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M. Iorga and G. Dougherty

12.4 Tortuosity

Normal retinal blood vessels are straight or gently curved, but they become dilated and tortuous in a number of disease classes, including high blood flow, angiogenesis, and blood vessel congestion [34]. It has been suggested that the severity of many retinal diseases, and the progression of retinopathy, could be inferred from the tortuosity of the blood vessel network if a consistent quantitative measure of tortuosity could be demonstrated [34]. In clinical practice, ophthalmologists commonly grade tortuosity using a qualitative scale (e.g., mild, moderate, severe, and extreme) [35], but a reliable quantitative measure would enable the automated measurement of retinal vascular tortuosity and its progression to be more easily discerned.

A multiplicity of tortuosity measures are in use, including the relative length increase over a straight vessel [36] or a smoothed curve through the vessel [37], the relative length increase for vessels in a range of spatial frequencies [36, 38], and various measures of integral curvature along the vessels [3943]. Those based on relative length increase only measure vessel elongation and have no value in measuring morphology or hemodynamic consequences, while those using integrated curvature require arbitrary smoothing schemes to smooth the noise in the coordinates resulting from limited sampling.

12.4.1 Tortuosity Metrics

Two robust metrics have been proposed for quantifying vascular tortuosity in terms of three-dimensional (3-D) curvature [44]. They are additive and scale invariant, and largely independent of image noise (for signal-to-noise ratios greater than 50 dB) and the resolution of the imaging system. The metrics were validated using both 2-D and 3-D clinical vascular systems [45], and are well suited to automated detection and measurement when used with a vessel tracking algorithm. In a preliminary application to retinal pathologies [46], they correlated strongly with the ranking of tortuosity by an expert panel of ophthalmologists, and were able to distinguish several pathologies from normal in a discretionary (i.e., referred) population.

One of these metrics, the mean tortuosity, is equivalent to the accumulating angle change along the length of a vessel considered to comprise straight-line segments between closely digitized points along its midline. Figure 12.2 shows how the tortuosity decreases as the length of these segments (viz., the sampling interval) increases. There are large digitization errors with small sampling intervals, which results in an artificially elevated tortuosity. Large sampling intervals miss high-frequency changes and underestimate the tortuosity of highly tortuous vessels. A sampling interval of five pixels minimized digitization errors and accurately traced the vessels in images corresponding to all retinopathy grades.

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