Eur. Radiol.

(2001) 11: 2616±2626

DOI 10.1007/s003300100828 P HY SI C S

J. J. James Developments in digital radiography:

A. G. Davies
A. R. Cowen an equipment update
P. J. O'Connor

Received: 26 June 2000

Revised: 27 December 2000
Accepted: 2 January 2001
Published online: 13 March 2001
)
J. J. James ´ P. J. O'Connor ( )
Department of Clinical Radiology,
The General Infirmary at Leeds,
Great George Street, Leeds,
LS1 3EX, UK
E-mail: philipo@ulth.northy.nhs.uk
Phone: +44-1 13-3 92 37 68
Fax: +44-1 13-92 82 41
A. G. Davies ´ A. R. Cowen
Department of Medical Physics,
The University of Leeds, Leeds,
LS1 3EX, UK
Abstract Digital X-ray imaging
technology has advanced rapidly
over the past few years. This review,
particularly aimed at those involved
in using and purchasing such tech-
nology, is an attempt to unravel
some of the complexities of this po-
tentially confusing subject. The
main groups of X-ray imaging de-
vices that are considered are digitis-
ers of conventional radiographs, im-
age-intensifier-based fluorography
systems, photostimulable phosphor
computed radiography, amorphous
selenium-based technology for tho-
rax imaging and flat-panel systems.
As well as describing these different
systems, we look at ways of objec-
tively assessing their image quality.
Concepts that are used and ex-
plained include spatial resolution,
grey-scale bit resolution, signal-to-
noise ratio and detective quantum
efficiency. An understanding of
these basic parameters is vital in
making a scientific assessment of a
system's performance. Image pro-
cessing and techniques are also
briefly discussed, particularly with
reference to their potential effects
on image quality. This review aims
to provide a basic understanding of
digital X-ray imaging technology
and enables the reader to make an
independent and educated assess-
ment of the relative merits of each
system.
Keywords Digital radiography ´
Radiographic image enhancement ´
Radiological technology ´ Thoracic
radiography ´ Fluoroscopy

processing can improve image quality by changing the

Introduction
Traditionally, the X-ray image has been recorded in an-
alogue form using conventional screen film combina-
tions. The term digital radiography refers to X-ray im-
aging techniques which at some stage utilise a digital
data format in acquiring, processing, displaying or
managing a medical X-ray image. In recent years there
have been major advances in digital technology applied
to X-ray imaging, with much promise for future devel-
opment. This technology is developing rapidly and is
potentially confusing given the diversity of approaches
being adopted by different manufacturers.
The main advantage of digital radiography is the
separation of image acquisition, processing and display,
allowing optimisation of each of these stages. Computer
overall contrast and brightness of an image, as well as
allowing image manipulation such as edge enhancement
and smoothing. These manipulations are mostly benefi-
cial, although there is a potential for image degradation
if incorrectly implemented.
This review is specifically aimed at practising radiol-
ogists and radiology managers, to provide a basic un-
derstanding of these processes and their impact on im-
age quality. This is required when both purchasing and
using digital X-ray imaging equipment. This review is an
attempt to unravel some of the complexities of modern
digital imaging.
Digital image acquisition can take place using nu-
merous methods, from digitisation of conventional ra-
diographs through to direct digital image acquisition.

Table 1 Comparison of the basic performance characteristics of modern X-ray image acquisition systems
Pixel sampling Field coverage
resolution (mm)
Screen-film radiog- < 100 equivalent Up to 35 ” 43 cm
raphy (400 speed)
Computed radiog- 150±200 Up to 35 ” 43 cm
raphy (PPCR)
Digital fluorography 400 to 150 de- 35/25/15 cm
(single/serial pending on diameter circu-
exposures) field size lar field
Selenium digital thorax 200 43 ” 49 cm
radiography
Flat-panel detector 143 43 ” 43 cm
(CsI:TIlayer+TFT
readout)
This review concentrates on currently available acqui-
sition systems as well as examining new and emerging
technology. Image processing and display techniques
are also briefly discussed.
Assessing image quality
Before reviewing the technologies used in digital X-ray
image acquisition, it is useful to introduce the key ter-
minology used to objectively describe image quality.
Concepts discussed herein include matrix spatial reso-
lution, grey-scale bit resolution, signal-to-noise ratio
and detective quantum efficiency. An understanding of
these basic parameters is crucial in making a scientific
assessment of a digital X-ray imaging system's perfor-
mance.
A digital image is constructed from discrete picture
elements (or pixels) laid out as a regular two-dimen-
sional matrix array. The number of pixels describing a
digital image is the matrix size. In general, the greater
the number of pixels for a given field of view, the greater
the maximum achievable spatial resolution of the im-
age. The typical pixel sizes and field coverage of a range
of modern digital radiography systems are listed in Ta-
ble 1. However, assessing the spatial resolution of an
imaging system purely in terms of ªpixel sizeº or ªma-
trix sizeº is simplistic and can be misleading. For in-
stance, in a photostimulable phosphor-based computed
radiography system (PPCR), spatial resolution is also
affected by optical scatter processes within the image
plate during image readout. In this case doubling the
sampling resolution, i.e. increasing the number of pixels
by a factor of four, would not improve the spatial reso-
lution of the displayed images to the same degree.
Another factor that affects image clarity in digital X-
ray imaging system is grey-scale bit resolution. It is the
distribution of different grey-scale values on a display
2617
Detective quan- Grey-scale dynamic Image processing
tum efficiency, range (exposure and display time
DQE(0) (%) latitude)
20 < 100:1 ~2 min
20 12 bits±4000:1 ~3 min
40 10 bits±1000:1 < 0.2 s
50 14 bits±16,000:1 ~20 s
70 14 bits±16,000:1 < 10 s
that actually represents the visible image. The number
of shades of grey is expressed in binary digits (or bits) of
information per pixel. We consequently talk in terms of
bit depth or grey-scale resolution of the image, where
each pixel is allocated a discrete (digital) grey-scale in-
tensity value. The greater the number of grey-scale lev-
els, the better the contrast resolution of the digital im-
age. One-bit grey-scale resolution would represent a bi-
nary image providing only a choice of ªblackº or
ªwhiteº at each pixel. In an 8-bit system each pixel can
have 28 (i.e. 256) grey-scale values. A 10-bit imaging
system, such as a digital fluorography unit, would typi-
cally use 210 or 1024 levels of grey. Modern PPCR sys-
tems acquire data with 12 bits per pixel, i.e. 212 or 4096
levels of grey. The latest designs of solid-state digital X-
ray image detector typically utilise 14-bit (or 16,000)
levels of grey, although this may increase with future
products. These characteristics are compared in Table 1.
Rather than simply consider the number and size of
the pixels produced by an imaging system, it is better to
describe the spatial resolution properties with the aid of
the modulation transfer function (MTF). The MTF de-
scribes the ability of an imaging system to reproduce
(sinusoidal) image signals over a range of spatial fre-
quencies. At a given spatial frequency, the value of the
MTF will lie between zero and one. An MTF of zero
represents no signal modulation being reproduced, and
an MTF of one representing perfect transfer of the sig-
nal. Typically, a system's ability to represent a signal
decreases as the spatial frequency of the signal increas-
es. The MTF can be applied to both analogue (e.g. film
based) and digital X-ray imaging systems. Typical MTFs
produced by a range of digital radiographic image de-
tector systems are presented in Fig. 1. Using MTF as a
measure of image quality is limited because it only con-
siders the reproduction of signal information, and takes
no account of the other major influence on image qual-
ity ªnoise in the imageº.
2618
Fig. 1 Typical modulation transfer functions (MTFs) of digital ra-
diography technologies
Fig. 2 Typical detective quantum efficiency (DQE) spectra of
digital radiography technologies
ªImage noiseº, or random variation in the recorded
image, is an inevitable consequence of the finite fluency
of X-ray photons in radiographic imaging. Noise mani-
fests itself as a random pattern (i.e. a graininess or mot-
tle) which is superimposed upon the image and de-
grades signal reproduction. The fundamental source of
noise in digital radiography arises from the statistical
fluctuations in the number of X-ray photons detected
per pixel: this noise process is known as ªX-ray quantum
mottleº. The magnitude of the noise in an image in-
creases as the radiation dose incident upon the image
receptor decreases. Image noise both reduces the aes-
thetic quality of images and also adversely affects the
radiologists' ability to perceive subtle, low-contrast sig-
nal details. Noise in an image can be ameliorated by in-
creasing dose to the receptor but at a cost of increasing
dose to the patient. This linkage between the visibility of
signals and magnitude of image noise leads to use of the
combined concept of signal-to-noise ratio (SNR) as a
more complete descriptor of image quality in radio-
graphic imaging.
The SNR is closely related to the concept of detail
information in the image. The efficiency with which
SNR or detail information is transferred through the
imaging system, from incident X-ray beam to displayed
image, provides a powerful measure of imaging system
performance. This measure, which gives an objective
indication of a system's ability to exploit the informa-
tion in the X-ray beam, is known as the detective quan-
tum efficiency (DQE) and is defined as follows:
DQE = [SNRout]2/[SNRin]2
An ideal imaging system would provide a perfect re-
production of the image information and as a result has
a DQE of one. Such a system would produce an output
SNR (i.e. in the displayed image) exactly equivalent to
the input SNR of the incident X-ray image field. Real
imaging systems always degrade the input SNR due to
addition of extraneous noise and contrast loss processes.
For example, in a digital fluorography system the video
camera system used to record the image introduces ad-
ditional electronic noise to the imaging process. As a
result, image quality is further degraded and the imag-
ing system exhibits a DQE of a value less than unity.
The DQE is often quoted as a percentage value: a sys-
tem with a DQE of 100 % is a perfect imaging system,
but real imaging systems exhibit values of DQE less
than this. Typical DQE values for a range of different
designs of digital X-ray image detector are listed in Ta-
ble 1. It is noteworthy that DQE can also be generalised
to take account of the information transfer distributed
with respect to spatial frequency. This is the so-called
DQE spectrum or DQE(f). DQE(f) measures system
performance over a range of spatial frequencies, effec-
tively incorporating the MTF plus the spatial frequency
characteristics of the various noise sources within the
analysis. Typical DQE spectra produced by different
digital radiographic image detectors are presented in
Fig. 2. For reference the DQE spectrum of a medium
(400 speed) screen-film radiography combination is also
included. Clearly screen film and PPCR exhibit com-
paratively modest DQE and hence image quality and
dose efficiency. The DQE spectrum of the new genera-
tion of flat-panel digital radiography system has excep-
tional DQE spectrum which will represent a major im-
provement in image quality and/or dose efficiency
compared with established technologies.
The DQE allows us to objectively compare the per-
formance of real X-ray imaging systems. The technique
has been applied successfully to both analogue and dig-
ital X-ray imaging devices. One of the major advantages
of DQE is that it enables image quality and dose effi-
ciency to be measured on an absolute basis. This makes
it possible to compare with confidence the performance
of X-ray imaging systems of completely different design.
It is noteworthy that DQE is now a practical tool for
evaluating X-ray image quality not only in the labora-
tory but also increasingly of systems operating in clinical

departments. [SNRin]2 can be estimated from the image
receptor entrance dose and knowledge of the radio-
graphic factors used. With digital radiography systems
[SNRout]2 can be calculated using digital test image data
derived by the device itself. To date, DQE has only been
applied to the acquisition phase of X-ray image pro-
duction. Currently, the concept does not encompass
digital image processing, or the manner in which the
image is presented to the radiologist. Research is re-
quired in the next few years to bridge this gap.
Acquisition systems
The various digital X-ray imaging devices can be cat-
egorised into several main groups: (a)´digitisers of
conventional radiographs; (b) image-intensifier-based
digital fluorography; (c) photo-stimulable phosphor
computed radiography (PPCR); (d) amorphous sele-
nium (a-Se)-based technology; and (e) flat-panel de-
tectors.
Digitisation of conventional radiographs
The first method of digital image acquisition we con-
sider is the digitisation of conventional radiographs.
Film digitisers are becoming increasingly common in
radiology departments. They have two main roles, in
teleradiology applications and in Picture Archiving and
Communications Systems (PACS).
Teleradiology enables radiographic images to be
transmitted to different geographical locations over a
telecommunications system. The potential benefits are
well described and include smaller institutions having
easy and rapid access to a specialist second opinion
from a centre of excellence, or the transmission of im-
ages to a radiologist's home for out-of-hours interpre-
tation [1].
Teleradiology requires the images to be in a digital
format before transmission. This can be achieved by di-
rect connection to digital radiographic equipment or by
digitisation of conventional hard-copy film. Even when
digital acquisition systems already exist in a department,
a film digitiser may still be useful as a result of in-
termanufacturer incompatibility [1]. In filmless depart-
ments with a PACS system, digitisation is necessary for
certain old films or for the archiving of hard-copy films
produced at other institutions.
High-quality digitisation of plain films is provided by
laser digitisers. They work by shining a high-resolution,
focused laser beam through the film, recording changes
in optical density by the transmission of the laser light.
A photodiode converts the transmitted light to an elec-
trical signal. This signal is then changed into digital form
using an analogue to digital converter.
2619
Digitisers using charge couple devices (CCDs) are
also available. These digitisers work by illuminating the
radiograph with conventional (polychromatic) light.
The transmitted light is detected by a linear array of
CCDs. They are based on silicon-chip solid-state tech-
nology. They comprise an array of photosensitive ele-
ments which store charge in direct proportion to the
quantity of incident light and then transfer that charge
to a readout point. The CCDs have shown themselves to
be highly reliable and sensitive light detectors and fur-
ther roles in medical imaging are discussed later.
Laser digitisers have several advantages over their
CCD-based counterparts. They have a much wider dy-
namic range and thus can operate over a much larger
range of film optical densities. Optical density is a mea-
sure of the blackness of a radiograph and is related to
the ratio of the intensity of light incident on a film to
that transmitted through a film. The higher the density
the blacker the film. Laser digitisers have a density
range extending above 3.0, and thus have improved im-
age reproduction at these high levels of optical density
[2].
The optical density range achievable is partly deter-
mined by the SNR of the digitiser. Laser digitisers have
superior SNR characteristics, particularly when optical
density is high [2]. They also tend to have a higher res-
olution and increased grey-scale bit depth [3].
The main advantage of the CCD digitiser is that is
typically less expensive. The digitisation process is also
quicker, with a CCD digitiser able to digitise approxi-
mately 130 films per hour compared with 100 films per
hour for a laser system [3].
Recently, the United Kingdom Royal College of Ra-
diologists produced guidelines for teleradiology and
PACS which include guidance notes on the performance
of film digitisers. These state that the digitiser should be
capable of resolving 3±5 line pairs per millimetre and
should achieve an optical density of at least 4.0 [4].
The laser digitiser remains the instrument of choice
for the digitisation of films; however, CCD devices are
approaching their laser counterparts in quality.
The problem with digitisation of conventional radio-
graphs is that there is the potential for image degrada-
tion in the digitisation process. Several studies have
compared digitised images with standard screen film
radiographs in the diagnosis of fractures in adults and
children [5, 6, 7, 8]. These studies have suggested that
the performance of digital systems employing a film
digitiser, network and workstation is inferior to the
original films in the evaluation of subtle orthopaedic
fractures. Of course, we must remember that the film
digitiser is only one component in this imaging chain.
Work station specifications and, probably most impor-
tantly, lack of user familiarity with soft-copy reporting
all play an important role in the overall performance of
an imaging system.
2620
Image-intensifier-based digital fluorography
Probably the most common type of digital radiography
system available is digital fluorography, used in most
departments for contrast-medium-based radiology from
basic barium studies to complex vascular work. These
systems have become widely accepted, with digital sub-
traction angiography showing the advantages obtain-
able with computer image processing.
The basic principle of the image intensifier is to ab-
sorb incident X-ray photons and produce a quantity of
light at the output window which is proportional to the
number of incident photons. The first image-intensifier
systems used a series of mirrors and lenses to enlarge
the intensified image to a viewable size. In current sys-
tems the real-time images are captured using a video
camera system optically coupled to the output screen of
the image intensifier [9].
The video camera produces an electronic video sig-
nal from the incident light. The size of the signal should
be directly proportional to the number of X-ray photons
which exit the patient. An analogue-to-digital converter
transforms the output from the video camera into digital
form.
The properties of the video camera depends on the
type of optical sensor it contains. The Vidicon camera
used in some systems employs a light-sensitive target
made of antimony trisulphide (Sb2S3). Plumbicon cam-
eras utilise a lead oxide (PbO) target and Saticon cam-
eras employ a composite of amorphous selenium, ar-
senic and tellurium. These latter systems have a more
linear response to light intensity. Plumbicon cameras
have a very low lag time [10]. This makes them more
suitable for applications such as cardiac angiography
where a good temporal response is important.
In recent years, the main method of trying to im-
prove image quality in digital fluorography involves re-
placing the video camera with a digital detector, such as
a CCD array. Many domestic ªcamcordersº now use
CCD image sensors instead of video camera tubes.
Commercial fluorography systems that employ this
technology are now available for use in cardiac and
vascular work, and are also employed in mobile C-arm
intensifier systems.
Currently, image-intensifier-based fluorography is
the only commercially available X-ray procedure that
enables real-time visualisation and intervention. Solid-
state X-ray image detectors offer great potential for
improving fluorography and are likely to supersede im-
age-intensifier technology in the next few years. Some
of these developments are discussed later.
Photo-stimulable phosphor computed radiography
The most successful digital radiography detector to date
is photo-stimulable phosphor (PPCR), which has gained
wide acceptance since it first appeared as a commercial
product back in 1981 [11]. Photo-stimulable phosphor
computed radiography is used for conventional plain-
film work, a storage phosphor coated imaging plate re-
placing the traditional film/screen combination. Placing
the imaging plate in a cassette enables its use in con-
ventional X-ray rooms without modification. The stor-
age phosphor material used is normally barium fluor-
ohalide with a europium activator. The cassette is ex-
posed in the usual way, and the phosphor stores the
pattern of absorbed X-ray energy as a latent image;
hence, the term ªstorage phosphorº. When X-ray pho-
tons interact with the barium fluorohalide crystals,
electrons are released, becoming trapped in storage
sites within the crystal structure. These electron traps
store the bulk of the excited electrons. Some of these
interactions result in instantaneous light emission by
fluorescence as occurs in conventional intensifying
screens.
The exposed cassette is placed into a PPCR reader,
where the imaging plate is removed and scanned by
high-resolution light from a solid-state (red-emitting)
laser. Exposure to the laser beam stimulates release of
trapped electrons. This triggers the emission of shorter
wavelength blue light with a brightness proportional to
the absorbed X-ray photon energy. This readout process
is termed photostimulated luminescence. A photodiode
system monitors the luminescence and generates an
electrical signal that is amplified and digitised. The dig-
ital signal is used to construct a grey-scale image which
is computer processed and displayed on a monitor or
printed as hard copy.
When the imaging plate has been scanned, any re-
sidual latent image is erased by exposure to a high-in-
tensity tungsten light. The imaging plate is then loaded
back into the cassette ready for reuse.
Photo-stimulable phosphor computed radiography
has many advantages in clinical practice. The film-char-
acteristic curve gives conventional film a non-linear re-
sponse to X-ray exposure and limited exposure latitude
(typically 50:1). On the other hand, in PPCR the re-
sponse is linear over a wide range of X-ray exposures.
This effect is particularly useful in areas of the body that
have a large range of subject contrasts and thicknesses.
In examinations of cervical, thoracic and lumbar spine
examinations, and lateral hip views, PPCR has resulted
in improved visualisation of these difficult areas and a
decrease in the number of repeat radiographs [12].
In the past, questions have been raised about the di-
agnostic accuracy of PPCR in view of its decreased spa-
tial resolution compared with traditional screen film
combinations. Photo-stimulable phosphor computed

radiography offers a spatial resolution of 2.5 to 5 line
pairs per millimetre (lpm) as opposed to 10±15 lpm for
screen film combinations [13]. As mentioned previously,
such a comparison is simplistic with contrast resolution
and noise playing an equally important role when com-
paring image quality. The subtle musculoskeletal ab-
normalities seen in the hand provide a useful test of the
ability of PPCR to detect high-frequency, high-detail
information. Several studies have shown no diagnostic
difference between PPCR and film-screen technology in
assessing fine detail abnormalities in the hand [14, 15].
Swee et al. [16] judged computed radiographs of the
hand to be slightly better than conventional radio-
graphs. The typical DQE value of a PPCR system is
approximately 20 %, which is similar to inferring similar
diagnostic performance to conventional screen-film
combinations (Table 1) [17].
Another area that has traditionally utilised the high-
resolution capabilities of the screen-film combination is
mammography. Improvements in PPCR imaging plate
technology has resulted in considerable improvement in
clinical image quality particularly in mammography
[18]. Photo-stimulable phosphor computed radiography
offers superior definition of the skin edge, subcutaneous
tissues and dense breast parenchyma, without compro-
mising the ability to detect microcalcifications, and uses
a radiation dose similar to that of conventional tech-
niques [19].
Reduction in radiation dose has been considered an
important benefit of PPCR; however, as the dose is re-
duced, X-ray quantum noise (image graininess) in-
creases. This increased image noise results in image
degradation. There is inconsistency in the literature re-
garding the potential dose savings with PPCR, with a
dose reduction of 50 % in radiography of the peripheries
having been reported without loss of diagnostic accura-
cy [12]. In contrast, Bragg et al. [20] reported a consid-
erable increase in entrance exposures with PPCR when
compared with standard film-screen techniques. This
was particularly noticeable for thicker body parts. They
also reported an initial increase in the number of repeat
examinations after installation of their PPCR equip-
ment. Dose reduction is most important in paediatric
practice. A study of numerous paediatric examinations
(abdomen, chest, pelvis and skull) has shown dose re-
ductions of 33 % for chest radiographs and 60 % for
other examinations while maintaining satisfactory im-
age quality [21]. In our experience, in a large teaching
hospital utilising both PPCR and conventional radiog-
raphy, the dose reduction potential per exposure with
PPCR is overstated, although the reduction of total pa-
tient dose by reducing the number of repeat exposures is
well established.
Photo-stimulable phosphor computed radiography
maintains the flexibility provided by conventional film/
screen cassettes for portable radiography in either the
2621
accident and emergency department or in an intensive
care setting. One of the major disadvantages of the sys-
tem is that it remains labour intensive with time spent
handling, transporting and loading cassettes into the
reader.
The financial costs of PPCR are higher compared
with screen-film radiography. Equipment purchase is
more expensive: the imaging plates and cassettes cost
twice as much as conventional film-screen cassettes and
have a shorter life span [20]. The increased cost of laser
film compared with conventional film adds to the oper-
ating costs, as does the higher maintenance and service
costs; however, if film is eliminated by soft-copy report-
ing or images printed on smaller-sized film, then savings
are possible [22]. Further economic savings are also
produced as a result of the significant reduction in reject
film rates achievable in digital departments [23].
There is objective evidence that PPCR systems are
more prone to scatter than conventional radiographs
[24]. This area is poorly covered in the literature. Scatter
increases with patient thickness, field size and kilovolt-
age of the incident X-rays. The assumption that PPCR
provides a direct replacement for conventional film/
screen techniques without revising radiographic prac-
tice is misplaced.
Another major disadvantage of PPCR is the use of
multiple conversion processes in the formation of the
digital image. X-ray energy is converted into light ener-
gy, which is then converted into electrical energy, which
is then finally digitised. Such multiple conversions are
best avoided, as each conversion results in ªconversion
lossesº, potentially producing increased image noise
and unsharpness [25]. In this respect, PPCR is little dif-
ferent to conventional screen-film radiography. Many
manufacturers are now looking at technology employ-
ing amorphous selenium (a-Se), which avoids these
conversion losses, and thus is described as being more
ªdirectº.
Amorphous selenium technology
Amorphous selenium is a photoconductor in which the
energy of the X-ray photon is converted directly into
electrical charge. The distribution of electrical charge is
directly related to the pattern of X-ray intensities.
An imaging device in clinical use which uses this
technology is the Philips Thoravision digital chest radi-
ography system (Philips Medical Systems, Hamburg,
Germany) [25, 26, 27]. The system was launched com-
mercially in 1993 and a unit was installed in our depart-
ment in 1995.
In the Thoravision system, a 0.5-mm-thick layer of
amorphous selenium is deposited onto a 50-cm-diame-
ter aluminium cylinder. The drum is housed in a detec-
tor unit which also contains a charging and image read-
2622
a PPCR (Table 1). Figure 3 shows a patient imaged with
b
Fig. 3 a, b Chest radiographs of a patient with sternotomy wires
and coronary artery bypass clips. a Performed on a phosphor-based
computed radiography (PPCR) system system. b Performed on the
Thoravision system
out system. Prior to an exposure, the drum is rotating
slowly (60 rpm) allowing a uniform positive charge to be
built up on the surface of the selenium by the charging
system. The patient is then positioned and exposed in
the usual way. When an exposure is made, the drum
stops rotating and where the X-ray photons strike the
selenium, electrons are freed and travel to the surface of
the detector. This leads to a partial discharge of the
uniform surface charge pattern. The degree of discharge
varies with the local radiation exposure leading to a la-
tent radiographic image in the form of a charge pattern
distribution.
Immediately after exposure, the drum is rapidly ro-
tated (300 rpm) and the charge pattern is read out by 36
electrometer probes which form the main part of the
image readout system. The resulting electrical signal is
then amplified, sampled, digitised and transferred to the
image processing computer. The selenium layer is re-
charged so the process can begin again. A complete
chest X-ray image is read out in 15 s and a further ex-
posure can be made within 20 s.
The basic specification of a Thoravision image is 14
bits of grey-scale information per pixel, with
2166 ” 2448 pixels per image. Great efficiency in the
detection of X-ray photons, coupled with the low noise
of the system, results in a DQE measurement of 50 %
[25, 28]. Performance characteristics are reviewed in
Table 1.
The thorax has a wide range of tissue densities, which
makes it difficult to obtain an optimal image of both
lung and mediastinum on the same radiograph. This se-
lenium-based system has a wider exposure latitude than
both the PPCR system and the Thoravision system.
Several studies have shown improved detection of
lung lesions and normal anatomy with selenium-based
digital chest radiography compared with conventional
screen-film chest radiography [29, 30]. Improvements in
detection of low-contrast microlesions and fine linear
lung lesions have even been seen when the system is
compared with PPCR [31].
The selenium-based system, like other digital sys-
tems, benefits from the increased capability of image
transfer, display and image storage. Like other digital
systems it suffers from high initial financial costs for
equipment purchase and higher operating costs [32].
The imaging characteristics of amorphous selenium
are leading to the development of other designs of direct
digital radiography systems based on this technology.
Flat-panel detectors
Much development work is currently focusing on the
development of flat-panel, direct X-ray imaging detec-
tors [10, 25]. The potential benefits are high image
quality, coupled with real-time readout, potential dose
savings and compact size. Such detectors are capable
of performing digital plain-film radiography, serial
(pulsed) acquisition and fluoroscopy, crossing the
boundaries that traditionally exist with different equip-
ment required for each activity. The detectors will be
compact providing better access to patients compared
with existing fluorography units, and being flat, they do
not suffer the problems of geometric distortion encoun-
tered by image-intensifier-based imaging systems. It
may well be that existing X-ray equipment could be
easily adapted to employ these new detectors. There can
be little doubt that the multifunctional potential of flat-
panel detectors will impact on departmental design and
practice.

Fig. 4 Construction of the flat-panel detector installed at the
General Infirmary at Leeds. (Courtesy of Philips, Best, The Neth-
erlands)
Flat-panel detectors consist of an X-ray-sensitive
layer superimposed on a readout array (as depicted in
Fig. 4). The X-ray-sensitive layer may be an X-ray pho-
toconductor such as amorphous selenium or a scintilla-
tor-like caesium iodide doped with thallium (CsI:Tl), a
material similar to that in many image intensifiers. The
readout structure for a flat-panel system employs a large
area, two-dimensional active matrix array. Similar tech-
nology has been used in liquid crystal displays (LCDs)
for over a decade. The active matrix is a large area-in-
tegrated circuit consisting of a large number of thin film
transistors (TFTs), made of amorphous silicon. The
amorphous structure of this form of silicon as opposed
to the more familiar crystalline form allows the devel-
opment of large area (lifesize) X-ray detectors.
Flat-panel systems using amorphous selenium have
been described [33]. A layer of amorphous selenium
(500-mm thick) is deposited onto the surface of the ac-
tive matrix. When X-rays interact with amorphous sele-
nium, electrons are released and positively charged
ªholesº created. These are guided to the surface of the
photoconductor by an applied electric field. The latent
charge image is collected via the TFTs. The resultant
signal is then amplified and digitised. Early work using a
prototype selenium-based flat-panel detector has sug-
gested that the visibility of fine boney detail in the hands
and feet is superior or at least equivalent to traditional
screen-film combinations [34].
Flat-panel detector systems using CsI:Tl as the X-ray
sensitive layer have been developed. Light photons
produced by the scintillator are channelled to a light-
sensitive element coupled to the TFT array. The readout
process is identical to that described previously. Systems
developed for skeletal radiography typically have a pix-
2623
el size of 143 m and a high DQE of more than 60 %. A
diagnostic performance at least equivalent to conven-
tional screen-film radiographs, coupled with significant
dose reduction potential has been reported [35, 36, 37].
A similar detector has also been developed specifically
for digital mammography (GE Medical Systems, Mil-
waukee, Wis.). This system has a contrast resolution of
14 bits with a pixel size of 100 m. Clinical trails are cur-
rently under way [38, 39].
Our department currently has a cooperative research
and development program with Philips Medical Systems
in the scientific evaluation of a flat-panel detector sys-
tem capable of both snapshot exposure and dynamic
image acquisition [40]. This detector (Fig. 4) comprises
a 550-mm layer of CsI:Tl superimposed on a matrix array
composed of photodiode and TFT elements. Measure-
ments of detector efficiency are very encouraging: the
DQE of the system approaches 70 % under most imag-
ing conditions. This compares very favourably with
computed radiography systems at 20 % and Thoravision
digital chest system at 50 %. This enables potential dose
reductions by factors approaching three without loss of
image quality compared with PPCR. The image-acqui-
sition process of the system allows real-time imaging at
videofluoroscopy resolutions (25 frames/s). Early clini-
cal experiences in both the radiographic and fluoro-
scopic modes are encouraging (Figs. 5, 6).
Image processing and display
One of the main advantages of digital imaging is the
separation of each of the components of the imaging
chain. Manipulation of the digital data is possible at
various stages between acquisition and final display.
These manipulations contribute critically to overall im-
aging performance of the system, and can significantly
influence the diagnostic quality of the output. It is en-
tirely feasible that the advantages of an advanced de-
tector are lost by sub-optimal image processing and dis-
play. Such degradation could lead to misdiagnosis, or
perhaps increased radiation dose to the patient, in order
to compensate. With over 50 % of all errors in diagnos-
tic radiology being attributable to the observer's visual
perception of the image [41], the manner in which the
data is manipulated and presented to the viewer is of
substantial importance and is in no way a merely cos-
metic process. It should be remembered that the eye has
only limited scope in terms of grey-scale appreciation,
recognising only approximately 32 distinct grey levels,
equivalent to five bits of grey-scale depth [42]. Data of a
bit depth in excess of this must be presented appropri-
ately to allow extraction of the relevant diagnostic in-
formation by a human observer.
Image processing has to condition the data according
to the type of display available, whether for monitors for
2624

Fig. 5 Radiographs of a hand

showing an aneurysmal bone
cyst in the metacarpal head of
the index finger, performed on
a a PPCR system and b a flat-
panel detector system

a b

Fig. 6 Selected view from a

knee arthrogram examination
acquired on a a digital fluorog-
raphy system and b a flat-panel
detector system

a b

soft-copy reporting or more traditional hard-copy film.
This can be complicated in a large radiology department,
where several different monitors of different technical
specification are used. Monitor display resolution de-
pends on the number of pixels present in the viewable
area of the monitor; 1000 ” 1000 and 2000 ” 2000 are
termed 1K2 and 2K2, respectively. Presenting 2K2 data
on a 1K2 display introduces a random variation (noise)
into the image data as a result of sampling errors. This
can be avoided if the data is correctly filtered prior to
decimation down to 1K2 before presentation.
A simple understanding or, more importantly, an ap-
preciation of the potential impact of these processes is
required when assessing and utilising digital X-ray im-
aging technologies.
Conclusion
This review outlines in broad terms the pros and cons of
different image detectors for digital radiography, un-
derlining the importance of image processing and dis-

play. Certain systems are already commercially avail-
able, whereas many others are still under development.
The next few years will see further breakthroughs and
change in this rapidly advancing field. These new image
acquisition systems will significantly reshape clinical ra-
diology.
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