Excerpted Note - 2 - Introduction - To - Medical - Imaging - + - A - Comparative

Chapter
Introduction to Medical Imaging
Medical imaging of the human body requires some form of energy. In the medical
imaging techniques used in radiology, the energy used to produce the image must
be capable of penetrating tissues. Visible light, which has limited ability to penetrate
tissues at depth, is used mostly outside of the radiology department for medical
imaging. Visible light images are used in dermatology (skin photography), gastroen-
terology and obstetrics (endoscopy), and pathology (light microscopy). Of course,
all disciplines in medicine use direct visual observation, which also utilizes visible
light. In diagnostic radiology, the electromagnetic spectrum outside the visible light
region is used for medical imaging, including x-rays in mammography and computed
tomography (CT); radiofrequency (RF) in magnetic resonance imaging (MRI), and
gamma rays in nuclear medicine. Mechanical energy, in the form of high-frequency
sound waves, is used in ultrasound imaging.
With the exception of nuclear medicine, all medical imaging requires that the
energy used to penetrate the body’s tissues also interacts with those tissues. If
energy were to pass through the body and not experience some type of interac-
tion (e.g., absorption or scattering), then the detected energy would not contain
any useful information regarding the internal anatomy, and thus it would not be
possible to construct an image of the anatomy using that information. In nuclear
medicine imaging, radioactive substances are injected or ingested, and it is the
physiological interactions of the agent that give rise to the information in the
images.
While medical images can have an aesthetic appearance, the diagnostic util-
ity of a medical image relates both to the technical quality of the image and the
conditions of its acquisition. Consequently, the assessment of image quality in
medical imaging involves very little artistic appraisal and a great deal of techni-
cal evaluation. In most cases, the image quality that is obtained from medical
imaging devices involves compromise—better x-ray images can be made when
the radiation dose to the patient is high, better magnetic resonance images can
be made when the image acquisition time is long, and better ultrasound images
result when the ultrasound power levels are large. Of course, patient safety and
comfort must be considered when acquiring medical images; thus, excessive
patient dose in the pursuit of a perfect image is not acceptable. Rather, the power
and energy used to make medical images require a balance between patient safety
and image quality.
1.1 The Modalities
Different types of medical images can be made by varying the types of energies and
the acquisition technology used. The different modes of making images are referred
to as modalities. Each modality has its own applications in medicine.
3
4 Section I • Basic Concepts
Radiography
Radiography was the first medical imaging technology, made possible when the
physicist Wilhelm Roentgen discovered x-rays on November 8, 1895. Roentgen also
made the first radiographic images of human anatomy (Fig. 1-1). Radiography (also
called roentgenography) defined the field of radiology and gave rise to radiologists,
physicians who specialize in the interpretation of medical images. Radiography is
performed with an x-ray source on one side of the patient and a (typically flat) x-ray
detector on the other side. A short-duration (typically less than ½ second) pulse
of x-rays is emitted by the x-ray tube, a large fraction of the x-rays interact in the
patient, and some of the x-rays pass through the patient and reach the detector,
where a radiographic image is formed. The homogeneous distribution of x-rays that
enters the patient is modified by the degree to which the x-rays are removed from the
beam (i.e., attenuated) by scattering and absorption within the tissues. The attenua-
tion properties of tissues such as bone, soft tissue, and air inside the patient are very
different, resulting in a heterogeneous distribution of x-rays that emerges from the
patient. The radiographic image is a picture of this x-ray distribution. The detector
used in radiography can be photographic film (e.g., screen-film radiography) or an
electronic detector system (i.e., digital radiography).
■■FIGURE 1-1 Wilhelm Conrad Roentgen (1845–1923) in 1896 (A). Roentgen received the first Nobel Prize
in Physics in 1901 for his discovery of x-rays on November 8, 1895. The beginning of diagnostic radiology is
represented by this famous radiographic image, made by Roentgen on December 22, 1895 of his wife’s hand
(B). The bones of her hand as well as two rings on her finger are clearly visible. Within a few months, Roentgen
had determined the basic physical properties of x-rays. Roentgen published his findings in a preliminary report
entitled “On a New Kind of Rays” on December 28, 1895 in the Proceedings of the Physico-Medical Society
of Wurzburg. An English translation was published in the journal Nature on January 23, 1896. Almost simul-
taneously, as word of the discovery spread around the world, medical applications of this “new kind of ray”
rapidly made radiological imaging an essential component of medical care. In keeping with mathematical
conventions, Roentgen assigned the letter “x” to represent the unknown nature of the ray and thus the term
“x-rays” was born.
Chapter 1 • Introduction to Medical Imaging 5
Transmission imaging refers to imaging in which the energy source is outside the body
on one side, and the energy passes through the body and is detected on the other side
of the body. Radiography is a transmission imaging modality. Projection imaging refers
to the case when each point on the image corresponds to information along a straight-
line trajectory through the patient. Radiography is also a projection imaging modality.
Radiographic images are useful for a very wide range of medical indications, including
the diagnosis of broken bones, lung cancer, cardiovascular disorders, etc. (Fig. 1-2).
Fluoroscopy
Fluoroscopy refers to the continuous acquisition of a sequence of x-ray images over
time, essentially a real-time x-ray movie of the patient. It is a transmission projection
imaging modality, and is, in essence, just real-time radiography. Fluoroscopic systems
use x-ray detector systems capable of producing images in rapid temporal sequence.
Fluoroscopy is used for positioning catheters in arteries, visualizing contrast agents
in the GI tract, and for other medical applications such as invasive therapeutic proce-
dures where real-time image feedback is necessary. It is also used to make x-ray movies
of anatomic motion, such as of the heart or the esophagus.
Mammography
Mammography is radiography of the breast, and is thus a transmission projection
type of imaging. To accentuate contrast in the breast, mammography makes use of
■■FIGURE 1-2 Chest radiography is the most common imaging procedure in diagnostic radiology, often
acquired as orthogonal posterior-anterior (A) and lateral (B) projections to provide information regarding
depth and position of the anatomy. High-energy x-rays are used to reduce the conspicuity of the ribs and other
bones to permit better visualization of air spaces and soft tissue structures in the thorax. The image is a map of
the attenuation of the x-rays: dark areas (high film optical density) correspond to low attenuation, and bright
areas (low film optical density) correspond to high attenuation. C. Lateral cervical spine radiographs are com-
monly performed to assess suspected neck injury after trauma, and extremity images of the (D) wrist, (E) ankle,
and (F) knee provide low-dose, cost-effective diagnostic information. G. Metal objects, such as this orthopedic
implant designed for fixation of certain types of femoral fractures, are well seen on radiographs.
much lower x-ray energies than general purpose radiography, and consequently the
x-ray and detector systems are designed specifically for breast imaging. Mammog-
raphy is used to screen asymptomatic women for breast cancer (screening mam-
mography) and is also used to aid in the diagnosis of women with breast symptoms
such as the presence of a lump (diagnostic mammography) (Fig. 1-3A). Digital mam-
mography has eclipsed the use of screen-film mammography in the United States,
and the use of computer-aided detection is widespread in digital mammography.
Some digital mammography systems are now capable of tomosynthesis, whereby the
x-ray tube (and in some cases the detector) moves in an arc from approximately 7 to
40 degrees around the breast. This limited angle tomographic method leads to the
reconstruction of tomosynthesis images (Fig. 1-3B), which are parallel to the plane
of the detector, and can reduce the superimposition of anatomy above and below the
in-focus plane.
Computed Tomography
Computed tomography (CT) became clinically available in the early 1970s, and is
the first medical imaging modality made possible by the computer. CT images are
produced by passing x-rays through the body at a large number of angles, by rotating
the x-ray tube around the body. A detector array, opposite the x-ray source, collects
the transmission projection data. The numerous data points collected in this manner
■■FIGURE 1-3 Mammography is a specialized x-ray projection imaging technique useful for detecting breast
anomalies such as masses and calcifications. Dedicated mammography equipment uses low x-ray energies,
K-edge filters, compression, screen/film or digital detectors, antiscatter grids and automatic exposure control
to produce breast images of high quality and low x-ray dose. The digital mammogram in (A) shows glandular
and fatty tissues, the skin line of the breast, and a possibly cancerous mass (arrow). In projection mammog-
raphy, superposition of tissues at different depths can mask the features of malignancy or cause artifacts that
mimic tumors. The digital tomosynthesis image in (B) shows a mid-depth synthesized tomogram. By reducing
overlying and underlying anatomy with the tomosynthesis, the suspected mass in the breast is clearly depicted
with a spiculated appearance, indicative of cancer. X-ray mammography currently is the procedure of choice
for screening and early detection of breast cancer because of high sensitivity, excellent benefit-to-risk ratio,
and low cost.
are synthesized by a computer into tomographic images of the patient. The term
tomography refers to a picture (graph) of a slice (tomo). CT is a transmission tech-
nique that results in images of individual slabs of tissue in the patient. The advan-
tage of CT over radiography is its ability to display three-dimensional (3D) slices of
the anatomy of interest, eliminating the superposition of anatomical structures and
thereby presenting an unobstructed view of detailed anatomy to the physician.
CT changed the practice of medicine by substantially reducing the need for
exploratory surgery. Modern CT scanners can acquire 0.50- to 0.62-mm-thick tomo-
graphic images along a 50-cm length of the patient (i.e., 800 images) in 5 seconds,
and reveal the presence of cancer, ruptured disks, subdural hematomas, aneurysms,
and many other pathologies (Fig. 1-4). The CT volume data set is essentially isotro-
pic, which has led to the increased use of coronal and sagittal CT images, in addition
to traditional axial images in CT. There are a number of different acquisition modes
available on modern CT scanners, including dual-energy imaging, organ perfusion
imaging, and prospectively gated cardiac CT. While CT is usually used for anatomic
imaging, the use of iodinated contrast injected intravenously allows the functional
assessment of various organs as well.
Because of the speed of acquisition, the high-quality diagnostic images, and the
widespread availability of CT in the United States, CT has replaced a number of imag-
ing procedures that were previously performed radiographically. This trend continues.
However, the wide-scale incorporation of CT into diagnostic medicine has led to more
than 60 million CT scans being performed annually in the United States. This large
number has led to an increase in the radiation burden in the United States, such that
now about half of medical radiation is due to CT. Radiation levels from medical imaging
are now equivalent to background radiation levels in the United States, (NCRP 2009).
■■FIGURE 1-4 CT reveals superb anatomical detail, as seen in (A) sagittal, (B) coronal, and (C) axial images
from an abdomen-pelvis CT scan. With the injection of iodinated contrast material, CT angiography (CTA)
can be performed, here (D) showing CTA of the head. Analysis of a sequence of temporal images allows
assessment of perfusion; (E) demonstrates a color coded map corresponding to blood volume in this patient
undergoing evaluation for a suspected cerebrovascular accident (“stroke”). F. Image processing can produce
pseudocolored 3D representations of the anatomy from the CT data.
Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) scanners use magnetic fields that are about
10,000 to 60,000 times stronger than the earth’s magnetic field. Most MRI utilizes
the nuclear magnetic resonance properties of the proton—that is, the nucleus of the
hydrogen atom, which is very abundant in biological tissues (each cubic millimeter
of tissue contains about 1018 protons). The proton has a magnetic moment and,
when placed in a 1.5 T magnetic field, the proton precesses (wobbles) about its axis
and preferentially absorbs radio wave energy at the resonance frequency of about
64 million cycles per second (megahertz—MHz).
In MRI, the patient is placed in the magnetic field, and a pulse of radio waves
is generated by antennas (“coils”) positioned around the patient. The protons in
the patient absorb the radio waves, and subsequently reemit this radio wave energy
after a period of time that depends upon the spatially dependent magnetic proper-
ties of the tissue. The radio waves emitted by the protons in the patient are detected
by the antennas that surround the patient. By slightly changing the strength of the
magnetic field as a function of position in the patient using magnetic field gradients,
the proton resonance frequency varies as a function of position, since frequency is
proportional to magnetic field strength. The MRI system uses the frequency and
phase of the returning radio waves to determine the position of each signal from the
patient. One frequently used mode of operation of MRI systems is referred to as spin
echo imaging.
MRI produces a set of tomographic images depicting slices through the patient, in
which each point in an image depends on the micromagnetic properties of the tissue
corresponding to that point. Because different types of tissue such as fat, white and
gray matter in the brain, cerebral spinal fluid, and cancer all have different local mag-
netic properties, images made using MRI demonstrate high sensitivity to anatomical
variations and therefore are high in contrast. MRI has demonstrated exceptional util-
ity in neurological imaging (head and spine) and for musculoskeletal applications
such as imaging the knee after athletic injury (Fig. 1-5A–D).
MRI is a tomographic imaging modality, and competes with x-ray CT in many
clinical applications. The acquisition of the highest quality images using MRI requires
tens of minutes, whereas a CT scan of the entire head requires seconds. Thus, for
patients where motion cannot be controlled (pediatric patients) or in anatomical
areas where involuntary patient motion occurs (the beating heart and churning intes-
tines), CT is often used instead of MRI. Also, because of the large magnetic field used
in MRI, only specialized electronic monitoring equipment can be used while the
patient is being scanned. Thus, for most trauma, CT is preferred. MRI should not
be performed on patients who have cardiac pacemakers or internal ferromagnetic
objects such as surgical aneurysm clips, metal plate or rod implants, or metal shards
near critical anatomy such as the eye.
Despite some indications for which MRI should not be used, fast image acquisi-
tion techniques using special coils have made it possible to produce images in much
shorter periods of time, and this has opened up the potential of using MRI for imag-
ing of the motion-prone thorax and abdomen (Fig. 1-5E). MRI scanners can also
detect the presence of motion, which is useful for monitoring blood flow through
arteries (MR angiography—Figure 1-5F), as well as blood flow in the brain (functional
MR), which leads to the ability to measure brain function correlated to a task
(e.g., finger tapping, response to various stimuli, etc.).
An area of MR data collection that allows for analysis of metabolic products in the
tissue is MR spectroscopy, whereby a single voxel or multiple voxels may be analyzed
■■FIGURE 1-5 MRI provides excellent and selectable tissue contrast, determined by acquisition pulse
sequences and data acquisition methods. Tomographic images can be acquired and displayed in any plane
including conventional axial, sagittal and coronal planes. (A) Sagittal T1-weighted contrast image of the brain;
(B) axial fluid-attenuated inversion recovery (FLAIR) image showing an area of brain infarct; sagittal image
of the knee, with (C) T1-weighted contrast and (D) T1-weighted contrast with “fat saturation” (fat signal is
selectively reduced) to visualize structures and signals otherwise overwhelmed by the large fat signal; (E) maxi-
mum intensity projection generated from the axial tomographic images of a time-of-flight MR angiogram; (F)
gadolinium contrast-enhanced abdominal image, acquired with a fast imaging employing steady-state acqui-
sition sequence, which allows very short acquisition times to provide high signal-to-noise ratio of fluid-filled
structures and reduce the effects of patient motion.
using specialized MRI sequences to evaluate the biochemical composition of tissues

in a precisely defined volume. The spectroscopic signal can act as a signature for
tumors and other maladies.
Ultrasound Imaging
When a book is dropped on a table, the impact causes pressure waves (called sound)
to propagate through the air such that they can be heard at a distance. Mechanical
energy in the form of high-frequency (“ultra”) sound can be used to generate images
of the anatomy of a patient. A short-duration pulse of sound is generated by an
ultrasound transducer that is in direct physical contact with the tissues being imaged.
The sound waves travel into the tissue, and are reflected by internal structures in the
body, creating echoes. The reflected sound waves then reach the transducer, which
records the returning sound. This mode of operation of an ultrasound device is
called pulse echo imaging. The sound beam is swept over a slice of the patient line by
line using a linear array multielement transducer to produce a rectangular scanned
area, or through incremental angles with a phased array multielement transducer to
produce a sector scanned area. The echo amplitudes from each line of ultrasound
are recorded and used to compute a brightness mode image with grayscale-encoded
acoustic signals representing a tomographic slice of the tissues of interest.
Ultrasound is reflected strongly by interfaces, such as the surfaces and internal
structures of abdominal organs. Because ultrasound is thought to be less harmful
than ionizing radiation to a growing fetus, ultrasound imaging is preferred in obstet-
rical patients (Fig. 1-6A,B). An interface between tissue and air is highly echoic, and
thus, very little sound can penetrate from tissue into an air-filled cavity. Therefore,
ultrasound imaging has less utility in the thorax where the air in the lungs presents a
■■FIGURE 1-6 The ultrasound image is a map of the echoes from tissue boundaries of high-frequency sound
wave pulses. A. A phased-array transducer operating at 3.5 MHz produced the normal obstetrical ultrasound
image (sagittal profile) of Jennifer Lauren Bushberg at 5½ months before her “first birthday.” Variations in
the image brightness are due to acoustic characteristics of the tissues; for example, the fluid in the placenta is
echo free, whereas most fetal tissues are echogenic and produce larger returned signals. Acoustic shadowing
is caused by highly attenuating or scattering tissues, such as bone or air, producing the corresponding low
intensity streaks distal to the transducer. B. Distance measurements (e.g., fetal head diameter assessment for
age estimation) are part of the diagnostic evaluation of a cross-sectional brain ultrasound image of a fetus. C.
From a stack of tomographic images acquired with known geometry and image locations, 3D image rendering
of the acoustic image data can show anatomic findings, such as a cleft palate of the fetus. D. Vascular assess-
ment using Doppler color-flow imaging can be performed by many ultrasound systems. A color-flow image of
the internal carotid artery superimposed on the grayscale image demonstrates an aneurysm in the left internal
carotid artery of this patient.
barrier that the sound beam cannot penetrate. Similarly, an interface between tissue
and bone is also highly echoic, thus making brain imaging, for example, impracti-
cal in most cases. Because each ultrasound image represents a tomographic slice,
multiple images spaced a known distance apart represent a volume of tissue, and
with specialized algorithms, anatomy can be reconstructed with volume rendering
methods as shown in Figure 1-6C.
Doppler Ultrasound
Doppler ultrasound makes use of a phenomenon familiar to train enthusiasts.
For the observer standing beside railroad tracks as a rapidly moving train goes
by blowing its whistle, the pitch of the whistle is higher as the train approaches
and becomes lower as the train passes by the observer and speeds off into the
distance. The change in the pitch of the whistle, which is an apparent change in
the frequency of the sound, is a result of the Doppler effect. The same phenom-
enon occurs at ultrasound frequencies, and the change in frequency (the Doppler
shift) is used to measure the motion of blood. Both the speed and direction of
blood flow can be measured, and within a subarea of the grayscale image, a color
flow display typically shows blood flow in one direction as red, and in the other
direction as blue. In Figure 1-6D, a color-flow map reveals arterial flow of the left
internal carotid artery superimposed upon the grayscale image; the small, mul-
ticolored nub on the vessel demonstrates complex flow patterns of an ulcerated
aneurysm.
Nuclear Medicine Imaging

Nuclear medicine is the branch of radiology in which a chemical or other substance
containing a radioactive isotope is given to the patient orally, by injection or by
inhalation. Once the material has distributed itself according to the physiological
status of the patient, a radiation detector is used to make projection images from
the x- and/or gamma rays emitted during radioactive decay of the agent. Nuclear
medicine produces emission images (as opposed to transmission images), because
the radioisotopes emit their energy from inside the patient.
Nuclear medicine imaging is a form of functional imaging. Rather than yielding
information about just the anatomy of the patient, nuclear medicine images pro-
vide information regarding the physiological conditions in the patient. For example,
thallium tends to concentrate in normal heart muscle, but in areas that are infarcted
or are ischemic, thallium does not concentrate as well. These areas appear as “cold
spots” on a nuclear medicine image, and are indicative of the functional status of
the heart. Thyroid tissue has a great affinity for iodine, and by administering radio-
active iodine (or its analogues), the thyroid can be imaged. If thyroid cancer has
metastasized in the patient, then “hot spots” indicating their location may be pres-
ent on the nuclear medicine images. Thus functional imaging is the forte of nuclear
medicine.
Nuclear Medicine Planar Imaging

Nuclear medicine planar images are projection images, since each point on the
image is representative of the radioisotope activity along a line projected through the
patient. Planar nuclear images are essentially 2D maps of the 3D radioisotope distri-
bution, and are helpful in the evaluation of a large number of disorders (Fig. 1-7).
■■FIGURE 1-7 Anterior and posterior whole-body bone

scan images of a 64-year-old male with prostate can-
L L R
cer. This patient was injected with 925 MBq (25 mCi) of R
99m
Tc methylenediphosphonate (MDP) and was imaged
3 hours later with a dual-head scintillation camera. The
images demonstrate multiple metastatic lesions. Lesions
are readily seen in ribs, sternum, spine, pelvis, femurs
and left tibia. Planar imaging is still the standard for
many nuclear medicine examinations (e.g., whole-body
bone scans and hepatobiliary thyroid, renal and pulmo-
nary studies). (Image courtesy of DK Shelton.)
Single Photon Emission Computed Tomography

Single photon emission computed tomography (SPECT) is the tomographic counter-
part of nuclear medicine planar imaging, just like CT is the tomographic counterpart
of radiography. In SPECT, a nuclear camera records x- or gamma-ray emissions from
the patient from a series of different angles around the patient. These projection data
are used to reconstruct a series of tomographic emission images. SPECT images pro-
vide diagnostic functional information similar to nuclear planar examinations; how-
ever, their tomographic nature allows physicians to better understand the precise
distribution of the radioactive agent, and to make a better assessment of the function
of specific organs or tissues within the body (Fig. 1-8). The same radioactive isotopes
are used in both planar nuclear imaging and SPECT.
Positron Emission Tomography

Positrons are positively charged electrons, and are emitted by some radioactive
isotopes such as fluorine-18 and oxygen-15. These radioisotopes are incorporated
into metabolically relevant compounds, such as 18F-fluorodeoxyglucose (18FDG),
which localize in the body after administration. The decay of the isotope produces
a positron, which rapidly undergoes a very unique interaction: the positron (e)
combines with an electron (e) from the surrounding tissue, and the mass of both
the e and the e is converted by annihilation into pure energy, following Einstein’s
famous equation E  mc2. The energy that is emitted is called annihilation radiation.
Annihilation radiation production is similar to gamma ray emission, except that
two photons are produced, and they are emitted simultaneously in almost exactly
opposite directions, that is, 180 degrees from each other. A positron emission
tomography (PET) scanner utilizes rings of detectors that surround the patient, and
has special circuitry that is capable of identifying the photon pairs produced during
■■FIGURE 1-8 Two-day stress-rest myocardial perfusion imaging with SPECT/CT was performed on an
9-year-old, obese male with a history of prior CABG, bradycardia, and syncope. This patient had pharmaco-
8
logical stress with regadenoson and was injected with 1.11 GBq (30 mCi) of 99mTc-tetrofosmin at peak stress.
Stress imaging followed 30 minutes later, on a variable-angle two-headed SPECT camera. Image data were
acquired over 180 degrees at 20 seconds per stop. The rest imaging was done 24 hours later with a 1.11 GBq
(30 mCi) injection of 99mTc-tetrofosmin. Stress and rest perfusion tomographic images are shown on the left
side in the short axis, horizontal long axis, and vertical long axis views. “Bullseye” and 3D tomographic images
are shown in the right panel. Stress and rest images on the bottom (IRNC) demonstrate count reduction in the
inferior wall due to diaphragmatic attenuation. The same images corrected for attenuation by CT (IRAC) on the
top better demonstrate the inferior wall perfusion reduction on stress, which is normal on rest. This is referred
to as a “reversible perfusion defect” which is due to coronary disease or ischemia in the distribution of the
posterior descending artery. SPECT/CT is becoming the standard for a number of nuclear medicine examina-
tions, including myocardial perfusion imaging. (Image courtesy of DK Shelton.)
a nnihilation. When a photon pair is detected by two detectors on the scanner, it

is assumed that the annihilation event took place somewhere along a straight line
between those two detectors. This information is used to mathematically compute
the 3D distribution of the PET agent, resulting in a set of tomographic emission
images.
Although more expensive than SPECT, PET has clinical advantages in certain diag-
nostic areas. The PET detector system is more sensitive to the presence of radioisotopes
than SPECT cameras, and thus can detect very subtle pathologies. Furthermore, many
of the elements that emit positrons (carbon, oxygen, fluorine) are quite physiologically
relevant (fluorine is a good substitute for a hydroxyl group), and can be incorporated
into a large number of biochemicals. The most important of these is 18FDG, which is
concentrated in tissues of high glucose metabolism such as primary tumors and their
metastases. PET scans of cancer patients have the ability in many cases to assess the
extent of disease, which may be underestimated by CT alone, and to serve as a base-
line against which the effectiveness of chemotherapy can be evaluated. PET studies are
often combined with CT images acquired immediately before or after the PET scan.
PET/CT combined imaging has applications in oncology, cardiology, neurology,

and infection and has become a routine diagnostic tool for cancer staging. Its role
in the early assessment of the effectiveness of cancer treatment reduces the time,
expense, and morbidity from failed therapy (Fig. 1-9).
Combined Imaging Modalities

Each of the imaging modalities has strengths (e.g., very high spatial resolution in
radiography) and limitations (e.g., anatomical superposition in radiography). In
particular, nuclear medicine imaging, whether with a scintillation camera or PET,
often shows abnormalities with high contrast, but with insufficient anatomic
detail to permit identification of the organ or tissue with the lesion. Furthermore,
in nuclear medicine, attenuation by the patient of emitted radiation degrades
the information in the images. Combining a nuclear medicine imaging system
(SPECT or PET) with another imaging system providing good definition of anat-
omy (CT or MRI) permits the creation of fused images, enabling anatomic local-
ization of abnormalities, and correction of the emission images for attenuation
(Fig. 1-10).
■■FIGURE 1-9 Two whole-body PET/CT studies of a 68-year-old male undergoing treatment for small cell lung
cancer. Maximal intensity projection images are shown before (A) and after (B) chemotherapy. For each study,
the patient was injected intravenously with 740 MBq (20 mCi) of 18FDG. The CT acquisition was immediately
followed by the PET study, which was acquired for 30 minutes, beginning 60 minutes after injection of the
FDG. The bottom panel shows the colorized PET/CT fusion axial images before (C) and after (D) chemotherapy.
The primary tumor in the right hilum (C) is very FDG avid (i.e., hypermetabolic). The corresponding axial slice
(D) was acquired 3 months later, showing dramatic metabolic response to the chemotherapy. The metastatic
foci in the right scapula and left posterior rib have also resolved. The unique abilities of the PET/CT scan in this
case were to assess the extent of disease, which was underestimated by CT alone, and to assess the effective-
ness of chemotherapy. (Images courtesy of DK Shelton.)
■■FIGURE 1-10 A planar and SPECT/CT bone scan done 3 hours after injection of 925 MBq (25 mCi) Tc-MDP.
A. Anterior (left) and posterior (right) spot views of the spine in this 54-year-old female with back pain. The
posterior view shows a faintly seen focus over a lower, right facet of the lumbar spine. B. Coronal views of the
subsequent SPECT bone scan (left) better demonstrate the focus on the right lumbar spine at L4. The color-
ized image of the SPECT bone scan with CT fusion is shown on right. C. The axial views of the SPECT bone
scan (left) and the colorized SPECT/CT fusion image (right) best localizes the abnormality in the right L4 facet,
consistent with active facet arthropathy. (Images courtesy of DK Shelton.)
1.2 Image Properties
Contrast
Contrast in an image manifests as differences in the grayscale values in the image.
A uniformly gray image has no contrast, whereas an image with sharp transitions between
dark gray and light gray demonstrates high contrast. The various imaging modalities
introduced above generate contrast using a number of different forms of energy, which
interact within the patient’s tissues based upon different physical properties.
The contrast in x-ray transmission imaging (radiography, fluoroscopy, mammog-
raphy, and CT) is produced by differences in tissue composition, which determine
the local x-ray absorption coefficient, which in turn is dependent upon the density
(g/cm3) and the effective atomic number. The energies of the x-ray photons in the
beam (adjusted by the operator) also affect contrast in x-ray images. Because bone
has a markedly different effective atomic number (Zeff < 13) than soft tissue (Zeff < 7),
due to its high concentration of calcium (Z  20) and phosphorus (Z  15), bones
produce high contrast on x-ray image modalities. The chest radiograph, which dem-
onstrates the lung parenchyma with high tissue and airway contrast, is the most
common radiographic procedure performed in the world (Fig. 1-2).
CT’s contrast is enhanced over other x-ray imaging modalities due to its tomo-
graphic nature. The absence of out-of-slice structures in the CT image greatly
improves its image contrast.
Nuclear medicine images (planar images, SPECT, and PET) are maps of the spa-
tial distribution of radioisotopes in the patient. Thus, contrast in nuclear images
depends upon the tissue’s ability to concentrate the radioactive material. The uptake
of a radiopharmaceutical administered to the patient is dependent upon the pharma-
cological interaction of the agent with the body. PET and SPECT have much better
contrast than planar nuclear imaging because, like CT, the images are not obscured
by out-of-slice structures.
Contrast in MR imaging is related primarily to the proton density and to relax-
ation phenomena (i.e., how fast a group of protons gives up its absorbed energy).
Proton density is influenced by the mass density (g/cm3), so MRI can produce images
that look somewhat like CT images. Proton density differs among tissue types, and
in particular adipose tissues have a higher proportion of protons than other tissues,
due to the high concentration of hydrogen in fat (CH3(CH2)nCOOH). Two differ-
ent relaxation mechanisms (spin/lattice and spin/spin) are present in tissue, and
the dominance of one over the other can be manipulated by the timing of the RF
pulse sequence and magnetic field variations in the MRI system. Through the clever
application of different pulse sequences, blood flow can be detected using MRI tech-
niques, giving rise to the field of MR angiography. Contrast mechanisms in MRI are
complex, and thus provide for the flexibility and utility of MR as a diagnostic tool.
Contrast in ultrasound imaging is largely determined by the acoustic properties
of the tissues being imaged. The difference between the acoustic impedances (tissue
density  speed of sound in tissue) of two adjacent tissues or other substances affects
the amplitude of the returning ultrasound signal. Hence, contrast is quite appar-
ent at tissue interfaces where the differences in acoustic impedance are large. Thus,
ultrasound images display unique information about patient anatomy not provided
by other imaging modalities. Doppler ultrasound imaging shows the amplitude and
direction of blood flow by analyzing the frequency shift in the reflected signal, and
thus, motion is the source of contrast.
Spatial Resolution
Just as each modality has different mechanisms for providing contrast, each modality
also has different abilities to resolve fine detail in the patient. Spatial resolution refers
to the ability to see small detail, and an imaging system has higher spatial resolution
if it can demonstrate the presence of smaller objects in the image. The limiting spatial
resolution is the size of the smallest object that an imaging system can resolve.
Table 1-1 lists the limiting spatial resolution of each of the imaging modalities
used in medical imaging. The wavelength of the energy used to probe the object
is a fundamental limitation of the spatial resolution of an imaging modality. For
example, optical microscopes cannot resolve objects smaller than the wavelengths
of visible light, about 400 to 700 nm. The wavelength of x-rays depends on the
x-ray energy, but even the longest x-ray wavelengths are tiny—about 1 nm. This is
far from the actual resolution in x-ray imaging, but it does represent the theoretical
limit on the spatial resolution using x-rays. In ultrasound imaging, the wavelength
of sound is the fundamental limit of spatial resolution. At 3.5 MHz, the wavelength
of sound in soft tissue is about 500 mm. At 10 MHz, the wavelength is 150 mm.
TABLE 1-1 THE LIMITING SPATIAL RESOLUTIONS OF VARIOUS MEDICAL

IMAGING MODALITIES. THE RESOLUTION LEVELS ACHIEVED IN
TYPICAL CLINICAL USAGE OF THE MODALITY ARE LISTED
MODALITY SPATIAL RESOLUTION (mm) COMMENTS
Screen film radiography 0.08 Limited by focal spot size and
detector resolution
Digital radiography 0.17 Limited by size of detector elements
and focal spot size
Fluoroscopy 0.125 Limited by detector resolution and
focal spot size
Screen film mammography 0.03 Highest resolution modality in
radiology, limited by same factors
as in screen film radiography
Digital mammography 0.05–0.10 Limited by same factors as digital
radiography
Computed tomography 0.3 About ½ mm pixels
Nuclear medicine planar 2.5 (detector face), Spatial resolution degrades
imaging 5 (10 cm from detector) substantially with distance from
detector
Single photon emission 7 Spatial resolution worst towards
computed tomography the center of cross-sectional image
slice
Positron emission tomography 5 Better spatial resolution than the
other nuclear imaging modalities
Magnetic resonance imaging 1.0 Resolution can improve at higher
magnetic fields
Ultrasound imaging (5 MHz) 0.3 Limited by wavelength of sound
MRI poses a paradox to the wavelength-imposed resolution rule—the wavelength of

the radiofrequency waves used (at 1.5 T, 64 MHz) is 470 cm, but the spatial resolution
of MRI is better than a millimeter. This is because the spatial distribution of the paths of
RF energy is not used to form the actual image (contrary to ultrasound, light microscopy,
and x-ray images). The radiofrequency energy is collected by a large antenna, and it car-
ries the spatial information of a group of protons encoded in its frequency spectrum.
Medical imaging makes use of a variety of physical parameters as the source of
image information. The mechanisms for generating contrast and the spatial resolution
properties differ amongst the modalities, thus providing a wide range of diagnostic
tools for referring physicians. The optimal detection or assessment of a specific clinical
condition depends upon its anatomical location and tissue characteristics. The selec-
tion of the best modality for a particular clinical situation requires an understanding
of the physical principles of each of the imaging modalities. The following chapters of
this book are aimed at giving the medical practitioner just that knowledge.
SELECTED REFERENCE
NCRP 2009: National Council on Radiation Protection and Measurements. Ionizing radiation exposure
of the population of the United States (NCRP Report No 160). Bethesda, Md: National Council on
Radiation Protection and Measurements; 2009.
International Journal of Information Science and Intelligent System, 4(2): 37-58, 2015
A Comparative Study of Medical Imaging

Techniques
H. Kasban 1, ∗, M. A. M. El-Bendary2 and D. H. Salama3
1
Engineering Department, Nuclear Research Center, Atomic Energy Authority, Egypt
2
Department of Communication Technology, Faculty of Industrial Education, Helwan University, Egypt.
3
Lecturer of Radiodiagnosis, National Center for Radiation Research and Technology, Atomic Energy Authority, Egypt
Received: 25 January 2015; Accepted: 12 March 2015

Abstract
Medical Imaging Techniques (MITs) are non-invasive methods for looking inside the body
without opening up the body surgically. It used to assist diagnosis or treatment of different
medical conditions. There are many medical imaging techniques; every technique has different
risks and benefits. This paper presents a review of these techniques; concepts, advantages,
disadvantages, and applications. The concerning techniques are; X-ray radiography, X-ray
Computed Tomography (CT), Magnetic Resonance Imaging (MRI), ultrasonography,
Elastography, optical imaging, Radionuclide imaging includes (Scintigraphy, Positron Emission
Tomography (PET) and Single Photon Emission Computed Tomography (SPECT)),
thermography, and Terahertz imaging. The concepts, benefits, risks and applications of these
techniques will present with details. A comparison between these techniques from point of view,
image quality (spatial resolution and contrast), safety (effect of ionizing radiation, and heating
effect of radiation on the body), and system availability (real time information and cost) will
present.
Keywords: Medical imaging; X-ray; CT; MRI; Ultrasonography; Elastography; Scintigraphy.

©Martin Science Publishing. All Rights Reserved.
1. Introduction
MITs consider one of the most common medical tests with the laboratory tests (blood and
specimen tests). Medical imaging has been undergoing a revolution in the past decade with the
∗
Corresponding author. Tel.:+201228587776
E-mail address: Hany_kasban@yahoo.com (H. Kasban) , dr_m.kassem@yahoo.com (M. El-Bendary), drdinahusseiny@yahoo.com (D. Salama)
38 H. Kasban et. al./ International Journal of Information Science and Intelligent System (2015)
fast development, more accurate, and less invasive devices [1]. MITs can be considered as tools
for learning more about the neurobiology and human behaviors. The basic concept of a medical
imaging system is shown in figure 1, it consists of a sensor or source of energy that can penetrate
the human body, the energy pass through the body, they are absorbed or attenuated at differing
levels, according to the density and atomic number of the different tissues, creating signals. These
signals are detected by special detectors compatible with the energy source, then mathematically
manipulated to create an image. The obtained images are through the energy from the human
tissue, leading to a classification based on the energy applied to the body.
Detectors Display
Energy
Mathematical
Sensor algorithms
Figure 1. Concept of a medical imaging system
According to the energy sources, there are many different techniques can be being used to get a
look inside the patient. These techniques are based on a signal travelling right through a patient.
These signals interact with the tissues of the patient. By detecting the signal coming out of the
body an image of the inside of the patient can be made. The interesting techniques in this paper
are; X-ray radiography, X-ray Computed Tomography (CT), Magnetic Resonance Imaging
(MRI), ultrasonography, elastography, optical imaging, radionuclide imaging includes
(Scintigraphy, Positron Emission Tomography (PET) and Single Photon Emission Computed
Tomography (SPECT)), thermography, and terahertz imaging. Up to 2010, 5 billion medical
imaging studies had been conducted worldwide [2].
Radiography started with the discovery of X-ray by Röntgen in 1895. Its medical use was
discovered when Rontgen saw a picture of his wife's hand on a photographic plate formed due to
X-ray. CT as an imaging technique was described by Cormack in 1963. In 1972, Hounsfield
presented the first clinical CT scanner [3]. Since then, the clinical X-ray CT has revolutionized
medical imaging and may be described as the greatest advancement in radiology since the
discovery of X-ray. Research on MRI started in the early 1970s and the first MRI prototypes were
tested in 1980. The first used for Sonography as a diagnostic tool has been presented in 1942 for
localizing brain tumors, and its used as real-time imaging in 1965. Now the medical Sonography
is used in the many different applications. Elastography developed in 1991 for detecting non-
uniform areas in tissue [4]. Recently, different types of Elastography (ultrasound elasticity
imaging, magnetic resonance elasticity imaging, optical elasticity imaging or tactile imaging)
have been applied to study tissues in a variety of different conditions.
The idea of using light as a medical diagnostic technique has been revisited in the past few
years as a result of theoretical and experimental advances in optical spectroscopy and imaging of
the human breast. Nuclear medicine started in 1936 when John Lawrence made the first
application in patients of an artificial Radionuclide when he used phosphorus-32 to treat leukemia.
H. Kasban et. al. / International Journal of Information Science and Intelligent System (2015) 39
The widespread clinical use of nuclear medicine began in the early 1950s, as knowledge
expanded about Radionuclide, detection of radioactivity, and using certain Radionuclide to trace
biochemical processes. In the 1980s, Radiopharmaceuticals were designed for use in diagnosis of
heart disease. The development of SPECT, around the same time, led to three-dimensional
reconstruction of the heart and establishment of the field of nuclear cardiology. More recent
developments in nuclear medicine include the invention of the first PET scanner. Nowadays, fully
integrated systems such as PET/CT and MRI/PET scanners are used. Clinical thermography
started as a diagnostic tool for different medical conditions since the 1960s. The rapidly
developing of this technology is used to detect and locate thermal abnormalities characterized by
an increase or decrease found at the skin surface. The Terahertz (THz) imaging started for
biomedical use in 1995 [5], and since then imaging modality has emerged. THz is still developing
and more research is still needed.
This paper presents a comparative study between the different medical imaging techniques, the
concepts, benefits, risks and applications of these techniques will present with details. A
comparison between these techniques from point of view, image quality (spatial resolution and
contrast), safety (allergy, ionizing effect of radiation, and heating effect of radiation on the body),
and system availability (real time information, scanning time, complexity and cost) will present.
The paper is organized as follows; Section 2 presents the X-ray radiography imaging technique.
Section 3 presents the X CT imaging technique. Section 4 presents the MRI technique. Section 5
presents the Ultrasonography imaging technique. Section 6 presents the Elastography imaging
technique. Section 7 presents the optical imaging technique. Section 8 presents the Radionuclide
imaging technique. Section 9 presents the thermography imaging technique. Section 10 presents
the Terahertz imaging technique. Section 11 presents a comparison between MITs. Finally,
section 12 gives the concluding remarks.
2. X-Ray Radiography
Radiography is a diagnostic technique that used the ionizing electromagnet radiation, such as
X-ray to view objects. X-ray is a high energy electromagnetic radiation that can penetrate solids
and ionize gas; it has a wavelength between 0.01 and 10 manometers. For medical imaging [6 - 9],
X-ray passes through the body, they are absorbed or attenuated at differing levels, according to
the density and atomic number of the different tissues, creating a profile. The X-ray profile is
registered on a detector creating an image as shown in figure 2-a. The construction of the X-ray
tube that used for medical imaging is shown in figure 2-b. Electrons are emitted by the filament
wire when it is heated by an electric current. A rotating metal anode attracted the electrons
providing an alternating current in the filament wire. The area of the anode from which X-ray are
emitted is referred to as the focal spot. The used photon energies range from 17- 150 KeV, the
choice for a particular application or tissue probed being a trade-off between acceptable radiation
dose and achievable image contrast. Figure 3 shows some examples of X-ray images.
2.1 X-Ray Radiography Benefits
• Noninvasive, quick, and painless.
• Support medical and surgical treatment planning.
• Guide medical personnel as they insert catheters or stents inside the body to treat tumors,
or remove blood clots.
(a) X-ray imaging concept (b) Rotating X-ray tube
Figure 2. X-ray radiographic medical imaging
Shoulder Head Pelvis Knee
Figure 3. Examples of X-ray images
2.2 X-Ray Radiography Risks

• Exposure to ionizing radiation, this increase the possibility of developing cancer later
in life.
• Tissue effects such as cataracts, skin reddening, and hair loss, which occur at relatively
high levels of radiation exposure.
2.3. X-Ray Radiography Medical Applications
• X-ray radiography is used in many types of examinations such as; chiropractic, dental.
• Fluoroscopy radiographs used for showing the movement of organs, such as the
stomach, intestine, and colon, in the body, also can be used for studding the blood
vessels of the heart and the brain.
• Projectional radiographs used for determining the type and extent of a fracture, also
used for detecting pathological changes in the lungs, and used for visualizing the
structure of the stomach and intestines.
• Mammography used for diagnosing and screening of the breast tissue.
• Bone Densitometry used for measures bone mineral content and density.
• Arthrography used for seeing inside the joint.
• Hysterosalpingogram used for examining of the uterus and Fallopian tubes.
3. X-Ray Computed Tomography

Computed Tomography (CT) [10, 12] is a diagnostic technology that combines X-ray
equipment with a computer and a cathode ray tube display to produce images of cross sections of
the human body. The Radiographic film is replaced by a detector which measures the X-ray
profile. Inside the CT scanner, there is a rotating frame that has an X-ray tube mounted on one
side and the detector mounted on the opposite side. A beam of X-ray is generated as a rotating
frame spins the X-ray tube and detector around the patient as shown in figure (4). Each time the
X-ray tube and detector make one complete rotation, an image or slice is acquired. As the X-ray
tube and detector make this rotation, the detector takes numerous profiles of the attenuated X-ray
beam. Each profile is reconstructed by the computer into a 2D image of the slice that was scanned.
3D CT can be obtained using spiral CT [13], spiral CT acquires a volume of data with the patient
anatomy all in one position. This volume data set can then be computer reconstructed to provide
three dimensional (3D) images of complex structures. The resulting 3D CT images help in
visualization of the tumor masses in three dimensions. Recently, four dimensional (4D) CT has
been introduced to overcome problems imposed by respiratory movements. 4D CT generates both
spatial and temporal information on organ mobility. Some examples of CT scans are shown in
figure 5.
(a) CT scanner (b) CT fan beam

Figure 4. X-ray CT imaging
2D CT 3D CT 4D CT
Figure 5. Example of CT scan
3.1 CT Benefits
• Non invasive, quick, and painless.
• Good spatial resolution.
• Global view of veins.
• Distinguished by small differences in physical density.
• Avoids invasive insertion of an arterial catheter and guidewire.
3.2 CT Risks
• Exposure to ionizing radiation, this increase the possibility of developing cancer later in
life.
• No real time information.
• Cannot detect intra-luminal abnormalities.
• Cannot be performed without contrast (allergy, toxicity).
• Less contrast resolution where soft tissue contrast is low.
3.3 CT Medical Applications
• Examining many parts of human body such as; brain, sinus, facial bones, dental, spines,
cervical, hands, wrist, elbow, shoulder, hip, knee, ankle foot, renal tract.
• Diagnosing disease, trauma and abnormality.
• Planning and guiding the interventional or therapeutic procedures.
• Monitoring the effectiveness of therapy (cancer treatment).
4. Magnetic Resonance Imaging (MRI)
MRI is a diagnostic technology that uses magnetic and radio frequency fields to image the
body tissues and monitor body chemistry [14-16]. The MRI used for visualizing morphological
alterations rests on its ability to detect changes in proton density and magnetic spin relaxation
times, which are characteristic of the environment presented by the diseased tissue. The MR
scanner consists of three main components; a main magnet, a magnetic field gradient system, and
a Radio Frequency (RF) system as shown in figure 6-a. The main magnet is a permanent magnet
generates a magnetic field. The magnetic field gradient system normally consists of three
orthogonal gradient coils, essential for signal localization. The RF system consists of a
transmitter coil that is capable of generating a rotating magnetic field, for exciting a spin system,
and a receiver coil that converts a precessing magnetization into an electrical signals as shown in
figure 6-b. The signals are measured by the MR scanner and digital computer reconstructs these
signals into images. Examples of MRI images are shown in figures 7- a, b. Recently, a new
procedure that uses MRI to measure the tiny metabolic changes that take place in an active part of
the brain called functional magnetic resonance imaging (fMRI) is designed [17-24]. Example of
fMRI image is shown in figure 7-c.
4.1 MRI Benefits
• Noninvasive and painless.
• Without ionizing radiation.
• High spatial resolution.
• Operator independent.
• Easy to blind and ability to measure flow and velocity with advanced technique.
• Can be performed without contrast (pregnancy allergy).
• Good soft tissue contrast.
4.2 MRI Risks
• Relatively low sensitivity.
• Long scan and post processing time.
• Mass quantity of the probe may be needed.

• No real time information.
• Cannot detect intra-luminal abnormalities.
• Can make some people feel claustrophobic.
• Sedation may be required for young children who can’t remain still.
• Relatively expensive.
Master Gradient
Controlle Controller
RF X Y Z
Controlle
DAC
RF
Amplifier
Receiver Gradient Coil
Preamp RF Coil
Magnet
(a) MR scanner drawing (b) MRI machine

Figure 6. MRI system
(a) MRI (b) MRI (brain) (c) fMRI (brain)

Figure 7. Example of MRI images
4.3 MRI Medical Applications

• Examining the abnormalities of the brain and spinal cord.
• Examining the tumors, cysts, and other abnormalities in various parts of the body.
• Examining the injuries or abnormalities of the joints.
• Examining the diseases of the liver and other abdominal organs.
• Knowing causes of pelvic pain in women.
• Finding the unhealthy tissue in the body.
• Planning the surgery.
• Providing a global view of collateral veins.
• Providing a global view of intra and extra cranial.
5. Ultrasonography
Ultrasonography is a diagnostic technology that uses high frequency broadband sound waves
in the megahertz range that are reflected by tissue to varying degrees to produce medical images
[25-28]. The ultrasound transducer is placed against the skin of the patient near the region of
interest. The transducer produces a stream of high frequency sound waves that penetrate into the
body and reflect from the organs inside. The transducer detects sound waves as they echo back
from the internal structures of the organs. Different tissues reflect these sound waves differently
resulting a signature that can be measured and transformed into an image. These waves are
received by the ultrasound machine and turned into live pictures. The real time moving image
obtained can be used to guide drainage and biopsy procedures. Doppler capabilities of the recent
scanners allow the blood flow in arteries and veins to be assessed. Figure 8 shows three types of
ultrasound machines and figure 9 shows some examples of ultrasound images.
Figure 8. Ultrasound machines
Figure 9. Examples of ultrasound images
5.1 Ultrasonography Benefits

• Noninvasive and painless.
• Without using ionizing radiation.
• High resolution.
• Real time information.
• Sensitive to detect flow changes, intra and extra luminal abnormalities.
• Ability to measure velocity.
• Possible control of respiratory phases.
5.2 Ultrasonography Risks

• No standardized guidelines.
• Operator dependent.
• Time consuming.
• Blinding procedures are challenging.
• Cannot perform global view of the veins.
• Influenced by hydration status.
5.3 Ultrasonography Medical Applications
• Checking the development of the fetus during pregnancy.

• Imaging most structures of the head and neck, including the thyroid and parathyroid
glands, lymph nodes, and salivary glands.
• Imaging the solid organs of the abdomen such as; the pancreas, aorta, inferior vena cava,
liver, gall bladder, bile ducts, kidneys, and spleen.
• Guiding the injecting of needles when placing local anesthetic solutions near nerves.
• Echocardiography used for diagnosing the heart and function of heart ventricles and
valves.
6. Elastography
Elastography is a non-invasive medical imaging technique that detects the biological tissues
based on their stiffness (elasticity) compared to normal tissue [29, 30]. Elastography imaging may
be ultrasound elasticity imaging, magnetic resonance elasticity imaging, optical elasticity imaging
or tactile imaging. Ultrasound Elastography was the first technology to perform Elastography and
is widely studied in clinical diagnostic applications to image the biomechanical properties of soft
tissues [31-34]. MR Elastography measures the mechanical properties of soft tissues by
introducing shear waves and imaging their propagation using MRI [35-39]. MR Elastography
works using the gradient waveform in the pulse sequence to sensitize the MRI scan to shear
waves in the tissue. The shear waves are generated by the electromechanical transducer on the
surface of the skin. The mechanical excitation and the motion sensitizing gradient are at the same
frequency. Optical Elastography is performed using of optical coherence tomography to perform
Elastography [40-43]. To make optical coherence elastography on human subjects feasible, an
annular piezoelectric loading transducer is designed, through it a simultaneous image can be
obtained [44]. Tactile imaging [45, 46] is a medical imaging modality that translates the sense of
touch into a digital image. The tactile image is a function of the pressure on the soft tissue surface
under applied deformation. Tactile imaging closely mimics manual palpation, since the probe of
the device with a pressure sensor array mounted on its face acts similar to human fingers during
the examination, slightly deforming soft tissue by a probe and detecting resulting changes in the
pressure pattern.
6.1. Elastography Benefits
• Noninvasive and non-ionizing radiation
• Results are obtained immediately.
• High precision 2D time shift based strain estimation techniques.
• High frame rate to obtain a detailed map of the transmural strain in normal.
6.2. Elastography Risks

• By increasing the applied pressure, the Elastography is influenced by both Elastography
images as well as elasticity score this may lead to wrong diagnosis.
• Suffering from medical conditions that cause stiffness in tissues affected by abnormal
growths.
• Low resolution.
6.3 Elastography Medical Applications
• Detecting and evaluating liver disease, particularly cirrhosis.
• Investigations of the soft tissues.
• Measuring the mechanical response of the cardiac muscle at the various phases of the
cardiac cycle.
• MR Elastography used for examining changes in material properties of muscle associated
with aging.
• MR Elastography used for diagnosing breast cancer.
• Ultrasound Elastography used for determining the muscle material properties.
• Ultrasound Elastography used for determining the stiffness of the plantar fascia.
• Tactile imaging used for imaging of the prostate, breast, vagina and pelvic floor support
structures, and myofascial trigger points in muscles.
7. Optical Imaging
Optical imaging is a noninvasive technology that uses the light to show the cellular and
molecular function in the living body. Optical imaging considered as a powerful tool for probing
in deep tissues, where light propagates in a diffuse manner [47, 48]. The information is ultimately
derived from tissue composition and biomolecular processes. Contrast is derived either from the
use of exogenous agents that provide signal or from endogenous molecules with optical
signatures. The light propagates in a diffuse manner. The interaction of light with different tissue
components enables the visualization of tissue abnormalities or pathologic processes [49]. Optical
imaging system that used commercially for breast cancer examination system is shown in figure
10-a, and an example of the captured image is shown in figure 10-b.
(a) Breast tumor imaging (b) Capture image

Figure 10. Optical imaging system [50]
7.1. Optical Imaging Benefits

• Noninvasive.
• Non-ionizing radiation.
• The tumor characteristics can be imaged while the patient is lying in a prone position, and
there is reasonably good coverage of most of the breast.
• Longitudinal measurements can be made over a period of time.
• Potential to differentiate between soft tissues, due to their different absorption or scatter.
• Specific absorption by natural chromophores allows functional information to be obtained.
7.2 Optical Imaging Risks
• Low spatial resolution due to the diffusive nature of light propagation in breast tissue.
• Sensitive to water blood concentration, blood oxygenation and lipid concentration in
breast tissue.
7.3. Optical Imaging Medical Applications
• Probing hemodynamics [51].
• Detecting tumors [52].
• Providing functional imaging of the brain [53].
• Scanning the breast cancer.
• Scanning the bone health.
• Scanning the teeth, gums and jaws.
8. Radionuclide Imaging
Radionuclide imaging or nuclear medicine is a diagnostic technology that uses small
amounts of radioactive material to produce images of internal body. Small amounts of low level
radioactive isotopes are given as an injection or by mouth. These isotopes are attracted to specific
organs, bones or tissues, which absorb the radioactive material. Once an organ or tissue has
absorbed the radioactive material, it produces emissions, which can be detected by special
radiation detectors. The scanner works with a computer to convert the emissions into an image.
Radionuclide imaging includes three techniques; planner Scintigraphy [54-57], SPECT [57-62]
and PET [62-64], a comparison between these techniques is shown in table 1.
Planner Scintigraphy uses a certain organs to accumulate either for a short time or permanently,
some radioactive substances after they have been administered to a patient by mouth or by
injection. Radioisotope such as Tc99m used within 2 hours and no later than 6 hours after
preparation. The recommended dose of Tc99m is 20 to 25 millicurie [65]. Hydration of the patient
before imaging is useful; it is suggested that the patient drink 4 to 6 glasses of water between the
injection of the isotope and imaging. The time of imaging depends on age; in patients younger
than 20 years, imaging is done 2 hours after injection, and in older patients, a 3 to 4 hour delay is
recommended to provide better image quality. The pattern of their distribution allows some
diagnostically useful conclusions to be drawn as to the size of the organ and its normal or
abnormal position within the body. Figure 11-a show the basis of planner scintigraphy, and an
example of the captured image is shown in figure 11-b.
Table 1. Comparison between radionuclide imaging techniques

Planar Scintigraphy SPECT PET
Source Radioisotope generates Radioisotope generates Radioisotope generates
gammay decay, which gammay decay. positron decay.
generates one photon in
a random direction at a
time.
Methodology Similar to X-ray, but Similar to X-ray CT, Capture projections on
uses emitted gamma the photons captured in multiple directions.
rays from the patient, multiple directions, Positron decay produces two
the photons captured in photons in two opposite
one direction only, directions at a time.
Detector Anger scintillation Rotating anger camera Special coincidence detection
camera to obtain projection circuitry to detect two
data from multiple photons in opposite
angles. directions simultaneously.
(a) Basic principles (b) Captured image

Figure 11. Planner scintigraphy
Single Photon Emission Computed Tomography (SPECT) is an imaging technique that relies on
drugs that are labelled with atoms that emit at least one gamma ray when they decay. Since
gamma rays are normally emitted equally in every direction, it is necessary to use a collimator in
front of the detector that allows only the gamma rays emitted in the direction of the detector to be
registered. In this way, the collimator defines the direction of the radiation when it is detected. By
moving the detector completely around the patient, a 360º image is obtained. Mathematical
methods are used to trace the emitted gamma rays back in the direction that they were emitted in
order to produce the image. Figure 12-a show the basis of SPECT, and an example of the
captured image is shown in figure 12-b.
(a) Basic principles (b) SPECT brain image

Figure 12. SPECT
PET is a very similar technique to SPECT in that they both provide information about the
metabolism of a disease. Isotopes used in PET imaging are decayed by positron emission. The
emitted positron travels only a minimal distance before it undergoes an annihilation reaction with
the production of two photons that travel in opposite directions to one another. Localization of the
annihilation event is achieved by placing two detectors on opposite sides of the patient. When the
photons are detected at the same time, the position of the emitted positron can be traced back with
a straight as shown in figure 13-a. An example of capture image using PET is shown in figure 13-
b.
(a) Physical principles (b) PET brain image

Figure 13. PET
Recently, image fusion has been used for combining PET images with CT images or with
MRI images to produce special views for capturing the information from the two different exams
to be correlated and interpreted on one image. This gives more precise information and accurate
diagnoses. Commercially there are three combinations; SPECT/CT [56, 66-68], PET/CT [69-71]
and PET/MRI [72-74].
8.1. Radionuclide Imaging Benefits

• Provides functional information that is often highly accurate and specific.
• Provides a global view of the system of interest.
• Good tissue specific contrast.
• Can check how far a cancer has spread and how well the treatment is working.
8.2. Radionuclide Imaging Risks
• Use ionizing radiation and makes the patient radioactive for a variable period of time.
• Relatively low spatial resolution.
• High cost (equipment and isotope production).
• Extra care required in handling radioactive materials.
• May cause some people to feel claustrophobic, which may mean sedation is required.
8.3 Radionuclide Imaging Medical Applications
• Diagnosing the cancers (breast, cervical, colorectal, esophageal, head and neck, lung,
lymphoma, melanoma, pancreatic, thyroid and others).
• Evaluating the potential effectiveness of therapy.
• Diagnosing the cardiovascular disease.
• Diagnosing the Alzheimer’s disease, Parkinson's disease, dementia, epilepsy and other
neurological diseases.
9. Infrared Thermography
Thermography is a diagnostic technology that uses infrared to maps the physiological
processes of the body. It is based on the measurement of the skin's surface temperature, where the
temperature is dependent on the blood circulation in the outer millimeters of the skin. Infrared
medical thermography is sensitive to detect slight, dynamic temperature changes (0,05°C) on the
surface of the skin [75]. Clinical thermography [76, 77] is the recording of temperature to form an
image (thermogram) of the temperature distribution on the surface of the body. An infrared
thermography imaging system that used commercially is shown in figure 14-a. Figure 14-b show
an example of an infrared image.
(a) Infrared thermography (b) Infrared image imaging system

Figure 14. Infrared thermography imaging
9.1 Thermography Imaging Benefits

• Noninvasive.
• Non-ionizing radiation.
• Low cost.
• Uniquely suited to observing dynamic physiological changes in the body.
• Able to identify connections and causes of pain and disease at a very early stage.
• Low processing time, a single image may contain several thousands of temperature points,
recorded in a fraction of a second.
9.2 Thermography Imaging Risks
• Limited as a primary (stand-alone) breast cancer diagnostic [78, 79].
• By increasing temperature breast cancer cells produce nitric oxide, this oxide interferes
with the nervous system control of breast tissue blood vessel flow by causing regional
vasodilation in the early stages of cancerous cell growth, and enhancing new blood vessel
formation in later stages [80].
• Poor spatial resolution
• Poor calibration systems.
9.3 Thermography Medical Applications
• Determining the areas of the body that have inflammation.
• Breast imaging thermography offers women information that no other procedure can
provide, but breast thermography is not a replacement for or alternative to mammography
or any other form of breast imaging.
10. Terahertz Imaging
Terahertz (THz) radiation is defined as the submillimeter (1 mm - 0.1 mm) electromagnetic
spectrum with frequencies between 300 GHz and 3 THz, and is a relatively new and expanding
area that promises unique imaging capability. Due to the high absorption of THz electromagnetic
radiation in the water, reflective THz imaging has distinct advantages over earlier transmission-
based systems. A commercial THz medical probe that used in particular is shown in figure 15-a.
In THz imaging, the probe beam interacts with the sample, and the detection signal is obtained by
combining the probe laser with the THz radiation. The image of the subject can be built up due to
the selective absorption of the THz radiation. The detector receives the signals and by scanning
the sample an image can be formed [81, 82]. Figure 15-b show an example of rough surface
scattering from porcine skin.
10.1. Terahertz Imaging Benefits
• Safe and nonionising radiation.
• Uniquely sensitive to the vibration modes of water.
• THz radiation can penetrate many materials due to the long wavelength of the THz
photons.
(a) THz medical probe (b) THz image

Figure 15. THz imaging
10.2. Terahertz Imaging Risks

• THz detectors were characterized by poor signal-to-noise ratio and slow processing.
• The emitters produce only incoherent and low-brightness THz radiation [81].
• THz sources require cryogenic operating temperatures [83].
• Low contrast between healthy and pathological tissues.
• Poor source performance [84].
10.3. Terahertz Imaging Medical Applications
• Detecting the cancers (skin, breast and colon) [85].
• Imaging the tooth crown.
• Used in medical imaging experiments on different in-vitro and some in-vivo biological
tissues and has shown promising results in differentiating certain features in those tissues
[86].
• Detecting certain polar molecules due to these molecules’ fingerprint in the Terahertz
range of frequencies tissues [86].
11. Comparisons Between Medical Imaging Techniques

The medical applications can be compared in terms of 3 concepts; the first concept is the
image quality that can be represented by the spatial resolution and better contrast. The spatial
resolution refers to the spatial extent of small objects within the image. Noise refers to the
precision with which the signal is received. The contrast refers to the difference in brightness or
darkness in the image between an area of interest and its surrounding background. The second
concept is the system available that can be represented by the system cost and the availability of
real time information. The third concept is the safety that can be represented by the effect of
ionizing radiation on the patient, and the effect of heating on the body. The comparison between
the different MITs is summarized in table 2.
Table 2. A Comparison between the different MITs
Image quality System availability Safety

Imaging Ionising
Technique Spatial Good Real time Heating
Cost radiation
resolution contrast information effect
effect
Soft tissues
Radiography 1 mm Medium No Yes Low
and fluid
Hard and
CT 0.5 mm High No Yes Low
soft tissue
Hard and
MRI 0.5 mm High No No Medium
soft tissue
Ultrasonography 1 mm Soft tissues Low Yes No Negligible
Elastography 200 µm Soft tissues Medium Yes No Low
Optical 100 nm Soft tissues Low No No Medium
Radionuclide 3 mm Soft tissues High No Yes Medium
Thermography 15 µm Soft tissues Low No No High
Terahertz 40 µm Soft tissues High No No High
12. Conclusions
The paper presented a comparative study between the different medical imaging techniques,
the concepts, benefits, risks and applications of these techniques has been presented with details.
The concerning techniques are; X-ray radiography, X-ray CT, MRI, ultrasonography,
elastography, optical imaging, radionuclide imaging includes (Scintigraphy, PET and SPECT,
thermography, and terahertz imaging. A comparison between these techniques from point of view,
image quality (spatial resolution and contrast), safety (effect of ionizing radiation, and heating
effect of radiation on the body), and system availability (real time information, and cost) has been
presented. The discussions show, nothing of these techniques can be individual reliable in all
medical applications.
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Chapter

Introduction to Medical Imaging

1.1 The Modalities

Magnetic Resonance Imaging

using specialized MRI sequences to evaluate the biochemical composition of tissues

Nuclear Medicine Imaging

Nuclear Medicine Planar Imaging

■■FIGURE 1-7 Anterior and posterior whole-body bone

Single Photon Emission Computed Tomography

Positron Emission Tomography

a­ nnihilation. When a photon pair is detected by two detectors on the scanner, it

PET/CT combined imaging has applications in oncology, cardiology, neurology,

Combined Imaging Modalities

1.2 Image Properties

TABLE 1-1 THE LIMITING SPATIAL RESOLUTIONS OF VARIOUS MEDICAL

MRI poses a paradox to the wavelength-imposed resolution rule—the wavelength of

A Comparative Study of Medical Imaging

Received: 25 January 2015; Accepted: 12 March 2015

Keywords: Medical imaging; X-ray; CT; MRI; Ultrasonography; Elastography; Scintigraphy.

Figure 1. Concept of a medical imaging system

(a) X-ray imaging concept (b) Rotating X-ray tube

Figure 2. X-ray radiographic medical imaging

Shoulder Head Pelvis Knee

Figure 3. Examples of X-ray images

2.2 X-Ray Radiography Risks

3. X-Ray Computed Tomography

(a) CT scanner (b) CT fan beam

• Mass quantity of the probe may be needed.

Receiver Gradient Coil

(a) MR scanner drawing (b) MRI machine

(a) MRI (b) MRI (brain) (c) fMRI (brain)

4.3 MRI Medical Applications

Figure 8. Ultrasound machines

Figure 9. Examples of ultrasound images

5.1 Ultrasonography Benefits

5.2 Ultrasonography Risks

• Checking the development of the fetus during pregnancy.

6.2. Elastography Risks

(a) Breast tumor imaging (b) Capture image

7.1. Optical Imaging Benefits

Table 1. Comparison between radionuclide imaging techniques

(a) Basic principles (b) Captured image

(a) Basic principles (b) SPECT brain image

(a) Physical principles (b) PET brain image

8.1. Radionuclide Imaging Benefits

(a) Infrared thermography (b) Infrared image imaging system

9.1 Thermography Imaging Benefits

(a) THz medical probe (b) THz image

10.2. Terahertz Imaging Risks

11. Comparisons Between Medical Imaging Techniques

Table 2. A Comparison between the different MITs

Image quality System availability Safety

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