SEMI-AUTOMATIC CORONARY ARTERY CENTERLINE EXTRACTION IN COMPUTED TOMOGRAPHY ANGIOGRAPHY DATA Coert Metz1 , Michiel Schaap1, Alina van

der Giessen2, Theo van Walsum1, Wiro Niessen1

1

Departments of Radiology and Medical Informatics 2 Department of Biomedical Engineering Erasmus MC - University Medical Center Rotterdam E-mail: c.metz@erasmusmc.nl
* Both authors contributed equally to this paper

ABSTRACT This paper presents a semi-automatic coronary centerline extraction algorithm for computed tomography angiography data. The method applies region growing to computed tomography angiography data and incorporates bifurcation and leak detection. The presented method is evaluated either on the original data and on data in which vessel-like structures have been enhanced. Semiautomatically extracted centerlines of the three main coronary arteries are compared with centerlines manually annotated by three observers, using an overlap and distance measure. The method successfully extracted vessel centerlines in up to 15 out of 18 evaluated cases, with a localization accuracy which was in the range of the interobserver variability. Vessel enhancement prior to centerline extraction did not improve the results. Index Terms coronary arteries, computed tomography angiography, vessel enhancement, centerline extraction, quantitative evaluation 1. INTRODUCTION Vessel centerline extraction is a useful image processing technique, which can be used for constructing application specic vessel visualization and as a rst step towards quantitative vascular image analysis. The most notable example is vessel stenosis evaluation and grading in multiplanar reformatted images [1]. A number of authors have presented techniques for vessel axis tracking, see e.g. Aylward and Bullit [2] and Wink et al. [3], and have successfully applied these methods to carotic, iliac, pulmonary, brain, portal and hepatic vessels. Automatic tracking of the coronaries in 3D computed tomography angiography (CTA) has proven more challenging, owing to the limited image resolution relative to the size of the coronaries, the presence of pathologies, such as severe stenoses and calcications, motion artifacts, and the proximity of other enhancing structures such as the aorta and the heart. In this paper we introduce a region growing based method for coronary vessel centerline extraction. The contribution of our paper is threefold. First, the region growing method includes branch and leak detection, in order to segment multiple coronary segments with a single seed point, and to limit leakage into the aorta and non-vascular structures. Second, it is investigated whether vessel enhancement prior to centerline extraction improves the results. Hereto, a recently introduced technique, coined vessel enhancing diusion (VED) [4], is applied. To the best of our knowledge, VED has not been evaluated on its potential to improve the performance of vessel centerline extraction. Third, the

method is quantitatively evaluated by comparing semi-automatically extracted vessel centerlines with centerlines that were manually annotated by three observers using an overlap and distance measure. 2. METHOD 2.1. Vessel enhancing diusion The vessel centerline extraction algorithm is applied both to the original image data, and to data preprocessed with VED. Manniesing et al. [4] propose a smoothed version V of the multiscale vessel lter dened by Frangi et al. [5] to tune a non-linear anisotropic diusion scheme such that vascular structures are enhanced in the image. The diusion tensor D, which is used in the diusion equation t u = (Du) [6], is dened as D Q QT (1)

with Q the eigenvectors of the Hessian matrix H corresponding to the scale for which the vesselness response is maximal and having the following functions on its diagonal 1 = 2 3 1 + ( 1) V
1 s

(2)
1

1 + ( 1) V s .

(3)

Parameter indicates the strength of anisotropic diusion, ensures the positive deniteness of the tensor and s denotes the sensitivity to the vesselness response. For non-vessel structures (V goes to zero) diusion is high and isotropic, and background noise is reduced, whereas for vessel structures (V goes to one) diusion is maximal () along the vessel. Two examples of VED processed coronary CTA data are shown in Figure 1. 2.2. Vessel centerline extraction Centerline extraction is achieved via region growing based segmentation and subsequent path extraction. Starting from a user-dened seed point, region growing iteratively adds neighboring voxels within a pre-dened greyscale range to the segmentation. The algorithm keeps track of vessel bifurcations by performing connected component analysis after every two region grow iterations on the voxels added to the segmentation in these two iterations. If these voxels are not connected, a bifurcation has been detected, but if these voxels are connected, it is assumed that no vessel bifurcation is present (see Figure 2). This procedure results in a

(a)

(b)

(c)

(d) (a) (b)

Fig. 1. Unprocessed coronary CTA data (a, c) and VED ltered equivalents (b, d).

Fig. 3. Path construction. A segmentation is constructed by region growing from a user-dened seedpoint s1 , light grey in (a). The skeleton of this segmentation is created by thinning, black in (a). Points in the thinned segmentation closest to the user-dened points (s1 , s2 ) are automatically selected and the centerline is dened by the longest possible path with minimal Euclidian length through these points and the thinned tree. In this example, the resulting path is path P from s1 to f , which is displayed in (b).

(a)

(b)

data are 0.3x0.3x0.4mm3 . Six of these data sets are used for optimization of the region growing parameters and six are used for the evaluation.

Fig. 2. Bifurcation detection. Region growing is started from seed point s. Voxels added in the last two region grow iterations are marked with N, N1 and N2 . Voxels added in the two previous region grow iterations are marked with P. If the voxels in N are connected, it is assumed that the vessel does not bifurcate. In the case of a bifurcation, voxels in N1 and N2 are not connected.

3.2. Evaluation method The semi-automatic centerline extraction algorithm is evaluated by comparing the extracted centerlines of the three main coronary arteries, namely the right coronary artery (RCA), left anterior descending (LAD) and left circumex (LCX), with manually annotated centerlines. Furthermore, semi-automatically extracted centerlines are compared with centerlines resulting from the presented method without VED preprocessing. The vessel centerline for manual annotation is dened as the center of the lumen. Three trained observers annotated these centerlines in two steps. In the rst step vessel points were annotated globally using axial, sagittal and coronal views of the data. In the second step the locations of these points were improved locally using multiplanar reformats orthogonal to the initial annotated path. In order to dene the interobserver variability and the accuracy of the semi-automatic centerline extraction method, two distance measures are dened: the similarity index and the mean distance. First, a third order spline is tted between each pair of neighboring points of the centerlines, which is subsequently sampled very densely (0.03mm). CTP is dened as the parts of centerline Ci that ij have corresponding points in centerline Cj , CFP as the parts of cenij terline Cj that do not have corresponding points in centerline Ci and CFN as the parts of centerline Ci that do not have overlap with cenij terline Cj (see Figure 4). The sum and mean of minimal Euclidian distances between cor responding points on CTP are dened as sdij and did . The similarity ij index between centerlines Ci and Cj (SIij ) is used as a measure for

tree representation of the segmented vasculature. To prevent leaking into the aorta or non-vascular structures during region growing, a threshold is imposed on the number of voxels that may be added to a vessel tree segment every two region grow iterations. When this threshold is exceeded, the corresponding segment is deleted from the segmentation. The coronary path is extracted by applying six sub-iteration thinning [7] to the segmented vessel tree. The user can subsequently interactively dene vessel segments by selecting a second point in this thinned tree. The corresponding centerline is dened by the longest path with minimal Euclidain length through the second point and the thinning result, see Figure 3. Resulting centerlines are smoothed with a Gaussian kernel ( = 1mm). 3. EXPERIMENTS 3.1. Data Twelve CTA data sets of patients who were referred for coronary intervention were randomly selected. Retrospectively ECG gated CTA scans were acquired in the Erasmus MC, Rotterdam with a Siemens R Sensation 64 scanner. Mean voxel sizes of the reconstructed CTA

100

80 Similarity index (%)

60

Fig. 4. Similarity index: the part of centerline (Ci ) that does not have overlap with centerline (Cj ) is marked as false negative (FN). The part in Ci that has overlap with Cj is marked as true positive (TP) and the part in Cj that has no overlap with centerline Ci is marked as false positive (FP). the amount of overlap SIij = 2|CTP | ij |CFP | ij + |CFN | ij + 2|CTP | ij 100%. (4)

40

20

0 Unfil. Fil. Int. LAD Unfil. Fil. Int. LCX Unfil. Fil. Int. RCA

The distance from a semi-automatically extracted centerline c to the manually annotated centerlines of the three observers is dened as Dc =
3 i sdic . 3 TP i |Cic |

Fig. 5. Mean similarity indices per subject for LAD, LCX and RCA on unltered and ltered data next to the interobserver variability. The six subjects are indicated by dierent symbols. Vessel LAD LCX RCA Unltered SIc , Dc 73%, 0.48 79%, 0.49 78%, 0.40 VED ltered SIc , Dc 70%, 0.42 80%, 0.49 77%, 0.34 Interobserver SIi , ID 90%, 0.40 74%, 0.55 88%, 0.36

(5)

and the mean similarity index SIc for a semi-automatically extracted centerline c with respect to the manually annotated centerlines as the mean of the three similarity indices. The interobserver variability is expressed in the interobserver distance 3 3 i j:j i sdij (6) ID = 3 3 TP i j:j i |Cij | and the mean of the six similarity indices between the manually an notated centerlines of the three observers (SIi ). 3.3. Parameters All VED parameters, except for the scale settings, were set to those reported by Manniesing et al. [4]. For the multiscale vessel response lter = = 0.5, = 5, c = 106 , min = 0.5 mm, max = 3.0 mm, with 5 dierent scales, exponentially distributed between min and max . Diusion is performed with = 25 and s = 5.0 (Eq. 2 and 3), and time step t = 103 . The leak detection parameter of the region grow procedure was set to 3000 voxels. This setting prevented leaking into the aorta and non-vascular structures. The threshold values (tmin , tmax ) for the region growing were determined by exhaustive parameter optimization. Centerlines for six training datasets, dierent from the datasets used during the evaluation phase, were manually annotated by two observers, each observer annotating centerlines for three datasets. The presented semi-automatic coronary centerline extraction algorithm was applied to these datasets using threshold values in the range [150-880] HU. Threshold values that maximized the similarity index were used for the evaluation experiment. Optimization was carried out separately for ltered and unltered data. The resulting lower bound values were 181 and 201 HU for respectively unprocessed and VED ltered data. The upper bound value was 876 HU for both unprocessed and ltered data. 4. RESULTS Figure 6 shows a typical example of manually annotated centerlines and the centerline resulting from our semi-automatic extraction.

Table 1. Average overlap (SIc ) and mean distance (Dc in mm) between successfully semi-automatically extracted and manually annotated centerlines for LAD, LCX and RCA.

Mean similarity indices per subject for semi-automatically extracted centerlines of the RCA, LCX and LAD in comparison with manual annotated centerlines are shown in Figure 5. For compari son, the interobserver similarity indices (SIi ) are also included in this gure. According to a paired Students t-test the results of the presented method are not signicantly dierent with or without VED preprocessing (P=0.29 for the similarity index and P=0.43 for the distances). Observations revealed that the semi-automatic centerline extraction algorithm found the proximal part of the vessels in 14 out of 18 evaluated cases when using VED as preprocessing step, and 15 out of 18 cases without VED ltering. The failed centerline extractions were caused by early leaking into parts of the heart due to the presence of stents or signicant calcications. Comparison with the evaluation results showed that the SI values of these failed center lines are 50% or lower. Only subjects with SI > 50% on both unltered and ltered data were taken into account in the average SI and mean distance values, which are shown in table 1. 5. DISCUSSION AND CONCLUSION A region growing based method for coronary artery vessel centerline extraction has been presented, which incorporates bifurcation and leak detection. Furthermore, the additional value of vessel enhancing diusion as a preprocessing step has been evaluated. Vessel centerlines were successfully extracted in 14 or 15 out of 18 evaluated cases when respectively using vessel enhanced or unprocessed data. For these successfully extracted centerlines the over-

Attention should also be paid to the leak detection method which can fail for small leakages. In order to solve problems caused by contrast dierences between dierent datasets we will investigate if the region growing step can be improved by taking, next to intensity information using xed threshold values, rst and second order dierential structure of the image into account. In conclusion, the presented method is promising for automatic vessel analysis and VED preprocessing with parameter settings proposed by Manniesing et al. [4] does not improve the extraction results for this application. 6. REFERENCES [1] C. Caussin et al., Comparison of coronary minimal lumen area quantication by sixty-four-slice computed tomography versus intravascular ultrasound for intermediate stenosis., Am. J. Cardiol., vol. 98, no. 7, pp. 871876, 2006. [2] S.R. Aylward and E. Bullitt, Initialization, noise, singularities, and scale in height ridge traversal for tubular object centerline extraction, IEEE Trans. Med. Img., vol. 21, no. 2, pp. 6175, 2002. [3] O. Wink, W.J. Niessen, and M.A. Viergever, Multiscale vessel tracking, IEEE Trans. Med. Img., vol. 23, no. 1, pp. 130133, 2004. [4] R. Manniesing, M.A. Viergever, and W.J. Niessen, Vessel Enhancing Diusion - A Scale Space Representation of Vessel Structures, Med. Image Anal., 2006. [5] A.F. Frangi, W.J. Niessen, K.L. Vincken, and M.A. Viergever, Muliscale Vessel Enhancement Filtering, in Proc. of MICCAI, 1998, pp. 130137. [6] J. Weickert, Anisotropic diusion in image processing, Ph.D. thesis, Dept. of Mathematics, University of Kaiserslautern, Germany, 1996. [7] K. Palagyi and A. Kuba, A 3d 6-subiteration thinning algorithm for extracting medial lines, Pattern Recogn. Lett., vol. 19, no. 7, pp. 613627, 1998.

Fig. 6. Example of manually annotated (colors) and semiautomatically extracted (white) centerlines overlayed on a maximum intensity projection.

lap and mean distance between semi-automatically extracted and manually annotated centerlines is close to the interobserver variability. Furthermore, VED did not signicantly change the overlap or distance between semi-automatically extracted and manually annotated centerlines. The additional failure when using VED happened in subject 5 and was caused by an early leak at the location of a stent in the image. Due to this stent the response of the vesselness lter is lower, leading to relatively more isotropic diusion in the vessel neigborhood. The VED settings used were directly taken from the work of Manniesing et al. [4] and therefore might not be appropriate for coronary arteries. In future work we will investigate whether optimizing the VED parameters improves the performance of the extraction algorithm.