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Digital APPLICATIONS
C- Arm & DSA
& Radiation Dose

July 2008
For RT 255 – SPRING
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MOBILE FLUOROSCOPY
• C-ARM UNIT -
• Tube at one end - I.I. at other end
• TV Monitor control cart separate from
unit
• Uses Digital Fluoroscopy
• Last Image Hold, Image Enhancement
• Save for hard copies from disk, Video
• Photographic Magnification,
Subtraction
• Static (pulsed) and continuous fluoro
• Maneuverable and Versatile
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RADIATION PROTECTION
Remember the “Cardinal Rules”
FLUOROSCOPIC
• Minimum source to skin distance = 12”
• Preferred SSD OF 18”
•  Distance from tube and patient
• ↓ Distance from II to the patient
• 5 min Audible Alarm
• At least .25mm lead apron to be worn
• 5 R/min – 10 R/min BOOST – 20 R/min
• 2.2R/ma @ 80 kVp
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RAD PROTECTION
RULES OF GOOD PRACTICE -continued

• Never place your hand or other body part in

primary beam
• Provide gonadal protection for the patient if
possible
• FOR C-ARM – IF BEAM FROM BELOW –
PLACE APRON ON TABLE BEFORE
PATIENT IS ON TABLE
• Achieve maximum distance from the patient
and tube (stand 90° from the patient- SEE Merrills
– pg 212)
• Minimum 6 foot exposure cord for
radiography
• Label and handle cassettes carefully
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FYI
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fluoroscan

•uMa
•No Apron Needed??
•“Per manufacturer”

• Is this SAFE????
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Digital Fluoroscopy and
Digital Subtraction Angiography (DSA)

• DIGITAL
FLUOROSCOPY • DIGITAL IMAGE DATA
• Introduction PROCESSNG IN
DIGITAL
• Design and Equipments
FLUOROSCOPY
• DIGITAL IMAGING
• Last Image Hold
CONCEPTS
• Gray-scale processing
• Binary Numbers
• Temporal Frame
• Pixels
Averaging
• Gray levels
• Edge Enhancement
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Digital Fluoroscopy
• A digital fluoroscopy system is commonly
designed as a conventional one in which
the analog video signal is converted to and
stored as digital data by an analog to
digital converter (ADC) (DAC to print image)
10 Last Image Hold reduces pt dose
The last frame acquired before stopping x-ray acquisition
is continuously displayed
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LIH - stays on screen
12 DIGITAL Angiographic Equipment
Single or biplane image intensification

• A C-arm or U-arm device is preferable

• to reduce the number of injections
of contrast required
• Is the radiation does
less?
• What are the
other advantages?
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Bi Plane
Digital Angio Equipment
• Less Time for Procedure
• Less contrast for patient
• BUT - Not Less Radiation
• ALSO
• Can POST PROCESS
• And use DSA
• faster processing time than film
• No “jammed” films
14 Advantages of Digital Fluoro
from Conventional Fluoro

• Post Processing results in

– ENHANCED Contrast
Resolution
• SPEED OF ACQUISITION
• 1024 x 10 24 image matrix
(1000 lines)
• System provides better
spatial resolution than the
525 line system
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Image digitizer
(ADC)

• This turns the analog TV image into a

digital image consisting of pixels
• the number of which depends on the lines
per inch of the TV image
• The usual pixel numbers in an image are
512 x 512 conventional (SNR of about
200:1)
• Digital 1024 x 1024 (high resolution)
– SNR of 1000:1 is necessary for DF.
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TV progressive scanning

• 30 images/sec acquired in the 512×512

matrix mode
• But higher spatial resolution image is
required for 1024 × 1024 mode
• then only 8 images per second can be
acquired.
• This limitation on data transfer is imposed by the time required to conduct the enormous
quantities of data from one segment of memory to another.
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DSA Equipment
• Digital subtraction angiography requires more
complex equipment than digital radiography,
• specifically because it has to manipulate a
number of pulsed images and at the same time
create a subtracted image using the first pre
contrast image as a mask
• DIGITAL FLUORO Range 100mA-200mA
18 Pulsed Fluoro
& RP

• Some fluoroscopic equipment

is designed for pulsed-mode
operation
• it can be set to produce less
than the conventional 25 or 30 What is the mA differences
images per second. for
• This reduces the exposure rate. Conventional Fluoro ______
• Collimation of the X ray beam to Digital Fluoro __________
the smallest practical size and
keeping the distance between
the patient and image receptor
as short as possible contribute
to good exposure management.
.5-5 mA /100-200 mA
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Dose rate to patients
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Digital Fluoroscopy

• ALTERNATE DIGITIZATION
• Digital video camera (Charge-couple
device)
• Direct capture of x-ray (flat–panel
detector)
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DF
• Reduces Pt DOSE
• Uses High Voltage generator
• Tube operates in Radiographic Mode
• So PULSE programming keeps tube from
overheating
• 1- 10 second image acquisition
• Generator can switch off/on rapidly =
– INTERROGATION TIME (ON TIME)
– Extinction time ( Switched OFF)
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Digital Fluoroscopy and
Digital Subtraction Angiography (DSA)

• DIGITAL IMAGE DATA PROCESSNG IN DIGITAL

FLUOROSCOPY
• Last Image Hold
• Gray-scale processing
• Temporal Frame Averaging
• Edge Enhancement
• MORE LINEAR RESPONSE than F/S
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Digital radiography principle

ANALOGUE
SIGNAL

I
ADC Memory t

DIGITAL
Iris SIGNAL

Clock

t
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Digital Fluoroscopy- CCD

• Digital video camera (Charge-couple

device)
• CCD is a solid state device that converts
visible light photons to electrons
• layer of cyrstalline silicon – e’s
• The electron signal is read pixel by pixel
and an image is formed
Fast – very little lag time
• First used by Military
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Digital Fluoroscopy

• Use CCD to generate electronic signal

• Signal is sent to ADC
• Allows for post processing and electronic
storage and distribution

• BETTER RESOLUTION WITH DIGITAL

UNITS
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Video Camera Charged Coupled
Devices (CCD)
• Operate at lower voltages than video
tubes
• More durable than video tubes

• Semiconducting device
• Emits electrons in proportion to amount of
light striking photoelectric cathode
• Fast discharge eliminates lag
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CCD’s Advantages of Charge-Coupled Device
for Medical Imaging
– High spatial resolution
– High signal-to-noise ratio
– High detective quantum efficiency
(DQE)
– No warm-up required
– No lag or blooming
– No spatial distortion
– No maintenance
– Unlimited life
– Unaffected by magnetic fields
– Linear response
– Lower dose
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Newer Digital Fluoroscopy
• Image intensifier output screen coupled to TFTs
• TFT photodiodes are connected to each pixel
element
• Resolution limited in favor of radiation exposure
concerns
• Direct capture of x-ray (flat–panel detector) a-
silicon a-seleniumExit x-rays interact with CsI
scintillation phosphor to produce light
• The light interact with the a-Si to produce a signal
• The TFT stores the signal until readout, one pixel
at a time
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CsI phosphor light detected by the

AMA (active matrix array) of silicon
photodiodes

Digital – CCD
using cesium iodide
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Direct or Indirect Capture TFT

• IN -DIRECT – CsI phoshor coated on a-Si

photodiode = light when exposed
• High DQE = lower dose

• DIRECT - a- Se (selenium) creates

electron holes – no light spread = better
spatial resolution
31 Modern Digital Fluoro System
under & over table tubes
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Digital Subtraction Angiography

• DSA uses an II/TV

system combined
with a high speed
image processor in
a digital angiographic
system.
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Digital Subtraction Angiography
• DSA uses an
II/TV
system
combined
with a high
speed
image processor
in
a digital
angiographic
system.
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Digital Subtraction Angiography (DSA)

• Performed for diagnostic and therapeutic

purposes of vessel visualization in the body.
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Digital Subtraction Angiography (DSA)
• DSA refers to a technique which compares two
images of a region of the body before and after
a contrast medium has been injected into the
body for the purpose of studying blood vessels.
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Digital Imaging Concepts

• FUNDAMENTALS

• Binary numbers

• Pixels

• Gray levels
39 Pixels and Matrix
• Pixel: The smallest element of a digital
image
• Matrix: A two dimensional series of square
boxes composed of pixels
• Digital fluoroscopy uses 512x512–1024x1024 pixels
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Comparison of a clinical image at different matrix sizes

16x16 32x32 64x64

128x128 256x256 512x512

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Gray Levels
in
Digital Fluoroscopy

• ADC samples the analog video signal

exiting the video camera tube and
converts the value of the video signal to a
binary number for processing and storage
42 Comparison of a clinical image at different bit depths
- gray levels

• 256 gray levels (8bits) 16 gray levels (4bits)

• 8 gray levels (3bits) 4 gray levels (2bits)

43 Which system ?
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Use of Road Mapping with Clinical Images

• .
46 Digital Subtraction Angiography (DSA)

Pre-contrast image Pos-contrast image Subtracted image

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DIGITAL ADVANTAGE -Edge Enhancement

Original Image Blurred Image

Subtracted Image Edge-Enhanced image

(Edge-enhanced image = [original image - blurred version] + original image.)
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Mask Pixel Shift

Subtracted image with the subtraction

mask image is shifted several pixels
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DSA

• MISREGISTRATION – CAUSED BY
PATIENT MOTION – CAUSES
BLURRING OF IMAGE

• RE-REGISTATION MAY BE ABLE TO FIX

THIS MY SHIFTING PIXELS

• SEE PG 416 Bushong

50 CINE
Equipment

• Cine radiography.
• Fluoroscopy unit with TV monitor:
• Single or biplane fluoroscopy units are
available.
• Video equipment – DIGITAL RECORDING
• Other image recording devices: Images
can be acquired and stored in a digital format
(postprocessing). This is the fundamental
principle of DSA.
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Cinefluorgraphy aka CINE

• 35 or 16 mm roll film (movie film)

• 35 mm ↑ patient dose / 16 mm –
• higher quality images produced
• 30 f/sec in US – (60 frames / sec)

• THIS MODALITY = HIGHEST PATIENT

DOSE (10X greater than fluoro)
• (VS SINGLE EX DOSE IS ↓)
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Cine
• Cinefluorography is used most
often in cardiology and
neuroradiology.
• The procedure uses a movie
camera to record the image
from the image intensifier.
• These units cause the greatest
patient doses of all diagnostic • Patient exposure
radiographic procedures, can be minimized in
although they provide very a number of ways.
high image quality. The most obvious
• The high patient dose results means of limiting
from the length of the exposure is to limit
procedure and relatively high
inherent dose rate. the time the beam is
• For this reason special care
on.
must be taken to ensure that • CINE - 2mR per
patients are exposed at frame (60f/sec)
minimum acceptable levels.
• 400 mr per “look”
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DIGITAL HAS REPLACED CINE
What type of camera tube was used for CINE? And Why?
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DR & GRID USE : QC

Name & Cause of this PROBLEM ??