Author’s Accepted Manuscript

“A NOVEL FUZZY LOGIC-BASED IMAGE

STEGANOGRAPHY METHOD TO ENSURE
MEDICAL DATA SECURITY”

R. Karakış, İ. Güler, İ. Çapraz, E. Bilir

www.elsevier.com/locate/cbm

PII: S0010-4825(15)00353-4
DOI: http://dx.doi.org/10.1016/j.compbiomed.2015.10.011
Reference: CBM2261
To appear in: Computers in Biology and Medicine
Received date: 24 April 2015
Revised date: 14 September 2015
Accepted date: 19 October 2015
Cite this article as: R. Karakış, İ. Güler, İ. Çapraz and E. Bilir, “A NOVEL
FUZZY LOGIC-BASED IMAGE STEGANOGRAPHY METHOD TO
ENSURE MEDICAL DATA SECURITY”, Computers in Biology and
Medicine, http://dx.doi.org/10.1016/j.compbiomed.2015.10.011
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 “A NOVEL FUZZY LOGIC-BASED IMAGE STEGANOGRAPHY METHOD TO ENSURE
MEDICAL DATA SECURITY”
R. Karakışa, İ. Gülerb, İ. Çaprazc, E. Bilirc
a
Department of Electronics and Computer Education, Faculty of Technical Education, Cumhuriyet
University, Sivas, Turkey, email: rukiyekarakis@gazi.edu.tr.
b
Department of Electronics and Computer Education, Faculty of Technical Education, Gazi
University, 06500, Teknikokullar, Ankara, Turkey, email: iguler@gazi.edu.tr.
c
Department of Neurology, Faculty of Medical, Gazi University, Besevler, Ankara, Turkey, e-mail:
ebilir@gazi.edu.tr, driremyildirim@yahoo.com.tr.

Abstract:
This study aims to secure medical data by combining them into one file format using
steganographic methods. The electroencephalogram (EEG) is selected as hidden data, and magnetic
resonance (MR) images are also used as the cover image. In addition to the EEG, the message is
composed of the doctor’s comments and patient information in the file header of images. Two new
image steganography methods that are based on fuzzy-logic and similarity are proposed to select the
non- sequential least significant bits (LSB) of image pixels. The similarity values of the gray levels in
the pixels are used to hide the message. The message is secured to prevent attacks by using lossless
compression and symmetric encryption algorithms. The performance of stego image quality is
measured by mean square of error (MSE), peak signal-to-noise ratio (PSNR), structural similarity
measure (SSIM), universal quality index (UQI), and correlation coefficient (R). According to the
obtained result, the proposed method ensures the confidentiality of the patient information, and
reduces data repository and transmission capacity of both MR images and EEG signals.

Keywords: medical image steganography, medical data security, fuzzy logic algorithm,
similarity based algorithm.

1. Introduction
These days, a recent cybercrime is the capture of medical data. If medical data is captured or altered, it
may cause a violation of patient’s rights and changes in medical treatment. Hence, all patient records,
especially medical images, must be kept confidential [1, 2].

An electronic health record (EHR) is a systematic collection of electronic health information about a
patient or population [3]. It may include clinical examinations, patient demographics, diagnosis
annotations, prescriptions, medications, past medical history, histological and other findings, vital
signs, immunizations, laboratory data, and radiology reports [4]. It is gathered for patient care, clinical
research, epidemiological studies, or insurance companies. It is shared by means of information
systems and local or wide networks.

The process of medical image information accounts for at least 90% of all the medical information in a
hospital system [5]. Medical images (X-ray, CT (computed tomography), MR (magnetic resonance)
imaging, ultrasound, etc...) are handled, stored, printed, and transmitted using the Digital Imaging and
Communications in Medicine (DICOM) standard. DICOM enables the integration between different
devices, software, and platforms into a picture archiving and communication system (PACS). The
DICOM format specifies a header that contains the metadata of the image (image size, data type,
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representation, etc…) and patient information, exam, modality, acquisition parameters, physician, and
health center. The DICOM metadata is stored in the DICOM header [6, 7]. Hence, patient information
in DICOM file must be secured within the network to prevent tampering, illegal copying, and patient
privacy leaks, and to ensure copyright protection, and other information security issues [8].

Medical information (MI) security protects the rights of patients and ensures the responsibilities of the
health professionals. Health information systems must possess three mandatory characteristics:
confidentiality, reliability, and availability [9]. Security tools such as firewalls, virtual private
networks (VPNs), and cryptography techniques (symmetric, asymmetric, or hashing encryption) are
used to secure medical data. However, firewalls are easily bypassed by hackers. Encryption does not
guarantee the confidentiality or secrecy of data; moreover, it increases computational costs. In
addition, the file headers of medical data can be captured in the plaintext format [1, 9]. Alternatively,
steganography techniques can be used to increase the security of medical data.

Steganography is the science that embeds a secret message in an appropriate multimedia cover, for
example graphic, audio, and video files. The ultimate objectives of steganography are imperceptibility,
robustness, capacity of the hidden message, and resistance to tampering [10]. Many methods
concerning steganography methods are proposed to ensure medical data security in literature [1, 9, 11,
12]. These methods, based on the processing domain, can be categorized as: (1) spatial domain and (2)
transform domain. Spatial domain techniques (least significant bit (LSB) embedding, spread
technique, fixed quantization, histogram methods, etc...) are simple and operate more rapidly, but they
are vulnerable to compression, geometric distortion, and filtering. Techniques of transform domain
(discrete wavelet transform, discrete cosine transform, discrete Fourier transform) are compatible
compression, robust against many geometric distortions (e.g. rotation, scaling, translation, cropping,
and filtering). However, they have high computational time and complexity. LSB embedding
techniques offer comparatively higher embedding capacity. In either case, properties of the human
visual system are exploited to control the quality of the image [1]. Hence, this study proposes two new
steganography algorithms to modify the LSB technique.

In the literature, many approaches were proposed to secure the patients’ medical image information
with different modalities (MR, CT, X-ray, etc...), or in biological signals (EEG, ECG, EMG, etc…) [1,
9, 11-15]. In particular, some studies examined a similar subject as our study [16-22]. These studies
used medical images as a cover to hide patients’ information (patient name, age, date of birth, weight,
gender, address, etc...). Furthermore, embedded messages are composed of both patients’ information
and biological signals such as EEG, ECG, or EMG. These studies worked on limited images and
biological signals, so that the capacity of hidden message was low.

2
This study aims to: i) secure multiple medical signals by combining them into one file format; ii)
propose a new steganography method in literature; iii) secure patients’ personal data by encryption and
compression algorithms; and iv) reduce data repository and transmission capacity of multiple medical
signals. In this study, the EEG and MR images of 22 epilepsy patients were tested by the proposed
steganography methods.

The remainder of the study is organized as follows. Section 2 describes materials and methods; the
proposed methods are also presented in Section 3. The obtained results of proposed methods and
discussion are given in Section 4. Finally, Section 5 includes the conclusion and future studies.

2. Materials and Methods

This study aims to use EEG signals and MR images that are obtained from same patients and to embed
more data with EEG into MR images of same patient. For this reason, the MR images and EEG of 22
epilepsy patients are collected from the Department of Neurology at Gazi University. Eleven females
and 11 males were included (age: 18-55 years; mean age: 32 ± 7.9 years). The details of the medical
dataset and capacity of the used data are presented in Table 1. Different sized 3762 MR images of 22
epilepsy patients with 16 bits were used as cover images. The embedded message was combined with
the patient’s information, doctor’s comments, and EEG file header information and segmented EEG
data. The patient’s information (patient name, patient ID, patient birth date, patient gender, patient age,
patient weight, patient address, study date, study time, study ID, study modality, study description,
series date, series time, and series description) were separately selected from the meta-header of each
of the DICOM files. An EEG was also recorded from 21 multiple electrodes that are placed on the
scalp using an International 10-20 system. EEG records take about 20-40 minutes for the diagnosis or
treatment. EEG file headers have information on record such as time points, number of electrodes,
sampling interval, starting time, and name of electrodes. In Table 1, EEG data is stored using short
data structure as 4 byte (The Capacity of EEG Data=The Number of Electrodes*Time Points of
EEG*4). Furthermore, Visual Studio .NET 2010 platform and MATLAB were used to code the
methods and analysis.

Least Significant Bit (LSB) embedding is a simple and fast strategy in steganography. It has high
imperceptibility and embedding capability. Hence, this study proposes two new methods to modify
LSB embedding using medical data. The analyses consist of two stages: embedding and extracting,
respectively.

The embedding stage is shown in Fig. 1. Initially, the patient’s information is obtained from DICOM
series of epilepsy patient. The EEG data is segmented according to the size of these DICOM images.

3
The information of the EEG file header and size of segmented EEG data are also integrated as
embedding EEG data for each DICOM image.

Table 1. Description and capacity of used MR images and EEG data of epilepsy patients
Capacity of Capacity of
Time points Capacity of Capacity of
Tiles of MR Total of MR Patient’s EEG file
Patients of EEG EEG Data Doctors
Images Data Images Data Information header
Data (byte) Comment (byte)
(byte) (byte)*
256x256x113
Patient-1 (P1) 232 224 334 21X275800 23 167 200 44
512x512x119
256x256x156
Patient-2 (P2) 275 224 344 21X239400 20 109 600 44
512x512x119
256x256x89
Patient-3 (P3) 209 220 344 21X246400 20 697 600 44
512x512x120
256x256x115
Patient-4 (P4) 234 224 344 21X243200 20 428 800 34
512x512x119
256x256x101
Patient-5 (P5) 220 220 344 21X214600 18 026 400 34
512x512x119
256x256x101
Patient-6 (P6) 221 216 344 21X225800 18 967 200 34
512x512x120
176x176x138
248x320x20
320x320x40
Patient-7 (P7) 241 284 344 21X223400 18 765 600 34
448x448x20
464x512x20
512x512x3
176x176x139
248x320x22
320x320x40
Patient-8 (P8) 243 280 344 21X290600 24 410 400 34
448x448x20
464x512x20
512x512x3
176x176x138
320x320x71
Patient-9 (P9) 448x448x20 273 284 344 21X268600 22 562 400 34
424x512x24
464x512x20
256x256x111
Patient-10 (P10) 230 220 344 21X255000 21 420 000 34
512x512x119
176x176x138
320x320x49
Patient-11 (P11) 267 284 344 21X223400 18 765 600 44
448x448x40
464x512x40
256x256x60
Patient-12 (P12) 100 260 344 21X217200 18 244 800 14
512x512x40
256x256x60
Patient-13 (P13) 100 264 344 21X249200 20 932 800 14
512x512x40
256x256x75
Patient-14 (P14) 117 260 344 21X228600 19 202 400 14
512x512x42
256x256x60
Patient-15 (P15) 100 260 344 21X190800 16 027 200 14
512x512x40
256x256x60
Patient-16 (P16) 100 272 344 21X206400 17 337 600 14
512x512x40
256x256x60
Patient-17 (P17) 100 264 344 21X223800 18 799 200 14
512x512x40
256x256x60
Patient-18 (P18) 100 268 344 21X329000 27 636 000 14
512x512x40
256x256x60
Patient-19 (P19) 100 260 344 21X200800 16 867 200 14
512x512x40
256x256x60
Patient-20 (P20) 100 264 344 21X242800 20 395 200 14
512x512x40
256x256x60
Patient-21 (P21) 100 264 344 21X230200 19 336 800 14
512x512x40
256x256x60
Patient-22 (P22) 100 264 344 21X211200 17 740 800 14
512x512x40
* EEG file headers includes time points, number of electrodes, sampling interval, starting time, and name of electrodes of EEG.

In the message preprocessing stage as shown in Fig. 1., lossless compression methods, which are LZW
(Lempel–Ziv–Welch) and Huffman Compression, are used to increase message capacity. Furthermore,

4
LZW and Huffman Compression methods also ensure the complexity of the message. The detail of
Huffman and LZW can be found in [23-25], respectively. To increase security, the compression
message is encrypted by the Rijndael symmetric encryption algorithm using a 128-bit key. Secondly,
the proposed methods, which are similarity-based LSB(SM-LSB) and fuzzy-logic-based LSB (FL-
LSB), select non- sequential LSBs of image pixels with using the differences in gray levels of the
pixels. Finally, the selected LSBs of the pixels are altered with the message bits in stego images. These
processes are simultaneously run with all DICOM series to decrease computational time.

Embedding Stage
(Similarity-Based
LSB Method
or
Fuzzy-Based
LSB Method)
Patient Data
snnt

Stego-MR Images

Comment

Message Preprocessing Stage

Compression& Encryption

Fig. 1. Embedding message stage using the proposed model.

The extracting message stage requires stego-DICOM images and a stego-key, which is the
authentication key for decryption, as shown Figure 2. Firstly, the proposed methods give the pixels
coordinates, which have an embedded message. These pixels are used to gather the message.
Secondly, the obtained message is decrypted and decompressed. Finally, the patient’s information,
segmented EEG, and the doctor’s comments are displayed in a GUI (Graphical User Interface) screen.
All hidden EEG data can be also gathered from the DICOM series. The comparison results of the
proposed algorithm are evaluated by correlation coefficient (R), PSNR (peak signal-to-noise ratio),
MSE (mean square of error), SSIM (structural similarity measure), UQI (universal quality index)
between the cover, and the stego-DICOM series.

5
 Extracting Stage
Patient’s Information
(Similarity-Based Patient Name, Patient
LSB Method ID, Patient Gender,
or Decompression Patient Age, etc…
Fuzzy-Based & …
LSB Method) Decryption

EEG Data
snnt
Comment
Stego-MR Images+ snnt
Authentication key Message

Fig. 2. Extracting message using the proposed model.

3. Proposed Methods for Medical Image Steganography

Two methods are proposed for medical image steganography, namely, the similarity-based LSB (SM-
LSB) and fuzzy logic-based LSB (FL-LSB).

3.1. Similarity-Based LSB Algorithm

An image is sampled by pixels. In the gray-scale image, pixels have gray level intensities. In color
images, pixels are also represented by three component intensities, being red (R), green (G), and blue
(B) [26]. A similarity measure is the similarity degree between two groups or between two objects. In
image processing, the similarity measure of two pixels is used with distance information in Euclidean
color space [27, 28]. Demirci [27] proposed a similarity-based method for edge detection.
Furthermore, pixel-value differencing (PVD) or adjacent pixel difference (APD) methods determine
embedding pixels in histogram-based steganography [29, 30]. These methods have high embedding
capacity and PSNR values [29, 30]. Karakis et al. [31] used similarity to embed patient’s information
and EEG into medical images. However, the capacity of message was too low, and it does not show
the capacities of proposed method. For this reason, this study proposes a new similarity-based LSB
(SM-LSB) method using the adjacent pixel value differencing in an image as shown in Figure 3.

6
 Start

Calculate
Select Image and ∆K, ∆Y, ∆M
Threshold Value

Calculate
Euclidean norm (d)
i ←1, height j←1, width k←1, 9

Calculate Similarity
(C)
Y Y Y

N
Calculate Similarity
(S)

Assign S value as
pixel value

Add pixel
coordinate
S>Th Y
in the
matrix

Send
the matrix

Stop

Fig. 3. The flow chart of similarity based-LSB (SM-LSB) algorithm

The main idea of this method is to generate a new image whose pixels have double values at the
interval [0 1]. This similar image of cover image is used to determine pixels for the embedding
message. In this method, if the values of similar pixels are higher than the determined threshold (Th)
by trial and error, they are selected to hide the message. The neighboring pixels of the image (P1, P2, ...
, P9 ) using the 3x3 window have three color component (R, G, B) as shown in Figure 4 [27, 28, 31].
These pixels are defined as .

P1 P2 P3
P4 P9 P5
P6 P7 P8
Fig. 4. Neighboring pixels

In the first stage, the similarity method calculates the pixel differences using color distance. The gray
level differences of each color component between pixels P1 and P2 can be defined with Eq. 1.

7
R  P1( R1 )  P2( R2 )

G  P1(G1 )  P2(G2 )

B  P1( B1 )  P2( B2 ) (1)

Where R is red, G is green, and B is blue in pixel in Eq. 1. The color distance between any two pixels
in the color space is calculated with respect to the gray level differences by the Euclidean norm,
following Eq. 2.

1
di , j  (R 2  G 2  B 2 ) (2)
3

In the second stage, the similarity of two pixels is measured using Eq. 2 and Eq. 3. Similarity can be
expressed in terms of an exponential or Gaussian function of distance [27, 28]. In this study, color
similarity is calculated with Eq. 3.

  d ijq 
Ck ( xi , x j )  exp 
 Dn  (3)
 

Where Dn is the normalization coefficient, and it is examined by trial and error in Eq. 3. The value of
Dn is determined as 128.
In third step, local similarity values are calculated using a 3x3 window, as shown in Figure 5. The
local smoothness of kth pixel can be estimated with Eq. 4. It is also provided to decrease noise. Figure
5 also shows the calculation similarity values for the P1 pixel with different color lines.
9

C
1
Sk  k ,n for kn (4)
8 n 1

P1 9
S1
1/8
C2(2,1) C
n 1
k ,n
P2 S2
1/8
C3(3,1)
P3 S3
. . 1/8
. .
C9(9,1)
P9 S9
1/8

Fig. 5. Similarity matrix of the pixels using a 3x3 window.

8
In fourth stage, the similarity values of all image pixels are used to generate a similar image whose
pixels have double values at the interval [0, 1]. The coordinates of the pixels in the similar image are
held in a new matrix to hide the message, if the similarity values of the cover image are higher than the
threshold (Th=0.5). These coordinates give pixels location in the byte array of image. Finally, the
message is embedded in a stego-image via these obtained coordinates.

In the extraction stage of the message in SM-LSB, the stego image and the same threshold (Th) was
used. The gray level differences of color components are calculated the neighboring pixels of the
stego image by Eq. 1. The color distance of pixels are calculated by the Euclidean norm in Eq. 2. The
similarity values of pixels are found by using Eq.3 and Eq. 4. Similarly, the coordinates of the pixels
are determined between the similarity values of pixels and threshold values. The hidden message is
extracted using the coordinates of the stego image’s pixels.

3.2. Fuzzy Logic-Based LSB Algorithm

In image processing, the Euclidean color space is generally used to measure the distances of the pixels.
However, some studies show that perceptual color proximity cannot be measured using Euclidean
distance. In the literature, rule based approaches were proposed to overcome this problem. These
approaches were also used for color image segmentation and filtering [27, 28, 32-34]. Karakis et al.
[35] proposed a rule-based steganography method in BMP images. For this reason, this study proposes
a new fuzzy logic-based LSB (FL-LSB) algorithm to determine pixels to embed the message into
medical images and to increase the capacity of the embedding message as shown in Figure 6.

9
 Start

Calculate
Select Image ∆K, ∆Y, ∆M

Calculate
membership values
i←1, height j←1, width k←1, 9

Fuzzy Inference

Y Y Y

Defuzzify

Calculate Similarity
(C)

Calculate Similarity
(S)

Assign S value as
pixel value

Find the mean

similarity values &
Add pixel coordinate
in the matrix

Send the matrix

Stop

Fig. 6. The flow chart of fuzzy based-LSB (FL-LSB) algorithm

In first stage, gray level differences of the neighbor pixels using a 3x3 window are used as inputs of
FL-LSB algorithm. These differences of each color component between P1 and P2 are calculated using
Eq. 1. Gray level differences ( R , G , and B ) of pixels are defined with three linguistic values as
Zero: ZE, Medium: MD, and Large: LR [35].

In the second stage, the FL-LSB algorithm calculates membership values of the gray level difference
of each color component for the neighbor pixels. Five triangular fuzzy sets are used to fuzzify the gray
level difference as shown in Figure 7. Their linguistic values are defined as: Not Similar: NS, Slightly
Similar: SS, Moderately Similar: MS, Quite Similar: QS, and Exactly Similar: ES. Figure 7 also shows
the membership values (µ) with respect to similarities (S). Red, blue, and green components of gray
levels in neighbor pixels are separately designed in Figure 7. Cetin et al. [28] proposed a fuzzy-based
10
filter and gray level differences were fuzzified by seven fuzzy sets and their linguistic values.
However, this study uses five fuzzy sets to decrease computational time. Similarly, three fuzzy sets are
not used due to obtaining different similar values [35].

µS(R,G,B)

1 NS SS MS QS ES

%S(R,G,B)
0 25 50 75 100

Figure 7. Fuzzified membership values of gray levels of red, green, and blue components for neighbor pixels.

In the third stage, the fuzzified gray level differences of each color component are combined according
to the fuzzy rules as shown in Table 2. The fuzzy rules are defined as follows:
Rule1: If R is Zero and G is Zero and B is Zero, Then P1 and P2 are Exactly Similar,
Rule2: If R is Large and G is Large and B is Large, Then P1 and P2 are Not Similar,
Rule3: If R is Large and G is Zero and B is Medium, Then P1 and P2 are Moderately Similar, and
so on.

Table 2. The fuzzy rules of the FL-LSB algorithm

R G B S
ZE ZE ZE ES
ZE ZE MD ES
ZE ZE LR QS
ZE MD ZE ES
ZE MD MD QS
ZE MD LR MS
ZE LR ZE QS
ZE LR MD MS
ZE LR LR SS
MD ZE ZE ES
MD ZE MD QS
MD ZE LR MS
MD MD ZE QS
MD MD MD MS
MD MD LR SS
MD LR ZE MS
MD LR MD SS
MD LR LR NS
LR ZE ZE QS
LR ZE MD MS
LR ZE LR SS
LR MD ZE MS
LR MD MD SS
LR MD LR NS
LR LR ZE SS
LR LR MD NS
LR LR LR NS
* ZE: Zero, MD: Medium, LR: Large, NS: Not Similar, SS: Slightly Similar, MS: Moderately Similar, QS: Quite Similar, and ES: Exactly
Similar.

11
In the fourth stage, the similar percentage of neighbor pixels values is obtained by using the center-
average defuzzification and product, presented in Eq. 5 [28].

S 
j 1
j
j
prem ( L)

S Z (5)
j 1
 prem
j
( L)

Where Sj denotes the center of similarity percent in the jth rule, and Z also denotes the number of the

rules.  prem
j
(L) is calculated in Eq. 6 [28].

 prem
j
( L)   Rj (R)Gj (G) Bj (B) (6)

In the fifth stage, the similarity values of image are obtained using a 3x3 window using Eq. 4. The
similarity values generate a new image whose pixels have double values at the interval [0, 1]. Finally,
the mean similarity values of the 3x3 window are selected as the LSB pixels to embed the message.
The FL-LSB method is modified as LSB method using similarity values of pixels according to the
differences of gray levels. Hence, non-sequential LSBs of pixels are directly replaced to embed the
message.

In the extraction stage of the message in FL-LSB, the stego image was used. Firstly, the gray level
differences of the neighbor pixels using a 3x3 window are calculated by Eq. 1. Secondly, the gray
level differences were fuzzified by five fuzzy sets and their linguistic values. The fuzzified gray level
differences of each color component are combined according to the fuzzy rules. Finally, the similar
percentage of neighbor pixels values is defuzzified by Eq. 5. The mean similarity values of the 3x3
window are selected as the LSB pixels to extract the message. The message is at last separated as
patient’s information, doctors’ comment and EEG data.

3.3. Comparison Methods

In this study, the performance of the proposed methods was evaluated between the cover and stego
DICOM series by five different comparison methods. These include: MSE (mean square of error),
PSNR (peak signal-to-noise ratio), SSIM (structural similarity measure), UQI (universal quality
index), and correlation coefficient (R), which are given as following in Eqs. 7-11, respectively.

M 1 N 1

 ( f ( x , y ) g ( x , y ))
1
MSE  i j i j
2
(7)
MN i 0 j 0

12
Where M and N are the dimensions of the images; f(x, y) and g(x, y) are the cover and the stego
images [35]. The peak signal-to-noise ratio (PSNR) calculates the noise effect of the embedding
message between cover and stego images [35].

255X 255
PSNR  10 log( ) (8)
MSE

MSE and PSNR are inconsistent with the human visual system (HVS). UQI evaluates the loss of
correlation, luminance distortion, and contrast distortion. SSIM considers image degradation
as perceived change in structural information. Hence, the performances of universal quality index
(UQI) and structural similarity measure (SSIM) are better than the MSE and PSNR.

(2 x  y  c1 )(2 xy  c2 )
SSIM( x, y )  (9)
(  x2   y2  c1 )( x2   y2  c2 )

(4 x  y 2 xy )
UQI ( x, y )  (10)
(    y2 )( x2   y2 )
2
x

 x is the average of X,  y is the average of Y,  x2 is the variance of X,  y2 is the variance of Y,  xy is

the covariance of X and Y. In Eq. 9, c1 ( c1  (k1 L) 2 ) and c2 ( c2  (k 2 L) 2 ) are two variables to stabilize
the division with a weak denominator. L is also the dynamic range of the pixel-values. k1 and k2 have
default values as 0.01 and 0.03, respectively [36].

The correlation coefficient (R) compares two images for image registration in image processing. It is
described in Eq. 11 [37].

M N

 ( f MN  f )  ( g MN  g )
R (11)
  
  f   g 
M N M N
 f
2
 g 
2

 MN
 MN

  

f is mean of pixels in cover image, and g is also mean of pixels in stego images in Eq. 11.

4. Results and Discussion

This section presents the analysis results of proposed algorithms using an epilepsy dataset, which was
obtained from the Department of Neurology at Gazi University.

13
4.1. Results of the Proposed Algorithms

Figure 8 shows the cover and stego images of proposed algorithms. Whatever DICOM Viewer does
not show any patient information in stego images after embedding the message as shown in Figure 8.
Patient information can be extracted from stego images by authorized person. The histograms of the
cover and stego images are also shown in Figure 8. There are little differences in the histograms of the
cover and stego images. The histograms of the background’s pixels on the interval [0 50] especially
changed. In this study, EEG data was sequentially segmented according to the size of the image for
each DICOM image, as shown in Figure 9. EEG data was also gathered from the DICOM series while
extracting the message.

a)

b)

c)
Fig. 8. Cover and stego images: a) Cover image and histogram, b) Stego image of the SM-LSB algorithm and
histogram, c) Stego image of the FL-LSB algorithm and histogram

14
 Segmented EEG for 1st DICOM Segmented EEG for 2nd DICOM
Fig
. 9. Segmented EEG data of patients according to the size of the cover images.

The performances of proposed algorithms were evaluated by PSNR, MSE, SSIM, UQI, and R values,
whose details were explained in Section 3. Table 3 shows the obtained comparison results of the SM-
LSB algorithm between the cover and stego DICOM images of 22 epilepsy patients. The mean PSNR
values ranged between 53.9520 dB and 62.5025 dB ± 2.3441. The mean of the MSE values were
between 0.0428 and 0.3535 ± 0.0786. The mean root of MSE (RMSE) values were between 0.2069
and 0.5946 ± 0.1035. The means of the obtained SSIM and UQI values were between 0.9994 and
0.9999. The mean correlation coefficient (R) values were between 0.717321 and 0.999156 ± 0.0795.
The percentage of obtained altered pixels ratio (PR) was the number of replaced pixels/number of
cover image pixels. The mean PR values were found between 4.2810% and 27.4140%.
Table 3. Performance results of the SM-LSB algorithm
Patients PSNR MSE RMSE SSIM UQI R PR %
P1 57.7964 0.1515 0.3892 0.999712 0.999684 0.9982 13.1255
P2 54.7430 0.1303 0.3610 0.999792 0.999775 0.9973 10.6588
P3 62.5025 0.0482 0.2195 0.999669 0.999630 0.9992 4.8219
P4 57.4631 0.1635 0.4044 0.999459 0.999378 0.9975 13.8005
P5 57.8316 0.1427 0.3778 0.999714 0.999698 0.9982 12.9147
P6 59.9360 0.0993 0.3151 0.999631 0.999561 0.9989 9.0406
P7 55.7668 0.2323 0.4820 0.999811 0.999806 0.7173 17.3619
P8 55.9870 0.2486 0.4986 0.999743 0.999737 0.7359 16.5165
P9 53.9520 0.3535 0.5946 0.999803 0.999797 0.8406 27.4140
P10 57.6764 0.1421 0.3770 0.999707 0.999681 0.9977 11.9838
P11 56.4447 0.1962 0.4429 0.999898 0.999896 0.8392 15.7279
P12 60.4063 0.0610 0.2470 0.999924 0.999923 0.9148 6.1044
P13 57.7866 0.1117 0.3342 0.999883 0.999881 0.9212 11.1691
P14 60.5455 0.0581 0.2410 0.999872 0.999870 0.9190 5.8072
P15 59.7319 0.0716 0.2676 0.999889 0.999887 0.8837 7.1569
P16 60.8035 0.0558 0.2362 0.999922 0.999921 0.9243 5.5806
P17 60.5941 0.0589 0.2427 0.999894 0.999892 0.8953 5.8856
P18 62.1346 0.0428 0.2069 0.999911 0.999909 0.9253 4.2810
P19 57.3811 0.1223 0.3497 0.999871 0.999869 0.9054 12.2341
P20 60.5006 0.0599 0.2447 0.999932 0.999931 0.9119 5.9898
P21 60.3670 0.0612 0.2474 0.999915 0.999913 0.9150 6.1192
15
P22 57.8782 0.1100 0.3317 0.999893 0.999891 0.9229 10.9998
Min* 53.9520 0.0428 0.2069 0.999459 0.999378 0.7173 4.2810
Max* 62.5025 0.3535 0.5946 0.999932 0.999931 0.9992 27.4140
Sd* 2.3441 0.0786 0.1035 0.000122 0.000143 0.0795 5.5042
* Min=minimum, Max=maximum, Sd=standard deviation

Table 4 shows the embedding performance of the FL-LSB algorithm between the cover and stego
images. The mean of PSNR values were between 53.8708 and 62.9892 ± 2.4389. The mean of MSE
values were between 0.0428 and 0.3598 ± 0.0812. The mean of RMSE values were between 0.2069
and 0.5998 ± 0.1060. The mean of SSIM and UQI values were between 0.9994 and 0.9999. The mean
of R values were between 0.814089 and 0.999277 ± 0.0586. The mean of PR values were between
4.2809% and 28.0235%. The performances values of the proposed algorithms have similar values
according to the obtained results, as shown in Table 3 and Table 4.

Table 4. Performance results of FL-LSB algorithm

Patients PSNR MSE RMSE SSIM UQI R PR %
P1 57.7964 0.1515 0.3892 0.999712 0.999684 0.9982 13.12552
P2 54.7430 0.1303 0.3610 0.999792 0.999775 0.9973 10.65882
P3 62.9892 0.0433 0.2081 0.999696 0.999658 0.9993 4.330891
P4 57.4631 0.1635 0.4044 0.999459 0.999378 0.9975 13.80047
P5 57.8434 0.1415 0.3762 0.999716 0.9997 0.9983 12.82817
P6 60.0257 0.0969 0.3113 0.999639 0.999569 0.9990 8.802772
P7 56.5125 0.1873 0.4328 0.999883 0.99988 0.8141 15.52878
P8 56.8729 0.1808 0.4252 0.999843 0.99984 0.8621 14.23622
P9 53.8708 0.3598 0.5998 0.999801 0.999795 0.8371 28.02354
P10 57.7006 0.1408 0.3752 0.999711 0.999684 0.9977 11.85890
P11 54.7384 0.2895 0.5381 0.999881 0.999878 0.8405 23.89260
P12 60.3198 0.0619 0.2488 0.999923 0.999922 0.9134 6.194917
P13 60.4180 0.0609 0.2468 0.999884 0.999882 0.9200 6.087525
P14 60.5455 0.0581 0.2410 0.999872 0.99987 0.9190 5.807245
P15 59.7319 0.0716 0.2676 0.999889 0.999887 0.8837 7.156903
P16 60.8035 0.0558 0.2362 0.999922 0.999921 0.9243 5.580629
P17 60.5941 0.0589 0.2427 0.999894 0.999892 0.8953 5.885576
P18 62.1346 0.0428 0.2069 0.999911 0.999909 0.9253 4.280992
P19 57.3811 0.1240 0.3521 0.999867 0.999865 0.9040 12.39595
P20 60.4156 0.0607 0.2464 0.999933 0.999933 0.9105 6.073809
P21 60.2887 0.0620 0.2490 0.999908 0.999907 0.9135 6.203587
P22 57.7906 0.1116 0.3341 0.999894 0.999892 0.9216 11.16233
Min* 53.8708 0.0428 0.2069 0.999459 0.999378 0.8141 4.28099
Max* 62.9892 0.3598 0.5998 0.999933 0.999933 0.9993 28.02354
Sd* 2.4389 0.0812 0.1060 0.000119 0.000140 0.0586 6.128659
*Min=minimum, Max=maximum, Sd=standard deviation

The embedding capacity of the proposed algorithms is given in Table 5. The SM-LSB method without
compression embedded data between 12.75% and 51.22%. The percentage of embedding capacity in
the FL-LSB method without compression was between 12.68% and 50.99%. As shown in Table 5,
even though the SM-LSB method embedded a bit more data than FL-LSB method, the embedding
16
capacities of the proposed methods were quite similar to the performance results. Moreover, the
capacity of SM-LSB method is related to the selection of threshold value. The threshold value has to
be optimized for each DICOM series.

This study also investigated the data embedding capacity of the lossless compression algorithm using
the epilepsy dataset in the proposed algorithms. Hence, the LZW and Huffman lossless compression
methods are used to increase the embedding capacity. Figure 10 and Figure 11 show the percentage of
embedding data according to total data by means of the proposed methods. Huffman compression was
better than the LZW method for both of the proposed algorithms, as shown in Figure 10 and Figure 11.
The percentage of embedding capacity in the SM-LSB algorithm using LZW compression was
between 13.41% and 57.96%. In Huffman compression, it was between 14.97% and 60.08%. The
percentage of embedding capacity in FL-LSB using LZW compression was between 5.38% and
56.67%. In Huffman compression, it was between 14.88% and 59.81%. Lossless compression methods
in FL-LSB also increased the capacity of the embedding message, as shown in Figure 10 and Figure
11.

Table 5. Comparison embedding capacities of the proposed algorithms

Capacity of Percentage of
Total Data Embedding Data Embedding Data
Patients
(byte) SM-LSB FL-LSB SM-LSB FL-LSB
(byte) (byte) (%) (%)
P1 23309184 9477996 9438516 40.66 40.49
P2 20277900 10147080 10090884 50.04 49.76
P3 20824672 9177232 9174796 44.07 44.06
P4 20570604 9514758 9478620 46.25 46.07
P5 18166332 9305592 9263676 51.22 50.99
P6 19098474 9361866 9322386 49.02 48.81
P7 18925142 4488314 4449254 23.72 23.51
P8 24570294 4520418 4520418 18.40 18.40
P9 22743126 5817210 5763450 25.58 25.34
P10 21557540 9453560 9410804 43.85 43.65
P11 18945024 6283032 6224904 33.16 32.86
P12 18306600 3531000 3514200 19.29 19.20
P13 20995000 3531400 3511240 16.82 16.72
P14 21005574 3767514 3749454 17.94 17.85
P15 16089000 3531000 3512520 21.95 21.83
P16 16090200 3532200 3513720 21.95 21.84
P17 18861400 3531400 3511240 18.72 18.62
P18 27698600 3531800 3511640 12.75 12.68
P19 16929800 3531800 3513320 20.86 20.75
P20 16929400 3531400 3512920 20.86 17.17
P21 19399000 3531400 3512920 18.20 18.11
P22 17803000 3531400 3512920 19.84 19.73

17
Fig. 10. Comparison of the percentage of embedding capacity in the SM-LSB algorithm

Fig. 11. Comparison of the percentage of embedding capacity in the FL-LSB algorithm

The embedding capacity of the different sizes of images is given in Table 6. The mean of embedding
capacity in the SM-LSB method was between 6962 bytes and 64838 bytes in DICOM images sized
176x176 and 512x512. The FL-LSB method embedded 6794 bytes and 64586 bytes in DICOM
images sized 176x176 and 512x512.

18
Table 6. Comparison of the embedding capacities of the proposed algorithms
Capacity of SM-LSB (byte) Capacity of FL-LSB (byte)
Size of
No- No-
Image LZW Huffman LZW Huffman
Compression Compression
176x176 6962 7802 8222 6794 7550 8054
256x256 15698 17714 18470 15614 17546 18218
248x320 14606 16286 17210 14522 16202 17126
320x320 24854 27626 29222 24686 27458 28970
424x512 44174 46442 51818 44090 46274 49046
448x448 49466 54926 57950 49214 54674 57698
464x512 53078 58958 62234 52994 58874 62066
512x512 64838 72734 76010 64586 72482 75086

The embedding capacities and performances of both SM-LSB and FL-LSB algorithms were obtained
as similarly. However, SM-LSB method determines the embedding pixel with a threshold value,
which is obtained by trial and error. For this reason, this study proposes FL-LSB algorithm to secure
multiple medical data.

4.2. Comparison of proposed algorithms

In other similar studies, Miaou et al. [16] embedded ECG record, the diagnosis report and the doctor’s
seals in medical images using LSB technique. PSNR values were obtained on the interval 33-43 dB.
However, the embedding capacities of methods were not given. The details of similar studies in
literature can be shown in Table 7.

Table 7. Comparison with the proposed algorithms and literature

Studies Method PSNR MSE Image Size Hidden Message Cryptology Capacity
(dB) of Message
Miaou et al. LSB 33 - 43 - - Patient Information+ Yes -
[115] ECG+ Doctor’s
Comment + Doctor’s
Seal
Giakoumaki et DWT 46,66±0,2 - 512x512x20 Patient Information + Yes 668 byte
al. [116] MR, PET ASCII text data (5348 bit)
Nambakhsh et DWT 48,15±0,22 - 256x256x25 PET Patient Information + Yes 2 KB
al. [18] [19] ECG
Anand and LSB - 0.0092 128x128x3 Patient Information Yes 2 KB
Niranjan [117] 0.0023 +EEG
0.0077

Acharya et al. LSB - - 128x128x3 Patient Information + Yes -

[89] MR, Ultrason, ECG
Ang*
Acharya et al. DCT - 0.70 196x260 MR Patient Information + Yes -
[118] 0.53 200x265 Ang ECG
0.50 200x265 Ultrason

Karakis et al. FL-LSB 53.87-62.99 0.04 - 176x176-MR Patient Information + Yes 6,63 KB**
± 2.44 0.36 ± 256x256-MR EEG + Doctor’s 15,3 KB
0.08 248x320-MR Comment 14,2 KB
320x320-MR 24,1 KB
424x512-MR 43,1 KB
448x448-MR 48,1 KB
464x512-MR 51,8 KB
512x512-MR 63,1 KB
*Ang=Angiogram, ** Capacity of message is calculated without compression.

19
Giakoumaki et al. [18] proposed a wavelet based method using 512x512x20 medical images. The
average PSNR values was found as 46.66±0.2 for nearly 668 bytes (5348 bits). Similarly, Nambakhsh
et al. [17] [19] introduced a new multi-resolution wavelet decomposition method to embed ECG and
demographic text data in 256x256x25 PET images. PSNR values were achieved as 48.15±0.22 for 2-
kilo bytes. This method is robust against the attacks. However, capacities of these methods were too
low. They have also high computational time and complexity. This study ensures to sequentially hide
message in DICOM series of patients.

Anand and Niranjan [20] proposed a LSB technique of data hiding in spatial domain. Firstly, text file
is encrypted and interleaved in the LSB of the gray level values. Graphical data such as ECG or EEG
signals are also hidden in the image. However, capacities of these methods were too low and they used
only three cover images.

Acharya et al. [21] introduced a LSB method of embedding patient’s information and ECG or EEG
data. Data was encrypted by using Rijndael algorithm. During transmission or storage the data,
channel coding technique has been used to decrease the effect of noise. Acharya et al. [22] proposed a
LSB technique using DCT in frequency domain. The coefficients are run length encoded. Variable
length Huffman encoding is used to save memory space. Text file is also encrypted and the bits in the
equivalent binary number are interleaved in the LSB of high frequency DCT coefficients. However,
the capacity evaluation of these methods were not given, and there are visible differences in the
histograms of the cover and stego images.

The capacity of proposed FL-LSB algorithm is higher than the results of similar studies as shown in
Table 7. The mean of PSNR values are obtained between 53.87 and 62.99 ± 2.44. Embedding and
extracting message were generated simultaneously for each DICOM series of patient. It also positively
affects the computational time. Message was secured by compression and encryption algorithm.
Furthermore, embedding message in each DICOM image can be separately observed in a GUI screen.
EEG data can be investigated in each DICOM image, or it can be gathered from DICOM series of
patient.

5. Conclusion
In medical information system, medical data is easily captured when being storing, receiving or
transmission through computer network and Internet. Cryptology and steganography are generally
used to ensure medical data security. For this reason, this study proposes two new algorithm that are
similarity-based LSB (SM-LSB), and fuzzy logic-based LSB (FL-LSB) to secure medical data. EEG
signals and MR images of 22 epilepsy patients are used to combine multiple medical signals into one
file format. The embedding message are composed of EEG signals, doctor’s comment, and patient

20
information in file header of DICOM images. The message are secured by using Huffman and LZW
lossless compression methods and Rijndael symmetric algorithm with 128 bit-key to prevent the
attacks.

The main idea of proposed methods is to create a similar image whose pixels have double values on
the interval [0 1]. It is obtained by means of measuring the similarity of neighbor pixels. SM-LSB
algorithm selects the LSB pixels to embed the message by a threshold value which is determined by
trial and error. FL-LSB algorithm hides the message with selecting non-sequential LSB pixels of
generated-similar image. The performance of stego image quality is measured by MSE, PSNR, SSIM,
UQI, and R. In FL-LSB algorithm, mean PSNR values is obtained between 53.8708 dB and 62.9892
dB. The capacity of proposed algorithm are higher than the result of similar studies in literature.
According to the obtained result, the proposed method ensures the confidentiality of the patients
information. The FL-LSB method hides EEG signals, patients information and doctor’s comment in
the pixels of MR images. It also reduces data repository and transmission capacity of the patients’
multiple medical data.

In the future, noise cancellation and data reduction would possible to increase embedding capacity.

6. Acknowledgements
This study has been supported by Gazi University Scientific and Research Project Fund (Project No:
07/2012-45).

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Graphical Abstract

Embedding Stage
(Similarity-Based
LSB Method
or
Fuzzy-Based
Patient Data
LSB Method)

Stego-MR Images

Comment

Message Preprocessing Stage

Compression& Encryption

Figure 1. Embedding message stage using the proposed model.

Patient’s Information
Extracting Stage Patient Name, Patient
(Similarity-Based ID, Patient Gender,
LSB Method Patient Age, etc…
Decompression …
or
&
Fuzzy-Based
Decryption
LSB Method)
EEG Data
snnt
Comment
Stego-MR Images+
Authentication key Message

Figure 2. Extracting message using the proposed model.

Highlights
This study aims to: i) secure multiple medical signals by combining them into one file format; ii)
propose a new steganography method in literature; iii) secure patients’ personal data by encryption and
compression algorithms; and iv) reduce data repository and transmission capacity of multiple medical
signals.