CHAPTER 1

INTRODUCTION TO RADIOGRAPHY,
FLUOROSCOPY, AND TOMOSYNTHESIS
Drew A. Torigian, MD, MA, FSAR

RADIOGRAPHY
1. What is radiography?
Radiography is an imaging technique that uses x-rays to create projectional (2D) images of a region of interest in the
body. It is performed by shining x-rays on a film or other image detector with a patient placed in front of it in a certain
orientation. Different types of tissues in the patient attenuate x-rays to different degrees, leading to formation of a
composite of x-ray shadows that will ultimately create the radiographic image. It is most commonly used to evaluate
the bones and joints, the chest (especially the lungs), the abdomen and pelvis (especially the bowel), and the breasts
(in which case it is called mammography).
2. When were x-rays discovered?
Wilhelm Conrad Roentgen is credited with the discovery of x-rays in 1895, and was the first to systematically study
them. He was also the first to obtain an x-ray photograph of part of the human body, his wifes hand, discovering its
potential medical use. In 1901, he received the first Nobel Prize in physics. X-rays are sometimes referred to as
Roentgen rays.
3. How do x-rays differ from other types of electromagnetic radiation?
X-rays have higher energies, higher frequencies, and shorter wavelengths in the electromagnetic spectrum than
ultraviolet light, visible light, infrared light, microwaves, and radio waves, and lower energies, lower frequencies, and
longer wavelengths than gamma rays. Diagnostic x-rays typically have energies between 20 and 150keV.
4. How do x-rays interact with matter?
X-rays may either pass through matter unaffected, may be absorbed, or may be scattered (the latter of which leads to
decreased image quality). Key factors that influence which interactions occur include the incident x-ray photon energy
and the physical density, thickness, and atomic number of the material being imaged.
5. What is an x-ray tube?
An x-ray tube is a device that is used to create x-rays for diagnostic imaging. It contains a negatively charged cathode
that contains a filament (usually made of coiled tungsten wire) to produce electrons. The electrons are accelerated
toward a positively charged anode that contains a target (usually made of tungsten or made of molybdenum and
rhodium in mammography) where x-rays are produced. Both the cathode and anode are housed within a vacuum tube.
6. How are x-rays for diagnostic imaging produced?
In the x-ray tube, about 90% of x-rays are created when electrons emitted from the cathode pass close to positively
charged atomic nuclei within the anode target and change direction, resulting in a loss of energy in the form of x-ray
photons known as bremsstrahlung (braking) x-rays. An additional 10% of x-rays are produced when inner shell
atomic electrons of the anode target are ejected by incident electrons, followed by relaxation of outer shell atomic
electrons to fill the inner shell vacancies, leading to emission of energy in the form of x-ray photons known as
characteristic x-rays.
7. What is a focal spot?
A focal spot is the apparent source of x-rays in an x-ray tube. Smaller focal spots (such as those used in
mammography) produce sharper images, whereas larger focal spots (such as those used in fluoroscopy) tolerate
greater amounts of heat.
8. What is a collimator?
A collimator is a device used to narrow the x-ray beam as it leaves the x-ray tube prior to entering the patient,
reducing x-ray scatter and improving image contrast.
9. What happens to most of the energy entering the x-ray tube?
Most (99%) of the energy is converted to heat, whereas about 1% is converted to x-rays.
10. What key input parameters may be adjusted when generating x-rays?
The key parameters are the voltage applied across the x-ray tube (measured in kilovolts [kV]), the current flowing
through the x-ray tube (measured in milliamperes [mA]), and the exposure time (measured in milliseconds [ms]). The
3

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 4 PART I INTRODUCTION TO IMAGING MODALITIES

X-ray tube
Filter
Collimator

Grid

Screen-film
cassette
Figure 1-1. Schematic for apparatus used in screen film radiography.

product of tube current (in mA) and exposure time (in s) can be expressed in milliampere-seconds (mAs), which is
directly proportional to x-ray tube output.
11. What are the effects of increasing kV?
X-ray peak and mean energies increase, penetration power increases, radiograph exposure increases, and image
contrast (which primarily depends on kV) decreases.
12. What are the effects of increasing mAs?
X-ray exposure of a radiograph increases radiograph exposure. X-ray peak energy, mean energy, and penetration
power do not change.
13. What is screen film radiography?
In screen film radiography (Figure 1-1), a sheet of film coated with a light-sensitive silver halide emulsion is placed in
a light-tight cassette between two intensifying screens. The screens convert incident x-rays into visible light which
then expose the film. The exposed film is then removed from the cassette, developed, and fixed to create a hardcopy
radiograph.
14. What is computed radiography (CR)?
In CR, a photostimulable storage phosphor plate is used to transiently store a latent image following an x-ray exposure
in the form of electrons trapped within the phosphor. This latent image is then extracted offline by a separate
laser-based device that scans the plate to create a softcopy digital radiographic image that is stored electronically. CR
eliminates the need to store hardcopy radiographic film and improves the ability to adjust the brightness and contrast
of the digital image as needed.
15. What is digital radiography (DR)?
In DR (Figure 1-2), x-ray exposures upon a flat panel image detector are automatically processed into digital
radiographic images in a fully integrated device without further user interaction.
16. What is dual energy radiography?
In dual energy radiography, two radiographic images of a patient are (nearly) simultaneously acquired at two different
mean x-ray beam energies. These images are then combined to create a subtraction image to highlight either soft
tissue or bone components present in the patient, as these components differentially attenuate the x-rays at different
energies.
17. What is an anti-scatter grid?
An anti-scatter grid is a device, typically composed of narrow parallel strips of lead, that is placed between the patient
and the image detector. It blocks scattered x-rays from reaching the film but allows nonscattered x-rays that pass
from the x-ray tube and through the patient to reach the film, improving image contrast. The grid moves during the
x-ray exposure, so that the grid is not visible on the radiographic image.

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 CHAPTER 1 Introduction to Radiography, Fluoroscopy, and Tomosynthesis 5

Figure 1-2. Typical DR unit with x-ray tube located on right and anti-scatter grid and flat panel detector located on left.

18. What is the inverse square law?

The x-ray beam intensity decreases with the square of the distance from the x-ray source. Thus, if the distance
between oneself and an x-ray source is doubled, the x-ray exposure decreases by fourfold.
19. What is the difference between a posteroanterior (PA) and an anteroposterior (AP) radiograph?
These differ based on the direction of the x-ray beam passing through a patient. A PA radiograph occurs when the
x-ray beam enters from the posterior aspect of the patient and exits anteriorly to reach the x-ray detector. An AP
radiograph occurs when the x-ray beam enters from the anterior aspect of the patient and exits posteriorly to reach
the x-ray detector.
20. What are the five basic densities seen on a radiograph?
These include air, fat, soft tissue, bone, and metal. Air appears black on a radiograph, because it minimally attenuates
the x-ray beam. Bone appears white and metal appears even more white on a radiograph, because they both markedly
attenuate the x-ray beam. Fat and soft tissue attenuate intermediate amounts of the x-ray beam and appear dark gray
and brighter gray, respectively.
21. How does mammographic technique differ from that performed in chest and abdominal
radiography?
A lower kV (for higher image contrast) and a higher mA (for a shorter exposure time) are used in mammography
compared to those in radiography of the chest and abdomen.

FLUOROSCOPY
22. What is fluoroscopy?
Fluoroscopy is a projectional (2D) imaging technique that uses continuously emitted x-rays to perform real-time
imaging of a patient. An x-ray tube in the fluoroscope (Figure 1-3) emits an x-ray beam that passes through the
patient and falls upon an image intensifier. The image intensifier converts the x-ray radiation into visible light images
and amplifies them. These images are then displayed on a monitor and can be viewed or recorded.
23. What are some clinical applications of fluoroscopy?
Fluoroscopy is commonly used to evaluate the gastrointestinal tract with esophagography, an upper gastrointestinal
examination (to evaluate the stomach), a small bowel follow-through, or a barium enema (to evaluate the large bowel).
It is also commonly used in interventional procedures such as arthrography, myelography, and angiography.
24. What general types of contrast agents are used in gastrointestinal fluoroscopic studies?
Barium sulfate is the standard oral contrast agent used for routine gastrointestinal fluoroscopic studies. More viscous
suspensions are used for double-contrast (air and oral contrast) studies, whereas less viscous suspensions are used
for single-contrast (oral contrast only) studies. When gastrointestinal tract perforation is suspected, a water-soluble
contrast agent such as Gastrografin is instead utilized to prevent barium peritonitis, although it is contraindicated when
there is a risk of aspiration because it may induce acute pulmonary edema.
25. What is digital subtraction angiography (DSA)?
DSA is a fluoroscopic imaging technique in which a precontrast digital mask image is subtracted from images acquired
after intravascular contrast administration. This results in improved image contrast between contrast-enhanced vessels
and background, because background structures such as bone and soft tissue do not enhance and are removed from
the image.

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 6 PART I INTRODUCTION TO IMAGING MODALITIES

Figure 1-3. Typical fluoroscope with x-ray tube located on top.

TOMOSYNTHESIS
26. What is tomosynthesis, and how does it work?
Tomosynthesis is an x-ray-based imaging technique that is used to create high-resolution tomographic (cross-
sectional) images of a region of interest in the body. It works by first acquiring multiple x-ray images of a patient from
various angles with a digital flat panel detector and then using computer algorithms to reconstruct the data into
tomographic images.
27. What are some clinical applications of tomosynthesis?
Tomosynthesis can be used to potentially improve the detection of breast cancer (particularly in women with dense
breast tissue) compared to mammography and to improve the detection of small lung nodules in the chest compared
to chest radiography.

KEY POINTS
Radiography is an imaging technique that uses x-rays to create projectional (2D) images of a region of interest in the
body.
Fluoroscopy is a projectional (2D) imaging technique that uses continuously emitted x-rays to perform real-time
imaging of a patient.
Digital tomosynthesis is an x-ray-based imaging technique that is used to create high-resolution tomographic
(cross-sectional) images of a region of interest in the body.
Increasing kV increases the peak energy, mean energy, and penetration power of x-rays, increases radiograph
exposure, and decreases image contrast.
Increasing mAs increases the amount of x-rays produced, does not change x-ray energy or penetration power, and
increases radiograph exposure.

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