CR to DR – Optimizing Image Quality and Dose

Bruce Apgar B.S.

George Curley R.T.
Agfa Healthcare Inc.
Greenville, SC
What is DR? Mobile Radiography:
What is DR? Retrofit DR Panels:
What is DR? In Room Systems:

Floor mounted

Ceiling mounted

R/F rooms
 Why the Move from CR to DR?

Benefits: Radiology Today:

Radiology Today April 2012
• Cost coming down
• “Need for speed”
• Detector sharing

Benefits: Radiology Today:

Radiology Today July 2014
• Workflow Improvement /
Automation
• Dose Reduction
• Improved Image Quality
 Why the Move from CR to DR?
Workflow Improvements:
Loma Linda University Medical Center Case Study
• DR Retrofit conversion from distributed multi-plate CR

Outcomes:
• Streamlined workflow & time savings
• 8.16 seconds less time per exam (portable chest, bone
surveys)
• More patients per day / year
• 100% FTE gain
• Rapid ROI
 Making the Move from CR to DR…
ASRT HCIAC:
ASRT White Paper
Best Practices, ASRT
Advisory Council 2012:

• Background
• Dose / ALARA
• Social Marketing and
Safety Initiatives
• ACR Guidelines before
getting to the scope of
the white paper
 Making the Move from CR to DR…

Challenges: Minimizing Patient ASRT Directed Reading: Radiation Safety

Dose with Pediatric DR Compliance; Radiologic Technology,
volume 87 - number 5 May/June 2016:
page 522
– Equipment variation
– Technique guides not always
provided
– Large detectors (AED target
area)
– Artifacts from pediatric
positioning devices may be
more easily seen
– Repeat/Reject Analysis
implementation critical
DR: Image Capture Technologies
 Image Capture Technologies
DR Panel Technology*

X-ray scintillator screen or charge collector TFT array

Converts x-rays to light Collects charges from the upper
or to electric charges layer

Electronic control
Triggers the switching diodes 1. Absorption of X-rays in the phosphor screen
2. X-ray is converted into visible light
3. Photo diodes read light signal and generates charges
4. Signals are amplified, digitized, processed and archived
5. Soft Copy display or hardcopy optional
in

Switching diodes
Connects each pixel to readout device
out

Analog-to digital
Multiplexer conversion
Readout the electronic signal

*Lança L., Silva A. (2013) Digital Imaging Systems for Plain Radiography, New York: Springer
 Image Quality Improvement
Requires Improved Phosphor Technology
Traditional Powder Phosphors High Efficiency Needle Phosphors

 Calcium Tungstate for Film  Cesium Iodide (CsI) for DR

 Barium Fluoride Bromide (BaFlBr) for CR  Cesium Bromide (CBr) for CR
 Gadolinium Oxysulfide (GOS) for DR
 Phosphor Technology

CR- BaFlBr DR- CsI

The thickness of CR BaFlBr powder phosphor layer is limited to less than 300 µm, because of light
scattering. This thickness limits the X-ray absorption.

Due to the low light scattering of CsI a thicker phosphor layer can be used without jeopardizing the
sharpness of the imaging system. Higher X-ray absorption is possible with DR detectors using CsI
needle crystalline phosphors. This results in lower dose and better image quality.
 Image Quality Improvement

CR DR

70 kVp 10 mAs
70 kVp 10 mAs 70 kVp 10 mAs
 Image Quality Improvement and Lower Dose

CR DR

70 kVp 10 mAs 70 kVp 5 mAs

DR Cesium Iodide (CsI) Phosphors*

• Significantly reduce internal light scatter

• Improve image sharpness
• Enable thicker phosphor layers
• Improve X-ray absorption
• Reduce Dose ~ 2 X
• Reduce scatter sensitivity

* When compared to BaFlBr CR phosphor plates

Image Processing Technology
Image Processing Technology
14 µGy 55 µGy 225 µGy
 Image processing can improve usable diagnostic
information at lower dose

Standard Processing 14 µGy Multi Scale

Neonatal Processing
Image Processing Can Reduce Image Noise
Standard Processing Noise Reduction Technology
 Proper Image Processing Should:
• Provide consistent performance
• For patient body habitus & age: Neonatal, Pediatric, Adult, Bariatric
• Over a wide range of exposure factors

• Increase productivity, not create more work

• Little or no post processing should be needed
• Should require few window / level adjustments, electronic masking, manual ROI selection

• Should not create artifacts

• Should be dose tolerant & low dose friendly

• Be easy to configure and set up

• Work well out of the box
• Provide simple understandable adjustment settings
• Not complex parameters requiring imaging specialists for set up
 Anti-Scatter Grids for DR “Key Factors”

Grid Performance How it will Impact Digital

Factors Image Quality:
• Grid Ratio • Very important clinically
• Bucky factor: amount by which the • Very important clinically
exposure has to be adapted
• Grid Positioning • Very important clinically
• Angle and Distance
• Stationary vs. Reciprocating • Critical
• Line Rate (frequency) in lines/cm or • Critical
lines/inch
• Grid line direction • Critical
• Focus vs. parallel • Least important to digital
Grid Line Suppression Algorithms
Purpose:
Identifies repeating patterns caused by grid/panel interference and removes them
Result:
Improved viewing conditions
DR Grid Recommendations*

Panel Type DX-D 30 / 35 C DX- D 40 C DX-D 45 C CR

Plate
125 micron 139 micron 124 micron 100-150 micron
Resolution
32 lines / cm Poor Results Poor Results Poor Results Poor Results
80 lines / inch Not Recommended Not Recommended Not Recommended Not Recommended

36 lines / cm Poor Results Poor Results Poor Results Good Results

90 lines/ inch Not Recommended Not Recommended Not Recommended Acceptable for Use
40 lines / cm Good Results Good Results Good Results Poor Results
103 lines / inch Acceptable for Use Acceptable for Use Acceptable for Use Not Recommended

50 lines / cm Best Results Best Results Best Results Best Results

132 lines / inch Recommended for Use Recommended for Use Recommended for Use Recommended for Use

70 lines / cm Poor Results Poor Results Poor Results Better Results

178 lines / inch Not Recommended Not Recommended Not Recommended Recommended for Use
80 lines / cm Better Results Better Results Better Results Better Results
215 lines / inch Recommended for Use Recommended for Use Recommended for Use Recommended for Use

10% variation In
* With Agfa Grid Line Suppression Software - GLS
grid specification
 Incorrect Grid Alignment = Poor Image Quality
Angle of tube collimator is not the same as the grid/panel
Tube/collimator is not parallel to the grid

Grid

Tube / collimator angle

- 20 degrees

Grid Angle -5 degrees

• Most “portable” stationary grids are the same size as the cassette being used
• Grid lines are often oriented along the long dimension
• May also be oriented along the short dimension (usually called “decubitus” grids)
• Grids in tables and upright buckys are usually 17 – 20 inch “square” grids

Square table or upright

Typical grid line orientation “Decubitus” grid orientation bucky grid
Tube Collimator and Grid are NOT Parallel (6:1)
High Scatter Poor Lung and Spine Detail
Proper Grid Alignment = Good Image Quality
Angle of tube the same as the grid/panel
Tube collimator parallel to the grid

Grid
Tube Collimator and Grid ARE Parallel (6:1)
Low Scatter Improved Lung and Spine Detail
Tube Collimator and Grid are not parallel
High Scatter Poor Lung and Spine Detail
 “Decubitus” grid orientation
Angled positioning but Good Lung and Spine Detail
 Incorrect Alignment = Poor Image Quality
Angle of tube collimator is not the same as the grid/panel
Tube collimator is not parallel to Grid

Grid

Tube / collimator angle

- 20 degrees

Grid Angle -5 degrees

 Angled Tube = Good Image Quality
Angle of tube collimator is off but it is centered
A “Decubitus Grid” was used

Grid

Tube / collimator angle

- 20 degrees

Grid Angle -5 degrees

“Decubitus” grid orientation

Grid Positioning and Orientation
• Most “portable” stationary grids are the same size as the panel being
used
• Grid lines are often oriented along the long dimension
• May also be oriented along the short dimension (usually called
“decubitus” grids) these good for landscape chests
• Grids in tables and upright buckys are usually 17 – 20 inch “square”
grids

“Decubitus” grid orientation Square table or upright

Typical grid line orientation bucky grid
 “Non-Grid”, Scatter Suppression Software

• Product Types
• Agfa MUSICA Chest +
• Fuji Virtual Grid
• Philips Skyflow
• Other ?
• How does it work ?
• Reduces the need for a grid using advanced image processing
• Scatter radiation is low frequency in an image
• Scatter Suppression Software reduces the visualization of low
frequencies while enhancing medium to high frequencies
 Scatter Suppression Software extracts low frequency scatter
information while enhancing relevant clinic information

Insert Non Grid Beside Chest

Image
GenRad Soft

Non Grid Chest with Standard Processing Low Frequency Scatter Contribution
 Scatter Suppression Software extracts low frequency scatter
information while enhancing relevant clinic information

Insert Non Grid Beside Chest

Image
GenRad Soft

Non Grid Chest with Scatter Suppression Low Frequency Scatter Contribution
Software
Scatter Suppression Software can improve lung field detail without
the use of an anti-scatter grid

Chest Phantom with 6:1 Grid Chest Phantom no Grid

flipped for comparison
MUSICA 2 GenRad Soft Chest Processing MUSICA 3 Chest + Processing
100 kVp 3.2 mAs 100 kVp 1.6 mAs
Scatter Suppression Software may also be used with a Grid to give the
best overall results but requires proper positioning at a higher dose*

Chest Phantom with 6:1 Grid Chest Phantom with 6:1 Grid
MUSICA 2 GenRad Soft Chest Processing MUSICA 3 Chest Processing flipped for comparison
100 kVp 3.2 mAs 100 kVp 3.2 mAs
* When compared to non grid exposures , grid exposures may require up to 50% higher exposure depending on conditions
 Clinical Examples

MUSICA 2 GenRad Soft Processing MUSICA 3 + Chest Processing

Non Grid Non Grid
Can Image Processing Software Eliminate the Need for a Grid with DR?
• It Depends
• On the application
• Mobile or In room
• On the Patient Size
• Pediatric, Normal, Obese
• On the workflow requirements
• Grid and Panel Weight
• On the examination criteria
• Image Quality
• Dose

• “Non-grid” image processing is another option in the toolbox

that should be considered and used when appropriate to
improve image quality and reduce dose.
Managing Exposure and Dose to Optimize Image Quality
 Dynamic Range: Film

1/2 ref dose ref dose 2x ref dose

5 mAs 10 mAs 20 mAs

 Dynamic Range: CR

2.5 mAs 10 mAs 160 mAs

 Dynamic Range: DR

1/4 ref dose ref dose 4x ref dose

2.5 mAs 10 mAs 40 mAs

 Managing Exposure and Dose to Optimize Image Quality

CR DR

70 kVp 160 mAs 70 kVp 160 mAs

 CR vs DR Image Quality and Dose

• Better image quality at lower dose

• DR images can be higher in contrast and sharpness
• DR panels (CsI) require less exposure to achieve equal to or better image
quality

• Significantly less Exposure Latitude with DR

• CR Exposure Range -4x to +16 x mAs
• DR Exposure Range ± 4x mAs
• Image Saturation can occur with DR !!!! Data is not recoverable !!!
• With DR Accurate exposure is key (similar to film)
Managing Exposure and Dose to Optimize Image Quality

To maintain proper exposure

One Uniform Standard required for measuring exposure
!!!! IEC
Exposure in
Fuji Canon Agfa Carestream Exposure
µGy
Index *

2.5 710 30 1.96 1451 250

5 355 60 2.26 1751 500

10 177 120 2.56 2051 1000

20 89 240 2.86 2351 2000

*Flatfield RQA5 beam quality

 A Better Approach; Exposure Index (IEC 62494-1)

• A standard way to measure the exposure to a digital detector

• Developed by IEC - International Electrotechnical Commission
• IEC 62494-1 “Exposure index of digital X-ray imaging systems”
• Standard Calibration Condition – RQA-5
• Designed to monitor exposure consistency within an exam type
• Consists of three values
• Exposure Index – EI
• Target Exposure Index - TEI
• Deviation Index - DI
• In a perfect situation the DI would be zero (0)

DI =10 * Log [ ]
EI_
TEI DI =10 * Log [ ]=0
500_
500
Target Exposure Index and Deviation Index
Actual Target
Exposure Exposure Deviation Exposure %
Index Index Index Factor Change
1300 500 4 2.6 160%
1000 500 3 2 100%
800 500 2 1.6 60%
630 500 1 1.26 26%
500 500 0 1 0%
400 500 -1 0.8 -20%
300 500 -2 0.6 -40%
250 500 -3 0.5 -50%
200 500 -4 0.4 -60%
. Exposure Monitoring Software
1. Color Coded Exposure Bar
2. Exposure Index Performance Table

60 kVp 1 mAs

“On Target” Exposure

EI = TEI
DI = 0
The dose bar is an indication to see how far the applied Exposure Index
(Detector exposure) is away from the reference exposure (Target Exposure
Index) identified for this exposure.

60 kVp 1.75 mAs

Overexposed within range Less

than + or - 2X exposure
Less than + or – 3.0 DI

Green
within range
The bar gives a relative indication of the exposure to the plate and it is a good
measure of the variation of exposure to the plate within a given exam type, but it
is not an absolute dose measurement value.

60 kVp 2.88 mAs

Overexposed outside of range

Greater than 2X exposure
Greater than 3.0 DI

Yellow Slightly
Overexposed
60 kVp 4.75 mAs

Overexposed far
outside of range.
Greater than 4X exposure
Greater than 6.0 DI

Red Significantly
Overexposed
60 kVp 0.23 mAs

Underexposed far
outside of range.
Less than 1/4X exposure
Less than - 6.0 DI

Red Significantly
Underexposed
Region of Interest ROI Selection Affects Exposure Index

Automatic ROI Selection

Deviation Index in range
EI 264
DI -0.6
TEI 300
Region of Interest ROI Selection Affects Exposure Index

Manual ROI Selection of appropriate

region for examination
Deviation Index in range

EI 375
DI 1.0
TEI 300
Region of Interest ROI Selection Affects Exposure Index

Manual ROI Selection of incorrect

region for examination
Deviation Index out of range

EI 64
DI -6.7
TEI 300
Region of Interest ROI Selection Affects Exposure Index

Manual ROI Selection of

incorrect region for examination
ROI outside of clinical region
Deviation Index out of range

EI 1924
DI 8.1
TEI 300
 Dose Monitoring

Ongoing Exposure - Trend Analysis

DICOM Mapping of EI, TEI, DI

The DICOM committee defined tags:

• EI : (0018,1411)
• TEI : (0018,1412)
• DI : (0018,1413)
• “DAP” Dose Area Product: (0018,115E)
Proper X-Ray Collimation is Key to Dose and Image Quality with DR

If the X-ray collimation is done correctly the area of

interest should be detected automatically and minimal
manual cropping should be required

Proper X-Ray Collimation for

region of interest
Proper Automatic image Collimation
(black borders) for region of interest
No Manual Collimation Required
Collimation Issues
Original Plate size 24 x 30 cm
X-Ray Collimated area size 20 x 28 cm (77%)
Region of interest size only 16 x 15 cm (33%)
Automatic collimation with black borders applied based on X-Ray collimation
The actual region of interest size is 16 x 15 cm (33%)

The technologist does additional manual

collimation (cropping) at the workstation

The Radiologist may be unaware of the actual

patient exposure – quantity and anatomically

If the X-ray collimation is correct, minimal

manual cropping should need to be done
Repeat Rates are Changing with DR
CR to DR – Optimizing Image Quality and Dose
1. Panel Technology and Phosphor Type - Can reduce dose 50% or more

2. Proper Image Processing - Can significantly reduce dose and improve image
quality

3. Proper Grid selection and position – Will greatly influence image quality
a. Grid lines per inch
b. Grid position and distance
c. Non Grid Scatter Suppression software - Is an option to improve workflow and dose

4. Repeat Rates with DR are increasing

a. Repeats for positioning are increasing because it is so easy to repeat
CR to DR – Optimizing Image Quality and Dose
5. Proper Technique Selection is more important than ever
a. DR Dynamic Range is much less than CR
b. DR images can be saturated (image recovery is not possible)
c. The IEC Exposure Index can be used to monitor and control exposure

6. X-ray Collimation
a. Influences scatter, image processing and overall image quality
b. Improper Electronic collimation or masking reduces image quality and increases
dose