ANALISIS PERBANDINGAN MEDICAL IMAGE PROCESSING DENGAN

IMAGE ENHANCEMENT

Diajukan oleh :
Bella Tri Yuni Arvianti
163112600150022

PROPOSAL TUGAS AKHIR

PROGRAM STUDI FISIKA

JAKARTA
2019
Abstract

Some means of recording images is a necessary part of most fluoroscopic systems. Several
methods are available for recording images during fluoroscopy. Screen-film recording methods
such as use of spot film devices and automatic film changers provide high-spatial-resolution
images. Recording images by using the image intensifier (fluorography) provides film or digital
images at relatively lower doses but with poorer spatial resolution. Digitally recorded images
have better contrast resolution than analog images but lower spatial resolution and represent a
compromise between dose and image quality. Motion picture (cine fluorographic) recording
requires extremely high dose rates compared with those of lower-resolution videotape recording
of motion. Recording systems in fluoroscopy require automatic exposure control for optimum
image quality. The same feedback system used to control fluorographic exposures can be used to
control exposure rates during fluoroscopy as well. Automatic brightness control maintains
intensifier exposure rates on the basis of subject thickness by adjusting various technique factors.
The type of control mechanism depends on the imaging task and the complexity (age and cost) of
the equipment. The operator can choose between better image quality (higher contrast) or lower
radiation dose.

Figure 1. Standard spot film imaging configuration typical of gastrointestinal fluoroscopy

Introduction
Automatic exposure control (AEC) systems are designed to adjust the kilovoltage,
milliamperage, or exposure time in order to obtain an image of diagnostic quality, be it for
radiography or fluoroscopy. These systems sense the amount of radiation immediately in front of
the image receptor and adjust the dose or dose rate to the patient in order to assure sufficient
photons are reaching the image receptor. However, these systems can also result in high patient
doses, especially with digital image receptors.

AEC systems may also be known by other names including automatic dose control (ADC),
automatic dose rate control (ADRC), and automatic brightness control (ABC).

Introduction

There are a number of technologies available for recording images during fluoroscopic
procedures. These technologies include spot film devices, automatic film changers,
photofluorography, digital fluorography, cine fluorography, and videotape recording. Each of
these technologies has its own characteristics and is preferred for particular imaging tasks. It is
valuable to be familiar with the general design of these imaging methods and to be able to
characterize their image quality in terms of spatial resolution, contrast, and noise. Methods used
for automatic exposure control for both still images and fluoroscopic viewing are also important
to understand to make optimum use of fluoroscopic and fluorographic systems.

This article describes the technologies used for recording images during fluoroscopy, identifies
the components that affect image quality, and discusses their effects on image quality and patient
radiation dose. General methods of image recording during fluoroscopy are direct film recording,
indirect recording, and recording motion. Automatic exposure control systems used in both
fluoroscopy and fluorography are also reviewed. The components of these systems are identified,
and their effects on image quality and radiation dose are discussed.

Important Principles

AEC systems work on different principles, primarily based on the design goals of the
manufacturer. Some systems may preferentially adjust the exposure time or tube current, while
others may preferentially adjust the kilovoltage. Some systems insert extra filtration (typically a
copper filter) into the beam to filter out additional soft radiation thereby reducing patient dose.

Most AEC systems have some practical limit beyond which they do not perform optimally. For
example, fluoroscopic imaging systems are limited to 100 mGy/min as a maximum fluoroscopic
exposure rate. If the system requires a dose rate greater than 100 mGy/min, the AEC cannot
deliver the higher dose rate and the image quality degrades significantly. This occurs for larger
patients or for oblique image angles.
It would be ideal to use the maximum tube current available for radiographic imaging at the
shortest exposure time and with the smallest focal spot. However, these three factors must be
traded off due to the anode heat capacity. For example, most small focal spots are limited to a
tube current of approximately 300 mA. Consequently, a large focal spot may be required for
large patients or oblique views.

AEC systems may not produce the same image quality, e.g., film density, over the typical range
of thicknesses encountered in the clinical setting. Consequently, a part of a good quality control
program will be to test image quality and patient dose over a typical range of patient thicknesses.

Direct Film Recording

Spot Film Devices Fluoroscopic systems designed for gastrointestinal imaging are generally
equipped with a spot film device. The spot film device allows exposure of a conventional screen-
film cassette in conjunction with fluoroscopic viewing. This rather familiar system, located in
front of the image intensifier, accepts the screen-film cassette and “parks” it out of the way
during fluoroscopy (Fig 1). Cassettes may be loaded from the front or rear depending on the
design of the system. A two-dimensional positioner centers the portion of the film to be used in
the xray field, and a formatting mask prevents x-ray exposure of the portion of the film that is
not used. The x-ray field size is also reduced automatically by the collimators at the time of
exposure to minimize scattered radiation and patient radiation dose. The fluoroscopist can
override this automatic collimation to further reduce the x-ray field. Spot film imaging uses
essentially the same technology as conventional screen-film radiography. The details of screen-
film imaging have been discussed in a previous tutorial series in this journal (1,2). Herein, we
will review only the differences and limitations of spot film imaging compared with general
radiography. One major limitation is the range of film sizes available for spot film imaging.
Although some older fluoros copy equipment is limited to a single size, usually 24 ´ 24 cm,
current equipment allows a range of film sizes to be used, from 20 ´ 25 cm to 24 ´ 35 cm. Spot
film devices usually allow more than one image to be obtained on a single film. Formats
typically include one, two, three, four, or six images on a film. Although some institutions may
still be using screen-film systems with lower speeds, screen-film combinations with a speed of
around 400 are generally used for spot film imaging. This speed usually yields a system with a
rather moderate level of contrast and noise and a spatial limiting resolution of around 7 line pairs
per millimeter (lp/mm). There is slightly more magnification of patients’ features with spot film
imaging than with general radiography. For a typical gastrointestinal system with an under-table
x-ray tube, a sourceto-film distance of 76 cm, and a source-to-skin distance of 38 cm, the part of
the body closest to the table can be magnified up to two times in the image. Because the patient
cannot be moved relative to the x-ray source in such systems, magnification is primarily
dependent on the position of the spot film device relative to the patient. Moving the spot film
device closer to the patient reduces the amount of magnification and decreases the patient
radiation dose. A number of factors affect patient doses in spot film imaging. The source-to-skin
distance is shorter in spot film imaging than in general radiography. Although the automatic
exposure con
trol system fixes the exposure to the screen, the shorter source-to-skin distance increases the
inverse square reduction in radiation intensity as it passes through the patient. This increase tends
to make the skin entrance exposure higher. The field size in spot film imaging is generally
smaller than that used in general radiography. This smaller field size reduces scatter and
therefore tends to reduce dose. For the same reason, grids used in fluoroscopy generally have a
lower grid ratio and therefore a smaller Bucky factor, which also leads to lower dose. These
effects tend to offset each other to a large extent. One of the major shortcomings of conventional
spot film devices is the delay involved in moving the cassette into position for exposure. In
gastrointestinal imaging, this delay can be overcome by using photofluorography. In vascular
imaging, more rapid film movement is achieved with automatic film changers.

Figure 2. Typical rapid film changer. Approximately 20 films are held in the supply magazine.
During exposure, a film is advanced between the high-speed screens, exposed, and removed to
the receiving magazine.

Automatic Film Changers

The automatic film changers used in vascular imaging are also screen-film systems. They can be
found in several varieties (3). Some are large, floor-mounted boxes, but systems more commonly
used today mount on the image intensifier (Fig 2). The system consists of a supply magazine for
holding unexposed film, a receiving magazine, a pair of radiographic screens, and a mechanism
for transferring the film. When an exposure is required, the screens are mechanically separated,
the film is pulled into place between them, and they are closed. After the film is exposed, the
screens separate again. The film is moved to the receiver, and another film is pulled into place
for the next exposure. The number of films and filming rates must be preprogrammed for proper
operation. Because the major requirement is capturing rapid motion of a contrast agent, 800-
speed screen-film combinations are typically used in film changers. This speed leads to a dose
half that of the more general-purpose 400-speed systems used for gastrointestinal imaging.
Resolution is also reduced to about 5 lp/mm. Unlike with spot film devices, the requirement for
rapid motion limits the automatic changer to one film size, usually 35 ´ 35 cm. The typical film
changer holds up to 30 films in the receiving magazine. At the maximum rate of four films per
second, a 7.5-second run is achieved without changing magazines. A problem common to many
film changer systems is that the film changer is mounted perpen

dicular to the image intensifier (Fig 2). Thus, there is a long delay between fluoroscopic viewing
and recording of the images. In some systems, the film changer is mounted in front of the
intensifier, limiting the size of the intensifier input field to something smaller than the film size
when the changer is in position (4). Other problems associated with film changers are motion
blurring, missed exposures, jamming, inadequate density and contrast, and film fogging (3).

Figure 3. Roll film photospot camera. The iris, lens, mirror, and film plane are shown.

Automatic Exposure Control

Kontrol eksposur otomatis sangat berharga untuk digunakan dalam pemeriksaan intensifikasi gambar
anak-anak karena memilih faktor eksposur yang benar jauh lebih sulit untuk anak-anak daripada orang
dewasa. Penting untuk dicatat bahwa MEA akan berfungsi dengan baik kecuali jika anak tersebut
menutupi seluruh perangkat deteksi. oleh karena itu, menggunakan AEC untuk bayi dan anak-anak yang
sangat kecil mungkin tidak memungkinkan. Namun, ketika struktur rediopaque berada di bidang AEC
yang terbuka, pajanan secara maksimal.

Automatic control of the radiation exposure to the image detector is needed for both fluoroscopy and
image recording in most cases. The exception to this requirement is the automatic film changer, for
which exposure techniques are usually preprogrammed for the body part being examined. The feedback
signal used for automatic exposure control of spot films is obtained from an ionization chamber located
between the grid and the film cassette (Fig 6). For cameras that view the image intensifier, the signal can
come from an optical detector, typically a photodiode, placed in the light field of the intensifier output
phosphor behind the collimating lens. The collimating lens is placed at a distance equal to its focal length
from the intensifier output, thus creating a beam of parallel light. A photodetector sensing any portion
of this beam receives light from the entire surface of the output phosphor. Therefore, the sensor can be
placed near the edge of the light field in a portion of the light field that will be cut off by the camera
irises. The same detector can be used for fluoroscopy and fluorography. A lens may be used to refocus
the image of the output phosphor onto the photodetector in such a way that it senses light from only
about the central 60% of the image, ignoring the relatively less observed areas around the edge.
Another method of exposure control that can be used with TV cameras is to feed the TV video output
signal back to the x-ray generator.

Figure 6. Feedback system for automatic exposure control of fluoroscopy and fluorography. The signal
from an ion chamber is used for spot film exposure control. The signal from the photodetector is used
for generator control in both fluorography and fluoroscopy. The TV video signal is also used to maintain
image brightness with or without changes in generator output.

Whether the signal comes from an ion chamber or photodetector, it is used in the same way. For
fluorography or radiography, charge from the sensor is accumulated on a capacitor until a
predetermined reference voltage is reached, at which time the exposure is terminated. For a spot film
system, an acceptable exposure, and hence the reference voltage, is based on the optical density
desired for the film and therefore on the speed of the screen-film system. For a photospot or cine
camera, an acceptable exposure is based on the desired level of quantum noise in the image and an iris
is used to adjust the light intensity reaching the camera to achieve the desired film density. This type of
exposure control system can be used to limit exposure times at a fixed tube kilovoltage and current
(milliamperes) or to limit milliampere-seconds at a fixed kilovolt peak in “falling load” systems, in which
the milliamperage varies during the exposure. The same sensor used for control of fluorographic
exposures is used to regulate the x-ray output during fluoroscopy. In this case, the signal from the
sensor is not accumulated but rather compared continually against a reference signal that corresponds
to the desired intensifier input exposure rate, which in turn corresponds to an acceptable level of
quantum noise in the TV image. Such systems are usually referred to as automatic brightness control or
automatic brightness stabilization systems (9). The x-ray exposure rate can be adjusted by varying
generator kilovolt peak, milliamperage, or x-ray pulse width. X-ray absorbing filters can also be selected
as part of the exposure control system. The Table shows some possible methods used for automatically
controlling brightness during fluoroscopy. The last two combinations listed in the Table are generally
found on fluoroscopic systems designed for vascular applications. The most common configuration for
gastrointestinal fluoroscopy uses automatic control of both kilovolt peak and milliamperage. Because it
is possible to achieve the same brightness with many combinations of kilovolt peak and milliamperage,
modern automatic brightness stabilization systems are programmed to follow a particular curve
describing the combinations of kilovolt peak and milliamperage to be used (Fig 7). The shape of this
curve has a dramatic effect on both patient dose and image quality. For example, the curve may
describe combinations of kilovolt peak and milliamperage that tend to cause higher kilovolt peaks to be
used when possible to increase radiation output to penetrate thicker body parts (Fig 7 [curve A]). The
milliamperage is increased significantly only after the maximum kilovolt peak has been reached. This
curve ensures that the most penetrating radiation is used, hence reducing patient dose. Or, the curve
may use higher milliamperage and lower kilovolt peak values to achieve the same brightness level (Fig 7
[curve B]). By keeping the kilovolt peak low, subject contrast is increased at the expense of patient dose.
Finally, the curve may offer a compromise between the preceding two situations (Fig 7 [curve C]).
Selection of a low, medium, or high dose rate by pressing a button on the intensifier control panel
selects a program, similar to those in Figure 7, for the automatic brightness stabilization system to use.
In some systems, these same buttons also select filters to be inserted in or removed from the x-ray
beam, a process that has an effect similar to changing the kilovolt peak. Good fluoroscopic practice
requires the fluoroscopist to start with the low-dose mode and increase the dose only if adequate
contrast cannot be achieved. Another curve in this configuration represents the maximum power at
which the generator and x-ray tube can be operated (Fig 7 [curve D]). The maximum x-ray output is
reached at the point where this power curve reaches the maximum kilovolt peak. At this point, if more
tissue is placed in the x-ray beam, the number of x-ray photons reaching the intensifier will go down and
the image will appear noisier. However, the brightness of the image will be maintained by another
system in the TV camera itself. The camera will simply amplify its signal electronically to maintain the
signal intensity required for adequate brightness on the TV monitor. This process is called automatic
gain control. The automatic gain control system does not alter the radiation dose rate in the way that
automatic brightness control does but only maintains video brightness.
 Figure 7. Power curves for automatic brightness control system. With curve A, kilovolt peak (kVp)
increases first in response to demand for more power, providing maximum penetration of x rays and low
radiation dose. With curve B, milliamperage (mA) and kilovolt peak increase simultaneously, providing
more contrast but higher radiation dose. Curve C provides a compromise. Curve D is the maximum
power loading possible for the system.

AEC 44

peralatan flourscopic modern termasuk fitur yang disebut kontrol kecerahan otomatis, AEC dan AERC,
yang semuanya merupakan mode variasi otomatis mA dan kV. dalam mode AEC, misalnya, output dari
sumber dimonitor dan pengaturan x-ray secara otomatis disesuaikan untuk memberikan kualitas dan
kecerahan gambar yang konsisten. jika jaringan yang dicitrakan tebal atau padat, mA dan kV keduanya
ditingkatkan untuk menghasilkan jumlah foton yang lebih banyak dan foton penembus yang lebih baik.
operator dapat menggeser lengan-C ke seluruh jaringan dengan ketebalan yang bervariasi untuk
memberikan informasi yang konsisten kepada reseptor gambar
Sirkuit AEC dari unit-unit fluoroskopi didasarkan pada bir-lambert la, yang merupakan faktor koefisien
absorbansi, konsentrasi zat-zat penyerap, dan jalur sinar-x ke dalam perairan. selain konsentrasi zat
penyerap (ketebalan jaringan), keberadaan bahan kontras atau benda logam di jalur dapat mengurangi
sinar x-ray, yang mengarah ke peningkatan intensitas dari sumber untuk meningkatkan berkali-kali lipat
dari sumber untuk memastikan sejumlah foton yang cukup mencapai detektor gambar

denyut nadi atau frekuensi nadi adalah jumlah gambar yang dihasilkan per detik, dan ini dapat bervariasi
dari 30 gambar per detik dalam mode kontinu hingga serendah satu atau 0,5 pulsa per detik. prosedur
intervensi memerlukan denyut nadi yang lebih tinggi untuk memberikan pembaruan waktu nyata dari
perubahan temporal dan memungkinkan manipulasi struktur yang bergerak. studi menelan barium
dapat dilakukan pada laju pulsa 7,7-15 pulsa per detik, dan studi GI dan VCUG dapat dilakukan pada
kecepatan bingkai 5 pulsa per detik atau kurang

memilih frekuensi nadi serendah mungkin yang dapat mengarsipkan kualitas gambar yang dapat
diterima secara klinis adalah teknik penting untuk mengurangi paparan radiasi pasien dan staf. telah
ditemukan bahwa mengurangi frekuensi nadi seringkali dapat memberikan gambaran fluoroskopi yang
memuaskan pada sebagian besar prosedur; karenanya, mengevaluasi kualitas gambar dan memanipulasi
laju bingkai dengan hati-hati dapat memberikan pencitraan yang relevan secara diagnostik tanpa
memaparkan pasien pada dosis radiasi yang berlebihan. efek pengurangan dosis ini dapat lebih
ditingkatkan dengan penggunaan filter untuk pengerasan balok