447

Review

Digital Subtraction
Angiography:
Principles
Pitfalls of Image
Techniques

David C. Levin1
M. Schapiro2
Lawrence
M. Boxt
Lance Dunham1
Donald P. Hamngton1
David L. Ergun1

American Journal of Roentgenology 1984.143:447-454.

Robert

and

Improvement

The
technology
of imaging methods
in digital subtraction
angiography
(DSA) is
discussed in detail. Areas covered include function of the video camera in both interlaced
and sequential
scan modes, digitization
by the analogto-digftal
converter,
loganthmic
signal processing, dose rates, and acquisition
of images using frame integration
and
pulsed-sequential
techniques.
Also discussed
are vanous methods
of improving
Image
content and qualfty by both hardware and software
modifications.
These include the
development
of larger image intensifiers,
larger matrices, video camera Improvements,
reregistratIon,
hybrid subtraction,
matched
fiftering,
recursive
filtering,
DSA tomography,
and edge enhancement.

Since the original digital subtraction angiography (DSA) systems were introduced
in the late 1970s, some important advances in imaging technology have occurred.
As a result, a variety of methods of improving DSA quality have been either
proposed
or implemented. This has created some confusion among radiologists
who must make decisions regarding purchase and use of such systems, but who
generally
lack the physics or engineering background needed to properly evaluate
them. Perhaps as a result, one can note that many recent publications on DSA fail
to describe the technical factors or equipment
specifications
used in performing
procedures, even though the very purpose of these studies is to assess the efficacy
of DSA as an imaging method.
First, we will review some of the basic principles
applicable
to all television (TV)
and DSA imaging techniques; second, we will discuss the various methods of
improving image quality (some already established, others under development)
and
point out some of their associated pitfalls. These image improvement methods
include frame integration, sequential video scanning, video camera modifications,
the use of larger image intensifiers and matrices, reregistration,
hybrid subtraction,
recursive filtration, matched filtration, DSA tomography,
and edge enhancement.
The discussion will primarily emphasize acquisition and processing
of serial-mode
images at 1-10 frames/sec, the type of imaging generally used by radiologists for
noncardiac applications. Image storage technology will not be addressed here, nor
will cardiac imaging, which is often performed at real-time frame rates (30 frames/
sec) and presents a somewhat different set of problems.
Received

February

14, 1984; accepted

after re-

vision May 8, 1984.

This work was supported in part by U.S. Public
Health Service grants GM1 8674 and HL20895.
1Department
of Radiology,
Harvard Medical

School, 25 Shattuck

St., Boston, MA 02115. Address reprint requests to D. C. Levin.

2Pheps Medical Systems, Shelton, CT 06484.
AJR

143:447-454,

S.pt.mber

1984

0361 -803X/84/1433-0447
American Roentgen Ray Socsety

Basic

Principles

The front-end components for video fluoroscopy

include the x-ray tube, table,
image intensifier, distributor, ins, TV camera, and suitable monitor for display. The
x-ray pattem
impinges
on the input phosphor
of the image intensifier
and is
converted
to a light pattem at the output phosphor.
This light image is conveyed

to the video camera by tandem lenses or fiberoptic coupling. The front of the
camera contains the target, a thin layer of tiny lead monoxide elements, which
become positively charged in proportion
to the amount of light they receive from

448

LEVIN

ET AL.

September1984

AJR:143,

1000
3-BAR
IMAGE

OBJECT
ON
INTENSIFIER

100

SIGNAL-TO-

NOISE

RATIO
10

J1J1J1

IDEAL

VIDEO
SIGNAL

LOW

VOLTAGE

10
BAND

BANDWIDTH

20

WIDTH

(MHz)

Fig. 2.-Mdeo
camera signal-to-noise ratio as function of bandwidth.
This
curve was plotted from tests of cameras prior to 1980. cameras of more recent
design

American Journal of Roentgenology 1984.143:447-454.

HIGH

Fig. 1 -Voltage
variation
as video camera electron beam sweeps along
single raster line and encounters
3-bar object. Top tracing shows ideal voltage
pattern to create TV image of this object. Middle tracing shows voltage pattern
that might occur if camera had extremely
low bandwidth. There would be no
video noise but very poor resolution.
Lower tracing shows pattern that might
occur if camera had extremely
high bandwidth.
Edges of object would be
detected very sharply, but because of high system sensitivity,
image would be
very noisy.

the image intensifier [1 2J. A thin electron beam sweeps

across the target horizontally,
providing a current flow path
for these charged elements. This creates a flow of current
with a voltage signal proportional
to the amount of discharge
that occurs at each successive
point. Most video cameras
,

create

images

by scanning

the target

in a raster

pattem

of

525 horizontal linear sweeps 30 times each second (thus,

about 33 msec is required for each complete TV image). At
the end of each horizontal linear sweep, the electron beam
retraces back to the opposite side of the target to begin
scanning the next line.
To perceive continuous
motion without flicker, the human
eye must integrate

at least 48 images/sec

would

show

higher

and somewhat

steeper

curve.

(Reprinted from

[3].)

BANDWIDTH

[2]. If only the 30

video images/sec
were created, a distracting
flicker would
appear on the TV screen during fluoroscopy.
To prevent this,
an interlaced
pattern is used. In interlaced scanning, the
electron beam completes its sweep of line 1, but then instead
of retracing back to begin at line 2, it skips to line 3, then line
5, line 7, and all 262 odd lines. This 262-odd-line
field is
completed in /eo sec. The beam then retraces back to the top
of the target to commence scanning line 2, then line 4, and
all 262 even lines. This also takes l/6o sec, so that a completed
TV frame consisting of odd and even fields is created each
1/3
sec. Because 60 fields are presented to the angiographers eye each second (even though they represent only 30
interlaced frames), no flicker is apparent. Each of the 60 TV
fields/sec
contains
continuously
upgraded
information
received from the output phosphor of the intensifier. Early DSA
units used cameras designed for fluoroscopic
applications,
with interlaced readout only and signal-to-noise
ratios (SNR5)
on the order of 200-400:1.
During each horizontal sweep of the video camera electron
beam, a rapidly varying voltage signal is created as the beam

encounters varying degrees of brightness or darkness represented by the charge pattern on the target. This voltage
variation is of course caused by both information-carrying
signal(e.g.,
iodine in an artery) and noise (particularly quantum
and video noise)-the
former desirable, the latter undesirable.
The bandwidth of the video camera is defined as its ability to
vary its voltage up or down rapidly in response to interfaces
between
opaque or less opaque structures.
Bandwidth
is

usually expressed
sec). To image

in megahertz

(1 MHz

1 ,000,000

cycles/

a high bandwidth
is obif the bandwidth is too high, the

very small vessels,

viously necessary. However,

camera becomes so sensitive that every bit of quantum or
video noise is also detected, with resultant degradation of the
image. This compromise
is illustrated in figure 1 SNR de.

creases as video bandwidth

increases (fig. 2).
The video signal is then passed through an analog-to-digital
converter (ADC). As the electron beam sweeps across each
horizontal raster line, the ADC samples the signal at specified
intervals and assigns a binary number according to the analog
voltage level at each sampling point. ADCs currently used in
DSA systems should have at least an 8-bit depth or preferably

a 10-bit depth

(meaning

assign any one of256

that at each sample

or 1 024 values,

respectively,

point,

it can

depending

on the voltage level). The number of samples along each

raster line determines the number of horizontal pixels in the
image matrix. Horizontal resolution of a DSA system is thus
determined to a large extent by the sampling frequency of
the ADC and the video bandwidth. On the other hand, vertical
resolution is determined
by the number of horizontal raster
lines in the video scan. Most medical-grade
TV systems
operate at a 5 MHz bandwidth
with 525 scan lines, while the
ADCs sample 512 times across the active part of each line.
Each pixel corresponds
to a specific site in the image processor memory. Once digitization
of the analog TV signal has
been accomplished,
this digital information
is transferred
to
the corresponding
position in the memory so that subsequent
subtraction,
contrast enhancement,
or other types of image
processing can be carried out.

Because of the exponential

attenuation
of x-rays in the
patients body, most DSA systems provide some form of
logarithmic processing of the video signal to compensate
for

AJR:143,

September

American Journal of Roentgenology 1984.143:447-454.

varying tissue

TECHNIQUES

1984

thickness
[1 4]. A logarithmic
amplifier accomplishes this by amplifying
signals in inverse proportion
to the
log of their intensity;
the net effect is that images of contrastfilled arteries will be uniform despite
variation
in overlying
tissue thickness.
Logarithmic
processing
can be carried out
either before or after digitization,
depending
on specific systern design.
It is important
to bear in mind that for intravenous
DSA
imaging, we deal with very low intensity
iodine signals due to
dilution
of the contrast
material.
The creation
of adequate
diagnostic
images thus requires noise reduction
to the lowest
possible
level so these weak iodine signals will not be interfered with. One important
way to reduce noise is to use higher
x-ray photon flux than in standard
fluoroscopy.
This requires
delivery of a higher dose of radiation
to the face of the image
intensifier.
The creation
of a single frame on a TV monitor
each 1/3 sec during routine fluoroscopy
requires
about 2-4
R (0.5-1 .0 nC/kg). The creation of a single serial mode DSA
image
requires
about
1 000 MR or 1 mA (0.26 SC/kg).
Whereas
routine fluoroscopy
is generally
performed
at 1-3
mA, serial-mode
DSA images are usually obtained
at 2001 300 mA [5-7]. With intraarterial
injection,
there is less dilution of contrast
material. This allows use of a lower radiation
dose while providing
superior
DSA image quality.
The above basic principles
apply to DSA systems in current
use. We will now consider methods
of improving
image quality
that involve either modification
or extension
of the capability
of the basic imaging system.

Frame

Integration

Because of the poor SNRs of early video cameras,

it was
found that high-quality
DSA images
could not be obtained
using single TV frames. Too much noise was present.
It was
instead necessary
to use integration,
or averaging,
of multiple
frames (typically
two to eight) to improve
the effective
SNR
[5, 8-1 1]. If n frames
are integrated,
SNR improves
by a
factor equal to the square root of n [1 2J. Frame integration
can thus be considered
a method of weighting
the incoming
information
to enhance
the desirable
signals at the expense
of the undesirable
ones. This technique
allows the use of
lower powered
generators,
since exposure
times are generally long (1 50-500
msec).
The use of integration
techniques
is not necessarily
limited
to averaging
some number
of TV frames to create a single
DSA image. It is also possible to integrate
an extended
series
of discrete
sequentially
scanned
images to try to improve
SNR. Sequential
scanning
will be described
below.
A major drawback
of frame or image integration
is that it
lengthens
the effective
exposure
time. As a result, motion
artifacts
and arterial pulsations
are likely to degrade
image
quality, especially
in studying
actively pulsating
high-flow
vessels, such as the thoracic
aorta and pulmonary
arteries.
Another
disadvantage
is that after exposure
begins, the first
few TV fields are wasted
to allow the video signal level to
stabilize, thus adding to patient exposure
and x-ray tube load.
Despite its drawbacks,
frame integration
remains
a basic
method of image improvement;
the capacity
to perform this

449

IN DSA

operation
is a desirable feature in DSA units being considered
for purchase.
It should be noted that frame integration
requires an increase in bit depth of the image processor
memory. For example,
if the memory is 8 bits deep, it can process
only a single frame having 256 different
shades of brightness.
To integrate
a second frame requires
256 additional
binary
values (i.e., a 9-bit memory).
Four-frame
integration
requires
a 10-bit memory;
eight frames
require
11 bits of memory
depth; and so on.

Sequential

Video

Scanning

with Pulsed

Radiation

A major variation of the older, interlaced

method of readout
of the video camera
target has already been introduced
by
most manufacturers
[1 3-1 5]-the
use of sequential
(sometimes termed
progressive)
readout
after a short pulsed
radiation
exposure
(hereafter
referred
to as the pulsed-sequential method).
With this technique
of creating
TV images,
a short but intense pulse of radiation (generally
1 0-1 00 msec)
creates
the image on the image intensifier,
which is then
imprinted
on the video camera
target.
The generator
then
shuts off, but the image remains stored on the target until it
is discharged
by the scanning
electron beam. Scanning
of the
target commences
after generator
shutoff.
Instead
of the
interlaced
method
of scanning
first the odd lines in /o sec
and then the even lines in another
/o
sec, the sequential
method scans all 525 lines in consecutive
order in /o sec to
create an entire TV frame.
Radiation
doses
with multipleframe integration
and the pulsed-sequential
technique
are
comparable.
There are several advantages
of pulsed-sequential
imaging,
the most important
of which is significant
shortening
of the
exposure
time. This helps alleviate the problem of motion and
vessel pulsation
that occurs when frame integration
is used.
Because
frames are not wasted
waiting for the video signal
to stabilize,
optimum
dose efficiency
is achieved
[1 6]. If
installation
of a biplane
DSA laboratory
is contemplated,
a
pulsed-sequential
system allows the use of alternate
pulsing
of the two tubes to minimize
scatter
[1 7]. Integration
of
individual pulsed images can be used with the pulsed-sequential method
[1 3, 1 8] and may prove to be of benefit
in
enhancing
image quality.
Not all systems
currently
provide
this capability,
however.
Use of the pulsed-sequential
method alters system requirements significantly.
Without
integration,
the images tend to

be noisier. Therefore,
a higher
reduce video noise. The shorter

SNR camera

is needed

to

exposure
times necessitate
the use of significantly
higher amperage
levels [1 3, 1 4J. This,
in turn, requires higher power generators
and x-ray tubes.
Equipment manufacturers
often encourage
radiologists
to
acquire DSA capability
by the simple expedient
of adding the
necessary
hardware
on to older existing
radiographic
and
fluoroscopic
rooms. This can be done if one is willing to use
only frame integration
as the primary method
of reducing
noise. However,
if one prefers to use shorter exposure
times
with pulsed-sequential
imaging
technique,
high-SNR
video
cameras
and higher powered
x-ray generators
and tubes will
be needed.

LEVIN

450

There is at present
some disagreement
among manufacturers as to which basic imaging method
is most desirable.
Some rely on interlaced
scanning
with frame integration
to
provide
sufficient
SNR for good image quality.
Others
use
single-frame
imaging with pulsed-sequential
technique
and do
not offer the option of frame integration.
Still others provide
the capability
for both pulsed-sequential
imaging and integration of discrete
frames.
It is not yet clear whether
either of
these
methods
is consistently
better
than the other,
or
whether
one might be preferable
for some vascular
beds
whereas
the second
is preferable
in other vascular
beds.
Further research
in this area is needed.

American Journal of Roentgenology 1984.143:447-454.

Larger

Image

Intensifiers

and Matrix

Sizes

A drawback
of early DSA systems
was that they were
limited to the 6 or 9 inch (1 5 or 22.5 cm) field size of most
image intensifiers.
This is often insufficient
coverage
for abdominal
or lower extremity
studies.
Several
manufacturers
have therefore
developed
large (and expensive)
1 4 inch (35
cm) or 1 6 inch (40 cm) intensifiers
to allow full angiographic
field coverage
[1 9, 20]. If matrix size remains constant
(e.g.,
51 2 x 51 2 pixels) but anatomic
field coverage
increases
from
9 inches (22.5 cm) to 14 inches (35 cm), spatial resolution
must decrease.
Price and James [1 1 estimated
that a 51 2 x
51 2 pixel matrix can resolve about 1 .1 -1 .2 line pairs (LP)/mm
on a 9 inch (22.5 cm) field, but only 0.7-0.8
LP/mm on a 14
inch (35 cm) field.
To try and maintain
satisfactory
spatial resolution
with a
large-intensifier-based
system,
some equipment
manufacturers are now developing
1024 x 1 024 pixel matrices.
As matrix
size increases,
the area included in each pixel decreases
and
resolution
improves.
To achieve this number of pixels in the
vertical dimension,
the camera scan pattern must have 1049
raster lines instead of 525. The larger matrix might seem to
be a simple way to improve resolution,
but this approach
has
certain drawbacks
that are not generally
appreciated.
Since
there are four times as many pixels to be imaged, a substantial
increase in video bandwidth
and frequency
of analog-to-digital
conversions
would be necessary
if the standard
scan readout
time of 33 msec were maintained.
However,
as indicated
earlier, an increase in video bandwidth
results in lower SNR,
which tends to defeat the whole purpose of the 1 024 x 1024
matrix (improved
resolution).
One solution
to this problem
is
the use of a slow video scan technique
described
by Ergun
et al. [21]. After the short pulse of radiation
stores an image
on the video camera tube target, sequential
scanning
by the
electron
beam commences
at a reduced
speed. Instead of
the usual 33 msec readout,
it is increased
fourfold
to about
133 msec. With this slower sweep speed of the beam, the
frequency
with which the camera must rapidly vary its voltage
up or down need not increase,
nor would it be necessary
to
increase
the frequency
of analog-to-digital
conversions.
A
lower bandwidth
can be used and SNR should be maintained.
However,
the maximum
signal current
obtainable
from the
video camera
is inversely
proportional
to the scan time. If
scan time is increased
fourfold,
average signal current will be

ET AL.

AJR:143,

September1984

significantly
reduced.
Camera SNR is determined
primarily by
the ratio of signal current to preamplifier
noise. Since the slow
scan technique
reduces signal current, proper camera design
incorporating
high inherent signal current and low preamplifier
noise becomes
vital to maintain acceptable
SNR.
Another drawback
of the slow scan method is that no more
than 2 or 3 images/sec
can be obtained.
An additional
problem
created
by the 1 024 x 1 024 matrix is that of transferring
information
to disks or tape for storage.
This process
is
already quite slow when digital storage
methods
are used,
and a fourfold
increase
in the amount
of information
to be
transferred
will make matters worse.
Because of the problems
detailed above, it is not yet clear
whether
imaging
with larger intensifiers
and 1 024 x 1024
pixel matrices
will be as readily achievable
as one is led to
believe by reading the promotional
literature.

Video

Camera

Improvements

As has been pointed out by Riederer

[22], it is difficult to
obtain high-quality
DSA imaging
with older video cameras
operating
with an SNR in the 1 00:1 or 200:1 range. Newer
cameras with SNRs well in excess
of 1 000:1
at 5 MHz
bandwidth
have recently
become
commercially
available.
Some of these, and most future cameras,
will use the Am-

perex XQ4502

frogs

head plumbicon

[4, 23, 24]. Like older

versions of the plumbicon,

this unit has a diode electron gun,
which improves
resolution
and dynamic
range (the ability to
respond
to wide variations
in image brightness
without
becoming
saturated)
and reduces
lag (persistence
of some
image information
on the target after discharge
by the electron

beam sweep).

The target of the XQ4502

plumbicon

has a 26

mm usable diameter,
which gives it an area about 50% larger
than that of the older tubes. This larger target scan area
improves
resolution.
It also increases
signal current, because
the latter is directly proportional
to scan area. The peak signal
current is 3500 nA-almost
double that of the most advanced
tubes previously
used. The target photoconductive
layer is
thinner, thereby decreasing
scatter and lateral light leakage.
When this tube is incorporated
into video cameras
having
improved
preamplifier
design that limits noise to less than 1
nA, a very high SNR can be achieved.
This is particularly
useful when 1 024 x 1 024 pixel matrices
are used in DSA
imaging since, as indicated
earlier, the slow video scan technique needed for the larger matrix might otherwise
reduce
SNR to unacceptable
levels.
It should be apparent that these advances
in camera design
are of great benefit in attempting
to maximize
DSA image
quality,
particularly
when using pulsed-sequential
systems
and 1024 x 1024 pixel matrices.
Radiologists
considering
purchase of such systems
are well advised to include a stateof-the-art
video camera in their planning,
despite its considerably higher cost. In the near future, we can expect significant improvements
in ADCs and camera preamplifier
design,
such that 1000:1 SNRs will be achievable
at wider bandwidths
and conventional
scan times of l/3 sec. This will increase the
feasibility
of imaging with 1024 x 1024 matrices.

AJR:143,

TECHNIQUES

September1984

Reregistration
The most

I 000

(Pixel Shifting)
common

problem

in clinical

to obtain exact superimposition

the mask and contrast images.

DSA imaging

is failure

of all anatomic structures on

The resulting misregistration

artifacts
are caused by swallowing,
movement
of bowel gas,
or other types of voluntary
and involuntary
patient
motion
during the few seconds
between
the mask and contrast
images. To try to alleviate this problem, all DSA systems allow

I 00
MASS
ATTENUATION

remasking-the
selection of an alternate mask image, usually
somewhat later in the filming sequence and temporally closer
to the contrast

inherent

451

IN DSA

image.

instability

Artifacts

caused

of raster-line

by slight

positioning

motion

10

COEFFICIENT
(cm2/g)

or

can also be re-

I .0

duced by reregistration,
or pixel shifting. This is a software
modification
that allows shifting of pixel information
horizontally, vertically,
or obliquely
to improve
superimposition
of
mask and contrast
images. Assume,
for example,
that pixel

American Journal of Roentgenology 1984.143:447-454.

A has a DSA

number

(determined

by the binary

right, pixel Bs new DSA number becomes 255, while pixel A

assumes whatever number had been present in the pixel to
left. This shift is of course

performed

number

originally
assigned
by the ADC to the site) of 255 and that
pixel B just to the right has a DSA number
of 1 55. If the
computer is instructed
to shift the image one full pixel to the

its immediate

0. I

throughout

the entire matrix. If the computer is instead instructed to shift

the image 0.1 pixel to the right, it calculates the difference
between
DSA numbers in A and B (1 00 units), multiplies by
0.1 and adds it to B. Thus, pixel Bs new DSA number
becomes
165.
Clinical experience with this technique has shown that it is
simple to use and may be of value in salvaging some studies
that otherwise
would have been nondiagnostic
[25]. One must
recognize, however, that any type of image manipulation may
create artifacts.

40

80

PHOTON

ENERGY

120
(keV)

Fig. 3.-Variation
in mass attenuation
coefficients
of iodine,
bone. and
muscle
with changes
in photon
energy
of x-ray beam. As photon
energy
increases,
absorption
ofx-rays by these three SUbstanceSdecreases.
However,
degreeofdecrease
differs among them. Thus age obtained at low kovoftage
will show same structures
as one obtained at hIgh kilovoltage,
but proportional
changes in video density from low to high kilovoltage w8 differ for the three
substances. (Reprinted from [3).)

Hybrid

Hybrid subtraction
is a combination
of standard temporal
and dual-energy
subtraction
[26, 27] that has recently been
attempted clinically as an adjunct in DSA imaging [28, 29].
subtraction

is based

on the principle

that iodine,

bone, and soft tissue each attenuate x-rays to different degrees at high and low photon energies (fig. 3). For example,
a typical DSA frame obtained at 70 kV during the contrastfilled phase contains
bone, soft tissue, gas, and weak iodine
signals. If another frame is then obtained
less than 50 msec

later

at 130 kV, this frame

will show

virtually

the same

anatomy
but with about an 80% reduction
in iodine signal, a
40% reduction
in bone signal, and a 25% reduction
in softtissue signal, compared
with the earlier 70 kV frame. Gas will
attenuate
very little of the x-ray beam at either energy, and
the gas signal (almost 0 attenuation)
will be virtually identical

in both images.

the 1 30 kV image is first weighted

(in this case
by a factor of about 1 .33, the subtraction
process
the soft-tissue
signals to cancel each other out as

well, leaving
type

of image

only bone and iodine

processing

may

images.

make

The use of this

it possible
to eliminate
reducing
misregistration

gas and soft-tissue

images, thus
artifacts due to swallowing or bowel gas motion. Bone signals
are then eliminated by standard temporal subtraction
(sub-

Subtraction

Dual-energy

subtraction,
multiplied)
will cause

If the information

stored in the image proces-

sor memory from the 130 kV frame is subtracted

from that of
the 70 kV frame, the gas images will effectively
cancel each
other out, a small soft-tissue
signal will remain, and significant
bone and iodine signals will also remain. If, instead of simple

traction
of a mask from a contrast-filled
the desired iodine signal.

image),

leaving

only

Van Lysel et al. [28] and Foley et al. [29] have used hybrid
subtraction
in preliminary
clinical DSA studies and have noted
certain drawbacks
inherent in this technique.
First, the iodine
signal intensity
is somewhat
reduced by the energy subtraction process.
Second,
since four separate
images contribute
to each hybrid subtraction
(as opposed to two for standard
temporal
subtraction),
the hybrid image will contain
more
noise. Thus the overall SNR of the process is reduced.
It has
been estimated
that the SNR of hybrid subtraction
is only
35%-40%
that of temporal subtraction
[28, 30]. To improve
SNR of their hybrid images, both Van Lysel et al. [28] and
Foley et al. [29] had to utilize 4-frame integration
of both
mask

and contrast

hybrid

images.

While

this improves

SNR,

it lengthens effective image acquisition time and could thus

introduce
arterial or patient motion artifacts. Theoretically,
these artifacts should not appear on these images because
they are cancelled by the hybrid subtraction
process. However, Foley et al. [29] did in fact note the presence of unexplained

soft-tissue

motion

artifacts

in some

of their

studies.

452

LEVIN

American Journal of Roentgenology 1984.143:447-454.

Another obvious
drawback
is the doubling
of the number of
exposures
required
to obtain pairs of images.
Patient dose
and tube loading are thereby increased.
Finally, the complexity
of the DSA equipment
is increased.
The image processor
must have increased
flexibility
and storage
capacity
[28].
Generator
switching,
changing
of x-ray beam filters,
and
stabilization
of video signal levels must all be accomplished
within extremely
short time intervals.
Van Lysel et al. [28]
used a constant
potential
generator
(Philips Optimus
M200)
for their study. Many noncardiac
angiographic
laboratories,
however,
are not equipped
with constant
potential
generators.
Foley et al. [29] estimated
that hybrid subtraction
produced
diagnostic
improvement
in about 20% of their small group of
clinical studies.
Van Lysel et al. [28] stated that their results
were inconclusive.
The future potential
of this technique
is
therefore
unclear.
Whereas
it can improve
image quality in
some cases, we do not yet know how costly or reliable it will
be, or whether the improvements
might be achieved
by other
more readily available methods.

Matched

Filtering

Matched filtering, recently described

by Riederer et al. [31,
32], is a postprocessing
method of temporal
integration
of a
sequence of subtracted
images that have all been weighted
to emphasize
the iodine signals and suppress
background
structures
and noise. After obtaining
a 1 0- to 1 5-sec run of
subtracted
images, matched
filtering was then performed offline by choosing
a region-of-interest
within a major artery and
plotting a curve of contrast
density as a function of time. The
resulting data points were fit by the least-squares
method to
a smooth bell-shaped
curve (gamma variate). A constant
value
was subtracted
from all points along the curve; this constant
was chosen so that the resulting
second curve would have a
mean value of 0 (fig. 4). Next, the same constant
was subtracted from each image in the sequence.
The weighted
subtracted
images in the run were then integrated
to form a
single final matched
filtered image. By subtracting
the constant from each already-subtracted
image in the run, much of
the remaining
noise and background
structures
would
be
removed. The stronger
iodine signals would also be somewhat suppressed
in individual
images, but the final integration
of all signal information
would result in an enhanced
iodine
signal on the final filtered image.
Riederer et al. [32] estimate that matched filtering produces
a 50% reduction in noise. Although
their original studies were
processed
off-line, they indicate
that an inexpensive
modification of video processor
hardware
could allow it to be done
on-line. Interestingly
enough,
they found that simple integration of the sequence
of unweighted
subtracted
images produced almost the same degree of noise reduction
as matched
filtering.
As might be expected
with a technique
using extensive
temporal
integration
of images acquired
during a 10- to 15sec DSA run, motion artifacts
can be a significant
drawback
(although
some of the minor ones can be suppressed
by the
filter). No consistent
improvement
in image quality could be
demonstrated
by matched
filtering
in the preliminary
clinical

ET AL.

AJR:143,

September1984

DSA

VALUES
TIME

SOFT

TISSUE
PIXEL

(sec.)

ARTERIAL
PIXEL

Fig. 4.-Matched
filtering. Upper solid curve in diagram a is plot of contrast
density over time in region-of-interest
placed over major artery shortly after
intravenous
contrast
injection.
Lower dashed curve is created by subtracting
constant from all points along upper curve. Constant
is such that DSA numbers
before and during passage
of contrast
bolus will have average value of zero
(i.e., shaded regions above and below horizontal
line are equal in area). This
constant
is then subtracted
from DSA values in each pixel throughout
matrix
as imaging
run proceeds.
In hypothetical
pixel in soft-tissue
area where no
arteries are present (represented
by diagram b), DSA values primarily
reflect
random noise. By subtracting
constant,
matched
curve well below horizontal
line is created.
In another hypothetical
pixel located in center of artery (represented by diagram C), DSA values initially reflect random noise but then rise to
peak as contrast
bolus passes. By subtracting
constant,
lower matched curve
5 created,
but this curves peak rises above horizontal
line. If, in creation
of
final image, only those DSA values above level of horizontal
line are used,
image will contain only iodine signals with noise filtered out.

studies [31 32], although

it did improve
images in individual
cases. It might prove to be particularly
appropriate
for studying extremity
arteries where motion of gas-containing
structures (e.g., larynx and bowel) or the arteries
themselves
is
not a problem.
This temporal
filtration
approach
to image
improvement
seems promising,
but further
investigation
is
needed.
,

Recursive

Filtering

Recursive
filtering
is another
temporal
filtering
technique
that can be performed
with an older, low-SNR
video camera,
using continuous
fluoroscopy
at 3-30 mA to obtain 30 interlaced TV frames/sec
[33-36].
Integration
of a short and long
sequence
of frames from the same run are carried out by a
dual-memory
digital recursive
filter. For example,
in one such
scheme [35], the short-sequence
filter integrates
frames during a 2-sec period corresponding
to peak opacification
of the
arteries. The long-sequence
filter integrates
frames during the
same 2 sec plus the preceding
6 sec. The latter thus acquires
much image information
before the arrival of the contrast
bolus. The signals in the two filters are weighted
so that their
sum equals 0. Both filters thus contain
background
structures, noise, and artifacts caused by certain types of repetitive
motion,
such as arterial pulsations.
However,
the short-sequence filter contains strong iodine signals, whereas the longsequence
filter (which has been more heavily weighted
with

AJR:143,

TECHNIQUES

September1984

IN DSA

453

how effective these would be. Another disadvantage

is the
extensive equipment
modifications
that would be required.

____

DSA

Value

Many DSA studies are now being done in laboratories

that
are also used for standard
catheter
angiography.
Virtually
none of these laboratories
have tomographic
capability,
and
it is doubtful that they could be satisfactorily
converted.
The
cost of designing
and building entirely new angiographic
mounting
units to incorporate
tomography
might well be
prohibitive.
Thus, DSA tomography
must at present
be con-

sidered

purely an experimental

technique.

Edge Enhancement
Edge enhancement
of image

American Journal of Roentgenology 1984.143:447-454.

Instantaneous
rate of change

the earlier non-contrast-containing

images) contains
weaker
iodine signals.
Subtraction
should thus yield an iodine-only
image.
An advantage
of recursive
filtering
is that it can be used
with a relatively
basic image
intensifier-TV
combination,
such as might be found in older angiographic
or fluoroscopic
laboratories.
As is true with matched
filtering,
however,
recursive filtering is susceptible
to patient motion artifacts.
The
technique
has not yet been shown to substantially
improve
on conventional
DSA imaging [35].

DSA Tomography
DSA tomography
has been studied
experimentally
by
Kruger
et al. [37]. They modified
a multidirectional
tomographic
unit by placing
an image intensifier
with a video
camera beneath the Bucky assembly.
A circular tomographic
motion
at 1 revolution/i
.5 sec was used. Because
of the
relatively
long exposure
time required
to allow completion
of
the rotary motion, recursive
filtration
was used. Their experimental
images,
obtained
in living dogs, indicated
that the
technique
is capable of isolating contrast-filled
arteries within
a single anatomic
plane, thereby
alleviating
the common
problem
of vessel overlap,
while motion artifacts
and background
structures
were largely eliminated
by the recursive
filter. However,
in order to obtain multiplanar
capability, tomosynthesis
algorithms
would have to be used. It is not clear

that

software-controlled

sharpens

method

borders
of contrast-filled
processed
as a kernel

vessels. Images are mathematically

(a square box 3-9 pixels on a side) sweeps across the image
and detects decreases in density as it crosses the borders of
vessels. Calculation
of the first derivatives
of the curve of
DSA numbers along this sweep line produces large defiections

Fig. 5-Edge
enhancement. To enhance unsharp blood vessel borders,
square
kernel sweeps across image. As it crosses one border of artery, there
is abrupt change
in DSA value. Another
abrupt change in reverse direction
occurs as kernel crosses
opposite
border.
Instantaneous
rate of change in
DSA values is greatest
in those pixels along edges of vessels.
By detecting
these peaks and enhancing
signals
of pixels where peaks occur,
vascular
borders can be made to appear sharper.

is another

processing

at the borders

of vessels,

corresponding

to a rapid

rate

of change in density at these borders (fig. 5). The computer

is instructed to enhance those pixels where the rate of change
is greatest.

In effect,

this

creates

a line

along

the

vessel

border, giving it a discrete rather than diffuse edge. This

sharpens the border and makes it more amenable to quantification
of vessel
diameter
and stenosis.
However,
edge
enhancement
introduces competing artifacts that may lead to
a generally
noisier image. Also, there is the possibility
that
diagnostic
information,
such as wall irregularity
due to atherosclerosis,
might be masked
by the sharpening
process.
This

technique
imaging

seems promising,

at least as an adjunct to standard

techniques.
has focused
on the technology
images in DSA. Although
this

This review
and improving

now quite sophisticated,

a number

of questions

equipment
still remain to be answered.
imaging
technique
preferable
to frame

versa,

or should

both

of producing
technology

capabilities

is

pertaining

to

Is pulsed-sequential
integration,
or vice

be available

for use as

circumstances

dictate? To what degree will advances

in video
camera and ADC design improve image quality? Are 14-16
inch (35-40 cm) image intensifiers
desirable
or cost-effective?
Will higher resolution
DSA imaging
with 1 024 x 1 024 pixel

matrices

prove feasible?

coupled

to older

ages

using

niques?

recursive

What

postprocessing

Can less sophisticated

fluoroscopic
will

units

filtering
be the

methods

role

produce

DSA systems
acceptable

im-

and other

processing

tech-

of hybrid

subtraction?

Will

like reregistration,

edge enhance-

ment, and matched

filtering significantly
enhance image quality? The answers to these questions
await further research
and development
in which both radiologists
and commercial
manufacturers
should participate.

ACKNOWLEDGMENTS

We
Marshall
reviews

thank

Walter Doesschate of Amperex Electronic

Inc., and B. Douglas
Lewis
for

of Xonics,

and

helpful

criticism.

Corp.,

Julian

comprehensive

LEVIN

454

ET

AL.

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