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DSA  ITS APPLICATION AND ADVANCEMENT,[object Object],Moderator:,[object Object],MR. S.R.CHOWDHURY,[object Object],TUTOR,,[object Object],DEPT.OF RADIO-DIAGNOSIS & IMAGING,,[object Object],PGIMER CHANDIGARH,[object Object],Presented by:,[object Object],DEEPAK GUPTA,[object Object],BSc  final year Student ,,[object Object],DEPT.OF RADIO-DIAGNOSIS & IMAGING,[object Object],PGIMER CHANDIGARH,[object Object]
2/24/2010,[object Object],2,[object Object],ANGIO?,[object Object],ANGIO  means blood vessel,[object Object],And angiography is the radiological study of blood vessel in the body  after the,[object Object], introduction of iodinated contrast media.,[object Object],SUBTRACTION? ,[object Object], It is simply a technique by which bone structures images are subtracted or canceled out from a film of bones plus opacified vessels, leaving an unobscured image of the vessels.,[object Object]
2/24/2010,[object Object],3,[object Object],WHAT DO YOU MEAN BY DSA,[object Object],DSA-The acquisition of digital fluoroscopic images combined with injection of contrast material and real-time subtraction of pre- and post contrast images to perform angiography is referred to as digital subtraction angiography,[object Object]
2/24/2010,[object Object],4,[object Object],HISTORY,[object Object],The Portuguese neurologist Egas Moniz,( Nobel Prize winner 1949), in 1927developed the technique of contrast x-ray cerebral angiography to diagnose diseases, such as tumors and arteriovenous malformations.,[object Object],The idea of subtraction images was first proposed by the Dutch radiologist Ziedses des Plantes in the 1935, when he was able to produce subtracted images using plain films.,[object Object],With the introduction of the Seldinger technique in 1953, the procedure became safer as no sharp devices need to remain inside the vascular lumen.,[object Object]
2/24/2010,[object Object],5,[object Object],HISTORICAL DEVELOPMENT,[object Object],CONVENTIONAL SUBTRACTION TECHNIQUE,[object Object],Photographic method used to eliminate unwanted images.,[object Object],No addition of information;only purpose to make diagnostically important information to see.,[object Object],First described by a Dutch radiologist, Zeides des Plantes, 1935.,[object Object],3 conditions:SCOUT FILM,[object Object],                    ANGIOGRAM FILM-CONTRAST                                    NO MOTION OF HEAD,[object Object]
2/24/2010,[object Object],6,[object Object],CONTD.,[object Object],The principles of subtraction are based on the following:,[object Object],The scout film shows the structural details of the skull and the adjacent soft tissue.,[object Object],Angiogram film shows exactly the same anatomic details, if the patient does not move, plus the opacified blood vessels.,[object Object],If all the information in the scout film could be subtracted from the angiogram film, only the opacified vessel pattern would remain visible. ,[object Object]
2/24/2010,[object Object],7,[object Object],EQUIPMENT,[object Object],THE  AOT CHANGER:,[object Object],Can change films –6/s or 1/5s,[object Object],  Two of these changers can be coupled electronically and mechanically and will operate out of phase or synchronously with each other.,[object Object],Radiographs in 2 planes simultaneously-one mounted vertically and other horizontal.,[object Object]
2/24/2010,[object Object],8,[object Object],AOT CONTD.,[object Object],LOADING MAGZINE,[object Object],Large steel container.,[object Object],Inside the container are arranged a no. of strong wire separators.,[object Object],30 sheets of film.,[object Object],Precautions :each film should slide into position by it’s own wt.,[object Object],RECIEVING / LOADING MAGZINE ,[object Object]
2/24/2010,[object Object],9,[object Object],EXPOSURE AREA :,[object Object],Rectangular, slightly recessed area at the top of the changer.,[object Object],Defined by heavy metal frame.,[object Object],Within this is a secondary grid.,[object Object],Supported on 4 small helical springs placed cornerwise and to consist of  a stout Al plate, to the lower side of which is attached an intensifying screen.,[object Object],30 SEPERATING WIRES ,[object Object],RECEIVING CASSETTE:,[object Object],Shallow,polished metal container.,[object Object],Lid is a sliding section in a side which can be pushed down  by firm finger pressure and is retained by central spring loaded catch.,[object Object]
2/24/2010,[object Object],10,[object Object],THE ROLL FILM CHANGER:,[object Object],Mechanically easier to wind roll films.,[object Object],12/s.,[object Object]
2/24/2010,[object Object],11,[object Object],DIGITAL  SUBTRACTION  ANGIOGRAPHY,[object Object],HISTORY:,[object Object],Developed in 1970s.,[object Object],University of Wisconsin, University of Arizona,University of Kiel.,[object Object],Commercial systems introduced in 1980.,[object Object]
2/24/2010,[object Object],12,[object Object],Angiography theory ages ,[object Object],Single shot angiography,[object Object],Manual changer,[object Object],AOT PUCK,[object Object],DSA,[object Object]
2/24/2010,[object Object],13,[object Object],EQUIPMENT AND   APPARATUS,[object Object],Both film and digital capabilities are usually present and the fluoroscopy equipment operates in the conventional way.,[object Object],Brief  review :,[object Object],Light detected,[object Object],amplified,[object Object],Input surface,[object Object],Visible light,[object Object],Output phosphor,[object Object],Electrical signal,[object Object],Light intensity,[object Object]
2/24/2010,[object Object],14,[object Object],DIGITAL IMAGE PROCESSOR,[object Object],DISPLAY ,[object Object],SECTION,[object Object],DIGITAL ARITHEMATIC ,[object Object],UNIT,[object Object],DIGITIZER,[object Object],DIGITAL IMAGE ,[object Object],MEMORY,[object Object],X-RAY,[object Object],CONTROL,[object Object],SIGNALS,[object Object],MONITOR,[object Object],COMPUTER,[object Object],MULTIFORMAT ,[object Object],CAMERA,[object Object],DIGITAL,[object Object],DISK,[object Object],STORAGE,[object Object]
2/24/2010,[object Object],15,[object Object],X-Ray Unit,[object Object],Should be capable of rapid serial exp.  @2-8 frames/sec for up to 20 sec.,[object Object],Near monochromatic beam consistent output.,[object Object],Isocentre motorized table ,tilt 90-0-90 , up-down,,[object Object],    sliding ,floating capable  ,[object Object],Ceiling mounted C-arm with versatile movements,[object Object],II system with multi field ( 6”,9”,12”,16”),[object Object],High resolution TV /CCD camera,[object Object],Computer with high definition monitor system,[object Object]
2/24/2010,[object Object],16,[object Object],Contd.,[object Object],High output preferably high frequency generator,[object Object],High heat loading capacity ,fast heat dissipation, high speed anode,[object Object],Target material tungsten,rhenium,graphite.,[object Object],Oil-water close loop cooling,[object Object]
2/24/2010,[object Object],17,[object Object],In our dept.Siemens polydoros SX 65-80,[object Object],Polystar ,[object Object]
2/24/2010,[object Object],18,[object Object],NECESSARY EQUIPMENT USED WITH ANGIO(DSA),[object Object],GAS , AIR & VACUUM  PORTS,[object Object],Boyle apparatus,[object Object]
2/24/2010,[object Object],19,[object Object],BED SIDE  MONITOR,[object Object],INJECTOR,[object Object]
2/24/2010,[object Object],20,[object Object]
2/24/2010,[object Object],21,[object Object],IMAGE INTENSIFIER-CONSTRUCTION,[object Object]
2/24/2010,[object Object],22,[object Object],WORKING,[object Object]
2/24/2010,[object Object],23,[object Object],   Modern DSA systems are based on digital fluoroscopy/fluorography systems, which are equipped with special software and display facilities. Digital subtraction angiography (DSA) was developed to improve vessel contrast. This is a technique that uses a computer to subtract two images, obtained before and after contrast media is injected into the vessels of interest. The anatomical structures that are the same in the two images can be removed and the resulting image shows the vessels only.,[object Object]
2/24/2010,[object Object],24,[object Object], The image before the contrast agent is administered is called the mask image. Once the contrast is administered, a sequence of images are taken by a television camera in analog form, which is then digitised by computer.,[object Object], The DSA processor has two separate image memories, one for the mask and the other for the images with contrast medium. These two image memories are subtracted from one another arithmetically, and the result goes to an image processing and display unit.,[object Object]
2/24/2010,[object Object],25,[object Object],IMAGE  PROCESSING ,[object Object],Adjust contrast & brightness.,[object Object],Remasking – correcting misregistered images.,[object Object],Pixel shifting.,[object Object],Edge enhancement – edges of the vessels can be enhanced so that small details can be made more obvious.,[object Object],Image zoom.,[object Object],land marking – a small amount of original image is added into the subtracted image.,[object Object],Noise smoothing – operates by reducing the statistical fluctuations in each pixel by averaging the pixel with it's closest neighbors. The visual prominence of noise has been suppressed by averaging, but resolution is decreased.  ,[object Object]
2/24/2010,[object Object],26,[object Object],Road Mapping ,[object Object],Road mapping is useful for the placement of catheters and wires in complex and small vasculature. A DSA sequence is performed, and the frame with maximum vessel opacification is identified;this frame becomes the road map mask. The road map mask is subtracted from subsequent live fluoroscopic images to produce real-time subtracted fluoroscopic images overlaid on a static image of the vasculature ,[object Object]
2/24/2010,[object Object],27,[object Object],    When a digital subtraction technique is used, patient motion that occurs between acquisition of the precontrast images and acquisition of the postcontrast images will result in artifacts due to misregistration of the two images. If these arti-facts are observed, it is possible to reregister the pre- and postcontrast images by shifting the subtraction mask (precontrast image) with respect to the postcontrast image and resubtracting the two images ,[object Object]
2/24/2010,[object Object],28,[object Object],VIDICON CAMERA TUBE ,[object Object],[object Object]
Length 6 inch
Main parts -
Target section
Electron gun
Electromagnetic focusing coil
Two pair of electrostatic deflecting coil
A scanning section,[object Object]
2/24/2010,[object Object],30,[object Object],SCANNING SECTION/ SYSTEMS ,[object Object],[object Object]
The electrons are focused on the target of tube and
The beam is moved over the target area in an orderly scanning scan
Two types scanning system
Sequential scanning pattern and
Interlaced scanning pattern ,[object Object]
Requires a wide frequency band during transmission  ,[object Object]
In this pattern the transmission is easier and cheaper because the actual picture frequency is lower  ,[object Object]
Contrast
Brightness
Image lag
Distortion  ,[object Object]
The resolution of imaging system refers to the amount of detail which is observable
It may be formulated as the number of pairs of black and white lines which an image forming or image recording device can demonstrate in a length of 1 mm
Vertical resolution is determined by no. of vertical scan lines (e.g. 625).In recent years the manufactures of radio diagnostic imaging equipment have developed his definition TV  system which employ 1249 or even more lines.,[object Object]
2/24/2010,[object Object],35,[object Object],Contrast,[object Object],The contrast of the image on a TV screen clearly depends on the contrast of the original image focused onto the signal plate of the pick up tube.,[object Object],Both camera and monitor affect the contrast of a TV image. ,[object Object],A vidicon camera reduces contrast by a factor of approx. 0.8 and the monitor enhances by a factor of 2. ,[object Object]
2/24/2010,[object Object],36,[object Object],Brightness,[object Object],The term luminance and brightness are often used when discussing the aspect of tv image,[object Object],Luminance can be defined as light emitted per unit area from a surface. It is measured in candela per square meter (cd/m2),[object Object],Automatic brightness control (ABC),[object Object],[object Object]
It is critical  to the patient dose and image quality,[object Object]
2/24/2010,[object Object],38,[object Object],Image lag,[object Object],Lag is the term used to describe inability of an imaging system to follow rapid changes in its input image ,[object Object],Distortion ,[object Object],Distortion of the image occur in the image intensifier or in the optical coupling system which links its output phosphor to the signal plate of the TV pick up tube ,[object Object],38,[object Object]
2/24/2010,[object Object],39,[object Object], Artifacts,[object Object],Lag,[object Object],Vignetting,,[object Object],Veiling glare ,[object Object],Pincushion distortion,[object Object],S distortion. ,[object Object],39,[object Object]
2/24/2010,[object Object],40,[object Object],Lag,[object Object],Lag is the persistence of luminescence after x-ray stimulation has been terminated. ,[object Object],	  Lag degrades the temporal resolution of the dynamic image. ,[object Object],	  Older imageintensifier tubes had phosphors with lag times on the order of 30–40 msec. Current imageintensifier tubes have lag times of approximately 1 msec.,[object Object],Vignetting,[object Object],A fall-off in brightness at the periphery of an image is called vignetting. Vignetting is caused by the unequal collection of light at the center of the imageintensifier compared with the light at its periphery. As a result, the center of an imageintensifier has better resolution, increased brightness, and less distortion. ,[object Object],40,[object Object]
2/24/2010,[object Object],41,[object Object],Veiling Glare,[object Object],Scattering of light and the defocusing of photoelectrons within the imageintensifier are called veiling glare. Veiling glare degrades object contrast at the output phosphor of the imageintensifier. As mentioned, the contrast ratio is a good measure of determining the veiling glare of an imageintensifier. X-ray, electron, and light scatter all contribute to veiling glare. ,[object Object],Pincushion Distortion,[object Object],[object Object]
The magnification difference at the peripheryof the image results from the projection of the x-ray beam ontoa curved input surface.
The distortion is easily visualizedby imaging a rectangular grid with the fluoroscope. 41,[object Object]
2/24/2010,[object Object],42,[object Object],S DISTORTION,[object Object],	Electrons within the imageintensifier move in paths along designated lines of flux. External electromagnetic sources affect electron paths at the perimeter of the imageintensifier more so than those nearer the center. This characteristic causes the image in a fluoroscopic system to distort with an S shape .,[object Object],	Manufacturers include a highly conductive mu-metal shield that lines the canister in which the vacuum bottle is positioned to reduce the effect of S distortion. ,[object Object],42,[object Object]
2/24/2010,[object Object],43,[object Object],INDICATIONS,[object Object],Non traumatic Subarachnoid Hemorrhage (SAH).,[object Object],Arterial dissection or laceration,[object Object],Aneurysm,[object Object],Pseudoaneurysm,[object Object],Thrombosis.,[object Object],Arterio-venous malformation (AVM). ,[object Object],Arterio-venous fistula (AVF).,[object Object],Tumor vascularity.,[object Object],Gastrointestinal bleed/Uterine artery bleed,[object Object],Therapeutic. ,[object Object],43,[object Object]
2/24/2010,[object Object],44,[object Object],CONTRAINDICATIONS,[object Object],[object Object],Poor renal reserve.,[object Object],Deranged coagulogram.,[object Object],Allergic to contrast media.,[object Object],Recent barium examination –abd.angio,[object Object],44,[object Object]
2/24/2010,[object Object],45,[object Object],   Contrast Media,[object Object],[object Object]
To increase image contrast, contrast agents, which are dense fluids with elements of high atomic numbers, such as iodine, are injected into a blood vessel during angiography. Because of its higher density and high atomic number, iodine absorbs photons more than blood and tissue.
This creates detailed images of the blood vessels in real time.
The first contrast media used for intravascular injection were called high-osmolar contrast media (HOCM). (osmolality is the measure of the particle concentration in a solution.)45,[object Object]
2/24/2010,[object Object],46,[object Object], HOCM had osmolarity seven to eight times higher than plasma. This high osmolarity caused adverse effects such as pain, endothelial damage, thrombosis, and increased pressure in the pulmonary circulation.,[object Object], Low-osmolar contrast media (LOCM) were first developed in the 1970's and these helped to reduce these side effects.,[object Object], One of the major risks of modern iodine contrast media is an allergic reaction to iodine.,[object Object],46,[object Object]
2/24/2010,[object Object],47,[object Object],[object Object]
30-40% dilution with normal saline.
50 ml of diluted contrast media is enough to do a standard cerebral angiogram with total 8 projections.
Approx. 5-8 ml diluted contrast / injection.47,[object Object]
2/24/2010,[object Object],48,[object Object],Materials used,[object Object],[object Object]
Disposable syringes
Local anesthesia
Heparin
Surgical gloves
Elastoplast
Catheters
Arterial sheath
Medicut
Guidewires
Contrast
Connector/100 cm.tubing
Surgical blade48,[object Object]
2/24/2010,[object Object],49,[object Object],Cathetars,[object Object],     Picard,[object Object],Pigtail,[object Object],49,[object Object],Sim-1,[object Object]
2/24/2010,[object Object],50,[object Object],        VASCULAR  SHEATH ,[object Object],GUIDE WIRES,[object Object],MEDICUT,[object Object],50,[object Object],ELASTOPLAST  STRIPS,[object Object]
2/24/2010,[object Object],51,[object Object],ANTICOAGULANT,[object Object],ANESTHESIA,[object Object],CONTRAST,[object Object],PVA-PARTICLES,[object Object],GEL FOAM,[object Object]
2/24/2010,[object Object],52,[object Object],PREPARATION,[object Object],Should be well hydrated.,[object Object],Should void before procedure.,[object Object],Peripheral pulses marked.,[object Object],I.V line in place.,[object Object],INFORMED CONSENT  MUST,[object Object],[object Object]
Nil orally 4-6 hrs.
On trolley
In hospital gown
Groin shave

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