SIViP (2008) 2:183–193
DOI 10.1007/s11760-007-0048-x
ORIGINAL PAPER
Non-invasive evaluation of carotid artery wall thickness
using improved dynamic programming technique
N. Santhiyakumari · M. Madheswaran
Received: 18 May 2007 / Revised: 6 December 2007 / Accepted: 6 December 2007 / Published online: 8 January 2008
© Springer-Verlag London Limited 2007
Abstract An improved dynamic programming (DP)
segmentation technique for detecting the intima-media layer
of the far wall of the common carotid artery (CCA) of longi-
tudinal and transversal ultrasound (US) images using optimal
search technique is presented here. The algorithm is devel-
oped considering the normalization and smoothing for esti-
mating the intima media thickness (IMT) of the normal and
abnormal subjects. The segmentation features of different
subjects obtained using the proposed technique have been
compared with the manual measurements. The results show
that an inter-observer error and a coefficient of variation are
found as ±0.035 mm and 3.55%, respectively. The magni-
tudes of the IMT values have been used to explore the rate
of prediction of blockage existing in the cerebrovascular
and cardiovascular pathologies, and also hypertension and
atherosclerosis.
Keywords B-mode ultrasound (US) image · Common
carotid artery (CCA) · Dynamic programming (DP) ·
Intima-media thickness (IMT) · Atherosclerosis
N. Santhiyakumari
Department of ECE, K.S.R.College of Technology,
Tiruchengode 637209, India
e-mail: santhiyarajee@rediffmail.com
M. Madheswaran (B)
Center for Advanced Research,
Department of Electronics and Communication Engineering,
Muthayammal Engineering College, Rasipuram 637 408,
Tamilnadu, India
e-mail: madheswaran.dr@gmail.com
1 Introduction
In recent years, the non-invasive B-mode ultrasound images
have been used for measuring various parameters to diag-
nose the cardiovascular pathologies [14]. In clinical practice,
Intima media thickness (IMT) of arteria carotis is considered
to be an important parameter to diagnose the atherosclerotic
disease [24]. Non-invasive B-mode imaging is used for study-
ing the progress and regress of atherosclerotic lesions in the
carotid artery [28]. Importantly, increased IMT is demon-
strated to have a strong correlation with the presence of ath-
erosclerosis elsewhere in the body. This may hence be used
as a descriptive index of individual atherosclerosis [17]. The
disease changes the thickness of layers that affect the normal
flow of blood in the artery. This change in the layer thick-
ness (such as stenosis or plaques) represents a risk index
for several pathologies like acute stroke or cardiac infarction
and cardiovascular events [3,20]. Increased common carotid
artery (CCA) IMT due to obesity [12,15,19] is an important
prediction parameter of coronary artery disease and stroke.
Clinically acquired B-mode images frequently have weak
echoes, echo dropouts and speckle noises. Hence, analysis of
such images becomes complex when conventional boundary
detection techniques are used [5,6]. The major limitation of
the analysis is the inability to distinguish the intimal from the
medial layers. It is well known that an increased thickness of
the CCA wall is correlated with a higher incidence of cardio-
vascular and cerebrovascular acute events [12,21]. Presence
of carotid plaques and increased cross-sectional IMT in the
CCA are the best parameters for predicting the myocardial
hyperfusion [16,23,25].
The use of ultrasound in the diagnosis and assessment
of carotid disease is well established because of its non-
invasive nature and the continuing improvement in image
quality [2]. However in practice, the detection of the
123
184
boundaries of the intima-media complex (IMC) is often
complicated and hindered by the presence of artifacts in
ultrasound images which make IMT measurements difficult.
Measurements are further complicated as the age of the
patient increases, due to the presence of acoustic holes in the
adventitia layer [30]. The alterations in the layer thickness
represent arterial diameter variations in the CCA. Certain
amount of mathematical interpretation is needed to estimate
the variations as the clinically acquired images are unclear
[8,10].
Generally, IMT is measured by the skilled operators based
on their experience gained from various subjects, just by
fixing the markers on the image. This leads to difference
in the IMT measurements done by the intra-observer and
inter-observer as normally reported [29]. This methodology
is highly user-dependent and creates problem when a large
image database is used. More features of the artery wall
need to be analyzed for a single patient because the oper-
ator-based methodology is not fully reliable. Several auto-
matic algorithms have been proposed by many researchers
worldwide to avoid the manual IMT and manual segmenta-
tion of CCA [7]. Some of the available techniques in this
area need the radiologists to select the region of interest,
and few others require them to select the point to start the
segmentation in horizontal and vertical positions [11]. In
either case, a radiologist is needed, as such segmentation
leads to a bias in the results. This may happen when the
starting point for the patients with abnormalities (such as
stenosis or plaques) is located in a wrong manner due to
human error.
A wide variety of algorithms for the carotid artery wall
segmentation have been proposed, but they require a cer-
tain degree of manual adjustments in fixing the markers in
the artery walls. In recent past, attempts have been made
to analyze the US arterial images [7,11,29]. Touboul et al.
[26] have performed the measurement on arterial segments
and reported that the intensity profile has two pulse pat-
terns which corresponds to echoes from the lumen–intima
and media–adventitia interfaces. The region of interest has
been assigned employing a user-friendly software. Later,
Gariepy et al. [9] have measured the lumen diameter and
IMT with the help of a trained radiologist using computer.
The position of the wall is traced by the operator and then
the software locates the layers by keeping the variations in
the intensity levels. On the other hand, Selzer et al. [23]
have approximated the locations of the interesting contours
obtained from manual tracing methods. The contour con-
tinuity is estimated to remove the non-edge portion of the
layer considering the maximum intensity gradient criteria.
The IMT is evaluated from the average distance between
the pixels considered. Barrett and Mortensen [1] have com-
puted the optimal boundaries for the region of interest by
graph search algorithm. The seed point for the region
123
SIViP (2008) 2:183–193
was specified by the interactive user, namely a trained
radiologist and an experienced system operator. Thus, the
involvement of the operator for settings during the initial-
ization process leads to inconsistency in the region due to
subjective decisions by the operators. Liang et al. [18] had
stated that the Dynamic programming procedure can be used
to detect the boundaries of the artery considering the approx-
imate location of vessel wall interfaces using optimality
principle.
The authors in their earlier work have proposed a method
[22] to segment the near wall of the CCA using DP method,
and region of interest (ROI) was selected manually. The IMT
was also measured only for a single subject. In the present
work automatic selection of ROI, and 100 subjects have been
considered. The DP algorithm is an optimization of the cost
function by finding optimal polyline, corresponding to artery
boundary. It also utilizes intensity normalization and smooth-
ing in US images of the carotid artery trying to overcome
the earlier difficulties discussed [11,14]. Generally, the DP
method has very high correlation with the manual measure-
ments, and it has very minute variation in the statistical values
as compared with the sonographer measurements. In view of
this, an attempt has been made to improve the initialization
of the horizontal and vertical positions of the vessel walls
based on automatic ROI using intensity profile as applied to
CCA images.
2 Methods
2.1 Anatomical structure of Arteria - Carotis
The CCA wall consists of three different layers namely an
internal tunica (intima), thick layer of transversal muscu-
lar tissues (media), and external and more connective layer
(adventitia) [20]. The IMT is correlated with an augmented
risk of severe pathologies. Hence, the analysis of the CCA
layers is of importance for an effective evaluation of a patient.
Near and far walls can be visualized on B-mode scanning, but
B-mode evaluation of the near wall is less reliable than the far
wall because far wall has better reflections (high intensity on
the image). This is due to the acoustics impedance sequence
of the lumen–intima–media–adventitia interface. It has been
shown that the measurement of far wall intima media thick-
ness is reflected by the distance between two edges. Figure 1a
shows a carotid artery image and Fig. 1b shows a schematic
illustration of echo zones (Z1–Z7) and relevant vessel inter-
faces (I2,I3,I5,I6) of the near wall and far wall. IMT is defined
as the distance between the leading edge of the first echogenic
line (lumen–intima interface) and the second echogenic line
(media–adventitia interface) of the arterial wall [20] i.e., I2
and I3 for the near wall and I5 and I7 for the far wall [14].
Lumen Diameter (LD) is the distance between I3 and I5.
SIViP (2008) 2:183–193
Fig. 1 a Definition of echo zones and interfaces. b. Longitudinal view
of CCA and carotid bifurcation and the double arrow line corresponds
to the end of the CCA, where near and far walls start diverging
2.2 Improved dynamic programming algorithm
implementation
DP algorithm for segmentation of the US images is given,
Step 1: Image acquisition using ultrasound system.
Step 2: Identification of the region of interest.
Step 3: Intensity normalization using average intensity
histogram.
Step 4: Horizontal smooth filtering to remove echo drop-
outs in US images.
Step 5: Blurring to locate the vessel interfaces.
Step 6: Determination of the Cost function for each point
in the polylines of identified region.
Step 7: Estimation of the boundaries by optimizing the
cost function.
Step 8: Measurement of the distance between the intimal
and medial layers of the far wall of identified region of the
image.
Step 9: Evaluation the IMT of various subjects.
2.3 Image acquisition
Aloka Prosound Alpha -10 (SSD α -10, Model No-M00720
Japan) ultrasound scanner with a high resolution and dig-
ital beam former with ultimate compound technology has
been used for the data acquisition of the images. The built-in
compound pulse wave generator optimizes the contrast and
obtains an enhanced focus and spatial resolution. A multifre-
quency linear transducer with a frequency range of 5–10 MHz
185
has been used for recording the arterial movements. The
transducer is operated at a frequency of 7.5 MHz to obtain the
arterial movements and the movements are recorded using a
video recorder. One can identify the exact transducer position
(at right angles to adventitia) by placing at different inclined
angles. The video is recorded for a period of 10 s for each
subject to show the transverse and longitudinal sections of
the CCA. To obtain an uniform lumen for different subjects
the transducer is placed exactly at the starting point of the
bifurcation of CCA. Thus, the left end of the image indi-
cates the starting point of bifurcation. The recorded video
is converted into frames employing OSS video decompiler.
The converted frames are stored as still images in a PC for
further processing. Thus, the above images have been used
to measure the IMT of CCA employing improved DP tech-
nique. In order to obtain the natural flow of lumen during
systolic and diastolic pressure, the video has been recorded
for 10 s. The still images obtained from 10 s video consist
of approximately 180 frames which reflect the changes in
the magnitude of vascular wall during systolic and diastolic
operations. Therefore, the IMT has been measured in all 180
images, and the average value has been used for further anal-
ysis. IMT measurements have been carried out at 30 points
from the identified region of the far wall CCA.
2.4 Identification of the region of interest (ROI)
The procedure is devised to have less operator dependence.
The first stage of the algorithm is the identification of the
portion of the image where the CCA region is located. Param-
eters pertaining to the vessel lumen and the adventitia have
been considered to identify CCA region correctly. The lumen
is characterized by low-intensity pixels and relatively low
variance (low US echoes of the blood cells and relative homo-
geneity of the medium) and surrounded by high-intensity
pixels belonging to the carotid walls. This feature is used
to identify the CCA region very precisely. Hence, for each
and every pixel in the image, the mean intensity and variance
are measured using N X N square neighborhood (N = 10
is utilized in this work). In CCA US vascular images, the
adventitia is characterized by a high value of pixel intensity
due to its higher acoustic impedance. This study searches for
high-intensity pixels belonging to the distal adventitial wall,
starting from the deepest imaged layers of the scan. The pixel
is considered as belonging to the adventitia if its intensity is
a local maximum and if atleast one pixel belonging to the
lumen is located above it.
The adventitial wall pixels are identified from the column-
wise intensity profile of the image to measure the IMT. The
pixels belonging to the entire adventitial layer are identi-
fied from the maximum intensity distribution (approximately
about 90%). Similarly the carotid lumen pixels are identified
from the minimum intensity distribution of the profile. The
123
186
Fig. 2 Flow graph for the identification of adventitia and lumen
steps used in the algorithm are shown in the flow graph in
Fig. 2. After finding the ROI the image is normalized.
2.5 Image normalization procedures
The identified image region has been preprocessed before
applying the DP procedure. Histogram of the image pro-
vides the contrast information and overall intensity distri-
bution. An intensity normalization procedure is carried out
by computing an average intensity histogram on the basis of
all the images, detecting its peak value, and then adjusting
each single image so that its histogram peak aligns to the
average histogram. Thus, the brightness of all pixels in the
image is readjusted according to the scale of the gray level
of the images ranging from 0 to 255. It is noted that the key
point to maintain high reproducibility is to ensure that the
ultrasound beam is at right angles to the adventitia. The nor-
malized image is further smoothed using 2 D median filter.
2.6 Filtering
Histogram equalization [13,27] helps in improving the con-
trast of the image without affecting the structure. While this
technique gives the output image with increased contrast, it
also causes an increase in the noise within the US image. In
this step, the images are smoothed horizontally to overcome
the difficulties of echo dropouts using the smoothing filter.
2D median filter (3 × 3 square filter) has been used prior to
boundary detection to reduce the amount of speckle noise in
the stack of 2D images [13,27]. This is preferred because it is
a very simple smoothing filter but at the same time preserves
the edges. After the filtering process the vessel interfaces is
located.
123
SIViP (2008) 2:183–193
2.7 Location of vessel interfaces
Initially, the horizontal start position of the CCA is defined
from the identified region of the image based on the intensity
profile after the preprocessing steps. In this step approximate
vertical location of the vessel interfaces are found by apply-
ing blurring [13,27]. 5 × 5 plus sign-shaped median filter is
used for blurring. This filter almost removes all of the impulse
noise and at the same time the corner pixels have not been
affected. This is done in order to get a sharp corner on the
wall. Finally the walls have been detected by applying an
improved dynamic programming procedure.
2.8 Intima–Media Complex Segmentation
The improved dynamic programming procedure implemen-
ted in this study is based on the optimization of the cost func-
tion as defined by Liang et al. [18]. In the previous work the
horizontal start position of vessel interfaces was defined by
the observer as stated in the papers [11,18]. In this work the
horizontal and vertical starting pixels of the vessel walls are
automatically obtained from the ROI using intensity profile.
Within the identified region close to the boundary searched
for, local measurements of echo intensity, edge strength and
boundary continuity are extracted and included as weighted
terms. The algorithm evaluates the boundary points which
forms a suitable path with minimum cost function.
2.9 The cost functions and cost terms
All the possible boundary lines in vessel interfaces I5 and
I7 of CCA images have been considered as polylines with N
vertices represented as
P = ( p1 , p2 , . . . , pi−1 , . . . , p N ) (1)
where pi−1 and pi are horizontal neighbors and N the hori-
zontal length of a contour line.
Cost function Csum which is defined as a sum of local costs
along this line has been used to determine a polyline to be an
exact boundary line. The minimization of the cost function
is used to determine the optimal polyline.


N
Csum = C( pi) (2)
i=1
The local cost C( pi ) is a weighted sum of cost components:
C( pi ) = W1 Cdiscont ( pi−1 , pi )−W2 Cint ( pi ) − W3 Cgrad ( pi )
(3)
where W1 , W2 , W3 are weighting factors. Cdiscont is the value
of polylines discontinuity (measure of smoothness), Cint the
average brightness below the tested pixel and Cgrad the value
of the intensity gradient (the rate of change of the intensity).
SIViP (2008) 2:183–193
The minimum local cost is calculated from the maximum
values of intensity gradient, brightness and proper continu-
ity in a line. The global minimum cost has been used to detect
the desired boundary.
The dynamic programming algorithm has been used to
estimate the optimal polyline corresponding to the CCA
boundary by optimizing the cost function. The cost function
is a weighted sum of echo intensity, intensity gradient and
boundary continuity of each pixel. The minimum cost func-
tion values have been used to estimate the boundary line.
Four major steps are utilized in this procedure. First step is
the determination of the maximum intensity cost i.e., Cint for
each pixel in the location considering the average brightness
of all the pixels in the column below to each pixel by uti-
lizing an intensity operator. It represents the echo intensity
below the interface, where the intensity is the normalized
average intensity of 8 pixels beneath pi . Second step is the
evaluation of the intensity gradient Cgrad for each pixel using
the gradient operator. It represents the intensity gradient in
the downward direction, where gradient is the normalized
value of vertical intensity slope of a rectangular 5 × 5 neigh-
borhood of the point pi . In this work, Laplacian operator
has been used to find the change in the intensity in a direc-
tion perpendicular to the line. Third step is the determination
of Cdiscont from the cost values of any of the pixels in the
previous column to each pixel of the column by consider-
ing the starting column with pixel in horizontal position. It
represents the boundary continuity, where continuity is the
change in the vertical distance between the boundary being
estimated and a smooth reference boundary which in case of
I7 is a horizontal line. This cost includes original intensity
plus gradient cost plus cost resulting from discontinuity plus
cost already accumulated in the previous column.
According to Eqs. (2) and (3), the cost function can be
expressed in the following form which leads to a state space
with M elements:


N

N
Csum = C 1 ( p1 ) + C2 ( pi−1 , pi ) (4)
i=1 i=1
The minimum cost is found and these minimum cost values
have been stored in a accumulator matrix i.e., two cost vec-
tors Caccu0 (M) and Caccu1 (M), and the path corresponds to
it is stored in a pointer P (N, M). This pointer is used for
computing the boundary P which minimizes the cost func-
tion in Eq. (4). Caccu0 (M) stores M accumulated cost values
for window at current position i, while Caccu1 (M) stores
M accumulated cost values for window at previous position
i − 1. P (N, M) stores for each pixel of the measured area, a
pointer to the pixel in the previous (left) column associated
with the lowest accumulation of cost.
Caccu1 (M) = 0 for m = 1 to M (5)
187
Caccu0 (m) = min k = 1, ..M(Caccu1 (k)
+C2 (p(n − 1)k, pnm) + C1 (pnm)
p(n,m) = (k |min k = 1, ..M(Caccu1 (k)
+C2 (p(n − 1)k, pnm) + C1 (pnm))) (6)
Caccu1 = Caccu0 . Fourth step is to measure Caccu0 (M) with
a lowest value. The position L0 where the lowest value has
been measured is the end point of the desired boundary. The
procedure has been carried out for all the columns from the
initial position. Beginning at the point with minimum accu-
mulated cost until reaching the first column. This gives all
the possible points in the boundary as
L 0 , P(N − 1, L 0 ), P(N − 2, P(N − 1, L 0 )), . . . .. (7)
The DP procedure for detecting one single interface typ-
ically includes three cost function terms and hence, three
weight factors, W1 –W3 . In this work, the values for the weight
factors have been utilized as W1 + W2 + W3 = 1. Two of
the weight vector values are used in steps of 0.09, such that
W1 + W2 < 1. The weights W 1 = 0.5 and W 2 = 0.2 has
been used in this technique. The extracted final DP contours
correspond to the leading echo boundaries I5 and I7. The
distance is computed between the leading echo boundaries
I5 and I7, at all points along the arterial identified region
of interest moving perpendicularly between pixel pairs, and
then averaged to obtain the mean IMT (IMT mean ). Also the
maximum (IMT max ), minimum (IMT min ) IMT values, are
calculated, displayed and plotted on the B-mode image.
2.10 Manual measurements and visual perception
evaluation
The IMT and the vessel wall are always defined as a pair of
two contours, which are represented by anatomical structure
of arteria carotis as shown in Fig. 1b. The two sonographers
delineated manually (using the mouse) the IMT on 100 lon-
gitudinal US images of the carotid artery by selecting 20–40
consecutive points for the adventitia and intima at the far wall
of the CCA. The manual delineations were performed using
a control system. The measurements are performed between
1 and 2 cm proximal to the bifurcation of the CCA on the
far wall [20] over a distance of 1.5 cm starting at a point
0.5 cm and finishing at a point 2 cm proximal to the carotid
bifurcation. The bifurcation of the CCA is used as a guide
and all measurements made from that region. The IMT is
then calculated as the average of all the measurements. The
measuring points and delineations are saved for comparison
with the improved dynamic programming method. Two sets
of measurements are carried out by both sonographers with a
12-month interval. All sets of manual segmentation measure-
ments are performed by the two sonographers in a blinded
manner, both with respect to identifying the subject and as
123
188 SIViP (2008) 2:183–193

Fig. 3 View of B-mode common carotid artery sample frame showing

transversal section

to the image delineation.

2.11 Univariate statistical analysis Fig. 5 a Pixel intensity verses depth (i.e., row index), corresponding
to a column of a sample image. b Identified region of the image

In order to evaluate how the results of the DP segmenta-

tion method differ from the manual delineation results, the
the two sonographers, the manual measurements on original
following evaluation metrics have been used in this analy-
image and normalized images have been repeated from both
sis. The parameters IMTmean , IMTmax and IMTmin as well
sonographers, 12 months after the first measurements.
as the intra-observer
√ error [4,18] according to the formula
S = SDIMT / 2, with SDIMT , the standard deviation for
each of the 100 subjects have been measured. The coefficient
of variation CV%, has been calculated, which describes the 3 Results and discussions
difference as a percentage of the pooled mean value with
CV% = (S .100)/IMTmean [4,18], where IMTmean is the The images of the common carotid artery are obtained from
pooled mean value. To measure the significant difference the US scanner and the procedure mentioned in the previous
between the two analyzing methods and two sonographers at section is applied. Set of images, corresponding to 100 sub-
p < 0.001 the Wilcoxon matched pairs rank sum test is used. jects out of which 81 subjects, both male and female with
The association between the manual and automated measures age varying from 20 to 70 have been acquired and used
is characterized by using Pearson’s correlation coefficient for the present analysis. For the analysis, 81 subjects with
(ρ). In order to assess the inter-observer variability between healthy, without a personal or family history of cardiovascu-

Fig. 4 a View of B-mode

common carotid artery sample
frame showing longitudinal
section. b Median filtered image

123
SIViP (2008) 2:183–193
Fig. 6 a Cumulative cost curve
for the entire image. b. Plot of
the cost matrix for the width of
the selected image
Fig. 7 a Segmented output of far wall B-mode transverse section
frames. b Segmented output of far wall B-mode longitudinal section
frames
lar and chronic pathologies have been considered. Remaining
19 subjects have abnormalities like hypertension and athero-
sclerosis. Sample B-Mode Image for the transversal and lon-
gitudinal sections are shown in Figs. 3 and 4a respectively.
Figure 4(b) shows the median filtered image of the longi-
tudinal section. It is used to locate the approximate vessel
interfaces as it preserves the edges.
The pixel intensity profile for the longitudinal section
image and the identified region of the sample image of the
same is shown in Fig. 5a, b. The profile is used to locate
the starting and ending point of intima–lumen interfaces and
189
adventitia-media interfaces in a polyline. It can be seen that
the adventitia tunica corresponds to the global maximum,
whereas the carotid tunica media and tunica intima corre-
sponds to the less intensity portion and the carotid lumen
corresponds to very low intensity of the intensity profile. The
cumulative cost values obtained by the DP procedure and the
plot of cost matrix for the width of the selected image are
shown in Fig. 6a, b, respectively. This cost curve indicates
the minimum cost function in the polyline, which is pointed
by means of a double arrow with respect to the I5 and I7
boundary. From the extracted boundary layers of intima and
media of the artery, the evaluations are made in upward and
downward directions. This is done for a series of consecu-
tive frames obtained from the video image of a single normal
subject. The frames are taken for about 2–3 cardiac cycles.
The view of the extracted far wall layer boundaries for the
normal subject under transverse and longitudinal B-mode
frames are shown, respectively, in Fig. 7a, b. After extracting
the far wall layers, the IMT is evaluated considering the dis-
tances between the upper and lower boundary lines. The IMT
is estimated both in transverse and longitudinal frames con-
sidering 30 points, while the transverse section segmented
frame shows an accurate value as compared to the longitu-
dinal frame. The locations of the artery wall with columns
of a single subject are viewed in the graph. This graph gives
an idea about the thickness of the vessel based on the eval-
uated distance between the locations of the interfaces. This
distance is a measure of length of the column in the inten-
sity distribution profile of the image. All the points in the
location of the interfaces along the columns are considered
for the evaluation, it has been shown that 1 mm is approxi-
mately equal to 8.52 pixels for transverse and 6.399 pixels
for longitudinal sections of CCA. The IMT of the healthy
subject is evaluated as 0.62 ± 0.012 mm for an age of 33,
after extracting the layers of intima and media from the CCA
and the same is shown in Fig. 8. The graph is shown for a
single subject with an age of 33. It is seen that the curve does
not show uniform locations i.e., at certain points the locations
are erratic. The reason may be due to improper placing of the
123
190 SIViP (2008) 2:183–193

Fig. 8 a Measured IMT of far

wall segmented B-mode images
(Transversal view). b Measured
IMT of far wall segmented
B-mode images (Longitudinal
view)

Table 1 Intima–media thickness of common carotid artery for different age groups of normal (healthy) subjects
S. no. 1 2 3 4 5

Age group (years) 21–30 31–40 41–50 51–60 61–70

Number of subjects 19 15 21 19 07
Male/Female F M F F M
DP method
IMTMax ± SD (mm) 0.52 ± 0.029 0.69 ± 0.006 0.62 ± 0.018 0.75 ± 0.003 0.80 ± 0.024
IMTMin ± SD (mm) 0.44 ± 0.065 0.59 ± 0.018 0.65 ± 0.016 0.73 ± 0.006 0.77 ± 0.007
IMTmean ± SD (mm) 0.48 ± 0.047 0.61 ± 0.018 0.67 ± 0.011 0.74 ± 0.005 0.79 ± 0.016
Manual method
IMTmean1 ± SD (mm) 0.47 ± 0.035 0.58 ± 0.011 0.66 ± 0.031 0.68 ± 0.041 0.76 ± 0.031
IMTmean2 ± SD (mm) 0.46 ± 0.010 0.58 ± 0.045 0.65 ± 0.014 0.67 ± 0.020 0.73 ± 0.021
Inter-observer error S (mm) 0.0312 0.0396 0.0318 0.0433 0.0367
Inter method error S (mm) 0.0390 0.0200 0.0300 0.0395 0.0350
Coefficient of variation CV (%) 3.35 3.73 2.46 2.52 3.20

Fig. 9 a Intima-media
thickness of CCA for normal
subjects. b Intima-media
thickness of CCA for abnormal
subjects

probe. Due to this effect the segmented wall is not continuous
and thickness measurement becomes uncountable. This can
be overcome by placing the probe in the proper place before
the bifurcation of the CCA. The observed results for the age
group of 31–40 are shown in Table 1.
The above procedure is applied to all the 81 subjects with
age group varying from 20 to 70. As a first step, measure-
ments have been made on the healthy subjects (free from
diabetes and atherosclerosis). The IMT is estimated consid-
ering all the age groups with normal and abnormal subjects
as presented in Fig. 9a,b. as well as in Table 1. It can be
seen that the IMT increases for higher age group people. The
observed results can be used to determine the morphological
changes in the layers which lead to blockage in the subjects
in very earlier stages in the near future.
The same procedure is applied to 19 subjects with abnor-
malities like hypertension and atherosclerosis. The observed
results indicate that the distance between the extracted lay-
ers is larger than the normal subject extracted layers, and
its results are shown in Figs. 10, 11. The IMT is estimated
and its values are presented in Table 2 while the graphical
results are shown in Fig. 12a, b. The graph is shown for a

123
SIViP (2008) 2:183–193 191

Table 2 Intima–media thickness of common carotid artery for abnor-

mal subjects like hypertension and atherosclerosis
S. no. 1 2

Age group (Years) 35–55 35–55

Number of subjects 13 06
Name of the pathology Hypertension Atherosclerosis
DP method
IMTmean ± SD (mm) 1.45 ± 0.05 2.35 ± 0.50
Manual method
IMTmean(1,2) ± SD (mm) 1.35 ± 0.12 2.04 ± 0.04
Inter method error S (mm) 0.030 0.038
Coefficient of variation CV (%) 2.020 1.752
Pearson’s correlation 0.980 0.925
coefficient (ρ)

single subject with an age of 50 (hypertension). The evalu-

Fig. 10 a Sample subject of B-mode CCA image with hypertension.
b Segmented output of far wall B-mode CCA image with hypertension
ated IMT is 1.1 ± 0.14 mm for this single subject, whereas for
the subject of same age group with atherosclerosis has been
segmented using the above procedure yields much wider gap
between intima and media layers and its evaluated IMT is
about 2.5 ± 0.05 mm. From the evaluated results (Fig. 12a,
b), Table 2 it is inferred that the subject with atherosclerosis
has higher layer thickness as compared to the subject with
the hypertension. It can be seen that IMT increases even for
middle age group people.
The segmented results show that the layers extracted using
the proposed technique provide accurate results compared to
manual method. The above technique is an efficient one as it
performs the computation in a faster way and requires mod-
erate effort to write the software. The algorithms resulted in
high accuracy and low inter-method as well as inter-observer
variability. The occurrence of wrong detection is so rare
and considered insignificant. It is the only method which
accounts for the continuity of the detected boundaries. The
segmented results are in line with the earlier studies
[4–7,11,18].
It is evident from the above observations that the IMT lin-
early increases with age. This is due to the reduction in the
circumference of the vascular tube which leads to early
prediction of blockage which causes the cerebrovascular
and cardiovascular pathologies. The tremendous increase
observed in the IMT magnitude for the subjects with hyper-
tension and atherosclerosis is ascribed due to the deposition
of calcification (or) plaque. The observed results are in line
with the earlier studies [2,11,13,27].

4 Conclusions

An improved method of detecting the IMT using DP proce-

Fig. 11 a Sample subject of B-mode CCA image with atherosclerosis. dure has been evaluated. The same has been tested for 81 nor-
b Segmented output of far wall B-mode CCA image with atherosclerosis
mal and 19 abnormal subjects. The proposed DP overcomes

123
192
Fig. 12 a Measured IMT of far
wall segmented B-mode CCA
image with hypertension. b
Measured IMT of far wall
segmented B-mode CCA image
with atherosclerosis
the difficulties of conventional detection techniques. Speckle
noises and artifacts produced from non-invasive Ultrasound
image have been reduced by image processing techniques.
The observed results indicate that the gradual increase in the
IMT magnitude reveals the rate of prediction of calcification
or plaque formation in the subjects like hypertension and ath-
erosclerosis and also the blockage exists in the cardiovascu-
lar and cerebrovascular pathologies. This study confirms that
the improved DP technique can be successfully employed to
reveal the early prediction of calcification or plaque.
Acknowledgments The authors would like to express their gratitude
to Dr. S.Suresh, Mediscan systems, Chennai for providing the necessary
images for this study.
References
1. Barrett, W.A., Mortensen, E.N.: Interactive live-wire boundary
extraction. Med. Image Anal. 1(4), 331–341 (1996)
2. Bots, M.L., Hoes, A.W., Koudstaal, P.J., Hofman, A., Grob-
bee, D.E.: Common carotid intima–media thickness and risk of
stroke and myocardial infarction: the Rotterdam Study. Circula-
tion 96, 1432–1437 (1997)
3. Bots, M.L., Baldassarre, D., Simon, A., de Groot, E., O’Leary,
D.H., Riley, W., Kastelein, J.J., Grobbee, D.E.: Carotid intima-
media thickness and coronary atherosclerosis: weak or strong rela-
tions? Eur. Heart J. 28(4), 398–406 (2007)
4. Chalana, V., Kim, Y.: A methodology for evaluation of boundary
detection algorithms on medical images. IEEE Trans. Med. Imag-
ing 16(5), 642–652 (1997)
5. Chan, R.C., Khaufhold, J., Hemphill, L.C., Lees, R.S., Karl,
W.C.: Anisotropic edge-preserving smoothing in carotid B-mode
ultrasound for improved segmentation and intima-media thickness
(IMT) measurement. Comput. Cardiol 27, 37–40 (2000)
6. Cheng, D., Schmidt-Trucksass, A., Cheng, K., Burkhardt,
H.: Using snakes to detect the intimal and adventitial layers of
the common carotid artery wall in sonographic images. Comput.
Methods Programs Biomed. 67, 27–37 (2002)
7. Cheng, D., Schmidt-Truckäss, A., Cheng, K., Sandrock, M., Pu, Q.,
Burkhardt, H.: Automatic detection of the intimal and the adventi-
tial layers of the common carotid artery wall in ultrasound B-mode
images using snakes. In: Proc. Int. Conf. Image Analysis Process-
ing, pp. 452–457 (1999)
123
SIViP (2008) 2:183–193
8. Eigenbrodt, M.L., Bursac, Z., Eigenbrodt, E.P., Couper, D.J.,
Tracy, R.E., Mehta, J.L.: Mathematical estimation of the poten-
tial effect of vascular remodeling/dilatation on B-mode ultrasound
intima-medial thickness. Int. J. Med. 97(11), 729–737 (2004)
9. Gariepy, J., Massonneau, M., Levenson, J., Heudes, D., Simon,
A., the Groupe de Prevention Cardio-vasculaire en Medecine du,
Travail: Evidence for in vivo carotid and femoral wall thickness in
human hypertension. Hypertension 22(1), 111–118 (1993)
10. Gerli, R., Gilburd, B., Bartoloni Bocci, E., Vaudo, G., Mannarino,
E., Shoenfeld, Y.: Thickened carotid artery intima-media in rheu-
matoid arthritis is associated with elevated anticardiolipin antibod-
ies. Lupus 16(4), 259–264 (2007)
11. Gustavsson, T., Abu-Gharbieh, R., Hamarneh, G., Liang,
Q.: Implementation and comparison of four different boundary
detection algorithms for quantitative ultrasonic measurements of
the human carotid artery. Comput. Cardiol. 24, 69–72 (1997)
12. Hallerstam, S., Larsson, P.T., Zuber, E., Rosfors, S.: Carotid ath-
erosclerosis is correlated with extent and severity of coronary
artery. Angiology 55, 281–288 (2004)
13. Jain, A.K.: Fundamentals of Digital Image Processing. Prentice-
Hall, Englewood Cliffs (1989)
14. Jegelevičius, D., Lukoševičius, A.: Ultrasonic measurements of
human carotid artery wall intima-media thickness. Ultragarsas, pp.
43–47 (2002)
15. Kasliwal, R.R., Bansal, M., Gupta, H., Agrawal, S.: Association
of carotid intima-media thickness with left main coronary artery
disease. Indian Heart J. 59, 50–55 (2007)
16. Kumeda, Y., Inaba, M., Goto, H., Nagata, M., Henmi, Y., Furumi-
tsu, Y., Ishimura, E., Inui, K., Yutani, Y., Miki, T., Shoji, T., Nishiz-
awa, Y.: Increased thickness of the arterial intima-media detected
by ultrasonography in patients with rheumatoid arthritis. Arthritis
Rheum. 46(6), 1489–1497 (2002)
17. Lamont, D., Parker, L., White, M., Unwin, N., et al.: Risk of car-
diovascular disease measured by carotid intima-media thickness at
age 49–51: life course study. BMJ 320, 273–278 (2000)
18. Liang, Q., Wendelhag, L., Wikstrand, J., Gustavsson, T.: A mul-
tiscale dynamic programming procedure for boundary detection
in ultrasonic artery images. IEEE Trans. Med. Imaging 19, 127–
142 (2000)
19. Lo, J., Dolan, S.E., Jenna, R., Kanter, B.A., Hemphill, L.C.,
Connelly, J.M., Lees, R.S., Grinspoon, S.K.: Effects of obesity,
body composition, and adiponectin on carotid intima-media thick-
ness in healthy women. J. Clin. Endocrinol. Metab. 91(5), 1677–
1682 (2006)
20. Pignoli, P., Tremoli, E., Poli, A., Paoletti, R.: Intimal plus medial
thickness of the arterial wall: A direct measurement with ultrasound
imaging. Circulation 74, 1399–1406 (1986)
SIViP (2008) 2:183–193
21. Salonen, J.T., Salonen, R.: Ultrasound B-mode imaging in observa-
tional studies of atherosclerotic progression. Circulation 87(suppl.
II), 1156–1165 (1993)
22. Santhiyakumari, N., Madheswaran, M.: Estimation of layer thick-
ness of arterio carotis using Dynamic Programming Procedure. In:
Proc. 3rd Cairo International Biomedical Engineering Conference,
EI cairo, Egypt (2006)
23. Selzer, R.H., Hodis, H.N., Kwong-Fu, H., Mack, W.J., Lee, P.L.,
Liu, C.R., Liu, C.H.: Evaluation of computerized edge tracking for
quantifying intima-media thickness of the common carotid artery
from B-mode ultrasound images. Atherosclerosis 111, 1–11 (1994)
24. Touboul, P.-J.: Clinical impact of intima media measurement. Eur.
J. Ultrasound 16, 105–113 (2002)
25. Touboul, P.J., Hennerici, M.G., Meairs, S., Adams, H., Amarenco,
P., Bornstein, N., Csiba, L., Desvarieux, M., Ebrahim, S., Fatar,
M., Hernandez, R., Jaff, H.M., Kownator, S., Prati, P., Rundek,
T., Sitzer, M., Schminke, U., Tardif, J.-C., Taylor, A., Vicaut,
E., Woo, K.S., Zannad, F., Zureik, M.: Mannheim carotid intima-
media thickness consensus. Cerebrovasc Dis. 23, 75–80 (2007)
193
26. Touboul, P.J., Prati, P., Scarab, P.Y., Adrai, V., Thibout, E.,
Ducimetiere, P.: Use of monitoring software to improve the mea-
surement of carotid wall thickness by B-mode imaging. J. Hyper-
tension 10(suppl. 5), S37–S41 (1992)
27. Weeks, A.R. Jr..: Fundamentals of Electronic image process-
ing. Prentice-Hall, India (2005)
28. Wendelhag, I., Gustavsson, T., Suurkula, M., Berglund, G., Wik-
strand, J.: Ultrasound measurement of wall thickness in the carotid
artery: fundamental principles and description of a computerized
analysing system. Clin Physiol 11(6), 565–77 (1991)
29. Wendelhag, I., Liang, Q., Gustavsson, T., Wikstrand, J.: A new
automated computerized analysing system simplifies reading and
reduces the variability in ultrasound measurement of intima media
thickness. Stroke 28, 2195–2200 (1997)
30. Wilhjelm, J.E., Gronholdt, M.L., Wiebe, B., Jespersen, S.K., Han-
sen, L.K, Sillesen, H.: Analysis of ultrasound B-mode images
of carotid atherosclerotic plaque: correlation with visual classi-
fication and histological examination. IEEE Trans. Med. Imag-
ing 17(6), 910–922 (1998)
123