FLUOROSCOPY

Fluoroscopy is a real time X-ray imaging

 Phosphor screen → converts pattern of X-rays into a similar pattern of light for
real time imaging.
 Intensity of light is proportional to the intensity of X-rays & γ= 1.
Direct vision fluoroscopy (early days)
 The fluorescent material → copper-activated zinc cadmium sulfide → emitted
light in yellow-green spectrum.
 The radiologist's eyes was protected by a sheet of lead glass.
 Disadvantages:
 High doses.
 Low brightness, even with examination carried out in a dark room & with dark-
adaptation of eyes by wearing red goggles for 20 to 30 minutes.
So, was dependent only on the Rods "scotopic" vision & couldn't stimulate
the cones "photopic" vision.
 The use of direct-vision fluoroscopy is now BANNED.
N.B. IRR99 states that no one can do fluoroscopic examination without image
intensifier or similar device.

4.1.1 THE IMAGE INTENSIFIER:

Used to increase the brightness of the image, while maintaining its
proportionality with the X-ray beam intensity
As Fig. 12-3 shows,
 The tube itself is an evacuated glass
envelope, a vacuum tube, which
contains four basic elements:
1. input phosphor & photocathode
2. electrostatic focusing lens
3. accelerating anode
4. output phosphor
Glass Tube:
 2 - 4 mm thick.
 Enclosed in a lead-lined metal
container → shielding.
Input Phosphor Screen:
 230 mm in diameter, 0.2 mm
thick.
 Coated on the inside of glass tube.
 The input fluorescent phosphor →
Cesium Iodide (CsI).
→ deposited on a thin aluminum substrate by a process called "vapor deposi-
tion" → tiny needles perpendicular to substrate surface.
 Phosphor absorbs about 60% of the X-ray energy → converted into light.

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 Image quality is better with CsI screens than ZnCdS due to:
1- Vertical orientation of the crystals:
 ↓ lateral light diffusion → ↓ blurring & ↑ resolution
→ ↑ screen efficiency → ↓ patient dose.
 The resolution of a CsI image intensifier = 4 line pairs per millimeter (3 - 5).
2- Greater packing density:
 Since cesium iodide can be vacuum-deposited "requires no inert binder" → ↑
packing density.
 The packing density of cesium iodide is three times greater than that of zinc-
cadmium sulfide → Phosphor thicknesses have been reduced comparably from
approximately 0.3 mm with ZnCd sulfide to 0.1 mm with CsI.
3- A more favorable effective atomic number.
 The more appropriate atomic numbers of cesium and iodine give these screens a
substantial advantage over those made of zinc-cadmium sulfide.
 Ideally, for maximum photoelectric absorption, the K-absorption edge of a phos-
phor should be as close to the energy of the x-ray beam as possible, provided the
energy of the edge does not exceed that of the beam.
 The absorption edges of Cesium (at 36 keV) & Iodine (at 33 keV) are
favorably placed in relation to the effective energy of the X-ray spectrum
"which typically have a mean energy between 30-40 keV".
Fig. 4.2 Mass attenuation coefficient of cesium
iodide (Csl) and zinc-cadmium sulfide (ZnCdS)
versus photon energy with the X-ray spectrum
superimposed → shows that the greater part of the
spectrum of X-rays leaving the patient lies on the
high absorption side of the absorption edge of
cesium iodide.
Cesium iodide input screens absorb approx-
imately 2/3 of the incident beam as opposed to
less than 1/3 for zinc-cadmium sulfide, even
though the cesium iodide screen is only one
third as thick.
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Photocathode
 Photoemissive metal "Cesium-Antimony photoelectric screen".
 It is coated directly over the phosphor screen → so, the light from the CsI input
phosphor passes directly & strike the photocathode → emit Photoelectrons in
numbers proportional to the brightness of the screen.
 MCQ: the max. fluoroscopic tube current is mainly limited by Patient Dose
N.B.:
Older tubes had a thin light transparent barrier between the input phosphor and the
photocathode. Light diffusion in this barrier reduced resolution.
Electrostatic Focusing Lens
 The lens is a series of +ve cylindrical electrodes "usually plated onto the inside
surface of the glass envelope".
 These electrodes focus the electron beam as it flows from the photocathode toward
the output phosphor "so called electron lens".
 Each point on the input phosphor is focused to a specific point on the opposite
side of the output phosphor.
 The image on the output phosphor is:
1. Inverted and reversed due to electron focusing by point inversion "all
electrons pass through a common focal point on their way to the output
phosphor" (Fig. 12-3)
2. Reduced in size, which is one of the principal reasons why it is brighter.
 For undistorted focusing, all photoelectrons must travel the same distance → so,
input phosphor is curved to ensure that electrons emitted at the peripheral regions
of the photocathode travel the same distance as those emitted from the central
region.
Accelerating Anode
 Located in the neck of the image tube (Fig. 12-3).
 Has a positive potential of 25 to 35 kV relative to the photocathode
 Accelerate electrons emitted from the photocathode to a tremendous velocity
toward the output screen.
Output Phosphor Screen:
 Typically 25 mm in diameter.
 The output fluorescent screen of image intensifiers is silver-activated zinc-
cadmium sulfide, the same material used in first-generation input phosphors
 Output phosphor converts the electron pattern back into one of light.
 Crystal size and layer thickness are reduced "since it absorb electrons, not X-
rays, need only be a few micrometers thick" → maintain resolution in the minified
image.
 The number of light photons from output screen is increased approximately
50-fold than light produced at the input screen due greatly accelerated electrons.

3
 The phosphor is covered with Thin Aluminum Film, through which the
accelerated electrons penetrate to fall on the phosphor screen.
BUT, prevents light from the output phosphor to travel backward to the input
photoelectric screen and cause further emission of electrons & ultimately of light.
Otherwise, reduce the image contrast.
The metal housing provides some shielding against external magnetic fields as
well as X-ray protection (protection against X-ray that might penetrate the glass
envelop into the detector tube, causing false signals).
In summary:
 A uniform x-ray beam passes through and attenuated by the patient → passes
through the glass front of the image intensifier tube & enters the image intensifier
tube → The input fluorescent screen absorbs x-ray photons → converts their
energy into light photons in proportion to the intensity of incident x-ray beam →
strike the photocathode → emit photoelectrons → immediately accelerated away
from the photocathode by the high potential difference between it and the
accelerating anode → as the electrons flow from the cathode toward the anode,
they are focused by an electrostatic lens → guides them to the output fluorescent
screen without distorting their geometric configuration → electrons strike the
output screen → emits the light photons that carry the fluoroscopic image to the
eye of the observer.
 In the intensifier tube, the image is carried first by x-ray photons, then by light
photons, next by electrons, and finally by light photons.

 The output phosphor image is viewed either directly through a series of lenses and
mirrors, or indirectly through closed-circuit television "in modern systems".

Mirror optical system "shown in Figure 12-4"

Disadv.:
 Light travels a long distance.
 Small viewing angle → difficult to palpate
patient.
 One observer can view the image → a serious
disadvantage in training.

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RECORDING IMAGE:
 On photospot or cine film.
 From the TV camera signal "image degraded by the television chain" or by
directly exposing the film to the output phosphor "better".
 Beam Splitter allows continuous TV viewing while exposing the film → by
splitting the light from the II output into two paths at the time of film exposure
using a 45° semitransparent "partially silvered" mirror positioned in the light
beam:
 90% of light is reflected to the film camera.
 10% pass through the mirror to TV camera "still produce a satisfactory TV
image since the exposure level has been increased "
 the image may be coupled to the TV camera by a fiberoptic bundle.

Gain:
 The image is intensified, minified & inverted by the electron lens.
 For each X-ray photon absorbed by the input phosphor → about 400 light
photons are emitted → producing 400 photoelectrons → which cause the output
phosphor to emit nearly 400000 light photons.
 Intensification can be measured in two ways:
Brightness gain Conversion factor
Equals the ratio is a ratio of the luminance of the output
brightness of the output phosphor phosphor to the input exposure rate
brightness of the input phosphor Equals the ratio
Also called intensification factor. brightness of the output phosphor
(candela/m2)
dose rate in air on the input surface of
the intensifier (µ Gy/s)
not directly measurable Measured with a photometer and a
dosemeter employing a flat circular
ionization chamber, respectively
The overall brightness gain is typically Typical figures are in the range 15-25, but it
5000-10000 decreases with age and use.
 The brightness gain of an image intensifier comes from two completely unrelated
sources, called "minification gain" and "flux gain".

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Minification Gain
 Produced by a reduction in image size.
 The quantity of the gain depends on the relative areas of the input and output
screens.
d1 2
Minification gain = ( )
d0
where dl is the diameter of input screen, and d0 is the diameter of output screen
Minification gain increase overall gain by about 100 times
 With a 1-in. output screen, the minification gain is simply the square of the
diameter of the input screen; that is, a 9-in. intensifier has a gain of 81.
 The brightness gain from minification does not improve the statistical quality of
the fluoroscopic image as the same number of light photons make up the image
regardless of the size of the output screen.
 Theoretically, brightness can be increased indefinitely by minification, but also the
picture becomes more grainy → due to magnification of the fluoroscopic crystals
in the output screen.
Flux Gain
 It is the increase in the number of light photons due to acceleration of electrons.
 It increases the brightness by a factor of approximately 50-100.
 For each light photon from the input screen, as ejecting one electron from the
photocathode. The electron is accelerated to the opposite end of the tube, gaining
enough energy to produce 50 light photons at the output screen.
The total brightness gain of an image intensifier is the product of the minification and
flux gains:
Brightness gain = minification gain X flux gain

Dual- And Triple-field Intensifiers (Zooming)

 Image quality increase as the size of the input field is decreased.
 Dual-field or triple-field image intensifiers can be operated in several modes,
including a 4.5-in., a 6-in., or 9-in. mode "or even larger image intensifiers (12- to
16-in.)" → resolve the conflicts between image size and quality
 The 9-in. mode is used when it is necessary to view large anatomic areas.
 When size is unimportant, the 4.5- or 6-in. mode is used "better image quality".
 Field size is changed by applying a simple electronic principle: the higher the
voltage on the electrostatic focusing lens, the more the electron beam is
focused; In figure 12-7
 In the 9-in. mode, the electrostatic focusing
voltage is decreased → the electrons crossover
point move close to the output phosphor →
smaller final image.
 In the 6-in. mode, the electrostatic focusing
voltage is increased → the electrons focus
farther away from the output phosphor →
diverge to form larger image on the output phos-
phor than in the 9-in. mode.

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 The central part of the input image (6-in in diameter) then fills the whole of the
output phosphor.
 Effect of Zooming (adv. & Disadv.)
 Magnifies the image.
 Improves the sharpness "resolution"
 But, makes the image less bright "less minification gain" → exposure factors
are automatically increased to compensate for the decreased brightness →
increases the patient's skin dose (↑ scatter).
BUT the X-ray beam is automatically recollimated → ↓↓ volume of irradiated
tissue → ↓↓ scatter & improve contrast

Viewing and Recording the Fluoroscopic Image

 The development of the image intensifier allowed displaying the fluoroscopic
image on television.
 Its small output phosphor simplifies optical coupling,
 Its bright image produces a strong video signal.
CLOSED-CIRCUIT TELEVISION
 Components of a TV system are a camera, camera control unit, and monitor.

 Fluoroscopic television systems are always closed-circuit systems; "i.e. the video
signal is transmitted from one component to the next through cables rather than
through the air, as in broadcast television".
 A lens system or a fiberoptic system conveys the fluoroscopic image from the
output phosphor of II to the video camera → image is converted into a series of
electrical pulses called the video signal → transmitted through a cable to the
camera control unit → amplified → forwarded through another cable to the
television monitor → converts the video signal back into the original image for
direct viewing.
Nature of the video picture
The television image is made up of a mosaic of
hundreds of thousands of tiny dots of different
brightness → each contributing a minute bit to the
total picture.
 The individual dots are clearly visible at close
range & with magnification.
 The lines are close together in a small picture
tube and spread apart in a large tube, but in both
the total number is the same.

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 The dots are arranged in a specific pattern along horizontal lines, called horizontal
scan lines.
 The number of lines varies from one television system to another but, in the United
States, most fluoroscopy and all commercial television systems use 525 scan lines.
The UK TV systems uses 625 scan lines
Television Camera
 The vidicon camera is the one usually employed for fluoroscopy "relatively
inexpensive, compact unit"
 There are several types of vidicons; one is the plumbicon.
 The essential parts of a vidicon camera are shown in Figure 13-3.

 The most important part is the vidicon tube, a small electronic vacuum tube that
measures only 1 in. (25 mm) in diameter and 6 in. in length.
 The tube is surrounded by coils:
An electromagnetic focusing coil and 2 pairs of electrostatic deflecting coils
 The fluoroscopic image from the image intensifier is focused onto the target
assembly, which consists of three layers:
(1) Glass face plate; (2) Signal plate; (3) Target.
The glass face plate:
 Its only function is to maintain the vacuum in the tube.
 Light merely passes through the face plate on its way to the target.
The signal plate:
 A thin transparent film of graphite located on the inner surface of glass face plate.
 It is an electrical conductor with a positive potential of approximately 25 V.
The vidicon target:
 It is functionally the most important element in the tube.
 It is a thin film of photoconductive material, usually antimony sulfide (Sb2S3)
suspended as globules in a mica matrix.
In a plumbicon the photoconductive material is lead monoxide (PbO).
 Each globule is about 0.001 in. in diameter and is insulated from its neighbors and
from the signal plate by the mica matrix.
 The globules behave like tiny capacitors, which converts the light pattern
focused on it into pattern of electrical resistance (see later).
The cathode
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 Located at the opposite end of the vidicon tube from the target.
 Heated indirectly by an internal electric coil.
 The heating coil boils electrons from the cathode (thermionic emission), creating
an electron cloud.
 These electrons are immediately formed into a beam by The Control Grid,
which also initiates their acceleration toward the target.
 The cathode-heating coil assembly with the control grid are called "electron
gun" because it shoots electrons out of the end of the control grid.
The anode
 The electron beam progresses down the tube → moves beyond the influence of the
control grid into the electrostatic field of the anode.
 The anode has a positive potential of approximately 250 V relative to the cathode.
 The anode extends across the target end of the tube as a fine wire mesh.
 The wire mesh and signal plate form a uniform decelerating field adjacent to the
target.
The signal plate (+ 25 V) has a potential of 225 V less than that of the wire mesh
(+ 250 V), so electrons should flow from the signal plate to the wire mesh.
 The electrons from the cathode are accelerated to high velocity, but they are still
low energy electrons (about 250 eV).
 Then they coast through the decelerating field → by the time they reach the
target, they have been slowed to near standstill (they are now 25-eV electrons).
 The decelerating field also performs a second function: it straightens the final
path of the electron beam → so it strikes the target perpendicularly.
Electromagnetic Focusing Coil
 Wraps around almost the entire length of
the vidicon tube → creates a constant
magnetic field parallel to the long axis of
the tube → keeps electron beam in a narrow
bundle essential to scans the fine mosaic of
photoconductive globules.
 The electrons progress down the tube in a
series of oscillating spirals.
Electrostatic deflecting coils
 The electron beam is steered by variable
electrostatic fields produced by two pairs of deflecting coils that wrap around the
vidicon tube. "Time-varying voltages from a 'sweep generator'"
 Vertical deflecting coils are shown in Figure 13-4B.
 By alternating the voltage on the coils, the focused electron beam is moved up
and down to scan the target.
 The other pair of coils moves the beam from side to side along a horizontal line.
 All four coils, working together, move the electron beam over the target in a
repetitive scanning motion.
Video Signal

9
 When a globule absorbs light, photoelectrons are emitted (Fig. 13-5B).
 The electrons are immediately attracted to the anode and removed from the tube.
 The globule, having lost electrons, becomes positively charged.
 Since the globule is insulated from its surroundings it behaves like half of a tiny
capacitor, and draws a current onto the
conductive signal plate → this current that
flows onto the signal plate is ignored, or
clipped, and is not recorded (Fig. 13-5C).
 Similar events occur over the entire surface
of the target.
 A brighter area in the light image emits
more photoelectrons than a dim area, and
produces a stronger charge on the tiny
capacitors.
 The result is a mosaic of charged globules
that store an electrical image that is an exact
replica of the light image focused onto the
target.
 The electron beam scans the electrical
image stored on the target and fills in the
holes left by the emitted photoelectrons (i.e.
discharging the tiny globule capacitors).
 After the capacitors are fully discharged (no
more positive charges are left), no
additional electrons can be deposited in the
globules.
 Excess electrons from the scanning beam
drift back to the anode and are removed
from the tube.
 When the electrons in the scan beam
neutralize the positive charge in the
globules, the electrons on the signal plate
(Fig. 13-5D) no longer have an electrostatic force to hold them on the plate. They
will leave the plate via the resistor.
 These moving electrons form a current flowing through a resistor → a voltage
appears across the resistor which constitutes the video signal (Fig. 13-5E).
It was indicated earlier that the electrons in the electron beam were reduced to low
energy electrons before they entered the target. There are two reasons for this.
 The first Reason is that we want no electrons to enter the target after the positive
charge has been neutralized.
 The second reason is that the electrons should not have sufficient energy to
produce secondary electrons when they do enter the globules. "high energy
secondary electrons would be able to neutralize the positive charge in other
globules and degrade the image".
The globules are not all discharged at the same time.
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  Only a small cluster, a dot, is discharged each instant in time. Then the electron
beam moves on to the next dot in an orderly sequence, discharging all the
globules on the target.
 The result is a series of video pulses, all originating from the same signal plate
but separated in time.
 Each pulse corresponds to an exact location on the target.
 Reassembling these pulses back into a visible image is done by the camera
control unit and the television monitor.
Television Monitor
 The last link in the television chain is the monitor.
It contains the picture tube and the controls for regulating brightness and
contrast.

Figure 13-6 Television monitor

 A picture tube is similar to a vidicon camera tube (Fig. 13-6).
 Both are vacuum tubes and both contain an electron gun, control grid, anode,
focusing coil, and deflecting coils.
 A picture tube, however, is much larger.
 This evacuated glass envelope contains:
 at the narrow end, an electron gun (c), which projects a pencil of
electrons, shown as a dashed line in the figure,
 A phosphor screen (e) coated on the inside of the wide end of the envelope,
where the pencil produces a small dot of light.
 The focusing and deflecting coils are wrapped around the neck of the tube, and
they control the electron beam in exact synchrony with the camera tube.
 The brightness of the individual dots in the picture is regulated by the control grid
→ modulate the brightness of spot of light on the monitor screen.
 The control grid receives the video signal from the camera control unit, and uses
this signal to regulate the number of electrons in the electron beam.
 To produce a bright area in the television picture, the grid allows a large number
of electrons to reach the fluorescent screen. To produce a dark area, the grid cuts
off the electron flow almost completely.
 The anode is plated onto the inside surface of the picture tube near the fluorescent
screen. It carries a much higher positive potential (10,000 V) than the anode of the

11
 camera tube (250 V), so it accelerates the electron beam to a much higher velocity.
 The electrons strike the fluorescent screen at the flared end of the tube, which
makes the screen emit a large number of light photons. The generation of light pho-
tons over the entire surface of the tube is the visible television image.
 Many secondary electrons are set free by the impact of the electron beam with the
screen, and they are attracted to the anode and conducted out of the picture tube.
TELEVISION SCANNING
 The television image is stored as an electrical image on the target of the vidicon
tube, and it is scanned along 525 lines by a narrow electron beam 30 times per sec-
ond.
 Each scan of the entire target is called a "frame".
 The electron beam scans the target in much the same manner that we read a page in
a book, only it does not have to turn pages. Instead, as the beam reads, it also
erases. As the electron beam discharges the globule capacitors, it erases their
image.
 As soon as a line is read and erased, it is ready to record a new image, and it begins
immediately.
 Because the electron beam scans the target 30 times each second → our eyes
perceive a continuous motion as in a cine film.
 But, the eye can detect individual flashes of light, or flicker, up to 50 pulses per
second. A television monitor only displays 30 frames per second, so an electronic
trick, called interlaced horizontal scanning, is employed to avoid flicker.
 Instead of scanning all 525 lines consequently, only the even-numbered lines are
scanned in the first half of the frame, and only the odd-numbered lines are
scanned during the second half (Fig. 13-7).
 Each pass of the electron beam over the video target is called a field, and consists
of 2621/2 lines.
 Although only 30 frames are displayed each second, they are displayed in 60
flashes of light (fields), and flicker disappears.

Figure 13-7 Interlaced horizontal scanning

Synchronization
 It is necessary to synchronize the video signal between the camera and monitor to
keep them in phase with each other.
 The camera control unit adds synchronization pulses to the video signal at the end
of each scan line & scan field "horizontal and vertical synchronization pulses".
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 They are generated during the retrace time of the electron beam, while no video
signal is being transmitted.
 First, the picture screen is blackened by a blanking pulse, and the
synchronization signal is added to the blanking pulse.
 If the synchronization pulses were added to the video signal while the screen was
white → white streaks of noise.

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 TELEVISION IMAGE QUALITY
I- RESOLUTION
 Spatial resolution is the ability to detect a single small structure against its
background or to distinguish two separate structures close together.
 It is tested by imaging a bar 'test tool' or 'resolution grid' (Fig. 4.5a).
 The bars are strips of lead affixed to a Perspex plate.
 The bars are equally spaced & each space = the width of a bar.
 A bar and a space together make up a line pair.
 The spatial frequency = the number of such line pairs per millimeter
(lp\mm).
 Figure 4.5a also plots the brightness of the screen image (or the video signal)
along a scan line.
 The higher the spatial frequency → ↑ blurring & ↓ contrast.
 if the blurring is too large or the bars too narrow and too close together → the
blur of the edges of each bar merges with that of the adjacent one → the gap
between them cannot be distinguished.
 The effect of blurring is to worsen resolution
So, the smaller the blurring → the better the resolution.

 The spatial resolution of the system is defined as the spatial frequency of the finest
pattern that can still be resolved.
Video Signal Frequency (Bandpass)
 Bandpass "bandwidth", is the frequency range that the electronic components
of the video system must be designed to transmit without distortion.
 The frequency of the video signal fluctuate from moment to moment, depending on
the nature of the television image "that's why we need to set range for frequencies"

14
 Figure 13-9 The video signal from one scan line of a line pair phantom
 Figure 13-9 shows one scan line of an image containing 4 line pairs (4 lp) → So,
video signal for this scan line consists of 4 cycles.
 We can calculate the frequency "number of cycles per second" of the video signal
generated by the four-line-pair image by multiplying the number of cycles per
scan line (four in this case) by the number of scan lines per frame by the
number of frames per second:
cycles scan lines frames
X X = cycles/sec
scan line Frame seconds
4 x 525 x 30 = 63,000
 When the number of line pairs in the image changes, the frequency of the video
signal also changes.
Resolution of the TV system
The TV system degrades the resolution further due to:
 Mosaic structure of the TV camera image plate.
 The two aspects of the way in which the image is scanned:
1- Line structure
2- Bandwidth
VERTICAL RESOLUTION (depending on the line structure)
 VERTICAL RESOLUTION is determined by the number of vertical scan lines
(525 in our illustration) → the test pattern positioned with the bars horizontal.
 For a 525-vertical-line system, the maximum line-pair structure that can be
resolved on the TV monitor is 262 1/2 line pairs per TV monitor image.
 Factors affecting vertical resolution:
1. The smaller fields, in magnification mode → ↑↑ resolution.
2. ↑ monitor size with fixed number of horizontal scan line → ↓ resolution
 525-line system displayed on a 6-in. monitor has better resolution than a 13-
or 19-in. monitor. So, the image on a small TV screen will look better than
that on a large screen.
3. ↑ Scan lines → ↑ vertical resolution.
HORIZONTAL RESOLUTION (depending on the bandpass)
15
 HORIZONTAL RESOLUTION depends on the bandwidth of the TV monitor
electronics → to test it; the test pattern is turned with the bars vertical.
 For a 525-line system, lowest and highest frequency signals will be as follows:

The frequency of the video signal will fluctuate between a minimum of 15,750 Hz
and a maximum of 4,130,000 Hz (i.e. bandpass = 4.1 MHz).
 Actually, a somewhat higher bandpass is required, because about 10% of the
scan time is lost in retracing from one line to another.
 This additional 10% increases the required bandpass to approximately 4.5 MHz
for a 525-line system.
 At this bandpass, vertical and horizontal resolutions are equal.
Remember,
 Vertical resolution depends on the number of vertical lines (such as 525),
whereas horizontal resolution is determined by the bandpass.
 Most X-ray TV systems have a bandpass of 5 MHz with a 525-line system.
Interlacing is not entirely satisfactory; resolution may be impaired if tissues move
between the two halves of a 1/25 s frame.
 A high-resolution image intensifier (II) TV system employs 1250 lines, non-
interlaced ('progressive') scan, can resolve 2 lp\mm, but requires a bandwidth of at
least 25 MHz.
 Digital photospot imaging produces high resolution with the normal bandwidth.
 In film-screen radiography, the film can resolve 100 lp\mm whereas a slow
('detail') intensifying screen can only resolve 10 lp\mm, and a fast screen 5 lp\mm.
Resolution of different imaging modalities:
1. Radiographic film ALONE 100 lp/mm. (but needs very high dose)
2. Film-screen with Slow screens 10 lp/mm.
3. Film-screen with Fast screens 5 lp/mm
4. Image intensifier 4-5 lp/mm
5. TV system 1 lp/mm
6. High resolution non interlaced TV system (II-TV system) 2 lp/mm
7. Photo spot cut film 100mm 4-5 lp/mm
8. Photo spot cut film 35mm 2 lp/mm
9. CT 1 lp/mm
10. Gamma camera 1-2 lp/cm Very poor resolution!!!
11. Mammography 10-20 lp/mm (or 5-20)


16
 We assumed that a 525-line TV system actually uses all 525 lines to form an image
→ absolute maximum resolution (but, we never attain maximum values).
 In fact, significantly fewer than 525 lines are available for image formation →
some lines are lost to prevent the retrace and blanking signals from showing
on the TV screen.
 Resolution of 370 lines (185 line pairs) is typical in a 525-line system.
N.B. 200 line pairs are typical in the UK 625-lines TV system
 The overall resolution of the imaging system depends on the size of the input
image.
↑↑ size of II input image → ↓↓ resolution.

Table 13-1 Resolution of a TV Imaging System for Various-Sized Image Intensifiers

SIZE OF IMAGE INTENSIFIER
TELEVISION RESOLUTION (lp/mm)
in. mm
4.5 114 1.6
6 152 1.2
9 229 0.8
'Based on a 525-line TV system with a total resolution of 185 Ip.
 Even though a resolution of 1.6 lp/mm is a considerable improvement, it falls far
short of displaying the entire resolution of cesium iodide image intensifiers.
→ The only way that this resolution can be adequately displayed is with a film
system such as a 35 mm cine, or spot film cameras.
Resolution of the image intensifier
 The image intensifier itself has a spatial resolution of about 4-5 lp/mm (or better in
the magnification mode).
 It is principally affected by
 The blurring caused by light spread in the input phosphor.
 Less significantly in the much thinner output phosphor.
 Due to defects in the electron lens, the periphery of the image has
 Worse resolution than the center.
 Greater magnification → 'pincushion' distortion.
 The resolution is always stated in relation to the size of the X-ray image on the
face of the intensifier.
 Resolution with 100 mm cut film is nearly as good as that of intensifier itself. but,
resolution on 35 mm film is only about half that of intensifier.

17
CONTRAST
CONTRAST OF IMAGE INTENSIFIER
 Tested using a lead disc (1/4-in. thickness & its diameter = 10% of the input screen)
 The disc is placed over the center of the input screen → exposed to radiation →
brightness is measured at the output phosphor.
 Contrast is the brightness ratio of the periphery to the brightness in the center
of the output screen "representing area under lead disc".
Contrast ratios range from 20:1 to 30:1
 Two factors tend to diminish contrast in image intensifiers.
1- The input screen does not absorb all the photons in the x-ray beam.
 Some transmitted through the intensifier tube & few absorbed by output screen.
 These transmitted photons contribute to the illumination of the output
phosphor but not to image formation → produce a background of fog "↓↓
image contrast".
2- Retrograde light flow from the output screen.
 Not all retrograde light photons blocked by the thin layer of aluminum → some
penetrate through it → pass back to activate the photocathode to emits
photoelectrons
 These electrons produce "fog" → ↓↓ image contrast.
 Contrast tends to deteriorate as an image intensifier ages.
Veiling glare
 It is due to scattering of light in the output window of the image intensifier, and to
a lesser extent in the TV camera tube → ↓ contrast of the image.
 It is worse with the larger sizes of intensifier.
CONTRAST OF TV CAMERA & MONITOR
 Both the camera and monitor affect the contrast of a television image.
 A vidicon camera → ↓↓ contrast by a factor of approximately 0.8.
A plumbicon camera → does not cause any decrease in image contrast.
A Vidicon camera has γ = 0.8 while a Plumbicon tube has γ = 1.0.
Remember: ↑ γ → ↑ contrast
 The monitor enhances contrast by a factor of 2.
 The net result is a definite improvement in contrast > the image intensifier alone.
 Furthermore, both brightness & contrast levels can be regulated with the monitor
→ the optimum combination can be selected to best show a point of interest.
Dynamic range (latitude) of the television monitor
This is the ratio
maximum acceptable brightness of the TV monitor screen
smallest detectable brightness above black
Typically = 1000:1, which is usually expressed as 30 dB, as explained in Section 7.16.
The choice of kV and the TV contrast are made so that the range of tissues being
imaged fall within the dynamic range.

18
 LAG
Lag of image intensifiers:
 = persistence of luminescence after x-ray stimulation has been terminated.
 With old image tubes → lag times were 30 to 40 ms.
With CsI tubes → lag times are about 1 ms.
Lag of TV camera & monitor:
 An undesirable property of most vidicon tubes is lag or stickiness.
 Lag becomes apparent when the camera is moved rapidly during fluoroscopy
(i.e., the image blurs).
 Lag occurs because it takes a certain amount of time for the image to build up
and decay on the vidicon target.
 Plumbicon tubes demonstrate significantly less lag than vidicon tubes.
 The lag of a vidicon is usually not a problem with routine fluoroscopy, but may
become a problem in cardiovascular fluoroscopy.
 In one respect a certain amount of lag is actually advantageous.
It averages out the statistical fluctuations that occur with low-dose fluoroscopy
→ minimizes quantum mottle.
The image generated by a plumbicon tube will show more quantum mottle than a
standard vidicon image ‫الحلو ما يكملش‬.
AUTOMATIC BRIGHTNESS CONTROL
 Problem: ↑↑ X-ray intensity when moving from a high-attenuation to a low-
attenuation area "e.g. from the abdomen to the chest" → sudden increase of
brightness → the image becomes chalky, and all detail is lost.
 Solution: A 'feedback' system to control the brightness of the TV monitor
automatically → used in cineradiography & also in fluoroscopy.
 The brightness of the image is monitored either by:
(a) Measuring the (average) video signal or
(b) By a sensor 'watching' the brightness of the output phosphor.
Then sending orders back to the X-ray tube & generator to modulate exposure
factors (feedback system)
There are three ways to change the radiation input to the II input phosphor:
1. kVp variability 2. mA variability 3. pulse width variability
kVp Variability
 kVp will vary while mA stays constant.
 Advantages:
 Fast response times.
 Satisfactory images over a wide dynamic range.
mA Variability
 The best general purpose automatic brightness control system.
 Varies the mA as needed with a convenient kVp control → offers the operator to
control of kVp.
 Advantages: relatively simple and inexpensive method.
 Disadvantages:

19
  Slow response time "changes in mA require change the temperature of the x-ray
tube filament".
 The dynamic range of this control is less than the kVp-variable units → operator
must choose appropriate kVp.
Combined Control
A number of systems vary both kVp and mA to control brightness → wide dynamic
range.
Pulse Width Variability
 Advantage: very fast response times - very broad dynamic range - allows the
operator to choose the mA and kVp levels best suited for the examination.
 The length of each exposure is controlled with a grid-controlled x-ray tube or a
constant potential generator with secondary switching.
AUTOMATIC GAIN CONTROL
 It is a simple and inexpensive way to control image brightness.
 It varies the brightness of the TV system by 1) varying the sensitivity of the TV
cameras or 2) varying the gain of the TV amplification system.
 Disadvantages
 It does not change the x-ray dose rate to the patient → unnecessary patient
exposure.
 Not improve quantum mottle and will increase electronic noise.

Noise
 Quantum mottle is noticeable in fluoroscopy > radiography.
 Noise is due to the statistical fluctuations in the number of X-ray photons absorbed
in the input phosphor → similar fluctuations in the brightness of the image, the
density recorded on a spot film and the video signal voltage from the camera tube.
 Noise reduces the perceptibility of a structure having low contrast.

Fig. 4.6 Resolution tests grids (a), (b) and

(c) having different inherent contrasts and
the corresponding plots of video signal or
image brightness along a scan line,
showing the effect of noise on
perceptibility.

 Figure 4.6 depicts part of each of three resolution grids having (a) high, (b)
medium, and (c) low contrast, made perhaps with strips of lead, aluminum, and
Perspex, respectively.
 The bars can easily be resolved in Fig. 4.6a. They can still be resolved in Fig. 4.6b,
but they would not be if the noise were greater. In Fig. 4.6c the contrast is
20
 completely obscured & the bars can't be distinguished from spaces between them.
 Thus the structures cannot be distinguished, if :
 The noise is too great.
 The contrast difference is too small.
 The structures are too small, or too close together.
 With a typical average dose rate in air of 1-2 μGy s -1 on the surface of the image
intensifier, during the 1/6 s time constant (lag) of a Vidicon camera tube, an
average of 3000 X-ray photons might be absorbed in each square millimeter of the
input phosphor.
 As a result, when trying to see a structure 1 mm 2 in size, the noise is 3000
, which is 2% of the signal.
 The signal-to-noise ratio (SNR) is 50:1.
 For a structure to be detectable, the contrast must be at least 2-5 times the noise
relative to signal.
So, a structure 1 mm in size will be seen against its background provided its
contrast is at least 5%.
 The image of a small structure is produced by the absorption of relatively few
photons and is noisy, and to see it requires a high contrast.
Either a high dose rate is used to increase the SNR, or the inherent contrast of the
object has to be increased, e.g. by changing the kV or using a contrast medium.
 Fig. 4.7, the solid curve plots on a
logarithmic scale the min. contrast
needed to see structures of different
diameters.
 Obtained using a special test object
(e.g. Leeds TO 10) with II.
 Details having a size and contrast
falling in region A can be resolved;
those falling in region B cannot.
 The dashed line shows the
improvement in perceptibility
produced by ↑ dose rate & ↓ noise.
To summarize:
 the contrast resolution (= smallest detectable contrast) improves with larger details;
 the spatial resolution improves with higher contrast;
 ↑↑ the dose rate → ↓↓ noise & improves the inherent detectability of all structures.
 This relationship (or 'trade-off') between spatial resolution, contrast and noise or
dose applies to all forms of imaging (digital, CT, gamma, etc.).
In film-screen radiography, noise is too small to affect the details.
 The lag in a Vidicon camera tube smooths out the statistical fluctuations and
reduces noise or mottle.
A Plumbicon tube shows less lag and less movement blurring but more noise.
 The noise is worse in the areas of the image where the brightness is low.

21
  Improved by ↑ the tube current & X-ray intensity → so, the quality of the image
is dose limited or photon limited
 But, increase patient dose.
 Full advantage cannot be taken of the brightness gain of an II in the reduction of
patient dose.
 The mA cannot be reduced much below that formerly used in direct vision
fluoroscopy → otherwise, increase noise.
 The real advantage of the image intensifier → the contrast and definition of the
image can be seen in ambient lighting and by more than one viewer "due to the
brighter image".
Typical doses and dose rates
 Images with acceptable noise are produced by the following approximate doses
and dose rates on the input surface of the image intensifier:
Fluoroscopy 1 μGy\s
Photospot film 1 μGy\frame
Cine 0.1 μGy\frame
Digital 10 μGy\frame
 Due to attenuation by the patient, grid, and couch top, the skin proximal to the tube
will receive doses around 300x greater. See also Section 6.7.
Quantum Sink
 The information in the image also suffers from statistical fluctuations in all the
other discrete 'events' occurring in the image chain:
→ Light photons emitted by the input phosphor
→ Photoelectrons emitted by the photocathode
→ Light photons emitted by the output phosphor
→ Electrons constituting the video signal, etc.
 The noise produced in each of the above stages is relatively low since the number
of light photons and electrons involved is very large.
 The Quantum Sink is It is the weakest link in the imaging chain
 The part of the system where the number of photons or electrons/mm 2 of the
image field is lowest → the relative noise the largest and the SNR the lowest.
 In an II-TV system, it lies in the absorption of X-rays in the input phosphor.
In radiography, it lies in the absorption of X-rays in the intensifying screens.
Vignetting
 Vignetting means that the center of the final
image is brighter than its edges.
 Figure 4.3b shows that all the light from the
center A of the output phosphor (2) that is
collected by the first lens (3) is collected
and focused by the second lens (4) onto the
image plane (5) at A'.
 However, some (perhaps 25%) of the light
from the edge B of the phosphor that is
collected by the first lens misses the second
22
 lens so that the image at B' is less bright.
 This occurs in the electron lens system also.

DISTORTION
 The electric fields that accurately control electrons in the center of the image are
not able to control peripheral electrons to the same degree.
 Peripheral electrons tend to flare out from an ideal course → do not strike the
output phosphor where they ideally should & are not well-focused.
 The result is unequal magnification → peripheral distortion.
 The amount of distortion is always greater with large intensifiers "the further an
electron is from the center of the intensifier, the more difficult it is to control".

Figure 12-6 Test film of a wire screen (35 mm

cine frame) from a 9-in. image intensifier

 Figure 12-6 shows a cine image of a coarse wire screen taken with a 9-in.
intensifier. As you can see, the wires curve out at the periphery; this effect is most
noticeable at the corners.
 This same effect has been observed in optical lenses and termed the "pincushion
effect," and the term is carried over to image tubes. The distortion looked like a
pincushion to the guy who named it.
 Generally this distortion does not hamper routine fluoroscopy, but it may make it
difficult to evaluate straight lines (for example, in the reduction of a fracture).
 Unequal magnification also causes unequal illumination.
 The center of the output screen is brighter than the periphery (Fig. 12-6).
 The peripheral image is displayed over a larger area of the output screen, and thus
its brightness gain from minification is less than that in the center.
 A fall-off in brightness at the periphery of an image is called vignetting.
 Unequal focusing has another effect on image quality; that is, resolution is better in
the center of the screen.
In summary, the center of the image intensifier screen has better resolution, a
brighter image, and less geometric distortion.

FLUOROSCOPIC IMAGE RECORDERS

 There are two modes of recording the fluoroscopic image.
First, Light Image Recorders
 The light image from the output phosphor of the image intensifier may be
recorded on film with a photospot camera or cine camera.
 Routine spot films are made directly with x rays.
Second, TV Image Recorders
23
  It makes use of the electrical signal generated by the TV camera.
 This group includes magnetic tape, magnetic discs, and optical discs.
 The three recorders may employ either analog or digital signals.
LIGHT IMAGE RECORDERS
Conventional Spot Film Recorder
 Spot film devices interpose an x-ray film cassette between the x-ray beam and the
image intensifier tube.
 The standard 91/2-in. square cassette is now replaced with several sized cassettes.
 During fluoroscopy, the radiologist can at any time move the cassette from its park
position (shielded by lead) to a position ready for exposure → But, there is a delay
before a film moved into position and an exposure made (3/4 - 1 sec).
Several factors make this delay necessary:
 First, Heavy cassette.
 Some changes at the x-ray factors are required.
 Fluoroscopy is conducted at about 80-90 kVp and 1-3 mA of tube current.
 Spot film uses fluoroscopic kVp, but requires much higher mA (300-400 mA)
 So, time is required to increase x-ray tube filament heating, and the x-ray tube
anode rotation speed.
 A phototimer controls the length of exposure.
Spot "or Photospot" Film Cameras
 Records the image output of an image intensifier on a film.
 Produce reduced size images: typically, the film is roll film of size 70 or 105 mm,
or cut film 100 mm in size.
Recall that the light from the output phosphor of the image intensifier is converted into a parallel
beam image by a lens placed close to the output phosphor (refer back to Fig. 12-5). A
semitransparent mirror placed in this parallel beam will allow about 10% of the light to travel on to
the TV camera, and reflect the remainder to a photospot camera or a cine camera
 Originally, it was confined to gastrointestinal fluoroscopy → now used for all
fluoroscopic images, including angiography.
This has been made possible by the improved resolution of cesium iodide image
intensifier tubes.
Large input phosphor diameters up to 16 in. allow large areas of the body to be
imaged without moving the image intensifier → a single photospot film can cover
almost the entire abdomen (this could not be done with a 9-in. tube).
Advantages:
1. Most significant → Marked reduction in patient exposure.
 The recommended per-frame exposure for photospot film cameras is 100 µR.
The exposure for a comparable spot film is 300 µR, three times as much.
 Generally, the dose to the patient is 3-5 times smaller than with full-size
(cassette-loaded) film.
N.B. 100 mm film requires a greater patient dose than 70 mm.
2. For gastroenterology, cameras are more convenient than conventional spot
films.
 The film does not have to be changed between exposures.

24
  The delay between initiation and completion of an exposure is shorter.
 Exposure times are shorter (in the 50-ms range) → ↓↓ motion.
 High framing frequency = 12 frames/second.
3. it is possible to record and view the image at the same time → since the camera is
recording directly from the output phosphor.
4. The resolution of the resulting films is that of the image intensifier, about 4 line
pairs per mm (a range of 3 to 5 Ip/mm).
Resolution of routine spot films is theoretically greater than that of spot film
camera films → but longer exposure times required for spot films may degrade the
image because of motion unsharpness.
5. Savings in film costs of greater than 80%.
Disadvantages:
 The little films are a nuisance to process and store.
 It needs practice to feel comfortable looking at angiograms on small format.
 The sharpness or resolution, being that of the image intensifier, is less good.

CINEFLUOROGRAPHY
 Cinefluorography is the process of recording fluoroscopic images on cine film.
 Records from the output phosphor of the image intensifier.
 A beam splitting mirror allows simultaneous cine recording and television viewing,
just as with spot film camera recording.
 Two film sizes: 16 mm and 35 mm.
 In the United States, 98% of all cine is done on 35 mm film, and 95% of all cine
studies involve the heart. Therefore, our major emphasis will be on 35 mm cardiac
cinefluorography.
Cine Camera
 The basic components of the camera are:
 Lens.  Shutter.  Pressure plate.
 Aperture  Pulldown arm.  Film transport mechanism.
 Light enters the camera through the lens and is restricted by the aperture.
 The shutter is a rotating disc located in front of the aperture with a sector cut out
of its periphery.
As the shutter rotates → it interrupts light flow into the camera.
 While the shutter is closed, the pulldown arm advances the film to the correct
position for the next exposure (Fig. 13-13).
 The x-ray pulses and shutter opening are synchronized.

25
 Figure 13-13 Cine camera
 The framing frequency = 60 "divided or multiplied by a whole number (e.g., 71/2,
15, 30, 60, or 120)".
 The combination of the framing frequency and shutter opening determines the
amount of time available for both the exposure and pulldown.
For example, with a 180° shutter opening and 60 frames per second, the time
available for both the exposure and pulldown is 1/120 sec.
Framing
 Framing is controlled by the lens of the cine camera.
 Exact framing means that the entire image (the output phosphor of the II) just fits
on the cine film.
 Over-framing means that only a portion of the image is recorded on the film →
so, some of the output image is not recorded.
 The film image with overframing is larger than the film image for exact framing,
and this increased size is usually desirable.
 Extremes of overframing are generally avoided because patient exposure in areas
not recorded is undesirable.
 Framing characteristics are established when the cine system is installed.
X-Ray Exposure
 The timing and intensity of the x-ray exposure are controlled during
cinefluorography by two electrical signals that originate from within the cine
system.
 One signal coordinates the x-ray exposure with the open time of the camera
shutter (synchronization).
 The other maintains a constant level of intensifier illumination by varying the
exposure factors for areas of different thickness or density (automatic brightness
control, mentioned before).
Synchronization
 In old cinefluorographic equipment, x rays were generated continuously

26
 throughout a filming sequence → the patient was needlessly irradiated when the
camera shutter was closed.
 These continuous exposures had two serious disadvantages:
 Large patient exposures.
 Decreased life expectancy of the x-ray tube.
 In all modern cinefluorographic systems → the x-ray output is intermittent & the
synchronized with the open time of the camera shutter.
 The shutter of the camera is timed by 60 Hz power → permits shutter speeds that
are fractions or multiples of the number 60 (e.g., 7 1/2 , 15, 30, 60, and 120 frames
exposed per second).
At low framing frequencies the image flickers because the x rays are pulsed, but
flicker does not interfere with monitoring.
TV IMAGE RECORDERS
 The second method of recording the fluoroscopic image involves recording the
electrical signal from the TV camera.
 This includes: magnetic tape, magnetic disc, and optional disc recorders.
Video Tape Recorders
 The 'write' head of the recorder is a small coil which has a narrow gap in its
closed iron core.
 The video signal is applied to the 'write' head → translates the video signal into a
time-varying magnetic field → the signal is recorded as variations in the
magnetism of the ferrous oxide coating of a plastic tape which travels at a high
speed across the narrow gap.
 Switching from the 'write' or recording mode to the 'read' or playback mode → the
traveling magnetic tape induces in the coil a voltage signal which, after
amplification, reproduces the image on the TV monitor. Alternatively a video disk
may be used.
 Contrast and brightness can be varied as with any TV image.
 The dose to the patient is less than with cineradiography but the quality of the
image is worse.
 No processing is needed; instant replay and frame freeze are possible.
 Magnetic tape is low in cost and widely used.
But it has significant limitations:
 The rate of data recording is limited by the speed of tape movement.
 Long time is needed to retrieve a stored image.
 Not a good permanent recording medium due to tape wear and degradation of
the recorded data → so, needs proper storage.
 Shelf life of magnetic tape is about 2 years.

27
 4.2 DIGITAL IMAGING
 The radiological images considered so far are analog images. In particular, the
video signal from the TV camera tube is an analog signal, a voltage which varies
smoothly as the image brightness is scanned in the raster of horizontal lines.
 If it is converted to digital form, the image can be enhanced in various ways - and if
necessary stored - using a computer, before it is displayed on a video monitor or
printed via a laser camera.
4.2.1 EQUIPMENT
Digitizer
 The video signal from the TV camera → applied to an analog-digital converter
(ADC) or digitizer.
This samples the signal at equally spaced intervals (say) 512 times along each of
512 scan lines.
 Figure 4.8 shows how the video signal varies during the time it takes to scan a
single line and how it is sampled at regular intervals.

Fig. 4.8 Sampling and digitization of a video signal along a scan line.
 The voltage at each data point, which gives the grey level, is expressed as the
nearest 10-bit binary number between 00000 00000 = (0) & 11111 11111 (= 1023)
Computer
 The image has in effect been divided into a matrix of 512 x 512 pixels (Fig. 4.9a).
Each pixel is roughly a square of side 0.5 mm. This permits a resolution of 1 mm
(= two pixels).
 The same diagram can be taken to represent a corresponding 'frame' of 512 x 512
memory locations in the core memory of a computer (microprocessor).

Fig. 4.9 Three successive image frames of a

digital image, each a matrix of pixels or
memory locations.

28
 The binary numbers representing the image brightness or 'grey level' of each pixel
are stored in a frame of 512 x 512 memory locations.
 Each location has an 'address', expressed as two binary numbers and is '10 bits
deep'. This requires a storage capacity of 10 x 512 x 512 bits = 320 kilobytes
(where 1 byte = 8 bits).
 Thus a 40 megabyte RAM (random access memory) can store 128 separate
images.
 If the sampling frequency were to be doubled, to 1024 per scan line → the pixel
size would be halved → the matrix size doubled, and → the resolution improved
by a factor of 2.
However, the 40 megabyte RAM could then only store 30 separate images.
For further remarks about sampling frequency, see Section 9.2.
Image display
 The image is displayed by reading out of the computer memory the brightness or
grey scale values of the pixels in sequence, in synchronism with the electron pencil
scanning the monitor (cathode ray tube).
 The data from the computer are converted into an analog voltage signal (by a
digital-analog converter, DAC) which modulates the brightness of the spot of light
on the screen.
Lost frame hold
A simple application is to store the last image of a fluoroscopic examination so that it
can continue to be observed on the monitor without continuing to expose the patient
('freeze frame').
Digital photospot high-resolution, slow television scan
 A very short exposure at high mA is made, thus freezing movement → the video
system is made inoperative ('blanked') during the actual exposure → the camera
then scans the image → writes it into the computer memory with a 1024 line
progressive (non-interlaced) raster at 6.25 frames /sec "four times more slowly
than normal" → thus allowing the usual bandwidth to be used.
 The stored image is read out of the memory at the usual 25 frames /sec for flicker-
free display on a monitor or is recorded with a laser camera.
 The spatial resolution is typically 2 lp/mm, compared with 4 lp/mm for an
ordinary photospot, but with the advantages of digital imaging.

29
4.2.2 Image Processing, Storage, And Recording
The below methods of processing, storing, and recording a digital image all find general application
in CT, gamma imaging, digital ultrasound, and MRI.
Before reading out the stored image from memory, the grey scale numbers in each
address can be processed and manipulated in a number of ways.

Fig. 4.10 Windowing

Windowing
 Windowing is sometimes called 'grey level mapping'.
 The digitized image contains more information than can be seen at once on the
monitor screen.
 The image stored in a 10-bit computer contains 1024 discrete intensity levels,
represented by scale a in Fig. 4.10 → but the eye can only distinguish about 32
gradations of brightness on a TV screen.
 A small range of values b, the window width, centered on the window level c, is
selected for display on the monitor as (say) 32 distinct shades of grey f in the range
from black to maximum white.
 Intensities in the range d are not differentiated, being all displayed as white, while
those in the range e are all displayed as black.
 It is possible to visualize subject contrast only in the structures or tissues whose
image lies within the window width.
 The window level is the mid-range value of the window, and it and the window
width can be independently set at the controls.
By moving the window level into the image areas d or e, these parts of the image
then become differentiated and can be visualized.
 Value:
 It allows the contrast and the average brightness of the image to be optimized
within the tissues and region of interest.
 It allows the speed and γ or latitude of the imaging system to be altered at will,
subsequent to a single X-ray exposure → cannot be done in film-screen
radiography.
 This feature can outweigh the poorer resolution of digital compared with film-
screen radiography.

30
Background subtraction
 A technique used to reduce the effect of X-ray scattering and veiling glare.
 Subtraction of the same number from each of the stored pixel values will increase
contrast. (This is the opposite of the effect of scatter or fog reducing contrast on a
radiograph.)
Noise reduction by frame addition or averaging
 Several successive images of the same subject, stored in memory, are added
together and averaged, pixel by pixel.
 The useful signals are in the same locations in all frames and so will add up.
The noise varies randomly from frame to frame & therefore partially averaged out.
 As a result, the SNR is improved by a factor = the square root of the number of
frames so averaged.
 This is sometimes called 'digital temporal altering'.
 It depends on the patient being immobile while the several images are acquired.
Noise reduction by 'low-pass spatial filtering'
 To the grey scale value of each pixel is added a proportion of the pixel values of
the eight surrounding pixels and an average taken → reduces noise but can impair
spatial resolution.
 Small bright or dark areas are removed whether they are noise or real images,
while leaving the images of larger objects.
 It can be compared to turning up the bass control of a hi-fi system.
Digital filtering is further explained in Section 9.1.
Edge enhancement by 'high-pass spatial filtering'
 Where the pixel values change at an edge or boundary in the image, the gradient
can be enhanced mathematically (It achieves digitally the edge enhancement feature
inherent in xerography - see section 3.11)
ADV. & DISADV.:
1. Reduce the effect of blurring in the imaging system. → enhance those parts of
the image with fine structure detail
2. But, increases noise.
 It can be compared with turning up the treble control of a hi-fi system.
Data shifting
 The pixel values can be moved horizontally and/or vertically within a frame, and
the image can be shifted, inverted, rotated, or even stretched.
Image storage
 A number of separate images can be stored in real time, usually in a solid state
memory (RAM).
 Access to stored images is rapid (microseconds) but the storage capacity is
limited by cost.
 To make the RAM available for further images → the stored data are transferred to
a magnetic disk "medium-term store" → access is reasonably fast (milliseconds),
and may be either:
1. A floppy disk, which is portable but has a storage capacity of only about 1
31
 megabyte, or
2. A hard (Winchester) disk able to store several thousand images.
 For long-term storage (archiving), the images are transferred to optical disks which
have a capacity of many gigabytes.
The digital information is burnt by a laser into a specially coated disk "the cheapest
form of storage".
Digital magnetic tape storage is also used, and has a very high storage capacity
(optical tape is even better), but again access is relatively slow.
 When required, digitally stored images can be played back into the solid state
memory and, after any necessary manipulation, displayed on the screen.
 A series of still images tan be presented in rapid sequence ('cine' mode).
CAMERAS
 The image on the monitor screen can be recorded on single-coated photographic
film (formulated so that its spectral sensitivity matches the light emitted by the
cathode ray tube phosphor), and it can be processed in the normal X-ray film
automatic processor.
 To obtain good images:
1. The cathode ray tube must be of a high grade; and
2. The film correctly exposed.
This is achieved by a light sensor attached to a corner of the screen which feeds
back to the modulator grid of the electron gun and controls the brightness of the
screen.
Laser Camera:
 A laser camera can be connected directly to the digital processor, bypassing the
cathode ray tube.
 A helium-neon gas laser (for example) emits a beam of light only 70 μm in
diameter → scanned in a raster across a moving film by means of a rotating or
oscillating mirror → so records the image.
 The image is recorded by reading out of the memory the brightness or grey scale
values of the pixels in sequence, in synchronism with the laser beam scanning the
recording film.
 The data from the computer are converted (by a DAC) into an analog voltage
signal winch modulates the brightness of the laser beam, it takes a total of 20 s to
scan a film, which, on account of the narrow laser beam, can record about 4096 x
4096 pixels, with a resolution of 10 lp\mm.
 The single-coated film is specially formulated for infrared and the automatic
processor. A green safelight may be used.
Multiformat Camera
 In a multiforrnat camera (whether conventional or laser) the whole of the screen
image can be made to fill either the whole film or just a part of it, in which latter
case a number of images may be recorded, reduced in size, side by side.

32
 4.3 COMPUTED TOMOGRAPHY (CT)
In CT scanning:
(a) A transverse slice of the patient "say 10 mm thick" is imaged → avoiding the
superposition of adjacent structures.
(b) The slice is defined by a 'sheet' of X-rays, produced by a narrow fan beam rotated
around the patient → ↓ scatter.
(c) The slice is subdivided into a matrix of 512 x 512 volume elements (voxels) , each
typically 0.5 x 0.5 x 10 mm. The image is reconstructed by a digital computer as a
corresponding matrix of 512 x 512 picture elements (pixels).
(d) The computer allows the use of 'windowing' (see Section 4.2.2) to selectively
display a restricted range of tissues.

.
Fig. 4.13 Matrix of tissue voxels,
corresponding memory locations in the
Fig. 4.12 Principle of CT imaging computer or image pixels.

 From (a), (b), & (d) → contrast resolution is more than conventional radiography
From (c) → the spatial resolution is less good
N.B. contrast resolution = the ability to display low contrast structures.
 The image is displayed as a matrix of pixels, each 0.5 x 0.5 mm.
 The brightness or grey scale value of each pixel in the image = the average
linear attenuation coefficient μ of the contents of the corresponding voxel.

33
 4.3.1 PRINCIPLE OF COMPUTED TOMOGRAPHY IMAGING
CT numbers
 The linear attenuation coefficient μt of each tissue pixel is compared with that μw
of water by the formula:
(μt - μw)
CT number = 1000
μw
 Water is used as the reference material because:
1) Its attenuation coefficient is close to those of soft tissues.
2) It is a reproducible material for machine calibration.
 The multiplier (1000) is used to obtain whole numbers.
 The CT number (or Hounsfield number) is defined as
 -1000 for air.  0 for water.
 For tissues CT number is depends on the kV employed. for example;
 If, at 80 keV the linear attenuation coefficient of typical bone and water are
0.38 and 0.19 cm-1, respectively → the CT number of the bone is +1000.
 CT number is higher in the case of cortical bone.
Scanning the patient:
 Commonest CT scanner use rotating anode tube with a 0.6 mm focal spot.
 It must have a high heat capacity because the examination takes several seconds.
 The tube is mounted with its axis perpendicular to the slice → ↓↓↓ heel effect.
 The X-rays are collimated to leave the tube into a fan beam which just covers the
body section.
 After emerging from the patient, the transmitted beam passes through a second
collimator set, accurately aligned with the first; both sets being motorized to set
the slice thickness.
 The beam then falls on a curvilinear array of (say) 700 detectors, individually
collimated and all carefully matched in sensitivity → convert the transmitted beam
intensity into a proportional signal current.
 The tube & detectors, mounted on opposite sides of a ring, rotate smoothly
around the patient.
In the 360° rotation, X-ray tube is pulsed 300 times. Each pulse lasts 2 - 3 ms, &
the scan can take about 1 s.
Acquiring the data
 Each time the tube is pulsed, each detector measures the logarithm of the
intensity of the radiation falling upon it "these are related to the sum of all the
CT numbers of the voxels each ray has passed through" → called Ray Sum.
 The set of ray sums collected at each position of the tube is called Projection.
 Each individual voxel is traversed by an X-ray pencil from several different
directions during the 360° rotation of the ring, to calculate CT number of voxel.
 If a pencil beam of width t passes obliquely through a pixel of size t x t, some of
the contents of the pixel will be 'missed' → the computer correct that.
Reconstructing the image

34
 In principle, if we have 256 x 256 voxels & 700 (detectors no.) x 300 (pulses no.)
ray sums → enough data for the CT numbers of all the voxels.
 The arithmetic involved can be performed in a sufficiently short time by a
computer and by taking various short cuts, e.g. ('filtered back-projection') → the
CT image can be produced in close to real time.
 The CT numbers so computed are stored in the computer memory locations, each
of which corresponds to a voxel and therefore to a pixel, as in Fig. 4.13.
Back-projection

Fig. 4.14 Back-projection: schematic, (a) Pencil beam routing around a small dense structure, (b-d)
image reconstructed with increasing numbers of projections.
 Imagine one voxel, the contents of which have a higher μ than its surroundings.
 As depicted in Fig. 4.14a, an X-ray pencil traverses the voxel and the ray sum
is measured. In principle, a stripe of light could now be projected backward along
the direction of the X-ray & its intensity being proportional to the ray sum.
 Repeating this for each of the rays which traverse the voxel in the course of a scan
would build up an image of the structure (Fig. 4.14b).
 With a moderate number of stripes the image would be spiky (Fig. 4.14c).
With ↑ number of stripes → blurring of edges of the image (Fig. 4.14d).
 The blurring could be removed by modifying the brightness near the edges of
each back-projected beam or stripe - a process known as 'filtering'.
 A simplified mathematical example is
given in Fig. 4.15, in which an array of 9
pixels is scanned from 4 successive
directions producing the ray sums shown.
 The 3 ray sums in Fig. 4.15a are entered
(as in Fig. 4.14e) into the memory-
locations corresponding to each of the
voxels encountered by each ray. Similarly
the ray sums shown in Fig. 4.15b-d.
 Adding the numbers (Fig. 4.15e-h),
results in the totals shown in Fig. 4.15i.
 A little further arithmetic manipulation,
involving background subtraction and
rescaling, finally yields Fig. 4.15k. This
is a fair representation of the CT numbers
of each pixel.
Filtered back-projection

35
 The blurring introduced by the back-projection process can be compensated by
a mathematical process carried out by the computer called 'filtering' → modifies the
brightness near the edge of each back-projected beam.
Filtering algorithms different "filters" can be used
 'Bone' algorithm → enhance fine detail but increase noise.
 'Soft tissue' filter → improve contrast by smoothing out noise, but impairs the
spatial resolution.
Windowing
 Although the scanner can distinguish
2000 different CT numbers, BUT the eye
cannot distinguish nearly as many
separate shades of grey on the screen.
 Soft tissues (excluding fat) only cover a
range of about 80 CT numbers.
 So a window is chosen which just
embraces all the tissues of interest, and
only these are displayed as shades of grey
within the range black to maximum white
on the monitor.
 Pixels with CT numbers outside this
window are undifferentiated, being
displayed as either black or white.
 Window level and window width can be
set independently at the control panel, for
example to differentiate lung tissues.
 They only affect the displayed image; the
whole of the data referring to the
reconstructed image is retained in the
computer.
Partial volume effect
 CT cannot reveal detail within a voxel.
 It measures the average CT number of the contents of each voxel.
 A high-contrast object occupying only part of a voxel will raise the CT number for
the corresponding pixel and so appear larger than it is → e.g. tiny calcifications
and small traces of contrast medium.
 The partial volume effect is reduced by using thinner slices & smaller pixels.
Beam-hardening effect
 The use of a relatively high kV (typically 120 kV constant potential):
 Reduces both patient dose and the hardening of the beam by the patient.
 Unfortunately, reduces efficiency of the detector and also the image contrast.
 It also increases scatter, making necessary the collimation in front of detectors.

36
 Hardening of the beam as it penetrates the patient results in the CT number of the
same kind of tissue decreasing along the ray. However, the image reconstruction
process assumes that, to the contrary, the CT number of each kind of tissue is
constant along each ray.
 Correction:
 Using a 'Beam-Hardening Algorithm' by the computer
 The use of a 0.5 mm copper filter mounted on the X-ray tube, which, with the
high kV, produces a relatively homogeneous beam.
 Recently, improved beam-hardening algorithms have allowed lighter filtration
→ resulting in a greater tube output and a shorter scan time.

 To compensate for diminishing patient thickness toward the edges of the fan
beam → 'Bow Tie" compensating filter is used.

THE COMPUTED TOMOGRAPHY SCANNER

Slip Ring Technology
 If the tube kV is supplied by high-tension cables, the gantry ring has to reverse
direction after each 360° rotation.
 Faster continuous rotation of the tube is achieved in modern scanners by mounting
a high-voltage generator, operating at high frequency (up to 100 kHz) on the
rotating gantry ring itself and supplying it with power through slip-rings.
 Tube can rotate in one direction indefinitely → making helical scanning possible.
1st generation 2nd generation 3rd generation 4th generation
Most common
Beam Single pencil Narrow fan Wide fan Wide fan
Translation 180 steps Less No No
Detectors Single Small curved array Large array (100s) Complete ring (1000s) of
rotate opposite tube stationary detectors
Rotation 1° at a time Through 360° with Continuous for 360° Tube alone rotate 360°
through 360° less angular steps
Scan time 3-5 min 20 sec 1 sec 1 sec
Adv. Better predetector i- avoid ring artifact
collimation ii- easy detector
calibration
Disadv. Ring artifact Higher pt. dose
(Tube is close to pt.)
Further increase of scan speed is possible by
simultaneous use of multiple X-ray tubes or by
inserting the patient into a huge funnel-shaped
X-ray tube in which an electron beam (1000 mA)
scans rapidly round a large semicircular target -
usually called the fifth-generation scanner.
 Multiple stationary detector rings allow
multiple slices to be scanned simultaneously.
 A scan time of 50-100 ms → used mainly for
cardiac imaging.

37
DETECTORS
The detectors need to have:
1. High-detection efficiency;
2. Fast response (short afterglow) to keep up with fast scanning;
3. Wide dynamic range - able to cope with both the high-intensity beam either side
of the patient and the highly attenuated beam passing through the patient
(intensity ratio 5000:1);
4. Linearity - signal accurately proportional to the X-ray intensity;
5. Stability in face of voltage and temperature fluctuations;
6. Reliability;
7. Small size to allow close packing, giving better resolution;
8. Low cost in view of the large number of detectors used.
SCINTILLATORS
 Originally: sodium iodide (thallium-activated) crystal, coupled to a
photomultiplier which required a highly stabilized high-voltage power supply.
 Sodium iodide has been superseded by other scintillators such as cesium iodide,
calcium fluoride, cadmium tungstate, and bismuth germinate → shorter afterglow
 Photomultipliers have been superseded by silicon photodiodes → ‫المزايا‬
 Very much smaller
 Very close packing can be achieved with crystals of cadmium tungstate or
cesium iodide, with a silicon light sensor embedded in each solid state detector.
 Do not need high-voltage supply.
 Detector size typically 1.0 x 15 mm (or 1.0 x 1.5 mm for multiple detector arrays)
IONIZATION CHAMBERS
 Features:
 Less sensitive but more easily matched for sensitivity.
 They are very stable → unaffected by voltage fluctuations.
 Have a wide linear response with no lag.
 They are narrow (and closely packed).

To compensate for the lower sensitivity, ionization champers are:

Filled with a high atomic number gas (xenon) rather than air & at high
pressure (25 atm, 2.5 MPa).
Made relatively deep & thick (e.g. 6 cm).

SCINTILLATORS IONIZATION CHAMBERS

 Better absorption efficiency than gas
detectors because of higher density and
higher effective atomic number
 A small gap between detector elements  Thin metal septa separating individual
is necessary to reduce crosstalk detectors improves geometric efficiency
between adjacent detectors → reducing by reducing dead space between
geometric efficiency detectors
 Top surface of detector is flat →  Must be positioned in fixed orientation

38
 capable of x-ray detection over a wide in respect to x-ray source.
range of angles  The tungsten electrodes, alternately
positive and negative (Fig. 4.17e),
converge toward the tube (like strips of
focused grid) → help to collimate beam
and reduce scatter.
 Required for 4th generation scanners:  Well suited for 3rd generation scanners,
particularly as their sensitivity can be where very stable detectors are needed
checked continuously by the leading or as their sensitivity cannot be checked or
trailing edge of the X-ray fan beam calibrated very often.
 But may be used in 3rd generation  Cannot be used for 4th generation
scanners as well scanners because those detectors must
record x-rays as the source moves over
a wide angle

4.3.3 IMAGE QUALITY

Noise:
 This can be tested by imaging a water phantom.
 The CT numbers of the pixels will not be all the same, due to statistical
variations in the number of X-ray photons absorbed in each voxel → the image
is not uniform but appears mottled or grainy.
 The computer can be asked to compute the mean CT number and also the
standard deviation or noise.
 The quantum noise is a fundamental limit to the quality of the CT image since it
both 1) reduces contrast resolution of small objects and
2) worsens the spatial resolution of low-contrast objects.
 Noise may be reduced by:
1. Increasing the number of photons absorbed in each voxel, by increasing the
slice thickness or the pixel size.
Improving contrast resolution in this way → impair spatial resolution
2. Increasing either the mA or the scan time.
Both of these involve increasing the patient dose.
To minimize patient dose the radiologist must accept the noisiest picture consistent
with good diagnosis.
 Other factors increasing noise:
 Zoom enlargement; "spreads available ray sum information over pixel matrix"
 Narrower window width "each grey level covers a smaller range of CT
numbers, i.e. derived from the absorption of fewer X-ray photons in each voxel"
 Reducing the scan time or reducing the slice thickness, unless the mA is
increased proportionally.
 Deficiency of photons →; occurring with:
 Thicker patients.
 High-attenuation materials such as bone or prostheses in the slice.
Spatial resolution of high-contrast objects

39
 High-contrast spatial resolution is good, being determined by Pixel Size.
 In CT terms 'high contrast' is between water and Perspex (about 12%).
 Spatial resolution may be tested with BAR PHANTOM having a range of
different line pairs per millimeter.
 As CT scanning smooths out the detail within each voxel → detail within a
voxel is not imaged →  2 pixels are needed to define a line pair
 Resolution is about 1 lp\mm → much poorer than film-screen radiography.
High-resolution imaging
 By increasing matrix size or reducing field of view → decreasing pixel size.
 Below a certain pixel size, spatial resolution is further limited by:
1) Size of the focal spot. 4) Spacing between detectors.
2) Collimators. 5) Patient movement.
3) Number and size of detectors.
Spatial resolution of low-contrast objects
Low-contrast spatial resolution is less good and is limited by the NOISE.
 The larger the structure → the greater the number of pixels over which the noise
is averaged → the better the SNR.
 A low-contrast structure may need to be 5-10 mm in diameter to be resolved.
 Low-contrast spatial resolution is assessed by imaging a slice though a Perspex
phantom with water-filled holes of different diameters and different depths →
providing different levels of contrast.
 A graph is plotted "Detail-contrast diagram"
showing the minimum contrast needed to see
structures of different diameters.
 The solid curve in Fig. 4.18 shows how the
spatial resolution depends on the contrast of
the image.
 The dashed curve shows the improvement in
low-contrast perceptibility produced by
increasing the mA, or dose per slice, and
so reducing the noise.
Contrast resolution
'The ability to detect small differences in the attenuation coefficient of adjacent
structures'
Contrast resolution is tied to the SNR
 The contrast between a structure and its surroundings is ONLY detectable if it is →
3-5 times greater than the noise in the image.
The more pixels a structure occupy → ↓ noise → better contrast resolution.
With a structure 10 mm in diameter, differences of 4-5 CT numbers "0.5%
difference in attenuation coefficient" can be detected → at least 10 times
better than can be achieved in film-screen radiography.

40
 In CT, soft tissue contrast is superior to that in plain film radiography
because:
 Not obscured by overlying bone.  Smaller Scatter.
 Windowing allows quite small differences of CT number to be selected from the
full range and displayed over the whole grey scale.
Resolution compromise (trade-off)
 Although a spatial resolution of 1 lp mm -1 and a contrast resolution of 0.5% are
quoted for CT → they cannot be achieved at the same time, as Fig. 4.18 makes
clear.
 It is not possible to achieve excellent spatial and contrast resolution
simultaneously, except by delivering an unacceptable dose to the patient.
 In fact: Well-established relationship among Noise (N), pixel dimensions (D), slice
thickness (T), and radiation dose (D):
1
D
T .N 2 .D3

or alternatively,

Accordingly,
 To improve contrast delectability by a factor of 2 involves increasing the dose by a
factor of 4.
 To improve spatial resolution by a factor of 2 involves increasing the dose by a
factor of 8.
 To halve the slice thickness without impairing image quality involves increasing
the dose by a factor of 2.
In conclusion:
Compared with x-ray radiography, CT has significantly worse spatial resolution
and significantly better contrast resolution
• Limiting spatial resolution for screen-film radiography is about 7 lp/mm; for CT it
is about 1 lp/mm
• Contrast resolution of screen-film radiography is about 5%; for CT it is about
0.5%
Dose
 The distribution of absorbed dose in the body section imaged is much more
uniform than in conventional radiography.
 With a single radiograph of the skull, if the entry skin dose is 100%, the exit
skin dose might be 0.1% and the central dose 3%;
 In CT, the skin dose is more or less uniform all round. The central dose in the

41
 head is about 100%, and in abdominal CT typically 60%, of the skin dose.
 Due to scatter from one slice into adjacent slices, the dose increases with the
number of slices, but not proportionally.
 Although the detector collimators are set to the nominal slice thickness, the actual
X-ray beams overlap, as their width is much greater, being determined by the
collimation near the tube.
 effective dose is directly proportional to the tube current and total scan length
(product of the slice thickness and total number of slices)
The CT dose index (CTDI):
 For calculating spread of dose outside a nominal slice.
 It is the integral of the dose along the axis of the patient from a single slice
divided by the nominal thickness of the slice.
 It can be measured by inserting a 10 cm long, thin cylindrical ionization
chamber dosemeter along the axis of a cylindrical Perspex phantom and
imaging one slice through its middle.
 Organ doses from CT examinations estimated by multiplying CTDI by the
appropriate conversion factors.
 Typical effective doses are in the range 5-10 mSv per examination.
 Although CT scans account for only 2% of X-ray examinations, they contribute
more than 20% of the radiation dose delivered to the UK population by medical
X-rays.
ARTEFACTS
I- Motion artefacts
 Cardiac motion produces streak artefacts (black and white bands).
 The reconstruction process is misled by a moving structure occupying different
voxels during the scan.
 Mechanical misalignment and movement of the patient have similar effects.
II- High-attenuation objects
 Neurosurgical clips, dental amalgam, Small areas of bone or contrast medium etc.,
give rise to star artefacts which may obscure the area of interest.
 The effect is accentuated by motion.
III- Defector malfunction
 In a third-generation scanner even a small
imbalance in the sensitivity of the scintillation
detectors can produce ring artefacts.
 Cause: the X-ray pencil associated with each
detector traces out a 'data ring' - a ring of tissue
which is 'seen' by that detector alone.
 This ring can be seen on the image as an artefact if
that detector malfunctions.
 The problem is reduced by frequent recalibration of
the detectors, between patients, and is less
noticeable with gas detectors, which are more

42
 easily matched.
IV- Beam hardening
 The reconstruction process assumes a homogeneous X-ray beam, with the result
that CT numbers are lower in the center of the patient (known as 'cupping').
 This is corrected to some extent by a "beam-hardening algorithm".
V- Geometrical artefacts
Because of the diverging beam → CT slices are narrower at the center than at
the edge → overlap at the edges or an unscanned region at the center.
VI- Aliasing
 A sharp and high contrast boundary (as at a bone edge) may produce a number of
parallel streaks nearby in the image, for reasons explained in Section 9.2.
 Similarly, at the boundary between the lung and diaphragm, spurious increased
density may appear in the base of the lung.
VII- Partial volume or volume averaging artefacts

Quality Assurance: summary

Each department should have a quality control protocol using appropriate test objects
to verify the performance of their scanners.
The topics, already mentioned in this chapter include:
1. Noise - the standard deviation of the computed pixel values for the image of a
water phantom, or other reference material;
2. Reproducibility – the consistency of mean CT number for reference material;
3. Uniformity - the variation of mean CT number over different areas of the scan
field for the reference material;
4. Sensitivity - the smallest detectable object for a series of various materials
(different contrasts) (see Fig. 4.18);
5. Contrast scale - the differences between the mean CT numbers for various test
materials;
6. Resolution - the spatial resolution at a high contrast level;
7. Alignment - the presence or absence of streak artefacts in the scan of, for
example, a high-contrast pin;
8. Slice thickness and spacing;
9. Light beam alignment for patient positioning;
10. Dose measurements - CTDI and dose profile.

43
 4.3.4 OTHER TECHNIQUES
Zoom reconstruction
 An area of interest can be delineated and displayed in an enlarged format.
 The computed data normally used to set the grey level of one pixel on the monitor
is shared between several contiguous pixels.
 Noise is increased but resolution is effectively improved.
Scanning in other planes
Longitudinal scan
 If the tube and detectors are held stationary and the couch is moved steadily along
its length during the exposure → a digital image can be obtained similar to a
conventional (anteroposterior, lateral, or oblique) radiographic projection.
 Performed at the beginning of an examination, in either the anteroposterior or
lateral plane → allows correct positioning & selection of subsequent axial images.
 These scout scans are produced with less patient dose than normal radiograph.
Multiplanar imaging (sagittal, coronal, and oblique sections)
 A section can be taken through the three-dimensional array of CT numbers
acquired with a series of separate contiguous slices and reconstructed as an image
in any plane through the patient.
 The image so obtained has a characteristic appearance
→ The pixels are rectangular, the longer side = the slice thickness.
This problem has been overcome by spiral scanning.
SPIRAL (HELICAL) SCANNING
 The couch moves continuously at a steady speed while the tube and detectors make
a number of revolutions around the patient.
 The tube receives its power supply through slip-rings, and the detectors send their
signals by radio.
 Suppose, for example, that the tube makes a complete rotation each second, the
couch moves 10 mm /sec, and the collimated slice thickness is 10 mm.
 In this case the pitch is 1:1.
 A block of anatomy 300 mm long will be covered in 30 s, a long breath hold.
 The data are acquired in the form of a continuous ribbon of contiguous slices.
 The data are reconstructed as a series of vertical slices, in this case 10 mm thick.
 Interpolation allows slices to be imaged at any level and with any incrementation.
For example, a series of overlapping slices, each 10 mm thick at increments of 2
mm, could be reconstructed through a volume of interest.
 Note that the slice thickness cannot be changed retrospectively.
Compared with sequential CT scanning, in which the tube reverses and the patient
couch is indexed between slices with separate breath holds, spiral scanning has the
following advantages and disadvantages:

44
Advantages:
1. It is faster → allowing a greater number of patients and also the use of a smaller
volume of contrast medium.
(A double-helical scanner with two rows of detectors is even faster.)
2. It overcomes the problem of slice-to-slice misregistration, particularly in the
region of the diaphragm, caused by variations in inspiration between the separate
breath holds needed in sequential scanning.
3. It reduces partial volume artefacts since the reconstructed slices can be
incremented in small steps.
4. Because of the volume acquisition of data, resolution in the axial direction is
good, and reformatting into other planes is improved.
Disadvantages:
1. No cooling periods between slices → high heat loading of the tube.
2. Even though a high-capacity tube and sensitive detectors are used → a lower mA
must be employed → ↓ patient dose but ↑ noise, particularly with thicker
patients.
3. There is some loss of spatial resolution due to the interpolation process.
4. A high-speed computer with a large data store is necessary.
Pitch
 Def.: the distance (millimeters) moved by the table during one rotation of the
tube divided by the slice thickness (millimeters)
 Increasing the pitch, by increasing the table speed, is like stretching the spring;
 ‫ سرعه‬Speeds up scanning.
 ‫ جرعه‬Reduces dose,
 BUT resolution may be lost "greater interpolation needed".
 Above a pitch of 2:1 there are gaps in the volume being scanned, and artefacts may
arise.
Two-dimensional reformatting
 Imaginary, mathematical, parallel 'rays' may be sent in any chosen direction
through the three-dimensional array of CT data in the computer memory, and
projected on to a selected image plane.
 As each ray encounters the CT numbers in the voxels it passes through, it may first
reject the high numbers corresponding to bone if it is required to remove bone
from the image. Then:
(a) In shaded surface display (SSD)
 Any CT number so encountered in any voxel along each ray is recorded in a
corresponding pixel in the image plane, provided it exceeds a set threshold
value.
 The image is displayed as if illuminated by an imaginary light source.
 Particularly useful in plastic surgery.

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 (b) In maximum intensity projection (MIP)
 The highest CT number so encountered in any voxel along each ray is
recorded in a corresponding pixel in the image plane.
 Calcified lesions and contrast media can be distinguished.
 Used particularly in CT angiography and arthrography.
Three-dimensional reformatting
 Multiple projections may be made in this way, around an axis of rotation, and
displayed in a cine loop as a rotating three-dimensional representation of anatomy,
either as a shaded surface image or a volume rendered (see-through) display.
 These software manipulations are very computer-hungry and may be time-
consuming.
Cine computed tomography scanning
A continuously rotating scanner can also be used with the couch stationary to take
a sequence of images of a single slice, e.g. to study the passage of contrast medium
through the slice and to allow the best image to be selected for interpretation.

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