniodinated background corrections, tissue iodine accumulation produced large errors in measured iodine content late in the contrast material curve. By using a model for tissue iodine accumulation, an algorithm was developed that appears to reduce these errors. The measured ejection fraction for ten beats following the peak of the contrast material curve declined an average of 1.8% following correction, compared with 14% prior to correction. Following correction for tissue iodine accumulation, correlation between area/length and video-densitometric ejection fractions was 0.94. By correcting for tissue iodine accumulation, much more of the contrast material curve provides usable data for estimating ejection fractions.

Digital subtraction angiography as a method of screening for coronary artery disease during peripheral vascular angiography.

Since myocardial infarction is the major cause of perioperative and postoperative death following peripheral vascular surgery, an accurate method of screening for coronary artery disease in this group of patients is needed. Digital subtraction angiography (DSA) with the use of intra-arterial aortic root injection of contrast material was evaluated as a method of screening for coronary artery disease in patients undergoing angiography for peripheral vascular disease. The feasibility of this method was demonstrated in animal experiments. Fifteen milliliters of Renografin-76 was power injected into the aortic root of seven anesthetized 20 kg mongrel dogs. Normal coronary artery anatomy was clearly demonstrated with DSA, and a series of iatrogenically created stenoses and occlusions were accurately identified. Excellent definition of patent grafts to the left anterior descending and circumflex coronary arteries was obtained in two dogs that had undergone previous coronary artery bypass grafting. A balloon occluder on one graft was used to demonstrate partial and near-total obstruction of the bypass graft. We are currently studying the use of aortic root injections using DSA to determine coronary artery disease in patients having standard angiography for peripheral vascular disease. Adequate visualization of coronary arteries and bypass grafts with only 20 ml of contrast has been obtained. The potential ability of this technique to identify and allow treatment of life-threatening coronary artery lesions in patients prior to or simultaneously with peripheral vascular surgery may result in reduced mortality.

Computerized fluoroscopy: new technique for the noninvasive evaluation of the aorta, coronary artery bypass grafts, and left ventricular function.

A computerized fluoroscopy system has been developed on the basis of real-time digital processing of x-ray transmission data from traditional image-intensified fluoroscopy equipment. High-quality visualization of any part of the arterial system is obtained following intravenous injection of 0.5 to 0.75 ml/kg of iodinated contrast materials. This report describes the use of this technique to evaluate the aortic arch, left ventricular function, and coronary artery bypass graft patency. Fifty intravenous studies were performed in 25 patients. Among 20 patients with coronary artery bypass grafts, computerized fluoroscopy correctly identified 11 of 15 patent grafts and 11 of 11 occluded grafts as confirmed by standard coronary arteriography in 11 of these patients. Unlike computerized tomography, our technique gives a longitudinal view of the bypass graft much like direct coronary angiography. Aortic arch studies included demonstration of a right aortic arch with a small left subclavian artery, a coarctation, and a normal aortic arch in a trauma patient with a wide mediastinum. Segmental wall motion abnormalities were clearly identified by a modification of the technique which produces a negative outline on the ventriculogram in dyskinetic segments. Ejection fractions may be calculated by determining the amount of iodine in the ventricle in systole and diastole. This technique may also be used to evaluate carotid disease and peripheral vascular disease in patients undergoing coronary artery bypass procedures. Computerized fluoroscopy, therefore, allows evaluation of the entire cardiovascular system by the relatively noninvasive technique of intravenous angiography.

A technique of scatter and glare correction for videodensitometric studies in digital subtraction videoangiography.

The logarithmic amplification of video signals and the availability of data in digital form make digital subtraction videoangiography a suitable tool for videodensitometric estimation of physiological quantities. A system for this purpose was implemented with a digital video image processor. However, it was found that the radiation scattering and veiling glare present in the image-intensified video must be removed to make meaningful quantitations. An algorithm to make such a correction was developed and is presented. With this correction, the videodensitometry system was calibrated with phantoms and used to measure the left ventricular ejection fraction of a canine heart.

Estimation and minimization of fetal absorbed dose: data from common radiographic examinations.

A simple method of estimating fetal absorbed dose from common abdominal and pelvic radiographic examinations is presented. The method uses experimentally determined normalized depth dose curves (rad/Roentgen exposure free-in-air) and sonographic localization of the fetus. The method is useful for estimating fetal absorbed dose when a pregnant woman inadvertently undergoes a radiographic examination. However, its primary value is in minimizing fetal dose when a woman, known to be pregnant, must undergo a radiographic examination. Selection of proper projection and deliberate adjustment of bladder volume can result in significant fetal dose reduction particularly in the critical first trimester.

Normalized organ doses for various diagnostic radiologic procedures.

Organ-absorbed doses for 24 diagnostic examination projections were measured using an Alderson Rando phantom. The organs of interest were testes, ovaries, thyroid, eyes, uterus, and active bone marrow. The reported values were normalized to the unit entrance exposure of each examination. Subsequent comparison of these measured values with the experimental and calculated values of other investigators showed reasonable agreement.