896 Rapid Communication
Influence of Grid Control and Object Detection on
Radiation Exposure and Image Quality using Mobile
C-Arms – First Results
Der Einfluss von Gridregelung und Objekterkennung auf Strahlenexposition und
Bildqualität bei transportablen C-Bogengeräten – erste Ergebnisse
Autoren
Institute
Key words
●
" C-arm
●
" dose reduction
●
" pulsed fluoroscopy
eingereicht 10.5.2007
akzeptiert 1.7.2007
Bibliografie
DOI 10.1055/s-2007-963389
Online-Publikation: 2007
Fortschr Röntgenstr 2007; 179:
896 – 900 © Georg Thieme
Verlag KG Stuttgart · New York ·
ISSN 1438-9029
Korrespondenzadresse
Dr. Dieter Gosch
Klinik und Poliklinik für Diag-
nostische und Interventionelle
Radiologie, Universitäts-
klinikum Leipzig AöR
Liebigstraße 20
04103 Leipzig
Tel.: ++ 49/3 41/9 71 74 16
Fax: ++ 49/3 41/9 71 74 09
gosd@medizin.uni-leipzig.de
Gosch D et al. Influence of Grid… Fortschr Röntgenstr 2007; 179: 896 – 900
D. Gosch1, A. Ratzmer2, P. Berauer2, T. Kahn1
1
Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Leipzig AöR
2
Ziehm Imaging GmbH, Nürnberg
Zusammenfassung
! !
Ziel: Ziel der Studie war, zu untersuchen, inwie-
weit eine neuartige Dosisleistungsregelung
(Gridregelung) die Bildqualität von mobilen C-
Bogen verbessern kann. Außerdem sollte die mö-
gliche Dosisreduktion durch automatische Rege-
lung der Pulsfrequenz bei gepulster Durchleuch-
tung mit 25 Pulsen pro Sekunde durch
Objekterkennung ermittelt werden.
Material und Methoden: Bei der Gridregelung
wird im Gegensatz zu den üblichen Dosisleis-
tungsregelungen, bei denen ein zentrales kreis-
förmiges Messfeld verwendet wird, ein enges
Gitter quadratischer Zellen über das gesamte
Röntgenbild gelegt. Das Belichtungssystem nutzt
nur die Zellen für die Belichtungssteuerung, die
vom abzubildenden Objekt abgedeckt werden.
Damit soll unabhängig von Größe, Form und
Lage des abzubildenden Objektes eine optimale
Belichtung erreicht werden. Das System erkennt
auch automatisch Objektbewegungen. Wenn
eine Pulsfrequenz von 25 Pulsen pro Sekunde an-
gewählt ist und keine Veränderungen im Bild re-
gistriert werden, wird die Pulsfrequenz der ge-
pulsten Durchleuchtung schrittweise reduziert.
Damit kann die Strahlenexposition verringert
werden. Der Einfluss der Gridregelung auf die
Bildqualität wurde mithilfe eines anthropomor-
phen Phantoms untersucht. Die Dosisreduktion
durch Objekterkennung wurde durch Auswerten
von Untersuchungsdaten von 146 Patienten aus
5 Ländern ermittelt.
Ergebnisse: Die Bilder des statischen Phantoms
waren mit Gridregelung unabhängig von der Posi-
tion des darzustellenden Objektes immer optimal
belichtet. Die durchschnittliche Dosisreduktion
bei 25 Pulsen pro Sekunde durch Objekterkennung
und automatische Pulsregelung betrug 21 %, die
maximale Dosiseinsparung lag bei 60%.
Schlussfolgerung: Durch die Gridregelung wird
die Bedienung der C-Bogengeräte vereinfacht, da
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Abstract
Purpose: The objective of this study was to ex-
amine the extent to which the image quality on
mobile C-arms can be improved by an innovative
exposure rate control system (grid control). In
addition, the possible dose reduction in the
pulsed fluoroscopy mode using 25 pulses/sec
produced by automatic adjustment of the pulse
rate through motion detection was to be deter-
mined.
Materials and Methods: As opposed to conven-
tional exposure rate control systems, which use
a measuring circle in the center of the field of
view, grid control is based on a fine mesh of
square cells which are overlaid on the entire
fluoroscopic image. The system uses only those
cells for exposure control that are covered by
the object to be visualized. This is intended to
ensure optimally exposed images, regardless of
the size, shape and position of the object to be
visualized. The system also automatically de-
tects any motion of the object. If a pulse rate of
25 pulses/sec is selected and no changes in the
image are observed, the pulse rate used for
pulsed fluoroscopy is gradually reduced. This
may decrease the radiation exposure. The influ-
ence of grid control on image quality was exam-
ined using an anthropomorphic phantom. The
dose reduction achieved with the help of object
detection was determined by evaluating the ex-
amination data of 146 patients from 5 different
countries.
Results: The image of the static phantom made
with grid control was always optimally exposed,
regardless of the position of the object to be vi-
sualized. The average dose reduction when using
25 pulses/sec resulting from object detection and
automatic down-pulsing was 21 %, and the maxi-
mum dose reduction was 60%.
Conclusion: Grid control facilitates C-arm op-
eration, since optimum image exposure can be

unabhängig von der Objektpositionierung eine optimale Belich-
tung erreicht wird. Die Objekterkennung kann zu einer Reduk-
tion der Strahlenexposition von Patient und Untersuchungsper-
sonal führen.
Introduction
! Nuremberg (Germany), is the first C-arm to use automatic ob-
The use of mobile C-arms in the operating room (OR) is con-
stantly increasing. The introduction of new surgical procedures,
for instance, has led to greater use of fluoroscopy [1]. Mainly as
a result of computer-assisted procedures, their acceptance and
relevance are expected to increase further, since these proce-
dures provide increased accuracy at low radiation exposure le-
vels compared to conventional surgical procedures [2]. A nega-
tive side effect of the increased use of mobile C-arms is radiation
exposure of patients and OR staff. A number of studies investi-
gate the level of radiation exposure of operating staff during dif-
ferent surgical procedures [3 – 5].
There is no threshold value for the occurrence of radiation-in-
duced cancer and hereditary diseases. The probability of oc-
currence depends on the dose applied. Since even the lowest
radiation doses may cause somatic and genetic radiation ef-
fects, radiation exposure minimization is imperative. Radiation
protection is particularly important for OR staff members, who
do not have any direct benefit from the application of radia-
tion and are exposed to ionizing radiation during their entire
professional life. Since the wearing of X-ray protective cloth-
ing is highly inconvenient and cumbersome under OR condi-
tions, technical solutions for reducing the X-ray dose are of
special importance. Enhancements of the image intensifier/TV
system by using more sensitive CCD chips, image intensifiers
with a higher conversion factor and more efficient coupling
of the TV camera to the image intensifier output have allowed
lower image intensifier input dose rates and consequently also
a reduction of the radiation exposure of patients and operat-
ing staff.
One of the most important technical means of reducing radia-
tion exposure is pulsed fluoroscopy, which may result in an X-
ray dose reduction of up to 70% [6]. The selection of a certain
pulse rate determines the temporal resolution. Low pulse rates
reduce radiation exposure, but also temporal resolution, a fact
which may lead to information loss especially when watching
fast-moving objects. Choosing the optimum pulse rate there-
fore requires a certain level of qualification of the operating
staff, which is not always met. Consequently, the maximum
pulse rate is often used instead of lower pulse rates, thus re-
sulting in high radiation exposure.
One of the main problems when using mobile C-arms in the OR
is the correct positioning of the object to be visualized. Sub-op-
timal positioning may cause problems with the automatic expo-
sure rate control system. On most C-arms, the image signal is
measured in a circular area in the center of the image intensifier.
The tube voltage and tube current necessary for penetrating the
object are then set automatically on the basis of this information
using a characteristic curve (automatic exposure rate control,
AERC). If the object is positioned, e. g., in such a way that it is lo-
cated on the periphery of the field of view (FOV) and the control
area of the image intensifier receives unattenuated useful radia-
tion, the AERC will set tube voltage and current values that are
too low, resulting in the object not being visualized adequately.
Rapid Communication 897
obtained independently of object positioning. Object detection
may lead to a reduction in radiation exposure for the patient
and operating staff.
The Ziehm Vision system, manufactured by Ziehm Imaging in
ject detection for solving such exposure problems. In addition,
the fluoroscopic image is monitored for motion. If no changes
occur in the image and a pulse rate of 25 pulses/sec is selec-
ted, the pulse rate used for pulsed fluoroscopy is reduced step
by step. The present study will explore the extent to which im-
age quality can be improved and radiation exposure can be de-
creased by means of this technology.
Materials and Methods
!
Downloaded by: Tehran University of Medical Sciences. Copyrighted material.
Conventional exposure rate control systems on mobile C-arms
use a central measuring circle in the fluoroscopic image, where
the average or peak value of the TV signal is measured. The tube
voltage and current required for penetrating the object are then
adjusted using a characteristic curve. For the grid control imple-
mented on Ziehm Imaging's Vision system, a grid of 256 × 256
measuring square cells is overlaid on the entire fluoroscopic im-
age instead of the measuring circle. The system uses only those
cells for exposure control that are covered by the object to be
imaged. According to engineering data of the manufacturing
firm, this approach ensures that no unattenuated useful radia-
tion adversely affects the exposure rate control regardless of
the size, shape and position of the object to be visualized.
The system also automatically detects any motion of the object
since the values measured in the individual cells change in this
case. If the system does not detect any object motion, the pulse
rate used in the pulsed fluoroscopy mode, which is normally set
to 25 pulses/sec, is gradually reduced to a minimum of 2 pulses/
sec. This takes less than 1 second (840 msec). Simultaneously,
the filter levels used for recursive filtering are increased to their
maximum in order to suppress noise in the image. As soon as the
system detects any motion, it increases the pulse rate to 25 pul-
ses/sec again, while at the same time lowering the recursive fil-
ter levels. This increases image noise but ensures that the spatial
resolution remains the same. The initial pulse rate of 25 pulses/
sec is reached after 500 msec.
The effects of grid control on image quality (correct exposure)
were examined with the help of an anthropomorphic phan-
tom. A skull phantom by Radiology Support Devices, Inc.
(Long Beach, CA, USA), consisting of human bones embedded
in tissue-equivalent materials, was used for this purpose. The
phantom was placed on the periphery and in the center of the
image intensifier's FOV and then visualized using both con-
ventional exposure rate control with a central measuring cir-
cle and grid control. The test was carried out with the same
C-arm.
To enable quantification of the dose reduction obtained via pulse
rate reduction in the case of non-moving objects, the C-arm logs
not only the fluoroscopy time and dose area product but also the
number of pulses actually used. Thus, the dose reduction can be
calculated using the ratio between the number of pulses that is
theoretically possible and the one that was actually used. The
Gosch D et al. Influence of Grid… Fortschr Röntgenstr 2007; 179: 896 – 900
898 Rapid Communication

Fig. 1 a Image of a skull phantom. The object

covers the measuring circle used for automatic ex-
posure rate control only partially (poor image
quality). b Image of a skull phantom in off-center
position, captured with grid control (good image
quality).

Table 1 Geographical distribution of patients and dose area product

country number of examinations Dose Area Product (in cGy × cm2)

Downloaded by: Tehran University of Medical Sciences. Copyrighted material.

average value minimum value maximum value standard deviation
China 6 208 17 826 313
Denmark 8 1449 195 3338 1102
England 17 195 20 387 122
Germany 100 911 2 8455 1741
Scotland 15 396 5 1471 435
all 146 775 2 8455 1502

linear relationship between the number of pulses and dose area Table 2 Dose reduction
product was checked experimentally.
country dose reduction (in %)
To quantitatively assess the dose reduction that can be achieved
with object detection, examination data from various C-arms average minimum maximum standard
used in 5 different countries were collected. The units were value value value deviation
used in a wide variety of OR applications, including orthopedic, China 22 17 25 3
traumatology, and vascular and neurosurgical procedures. The Denmark 30 17 35 6
selection of C-arms and procedures occurred accidentally. Only England 26 14 57 11
data from examinations with a pulse frequency of 25 pulses/sec Germany 19 1 60 13
and object detection were evaluated. Scotland 29 12 41 10
all 21 1 60 13

Results
! distribution of patients and shows the average, minimum, and
●" Fig. 1a shows an image of a skull phantom. The measuring maximum values as well as the standard deviation of the cor-
circle is only partially covered by the object, whereas the re- responding dose area product values. ● " Table 2 summarizes

maining area receives unattenuated useful radiation. Conse- the dose reduction that was achieved. ● " Fig. 3 is a graphical

quently, the exposure rate control system sets insufficient representation of the frequency distribution of the dose reduc-
fluoroscopy values, and the object is clearly underexposed. tion.
The effect of grid control on image quality is visible in
●" Fig. 1b, which shows the same object, however with grid

control. In this case the skull is correctly exposed, although po-
sitioned off-center. Exposure control was based solely on the
measuring cells represented in the image. The measuring circle
and measuring cells are normally not displayed. They are
drawn in the figures as an addition. An example from clinical
practice is illustrated in ●
" Fig. 2, which shows a foot in off-cen-
ter position captured with grid control. The image quality is
good, although the object is positioned on the periphery of the
FOV.
The possible reduction of radiation exposure resulting from
object detection and gradual pulse rate reduction in static ima-
ges was examined on the basis of a total of 146 patients from 5
different countries. ● " Table 1 breaks down the geographical
Discussion
!
The use of mobile C-arms for intraoperative imaging has in-
creased over the last few years as a result of minimally invasive
procedures [7]. To achieve optimum image quality regardless
of the object to be screened, the C-arm must provide automatic
exposure rate control. In Germany, automatic exposure rate
control is required by law for fluoroscopic X-ray examination
of humans (Art. 26 of the German X-Ray Ordinance) [8]. In the
event of inadequate positioning, especially of small objects that
only partially cover the image intensifier's FOV, the use of con-
ventional exposure rate control systems with a central measur-
ing circle may result in bad image quality due to an insufficient

Gosch D et al. Influence of Grid… Fortschr Röntgenstr 2007; 179: 896 – 900

Fig. 2 Foot of a patient in off-center position, captured with grid control
(good image quality).
Fig. 3 Frequency distribution of dose savings.
dose rate since the exposure control system is misled by unat-
tenuated useful radiation hitting its measuring area (● " Fig. 1a).
Grid control may solve this problem. As shown in ● " Fig. 1b
(skull phantom) and in ● " Fig. 2 (foot of a real patient), grid
control ensures that good image quality is achieved indepen-
dently of patient positioning and even with less qualified oper-
" Fig. 2). In addition, it can shorten the fluoroscopy
ating staff (●
time that is required for correct patient-specific imaging. Smal-
ler metal objects such as screws or wires do not noticeably in-
fluence exposure control (● " Fig. 2). However, larger metal ob-
jects in the measuring field can decrease image quality. Object
detection is not able to detect metal objects and eliminate the
negative influence on exposure control.
Mobile C-arms using movable measuring fields (auto track
from GE) are on the market. The difference between object de-
tection (Ziehm) and auto track (GE) is that object detection
uses 256 × 256 measuring cells which can be adapted to the
shape and position of the object to be displayed whereas auto
track uses only one movable measuring circle. Therefore, part
of the measuring circle may be not covered by the object.
Rapid Communication 899
The level of radiation exposure of patient and operating staff
caused by mobile C-arms depends on the fluoroscopy unit, the
operating staff and finally also the patient. A notable technical
solution for reducing radiation exposure is pulsed fluoroscopy.
A significant dose reduction can be achieved using lower pulse
rates [9]. Since the pulse rate also affects the temporal resolu-
tion of object motion during fluoroscopy, the optimum pulse
rate must be chosen by the examining physician for each indi-
vidual case according to the medical indication. This problem is
often avoided by choosing the maximum pulse rate at the ex-
pense of increased radiation exposure. Object detection gradu-
ally reduces the pulse rate down to 2 pulses/sec in those cases
where the maximum pulse rate is not necessary due to the lack
of motion in the fluoroscopic image. During examinations of
the heart or moving parts of the chest for instance, object de-
tection would not change the pulse rate of 25 pulses/sec.
The results presented in ● " Table 2 indicate an average dose re-
duction of 21 % and a maximum dose reduction of 60%. ● " Fig. 3,
which shows the frequency distribution of dose reduction, de-
Downloaded by: Tehran University of Medical Sciences. Copyrighted material.
monstrates that a dose reduction of more than 20% was achieved
in approx. 56 % of all examinations. The average dose reduction
of 21 % was achieved using 25 pulses/sec with object detection
compared to 25 pulses/sec without object detection.
As listed in ●" Table 1, the examination data were collected in
5 different countries in the course of 146 fluoroscopic exami-
nations of different body regions performed by various opera-
tors. A dose reduction by means of object detection depends
on the mode of operation and the qualification of the operat-
ing staff and will be important if the fluoroscopy time is long
and no variation occurs in the image.
The medical team may further reduce the patient's radiation
exposure by using optimum collimation settings, correct po-
sitioning geometry (maximum focus/patient distance and
minimum patient/image receptor distance) and short fluoro-
scopy times which can be achieved with the electronic image
memory (LIH) and pulsed fluoroscopy with a low pulse rate.
A reduction in radiation exposure can be achieved by im-
proving medical staff training [6]. The higher the amount of
radiation delivered to the patient, the higher the level of ex-
posure received by the operating staff as a result of the scat-
tered radiation emerging from the patient. Therefore, any de-
crease in patient exposure also leads to a reduction in the
radiation exposure of the operating staff.
Other factors that are decisive for the level of radiation expo-
sure of the medical team are distance from the patient, ade-
quate shielding against scattered radiation in the form of sui-
table X-ray protective clothing, and beam direction. Increasing
the distance to the patient can significantly reduce the radia-
tion exposure of medical staff, as the inverse square law is
basically applicable [10]. Regarding X-ray protective clothing,
special care should be taken to always wear thyroid and ster-
num protection, since they will help to reduce the effective
dose [11]. Lead-free protective clothing often has a weaker
protective effect, and should therefore be used only after cri-
tical evaluation [12].
Stationary X-ray equipment often provides additional radiation
protection devices for medical staff (e. g. lead rubber protective
curtains, lead glass windows, etc.) which are not available on
mobile C-arms. As a result, medical staff members might be ex-
posed to higher radiation levels when working with mobile C-
arms than when working with stationary X-ray equipment [13,
14].
Gosch D et al. Influence of Grid… Fortschr Röntgenstr 2007; 179: 896 – 900
900 Rapid Communication
The generalizability of the results of the present study is limited
due to the use of a static phantom and the small patient sample
size. Further investigations using dynamic phantoms and larger
patient groups are needed to confirm the first results regarding
image exposure optimization and dose reduction as a result of
grid control and automatic object detection. In addition, possi-
ble dose reduction depending on the type of examination and
selected pulse rate should be explored.
Our study has shown that the grid control implemented on
Ziehm Vision mobile C-arms is able to produce good image
quality (correct exposure) regardless of the position of the sta-
tic object under examination, thus facilitating operation of the
unit. Object detection and automatic pulse rate reduction ap-
plied to static objects in the pulsed fluoroscopy mode using
25 pulses/sec yielded an average dose reduction of 21 % in a
total of 146 examinations.
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