Interventional Rad 1

Evolve.
Adapt.
Overcome.
CEFI is now ready.
DIGITAL SUBTRACTION ANGIOGRAPHY
COURSE CODE: RT – 310: INTERVENTIONAL RADIOLOGY
DANIELE CLYDE P. CACHA, RRT

College of Radiologic Technology
COLLEGE OF RADIOLOGIC TECHNOLOGY
Calayan Educational Foundation, Inc.
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Overview of DSA
Perhaps one of the greatest impacts on diagnostic radiology during the last 2
decades has been the introduction of digital computers to radiology and their
application in Computed Tomography (CT), Digital Subtraction Angiography (DSA),
and Magnetic Resonance Imaging (MRI).
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1970’s – CT served as springboard for computer application in therapeutic &
diagnostic angiography
DSA – presented as possible replacement for intra-arterial studies.
- was envisioned that it would result in reduced hospital stays of patient, shorter
examination times, reduced film exposure, and less cost to the patient.
- aid in the diagnosis of heart disease and other circulatory disorder.

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In DSA, x-ray images of arterial blood vessels are taken both before and after
introduction of contrast media.
Images are converted into digital data; and a computer “subtracts” one set
of data from another with resulting image showing only the dye and, therefore, the
shape of the artery.
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Lateral carotid arteriogram

Lateral skull radiograph
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The Imaging Chain
Sir Thomas A. Edison – invented the fluoroscope in 1896.
Fluoroscope – an instrument with a fluorescent screen used for viewing X-ray images
without taking and developing X-ray photographs. It is used primarily for dynamic
studies. (e.g. internal structures and fluids)
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Digital Fluoroscopy
A digital x-ray imaging system that produces dynamic images obtained with
an area x-ray beam.
Conducted in much the same manner as a conventional fluoroscope study

but with a more complex operating console.
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Equipment and Apparatus
Operating console of a DF:
1. Multiple monitors
2. X-ray tube
3. X-ray generator
4. Image intensifier
5. TV lens system
6. TV camera
7. Video signal
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X-ray tube – located under the patient and operates in radiographic mode.
Tube current is measured in hundreds of mA.
Pulse-progressive fluoroscopy – manner of obtaining images from DF by

pulsing the x-ray beam.
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X-ray generator – must be capable of switching on and off very rapidly.
• Interrogation time – is the time required for the x-ray tube to be switched on and
reach selected levels of kVp and mA.
• Extinction time – is the time required for the x-ray tube to be switched off.
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Monitors – has multiple functions due to different operations in the DF system.
Contains:
1. Right monitor
• alphanumeric and special function keys for entering patient data.
• additional special function keys for data acquisition and image display.
• Computer-interactive video controls and a pad for cursor and region-of-interest (ROI) manipulation
2. Left monitor
• Display subtracted images
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Image intensifier tube – a complex electronic device that receives the image-
forming x-ray beam and converts it into visible-light image of high intensity.
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Subtraction Technique
First introduced by Ziedses des Plantes in 1961 and makes possible the
visualization of certain information on angiogram by the removal of non-essential
structures.
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Bernard George Ziedses des Plantes (1902-1993)
Trained as nervous diseases specialist at Utrecht, Netherlands. He built the

first machine for planigraphy, in which the X-ray tube and the film moved together
around the plane of interest, but he also designed the subtraction method to improve
images after injection of contrast agents.
Eventually a full-time radiologist, he also developed the 'somersault' technique

of ventriculography and pioneered isotope scintigraphy.
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It is important in subtraction to keep all radiographic factors constant
between the reference film and the angiograms that should immediately follow.
Without the same patient position, same radiographic distance, and

exposure factors, subtraction is usually impossible.
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MANUAL SUBTRACTION TECHNIQUE/PHOTOGRAPHIC SUBTRACTION
1. Registration film
• Matching of one image over another so that bony landmarks are precisely
superimposed.
• Films are taped together to prevent slippage.
• (Involves 2 or more films)

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2. Reversal film (Positive or Diapositive Mask)
• Reverse-tone duplicate of radiographic image, showing black changed to white and

white to black.
• Positive transparency is obtained by exposing single-emulsion film through

traditional radiographic film.
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3. Zero film/Base film (Control Film)
• Film showing bone structures only, with no patient motion between it and
subsequent contrast studies.
• Taken just before contrast media is injected into vessels.

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EQUIPMENT AND MATERIALS:
• A contact printer
• Radiographic processing facilities
• Films – subtraction mask film for making the reversal masks & subtraction print film
for making photographic prints of the final subtracted image
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FIRST ORDER SUBTRACTION
• The simplest method of photographic subtraction.
• It consist of obtaining a positive mask (reversal film), of the first film (zero film) of
the angiographic series (without contrast media).
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PROCEDURE:
Step 1: In a darkroom, place the non-emulsion side of the sheet of subtraction mask film in
contact with the zero film, and expose it to light for approximately 5 seconds. When processed,
this becomes the mask.
Step 2: On a light box, carefully register the mask over the selected series film and tape the
two securely together.
Step 3: In the darkroom, place the mask-series film combination in contact with the emulsion
side of a sheet of subtraction print film, and expose it to light for approximately 5 seconds. This
produces the final subtraction image
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SECOND ORDER SUBTRACTION
• The reversal of the zero film obtained in the first order subtraction is usually not the
exact reversal of the density of the selected angiographic film; thus the subtraction
result is imperfect.
• This can be corrected with second order subtraction.
• Hanafee and Shinno – introduced second order subtraction.

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• This method consists of superimposing the zero film on its own reversal mask.
• The combination of the zero film, correction film, and angiographic film are exposed
to obtain the final subtraction print.
• A further advancement toward the goal of complete subtraction was published by

Sucher & Strand in 1974. This modification is called composite-mask subtraction or
white-over-white technique.
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COMPOSITE MASK SUBTRACTION PROCEDURE:
Step 1: In a darkroom, place the non-emulsion side of a sheet of subtraction mask film in
contact with zero film, expose to light for 5 seconds. (Mask film)
Step 2: In a darkroom, place the emulsion side of a sheet of subtraction mask film in
contact with the selected angiographic series film, which is then exposed to light. (Series
reversal film)
Step 3: On a light box, carefully register the series reversal film with the zero film, and
tape the two securely together.
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Step 4: In a darkroom, place the zero-series reversal film combination in contact with
the emulsion side of a sheet of subtraction mask film, and expose to light for 20
seconds.
Step 5: On a light box, carefully register the series film and the mask, and tape the
two securely together. Carefully register and tape the secondary mask to this
composite.
Step 6: In a darkroom, place the series film-mask-secondary mask combination in

contact with the emulsion side of a sheet of subtraction print film, expose to light for
5 seconds. (Subtraction final film)
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DIGITAL SUBTRACTION TECHNIQUE
First step: select a scout film (preliminary film) for the creation of a diapositive mask
Second step: prepare the diapositive mask (reversal film)
Third step: select one of the contrast-filled angiogram (series film) films and superimpose that film
over the mask. “Registration”
Fourth step: when the diapositive mask is superimposed over contrast filled angiogram film, the
positive and negative image of the bones tend to negate each other. “subtraction mask or series
reversal film”

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Evolve.

DIGITAL SUBTRACTION ANGIOGRAPHY

COURSE CODE: RT – 310: INTERVENTIONAL RADIOLOGY

DANIELE CLYDE P. CACHA, RRT

DSA – presented as possible replacement for intra-arterial studies.

- aid in the diagnosis of heart disease and other circulatory disorder.

Lateral carotid arteriogram

Sir Thomas A. Edison – invented the fluoroscope in 1896.

Conducted in much the same manner as a conventional fluoroscope study

Operating console of a DF:

Pulse-progressive fluoroscopy – manner of obtaining images from DF by

Trained as nervous diseases specialist at Utrecht, Netherlands. He built the

Eventually a full-time radiologist, he also developed the 'somersault' technique

Without the same patient position, same radiographic distance, and

• Films are taped together to prevent slippage.

• (Involves 2 or more films)

• Reverse-tone duplicate of radiographic image, showing black changed to white and

• Positive transparency is obtained by exposing single-emulsion film through

• Taken just before contrast media is injected into vessels.

• Radiographic processing facilities

• The simplest method of photographic subtraction.

• This can be corrected with second order subtraction.

• Hanafee and Shinno – introduced second order subtraction.

• A further advancement toward the goal of complete subtraction was published by

Step 6: In a darkroom, place the series film-mask-secondary mask combination in

Second step: prepare the diapositive mask (reversal film)

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