X-ray Imaging

This chapter focuses on the production of an x-ray beam and the utilisation of that beam to create an image. Screen
film radiography is rarely used nowadays and does not feature prominently in the exams but the principles learnt
from this method of radiography are useful, hence I have still included it in these notes.

This document covers:

 Production of x-rays
 Interaction with matter
 Screen film radiography
 Digital radiography
 Image quality
 Quality assurance

Production of X-Rays
A current is passed through the tungsten filament and heats it up. As it is heated up the increased energy enables
electrons to be released from the filament through thermionic emission. The electrons are attracted towards the
positively charged anode and hit the tungsten target with a maximum energy determined by the tube potential
(voltage). As the electrons bombard the target they interact via Bremsstrahlung and characteristic interactions and
result in conversion of energy into heat (99%) and x-ray photons (1%). The x-ray photons are released in a beam with
a range of energies (x-ray spectrum) out of the window and form the basis for x-ray image formation.

Equipment

Cathode
Filament
 Made of thin (0.2mm) tungsten wire because tungsten:
 Has a high atomic number (A 184, Z 74)
 Is a good thermionic emitter (good at emitting electrons)
 Can be manufactured into a thin wire
 Has a very high boiling point (3370°c)
 Some cathodes have two filaments for broad and fine focusing
Focusing cup
 Made of molybdenum as:
o High melting point
o Poor thermionic emitter so electrons aren't released to interfere with electron beam from filament
o Negatively charged to repel electrons towards the anode
Anode
 Target made of tungsten for same reasons as for filament
 Rhenium added to tungsten to prevent cracking of anode at high temperatures and usage
 Set into an anode disk of molybdenum with stem
 Positively charged to attract electrons
 Set at angle to direct x-ray photon beam down towards patient. Usual angle is 5°-15°
Definitions
 Target, focus, focal point, focal spot: where electrons hit the
anode
 Actual focal spot: physical area of the focal track that is
impacted
 Focal track: portion of the anode where the electrons
bombard. On a rotating anode this is a circular path
 Effective focal spot: the area of the focal spot that is
projected out of the tube

Types of anode:
1. Stationary anode: used in mobile fluoroscopy, dental radiology and ward radiography. Consists of an anode
fixed in position, the electron beam is constantly streaming onto one small area
2. Rotating anode: used in most radiography. Consists of a disc with a thin bevelled rim of tungsten around the
circumference that rotates at 50Hz. Because it rotates it overcomes heating by having different areas
exposed to the electron stream. It consists of:
 Molybdenum disk with thin tungsten target around circumference
 Molybdenum stem, which is a poor conductor of heat to prevent heat transmission to the metal
bearings
 Silver lubricated bearings between the stem and rotor that have no effect on heat transfer but allow
very fast rotation at low resistances
 Blackened rotor to ease heat transfer

Heating of the Anode

This is the major limitation of x-ray production.

Heat (J) = w x kVp x mAs

W = waveform. The more uniform the waveform the lower the heat production
kVp = maximum accelerating voltage
mAs = current per second

Heat is normally removed from the anode through radiation through the vacuum into the conducting oil outside the
glass envelope. The molybdenum stem conducts very little heat to prevent damage to the metal bearings.

Heat capacity:
 A higher heat capacity means the temperature of the material rises only a small amount with a large
increase in heat input.
Temperature = heat applied / heat capacity

Heat rating:
 This is the mAs at a particular kV and is related to the heat produced by the machine. Allowable mA, or the
amount of mA produced per unit time that is acceptable, decreases with:
o Lengthening exposure time
o Increasing kV
o Decreasing effective focal spot size (heat spread over a smaller area)
 o Larger target angles (see anode heel effect, more material for electron beam to travel through,
hence, higher heat production)
o Decreasing disk diameter (smaller circumference and area to disperse heat to)
o Decreasing speed of disk rotation

Anode cooling chart: As well as withstanding high temperatures, an anode must be able to release the heat quickly
too. This ability is represented in the anode cooling chart. It shows how long it takes for the anode to cool down
from its maximum level of heat and is used to prevent damage to the anode by giving sufficient time to cool
between exposures.

Anode Heel Effect

X-ray gets attenuated on the way out by the target material
itself causing a decrease in intensity gradually from the
cathode to anode direction as there is more of the target
material to travel through. Therefore, the cathode side
should be placed over the area of greatest density as this is
the side with the most penetrating beam. Decreasing the
anode angle gives a smaller focal spot size, which is useful in
imaging, but a larger anode heel effect, resulting in a less
uniform and more attenuated beam.

** smaller angle = smaller focal spot size but larger anode heel effect **

Others
Window: Made of beryllium with aluminium or copper to filter out the soft x-rays. Softer (lower energy) x-ray
photons contribute to patient dose but not to the image production as they are attenuated and absorbed into the
patient and do not have enough energy to pass through to the detector.

Glass envelope: Contains vacuum so that electrons do not collide with anything other than target.

Insulating oil: Carries heat produced by the anode away via conduction.

Filter: Total filtration must be >2.5mm of aluminium for a >110 kV generator

Total filtration = inherent filtration + additional filtration (removable filter)

Producing an X-Ray Beam

1. Electrons Produced: Thermionic Emission

A current is applied through the cathode filament, which heats up and releases electrons via thermionic emission.
The electrons are accelerated towards the positive anode by a tube voltage applied across the tube. At the anode,
99% of energy from the electrons is converted into heat and only 1% is converted in x-ray photons.

Accelerating Potential
This is the voltage applied across the tube to create the negative to positive
gradient across the tube and accelerate the electrons across the anode. Normally
30-150 kV. UK mains supply is 230V 50Hz of alternating current. When the charge
is negative, the accelerating potential is reversed (the cathode becomes positive
and the anode negative). This means the electrons are not accelerated towards
the anode to produce an x-ray beam. Ideally you want a uniform output with a constant charge. This is done by
rectification.
Full wave rectification: Use rectification circuit to convert negative into positive
voltage. However, there are still points at which it is zero and most of the time it
is less than the maximum kV (kVp). This would lead to a lot of lower energy
photons.

Rectification is achieved via two mechanisms:

1. Three phase supply: Three electrical supplies are used, each applied at a
different time. The "ripple" (difference between maximum and minimum
current) is about 15% of the kVp.
2. High frequency generator: This can supply an almost constant potential. The supply is switched on and off
rapidly (1kHz) which can then be rectified. They are much more compact than three phase supply and more
commonly used.

Effect of rectification on spectrum:

 Increases mean photon energy - fewer photons at low energy
 Increases x-ray output - stays closer to the maximum for longer
 Shorter exposures and lower patient doses - as output higher, can run exposure for shorter time to get same
output

Filament Current
The current (usually 10A) heats up the filament to impart enough energy to the electrons to be released i.e. it affects
the number of electrons released.

Tube Current
This is the flow of electrons to the anode and is usually 0.5 - 1000mA.

Summary:
Filament current is applied across the tungsten cathode filament (10A) and affects the number of electrons released
Tube current is applied across the xray tube from cathode to anode and affects the energy and number of electrons
released

2. X-Ray Production at the Anode

The electrons hit the anode with a maximum kinetic energy of the kVp and interacts with the anode by losing energy
via:
 Elastic interaction: rare, only happens if kVp<10eV. Electrons interact but conserve all their energy.
 Inelastic interaction: causes excitation/ionisation in atoms and releases energy via electromagnetic (EM)
radiation and thermal energy

Interactions
At the anode, electrons can interact with the atoms of the anode in several ways to produce x-ray photons.
Outer shell interaction: low energy EM released and quickly converted into heat energy.
 Inner shell interaction: produces characteristic radiation via interaction with inner shell electrons.
 Nucleus field interaction: aka Bremsstrahlung.

a. Characteristic Radiation
1. A bombarding electron knocks a k- or l-
shell electron out.
2. A higher shell electron moves into the
empty space.
3. This movement from a high to a lower
energy state releases energy in the form
of an x-ray photon.
4. The bombarding electron continues but is
diverted.
It is called "characteristic" as energy is dependent on the element not the tube voltage. Energy is released in
characteristic values corresponding to the binding energies of different shells.

For tungsten: Ek - El (aka Kα) = 59.3

Ek - Em (aka Kβ) = 67.6 keV
b. Bremsstrahlung
1. Bombarding electron penetrates k shell and approaches the nucleus.
2. Electron is diverted by the nucleus.
3. The energy loss from this diversion is released as a photon
(Bremsstrahlung radiation)

Bremsstrahlung causes a spectrum of photon energies to be released. 80% of x-

rays are emitted via Bremsstrahlung. Rarely, the electron is stopped completely
and gives up all its energy as a photon. More commonly, a series of interactions
happen in which the electron loses energy through several steps.

Summary
Characteristic Radiation Bremsstrahlung
Only accounts for small percentage of x-ray photons Accounts for 80% of photons in x-ray beam
produced
Bombarding electron interacts with inner shell electron Bombarding electron interacts with whole atom, does not
penetrate atom
Radiation released due to electron dropping down into Radiation released due to diversion of bombarding
lower energy state electron as a result of the atomic pull
Radiation released is of a specific energy Radiation released is of a large range of energies
X-ray beam energy depends on element of target atoms X-ray beam energy depends on tube voltage
not tube voltage

Summary of Steps:
1. Filament current applied through tungsten filament at cathode
2. Heats up filament to produce enough energy to overcome binding energy of electrons (thermionic emission)
3. Electrons released from filament
4. Tube current means cathode is negatively charged and anode is positively charged
5. Electrons, therefore, are accelerated towards to positively charged anode, which gives them a certain energy
6. The electrons strike the anode and the energy released via interaction with the anode atoms produces x-ray
photons
7. These x-ray photons leave the x-ray tube through the window in an x-ray beam towards the patient
8. They pass through the patient to the film to produce the x-ray image (this section covered in the chapter
"Interaction with Matter")

X-Ray Spectrum
The resulting spectrum of X-ray photon energies released is shown in the graph to the right. At a specific
photoenergy there are peaks where more
x-rays are released. These are at the characteristic radiation energies and are
different for different materials. The rest of the graph is mainly
Bremsstrahlung, in which photons with a range of energies are produced.
Bremsstralung accounts for the majority of x-ray photon production.

Beam Quality: the ability of the beam to penetrate an object or the energy of
the beam.
Beam Quantity: the number of x-ray photons in the beam.
Altering the X-Ray Spectrum
Increasing the Tube Potential (kV)

Increased :
 Quantity of x-ray photons
 Average energy
 Maximum energy

If kV great enough, characteristic energy produced

Increasing the Tube Current (mA)

Increased quantity of x-ray photons

No change in:
 Characteristic energy
 Average energy
 Minimum energy
 Maximum energy
Filtration

Fewer lower energy photons

Increased:
 Quantity of photons
 Average energy of photons

Increasing Atomic Number of Target

Increased:
 Quantity of x-ray photons
 Characteristic energy

Waveform of Current

Having a more uniform current (rectified) results in -

Increased:
 Average energy
 Quantity of x-ray photons
 Same maximum keV
 Interaction with matter
A beam of x-rays may be:

A. Transmitted: pass through unaffected

B. Absorbed: transfer all energy to matter and do not pass through the
patient to the film
C. Scattered: diverted with or without energy loss

Attenuation
Attenuated x-rays are those that are absorbed or scattered. It is an exponential process and, therefore, the beam
intensity never reaches zero. Attenuation of the beam can be represented numerically by:
 Half value layer
 Linear attenuation coefficient
 Mass attenuation coefficient

Half Value Layer

This is the measure of the penetrating power of the x-ray beam and is the amount of matter required to attenuate
the beam to half its value. It differs for different materials and strengths of beams. To calculate the factor of
reduction use: 2HVL

e.g. if the HVL of a beam is 2mm, by what factor is the beam attenuated by if it passes through 8mm of material?
8mm = 4 HVLs
24 = 16
The beam is attenuated by a factor of 16

Linear Attenuation Coefficient

This is the probability of the material to attenuate the beam. It can also be expressed as the amount of energy
transferred to the medium per unit of track length of the particle. The linear atteunation coefficient (LAC or µ) is
calculated by:
µ = 0.693 / HVL µ = LAC, units: m-1

Mass Attenuation Coefficient

Independent of density and depends only on the atomic number of the material and photon energy.

MAC = µ / ρ ρ = density
MAC units = m2k-1

Effect of Beam Quality on Attenuation

The above only really apply to a monoenergetic (one energy value) beam of x-rays from a point source (infinitely
small area) travelling in a vacuum. In reality, the x-ray beam focus is not a fine point and contains photons of
different energies.

Wide Beam
Increased width of beam = increased scatter = greater attenuation = larger actual HVL.

Heterogenous Beam
 The beams produced by x-ray tubes are photons of a wide range of energies.
 The lower-energy photons are attenuated proportionally more than the higher-energy photons and are
removed, leaving behind higher energy photons aka "beam hardening".
 The resulting beam is of a higher average energy.
 In can, therefore, penetrate tissue easier and the HVL is increased.
 Interactions with Matter
Three processes may occur and contribute to attenuation:
 Compton effect
 Photoelectric absorption
 Elastic scatter

Compton Effect
1. Photon hits free electron
2. Electron absorbs some of the photon's energy and is deflected
3. The photon, having lost some energy, is deflected and
scattered

The greater the angle of scatter the:

 Lower the residual deflected photon energy
 Higher the subsequent electron energy

Compton Linear Attenuation Coefficient

Compton scatter is dependent on electron density and physical density but not on atomic number. The amount of
scatter decreases with increasing photon energies but not significantly within the range of diagnostic x-ray energies.
The Compton linear attenuation coefficient does not change over a large range of photon energies.

Compton scatter ∝ density / energy

Photoelectric Effect

In low Z materials (e.g. tissue and bone)

the high energy photon collides with
bound electron. The released photon has very
little energy and is absorbed immediately with
the ejection of a further, low-energy
or "Auger" electron and all the energy is said to
have been absorbed by the material.

1. Ejects it as a photoelectron if energy greater than binding energy.

2. All the photon energy is absorbed in the interaction.
3. An outer shell electron falls to fill in vacancy.
4. A low energy photon is emitted (electron moves from high to low energy state and, therefore, gives out the
energy).

In high Z materials (e.g. iodine) the released radiation may be sufficiently energetic to leave the body. This is why
high Z materials are used as contrast.

Photoelectric Linear Attenuation Coefficient

Probability of photoelectric effect increases:
 When electrons more tightly bound (i.e. higher Z)
 When photon energy closer to binding energy. The higher the photon energy the less likely the photoelectric
effect.
τ ∝ ρZ3 / E3 τ = photoelectric linear atteunation coefficient
ρ = density
Z = atomic number
E = photon energy
Absorption Edges
When the photon energy is as strong as the binding energy of
the k-shell electrons (Ek, for iodine this is 33keV) the probability
of photoelectric absorption jumps to a higher value resulting in
a sharp increase in attenuation (the k-edge).

For iodine, this k-edge is in the diagnostic x-ray energy range

and is utilised to give maximum attenuation and, therefore,
greater tissue contrast. Soft tissues and bone also have a k-edge
but these occur at 1 keV or less so the k-edge doesn't appear in
the diagnostic energy range.

As you can see from the graph above, the Compton effect does not change significantly over the range of photon
energies.

Elastic Scatter
Aka coherent, classical, unmodified or Rayleigh scattering.
 Photon bounces off an electron that is firmly bound to its parent atom.
 Occurs if photon energy less than binding energy of electron.
 No secondary electron is set moving and no ionisation or other effect is produced in the material.
 Little significance in radiology.

Summary

 Attenuation is an exponential process - beam intensity never reaches zero

 Attenuation measured by half value layer - factor of reduction = 2HVL
 Mass attenuation coefficient independent of density of material - depends only on atomic number of
material and photon energy
 Wide beam decreases HVL
 Heterogeneous beam - HVL increases with distance travelled due to beam hardening

Compton Effect Photoelectric Absorption

Interactions with free/outer shell electrons Interactions with inner shell electrons
Part of photon energy transferred Whole of photon energy transferred
Depends on: Depends on:

 Electron density of target  Atomic number of target

 Physical density of target  Photon energy
 Photon energy (minimally)  Physical density of target
 NOT atomic number

More important in low density structures More important in high Z structures

(e.g. air, water, soft tissues) with high (e.g. iodine, lead) and low photon energy
energy photons
Both processes occur equally at:

 30keV for air, water and tissue

 50keV for aluminium and bone
 300keV for iodine and barium
 500keV for lead
 Screen Film Radiography
Screen film radiography is the use of silicon films within a cassette being placed behind the object to be imaged and
exposed to an x-ray beam. These films are then processed.

Film
Types of Film

 Double-sided radiographic film: emulsion layer of light-sensitive crystals coated onto both sides of a
transparent base material. Used most in plain film imaging
 Single-sided camera film: one emulsion layer only. Used in mammography
 Non-screen film: x-ray photons used directly to expose film. Used in dental x-rays

Basic Structure
Base
 Clear polyester material about 150µm thick
 Provides physical support of the other film
components
 Does not participate in the image-forming process
Emulsion
 Active component in which image is formed
 Typically 5-10µm thick
 Consists of many small, irregularly-shaped silver halide crystals suspended in gelatine
 The silver halide used is typically silver iodobromide (10% bromide, 90% iodide)
 Each grain has a structural "defect" built in called the "sensitive spot". Each crystal is 1µm
 Most sensitive to light energy, therefore intensifying screens used

Forming an Image
An image is formed on film by:
1. Exposure to radiation
2. Development of film
3. Fixing

1. Exposure to Radiation
1) Unexposed Film: Each silver bromide grain contains a number of free Ag+ and Br- ions.
The sensitive spot is caused by a crystal structural imperfection.

2) Exposure: Absorption of light photons by the bromide ions frees the extra electrons which
move to and get trapped by the sensitive spot. This causes it to become negatively charged.
A positive silver ion is attracted to the spot and neutralised, depositing an atom of black
silver.

3) Repeated exposure: Process repeated as more photons reach the grain to cause several silver atoms to be
deposited. This forms the latent image. 10-80 photons are needed to make the grain developable.

2. Development of Film
The latent image is invisible. It is converted into a visible image through the process of chemical development. The
developer supplies electrons that migrate into the exposed grains in the silver bromide and converts the other silver
ions into black metallic silver:
 AgBr + electron = Ag + Br

Only exposed grains accept these electrons as their negatively charged bromide layer has been breached through
exposure. Given enough time, the developer will also penetrate the unexposed crystals producing background fog.

Developer solutions contain:

 Reducer: supplies electrons e.g. phenidone

 Activator: soften and swell the emulsion so that reducers can reach exposed grains. Usually sodium
carbonate
 Restrainer: moderates rate of development. Usually alkali such as potassium bromide
 Preservative: protects reducing agents from oxidation because of their contact with air. Reacts with
oxidation products which accumulate to reduce their activity which would otherwise retard development
and stain the film. Usually sodium sulphite.

3. Fixing
The film is immersed in fixer solution so that the unexposed and unreduced silver halide is removed to render the
image stable in white light. The fixer solution contains:

 Neutraliser: acetic acid to stop ongoing development after removal from developer solution
 Clearer: ammonium or sodium thiosulphate used to clear the undeveloped silver halide grains from the film
 Preserver: sodium sulphite
 Hardener: aluminium chloride shrinks and hardens the emulsion to produce final film

Automatic Processors
An automatic processor:
1. Unloads the film from the cassette
2. Transport the film through the processing chemicals in the right order
3. Produces a developed, hardened and dried film

Optical Density
The darkness of the film increases as the exposure is increased. This is measured as the optical density, which is a
log scale of the blackness of the film.
D = log10 (I0 / In) D = optical density
I0 = intensity of incident light beam
In = intensity of transmitted light beam at n

Double sided film increases the optical density for the same exposure (the total
optical density equals the sum of optical densities produced by each film).

Optical density Film

0 Clear piece of film that allow 100% of light to penetrate. The minimum density is usually in the
range of 0.15 to 0.2 density units because radiographic film is never completely clear. The value is
designated as base plus fog density
1 Each unit of density decreases light penetration by a factor of 10. A film area with a density value
of 1 allow 10% of the light to penetrate.
2 This allows 1% (10% of 10%) of light penetration. It is possible to see through areas of film with
density values of up to ~2 units
3 This allows 0.1% of light to penetrate
 Film Qualities

The Characteristic Curve

The behaviour of the film when exposed to light is represented
by its characteristic curve.

1. Low Exposure (Toe)

Small increases in exposure produces hardly any change in
density, resulting in a white image with no contrast.

Base plus fog: density produced on unexposed part of a

developed film Due to the density of the film itself and
blackening caused by the emulsion. It is usually in the range of
0.15 to 0.2. This increases if the film is stored for a long time or
at too high a temperature.

2. Linear Region
At higher exposures the probability of producing a developable
crystal increases with exposure. This is the region of most use
and provides the highest contrast.

3. High Exposures (Shoulder)

At high exposures nearly all crystals will be developed resulting in a dark image with no contrast.

Dmax: maximum density that a film can reach when all the grains are developed. Usually 3.5 to 4. Depends on the
characteristics of the film and processing conditions.

Film Speed
Aka the sensitivity. This determines the amount of exposure needed to
produce an image. The sensitivities of films are generally compared by the
amount of exposure required to produce an optical density of 1 unit
above the base plus fog density.

Speed = 1000 / (air kerma required for density of base-plus-fog + 1)

The typical speed for a rare earth film screen combination is 400.

 High sensitivity: requires less exposure but produces more noise

 Low sensitivity: used to reduce image noise

Contrast
 Radiation contrast: aka subject contrast. The ratio of radiation
intensities transmitted by different tissues or structures (a property of
the object being imaged)
 Radiographic contrast: the difference (not ratio) between optical
densities produced in areas of the film corresponding to different tissue

Latitude
This is the range of exposure that will result in a density within the useful range
of film densities (0.25 - 2).
 Wide latitude: greater range of soft tissues visualised but poor contrast
as lower gamma
  Narrow latitude: smaller range of soft tissue visualised but higher contrast as higher gamma

Gamma
Ratio between radiographic contrast and radiation
contrast i.e. the slope
 High gamma: steep slope. Smaller latitude,
greater contrast.
 Low gamma: shallow slope. Larger latitude,
low contrast

Effect of Grain Size

 Large Grain Size: fast emulsion. A larger grain presents a larger target for photons so fewer photons are
needed to blacken film resulting in a faster film.
 Variable Grain Size: small gamma. Grains of a uniform size tend to become developable at the same
exposure, so that the range of exposures go from low to high density is small, resulting in a large gamma.

Intensifying Screen
With emulsion, it has to thick enough to absorb enough photons to produce a decent image. However, a thicker
screen increases the scatter. An intensifying screen is placed in front of the film to amplify the photons and increase
the signal to the film without needing a thicker emulsion.

Intensification factor = exposure required to produce given optical density without screen
exposure needed with screen

Advantages
 A screen can absorb 20-40 times more x-rays than film alone
 A single x-ray photon can cause the emission of about 1500 light photons
 The same optical density can be achieved with smaller exposures (reduction factor 30-300) than when film
used alone
 Increased gamma

Properties
The intensification screen needs a large attenuation factor to
absorb the largest number of photons instead of allowing
them to have enough energy to pass straight through. This is
achieved by it having:
 High density
 High atomic number (Z)
 A favourable K-edge

Material
Calcium tungstate was widely used for its atomic number. More recently "rare earth screens" have become the
standard. They use gadolinium and lanthanum. Although Tungsten has a higher atomic number (Z=74) than
lanthanum (Z=56) or gadolinium (Z=64) the K-edge of lanthanum is at 39 keV, and this sudden increase in
attenuation takes its mass attenuation coefficient above that of tungsten.

Conversion Efficiency
Measures the proportion of the x-ray energy that is converted into light. Rare earth screens have a greater
conversion efficiency than calcium tungsten. However, a higher conversion efficiency leads to worse resolution.
Colour Matching
Different types of screen can produce different colours of light.
 Calcium tungstate produces bluish light
 Rare earth screens produce green light

Because of this the film needs to be used with a specific intensification screen.

Screen Thickness
A thicker screen leads to better absorption of x-rays and, therefore, more production of light. However, the thicker
the screen the more the spread of light before it reaches the film and, therefore, the greater the screen
unsharpness.
 Double-sided film: the disadvantages of a thicker screen can be overcome by sandwiching a double-sided
film between two screens to add the optical densities of the two emulsions together.
 Double screens: reduces the film screen unsharpness but causes other problems:
o Parallax - viewed from Z, the two images line up. Viewed from B, they won't. This
results in increased sharpness
o Crossover - when light produced in one screen is transmitted through the film base
to produce an image in the opposite emulsion. The increased spread of light means
greater unsharpness.

Reciprocity
A greater quantity of radiation from the x-ray tube is produced by:
 Increasing x-ray tube current (mA)
 Increasing exposure time (s)

To give the same mAs you can have a large tube current or a large exposure time = reciprocity.

Usually, the exposure determines the optical density of the image and the combination of current and time used to
achieve it does not matter. But, at very small exposure rates (small mA, long s) the level of light in the film may be
insufficient to produce a latent image. Image formation has time to reverse before it is complete. This reduction in
optical density is called the reciprocity failure.

Anti-Scatter Grids
Properties
Grid Ratio
This is the ratio of the thickness of the grid to the distance
between the lead strips. The larger the grid ratio the smaller the
angle of acceptance (θ) and the smaller the proportion of scatter
than can pass through the grid.

Grid Factor
This indicates the increase in exposure, and hence the increase
in patient dose, required to keep the dose to the image receptor
the same as without a grid. This is determined by the design of
the grid and the amount of scatter present in the x-ray beam.

Primary Transmission
This is a measure of how much of the primary (as opposed to the
scattered secondary) beam is stopped.

Image taken from e-learning module

Types of Grid
Grids are placed between the patient and the film-screen combination. The most
commonly used grids are focused crossed grids. If a focused grid is placed the wrong
way around it produces a linear artefact on the film with bands of very low exposure
due to the orientation of the grid obstructing the photon beam.

To avoid grid lines the grid is vibrated back and forth so that the lines are blurred out
by the motion e.g. the Potter-Bucky grid.

Disadvantages and Alternatives

Disadvantages of Grid

 Increased dose
 Incorrect usage: when there is less tissue (e.g. paediatrics) the small kV used means the amount of scatter is
small enough that the increased dose required by using a grid is not justified

Use of Air Gaps

Instead of using an anti-scatter grid, if dose increase is of concern, one
can use an air gap between the patient and the receptor. Increasing
the distance between the patient and the film means scattered
photons are more likely to miss the film due to their divergent paths
and lower intensities.

Summary
 Forming an image:
1. Exposure to radiation: silver bromide crystals form emulsion. Photons interact with crystals
depositing silver ions in proportion to exposure
2. Development of film: invisible latent image converted into visible image by chemical development
3. Fixing: image rendered stable in white light
 Optical density:
o Darkness of film measured as a log scale
o Base plus fog density = minimum density due to background fog. Usually 0.15 to 0.2
o Dmax = maximum density film can reach when all grains are developed. Usually 3.5 to 4
 Characteristic curve:
o Specific to each film-screen combination
o Film speed = sensitivity. Speed = 1000 / (air kerma required for density base-plus-fog +1)
o Gamma = steepness of curve.
 High gamma = steeper line, smaller latitude and greater contrast
 Low gamma = shallower line, larger latitude and smaller contrast
o Latitude = range of exposures that result in a density within the useful range of film densities
 Wide latitude = greater range of soft tissues visualised but poor contrast as low gamma
 Narrow latitude = smaller range of soft tissues visualised but higher contrast as higher
gamma
 Grains:
o Large grain = fast emulsion
o variable grain sizes in emulsion = small gamma
 Intensifying screen:
o Rare earth screens (lanthanum and gadolinium) have k-edge that give high absorption
o They also give higher conversion energy
o Artefacts of double screen
 Parallax
 Crossover
 Anti-Scatter Grids:
o Grid ratio = thickness / distance between lead lines
o Grid factor = exposure necessary with a grid / exposure without a grid
o Grids are: crossed vs linear. Parallel vs linear
o Advantages
 Reduce scatter
o Disadvantages
 Increased dose
 Incorrect usage
o Air gaps can be used instead if dose of concern
 Digital radiography
There are a number of limits to screen-film radiography and we now use mainly computed radiographer although
digital radiography is also coming into practice.

1. Computed Radiography
Cassettes are used that have a phosphor screen. When the x-rays hit they form a latent image in the phosphor. The
cassette is then placed into a reader with a laser shone on to it which releases the stored photons, collects the signal
and digitises it to be displayed on a display screen.

2. Digital Radiography
With digital radiography no cassettes are used. The x-rays hit a permanently placed set of hardware, which then
sends the digital information directly to a readout mechanism.

 Indirect DR: x-ray photons hit a scintillator layer, which releases light photons that then hit an active matrix
array that digitises the signal
 Direct DR: x-ray photons act directly on a photoconducter layer producing positive and negative charge.
The positive charge is attracted to a charge capacitor that stores the latent image. It is then read out by TFT
switches pixel by pixel.

Standard DR Process

1. X-ray produced by standard radiographic x-ray tube

2. Image captured by digital image detector
3. Digitised into a stream of data via an analogue-to-digital converter (ADC)
4. Transfer to system computer
5. Output via digital-to-analogue converter (DAC) to video format
6. Post-processing of image
7. Display onto suitable display device

Limitations of Screen-Film Radiography

 Each screen film combination exhibits it own characteristic curve
 The radiographic speed is fixed and not possible to adjust patient dose on the spot.
 The dose latitude is fixed
 Fixed brightness and grey-scale that can't be adjusted
 Lot of toxic chemicals are used
 Time intensive
 There is a high repeat exposure rate. In some branches 20% of examinations may have to repeated.
 Archiving images difficult as film physically bulky, the recall and management of archived film images is
inefficient, a large number of images are lost over time, and film is not immediately compatible with digital
picture archiving.
 Computed Radiography (CR)

X-Ray Luminescence
This is the physical mechanism by which x-ray energy is converted into light in a phosphor screen. It involves two
mechanisms that both occur to some degree when a phosphor screen is irradiated.

 X-ray fluorescence: the prompt (immediate) emission of

light. This is the mechanism that predominates in screen
film radiography

 X-ray phosphorescence: this is when the emission of light

is delayed over a timescale of many minutes, hours or
days and can be accelerated by shining specific coloured
light onto the phsophor. This is the mechanism exploited
in computed radiography. It allows x-ray energy to be
temporarily stored in a phosphor screen without the need
for a sheet of radiographic film.

CR Image Plate (CR IP)

Layer of phosphor crystals (made of barium fluorohalide activated with divalent europium ions) embedded in a
polymer binder with top surface protected by layer of toughened plastic. Typically 0.3 mm.

Standard IP High resolution IP

Layer of phosphor crystal Thicker layer Thinner layer

Crystal size Larger Smaller

Light reflection layer Yes No

Uses General radiographic High spatial resolution

examinations

Fractional X-ray absorption efficiency 40% (good) Lower i.e. need larger x-ray dose

Image Processing
1. Latent Image Formation
X-ray photons are absorbed into a phosphor crystal giving rise to a high energy photoelectron. This ionises a large
number of atoms along its track releasing thousands of electrons (one x-ray photon absorbed gives rise to over 100
trapped electrons). The electrons become temporarily trapped at specific sites throughout the layer of phosphor
crystals producing the latent image.

2. Laser Stimulated Emission

If left long enough, the electrons spontaneously relax back to their ground state and the image decays over time.
During readout the IP is scanned with a red laser beam stimulating the trapped electrons to immediately relax back
to their ground state and release their stored energy as light photons in the blue part of the spectrum, which are
collected by optical fibres to a photomultiplier tube. The PM tube produces an electrical current.

This film can be read in 30 seconds. Films can also be queued by the machine to process them automatically in turn
so radiographers do not have to place each individual cassette into the reading and can save time.

3. Resetting Cassette
Readout is "destructive" as it eliminates the latent image. The film is then exposed to bright light to erase any
residual signal before re-using the cassette.

4. Post-Processing of Image

Digital Image Structure

Pixel
Pixel size is determined by spatial resolution. Each pixel records a value, in binary format, related to intensity of
signal in the corresponding part of the image. In binary system, 1 bit is one value of grey.

N bits = 2n (number of different values (greys))

Computer memory is measured in bytes:

1 byte = 8 bits (28 = 256 values)

Image Quality

Speed
In CR systems the speed is defined as:

Speed = 2000 / X X = dose incident on the IP

In CR, systems produce images with consistent density independent of the exposure factors used (unlike in SFR). To
help estimate the mean dose incident on the image plate the S-number (speed index) is used, usually operating from
200-400.

S < 200 improved SNR but at increased patient dose

S > 400 used when minimal radiation required e.g. repeated paeds films
Latitude (Dynamic Range)
Unlike SFR (which has a characteristic curve), the dynamic range is a straight line meaning CR produces good contrast
over a much wider range of exposures.

Spatial Resolution
Improved by:

 Smaller diameter of readout laser beam (thinner line of image plate "read-out")
 Smaller pixels
 Smaller size of phosphor crystals
 Thinner phosphor layer
 No light reflection/absorption backing layer (as this produces scatter despite improving efficiency by using
more of the photons for image production)

Spatial resolution is best described by the modulation transfer function.

Modulation Transfer Function

The MTF represents the ratio of output to input modulation. An MTF of 1 means the spatial resolution imaged and
displayed are the same. As the spatial frequency increases, the MTF decreases until, with the addition of noise, it is
impossible to visualise details of higher spatial frequencies - the "limiting spatial resolution" - and the MTF is 0 (i.e.
no information conveyed).

Detective Quantum Efficiency (DQE) of CR Imaging

This is defined by the following equation:

DQE = SNR2out / SNR2in

The greater the DQE the more efficiently the detector can record information. A DQE of 0.25 implies that the
detector can only exploit ¼ of the incident x-ray photons. For a CR imaging system it is typically:

 0.25 for a standard IP

 0.12 for high resolution IPs

Artefacts
Moiré Pattern: When a stationary x-ray anti-scatter grid is used there is interference between the
linear structure of the grid and the regular pixel array of the digitised image.

Ghost Image: Due to carry-over of image content from a previous exposure.

Excessively High/Low Image Density: Due to faulty operation of the data auto-ranging software,
previously due to incorrect identification of the x-ray colimators.

Excessive Digital Enhancement: e.g. ringing effects along the edges of high density structures or
shadowing within such structures.
 Digital Radiography
In CR, the film cassette has to be removed from under the patient and fed into a reader to be processed. In digital
radiography (DR) the image is produced directly from the image detector and displayed on the screen.

There are two types:

 Indirect DR: x-ray → light photons → readout electronics
 Direct DR: x-ray → charge → readout electronics

Indirect DR

Hardware

1) Scintillator Layer
A thin 500µm layer of caesium iodide (CsI:TI) is used as a scintillator to capture the image and coated onto the a-Si:H
active matrix array. The CsI:TI is a channelled crystal structure that ensures minimum unsharpness of the recorded
image produced by scatter. Absorption of an x-ray photon releases ~3000 light photons in the green part of the
spectrum.

2) Active Matrix
This is formed by an amorphous silicon layer doped with hydrogen (a-Si:H) and forms the readout electronics. The
active matrix consists of a high resolution array of electronic components. Each pixel typically comprises a:
 Photodiode (a light sensor)
 Charge storage capacitor
 Thin-film transistor (or TFT switch)
This circuitry (TFT and charge storage capacitor) takes up a small area of each pixel preventing image formation in
this area. This is calculated by the fill factor.

Fill factor = sensitive area / overall area

Decreasing the pixel size (making each area smaller) improves the resolution but, as the circuitry remains the same
size, the fill factor and, therefore, the efficiency of the array, decreases.

3) TFT Array
This is a device that amplifies the signal then stores it as an electrical charge. The charge can be released, and read,
by applying a high potential. In the array, each transistor corresponds to a pixel.

4) X-Ray Window
The translucent x-ray window is made of aluminium or carbon fibre over the detector entrance to minimise
unnecessary absorption and scatter of x-ray photons.
Image Formation

1. CsI:TI absorbs x-ray photons and releases light photons

2. These light photons are then absorbed in the photodiodes, releasing charge carriers
3. The charge carriers released at each pixel location accumulate in the associated storage capacitor to form
the latent image
4. The latent image is read out sequentially and transferred to a bank of charge sensitive amplifier (TFT
switches)
5. The resulting voltage signal is then digitised and transferred to the system computer where the DR image is
built up

Direct DR

A layer of x-ray photoconductor material is used instead of an x-ray scintillator.

Photoconductor
This directly converts x-ray photon energy into free electrical charge carriers (electrons and holes) i.e. the "middle-
men", or light photons, are cut out. The most commonly used photoconductor is amorphous selenium or a-Se.

Sequence of Image Formation

1. X-ray photon absorbed by a-Se photoconductor

2. Electrical charge carriers (negative electrons and positive holes) are created in the a-Se
3. A surface electrode at positive potential attracts all the electrons
4. The positive charges are drawn to the charge storage capacitor forming the ltent image
5. The latent image is then read out sequentially by gating each row of TFT switches (each TFT corresponds to
one pixel) in turn to read the charge pattern and transfer to a bank of charge sensitive amplifiers
6. The resulting voltage signal is then digitised and transferred to the system computer where the DR image is
built up
7. Post-processing

Post-Processing

Artefacts and Correction

 Irregular Shading Across Field: due to non-uniform variations in the sensitivity or gain of the x-ray
absorption layer
 Bright/dark spots or lines in image: due to individual or rows and/or columns of defective pixels in the
active matrix array.
Correction
 Gain-Calibration: uses previously acquired mask image comprising an image acquired with a uniform x-ray
beam and subtracting this gain mask image from the patient image.
 Pixel-Calibration: defects in pixel array can be corrected by interpolating the data values of neighbouring
pixels which are functioning correctly using a reference map.

Auto-Ranging
The data needs to be matched to the display device.
1. Identification of relevant image field
2. Generation of a histogram of the data representing the number of pixels at each grey-scale value
3. Analysis of the histogram to exclude ranges of data which contain no clinical information (very high and low
values)
4. Selected grey-scale range normalised to match the display image

Digital Image Enhancement

Grey-Scale Modification
A look-up-table (LUT) is a method of systematically re-mapping the grey-scale values in the recorded image to a new
range of values in order to improve the displayed image in some way. Shifting the LUT gradient and position adjusts
the mean brightness and displayed contrast of the image.

Spatial Feature Enhancement

1. An unsharp mask algorithm is used to produce a blurred version of the original image
2. This is then subtracted from the original image to produce an image which retains the fine detail structures
in the image alone
3. Add the fine detail image back onto the original
4. Produces enhanced composite image

Monitor Display
Cathode Ray Tube (CRT)
Visible image generated by scanning a phosphor screen with a focused beam of electrons all contained within an
evacuated glass tube.

Flat Panel Displays

Most display monitors are based on liquid crystal (LC) technology. Application of the appropriate voltage distribution
to an active matrix modulates light polarisation on a pixel-by-pixel basis varying the light emission that comprises the
image seen on the screen. It produces a higher contrast image with greater resolution and less power usage.

Hardcopy
On occasions, it is necessary to print a hardcopy image. A hardcopy image is recorded using a laser printer onto a
film with silver crystals to create a latent image. This is converted into a visible image by applying heat to the film.
This ‘dry’ film processing eliminates the need for traditional we chemical processing.
 Image quality
There are certain qualities of an image that affect each other and determine the quality of the displayed image:

1. Contrast
2. Resolution
3. Noise

As well as:

4. Unsharpness
5. Magnification
6. Distortion
7. Artefacts

I've also included a special note on image quality in Digital Radiography taken from the previous chapter.

1. Contrast
Contrast is defined as the difference in the shades in different parts of an image. A high contrast image has a greater
difference but a smaller range of greys. A low contrast image has a smaller difference (i.e. it's more difficult to make
out different areas) but a larger range of greys.

Subject Contrast
Subject contrast is the ratio of the radiation intensities in different parts of an image due to the quality of
the subject being imaged. The contrast is due to the differential attenuation by the tissues.

C ∝ (µ1 - µ2) x t

Key: C = contrast
µ = attenuation coefficient of object 1 and 2 in the material being imaged
t = thickness of the structure

From the above equation you can see that a higher contrast is achieved with:
 Thicker structure being imaged
 Greater difference between the attenuation of the two objects

In the diagram to the left, tissue A absorbs 50% of the

radiation incident upon it, B absorbs 90%. If there are 1000
photons for every element of the image then 500 photons will
emerge from A and 100 from B (a ratio of 5:1).

As optical densities (the displayed shade in the image) vary

with the log of the exposure, log500 = 2.7 and log100 = 2.0 - so
the subject contrast has a difference in logs of 0.7.

Image taken from e-LfH 8a_068 Factors Affecting Image

Quality in Radiography
Factors Affecting Contrast
Linear attenuation coefficient of subject
The linear attenuation coefficient depends on the Compton and the photoelectric linear attenuation coefficient.

Compton linear attenuation coefficient ∝ ρ/E

Photoelectric linear attenuation coefficient ∝ ρZ3/E3

Key: ρ = density
E = energy (kV)
Z = atomic number of material

From the equations above we can see contrast can be improved by:
 Decreasing the energy (tube potential kV)
 Increasing the difference in Z (atomic number) (e.g. use of iodine or barium as a contrast medium)
 Increasing the difference in ρ (density) (e.g. use of barium or gas as a contrast medium)

Overlying Tissue
If there is overlying tissue over both A and B, subject contrast is not changed as the same ratio of photons is
absorbed in tissue A and B.

Scatter
Suppose scatter contributes an additional 50 photons to each element in the image, there will now be 150 photons
in the film under tissue A and 70 under tissue B. The ratio of signals is now 2.14 (150/70) and the difference in logs is
0.33 i.e. a reduced contrast.

Scatter is reduced by:

 Using an anti-scatter grid
 Using an larger air gap

Summary
Improve contrast:
 Thicker structure
 Greater attenuation between objects
 Decreasing kV
 Increasing difference in Z of objects
 Increasing difference in density of objects

Reduce contrast:
 Increased scatter

No effect:
 Overlying tissue
Image Contrast

In Film Screen Systems

This is the difference
in optical densities of
the film. It depends on the
subject contrast and the gamma of the film
(refer to Screen Film Radiography). The greater
the gamma, the steeper the curve and the
greater the difference in optical densities. BUT,
increasing the gamma leads to reduced latitude
and fewer optical densities can be displayed
adequately.

In Digital Imaging Systems

This is achieved by windowing on the viewing monitor. Images are presented at a certain width and centre of
Hounsfield units displayed. The larger the width, the larger the range of shades displayed and, therefore, the smaller
the difference and contrast between each shade. The window is adjusted for the Hounsfield unit of the tissues that
need to be assessed.

2. Spatial Resolution
Resolution is the measure of how far two objects must be apart before they can be seen as separate details in the
image. There are several ways to measure spatial resolution.

Measuring spatial resolution

Line Spread Function
This is a measure of how spread out the image of a sharp object becomes. However, this is difficult to calculate and it
is easier to look at the image in terms of spatial frequency content.
Spatial Frequency
This is measured in line pairs per mm or lp/mm. An image with a high lp/mm is a high spatial
frequency image as there are many alternating light and dark regions in a single millimetre. We,
therefore, need a system that can reproduce the image with the appropriate frequency. How close a
system is able to represent the object spatial frequency is expressed as the modulation transfer
function (MTF). The lp/mm of different radiographic techniques can be found in the appendix.

Modulation Transfer Function

MTF = 1 same range is obtained in the E.g. for an imaging system that can fully change from black to
image white over 1mm:
MTF < 1 lower range in the image For images with 0.5 lp/mm, it gives and MTF of 1
For images with >0.5 lp/mm, it gives an MTF of <1
MTF = 0 no information in the image

MTF is calculated from the lines spread function using Fourier Transform analysis. The total MTF is the product of the
MTF of all constituent parts of the imaging system.

Factors affecting spatial resolution:

 If the object frequency is too high for the system,
the system will be unable to display the image
adequately. The higher the object frequency, the
lower the MTF until the system cannot distinguish
the line pairs at all resulting in a homogeneous
grey i.e. MTF = 0.

 If the object has low contrast the system will reach

an MTF of 0 earlier as the smaller difference in the range of shades means that the image will reach a
homogeneous grey much sooner than if it was a high contrast image (e.g. alternating bands of black and
white).

 Anything that increases the unsharpness will blur the edges and further reduce the spatial frequency.

Digital Detectors
There several things that affect the resolution of digital detectors.

Detector Aperture
The signal is averaged over the area of the detector element. If object details
are much smaller than the size of the element they are not visible unless they
have enough contrast to have a significant effect on the average signal.
(Image from e-lfH)
Sampling Pitch
This is the centre-to-centre distance between individual detector elements. It determines the highest spatial
frequency that can be imaged called the Nyquist frequency.

Nyquist criterion states that the sampling frequency must be at least twice the
highest signal frequency. The highest signal frequency is also called the "Nyquist
frequency" i.e. for a system to be able to accurately represent the spatial resolution
of the object it must have the appropriate sampling pitch which is no less than
double the object spatial frequency.

Sampling frequency = 2 x Nyquist frequency

 3. Noise
There is a random variation in the number of photons forming each part of the image, called noise, that can obscure
the signal received from the subject. The amount of noise is proportional to the square root of the total number of
photons.
Noise ∝ √photons

Average number of photons absorbed by each 1000 100

detector (N)
Noise 31.6 10
Proportion of signal which is noise 31/1000 x 100 = 10/100 x 100 =
3% 10%

Signal to noise ratio (SNR) = N / √N 31 10

Reducing the proportion of noise in an image will improve the quality. The main way to achieve this is to
increase the number of photons detected and used to form each image pixel / element. This can be done in several
ways:

 Increasing the dose (mA): higher number of photons and smaller proportion of noise
 Using an image receptor with a greater attenuation coefficient: more photons are absorbed and converted
into a signal
 Make the image receptor thicker: again, more photons will be absorbed and converted into a signal
 Using larger detector elements: more area to absorb photons per pixel. However, the spatial resolution will
decrease

Factors that don't reduce noise:

 Amplification: attaining a higher signal from each absorbed photon, either by using a faster film-screen
combination or gain of an image intensifier would just amplify the signal from noise as well
 Using a narrower window to produce a high contrast image

4. Unsharpness

Geometric unsharpness
The boundaries between a dark and a light area may be be very well defined,
resulting in a blurred edge. This is called "unsharpness". There are several causes
and types of unsharpness as outlined below.

The focal spot is not infinitely small. There will be areas of the image that are:

 Low signal - all x-ray photons have passed through the object
 High signal - no x-ray photons have passed through
 Intermediate - not all photons have passed through the object. The size of
this area determines the unsharpness and is called the penumbra.

Moving an object further away from the focal spot will increase the penumbra
and, hence, the unsharpness.

The geometric unsharpness (Ug) is determined as follows:

Ug = f x a / b
Key: f = X-ray focal spot size
a = distance from x-ray source to front surface of object
b = distance from object to detector

Image receptor unsharpness Movement unsharpness Edge unsharpness

Film screen images: In intensifying If an object moves during the If an object has a tapering edge, the
screens, the absorbed x-ray is acquisition the edge will be blurred attenuation will gradually decrease
converted into light photons which resulting in unsharpness. along the object.
then travel through to the film. If the
screen is thick the light photons can
spread out more before reaching the
film and produce a more blurred
image.

Digital images: if a detector element

lies across the border between a
light and a dark area, the pixel
displayed will be an average of these
two values creating a blurred
border.

5. Magnification
Magnification (M) depends on the relative distance of
the object between the x-ray source (focal spot) and
the image receptor. The further away from the source
the object is the more the image is magnified.

M = image size / object size

= d2 / d1

As we saw in the section on unsharpness, the closer to

the focal spot an object is the larger the magnification,
the larger the penumbra and the larger the geometric
unsharpness.

6. Distortion
Depending on the angle at which the x-ray beam passes through an object it can distort the shape and create a
distortion artifact.

7. Artefacts
There are a variety of patient and system factors that can create artifacts:

 Motion artifact
 Double exposure
 Grid cut off
 Radio-opaque objects on or external to the patient
 Digital Radiography - special notes

Speed
In CR systems the speed is defined as:

Speed = 2000 / X X = dose incident on the IP

In CR, systems produce images with consistent density independent of the exposure factors used (unlike in SFR). To
help estimate the mean dose incident on the image plate the S-number (speed index) is used, usually operating from
200-400.

S < 200 improved SNR but at increased patient dose

S > 400 used when minimal radiation required e.g. repeated paeds films

Latitude (Dynamic Range)

Unlike SFR (which has a characteristic curve), the dynamic range is a straight line meaning CR produces good contrast
over a much wider range of exposures.

Spatial Resolution
Improved by:

 Smaller diameter of readout laser beam (thinner line of image plate "read-out")
 Smaller pixels
 Smaller size of phosphor crystals
 Thinner phosphor layer
 No light reflection/absorption backing layer (as this produces scatter despite improving efficiency by using
more of the photons for image production)

Spatial resolution is best described by the modulation transfer function.

Modulation Transfer Function

The MTF represents the ratio of output to input modulation. An MTF of 1 means the spatial resolution imaged and
displayed are the same. As the spatial frequency increases, the MTF decreases until, with the addition of noise, it is
impossible to visualise details of higher spatial frequencies - the "limiting spatial resolution" - and the MTF is 0 (i.e.
no information conveyed).

Detective Quantum Efficiency (DQE) of CR Imaging

This is defined by the following equation:
DQE = SNR2out / SNR2in

The greater the DQE the more efficiently the detector can record information. A DQE of 0.25 implies that the
detector can only exploit ¼ of the incident x-ray photons. For a CR imaging system it is typically:

 0.25 for a standard IP

 0.12 for high resolution IPs

Summary
 Contrast
o Difference in attenuation (subject contrast) or displayed shade (image contrast) of an image.
o Subject contrast
  Contrast ∝ (µ1 - µ2) x t (µ = attenuation coefficient of object 1 and 2, t = object thickness)
 Improve contrast by:
 Thicker object
 Greater attenuation between objects
 Decreasing kV
 Increasing Z (atomic number) difference in objects
 Increasing difference in density of objects
 Contrast reduced by:
 Increased scatter (no anti-scatter grid, smaller air-gap used)
 No effect:
 Overlying tissue
o Image contrast
 Film screen system: greater gamma gives greater contrast
 Digital imaging system: achieved by windowing at the imaging monitor
 Spatial resolution
o Measure of how far apart two objects must be before the can be seen as separate details in an
image
o Measured as:
 Line spread function: how spread an image of a sharp object becomes. Difficult to measure
 Line pairs per mm (lp/mm)
o Accuracy of system display of object spatial frequency: modulation transfer function (MTF)
 MTF = 1 same range obtained
 MTF < 1 smaller range obtained
 MTF = 0 no information in image
o Factors affecting spatial resolution:
 Object properties:
 Object spatial frequency: if it is too high for the system it will not be displayed
accurately
 Object low contrast: lower contrast objects reach an MTF of 0 at lower spatial
frequencies
 Computed / digital radiography
 Detector element size: smaller element = higher spatial resolution
 Distance between detector elements: smaller distance = higher spatial resolution
 Others:
 Anything that increases unsharpness
 Noise
o Noise ∝ √photons
o Reducing noise - anything that increases number x-ray photons (x-ray beam) produced and absorbed
and number of light photons (image receptor) produced:
 Increasing dose (mA)
 Using an image receptor with a greater attenuation coefficient
 Making the image receptor thicker
 Using larger detector elements
o Factors that don't reduce noise:
 Amplification
 Using narrower window to produce a high contrast image
 Unsharpness
o Geometric unsharpness
 Focal spot not infinitely small therefore blurred penumbra produced at object edge
 Ug = f x a / b
o Image receptor unsharpness
 Film screen images: thicker screen causes light photons produced to spread out before
reaching film
 Digital images: if detector element straddles light and dark area pixel displayed will be an
average of these two values
o Movement unsharpness
 o Edge unsharpness
 Magnification
o Greater magnification (by moving object closer to focal spot) = greater unsharpness
 Distortion
o Due to the finite size of the focal spot an image may be distorted depending on the angle at which it
is imaged
 Artifacts
o These may be due to patient or system factors
 Digital radiography - special notes
o Speed
 Speed = 2000 / X
 S < 200 = improved SNR but increased patient doses
o Spatial resolution
 Measured by MTF
 Detective quantum efficiency (DQE) = SNR2out / SNR2in
 Greater DQE = more efficient detection of incident x-ray photons
 Improved by:
 Smaller diameter of readout laser beam
 Smaller pixels
 Smaller size of phosphor crystals
 Thinner phosphor layer
 No light reflection / absorption backing layer (produces scatter)
 Quality Assurance
Quality assurance is a requirement of IRR 1999 and each hospital should establish its own quality manual detailing:

 What tests have to be done

 How the tests should be done
 How often the tests should be done
 How the test results are recorded and analysed
 What the acceptable margin of deviation from the standard is
o If test differs by a margin that requires action to rectify it = remedial level
o If test differes by substantial margin that means equipment no longer fit to use = suspension level
 What to do if a test is failed

The Institute of Physics and Engineering in Medicine (IPEM) report 91: Recommended standards for the routine
performance testing of diagnostic x-ray systems is used to guide quality assurance tests and timelines.

IPEM report 91 divides QA tests into two levels, which it calls level A and level B.

Level A tests:
 Are generally quick and simple
 Do not need expensive or complex equipment
 Do not need detailed analysis
 Are done frequently
 Are usually done by the equipment user

Level B tests:
 Take longer
 Might require expensive or complex equipment
 Need more analysis
 Might be done less frequently than level A tests
 Are often done by medical physics departments or by manufacturers’ engineers

Equipment tests

Speed of Film Processor

Test frequency: Daily to weekly

Four values are calculated daily:

1. Speed index
2. Contrast index
3. Base plus fog
4. Dmax

Sensitometry
a) Sensitometer exposed film to a range of different light levels (usually approx 20 steps)
b) Densitometer measures transmission of light through the film to measure the optical density (OD)

Then there are two methods to assess the performance of the processor:
1. Speed index:
 Step at which OD approx 1.2 identified
 Each time sensitometric film processed the density of this same step measured (result called the speed
index) and used as proxy for the characteristic curve
 Speed index plotted on daily chart

2. Contrast index:
 Two steps chosen with a difference in OD of 1
 Each time sensitometric film processed the densities of these steps measured
 The difference in the OD between the steps is the contrast index and is used as a proxy for the actual
contrast (gamma) of the characteristic curve

IPEM report 91 suggested margins for both speed and contrast index:
 Remedial level = 0.15 OD from baseline
 Suspension level = 0.3 OD from baseline

3. Base plus fog

The OD of an unexposed area of film measured to find the base plus fog level
 Remedial level = >0.25 OD
 Suspension level = > 0.3 OD

4. Dmax
OD of darkest step measured.

Solutions
 Gradual Changes
o Incorrect replenishment rates
o Drift in developer temperatures
o High film throughput
 Step Changes
o Change of film batch
o Change of developer chemistry

X-ray Set Tests

X-ray tube output

 Test every 1-2 months
 Ionisation chamber placed at a known distance from the x-ray tube. The measurements of does (using an
electrometer) are made for various exposures to determine:
o Dose per mAs (output) for range of exposures
o Whether output varies with mA
o How output varies with kV
o Repeatability - Whether output is consistent when same exposure repeated
 Remedial level = +/- 10%
 Suspension level = +/- 20%
o Consistency - whether output has changed since the baseline set of QA checks
 Remedial level = +/- 20%
 Suspension level = +/- 50%

X-ray tube kV
 Test every 1-2 years
  Potential measured using an electronic kV meter. The kV is then measured at a range of different exposure
settings.
o Is it accurate - do we get the value we have selected?
o Does it change if we change the mA range or exposure time?
o Does it vary during the exposure?
 Remedial level = +/- 5% or +/- 5 kV from baseline, whichever is greater
 Suspension level = +/- 10% or +/- 10 kV from baseline

Filtration
 Dose for fixed exposure measured with varying thicknesses of aluminium placed in the beam
 The thickness that gives 50% transmission (half original dose) is the half-value thickness (HVT) or half value
layer (HVL).
 Data is available that enables the filtration to be estimated from the HVT

Automatic exposure control

 Test every 1-3 months
 The AEC terminates the exposure once the film has received an appropriate level of dose.
 It should produce a consistent optical density in the film for a wide range of tube potential (kV) and for a
wide range of patient thickness.
 Perspex or water blocks used to simulate a patient
 A series of exposures at different tube voltages and using a different thickness of material is taken. The OD
and mAs is noted
o Remedial level = +/- 0.3 OD relative to baseline
o Suspension level = +/- 0.5 OD relative to baseline

 AEC chamber consistency

o Test every year.
o There are usually three ionisation chambers in each AEC.
o Remedial level = +/- 0.3 OD relative to baseline
o Suspension level = +/- 0.5 OD relative to baseline

Light beam alignment

 Test every 1-2 months.
 Edges of light beam marked on film the film exposed. Area of exposed filed then compared to light field
 Remedial level = 1 cm misalignment on any side at 1 m from focal spot
 Suspension level = 3 cm

Focal spot measurement

 Pinhole
o Pinhole a few microns across (smaller than the focal spot) radiographed.
o Taking into account the distance from the focus to the pinhole and the focus to film distance you can
then calculate the size of the focal spot by measuring the image produced on the film.
o Can estimate size, shape and irregularities in the focal spot with this method

 Star test object

o An array of radiating lead spokes is radiographed with a geometric magnification of approx 3
o The spokes at the centre will come to a point at which they can no longer be distinguished by the
system due to being too small and close together.
o The diameter of the blurred area can be used to calculate the focal spot size
Films and Intensifying Screens
Screens
 Test every 12 months
 May lose sensitivity and suffer mechanical damage over time.
 Inspected for damage and cleaned every 6-12 months
 Suspension level = sensitivity differs by > 20% from batch

Films
 Crossover check performed when new batch of films used

Summary
 Quality assurance a requirement of IRR 1999 but exact schedule and test list is not specified - up to
individual hospital
 IPEM report 9.1 provides guidelines
 Remedial level - action required to improve equipment performance
 Suspension level - equipment should not be used any more. Not every piece of equipment has a suspension
level

Example testing timeline and summary

Equipment tested Frequency of Method of testing Performance criteria
testing
Speed of film Daily to weekly Sensitometry and densitometry Speed and contrast index
processor  Remedial level = 0.15 OD
Assess: from baseline
 Speed index  Suspension level = 0.3 OD
 contrast index from baseline
 Base plus fog Base plus fog
 Dmax  Remedial = >0.25 OD
 Suspension = > 0.3 OD
X-ray tube output 1-2 months Electronic kV meter measures kV at  Remedial = +/- 5% or +/- 5 kV
different exposure settings from baseline
 Suspension = +/- 10% or +/- 5
kV from baseline
Light beam 1-2 months Light beam field compared to  Remedial level = 1 cm
alignment exposed field on film misalignment on any side at 1 m
from focal spot
 Suspension level = 3 cm
Automatic 1-3 months Film exposed at different tube  Remedial level = +/- 0.3 OD
exposure control voltages and different perspex relative to baseline
(AEC) performance thicknesses to ensure consistent  Suspension level = +/- 0.5 OD
OD relative to baseline
AEC ionisation Annual Expose ionisation chambers  Remedial level = +/- 0.3 OD
chamber separately and compare (usually relative to baseline
consistency three)  Suspension level = +/- 0.5
OD relative to baseline
Focal spot Annual Pinhole
 Pinhole radiographed and
size, shape and
inconsistencies of focal
spot calculated from image
produced
Star test object
  Radiating lead spokes
radiographed and central
blurred area size used to
calculate focal spot size
Filtration Annual Half value thickness / layer of filter
determined and compared to
available data to calculate filtration
Should be equivalent to 2.5mm
aluminium
Intensifying screen Annual Compare images produced at same Suspension level = sensitivity differs
settings using different screens by > 20% from batch
Film With every new Crossover check with old batch
batch