Introduction to Medical Imaging

Modalities in Radiology
 Contents

• Objective • Dental Radiography

• Expected questions to know • Bone Mineral Densitometry
• Computed Tomography
after studying this lecture • Image Properties
• Introduction • Typical Technical Parameters
• Modalities in Radiology of Diagnostic X-ray
• Radiography Equipment
• Detectors used in X-ray • Summary/ Learning
Imaging Outcomes
• Expected Questions
• Fluoroscopy • References and sources
• Mammography for additional
information
 Objective
• To become familiar with basic knowledge of the components of the
radiographic chain.
• To become familiar with the component of the fluoroscopy system (design,
technical parameters that affect the fluoroscopic image quality and Quality
Control).
• To understand the principles of interventional radiology system including
equipment design, operational consideration and Quality Control.
• To understand the principles of dental radiology system and
mammography system
including design and Quality Control.
• To understand the principles and the technology of CT equipment.
 Topics to know after studying this
lecture
• Different modalities of X-ray imaging
• Different Detectors used in X-ray Imaging
• How X-ray image is formed in radiography?
• Difference between mammography system and diagnostic X-ray
system
• Difference between Dental (intra-oral) and Dental (OPG)
equipment
• Difference between radiography & CT images
 Introduction
• X-rays were first discovered by German Physicist, W. C. Roentgen
in 1895.
• In India, medical x-rays were first used in1898 within three years
of the discovery of X-rays.
• In 1972, Computed Tomography was first introduced in medical
field.
• In 1913, Albert Solomon, German Surgeon, was the first scientist
who used X-ray
techniques in breast cancer radiology which came to be known as
mammography.
• In 1960, John R. Cameron invented the bone densitometer. 5
 Introduction
• Medical imaging of the human body requires some form of energy (radiation). In imaging
techniques used in radiology, the energy used to produce the image must be capable of
penetrating tissues.
• In diagnostic X-ray imaging, images are formed by the interaction of the X-ray beam with the
patient.
• As the X-ray beam passes through the patient, the photons interact with the body
tissues and are absorbed/scattered by the patient. The degree of absorption is related to the
density of the material that is in the beam’s path.
• Dense objects (such as bone and metal) have a high degree of photon absorption, while less
dense objects (such as fat and water) absorbs less photons.
• The differential absorption of photons by different materials in the photons' path results in the
beam exiting
the patient with different intensities. This is known as transmitted beam.
• A detector is used to measure the intensity variation, thus providing information on the
different densities in the beam’s path.
 Imaging Modalities in Radiology

The different modes of making images are referred to as imaging

modalities. Each Imaging Modality has its own applications in
medicine.
Various Modalities of Radiology are:
• Radiography
• Fluoroscopy
• Mammography
• Dental Radiography
• Bone Mineral Densitometry
• Computed Tomography
Origin of X-ray Source remains same
for all x-ray imaging devices
i.e X-ray tube

Evacuated
glass tube

Target

Filament
 Radiography
• Radiography X-ray equipment has an x-ray tube on one side and an x-ray detector on the
other side of the patient. A short duration pulse of x-rays is emitted by the x-ray
tube, a large fraction of the x- rays interacts in the patient, some of the x-rays
pass through the patient (transmitted x-rays) and reach the detector. These
transmitted x-rays form the radiographic image on the film/detector.
• In radiography, the image is formed with screen-film system, CR cassette or with digital
detectors.
• In screen-film radiography, areas of high intensity (thus low material absorption) within
transmitted beam result in more blackening of the film, while areas of low intensity
(thus high material absorption) will result in less blackening of the film. The film will
remain white in areas with no photons.
• Human body is made up of tissues with varying densities, in the film black corresponds to
tissues with little attenuation (such as air) and white corresponds to tissue with a
high degree of attenuation (such as bone).
Radiography....

• Radiography is a transmission
imaging modality.
• Radiography is also referred as
projection
imaging modality.
• Projection imaging refers to the
acquisition of a two–dimensional
image of the patient’s three-
dimensional anatomy.
• Typical tube voltages range from 50
-150 kVp.
Typical layout of a Radiography
room
 X-ray Image
Formation
Film, fluorescent screen
or image intensifier
Scattered
radiation

« Latent »
Bone radiological
Image
formed by
X Soft
tissue transmitted
beam
Air
Primary
collimation

Antiscatter Grid Beam intensity

at detector level
Image acquisition-Detectors used in Radiography

1) Screen film based

2) Photostimulable phosphor plates
(PSP).
– Called CR (computed radiography)
3)Direct digital radiography (flat panel
detectors)
-------Direct conversion (selenium)
12
-------Indirect conversion (scintillation)
 Detectors used in X-ray
Imaging
Screen- Film System
• The X-ray film is sandwiched between two intensifying screens. Radiographic film consists of one
or two layers of film emulsion {grains of silver halide, silver bromide (AgBr )and silver iodide (AgI)
bounded in a gelatin base} coated on a flexible sheet of Mylar (a type of plastic).
• Intensifying screens are made of a scintillating material, called phosphor. Earlier screens use
calcium tungstate phosphors, while now rare earth screens use gadolinium or lanthanum phosphors.
Gadolinium Oxy Bromide and Lanthanum Oxy Sulphide are some commonly used intensifying screen
phosphors.
• Intensifying Screens are used to reduce the radiation dose to the patient in diagnostic radiography.
• As X-ray films are more sensitive to light than X-rays, the Intensifying screen are used to convert X-
rays falling on it into light. Each X-ray photon falling on the screen releases many light photons,
which reach the film and form the image.
• Image formation is done by transmitted radiation. However, scatter radiation also reaches the film,
thereby reducing the image quality. The antiscatter grid (bucky) is used to cut off the scatter radiation
reaching the film. It is placed above the screen-film during imaging.
 Film-Screen
Imaging
Traditionally, all X-ray image capture has been through X-ray
film
Emulsion

Protective
Adhesive
layer Film base layer

Emulsion
 Intensifying
screens
• Film is relatively insensitive to X-rays directly
• Only about 2% of the X-rays would interact with the emulsion
• Requires unacceptably high doses to give a diagnostic image
• An intensifying screen is a phosphor sheet the same size as the film,
which converts the X-rays to a pattern of light photons
• The intensity of the light is proportional to the intensity of X-rays
• The pattern of light is then captured by the film
• One exception is intraoral dental radiography, where screens are
not practical
 The film-
• Flat, cassette
light tight box with pressure pads to
ensure film in good contact with
the screen(s) mounted on the front
(and back)

• The tube side of the cassette is low

atomic number material (Z~6) to
minimise attenuation
• Rear of often backed to
minimise
cassette lead (not
mammography)
back scatter in
 Film
Processing
• The invisible latent image is made
visible by processing
• There are three stages to this process;
• Development
• Fixing
• Washing
Computed Radiography
(CR)
 Computed
Radiography
• Computed radiography (CR) is a marketing term for photostimulable
phosphor (PSP) detector systems.
• When X-rays are absorbed by photostimulable
• Phosphors, some light is promptly emitted much of absorbed
energy is trapped in the PSP screen and can be read out later
• CR imaging plates are made of BaFBr and BaFI
• The imaging plate is exposed in a procedure identical to screen-film
radiography
and the CR cassette is then brought to a CR reader unit
• The cassette is moved into the reader unit and the imaging
plate is mechanically removed
Rota ing
Mirror

Tr.ans
a1lion
R.orUe
r' S
PSP digitizer

Cassette and PSP

Digital
Radiography

Workstation
Digital
Radiography
 Digital Radiography
• Receptor provides(DR)
direct digital
output
• No processor / reader required
• Images available in < 15 seconds
• Much less work for technologist
Digital Radiography
System • Digital radiography is
performed with a system
of the following
functional components:

• A digital image receptor

• A digital image processing
unit
• An image management
system
 Risk of increased
doses
•The wide dynamic range of digital
detectors results in good image quality while
using high dose technique at the entrance
of the detector and at the entrance of the
patient
•This is not possible with conventional screen-
film systems since high dose techniques always
result in an image which is too dark
 Detectors used in X-ray
Flat Panel Detectors
Imaging…
Indirect Flat panel Detectors: Indirect flat panel detectors are sensitive to visible light, and an X-ray
intensifying screen is used to convert incident X-rays to light, which is then detected by the flat
panel detector. Silicon is commonly used flat panel detector.
Direct Flat panel Detectors: Direct flat panel detectors are made from a layer of photoconductor
material on top
of a Thin-Film-Transistor (TFT) array. Selenium is commonly used as the photoconductor.

Indirect Flat Panel Direct Flat Panel

Detector Detector
 Fluoroscop
• Fluoroscopy refers to the y
continuous acquisition
of a sequence of x-ray images over time,
essentially a real-time x-ray movie of the
patient. It is called dynamic imaging.
• Most general-purpose fluoroscopy systems use
television technology, which provides images at
the rate of 30 frames per second.
• Newer fluoroscopy systems allow the acquisition of
a real- time digital sequence of images (digital
video), that can be played back as a movie loop.
• Fluoroscopy is used for positioning catheters in
arteries, for visualizing contrast agents in the
gastrointestinal (GI) tract, and for other
medical applications such as invasive
therapeutic procedures where real-time image
2
feedback is necessary. 7
 Fluoroscopy
Fluoroscopy mode of Operation ….
Continuous Fluoroscopy
• Continuous fluoroscopy is the basic form of fluoroscopy. It uses a continuously
on x-ray beam using typically 0.5 and 4 mA
(depending upon patient thicknesses).
• A video camera displays the image at 30 frames/sec, so that each fluoroscopic frame
requires 33 milliseconds.
Pulsed Fluoroscopy
• In pulsed fluoroscopy, the x-ray generator produces a series of
short x-ray pulses. Pulsed fluoroscopy offers better image quality in
fluoroscopic procedures where body motion is high.
• Pulsed fluoroscopyat variable frame rates (typically 30,15 and 7.5
frames/sec) allows the
fluoroscopist to reduce temporal resolution when it is not needed sparing dose in
return.
Last –Frame –Hold
• When the fluoroscopist takes his or her foot off of the fluoroscopy pedal, rather
than seeing a blank monitor, last-frame-hold enables the last live image to be shown
continuously, until the next image acquisition.
 Detectors used in
Fluoroscopy…
In fluoroscopy equipment following detectors are used:
• Intensifying Screen: Used in conventional fluoroscopy
• Image Intensifier: (discussed below)
• Digital detectors: As discussed in the earlier slides of
Radiography

Image Intensifier
The function of the x-ray Image Intensifier is to convert an x-
ray image into a minified light image.

Input screen (CsI): conversion of incident X-rays into light

photons 1 X –ray photon creates  3,000 light photons

Photocathode: conversion of light photons into electrons

only 10 to 20% of light photons are converted into
photoelectrons

Electrodes : focalization of electrons onto the output

screen. electrodes provide the electronic
magnification 2
9
Output screen: conversion of accelerated electrons into
 Fluoroscopy
….
C-Arm equipment

• Ability to maneuver c-arm around

patient without moving the patient

• Often used as “mobile” unit

• Critical care units
• Operation Theatre

• Modern units allow fluro +

radiography

3
0
 Fluoroscopy
….
Angiography

• Angiography is a specialized
examination
fluoroscopic in which a contrast agent
is used to highlight
vasculature in the patient.
• Contrast is a radiographic (high
density) material
injected into the blood vessels of the patient.
• Vessels containing contrast show up dark
on the image, while areas without contrast
show up bright.
• Advanced techniques, such as Digital
Subtraction Angiography can be utilized to
improve vessel visualization and also guide
percutaneous tools. 3
 Fluoroscopy…
..
Interventional radiology
• Interventional radiology uses the high C-
capacity
equipment with additional features armto
guide minimally invasive
•surgical procedures.
Interventional radiology comprises
guided therapeutic and diagnostic techniques.
fluoroscopically
• Interventional techniques are used during
diagnostic interventions or for therapeutic
purposes as well as during surgical procedures
to guide or monitor the surgeon’s actions.
•A good knowledge of equipment
specification and characteristics is essential for
an effective optimization of radiation protection

Typical layout of an IR facility

 Mammograp
• X-ray hy is the most
mammography reliable method of
detecting breast cancer.

• It is employed both as a screening tool and for diagnosis.

• Mammography also uses x-rays for breast imaging;

however, there are fundamental differences between a
mammography system and a diagnostic x-ray system. Due
to the tissue characteristics of the breast and pathology of
interest, mammography systems utilize lower tube potential
(15-35 kVp ).
• Molybdenum (Mo) and Rhodium (Rh) are the commonly
used
target/filter combinations in mammography.
Characteristic X-ray produced by these target materials is used
for breast imaging.

• In addition, two compression plates are used to

decrease breast thickness and minimize motion, thus
resulting in the less scatter radiation and better overall
image quality.

Typical layout of Mammo room

 Dental
Radiography
A) Dental (Intra-oral x-ray
•examination)
Dedicated equipment used for radiography of tooth with
low power stationary anode tube
• Tube is deployed on an extendable arm for easier
positioning
• Tube potential : 60-70 kVp
• Tube current : 6-7 mA
• Exposure is varied by altering the exposure time
• Exposure time varies from 30 ms to 2.5 s
10 cm for 60 kV,
• Focus-skin distance
20 cm for 60-75
• kVp
Diameter of lead cone (collimator) diameter shall be less
than 7.5 cm at the end of cone.
It uses x-ray film (without film) or sensor for imaging purpose as
detector.
 Dental
Radiography…
B) Dental (OPG)
• Both film and Tube head rotate around the patient:
The X-ray tube rotates around the patient head in one direction and
the film rotates in the opposite direction, while the patient sits
(or stands) in a stationary position.
• The collimator used in the panoramic x-ray machine is a lead
plate with a narrow vertical slit.
• The Tube head always rotates behind the patient head as the film
rotates in front of the patient.
• Tube potential 85-90
• Tube current: kV
• Exposure time 4-15
: 12 s (typically standard OPG
mA
scan)
0.16-3.2 s (cephalometric
projection)
• Flat panoramic cassette 15 cm x 30cm
 Dental
Radiography…
C) Dental (CBCT)

• Dental Cone Beam CT scanner uses a cone shaped x-ray

beam rather than a conventional linear fan beam, as
in the case of common CT, to provide images of the
skull bony structures.

• Tube potential: 85-90 kV

• Tube current: 4-15 mA

• Leakage from tube housing: less than 1.0 mGy in one hour
at 1m from focus of Dental Cone Beam CT scanner.
 Bone Mineral Densitometry
Equipment
• Bone density or bone mineral density
(BMD) is the amount of bone mineral in bone
tissue.

• Bone density scanning, also called dual-energy

x-ray
absorptiometry (DEXA) or bone densitometry.

• Two x-ray beams with different energies are

aimed at the patient’s bones. When
soft tissue absorption is subtracted out, the
BMD can be determined.
• Tube potential : 80-140 kV
• Tube current : 1.5-7 mA
• Bone density testing is used to assess the
strength of the bones and the probability
of fracture in persons at risk for osteoporosis.
3
7
 Computed
Tomography
• Computed Tomography (CT) was introduced into
clinical in 1972 and revolutionized
practice imaging
X-ray providing high quality by
images which transverse cross reproduce
sections of the body. d

• The technique offered in particular

improved low contrast resolution for better
visualization of soft tissue, but with
relatively high absorbed radiation dose.

• CT uses a rotating X-ray tube, with the beam in

the form of a thin slice (about 0.5 - 10 mm).

• The “image” is a simple array of X-ray

intensity, and many hundreds of these are
used to make the CT image, which is a
“slice” through the patient.
 Computed
Helical Spiral (CT)
Tomography
• If the X –ray tube can rotate constantly, the patient can then be moved continuously through the
beam, making the
examination much faster.
• For helical scanners to work, the X –ray tube must rotate continuously.
• Helical CT imaging allows for the continuous movement of the CT Couch during imaging.

• Scanning
Geometry

X-ray beam

Table
movement

• Continuous Data Acquisition and Table

Feed
 Computed
Tomography
Generator
• High frequency, 30 - 70 kW
X- ray tube
• Rotating anode, high thermal capacity: 3-7
MHU
• Dual focal spot sizes: about 0.8 and 1.4
mm

Gantry
• Aperture: > 70 cm of diameter
• Detectors: solid state; > 600 detectors
• Scanning time: <1 s, 1 - 4 s
• Slice thickness: 0.5 - 10 mm
• Spiral scanning: up to 1400 mm
 Computed
Tomography
• Computed Tomography (CT) images are produced by
passing x-rays through the body, at a large number
of angles, by rotating the x-ray tube around the
body.
• Multiple linear array detectors, opposite the x-ray
source, collect the transmission projection data. The
numerous data points collected in this manner are
synthesized by a computer into a tomographic
image of the patient.
• The term tomography refers to a picture (graph) of
a slice (tomo).
• CT is transmission technique that results in images of
individual slices of tissue in the patient.
• The advantage of a tomographic image over projection
image is its ability to display the anatomy in a slice
of tissue in the absence of over or underlying
structures . Typical layout of CT room
 Typical Technical Parameters of Diagnostic X-ray
Equipment
Sr. No. Type of diagnostic x- Maximum Maximum
ray equipment operating operating current
potential (kVp) (mA)
1 Radiography/ 150 1100
Radiography &
fluoroscopy
2 C-Arm 110-120 150
3 Dental (intra-oral) 60-70 6-7 (up to 10 mA)
4 Dental (extra-oral) [OPG/CBCT] 85-90 10-15

5 Computed Tomography 140 800

6 Interventional Radiology 150 1250
7 Mammography 49 (Mainly 35 kVp) 200

8 Bone Densitometer 140 5-7

 Summary/Learning Outcomes

• This Presentation gives a brief overview of all diagnostic x-ray

imaging modalities.
• This presentation elaborates the technical aspects of
various X-ray imaging modalities, image detection systems,
operating parameters and image properties of medical diagnostic
X-ray equipment.
• This presentation will be helpful for the medical professionals
associated with use of diagnostic X-ray equipment for
understanding the various x- ray based imaging modalities
and their applications in the field of medicine.
 Expected
Questions
Q.1 How radiography examination is performed of a patient?
Ans. Radiography is performed with an x-ray source on one side and an x-ray detector on
the other side of the patient. A short duration pulse of x-rays is emitted by the x-ray
tube, a large fraction of the x-rays interacts in the patient, some of the x-rays pass
through the patient (transmitted x-rays) and reach the detector. These transmitted x-
rays form the radiographic image on the film/detector.
Q.2 Why intensifying screens are used in radiographic examinations?
Ans Intensifying Screens are used to reduce the radiation dose to the patient in diagnostic
.
radiography. The main function of the Intensifying screen is to convert x-rays falling on
it into light.
Q.3 What is the function of image intensifier?
Ans The function of the x-ray Image Intensifier is to convert an x- ray image into a minified
. light image.
 Expected
Questions
Q.4 What is fluoroscopy?
Ans. Fluoroscopy refers to the continuous acquisition of a sequence of x-ray images over time, essentially a
real-time x-ray
movie of the patient. It is called dynamic imaging.
Q.5 How occupational exposure can be minimized in interventional radiological procedures?
Ans. Using protective lead
aprons Avoiding direct
beam Maintaining
distance
Limiting the total beam–on time Avoiding
oblique lateral projections
Q.6 Which type of x-ray radiation is used in mammography examinations?
Ans Characteristic x-ray radiation is used in mammography examinations.
.
Q.7 What is the limit of tube housing leakage for dental (intra oral) x-ray equipment?
Ans Leakage from tube housing shall be leas than 0.25 mGy in one hour at 1m from focus of dental (intra-
. oral) equipment.
 Expected
Questions
Q.8 How Dental (OPG) scans of patient is performed?

Ans In Dental (OPG) scans, the X-ray tube rotates around the patient head in one direction
. and the film rotates in the opposite direction, while the patient sits (or stands) in a
stationary position.

Q.9 What is the advantage of tomographic image over projection image?

Ans The advantage of a tomographic image over projection image is its ability to display the
. anatomy in a
slab (slice) of tissue in the absence of over or underlying structures. It improves its image
contrast
Q.10 What do you mean about the contrast of the image?

Ans. Contrast in an image is the difference in the gray scale of the image. It is the difference
in darkness of
the image and its surroundings.
 References and sources for additional
information
• The Essential Physics of Medical Imaging (J. T. Bushberg, J.A. Seibert,
E.M. Leidholdt, J M Boone)
• The Physics of Radiology (H.E. Johns, J.R. Cunnighnam)
• IAEA Presentations on Diagnostic Radiology
List of presentations in the training Module

Basics of Diagnostic X-ray Equipment

Biological effects of Radiations
Medical X-ray imaging techniques
Planning of Diagnostic X-ray facilities
Quality Assurance of X-ray equipment
Quality Assurance of Computed Tomography equipment
Radiation Protection in Diagnostic Radiology Practice
Causes, prevention and investigation of excessive exposures in
diagnostic radiology
Regulatory Requirements for Diagnostic Radiology Practice