The Patient Orientation (0020,0020) relative to the image plane shall be specified by two values that designate the anatomical direction of the positive row axis (left to right) and the positive column axis (top to bottom). The first entry is the direction of the rows, given by the direction of the last pixel in the first row from the first pixel in that row. The second entry is the direction of the columns, given by the direction of the last pixel in the first column from the first pixel in that column. Shall be consistent with Image Orientation (Patient) (0020,0037), if both Attributes are present and Patient Orientation (0020,0020) is not zero length.
If Anatomical Orientation Type (0010,2210) is absent or has a value of BIPED, anatomical direction shall be designated by abbreviations using the capital letters:
If Anatomical Orientation Type (0010,2210) has a value of QUADRUPED, anatomical direction shall be designated by the abbreviations using capital letters:
LE (Le or Left)
RT (Rt or Right)
CR (Cr or Cranial)
CD (Cd or Caudal)
PR (Pr or Proximal)
DI (Di or Distal)
PA (Pa or Palmar)
PL (Pl or Plantar)
Notes: 1. These abbreviations are capitalized versions of those defined in Smallwood et al for describing radiographic projections. Because of the Code String (CS) Value Representation of the Patient Orientation (0020,0020), lowercase letters cannot be used.
2, It is unfortunate that the conventional veterinary abbreviations (e.g., R for rostral and Rt for right) differ from those chosen for humans for DICOM usage (e.g., R for right), but confusion with in the respective human and animal domains will be reduced. Hanging protocols may need to account for the difference by checking for the correct species.
3. Smallwood et al define an O (Oblique) abbreviation, which is useful for describing radiographic projections, but do not specify its use for directional terms, and hence it is not included here for describing the row and column directions.
4. The terms “anterior” and “posterior” are commonly used in vertebrate zoology to describe the cranial and caudal directions respectively, the veterinary terms are used in preference here, also in order to avoid confusion with the contradictory human use of anterior and posterior to mean ventral and dorsal.
5. For animals other than quadrupeds, for example, birds and fish, it is anticipated that the same nomenclature can be logically extended to describe, for example, wings and fins.
Each value of the orientation attribute shall contain at least one of these abbreviations. If refinements in the orientation descriptions are to be specified, then they shall be designated by one or two additional abbreviations in each value. Within each value, the abbreviations shall be ordered with the principal orientation designated in the first abbreviations.
Notes: 1. For bipeds, since each abbreviation is a single character, no delimiter is required within a single value and none is used. For quadrupeds, though lowercase letters cannot be used, delimiters are not necessary within a single value to eliminate ambiguity, since the abbreviations used are sufficiently distinct, and can be parsed from left to right with a single character of lookahead.
2. E.g., a medio-lateral oblique projection of the left breast of a human might be encoded with Patient Orientation values of “A\FR” rather than “A\F”, since the plane is obliquely inclined such that the colums are directed both downwards and medially, which for a left breast is towards the right, though the downwards direction is the principal column orientation.
3. E.g., a right dorsal-left ventral oblique view of a quadruped’s abdomen might be encoded with Patient Orientation values of “LTV\CD”, rather than “LT\CD”, since the plane is obliquely inclined such that the rows are directed both to the left and ventrally, though the left direction is the principal row orientation. The abbreviations “LTV”, “LT” and “CD”, correspond to the designations in Smallwood et al of “LtV”, “Lt” and “Cd”, respectively
The Image Type (0008,0008) Attribute identifies important image identification characteristics. These characteristics are:
a. Pixel Data Characteristics
1. is the image an ORIGINAL Image; an image whose pixel values are based on original or source data
2. is the image a DERIVED Image; an image whose pixel values have been derived in some manner from the pixel value of one or more other images
b. Patient Examination Characteristics
1. is the image a PRIMARY Image; an image created as a direct result of the Patient examination
2. is the image a SECONDARY Image; an image created after the initial Patient examination
c. Modality Specific Characteristics
d. Implementation specific identifiers; other implementation specific identifiers shall be documented in an implementation's conformance statement.
The Image Type attribute is multi-valued and shall be provided in the following manner:
a. Value 1 shall identify the Pixel Data Characteristics; Enumerated Values for the Pixel Data Characteristics are:
ORIGINAL identifies an Original Image
DERIVED identifies a Derived Image
b. Value 2 shall identify the Patient Examination Characteristics; Enumerated Values for the Patient Examination Characteristics are:
PRIMARY identifies a Primary Image
SECONDARY identifies a Secondary Image
c. Value 3 shall identify any Image IOD specific specialization (optional)
d. Other Values which are implementation specific (optional)
Any of the optional values (value 3 and beyond) may be sent either with a value or zero-length, independent of other optional values, unless otherwise specified by a specialization of this attribute in an IOD.
If the pixel data of the derived Image is different from the pixel data of the source images and this difference is expected to affect professional interpretation of the image, the Derived Image shall have a UID different than all the source images.
If an Image is identified to be a derived image (see C.184.108.40.206.2 Image Type), Derivation Description (0008,2111) and Derivation Code Sequence (0008,9215) describe the way in which the image was derived. They may be used whether or not the Source Image Sequence (0008,2112) is provided. They may also be used in cases when the Derived Image pixel data is not significantly changed from one of the source images and the SOP Instance UID of the Derived Image is the same as the one used for the source image.
Notes: 1. Examples of Derived Images that would normally be expected to affect professional interpretation and would thus have a new UID include:
a. images resulting from image processing of another image (e.g. unsharp masking),
b. a multiplanar reformatted CT image,
c. a DSA image derived by subtracting pixel values of one image from another.
d. an image that has been decompressed after having been compressed with a lossy compression algorithm. To ensure that the user has the necessary information about the lossy compression, the approximate compression ratio may be included in Derivation Description (0008,2111).
An example of a Derived Image that would normally not be expected to affect professional interpretation and thus would not require a new UID is an image that has been padded with additional rows and columns for more display purposes.
2. An image may be lossy compressed, e.g., for long term archive purposes, and its SOP Instance UID changed. PS3.4 provides a mechanism by which a query for the original image Instance may return a reference to the UID of the lossy compressed version of the image using the Alternate Representation Sequence (0008,3001). This allows an application processing a SOP Instance that references the original image UID, e.g., a Structured Report, to obtain a reference to an accessible version of the image even if the original SOP Instance is no longer available.
If an Image is identified to be a Derived image (see C.220.127.116.11.2 Image Type), Source Image Sequence (0008,2112) is an optional list of Referenced SOP Class UID (0008,1150)/ Referenced SOP Instance UID (0008,1150) pairs that identify the source images used to create the Derived image. It may be used whether or not there is a description of the way the image was derived in Derivation Description (0008,2111) or Derivation Code Sequence (0008,9215).
Note: Multiple Items may be present within Source Image Sequence (0008,2112), in which case either:
a) those images were combined to make the derived image (e.g. multiple source images to make an MPR or MIP), or
b) each of the items represents a step in the successive derivation of an image (e.g. when an image has had successive lossy compression steps applied to it),
c) some combination of the above.
The Purpose of Reference Code Sequence (0040,A170) and the Attributes within the referenced images themselves may be used to determine the history of the derivation, which is not otherwise explicitly specified.
The Attribute Lossy Image Compression (0028,2110) conveys that the Image has undergone lossy compression. It provides a means to record that the Image has been compressed (at a point in its lifetime) with a lossy algorithm and changes have been introduced into the pixel data. Once the value has been set to “01”, it shall not be reset.
Note: If an image is compressed with a lossy algorithm, the attribute Lossy Image Compression (0028,2110) is set to “01”. Subsequently, if the image is decompressed and transferred in uncompressed format, this attribute value remains “01”.
The value of the Lossy Image Compression (0028,2110) Attribute in SOP Instances containing multiple frames in which one or more of the frames have undergone lossy compression shall be “01”.
Note: It is recommended that the applicable frames be noted in the Attribute Derivation Description (0008,2111).
If an image is originally obtained as a lossy compressed image from the sensor, then Lossy Image Compression (0028,2110) is set to “01” and Value 1 of the Attribute Image Type (0008,0008) shall be set to ORIGINAL.
If an image is a compressed version of another image, Lossy Image Compression (0028,2110) is set to “01”, Value 1 of the Attribute Image Type (0008,0008) shall be set to DERIVED, and if the predecessor was a DICOM image, then the Image shall receive a new SOP Instance UID.
Note: 1. It is recommended that the approximate compression ratio be provided in the Attribute Derivation Description (0008,2111). Furthermore, it is recommended that Derivation Description (0008,2111) be used to indicate when pixel data changes might affect professional interpretation. (see C.18.104.22.168.3).
2. The attribute Lossy Image Compression (0028,2110) is defined as Type 3 for backward compatibility with existing IODs. It is expected to be required (i.e., defined as Type 1C) for new Image IODs and for existing IODs that undergo a major revision (e.g. a new IOD is specified).
The Defined Terms for Lossy Image Compression Method (0028,2114) are:
ISO_10918_1 = JPEG Lossy Compression
ISO_14495_1 = JPEG-LS Near-lossless Compression
ISO_15444_1 = JPEG 2000 Irreversible Compression
ISO_13818_2 = MPEG2 Compression
An Icon Image may be used as a key representative of an Image. It is defined as a Sequence that contains a single Item encapsulating the Data Set made of the Data Elements of the Icon Image. The Data Elements are defined by the Image Pixel Macro (see Section C.7.6.3). The restrictions defined in Section F.7 shall apply.
An irradiation event is the occurrence of radiation being applied to a patient in single continuous time-frame between the start (release) and the stop (cease) of the irradiation. Any on-off switching of the irradiation source during the event shall not be treated as separate events, rather the event includes the time between start and stop of irradiation as triggered by the user. E.g., a pulsed fluoro X-Ray acquisition shall be treated as a single irradiation event.