Unit IV- Medical Imaging Modalities and Analysis

Medical Imaging

• Non-invasive visualization of internal organs, tissue, etc.

• Image – a 2D signal f(x,y) or 3D f(x,y,z)

Medical imaging using ionising radiations

• Medical imaging has come a long way since 1895 when Röntgen first described a ‘new kind
of ray’.

• That X-rays could be used to display anatomical features on a photographic plate was of
immediate interest to the medical community at the time.

• Today a scan can refer to any one of a number of medical-imaging techniques used for
diagnosis and treatment.

Major Modalities

• Projection X-ray (Radiography)

• X-ray Computed Tomography (CT)

• Nuclear Medicine (SPECT, PET)

• Ultrasound

• Magnetic Resonance Imaging

Projection X-ray Imaging

• Image records transmission of x-rays through object

• The integral is a line-integral or a “projection” through obj

• m(x,y,z) – x-ray attenuation coefficient, a tissue property, a function of electron density.

X-Ray tube
  The X-rays are produced from electrons that have been accelerated from

in vacuum from the cathode to the anode.

 Emission occurs when filament is heated by passing current through it.

 When the filament is hot enough, the electrons obtain thermal energy

sufficient to overcome the energy binding the electron to the metal of the

filament.

 After accelerated they will be stopped at a short distance.

Most of the electron Energy will produce heat at the anode. Only Some

percentage will be converted to X-ray.

 Deceleration of charged particle results in the emission of electromagnetic

field called Bremmstralung radiation.

 These rays will have wide, continuous distribution of energies with the

maximum being the total energy the electron had when reaching the anode.

 The number of X-rays will be small at higher energies and

increased for lower energies.

Principle of an X-ray system with image intensifier. X rays impinging on the image intensifier are
transformed into a distribution of electrons, which produces an amplified light image on a smaller
fluorescent screen after acceleration. The image is observed by a television camera and a film
camera and can be viewed on a computer screen and stored on a CD-ROM or a PACS.
Summary: X-ray Imaging

• Oldest non-invasive imaging of internal structures

• Rapid, short exposure time, inexpensive

• Unable to distinguish between soft tissues in head, abdomen

• Real time X-ray imaging is possible and used during interventional procedures.

• Ionizing radiation: risk of cancer.

Computerized Tomography

 Imaging of a cross sectional slice of the body using X-rays.

 Invented by Dr. G. N. Housfield in 1971. Received the Nobel prize in

medicine in 1979.

 The method is constructing images from large number of

measurements of x-ray transmission through the patient. The resulting

images are tomographic maps of the X-ray linear attenuation

coefficient.

CT imaging

• Goal of x-ray CT is to reconstruct an image whose signal intensity at every point in region
imaged is proportional to μ (x, y, z), where μ is linear attenuation coefficient for x-rays.

• In practice, μ is a function of x-ray energy as well as position.

• X-ray CT is now a mature (though still rapidly developing) technology and a vital component
of hospital diagnosis.

Principles of x-ray attenuation

• In a uniform substance of linear attenuation coefficient μ, x-ray “intensity”, as measured by

a detector placed at depth d is

First generation CT
CT and corresponding pixels in image
Ultrasound for imaging

• Basic principle same as used in radar and sonar and similar to echo-location method of bats.

• Emitter sends out pulses of sound. These bounce off objects and returned echoes provide
information about object, in particular location, size and reflectional properties.

• Gases and liquids support only longitudinal waves; solids support transverse waves as well,
but these are rapidly attenuated for non-rigid, “soft” solids.

• Acoustic waves with frequencies above those which can be detected by the human ear. In
practice, 20 kHz < f < 200 MHz.

• An acoustic wave is a propagating disturbance in a medium, caused by local pressure

changes at a transducer.

• The molecules of the medium oscillate about their resting (equilibrium) positions, giving rise
to a longitudinal waves.

• c  1540 m/s  6.5 μs/cm in most body tissues

• λ = c / f = 1.5 mm at 1 MHz.
• Most widespread use is in medical imaging

• Non-invasive, low risk

• Obstetrics, abdominal problems, measurement of blood flow and detection of constrictions

in arteries and veins.

• Also used in non-destructive testing in industry: e.g., cracks in structures.

• Sonar, underwater imaging (e.g., in submarine echo-location devices).

• Reflections occur when the incident wave encounters a boundary between two materials
with different acoustic impedances.

• Acoustic impedance Z is the material property which relates pressure changes p (in excess of
atmospheric) to the vibrational velocity u of the particles in the medium.

• At a single plane wave through a substance with density ρ and speed of sound c, then Z = ρc.

• When an incident plane wave, with amplitude pi, travelling through a medium with acoustic
impedance Z1 hits a boundary with a second material of impedance Z2 at normal incidence,
there is in general both a reflected wave pr and a transmitted wave pt:

• At a single plane wave through a substance with density ρ and speed of sound c, then Z = ρc.
• When an incident plane wave, with amplitude pi, travelling through a medium with acoustic
impedance Z1 hits a boundary with a second material of impedance Z2 at normal incidence,
there is in general both a reflected wave pr and a transmitted wave pt:

0
50
10 0
15 0
Reflecting

20 0

0
Surfaces

50
10 0
15 0
20 0
Ultrasound
beam

Other orientations
Image Formed
Boundaries giving
of ultrasound beam
rise to echoes

• B-scan is “simply” an A-scan in which the ultrasound beam is moved and the results are
spatially displayed. The ultrasound signal changes the brightness of a spot on an oscilloscope
screen instead of amplitude of the trace in A-mode.

P R F g e n e r a to r P u ls e g e n e r a to r N ew

B e a m s te e r in g
d e v ic e
P r o te c tio n c ir c u it
P ro b e

V a r ia b le g a in
a m p lif ie r
T G C g e n e r a to r (T G C )

V (d B )

t
D e m o d u la to r

N ew C o m p r e s s io n a n d
V id e o A m p lif ie r

B r ig h tn e s s

C o - o r d in a te ( x ,y ) D is p la y
G e n e r a to r
 MRI: Introduction

• In 1970s Lauterbur introduced concept of magnetic field gradients, leading to images based
on magnetic resonance.

• By 1980s whole body magnets produced in UK, permitting first in vivo images of human
anatomy.

• An estimated 20 million scans now performed worldwide annually.

• Provides excellent soft-tissue contrast; can be acquired in any imaging plane; unlike CT, does
not involve ionising radiation.

• Imaging modality of choice in brain and spinal cord; routinely used in many other clinical
settings.

• EM tells us that a current carrying conductor e.g. a piece of wire, produces a magnetic field
encircling it.

• When wire formed into a loop, field acts perpendicular to surface area of loop.

• Analogous to this is field produced by negatively charged electrons orbiting nucleus in an

atom, or spinning charge of nucleus itself.

• Spinning momentum of nuclear charge ('the spin') produces small magnetic field referred to
as magnetic moment.

• Under normal circumstances these moments have no fixed orientation so no overall

magnetic field.

• However, when nuclei placed in external magnetic field, for example patient placed in MRI
scanner, they begin to align in given directions.

• In case of hydrogen nucleus (single proton with spin quantum number, I = ½), two discrete
energy levels (2I +1) created;

• (i) a higher energy level where magnetic moments oppose the external magnetic field, & (ii)
a lower energy level in which the nuclei aligned with magnetic field.

• Tiny majority of spins in latter energy state thereby creating net magnetisation in direction
of main magnetic field.

• Population difference & therefore sensitivity of technique, can be altered by reducing

temperature or increasing field, hence need for strong magnetic field; for modern clinical
scanners, between 0.5 and 3.0 Tesla.

• In both cases there is a net magnetisation, M0, created by the main magnetic field which is
the basis of the imaged signal.

• The net magnetisation can be considered in terms of one big spin.

• In order to detect this signal a second magnetic field is introduced referred to as B1. Two
things are important about this field: (i) it has to be applied perpendicular to B0, and (ii) it
has to be at the resonant frequency.

• Appropriate RF coils are used to transmit B1, which acts to tip the spins out of alignment
with B0 and towards the direction of the coil (i.e. out of the longitudinal plane and towards
the transverse plane).

• If the pulse is applied for long enough the spins are flipped into the transverse plane and a
90° RF pulse is said to have been applied.

Magnetic Resonance Imaging

• The magnetization is excited into an observable state

• Magnetization emits energy at a resonant frequency:

• Frequency is proportional to magnetic field

• We can create a frequency vs. space variation:

• Use Fourier analysis to determine spatial location

• Magnetic field gradients cause signals from different parts of the body to have different
frequencies.
• Signals collected with multiple gradients are processed by computer to produce an image,
typically of a section through the body.

• No ionizing radiation – expected to not have any long-term or short-term harmful effects

• Many contrast mechanisms: contrast between tissues is determined by pulse sequences

• Can produce sectional as well as projection images.

• Slower and more expensive than X-ray

ENDOSCOPY
BIOTELEMETRY

1. It is the measurement of biological parameters over long distance

2. This involves radio frequency signal as a carrier for modulation, referred to as radio
telemetry

DESIGN

1. The telemetry system should be selected to transmit the bioelectric signal with maximum
fidelity and simplicity

2. The system should not affect the living system by any interference.

3. Smaller in size and light in weight

 4. The power consumption should be small

5. The system should reject common mode interference rejection

6. A miniature radio telemetry system should be used to reduce noise

Retinal Imaging
Retinal imaging has developed rapidly during the last 160 years and is a now a mainstay of
the clinical care and management of patients with retinal as well as systemic diseases. Fundus
photography is widely used for population-based, large scale detection of diabetic
retinopathy, glaucoma, and age-related macular degeneration. Optical coherence tomography
(OCT) and fluorescein angiography are widely used in the diagnosis and management of
patients with diabetic retinopathy, macular degeneration, and inflammatory retinal diseases.
OCT is also widely used in preparation for and follow-up in vitreo-retinal surgery.

A. Fundus Imaging

We define fundus imaging as the process whereby a 2-D representation of the 3-D retinal
semi-transparent tissues projected onto the imaging plane is obtained using reflected light.
Thus, any process which results in a 2-D image, where the image intensities represent the
amount of a reflected quantity of light, is fundus imaging. Consequently, OCT imaging is not
fundus imaging, while the following modalities/techniques all belong to the broad category of
fundus imaging:

1. fundus photography (including so-called red-free photography)—image intensities

represent the amount of reflected light of a specific waveband;
2. color fundus photography—image intensities represent the amount of reflected R, G,
and B wavebands, as determined by the spectral sensitivity of the sensor;
3. stereo fundus photography—image intensities represent the amount of reflected light
from two or more different view angles for depth resolution;
4. hyperspectral imaging—image intensities represent the amount of reflected light of
multiple specific wavelength bands;
5. scanning laser ophthalmoscopy (SLO)—image intensities represent the amount of
reflected single wavelength laser light obtained in a time sequence;
6. adaptive optics SLO—image intensities represent the amount of reflected laser light
optically corrected by modeling the aberrations in its wavefront;
7. fluorescein angiography and indocyanine angiography—image intensities represent
the amounts of emitted photons from the fluorescein or indocyanine green fluo-
rophore that was injected into the subject’s circulation.

1) Technical Challenges in Fundus Imaging

Since the retina is normally not illuminated internally, external illumination projected into the
eye as well as the light reflected by the retina must traverse the pupillary plane. Thus the size
of the pupil, the small opening in the iris usually between 2 and 8 mm in diameter, has always
been the primary technical challenge in fundus imaging. Fundus imaging is complicated by
the fact that the illumination and imaging beams cannot overlap because that results in
corneal and lenticular reflections diminishing or eliminating image contrast. Consequently,
separate paths are used in the pupillary plane, resulting in optical apertures on the order of
only a few millimeters. Because the resulting imaging setup is technically challenging,
fundus imaging historically involved relatively expensive equipment and highly trained
ophthalmic photographers. Over the last ten years or so, there has been a major effort to make
fundus imaging more accessible, resulting in less dependence on such experience and
expertise due to the following three most important developments:
 1. Move from film-based to digital imaging and as a consequence the importance of
Picture Archiving and Communication Systems (PACS) increased in clinical
ophthalmology, also allowing integration with electronic health records;
2. Requirement for population-based early detection of retinal diseases using fundus
imaging
3. More straightforward operation of fundus cameras by non-ophthalmic
photographers due to non-mydriatic imaging, digital imaging with near-infrared
focusing, and increasing reproducibility through standardized imaging protocols.

Though standard fundus imaging is widely used, it is not suitable for retinal tomography,
because of the mixed backscatter caused by the semi-transparent retinal layers. Consequently,
the backscatter’s origin is decoupled from the specific retinal depth location.

Principle of digital image capture, processing and analysis

Digital images are made up in such a way that makes them accessible to simple and complex
mathematical manipulation. For black and white images (grey scale) at any given locus of pixel,
typically there is a corresponding intensity on a range from 0 (black) to 255 (white) (28 for 8-bit
images) {for 12-bit images, there are 4096 grey levels (212), etc.}. Hence, the image is composed of
an array of pixels of varying intensity across the image, the intensity corresponding to the level of
“greyness” at any particular point in the image. If we were to express this image as an equation or
function, we could say that at any point of spatial co-ordinates (x,y) the image has a set shade or
intensity. When x,y and the amplitude of intensity of points of an image are all described as finite
and discrete quantities, the image is termed digital. A simple digital image may consist of many such
points, or pixels (derived from ‘picture element’). Each pixel's intensity for a monochrome grey-scale
image is known as its grey value. Thus, a grey-scale digital image may be defined as a two-
dimensional function, f(x,y), where x and y are spatial co-ordinates and f the amplitude at any pair of
co-ordinates. Pixels surrounding any given pixel constitute its ‘neighbourhood’. This mathematical
means of describing an image is the basis for allowing complex manipulations and calculations that
are termed image processing and analysis.

Colour images use three channels (red, green and blue—RGB) to produce an overall composite RGB
images require a three-dimensional array to convey the extra colour information. The first plane in
the extra, third dimension represents the red pixel intensities, the second plane represents the
green pixel intensities and the third plane represents the blue pixel intensities. Often contrast is
greater when the green channel alone is utilised in fundal image analysis as this enhances contrast
between the background and features, such as blood vessels and haemorrhages processing and
measurement tools, however, are written to operate on grey-scale image and this may need to be
extracted from an RGB colour image.

Indexed images use matrices, or colour maps that predefine a limited set of combinations of RGB
values. Then, instead of each point in the digital image defining RGB levels individually, the pixel
value simply refers to the closest combination from the colour map, thus saving computational
memory for storage of the image.
A binary image is one containing only black and white pixels. The image consists of a binary array,
typically of 0's and 1's. Images of any type may be converted to this format for processing or
analysis.

Image capture

The first stage in fundal digital image analysis is image capture. This is normally acquired by a fundal
camera (mydriatic or non-mydriatic) that has a back-mounted digital camera. The digital camera
operates in the same fashion as a conventional camera, but instead of having film, digital cameras
use an image sensor. Direct digital sensors are either a charge-coupled device (CCD) or
complementary metal oxide semiconductor active pixel sensor (CMOS-APS). The CCD is an array of
tiny light-sensitive diodes which convert the light signal (photons) into electrical charge (electrons).
This then converts the analogue light image into a digital pixellated (pixel=picture element) image.
At each element (or pixel) in the array, the electrical current proportional to the analogue light level
is converted into a digital level. The spatial resolution of the image depends on the number of pixels
that can be created from the analogue image by the CCD array. The CMOS-APSs employ active pixel
technology and are less expensive to manufacture. The APS technology reduces by a factor of 100
the system power required to process the image compared with the CCD. In addition, the APS
system eliminates the need for charge transfer and may improve the reliability and lifespan of the
sensor .

Image processing

Image-processing operations transform the grey values of the pixels. There are three basic
mechanisms by which this is done. In its most simple form, the pixels grey values are changed
without any processing of surrounding or ‘neighbourhood’ pixel values. Neighbourhood processing
incorporates the values of pixels in a small neighbourhood around each pixel in question. Finally,
transforms are more complex and involve manipulation of the entire image so that the pixels vales
are represented in a different but equivalent form. This may allow for more efficient and powerful
processing before the image is reverted to its original mode of representation.

The aims of processing of an image normally falls into one of the three broad categories:
enhancement (e.g., improved contrast), restoration (deblurring of an image) and segmentation
(isolating particular areas of interest within the image)

Image enhancement

One of the difficulties in image capture of the ocular fundus is image quality which is affected by
factors, such as medial opacities, defocus or presence of artefact. Image enhancement involves the
development or improvement of an image so that the result is more suitable for subsequent use.
Improvements may mean the image is more acceptable for viewing, processing or analysis. This
might involve processes, such as improving contrast or brightening an image.

The image histogram provides basic information about the appearance of an image. It consists of a
graph indicating the number of times each grey level occurs in the image. Across the horizontal axis
of this graph is the range of possible pixel intensity values, e.g., 0–255. The vertical axis represents a
measure of the frequency of occurrence of each intensity value. In an excessively dark or bright
image, the grey level would be clustered to the extremes of the histogram, but in a well-contrasted
image these levels would be well spread out over much of the range. Histogram stretching
algorithms act to distribute grey levels more equally across the range according to specific user
defined equations and thus produce an image with greater contrast than the original. Histogram
equalisation works on a similar principle but is an entirely automatic procedure that aims to make
the histogram as uniform as possible.

Image restoration

Processes in this class aim to reverse damage by known causes. Algorithms such as deblurring or
removal of interference patterns belong to this category. Noise occurs due to errors in pixel values
caused by external disturbance. There are many forms of noise, such as salt-and-pepper noise,
Gaussian noise or periodic noise.

Salt-and-pepper noise causes the appearance of randomly scattered white or black pixels over the
image but it is possible to reduce this by using filters in which the mask evens out aberrations or
ignores excessively high or low values. Gaussian noise is caused by random fluctuations in the signal.
It can be reduced by using several versions of that same image and averaging values for each pixel.
Periodic noise occurs if the imaging equipment is subject to electronic repeating disturbance. This
can be reduced by transforming the image to a different structure known as a Fourier transform,
then applying noise filters before transforming back to the original image. Deblur functions rely on
modelling of the blurring process then using filters to remove the known effects of blur.

Image segmentation

Segmentation involves dividing images into subsections that are of particular interest, such as
defining areas of an image that are appropriate to be subsequently analysed, or finding circles, lines
or other shapes of interest. Segmentation can stop when such objects of interest have been isolated.
Segmentation algorithms for monochrome images are generally based on discontinuity of image
intensities such as edges in an image, or on similarities judged by predefined criteria .

Thresholding

Thresholding allows the separation of an image into separate components by turning it into a binary
image. This involves the image being separated into white or black pixels on the basis of whether
their intensity value is greater or less than a certain threshold level. The process of thresholding may
be particularly useful to remove unnecessary detail or variations and highlight detail that is of
interest. A global threshold value may be chosen automatically or on the basis of clear points in the
image histogram that would allow for efficient separation. More complex intensity criteria may be
used to allocate whether pixel values become white or black. For some images, adaptive or local
thresholding is useful where different thresholds are applied to different sections of the image, e.g.,
the image has varying levels of background illumination.

Edge detection
Edges contain some of the most useful information in an image. They can be used, e.g., to measure
the size of objects or to recognise and isolate objects. An edge in a digital image consists of an
observable difference in pixel values within a certain area. Most edge detection algorithms assess
this change by finding the magnitude of the gradient of the pixel intensity values. This can be done
by the application of specialised filters of varying complexity and utility. A threshold can be applied
to the resultant image to create a binary image of the edges. Examples of edge detection masks
include Sobel and edge detection programs. The Sobel edge detector uses a pair of 3×3 convolution
masks, one estimating the gradient in the x-direction (columns) and the other estimating the
gradient in the y-direction (rows). However, in a comparison of three automated techniques of edge
detection to identify the boundaries and corresponding widths of retinal blood vessels, Sobel was
found to be the most inconsistent, possibly related to the program identifying the central light reflex
from the blood vessel as an edge . The Canny edge detection program has been used in neural
networks to automatically localise retinal blood vessels in fundal RGB images.

Filters

Neighbourhood processing extends the power of processing algorithms by incorporating values of

adjacent pixels in calculations. A user defined matrix, or mask is defined with enough elements to
cover not only a single pixel but also some of its adjacent pixels. Each pixel covered by the elements
of the mask is subject to a corresponding function. The combination of mask and function is called a
filter. Thus, the result of applying a mask to a particular location is that the final resultant value is a
function not only of the central pixel's values but also of its neighbouring pixel values.

Morphological processing

Mathematical morphology in image processing is particularly suitable for analysing shapes in

images. The two main processes are those of dilation and erosion. These processes involve a special
mechanism of combining two sets of pixels. Usually, one set consists of the image being processed
and the other a smaller set of pixels known as a structuring element or kernel. In dilation, every
point in the image is superimposed onto by the kernel, with its surrounding pixels. The resultant
effect of dilation is of increasing the size of the original object. Erosion is an inverse procedure in
which an image is thinned through subtraction via a structuring element or kernel. The kernel is
superimposed onto the original image and only at locations when it fits entirely within its boundaries
will a resultant central pixel be accepted. The algorithms of opening and closing are based upon
these processes. Opening consists of erosion followed by dilation, and tends to smooth an image,
breaking narrow joints and removing thin protrusions. Closing consists of dilation followed by
erosion and also smoothes images, but by fusing narrow breaks and gulfs and eliminating small
holes. Algorithms combining the above processes are used to creating mechanisms of edge
detection, noise removal and background removal as well as for finding specific shapes in images.

Image registration

Image registration is a process of aligning two or more images of the same scene. One image (the
base image is compared to the other input images. The aim of registration is to apply spatial
transformations to the input image to bring the input image into alignment with the base image.
Commonly, the input images may be misaligned due to different camera angles or different imaging
modalities. The details of the exact alignment algorithm are calculated after the user identifies pairs
of points that should exactly correspond in the two images. A spatial mapping is inferred from the
positions of these control points. Registration can be based on identified landmarks (e.g., retinal
vessel bifurcation points), on the alignment of segmented binary structures (segmentation based),
or directly onto measures computed from the image grey values. The input image is transformed
then to correspond with the base image so that direct comparisons can be made. Registration of
images in this manner is commonly used as a preliminary step in processing applications.
Alternatively, two images taken at different time intervals may need to be registered (temporal
registration) using an automated process in order for time-dependent changes to be identified. This
has been performed for sequential fluorescein angiography and colour fundal images. The available
registration methods are divided into intensity based and feature based. Intensity-based methods
have the drawback of poor performance under varying illumination, whilst feature-based methods
rely heavily on accurate and repeatable extraction of the features. Image mosaicing is the act of
combining two or more images and is used to combine images such that no obstructive boundaries
exist around overlapped regions and to create a mosaic image that exhibits as little distortion as
possible from the original images, and may be used to create wide-field retinal montages. It also has
applications in video frame capturing.