Pediatr Radiol (2013) 43:269–284

DOI 10.1007/s00247-012-2468-1

MINISYMPOSIUM

Technical developments in postprocessing of paediatric

airway imaging

Savvas Andronikou & Benjamin Irving &

Linda Tebogo Hlabangana & Tanyia Pillay & Paul Taylor &
Pierre Goussard & Robert Gie

Received: 15 May 2012 / Accepted: 9 July 2012

# Springer-Verlag 2012

Abstract CT postprocessing allows more scan information to
be viewed at one time allowing an accurate diagnosis to be
made more efficiently, and is particularly important in paediat-
ric practice where invasive clinical diagnostic tools can be
replaced or at least assisted by modern postprocessing techni-
ques. Four visualization techniques in clinical use are described
in this paper including the advantages and disadvantages of
each: multiplanar reformation, maximum and minimum inten-
sity projections, shaded surface display and volume rendering.
Volume-rendered internal visualization in the form of virtual
endoscopy is also discussed. In addition, the clinical usefulness
in paediatric practice of demonstrating airway compression and
its causes are discussed. Advanced postprocessing techniques
that must still find their way from the biomedical research
environment into clinical use are introduced with specific ref-
erence to computer-aided diagnosis.
S. Andronikou : L. T. Hlabangana : T. Pillay
Radiology Department, Faculty of Health Sciences,
University of the Witwatersrand,
Johannesburg, South Africa
B. Irving : P. Taylor
CHIME, Division of Population Health,
University College London,
London, UK
P. Goussard : R. Gie
Department of Pediatrics and Child Health,
Faculty of Health Sciences, University of Stellenbosch,
Stellenbosch, South Africa
S. Andronikou (*)
700 Harbouredge, 10 Hospital Str, Greenpoint,
Cape Town 8005, South Africa
e-mail: docsav@mweb.co.za
Keywords Minimum intensity projections . Multiplanar
reconstruction . Volume rendering . Computer aided
diagnosis . Paediatric
Introduction
Diagnostic methods for suspected airway obstruction in chil-
dren include imaging in the form of chest radiographs and CT
scanning as well as fibre-optic tracheobronchoscopy (FTB).
FTB is an excellent way of evaluating stridor caused by airway
compression and for visualizing the dynamic changes in airway
calibre [1]. It is usually performed by a pulmonologist and
represents the gold standard for airway investigation, but it
has numerous limitations. Even though the procedure is con-
sidered a safe examination if performed by an experienced user,
it is invasive and requires general anaesthesia, which carries
further risks [1]. Complications such as hypoxaemia, hyper-
carbia, cardiac arrhythmia and subglottic oedema have resulted
in the search for noninvasive diagnostic techniques [1]. Imag-
ing is one of these solutions, but it must meet the aims of FTB.
The main aims of FTB are to confirm airway narrowing,
evaluate the degree of stenosis, aspirate endobronchial con-
tents and perform transbronchial biopsy [1]. Imaging should
also provide additional information acceptable as an alterna-
tive, particularly where FTB has limitations such as in dem-
onstrating the cause of a stenosis, demonstrating relationships
with surrounding structures and navigating airways that are
difficult to access by FTB (such as the lingual and left lower
lobe bronchi) and the airways beyond a tight stenosis [1].
CT has established its place in the evaluation of paediat-
ric stridor as it is easy to perform and requires no sedation
due to the speed of the procedure. It does, however, carry a
radiation burden, which must be considered. Simple solu-
tions such as reducing the kV and mAs can reduce the dose
270 Pediatr Radiol (2013) 43:269–284

by up to 65% [1]. CT volumes have traditionally been

viewed as individual axial slices, but the availability of
multidetector row CT (MDCT) has led to an increase in
the clinical use of images in other planes. The advances in
postprocessing have expanded the role of CT to a degree
where it challenges other diagnostic techniques as the gold
standard for diagnosis [2].
Postprocessing allows more scan information to be
viewed at one time allowing an accurate diagnosis to
be made more efficiently. The speed at which this can
be done may be considered as a real-time interactive
modification process. Therefore, understanding the need
for routine thin-section axial MDCT to allow 3-D applications
is critical for making clinical use of postprocessing [3]. Use of
postprocessing including 3-D visualization has become a ne-
cessity [4] that is particularly important in paediatric practice
where invasive clinical diagnostic tools can be replaced or at
least assisted by modern postprocessing techniques.
This review describes the MDCT postprocessing
tools in routine clinical use and identifies indications,
advantages and disadvantages of each in relation to
imaging the paediatric airways. It also explores more
advanced postprocessing, more familiar to biomedical
researchers, that will soon find their way into clinical
practice, in particular in relation to computer-aided diagnostic
tools.

Visualization techniques

Four visualization techniques are in clinical use on clinical

workstations: multiplanar reformation (MPR) including
curved plane reformation (CPR), maximum and minimum
intensity projections (MIP/MinIP), shaded surface display
(SSD) and volume rendering (VR). The first two techniques
are limited to external visualization while SSD and VR
can be used for both external and internal visualization
[4].
Multiplanar reconstruction and curved plane reformation
MPR is the process of using the data from axial CT
scans to create non-axial 2-D images. MPR images are
coronal, sagittal, oblique or curved plane images gener-
ated from only one voxel thickness transecting a set or
stack of axial images (Fig. 1). MPR images are in
routine use, including for the evaluation of airways.
Similar to MPR, CPR is a tomogram one voxel thick,
but it is capable of demonstrating an uninterrupted lon-
gitudinal cross-section because the display plane curves
along the structure of interest. A CPR can be created to
include an entire structure on a single image [3]. CPRs
are created along points that are manually positioned
Fig. 1 Multiplanar reconstruction. Using a cross-hair on (a) the coro-
nal image, it is possible to confirm the location and calcification of
right hilar lymphadenopathy (thick arrow) on (b) the axial image (thin
arrow)
over the structure of interest as viewed on transverse
sections, MPRs, MIPs, SSDs or VRs. The points are
connected to form a 3-D curve that is then extruded
through the volume perpendicular to the desired view to
create the CPR [4]. CPRs are very useful for displaying
the interior of tubular structures such as blood vessels,
airways and bowel. They are also useful for visualizing
structures immediately adjacent to these lumina, such as
mural thrombus [4]. Unlike SSDs or VRs, CPR images
display the cross-sectional profile of a vessel along its
length, facilitating characterization of stenosis or other
intraluminal abnormalities [3].
Limitations
One major limitation of traditional MPR is that structures
must lie in a plane, and almost all structures for which 3-
D visualization is desired do not lie within a single plane.
Pediatr Radiol (2013) 43:269–284 271

MPR therefore cannot be used to demonstrate an entire

structure at one time and pseudostenoses may appear on
MPR images. One solution to this problem is to use CPR
[4]. An important limitation of CPRs is that they are
highly dependent on the accuracy of the curve. Inaccu-
rately positioned or insufficient numbers of points can
result in the curve slipping-off the structure of interest,
again leading to pseudostenoses [3, 4]. A single curve also
cannot accurately display eccentric lesions. Therefore, two
orthogonal curves should always be created to provide a
more complete depiction of eccentric lesions, particularly
in stenosis [4]. Manual derivation of the curved plane is
also time-consuming [3].

Maximum intensity projection

Multiplanar images can be thickened into slabs using

projectional methods such as MIP, MinIP and average Fig. 2 Maximum intensity projection. When viewed parasagitally, the
intensity projections/raysum (sum of all pixel values en- MIP image clearly demonstrates the contrast-enhanced blood vessels
countered by each ray to provide an image similar to a that are displaced and encased by a mass lesion (arrow) in the neck.
Extension of the mass into the thorax is clearly demonstrated
radiograph) [3, 4]. MIP is a widely used rendering tool
particularly for evaluation and display in CT angiography,
and has been shown to be more accurate than surface
rendering for evaluating the vasculature. However, an but this is mainly a problem when evaluating atherosclerotic
understanding of how the MIP algorithm produces render- vessels in adults where there are large calcifications within
ings and of the limitations of MIP is essential for the the vascular lumen. The 2-D MIP display can also depict the
correct interpretation of MIP images [2]. 3-D relationships of structures inaccurately, causing misrep-
MIPs are created when a specific projection is selected resentation, especially when there are overlapping struc-
(e.g. anteroposterior) and rays are cast perpendicular to tures, because there are no visual cues for depth perception
the view through the volume data MIP with only the [3]. This limitation can partially be overcome by thinner
brightest voxel being projected into the resultant image. sliding slab MIP reconstructions [6, 7].
The algorithm achieves this by selecting the voxels with
the highest attenuation along lines projected through the
volume dataset [4, 5]. The result is a 2-D image of 3-D Table 1 Comparison of advantages and disadvantages of VR and
information because the entire volume is collapsed with MinIP/MIP
only the brightest structures being visible. Thick-slab
Volume Rendering (VR) MinIP/MIP
MIPs can be applied to angiography data to include long
segments of a vessel [3] (Fig. 2). There tends to be much Accurate 3-D relationships Inaccurate 3-D relations
less variability in MIP image reconstruction than in VR demonstrated
because fewer parameters are factored into the MIP al- Shows additional structures Only shows airways or vessels
(soft tissue, bone) in detail
gorithm [4] (Table 1). The application of MIP reconstruc-
Colour display helps interpret Grey-scale windowing only
tions for the lung has been shown to increase nodule complex relationships
detection and can help differentiate between small nod- Calcified vessels not a major Calcified vessels result in
ules and vessels [6]. This is not an ideal method for problem for depicting lumen size inaccurate representation of
demonstrating the airway itself, but it is useful for eval- vessel size
uating the surrounding structures to determine a cause of Does not require editing Requires editing
airway compression. Does require adjustment of Simplicity makes it easy to
parameters, and interactive nature master and does not require
makes it subject to interobserver much interactivity
Limitations variability (speed depends on the
user)
MIP images usually contain 10% or less of the original data Advantages in ability to rotate a Some advantages in
structure demonstrating smaller vessels,
[3]. The presence of high-attenuation voxels, other than especially collaterals
those of interest, may obscure evaluation of the vasculature,
272 Pediatr Radiol (2013) 43:269–284

Minimum intensity projection

This is a particularly useful technique for imaging the major

airways [4, 5]. MinIP images are a variation of the MIP
approach where multiplanar slab images are produced by
projecting only the lowest attenuation value when a ray is cast
perpendicular to the view through the volume of data (Fig. 3)
highlighting air-filled structures (as these have the lowest
Hounsfield unit value). Most MinIP and MIP methods use only
windowing parameters (window width and centre, specified in
Hounsfield units) and not colour (Fig. 4). An advantage of
MinIPs over MPRs is that structures that do not lie in a single
plane, such as the bronchial tree, are visible in their entirety
[5]. This allows determination of the length of airway stric-
tures on one slice (Fig. 5). Thin-slab MinIP images (with
section thickness less than 10 mm) viewed in sequence
(much like scrolling through single-pixel MPR images),
also known as a sliding slab, may provide more useful Fig. 4 Thick-slab coronal MinIP image using a soft tissue window
demonstrates the full length of the major airways as well as lymph-
diagnostic information, as small structures are better adenopathy, which is causing subtle compression of the left main
detected [3] (Fig. 6). bronchus (arrows)

Limitations allow several threshold ranges to be defined and displayed

Limitations are the same as for MIP especially with regard
to lack of appreciation of depth relationships [3].
Shaded surface display
SSD is termed a threshold-based classification technique. It
provides 3-D views of the surface of an object by using grey-
scale to demonstrate surface reflections from an imaginary
source of light. SSD displays a single surface generated from
thresholds selected by the user [4] (Fig. 7). The CT data are
reduced to binary data to achieve this, defining each pixel as
either in or out of the threshold range [3, 4]. Some versions
using different colours. In this setting, different tissue types or
structures are coded as different colours to allow differentia-
tion of adjacent structures, but for each classification, data
segmentation is required, typically by using a threshold and
editing, which dramatically increases postprocessing time.
However, the main advantage of threshold-based rendering
is its processing speed, since a comparatively small amount of
computational power is needed [4].
Limitations
Much like MIP, SSD is flawed because it uses less than 10% of
the acquired data [3]. The reduction to binary data limits

Fig. 3 Minimum Intensity

projection. a The thickness of
the coronal slab is decided on
the sagittal image as a vertical
thick slab selection (white
arrows). b This yields a coronal
MinIP image that includes the
full thickness of all major
branches of the
tracheobronchial tree, thereby
reliably demonstrating
compression of the trachea and
the right bronchus (black
arrows) in this patient with situs
inversus
Pediatr Radiol (2013) 43:269–284
Fig. 5 Coronal MinIP images
utilizing a lung window. The
major airways are demonstrated
on a single image, providing
information on the degree of
compression of the bronchus
intermedius (a white arrow) as
well as allowing measurement
of the length of the compression
(b black arrow), which has
resulted from right hilar and
subcarinal lymphadenopathy
flexibility and makes this postprocessing technique prone to
artefacts. Regardless of the number of tissue groups or classes
assigned, the selection of the threshold range that defines the
groups is arbitrary and this limits accuracy [4]. Voxels that
represent mixed tissue interfaces cannot be accurately classi-
fied. This makes the system incompatible with volume aver-
aging and results in incorrect classification of voxels that
contain volume averages [3]. The thresholding makes the
technique susceptible to noise introduced during scanning. A
small amount of noise can modify attenuation values and create
the appearance of soft tissue in a voxel that actually represents
mostly bone [2]. All of these disadvantages add up and many
artefacts are described on the end image: “holes in structures,
contours that represent voxel boundaries rather than true tissue
interfaces, fragments of structures floating in space, and ab-
sence or exaggeration of details such as bone fractures” [2].
Fig. 6 Sequential coronal oblique thin-slice sliding slab MinIP images
using soft-tissue window. Thin slab images do not demonstrate the
airway on one single slab but rather demonstrate (a) the right major
airways (white arrow) on an anterior slice and (b) the left airways
(black arrow) on contiguous thin slabs. This is similar to scrolling
through a coronal MPR but having a choice of slice thickness. In this
273
Volume rendering
VR is the most advanced of the rendering techniques and
is the technique that allows the majority of clinically
useful postprocessing. It refers to a 3-D volume recon-
struction method that allows every voxel in the volume
data to contribute to the reconstructed image [7]. The
technique is termed a percentage classification (semitrans-
parent volume-based/continuous technique). Simplistical-
ly, all voxel values are assigned an opacity level that
varies from total transparency to total opacity. This can
be applied to voxel values as a whole or to regions of
the histogram that are classified as specific tissue types
[4]. In percentage classification, it is assumed that a
voxel may represent one or more tissue types and that
the amount of each tissue as a percentage of the entire
patient, there is complete occlusion of the right upper lobe bronchus
and moderate narrowing of the bronchus intermedius resulting from
tuberculous lymphadenopathy (L). There is also extensive parenchy-
mal disease distal to the right upper lobe obstruction with necrosis and
breakdown
274
Fig. 7 Surface-shaded display image of the chest, anterior view. The
image was generated using a threshold setting to preferentially dem-
onstrate dense structures including bones, contrast-enhanced blood
vessels and heart
voxel is between 0% and 100% [4, 7]. Once colour and
transparency are assigned to each classified voxel, a 3-D
image is produced by casting simulated rays of light
through the volume. In addition, in VR there are adjust-
able parameters to change the way the image looks,
including window setting, colour, degree of opacity and
shading (Fig. 8). Angle and distance can also be deter-
mined. VR allows the operator to select a variety of
Fig. 8 3-D volume-rendered image generated using density, transpar-
ency and colour suited to demonstrating bone and blood vessels
enhanced by contrast. As well as demonstrating these structures, the
depth relationship of each can be appreciated as a possible cause of
tracheal compression
Pediatr Radiol (2013) 43:269–284
viewing perspectives by rotating the 3-D reconstruction
through a preset number of views or by manually cus-
tomizing a desired view in real time (Fig. 9). VR
images do not have many of the computer artefacts found
with SSD. Most importantly, it has been shown that average
reading time using VR images is significantly shorter than
with MIP images [7].
Limitations
Inaccuracies in VR stem from mucus secretions, dynamic
airway changes and artefacts such as the stair-step artefact
encountered in up to 3% of images [1] (Fig. 10). VR also
requires more computational power than SSD because each
voxel must be projected into an image, while in SSD only the
surface data need processing. On modern computers, even
large datasets can be manipulated interactively, and the display
can be instantaneously changed from VR to MIP as
required. Interactive adjustment of VR parameters, rota-
tion of the dataset and automated clip plane editing all
can be performed in real time, but this places additional
time constraints on the radiologist, who needs to be
involved interactively.
Endoluminal visualization/virtual endoscopy
Both SSD and VR allow the production of images of the
inner surface of tubular lumens, and the technique has been
termed virtual endoscopy. This can be used to examine the
bowel, airways, blood vessels and the urinary tract [4, 5].
The basic technique involves identification of threshold
levels for SSD that exclude pixels of similar attenuation to
the lumen (−900 to −1,000 HU for air-filled volume and 150
to 400 HU for contrast-enhanced volume) or an opacity
curve for VR that results in complete transparency of the
lumen. Rendering creates an image of the interface between
luminal contrast and extraluminal attenuation and not the
mucosa or intimal surface. The two methods widely in use
are orthographic external rendering with cut planes and immer-
sive perspective rendering [4].
Orthographic rendering
This is the most commonly used technique particularly for
external visualization of a lumen from a viewpoint that is
external to the data [3, 4]. It can, however, also be used for
internal visualization when combined with cut planes posi-
tioned within the lumen of the structure of interest. This can
be compared to cutting a “window into a piece of pipe to
visualize its interior” [4].
Pediatr Radiol (2013) 43:269–284 275

Fig. 9 3-D volume-rendered

images generated using density
and transparency settings suited
to airway and lung visualiza-
tion. Rotation of the dataset
allows the degree and length of
left main bronchus narrowing
(arrows) to be visualized. In
this patient, the left main bron-
chus compression was due to an
anomalous artery

Limitations/disadvantages Immersive/perspective rendering

This method only provides a regional snapshot; it cannot
provide a continuous demonstration of all interior surfaces
of a lumen [4].
The viewpoint using this technique is from within the lumen
(Fig. 11) mimicking fibre-optic endoscopy, and bypassing the
limitations of the invasive technique that requires access to the
lumen and has a restricted direction of viewing. For the viewer
to have perspective on depth relationships at close range, a
modelling technique is used that functions in a manner similar
to the human visual system. In the same way that light rays are
focused to converge on the retina, the viewer recognizes the
distance of structures depending on their size. A structure
close to the eye appears larger than a structure farther away.
This effect is determined by the field of view of the virtual lens
[4].

Limitations

Opacity and colour selection and the complexity of creating

these visualizations can be daunting. The greatest problem
with immersive visualization, however, is navigation. This is
because there are three spatial degrees of possible position and
three spatial degrees of possible view direction [4]. Without an
external guide of the view position, it is easy to lose track of
location within the lumen. Techniques that automatically cre-
ate a flight path through the centre of a lumen are being
developed to address this [4].

Advantages of CT postprocessing of the airway

in children
Fig. 10 3-D VR image showing the stair-step artefact (arrows) in a
child with mild narrowing of the bronchus intermedius and left main Even though there is a shift away from the use of MDCT in
bronchus children because of the radiation dose, it is important that,
276
Fig. 11 The immersive (perspective) rendering technique results in images that mimic fibre-optic tracheobronchoscopy. Navigation tool image (a)
and virtual endoscopy image (b) at the level of the right upper lobe bronchus (white arrow) and bronchus intermedius (black arrow)
having decided to use CT, a full volume of data is obtained
after administration of intravenous contrast agent. This then
represents a single and complete MDCT study that can be
reconstructed as many times as necessary, in as many ways
as desired and for as long as the raw data are stored.
To be useful, CT postprocessing must result in better
anatomical detail and supply additional information relevant
to diagnosis and management of the disease than the origi-
nal axial images. A radiologist may, however, see the ad-
vantage of providing imaging information that is more easy
to interpret and more easy to communicate to the referring
clinician or parent even in situations where there is no
further diagnostic value than the original axial views. For
Fig. 12 Thick-slab MinIP in a child with primary lymphobronchial
tuberculosis. Axial (a) and coronal (b) views demonstrate airway
compression by lymphadenopathy (L) at multiple sites including the
right upper lobe bronchus (RULB), the bronchus intermedius (BI) and
Pediatr Radiol (2013) 43:269–284
demonstrating airways, it is advantageous to depict the full
tracheobronchial tree at once, the relationships of normal
anatomical structures to the airway, any anomalies associat-
ed and any pathology that may be causing the airway
compression in a way that clinicians and parents can under-
stand. This can be achieved using postprocessing of images
to mimic gross pathological specimens or endoscopic views.
Thus, without additional imaging or radiation burden to a
child, a clinician or a parent may be convinced of the
benefits of further management or even of conservative
management so that unnecessary interventions are avoided.
Reconstructed CT views of the airway in children have been
reported to have significantly reinforced the confidence in
the left main bronchus (LMB). This provides a practical means of
demonstrating pathology to pulmonologists and thoracic surgeons
who are contemplating lymph node enucleation for relieving the
obstruction
Pediatr Radiol (2013) 43:269–284
diagnoses and improved communication with clinicians allow-
ing more comprehensive surgical planning [8–11].
MPR is as accurate as axial CT, is easy to create and view,
and improves perception as it displays information effectively
[8, 9]. MinIP allows the detection of low-density structures
and is therefore ideal for improving evaluation of paediatric
airways [9, 10] (Fig. 12). MIP is ideally suited to demonstrat-
ing hyperdense pathologies such as vessel abnormalities, nod-
ules, calcifications and foreign bodies that are associated with
airway pathology [9]. VR techniques add value to imaging
complex structures and interfaces that cross the traditional
imaging planes [8, 9]. The 3-D images [9] simplify demon-
stration of pathology to the referring clinician and increase
diagnostic confidence for all involved [8]. They are excellent
for demonstrating a decrease in airway calibre, spatial rela-
tionships of structures, measuring stenoses to determine
Fig. 13 MinIP images on lung window in children presenting with
airway symptoms and signs. a Right tracheal displacement due to a left
neck mass (arrow). b Focal left main bronchus compression by tuber-
culous lymphadenopathy. c Multifocal airway narrowing by tubercu-
277
degree and length and identifying the cause of an airway
stenosis [1]. The accuracy of detection of airway compression
by 3-D VR has been reported to 95.7% compared to 91.5% for
conventional CT [12].
Virtual bronchoscopy (VB) is a noninvasive endoluminal
visualization technique that simulates bronchoscopy [9]. It
provides a realistic endoscopic 3-D view of the tracheobron-
chial tree and is particularly useful in children. VB has addi-
tional advantages over true bronchoscopy in that it also allows
simultaneous visualization of structures around the tracheo-
bronchial tree, which helps in the identification of the cause of
an obstruction [11]. VB is particularly attractive for imaging
airway stenosis when traditional bronchoscopy presents a risk
to a child, or when navigation of a bronchoscope is not
possible due to a high-grade stricture [8], and VR is used to
outline the bronchial lumen beyond this. The technique can
lous lymphadenopathy (right upper lobe, bronchus intermedius and left
main bronchus). d Isolated narrowing of the left lower lobe bronchus
(arrow) due to tuberculous lymphadenopathy
278 Pediatr Radiol (2013) 43:269–284

Fig. 14 3-D VR images. Multiple rotated views demonstrate the advantages of 3-D VR in the diagnosis and evaluation of this double aortic arch
anomaly (arrows) as a cause for stridor and tracheal stenosis

also be used for planning transbronchial biopsy, endobron- defining bronchoceles [8] and when planning a diagnos-
chial laser therapy and stenting [5]. tic lung biopsy [8].
For imaging lymphobronchial tuberculosis (i.e. the in-
volvement of the airway by compressive lymphadenopathy
Postprocessing for airway diseases in children of primary tuberculosis), the relationships between the bron-
chial walls and lymph nodes are extremely well demonstrat-
Identification and better characterization of tracheobronchial ed using reconstruction techniques [8]. The airway is most
stenosis is the main indication for airway postprocessing
techniques. Even though MPR and MinIP are extremely use-
ful tools in evaluating tracheobronchial stenoses (Fig. 13),
which are vertical or slightly oblique [8], it is 3-D VR
that both allows 3-D reformatting of airways and demon-
strates associated adjacent vascular structures [8]. It illus-
trates focal areas of narrowing, the craniocaudal length of
tracheobronchial stenoses and even demonstrates the air-
way beyond the major stenosis. MinIP may demonstrate
the airway equally as well, but VR is more useful when
complex tracheobronchial congenital anomalies with vas-
cular and other anatomical associations are being evaluated
(Fig. 14) [8, 10].
Causes of tracheobronchial stenosis in children in-
clude tracheomalacia often associated with compressive
vascular rings (Fig. 13), tracheooesophageal fistulas, Fig. 15 Coronal MinIP image on lung window. MinIP adequately
hilar or mediastinal tumours, foreign bodies (Fig. 15) demonstrates endobronchial material (arrow) in the right main bron-
chus and bronchus intermedius (in this case granulation tissue from a
[8, 11] and mucoid impaction. In addition, reconstruc- tuberculous lymph node erosion into the airway). Fibre-optic tracheo-
tions can be used for imaging the distal airways [8, 10], bronchoscopy was performed and the material was aspirated acting as
especially in suspected bronchiectasis (Fig. 16), for both a therapeutic and a diagnostic procedure
Pediatr Radiol (2013) 43:269–284 279

Fig. 16 Coronal MinIP images

on lung window. MinIP
demonstrates the distal airways
and can distinguish air
bronchograms related to an air-
space process (white arrows)
(a) from bronchiectasis (black
arrows) (b)

easily compared to a chest radiograph using the MinIP
technique, which is considered to be a useful training tool
for tuberculosis workers restricted to the use of plain radio-
graphs (Fig. 13). Du Plessis et al. [1] compared 3-D VR with
FTB in 26 children with lymphobronchial tuberculosis (me-
dian age 21 months) and demonstrated a 92% sensitivity and
85% specificity for airway compression compared to tradi-
tional bronchoscopy. However, the VR technique was
additionally successful in demonstrating a further 51 sites
of stenosis, provided a description of the degree of stenosis
in all patients, and in three of four patients even dem-
onstrated stenotic airways beyond a proximal stenosis
that the bronchoscope could not pass [1]. The readers
also expressed the length of the stenosis and identified
the cause of the stenosis in all children. FTB assumed
the cause to be lymphadenopathy in all children, but

Fig. 17 3-D VR images.

Multiple views demonstrate
tracheal (a white arrow) and left
main bronchus (a black arrow)
narrowing caused by large
mediastinal and subcarinal
lymphadenopathy (a–d L) in a
child with primary pulmonary
tuberculosis
280 Pediatr Radiol (2013) 43:269–284

Fig. 18 Immersive virtual

endoscopy in the same child as
in Fig. 17 shows tracheal
narrowing (a white arrows) and
left main bronchus narrowing
(b black arrows) adjacent to the
respective navigation coronal
images that help orientate the
operator

VR demonstrated that 14% of the airway stenoses were
from other causes [1].
Figure 17 demonstrates the usefulness of the 3-D VR
technique in demonstrating tracheal and left main bronchus
compression while also demonstrating the causative lymph-
adenopathy and relationships to blood vessels. Figure 18
demonstrates the navigation and endoscopic views in the
same patient, which may assist in communicating the loca-
tion and severity of stenosis to a bronchoscopist planning to
perform a transbronchial biopsy.
postprocessing can apply learning algorithms to develop
models from entire datasets of CT scans. These models
can then be used to automatically identify each anatom-
ical airway branch and then detect normal and patho-
logical variations related to a specific disease. Most
postprocessing methods have been developed for and
tested on adult airways, and limited work has focused
on paediatric airways. Paediatric airway analysis

Research tools: advanced postprocessing currently

for research and CAD

Automatic segmentation of high-resolution CT images

can extract and analyse the structure of the tracheobron-
chial tree and distinguish airway regions from surround-
ing tissue, including the lung. Improvements to these
methods mean that smaller branches can be visualized.
Postprocessing can be used to perform various measure-
ments including identification of branching topology as
well as branch dimensions and cross-section measure-
ments. This technique can generate automated airway Fig. 19 Segmentation with bone rendering of the airway in a 20-
statistics at the click of a button. More sophisticated month-old patient
Pediatr Radiol (2013) 43:269–284
introduces additional challenges to postprocessing.
Smaller patient size and radiation dose considerations
mean that the airways are extracted at a lower resolu-
tion and fewer branches are extracted [10]. In this
section, we present general methods that can be applied
to adults and children as well as specific methods and exam-
ples from our own work in paediatric airway analysis.
Segmentation
There are many airway segmentation algorithms that use
a variety of mathematical techniques, but these methods
usually comprise common steps. A typical airway seg-
mentation algorithm would consist of the following steps:
(1) identification of an initialization point within the air-
ways, (2) application of filtering techniques to enhance
the airways, (3) detection of connected airway regions
from the initialization point, and (4) detection and re-
moval of non-airway regions that have been mistakenly
classified.
The main airways can be segmented more easily than
smaller bronchi because they have a well-defined wall and
therefore there is greater contrast between wall and lumen.
Simple thresholding methods are often used to extract the
larger airways while more sophisticated methods are used for
the smaller bronchi. This saves processing time and allows the
algorithm to be tailored more specifically to the smaller air-
ways [13]. Airway segmentation methods include: adaptive
thresholding [14], fuzzy connectivity [15], rule-based segmen-
tation [13], morphology-based connection cost [16], and mor-
phological filtering [17, 18]. The evaluation of these methods
is a challenge because there is no common gold standard
airway segmentation dataset. However, a number of state-of-
the-art airway segmentation methods were evaluated as part of
the EXACT'09 airway segmentation competition [19].
Fig. 20 Airway centre line and bifurcation point detection from a
paediatric chest CT scan
281
Fig. 21 Branch measurement by projection of points onto the airway
surface from the medial line
Very few of the methods have been applied to paedi-
atric CT volumes. Irving et al. [18, 20] developed a
method targeted at paediatric airway volumes in which a
threshold is applied to extract air-filled regions and there-
fore approximate the lung regions. The trachea is identi-
fied in the axial slices above the lung region and used to
initialize the segmentation. The trachea is air-filled and
therefore has a lower HU value than the surrounding
tissue, and can be identified in cross-section. However,
other objects within the same HU range may also be extracted
so that a number of features, including the cross-sectional
area, location and circularity, are used to identify the trachea
[18]. A morphological filtering method is then applied to the
CT volume in the axial, coronal and sagittal directions. This
filter uses morphological closing and reconstruction to en-
hance regions with a circular appearance [21] and therefore
enhances cross-sections of the airway in the three directions.
Once a range of morphological filters have been applied to
enhance airways of various sizes, a threshold value is applied
to extract likely airway regions. Finally, a region-growing
method is applied to extract just the connected airway. This
region-growing method starts at the seed point located in the
trachea and adds neighbouring voxels with 26-connectivity
until no other voxels can be added [18].
Segmentation of the airway can be used to improve the
rendering of the airway as well as to provide automated
analysis of the airway that cannot be achieved with just
rendering. An example of the resulting segmentation of the
airways in a 20-month-old patient is shown in Fig. 19. Note
also that some small regions have been misclassified as airway
and there is a limit to the number of branches that are seg-
mented. Each improvement in paediatric CT imaging and
segmentation will lead to more accurate airway extraction.
The limitation of many segmentation algorithms is that in
order to extract just the airways without additional regions
being mistakenly included, the airway needs to be complete-
ly connected, i.e. branches are not obstructed. To include
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obstructed branches, our algorithm performs a shape analy-
sis of each section of the airway to identify obstructed
branches and then searches for additional airway compo-
nents beyond the obstruction [20].
Skeletonization
Once the airways have been segmented, centre-line extrac-
tion is an important intermediate step before more advanced
airway processing can be performed.
Airway centre-line extraction algorithms produce a centre-
line one voxel thick that bifurcates to form the centre line
for each child branch (Fig. 20). The topological structure—
including branch start and end points and the relationships
between parent and child branches—can be extracted. The
extracted medial line can also be used to direct VB and
extract airway cross-sections. One method uses iterative
“thinning” of the segmentation by removing voxels that
do not affect the airway structure until only a one-voxel
thick branching centre line remains [22]. The centre line
extracted using this method in a child is shown in Fig. 20.
Branch measurements
Once the branching structure has been extracted, the start,
endpoint and centre line of the branch are defined. This
allows automatic measurement of the length, curvature and
cross-section of the branch. The voxel size is used as a
scaling factor for the volume. Branch length can be
Fig. 22 Principal component
analysis variation along one
example mode of the trachea/
right main bronchus/left main
bronchus (Trachea-LMB-RMB)
and one example mode of the
right main bronchus/right upper
lobe/bronchus intermedius
(RMB-RUL-BI) regions
Pediatr Radiol (2013) 43:269–284
calculated from the skeleton length and branch volume is
approximated as the number of voxels in the branch multi-
plied by the voxel dimensions [22]. From this, the approx-
imate mean radius of the branch can be determined. Cross-
sections can also be measured along each branch by projec-
ting vectors orthogonal to the centre line to the branch
surface [15]. This allows cross-sectional area and radius to
be calculated, and can be extended to identify and measure
branch local minima and maxima [23]. Figure 21 shows the
projection of orthogonal vectors and calculation of the in-
tersection of these vectors with the surface of the airways to
measure a branch.
Branch labelling
The topological structure of the airway can be used to match
each branch to its anatomical label. This can be used to
provide annotated visualizations of the airway, present data
about a branch of interest, and automatically compare
branches in a dataset of airways. However, the labelling is
made difficult by the variation in the shape and orientation
of the branches, and the possibility of anomalous branches.
Common methods use a template of the airway branching
structure and match this to individual airway trees. Branch
measurements such as branch length and orientation, angles
between branches, and relationships between parent and
child branches are used to match the template to the airways
and a function is used to optimize these labels over the
whole airway tree [24, 25].
Pediatr Radiol (2013) 43:269–284
Computer-assisted detection of airway pathology
Automated segmentation and branch analysis can be used to
evaluate and classify airways in a paediatric CT volume data-
set. This procedure is used to differentiate airway deformation
and stenosis from lymphadenopathy in children with tubercu-
losis. However, this can be extended to other airway patholo-
gies and used in conjunction with other features of pathology.
Once a dataset of airways has been segmented and the
structure analysed, the dataset can be used to train a classi-
fier to distinguish between normal and abnormal airway
variations. Irving et al. [23] created a point distribution
model that represents the airways as a set of points each
corresponding to a point on every other airway in the data-
set. The point distribution model for each airway is auto-
matically generated using a thin plate spline warp and
localized matching to fit a template airway onto each airway
segmentation. In the model of Irving et al. [23], three branch
sections of the airway are represented by a set of about
1,500 (n) vertices. Each is a point in 3-D space and therefore
each airway is represented by (3×n) features. Principal
component analysis is a technique that can be used to reduce
the dimensionality of this feature space and extract the main
modes of variation from the covariance of the points within
the airway dataset. This results in a more tractable number
of features that can be used to classify normal and abnormal
variations. Figure 22 shows one mode of variation from the
trachea/right main bronchus/left main bronchus region
and one from the right main bronchus/right upper
lobe/bronchus intermedius region. Irving et al. [23] used
ten modes of variation to represent each airway.
This method was evaluated using cross-validation on a
dataset of 61 patients with and without tuberculosis. All the
patients with tuberculosis showed symptoms and signs of
major airway compression. The method was able to distin-
guish between patients with and those without tuberculosis
with a sensitivity of 86% and a specificity of 91%.
Kiraly et al. [26] reviewed a number of other automat-
ed methods for airway assessment and visualization. Al-
though these methods were evaluated on adult datasets,
many methods could also be applied to paediatric airway
analysis. These include methods to determine airway lu-
men size and wall thickness, identify mucus plugs and
determine bronchus–artery ratios. These measurements can
then be presented as colour-coded airway visualizations
for assessment.
Conclusion
CT postprocessing techniques permit the demonstration
of fine anatomical detail, provide additional information
relevant to diagnosing and managing airway disease and
283
supply images that are easily interpreted, specifically for
improved communication with referring clinicians and
parents. Postprocessing methods also have the potential
to automate airway visualization, identify airway anato-
my and detect regions of pathology. Improved airway
segmentation will offer improved visualization of the
smaller bronchi and allow automatic extraction of the
airway structure. Branch measurements can then be au-
tomated and analysis of large datasets of images can be
performed. These methods would allow clinicians to
view the airways with overlays indicating airway prop-
erties or the likelihood of disease based on comparison
to a dataset of airway images.
References
1. du Plessis J, Goussard P, Andronikou S et al (2009) Comparing
three-dimensional volume-rendered CT images with fibreoptic tra-
cheobronchoscopy in the evaluation of airway compression caused
by tuberculous lymphadenopathy in children. Pediatr Radiol
39:694–702
2. Fishman EK, Ney DR, Heath DG et al (2006) Volume rendering
versus maximum intensity projection in CT angiography: what
works best, when, and why. Radiographics 26:905–922
3. Dalrymple NC, Prasad SR, Frecketon MW et al (2005) Informatics
in radiology (infoRAD): introduction to the language of three-
dimensional imaging with multidetector CT. Radiographics
25:1409–1428
4. Rubin GD (2003) 3-D imaging with MDCT. Eur J Radiol 45
(Suppl 1):S37–S41
5. Kirchgeorg MA, Prokop M (1998) Increasing spiral CT benefits
with postprocessing applications. Eur J Radiol 28:39–54
6. Ueno J, Murase T, Yoneda K et al (2004) Three-dimensional
imaging of thoracic diseases with multi-detector row CT. J Med
Invest 51:163–170
7. Peloschek P, Sailer J, Weber M et al (2007) Pulmonary nodules:
sensitivity of maximum intensity projection versus that of volume
rendering of 3D multidetector CT data. Radiology 243:561–569
8. Papaioannou G, Young C, Owens CM (2007) Multidetector row
CT for imaging the paediatric tracheobronchial tree. Paediatr
Radiol 37:515–529
9. Perandini S, Feccioli N, Zaccarella A et al (2010) The diagnostic
contribution of CT volumetric rendering techniques in routine
practice. Indian J Radiol Imaging 20:92–97
10. Siegel M (2003) Multiplanar and three-dimensional multi-detector
row CT of thoracic vessels and airways in the pediatric population.
Radiology 229:641–650
11. Sodhi KS, Aiyappan SK, Saxena AK et al (2010) Utility of multi-
detector CT and virtual bronchoscopy in tracheobronchial obstruc-
tion in children. Acta Paediatr 99:1011–1015
12. Remy-Jardin M, Remy J, Artaud D et al (1998) Volume rendering
of the tracheobronchial tree: clinical evaluation of bronchographic
images. Radiology 208:761–770
13. Sonka M, Park W, Hoffman E (1996) Rule-based detection of
intrathoracic airway trees. IEEE Trans Med Imaging 15:314–326
14. Mori K, Hasegawa J, Toriwaki J et al (1996) Recognition of
bronchus in three-dimensional X-ray CT images with application
to virtualized bronchoscopy system. In: Proceedings of the 13th
International Conference on Pattern Recognition, vol 3. Vienna,
Austria. IEEE Computer Society, Washington DC, pp 528–532
284
15. Tschirren J, Hoffman E, McLennan G et al (2005) Intratho-
racic airway trees: segmentation and airway morphology anal-
ysis from low-dose CT scans. IEEE Trans Med Imaging
24:1529–1539
16. Fetita C, Preteux F, Beigelman-Aubry C et al (2004) Pulmonary
airways: 3-D reconstruction from multislice CT and clinical inves-
tigation. IEEE Trans Med Imaging 23:1353–1364
17. Kiraly A, Higgins W, McLennan G et al (2002) Three-dimensional
human airway segmentation methods for clinical virtual bronchos-
copy. Acad Radiol 9:1153–1168
18. Irving B, Taylor P, Todd-Pokropek A (2009) 3D segmentation of the
airway tree using a morphology based method. In: Brown M, de Bruijne
M, van Ginneken B et al (eds) Proceedings of the second international
workshop on pulmonary image analysis. London, pp 297–307
19. Lo P, van Ginneken B, Reinhardt J et al (2009) Extraction of
airways from CT. In: Brown M, de Bruijne M, van Ginneken B
et al (eds) Proceedings of the second international workshop on
pulmonary image analysis. London, pp 175–189
20. Irving B, Goussard P, Gie R et al (2011) Segmentation of
obstructed airway branches in CT using airway topology and
Pediatr Radiol (2013) 43:269–284
statistical shape analysis. In: Proceedings of the eighth IEEE
international symposium on biomedical imaging: from nano to
macro. IEEE, Piscataway, NJ, pp 447–451
21. Vincent L (1993) Morphological grayscale reconstruction in image
analysis: applications and efficient algorithms. IEEE Trans Image
Process 2:176–201
22. Palágyi K, Tschirren J, Hoffman E et al (2006) Quantitative analysis
of pulmonary airway tree structures. Comput Biol Med 36:974–996
23. Irving B, Goussard P, Gie R et al (2011) Identification of paediatric
tuberculosis from airway shape features. Med Image Comput
Comput Assist Interv 14:133–140
24. Tschirren J, McLennan G, Palágyi K et al (2005) Matching and
anatomical labeling of human airway tree. IEEE Trans Med Imag-
ing 24:1540–1547
25. Mori K, Hasegawa J, Suenaga Y et al (2000) Automated anatomical
labeling of the bronchial branch and its application to the virtual
bronchoscopy system. IEEE Trans Med Imaging 19:103–114
26. Kiraly A, Odry B, Godoy M et al (2008) Computer-aided diagno-
sis of the airways: beyond nodule detection. J Thorac Imaging
23:105