title: Objective criteria for acceptability and constancy tests of digital subtraction angiography.
abstract: OBJECTIVE
  Demonstrate an objective procedure to quantify image quality in digital subtraction angiography (DSA) and suggest thresholds for acceptability and constancy tests.
  
  
  METHODS
  Series of images were obtained in a DSA system simulating a small (paediatric) and a large patient using the dynamic phantom described in the IEC and DIN standards for acceptance tests of DSA equipment. Image quality was quantified using measurements of contrast-to-noise ratio (CNR). Overall scores combining the CNR of 10-100 mg/ml Iodine at a vascular diameter of 1-4 mm in a homogeneous background were defined. Phantom entrance surface air kerma (Ka,e) was measured with an ionisation chamber.
  
  
  RESULTS
  The visibility of a low-contrast vessel in DSA images has been identified with a CNR value of 0.50 ± 0.03. Despite using 14 times more Ka,e (8.85 vs 0.63 mGy/image), the protocol for large patients showed a decrease in the overall score CNRsum of 67% (4.21 ± 0.06 vs 2.10 ± 0.05). The uncertainty in the results of the objective method was below 5%.
  
  
  CONCLUSIONS
  Objective evaluation of DSA images using CNR is feasible with dedicated phantom measurements. An objective methodology has been suggested for acceptance tests compliant with the IEC/DIN standards. The defined overall scores can serve to fix a reproducible baseline for constancy tests, as well as to study the device stability within one acquisition series and compare different imaging protocols. This work provides aspects that have not been included in the recent European guidelines on Criteria for Acceptability of Medical Radiological Equipment.
authors.affiliation: Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), c. Profesor Martín Lagos, S/N, 28040 Madrid, Spain. Electronic address: hugo.heras@daad-alumni.de.
authors.forename: Hugo
authors.initials: H
authors.lastname: de las Heras
authors.affiliation: Servicio de Radiofísica y Protección Radiológica. Hospital Universitario Río Hortega, c/ Dulzaina, 2, 47012 Valladolid, Spain.
authors.forename: Ricardo
authors.initials: R
authors.lastname: Torres
authors.affiliation: Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), c. Profesor Martín Lagos, S/N, 28040 Madrid, Spain; Departamento de Radiología, Facultad de Medicina, Universidad Complutense, Avda. Complutense s/n, 28040 Madrid, Spain.
authors.forename: José Miguel
authors.initials: JM
authors.lastname: Fernández-Soto
authors.affiliation: Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), c. Profesor Martín Lagos, S/N, 28040 Madrid, Spain; Departamento de Radiología, Facultad de Medicina, Universidad Complutense, Avda. Complutense s/n, 28040 Madrid, Spain.
authors.forename: Eliseo
authors.initials: E
authors.lastname: Vañó
mesh_terms: D000328:Adult; D000388:Air; D000465:Algorithms; D015901:Angiography, Digital Subtraction / Q000379:methods* / Q000592:standards*; D002648:Child; D003287:Contrast Media; D004867:Equipment Design; D005471:Fluoroscopy / Q000295:instrumentation / Q000379:methods; D006801:Humans; D008962:Models, Theoretical; D015588:Observer Variation; D019047:Phantoms, Imaging; D011786:Quality Control; D011829:Radiation Dosage; D015203:Reproducibility of Results; D012542:Scattering, Radiation; D059629:Signal-To-Noise Ratio
chemical_list: D003287:Contrast Media
keywords: Digital subtraction angiography; Quality control; Radiation dose; Radiologic phantom