I was involved in the initial ITK implementation. We decided o start with an oriented image then transition that to the regular image.I would not do that again. I recommend adding the meta date to the current image and work from there.
See this discussion:
https://cmake.org/pipermail/insight-users/2008-October/027508.html
Also some early developer discussions:
https://itk.org/Wiki/Proposals:Oriented_Image_Registration
Also, I recommend looking at itk’s implementation and hopefully, vtk’s will be similar.
Finally, the Slicer folks have had lots of experience in using orientation. They are a valuable resource.
Bill