Essentials of Digital Imaging

Module 3 Transcript

©2016 ASRT. All rights reserved.

 Essentials of Digital Imaging
Module 3 – Display

1. ASRT Animation

2. Welcome
Welcome to the Essentials of Digital Imaging – Module 3 Display.

3. License Agreement

4. Objectives
After completing this module, you will be able to:
 Differentiate between a cathode ray tube and a liquid crystal display monitor.
 Define the characteristics of a monitor that affect image display.
 Explain the features of a modality workstation monitor.
 Describe how a modality workstation functions.

5. CRT Monitor Animation

CRT technology has been around much longer than LCD equipment, and is still used to provide excellent
images. An electron gun, or “cathode,” creates images by beaming electrons towards an anode. Instead
of striking the anode, however, these electrons are deflected toward the monitor’s fluorescent screen to
construct the image. There are 2 types of image acquisition: interlaced and progressive. There is an
obvious difference between how the image is produced based on how they acquired data is transferred to
the monitor display. The progressive process fills each line from top to bottom, whereas interlaced
acquisition fills every other line top to bottom and then returns to the top to fill in the missing lines of data.

6. LCD and LED-LCD Monitors

The LCD and LED-LCD monitors are constructed of 2 sections of polarized glass with liquid crystals
sandwiched between the glass layers. The crystals allow different light waveforms to pass through the
monitor and be viewed on the screen, diffusing the light as appropriate. The difference between the two
monitor types is the light source for the liquid crystals. A traditional LCD monitor uses a cold cathode
fluorescent light source and the LED-LCD uses a light emitting diode as the light source.

7. Display Characteristics
There are several factors that affect image display. Although technologists can’t modify the image display
characteristics of a digital imaging system, it’s important to understand the role a display monitor has in
viewing digital images.

The monitors used with acquisition workstations can be cathode ray tube (CRT) or liquid crystal display
(LCD) types. Their dimensional shape is one way to distinguish between them. A CRT monitor is much
deeper from the screen to the back of the device. An LCD monitor is thinner from front to back.

In general, a CRT monitor provides more luminance, especially in the center of the image. They have
lower measurable black levels and better color reproduction. The phosphor granularity of a CRT adds to
the spatial noise recognition of the image, the viewable area is actually smaller than the stated size, and
the aspect ratio is 4:3. Not only are CRT monitors more responsive on redraw they are more durable than
LCD monitors. On the other hand, an LCD monitor produces less screen glare, or veiling glare, offers
better spatial resolution, and is easier to move and reposition. The LCD monitor consumes less energy
and provides a larger viewing area that is closer to the described size. Additionally, it leaves a smaller
footprint than the CRT counterpart while providing a wider screen aspect ratio of 16:9. A limitation of the
LCD is that it can only display the designed resolution.

There are several characteristics of the monitor that can affect its display which include spatial resolution,
vertical and horizontal resolution, the size of the display, aspect and matrix ratio, pixel size and pixel
pitch.

©2016 ASRT. All rights reserved. Essentials of Digital Imaging Module 3 – Display
8. CRT and LCD Resolution
For a CRT monitor, spatial resolution is determined by the bandwidth, line spacing, and electron beam
size. The vertical resolution depends on line spacing and spot size which is the ability of the tube to focus
the electron beam. Horizontal resolution depends on bandwidth and spot size.

An LCD monitor's resolution is determined by the pixel size and pitch. The smaller the pixel size the
greater the spatial resolution. The pixel pitch is the distance between the cells of the same color. The
vertical and horizontal resolution is determined by the pixel pitch in that given direction.

9. Display Size
The size of the display screen also plays a role in resolution. The screen is measured diagonally from
corner to corner. For a CRT monitor, the measurement is taken from the outside edges of the display
casing. For an LCD monitor, the screen is measured from the inside of the beveled edge.

There are several display characteristics, uses, and sizes for image viewing monitors such as XGA, an
extended graphics array, up through WUXGA, a wide ultra XGA display. Each display type has its own
unique resolution. These resolution values are similar to a laptop computer or your home PC, with
resolutions such as 1024 x 768 or 1600 x 1200. These values represent the relationship of pixels on a
vertical and horizontal axis across the monitor.

An important consideration is the difference in resolution between the image acquisition work station and
the diagnostic workstation used by the radiologist. The increased resolution of the diagnostic workstation
can display suboptimal characteristics that are not apparent on the acquisition workstation. For example,
a common issue is lost spatial resolution from motion seen on the diagnostic workstation.

10. Aspect Ratio

Aspect ratio is another important display characteristic. Aspect ratio refers to the proportional relationship
of the width and height of the display screen. Most CRT monitors have an aspect ratio of 4:3, whereas
LCD monitors have an aspect ratio of 16:9 when viewed in a landscape format.

11. Matrix Ratio

Matrix size also affects how an image appears. The larger the matrix, the more pixels on the display
monitors, which results in smaller pixels and greater resolution. A 1 x 1 matrix doesn't really demonstrate
what is contained in the image. The 100 x 100 display matrix provides a better image of the letter “R” in
terms of spatial resolution compared with the smaller matrix sizes.

12. Pixel Size and Pixel Pitch

Pixel size and pixel pitch values vary depending on the display monitor being used. The number of pixels
is an important display characteristic. As the number of pixels per square centimeter increases, the
monitor is able to display radiographs in a higher-resolution.

Pixel pitch, also known as dot pitch, determines the sharpness of an image. In a CRT monitor, the pitch is
the distance between phosphors. Gaps between pixels represent dead space meaning no image
information can be displayed in that area. In an LCD monitor, the pitch measures from the center of 1
pixel to the center of an adjacent pixel and includes any gaps between them. The closer the pixels are
together, the sharper the image because there are more pixels in the area.

13. Knowledge Check

14. Knowledge Check

15. Gray Scale

To accurately display the gray scale in a radiograph, the display monitor needs to be able to demonstrate
at least 256 shades of gray which is equivalent to 8 bits. In addition to the minimum gray-scale display,
the American College of Radiology, or ACR, has determined the minimum requirement for spatial

©2016 ASRT. All rights reserved. Essentials of Digital Imaging Module 3 – Display
resolution on diagnostic monitors must be 2.5 line pairs per millimeter when viewing a 14 x 17-inch, or
35.6 x 43.2 cm, image.

16. Display Noise

Display noise, also referred to as monitor noise, is not the sound that you hear but rather what is visible
on a finished radiograph. Monitors have 2 types of display noise. Spatial noise is caused by phosphor
granularity. This type of image noise is the result of random luminance variations from construction
characteristics and electrical signal variability inherent in LCD monitors. Temporal noise occurs when the
electron beam intensity fluctuates as the beam scans back and forth across the back of the phosphor in
the monitor.

17. Contrast Resolution

The contrast resolution of a monitor is the difference between the maximum and minimum luminance of
the display. Color depth determines the colors that can be displayed and depends on the graphics
adapter and color capabilities of the monitor. Color bit depth refers to the number of bits used to create
the color of a single pixel.

18. Maximal Luminance

Maximal luminance, when referring to a video display, refers to monitor brightness. Current ACR
standards specify that gray-scale monitors used for interpreting radiographs provide a minimum of 171
candela per square meter. The minimum level of luminance is called the black level, and CRTs have a
measurably lower black level than LCD displays.

Analog display brightness differs significantly compared with digital image display brightness. This is one
reason that viewing angle and ambient lighting surrounding a workstation has such a tremendous effect
on a technologist's ability to evaluate a digital image. Analog images on view boxes are much brighter.

A mammography view box has a luminance between 3,000 and 7,500 cd/m2 where a standard view box
has a luminance between 1,500 and 3,500 cd/m2. An LCD gray-scale monitor at a technologist’s
workstation has a luminance of 120 to 1000 cd/m2. If the monitor is a CRT then the luminance is 120 to
450 cd/m2. As a comparison, a standard PC color monitor displays at a luminance of 65 to 130 cd/m2.

19. Refresh Rate

The refresh rate of CRT monitors refers to the number of times an image is drawn on the screen each
second. Refresh rates range from 60 to 120 images per second. Large CRT monitors flicker more visibly.
Refresh rates vary. The refresh rate for a 1280 x 1024 matrix might be 85 hertz, or 85 cycles per second,
whereas a 1600 x 1200 matrix has a refresh rate of 75 Hz, or 75 cycles per second.

20. Persistence
Persistence is the delayed light emission from the phosphor after a CRT screen refreshes. Persistence
helps when viewing static images, but it produces image lag in a cine-type display. Persistence with LCD
based monitors is the result of the liquid crystals staying in one position following the termination of the
applied electrical signal. In the case of LCD based monitors, image persistence is also known as image
retention.

21. Technologist Workstation

The technologist workstation has modality specific software that enables the workstation to be
multifunctional. Technologists often can choose the patient name and exam from a modality work list,
select the type of examination performed and the processing parameters for the image data, and
determine how to display the resulting image.

Technologist workstation monitors are used in bright, or well lit, areas. Monitoring luminance, or the
brightness of a monitor display, is an important consideration when evaluating image quality. The monitor
must allow a technologist to discern motion and to ensure anatomy is demonstrated properly. The ability
of the monitor to display contrast directly affects the visibility of structures in an image. The display
monitor is only as functional as its video card.

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22. Tiling
Depending on the manufacturer's software, the examination list screen may display thumbnail-sized
images of the examinations. Most often the display includes images recently received by the workstation
as the images are acquired during a series of radiographic exposures. Thumbnails vary based on
manufacturer specific designs and are selectable. Selecting a thumbnail allows technologists to view a
larger image to determine whether it can be accepted or rejected according to the diagnostic principles of
the examination.

23. Activity Tracking

Modality workstations can track any activity associated with an imaging exam that displays on the
workstation comprehensive list, such as date and time. The list of displayed items is configurable but not
comprehensive. More examination data is available than is displayed on the exam list screen. For
example, the times associated with an examination might include when the imaging order was received
by the work list and when the patient's individual images were performed which is based on specific plate
processing times, the image capture, and when the image was sent to PACS.

24. Image Data

To view an individual study, the user activates a command on the screen showing all the examinations
stored on the workstation. The screen then displays information about the images selected that includes
the date and time the image is processed, the anatomical menu used to process the image, exposure
indicator, which is identified by exposure to the digital receptor, exposure factors, in the case of cassette-
less digital imaging systems, brightness level, and contrast level.

The data displayed on the image frame and the examination screen can be configured by the user.
However, the addition or rejection of certain data fields displayed might be restricted based on an
individual technologist’s permissions. An image list can offer configurable displays for patient
demographics, examination data, image data, and the plate exposure number. Certain users are able to
access specific data fields in addition to being able to make general modifications.

25. Knowledge Check

26. Knowledge Check

27. Super Users

The terms “advanced user” and "super user" often apply to technologists with higher levels of access than
the rest of the team. Super users can have permission to turn certain data displays on and off and add
data to free fields. The configurable areas that advanced users might access include patient
demographics, examination data, image data, and plate exposure number. Changes made in these areas
often are more complex than simple orders to change the display or add a data column. Super users may
control additional data sets or end user access to those data sets.

28. Retrieve To Display

Manufacturers provide different types of user controls to manage images, even though the end product is
very similar. A touch screen, mouse, or keyboard is used to activate the modality workstation for retrieve-
to-display commands. As with most computer-based retrieval functions, it’s possible to indicate the
quantity and sequence of images, or studies, the user wants to retrieve. The display screen provides a
retrieval method or methods to step through the images or studies.

29. Editing Image Information

The designated privilege levels restrict who can edit and modify images and demographic data.
Manufacturers' systems allow varying amounts of change during and after installation. In most cases, the
institution and job responsibilities of users drive who can make these changes.

It’s important to understand that modifying demographic and image data alters the examination and
permanent patient record. Therefore, all changes must comply with institutional guidelines. If an order is

©2016 ASRT. All rights reserved. Essentials of Digital Imaging Module 3 – Display
modified after a work list entry is generated, this change must be described in the patient's chart with an
explanatory note. Again, the ability to make these changes depends on the privilege level of the user.

30. Manipulating Image Appearance

Editing image data can include altering image orientation, image and display annotation, stitching,
applying shuttering or a black border, adjusting image brightness and modifying image contrast.
Technologists must follow departmental policy and procedure and standard practice for any and all
modifications.

Imaging protocols require placing the digital capture device appropriately so that the resulting image is
displayed in the proper orientation. On occasion, when a patient's condition or exam parameters make
this impossible, modality workstation software allows the image to be rotated or flipped. The image on the
left is the original image and the image on the right has been flipped. The ability to flip images makes it
critical for the technologist to use lead, left or right side, anatomical markers at the time of image
acquisition. Doing so would help to minimize the potential for incorrect placement of electronic left or right
side anatomical markers that might be used in addition to lead markers for image acquisition.

31. Image Flip

The main processing page on Fuji’s cassette-based system allows an image to be flipped. The image is
flipped horizontally when the technologist selects the button on the left. This action moves the image
much like how you turn the page of a book. When the button immediately to the right of the horizontal flip
button is pressed, the image is flipped vertically, or upside down. These buttons can be pressed as many
times as necessary until reaching the desired orientation.

Konica’s cassette-based system also allows an image to be flipped from the main processing page,
although the user interface is very different. In this case, a menu of different images is brought up when
the technologist selects image flip. These images are thumbnail size and display all the possible
variations for flipping the image in horizontal and vertical directions.

The technologist can look through the thumbnail images and select the one that presents the desired
orientation. The image automatically is flipped once the thumbnail is selected. If the technologist does not
approve of this orientation, the entire process can be quickly repeated.

32. Annotating Images

Imaging departments have established protocols for the type and placement of the data displayed on a
digital image. The actual display may be different on a modality workstation and a PACS workstation.
There are a variety of annotations available that can be added to an image keeping in mind that left and
right side anatomical markers should always be used during image acquisition for legal reasons.

Technologists must include certain basic information on every digital image, just as they do for analog
images. Generally, the technologist performing the examination should alter the data, and most systems
provide a way to add text. Additional text may include predetermined labels such as, "erect," "10 min" and
so forth. Another method adds text by using a free-form text box. When using these display annotations,
technologists must follow standard practice and departmental policies and procedure.

Fuji’s cassette-based system allows image annotation from the processing menu. After the user selects
image annotation, a menu of preset annotation markers is displayed. Fuji’s system has 7 pages of
markers to choose from. The technologist selects the desired marker and then clicks on the image in the
general area where the marker should be displayed. The marker is automatically placed on the image
where it then can be moved to an exact location and enlarged if necessary. Multiple markers can be
placed on the same image.

The Fuji cassette-based system also allows technologists to type free text in a marker and place it on the
image using a dialog box. A technologist can type a note by clicking on the box in the image annotation
menu of the processing main menu. In this case the technologist typed “upright.” Once the technologist
has typed the necessary information, the marker can be placed on the image in the same way that other

©2016 ASRT. All rights reserved. Essentials of Digital Imaging Module 3 – Display
annotation markers are placed. This marker also can be enlarged and moved to any desired location.
Technologists should avoid placing the annotation directly over the anatomy displayed in the image.

33. Stitching
For examinations such as a scoliosis series or leg length study in which the anatomical parts are longer
than 43 cm, or 17 inches, multiple imaging plates or multiple exposures can be used to acquire the
image. When these images are obtained, the equipment provides an indexing mark to ensure that the
entire anatomical region is displayed.

The technologist can open the processed images on the workstation and use a software function to join
the separate images into a single-image format. This process is commonly referred to as stitching. After
the cassettes are processed in the correct order, the software uses the identifying markers in the
cassettes to join the anatomy, creating a continuous image.

34. Overlapping PSP

An alternative to making separate exposures for a scoliosis examination or a long-leg, hip-to-ankle,
examination is to use a specially designed cassette. The exam is performed as it would be with a film-
screen image receptor and only 1 exposure is needed. The cassette is designed so that the
photostimulable phosphor plates, or PSPs, inside the cassette overlap slightly to cover all the relevant
anatomy. Markers inside the cassette assist the stitching software to reconstruct the full-length image.

After the exposure is complete, the single cassette on the top is detached from the longer cassette and
placed into the plate reader to extract the image. The longer cassette on the bottom contains 2
photostimulable phosphor plates. The cassette is fed from 1 side first to unload 1 PSP. Once the image
extraction process is complete for that plate, the cassette is turned around and the final PSP is extracted
from the other end of the long cassette. In all, 3 cassettes are processed for a hip-to-ankle examination
and 2 plates are processed for a scoliosis exam.

It’s important to identify the exam to the plate reader before beginning the image extraction process, or
the stitching software won’t automatically stitch all the images together. A beam-attenuating marker also
should be placed on each PSP plate in case an image is misidentified.

35. Image Shuttering

A workstation software function allows a black mask to be placed over bright areas which is a practice
known as shuttering. Other terms for shuttering include “black border,” “black mask” and “collimation,”
although this type of collimation shouldn’t be confused with beam restriction. The mask can be configured
to apply automatically or manually, depending on the manufacturer. The ability to adjust the mask size
depends on the vendor as does the option to select a rectangle, circle, or polygon from the menu and use
the computer’s mouse to resize the shape to the desired shutter size over the image. Once the
technologist has shuttered the image or images to the desired size, the changes are accepted. The area
outside of the shuttered area is darkened, although a faint image of the anatomy can still be seen outside
the shuttered area.

Keep in mind that proper beam restriction, or collimation, to the area of interest is the accepted clinical
practice when working with digital equipment. However, when the image is displayed, it is typically
surrounded by an unexposed area that appears clear and extremely bright compared with the exposed
area. This bright area can result in viewer fatigue when displayed on PACS.

The black mask, border or shuttering should not be used in place of effective beam restriction to crop off
anatomy. It is critical to apply the black mask or shuttering to an image outside the actual collimated
border of the exposure field. This practice is important to show that the technologist exercised prudent
judgment in using beam restriction.

The Carestream system allows a technologist to shutter an image manually using a function called a
mask. The technologist uses a touch-sensitive screen to position the boundaries of the mask in the

©2016 ASRT. All rights reserved. Essentials of Digital Imaging Module 3 – Display
desired location. Once the lines of the mask have been properly set and accepted, the area outside the
shuttered area darkens, making it easier for the radiologist to view the pertinent anatomy.

36. Image Brightness and Contrast

Windowing is the term used when changing the clarity and variances of an image. By changing the
window levels, the technologist is adjusting what is called the brightness and contrast of that image.
Brightness refers to the overall lightness or darkness and contrast is the degree of differences in densities
of adjacent structures on an image. The differences in clarity and anatomical structures are manipulated
using varying degrees of technical factor selection.

37. Institutional Protocol

Although the capabilities of all digital imaging displays are similar, different terminology is used and
different processes are followed. It is essential to become familiar with the protocols and equipment used
at each facility.

38. Knowledge Check

39. Knowledge Check

40. Conclusion
This concludes Essentials of Digital Imaging: Module 3 -- Display. You should now be able to:
 Differentiate between a cathode ray tube and a liquid crystal display monitor.
 Define the characteristics of a monitor that affect image display.
 Explain the features of a modality workstation monitor.
 Describe how a modality workstation functions.

41. References
AAPM Report No. 116. An exposure indicator for digital radiography. July 2009. American Association of
Physicists in Medicine website. [Link] Accessed February 14,
2013.

Bushong SC. Radiologic Science for Technologists: Physics, Biology, and Protection. 10th ed. St Louis,
MO: Mosby Elsevier; 2012.

Carlton RR, Adler AM. Principles of Radiographic Imaging: An Art and A Science. 5th ed. Clifton Park,
NY: Thomson Delmar Learning; 2012.

Carroll QB. Radiography in the Digital Age: Physics, Exposure, Radiation Biology. Springfield, IL: Charles
C Thomas; 2011.

Carter CE, Vealé BL. Digital Radiography and PACS. St Louis, MO; Mosby Elsevier; 2009.

Practice Standards for Medical Imaging and Radiation Therapy. Radiography practice standards. June
19, 2011. American Society of Radiologic Technologists website. [Link]
regulations/practice-standards/practice-standards. Accessed February 14, 2013.

Seeram E. Digital Radiography: An Introduction for Technologists. Clifton Park, NY: Delmar Cengage
Learning; 2011.

Strategic Document. Version 2012-3, April 11, 2012. Digital Imaging and Communications in Medicine
website. [Link] Accessed February 14, 2013.

©2016 ASRT. All rights reserved. Essentials of Digital Imaging Module 3 – Display