INTRODUCTION

Imagine being able to see inside the human body with incredible clarity. That's
what medical imaging has made possible, and it's revolutionized the way
doctors diagnose and treat patients. But with so many images to review, it's like
trying to find a needle in a haystack. That's where AI comes in – like a trusted
sidekick, helping doctors work more efficiently and effectively. By using clever
algorithms to analyze images, AI tools can spot patterns and provide valuable
insights that might have gone unnoticed. The result? Doctors can detect
diseases earlier, make more accurate diagnoses, and create personalized
treatment plans that are tailored to each patient's unique needs. In this
journey, we'll explore the exciting ways AI is transforming medical imaging and
what the future holds for this rapidly evolving field.
 ABSTRACT

Artificial intelligence (AI) has been entwined with the field of radiology ever
since digital imaging began replacing films over half a century ago. These
algorithms, ranging from simplistic speech-to-text dictation programs to
automated-interpretation neural networks, have continuously sought to
revolutionize medical imaging. With the number of imaging studies outpacing
the amount of trained of readers, AI has been implemented to streamline
workflow efficiency and provide quantitative, standardized interpretation. AI
relies on massive amounts of data for its algorithms to function, and with the
wide-spread adoption of Picture Archiving and Communication Systems (PACS),
imaging data is accumulating rapidly. Current AI algorithms using machine-
learning technology, or computer aided-detection, have been able to
successfully pool this data for clinical use, although the scope of these
algorithms remains narrow. Many systems have been developed to assist the
workflow of the radiologist through PACS optimization and imaging study
triage, however interpretation has generally remained a human responsibility
for now. In this review article, we will summarise the current successes and
limitations of AI in radiology, and explore the exciting prospects that deep-
learning technology offers for the future.
 CURRENT AI UTILIZATION IN
RADIOLOGY

The current state of AI utilization in the field of radiology is variable based

oninstitution, although there are several widely-adopted systems. Aligning with
the newer philosophy of “working with radiologists”, many of the current AI
systems are being used in a limited capacity as tools to enhance the
radiologist’s workflow. Many of these AI systems fall under the category
of“micro-optimizations”

The primary goal for micro-optimization algorithms is to assist the radiologist in

his or her daily tasks rather than fully automating the radiologic process. Micro-
optimizations can be broken down into two categories; nonpixel-based
optimizations and pixel-based optimizations. By using AI to streamline the
efficiency and standardization of time-consuming, mundane, or non
interpretive tasks, radiologists can better allocate their time and energy to
further focus on image interpretation, consultation, and overall patient care.
 LIMITATIONS

Despite the constant development of new AI companies, advanced algorithms,

and enhanced learning technology, AI has not yet become mainstream in the
radiology world due to a combination of both logistical and clinical challenges.
The ease of which AI programs can be implemented varies widely based on the
scope and technicalities of the clinical problem they aim to solve, as well as the
mechanism by which they solve them. In general terminology, there are two
main types of AI systems, machine- learning and deep-learning, each of with
have some specific limitations of their own

1. Machine-learning AI
Machine-learning functions largely on the principal of pattern recognition. If
the machine is able to “see” enough example image characteristics of a certain
disease, it can then look at new images and be able to recognize them based
on those previously defined features. The caveat here, is that these “pre-
defined features”, such as tumor volume, density, etc., must be hand-fed into
each specific machine- learning classifier. In this way the AI does not actually
learn, but rather applies the specifics of its pre-engineered programming.
Consequently, machine-learning AI is intrinsically limited by these specific
characteristics which can reduce its ability to recognize image features, such as
rare or unusual disease presentations. Figure 1 demonstrates a schematic
example of how machine-learning AI systems utilize these pre-defined features
for classification. Furthermore, as the breadth of medical knowledge continues
to expand, previous CAD systems may become outdated, and therefore
obsolete. The theoretical solution to these hard-wired restrictions is the use of
AI algorithms that do not rely on pre- engineered feature recognition, but
rather one that can learn and adapt in a manner similar to the human brain
 2. Deep-learning AI
Deep-learning is programmed to mimic the pattern of neural networks such as
those in the human brain, referred to in the literature as convolutional neural
networks (CNNs). The principal mechanism behind AI algorithms relies on a
vast quantity of data, and through this data the AI can develop its own pattern
of feature recognition without the need for pre-programming from human
experts. Deep-Learning AI uses these features to create connections and draw
conclusions in a way similar to the human brain, and allowing it to operate
freely from human input thus increasing its automaticity and decreasing
restrictions. While in theory this method appears to be a step-up from classical
machine-learning technology, the reliance on data and complexity of the
mechanism has its limitations.

3. Industry acceptance
Questions regarding the mechanism of how deep-learning functions can also
create additional limitations, specifically regarding FDA approval and the
accuracy of the AI’s results. The mechanism is extremely complex, and in many
instances, the exact way in which the AI forms these CNNs is either unknown or
proprietary. If the way the AI algorithm functions to produce its results is not
well understood, this begs the question of whether or not its results can be
trusted . This question has haunted AI since its inception, and the answer of
whether or not health professionals and patients would be willing to put their
faith in the recommendation of a 100% computer-controlled radiologic study is
ess not an easy one to answer. A variety of comparison studies have been
conducted to determine whether AI accuracy is comparable to that of human
readers, and the results have been mixed.
In the previously mentioned Schaffter study on breast cancer detection, no
single AI algorithm was able to outperform the radiologists, with a specificity of
66.1% for the top-performing algorithm compared to 90.5% for the
radiologists. In a breast cancer detection study using a different AI system, the
AI outperformed the radiologists with an AUC of 0.740 compared to the
radiologists’ AUC of 0.625. In a study comparing chest radiograph
interpretation, AI outperformed the radiologists on detection of pulmonary
edema, underperformed on detection of consolidation, and had comparable
performance for detection of pleural effusions. . These studies collectively
demonstrate that AI systems have mixed performance compared to human
radiologists. The utilization of different algorithms, training datasets, and
radiologist experience in these studies makes drawing conclusions about AI’s
general trustworthiness difficult. Concerns such as these are why the shift
toward micro-optimizations has been an attractive one for the interim,
however as new techno-Logies are developed and deep-learning systems are
polished the future of AI continues to push the boundaries of possibility.
 FUTURE DIRECTIONS
The future of AI in radiology is constantly evolving, and with new computer
systems, implementation targets, and algorithms being developed seemingly
by the day there is no discernable end to what is possible . Within PACS, the
utilization of deep learning AI could theoretically be implemented wherever
large quantities of data are available, although as previously stated there are
several limitations to deep learning technology. With the interconnectivity,
digitization, and increasing data pool in modern radiology, the limitations of
deep-learning may slowly start to be overcome, and the use of micro-
optimization may ramp up in scale. The next phase in AI utilization will likely
continue the trend of micro-optimization, but with increased efficiency. As
hospital systems become more integrated, with imaging devices and PACS
being able to directly communicate with each other, it would only make sense
that the AI algorithms within these systems do the same. With AI’s current
narrow clinical usage, each system excels at only one specific task. By
combining these systems, the scope of each can be summated into a larger,
more efficient system. For example a lung cancer screening CT reconstruction
algorithm could be used alongside a hanging protocol algorithm, with CADe for
detection, and another algorithm for report generation . Until a more
encompassing system is created, combining existing micro-optimizations can
scale efficiency in clinical workflow
 1. Disease recognition and triage
Despite the profound promise of deep learning, it has yet to have seen wide-
spread clinical utilization. That being said, the power behind deep learning is
data and the amount of available data is continuously growing. As we gather
more high-quality data, the deep learning systems should become. more
powerful, increasing their usage potential. The full potential of deep learning is
still unknown, however there are several promising applications in detection
and automated disease monitoring. One of these applications is in the
identification of incidental findings. When a radiologist is examining a trauma
study, the AI system can detect incidental pulmonary nodules, allowing the
radiologist to focus on the primary clinical issue without overlooking other
findings. Looking to improve upon current CAD systems, utilizing deep learning
AI for triage is another attractive target, where the urgency of a given study is
prioritized and then sent to a radiologist for final interpretation. These
algorithms pool hundreds of thousands of imaging studies along with their
subsequent reports, and use this information to train their CNNs. In a study of
one such algorithm on assigning priority to adult chest radiographs, AI was able
to assign priority with a sensitivity of 71% and a specificity of 95%. Importantly,
the time taken to report critical findings was reduced significantly from 11.2 to
2.7. Another study on triaging patients based on head CT findings produced
similar results, with an AUC of 0.92 for accurately detecting intracranial
hemorrhage.
 2. DISEASE MONITORING
The prospect of monitoring disease progression is a more complicated one, but
the ability of the deeplearning system to accumulate and track data changes
over time makes this an attractive target. These systems may also have the
ability to automatically adjust for changes in patient position or body habitus at
the times the studies were conducted. One of the obvious applications for this
is oncology, with AI models already demonstrating their ability to accurately
measure therapeutic response and tumor recurrence . Throughout the
coronavirus disease 2019 (COVID-19) pandemic, the ability to track disease
progression has been crucial for medical decision making. Unfortunately, the
wide variability in an individual’s disease course has been difficult to predict. To
solve this problem, several deep learning systems have been tested to identify
minute chest CT changes based on quantitative pixel analysis, giving us a more
sophisticated look into the pathophysiology of the disease. Not only does this
present the potential to make educated decisions for COVID-19 patients
regarding the need for hospital-ization and allocation of resources, but the
pandemic in general has further stressed the need of increased efficiency in
radiology during times of unprecedented volume.
 CONCLUSION

As the role of AI in radiology continues to advance and diversify, the potential

for revolutionary clinical impact persists. One of the most important factors for
the continued development of AI in radiology is achieving wide-spread
implementation, and to achieve this AI must be embraced by radiologists.
Currently, only an estimated 30% of radiologists use AI in day-to-day workflow .
With the shift of AI philosophy away from replacing radiologists, the view of AI
as a threat to fear may be replaced with its view as a tool to exploit. As more
algorithms are approved, more studies published, and more systems
implemented into clinical practice, radiologists and trainees alike need to
educate themselves on what AI can do for them and their patients. When
radiologists and AI learn to work together, the potential clinical benefits of a
human-machine symbiosis can be fully realized.
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