Computer Science in

Radiology
A Quest for Accuracy and Efficiency

Carter Chu
11/12/2017
Abstract

Computer science has proven itself vital in medicine. To complement the revolutionary

discoveries in medical imaging technology, computer science is needed to analyze and refine

medical images. Computer science is being used to diagnose patients, replacing the time-

consuming traditional techniques that lack accuracy. In the case of left ventricular

noncompaction (LVNC), researchers are studying the potential of fractal analysis and other

ratios to better identify LVNC than current criteria do. Results from fractal analysis show

potential, but it still suffers from limitations. Computer science also provides a much powerful

tool for diagnosis machine learning. A constantly evolving and adapting algorithm, machine

learning allows for the accurate diagnosis of major diseases, such as stroke, coronary artery

disease, and Parkinsons disease. The development of various machine learning techniques has

allowed for patient data to be analyzed for effective diagnosis. Computer science has

applications apart from diagnosis, as 3D printing has become an important consideration. By

turning medical images into tangible models, surgeons are capable of experimenting and refining

their surgeries before performing them on human patients. This improves the treatment of

patients and increases a hospitals effectiveness.

Introduction

Computer programming is becoming an increasingly considered field for all professions.

The past two decades have been characterized by advances in processing power and data by

computers. Many tasks that were deemed impossible in the past are now being done with

computers. Even with the explosive innovations in image viewing, fast retrieval of images, better

access to clinical information, and reporting improvements, radiologists are forced into more

time-consuming techniques (e.g. CT colonography screening) (Kotter & Langer). These

innovations are accompanied by time consuming methods, making the productivity provided by

computer programs to be even more crucial in the function of hospitals. With computer aided

detection in radiology, researchers are hoping for an increase in interpretation speed without

sacrificing accuracy, with the best case being an increase in precision (Kotter & Langer).

With accuracy and speed in mind, researchers are trying to find optimal ways to include

computer science in medicine. Studies are ongoing, often with promising results and high

accuracy. Computer programming has allowed for numerous meaningful contributions to the

medical field, through improving previous diagnosis criteria, machine learning, or even 3D

printing.

Diagnosis Criteria: Left Ventricular Noncompaction

The world of computer science has expanded into the medical field, making diagnosis of

numerous diseases easily reproducible and accurate. Fractal dimension, which is used in the

analysis of medical images of the lungs, bones, and brain, is being considered for the diagnosis

of left ventricular non-compaction (LVNC). LVNC is characterized by large trabeculations and

deep intertrabecular recesses in the left ventricle, typically in the apex, or bottom of the heart,

making the muscle seem spongy. Although many patients do not experience symptoms, they

suffer the risk of heart failure and sudden cardiac death. Currently, three methods of quantifying

trabeculations and LVNC exist: the Jenni, Peterson, and Jacquier criteria. The most widely used

criteria is the Jenni criteria, which compares a ratio between the noncompacted and compacted

myocardium layer. However, due to its low reproducibility and high sensitivity (true positive

rate), it overestimates the amount of LVNC patients, making it not ideal. The Peterson criteria

considers the maximum ratio between the noncompacted and compacted myocardium layer, but

it fails to consider the apical involvement in LVNC. The Jacquier criteria proposes using the
amount of noncompaction as a percentage of the left ventricle mass (Choi, et al.). Inaccurately,

the Jacquier method includes a large amount of the left ventricle cavity in the noncompacted

mass calculation, making it overestimate the latter (Grothoff). Overall, these techniques lack

reproducibility and poorly correlate with one another due to the large amount of human error, as

they rely on human measurements and only semi-quantitative data (Captur, Muthurangu et al.).

A radiologist may decide to take a certain measurement due to his own interpretation of

noncompaction and myocardium, hurting the reproducibility of the current diagnosis methods of

LVNC. By replacing humans with computers, measurements are consistent from patient to

patient, allowing for better quantification and identification of LVNC.

Before utilizing fractal analysis, it is important to understand its use and limitations.

Fractal analysis measures how completely a structure takes up space, making it an ideal method

to quantify LVNC, due to the spongy noncompacted myocardium tissue. Fractal dimension

values can be calculated from cardiovascular magnetic resonance (CMR) images of patients in

all three parts of the left ventricle, the basal, mid, and apical thirds. Fractal dimension offers

quantitative data using boxcounting, meaning that patients with LVNC would have a higher

fractal dimension value than those with normal hearts. The effectiveness of fractal analysis for

identifying LVNC has been tested in many studies. A study at The Heart Hospital, UCLH,

proved that fractal analysis could be used on all hearts with a fast run-time of around 5.3

minutes. Across all patients, the fractal dimension was higher in LVNC patients compared to

healthy ones. Both healthy and LVNC patients had similar fractal dimension values in the basal

third, but the values increased in all other parts for LVNC patients with the biggest difference

being in the apical third. In fact, fractal dimension was so effective that there was no overlap

between fractal dimension values of healthy and LVNC volunteers, meaning that patients would
not be falsely diagnosed with fractal dimension (Captur, Muthurangu, et al.). In a later study,

Captur proved the reproducibility and accuracy of the fractal method. Based on the sensitivity

and specificity (true negative rate), fractal analysis is far superior to current techniques and

would be able to halve the patients needed to detect differences in trabecular complexity in

clinical trials (Captur, Flett, et al.). Capturs extensive work with fractal analysis proves its

effectiveness and possibility for use in the diagnosis of LVNC.

Unfortunately, fractal analysis is not without its flaws. The volunteers in studies were all

identified using a composite of current methods, and since there is a lack of a LVNC reference

standard, there is bias in the studies. Another limitation is the effect of race on fractal dimension

values. Black people have naturally higher fractal dimension values than white people, meaning

that race and other factors would require numerous fractal dimension reference values to

determine whether a patient should be diagnosed with LVNC or not, hurting its reproducibility.

Additionally, papillary muscles and subvalvular apparatus are counted as trabeculations in fractal

analysis even though they are found in all healthy humans (Captur, Muthurangu, et al.). Another

limitation is human error, as the amount of embedding space in a CMR image changes the fractal

dimension value significantly. Different clinicians may crop images differently, causing fractal

dimension values to be inaccurate. Most importantly, techniques such as fractal analysis are only

accurate for the quantifying trabeculations, as there are other characteristics that lead to LVNC.

For example, as the left ventricle tissue becomes noncompact, the myocardium wall thins,

leading to numerous cardiovascular diseases due to an interference in electrical signal and blood

flow. By quantifying only trabeculations, it would be difficult to distinguish LVNC from other

cardiomyopathies like dilated cardiomyopathy or hypertrophic cardiomyopathy, which may be

characterized with highly variable left ventricular trabeculations (Grothoff). In many ways,
fractal dimension suffers from the same limitations as current methods, but it is a step towards

the right direction, eliminated most human error and giving quantitative data.

Because of these additional factors found in LVNC, there needs to be supplemental

diagnostic criteria. Some proposed diagnostic criteria include an apical trabeculation thickness to

compacted tissue ratio and a noncompacted tissue to septal wall thickness ratio, as those have

been found to be correlated to LVNC in a study conducted by the Samsung Medical Center

(Choi, et al.). In other studies, the most successful diagnostics incorporate combined criteria,

allowing for a compromise of sensitivity and specificity. By combining criteria, specificity and

sensitivity rose to the high 90s, but due to the small sample size, multicenter studies would be

necessary to confirm the results with a larger sample size (Grothoff). There is potential for fractal

analysis to be the new reference point and diagnostic criteria for LVNC, but the methods of

diagnosis need to be refined or other techniques must be explored before its universal use in

clinics.

Machine Learning

In a world where computers are constantly evolving in processing power, storage, and

memory, computer scientists are exploring machine learning for the medical field. Machine

learning revolves around computers learning from data, making it possible for machines to

diagnose patients with input data. These techniques are already being tested in medicine, some

with great success and others with skeptical results.

Some researchers have been exploring the use of machine learning to diagnose one of the

leading causes of death worldwide, coronary artery disease. By detecting the presence of

coronary artery disease early, many lives would be saved and optimal treatment can be started

earlier. Currently, techniques involving magnetocardiography (MCG) have already been

developed. MCG measures the magnetic field that is released from cardiac tissues, offering a

non-invasive, highly reproducible, and accurate alternative to the traditional method of

electrocardiography, which uses electrodes to monitor the electrophysiological activity of the

heart. However, MCG requires highly specialized clinicians and is time consuming, making

machine learning algorithms that analyze MCG results and identify coronary artery disease

preferable (Tantimongcolwat, et al.). Of course, many hospitals are skeptical of relying on

machine learning for diagnosis. Since highly skilled personnel are usually more accurate than

machine learning algorithms, hospitals would rather keep the skilled workers than utilize

machine learning, even at the cost of millions of dollars and a slower diagnosis by hand (Deo).

The solution is simple. Hospitals can use supervised machine learning to predict an outcome and

find relationships that are not clear to physicians, enhancing the diagnosis process of coronary

artery disease. Currently, for coronary artery disease, new machine learning techniques are being

researched for a rapid and accurate diagnosis. When studying machine learning in medicine, it is

crucial to consider coronary heart disease, as it may in fact be the most commonly used instance

of supervised learning in medicine (Deo). Two methods of machine learning are currently being

tested to identify coronary artery disease, back-propagation neural networks (BNN) and direct

kernel self-organizing maps (DK-SOM) (Tantimongcolwat, et al.). BNN is a supervised learning

method that uses input patterns and output targets to train the network (Tantimongcolwat, et al.).

It uses multiple layers with processing units, called nodes or neurons, to process and transfer

computed data. This technique is combined with DK-SOM, which uses pattern recognition

algorithms to identify similarities among data and clusters unknown data patterns into functional

layers (Tantimongcolwat, et al.). The results of using these two machine learning techniques

together to diagnose coronary artery disease are promising. After applying these methods on 55
MCG patterns of diseased patients and 70 healthy ones, it had shown that BNN provides less

specicity and accuracy, which on the contrary yields high sensitivity (90%). Therefore, BNN

may be used initially to detect high risk individuals while false positive cases can subsequently

be ruled out by the DK-SOM (Tantimongcolwat, et al.). Together, using both BNN and DK-

SOM to identify coronary artery disease can lead to better MCG analysis and a faster diagnosis

than human clinicians.

Not only is machine learning used for diagnosing coronary artery disease, but it is also

used to differentiate between and identify Parkinsons disease (PD) and progressive supranuclear

palsy (PSP) (Salvatore, et al.). Both diseases are common neurodegenerative diseases that affect

millions of people. However, PD diagnosis is prone to errors, as there are multiple symptoms

that PD has in common with other parkinsonisms, such as PSP. In attempt to increased diagnosis

accuracy, using a technique from Support Vector Machines (SVM) as a supervised classification

algorithm on MATLAB, a study attempted to individually diagnose PD and PSP patients using

machine learning. SVM identifies biomarkers in the midbrain, pons, corpus callosum, and

thalamus regions of the brain, which are strongly affected by parkinsonisms, with accuracy

higher than previous morphological metrics (Salvatore, et al.). Supervised machine learning has

revolutionized identifying biomarkers, allowing the diagnosis of patients to be faster and more

accurate. SVM proved to be very accurate, as the sensitivity and specificity were both above

90% (Salvatore, et al.). Machine learning algorithms can discover patterns and other

characteristics common in many diseased patients, making it able to diagnose patients with

significant accuracy.

Machine learning can do much more than diagnose patients; it can predict the outcome of

diseases so that accurate treatment can be used. Stroke is the considered the third most costly
health condition (Asadi, et al.). Any algorithm or program that could predict the outcome and

possibility of stroke could save patients thousands of dollars and allow clinicians to offer correct

treatment. Machine learning is more capable of simulating a complex system than physicians,

making the process much more efficient. Neural networks and support vector machines used on

datasets of patients who have suffered acute anterior or posterior circulation stroke have shown

decent accuracy. Comparing the output data and actual patient results, machine learning achieved

a 70% accuracy. Although 70% may seem lackluster and poor, it is difficult to predict outcomes

by conventional methods due to the numerous factors that influence stroke outcome which is

machine learning is independent of (Asadi, et al.). Machine learning, with more improvements

and access to datasets from multiple institutions to increase the algorithms precision, would be

able to accurately predict stroke.

Although machine learning seems to be a possible replacement for typical radiologists, it

is far from being optimal and trustworthy enough for hospitals to use in most cases. Although it

seems accurate in the diagnosis of parkinsonisms, heart diseases, and stroke, machine learning

has a black-box nature. Although machine learning may prove to be more accurate than human

physicians, physicians would have to be comfortable with the risk of medical error, since

automated systems do not give them insight on the diagnosis process (Deo). The liability of

machine learning comes into question, which may possibly be alleviated by constant on-site

evaluation. Machine learning still has a long way to go before it is fully implemented in the

medical field, but it shows promise and progress with increasing scientific research.

3D Printing

Rapid developments in medical imaging has led to an increase of magnetic resonance

imaging (MRI), computed tomography (CT), and ultrasound apparatuses. These techniques have
increased patient data while reducing the invasiveness of medical imaging. Multiplanar

reformation, three-dimensional (3D) visualization, and image navigation have revolutionary

roles in diagnosis treatment, allowing for the development of 3D printed objects, offering an

intuitive and tangible 3D model that goes beyond a simple 2D computer screen (Kim, et al.).

The process of creating a medical 3D model is divided into three parts: image acquisition,

image postprocessing, and 3D printing. 3D models can be printed from any volumetric image

dataset, making even a fusion of images from different imaging techniques capable of producing

an accurate model design. Usually, CT images are used for 3D printing, as they are simple to use

in postprocessing and have a variety of applications (Mitsouras, et al.). During image

postprocessing, radiologists segment the images into regions of interest. They later refine these

segments to enhance the 3D model accuracy. Refinement requires specialized software and skills

that are found in engineering, as the model must closely resemble the source images. Once image

postprocessing is complete and the model is ready to be printed, it is sent to a 3D printer,

beginning the printing process.

The printing process in itself is quite complex and is characterized by a large variety in

printing techniques and printing materials. Common materials used include thermoplastic, metal

powder, ceramic powder, eutectic metals, alloy metals, and much more. The continued research

on different materials have significantly reduced the cost associated with most 3D printing

materials, allowing for 3D printing to have a more widespread and practical use in the medical

field. 3D printing techniques also vary significantly, as different techniques are capable of

creating phantoms, surgical tools, or even medical implants. Stereolithography apparatus (SLA)

is the most common 3D technique for surgery, proving its usefulness in the grafting of a skull

defect in 1994 (Kim, et al.). SLA uses a computer controlled ultraviolet laser to cure the resin
slice-by-slice, one level at a time. These layers of resin solidify and bind together to form a solid

object, from the bottom upwards (Kim, et al.). Generally, SLA is considered to have the best

accuracy and finish (Kim, et al.). Other techniques have other uses and are either advantageous

or disadvantageous in other considerations such as time, cost, and availability.

3D printed models have seen a large amount of use in the field of surgery planning and

preparation. 3D printed models have allowed for successful treatments of various cases of

splenic artery aneurysms. Models of the splenic artery and its interior structure have allowed

complex endovascular procedures to be practiced and perfected before the actual surgery. The

case of a certain 62-year-old female was presented with multiple asymptomatic splenic artery

aneurysms. Conventional techniques, such as stent-graft placement, were considered, but

surgeons deemed those procedures to be impossible due to the unusual anatomic limitations.

Using the 3D printed models, an optimal technique was found with extensive testing of different

wires to deliver the NeuroForm stent, which led to a successful surgery and treatment (Itagaki).

3D printed models can prove to be critical in the preparation and practice of surgeries.

3D printing has shown its potential in many medical applications. During the creation of

a 3D printed mouse bed, even tiny details, like the saw tooth ratchet, or internal structures, like

the temperature sensor canal with 3 mm diameter, could be printed successfully (Herrmann, et

al.). This proves the accuracy of 3D printing, as models are able to take the form of complex and

small shapes with astonishing accuracy. Most errors can be attributed to the errors in image

acquisition and image postprocessing, meaning that skilled radiologists are required to create

consistently accurate models of medical images. In regards to cost, 3D printing is not nearly as

expensive as before. Despite its seemingly expensive initial investment, 3D printing materials are

becoming cheaper and printing techniques are being refined for greater efficiency. In fact, the 3D
printer itself is typically amortized in just a few projects (Herrmann, et al.). Research in 3D

printing technology would lead to more successful surgeries, more realistic materials, lower

costs, and the widespread use of 3D printers in hospitals around the world.

Global Impact

Health is a global concern. The availability of technology is rapidly increasing

worldwide, allowing for computer aided diagnosis to be possible in many developed and

developing countries in the world. Radiologists from around the world, from the United States to

Korea, are all working to achieve a similar goal improve the detection and treatment of

different diseases. Computer science is explored globally to improve medical treatment, making

it important to fund medical research so that accuracy and correct treatment can be assured to

patients.

Additionally, along with the rise of computers, computer science is becoming

increasingly crucial in the professional world. Nearly every job can utilize computer science,

making it important that students, especially in developed and developing countries, learn

computer programming in schools.

Conclusion

New medical imaging and radiology techniques are being discovered at an alarmingly

rapid rate. Unfortunately, the number of radiologists is not increasing in parallel (Kotter &

Langer). This trend emphasizes the need for computer aided diagnosis to increase efficiency and

supply faster treatment. Older research on computer aided diagnosis only considered accuracy,

forgetting to take into account the time to achieve the results (Kotter & Langer). Luckily, recent

studies are taking run time into consideration. As research into computer science application in

medicine grows, researchers must not forget that speed is the ultimate goal. Of course, a
substantial amount of accuracy should not be sacrificed for efficiency. Some programs have been

shown to either speed up reading time without a large loss in sensitivity or increasing sensitivity

at the expense of longer reading times, making it a difficult choice for departments (Kotter &

Langer). It is in every hospitals consideration to have the most accurate diagnosis and treatment,

making it essential that these techniques are researched and that the computer algorithms are

refined and perfected. Radiologists need to be comfortable and confident in computer aided

diagnosis, which then speed up diagnosis times considerably.

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