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Computers Application in Radiology Dr.

Awadh Alqubati

Computers Application in
Radiology

By:

Dr. Awadh Ali Alqubati


Computers Application in Radiology Dr. Awadh Alqubati

Outline

Introduction

Section I: History of computerized radiography

Section II: Computer basics

Section III: Pixels and Voxel

Section IV: Hardware used in digital radiography

Section V: The digital imaging processor

Section VI: Fundamentals of Computed Radiography (CR)

Section VII: Overview on using the CR System

Section VIII: Concepts of Direct Digital Radiography (ddR)

Summary and References


Computers Application in Radiology Dr. Awadh Alqubati

Course Objectives

Upon completion the reader will be able to:

 Define basic terms of the binary computer system: byte, kilobyte, megabyte,
gigabyte, and terabyte.

 Define the terms pixel, voxel, and their relationship to digital imaging gray scale.

 Discuss the formation of a digital image and digitalization.

 State the ionizing radiation range for photostimulable phosphors using


electromagnetic radiation and alpha particles.

 State other medical or scientific applications for photostimulable phosphor imaging


besides CR and DR imaging.

 Define the terms pixel and voxel.

 Discuss how the gray scale seen with digital imaging is produced electronically.

 Discuss the historical aspect of the development of computerized radiography.

 Define the term image matrix and what is meant by gray-scale dynamic range.

 Calculate the number of pixels an image may have given the matrix size.

 State two components of a computers CPU and discuss their functions.

 List 2 components of the digital image processor and discuss the application of each
to imaging.

 List the basic hardware components of a CR imaging system.

 Define what is meant by the term photostimulable phosphor.

 Discuss the process of photostimulation luminescence.


Computers Application in Radiology Dr. Awadh Alqubati

 State the wavelength of light needed to cause photo luminescence and the wavelength
of light emitted from the phosphors during laser scanning of the plate.

 Discuss why the photostimulable plate must be erased following each exposure and
reader scan.

 Define the term exposure index and discuss its role in technique selection by the
technologist.

 Discuss text information data entry into the CR unit using the RIS/HIS broker.

 Discuss the process of cassette labeling for reader algorithm selection during
processing of the image plate.

 State the role of CR image capture into PACS for image display and storage.

 Discuss what direct digital radiography (ddR) is and how it is revolutionary over
analog radiography and computed radiography.
Computers Application in Radiology Dr. Awadh Alqubati

Outline

Introduction
I. History of computerized radiography
II. Computer imaging basics:
a. Binary system; Bits and Bytes.
b. Digital imaging shades of grey.
c. Formation of the digital image and digitalization.
III. Pixels and Voxels
a. Gray-scale range and dynamic range.
b. Image matrix and pixels
c. Spatial resolution and pixel size
d. From pixel to voxel
e. 3D reconstruction
IV. Hardware used in digital radiography
a. The CPU and its component features
b. Computer memory primary and secondary memory
c. Applications, programs, routing software.
V. The digital imager processor
a. Analog-to-Digital converter
b. Look-up Tables (LUT) and their functions
c. ALU and Array processor
VI. Fundamentals of computed radiography (CR)
a. Photostimulable phosphor plates and cassette holders
b. Mechanisms of Image storage phosphor imaging
c. Exposure characteristics of photostimulable phosphors
d. Photostimulation using laser scanner and image amplification
e. PMT and image signal focusing
Computers Application in Radiology Dr. Awadh Alqubati

f. Image viewing on CRT


g. Exposure index
VII. Overview on using the CR system
Computers Application in Radiology Dr. Awadh Alqubati

Introduction

Radiography has evolved from screen-film imaging to a highly integrated, high


quality image and information acquisition, display, archival, and retrieval system. The
characteristics of images produced and processed for analog standards are the result of
many consultations with radiologists over decades, which led to improved discrimination
of image detail; the same is now true of digital imaging. As with conventional x-ray film-
screen imaging, radiographic image quality for digital imaging remain driven by
radiologist preference and their tolerance for image noise. Through much consultation
with radiologists and the American College of Radiology, digital standards that display
fine image details and yield high sensitivity and specificity are now in place. These
standards are continuously being evaluated and are a part of an ever evolving Digital
Imaging and Communications in Medicine (DICOM) language. Notwithstanding, the
radiographer still controls certain factors that determine the quality of a digital image
including: the use of ionizing radiation, handling raw image data to be sent to Picture
Archiving and Communication Systems (PACS) or to film printing, and patient
positioning. In this module we will discuss some of the principles of digital radiographic
imaging that when practiced by the technologist may enable the radiologist to resolve
diagnostic issues.

Time has proven that the generic performance of x-ray equipment, radiographic
technique selection (mAs and kVp), and film processing within a given institution and
between institutions is variable enough to make optimal imaging for all viewers under
screen-film standards impossible. The need for optimization of radiographic images has
spawned a new way in which radiographs are acquired-digitally. The use of computers to
capture and process radiographs have given the viewer new tools that allow for dynamic
manipulations of digital images through processes like changing algorithms and
windowing. Windowing allows the viewer to change the contrast and density of an image
to ones liking but does not permanently change the stored raw data. With digital imaging
each viewer has the flexibility to control subject and radiographic density while viewing
Computers Application in Radiology Dr. Awadh Alqubati

a radiograph. A fundamental difference between PACS and computed radiography


(CR)/direct digital radiography (ddR) is that CR/ddR allows the technologist to change
the raw data prior to saving it. If the technologist changes the raw data prior to sending it
to PACS it is permanently lost to PACS and therefore to diagnostic and clinical
workstations. Radiographer professionals must understand when and how we may
manipulate raw digital image data and its impact on others who may make algorithm and
windowing changes when viewing stored images from PACS.

In addition to achieving high quality digital images with CR/ddR imaging,


implementing ALARA (as low as is reasonably achievable) has been very difficult. The
difficulty lies in trying to use dose reduction techniques commonly practiced with analog
film imaging. Principles that apply to film/screen imaging, mainly selecting mAs, kVp,
source-to-image distance (SID), decreasing object-to-image receptor distance (OID) , or
trying to achieve wide latitude techniques with automatic exposure control have
transferred nicely to digital imaging. But maintaining high diagnostic imaging standards
within the noise tolerance most radiologists will accept and practicing ALARA has been
very difficult with digital imaging. Analog film production has reached its full potential
for achieving wide exposure latitude and minimal patient dose; however, better
communication and display of radiographic images, as well as film duplication and
archiving are fixed in antiquity. Fixed images on a film can only be viewed by one set of
observers and requires shuttling between physicians to be viewed. Furthermore, the
incidences of lost films and archiving pitfalls of analog imaging have reached the limits
of radiographers' tolerance.

Digital computerized radiographic imaging (CR) has achieved technological


improvement over analog film imaging by optimizing each function of radiographic
imaging from production and its subsequent communication layers of image display,
archiving, and image retrieval as independent developments that enhance the total
diagnostic process. The basic advantages of CR and direct digital radiography over
analog imaging is the optimization of image acquisition, optimization of image display,
optimization of image transmission, and optimization of image storage as independent
Computers Application in Radiology Dr. Awadh Alqubati

but closely networked functions. The key word here is optimization. The management of
digital images through PACS has many functions within each specific layer, for example,
digital images can be stored on multiple servers, on optical disk, and on digital linear tape
for back-up files. The advantage is that these images are never lost, easy to retrieve, easy
to purge, easy to distribute, and privacy is protected by passcode and user authorization.
These optimizations are not possible or cost effective with analog films. PACS should be
an integral part of any CR/ddR system, and existing radiographic equipment can be used
with CR and PACS with minimal modifications.

Computerized x-ray like imaging is not unique to radiography; it is used throughout


the scientific community in areas like molecular biology and chemistry for
autoradiography and pulsed-field gel electrophoresis. Its wide spread use is due to the
sensitivity of photostimulable phosphors and improvements in light detector technology.
Modern detectors can differentiate light emission by photostimulation for
electromagnetic radiation exposures of slightly greater than 100 milliroentgen (mR), and
as low as 0.195 alpha particles per square millimeter equivalency for particulate
radiation. This makes photostimulable phosphor technology a very useful and powerful
tool in resolving radiation patterns traditionally captured in radiographic film from X-ray
diffraction, protein crystallography, and electron microscopy techniques.

Computerized radiography is a digital imaging science that uses photostimulable


phosphors to create images rather than photographic screens and film. In this module we
will discuss the characteristics of these phosphors, and how CR images are formed as
well as discuss the various components of the computed radiography system.
Computers Application in Radiology Dr. Awadh Alqubati

Section I:

History of computerized radiography

As early as 1975 the Eastman Kodak company patented a device that used
thermoluminescent infrared stimulable phosphors thereby releasing a stored image.
Unfortunately its design application was towards improving a nearly antiquated
microfilm storage system. The FUJI Photo Film Company recognized the far reaching
possibilities of this new discovery and in 1980 patented the first process that made use of
photostimulable phosphors to record a reproducible radiographic image. The basic
common finding of both applications was that some phosphors (called storage phosphors,
a.k.a. photostimulable phosphors) could capture an image from absorbed electromagnetic
or particulate radiation. Part of the energy stored in the phosphor was afterwards released
when stimulated by a high frequency helium-neon laser. By detecting the phosphor’s
luminescence using a photomultiplier tube (PMT) to generate an electrical signal that was
ultimately reconstructed into a digital radiographic image-computerized imaging was
born.
Computers Application in Radiology Dr. Awadh Alqubati

Section II:

Computer basics

Computers are ubiquitously used throughout radiology; however, the focus of this
module is their use in medical imaging modalities such as: nuclear medicine (NM),
ultrasound (U/S), magnetic resonance imaging (MRI), computed tomography (CT), direct
digital radiography (ddR), computed radiography (CR), digital subtraction angiography
(DSA), bone densitometry (DEXA), and others. Because there are so many different
vendors, each with their own special equipment features it is impossible to cover all the
particulars of any given manufacturer. But what we can do is give an overview of how
digital imaging processors, computer hardware, and software are designed to function
together to produce electronic patient image files. However, before we can indulge in the
smorgasbord of information on the subject we must discuss some of underpins of
computer technology in order to place our discussion into its proper context.

Computers manipulate data based on what is called a binary numbers meaning two
digits. A binary system requires that any binary number can have only one of two
possible values. For computer technology the two digits used are zero or one (“0” or
“1”), and are referred to as binary digits or "bits". Using these digits many combinations
of numbers are spread out on a grid of rows and columns called a matrix. The matrix can
have thousands even millions of tiny “bits” of information in the form of varying
densities that make a digital image. Digital medical imaging is now mainstream
radiology being validated monthly in every medical journal nationally and
internationally. Almost all dialog on radiology imaging issues, case studies, new
procedures and the like, are referenced to digital imaging. Therefore, it is utterly
important for the radiographer to understand how digital imaging works as this “not so
new” technology is now an integral part of our armamentarium of imaging skills.

No doubt, you have heard or seen computer advertisements that use the words bits
and bytes, such as an ad for a 16-bit Pentium processor with 256 megabytes of RAM.
Computers Application in Radiology Dr. Awadh Alqubati

These words have meaning to our profession and practice of modern radiography. How
digital information is acquired and displayed are partly in the control of the radiographer.
In this section, we will look at some concepts in a way that can edify our understanding
of digital imaging, particularly its application in computed radiography and direct digital
radiography science.

Bits and Bytes

Mathematics uses numbers called digits to represent dimension having a magnitude


ranging from 0 to 9. They can be combined in a variety of ways to create large or smaller
values and fractions thereof. Numbers and therefore bits have weighted value. For
example, the number 4,325 is understood to mean that the 4 fills the 1000s place, 3 the
hundreds place, 2 the 10s place, and 5 fills the 1s place. Mathematically numbers can be
express in a variety of equivalent ways. Using the number 4,325 we can illustrate this
point:

(4 x 1000) + (3 x 100) + (2 x 10) + (1 x 5) = 4000 + 300+ 20 + 5 = 4325

Or, as powers of 10

(4*10^3) + (3*10^2) + (2*10^1) + (5 x10^0) = 4000 + 300 + 20+ 5 = 4325

The number system we all learned in elementary and secondary schools taught us
the basic functions of the base-10 system: addition, subtraction, multiplication, division,
algebraic and geometric expression, and the like. This system used ten different digits
with values from zero to nine. Nevertheless, we will see that any base system of numbers
can be adapted, such as a base-8 digit system, or a base-14 digit system that would
require us to invent new digits. So long as we all agree to the terms of numerical use and
its meanings, the number of digits can vary. In computing, we use what is called a binary
number system or base-2 system because it is simple and limitless data combinations are
Computers Application in Radiology Dr. Awadh Alqubati

possible without redundant lettering. As we have stated, in the binary number system
there are only two digits, zero and one (“0” and “1”). But in all fairness to our base-10
system we could have computers operate on ten digit technology: the expense of doing so
would be outrageously pricey.

Computer binary codes can have only two digits "0" and "1" that are used to make
numbers of all mathematical magnitude. Consider the use of binary coding to count from
0 to 20:

To our advantage, bits are not referred to singly or used singly in assembling
computed data; instead, they are bundled together as a collection consisting of 8 bits,
which is called a byte. Therefore, eight bits equals one byte. This terminology is more
than just an arbitrary arrangement for our numbers to have like meaning analogous to a
dozen being equal to twelve. What is gained by grouping numerical bits into bytes are
more mathematical combinations for our two digits that permit more discretely
identifiable values. For every one byte of numerical formatting 256 values or details can
be represented. Each value can be a letter of the alphabet, a character like those on a
typewriter, a symbol, or part of a language, a representation of light brightness, a unique
radiographic density, or any of many other possibilities. Byte groupings give our
numbering a slightly different representation. Consider the numbers “0”, “1”, and
“245”below p>
Computers Application in Radiology Dr. Awadh Alqubati

0 = 00000000
1 = 00000001
2 = 00000010
...

254 = 11111110
255 = 11111111

With 1 byte it is possible to differentiate 256 shades of grey in a matrix. Then, with
each added bit, the number of potential details is at least doubled. For example, 9 bits
will discriminate 512 density differences, and with 10 bits 1,042 shades of grey are
possible, 11 bits correspond to 2048 densities, 12 bits can show 4096 contrast grey
shades, and so forth. A computer device that uses 16 bits will give each sample a density
range of 0 to 65,535:

0 = 0000000000000000
1 = 0000000000000001
2 = 0000000000000010
...

65534 = 1111111111111110
65535 = 1111111111111111

Consider that each bit represents a yes/no, or on/off switch for a specific detail or
density. By design “on or yes” is typically controlled by a low voltage. This voltage is
about 5 volts or lower, and “off or 0” is near zero voltage. Modern electronics manage the
change in low voltage using microchip technology. These highly complex circuitries are
compressed to form small plastic circuit boards and given the name an ‘integrated
circuit’. Such circuits are made of silicon or other semiconductor materials which have
Computers Application in Radiology Dr. Awadh Alqubati

the ability to move electrons thereby performing compound electrical processes. These
circuits are best known as “silicon chips.” Voltage within the chip (generally 5 volts)
represents the binary digit “1,” and the binary digit “0” is represented by zero voltage.
The same is true for a value of off or on, off being zero voltage and 1 being 5 volts.
Another way of looking at the binary code is that each of the digits either represents an
event or the absence of an event. Voltage or absence of a voltage can represent a yes/no
switch, or can be a point on an optical disc which is marked or unmarked, or a
magnetized part of a streamer tape or LED carrying information such as ones ATM bank
card number.

What is amazing about the electrical component of digital information is the very
high speed at which the two voltage levels can be changed within a circuit resulting in
the manipulation of digital binary information. We should all applaud those scientists
who developed low voltage micro circuitry. Not only because of the applications of low
voltage, but because it allows computers to have a low heat output, greatly reduced the
size of all components. As a result, computers do not require special air cooled rooms to
help with the distribution of heat as was once required. Low voltage micro chip
technology help bring computers into the mainstream for all occupations, business, and
personal use.

Now getting back to our discussion of the byte we can see why it is the most
common base unit of binary-coded information. In computer language a byte is also
called a character, often abbreviated char. Bytes are used to hold individual coded
characters in a text document. An example of how the code is applied to a character set is
the ASCII character set. ASCII is a character code language that makes use of binary
numbers to store text documents both on disk and in memory. You may be using this code
when you type a document on your computer such as the one you are now reading. The
binary coding is used to create numbers and character as well as the space bar between
words, punctuations, etc.
Computers Application in Radiology Dr. Awadh Alqubati

Basic coding requires a lot of memory and bytes; therefore, plenty of memory is
required for ongoing operations of computers used in radiographic imaging. Prefixes
such as kilo (kilobyte), mega (megabyte), etc. are common terms; however, they do not
correspond exactly to their conventional S.I. units because their reference is to eight
digits that make up the unit called a byte. A chart such as the one below should be
referenced for exact bit size conversions. When we consider the enormous size of
medical image documents that will make up the patient’s electronic film file, most
institutions will need memory on the order of terabytes to accommodate growth.
Computers Application in Radiology Dr. Awadh Alqubati

Section III:

Pixels and Voxel

A digital radiographic image is formed as an electronic image that is displayed on a


grid called a matrix. The image is laid out in rows and columns called an image matrix.
An image can be made of thousands, preferably millions of these small cells. Each cell in
the image matrix is called a picture element, or pixel (yellow cells). With digital imaging,
each pixel will have a numerical value that determines the brightness (density) or other
details of the cell. Each box has its on dynamic range of values according to the number
of bytes of processing; this is called a gray-scale range. Remember that for one byte
there are 256 possible values for the density of each pixel, and with 16 bit processing
there are 65,535 possible densities any cell can have. These densities can be correlated
with the energy of the photons that strike phosphors in the recording medium from which
the image will be reconstructed. So, if we use for example, 16 bit processing, and
millions of cells in our matrix, we can have tremendous latitude for exposure and image
details. Using our binary code of “0” and “1” a different density is assigned for each of
our 65,535 numbers in our gray scale range. The brightness of the phosphor
corresponding to that area covered by each pixel can be assigned.
Computers Application in Radiology Dr. Awadh Alqubati

Our example above of a knee radiograph shows a 10 x 10 matrix which contains 100
pixels. A digital computerized radiography image matrix is at least 512 x 512 which
contains 262,144 pixels. This pixel size is comparable to analog screen-film imaging.
Advanced CR systems can produce images using a 1024 x 1024 matrix or greater which
will contain more information than a comparable analog image. To determine the number
of pixels in an image matrix, simply multiply the column length by its width.

How many pixels are there in a 1024 x 1024 matrix?

 Answer: 1024 x 1024 = 1048576 pixels

Spatial resolution of a digital image is related to


pixel size. The smaller the pixel size the greater the
spatial resolution. Therefore, a 1024 x 1024 matrix will
provide better resolution than a 512 x 512 matrix

The picture to the left demonstrates the dynamic


range of gray that can be achieved with each pixel to
form the digital image.

Pixel size alone does not determine the detail of an image; the range of values each
pixel may have is also very important, as well as the number of pixels. We have already
stated that the range of values each pixel may have in a matrix is called the dynamic
range. The dynamic range is a function of both the hardware and software in converting
the image into digital form. For example, a dynamic range of an 8-bit processor is 0-256
densities or details. With all other factors equal, 8-bit processing will have less gray scale
resolution than an image produced by 9-bit or 10-bit processing. The dynamic range is
expressed in bits, meaning an 8-bit image will have less clarity and gray scale than a 10-
bit or 12-bit processor. Many of today's computed radiography and direct digital
radiography images use 16-bit processing or higher.
Computers Application in Radiology Dr. Awadh Alqubati

Voxel

We are all familiar with 2D imaging commonly used in some radiography


modalities. For example, computed tomography (CT) uses thin slice axial images to
reconstruct coronal and sagittal 2D images. In some cases like a displaced acetabular
fracture or pelvic ring fracture, 3D images may be requested. Computer scientists have
make great improvements in 3D imagery proven by its reliability for diagnostic
information. If we consider the CT axial image as our starting point, successive pixels are
strung in depth order to form a three dimensional representation of the scanned part. The
process includes the converting of geometric representations into volume sets called
voxels. These voxels approximate a continuous object using a process called
voxelization. Each data point is a geometric cube is called a voxel, and a volume of
voxels are called a voxel space. It is sometimes easier to think of a voxel as a volume
pixel element.

The formation of a 3D radiographic image is very complex process and will not be
discussed further here; however, the viewing window of a 3D image is worth mentioning.
The viewing window defines the orientation of the voxel space and what part of that
Computers Application in Radiology Dr. Awadh Alqubati

space is presented on the monitor. This is important because 3D images are not
transparent like a radiograph. There are now new algorithms that demonstrate a
transparent 3D view, but this requires expensive software upgrades to the workstation. In
our picture of the hip (above) the posterior aspect of the pelvis and hip are demonstrated.
It would have been just as easy to demonstrate the anterior view or any number of views
in cine format from 0 through 360 degrees of rotation.
Computers Application in Radiology Dr. Awadh Alqubati

Section IV:

Hardware used in digital radiography

Computers are an integral part of radiographic imaging whether it is a CT scanner, a


MR scanner, an ultrasound machine, or a CR reader; they are all designed for
compatibility on a PACS network. When considering the purchase of a new piece of
equipment the administrator must make sure it is compatible with their institutional
network strategy. For example, new equipment must be compatible with radiology and
hospital information systems. And the input/output speed of the computer must not slow
down an existing PACS network. The hardware in these devices include one or more
central processing units (CPU), a main memory capacity, a secondary memory device,
input/output data transfer devices, and network connectivity interfacings. For the most
part hardware should only be purchased if it meets DICOM connectivity standards. For
instance, one would not purchase a CD-ROM burner thinking it will reduce the need to
print films without checking to make sure it meets current DICOM connectivity
standards.

Perhaps the most important hardware component of a computer is the central


processing unit (CPU), which is the brain of the computer. It uses an integrated circuit
called a ‘microprocessor’ to interpret and execute functions and to manipulate data. The
CPU has two main components: the Control Unit (CU), and the Arithmetic/Logic Unit
(ALU). The control unit interprets instructions contained in the computers programs as
well as executes those instructions. For example, the CPU often sends commands to other
components of the computer to control internal as well as external operations. Another
component of importance to our study is the ALU. Its functions include manipulations of
data that require a mathematical application. Remember, bytes are essentially numbers
that have a functional component and can be used for all mathematical applications. Just
think of all the computing applications of a high quality calculator (addition, subtraction,
Computers Application in Radiology Dr. Awadh Alqubati

multiplication, algebraic expressions, geometry, etc), the same is true of the computer’s
ALU.

A computer’s main memory consists of a large number of integrated circuits that


store information the user requires for immediate performance. This circuitry is generally
called Random Access Memory (RAM) because it is a volatile form of memory that can
be lost if power to the computer is lost (e.g. electrical glitch). The contents of RAM is
rapidly erased and refilled as new information is added to a document. For instance, as an
image is acquired by a CT scanner it may be sent to PACS from the computer’s RAM
store. RAM is more volatile with a home computer than with computers used in
radiographic imaging equipment because when power is lost it is usually erased.
Manufacturers of digital radiographic equipment so not rely on RAM, instead, images are
immediately stored in secondary memory within the base unit. Another option that is
popular with manufacturers is to provide battery back-up that maintain the electrical
supply for a few minutes in case of a power glitch. Notwithstanding, a radiographic
image must be permanently saved by converted it to Read Only Memory. This is the type
of memory that is on a magnetic disk like the hard drive, or an external drive like an
optical disk, or a CD-ROM, et cetera.

Secondary memory is used to store information in permanent, erasable, rewritable


form for long term purposes. In part I of this module we talked about the optical disk and
the optical disk jukebox used to store PACS images. We also talked about PACS having
quick access to large image files through a network attached server. In any case, memory
is component that allows computers to store and retrieve data. Memory is based on
principles of micro magnetisms on many localized domains. A magnetic disk is made of
aluminum or a glass plate on to which a magnetic material is applied. These materials can
store “bits” as local magnetism at different points on the storage material called writing.
Data is recovered by detecting these magnetisms and assembling them into bytes, a
process called reading.

When we speak of the hard drive we are referencing a hardware component that
contains fixed memory on multiple plates. This memory is divided into sectors that can
Computers Application in Radiology Dr. Awadh Alqubati

identify the location of named files. Magnetic labeling of files allows the computer’s
CPU to access its operating systems files, and its installed program software files. The
PACS server contains multiple hard drives on which radiographic images and text data
are stored. Memory is a way of storing radiographic images on to hard drives. Having a
storage component as a node on the PACS network is a huge advantage because most
digital radiographic equipment does not contain enough memory for vast long-term
image storage. Besides most CR operator panels can retrieve images from PACS just like
a workstation and display them. This is because memory on the PACS network is an open
software program that allows a user computer to access image files. The user is also
permitted to manipulate image quality and perform various software functions on it
without permanently changing it in PACS.

Another method of data storage is digital linear tape used to archive data for disaster
recovery. The difference between tape and an optical disk memory system is the linear
nature of DLT storage makes routine recovery from a tape a lengthy process. With disk
technology the read/write arm can access any data point on the disk effortlessly. Because
data is not sequential on a disk, writing and retrieval of data is faster than with linear
tape. DLT is therefore only good for back-up disaster recovery of stored images and is
not accessed by the PACS archive server for retrieval of image documents to
workstations. An optical disk, which is similar to a DVD, contains more memory and
takes less recovery time than tape media.

In order to communicate with the computer’s CPU to give it instructions, the user
will need certain peripheral devices. Some of these we are all familiar with such as the
mouse, bitpad, joystick, keyboard, and so forth. These devices are quite handy especially
since computers today are windows driven and the keyboard is almost always used to
enter text data into specific data fields. As we will discover later in our discussion on
digital radiography most manufacturers of digital equipment are now providing a touch
screen keypad called a remote operator processor (ROP) which is a peripheral input
device. Output devices like a laser printer or a CD-ROM burner are quite common in
radiology practice as well.
Computers Application in Radiology Dr. Awadh Alqubati

Communication pathways for a digital imaging system can be compared to the


central nervous system. Image data is communicated along specific routes controlled by
instructions that direct it to various network components. Communication pathways route
data to memory and retrieve it, and transmit in DICOM subclass protocols for display,
printing, and the like. This is why with PACS networking, the bus topology works better
than other architectural schemes. The topology of a network plays a role in the speed at
which communications are handled. To have smooth flow of information between
computers on a PACS network, which consist of all imaging computers and radiology
information systems, they must have compatible send/receive rates. Network cables must
be equal to or preferably greater than the input/output speeds of all computers on the
network. Each device’s CPU including the archiving server should have compatible data
transfer rates to prevent “network failure” discussed earlier in part II.

The hardware alone does not determine the functionality of a computer system; special
software is required to orchestrate how its components will operate. For the CPU to
perform its duties precisely, instructions from the computer’s operating system (DOS,
UNIX, or MacOS) are required. In addition to the computer’s operating system
applications, software is required to manage specific functions such as database access,
graphics, and in our case digital imaging processing for computed and direct digital
radiography. Other software needs include programs software, data Editor, Library of
subroutines, a Linker to link the user written programs to the subroutine library, a
Compiler for translating user written programs into binary computer code and the like.
All of these functions are controlled by specific software. For direct digital and computed
radiography imaging, the software is just as important as is the hardware. Software
upgrades are routinely needed with digital imaging and are relatively expensive.
Computers Application in Radiology Dr. Awadh Alqubati

Section V:

The digital imaging processor

Some computers are used to process radiographic images. They are greatly different
from general purpose computers. They are specialized to handle large volumes of
information quickly. These computers must capture, store, and retrieve information, as
well as perform manipulations on it at the users command. Digital image processing is a
complex process of data analysis and image analysis which is a function of the software
the computer uses. In traditional film screen radiography many of these features are a
result of quality of the exit radiation used to form the image. The image processor is a
component of the base device’s computer. It is concerned with specific tasks like image
acquisition, image display, image archiving, image arithmetic functions, and transfer
speed capabilities. In other words, an image acquired by a base device is acted upon by
its software. If the device is connected to a PACS network the software communicates
with the CPU’s of PACS servers (archive server, workflow server, RIS/HIS server, etc.).

A base device is one that produces primary image information. These devices
include: digital fluoroscopy, digital ultrasound, MRI scanner, gamma camera acquisition,
positron emission tomography (PET), CT scanning, CR and ddR radiographic equipment
and so forth. In most scenarios the base unit sends image data to the acquisition circuitry
of the digital image processor and then to the PACS server if networked.

Most base devices produce images as an analog picture that must be converted to a
digital image. An image acquisition component of the digital processor is responsible for
converting analog information produced by a base unit into digital binary coded numbers.
The device that performs this function is called an Analog-to-Digital Converter (ADC).
In addition to converting image data to digital data the converter may manipulate the data
and correct any deviations in it using an Input Look-Up Table. In addition to converting
image data to digital data the converter may manipulate the data and correct any
deviations in it using an Input Look-Up Table. Look-up-tables contain registers of data
Computers Application in Radiology Dr. Awadh Alqubati

points the computer uses when interpolating a connection between disjointed data bits. It
stands to reason that an ultrasound image is not initially acquired as a digital image;
therefore, ultrasound image data must be processed into digital information. The
acquisition of a sound image into a digital signal will require some data interpolation
which is found in look-up-tables etched into the computer’s operating system memory.
Likewise, logarithmic transformation of fluoroscopy data must be accomplished in order
to have digital fluoroscopy. The digital acquisition circuitry will manipulate any data it
receives that have “gaps” in it and interpolate data points using look-up-tables .

Digital images should be displayed on a high resolution monitor or printed for


viewing. Binary language is used only for transferring and storing data, radiographic
images are displayed in analog form. Whether viewed on a monitor, or printed, both
require that digital images be converted to analog form. A Digital-to-Analog Converter is
a component used for this purpose. Devices such as a high resolution monitor and most
printers used in radiology today require analog formatted data for displaying images
rather than binary formatted data. The digital-to-analog converter contains a complex
circuitry system for this purpose. In addition to converting signals, it is responsible for
some of the image manipulations we call post processing functions. Special functions
such as ‘windowing, magnification, multiple image display, measurement functions,
annotation of images, and so forth are all processed by these circuits.

Two other components that handle image data are the image ALU and the Array
Processor. The image arithmetic/logic unit (ALU) is also a component dedicated to
managing image data. It performs complex calculations on image data, such as
subtraction of binary digits to produce an image subtraction mask during digital
subtraction angiography (DSA). In analog radiography, a subtraction mask must be made
of an image and overlaid on the film; however, in digital imaging our picture data can be
subtracted; a function performed by the image ALU.

The ALU is also responsible for reducing image graininess also called noise through
a process called image averaging. The graininess of a digital image is based on the
radiologist tolerance for image noise. In digital imaging much more complex
Computers Application in Radiology Dr. Awadh Alqubati

manipulation of image data is required than is performed by a standard home computer’s


ALU. This is because the speeds at which these manipulations must be performed are a
critical component of the computer's workflow management. For radiographic imaging
an additional component is needed to handle digital imaging data at workflow pace. The
hardware component that assists with fast data manipulation is the array processor.
Essentially the array processor is a separate CPU that is designed for computational
speed in parallel mode rather than in sequential mode. The array processor is a CPU that
has diminished operational flexibility with a gain of computational speed. Consider that
many of the calculations used in digital imaging need to be done simultaneously rather
than in sequence and the amount of data flowing in a networked system can be enormous.
Having a separate fast computer brain dedicated to calculating is a must. Examples of
array processor functions include reconstruction of axial CT images into coronal and
sagittal planes which is useful to imaging modalities like MRI, CT, and SPECT nuclear
medicine imaging.
Computers Application in Radiology Dr. Awadh Alqubati

Section VI:

Fundamentals of Computed Radiography (CR)

The fundamental difference between computed radiography and analog imaging is


the replacement of film-screens with photostimulable phosphor plates and the successive
innovations that followed. Digital plates require a plate reader, a port of linkage to patient
text data (i.e. RIS, or HIS), and connection to an output device such as a printer, or to a
PACS network. The technologists need a CR imaging system that includes storage
phosphor cassettes, storage phosphor reader(s), bar code scanner, remote operator panel
for entering patient data, and a clinical workstation for reviewing and printing from
PACS.
Computers Application in Radiology Dr. Awadh Alqubati

Currently CR is a more popular purchase over ddR because existing radiographic


equipment (X-ray tube systems, x-ray tables, portable machines, etc) does not have to be
modified. These pieces of equipment alone do not constitute the full requirement to
operate a CR system. It should be remembered that a major reason for investing in
CR/ddR imaging is that it is the entry point for general diagnostic imaging into PACS.
The advantages of CR and DR imaging over conventional analog imaging are huge and
well worth the upgrade.

Photostimulable plate and cassette

Radiographers have needed to understand the mechanism of image production using


screen-film technology in order to maximize image quality; the same is true of the
photostimulable phosphor plate technology used in CR imaging. Furthermore, it is
imperative that the radiographer understands the basic characteristics of storage
phosphors and how they differ from their analog counterpart. Computerized radiography
and direct digital radiography will in the near future become the standards of
radiographic imaging because of its digital link to PACS and potential for internet
connectivity. In this section we will discuss the characteristics of these storage phosphors
and what is accepted as the "theoretical" mechanism by which they store and release a
latent image. The structure of the phosphor screen and cassettes is also important to our
study, as well as the process of digitation of the storage phosphor image.
Computers Application in Radiology Dr. Awadh Alqubati

The basic component of CR image capture is the photostimulable phosphor cassette.


The phosphors used to coat the screen are europium-activated barium fluorohalide
crystals (BaFX:Eu2+ where X is a halogen of either iodine or bromine). These phosphors
are not all together unique to CR imaging, for years screens made of photostimulable
phosphors have been used in intensifying screens for conventional film-screen imaging.
The phosphors in these screens fluoresce upon exposure to ionizing radiation emitted
from the x-ray tube. Radiation energy causes the phosphors to fluoresce, releasing a high
fraction of the absorbed energy from the screens; the remnant energy is stored in the
phosphors as a latent image. It is the stored energy in the form of a latent image that is
used to produce the CR image, but the image must be released from the phosphors and
further processed. When stimulated with infrared or white light photostimulable
phosphors release light proportional to the stored energy which can be detected by a
photomultiplier tube(s) as an image signal.
Computers Application in Radiology Dr. Awadh Alqubati

Mechanism(s) of image storage in phosphors

The exact mechanism(s) of photostimulated luminescence is not completely


understood; however, there are a few very good current theories that explain
luminescence and the linear response of photostimulation over wide exposure values seen
in diagnostic imaging. Consider that the dynamic range of exposure for photostimulable
phosphors is linear over a range of greater than 10,000 to 1, whereas for analog
radiographic images produced by screens it is roughly 40 to 1. What this means is that
over exposure or underexposure of radiographic images seen in conventional film-screen
imaging is virtually eliminated by photostimulable phosphor technology imaging. This
does not mean that images acquired at the extreme low and high values can be optimized
into high a quality image, it simply means that all values of an exposure can be
represented on the final image and be discriminated. Computed radiography can detect
exposures up to and greater than 100 milliroentgen (mR) which is far beyond D max for
screen-film imaging. Digital radiography has been demonstrated to produce images at
high energy values used in radiation oncology to treat cancer. It even can detect low
energy from particulate radiation, (0.195 alpha particles per square millimeter).

Although there are several theories on the mechanism of photostimulated


luminescence we will describe the most commonly accepted model for BaFBr:Eu 2+
phosphor photostimulated luminescence:

The simplest explanation for luminescence is that impurities in the crystal lattice are
responsible for luminescence. As the concentration of impurity ions increase the greater
the intensity of the luminescence. CR screens use barium fluorohalides doped with
europium (europium is the impurity in the crystal). When phosphors are stimulated with
x-ray photon energy electron pair holes are created. In effect, europium is raised to an
excited state and upon luminescence it is returned to its ground Eu 2+ state. This
mechanism holds for both spontaneous luminescence and photostimulated luminescence.
The shifting of europium from its excited state back to its ground state for both
Computers Application in Radiology Dr. Awadh Alqubati

spontaneous and photostimulated luminescence is about 0.6 - 0.8 microseconds. With


screen-film imaging these crystals spontaneously luminescence to expose a film, but with
CR imaging the luminescence occurs, then there is also photoluminescence that occurs
when the screen is stimulated by a narrow beam of infrared light.

The holes or vacancies in the lattice are portions of the lattice normally occupied by
halogens (fluoride, bromide, or iodine). These vacancies will trap free electrons when
irradiated and are called Farbzentren centers or F-centers. Within the BaFBr:Eu
phosphors there are two potential types of F-centers that trap electrons: F(Br-) and F(F-),
these represent electrons trapped in the bromide and fluoride vacancies. When the
photostimulable plate is exposed to high frequency light, usually from a helium laser, the
electrons in these F-centers are liberated and cause luminescence at readout.

Structure of the phosphor screen and cassette

There are some differences in the structure of phosphor screens and cassettes by
different manufacturers, for example, Kodak cassettes are designed to withstand 400lbs
of pressure. The strength of a cassette system is very important, for example, if standing
feet x-ray images are routinely performed at an orthopedic clinic, the technologist must
be able to safely obtain them on patients of varying weights. The cassette front is made of
carbon fiber and the backing of aluminum. But notwithstanding, the phosphor screens are
made of a base, a phosphor layer, and a protective coating The figure below demonstrates
a cross section of a Kodak Photostimulable plate and cassette.
Computers Application in Radiology Dr. Awadh Alqubati

These screens are designed slightly different than screens for film imaging. They are
balanced for x-ray absorption characteristics, light output, laser light scatter and screen
thickness. These variables affect electronic noise, image resolution properties, and the
speed of the imaging system. BaFBr:Eu2+ phosphor is coated onto base (Estar) using
polymers that act as glue to hold it. Then a clear coat solvent is coated over the phosphor
to seal it, protecting it from physical damage. A black reflective base under the phosphor
helps improve image resolution by reducing dispersion of light as the laser exposes the
phosphors at reading; the black base also allows for a thicker phosphor layer into which
photon energy is trapped. These are all mounted onto a lead sheet that absorbs excess
photons and reduces backscatter, and to an aluminum panel that is mechanically removed
from the cassette during scanning.

On the back of the panel is a label indicating the speed of the cassette, which in CR
imaging is the brightness of the phosphor, speed is also used in calculating the exposure
index.

Cassette scanning and plate reading


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The three pictures above are of the Kodak series of CR units: the first picture is of
the 8 cassette multiloader, and the other two are of the single loader reader that is
sufficient for low volume institutions. There are five processing functions of the reader
that are important to the technologist: Unloading of the photostimulable plate, laser
scanning of the plate, light collection onto the PMT, erasing the plate for reuse, and
reloading of the plate into the cassette. Unloading the cassette is all mechanically driven
with care not to touch the photostimulable phosphor side of the plate. The purpose of the
reader is to scan the photostimulable phosphor plate releasing the latent image. Within
the "reader" light emitted by stimulating the phosphor to luminescence is converted to an
electrical signal. The plate is then erased and reloaded into the cassette for reuse.

To recover the latent image the screen is scanned with a helium-neon laser that uses
a low 20 milliwatt 633 nm wavelength output laser. The photostimulable screen is
scanned in a raster fashion. The wavelength of light required to stimulate phosphor
luminescence is different from the wavelength released from the phosphors during
luminescence. From the figure below we see that the wavelength of light released from
the phosphor screen is about 400 nanometers. The laser emits light in the range of 600
nanometers, which is required to cause stimulation of photostimulable phosphor
luminescence. Thus there is an energy difference between the emitted light at stimulation,
and the light emitted from the laser to cause photo stimulated luminescence. The light
from the laser should not be part of the CR image and must be extracted from the image
data.
Computers Application in Radiology Dr. Awadh Alqubati

In addition to the difference in the wavelength of light required to stimulate phosphor luminescence and
the wavelength of light thereby emitted, there is residual energy trapped in the phosphors following stimulation.
To release all of the stored energy the phosphor plate must be exposed to white light following stimulation by
the laser in a process that erases the plate for reuse (the picture below shows the white fluorescent bulbs used
to erase the plate after acquiring the latent image).

The picture to the left shows the inside


of a Kodak multi-loader reader unit. For
safety reasons the helium laser is enclosed;
however, a sliding pull-out rack
demonstrates the fluorescent light bulbs that
expose the phosphor plate following it being
"read" to clear any stored energy in the
phosphors before reuse.

The laser reads a preset number of line-pairs based on the size of the cassette's
screen. The Kodak CR system reader is a computer that includes software that reads the
screen size and its associated image size according to the table below:

Did you notice how large the study size is for each image? This is why the storage
capacity for PACS must be sufficiently large enough to accommodate long-term image
capture from not only CR, but from all imaging modality. Especially if data is received
from multiple radiology modalities such as CT, MRI, Nuclear Medicine, etc. The
memory requirements for PACS networking in order to have fast archive retrieval need
creative networking such as archiving on a (NAS) with a capacity in the order of
terabytes.
Computers Application in Radiology Dr. Awadh Alqubati

Light is emitted in all directions as an inherent physical characteristic of screen


fluorescence; the same is true of photostimulated luminescence. Therefore emitted light
must be focused by a collector onto the photomultiplier tube (PMT). The PMT is a device
that converts light from the photostimulated screen to an electronic signal that can be
further converted to digital "bits". Depending on the CR system there can be from one to
five photomultiplier tubes. Remember, the laser's light is in the red spectrum in the order
of 633 nm while the luminescent light is 400 nm. Therefore, an optical filter is placed in
front of the collector to filter the laser light prior to it reaching the PMT.

The PMT is calibrated to the storage characteristics of an exposed photostimulable


phosphor plate. This calibration that affects the overall brightness of the extracted image
is based on a delay of 15 minutes from the time of exposure to the time of scanning since
the signal in the phosphor degrades exponentially over time. This time delay is not
apparent to the technologist and the plate can be scanned anytime within 24 hours
without appreciated loss of image data that would warrant a repeat exposure. Calibration
of the image from the PMT is set at about 3000 pixels. All PMTS in a unit must be
calibrated so that the reading across the plate is equalized and balanced.

The electronic data signal from the PMT is then sent to a device that converts the
analog data to digital data. This device is called an Analogue-to-Digital Converter and
associated Input Look-Up Tables (ILUT) are referenced. These LUT contain circuitry for
manipulating digitized data so as to correct for any aberrations in the image data caused
by the converting of it from a light latent image to an electronic image, and to a digital
image. The process of digitization is complex but briefly, the signal must be amplified
and passed through several filters such as a Bessel Filter for anti-aliasing. An anti-
aliasing filter is used to smooth edges in an image and smooth jagged diagonal lines
caused by seamed transfers to produce seamless final images.

Photomultiplier tubes are about 20-25% efficient in light compilation from the stimulated luminescence;
therefore, the image is acquired over four decades of exposure and requires optimization before viewing. Tone
scaling is a type of contrast enhancement that involves remapping of gray scale values using special look-up
tables. Look up tables are a common way of converting digital data from different modalities such as ultrasound
Computers Application in Radiology Dr. Awadh Alqubati

and MRI into digital format. The process of tone scaling involves transforming the raw data in three or 4 steps
into a finished image. First the collimated field is detected using the raw data image as a guide. Next the
anatomic region is defined, the image is then tone scaled, and final reprocessing is applied.

Top left picture shows the image as


released from the phosphor and collected by the
PMT tube. This is the first image produced by
an electrical signal from the PMT. The top right
picture shows the establishment of the
collimated border of the film during tone
scaling. The bottom left picture defines the
anatomic region for specific algorithm, and the
bottom right picture demonstrates the finished
image produced by tone scaling.

The process of enhancing the raw image data is called image segmentation. The CR
image is acquired over four decades of exposure, 1) light release from storage phosphors, 2) conversion to an
electronic signal by the PMT tube, 3) identifying the collimated image border, and 4) tone scaling the image.
These are the post processing functions that must take place before the image is presented on the CR reader
monitor. The image must then be fixed before the data is sent to PACS, then to workstations, or is printed. The
raw data is subjected to various algorithms and LUT that define areas of interest and collimated areas. The
average density and LUT control the overall density and contrast of an image. The final image is first available on
the CRT monitor at the reader or on remote operator panels (ROP). What is important for the technologist to
understand is that the image released from stimulating the phosphor plate is not a readable diagnostic image
and requires post processing. Specific software algorithms must be applied to the image prior to presenting it as
Computers Application in Radiology Dr. Awadh Alqubati

a finished radiograph. These modifications of the image occur in the reader programs and at the workstation
using look-up tables as references.

Inside the reader is its own central processing unit (CPU) that
acts as the brains of the entire system. This unit contains various
circuitries for image processing including Input Look-Up Tables
and Output Look-Up Tables that process digital-to-analogue
conversions for monitor display of the finished image.

Left picture. Kodak multi-loader is


displayed to demonstrate that all CR images
are displayed on the CRT monitor following
processing. Here the technologist approves
the images and sends them to PACS and/or
prints them.

Regardless of the CR imaging system the technologist must view the image on the
CRT monitor and either accepts it based on the exposure index, or rejects the image. An
accepted image is then sent to PACS for image review on network workstations, or the
image can be printed for conventional reading and filing.

Three different vendor CR units are shown in the pictures above. The left image of
the Agfa CR system multi-loader and CRT monitor for approving images; the middle
Computers Application in Radiology Dr. Awadh Alqubati

picture is of the Kodak remote operator panel (ROP) which is a remote display CRT that
can be mounted anywhere in the department to reduce clutter around the reader; the right
picture is of a FUJI CR system multi-loader and CRT image monitor.

Exposure Index

Because the CRT monitor image is post processed using workstation algorithms and
Look-up Tables, the technologist needs feedback on the exposure to the phosphor screen
that produced the image. Most technologists understand that storage phosphor screen
exposure can be optimized and therefore is not overly concerned with over or under
exposure. Because of the increased exposure latitude enjoyed with CR imaging
radiographers tend towards higher than necessary exposures desiring to see less noise on
radiographs displayed on the CRT. The exposure index is a tool provided for the
technologist to monitor their plate exposure; it is analogous to the optical density used in
Computers Application in Radiology Dr. Awadh Alqubati

screen-film imaging. The exposure index is not a measure of the patient’s exposure;
however, if the exposure is greater than the recommended exposure index range the
patient has been overexposed. The degree of that over or underexposure can be correlated
but is not commonly done except for the log of the exposure index recorded for viewing
on the workstation and film.

The PMT calibrated exposure index is set by the manufacturer and this calibration
of the PMT is not variable. Then it follows that when different speed screens are used
(for Kodak the phosphor speed is equivalent to 200 screen-film speed, FUJI plates are
approximately 400 screen-film speed) the PMT reads an exposure index of 2000 for a 1
mR screen exposure. Each vendor will calibrate the exposure index differently, for
example, Kodak sets the exposure index reading at the PMT at 1 mR is equal to an
exposure index of 2000. Ideally, the technologist should strive to keep the exposure index
consistent from patient to patient. Kodak recommends that the exposure index for any
image should fall in the range of 1800 to 2200; each increase in the initial exposure index
of 300 is a doubling of the screen exposure.
Computers Application in Radiology Dr. Awadh Alqubati

Images outside the acceptable exposure index range do not necessarily need
repeating; however, the technologists should use their judgment as to when an image
should be repeated. CR image processing cannot compensate for too little exposure, such
as an exposure index of 300, or an extremely overexposed image outside the range.

There are several possible factors within the technologist controls that can alter the
exposure index. The primary controller is technique selection. Others include improper
centering on the cassette, and placing two or more views on the same cassette. Most CR
readers calculate the exposure index starting from the center of the cassette and outward,
even though the cassette is read in raster fashion. Sometimes when three views such as a
finger or the wrist is placed on one cassette the anatomic and non-anatomic regions of the
image are not correctly identified by post processing software. This causes an improper
calculation of the exposure index that is not taken from the relevant portions of the image
and the image may appear dark. The improper reading of the CR image due to multiple
images on a plate that give false over or under exposure indices are called image
segmentation failure. Although in theory, it is impossible to over or under expose an
image the image may appear over or underexposed due to the image segmentation
algorithm that handles the raw data. Generally speaking a segmentation failure results in
a high exposure index. What is important is how the technologist handles these awkward
exposure indexes when they occur. The scenario is that the radiographic image on the
CRT monitor appears overexposed and the technologist desires to manipulate the raw
data to make an eye-pleasing image prior to sending it to PACS.
Computers Application in Radiology Dr. Awadh Alqubati

In each of the three graphs above the technologist adjusted the image using the raw
data controls below each picture. Notice that the slope of the line also changed indicating
that raw data is being lost that may affect image detail characteristics that can be
windowed at the workstation. The technologist should remember that workstation
software can adjust windowing and leveling. Therefore, if the image can be windowed
from the raw data on the CRT monitor, it can also be windowed to form a high-resolution
image on the workstation. In this regard it should be left alone and the data saved to be
manipulated at the workstation. In this way pertinent image data is not erased just to
make an eye-pleasing radiograph on the CRT, a low resolution monitor.
Computers Application in Radiology Dr. Awadh Alqubati

Section VII:

Overview on using the CR System

One of the many advantages of CR imaging is that existing radiography equipment


can be used with just a few modifications in how images are acquired by the system. In
this section we will look at how information such as from the radiology Information
System (RIS) and Hospital Information System (HIS) into the CR system and ultimately
into PACS for local and wide area networking. For the most part there are four equipment
items that sponsor the trafficking of information into the CR/DR system for image
display. These are the data entry, examination algorithm selection, post image processing,
and networking into PACS for storage/retrieval.

A CR system can be added to PACS network as a node on the Bus topology with
servers that share patient file information from the HIS/RIS broker. The first step in
digital and CR imaging is that specific data fields must be entered into the CR or DR
unit. This is because all digital images must have patient information such as the patient's
name, medical record number, exam number, date, and time, etc., printed on each image
document as it is sent to storage, else it is inaccurately retrievable from archive. Specific
data fields are filled by the HIS/RIS broker, a type of server that links text information
Computers Application in Radiology Dr. Awadh Alqubati

from RIS to the base CR/DR unit and to PACS. Once the RIS/HIS server receives data
that is the patient's radiology request any base unit on the network can accesses this
information as part of the examination database using a workflow dialog box. There are
several ways to begin the process of patient selection. Some unites such as the FUJI
system uses a magnetic I.D. card that can access the patient file. Other systems such as
advanced FUJI and Kodak systems use a barcode reader to directly populate text fields
through a HUB to the RIS broker.

Above. The earlier models of FUJI CR systems rely on a magnetic card that
interfaces with the ROP to enter patient data. Through the appropriate server(s) this
system draws data from RIS and pushes it onto PACS images for print and memory into
long-term storage. Magnetic stripe cards are fully reusable; however, the down side of
this technology is that the magnetic card system does not reference a specific exam and is
generic for patient text information transfer. The device on the left is used to create the
patient data card (usually made by the radiology clerk), and the device on the right
receives the swipe-technology to enter patient data into the CR system.

Advanced FUJI and Kodak systems use the full capabilities of the HIS/RIS server
and CR units to transfer patient information data directly to a workflow manager.
Radiology orders are entered into the RIS computer from any link and are received by the
radiology clerk. The RIS broker is a server that networks patient information directly to
the base CR unit and to PACS and can be accessed from the workflow list functions of
the base unit. This is generally done using barcode technology and the patient radiology
Computers Application in Radiology Dr. Awadh Alqubati

request. Barcode technology linkage is ubiquitous throughout the PACS network because
DICOM contains a barcode subclass operations protocol. The technologist uses the
patient request and a barcode reader to access the patient file already in the workflow list.
Each study will have its own request, study I.D. and barcode as part of the workflow
manager function. So the technologist uses the patient exam request and a barcode reader
to begin the imaging process.

Above. The image to the left is of a Kodak ROP with barcode reader. To the right is
the radiology request with barcodes containing patient medical record number, exam
number, and information for interfacing with the RIS broker. The barcode device is used
to access the workflow manager of the RIS and PACS servers. The radiologist only needs
the radiology request and can barcode it to bring up images in the patient’s data file.

The next step in the CR imaging process is to set the study algorithm the reader
should process the exposed plate under. This function is also controlled by a barcode
reader. The technologist selects the appropriate study, e.g. ABDOMEN, CHEST,
FOREARM, KNEE, etc., from the programmed list. The reader must then be told what
cassette contains the image. This is done by barcoding the cassette with the appropriate
algorithm selected at the reader or ROP.
Computers Application in Radiology Dr. Awadh Alqubati

These three pictures demonstrate the CR cassette and


barcode system for matching cassette to pre-selected
processing algorithm the reader is to use. The cassette is
registered using barcode at the remote operator panel. This
information can be entered either before exposure or after
exposure.

Once the study is selected and the cassette is bar-coded and the technologist may proceed using the
cassette just as they would a screen-film cassette. In digital imaging algorithms are selected rather than cassette
types. In screen film imaging the technologist may use a different screen-film type for a KUB than they would for
a forearm image. In digital imaging the same cassette is used but the computer’s software selects the
appropriate processing algorithm to process the photostimulable plate. This is a very important difference
between screen film imaging and CR. Being able to use any cassette for imaging is a huge time savings to the
technologist. It eliminates darkroom time spent to load special extremity cassettes with extremity film, or the
repeats that occur when the extremity cassette is loaded with non extremity film. Remember having to load
special chest film into "chest" cassettes and a failure to do so resulted in a high contrast chest x-ray? These issues
are eliminated by algorithms that can be changed if the image of a chest is processed under a foot algorithm, a
feature unique to digital imaging.

Left. This picture demonstrates all of the components of


the CR system required for imaging. The patient data entry
panel uses a magnetic card to enter patient information (white
arrow). Once the technologist selects the proper image
processing algorithm the cassette can be barcoded with the
barcode reader (blue arrow) and placed into the reader for
processing. The CRT monitor on the unit will display the
processed image for the technologist to approve and send to
PACS or to be printed.
Computers Application in Radiology Dr. Awadh Alqubati

Steps in the CR imaging process: 1) patient information data is entered into the CR
unit or is accessed through RIS using a barcode or magnetic stripe card, 2) the
appropriate algorithm is selected (e.g. chest, hand, C-spine, etc), 3) the cassette’s unique
barcode is entered into the CR system so the reader can identify the image and process it
according to the pre-selected algorithm.

Acquiring the CR Image

A characteristic that is unique to CR imaging is that there is only one screen type for
all studies so that the same cassette is used for portable radiography, bucky radiography,
tabletop radiography, and the like. There is no need to look for special detail cassettes for
extremity work, or high speed screen with low scale contrast for chest radiography. These
functions are handled by the software performing algorithm functions. Even the grid lines
commonly seen with screen-film imaging can be removed from the digital image using
LUT for that specific function.
Computers Application in Radiology Dr. Awadh Alqubati

The CR cassette can be placed in the Bucky tray or used tabletop just as would a screen-film cassette. If
Automatic Exposure Control (AEC) is used it may have to be calibrated for CR cassette exposure otherwise the
technologist must strive through manual techniques to produce consistent exposure index in the range of 1800-
2200 for Kodak CR, and 50-200 for FUJI CR. Manual techniques are extremely important in digital imaging for
tabletop radiography because a variable-kVp or variable mAs Chart will help the technologists achieve uniform
exposure indexes for tabletop and portable images.

Above. The same cassettes can be used in the bucky tray or


tabletop.

Left. By placing ROPs in locations near the


exposure console, the technologist is able to enter and
approve images between radiographic exposures.

The chronology of the image processing following exposure is as follows: the


exposed cassette is placed on the reader where the cassette is mechanically opened and
the photostimulable plate removed. Inside the reader a laser is passed over the plate in
raster fashion using a wavelength of 633nm to stimulate luminescence of the phosphors.
This stimulated luminescence releases the latent image in the form of light that is filtered
and collected onto a photomultiplier tube (PMT). The PMT converts the light signal to an
electrical signal that is then converted from analog-to-digital data bits by a special
converter. The raw data is subjected to algorithms and Look-up Tables (LUT) that
Computers Application in Radiology Dr. Awadh Alqubati

interpolate data points and allow for manipulation of digital information. Through a
process of image segmentation it is optimized. Finally the image is presented on the CRT-
monitor for technologist viewing. All of this takes place in a matter of seconds rather than
minutes as in conventional screen-film image processing.

One of the niceties of computed radiography is that image data is already in digital
form so it can easily be linked onto the PACS network. Because computerized
radiography adheres to DICOM standards, these units adhere to the various subclass
standards for compatibility. From the reader a link can be established directly to a wet or
dry laser printer using DICOM Print Management Service Class, and to PACS storage
servers using DICOM Query/Retrieval Service Class. The images can also be displayed
to any workstation in the PACS network which significantly decreases ER/Trauma wait
time.

This is a summary of the special advantages of digital computed radiography that


cannot be achieved by analog screen-film imaging for the following reasons. 1) X-ray
exposure and display of the image are uncoupled; therefore characteristics of image
Computers Application in Radiology Dr. Awadh Alqubati

presentation, mainly optical density and contrast become less significant in the raw data.
2) There are a limitless number of “original images” available for viewing which can be
outputted to multiple stations simultaneously without intermediate copying of the images
as with screen-film radiographs. 3) Digital images can be transferred over a LAN or
WAN without any deterioration for all degrees of image spatial frequency. This includes
CD-ROM, Internet, and teleradiology. 4) A film cost savings is definitely possible if
viewing over a workstation is the primary means of display and multiple images printed
on a single sheet when measurement is not a consideration. 5) The digital image can be
adapted to any viewer’s requirements by image processing algorithms and post
processing functions of software.
Computers Application in Radiology Dr. Awadh Alqubati

Section VIII:

Concepts of Direct Digital Radiography (ddR)

Unequivocally, direct digital radiography is fast becoming the industry leader in the
direction that diagnostic radiographic imaging is developing. The reason for the dramatic
challenge to computed radiography (CR) is that it offers full resolution images that are
displayed and stored in about 8 seconds. This translates into faster throughput of imaging
procedures; some imaging centers report a conduction time of 2-4 times faster than with
traditional screen-film-darkroom based technology. As with CR, direct radiography
adheres to DICOM standards for connectivity and workflow operations making it fully
compatible with existing PACS sharing.

Direct digital radiography is developing on the principles of amorphous silicon


technology that uses a cesium iodide scintillator to perform x-ray detection. These
systems are well thought out productions that allow for modification of existing x-ray
equipment such as replacement of the bucky tray with a detector array. Cost advantages
of direct digital radiography are already proving to be more cost effective than CR
equipment purchase and replacement of outdated conventional radiography equipment.
This is because only one technologist is needed to throughput 2-4 times the workflow as
with conventional systems using cassettes of any type (CR or screen-film).
Notwithstanding, direct digital radiography does not have the total flexibility that CR
image has particularly in the area of portable imaging.
Computers Application in Radiology Dr. Awadh Alqubati
Computers Application in Radiology Dr. Awadh Alqubati

SummaryPoints

 The bass of CR and digital imaging is optimization of image acquisition, image


transmission, and image display and image storage as independent optimized
functions.

 Photostimulable phosphors have demonstrated a range of exposure greater than 100


mR and as low as 0.195 alpha particles.

 Eastman Kodak Company patented a thermoluminescent infrared stimulable


phosphor system in 1975; however, FUJI Photo Film Company in 1980 patented the
first radiographic imaging system using photostimulable phosphors.

 Computers store and manipulate data in the form of binary digits or bits, or base-2
system of digits.

 A bit is either a "1" or a "0" with 1 being represented as a 5 volt charge and 0 is
represented by a zero voltage.

 A bundle of 8-bits equals one byte and one byte can display 256 shades of gray or
other details.

 A radiographic image is laid out in rows and columns called an image matrix. Each
cell in the matrix is called a pixel which for each byte can have a value of 256
possible details.

 The number of pixels in an image is calculated by multiplying the number of matrix


columns by the number of rows. For example a 10 x 9 matrix will contain 90 pixels.
Computers Application in Radiology Dr. Awadh Alqubati

 A volume pixel element is called a voxel because it contains the voxel space of a 3D
image.

 The Central Processing Unit (CPU) is the brains of the computer, it has an
integrated microprocessor to interpret, execute, and manipulate data.

 Two parts to the CPU are the Control Unit (CU) that interprets programs and
executes them, and the Arithmetic/Logic Unit (ALU) that performs mathematical
operations of the computer’s component programs.

 RAM or random access memory is a volatile form of memory that is rapidly erased
and refilled as new information is added to a document; it is temporary memory that
is lost if the computer is turned off.

 The digital network of PACS is of the BUS topology as architecture does affect data
transfer speed; however, network design speed must be consistent with that of other
components of the computers such as the CPU speed and main memory.

 Besides hardware, specific software is necessary to operate the CR system:


Operating systems software, program software, Editor, Library of subroutines, a
Linker, a Compiler, etc.

 The digital imaging processor is a device that is responsible for converting analogue
information produced by the base unit into digital or binary coded numbers. The
device that performs this function is called an Analog-to-Digital Converter.

 An Array processor is a separate CPU used by the computer for computational speed
in parallel mode rather than in sequential mode. This allow for simultaneous
computer processing rather than a linear sequence of processing functions.

 Hardware components of a CR system include: Photostimulable phosphor cassettes,


Cassette reader, Remote Operator Processor/Panel, Printer and/or Workstation.

 PACS is a network of computers into which a CR unit may input data for display
and storage.
Computers Application in Radiology Dr. Awadh Alqubati

 The basic component of CR image capture is the photostimulable phosphor screen


and cassette.

 Photostimulable phosphor screens are composed of europium-activated barium


fluorohalide crystals (BaFX:Eu2+) where X is a halogen of iodine or bromine.

 Photostimulable phosphors fluoresce from radiation energy just as do analog


screens; however, to release the latent image contained in the storage phosphors the
screen must be subjected to light from a finely collimated laser beam.

 The wavelength of light used to release a storage phosphor’s latent image is about
633 nm.

 The wavelength of light emitted during photostimulation of the storage phosphor


screen is about 400 nm.

 The dynamic range of exposure for photostimulable phosphors is linear over a range
of 10,000 to 1 vs. analogue screens which is roughly 40 to 1. This means that it is
nearly impossible to overexpose or underexpose a CR phosphor image.

 Light emitted from CR screens during photostimulation is filtered and collected by


photomultiplier (PMT) tube(s) and converted to an electrical signal that can be
digitized.

 Light energy is stored in holes in the BaFBr:Eu2+ crystals in what are called F-
centers which are fluoride and/or bromide vacancies.

 The structure of a photostimulable phosphor screen is from within outward:


Aluminum panel, lead layer, black cellulose acetate layer, Estar support, phosphor
layer, and a overcoat to protect the phosphor.

 Each CR screen must be erased after use or before use if the cassette has not been
used in over 24 hours. The reader erases the plate using fluorescent white light.
Computers Application in Radiology Dr. Awadh Alqubati

 An optical filter is used to filter out the laser light from the luminescent light of the
CR screen during read-out.

 Electrical signal from the PMT is sent to the Analog-to-Digital Converter where it is
converted to digital bits; an Input LUT within the device is used to correct any
aberration in the data.

 Anti-aliasing is a filtering process used to smooth edges in the image and to reduce
jagged diagonal lines.

 The raw data image is segmented and enhanced by specific imaging software before
presentation on the CRT and workstations.

 Image segmentation is a process by which the raw image is enhanced by software


that locates the image field, the collimated field, and image edges and enhances each
independently then compiles the final image from these enhancements.

 The exposure index is a tool provided to the technologist to monitor the exposure to
the screen. It is analogous to the averaged optical density reading of the exposed
film.

 The technologist sets the algorithm the CR screen is to be process under by the
reader. This is a software function and is amendable upon the image at
preprocessing and post processing from storage.

 Digital data converted back to analog for printing or display on a workstation


monitor by a Digital-to-Analog Converter.
Computers Application in Radiology Dr. Awadh Alqubati

References

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4. Glassner, A.S., "Space Subdivision for Fast Ray Tracing", IEEE Computer Graphics
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04581/999*, 1994

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10.U.Ewert, H. Heidt, "Approach for Standardization of X-ray Film Digitizers and


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Fl. 03/22-03/27, 1999, proceedings p. 171-173. Kodak Learning Center., available at:
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