Digital subtraction angiography

Roshan Chaudhary
 Introduction
Fluoroscopic technique used extensively in interventional radiology
for visualizing blood vessels.
Radiopaque structures such as bones are eliminated ("subtracted")
digitally from the image, thus allowing for an accurate depiction of
the blood vessels.
Pre-contrast image is digitally subtracted from post-contrast image
to provide background suppression.
The images are all produced in real time by the computer, as the
contrast is injected into the blood vessels.
However DSA is being taken over by Computed Tomography
Angiography (CTA), which can produce 3D images through a test
which is less invasive and stressful for the patient.
DSA is still the gold standard for arterial imaging.
DSA-Principle
 DSA Steps

Processes involved in DSA :

 Preprocessing :- Digitalization : Analog to digital conversion.
 Processing :- Subtraction Techniques
 Post-processing :- Manipulations to enhance visibility
 Information Extraction
 Pre-Processing

Why Digitalization
 For all the image processing and manipulations done in DSA,
computer is must.
 Because computer can handle data only in bit format, conversion is
necessary for subtraction techniques to be applied by computer.
 Also Easy storage and retrieval is possible
 Pre-Processing

Why Digitalization
 Basic operation :- Central control computer is incharge of all the other
components of the image processor.
 Computer uses first image as a mask
 Display each subsequent images in subtracted form.
 We set the exposure techniques on generator and instruct the computer to begin.
 It sets up the digitizer to convert entire TV frame into digital image and starts
the digitizer at appropriate time.
 Meanwhile computer has instructed what to do with first digitized image which
is simply to place the image in appropriate form and to store it in a particular
block of image memory.
 The computer tells the digital disc where that particular block is located in
image memory, how big the image is, and when to start storing the image.
Pre-Processing
 Pre-Processing

Why Digitalization: ANALOG to DIGITAL conversion

 One of the most important step
 Analog information is any information represented in continuous
rather than discrete fashion.
 Digital information is any information that is represented in discrete
units.
 Video images are in form of lines with each point on line represented
as voltage.
 Digitalization involves conversion of all the points of voltage into
pixels of discrete value.
 Processing
(Types of Subtraction Techniques)
Temporal Subtraction
--Mask mode subtraction
--Time interval difference(TID) subtraction
Dual energy subtraction
Hybrid subtraction
 Types of Subtraction
Mask mode subtraction
 Most widely used process of subtraction.
 Temporal subtraction is done.
 Initial acquisition of a frame of region of interest.
 Second image is taken and stored as mask image.
 This mask image is subtracted from subsequently acquired images
and show only contrast filled structures.
 Processing
(Types of Subtraction Techniques)
Mask Mode Subtraction
 Processing
(Types of Subtraction Techniques)

A. The pre-injection mask, B. A post-injection image, C. Image produced when the pre-
injection mask is subtracted from the post-injection image.
 Processing
(Types of Subtraction Techniques)

TID mode subtraction

 Another mode of temporal subtraction where a consecutive
previous frame is subtracted from current frame.
 TID mode produces subtracted images form progressive masks
and following frames
 This technique is very useful in cardiac imaging where there is
rapid motion.
 Processing
(Types of Subtraction Techniques)
TID mode subtraction
 Processing
(Types of Subtraction Techniques)
TID mode subtraction
 If the patient motion occurs between the
mask image and a subsequent image, the
subtracted image will contain
misregistration artifacts.
 The same anatomy is not registered in
the same pixel of the image matrix.
 Eliminated by the registration of the
mask by shifting the mask by one or
more pixels so that superimposition of
images is again obtained.
 Processing
(Types of Subtraction Techniques)
 Region of interest is exposed to higher kV(120 to 130kV) and
lower kV (70kV) at very short interval (about 50ms).
 Then, the higher kV image is subtracted from lower kV image to
produce the image.
 Comparison Between Temporal and Energy Subtraction
Temporal Subtraction Energy Subtraction
A single kVp setting is used. Rapid voltage switching is required.

Normal X-ray beam filtration is adequate. X-ray beam filter switching is preferred.

Contrast resolution is 1 mm at 1% is Higher X-ray intensity is required for

achieved. comparable contrast resolution.

Simple arithmetic image subtraction is

Complex image subtraction is necessary.
necessary.

Motion artifacts are a problem. Motion artifacts are greatly reduced.

Total subtraction of common structures is Some residual bone may survive

achieved. subtraction.
Subtraction possibilities are limited by the Many more types of subtraction images
number of images. are possible.
 Processing
(Types of Subtraction Techniques)
Hybrid subtraction
 Is a combination of dual energy and temporal subtraction.
 In Hybrid subtraction, image acquisition follows the mask-mode
procedure.
 The mask and each subsequent images are formed by an energy
subtraction technique.
 If patient motion can be controlled, hybrid imaging theoretically
can produce the highest-quality DF images.
 Advantage – eliminates effect of patient motion.
 Processing
(Types of Subtraction Techniques)
 Special techniques used in DSA

Road map technique.

Fluoroscopy fade technique.
Dynamic 3-D road mapping technique.
 Special techniques used in DSA

Road map technique

 Static fluroscopic image is subtracted from densely opacified vessel.
 Here , a short contrast run of vessel is done under fluoroscopy to
select the frame with maximum opacification of the vessel as the
road map mask.
 Then subsequent live fluoroscopic image is subtracted from the road
map mask for visualisation of the vessel and the catheter/guide wire.
 This technique is very useful in placement of catheters and guide
wires in complex and small vessels.
 Motion after road map acquisition may affect subsequent
intervention
 Special techniques used in DSA

Fluroscopy fade technique

A reference DSA image is overlaid on the real time fluoroscopic
image.

Dynamic 3D road mapping

New development allows projection of 3D reconstructed vessel on
live 2D fluoroscopic image.

An important advancement in digital fluoroscopy is rotational

angiography.
In this x ray tube-detector system rotates through visually 90 degree
to 180 degree while acquiring continuous images
 Peripheral DSA

 Can be performed with single contrast injection using stepping technique.

 Two types- 1) Stepping table technique 2)Stepping gantry method

Stepping table technique

In this table moves into three stations with x ray tubes and detector
remaining fixed.

Stepping gantry method

In this method the tube –detector or image intensifier moves keeping the
table fixed.
 Peripheral DSA

 In both methods pre-contrast images are acquired at different

stations and stored as mask image
 Subsequently matching post contrast injection images are taken at
same position and subtracted from the corresponding mask image
to produce clear image of peripheral arteries.
 Reduce examination time.
Disadvantage: Increased chances of movement between pre-contrast
and post-contrast images.
 Post Processing

Mask pixel shift

 It is a software modification feature.
 Used when smaller patient motion occurs after the mask image is
acquired.
 By shifting the pixels of the mask image reregistering of the mask
with post contrast mask image is possible- thus obviating motion
artifacts
 This technique may be manual or automatic.
Post Processing
 Post Processing
Remask:
 It is a similar feature where another mask image is selected which
is temporally closer to the contrast image.
 This is useful when patient motion occurs prior to contrast image ,
but after initiation of the acquisition.

Image summation
 It is property in which two or more frames of DSA acquisition are
summed into a single image.
Benefits of image summation
 This is beneficial when rapid acquisition opacifies part of a vessel
in each frame and summation adds up the frames to produce a
single image showing the entire vessel.
Post Processing
 Post Processing

NOISE SMOOTHENING
 The operation has suppressed small structures and had little effect
on large structures.
 Noise smoothening is attempt to decrease the visual prominence of
noise so that low contrast objects of moderate to large size may be
better appreciated.
 The techniques operates by reducing the statistical fluctuation in
each pixel by averaging the pixel with its closest neighbours.
 The first pixel is smoothened by averaging nine nearest neighbours.
 The final image is blurred image of the original.
 Post Processing

NOISE SMOOTHENING
 Post Processing
EDGE ENHANCEMENT
Substracting noise smoothened image form the original image results in edge
enhancement.
 Post Processing

EDGE ENHANCEMENT
 Information extraction

Extraction of numerical or graphic information from images.

 Quntitative algorithms are available to measure:-
Stenosis sizing:- Length, Area
Distance Measurements
Perfusion- functional Studies
Vessel Tracking
Relative flow and volumetric measurement
 Complications

 0.16% major complication rate.

 Local complications: hematoma, vessel laceration, dissection,
peudoaneurysm, AV fistula.
 Systemic complications: contrast reactions, fever, sepsis,
dehydration, death.
 CNS complication: aggravation of preexisting complaints,
neurological deficit.
 Post-Procedural Care

 After the catheter is removed compression is applied to the

puncture site.
 The patient is asked for bed rest for a minimum of 4 hours.
 During rest patient and vital sign is monitored.
 The extremity is also checked for warmth, color, numbness to
ensure circulation has not been disrupted.
 Post-Procedural Care

 Oral fluid is given and analgesics are given if required.

 Special care should be given in case of children and geriatric
patient.
 Geriatric patient also frequently feel nervous and afraid of falling
off the table.
 Reassurance and additional care from the technologist will
enable the Patient to feel secure and comfortable.
 Diagnostic Usage

Arterial-venous malformation

ICA aneurysm
 Diagnostic Usage
Tumour vascularity
Therapeutic Usage

Coiling of cerebral aneurysms

Therapeutic Usage

Stenting of ICA stenosis

 Therapeutic Usage

Particle embolization
Gel embolization
Therapeutic Usage

Thrombolysis