period may help isolate the nature of the problem.
Suitable phantoms for daily
evaluation of fluoroscopic image quality and system performance are described
in the literature28 and available commercially.
Hard Copy. System contrast transfer function should be checked for stability
in accordance with section 16.1, Hard-Copy Device.
9.2 Monthly or More Frequently if Indicated
System Function. A periodic check of the fluoroscopic system by the technol-
ogists who use the room on a daily basis is appropriate. Evaluation of spatial res-
olution and contrast resolution using a simple phantom (consisting of an
attenuator, a wire mesh phantom, and a step-wedge) are important. Problems that
can arise with the fluoroscopic system between the evaluations by the medical
physicist may be identified during these periodic audits. The operator may track
kV and mA required to produce an acceptable image as an index of system sta-
bility. The step-wedge may also be used as a daily check on monitor brightness
and contrast settings.
9.3 Fluoroscopic Mode: Tested Annually or More
Frequently If Indicated
9.3.1 Typical Exposure Rates
The entrance exposure rate including backscatter for a “typical” patient should
be evaluated at least annually. In some regulatory environments, more frequent
(i.e., quarterly or monthly) evaluation may be required. This measurement requires
the system to be set up in the same geometric configuration as it is used for typi-
cal patient examinations, using automatic brightness control mode.30,31,32 This usu-
ally involves placing thicknesses of PMMA (polymethylmethacrylate or “acrylic”)
or another tissue-mimicking attenuator29 (10, 20, and 30 cm thicknesses are rec-
ommended) in the beam, and measuring the exposure between the x-ray tube and
the entrance of the PMMA. The Automatic Brightness Control (ABC) system
should be activated, and operated in a typical clinical mode. The determination
should be made in all available magnification modes. A radiotransparent dosime-
ter is required for these measurements to avoid interference with the ABC system.
If a free-in-air measurement is desired, a phantom material other than PMMA is
required unless the geometry of the measurement can be altered to accommodate
the necessary air gap.
For portable C-arm systems and for C-arm or U-arm systems, the tabletop expo-
sure is not appropriate since these systems allow lateral exposure to the patient,
without attenuation of the beam due to the table. With the SID set at 100 cm, the
ionization chamber should be placed at 30 cm in front of the input to the imaging
23
assembly for entrance exposure rates including backscatter. If a free-in-air meas-
urement is desired, the ionization chamber should be placed 50 cm (20 in.) from
the front surface of the imaging assembly to create an air gap between the phan-
tom and ionization chamber. With the phantom in front of the image intensifier,
the exposure rate is recorded, and the inverse-square law is used to calculate the
entrance skin exposure at 30 cm in front of the input to the imaging assembly.
If the system is typically operated in a lateral mode with a separate AP/PA
(antero-posterior/postero-anterior) imaging chain, the scattering phantom should
be centered at the midpoint of the SID with the ionization chamber placed between
the x-ray tube and the phantom. This geometry measures entrance exposure with
or without backscatter dependent on the presence or absence of an air gap between
the ionization chamber and phantom entrance surface. The entrance skin exposure
should be calculated at a point 15 cm toward the x-ray focal spot from the mid-
point of the SID.
If the system is capable of HDR fluoroscopy, the typical exposure values should
be determined for this mode(s) of operation as well.
9.3.2 Maximum Exposure Rates
The maximum patient exposure rate should be evaluated without backscatter;
a PMMA scattering phantom should not be used. The maximum exposure rate
should be determined by placing a sheet of lead over the input of the image inten-
sifier, which causes the ABC circuitry to produce a maximum exposure rate. The
image on the monitor should be blank, assuring that the ABC is driving the kV
and mA to their maximum values. The exposure rate should be measured at the
tabletop for under-table x-ray tube systems. If it is possible to adjust the distance
between the x-ray focal spot and tabletop, this distance should be minimized.
Federal regulations concerning maximum patient exposure rates during fluo-
roscopy are somewhat complex due to the variety of operational modes provided by
equipment manufacturers. To further complicate the issue, these rules were rewrit-
ten in 1994 due to concern over the potential for occult patient injury during HDR
fluoroscopy when used in combination with cineradiography or Digital Subtraction
Angiography (DSA).27 In concert with the new regulations, the AAPM recommends
that all fluoroscopy systems be limited to 10 R/min during normal operation and to
20 R/min in HDR regardless of the date of manufacture of the system.
For portable C-arm systems, and for C-arm or U-arm systems, the tabletop
exposure measurement is not appropriate since these systems allow lateral expo-
sure to the patient, without attenuation of the beam due to the table. With the SID
set at the minimum, the exposure meter should be placed 30 cm (12 in.) from the
front surface of the imaging assembly. With the lead sheet in front of the image
intensifier, the maximum exposure rate is recorded.
If the system is capable of HDR fluoroscopy, the maximum exposure values
should be determined for this mode(s) of operation as well.
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