Introduction to Medical Imaging

Lecture -1
Introduction to Medical Imaging

1) Introduction
Imaging studies include a wide variety of techniques that allow direct
visualization of anatomy and provide insights into physiologic, metabolic,
and pathological processes within the human body.
Imaging plays a role in all aspects of medical care, from primary diagnosis
(including screening) to treatment planning, treatment response assessment,
and long term follow-up.
Imaging Modalities can be divided into structural and functional imaging.
− Structural imaging
This includes plain X-ray, CT or MRI. These will demonstrate anatomical
information . The sensitivity of such imaging may be improved by the use
of contrast, including intravenous or intraluminal contrast.
− Functional imaging
These fall within the realm of nuclear medicine. A radioactive isotope is
administered which localizes to specific areas. The areas of tracer
accumulation are collected by a special detector (e.g. gamma camera) and
reconstructed to form a picture. These can quickly highlight abnormal
areas which may be difficult to see on structural scans.

2) Imaging modalities

1. X-Ray-Based Modalities
X-ray imaging is based upon the differential attenuation of x-rays within
different tissues in the body.

a) Plain Radiography
The central elements of x-ray based systems are x-ray tube and a 2
dimensional (2D) detector on either side of the subject .

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The X-ray beam is attenuated as it passes through a tissue, to a degree that is

proportional to the thickness, density, and composition of that tissue. Air
causes minimal attenuation of the x-ray beam, so air-filled structures (such as
lungs and bowel) appear lucent (black) on plain radiography. At the other
extreme, dense materials (such as calcium in bones, metals in prosthesis)
extensively attenuate x-ray beams and appear opaque (white) on radiography.
Figure-1

Figure -1 Production of X-ray

a) Computed Tomography (CT)

The basic physics principle is the same as for plain radiography and is
based on the attenuation of x-ray beams as they pass through tissues. In CT,
however, an x-ray producing source and x-ray detector(s) are positioned
opposite each other within a gantry which rotates continuously around the
patient. As a result, x-ray beams are directed toward the patient from multiple
angles, and a large amount of data is generated regarding the attenuation of
each x-ray beam. Computer algorithms are then applied to produce a detailed
representation of a “slice” of the human body, typically in the axial plane,
based on the differences in x-ray attenuation by different organs. Figure-2

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Figure-2 CT Scan of the abdomen

Modern CT scanners can acquire multiple slices simultaneously and images

of the entire body can be acquired by moving the patient through the CT
scanner during rotation. CT has the advantage that it achieves high spatial
resolution soft-tissue discrimination, is highly reproducible, and can be
employed quantitatively for measuring tumor size and detecting response.

2. Ultrasound (US)

The basic Principle of this modality exploits the physical properties of sound
waves to generate “real-time” images of the human anatomy. The properties
of US are similar to those of audible sound, except that the frequency of
audible sound is between 0.01 and 0.02 MHz while the frequency of medical
US is typically in the range of 3–12 MHz.
A US transducer in contact with a body surface emits an US pulse, which is
transmitted into the body, then reflects off anatomical structures and returns
to the transducer. The time from emission to reception is used to calculate the
depth of a structure and its “brightness” or echo-genicity on gray-scale images
(B-mode US). US can also be used to detect the change in frequency of a
moving sound wave, which is the basis for Doppler ultrasound, commonly
used to image vascular structures. Figure-3

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Figure-3 Ultrasound image of the thyroid gland

US imaging has the advantages that no ionizing radiation is involved, and

there are no proven harmful effects to humans at the frequencies used in
diagnostic US. Also, “real-time” images are produced, and modern equipment
is extremely portable (some devices are the size of a conventional hand-held
or laptop computer) and relatively inexpensive.
The main limitation of US waves , it cannot propagate through air and dense
tissue (calcium), therefore the presence of air-containing or calcified
structures (such as bowel gas, lungs, and bones) hinders the evaluation of the
adjacent anatomy. Also, US is more operator-dependent than other imaging
modalities.
3. Magnetic Resonance Imaging (MRI)
Basic Principle: When nuclei composed of an odd number of protons and
neutrons are placed in a magnetic field (usually measured in units of Tesla)
and excited by the addition of radiofrequency pulses, they momentarily gain
energy. When the radiofrequency pulses are turned off, the nuclei return to
their resting state and emit the previously absorbed energy. Complex
mathematical algorithms are then performed to convert the data generated
from these changes in energy levels into images. The magnitude of the
emitted signal and the time it takes for the nuclei to return to the resting state
is dependent upon certain intrinsic properties of the nuclei, including the
nuclear spin density (or proton density), longitudinal (T1) relaxation time,
and transverse (T2) relaxation time. The most commonly imaged nucleus is
hydrogen (1H).Figure-4

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Figure-4 Brain MRI

4. Nuclear Medicine Imaging Modalities ( scintigraphic Studies)

Basic Principle: radioactive tracers (which emit gamma rays) are injected
into the body and then their physiological and pathological distribution is
recorded using a radioactivity detector system. Figure-5 Several such
detectors exist, including the gamma camera, which produces two-
dimensional images, and the single photon emission computed tomography
(SPECT) and the positron emission tomography (PET), which provide three-
dimensional information.

Figure-5 Difference between x-ray and NM imaging

b) Modes of Acquisition

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− Static study : the camera is placed over a region of the body and
an acquisition is performed for a predetermined number of
counts or interval of time. Figure-6

Figure-6 Example of a static scan : Bone Scan

− Dynamic imaging : refers to the acquisition of multiple sequential

images at defined time intervals Figure-7

Figure-7 Example of a dynamic scan : hepato-billiary scan

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c) Interpretation of scintigraphic images :

In general , the scintigraphic images reflect the functional status of the
studied tissue or organ. Body tissues affected by certain diseases,
may accumulate more or less of the administered
radiopharmaceutical than normal tissues.
− Interpretation of the static images: heir the distribution of the
tracer is evaluated . Four main findings can be distinguished ,
figure -8:
▪ Normal , homogenous uptake of the tracer throughout the
tissue.
▪ Increased or decreased uptake throughout the tissue
▪ Focally decreased uptake , usually called " cold area ".
▪ Focally increased uptake , usually called " hot area.

(a) (b) (c)

(d) (e)
Figure -8 Scintigraphic images of the thyroid gland illustrate the
possible findings which can be found.on a static study : (a) Normal
,homogenous uptake .(b) Increased uptake throughout the gland. (c)
decreased uptake throughout the gland (d) Focally increased uptake (
hot thyroid nodule ). (e) Focally decreased uptake ( cold thyroid
nodule).

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− Interpretation of dynamic study :

The changes in the distribution of the radiopharmaceutical with time can be
observed ,and time-activity curves can be plotted which show how the
number of counts varies between image frames, i.e. with time.Figure-9.

Figure -9 (A) Normal renal dynamic study ( image/1 min ) demonstrate

normal tracer uptake by both kidneys and rapid washout, with bladder activity
visible from third minute after injection . (B) Left and right renal time-activity
curves show symmetric relative function (left, 50%; right, 50%) and normal
time to peak (,180 s).