01/11/1601/11/

16
SUN MON TUE WED THU FRI SAT

01 02 03 545555 05
02 04

06 07 08 09 10 11 12
Click here to -rays are
replace text. produce by
electron
deceleration
13 14 15 16 17 18 19

20 21 22 23 24 25 26

27 28 29 30
SUN MON TUE WED THU FRI SAT

-rays are
produce by
electron
deceleration

-rays are produce by electron deceleration in the electric fields of W nuclei. Characteristic x-rays are produced
when k-shell electrons are ejected by energetic electrons. Spectra show the number of x-ray photons at each
energy, with most photons bremsstrahlung. The average energy is somewhere around half the maximum
energy for most spectra.
Typical voltages are 60 kV (extremities), 80 kV (abdomen) and 120 kV (chest).
2
The number of photons produced is supralinear (e.g., kV ) in radiography.
Tube currents are typically hundreds of mA in radiography/CT, and a few mA in fluoroscopy. Exposure times
are a few ms (chest), 50 ms (abdomen), 500 ms (CT) and “minutes” in fluoro. Total output is the product of
tube current (mA) and exposure time (ms) in mAs.
Chest x-ray uses 120 kV/1 mAs and an abdomen x-ray 80 kV/20 mAs.
Changing mAs (mA and/or s) does not change the average photon energy.

X-ray Interactions

Coherent scatter transfer no energy to atomic electrons, and are < 5% of all x-ray interactions. Photoelectric
interactions totally absorb x-rays by k-shell electrons, and deposit energy locally. Photoelectric interactions are
important at high Z (e.g., I, Ba, Pb) and lower energies.
To maximize photoelectric interactions, photon energy should be just above the k-edge energy. A k-edge filter
transmits photons just below the k-edge energy (e.g., < 20 keV for Mo filter). Compton scatter occurs with
outer shell electrons, and results in (lower energy) scatter photons. Scatter photons can reach the x-ray
detector, and degrade image quality (contrast).

Compton Scatter is proportional to electron density (i.e., physical density in humans). Photoelectric and
Compton interactions both decrease with increasing photon energy.
In tissue, Compton and Photoelectric are equal at 25 keV.
PE dominates at lower energies (< 25 keV), and Compton dominates at higher energies. Attenuation
-1
coefficient (μ cm ) describes exponential attenuation of x-rays.

-1
When μ is 0.1 cm , 10% of x-rays are attenuated in 1 cm, and 9% transmitted.
rd
30 mm tissue (Z = 7.5) attenuates 50% of x-rays, as does 3 mm Al (13) and 0.3 mm Cu (29). 2/3 of x-ray
rd
energy is absorbed by the patient, 1/3 scattered out, and < 1% transmitted.

X-Rays II

Quantity & Quality

 2
X-ray radiation intensity (number of x-rays per mm ) is measured in Air Kerma (Kair) in mGy. Entrance Kair for a
lateral skull is ~ 1 mGy, known as the x-ray beam “Quantity” or amount. Most radiographs have ~ 3 μGy
incident on the image receptor.
Intensity at image is lower due to patient attenuation, grid losses, and inverse square law. Entrance Kair in
Interventional Radiology is generally a few Gy, 1000 times more than an x-ray. X-ray beam “Quality” refers to
the beam penetrating power, and is related to beam energy. Quality is measured by the amount of Al required
to reduce x-ray beam by 50% of initial value. Quality can be increased by increasing tube voltage (energy) or
adding filtration.

Passing x-rays through filters knocks out lower energy photons, increasing average energy. Al and Cu are
common filters used in radiology, and “harden” the x-ray beam (↑energy). Beam qualities are 0.5 mm Al
(Mammo), 3 mm Al (x-ray), and 6 to 9 mm Al (CT).
To get more x-rays (quantity), the mAs is increased (not kV)

To increase patient penetration, kV and/or filtration increases, and then mAs is adjusted. When beam quality
increases, patient doses are reduce for a fixed Kair at image receptor. More penetrating beams require less
radiation into patient (Automatic Exposure Control).

“Physical” Doses

Entrance Kair is 0.1 mGy for chest x-ray, and 10 mGy a lateral lumbar spine x-ray. Entrance Kair rate is 10
mGy/minute in fluoroscopy (average adult).
2 2
Kerma-Area Product (KAP) is the Entrance Kair (mGy) times beam area (cm ) in Gy-cm . KAP (AKA DAP) is ~
2 2 2
1 Gy-cm (radiography), ~ 20 Gy-cm (GI/GU), and 200 Gy-cm (IR). Absorbed Dose is energy absorbed
divided by mass, measured in mGy.

Kair differs from dose because it depends on the absorber characteristics (tissue vs bone). Converting Kair into
Dose is the responsibility of Medical Physicists (tissue type, backscatter). Skin doses are < 10 mGy in
radiography, but > 500 mGy in IR.
Eye lens doses can be ~ 1 mGy in radiography, but should be kept < 500 mGy in IR. Average Glandular
Doses in mammography are 2 mGy/view, or 4 mGy for a screening exam. Organ doses can be used to
estimate cancer risks.

Embryo doses are ~ 1 mGy in radiography, and ~ 30 mGy in CT.

Embryo and fetal doses are used to estimate the likelihood of stochastic/deterministic risks.

“Biological” Doses

X-rays, gamma rays, and beta particles produce a diffuse pattern of energy deposition. Alpha particles and
neutrons produce more concentrated patterns (more damaging).
Alpha particles kill many more cells than x-rays at exactly the same radiation dose (Gy). Equivalent dose
(mSv) is the absorbed dose (mGy) times a radiation weighting factor (wr). Values of wr are always 1 in
radiology, but are as high as 20 for alpha/neutron radiation. Organ absorbed dose (mGy) and equivalent dose
(mSv) are always the same in Radiology. Effective doses (mSv) enable non-uniform doses to be directly inter-
compared (GI vs NM). Effective dose (mSv) take into account organ doses, as well as organ sensitivity.

The effective dose results in the same patient detriment as a given pattern of energy deposition. The most
sensitive organs are the RBM, breast, lung, colon, and stomach.
Very low dose exams have effective doses < 0.1 mSv and low dose exams are 0.1 to 1 mSv. Moderate exams
have effective doses 1 to 10 mSv and High Dose exams are > 10 mSv. Average Americans get 1 mSv/year
(ubiquitous radiation), and ~ 2 mSv/year from Radon. Higher background doses can occur at higher
elevations, and where terrestrial activity is higher.

3
Imaging I

Scatter Removal

Typical Scatter:Primary ratios in abdominal imaging are 5:1

Scatter increases with increasing thickness, beam area, and x-ray tube voltage (kV). Increased scatter
reduces lesion contrast, and must be “reduced” for thicknesses > 12 cm. Anti-scatter grids are used in most
radiographic and fluoroscopy examinations.
Grids use high attenuating strips (Pb or W) that are aligned with the primary x-ray beam.
Grid ratios (Height/Gap) are typically 10:1 for most examinations.
Grid lines are generally not seen because these move (Bucky) during exposures.
Grids must be carefully aligned, and used at the right distance from the focal spot.
Grids typically transmit 70% of primary photons, and 90% of scattered photons.
Increasing the grid ratio will reduce primary transmission, and increase scatter removal.
The Bucky Factor is the ratio of the incident radiation on a grid to that transmitted through grid. Typical Bucky
Factors are 5:1, and imply patient doses increase x 5 when grid used (AEC). Grids are generally not used for
thin body parts, or for extremity radiography.
Bedside radiography generally does not use girds (positioning problems).

Analog Imaging

Film uses thin emulsions containing small silver bromide grains on a plastic support. Film processor passed
an exposed film through a developer, fixer, and washer/drier. Exposed grains are reduced to clumps of sliver
(μm) in the developer.
Non-exposed grains are removed by the fixer.

Exposed regions of film contain a large number of silver specks that absorbs incident light. A characteristic
curve plots film blackening (density) as a function of radiation exposure. Characteristic curves have a toe and
shoulder region where image contrast is very low. The linear part of the characteristic curve has high image
contrast (density ~ 1.5).

Steeper slopes of the linear part of the characteristic curve have higher image contrast.
Films are used with screens (scintillators) that efficiently absorb x-rays and generate light (lots). A screen-film
Kair of 3 μGy is required to produce the “right” film density (1.5).
Latitude is the difference between the highest and lowest Kair values that can be used with film. Dynamic
Range is the ratio of the highest and lowest Kair values that can be used with film. Chest x-rays require wide
latitude screen-film, whereas mammography uses narrow latitudes.

Digital Imaging

Films are analog systems that capture, store, and display the radiographic image.
Digital detectors capture the data from single pixel elements, and stored in computers (0 & 1). Scintillators
absorb x-rays, and light produced is captured by a digital light detector (pixel).
CsI is a digital detector used in image intensifiers and Flat Panel Detectors (indirect).
Se is a photoconductor used in Flat Panel Detectors (Direct) in mammography. Photostimulable Phosphors
(BaFBr) captures x-ray energy that can be released by laser light. Thicker detectors capture more of the
incident x-rays and thereby help reduce patient doses. Thinner detectors minimize the spread of light, and
generally produce sharper images.
PSPs generally have the worst resolution, and photoconductors have the best.
Scintillators generally absorb most x-rays, and result in the lowest patient doses.
Digital detectors have a wider dynamic range (10,000:1) than screen-film (40:1).
A chest x-ray has a 2 k x 2.5 k matrix, and uses 10 bits (2 Byte) to code for each pixel.
A chest x-ray requires 10 MB to store, and a CT image requires 0.5 MB.
Most diagnostic workstations have 3 MegaPixels, and can be checked with an SMPTE pattern. Unsharp Mask
Enhancement is excellent for processing ICU chest x-rays (enhances lines). Dual energy imaging (high & low
kV) can generate tissue and bone images.

Imaging II

Contrast & Noise (CNR)

Subject contrast is difference in x-ray transmission by a lesion relative to background tissue. Image contrast is
the appearance of this subject contrast in an image (black vs white).
Low photon energies result in high contrast, and higher photon energies reduce contrast. Photon energy
affects the contrast of high Z lesion much more than tissue lesion (Z ~ 7.5). Presence of scatter will markedly
reduce the amount of contrast in an image.

Display settings (Window/Level) influence image brightness and contrast.

Increasing Level reduces image brightness, and increasing Window (width) reduces contrast. The number of
photons in an image (Kair) affects the amount of mottle in an image.
An average of 100 x-ray photons per pixel will have a random fluctuation of ± 10%.
Increasing the number of photons to 10,000 reduces the random pixel fluctuations to ± 1%. Radiographs use
X 100 more radiation than fluoroscopy frames, and have 10 times less mottle. X-ray imaging in Radiology is
Quantum Mottle limited requiring more radiation to reduce mottle. Lesion visibility is determined by the
contrast relative to noise level (Contrast to Noise Ratio). CNR can be increased by reducing noise (↑mAs),
increasing contrast (↓kV), or both.
CNR is a relative indicator of lesion visibility as techniques (kV/mAs) are modified.

(Spatial) Resolution

Spatial resolution relates to the ability of seeing two small closely spaced lesions.
Image of a line (Line Spread Function) has width measured as Full Width Half Maximum (mm). Resolution is
also measured using spatial frequencies (line pairs) imaging line pair phantoms. High spatial frequencies
relate to small objects (& edges), whereas low frequencies are “large”. Any image can be considered as being
composed of high and low spatial frequencies.
Low spatial frequencies affect image contrast, and high spatial frequencies provide “detail”. Resolution is
determined by the focal spot, image size, and (any) motion during imaging. Larger focal spots reduce image
sharpness, and increasing magnification increases focal blur. Motion blur is independent of geometric image
magnification (SID/SOD).
In scintillators, the detector thickness affects the amount of blur.
Pixel size is the image dimension divided by the number of pixels.
Pixel size is one determinant of spatial resolution, with larger pixels blurring the image.
Chest x-rays have small pixels (0.175 mm), with a sampling rate of six pixels per mm.
With six pixels per mm, best achievable resolution is 3 line pairs per mm (Nyquist frequency). When objects
contain frequencies > fNyquist, aliasing occurs (high frequencies poorly seen). Technique factors (kV, mAs etc.)
influence CNR, but not spatial resolution performance. Modulation Transfer Function is a scientific way of
representing resolution performance.

Receiver Operating Characteristics (ROC)

True Positives correctly identified is the sensitivity, and True Negatives the Specificity. Errors of diagnostic
tests are False Positives, and False Negatives.
An ROC curve plots the Sensitivity vs False Positive Fraction (I – Specificity).
The ROC curve is plotted as the Strictness Criterion is relaxed (Strict to Lax).

As strictness criterion is relaxed, Sensitivity and FPF both increase monotonically. ROC performance is
measured as the Area Under the ROC Curve (AUC).
A perfect diagnostic test has an AUC of 1, and a useless test has an AUC of 0.5. Under reading relates to a
very low sensitivity (and low FPF).

Over reading relates to a high FPF (and high sensitivity).

ROC analysis is currently the gold standard for comparing diagnostic performance.
Image Quality is ALWAYS task dependent; there is “no image quality” without a defined task.

Radiation Safety I

Deterministic Effects

Ionizing radiation breaks deposits energy that breaks apart biological molecules (DNA). Chromosome damage
can occur (dicentrics, rings, deletions etc) that quantify “exposures”. Radiobiologist categorize radiation effects
(somatic vs genetic) and (early vs late).
Cell survival curves plot surviving fraction against radiation exposure.

Dose rate, oxygenation, and fractionation as well as cell type influence cell survival curves. Deterministic
effects have a threshold dose, and are related to cell killing.
Stochastic effects are assumed to have no threshold, and are related to “cell transformation”. Deterministic
effects may be dose dependent (temporary vs permanent epilation).

Stochastic effects are independent of dose, which only influences likelihood (not severity).
High acute whole body doses “kill” (Hematopoietic [2 to 8 Gy], GI [10+ Gy], & CNS [50+ Gy]).
< 2 Gy, no skin effects, and between 2 and 5 Gy, transient erythema is possible.
5 to 10 Gy produces erythema (10 days), and 10 to 15 Gy produces dry/moist desquamation. Radiation
produces temporary (3 Gy) and permanent (7 Gy) epilation.
Radiation induced cataracts have a threshold dose of 0.5 Gy (acute & chronic).
Sterility is another deterministic effect in males and females.
In Radiology, exposures < 2 Gy are generally taken to result in no (clinical) deterministic