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For personal use only; all rights reserved

781

Digital
Subtraction
Angiography:
Overview
Technical

Donald
P. Harringto&
Lawrence
M. Boxt
Philip

D.

Murray

Principles

The rapid development

of equipment
for digital subtraction
angiography
(DSA) has
created a new diagnostic
imaging method, the limits of which have not been scientifically determined.
Yet through aggressive
marketing,
the technique
is already beginning
to permeate
radiologic
practice.
The radiologist
requires
technical
understanding
of
the instrumentation
for informed
judgment
on clinical applications.
DSA depends
on
the mating of high-resolution
image-intensifier
and television
technology
with computerized information
manipulation
and storage.
In this overview,
the individual
components of the system are analyzed,
from the generator
to the image intensifier
to the
television
system to the associated
computer.
By examining
the role of each component, the current limitations
and the areas of possible future development
of DSA can
be understood.
This provides
a basis for dealing
with current
technology
and for
evaluating
the rapid technological
changes that will occur over the next few years.

Digital
many

subtraction

angiognaphy

characteristics

the i 970s.
digital
data
further
years,

(DSA)

in common

with

Like CT scanning,
DSA
collection
and computer

similarity
is simultaneous
CT evolved
through
four

is an

the

emerging

development

concerns
for premature
The theoretical
basis
and

its

scanning,

associated
its operation

Received
June 8, 1 982;
12, 1982.
1 All authors:
Department

Medical
School,
75 Francis
St.,
print

requests

Brigham
Boston,

accepted

after revision

of Radiology,

Harvard

and Womens
Hospital,
MA 021 i 5. Address
re-

to D. P. Harrington.

AJR 139:781 -786, October 1982

o36i-8o3x/
82/1394-0781
$00.00
American
Roentgen
Ray Society

does

the case with DSA

under
user control.

where

A second
cause
component-by-component

for

optimum
low-contrast
the imaging
chain
individual
resolution,
of current
This

development
generations

and marketing
of scanners
with

and

one

source.

not need

image

While

the active

processing

visualization,
the
be individually

four factors,
contrast
resolution,
must each

future

DSA

defines

the

that

underlie

some

associated

improvement.

of the jargon
for

technology
underlies

user.

of viewing

equipment
imaging

This

CT
is not

modes

are

is the need for a

chain.
To achieve

advantage
of DSA, all links
and optimized.
In evaluating
x-ray

exposure,

in

temporal

for an understanding

equipment.
concepts

made

a background

a variety

be considered

imaging
chain.
of a composite

of further

of the

sensitivity,

component
in the
of the components

to offer

direction

DSA
whole

evaluates
each
representation
to define

Computer
computer

principal
evaluated

integrating
image.

of equipment.
In 5
profound
changes

the

and

has

during

was vigorously
marketed.
It
significantly
oven the next
more difficult
because
of

obsolescence.
presents
difficulties.

difficulty
in evaluating
evaluation
of the

must

components,
and spatial
report

are

that

CT scanner

is a computer-assisted
technique,
processing
to produce
a medical

technological
of DSA also

jargon

technology
of the

between
the first and last generation,
each of which
is reasonable
to assume
that DSA will also evolve
several
years,
making
selection
of current
equipment

July

of

evaluation

of specific

with

the

development

Figure
1 provides
DSA system.
the computer
equipment

and

of DSA

and

a schematic
An attempt
technology
the

possibilities

is

and

782

HARRINGTON

Basic

Principles

DSA

is part

radiology.

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of Digital
of the

For

converted
manipulated

Subtraction

larger

DSA,

televised

subtraction,
also
For this process,

before
placed

known

image

images
are obtained
placed
into a second

is digitally

image,

with

rendered

subtracted

the

result

visible

The

free

second

after
digital

from
that

operation

image

the

because

the

image

is very

ment
are
processing
available

performed
of data
in time

range

succeeding

subtraction

and

of contrast

within

Subtraction

the

and

is

image
This
is
initial

enhance-

in real time,
which
means
that
is sufficiently
rapid
that the results
the

clinical

and

logarithmic

signal
value.

The

in

In

the

former,

the

unsubtracted

is amplified
linearly,
independent
of its numerical
This is appropriate
if there
is uniform
tissue
density

the

field,

amplification,
proportion
cified

such

blood

density

as

in

abdominal

imaging.

in which
amplification
to the signals
strength,
vessels

structures.

unaffected
This

vertebral
imaging
image
amplification.

and

mental
After

form being
amplification,

analogue

form

is the

represents
Square-root

investigated
the image

to a digital

form.

of the
provides

Logarithmic

input signal
is in
images
of opa-

by overlying

high-

technique

used

and

low-

in carotid-

the most common

form of
amplification
is an expeniat the
must
The

University
of Arizona.
be converted
from its
analogue

image,

which

is a representation
(or analogue)
of a fixed
quantity
by
means
of a physical
variable,
such as shades
of gray in the
radiographic
film or the brightness
of the image
intensifier,
must
be converted
to the digital
form in which
a discrete
value,
rather
than a continuous
variable,
rays exiting
an object.
The digital
signal
and

easily

defined

transmitted
digital

data

than
make

an analogue
computer

represents
the
is more accurately
signal,

manipulation

simple
task. It is much
easier
to perform
on digital
data than on analogue
data.
This process
of digitization
is performed
to-digital
converter
(A/D
converter),
the

image

Image

manipulation

formed
by the
such as signal
image
different

can

be

simple

subtraction/enhancement

per-

image processor/computer
or more complex
procedures,
filtration
or edge enhancement
performed
by advanced

processor/computer.
hardware
in different

Different
systems
configurations.

allocate
these
Current
systems

functions
transfer

to
pro-

cessed
images
to either analogue
or digital
short-term
storage
module.
Images stored in analogue
system can be redigitized
and further processed
or archived
on disk or tape. Images stored in digital form can be directly
reprocessed
or archived.

process.
is one.

may occur
before
or after digitization
of
be fixed or selectable,
depending
on the
Choices
for amplification
include
linear
modes.

Fig. 1 -Flow
of information
in generalized
digital subtraction
system.
Display
console
contains
TV monitors
for display
of unprocessed
images
from TV chain on left or processed
images
from image storage.
Control
functions
include x-ray generator
settings
and choice of images for manipulation.

the
are

examination.

further
steps
are a routine
part of the
of the output
of the image
intensifier

This amplification
the data and may
individual
system.

IMAGESTORAGE

are

speed
and apparent
simplicity
of computerized
subtraction
are two major
advantages
of DSA over standard
film subtraction
angiography.
Several
Amplification

ADVANCED

contrast

structures

after

small.

to influence

PROCESSOR

IMAGE

detail.

occurs

subtracted

is

arrival
of a contrast
memory.
The mask

expansion
of the dynamic
range
of the subtracted
which
results
in enhancement
of the final image.
necessary

1982

area of interest,
is
Then one or more

contrast-filled

of background

October

data are then

is the process

known
as temporal
or time suban image
(the mask)
obtained

arrival
of contrast
material
at the
into one of two digital
memories.

subsequent
bolus
and

AJR:139,

as digital

fluoroscopic

point-by-point
to digital
data. These
in two operations
[1 -5]. The first

of image
traction.

AL.

Angiography

phenomenon

the

ET

and

x-

the well

a relatively
processing

by an analogueefficiency
of which

can be defined
by the rate of digitization
or conversion
time
and intensity
resolution
or depth
of digitization.
This device
assigns
the output
signals
of the television
camera,
specific

discrete

digital

values.

The

rate

of digitization

is in micro-

seconds
for all systems.
The depth
of digitization
(or exactness of the assigned
value)
is important
because
it is related
to the number
of shades
of gray that can be displayed;
the
greater
the depth of digitization,
the larger number
of shades
of gray
available
1 ,024

become
available
A/D
converters
gray

(210

or

for the
provide

1 0 bits)

entry on the market

or 1 2 bits) for each

levels.

claims
selective
discrete
point

conversion
process
influences
system
in that noise
may be
affecting
scnibed,

image
quality.
At
there
is no significant

the present
quantification

are

may

exposure

latest

4,096
in the

the depth
limitation

to

commercial

gray
image.

levels
The

(212

A/D

resolution
of the
by this process,
of digitization
deto image
quality
in

the

be discussed
subsequently.
that the image
is entered
and the subtraction
and

performed.

be performed
most

in several

common

acquisition
rates
can
images
per second).
degree
achieved

The

DSA systems,
but noise may be significant
when
of the image
data is attempted.
The concept

enhancement
imaging,

image.
Commercially
gray (28 or 8 bits)

the ultimate
introduced

of noise in the DSA system

will
It is at this point after digitization
into
one of the two
memories
DSA

final
256

mode,

be relatively
This
mode

different

modes.

Serial

is used

where

image

low (from
allows
for

one
the

of flexibility
in image
acquisition
with a short-pulsed
x-ray exposure
with

variable

addition

and

averaging

to eight
greatest

and
may
be
or by a longer
of individual

television
frames.
The difference
between
these
methods
will also be discussed
later. A second
mode,
the continuous
or dynamic
mode,
uses an acquisition
rate of 30 fnames/

AJR:139,

sec

October

with

resultant

photon

flux

panison

to the

changing
imaging.

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DIGITAL

1982

shorter

per

x-ray

image,
serial

and

exposure

This

mode

followed

by contrast

mode,
termed
30 frames/sec

is used

and

injection.

With

a third

the time-interval-difference
is used,
but the subtraction

so on).

between
explored

the
and

This

which

two
successive
it is not available

Variations

in the

manufacturers
enhancement
further

mode

way

processed

are

displays

handled

and

other

In
of

fully

and
be
or be

stored.
This choice
introduces
several
major considerations.
The first is whether
these
images
should
now be converted
back
into an analogue
format
or remain
digital.
Ideally
an
all-digital
images
used.
format

system
is preferable,
unless
improved
and

but storage
is limited
to a few
highly
expensive
technology
is

But if the images

are converted
for storage,
the number
of

problem.

Another

issue

is what

capacities
are necessary
quantification,
and finally,
stored?
This
sketch
of
amplified

by evaluating

of the

imaging

chain

memory

to the analogue
is no longer
and

computing

for further
processing
and/or
how should
the data be ultimately
basic
principles
can be usefully
each

[6,

back
images

of the

individual

X-ray

components

7].

Components

Tube

and

Generator

Two components
can be taken
together,
the x-ray
and generator.
While
a high photon
flux is a necessity

tube
for

DSA, standard
angiographic
x-ray tubes and generators
are
generally
adequate
to the task. One notable
exception
is the
0.3-mm-focal-spot
magnification
tube, which
does not allow
sufficient
photon
flux for DSA.
A compromise
x-ray
tube
might have
accomplished

0.6

and
with

1 .2 mm dual focal
the larger
focal

size is not a major

system
[8].
As to the generator,
control.

Such

factor

in this

a highly

a system

allows

spots.
spot,

DSA
since

relatively

desirable
rapid

is routinely
focal-spot

low-resolution

feature

is computer

determination

of expo-

sure factors,
without
multiple
trial and error exposures
which
waste
time and radiation.
In a computer-controlled
system,
a first approximation
of the exposure
factors
is based
on
the

size

of the

patient,

the

area

of interest,

as the number
of video
frames
averaging
is used.
A particular

to provide

intensifier.
which
the
the output

for the

proper

such

factors

to be integrated
if frame
amperage
is then
picked,

and a test exposure

(or preferable
is made
with automatic
computation
factors

and

fluonoscopic
of the final
light

output

from

This is a critical
factor,
as the light
TV camera
functions
is quite narrow
range
of the intensifier.

exposure)
exposure
the

example,

a high

the

circumstances,

is lauded

flux

in an

elderly

patient

dose

could

be chosen

dose
larger

photon

opacity

x-ray

contrast

of the
the

of

necessary

in

study.

injections
factor

as a relatively

with

for the

contrast

allow

in DSA.

noninvasive

at

injected

The

angiographic

image

range
within
compared
to

from

1 30-1

80

mR [2]

to 46-i

75 mR

[9]

per

image.

Our own experience

suggests
that dose
rates
are
200-700
mR pen image.
Radiation
requirements
intensifier
face
are i -2 mR pen image
depending
manufacturer.
If 2 mR is delivered
to the intensifier,
a minimum
200

mrad

the

entrance

(2 mGy)

per

skin

dose

image.

would

Dose

be in the

reduction

higher,
to the
on the
then at
range

is not

of

gener-

ally a high priority

item but can be realized
with a better
understanding
of x-ray
dose vs. contrast
sensitivity
of the
system.
This subject
should
be examined
when one considens individual
DSA units. It is also worth
pointing
out that the
expected
tube life in the DSA system
may be shorter
than
for

angiographic

high photon
A future

tubes

because

flux in all systems.

prospect
is that DSA

energy
subtraction
rather
subtraction,
an alternative
is based
on subtraction
rather

DSA System

For

to

lesser
x-ray exposure.
X-ray
exposure
is a misunderstood

varied

subtraction
must either

is control

relation

substitute,
which
is also said to be possible
with lessen
xray exposure
compared
to standard
angiography.
In a previously
published
clinical
series,
entrance
skin dose
rates

different

manipulation

other

in

function,

to reduce

procedure

differences

between

design

face

material.
renal

order

from a single
3 minus frame
the

evident
after
the
The images
formed

for viewing

poor

imaging

mode,
a rate
is performed

advanced

intensifier

contrast

rapidly

images
has not been
from all manufacturers.

data

become
process.

for

as occur
in cardiac
image
is used as the

between
each successive
image
rather
than
first image (i.e. , frame 2 minus frame
1 , frame
2,

Another
the

in com-

783

ANGIOGRAPHY

decreased

resolution

dynamic
processes,
such
In both modes,
a precontrast

mask,

times,

decreased

mode.

SUBTRACTION

than

in different

of the
may

large
be

demands
performed

for
with

than temporal
subtraction.
Energy
being tested
in several
centers,
of images
of different
kilovoltage,
time

[i 0]. The

advantage

is that

the

different
kilovoltages
can be programmed
within
milliseconds of each other,
so that motion
no longer
introduces
an
artifact.
Current
fluonoscopically
based
DSA units are incapable of energy
subtraction
although
one manufacturer
is
planning
to provide
such a system
in the future.
The circuitry
of the generator
nique.
An important

must

be extensively

purchasing

consideration

altered

for

this

is whether

units can be added

to existing
equipment.
Some
mainly
full-range
x-ray equipment
manufacturers,
DSA units only as a package
with their x-ray

techDSA

companies,
sell their

equipment,
while other companies
provide
an add-on
unit to already
standing
equipment.
One reason given for not mixing equipment is the need for optimization
of all links in the imaging
chain. For example,
a 5-year-old
image intensifier
may not
meet the specifications
of a new cesium-iodide
image intensifier. A further argument
is that synchronization
of the DSA
equipment
and the x-ray generators
is complicated,
and
incompatibilities
may exist between
different
manufacturers
generators.
However,
the continued
success
of add-on
installations
tends to deny that argument,
but the controversy
continues
along well defined
parochial
lines.

Image

Intensifiers

The modern
cesium-iodide
strongest
links in the DSA

image intensifier
is one of the
image chain, but the character-

HARRINGTON

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784

istics of these intensifiers

are somewhat
different
from standand fluorographic
intensifiers
[1 1 , 1 2]. For DSA applications, the image intensifier
must operate
at a 1 -2 mR per
image exposure
rate without
loss of contrast
or resolution.
This is higher
than for conventional
fluoroscopy
or even
cinefluoroscopy.
This operation
level alone
can lead to
abnormalities
such as pulse-charge
defocusing
or saturation
of the output phosphor
in standard
image intensifiers
[6].
A second

aspect

of the intensifier

operation

is that

at high

is a correspondingly
high gain or light
level which adversely
affects the TV camera,
and appropniate variable
filtration
or aperture
control
is necessary
for
proper
light-level
control
[6]. This control
is also necessary
radiation

levels,

to allow

variability

there

in the

photon

flux to the image

intensifier

face as mentioned
above.
The cesium-iodide
image intensifier
is the standard
for
production
DSA units, but state-of-the-art
image intensifiers,
such as the Thompson
CSF 96 intensifier
and the Philips
1 4-inch
(36 cm) intensifier,
are proposed
for future
DSA
units. Further modifications
will include thicker
image phosphors in order to better control and use the light output [6].
The size of the image
intensifier
is also an important
factor, especially
for demonstrating
large vascular
areas, as
in the extremities.
Large intensifiers,
such as the Philips 14inch (36 cm), offer superior
contrast
resolution
capabilities,
but have the disadvantages
of decrease
in spatial resolution
due to the fixed matrix size of the image processor
and the
considerable
increase
in cost.
Television

System

The TV system serves to convert the optical image of the

image intensifier
to an electronic
signal that will be digitized.
Many believe this limits the overall resolution
of the system,
and most manufacturers
agree that the television
component of the DSA system
must be state-of-the-art.
Newly
developed
video tubes, such as the Amperex
45-XQ ( frogs
head
plumbicon),
as incorporated
into a Sierra Scientific
camera,
and the lead oxide Videcon
tube are examples
[1,

2]. Concepts

of noise

and signal-to-noise

ratio

in TV systems

need special consideration.

Noise is anything
that obscures
a signal that is being
measured.
In the context
of the DSA system,
it can be
caused
by another
electrical
signal
(interference)
which
originates
primarily
from the TV camera,
by some physical
process
such as the quantum
noise which originates
from a
limitation
in the number
of x-rays per image, and from the
digitization
noise which reflects
the uncertainty
associated
with quantizing
the video signal into a finite number of digital
levels [8]. Signal-to-noise
ratio (SNR)
is the ratio of the
signal voltage
to the noise voltage
(100:1 , 1000:1
, etc.).
The SNR of a standard
radiographic
system
is roughly
1 00:1 , while the standard
fluoroscopic
system raises this to
200:1 . These systems
have poor low-contrast
detectability
(low-contrast
sensitivity).
CT has an SNR of 2000:1
and,
like DSA, has high contrast
sensitivity.
In any ideal radiographic
system,
the SNR should be limited by the quantum
statistics
of the photon flux and not the components
of the
system.
Since the TV system is an important
source of noise

ET

AL.

AJR:139,

October

1982

for DSA, one method

for improving
the entire system
is to
achieve
the highest possible
signal-to-noise
ratio for the TV
link, which is obtained
with state-of-the-art
television
systems.
Work by Mistretta
et al. [4, 5] in Wisconsin
indicates
that
a standard
plumbicon
television
system
will give a 500:1
SNR and the newer
frogs
head
plumbicon,
800:1 , and
they have suggested
an alternative
method
for improving
the SNR of the imaging
chain, which is known
as signal
averaging.
In this technique,
a series of serially
acquired
television
frames
are averaged
; that is, one collects
a
sum of repetitive
analogue
signals and an average
signal
is derived.
This technique
can provide
an SNR of 1200:1
[4]. The disadvantages
of this technique
are that motion
artifacts
may be introduced
as the number
of averaged
frames
is increased,
and that the need for long exposure
times increases
the radiation
exposure
to the patient. Such
an averaging
technique
also demands
a high-quality
television system with low lag and good image stability.
A second
alternative
is termed the
snapshot
mode [1],
which incorporates
a slow-scan
video technique
where the
image is stored on the target of the TV pick-up
tube and
then read out and digitized.
This method
is limited by the
need for a progressive
TV readout
where the entire video
frame, consisting
of 525 lines per field is read out progressively rather than the standard
interlaced
system where two
fields of 262.5
lines are alternatively
placed
on the video
frame. A further advantage
of this latter system is economy
of radiation
exposure
in both dose and time, which
decreases
the chance for motion artifact.
The disadvantage
of
the snapshot
method
is that it will not serve for rapid
acquisition
of images.
One limitation
of most current
television
systems
is that
they are formatted
to 525 television
raster lines. This is not
a limiting
factor
to resolution,
however,
if the matrix size
remains
at 51 2 x 51 2. Manufacturers
are introducing
new
high-resolution
television
systems
which
will incorporate
1 ,000-raster-line
(on more) television
cameras
and monitors.
This will improve
the display
of the image but will be most
useful only when larger matrices,
such as 1 024 x 1024,
are incorporated
into future image processing
systems.

Image

Processor

The image processor

is the heart of DSA because
it is the
part of the system where subtraction
and image enhancement takes place. Two principal
types have been developed.
The design
concept
put forth by Mistretta
[1 3] at the Univensity of Wisconsin
was that a subtraction
system should
be fast, easy to operate,
and relatively
inexpensive
as compared to standard
film subtraction.
The image processor
described
by Mistretta
is a hard-wined
system, which means
that the subtraction
circuits
are fixed and not alterable
or
programmable.
The design
concept
developed
by Nudelman
and colleagues at the University
of Arizona (Ovitt et al. [1 1) calls for
a more complex
system for subtraction
and image enhancement
requiring
considerable
operator
interaction
with
choices
to be made of types of amplifications
and methods

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AJR:139,

October

1982

DIGITAL

SUBTRACTION

of enhancement.
In this more complicated
system, programmable computer
hardware
(as opposed
to Mistrettas
nonprogrammable
subtraction
circuits)
control
the system
operation.
These
systems
are capable
of handling
patient
information
and an array of alternative
and more complicated image manipulations
(limited by the ability of programmers to write programs
for them). A large number
of additional algorithms
are available
as a part of some DSA units.
One such algorithm
is for image-edge
enhancement.
This is
accomplished
by increasing
the contrast
density
in the
picture
elements
so that edges of areas where there is a
shift in contrast
density
are enhanced,
thus making
the
object more prominent.
The application
of such algorithms
are under
active
investigation,
but the diagnostic
value
beyond
basic subtraction
is still unknown.
Despite the increasing
complexity
of systems,
subtraction
of the background
still remains the most important
function
of any DSA system.
There are further options
available
for
image manipulation.
An array processor
is a device capable
of performing
a series of image manipulations
very rapidly.
One such manipulation
is image reregistration,
which shifts
the contrast
image up on down in relation to the mask image
to compensate
for motion between
the mask and the contrast image.
It is not unreasonable
to suggest
that the
greatest
percentage
of the image
in DSA is due to the
subtraction
process,
while a further
improvement
is produced from contrast
enhancement.
Other manipulations
of
the images,
as previously
described,
have not yet had a
significant
impact on the imaging
process.
The matrix
of the image processor
(mentioned
above)
needs further
description.
For our purpose,
a matrix
is a
rectangular
array of picture
elements
(pixels).
The size of
the matrix is defined
by the number of pixels on a side. The
most common
sizes in DSA are 256 x 256 and 51 2 x 512.
As the pixel is the smallest
element
in the picture,
the
resolution
of the system
is defined
by the pixel size. The
matrix size should also be considered
in the context
of the
image intensifier.
If the field size is 6 inches
(1 5 cm) in
diameter
and the matrix size is 51 2 x 51 2, there are 3.3
pixels/mm
(1 .6 line pairs/mm)
or for a 9-inch-diam
(23 cm)
field, 2.2 pixels/mm
(1 .1 line pairs/mm).
With a fixed matrix,
improved
spatial
resolution
is achieved
by decreasing
the
field size. The loss in spatial resolution
with increasing
field
size is important
in a system
that is already
deficient
in
spatial resolution,
as has been discussed
with reference
to
large-field
intensifiers.
Some users of large-field
image intensifiers
have found that the loss of spatial
resolution
is
outweighed
by the increased
field size and contrast
sensitivity afforded
by the advanced
design of such intensifiers.
This points out that theoretical
advantages
and disadvantages
of any system
or component
should
be carefully
evaluated
in a clinical
situation
before
conclusions
about
utility or limitations
are drawn.
The same controversy
will
arise when enlarged
matrix
sizes (e.g. , 1 024
x 1024)
become
available.
It is difficult
to say whether
the cost of
development
and extra instrumentation
needed
(such as
extra memory
and high-resolution
TV system) will be offset
by the increased
spatial resolution
they may provide.

785

ANGIOGRAPHY

Data

Transfer

and

Storage

The matrix size also defines the problem

of data storage
and transfer.
For example,
a matrix
size of 51 2 x 512
contains
262,1 44 bits of data on pieces of information
for
storage
in digital form. Data are conveniently
quantified
in
terms of bits and bytes (8 bits = 1 byte; 1 06 bytes = 1
megabyte).
To double
the matrix size from 51 2 x 51 2 to
1 024 x 1 024, one needs to quadruple
the memory
necessary to store each image.
The basic problems
with transfer
and storage of data are
the time necessary
to transfer
large amounts
of data and
the cost of storage.
Until the introduction
of CT scanning,
xray film storage
was an acceptable
mode for storage
of all
radiographic
images,
but this is not the case for CT images
or DSA. In CT, the digital data are stored on magnetic
tape
or magnetic
disks.
The average
CT study will consist
of
20-30
images, which requires
1 0 megabytes
(about
mB/
image) to store. This is a large storage
requirement.
DSA is
similar. The DSA image processing
is done in the computers
central
processing
unit (CPU) which allows for rapid penformance
of subtraction.
But the CPU cannot
be used for
storage
of images.
The processed
images must be transferred to an auxiliary
storage device. The rate of transfer
of
data within the CPU is about 1 0 million bytes/sec,
which
allows images obtained
at 30 frames/sec
to be subtracted
and enhanced.
Transfer
of the processed
information
to
storage
is limited to about 500,000
bytes/sec.
Thus, a 512
x 51 2 image contains
so much information,
that only two
images/sec
can be transferred
in digital form. To go faster
entails more advanced
technology
and expense.
One solution that preserves
the digital nature of this information
is to
decrease
the matrix size and therefore
the amount of infonmation
to be stored.
Thus, at a 1 28 x 1 28 matrix,
30
frames/sec
may be processed.
The solution
proposed
by
Mistretta
is to transfer
images in an analogue
form. In this
1/3

form,

512

x 512

matrix

images

can

be acquired

and

pro-

cessed
at 30 frames/sec
without
difficulty.
The drawback
to this solution
is that the images
must be nedigitized
for
further processing.
There are three further questions
that must be addressed
concerning
the storage
and retrieval
of images
generated
by DSA systems.
In what form will be data be stored? Which
data will be stored?
What storage
devices will be used?
Conversion
of data from digital to analogue
causes
immediate
loss of information
content
and subsequent
degradation
of image quality.
It is not clear, however,
to what
extent this affects
the diagnostic
quality of the study. Furthermore,
conversion
to analogue
necessitates
reconversion to digital
for later manipulation.
Digital
data can be
handled
faster
by DSA systems
and is the basis for all
manipulation.
Thus, it would be advantageous
to keep all
stoned data in digital form. The present state of the technology dictates,
however,
that analogue
data
storage
is
cheaper
and the only means for real-time,
high-resolution,
high-frame-rate
image acquisition.
As digital technology
advances, there will be greaten imperative
to store all collected
data in the digital mode. Manufacturers
of DSA systems
are

HARRINGTON

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786

ET

AL.

AJR:i39,

currently
working
to fulfill this imperative.
The question
of which data to save is by no means a new
problem.
Radiologists
have always
had this problem
and
have yet to solve it. There exists a temptation
to save all
data generated
in a digital subtraction
examination
because
it appears
to be less voluminous
than a conventional
film
examination.
This, however,
is misleading.
The number
of
images generated
and processed
by these electronic
techniques can be as many as hundreds
per patient per examination, and this amount of data adds up quickly.
It is clear that unlimited
space for electronic
data storage
is no more available
than for film storage.
Thus, some
criteria
for image selection
must be developed.
Should only
diagnostic
images
be archived,
all other
image
data
erased and lost forever?
Is there any advantage
to saving
only enhanced,
as opposed
to raw or unprocessed,
images? Certainly
there are more questions
than answers.
Finally,
a word about the image storage
medium.
Analogue storage
media (video
magnetic
tape and disk, and
film) theoretically
limit the range of later reprocessing
and
manipulating
of archival
data. For the present,
video disk is
too expensive
for large-scale
image storage.
This leaves
videotape
or hard-copied
film of CRT (cathode-ray-tube
video screen)
images.
The former is suboptimal;
the latter
takes us back to the original
problem
of giving up electronic
information
for analogue
image. Most archived
digital subtraction
images are in the form of hard-copied
film transpanencies of CRT images.
This form of image storage
is madequate
because
it has been difficult
to reliably
reproduce
high-resolution
CRT images
on film. Although
there
are
theoretical
reasons for optimism
in its solution,
this problem
has yet to be solved.
A soon-to-be-available
method
of
digital image storage
is the laser disk [14]. This technique
would provide
permanent
digital images stored in a random
access
manner.
It is analogous
to a phonograph
record,
in

REFERENCES

that one can select any spot on the disk to display.

Magnetic
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inexpensive
means
of digital
data
storage,
but has the drawbacks
of being cumbersome
(no
more than five or six patients
images per 2,400 foot [732
m] reel) and necessitating
sequential
access to images. That
is, one image
after another
has to be passed
until the
desired
image data is reached.
Until digital disks become
commercially
available
at reasonable
cost, tape is probably
the best means of long-term
digital data storage.

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