MEDICAL IMAGING TECHNIQUES

Medical imaging techniques are the special non-invasive procedure for obtaining images of
the internal structures or organs of the body. The image is not exactly like a real photo but
one which highlights certain required regions of the organ. The images of heart, brain, blood
vessel, bone, muscle, etc are obtained either using x-rays, ultrasonic waves, radio frequency,
infrared or radioisotopes substances. Medical imaging techniques are classified as:
 Radiography
 Computed Tomography
 Digital Subtraction Angiography
 Ultrasonography
 Positron Emission Tomography
 Medical Thermography
 Magnetic Resonance Imaging
 Nuclear Medicine
 Others
The main objectives are:
1. To produce / reconstructed images of the internal structure or organs of the human
body
2. Helps to interpret and facilitates diagnosis

X-RAYS / RADIOLOGY
X-Rays were discovered accidentally by Rontgen on November 8, 1895 when he was
experimenting with a partly evacuated cathode ray tube. The tube was completely wrapped in
black paper to keep the room in total darkness. So he noticed the glow of a plate covered with
fluorescent material lying nearby. Further investigations showed that this “X-light” was able
to penetrate solid material such as wood, aluminium and even hand, showing the bones on a
photographic plate.

X-rays were first discovered in 1895 by Wilhelm Conrad

Roentgen, German Physicist who was awarded Nobel Prize in 1901

Roentgen's remarkable discovery was one of the most important medical advancements in
human history. X-ray technology lets doctors see straight through human tissue to examine
broken bones, cavities and swallowed objects with extraordinary ease. Modified X-ray
procedures can be used to examine softer tissue, such as the lungs, blood vessels or the
intestines.
Roentgen placed various objects between the tube and the screen, and the screen still glowed.
Finally, he put his hand in front of the tube, and saw the shadow of his bones projected onto
the fluorescent screen. So he not only discovered X-rays but also, their most beneficial
application.

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X-rays are electromagnetic radiations (waves) located at the low wavelength (0.01 0A to
1000A) end of the electromagnetic spectrum with high frequency (1016 to 1020 Hz) and
processes high energy. It can easily pass through the body and indicate relative tissue density
on a photosensitive plate. The X-rays in the medical diagnostic region have wavelength
ranging from 0.01 to 10 nanometers (0.10A to 100A), corresponding to frequencies in the
range 30 petahertz to 30 exahertz (3×1016 Hz to 3×1019 Hz) and energies in the range 120 eV
to 150 keV. X-ray wavelengths are shorter than those of UV rays and typically longer than
those of gamma rays. It propagates with a speed of 3x1010cm/s (like light) and are unaffected
by electric and magnetic fields. X-rays can penetrate solid objects, and their largest use is to
take images of the inside of objects in diagnostic radiography and crystallography. As a
result, the term X-ray is used to refer to a radiographic image produced using this method. In
addition to the method itself, X-rays are a form of ionizing radiation, and exposure to them
can be a health hazard.

X-rays from about 0.12 to 12 keV are classified as soft X-rays, and from about 12 to 150 keV
as hard X-rays, due to their penetrating abilities. X-rays are generated by an X-ray tube, a
vacuum tube that uses a high voltage to accelerate electrons released by a hot cathode to a
high velocity. The high velocity electrons collide with a metal target, the anode, creating the
X-rays. In medical X-ray tubes the target is usually tungsten or a more crack-resistant alloy of
rhenium (5%) and tungsten (95%), but sometimes molybdenum for more specialized
applications, such as when soft X-rays are needed as in mammography. In crystallography, a
copper target is most common, with cobalt often being used when fluorescence from iron
content in the sample might otherwise present a problem. The maximum energy of the
produced X-ray photon is limited by the energy of the incident electron, which is equal to the
voltage on the tube, so an 80 kV tube cannot create X-rays with energy greater than 80 keV.

According to the quantum theory, electromagnetic radiation consists of “photons” which are
conceived as “packet of energy” and expressed as

E = h ν = h. c/λ

Where, h is the Plank’s constant = 6.626 x 10-34 Js

c is the velocity of photons, 3x1010cm/s
ν is the frequency (f) of radiation
Λ is the wavelength of the radiation

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Electromagnetic radiation can also be regarded as sinusoidal varying electric and magnetic
fields. They are transverse waves: the electric and magnetic field vectors point at right angles
to the each other and to the direction of the travel of the wave.

Electromagnetic radiation
X-rays are produced when an accelerated electron with tremendous velocity with tremendous
velocity bombard (strike) suddenly on a metal target. The kinetic energy of the electrons is
converted into X-rays (1%) and into heat (99%).
Kinetic energy = charge of electron x voltage

eV = hf = h c/λ
h. c/λ

X-rays in medical field are mainly used for:

 Examination of fractures in bones
 Examination of teeth for any decay
 Looking for the shadow caused by tumors and other diseases in soft tissue
 Treatment of tumors by radiotherapy

PHYSICS OF X-RAYS/ SOURCE OF X-RAYS

The X-rays are produced when the accelerated electrons collide with the atoms and nuclei of
the metal target. There are two types of X-ray generated: characteristic X-ray radiation and
bremsstrahlung radiation.

Characteristics X-ray Radiation:

When an accelerated electron collides with an electron in the K-shell of an atom, an electron
will be ejected from the atom, provided that the energy of the bombarding electron is greater
than the binding energy of the shell.

The hole so created in the K-shell is most likely to be filled by an electron falling in from the
L-shell with the emission of a single X-ray photon of energy equal to the difference in the
binding energies of the two shells, E k-EL. The photon is referred to as Kα radiation.

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 Characteristics Radiation

For tungsten (74W) , Ek = 70 KeV, EL = 12 KeV, EM = 2 KeV

[In case of K-shell, the binding energies of different elements are different but never exceed
100 KeV.]
For W, Kα = (Ek-EL) = 58 KeV, Kβ = (EK-EM) = 68 KeV

Alternatively, but less likely, the hole may be filled by electron from M-shell with the
emission of a single X-ray photon to energy, EK-EM and referred to as Kβ radiation.

There is also L-radiation produced when a hole is created in the L-shell is filled by an
electron from further out. In case of tungsten, these photons energy have only 10 KeV of
energy insufficient to leave the X-ray tube assembly, and so they play no part in radiation.
The X-ray photons produced in an X-ray tube in this way has a few discrete or separate
photon energies and constitutes a line spectrum.

Bremsstrahlung (Braking) X-ray Radiation:

X-rays are produced by high-energy electrons bombarding a target, especially targets that
have a high proton number (Z). When bombarding electrons penetrate into the target, some
electrons travel close to the nucleus due to the attraction of its positive charge and are
subsequently influenced by its electric field. The course of these electrons would be
deflected, and a portion or all of their kinetic energy would be lost. The principle of the
conservation of energy states that in producing the X-ray photon, the electron has lost some
of its kinetic energy (KE):
Final KE of electron = initial KE of electron - energy of X-ray photon
The 'lost' energy is emitted as X-ray photons, specifically bremsstrahlung radiation
(bremsstrahlung is German for 'braking radiation'). Bremsstrahlung can have any energy
ranging from zero to the maximum KE of the bombarding electrons, depending on how many
the electrons are influenced by the electric field, therefore forming a continuous spectrum.
Approximately 80% of the population of X-rays within the X-ray beam consists of X-rays
generated in this way.

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 Bremsstrahlung (Braking) Radiation
The X-ray spectrum: As a result of characteristic and bremsstrahlung radiation generation a
spectrum of X-ray energy is produced within the X-ray beam.

PROPERTIES OF X-RAY:
X-ray photons carry enough energy to ionize atoms and disrupt molecular bonds. This makes
it a type of ionizing radiation, and therefore harmful to living tissue. A very high radiation
dose over a short amount of time causes radiation sickness, while lower doses can give an
increased risk of radiation-induced cancer. In medical imaging this increased cancer risk is
generally greatly outweighed by the benefits of the examination. The ionizing capability of
X-rays can be utilized in cancer treatment to kill malignant cells using radiation therapy. It is
also used for material characterization using X-ray spectroscopy.

Hard X-rays can traverse relatively thick objects without being much absorbed or scattered.
For this reason, X-rays are widely used to image the inside of visually opaque objects. The
most often seen applications are in medical radiography and airport security scanners, but
similar techniques are also important in industry (e.g. industrial radiography and industrial
CT scanning) and research (e.g. small animal CT). The penetration depth varies with several
orders of magnitude over the X-ray spectrum. This allows the photon energy to be adjusted
for the application so as to give sufficient transmission through the object and at the same
time good contrast in the image. X-rays have much shorter wavelength than visible light,
which makes it possible to probe structures much smaller than what can be seen using a
normal microscope. This can be used in X-ray microscopy to acquire high resolution images,
but also in X-ray crystallography to determine the positions of atoms in crystals.

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INTERACTIONS OF X-RAY WITH MATTER
When X-ray photon enters a layer of matter such as human body, it is possible that it will
penetrate through without any interaction, or it may interact and transfer energy to the matter
in one or two of the interactions. The strength of these interactions depend on the energy of
the X-rays and the elemental composition of the material, but not much on chemical
properties since the X-ray photon energy is much higher than chemical binding energies.
There are four major types of interactions of X-ray photons with matter, the first three of
which play a role in diagnostic radiation.
1. Photoelectric Effect
2. Compton Effect
3. Rayleigh (Coherent) Scattering
4. Pair Production (Annihilation Radiation)

Photoelectric Effect or Photoelectric Absorption is one of the principal forms of

interaction of X-ray and gamma photons with matter. A photon interacts with an inner shell
electron in the atom and removes it from its shell. In the photoelectric effect, all of the
incident photon energy is transferred to an electron which is ejected from the atom. Hence,
the photoelectric effect contributes to the attenuation of the X-ray beam as it passes through
matter. The energy which is lost by this electron as it drops to the inner shell is emitted as
characteristic radiation (an x-ray photon) or as an Auger electron.

After ejection of the electron, the neutral atom becomes a positively charged ion with a
vacancy in an inner shell that must be filled with a nearby less tightly bound electron. The
kinetic energy of the ejected photoelectron (Ee) is equal to the incident photon energy (E 0)
minus the binding energy of the orbital electron (Eb). Ee = E0-Eb.

The probability of this effect is maximum when:

 the energy of the incident photon is equal to or just greater than the binding energy of
the electron in its shell (absorption or k edge) and
 the electron is tightly bound (as in K shell)
Photoelectric absorption per unit mass is approximately proportional to Z3/E3, where Z is the
atomic number of the attenuating medium and E is the energy of the incident photon. The
benefit of photoelectric absorption in X-ray transmission imaging is that there are no
additional secondary photons to degrade the image.

Photoelectric Absorption

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Compton Effect or Inelastic Scattering is the predominant interaction of X-ray with soft
tissue in the energy range approximately from 30KeV to 24MeV. This interaction is most
likely to occur between photons and outer valance shell electrons. The electron is ejected
from the atom and the photon is scattered with some reduction in its energy. The scattered
photon will have a different wavelength and thus a different energy (E=hc/λ). The Compton
Effect is a partial absorption process and as the original photon has lost energy, known as
Compton shift (i.e. a shift of wavelength/frequency). The energy of the incident photon (E0)
is equal to the sum of the energy of the scattered photon (ESE) and the kinetic energy of the
ejected electron (Ee-). The binding energy of the electron that was ejected is very small and
can be ignored.
[The wavelength change of the scattered photon can be determined by 0.024 (1- cos θ),
where θ is scattered photon angle. Thus, the energy of the scattered photon decreases with
increasing scattered photon angle.]
Probability of Compton Effect:
 directly proportional to number of outer shell electrons, i.e. the electron density and
physical density of the material
 inversely proportional to photon energy
In other words, the probability of the Compton effect is dependent on the number of electrons
per gram in the absorbing material, which for most elements is approximately the same
(approx. 3 x 1023). Thus the Compton Effect is independent of the atomic number (Z) of the
absorber.

Compton Effect or Inelastic Scattering

Rayleigh Coherent Scattering (also known as unmodified, classical or elastic scattering)

occurs when the energy of the X-ray or gamma photon is small in relation to the ionization
energy of the atom thus ionization does not occur. This low energy photon (15 to 30 keV)
does not have enough energy to liberate the electron from its bound state (i.e. the photon
energy is well below the binding energy of the electron) so no energy transfer occurs. The
electric field of the incident photon’s electromagnetic wave expends energy, causing all of
the electrons in the scattering atom to oscillate in at the same frequency. There is no energy
deposition and thus no dose resulting from coherent scattering. The X-ray photon is scattered
through small angle without change of X-ray energy or loss or energy to the medium, hence
'unmodified' scatter. Coherent scattering is not a major interaction process encountered in
radiography at the energies normally used. Coherent scattering varies with the atomic number
of the absorber (Z) and incident photon energy (E) by Z/E 2.

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 Coherent Scattering

Pair production (PP) is a photon-matter interaction that is not encountered in diagnostic

procedures because it can occur only with photons with energies in excess of 1.022 MeV. In
pair production, an X-ray photon interacts with the electric field of the nucleus of an atom.
The photon’s energy is completely converted into an electron-positron pair. These two
particles have the same mass, each equivalent to rest mass energy of 0.51 MeV.

These two particles form the pair referred to in the name of the process. At least 1.022 MeV
of photon energy is necessary as the resting mass (using E=MC2) of the electron and positron
expressed in units of energy 0.511 MeV each (0.511 MeVx2 = 1.022 MeV). Photon energy in
excess of 1.02 MeV appears as kinetic energy which may be distributed in any proportion
between the electron and the positron.

The electron and positron lose their kinetic energy via excitation and ionization, when the
positron comes to rest it interacts with an electron. Then both particles undergo mutual
annihilation, with the appearance of two annihilation photons each with an energy of
0.511MeV travelling in opposite directions. Pair production becomes more likely with
increasing atomic number and increasing photon energy. Pair production has no importance
in diagnostic X-ray imaging because of the extremely high energies required for this
interaction to occur.

Pair Production

X-rays have several fates as they traverse tissue. These fates fall into 3 main categories.
No interaction: X-ray passes completely through tissue and into the image recording device.
Complete absorption: X-ray energy is completely absorbed by the tissue. This produces
radiation dose to the patient.
Partial absorption with scatter: Scattering involves a partial transfer of energy to tissue, with
the resulting scattered X-ray having less energy and a different trajectory. This interaction

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does not provide any useful information (degrades image quality) and is the primary source
of radiation exposure to staff.

The probability of X-ray interaction is a function of tissue electron density, tissue thickness,
and X-ray energy (kVp). Electron dense material like bone and contrast dye attenuates more
X-rays from the X-ray beam than less dense material (muscle, fat, air). The differential rate of
interaction provides the contrast that forms the image.

Tissue Electron Density Interaction Effects:

As electron density increases, the interaction with X-rays substantially increases. Higher
atomic number materials have increased electron density. Thus, bone, which is substantially
comprised of calcium, produces more attenuation, than tissue, which is comprised of carbon,
hydrogen and oxygen (all of which have a lower electron density or atomic number than
calcium). Thus, the image of bone and soft tissue has contrast, or difference, between bone
and soft tissue.
Assume 1,000 X-rays strike the following body portions. The number of X-rays reaching the
recording media (film, TV monitor) directly affects the image's brightness.

In this example, 900 X-rays are capable of penetrating the soft tissue, while only 400
penetrate the bone (Higher electron density compared with soft tissue). The contrast between
the bone and soft tissue is (900-400)/900 = 0.56.

Tissue Thickness:
As tissue thickness increases, the probability of X-ray interaction increases. Thicker body
portions remove more X-rays from the useful beam compared to thinner portions. In
fluoroscopy, this effect must be compensated for while panning across variable tissue
thickness to provide consistent information to the image-recording device.

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 X-Ray Penetration Vs Patient Thickness (80 kVp Tube Voltage)

Note that on average, only 1 percent of the X-rays reach the image-recording device (e.g., image intensifier,
film), yielding useful information. Thus, 99 percent of the X-rays generated are either absorbed within the
patient (patient radiation exposure) or are scattered throughout the examination room (staff radiation exposure).

Energy:
Higher kVp X-rays are less likely to interact with tissue and are described as more
"penetrating." Increasing kVp, thereby generating more penetrating radiation, reduces the
relative image contrast (or visible difference) between dense and less dense tissue.
Conversely, less radiation dose results to the patient since less X-rays are absorbed. The X-
rays that do not reach the image recording device are either absorbed in the patient (patient
radiation dose) or are scattered throughout the exam room (staff radiation dose)

X-Ray Penetration Vs Tube Voltage (20 cm Thick Patient)

RADIOGRAPHS
A radiograph is an X-ray image obtained by placing a part of the patient in front of an X-ray
detector and then illuminating it with a short X-ray pulse. Bones contain much calcium,
which due to its relatively high atomic number absorbs x-rays efficiently. This reduces the
amount of X-rays reaching the detector in the shadow of the bones, making them clearly
visible on the radiograph. The lungs and trapped gas also show up clearly because of lower
absorption compared to tissue, while differences between tissue types are harder to see.

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 A chest An arm radiograph,
radiograph of demonstrating
a female, broken ulna and
demonstrating radius with
a hiatus hernia implanted internal
fixation.
Radiographs are useful in the detection of pathology of the skeletal system as well as for
detecting some disease processes in soft tissue. Some notable examples are the very common
chest X-ray, which can be used to identify lung diseases such as pneumonia, lung cancer or
pulmonary edema, and the abdominal X-ray, which can detect bowel (or intestinal)
obstruction, free air (from visceral perforations) and free fluid (in ascites). X-rays may also
be used to detect pathology such as gallstones (which are rarely radiopaque) or kidney stones
which are often (but not always) visible. Traditional plain X-rays are less useful in the
imaging of soft tissues such as the brain or muscle. Dental radiography is commonly used in
the diagnoses of common oral problems, such as cavities.

In medical diagnostic applications, the low energy (soft) X-rays are unwanted, since they are
totally absorbed by the body, increasing the radiation dose without contributing to the image.
Hence, a thin metal sheet, often of aluminium, called an X-ray filter, is usually placed over
the window of the X-ray tube, absorbing the low energy part in the spectrum. This is called
hardening the beam since it shifts the centre of the spectrum towards higher energy (or
harder) X-rays. To generate an image of the cardiovascular system, including the arteries and
veins (angiography) an initial image is taken of the anatomical region of interest. A second
image is then taken of the same region after an iodinated contrast agent has been injected into
the blood vessels within this area. These two images are then digitally subtracted, leaving an
image of only the iodinated contrast outlining the blood vessels. The radiologist or surgeon
then compares the image obtained to normal anatomical images to determine if there is any
damage or blockage of the vessel.

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GENERATION OF X-RAYS / PRODUCTION X-RAYS
The X-ray is produced in X-ray tube. This is a fairly typical electronic "vacuum" tube. One
electrode is connected to the positive terminal of the power supply and is called the anode. The
other electrode is connected to the negative pole of the power supply and is called the cathode. In
clinical terminology, the anode is frequently referred to as the target, while the cathode is
sometimes called the filament. The X-ray tube serves the function of creating X-ray photons
from electric energy supplied by the X-ray generator. The process of creating the X-ray beam is
very inefficient, with only 1% of the electric energy is converted to X-ray photons and the
remaining 99% converted to heat in the X-ray tube assembly. Thus, to produce sufficient X-ray
output for diagnostic imaging, the X-ray tube must withstand and dissipate a substantial heat
load, a requirement that affects the design and composition of the X-ray tube. The major X-ray
tube components are the cathode and anode assemblies, the tube envelope, the rotor and stator
(for rotating anode systems), and the tube housing. The design of the X-ray tube determines the
basic characteristics of the X-ray beam such as focal spot size, X-ray field uniformity, and the X-
ray energy spectrum. These X-ray beam characteristics are important because they affect
radiologic parameters such as spatial resolution, image contrast, and patient dose. The entire X-
ray tube is surrounded by a thick lead shield. This keeps the X-rays from escaping in all
directions. A small window in the shield lets some of the X-ray photons escape in a narrow
beam. The beam passes through a series of filters (thin aluminium sheet in the window acts as
inherent filter) on its way to the patient.

X-rays are generated when accelerating electrons interact with matter. In a radiographic X-ray
tube, energetic electrons interact with a target material and a portion of the kinetic energy of the
electrons is converted to electromagnetic radiation, or X-rays. X-rays are produced in a specially
constructed high vacuum diode tube (gas pressure near about 10 -2 mm of Hg). The vacuum tube
consists of a filament, a cathode and an anode i.e. a heavy metal target. The tungsten wire
filament is heated by current supplied by a step-down transformer and ultimately heated the
(nickel) cathode. The heated cathode emits copious thermions which is directed towards the
target anode by a high potential difference setup between the cathode and anode by means of a
step-up transformers i.e. electrostatically focused on a target anode. The excited accelerated
electrons with tremendous velocity strike the target anode (tungsten metal). Part of this energy is
converted into X-rays. The anode is kept at 450 so that photons will come out and collect at 900.
The electron beam intensity and hence the X-ray intensity can be controlled by varying the
filament heating current. The quality of X-ray output is also controlled by altering the potential
difference across the tube. This radiation is filtered and collimated to produce optical contrast
relative to the patient dose.

X-ray Tube & X-ray Production

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Important factors for X-ray generation:
1. High voltage generation
2. Heating of cathode and its isolation from high voltage
3. Timer for selecting time (exposure time)
4. KV selection
5. mA selection (mAS – milli ampere second)
6. Line voltage compensation.

[The interactions of the accelerated electrons with the tungsten of the target, two possibilities for
interaction are common. In the first, the accelerated electron interacts directly with an electron in
an orbital shell of a tungsten atom. The orbital electron is displaced but the orbital gap is rapidly
filled by an electron from a more distant orbit. The difference in the energies of the two electron
orbits is radiated as an X-photon the energy of which is characteristic for the specific element
and the specific orbital shell. The other and more frequent interaction is termed Bremsstrahlung.
This German word means "braking" radiation and that describes what happens to the incoming
electron. In this interaction, the accelerated electron passes relatively close to the nucleus of a
tungsten atom in the anode. The path of the accelerated electron is affected by the nucleus with a
resulting change in direction (decelerated) and the kinetic energy of the electron is dissipated.
The difference in the kinetic energy before and after interacting with the nucleus is radiated as an
X-photon. This type of interaction (Bremsstrahlung) can result in X-photons of almost any
energy, limited only by the tube potential. A typical radiation spectrum from a medical X-ray
tube is illustrated where, the most frequent photon energy will be approximately one third (1/3)
of the tube potential voltage. There will be superimposed "characteristic" photon spikes which
correspond in energy to differences of the specific electron orbits.]

Characteristic Radiation Bremsstrahlung Radiation

A typical radiation spectrum from a medical x-ray tube

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The energy (consider this the penetrating power) of the X-ray beam is controlled by the voltage
adjustment. This control usually is labeled in keV (thousand electron volts) and sometimes the
level is referred to as kVp (kilovoltage potential) by which the difference in potential between
the cathode and anode can be controlled. The higher the voltage setting, the more energetic will
be the beam of X-ray. A more penetrating beam will result in a lower contrast radiograph than
one made with an X-ray beam having less penetrating power. It is probably obvious that the
more energetic the beam, the less effect different levels of tissue density will have in attenuating
that beam.

The second control of the output of the X-ray tube is called the mA (milliamperage) control.
This control determines how much current is allowed to flow through the filament which is the
cathode side of the tube. If more current (and therefore more heating) is allowed to pass through
the filament, more electrons will be available in the "space charge" for acceleration to the target
and this will result in a greater flux of photons when the high voltage circuit is energized. The
effect of the mA circuit is quite linear.

The third control of the X-ray tube which is used for medical imaging is the exposure timer.
This is usually denoted as an "S" (exposure time in seconds) and is combined with the mA
control. The combined function is usually referred to as mAS or milliampere seconds, so to give
an exposure using 10 milliampere seconds may use a 10 mA current with a 1.0 second exposure
or a 20 mA current for a 0.5 second exposure or any combination of the two which would result
in the number 10. Both of these factors and their combination affect the film in a linear way.

THE X-RAY MACHINE

X-ray machine consists of vacuum tube, high voltage transformer, control console and other
accessories. The heart of an X-ray machine is an electrode pair: a cathode and an anode that sits
inside a glass vacuum tube.

Basically, there are two parts of the circuit. One of them is for producing high voltage, which is
applied to the tube’s anode and cathode and comprises a high voltage step-up transformer
followed by rectification. The current through the tube follows the HT pathway and is measured
by a mA meter. A KV selector switch facilitates change in voltage between exposures. The

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voltage is measured with the help of a KV meter. The exposure switch controls the timer and
thus the duration of the application of KV. To compensate for mains supply voltage (230V)
variations, a voltage compensator is included in the circuit.

The second part of the circuit concerns the control of heating X-ray tube filament. The filament
is heated with 6–12V of AC supply at a current of 3–5 amperes. The filament temperature
determines the tube current or mA and therefore, the filament temperature control has an
attached mA selector. The filament current is controlled by using in the primary side of the
filament transformer, a variable choke or a rheostat. The rheostat provides a stepwise control of
mA and is most commonly used in modern machines.

A preferred method of providing high voltage DC to the anode of the X-ray tube is by use a
bridge rectifier using four valve tubes or solid state rectifiers. This results in a much more
efficient system than the half wave of self-rectification methods.

High Voltage (Cathode-Anode) Circuit and X-ray Tube Filament Circuit

Block Diagram of an X-ray Machine

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TUBE ENCLOSURE
It consists of X-ray tube envelope, housing and radiation shielding.
X-ray Tube Envelope:
Borosilicate glass is the common materials for construction of high vacuum X-ray tube. It is high
heat resistant material and strong enough to withstand atmospheric pressure. The material is
transparent and facilitates heat radiation from the anode. The insulating properties slowly
reduced during the life of the tube as metal atoms from the incandescent filament and those
vaporized from the focal spot (anode) are deposited on the glass walls. Moreover, glass
envelopes are particularly prone to break-down. More compact tube design consists of metal
envelope which is stronger, unaffected by vaporized metal and more efficient in heat exchanger.
The insulating regions in metal tubes are made from ceramic material.

Housing:
X-ray tube itself is enclosed in metal (aluminum) sealed housing. Circulating air is sufficient to
cool (remove heat) mobile and mammography units, but insulating oil (fixed / circulate) is
necessary within the enclosure for cooling conventional and DSA equipment. The total heat
capacity of the tube enclosure is largely dependent on the volume of oil. The metal housing is
also properly grounded to prevent shock.

Radiation Shielding:
X-rays are emitted from the tube in all directions and overall lead shielding must cover the
complete housing assembly except window region. The lead shielding prevents any leakage
radiation [˂1mGyh-1 (100mR) at one meter]. A fixed lead diaphragm in the window region
restricts beam dimensions yielding the useful beam width. Other adjustable diaphragm /
collimators are used for varying the overall beam size for different field of views.

X-ray Tube Enclosure

STATIONATY AND ROTATING ANODE TUBE

The bombarding electrons in the X-ray tube generate high heat (99% of kinetic energy converted
into heat) and develops high temperature at anode. This high temperature leads to crack in the
anode. Two methods are used to overcome the heat problem in X-ray tubes (the target anode
must be able to withstand tremendous heat). The one is stationary anode and other is rotating
type anode.

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Stationary Anode:
It is constructed from tungsten alloy, which is embedded in a large mass of copper. The target is
normally comprised of a small tablet of tungsten about 15 mm wide, 20 mm long and 3 mm thick
soldered into a block of copper. Tungsten is chosen since it has high atomic number (74) and
making it comparatively efficient in the production of X-rays. It has high melting point (34000C)
enabling it to withstand the heavy thermal loads. In mammography, molybdenum ( 42Mo) is used
as anode but unsuitable for general radiography due to its low efficiency of X-ray production and
the lower melting point.

Copper being an excellent thermal conductor and carrying the heat rapidly away from the
tungsten target. Finally, the heat is removed from the total anode surface to the outside of the
tube by convection. Generally, an oil environment is provided for convection current cooling. In
addition, the electrodes have open high voltages on them and must be shielded. The tube will
emits X-rays in all directions and a lead lining over the glass envelop is provided except (where
the useful beam emerges from the tube) window area. A metal housing surrounding the tube and
is called “shield”. Every joint on a shield are hermetically sealed and must be made shockproof
by an efficient grounding (earthing) arrangement.
Application: Stationary x-ray tubes are only suitable in dentistry and small mobile X-ray units.

Construction of Stationary Anode Tube

Rotating Anode Tube:

Rotating anode enables higher X-ray output owing to more effective cooling. The basic design of
a simple rotating anode consists of a tungsten disk or an alloy of tungsten and 10% rhenium
(75Re – reduces surface pitting), typically between 90 and 200 mm diameter. It is attached to a
molybdenum stem which connects with a rotor forming, together with the stator windings, an
induction motor which rotates the anode. The anode rotates at a speed of 3000-3600 or 9000-
10000 rpm.

The electron source (cathode) is placed so that it will impinge (hit) on only a small spot on the
rim of the disc. This keeps the focal area down to a few square millimeters, yet the structure is
large enough to permit the dissipation of a large amount of heat. Rotating anode increases the
heat-loading capacity of the tube and allows higher power level for the generation of more
intense X-radiation. In CT or DSA, graphite is brazed onto the back of the anode which increases
heat radiating efficiency in tubes. Graphite is a very low mass material with high melting point.

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 Construction of Rotating Anode Tube

STATOR-ROTOR ASSEMLY
The electric induction motor that turns the rotating anode consists of a rotor which rotates on a
set of bearings within the glass X-ray tube envelope and the stator consists of wire windings
external to the envelope. An alternating current is applied to the stator windings, inducing a
changing magnetic field within the region of the rotor. The metal rotor turns in response to the
changing magnetic field causing the attached anode to turn. Anode rotation speeds range from
3,000 rpm (revolutions per minute) to 10,000 rpm for a high-speed anode. The rotor is connected
to the anode disk by the anode stem which is typically made of molybdenum or stainless steel.
The stem is designed to protect the bearings from heat damage, a common cause of x-ray tube
failure.

Induction Motor
The Rotor is made of copper which is actually part of a motor that is made to rotate by the device
called the stator. The stator is a set of electric coils that produces a very strong magnetic field
outside of the glass envelope that in turn “pulls along” the copper rotor. The stator causes the
rotor to rotate very fast just like any electric motor. The stator is also called an induction motor.
The bearings which permit a very smooth rotation of the anode are very sensitive and if the X-
ray tube heats up abnormally high, they can be damaged. If this occurs, the target surface can be
damaged or “pitted”

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X-RAY TUBE RATING
Tube ratings are the defined input parameters (kVp, mA, exposure) that can be safely used
during its operation without causing damage to the X-ray tube itself and unique to each
individual X-ray tube model. An X-ray tube rating is the maximum allowable kilowatts (kW) in
0.1 second. When the electron beam strikes the target material in the anode only 1% of the
kinetic energy of the electrons is converted into X-rays whilst the rest is converted into thermal
energy. Increasing the kVp, mA, or exposure time increases the thermal energy produced per
examination. Thermal energy is dissipated in the anode and surrounding X-ray tube. If too much
heat is created (or not enough is dissipated), excess residual thermal energy will damage the
anode and tube.

X-ray tube rating is the total workload that can be placed on a tube. The combining effects of
kilovolts (kVp), tube current (mA) and exposure time (S) for a certain focal spot size is called
electrical rating, whereas anode heat gain and heat loss determines the thermal rating,
commonly referred to as loadability. The workload or rating of X-ray tube depends on factors:
(a) Variable: tube kVp, tube current, filament current, focal spot size and exposure time, (b)
Non-variable: anode diameter and anode rotational speed. By creating tube ratings the operator
can ensure that the parameters set are appropriate for the examination whilst minimizing the risk
of damage to the X-ray tube. Typical X-ray tube ratings are between 5-100kW and are dependent
on focal spot size.

X-ray Tube Rating Chart

X-RAY TUBE FAILURE

The failure of an X-ray tube is almost always related to heat production and tube life can be
lengthened simply by controlling the amount of heat generated in the tube. Although a number of
factors come into play, X-ray tubes are damaged basically by: (1) overheating a cold target
(anode), (2) heating the filament over an unduly extended period, (5) overloading the tube and
(4) misusing the high speed rotor control.

Overheating a Cold Anode: Warming up an X-ray tube is an important step in prolonging the
useful life of the tube, if heat is generated in a cold target too quickly the target will not expand
uniformly and in many cases it will crack.

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Filament Evaporation: Filament evaporation is another major problem. Normally, as current
(mA) flows through the X-ray tube filament, the filament is heated to a predetermined
temperature before the X-ray exposure is made. Filament heating continues until a high voltage
is placed across the cathode and anode. Heating the filament over a prolonged time produces
what is known as filament evaporation; minute particles of tungsten metal are deposited on the
glass envelope of the tube. Eventually an electrical “short circuit” will occur with the high
voltage arcing between the cathode, the glass envelope and the anode. A major contribution to
filament evaporation results from delaying or withholding exposures after the filament has been
heated and the rotor has been brought up to speed.

Exceeding Tube Heat Capacity: The importance of X-ray tube heat rating charts has been
taught by radiologic technology programs for many years but in actual practice a few
technologists ever refer to them. To overcome the problem of exceeding instantaneous tube
ratings, most modem generators are designed with overload relays that will come into play if the
combination of milliampere, time and kilovoltage exceeds the kilowatts allowed for an
instantaneous exposure on that particular tube.

Misuse of High Speed Rotation: The question of high speed rotation of the X-ray tube anode is
a perplexing one. In normal tube operation, the anode rotates approximately 3,000 times per
minute (rpm); at high speed, 9000-10,000 rpm. High speed rotation is three times faster than
standard speed (and, thus provides for more rapid dissipation of heat) whereas, the wear factor
on the X-ray tube bearings is nine times that experienced at standard speed. This leads to a great
decrease in tube life.
The most common causes of X-ray tube failure are:
 Extremely high voltage
 Excessive heat generation
 Poor cooling system
 Rough handling / careless
 Aging

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CONVENTIONAL ELECTRICAL CIRCUIT OF X-RAY MACHINE
X-ray machines generate high-energy, high-frequency electromagnetic waves (X-rays) for use in
diagnostic and treating diseases and physical malfunctions. The conventional electrical circuit of
X-ray machines has the following major sections:
1. Multitap ac line autotransformer, which allows selection of taps to compensate incoming
line variations. These also permit the operator to choose voltages for specific
applications.
2. X-ray tube filament circuit and transformer, which transforms the ac line to supply power
for heating the cathode filament. This power can be selected by taps to change filament
heat (filament mA), which changes X-ray tube current (tube mA) and, hence, total X-ray
energy delivered to the patient.
3. X-ray tube high-voltage circuit, transformer and bridge rectifier, which transforms the ac
line to supply the high dc voltage for accelerating electrons from cathode to anode. The
high voltage can be selected by taps to change the kVp (kilovolt peak) and, hence, total
X-ray energy delivered to the patient.
4. Timing circuit, which controls turn-on, turn-off, and length of X-ray exposure delivered
to the patient.

Circuit diagram of an X-ray machine

Essentially, three basic controls exist on X-ray machines to control patient X-ray dose
(penetrating quality, quantity and timing). These are inter-related and must be properly chosen to
suit the slim or obese patient. Good photographic results are sometimes difficult to obtain. These
controls are filament heat control (mA) for exposure strength, not depth; kilovolt control (kV) for
penetration depth and contrast; and timing devices for time exposure length.

The multitap ac line autotransformer (3) is a single-coil transformer that serves three functions:
it provides the means for kVp selection, it provides compensation for fluctuations in
the incoming line voltage (9), and it supplies power to other parts of the x-ray circuit. The
autotransformer’s primary purpose is to vary the voltage to the primary side of the step-up
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transformer. This is accomplished by the major and minor kVp selectors (4), which are on the
secondary (output) side of the autotransformer. The autotransformer varies the kVp to the tube
by controlling the input to the step-up transformer.

The low voltage circuit is the sub-circuit between the alternating current (AC) power supply (1)
and the primary (input) side of the high-voltage (step-up) transformer (7). With the exception of
the step-up transformer, all of the devices in this sub-circuit are actually located within
the control console. The control console is the unit where the operator sets all of the exposure
techniques, such as kilovolts peak (kVp), milliamperes (mA), and exposure time. They include
the main switch (2), autotransformer (3), kVp selectors (4), exposure switch (5), and exposure
timer (6).

Filament Circuit is divided into two parts by the step-down transformer (11 and 12). The
primary purpose of the filament circuit is to supply a low current to heat the x-ray tube filament
for thermionic emission of electrons. The filament circuit is activated any time the operator
adjusts the mA on the generator. The primary side of this circuit begins and ends with the
contacts on the autotransformer (9). Current in this circuit flows from the autotransformer,
through the mA selector (10) and the primary side of the step-down transformer (11), and back to
the autotransformer. The secondary side begins and ends with the secondary side of the step-
down transformer (12) conducting current through the x-ray tube filament (13). The step-down
transformer reduces the voltage on the secondary side, providing an appropriate current to heat
the filament. The mA selector (10) controls amperage in the filament circuit. Since the current
through this circuit controls filament heat, this setting determines the number of available
electrons at the x-ray tube filament and thus determines the mA in the high-voltage circuit that
includes the x-ray tube.

High-Voltage Circuit begins and ends with the secondary side of the step-up transformer (8). It
includes the x-ray tube (14) and the rectifier unit (15). Current flows in this circuit only during
an exposure. This is a dangerous circuit due to the very high voltage. The high-voltage cables
going to the x-ray tube are very thick due to their high insulation requirement. The step-up
transformer is also referred to as the high-voltage or high-tension transformer. The primary
purpose of the high-voltage circuit is to supply the x-ray tube with voltage high enough to create
x-rays.

The exposure switch (5) closes the circuit, allowing electric current to flow through the primary
side of the step-up transformer. When this occurs, current is induced to flow through the
secondary side of the transformer, creating voltage across the x-ray tube. This voltage causes the
electron stream to flow across the tube, producing x-rays. The exposure timer (6) is a device
that terminates the exposure and is set by the operator on the control console.

HIGH VOLTAGE GENERATION

High voltage in X-ray machine is generated by using a step-up transformer. Generally, 0-230V
line input is converted to 0-150KV or more according to the winding (turns) in the secondary
coil of the transformer. The number of windings of secondary coil is very high, ranging from
45000 to 50000 and wire gauge (dia./thickness) is 45 swg (standard wire gauge), whereas for
primary, windings is 75-100 and gauge is 10-14 swg.

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 [16 swg = 0.64ʺ dia. & 48 swg = 0.028ʺ dia.]
Normally, this transformer has a very high ratio of at least 500:1. For example, if the primary
side of the step-up transformer receives 180 V from the autotransformer, and the ratio is 500 : 1,
the voltage induced on the secondary side will be 90,000 V, or 90 kVp.

The core of the transformer is very important to increase the efficiency or to minimize the heat
loss. Generally silicone steel or sometimes cold roll steel is used to improve efficiency. A full
wave rectifier bridge to output terminals of secondary coil is connected for converting AC to DC
voltage output.

Full wave bridge rectifier

Rectifiers use diodes to convert the circuit from AC to DC. A diode is an electronic device that
permits current to flow in one direction only. Each diode can withstand 1 kV. Both primary and
secondary coils and bridge rectifier are immersed in high grade insulating oil for isolation of the
part from other parts of the instruments.

HIGH FREQUENCY GENERATOR X-RAY MACHINE

High frequency x-ray generators are better as compared to conventional single-phase generators
due to efficient generation and control of high voltage power required to drive the X-ray tube. In
order to obtain similar film optical density and/or to obtain similar radiation dose the HF X-Ray
generators require less exposure time (nearly half- to- 2/3rd) as compared to single-phase (SP)
generators, due to constant potential and radiation. HF generators produce constant potential
which give very low ripple (˂1%). It is found to be approximately two times more efficient, has
better reproducibility and produces sharper, better quality images than single phase/ three phase
generator.

In the Medium/ HF generators, higher frequency square wave voltage is sent to primary of the
high-frequency transformer. Higher frequency of pulses to the high tension supply of an X-ray
generator results in the spectrum of the X-ray beam being narrowed, potentially lowering of
patient dose. The exposure timing can be more precise with and short with near constant
potential wave form. Further, when an X-ray transformer operates in the high range of 2000 to
over 8000Hz, instead of the conventional line frequency, it becomes more efficient. HF
generators significantly decrease in transformer size for the same power output. It can be reduced
in weight to perhaps one-tenth and even more in bulk. As a result of the diminished size,
transformers up to 30kW can be mounted within the tube head obviating high-tension cables.

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 Block-diagram of modern computer-controlled medium frequency X-ray Generator (~20 kHz)

The low frequency (50/60Hz) main supply is first rectified to give a DC voltage which then
supplies a high frequency generator (2 to 20 KHz). The output of high frequency generator is
rectified and supplied the X-ray tube circuit. The generator design can utilize either single or 3-
phase (3-sine waves with a 1200 phase difference) main supply. These are full wave rectified and
smoothed to give a steady DC voltage supplies a thyristor converter which switches the DC
voltage producing a medium (2 KHz) to high (20 KHz) square waveform. A high frequency
transformer then converts this low voltage high frequency AC to KV levels. Rectification and
smoothing gives high voltage DC for the x-ray tube. The thyristor converter can be controlled by
low voltage signals to regulate its high voltage output.

The tube KV can be electronically switch on and off at any point in time. Tube voltage is present
according to reference control value Vref. For power rating up to 50 KW, generator is small
enough to be built into a single housing with X-ray tube but for 150 KW, generator and tube
must be separated.

CONTROL CIRCUITS
Controlling high frequency generator output is achieved by altering frequency by a feedback
control signal. In this way, KV can be finely adjusted within a close tolerance (˂1%).

Feedback controls for high voltage and filament current

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High Voltage Control:
The sample signal is derived from a resistor divider (R) circuit in the high voltage line and feeds
one input of a comparator. When a difference is found between sampled voltage and the set
reference, a DC control voltage alters the frequency of the converter which alters high voltage
level. A tolerance better than 1% is essential for special applications eg DSA, CT,

Filament Control Current:

Slight variation in filament current produces large variation in the tube current. The filament
receives its power from an individual low voltage “step down” transformer. The transformer
supplies between 8 to 12 volts at 6 amps. The electron emission from cathode surface provides
the tube current. Precise stabilization of the filament current is done by means of feedback
controls. Both KV and tube current are monitored so that when either is changed the filament
current is adjusted to the provde consistent output.

Exposure Control:
Control of X-ray exposure was obtained by using mechanical timers either clockwork or
electrical. They are unable to offer fast switching rates necessary for effective X-ray exposure
(0.01 to 0.05s) and have been replaced by either electronic, digital timers, frequency control or
exposure control timers (microcontroller based).
A. Electronic Timer:
Various types of electronic timers are developed as exposure time is too short to be
controlled by mechanical timers.

RC Timing Circuit
The exposure time is decided by the time constant of the RC circuit. Switch “S” is closed to
initiate exposure and “S” is opened to stop exposure and the relay in primary of the high
voltage transformer circuit is closed beginning exposure capacitor charging.
𝑡
𝑉𝑡 = 𝑉𝑠 (1 − 𝑒 ⁄𝑅𝐶 ) Where C is constant and R is variable
B. Digital Timer: Frequency or Pulse Counting Timer
Modern x-ray machine use digital timers. These are either use dedicated timer ICs or circuit
using a reference oscillator, a counter and associated logic. The generation of time period
‘T’ is based on counting ‘N’ cycles of a precise frequency ‘F’ by a relation- F x T = N

Frequency Counting Timer

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 The reference oscillator generates frequency (cycles/sec) given to input of an AND gate. The
value of ‘N’ is programmed into counter logic. The start of time period is controlled by flip-
flop (F/F) which is set to 1 by a start signal. When ‘N’ counts are made corresponding to
time ‘T’ a pulse is issue that reset the F/F and disconnect the oscillator from counter. The
pulse output of the counter is used to trigger the x-ray exposure. The exposure time can be
changed by changing ‘T’ or ‘N’.

AUTOMATIC EXPOSURE CONTROL (AEC) SYSTEM

In modern X-ray equipment, the exposure is controlled by an arrangement usually described as
"phototiming". With this system, the machine automatically measures the exposure in the sense
of how many photons reach the film. With this approach, all the operator has to do is to set the
desired degree of film blackness and the machine will monitor the exposure so that the resulting
density of the film is very close to what is wanted. That system would work very well if the
human body were equally thick in all parts. Unfortunately, the variation in body thickness makes
phototiming sometimes give inappropriate exposure results.

Automatic exposure control is a device incorporated into radiographic and mammographic

imaging systems. Its function is to automatically terminate exposure when a preset amount of
radiation has been detected. This system of exposure control is also known as anatomically
programmed radiography (APR). Automatic exposure control systems help to provide a
consistent optical density/signal-to-noise ratio, regardless of patient-centric factors such as size
and density.
Automatic exposure control systems also help to reduce 'dose creep' that can occur with
inadvertent radiation overexposure by the technologist. The first generation of automatic
exposure control systems is photo timers, which have now largely been superseded by ionization
chambers or photocells. In radiography, the automatic exposure control device is placed in front
of the image receptor. In mammography, the automatic exposure control device is placed
underneath the image receptor.
Automatic Exposure Control (AEC) system

Block diagram showing two typical AEC types.

C1 –used for chest radiography and C2 used for mammography.

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Photocell APR:
In photocell method a fluorescent detector is placed behind the radiographic cassette which
monitors the x-ray intensity transmitted through the films grid system. The circuit contacts the x-
ray exposure switch and turn off the x-ray radiation when a radiation flux sufficient to properly
expose the film is detected.

Actually, there are two sandwich design detectors separated by a metal filter. The output signals
from D1 and D2 are electronically balanced; detector D2 behind its beam hardening filter acts as
a reference. Any magnitude of differential signal controls the film exposure (mAS value).
Information concerning screen and film sensitivity, kV and tube current influence this difference
signal to give an optimum exposure value for all variables.

Ionization Chamber:

Ionization chamber is placed between the patient and the cassette. The signal from the chamber
is amplified and used to control a high speed relay which terminates the exposure when a preset
density is reached.

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 X-ray Imaging System and Different Types of X-ray Machines
FILTERS
Filtration is the process of shaping the X-ray beam to increase the ratio of photons useful for
imaging to those photons that increase patient dose or decrease image contrast. Diagnostic X-ray
beam is polychromatic, comprising of whole spectrum of energies. The mean energy will vary
from 1/3rd to ½ of their peak energy. The first few centimeters of the tissue receive much more
radiation than the rest of the body tissues of the patient. Filters are sheets of metal attached at the
opening of the tube housing which will absorb the low energy photons from the X-ray beam
before it reaches the patient.

The X-ray beam is filtered by absorbers at three different levels: Inherent filtration, Added
filtration & Patient. Inherent filtration: Glass envelope, the insulating oil surrounding the tube
aand window in the tube housing. Added filters: either Aluminiu, copper or compound (Al +
Cu). Copper will absorb high energy photons (also cut down the thickness), aluminum will
absorp characteristics radiation (10 KeV)

COLLIMATORS AND GRIDS

In order to increase the image contrast and to reduce the dose to the patient, the X-ray beam must
be limited to the area of interest. Two types of devices are used for this purpose, viz. collimators
and grids.

Collimator, Grid and X-ray Film-Cassette System in X-ray Imaging

Collimators:
Collimators adjust the X-ray beam width and focusing the X-ray beam (also called X-ray beam
restrictors). It is placed between the X-ray tube and the patient, normally attached at the window
of X-ray tube. Collimator consists of tube having an achromatic lens is fitted at one end. The
other end is fitted with a second brass-tube which can slide inside the 1st tube. The outer end of
the sliding tube has vertical slit (circular / rectangular) whose width is adjustable with the help of
four lead strips which can be moved relative to each other. In practice, it is advisable to use the
smallest possible field size. This results in a low dose to the patient and simultaneously increases
the image contrast, because less scattered radiation reaches the image plane. The scattered
radiation produces diffuse illumination and fogging of the image without increasing its

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information content, and therefore, by choosing the smallest possible field size and using a
collimator, the loss of contrast due to scattered radiation is reduced.
Collimators are usually provided with an optical device, by which the X-ray field can be exactly
simulated by a light field. This can be projected on the patient to ensure proper positioning of the
apparatus. Beam collimators are 'beam direction' devices used in the X-ray tube housing, along
with an arrangement of mirrors and lights, in such a way that the light and X-ray fields match
each other.

Collimator Housing Collimator Shutters-Arrangement of four lead strips

Grids:
One of the problems in getting a sharply defined image in clinical radiology is the presence of
scattered or secondary radiation. These photons are created in the body of the patient or closely
surrounding objects by the interaction of that material. In the typical clinical imaging, the most
common method of reducing scatter is to use a radiographic grid. The separation of scatter from
primary radiation was first addressed by Bucky (in 1913) who introduced a grating or grid of thin
lead strips. Grids are placed between the patient and the film cassette in order to reduce the loss
of contrast due to scattered radiation. It is actually composed of radiopaque (lead) and
radiolucent (low attenuating material such as carbon fiber, aluminium or organic spacer) strips.
These are arranged on edge and the edge of these strips is turned towards the source of X-ray.
This arrangement of the radiographic grid will give the highest possibility for primary X-ray
photons passing between the lead strips and reaching the film, while the off-focus or secondary
photons are likely to interact in the lead strips and never reach the film. The use of this
radiographic grid will greatly improve image sharpness when a relatively thick body part is being
imaged.

Antiscatter Grid Designing and Functioning

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The working ability of a grid is described by the grid ratio (r), which is the ratio of the height of
the lead strips (h) to the distance between two strips, i.e. the interspace (D). A grid ratio of 8:1 is
generally used for 70-90 kVp technique and 12:1 is used for >90 kVp technique. The strip line
density (number of strips per cm) is 1/(D+d), where d is the thickness of the strip. This is
typically 20-60 strips per cm.
Types of Grid:
(i) focused grids (most grids): strips are slightly angled so that they focus in space so must
be used at specified focal distances
(ii) parallel grid: used for short fields or long distances
(iii)moving grids (also known as Potter-Bucky or reciprocating grids): eliminates the fine
grid lines that may appear on the image when focused or parallel grids are used; cannot
be used for portable films.

Mammographic X-ray Machines

Mammography is an X-ray imaging procedure used for examination of the female breast. It is
primarily used for diagnosis of breast cancer and in the guidance of needle biopsies. The female
breast is highly radiation-sensitive. Therefore, the radiation dosage during mammography should
be kept as low as possible. Also, it is required to achieve better spatial resolution than other types
of film/screen radiographs. In order to achieve these goals, an X-ray tube with a small focal spot
size is used to minimize the possibility of geometric blur. The film/screen cassette has a single
emulsion film and a single screen, and is designed to provide excellent film/screen contact.

Mammographic X-ray equipment can either be used with special film/screen cassette or as xero-
radiographic units. The units intended for film/screen use have a molybdenum target X-ray tubes
with a beryllium window and a 0.03 mm molybdenum filter. Radiographs are usually taken at
25–35 kV and tube current 5-10 mA. Xero-radiographic systems use X-ray tubes with tungsten
targets and about 1 mm aluminum filter. Radiographs with this technique are taken at 40–50 kV.
Hence, both types of mammographic units operate at low peak voltages.

Film-based mammography has several disadvantages such as limitations in detection of micro

calcifications and other fine structures within the breast, and inefficiency of grids in removing
the effects of scattered radiation. Many of these limitations can be effectively removed by using
a digital mammography system in which image acquisition, display and storage are performed
independently, allowing for optimization of each process. However, the availability of a suitable
X-ray detector for this purpose is still a challenge that precludes the widespread use of digital
mammography. Various detector technologies which are under evaluation in digital
mammography are large area CCDs (Charge Coupled Devices), photo-stimulable phosphors,
amorphous silicon coupled to scintillators, amorphous selenium and other solid-state devices.

Dental X-ray Machines

X-rays are the only media available to detect location of the teeth, their internal condition and the
degree of decay at an early stage. Since the object–film distance is rather low, and the tissue and
the bone thickness are limited, an X-ray machine of low power is adequate to obtain the
radiograph with sufficient contrast. In practice, most dental units have a fixed tube voltage, in the
region of 50 kV, and a fixed tube current of about 7 mA. The system combines the high voltage

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transformer and X-ray tube into a singly small case, thus greatly simplifying handling and
positioning as no high voltage cables is required.

The primary winding of the transformer is fed with mains voltage via an exposure timer and the
high voltage developed in the secondary windings is fed to the self-rectifying X-ray tube. The
complete assembly is contained in a metal case filled with special insulating oil. The X-ray tube
is of special design and employs a third electrode, called a ‘grid’, between the anode and the
cathode electrodes. The grid restricts electrons from leaving the cathode until the high voltage
reaches its peak value, whereupon all electrons are released and impinge on the anode at a very
high velocity. Consequently, the x-radiation generated contains fewer useless soft X-rays and
more hard rays. The total radiation is, therefore, more effective and can be compared
mathematically to a much higher output resulting in shorter exposure times.

Mammographic X-ray Machine Dental X-ray Machine

Portable and Mobile X-ray Units

In many situations, portable and mobile X-ray units are necessary for X-ray patients who, for
some reason, may not be able to go to X-ray departments. Such situations emerge when the
patient is too ill to be moved from the hospital bed, is seriously ill at home or undergoing surgery
in the theatre. Thus, the need arises to have X-ray equipment, which can be moved to the patients
rather than the patient moving to the X-ray machine.

Portable X-ray Units

A portable unit is so designed that it can be dismantled, packed into a small case and
conveniently carried to the site. The tube head is so constructed that the X-ray tube and the high
voltage generator are enclosed in one earthed metal tank filled with oil. The X-ray is usually a
small stationary anode type, operating in the self-rectifying mode and connected directly across
the secondary winding of the transformer. The only connection required from the control desk is
for the low voltage supply. The controls provided are fairly limited and include a mains voltage
compensator, combined kV and current switch and time selector. As the unit is designed to be
used on the domestic supply, the current must be limited to 15 A. Thus the maximum
radiographic output commonly found on portable units is in the range 15–20 mA at 90–95 kV.

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The tube head is mounted on a cross arm which is carried on a vertical column. The cross arm
may be moved up and down this column by means of a rack and pinion drive.

Mobile X-ray Units

A mobile unit carries the control table and the column supporting the X-ray tube permanently
mounted on the mobile base. Mobile units could be much heavier than the portable units and are
capable of providing higher outputs. Mobile units provide a greater selection of mA and kV
values. The high voltage generator has a full wave rectification circuit feeding a double focus
rotating anode X-ray tube. Most mobile units have a radiographic output of up to 300 mA and a
maximum of 125 kV. This type of output requires a main supply current of 30A. The units are,
therefore, usually fitted with a 30A plug and special sockets need to be provided throughout the
hospital for this purpose.

Because of the high current requirements of the mobile units, the mains resistance becomes a
problem, especially if the mobile is to be used in different parts of the hospital. In order to ensure
consistent results from one power supply socket to another, a means for mains resistance
calibration is provided and must be adjusted to suit each location before making an exposure.

Where there are limitations on the electrical supply, mobile units make use of stored energy. This
may be from the capacitor discharge or battery-powered invertor circuits. The former releases
stored energy from the capacitor during exposure, while the latter converts energy stored in the
battery.

Portable X-ray Machine Mobile X-ray Machine

Prepared by Dr. S. Roy, Prof.-Dept. of Biomedical Engineering, NSEC Page 5

 X-RAY IMAGES: RADIOGRAPHS

X-RAY SCREEN-FILM SYSTEM

Film is the most common hard copy used in radiology. A good quality image is formed if enough
information is transmitted to the film. X-ray film displays the radiographic image and consists of
emulsion on one side (single emulsion film) or on both side (double emulsion film) of a transparent
film base that is about 0.2 mm thick. The base is either cellulose acetate or a polyester resin. Single
emulsion film is less sensitive to radiation and it is used primarily when exceptionally fine detail is
required in the image. The emulsion is a mixture of silver halide granules (AgBr is most common)
suspended in a gelatin matrix. The silver halide is the light sensitive compound and gelatin acts
both as a supporting material and keeps silver halide as separate granules. The emulsion is covered
with a protective coating (T-coat) and is sensitive to visible, UV and ionizing radiation.

Construction of X-ray Film

Silver halides: silver chloride, bromide and iodide are used in various mixtures to alter the
sensitivity of the film. The order of light sensitivity is AgBr > AgCl > AgI. They have a cuboid
crystal structure and are formed by reacting silver nitrate with alkaline halides.
AgNO3 + (KBr or NaCl or KI) AgBr or AgCl or AgI
Silver Nitrate and Potassium Bromide are combined Silver Bromide precipitates out. Potassium
Nitrate is washed away as a waste product. Silver halides are flat and roughly triangular in shape.
They create the density on the film. Normally, 95 to 98% are silver bromide (AgBr) with the
remaining being silver iodide (Agl). Each crystal is a cubic lattice (or matrix) of silver, bromide and
iodide atoms. Negative bromine and iodine halides ions remain on the surface of positive silver
ions inside.

Sensitivity Speck:
Silver halide crystal (SHC's) have an impurities added (usually silver sulfide, AgS) to form
sensitivity specks. The sensitivity speck is what makes the SHC photosensitive. During latent
image formation sensitivity specks attract the silver ions inside the SHC.

Cuboid Crystal Structure of Silver Halides

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A single emulsion film consists of four layers:
1. Supporting Base (cellulose triacetate or polyester): Provides strength, wear resistance, water
proof, non-flammable, and good aging properties.
2. Adhesive Layer (Substratum): Sub-coating containing gelatin and solvents which ensures
the emulsion adheres to the film base.
3. Halide Emulsion: Silver halide and gelatin with some hardening agents.
4. Protective Layer: T-coat which protects the emulsion from mechanical damage.
The total thickness of the film is about 0.25 mm.

Conventional screen film has a thin emulsion layer designed for automatic processing. The thinner
emulsion gives – (i) shorter development and fixing times, (ii) more efficient washing (removing
practically all of the resident chemicals) and (iii) rapid drying. Non-screen film has thicker
emulsion which is more sensitive to X-ray radiation and useful for bone imaging.

Types of films:
A. Screen type films: faster when used with intensifying screen
- Conventional / Monochromatic (without optical sensitizer) sensitive to UV and
blue light.
- Orthochromatic film (with optical sensitizer) sensitive to UV, blue and green
light.
B. Direct exposure type: used for dental exposures
It is important to note that the colour of the light emitted (wavelength) must match the light
sensitivity of the film used. This is known as spectral matching.

Film Storage:
Ideal storage conditions for unexposed film are 200C (max.) with a relative humidity of 50%. Cold
storage can significantly lengthen the useful life of a film. X-ray film is always kept in a cassette
(made up of metal cover).

Cassettes are rigid holders used in conventional and computed radiography (CR) for the screen
film system and imaging plate respectively. The back side of the cassette has a rubber or felt for
adequate contact between screen film systems or with the imaging plate. The front is made of low
atomic number material (e.g. plastic or carbon) and the back is made of high atomic number
material (e.g. lead) to reduce backscatter.

In case of conventional radiography, two screens are mounted on each side of the cassette, except
in mammography, where a single screen is mounted on the back side. These cassettes have to load
with film in the darkroom unlike the cassettes used in CR which can be loaded with imaging plate
in the light. The formats of the cassettes used in conventional radiology are: 13 x 18 cm; 18 x 24
cm; 24 x 30 cm; 20 x 40 cm; 30 x 40 cm; 35 x 35 cm; 35 x 43 cm; 30 x 90 cm.

Intensifying screens are used in the X-ray cassette to intensify the effect of the X-ray photon by
producing a larger number of light photons. It decreases the mAs required to produce a particular
density and hence decreases the patient dose significantly. It also reduces motion blur and X-ray
tube loading by reducing exposure time. In cassettes, which use double emulsion films, two screens
are used, mounted on both sides of the cassette. In mammography, however, a single screen on the
back side and a single emulsion film is used.

The thickness of an intensifying screen is about 0.4 mm. The thickness of the screen affects the
screen speed and spatial resolution: thicker screen improves speed but reduces spatial resolution
(increased diffusion of light before image formation). The intensity factor is a measure of efficiency
of intensifying screen and is the ratio photon exposures with and without intensifying screen to
achieve a designated film density. The absorption and conversion efficiency of the screen affect the
intensity factor.

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Intensifying screens contains:
 Reflecting layer/absorptive layer
 Phosphor: absorbs the X-ray photon and converts it to visible light that is recorded by the
film [calcium tungstate (CaWO4): blue light, lanthanum oxybromide (LaOBr): blue light &
gadolinium oxysulfide (Gd2O2S): green light]
Rare earth elements are used in present-day screens as they are faster and have higher absorption
and conversion efficiency: gadolinium for green light, lanthanum for blue light and yttrium.

Generally, doctors keep the film image as a negative. That is, the areas that are exposed to more
light appear darker and the areas that are exposed to less light appear lighter. Hard material, such as
bone, appears white, and softer material appears black or gray. Doctors can bring different
materials into focus by varying the intensity of the X-ray beam.

Radiographic Screen-Film System

FILM SENSITOMETRY
Film is originally constructed for recording the changes in photon intensity. The film is more
sensitive to light than X-ray energy. At least 2.4 eV energy is required to free electron from
bromide and is corresponds to 520 nm i.e. blue light or shorter. However, it does have a useful
linear response to X-ray and γ-ray radiation which is utilized for measuring radiation dose as a film
dosimeter. Film sensitometry is the quantitative evaluation of how a film emulsion is responds to
radiation and processing. This study is important in order to produce images with optimum contrast
that reveal high details of the object examined. Film sensitometry actually measures the response of
photosensitive film to different levels of exposures. The response of the film to exposures is
manifested as a degree of blackening produced after chemical processing.

In radiography, the degree of blackening is quantitatively indicated by the term optical density. The
optical density describes how much a certain area of the film is opaque to light incident upon it. A
film contains number of areas with different optical densities from white (fully transparent) to black
(fully opaque). A film can be considered as a contrast converter. A contrast is the variation in film
density (shades of gray) that actually forms the image. One of the functions of film is to convert
differences in exposure (subject contrast) into film contrast (differences in density). The amount of
film contrast resulting from a specific exposure difference can vary considerably. The exposure
range in which a film can produce useful contrast is known as its latitude. The latitude of a specific
film is determined primarily by the composition of the emulsion and, to a lesser extent, by
processing conditions. The significance of film latitude is that it represents the limitations of the
exposure range that will yield useful image contrast.

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General Relationship between Optical Density & Light Penetration and Exposure Contrast & Film Contrast

Film characteristics are best obtained by illuminating the film with a calibrated gray scale from a
densitometer. The gray scale densities (resultant optical densities) are plotted against exposure (log
relative exposure) then a film characteristic curve is obtained. The curve describes the film
quantitative response to photon and reveals many important film qualities.

Characteristics / H and D (Hurtet and Driffield) Curve of a Radiographic Film

The film characteristic curve has three distinct regions with different contrast transfer
characteristics. The part of the curve associated with relatively low exposures is designated the toe
and also corresponds to the light or low-density portions of an image. When an image is exposed so
that areas fall within the toe region, little or no contrast is transferred to the image

A film also has a reduced ability to transfer contrast in areas that receive relatively high exposures.
This condition corresponds to the upper portion of the characteristic curve in which the slope
decreases with increasing exposure. This portion of the curve is traditionally referred to as the
shoulder.

The highest level of contrast is produced within a range of exposures falling between the toe and
the shoulder. This portion of the curve is characterized by a relatively straight and very steep slope
(γ) in comparison to the toe and shoulder regions. In most imaging applications, it is desirable to
expose the film within this range so as to obtain maximum contrast.

The fog level is a density reading of the background noise caused mainly by thermal effects. The
threshold value (Dmin) marks the lowest exposure that fives a density value above the fog level. The
shoulder (Dmax) region (non-linear response) indicates that all the film grains have been saturated.

The precise shape of the curve depends on the characteristics of the emulsion and the processing
conditions. The primary use of a characteristic curve is to describe the contrast characteristics of the
film throughout a wide exposure range. At any exposure value, the contrast characteristic of the
film is represented by the slope of the curve. At any particular point, the slope represents the
density difference (contrast) produced by a specific exposure difference.

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RADIOGRAPHIC FILM IMAGE FORMATION
Radiographic film image is based on the lattice properties of AgBr (95-98% AgBr & rest AgI)
crystals in the film emulsion. The transmitted photon (X-rays) interacts with halides (bromide or
iodide) on the surface of the matrix. As a result, halides are energized and electrons are ejected
(bromide and iodide become neutral). The ejected electrons are absorbed by the sensitivity speck
causing it to become negatively charged. The inner positive silver ions migrate to the negative
charge. The positive silver neutralizes the sensitivity speck and then another electron is absorbed,
and so on. A single incident photon may free thousands of electrons. The neutralizing electron may
be lost thermally and Ag atom bound again to the lattice. But, it five or more contiguous silver
atoms are freed at almost the same time, then they remain in the free metallic stage and the latent
image is formed.
Initially, a free bromine atom is produced when the bromide ion absorbs the photon of light:
Ag+Br- (crystal) + hv (radiation) Ag+ + Br + e-
The silver ion can then combine with the electron to produce a silver atom.
Ag+ + e- Ag0
The developer causes adjacent silver atoms to from a grain of about 109 metallic silver atoms while
remaining (unexposed) AgBr are carried away by the fixer solution.

The number of grain per unit area and size can vary with type of emulsion and developer, but the
amount of photon energy required per grain is constant. Thus fine-grain films require more photon
energy per unit area than the coarse-grain films. The energy required to free the electron from the
bromide is at least 2.4 eV (1 eV = 1.602 x 10-19 J).

The image formed prior to chemical development is called “latent image”. It is still possible for
some of the metallic silver atoms to return to their lattice coupling because of slow thermal effects
and is called “latent image fading”. All films have some range of exposure times such that a
constant photon intensity time product will bring the film to a particular value of latent image
𝟏
density (D). 𝐃 = 𝐥𝐨𝐠 𝐓
Where, T = Intensity of the transmitted X-ray beam that expose the film
D = Density of latent image
The areas of the emulsion most exposed to the photons end up with greatest concentration of
metallic sliver. These are the darkest areas when project light through them. Areas with little light
end up with less metallic silver and are more transparent. This is negative film. On the negative
film all the brightness values of the original scene are reversed. Light becomes dark and dark
becomes light.

Gurney-Mott Theory of Latent Image Formation

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DARK ROOM ACCESSORIES: DEVELOPER AND FIXER
The manual process for developing hard copy film image uses the standard time-temperature
method and small containers of the different processing solutions. Manual processing is the primary
method whereby film will be processed when field equipment is used.
Processing Tank: The processing tank most commonly used in radiology clinics has three
compartments. The compartment contains the developing solution, water and fixing solution. In
addition to the three compartments, a source of hot and cold water, a drain, an overflow valve and a
cover are needed. The water is adjusted to the proper temperature and is allowed to circulate in the
middle compartment and pass from the tank by the overflow valve. This action provides
temperature controls to the developing and fixing solution.

Tank for Processing Radiographic Film

Processing Procedures: In order to produce a radiographic image, the processing procedure for the
film is sequenced as follows: developing, rinsing, fixing washing, and drying. The quality and
diagnostic value of radiographs depend upon proper processing procedures.

Radiographic Film Developing Procedure:

Remove the lightproof wrapper from the film. Place the film on the film holder. The film should be
held lightly by its edges to avoid the appearance of smudges or fingerprints on the developed film.
Set the interval timer (clock) for the prescribed developing time. Timer should start when the film
is placed in the developing solution (developer). Immerse the film in the developing solution,
moving the film holder up and down several times to break up air bubbles that may have formed on
the surface of the film. Remove the film at the expiration of the developing time. Hold the film rack
in a tilted position for a few seconds to allow excess solution to drain into the developing section of
the tank. The film should remain in the rinse water at least 20 seconds to remove the developing
solution. After removing the film from the rinse water and draining, place it in the fixing solution
(fixer).

Film Fixing, Washing and Drying Procedure:

During the first stage of fixation, unexposed silver crystals are removed from the film, thereby
clearing the film and making the image translucent. The hanger should be moved up and down
several times to make sure the fixer contacts all surfaces. An average safe time for the film to
remain in a fresh fixing solution is 10 minutes. This provides time for the emulsion to harden
properly after the film has cleared. The film may be examined briefly after 1 minute in the fixer,
but it must be returned to the solution to complete the hardening process. For wet readings, a
minimum of 2 minutes of fixation is required. After readings, the film must be returned to the
fixing solution to complete the process.

Upon the completion of fixation, the film should be immersed in fresh, cool, circulating water for
at least 20 minutes to ensure complete removal of the fixing solution. If not washed properly, the
radiograph will turn yellow and fade with time if any of the fixing chemical remains on its surface.

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Wet films must be handled carefully so that the emulsion is not touched or marred. After washing,
the hanger should be hung carefully upon the drying rack. A pan under the rack serves to catch
water dripping from films. Drying is done by leaving the film suspended in the air until it is
completely dry. Drying may be speeded up by directing a current of air from a small electric fan
over the film's surface or by using an X-ray film drier.

Developers:
Developers usually contain ring compounds of hydroquinone, amitol or metol.

Silver halide crystals reduced completely to silver atoms representing amplified latent image
information.

Fixers:
The fixer compound is ammonium thiosulfate (NH4)2S2O3 which removes the unexposed, unaltered
silver halides as a soluble complex.
Ag+Br- + (S2O3)2- Ag (S2O3)- + Br-
The silver thiosulfate complex is carried out of the emulsion when film is thoroughly washed with
clean water.

IMAGE QUALITY FACTORS

The term “image quality” means the degree to which an image allows medical professional to
accomplish their goals viz., diagnosis, determine underline mechanism, guide therapeutic
procedure, monitoring the effectiveness of treatment. Image quality depends on the particular
imaging modality used viz. particular set-up, skill of the operator, patient characteristics and
imaging time. Overall, image quality depends on six important factors: A. Contrast, B. Resolution,
C. Noise, D. Artifacts, E. Distortion & F. Accuracy.

A. Contrast: Contrast quantifies the differences between image characteristics (eg. Shades of
gray or colour) of an object or feature within an object and surrounding objects or
background. It describes the amount of additional darkening caused by an additional
amount of light when working near the center of a film exposure range. The ability of
medical professional to discriminate among anatomical or functional features in a given
image strongly contrast. It is influenced by system performance but also by the physical
attributes of the different tissues, KV, detectors, etc.
B.
C. Resolution: It refers to the degree to which the measuand can be broken into identifiable
adjacent parts. Resolution can be thought of as the ability of a medical imaging system to
accurately depict two distinct events in space, time or frequency as separate i.e., spatial,
temporal or spectral resolution. Resolution is influenced by the machine itself (X-ray tube),
movement (patient) and recording medium (film, image plate, etc.)
Image quality in the brighter areas of the images is limited by blurring or poor spatial
resolution. Spatial resolution is the ability to detect a small structure against its background
or to distinguish as separate two structures close together. Any objects or points is
distinguishable by two times, therefore, spatial resolution is measured in line pairs per mm
(LPmm-1).

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 Resolution Spatial Resolution Contrast
D. Noise: Noise is a generic term refers to any type of random variation / fluctuation in an
image and it can have a dramatic impact on image quality. Image quality decreases as noise
increases. It is actually an unwanted characteristic of medical imaging system and is
introduced either by quantum effects (photon density), mottle, film graininess or electronic
noise. The source and amount of noise depend on the imaging method and particularly
imaging system. E.g. in X-ray system, the discrete nature of arrival of photons lead to
random fluctuations called quantum mottle.
E. Artifacts: Artifact means creation of image features that do not represent a valid object
within or characteristics of the patient. This can frequently obscure important features or be
falsely interpreted as abnormal findings.
F. Distortion: It is geometrical in nature and refers to the inability of a medical system to give
an accurate impression of shape, size or position of an object of interest.
G. Accuracy: Accuracy means both conformity of truth (i.e. freedom from error) and clinical
utility. In medical field, it is concerned with quantitative and diagnostic accuracy.

MODULATION TRANSFER FUNCTION (MTF)

The image quality is chiefly determined by spatial resolution and contrast. The ability of an optical
system to resolve a structure is expressed in terms of modulation transfer function (MTF). It defines
how well the imaging system transfers the different frequency components of the object into the
final image. The ratio of the output signal amplitude to the input signal amplitude at each frequency
is the MTF.
MTF = Recorded signal frequencies / Original signal frequencies
An MTF value of 1 or zero means that all or none of the frequency components of the original
object exists in the final image.

X-RAY IMAGE INTENSIFIER (XRII)

It detects the X-rays and converts it into a small, bright visible image. This visible image is then
focused by lenses to a TV camera for final display on a monitor. It is particularly useful for large
field of view at moderate resolution and high contrast, eg upper and lower GI Tract. The key
components of an XRII are an input phosphor layer, a photocathode, electron optics and an output
phosphor. All the components are held in a vacuum by an enclosure made of glass or metal. The

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input phosphor layer diameter ranging from 15–32 cm, whereas output phosphor diameter 6-15
mm. The image intensification takes place because of the very small output screen size and electron
magnification in the tube. The transmitted X-rays enter through a low absorption window and then
strike the input phosphor usually made of dope CsI (CsI:Tl) which produces visible light. The
photocathode cathode absorbs the visible light and emits a number of low energy electrons that
initially spread in all direction. The photoelectrons are accelerated and steered by electron optics (a
set of anodes / grids / electrostatic lenses 100V to 35KV). Electrons beam path becomes narrowed
and finally strike or impinge on a small diameter output phosphor (ZnCdS:Ag) which converts it
into much brighter visible light. The brightness gain is due to the acceleration of the electrons in the
lens system and the fact that the output image is smaller than the primary image. The gain is several
hundred times. The light travels through output window to a lens system of a video camera.

The ratio of image brightness of the two phosphors is called brightness gain (range 2500 to 7000 in
practice) of the intensifier tube. The brightness gain is the product of geometric gain and electronic
gain. A lens mounted on the image intensifier has the purpose of collimating or focusing the image.
Geometric gain: Ratio of the areas of input and output phosphor.
Electronic gain: Product of input quantum efficiency, photocathode efficiency, potential
difference between input and output phosphors and phosphor output efficiency.

X-ray Image Intensifier (XRII)

DIGITAL RADIOGRAPHY (DR)

Digital radiography generates images through electronic processing. In digital radiography, the
conventional film image system is replaced with digital image which is stored in a computer. The
digital radiography could bring several advantages to X-ray image processing for
(i) Improvement of contrast
(ii) Better displayed images
(iii)The use of low doses
(iv) Avoiding repeat radiography
(v) Opening up the possibility of digital storage with a picture archiving and communication
system (PACS) or remote image viewing via tele-radiology.
Here, the patient is positioned in front of detectors that record the X-ray intensity transmitted
through the patient. All detectors produce an analog signal which is transformed into digital signal
by analog to digital converter (ADC). The digital signal is sent to a computer or digital image
processor that can analyze, transform or display the image. Digital image signal can be recorded on
media such as magnetic tape, magnetic disk, or optical disk. The digital signal also can be
transformed back into analog signal (by DAC) for display on a conventional video terminal.

Digital X-rays
Digital radiography is currently practiced through the use of three commercial approaches, two of
which also depend on phosphor screens. The first phosphor based approach is to digitize the signal
from a video camera that is optically coupled to an X-ray image intensifier to provide an instant
readout The second phosphor based approach is a stimulable phosphor system, in which the

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phosphor contains traps for electrons excited by incident X-rays. The latent image formed by the
trapped electrons is then brought out in the form of a blue-light image by illuminating the phosphor
point to point with a red laser. Unlike the intensifier system, the stimulable phosphor system cannot
produce instant images for the cassette must be carried to a laser scanner for readout by a photo-
multiplier which performs the digitization. The third commercial digital system is based on using
an amorphous selenium (a-Se) photoconductive layer to convert X-ray photons directly to charge
carriers. After exposure to X-rays, the image resides as a charge distribution on the a-Se surface,
which is read out electronically and then digitized. With the use of flat panel detectors in the a-Se
method the X-ray image is captured and is converted directly to a digital signal for display,
processing and storage.

Digital X-ray imaging system consists of: (1) X-ray machine, (2) X-ray imaging transducer or data
collector & (3) computer for processing, storage and data display. Two major variant of detectors
used for digital image capture are – (A) Flat Panel Detectors (FPDs) & (B) High density line scan
solid state detectors.

FLAT PANEL DETECTORS

A. Indirect: Flat panel detectors consist of an array of individual detector elements. The
elements are square, 140–200 microns per side and are fabricated using amorphous silicon
(a-Si) thin-film technology onto glass substrates. Detector arrays used ranging from about
20 x 20 cm up to 40 x 30 cm. A single detector may contain as many as 5 million individual
detector elements. A cesium iodide (CsI) scintillation crystal or gadolinium oxysulfide
(Gd2O2S) is coated onto the amorphous silicon coupled with thin-film photodiodes and
transistors (TFTs) capturing the visible light signal from the scintillator to form the digital
image. Scintillation crystal converts X-rays into light which is channeled through silicon
photo-detector layer where it is converted to a digital output signal. The digital signal is
then read out by thin film transistor or fiber coupled CCDs. The image is then transferred to
a computer for display at a frame rate selected by the user. Frame rates can be as high as 30
frames per second.
B. Direct: Amorphous selenium (a-Se) convert X-ray photons into charges (create electron-
hole pairs) and the resultant charge pattern is read out by a TFT array, active matrix array,
electrometer probes or microplasma line addressing.

Flat Panel Detector

High-density Line-scan Detector
Solid state detector composed of a photostimulable barium fluorobromide doped with europium
(BaFBr:Eu) or cesium bromide (CsBr) phosphor. The phosphor detector records the X-ray energy
and is scanned by a laser diode to excite the stored energy which is released and read out by a
digital image capture array of CCD.

DETECTOR QUANTUM EFFICIENCY

Detectors detect X-ray or γ-radiation and provide signals proportional to the radiation energy
absorbed. Such conversion occurs through three basic reactions:
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 (a) Chemical Reaction: Radiation caused atomic or molecular excitation of electrons, eg.
Interaction with the film emulsion.
(b) Ionization Reaction: Atoms lose electrons and becomes current carrying ions, eg. Gas or
semiconductor detectors.
(c) Luminescence Reaction (Light Production): Valence electron in the crystalline material gain
energy and enter into higher conduction band. Later move into lower energy orbit and emits
photons in the UV / Visible ligh, eg. CsI, NaI.
Radiation detectors are: (1) Ionization Chamber, (2) Geiger Counter, (3) Proportional Counter, (4)
Scintillation Detector, (5) Semiconductor Detector.
A detector’s response to radiation is measured in terms of both its efficiency and sensitivity. The
sensitivity of a detector is the response relative to photon energy. The efficiency can be classified
into three types:
i. Geometric Efficiency: The area or volume of the detector intercepting the radiation.
ii. Intrinsic Efficiency: The absorbing power of the detector for the particular energy radiation
and also called quantum efficiency, E Q.
iii. Extrinsic Efficiency: It is the usefulness of the detector signal itself i.e. light output and
light collection and is called conversion efficiency, E C. The photons absorbed by the
detector must contribute to a measurable signal either electrical or light.
Detector quantum efficiency (EQ) is the ability of a detector to absorb incident photons.
Detector quantum efficiency is measured as: 𝐸𝑄 = 1 − 𝑒 −𝜇𝑥𝑑
Where, µ is the linear attenuation coefficient and xd the detector thickness.
Since µ is dependent on photon energy, there are three parameters influencing quantum efficiency.
1. Linear attenuation coefficient of the detector material
2. Detector thickness
3. Photon energy
Overall, detector quantum efficiency is also modified by the shielding material surrounding the
detector volume such as the input window (Al, Glass, Ti, etc) and any collimator or girds which
would also absorb incident radiation. So E Q is modified as:
𝐸𝑄 = 𝑒 −𝜇𝑥𝑤 . (1 − 𝑒 −𝜇𝑥𝑑 )
Where, µxw is the attenuation coefficient and thickness of the covering material

RADIATION DOSES, DOSE EQUIVALENT AND REM

The X-ray machine output is described in terms of Entrance Skin Exposure (ESE) and is the
amount of radiation delivered to the patient's skin at the point of entry of the X-ray beam into the
patient. The unit for ESE is Roentgens (R) (C/kg air in SI units). The unit Roentgen is defined in
terms of charge (Coulombs) created by ionizing radiation per unit mass (kg) of air (1 R =2.58x10-
4
C/kg air). One R is the amount of radiation which will produce 2.08x10 9 ion pairs per CC of air at
STP. Usable units are mR (10-3R) or µR (10-6R). The radiation exposure can also be measured at
other locations and is the quantity indicated by many radiation detectors such as Geiger-Muller
meters.

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The biological effects of X-rays are due to energy imparted to matter. There are two dose quantities
for describing energy deposited in a tissue: (a) absorbed & (b) equivalent dose.

(a) Absorbed Dose (DT): It is the ratio of energy absorbed by a unit mass measured in J/kg.
This is fundamental quantity in radiation protection and is called gray (Gy) normally
describe the average dose to an organ or tissue Radiation dose is the energy (joules)
imparted per unit mass of tissue and has the US units of rad (radiation absorbed dose).
Patient exposures, particularly in Radiation Oncology are described in units of radiation
dose. The international (SI) unit for dose termed the Gray (Gy). The conversion between
the units is: 100 rad = 1 Gy. One rad is the radiation dose that will result in energy
absorption of 1.0x10-2J/kg of irradiated material.
The relation between absorbed dose (D) and radiation exposure (R) is as follows:
DT = f x R
Where, f is a proportionality constant which depends on the composition of the irradiated
material and quality of the radiation beam. Generally, f is 0.87 rad/R for air, 1 rad/R for soft
tissue and f is >1 rad/R for hard tissue. The value of f is significantly decreases with
increases in KV.

(b) Equivalent Dose (HT): It is a measure of the radiation dose to tissue where an attempt has
been made to allow for relative biological effects of different types of ionizing radiation.
This is related to biological damage and is denoted as rem (radiation equivalent man, US
unit). The probability of tissue radiation damage depends not only on the absorbed dose but
also on type and energy of radiation. The unit rem is used to compare dose received by
different types of radiations (e.g. alpha particles) which have a different capacity for causing
harm than X-ray radiation. This unit is properly termed dose equivalent. The dose
equivalent is the product of the dose times a quality factor. In quantitative terms, equivalent
dose is less fundamental than absorbed dose, but it is more biologically significant.
Equivalent dose is measured using Sievert (SI unit) but rem is still commonly used (1 Sv =
100 rem). The relation between equivalent dose and absorbed dose is as follows:
Sv = Q x DT (rad)
Q is the quality factor and in diagnostic X-ray, Q=1 and therefore, 1 rad = 1 rem.
Q has been applied to the absorbed dose at a point and not over the organ as a whole. So,
this dose equivalent (HT) can be rewrite as HT = ∑DTWR.
HT is the equivalent dose in tissue for an absorbed dose DT from a radiation having a
weighting factor WR. The equivalent dose is measured in Sievert (Sv) and forms the
fundamental unit for other parameters in radiation protection. [The radiation weighting
factor, WR is dependent on the type and energy of the incident radiation. The value of WR is
1 for X-rays].

Effective Dose Equivalent (EDE): The effective dose is used to compare the stochastic
risk of non-uniform exposure to radiation. Body tissues react differently to radiation and
cancer-induction occurs at different rate of dose in different tissues. Hence, the effective
dose is the risk of developing fatal cancer in the tissue in question. If the body is uniformly
irradiated, the summed effective doses are equal to 1.
The effective dose is calculated by multiplying the equivalent dose (HT) by a tissue
weighting factor (WT).

[Radiation absorbed dose and effective dose in the international system of units (SI system) for
radiation measurement uses "gray" (Gy) and "Sievert" (Sv), respectively.
In the United States, radiation absorbed dose, effective dose and exposure are sometimes
measured and stated in units called rad, rem, or roentgen (R).]

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RADIATION PROTECTION AND RADIATION MEASURING INSTRUMENTS
Radiation protection is the science and practice of protecting people and the environment from the
harmful effects of exposure to ionizing radiation. Exposure can be from a source of radiation
external to the human body or due to internal irradiation caused by the ingestion of radioactive
contamination
.
Ionizing radiation is widely used in industry and medicine and can present a significant health
hazard by causing microscopic damage to living tissue. There are two main categories of ionizing
radiation health effects. At high exposures, it can cause "tissue" effects, also called "deterministic"
effects due to the certainty of them happening, conventionally indicated by the unit gray and
resulting in acute radiation syndrome. For low level exposures there can be statistically elevated
risks of radiation-induced cancer called “stochastic effects" due to the uncertainty of them
happening conventionally indicated by the unit Sievert.

Fundamental to radiation protection is the avoidance or reduction of dose using the simple
protective measures of time, distance and shielding. The duration of exposure should be limited to
that necessary, the distance from the source of radiation should be maximized and the source
shielded wherever possible. To measure personal dose uptake in occupational or emergency
exposure for external radiation personal dosimeters are used and for internal dose to due to
ingestion of radioactive contamination bioassay techniques are applied.

According to the International Atomic Energy Agency (IAEA), radiation protection can be divided
into three groups:
 occupational radiation protection, which is the protection of workers in situations where
their exposure is directly related to or required by their work
 medical radiation protection, which is the protection of patients exposed to radiation as part
of their diagnosis or treatment
 public radiation protection, which is the protection of individual members of the public and
of the population in general

According to the International Commission on Radiological Protection (ICRP), the System of

Radiological Protection is based on the following three principles:
1. Justification. “Any decision that alters the radiation exposure situation should do more
good than harm.”
2. Optimization of Protection. “Doses should all be kept as low as reasonably achievable /
practicable, taking into account economic and societal factors.” (known as ALARA or
ALARP)
3. Dose Limitation. “The total dose to any individual … should not exceed the appropriate
limits.”

External Dose Uptake

External exposure is radiation that comes from outside our body and interacts with us. There are
three factors that control the amount or dose of radiation received from a source. Radiation
exposure can be managed by a combination of these factors:
 Limiting Time: The amount of radiation exposure depends directly (linearly) on the
time people spend near the source of radiation. Reducing the time of an exposure reduces
the effective dose proportionally.
 Distance: The amount of radiation exposure depends on the distance from the source of
radiation. Increasing distance reduces dose due to the inverse square law.
 Shielding: Sources of radiation can be shielded with solid or liquid material, which absorbs
the energy of the radiation. The term 'biological shield' is used for absorbing material placed
around a nuclear reactor, or other source of radiation, to reduce the radiation to a level safe
for humans. The shielding materials are concrete and lead shield which is 0.25mm thick for
secondary radiation and 0.5mm thick for primary radiation.

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Internal Dose Uptake
Internal dose, due to the inhalation or ingestion of radioactive substances, can result in stochastic or
deterministic effects, depending on the amount of radioactive material ingested and other
biokinetic factors. Protection from internal exposure is more complicated. Most radionuclides will
give much more radiation dose if they can somehow enter inside the body than they would if they
remained outside.

Radiation Measuring Instruments

Radiation doses to designated workers are monitored on a regular basis by means of dosimeter
badges which integrate the workers radiation dose over a fixed period of times, usually one month
but could be over a shorter period (2 weeks for pregnant staff) or longer (2 months for occasional
exposure i.e. ancillary staff). There are three methods available for monitoring radiation: (i) film
badge dosimeters, (ii) thermo-luminescent dosimeter (TLD) & (iii) direct readout electronic
monitors.
Film dosimeter badges have a sensitivity of 0.1 mSv over 1 month.
Thermo-luminescent dosimeters (lithium fluoride, LiF fluorescent material) have sensitivity of 0.08
mSv.
Electronic dosimeter (small calibrated Geiger tube but more recently PIN semiconductor diodes)
have sensitivity 1 µSv to 1000 mSv.

RADIOTHERAPY
Radiation therapy has a pivotal role in the treatment of cancer. Radiation therapy uses high-energy
radiation to shrink tumors and kill cancer cells. X-rays, gamma rays and charged particles are types
of radiation used for cancer treatment. The types of radiation therapy are:
A. External Beam Radiation Therapy (EBRT) or Teletherapy: This technique involve the
delivery of electromagnetic radiation (X-rays, γ-rays) or particulate radiation (electrons,
protons) from a linear accelerator or radionuclide source (Co-60) from outside of the body.
It accounts for almost 90% of radiation treatment.
B. Internal Radiation Therapy (IRT) or Brachytherapy or Implant Radiation Therapy:
Radioactive material sealed in needles, seeds, wires or catheters is placed directly into or
near a tumor.
C. Systemic Radiation Therapy: Radioactive substances (radioactive iodine-131, strontium-89,
samarium-153) are injected in the blood stream ad are travel in the blood to kill cancer cells.

Radiation therapy may be curative in a number of types of cancer if they are localized to one area
of the body. It may also be used as part of adjuvant therapy to prevent tumor recurrence after
surgery to remove a primary malignant tumor (eg. early stages of breast cancer). Radiation therapy
is synergistic with chemotherapy and has been used before, during and after chemotherapy in
susceptible cancers.

RADIOTHERAPY PRINCIPLES
Radiation therapy is commonly applied to the cancerous tumor because of its ability to control cell
growth. The underlying principle of radiation therapy is the destruction of malignant tissues while
minimizing damage to normal tissues within a treatment field. Radiation therapy kills cancer cells
by damaging their DNA (the molecules inside cells that carry genetic information and pass it from
one generation to the next). Radiation therapy can either damage DNA directly or create charged
particles (free radicals*) within the cells that can in turn damage the DNA. Cancer cells whose
DNA is damaged beyond repair stop dividing or die. When the damaged cells die, they are broken
down and eliminated by the body’s natural processes.
*A type of unstable molecule that is made during normal cell metabolism (chemical changes that
take place in a cell). Free radicals can build up in cells and cause damage to other molecules, such
as DNA, lipids, and proteins. This damage may increase the risk of cancer and other diseases.

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The principal limitation of radiation therapy is radiation exposure of healthy tissues. To spare
normal tissues (such as skin or organs which radiation must pass through to treat the tumor), shaped
radiation beams are aimed from several angles of exposure to intersect at the tumor providing a
much larger absorbed dose there than in the surrounding healthy tissue. Radiation toxicities, such as
cognitive dysfunction, esophagitis, and myelosuppression depend on the irradiated organs and on
the radiation dose and scheduling. Traditionally radiation oncologists have limited adverse effects
by reducing the dose of radiation or by spreading the dose over multiple administrations (i.e., dose
fractionation). Over the past decade, advances in radiation planning and delivery have markedly
improved the ability to focus radiation on target tissues sparing nearby healthy tissues.

RADIOTHERAPY DOSE
The amount of radiation used in photon radiation therapy is measured in gray (Gy) and varies
depending on the type and stage of cancer being treated. For curative cases, the typical dose for a
solid epithelial tumor ranges from 60 to 80 Gy, while lymphomas are treated with 20 to 40 Gy.
Preventative (adjuvant) doses are typically around 45-60 Gy in 1.8-2 Gy fractions (for breast, head
and neck cancers.)

Recent advances in Radiation Therapy

Recent advances have improved the effectiveness, decreased the complications and expanded the
implications of radiation therapy. These advances include 3-D conformal radiation therapy,
intensity-modulated radiation therapy, stereotactic radiotherapy, brachytherapy and radio-
immunotherapy. Each of these modalities has improved radiation targeting, thereby limiting
radiation exposure of healthy tissues. The way radiation therapy is administered has also changed.
Although traditional external beam radiation therapy is administered daily over several weeks,
stereotactic radiotherapy may be administered as a one-time treatment. Radio-immunotherapy is
administered intravenously. Contemporary radiation techniques also have distinct toxicity profiles.
The high radiation doses employed during stereotactic radiotherapy have been associated with
obliteration or obstruction of tubular structures such as bronchi and bile ducts limiting its use near
these tissues. Radio-immunotherapy may be complicated by anaphylactic reactions during and
following infusions.

RADIATION THERAPY TREATMENT PLANNING AND MODALITIES

A radiation oncologist develops a patient’s treatment plan through a process called treatment
planning, which begins with simulation. During simulation, detailed imaging scans show the
location of a patient’s tumor and the normal areas around it. These scans are usually computed
tomography (CT) scans, but they can also include magnetic resonance imaging (MRI), positron
emission tomography (PET) and ultrasound scans.

Radiotherapy is an effective treatment method for cancers. During radiation treatment, a patient
must be in the same position from the start to the end of radiation treatment. Patient movements are
usually monitored by the radiation technologists through the closed circuit television (CCTV)
during treatment. The success of radiotherapy is to deliver maximum dose of radiation to the tumor
tissue. At the same time, the minimum dose of radiation has to be ensured to the surrounding
normal tissues to reduce the incidence of radiation of acute and late effects. To achieve this, proper
treatment planning and careful execution is mandatory. Patient immobilization is an important
parameter during the radiotherapy treatment.

Determining the treatment plan

High-end computers and special software are used to plan the treatment so that all beams meet and
produce a high, focused dose of radiation at a central point within the target. The team (radiation
oncologist and physicist) determines the radiation prescription:
 appropriate radiation dose
 number and angle of treatment arcs

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  size and shape of the beams
 number of treatment fractions

Adverse effect of radiation therapy

With radiation therapy, the side effects depend on the treatment dose and the part of the body that is
treated. The most common side effects are tiredness, skin reactions (such as a rash or redness,
permanent pigmentation, and scarring) in the treated area, and loss of appetite. Radiation therapy
can cause inflammation of tissues and organs in and around the body site radiated.

EXTERNAL BEAM RADIATION THERAPY (EBRT)

EBRT uses either a linear accelerator to target the tumor and deliver the radiation or Cobalt-60, a
beta-emitting radioactive isotope.
Linear Accelerator:
Many types of external-beam radiation therapy are delivered using a machine called a linear
accelerator (also called a LINAC). A LINAC uses electricity to form a stream of fast-moving
subatomic particles. This creates high-energy radiation that may be used to treat cancer. External-
beam radiation therapy is most often delivered in the form of photon beams (either x-rays or
gamma rays). A photon is the basic unit of light and other forms of electromagnetic radiation. It can
be thought of as a bundle of energy. The amount of energy in a photon can vary. For example, the
photons in gamma rays have the highest energy, followed by the photons in x-rays.

Linear Accelerator Used for External-beam Radiation therapy

Cobalt-60 Therapy:
Most common RT can be used anywhere on the body and particularly useful in brain tumor. Under
local anesthesia, the patient is positioned on a table with a special rigid frame covering the head.
Based on the results of an image study conducted just prior to treatment, Co-60 therapy unit directs
approximately 200 beams of 200 beams of gamma radiation at the patient’s tumour. Treatment
takes anywhere from several minutes to a few hours to complete. Following treatment, the head
frame is removed and the patient may return to normal activity.

As used in radiotherapy, cobalt units produce stable, dichromatic beams of 1.17 and 1.33 MeV,
resulting in average beam energy of 1.25 MeV. The cobalt-60 isotope has a half-life of 5.3 years so
the cobalt-60 needs to be replaced occasionally.

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 Cobalt-60 Radiation Therapy

INFORMATION CONTENT OF AN IMAGE [Beyond Syllabus]

The total information content of an image is the product of the number of discrete picture elements
(pixels) and the amplitude levels of each pixel. Resolution can be defined as the objectives and the
spaces (between objects) are counted equally with an object. An image can be considered as a
surface of given dimension having a spatial resolution expressed in line pairs per mm (LP/mm). A
line pair is a pair of equal-sized black-white bars. The number of line pairs in digital imaging is
specified as spatial frequency.

The X-ray image is resolution limited by the dimension of X-ray source and noise limited by beam
intensity. The X-rays emerging from the anatomy are detected to for a one-dimensional image

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where each point has a brightness related to the intensity of the X-rays at that point. The
conventional X-ray radiography produces images of anatomy that are shadwogram based on X-ray
absorption.

A digital image is a numerical representation of an image via a set of picture elements known as
pixels. This simplified article lists three parameters of a digital image that moderate spatial and
contrast resolution.
Image matrix
The image matrix is comprised of columns (M) and rows (N) that define the elements or pixels
within an image. The size of an image is:
Matrix = M x N x k bits
The field of view (FOV) is the size of the displayed image. For same FOV and increase the matrix
size, the pixels will be smaller and hence spatial resolution is improved.
Pixel
The pixel is the discrete picture element (2D information) that makes up the image matrix; each
pixel is a respective value that will represent a brightness level. The size is determined via: pixel
size = FOV/matrix. A decreased FOV means that the pixel is smaller and results in an improvement
in spatial resolution.
Voxel
The voxel is a pixel that represents information that is contained in a volume (3D information).
Bit depth (k bit)
The k bit is the number of bits per pixel, the grey scale of an image is equal to 2 k-bit, for example:
k bit of 2 = 4 shades of grey
k bit of 8 = 256 shades of grey
The higher the bit depth means more grey scale and therefore the higher the contrast resolution.

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 Digital Subtraction Angiography (DSA)

Introduction
Digital subtraction angiography (DSA) is a type of fluoroscopic technique used extensively in
interventional radiology to clearly visualize blood vessels in a bony or dense soft tissue
environment. Radiopaque structures such as bones are eliminated ("subtracted") digitally from
the image, thus allowing for accurate depiction of the blood vessels. “Angio” means blood vessel
and angiography is the radiological study of blood vessel in the body after the introduction of
(iodinated) contrast media. Subtraction is a simple technique by which bone structures images
are subtracted or cancelled out from a film of bones plus opacified vessels, leaving an
unobscured image of the blood vessels. The acquisition of digital fluoroscopic images combined
with injection of contrast material and real-time subtraction of pre- and post-contrast images to
perform angiography is referred to as digital subtraction angiography.

Digital subtraction angiography is a computer assisted technique, whereby a pre-contrast image

is acquired, then subtracted from subsequent post-contrast (after injecting iodine contrast bolus)
images from exactly the same location. The first image (pre-contrast) is called “Mask” denoted
as “M” containing background anatomy and the second image (post-contrast) is called “Contrast
or Opacification” image denoted as “C” contains the vessels together with the background
anatomy. After some data processing, the mask is subtracted from the contrast image to reveal
the vessels in the difference image “D”.
D=C-M
Basic Principles of Digital Subtraction Angiography
DSA is part of the larger phenomenon known as digital radiology. For DSA, the televised
fluoroscopic image is converted point-by-point to digital data. These data are then manipulated
in two operations. The first is the process of image subtraction, also known as temporal or time
subtraction. For this process, an image (the mask) obtained before arrival of contrast material at
the area of interest, is placed into one of two digital memories. Then one or more subsequent
images (contrast) are obtained after arrival of a contrast bolus and placed into a second digital
memory. The mask image is digitally subtracted from the succeeding contrast image, with the
result that contrast-filled structures are rendered visible free of background detail.

The second operation occurs after subtraction and is expansion of the dynamic range of the
subtracted image which results in enhancement of the final image. This is necessary because the
range of contrast within the initial subtracted image is very small. Subtraction and enhancement
are performed in real time, which means that the processing of data is sufficiently rapid that the
results are available in time to influence the clinical examination. The speed and apparent
simplicity of computerized subtraction are two major advantages of DSA over standard film
subtraction angiography.

Several further steps are a routine part of the process. Amplification of the output of the image
intensifier is one. This amplification may occur before or after digitization of the data and may
be fixed or selectable, depending on the individual system. Choices for amplification include
linear and logarithmic modes. In linear amplification, the unsubtracted signal is amplified
linearly, independent of its numerical value. This is appropriate if there is uniform tissue density

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in the field, such as in abdominal imaging. Logarithmic amplification, in which amplification of
the input signal is in proportion to the signal’s strength, provides images of opacified blood
vessels unaffected by overlying high and low density structures. This is the technique used in
carotid vertebral imaging and represents the most common form of image amplification.

Modes of Operations may be performed

DSA may be performed in several different modes. Serial imaging, the most common mode, is
used where image acquisition rates can be relatively low (from one to eight images per second).
This mode allows for the greatest degree of flexibility in image acquisition and may be achieved
with a short-pulsed x-ray exposure or by a longer exposure with variable addition and averaging
of individual television frames. A second mode, the continuous dynamic mode, uses an
acquisition rate of 30 frames / sec with resultant shorter X-ray exposure times, decreased photon
flux per image, and decreased resolution in comparison to the serial mode. This mode is used for
rapidly changing dynamic processes, such as occur in cardiac imaging. In both modes, a pre-
contrast image is used as the mask, followed by contrast injection. With a third imaging mode,
termed the time-interval-difference mode, a rate of 30 frames / sec is used, but the subtraction is
performed between each successive image rather than from a single first image (i.e. frame 2
minus frame 1, frame 3 minus frame 2, and so on). This mode which displays the differences
between the two successive images has not been fully explored and it is not available from all
manufacturers.

/
DSA Principles

DSA Equipment
The fluoroscopy unit consists of a C-arm unit that can be rotated axially and sagittally around the
floating-top table. The distance between the X-ray tube and the image intensifier can be adjusted,
as can collimation and several other parameters. In dedicated angiography units, there is a second
set of controls for the angiographer (radiographer). A modern angiography unit has all of the
following features:
 Collimators (including oblique) and filters for dose reduction
 Pulsed fluoroscopy with a variety of frame rates for dose reduction
 Ability to change and display collimator position without fluoroscopy
 Road mapping and land marking
 Last image hold and frame-grab
 Display of images side-by-side

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  Masks
 Image enhancement
 Different image manipulations
 Cine
 Measurements and quantification (e.g. of degree of arterial stenosis)
The image is at least a 1024 x 1024 pixel matrix. Most modern medical displays are flat screens;
some of the detectors are flat panel.

Block Diagram of DSA

Digital Subtraction Angiography System

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DSA Technique
Digital subtraction angiography is used to produce images of the blood vessels without
interfering shadows from overlapping tissues. This provides a clear view of the vessels and
allows for a lower dose of contrast medium.
 The non-contrast image (mask image) of the region is taken before injecting contrast
material and therefore shows only anatomy, as well as any radiopaque foreign bodies
(surgical clips, stents, etc.) as would a regular X-ray image.
 Contrast images are taken in succession while contrast material is being injected. These
images show the opacified vessels superimposed on the anatomy and are stored on the
computer.
 The mask image is then subtracted from the contrast images pixel by pixel. The resulting
subtraction images show the filled vessels only.
 Recording can continue to provide a sequence of subtracted images based on the initial
mask.
 The subtraction images can be viewed in real time. Even if the patient lies still, there is
bound to be some degree of misregistration of images due to movement between the
acquisition of the mask image and the subsequent contrast images. The effect is
prominent at high-contrast interfaces, such as bone-soft tissue, metal staples and coils,
and bowel air. Pixel shifting (either manual or automatic), i.e. moving the mask
retrospectively, can minimize misregistration, but focal movement such as bowel
peristalsis, will not be corrected.

It should be noted that since image subtraction causes a decrease in signal-to-noise ratio, the
subtraction images appear noisier than the source images. The inevitable solution to this is to
increase mA. There are also algorithms in place for reducing scatter.

Procedural Technique
For every purpose, there is at least one technique, but common to them all is the application of
DSA for visualization:
 Patient lies on the angiography table
 Local anesthesia is administered at the intended puncture site (usually lidocaine
hydrochloride 1% or 2% w/v)
 In certain procedures (e.g. a child undergoing cerebral angiography) general anesthesia is
performed
 The Seldinger technique is used to gain access to a blood vessel
 ultrasound is often used for visualizing the vessel in real-time for puncturing
 a standard access kit includes a straight 18 gauge needle and .035" guidewires, on
which the diagnostic and therapeutic catheters are threaded
 in many cases, a micro-introducer access kit (.018" guidewire threaded through a
21 gauge initial access needle) is used for access, either for the entire procedure or
to be replaced with the standard kit. Using a micro-introducer facilitates less
traumatic entry and can be retrieved without massive bleeding should there be a
need for re-puncturing
 On procedure completion, hemostasis is applied to the puncture site

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DSA Programming
A computer program for generating a sequence of digital subtraction angiography images from a
digitized mask comprising pixel values and a sequence of digitized opacified images comprising
pixel values, the execution of the computer program creating the following actions:
 applying a logarithmic function to the values of the pixels of the digitized mask and to the
values of the pixels of the sequence of digitized opacified images in order to obtain
logarithmic pixel values;
 subtracting the logarithmic value of each pixel of a digitized opacified image from the
logarithmic value of the corresponding pixel in the digitized mask;
 decreasing certain pixel values of the digitized mask and of the digitized opacified
images prior to applying the logarithmic function;
 selecting, in the sequence of digitized opacified images, the lowest pixel value; and
 subtracting, from all the values of the pixels in the sequence of digitized opacified images
and the digitized mask, a certain fraction of the selected lowest pixel value, wherein said
certain fraction is less than 1
 applying a logarithmic function to the values of the pixels is applied approximately just
before the subtraction step to the individual pixels of the images.

Applications of Digital Subtraction Angiography:

1. Used to image blood vessels.
2. It is useful in the diagnosis and treatment of:
 Arterial and venous occlusions, including carotid artery stenosis, pulmonary
embolisms and acute limb ischemia.
 Arteiral stenosis, which is particularly useful for potential renal donors in
detecting renal artery stenosis,
 Cerebral aneurysms and arterivenous malformation (AVM)

Block diagram of digital subtraction angiography

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 Fluoroscopic Imaging System

Introduction
Fluoroscopy is a type of medical imaging to obtain a continuous X-ray image on a monitor,
much like an X-ray movie. During a fluoroscopy procedure, an X-ray beam is passed through
the body. The transmitted beam then strikes a fluorescent plate that is coupled to an image
intensifier. The image intensifier itself is coupled to a video camera that captures and display
the image on a monitor. The image is transmitted to a monitor so that the movement of a body
part or of an instrument or contrast agent (“X-ray dye”) through the body can be seen in
detail. Fluoroscopy provides real-time X-ray images that are especially useful for guiding a
variety of diagnostic and interventional procedures. The ability of fluoroscopy to display
motion is provided by a continuous series of images produced at a maximum rate of 25-30
complete images per second. Modern fluoroscopes couple the screen to an X-ray image
intensifier and charge coupled device (CCD) video camera allowing the images to be recorded
and played on a monitor.

The X-ray exposure needed to produce one fluoroscopic image is low (compared to
radiography), whereas long exposures to patients can result from the large series of images
that are encountered in fluoroscopic procedures. Therefore, the total fluoroscopic time is one
of the major factors that determine the exposure to the patient from fluoroscopy. The X-ray
beam is usually moved over different areas of the body during a procedure, there are two very
different aspects that must be considered. One is the area most exposed by the beam, which
results in the highest absorbed dose to that specific part of the skin and to specific organs. The
other is the total radiation energy imparted to the patient’s body, which is related to the Kerma
Area Product (KAP or PAK), a quantity that is easily measurable.

The absorbed dose to a specific part of the skin and other tissues is of concern in fluoroscopy
for two reasons: one is the need for minimizing the dose to sensitive organs, such as the
gonads and breast, by careful positioning of the X ray beam and using shielding when
appropriate. The second is the possible incidence of the radiation beam to an area of the skin
for a long time that can result in radiation injuries in cases of very high exposure.

Fluoroscopy is used in a wide variety of examinations and procedures to diagnose or treat

patients. Some examples are:
 Barium X-rays and enemas (to view the gastrointestinal tract)
 Catheter insertion and manipulation (to direct the movement of a catheter through
blood vessels, bile ducts or the urinary system)
 Placement of devices within the body, such as stents (to open narrowed or blocked
blood vessels)
 Angiograms (to visualize blood vessels and organs)
 Orthopedic surgery (to guide joint replacements and treatment of fractures)

Radiation-related risks associated with fluoroscopy include:

 Radiation-induced injuries to the skin and underlying tissues (burns), which occur
shortly after the exposure, and
 Radiation-induced cancers, which may occur sometime later in life.

Prepared by Dr. S. Roy, Prof.-Dept. of Biomedical Engineering, NSEC Page 1

Principles of Fluoroscopic Imaging System

The fluoroscope is a type of X-ray machine that can use either a continuous or a pulsing X-ray
beam. The fluoroscope uses X-rays and as they pass through a patient's body the tissues and
bone will absorb different amount of X-rays. The transmitted beam / rays hits an image
intensifier that increases the brightness of the image many times (e.g. x1000 to x5000) so that
it can be viewed on a display screen. The image intensifier itself is coupled to a video camera
that captures and encodes the two-dimensional patterns of light as a video signal from the X-
ray machine. The signal is converted back into a pattern of light seen as the image on the
monitor.

The fluoroscope consists of X-ray generator, X-ray tube, collimator, filters, patient table, grid,
image intensifier, optical coupling and television system. Fluoroscopy is normally performed
using 2-6 mA and an accelerating voltage of 75 to 125 kVp. The rate of X-ray production is
directly proportional to the tube current, but is more sensitive to increasing kVp than mA. For
example, increasing the kVp by 15% is equivalent to doubling the mA. [The flow of electrons
from the filament to the target is called the tube current and is described in units of
milliamperes (mA)].

Fluoroscopy units are usually operated in an automatic brightness control (ABC) model in
which a sensor in the image intensifier monitors the image brightness. When there is
inadequate brightness, the ABC increases the kVp first, which increases the X-ray penetration
through the patient, and then adjusts the mA to increase the brightness. The thicker tissue or
larger cross-sectional area, such as the abdomen, will require greater exposure.

Digital Fluoroscopy c-arm system

A digital fluoroscopy system is commonly designed as a conventional one in which the analog
video signal is converted to and stored as digital data by an analog to digital converter (ADC).
The system produces a digital moving picture sequence that can be viewed on a monitor. The
camera output of a conventional system can be digitized for computer image enhancements.
The term “c-arm” stands for its special, arched, semi-circular design. The equipment can be

Prepared by Dr. S. Roy, Prof.-Dept. of Biomedical Engineering, NSEC Page 2

rotated rather than the patient when visualization of the internal structure or catheter is
critical. C-arm machines are designed to operate under lower amounts of patient exposure. A
Digital Fluoroscopic examination can take from 30 – 60 minutes to complete depending on
the examination requested.

A major change from conventional fluoroscopy to digital fluoroscopy (DF) is the use of a
charge-coupled device (CCD) instead of a TV camera pickup tube. The CCD has greater
sensitivity to light (detector quantum efficiency [DQE]) and a lower level of electronic noise
than a television camera tube. The result is a higher signal-to-noise ratio and better contrast
resolution (1000 lines than the 525 lines for conventional fluoroscope). These characteristics
also result in substantially lower patient dose. The response of the CCD to light is very stable
and warm-up is not required. It has essentially an unlimited lifetime and requires no
maintenance. Perhaps the single most important feature of CCD imaging is its linear response.
The speed of acquisition is very high and the usual pixel numbers in an image are 1024 x
1024 than the 512 x 512 for conventional. The digital image allows for post processing and
electronic storage and distribution.

Newer digital fluoroscopy

 Image intensifier output screen coupled to TFTs
• TFT photodiodes are connected to each pixel element
• Resolution limited in favor of radiation exposure concerns
• Direct capture of x-ray (flat–panel detector) a-silicon or a-selenium

Prepared by Dr. S. Roy, Prof.-Dept. of Biomedical Engineering, NSEC Page 3

 Medical Thermography / Infrared Imaging System

Introduction
Medical Thermography (MT) is the science of visualizing the temperature (heat) distribution
pattern over the surface of the human skin. The term comes from the Greek words "therme,"
meaning heat and "graphos," meaning writing or drawing. This technique involves the
detection of infrared (IR) radiation (heat energy) that can be directly correlated with the
temperature distribution of a defined body region. Infrared camera generates images based on
the amount of heat dissipated at the surface. This is a non-invasive, non-contact method that
uses heat from the body to aid in making diagnostic tool for analysing physiological functions
related to the control of skin-temperature. This rapidly developing technology is used to
detect and locate thermal abnormalities characterized by an increase or decrease found at the
skin surface. Infrared cameras generate images based on the amount of heat dissipated at the
surface by infrared radiation. The technology is a sophisticated way of receiving
electromagnetic radiation and converting it into electrical signals. These signals are finally
displayed in gray shades or colors which represents temperature values. The image is actually
the map of body’s temperature / heat distribution pattern and is referred as “Thermogram”. It
identifies physical changes in the body at the cellular level. It detect skin temperature
variances caused by new blood vessel growth reflecting possible predisposition to cancer,
hormonal changes, cardiovascular diseases, diabetes, musculo-skeletal changes and soft
tissue injury.

Spectral distribution of infrared emission from human skin

Thermography is a sophisticated clinical imaging tool which records thermal changes in skin
temperature. Medical thermography is so sensitive that it can detect slight and dynamic
temperature changes (0.050C) on the surface of the skin. Human body has higher degree of
thermal symmetry in normal condition and any subtle (abnormal) temperature asymmetry can
be easily identified. It helps to detect the pathological changes in some circumstances and
used as an early diagnostic tool. It is safe for women with mastectomies, implants, and can be
performed on all ages. The examination of the female breast as a reliable aid for diagnosing
breast cancer is probably the best known application of thermography.

Physics of Thermography
Any object having a temperature above absolute zero (00K) or higher, radiates heat in the
form of infrared radiation (wavelength, 0.75-100 µm) and sometimes called heat wave.

1
Therefore, infrared is an indicator of temperature of an object. The total energy “W” emitted
by the object and its temperature are related to Stefan Boltzman formula,

W = ϬЄT4
Where, W = Radiation flux density and is expressed in W/Cm2
Є = Emissivity factor
Ϭ = Stefan-Boltzman constant = 5.67 x 10-12 W/ Cm2K4
T = Absolute temperature
Emissivity refers to an object’s ability to emit radiation. Regarding the spectral region,
human skin is a black body radiator with an emissivity factor of 0.98 and is therefore a
perfect emitter of infrared radiation at room temperature. Human skin emits infrared radiation
mainly in the wavelength range of 2–20 μm with an average peak of 9–10 μm. Based on
Plank’s Law roughly 90% of the emitted infrared radiation in humans is of longer wavelength
(8–15 μm).

IR Imaging System
An infrared scanning device convert IR radiation emitted from the skin surface into a visual
image that depicts temperature variations on a monitor. Most systems have a wide range of
absolute temperature sensitivity ranging from 1 to 50 0C. The IR equipment usually has two
parts, the IR camera and a standard PC or laptop computer. These systems have only a few
controls and relatively easy to use. The main IR camera components are a lens, a detector in
the form of a focal plane array (FPA), possibly a cooler for the detector. Most detectors have
a response curve that is narrower than the full IR range (~ 900–14,000 nm or 0.9–14µm). The
optical system of IR camera scans the field of view at a very high speed and focuses the IR
radiation onto the detector which covert the radiation into an electrical signal. The signal
from the camera is amplified, processed and stored in the computer. The image is finally
displayed on a monitor with adjustable controls for contrast (temperature range) and
brightness (temperature level) on the display unit.

The PC or laptop computer can able to store tens of thousands of images (and these images
may be retrieved for later analysis). The ability to statistically analyse the thermogram at a
later date is very important in clinical work. Copies of images can easily be sent (via e-mail,
floppy disk, etc.) to referring doctors or other healthcare professionals. Monitors are high-
resolution full colour, isotherm or grey scale, and usually include image manipulation,
isothermal temperature mapping, and point-by-point temperature measurement with a cursor
or statistical region of interest. The systems measure temperatures ranging from 10° C - 55°
C to an accuracy of 0.1° C. Focus adjustment should cover small areas down to 75 x 75mm.

2
 IR Imaging System

Block Diagram of IR Thermography

IR Detectors
IR detectors are used to convert IR energy into electrical signals. The two main types of
detectors: Thermal and Photo detectors. Thermal detectors respond to temperature changes
from incident IR radiation through changes in physical and electrical properties. Photo
detectors generate free electrical carriers through interaction of photons and bound electrons.
Thermal detectors include thermocouple and thermistor bolemeter. Photo detectors are
semiconductors with narrow band gaps, eg. Indium Gallium Arsenide (InGaAs), Germanium
(Ge), Lead Selenide (PbSe), Indium Antimonide (InSb), Indium Arsenide (InAs), Mercury
Cadmium Telluride (MCT, HgCdTe), etc. The response time and sensitivity of photo detector
can be higher but they generally have to be cooled in order to cut thermal noise.
3
Most IR cameras use InSb detector which detects IR radiation in the range of 2-6 µm (2.4%
of total IR). They are highly sensitive and are capable of detecting small temperature
variations as compared to a thermistor.

MCT also find application which detect IR rays in the range of 0.8-25 µm but need to cool
with liquid nitrogen.

Clinical Thermography & Modern Applications

Medical thermography is an auxiliary tool for detecting and locating thermal abnormalities
characterised by increase or decrease in skin surface temperature. This temperature is
dependent on the blood circulation near the skin which is complex regulation by the nervous
system and local factors. The pathological processes such as tumours, inflammation or tissue
damages, etc, have more impact on the skin temperature variations. The underlying processes
lead to vascular and nervous reactions which can be displayed as different heat patterns
(thermogram) by means of IR screening. It is assumed that since cancer tissue metabolizes
more actively than other tissues and thus has higher temperature in the skin directly over the
malignancy than in other regions. Hence, medical thermography helps in early detection of
cancers in the body surface region.

Medical thermography is a reliable aid for successful evaluation of breast cancer. It is also
find application in the assessment and monitoring of inflammatory joints diseases, diagnosis
of deep vein thrombosis, peripheral vascular diseases, neurological disorders, musculo
skeletal disorders and mass fever screening.

Some of the common applications of Thermography are in:

 Breast pathologies
 Extra-Cranial Vessel Disease
 Neuro-Musculo-Skeletal
 Vertebrae (nerve problems/arthritis)
 Lower Extremity Vessel Disease

Development of infrared sensor technology

OLD TECHNIQUE NEW TECHNIQUE
Liquid detector cooling Uncooled camera technology
Single element detector Focal plane array detector
Slow mechanical scan mechanism Real time, high-speed imaging with multi elements arrays
Low resolution camera High-resolution camera
Analogue conversion and Digital conversion and computing, electronic transfer of
computing images from camera to PC in real time
No sufficient knowledge about Standardization protocols and recommendations for
standardization methods medical use
Gray shade images Color visible images
Expensive, big in size, not mobile Affordable, smaller and fully mobile
Predominantly low sensitivity Improved sensitivity (0.02 degrees celcius)

4
OLD TECHNIQUE NEW TECHNIQUE
Insufficient software and tools User-friendly image processing software

Liquid Crystal Thermography (LCT)

LCT can produce a colour thermogram over a skin area with a temperature sensitivity of
0.10C. The spectrum of colour indicates an increase and decrease in the amount of IR
radiation being emitted from the body surface. Liquid crystal (LC) is a unique material which
exists between the solid and isotropic liquid phase. The exhibit colour temperature sensitivity
when in a cholestatic phase. Owing to their colour changes with temperature, the cholestatic
LC are also called thermochromic LCs (TLCs). The TLC changes their reflected colour as a
function of temperature when illuminated by white light. Hence, reflected visible light at
different wavelengths. Components for LCT:
1. A precision 2D traversing test table for accurate positioning
2. Fiber optic lighting for high intensity uniform illumination
3. Polarized optics to enhance image viewing and measurement accuracy
4. Charge Couple Device (CCD) camera
5. Data Acquisition System (DAS) and image processing software
6. Display monitor
https://www.youtube.com/watch?v=JlZhHhpVRrI [LCT]

5
 ULTRASOUND IMAGING SYSTEM

Introduction to Medical Ultrasound

The term “Ultrasound” refers to acoustic waves having frequencies many times higher than the
upper limit for human hearing (˃20 KHz). The frequency of the sound waves used in medical
ultrasound is in the range of millions of cycles per second (megahertz, MHz). The sound waves
reflected / bounce off body parts and a computer to create images of blood vessels, tissues, and
organs from the echo signals. The technique is similar to the echolocation used by bats, whales
and dolphins, as well as SONAR used by submarines. Medical ultrasonography (USG) is an
ultrasound-based diagnostic imaging technique used to visualize muscles and internal organs,
their size, structures and possible pathologies or lesions. There are a plethora of diagnostic and
therapeutic applications practiced in medicine. Sonographers typically use a hand-held probe
(called a transducer) that is placed directly on and moved over the patient. A water-based gel is
used to couple the ultrasound between the transducer and patient. An ultrasound (US) scanning
gel (ultrasonic couplant) has the same conductivity as the human body and is applied between
the transducer and the skin surface. Typical diagnostic sonographic scanners operate in the
frequency range of 2 to 15 megahertz. The choice of frequency is a trade-off between spatial
resolution of the image and imaging depth: lower frequencies produce less resolution but image
deeper into the body.

Ultrasonography is a useful and flexible modality in medical imaging, and often provides an
additional or unique characterization of tissues, compared with other modalities such as
conventional radiography or computer tomography (CT). Ultrasound relies on properties of
acoustic physics (compression/rarefaction, reflection, impedance, etc.) to localize and
characterize different tissue types. Ultrasonography can be used to examine many parts of the
body, such as the abdomen (liver, kidney, spleen, pancreas, bladder, etc.), female reproductive
system, prostate, heart, major blood vessels, foetus and even possible detection of cysts, tumors
in these organs. It has also been useful to image thyroid glands, eyes, breasts, and a variety of
other superficial structures. Ultrasound studies have also been extensively used to investigate the
dynamics of blood flow in the cardiovascular system.

Ultrasonography is increasingly being used in the detection and diagnosis of heart disease, heart
attack, and vascular diseases that can lead to stroke. It is also used to guide a fine needle, for
tissue biopsy and amniocentesis, and to assist in taking a sample of cells from an organ or
structure for lab testing (for example, a test for cancer in breast tissue and fetal growth in uterus).
Superficial structures such as muscles, tendons, testes, breast and the neonatal brain are imaged
at a higher frequency (7-15 MHz), which provides better axial and lateral resolution. Deeper
structures such as liver and kidney are imaged at a lower frequency 2-6 MHz with lower axial
and lateral resolution but greater penetration.

An ultrasound transducer sends an ultrasound pulse into tissue and then receives echoes back.
The echoes contain spatial and contrast information. The concept is analogous to sonar used in
nautical applications, but the technique in medical ultrasound is more sophisticated, gathering
enough data to form a rapidly moving two-dimensional gray scale image. Some characteristics of
returning echoes from tissue can be selected out to provide additional information beyond a gray
scale image. Doppler ultrasound, for instance, can detect a frequency shift in echoes, and

Prepared by: Dr. S. Roy, Prof.-Dept. of Biomedical Engineering, NSEC Page 1

determine whether the tissue is moving toward or away from the transducer. This is invaluable
for evaluation of some structures such as blood vessels or the heart (echocardiography).
Ultrasound continues to evolve additional functions, including 3D ultrasound imaging,
elastography and contrast-enhanced ultrasound using micro bubbles.

Ultrasound Machine

Benefits vs. Risks

Benefits:
 Ultrasound scanning is noninvasive (no needles or injections) and is usually painless.
 Ultrasound is widely available, easy-to-use and less expensive than other imaging
methods.
 Ultrasound imaging uses no ionizing radiation.
 Ultrasound scanning gives a clear picture of soft tissues that do not show up well on x-
ray images.
 Ultrasound causes no health problems and may be repeated as often as is necessary if
medically indicated.
 Ultrasound is the preferred imaging modality for the diagnosis and monitoring of
pregnant women and their unborn infants.
 Ultrasound provides real-time imaging, making it a good tool for guiding minimally
invasive procedures such as needle biopsies and needle aspiration of fluid in joints or
elsewhere.
 Medical diagnostic ultrasound is biologically safe and can travel 20 to 30 cm through
human tissues.
Risks:
 For standard diagnostic ultrasound there are no known harmful effects on humans.

Limitations of General Ultrasound Imaging

Ultrasound waves are reflected by air or gas; therefore ultrasound is not an ideal imaging
technique for the bowel. Barium exams and CT scanning are the methods of choice for bowel-
related problems.
Ultrasound waves do not pass through air; therefore an evaluation of the stomach, small
intestine and large intestine may be limited. Intestinal gas may also prevent visualization of
deeper structures such as the pancreas and aorta. Patients who are obese are more difficult to
image because tissue attenuates (weakens) the sound waves as they pass deeper into the body.

Prepared by: Dr. S. Roy, Prof.-Dept. of Biomedical Engineering, NSEC Page 2

Ultrasound has difficulty penetrating bone and therefore can only see the outer surface of bony
structures and not what lies within. For visualizing internal structure of bones or certain joints,
other imaging modalities such as MRI are typically used.

Medical Applications
Ultrasound examinations can help to diagnose a variety of conditions and to assess organ
damage following illness. Ultrasound is used to help physicians diagnose symptoms such as:
 pain
 swelling
 infection
Ultrasound is a useful way of examining many of the body's internal organs, including but not
limited to the:
 heart and blood vessels, including the abdominal aorta and its major branches
 liver
 gallbladder
 spleen
 pancreas
 kidneys
 bladder
 uterus, ovaries, and unborn child (fetus) in pregnant patients
 eyes
 thyroid and parathyroid glands
 scrotum (testicles)
Ultrasound is also used to:
 guide procedures such as needle biopsies, in which needles are used to extract sample
cells from an abnormal area for laboratory testing.
 image the breasts and to guide biopsy of breast cancer
 diagnose a variety of heart conditions and to assess damage after a heart attack or other
illness.
Doppler ultrasound images can help the physician to see and evaluate:
 blockages to blood flow (such as clots)
 narrowing of vessels (which may be caused by plaque)
 tumors and congenital malformation
With knowledge about the speed and volume of blood flow gained from a Doppler ultrasound
image, the physician can often determine whether a patient is a good candidate for a procedure
like angioplasty.

Ultrasound Frequencies (Diagnostics)

Ultrasound frequencies in diagnostic range are extending from 2 MHz to approximately 15 MHz.
It is important to remember that higher frequencies of ultrasound have shorter wavelengths and
are absorbed / attenuated more easily. Therefore, higher frequencies are not as penetrating. This
explains why high frequencies are used for the superficial body structures and low frequencies
are used for those that are deeper.

Prepared by: Dr. S. Roy, Prof.-Dept. of Biomedical Engineering, NSEC Page 3

Medical ultrasound transducers contain more than one operating frequency. The following
frequencies are a guide to frequencies typically used for ultrasound examination:
 2.5 MHz: deep abdomen, obstetric and gynecological imaging
 3.5 MHz: general abdomen, obstetric and gynecological imaging
 5.0 MHz: vascular, breast, pelvic imaging
 7.5 MHz: breast, thyroid
 10.0 MHz: breast, thyroid, superficial veins, superficial masses, musculoskeletal imaging.
 15.0 MHz: superficial structures, musculoskeletal imaging.

Physics of Ultrasound
Ultrasound is simply sound waves, like audible sound. Although some physical properties are
dependent on the frequency, the basic principles are the same. Sound consists of waves of
compression and decompression of the transmitting medium (e.g. air or water), travelling at a
fixed velocity. Sound is an example of a longitudinal wave oscillating back and forth in the
direction the sound wave travels, thus consisting of successive zones of compression and
rarefaction. Transverse waves are oscillations in the transverse direction of the propagation. (For
instance surface waves on water or electromagnetic radiation.)

Schematic illustration of a longitudinal compression wave (top) and transverse wave (bottom). The bottom figure
can also represent the pressure amplitude of the sound wave.

Ultrasound obeys the law of reflection and refraction same as light. Ultrasound waves may be
longitudinal, transverse or shear but diagnostic applications, only longitudinal waves are used.
Ultrasound waves are vibration or disturbances causing of alternating zones of compression and
rarefaction in a medium. A single sound wave (one compression and one rarefaction) has a
temporal (duration / period, Sec) and a spatial (λ, mm) dimension. It causes particles in the
medium to oscillate to and fro (back & forth) at a particular frequency so that mechanical energy
is transported across the medium. This can be treated as sine wave having wavelength (λ),
frequency (f) and amplitude (A) depending on the sound pressure characteristics and transmitting
medium.

Prepared by: Dr. S. Roy, Prof.-Dept. of Biomedical Engineering, NSEC Page 4

 US wave propagation
Definitions:
Cycle - the combination of one rarefaction and one compression equals one cycle.
Amplitude - the maximum displacement of a particle or pressure wave.
Wavelength - the distance between the onset of peak compression or cycle to the next.

Sound of different frequencies travel at same speed in the same medium i.e. it is the medium that
determines the velocity of the sound waves. Velocity is the speed at which sound waves travel
through a particular medium and is equal to the product of frequency and wavelength.
𝑉=𝑓𝑥𝜆
Sound propagation velocity is greater in stiffer (high molecular bond strength) material with
smaller mass. Propagation speed increases from gas to liquid and highest in solids.
Solid ˃ Liquid ˃ Gas

Ultrasonic energy is transmitted through a medium as a wave motion and, therefore, no net
movement of the medium is expected to occur. The velocity of propagation of the wave motion
is determined by the density of the medium it is travelling through and the stiffness of the
medium. At a given temperature and pressure, the density and stiffness of the biological
substances are relatively constant, and, therefore, the sound velocity in them is also constant. The
velocities of ultrasound through human soft tissue are 1540 m/s and for bone 4080 m/s [air 330
m/s].

The knowledge of velocity of sound in a particular medium is important in calculating the depth
to which the sound wave has penetrated before being reflected. If the time taken by the ultrasonic
wave to move from its source through a medium, reflect from an interface and return to the
source can be measured, then the depth of penetration is given by:
Velocity of sound in the medium x time
Depeth of peneration =
2
Sound and ultrasonic waves consist of a mechanical disturbance of a medium such as air. The
disturbance passes through the medium at a fixed speed causing vibration. The rate at which the
particles vibrate is the frequency, measured in cycles per second or Hertz (Hz). The pressure of
sound is reported on a logarithmic scale called sound-pressure level, expressed in decibel (dB).

Basic Principles - Production of an Ultrasound Waves

Ultrasound is produced by electrically stimulating a certain crystalline structure called
piezoelectric (pressure-electric) crystal or transducer (PZT). They have molecular dipoles
(positive and negative charges) and experience a change in shape on application of an alternating
electrical current. The word Piezoelectricity comes from Greek and means “electricity by

Prepared by: Dr. S. Roy, Prof.-Dept. of Biomedical Engineering, NSEC Page 5

pressure” (Piezo means pressure in Greek). The piezoelectric (PZ) materials alternatively
contracts and expands generating compression and rarefaction in the medium i.e. sound waves.
Conversely, mechanical vibration results in generation of an electrical signal this property of
PZT was first demonstrated by Jacque and Pierre Curie in 1881 and termed as transmitting and
receiving of ultrasound.

Molecular Model of Direct Piezoelectric Effect

The effect is demonstrated by crystals of materials like quartz, tourmaline and Rochelle salt. This
phenomenon offers an excellent method for converting electrical energy into mechanical energy
and vice versa.

 Z axis or Optical axis: joining the

pointed end
 X axis or Electrical axis: joining the
corner of hexagon
 Y axis or Mechanical axis: joining
the mid points of the sides

Quartz Crystal

While working with natural crystals, it is difficult to establish the appropriate axis and cut the
crystal in the required form. Therefore, quartz has generally been replaced by synthetic
piezoelectric materials namely barium nitrate and lead zirconate titanate (PbZrTiO4). They offer
several advantages because they are far cheaper to produce and are much easier to construct
transducers of complex shape and large areas. They can be moulded to any shape to obtain a
better focusing action for producing high intensity ultrasonic waves.

The choice of piezo-electric material for a particular transducer depends upon its applications.
Materials with high mechanical Q factor are suitable as transmitters whereas those with low
mechanical Q and high sensitivity are preferred as receivers and in case of non-resonance
applications. There are three parameters that are important in optimizing transducers for various
types of applications. These are frequency, active element diameter and focusing. Their effects
on the performance are as follows:

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Frequency: With increase in frequency, the sound beam becomes more directional and the axial
resolution improves. However, due to attenuation of higher frequency ultrasound waves in the
tissues, the penetration decreases. For most abdominal ultrasound examinations, the frequencies
used are in the range of 2-6 MHz, whereas the wavelength is in the range of 1 mm. Higher
frequencies (7-15 MHz) are used for superficial organs, such as the eye, where deep penetration
is not required and where advantage may be taken of the 0.1 mm wavelength to improve
geometrical resolution.
The following are general rules which apply to frequency:

Frequency also influences lateral resolution by affecting beam divergence. The following rule
applies, assuming all other factors remain constant.

Active Element Diameter (AED): As the transducer face diameter increases, the beam width
decreases and therefore, lateral resolution improves.

Focusing: Focusing a transducer is a means of minimizing the beam width and adjusting the
focal zone to give optimum results for a particular examination. Acoustic lenses can be used to
shape the ultrasonic beam pattern. The width of the beam can be made narrow with the result that
better lateral resolution can be obtained. The focal point can be selected at different depths from
the face of the transducer. The ability to select different focal points allows for the optimization
of transducers for a particular type of studies. Modern transducers are internally focused and
externally are of flat face.

For production of ultrasound, piezoelectric crystal is placed in between two metal plates and
connected to an AC voltage. The crystal vibrates mechanically and the amplitude becomes max.
when the frequency of the applied AC voltage is equal to the natural frequency of the crystal
(called PZ resonator / crystal resonator). If the thickness of the crystal is small, the frequency is
high.

Circuit for US production Equivalent Series Circuit Equivalent Parallel Circuit

Prepared by: Dr. S. Roy, Prof.-Dept. of Biomedical Engineering, NSEC Page 7

Medical Ultrasound
The use of ultrasound in the medical field can be divided into two major areas: the therapeutic
and the diagnostic. The major difference between the two applications is the ultrasonic power
level / intensity and duration of application. In therapeutic applications, the systems operate at
ultrasonic power levels of up to several watts/cm 2 while the diagnostic equipment operates at
power levels of well below 100 mW/cm 2. The therapeutic equipment is designed to agitate the
tissue to the level where thermal heating occurs in the tissue, and experimentally has been found
to be quite successful in its effects for the treatment of muscular ailments such as lumbago.
Heat generated in therapeutic ultrasound is the product of the applied beam intensity and
absorption coefficient.
UH = I x α
Where, UH = Heat in watts (W), I = Beam intensity (W/cm2), α = Absorption coefficient (cm-1)

In diagnostic purposes, sufficient amount of signal has to be reflected from the interface for
electronic processing, no additional energy is necessary. Therefore, considerably lower
ultrasonic power levels are employed for diagnostic applications. A cross sectional images can
be formed from a mapping of echo intensities. The intensity of the echo is used to determine the
brightness of the image at the reflecting tissue surface. Diagnostic ultrasounds are used either as
continuous waves or in the pulsed wave mode. Applications making use of continuous waves
depend for their action on Doppler’s effect. Among the important commercially available
instruments based on this effect are the foetal heart detector and blood flow measuring
instruments.

There are, however, many applications where only pulsed waves can be employed. In fact, the
majority of modern ultrasonic diagnostic instrumentation is based on the pulse-technique. Pulse
echo based equipment is used for the detection and location of defects or abnormalities in the
structures at various depths in the body. The pulse-echo technique, basically, consists in
transmitting a train of short duration ultrasonic pulses into the body and detecting the energy
reflected by a surface or boundary separating two media of different specific acoustic
impedances.

Extracorporeal shock wave lithotripsy (ESWL) is a special use of kidney ultrasound, where high
intensity focused ultrasound pulses are used to break up calcified stones in the kidney, bladder,
or urethra. Pulses of sonic waves pulverize dense renal stones, which are then more easily passed
through the ureter and out of the body in the urine. The ultrasound energy at high acoustic power
levels is focused to a point exactly on the stone for maximum acoustic transmission. The acoustic
power of sound and ultrasound is the energy delivered per unit of time. The power is measured in
Watt (W) and is proportional to the square of the amplitude. 1 W = 1 joule/second. The intensity
(I) of a wave is the rate of power through a unit region perpendicular to the direction of
propagation. The unit of intensity is watts per square meter (W/cm2).

The therapeutic uses of ultrasound fall into two categories: inducing nondestructive heating or
other, mechanical effects to stimulate or accelerate normal physiological response to injury; and
the production of controlled, selective destruction of tissue. The first category includes
physiotherapeutic applications; focused ultrasound surgery (FUS) falls into the second.
Ultrasound is used by physiotherapists for a number of purposes, including relieving pain,

Prepared by: Dr. S. Roy, Prof.-Dept. of Biomedical Engineering, NSEC Page 1

accelerating wound healing, and reducing swelling. It may also be used to enhance the transport
of drugs across the skin (sonophoresis).

Typical Parameters of Medical Ultrasound

Frequency Source area Power Maximum intensity Pulse
(MHz) (cm2) (W) (W cm-2) Length
Diagnostic imaging
Pulse-Echo (B-Mode) 1-20 1-30 0.05 1.75 0.2-1 μs
Pulsed Doppler 1-20 1 0.15 15.7 0.3-10 μs
Physiotherapy 0.5-3 3 <3 2.5 2-8 ms or
continuous
Surgery 0.5-10 50 ~200 1.5 x 103 1-16 s

Acoustic Impedance
Ultrasound travels in a very straight line. An ultrasonic wave is reflected when it strikes an
interface between materials with different speeds of sound (acoustic impedance). Furthermore,
an interface between materials with a larger difference in acoustic impedance reflects ultrasonic
waves more strongly and that with a smaller difference in acoustic impedance reflects them less
strongly and lets part of them travel through. For example, the human body consists of a variety
of cells and tissues with their acoustic impedance different from each other. Ultrasonic waves
striking these cells or tissues are reflected differently. Using the difference in energy level of the
echoes makes it possible to image the internal tissues of the body. Ultrasonic waves are gradually
attenuated to become weaker while travelling through the medium. Those with a higher
frequency show a higher attenuation factor.

Acoustic impedance (Z) is a physical property of tissue. It describes how much resistance
ultrasound beam encounters as it passes through a tissue. Acoustic impedance of a material is
actually a measure of its opposition to the propagation of sound waves. On the other hand, it is
characterized as the ability of tissues to transmit sound waves. Acoustic impedance is a constant
for a specific material and is analogous to electrical impedance. It is defined as the product of the
density of the medium with the velocity of sound wave in the same medium.
Z = ρ0 x c
Where, Z = Acoustic impedance (kg/m2s), ρo = density of the tissue (kg/m3), c = speed of the
sound wave (m/s)

So, if the density of a tissue increases, impedance increases. Similarly, but less intuitively, if the
speed of sound increases, then impedance also increases. The effect of acoustic impedance in
medical ultrasound becomes noticeable at interfaces between different tissue types. The ability of
an ultrasound wave to transfer from one tissue type to another depends on the difference in
impedance of the two tissues. If the difference is large, then the sound is reflected. Similarly,
when an ultrasound beam passes through muscle tissue and encounters bone, it reflects off of it
due to the difference in density between the tissues.

Biological tissues are not homogenous acoustically i.e. ρ & v are not constant within the
medium. The acoustic impedance determines the degree of reflection and refraction between two

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medium. If ultrasound strikes the interface at right angle (perpendicular direction), the intensity
of reflected ultrasound is expressed by:
Reflection fraction, R = [(Z2 - Z1) / (Z2 + Z1)]2
Where Z1 and Z2 represent the impedance in tissue 1 and tissue 2, respectively.
There is little reflection if the materials are acoustically similar and a lot of reflection when there
is a mismatch of acoustic impedance. A wide difference results in complete / total reflection
from the boundary eg. soft tissue / bone interface (40% reflection) or soft tissue / air (90%
reflection). Therefore, structures beneath bone or gas containing organs are difficult to image
using ultrasound. A special gel (coupling medium eg castor oil, olive oil, special jelly) is used to
minimize reflection from the interface of skin and transducer (air) so that ultrasound can
penetrate the body for imaging the organs.
.
Examples of impedance for bodily tissues (in kg/m2s):
 Air 0.0004 × 106
 Lung 0.18 × 106
 Fat 1.34 × 106
 Water 1.48 × 106
 Kidney 1.63 × 106
 Blood 1.65 × 106
 Liver 1.65 × 106 Reflection and refraction of ultrasound at an
 Muscle 1.71 × 10 6 interface between two media having different
acoustic impedances
 Bone 7.8 × 10 6

The SI unit for acoustic impedance is the Rayl, kg/(m2s), after J W Strutt, 3rd Baron Rayleigh.

Interactions of Ultrasound with Matter: Absorption and Attenuation

As an ultrasound pulse passes through matter, such as human tissue, it interacts in several
different ways. Some of these interactions are necessary to form an ultrasound image, whereas
others absorb much of the ultrasound energy or produce artifacts and are generally undesirable in
diagnostic examinations. The amplitude and intensity of ultrasound waves decrease as they travel
through tissue, a phenomenon known as attenuation. Given a fixed propagation distance,
attenuation affects high frequency ultrasound waves to a greater degree than lower frequency
waves. This dictates the use of lower frequency transducers for deeper areas of interest, although
at the expense of resolution. Attenuation is the result of several features of sound wave
interaction with tissue and tissue boundaries, including: (1) absorption, (b) scatter, and (c)
reflection.

In ultrasound, absorption is the reduction in intensity of the sound waves as it passes through
tissue. An absorption result in heat due to frictional forces as the particles in the medium opposes
the motion. The amount of absorption is determined by the viscosity of the medium, its
relaxation time and frequency of ultrasound. Quantitatively, the average value of sound
absorption in soft tissues is of the order 0.5-1 dB/cm/MHz.

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 Three Types of Ultrasound Pulse Interactions within a Body

Ultrasound pulses lose energy continuously as they move through matter. This is unlike x-ray
photons, which lose energy in "one-shot" photoelectric or Compton interactions. Scattering and
refraction interactions also remove some of the energy from the pulse and contribute to its
overall attenuation, but absorption is the most significant. Overall, the beam energy decreases
more or less exponentially as it penetrate the tissue (similar to the attenuation of x-ray).
𝐼𝑥 = 𝐼0 𝑒 −𝜇𝑥
Where, I0 = Initial intensity of US
Ix = Intensity of US at a distance x
μ = Attenuation coefficient (dB/cm)
1 𝐼𝑥
𝜇 = − ( ) 10 log( )
𝑥 𝐼0

Conversion of transmitted energy to another form of energy such as heat (absorption) is the
primary means by which attenuation of ultrasound occurs in biologic tissue, with scatter
comprising the other significant contributing factor. The intrinsic property of a medium to
attenuate sound waves at a given frequency may be represented by its attenuation coefficient.
The rate at which an ultrasound pulse is absorbed generally depends on two factors: (1) the
material through which it is passing, and (2) the frequency of the ultrasound. The attenuation
(absorption) rate is specified in terms of an attenuation coefficient in the units of decibels per
centimeter. Since the attenuation in tissue increases with frequency, it is necessary to specify the
frequency when an attenuation rate is given. The attenuation through a thickness of material, x, is
given by:
Attenuation (dB) = (μ) (f) (x)

Ultrasound Pulse: Attenuation & Absorption (dB/cm)

and Reduction of Pulse Amplitude by Absorption of Energy

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[Highest attenuation coefficients: aerated lung (μ > 34.0) presents a virtually impermeable
barrier to ultrasound, as does cortical bone (μ ~ 20.0)
Lowest attenuation coefficients: water and blood attenuate ultrasound waves to a hardly
appreciable degree (μ ~ 0.18), whereas soft tissue (avg. μ ~ 0.9]

Scattering occurs when a sound wave strikes a structure with different acoustic impedance to the
surrounding tissue and which is smaller than the wavelength of the incident sound wave. Such
structures are known as “diffuse reflectors,” with examples being red blood cells and non-smooth
surfaces of visceral organs. In contrast to “specular reflectors”, tissues with smooth interfaces
from which ultrasound waves are reflected in a specular fashion. Diffuse reflectors cause
ultrasound waves to scatter in all directions thus resulting in multiple echoes propagating from
the numerous tiny structures. Not only does this scattering result in echoes with smaller
amplitudes (compared to specular reflection) but the scattered echoes also interact with each
other. This interaction causes constructive and destructive interference of the waves. The
resultant image is termed “speckle” due to the various intensities of the echoes received by the
transducer, and this is seen as an irregularity in the grey scale of the image. Most echoes from
ultrasound imaging arise from scattering, rather than the reflection from specular reflectors. The
speckle arising from this scatter results in the grainy appearance of the parenchyma of organs
and also the signal in Doppler ultrasound.

Reflection of a sound wave occurs when the wave passes between two tissues of different
acoustic speeds and a fraction of the wave 'bounces' back. This forms one of the major principles
of ultrasound imaging as the ultrasound probe detects these reflected waves to form the desired
image.

Types of Echoes
Specular - echoes originating from relatively large regularly shaped objects with smooth
surfaces. These echoes are relatively intense and angle dependent (i.e. IVUS, valves).

Scattered - echoes originating from relatively small, weakly reflective, irregularly shaped objects
are less angle dependent and less intense (ie. blood cells).

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 Ultrasound Probe Design and Principles of Image Formation

Ultrasonic Transducers and Probe Design

Ultrasonic transducer converts ac oscillations into acoustic vibrations and vice versa. These two
function are to transmit and receive transducers. At high frequencies, the ultrasound transducer is
the piezoelectric resonator, sometimes called crystal resonator. The thickness of the crystal is one
half the wavelength of the particular frequency.
D=½λ [D is the thickness of the crystal & λ is the wavelength]
Now-a-days, synthetic piezoelectric crystals (PZTs) viz. barium titanate, lead zirconate titanate
are widely used because they are cheap, easier to construct complex shape and better focusing.
Other synthetic PZTs are: polyvinylidene difluoride (PVDF), lead magnesium niobate, etc.

There are three parameters that are important in optimizing transducer for various types of
applications: (a) frequency, (b) active element diameter, and (c) focusing.

US Probe Design:
Ultrasound probe (called a transducer) is a hand-held device that is placed directly on and moved
over the patient. A single transducer is now rarely used instead a multiple crystals (multi-
element) transducers are most common for probe design. In multi-element probe, each crystal
has its own circuit. The advantage is that the ultrasound beam can be controlled by changing the
timing in which each element gets pulsed. Probes are formed in many shapes and sizes. The
shape of the probe determines its field of view. Transducers are described in megahertz (MHz)
indicating their sound wave frequency. The frequency of emitted sound waves determines how
deep the sound beam penetrates and the resolution of the image. The field of view (FOV) is the
plane or area depicted by the ultrasound transducer.

Basic Construction of Ultrasound Probe

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 Basic Construction of Ultrasound Probe

It consists of five main components:

1. Crystal/ceramic element with piezoelectric properties
 usually lead zirconate titanate (PZT) (ZT = 30 x 106 kg/m2s)
 may consist of a single element or be a broadband transducer with multiple elements
 element thickness is determined by what resonance frequency is desired (usually
equal to half the wavelength)
 a thicker element produces a lower frequency oscillation while a thinner element
produces a higher frequency oscillation

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 2. Positive and ground electrodes on the faces of the element
 this allows for electrical connection
 positive electrode is in the back of the element
 ground electrode is on the front of the element

3. Damping (backing) block

 adhered to the back of the crystal (rear surface) composed of epoxy resin loaded with
a mixture of tungsten & aluminium powder (ZB = 30 x 106 kg/m2s)
 absorbs ultrasound energy directed backwards and attenuates stray ultrasound signals
from the housing
 dampens the resonant vibrations in the element which creates a shorter spatial pulse
length; this allows for better axial resolution but higher bandwidth

4. Matching layer
 interface between the transducer element and the tissue.
 plastic polymer layer (Perspex/Plexiglas) reduces the impedance mismatch between
crystal and soft tissues.
 allows close to 100% transmission of the ultrasound from the element into the tissues
by minimizing reflection due to traversing different mediums (Z M = 6.7 x 106 kg/m2s)
 achieves this by consisting of layers of material with acoustic impedances that are
between soft tissue and transducer material.
- may consist of one or multiple layers
- each layer is one-quarter wavelength thick
𝑍𝑀 = √𝑍𝑇 𝑥𝑍𝑇𝑖

5. Housing
 electrical insulation and protection of the element
 includes a plastic case, metal shield and acoustic insulator

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The concavity can be filled with acoustic transparent material, thus yielding a transducer with a
hard, flat surface for good patient contact. A get coupling medium between the skin and
transducer surface is used to remove air bubbles as well as to prevent significant signal loss.

Transmitter Circuit in the US Probe

Transmitter: The transmitting crystal is driven by a pulse from the PRF generator and is made to
trigger an SCR circuit which discharges a capacitor through the piezo-electric crystal in the
probe to generate an ultrasonic signal.

Circuit diagram of a transmitter used in pulse-echo application

Under normal conditions, the SCR is non-conducting. The capacitor C1 can charge through the
resistance R to the +V potential. If a short triggering positive pulse is applied to the gate of the
SCR, it will fire and conduct for a short time. Consequently, the voltage at ‘A’ will fall rapidly
resulting in a short duration, high voltage pulse at ‘B’. This pulse appears across the crystal
which generates short duration ultrasonic pulse. For producing a pulse with a very short duration
it is necessary to use an SCR with a fast turn ‘on’ time and high switching current capability,
which can be able to withstand the required supply voltage. SCR 2N4203 can be used because of
its high peak forward blocking voltage (700 V), high switching current capability (100 A) and
fast turn-on time (100 ns).
Receiver: The function of the receiver is to obtain the signal from the transducer and to extract
from it the best possible representation of an echo pattern. To avoid significant worsening of the
axial resolution, the receiver bandwidth is about twice the effective transducer bandwidth.

Types of Probes
Product for 2D imaging
Radius
Central
Probe type Feature Application Element of
frequency
curvature
Vasucular application
•Arteria carotis
•IMT,FMD measurement
for early detection of 2.5MHz 64ch
arterial sclerosis | | -
venipuncture,blood vessel 12MHz 256ch
wide footprint and keep visualization
Linear type same field of view at deep Breast,Thyroid
part. Tendon,arthrogenous

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 Intraoperative,laparoscopy
The thickness measurement of Body
fat and Musculus for daily healthcare
check and locomotive syndrome check
Photoacoustic imaging,ultrasonic
velocity change imaging
Crack detection of metal and concrete.

Abdominal application.
2.5MHz 64ch 5R
Transvaginal and Transrectal
| | |
application.
7.5MHz 192ch 80R
Convex(Curved) wide footprint, field of Diagnoses organs.
type view will be spreaded at
deep part.

Cardiac application.
2MHz 32ch
Transesophageal application.
| | -
Abdominal application.
7.5MHz 128ch
small footprint, field of Brain diagnosis
Phased(Sector) view will be spreaded
type widely at deep part.

Ophthalmology
Transesophageal application.
Transvaginal and Transrectal 2MHz
application. | - -
Transurethral application. 22MHz
The blood flow measurement with
Single type A) The measurement of Doppler.
distance.
B) B mode scanning by
mechanical rotation.

Product for 3D imaging

Central
Probe type Feature Application Element Radius
frequency

Breast, Thyroid and 7.5MHz 128ch

Arteria carotis of | | -
vascular application. 11MHz 192ch

Linear type Real time 3D imaging with wide footprint

and keep same field of view at deep part.

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 Abdominal application. 3.5MHz 128ch 10R
Transvaginal and | | |
Transrectal application. 6.5MHz 192ch 40R
Real time 3D imaging with wide footprint,
Convex(Curved) field of view will be spreaded at deep part.
type

Beam Steering / Transducer focusing

Focusing of ultrasound beam
The shape of the ultrasound beam can be influenced to varying extents by applying different
focusing methods
1. Shape of the crystal element: The crystal element can be suitably shaped by concave
curvature to focus the ultrasound beam. This is an internal focusing method, because it is
effected in the crystal itself. The degree of focusing depend on the extent of curvature
(radius of curvature) of the crystal.
2. Acoustic lenses: Acoustic lenses made from materials which propagate ultrasound at
velocities different from that in the soft tissue can be used to focus the beam by
refraction. The lens will have concave curvature and the degree of focusing will be
determined by the radius of curvature of the lens.
3. Acoustic mirrors: A concave mirror can be used to focus ultrasound by reflection. Again,
the degree of focusing will depend on the radius of curvature.
Acoustic lenses and mirrors provide external focusing.

Concave Crystal Acoustic Lens Acoustic Mirror

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 Electronic Focusing
Electronic focusing is employed in multi-crystal transducers. In such, transducers with many
crystal elements, movement of the ultrasound beam across the plane of interest in the subject
is effected electronically by pulsing small groups of crystal elements at a time. By applying a
pulsing programme with carefully controlled time delays between different crystal elements,
ultrasound waves from all the crystals in the array can be made to arrive in phase at one
particular point (the focus), where they reinforce to produce a high intensity zone. Electronic
focusing offers the advantage of providing variable focus, or dynamic focus, as opposed to
the other methods which provide fixed focus. Variable focusing is achieved by altering the
time delay programme.

Focus of a Transducer, Focal Zone

The focus, F, of a transducer is that point along the central axis of the beam which is
equidistant in time from all points on the surface of the transducer. The times of fight of the
ultrasound waves are equal for al linear paths between the surface of the transducer and F.
the waves therefore arrive at F in phase and reinforce each other by constructive interference.
Attractive beam properties are associated with the point F: the beam has its narrowest width,
greatest intensity, and best spatial resolution.

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 The focus of a transducer is not sharply defined. Areas within the beam close to F will have
properties which will closely match those at F itself. The region around F over which these
conditions prevail is called the focal zone of the transducer.

Shape of Focused Beam, showing the Focal Zone

Transducer Focusing
Transducers can be designed to produce either a focused or non-focused beam, as shown in the
following figure. A focused beam is desirable for most imaging applications because it produces
pulses with a small diameter which in turn gives better visibility of detail in the image. The best
detail will be obtained for structures within the focal zone. The distance between the transducer
and the focal zone is the focal depth.

An unfocused transducer produces a beam with two distinct regions, as shown in the previous
figure. One is the so-called near field or Fresnel zone and the other is the far field or Fraunhofer
zone. In the near field, the ultrasound pulse maintains a relatively constant diameter that can be
used for imaging.
In the near field, the beam has a constant diameter that is determined by the diameter of
the transducer. The length of the near field is related to the diameter, D, of the transducer and the
wavelength, l, of the ultrasound by
Near field length = D2/4l.

Principles of Ultrasound Image Formation

Sound reflection is the basis of ultrasound image formation. Reflection occurs when the
ultrasound beam strikes a smooth boundary between two layers of an organ having different
acoustic impedance. The ratio of the amplitude (energy) of the reflected pulse and the incident is
called the reflection coefficient. The ratio of the amplitude of the incident pulse and the

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transmitted pulse is called the transmission coefficient. Both are dependent on the differences in
acoustic impedance of the two materials. The acoustic impedance of a medium is the speed of
sound in the material × the density:
Acoustic Impedance, Z = v x ρ
When an ultrasound beam strikes the interface perpendicularly, the reflected sound waves remain
in phase with the incident beam and are detected by the transducer on their return. The
characteristic impedance determines the degree of reflection and refraction at the interface
between two media. The percent of the incident wave energy which is reflected is given by:
𝑍1 − 𝑍2 2
𝑅=[ ] 𝑥100
𝑍1 + 𝑍2

The ultrasound beam intensity decreases with time, therefore, intensity of returning echoes are
compensated with time gain. As a result, exact amplitude of the echoes is reproduced from the
same impedance difference irrespective of the depth. The reflected or echo pulses provide two
types of information: (a) amplitude indicates the relative density / thickness of the tissue layers
and represented in the form of brightness, and (b) time between transmitting and receiving a
pulse reveals the tissue depth or position within a structure or organs.

Basically, all ultrasound imaging is performed by emitting a pulse, which is partly reflected from
a boundary between two tissue structures, and partially transmitted. The reflection depends on
the difference in impedance of the two tissues. The pulse is thus emitted, and the system is set to
await the reflected signals, calculating the depth on the basis of the time from emission to
reception of the signal. The total time for awaiting the reflected ultrasound is determined by the
preset depth desired in the image.
D = (v x t)/2 Where, D is the depth / position of the tissue

Schematic illustration of the reflection of an ultrasound pulse emitted from the probe P, being reflected at a, b and
c. Part of the pulse energy is transmitted from the scatterer a, the rest is transmitted, part from b and the rest from c.
When the pulse returns to P, the reflected pulse gives information of two measurements: the amplitude of the
reflected signal, and the time it takes returning, which is dependent on the distance from the probe

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The reflected sound waves are recorded and processed to reconstruct real time visual images by
the computer. The echo signals reveal / highlight the size and shape of the organ and also
indicate the nature eg. solid, fluid or something in between them.

The Ultrasound Machine

A basic ultrasound machine has the following parts:
1. transducer probe - probe that sends and receives the
sound waves
2. central processing unit (CPU) - computer that does all of
the calculations and contains the electrical power
supplies for itself and the transducer probe
3. transducer pulse controls - changes the amplitude,
frequency and duration of the pulses emitted from the
transducer probe
4. display - displays the image from the ultrasound data
processed by the CPU
5. keyboard/cursor - inputs data and takes measurements
from the display
6. disk storage device (hard, floppy, CD) - stores the
acquired images Ultrasound machine with various
transducer probes
7. printer - prints the image from the displayed data

The schematic diagram of an ultrasound machine

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Real-Time Ultrasonic Imaging Systems
Real-time mode has been developed to present motion like a movie of the body's inner workings,
showing this information at a high rate. Real time imaging system produces a sequence of image
at a faster rate to follow the movement of organs. Such system can capture the beating heart on
the screen, allowing the physician to observe its motion. A typical image might have 120 scan
lines and each 20 cm length. Therefore, each line has time of flight of 267μs.
D = (v x t)/2 or t = 2D/v = (2 x 20 cm)/(1500m/s) ≃ 267μs
The total time for an image / frame is around 32ms (120 x 267μs ≃ 32ms). It is therefore
possible to produce images at a standard video frame rate of 32 frames / sec (1000/32 ≃ 32).
Such fast and rapid scanning can be achieved by fast physical movement of transducers or using
array transducers. This mode is used to visualize the moving structure e.g. heart and foetus.

Real time imaging system is an automatic scanning and is generally grouped into (a) Mechanical
and (b) Electronic Scanner. Mechanical scanner represents a low cost technique extending the
performance of a manually scanned system to achieve 2D field of view. The probe consists of
one or more transducers depending upon the need and types. The image is produced by rapidly
rotating the crystal to generate fan-shaped ultrasound beam, resulting a V-shaped sector image.
Depending upon the movement of transducer, mechanical scanner classified as (1) Rotating
wheel transducer, and (2) Oscillatory motion transducer.

Electronic Scanners
Electronic scanner is a multi-element (i.e. multiple piezo electric crystal element) array
transducers. Mechanical scanning methods have almost entirely been replaced with electronic
scanner. Electronic scanner differs from mechanical scanner both in construction and beam
deflecting system. There are two basic types of electronic scanners: (a) Linear sequence /switch
transducer arrays (bilinear or curvilinear) and (b) Phase transducer arrays (linear or annular).
a. Linear Sequential Array
The linear array is formed from a large number of (up to 256) individual transducer
elements covering 4 to 10 cm length. Each parallel rectangular transducer has dimension
2mmx10mm or 4mmx18mm. A group of transducer called aperture which typically
consists of 16 to 32 elements. During each transmission / receive cycle only one
transducer group is active. The 1st aperture produces one scan line and then electronically
shifted over next one element with exclusion of 1 st one and forms the 2nd scan line. In this
way, it produces 100-115 scan lines for a complete sectional image.

Linear Sequential Array Transducers

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 b. Linear Phased Array:
Phase array scanner consists of 48 to 128 crystal elements arranged in a row and each
produces scan line. All elements are not excited simultaneously, slight delay 1ns (10 -9s) is
introduced and the elements are excited at a given sequences.

Transmit pulse are applied to each element via a delay which gives a swiveled (angled)
wave front. The degree of swivel requires very narrow elements of about ½ λ diameter.
The effective aperture A' = A Cosθ. Annular phase array consist of a series of concentric
transducers. This produces a conical beam section.

Linear Phase Array Transducers

Types of Transducer Array

Linear Scan:
This linear type uses the world's first "linear scan" technology that allows the built-in probe to
directly move in a lateral direction (reciprocal scan) by a motor. Compared to the traditional arc
scanning, this linear scanning provides higher lateral resolution of diagnostic images. The probe
also has a flat surface that touches the target part of the human body (the surface that sends and
receives ultrasonic waves). This geometry allows the probe to ensure more uniform contact with
the irregular surface of breasts and other parts of the human body.

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A linear array transducer with multiple crystal elements displays real-time compound B-mode
images with up to 100 images per second.

Ultrasound Image Artifacts

Artifacts are errors in images. They are normally caused by physical processes that affect the
ultrasound beam and that in some way alter the basic assumptions the operator makes about the
beam. Artifacts in diagnostic ultrasound are a reflection or an echo, which appears on the display
and represents the real anatomical structure not correctly. An artifact can be a false, multiple or
misleading information introduced by the imaging system or by interaction of ultrasound with
the adjacent tissue.
A. Reverberation
Reverberation artifacts appear as multiple equally spaced lines along a ray line. Reverberation is
caused by the sound bouncing back and forth between tissue boundaries and then returning to the
receiver. Comet-tail artifact is a specific type of reverberation artifact. This results a short train
of reverberations from an echogenic focus which has strong parallel reflectors within it (e.g.
cholesterol crystals in adenomyomatosis)
B. Ring Down
Ring-down artifacts are produced when small crystals such as cholesterol or air bubbles resonate
at the ultrasound frequency and emit sound. Because the sound is emitted after the transducer
receives the initial reflection, the system thinks the emitted sound is coming from structures
deeper in the body. Air bubbles in the abdomen are shown.

Reverberation Artifact Ring-down Artifact

C. Mirror Images
Sound can bounce off a strong, smooth reflector such as the diaphragm. The surface acts as
mirror and reflects the pulse to another tissue interface. The ultrasound system believes the
second interface is beyond the first surface, and this is where it appears on the scan.

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 D. Reflections
Reflection is somewhat similar to the mirror image described above but has a very different
appearance and is caused by multiple reflections. Sound can bounce off a strong, smooth
reflector, such as the posterior bladder wall, and be reflected back to the transducer, giving the
appearance of the structure deep to the bladder wall as would be seen with fluid collection.

Mirror-image Artifact Reflection Artifact

E. Enhancement
Enhancement is seen as an abnormally high brightness. This occurs when sound travels through
a medium with an attenuation rate lower than surrounding tissue. Reflectors at depths greater
than the weak attenuation are abnormally bright in comparison with neighboring tissues.
Enhancement of tissues deeper than cysts or ducts is common. The attenuation of the sound
through the fluid in these tissues is less than that of the surrounding tissues and results in this
abnormal brightness. The tissues deeper than the gallbladder show abnormal brightness.
F. Attenuation
Tissues deeper than strongly attenuating objects, such as calcification, appear darker because the
intensity of the transmitted beam is lower. In the scan of the gallbladder in below, the left side
shows enhancement as described above; the right side shows decreased beam intensity because
of attenuation in calcified gallstones (arrow).

Enhancement Artifact Scan of the gallbladder, left side shows enhancement;

right side shows a hypoechoic shadow distal to
a brightly echogenic stone
Acoustic Shadowing - the loss of information below an object because the greater portion of the
sound energy was reflected back by the object. This occurs in objects like prosthetic valves.

Aliasing is a phenomenon inherent to Doppler modalities which utilize intermittent sampling in

which an insufficient sampling rate results in an inability to record direction and velocity
accurately.

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Side lobe artifacts occur where side lobes reflect sound from a strong reflector that is outside of
the central beam, and where the echoes are displayed as if they originated from within the central
beam. Side lobe artifacts are echogenic, linear or curvilinear artifacts. Strong reflectors include
bowel gas adjacent to the gallbladder or urinary bladder.

Speckle artifact may be encountered in ultrasound. It is caused by the scattering of waves from
the surface of small structures within a certain tissue. The artifact produces a textured
appearance.

Anisotropy is an artifact encountered in ultrasound, notably in muscles and tendons during

a musculoskeletal ultrasound. In musculoskeletal applications, the artifact may prompt an
incorrect diagnosis of tendinosis or tendon tear.

Ultrasound beam width artifact occurs when a reflective object located beyond the widened
ultrasound beam, after the focal zone, creates false detectable echoes that are displayed as
overlapping the structure of interest.

A multipath artifact is an ultrasound beam artifact in which the primary beam reflects off
anatomy at an angle, resulting in a portion of the beam returning to the transducer, whilst another
portion takes a longer duration as it reflects a second structure. This phenomenon results in a
propagation path error in which the transducer will interpret a structured to be deeper than it is.

Doppler Ultrasound and Colour Velocity Mapping

The Doppler Effect is a change in the frequency of sound waves reflected by a moving object.
The Doppler Effect was discovered by Christian Andreas Doppler (1803 - 1853) and shows how
the frequency of an emitted wave changes with the velocity of the emitter or observer. The basis
for the Doppler effect is that the propagation velocity of the waves in a medium and is constant,
so the waves propagates with the same velocity in all directions, and thus there is no addition of
the velocity of the waves and the velocity of the source. As the source moves in the direction of
the propagation of the waves, this does not increase the propagation velocity of the waves, but
instead increases the frequency.
In ultrasound, the wave is sent from a stationary transducer, the moving blood or muscle is firstly
moving towards the transducer and then following the reflected wave towards the transducer,
thus the Doppler shift. In the case of reflected ultrasound, the Doppler shift is:
𝑣 𝑓 𝐶
𝑓𝐷 = 2𝑓0 𝑐 𝐶𝑜𝑠𝜃 or 𝑣 = 2 𝑓 𝐷𝐶𝑜𝑠𝜃
0
Where, fD = Doppler shift frequency, f0 = Incident frequency of ultrasound, C = velocity of
ultrasound through medium, v = velocity of blood or tissue, θ = Insonation angle between the
ultrasound beam and the direction of motion (velocity vector).

A Doppler ultrasound is a noninvasive test that can be used to evaluate blood flow and pressure
by bouncing high-frequency sound waves (ultrasound) off red blood cells. A Doppler ultrasound
can estimate how fast blood flows by measuring the rate of change in its pitch (frequency). It
helps doctors evaluate blood flow through the major arteries and veins of the arms, legs, and

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neck. It can show blocked or reduced blood flow through narrowing in the major arteries of the
neck that could cause a stroke. It also can reveal blood clots in leg veins (deep vein thrombosis-
DVT) that could break loose and block blood flow to the lungs (pulmonary embolism), heart
valve defects and congenital heart disease, a blocked artery (arterial occlusion), narrowing
(stenosis) of an artery or to monitor arterial reconstruction and bypass grafts. During pregnancy,
Doppler ultrasound may be used to look at blood flow in an unborn baby (fetus) to check the
health of the fetus.

Principles of Doppler Ultrasound

Colour Flow Imaging (CFI) or Colour Velocity Imaging (CVI) or Triplex Ultrasound

The most recent technology change in diagnostic ultrasound is color flow imaging (CFI), which
is a merging of gray-scale and motion-detection processing to produce an image that depicts soft
tissue in gray scale and blood flow in color. Color-flow imaging (also called triplex ultrasound)
is an enhanced form of Doppler ultrasound technology. This technique is similar to duplex
ultrasound and use third parameter i.e. color to highlight the direction of blood flow. Vessels in
which blood is flowing are colored: red for flow in one direction and blue for flow in the other,
with a color scale that reflects the speed of the flow.

CFI is a US imaging modality that processes echo signals for amplitude and motion information
to produce a composite image that depicts soft tissues in gray scale and blood flow in color in a
real-time format. The motion information comes from either Doppler signal processing on a
direct measurement of movement oven time. The system combines the signal processing to form
anatomic (soft tissue) and physiologic (blood-flow) information in the same image at the same
time.

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CFI currently comes in three basic forms: synchronous signal processing, asynchronous signal
processing, and feature on time domain analysis (TDA). Both synchronous and asynchronous
processing use Doppler principles to detect and depict blood flow events. TDA, in contrast, uses
a direct measurement of echo-source motion within the image. TDA, which is commercially
called color velocity imaging (CVI), uses amplitude signal processing for the gray-scale portion
of the image and a non-Doppler technique to detect and characterize blood flow. This method of
depicting blood flow requires imaging blood like a soft tissue to obtain a unique textural pattern
rather than processing the echo signals for Doppler shift frequencies.

This technique is used to depict the peripheral arterial flow and blood cells geometry. The echo
image is used to locate the artery and determine the position of the walls. The echo image is then
used as a guide to map out the flow field with the Doppler shift. The frequency shifts are
encoded as colour bar. In a typical display, blood flowing towards the transducer (positive
Doppler shift) is coded as red and away (negative shift) as blue. Various intermediate colours
represent the different velocities of the flow.

Color flow Doppler ultrasound produces a color-coded map of Doppler shifts superimposed onto
a B-mode ultrasound image (color flow maps). Although color flow imaging uses pulsed wave
ultrasound, its processing differs from that used to provide the Doppler sonogram. Color flow
imaging may have to produce several thousand color points of flow information for each frame
superimposed on the B-mode image. Color flow imaging uses fewer, shorter pulses along each
color scan line of the image to give a mean frequency shift and a variance at each small area of
measurement. This frequency shift is displayed as a color pixel. The scanner then repeats this for
several lines to build up the color image, which is superimposed onto the B-mode image.

An arterial duplex ultrasound showing blood flow A venous duplex ultrasound showing blood flow
in the right femoral artery in the leg in right Sapheno-femoral junction in the leg

Colour velocity imaging (CVI) identifies a group of blood cells in a vessel and times their shift.
The grout which is identified at a timeT 1 has moved to a new position at T2 and the separation is
measured. A group of blood cells gives a unique signal which is followed for a fixed time in a
“window”. The blood velocity is computed from the time. When utilizing this equipment for
ultrasonography, two displays are available. These are color-flow Doppler and gray-scale B-
mode. The color-flow Doppler displays a flow velocity distribution while the gray-scale B-
mode provides an anatomic image.

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Duplex Ultrasound and Power Doppler
Duplex Ultrasound
Duplex ultrasound imaging system combines high-resolution real-time imaging with
simultaneous Doppler analysis for accurate evaluation of blood flow in the veins and arteries.
The term "duplex" refers to the fact that two modes of ultrasound are used, Doppler and B-
mode. The B-mode transducer obtains an image of the vessel being studied whereas the Doppler
probe within the transducer evaluates the velocity and direction of blood flow. Duplex
ultrasonography combines the principles of anatomic and flow ultrasonography to deliver
diagnostic information. The echo image is used as a guide to map out the flow field with the
Doppler.

Duplex ultrasound produce images show how blood is moving through arteries and veins. It
enables the physician to see the speed and direction of blood flow and where the blood flow may
be blocked. This type of Doppler examination provides a 2-dimensional (2-D) image of the
arteries so that the structure of the arteries and location of an occlusion can be determined, as
well as the degree of blood flow. This system is used in the evaluation of the extracranial carotid
arteries, iliofemoral arteries, and hemodialysis shunts. The system obtains information regarding
blood velocity, lumen area, plaque composition and ulceration, and hemodynamic turbulence.

Necessary equipment consists of an ultrasound machine with duplex capabilities. This will
include a probe with piezoelectric crystals. The machine and transducers enable varying
focusing, direction, and adjustment of the gain, resolution, and depth of the ultrasound waves.
Typical depth adjustments range from less than 1 cm to 20 cm. Equipment is also generally
compatible with multiple transducers which provide differing advantages. The linear array
transducers are beneficial for anatomic mapping of arterial and venous systems. Lower
frequency transducers, which are typically curved linear or phased array, are better for visceral
vessels or abdominal imaging studies. Two-dimensional transducers are also available which
provide the construction of three-dimensional imaging from ultrasound data.
A duplex ultrasound may help diagnose many conditions, including:
 Blood clots
 Poorly functioning valves in leg veins, which can cause blood or other fluids to pool in
legs (venous insufficiency)
 Heart valve defects and congenital heart disease

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  A blocked artery (arterial occlusion)
 Decreased blood circulation into legs (peripheral artery disease)
 Bulging arteries (aneurysms)
 Narrowing of an artery, such as in neck (carotid artery stenosis)

Various arterial diseases are identified and monitored via duplex ultrasonography. These include
cerebrovascular, renal, mesenteric, and aortoiliac disease. Additional diagnostic testing should
follow a screening study and positive results. In the case of cerebrovascular arterial analysis,
duplex ultrasound is particularly useful for carotid arteries evaluation. This type of Doppler
examination provides a 2-dimensional (2-D) image of the arteries so that the structure of the
arteries and location of an occlusion can be determined, as well as the degree of blood flow. It is
highly sensitive and specific for the identification of plaques and can be used to characterize and
identify plaques which are more likely to increase the risk of future strokes.

Power Doppler Sonography

Power Doppler sonography is a new technique that displays the strength of the Doppler signal in
color, omitting the other parameters of speed and direction. It has three to five times the
sensitivity of conventional color Doppler for detection of flow and is particularly useful for small
vessels and those with low-velocity flow. The frequency is determined by the velocity of the red
blood cells, while the power depends on the amount of blood present. All moving blood cells
(and, alas, all moving particles) yield a color signal, regardless of their speed or direction. The
more cells in motion there are, the stronger the color signal. In addition to the number of moving
cells in the sample, the diameter of the vessel studied influences the strength of the power
Doppler signal.

Power Doppler can get some images that are hard or impossible to get using standard color
Doppler. Power Doppler is most commonly used to evaluate blood flow through vessels within
solid organs. Power Doppler is also referred to as energy Doppler, amplitude Doppler and
Doppler angiography. Power Doppler sonography finds potential for detecting areas of ischemia
in the kidney, brain, and prepubertal testis and for demonstrating hyperemia in areas of
inflammation. In inflammatory conditions, power Doppler is valuable in depicting increased
flow in vessels that are dilated because of inflammatory response.

Bio-effects and Safety Levels

Risks and side-effects:
Ultrasonography is generally considered a "safe" imaging modality. Diagnostic ultrasound
studies of the fetus are generally considered to be safe during pregnancy. This diagnostic
procedure should be performed only when there is a valid medical indication, and the lowest
possible ultrasonic exposure setting should be used to gain the necessary diagnostic information
under the "as low as reasonably achievable" (ALARA) principle. Thermal effects are most
closely related to the spatial-peak and temporal-average intensity (ISPTA). This expresses the
maximum intensity delivered to any tissue averaged over the duration of the exposure. Thermal
effects (increase in temperature) also depend on the duration of the exposure to the ultrasound.

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Ultrasound methods are apparently safe but types of damage sought include genetic and
teragenetic effects, disorders of physiological function and inhibition of biological development
Chromosome damage: Single stranded DNA breaks have been seen in human leukocytes.
Various continuous and pulsed frequencies were used but 94 W/cm2 spatial peak temporal
averages (SPTA) at 8MHz continuous wave yielded consistent breaks associated with cavitation
effect (mechanical effect). This is much higher power than would be available from diagnostic
equipment.

Safety Levels:
In low MHz frequency range there have been no confirmed biological effects in mammalian
tissues exposed in-vivo to unfocussed ultrasound with ISPTA (spatial peak temporal average
intensity) below 100mW/cm2 for less than 500 sec or for focused ultrasound with I SPTA below
1W/cm2 for less than 50 sec. furthermore, for exposure times more than one second and less than
500sec (unfocussed) or 50sec focused such effect have not been demonstrated at even high
intensities. The zone of safety was valid for 0.5 to 15 MHz and for all anatomic sites except the
eye. Re-exposures are limited to 10% and 30% per year. Biologically sensitive areas would be:
1. 1st trimester embryo
2. Fetus skeletal heating
3. Transcranial Doppler
4. Eye
5. Intracavity

The Future of Ultrasound

As with other computer technology, ultrasound machines will most likely get faster and have
more memory for storing data. Transducer probes may get smaller, and more insertable probes
will be developed to get better images of internal organs. Most likely, 3D ultrasound will be
more highly developed and become more popular. The entire ultrasound machine will probably
get smaller, perhaps even hand-held for use in the field (e.g. paramedics, battlefield triage). One
exciting new area of research is the development of ultrasound imaging combined with heads-
up/virtual reality-type displays that will allow a doctor to "see" inside and performing a
minimally invasive or non-invasive procedure such as amniocentesis or biopsy.

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 US Image Processing Sequences & Display Modes
Ultrasound Image Processing Sequences
The ultrasound image processing sequences are pulser, receiver (probe), signal pre-processing
and post processing.

Simplified Block Diagram Ultrasound Image Processing Sequences

A. Pulser
It produces pulses for the transducer probe. The pulse repetition frequency (PRF) of pulser is
controlled by the Master Clock which is the heart of the system. The master clock also
controls the time gain compensation (TGC).
B. Receiver
The same transducer (probe) will receive all the echoes from the object. A single ultrasound
wave may produce many echoes in the path. A series of echoes will be received during
scanning and the amplitude will vary depending upon the depth of tissue and its nature.
C. Signal Pre-processing
The signal pre-processing unit consists of the following sub-units:
1. Amplification:
Echo signals are small with a dynamic range from 100 & 150 dB (1μV to 316μV) and are
linearly amplified to millivolts range. The amplification is achieved in a wide band
amplifier with a desirable gain of 80-100dB. In modern instruments, the input amplifier is
dual gate MOSFET.
2. Time-Gain Compensation (swept gain):
It is known that the emitted ultrasound wave amplitude gets smaller as it penetrates
tissue, a phenomenon called attenuation. So, one might expect late echoes (from deep
layers) to have smaller amplitudes than early (superficial) echoes even if those layers
have the same echogenicity. A way to overcome ultrasound attenuation is time gain
compensation (TGC), in which signal gain is increased as time passes from the emitted
wave pulse. This correction makes equally echogenic tissues look the same even if they
are located in different depths.

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 The echo signal intensity decreases with tissue depth and need a time varying
amplification to compensate for continuous attenuation of ultrasound along the line of
travel. The time gain compensation (TGC) circuit amplifies the signal depending on the
time of arrival i.e. the later signal undergo greater amplification to rectify the signal
amplitude loss for tissue attenuation. This process is also known as swept gain or time
varied gain.
In simple form of TGC, the amplification is linear but modern imaging system
incorporate non-linear amplification (Look-Up Table). The rate of gain increases with
depth and is set in the order of 0 to 10dB.
3. Compression:
The dynamic signal range is compressed using logarithmic amplification for effective
display of all signals at a time. The smaller input signals (10-20μV) will undergo greater
amplification than stronger signals (70-80μV). The dynamic range is usually reduced to
about 20 to 30 dB.
4. Demodulation & Rejection:
The compressed signals undergo full wave rectification which defines their outline or
shapes (envelope) and is called demodulated signals. Later, a threshold is placed to reject
smaller amplitude signals (acoustic or electronic noise) and then digitized for computer
processing.
D. Signal Post Processing
The digital signals are stored as 6 to 8 bit number in the memory i.e. 64 x 64 to 256 x 256
matrixes. The scan line information from each transducer (element group) is stored in an
image matrix according to element position (matrix X-axis) and echo depth (matrix Y-axis).
The digital values are fed out from the matrix in sequence into a DAC and the varying analog
voltage coded with a video signal to give a video raster display.

Types of Ultrasound Scans and Display Modes

In ultrasound, scanning patterns is of three types: linear, sector and compound. In linear scan
transducer positions are parallel to the surface of the object and the sound beams are
perpendicular to transducer movement. The transducer location is changed but the angle of the
beam is held constant. In sector scan the transducer is rocked about a fixed point so that the
sound beam covers a sector. The compound scanning is merely a combination of linear and
sector scans.

Types of scanning arrangement: (a) Linear, (b) Sector & (c) Compound

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Display Modes of Ultrasound / Clinical Modes
Clinical ultrasound machines present the image data in one of three (or four if the machine is
modern) modes. These are A-Mode, B-Mode and M-Mode display.
A-Mode (Amplitude Mode):
This type of scan offers only one-dimensional information echoes project spikes vs. time. Wave
spikes are represented when a single beam passes through objects of different consistency and
hardness. The echo signals are applied to the Y-deflecting plates of the CRT so that they are
displayed as vertical blips as the beam is swept across the CRT. The height (amplitude of
individual echo) of the vertical blip corresponds to the strength of the echo and its position from
left to right across the CRT face corresponds to the depth of its point of origin from the
transducer.

The first is the A-mode, in which the amplitude of the reflections is plotted against time (or
distance assuming that the velocity of sound in the body is 1540 m·s-1). A-mode ultrasound is
used to judge the depth of an organ, or otherwise assess an organ’s dimensions. A-mode is has
been used extensively in midline echoencephalography and ophthalmologic scanning. Echo-
encephaloscope uses 1-3 MHz whereas echo-ophthalmoscope employs a 7.5–15 MHz pencil
type transducer.

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 Elements of an A-mode pulse echo instrument

The details of the arrival times of echoes from the interior tissue boundaries are illustrated in the
figure below. The boundary depths can be related to echo arrival times through the
proportionality constant 2/c.

Illustration of arrival times in A-mode ultrasonography.

The electronics of the receiver system tailors the received signal for maximum readability. This ‘tailoring” includes
a time gain control (TGC) that helps compensate for the ever-decreasing signal strengths from deeper tissues due to
the greater attenuation over longer paths. The rate of TGC increase should be approximately 1 dB/MHz for each
interval of time that corresponds to 1 cm of travel. For example, assuming c=1.54x105 cm s-1, the gain should
increase at a rate of approximately 154 dB ms-1.

B-Mode / 2D-Mode (Brightness Mode):

The B-mode representation is a two-dimensional display of the tissues. There are 16, 64, or 256
levels of gray scale. In a Gray Scale image display, each pixel represents the echo intensity. It
displays the echoes as dots on the monitor corresponding to the points of origin in tissues. The
differences in amplitudes of returning echoes manifests as different brightness dots and carries
information about probe position and orientation (depth of tissues).

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It produces 2-D cross sectional sector images by sweeping the beam repeatedly back and forth
through the patient body. A 3-D image can be obtained by adding additional rows of crystal
elements to permit sweeping in a direction perpendicular to the plane of the B-Mode scan.

B-mode ultrasound produces the sector (or pie segment-shaped) scans that one normally sees. B-
model machines represent the vast majority of machines in existence. These machines are used
in echocardiology, obstetrical scans, abdominal scans, gynecological scans, etc. These scans
require either a mechanical scanner transducer (the transducer moves to produce the sector
scan), or a transducer with a linear array operated as a phased array (as discussed in class).

Components of a B-mode Instrument

A mechanical scanned B-mode ultrasound system, the transducer is rocked back and forth to
produce a corresponding sector scan. Instead of using a mechanical scanned probe, modern
machines use an electronically scanned phased array of piezoelectric probes. This is illustrated
in in which the direction of the ultrasound beam is altered by phasing the excitation of the array
elements.

M-Mode (Time-Motion Mode /Time Position Modulation):

M-mode is used for analyzing moving body parts (the M-mode is sometimes called the “Time
Motion” or TM mode). The gathered data is stored sequentially in the memory by line time count
(t1, t2, t3 ...tn), rather than line number. M-mode is particularly useful for imaging moving artery
wall, heart wall and heart valves (echocardiography). It displays the successive position of a
moving object at various instant i.e. brightness dots move on the monitor screen as actual
interface. It is actually the application of modified B-mode to moving structure. Here, tissue
depth is displayed along vertical axis and time on horizontal axis as a result time-position image
is obtained. Some modern system, colour coding reveals the direction of the movement.

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 Components of M-mode Instrument
The transducer beam is stationary while the echoes from a moving reflector are received at varying times.

Representation of A-Mode, B-Mode & M-Mode Display

Other derived modes are possible. One particularly useful mode is the C-mode in which an
image is derived by either placing a receiver opposite a transmitter (ignoring reflections), or by
deriving the cross-section C-model data from three-dimensional imaging.
Most modern machines can generate multiple modes, and the choice is left to the user. Most
modern machines can also display Doppler echo pictures in which the data being imaged are
due to Doppler shifts resulting from moving parts. This is particularly useful for imaging blood
flow.

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