Radiation Protection in Digital Radiology

Fundamentals of Digital Radiography

L01

IAEA
International Atomic Energy Agency
 Educational Objectives

• Explain how ordinary

radiographic images can be
captured in digital form
• Discuss the advantages and
limitations of digital images
• Explain how the dissociation of
acquisition and display in DR can
contribute to unnecessary
radiation exposure to patients

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Radiation Protection in Digital Radiology L01 Fundamentals of Digital Radiography
 What is a digital image?

• An approximation of an analog
image, with regard to
• spatial information
• contrast information
• A computer file composed of
discrete picture elements, or pixels
• location in file (array or matrix) Etruscan Roman Mosaic
represents image position circa 50BC
• numeric value represents signal
intensity

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 Why would we want digital images?

• Availability
• a digital image can be transmitted electronically to distant
locations and can exist simultaneously at multiple locations
• Flexibility
• the appearance of a digital image can be modified
• Convenience
• a digital image can be stored electronically without occupying
physical space

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Radiation Protection in Digital Radiology L01 Fundamentals of Digital Radiography
 Conventional screen-film radiography

• Radiation strikes intensification screen(s) producing fluorescence

• Fluorescent light exposes photographic film producing latent
image
• Latent image is chemically developed to produce density in film
• Film density is viewed by trans-illumination

1895

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 Developed film is effectively analogue

• Density is the result of many developed silver grains

• Grains in intensification screen are quite small
1 0 2 3 4
[1,0,0,2,3,4]
[1,0,0,2,3,4]
[1,0,0,2,3,4]
[0,0,0,0,0,0]

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Radiation Protection in Digital Radiology L01 Fundamentals of Digital Radiography
 Three approaches to digital radiography

I. Translate developed film into digital form.

II. Capture the radiographic projection by non-
photographic method and digitize during
development.
III. Capture the radiographic projection or its
fluorescence directly in digital form.

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 Method I: Film Digitization
• Video of transilluminated radiographs
• “Camera-on-a-stick”
• Low cost, low quality
• LASER film digitisers
• Best quality
• Expensive and involves periodic maintenance
• CCD film digitisers
• Less cost than LASER, less maintenance, better quality than
camera-on-a-stick
• Old problems of drift, noise, non-uniform illumination, and
veiling glare – mostly rectified

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 Process of film digitization
• Light is directed onto
a film
• Light passing
through the film is
measured
• Amount of light
attenuated is
converted into a
digital code value
Bushberg, Seibert, Leidholdt, Boone
The Essential Physics of
IAEA Medical Imaging 2 Ed
nd
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Radiation Protection in Digital Radiology L01 Fundamentals of Digital Radiography
Fundamental limitations of film digitization
• Prone to artefacts
• Labour intensive – an extra step
• Best quality achievable is limited by original screen-film
image

How many of us maintain capability to digitize film?

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 Method II: Non-photographic capture with
digital development
• Xeroradiography
• Charged Selenium plate
• Electrostatic latent image
• Charge distribution transferred to paper using toner
• Selenium drum detector
• Selenium deposited on cylindrical Al drum
• Selenium uniformly charged before exposure
• X-rays partly neutralize the charge
• Charge distribution measured by electrometer array

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Radiation Protection in Digital Radiology L01 Fundamentals of Digital Radiography
 Computed Radiography (CR) or Photostimulable
Phosphor (PSP) Radiography

• Latent image of trapped electrons is formed when x-rays hit the

imaging plate
• Latent image is read out physically instead of chemical process
• As the latent image is read out…
• Stimulated light emitted with the help of LASER is directed to a
Photomultiplier Tube (PMT)
• The PMT signal is digitized using Analog-to-Digital Converter (ADC)
• The digital image consists of an array of ADC Code Values
• ADC Code values represent exposure information
• Array locations represent spatial information

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 Photostimulable phosphor reader

Rotating polygon mirror Analog-to-Digital Converter

Photomultiplier tube
?
Light guide Amplifier
Laser

fast scan

Latent Image slow scan

Imaging plate
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 Characteristics of PSP systems

• Generally, but not exclusively, cassette-based

systems
• Moderate initial capital investment
• Simple retrofit to existing radiographic
equipment
• Individual scanner can serve multiple acquisition
devices
• Workflow comparable to daylight loader film
processing

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 Method III: X-rays are converted immediately
into digital signals without latent image
• Fluorescent screen with video camera (video-fluoroscopy,
image intensifiers)
• Fluorescent screen with Charged-Coupled Devices (CCD) or
Complementary Metal Oxide Semiconductor (CMOS) array
• Optical lens coupling
• Secondary quantum sink
• Fiber optic coupling
• Small area
• Hydrogenated Amorphous Silicon (a-Si:H) with Thin Film
Transistors (TFT)
“Flat panels”

• alternative = switching diode

• requires x-ray converter (Gadolinium oxysulphide or Caesium Iodide)
• Amorphous Selenium (a-Se) electronically coupled to TFT

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Characteristics of “Direct” capture systems

+ Rapid acquisition and processing

+ Typically integrated with x-ray
generator
+ No mechanical scan mechanism
— High initial capital investment
— Challenging manufacturing processes
— Limited systems for bedside
radiography
? Brief history of clinical operation
? Life cycle issues unknown (durability?)
? Image rendering unknown
? Exposure factor issues

IAEA Courtesy JA Seibert, UC-Davis

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Radiation Protection in Digital Radiology L01 Fundamentals of Digital Radiography
 How good an approximation does the digital
image make?

• Spatial information depends on …

• Dimensions of the pixels (matrix size)
• Blur
• Contrast information depends on …
• Grayscales (Code values) per pixel (i.e. quantization)
• Characteristic function (Code values vs. exposure)
• Noise

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 Effects of Pixel size and Bit-depth

Larger
pixels

1024 x 1024 64 x 64 32 x 32 16 x 16

More
bit-depth

1 bit/pixel 2 bits/pixel 3 bits/pixel 8 bits/pixel

For an image of M x N matrix, k bytes/pixel,
the memory needed to store the image is k x M x N bytes
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 Practical resolution is less than the Nyquist
frequency

• Factors besides sampling compromise

sharpness; depends on
• X-ray focal spot dimensions
• Blur in Indirect DR and CR
• Optical and mechanical imprecision in IDR
and CR
• Afterglow in fast-scan dimension in CR
• Limit of resolution is where Modulation
Transfer Function (MTF) has decreased
to 10%

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MTF of DR depends on more than just
sampling

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 Noise interferes with our ability to detect
contrast
σ = √N
SNR = N/σ = √N

Air KER MA Photons Nois e

(µGy) /100 m X100µm (%)

9.0 1333 2.7

0.9 133 8.6

0.09 13 27.4
Bushberg, Seibert, Leidholdt, Boone The Essential
Physics of Medical Imaging 2nd Ed

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Combination of quantum noise and anatomic
noise limits low contrast detection

DR Image CT Image

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Detective Quantum Efficiency (DQE) of DR
Combines SNR and Resolution
Ideal
detector (200 um)

(143 um)

(200 um)

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 DR has wide dynamic range (latitude)
3 10000
2.5
1000

Intensity (rel)
Density (OD)

2
Film/screen
1.5 100 PSL
1
10
0.5

0 1
1023
0.1 1 10 100 1000
Air kerma (μGy)

EDR Signal
High kV
L=2.2, S=50
Histogram re-scaling Over-Exposed

00.1 µGy Raw Plate Exposure 1000 µGy

Low kV, L=1.8, S=750
Under-Exposed
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 Rescaling of DR images is a double-edged
sword

• Variations in exposure factor selection are automatically

compensated by rescaling for consistent appearance
• Inappropriately high or low exposures are not
immediately apparent from the appearance of the image
until the range-of-adjustment is exceeded
• Underexposure makes noisy images
• Overexposure makes crisp, noiseless images, that are
preferred by radiologists

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 There is a documented tendency to
overexpose in CR and DR
• Oversight of exposure factor selection is impossible without an
exposure indicator

Freedman et al. SPIE 1897 (1993),472-479.

Gur D et al. Proc 18th European Congress of Radiology. Vienna Sep 12-17.(1993)154.

Barry Burns, UNC

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What would be the appropriate exposure?

• Seibert, et al Acad Radiol (1996) 4: 313-318

• QA based on exposure indicator reduces doses
• Willis Ped Radiol (2002) 32: 745-750
• 33% dose reduction if exposure indicator target followed
• AAPM Task Group #116 is effort to standardize indicators
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 Five ways of making a radiographic
projection with lower dose to the patient

• Each method has consequences with respect to the five

aspects of image quality

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 Important information about DR acquisition
and processing is in metadata

• CR vs. DX object
• Mandatory vs. optional
vs. private tags
• Automatic vs. manual
entry of data
• PACS interpretation of
metadata

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 New artefacts from the
discrete nature of DR

• Interference pattern
between fixed grid
lines and down-
sampling rate for
display

• Disappeared on zoom

• Bad choices
• Display default
magnification factor
• Line rate of grid

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 X-ray energy sensitivity differs among
detectors
Martin Yaffe/Tony Seibert

1.0
Gd2O2S:Tb 120 mg/cm2 (Lanex)

BaFBr 100 mg/cm² (CR)

Quantum Efficiency

A-Selenium 25 mg/cm2

0.1

CsI:Tl 45 mg/cm2 (a-Si/CsI)

0.01
0 20 40 60 80 100 120 140

Photon Energy (keV)

Would you expect to use the same kVp?
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 Emerging digital technologies
The EOS Imaging system
Charpak Detector: Detector amplification by photon gaz cascade
 High gain signal, sensitivity maximized
Detectors

X ray tubes
Two simultaneous digital planar radiographs (PA and LAT) in the standing
position by linear scanning of a fan-shaped collimated X ray beam from 5 cm
to 180 cm (whole body).
EOS allows for a dose reduction up to 10 times compared to CR

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 Advantages of digital radiology

• Digital imaging has practical technical

advantages compared with film techniques:
• wide contrast dynamic range,
• post-processing functionality,
• multiple image viewing options,
• electronic transfer,
• electronic archiving possibilities.

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 How to move from film-screen to digital?

• Training should be planned with anticipation.

• Selection of equipment, connectivity and quality control
requires good advice (not only from the manufacturers)
and visits to other installations.
• Patient dose and image quality should be audited
carefully during the transition. The risk of increasing
patient doses exists.

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 How to move from film-screen to digital?

• Typically the initial setting for the automatic exposure

control using CR, should be the same or similar to the
existing with film-screen. Optimisation (including
possible kV changes) and potential dose reduction
should be initiated later once radiologists become
familiar with digital.
• Audit DICOM header. It contains a lot of useful
information.

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 Checklist of practical advice (ICRP 93)

• When introducing a new digital system into clinical

practice, the system should be set up to achieve the best
balance between image quality and patient dose.
• Avoid deleting non diagnostic images at the workstation
and carry out a statistical rejection rate analysis
periodically.

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 Checklist of practical advice (ICRP 93)

• Be familiar with your workstation capabilities (post-

processing capabilities, options in the monitor to
visualise the images, etc).
• Identify correctly all the images to avoid their loss in the
PACS.
• Ask for a calibration of the automatic exposure control
that is appropriate for the sensitivity range of the digital
system and the selected post processing.

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 Checklist of practical advice (ICRP 93)

• Avoid manual exposures if the automatic exposure

control is usable. However, ensure it is used correctly,
as only some possible errors are correctable by post
processing.
• Control the number of images per examination to
maintain it at a number similar (or lower) than that for
conventional radiology.

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 Checklist of practical advice (ICRP 93)

• Make available a workstation for radiographers to post-

process images in order to avoid retakes.
• Pay attention to the dose indication on the panel of the
x-ray system or in the in-room monitors and utilise the
information to manage patient doses.
• Establish easy access to the PACS to review previous
images, in order to avoid retakes.

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 Checklist of practical advice (ICRP 93)

• Pay attention to proper collimation for the desired

anatomical area. Once the image is acquired, numerical
methods (i.e. software) may automatically crop part of
the image, and when the image is received for reading
the radiologist will not be aware that a larger anatomical
area than necessary was irradiated.
• Select the correct pre-programmed technique e.g. using
an abdominal technique (70-80 kV) for chest imaging
(120-130 kV) will result in a higher entrance surface
dose.

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 Summary
• A digital radiographic image is a matrix of numbers with discrete physical pixel
dimensions and gray-levels.
• The discrete nature of the DR image is the source of its advantages and
limitations
• Digital radiographs can be produced by three methods:
• Digitization of screen-film radiographs
• Non-photographic capture and digitization
• Direct capture with or without conversion to light
• DR technologies have advantages of availability, flexibility, and convenience
over conventional screen-film
• The utility of the DR image is enhanced by demographic, exam, and processing
information in the DICOM header
• Except for digitized radiography, DR has the potential for unnecessary patient
radiation exposure

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 Answer True or False

• A digital image contains numeric value representing

signal intensity.
• In computed radiography (CR), the electronic latent
image is developed by chemical process
• Amorphous selenium is used in direct capture flat
panel detectors

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 Answer True or False

• True. A digital image is a computer file composed of

discrete elements or pixels representing signal intensity.
• False. The electronic latent image in the CR plate is read
out using LASER
• True. Amorphous selenium (aSe) is electronically
coupled to the thin film transistor (TFT) in a direct
capture flat panel detector.

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 References

• Managing patient dose in Digital Radiology

ICRP Publication 93 Ann ICRP 2004 Elsevier.

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