Radiology Quality

Control

IAEA Medical Radiation Protection - Radiology QC 1

 Scope
• What is radiology QC?
• What is needed?
• What should be tested?
• Common problems
• QC test methods
• Interpretation and recording of results

IAEA Medical Radiation Protection - Radiology QC 2

• Lee R75 (very early hand x-ray), R40 (1897
x-ray apparatus)

IAEA Medical Radiation Protection - Radiology QC 3

 The Goal of QC

To obtain the best possible image quality

for diagnosis, at the lowest reasonable
radiation dose to the patient

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 Extent of QC Tests
• Anything which affects :

– image quality
– dose to patient and staff
– safety of patient and staff
– comfort of patient

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 Extent of QC Tests
• Therefore, QC tests could include
– x-ray equipment parameters (eg. kVp, time)
– radiation dose
– mechanical features (eg. gantry, cables)
– image receptor parameters (film, screen, II,
processing)
– systems (eg. film repeat analysis)
– specification and acceptance testing

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 Why Do We Have Acceptance
Testing
• We must be sure that the equipment does
what we want it to do
• When it is delivered, we must be sure that it
performs to specification
• We should not pay the supplier until it does!!

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 Part 1 : X-Ray Parameters
• Minimum testing :
– X-ray beam/light beam alignment
– kVp accuracy and reproducibility
– Timer accuracy and reproducibility
– Beam HVL
– Output linearity (mR/mAs)
– tube leakage
– (focus size)

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 What Minimum Equipment is
Needed?
• Device(s) to measure kVp, time, dose
• Beam alignment tool
• Resolution gauge
• (Focal spot tool)
• High purity aluminium
• Good protocols

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Multi-Function Meter - NERO 4000

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Ion Chamber Dosemeter

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 Light Field/X-Ray Field
Alignment
• Method:
– place loaded cassette on table at 100 cm FFD
(focus-film distance)
– set up light beam for ~ 20 x 20 cm field
– place metal markers (eg. coins) at each field edge
plus one at anode end, and one at top of field - use a
test device if you have one
– take exposure of ~5 mAs at 70 kVp
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Light Field/X-Ray Field
Alignment

Coins
Anode marker

Orientation marker
Light field

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 Alternative Method
• Place two coins at each edge - touching at the
light field edge
• Make a slightly lower exposure, then open the
light beam to include both coins, and take
another exposure, about half the mAs of the first
• This makes the coins visible even if the x-ray
field is very badly aligned

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Alternative Method - Light Field Set for Second Exposure

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 Light Field/X-Ray Field
Alignment
• Analysis :
– Develop the film
– check that you can see each coin
– measure the distance between the coin and the x-
ray beam edge

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 Light Field/X-Ray Field
Alignment
Alignment error Coin shadows

X-ray Field

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Exposed Film - Alternative Method

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 kVp Accuracy
• Before making measurements, you must
understand what “kVp” means
• There are 3 definitions of kVp, only one is
commonly used
• CAUTION : some mobile x-ray units use a
capacitor, and the kVp decreases during the
exposure
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 kVp Definitions

kVp max kVp eff

kVp av.

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 kVp Accuracy
Method :
– set meter at about 70 cm from focus
– set ~ 20 mAs
– measure kVp from about 60 - 120 kVp (eg. 60, 70,
80 100, 120)
– calculate error between set and measured value

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 kVp Accuracy
Analysis :
– kVp should be +- 5% of set value

Frequency :
– acceptance
– tube change, generator maintenance
– annual

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 kVp Reproducibility
• This checks that the kVp will stay the same
from exposure to exposure

Method :
– same setup, but at 70 kVp only
– perform 5 exposures (be careful of tube!)

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 kVp Reproducibility
Analysis :
– calculate coefficient of variation (CV)
– CV = (standard deviation/mean) of the 5 readings
– CV must be less than 2%

Frequency :
– as for accuracy

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 kVp Reproducibility
Further test :
– older x-ray units may have a mechanical selector
for kVp
– test this by moving the kVp dial up, down, then
back to 70 before each exposure
– a variation of +- 3 kVp is permitted

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 Timer Accuracy
Method :
• Approx. 70 kVp, 200 mA
• Measure time at all commonly used time
settings
• Calculate error between set and actual time

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 Timer Accuracy
• Time is normall measured from when the x-
ray output reaches 75 % of the maximum, to
when it falls below 75 %
• This can cause problems when the x-ray
exposure has a slow rise and fall time

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 Timer Accuracy

X-Ray Output

75 % of max.

Measured exposure time Time

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 Timer Accuracy
Analysis :
• Actual time should be within +-5% of set time,
OR +- 1 pulse (single phase, short exposures)

Frequency :
• acceptance, timer maintenance, annual

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 Linearity
• An important test - checks that the radiation
output per mAs remains constant as the mA is
varied
• Checks so-called kVp and mA
“compensation”, where the extra loads on a
HV generator at high mA are compensated
for

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 Linearity
Method :
• Use an ion chamber or solid state detector at ~ 75 cm
from the tube focus
• Place some lead vinyl under the detector to
standardise backscatter
• Use fixed 70 kVp and exposure time (~ 100 ms)
• Measure dose at all mA settings in use (useful to also
measure kVp)

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 Linearity
Analysis :
• For each exposue, calculate the mAs, then the
radiation dose / mAs (this ideally should be
constant)
• Find the maximum and minimum values of
dose/mAs

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 Linearity
• Calculate (max-min)/(max+min)
• Should be < 0.1
• If > 0.1, then check the kVp - high values of
dose/mAs might be associated with high kVp
• If the tube has large and small focus settings,
measure linearity for each separately

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 Half Value Layer (HVL)
• Possibly the most important test
• Checks whether there is sufficient filtration in the
x-ray beam to remove damaging low energy
radiation
• Need not only a radiation detector, but also high
purity (1100 grade) aluminium - most Al has high
levels of high atomic number impurities eg. Cu

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 Half Value Layer (HVL)
• Method (simplest - using a multifunction test
meter) :
• Place the detector at ~ 75 cm from the focus, on
some lead or lead vinyl (to standardise backscatter)
• Set 80 kVp, fixed mAs (eg, 50 mAs)
• Collimate x-ray beam to size of detector
• Measure exposure three times

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 HVL Measurement Geometry
X-Ray Tube

Collimator

Aluminium Sheets

X-Ray Beam ~ 75 cm

Detector

Lead

Table
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 Half Value Layer (HVL)
• Add 1 mm aluminium to beam (at collimator
is best), and measure the dose
• Add another 1 mm Al, measure again, and
repeat until the dose has fallen to below 50%
of the initial, unattenuated, value
• Remove all Al, and take 3 more exposures

IAEA Medical Radiation Protection - Radiology QC 37

 Half Value Layer (HVL)
Analysis :
• Average all the “no Al” measurements
• Plot all results on semilog graph paper
• From the graph, find the thickness of Al required to
reduce the unattenuated dose by 50% - this is the HVL
• The HVL must be at least the level specified in local
regulations, eg. 2.3 mm Al at 80 kVp

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 HVL Measurement
Dose
• Be careful of beam hardening
10
(semilog plot is not a straight
line)
• Use points either side of half
initial value
• Calculate HVL :
(initial value = 10 1
0 1 2 3 4
50% of this = 4.5,
thus HVL = 2.6 mm Al)
mm Aluminium

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Minimum HVL Values (IEC)

Acceptable

Not acceptable

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 Tube Leakage
Not easy to measure, but easy to detect!
Method :
• Place loaded x-ray cassettes around the tube (be careful to
know where each cassette was placed, and its orientation!)
• Concentrate on the join between tube and collimator, and
where the HV cables enter the tube
• Take a long exposure at maximum kVp (be careful of the
tube!)

IAEA Medical Radiation Protection - Radiology QC 41

 Tube Leakage
Analysis :
• Develop the films
• Look for significant x-ray leakage (remember there
will always be some leakage)
• If a very high level is found (black film), then you
will need to measure the radiation level with a
large volume (~180 cc) ion chamber at that place

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 Focal Spot
• Measurement of focal spot size is not easy :
– pinhole camera
– star pattern
– slit camera
• The most useful indication of focal spot
condition is the actual high contrast
resolution, measured with a line pair gauge
IAEA Medical Radiation Protection - Radiology QC 43
 Focal Spot - Line Pair Gauge
• The line pair gauge is a series of lines etched
in lead - the lines become closer together as
resolution increases
• The measurement is in “line pairs per mm”
• A simple procedure involving a film taken of
the gauge resting on the image receptor or
patient support
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 Resolution - Line Pair Gauges
• Warning - if the line pair gauge is placed on
the surface of a phantom, scatter will degrade
the apparent resolution
• Often however this is the best test - for
example mammography resolution is
measured with the gauge on a 4 cm block of
perspex (lucite, PMMA)

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 Line Pair Gauges
Good Resolution Poor Resolution

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 Fluoroscopy QC
• Fluoroscopy equipment must have normal
tests for kVp, field alignment, and HVL
• Image quality is tested with a “phantom”
• Also need to check maximum and typical
radiation dose rates to the patient

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Fluoroscopy - Image Quality Phantom
• There are many devices available, but they should
be able to measure :
– high contrast resolution
– low contrast resolution
– contrast detectability threshold
– field size and distortion
– TV monitor setup
• One type of phantom is used as an example

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 Westmead Fluoroscopy Phantom
• Incorporates all common
tests (resolution can be
measured with grids, as
shown here, or line pair
gauges as shown later)

• Test time : 10-15 mins

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Fluoroscopy Phantom - Simple
X-Ray

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Fluoroscopy Phantom - Fluoroscopy Image

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 Fluoroscopy Phantom - Image
Quality Evaluation
• Analysis depends on the phantom used
• For the phantom shown here (Westmead Hospital
Phantom), limits are (for 23 cm diameter field) :
– high contrast resolution : at least 2 meshes or 1.2
lp/mm
– low contrast resolution : at least 5 circles
– contrast threshold : at least 10 circles

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 High Contrast Resolution
• angle test object at 45 degrees
to TV raster lines
• count number of mesh sizes
visible
• can also use a line pair gauge
• best results in centre of II field

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 Low Contrast Resolution
• View the small circles
at centre
• Count the number of
circle sizes seen
• At least 5 small circles
are required

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 Threshold Contrast
• View the large circles
around edge
• Count the number
visible
• At least 10 large circles
are required

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 Fluoroscopy - Image Quality
Phantom
TV Monitor setup :
– very important, as a monitor with the brightness
set low can cause a high dose rate to be used
– need to see the circle inside the square at both
high and low contrast
– screen under normal automatic control, and set the
monitor as above

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 TV Monitor Setup
 Adjust brightness &
contrast controls:
- optimise black and white
circles in squares
- full grey scale should be
visible

 Leave TV controls unchanged for remaining tests

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 Fluoroscopy - Maximum Dose
Rate
Purpose :
– to know the maximum dose rate to the patient
Method :
– place ~2mm lead over the image intensifier (II)
– place a dosimeter ~ 30 cm from the II
– operate unit at maximum kVp and mA
– measure dose rate

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Fluoroscopy - Maximum Dose Rate
Analysis :
– maximum dose rate should not exceed 100 mGy/min
for units with automatic brightness control, and 50
mGy/min for manual units
– “boost” mode may go to 150 mGy/min
Frequency :
– acceptance, 6-monthly
– tube change, generator repair

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Fluoroscopy - Typical Dose Rate
Purpose :
– to know the normal dose rate to the patient
Method :
– use 20 cm water equivalent absorber on II face (or 2
mm copper sheet)
– place dosimeter on input (x-ray tube side) of absorber
– measure dose rate under automatic exposure, or manual
at 70 kVp with mA set for good image

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 Fluoroscopy - Typical Dose Rate
Analysis :
– should be < 25 mGy/min
Frequency :
– acceptance, tube change
– generator repair
– II repair
– 6 monthly

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Fluoroscopy - Distortion

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 Film Processor QC
• “ Most 1 hour photo labs. have better
processor QC than X-Ray departments”
• True statement!
• Processor QC very important for good images
• It is a long topic, so only briefly covered here
(see later lecture on manual processing)

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 Film Processor QC
• Most important QC features :
– proper film storage
– cassette and screen care
– processor chemical care
– sensitometry
– artifacts
– processor cleanliness

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Film Processor QC - Film Storage
• Film should be stored in cool, dry conditions -
< 26 degrees, 30-60% relative humidity
• Too low humidity allows static discharge
• Storage period must not be too long
• Stack film boxes vertically to avoid pressure
on films (causes pressure marks)

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Film Processor QC - Cassette and
Screen Care
• Clean screens regularly to avoid dust shadows
and scratches
• Use manufacturer’s recommended cleaning
solutions
• An ultraviolet (“Black Light”) light can show
up dust

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 Film Processor QC - Processor
Chemical Care
• Chemicals (developer and fixer) degrade with time
and use

• Developer in particular will oxidise (go brown) and

cause poor, dirty films

• Fixer will change pH and lose emulsion hardener

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 Film Processor QC - Processor
Chemical Care
• Chemicals must be replaced or replenished
(continual automatic replacement) regularly

• Use manufacturer’s recommendations

• Check the developer temperature daily -

processing is very sensitive to temperature
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 Film Processor QC - Artifacts
• Anything on the film which is not related to
the x-ray image
• Examples :
– dust marks, static discharge
– fixer stains (poor washing)
– film storage problems
– processor problems (roller marks, scratches)

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 Film Processor QC - Artifacts
• Kodak can supply a very good manual on
how to recognise artifacts, and where they
come from
• Mostly you will learn from experience
• Talk to the person who services the processor
- they might be able to help you

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 Film Processor QC - Processor
Cleanliness
• All processor will eventually get dirty

• Strip down and thoroughly clean processor at

least every 6 months

• Daily cleaning of entrance trays

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 QC Summary

• QC is meant to help you take good radiographs

• The best radiographer in the world will still take
bad x-rays if the equipment is not working properly
• More importantly, the patient will get higher and
unnecessary radiation doses, as will the staff
• You will also waste money on x-ray film

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