Clinical Radiology (2005) 60, 11331140

REVIEW

DICOM demystified: A review of digital file formats

and their use in radiological practice
R.N.J. Graham, R.W. Perriss, A.F. Scarsbrook*
Department of Radiology, John Radcliffe Hospital, Headington, Oxford, UK
Received 28 June 2005; received in revised form 18 July 2005; accepted 28 July 2005

KEYWORDS
Internet; Digital imaging and communications in medicine
(DICOM); PACS

Digital imaging and communications in medicine (DICOM) is the standard image file
format used by radiological hardware devices. This article will provide an overview of
DICOM and attempt to demystify the bewildering number of image formats that are
commonly encountered. The characteristics and usefulness of different image file
types will be explored and a variety of freely available web-based resources to aid
viewing and manipulation of digital images will be reviewed. How best to harness
DICOM technology before the introduction of picture archiving and communication
systems (PACS) will also be described.
Q 2005 The Royal College of Radiologists. Published by Elsevier Ltd. All rights
reserved.

Introduction

What is the DICOM file format?

Digital images are generated by a wide variety of

radiological hardware. Each device collects data,
which are then encoded and stored electronically in
DICOM format. This is a universal file type,
developed to facilitate data exchange between
hardware, irrespective of manufacturer. DICOM
files store a large amount of data and usually need
to be viewed on dedicated workstations but may be
transferred electronically to other computers
where they can be displayed provided appropriate
DICOM viewing software is installed. DICOM files can
easily be converted to a variety of image formats
and edited before use in teaching and publications.
There are a number of useful DICOM-related
resources that are freely available on the internet.

In response to the increased use of digital images in

radiology the American College of Radiology (ACR)
and the National Electrical Manufacturers Association (NEMA) formed a joint committee in 1983 to
create a standard format for storing and transmitting medical images.1 The committee published the
original ACR-NEMA standard in 1985.1 This has
subsequently been revised and in 1993 the standard
was renamed DICOM.1 More recent improvements in
DICOM (Version 3.0) have permitted transfer of
medical images in a multi-vendor environment, and
importantly, have facilitated the development of
PACS and digital interfacing with medical information systems.1 DICOM is administered by the
NEMA Diagnostic Imaging and Therapy Systems
division and each year the standard is updated.
Details of recent improvements can be found on the
NEMA website (http://medical.nema.org/).2
Each DICOM file has a header containing amongst
other items, patient demographic information,
acquisition parameters, referrer, practitioner and
operator identifiers and image dimensions. The
remaining portion of the DICOM file contains the
image data. Because they often contain multiple
high-resolution images, DICOM files tend to be large

* Guarantor and correspondent: A.F. Scarsbrook, Department

of Radiology, John Radcliffe Hospital, Headley Way, Headington,
Oxford OX3 9DU, UK. Tel.: C44 1865220815; fax: C44
1865220801.
E-mail address: andyscarsbrook1@aol.com (A.F. Scarsbrook).

0009-9260/$ - see front matter Q 2005 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.crad.2005.07.003

1134

R.N.J. Graham et al.

Lossy compression file types

Figure 1 Lossless compression of a dataset: Repeated

values are coded to reduce the overall file size.

[e.g., 35 megabytes for a pre and post-contrast

computed tomography (CT) images of the brain]
and are frequently compressed before storage and
transfer.

Joint photographic experts group format (JPEG)

This image type allows the user to specify how much
compression is applied and hence how much of the
original data are lost. JPEG files exploit the fact
that the human eye perceives small colour changes
less accurately than changes in brightness. The
disadvantage with JPEG is that data are irreversibly
lost and this may lead to an unacceptable level of
image degradation (Fig. 2). The advantage, however, is a very small file size.

Digital image compression

Lossless compression file types

Image compression is a method of reducing file size

to increase the amount of data that can be archived
onto storage media and to speed up data transmission. DICOM images can be compressed by
converting the data into smaller image file types
using specialized software, which will be described
in more detail later in the article.
There are two main types of data compression:
Lossless and lossy. Lossless compression allows the
file size to be reduced without any loss of
information. This allows all the original data to be
recovered if necessary. In lossless data compression
repeated identical values within the dataset are
replaced with one value (Fig. 1) in a way that allows
unambiguous decoding without loss of information.
This process uses a substantial amount of processing power and makes compressed files slower to
open and save.
By contrast, lossy image compression permanently eliminates some of the file data and can
result in a remarkable reduction in file size. The aim
is to eliminate redundant information from the
dataset without adversely affecting image quality,
but excessive compression inevitably results in
image degradation (Fig. 2).

Portable network graphics format (PNG)

The PNG image format has several good features:
Variable degree of transparency; image brightness
control (gamma correction) and two-dimensional
interlacing (initially every other line of the image
data is displayed) for rapid image viewing.6 The
lossless compression algorithm was written by
Lempel and Ziv in 1977.7 A useful feature of the
PNG format is the ability to embed text within the
image file as so called metadata.3 This is rather
like the header associated with a DICOM image, and
is convenient when setting up a teaching file
database as certain web-based search engines can
find images based on this embedded information.

Image file formats

Graphic interchange format (GIF)

This image format was first produced in 1987 and
uses the LZW lossless compression algorithm.9 The
compression of GIF images is less efficient than PNG
files (by about 525%) and this file type lacks the
wide-ranging features of the newer PNG.9 As a
result GIF has been largely superseded by PNG.

Aside from DICOM there are a plethora of different

digital image file formats, which can easily confuse
the uninitiated. An extensive review of these is
beyond the scope of this article, however, the
interested reader may find additional information
in an excellent article on image file formats by
Wiggins et al.3 In simple terms, the different
formats can be divided into those involving lossy
compression such as Joint Photographic Experts
Group (JPEG)4 and those using lossless compression, e.g., tagged image file format (TIFF).5

Tagged image file format (TIFF)

With TIFF files either lossless or lossy data
compression can be specified. Lossless compression
is generally performed using the Lempel-Ziv-Welch
(LZW) algorithm written by Abraham Lempel and
Jacob Ziv in 1977 and 1978 and improved by Terry
Welch in 1984, hence the name LZW.7,8 The
disadvantage with TIFF is its relatively large file
size making it less than ideal for Internet or
PowerPoint (Microsoft, Redmond, WA, USA)-based
applications.

Joint photographic experts group 2000 format

(JPEG 2000)
This is another example of an image file using
lossless compression. JPEG 2000 images allow
certain parts of the image to be defined as a region

DICOM demystified

1135

Figure 2 Image degradation resulting from excessive lossy data compression: (a) High-resolution JPEG image (144 kb)
of an axial T2-weighted MRI image of the brain showing a right-sided acoustic neuroma (white arrow); (b) moderate
compression of the same JPEG image (64 kb) showing no significant image degradation; (c) highly compressed JPEG
(32 kb) demonstrating marked image degradation.

1136

R.N.J. Graham et al.

of interest (ROI), which can then be displayed

before other parts of the image, or be losslessly
compressed, whilst other less critical parts of the
image undergo lossy compression. Like PNG, JPEG
2000 allows metadata to be embedded in the image
file.4 JPEG 2000 is a new file format, and is not yet
in wide use by radiologists. With its advanced
features it is predicted that it is likely to be
increasingly used in the future.
So which of these file types should one use?
Generally speaking, lossy files are perfectly suitable
for image display in computer and web-based
presentations where the small file size allows
rapid image upload and facilitates easy image
transfer between computers. In contrast, lossless
formats are more suitable for archiving, teaching
and for submission for publication. For example,
Elsevier, the publisher of Clinical Radiology,
provide guidance for submitting images
electronically
(http://authors.elsevier.com/
ArtworkInstructions.html?dcZAI1) the TIFF format
is a preferred option. The most commonly used file
formats in radiology are compared in Table 1.

Proprietary DICOM viewers

Proprietary DICOM viewers tend to be written by
the manufacturers of and supplied with medical
imaging hardware, e.g., Advantage Workstation
produced by General Electric Healthcare (Chalfont
St Giles, UK). These dedicated workstations allow
dynamic scrolling through stacks of images and
many advanced functions, such as multiplanar
reconstruction and three-dimensional volume rendering (Fig. 3). There is usually the ability to export
images to portable storage media (e.g., CD-R) or to
transfer images to other networked workstations.
Exported files are typically converted by the
proprietary software to smaller files (e.g., JPEG or
PNG) that can then viewed on a PC without any
special software. Once the DICOM images have been
converted to other file formats the ability to view
consecutive images from a series, as an interactive
stack is lost. The downside is that workstations are
often in constant use in radiology departments,
particularly in those that do not yet have PACS
installed and little time is available to use these for
image manipulation purposes or for use in teaching.
The use of third-party DICOM-viewing software can
ameliorate this problem.

DICOM-viewing software
Third-party software
All of the image file types described above can
easily be opened and viewed on a standard personal
computer (PC) with a contemporary operating
system such as Windows XP (Microsoft, Redmond,
WA, USA) without the need for any special software. By contrast DICOM images require additional
software to be installed before they can be opened
and viewed. DICOM-viewing software falls into two
main categories: Proprietary viewers, which are
supplied with imaging systems such as CT or
magnetic resonance imaging (MRI) machines; and
third-party DICOM-viewing software, either in the
form of PACS or as a stand-alone viewer for
individual PCs.
Table 1
formats.

There are a number of stand-alone DICOM-viewing

packages that are commercially available. Probably
the best known of these is eFilm (Merge eFilm,
Milwaukee, WI, USA, available at: http://www.
merge-efilm.com/products/efilmworkstation.asp)
which has many advanced features and was, until

Comparison of lossy and lossless image file

File type

Compression
method

Most suitable uses

JPEG
TIFF

PowerPoint and website images

Publications

PNG

Lossy
Lossy or
lossless
Lossless

JPEG 2000
GIF

Lossless
Lossless

Publications, teaching files and

website images
Publications and teaching files
Website images

Figure 3 Screenshot from an example proprietary

DICOM-viewing software package: GE Healthcare Advantage Windows workstation.

DICOM demystified

1137

relatively recently available free of charge (Fig. 4).

This is no longer the case, and the current version is
relatively expensive (Version 2.0.1 single licence
costs $2500). Fortunately there are a number of
free DICOM viewers that can be downloaded from
the internet. These are of variable quality and other
authors have reviewed a large number of the
available resources.10,11 Good examples of free
DICOM viewing software for use on individual PCs
include Osiris (University Hospital of Geneva,
Switzerland, available at: http://www.sim.hcuge.
ch/osiris/01_Osiris_Presentation_EN.htm) and
Dicom Works (Developed by Phillipe Puech & Loic
Boussel, available at: http://dicom.online.fr/;
Fig. 5). Free DICOM software is also available for
use on Apple Mac computers and Osirix (Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, CA,
USA, available at: http://homepage.mac.com/
rossetantoine/osirix/) is probably the best example
(Fig. 6). All these programs have full DICOM
functionality and allow individual or stacked images
to be viewed and manipulated. A comparison of the
main features of these example software packages
is provided in Table 2.
DICOM images can also be exported into Microsoft PowerPoint using a special plug in which can be
downloaded, free of charge, from the internet
(University of Toronto Medical Faculty, Toronto,
Canada, available at: http://www.radfiler.com/
dicomppt.htm). A future article in this series will
explore advanced uses of PowerPoint (Microsoft),
including how to incorporate DICOM images into
presentations.
Figure 5 Screenshots from example freely available
DICOM viewers for PCs: (a) Osiris and (b) Dicom Works.

Figure 4 Screenshot from an example commercially

available DICOM viewer: Merge E-Film.

Figure 6 Screenshot from an example freely available

DICOM viewer for Mac computers: Osirix.

1138

R.N.J. Graham et al.

Editing exported images

After choosing which images to export it is often
necessary to anonymize them. If images are for use
in teaching or for publication this may be essential
to comply with the Data Protection Act. The Royal
College of Radiologists have produced a document,
The Data Protection Act 1998Practical Implications12 that provides further guidance in this
area. Removing the overlay containing patient
demographic information on the image before
export can anonymize images. Most DICOM viewers
are able to do this, including the ones reviewed
above. Exported image files can be imported into
photo-editing software such as Adobe Photoshop
(Adobe, San Jose, CA, USA, available at: http://
www.adobe.co.uk/products/photoshop/main.html)
or Irfanview (Developed by Irfan Skiljan, available
at: www.irfanview.com) for further manipulation
(Fig. 7). Adobe Photoshop is the industry standard
desktop digital imaging package with extensive
image editing features but is relatively expensive
(w540). Adobe also produce Photoshop Elements
(available at: http://www.adobe.co.uk/products/
photoshopelwin/main.html) which has much of the
features of the more expensive product apart from
some of the high-end professional editing functions
and is available at a fraction of the cost (49.99).
Irfanview, whilst less comprehensive, has most of
the basic image editing functions that a radiologist
will need and can be downloaded from the internet
free of charge.
Once an image has been imported into editing
software, cropping so that only the region of
interest is displayed can reduce the size of the
file. Cropping can also be used to remove any
patient identifiers from the image. Altering the
colour depth of the image can further reduce the
file size. Saving a grey-scale image as an 8 bit grey
scale rather than as a 24-bit colour image will
decrease the file size by a factor of three without
degrading the image.
Often it is advantageous to place arrows on
radiological images for presentations or publications. This can be done with ease in presentation
packages such as Microsoft PowerPoint. The image
Table 2

Figure 7 Screenshot from an example freely available

image editing software package: Irfanview.

is imported into the presentation and arrows can

easily be added as an overlay using the arrow tool
from the draw toolbar. Arrows added in this manner
do not alter the underlying image, so if the image is
exported from PowerPoint it will be saved without
any of the modifications. Photo-editing packages
allow arrows or text to be added in so-called
layers. Each layer is like an overlay on the image
and individual arrows or items of text can be altered
or deleted independently of each other. When the
modified image is saved, the layers can be merged
or kept separate. The advantage of keeping layers
separate is that further manipulation can be
performed at a later date; the file size is increased
as a result. There are a vast number of other
features within Adobe Photoshop, for example
altering image contrast and brightness, rotating
images, masking unwanted annotations and conversion from one image format to another. Many
other image editing functions of use to radiologists
are detailed in a number of articles.1318

Image manipulation for clinical meetings

or teaching purposes
Before the widespread introduction of PACS into
radiological departments, remote DICOM image display in clinico-radiological meetings and for teaching
purposes was a technical challenge. Many proprietary

Comparative features of stand-alone DICOM viewing packages.

Feature

Osiris

DicomWorks

Osirix

eFilm

Export images as TIFF or JPEG

View two series linked together
Multiplanar reformating
Windowing of images
Measurement tools

Yes
No
Yes
Yes
Yes

Yes
Yes
No
Yes
Yes

Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes

DICOM demystified

workstations allow export of DICOM images to a CD-R

along with a rudimentary DICOM viewer. The
exported images can then be displayed on most PCs
and use a Java-enabled web browser such as Internet
Explorer (Microsoft) to display the images. However,
these web viewers tend not to have many image
manipulation or calibration features. Alternative
methods of digital image display either require
time-consuming manual transfer of images from
workstations using portable storage media, or if
available, direct electronic transmission via the local
network to a dedicated PC for viewing.
Any PC with sufficient memory and processing
power can receive DICOM images if appropriate
software is installed. Whilst DICOM receiving software is incorporated into commercial viewing
packages, there are freely available DICOM receiving programs on the internet, which can be downloaded and installed such as SimpleDICOM
(University of Pittsburgh Medical Centre, PA, USA,
available at: http://www.radiology.upmc.edu/
Public/public_resources/software/index.html)
(Fig. 8). This package is both a DICOM viewer and
receiver, which can be installed together or
individually. It is possible to use the SimpleDICOM
receiver with a different DICOM viewing program
such as one of those mentioned above. Setting up a
DICOM receiver on a PC, while relatively simple,
may require technical input from the local network
manager to help configure the system correctly.
Once the method of image transfer has been
decided the next step is to choose how to display
digital images at meetings or teaching sessions. In
the absence of PACS there are several options. The
first option is to transfer images in DICOM format to
a laptop or PC with a DICOM viewer installed on it.
Images can then be displayed via a digital projector
and the DICOM stacks viewed rather like on a
workstation. The advantage with this method is

1139

that all the images are available for review and can
be windowed and reformatted (if supported by the
DICOM viewer) during the meeting.
Another option is to select specific images that
demonstrate the salient information and export
them as JPEG or TIFF files. This is a time-consuming
process but is useful when preparing presentations
for teaching. The easiest way to present these
images is by importing them into a presentation
package such as Microsoft PowerPoint. Clinical
cases can easily be made into slides with relevant
case history and images inserted. This method can
be used by trainees to prepare cases for departmental meetings. The presentations could subsequently be used as teaching resources as part of
a digital image library. The development of a digital
teaching file has been discussed in a previous article
in this series.19

Conversion of image file formats

Image file types may be converted from one type to
another without even viewing them. Irfanview has a
very easy to use file conversion function. It allows
conversion of most types of image file and will
convert whole DICOM stacks to another image file
format.

Conclusion
The advent of the DICOM file format has been a
major step forward in clinical radiology by allowing
digital images to be easily stored and transferred
electronically. Digital images can be manipulated in
many ways and converted to different formats for
teaching and publication purposes. We have outlined a variety of ways in which radiologists may
utilize digital images and how to make the most of
the capabilities of DICOM before the introduction of
PACS.

References

Figure 8 Screenshot from an example freely available

DICOM receiver: SimpleDICOM.

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